Richmond Castillo MD, Children’s National Health System

A 5-year-old male with no past medical history presents with right eye pain. Per mom, who had not witnessed event, describes that patient was at school three days prior and was told by school nurse that he fell and hit his eye on the floor. Unclear if he hit any object. Patient did not lose consciousness or have any vomiting. Today, the family brought him in because he had not opened his right eye since the day of the fall. Otherwise, the patient has been acting his usual self and has been playing, eating, drinking, and urinating without difficulty. Immunizations up-to-date

HR: 104, RR: 20, BP 93/63, SpO2 99% on RA, T: 37.1

General: Alert, Interactive, Nontoxic
Head: Normocephalic, atraumatic
Left Eye: Left pupil reactive to light 5mm to 3mm, eye extraocular movements intact, no erythema or conjunctival injection, patient appears to not be in pain when walking around the room. No erythema, no upper or lower lid swelling. No obvious laceration or abrasions on external exam.
Right Eye: Right eye exam unable to obtain given patient cooperation other than slight right upper lid swelling. No erythema, no lower lid swelling. No obvious laceration or abrasions on external exam.
Ears, Nose, Throat: Normal external ear, normal external nose, moist mucous membranes
Neck: Supple, Trachea Midline
CV: Distal pulses intact. Warm well perfused extremities. 
RESP: Normal work of breathing. 
ABD: no obvious distention
SKIN: warm, dry
NEURO:  Alert

Coaching using mom, aunt, and watching TV/using iPhone in an attempt to do an eye exam. Patient is extremely irritable when trying to go near the right eye, crying immediately, and moving his head around. You consult ophthalmology and in the meantime try to do an exam.

Oral Midazolam given. Nurse reports the patient spat out about 10-20% of oral medicine. Upon re-examine 30 minutes later, the patient was still irritable so the patient was placed in papoose. Additional team members present to help hold the patient. On quick view, you are able to see right eye conjunctival injection, but unable to see the pupil because the patient is constantly looking up. 

Ophthalmology calls back. You tell them how difficult it was to obtain an exam. Ophthalmology will come see the patient and in the meantime recommends CT orbits.  It is obtained and shows “Mild swelling/edema of the left upper eyelid of preseptal soft tissues. No findings in the left globe. No fracture. Please note that small globe injuries are not well depicted on CT; it would need ophthalmologic evaluation.”