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Rapid onset of severe ocular injury after exposure to a button battery
Short Reports Rapid onset of severe ocular injury after exposure to a button battery Yasir Khan, MBBS, MRCOphth, Sundas Maqsood, MBBS, Suresh Marpuri, MBBS, Saab Bhermi, FRCOphth, and Vernon Geh, FRCOphth Button batteries are commonly used in many household electronic items and are a potential health hazard, especially in children. We present the case of a 2-year-old girl presented with swelling and redness of her right eye of 3 hours’ duration. Examination revealed a button battery that had became lodged in the superior fornix of her right eye. After the intact battery was removed, the patient was found to have suffered an alkali burn to the underlying conjunctiva and sclera. The burn healed with symblepharon formation.
FIG 1. Eyelid and anterior segment at initial presentation (A) and at 2 weeks’ follow-up (B).
Case Report
A
2-year-old girl presented to eye casualty of the Southend University Hospital, Southend, UK, with mild swelling and redness of her right upper eyelid of 3 hours’ duration. She complained that “her eye was hurting,” and her mother had noticed that the child had been rubbing her eye constantly for the past 3 hours. On examination, the right upper eye lid was slightly swollen, erythematous, and had a pseudo-ptosis (Figure 1). The conjunctiva was congested, and fluorescein staining revealed a corneal and conjunctival abrasion extending from the 12 to 3 clock hours position. Further examination revealed a shiny metallic foreign body, later identified as a button battery, lodged in the superonasal conjunctival fornix. There was no history of trauma and, according to her mother, she had found a box of button batteries near where the child had been playing. The battery could not be dislodged under topical anesthesia because the child became uncooperative; however, it was easily removed under general anesthesia. Introperatively, the surrounding conjunctiva appeared to be pigmented and necrotic (Figure 2). The battery’s positive end was smooth, whereas the negative end was rough and corroded (Figure 3). The pH of affected ocular tissue was 8 and the battery pH was 9. The eye was irrigated with 1.5 l of saline solution (0.9%) and the pH neutralized to 7.5. The child was treated with topical
Author affiliations: Southend University Hospital, NHS Foundation Trust, Southend, United Kingdom Submitted January 14, 2014. Revision accepted June 29, 2014. Published online October 24, 2014. Correspondence: Yasir Khan, MBBS, MRCOphth, Southend University Hospital 67 Lancing Road, Newbury Park, London, UK IG2 7DQ (email: [email protected]). J AAPOS 2014;18:600-601. Copyright Ó 2014 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2014.06.018
600
FIG 2. Conjunctival pigmentation noted following removal of battery.
antibiotics and steroids and prophylactic intravenous antibiotics. She made an uneventful recovery and was discharged the following day. She continued on topical steroids and antibiotics for 1 month, at the end of which time her visual acuity remained good (20/20) in the right eye. There was evidence of mild symblepharon in the upper fornix nasally and pigmentation of the underlying sclera (Figure 4). The rest of the eye examination, including dilated fundus examination, was otherwise normal. The child was asymptomatic and no further treatment was necessary.
Discussion Button batteries are commonly used in many household electronic items and are a potential health hazard, especially for children under the age of 6 years. Therefore, awareness of its potential danger and prompt management should be emphasized. Several reports have been published demonstrating tissue damage to various organs, including ear, nose, airways, esophagus, and vagina.1-3 The National Capital Poison Center has reported 129 cases of buttonbattery-induced tissue injury from 1982 to 2014,4 and 34 cases resulting in fatal complications from battery ingestion due to aorto-esophageal or trachea-esophageal fistulas. Various pathophysiological mechanisms have been suggested that lead to tissue necrosis in contact with the
Journal of AAPOS
Volume 18 Number 6 / December 2014
Zanolli et al
601
injury from button battery, button battery package regulations, systemic complication from button battery, button battery injury in young children. References
FIG 3. Button battery removed under general anesthesia from superonasal fornix. The positive electrode was smooth (A) and the negative electrode, facing the bulbar conjunctiva and sclera, was rough corroded (B).
FIG 4. Mild symblepharon in supero-nasal fornix.
battery.5,6 These include (1) leakage of battery contents, especially alkaline electrolyte; (2) generation of an electric current that hydrolyzes tissue fluid and produces hydroxide ions at battery’s negative pole; and (3) physical pressure on adjacent tissue. In our case, it is likely that battery corrosion led to leakage of alkaline content that caused local tissue damage. This was evident by the high PH of the effected tissues and also by the fact that the battery’s negative electrode facing the bulbar conjunctiva and sclera was corroded. Ocular injury from button batteries is uncommon. Only 3 other case reports have been published.7-9 Clinical features mentioned in 1 report7 suggest that the tissue injury was secondary to blunt trauma; the other 2 cases,8,9 presented with delayed onset of symptoms. Although the exact time of exposure in our case cannot be known for certain, based on the history, it seems that that exposure time was only 3-4 hours. We believe this is the first reported case of such rapid onset of symptoms from exposure to a button battery. Button battery–induced ocular injuries may be severe and require prompt diagnosis and treatment to avoid potential complications such as symblephron formation, scleral thinning, perforation, or limbal stem deficiency. Our case demonstrates how fast injury can occur.
Literature Search The authors searched PubMed and the Athens and University College London (UCL) Library database October 2013 through January 2014 using the following terms: button battery injury, mechanism of button battery injury, ocular
Journal of AAPOS
1. Gomes CC, Sakano E, Lucchezi MC, Porto PR. Button battery as a foreign body in nasal cavities: special aspects. Rhinology 1994;32:98-100. 2. Kavanagh KT, Litovitz T. Miniature battery foreign bodies in auditory and nasal cavities. JAMA 1986;255:1470-72. 3. Huppert J, Griffiths S, Breech L, Hillard P. Vaginal burn injury due to alkaline batteries. J Paediatr Adolesc Gynecol 2009;22:e133-6. 4. National Capital Poison Center. Nonfatal button battery ingestions with severe esophageal or airway injury: 125 cases. http://www. poison.org/battery/severecases. 5. Tanaka J, Yamashita M, Yamashita M, Kajigaya H. Esophageal electrochemical burns due to button type lithium batteries in dogs. Vet Hum Toxicol 1998;40:193-6. 6. Yoshikawa T, Asai S, Takekawa Y, Kida A. Experimental investigation of battery-induced esophageal burn injury in rabbits. Crit Care Med 1997;25:2039-44. 7. Mazer-Amirshahi M, Whitaker N, Kayewilson L, Litovitz T. Severe ocular injury after button battery exposure. J Emerg Med 2013;44:e187-9. 8. Ogasawara M, Goto S, Shiba T, et al. A case of button battery-induced corneal and conjunctive burn injury and experimental findings of local damage [in Japanese]. Nippon Ganka Gakkai zasshi 2011;115:711-17. 9. Ratnarajan G, Calladine D, Bird KJ, Watson SL. Delayed presentation of severe ocular injury from a button battery. BMJ Case Rep 2013. May 2, 2013.
Unusual retinal abnormalities in sisters with tetralogy of Fallot Mario T. Zanolli, MD,a Jenina Capasso, CGC, MS,a Vikas Khetan, MD,a Bego~ na Aristimu~ no, MD,c and Alex V. Levin, MD, MHSca,b Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease and can occur in the setting of chromosomal aberrations or multisystem malformation syndromes. We report unusual focal bilateral retinal defects in sisters with TOF.
Author affiliations: aOcular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; b Thomas Jefferson University, Philadelphia; c360 St. Charles Way, York, Pennsylvania Funded in part by the Foerderer Fund (AVL), the Robison D. Harley, MD Endowed Chair in Pediatric Ophthalmology and Ocular Genetics (AVL), the Joseph F. Bradway, Sr. Endowed Research Scholar Fund, and the Alcon Ocular Genetics Fellowship (MTZ). The funding organizations had no role in the design or conduct of this research. Submitted April 24, 2014. Revision accepted July 5, 2014. Published online October 24, 2014. Correspondence: Alex V. Levin, MD, MHSc, Chief, Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Suite 1210, 840 Walnut Street, Philadelphia, PA 191075109 (email: [email protected]). J AAPOS 2014;18:601-604. Copyright Ó 2014 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2014.07.163
FIG 1. Eyelid and anterior segment at initial presentation (A) and at 2 weeks’ follow-up (B).
Case Report
A
2-year-old girl presented to eye casualty of the Southend University Hospital, Southend, UK, with mild swelling and redness of her right upper eyelid of 3 hours’ duration. She complained that “her eye was hurting,” and her mother had noticed that the child had been rubbing her eye constantly for the past 3 hours. On examination, the right upper eye lid was slightly swollen, erythematous, and had a pseudo-ptosis (Figure 1). The conjunctiva was congested, and fluorescein staining revealed a corneal and conjunctival abrasion extending from the 12 to 3 clock hours position. Further examination revealed a shiny metallic foreign body, later identified as a button battery, lodged in the superonasal conjunctival fornix. There was no history of trauma and, according to her mother, she had found a box of button batteries near where the child had been playing. The battery could not be dislodged under topical anesthesia because the child became uncooperative; however, it was easily removed under general anesthesia. Introperatively, the surrounding conjunctiva appeared to be pigmented and necrotic (Figure 2). The battery’s positive end was smooth, whereas the negative end was rough and corroded (Figure 3). The pH of affected ocular tissue was 8 and the battery pH was 9. The eye was irrigated with 1.5 l of saline solution (0.9%) and the pH neutralized to 7.5. The child was treated with topical
Author affiliations: Southend University Hospital, NHS Foundation Trust, Southend, United Kingdom Submitted January 14, 2014. Revision accepted June 29, 2014. Published online October 24, 2014. Correspondence: Yasir Khan, MBBS, MRCOphth, Southend University Hospital 67 Lancing Road, Newbury Park, London, UK IG2 7DQ (email: [email protected]). J AAPOS 2014;18:600-601. Copyright Ó 2014 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2014.06.018
600
FIG 2. Conjunctival pigmentation noted following removal of battery.
antibiotics and steroids and prophylactic intravenous antibiotics. She made an uneventful recovery and was discharged the following day. She continued on topical steroids and antibiotics for 1 month, at the end of which time her visual acuity remained good (20/20) in the right eye. There was evidence of mild symblepharon in the upper fornix nasally and pigmentation of the underlying sclera (Figure 4). The rest of the eye examination, including dilated fundus examination, was otherwise normal. The child was asymptomatic and no further treatment was necessary.
Discussion Button batteries are commonly used in many household electronic items and are a potential health hazard, especially for children under the age of 6 years. Therefore, awareness of its potential danger and prompt management should be emphasized. Several reports have been published demonstrating tissue damage to various organs, including ear, nose, airways, esophagus, and vagina.1-3 The National Capital Poison Center has reported 129 cases of buttonbattery-induced tissue injury from 1982 to 2014,4 and 34 cases resulting in fatal complications from battery ingestion due to aorto-esophageal or trachea-esophageal fistulas. Various pathophysiological mechanisms have been suggested that lead to tissue necrosis in contact with the
Journal of AAPOS
Volume 18 Number 6 / December 2014
Zanolli et al
601
injury from button battery, button battery package regulations, systemic complication from button battery, button battery injury in young children. References
FIG 3. Button battery removed under general anesthesia from superonasal fornix. The positive electrode was smooth (A) and the negative electrode, facing the bulbar conjunctiva and sclera, was rough corroded (B).
FIG 4. Mild symblepharon in supero-nasal fornix.
battery.5,6 These include (1) leakage of battery contents, especially alkaline electrolyte; (2) generation of an electric current that hydrolyzes tissue fluid and produces hydroxide ions at battery’s negative pole; and (3) physical pressure on adjacent tissue. In our case, it is likely that battery corrosion led to leakage of alkaline content that caused local tissue damage. This was evident by the high PH of the effected tissues and also by the fact that the battery’s negative electrode facing the bulbar conjunctiva and sclera was corroded. Ocular injury from button batteries is uncommon. Only 3 other case reports have been published.7-9 Clinical features mentioned in 1 report7 suggest that the tissue injury was secondary to blunt trauma; the other 2 cases,8,9 presented with delayed onset of symptoms. Although the exact time of exposure in our case cannot be known for certain, based on the history, it seems that that exposure time was only 3-4 hours. We believe this is the first reported case of such rapid onset of symptoms from exposure to a button battery. Button battery–induced ocular injuries may be severe and require prompt diagnosis and treatment to avoid potential complications such as symblephron formation, scleral thinning, perforation, or limbal stem deficiency. Our case demonstrates how fast injury can occur.
Literature Search The authors searched PubMed and the Athens and University College London (UCL) Library database October 2013 through January 2014 using the following terms: button battery injury, mechanism of button battery injury, ocular
Journal of AAPOS
1. Gomes CC, Sakano E, Lucchezi MC, Porto PR. Button battery as a foreign body in nasal cavities: special aspects. Rhinology 1994;32:98-100. 2. Kavanagh KT, Litovitz T. Miniature battery foreign bodies in auditory and nasal cavities. JAMA 1986;255:1470-72. 3. Huppert J, Griffiths S, Breech L, Hillard P. Vaginal burn injury due to alkaline batteries. J Paediatr Adolesc Gynecol 2009;22:e133-6. 4. National Capital Poison Center. Nonfatal button battery ingestions with severe esophageal or airway injury: 125 cases. http://www. poison.org/battery/severecases. 5. Tanaka J, Yamashita M, Yamashita M, Kajigaya H. Esophageal electrochemical burns due to button type lithium batteries in dogs. Vet Hum Toxicol 1998;40:193-6. 6. Yoshikawa T, Asai S, Takekawa Y, Kida A. Experimental investigation of battery-induced esophageal burn injury in rabbits. Crit Care Med 1997;25:2039-44. 7. Mazer-Amirshahi M, Whitaker N, Kayewilson L, Litovitz T. Severe ocular injury after button battery exposure. J Emerg Med 2013;44:e187-9. 8. Ogasawara M, Goto S, Shiba T, et al. A case of button battery-induced corneal and conjunctive burn injury and experimental findings of local damage [in Japanese]. Nippon Ganka Gakkai zasshi 2011;115:711-17. 9. Ratnarajan G, Calladine D, Bird KJ, Watson SL. Delayed presentation of severe ocular injury from a button battery. BMJ Case Rep 2013. May 2, 2013.
Unusual retinal abnormalities in sisters with tetralogy of Fallot Mario T. Zanolli, MD,a Jenina Capasso, CGC, MS,a Vikas Khetan, MD,a Bego~ na Aristimu~ no, MD,c and Alex V. Levin, MD, MHSca,b Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease and can occur in the setting of chromosomal aberrations or multisystem malformation syndromes. We report unusual focal bilateral retinal defects in sisters with TOF.
Author affiliations: aOcular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; b Thomas Jefferson University, Philadelphia; c360 St. Charles Way, York, Pennsylvania Funded in part by the Foerderer Fund (AVL), the Robison D. Harley, MD Endowed Chair in Pediatric Ophthalmology and Ocular Genetics (AVL), the Joseph F. Bradway, Sr. Endowed Research Scholar Fund, and the Alcon Ocular Genetics Fellowship (MTZ). The funding organizations had no role in the design or conduct of this research. Submitted April 24, 2014. Revision accepted July 5, 2014. Published online October 24, 2014. Correspondence: Alex V. Levin, MD, MHSc, Chief, Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Suite 1210, 840 Walnut Street, Philadelphia, PA 191075109 (email: [email protected]). J AAPOS 2014;18:601-604. Copyright Ó 2014 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2014.07.163