Medical mystery: A mischievous toddler and a sharp object

The trouble began with a toddler running with a sharp object in her hands.

On a very busy Monday night in the emergency department  of the Children’s Hospital of Pittsburgh, things didn't slow down until nearly midnight. But just as the staff thought they'd catch their breath, in came a 19-month-old girl , with a badly swollen upper left eyelid.

JJ's mother brought her to the "FastTrack," an area for children with relatively minor problems, such as  simple fractures, earaches, viruses, fevers that aren't extremely high, and most eye problems. 

The mother said she had found her little girl running around the house holding a pen that she had found in her older sister’s school bag. Rather than surrender the pen as her mother asked, JJ ran away and tripped, and the point of the pen went into her left eye.

She cried a bit, but then got up and seemed fine -- at first.  Then, a few minutes later, the left upper lid began to swell.  The lid was not red or tender but it kept getting bigger, so mom took her to the hospital. 

On physical examination, doctors observed two things in this otherwise healthy little girl: The left upper lid was five or six times normal size and on the inside of the upper lid, near the nose, there was a small hole with a little bleeding around it.

The eye was full of clear liquid but that wasn't surprising, given that JJ was crying. The eyeball itself seem uninjured. The swollen eyelid’s consistency was loose, like a half-filled water balloon, not firm  and tender as it would have been if there were internal bleeding.

A pediatric eye surgeon was called in from home,  and after confirming the physical exam findings, and that there was no damage to the eyeball, asked that a CT scan of the eyes be done. Why was only the left upper lid swollen, the surgeon wondered. If the eye was irritated, usually both lids would swell up. 


The CT-scan answered the question.  When JJ fell, the pen jab produced a small fracture of the top of the left orbit (the bone around the eyeball), and central nervous system fluid  was leaking into the upper lid. Such a leak is very dangerous, as it can let germs into the brain space, leading to meningitis and death. 

She was admitted to the intensive-care unit for observation and antibiotic treatment to prevent brain infection. Luckily, the hole was only 4 mm (1/8 inch) across and it sealed itself shut over 36 hours, stopping the leak.  JJ was sent home on another week of antibiotics.  

It could have been a lot worse; though the tip of the pen did not even scratch the eyeball, it penetrated the eyelid very close to the brain, fractured the inside of the skull, and yet, caused no permanent damage.

Three conclusions:
1. JJ is a very lucky little girl.
2. Though it was a busy night, and JJ seemed very healthy, the emergency department staff paid attention to the fact that the findings did not really make sense and figured out what was causing the lid swelling before anything more serious could happen.
3. Maybe the old expression should be updated to "Never run with scissors -- or pens."

Gary A. Emmett, M.D., is a professor of Pediatrics at the Sidney Kimmel Medical College of Thomas Jefferson University