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Mehu108 - U3 - T3 - Clinical Evaluation of Red Eyes in Pediatric Patients PDF
Mehu108 - U3 - T3 - Clinical Evaluation of Red Eyes in Pediatric Patients PDF
Mehu108 - U3 - T3 - Clinical Evaluation of Red Eyes in Pediatric Patients PDF
Viral Conjunctivitis
Definition
Viral conjunctival infection is most commonly caused
by adenovirus types 8, 19, and 37 (LaMattina &
Photo courtesy of Phuchong Choksamai. Thompson, 2014). Some common variants of the
q123rf.com. This figure appears in color online at classic viral conjunctivitis are pharyngoconjunctival
www.jpedhc.org. fever and acute hemorrhagic conjunctivitis.
Physical examination
Examine the inferior conjunctiva by pulling down
on the lower eyelid to evert it, which usually shows
a follicular conjunctival reaction (Figure 2)
External examination shows diffuse conjunctival
erythema (Figure 3)
An enlarged preauricular lymph node is almost al-
ways noted
Diagnostic tests
AWood’s lamp (i.e., a lamp emitting long-wave ul-
Photo courtesy of Phuchong Choksamai. traviolet light named for Robert W. Wood) or a
q123rf.com. This figure appears in color online at direct ophthalmoscope switched to its cobalt
www.jpedhc.org. blue light setting and fluorescein are used to eval-
uate for corneal abrasions
Pharyngoconjunctival fever presents with a triad of sore No cultures are needed in these cases
throat, fever, and conjunctivitis and is caused by adeno-
virus type 3 or 7 (LaMattina & Thompson, 2014). Acute
hemorrhagic conjunctivitis, although not common, is Treatment
significant for extensive subconjunctival hemorrhages Symptomatic care
in addition to conjunctival injection. These cases are ¤ Artificial tears as needed
commonly caused by Coxsackie virus A2 and entero- ¤ Cool compresses
virus 70 (Wong, Lai, Chi, & Lam, 2011). Zika virus, which Counsel patient and families on contagious nature
has recently emerged in the Western hemisphere, also of the disease
¤ Wash hands frequently and don’t share towels or
FIGURE 3. Viral conjunctivitis—diffuse pillows
conjunctival injection and tearing. ¤ Conjunctivitis can be contagious from 10 days to
3 weeks or as long as the eyes are red (Pinto et al.,
2014). It has been recommended that persons
who are infected stay home for 2 weeks to pre-
vent spread of the virus (Kaufman, 2011),
although this recommendation is often unrealis-
tic for working parents or patients in school. Sim-
ple precautions such as frequent hand washing
and avoiding direct contact with the eyes are
more realistic and will decrease the risk of trans-
mission. The viral load decreases exponentially
as healing occurs, and thus the infectivity will
drop significantly during the first 7 days.
¤ Antibiotics have shown no value in treating viral
conjunctivitis and should not be prescribed
Photo courtesy of Phuchong Choksamai. (Rose et al., 2005)
q123rf.com. This figure appears in color online at ¤ All contact lenses, solutions, cases, and eye
www.jpedhc.org. makeup should be discarded
Allergic Conjunctivitis
Definition
Simple allergic conjunctivitis is extremely common,
affecting 15% to 40% of the population (Bielory,
O’Brien, & Bielory, 2012). It is caused by an inflamma- Photo courtesy of Phuchong Choksamai.
tory reaction to allergens in the environment. q123rf.com. This figure appears in color online at
www.jpedhc.org.
History of present illness
Significant eye itching bilaterally
influenza. (See the subsequent ‘‘Ophthalmia Neonato-
Usually a seasonal component is present, and it is
rum’’ section as well, because conjunctivitis caused by
commonly seen in conjunction with allergic
Neisseria gonorrhoeae and Chlamydia trachomatis
rhinitis and/or asthma
also can occur in adolescents.)
Definition Definition
Bacterial conjunctivitis in the neonatal period is most Blepharitis, an inflammation of the eyelid margins
commonly caused by C. trachomatis or N. gonorrhoeae involving the eyelashes, is very common in the pediat-
and can cause significant morbidity and even mortality. ric patient population. Most patients are completely
asymptomatic, but blepharitis can cause significant
History of the present illness eye pain and even vision loss in some children. Ble-
Conjunctival redness, discharge, and eyelid edema pharitis is a type 3 hypersensitivity reaction to bacterial
in the first 14 days of life exotoxins, most commonly staphylococcal skin flora
N. gonorrhoeae classically presents in the first 3 to located at the lid margin.
4 days of life
C. trachomatis classically presents a little later than History of the present illness
N. gonorrhoeae, at around 1 week of life Chronic burning, itching, and tearing of the eyes
that is worse toward the end of the day; it is always
bilateral but can be asymmetric
Physical examination
Typical age of onset is between 6 and 10 years
Significant conjunctival erythema, edema, and
(Gupta, Dhawan, Beri, & D’souza, 2010; Teo,
discharge
Mehta, Htoon, & Tan, 2012)
C. trachomatis typically results in thin, ‘‘ropy’’
Recurrent chalazia or red, swollen areas of the eye-
white discharge, whereas N. gonorrhoeae results
lids also are common in these patients
in exuberant purulent white discharge
Physical examination
Diagnostic tests Crusting at the base of the eyelashes and erythema
Gram stain with culture or polymerase chain reaction of the eyelid margins with diffuse reactive conjunc-
for C. trachomatis and N. gonorrhoeae should be ob- tival erythema
tained from conjunctival discharge. An examination with a Wood’s lamp and fluores-
cein staining should be performed to evaluate for
Treatment corneal abrasions
Treatment for C. trachomatis includes administra-
In severe forms, corneal scarring and neovasculariza-
tion of oral or intravenous (IV) erythromycin and
tion can be seen as white areas on the otherwise trans-
use of erythromycin ophthalmic ointment four
lucent cornea. Although these lesions might be seen
times daily for 14 days, and an ophthalmology
without use of a Wood’s lamp, they become more
consultation should be obtained
apparent upon its use with fluorescein.
Treatment for N. gonorrhoeae infection requires
hospital admission, saline solution irrigation of Treatment
the eyes every hour until the discharge clears,
Wash the eyelashes daily with a mild baby
administration of ceftriaxone IV or intramuscu-
shampoo
larly, and an ophthalmology consultation
Apply warm compresses to the eyelids twice daily
(American Academy of Pediatrics, 2015)
or more often for associated chalazia
The mother and her sexual partner(s) also should
Apply topical erythromycin ointment to the eye-
be treated
lashes nightly as needed
The infection should be reported to the local
Provide a referral to ophthalmology if no improve-
health department ment occurs with conservative treatment or if
N. gonorrhoeae and C. trachomatis conjunctivitis
corneal scarring is noted
can also occur in adolescents and should be sus-
pected if severe or chronic discharge is present.
C. trachomatis conjunctivitis in the adolescent is Episcleritis and Scleritis
treated with oral doxycycline, azithromycin, or
erythromycin in addition to topical erythromycin Definition
ophthalmic ointment. N. gonorrhoeae conjuncti- Episcleritis is inflammation of the episclera (which lies
vitis in the adolescent is treated with intramuscular just posterior to the conjunctiva), and scleritis is
Physical examination
Persons with episcleritis will have localized or Photo courtesy of Phuchong Choksamai.
diffuse conjunctival erythema that is tender to q123rf.com. This figure appears in color online at
palpation (Figure 5); in contrast, simple conjuncti- www.jpedhc.org.
vitis is more ‘‘irritating’’ rather than ‘‘tender to
palpation’’ Physical examination
Scleritis is characterized by inflammation of the Diffuse conjunctival erythema that is most promi-
deeper eye structures and will have localized ery- nent near the cornea
thema, tenderness to palpation, and a bluish Direct and consensual photophobia (i.e., pain in the
discoloration underlying it affected eye when light is shown in the normal eye)
Most cases are unilateral, although uveitis can be
Treatment bilateral
Patients should be referred to ophthalmology for
treatment and management; artificial tears, steroid Diagnostic tests
eye drops, oral nonsteroidal anti-inflammatory If recurrent or severe disease is present, rule out in-
drugs (NSAIDs), and sometimes systemic immuno- fectious/inflammatory causes, including syphilis,
suppression are the treatments of choice sarcoidosis, Lyme disease, tuberculosis, and HLA-
Uveitis B27 seropositivity
Definition Treatment
Uveitis is an inflammatory disorder of the uveal tract If uveitis is suspected, the patient should be
that includes the iris, ciliary body, and choroid. It is clas- referred to an ophthalmologist for evaluation and
sified as anterior, intermediate, posterior, or pan uveitis treatment including topical steroids, cycloplegic
based on the portion of the eye that is involved. Anterior drops, and systemic immunomodulators
uveitis, also known as iritis, is the most common type
that should be considered when a pediatric patient pre-
sents with an acute red eye, and therefore we will focus EYE INJURIES
on that type or uveitis in this article. Uveitis occurs in Corneal Abrasion
11% to 13% of all patients with juvenile idiopathic
arthritis (JIA) and can cause significant ophthalmic Definition
morbidity (Tappeiner et al., 2015). It is more common A corneal abrasion is an epithelial defect on the surface
in patients with pauciarticular JIA and those who are of the cornea that is most commonly associated with
positive for antinuclear antibodies. The uveitis associ- trauma.
ated with JIA can be low grade and asymptomatic,
and thus these patients require frequent routine eye ex- History of the present illness
aminations by an ophthalmologist. Acute-onset, severe eye pain associated with blunt
trauma or rubbing of the eye
History of the present illness Pain worsens with blinking
Acute or subacute onset severe photophobia, eye
redness, and a ‘‘boring’’ type pain with blurry Physical examination
vision Diffuse mild conjunctival erythema, tearing
Physical examination
The foreign body usually can be seen easily on the
surface of the cornea or conjunctiva (Figure 7)
Evert the upper and lower eyelids to ensure that no
other foreign bodies are present
Photo courtesy of Casey Beal, MD. This figure
appears in color online at www.jpedhc.org.
Treatment
Pain improves with instillation of topical If a foreign body is seen, refer the patient to the
ophthalmic proparacaine drops in the clinic; these emergency department or urgently to an ophthal-
drops should never be provided to patients mologist
because they can lead to corneal melting if used
frequently
Subconjunctival Hemorrhage
Evert the upper and lower eyelids to evaluate for
foreign bodies
Definition
A subconjunctival hemorrhage is rupture of a small
Diagnostic tests conjunctival capillary with resultant bleeding into the
Use a Wood’s lamp and fluorescein staining of the subconjunctival space. Commonly, eye rubbing,
cornea to diagnose the abrasion and evaluate its cough, the Valsalva maneuver, or blunt trauma cause
extent (Figure 6) subconjunctival hemorrhages. These hemorrhages
can be very alarming to patients and their family
because of their size, color, and acute onset. However,
Treatment
they do not affect vision and do not cause any signifi-
Treatment entails use of a topical antibiotic drop or oint-
cant pain.
ment four times daily for 3 to 5 days; options include
polymyxin B/trimethoprim, ciprofloxacin, moxifloxa-
cin, erythromycin, or bacitracin ophthalmic drops or
FIGURE 7. A corneal foreign body.
ointment
Follow-up should be scheduled for 48 hours to
evaluate for improvement
Patching the eye is not recommended
Contact lenses should not be worn until the abra-
sion heals
If an underlying infection is associated with the
abrasion, the patient should be referred to ophthal-
mology
Definition
Corneal and conjunctival foreign bodies become
embedded in the conjunctival or corneal epithelium. Photo courtesy of Phuchong Choksamai.
Commonly seen foreign bodies include vegetative mat- q123rf.com. This figure appears in color online at
ter and metal shavings. www.jpedhc.org.
Physical examination
Blood, which may be seen in the anterior chamber
of the eye overlying the iris, is usually settled infe-
riorly because of the effect of gravity
Treatment
All patients with hyphemas should be referred ur-
gently to an ophthalmologist for further manage-
ment and care with steroid and cycloplegic
eyedrops. A main concern is the risk for recurrent
hemorrhage as the blood clot begins to dissolve.
Photo courtesy of Phuchong Choksamai. Recurrent hemorrhage is most likely in the first
q123rf.com. This figure appears in color online at 5 days after the injury, and thus patients should
www.jpedhc.org. be instructed to avoid any strenuous activity,
keep their head elevated, and avoid NSAIDs to
History of the present illness
reduce this risk.
A sudden onset localized area of subconjunctival
blood
Specifically inquire about trauma, coughing, or Ruptured Globe
eye rubbing
No photophobia, pain, or vision changes are pre- Definition
sent A ruptured globe is the result of any breach in the struc-
tural integrity of the eye, including corneal or scleral
full-thickness lacerations. A ruptured globe is the result
Physical examination
of direct trauma to the eye.
A localized area of subconjunctival blood
(Figure 8) that does not involve the cornea
History of the present illness
The speed, size, type, and shape of the projectile
Treatment determines the extent of the injury
No treatment is required, although patients may Other associated head or facial injuries
use artificial tears for any discomfort
If a child has recurrent or large subconjunctival
Physical examination
hemorrhages, a bleeding disorder (Khaja,
If a ruptured globe is suspected based on history, it
Pogrebniak, & Bolling, 2015) or nonaccidental
is important to avoid applying any pressure to the
trauma should be suspected
eye during the examination
Signs of a ruptured globe include an irregularly
Hyphema shaped pupil, a shallow anterior chamber or
exposed iris, or dark choroidal tissue showing
Definition through the white sclera
A hyphema is defined as red blood cells that are present Almost always, a significant decrease in visual acu-
in the anterior chamber of the eye just posterior to the ity is found
cornea. Most commonly, hyphemas are caused by
blunt trauma; however, rarely, a hyphema can present
spontaneously without a history of trauma, and this pre- Treatment
sentation raises concern for leukemia or juvenile xan- If a ruptured globe is suspected, a Fox shield
thogranuloma (Samara et al., 2015). (i.e., a metal eye shield named for Sidney Fox,
MD) should be taped across the eye to protect
History of the present illness it without applying any pressure to the eye; a Sty-
Inquire about a history of trauma and whether the rofoam cup also can be used if a Fox shield is not
patient has sickle cell disease available