Mom, There s Something Wrong With My Eye
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- Jocelin Neal
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1 Mom, There s Something Wrong With My Eye Veeral Shah MD, PHD Texas Children's Hospital Most Common Issues Seen by the Pediatrician Emergent Ocular Issues Seen by the Pediatrician 1
2 What does this baby have? A. Viral Conjunctivitis B. Chemical Conjunctivitis C. Allergic Conjunctivitis D. Bacterial Conjunctivitis E. All of the above Page 3 2
3 Viral Conjunctivitis/ Epidemic Keratoconjunctivitis in Children History: Sick contacts, recent cold URI, timing of conjunctivitis Symptoms: Red or Pink Eye Unilateral or Bilateral at presentation Discharge- typically clear; Matted eyelids Hemorrhages Causes: Adenovirus (DNA virus) EKC = Types 18,19, 37 Pharyngoconjunctival Fever = Types 3 and 7 Acute hemorrhagic = Types 11 and 21 Epidemic Keratoconjunctivitis Signs and course of the disease : Acute follicular reaction Preauricular lymphadenopathy Second week= subepithelial opacities (can last 2 years) Conjunctival membranes in severe cases Treatment Avoid hand contact with others, avoid eye rubbing Counsel patient about 7-10 days of being contagious Hygiene, cool compresses, artificial tears Ophth: Remove pseudomembranes if possible PLEASE NO VIGAMOX 4TH Fluoroquinolones NOT NECESSARY!!!!!!! NO STEROIDS!!! PREFERABLE Erythromycin or Polymyxin B ointment; Sulfacetamide 3
4 1/24/15 H/o of continuous discharge from the left eye since birth What does this boy have? A. Nasolacrimal duct obstruction B. Foreign body C. Trichiasis D. Glaucoma E. All of the above Page 7 Page 8 4
5 Nasolacrimal Duct Obstruction Congenital vs acquired 5% of newborns Symptoms by 1 month Non-patent at lower end of nasolacrimal duct system Spontaneous resolution in 65% by 6 months, 90% by 1 year Treatment: h"p:// Condi8ons- Services_575/Eye- Condi8ons- Services_150/Blocked- Tear- Duct- (Tearing)_725 Erythromycin ointment and nasolacrimal massage Ophthalmology probing and irrigation Epiphora in an Infant Congenital NLDO Congenital anomalies of outflow pathway Punctal atresia Canalicular atresia Blepharitis Conjunctivitis Keratitis Foreign body Congenital glaucoma!!! Page 10 5
6 Infantile Glaucoma Page 11 What Does this Baby Have? A. Herpes dermatitis B. Sebaceous gland carcinoma C. Preseptal cellulitis D. Chalazion Page 12 6
7 Chalazion/ Hordeolum in Children History: Recurrent history of blepharitis or rosacea Signs and Symptoms Visible or palpable well-defined subcutaneous nodule Discharge with anterior or posterior fistulization Hordeolum vs Chalazia Treatment Instruction: Warm compresses for minutes Drainage or discharge Bacitracin or Erythromycin oint Failure 4 weeks consider Surgical drainage of Chalzia 7
8 Chalzion Drainage Page 15 What Does this Baby Have? A. Exotropia B. Esotropia C. Pseudostrabismus D. 6th Cranial nerve Page 16 8
9 Pseudostrabimus Strabismus is the medical term for eye misalignment Pseudostrabismus refers to a false appearance of strabismus EXAM: Wide nasal bridge Pseudostrabismus does NOT require treatment and the appearance tends to improve with time As facial features mature, the widened nasal bridge tends to narrow 9
10 Exam Va sc 20/20 OD and 20/60 OS Pupils Normal Using prism measure alignment Left esotropia of 35 prism diopters Ocular motility normal Ant segment exam and dilated fundus exam: NORMAL CRet: OD: DS, OS: DS Page 20 10
11 Accommodative Esotropia Give full plus spectacles before operating Treat any amblyopia before operating Operate if there is residual esotropia once the child is wearing full + spectacles and the amblyopia has been treated 3 Main Types of Amblyopia Amblyopia occurs when one eye perceives a blurred view and the other eye perceives a normal view, but he brain favors the normal view and suppresses the eye with the blurred view Deprivation (cataract) Strabismus Refractive 11
12 1/24/15 Most Common Issues Seen by the Pediatrician Emergent Ocular Issues Seen by the Pediatrician 11 yo Girl With Acute Double Vision What Does this Girl Have? Ocular Motility Examination 12
13 Imaging Suprasellar Mass causing Pupil involving 3 rd nerve palsy Page 25 What Does this Boy Have? A. Exotropia B. Esotropia C. Pseudostrabismus D. 6th Cranial nerve E. Something else Page 26 13
14 What Does this Baby Have? A. Cataract B. Vitreous Hemorrhage C. Retinal detachment D. Retinoblastoma E. Retinopathy of Prematurity F. All of the above Page 28 14
15 Differential Diagnosis of Leukocoria White Pupil Retinoblastoma PHPV Cataract Retinopathy of Prematurity Toxocariasis Coloboma of Choroid Uveitis Coat s Disease Vitreous Hemorrhage Retinal Dysplasia Tumors Retinal Detachment Corneal Opacity Myelinated Nerve Fibers Retinal Astrocytic Hamartomas (Tuberous Sclerosis) Page 30 15
16 Urgent or Emergent? Page 31 Urgent or Emergent? 16
17 ER Management Do not apply pressure to the globe Protective shield (not patch) Consult ophthalmology Antiemetics prn Analgesics prn Tetanus immunization or booster prn Hyphema Blood in the anterior chamber of the eye Rebleeding (e.g., from manipulation of the eye during surgery) is associated with a significantly higher incidence of late complications. Page 34 17
18 Same eye rebleed 3-5 days later 18
19 The Weakest Link The canaliculus Almost any tearing injury will damage the lacrimal system Fingers, car doors, display hooks DOG BITES!! 19
20 20
21 1/24/15 21
22 Take Away Points Distinguish the types of conjunctivitis using history, exam, laterality, and symptoms. Avoid using unnecessary antibotics, NO Vigamox and NO steroids Identify the common causes of infant tearing and the pathophysiology of nasolacrimal duct obstruction. It s important to rule out congenital glaucoma Learn the pathophysiology of chalazion and hordeolum. It is important to review warm compresses instruction with the patient Identify pseudostrabismus vs. REAL strabismus Emergent reasons for an Ophthalmology consult are acute onset strabismus (cranial nerve palsies) or diplopia, ptosis, pupil changes, and leukocoria Pediatrician management of common ocular trauma Page 43 Every Pediatric New Patient Exam View the patient for 2 secs through a direct ophthalmoscope 2-3 feets back External exam Eyelid symmetric NO discharge NO eyelid lesions Eye size the same (R/O Congenital glaucoma) Pupils Symmetric and round Alignment Strabismus vs Pseudostrabismus (+) RED reflex No cataract and no leukocoria, or retinal detachment Page 44 22
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