Anterior Segment Disease in Infants and Young Children. 7 Case Reports Thursday 11/8/ AM

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1 Anterior Segment Disease in Infants and Young Children. 7 Case Reports Thursday 11/8/ AM John JT Tassinari OD FCOVD jtassinari@westernu.edu Assoc prof. Western Univ Health Sciences College of Optometry Diplomate Binocular Vision, Perception, and Pediatric Optometry Section, Amer Acad Optom No Disclosures

2 Pediatric Considerations 1. AVERSION: young children resist testing and treatment. Strategies to counteract aversion presented in case reports 2. AGE Dependent: known safety and efficacy. Very few ophthalmic drugs have clear cut contraindication 3. WEIGHT DEPENDENT for orals: formulae result in safe upper limit of drug that can be consumed in a day 4. POTENCY: drugs more potent in children versus adults 2

3 Example of AGE consideration 8.4 Pediatric Use The safety and effectiveness of Besivance in infants below one year of age have not been established Unknown if safe effective if younger than 1 year.

4 Topical Antibiotics Erythromycin ointment age 0 / 2 mos Polytrim drops > 2 months Polysporin ointment not established Tobramycin > 2 months Moxeza > 4 mos Gentamicin not established Besivance Ciloxan Vigamox Zymar > 1 year Azasite drops > 1 year Zirgan gel > 2 years Blue means drug mentioned in lecture

5 Topical Steroids Fluoromethalone alcohol.1% (FML) > 2 years Tobradex > 2 years Lotemax, Alrex, Vexol, Prednisolones NOT Established Pred with sulfa (blephamide etc.) > 6 years Zylet > 1 year

6 Allergy Drops; > 3 years Patanol & Pataday All sting upon insertion Lastacaft & Bepreve Approved for > 2years Optivar Zaditor / Alaway Elestat

7 1. Aversion 2. Age dependent Pediatric Considerations (cont.) 3. Oral meds: Weight dependent Augmentin Oral tablets BID Upper consumption limit in 1 day 45mg of the drug per 1 kg of child s weight 4. Potency 7

8 Aversion Age dependent Weight dependent Pediatric Considerations (cont.) incomplete instillation still works single therapy, not multiple Potency weak drugs effective (P-FAT flush) 8

9 1. AG, 9 y.o. Girl. Sore temporal canthus and red OD Cc: Sore right here x 4 days. Unchanging Onset event: nothing Scant lacrimation & AM crusting. No itch no photophobia K, L Margins & Lashes normal Conj: inflammation inferior temporal conj + tarsal swelling and follicles Pupils, V.A.s etc normal OS Normal

10 AG, 9 y.o. girl Dx: Non-specific Conjunctivitis OD w follicular hyperplasia DDx: Allergic? No itch, not bilateral, no papillae Bacterial? No papillae, discharge bacterial Viral? Toxic? Maybe. Not OU. Inflamm localized. Discharge < viral PA Node normal Probably. But why no toxic event? Why not self correct?

11 AG, Low Grade non-specific, probably Toxic Conjunctivitis OD Tx: Flush OD with Preservative Free Artificial Tears (PFAT) 5x Day for 3 Days. Topical steroid = alternate Tx if PFAT failed Outcome: Afternoon of Day 3: It s not sore since, like, yesterday after school Clinical signs resolved

12 PFAT F. Preservative Free Artificial Tears Flush F = FLUSH Painless Safe Versatile Inexpensive Mild Allergy Mild Viral TOXIC 12

13 2. JH, 6 weeks Recalcitrant NEONATAL CONJUNCTIVITIS Irritated RE Onset: Day 1 Today: way worse 1. Erythro ung TID 2. Gentamicin drops TID Macrolide, non-toxic, routine prophylaxis. Gram neg: poor Gram +: Good, not great +mucous +mattering all day Denies serous discharge + Lid swelling and inflammation Aminoglycoside. Broad spectrum. Rxd by OBGYN

14 Neonate w/ Infectious Conjunctivitis age: 1 4 weeks Acquired during vaginal birth neonatal Acquired post-natal Ordinary survived prophylactic (G-) G- or G+ SERIOUS from mom s STD nosocomial resistant need hospitalization, oral ABs swab and culture Neonatal Conjunctivitis = Ophthalmia Neonatorium

15 ORDINARY BACTERIAL Mild-moderate Mucous. Trace / no conj inflammation SERIOUS From mom s STD Unresponsive to Polytrim SERIOUS Nosocomial Resistant Bacterial Cured by Polytrim. Unresponsive to Polytrim Hospital stay > 2 days Not necessarily virulent Moxifloxacin option?

16 ORDINARY BACTERIAL Mild-moderate Mucous. Trace / no conj inflammation Cured by Polytrim. SERIOUS From mom s STD N. Gonorrhoeae copious discharge, rapid onset Herpes Simplex Virus 1 or 2 delayed onset: 5 14 days serous discharge + K dendrites Follicles Chlamydia Delayed onset. Incubation: 5 14 days Serous mucopurulent Red tarsal conj, no follicles. Uni or Bilat. Lid edema Psuedomembr possible SERIOUS Nosocomial Resistant Bacterial, Polytrim fails Hospital stay > 2 days Not necessarily virulent

17 Neonate w/ Conjunctivitis in your Office Onset: Age 9 days Presents: day 12 Onset day 1, presents day 12 Serous discharge Mucopurulent H Simplex ordinary mid-stage chlamydial Hospital > 2 days? Suggests nosocomial resistant Responds to Polytrim drops Unresponsive to Polytrim drops. Refer Unresponsive to Polytrim. Refer for bacterial cultures. Rx moxifloxacin?

18 JH, 6 weeks Recalcitrant Conjunctivitis Red RE Onset: day 1 Today: way worse Erythro ung TID Gentamicin drops TID +mucous +mattering Onset suggests true neonatal conjunctivitis not acquired later + Eyelid possible chlamydia No serous discharge not H Simplex Left hospital on day 2 less likely it is nosocomial Recalcitrant / duration / onset suggests resistant organism

19 JH, 6 weeks Recalcitrant Conjunctivitis. DDx 1. Ordinary Resistant Bacterial Conjunctivitis Gram + Doubtful, Erythro ung or Gent should have cured ordinary gram + Gram - Maybe. Erythro ineffective on G and Gent has G- resistance, esp E Coli 2. Toxic conjunctivitis due to gentamicin Maybe 3. Chlamydia or nosocomial resistant Maybe (uh oh)

20 JH, 6 weeks Recalcitrant Conjitis Tx: 1. D/C Gentamicin 2. Cont Erythro ung 3. Add Polytrim drops 4. Add Ocusoft pads Outcome: cure by day 4 Polymixin B Gram Trimethoprim Gram +

21 Case 3. KS, 2;0 Apprehensive + Chalazion LUL x 3 mos Pre-chalazion, it was a red tender bump. Tx: polytrim drops + warm compress. Rxd by Pediatrician Outcome of the treatment of the red tender bump that was present 3 months ago: Drops difficult to instill Unable to keep wash cloth on her eyelid. Red tender bump (Hordeolum) converted to chalazion Use ung, not drops!

22 KS, age 2;0. Exit exam room cooperation improved Chief complaint: Red bump Right Lower Lid. Onset yesterday No discharge Rubs eye sometimes No AM mattering + localized pain w palpation N lacrimal sac normal Bulbar conj & K normal No Strab Retinoscopy: wnl Healthy (no fever or otitis media)

23 Case 3. KS, apprehensive 2 yo A: 1. Internal hordeolum of RLL 2. + chalazia LUL, h/o previous Hordeolum 3. Denies penicillin allergy P: Oral antibiotic (Augmentin) & Ilotycin ointment 5x day until next appointment

24 Pediatric Oral Antibiotics, Brief Review Augmentin & Erythromycin. Augmentin is JTs first choice Penicillin allergy, use Erythromycin Both drugs: oral suspension or chewable tablets. w/ food ok (helpful) Weight dictates upper limit of drug / day Formulae less severe infection (internal H) or more severe infection (preseptal cellulitis ) BID dosing or TID dosing

25 FORMULAS FOR AUGMENTIN Infection Dosed More Severe Less Severe Formula q12h X 45 mg/kg/day q12h X 25mg/kg/day q8h X 40mg/kg/day q8h X 20mg/kg/day

26 Pediatric Dosing. Augmentin Oral Infection = More Severe. BID dosing 45mg drug / child kg / day = upper limit Ex. 30 pound child 30 pounds = 13.6kg 13.6 x 45 = 612 Upper limit is 612mg / day. 250mg BID safe 400mg BID unsafe

27 Weight Augmentin Dosing Table, Abbreviated Diagnosis: Internal Hordeolum. Diagnosis: Pre-septal cellulitis Duration of therapy: 7 days Duration of therapy: 10 days Pounds 250mg chewable tabs 2x day 250mg chewable tablets 3x day Pounds 125mg/5ml oral suspension 2x day 250mg/5ml oral suspension 2x day Pounds 125mg/5ml 2 oral suspension 2x day 2.5ml per dose, 125mg total per day 88 pounds and above 500mg tabs every 12 hours 875mg tabs every 12 hours 125mg/5ml oral suspension 2x day

28 Weight (pounds) Erythromycin Dosing Table Internal Hordeolum. Duration of therapy: 7 days Pre-septal cellulitis Duration of therapy: 10 days >45 200mg 3x day 400mg 3x day mg 2x day 400mg 2x day mg 2 (2.5ml) 2x day 200mg 2x day Erythromycin suspension: 200mg/5ml or 400mg/5ml Erythromycin chewable: 200mg only

29 Case 4. Age 7 years. Saturday morning exam Swollen, tender, warm right upper and lower eyelids Onset: yesterday afternoon ( quick onset suggests bacterial). Worse now Denies penicillin allergy No pain behind eye, no pain with eye movement, no fever, no coincident ear or sinus infection (rules out orbital cellulitis) Weight: 55 pounds Diagnosis: Pre-septal cellulitis of RUL and RLL Tx: Oral Augmentin chewable tablets (see chart) 250mg 3x day Outcome: Healed by Tues afternoon (7 tablets total)

30 Augmentin Dosing Table, Abbreviated Weight Diagnosis: Internal Hordeolum. Duration of therapy: 7 days Diagnosis: Pre-septal cellulitis Duration of therapy: 10 days Pounds 250mg chewable tabs 2x day 55 lbs 250mg chewable tablets 3x day Pounds 125mg/5ml oral suspension 2x day 250mg/5ml suspension 2x day Pounds 88 pounds and above 125mg/5ml oral suspension 2x day 500mg tabs every 12 hours 125mg/5ml oral suspension 2x day or 875mg tabs every 12 hours

31 Case 3. KS apprehensive (cont.) Weight = 18 ½ pounds Dx: Internal hordeolum of RLL Per formula, 204mg/day = upper limit. Tx: Augmentin Oral Susp. 2.5ml of 125mg/5ml 2 x day (125mg per day total) + Ilotycin (erythromycin) ung 5x day until next appt Note: the mg per day of Augmentin is well under upper limit Outcome: healed on day 4 with Ilotycin ung only

32 Augmentin Dosing Table, Abbreviated Weight Diagnosis: Internal Hordeolum. Duration of therapy: 7 days Diagnosis: Pre-septal cellulitis Duration of therapy: 10 days Pounds 250mg chewable tabs 2x day 250mg chewable tablets 3x day Pounds Pounds 88 pounds and above 125mg/5ml oral suspension 2x day 125mg/5ml 2 oral suspension 2x day 500mg tabs every 12 hours 250mg/5ml oral suspension 2x day 125mg/5ml oral suspension 2x day 875mg tabs every 12 hours

33 No sting QHS ready Lubricate Ease of application Visibility of success Topical Antibiotic Ointments Brief Review Increased contact time Less systemic absorption Rub on eyelid margin option Treats lid margins Preservative Free

34 Written AB Ung Rx. 5x5 ILOTYCIN or POLYCIN erythromycin 3.5g Generic OK Bacitracin + polymixin B 1 refill 1/2 inch ribbon inside lower eyelid 4 x day + bedtime for 5 days Nap

35 Ped Topical Antibiotic Formulary, Ointment (usually) Bacterial Conjunctivitis Lid Disease and/or not virulent No Lid Disease Erythromycin ung 5 x 5 Pliable child, ordinary conjunctivitis Fighter / Crying or Virulent Besifloxacin suspension (Besivance) > age 1 y. $$$$ Polytrim Drops Polysporin Ung 5 x 5

36 Polysporin Ophthalmic Ointment Pediatric not established Polytrim drops Polysporin ung G- Polymixin B Polymixin B G+ Trimethoprim Bacitracin Potency Less More

37 5. DH, age 2;0. Very Active Cc: frequent eye rubbing, each eye x 4 mos Patanol Drops: difficult to instill + no relief PMH: Rhinitis / allergies. Children s Claritin (loratadine 5mg syrup) Exam, each eye: obvious allergic shiner + lacrimation. B Conj: wet & red with gross inspection Inf T Conj: thick & dark red Allergic shiner Swelling and discoloration from congestion of small BVs in skin of eyelid

38 DH, age 2;0 Dx: Marked longstanding bilateral seasonal allergic conjunctivitis Plan: FML suspension 5ml 5x day for 1 week. 1 refill Instillation method?

39 FML Fluoromethalone alcohol 0.1% Low potency Approved for age 2 years and older Suspension (shake) or ointment Why not ointment for DH? Good for marked pediatric allergic conjunctivitis

40 FML Suspension Instillation Strategy Ordinary?.. No DH age 2;0 4 Days Later. Eye rubbing ceased. Eyes quiet P: 1 more day then d/c Head Back, eyes closed, corner eye? No meyes Closed- Finger-Dab on eyelashes Immediate distraction after instillation

41 Pediatric BLEPHARITIS

42 Asymptomatic or simple debris accumulation w/o inflammation. Baby Shampoo home remedy works fine Blepharitis + chronic dermatologic conditions (Eczema) or dandruff: Rx a product specifically made for blepharitis

43 Case 6. CG 8yo Girl. Incessant blinking x 3 weeks Getting worse +eczema: epidermis wrists: red rash + itch forehead dry flaky epidermis Lashes: NORMAL Lid margins: minor telangiectasia Bulbar conj: vasodilation + wet/shiny Corneae normal Case Hx somewhat suggestive of nervous tic as the cause of her blinking Dx: Posterior Blepharitis coincident with eczema Conjunctiva is more inflamed than lid Tx: Ocusoft lid scrubs 2xday until next appointment Successful outcome

44 Case 7. CR, 8 mos old Bilateral nearly constant lacrimation. Wants to know if more can be done. can you do surgery? Onset first week of life Needed topical antibiotics once Pediatrician Rxd rubbing the tear ducts no benefit with once or twice per day application (were rubbing up and down)

45 Congenital Nasolacrimal Duct Obstruction N L D O Common (20%) Onset: first month of life Presents as epiphora. Uni or Bi lateral Etiology: Valve of Hasner fails to open..

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47 Congenital N L D O (cont) Common (20%) Onset: first month of life Presents as epiphora. If accompanied by mucopurulent discharge, Rx er Etiology: Valve of Hasner fails to open 96% spontaneously resolve by age 1 DDX: dacryocystitits pus upon palpation, redness, swelling Treatment: 1. If accompanied by mucopurulent discharge, Rx Ilotycin ung 5 x 5 2. Digital massage

48 Digital Massage for NLDO Method: Index finger between puncta and inner canthus on the skin Exert downward pressure toward the valve of Hasner 10 strokes 4 x day If not resolved by age 12 months, refer for consideration of probing

49 CR, age 8 months. Additional Hx and Exam Data Visually guided reaching and activity on floor muted My observ: visual regard during exam sluggish No Strabismus Dry Ret Near Ret Cycloplegic Ret High Lag, aniso confirmed Hyperopic crescent visible in photo after mydriasis

50 CR, age 8 mos. A & P Persistent bilateral under-treated NLDO Marked Hyperopia & astigmatism 1.00D anisometropia Delayed motor and visual motor per case Hx and observation Risk for Esotropia and amblyopia Risk for further developmental delays P: Digital massage Visual Stimulation Home activities. RTC 2 mos Follow-Up Age 11 mos Epiphora gone after a few days Refractive Status unchanged. SRx prescribed

51 Thank You.

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