DISCLOSURES Consultant/Speakers bureaus Research funding PEDIATRIC RED EYES Rachel M. Smith, OD, FCOVD Pediatric Optometrist Children s Hospital & Medical Center Stock ownership/corporate boards employment Off-label uses WHY RED EYES? Red eyes are COMMON Most common ocular sign encountered in outpatient and emergency settings Is it conjunctivitis, or something more serious? Many causes, many treatments When do I need to refer?? Key red flags to know HISTORY, HISTORY, HISTORY Things to know: Duration Nature of symptoms: One eye or both? Any photophobia? Any discharge from the eye? What COLOR How much? Constant or intermittent? Any changes to vision? Any history of trauma to the eye or chemical exposure? Any previous episodes? Presence of other symptoms? Recent URI? Joint pain? Does the patient wear contact lenses? EXAMINE THE EYE Things to look for: Visual acuity is it normal? Pattern of injection diffuse or just surrounding iris? Discharge color? Pupils equal? Round? Reactive? Swelling of eyelids or conjunctiva? Cornea: is it clear? RED FLAGS TO REFER Reduced Visual Acuity Significant eye pain Suspect chemical burn irrigate until ph neutral, then refer Suspect foreign body or penetrating injury Significant redness in one eye when it just doesn t feel right 1
BACTERIAL CONJUNCTIVITIS Usually younger population (1-5yo) May be associated with ear infection Eyes often mattered shut in am Can be associated with NLDO Key findings: Diffuse redness to conjunctiva Discharge: mucopurulent yellow-green Common Causes: H. Flu Strep Staph. Aureus Staph. Epidermidis Moraxella catarrhalis BACTERIAL CONJUNCTIVITIS Treatment: Topical antibiotics broad spectrum 4th generation Fluoroquinolones: Moxeza Q12h x 1 week (FDA approved >4mo age) Vigamox Q8h x 1 week Treat OU HYGIENE to prevent spread When to refer:.it may not be bacterial VIRAL CONJUNCTIVITIS Usually older kids Often have pharyngitis Watery eyes Key findings: Lymphadenopathy Diffuse redness to conjunctiva Bilateral Discharge: clear or white Light sensitivity and mild pain VIRAL CONJUNCTIVITIS COMMON CAUSES Adenoviral = Subepithelial Infiltrates Herpetic = Dendrites & Vesicles Molluscum Contagiosum = pox virus VIRAL CONJUNCTIVITIS Treatment: TIME NO antibiotics Treat underlying viral cause if able HSV: oral acyclovir + topicals antivirals when indicated ALLERGIC CONJUNCTIVITIS ITCHING! Key Findings: Clear mucous discharge Chemosis boggy eye Eyelid swelling 2
ALLERGIC CONJUNCTIVITIS COMMON CAUSES ALLERGIC CONJUNCTIVITIS TREATMENT Seasonal - IgE Household dust Pollen Mold Animal Dander Chemicals/Scents Detergents recent change? Remove allergen when possible Systemic antihistamines Topical antihistamine + mast cell stabilizer Pataday QD OU Cool compresses Pre-septal Normal Vision Lid edema resolves with treatment Normal eye alignment Normal pupils Mild discomfort No proptosis Normal eye motility Rare fever Orbital Decreased Vision Lid edema does not resolve with treatment May have strabismus Irregular or fixed pupil (+APD) Increased pain even with treatment Proptosis Restricted eye motility Fever Pre-septal treatment: Oral antibiotics: Augmentin 20-40 mg/kg/day x 10 days Amoxicillin Bactrim Should improve within 24-48 hrs ORBITAL TREATMENT 1. Admit with CT 2. ID the causative agent 3. Broad Spectrum IV AB 4. Topical AB (after culture) 5. Eye & ENT consult 6. Surgical Drainage 3
CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION Cause: Failure of nasolacrimal duct to open DDx: congenital glaucoma History & Findings Chronic watering Unilateral or bilateral Recurrent infections Mattering of lashes Massage nasal canthus Topical antibiotics Erythromycin ointment BID Probing with irrigation if persistent >1yr CORNEAL ABRASION Trauma/foreign body Pain Foreign body sensation Light sensitivity Tearing Epithelial defect Stains with fluorescein Conjunctival injection Normal or decreased vision FOREIGN BODY Evert lid Removal of foreign body Antibiotic: Ointment: Erythromycin, Bacitracin qid Drops: Moxifloxacin qid NSAIDs for pain Cyclopentolate 1% (reduces photophobia) Bandage lens Follow carefully OCULAR TRAUMA RUPTURED GLOBE ORBITAL TRAUMA ORBITAL BLOW-OUT CHEMICAL BURNS Treat IMMEDIATELY IRRIGATE, IRRIGATE, IRRIGATE 30 entire minutes *use saline or water* Goal = neutralize eye ph What is the agent? Acid vs. base Prior irrigation? How soon and how long? 4
CHEMICAL BURNS Acid vs. base Acidic: Eye is red Normal to reduced vision Epithelial defects Alkali: Much worse prognosis that acidic Penetrate lipid membranes White and quiet eye IRRIGATE, IRRIGATE, IRRIGATE Lubrication: preservative free tears q1h Antibiotic broad spectrum Moxifloxacin qid Erythromycin ointment Cycloplegic PEDIATRIC UVEITIS Commonly have systemic cause JIA = most common association Wegener s, SLE, Inflammatory bowel disease, Behcet s Asymptomatic May not be detected until severe Iritis = picked up on slit-lamp exam Bilateral in 70% Eye = usually white PEDIATRIC UVEITIS JIA OCULAR MONITORING Underlying cause Topical steroids Complications with long term treatment JIA Subtype Pauciarticular ANA (+) ANA (-) Polyarticular ANA (+) ANA (-) Every 3 4 Every 3 4 Age of Onset < 7 Years > 7 Years Systemic Every 12 Every 12 THANK YOU! rachsmith@childrensomaha.org SOURCES Beal, Casey and Giordano, Beverly. Clinical Evaluation of Red Eyes in Pediatric Patients https://www.sciencedirect.com/science/article/abs/pii/s089152451600063 8 March 1, 2019 Bhat, Pooja and Goldstein, Debra. Pediatric Anterior Uveitis https://www.aao.org/disease-review/pediatric-anterior-uveitis March 1, 2019 Ehlers et. al. The Wills Eye Manual 5 th Edition. Philadelphia: Lippincott Williams and Wilkins, 2008 Friedman et. al. The Massachusetts Eye and Ear Infirmary 3 rd Edition. Saunders Elsevier, 2009 Kanski and Bowling Clinical Ophthalmology A Systematic Approach 7 th Edition. Philadelphia: Elsevier Saunders, 2011 Seth, Divya. Causes and Management of Red Eye in Pediatric Ophthalmology https://www.researchgate.net/publication/50851980_causes_and_manage ment_of_red_eye_in_pediatric_ophthalmology March 1, 2019. 5