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PEDIATRIC Summary of a Round Table

By James E. Miller, M.D. Department of Ophthalmology, School of Medicine, Washington University

T HE ROUND TABLE covered two principal The lacnimal glands in the upper part topics : first, external diseases of the of the lid are seldom involved in an inflam- eye, especially in relation to infection and matory process, except occasionally in to lid and conjunctival lesions; and, second, mumps or sarcoid. growth and development of the eye with Herpes simplex of the lid, consisting of stress upon eye movements, refractive er- a vesicle which crusts and then heals, is rors, and . often seen with concomitant mouth lesions. External diseases of the eye are often Involvement of the conjunctivae is also primary, but pathology in this area fre- seen. quently is found to reflect systemic illness. Herpes zoster may affect the lid when it involves the first division of the tnigeminal LID nerve. Intraocular involvement usually fol- Various glands of the lid were defined lows skin manifestations on the tip of the and the pathology of each reviewed. In the nose. Topical use of adrenal steroids is fibrous tarsal portion of the lid lies the sometimes employed in the treatment of Meibomian gland, the sebaceous secretion herpes zoster. Varicella is closely related of which prevents the spillage of tears and or may be due to the same virus as herpes protects the lid margin. The acute inflam- zoster; it also produces vesicles on the con- rnation is usually staphylococcal, and tends junctivae, but these usually resolve them- to persist to produce a granuloma sur- selves without any sequelae. rounded by fibrous tissue. A chronic cha- Chronic marginal blephanitis is of two lazion consists of round, epithelial and giant types. The first is that accompanied by cells without acid-fast organisms. Heat may seborrheic dermatitis and manifested by be useful initially in the acute stage; how- flakes of dandruff-like material on the lid ever resolution is slow and usually termi- margin. In addition, there is a secondary- nates in a hard, persistent nodule. The re- infection type usually due to staphylo- moval of the chronic is by curet- coccus, and with this marginal ulcers ap- tage. pear. The squamous blephanitis responds to The glands of Zeiss are the sebaceous local selenium-sulfide preparations, whereas glands for the lash follicles. By contrast, antibiotics are useful in ulcerative ble- infection of these results in a self-limited phanitis. disease, hordeolum or , which drains itself spontaneously or may require local CONJ UNCTIVA incision. Rarely are there complications fol- Acute purulent is less fre- lowing a hondeolum. Some individuals are quent in present times than formerly, and more susceptible to repeated infections, and this is probably due to antibiotics. Gono- prevention remains an unsolved problem. coccal conjunctivitis is extremely rare and The sweat glands of the lid, or glands of usually appears as a fulminating ocular or Moll, may form simple cysts on the lid orbital reaction starting on the second on margins which rupture easily. third day of life. Often the appearance is

Presented at the Annual Meeting of the American Academy of Pediatrics, October 21, 1958. Report prepared by Dr. Marguerite Gates. ADDRESS: 640 S. Kingshighway Boulevard, St. Louis, Missouri. PEDIATRICS, April 1959 791

Downloaded from www.aappublications.org/news by guest on September 27, 2021 792 ROUND TABLE in one eye, with rapid spreading to the op- coagulum; it also has a direct effect on the posite side. A copious purulent yellow dis- organism, but perhaps the coagulum is charge is characteristic, and gangrene of just as important. the lids may supervene as the disease pro- Returning then to conjunctivitis, the ceeds. speaker described the chronic state as being Other organisms which produce acute most obvious in the early morning when the conjunctivitis are meningococci and staphy- lids are adherent with accumulated dis- lococci. These two organisms are usually change and the is moderately found in older children. red. This condition rarely persists, and gen- Acute catannhal conjunctivitis may be erally accompanies chronic blephanitis. secondary to Koch-Weeks bacillus (pink Follicular conjunctivitis was subdivided eye), staphylococcus, pneurnococcus, or into an inclusion type and the adenovirus Hemophilus influenzae. The discharge is typ e. Inclusion conjunctivitis of the new- usually mucopurulent. The pneumococcal born occurs about the fifth day and is type often presents with petechial con- characterized by a purulent discharge with junctival hemorrhages. Smear of the dis- numerous monocytes containing inclusion charge and culture confirm the diagnosis. bodies. In addition to the characteristic dis- DR. DIXON (WoositR, Omo) : Are there charge, there may also be enlargement of other causes of chronic ? the pre-auricular lymph nodes. It is ye- ANSWER: Vitamin A deficiency is a rare nereal in origin. Topical suiphonarnide cause. preparations seem effective. In olden chil- DR. DixoN: What about refractive errors? dren inclusion conjunctivitis is of the ANSWER: The speaker is not convinced “swimming pool” type and is found more that any external is caused by commonly in users of private pools than refractive errors. public pools. The difference is probably due Voici: Should chalazion be surgically to the higher concentration of chemicals in treated? public pools. ANSWER: In the acute state hot packs Epidemic is caused may be applied and antibiotics that are by an adenovirus and is characterized by effective against staphylococcus may also follicles in the conjunctival cul-de-sac and be used at this time. If an unsightly residual preauricular adenopathy. In addition there remains, then surgical excision may be are corneal infiltrates which may lead to necessary. Younger children are usually conneal scarring. There is no proven form treated medically for longer periods due of therapy and an astringent such as zinc to the problems of anesthesia. sulfate was recommended. Voice: How important is it to identify of three types was the organism? discussed. Vernal conjunctivitis, occurring ANSWER: Very important, especially if in spring, summer or fall, forms a pseudo- antibiotics are to be used. membrane over the conjunctival surface. DR. DIXON: What prophylaxis against Smear reveals lymphocytes and eosinophils. gonococci are you using in St. Louis? The incidence of phlyctenular conjunctivitis ANSWER: Silver nitrate solution or ap- is decreasing because of our higher eco- propniate antibiotics. nomic status. In the past, treatment con- DR. Gnis (Vlcroiii*, B.C.) : How sisted of hospitalization with increased long do you leave silver nitrate solution in caloric intake. The involvement of the cor- the eyes? nea may proceed to degeneration and ANSWER: In vitro it is effective in a few ulceration. Recurrence is frequent, so long seconds. If left in for 15 to 30 seconds in duration of therapy was emphasized. In vivo, silver nitrate is effective in two ways: contact conjunctivitis of the allergic type, It coagulates the protein and produces a antigen is introduced into the eye by the

Downloaded from www.aappublications.org/news by guest on September 27, 2021 AMERICAN ACADEMY OF PEDIATRICS - PROCEEDINGS 793 finger, causing redness and intense itching. the first one; the rest run down the side of This is rare in children. Topical adrenal the face. Ointments are better localized steroids and antihistaminics are useful in in the eye. When asked for hints regarding these allergies. technique of getting medication into the Discussion of diagnostic procedures and eye, Dr. Miller commented that ointments management followed. Dr. Miller empha- were easier to use and could be applied to sized the importance of swabbing the dis- the everted exposed conjunctiva of the charge, making a smear directly from swab lower lid, that brute force by the parent to slide, rather than smearing with pres- was sometimes necessary to instill it into sure from another slide as in preparing the cul-de-sac, and that cold drops just out blood smears. A wet-swab technique seems of the refrigerator were exceedingly uncom- preferable to dry. In managing conjunctiv- fortable. If one can start from a point close itis, one must remember that it is usually a to the eye, the aim is better. Parenthetically, self-limiting disease; the organisms are only he added that his secretary had removed in the superficial conjunctival layers, so such problems from his own practice for that when slough occurs, most of the organ- she has a “woman’s touch” which manages isms go with it. Most types can be identi- to instill the medication in the proper place. fled by smear alone. A smear containing The advantages of conservative therapy eosinophils suggests allergic conjunctivitis, were stressed again. The use of topical an- whereas polymorphonuclear leukocytes sug- tibiotics and their relation to development gest bacterial infection, and monocytes indi- of sensitivity were emphasized. Dr. Miller cate viral etiology. Pneumococcal conjunc- urged the use of topical antibiotics that are tivitis may require culture for verification. not given systemically, such as bacitracin. Sensitivity studies are desirable before anti- He pointed out that once antibiotic therapy biotic treatment is undertak#{128}n. Most get is begun, it must be continued beyond the along well without antibiotic therapy. first few days. One must bear in mind that the usual Prevention of contact infection in fami- untreated case is well by the fifth day. lies was recommended by avoiding spread Since most cases do not appear in the office through hand towels, etc., that are used until the second day of illness, antibiotic around the eye. In upper respiratory infec- therapy may shorten duration by only a tions a catarrhal conjunctivitis may develop single day. A simpler measure, such as zinc due to obstruction of the lacnimal duct of sulfate solution (3%), provides a moderately the nose. This may be effectively alleviated bactericidal astringent effect, rarely elicits by nasal astringents. an allergic reaction, and is pleasant to use. VoIce: If one starts using zinc sulfate and Many “eye drops” must be buffered before is unsuccessful, are further cultures useless? they are suitable for application to the eye, ANSWER: Zinc sulfate suppresses orga- for they burn if acid or alkaline; an ex- nisms, but repeat cultures should still be ample is a 6: 1 mixture of Zephiran#{174} hydro- attempted. An early smear will help deter- chloride (1 :5000) and epinephrine (1:1000), mine therapy. About 95% of conjunctivitis which requires buffering due to the acidic needs only zinc sulfate. Zephiran#{174}. In addition to its soothing prop- Following this Dr. Miller emphasized the erties, this mixture blanches the redness attendant dangers of topical adrenal ster- of the inflamed eye. Although boric acid oids. He demonstrated a steroid-induced can be used in drops, zinc sulfate is more fungus following 3 consecutive pleasant. months of steroid therapy. Ulceration pro- Dr. Miller was asked whether ointment ceeded to perforation, and eventually enu- on drops were preferable. Ointments last cleation of the eye was necessary. A corn- longer, but are unsightly and greasy. With bination of a steroid and an antibiotic is fluid medications the only effective drop is most likely to produce this type of lesion,

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which has little action against the offending quently found without apparent cause. fungus. They naturally fade from red to brown and The use of fluorescein was discussed. The reabsorb spontaneously. Occasionally they liquid preparation has been found to be a are the first manifestations of metastatic good culture medium for pyocyaneus. In- disease, e.g., neuroblastoma. fection can be avoided by the use of in- Systemic herpes zoster that involves the dividual fluorescein-impregnated paper tip of the nose may lead to initis with con- strips, moistened in saline solution just be- neal infiltrates at the periphery. Adrenal fore application to the eye. steroids are of questionable aid. Herpes

Q UESTION : What therapy is recom- simplex often leads to dendritic ulcer of the mended for chemical burns of the eye? , which if treated with steroid goes ANSWER: Such injuries may be divided wild. Therapeutic efforts should be directed into acid or alkaline. Acid burns tend to be toward removal of the corneal epithelium, self-limiting, not entering the eye itself, but with recognition that recurrence is common. merely coagulating the protein. In con- TEAR DUCTS trast, alkali penetrates within 30 seconds, reaching the anterior chamber promptly, Discussion of the management of defec- and within 5 minutes has penetrated to the tive tear ducts followed. Infection is second- back of the eye. It does not form coagulum, any to obstruction, which in some cases but chemically active soaps. The most effec- resolves itself early. In treating the infec- tive treatment of acid or alkaline burns is tion one should culture the discharge which the immediate lavage of the eye with co- often yields a mixture of organisms. Sulfon- pious amounts of water. arnide therapy is frequently useful, but ne-

Q UESTION : What about the effects of lief of the obstruction is essential. Parents smog? can be instructed to massage toward the ANSWER: It does produce chronic con- nose, creating pressure so that drainage junctivitis, but no therapeutic recommen- may occur into the nasal cavity. If this is dation can be made. unsuccessful, the lacnimal sac should then Q UESTION : Hydrocarbons? be emptied by massaging toward the punc- ANSWER: Water usually removes hydro- ta. Following evacuation, topical sulfona- carbons. If its use is followed by use of an mide may be given. Probing should be de- oily substance like castor oil, the latter will layed if possible until the child is about 1 coat the surface and deter adhesions be- year of age. Additional therapy may con- tween lid and . sist of an astringent to shrink the mucosal QuisnoN: Ultraviolet-radiation burns? membrane. Around the age of 18 months,

ANSWER: There is a superficial keratitis if conservative therapy is unsuccessful, de- and . Sedation and a drop of finitive surgery may be indicated. This usu- %% pontocaine in each eye is good therapy. ally consists of anastomosing the lacnimal Dr. Miller was then asked about the use sac with the nasal mucosa. Avoidance of of topical anesthetics. He cautioned against long-standing infection is important as the their use except for temporary anesthesia. tear sac may be altered by chronic inflarn- They give satisfactory relief on first ad- mation. ministration but are less effective with each Q UESTION: What is a good medication to re-application. In addition they produce dilate ? conneal damage with prolonged use and ANSWER: 10% Neosynephrine#{174} has the delay wound healing. Foreign bodies or a advantage of rapid dilation without cyclo- protective bandage may also contact the plegia. However, it stings intensely upon eye without arousing the normal protective application. 1% Cyclogyl#{174} is good for pu- mechanisms. pillary dilation and has a cycloplegic action Subconjunctival hemorrhages are fre- of only 12 hours.

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The remainder of the discussion centered acuity stated below, they are routinely re- on the development of the eye, its move- ferred to an ophthalmologist.

ments and visual acuity. Class Visual Acuity Kindergarten 20/SO DEVELOPMENT First Grade 20/40 The adult eye has an antero-postenior di- Second Grade 20/30 arneten of 25 mm, whereas that of the new- Third Grade 20/25 Fifth Grade 20/20 born is 18 mm, a fact which demonstrates that eye development is relatively far along Referrals are made for the following at birth. In contrast with other measure- reasons: rnents, the distance from fovea to disc re- 1. Symptoms and a teacher’s impression. mains constant throughout life. The short 2. Failure of visual acuity. antero-postenior diameter is compensated 3. Difference of two lines between the by the increased curvature of the and two eyes. cornea which produces a stronger optical 4. Decreasing vision on subsequent effect. The retinal area is relatively greater examinations. than that of the adult, whereas there is 5. Crossing of eyes. relatively little and little aque- Symptoms of visual difficulties include: ous secretion. inability to see at a distance, headaches, squinting of lids, tearing or seeing double. MOVEMENTS AND VISUAL ACUITY Stnabismus was next discussed. , All infants have poor ability to use their the tendency to turn one eye inward, is eyes together, therefore, strabismus. Not frequently accommodative, giving too much until they are 6 weeks to 3 months of age convergence. Usually it occurs on a refrac- do they converge well. Prior to this they tive basis in patients with hyperopia. One use tonic neck reflexes when looking right observes it in schoolwork, or at dinner as or left. Myelinization of the is the child’s eyes attempt to follow an errant complete soon after birth. The foveal area pea across his plate. , hypertnopia alters slightly as the infant develops, but and cyclotropia were briefly mentioned. acuity is poor in early infancy. A rotating- Variations in strabismus include: constant drum technique is useful in assessing visual or intermittent types, monocular or alter- acuity in infants or in hysterically “blind” nating types. With the latter the child usu- adults who manifest a revealing ally retains good vision in both eyes. Most when subjected to this test. youngsters with strabismus do not see At birth the infant has about 2 diopters double, but develop suppression and ignore of hyperopia. This increases to a maximum what is seen by one eye. This may lead to at 6 to 8 years of age. He has good accorn- . modation to compensate for it. The most Probably all deviations are related to re- normal refraction occurs between the ages fractive errors on neurologic maldevelop- of 20 and 30 years. is normal for ment. Causes may be congenital, in which age 85 years. case, prognosis for is poor. Dr. Miller discussed screening examina- Accommodative effort is responsible for tions for visual acuity in school age chil- many cases of esotropia, especially in far- dren. The most effective device for screen- sighted children. Neurologic defects, such ing is the Snellen Chart. Screening tech- as , account for a small niques tend to pick up more myopic than number, as do orbital diseases such as frac- hyperopic children. A persistent examiner tune or hemorrhage. The incidence is 2% in can usually find a visual acuity of 20/20 in the general population. a normal 3-year-old child. If children in Therapy varies with type and achieve- St. Louis schools do not meet the visual ment. A child with hyperopia and strabis-

Downloaded from www.aappublications.org/news by guest on September 27, 2021 796 ROUND TABLE mus may correct the strabismus merely by whom it occurs only with fatigue? the use of glasses to correct the hyperopia. ANSWER: Remember that the best results If amblyopia is developing, patching the are obtained in young children who have better eye will usually relieve the situation. had surgery before 2 years of age. Exercises alone rarely are successful unless Dr. Miller demonstrated the reflection of the child still retains some ability to use light into the eyes, which centers in the both eyes together. Around 50% of all chil- middle of the in normals, but away dren of this type, without an accommoda- from the center in one eye when strabismus tive error, need surgical correction. is present. Wide epicanthal folds were Q UESTION : When should referral be shown to suggest esotropia in a normal made? child. The was demonstrated in ANSWER: From the onset, even at 3 to 6 motion pictures, as were examples of chil- months of age. Glasses at age 1 year may dren with spasmus nutans, latent nystag- help. mus, ocular nerve palsies and the Marcus- Qu ESTION: Do you want to see those in Gunn phenomenon.

ADVANCES IN PnuAmcs, Vol. X, edited by well-read pediatrician will need all of them. S. Z. Levine, M.D. Chicago, The Year The muscular disorders of childhood are dis- Book Publishers, Inc., 1958, 362 pp., $9.00. cussed unusually clearly in a chapter by the eminent authority, Dr. Frank H. Tyler. The The editor of this series, Dr. S. Z. Levine, is practicing pediatrician will find much-needed to be congratulated on his perceptive selection assistance in the chapter on psychologic pm- of topics which are in need of review at this ciples in pediatric practice by Dr. Barbara time, and for his wise choice of authors to Korsch. The timeliness of the selections is il- take on these assignments. Such a group of lustrated by the chapters on prevention of reviews as are contained in this volume are poliomyelitis by vaccination by Dr. Albert B. essential for anyone who strives to maintain a Sabin and the one on staphylococcal infections broad grasp of the subject matter of pediatrics. in nurseries by the group of investigators at The same well-balanced assortment of ma- Ohio State University. There is a very interest- tenial which has characterized this series of re- ing chapter on the transfer of antibodies from views is maintained in the present volume. It is mother to offspring by Vahlquist from Sweden. fortunate that there is so little duplication in It is not feasible to undertake a review of these the subjects treated in the several books now reviews but the reader can be assured of pleas- available each year containing reviews of topics ant and profitable reading in this volume. in pediatrics. To the respective publishers it will be a source of delight to learn that the CHARLES D. MAY, M.D.

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1959 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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