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PEDIATRIC OPHTHALMOLOGY of a Round Table

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PEDIATRIC OPHTHALMOLOGY of a Round Table PEDIATRIC OPHTHALMOLOGY 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 strabismus. 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 chalazion 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 stye, which drains itself spontaneously or may require local CONJ UNCTIVA incision. Rarely are there complications fol- Acute purulent conjunctivitis 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 conjunctiva 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 blepharitis? 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 eye disease 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 keratoconjunctivitis 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 Allergic conjunctivitis 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.
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