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Home , Allergic conjunctivitis, Congenital cataract, Herpes simplex keratitis, Madarosis, Retinitis

7/31/2017

In the next 2 hours…….

Pediatric Pharmacology and Pathology . Ocular Medications and Children

The content of th is COPE Accredited CE activity was prepared independently by Valerie M. Kattouf O.D. without input from members of the optometric community . Brief review of examination techniques/modifications for children

The content and format of this course is presented without commercial bias and does not claim superiority of any commercial product or service . Common Presentations of Pediatric Pathology

Valerie M. Kattouf O.D., F.A.A.O. Illinois College of Chief, Pediatric Service Associate Professor

Ocular Medications & Children Ocular Medications & Children

. Pediatric systems differ in: . The rules: – drug excretion – birth  2 years old = 1/2 dose  kidney is the main site of drug excretion

– 2-3 years old = 2/3 dose  diminished 2° renal immaturity

– > 3 years old = adult dose – biotransformation  liver is organ for drug metabolism  Impaired 2° enzyme immaturity . If only 50 % is absorbed may be 10x maximum dosage  Punctal Occlusion for 3-4 minutes ↓ systemic absorption by 40%

Ocular Medications & Children Ocular Medications & Children . Systemic absorption occurs through….. . Ocular Meds with strongest potential for pediatric SE : – Mucous membrane of Nasolacrimal Duct  80% of each gtt passing through NLD system is available for rapid systemic absorption by the nasal mucosa – 10 % Phenylephrine

–

– Oropharynx – 2 % Epinephrine

– Digestive system (if swallowed)  Modified by variation in Gastric pH, delayed gastric emptying & intestinal mobility – 1 % Atropine

– Skin (2° overflow from conjunctival sac)  Greatest in infants – 2 % Cyclopentalate  Blood volume of neonate 1/20 adult  Therefore absorbed meds are more concentrated at this age – 1 % Prednisone

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Ocular Medications & Children Ocular Medications & Children

. Distribution to Site of Action in Pediatric Patients determined by : – Size of body fluid compartment . Package inserts warn – Muscle mass ”safety and efficacy has not been established in children” – Fat storage  – Tissue blood flow FDA recognizes that accepted medical practice often includes prescribing medications for use in patient populations that are not included in – Protein binding capabilities approved labeling (PDR )

Anterior / Posterior Segment

. 20D . MODIFICATION OF AN EXAMINATION Hand Held Slit Lamp FOR THE PEDIATRIC PATIENT . Burton Lamp . BIO . Direct Ophthalmoscope

Anterior Segment Examination Guidelines Anterior Segment Norms

. Lids / Lid Margins

– Observe for :  Shape irregularity  Corneal Horizontal Diameter in Neonate  Discharge on lashes/lid margin  9-10 mm – Evert Lower lids to expose  Corneal Horizontal Diameter in a 1 year old  Bulbar/ Palpebral conjunctiva, observe for:  11 mm  Follicles  Corneal Horizontal Diameter in Adult  Papillae  Discharge  11.5 –12.0 mm   Reached by 3-4 years

. / / Lens – Observe clarity / opacities/ irregularity

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Anterior Segment Norms

 Size  Constricted - 1.2 - 2 mm  Fully dilated - 7.5 – 8 mm Ocular Pharmaceuticals  Resting – 2.5 - 4 mm

 In infancy pupillary rxn to light less than in childhood Side Effects of Diagnostic Pharmaceutical Agents in Children  Often absent in very premature infants (1st response at 28-32 wks)

 IOP  8-15 mmHg

 Increases by 1 mmHg/yr from birth to age 5

Medication Class Example Ocular/ Systemic Side Local Effect ADMINISTRATION OF CYCLOPLEGIC IN CLINIC

Adrenergic Agonist Phenylephrine Conjunctival Hypertension, Blanching tachycardia, arrhythmias . Cycloplegic Spray 0.5% Tropicamide 0.5% Cyclogel Cholinergic Agents Cyclopentalate Ocular irritation, Hyperactivity, 2.5% Phenylephrine Atropine follicular restlessness, Tropicamide , delirium, seizures, GI cutaneous disturbance, hyperemia temperature elevation, respiratory . O’BRIEN Pharmacy depression 800-627-4360

Side Effects of Diagnostic Pharmaceutical Agents in Children Treatment with Atropine

. Proper patient selection… . Phenylephrine risks – Moderate-high hyperopia – and cardiovascular problems  may result is tachyarrhythmia – Moderate (20/100 or better visual acuity) . Premature / ROP patients =  systemic side effects – Use Cyclomydril 0.2% cyclo / 1 % phenylephrine . Administration schedule  no increased blood pressure – 1 gtt 1.0% Atropine sulfate daily vs. weekend only

. Cholinergic Agents  frequency of installation can be reduced as acuity improvement is – Education: parents may call with dilation concerns not expecting it to last into next day observed

– Atropine toxicity more susceptible to  minimal installation is one drop of 1% Atropine sulfate two times per  Lightly pigmented week  Brain damage  . Side Effects / Emergency contact information

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The following Atropine instillation program is prescribed:

Atropine Instillation for Amblyopia Prescription glasses should be worn for: full time / near activities / distance activities

Our evaluation found that ______has amblyopia of the Install 1 Drop Atropine into the RIGHT / LEFT eye on the indicated days: right / left / both . Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Amblyopia is reduced vision in an eye that has not received adequate or appropriate use during early childhood, often known as “lazy eye”, and has ***please keep medication out of reach from other family members*** many causes which have been explained by your doctor. If not treated, the amblyopic eye may never develop good vision and may even be functionally Special Instructions: ______blind. Possible Atropine Ophthalmic Solution Side Effects: Burning/stinging/redness of the eye, eye irritation, or temporary blurred vision may occur. Most people do not experience serious The treatment of amblyopia may require multiple therapy methods in which side effects from using this medication. Tell your doctor immediately if any of these unlikely but serious side effects occur: dizziness, fainting, new or increased eye your doctor may prescribe occlusion therapy with patching or atropine pressure/pain/swelling/discharge, rash, or itching/swelling (especially of the fact/tongue/throat. Rare, but very serious side instillation. Active amblyopia vision therapy may be recommended to effects include: slow/shallow breathing, mental/mood, fast/irregular heartbeat. enhance the effectiveness of occlusion therapy. Glasses are also prescribed Your next appointment is on ______. If you have any questions, please feel free to contact us at (312) 949-7280 or after in most cases. hours via our EMERGENCY number at (312) 225-6200.

Administration of Ocular Meds Ointment vs. Drops

. Ointment – blurred vision Ocular Pharmaceuticals – 

Commonly Used Ocular Anti-Biotic Medications in Children . Drops –  risk of systemic toxicity

–  contact time with cornea (diluted by )

Ocular Medications & Children Ocular Medications & Children Anti-biotic Ointments Anti-biotic Ointments

Drug Age Approval Drug Dosing

Erythromycin > 2 months Erythromycin qid

Tobrex > 2 months Tobrex qid Ciloxan > 2 years Ciloxan tid x 2 days, bid x 5 days Polysporin > 2 years Polysporin qid

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Ocular Medications & Children Anti-biotic Drops Ocular Medications & Children Drug Age Approval Anti-biotic Drops Polytrim  2 months

Fluoroquinolones

Besivance 1 yr • Polytrim – Broad spectrum, effective, inexpensive Moxeza > 4 months

Ciloxan 1 yr • AzaSite – macrolide anti-biotic (Z-pack) Ocuflox 1 yr • Prolonged ½ life -  dosing schedule Quixin 1 yr • 1 gtt q 8-12 hrs (tid) x 2 days Vigamox 1 yr • 1 gtt qd x 5 days Zymaxid 1 yr • Broad spectrum, effective, expensive Iquix 6 yr Other Antibiotics Azasite > 1 yr

Gentamycin unknown Sulfacetamide unknown

Ocular Medications & Children Ocular Medications & Children Anti-biotic Drops Anti-biotic Drops

• Fluoroquinolones (concentration dependent) Drug Dosing

• Besivance (0.6%)– new, Advanced A-B Polytrim qid  Vehicle: DuraSite mucoadhesive – provides enhanced ocular surface residency time Flouroquinolones  Dosing = tid (q 8 hrs)  Pediatric schedule: AM → after school → at bed time Besivance tid

• Ciloxan (0.3%) Moxeza bid • Ocuflox (0.3%) • Moxeza (0.5%) prolonged contact due to gum base = bid dosing Ciloxan 1gtt q 2hrs x 2days, qid x 5 days

• Quixin (0.5%) Ocuflox 1gtt q 2hrs x 2days, qid x 5 days • Vigamox (0.5%) no preservative • Zymar (0.3%) Quixin 1gtt q 2hrs x 2days, qid x 5 days • Zymaxid (0.5%) ↑ concentration may enhance clinical results • Iquix (1.5%) Vigamox tid

Zymar 1gtt q 2hrs x 2days, qid x 5 days

Zymaxid 1gtt q 2hrs x 2days, qid x 5 days Azasite tid x 2days, qd x 5days

Ocular Medications & Children Anti-biotic Drops

Drug Dosing

Polytrim qid Azasite tid x 2days, qd x 5days Besivance tid Moxeza bid Anterior Segment Pathology Ciloxan qid Ocuflox qid Nasolacrimal Duct Obstruction Quixin qid Vigamox tid Zymar qid Zymaxid qid

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Nasolacrimal Duct Obstruction Nasolacrimal Duct Obstruction Etiology and Anatomy

. Clinical Characteristics – 5-6% of newborns – 1/3 bilateral . Membranous blockage of valve of Hasner – Unilateral associated with amblyogenic anisometropic (20%) . Incomplete opening of lower end of the NLD along side of nose between inner – Clinically evident at 3-4 weeks of age canthus of and inferior turbinate of the nasal cavity – Redness irritation of lids – **With secondary conjunctivitis  discharge  injection  swelling over innermost aspect of lower lid  pain  fever

Instructions Nasolacrimal Duct Obstruction

. Warm Compress TREATMENT OPTIONS – 5- 10 minutes of continuous warmth – Options 1) Warm compress / Hydrostatic Massage . Lacrimal Sac Massage 2) Topical Antibiotic Drops – Use index finger wrapped in clean, thin, cloth – Begin between infants 3) Surgical Options – Drag finger down towards affected side, closing lid simultaneously – Continue movement, pressing firmly into the canthus – Continue onto cheek – 10 strokes / tid

Surgical Treatment Options Nasolacrimal Duct Obstruction PEDIG studies

. NLD 1 . Probing and Irrigation  A prospective study of Primary Surgical Treatment of NLDO in Children Less . Silicone tube intubation than 4 years old . Balloon catheter dilation . NLD 2 . Medical infrastructure of the inferior turbinate  A prospective study of Surgical procedures for persistant NLDO in Children . Dacryocystorhinostimy Less than 4 years old . NLD 3  A Randomized trial comparing immediate probing in office setting with deferred probing in a facility for initial surgical treatment of unilateral NLDO in children 6-<10 months old

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Nasolacrimal Duct Obstruction PEDIG studies The Course of Nasolacrimal Duct Obstruction

. NLD 1  In children 6 - <36 months old, probing is a successful primary tx 75%  In children 12 - <48 months old, balloon dilation is a successful primary tx 80% 1983 T. Otis Paul  In children 6 - <45 months old, intubation is a successful primary tx 90% 55 infants diagnosed with NLDO prior to 3 month old

. NLD 2  A prospective study of Surgical procedures for persistent NLDO in Children Less Percentage of Spontaneous Resolution by 1 year of age than 4 years old

. NLD 3 3 months - 15%  The majority of deferred subjects had NLDO resolution within 6 months 6 months - 46%  75% success rate for immediate office probing 12 months - 93%  Immediate office probing likely most cost effective

NLDO Patient Examination of NLDO Patients

. 4 week old AA male – Right eye tearing since birth – Red right eye with purulent discharge x 2 weeks . Fluorecein Disappearance Test

– Anterior Segment Evaluation – Instill NaFl into conjunctival sac  Erythema and Edema OD – Note significant retention after 5-10 minutes  Yellow-green discharge OD – Grade NaFl left behind 0-3  (+) Tear lake OD >>>OS  3 = fluorecein disappearance test  0 = no  (-) corneal staining  3 = fluorescein left behind  0-1 = Normal – Assessment / Plan  NLDO with 2° Bacterial Conjunctivitis OD  If the dye fails to disappear in several minutes an obstruction in the  Rx Polytrim qid OD x 1 week lacrimal drainage system can be presumed  Warm compress / Hydrostatic Massage qid  RTC 1 week  No dye in the nose or pharynx after 10-15 minutes

NLDO Patient NLDO Patient . 5 weeks old – ↓ Lid edema and tear lake – No NaFl stain . 12 weeks old – 2-3 = fluorecein disappearance test – Mild lid edema – (+)mucous in tear film  Continue with previous treatment regimen. RTC 2 weeks – (-) discharge – ↓ tearing OD > OS . 8 weeks old – 2 = fluorecein disappearance test – Mom notes tearing has decreased significantly – Minimal lid edema and injection – d/c Polytrim, restart if conjunctivitis recurs – Minimal discharge – (+) tear lake OD – 2-3 = fluorecein disappearance test . 4 month old AA male – Tearing significantly improved  ↓ Polytrim bid ( to qid if conjunctivitis worsens)  Continue with warm compress / massage – 1 = fluorecein disappearance test  Add lids scrubs with baby shampoo – Partial vs. Resolved NLDO – Restart Polytrim / return to clinic if conjunctivitis returns

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Differential Diagnosis The Pediatric

Conjunctivitis Bacterial Anterior Segment Pathology Viral Allergic Pediatric Red Eyes / Conjunctivitis

Rules of Thumb CONJUNCTIVITIS Bacterial vs. Viral

If , it’s allergic SIMILARITIES If it burns, it’s dry eyes Bilateral If eye cannot open in the AM it is likely bacterial Eyelid Swelling Conjunctival Erythema If they have a cold it is viral

CONJUNCTIVITIS Viral Conjunctivitis Bacterial vs. Viral

. Typically caused by adenovirus

DIFFERENCES . Signs

• Watery discharge (typically bilateral??) Conjunctival Discharge • Erythema Conjunctival Response • Conjunctival response = follicular Systemic Associations • Often in presence of a viral URI (upper respiratory ) • May have palpable pre-auricular node often on more affected side

Determination important because it drives decisions about treatment and school exclusion . Most common conjunctivitis seen in school aged children

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Bacterial Conjunctivitis Viral Conjunctivitis Tx

. Treatment Options – Self limiting therefore supportive treatment - Artificial Tears . Typically caused by haemophilus influenzae / streptococcus pneumoniae - Cool Compress

. Signs - Instruction of proper hygiene / avoidance of family members • Purulent discharge

• Minimal erythema - Discuss daycare / School attendance issues • Conjunctival response = follicular + papillary - Frequently asked questions…….

- How long does conjunctivitis/pink eye last? - Signs and symptoms of conjunctivitis usually improve within three to seven days.

• - When is it appropriate for a child to return to school or child care? Most predictive sign of bacterial conjunctivitis dx: awakening with - When tearing and discharge are no longer present one or both eyes “glued” shut

Bacterial Conjunctivitis Tx

. Less likely to use: – Gentamycin – Corneal Toxicity – Sulfacetamide -  / SJS – Chloramphenicol – aplastic anemia

. Common Drop : – Polytrim – wide spectrum,  toxicity Anterior Segment Pathology . With ↓ response to treatment with Polytrim: – Fluoroquinolones Chronic

Topical Antibiotic Therapy for 7- 10 days

Chronic Blepharitis

. May result in: • Chronic blepharoconjunctivitis • Recurrent chalazia • Loss of lashes / Ocular Pharmaceuticals • Thickening of lid margins

. Treatment Commonly Used Ocular Medications in Children • Warm compress/massage/lid scrubs • Topical Anti-biotic (drop vs. ung) • Oral Antibiotic • Surgical Excision

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Ocular Medications & Children / Topical Allergy Drops Ocular Medications & Children / Topical Allergy Drops Anti –/ stabilizer Anti –histamine/ Ocular Allergy Medications Rx OTC Drug Age approval Drug Age approval Drug Dosing Pataday/Patanol 3 years old Zaditor  3 years old Pataday qd Pazeo ≥ 2 years old Claritin Eye 3 years old (0.2% ) Lastacaft 2 years old Pazeo qd Refresh Eye 3 years old (0.7% olopatadine) Elestat 3 years old Relief Patanol bid Bepreve 2 years old Alaway 3 years old Optivar 3 years old Lastacaft qd

Elestat bid Topical Rx Bepreve bid Drug Age Approval Zaditor bid

Alrex 3 years old Alrex qid

Case History Question Atopic Facial Appearance in Children (allergic facies)

Is your child atopic? . Allergic “shiners”

Nasal allergies . Dark circles under eyes Food allergies Hay fever . Denni-Morgan lines / double skin fold Eczema . Extra skin fold or line under lower eyelid

Nasal and Ocular Allergy Allergic Cascade

. 70-90% of allergic patients have ocular allergy

. Allergic rhinoconjunctivitis  25% of the population  80-90% of all allergic disorders IgE

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Vernal

. Symptoms • Pain • Itching (severe) • Conjunctival injection Ocular Pharmaceuticals • • Mucous discharge Commonly Used Ocular Medications in Children/ Additional Agents . Clinical Signs: • Large papillae • Conjunctival hyperemia with edema • Horner-Trantas dots = clumps of eosinophils with dead epithelial cells

Ocular Medications & Children Ocular Medications & Children Additional Treatment Agents Additional Treatment Agents

Steroids Steroid/Antibiotic Combination Drug Age Approval Drug Age Approval

FML 2 years Tobradex 2 years

Alrex 3 years Blephamide 6 years

Lodemax 3 years Zylet 3 years

Ocular Medications & Children Ocular Medications & Children Topical Steroids Topical Steroids

• Alrex (0.2% Lodeprednol) • Tobradex has dexamethasone as steroid agent known to increase IOP • Approved for treatment of seasonal

• Lubricant included/ increases comfort (viscous nature for soothing)

. Lotemax (0.5% Lodeprednol) • Alrex • Use for intraocular inflammation • Zylet  Anterior • Lotemax  Post-op • Have as steroid agent = less likely to increase IOP  Ocular allergy / GPC

• Zylet (0.5% Lodeprednol) • Treatment of inflammation + Ocular surface disease • Conjunctivitis/ blepharoconjunctivitis

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Ocular Medications & Children Additional Treatment Agents

Antiviral Agents Drug Age Approval Viroptic 6 years Zirgan 2 years

Herpes Simplex Keratitis Keratitis

. Summary of Findings . 3.5 year old Caucasian female (September 03) – Vesicular Blepharitis – 1 month of redness OD – Lid vesicles above and below lid margin OD  Involvement of external surface / periocular structures – Active corneal dendrite OD – Clinically Non-specific Conjunctivitis – 20/30 VA  Involvement of the conjunctiva – No uveitis – Tx : – Dendritic Keratitis →Ulcerative Keratitis  Acyclovir (200 mg 5x / day)  Involvement of the cornea  Viroptic (qid)  RTC 1 wk . Treatment . One week F/U : – Topical and systemic antiviral therapy – Improved HSV Keratitis – ↓ Viroptic bid OD / d/c Acyclovir

Herpes Simplex Virus Keratitis Topical Ocular Agents Instructions for home use

. History of Recurrence (3.5 – 5 years of age) . Emergency contact number

– October 03  HSV Blepharitis – no keratitis OD  Tx : Acyclovir 200 mg qid x 1 wk, bid x 1 wk, Viroptic qid x 1 wk, RTC 1 wk . Diagnosis  Resolved at 1 wk f/u

– March 04  HSV Blepharitis / No active keratitis . Name of medication  Tx: Acyclovir / Viroptic qid x 1 wk – Dosage Instructions – February 05  HSV Blepharitis / No active keratitis  Which eye (s)  20/40 OD, 20/20 OS  RTC 1 wk  How many times per day  Dendrite /Keratitis noted at 1 wk f/u  When to discontinue  Resolved at 2 wk f/u

– July 05  HSV Blepharitis / No active keratitis . Follow-up visit date(s)  Resolved x 2 wks

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Prescribing for Children: Guidelines & Helpful Hints

. Children ≥12 years and older = dosed as adult

. Children ≤11 years

• Look up dosage – given in mg/kg/day Prescribing Oral Medications to Children • Determine weight in kg – 1kg = 2.2lbs

• Mg x Kg = DAILY dose

• Divide daily dose to get desired doses per day

• Choose closest available dosage strength

PEDIATRIC SAMPLE: Augmentin Rx for 40lb, 5 yo with preseptal cellulitis Oral Anti-Biotics

. Augmentin = 20-40 mg/kg/day in divided doses every 8-12 hours . Children with no Penicillin Allergy • Available in 125mg/5 ml and 250mg/5ml suspensions *[1tsp = 5ml]*

. [1kg=2.2lbs] 40 lb ÷ 2.2 = 18kg . Penicillin V x 10 days . children < 30kg/65 lbs = 250mg bid . 40 mg/kg/day x 18kg = 720mg/day (DAILY dose) . children > 30kg/65 lbs = 500mg bid

. 720mg/day ÷ 3 = 240mg q8h . Amoxicillin x 10 days

. children < 30kg/65 lbs = 40mg/kg/day . Choose closest available strength by rounding to 250mg q8h; 150ml gives 10 day course . children > 30kg/65 lbs = 250mg tid . PRESCRIBE: Augmentin 250mg/5ml 1 tsp q8h x 10 days

Oral Anti-Biotics Prescribing for Children: Guidelines & Helpful Hints

. Consult pediatrician for children ≤ 5 years of age . Children with Penicillin Allergy (for children < 60 lbs) . In most cases prescribe the highest recommended mg/kg/day . Eurythromycin x 10 days . 40mg/kg/day tid . Pharmacists are very helpful in dosing

. Azithromycin (Zithromax) x 5 days . For drug information: . 12mg/kg qd  Epocrates.com . Cephalexin (Keflex)  Drugs.com . 25-30 mg/kg . ≤ 4000 mg/day

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PRESEPTAL CELLULITIS

. Definition - infection of soft tissues of the eyelid and periocular region anterior to the orbital septum

. Clinical Characteristics – eyelid edema – erythema Anterior Segment Pathology – warmth of eyelid Preseptal and – conjunctival chemosis / ocular discharge

– NOT PRESENT  proptosis  restriction of ocular motility  pain with eye movement

PRESEPTAL CELLULITIS PRESEPTAL CELLULITIS

. Possible Etiologies . Differential Diagnosis

– Chronic Blepharitis / conjunctivitis – Orbital Cellulitis **** – Internal Hordeolum – Acute – Allergic Lid Edema – Penetrating Injury – Bite Wounds – Viral Conjunctivitis with Lid Edema – Respiratory Infection – – Dermatitis

PRESEPTAL CELLULITIS PRESEPTAL CELLULITIS

TREATMENT OPTIONS . How to determine severity / treatment options:

Mild > 5 y.o. – Is patient toxic? ORAL ANTIBIOTICS – Is patient/parent non-compliant with treatment? Moderate to Severe – Child < 5 years old Consult – No improvement within 3-4 days of administering oral anti-biotic Hospitalization IV ANTIBIOTICS

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ORBITAL CELLULITIS ORBITAL CELLULITIS

. Definition – infection of the soft tissues of the posterior to the orbital septum . Differential Diagnosis – Preseptal Cellulitis . Clinical Characteristics – Differentiation made by : – unilateral orbital tenderness  Fever – Pain on eye movement  Vision loss – PARALYSIS of  Motility limitation – Proptosis – Papillodema  Proptosis – Blurred vision – fever / systemic illness

ORBITAL CELLULITIS Cellulitis Case

. 5 yo AA female – Left eye swelling x 5 days TREATMENT OPTIONS – Given Augmentin (ER) – NI – Symptoms worsening – (+) injection, discharge and tenderness CT Scan – (-) hx of trauma or allergies

. Examination Findings (ER) IV ANTIBIOTICS – VA = 20/20 OD, OS – 4+ lid edema OS – area of tenderness left upper brow – (+) injection and discharge – (-) cell / flare in AC – (-) proptosis – (-) EOM restriction, – (-) Pain on eye movement

Cellulitis Case Cellulitis Case

. Assessment / Plan . Two-week Follow-up – Likely Preseptal cellulitis – Ordered CT orbit / sinus (if seen = admit) – Rx Zymar tid – Elicit history of and allergies as per Mom – Continue with Augmentin – (+) papillae and mild conjunctival chemosis – RTC 1 day – Minimal injection – One week follow-up – Minimal lid edema – Mom notes decreased edema and injection – Possible hordeolum in left UL – D/C anti-biotic medications – (+) UL edema – Rx Patanol prn for ocular allergies – (+) conjunctival injection – (-) discharge – Rx Lid scrubs and warm compresses bid to aid in decreasing – Continue with development of chronic hordeola – Zymar tid – Augmentin (10 day cycle) – RTC 1 week

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Leukocoria

. Must determine anatomic location of lesion

– Differential Diagnosis:  Congenital  Retinoblastoma Presentations of Pediatric Pathology  Coat’s Disease of Prematurity  Persistent Hyperplastic Primary Vitreous (PHPV)

Leukocoria Differential Diagnosis

. Congenital Leukocoria  1/10,000, 400-500 infants per year

Congenital Cataracts  Risk of Image Degradation Amblyopia

Congenital Cataract

. Treatment – Cataract Extraction  IOL implant – Fit – Amblyopia Therapy Leukocoria

. Contact Lens Fit – May combine with spectacles Retinoblastoma –  magnification  20-30 % with specs  8-12 % with contact lenses – Improves development, cosmesis

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Retinoblastoma Leukokoria Differential Diagnosis . Retinoblastoma Characteristics  1/15,000 births . It occurs bilaterally in 30% - 40%  Fatal if not treated /early detection before spread to the other . In unilateral disease, mean age at diagnosis is 24 months eye  survival rate  In the developed world >90% of patients with intraocular . In bilateral disease, 12 months retinoblastoma survive . With a known family history, 4 months

. Overall, 90% are diagnosed in patients under 3 years old  Presenting signs  Leukocoria (#1)  (#2)  Red/painful eye with  Poor vision

 Treatment  Immediate referral and likely enucleation

Leukokoria

. Must determine anatomic location of lesion

– Differential Diagnosis:   Retinoblastoma Leukokoria  Coat’s Disease  Retinopathy of Prematurity  Persistent Hyperplastic Primary Vitreous (PHPV) Coat’s Disease

Coats Disease Coat’s Disease Stages Epidemiology

. Exudative , retinal telangiectasis . I = abnormal dilation of retinal blood vessels  Increased permeability of these abnormal retinal vessels causes . II= telangiectasia and exudation leakage of the serum into intraretinal and subretinal spaces . III= exudative . Inheritance pattern unknown . IV= total retinal detachment . Very rare; young males (M:F, 3:1) . V = characterized by irreversible blindness . 80% unilateral . Characterized by abnormal vessel development . Poor prognosis in advanced stages . Retinal detachment in advanced stages

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Coats Disease Coats Disease Diagnosis Treatment

. CT Scan . Ablation of causative lesions  the appears hyper dense compared to normal vitreous due to the . Laser photocoagulation or cryotherapy exudate . Steroid and anti-VEGF injections . Enucleation

Summary QUESTIONS?

Contact : . Ocular Meds in Children . Pediatric Examination techniques . NLDO . Conjunctivitis Valerie M. Kattouf O.D. . Preseptal / Orbital Cellulitis . Leukocoria Differentials

[email protected] Use an “ocular emergency” visit for a child to educate the (312) 949-7279 parent on the importance of early and regular optometric visits

Optic Nerve Hypoplasia

. Congenital condition in which the is underdeveloped

. Causes: Unknown Posterior Segment Pathology  Association with maternal DM, alcohol abuse, young maternal age, etc

. May be isolated as Optic Nerve issue or associated with neurological and hormonal abnormalities

. Wide spectrum of visual function and affect on Visual field

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Optic Nerve Hypoplasia Associated Conditions

. Midline anomalies of brain  Septo optic dysplasia (absence of septum pellucidum and corpus callosum)  Anomalies of ventricles  Cerebral atrophy  Tumors (rare)

. Hormonal insufficiencies Case Example  Thyroid  Growth hormone  Pituitary  Adrenal A Red Eye ???  anti-diuretic hormone (ADH)

Case History, 9 year old male Refractive Error History

. Red eye x 4 mo. OS, “bump” on LUL (has increased in size over time) . Last eye exam 8 months ago, do not have exam info . (+) seasonal allergies, Rx given for Pataday, uses daily, NI . 1st Rx at 5 years old  Has also used topical antibiotic and artificial tears to treat the chronic red eye

. Patient is miserable with red eye  -3.00 -1.50 x 180 OD 20/20  (+) discharge, tearing, , itching, redness OS  Also note skin “bumps” on L side of mouth (PCP says they are related to chicken pox family)  -3.75 -1.00 x 005 OS 20/60  Brother also had bumps on arms (have resolved) possibly molluscum???

Anterior Segment Evaluation Molluscum Dx

. OD - wnl . Surgical Removal planned at weeks end . OS  Once lesion removed all sx should resolve immediately  Vascularized lesion on LUL 2mm round  3+papillae upper and lower palpebral conjunctiva . Will re-appoint patient Post op to investigate decreased VA OS  Upper and lower lid edema  4+ injection upper bulbar conjunctiva  (+) conjunctival chemosis

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Molluscum Molluscum

. is caused by a virus that is a member of the poxvirus family Treatment may be sought for the following reasons:

. common infection in children and occurs when a child comes into direct contact with a lesion. It is . Medical issues including: frequently seen on the face, neck, armpit, arms, and hands but may occur anywhere on the body  Bleeding except the palms and soles.  Secondary . The virus can spread through contact with contaminated objects, such as towels, clothing, or toys  Itching and discomfort  Potential scarring . In people with normal immune systems, the disorder usually goes away on its own over a period of  Chronic keratoconjunctivitis months to years.

. Social reasons . Individual lesions may be removed surgically, by scraping, de-coring, freezing, or through needle  Cosmetic electrosurgery. Surgical removal of individual lesions may result in scarring.  Embarrassment  Fear of transmission to others  Social exclusion

Possible reasons for decreased VA OS One month Follow up exam

. Patient happy, all sn/sx of conjunctivitis resolved . Blur 2º to conjunctivitis (tearing and discharge ) . Examination today to evaluate decreased VA OS

. Incorrect refractive error correction  -3.00 -1.50 x 180 OD 20/20  -3.75 -1.00 x 005 OS 20/60 PH 20/40 -2

. Amblyopia . /Manifest  Due to……?  3.25 -1.50 x 180 OD 20/20  -3.00 -1.75 x 180 OS 20/40

One month Follow up exam

. Cover Test (cc)  Distance and Near 8-10 ∆ CLET

. EOM – FROM OD, OS Assessment / Plan

. Stereopsis  (-) RDS, (+) Stereo Fly

. Worth 4 Dot  4 dots Near  LE Suppression at Distance

. Visuoscopy – later……………

. DFE - wnl

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Assessment Plan

. Small Angle OS . Small Angle Esotropia OS . Strabismic Amblyopia OS . Strabismic Amblyopia OS . Myopic OU  New Rx given FTW / Discussed options for CL wear  . Discussed amblyopia and treatment options, no treatment recommended, Ptosis OS monitor at FU

. Myopic Asigmatism OU . Ptosis OS  Bring in photo at follow up to evaluate nature of ptosis . Molluscum with 2º conjunctivitis OS resolved s/p removal of lesion  Congenital (likely vs resolving secondary to conjunctivitis)

Case #1: Patient History Case #1: Patient History

Age Visual Acuity Comments Age Visual Acuity Comments

2.5 none Cyclo Rx OD +2.00 D 3.9 OD 20/60 Dry Ret OD +0.50 D, OS +2.50 OS +4.50 D OS 20/125 Occlusion d/c. Atropine started (1 gtt 2.9 OD 20/60 No stereo fly, OD Saturday and Sunday ) OS 20/200 occlusion started 2-4 hrs/day OD 3.11 OD 20/70 Atropine Installation wrong eye 3.0 OD 20/60 occlusion 2-4 hrs/day OD OS 20/80 OS 20/125 4.1 OD 20/80 Atropine Installation now 3.1 OD 20/40 ?? occlusion 2-4 hrs/day OD OS 20/150 appropriate OS 20/80?? Poor compliance 4.5 OD 20/60 VA not making sense, repeat DFE at 3.5 OD 20/80 occlusion 2-4 hrs/day OD OS 20/80 FU, r/o pathology, repeat cyclo OS 20/125 Poor compliance 4.8 OD 20/125 Cyclo Ret OD +2.00 D, OS +2.50 OS 20/125 Cataract noticed on retinoscopy Poor dilation with spray

Case #1: Patient History

Age Visual Acuity Comments

4.9 OD 20/60 Cyclo Ret OD +3.25, OS +4.00 OS 20/125 Schedule posterior pole photos and OCT, suspect retinal disease

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X Linked Juvenile

. Symmetric bilateral macular involvement . Onset in 1st decade of life . Fundus exam shows areas of schisis (Splitting of NFL) in macula (Spoke wheel pattern) . Schisis of peripheral in 50% of cases . Affected males have vision 20/60 -20/120 . VA deteriorates durin 1st-2nd decade of life and remains stable until 5th-6th decade

X Linked Juvenile Retinoschisis

. Future testing / Treatment  ERG to confirm diagnosis  Low Vision referral  Consider topical dorzolamide (Trusopt)  Tid administration, Found to decrease the number of foveal cysts Low Vision Evaluation  Patients showed one line of VA improvement in at least one eye  Concerns : rebound phenomena

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Summary QUESTIONS?

Contact : . Ocular Meds in Children . Pediatric Examination techniques . NLDO . Conjunctivitis Valerie M. Kattouf O.D. . Preseptal / Orbital Cellulitis . Leukokoria Differentials

[email protected]  Use an “ocular emergency” visit for a child to educate the (312) 949-7279 parent on the importance of early and regular optometric visits

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