1/24/15 Mom, There’s Something Wrong With My Eye… Veeral Shah MD, PHD Texas Children's Hospital Most Common Issues Seen by the Pediatrician Emergent Ocular Issues Seen by the Pediatrician 1 1/24/15 What does this baby have ? A. Viral Conjunctivitis B. Chemical Conjunctivitis C. Allergic Conjunctivitis D. Bacterial Conjunctivitis E. All of the above Page 3 xxx00.#####.ppt 1/24/15 12:05 PM 2 1/24/15 Viral Conjunctivitis/ Epidemic Keratoconjunctivitis in Children • History: – Sick contacts, recent cold URI, timing of conjunctivitis • Symptoms: – Red or Pink Eye – Unilateral or Bilateral at presentation – Discharge- typically clear; Matted eyelids – Hemorrhages • Causes: Adenovirus (DNA virus) – EKC = Types 18,19, 37 – Pharyngoconjunctival Fever = Types 3 and 7 – Acute hemorrhagic = Types 11 and 21 Epidemic Keratoconjunctivitis • Signs and course of the disease : – Acute follicular reaction – Preauricular lymphadenopathy – Second week= subepithelial opacities (can last 2 years) – Conjunctival membranes in severe cases • Treatment – Avoid hand contact with others , avoid eye rubbing – Counsel patient about 7-10 days of being contagious – Hygiene, cool compresses, artificial tears – Ophth: • Remove pseudomembranes if possible PLEASE NO VIGAMOX – 4TH Fluoroquinolones NOT NECESSARY!!!!!!! NO STEROIDS !!! PREFERABLE – Erythromycin or Polymyxin B ointment; Sulfacetamide 3 1/24/15 H/o of continuous discharge from the left eye since birth What does this boy have ? A. Nasolacrimal duct obstruction B. Foreign body C. Trichiasis D. Glaucoma E. All of the above Page 7 xxx00.#####.ppt 1/24/15 12:05 PM Page 8 xxx00.#####.ppt 1/24/15 12:05 PM 4 1/24/15 Nasolacrimal Duct Obstruction • Congenital vs acquired – 5% of newborns – Symptoms by 1 month • Non-patent at lower end of nasolacrimal duct system • Spontaneous resolution in 65% by 6 months, 90% by 1 year hp://www.eyespecialist.com.sg/Eye-Condi8ons-Services_575/Eye-Condi8ons- • Treatment: Services_150/Blocked-Tear-Duct-(Tearing)_725 – Erythromycin ointment and nasolacrimal massage – Ophthalmology probing and irrigation Epiphora in an Infant • Congenital NLDO • Congenital anomalies of outflow pathway – Punctal atresia – Canalicular atresia • Blepharitis • Conjunctivitis • Keratitis • Foreign body • Congenital glaucoma!!! Page 10 xxx00.#####.ppt 1/24/15 12:05 PM 5 1/24/15 Infantile Glaucoma Page 11 xxx00.#####.ppt 1/24/15 12:05 PM What Does this Baby Have? A. Herpes dermatitis C. Preseptal cellulitis B. Sebaceous gland D. Chalazion carcinoma Page 12 xxx00.#####.ppt 1/24/15 12:05 PM 6 1/24/15 Chalazion/ Hordeolum in Children • History: • Treatment – Recurrent history of – Instruction: blepharitis or rosacea Warm compresses • Signs and Symptoms for 10-15 minutes – Visible or palpable – Drainage or discharge well-defined subcutaneous Bacitracin or nodule Erythromycin oint – Discharge with anterior or – Failure 4 weeks posterior fistulization consider Surgical drainage of Chalzia – Hordeolum vs Chalazia www.medcomic.com%2F021614.html 7 1/24/15 Chalzion Drainage Page 15 xxx00.#####.ppt 1/24/15 12:05 PM What Does this Baby Have? A. Exotropia B. Esotropia C. Pseudostrabismus D. 6th Cranial nerve Page 16 xxx00.#####.ppt 1/24/15 12:05 PM 8 1/24/15 Pseudostrabimus • Strabismus is the medical term for eye misalignment • Pseudostrabismus refers to a false appearance of strabismus • EXAM: Wide nasal bridge • Pseudostrabismus does NOT require treatment and the appearance tends to improve with time • As facial features mature, the widened nasal bridge tends to narrow 9 1/24/15 Exam • Va sc 20/20 OD and 20/60 OS • Pupils Normal • Using prism measure alignment Left esotropia of 35 prism diopters • Ocular motility normal • Ant segment exam and dilated fundus exam: NORMAL • CRet: – OD: +4.00 DS, – OS: +4.25 DS Page 20 xxx00.#####.ppt 1/24/15 12:05 PM 10 1/24/15 Accommodative Esotropia • Give full plus spectacles before operating • Treat any amblyopia before operating • Operate if there is residual esotropia once the child is wearing full + spectacles and the amblyopia has been treated 3 Main Types of Amblyopia Amblyopia occurs when one eye perceives a blurred view and the other eye perceives a normal view, but he brain favors the normal view and suppresses the eye with the blurred view Deprivation (cataract) Strabismus Refractive 11 1/24/15 Most Common Issues Seen by the Pediatrician Emergent Ocular Issues Seen by the Pediatrician 11 yo Girl With Acute Double Vision What Does this Girl Have? Ocular Motility Examination 12 1/24/15 Imaging Suprasellar Mass causing Pupil involving 3rd nerve palsy Page 25 xxx00.#####.ppt 1/24/15 12:05 PM What Does this Boy Have? A. Exotropia B. Esotropia C. Pseudostrabismus D. 6th Cranial nerve E. Something else Page 26 xxx00.#####.ppt 1/24/15 12:05 PM 13 1/24/15 What Does this Baby Have? A. Cataract B. Vitreous Hemorrhage C. Retinal detachment D. Retinoblastoma E. Retinopathy of Prematurity F. All of the above Page 28 xxx00.#####.ppt 1/24/15 12:05 PM 14 1/24/15 Differential Diagnosis of Leukocoria “White Pupil” • Retinoblastoma • Vitreous Hemorrhage • PHPV • Retinal Dysplasia • Cataract • Tumors • Retinopathy of Prematurity • Retinal Detachment • Toxocariasis • Corneal Opacity • Coloboma of Choroid • Myelinated Nerve Fibers • Uveitis • Retinal Astrocytic • Coat’s Disease Hamartomas (Tuberous Sclerosis) Page 30 xxx00.#####.ppt 1/24/15 12:05 PM 15 1/24/15 Urgent or Emergent? Page 31 xxx00.#####.ppt 1/24/15 12:05 PM Urgent or Emergent? 16 1/24/15 ER Management • Do not apply pressure to the globe • Protective shield (not patch) • Consult ophthalmology • Antiemetics prn • Analgesics prn • Tetanus immunization or booster prn Hyphema • Blood in the anterior chamber of the eye • Rebleeding (e.g., from manipulation of the eye during surgery) is associated with a significantly higher incidence of late complications. Page 34 xxx00.#####.ppt 1/24/15 12:05 PM 17 1/24/15 Same eye rebleed 3-5 days later 18 1/24/15 The Weakest Link • The canaliculus • Almost any tearing injury will damage the lacrimal system – Fingers, car doors, display hooks – DOG BITES!! 19 1/24/15 20 1/24/15 21 1/24/15 Take Away Points • Distinguish the types of conjunctivitis using history, exam, laterality, and symptoms. • Avoid using unnecessary antibotics, NO Vigamox and NO steroids • Identify the common causes of infant tearing and the pathophysiology of nasolacrimal duct obstruction. It’s important to rule out congenital glaucoma • Learn the pathophysiology of chalazion and hordeolum. It is important to review warm compresses instruction with the patient • Identify pseudostrabismus vs. REAL strabismus • Emergent reasons for an Ophthalmology consult are acute onset strabismus (cranial nerve palsies) or diplopia, ptosis, pupil changes, and leukocoria • Pediatrician management of common ocular trauma Page 43 xxx00.#####.ppt 1/24/15 12:05 PM Every Pediatric New Patient Exam View the patient for 2 secs through a direct ophthalmoscope 2-3 feets back • External exam – Eyelid symmetric – NO discharge – NO eyelid lesions – Eye size the same (R/O Congenital glaucoma) • Pupils – Symmetric and round • Alignment – Strabismus vs Pseudostrabismus • (+) RED reflex – – No cataract and no leukocoria, or retinal detachment Page 44 xxx00.#####.ppt 1/24/15 12:05 PM 22 .