Nothing to Disclose Pediatric Anterior Segment Conditions Marie I. Bodack,OD, FAAO, FCOVD, Dipl BVPPO Chief, Pediatric Primary Care @ Southern College of Optometry [email protected] Course Goals • To review commonly encountered pediatric anterior segment conditions and their treatment options. • To become comfortable with FDA age guidelines and dosing for ophthalmic medications including orals • To become comfortable in treating pediatric anterior segment disorders • To instill clinical ‘pearls’ for examining children Capillary Hemangioma Capillary Hemangioma • Benign, Soft Tissue Tumor composed of blood • Location: palpebral conjunctiva, upper lid vessels • Bright red mass (superficial) • Most common orbital tumor of childhood • Blanch on pressure • 1/200 births • May bleed spontaneously • Females:Males 3:2 • When crying may enlarge • 30% at birth, 100% by 6 months • Rapid growth in first 12 months of life • Most spontaneously regress by age 5/6 • 30% age 3 • 60% age 4 • 76% age 7 1 Capillary Hemangioma Capillary Hemangioma - Evaluation • Retinoscopy • Concerns • Cardiac/neurological workup & CT/MRI of orbit • Amblyopia 25‐60% • If extensive facial dysmorphia = may be orbital • Occlusion of visual axis by lid • Posterior fossa malformation • Induced corneal astigmatism • Hemangioma • Arterial anomalies • Cardiac defects • Eye abnormalities Capillary Hemangioma - Treatment • Correct refractive error • Treat amblyopia • Steroid injection • Regression in 2‐4 weeks • Oral Beta blocker (propanolol ‐1‐2mg/kg/day) • Mechanism: vasoconstriction, reduction in pro‐ angiogenic signals • Topical timolol maleate 0.25% bid Pope E et al, Topical Timolol Gel for • Surgical excision Infantile Hemangiomas: A Pilot Study. • If severe (cosmesis), amblyopia Arch Dermatol. 2010;146(5):564-565. Ptosis • Unilateral or bilateral • Etiology • Congenital • Acquired • CNIII Palsy • Systemic • Myasthenia Gravis • Trauma • Mechanical • Chalazion/Hordeolum • Hemangioma www.aapos.org 2 Congenital Ptosis • Signs • Levator function • Upper eyelid fold • Concerns • Amblyopia • Deprivation • Induced astigmatism Horner Syndrome Neuroblastoma • Triad • Most common extracranial solid tumor in • Anisocoria dim>bright infants/children • Etiology: disruption of sympathetic nerve • 8‐10% childhood cancers supply • Overall incidence 14/100,000 • Congenital • 85% < age 5 • Iris color lighter • Abdomen • Acquired • Adrenal gland • Neuroblastoma (children) • Can metastasize • Pancost tumor of lung (adults) Ptosis Evaluation Ptosis - Treatment • Observation • Congenital • Frontalis • Treat Amblyopia • Head position • If vision deprivation or cosmetic concerns • Work Up • Surgical correction • Palpebral aperture • Acquired • Upper lid fold • Treat condition • Pupils • Myasthenia • Pearl: Direct ophthalmoscope • Neuroblastoma • Iris color • Ice pack test • MRI abdomen 3 Chalazion/Hordeolum • Treatment • Hot compresses • Topical Medications • Surgery? • Size • Duration • Risk of occlusion amblyopia • Anesthesia • Omega 3s • Oral Antibiotics? Steroid Antibiotic Combination Chronic Treatment • TobraDex (Dexamethasone 0.1%,Tobramycin 0.3%) •Omega 3 • Ages 2+ • gtts (generic) and ung • Adult dose 2‐1000 mg tid • TobraDex ST (Dexamethasone 0.3%, Tobramycin 0.05%) •Pediatric Availability • Ages 2+ • Zylet (Loteprednol 0.5%,Tobramycin 0.3%) • Chewable daily • Blepharitis and lid inflammation 0‐6 years • Maxitrol (Dexamexasone 0.1%,Neomycin,Polymixin B) • Ages 2+ • gtts and ung Macai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008;106:336-56. Oral Antibiotics • Erythromycin Ethylsuccinate (EES) – 30‐50mg/kg/day q 6 h – Formulations: 200/400 mg/5ml • Dicloxacillin – 12.5‐50mg/kg/day q 6 h • Amoxicillin – 25‐45mg/kg/day q12 h – 20‐40 mg/kg/day q8h – Formulations: 125/200/250/400 mg/5ml • Tetracycline (Ages 8+) – 250 mg qid 4 Preseptal Cellulitis Preseptal Cellulitis • Infection of eyelid anterior to septum • Examination • 5x more common than orbital • VA • Causes • Pupils • Lid/cutaneous infections • EOMS • Hordeolum/Impetigo • Slit Lamp • HSV/HZV • Treatment • URI/Sinusitis • Oral Medications • Differentials • Referral? • Allergic • Adenovirus (16%) Oral Antibiotics Oral Antibiotics • Amoxicillin, Clavulanate (Augmentin) • 20‐40mg/kg/day q 8h • Formulations: 125/200/250/400mg/5ml •Sulfa Allergy Precautions • Cephalexin (Keflex) – 1st gen •No tetracycline < 8 years • 25‐50mg/kg/day q 6h • Formulations: 125/250/500 mg/5ml •PCN Allergy Precautions • Cefaclor (Ceclor) – 2nd gen st • 20‐40mg/kg/day q 8h • Cross‐reactive to cephalosporins (1 gen)? • Formulations: 125/187/250/375 mg/5ml • Cefdinir (Omnicef) – 3rd gen • 7 mg/kg/day q 12 hr • Formulations: 125/250 mg/5ml • Trimethoprim/Sulfamethaxole (Bactrim) • 8‐12/40‐60mg/kg/day q12h Oral Antibiotics Dosing • PCN Allergy • Cross‐reactivity with cephalosporins • Follow FDA Guidelines • Need to know • Child’s weight in kg • Formulations of medication • 1 tsp = 5ml Apter AJ et al. Am J Med 2006;119, 354 Campagna JD et al. J Emerg Med 2012;42:612 5 Example 5 y/o preseptal: Example 5 y/o preseptal: • 40 lbs = 18.14 kg • 40 lbs = 18.14 kg • Keflex • Augmentin – Dose 25‐50mg/kg/day q 12 h • 20‐40mg/kg/day tid – Formulations 125/250/400mg for 5 ml • Formulations 125/200/250/400mg for 5 ml • Determine min and max mg/day • Determine min and max mg/kg – 453.5 to 907 mg/day • 362.8 to 725.6 mg/day • Therefore : • Therefore : – Can do 250mg q 12 h (500mg daily) • Can do 125 (375 daily) or 200 (600 daily) – Can do 400mg q 12 h (800mg daily) – Can do 1.5 tsp (7.5ml) of 250mg (375) q 12 h (750mg • On Rx: daily) • Giving 5ml tid (15ml/day) for 10 days so dispense • On Rx: 150 ml – 5ml bid x 10 days = 100ml – 7.5ml bid (15ml/day) x 10 days = 150ml Dermoid Cyst • Choroistoma • Congenital • Location: • Conjunctiva = Limbal dermoid • Firm • Color: variable • Concern • Associations • Goldenhar syndrome • Linear nevus sebaceous syndrome Dermoid Cyst Dermoid Cyst - Treatment • Lateral Canthus = Dermolipoma • Monitor • Ddx: prolapsed fat • Correct astigmatism • Amblyopia treatment • Surgical? 6 Allergic Conjunctivitis • Immediate hypersensitivity Type I reaction • Mast cell degranulation • Histamine and leukotriene release • Increased vascular permeability • Seasonal • Year round (Perennial) Ocular Allergy – Antihistamines, Mast Cell Allergic Conjunctivitis Stablizers, & Combination – OTC • Signs: • Ketitofen 0.025% • Bilateral injection • Zaditor • Papillary reaction – bulbar conjunctiva • Alaway • Ages 3+ • Tearing • bid • “Allergic shiner” • Olopatadine 0.1 %0.2% (Pataday) • Symptoms • bid/qd • Ages Antiallergy -Rx Antiallergy -Rx • Azelastine 0.05% (Optivar) • Cromolyn Sodium 4% • Olopatadine 0.1% (Patanol) (Crolom) • Loteprednol etabonate 0.2% (Alrex) • Olopatadine 0.7% (Pazeo) • Ages 4+ • 4‐6 times/day • daily • Safety information in pediatric patients • Vernal • Ages 2+ has not been established • Epinastine 0.05% (Elestat) • Lodoxamide 0.1% (Alomide) • Ages 2+ • Ages 2+ • • 2‐4 times a day up to 3 months Dosing: qid • Bepotastine 1.5% (Bepreve) • Vernal • Ages 2+ • Alcaftadine 0.25% (Lastacaft) Unless stated FDA approved for ages • Daily 3+ and bid • Ages 2+ • Emedastine 0.05% (Emadine) • Up to qid • Cetirizine 0.24% (Zerviate) 7 Vernal Conjunctivitis (VKC) • IgE and T cell mediated • Association: asthma, eczema, seasonal allergic rhinitis • Males>Females (2‐3:1) • Onset <10 years (5‐6 years) • Spring • Symptoms Vernal Conjunctivitis (VKC) Vernal Conjunctivitis - Treatment • Signs • Cobblestone Papillae • Ropy mucus discharge • Mast Cell Stabilizer • Injection • • Cobblestone Papillae Trantas Dots • Cornea • Steroid • Trantas dots • Shield Ulcer • Shield ulcer (5%) • Antibiotic drops • Oval • Superior • Plaque Steroids • Lotoprednol etabonate 0.2% (Alrex) • Lotoprednol etabonate 0.5% (Lotemax) • Drops, ointment and gel • QID • Fluromethalone 0.1% (FML) • Fluromethalone 0.25% (FML Forte) • Ages 2+ • bid to qid • Prednisolone Acetate 1% (Pred Forte) • Use is supported by evidence • Difluprednate (Durezol) • 0 to 3 years of age s/p cat sx Unless stated, no safety information for pediatric patients 8 Bacterial Conjunctivitis Bacterial Conjunctivitis • 50% of cases of acute conjunctivitis • Symptoms • Gigliotti. 1981 J. Pediatrics • Signs • Pathogens • Bulbar/tarsal conjunctival injection • H. flu • Hemorrhagic with H. flu • S. pneumonia • Discharge • 39% concurrent ear infection • Treatment • < 5 years old • Culture? • H. flu • Topical Medication Ointments vs. Drops? Antibiotics - Ointments • Ointment: • Erythromycin 0.5% (Ilotycin) – Neonatal prophylaxis • Easier Installation • Ciprofloxacin 0.3% (Ciloxan) – Up to 6 times/day • 2+ years • Longer lasting • Bacitracin (Ak‐Tracin, Bacticin) • tid x 2 days then bid x 5 – Safety in peds not established • Blurry vision days – 1‐3 times/day • Sulfacetamide 10%, 15% • Better for infants • Tobramycin 0.3% (Tobrex) • Rarely used • Drops: • 2+mos • 2‐3 times/day • No blur • Gentamicin 0.3% (Gentak) • More options – Safety in neonates not established • May sting – 2‐3 times/day – More toxic to cornea • Taste in mouth Antibiotics - Drops Stevens-Johnson • Life‐Threatening Skin Condition • Polymxin B+ • Aminoclycosides • Trimethoprim (Polytrim) • Tobramycin 0.3% Mucus Membranes • 2+mos • Gentamicin 0.3% • Etiology: Hypersensitivity to medications • Dose q3h (6x day) • Sulfacetamide 10%, 15% • Stings • Rarely used 9 Antibiotic Drops - Fluroquinolones • Ages (1+) Antibiotics–Azithromycin (AzaSite) • Q2h x 2 days then qid x 5 days