Download Mom, There`s Something Wrong With My Eye…

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
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What does this baby have ?
A. Viral Conjunctivitis
B. Chemical Conjunctivitis
C. Allergic Conjunctivitis
D. Bacterial Conjunctivitis
E. All of the above
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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
– 
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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
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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
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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
•  Treatment:
h"p://www.eyespecialist.com.sg/Eye-­‐Condi8ons-­‐Services_575/Eye-­‐Condi8ons-­‐
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!!!
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Infantile Glaucoma
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What Does this Baby Have?
A. Herpes dermatitis
C. Preseptal cellulitis
B. Sebaceous gland
carcinoma
D. Chalazion
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Chalazion/ Hordeolum in Children
•  History:
–  Recurrent history of
blepharitis or rosacea
•  Signs and Symptoms
–  Visible or palpable
well-defined subcutaneous
nodule
–  Discharge with anterior or
posterior fistulization
–  Hordeolum vs Chalazia
•  Treatment
–  Instruction:
Warm compresses
for 10-15 minutes
–  Drainage or discharge
Bacitracin or
Erythromycin oint
–  Failure 4 weeks
consider Surgical
drainage of Chalzia
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Chalzion Drainage
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What Does this Baby Have?
A. Exotropia
B. Esotropia
C. Pseudostrabismus
D. 6th Cranial nerve
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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
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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
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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
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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
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Imaging
Suprasellar Mass causing Pupil involving 3rd nerve palsy
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What Does this Boy Have?
A. Exotropia
B. Esotropia
C. Pseudostrabismus
D. 6th Cranial nerve
E. Something else
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What Does this Baby Have?
A. Cataract
B. Vitreous Hemorrhage
C. Retinal detachment
D. Retinoblastoma
E. Retinopathy of
Prematurity
F. All of the above
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Differential Diagnosis of Leukocoria
“White Pupil”
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Retinoblastoma
PHPV
Cataract
Retinopathy of Prematurity
Toxocariasis
Coloboma of Choroid
Uveitis
Coat’s Disease
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Vitreous Hemorrhage
Retinal Dysplasia
Tumors
Retinal Detachment
Corneal Opacity
Myelinated Nerve Fibers
Retinal Astrocytic
Hamartomas
(Tuberous Sclerosis)
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Urgent or Emergent?
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Urgent or Emergent?
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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.
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Same eye rebleed 3-5 days later
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The Weakest Link
•  The canaliculus
•  Almost any tearing injury
will damage the lacrimal system
–  Fingers, car doors, display hooks
–  DOG BITES!!
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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
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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
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