Pediatric Ophthalmic Infections And Injuries - Texas Children's Hospital
Pediatric OphthalmicInfections and InjuriesHoney Herce, MDAssistant Professor in the Department ofOphthalmologyTexas Children's HospitalBaylor College of Medicine
Pediatric OphthalmicInfections and InjuriesObjectivesBe able to perform a basic eye exam.Be able to manage commonophthalmic findings in children.Be able to identify key exam points forocular trauma
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Ocular Anatomyxxx00.#####.ppt 3/27/19 10:20:52 AM
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Eye Infections and Injuries Nontraumatic––Subconjunctival HemorrhageConjunctivitis–Keratitis Microbial Keratitis– Marginal KeratitisUveitis––Periorbital EcchymosisOrbital Cellulitis Traumatic–Subconjunctival Hemorrhage––Chemical BurnsIritis––Corneal AbrasionsCorneal Foreign Bodies––Orbital FracturesHyphemas/Uveitis––Lid LacerationsOpen Globexxx00.#####.ppt 3/27/19 10:20:55 AM
Get a Good History of the Child’sEyesPast eye history Prior surgeries Ocular medications Ocular diagnosesPreexisting visual impairment Amblyopia (lazy eye) Other causes of visualimpairment Use of glasses orcontact lensesEvent history Onset of complaint and associated symptoms Time, place, activity and circumstances of injury Treatment rendered prior to arrivalxxx00.#####.ppt 3/27/19 10:20:55 AM
Ocular Examination Visual Acuity––––Monocular assessment at distance or nearCheck with correction in place i.e. glasses.Depends on age.Nonverbal patients Blinks to light/Reacts to light: develops byGA 31 weeks Fixation: develops by 2-3 mos gestationalage. Pictures: Allen chart Letters: HOTV chart/matching, SnellenChart, crowding bars.xxx00.#####.ppt 3/27/19 10:20:55 AM
Ocular Examination Alignment and Ocular Motility– Check Cranial Nerves III, IV, VI.– Gross Observation– Corneal light reflex testing Hirschberg testing– Cover/Alternate cover testing– Doll’s head if necessaryxxx00.#####.ppt 3/27/19 10:20:56 AM
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Bruckner Testing Trans-Illumination testing tohelp diagnose small angledeviations and amblyopia. Uses the directophthalmoscope to illuminateboth eyes. Check red reflex Check corneal light reflex We use it to detect largerefractive errors.xxx00.#####.ppt 3/27/19 10:20:57 AM
Ocular examination Ocular Examination– Pupils Size, shape Response to direct andconsensual light Check for an relative afferent pupillary defect.– Lids/Adnexa Evaluate position of lid, contour, and periocular areas Check for evidence of lesions and edema– Orbit Inspect for symmetry and proptosis Palpate the orbit for “step-offs”xxx00.#####.ppt 3/27/19 10:20:58 AM
Ocular examination Slit Lamp– Best for examination of anteriorstructures.– Conjunctiva, Cornea, Iris, Lens,Anterior Chamber.xxx00.#####.ppt 3/27/19 10:20:59 AM
Ocular Examinations Ocular Examination– Fluorescein Staining Increased dye uptake indicative of damage to the cornealepithelial cells Can help diagnose the following:––––Corneal AbrasionChemical InjuryHerpetic DiseaseLeaking woundxxx00.#####.ppt 3/27/19 10:20:59 AM
Ocular Examination Intraocular Pressure (IOP)– Applanation– Schiotz tonometry- Tonopen- iCare.xxx00.#####.ppt 3/27/19 10:20:59 AM-Tactile
Ocular Examination Funduscopic exam– For evaluation of the opticnerve, blood vessels and retinaxxx00.#####.ppt 3/27/19 10:21:00 AM
The Non-ophthalmologist’sEye Exam Vision (near, one eye at a time) External inspection Alignment / motility Pupil reactions to light Penlight or slit lamp exam Red reflex test (Bruckner test)xxx00.#####.ppt 3/27/19 10:21:00 AM
Eye Consult TimelineUrgent – Surgical Open globes Intraocular foreign bodiesUrgent – Nonsurgical Severe chemical burns (but start irrigation at once!)– Hyphema, if total (“8-ball”) or painfulxxx00.#####.ppt 3/27/19 10:21:01 AM
Eye Consult TimelineLess urgentCorneal foreign bodies – no penetrationHyphema – partial, non-painfulAnterior segment traumaLens, irisTraumatic optic neuropathyRetinal traumaMost corneal abrasionsNon urgentSubconjunctival hemorrhageClean, small corneal abrasionsxxx00.#####.ppt 3/27/19 10:21:01 AM
Videos For ReferenceSlit Lamp Exam Video: https://www.youtube.com/watch?v 7UH4HBKYeJcRelative Afferent Pupillary Defect: https://www.youtube.com/watch?v WrNYqNH3b3Axxx00.#####.ppt 3/27/19 10:21:01 AM
Pediatric OphthalmicInfections/ Injuries Red Eye– Conjunctivitis– Keratitis– Corneal Abrasions Infectious Causes– Chalazion– Preseptal Cellulitis– Orbital Cellulitis Trauma– Traumatic Iritis– Hyphema– Corneal Foreign Body– Eyelid Lacerations– Orbital Fractures– Open Globexxx00.#####.ppt 3/27/19 10:21:01 AM
The Red EyeThe key to the RED EYE: Is it infected? Is it inflamed Is it neoplastic Is it just irritated Is it something else ?xxx00.#####.ppt 3/27/19 10:21:01 AM
Red eye is a complexnon-specific signxxx00.#####.ppt 3/27/19 10:21:02 AM
Causes of Red EyeConjunctivitisCongenital glaucoma- ViralCorneal infection- BacterialTrauma- AllergicCorneal abrasion Foreign body reaction Hyphema BurnsBlepharitis Chemical injuryChalazion Open globeUveitis JIAOrbital cellulitisSteven-Johnson syndromeRetinoblastomaxxx00.#####.ppt 3/27/19 10:21:02 AM
HistoryUnilateral vs bilateralSymptomsOnset/durationContact lens wearxxx00.#####.ppt 3/27/19 10:21:02 AM
Conjunctivitis Inflammation or infection ofthe membrane lining the eyelids Age and presentation willdictate management– Neonatal: gonorrhea,chlamydia, HSV– URI Symptoms: adenovirus– Purulent: bacterial– Allergicxxx00.#####.ppt 3/27/19 10:21:03 AM
Conjunctivitis Viral– Acute or subacute onset with usually an exposure history.– Minimal pain level .– Clear watery discharge, photophobia and itching– *Very contagious– Treatment: Self limited, supportive care with artificial tears and cool compresses. Bacterial– Acute onset, with minimal pain.– Chemotic conjunctiva, copious thich and purulent discharge– Treat with antibiotic eye drops. i.e. Polytrim Allergic–Acute to subacute onset. May be seasonal–Hallmark of symptom is itching and a clear watery discharge.–Treat with antihistamine drops and mast cell stabilizers. I.e. Zaditor, Patadayxxx00.#####.ppt 3/27/19 10:21:03 AM
Adenoviral conjunctivitis Acute onset watery discharge,photophobia and a foreignbody sensation. Usually will present aroundtime of URI symptoms. Can have pre-auricularlymphadenopathy and afollicular conjunctivitis. Can have subconjunctivalhemorrhage, moderateconjunctival chemosis and apseudomembrane formation.xxx00.#####.ppt 3/27/19 10:21:03 AM
J of Optom. Vol. 6. Num. 2.April - June 2013, 67-122.xxx00.#####.ppt 3/27/19 10:21:03 AM
Treatment No antiviral treatmentavailable Symptomatic relief – coolcompresses, artificialtears. Strict Hand Hygiene tohelp prevent spread.– Make up needs to bethrown away– Bedding cleaned.xxx00.#####.ppt 3/27/19 10:21:04 AM
Kawasaki Disease (KD) Usually presents in childrenyounger than 5, but cases ofKD in adolescents and adultshave been reported Vasculitic disease affectingseveral organ systems Concerning due to the possibledevelopment of coronaryartery aneurysms (CAA)xxx00.#####.ppt 3/27/19 10:21:04 AM
Signs/SymptomsFever 5 days4 out of the 5 symptoms: Bilateral bulbar conjunctival injection Oral mucous membrane changes (strawberry tongue,fissured lips) Peripheral extremity changes (periungualdesquamation, edema of hands or feet, palmar/soleerythema) Polymorphous rash Cervical lymphadenopathy ( 1 node 1.5c m indiameter)xxx00.#####.ppt 3/27/19 10:21:04 AM
www.kdfoundation.org/kd-symptoms/xxx00.#####.ppt 3/27/19 10:21:04 AM
Eye Signs/Symptoms Bilateral nonexudative conjunctivitis which mayspare the limbus Self-limited uveitis (anterior) may be present in70% of patients– Useful when incomplete (atypical) KDxxx00.#####.ppt 3/27/19 10:21:05 AM
Texas Children’s Hospital RecommendedTreatmentIntravenous immune globulin (IVIG) If given within 10 days can decrease the prevalence ofcoronary artery aneurysms by five-fold 2g/kg as a single infusionAspirin 50 mg/kg/day in 4 divided doses for first 14 days or untilfever resolves Then reduce dose to 5mg/kg/day single dose Discontinue aspirin if follow up echo at 6-8 weeks showsabsence of CAAxxx00.#####.ppt 3/27/19 10:21:05 AM
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Corneal Ulcers Infection of the corneal stroma. Typically occurs after disruption of the cornealepithelium.– Corneal Abrasions– Contact lens use. Always consult ophthalmology.xxx00.#####.ppt 3/27/19 10:21:06 AM
Marginal Keratitis Inflammation of the corneausually due to blepharitis. Located near the limbus. Ask for history of recurrentsymptoms, styes orchalazions Sx: eye redness, irritation,light sensitivity, foreign bodysensation. Tx: Lid scrubs and warmcompresses.xxx00.#####.ppt 3/27/19 10:21:07 AM
HSV Keratitis Primary HSV infection Patients may have a history of perioral cold sores- alsoask for family members with a history of this. Can initially manifest as unilateral – can be recurrent,conjunctivitis. (Follicular) May have had a history of vesicles on eyelid as initialpresentation. Treatment with trifluridine 1% drops or ganciclovir 0.05%ointment 5x/day. If poor compliance can also treat withPO Acyclovir 20mg/kg QID x 7 days.xxx00.#####.ppt 3/27/19 10:21:07 AM
HSV Keratitisxxx00.#####.ppt 3/27/19 10:21:08 AM
Corneal Abrasions Corneal epithelial defect Etiology– Trauma– Contact lens– Foreign body Photophobia Burning eye pain Blinking intensifies painxxx00.#####.ppt 3/27/19 10:21:09 AM
Corneal Abrasion *If you see linear abrasions, suspect a foreignbody under the eyelid.xxx00.#####.ppt 3/27/19 10:21:09 AM
Corneal abrasions Fluorescein staining. Evaluate for a foreign body. Send to PCP Treatment:– Antibiotic ophthalmic ointment Needs to be followed daily for pediatric population.– Why? If very large can cause amblyopia if nothealed properly.xxx00.#####.ppt 3/27/19 10:21:10 AM
Pediatric OphthalmicInfections/ Injuries Red Eye– Conjunctivitis– Keratitis– Corneal Abrasions Infectious Causes– Chalazion– Preseptal Cellulitis– Orbital Cellulitis Trauma– Traumatic Iritis– Hyphema– Corneal Foreign Body– Eyelid Lacerations– Orbital Fractures– Open Globexxx00.#####.ppt 3/27/19 10:21:10 AM
Chalazion A localized bump on the eyelid due to blockage ofone or more meibomian glands. (oil glands) This is different from a stye or a hordeolum whichis a small abscess due to the glands gettinginfected.xxx00.#####.ppt 3/27/19 10:21:10 AM
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Treatment Frequent warm compresses and lid scrubs helpunclog the oil glands. Anti-inflammatory eye drops and ointmentssometimes are needed. For long-standing chalazia, surgical drainage maybe necessary.xxx00.#####.ppt 3/27/19 10:21:11 AM
Preseptal Cellulitis Inflammation and infection of the tissuesanterior to the orbital septum. Swollen and erythematous lid, but the eye iswhite and motility is full. Three main routes– Direct inoculation with eyelid trauma i.e.insect bites.– Spread from contiguous structures Paranasal sinuses i.e. ethmoid disease Chalazia/Hordeoleum Dacryocystitis Impetigo HSV– Hematogenousxxx00.#####.ppt 3/27/19 10:21:11 AM
Preseptal Cellulitis Treatment: Oral antibiotics If the patient does not respond to oral antibiotics in48 hours or if suspecting orbital disease- IVantibiotics needed. CT scan if suspecting orbital cellulitis.xxx00.#####.ppt 3/27/19 10:21:12 AM
Orbital Cellulitis Infection of orbital contentsposterior to the orbital septum tisDacryoadenitisDental infectionsIntracranial infectionsTraumaPostorbital surgeryxxx00.#####.ppt 3/27/19 10:21:12 AM
Orbital Cellulitis Symptoms:– Decreased vision– Pain with eye movements– Diplopia Signs:FeverLid erythema and edemaProptosisMotility restrictionsRelative afferent pupillarydefect– Conjunctival injection– Optic nerve swelling–––––xxx00.#####.ppt 3/27/19 10:21:13 AM
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Pediatric OphthalmicInfections/ Injuries Red Eye– Conjunctivitis– Keratitis– Corneal Abrasions Infectious Causes– Chalazion– Preseptal Cellulitis– Orbital Cellulitis Trauma– Traumatic Iritis– Hyphema– Corneal Foreign Body– Eyelid Lacerations– Orbital Fractures– Open Globexxx00.#####.ppt 3/27/19 10:21:14 AM
Sports-related Injuries100,000 patients affected bysports-relatedinjuries40,00013,500of these patients can result inaccount forPERMANENTeye injuriesBLINDNESSxxx00.#####.ppt 3/27/19 10:21:14 AM90%ofthesesports-relatedinjuries can bePREVENTABLE
Serious Pediatric Eye Injuries70% require major surgery30% require 2 or more surgeries25% result in monocular blindness25% result in severe visual impairment in oneeyexxx00.#####.ppt 3/27/19 10:21:14 AM
What Activities Lead to Eye Injuries?Air rifle, BB gun,Paintball, sBicycling11%9%8%7%Football6%Most common typesare either Penetrating injuries Blunt injuries Radiation injuriesxxx00.#####.ppt 3/27/19 10:21:14 AM
Eye Injuries from TraumaMales areaffected Trauma is a leading cause of visualimpairment; usually unilateral A unilaterally blindchild is more likelyto become blindin second eyecompared tomore often bilaterallythan females sighted child9xxxx00.#####.ppt 3/27/19 10:21:15 AM
Pediatric Eye Injuries46% of90% of67% ofBB injuries fireworks injuriessports-relatedinjuriesxxx00.#####.ppt 3/27/19 10:21:15 AM20% ofMVA-relatedinjuries
Traumatic Iritis: Inflammation of theIris Following Trauma Pupil can be sluggish,dilated, irregular Photophobia Eye injected (ciliary flush, limbalflush) Slit lamp exam: cells inthe anterior chamber R/O other ocular injuriesxxx00.#####.ppt 3/27/19 10:21:15 AM
Hyphema: Blood in Anterior Chamber Due to rupture of iris vasculature Evaluate for other globe injuries Glaucoma risk– check eye pressure– Evaluate for sickle celldisease or trait. Risk of re-bleeding Place eye shield Consult ophthalmology ASAPxxx00.#####.ppt 3/27/19 10:21:15 AM
Corneal Foreign Bodies History of trauma or sudden onset foreign bodysensation/pain. Commonly metal for adults, kids (anything) Symptoms similar to corneal abrasion. Need to rule out open globe. Assess depth via slit lampxxx00.#####.ppt 3/27/19 10:21:16 AM
Corneal Foreign Bodies If no open globe. Treatment– Needs Removal by Ophthalmologyxxx00.#####.ppt 3/27/19 10:21:16 AM
Eyelid Lacerations Usually due to dog bites,trauma. Determine if full vs. partialthickness. Determine if involving the lidmargin or canaliculus. Evaluate for other ocular injury. Broad spectrum antibioticcoverage (If animal or humanbite cover with Augmentin orClindamycin) Need Tetanus prophylaxis.xxx00.#####.ppt 3/27/19 10:21:17 AM
Eyelid LacerationsAlways evaluate for possible globe injury.Always, Always, Alwaysxxx00.#####.ppt 3/27/19 10:21:17 AM
Canalicular Lacerationsxxx00.#####.ppt 3/27/19 10:21:17 AM
Orbital Fractures Periorbital ecchymosis Periorbital edema Motility restrictions– Muscle entrapment– Orbital fat entrapment– Orbital edema Orbital rim step-offs CT of face and orbits Broad spectrum antibiotics Consult– Face Trauma Team– Ophthalmologyxxx00.#####.ppt 3/27/19 10:21:18 AM
Orbital Fractures Be Careful of a white quiet eye in an orbital fracture! Trap-Door Orbital Floor Fracture. Other signs of entrapment– Oculocardiac reflex: Patient’s will have nausea and havebradycardia when asked to look up.– Increased IOP when looking in the restricted gaze. Other emergencies: Roof Fracturesxxx00.#####.ppt 3/27/19 10:21:18 AM
Open (Ruptured) GlobeSuspect if: Pupil peaked or irregular Extensive subconj. hemorrhage Decreased vision 8 ball hyphema Soft / distorted eye Prolapse of ocular contentsxxx00.#####.ppt 3/27/19 10:21:19 AM
Occult Open GlobeSuspect if: History consistent with open globe VA is markedly decreased Eye is soft Anterior chamber is shallow Pupil is peakedxxx00.#####.ppt 3/27/19 10:21:19 AM
Open Globe – Initial RxSTAY CALM Place shield over eye Elevate head Pain and Nausea Control Avoid Valsava, pressure onglobe, bending, lifting Check tetanus status Broad spectrumsystemic antibiotics Imaging, R/O FBNO TOPICAL MEDSxxx00.#####.ppt 3/27/19 10:21:19 AM
Open Globes Eye-shield placement: If you don’t have one- use astyrofoam cup. DO NOT use gauze.xxx00.#####.ppt 3/27/19 10:21:19 AM
Important Points Eye protection for childhood sports is important A pre-participation sports physical can be helpful inidentifying patients who may be at increased risk Glasses and sunglasses are not enough protection.Safety Sports eyewear that conforms to theAmerican Society for Testing and MaterialsStandard for selected sports is recommendedxxx00.#####.ppt 3/27/19 10:21:20 AM
Resource: Vision Council’s Eye SafetyAt-a-Glancexxx00.#####.ppt 3/27/19 10:21:20 AM
Questions/Comments?Thank you for your attention !xxx00.#####.ppt 3/27/19 10:21:21 AM
The Non-ophthalmologist's Eye Exam Vision (near, one eye at a time) External inspection Alignment / motility Pupil reactions to light . Needs to be followed daily for pediatric population. - Why? If very large can cause amblyopia if not healed properly. xxx00.#####.ppt 3/27/19 10:21:10 AM Red Eye - Conjunctivitis
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The physicians at Albany Med's Bernard & Millie Duker Children's Hospital are specially trained in more than 40 pediatric fields, including pediatric pulmonary disease, pediatric surgery, pediatric gastroenterology, pediatric anesthesia and pediatric neurology. Albany Med houses the region's only Pediatric Intensive Care Unit (PICU) and
