Ординатура / Офтальмология / Английские материалы / Oxford American Handbook of Ophthalmology_Tsai, Denniston, Murray_2011

616 CHAPTER 18 Pediatric ophthalmology

Table 18.13 Orbital tumors of childhood (selected)

Abnormal eye size

Abnormalities of globe size usually result from abnormalities of development, although it may arise secondary to ocular disease (e.g., buphthalmos in glaucoma) (Table 18.14). While severe forms may be obvious from simple observation, milder isolated aberrations of size may only be evident as an axial refractive error.

Table 18.14 Abnormal eye size: causes and key features

Abnormally large eye

COMMON CLINICAL PRESENTATIONS 617

Common clinical presentations: cloudy cornea and leukocoria

Opacification of the cornea, lens, or posterior structures is usually associated with poor vision and may indicate serious, even life-threatening, pathology.

Cloudy cornea

Corneal opacities may be focal (either central or peripheral) or diffuse in nature (Table 18.15). They may be an isolated finding, associated with other ocular abnormalities, or part of an inherited syndrome. They may be congenital, acquired at birth, or develop during childhood.

Leukocoria

All patients with leukocoria (Table 18.16) must be urgently assessed for the possibility of retinoblastoma. Congenital cataracts are generally easily identified. Other conditions may be less readily differentiated from retinoblastoma, most commonly persistent fetal vasculature syndrome, Coats’ disease, toxocara infection, and ROP.

Table 18.15 Corneal opacities: etiologies and key features

618 CHAPTER 18 Pediatric ophthalmology

Table 18.16 Leukocoria: etiologies and key features

620 CHAPTER 18 Pediatric ophthalmology

Table 18.17 Clinical features of congenital toxoplasmosis

Table 18.18 Clinical features of congenital syphilis

Early disease (<2 years of age)

Table 18.19 Clinical features of congenital rubella

Table 18.20 Clinical features of congenital CMV

Table 18.21 Clinical features of congenital HSV

OPHTHALMIA NEONATORUM 621

Ophthalmia neonatorum

Ophthalmia neonatorum is defined as a conjunctivitis occurring within the first month of life. Organisms are commonly acquired from the birth canal. The main risk factor is therefore the presence of sexually transmitted disease in the mother.

Ophthalmia neonatorum affects up to 12% of neonates in the Western world and up to 23% in developing countries. It is potentially sight threatening and may cause systemic complications. In some countries (including the United States), it is a reportable disease (within 12 hours).

Gonococcal neonatal conjunctivitis

Clinical features

•Hyperacute (within 1–3 days of birth), with severe purulent discharge, lid edema, chemosis, ± pseudomembrane, ± keratitis.

Investigation

•Prewet swab or conjunctival scrapings: immediate Gram stain (gramnegative diplococci), culture (chocolate agar), and sensitivities.

Treatment

•Ceftriaxone 50 mg/kg IV 1x/day 1 week; frequent saline irrigation of discharge until eliminated.

•After appropriate counseling, refer mother (with partner) to urogenital physician.

Chlamydial neonatal conjunctivitis

This is the most common cause of neonatal conjunctivitis. A papillary rather than follicular reaction is seen from delayed development of palpebral lymphoid tissue.

Clinical features

•Subacute onset (4–28 days after birth), mucopurulent discharge, papillae, ± preseptal cellulitis.

•Systemic (uncommon): rhinitis, otitis, pneumonitis.

Investigation

•Prewet swabs are usually for immunofluorescent staining, but cell culture, PCR, and ELISA may be used.

•Conjunctival scrapings: Giemsa stain.

Treatment

•Erythromycin 25 mg/kg 2x/day for 2 weeks.

•After appropriate counseling, refer mother (with partner) to urogenital physician.

Other bacterial neonatal conjunctivitis

Other bacterial causes include Staphylococcus aureus, Streptococcus pneumoniae (which require topical antibiotics only), and Haemophilus and Pseudomonas (which requires additional systemic antibiotics to prevent systemic complications).

Clinical features

•Subacute onset (4–28 days after birth), purulent discharge, lid edema, chemosis, ± keratitis (Pseudomonas)

622 CHAPTER 18 Pediatric ophthalmology

Investigation

• Prewet swab or conjunctival scrapings: Gram stain, culture, sensitivities.

Treatment

•Gram-positive organisms: topical (e.g., erythromycin ointment 4x/day); adjust according to sensitivities.

•Gram-negative organisms: topical (e.g., tobramycin ointment 4x/day); adjust according to sensitivities.

HSV neonatal conjunctivitis

Although viral causes of neonatal conjunctivitis are uncommon, they may cause serious ocular morbidity and systemic disease.

Clinical features

•Acute onset (1–14 days), vesicular lid lesions, mucoid discharge ± keratitis (e.g., microdendrities), anterior uveitis, cataract, retinitis, optic neuritis (rare).

•Systemic (uncommon but may be fatal): jaundice, hepatosplenomegaly, pneumonitis, meningoencephalitis, disseminated intravascular coagulopathy (DIC).

Investigation

•Swab or conjunctival scrapings transported in viral culture medium; PCR.

•Newborns with ocular HSV infection must be evaluated for systemic infection. There should be a very low threshold for hospital admission and systemic antiviral treatment.

Treatment

•Acyclovir ointment 5x/day for 1week ± acyclovir IV 10 mg/kg 3x/day for 10 days.

Chemical conjunctivitis

Silver nitrate drops are commonly used in some parts of the world as a protective measure against ophthalmia neonatorum (Table 18.22). While effective against gonococcal disease, they are of limited use against other bacteria and are of no use against Chlamydia or viruses. In most neonates the drops cause red, watery eyes 12–48 hours after instillation.

Conjunctivitis in the older child

Children are commonly affected by infective and allergic conjunctivitis. In the older child, it behaves in a more similar manner to adult disease: viral (p. 142), bacterial (p. 140), chlamydial (p. 144), and allergic (p. 146).

Table 18.22 Timing of onset of ophthalmia neonatorum by etiology

ORBITAL AND PRESEPTAL CELLULITIS 623

Orbital and preseptal cellulitis

Orbital cellulitis may cause blindness and even death. It requires emergency assessment, imaging, and treatment under the joint care of an ophthalmologist, ENT specialist, and pediatrician. Part of the ophthalmologist’s role is to assist in differentiating orbital cellulitis from the more limited preseptal cellulitis.

Orbital cellulitis

Infective organisms include Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, and Haemophilus influenza (previously common in younger children, but less likely if Hib vaccinated).

Risk factors

•Sinus disease: ethmoidal sinusitis (common), maxillary sinusitis.

•Infection of other adjacent structures: preseptal or facial infection, dacrocystitis, dental abscess.

•Trauma: septal perforation.

•Surgical: orbital, lacrimal, and vitreoretinal surgery.

Clinical features

•Fever, malaise, painful, swollen orbit.

•Inflamed lids (swollen, red, tender, warm), proptosis, painful restricted eye movements ± optic nerve dysfunction (dVA, dcolor vision, RAPD).

•Complications: optic nerve compromise is the most important; also exposure keratopathy, iIOP, CRAO, CRVO.

•Systemic: meningitis, cerebral abscess, cavernous sinus thrombosis, orbital or periorbital abscess.

Investigation

•Temperature.

•CBC, blood culture.

•CT (dedicated CT for orbit and sinuses; possibly brain): diffuse orbital infiltrate with fat stranding, proptosis ± sinus opacity, orbital abscess.

Treatment

•Admit for intravenous antibiotics (e.g., either floxacillin 25 mg/kg 4x/day or cefuroxime 50 mg/kg 4x/day with metronidazole 7.5 mg/kg 3x/day).

•ENT specialist to assess for sinus drainage (required in up to 50%).

Preseptal cellulitis

Preseptal infection is much more common than orbital cellulitis. The main causative organisms are once again staphylococci and streptococci.

This is generally a less severe disease, at least in adults and older children (see Table 18.23). In younger children in whom the orbital septum is not fully developed, there is a high risk of progression, thus the disease should be treated similarly to orbital cellulitis.

624 CHAPTER 18 Pediatric ophthalmology

Clinical features

•Fever, malaise, painful, swollen lid/periorbita.

•Inflamed lids but no proptosis, normal eye movements, normal optic nerve function.

Investigation

Investigation is not usually necessary unless there is concern about possible orbital or sinus involvement (Table 18.24).

Treatment

•Admit young or ill children; otherwise daily observation is sufficient until disease resolution.

•Treat with oral antibiotics (e.g., floxacillin and metronidazole).

Table 18.23 Differentiating features of orbital vs preseptal cellulitis

Table 18.24 Development of paranasal sinuses