Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology for Primary Care 3rd edition_Wright, Farzavandi_2008
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almost never interferes with vision and the red reflex is normal. Conjuncti val cultures are not routinely obtained, and patients are treated on the basis of their signs and symptoms. Table 13 4 lists the diagnosis and treatment of common types of pediatric conjunctivitis by presenting symptoms. Indica tions for an ophthalmology referral include decreased visual acuity (worse than 20/40) or an abnormal red reflex. Fluorescein staining of the corneal epithelium is indicated if a corneal abrasion is the suspected cause of the pink eye. Fluorescein staining indicates a defect of the corneal epithelium most commonly caused by a traumatic abrasion or less frequently, an infec tious process such as a bacterial corneal ulcer or herpes simplex keratitis. Be suspicious of a unilateral conjunctivitis because it may be caused by a foreign body, corneal ulcer, or herpes simplex keratitis. Table 13 5 lists the initial workup and evaluation of nonspecific pediatric pink eye.
Hemorrhagic Conjunctivitis
An alarming form of pediatric pink eye is conjunctivitis and subconjunctival hemorrhage, or hemorrhagic conjunctivitis. The most common causes
of hemorrhagic conjunctivitis include H influenzae, adenovirus, picornavi rus, and spontaneous subconjunctival hemorrhage without infection.
H influenzae hemorrhagic conjunctivitis is associated with a purplish
Table 13-4. Symptoms, Diagnosis, and Treatment
of Common Pediatric Pink Eye
Symptoms |
Diagnosis |
Treatment |
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Itching, rubbing, watery discharge, mini- |
Allergic |
Topical antihistamine mast cell |
mal injection, lower lid shiners, bilateral |
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stabilizer (Patanol twice a day) |
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Irritation, watery discharge, severe |
Viral |
No good treatment; try topical |
injection, discomfort, possible subcon- |
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antihistamine mast cell stabilizer |
junctival hemorrhage, light sensitivity; |
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(Patanol); ophthalmologist refer- |
starts unilateral but becomes bilateral. |
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ral for topical steroids. |
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Thick discharge, usually unilateral, |
Bacterial |
Topical antibiotics (Vigamox 3 or |
irritation, injection; subconjunctival |
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4 times a day) |
hemorrhage may be present (Haemoph |
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ilus influenzae). |
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Lid margin redness, eyelash crusting |
Blepharitis |
Baby shampoo lid wash every |
in morning, chronic low-grade bilateral |
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day; erythromycin ointment |
conjunctival injection, no discharge, |
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twice a day |
recurrent chalazion |
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Table 13-5. Initial Evaluation and Treatment of Nonspecific Pediatric
Pink Eye
1.History (trauma or foreign body, personal contacts, contact lens use, or allergy/itching).
2.I-ARM (inspection, acuity, red reflex, motility).
3.Fluorescein staining to identify abrasion or ulcer.
4.No itching—treat with topical antibiotic 3 times a day (eg, polymyxin B-trimethoprim, tobramycin, levofloxacin, ciprofloxacin).
5.Itching—treat with topical antimicrobial or mast cell stabilizer.
6.Refer to an ophthalmologist if a corneal ulcer is suspected, conjunctivitis worsens with treatment, or no improvement over 5 to 7 days.
discoloration of the eyelids caused by multiple tiny subcutaneous hemor rhages (Figure 13 4).
A spontaneous subconjunctival hemorrhage is a painless rupture of a small conjunctival vessel, usually for no known reasons. The conjunctiva
surrounding the hemorrhage will be normal and there is no tearing or exu date. The hemorrhage resolves without treatment and a systemic workup is usually not necessary unless the hemorrhage becomes recurrent or if there is a history of prior bleeding or bruising.
Bacterial Conjunctivitis
The conjunctiva is constantly exposed to bacteria, but conjunctival and tear defense mechanisms work to prevent infection. When bacterial infections do occur, they present as watery irritation of the eyes that can progress to a
Figure 13 4.
Patient with hemorrhagic conjunctivitis secondary to Haemophilus influenzae infection. Patient also has an otitis media. Note the purplish or violaceous hue to the eyelid.
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mucopurulent discharge (Figure 13 5). Children with a bacterial conjunc tivitis often complain that their eyelids stick together in the morning. Most often, one eye is involved; subsequently, the fellow eye becomes involved.
The bulbar conjunctiva is diffusely injected and a mucopurulent exudate is present in the inferior conjunctival fornix. The most common bacteria in children include H influenzae, Streptococcus pneumoniae, Moraxella catarrha lis, and Staphylococcus. Other organisms that cause conjunctivitis are listed in Table 13 6 and are categorized as acute or chronic bacterial infections.
In general, cultures and Gram stain are not routinely performed for mild to moderate conjunctivitis, and patients are treated with topical antibiotic drops every 4 to 6 hours. Treatment of presumed bacterial conjunctivitis usually consists of topical antibiotics. Many topical antibiotics have been effective including trimethoprim sulfate and polymyxin B sulfate (Polytrim solution) or a fluoroquinolone such as ciprofloxacin (Ciloxan), ofloxacin (Ocuflox), or levofloxacin (Quixin) and moxifloxacin (Vigamox). This author prefers a fluoroquinolone such as Vigamox because it provides broad spectrum coverage including Haemophilus, it is highly effective
even with dosage 3 times a day, and the drop does not sting. Consider an ophthalmology referral for severe conjunctivitis or a chronic conjunctivitis that does not improve after 7 days of treatment.
Figure 13 5.
Severe bacterial conjunctivitis with mucopurulent discharge.
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Table 13-6. Causes of Bacterial Conjunctivitus
Acute Conjunctivitis
1.Staphylococcus aureus
2.Haemophilus aegyptius
3.Haemophilus influenzae
4.Streptococcus pneumoniae
5.Streptococcus pyogenes
6.Beta streptococcus
7.Pseudomonas aeruginosa
8.Corynebacteria diphtheriae
9.Moraxella catarrhalis
Chronic Conjunctivitis
1.Staphylococcus aureus
2.Moraxella lacunata
3.Proteus
4.Klebsiella
5.Serratia
6.Beta streptococcus
Viral Conjunctivitis
Viral conjunctivitis is usually caused by an adenovirus and is extremely contagious. Patients often present with a history of one eye involvement and subsequent second eye involvement. There is severe tearing, redness, and the sensation of having a foreign body lodged in the eye. This combina tion of findings is termed catarrhal conjunctivitis. In children, the eyelids may be quite swollen and present with reactive ptosis as well as severe conjunctival hyperemia and hemorrhagic conjunctivitis. The cornea may be involved; in these cases, patients are very light sensitive (photophobia). Often, there is a history of other family members or friends having pink eye.
Pharyngoconjunctival Fever
Pharyngoconjunctival fever is usually seen in children and consists of an upper respiratory infection (pharyngitis and fever) with bilateral conjuncti vitis. It is most commonly associated with adenovirus types 3 and 7. There is a severe, watery conjunctival discharge; hyperemic conjunctivitis; chemosis (conjunctival edema); preauricular lymph adenopathy; and quite often, a foreign body sensation due to corneal involvement. The disease is highly contagious and lasts approximately 2 to 3 weeks.
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Epidemic Keratoconjunctivitis
Epidemic keratoconjunctivitis (EKC) is caused by adenovirus types 8, 19, and 37 and occurs most often in older children and adolescents. In contrast to pharyngoconjunctival fever, EKC is isolated to the eyes. This is a severe bilateral conjunctivitis with conjunctival hyperemia, watery discharge, eyelid swelling, and a reactive ptosis (Figure 13 6). Petechial conjunctival hemorrhages are also common. In addition, there may be a pseudomem brane along the conjunctiva and pre auricular lymphadenopathy is often present. Usually, one eye is involved first and several days later the second eye becomes infected.
Approximately one third of patients develop corneal inflammation (keratitis) with subepithelial infiltrates, 7 to 10 days after onset of the con junctivitis (Figure 13 7). The keratitis is a hypersensitive reaction to the
Figure 13 6.
Epidemic keratoconjunctivitis bilateral involvement. A, Note the severe lid swelling, right eye, and tearing, left eye. There is a wide spectrum of severity; some are mild while others present with a severe conjunctivitis that may have severe lid swelling and the appearance of a preseptal cellulitis. B, A lid speculum is placed to open the right eye to show a severe hemorrhagic conjunctivitis.
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Figure 13 7.
Subepithelial infiltrates of the cornea associated with epidemic keratoconjunctivitis. These infiltrates occur during the second week of the infection and may persist for several months or longer. The infiltrates represent an immune response to the disorder and will resolve spontaneously.
virus, not a true viral infection. Corneal infiltrates cause severe photophobia and irritation.
The treatment of adenoviral conjunctivitis is prevention of further trans mission. If a patient presents with possible adenoviral conjunctivitis, be sure to thoroughly wash everything before seeing another patient. A patient with this disease will be contagious for up to 2 weeks and should observe isolation precautions during this time. Because of the possibility of corneal involvement, patients with adenoviral conjunctivitis should be referred to an ophthalmologist. Unfortunately, there is no effective antiviral treatment at this time. Cold compresses and topical nonsteroidal anti inflammatory drops may reduce symptoms. Because of the contagious nature of the adeno viral conjunctivitis, a scraping for viral antigen quick prep is indicated. If positive, patients should not return to school for 1 to 2 weeks. Topical cor ticosteroids historically have been discouraged except for the treatment of keratitis. Recent data suggest that the early use of topical corticosteroids may reduce the incidence and severity of the post viral keratitis. If given, topical corticosteroids should be administered only by an ophthalmologist.
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The corneal disease from recurrent herpes simplex virus affects the cor neal surface epithelium. Active viral replications cause punctate, dendritic, or geographic epithelial defects. The dendritic pattern is a classic sign of herpes simplex keratitis (corneal infection) (Figure 13 9). Recurrent herpes keratitis is almost always unilateral. In addition, the cornea becomes anes thetized because of sensory nerve damage. With recurrent herpes, the cor nea can scar and a secondary inflammatory reaction can occur in response to the viral antigen.
The treatment for acute recurrent herpes keratitis is topical antivirals, usu ally trifluridine (Viroptic) 1% every 2 hours while awake. Systemic treatment with acyclovir has been shown to be effective. Long term use of oral acyclovir has been shown to be useful in preventing recurrence of herpes keratitis (Isenberg et al; Rezende et al). Topical corticosteroids are not indicated for active herpes keratitis because this will decrease the body’s immune response.
Herpes Zoster and Varicella Zoster Virus
Chickenpox, or varicella zoster, rarely affects the eye even when vesicular lesions occur on the eyelid or eyelid margin. Some physicians have advo cated topical trifluridine (Viroptic) 1% every 2 hours if the conjunctiva
Figure 13 9.
Active herpes keratitis with both dendritic and geographic patterns. Superiorly at the limbus is the confluent area of staining showing a geographic pattern, while the mid-cornea shows the branching, dendritic pattern.
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becomes involved; however, oral acyclovir early in the course is the preferred treatment. In immunocompromised patients, herpes zoster can present a high risk; these patients especially should be treated with antivirals. Second ary or recurrent herpes zoster ophthalmicus is a disease striking patients older than 50 years or immunocompromised children. Herpes zoster oph thalmicus is a severe ocular inflammation and can affect all layers of the eye.
Blepharitis
Blepharitis, or eyelid inflammation, is one of the most common causes of pediatric pink eye. The 2 most common types of blepharitis are staphylo coccal blepharitis and meibomian gland dysfunction. Both types of ble pharitis are treated with lid hygiene (baby shampoo lid scrubs) and topical antibiotics.
Staphylococcal Blepharitis
Children with staphylococcal blepharitis complain of itching and burning and often awaken with their eyelids stuck together with crusting. Their eyes are irritated but there is not the “true” itching as there is in patients with allergic conjunctivitis. Other signs of staphylococcal blepharitis include crusting and scales at the base of the eyelashes. Scales that encircle an eye lash are called collarettes. The eyelid margins are thickened and hyperemic with vascularization of the eyelid margin. Over time, lashes may become misdirected, broken, or absent (madarosis). The formation of a stye or external hordeolum is common. An external hordeolum is an abscess of the gland of Zeis on the anterior eyelid margin (figures 13 10 and 13 11). This is in contrast to a chalazion, which is deeper and represents inflam mation of the meibomian gland secondary to breakdown of the fatty secre tions. Blepharitis may be associated with corneal changes that cause severe photophobia. These corneal deposits represent an immunologic response to the bacterial antigen.
Treatment of staphylococcal blepharitis includes eyelid hygiene and topical antibiotic ointment, usually erythromycin, applied 3 times a day. In severe cases, systemic erythromycin may be indicated. Eyelid
hygiene may include baby shampoo lid scrubs twice a day. Prevention of recurrent blepharitis consists of ongoing lid hygiene. Eyelid cultures are
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Figure 13 10.
Staphylococcal blepharitis with small external hordeolum.
not routinely performed because most eyelids are normally colonized with staphylococcus organisms.
Phlyctenular Conjunctivitis
Phlyctenular conjunctivitis is a delayed hypersensitivity reaction to bacterial protein, usually associated with staphylococcal blepharitis. The lesions are usually located at the 3 and 9 o’clock position around the limbus and are creamy white or yellowish colored elevated nodules with a surrounding ery thematous base (Figure 13 12). Treatment consists of treating the blephari tis (lid scrubs and topical antibiotics) and the use of topical corticosteroids. If topical corticosteroids are recommended, treatment should be monitored by an ophthalmologist. When tuberculosis was prevalent, it was a significant cause of phlyctenulosis. Patients with phlyctenular conjunctivitis, who are at risk for having tuberculosis, should have a tuberculosis workup.
Meibomian Gland Dysfunction—Blepharitis
Meibomian glands are sebaceous glands with orifices at the eyelid margins (Figure 13 11, top). Meibomian gland secretions consist of sterol esters and waxes that provide a covering to the tear film, thereby preventing evaporation. Dysfunction or blockage of the meibomian gland orifice by desquamated epithelial cells results in stagnation of the lipids and causes a