Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology for Primary Care 3rd edition_Wright, Farzavandi_2008
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Figure 13 11.
Top, Sagittal section of the upper lid showing various tear-secreting glands. Bottom, Photograph of eyelid margin showing droplets at the orifice of the meibomian glands. *Note: The meibomian gland opens at the lid margin.
secondary local inflammation (Figure 13 11, bottom). Microbial lipases from Propionibacterium acnes and other bacteria contribute to producing irritating fatty acids that increase the inflammatory response.
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Figure 13 12.
Photograph of phlyctenule in a patient with staphylococcal blepharitis. The phlyctenula is the yellow lesion at the lower lid margin surrounded by erythematous conjunctival reaction.
Meibomian gland dysfunction produces irritation, burning, and redness of the eyelid margins and conjunctiva, causing a blepharoconjunctivitis. The treatment of meibomian gland dysfunction is eyelid hygiene with baby shampoo lid washes and eyelid massage to express the meibomian glands. The use of oral erythromycin may be necessary in severe cases. Controlling meibomian gland dysfunction helps prevent chalazia.
Chalazion
Obstruction of the meibomian gland orifices may result in a chalazion, which is a constipated meibomian gland. A chalazion appears as a lump near the eyelid margin on the upper or lower lid. Because the chalazion is a swell ing of a meibomian gland, the swelling can occur externally as a lump on the skin or internally as a lump underneath the conjunctiva (Figure 13 13 A through C). A chalazion is not an infection but in fact is a granulomatous inflammation secondary to the irritating lipids within the meibomian gland. Chalazia may resolve spontaneously; however, applying hot soaks several times a day with baby shampoo eyelid washes twice per day helps drain lipid material, decompressing the chalazion. If the chalazion does not resolve over several weeks of treatment, incision and drainage may be necessary.
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A
B
C
Figure 13 13.
A, Chalazion lower lid. Note that there is a subcutaneous lid mass with some erythema. Over time, the overlying skin can become erythematous and inflamed. B, Internal chalazion where the meibomian gland has extended posteriorly under the conjunctiva. This is sometimes called pyogenic granuloma. C, Infected chalazion.
External Hordeolum
Infections of the accessory glands (Zeis and Moll) of the eyelids cause small styes called external hordeolum (Figure 13 10). They are best treated with erythromycin ophthalmic ointment and hot soaks. They can be prevented by daily eyelid washes with dilute baby shampoo.
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Molluscum contagiosum
Molluscum contagiosum is a viral disease of the skin, often occurring on the eyelids, caused by a DNA virus of the pox virus group. The lesions are small, round, discrete bumps with a central pit (Figure 13 14). They are presumed to be contagious, transmitted by direct touch. When present on the eyelid margin, they can cause a conjunctival reaction and a follicular conjunctivitis. These lesions can be treated by excising the central core or rarely, through the use of cryotherapy or application of chemical caustics such as trichloro acetic acid or aqueous phenol.
Figure 13 14.
Molluscum contagiosum.
Allergic Pediatric Conjunctivitis
Seasonal Allergic Conjunctivitis
Seasonal allergic (hay fever) conjunctivitis is very common and affects approximately 10% of the general population. The hallmark of this allergy is itching and tearing, with the eye being relatively quiet compared with the severity of the symptoms. Seasonal allergic rhinitis often accompanies seasonal allergic conjunctivitis. Seasonal allergic conjunctivitis is a type 1 hypersensitivity reaction, and conjunctival scrapings or biopsy reveals mast cells and eosinophils. Serum quantitative IgE are usually elevated, and skin tests may be positive for environmental allergen. Allergic conjunctivitis is
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most common in the spring when pollen levels are high; however, a signifi cant number of cases occur during the winter when the forced air heating is turned on and filters have not been cleaned or replaced.
A laboratory workup is usually not necessary, as a diagnosis can be made through clinical signs and symptoms. Family history may be positive for allergies, atopic disease, or asthma. For chronic, recurrent conjunctivi tis, therapy consists of removal of environmental allergens and the use of topical mast cell stabilizing agents such as cromolyn sodium, lodoxamide, and pemirolast. Mast cell stabilizers prevent the release of histamine and require 2 to 3 days of continued use to reduce symptoms. This is because mast cell stabilizers stop the release of histamines but do not inhibit activity of circulating histamines, and time is required for circulating histamines to dissipate. Topical antihistamines such as levocabastine (Livostin) provide immediate relief because they directly block histamine receptors. Newer drugs have antihistamine and mast cell stabilizer actions and they have revolutionized the treatment of allergic conjunctivitis. Topical antihistamine– mast cell stabilizers such as Patanol are used twice a day or, Pataday, once
a day; are very comfortable (no sting); and are very effective in treating allergic conjunctivitis. Many children require chronic treatment with topi cal antihistamine–mast cell stabilizers during the allergic season and even throughout the year to control symptoms. Side effects of these nonsteroidal are almost unheard of and they can be safely used on a daily basis. Control of allergic conjunctivitis with topical antihistamine–mast cell stabilizers has significantly reduced progression of allergic conjunctivitis to vernal con junctivitis, which can be vision threatening. Oral systemic antihistamines such as loratadine (Claritin) or cetirizine (Zyrtec) can be used alone or in combination with topical medication to treat allergic conjunctivitis. Topical corticosteroids are reserved for severe allergic conjunctivitis such as vernal conjunctivitis and are only used for short courses (1 to 2 weeks). If corti costeroids are used, an ophthalmologist should monitor the patient for the potential side effects of glaucoma and cataracts.
Vernal Conjunctivitis
Vernal conjunctivitis is a severe allergic condition presenting with severe itching, tearing, mucus production, and giant papillae of the upper tarsal conjunctiva (Figure 13 15). It most commonly affects young boys of the
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Figure 13 15.
Vernal conjunctivitis. An everted upper eyelid reveals a giant papillary conjunctival reaction. Patients present with severe itching, burning, and mucous discharge. Eversion of the upper lids shows the classic giant papillary reaction.
Mediterranean and Central and South American region. Patients often have reactive ptosis and squint in bright light due to secondary keratitis caused by the giant papillae scraping the cornea. There may be papillae around the limbus (junction of the sclera and cornea) with characteristic white centers (Trantas dots) that represent an accumulation of inflammatory cells (pre dominantly eosinophils). Conjunctival scrapings of the papillae show many eosinophils. The incidence of vernal conjunctivitis has dramatically dropped since the use of topical antihistamine–mast cell stabilizers for allergic conjunctivitis.
Treatment is based on avoiding allergens and daily use of topical antihis tamine–mast cell stabilizers. It is critical to use topical antihistamine–mast cell stabilizers every day (usually twice a day) without exception during the allergy season and in some cases year round to control vernal conjunctivitis. There have been virtually no side effects reported from the chronic use of topical antihistamine–mast cell stabilizers In some instances, severe episodes of inflammation can only be controlled with intermittent short courses
of topical corticosteroids. Topical corticosteroids should be administered and supervised by an ophthalmologist to monitor intraocular pressure (to rule out glaucoma) and the lens status (to rule out cataracts). Long term
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corticosteroid use should be avoided. The prognosis has improved with the chronic use of topical antihistamine–mast cell stabilizers but if uncontrolled, patients may sustain permanent vision loss as a result of corneal scarring.
Giant Papillary Conjunctivitis
Giant papillary conjunctivitis is secondary to soft contact lens use. Like vernal conjunctivitis, there are large papillae underneath the superior tarsal conjunctiva. The reaction is caused by a sensitization of the conjunctiva to allergic materials present on the surface of the contact lens or in contact lens solutions. Recommended treatment is the use of topical mast cell stabilizers such as nedocromil (Alocril), pemirolast (Alamast), cromolyn (Crolom); discontinuing contact lens wear; or changing to a regimen of frequent con tact lens replacement. Prognosis is good.
Atopic Conjunctivitis
Atopic conjunctivitis is a form of allergic conjunctivitis associated with atopic dermatitis (eczema). Serum IgE concentrations are often elevated, resulting from what appears to be a deficiency in cellular immunity (defi ciency of T suppressor cells). Patients with atopic dermatitis often have associated conjunctivitis with itching, burning, and mucus discharge. These patients have an increased risk of developing molluscum contagiosum. Symptomatic treatment of eye complaints includes using cold compresses, topical vasoconstrictors, topical antihistamines, and topical mast cell stabi lizers. Topical corticosteroids should be used for only short periods while being monitored by an ophthalmologist.
Conjunctivitis Associated With Systemic Disease
Stevens Johnson Syndrome (Erythema Multiforme Major)
Stevens Johnson syndrome is most likely a type 3 hypersensitivity reaction. It may be associated with mycoplasmal pneumonia, herpes simplex virus, and drugs such as sulfonamides, tetracycline, and penicillin. Patients present with fever, malaise, headache, loss of appetite, and nausea. There is a gen eralized erythematous papular rash. The skin is very friable and traction on
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the skin can produce tears. Mucous membranes including the nose, mouth, vagina, anus, and conjunctiva are most severely affected. Eye involvement consists of conjunctival injection and the formation of bullae that can rup ture and lead to secondary scarring. Conjunctival scarring can distort the eyelids and turn the lashes toward the cornea, causing corneal damage.
Therapy remains controversial. This author has found fewer ocular com plications if topical corticosteroids are administered early, before advanced disease leads to conjunctival scarring. A topical corticosteroid/antibi
otic combination, used every 2 to 4 hours, may prevent the severe ocular sequelae. Once conjunctival scarring occurs, however, there is no effective treatment. It is this author’s suggestion that patients with Stevens Johnson syndrome should have an immediate ophthalmology consultation, with topical corticosteroids being started promptly. In addition to topical corti costeroids, a topical antibiotic should be prescribed to prevent secondary bacterial infection. This treatment is controversial because there are no con trolled studies that establish a specific treatment protocol.
Kawasaki Disease
Kawasaki disease is a systemic vasculitis occurring in children younger than 8 years. It has an onset of fever, present for more than 5 days, along with
4 out of the following 5 criteria: non purulent conjunctivitis with limbal sparing, oral mucus membrane injection or swelling, erythema and edema of the hands and feet, polymorphous rash, and cervical lymphadenopathy. The vasculitis may involve the coronary arteries and cause a coronary aneu rysm or thrombosis that may lead to sudden death. The cause of Kawasaki disease is unknown.
Toxic Epidermal Necrolysis (Lyell Syndrome)
Toxic epidermal necrolysis is a generalized peeling of the epidermis in large geographic areas of the skin and mucous membranes and in children is actu ally the result of medication. The ocular manifestations are similar to Stevens Johnson syndrome, with acute conjunctivitis and secondary scarring being the most common presenting features. It is important that children with this syndrome be referred to an ophthalmologist for evaluation and treatment, with close follow up during the acute periods.
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Graft Versus Host Disease
Approximately 40% of patients who receive a bone marrow transplant will have graft versus host disease. Donor T lymphocytes attack the recipient cells, primarily affecting the skin, liver, intestine, oral mucosa, conjunctiva, lacrimal gland, vaginal mucosa, and esophageal mucosa. The ocular effects of graft versus host disease consist of conjunctivitis, dry eye, corneal epithe lial erosions, and corneal ulcerations. Treatment with topical artificial tears, short courses of topical corticosteroids, and in severe cases, cyclosporine may improve symptoms. These patients should be referred to an ophthal mologist for careful follow up.
Conjunctival Nevi
These are congenital or acquired lesions of the conjunctiva usually located near the corneal limbus and may be darkly pigmented or appear as pink or inflamed conjunctiva (Figure 13 16). Nevi come from melanocytes but
have varying amounts of pigmentation, with 30% having minimal pigmenta tion. Most common types include junctional, compound, and subepithelial nevi. All have low malignant potential and usually become noticeable in the first decade of life through puberty. Treatment is controversial, but growth
Figure 13 16.
Lightly pigmented compound conjunctival nevi.
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or change in pigmentation of the nevus may be an indication for surgi cal removal. Malignant melanoma is very rare in children but has been reported to occur.
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