Ординатура / Офтальмология / Английские материалы / Pediatric Opthalmology_Mukherjee_2005

(c) Endophthalmitis,

(d) Cellulitis—Orbit, lids

(e) Cavernous sinus thrombosis.

3. Systemic condition. Hypoproteinemea, thyrotoxicosis, myxedema, emphysema :

(a) In the head neck area, (b) fracture of paranasal sinuses, hypersensitivity to drugs, nephrotic syndrome.

Treatment

(1)In mild cases of chemosis without infection or systemic involvement local vasoconstrictors relieve the symptoms.

(2)Acute allergic chemosis may require local steroid drops.

(3)In chemosis secondary to infection like ophthalmia neonatorum, endophthalmitis and panophthalmitis treatment is directed towards the primary cause.

4. Systemic causes are best treated in consultation with pediatrician.

Subconjunctival haemorrhage. Sub-conjunctival haemorrhage is yet another common symptom that makes alarmed parents to bring the child to the ophthalmologist. The subconjunctival haemorrhage is most alarming when it occurs in the bulbar conjunctiva where a small speck of redness stands out prominently against white sclera. Subconjunctival haemorrhage in the hidden part of the conjunctiva may go unnoticed.

Subconjunctival haemorrhage is in fact an intraconjunctival bleeding when blood accumulates between the sclera and deeper layers of conjunctiva. If the same blood breaks the anterior surface of the conjunctiva then it results into conjunctival bleeding.

Subconjunctival haemorrhage may be unilateral or bilateral. It may have only conjunctival involvement or may be associated with orbital or systemic condition.

Causes of subconjunctival haemorrhage are : 1. Trauma

(a) Direct trauma to conjunctiva. Accidental or surgical trauma may range from small foreign body to large lacerated wound. The wound could be blunt or penitrating. Amount of sub conjunctival haemorrhage is not always proportional to the trauma. Trivial injury can give rise to large haemorrhage while large cuts in conjunctiva may give rise to surprisingly small haemorrhage.

(b) Trauma to orbit. In fractures of orbital walls, and para nasal sinuses sub conjunctival haemorrhage appear few hours after the actual incident as it takes time for the blood to trickle down either along the orbital wall or along the recti muscles. These haemorrhages appear gradually, spread towards the cornea, hence the outermost limit of these haemorrhages are not visible.

(c) Head Injury : (i) Scalp injuries may cause moderate to severe haemorrhage in the conjunctiva. Generally they are associated with ecchymosis of lids and take hours to manifest following injury. (ii) Fracture base of skull is associated with delayed development of such conjunctival haemorrhage in which outer limit is not visible. There may be epitaxis and bleeding from the ears.

(d) Remote injuries. Multiple fractures of long bone or crush injury of the chest and abdomen may produce sub conjunctival haemorrhage generally as streaks in the fornices.

(e) Indirect injury :

(1) Rupture of conjunctival vessels : (i) Sudden recurrent rise of intra thorasic pressure may cause rupture of conjunctival vessels. This is most commonly seen in a child with a whooping cough. It is such a constant feature that if there is no history of trauma in presence of sub conjunctival haemorrhage the first thing that should come to mind of the treating physician is that the child is not immunised against whooping cough and must be directed to pediatrician to exclude possibility of whooping cough. (ii) Rupture of telangiectasia may also lead to sub conjunctival haemorrhage.

2.Infection. Some of the conjunctivitises regularly produce sub conjunctival haemorrhages generally as patechea which may join to form large patch of sub conjunctival haemorrhage. The causes are—pneumococcal conjunctivitis, membranous and pseudo membranous conjunctivitis, epidemic conjunctivitis, haemophilus conjunctivitis.

3.Systemic conditions. In adults diabetes, hypertension and arterio-sclerosis are main systemic causes of sub conjunctival haemorrhage. In children blood dyscrasias are main systemic causes of sub conjunctival haemorrhage. It is commonly seen in thrombo cyto penic purpura, leukemia and aplastic anaemia or idiopathic. There may be a group of children with sub conjunctival haemorrhage for which no etiological factor can be pinpointed in spite of numerous investigations. These are mostly due to trivial injuries.

Treatment. Traumatic sub conjunctival haemorrhage unless associated with laceration of conjunctiva do not require any treatment except reassurance. However the bright red colour against white background is so alarming that patient shift from ophthalmologist to ophthalmologist till the blood clears. If the outer limit of subconjunctival haemorrhage is not visible. A neuro ophthalmic work up should be done along with CT and MRI. In subconjunctival haemorrhage associated with ocular infection or systemic disorder treatment should be directed towards primary disorder.

Conjunctival bleeding

Frank bleeding from the conjunctiva is relatively infrequent as compared to sub conjunctival bleeding. It happens when conjunctiva is cut or lacerated or when large sub conjunctival haemorrhage ruptures over the surface. A haemangioma or telangiectasia may also bleed into conjunctival sac. A rhinosporidiosis granuloma in the upper fornix may present as recurrent bleeding from the conjunctiva.

Conjunctival follicles

Conjunctiva is rich in lymphoid tissue, any assault to it microbial or chemical results in its proliferation as small nodules called follicles. They are less frequent in adults and do not develop during first three months of life. Their presence is not always diagnostic specially if they are in lower fornix or lower tarsal conjunctiva. Their presence in upper tarsal conjunctiva denote chronic viral infection and trachoma. Presence of follicles along with conjunctivitis is called follicular conjunctivitis which is very common in children and are mostly self limiting. Folliculosis can be acute or chronic, in the former they last less than one month. If follicle persists for more than one month, the condition is called chronic follicular

conjunctivitis. Number, size, position and location of follicles depend upon duration, severity and type of conjunctivitis. The size vary between 1mm to 2mm, they are pale, round, raised bodies. They neither contain blood vessels nor blood vessels pass over them.

Causes of follicle formation are : Trachoma, simple follicular conjunctivitis in children and drugs.

Treatment. Follicles themselves do not require any treatment. Treatment should be directed to primary cause specially trachoma.

Conjunctival papillae

Papillae formation is a non specific vascular reaction to infection and allergy in contrast to lymphoid reaction of the follicle. A papilla develops when the conjunctiva gets anchored to either tarsus or limbus by fine fibrous septa. A tuft of blood vessels grow from beneath to reach the basement membrane of the conjunctival epithelium. This vessel then radiates like spokes of a wheel. The papillae are mostly seen on the upper tarsus and near the limbus. They are larger than follicles. Size of papillae vary from 1mm to 5mm. When papillae are small the conjunctiva is velvety and smooth. A hyperemic papillae represent bacterial and chlamydia infection. Large polygonal flat topped papillae in upper tarsus are seen in vernal conjunctivitis. Papillae in lower tarsus is seen in atopic conjunctivitis. Limbal papillae are seen in limbal form of spring catarrh. They are not seen over bulbar conjunctiva or caruncle.

Scarring of conjunctiva

Conjunctiva being highly vascular and lax at mostof the places. Scarring is less common in bulbar Conjunctiva unless the wound has not been repaired well. To avoid ugly scar in bulbar Conjunctiva, a lacerated conjunctiva should be repaired in layer i.e. conjunctiva and Tenon’s capsule separately. Stitching should approximate the cut ends properly. Scarring in palpebral conjunctiva is seen best in the tarsal conjunctiva as opaque star shaped areas that obscure the tarsal gland and its ducts commonly in trachoma. Scarring of fornices is seen following mechanical trauma, acid, alkali burn, Steven’s Johnson’s syndrome and ocular pemphigus. The scarring may be strong enough to produce deformity of the lid resulting in entropion in adults.

Conjunctival discharge

Normal conjunctiva is always wet due to constant flow of tears. Any irritation of conjunctiva results in reflex production of tear in excess but this does not contain any formed matter like mucus, cells, or pus. Presence of discharge is indication of conjunctival inflammation microbial or allergic. Conjunctival discharge contains exudated fluid from dilated vessels. It also contains tear, mucus, pus, micro-organism, inflammatory cells and sometimes RBC. Conjunctival discharge varies in character in different types of conjunctivitis.

Watery discharge is seen in viral conjunctivitis, and chemical conjunctivitis of short duration. If there is super added bacterial infection the discharge becomes thick with more mucus and exudate.

Muco purulent discharge is seen in milder form of bacterial conjunctivitis. Purulent discharge is characteristics of gonococcal conjunctivitis. Ropy discharge is typical of spring catarrh. Mucinous discharge is seen in some of the dry eye syndromes.

Cytology of discharge. Identification of cells in discharge have diagnostic significance. Predominant polymorphonuclear cells in bacterial conjunctivitis. Lymphocytic preponderance is met in chronic conjunctivitis, viral conjunctivitis and toxic conjunctivitis. Eosinophils are seen in allergic conjunctivitis.

Conjunctival membrane formation

Deposition of coagulated material transudate on the surface of the conjunctiva in a sheet form is called conjunctival membrane. It has been divided in to two types :

1.True membrane, where the coagulum penetrates the conjunctival epithelium and can not be peeled off without tearing the conjunctival epithelium which in turn produces bleeding.

2.Pseudo membrane is a milder form where the sheet can be removed with ease without bleeding. The pseudo membrane is in fact a milder form of inflammation and the same organisms that produce pseudo membrane may, in severe form produce true membrane. Previously diphtheria was the only organism thought to be capable of true membrane formation. The organism that produce pseudo/true membrane could be viral, bacterial, fungal or chemical. The organisms are - Herpes simplex, epidemic kerato conjunctivitis, diphtheria. It may be seen in erythema multi formis, and some alkali burns. Severe form of membrane formation may not only cover the conjunctiva but also may hamper its nutrition. End-result of membranous conjunctiva is xerophthalmia, symblepharon, ankyloblepharon, trichiasis and rarely entropion.

Granulomas of conjunctiva

Granulomatous lesions of conjunctiva may be due to either exogenous causes or endogenous causes, latter are more common. Exogenous cause of conjunctival granuloma are - Embedded foreign bodies, both organic and inorganic. They may be inert or chemically active. They may be small wooden particles, wings and other parts of insect body, caterpillar hair (ophthalmia nodosa), hair from cacti, suture material and scleral implants. Endogenous granulomas are seen in Tuberculosis, leprosy, syphilis, oculosporidiosis, burst chalazia.

Conjunctival ulcers are rare, mild and self limiting. They are seen in tuberculosis, herpes simplex, Stevens-Johnson’s Syndrome, chemical burn.

Cysts of conjunctiva

Cysts of conjunctiva can be part of congenital anomaly or acquired. They may be seen anywhere on the conjunctiva but commonest sites are the fornices and limbus. They may be small enough not to be noticed by the patients or large to draw attention, generally they are painless, non tender, non reducible, translucent, may be punctured only to get filled.

Conjunctival cysts may be : 1. Congenital, 2. Acquired.

1.Congenital cysts—These are rare, they can be cystic form of limbal dermoids or congenital corneo scleral cysts.

2.The acquired cysts can be traumatic or non traumatic.

A. Traumatic cysts :

(i) Accidental. Following lacerated conjunctival wound that has not been repaired properly.

(ii) Surgical wounds in squint, retinal detachment, pterygium which have not been repaired well.

(iii) Cystoid cicatrix following glaucoma surgery or badly repaired wound at limbus. (iv) Cyst over iris prolapse.

(v) Conjunctiva covering prolapsed, vitreous and uvea.

(vi) Phacocele. This is seen when there is corneo scleral injury and the lens with intact capsule is extruded under the conjunctiva. It is not a true cyst.

B. Non-traumatic cyst :

(i) Lymphatic cyst—These are generally small cysts anywhere in the conjunctiva without symptom, do not require treatment.

(ii) Degenerative cyst—Sometimes pterygia undergo cystic degeneration at apex. (iii) Parasitic cyst—Cysticercus and hydatid cyst.

(iv) Retention cyst.

INFLAMMATION OF CONJUNCTIVA

Conjunctivitis is commonest eye disease seen in children. It may be seen soon after birth as ophthalmia neonatorum that is very serious in nature and if not attended, may be vision threatening or may be just mild hyperemia. Conjunctivitis may be acute, sub-acute or chronic. They are mostly bilateral. In children they are diffuse. Most of them are self limiting.

There are two main groups of conjunctivitis i.e. Microbial and Allergic. Besides this there is a large group of conditions where exact etiology is not known. Some of the systemic diseases may also produce conjunctivitis.

Microbial conjunctivitis are generally due to exogenous organisms, while allergic conjunctivitis can be both due to exogenous or endogenous allergen. Microbial (Infectious) conjunctivitis can be caused by Bacteria, virus, chlamydia fungi, parasites.

Bacteria causing conjunctivitis can be cocci, bacilli, mixed, may be gram positive or gram negative. However conjunctivitis is more frequent with cocci than, bacilli. Common bacteria that produce conjunctivitis are :

1.Neisseria gonorrhoea and N. meningitis, both produce purulent conjunctivitis, former is more serious.

2.Pneumococci, Koch-Weeks (H aegypti). They produce acute muco purulent conjuncti-

vitis.

3.Haemophilus influenzae produces subacute conjunctivitis.

4.Staphylococcus aureus produces chronic blephroconjunctivitis.

5.Coryy bacterium diphtheriae produces membranous conjunctivitis.

6.Neisseria gonococci and C. diphtheriae may have serious systemic involvement in

children.

7.Many of the non pathogenic bacteria may become pathogenic and cause conjunctivitis.

Viruses responsible for conjunctivitis in children are :

Herpes simplex, herpes zoster, measles, chicken pox, pharyngo conjunctival fever (adeno virus 3 and 7), epidemic kerato conjunctivitis (adeno virus 8 and 19), acute haemorrhagic conjunctivitis, molluscumcontagiosum.

CONJUNCTIVITIS

Conjunctivitis in children differ from those in adult. Some of the conjunctival infections like ophthalmia neonatorum and diphtheretic conjunctivitis are not only vision threatening, they can be life threatening also. Best classification of conjunctivitis would be on the basis of etiology. However some of the organisms produce identical clinical picture and are amenable to same treatment, hence for the sake of convenience infectious conjunctivitis will be discussed according to their mode of presentation i.e. Acute, sub-acute, or chronic under two broad heads i.e. Bacterial and Viral. Rest of the conjunctivitis would be discussed under individual heads.

Bacterial conjunctivitis

According to mode of onset, acute infectious conjunctivitis can be—Catarrhal, muco purulent, and membranous.

Catarrhal conjunctivitis is very common among children. They involve both eyes which are red and there is minimal discharge that is mostly serous in nature. There may be accumulation of discharge near the inner canthus during sleep. Occasionally the lids may get glued in the morning. It is a self limiting disease caused by bacteria of low virulence. There are no corneal complication, no lympadenopathy.

Muco purulent conjunctivitis

This is more severe form of the former. Whole of the conjunctiva is bright red. The congestion is most marked in the fornices and fade towards cornea. Lids are slightly oedematous. There is no lymphadenopathy. There is muco purulent discharge with watering. The discharge may accumulate on the lashes which get matted together. The lids may get stuck in the morning causing discomfort, warm swabs may be needed to separate the lids. Generally there is no pain, have mild discomfort. Excess of watering, blepharospasm, foreign body sensation and occasional pain with onset of congestion round the limbus denotes corneal involvement that vary from superficial keratitis, marginal keratitis to frank ulcer.

In severe infection there may be formation of pseudo or true membrane. In cases of pneumococcal infection there may be patecheal haemorrhage.

Mucopurulent conjunctivitis is a contagious disease, transmitted directly by discharge. The disease is caused by many organisms, generally single organism is responsible for the disease but mixed infection is not uncommon.

Common organisms that produce muco purulent conjunctivitis are : Staphylococci, Koch-Weeks bacilli (H. aegypti), pneumo cocci, strepto cocci, rarely pseudomonas. Pneumococci and haemophilus influenzae are more common in children than other organisms. They are frequent between three to eight years of age.

Management. Management is to take a conjunctival smear from the lower fornix for Gram’s stain examination, culture and sensitivity. A smear stained with gram’s stain will

almost same. Membranous conjunctivitis is more severe form of the two. Though many organisms produce membranous conjunctivitis, diphtheretic conjunctivitis is more important than others due to its systemic complication.

Diphtheretic conjunctivitis9,10. This form of conjunctivitis was very common when immunisation against diphtheria was not available. It used to occur in epidemics. It still occurs in non immunised children. Sometimes it can occur in immunised children in a milder form. However it should be remembered that there are other causes of membranous conjunctivitis that may mimic as diphtheria conjunctivitis.

Commonest age to develop diphtheretic conjunctivitis is between 2 years to 8 years. Diphtheric conjunctivitis may present as pseudo membranous conjunctivitis as well but incidence of pseudo conjunctivitis is less than true membranous conjunctivitis indiptheria.

Clinically diphtheretic conjunctivitis can be divided into (1) Stage of infiltration, (2) Stage of membrane formation, (3) Stage of cicatrisation, (4) Corneal involvement, (5) Extra ocular muscle palsy.

1.Stage of infiltration. Generally bilateral, the lids are swollen, hard and temperature is raised. They are tender, board like rigidity is classical of diphtheretic conjunctivitis. The lid can not be separated or everted. The pre auricular lymph nodes are enlarged. It is generally associated with diphtheretic membrane of nasopharynx.

2.Membrane formation. Changes in conjunctiva go along with the changes in the lid. In fact the changes in lid are mostly due to changes in tarsal conjunctiva. A true membrane develops over both the palpebral and tarsal conjunctiva. In severe cases the membrane may slough off leaving a raw bleeding surface. No attempt should be made to peel off the membrane as its bleeds profusely and leave a raw area.

3.Cicatrisation. This follows as the membrane heals and shrinks. The resulting scar may produce xerophthalmia, symblepharon, trichiasis and rarely entropion.

4.Corneal complication. Involvement of the cornea occurs due to two factors : (1) The bacteria can invade intact epithelium without trauma and cause corneal ulceration and perforation. (2) The corneal nutrition suffers due to widespread thrombosis of peri limbal blood vessels.

5.Extra ocular muscle palsy is due to involvement of third, fourth and sixth cranial nerves either as isolated palsy or in combination. There may be paralysis of accommodation and iridoplegia. There can be paralysis of convergence or divergence.

Management :

1.All cases of membrane formation on conjunctiva true or pseudo must be treated as diphtheretic unless proved otherwise.

2.As diphtheria produces a potent toxin that can be neutralised by antitoxin only before it gets fixed to the tissues. Antitoxin is administered systemically and locally in consultation with physician.

3.The toxin is not neutralised by antibiotic. Systemic antibiotic only reduces number of bacteria thus diminishing the source of toxin production. It also eliminates other bacteria that are seen frequently in diphtheretic conjunctivitis. The drugs commonly

used are - Penicillin G 600,000 IU BD for ten days, Erythromycin in dose of 25 mg to 50/kg for days. Other drugs used are ampicillin, clindamycin and tetracyclin.

Local treatment consists of :

1.Local administration of antitoxin in the conjunctival sac between 10,000 to 100,000 IU for 24 to 48 hours.

2.Local instillation of fresh solution of Penicillin, Erythromycin and ointment along with antitoxin.

3.Cycloplegic should be used least keratitis develops. Once corneal involvement is noticed it should be treated vigorously.

Other causes of membranous and pseudo membranous conjunctivitis :

Ophthalmia Neonatorum11,12,13

Ophthalmia neonatorum or conjunctivitis in new born is a serious infection of new born. Any conjunctivitis developing within first month of life is called ophthalmia neonatorum. It is a notifiable disease. Etiology comprises of three groups of causative agents i.e. Bacteria, viruses and chemical.

Out of the above three, the bacterial conjunctivitis in neonate is most common. The condition is potentially vision threatening if not managed in time. Previously Gonococcus14 was considered to be commonest organism to cause ophthalmia neonatorum. With better health care and antenatal screening of the mother, incidence of gonococcal ophthalmia neonatorum has come down considerably. However it remains an ocular emergency. All

purulent conjunctivitis in neonate must be considered as gonococcal unless proved otherwise.2 Bacteria other than gonococci that produce ophthalmia neonatorum are : Staphylococcus, pneunococcus, haemophilus3, pseudomonas, and streptococcus, in fact any bacteria that may find its way to conjunctiva of new born can cause purulent conjunctivitis. Out of all bacteria, gonococcus has most severe form of infection and has shortest incubation period of 2- 3 days. It is seen in children born to mothers who suffer from gonococcal infection of birth canal or there is contamination during delivery from sources other than birth passage. It is a bilateral condition that starts as redness of the conjunctiva which is often missed because the infant keeps the eyes closed almost throughout the day and night and has a relatively narrow inter palpebral aperture. The disorder is noticed only after there is out pouring of muco purulent discharge from the eye. The lids are swollen, rigid and may stick together. On separation of the lids that may require use of lid retractor the conjunctiva is chemosed, may protrude through the lids. There may be blood discharge, formation of true or pseudo membrane.

Corneal involvement is most serious vision threatening findings. Loss of lustre of cornea is a bad sign. There may be corneal infiltration, central corneal ulcer which may perforate in very short period. Gonococcus is one of the few organisms that can pass through intact corneal epithelium. Once perforation has occurred endophthalmitis and panophthalmitis is very common. Otherwise a small perforation may heal by formation of central leucoma, leucoma adherent and anterior pallor cataract. The eye soon develops nystagmus. Even if there is no perforation gonococcal uveitis is very common.

Neonatal conjunctivitis by other bacteria are milder than gonococcal, they have longer incubation period i.e. 4-5 days and are generally due to secondary infection after birth. pseudomonas infection is more common in prematures. Incidence of gonococcal conjunctivitis in neonates has shown a gradual decline due to better maternal and child care and use of prophylactic anti microbial.

Non bacterial micro organism that produce ophthalmia neonatorum are

Chlamydia trachomatous and herpes simplex. Incidence of neonatal conjunctivitis by Chlamydia and herpes simplex is showing an upward surge. Chlamydia caused inclusion conjunctivitis, takes five to seven days to develop. Source of infection is birth canal. It is far milder than bacterial conjunctivitis. Corneal involvement is milder in the form of micro pannus that may cause permanent scarring. It never perforates.

Herpes simplex conjunctivitis is also acquired from infected birth canal. If the mother has active lesion of genital passage a caesarean sections saves the child from getting conjunctivitis. It develops after 10 days as mild conjunctivitis, watery discharge, diffuse or dendritic keratitis. There may be associated skin vesicles.

Diagnosis of ophthalmia neonatorum specially bacterial is not difficult. All cases of mucopurulent bilateral conjunctivitis should be considered to be due to gonococcus unless proved to be otherwise. Presence of gonococcus is confirmed by Gram’s stain and preferably by positive culture in suitable media (Thayer Martin medium).

In all cases of purulent conjunctivitis a conjunctival smear should be taken and stained by Gram and Giemsa stain to see if it is gram positive or negative. It also gives nature of intra cellular or extra cellular inflammatory cells i.e. polymorph, basophils, lymphocytes and inclusion bodies. Gram negative intracellular diplococci and polymorpho nuclear neutrophils indicate gonococcal infection. This should be sufficient to start anti gonococcal treatment but