Ординатура / Офтальмология / Английские материалы / Pediatric Opthalmology_Mukherjee_2005

to find out if the stain is penicillin resistance or not and its sensitivity to other antibiotics, culture and sensitivity test must be done because resistant stain may prove to be life threatening.

Management consists of—(1) Prophylaxis, (2) Treatment of various microbial ophthalmia in new born.

1. Prophylaxis15,16. This includes (a) Antenatal screening of mother for evidence of gonococcal, chlamydia and herpes simplex of genital tract. If found to be infected, proper treatment should be initiated. In case of herpes simplex of birth canal an elective caesarean section may be done. (b) Complete antisepsis and asepsis should be followed during and after delivery. The eyes of new born should be cleaned by two separate wet cotton swabs, one for each eye from lateral to medial side. (c) Prophylactic anti microbial drop :

(i) 1% silver nitrate drop (Cred’s prophylaxis) One drop of freshly prepared solution (not more than seven days on the shelf) that is stored in coloured bottle and kept in cool place is instilled in each eye. Crede’s prophylaxis does not always eliminate possibility of ophthalmia neonatorum. It reduces severity of the condition. Crede’s method was universal prophylaxis against ophthalmia neonatorum but has been replaced by antibiotics because AgNO3 itself can cause chemical conjunctivitis that mimics ophthalmia neonatorum if used in concentration more than 2% and instillation more than two drops in each eye. This chemical conjunctivitis develops earlier than any other conjunctivitis i.e. within 24 hours and is mild and self limiting. Causes redness of conjunctiva, edema of lids discharge and redness of surrounding skin.

(ii) Povidon—Iodine 2.5% has been claimed to be better than AGNO3 without side effects of latter.

(iii) Antibiotic. Any of the following antibiotics can be used as drops or ointment— 0.3% Ciprofloxicin, 1% Tetracyclin, 0.5% erythromycin, 0.3% gentamycin. In suspected chlamydia infection of the mother 10% sulpha cetamide may be added to any of the above.

(iv) If the mother is known to suffer from gonococcal infection, the neonates are at high risk of developing ophthalmia neonatorum. Such infants should get single intra muscular injection of 50,000 IU of crystalline penicillin or single dose of 1m injection of ceftriaxone 125 mg or cefotaxime 100 mg of course the mother also gets sufficient systemic antibiotic.

Management of clinically established gonococcal conjunctivitis13, 16 in neonates comprise of :

1.Cleaning of ‘muco purulent discharge frequently using separate swab for each eye and each cleaning. Irrigation with balanced solution have doubtful efficacy.

2.Instillation of fresh aqueous solution of crystalline penicillin G. in strength of 100,000 unit per ml. every five minutes for six times, then every ten minutes for six instillation’s, then one hourly for six instillation. Then every two hourly. As ointment of penicillin is no more available erythromycin 0.5% may be put to reduce stickiness of lids. Other drugs like 0.3% Ciprofloxicin, gentamycin 0.3% or any ophthalmic drop that is effective against gonococci may

be used in the same frequency. Recent studies have started doubting need and efficacy of local antibiotic drops. They prefer systemic administration of systemic crystalline penicillin twice a day for seven days or cefotaxime in neo natal dose in consultation with neonatologist.

3. If cornea shows any evidence of involvement 0.5% atropine ointment is put to treat and/or prevent associated uveitis. Atropine drops are better avoided as it is likely to be absorbed from nasolacrimal passage and throat in amount sufficient to produce systemic toxicity.

Treatment of other bacterial conjunctivitis :

(a) Pseudomonas conjunctivitis requires as prompt treatment as gonococcus specially in pre mature infants—Topical gentamycin or tobramycin in strength of 0.3% as in case of gonococcus with ointment of the same antibiotic three to four times recommended.

(b) Haemophilus is best treated either by local gentamycin drops or 10-15 percent sulphacetamide drops.

(c) Conjunctivitis with other gram positive cocci and diplococci is treated with 0.5% erythromycin every 2 hourly.

(d) Coliform organisms can be treated with gentamycin drops.

(e) Acineto bactor17. In recent years hyper acute conjunctivitis similar to ophthalmia neonatorum has been reported from various parts of the world. The organism belongs to family Neissericeae. It is difficult to differentiate it on gram’s stain from gonococcus, both are gram negative cocci. The acinetobactor fortunately does not cause systemic infection but is penicillin resistant. It is best treated by local 0.3% ciprofloxacein or 0.3% Tobramycin.

(f ) Chalmydia conjunctivitis in neonate has become more common than in the past. It is milder than bacterial infection but may have long term local as well as systemic effect i.e. otitis, rhinitis and pneunonitis. Diagnosis of chlamydial conjunctivitis is confirmed by Giemsa stain that shows besophilic cytoplasmic inclusion bodies. Treatment comprises of instillation of 10% sulpha-cetamide drop and erythromycin 0.5% ointment 4 times a day in severe cases erythromycin syrup in dose of 50mg/kg/day in 4 divided doses is given for 2-3 weeks.

Herpes virus—conjunctivitis is uncommon but it is potentially vision and life threatening infection in neonate, untreated cases may be fatal in as many as 50% of cases. Presence of skin vesicles may point towards diagnosis of herpes simplex. Treatment with systemic anti viral drugs is needed in consultation with neo-natologist.

Pneumococcal conjunctivitis

Pneumococci are generally present in respiratory system, but can be found as a symptomatic strain in conjunctival sac. It gradually produces systemic infection with ocular involvement and is a common cause of hypopyon. It is one of the commonest organisms that cause chronic dacryocystitis. It can involve the conjunctiva independent of systemic involvement. It is mostly seen in children as acute muco purulent conjunctivitis, with patecheal haemorrhage. It can cause ophthalmia neonatorum, membranous or pseudo membranous conjunctivitis. It is

spread by hand to hand contact in children. Management is similar to any other bacterial conjunctivitis. Commonly used antibiotics are :

1.Fortified aqueous penicillin G. solution containing 100,000 unit per cc every hourly during day and every four hourly by night, till the acute symptoms subside.

2.Erythromycin 0.5% may be given at night as ointment.

3.Becitricin 10,000 units per cc can also be given as hourly drop.

4.Cefazoline 50mg/cc may be given in place of penicillin.

Systemic antibodies do not seem to have any advantage over local instillation. However every child suspected to have pneumococcal conjunctivitis should have a pediatric consultation for possible systemic involvement. Corneal involvement consists of a central ulcer with or without hypopyon. All cases of suspected corneal involvement should be treated as emergency with atropine, vigorous antibiotic instillation and beta blockers.

Haemophilus influenzae18 and H. aegyptius, Koch-Weeks bacteria are common causes of conjunctivitis in children, with acute onset that lasts for about 10 days. that can cause patchy sub conjunctival haemorrhage. Inferior corneal infiltration is common, can have serious systemic involvement and peri orbital cellutitus. The organism is best grown on chocolate agar medium.

Other Bacterial Conjunctivitis

Viral conjunctivitis

Viral conjunctivitis in children can be (1) Acute or (2) Chronic.

1. Acute (i) Herpes simplex. Conjunctiva is involved in children as primary infection mostly by type I but occasionally by type II virus as well. There are three age groups in which herpes simplex involves a pediatric patients i.e. (1) Neonates, (2) Between six months to 5 years, (3) Teenage.

Neonatal herpes simplex conjunctivitis can be congenital or acquired. The former is, rare and associated with severe systemic involvement hence most of the time fatal. In acquired form the neonate gets infection during passage through birth canal.

The child between 3 to 5 years gets infection from infected adults. The teenager gets it by kissing an infected person and rarely as sexually transmitted disease.

Herpes simplex conjunctivitis irrespective of age of onset have cutaneous, conjunctival and corneal involvement in various combinations. It is generally unilateral, incubation period is 3 to 12 days. It develops as follicular conjunctivitis (after three months of age) with lymphadenopathy, the eye is congested. There is watery discharge. Onset of photophobia denotes corneal involvement. There may be pseudo membrane formation. The corneal involvement starts as small epithelial lesions that join together to form typical dendritic keratitis. The skin lesion consists of vesicles over the skin of the lid, forehead, lid margin. The vesicles may cross over the mid line. The infection is self limited, it lasts for two to three weeks. It is difficult to diagnose clinically. As herpes simplex conjunctivitis is a primary infection, the virus may pass into the trigeminal ganglion and remain dormant, recur as herpetic keratitis later.

Treatment. As it is a self limiting disease, it does not require any specific treatment. Corneal involvement require local use of anti viral drugs along with cycloplegic. Local antibiotics are prescribed to prevent secondary bacterial infection. Steroids are contra indicated.

(ii) Herpes zoster conjunctivitis. Herpes zoster conjunctivitis is caused by vericella zoster virus. It is less common in children but children are not immune. The disease has more serious corneal and lid involvement than herpes simplex. Conjunctivitis is muco purulent always associated with vesicle formation on the lid. There may be actual vescicles on the conjunctiva. The conjunctivitis to beginwith is papillary, there may be follicle formation. In severe cases pseudo membrane develops. Conjunctivitis is self limiting and resolves in a week. Tender pre auricular nodes develop in early stage of disease. It is always unilateral. There may be secondary bacterial infection.

Treatment. Conjunctivitis does not require any specific treatment. Treatment is directed towards the disease in toto.

(iii) Pharyngo conjunctival fever. Conjunctivitis in pharyngo conjunctival fever is very common in children. It is a part of syndrome consisting of fever, pharyngitis, pre auricular non tender lymphadenopathy. The conjunctivitis is follicular in nature, generally unilateral may become bilateral generally there is a watery discharge. Mucopurulent discharge denotes superimposed bacterial infection. The lids are generally edematous. Cornea may be involved in the form of superficial fine epithelial keratitis.

The causative viruses are adeno virus 3 and 7. Sometimes adeno virus 4 may also cause pharyngo conjunctival fever and conjunctivitis. It sometimes develops following bath in a contaminated swimming pool. Incubation period is 5 to 12 days.

Treatment. Conjunctivitis is self limiting lasting for seven to fifteen days. However corneal infiltrates may persist for a month. Treatment is non specific and symptomatic.

(iv) Epidemic kerato conjunctivitis. This contagious conjunctivitis is common in children. It is caused by adeno virus 8 and 19. Other sero types may also cause the disease. In children it is associated with sore throat, fever and diarrhoea. It has incubation period of 5 to 12 days. One eye is first involved and more severe than the other eye. Conjunctivitis is

follicular in nature, there may be papillary reaction and pseudo membrane formation.

Pre auricular lymphadenopathy is a common feature. The disease spreads among the school children in epidemics. Occasionally it may be spread by contaminated instruments, lotions or drops following ocular examination. Corneal involvement is common, it presents as sub epithelial opacities that may appear after conjunctivitis subsides and may persist for months. Treatment is symptomatic. No anti-viral drugs are required.

(v) Acute haemorrhage conjunctivitis. This acute conjunctivitis was first noticed in 1969 and has been known by various eponyms. The epidemics keep on appearing at regular intervals mostly in the months of late June and early July. It is caused by entero virus type70. The incubation period is short i.e. 12 to 48 hours. It is most commonly seen in crowded localities i.e. schools etc. It has an acute onset first in one eye with in few hours the other eye gets involved. The symptoms are intense redness of conjunctiva with copious watery discharge, lid edema and pain ranging from mild discomfort to severe pain.

Sub conjunctival haemorrhages are constant feature which generally start as small spots on the periphery of the bulbar conjunctiva later whole of the conjunctiva gets involved. These spots may join together and form a large sub-conjunctival haemorrhage. The patechea disappear early, large haemorrhage take ten to fifteen days to clear. Sometimes there may be chemosis of conjunctiva and follicle formation. There may be lymphadenopathy. Onset of corneal involvement in form of epithelial keratitis heralds photophobia. Conjunctivitis may be associated with fever, malaise, and body ache. Occasionally there may be uveitis, motor paralysis of lower limbs have been reported. The virus is transmitted by close person to person contact and by fomites, water, common linens or ophthalmic instruments used to examine infected eye.

Treatment. There is no specific treatment known. The disease does not give immunity. Recurrence in the same patient has been observed. Treatment is directed towards symptoms. Non steroidal anti inflammatory drugs are given to relieve pain. Dark glasses help in reducing photophobia. It is a misconception that dark glasses prevent spread. Broad spectrum antibiotics are given to prevent and treat associated secondary bacterial infection. The disease is self limiting lasting for seven to ten days. In absence of corneal involvement weak solution of steroid drops may shorten duration.

Other viral infections that produce conjunctivitis in children : Viral—Conjunctival lesions.

Influenza—Catarrhal conjunctivitis, sub conjunctival haemorrhage. Mumps—Papillary or follicular conjunctivitis, subconjunctival haemorrhage. Measles—Koplik’s spot, follicular sub conjunctival haemorrhage.

Chicken pox—Muco purulent conjunctivitis, vescicle formation, phlycten.

Molluscum contagiosum—Chronic unilateral conjunctivitis, pannus formation, follicle formation, umblicated vesicle may be seen.

Chlamydia infection in children19

Chlamydia (formerly known as Bedsonia) are a group of micro-organism in between bacteria and viruses. They are intracellular organisms that are difficult to culture. Their

intracellular nature gives them partial immunity against drugs. Hence drugs are to be administered for long time. They multiply by binary fission. Common chlamydiae are :

The former two produce kerato conjunctivitis in children. Out of C Trachomatis and C. Psittacosis former is more common cause of ocular manifestation while latter produces more systemic infection. C. Trachomatis is gram negative organism that is sensitive to sulphonamide, it is almost exclusively human pathogen. C. Trochomatis has many types i.e. A, B, Ba, C that produce trachoma and D to K that produce inclusion conjunctivitis also called paratrachoma. The organism is also known as TRIC where TR stands for trachoma and IC stands for inclusion conjunctivitis. Inclusion conjunctivitis effects patient in two distinct age groups : 1. Neonate, 2. Young adults.

Para trachoma causes urethritis, cervicitis in adults and secondary conjunctivitis in adults which resembles trachoma in many aspects but is milder than trachoma. it is a sexually transmitted disease.

Neonatal chlamydiae disease is acquired by new born during birth via infected birth canal of the mother. It produces nongonococcal ophthalmia neonatorum. The incubation period is longer than gonococcal ophthalmia i.e. 5 to 12 days. There is lacrimation and serous discharge, the lids are swollen. It is not prevented by usual Crede's prophylaxis but can be prevented by tetracyclin or erythromycin. Untreated cases heal in four to five months but may persist for years causing chronic follicular conjunctivitis and pannus formation. Infants with inclusion conjunctivitis may develop pneumonitis and gastro-enteritis in first six months of life.

Trachoma20, 21, 22

Trachoma is a chronic kerato conjunctivitis due to C Trachomatous sero type A, B, Ba and C. It is commonest preventable infectious disease of eye that may otherwise lead to blindness in adults. It is mostly acquired in childhood. Uncomplicated trachoma in children do not cause blindness, however secondary bacterial infection, associated malnutrition and xerophthalmia may lead to corneal ulceration, perforation and loss of eye in children.

No race is immune. It is a bilateral condition. In children, boys and girls are equally affected. In adults women have more serious involvement than men. Trachoma is a disease of dry, dusty climate. It is a disease of poor children with poor hygiene. Improvement of health care and awareness of cleanliness has drastically reduced incidence of disease in areas where it used to be endemic. The children get trachoma from infected family members, and playmates. The disease is transmitted from person to person by fomites. Contaminated KAJAL, SURMA and flies play an important part in spread of trachoma in children. It has been noticed that reduction in fly population, regular cleaning of face, availability of free flowing water and ownership of flush latrine in the family reduce spread of trachoma.29

Clinical feature of trachoma

Clinical features of trachoma in children differ from those in adults. The trachoma does not reach the cicatricial stage in children as it takes more than decade to develop cicatricial stage. However, most of adults acquire trachoma in childhood.

Incubation period of trachoma is short i.e. seven days (range 5 to 12 days) It begins as mild conjunctivitis similar to bacterial conjunctivitis and indistinguishable form it. Smear from conjunctival sac in a case of pure trachoma does not grow bacteria on culture.

Symptoms. Symptoms are mild in children unless secondary bacterial infection is superimposed. Symptoms are so common in endemic areas that it is taken as natural phenomenon. Symptoms consist of watering, discharge, redness of the eye, moderate swelling of the lids, pre auricular nodes may be enlarged.

Signs. Conjunctival congestion, follicular hypertrophy mostly in the fornices and upper part of tarsal conjunctiva, papillae formation, superficial keratitis in the upper part and mild vascularisation.

McCallau23, 23A classified the conjunctival signs into following grades : (1) Incipient trachoma, (2) Established trachoma (3) Cicatrising trachoma, (4) Healed trachoma.

Various stages are :

Stage I : Immature follicles in upper palpebral conjunctiva. Stage II (a) : Prominent follicular hypertrophy.

(b) : Papillary hypertrophy masking follicular hypertrophy. Stage III : Follicles and scarring at upper tarsal conjunctiva.

Stage IV : Healed trachoma. No sign of inflammation and late scarring of tarsal conjunctiva.

Stage III and IV are generally not seen in chidden under fifteen years

Above classification has been followed for more than half a century. The classification takes into consideration only conjunctival changes. No weightage is given to keratopathy and ; which have great prognostic value.

WHO 198724 adopted a better classification.

Blinding trachoma is seen in endemic areas, infection is caused by sero type A, B, Ba and C with secondary bacterial infection superimposed. Flies in unhygienic condition where free flowing water is not available is most important factor in causing blinding trachoma. Trachoma in any stage does not produce perforation unless bacterial infection is superimposed.

WHO grading of trachoma as guidelines for treatment :

TF—Trachomatous inflammation—Follicular seen in children, in upper tarsal conjunctiva. Presence of five or more follicles of 0.5 mm or larger is significant.

TI—Trachomatous inflammation—Intense, pronounced inflammatory thickening of tarsal conjunctiva that obscure more than 50% of deep tarsal vessels.

TS—Trachomatous scarring. Presence of easily visible scarring in upper conjunctiva. TT—Trachomatous trichiasis. At least on eye lash rubs on the eye ball. CO—Corneal opacity—Easily visible corneal opacity over the pupil.

TS TT and CO due to trachoma are not seen in children. WHO recommended for management of trachoma25, 26, 27 : TF—Topical antibiotic

T1—Topical and systemic antibiotic TT—Surgery

Corneal changes in trachoma

Corneal changes in trachoma are early to appear. They can be due to (1) chlamydia infection of corneal epithelium, (2) Lid changes leading to secondary changes in cornea (Not generally seen in children).

The corneal changes are :

1.Epithelial and sub epithelial punctate keratitis, these are small in size seen generally in the upper part of the cornea. Sub epithelial punctate keratitis are large enough to be visible without magnification.

2.Vacularization. Vascularization of cornea is superficial in nature. It consists of epithelial invasion of conjunctival vessels with diffuse infiltration and epithelial punctate keratopathy. Initially the vessels lie between epithelium and Bowman’s membrane, later the Bowman’s membrane may be destroyed. Severity of pannus formation depends upon duration and severity of infection. In early stage it is visible only on slit lamp examination. The pannus of trachoma is mostly seen in the upper part of cornea associated with cloudiness of cornea. However, it can occur at any part. Trachomatous pannus is said to be :

(i) Progressive when cellular infiltration extends beyond the terminal end of the newly formed blood vessels.

(ii) Regressive when the ends of the vessels extend beyond the cellular infiltration. The cellular infiltration is lymphoid in nature with treatment the vessels disappear leaving a clear cornea, only obliterated vessels may be visible on higher

magnification. A permanent haze results with destruction of Bowman’s membrane.

Limbal changes in trachoma

Hyperemia, edema and follicle formation are common changes in trachoma. The follicles are generally small and transient, disappear without any trace but larger follicles stay for longer time and when rupture leave depressed areas called Herbert’s pits which are generally not seen in children.

Diagnosis of trachoma

Diagnosis of trachoma in endemic area is easy clinically. Characteristic signs of trachoma in children :

1.Follicles in tarsal conjunctiva and/or limbus.

2.Epithelial keratitis.

3.Trachomatous pannus.

Combination of trachomatous pannus with any of above two is pathognomic in established trachoma.

Early trachoma and trachoma outside endemic area present difficulty in diagnosis because there are other causes that produce similar signs.

Diagnosis of early trachoma

1.Conjunctival smear for inclusion bodies. Presence of basophilic intra cytoplasmic inclusion bodies in epithelial cells are diagnostic.

2.Presence of immuno fluorescent monoclonal antibodies is specific.

3.Culture of C. Trachoma on McCoy cells is said to be gold standard but is very difficult and costly.

Differential diagnosis of trachoma in children :

Consist of all case that produce following bilateral signs either alone or in combination.

1.Superficial vascularisation,

2.Follicle formation,

3.Papillary hypertrophy.

Common conditions are : Acute and chronic follicular conjunctivitis, palpebral type of spring catarrh, multiple phlycten, riboflavin deficiency, dry eye syndrome, chronic conjunctivitis, healed interstitial keratitis.

Management of trachoma in children :

Prophylaxis : (a) Chemo prophylaxis, (b) Awareness about trachoma.

Prophylaxis. Trachoma is one of major cause of blindness yet it is one of the most treatable and preventable disease.

Chemo prophylaxis

All children in endemic area should be put on any of the local anti-trachoma chemo therapeutic drugs :

1.1% Tetracyclin, oxy tetracyclin ointment;

2.1% chloramphenicol ointment,

3.0.5% Erythromycin ointment twice a day for six weeks. Then a gap of six weeks is given and the regime is repeated. Rifampin eye ointment, ciprofloxin eye ointment have also been found to be effective. In the mean time all the other members of community who have active trachoma are treated for trachoma.

Trachoma awareness28, 29, 30, 31. It is emphasised that trachoma is :

—Preventable and curable disease.

—Preventing use of KAJAL and SURMA from common container.

—Face wash—Regular face wash with running water greatly reduces incidence of trachoma.

Vector control. Fly is commonest vector that disseminate trachoma. If fly density can be reduced in the community trachoma can be eliminated.

Environment. Availability of running water, ownership of septic latrine in the family/ community reduces incidence of trachoma.29

Treatment of trachoma

C. Trachoma is sensitive to both sulpha and many broad spectrum antibiotics. As the organism is obligatory intracellular in nature prolonged treatment in effective dose is required.

Local chemotherapeutic drugs (TF Stage) :

1.Sulpha cetamide drops 10% to 20% 4 times a day in both eyes is prescribed for six weeks.

2.Chloramphenicol 0.5% drop or Ciprofloxin 0.3% drop 4 times a day for six weeks.

3.Tetracyclin 1% oxy tetracyclin 1%, Chlortetracyclin 1%, ciprofloxin 0.3% ointment three times a day alone or at the bed time along with local sulpha or antibiotic drops for six weeks.

Oral antibiotic agents—In TT stage :

1.Sulpha methoxazole 30mg/kg in divided doses for 3 weeks along with local antibiotic drops.

2.Tetracyclin – 15mg/kg in divided dose along with local antibiotics for 3 weeks not given under eight year of age.

3.Erythromycin – 30 mg/kg in divided dose for 3 weeks.

4.Doxycycline – 1.5 mg/kg single dose for 15 days.

5.Azithromycin – 250 mg of single dose is said to be as effective as 1% tetracyclin TDS for six weeks.

Systemic Tetracyclin and doxycycline should not be used in children under eight years