OCULAR EMERGENCIES IN PEDIATRICS [Autosaved].pptx

OCULAR EMERGENCIES IN PEDIATRICS

1. EYE EMERGENCIES IN INFANTS AND CHILDREN Dr. Sarthak Mishra PG2 – Department of Emergency Medicine

2. EYE EXAMINATION IN A CHILD If a history of chemical exposure is obtained, triage as highest priority, and immediately irrigate the eye with 1 to 2 L of saline. A complete eye exam includes gross examination, assessment of visual acuity, extraocular movements, and ophthalmoscopic exam of the eye. A slit lamp exam of the eye should be performed whenever possible. Newborns may appear cross-eyed during the first 2 months of life as ocular fixation develops. 1. VISUAL ACUITY AND EXTRAOCULAR MOVEMENTS Visual acuity is the vital sign of the eye, and it should be the first objective measurement obtained after the history . Obtaining visual acuity in a child will depend on the child’s age and level of development. 6 months to 3 years old should be able to fix and follow a face, toy, or light; 3 to 5 years old should have a visual acuity of 20/40 or better with one line acuity difference between eyes; >5 years old should have a visual acuity of 20/25 or better with no acuity difference between eyes. Check acuity in the nonaffected eye first to establish baseline function.

3. Several different eye charts can be used to check distance visual acuity in children, including the Snellen, Allen picture, and tumbling E charts . If the child knows letters of the alphabet (typically 4 to 6 years of age), use the standard Snellen eye chart. Consider using the tumbling E chart if the child is illiterate or has a cognitive disability. To use the Snellen chart, check acuity at a distance of 20 ft. When using the Allen picture or tumbling E chart, assess acuity at a distance of 10 ft. Assess visual acuity with the child’s glasses. If not available, then use a commercial pinhole occluder or a card with five to six holes created with an 18-gauge needle . If the child is unable to read the top line of an eye chart, then ask to count fingers and see motion. If the child is unable to see motion, then shine a bright light into the eye and document the presence or absence of light perception.

4. 2. Extraocular movements can be assessed after visual acuity. Relieving pain will make your exam much easier, especially in a child unwilling to open his or her eye. With the patient supine, analgesic drops can be applied to the space between the medial canthus and the nose. The drops will flow into the eye when the child eventually opens his or her eye.

5. EXAMINATION OF PUPILS AND FUNDUS First, document pupil diameter in ambient light. If the difference between pupils is 0.5 mm or greater, then anisocoria exists . A greater size discrepancy in a dark room when compared with a light room indicates physiologic anisocoria, which is of no clinical significance. It is also important to look for leukocoria (white appearance of pupil), which may be indicative of problems with the cornea, lens, or anterior or posterior chamber. Next, check the direct and consensual light reflexes . Then assess for a relative afferent pupillary defect, a sign of unilateral optic neuropathy . Some children will have a small amount of pupillary movement (dilation and contraction) in the consensual eye when the light is swung from the direct to the consensual eye. This is pupillary escape and can be a normal response. Continue with examination of the red reflex , which should be performed in children of all ages. In a dimly lit room, look at the pupils through the direct ophthalmoscope or panoptic scope; position yourself at the patient’s eye level about 1 to 2 ft. away. Document the presence or absence of the red reflex for each eye. With older children, perform the same funduscopic examination that you would in an adult.

6. An abnormal red reflex can represent many abnormalities, including: Retinoblastoma: the most common ocular tumor in children and can be fatal Congenital cataract (or any corneal opacity) Retinopathy of prematurity TORCH infections (Toxoplasma, Other, Rubella, CMV, HSV) Strabismus (i.e. misalignment of the eyes) Anisometropia: each eye having different refraction power

7. STRABISMUS Strabismus is ocular misalignment. Misalignment can be described as a “ tropia ,” or constant misalignment, or a “phoria,” or intermittent misalignment, such as when the patient is tired or fusion is broken. With a “phoria,” the eyes will revert to normal (equal) alignment when both eyes are uncovered. Normal newborns may have transient misalignment that usually improves by 3 to 4 months of age as the strength of extraocular muscles improves. Amblyopia is a loss of visual acuity not correctable by glasses in an otherwise healthy eye. Uncorrected strabismus can cause amblyopia. If children have unilateral visual impairment, their brain will “choose” the image presented by the eye with better vision. If amblyopia is not corrected by about age 10 years old, the brain eventually suppresses visual information presented by the impaired eye, leading to permanent vision loss.

8. DIAGNOSIS: Strabismus is usually suspected after general inspection. Some children have epicanthal folds that lead to pseudostrabismus , or the appearance of ocular misalignment, when the eyes are in fact in proper alignment. Two simple tests can identify true strabismus. Hirschberg test by holding a penlight several feet from the child and observe the reflection of the light on each cornea. In normal ocular alignment ( pseudostrabismus ), the light reflection will appear on the same position of each eye. In true strabismus, the light reflection will not be on the same position of each eye. C over test . Have the child fixate on a distant object and then cover one of the child’s eyes. If the uncovered eye then moves, it can be assumed that it was not properly fixated on the object and true strabismus is present. When the eyes are uncovered, they will revert to their original misalignment.

9. CAUSES OF STRABISMUS: Cranial nerve palsy and muscle restriction or entrapment that may be associated with trauma, stroke, tumor , aneurysm, thyroid-associated orbitopathy or other infiltrative process, increased intracranial pressure, or infection. The innervation of the extraocular muscles (LR6SO4Rest3) defines which cranial nerve is involved. Cranial nerve VI innervates the ipsilateral lateral rectus muscle, and palsy will lead to esotropia. Cranial nerve IV innervates the ipsilateral superior oblique muscle, and palsy will cause hypertropia. Cranial nerve III innervates all other extraocular muscles, and palsy will lead to exotropia, hypertropia or hypotropia (depending on which branch is affected), and ptosis. MANAGEMENT: Historical clues to an emergent cause of strabismus include trauma, diplopia, report of abnormal extraocular movements, sunsetting of the eyes ( upgaze deficit), nausea, vomiting, and lethargy. If an emergent cause of strabismus is suspected, obtain imaging directed at the suspected condition. Congenital strabismus caused by extraocular muscle weakness usually self-resolves in infancy. Stable strabismus that persists into childhood should be referred non-emergently to an ophthalmologist. Strabismus caused by amblyopia often resolves with glasses that equalize the vision, although a patch over the “good” eye or surgical correction may be required.

10. DISORDERS OF THE LACRIMAL SYSTEM Tears are produced in the lacrimal gland and drain at the medial aspect of the eye through the nasolacrimal duct and lacrimal sac through the canalicular system to the Hasner valve and finally into the nose. Several common problems seen in pediatrics can arise in the gland and canalicular system.

11. Dacryostenosis : nasolacrimal duct obstruction, is a narrowing or obstruction of the nasolacrimal duct. It occurs in 6% of all newborns and usually resolves with conservative management. Clinical Features in infants: Epiphora, eyelash matting, and tears that appear thicker and yellowish in colour, which may be mistaken by parents as infection. Fluorescein applied to the eye and left for 5 minutes will accumulate, whereas it normally would be cleared by the lacrimal system. Lack of accompanying signs or symptoms, such as fever, irritability, or conjunctivitis. Treatment: Supportive and does not require antibiotics . Teach parents gentle massage with a downward motion to the nasolacrimal duct three to four times a day. If still present after 12 months of age, ophthalmology referral is indicated for possible dilation of the duct.

12. DACROCYSTITIS Inflammation and bacterial superinfection of the lacrimal sac will cause dacryocystitis . Causative Organisms : S treptococcus pneumoniae , staphylococci, and Haemophilus influenzae. Patients develop a chronic mucopurulent discharge followed by erythema and swelling inframedially to the eye. In children of all ages, dacryocystitis is usually a secondary bacterial infection following a viral upper respiratory infection. The diagnosis is made when gentle pressure with a finger or cotton swab applied to the nasolacrimal sac causes a reflux of mucopurulent material. The discharge should be cultured to identify the causative agent. Improperly treated dacryocystitis may lead to periorbital and orbital cellulitis. Children are often quite ill and require hospital admission with parenteral antibiotics until the infection begins to improve. A cephalosporin, such as cefuroxime (50 milligrams/kg IV every 8 hours) or cefazolin (33 milligrams/kg IV every 8 hours), may be used, or clindamycin (10 milligrams/kg IV every 6 hours) may be used for penicillin-allergic patients. If methicillin-resistant Staphylococcus aureus is suspected, vancomycin (10 to 13 milligrams/kg IV every 6 to 8 hours) is indicated .

13. Dacryoadenitis is inflammation of the lacrimal gland and can be acute or chronic. Chronic dacryoadenitis is caused by non-infectious inflammatory disorders such as Sjögren’s syndrome, sarcoidosis, or thyroid disease. Acute dacryoadenitis is usually infectious (systemic symptoms such as malaise and fever may also be present). In both acute and chronic disease, children will have soft tissue swelling, especially in the region of the lateral upper lid. Viral dacryoadenitis causes less intense discomfort and erythema than bacterial dacryoadenitis. Causative viral pathogens include Epstein-Barr virus, mumps virus, coxsackievirus, cytomegalovirus, and varicella-zoster virus. Bacterial dacryoadenitis is associated with intense eye discomfort, tenderness, and erythema. The most common causative bacterial pathogen causing dacryoadenitis is S. aureus , although streptococci, Neisseria gonorrhoeae , Chlamydia trachomatis , and Brucella melitensis have also been implicated. The first-line treatment of bacterial dacryoadenitis is oral or parenteral antibiotics against S. aureus . For mild infections, an oral first-generation cephalosporin, such as cephalexin (25 milligrams/kg PO every 6 hours), until the infection has resolved is appropriate. If methicillin-resistant S. aureus is suspected, sulfamethoxazole-trimethoprim (10 mg/ killigram PO [or IV] every 12 hours) or linezolid (10 milligrams/kg PO [or IV] every 12 hours) may be used. For more severe infections, parenteral antibiotic therapy is indicated. Nafcillin (37.5 milligrams/kg IV every 6 hours) is appropriate when methicillin-resistant S. aureus is not suspected. Vancomycin (10 to 13 milligrams/kg IV every 6 to 8 hours) is indicated for severe dacryoadenitis caused by methicillin-resistant S. aureus .

14. DACRYOCELE : a small, bluish-hued, palpable mass in the location of the nasolacrimal duct (inferior and medial to the eye) without conjunctival erythema, discharge, or other pathologic findings. It is caused by an obstruction at the valve of Hasner and the common canaliculus. Due to possible need for marsupialization, patients should be urgently referred to a pediatric otolaryngologist or ophthalmologist. Dacryoadenitis

15. BLEPHARITIS: Inflammation of the eyelid that may present with eye redness, tearing, photophobia, crusting of the lid margin, swelling, or pruritus. Both types of blepharitis are treated with warm compresses and baby shampoo scrubs once to twice daily. This should be continued until symptoms have resolved completely, which usually requires prolonged treatment. In addition, staphylococcal blepharitis should be treated with erythromycin or bacitracin-polymyxin ointment one to three times a day for 7 days, with the length of treatment depending on severity.

16. PERIORBITAL AND ORBITAL CELLULITIS The orbital septum is a connective tissue extension of the orbital periosteum that extends into the upper and lower eyelids and acts as a barrier to the spread of infection. However, infection can be facilitated by the valveless drainage system of the midface region that permits bacteria to travel hematogenously in an anterograde fashion (i.e., away from the heart) despite a retrograde venous system. Periorbital, or preseptal , cellulitis must be distinguished from orbital, or postseptal , cellulitis. The diagnosis may be difficult clinically, and imaging is often required to make the appropriate diagnosis.

17. PERIORBITAL CELLULITIS Average age of presentation with periorbital cellulitis is 2 years old. Periorbital cellulitis can be caused by local infection, hematogenous spread, and extension of sinusitis. Local infection, such as conjunctivitis, dacryoadenitis, dacryocystitis , hordeolum, or even a minor traumatic cellulitis after an insect bite or small scratch, can spread to the periorbital area.Hematogenous spread of nasopharyngeal pathogens can also lead to periorbital cellulitis. Affected children tend to be younger (often <18 months old) and have a history of a viral upper respiratory infection followed by abrupt onset of fever and eyelid swelling. The most common pathogens are S. pneumoniae and Streptococcus pyogenes. CLINICAL FEATURES AND DIAGNOSIS Characterized by an erythematous, tender, indurated, swollen, and warm eyelid and periorbital area. There is no associated decrease in visual acuity, conjunctival injection, impairment of extraocular movements, proptosis, pain with eye movement, or other intraorbital pathology. A CT scan of the orbits can differentiate between periorbital cellulitis and the often more severe but less common orbital cellulitis. TREATMENT, DISPOSITION, AND FOLLOW-UP Children with periorbital cellulitis who are well appearing and are afebrile are candidates for outpatient oral antibiotic therapy: Amoxicillin-clavulanate (20 milligrams/kg PO twice a day) is appropriate oral therapy. Those with more severe periorbital cellulitis or in whom hematogenous spread is suspected require parenteral therapy and hospitalization. Cefuroxime (50 milligrams/kg IV every 8 hours), ceftriaxone (50 milligrams/kg IV every 12 hours), or ampicillin-sulbactam (50 milligrams/kg IV every 6 hours) are appropriate choices. Add vancomycin if methicillin-resistant S. aureus is suspected.

18. ORBITAL CELLULITIS Orbital cellulitis is usually an extension of a sinus infection into the orbit behind the septum but may also be spread hematogenously or from traumatic inoculation. Average age of presentation is 12 years old. Complications include subperiosteal abscess, orbital abscess, cavernous sinus thrombosis, panophthalmitis , or endophthalmitis. The most common bacterial pathogens are S. pneumoniae , M. catarrhalis , S. aureus , S. pyogenes , and anaerobic upper respiratory flora such as Bacteroides and Fusobacterium species. Non-typeable H. influenzae remains a pathogen in the postvaccine era. CLINICAL FEATURES AND DIAGNOSIS Orbital cellulitis is characterized by erythema and swelling around the eye. Suspect orbital cellulitis if the eyelid or periorbital inflammation is accompanied by any of the following: proptosis, impaired extraocular movements, pain with eye movement, decreased visual acuity, chemosis, or an afferent pupillary defect. Fever may or may not be present. Diagnosis of orbital cellulitis is primarily clinical, but an orbital and sinus CT differentiates between periorbital and orbital cellulitis and can identify a concomitant abscess or other pathology. CT findings are also useful to predict the need for surgical intervention. Culture of the blood, nares, and conjunctiva may be obtained to help identify the bacterial source. After neuroimaging, consider lumbar puncture for symptoms such as headache, lethargy, neurologic symptoms, or toxic appearance to exclude associated meningitis.

19. PERIORBITAL V/S ORBITAL CELLULITIS ON CT

20. TREATMENT: Orbital cellulitis requires inpatient management. Consult otolaryngology and ophthalmology for evaluation and possible surgical drainage of abscesses. Parenteral therapy is indicated until significant clinical improvement is noted, followed by oral antibiotics to complete a 3-week course. Cefuroxime (50 milligrams/kg IV every 8 hours) and ampicillin-sulbactam (50 milligrams/kg IV every 6 hours) are appropriate first-line antibiotics. If cefuroxime is used or if an anaerobic infection is strongly suspected, add clindamycin (10 milligrams/kg IV every 6 hours) or metronidazole (15 milligrams/kg IV every 12 hours). Also add vancomycin for life-threatening infections or suspected methicillin-resistant S. aureus .

21. CAUSES OF RED EYE Ophthalmia neonatorum : conjunctivitis in neonates up to 30 days old. The five primary categories of neonatal conjunctivitis are chemical, gonococcal, chlamydial, other bacterial, and viral ( Table 122-2 ). Gonococcal, chlamydial, and viral neonatal conjunctivitis can all lead to severe morbidity.

22. Gonococcal conjunctivitis : The diagnosis is made by Gram stain, revealing gram-negative diplococci, and culture using chocolate agar. Admit all infants with gonococcal conjunctivitis, obtain ophthalmology consultation, and evaluate for disseminated disease. Test blood, urine, cerebrospinal fluid, and any other sites with suspected infection. Therapy for isolated conjunctivitis in a neonate without hyperbilirubinemia is a single dose of parenteral ceftriaxone (50 milligrams/kg IV; maximum, 125 milligrams) . To avoid exacerbation of hyperbilirubinemia or if disseminated infection is suspected and longer-term antibiotics are required, use cefotaxime (50 milligrams/kg IV every 8 hours) . Irrigate the infant’s eyes with normal saline frequently to eliminate the purulent discharge. Gonococcal ophthalmia neonatorum may progress to ulceration and perforation of the cornea if improperly treated.

23. CHLAMYDIAL OPHTHALMIA NEONATORUM Symptoms by 7-14 days. Signs are unilateral or bilateral purulent discharge with intense erythema of the palpebral conjunctiva Chlamydial ophthalmia may be associated with chlamydial pneumonia. Diagnosis is confirmed with Giemsa stain, culture, or nucleic acid amplification of conjunctival scrapings. Treat chlamydial conjunctivitis with or without associated pneumonia with a 14-day course of oral erythromycin (12.5 milligrams/kg PO every 6 hours) and erythromycin ophthalmic ointment. Ophthalmology consultation is recommended. Patients with isolated chlamydial ophthalmia who do not have respiratory symptoms or evidence of pneumonia may be safely discharged to home with follow-up in 24 hours.

24. CORNEAL ABRASION CLINICAL FEATURES Corneal abrasions in older children are characterized by a foreign body sensation, pain, photophobia, injection, and a history of direct trauma, ultraviolet light exposure, or pain from windblown particulate matter in the eye. Smaller children and infants often lack a history of trauma to the eye and may present with a chief complaint of inconsolable crying and an otherwise normal physical examination . If instillation of an anesthetic drop such as tetracaine 0.5% onto the surface of the eye calms the child, it strongly suggests that injury to the surface of the eye may be the source of the child’s distress.

25. DIAGNOSIS AND TREATMENT A thorough eye examination with instillation of fluorescein confirms the diagnosis of corneal abrasion. An abrasion will fluoresce to a yellow-green colour under the cobalt blue filter in the slit lamp or handheld Wood’s lamp. The presence of a vertical linear abrasion suggests the presence of a retained foreign body, so make sure to evert the upper eyelid and examine the superior conjunctiva. If details on the iris are not visible due to corneal opacification, this may indicate a corneal ulcer, needing an emergency ophthalmology consult.

26. Treatment of a corneal abrasion is erythromycin or bacitracin-polymyxin ophthalmic ointment to help avoid superinfection and provide lubrication . Avoid ointments containing neomycin due to hypersensitivity reactions. Cyclopentolate 0.5% drops may alleviate pain by reducing ciliary spasm. Occasionally nonsteroidal anti-inflammatory drops are also used (such as ketorolac), but the evidence is not robust. Eye patching is not routinely recommended but may be useful for any child who frequently attempts to scratch or rub the injured eye. Instillation of topical anesthetics at home is currently not recommended. Although the need for tetanus prophylaxis of a corneal abrasion is debatable , the ED visit should be used to remind the caregiver to check the child’s tetanus status with the primary care provider. In a tetanus-prone injury, using the same criteria as a standard skin abrasion, updating unknown tetanus status is recommended. For uncomplicated and simple corneal abrasions, recommend follow-up in 48 hours with the pediatrician or other primary care provider. Children with involvement of the visual axis should follow up the next day with ophthalmology. Children or adolescents who use contact lenses, have a history of herpes, or may have a retained foreign body should also be evaluated by an ophthalmologist. If the child wears contact lenses , give tobramycin ophthalmic solution to treat Pseudomonas . Ciprofloxacin and ofloxacin ophthalmic are acceptable options for children due to limited absorption .

27. PEDIATRIC GLAUCOMA Primary pediatric glaucoma is the result of dysgenesis of the chamber angle leading to decreased outflow of aqueous humor and increased intraocular pressure. Secondary glaucoma, aqueous outflow is diminished by systemic disease, scarring, trauma, inflammation, or infection. Primary pediatric glaucoma is more common than secondary glaucoma in children and is often familial. Pediatric syndromes associated with glaucoma include Sturge-Weber syndrome, Lowe’s syndrome, Down syndrome, neurofibromatosis, and maternal rubella syndrome. Intraocular pressure will be elevated (≥20 mm Hg) , and the cornea will appear enlarged and often cloudy and edematous . A full-term newborn cornea is nearly adult sized, with a horizontal diameter range of 9.0 to 10.5 mm versus 10.5 to 13.0 mm in an adult. Children <1 year of age should not have a corneal diameter >12 mm, and no child should have a corneal diameter >13 mm. There is associated blepharospasm, conjunctival injection, and myopia. The globe may appear enlarged. If the optic disc can be visualized, abnormal cupping or asymmetry may be found. Consult ophthalmology, and initiate medical therapy of pediatric glaucoma to temporarily decrease intraocular pressure while awaiting definitive surgical repair. Therapies include oral and topical carbonic anhydrase inhibitors and topical β-blockers. Acetazolamide (3 milligrams/kg PO every 6 hours) can be used for short periods of time, and pediatric doses are prepared by crushing the tablets used for adults. Topical carbonic anhydrase inhibitors such as dorzolamide or brinzolamide may also be used with fewer systemic side effects. Topical β-blockers such as timolol 0.25% are recommended at a starting dose of one drop daily.

28. LEUKOCORIA CONGENITAL CATARACT Children with cataracts present with any one of the following: leukocoria, strabismus, and/or nystagmus. On direct or slit lamp examination, lens opacities will be seen that can have partial or complete lens involvement, obscuring the retina. Cataracts recognized in the neonatal period are most frequently from the TORCH infections (toxoplasmosis, syphilis, rubella, cytomegalovirus, and herpes simplex). Cataracts may also be associated with a variety of systemic illnesses and syndromes such as Down syndrome, galactosemia, Lowe’s syndrome, Alport’s syndrome, homocystinuria, Wilson’s disease, and many more. RETINOBLASTOMA The most common presenting signs of retinoblastoma are leukocoria and strabismus, and most children are identified by 3 years of age. Children may also present with proptosis, retinal detachment, glaucoma, hyphema , vitreous hemorrhage , and a red, painful eye due to ocular inflammation that may be confused with orbital cellulitis.

29. Retinal hemorrhages appear to be caused by shaking of the infant’s head and are not sequelae of intracranial injury. Although retinal hemorrhages are pathognomonic of abusive head trauma in most settings, rarely, victims of a severe head crush injury have similar findings.

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