Common Eye Problems Pediatrics

Child's Ocular History

Date (and results) of the last vision screening and prior eye problems or diseases, including diagnoses and treatments If history of eye injury: unilateral or bilateral injury? Were there visual changes or photophobia? What treatment was received? Prescription and use of eyeglasses or contact lenses. Does the child have glasses that were prescribed? Are they used? If not, why?; use of sunglasses with ultraviolet (UV) protection or protective eyewear for sports activities symptoms: problems with fixing or focusing (holding objects up close to see), tracking, squinting, head tilt, eye-hand coordination, grasp, gait, balance, behavior, and changes in the ability to maintain eye contact; eyelid droop Photophobia - irritability, shielding, or rubbing of the eyes

Standards for Visual Screening and Care

Healthy People 2020: • Increase the proportion of preschool children ages 5 years and younger who receive vision screening. • Reduce blindness and visual impairment in children and adolescents ages 17 years and younger. • Reduce uncorrected visual impairment due to refractive errors. • Increase the use of personal protective eyewear in recreational activities and hazardous situations around the home. USPSTF: Screening tests have reasonable accuracy in identifying strabismus, amblyopia, and refractive errors in children younger than 5 years. Providers should be alert for signs of ocular misalignment when examining infants and children. Treating strabismus and amblyopia early greatly reduces long-term amblyopia and improves visual acuity. AAP: Well-child exam should include ocular history, vision assessment, external inspection of the eyes (pupils and red light reflex), lids, and ocular mobility. evaluation of fixation and following (binocularly and monocularly) starting at birth, with patched visual acuity screening starting at 3 years old. If uncooperative, retesting should occur 6 months later. Inability to fix and follow after 3 months of age -> referral to a pediatric ophthalmologist Subsequent testing should occur at 4, 5, 10, 12, 15, and 18 years old. Children who are difficult to screen after two attempts or who demonstrate any other eye abnormality should undergo photoscreening techniques to detect amblyopia, media opacities, and treatable ocular disease processes. high-risk children -> asymptomatic children have a comprehensive examination by an ophthalmologist: • Health and developmental problems that make screening by the primary care clinician difficult or inaccurate (e.g., retinopathy of prematurity [ROP], or diagnostic evaluation of a complex disease with ophthalmologic manifestations) • A family history of conditions that cause or are associated with eye or vision problems (e.g., RB, significant hyperopia, strabismus [particularly accommodative esotropia], amblyopia, congenital cataract, or glaucoma) • Multiple health problems, systemic disease, or the use of medications that are known to be associated with eye disease and vision abnormalities (e.g., neurodegenerative disease, juvenile rheumatoid arthritis, systemic steroid therapy, systemic syndromes with ocular manifestations, or developmental delay with visual system manifestations).

Eye Injury Prevention

Ocular trauma -> 1/3 of all cases of acquired blindness in children. most common - males 11 to 15 years old prevented by using protective eyewear 50% - sports-related accidents 40% cases of battered child syndrome have ocular findings >44% of eye injuries occur in the home cornea (50%), conjunctiva (49%), and sclera; most serious -> cornea, iris, lens, and optic nerve and may result from anterior chamber hyphema, vitreous hemorrhage, or retinal tear or detachment Prevention includes such fundamental concepts as the following: • Children need to be instructed to: Not run with or throw sharp objects Use protective eyewear when hammering, using power tools or lawnmowers, or participating in a sport where there is a higher risk of ocular injury Use orthodontic headwear that breaks away if force is applied Not shine laser pointers in eyes Use eye wash fountains when indicated • Parents further need to be instructed to: Store harmful chemicals and sharp objects out of the reach of small children Limit and supervise the use of BB guns, air rifles, paintball devices, darts, and fireworks. games should be supervised by adult and protective eyewear should be worn by participants. Protective glasses are mandatory for all functionally one-eyed individuals (with best corrected vision worse than 20/40 in the poorer-seeing eye) or for any athlete who has had eye surgery or trauma or whose ophthalmologist recommends eye protection. should not participate in boxing or full- contact martial arts, caution with wrestling

Strabismus a. Description b. Epidemiology c. Clinical Findings d. Diagnostic Techniques e. Management f. Complications

a. a defect in ocular alignment, the position of the eyes in relation to each other; "lazy eye." the visual axes are not parallel because the muscles of the eyes are not coordinated; when one eye is directed straight ahead, the other deviates. one or both eyes appear crossed. may be manifested as a phoria or a tropia Pseudostrabismus - the sclera between the cornea and the inner canthus is obscured by closely placed eyes, a flat nasal bridge, or prominent epicanthal folds > 7 to 9 years w/ acquired tropia -> double vision <6 to 7 years old, cortical suppression of vision in the deviated eye stops the diplopia, but leads to amblyopia. Exo-deviations may be constant or intermittent (int. more frequent) may be hereditary or the result of various eye diseases (e.g., neuroblastoma), trauma, systemic or neurologic dysfunction that paralyzes the extraocular muscles, uncorrected hyperopia, craniofacial abnormalities, accommodation and accommodative convergence. Esotropia - history of prematurity, low birthweight, cerebral palsy, hydrocephalus, and maternal substance abuse or tobacco use A phoria - intermittent deviation in ocular alignment that is held latent by sensory fusion. can maintain alignment on an object. A tropia - a consistent or intermittent deviation in ocular alignment. unable to maintain alignment on an object of fixation. • Hyper- (up) and hypo- (down) - vertical strabismus. • Exo- (away from the nose) and eso- (toward the nose) - horizontal deviations. • Cyclo - rotational or torsional deviation. b. 1% to 6% of population, Accommodative esotropia most visible when child (1-8, avg 2-3) is looking at a near object seen in children with a history of acquired intermittent or constant crossing Variable alignment - common in the newborn. Most have straight eyes; up to 70% can exhibit transient exotropia, resolve by 6 months of age, and 0.5%-2% have esotropia. Up to 25% of esotropia between age 3-6 months resolves over time Congenital esotropia - an infant with an onset <6m who did not have deviation as a newborn. Accommodative esotropia is an inward deviation caused by high hyperopia c. • Intermittent exotropia in normal children 6m-4yo who are ill, tired, exposed, bright light or sudden changes from close to distant vision. more often seen with distant fixation. • When only one eye is affected, the child always fixates with the unaffected eye. • When both eyes are affected, the eye that looks straight at any given time is the fixating eye. • The angle of deviation may be inconsistent in all fields of gaze, actually changing in some forms • Persistent squinting, head tilting, face turning, overpointing, awkwardness, marked decreased visual acuity in one eye, or nystagmus may be seen. • Cataracts, RB, anisometropia, and severe refractive errors are found infrequently. d. corneal light reflection technique - Asymmetry of light reflection on the cornea is indicative of a deviation in ocular alignment. cover-uncover test - detect tropias alternating cover test detects phorias photoscreener - detect strabismus. e. Any ocular misalignment seen >4 months old is considered suspicious -> referred. Hypertropia or hypotropia, exotropia, acquired esotropia or exotropia, cyclovertical deviation, or any fixed deviation -> referral as soon as it is first observed. • The unaffected ("good") eye is occluded (using an adhesive bandage eyepatch, an occlusive contact lens, or an overplussed lens), which forces the child to use the deviating eye. Pharmacologic penalization with the daily instillation of 0.5% to 1% atropine sulfate is also used, as effective as conventional occlusion • Surgical alignment of the eyes may be necessary • Orthoptic exercises indicated in certain forms of intermittent strabismus or when the visual axes are nearly aligned. -Corrective lenses may or may not be indicated, • Assessment for amblyopia should be done at every visit, even after straightening the eyes, because changes in alignment can occur through the fifth year. • The ocular status of an affected child's siblings is monitored. • Local botulinum toxin injection may also be used with certain deviations. f. Amblyopia (secondary visual loss) occurs in 30%-50% of children with strabismus. Uncorrected strabismus -> negative effect on self-esteem.

Glaucoma a. Description and Epidemiology b. Clinical Findings c. Management d. Complications

a. a disturbance in the circulation of aqueous fluid that results in an increase in IOP and subsequent damage to the optic nerve. classified according to age at the time of its appearance and other associated conditions. Congenital glaucoma - first 2 to 3 years of life; congenital abnormality of the structures that drain the aqueous humor. it is rare and generally caught early. 25% cases are newborns, 60% before 6 months old, and 80% by 12 months old; 65% to 80% occur bilaterally seen in association with other developmental anomalies, such as neurofibromatosis; diffuse facial nevus flammeus (port-wine stain); Sturge-Weber, Marfan, Hurler, or Pierre Robin syndromes; intraocular hemorrhage; or intraocular tumor. higher incidence in children with a history of congenital cataracts (up to 25% of children who have glaucoma have had prior cataract surgery) Secondary or juvenile glaucoma (glaucoma between 3 and 30 years of age) occurs when the drainage network for aqueous humor becomes obstructed after ocular infection, trauma, systemic disease, or long-term corticosteroid use. b. Parents - something is unusual in eyes. more often in unilateral glaucoma when the orbital size discrepancy is more noticeable. infantile glaucoma: • "Classic triad" of tearing, photophobia, and excessive blinking or blepharospasm caused by irritation (30% of patients manifest this triad). Infants may turn away from light • Hazy corneas • Corneal edema. Corneal and ocular enlargements are common in infants and young children. Bulbar conjunctival erythema, and visual impairment may occur. If bilateral, no noticable difference in the size of the corneas. Symptoms of secondary glaucoma include the following: • Extreme pain, vomiting • Blurred or lost vision • Tunnel vision • Pupillary dilation • Erythema (often in only one eye) • Change in configuration of optic nerve cupping, with asymmetry between the eyes and loss of vision over time c. The goal is normalization of IOP and prevention of optic nerve damage along with correction of associated refractive errors and prevention of amblyopia. • Refer to an ophthalmologist. surgery ASAP (often multiple surgeries are required). • importance of medication compliance and discourage excessive physical or emotional stress and straining during defecation. • A medical identification tag is worn at all times. • Follow-up is for life, often every 3 to 6 months. • Ophthalmoscopic examination (including tonometry) is needed for every member of the family. d. permanent vision loss secondary to stretching of the cornea and sclera with resultant scarring, glaucomatous optic nerve damage, or amblyopia.

Chalazion a. Description b. Clinical Findings c. Management

a. a chronic sterile inflammation of the eyelid resulting from a lipogranuloma of the meibomian glands that line the posterior margins of the eyelids. deeper in the eyelid tissue than a hordeolum and may result from an internal hordeolum or retained lipid granular secretions. b. mild erythema and slight swelling of involved eyelid After a few days the inflammation resolves, and a slow growing, round, nonpigmented, *painless* (key finding) mass remains. may persist for a long time and is a commonly acquired lid lesion seen in children. c.• Acute lesions are treated with hot compresses. • Refer to an ophthalmologist for surgical incision or topical intralesional corticosteroid injections if the condition is unresolved or if the lesion causes cosmetic concerns. can distort vision by causing astigmatism as a result of pressure on the orbit. Complications Recurrence is common. Fragile, vascular granulation tissue called pyogenic granuloma that enlarges and bleeds rapidly can occur if a chalazion breaks through the conjunctival surface.

Traumatic Hyphema a. Description and Epidemiology b. Clinical Findings c. Management d. Complications e. Prognosis

a. accumulation of visible blood or blood products in the anterior chamber of the eye and is the result of blunt trauma to the globe without penetration or perforation. most often caused by balls, fists or fingers, elbows, rocks, exploding airbags, and sticks. may also occur in infants with birth trauma or in patients with RB, abnormal iris vessels (rubeosis), leukemia, juvenile xanthogranuloma of the iris, or abnormal hematologic profiles, such as sickle cell trait or disease, or secondary to child abuse. 75% in males b. Vision, pupil motility, the lids and adnexa, the cornea and anterior segment, and the red light reflex should be assessed. • History of traumatic eye injury • Somnolence (often associated with intracranial trauma) • Blood appearing as a dark red fluid level between the cornea and iris on gross examination or as a hazy-appearing iris • Inability to detect a bilateral red light reflex • Pain, photophobia, and tearing • Visual acuity changes and impaired vision (light perception and hand motion perception) • Abnormal pupillary reflex c. resolving the hyphema, making the patient comfortable, and preventing complications. • Refer the patient immediately to an ophthalmologist. A slit-lamp examination is indicated. • Restrict oral intake until the child has been seen by an ophthalmologist. • Place a perforated eye shield (not a patch) over the eye—avoid pressure to prevent reinjury. • If a hematologic disorder is detected, ensure quick intervention and close follow-up. • Outpatient management is acceptable for those with small hyphemas (grade I): Elevate the head of the bed to 30 degrees. Child should wear a Fox shield; maintain bed rest with bathroom privileges for 5 days; participate in no strenuous activities for 10 days; have daily eye examinations to check for blood staining and IOP. Cycloplegic agents may be used • Children should be hospitalized with a hyphema of grade II or III, those with sickle cell, if there is an increase in IOP, or if there is a question about compliance with outpatient treatment. • Acetaminophen is the analgesic of choice; avoid aspirin and NSAIDs because they may add to the risk of a rebleed. Sedatives may be necessary in pediatric patients. • Surgery may be necessary to remove the trapped blood from the chamber if (1) it is causing an increase in IOP; (2) in sickle cell patients; to prevent corneal blood staining; (3) if the hyphema remains without some clearing in the first 4 days; or (4) a clot is pressing against the corneal epithelium • After hospital discharge, the child should be followed closely by an ophthalmologist because long-term monitoring is necessary to detect possible traumatic cataract, retinal detachment, or glaucoma. d. A second hemorrhage can occur within 3 to 5 days of the first, increasing the risk of glaucoma, amblyopia, or corneal blood staining that can result in permanent visual loss. occurs in 7% to 38% cases. The larger the hyphema, the more likely the rebleed. Patients with abnormal hematologic profiles (e.g., sickle cell hemoglobinopathies) are more likely to have visual loss because of optic atrophy e. Success determined by the recovery of visual acuity. When less than a third of the anterior chamber is filled with blood, approximately 80% regain acuity of 20/40 or better. When more than half (but less than total) of the chamber is filled this same visual acuity is regained in about 60%. only 35% of those with total hyphema will have this return in acuity. <6 years of age, about 60% have good visual return

allergic and vernal conjunctivitis a. incidence/etiology b. clinical findings c. diagnosis d. mgmt

a. atopy sufferers, seasonal usually occurs in childhood but can occur after adolescence. Four types: (1) hay fever-associated: mild injection and swelling; exposing the eyes to environmental allergens (dust, grass, molds, animal dander); generalized allergic reaction including nasal congestion; (2) vernal: more severe, with peak incidence in 10- to 12-year-olds, boys 2x rate of girls, increased prevalence in warm weather; (3) atopic keratoconjunctivitis: atopic dermatitis and/or asthma; affects the lower tarsal conjunctiva, usually occurs in late adolescence, significant (beyond that seen in allergic conjunctivitis) itching, burning, and tearing that are often chronic. 4) Giant papillary conjunctivitis: contact lens wearers; 10x more common in soft contacts than hard contacts Seasonal allergens (notably grass pollens and ragweed) cause Rhinitis, eczema, and asthma may be associated conditions. 40% of the general population and is experienced by approximately 32% of atopic children b. stringy, mucoid exudate, swollen eyelids, and conjuctivate, palpebral follicles, headache, rhinitis *Severe itching and tearing* (key findings) • Family history of atopy or seasonal allergies • eczema, asthma • Acute attacks precipitated by allergens (e.g., pollen, animals, molds, dust, dust mites, occasionally food) • Redness and swelling of the conjunctiva or eyelid (or both) Follicular reaction of the conjunctiva • Bilateral involvement most common • Cobblestone papillary hypertrophy in the tarsal conjunctiva • Vision screening should be normal; document in patient's record c. eosinophils in conjunctival scrapings Conjunctival or nasal smears (using Wright stain) d. naphozoline/pheniramine, naphazoline/antazoline ophthalmic solution mast cell stabilizer refer to allergist if needed • Prevention is best; avoid allergens. • mild cases, saline solution or artificial tears, cool compresses. Refrigerated eyedrops are more soothing. • next step is topical decongestants, oral or topical antihistamines, topical mast cell stabilizers, or topical NSAIDs decongestants do not decrease the allergic response, but do relieve erythema, injection, and lid edema. Prescribed agents can provide quicker, more long-term relief with fewer side effects than over- the-counter agents. Vasoconstrictors should be avoided because of rebound hyperemia Patients may be treated with systemic antihistamines (fexofenadine, loratadine, or cetirizine) if systemic symptoms are present Topical decongestants include naphazoline hydrochloride ophthalmic solution (1 or 2 drops every 3 to 4 hours). A combination antihistamine-decongestant is more effective than either agent alone: naphazoline hydrochloride plus antazoline ophthalmic solution (1 or 2 drops four times a day) can be used sparingly to reduce ocular congestion, irritation, and itching. • Topical mast cell stabilizers may be helpful for maintenance therapy, chronic allergies, or vernal conjunctivitis. Cromolyn sodium 4%: 1 or 2 drops every 4 to 6 hours for children older than 4 years on a regular basis Nedocromil sodium 2%: 1 or 2 drops two times a day Pemirolast potassium: 0.1% or lodoxamide tromethamine 0.1% 1 or 2 drops four times a day for children older than 2 years • Topical olopatadine hydrochloride 0.1% is a mast cell stabilizer combined with an antihistamine for children older than 3 years (1 drop 8 hours apart). • Topical NSAIDs can be used for late-phase treatment of itching and burning. Ketorolac tromethamine 0.5%, 1 drop four times a day up to 1 week in children older than 12 years; it often stings when applied. • Topical steroids used with caution -> s/e increased IOP, potential for viral infection, contraindication with herpes, potential to cause cataracts, and poor corneal healing. An ophthalmologist should be consulted before using. At maximum, they should be used for 1 week. • Refer to an allergist for allergen immunotherapy when rhinitis is present because therapy can lead to better control without the need for medication. • Refer to an ophthalmologist if unresponsive to treatment or if the following is present: corneal abrasions, impaired vision, need for corticosteroids, severe keratoconjunctivitis, or atypical manifestations. • Maintain a high threshold of suspicion for herpes-induced blepharitis or atopic keratoconjunctivitis if pain is present. Complications corneal ulceration, scarring and vision loss, corneal degeneration, and changes in the corneal curvature

Bacterial conjuctivities a. incidence/etiology b. clinical findings c. diagnosis d. mgmt

a. in neonates 5-14 days old, preschoolers, and sexually active teens: Haemophilus influenzae (nontypeable), Streptococcus pneumoniae, S. aureaus, GC H. influenzae - most common organism isolated in children younger than 7 years S. pneumoniae, M. catarrhalis, and adenovirus are also common pathogens. most common in the winter and in toddlers and preschoolers. since pneumococcal vaccine - incidence of vaccine-type invasive pneumococcal infections has decreased by 99%; the incidence of invasive pneumococcal disease has decreased by 77% in children younger than 5 years b. erythema, chemosis, itching, burning, mucopurulent exudate, matter in eyelashes, increased in winter Erythema of one or both eyes, *usually starting unilaterally and becoming bilateral* (key finding) • *Yellow-green purulent discharge* (key finding) • *Encrusted and matted eyelids on awakening* (key finding) • stinging and a feeling of a foreign body • Photophobia • Petechiae on bulbar conjunctiva • Symptoms of upper respiratory infection, otitis media, or acute pharyngitis • Vision screen should be normal and documented in the patient's record c. cultures (optional); Gram stain (optional); chocolate agar (for GC) R/O pharyngitis, GC, AOM, URI, seborrhea Routine culture testing is not necessary. Gram stain and culture can be done if the conjunctivitis is chronic, recurrent, or difficult to treat. Cultures or scrapings are appropriate for unresolved infection. Differential: nasolacrimal duct obstruction in infants, ear infection, Kawasaki syndrome, foreign body, corneal abrasion, uveitis, herpetic conjunctivitis, poor compliance, or wrong choice of drug. d. neonates: erythromycin 0.5% ophalmic ointment ->=1 year old: 4th generation fluoroquinolone -for concurrent AOM: treat for AOM -warm soaks to eye 3x/day until clear -no sharing towels, pillows -no school until treatment begins a self-limited disease (unless caused by gonorrhea or Chlamydia) usually resolves within 8 to 10 days. children who receive topical antibiotics demonstrate faster clinical improvement, can return to daycare or school faster, and cause less parental work loss. common practice of prescribing antibiotics for conjunctivitis -> an increasing rate of drug resistance. older children and teens may be treated conservatively without using antibiotics. Choose broad-spectrum coverage that has the lowest resistance rate, greatest compliance, and best penetration of tissues. Parents can be instructed to put pressure over the lacrimal duct when instilling the medication to prevent drainage into the nasolacrimal system. If improvement is not seen in 3 days after treatment is initiated, refer to or consult as appropriate with an ophthalmologist. Contacts should not be worn during treatment. Disposable lenses should be discarded and permanent contacts sterilized before reinserting uncomplicated: • Sodium sulfacetamide 10% ophthalmic solution or ointment; not effective against H. influenzae; stings; can cause allergic reactions (including Stevens-Johnson syndrome). Dosage: 1 or 2 drops four times a day for 5 to 7 days. • Trimethoprim sulfate plus polymyxin B sulfate ophthalmic solution. Dosage: 1 or 2 drops four times a day for 5 to 7 days. • Erythromycin 0.5% ophthalmic ointment is recommended for patients with sulfa allergy and for infants. Dosage: 1⁄2-inch ribbon four times a day for 7 days. • Azithromycin drops for children older than 12 months. Dosage: 1 drop twice a day for 2 days, then 1 drop daily for 5 days. • Fluoroquinolone ophthalmic drops including besifloxacin, ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, ofloxacin may be prescribed for children older than 12 months. Dosage: 1 or 2 drops four times a day for 5 to 7 days The aminoglycosides (neomycin, tobramycin, gentamicin) are to be avoided because of possible hypersensitization, severe allergic reactions, and increasing resistance Conjunctivitis Otitis Syndrome caused by H. influenzae. Treat for the otitis media Concurrent use of a topical antibiotic is not necessary. Patient Education If only one eye is involved, it is likely that the infection will spread within a day or two to involve both eyes. • Cleanse the eyelashes several times a day with a weak solution of no- tears shampoo and warm water. The importance of wiping from the inner canthus outward and using a different cloth or cotton ball for each eye should be emphasized. • Use warm soaks three or four times a day to relieve itching and burning. • Instill the prescribed ophthalmic solution or ointment into the lower conjunctival sac. A moistened cotton swab may be used to facilitate instillation of ointments. Dosing while the child is sleeping greatly increases compliance and effectiveness. • Wash hands frequently and avoid shared linens to limit spread of the infection. treat seborrheic dermatitis on the scalp and face if present Daycare center exclusion policies vary (some allow return once the treatment is started, while others only after completing 1 to 2 days of treatment). Improvement in the child's condition should be seen within 48 hours. If medication compliance is not in question and improvement is not seen within 72 hours of administration, the parent should be instructed to return so that a smear of the exudate can be taken for culture and sensitivity testing. Complications recalcitrant to treatment, eye pain is present, vision is blurred, or ophthalmoscopic examination reveals a bulging iris and a contracted, fixed pupil, suspect more serious inflammation of the uveal tract (iritis, cyclitis, or choroiditis). Refer immediately to an ophthalmologist to avoid ocular morbidity.

Periorbital Cellulitis a. Description and Epidemiology b. Clinical Findings c. Laboratory Studies d. Management

a. inflammation of the tissues surrounding the involved eye, often associated with trauma or focal infection near the eye, eyelid abscess, bacteremia, or sinusitis. It is predominantly an infection in children, spread from the upper respiratory tract or middle ear. most commonly seen in children up to 6 years old. occur with infected lacerations, abrasions, insect stings or bites, impetigo, or a foreign body where the infection is spread via venous or lymphatic channels. secondary to paranasal sinusitis etiology is often unknown bacteria most commonly responsible - streptococcal organisms (nonvaccine streptococcal strains in children who have received both HIB and pneumococcal conjugate vaccine), S. aureus, and, HIB M. catarrhalis can also be a causative agent in children younger than 4 years of age. b.• Acute febrile illness (temperature higher than 102.2° F [39° C] if associated with bacteremia) • Swelling and erythema of tissues surrounding the eye; upper lid affected more often than the lower lid. • Deep red eyelid (color is purple-blue with H. influenzae infection) • Symptoms of bacteremia or sinusitis (headache, decreased vision) • Orbital discomfort or pain, proptosis, or paralysis of extraocular muscles c. • CBC with differential (WBC count usually greater than 15,000 if bacteremic) • Blood cultures and culture of purulent wounds near the eye • Lumbar puncture (infants younger than 1 year old) • CT scan to rule out sinusitis, orbital cellulitis, or subperiosteal abscess • Visual acuity, extraocular movement, and pupillary reaction testing Differential Diagnosis Conjunctivitis (bilateral conjunctival inflammation), cavernous sinus thrombosis, and orbital cellulitis (proptosis, limited extraocular movement, and reduced visual acuity); in neonates - conjunctivitis, dacryocystitis, and ruptured dacryocystocele. d. outpatient if: • The cellulitis is mild. • The orbit is not involved (full eye movements are present, no pain with eye movement, visual changes, or ptosis). • no symptoms of systemic bacterial sepsis. • older than 1 year. Consultation is needed when proptosis, ophthalmoplegia, or changes in visual acuity occur -> orbital cellulitis. Outpatient : • Ceftriaxone (50 to 75 mg/kg [up to a maximum of 1 g] IM divided every 12 hours). The child is monitored daily until blood cultures are negative for 48 hours or clinical improvement is seen. Oral antibiotics may then be used to complete a 7- to 14-day course. Amoxicillin (high-dose), amoxicillin with clavulanic acid, and cefixime are first-line choices for treatment. Warm soaks to the periorbital area every 2 to 4 hours for 15 minutes - comfort and speed healing. call immediately if there is any change in condition. Hospitalization and iv administration of antibiotics followed by a 10-day course of oral antibiotics for: • Moderate to severe cases of cellulitis • A poor response to outpatient management • A purulent wound near the eyelid • Children < 1 year old • Children with suspected sepsis Complications orbital cellulitis or extension of the infection into the orbit, subperiosteal or orbital abscess, optic neuritis, retinal vein thrombosis, panophthalmitis, meningitis, epidural and subdural abscesses, and cavernous sinus thrombosis.

most common eye disorders

permanent central visual loss (amblyopia), opacities (congenital cataracts), refractive errors not associated with amblyopia, strabismus (ocular misalignment) other conditions that interfere with visual acuity (ptosis, anisometropia).

Assessment of Visual Loss

referred immediately to an ophthalmologist, after performing functional tests: • Shine a penlight into the eye from a lateral position and turn the light off and on several times to assess light perception. If the child can identify when the light is on or off, vision is described as "LP" (light perception). • If hand movement (H/M) can be seen 12 inches from the child's face, it is documented as "H/M at 1 ft." Indication of search and recognition should be seen as the hand is slowly moved back and forth with periodic cessation. • Ask the child to count the number of fingers (C/F) seen when one, two, or three fingers are held up 12 inches from the child's face. If the child is correct, document the vision as "C/F at 1 ft."

Development of Ocular Structures

21 days of gestation - the first recognizable ocular tissue visible on each side of the head. end of 8th week - the eyes have moved medially toward the front of the face. eyelids completely formed, edges of upper and lower lids fuse to seal the eye while it develops. 16 weeks of gestation - the eyes are fully anterior, continue to move closer to the bridge of the nose. 7 month of preg - fetus can open eyes birth - Development of the eye as a visual organ is not complete, normal demonstrates disconjugate fixation 2 to 3 months - ability to focus at any range develops as the eyes become coordinated horizontally and vertically. Jerky eye movements can be seen 3-4 months - convergence and accommodation normally develop, time smooth tracking movements are expected. 5-6 months - parallel alignment without nystagmus or strabismus 1 year old - shape and contour of the eyeball changes, visual acuity and binocularity gradually increase with age. The volume of the orbits doubles 6-8 years old - volume of orbit doubles again until 7-8 year old - visual pathways are amenable to the greatest corrective influences, adequate treatment of amblyopia 10-13 years old - Eye growth is completed, adult visual field obtained corneal dimension changes minimally from full-term newborn to adulthood. early childhood - visual pathways that ensure central vision are developing. brain must receive equally clear, bilaterally focused images at the same time the visual system of teens and adults with amblyopia might still retain substantial plasticity

Recommended Ages and Methods for Pediatric Eye Evaluation Screening a. Newborn-3 months b. 3-6 months (approximately) c. 6-12 months and until child is able to cooperate for verbal visual acuity d. ≥3 years and every 1-2 years after 5 years

Method - Indications for Referral to an Ophthalmologist a. Red reflex - Abnormal or asymmetric (if the examiner cannot see into the eye (absent red light reflex), the patient cannot see out.) Ocular history Inspection - Structural abnormality b. Fix and follow - Failure to fix and follow in a cooperative infant Ocular history Red reflex - Abnormal or asymmetric Inspection - Structural abnormality c. Fix and follow with each eye - Failure to fix and follow Alternate occlusion - Failure to object equally to covering each eye Ocular history Corneal light reflex - Asymmetric Red reflex - Abnormal or asymmetric Inspection - Structural abnormality d. Visual acuity* (monocular) - 3 years: 20/50 or worse; 5 years: 20/40 or worse Ocular history - >5 years: 20/30 or worse, or two lines of difference between the eyes Corneal light reflex/cover- uncover reflex - Asymmetric/ocular refixation movements Red reflex - Abnormal or asymmetric Inspection - Structural abnormality Attempt ophthalmoscopy

When To Refer to Opthalmology

Risk factors (general health problems, systemic disease, or use of medications that are known to be associated with eye disease and visual abnormalities) Prematurity (birthweight less than 1500 g or gestational age 30 weeks or less) Retinopathy of prematurity Intrauterine growth retardation Perinatal complications (evaluation at birth and at 6 months) Neurologic disorders or neurodevelopmental delay (at diagnosis) Juvenile idiopathic arthritis (at diagnosis) Thyroid disease Cleft palate or other craniofacial abnormalities Diabetes mellitus (5 years after onset) Systemic syndromes with known ocular manifestations (at 6 months or at diagnosis) • Chronic systemic corticosteroid therapy or other medications known to cause eye disease • Suspected child abuse A family history of conditions that cause or are associated with eye or vision problems • Retinoblastoma • Childhood cataract • Childhood glaucoma • Retinal dystrophy/degeneration • Strabismus • Amblyopia • Eyeglasses in early childhood • Sickle cell anemia • Systemic syndromes with known ocular manifestations • Any history of childhood blindness not due to trauma in a parent or sibling Signs or symptoms of eye problems by history or observations by family members* Defective ocular fixation or visual interactions Abnormal light reflex (including both the corneal light reflections and the red fundus reflection) Abnormal or irregular pupils Large and/or cloudy eyes Drooping eyelid Lumps or swelling around the eyes Ocular alignment or movement abnormality Nystagmus Persistent tearing, ocular discharge Persistent or recurrent redness Persistent light sensitivity Squinting/eye closure Persistent head tilt Learning disabilities or dyslexia

Pterygium

a fibrovascular mass of thickened bulbar conjunctiva that extends beyond the limbus onto the cornea. Elastic and hyaline degenerative changes occur. usually triangular commonly found on the nasal side of the orbit. caused by irritation of the bulbar conjunctiva from sunlight, wind, dust, fumes, or airborne allergens; can be hereditary. Growth rates vary. A pinguecula may precede a yellow-white, slightly raised mass on the bulbar conjunctiva. usually painless, may itch, occasional complaints of blurred vision if the lesion enlarges. uncommon in children, consider other causes: papillomas, dermoids, keratoacanthomas, an epithelial inclusion or a dermoid cyst, or a rare malignancy Treatment involves protecting against irritants (use of goggles or sunglasses, or topical lubricants, such as artificial tears) and using mild vasoconstrictors or short-term steroids for inflammation. Surgical removal may be needed if impedes vision. Recurrence after surgical removal, restricted ocular mobility (especially with abduction), and diplopia may be complications.

Corneal Abrasion a. Description b. Clinical Findings c. Management

a. Damage to or loss of the epithelial cells of the cornea relatively common. Scratches from forceps delivery, paper, brushes, fingernails, contact lens overuse, improperly fitted cosmetic contact lenses, airbag deployment, plants, or foreign body in the conjunctival sac are often responsible. b.• Evidence and sensation of a foreign body • Severe pain and photophobia • Tearing and blepharospasm • Decreased vision • Conjunctival erythema • On examination, disrupted tear film over the corneal epithelium is seen with a penlight. • Fluorescein staining with superficial uptake is indicative of a minor corneal abrasion. If the fluorescein staining goes deeply into the cornea, subepithelial corneal damage is possible. Vertical striations on the cornea suggest a foreign body embedded under the eyelid. c. Refer severe corneal injuries or possible subepithelial damage to an ophthalmologist. Refer those who wear contact lenses with an abrasion to an ophthalmologist to rule out bacterial corneal infection (a prophylactic topical antibiotic [e.g., gentamicin or ciprofloxacin] may be prescribed in these circumstances to cover Pseudomonas). • If no symptoms of corneal infection, use topical antibiotics (0.5% erythromycin or polysporin drops or ointment [preferred as more lubricating]) four times daily. The use of a patch does not improve healing or decrease pain and a poorly applied patch may cause a corneal abrasion An abrasion generally heals in 24 to 48 hours. Some specialists apply a soft contact lens as a protective barrier. • Advise the patient to return daily for follow-up evaluation or refer for slit-lamp examination within 24 to 36 hours. If responding, continue the ointment for 2 to 3 days. If no improvement is seen after 24 to 48 hours or if symptoms worsen, refer to an ophthalmologist. • Use elbow restraints for the infant to ensure that the eye is not rubbed or further irritated. • Oral analgesics or ophthalmologic NSAIDs (e.g., ketorolac 0.5%) may be used to ease the discomfort. Do not use topical anesthetics because they are toxic to the epithelium.

Normal Visual Development Milestones a. Birth-2 weeks b. 2-4 weeks c. By 3-4 months d. By 4 months e. By 6-10 months f. By 12 months

a. Infant sees and responds to change in illumination; refuses to reopen eyes after exposure to bright light; increasing alertness to objects; fixes gaze on contrasts (e.g., black and white); jerky movements; pupillary reaction present. b. Infant fixes and follows on an object, though sporadically. c. Infant recognizes parent's smile; looks from near to far and focuses close again; beginning development of depth perception; follows 180-degree arc - follow moving objects; reaches toward toy; few exodeviations; esotropia abnormal. visual recognition of familier objects d. Color vision near that of an adult; tears are present. e. Infant fixes on and follows toy in all directions; movements smooth. f. Vision is close to fully developed.

Keratitis and Corneal Ulcers a. Description and Epidemiology b. Clinical Findings c. Management

a. Inflammation of the cornea can cause a dramatic alteration in visual acuity and can progress to corneal ulceration and blindness. medical emergency and requires prompt referral to an ophthalmologist begins as a well-defined infiltration at the center or edge of the cornea and subsequently suppurates and forms an ulcer that may penetrate deep into the corneal tissue or spread to involve the width of the cornea. usually unilateral. causative agents include viruses (HSV-1, varicella-zoster, hepatitis C), bacteria (H. influenzae, Moraxella, S. aureus, S. pneumoniae, Pseudomonas, N. gonorrhoeae, Enterobacteriaceae [including Klebsiella, Enterobacter, Serratia, and Proteus]), fungi (rare), and protozoa. most common risk factor: trauma (result from wearing extended-wear contact lenses or having poor contact lens hygiene). high risk factors: Age (<30 and > 50 years old), gender (males >females [secondary to increased ocular trauma]), smoking, and low socioeconomic status, with vitamin A deficiency Less common causes: allergic reaction, conjunctivitis, systemic infections, toxic chemicals, and the use of corticosteroids. improperly fitted decorative contact lenses, popular with teenagers, has also been implicated (these lenses are often purchased over-the-counter from outlet stores) b. Symptoms vary in intensity according to the depth and extent. • Exposure to an infected individual • History of illness, eye trauma, extended contact lens wear, foreign body, or history of recent antibiotic treatment for conjunctivitis that was unresponsive • White lesions on cornea • Vesicles on the skin or eyelids and herpes lesions elsewhere on the body • Severe pain, sensation of a foreign body ("gritty"), and photophobia • Tearing, erythema, and spasms of the eyelid • Inflamed eye • Blurred vision • Occasional corneal opacification • Area staining green with a fluorescein strip (if herpes, a dendritic ulcer is seen) c. referred immediately for a slit-lamp examination. Delay can result in loss of vision in the eye. Do not attempt to treat. Visual acuity outcome is good when treated aggressively • Steroids should never be used. • Treatment with antivirals, such as trifluridine or vidarabine, may be used to speed healing in herpes simplex infections. Complications Corneal opacification, scarring, and loss of vision can occur if treatment is delayed.

Deformities of the Eyelids a. Entropion b. Ectropion c. Euryblepharon

a. a condition in which the eyelids invert so that the cilia or epithelium rubs against the corneal surface, causing abrasion or irritation. upper and lower eyelids may be involved. a rare congenital form. Examination reveals evidence of lid laxity. Pain or irritation and photophobia Complications - corneal scarring and corneal infections. Management - surgical intervention. b. a rare condition in which the eyelid margins evert. may be congenital, seen after infection, or secondary to scarring after trauma, radiation, or prior surgery. It can be confused with euryblepharon. Management - lubrication for mild cases; surgery is indicated for chronic or symptomatic cases. c. appears as a wide palpebral fissure with the appearance of a sagging half of the lower eyelid (temporal side) or a pulling away of the lid from the orbit. can have a genetic etiology (e.g., Down syndrome), be associated with other ocular anomalies (e.g., congenital cleft lip, strabismus, congenital ptosis), or be seen in association with nonocular anomalies (e.g., hypospadias, inguinal hernias, dental anomalies). It is often confused with ectropion. usually a mild cosmetic condition that the child may outgrow. No treatment is indicated unless chronic tearing or exposure keratitis occurs; in such cases, reconstruction can be done.

Orbital Fractures a. Description and Etiology b. Clinical Findings c. Management

a. a fracture of the walls of the orbit secondary to blunt trauma to the orbital rim or eye(s). The orbital floor is thin and subject to fracture. The inferior rectus muscle may become caught in the fracture site. a blow or blunt trauma to the orbit (e.g., ball, fist, motor vehicle accident [hitting the dashboard], fall). b. • Pain, diplopia • Numbness below orbit • Ecchymosis of the lids, nosebleed, trouble chewing • Limited ocular movement (especially upward) and weakness in downward movement • Globe displacement with a sunken-eye appearance or a protruding eye • Bony discontinuity or "step-off" • Subcutaneous emphysema in surrounding tissues and edema • Enophthalmos • Corneal laceration • Irregular pupil • Hyphema or absent red light reflex Diagnostic Studies Plain film radiography and CT scan c.• an ophthalmologic emergency requiring immediate intervention and referral. Diagnostic studies are performed to rule out injury to the skull and cranial contents. Open reduction may be necessary if any of the orbital bones are displaced or to rule out displacement of the globe or enophthalmos. • Icing the injury for 24 hours, followed by heat for 2 to 3 days, allows the swelling to subside before surgical repair. Surgery is often best done within 2 to 7 days up to 2 to 4 weeks, depending on the injury • Antibiotic prophylaxis is administered. Nasal decongestants may also be used.

Cataracts a. Description and Epidemiology b. Clinical Findings c. Management d. Complications e. Prognosis

a. a partial or complete opacity of the lens affecting one or both eyes most common cause of an abnormal pupillary reflex. congenital or acquired. result of infection (e.g., congenital rubella, CMV, toxoplasmosis), trauma to the eye (including physical abuse, airbag deployment), metabolic disease (e.g., galactosemia, hypocalcemia), long- term use of systemic corticosteroids or ocular corticosteroid drops, prematurity, CNS anomalies (e.g., craniosynostosis, cranial defects), genetic defects (e.g., Down syndrome, albinism), and demyelinating sclerosis and ataxia-telangiectasia. may be seen in children who have strabismus or pendular nystagmus, diabetes mellitus, atopic dermatitis, or Marfan syndrome. may be family history of cataracts; if present in multiple family members, a referral to a geneticist is indicated Worldwide, cataracts are responsible for visual loss in up to 10% of children b. • A history of maternal prenatal infection, drug exposure, or hypocalcemia • opacity on the lens, unilateral or bilateral. • Visual acuity deficits • A pale red reflex in dark-skinned people should not be confused with a cataract. c. Management depends on the size, density, and location of the cataract. congenital or infantile cataracts - monitored over several years, could produce amblyopia; some types do not progress Surgical removal of the lens optically clears the visual axis. aphakic refractive error is corrected with contact lenses. Ophthalmic surgeons may insert an intraocular lens into the posterior chamber to partially correct aphakia, with residual refractive error corrected with spectacles. Any sensory deprivation amblyopia is treated aggressively and spectacles are prescribed beginning at age 4 months d. Complications include amblyopia; residual anisometropia (unequal refractive power); aniseikonia (unequal ocular image between eyes); or intraocular competition. e. The ultimate degree of visual function depends on the cataract type, age at time of surgery, underlying disease(s), age of onset and duration, and presence of amblyopia or other ocular abnormalities. If dense and present at birth, outcomes are better if removed within the first few weeks of life or before 2 months poorer results seen with congenital unilateral cataracts than with congenital incomplete bilateral cataracts Children with histories of cataract surgery may exhibit later inflammatory sequelae, glaucoma, retinal detachment, secondary membranes, and orbital architectural distortions

Viral conjunctivitis a. incidence/etiology b. clinical findings c. diagnosis d. mgmt

a. adenovirus 3, 4, 7; HSV, herpes zoster, varicella can also be caused by enterovirus, molluscum contagiosum more common in children older than 6 years and in the spring and fall b. erythema, chemosis, *tearing* (bilateral); HSV and herpes zoster: unilateral with photophobia, fever; zoster: nose lesion; spring and fall *profuse clear, watery discharge* (key findings) • Fever, headache, anorexia, malaise, upper respiratory symptoms (*pharyngitis-conjunctivitis-fever triad with adenovirus* [key findings]) • *Pharyngitis with enlarged preauricular nodes* (key findings) • Itchy, red, and swollen conjunctiva • Hyperemia and swollen eyelids • Photophobia with measles or varicella rashes • Herpetic vesicles on the eyelid margins and eyelashes (marginal blepharitis) or on the conjunctiva and cornea (keratoconjunctivitis) c. cultures, r/o corneal infilturation d. refer to ophthalmologist if HSV or photophobia present cool compresses three or four times a day self-limited and should resolve in 7 to 14 days. difficult to distinguish from keratitis. any question about dx, refer for ophthalmologic assessment. • Warm or cold compresses and artificial tears • Prophylaxis with antibiotics is not recommended • Antihistamine or vasoconstrictive ophthalmic solutions may be used for symptomatic relief. Topical corticosteroids avoided because they may worsen the course. • Molluscum on the eyelid margins requires referral for excision. Conjunctivitis Pharyngitis Syndrome: more likely to be caused by adenovirus than by a bacterium. Complications Involvement of deeper layers of the cornea (keratitis) can occur and must be differentiated from conjunctivitis. Scarring of the cornea resulting in blindness is a significant complication of HSV infection. If in any doubt, refer to an ophthalmologist for a slit-lamp examination.

Blepharitis a. Description and Etiology b. Clinical Findings c. Management

a. an acute or chronic inflammation of the eyelash follicles or meibomian sebaceous glands of the eyelids (or both). usually bilateral. history of contact lens wear or physical contact with another symptomatic person. commonly caused by contaminated makeup or contact lens solution. Poor hygiene, tear deficiency, rosacea, and seborrheic dermatitis of the scalp and face are also possible etiologic factors. The ulcerative form usually caused by S. aureus. Nonulcerative blepharitis is occasionally seen in children with psoriasis, seborrhea, eczema, allergies, lice infestation, or in children with trisomy 21. b. • Swelling and erythema of the eyelid margins and palpebral conjunctiva • Flaky, scaly debris over eyelid margins on awakening; presence of lice • Gritty, burning feeling in eyes • Mild bulbar conjunctival injection • Ulcerative form: Hard scales at the base of the lashes (if the crust is removed, ulceration is seen at the hair follicles, the lashes fall out, and an associated conjunctivitis is present) Differential Diagnosis Pediculosis of the eyelashes. c. may be chronic or relapsing. • Scrub the eyelashes and eyelids with a cotton-tipped applicator containing a weak (50%) solution of no-tears shampoo to maintain proper hygiene and debride the scales. • Use warm compresses twice daily for 5 to 10 minutes and wipe away lid debris. • Apply antistaphylococcal antibiotic (e.g., erythromycin 0.5% ophthalmic ointment, 0.25 to 0.5 inch into each eye three or four times daily) until symptoms subside and for at least 1 week thereafter. Ointment is preferable to eyedrops because of increased duration of contact with the ocular tissue. • Treat associated seborrhea, psoriasis, eczema, or allergies as indicated. • Remove contact lenses and wear eyeglasses for the duration of the treatment period. Sterilize or clean lenses before reinserting. • Purchase new eye makeup; minimize use of mascara and eyeliner. • Use artificial tears for patients with inadequate tear pools. Chronic staphylococcal blepharitis and meibomian keratoconjunctivitis respond to oral erythromycin (250 mg daily for maintenance). Doxycycline (50 to 100 mg twice daily), tetracycline, or minocycline can be used chronically in children older than 8 years

Burns a. Etiology b. Clinical Findings c. Management

a. can be thermal (caused by exposure to steam, flame, intense heat [e.g., touching cornea with a curling iron], cinders, or cigarettes), chemical (e.g., cleaning agents, fertilizers, pesticides, battery fluid, or laboratory products), or induced by UV light (from bright snow, laser pointers, or a sunlamp). amount of damage directly related to the length of exposure and the nature of the source of the burn. Chemical burns are true emergencies because of the progressive damage that can occur. Alkaline solutions are especially damaging. Burns on the eyelids are classified and treated the same as burns elsewhere on the body. b.• Pale or necrosed appearance of the surrounding skin and eyelids • Opacity of corneal tissue • Visual impairment (decreased acuity) • Initial exquisite pain or delayed complaints of pain (e.g., in UV burns, pain emerges about 6 hours after exposure) • Photophobia • Tearing within 12 hours of exposure • Swollen corneas • Fluorescein stain revealing pinpoint uptake c.• Instill a topical anesthetic if available. • Chemical burns require immediate, ongoing, copious irrigation. With the eyelids held apart, instill a steady, gentle solution of tepid water, saline, or Ringer irrigation for 20 to 30 minutes or until the pH of the tear film is 7.3 to 7.7. The pH should be rechecked after 30 minutes to ensure it maintains this level. Refer to an ophthalmologist after irrigation to determine the extent of the damage. Do not patch the eye; allow tearing to continue to cleanse the eye. Cool compresses applied to the surrounding skin may be comforting. Hospitalization may be needed for sedation and analgesia. • Thermal burns may be treated the same way as corneal abrasions • UV burns are treated by using topical antibiotic prophylaxis, patches, and analgesics. Healing should occur in 1 to 2 days.

Lacerations of the Orbit a. Description b. Clinical Findings c. Management

a. cause perforation of the cornea and lead to uveal prolapse. anterior segment (cornea, anterior chamber, iris, lens) or posterior segment (sclera, retina, vitreous). b. • Anterior segment: Irregular pupil (retracted or peaked), Iris prolapse • Posterior segment: Poor red light reflex Decreased vision Black tissue or fluid seen under the conjunctiva c. Apply an eye shield (can be made from a cup) to protect the eye. Refer the patient immediately to an ophthalmologist to rule out damage to the globe and surrounding structures.

Trachoma a. Description and Epidemiology b. Clinical Findings c. Management

a. chronic infectious disease of the eye characterized by follicular keratoconjunctivitis with neovascularization of the cornea. second leading cause of blindness in the world. caused by one of the two C. trachomatis bivars that exist in the world. endemic in the Middle East and Southeast Asia. rare in the U.S. but is endemic among Navajo Indians in the southwestern U.S. It is contagious, often spread from eye to eye by flies. b.• Inflammation • Pain • Photophobia • Excessive tearing • Granulation follicles on the upper tarsal conjunctiva, eventual inversion (entropion) of the eyelid leading to corneal trauma, scarring, and blindness Laboratory Studies Cultures and staining are done. c. Consult with an ophthalmologist treatment is difficult and recommendations vary. WHO recommends treating with azithromycin (single dose of 20 mg/kg, maximum 1 g) Other drugs used include oral doxycycline (for children older than 8 years) or erythromycin for 40 days; or a topical antibiotic ointment (erythromycin, tetracycline, sulfacetamide [twice daily for 2 months or intermittently over 6 months]) to rapidly reduce inflammation to prevent scar formation Steroids are contraindicated. Reinforce frequent handwashing and careful cleansing of the eyes. Discourage sharing of towels and handkerchiefs.

Retinal Detachment a. Description and Epidemiology b. Clinical Findings

a. detachment of the neurosensory retina from its retinal pigment epithelium base within the globe. rare in children - traumatic causes (child abuse), a congenital abnormality or syndrome (aphakia, cataracts, Ehlers-Danlos, Stickler, Marfan, Norrie syndromes), or specific disease (ROP, viral retinitis, RB, or various retinopathies) Some may not be diagnosed for months or years after a blunt trauma injury There may be concurrent ocular disease or a family history of retinal detachment. b.• Blurry vision that becomes progressively worse • Dark cloud in one visual field, flashing lights, or a "shower of floaters" • Darkening of retinal vessels on funduscopic examination • Gray elevation at the site of detachment Management Instruct the patient not to eat and refer to an ophthalmologist for evaluation.

Inflammation of the Uveal Tract a. Description and Epidemiology b. Clinical Findings c. Management

a. iris, ciliary body, choroids and other ocular structures is often called uveitis. may be anterior (affecting the iris, ciliary body, or both) or posterior (affecting the choroid). the retina, vitreous, sclera, lens, and optic nerve. acute or chronic. 6% in children; those with juvenile idiopathic arthritis (JIA) and a spondyloarthropathy most of those cases. Globally, 2.2% to 33.1% infectious and noninfectious. viral or bacterial infections, ocular trauma, and infection in the eye. allergy, malignancy, and systemic diseases, such as JIA, inflammatory bowel, Kawasaki syndrome, herpes simplex, tuberculosis, Lyme disease, cytomegalovirus (CMV), toxoplasmosis, syphilis, acquired immunodeficiency syndrome (AIDS), ulcerative colitis, rubella retinitis, and Stevens-Johnson syndrome b.• *Acute onset of pain* (key finding) • *Red eye, photophobia, and blurred or decreased vision* (key findings) • Excessive tearing and eyelid edema • Conjunctival erythema • Circumcorneal injection • Hypopyon (pus layer in the bottom of the anterior chamber) • Cloudy appearance of the eye with a bulging iris and a contracted, irregular, or fixed pupil • If chronic, there may be no ocular pain, photophobia, redness, or tearing. • There may be a history of prior viral infection, joint pain, trauma, gastrointestinal problems. Differential Diagnosis Conjunctivitis c. Evaluate and treat systemic disease. Refer the patient to an ophthalmologist; definitive dx is made by slit-lamp examination prognosis is improved with early treatment. Cycloplegics and topical or systemic corticosteroids (depending on the cause of the inflammation) Cycloplegic-mydriatics prevent posterior synechiae (adhesions of iris to lens and cornea); NSAIDs may be used as adjunct treatment. Complications Anterior and posterior synechiae, changes in IOP, corneal edema, various degrees of visual impairment, papillary scarring, retinal detachment, glaucoma, enucleation, and cataracts

Retinopathy of Prematurity a. Description and Epidemiology b. Clinical Findings c. Management d. Complications e. Prevention

a. multifactorial retinal vasculopathologic disease primarily caused by early gestational age with low birth weight. abnormal growth of the retinal vessels in incompletely vascularized retinas of premature infants. classified according to the distance to which the vascularization has progressed away from the optic nerve (zone I, II, or III), severity of inflammatory changes (stage), duration (clock hours), extent of disease, presence of plus disease (degree of large vessel engorgement and tortuosity), scarring patterns, prethreshold and threshold ROP (a clinical subclassification system), and presence of Rush disease (rapidly progressing ROP, especially posterior retina) Developing retinal vessels grow outward from the optic nerve. The immature and incompletely vascularized retina is in a state of hypoxia, which stimulates the production of vascular endothelial growth factor (VEGF). Requisite levels of VEGF are needed to maintain the integrity of and stimulate retinal vessel growth. Exposure to supplemental oxygen presents an additional risk factor Higher oxygen concentrations produce lower VEGF levels and result in slowed vessel growth. Over several weeks, an avascular retina becomes ischemic, and, stimulates renewed VEGF production. The increase in VEGF stimulates vessel growth but not necessarily in an ordered manner. Other risk factors: history of maternal third-trimester bleeding, preeclampsia, diabetes, heavy smoking; in utero ischemia, hypercarbia, and hypocarbia; neonatal patent ductus arteriosus, sepsis, exchange and replacement transfusions, use of prostaglandins, lactic acidosis, congenital anomalies (e.g., anencephaly and trisomy 18), multiple birth, and being of a racial or ethnic group other than Black occurs primarily in premature infants born at or less than 28 weeks of gestation or weighing less than 1500 g. The risk is higher with lower birth weights; infants between 1000 and 1251 g have a 47% incidence, and infants smaller than 1000 g a 80.6% incidence. Infants demonstrating an unstable clinical course, despite a birth weight more than 1500 g, also are at higher risk b. initially diagnosed by a pediatric ophthalmologist while the infant is in the nursery (at 32 to 44 weeks postconception). Once the baby is discharged, the following may be seen: • Leukokoria (white fibrovascular tissue in the retrolental space), glaucoma, cataracts • Pupillary rigidity • Vitreous haziness, hemorrhage • Retinal and iris changes • Pallor of optic nerve • Strabismus • Cataracts • Detached retinas (often with secondary glaucoma, entropion, and eye infections) An infant (especially if full or near term) not previously diagnosed with ROP with detached retinas or leukokoria needs an ophthalmologic evaluation to rule out genetic disorders (e.g., Norrie syndrome, familial exudative vitreoretinopathy [X-linked recessive]). c. progresses at variable rates. Initial ophthalmologic examinations should be done on all infants born at <28 weeks' gestation or weighing <=1500 g those born at >1500 g or 29 to 34 weeks with an unstable course during hospitalization. Examinations - 31 to 32 weeks of postconceptual or postmenstrual age or 4-6 weeks of chronologic age; any vitreoretinal sequelae need to be followed throughout life The PCP's role is to ensure that all infants fitting these criteria (even in those whose ROP resolved or who did not have ROP) receive the initial and follow-up ophthalmologic examinations (within 2 weeks or less after discharge) by a specialist experienced in examining preterm infants. The PCP further needs to: • Discuss implications of their child's disease. • Monitor for late sequelae or ROP progression (e.g., strabismus, pseudostrabismus, amblyopia, myopia, anisometropia, leukokoria, and cataracts). • Assist children who have sequelae - referring to early intervention services for low-vision children, to low-vision community support services, and to family support groups. • Refer all children for yearly ophthalmologic follow-up if ROP required any treatment (even if ROP has resolved completely); less frequent follow-up is needed if no treatment was needed. Cryosurgery or laser photocoagulation is used to arrest the progression of abnormally growing blood vessels (laser is treatment of choice) ( d. Complications - Retinal detachment, strabismus, amblyopia, cataracts, serious myopia, nystagmus, astigmatism, anisometropia, uveitis, hyphema, macular burns, occlusion of the central retinal artery, glaucoma, and cicatrix (residual retinal scars) leading to later vision loss are possible. Any cicatricial formation is complete at about 8 months old. Less than 2% to 3% of infants have any visually threatening complications e. decreasing the occurrence of premature births and minimizing the oxygen needed.

Refractive Errors and Amblyopia a. description b. Myopia c. Hyperopia d. Astigmatism e. Anisometropia f. etiology g. Clinical Findings h. Management i. Complications

a. myopia, hyperopia, astigmatism, accommodation, and anisometropia. normal eye - light from distant object focuses directly on retina. variations in axial length of eyeball or curvature of cornea or lens exist, light focuses in front of or behind retina. abnormal focusing produces an alteration in the refractive power of the eye that results in a visual acuity deficit b. nearsightedness, the axial length of eye is increased in relation to the eye's optical power. light from distant object is focused in front of the retina rather than directly on it. child sees close objects clearly, but distant objects are blurry. c. farsightedness, the visual image is focused behind the retina. distant objects are seen clearly, but close objects are blurry. d. the curvature of cornea or lens is uneven; the retina cannot focus light from an object regardless of the distance, which makes vision blurry close up and far away. Rarely, can be caused by an alteration in the corneal sphere caused by a soft tissue mass on the inner aspect of the eyelid, such as a chalazion or hemangioma. e. a different refractive error in each eye. any combination or it may occur with aphakia (absence of the lens of the eye) f. Genetic and heritable - half cases Cortical visual impairment, ROP, and optic nerve hypoplasia - most prevalent conditions in preschool children Amblyopia - a unilateral deficit in which there is defective development of the visual pathways needed to attain central vision. Clear focused images fail to reach the brain -> reduced or permanent loss of vision. deprivational, or obstruction of vision (e.g., caused by ptosis, cataract, nystagmus); strabismic (caused by strabismus or lazy eye); or refractive (myopia, hyperopia, astigmatism, anisometropia). Refractive errors - most common visual disorders seen in children. Myopia may be present at birth, more likely to develop between 6 and 9 years and continue to increase throughout adolescence; Mild hyperopia is normal in a young child but should decrease rapidly between 7 and 14 years old. Definitions of varying degrees of visual impairment include: • Legal blindness: best corrected distance acuity in the better eye is less than 20/200, a visual field restriction in the better eye of less than 20 degrees, or both. • Low vision: corrected acuity is in the 20/70 to 20/200 range; these individuals generally meet requirements for special education. g. • Squinting • Fatigue • Headaches (rare) • Pain in or around eyes • Dizziness • Mild nausea • Developmental delay • Tendency to cover or close one eye when concentrating • Family history of refractive errors, strabismus, or amblyopia h. • Refer to an ophthalmologist or optometrist for prescription corrective lenses. Extended-wear contact lenses -> unilateral aphakia, severe anisometropia, corneal scarring with irregular astigmatism, and keratoconus. • Older children -> annual refraction and eyeglass evaluation. • Unilateral visual occlusion and occasionally surgery may be necessary. • Infants and toddlers need distraction, with consistent replacement of glasses once removed. i. Untreated or insufficiently treated amblyopia in young childhood -> irreversible and lifelong visual loss.

inclusion conjucntivitis a. incidence/etiology b. clinical findings c. diagnosis d. mgmt

a. neonates 5-14 days old, and sexually active teens; C. trachoma's usually caused by one of eight known strains of C. trachomatis demonstrate symptoms to 6 weeks, whereas N. gonorrhoeae symptoms are usually detected earlier. Nasopharyngeal infection with C. trachomatis is found in 50% b. erythema, chemosis, clear or mucoid exudate, palpebral follicles. • Maternal history of an STI or a history of a sexual partner with an STI • mild to severe mucopurulent to bloody discharge, usually bilateral • Follicular reaction (large, round elevations) in the conjunctiva of the lower eyelids; conjunctiva may bleed if stroked • Associated cervicitis, urethritis, or rectal infection • Infants may have symptoms suggestive of chlamydial pneumonia at 1 to 3 months old. c. cultures (ELISA, PCR) r/o sexual activity Definitive diagnosis - isolating the organism by tissue culture and by nucleic acid amplification (NAA) testing Conjunctival scrapings for Giemsa staining are indicated. Scrapings must contain epithelial cells because Chlamydia is an obligate intracellular organism Other nonculture tests: direct fluorescent antibody (DFA) and enzyme immunoassay (EIA). test for gonorrhea Ocular morbidity can result if gonorrhea is missed d. neonates: erythromycin PO adolescents: doxycycline, azithromycin, EES, erythromycin base, levofloxacin PO traditional use of oral erythromycin ethylsuccinate (EES) to other macrolides, azithromycin, and clarithromycin. increased incidence of idiopathic hypertrophic pyloric stenosis (IHPS) in infants less than 6 weeks old following systemic EES. Treatment recommendations include: • A 14-day course of oral EES (50 mg/kg/day in four divided doses or 500 mg twice a day for 14 days). A second 14-day course is sometimes required - failure rate with EES is 10% to 20%. Either EES is repeated, or oral azithromycin (20 mg/kg/24 hours daily for 3 days) has been found effective use systemic EES with caution; development of IHPS. • Trimethoprim-sulfamethoxazole (0.5 mL/kg/day in two divided doses for 14 days) is an alternative systemic treatment after the neonatal period, and azithromycin and clarithromycin have been used, not FDA approved in this age group. • Doxycycline (200 mg twice a day for 7 days), erythromycin base (2.5 g, divided four times daily for 7 days), EES (3.2 g, divided four times daily for 7 days), azithromycin (1 g orally in a single dose), ofloxacin (600 mg divided twice daily for 7 days), or levofloxacin (500 mg daily for 7 days) can be used in young adults. • Topical ointment (erythromycin, moxifloxacin) is sometimes recommended despite systemic drug treatment; the AAP notes that such concurrent treatment is unnecessary and ineffective • Mothers of infants with C. trachomatis conjunctivitis, partners of such mothers, and partners of sexually active adolescents also need examinations and treatment for 2 weeks with tetracycline or erythromycin. Complications chlamydial pneumonia (5% to 20% of infants will develop pneumonia if their mother has a chlamydial infection at delivery), nasopharyngeal colonization (in up to 50% of infants treated for inclusion conjunctivitis), or gastroenteritis in infants may occur 6 to 8 weeks following the conjunctivitis.

Opthalmia neonatorum: a. incidence/etiology b. clinical findings c. diagnosis d. mgmt

a. neonates: chlamydia trachomatis, Staphylococcus aurea, Neisseria gonorrhoaea (GC), herpes simplex virus (HSV). Silver nitrate reaction occurs in 10% of neonates Conjunctivitis in the newborn, neonatal blennorrhea a form of conjunctivitis - first month of life. reportable infectious disease. 0.3% to 11% of newborns. common cause - chemical conjunctivitis from the prophylactic instillation of silver nitrate at birth, product no longer recommended. Chlamydia trachomatis - 2% to 50% 50% of newborns with a mother positive for C. trachomatis at the time of delivery will contract the disease. 30% to 50% of cases (Staphylococcus, Streptococcus, Pseudomonas, H. influenzae, Escherichia coli, Corynebacterium species, Moraxella catarrhalis, Klebsiella pneumoniae, Pseudomonas aeruginosa) Neisseria gonorrhoeae and HSV are also implicated b. erythema, chemosis, purulent exudate with GC, clear to mucoid exudate with chlamydia History and Physical Examination • Chemical conjunctivitis - first 24 to 72 hours of life. • Septic conjunctivitis caused by: Bacteria - 5 to 14 days of life. C. trachomatis - 5 to 14 days of life; can occur in newborns born via c-section with intact membranes. N. gonorrhoeae - first 3 to 5 days of life (up to 28 days). HSV - birth or in the first 4 weeks of life. Symptoms: • Chemical-induced conjunctivitis: nonpurulent discharge and edematous bulbar and palpebral conjunctiva. • C. trachomatis: moderate eyelid swelling and palpebral or bulbar conjunctival injection and moderate thick, purulent discharge. • N. gonorrhoeae: acute conjunctival inflammation, lid edema, erythema, and excessive, purulent discharge. • Bacteria present with conjunctival erythema, purulent discharge. • HSV: mild conjunctivitis, erythema, corneal opacity, serosanguineous discharge, and vesicular rash on eyelids, unilateral. maternal history of vaginal infection during pregnancy or current STI c. culture (ELISA, PCR), Gram stain, R/O GC, chlamydia Laboratory Studies Swabs and scrapings must be done. Gram and Giemsa staining, direct immunofluorescent monoclonal antibody staining, cultures, ELISA, or PCR testing can be used. Any infant younger than 2 weeks of age should be tested for gonorrhea. A culture for gonorrhea (on chocolate agar or Thayer-Martin medium) or aggressive scraping for a Gram stain is used for diagnosis (do not just sample the purulent discharge). If gonorrhea is suspected, also check for C. trachomatis. d. saline irrigation to eyes until exudate gone; follow with erythromycin ointment -for GC: ceftriaxone or cefotaxime IM or IV -for chlamydia: EES PO -for HSV: antivirals IV or PO Management • Irrigate the eyes with sterile normal saline until clear of exudate. • Gonococcal conjunctivitis: 10- to 14-day course of IV or IM cefotaxime. Ceftriaxone is another option, avoided in neonates with hyperbilirubinemia. Ocular morbidity (corneal infection with possible scarring or perforation) can result in missed infections. Infants born by cesarean delivery need to receive prophylaxis against this agent. Nongonococcal conjunctivitis: topical ophthalmic antibiotic, such as erythromycin 0.5% ointment (0.25- to 0.5-inch strip to each eye), is applied three or four times a day, or moxifloxacin (four times a day for at least 5 days) cleanse eyes with water or saline applied to cotton balls before instilling the ointment into the lower conjunctival sac. • Herpes simplex conjunctivitis: Hospitalization and topical and systemic antivirals. 2/3s of infectious cases can spread to the CNS, mouth, and eyes; one third to the skin • Chlamydia: Assess for systemic infection (pharyngitis, ear infection, pneumonia). oral erythromycin base or ethylsuccinate (50 mg/kg/day in four divided doses) for 14 days. Topical treatment - not indicated, does not lower the risk for a subsequent pneumonia caused by Chlamydia • Chemical-induced conjunctivitis resolves spontaneously within 3 to 4 days without specific treatment. • Mothers and their sexual partners should receive treatment if gonococcal and/or chlamydial infections occur in their newborns. Prevention CDC recommends prophylactic administration of antibiotic eye medication within 1 hour of delivery to prevent. eyelids wiped gently with sterile cotton prior to application. Erythromycin ointment 0.5% (0.25 to 0.5 inch to each eye)

Retinoblastoma a. Description and Epidemiology b. Clinical Findings c. Management d. Complications e. Prognosis

a. one type of intraocular tumor. a rare malignant tumor of the retina, most common tumor in childhood. highest in infants and young children and extremely low in children 6 years and older A single or multiple tumors may be found in one or both eyes. carrier and prenatal diagnosis is now possible. Bilateral disease and multifocal tumors are usually found in hereditary forms, nonhereditary forms are unilateral and unifocal (30% to 40% of cases). Unilateral disease occurs 60% to 70% of the time, is due to genetic mutation, and is commonly recognized by 25 months of age. The median age of diagnosis in children with bilateral disease is 12 months and 24 months in children with unilateral disease Alaska Native children and New Mexico American Indians higher incidence diagnosis in developing countries can be delayed and the care suboptimal due to poor education, lower socioeconomic conditions, and inadequate access to health care The extraocular spread due to delayed diagnosis -> death b.• Positive family history Strabismus - the most common finding. • Unilateral or bilateral white pupil (leukokoria), an intermittent "glow, glint, gleam, or glare", usually in low-light settings • Decreased visual acuity • Possible orbital cellulitis and photophobia (causes pain), hyphema, abnormal red reflex, nystagmus, glaucoma, hypopyon (pus in anterior chamber of eye), or signs of global rupture Diagnosis is made via CT scan with contrast and/or echography and/or MRI. Other tests: fundus photography, fluorescein angiography, ocular ultrasonography, or fine-needle aspiration. c. Refer patient to ophthalmologist criteria of tumors based on their size, location, number, and degree of invasiveness or seeding. treatment may involve external beam radiation, cryotherapy, laser photocoagulation, episcleral plaque brachytherapy, or systemic chemotherapy. Early detection and advances in treatment -> less enucleation (removal of eye) and less use of external beam radiation, preserving sight. advanced tumors requiring enucleation, the hydroxyapatite implant provides excellent cosmetic appearance and acceptable motility of the implant Siblings and parents should receive a referral for fundi examinations. Frequent follow-up (every 3 months until 6 or 7 yo) to assess treatment and monitor for recurrence Up to 45% of children treated with eye-preserving therapy will develop new or recurrent ocular tumors that require further treatment d. Metastasis (most commonly to bone or bone marrow) is possible if the diagnosis is delayed. high risk for a secondary nonocular malignancy, cataracts, vitreous hemorrhage, neovascular glaucoma, lacrimal duct or gland injury, impaired orbit bone growth, radiation retinopathy, optic neuropathy, or extraocular tumor with CNS or bone marrow suppression Untreated children usually die from intracranial metastasis e. size and extent of tumor determines prognosis. increased risk of death from nonretinoblastoma over their lifetime. 20% risk of survivors developing a malignancy within 25 years of treatment. From the time of diagnosis until about 2 years after, the most common malignancies are pineoblastoma and intracranial retinoblastoma

Blepharoptosis a. Description and Etiology b. Management

a. ptosis is drooping of the upper eyelids affecting one or both eyes. congenital or acquired, secondary to trauma or inflammation. Congenital ptosis - striated muscle fibers of the levator muscle being replaced by fibrous tissue. can be transmitted as an autosomal dominant trait. trauma to CN III during the birthing process, trauma to the eyelid or neck, chronic inflammation (particularly of the anterior segment of the eye), or a neurologic disorder (myasthenia gravis, botulism, muscular dystrophy). one eye appears smaller severe cases - children may have a chin-up head position or adapt by raising their brow. b.• Refer to an ophthalmologist. If vision is compromised, surgery is performed in an effort to prevent amblyopia and developmental delay. The amblyopia should be under treatment prior to surgical correction for the ptosis Surgical correction depends on the degree of levator muscle compromise • Correct any underlying systemic disease. • Evaluate for anisometropia (unequal refractive errors in each eye), anisocoria, and decrease in pupillary light reflex.

Chronic bacterial conjunctivitis (unresponsive conjunctivitis previously treated as bacterial in etiology) a. incidence/etiology b. clinical findings c. diagnosis d. mgmt

a. school-age children and teens: bacteria, viruses, C. trachoma's b. same as bacterial conjunctivitis; foreign body sensation c. cultures, gram stain; r/o dacryostenosis, blepharitis, corneal ulcers, trachoma d. depends on prior tx, lab results and diff dx review compliance and prior drug choices of conjunctivitis treatment consult with ophthalmologist

Hordeolum a. Description b. Clinical Findings c. Management

a. stye, an infection of either the sebaceous glands (Zeis or Molls glands), the eyelids (external hordeolum), or the meibomian glands of the eyelid (internal hordeolum). The causative organism is S. aureus or, rarely, P. aeruginosa. b. A tender, swollen red furuncle is seen. external hordeolum - swelling is generally smaller, superficial, and located along the lid margin. internal hordeolum - larger and may point through the skin or conjunctival surface foreign body sensation. An internal hordeolum on the palpebral conjunctiva can be inspected by rolling back the eyelid. Differential Diagnosis If does not resolve, cellulitis of the lid or orbit, sebaceous cell cancer, or pyogenic granuloma. c. • Rupture often occurs spontaneously when the furuncle becomes large and a point develops. Removal of an eyelash near the furuncle frequently promotes rupture. • Warm, moist compresses three or four times daily, 10 to 15 minutes each time, facilitate the process of rupturing. scrubbing the eyelashes and eyelids with a cotton-tipped applicator containing a weak (50%) solution of no-tears shampoo once or twice a day. • Antistaphylococcal ointment (e.g., 0.5% erythromycin, 0.25 to 0.5 inch into each eye 3 or 4 times a day) until 2 to 3 days after resolution is effective treatment. • Steroids are not indicated. • Refer to an ophthalmologist for incision and drainage if does not rupture on its own after coming to a point or for multiple or recurrent

Foreign Body a. Description and Epidemiology b. Clinical Findings c. Management

a. superficial - usually lodged on the surface of the eye or superficially in the cornea. It rarely results in serious trauma, but they may penetrate the globe (intraocular) with more serious consequences. commonly occur in younger children during play and in older children during sports; include dirt, dust, metallic particles, or alkaline products from the deployment of an airbag. b. include in the history if individual was working on a metal-on-metal activity. • Pain and foreign body sensation • Foreign body visible in the conjunctival sac • Tearing • Inflammation • Irregular or peaked pupil • Photophobia • Opaque lens • Perforating wound to the cornea or iris • Fluorescein staining may be useful if no foreign body is visualized. Diagnostic Studies Ultrasonography or CT scan may be needed, depending on the foreign body and its location. An MRI is contraindicated. c. • Never remove an intraocular foreign body (including a metal object or fragment) and never remove a foreign body if the history indicates that a projectile object was possibly involved in the injury or patient has had LASIK procedure. Refer immediately to an ophthalmologist. • View the upper bulbar conjunctiva by having the patient look down while the upper lid is pulled away from the globe and the upper recess illuminated. Evert the eyelid to visualize the superior tarsal conjunctiva. • Use of a topical anesthetic (proparacaine 0.5% or tetracaine 0.5%, 1 drop —may repeat at 3- to 5-minute intervals) facilitates patient cooperation • If not visualized but suspected, remove an extraocular foreign body via irrigation with sterile saline or sterile eye irrigant. • If the object is visualized, either irrigate or gently lift object away with a moistened cotton-tipped swab (after instillation of topical anesthetic). used only for cooperative individuals and for small FBs in order to avoid further trauma to the epithelial surface. • If any difficulty is encountered, stop all efforts, patch the eye, and refer the patient immediately to an ophthalmologist. • After removing any extraocular object, instill fluorescein stain and inspect the cornea with cobalt-blue light to look for green staining or lines; check visual acuity. Follow guidelines for managing a corneal abrasion. • Reschedule the patient in 24 hours or refer to an ophthalmologist for follow-up. • In the case of an airbag deployment (talc, cornstarch, and/or baking soda are released), irrigate the eyes with sterile saline or sterile eye irrigant and carefully examine the eye(s) for further evidence of trauma. Complications Sympathetic ophthalmia, chronic siderosis, or a uveitis of the injured eye can occur any time from 10 days to many years after a penetrating injury of the globe.

Nystagmus a. Description and Epidemiology b. Clinical Findings c. Management

a. the presence of involuntary, rhythmic movements that may be pendular oscillations or jerky drifts of one or both eyes. Movement is horizontal, vertical, rotary, or mixed. can occur in association with albinism, high refractive errors, CNS abnormalities, tumors, post-infection (e.g., coxsackievirus B, cytomegalovirus [CMV], Haemophilus influenzae meningitis), various diseases of the inner ear and the retina, middle ear trauma, visual loss before 2 years old, and pharmacologic toxicity. Congenital nystagmus accounts for 80% birth history of prematurity, intraventricular hemorrhage, intrauterine psychogenic drug exposure, developmental delays, hydrocephaly, or be an infant of a mother with gestational diabetes. b. note about the type of movement (up, down, sideways), frequency (number of oscillations per a time unit), distance of movement, field(s) of gaze within which the nystagmus is evident (e.g., field of gaze straight ahead, left, or up), and any compensatory head or neck postures of the child. The movements may be constant or varied, depending on the direction of gaze and head position. Oscillation of the newborn's eyes is common and exists for a short time during the neonatal period Involuntary oscillation (opsoclonus) that persists or occurs beyond the initial weeks of life indicates a pathologic condition c. treating any underlying systemic disorder and referring the patient to an ophthalmologist. acquired nystagmus requires prompt evaluation.

Orbital Hematoma and Contusion of the Globe a. Description and Etiology b. Clinical Findings c. Management

a. usually the result of a blow to the globe. degree of damage depends on the energy of the object hitting the globe. result of sports activities, motor vehicle accidents, assault, BB gun accidents, or airbag deployment. b. • Milky white appearance of the retina • Visual acuity changes • Severe bruising of the eyelids and periorbital tissues • Lens dislocation • Retinal detachment or edema • Vitreous, retinal, or choroid hemorrhage • Rupture of the eyeball c. Refer the patient immediately to an ophthalmologist. A closed head injury, damage to the skull, and facial bone fractures need to be ruled out via CT scan, MRI, or ultrasound radiography. Occasionally cryopexy or laser photocoagulation surgery is needed for contusions of the globe. Complications Possible complications include permanent visual loss, retinal necrosis, subretinal hemorrhage, and retinal or macular holes.

Conjunctivitis

an inflammation of the palpebral and bulbar conjunctiva. 78% - bacteria are the cause, most commonly H. influenzae (68%), Streptococcus pneumoniae (20%), and Staphylococcus aureus (up to 8%) (; both gram-negative and gram- positive organisms also occurs as a viral or fungal infection or as a response to allergens or chemical irritants. Bacterial often unilateral, viral most often bilateral. Unilateral disease - toxic, chemical, mechanical, or lacrimal cause. Blockage of the tear drainage system (e.g., from meibomianitis or blepharitis), injury, foreign body, abrasion or ulcers, keratitis, iritis, herpes simplex virus (HSV), and infantile glaucoma are other known causes. A major indicator of etiology is also age of the patient

Corrective Lenses

eyeglasses -> correct refractive errors. Gas-permeable or soft contact lenses can be worn by >=8yos Tinted lenses can be used for photosensitivity; ultraviolet (UV) light filters are helpful with aphakia (absence of lens), congenital absence of iris, and albinism. Contact lenses are helpful for an aphakic child who would otherwise need very thick glasses that distort images • Wear protective outer eyewear for sports. • Do not wear contact lenses if one or both eyes are inflamed or when using topical ophthalmic medications. Children with recurrent conjunctival or corneal infections, inadequate tears, severe allergies, or excessive exposure to dust or smoke should not wear contact lenses. • Omit wearing extended-wear contact lenses (usually worn overnight) for 1 night a week in order to perform lens hygiene procedures. contacts provide better refractive error correction than eyeglasses, enhancing visual acuity and the total corrected field of vision

Screening Tests

observe children for behavior indicating that they are having difficulty - straining, squinting, excessive blinking, head tilting or shaking, or thrusting the trunk or head forward. tendency to peek out from behind the eye shield may or may not reflect difficulty; may be desire to be successful and please the tester. resist the tendency to correct a mistake or give the child nonverbal clues that can influence results. 3yo - difficulty performing any of the vision tests -> tested again within 6 months; >4 yo - unable to perform -> retested in 1 month uncooperative 2nd attempt -> referred for formal examination red light reflex - tested at every well examination, including initial newborn examination. Bruchner test - detect the presence of asymmetric refractive errors, strabismic deviations, and abnormalities in the ocular media (e.g., cataracts, corneal abnormalities, RB). any asymmetry, dark or white spots, opacities, or leukokoria (white pupillary reflex) requires either: Prompt referral to an ophthalmologist, or Dilation of the pupils. visual acuity testing - American Optometric Association - 6 months, 2 and 4 years, and every 2 years afterward Color vision testing - Red-green color deficiency is X-linked inherited disorder or may indicate optic nerve disease. more common in males. may also be acquired - Diabetes, infections, optic neuritis, and toxins. Blue- yellow deficiency most common can affect school performance; safety implications, unable to distinguish traffic or vehicle brake lights; and can affect career choices. Richmond pseudoisochromatic plates or Ishihara plates.

Eyelid Contusion ("Black Eye")

result of blunt injury to the eye and surrounding tissues. bruising, swelling, and often an impressive appearance ("black eye"). if increased pain or swelling, decrease in visual acuity, double vision, flashing lights or "floaters" or develops a bilateral "raccoon eyes" appearance, an ophthalmologic evaluation is needed to rule out a more serious eye injury (e.g., ruptured globe, basilar skull fracture, detached retina, hyphema). Examine all eye structures before excessive swelling sets in. Treatment - elevating the head and intermittent ice compresses for 48 hours. A CT scan may be warranted

Opthalmic Medications

smaller body mass and faster metabolism may potentiate the action of the drugs and result in adverse ocular and systemic side effects. Ophthalmic ointments are generally preferred over solutions for use in children, especially infants, because they last longer, do not sting, do not need to be given as often, and are less likely to be absorbed into the lacrimal passage. they do temporarily interfere with vision because they coat the eye, and they can cause contact dermatitis. ensure tip of tube or dropper is not contaminated. ointment should be transferred from the tube to moistened cotton swabs (one for each eye) and then rolled into the lower portion of each conjunctival sac.

Subconjunctival Hemorrhage

splotchy bulbar conjunctival redness that spontaneously occurs or is secondary to increased intrathoracic pressure (from coughing, sneezing, straining, or trauma) that results in the bursting of conjunctival vessels. commonly found in neonates as a benign occurrence to a vaginal delivery. painless and usually spontaneously resolve within 2 to 3 weeks. No treatment is indicated unless there is pain, vision loss, or photophobia, which indicate a referral to an ophthalmologist. Spontaneous hemorrhages can (rarely) occur with hypertension, diabetes mellitus, and blood dyscrasias, or can be a sign of a ruptured globe if there is a history of trauma

Nasolacrimal Duct Conditions: Dacryostenosis and Dacryocystitis a. Description and Epidemiology b. Clinical Findings c. Management

stenosis - abnormal obstruction (imperforate valve of Hasner) of the nasolacrimal duct that prevents tears from flowing into an opening in the nasal mucosa. cystitis - inflammation of the involved nasolacrimal duct; infection can result. obstruction common in neonates (up to 6% of live births due to a membrane at birth that covers the nasolacrimal duct, which fails to break down quickly. any age secondary to trauma to the duct or to a chronic duct obstruction complicated by an upper respiratory infection. more frequent in those with craniofacial disorders and Down syndrome. Congenital failure of the duct to canalize may be unilateral or bilateral, and clinical signs appear 2 to 6 weeks after birth when tear production develops. Duct blockage usually resolves spontaneously in 96% of infants by 12 months of age infection - most commonly caused by S. aureus and is often unilateral (other isolates include streptococci and E. coli). b.• Continuous or intermittent tearing, stickiness, and mucoid discharge at the inner canthus that can become purulent • Blepharitis in lids and lashes • Occasional nasal obstruction and drainage • Expression of thin mucopurulent exudate from the punctum lacrimale • Fluorescein dye, instilled bilaterally in the inferior conjunctival sac and checked in 2 and 5 minutes with a cobalt blue light source, will disappear if duct is patent. symptoms if bacterial superinfection is present: • Tenderness and swelling over the lacrimal duct (can be exquisite) • Eyelids stuck shut on awakening • Edema and erythema of the tear sac (most prominent in the triangular area just below the medial canthus) • Excoriation and thickening of the periorbital skin • Conjunctival injection • Fever • Expression of purulent material • Mucocele of inner canthal tendon (unusual; presents as a bluish mass) Laboratory Studies WBC count (elevated) and cultures are obtained from the expressed exudate if the inflammation is severe. Differential Diagnosis Punctual or canalicular atresia, conjunctivitis, foreign body, congenital glaucoma, dacryocele, intraocular inflammation, and nasal mucosal edema, glaucoma, dacryocele, intraocular inflammation, and nasal mucosal edema c. minimize stagnation in the tear duct and prevent infection. • Daily massage of the lacrimal sac to facilitate canalization of the duct. placing a clean finger over the medial canthus and pressing in a posterior direction until the fingertip enters the space behind the inferior bony orbital ridge. Gentle pressure applied in a downward and medial direction transmits hydrostatic force through the nasolacrimal duct to the obstruction. performed about 10 times, two or three times a day. The eyelid should be cleaned with plain water after massage • For excessive mucopurulent exudates: topical ophthalmic ointment or ophthalmic drops (drops may penetrate more quickly), such as 0.5% erythromycin (0.25 to 0.5 inch into each eye three or four times a day) for 5 days or polymyxin B/trimethoprim (1 drop three or four times a day) for 1 to 3 weeks with massage and frequent cleansing of secretions. The duct may open spontaneously with resolution of the bacterial infection. • Saline drops into the nose, followed by aspiration before feeding and at bedtime, help relieve any concurrent nasal congestion. mucopurulent exudate persists for 1 to 2 weeks, the infant or child needs a referral to an ophthalmologist regardless of age. Some ophthalmologists may probe the duct in an infant as early as 4 months old, others wait until 9 to 12 months old. If probing fails to alleviate the problem, surgery may be required for placement of a tube stent or for a dacryocystorhinostomy (DCR). Chronic obstructions usually indicate bacterial colonization, which generally will persist without probing When fever, marked erythema, swelling, tenderness, and toxic appearance occur, hospitalization is indicated for parenteral antibiotics Complications Periorbital or orbital cellulitis is a complication of chronic dacryocystitis.