2/13/2014 Red and Pink and Injured Eyes in Children Disclosures No actual or perceived financial conflicts of interests Iason S Mantagos, MD Boston Children’s Hospital Harvard Medical School Boston, MA AAPOS and NAPNAP are partners in their commitment to care for children's eye health Common Causes of the NonTraumatic Red/Pink Eye in the Pediatric Population Red Eye “Conjunctivitis” Definition = Conjunctiva + Inflammation Does not indicate the cause of the redness! Get a History! • Trauma? (remember kids may not tell the whole story…) • Infectious risk factors? – Red eye contact at school or home – Illness • Upper respiratory infection • Otitis media • Fever – Drainage – History of herpes 1 2/13/2014 Red Eye Red Eye Red Flags (warnings that it’s not simple conjunctivitis) Get a History! • Allergy? • • • • • • • • – Itchy, itchy, itchy • Contact lens wearer? – Extended wear – Decorative • Use of eye drops? Pain Photophobia (light sensitive) History of injury Chronic duration Loss of vision Hx of herpes Fever Red swollen lids – Over the counter drops often forgotten Red Eye Exam Red Eye Exam • Check visual acuity – One eye at a time (use a patch) – Distance vision, Near card vision is also good – Use their specs! • Penlight Exam – Eyelids – Eye alignment and movement – Eyeball • Conjunctiva • Cornea • Pupil Common Causes of non-traumatic Conjunctivitis • • • • • Bacterial Viral Allergic Toxicity from eye drops Contact lens related 3YO sent to office with goopy eyes •Hx – brother had “pink eye” •Complains of mild irritation and photophobia Diagnosis? 2 2/13/2014 Bacterial Conjunctivitis Cause Bacterial Conjunctivitis – From direct contact with infected individual (hand‐to‐eye contact) • Usually occurs in preschool‐aged children • Signs and symptoms • Person at school or home with “pink eye” – Bilateral but can be unilateral – Mucopurulent discharge with matting, often gluing of the lids shut on awakening – Mild lid swelling – May be associated with otitis media – Spread of infection from patient’s own nasal and sinus bacteria • Patient has bacterial otitis media, sinusitis, or pharyngitis • Highly contagious Bacterial Conjunctivitis Common Pathogens in Children Bacterial Conjunctivitis Treatment –Self limiting in 65% –Antibiotic treatment reduces time to resolution –Almost every antibiotic drop will be effective in eradicating the bacteria –Antibiotic choice usually empirical, broad‐spectrum –Fluoroquinolone drops most effective and convenient – Staphylococcus aureus – Staphylococcus epidermidis – Streptococcus pneumoniae – Haemophilus influenzae – Moraxella catarrhalis In the neonate, keep chlamydia and gonorrhea in the DDx Treatment – Ointments Antibiotic Dosing Treatment – Eye drops Coverage Cost Erythromycin Up to 6 times per day Gm (+) and (‐) $12 Gentamicin 0.3% 2‐3 times per day for 10 days; >1 month Gm (‐) aerobes $16 Tobramycin 0.3% 2‐3 times per day for 10 days; >2 month Gm (‐) aerobes Ciprofloxacin 0.3% TID for 2 days, then bid for 5 days; > 2 yoa Gm (‐) rods, Gm (+), Pseudomonas $205 Bacitracin Every 3‐4 hours up to 10 days Gm (+) Bacitracin & polymyxin B Every 3‐4 hours up to 10 days; >2 yoa Sulfacetamide 10% Q3‐4hrs for 7‐10days; >2 month Antibiotic Dosing Coverage Azithromycin 1% BID for 2days, then daily for 5days; >1yoa Some Gm(+) and (‐), MSSA Cost $128 Gentamicin 0.3% 2‐3 times per day for 10 days; >1 month Gm (‐), MSSA, Pseudomonas $16 Tobramycin 0.3% 2‐3 times per day for 10 days; >2 month Gm (‐), MSSA, Pseudomonas $18 Ciprofloxacin 0.3% TID for 2 days, then BID for 5 days; > 2 yoa Some Strep sp, MSSA, Gm(‐), Pseudomonas $32 Ofloxacin 0.3% Q3‐4 hours up to 10 days Some Strep sp, MSSA, Gm(‐) $81 Gatifloxacin 0.3% Q3‐4 hours up to 10 days; >2 yoa Gm(+) & (‐), anaerobes, MSSA, +/‐ MRSA $83 $74 Levofloxacin 0.5% Q2‐4hr for 2days, then Q4hr for 5days; >1 yoa Gm(+) & (‐), MSSA $84 Gm (+), Pseudomonas $40 Moxifloxacin 0.5% Moxeza: BID for 7 days; >4 month Vigamox: TID for 7 days; >1 yoa Gm(+) & (‐), anaerobes, MSSA, +/‐ MRSA $113 $118 Gm (‐) and (+) $70 Besifloxacin 0.6% TID for 7 days; >1 yoa Gm(+) & (‐), MRSA, anaerobes $123 Trimethoprim‐polymixin B Q3hr for 7‐10days; >2 month Some Gm(+) and (‐) $25 Sulfacetamide 10% Q2‐3hr for 7‐10days; >2 month Some Gm(+) and (‐) $82 $37 3 2/13/2014 When to Return to School 14 YO with R eye redness and irritation, watery, mucoid discharge Able to return to school as soon as clinical improvement (decreased redness and discharge) is noted – Rapid improvement (2‐3d) after the antibiotic drop is begun (need to use full 7 d) • Helps confirm the diagnosis of bacterial conjunctivitis • Viral conjunctivitis does NOT improve quickly on antibiotic drops Pain? no Light sensitive? no History of injury? no Chronic? 3d Loss of vision? no Hx of herpes? NO!! Fever? no Red Swollen lids? A little Contact lenses? no Red eye contacts? no Eye drops? No Sick? Cold and sore throat… Viral Conjunctivitis - Symptoms Viral Conjunctivitis – Irritation, mild light sensitivity, mild foreign body sensation, slightly swollen lids – Range of redness • Causes – Adenovirus • Mild conjunctival hyperemia to intense hyperemia with subconjunctival hemorrhages – Herpes Simplex Virus (HSV) – Herpes Zoster Virus (HZV) – Molluscum Contagiosum Mild Viral Conjunctivitis - Signs – Conjuntival hyperemia • • • • • • • • • • • • Severe Adenovirus conjunctivitis • Adenoviruses also cause – Upper respiratory tract infections – Discharge is watery, possibly mucoid, but not purulent – Preauricular lymphadenopathy • • • • • Cold Sore throat Cough Fever Headaches 4 2/13/2014 Viral Conjunctivitis - Treatment • • • • Most cases resolve in few days ‐ 2 weeks Antibiotic drops not effective for viral infections Cool compresses, artificial tears Topic steroids for severe cases (prescribed by an ophthalmologist) Herpes Simplex Virus Conjunctivitis When to Return to School • There are no firm guidelines about when to release a student with adenoviral conjunctivitis because – Virus may shed for 7 days or longer • The current American Academy of Ophthalmology textbook on conjunctivitis recommends absence from school (or work) until redness or tearing have resolved. Herpes Simplex Virus Conjunctivitis - Causes • HSV1 (usually occurs above the waist) • HSV2 (usually occurs below the waist) • Spread by contact with: • Persons with infected lesions • Persons asymptomatically shedding virus HSV Conjunctivitis – Signs & Symptoms • Skin vesicles (if present helps with diagnosis) • Conjunctivitis • Corneal infection with classic “dendrite” (the hallmark of this condition) – Causes intense photophobia and watering – Patient can barely open their eyes HSV Conjunctivitis – Treatment Medication Dosing Cost Trifluridine 1% Q2hr until re‐epithelialization, then Q4hr for 7 days; >6 yoa 152 Vidarabine (ointment) ½” paste Q3hr until re‐epithelialization then bid for 7 days; >2 yoa Idoxuridine 0.1% Not approved for use in children Q1hr until re‐epithelialization then Q2hrs for 3‐5 days Gancyclovir 0.15% 5x/days until re‐epithelialization then TID for 7 days; >2 yoa $255 Acyclovir 40‐80mg/Kgr/day PO 100‐400mg PO TID for acute disease; BID for prophylaxis when recurrences occur $40 5 2/13/2014 Allergic conjunctivitis Cause – Usually environmental allergen – May be seasonal, associated with sneezing and congestion, or isolated Symptoms: – Bilateral – Sensitivity to lights – Itchy, itchy, itchy Allergic Conjunctivitis – Signs – Swollen lids – Diffuse milky conjunctival hyperemia – Swollen conjunctiva – Tearing, maybe slight mucoid discharge – Occasionally “bumps” on conjunctiva – called papillae, another hallmark of allergy • Hallmark of an allergy Medication Brand names Vasoconstrictor/Anti‐histamine Naphazoline/pheniramine (OTC) Naphacon A, Opcon‐A, Visine‐A Dosing Cost Ocular Allergy Meds 1‐2 drops qid prn; >6yo $6‐11 1 drop qid; >3yo $120 NSAIDS Allergic Conjunctivitis – Treatment – Don’t rub! Induces more itchiness – Cool artificial tears – Anti allergy eye drops (OTC and prescription) very helpful – Severe ocular allergies might require topical steroids (Rx by ophthalmologist) – Oral anti‐allergy meds not very helpful for conjunctivitis – Eliminate triggers Toxic conjunctivitis • Cause – Use/overuse/abuse of topical ocular medications • Antibiotics most common – Classic story: Kept using pink eye drops b/c redness did not go away • Chronic use of “take the red out” drops • Signs and symptoms – Clear, watery discharge – Red conjunctiva • Treatment – Stop the drop!!!!!!!! Ketorolac 0.5% Anti‐histamine Emedastine 0.05% Emadine 1 drop qid; 3 yo $108 Alcaftadine 0.25% Lastacaft 1 drop daily; >2yo $160 Beptotastine 1.5% Bepreve 1 drop bid >2yo $162 1‐2 drops 4‐6x/day; >4yo $36 Lodoxamide Alomide 1‐2 drops qid; >2yo $130 Nedocromil Alocril 1‐2 drops bid; >3yo $133 Ketotifen 0.025% (OTC) Alaway, Zaditor 1 drop q8‐12hrs; >3 yo $13 Olopatadine Patanol 0.1% Pataday 0.2% 1 drop bid; >3yo 1 drop daily; >3yo $169 $144 Epinastine 0.05% Elestat 1 drop bid; >3yo $159 Azelestine 0.05% Optivar 1 drop bid; >3yo $233 Mast cell stabilizer Cromolyn 4% Mast cell stabilizer/anti‐histamine Contact Lens Related Conjunctivitis • Acute conjunctivitis – Extended lenses over worn – Lenses dirty, old – Cornea is irritated or infected from contact lens • Chronic conjunctivitis – Developing an allergy or reaction to contact lens or contact lens solutions 6 2/13/2014 Blepharitis • Inflammation/infection of the eyelid margin • Typical causes of blepharitis: – Inflammation for the eyelid oil glands (meibomian glands) PLUS – Staphylococcal infection at lash bases Blepharitis - Treatment – Lid scrubs once or twice a day • Many products – Erythromycin ointment at night – May last several months or be chronic Chalazion (stye) Chalazion - Treatment • Obstructed meibomian (oil) gland – Warm compresses, time, patience – Causes an acute mass in lid – Initially red and tender • Lid might be swollen • Looks like cellulitis • Most resolve in weeks to months – Antibiotic don’t help – Surgical drainage • If no resolution in few months – Few days later a chalazion is apparent – Often associated with blepharitis 7 2/13/2014 Another cause of Blepharitis… Phthiriasis palpebrum • Phthiriasis palpebrum – LICE! – Usually cause is pubic lice, rarely head or body lice Nits Louse Louse grabs neighboring lashes Looks like blepharitis, EXCEPT: – Eyelash crusting is red‐brown, unlike typical blepharitis (white – clear) Lice live off blood  feces (crust) red/brown Phthiriasis Palpebrum - Treatment –Drowning the lice and nits in petroleum jelly, applied to lids twice a day for 14 days • Nits hatch in 10‐12 days –Wash all clothing and bedding in highest temperature Objectives • Review causes, symptoms, treatment and when/where to refer simple and complicated ocular trauma • Answer any questions regarding ocular trauma • Stay awake! Red and Pink Eyes in Children: Ocular trauma Types of trauma • • • • • • • • Corneal abrasion Foreign bodies Subconjunctival hemorrhage Open globe Eyelid laceration Traumatic iritis Hyphema Chemical injuries 8 2/13/2014 Corneal abrasion • Cause Case 1 • • • • 10 yo, poked to the eye while playing basketball He will not open the eye You try to pry it open He screams and closes it tighter •Defect of the epithelial layer only •Typically the rest of the cornea is not damaged •VERY painful because of many nerve endings in the cornea Corneal abrasion Area of corneal epithelial defect stains with fluorescein dye and “lights up” with a blue light Linear abrasion – look for FB under upper lid • Signs and symptoms Rough edge of abraded cornea – Intense sensitivity to light, extreme pain, typically have trouble even opening the eye – Copious tearing – Foreign body sensation—resolves with topical anesthetic Corneal abrasion supplies Corneal Abrasion Diagnosis – Trauma, foreign body or chemical exposure Anesthetic drops and fluorescent dye papers Penlight with blue filter in cap Corneal abrasion - Treatment – Make patient comfortable and exam easier with drop of proparacaine (anesthetic drop) • Lasts 20 min • Beware of abuse potential – with chronic use will scar cornea (never give to a patient) – Look for foreign bodies by pulling down lower lid and looking under upper lid with patient looking down – Irrigate if suspect foreign body or chemical exposure 9 2/13/2014 Corneal abrasion – Rule out other trauma – Refer to Ophthalmology Case 2 • High school student was working in the shop and thinks he might have something in his eye. In general…. – Abrasions heal quickly – Topical antibiotic ointment often prescribed – Pain medications as necessary More info…. • • • • Exam Feels like there is a rock in the eye. Vision is good. His eye won’t stop watering. He washed in with water, but it didn’t help. Foreign body Treatment • Urgent referral to ophthalmologist for eye exam to rule out penetration • If on surface of the eye, including cornea, use cotton tip applicator and wipe off – Drop of anesthetic first! – Occasionally we use a burr for stuck‐on metallic FBs • If embedded under conjunctiva or sclera, or inside the globe, will need surgery for removal and exploration 10 2/13/2014 Examples Examples Foreign body embedded in the sclera • Second grade student comes to your office after the teacher notices a red eye. Subconjunctival hemorrhage • Blood under the conjunctiva • Causes: • Signs and symptoms – Under the lid, upper or lower – On or under the conjunctiva – Embedded in cornea – Can penetrate into the eye Questions? Case 3 – Trauma – Sudden increase of pressure in the chest (sneeze, cough, vomiting, strangulation, etc) • Locations F. Netter • • • • • Does it hurt? No. Is the vision okay? Yes. Do bright lights bother you? No. Did someone hit you? No. But, I did poke myself in the eye with my pencil. If…mild and no other signs of trauma • Is benign and will disappear within a week • No treatment necessary • No need to refer – May be associated w/ aching if hx of trauma. – Hemorrhage itself doesn’t cause pain generally 11 2/13/2014 If moderate or severe. . . . • Signs of trauma (eyelid bruising, worrisome history) • Concern for more extensive eye injury • Refer to ophthalmology or ER Vision okay and remainder of eye looks normal so probably no other ocular injury… Vision loss, irregular pupil and swollen conjunctiva – possible globe rupture Open/Ruptured Globe Causes: Trauma, blunt or penetrating Blunt trauma with subconjunctival hemorrhage with dark brown spot… Part of the iris is protruding through a scleral laceration Scleral rupture with interior of eye exposed Treatment Occult globe rupture • Refer to Ophthalmology or ER STAT • Protect the eye (avoid putting pressure on the eye) • In general… • Will be taken to the operating room soon for repair Obvious globe rupture 12 2/13/2014 Case 4 • 14 yo presents after being punched to the left eye • Painful • He can see well Eyelid lacerations • Treatment 16 yo CC “something” hit left upper eyelid – Requires repair, often in the operating room – Put gauze over the eye and send to ER 13 2/13/2014 Case 5 The “something” was a .22 shotgun casing • 14 year old female with left eye pain. • Vision: – slightly decreased • Bothered by bright lights: – yes • Red eye: – yes Physical exam • Conjunctival injection • Abnormal pupil • Hazy cornea More history… • Hit in the eye with a tennis ball three days ago http://www.flickr.com/photos/amaz0n/508311190/ Traumatic Iritis • Pathophysiology: Inflammation of the iris Traumatic Iritis • Cause: blunt force trauma • Symptoms: headache, photophobia, irregular pupil, decreased vision, red eye • Timing: 2‐5 days • Referral to ophthalmologist in the next 24hours http://delhimedicalcouncil.nic.in/RedEye.htm 14 2/13/2014 Treatment • Dilating drop • Steroid drop Case 6 • • • • • • • Hyphema • Blood in the anterior chamber (space in between iris and cornea) • Causes – Trauma, blunt or penetrating – May be associated with other eye injury • Corneal abrasion • Open globe – Extensive subconjunctival hemorrhage – Peaked pupil • Cataract • Vitreous hemorrhage • Retinal detachment 8 yo hit with badminton birdie Bright lights cause pain Decreased vision Pupil bigger Blood in the eye +/‐ nausea/vomiting +/‐ foreign body sensation In general. . . . • If the hyphema is mild, no other damage to eye, and intraocular pressures normal – Sickle cell prep – Bed rest at home or in hospital – Steroid and dilating eye drops – Frequent visits in first 2 weeks to ophthalmologist to make check for re‐bleed • If the hyphema is severe, or associated with open globe, may need evacuation in OR Case 7 • 4 yo boy banged heads with sister • ER glued the laceration • 2 days later, inc swelling/redness 15 2/13/2014 “Eye” tooth “Eye” tooth Chemical Injuries Chemical Injuries • EMERGENCY • Chemicals harm the eye primarily because of acid or alkaline pH • May be in the form of: – Liquid – Solid – Powder – Mist – Vapor Chemical Injuries • Severity of the injury depends on – pH • Alkaline agents (high pH) much more damaging to the eye than acids (low pH) – Volume – Duration of contact 16 2/13/2014 Acute Acid Burn ‐ Large corneal and conjunctival abrasion ‐ Mild Corneal Haze ‐ Good prognosis for full recovery Acute Alkali Burn ‐ Damage to the corneal epithelium and stroma (corneal haze) ‐ White (not red) conjunctiva (ischemia) ‐ POOR prognosis Common alkali: •Cleaning products (ammonia) •Fertilizers (ammonia) •Drain cleaners (lye) •Cement, plaster, mortar (lime) •Airbag rupture (sodium hydroxide) •Fireworks (magnesium hydroxide) Common acids: • Battery acid (sulfuric acid) • Bleach (sulfurous acid) • Vinegar (acetic acid) Treatment • Recognize that exposure has occurred • STAT irrigation with water or normal saline – COPIOUS – Use shower/hose if needed – NOT “eye wash” – Swipe the fornix for foreign bodies – Identify the agent whenever possible and call Poison Control about the pH Chronic Alkali Burn ‐ Corneal scarring ‐ Neovascularization of the cornea ‐ High risk of corneal transplant failure • Send to ER via ambulance Super glue Thank you 17 2/13/2014 Acknowledge: Jane C. Edmond, MD Robert S. Gold, MD Daniel E. Neely, MD David A. Plager, MD 18 Pediatric Pink Eye Iason Mantagos, MD Boston Children’s Hospital – Harvard Medical School 1. Red eye assessment a. History i. Vision loss ii. Pain iii. Photophobia iv. Chronic v. Trauma vi. Hx Herpes vii. Contact lens use viii. Fever ix. Swollen eyelids b. Exam: i. Visual acuity ii. Pupils iii. Ocular motility iv. Anterior segment pen light exam v. Attempt funduscopy 2. Conjunctivitis a. Bacterial i. Can be unilateral or bilateral ii. Mucopurulent discharge iii. Red eye, photophobic iv. Contagious v. Often self‐limiting, but antibiotics reduce time to resolution vi. Return to school when clinical improvement is noted b. Viral i. Starts unilateral, can progress to bilateral ii. Clear discharge iii. Mild photophobia, redness, foreign body sensation, burning iv. Pre‐auricular lymphadenopathy v. URI vi. Highly contagious vii. Artificial tears and cool compresses for comfort viii. Return to school when discharge resolves c. HSV conjunctivitis i. HSV 1 or 2 ii. Associated skin lesions iii. Corneal involvement is vision threatening d. Allergic i. Bilateral ii. Seasonal iii. Photophobia, ITCHY, clear discharge iv. Lid swelling, allergic shiners v. Treatment: no rubbing, artificial tears, allergy eye drops, eliminate triggers e. Toxic i. Clear, watery discharge ii. Redness iii. Stop offending drop f. Contact lens related i. Acute or chronic ii. Inquire about contact lens hygiene iii. Corneal ulcer is vision threatening 3. Blepharitis a. Inflammation/infection of lid margin b. Can cause chalazia, dry eye, foreign body sensation c. Warm compresses, lid scrubs, erythromycin ointment at bedtime 4. Chalazion (Stye) a. Obstructed meibomian oil glands b. Red swollen c. Eventually goes away on it’s own, may consider I&C 5. Trauma a. Corneal abrasion i. Trauma, exposure, chemical, foreign bodies ii. Intense pain, photophobia, unable to open eyes, foreign body sensation iii. Fluorescein exam, look underneath the eyelids iv. Heal quickly. Topical antbiotics, pain control v. Do not pressure patch b. Foreign body i. Concern for open globe ii. Consult ophthalmology c. Subconjunctival hemorrhage i. Trauma/straining/coughing ii. Less worrisome If flat without history of trauma, normal vision iii. Suspicious of additional pathology: trauma, elevated, abnormal pupil, decreased visual acuity, “brown” tissue visible within hemorrhage d. Open globe i. Rupture, penetrating, perforating injuries ii. Requires urgent referral for surgical management iii. NPO, Tetanus prophylaxis, do not put pressure on eye e. Eyelid laceration i. Simple lid lacerations, marginal, canalicular ii. Beware of injury to the globe underneath iii. Wet gauze on the wound and send to ER f. Traumatic iritis i. Inflammation as a result of blunt trauma ii. Red, painful, photophobia, decreased acuity iii. Ophthalmologic evaluation iv. Treated with steroids and dilating drops g. Hyphema i. Blood in the anterior chamber due to trauma ii. Red, painful, photophobia, decreased acuity iii. Beware of patients with sickle cell dz iv. IOP can be elevated and vision threatening v. Risk for rebleeding vi. Treat: bed rest, topical steroids and dilating drops. Rarely surgical h. Chemical injuries i. TRUE emergency ii. Check pH and start irrigating iii. Sent to ER via EMS iv. Acid burns have better prognosis than alkali v. Can cause corneal opacification, neovascularization, blindness