Red Eye and Orbital Trauma – Pediatrics | Lecturio


In this lecture, we’ll review the red
eye in children and orbital trauma. So let’s start with some infections. Blepharitis is an inflammation of the
eyelid margin that is due to infection. This in turn can result
in styes which include the hordeolum which is acute and
the chalazion which is chronic. So antibiotics are really only
needed in these sorts of things if it spreads and becomes are preseptal
cellulitis, which is quite rare. In general, we can treat these with
warm compresses until resolution. We recommend about 10 minutes four
times a day of warm compresses. So the next potential complication, which
is actually fairly common in infants, is the blocked tear duct which
can result in dacryocystitis. This is an infection and inflammation
of the nasolacrimal duct. If you recall, tears are
generated laterally. They sweep across the eye and then they drain down in the
nasolacrimal duct into the nose. This will present with redness and
tearing and often excessive tearing, but the sclera typically
looks normal. This is more common in infants. Again, antibiotics are
really not necessary unless it spreads into a
preseptal cellulitis. I might use antibiotics
in some of these cases. And generally, warm compresses, once
again, are the way to go for this, 10 minutes four times a day. Moving on to conjunctivitis. Conjunctivitis is an infection
of the conjunctiva of the eyes. So generally, this is what
we typically call pink eye. It’s usually caused by viruses. It’s rare for this to be bacteria. We really probably over treat this. Viral is the most common entity and classically, we’re taught if it’s
one side, it’s bacterial or viral. If it’s both, it’s bacterial or
viral, that’s just not true. It’s very hard to predict whether
something is bacterial or viral, but generally they’re
almost all viral. A bacterial conjunctivitis is very
severe with purulence and drainage. So antibiotics are probably
overused in substantial portion of patients
with conjunctivitis. Generally, watchful waiting is appropriate
unless it’s bilateral and severe and then probably, we’ll
start with some antibiotics. It’s also highly contagious
when it’s viral, so we recommend people avoid rubbing and
touching their eyes as much as they can and washing their
hands frequently. If we are to cover with antibiotics,
we can usually do topical drops, although rarely we may do something
systemic like high dose amoxicillin. There is one exception, actually
a few exceptions in infants. So infants, gonorrhea of the
eye is common in infants who are born to mothers
with active gonorrhea. It generally will show
up in two or three days and will be a very vigorous and aggressive
bacterial conjunctivitis of the eye. We can test it with a PCR of the
eye, which then is sent to the lab, and they look for genetic
material of the gonococcus. This, we need to treat with ceftriaxone. We need to admit these
infants to the hospital and if treated, the
prognosis is outstanding. Chlamydia is a bit different than
gonorrhea in the eye of infants. While gonorrhea grows quickly and
will show up in two to three days, chlamydia appears later
in two to three weeks. So any infant with a delay in eye
response, two to three weeks of age, you have to worry
about chlamydia. Another alternative is they’re having
a toxic reaction to some of the antimicrobial ion that was applied at birth that can also show up
at two to three weeks. To test, we do a PCR of the eye and then we will treat these
infants with azithromycin. The problem is this is sometimes
hard to cure and it can recur. This is a major cause of
blindness worldwide in infants, so we just need to be aware of this, that if untreated, this can
result in blindness or trachoma. Another sexually transmitted infection for
an infant that can be exposed in utero or it can also happen later
on in life is HSV of the eye. This typically in infants will
present in the first month of life as skin, eye, mouth disease. This, we have to aggressively treat. We test it with an HSV culture, which
grows very quickly, usually within a day. For these infants, we will treat
them with IV acyclovir for 14 days. These infants really
need to be hospitalized and an ophthalmologist should be consulted. This can cause vision defects. If you can see here, the eye is
actually aggressively infected and if that infection goes over
the area where the pupil is, you can have defects in vision. So we really want to aggressively
treat these infants. Another thing you will see frequently
which really isn’t much of a problem is subconjunctival hemorrhage. This is when patients have bleeding
just under the conjunctiva. It usually is caused by acute
cough or sneeze or vomiting and it’s really just a little
hemorrhage that can happen there. It self-resolves and there’s
really no therapy needed, but sometimes patients will show
up and be worried about this. This is an unusual one that we see really
more often in the American Southwest which is caused by very
dry or sunny climates. This is called pterygium. And this pterygium can grow out
from the corners of the eye and very rarely can actually
even obstruct vision, though usually they don’t and therapy
is really usually unnecessary. Usually, they’re asymptomatic. If it grows into the field of
vision, surgery may be indicated and you should consult
an ophthalmologist. Another one we see fairly
frequently is the corneal abrasion. This is in a differential
diagnosis for a child who is crying and you
can’t figure out why. Sometimes, they just
scratch their own eye or anyone who has
had eye trauma. Usually in older children that were called
a trauma and you’re worried about it, the way you check for it
is do a fluorescein exam. So while the patient is looking away, you put some fluorescein drops in the
eye and then you hold up a Wood’s lamp and if you see that fluorescein
pulling over the eye, you know they had a corneal abrasion. So it arises from direct eye trauma. It’s painful and persistent and
is usually worse with blinking. They may have no exam finding
without the fluorescein dye. So you really have to do
that fluorescein dye exam and that requires a little bit of practice,
have someone show you how to do it. The pain resolves usually in a day or two. There’s really not
much you need to do, although I do recommend
following up with ophthalmology if the lesion goes over the pupil
just to make sure the vision is okay. Sometimes, folks will
treat this with topical erythromycin just to
prevent superinfection, although that’s very rare. This usually heals up very
quickly within a day or two. This is a result of anterior
chamber eye trauma. So a hyphema is an acute bleed as a result of direct blunt
force trauma to the eye in the anterior chamber of the eye. And what you can see if you look carefully
is this blood sort of layered out, about half way up the eye. When you see that layering of
blood, you know that’s a hyphema. It usually happens right
in front of the iris. So it’s basically a result of direct
trauma, say a baseball to the eye. This is an orbital emergency and we
generally want to call ophthalmology to get them to come
and check things out. The blood can interfere with drainage
of fluid and result in glaucoma. Generally, this is usually either
in or outpatient treatment. We used to treat them more
inpatient, now more outpatient. We do admit these infants and children if they’re expected
poor compliance or if they have an underlying
problem like sickle cell disease, which in general they
do much worse with. So, patients with sickle cell or patients where they’re
not likely to stay still and generally, we don’t want them
running around too much with this. And they often will recommend bed
rest until it’s healed up. So how do we treat it? We’ll put a shield patch over their eye and aminocaproic acid can reduce
the incidence of rebleed. You may need an inpatient experience for
that because of the toxicity of the drug which causes nausea,
vomiting or hypotension. Sometimes, often, I will just recommend
a topical steroid and dilating drops and they may or may not
require glaucoma meds depending on how the blood is
interfering with the drainage of the fluid from the anterior
chamber of the eye. So that’s my review of causes
of red eye in children. Thanks for your time.

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