Anteiror Seg In Peds II Flashcards
More than 2mm difference in pupil size
Anisocoria
Unequal pupil diameter, but less than or equal to 1mm differnece in both dim and bright
Physiological anisocoria
Aides tonic pupil
- abnormal larger pupil
- anisocoria greater in bright
- sluggish pupil with segmental repsosne to light
- But more response at near
- Greater than normal response/constriction with pilocarpine
- slower tonic re-dilation is diagnostic
- repsosne at near > response to light
Horners syndrome
- abnormally smaller pupil
- anisocoria greater in dim (unaffected eye dilates more)
- ptosis secondary to paralysis of the muller muscle
- congenital cases have iris heterochromia (affected pupil is lighter)
- miosis, ptosis, anhidrosis (loss of hemifacial sweating)
- congential or acquired
When is cocaine not necessary in horners
If common features are present
Confirming horners
Confirming diagnosis with topical cocaine (2-10%)
-horners pupil will not dilate
Apraclonidine (0.5% or 1%) can also be used
-horners pupil will dilate
What could cause horners
Trauma, surgery, or a neuroblastoma, affecting the sympathetic chain in the chest
Acquired horners
Need imaging of the brain, neck, and chest
Acquired corneal conditions
Keratitis
- epithelial
- stromal
- peripheral
Punctuate epithelial erosions
Seen in children with
- lagophthalmos
- dry eye
- CL overwear
- floppy eyelid syndrome
Ophthalmia neonatorum
- conjunctivitis occurring in the 1st month of life
- form viral, bacterial, and chemical agents
- prophylaxis has reduced the occurrence in developed countries, but still an issue in some areas of the world
Where is ophthalmia neonatorum found
Areas of high prevalence of sexually transmitted diseases and poor health care
- infant infected through direct contact after passage through he birth canal
- if the infection ascends into the uterus, even a cesarean infant can be infected
- silver nitrate was once used as widespread prophylaxis, but erythromycin is not used for coverage against chlamydia or N gonorrhea
Neisseria gonorrhea
- can cause ophthalmic neonatrum
- seen int he first 3-4 days of life
- mild conjunctival hyperemia and discharge, or even marked chemosis, copious discharge, potential for corneal ulceration
- treatment with systemic antibiotics and topical saline irrigation
- topical antibiotics if corneal invovlemtn
Congential herpes simplex infection
- due to HSV 2
- presents inthe 2nd week of life
- conjunctivitis, keratitis (epithelial or stromal), cataracts
- vesicular lesions, CNS invovlemt, retinal necrosis
Bacterial conjunctivitis
- copious discharge
- diagnosis is by clinical presentation
- culture for the agent not necessary in mild cases, but in severe cases
- topical agents such as plymyxin cominbations. Erythromycin, bacitracin and FQs are effective
Trachoma
- caused by poor hygiene and poor sanitation
- spreads from eye to eye
- acute purulent conjunctivitis, follicular reaction, tarsal scarring, papillae hypertrophy, vascularization of the cornea
- culture for diagnosis
- treatment with topical and systemic erythromycin
- tetracycline can be used in chidlren older than 8 years
EKC
- highly contagious in epidemic outbreaks
- acute, bilateral follicular conjunctivitis
- preauricular adenopathy
- initial symptoms are FB sensation nand periorbital pain
- diffuse SPK and the focal epithelial lesions
- after 11 to 15 days, subepithelial opacities form under focal epithelial infiltrates
- opacities can last for 2 years
- conjunctival membranes can form in severe cases with marked eyelid swelling. Differentials are orbital and preseptal cellulitis
- complications include persistent subepithelial opacities and conjunctival scarring
- diagnosis is by clinical presentation, confirmed by rapid culture
- supportive treatment: AT and cool compresses
- topical steroids may be used with caution in severe cases with decreased vision from subepithelial opacities
Molluscum contagiosum
- caused by DNA poxvirus
- shiny dome-shaped waxy umbilical skin papule
- seen at or near the lid margin
- spontaneous resolution can take months or years
Blepharitis
- less common in kids
- causes chronic conjunctivitis in kids
- signs and symptoms are similar to adults. Ocular irritation, morning crusting, eyelid erythema, meibomian gland obstruction
- intermittent blur
- inferior keratitis in severe cases
- recurrent chalazion
Treatment for blepharitis
- warm compresses
- eyelid scrubs with baby’s shampoo
- topical antibiotic ointment
- oral erythromycin or tetracycline (caution because of dental staining) in severe cases
- caution with steroids in patients withcorneal disease
Blepharokeratoconjunctivitis
Secondary to chronic meibomian gland disease
-affects the lids and cornea
Ocular allergy
- common in children
- could be associated with asthma, allergic rhinitis, atopic dermatitis
- itching
- bialteral chronic conjunctival inflammation
- tearing, burning, photophobia
- immediate response to allergens
Seasonal allergic conjunctivitis
- seen in spring and fall
- triggered by environmental allergens (pollens, trees). Red, watery eyes, itching, blue-gray/purple discoloration of lower eye lids
- treatment: removal of allergens, topical or oral meds
Treatment for seasonal allergic conjunctivitis
- topical meds are mast cell stabilizers (alamide, alamast)
- mast cell stabilizers and H1 blocker combo (pataday, bepreve)
- vasoconstriction
- steroids (FML, lotemax, Alex, pred)
- NSAID (Acura) or combo drugs
VKC
- due to immediate and delayed hypersentivity reactions
- common in males in the first 2 decades of life
- spring and fall
- severe itching
- limbal and bulbar form
- limbal form common in chidlren of African and Asian decent. Limbal more prevalent in hitter climates
VKC appearance
- commonly affects tarsal conjunctiva of the upper eyelid
- initially there is diffuse injection with little discharge
- papillae multiply, cover the tarsal with flat papules
- thick, ropy whitish discharge may develop
Limbal VKC
- thickening and opacification of the conjunctiva at the limbus, usually marked at the upper margin of thecoenea
- the limbal nodules are gray, jelly-like, elevated bumps
- a whitish center may appear to the raised filled with eosinophils
- they persist as long as the season exacerbates it
- horners trantas dots (mostly upper limbus, but can be all over limbus)
Cornea and VKC and treatment
- could be invovled with punctate epithelial erosions
- eye drops with mast cell stabilizers and H1 receptor blockers can be used
- severe cases get topical steroids
Papillomas
- benign epithelial proliferation’s that look like masses at the limbus or as pedunculated lesions of the caruncle, fornix or palpebral conjunctiva.
- transparent or pale color
- resolve spontaneously
Conjunctival epithelial inclusion cyst
- clear
- fluid filled conjunctival cyst
- excision only for irritation
Conjunctival nevus
- common in kids
- flat or elevated
- can be brown, non pigmented or pink
- can be noted at birth, develops more in childhood to puberty
- removal is there is significant growth
- rarely transforms into a malignancy
Ocular melanocytosis
- congenital
- unilateral gray or bluish patchy discoloration of the sclera
Preseptal cellulitis
- inflammation of tissues anterior to the orbital septum
- eyelid edema: can extend to brow and forehead
- no proptosis, no globe involvement
- full EOMs with no pain-unlike orbital cellulitis
- could occur due to: truama, laceration, insect bite, EKC, skin infection like herpes zoster, sinus infection
Treatment for preseptal cellulitis
Can do oral antibiotics as outpatients
Impatient care for very young kids and sicker kids
Need cultures, imaging of issues and orbits, IV abx
Orbital cellulitis
- infection of the globe involving tissue posterior to orbital septum
- commonly associated with sinusitis
Orbital cellulitis could offater
Penetrating injuries
Signs and symptoms of orbital cellulitis
Fever Eyelid edema Orbital pain Headache Proptosis Chemosis Limited EOMs because of orbital involvement Venous congestion could cause an increase in IOP
Treatment for orbital cellulitis
- need imaging to confirm orbital involvement, rule out FB, view sinus involvement and rule out bone tumors
- requires impatient care and IV abx to prevent complications
