Eye and Upper Respiratory Disorders Flashcards
visual screening method in children (by age)
birth
Age 2
Age 3
birth: red reflex, corneal light reflex, pupillary response to light
Age 2: add cover/uncover test
Age 3+: add visual acuity (first with tumbling “E” chart→ kindergarden shape charts→ Snellen chart
Normal red reflex= red glow with no evidence of opacitites
DDx of abnormal red reflex?
normal= white reflex in AA
Abnormal red/white reflex:
stellate dark lesion= congenital cararacts
difference between two eyes should alert to pathology (eg retinoblastoma→malignant eye tumor (until proven otherwise), large refractive error, strabismus
Normal Hirshberg’s Test= equal light reflection in both eyes
DDx for abnormal Hirshberg?
abnormal Hirshberg test= strabismus
(unequal eye muscle weakness)
4 types of strabismus
(direction of eye movement)
esotropia= turning inward
exotropia= turning outward
hypertropia= turning upward
hypotropia= turning downward
Normal cover/uncover test= both eyes maintain conjugate gaze, even with one eye being covered
(performed 5months to 6yo)
DDx abnormal test?
abnormal cover/uncover= amblyopia
affected eye moves when covered and then has to return to conjugate gaze when uncovered
d/t strabismus or refractive error
At about what age does conjugate gaze develop?
around 5 mo
Normal visual acuity test= 20/20
(by age 8, with or without glasses)
What does 20/20 mean?
the numerator is the distance between the subject and the chart, while the denominator is the distance at which a person with 20/20 acuity would just discern the same optotype
DDx of abnormal visual acuity test:
**visual acuity is vital sign of the eye
MC abnormality= refractive errors
also: astigmitism, corneal irregularities, neural issues
why is urgent opthalmology consult required for:
congenital cateracts?
must be removed before 6weeks old or risk blindness
why is urgent opthalmology consult required for:
corneal ulcer?
corneal abrasion has become infected
(often in contact lens wearers)
urgent opthalmology consult is needed for ocular trauma → will need to know the % of the anterior chamber that has hyphema
what is hyphema?
reddish discoloration occluding the pupil and iris = hyphema
(blood in the anterior chamber)
higher % of chamber with hyphema= associated with acute angle closure glaucoma
also, trauma itself poses risk of retinal detachment
Treatment for strabismus:
should be followed by opthalmologist bc at risk for developing amblyopia
mild→ patch dominant eye or use cycloplegic drops in the good eye (encourages deviant eye to strengthen)
severe→ surgery
Treatment for amblyopia (and age for best outcomes)
best if treated before 6yo, but 8-9yrs may still have good outcome
any older, and Tx will not restore proper vision bc central vision will be permanently compromised
Tx: same as for strabismus (patching or cyclopegic drops)
MC cause of purulent eye discharge in neonate
(in US)
(in developing countries)
in US→ purulent eye discharge in neonates likely chlamydia
in developing countries→ gonorrhea
Common cause of watery eye(s) in infants
dacryostenosis= blocked tear duct
majority of kids with red eyes (with or without discharge) have a type of this:
conjunctivitis
(allergic, bacterial or viral)
What are the red flags in Hx and PE of “red eye” or “eye discharge”?
trauma
photophobia
eye pain
type of conjunctivitis:
Sx: itchy eyes or nose, seasonal reoccurance, watery/stringy discharge, cobblestoning on the palpebral conjunctiva
allergic conjunctivitis
type of conjuctivitis:
Sx: purulent eye discharge with significant erythema of the palpebral (and sometimes bulbar conjunctiva) without eye pain
**swelling of bulbar conjunctiva= chemosis
bacterial conjunctivits
type of conjunctivitis:
Sx: red eye +/- watery discharge, likley with URI
Viral conjunctivitis
(still may give Abx drops bc often 2º bacterial infxn)
**herpetic conjunctivitis is viral BUT has red flags of significant eye pain and photophobia
Eval/Tx for neonate with red eye and discharge
culture eye discharge, gram stain if gonorrhea is possibility
empiric IV abx until culture results returned
Tx for infant with dacrostenosis:
amniotic debris can clog tear duct in neonate
Tx: **massage inner canthus of eye 3x/day **(debatable effect)
Abx needed if discharge becomes purulent
if still blocked at 6mo old→ refer to opthalmology for probing of the tear duct, which usually opens it
Abx Tx for bacterial conjunctivitis:
Polytrim, Vigamox, Ocuflox
[erythromycin ointment in neonates]
Eval/ Tx for herpetic conjunctivitis:
* pt will present with significant eye pain and photophobia
confirm with fluorescein stain
MUST refer to opthalmology
Antihistamine Tx for allergic conjunctivitis:
responds very well to antihistamine eye drops
Patanol or Pataday (q day formula)
Naphcon or Ketotifen (OTC formulas)
Eval for corneal abrasion:
potential complications?
stain with fluorescein, then use black light (Wood’s lamp)
consider in inconsolable infant, esp if facial ezcema as baby may scratch eye trying to scratch itchy skin
Document: location and % corneal involvement
Rx: Abx eye drops and Tylenol #3 (for pain)
RTC next day→ should heal overnight!
Complication= infected (corneal ulcer)→ medical emergency (to opthalmology immediately)
Eval/ Tx for blunt eye trauma:
**hyphema= blood in the anterior chamber
(can occude iris and pupil)
also examine eye socket, facial bones for fractures
refer to opthalmology (know % of anterior chamber that has hyphema)
►higher % assoc with acute angle closure glaucoma
►trauma itself is risk for retinal detachment
Exam findings for periorbital (pre-septal) and orbital (post-septal) cellulitis
exam finding that distinguishes the 2?
erythematous, edematous, warm eyelid, fever
distinguished by: extra-ocular eye movements INTACT with periorbital cellulitis but not with orbital
likley cause of periorbital cellulitis?
of orbital cellulitis?
periorbital→ insect bite (may see bite mark) or scratched face
orbital→ eye trauma or sinusitis that has eroded the orbital bone (muscle and fat surrounding the eye are infected and post-septal area fills with pus)
management for periorbital cellulitis (pre-septal):
monitor for sepsis, meningitis and check Hib and pneumococcal vaccine status
need close monitoring/RTC precautions, but can Tx outpatient with Augmentin or cephalosporins
management for orbital cellulitis (post-septal):
if unsure of Extra Ocular Movement exam→ ask for help or admit pt for CT scan and IV Abx
ENT consult req’d as surgical eye orbit debridement req’d
significant risk of spread to brain, so speed/vigilance needed!
what is retinopathy of prematurity?
why is it so important to refer to opthalmology?
infants born <32weeks or <1500grams at risk for retina not to develop appropirate blood vessels (in photo, note absence of blood vessels in bottom portion of retina)
stage 1= minimal change→ stage 5=retinal detachement
Retinopathy of prematurity is signif cause of blindness in US
PCP’s job: make sure NICU grads follow-up with opthalmology rechecks every 1-2 weeks. Document discussion of importance of follow-up in patient’s chart.
Differentiate the clinical S/Sx assoc with the MCC of rhinitis:
MC→ viral URI (lasts 7-14 days, so rhinorrhea 1-2 weeks/month… more during winter months) *as long as brief periods of resolution, likley reoccurences of viral URIs
**Allergic rhinitis→ **no break in Sx, Hx of seasonal Sx, itchy nose, some eye involvement
2° bacterial infxn→ Sx 10+days (but <1mo), esp with fever after initial cold Sx, purelent discharge, Sx worsening rather than improving (**yellow-green nasal discharge is common around days 3-4 and does NOT indicate a 2° bacterial sinusitis)
**Foreign Body/ Choanal atresia **(congenital blocked nasal passage)→ persistent purulent discharge
pathophys of common cold in young kids:
kids under 5yo average ~6-8 viral URIs/year (fewer as get older), each one lasts 1-2weeks
*about 1/4 of time kids have a cold
MCC are rhinoviruses (there are many rhinoviruses, so continue to get colds)
Tx plan for child with suspected viral URI:
SUPPORTIVE care: nasal irrigation with normal saline using a bulb syringe q few hours. Parents can buy or make the soln.
honey helps with cough but is CONTRAINDICATED under 1yr
**cough/cough preparations NOT recommended **under 6yo and are CONTRINDICATED under 2yo
humidifiers somewhat helpful to relieve congestion
Tx plan for child with suspected bacterial sinusitis
(including dosing indications):
1 MC organism= Strep pneumo
same organisms as AOM, so same treatment
first line amoxicillin (80-90mg/kg, divided BID (max 3g/day) then Augmentin (amox+clavulanic acid→ inactivates bacterial beta lactamase)
nasal steroids helpful
Eval of child with suspected Group A strep pharyngitis:
90% of sore throats are caused by a virus and need no intervention
PE not always helpful in determining who to test→use scoring system
Sx of GAS often include→ obrupt onset HA, upset stomach, vomiting, sandpaper rash to trunk and groin in some
►kids with rash likley have scarlet fever (expect +rapid strep test)
Tx of GAS pharyngitis
Tx GAS to avoid complications of post-streptococcal glomerulonephritis or rheumatic fever
Tx with penicillin/amoxicillin/ampicillin for 10days
expect rapid improvement
can return to school after 24hrs Abx
stress importance of completeing entire Abx regimen
scoring system for deciding who to test for GAS
(1 point for each “yes” answer)
**all neg rapid strep test needs confirmatory culture bc test has low sensitivity
- age 5-15yr
- late fall/early spring presentation
- pharyngeal erythema, edema or exudates on exam
- tender, >1cm anterior cervical LAD
- fever of 101-103
- absence of URI Sx (cough/ rhinorrhea)
score of 5→ culture only bc rapid test only 50% chance of coming up positive (avoids dual testing)
S/Sx of abscesses that require emergent ENT consult, hospital admission, IV abx, incision/drainage:
differentiate between peritonsillar and retropharyngeal abscess
severe sore throat, fever, difficulty swallowing and talking (“hot potato” voice)
►life threatening due to airway obstruction
Peritonsillar abscess is more common: begins as cellulitis, often GAS. PE→ bulging soft palate and deviated uvula
Retropharyngeal abscess→ stiff neck/lateral flexion due to presence of mass near neck muscle
risk factors for obstructive sleep apnea in kids
Signs/Sx of OSA:
Risk factors: obesity (BMI > 97th %), 3-4+ tonsils, adenoidal hypertrophy (have to get lateral neck x-ray to see adenoids)
to a lesser degree: FHx of OSA, Down syndrome, CP
Signs/Sx: habitual snoring, episodes of arrested breathing/choking during sleep, behavior/learning problems including ADHD and nocturnal enuresis
management of suspected OSA
if risk factors, or S/Sx of OSA→ can refer directly to ENT or can send for sleep study and refer if +
Tx: tonsilecotmy/ adenoidectomy, +/- CPAP machine for sleep
differentiate between clinical signs and Sx of acute otitis media vs serous otitis media
(around 6yo, the eustachian tubes become longer and positioned at a downward slant into the throat, making AOM less common)
AOM: acute ear pain, bulging TM, +/- fever or otorrhea
→mastoiditis is potential complication of AOM (protruding ear, erythema over mastoid process→ emergency ENT referral
Serous otitis media= middle ear effusion: air/fluid levels, fluid behind TM may be clear or yellow (non-invasive, quick test for MEE with tympanometer)
→after AOM infxns are treated, fluid remains in the middle ear for a few days/weeks (60% of MEE resolve by 1 month, 90% by 3 months)
Tx plan for child with AOM (including amox dosing):
most providers treat whether or not febrile (have the option to watch and wait→ make f/u plan and start Abx if Sx persist at day 3→ consider Safety Net Abx Prescription (SNAP) for caregiver to fill if necessary
Pts with high fever and ear pain should get Abx and acetominophen or ibuprofen for pain
RTC if Sx not improved within 2-3 days of Abx (need to change to 2nd line therapy like Augmentin)
First line Abx (use unless pt treated with amoxicillin in past 30days or has both AOM & purulent conjunctivitis). Give macrolide if PCN allergy
Amoxicillin 80-90mg/kg/day, divided BID→ max 3g/day
