Eye Problems

Question 1

test vision in infant/young child

Answer 1

Infant and younger child - have the child look at and follow the expression and movement of the caregiver’s face.

Question 2

test vision in kids 3-4 years

Answer 2

Child (> 3-4yrs) Allen cards (pictures of familiar objects) and the HOTV test can be used to assess acuity

Question 3

test vision in kids age 4-6

Answer 3

Child (4-6 yrs) the tumbling E test can be used; Snellen eye chart may be considered when the alphabet is mastered

Question 4

amblyopia

Answer 4

a functional reduction in visual acuity caused by abnormal visual development early in life

Strabismic — Caused by abnormal alignment of the eyes
Refractive — Caused by unequal focus between eyes
Deprivational — Caused be structural abnormalities of the eye that obscure incoming images

Question 5

referral to ophtho

Answer 5

Visual acuity worse than 20/40 in a child 3-5 yrs
Visual acuity worse than 20/30 in a child ≥6 years
Visual acuity difference of ≥2 lines between eyes
Abnormal ocular alignment (i.e., strabismus)
Abnormal red reflex
Asymmetry of vision (eye preference)
Unilateral ptosis or other lesions obstructing the visual axis (i.e., eyelid hemangioma)

Question 6

strabismus phoria

Answer 6

“Phoria” − Latent strabismus present only when binocular fusion is disrupted

Latent deviations are rarely associated with amblyopia.

Question 7

strabismus tropia

Answer 7

“Tropia” − Manifest strabismus is present when there is no disruption of binocular fusion; can be intermittent, occurring only when fusional capabilities are exceeded (e.g., when the child is tired)
Manifest strabismus can be monocular, when deviation always involves the same eye, or alternating, when either eye may deviate.

Manifest deviations have a greater potential to cause amblyopia, caused by disuse or misuse of vision during the critical period of visual development.

Question 8

presenting signs of retinoblastoma

Answer 8

strabismus most common finding

after leukocoria (white pupil), esotropia is the most common presenting sign of retinoblastoma (eyes turn inward)

Question 9

Dacryostenosis

Answer 9

unilateral or bilateral obstruction of lacrimal duct, usually at nasal punctal opening.

Congenital nasolacrimal obstruction (dacryostenosis)
6 percent of newborns
Most common cause of persistent tearing and ocular discharge in infants and young children.
90% resolve spontaneously by 12 months
Due to failure of duct canalization.
Conjunctival erythema is not typical. On physical examination, there is often an increase in the size of the tear meniscus. Palpation of the lacrimal sac may cause reflux of tears and/or mucoid discharge onto the eye through the puncta.

Question 10

Acute Dacrocystitis

Answer 10

bacterial infection of lacrimal sac that may spread to surrounding soft tissues resulting in cellulitis.

Question 11

dacroadenitis

Answer 11

Dacryoadenitis. The lacrimal gland has become swollen and inflamed and is visible beneath the lateral aspect of the upper eyelid. The swelling is frequently accompanied by symptoms of pain and tenderness.

Question 12

primary juvenile glaucoma

Answer 12

Dx after 4-5 years

Patients typically are asymptomatic, and optic nerve damage is occult.
Elevations of IOP usually are unrecognized unless optic nerve cupping is noticed.
The diagnosis generally is made because of coexisting ocular or systemic disease or because of a positive family history.

Question 13

secondary glaucoma

Answer 13

Secondary Glaucoma – juvenile – usually acquired through retinopathy of prematurity, intraocular inflammation, ocular tumors, trauma, and glucocorticoids, Sturge Weber.
Clinical Findings: (Listen to parents)
Classic Triad: tearing, photophobia, excessive blinking (30%)
Hazy corneas, enlarged corneas or edema, ocular enlargement, bulbar conjunctival erythema

Secondary Glaucoma more likely to present with: pain, vomiting, blurred vision, tunnel vision, pupillary dilation, optic nerve cupping.

Question 14

newborn conjunctivitis (chemical)

Answer 14

Chemical -presents several hours following opthalmic drop/ointment instillation; mild injection of conjunctiva, minimal lid edema, scanty drainage - lasts 3-4 days

no treatment necessary; resolves without sequella

Question 15

newborn.conjunctivitis

gonococcal

Answer 15

Gonococcal – chemosis, significant lid edema, acute PURULENT discharge 2-4 days after birth

HOSPITALIZE – Irrigate eye w nl saline q 10-30 min gradually decreasing until purulent dx cleared; ceftriaxone 20-50 mg/kg/d/IV or IM not to exceed 125 mg as single dose or Cefotaxime 100 mg/kg/d IV or IM as single dose

Question 16

newborn conjunctivits- chlamydia

Answer 16

Chlamydia – usually presents with mild mucopurulent discharge, minimal lid edema, a 5-14 days after birth – concomitant pneumonia ( afebrile, repetitive staccato cough, tachypnea, rales)
Other bacteria – purulent dx normally seen on 5th day, lid edema, chemosis

-pneumonia somtimes occurs with
Rales (but no wheeze and no fever) helps to distinguish from RSV

Chlamydia conj and/or pneumonia – oral erythromycin 50 mg/kg/d in 4 divided doses for 10-14 days. 20% require second course (assoc w pyloric stenosis)

Question 17

organisms- infectious conjunctivitis (pink eye)

Answer 17

Bacterial causes -  60-70%
Non type H Flu 42% (Jan, Feb, Mar) 
Associated with ipsilateral otitis media 
Strep Pneumoniae 15%
Viral – 10-20%
Adenovirus 15-20% (pharyngitis)

Question 18

viral vs bacterial conjunctivits

Answer 18

Age: 
Bacterial – Younger; mean age 3.6 yr.
Viral – Older ( 8.5 yrs)
Seasonality – Bacteria in winter
Discharge – Purulent, thick color = bacteria
Conjunctival Response: (slit lamp)
 papillary =bacteria; 
follicular = viral
Concurrent Disease: otitis media? (H Flu) Pre-auricular nodes? PCF triad? Adenovirus 3,8,19;  Sinusitis?
Response to therapy: 
Bacteria= 2-5 day with antibiotic
Viral – self limiting 7-10 days with no treatment

Question 19

hsv viral conjunctivits

Answer 19

Mainstay of tx of bacterial is topical antibiotics.

Common choices: erythromycin oint; trimethoprim sulfate/polymyxin gtts; sulfacetamide gtts
(Polytrim) - + + H Flu and S pneumonia; seldom hypersensitivity, approved as young as 2yr; comfortable

never corticosteroid

Question 20

allergic conjunctivitis

Answer 20

Red, watery, itchy eyes.
Part of larger allergic picture (hay fever) or direct contact with airborne allergen
Bilateral usually, but one eye could be inoculated with dander etc.
Nasal salute, allergic rhinitis, shiners – grey boggy, papillary conjunctiva
Avoidance, Avoidance, Avoidance

Question 21

chalazion

Answer 21

Obstruction of meibomian glands lining posterior margins of upper and lower lids.
Cause – unknown
S/S – progressive swelling of lid, slight discomfort, minimal redness.
DD: Blepharitis? Hordeolum? Sebaceous cell carcinoma ( rare)
PE - Firm, non-tender non moveable nodule often on palpebral surface of lid

Small chalazions may resolve w/o tx.
Warm compresses 2-3 x day for 2-3 days
If large, recurrent or infections lesions, local antibacterial drops or ointment for 1 week
If persistent or large, refer for surgical excision or corticosteroid injections.

Question 22

blepharitis

Answer 22

granulation of eyelids
bacterial infection of lash follicles

tx: Symptomatic, warm moist compresses to lid margins several x a day; Daily mechanical scrubbing and cleansing of lid margins w dilute baby shampoo, topical antibiotic ointment in lid margins
Treat coexisting seborrhea of scalp

Question 23

periorbital vs orbital cellulitis

Answer 23

Orbital – inflammation of orbital contents posterior to orbital septum; often decreased visual acuitiy

Peri-orbital – inflammation/infection of skin and subcutaneous tissue surrounding eye; often associated with trauma, septicemia, sinusitis and bacteremia/infection near the eye
-usually normal visual acuity

Ophthalmoplegia= paralysis of eye muscles and proptosis – classic findings distinguish orbital from periorbital cellulitis

Question 24

common causes / organisims periorbital / orbital cellulitis

Answer 24

Most common causes in children: paranasal sinuses and ethmoiditis
Others: insect stings, bites, impetigo, FB

Most common Organisms: Staph aureus, Strep pneumoniae, H Flu

Question 25

s/sx cellulitis

Answer 25

Orbital Cellulitis:
Insidious onset
Orbital pain, headache
Decreased Vision
Fever
Peri-orbital
Acute onset unilateral eyelid swelling
Warmth, swelling, tenderness of overlying skin
Eye itself and vision usually normal

Question 26

hyphema

Answer 26

Accumulation of blood in anterior chamber
Etiology:
Due to blunt or perforating trauma (fists, balls, sticks) leading to rupture of iris or ciliary body blood vessels
May also occur with bleeding disorders (sickle cell)
Usually lasts 5-6 days; high risk of ocular complications

tx: Refer: Reduce activity for several days; bed rest in supine, with hob elevated, eye patch (No pressure on globe)

Question 27

cataracts sx

Answer 27

Partial or complete opacity of lens

Physical FindingsStrabismus – may be initial sign
Absent red reflex, black dot surrounding red reflex or white plaque-like opacity.
Signs of other systemic disease or ocular abnormalities

Differential Diagnosis:
Retinoblastoma?
Glaucoma?