Eyes Flashcards
Vision Screenings
- Inability to fix and follow after 3 months - warrants referral
- Photoscreening and autorefraction - ages 6 months to 3 years
- Visual acuity charts starting at 4-5 years
Vision screening detects amblyopia (lazy eye) which affects 1-4% of children
PMH and FMH Risk factors related to the EYE:
Pertinent PMH:
- Maternal substance abuse during preg
- TORCH exposure
- Prematurity
- Development delay
- Neurological abnormalities
- Metabolic abnormalities
- Congenital/genetic abnormalities associated with eye problems
- Allergies
Pertinent FMH:
- Congenital abnormalities
- Blindness
- Retinoblastoma
- Metabolic/genetic/congenital disorders
- Need for corrective lenses
- Glaucoma
- Blood dyscrasias
- HTN
- Glasses
Physical Exam of the EYE
- Observation of structures and response to exam by:
EOM
PERRL
Accommodation (ability to focus the eyes to see up close and change from close to far) - External Eye Exam
- Corneal Light Reflex (Reflection of light from both eyes - should be symmetrical)
- Red reflex (Reflection from the retina - both eyes should have crisp, round, red, orange, or tan reflex)
- Ophthalmoscope exam
Dx studies:
- Culture/gram stain of eye discharge
- US, CT, MRI for orbital cellulitis, trauma, or tumor
- No US if ruptured globe
- No MRI if metal foreign body
- Fluorescein staining for corneal damage
Normal Vision Development (Table 35.3 - page 619)
- Soon after birth: Fix and follow a light source
- 1 month: Fixation is central, steady and can follow a slow target
- 3 months: Binocular vision and eye coordination
- 6 months: Reaches out accurately at an object
- 9 months: Object permanence
- 2 years: Picture matching
- 3 years: Letter matching (E chart)
- 5 years: Snellen chart
Ophthalmic Antibiotics:
- Fluoroquinolines, sulfacetamide, and trimethoprim/polymyxin B; erythromycin
- Avoid topical penicillins
- Ointments preferred in children (last longer, don’t sting)
Chlamydia Trachomatis Conjunctivitis
Key Characteristics:
- Commonly presents during 5 to 14 days of life
- S/Sx: mild to moderate injections and chimosis (examine for signs of increased WOB)
Purulent discharge and complication of other STIs
Dx: Culture conjunctivae & r/o pneumonia with chest XR
Management: Erythromycin for 2 to 3 weeks and hospitalize for respiratory symptoms
Education: Good handwashing, mother and partner treatment, pneumonia
Gonococcal Ophthalmia Neonatorum
Key Characteristics:
- 2 to 5 days after birth
- Marked chemosis and eyelid edema, everted
- Marked mucopurulent eye drainage
S/Sx: significant purulent discharge in very young infants
Labs: culture drainage
Management: hospitalize with IV antibiotics for 7 days (ceftriaxone or cefotaxime)
Bacterial Conjunctivitis (“Pink Eye”)
Etiology: Hib, strep pneum, staph aureus, moraxella catarrhalis (common in Dec-April)
S/Sx: red eyes with purulent yellow-green discharge, URI, photophobia; diffuse and marked conjunctival hyperemia
Tx: Medications & cool, wet compresses
- sodium sulfacetamide, trimethoprim sulfate plus polymyxin B, azithromycin, fluoroquinolone, erythromycin
Complications: systemic infection and blindness
Viral Conjuncitivitis
Etiology: adenoviruses, HSV, VZV, Coxsackie
S/Sx: Pinkish-red eyes, watery or serous discharge, pharyngitis; diffuse conjunctival hyperemia with follicles, discomfort
Tx: Warm or cool, wet compresses; Artificial tears; antihistamine
More common in children > 6 years
If suspect HSV with eye involvement - refer out
Allergic Conjunctivitis
S/Sx: Bilateral itching or burning, excessive (clear) tearing; diffuse conjunctival hyperemia; boggy conjunctiva, cobblestone, papillary hypertrophy
Tx: Eliminate agents, oral histamine, topical ophthalmic mast cell stabilizer
Strabismus (“Lazy Eye”)
Misalignment of the eyes (5% of children)
S/Sx: eyes turn in (eso); out (exo); up (hyper); down (hypo)
Amblyopia in affected eye
When to Refer: Persists or loss of vision acuity; refer if >4 months
Amblyopia
Functional reduction in visual acuity (caused by abnormal visual development early in life)
Predominately unilateral
S/Sx: strabismus, refractive errors, unequal red reflexes; decrease in visual acuity, unequal vision
Dx: All children < 5 should be screened
Tx: Occlusive therapy, visual blurring (Educate on compliance with treatment)
Blepharitis
Inflammation of eyelid margin (eyelash follicles) associated with eye irritation
S/Sx: Red, itchy, crusting eyelid margins, chronic or recurrent; gritty feeling; seborrhea, staph, pediculosis
Tx: Clean eyelid margins twice a day; warm compresses
Nystagmus
Involuntary, rhythmic movements
Pendular oscillations or jerky drifts
Congenital or acquired
Normal up to 1 month
Management: refer to ophthalmologist
Cataracts
Partial or complete opacity of the lens
Congenital or acquired
Clinical findings: Maternal prenatal infection, drug exposure; opacity on lens; varying visual acuity deficits
Management: refer to ophthalmologist
Associated with: hypoglycemia, hypoPTH, galactosemia, and microthalamus
Hordeolum (“Stye”)
Infection of meibomian glands, glands of Zeis or Moll (sebaceous) usually from staph aureus
S/Sx: painful and tender eyelid, red eye, pustule dependent on internal or external
Tx: Frequent warm compresses; topical anti-infective ointment; Antistaphylococcal ointment
Chalazion
Chronic inflammation of meibomian glands from granulomatous inflammation
S/Sx: hard, painless mass in eyelid, not red or pustular, chronic; no eye discharge
Tx: warm compresses, surgical removal
Congenital Nasolacrimal Duct Obstruction (Dacryostenosis and Dacryostitis)
Defect of the lacrimal drainage system resulting in blockage (6% of newborns)
- Dacryostenosis: abnormal obstruction of NL duct
- Dacryostitis: inflammation of NL duct
S/Sx: continuous watery eyes, mucopurulent discharge
Dx: pressure over nasolacrimal sac produces mucopurulent discharge from punctum
Tx: Massage lacrimal sac several times the day, saline in nose
Refer if not resolved by 6-7 months
Preseptal / Periorbital Cellulitis
Inflammation and infection of eyelids and periorbital tissue
S/Sx: Red painful swelling around eye; tender, warm; regional adenopathy, fever
Dx: CBC, blood cx, head CT scan
Tx: MRSA concerns, complicated or <1 year, oral abx, warm compresses
Corneal Abrasion
Scratched, abraded, or denuded cornea usually from accidental contact with object
S/Sx: Pain, tearing, photophobia, decreased vision; uneven light reflex or cloudiness, foreign body, green staining
Dx: Fluorescein staining and cobalt-blue light or Wood’s lamp
Tx: Topical ophthalmic anti-infective ointment
- Follow-up in 24 - 48 hours or sooner
- May refer, especially if noncompliant
Foreign Body (Conjunctival or Corneal)
S/Sx: Excessive tearing, Photophobia, Pain, FB sensation
Tx: Test visual acuity, remove foreign body, inspect for corneal abrasion, topical ophthalmological abx
- Follow-up in 24 hours or sooner
Hemorrhage (Subconjunctival)
Rupture of small blood vessels in the conjunctiva
Etiology: Sudden increase in intrathoracic pressure, direct ocular trauma
S/Sx: blotchy, bulbar erythema of conjunctiva
Tx: will resolve in 5 to 7 days
(Educate on measures to avoid increasing intrathoracic pressure)
Hyphema
Blood in the anterior chamber of eye due to trauma
S/Sx: bright or dark red area near iris, painful, photophobia, tearing
- No bilateral red reflex
Tx: immediate referral to ophthalmologist
Education: weeks for return of normal vision, prevention, follow-up from ophthalmologist
Chemical Burn
Instillation of alkali or acid solution or substance into eye
S/Sx: eye pain, unable to open eye; opacity of corneal tissue, photophobia, tearing, swollen cornea
Tx: irrigation with water or saline, emergency referral
Could cause loss of vision
Ocular Trauma
Indirect or direct serious injury to the eye
S/Sx: double, blurred, or decreased vision; eye pain; tearing; unable to open eye, Corneal redness
Tx: Referral to ER or ophthalmologist
Retinopathy of Prematurity
Multifactorial retinal vasculopathologic disease (from prematurity or LBW) - Abnormal growth of retinal vessels
Dx: in NICU by pediatric ophthalmologist
S/Sx: leukokoria, pupillary rigidity, vitreous haziness, hemorrhage, retinal and iris changes, pallor of optic nerve, strabismus, cataracts, detached retinas may occur
Management: follow up with ophthalmologist; Monitor and referred for low vision children
Complications: retinal detachment, strabismus, amblyopia, myopia, nystagmus, astigmatism, anisometropia, Cataracts, uveitis, hyphema, macular burns, occlusion of central retinal artery, glaucoma, cicatrix
Prevention: decrease occurrence of premature births
Retinoblastoma
Intraocular tumor (malignant)
S/Sx: Positive family history, strabismus, unilateral or bilateral leukokoria, Decreased visual acuity, abnormal red reflex
Management: refer to ophthalmologist; enucleation of eye for advanced tumors
Conjunctivitis of Newborn (ophthalmia neonatorum)
Occurs in first few months of life
Chlamydia = most common cause (also HSV & gonorrhea)
S/Sx: moderate eyelid swelling, purulent discharge (usually in 5-14 days)
Management: irrigate with sterile saline, systemic erythromycin, mother should be treated for STI
