ON Abnormalities In Children Flashcards
Hypertropia
Describes an ocular misalignment where one eye is deviated above the fixating eye
Hypotropa
Ocualr misalignment where one eye is evicted below the fixating eye
Most common cause of vertical diplopia
CN IV palsy and thyroid related eye disease
Eye deviations may be
Paralytic (CN palsy) or non paralytic (childhood strab, decompensated phoria, mechanical restriction)
Remember to check comitancy and forced duction to differentiate paralytic strab vs other form
Dominant optic atrophy (Kjer)
- bilateral central vision loss
- begins before 10 years
- VA between 20/40 and 20/100, could be worse as 20/200
- VF shows central or cecocentral scotoma with normal peripheral field
- focal wedge shaped temporal pallor seen OU
- AD
- blue yellow (tritanopia) deficnicy
- imaging should be done
- one treatment because there is stability and very little progression
LHON
- mitochondrial disease-maternally inherited
- typically boys and men aged 10-30 years
- M»»F
- acute painless bialteral loss of central or cecocentral field (seen onVF)
Classic presentation of LHON
Hyperemia and ONH elevation (no leakage on NaFL
- peripapillary telangiectasia
- tortuosity of medium retinal arteries
Lever hereditary optic neuropathy is an _________
ATROPHY
Findings of LHON
ONH findings before vision loss or appear completely normal
Imaging if there is a negative family Hx
Differentials for LHON
Optic neuritis
Compressive optic neuropathy
Infiltration optic neriopathy
Treatment for LHON
No prove treatemnt
Color deficiency and LHON
Acquire RG color deficiency
Things to make LHON worse
Tobacco use and excessive alcohol can further stress mitochondrial function, thereby contribute to vision loss
Optic neuritis
- any optic nerve inflammation, affecting any part of the nerve
- seen in kids after system infection. Like viral infections, can also be assocaited with immunizations or bee stings
- mor elikely bilateral with edema (not unilateral in adutls)
- severe vision loss
- may have systemic symptoms-HA, nausea, vomiting, lethargy and malaise
Treatment for optic neuritis
Treatment in kids not studies, but IV steroids can be used
Neuroretinitis and optic neuritis
Neuroretinitis when there is a stellate pattern exudates in the macula
-due to toxocariasis, TB, syphilis, Lyme, sarcoidosis, viruses
Ppilledema
- disc edema from elevated ICP
- bialteral
- VA, color vision and pupils could initally look normal
- edema in kids could be due to any of the following: intracranial mass, meningitis, IIHTN, hydrocephalus
- patons lines
Testing for papilledema
Neuroimaging and lumbar are needed
Symptoms of papilledema
- Nausea, vomitting, HA
- older chidlren may have transient visual obscurations
- 6th nerve palsy could occur causing ET and diplopia. Usually resolves when pressure is reduced
Pseudotumor cerebri (idiopathic intracranial hypertension)
- increases intracranial pressure with normal sized ventricles on imaging
- seen in teen girls
Pseudotumor cerebri could be asscated with
Viral infection Tetras Steroids Vitamin A Down syndrome Thyroid medications Growth hormones Lithium BC Obesity
Signs and symptoms of papilledema
- HAs, vision loss, diplopia, transient visual obscurations
- papilledema can be seen on an asymptomatic child
- VF is able on a child (difficult to interpret)
- 6th nerve palsy could occur
- HA could get worse
- HAs can worsen
Treatment for pseudotumor cerebri
Treat by stopping the cause
- acetazolamide (diamond) or topiramate (topamax)
- surgical treatment options include optic sheath fenestration or shifting (in the case of good VA, but severe HAs). Both surgical option are to prevent vision loss
Prognosis of pseudotumor cerebri
Excellent due to spontaneous resolution after treatment (about 12 months)
Vision loss and papilledema
Can occur if chronic
Pseudopapilledema
- resembles papilledema e.g. drusen, hyperopia, prominent glial tissue
- there is NO DISC HYPEREMIA
- NO RETINAL HEMORRHAGES
- NO EXUDATES
- there are NO SYSTEMIC FINDINGS assocaited with elevated ICP
- can be seen in Down syndrome and RP
ONH drusen
- most common cause of pseudopapilledema in kids
- frequently AD (look at parents)
- elevated disc has irregualr borders and does not obscure retinal arterioles
- no exudates or Hemes
- if not completely buried, appears as translucent shiny refractile bodies
Signs and symptoms of ONH drusen
- VF defect (inferior nasal common, accurate or central defects occur) can slowly progress
- VA IS STABLE AND UNAFFECTED
- B scan to detect the bright calcific reflections
- no systemic problems associated in these children
Medication considerations in kids
- Age of kid/weight
- Metabolism
- Blood brain barrier: not fully developed/thinner. Higher absorption into CNS, mroe concentrated, stays in bloodstream longer
- Punctal occlusion to decrease systemic absorption
- getting the drops in the yees: lids, lashes ar barriers
- crying will dilute
- beard not to hurt agitated kids
- drains into the lacrimal duct
- major site of drug metabolism: liver
- major site for excretion: kidney (drug can stay longer)
- both metabolism and exertion are at different rates than adult
Aversion to drops in kids
Use ointment
What should you always do before putting drops in
Always verify the medication, allergies and the expiration date before administration
Bacitracin
Gram +
- staph bleph
- not 1st choice for conjunctiva
Aminoglycosides
Broad spectrum
Significant hypersensitivity
Neomycin does not cover pseudomonas
Neo>genta>tobramycin
-tobramycin has less sensitivity with it
-FQs are the go to for broad coverage now
Plymyxin B
- gram negative
- usually coupled with gram positive
Polysporin ung (polymyxin B and Bacitracin
- go to for peds
- nighttime coverage
News-Orin
Not common used because of the neomycin hypersensitivity
FQs
Besivance
-suspension
Ciloxan
Vifamox/moxeza (Moxifloxacin)
-PF free, not for kids under 4months
Ocuflox
Zymaxid
Drugs that can be used for pediatric under one year
Moxeza
Tobramycin
Poly trim
Erythromycin
Erythromycin
- gentle for peds
- NLDO
- ineffective against pseudomonas
- some blurred vision
- ung only
NLDO
Topical Abx-for significant discharge (not to cure the obstruction)
- any broad spectrum Abx can be used
- dosing for a number of days for an acute infection and then as needed
- polysporin ung, tobramycin ung or erythromycin BID ung
Bacterial conjunctivitis
- copious discharge
- culture for the agent not necessary in mild cases, but in severe cases
- topical agents such as a polymyxin combinations, erythromycin, bacitracin, and FQs are effective
Medications not on the list for kids
Sulfacetamide
-SJS syndrome
Chloramphenicol
-can cause aplastic anemia and lead to death
Gentamicin and kids
Don’t RX, too much hypersensitivity
Acute preseptal hordeolum Tx
Oral antibiotics
- cephalosporin (gram positive)
- Keflex BID x 7 days (or augmentin, consider doxy, erythromycin, or a FQ if patient has PCN allergies)
- warm compresses
- can add tobradex (tobramycin and dexamethasone) BID
Allergy meds
- topical meds are mast cell stabilizers (alomide, alamast, crolom) may not work for immediate itch relief
- mast cell stabilizers and H1 blocker combo (pasta day, bepreve, zaditor)
- vasoconstriction (opcon A, similar to visine)
- NSAIDs (Acular)
- remove allergens
Mast cell stabilizers and H1 blocker combo that can be used in 2 year olds
Bepreve
Lastacraft
Pazeo
Alomide
Steroids in kids with allergies
FML, lotemax or Alex, pred)
Dosing
-should be based on the severity of the signs and symptoms
-Q2hrs, QID x 1 week, then taper to BID x 1 week
-can switch to antihistamine.mast cell stabilizers combo when stable
-severe cases get topical steroids
-the initial dose has to be frequent enough to quick reflief and remission
-follow up is very important
Durezol
- stronger
- less dosing
- proper follow ups
Pred forte
- tell patien to shake it well
- more dosing than durezol
Lotemax
- more chronic inflamamtory conditions
- less side effects
Alrex
Allergies
Good for horners trantas dots
Steroids are contraindicated in
Epithelial herpetic disease
-you can use it stromal
Antivirals
HSV keratitis
- Zirgan better than viroptic for kids
- zirgan less dosing, ointment form, decrease toxicity
Skin disease
- oral antivirals
- 7-10 days
- acycloviris a good choice in kids
Acquired brain injury
- sudden neurological damage due to TBI and/or stroke
- TBI sudden neurological damage due to shearing forces within the brain that lead to injury and death of axons
- CVAs can cause neurological damage due to ischemia
- teenage boys and young chidlren are at greatest risk
Symptoms of ABI
Diplopia, photophobia, asthenopia, blurred vision, skipping words, HA, etc
Clinical findgins or ABI
- CI-40%-most common BV dysfunction
- oculomotor dysfunction (40-85%)
- accommodative dysfunction (10-41%)-test both amplitude and faciltiy
- CN 5 palsy-most common non-comitant deviation after trauam
- cyclovertical heterphoria-double Maddox rod should be used to quantify
- visual perception deficits-visual spatial and motor reduces visual perception
- bilateral visual field loss (14%)-homonymous hemianopsia is the most common VF defect
