Therapeutics Flashcards
Goal of Drops for Peds
least sting, long-acting for shorter treatment time and lowest cost
ointments are longer lasting and sting the least compare to drops
Drop Instillation
90% to lacrimal ducts to mucous membrane of nasopharyngeal (systemic)
Metabolism in Kids
children have a longer clearance time and higher concentration in blood (lasts longer in kids) vs adults with the same dosage
Antibiotics Usage
bacterial conjunctivitis, corneal abrasion, and corneal ulcers
Antibiotic Ointments
Erythromycin: 2+ mos
Tobramycin: 2+ mos
Gentamicin: more toxic (safety is not established)
Bacitracin: gram +
Ciprofloxacin: 2+ years
Antibiotic Drops
Polymxin B and Trimethoprim: 2+ mos (stings)
Aminoglycosides: Tobramycin + Gentamicin
Sulfacetamides: rarely used bc it can cause Steven Johnson Syndrome (mucus membranes affected)
- allergy as well
Fluoroquinolones: 1+ yr + for corneal ulcers
Azithromycin: 1+yr for bacterial conjunctivitis and posterior blepharitis
Antifungals
fungal infection: non-healing abrasion with organic matter
Natamycin: no safety profile
Herpes Simplex Virus
oral antiviral: Acyclovir
HSV Epithelial
Topical Antiviral
Trifluorothymidine: 6+ year old
- toxic to cornea (keratitis)
Ganciclovir: 2+ years
Vernal Conjunctivitis
use a mast cell stabilizer
Cromolyn: 4+ year old
Lodoxamide: 2+ year old
Ocular Allergy
OTC: antihistamine, mast cell stabilizer, combos
Ketitofen
Olapatadine
Cetirizine (oral and more gentle on eye)
FML
steroid: 2+ year old
anterior seg issues
FML Forte
steroid: 2+
only one with safety profile
Durezol
Steroid
88% improved uveitits BUT caused increase in IOP and cataract development in 50% patients
must monitor use!
Glaucoma
Beta Blockers: TImolol + Betaxolol (safe in peds)
Alpha Adrenergic Agonists: Apraclonidine, Brimonidine (safe in peds, 2+, crosses BBB, cause excessive sleepiness)
CAI: Dorzolamide: safe in meds but no profile
Prostaglandins: 16+ with pigment changes (blue eyes turn brown/darker)
Rho Kinase Inhibitors: Netarsudil: 53% get conjunctivial hyperemia (red eye)
Bacterial Conjunctivitis
most common pathogen in kids from H. flu or s. pneumoniae
Tx: clean lids + antibiotic drops (tobramycin)
mucopurulent discharge + concurrent ear infection
Ophthalmia Neonatorum
newborn conjunctivitis that occurs within first 4 weeks of birth
Tx: ocular, systemic and including mom on antibiotics
chemical conjunctivitis from gonorrhea (1-3 days after birth) or chlamydia (5-25 days after birth)
CULTURE AND GRAM STAINS NECESSARY DURING NEONATAL PERIOD (INFANT CULTURES!!)
c-section is likely not to pass infection
Viral Conjunctivitis
many types but check pre-auricular nodes (if inflamed, it is confirmed viral)
red, teary eye with discharge
Mild Viral: unilateral but will spread in 1-2 days
Epidemic Keratoconjunctivitis (EKC): adenovirus, very contagious, can get subconjunctival hemorrhages and subepithelial infiltrates - does not clear for a few weeks
Herpes Simplex Virus
Type 1: above the waist
- 48% of children have recurrence within 15 mos
Vesicular lesions on lid: antibiotic ointment
Epithelial Defect: antibiotic
Conjunctival Injection: resolves on its own
Stromal opacities and iritis: steroid
6% epithelial/stromal disease will develop recurrence
48% stromal scarring led to Amblyopia
26% OU - concomitant or sequential
Nasolacrimal Duct Obstruction
5% infants and more common in down syndrome
absent or anomalous duct where the lower duct obstructed my mucous membrane of nose (valve of hasner)
90% clear spontaneously by 1 year old
Tx: observe and massage (eye to nose and back)
- if recurrent infection, treat with antibiotics (topical)
- probing is sx (anesthetic used)
Allergic Conjunctivitis
cool compress and antihistamine and then mild steroid, oral antihistamine, allergy testing (find cause)
remove the offending agent if known
usually systemic so OU is affected
Vernal Conjunctivitis
young males, warm months (spring), and recurrent
Cornea: Tranta Dots + Shield Ulcers: steroids for dots
- FML
Evert Lids: Papillae (use mast cell stabilizer)
Tx: educate and treat with mast cell stabilizer before spring season
Limbal Dermoid
choristoma (normal tissue in abnormal area) and often present at birth
does not grow much, no progression; variable size and color
Limbus: limbal dermoid vs Lateral Canthus: dermolipoma
associated with DC if affects cornea
Tx: artificial tears or sx if serious
Ptosis
unilateral or bilateral
Acquired: CNP III, MG, Trauma, Chalazia/Hemiangioma
Congenital: poor levator function, absence of upper lid fold, lagophthalmos on down gaze, and brow elevation
Tx: correct RE, patch for amblyopia, Sx consult
- head tilt or cosmesis
- levator resection or frontalis sling (pull eyelid up)
Marcus Gunn Jaw Winking
synkinesis between nerve supply to pterygoid muscles and levator palpebrae superioris
not serious; when jaw moves to opposite side of ptotic lid, the ptotic lid elevates
Capillary Hemangioma (strawberry birthmark)
benign soft tissue tumor composed of blood vessels
- most common orbital tumor in childhood
located usually on palpebral conjunctiva or upper lid
- superficial bright red mass that will blanch with pressure, bleed spontaneously, and enlarge when crying
100% by 6 months + most spontaneously regress
- 30% by 3 years old and 75% by 7 years old
concerned with amblyopia if occlusion of visual axis by lid or induced corneal astigmatism
Eval: cardiac/neuro work up and CT/MRI orbit
- Posterior Fossa Malformation
- Hemangioma
- Arterial Anomalies
- Cardiac Defects
- Eye abnormalities
Chalazion (Chronic) vs Hordeolum (acute)
inflammation of blocked meibomian gland
swollen lid + oily MG
can recur with children
Tx: topical, oral, sx (>10mm) and hot compress
if chronic: omega-3 supplements
FDA Dosing
1kg = 2.2 lbs and 1 tsp = 5 ml
need to know kids weight and dose formulations for drugs (on label)
1) find the min + max range
2) pick closest to middle out of the formulations
Preseptal Cellulitis
infection of anterior portion of lid (septum)
- should still have normal VA, EOM, Pupils
due to insect bite, chalazion, sinus infection, trauma
- s. pneumoniae most common
Orbital Cellulitis
infection of lid but more serious because decreased VA, restricted EOMs, abnormal pupils seen with proptosis (bulging eyes)
Tx: go to hospital for IV antibiotics
Information about a Pediatric Cataract
location in eyes, location in lens, size, shape, duration
- more posterior = poor prognosis
- > 3mm is significant in vision
- congenital or acquired (duration)
Bilateral Cataract
60% idiopathic
30% hereditary without systemic disease
5% metabolic syndrome
3% maternal infection
2% ocular anomalies
Meds (steroids, radiation)
Bilateral: more work up if no family history
- CBC, BUN, TORCHS, ca/P, urine
Unilateral Cataract
80% idiopathic
20% ocular anomalies like Uveitis
10% traumatic
Unilateral: may not require systemic work up
- hx, lens eval, maybe TORCHS to find cause
Galactosemia
oil droplet cataract
- galacitol in lens leads to refractive lens change
if you remove galacitol from diet, lens will clear up (not TRUE cataract)
Anterior Polar Cataract
small (<3mm), central, abnormal separation from lens vesicle and surface ectoderm
Anterior Pyramidal Cataract
conical, surrounding cortical changes
usually bilateral
Nuclear Cataract
located in the embryonic/fetal nucleus between y sutures
unilateral or bilateral
often Autosomal Dominant + poor VAs
Posterior Lenticonus
Congenital thinning of posterior capsule with bowing of thinned area and becomes opacified over time
usually unilateral
may get irregular astigmatism - ambylopic
Cerulean (Blue Dot)
blue/white opacities in lens cortex
autosomal dominant (genetic mutation)
associated with down syndrome
Eval of Cataracts
HISTORY (family, duration, meds, trauma, health, prematurity)
VA visual preference
RE + DFE (IOP + lens assessment)
Infant Aphakia Study Results
114 infants (1-6 mos) with unilateral cataracts sx
81% IOL got glaucoma vs 56% CLS got glaucoma
children should be left aphakic and treat with cls until IOL implant is necessary
Cataract Tx
Infants: the earlier the intervention the better outcome
- if no treatment: can lead to deprivation amblyopia
if unilateral: sx by 4-6 weeks (ASAP) vs if bilateral (6-8 wks)
Toddler: sx only if severe
- VA worse than 20/50, RE, patch, dilate with PEP for improvement
School-Age: 8+ year old
- if congenital and no prior tx: poor prognosis
- if acquired, more conservative tx
Aphakia gls/ BIFOCAL TX NECESSARY
monitor for glaucoma!!
Ectopia Lentis
lens subluxation due to disorders that disrupt the microfibrils of the zonules
remain attached usually but can detach
Caused by Homocystinuria + Marfan’s Syndrome
Homocystinuria
methionine catabolism disorder which leads to developmental delays and blood clots and pupil Block glaucoma
Dx: urine test
Tx: B6 + diet changes
Marfan’s Syndrome
mutation in gene for fibrillin-1
tall stature, MVP, aortic root dilation – cardiac defects
Myopia (>3D), Ectopia Lentis, FMHx, and genetic tests
Primary Infantile / Congenital Glaucoma
onset 1-2 year olds where angle structures seen at 7-8 mos of gestation are now seen as congenital glaucoma
- they do not develop fully
CB and Iris positioned more anteriorly and overlap TM causing decrease in aqueous outflow
Caused by: cataract removal (up to years later) or Juvenile Onset Open Angle Glaucoma (autosomal dominant)
66% bilateral
86% dx by 1 year old
Signs: tearing, photophobia, blepharospasm (eye twitch), megalocornea (>12mm), Buphthalmos (enlarged eye), Myopia, corneal opacities, increased IOP (>21mmHg)
- reproducible VFD
- increased corneal diameter
:newborn >11mm
:infant >12mm
:1+year >13mm
- increasing cupping and diff of 0.2 or more
- focal rim thinning
- progressive myopic shift
Work up: IOP, Gonio, Dilation/ON, EUA (under anesthetic)
Tx: sx or meds
