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Clinical Evaluation of Red Eyes in Pediatric Patients
DEPARTMENT
Practice Guidelines
Clinical Evaluation of Red Eyes in Pediatric Patients Casey Beal, MD, & Beverly Giordano, MS, RN, CPNP, PMHS
ABSTRACT Patients with the primary symptom of a red eye are commonly seen in pediatric primary care clinics. The differential diagnoses of a red eye are broad, but with a succinct history and physical examination, the diagnosis can be readily identified in many patients. Identifying conditions that threaten vision and understanding the urgency of referral to an ophthalmologist is paramount. Some systemic diseases such as leukemia, sarcoidosis, and juvenile idiopathic arthritis can present with the chief symptom of a red eye. Finally, trauma, ranging from mild to severe, often precipitates an office visit with a red eye, and thus understanding the signs that raise concern for a ruptured globe is essential. In the primary care setting, with a focused history, a few simple examination techniques, and an appreciation of the differential diagnosis, one can feel confident in managing patients with acute red eyes. J Pediatr Health Care. (2016) -, ---.
KEY WORDS Red eye, conjunctivitis, pediatric, corneal abrasion
Patients with the primary symptom of a red eye are often seen in the pediatric primary care setting, and because the differential diagnoses are broad, the
Casey Beal, Assistant Professor, Department of Ophthalmology, University of Florida, Gainesville, FL. Beverly Giordano, Pediatric Nurse Practitioner, Department of Pediatrics, University of Florida, Gainesville, FL. Funded in part by an unrestricted grant from Research to Prevent Blindness, New York, NY. Conflicts of interest: None to report. Correspondence: Casey Beal, MD, Department of Ophthalmology, University of Florida, PO Box 100284, Gainesville, FL 32610; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2016 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2016.02.001
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diagnosis can sometimes be elusive. However, with use of a focused history and simple clinical examination techniques, the provider can be more confident in the diagnosis and management of red eyes in children. Clinic visits for red eyes are common; approximately 1% of all primary care office visits are due to conjunctivitis (Azari & Barney, 2013). The eye becomes red as a nonspecific reaction to any type of insult, including infection, allergy, trauma, dryness, or systemic inflammation. The redness stems from engorgement of the conjunctival vessels. In trauma and some types of infection, the redness can be caused by subconjunctival hemorrhages. The red eye has a broad differential diagnosis, but very often, a simple history and physical examination can help elucidate the diagnosis (Table). HISTORY The importance of obtaining a detailed history when evaluating a patient with a red eye cannot be overstated. The following items in the history require a specific focus:
Duration of symptoms Presence of pain or itching Photophobia History of trauma—high or low velocity History of similar episodes Previous treatment
CONJUNCTIVITIS Conjunctivitis is one of the most common ophthalmologic disorders encountered by pediatric primary care practitioners. The eye becomes red as a result of dilation of the conjunctival blood vessels, which is sometimes associated with discharge and edema. When edema accumulates under the conjunctiva, the conjunctiva begins to look ‘‘boggy’’; this appearance is referred to as chemosis (Figure 1). It is important to examine the palpebral conjunctiva—that is, the portion that covers the inside of the eyelid—which can be seen by pulling down on the lower eyelid or everting the upper eyelid. A papillary or follicular reaction may be -/- 2016
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TABLE. Differential diagnosis of red eye in children Diagnosis Conjunctivitis Viral
Pain
Itching
Discharge
History
Other symptoms
Burning sensation
No
Tearing
Positive for contact with sick people
Enlarged preauricular lymph node
No
Yes
Tearing
May have other allergy symptoms
Allergic shiners
Bacterial Blepharitis
Yes Burning sensation
No Copious Sometimes No
Episcleritis
Prominent
No
Tearing
Scleritis
Severe
No
Tearing
Uveitis
Usually severe No
Tearing
Allergic
Trauma Corneal abrasion Moderate
Unilateral or bilateral Chronic crusting; chalazion; common in children aged 6-10 years Occurs most often in older children/ adolescents Connective tissue disease Unilateral or bilateral
Eye discomfort that is worse in the afternoons
May be associated with autoimmune disease
Tearing
Common in contact lens wearers
Photophobia, pain with blinking
High-velocity projectile vs lowvelocity objects Blunt trauma, cough, Valsalva maneuver Blunt trauma Penetrating trauma
Pain with blinking
Variable
No
Tearing
Subconjunctival hemorrhage Hyphema Ruptured globe
None
No
No
Moderate Severe
No No
No No
Conservative; contagious for 10-21 days Artificial tears; oral antihistamines; mast cell stabilizer/ antihistamine drops Antibiotic eyedrops Eyelid washes, warm compresses
NSAIDS; refer to ophthalmologist
Vision loss, blue hue to Refer to ophthalmologist sclera Photophobia, decreased Refer to ophthalmologist vision
No
Foreign body
Treatment
Fluorescein examination, topical antibiotic drops; no use of contact lenses until the abrasion resolves Refer to ED or ophthalmologist
None
No treatment needed
Photophobia Decreased vision
Refer to ophthalmologist Refer to ED, keep NPO
Note. ED, emergency department; NPO, nothing by mouth; NSAIDS, nonsteroidal anti-inflammatory drugs.
FIGURE 1. Chemosis—edema of the conjunctiva.
observed, depending on the underlying cause of the conjunctivitis. A papillary reaction creates large, flat nodules with a central vessel that is commonly described as ‘‘cobblestoning.’’ A follicular reaction creates smaller, dome-shaped, gelatinous-appearing lesions that are best seen on the palpebral conjunctiva (Figure 2). Conjunctivitis can be caused by viral or bacterial infections, allergies, or chemical exposure; viruses and allergies are the most commonly encountered causes. Viral Conjunctivitis
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. 2
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Definition Viral conjunctival infection is most commonly caused by adenovirus types 8, 19, and 37 (LaMattina & Thompson, 2014). Some common variants of the classic viral conjunctivitis are pharyngoconjunctival fever and acute hemorrhagic conjunctivitis. Journal of Pediatric Health Care
FIGURE 2. Follicular conjunctival reaction of the inferior palpebral conjunctiva seen here by everting the lower eyelid with a cotton tip applicator.
can cause a viral conjunctivitis along with fever, rash, and arthralgias (Petersen et al., 2016). Infection with Zika virus should be suspected in a patient with a recent history of travel to an endemic country. History of the present illness Acute-onset eye redness, irritation, tearing, and a burning sensation Contact with people who are sick One eye is often affected first, followed by the other eye in a few days Physical examination Examine the inferior conjunctiva by pulling down on the lower eyelid to evert it, which usually shows a follicular conjunctival reaction (Figure 2) External examination shows diffuse conjunctival erythema (Figure 3) An enlarged preauricular lymph node is almost always noted
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. Pharyngoconjunctival fever presents with a triad of sore throat, fever, and conjunctivitis and is caused by adenovirus type 3 or 7 (LaMattina & Thompson, 2014). Acute hemorrhagic conjunctivitis, although not common, is significant for extensive subconjunctival hemorrhages in addition to conjunctival injection. These cases are commonly caused by Coxsackie virus A2 and enterovirus 70 (Wong, Lai, Chi, & Lam, 2011). Zika virus, which has recently emerged in the Western hemisphere, also FIGURE 3. Viral conjunctivitis—diffuse conjunctival injection and tearing.
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. www.jpedhc.org
Diagnostic tests AWood’s lamp (i.e., a lamp emitting long-wave ultraviolet light named for Robert W. Wood) or a direct ophthalmoscope switched to its cobalt blue light setting and fluorescein are used to evaluate for corneal abrasions No cultures are needed in these cases
Treatment Symptomatic care ¤ Artificial tears as needed ¤ Cool compresses Counsel patient and families on contagious nature of the disease ¤ Wash hands frequently and don’t share towels or pillows ¤ Conjunctivitis can be contagious from 10 days to 3 weeks or as long as the eyes are red (Pinto et al., 2014). It has been recommended that persons who are infected stay home for 2 weeks to prevent spread of the virus (Kaufman, 2011), although this recommendation is often unrealistic for working parents or patients in school. Simple precautions such as frequent hand washing and avoiding direct contact with the eyes are more realistic and will decrease the risk of transmission. The viral load decreases exponentially as healing occurs, and thus the infectivity will drop significantly during the first 7 days. ¤ Antibiotics have shown no value in treating viral conjunctivitis and should not be prescribed (Rose et al., 2005) ¤ All contact lenses, solutions, cases, and eye makeup should be discarded -/- 2016
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Ophthalmology referral Refer for vision changes, corneal abrasions as identified with the fluorescein examination previously described, significant discharge that is more likely to be bacterial, or no improvement in 5 to 7 days Other viral causes of conjunctivitis include herpes simplex virus and varicella zoster virus, which frequently manifest with skin findings as well. These patients should be referred to ophthalmology immediately for close follow-up.
FIGURE 4. Bacterial conjunctivitis. White discharge is present on the conjunctiva, seen with eversion of the upper eyelid.
Allergic Conjunctivitis Definition Simple allergic conjunctivitis is extremely common, affecting 15% to 40% of the population (Bielory, O’Brien, & Bielory, 2012). It is caused by an inflammatory reaction to allergens in the environment. History of present illness Significant eye itching bilaterally Usually a seasonal component is present, and it is commonly seen in conjunction with allergic rhinitis and/or asthma Physical examination ‘‘Allergic shiners’’ or dark circles under the eyes are frequently present Excessive tearing is present with diffuse conjunctival erythema, variable amounts of chemosis, and a papillary reaction or ‘‘cobblestoning’’ appearance to the conjunctiva Treatment Limit exposure to the inciting agent, if it is known Artificial tears are helpful for rinsing out any allergens Combination mast cell stabilizer/antihistamine eyedrops (e.g., olopatadine, 0.1% or 0.2%, or ketotifen, 0.035%) are the first-line treatments; these drops can take up to 2 weeks to have their full effect, so patients are encouraged to continue using them for this period before evaluating their effectiveness Oral antihistamines Topical steroids or immunomodulators should only be prescribed by an ophthalmologist Bacterial Conjunctivitis Definition Bacterial conjunctival infection is less common than viral conjunctivitis but can have significant morbidity. The most common causes are Staphylococcus aureus, Streptococcus pneumonia, and Haemophilus 4
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Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. influenza. (See the subsequent ‘‘Ophthalmia Neonatorum’’ section as well, because conjunctivitis caused by Neisseria gonorrhoeae and Chlamydia trachomatis also can occur in adolescents.) History of the present illness Acute onset conjunctival redness, tearing, and discharge Unilateral or bilateral Physical examination The hallmark finding is copious, usually white, discharge (Figure 4), along with conjunctival erythema; the presence of this significant discharge helps distinguish bacterial from viral conjunctivitis Diagnostic tests A culture can be obtained if significant discharge is noted AWood’s lamp and fluorescein are used to evaluate for corneal abrasions Treatment Empiric treatment consists of polymyxin B sulfate/ trimethoprim drops or a fluoroquinolone eyedrop such as ofloxacin, ciprofloxacin, or moxifloxacin four times daily for 5 to 7 days; antibiotic choices can be adjusted on the basis of culture results if they are available Ophthalmology referral If corneal involvement is suspected, changes in vision occur, or no improvement is noted with Journal of Pediatric Health Care
topical antibiotics, then a corneal ulcer is suspected and the patient should be referred immediately to an ophthalmologist Ophthalmia Neonatorum Definition Bacterial conjunctivitis in the neonatal period is most commonly caused by C. trachomatis or N. gonorrhoeae and can cause significant morbidity and even mortality. History of the present illness Conjunctival redness, discharge, and eyelid edema in the first 14 days of life N. gonorrhoeae classically presents in the first 3 to 4 days of life C. trachomatis classically presents a little later than N. gonorrhoeae, at around 1 week of life Physical examination Significant conjunctival erythema, edema, and discharge C. trachomatis typically results in thin, ‘‘ropy’’ white discharge, whereas N. gonorrhoeae results in exuberant purulent white discharge Diagnostic tests Gram stain with culture or polymerase chain reaction for C. trachomatis and N. gonorrhoeae should be obtained from conjunctival discharge. Treatment Treatment for C. trachomatis includes administration of oral or intravenous (IV) erythromycin and use of erythromycin ophthalmic ointment four times daily for 14 days, and an ophthalmology consultation should be obtained Treatment for N. gonorrhoeae infection requires hospital admission, saline solution irrigation of the eyes every hour until the discharge clears, administration of ceftriaxone IV or intramuscularly, and an ophthalmology consultation (American Academy of Pediatrics, 2015) The mother and her sexual partner(s) also should be treated The infection should be reported to the local health department N. gonorrhoeae and C. trachomatis conjunctivitis can also occur in adolescents and should be suspected if severe or chronic discharge is present. C. trachomatis conjunctivitis in the adolescent is treated with oral doxycycline, azithromycin, or erythromycin in addition to topical erythromycin ophthalmic ointment. N. gonorrhoeae conjunctivitis in the adolescent is treated with intramuscular
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ceftriaxone, oral azithromycin, or doxycycline, as well as saline solution lavage of the conjunctiva. INFLAMMATORY EYE CONDITIONS Blepharitis Definition Blepharitis, an inflammation of the eyelid margins involving the eyelashes, is very common in the pediatric patient population. Most patients are completely asymptomatic, but blepharitis can cause significant eye pain and even vision loss in some children. Blepharitis is a type 3 hypersensitivity reaction to bacterial exotoxins, most commonly staphylococcal skin flora located at the lid margin. History of the present illness Chronic burning, itching, and tearing of the eyes that is worse toward the end of the day; it is always bilateral but can be asymmetric Typical age of onset is between 6 and 10 years (Gupta, Dhawan, Beri, & D’souza, 2010; Teo, Mehta, Htoon, & Tan, 2012) Recurrent chalazia or red, swollen areas of the eyelids also are common in these patients Physical examination Crusting at the base of the eyelashes and erythema of the eyelid margins with diffuse reactive conjunctival erythema An examination with a Wood’s lamp and fluorescein staining should be performed to evaluate for corneal abrasions In severe forms, corneal scarring and neovascularization can be seen as white areas on the otherwise translucent cornea. Although these lesions might be seen without use of a Wood’s lamp, they become more apparent upon its use with fluorescein. Treatment Wash the eyelashes daily with a mild baby shampoo Apply warm compresses to the eyelids twice daily or more often for associated chalazia Apply topical erythromycin ointment to the eyelashes nightly as needed Provide a referral to ophthalmology if no improvement occurs with conservative treatment or if corneal scarring is noted Episcleritis and Scleritis Definition Episcleritis is inflammation of the episclera (which lies just posterior to the conjunctiva), and scleritis is
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inflammation of the deeper, avascular, white sclera. These conditions are commonly idiopathic in origin but can be associated with a systemic autoimmune disorder. Thirty-seven percent of patients with scleritis have an associated systemic connective tissue disease (Wieringa, Wieringa, ten Dam-van Loon, & Los, 2013). Scleritis, as opposed to episcleritis, is exceedingly rare in the pediatric population, with the largest case series consisting of only 13 patients (Cheung & Chee, 2012).
FIGURE 5. Nodular scleritis. A discrete raised conjunctival nodule with surrounding erythema.
History of the present illness Eye pain that is acute to subacute in onset along with redness, which is usually unilateral Physical examination Persons with episcleritis will have localized or diffuse conjunctival erythema that is tender to palpation (Figure 5); in contrast, simple conjunctivitis is more ‘‘irritating’’ rather than ‘‘tender to palpation’’ Scleritis is characterized by inflammation of the deeper eye structures and will have localized erythema, tenderness to palpation, and a bluish discoloration underlying it Treatment Patients should be referred to ophthalmology for treatment and management; artificial tears, steroid eye drops, oral nonsteroidal anti-inflammatory drugs (NSAIDs), and sometimes systemic immunosuppression are the treatments of choice Uveitis Definition Uveitis is an inflammatory disorder of the uveal tract that includes the iris, ciliary body, and choroid. It is classified as anterior, intermediate, posterior, or pan uveitis based on the portion of the eye that is involved. Anterior uveitis, also known as iritis, is the most common type that should be considered when a pediatric patient presents with an acute red eye, and therefore we will focus on that type or uveitis in this article. Uveitis occurs in 11% to 13% of all patients with juvenile idiopathic arthritis (JIA) and can cause significant ophthalmic morbidity (Tappeiner et al., 2015). It is more common in patients with pauciarticular JIA and those who are positive for antinuclear antibodies. The uveitis associated with JIA can be low grade and asymptomatic, and thus these patients require frequent routine eye examinations by an ophthalmologist. History of the present illness Acute or subacute onset severe photophobia, eye redness, and a ‘‘boring’’ type pain with blurry vision 6
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Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. Physical examination Diffuse conjunctival erythema that is most prominent near the cornea Direct and consensual photophobia (i.e., pain in the affected eye when light is shown in the normal eye) Most cases are unilateral, although uveitis can be bilateral Diagnostic tests If recurrent or severe disease is present, rule out infectious/inflammatory causes, including syphilis, sarcoidosis, Lyme disease, tuberculosis, and HLAB27 seropositivity Treatment If uveitis is suspected, the patient should be referred to an ophthalmologist for evaluation and treatment including topical steroids, cycloplegic drops, and systemic immunomodulators EYE INJURIES Corneal Abrasion Definition A corneal abrasion is an epithelial defect on the surface of the cornea that is most commonly associated with trauma. History of the present illness Acute-onset, severe eye pain associated with blunt trauma or rubbing of the eye Pain worsens with blinking Physical examination Diffuse mild conjunctival erythema, tearing Journal of Pediatric Health Care
FIGURE 6. A corneal abrasion with fluorescein staining under a Wood’s lamp.
Photo courtesy of Casey Beal, MD. This figure appears in color online at www.jpedhc.org. Pain improves with instillation of topical ophthalmic proparacaine drops in the clinic; these drops should never be provided to patients because they can lead to corneal melting if used frequently Evert the upper and lower eyelids to evaluate for foreign bodies Diagnostic tests Use a Wood’s lamp and fluorescein staining of the cornea to diagnose the abrasion and evaluate its extent (Figure 6) Treatment Treatment entails use of a topical antibiotic drop or ointment four times daily for 3 to 5 days; options include polymyxin B/trimethoprim, ciprofloxacin, moxifloxacin, erythromycin, or bacitracin ophthalmic drops or ointment
History of the present illness The inciting event usually can be recounted by the patient The speed and size of the foreign body are crucial for determining the object’s potential for damaging the eye; if it was a high-velocity object, such as a piece of metal from a circular saw, it is likely that it is more deeply embedded and therefore more difficult to remove than a low-velocity object, such as vegetative matter or dirt blown up in the wind Physical examination The foreign body usually can be seen easily on the surface of the cornea or conjunctiva (Figure 7) Evert the upper and lower eyelids to ensure that no other foreign bodies are present Treatment If a foreign body is seen, refer the patient to the emergency department or urgently to an ophthalmologist Subconjunctival Hemorrhage Definition A subconjunctival hemorrhage is rupture of a small conjunctival capillary with resultant bleeding into the subconjunctival space. Commonly, eye rubbing, cough, the Valsalva maneuver, or blunt trauma cause subconjunctival hemorrhages. These hemorrhages can be very alarming to patients and their family because of their size, color, and acute onset. However, they do not affect vision and do not cause any significant pain.
FIGURE 7. A corneal foreign body.
Follow-up should be scheduled for 48 hours to evaluate for improvement Patching the eye is not recommended Contact lenses should not be worn until the abrasion heals If an underlying infection is associated with the abrasion, the patient should be referred to ophthalmology Corneal and Conjunctival Foreign Bodies Definition Corneal and conjunctival foreign bodies become embedded in the conjunctival or corneal epithelium. Commonly seen foreign bodies include vegetative matter and metal shavings. www.jpedhc.org
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. -/- 2016
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FIGURE 8. Subconjunctival hemorrhage.
If the patient has sickle cell disease or trait, the sickling of the red blood cells in the anterior chamber of the eye can clog the drainage system of the eye and cause an acute rise in intraocular pressure, which can precipitate permanent vision loss Physical examination Blood, which may be seen in the anterior chamber of the eye overlying the iris, is usually settled inferiorly because of the effect of gravity
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. History of the present illness A sudden onset localized area of subconjunctival blood Specifically inquire about trauma, coughing, or eye rubbing No photophobia, pain, or vision changes are present Physical examination A localized area of subconjunctival blood (Figure 8) that does not involve the cornea Treatment No treatment is required, although patients may use artificial tears for any discomfort If a child has recurrent or large subconjunctival hemorrhages, a bleeding disorder (Khaja, Pogrebniak, & Bolling, 2015) or nonaccidental trauma should be suspected Hyphema Definition A hyphema is defined as red blood cells that are present in the anterior chamber of the eye just posterior to the cornea. Most commonly, hyphemas are caused by blunt trauma; however, rarely, a hyphema can present spontaneously without a history of trauma, and this presentation raises concern for leukemia or juvenile xanthogranuloma (Samara et al., 2015). History of the present illness Inquire about a history of trauma and whether the patient has sickle cell disease 8
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Treatment All patients with hyphemas should be referred urgently to an ophthalmologist for further management and care with steroid and cycloplegic eyedrops. A main concern is the risk for recurrent hemorrhage as the blood clot begins to dissolve. Recurrent hemorrhage is most likely in the first 5 days after the injury, and thus patients should be instructed to avoid any strenuous activity, keep their head elevated, and avoid NSAIDs to reduce this risk. Ruptured Globe Definition A ruptured globe is the result of any breach in the structural integrity of the eye, including corneal or scleral full-thickness lacerations. A ruptured globe is the result of direct trauma to the eye. History of the present illness The speed, size, type, and shape of the projectile determines the extent of the injury Other associated head or facial injuries Physical examination If a ruptured globe is suspected based on history, it is important to avoid applying any pressure to the eye during the examination Signs of a ruptured globe include an irregularly shaped pupil, a shallow anterior chamber or exposed iris, or dark choroidal tissue showing through the white sclera Almost always, a significant decrease in visual acuity is found
Treatment If a ruptured globe is suspected, a Fox shield (i.e., a metal eye shield named for Sidney Fox, MD) should be taped across the eye to protect it without applying any pressure to the eye; a Styrofoam cup also can be used if a Fox shield is not available Journal of Pediatric Health Care
The patient should be directed to ingest nothing by mouth and should be sent directly to the nearest emergency department for emergent evaluation by an ophthalmologist for surgical repair CONCLUSION Patients with the chief symptom of a red eye are commonly encountered in the pediatric primary care setting, but with a focused history and examination, the diagnosis and management can be accomplished with confidence. Understanding the pathophysiology of each disease manifestation and when to utilize special tests such as fluorescein staining is essential to diagnosing and treating these patients. Certain signs that indicate that sight might be threatened are important to identify and require referral to an ophthalmologist. These signs include corneal abrasions, corneal opacities, recurrent or chronic symptoms, severe pain, photophobia, vision changes, or concern that the globe may be ruptured. In addition, topical anesthetic medication should never be provided to the patient, and topical corticosteroids should only be prescribed upon consultation with an ophthalmologist. With use of some simple techniques, pediatric patients presenting with a red eye can be fully evaluated in the primary care setting and treated or triaged with confidence. REFERENCES American Academy of Pediatrics. (2015). Gonococcal infections. In D. W. Kimberlin, M. T. Brady, M. A. Jackson & S. S. Long (Eds.), Red Book: 2015 Report of the Committee on Infectious Diseases (30th ed., pp. 356-367). Elk Grove Village, IL: American Academy of Pediatrics. Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: A systematic review of diagnosis and treatment. Journal of the American Medical Association, 310, 1721-1729. Bielory, B. P., O’Brien, T. P., & Bielory, L. (2012). Management of seasonal allergic conjunctivitis: Guide to therapy. Acta Ophthalmologica, 90, 399-407. Cheung, C. M., & Chee, S. P. (2012). Posterior scleritis in children: Clinical features and treatment. Ophthalmology, 119, 59-65. Gupta, N., Dhawan, A., Beri, S., & D’souza, P. (2010). Clinical spectrum of pediatric blepharokeratoconjunctivitis. Journal of the
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American Association for Pediatric Ophthalmology and Strabismus, 14, 527-529. Kaufman, H. E. (2011). Adenovirus advances: New diagnostic and therapeutic options. Current Opinion in Ophthalmology, 22, 290-293. Khaja, W. A., Pogrebniak, A. E., & Bolling, J. P. (2015). Combined orbital proptosis and exudative retinal detachment as initial manifestations of acute myeloid leukemia. Journal of the American Association for Pediatric Ophthalmology and Strabismus, 19, 479-482. LaMattina, K., & Thompson, L. (2014). Pediatric conjunctivitis. Disease-A-Month, 60, 231-238. Petersen, E. E., Staples, J. E., Meaney-Delman, D., Fischer, M., Ellington, S. R., Callaghan, W. M., & Jamieson, D. J. (2016). Interim guidelines for pregnant women during a Zika virus outbreak—United States, 2016. Morbidity and Mortality Weekly Report, 65, 30-33. Pinto, R. D., Lira, R. P., Abe, R. Y., Zacchia, R. S., Felix, J. P., Pereira, A. V., . Bonon, S. H. (2014). Dexamethasone/povidone eye drops versus artificial tears for treatment of presumed viral conjunctivitis: A randomized clinical trial. Current Eye Research, 40, 8870-8877. Rose, P. W., Harnden, A., Brueggemann, A. B., Perera, R., Sheikh, A., Crook, D., & Mant, D. (2005). Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: A randomised double-blind placebo-controlled trial. Lancet, 366, 37-43. Samara, W. A., Khoo, C. T., Say, E. A., Saktanasate, J., Eagle, R. C., Shields, J. A., & Shields, C. L. (2015). Juvenile xanthogranuloma involving the eye and ocular adnexa: Tumor control, visual outcomes, and globe salvage in 30 patients. Ophthalmology, 122, 2130-2138. Tappeiner, C., Klotsche, J., Schenck, S., Niewerth, M., Minden, K., & Heiligenhaus, A. (2015). Temporal change in prevalence and complications of uveitis associated with juvenile idiopathic arthritis: Data from a cross-sectional analysis of a prospective nationwide study. Clinical and Experimental Rheumatology, 33, 936-944. Teo, L., Mehta, J. S., Htoon, H. M., & Tan, D. T. (2012). Severity of pediatric blepharokeratoconjunctivitis in Asian eyes. American Journal of Ophthalmology, 153, 564-570. Wieringa, W. G., Wieringa, J. E., ten Dam-van Loon, N. H., & Los, L. I. (2013). Visual outcome, treatment results, and prognostic factors in patients with scleritis. Ophthalmology, 120, 379386. Wong, V. W., Lai, T. Y., Chi, S. C., & Lam, D. S. (2011). Pediatric ocular surface infections: A 5-year review of demographics, clinical features, risk factors, microbiological results, and treatment. Cornea, 30, 995-1002.
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Practice Guidelines
Clinical Evaluation of Red Eyes in Pediatric Patients Casey Beal, MD, & Beverly Giordano, MS, RN, CPNP, PMHS
ABSTRACT Patients with the primary symptom of a red eye are commonly seen in pediatric primary care clinics. The differential diagnoses of a red eye are broad, but with a succinct history and physical examination, the diagnosis can be readily identified in many patients. Identifying conditions that threaten vision and understanding the urgency of referral to an ophthalmologist is paramount. Some systemic diseases such as leukemia, sarcoidosis, and juvenile idiopathic arthritis can present with the chief symptom of a red eye. Finally, trauma, ranging from mild to severe, often precipitates an office visit with a red eye, and thus understanding the signs that raise concern for a ruptured globe is essential. In the primary care setting, with a focused history, a few simple examination techniques, and an appreciation of the differential diagnosis, one can feel confident in managing patients with acute red eyes. J Pediatr Health Care. (2016) -, ---.
KEY WORDS Red eye, conjunctivitis, pediatric, corneal abrasion
Patients with the primary symptom of a red eye are often seen in the pediatric primary care setting, and because the differential diagnoses are broad, the
Casey Beal, Assistant Professor, Department of Ophthalmology, University of Florida, Gainesville, FL. Beverly Giordano, Pediatric Nurse Practitioner, Department of Pediatrics, University of Florida, Gainesville, FL. Funded in part by an unrestricted grant from Research to Prevent Blindness, New York, NY. Conflicts of interest: None to report. Correspondence: Casey Beal, MD, Department of Ophthalmology, University of Florida, PO Box 100284, Gainesville, FL 32610; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2016 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2016.02.001
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diagnosis can sometimes be elusive. However, with use of a focused history and simple clinical examination techniques, the provider can be more confident in the diagnosis and management of red eyes in children. Clinic visits for red eyes are common; approximately 1% of all primary care office visits are due to conjunctivitis (Azari & Barney, 2013). The eye becomes red as a nonspecific reaction to any type of insult, including infection, allergy, trauma, dryness, or systemic inflammation. The redness stems from engorgement of the conjunctival vessels. In trauma and some types of infection, the redness can be caused by subconjunctival hemorrhages. The red eye has a broad differential diagnosis, but very often, a simple history and physical examination can help elucidate the diagnosis (Table). HISTORY The importance of obtaining a detailed history when evaluating a patient with a red eye cannot be overstated. The following items in the history require a specific focus:
Duration of symptoms Presence of pain or itching Photophobia History of trauma—high or low velocity History of similar episodes Previous treatment
CONJUNCTIVITIS Conjunctivitis is one of the most common ophthalmologic disorders encountered by pediatric primary care practitioners. The eye becomes red as a result of dilation of the conjunctival blood vessels, which is sometimes associated with discharge and edema. When edema accumulates under the conjunctiva, the conjunctiva begins to look ‘‘boggy’’; this appearance is referred to as chemosis (Figure 1). It is important to examine the palpebral conjunctiva—that is, the portion that covers the inside of the eyelid—which can be seen by pulling down on the lower eyelid or everting the upper eyelid. A papillary or follicular reaction may be -/- 2016
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TABLE. Differential diagnosis of red eye in children Diagnosis Conjunctivitis Viral
Pain
Itching
Discharge
History
Other symptoms
Burning sensation
No
Tearing
Positive for contact with sick people
Enlarged preauricular lymph node
No
Yes
Tearing
May have other allergy symptoms
Allergic shiners
Bacterial Blepharitis
Yes Burning sensation
No Copious Sometimes No
Episcleritis
Prominent
No
Tearing
Scleritis
Severe
No
Tearing
Uveitis
Usually severe No
Tearing
Allergic
Trauma Corneal abrasion Moderate
Unilateral or bilateral Chronic crusting; chalazion; common in children aged 6-10 years Occurs most often in older children/ adolescents Connective tissue disease Unilateral or bilateral
Eye discomfort that is worse in the afternoons
May be associated with autoimmune disease
Tearing
Common in contact lens wearers
Photophobia, pain with blinking
High-velocity projectile vs lowvelocity objects Blunt trauma, cough, Valsalva maneuver Blunt trauma Penetrating trauma
Pain with blinking
Variable
No
Tearing
Subconjunctival hemorrhage Hyphema Ruptured globe
None
No
No
Moderate Severe
No No
No No
Conservative; contagious for 10-21 days Artificial tears; oral antihistamines; mast cell stabilizer/ antihistamine drops Antibiotic eyedrops Eyelid washes, warm compresses
NSAIDS; refer to ophthalmologist
Vision loss, blue hue to Refer to ophthalmologist sclera Photophobia, decreased Refer to ophthalmologist vision
No
Foreign body
Treatment
Fluorescein examination, topical antibiotic drops; no use of contact lenses until the abrasion resolves Refer to ED or ophthalmologist
None
No treatment needed
Photophobia Decreased vision
Refer to ophthalmologist Refer to ED, keep NPO
Note. ED, emergency department; NPO, nothing by mouth; NSAIDS, nonsteroidal anti-inflammatory drugs.
FIGURE 1. Chemosis—edema of the conjunctiva.
observed, depending on the underlying cause of the conjunctivitis. A papillary reaction creates large, flat nodules with a central vessel that is commonly described as ‘‘cobblestoning.’’ A follicular reaction creates smaller, dome-shaped, gelatinous-appearing lesions that are best seen on the palpebral conjunctiva (Figure 2). Conjunctivitis can be caused by viral or bacterial infections, allergies, or chemical exposure; viruses and allergies are the most commonly encountered causes. Viral Conjunctivitis
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. 2
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Definition Viral conjunctival infection is most commonly caused by adenovirus types 8, 19, and 37 (LaMattina & Thompson, 2014). Some common variants of the classic viral conjunctivitis are pharyngoconjunctival fever and acute hemorrhagic conjunctivitis. Journal of Pediatric Health Care
FIGURE 2. Follicular conjunctival reaction of the inferior palpebral conjunctiva seen here by everting the lower eyelid with a cotton tip applicator.
can cause a viral conjunctivitis along with fever, rash, and arthralgias (Petersen et al., 2016). Infection with Zika virus should be suspected in a patient with a recent history of travel to an endemic country. History of the present illness Acute-onset eye redness, irritation, tearing, and a burning sensation Contact with people who are sick One eye is often affected first, followed by the other eye in a few days Physical examination Examine the inferior conjunctiva by pulling down on the lower eyelid to evert it, which usually shows a follicular conjunctival reaction (Figure 2) External examination shows diffuse conjunctival erythema (Figure 3) An enlarged preauricular lymph node is almost always noted
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. Pharyngoconjunctival fever presents with a triad of sore throat, fever, and conjunctivitis and is caused by adenovirus type 3 or 7 (LaMattina & Thompson, 2014). Acute hemorrhagic conjunctivitis, although not common, is significant for extensive subconjunctival hemorrhages in addition to conjunctival injection. These cases are commonly caused by Coxsackie virus A2 and enterovirus 70 (Wong, Lai, Chi, & Lam, 2011). Zika virus, which has recently emerged in the Western hemisphere, also FIGURE 3. Viral conjunctivitis—diffuse conjunctival injection and tearing.
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. www.jpedhc.org
Diagnostic tests AWood’s lamp (i.e., a lamp emitting long-wave ultraviolet light named for Robert W. Wood) or a direct ophthalmoscope switched to its cobalt blue light setting and fluorescein are used to evaluate for corneal abrasions No cultures are needed in these cases
Treatment Symptomatic care ¤ Artificial tears as needed ¤ Cool compresses Counsel patient and families on contagious nature of the disease ¤ Wash hands frequently and don’t share towels or pillows ¤ Conjunctivitis can be contagious from 10 days to 3 weeks or as long as the eyes are red (Pinto et al., 2014). It has been recommended that persons who are infected stay home for 2 weeks to prevent spread of the virus (Kaufman, 2011), although this recommendation is often unrealistic for working parents or patients in school. Simple precautions such as frequent hand washing and avoiding direct contact with the eyes are more realistic and will decrease the risk of transmission. The viral load decreases exponentially as healing occurs, and thus the infectivity will drop significantly during the first 7 days. ¤ Antibiotics have shown no value in treating viral conjunctivitis and should not be prescribed (Rose et al., 2005) ¤ All contact lenses, solutions, cases, and eye makeup should be discarded -/- 2016
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Ophthalmology referral Refer for vision changes, corneal abrasions as identified with the fluorescein examination previously described, significant discharge that is more likely to be bacterial, or no improvement in 5 to 7 days Other viral causes of conjunctivitis include herpes simplex virus and varicella zoster virus, which frequently manifest with skin findings as well. These patients should be referred to ophthalmology immediately for close follow-up.
FIGURE 4. Bacterial conjunctivitis. White discharge is present on the conjunctiva, seen with eversion of the upper eyelid.
Allergic Conjunctivitis Definition Simple allergic conjunctivitis is extremely common, affecting 15% to 40% of the population (Bielory, O’Brien, & Bielory, 2012). It is caused by an inflammatory reaction to allergens in the environment. History of present illness Significant eye itching bilaterally Usually a seasonal component is present, and it is commonly seen in conjunction with allergic rhinitis and/or asthma Physical examination ‘‘Allergic shiners’’ or dark circles under the eyes are frequently present Excessive tearing is present with diffuse conjunctival erythema, variable amounts of chemosis, and a papillary reaction or ‘‘cobblestoning’’ appearance to the conjunctiva Treatment Limit exposure to the inciting agent, if it is known Artificial tears are helpful for rinsing out any allergens Combination mast cell stabilizer/antihistamine eyedrops (e.g., olopatadine, 0.1% or 0.2%, or ketotifen, 0.035%) are the first-line treatments; these drops can take up to 2 weeks to have their full effect, so patients are encouraged to continue using them for this period before evaluating their effectiveness Oral antihistamines Topical steroids or immunomodulators should only be prescribed by an ophthalmologist Bacterial Conjunctivitis Definition Bacterial conjunctival infection is less common than viral conjunctivitis but can have significant morbidity. The most common causes are Staphylococcus aureus, Streptococcus pneumonia, and Haemophilus 4
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Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. influenza. (See the subsequent ‘‘Ophthalmia Neonatorum’’ section as well, because conjunctivitis caused by Neisseria gonorrhoeae and Chlamydia trachomatis also can occur in adolescents.) History of the present illness Acute onset conjunctival redness, tearing, and discharge Unilateral or bilateral Physical examination The hallmark finding is copious, usually white, discharge (Figure 4), along with conjunctival erythema; the presence of this significant discharge helps distinguish bacterial from viral conjunctivitis Diagnostic tests A culture can be obtained if significant discharge is noted AWood’s lamp and fluorescein are used to evaluate for corneal abrasions Treatment Empiric treatment consists of polymyxin B sulfate/ trimethoprim drops or a fluoroquinolone eyedrop such as ofloxacin, ciprofloxacin, or moxifloxacin four times daily for 5 to 7 days; antibiotic choices can be adjusted on the basis of culture results if they are available Ophthalmology referral If corneal involvement is suspected, changes in vision occur, or no improvement is noted with Journal of Pediatric Health Care
topical antibiotics, then a corneal ulcer is suspected and the patient should be referred immediately to an ophthalmologist Ophthalmia Neonatorum Definition Bacterial conjunctivitis in the neonatal period is most commonly caused by C. trachomatis or N. gonorrhoeae and can cause significant morbidity and even mortality. History of the present illness Conjunctival redness, discharge, and eyelid edema in the first 14 days of life N. gonorrhoeae classically presents in the first 3 to 4 days of life C. trachomatis classically presents a little later than N. gonorrhoeae, at around 1 week of life Physical examination Significant conjunctival erythema, edema, and discharge C. trachomatis typically results in thin, ‘‘ropy’’ white discharge, whereas N. gonorrhoeae results in exuberant purulent white discharge Diagnostic tests Gram stain with culture or polymerase chain reaction for C. trachomatis and N. gonorrhoeae should be obtained from conjunctival discharge. Treatment Treatment for C. trachomatis includes administration of oral or intravenous (IV) erythromycin and use of erythromycin ophthalmic ointment four times daily for 14 days, and an ophthalmology consultation should be obtained Treatment for N. gonorrhoeae infection requires hospital admission, saline solution irrigation of the eyes every hour until the discharge clears, administration of ceftriaxone IV or intramuscularly, and an ophthalmology consultation (American Academy of Pediatrics, 2015) The mother and her sexual partner(s) also should be treated The infection should be reported to the local health department N. gonorrhoeae and C. trachomatis conjunctivitis can also occur in adolescents and should be suspected if severe or chronic discharge is present. C. trachomatis conjunctivitis in the adolescent is treated with oral doxycycline, azithromycin, or erythromycin in addition to topical erythromycin ophthalmic ointment. N. gonorrhoeae conjunctivitis in the adolescent is treated with intramuscular
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ceftriaxone, oral azithromycin, or doxycycline, as well as saline solution lavage of the conjunctiva. INFLAMMATORY EYE CONDITIONS Blepharitis Definition Blepharitis, an inflammation of the eyelid margins involving the eyelashes, is very common in the pediatric patient population. Most patients are completely asymptomatic, but blepharitis can cause significant eye pain and even vision loss in some children. Blepharitis is a type 3 hypersensitivity reaction to bacterial exotoxins, most commonly staphylococcal skin flora located at the lid margin. History of the present illness Chronic burning, itching, and tearing of the eyes that is worse toward the end of the day; it is always bilateral but can be asymmetric Typical age of onset is between 6 and 10 years (Gupta, Dhawan, Beri, & D’souza, 2010; Teo, Mehta, Htoon, & Tan, 2012) Recurrent chalazia or red, swollen areas of the eyelids also are common in these patients Physical examination Crusting at the base of the eyelashes and erythema of the eyelid margins with diffuse reactive conjunctival erythema An examination with a Wood’s lamp and fluorescein staining should be performed to evaluate for corneal abrasions In severe forms, corneal scarring and neovascularization can be seen as white areas on the otherwise translucent cornea. Although these lesions might be seen without use of a Wood’s lamp, they become more apparent upon its use with fluorescein. Treatment Wash the eyelashes daily with a mild baby shampoo Apply warm compresses to the eyelids twice daily or more often for associated chalazia Apply topical erythromycin ointment to the eyelashes nightly as needed Provide a referral to ophthalmology if no improvement occurs with conservative treatment or if corneal scarring is noted Episcleritis and Scleritis Definition Episcleritis is inflammation of the episclera (which lies just posterior to the conjunctiva), and scleritis is
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inflammation of the deeper, avascular, white sclera. These conditions are commonly idiopathic in origin but can be associated with a systemic autoimmune disorder. Thirty-seven percent of patients with scleritis have an associated systemic connective tissue disease (Wieringa, Wieringa, ten Dam-van Loon, & Los, 2013). Scleritis, as opposed to episcleritis, is exceedingly rare in the pediatric population, with the largest case series consisting of only 13 patients (Cheung & Chee, 2012).
FIGURE 5. Nodular scleritis. A discrete raised conjunctival nodule with surrounding erythema.
History of the present illness Eye pain that is acute to subacute in onset along with redness, which is usually unilateral Physical examination Persons with episcleritis will have localized or diffuse conjunctival erythema that is tender to palpation (Figure 5); in contrast, simple conjunctivitis is more ‘‘irritating’’ rather than ‘‘tender to palpation’’ Scleritis is characterized by inflammation of the deeper eye structures and will have localized erythema, tenderness to palpation, and a bluish discoloration underlying it Treatment Patients should be referred to ophthalmology for treatment and management; artificial tears, steroid eye drops, oral nonsteroidal anti-inflammatory drugs (NSAIDs), and sometimes systemic immunosuppression are the treatments of choice Uveitis Definition Uveitis is an inflammatory disorder of the uveal tract that includes the iris, ciliary body, and choroid. It is classified as anterior, intermediate, posterior, or pan uveitis based on the portion of the eye that is involved. Anterior uveitis, also known as iritis, is the most common type that should be considered when a pediatric patient presents with an acute red eye, and therefore we will focus on that type or uveitis in this article. Uveitis occurs in 11% to 13% of all patients with juvenile idiopathic arthritis (JIA) and can cause significant ophthalmic morbidity (Tappeiner et al., 2015). It is more common in patients with pauciarticular JIA and those who are positive for antinuclear antibodies. The uveitis associated with JIA can be low grade and asymptomatic, and thus these patients require frequent routine eye examinations by an ophthalmologist. History of the present illness Acute or subacute onset severe photophobia, eye redness, and a ‘‘boring’’ type pain with blurry vision 6
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Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. Physical examination Diffuse conjunctival erythema that is most prominent near the cornea Direct and consensual photophobia (i.e., pain in the affected eye when light is shown in the normal eye) Most cases are unilateral, although uveitis can be bilateral Diagnostic tests If recurrent or severe disease is present, rule out infectious/inflammatory causes, including syphilis, sarcoidosis, Lyme disease, tuberculosis, and HLAB27 seropositivity Treatment If uveitis is suspected, the patient should be referred to an ophthalmologist for evaluation and treatment including topical steroids, cycloplegic drops, and systemic immunomodulators EYE INJURIES Corneal Abrasion Definition A corneal abrasion is an epithelial defect on the surface of the cornea that is most commonly associated with trauma. History of the present illness Acute-onset, severe eye pain associated with blunt trauma or rubbing of the eye Pain worsens with blinking Physical examination Diffuse mild conjunctival erythema, tearing Journal of Pediatric Health Care
FIGURE 6. A corneal abrasion with fluorescein staining under a Wood’s lamp.
Photo courtesy of Casey Beal, MD. This figure appears in color online at www.jpedhc.org. Pain improves with instillation of topical ophthalmic proparacaine drops in the clinic; these drops should never be provided to patients because they can lead to corneal melting if used frequently Evert the upper and lower eyelids to evaluate for foreign bodies Diagnostic tests Use a Wood’s lamp and fluorescein staining of the cornea to diagnose the abrasion and evaluate its extent (Figure 6) Treatment Treatment entails use of a topical antibiotic drop or ointment four times daily for 3 to 5 days; options include polymyxin B/trimethoprim, ciprofloxacin, moxifloxacin, erythromycin, or bacitracin ophthalmic drops or ointment
History of the present illness The inciting event usually can be recounted by the patient The speed and size of the foreign body are crucial for determining the object’s potential for damaging the eye; if it was a high-velocity object, such as a piece of metal from a circular saw, it is likely that it is more deeply embedded and therefore more difficult to remove than a low-velocity object, such as vegetative matter or dirt blown up in the wind Physical examination The foreign body usually can be seen easily on the surface of the cornea or conjunctiva (Figure 7) Evert the upper and lower eyelids to ensure that no other foreign bodies are present Treatment If a foreign body is seen, refer the patient to the emergency department or urgently to an ophthalmologist Subconjunctival Hemorrhage Definition A subconjunctival hemorrhage is rupture of a small conjunctival capillary with resultant bleeding into the subconjunctival space. Commonly, eye rubbing, cough, the Valsalva maneuver, or blunt trauma cause subconjunctival hemorrhages. These hemorrhages can be very alarming to patients and their family because of their size, color, and acute onset. However, they do not affect vision and do not cause any significant pain.
FIGURE 7. A corneal foreign body.
Follow-up should be scheduled for 48 hours to evaluate for improvement Patching the eye is not recommended Contact lenses should not be worn until the abrasion heals If an underlying infection is associated with the abrasion, the patient should be referred to ophthalmology Corneal and Conjunctival Foreign Bodies Definition Corneal and conjunctival foreign bodies become embedded in the conjunctival or corneal epithelium. Commonly seen foreign bodies include vegetative matter and metal shavings. www.jpedhc.org
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. -/- 2016
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FIGURE 8. Subconjunctival hemorrhage.
If the patient has sickle cell disease or trait, the sickling of the red blood cells in the anterior chamber of the eye can clog the drainage system of the eye and cause an acute rise in intraocular pressure, which can precipitate permanent vision loss Physical examination Blood, which may be seen in the anterior chamber of the eye overlying the iris, is usually settled inferiorly because of the effect of gravity
Photo courtesy of Phuchong Choksamai. q123rf.com. This figure appears in color online at www.jpedhc.org. History of the present illness A sudden onset localized area of subconjunctival blood Specifically inquire about trauma, coughing, or eye rubbing No photophobia, pain, or vision changes are present Physical examination A localized area of subconjunctival blood (Figure 8) that does not involve the cornea Treatment No treatment is required, although patients may use artificial tears for any discomfort If a child has recurrent or large subconjunctival hemorrhages, a bleeding disorder (Khaja, Pogrebniak, & Bolling, 2015) or nonaccidental trauma should be suspected Hyphema Definition A hyphema is defined as red blood cells that are present in the anterior chamber of the eye just posterior to the cornea. Most commonly, hyphemas are caused by blunt trauma; however, rarely, a hyphema can present spontaneously without a history of trauma, and this presentation raises concern for leukemia or juvenile xanthogranuloma (Samara et al., 2015). History of the present illness Inquire about a history of trauma and whether the patient has sickle cell disease 8
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Treatment All patients with hyphemas should be referred urgently to an ophthalmologist for further management and care with steroid and cycloplegic eyedrops. A main concern is the risk for recurrent hemorrhage as the blood clot begins to dissolve. Recurrent hemorrhage is most likely in the first 5 days after the injury, and thus patients should be instructed to avoid any strenuous activity, keep their head elevated, and avoid NSAIDs to reduce this risk. Ruptured Globe Definition A ruptured globe is the result of any breach in the structural integrity of the eye, including corneal or scleral full-thickness lacerations. A ruptured globe is the result of direct trauma to the eye. History of the present illness The speed, size, type, and shape of the projectile determines the extent of the injury Other associated head or facial injuries Physical examination If a ruptured globe is suspected based on history, it is important to avoid applying any pressure to the eye during the examination Signs of a ruptured globe include an irregularly shaped pupil, a shallow anterior chamber or exposed iris, or dark choroidal tissue showing through the white sclera Almost always, a significant decrease in visual acuity is found
Treatment If a ruptured globe is suspected, a Fox shield (i.e., a metal eye shield named for Sidney Fox, MD) should be taped across the eye to protect it without applying any pressure to the eye; a Styrofoam cup also can be used if a Fox shield is not available Journal of Pediatric Health Care
The patient should be directed to ingest nothing by mouth and should be sent directly to the nearest emergency department for emergent evaluation by an ophthalmologist for surgical repair CONCLUSION Patients with the chief symptom of a red eye are commonly encountered in the pediatric primary care setting, but with a focused history and examination, the diagnosis and management can be accomplished with confidence. Understanding the pathophysiology of each disease manifestation and when to utilize special tests such as fluorescein staining is essential to diagnosing and treating these patients. Certain signs that indicate that sight might be threatened are important to identify and require referral to an ophthalmologist. These signs include corneal abrasions, corneal opacities, recurrent or chronic symptoms, severe pain, photophobia, vision changes, or concern that the globe may be ruptured. In addition, topical anesthetic medication should never be provided to the patient, and topical corticosteroids should only be prescribed upon consultation with an ophthalmologist. With use of some simple techniques, pediatric patients presenting with a red eye can be fully evaluated in the primary care setting and treated or triaged with confidence. REFERENCES American Academy of Pediatrics. (2015). Gonococcal infections. In D. W. Kimberlin, M. T. Brady, M. A. Jackson & S. S. Long (Eds.), Red Book: 2015 Report of the Committee on Infectious Diseases (30th ed., pp. 356-367). Elk Grove Village, IL: American Academy of Pediatrics. Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: A systematic review of diagnosis and treatment. Journal of the American Medical Association, 310, 1721-1729. Bielory, B. P., O’Brien, T. P., & Bielory, L. (2012). Management of seasonal allergic conjunctivitis: Guide to therapy. Acta Ophthalmologica, 90, 399-407. Cheung, C. M., & Chee, S. P. (2012). Posterior scleritis in children: Clinical features and treatment. Ophthalmology, 119, 59-65. Gupta, N., Dhawan, A., Beri, S., & D’souza, P. (2010). Clinical spectrum of pediatric blepharokeratoconjunctivitis. Journal of the
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American Association for Pediatric Ophthalmology and Strabismus, 14, 527-529. Kaufman, H. E. (2011). Adenovirus advances: New diagnostic and therapeutic options. Current Opinion in Ophthalmology, 22, 290-293. Khaja, W. A., Pogrebniak, A. E., & Bolling, J. P. (2015). Combined orbital proptosis and exudative retinal detachment as initial manifestations of acute myeloid leukemia. Journal of the American Association for Pediatric Ophthalmology and Strabismus, 19, 479-482. LaMattina, K., & Thompson, L. (2014). Pediatric conjunctivitis. Disease-A-Month, 60, 231-238. Petersen, E. E., Staples, J. E., Meaney-Delman, D., Fischer, M., Ellington, S. R., Callaghan, W. M., & Jamieson, D. J. (2016). Interim guidelines for pregnant women during a Zika virus outbreak—United States, 2016. Morbidity and Mortality Weekly Report, 65, 30-33. Pinto, R. D., Lira, R. P., Abe, R. Y., Zacchia, R. S., Felix, J. P., Pereira, A. V., . Bonon, S. H. (2014). Dexamethasone/povidone eye drops versus artificial tears for treatment of presumed viral conjunctivitis: A randomized clinical trial. Current Eye Research, 40, 8870-8877. Rose, P. W., Harnden, A., Brueggemann, A. B., Perera, R., Sheikh, A., Crook, D., & Mant, D. (2005). Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: A randomised double-blind placebo-controlled trial. Lancet, 366, 37-43. Samara, W. A., Khoo, C. T., Say, E. A., Saktanasate, J., Eagle, R. C., Shields, J. A., & Shields, C. L. (2015). Juvenile xanthogranuloma involving the eye and ocular adnexa: Tumor control, visual outcomes, and globe salvage in 30 patients. Ophthalmology, 122, 2130-2138. Tappeiner, C., Klotsche, J., Schenck, S., Niewerth, M., Minden, K., & Heiligenhaus, A. (2015). Temporal change in prevalence and complications of uveitis associated with juvenile idiopathic arthritis: Data from a cross-sectional analysis of a prospective nationwide study. Clinical and Experimental Rheumatology, 33, 936-944. Teo, L., Mehta, J. S., Htoon, H. M., & Tan, D. T. (2012). Severity of pediatric blepharokeratoconjunctivitis in Asian eyes. American Journal of Ophthalmology, 153, 564-570. Wieringa, W. G., Wieringa, J. E., ten Dam-van Loon, N. H., & Los, L. I. (2013). Visual outcome, treatment results, and prognostic factors in patients with scleritis. Ophthalmology, 120, 379386. Wong, V. W., Lai, T. Y., Chi, S. C., & Lam, D. S. (2011). Pediatric ocular surface infections: A 5-year review of demographics, clinical features, risk factors, microbiological results, and treatment. Cornea, 30, 995-1002.
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