TREAT PEDIATRIC EYE CONDITIONS

1. 1 TREAT PEDIATRIC EYE CONDITIONS Unit 4: Part 1 Module 1

2. 2 REFERENCES Ophthalmology for the Primary Care Physician Toronto Sick Kids Manual Toronto Notes Lecture Notes From EO 012.01, 012.02, 012.03 Class handout

3. 3 DIFFERENTIAL DIAGNOSIS RED EYE Ophthalmia neonatorum Conjunctivitis (bacterial, viral or allergic) Traumatic injury (e.g., corneal abrasion) Corneal infection/keratitis Foreign body Glaucoma Uveitis (iritis)( anterior) Preseptal and orbital cellulitis

4. 4 ALGORHYTHM RED EYE DIFFERENTIAL DX Source FNIHB PEDIATRIC GuidelinesSource FNIHB PEDIATRIC Guidelines

5. 5 DANGER FEATURES- RED EYE Severe pain (unilateral) Photophobia Reduced visual acuity/ persistent blurring Reduced ocular movement Ciliary flush Irregular corneal light reflection

6. 6 DANGER FEATURES- RED EYE Pupil non-reactive to direct light Corneal epithelial defect/opacity Exophthalmos Worsening symptoms after 2-3 days of Rx of a simple conjunctivitis Compromised host - neonate, contact lens wearer, immuno-suppressed patient

7. 7 RED EYE - HISTORY An accurate history is very important History may point to a systemic illness such as juvenile rheumatoid arthritis, IBD, sarcoidosis or the possibility of trauma Do OPPQQRST of presenting S&S Ask the child (if of an appropriate age) about visual acuity, pain on movement of the eye and contact with chemical agents or makeup (the last of which might indicate allergic conjunctivitis)

8. 8 RED EYE- HISTORY Ask about preceding viral URTI (which would indicate infectious conjunctivitis) Inquire about contact with others with � pink eye� For newborns, inquire about the possibility of maternally acquired infections such as gonorrhea/chlamydia

9. 9 PHYSICAL FINDINGS Inspect both eyes for shape, symmetry Redness, swelling, drainage/crusting Carefully document any evidence of external trauma Assess visual acuity and pupillary reaction Examine the anterior segment of the globe with a small penlight, and use a fluorescent stain to assess for corneal abrasion or ulcers Assess ocular mobility by checking range of movement Assess visual acuity and pupillary reaction, essential for measuring improvement or deterioration When in doubt about the diagnosis or if there is significant associated ocular trauma or decreased visual acuity, urgent consultation with a physician and referral to an ophthalmologist is indicated Assess visual acuity and pupillary reaction, essential for measuring improvement or deterioration When in doubt about the diagnosis or if there is significant associated ocular trauma or decreased visual acuity, urgent consultation with a physician and referral to an ophthalmologist is indicated

10. 10 CASE STUDY 10 day old female infant 1 day Hx. of red, watery eyes No cough , no fever Born at term gestation, healthy pregnancy Birth weight 3238 gms, SVD, no complications No one else ill at home Additional history onset, progression ?fever, URI S&S, nasal/ear discharge Eyes sticky, stuck together, crusting Additional history onset, progression ?fever, URI S&S, nasal/ear discharge Eyes sticky, stuck together, crusting

11. 11 CASE STUDY Physical Examination T � 37.2, HR 120, RR 40 Eyes- bilateral conjunctival injection, small amount purulent discharge, bilateral red reflexes present Rest of CPX is normal

12. 12 CASE STUDY Differential diagnosis Laboratory tests Chemical conjunctivitis secondary to eye antibiotic prophylaxis at birth e.g silver nitrate, Ilyotocin Viral/bacterial conjunctivitis Trauma Nasolacrimal duct obstruction (dacryostenosis) Culture of discharge for C&S, chlamydia swab, gram stain Chemical conjunctivitis secondary to eye antibiotic prophylaxis at birth e.g silver nitrate, Ilyotocin Viral/bacterial conjunctivitis Trauma Nasolacrimal duct obstruction (dacryostenosis) Culture of discharge for C&S, chlamydia swab, gram stain

13. 13 OPHTHALMIA NEONATORUM Moderate -Severe bacterial conjunctivitis in newborns <28 days of age This condition must be differentiated from the more common mild conjunctivitis

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15. 15 OPHTHALMIA NEONATORUM Causes - Generally acquired from the maternal genital tract - Bacterial organisms include Chlamydia and Neisseria gonorrhea - Chlamydial infection is the more common cause of neonatal conjunctivitis - Less commonly, Hemophilus strains, Staphylococcus aureus, Streptococcus pneumoniae and other gram-negative organisms may be involved Herpes is another potential cause of keratoconjunctivitis and is Dx by finding a dendritic ulcer upon Fluorescein staining the eye With herpes d/c is clear, injection of the conjunctiva is moderate, lid swelling minimal, unilateral eye involvementHerpes is another potential cause of keratoconjunctivitis and is Dx by finding a dendritic ulcer upon Fluorescein staining the eye With herpes d/c is clear, injection of the conjunctiva is moderate, lid swelling minimal, unilateral eye involvement

16. 16 OPHTHALMIA NEONATORUM History- depends on causative organism Gonorrhea - Generally presents early (day 3-5 of life) - Should be considered in any infant who presents with conjunctivitis at less than 2 weeks of age

17. 17 OPHTHALMIA NEONATORUM Chlamydia Infection - Children present with a history of eye redness and discharge after incubation period of 1-2 weeks - Should be considered in any child who presents with conjunctivitis in the first 3 months of life and who does not respond to usual topical antibiotics for mild conjunctivitis

18. 18 OPHTHALMIA NEONATORUM Physical Findings - The child may appear severely ill, but the physical findings are generally limited to the eye examination: - Edema or erythema of the conjunctiva - Purulent secretion - Eyelids may be stuck together secondary to the purulent secretions

19. 19 OPHTHALMIA NEONATORUM Differential Diagnosis - Viral/chemical/ conjunctivitis - Trauma - Nasolacrimal duct obstruction (dacryostenosis)

20. 20 OPHTHALMIA NEONATORUM Diagnostic Tests - Swab eyes/nasopharynx for culture and sensitivity, N. gonorrhoeae and Chlamydia Gram stain- for gonorrhea - It is important to rule out chlamydial infection by means of a Chlamydia antigen swab

21. 21 OPHTHALMIA NEONATORUM Management -Prevention - Prevention of perinatally acquired infections through prenatal screening and through STD control by appropriate follow-up of infected mother and her partner - Routine prophylaxis with erythromycin ointment (Ilotycin; for all newborns at birth

22. 22 OPHTHALMIA NEONATORUM Treatment for potential chlamydia infection if gram stain negative for GC � start: - Topical erythromycin eye ung tid Erythromycin ethylsuccinate suspension (EES-200), 40-50 mg/kg daily, divided qid, PO for 14-21 days Refer all cases of Chlamydia infection to ophthalmology if there is no improvement after 2 or 3 days of oral treatment Treat mother and partners Topical erythromycin ointment alone is not effective in eliminating nasopharyngeal colonization Oral therapy reduces risk of chlamydia pneumonitis by eradicating nasopharyngeal colonization Topical erythromycin ointment alone is not effective in eliminating nasopharyngeal colonization Oral therapy reduces risk of chlamydia pneumonitis by eradicating nasopharyngeal colonization

23. 23 OPHTHALMIA NEONATORUM Refer all suspected cases of gonorrheal ophthalmia to a Ophthalmology immediately The child must usually be admitted to hospital for IV administration of antibiotics � ceftriaxone Assess child for other STD/STI e.g. chlamydia, syphilis Treat mother and partner(s) Ocular lavage with normal saline may be beneficialOcular lavage with normal saline may be beneficial

24. 24 OPHTHALMIA NEONATORUM Complications - Gonorrheal conjunctivitis (also known as GC conjunctivitis) may be fulminant, leading rapidly to extensive orbital infection and possibly blindness - Systemic infections, including blood, joint and CNS infections, may occur secondary to N. gonorrhoeae infection

25. 25 CASE STUDY - RESOLUTION Gram stain negative for GC Empiric Rx with oral erythromycin x 14 days Swab confirmed chlamydia infection Follow up swab post Rx

26. 26 NASOLACRIMAL DUCTOBSTRUCTION �DACRYOSTENOSIS A congenital disorder of the lacrimal system characterized by blockage of the nasolacrimal duct Results in excessive tearing and mucopurulent discharge from the affected eye The condition occurs in approximately 2% to 6% of newborns Onset is usually within the first few weeks of life

27. 27 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS Cause Persistence of a membrane at the lower end of the nasolacrimal duct results in incomplete canalization of the duct and its consequent obstruction

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29. 29 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS History And Physical Findings - Tearing within the affected eye - Pooling or puddling of tears - Epiphora (frank overflow of tears) - Accumulation of mucoid or mucopurulent discharge in the affected eye, which results in crusting (usually evident upon awakening)

30. 30 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS History And Physical Findings - Erythema or maceration of the skin under the eye - Expression of clear fluid or mucopurulent discharge which may be intermittent or continuous over several months URTI may exacerbate the condition - Usually unilateral but may be bilateral - Conjunctival erythema and irritation minimal Expression of clear fluid or mucopurulent discharge when the area of the nasolacrimal sac is massaged, which may be intermittent or continuous over several monthsExpression of clear fluid or mucopurulent discharge when the area of the nasolacrimal sac is massaged, which may be intermittent or continuous over several months

31. 31 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS Complications Dacryocystitis: Pericystitis: - Mucocele: a bluish, subcutaneous mass below the medial canthal tendon - Periorbital cellulitis: inflammation around the ipsilateral eye (this is an eye emergency) Dacryocystitis: inflammation of the nasolacrimal sac, accompanied by edema, erythema and tenderness of the skin over the area of the affected duct (acute or chronic) - Pericystitis: inflammation of the tissues surrounding the affected duct - Mucocele: a bluish, subcutaneous mass below the medial canthal tendon - Periorbital cellulitis: inflammation around the ipsilateral eye (this is an eye emergency) Dacryocystitis: inflammation of the nasolacrimal sac, accompanied by edema, erythema and tenderness of the skin over the area of the affected duct (acute or chronic) - Pericystitis: inflammation of the tissues surrounding the affected duct - Mucocele: a bluish, subcutaneous mass below the medial canthal tendon - Periorbital cellulitis: inflammation around the ipsilateral eye (this is an eye emergency)

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33. 33 NASOLACRIMAL DUCTOBSTRUCTION -DACRYOSTENOSIS Diagnostic Tests - Eye swab for culture and sensitivity (if purulent discharge present) Management - In 90% of cases, the condition resolves, with conservative management, once the child reaches 1 year of age. - Monitor for and prevent complications

34. 34 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS Nonpharmacologic Interventions - Provide reassurance to parents or caregiver - Offer support and encouragement, as condition may take many months to resolve - Recommend nasolacrimal massage two or three times daily, followed by cleansing of the eyelid with warm water - Suggest gentle massage of lacrimal sac toward the nose, to clear the passage - Teach parents or caregiver the signs and symptoms of complications, and instruct them to report any that occur

35. 35 http://www.academy.org.uk/tutorials/dilate4.jpg Copyright Dr.D. Austenhttp://www.academy.org.uk/tutorials/dilate4.jpg Copyright Dr.D. Austen

36. 36 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS Pharmacologic Interventions Topical antibiotics for mucopurulent drainage i.e. Erythromycin 0.5% eye ointment (Ilotycin) hs

37. 37 NASOLACRIMAL DUCT OBSTRUCTION -DACRYOSTENOSIS Refer if the condition has not responded to conservative management by the time the child reaches 6 months of age or any time there are complications (e.g., dacryocystitis, preseptal /orbital cellulitis A surgery consult may be necessary for lacrimal probing, which may be repeated once or twice Definitive surgery is indicated if lacrimal probing (performed up to three times) fails to resolve the problem

38. 38 CASE HISTORY 10 month old boy brought in by MOM Concerned that every time son looks to the side his eyes seem crossed No other eye s&S Otherwise child appears well and is growing/developing normally

39. 39 CASE HISTORY EXAMINATION OF EYES Eyes appear widely spaced but aligned symmetrically Prominent epicanthal folds No S&S of inflammation/infection Bilateral red reflex present PERRLA EOM�s normal

40. 40 CASE HISTORY What conditions can make eyes appear to be crossed? What tests can be done in an office setting to evaluate for crossed eyes in a child? Which infants with crossed eyes need referral for evaluation and RX?

41. 41 STRABISMUS An abnormality in the alignment of the eyes The classification of strabismus is complex On an etiologic basis, it may be paralytic or non-paralytic It can also be classified as congenital or acquired, intermittent or constant, or convergent or divergent

42. 42 STRABISMUS Pathogenesis - When the eyes are positioned so that an image falls on the fovea (the area of best visual acuity) of one eye, but not the other, the second eye will deviate so that the image falls on it�s fovea as well - This deviation may be up, down, in or out and results in strabismus. Early recognition and treatment are important for the development of both normal binocular vision and good cosmetic results. Persistent, untreated strabismus may lead to decreased visual acuity of the deviating eye. For best results, strabismus must be treated before the child reaches 5 years of age. Early recognition and treatment are important for the development of both normal binocular vision and good cosmetic results. Persistent, untreated strabismus may lead to decreased visual acuity of the deviating eye. For best results, strabismus must be treated before the child reaches 5 years of age.

43. 43 STRABISMUS Patterns of Deviation - Esotropia: both eyes converge medially (crossed eyes) - Esotrophia: one eye deviates medially - Exotrophia: one eye deviates laterally - Hypertrophia: one eye deviates upward - Hypotrophia: one eye deviates downward

44. 44 MAIN TYPESSTRABISMUS Heterophoria - Intermittent (latent) tendency to misalignment. - Eyes deviate only under certain conditions (e.g., stress, fatigue, illness) - Common - May be associated with transient double vision, headaches, eye strain

45. 45 MAIN TYPES STRABISMUS Heterotropia - Constant misalignment of eyes - Occurs because normal fusional mechanisms are unable to control eye deviation - Child is unable to use both eyes to fixate on an object and learns to suppress the image in the deviating (non-fixating) eye

46. 46 MAIN TYPES STRABISMUS Heterotropia - Alternating: child uses either eye for fixating and the other eye deviates - Vision develops normally in both eyes because there is no preference for fixation - Consistent: one eye is used consistently for fixating, and the other eye consistently deviates - Child is prone to defective development of vision in the deviating eye (because of constant suppression of the visual image)

47. 47 CAUSES OF STRABISMUS Paralytic - Weakness or paralysis of one or more ocular muscles - Deviation is asymmetric - Congenital: secondary to developmental defect in muscle or nerves or to congenital infection - Acquired: due to extraocular nerve palsies; indicates a serious underlying problem (e.g., fracture of facial bone, CNS tumor, neurodegenerative disease, myasthenia gravis, CNS infection)

48. 48 CAUSES OF STRABISMUS Non-paralytic - Most common type of strabismus - Extraocular muscles and the nerves that control them are normal - Occasionally, this form may be secondary to underlying ocular or visual defects such as cataracts or refraction errors - Overall, seen in 3% of children

49. 49 CAUSES OF STRABISMUS Pseudostrabismus - Young infants have a broad nasal bridge; therefore, less of the inner eye is seen, which may give the impression of squinting - Intermittent eye convergence (crossed eyes) in infants 3-4 months of age is usually normal but should be monitored. If it persists, the child should be evaluated by a physician

50. 50 STRABISMUS History - Family history (about 50% of cases are hereditary) - Constant or variable squint in one or both eyes - Squinting worse with fatigue or stress - Child tilts head or closes one eye (compensatory mechanisms for weak eye)

51. 51 STRABISMUS Physical Exam -assess the following: - Observe eyes for symmetry of position - Extraocular eye movements (by having child visually follow an object): watch for asymmetry of movement - Visual acuity (with Snellen or similar chart) - Assess alignment with the following two main techniques.

52. 52 STRABISMUS Assessment Techniques to assess alignment - Corneal Light Reflex Test (Hirschberg Test) - Direct a small, focal light toward the child's face, and observe the reflections in each cornea - If the eyes are aligned, the reflection should be on symmetric points of the corneas

53. 53 STRABISMUS Cover-Uncover Test - Child is asked to fix gaze on an object (toy, colored yarn) - Examiner covers an eye - Allowing time for the eyes to drift - Uncover the eye - Observe eye movements of the eye just uncovered - Normal alignment: no movement of either eye - Repeat procedure on opposite eye

54. 54 STRABISMUS Abnormal Cover/Uncover test responses - Phoria: - when deviating eye is covered, it tends to move - when the deviating eye is uncovered, the examiner can observe the eye resume it�s former position - movement is seen on uncovering the deviating eye

55. 55 STRABISMUS Abnormal Cover/Uncover test responses - Tropia: - when fixating eye is covered, the deviating (uncovered) eye moves - movement is seen on covering the deviating eye

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59. 59 STRABISMUS Complications - Amblyopia

60. 60 STRABISMUS Management All children with fixed (paralytic) strabismus need urgent referral to ophthalmology particularly if the paralytic strabismus is acquired - A young infant with intermittent, non-paralytic strabismus may be kept under observation until he or she reaches 6 months of age, when referral may become necessary if no resolution occurs Early referral and treatment give the best chance for good vision in both eyes and good ocular alignment Early referral and treatment give the best chance for good vision in both eyes and good ocular alignment

61. 61 CASE RESOLUTION Boys eyes appear to deviate Corneal light reflex and cover /uncover test were normal Wide nasal bridge and prominent epicanthal folds noted No family hx. of eye problems What is diagnosis and management? DX: Pseudostrabismus, reassurance to mother than problem is benign and related to facial features and will resolve as child growsDX: Pseudostrabismus, reassurance to mother than problem is benign and related to facial features and will resolve as child grows

62. 62 CONGENITAL CATARACTS Incidence is 1/250 Present as leukocoria ( white pupil) Partial or complete Unilateral Often associated with other ocular anomalies and developmental disabilities Congenital cataracts present with leucocoria and are often noticed very early by the parents as they feed their child. the cataract may be less than complete and not interfere significantly with visual development... More common situation is a complete opacity of the lens These must be operated on immediately to clear the visual axis and a contact lens or spectacle correction used to correct for the resultant high hyperopia. Because of the rapid growth of the eye during the first two years of life, and the resultant change in refractive power of the eye, intraocular lenses are not currently recommended for infants. Aggressive occlusion therapy is always necessary to force use of the involved eye, and patching is frequently continued to the age of eight years. Even with early surgery and aggressive optical correction and patching therapy, the visual prognosis in an eye harbouring a uniocular congenital cataract is quite poor Past the age of three months cataract surgery is not recommended at all because the visual prognosis is so grim from the resultant deprivational amblyopia.   Congenital cataracts present with leucocoria and are often noticed very early by the parents as they feed their child. the cataract may be less than complete and not interfere significantly with visual development... More common situation is a complete opacity of the lens These must be operated on immediately to clear the visual axis and a contact lens or spectacle correction used to correct for the resultant high hyperopia. Because of the rapid growth of the eye during the first two years of life, and the resultant change in refractive power of the eye, intraocular lenses are not currently recommended for infants. Aggressive occlusion therapy is always necessary to force use of the involved eye, and patching is frequently continued to the age of eight years. Even with early surgery and aggressive optical correction and patching therapy, the visual prognosis in an eye harbouring a uniocular congenital cataract is quite poor Past the age of three months cataract surgery is not recommended at all because the visual prognosis is so grim from the resultant deprivational amblyopia.

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64. 64 AMBLYOPIA Definition - Poor vision not correctable with eyeglasses - No known organic cause Epidemiology - Prevalence: 2-4% of Children - Occurs in children up to age 6 years

65. 65 AMBLYOPIA Etiologies - Strabismus (most common cause of amblyopia) - Misalignment of eyes - Anisometropia (Refractive Amblyopia) - Large difference in Refractive Error between eyes

66. 66 AMBLYOPIA Deprivation Amblyopia - Congenital Cataract - Retinoblastoma - Corneal scarring - Vitreous opacity - Severe Ptosis - Optic atrophy - Iatrogenic patching

67. 67 AMBLYOPIA Pathophysiology - Occurs in developmentally immature eye - During first 6 months of life acuity normally improves rapidly 20/400 => 20/80 - Eye fully matures by age 9 years Normal maturity - Requires clear, equal, aligned image for each eye

68. 68 AMBLYOPIA Conflicting data with - Strabismus (2 competing images) - Anisometropia (1 clear, 1 blurred image) Brain suppresses information from the "bad" eye Continued suppression leads to permanent vision loss Adults unable to suppress different images Adults experience DiplopiaAdults unable to suppress different images Adults experience Diplopia

69. 69 AMBLYOPIA Screening - Visual Acuity testing first done age 3 - Exam for associated ocular disease Management: Force child to use amblyopic eye - Patch "good", dominant eye (usual course) - Atropine to blur dominant eye Prognosis - Amblyopia irreversible after age 9 years

70. 70 EYE INJURIES Review eye injuries and foreign body from EO012.03 No changes for Pediatrics Infants get corneal abrasions from scratching own eye accidentally- keep nails short Sunconjunctival hemorrhage � think trauma- child abuse--? �shaken baby syndrome�

71. 71 EYE INJURIES Non Accidental Trauma/Shaken Baby Syndrome - Hallmark of diagnosis is retinal hemorrhage - Presence and severity of hemorrhages correlates well with level of brain injury - History of injury often vague and not well correlated with extent of injuries - Other findings associated with non- accidental injury include ecchymosis of lids, sub-conjunctival hemorrhages, and hyphema

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73. 73 PRESEPTAL CELULITIS Infection of the tissues anterior to the orbital septum Bacteria gain access to the tissues around the orbit through trauma, skin pustules, insect bites, URTIs, infections of the teeth and occasionally sinusitis Preseptal cellulitis and orbital cellulitis may coexist in the same person Preseptal cellulitis and orbital cellulitis may coexist in the same person

74. 74 PRESEPTAL CELLULITIS Commonest organisms Bacterial infection of the deep tissues of the posterior orbital space Usually a serious complication of acute sinusitis or other facial infection or trauma. Streptococcus pneumoniae Hemophilus influenzae (non-typable) Branhamella catarrhalis Staphylococcus (less common) Bacterial infection of the deep tissues of the posterior orbital space Usually a serious complication of acute sinusitis or other facial infection or trauma. Streptococcus pneumoniae Hemophilus influenzae (non-typable) Branhamella catarrhalis Staphylococcus (less common)

75. 75 PRESEPTAL CELLULITIS Etiology trauma to eye area insect bites to the eye area stye, chalazion, meibomitis frequently there is no antecedent history - systemic features, such as fever and irritability Examination of the child may be very difficult, because of edema, pain and anxietyExamination of the child may be very difficult, because of edema, pain and anxiety

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77. 77 PRESEPTAL CELLULITIS Signs/Symptoms - Child may be febrile, ill-looking - No pain on movement of the eye - Normal visual acuity (if it can be assessed), EOM�s, pupils - Orbital edema and erythema - Discharge may be present

78. 78 PRESEPTAL CELLULITIS Differential Diagnosis - Orbital cellulitis COMPLICATIONS Orbital cellulitis - Diagnostic Tests - Swab any discharge for culture and sensitivity

79. 79 PRESEPTAL CELLULITIS Consult a physician for all cases Nonpharmacologic Interventions - Warm compresses qid - Explain to parents or caregiver the nature, course, expected treatment and outcomes of the disease - Counsel parents or caregiver about appropriate use of medications (dose, route, side effects) . .

80. 80 PRESEPTAL CELLULITIS Pharmacologic Interventions Topical antibiotic ointment e.g. sodium sulamyd Systemic antibiotics � Clavulin Follow up in 24-48 hours to assess response Advise immediate return if infection spreading

81. 81 ORBITAL CELLULITIS Bacterial infection of the deep tissues of the posterior orbital space Orbital cellulitis and preseptal cellulitis may coexist in the same person Usually a serious complication of acute sinusitis or other facial /dental infection or trauma Streptococcus pneumoniae Hemophilus influenzae (non-typable) Branhamella catarrhalis Staphylococcus (less common) Preceding history of acute sinusitis (although such a history is not often present in young children, i.e., <6 years old) Often no obvious antecedent event in children Preceding history of acute sinusitis (although such a history is not often present in young children, i.e., <6 years old) Often no obvious antecedent event in children

82. 82 ORBITAL CELLULITIS Symptoms/Signs Child may appear mildly ill to moribund, depending on severity of infection Fever � low-high grade Adenopathy - Inflammation and swelling of the surrounding orbital tissues and eyelids - Exophthalmos (proptosis) may be present in severe cases

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84. 84 ORBITAL CELLULITIS Symptoms/Signs ( continued) - Mild to moderate ophthalmoplegia (inability to move eye) Mild to significant decrease in visual acuity Papilledema Assess for any neurological complications and level of consciousness (see pediatric Glasgow coma scale The significant eye findings e.g. decreased VA, proptois, inability to move eye , pain on eye movement etc. helps differentiate orbital cellulitis from prreseptal cellulitis

85. 85 ORBITAL CELLULITIS Complications - Intracranial cavernous sinus thrombosis (associated with signs of CNS irritation, puffiness of the face, deterioration in level of consciousness) - Orbital or subperiosteal abscess - Infection of other orbital structures - Meningitis - Intracranial abscess - Blindness

86. 86 ORBITAL CELLULITIS Diagnostic Tests Swab any discharge for culture and sensitivity before starting antibiotics Blood cultures x 3 CT of orbit

87. 87 ORBITAL CELLULITIS Management Urgent MD consult Admit/Urgent referral to hospital - IV antibiotics should be started urgently - Discuss choice of antibiotics with a physician - Antibiotic of choice: cefuroxime (Zinacef)

88. 88 REFRACTIVE ERRORS Normal vision - Develops over time from birth reaching maturity at age 9 Visual acuity in children - Birth 20/200 - Infants 6-12 months = 20/120 - 1-2 years = 20/80 2- 4 years = 20/30 Vision develops from experience At Birth � macula not fully formed, light perception only Central visual acuity evolves from 20/200 at birth ,20/20 by age 5, although vision continues to be perfected up to age 9 VA in newborn assessed by presence of red reflex, pupillary reaction, blink reaction to bright light and blink response to object moving toward eyes Age 2-3 weeks newborn can fix eyes on an object in the midline Age 5-6 weeks can follow a face/object with eyes Age 3-4 months, macula developed, eyes converge, baby begins to reach for objects, eye/hand co-ordination and ability to focus well are accomplished Vision develops from experience At Birth � macula not fully formed, light perception only Central visual acuity evolves from 20/200 at birth ,20/20 by age 5, although vision continues to be perfected up to age 9 VA in newborn assessed by presence of red reflex, pupillary reaction, blink reaction to bright light and blink response to object moving toward eyes Age 2-3 weeks newborn can fix eyes on an object in the midline Age 5-6 weeks can follow a face/object with eyes Age 3-4 months, macula developed, eyes converge, baby begins to reach for objects, eye/hand co-ordination and ability to focus well are accomplished

89. 89 REFRACTIVE ERRORS At risk children for refractive errors; - Down�s syndrome - premature babies - offspring of parents with severe refractive errors

90. 90 REFRACTIVE ERRORS Myopia - presents in first decade- age 8 - commonest childhood refractive error - squinting to improve distance vision - headaches are a common compliant - globe too long, image falls in front of retina - blurring of distant vision - corrected with concave (-) lenses

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92. 92 REFRACTIVE ERRORS Hyperopia - may be developmental or acquired - globe too short or refractive mechanisms weak - image falls behind retina without accommodation - near vision is blurred - children usually do not require glasses because they have sufficient accommodative ability to focus image on retina - diminishes around age 8 - corrected with convex (+) lenses Newborns are hyperopic at birth but have great ability to accommodate to effect near visionNewborns are hyperopic at birth but have great ability to accommodate to effect near vision

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94. 94 REFRACTIVE ERRORS Astigmatism - light rays not uniformly refracted in all meridians - due to nonspherical shape of cornea or of lens - may lead to amblyopia if severe and not corrected at an early age - corrected with cylindrical lenses

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97. 97 CONGENITAL GLAUCOMA Associated with other congenital syndromes such as Down�s Turner�s S&S � Decreased vision, photophobia Increased tearing during daylight or in bright light, Corneas hazy/cloudy, decreased corneal reflex Referral to Ophthalmology Medications, surgeries Good prognosis if picked up early, but is a lifelong condition

98. 98 RETINOBLASTOMA The average age of children with retinoblastoma is 18 months. More than 75% of children are first noted to have a �white-pupil� leukocoria, or strabismus or a red and painful eye (usually due to glaucoma). CAT scans, and ultrasound can diagnose intraocular retinoblastomas in over 95% of cases. Retinoblastoma is the most common intraocular cancer of childhood the first cancer to be directly associated with a genetic abnormality (Deletions or mutation of the q14 band of chromosome Retinoblastoma can occur sporadically (without a family history) or it can be inherited (with a family history). If a genetic mutation is found there is a 45-50% chance that the parents will have another child with retinoblastoma. If there is no family history and no mutation is found, the risk of having a second child with retinoblastoma is 2-5%. In order to be 100% correct all the time, eye-cancer specialists would have to perform a biopsy. Biopsies of intraocular retinoblastoma are avoided in order to prevent cancer cells from spreading outside of the eye.  Retinoblastoma is the most common intraocular cancer of childhood the first cancer to be directly associated with a genetic abnormality (Deletions or mutation of the q14 band of chromosome Retinoblastoma can occur sporadically (without a family history) or it can be inherited (with a family history). If a genetic mutation is found there is a 45-50% chance that the parents will have another child with retinoblastoma. If there is no family history and no mutation is found, the risk of having a second child with retinoblastoma is 2-5%. In order to be 100% correct all the time, eye-cancer specialists would have to perform a biopsy. Biopsies of intraocular retinoblastoma are avoided in order to prevent cancer cells from spreading outside of the eye.

99. 99 RETINOBLASTOMA Over the last 30 years, treatment has evolved from simple enucleation (removal of the eye), to eye-sparing radiotherapy, and more recently to chemotherapy-based multimodality therapy. Though retinoblastomas are usually cured by radiation, investigators have suggested that irradiation and chemotherapy increases the risk of developing second cancers later in life Which children are at risk to develop these second cancers?Children with retinoblastoma in both eyes.Children with a family history of retinoblastoma.Children with a history of multiple tumors in their eye.Children who are diagnosed with their original retinoblastoma at less than one year of age.Children who were treated with radiation at less than one year of age. Genetic testing available for familiesWhich children are at risk to develop these second cancers?Children with retinoblastoma in both eyes.Children with a family history of retinoblastoma.Children with a history of multiple tumors in their eye.Children who are diagnosed with their original retinoblastoma at less than one year of age.Children who were treated with radiation at less than one year of age. Genetic testing available for families