Red eye resident survival guide (pediatrics)

Jump to navigation Jump to search


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Synonyms and Keywords: Horner syndrome; Pupil; dorsal midbrain syndrome; paradoxic pupils; third nerve palsy.

Red eye resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Red eye is one of the most common ophthalmologic conditions in the primary care setting in children. A detailed history as Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial., baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (uni- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for a general practitioner from diseases calling for an elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.[1]


Causes

Life Threatening Causes

Life-threatening causes include conditions that could lead to death or permanent disability within 24 hours if left untreated.[2]

  • globe ruptures or perforations
  • intraocular infections
  • Carotid–cavernous sinus fistula

Common Causes[3][4][5][6][7]

infectious[8]



noninfectious

FIRE: Focused Initial Rapid Evaluation

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.[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], or eye emergencies requiring urgent ophthalmic surgery.[24][25]


Complete Diagnostic Approach

Localized, diffused and perikeratic injection. [26]

Shown below is an algorithm summarizing the diagnosis of [[red eye]] according to the [ Nelson Essentials of Pediatrics .] guidelines. [27]

Age Group Common Etiology
Neonates* < 24 hrs Chemical conjunctivitis
< 1 week Neisseria gonorrhea
1-2 wks Chlamydia trachomatis
Infants and Toddlers Without otitis Haemolphilus. influenzae, Streptococcus pneumoniae
With otitis H. influenzae
School Age Children 1-5 years Herpes simplex virusVaricella-zoster
School Age Children and Adolescents Viral conjunctivitisAllergic conjunctivitis

Treatment


  • Shown below is an algorithm summarizing the treatment of [[Red eye ]] according to the [American journal of medicine ][6] guidelines.


 
 
 
 
 
 
 
 
 
Patient with red eye
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergency
 
 
 
 
 
Acute conjunctivitis
 
 
 
 
 
 
Chronic blepharitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urgent ophthalmic surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eyelid hygiene
Topical antibiotics
•Oral tetracycline or doxycycline
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe
 
 
 
 
Mild
 
 
 
 
Moderate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Viral
 
Bacterial
 
 
Over the counter
Antihistamine
Vasocontricter agent or with more effective second generation topical histamine H1 receptor antagonist
 
 
 
 
Antiinflammatory agents (eg. topical cyclosporine)
Topical corticosteroids
Systemic omega 3 fatty acids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hand washing and meticulous hygiene or normal saline spray
 
Ophthalmic antibiotic such as gentamycin
 
 
 


  • Good hygiene, such as meticulous hand washing, is important in decreasing the spread of acute viral conjunctivitis.[28][29]
  • Any ophthalmic antibiotic may be considered for the treatment of acute bacterial conjunctivitis because they have similar cure rates.[30] [31]
  • Mild allergic conjunctivitis may be treated with an over-the-counter antihistamine/vasoconstrictor agent, or with a more effective second-generation topical histamine H1 receptor antagonist.[32]
  • [33]Anti-inflammatory agents (e.g., topical cyclosporine [Restasis]), topical corticosteroids, and systemic omega-3 fatty acids are appropriate therapies for moderate dry eye.
  • Patients with chronic blepharitis who do not respond adequately to eyelid hygiene and topical antibiotics may benefit from an oral tetracycline or doxycycline.

Do's

    • Be caution when prescribing steroids: you should exclude the possibility of herpetic keratitis.
    • Ocular pain[35][36] and change in vision are two extremely specific warning signs of eye pathology, and unless doctor are absolutely certain of a benign diagnosis doctor must refer him for ophthalmological assessment if he has these.

Don'ts

  • Don’t miss the pupillary exam in the pediatric population is a vital part of any clinician's workup. In the right clinical setting, pupillary abnormalities such as anisocoria, light-near dissociation, an afferent pupillary defect, and paradoxic pupillary constriction in the dark can be red flags that trigger further examination and workup. Through both careful physical examination and detailed history taking and observation, potentially vision- and life-threatening conditions can be detected So eye emergencies requiring urgent ophthalmic surgery.[1]

.

References

  1. 1.0 1.1 Lambert, Jennifer E.; Christiansen, Stephen P.; Peeler, Crandall E. (2019). "Don't Miss This! Red Flags in the Pediatric Eye Exam: Pupils". Journal of Binocular Vision and Ocular Motility. 69 (3): 102–105. doi:10.1080/2576117X.2019.1609893. ISSN 2576-117X.
  2. Wirbelauer C (2006). "Management of the red eye for the primary care physician". Am J Med. 119 (4): 302–6. doi:10.1016/j.amjmed.2005.07.065. PMID 16564769 PMID: 16564769 Check |pmid= value (help).
  3. Frings A, Geerling G, Schargus M (2017) Red Eye: A Guide for Non-specialists. Dtsch Arztebl Int 114 (17):302-312. DOI:10.3238/arztebl.2017.0302 PMID: 28530180 : 28530180
  4. Pflipsen M, Massaquoi M, Wolf S (2016) Evaluation of the Painful Eye. Am Fam Physician 93 (12):991-8. PMID: 27304768 PMID: 27304768
  5. Wong MM, Anninger W (2014) The pediatric red eye. Pediatr Clin North Am 61 (3):591-606. DOI:10.1016/j.pcl.2014.03.011 PMID: 24852155 PMID: 24852155
  6. 6.0 6.1 Wirbelauer C (2006) Management of the red eye for the primary care physician. Am J Med 119 (4):302-6. DOI:10.1016/j.amjmed.2005.07.065 PMID: 16564769 PMID: 16564769
  7. Ismail, M.; Adel, A. (2020). "Prediction of α -decay chains and cluster radioactivity of 121300–304 and 122302–306 isotopes using the double-folding potential". Physical Review C. 101 (2). doi:10.1103/PhysRevC.101.024607. ISSN 2469-9985. line feed character in |title= at position 15 (help)
  8. Høvding, Gunnar (2008). "Acute bacterial conjunctivitis". Acta Ophthalmologica. 86 (1): 5–17. doi:10.1111/j.1600-0420.2007.01006.x. ISSN 1755-375X.
  9. Petersen EE, Staples JE, Meaney-Delman D, Fischer M, Ellington SR, Callaghan WM | display-authors=etal (2016) Interim Guidelines for Pregnant Women During a Zika Virus Outbreak--United States, 2016. MMWR Morb Mortal Wkly Rep 65 (2):30-3. DOI:10.15585/mmwr.mm6502e1 PMID: 26796813 PMID: 26796813
  10. Singh, Gagandeep; Galvis, Alvaro; Das, Samrat (2018). "Case 1: Eye Discharge in a 10-day-old Neonate Born by Cesarean Delivery". Pediatrics in Review. 39 (4): 210–210. doi:10.1542/pir.2016-0090. ISSN 0191-9601.
  11. Azari, Amir A.; Barney, Neal P. (2013). "Conjunctivitis". JAMA. 310 (16): 1721. doi:10.1001/jama.2013.280318. ISSN 0098-7484.
  12. Bielory, Brett P.; O’Brien, Terrence P.; Bielory, Leonard (2012). "Management of seasonal allergic conjunctivitis: guide to therapy". Acta Ophthalmologica. 90 (5): 399–407. doi:10.1111/j.1755-3768.2011.02272.x. ISSN 1755-375X.
  13. Cheung, Chui Ming Gemmy; Chee, Soon-Phaik (2012). "Posterior Scleritis in Children: Clinical Features and Treatment". Ophthalmology. 119 (1): 59–65. doi:10.1016/j.ophtha.2011.09.030. ISSN 0161-6420.
  14. Gupta, Noopur; Dhawan, Anuradha; Beri, Sarita; D'souza, Pamela (2010). "Clinical spectrum of pediatric blepharokeratoconjunctivitis". Journal of American Association for Pediatric Ophthalmology and Strabismus. 14 (6): 527–529. doi:10.1016/j.jaapos.2010.09.013. ISSN 1091-8531.
  15. Kaufman, Herbert E (2011). "Adenovirus advances: new diagnostic and therapeutic options". Current Opinion in Ophthalmology. 22 (4): 290–293. doi:10.1097/ICU.0b013e3283477cb5. ISSN 1040-8738.
  16. Khaja, Wassia A.; Pogrebniak, Alexander E.; Bolling, James P. (2015). "Combined orbital proptosis and exudative retinal detachment as initial manifestations of acute myeloid leukemia". Journal of American Association for Pediatric Ophthalmology and Strabismus. 19 (5): 479–482. doi:10.1016/j.jaapos.2015.05.018. ISSN 1091-8531.
  17. LaMattina K, Thompson L (2014) Pediatric conjunctivitis. Dis Mon 60 (6):231-8. DOI:10.1016/j.disamonth.2014.03.002 PMID: 24906667 PMID: 24906667
  18. Schmoldt A, Benthe HF, Haberland G (1975) Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol 24 (17):1639-41. PMID: https://doi.org/10.3109/02713683.2014.964419
  19. Rose PW, Harnden A, Brueggemann AB, Perera R, Sheikh A, Crook D | display-authors=etal (2005) Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet 366 (9479):37-43. DOI:10.1016/S0140-6736(05)66709-8 PMID: 15993231 PMID: 15993231
  20. 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. Clin Exp Rheumatol 33 (6):936-44. PMID: 26517055 PMID: 26517055
  21. Teo L, Mehta JS, Htoon HM, Tan DT (2012) Severity of pediatric blepharokeratoconjunctivitis in Asian eyes. Am J Ophthalmol 153 (3):564-570.e1. DOI:10.1016/j.ajo.2011.08.037 PMID: 22071229 PMID: 22071229
  22. Wieringa WG, Wieringa JE, ten Dam-van Loon NH, Los LI (2013) Visual outcome, treatment results, and prognostic factors in patients with scleritis. Ophthalmology 120 (2):379-86. DOI:10.1016/j.ophtha.2012.08.005 PMID: 23177360 PMID: 23177360
  23. Wong VW, Lai TY, Chi SC, Lam DS (2011) Pediatric ocular surface infections: a 5-year review of demographics, clinical features, risk factors, microbiological results, and treatment. Cornea 30 (9):995-1002. DOI:10.1097/ICO.0b013e31820770f4 PMID: 21705879 PMID: 21705879
  24. Frings A, Geerling G, Schargus M (2017) Red Eye: A Guide for Non-specialists. Dtsch Arztebl Int 114 (17):302-312. DOI:10.3238/arztebl.2017.0302 PMID: 28530180 : 28530180
  25. Cronau H, Kankanala RR, Mauger T (2010) Diagnosis and management of red eye in primary care. Am Fam Physician 81 (2):137-44. PMID: 20082509 PMID: 20082509
  26. Sauer A, Speeg-Schatz C, Bourcier T (2008). "[Red eye in children]". Rev Prat. 58 (4): 353–7. PMID 18506971 PMID: 18506971 Check |pmid= value (help).
  27. Teoh DL, Reynolds S (2003) Diagnosis and management of pediatric conjunctivitis. Pediatr Emerg Care 19 (1):48-55. DOI:10.1097/00006565-200302000-00014 PMID: 12592117 PMID: 12592117
  28. Høvding G (2008). "Acute bacterial conjunctivitis". Acta Ophthalmol. 86 (1): 5–17. doi:10.1111/j.1600-0420.2007.01006.x. PMID 17970823 PMID: 17970823 Check |pmid= value (help).
  29. Leibowitz HM (2000). "The red eye". N Engl J Med. 343 (5): 345–51. doi:10.1056/NEJM200008033430507. PMID 10922425 PMID: 10922425 Check |pmid= value (help).
  30. "Trimethoprim-polymyxin B sulphate ophthalmic ointment versus chloramphenicol ophthalmic ointment in the treatment of bacterial conjunctivitis--a review of four clinical studies. The Trimethoprim-Polymyxin B Sulphate Ophthalmic Ointment Study Group". J Antimicrob Chemother. 23 (2): 261–6. 1989. doi:10.1093/jac/23.2.261. PMID 2540136 PMID: 2540136 Check |pmid= value (help).
  31. Protzko E, Bowman L, Abelson M, Shapiro A, AzaSite Clinical Study Group (2007). "Phase 3 safety comparisons for 1.0% azithromycin in polymeric mucoadhesive eye drops versus 0.3% tobramycin eye drops for bacterial conjunctivitis". Invest Ophthalmol Vis Sci. 48 (8): 3425–9. doi:10.1167/iovs.06-1413. PMID 17652708 PMID: 17652708 Check |pmid= value (help).
  32. Varu DM, Rhee MK, Akpek EK, Amescua G, Farid M, Garcia-Ferrer FJ; et al. (2019). "Conjunctivitis Preferred Practice Pattern®". Ophthalmology. 126 (1): P94–P169. doi:10.1016/j.ophtha.2018.10.020. PMID 30366797 PMID: 30366797 Check |pmid= value (help).
  33. Akpek EK, Amescua G, Farid M, Garcia-Ferrer FJ, Lin A, Rhee MK; et al. (2019). "Dry Eye Syndrome Preferred Practice Pattern®". Ophthalmology. 126 (1): P286–P334. doi:10.1016/j.ophtha.2018.10.023. PMID 30366798 PMID: 30366798 Check |pmid= value (help).
  34. Bal, Sharon K; Hollingworth, Gary R (2005). "Red eye". BMJ. 331 (7514): 438. doi:10.1136/bmj.331.7514.438. ISSN 0959-8138.
  35. Aguilera, Zenia P.; Chen, Pauline L. (2016). "Eye Pain in Children". Pediatrics in Review. 37 (10): 418–425. doi:10.1542/pir.2015-0096. ISSN 0191-9601.
  36. Aguilera, Zenia P.; Chen, Pauline L. (2016). "Eye Pain in Children". Pediatrics in Review. 37 (10): 418–425. doi:10.1542/pir.2015-0096. ISSN 0191-9601.