EYE PROBLEMS
| PEDIATRIC OPHTHALMOLOGY IN THE PRIMARY CARE SETTING: PEARLS AND PITFALLS —Craig A.
McKeown, MD, Associate Professor of Clinical Ophthalmology, Bascom Palmer Eye Institute, University of Miami
Miller School of Medicine, Miami, FL
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| Pediatric eye examination: 9-point examination difficult to accomplish in pediatric population; in primary care
setting, consider performing limited examination using something to attract attention of preverbal child (eg, toy,
ruler, penlight) and equipment such as direct ophthalmoscope, magnifying glass, eye patch, and visual test card; in
emergency department, need eye patch, eye shield, tape, fluorescein strips, saline solution, topical anesthetic, and
nonsteroidal antibiotic eye drops; use paper clip and hemostat as retractor for eye; history-taking in children—
examine child within family context to look for inherited disorders; children unable to provide history in some instances;
children complain of pain, and adults report unusual appearance; children rarely complain of visual problems;
child may give inaccurate history, especially in cases involving ocular trauma and if injury occurred during
forbidden activity; high degree of awareness of possible trauma necessary to make accurate diagnosis; parental
barriers to accurate history—misinterpretation of symptoms and signs; misunderstanding of anatomy and physiology;
withholding of information, especially in cases of trauma or child abuse; diagnostic considerations—high
level of suspicion required if parent complains “my child’s eyes don’t look right”; “family album tomography”
(“FAT” scan) can establish time of onset of disorder or help diagnose disorders, eg, monthly photographs of infant
dated onset of retinoblastoma as indicated by asymmetric red reflex in photograph; tilting of head to side to compensate
for partial paralysis of fourth cranial nerve indicative of torticollis with fourth nerve palsy; problems encountered
during examination—some children unable to perform subjective tests; malingering and reverse
malingering common in children; look for inconsistent findings without anatomic or optic reason; patience best
course of action; use patch to cover eye during visual acuity testing to avoid peeking; poor cooperation can occur
during various portions of examination; eye drop administration difficult
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| Visual development: components of vision include sharp central vision (measured as visual acuity), peripheral vision,
color perception, and binocular vision; subjective visual acuity testing usually not possible in developmentally
normal child until 2.5 to 3 yr of age; visually evoked cortical potentials (VECP) technique and forced-choice
preferential looking techniques (eg, Teller acuity cards) used to measure visual acuity; infants 1 to 2 mo of age
have visual acuity estimated at 20/1200 to 20/2000; rapid improvement occurs within first 6 mo of age; visual acuity
equal to adult levels at 3 yr of age; showing and/or giving copy of visual development graph to parents recommended
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| Masquerade associations: amblyopia—ie, loss of central vision or visual acuity; competition occurs between
right and left eyes during first decade of life; unilateral vision loss can occur if either eye disadvantaged; some patients
have obvious physical manifestations, eg, ptosis, strabismus; some patients do not have external findings,
and diagnosis made during thorough examination or test for visual acuity; congenital glaucoma disguised as
blocked nasolacrimal duct (NLD)—congenital glaucoma occurs in 1 in 12,000to 1 in 15,000newborns; look for
external findings, eg, furrowed brow, slightly larger cornea in one eye, photoaversion, and tearing; strabismus—
common diagnosis; can overlap with amblyopia; esotropia most common subtype of strabismus; treatment depends
on subtype; no treatment needed in some patients; patients with infantile esotropia need surgery; neurologic
disease disguised as strabismus—in children, most strabismus of neurologic origin; atypical presentation requires
imaging studies; 25% of cases of retinoblastoma present as strabismus
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| COMMON EYE PROBLEMS IN CHILDREN —Cynthia L. Alley, MD, Assistant Professor of Ophthalmology,
Temple University Medical School, Philadelphia, PA
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 | Viral conjunctivitis: adenovirus most common; serotypes differ in disease severity and associated conditions; acute
follicular conjunctivitis presents within 24 hr; conjunctival follicles resemble round elevated smooth and shiny
lesions; associated with watery discharge, redness in eyelid skin and conjunctiva, ecchymosis or swelling of conjunctiva,
swollen eyelid, and focal red spots under conjunctiva due to hemorrhage; often begins in one eye and
spreads to other eye within 1 to 2 days; check for palpable preauricular tender lymph node (suggestive of viral
illness); patient may present with upper respiratory infection and sore throat (depending on serotype involved);
recommend supportive treatment (cool compresses and frequent administration of artificial tears); prevent with
frequent hand washing, separate personal hygiene items (eg, face towels, pillow cases), and avoidance of sharing
eye drops; clean surfaces with 10% sodium hypochlorite solution; keep child out of school for 1 to 2 wk until
symptoms resolve; tell patient to discard used eye drops
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| Bacterial conjunctivitis: often bilateral; look for mucopurulent thick yellowish discharge to distinguish from viral
conjunctivitis; characterized by papillary conjunctivitis; look for smooth sandpaper appearance when eyelid
pulled down; commonly caused by Haemophilus influenzae and Streptococcus pneumoniae; H influenzae produces
characteristic dense conjunctival hemorrhagic appearance that can bleed into tears and produce violaceous
hue to skin because of broken blood vessels; infection can be prevented with overall good hygiene, including
hand washing; self-limiting in most cases; consider topical antibiotics to produce more rapid clinical response
(eye drops up to 6-8 times per day for first 2-3 days, then qid after response; ointment qid, cutting down after 2-3
days); use broad-spectrum antibiotic, eg, polymyxin B and trimethoprim ophthalmic solution
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| Allergic conjunctivitis: seasonal and more long-term than viral or bacterial conjunctivitis; involves type 1 hypersensitivity
reaction; usually bilateral and symmetric; itching best diagnostic symptom; also tearing and stringy
mucoid discharge; history usually enough to make diagnosis; treat according to symptom severity; with mild
symptoms, cold compresses and artificial tears typically sufficient during season when condition occurs; in more
serious conditions, one or more of topical vasoconstrictors, topical antihistamines, topical mast cell stabilizers, or
combination agent (antihistamine and mast cell stabilizer); can consider use of topical nonsteroidal anti-inflammatory
drugs (NSAIDs; use with caution because too frequent use and long-term use can result in corneal melting);
consider systemic antihistamines to relieve some ocular symptoms; consider combination antihistamine and
mast cell stabilizer (eg, olopatadine; effective in most patients)
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| Corneal abrasion: patient presents with severe pain, photophobia, and tearing; use fluorescein dye (speaker prefers
strip form) technique to diagnose abrasion; recommend broad-spectrum antibiotic until healing occurs; dose similar
to that for bacterial conjunctivitis; consider cycloplegic agent (atropine derivative) to relax or paralyze iris
and ciliary muscle; traumatic iritis or spasm of iris and ciliary body can occur after injury to cornea, resulting in
photophobia; cycloplegic agent relieves discomfort while cornea heals; use pressure patch or bandage contact
lens with caution; avoid patch in contact lens wearers; use of topical antibiotic contraindicated; inappropriate
treatment can result in infection, scarring that can lead to vision loss, and syndrome of recurrent epithelial erosion
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| Watery eyes: results from excessive production of tears or failure of drainage; congenital NLD obstruction—
usually results from delay in maturation of valve of Hasner; diagnosis usually made on history alone; most often
unilateral; keep suspicion high in child with watery nonirritated eye without photophobia; may see increased tear
meniscus; eye often looks wet, and tears may overflow lid; crustiness and stickiness on lashes; some patients have
mucopurulent discharge; skin surrounding eye can become red and excoriated; conjuntiva remains white and clear,
unless condition associated with intermittent conjunctivitis; perform fluorescein disappearance test in questionable
cases; up to 20% of newborns have NLD obstruction, but by 3 mo of age 50% have resolved, and by 1 yr of age
95% of cases have resolved without treatment; up to 1 yr of age, recommend cleansing lid and lash area with tissue
or damp cloth to wipe away debris, and applying petroleum jelly to periocular skin to protect it from tears; antibiotics
contraindicated unless evidence of concurrent conjunctivitis; massaging NLD mainstay of treatment during first
year; probing and irrigation procedure recommended if condition does not resolve within 1 yr; 90% of patients require
one probing procedure for symptom improvement; congenital glaucoma—associated with lacrimation, blepharospasm,
and photophobia; cloudy cornea and buphthalmos not always present in early stages; photophobia key
to diagnosis; treatable condition in children; surgery required (more successful if performed early)
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| Eyelid lesions: chalazion—sebaceous material trapped by plugged gland leads to chronic granulomatous inflammation;
resolves spontaneously or progresses to painless localized mass; treat with frequent application of warm
compresses to help open gland, get blood flow to area, and reduce inflammation; avoid expressing material from
plugged gland; topical antibiotics not effective; topical steroids not indicated and associated with side effects; consider
systemic antibiotics in patients who develop secondary cellulitis; consider incision and drainage if condition
does not resolve within 1 mo; herpes simplex virus (HSV) infection—usually unilateral; can result in blepharokeratoconjunctivitis;
usually associated with HSV type 1 infection; look for palpable preauricular lymph node; self-limited
disease, but topical or oral antiviral agents effective in hastening healing and reducing risk for recurrence; refer
patient to ophthalmologist for evaluation and treatment of corneal involvement; molluscum contagiosum—virus
transmitted by close contact; patient may have single or multiple raised lesions on eyelid; conjunctival involvement
can occur if lesions close to eyelid margin, resulting in follicular conjunctivitis; can resolve over months to years;
can excise, curette, or freeze lesions
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| Failed vision screen: vision screening guidelines—every child should have at least one initial vision screening examination
by 6 mo of age; formal vision evaluation, including visual acuity testing, begins at 3 yr of age; screening
examination should include detailed history and external inspection of eyes; visual acuity testing performed on age-
appropriate basis, with each eye tested individually; refer to ophthalmologist if—young child objects to covering
one eye but not other; visual acuity in child 3 to 5 yr of age worse than 20/40 in either eye; visual acuity in child ≥6
yr worse than 20/30; 2-line difference in visual acuity between eyes; ocular misalignment seen on examination; child
cannot be tested (eg, poor cooperation or attention span)
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| OFFICE MANAGEMENT OF OPHTHALMOLOGIC TRAUMA: KEEP YOUR EYE ON THE BALL —Douglas
R. Fredrick, MD, Associate Professor of Clinical Ophthalmology and Pediatrics, Vice Chair, Department of Ophthalmology,
and Residency Program Director, University of California, San Francisco, School of Medicine
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| Evaluation of ocular trauma: check visual acuity—document visual acuity using Snellen chart, near card, magazine,
counting fingers, HOTV card, or child recognition card; relieve pain—use numbing agent to relieve pain
(eg, proparacaine [eg, Ophthetic]), tetracaine) prior to eye examination; place drop of numbing agent in other eye
as well; examining eye—apply pressure to superior orbital rim and maxillary or malar eminence to open eye;
check vision simultaneously; use direct ophthalmoscope to check quality of light reflex and check pupil; check
clarity of light reflex, looking for irregularities; check for corneal abrasion; may use ophthalmoscope as magnifying
lens to examine eye for foreign bodies
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| Ocular injuries: blowout fracture—caused by blunt trauma to eye; signs include enophthalmos, restricted ocular
movements, infraorbital hypesthesia, and excessive nausea and vomiting; obtain computed tomography (CT) of orbits
and sinuses to diagnose; indications for repair include entrapped extraorbital muscle, large fracture, and significant
enopthalmos; central nervous system (CNS) injury—can occur after penetrating injury, subdural or epidural
hemorrhage, or intracranial foreign body; use CT to check for foreign body; chemical injury—test tears with pH
paper if available; apply numbing agent and irrigate with saline until pH normal; refer patients with acid or alkaline
burns to ophthalmologist; alkaline burns (saponify tissue) can cause uveitis, glaucoma, corneal opacification, and
phthisis; traumatic optic neuropathy—consider diagnosis if afferent pupil defect present; perform swinging flashlight
test for afferent pupil defect (Marcus Gunn pupil); paradoxical pupil dilation to direct light occurs on moving
light from opposite to affected eye if optic nerve damaged; consider steroids (if not contraindicated) in patient with
some vision and without obvious orbital fracture; however, studies show no significant advantage to steroids; ruptured
globe—signs include poor vision, irregular pupil, shallow anterior chamber, low intraocular pressure, and
positive Seidel’s sign; place protective shield over eye; obtain CT to rule out occult foreign body; give patient 1 g
cefazolin (eg, Ancef) intravenously; keep patient npo; corneal abrasion—look for pain, watery eye, photophobia,
poor vision, and consistent history; rule out corneal ulcer, glaucoma, and ruptured globe; consider foreign body; dilate
eye; use broad-spectrum antibiotic ointment; place tight patch; reexamine in 24 hr and refer to ophthalmologist
if condition not improved
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Suggested Reading
Committee on Practice and Ambulatory Medicine, Section on Ophthalmology: Eye examination in infants,
children, and young adults by pediatricians. Pediatrics 111:902, 2003; Friedman LS et al: Guidelines for pediatrician
referrals to the ophthalmologist. Pediatr Clin North Am 50:41, 2003; Rychwalski PJ et al: Evaluation
and classification of pediatric ocular trauma. Pediatr Emerg Care 15:277, 1999; Simon JW et al: Commonly
missed diagnoses in the childhood eye examination. Am Fam Physician 64:623, 2001; Shields SR: Managing eye
disease in primary care. Part 3. When to refer for ophthalmologic care. Postgrad Med 108:99, 2000.
Educational Objectives
| The goal of this program is to improve diagnosis and treatment of common eye conditions and ophthalmologic
trauma seen in the primary care setting, as well as to increase knowledge of when to refer. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Explain the development of vision in infants and children.
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| 2. Discern potential barriers to obtaining an accurate history and/or performing an eye examination in children.
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| 3. Manage common eye disorders in children.
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| 4. Determine when to refer a pediatric patient to an ophthalmologist after a failed vision examination.
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| 5. Optimize in-office management of the pediatric patient who has experienced ocular trauma.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. McKeown was recorded at Masters of Pediatrics 2007 Leadership Conference, February 21-26, 2007, in Miami,
FL, sponsored by the University of Miami Miller School of Medicine. Dr. Alley was recorded at the 26th Annual Pediatric
Novemberfest, November 9-10, 2006, in Atlantic City, NJ, sponsored by Temple University School of Medicine.
Dr. Fredrick was recorded at Advances and Controversies in Clinical Pediatrics, held June 1-3, 2006, in San
Francisco, and sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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