OPHTHALMIC ISSUES FOR THE PRIMARY CARE PHYSICIAN
From Primary Care Pediatrics, presented by Massachusetts General Hospital and Harvard Medical School
Mitchell B. Strominger, MD, Chief, Pediatric Ophthalmology and Ocular Motility, and Associate Professor of
Ophthalmology and Pediatrics, Tufts Medical Center, Boston, MA
Educational Objectives
| The goal of this program is to improve the management of common eye conditions in children. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Differentiate and recognize the various causes of conjunctivitis, based on the patient’s history and signs and
symptoms.
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| 2. Distinguish between the various ocular allergic conditions.
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| 3. Discuss the pharmacologic management of bacterial and allergic conjunctivitis.
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| 4. Recognize which ocular conditions require emergent referral.
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| 5. Recognize and treat ocular conditions associated with contact lenses and trauma.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee 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 following has been disclosed: Dr.
Strominger is on the Speakers’ Board of Alcon Laboratories. The planning committee reported nothing to disclose.
Acknowledgements
Dr. Strominger was recorded at Primary Care Pediatrics, held December 3-5, 2008, in Boston, MA, and sponsored by
Harvard Medical School. The Audio-Digest Foundation thanks Dr. Strominger and Harvard Medical School for their
cooperation in the production of this program.
| Introduction: challenges in ophthalmic diagnosis—making right diagnosis; not worsening disorder; knowing
when to refer
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Evaluation of the Red Eye
| Overview: most important elements history, general examination, and ocular examination; not diagnosis but descriptive
term; due to injected conjunctiva with dilated vessels; also look into fornix and palpebral conjunctiva under
eyelid
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| Management guidelines: prompt diagnosis; optimal intervention; rapid relief; lower costs; appreciative patients
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| Conjunctiva: protective covering of eye that has palpebral and bulbar components that prevent contact lenses from
slipping behind eye and into brain; eyelid has other structures, including Meibomian gland orifices next to eyelashes
and perifollicular glands that help to keep eye moist and lubricated; tear film has lipid, aqueous, and mucinous
components
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| Potential causes: conjunctivitis (bacterial, viral, allergic, or chemical); foreign body or trauma; uveitis (inflammation
in eye itself); orbital cellulitis (infection or inflammation in eye socket; emergency); cause and effect—if
symptom itching, more likely allergy; scratchiness, foreign body or dry eye; burning, blepharitis or conjunctivitis;
localized tenderness, stye or chalazion; deep intense pain with photophobia, corneal abrasion or iritis; poor vision,
corneal edema
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| Issues to consider: eyelid involvement; whether unilateral or bilateral; localized or diffuse redness; discharge;
vision; pupils; cornea; red reflex; posterior pole and optic nerve; determine whether nonvision-threatening (eg,
subconjunctival hemorrhage, chalazion, blepharitis, conjunctivitis, dry eye, corneal abrasion); vision-threatening
conditions include corneal infections, scleritis, hyphema, iritis, acute glaucoma (rare in children), and orbital
cellulitis
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Conjunctivitis
| Types: allergic, bacterial, viral, acute, chlamydial, giant papillary, phlyctenular, and ophthalmia neonatorum
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| Viral conjunctivitis: typically associated with pharyngitis, preauricular or submandibular adenopathy, and whitish
mucoid discharge; chemosis pearly swelling of conjunctiva; usually affects older children; usually unilateral, then
affects fellow eye
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| Allergic conjunctivitis: usually associated with itching and stringy clear discharge; usually occurs during spring
and fall; chemotic swelling and eyelid swelling often present, with tearing; usually bilateral
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| Bacterial conjunctivitis: usually associated with otitis, sinusitis, and purulent yellow-green discharge; usually occurs
in preschool-aged children; typically bilateral (but can be unilateral); mucopurulent discharge with matting
of eyelashes; highly contagious; major cause of conjunctivitis in children presenting to primary care physician
(80%; viral and allergic next most common); most common pathogen Haemophilus influenzae, followed by
Streptococcus, Moraxella, and Staphylococcus; treatment—topical antibiotic and eyelid hygiene; tends to be
self-limited if patient on oral antibiotic, although contagious for some time; eyelid hygiene using warm water
with few drops of baby shampoo; achieving early cure reduces contagion and enables early return to school and
early identification of masquerade disease; study—2002 outbreak in elementary school in Maine; 101 cases of
conjunctivitis; causative agent Streptococcus pneumoniae nonencapsulated strain resistant to erythromycin;
highly contagious; antibiotics used include sulfonamides and third-generation cephalosporins; most pediatric
ophthalmologists switching to treat with third-generation cephalosporin (easier to comply with treatment due to
bid or once-daily dosing); erythromycin and moxifloxacin only 2 antibiotics that cover Chlamydia
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| Allergic conjunctivitis: children usually present with eye rubbing; oftentimes present with frequent blinking and
eye maneuvers, usually due to giant papillae or follicles under eyelids; determine whether condition occurs at
specific time of year, whether oral antihistamines used, whether other allergies, atopic signs, or asthma present,
or whether intranasal steroids used
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| Types of ocular allergy: seasonal allergic conjunctivitis—eyelid or conjunctival edema; watery discharge and
white stringy mucus; itching predominant symptom; associated with hay fever, asthma, and eczema; occurs primarily
in spring and fall (pollens or outdoor molds); sometimes related to contact allergy to drugs, chemicals, or
cosmetics; perennial allergic conjunctivitis—causes include indoor molds, cockroaches, dust mites, and pet
dander; atopic keratoconjunctivitis—associated with atopic dermatitis; may be perennial; has genetic predisposition;
precipitated by environmental allergen; signs and symptoms similar to those of regular allergy, but sometimes
worse; if not treated appropriately, corneal ulcerations may develop; in children, may be necessary to use
steroid drops; vernal keratoconjunctivitis—associated with atopy; associated with IgE immune responses; IgE
deposition at limbus present (appears as grey glassy ring around cornea) called Horner-Tranta dots; requires
treatment with steroid or cyclosporine drops; tends to occur each year at specific time; may see corneal ulcerations
secondarily infected with bacteria; treat aggressively; giant papillary conjunctivitis—due to repeated mechanical
irritation (usually contact lens); not seen as often (due to disposable contact lenses and better lens
solutions); conjunctival mast cells most similar to tryptase/chymase mast cells of skin connective tissue
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| Pharmacologic management: includes antihistamines, antihistamine and vasoconstrictor combinations, mast cell
stabilizers, antihistamine and mast cell stabilizers, steroids, and nonsteroidal anti-inflammatory drugs (NSAIDs);
over-the-counter (OTC) preparations—most common topical treatment of allergic conjunctivitis; antihistamine
and vasoconstrictor components short-acting (requires dosing every 3-4 hr; conjunctival vessels become dependent
on vasoconstrictor component; if drug stopped, rebound vasodilation and hyperemia occur); vasoconstrictor
phenylephrine component causes pupillary dilatation, leading to blurry vision and central nervous system depression
in infants and children; cromolyn ophthalmic (Crolom)—mast cell stabilizer; effective, but takes 7 to 10
days before effect seen; therefore, 2 drugs required to treat appropriately; antihistamine and mast cell
stabilizer—effective in children; ketotifen ophthalmic solution (Alaway; Zaditor) available OTC; olopatadine
(Patanol) formulated specifically for triptase-chymase mast cell of eye (once-daily dose)
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| Epidemic keratocojunctivitis: associated with reduced visual acuity; examination with direct ophthalmoscope
demonstrates tiny white “dots” on cornea; caused by specific strains of adenovirus; subepithelial infiltrates under
cornea, causing vision loss; usually self-limited; no good treatment; extremely contagious; should refer to ophthalmologist;
sometimes necessary to treat with steroids to decrease inflammatory component responsible for corneal
swelling; necessary to taper steroid for long time (sometimes months); if not treated, permanent vision loss possible
due to scar formation
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Stye or Chalazion
| Pathophysiology: terms used interchangeably, depending on which gland blocked; typically, orifices of Meibomian
gland on lid margin blocked, with crusting and blepharitis; Meibomian gland enlarges, becoming red and “hot”;
sometimes associated with preseptal cellulitis if bacteria “stuck”; chalazion—points internally (sometimes external);
treated by opening Meibomian gland and removing mucopurulent discharge through warm compresses and
eyelid hygiene; if preseptal component present, start oral antibiotic; if purulent discharge present, start topical antibiotic;
if no resolution seen in few months, perform incision and drainage; often recurrent
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Chemical Injury to Eye
| Base: causes degeneration of lipid-filled tissue; much lipid present in cornea, leading to permanent blindness; start irrigation
of eye before taking patient to emergency department (ED); helpful to anesthetize eye before examination;
topical anesthetic toxic to cornea; irrigate as much as possible
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| Acid: treated with supportive care, topical steroids, and irrigation
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| Bleach: causes cornea to degenerate and destroys cells around edge of cornea (limbal stem cells) that regenerate corneal
epithelium; corneal transplantation may be necessary; treat as soon as possible with irrigation and topical steroids
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Other Conditions
| Subconjunctival hemorrhage: localized, with discrete border; normal visual acuity; no history of trauma; common
in children with upper respiratory infection (coughing); antihistamine and mast cell stabilizer used if irritation
present and patient complains of itching; takes ≈10 days for hemorrhage to resolve
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| Pterygium: similar to seborrheic dermatosis; due to long-term sun exposure; may become irritated and itch; treated
symptomatically with artificial tears and antiallergy drops; not necessarily excised because of tendency to recur
easily; if excised, membrane grafting also performed; does not affect vision until it extends into cornea; called
pinguecula if not on cornea
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| Scleritis or episcleritis: presents as localized redness and discomfort; inflammation of sclera or layer between
sclera and conjunctiva; needs emergent referral; associated with autoimmune problems; must treat underlying systemic
disorder; if not treated, progresses to corneal ulceration and melting, with vision loss
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| Corneal abrasion: mechanism of injury key; tendency for colonization with Pseudomonas in children with contact
lenses; should not patch eye (Pseudomonas has affinity for moist environment); study looked at patching and
showed no difference in healing whether patched or not; if present in contact lens wearer, high risk for development
of corneal ulceration; treat with topical antibiotic and determine whether child improving day after
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| Hypopion: associated with sharing of cosmetic contact lenses (presently off market); causative organism
Pseudomonas; typically see ulcers; “white” corneal abrasion signifies infectious character and immediate referral
indicated; involves anterior segment and causes permanent vision loss
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| Herpes simplex virus (HSV) involving eyelids: should refer emergently; most pediatricians start with oral acyclovir;
if dendrites seen, topical antivirals started; should not start on topical steroids (may lead to corneal scarring,
as infection spreads deeper)
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| Hyphema: most likely cause blunt trauma; needs immediate referral; pupil dilated to prevent scarring; topical steroids
started and pressure watched; if pressure increases, surgery performed to relieve pressure
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| Iritis: presents as pain, circumoral redness, and decreased vision; work-up should include antinuclear antibody,
rheumatoid factor, chest x-ray, angiotensin-converting enzyme (ACE) inhibitor, and gastrointestinal work-up; seen
in juvenile rheumatoid arthritis and inflammatory bowel disease; pupil irregularity due to scars
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| Cataract: if subtle, picked up by red reflex test
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| Preseptal cellulitis: need to differentiate between preseptal cellulitis and orbital cellulitis; in orbital cellulitis, eye
red and swollen but does not move (must be referred); mostly bacteria-related, spreading from sinus to orbit;
treated with antibiotic
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Suggested Reading
de Groot H et al: Allergic rhinoconjunctivitis in children. BMJ 335:985, 2007; Horgan N et al: Eye injuries in children: a
new household risk. Lancet 366:547, 2005; Mah F: Bacterial conjunctivitis in pediatrics and primary care. Pediatr Clin North
Am 53 Suppl 1:7, 2006; Misra A et al: Orbital varices diagnosed as episcleritis in a child with juvenile idiopathic arthritis. J Pediatr
146:574, 2005; Normann EK: Conjunctivitis in children. Lancet 366:6, 2005; Sacchetti M et al: Development and
testing of the quality of life in children with vernal keratoconjunctivitis questionnaire. Am J Ophthalmol 144:557, 2007; Tarabishy
AB et al: Bacterial culture isolates from hospitalized pediatric patients with conjunctivitis. Am J Ophthalmol 142:678,
2006; Wise R: Antibiotics for acute infective conjunctivitis in children. Lancet 366:1431, 2005.
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