Pediatric Annals

The Red Eye-A Practical Approach

Flavius G Pernoud, III, MD

Abstract

(ProQuest: Text stops here in original.)

INTRODUCTION

Children suffer from a variety of ocular problems which present to the pediatrician as a red eye. Many of these problems are self-limiting and will fortunately clear regardless of therapy. However, there are a number of problems which result in serious sequelae if a misdiagnosis is made or if a delay in adequate treatment occurs. Adequate history is often difficult to obtain, and delays in discovery of a problem by the parents make the diagnosis on clinical appearance most important. The ocular response to many very different insults is the same and one can be lulled into a false sense of security when presented with "just another conjunctivitis."

TRAUMA

Baseballs, bats, mudballs, fists, bottle rockets, hockey pucks, BBs, darts, household chemicals, and delivery forceps are but a few of the myriad of instruments which inflict varying degrees of injury to children's eyes.

Blunt or Perforating Injuries

Blows to the eye may result in a "pink eye" with lacrimation. This may be only a mild hypermia of the conjunctiva or it may represent a traumatic iritis which requires treatment by an ophthalmologist. A subconjunctival hemorrhage in itself has no consequential effects; however, one must be alert to a possible scleral laceration or rupture hiding beneath a seemingly innocent hemorrhage. Any rupture or laceration must be treated surgically as early as possible. Perforating corneal lacerations, which may be deceiving due to the relative lack of early inflammation or pain, must be closed without delay. Conjunctival lacerations should be explored to rule out an underlying scleral laceration. Most conjunctival lacerations need not be sutured unless very large. Topical antibiotic drops or ointment several times a day for four to five days should be given as a prophylactic against infection when the conjunctiva has been disrupted.

Descemet's membrane is the tough non-cellular layer of the cornea which lies just anterior to the endothelial cell layer. It provides the last line of defense against perforation. If ruptured, aqueous is allowed access to the corneal stroma which imbibes the water and becomes cloudy. Most ruptures repair themselves eventually; however long-standing corneal edema in a very young child could result in amblyopia.

The cornea is exposed to numerous insults and can be abraded quite easily. Abrasions never result in scars unless Bowman's membrane (underlying the epithelium) has been damaged. Epithelial cells spread to cover defects very rapidly, small lesions often healing overnight. Surprisingly, very young children seem not to suffer as much pain from corneal abrasions as older children and adults. Often, the parent notices only a slightly injected eye with tearing.

Corneal abrasions often result in extreme blepharospasm making an adequate exam impossible. One should instill a drop of topical anesthetic and sterile fluorescein. Individually wrapped fluorescein strips maintain sterility for long periods of time. Fluress is a solution containing a topical anesthetic with fluorescein mixed in it. This solution can be helpful in examining a frightened child in a lot of pain in that it takes only "one shot" to get the dye and the anesthetic in the eye; however, one should be careful not to allow the dropper to be contaminated or the bottle to become outdated. Instillation of an antibiotic ointment (preferably not containing neomycin) and tight patching is the preferred treatment. A folded eye patch or a double patch is necessary to keep the lid tightly closed. Keeping the lid closed probably speeds the spreading of the epithelial cells, adds to the comfort, and helps to keep dirt and the child's fingers out of the eye. If the lid cannot be kept closed or if…

(ProQuest: Text stops here in original.)

INTRODUCTION

Children suffer from a variety of ocular problems which present to the pediatrician as a red eye. Many of these problems are self-limiting and will fortunately clear regardless of therapy. However, there are a number of problems which result in serious sequelae if a misdiagnosis is made or if a delay in adequate treatment occurs. Adequate history is often difficult to obtain, and delays in discovery of a problem by the parents make the diagnosis on clinical appearance most important. The ocular response to many very different insults is the same and one can be lulled into a false sense of security when presented with "just another conjunctivitis."

TRAUMA

Baseballs, bats, mudballs, fists, bottle rockets, hockey pucks, BBs, darts, household chemicals, and delivery forceps are but a few of the myriad of instruments which inflict varying degrees of injury to children's eyes.

Blunt or Perforating Injuries

Blows to the eye may result in a "pink eye" with lacrimation. This may be only a mild hypermia of the conjunctiva or it may represent a traumatic iritis which requires treatment by an ophthalmologist. A subconjunctival hemorrhage in itself has no consequential effects; however, one must be alert to a possible scleral laceration or rupture hiding beneath a seemingly innocent hemorrhage. Any rupture or laceration must be treated surgically as early as possible. Perforating corneal lacerations, which may be deceiving due to the relative lack of early inflammation or pain, must be closed without delay. Conjunctival lacerations should be explored to rule out an underlying scleral laceration. Most conjunctival lacerations need not be sutured unless very large. Topical antibiotic drops or ointment several times a day for four to five days should be given as a prophylactic against infection when the conjunctiva has been disrupted.

Descemet's membrane is the tough non-cellular layer of the cornea which lies just anterior to the endothelial cell layer. It provides the last line of defense against perforation. If ruptured, aqueous is allowed access to the corneal stroma which imbibes the water and becomes cloudy. Most ruptures repair themselves eventually; however long-standing corneal edema in a very young child could result in amblyopia.

The cornea is exposed to numerous insults and can be abraded quite easily. Abrasions never result in scars unless Bowman's membrane (underlying the epithelium) has been damaged. Epithelial cells spread to cover defects very rapidly, small lesions often healing overnight. Surprisingly, very young children seem not to suffer as much pain from corneal abrasions as older children and adults. Often, the parent notices only a slightly injected eye with tearing.

Corneal abrasions often result in extreme blepharospasm making an adequate exam impossible. One should instill a drop of topical anesthetic and sterile fluorescein. Individually wrapped fluorescein strips maintain sterility for long periods of time. Fluress is a solution containing a topical anesthetic with fluorescein mixed in it. This solution can be helpful in examining a frightened child in a lot of pain in that it takes only "one shot" to get the dye and the anesthetic in the eye; however, one should be careful not to allow the dropper to be contaminated or the bottle to become outdated. Instillation of an antibiotic ointment (preferably not containing neomycin) and tight patching is the preferred treatment. A folded eye patch or a double patch is necessary to keep the lid tightly closed. Keeping the lid closed probably speeds the spreading of the epithelial cells, adds to the comfort, and helps to keep dirt and the child's fingers out of the eye. If the lid cannot be kept closed or if the child is intolerant of the patch, it is probably better to leave the eye unpatched. A loose patch may rub on the cornea causing further injury or may prop open the lid allowing exposure and drying of the cornea. Patching of infants and very young children is not only impractical but may lead to amblyopia. Under no circumstances should a parent be allowed to administer topical anesthetics as the toxic effects of repeated instillation are cumulative and may lead to ulceration or perforation of the cornea. Neomycin, which is present in many topical preparations, adds little to prophylaxis and may often cause a contact dermatitis which may confuse the course. Topical steroids are not indicated because they may impede normal healing and may enhance a traumatically introduced herpes. Daily examination should be carried out until the epithelium has healed. Visual acuity should be monitored, if possible. Final recovery of pre-injury visual acuity may occur only after seven to ten days due to the fact that the epithelium, even though healed, does not become smooth for several days.

One must be alert to concomitant injuries. Obviously, examine the "opposite eye" as unnoticed injuries or abnormalities may be present. A hyphema may be present in the injured eye and might be quite subtle if the blood has not had time to settle. Microscopic hyphemas are probably as dangerous as those which are obvious.1 The danger lies in the recurrence of bleeding which may lead to uncontrollable glaucoma, permanent blood staining of the cornea, and possibly amblyopia (if the child is young).

Traumatic recession of the anterior chamber angle may lead to unrecognized glaucoma which may appear only much later. Be aware of intraocular problems such as tears in the iris, subluxation of the lens, retinal tears and detachment, vitreous hemorrhage and retinal edema.

Extraocular muscles should be checked if possible to rule out blow out fractures resulting from frontal blows to the eye with entrapment of a muscle. Often, hemorrhage or edema in a muscle causes its underaction which usually clears within a few days. Eyelid lacerations need exploration and repair.

Burns

Burns of the eye may be due to heat, chemicals, or radiation. Severe burns of any nature may lead to corneal necrosis and perforation with loss of the eye; or, at best, severe scarring. Thermal burns can be severe but the brunt of most burns is borne by the eyelids. The cornea is usually protected by eyelid closure and by the evaporative cooling of the tears. One should treat the eyelids appropriately for skin burns and check the cornea with fluorescein for the presence of keratitis. If mild, the keratitis may be treated as a corneal abrasion.

Chemical burns can be divided for convenience into those due to acids, alkali, or petroleum products. Acids are often buffered by the tears and coagulated protein from the epithelial cells and penetrate the cornea poorly but strong acids can cause severe burns if not treated promptly. Alkalis much more commonly cause severe corneal and intraocular damage due principally to the very rapid penetration of the cornea. Alkali has been found experimentally in aqueous as soon as five seconds after exposure.' Blanching of the conjunctiva often occurs giving the eye the false appearance of only mild injury when, in fact, it is quite severe. Severe shrinkage of the conjunctiva with destruction of the mucous-producing goblet cells occurs. Numerous early and late sequelae occur and all but the very mildest burn should be treated by an ophthalmologist after initial emergency irrigation has been carried out.

Petroleum products and other chemicals usually cause some damage to the epithelium which may produce much irritation but seldom cause any permanent damage.

Penetration beyond the epithelium is unlikely.

Regardless of the agent, parents should be instructed to flush the child's eye with at least a quart of tap water prior to bringing the child to the office or emergency room. When the patient presents in your office, copious irrigation of the conjunctival sac should be carried out immediately (especially if a strong acid or any alkali is involved) even priortoexaminations. A topicalanesthetic can be used to aid the child's tolerance to irrigation. It is very important to remove any particulate matter from the cornea and conjunctiva which may continue to leach chemicals into the eye. After at least 500cc of water or saline irrigation, test the conjunctival sac with pH test paper. Continue irrigation until test paper remains neutral. Instill a topical antibiotic and patch the eye tightly, if possible. Consult an ophthalmologist immediately.

Table

TABLE 1COMMON CAUSES OF CONJUNCTIVITIS

TABLE 1

COMMON CAUSES OF CONJUNCTIVITIS

Ultraviolet light and radiation cause damage to the epithelium which is usually transient. Treatment should be the same as that for a corneal abrasion.

Foreign Bodies

In general all superficial foreign bodies should be removed as soon as possible to prevent further damage. Always remember to instill fluorescein dye, examine the opposite eye, and evert the upper eyelid to examine the upper tarsal conjunctiva, a common location for foreign bodies. Vertical staining streaks on the cornea are often an indication of a foreign body on the tarsus.

Tiny fragments of glass or inert material may sometimes be allowed to remain in deeper corneal layers if too much damage will be created in removing them. Foreign bodies may extend into the anterior chamber and should be removed by an ophthalmologist in the operating room.

Iron-containing foreign bodies almost universally create rust rings in the cornea. The particle should be removed carefully with a moistened sterile Q-tip. sterile needle or spud. Rust rings are best removed with stereoscopic magnification to minimize scarring particularly in the visual axis. Plant material often carries fungi as well as other organisms and should also be removed quickly.

Instillation of a topical anesthetic facilitates examination. Remove all foreign bodies if superficial, instill a broad spectrum antibiotic ointment (preferably not neomycin), and patch the eye tightly except in infants.

The patient should be examined the following day.

Intraocular foreign bodies should be removed quickly by the ophthalmologist (quick removal is not always possible) to prevent further damage and to repair any retinal damage.

Corticosteroids add little to therapy and should be avoided to prevent enhancement of any possible fungal or herpetic activity.

Insect stings of the conjunctiva occur in children more commonly than in adults. A localized area of erythema and edema occurs at the site. The site should be inspected for remnants of insect parts or the stinger. Any foreign material present should be removed. A topical antibiotic should be given three or four times a day for two or three days. Bee stings and the like can be extremely painful and may cause a tremendous inflammatory reaction. Such a violent iridocyclitis may ensue that the eye may be lost. Topical steroids in addition to antibiotics may be necessary to quiet the eye.

Caterpillar hairs may become lodged in the conjunctiva or the cornea.1 These hairs are extremely irritating and tend to penetrate any ocular tissue includingthe globedue to the arrangement of barbs on the shafts. Focal granulomas develop around the shafts and severe uveitis may develop if the globe is penetrated.

INFLAMMATORY DISEASE

This group of diseases consists principally of connective tissue disease and ocular diseases of uncertain etiology. Many of the features of connective tissue disease occur as isolated ocular disease in otherwise healthy patients.

Keratoconjunctivitis sicca occurs quite frequently in association with connective tissue diseases. Commonly, itching or foreign body sensation may be the presenting complaint. Young children seem to tolerate the condition much better than adults however, and may have few, if any, complaints. Mild hyperemia may be present with punctate staining of the cornea. There may be a stringy mucous present in the tear film. Treatment is symptomatic only and is usually only minimally effective. Tear substitutes should be used frequently, sometimes as often as every 30 to 60 minutes to be helpful.

Episcleritis is a mild patchy inflammation of the tissue beneath the conjunctiva. Scleritis is a patchy inflammation of the sclera itself. The distinction between the two conditions is difficult by simple inspection.4 Pain is more pronounced in scleritis which may become quite severe. Scleromalacia perforans, or focal necrosis of the sclera from the deep inflammation may be the end result of scleritis. Surgical patching with donor sclera may be necessary in impending or frank perforation to insure the integrity of the eye. Topical steroids are contraindicated in scleritis because they may enhance melting, but in episcleritis they usually lead to a rapid remission. Uveitis may be isolated as a single episode without a determined etiology in one or both eyes but is often associated with the connective tissue diseases. Symptoms include photophobia, tearing, and a deep aching pain. There is usually an overall injection of the eye with prominent perilimbal blood vessels. Unfortunately, in children, especially those with rheumatoid arthritis, the uveitis may be silent. Only frequent ophthalmologic exams can insure that active inflammation and ongoing complications such as secondary glaucoma, cataracts, and pupillary block due to synechia between the iris and lens do not cause permanent loss of vision.

Limbal corneal melting may occur with surprisingly few symptoms.5 A furrow appears near the limbus with or without significant inflammation attendant to it. Continuing melting of the cornea may lead to perforation and loss of the eye if not aggressively treated.

Diagnosis of each of these problems is relatively easy with biomicroscopy; however, determining the etiology may be difficult if not impossible. Events may predate systemic signs and symptoms by long periods of time. A basic laboratory screen should include S M A- 1 2, CBC, sedimentation rate, antinuclear antibodies, LE prep. Further investigation for granulomatous disease may be justified. This should include a chest X-ray, TB skin tests, and appropriate syphilis antibody screen.

Treatment usually involves corticosteroids, antiinflammatory agents, and possibly immunosuppressive drugs, anti-tuberculous agents and antibiotics. Therapy should be a coordinated effort between the pediatrician and the ophthalmologist to avoid the serious systemic side effects of the drugs and to monitor the eye.

ALLERGIC PHENOMENA

The eye is exposed to many allergens from the air, hands, and chemicals as in cosmetics or eyedrops. The thin skin of the eyelids and the exposed filmy conjunctiva allow allergens easy access. Immediate and delayed type reactions occur frequently and common features of allergic reactions include the following.

The typical immediate type reaction of the eye is that of hay fever conjunctivitis. The rapid onset of conjunctival injection, Chemosis, tearing, and itching is usually dramatic. The reaction may be unilateral and may at times simulate an infectious problem except that itching is usually a prominent feature. The reaction is usually selflimited and no treatment is necessary. Topical vasoconstrictors may reduce itching and injection. Topical antihistamines are of limited value.

Contact dermatitis occurring from substances applied to the skin of the eyelids or instilled in the eyes is common. This is a prototype of a cell-mediated response. Children are probably somewhat less affected than adults because few chemicals are intentionally placed on the face, eyes, or hands.

Typically with substances on or near the lids the contact dermatitis causes the very thin skin to become edematous and reddened. This may be confused with preseptal cellulitis, but itching is usually a prominent feature of contact dermatitis but not of cellulitis. The skin may become very scaly and fissured.

Treatment with topical steroid cream or lotion applied to the skin three times per day usually produces dramatic improvement. Parents should be instructed to try to discover the probable allergen. Laundry detergents, fabric softeners, shampoo, soap, and cosmetics are common offenders. Avoidance of the offending substance is paramount to treatment. Steroids should not be continued beyond a week unless the patient is closely supervised by an ophthalmologist. Drops or ointments instilled in the eye may cause the same reaction on the eyelids; but, in addition, the conjunctiva becomes inflamed and chemotic.

Vernal conjunctivitis is a recurring inflammation of the conjunctiva which has a presumed allergic origin. As the name implies, it predominantly occurs in warm weather. It is usually bilateral, and occurs in patients under the age of 20. The clinical features include itching, redness, and a thick ropy discharge. There is commonly a diffuse punctate keratitis and rarely an ovoid corneal ulcer. The most prominent pathological features are large excrescences of the tarsal conjunctiva caused by the breakdown of subconjunctival fibrous bands probably from the chronic edema. There may be limbal follicles as well, which are edematous areas surrounding the cornea. Tiny white dots (Trantas dots) may be present in the limbal follicles which are actually conglomerations of eosinophils which can be seen on a conjunctival scraping.

Therapy should be symptomatic. Simple irrigation of the secretions several times per day is helpful. Topical decongestants help to relieve itching but antihistamines are of limited value. Topical steroids may abate the symptoms in many cases but because of the attendant side effects, one should exercise extreme caution in their use. Chromalyn topically applied in a 49c solution q.i.d. is very helpful in a few recalcitrant cases. The presumed mechanism of action of chromalyn is the stabilization of mast cell membranes, thereby interfering with the release of histamine. The powdered chromalyn is extremely difficult to dissolve- triple distilled water must be used with continual warming and stirring.

INFECTIONS

Virulent organisms may attack the eye; and, due to the relatively poor immune response and poor penetration by antibiotics, the eye may be lost in spite of massive antibiotic therapy. For the same reasons even "nonvirulent" organisms may be extremely destructive. What might be "normal flora," under certain conditions may cause severe ocular infections. It is not surprising to find organisms which usually do not cause infections elsewhere in healthy patients infecting the eye. Remember that almost any organism cultured may be significant. It is not uncommon to have only two or three colonies on a culture plate, therefore, the laboratory should be instructed not to ignore isolated coloniesascontaminants.

The eyelids are the site of infection for a number of organisms. Vascularization of the lids is extremely good; however, staph, strep, hemophilus, and herpes may set up infections in the eyelid skin and meibomian glands. Bacterial cellulitis causes acute swelling and erythema of the lids. Pre -septal cellulitis should be treated with topical and systemic antibiotics and the patient followed closely to prevent advancement to orbital cellulitis. Differentiation can be made by the lack of pain on movement of the eye and lack of inflammation of the eyeball in pre-septal cellulitis. Orbital cellulitis produces significant edema of the lids. Chemosis, pain, decreased vision, limitation of motion of the globe, pyrexia, and systemic symptoms. Aggressive IV antibiotic therapy is necessary to prevent septicemia and or spread of the infection through the orbital veins to the cavernous sinus.

Table

TABLE 2OPHTHALMIA NEONATORUM

TABLE 2

OPHTHALMIA NEONATORUM

Bacterial or viral conjunctivitis is generally self-limited and not usually severe. Severe cases may result from many organisms including herpes type 1 and II. Adjacent areas, especially the cornea, may become involved with subsequent loss of the eye or. at best, loss of vision due to scarring. The conjunctiva, especially in the newborn or compromised host, may serve as the portal of entrv in cases of meningoencephalitis. Ophthalmia neonatorum can never be taken lightly and the etiologic agent should be sought in all cases. Pseudomonas or steroid enhanced herpes may cause extremely rapid necrosis of the cornea with penetration of the eye. N. Gonorrhoeae and C. Diphtheriae may penetrate intact epithelium.

A wide range of organisms can be implicated but the ...

TABLE 1

COMMON CAUSES OF CONJUNCTIVITIS

TABLE 2

OPHTHALMIA NEONATORUM

10.3928/0090-4481-19830701-05

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