EYE DISEASES IN NEONATES

DISEASE ETIOLOGY and EPIDEMIOLOGY CLINICAL DIAGNOSIS and MANAGEMENT

PATHOPHYSIOLOGY MANIFESTATIONS DIFFERENTIAL
DIAGNOSIS
Ophthalmia Inflammation of the ocular - Usually acquired a. Chemical a. Gram stain & culture a. Chemical ophthalmia
neonatorum surface that occurs during during vaginal delivery ophthalmia of purulent discharge. • prophylaxis of 2.5%
the 1st month of life due to & reflects the STIs • self-limiting b. Viral culture, if a viral povidone-iodine solution
either chemical or bacterial prevalent in the irritation & redness cause is suspected b. Bacterial ophthalmia
causes. community b. Bacterial ophthalmia c. In chlamydial • Neisseria gonorrhea –
a. Chemical - Gonococcal • Neisseria conjunctivitis: Ceftriaxone 28 to 50mg/kg by
ophthalmia – ophthalmia gonorrhea – • examining Giemsa IV or IM
occurs during the neonatorum has an marked red stained epithelial • Chlamydia trachomatis –
1st 24 hours incidence of 0.3/1,000 chemosis & cells for the erythromycin ointment to OU;
secondary to silver live births in US. copious discharge characteristic for disseminated infection
nitrate use - Chlamydia w/c may lead to intracytoplasmic erythromycin oral 50mg/kg/d
b. Bacterial trachomatis is the rapid ulceration & inclusions in 4 divided doses for 10-14
ophthalmia most common perforation of the • immunofluorescent days
a. Neisseria organism causing cornea; systemic staining of c. Viral conjunctivitis
gonorrhea ophthalmia infection may conjunctival • Self-limiting; supportive
which neonatorum in the US, cause sepsis, scrapings for treatment w/ cold compress &
occurs in with an incidence of meningitis & chlamydial artificial tears
the 1st 1 – 8.2/1,000 births arthritis inclusions
3 days of • Chlamydia • tests for chlamydial
life up to 3 trachomatis – mild antigen or DNA.
weeks swelling,
b. Chlamydia hyperemia & DDx: includes
trachomati papillary reaction dacryocystitis caused
s during w/ minimal to by congenital
the 1st moderate nasolacrimal duct
week after discharge obstruction with
birth, which c. Viral conjunctivitis lacrimal sac distention
is • minimal
associated conjunctival
with PROM hyperemia &
c. Viral conjunctivitis watery discharge
– may be due to
Adenovirus or
herpes simplex
virus that occurs
during the 1st 2
weeks of life
TORCH Congenital infections TORCH infections are a. Toxoplasmosis Physical examination a. Toxoplasmosis
Syndromes caused by toxoplasma, major contributors to • Triad: and appropriate • Pyrimethamine, sulfadiazine,
rubella, cytomegalovirus, prenatal and infant hydrocephaly, investigation of the trisufalpyrimidine & folinic
herpes simplex virus morbidity and mortality intracranial infant. acid
(TORCH) & syphilis. in low to middle- a. Toxoplasmosis
a. Transmission may occur
prenatally, perinatally, and
postnatally via:
• transplacental passage
of organisms
• contact with blood and
vaginal secretions
• exposure to breast
milk.
** CMV – more prevalent in
immunocompromised
patients
income countries, calcifications & • Serial IgG • Recurrent: same agents w/ or
where the burden of ocular lesions measurement (for w/o clindamycin
disease is greatest. • Ocular: maternal infection) b. Rubella
retinochoroiditis, • Amniotic fluid PCR • Lensectomy
gliosis, moderate- (for fetal infection) • Topical steroids & mydriatics
to-dense b. Rubella • Visual rehabilitation to treat
pigmentation • Isolation of virus amblyopia
b. Rubella • Evidence of • Glaucoma surgery to treat
• Birth defects, seroconversion congenital clacuma
blindness, hearing c. Cytomegalovirus c. Cytomegalovirus
loss & mental • Viral culture, PCR • Ganciclovir or valganciclovir
retardation. d. Herpes Simplex IV
• Ocular: glaucoma • HSV culture or d. Herpes Simplex
or cataract, PCR • Idoxyuridine 1.0%,
microphthalmos & • Immunofluorescent Vidarabine 3.0% &
salt-and-pepper e. Syphilis Trifluorothymidine 1.0%
retinopathy • darkfield • Acyclovir 20mg/kg TID by IV
c. Cytomegalovirus microscopy of infusion
• Sensorineural lesions, e. Syphilis
hearing loss, placenta, or • Topical corticosteroids &
mental retardation umbilical cord cycloplegics
& retinochoroiditis • serologic
• Ocular: cataract, testing of ** Immunization with MMR
microphthalmos, mother and vaccine decreases clinical cases
anomalies of optic neonate; CSF
nerve & analysis
retinochoroiditis
d. Herpes Simplex
• External infection
of skin, eyes,
mouth or
disseminated
infection involving
the brain
(encephalitis), liver
& lungs
• Ocular:
conjunctivitis,
keratitis, cataract &
retinochoroiditis
e. Syphilis
• Interstitial keratitis,
rapidly progressive
corneal edema &
vascularization
“salmon patch”
Congenital Lens opacity present at
Cataract birth.
Most congenital cataracts
have unknown etiology.
• Unilateral cataracts
may present an
abnormality in lens
development or may be
assoc. w/ other eye
abnormalities
• Bilateral cataracts have
a systemic association
or inheritance pattern
Congenital a. Primary congenital
Glaucoma glaucoma or infantile
glaucoma is present within
the 1st 2 years of life
• It is the most common
cause of glaucoma in
infancy
b. Secondary glaucomas
occur as result of
- Incidence of infantile • Cloudiness of the a. General PE of infants a. Surgical removal of cataracts
cataracts is approx. 2- lens with cataracts • Unilateral cataracts should be
13/10,000 live births. • Leukocoria (white (including removed before the infant is 6
- Cataracts are more pupil) ophthalmologic & weeks old for the best visual
common in LBW developmental exams) outcome
infants. b. Beta-scan UTZ to • Dense bilateral cataracts
- Hereditary cataracts rule out concomitant should be removed before 10
comprise 30% of intraocular tumor or weeks of age, after which
bilateral cataracts, w/ retinal detachment nystagmus develops
autosomal dominant c. Lab work-up for b. Lensectomy to extract infant
inheritance pattern. unilateral cataracts: cataracts
- Cataract is present in • TORCH titer c. Automated vitrectomy for
10% of patients with • VDRL test capsulectomy & anterior
Down syndrome. d. For bilateral vitrectomy to prevent secondary
cataracts: re-opacification of visual axis
• Same with d. Intra-ocular lens (IOL)
unilateral placement best done after 2
• Urine-reducing years of age
substances e. Aphakic glasses for bilateral
• Urine amino acids aphakic infants
for Lowe syndrome f. Occlusion therapy for
• IgM antibodies in amblyopia
cord blood or rising
IgG titers if
congenital rubella
is suspected
• Calcium &
phosphorus for
hypoparathyroidism
DDx:
• TORCH infections
• Hypoparathyroidis
m
• Lowe syndrome
• Prematurity
• Galactosemia
- More than 50% of Symptoms of infantile a. Eye examination with a. Glaucoma surgery to increase
infantile cases are glaucoma include the findings of: outflow of aqueous from eye:
primary glaucoma with classic triad: • increased IOP • goniotomy
an incidence of 0.03%. • epiphora (tearing) • enlarged corneas • trabeculotomy
- In secondary • photophobia • optic disc changes • trabeculectomy
glaucoma, other ocular (sensitivity to light), b. Anti-glaucoma meds as
or systemic • blepharospasm DDx: adjunct to surgery:
abnormalities are (eyelid squeezing)
associated, even if a
 inflammation, trauma or
surgery to the eye during
infancy
• aphakic or
pseudophakic
glaucoma occurs after
surgery & is the 2nd
most common form of
glaucoma in infancy
Retinopathy of Premature infants and
Prematurity those with low birth weights
(POM)
also blood transfusion,
patent ductus arteriosus,
intraventricular
hemorrhages.
Arrest of normal
vascularization, leaving
anterior parts of the retina
avascular.
Neovascularization invades
the vitreous and the
fibrovascular proliferation
leading to traction and
retinal detachment
ETIOLOGY and
PATHOPHYSIOLOGY
Congenital Systemic conditions: Down
esotropia Syndrome & albinism.
similar developmental Increased ocular • Nasolacrimal duct • Timolol 0.25% or 0.5% given
defect of the pressure: obstruction to topically BID is the drug of
trabecular meshwork • Buphthalmos • megalocornea, choice
is also present. • Corneal edema corneal scarring • Acetazolamide 5-10 mg/k/d
• tearing from obstetrical PO
trauma • Dorzolamide & brinzolamide
• Congenital rubella topical
• Latanoprost
c. Cyclodestructive procedures:
• Cyclocryotherapy
• Transcleral laser
cycloablation
Severe ROP in 37%of Regression myopia, Dilated fundus exam Treatment
infants w/a bw of 750g astigmatism, using cyclopentolate, Cyrotheraphy
8.5% of infants w/a bw anisometropia tropicamide, and
of 1000g-1250g ,strabismus, glaucoma phenylephrine (Anti-VEGF) ex. Bevacizumab
and late retinal Laser therapy via binocular
detachment. DDx: The main indirect opthalmascope
differential diagnostic
considerations for early
ROP are conditions Lens sparing vitrectomy for Stage
associated with 4a
peripheral avascular
retina and intravitreal Vitreo-retinal surgery for stages 4
neovascularization, &5
including familial
exudative Prevention
vitreoretinopathy Screening
(FEVR) or incontinentia neonates (AOG 22-27weeks) 1st
pigmenti (see these examination at 31 weeks
terms). For stage 5
ROP, other conditions (AOG 28-32)
causing leukocoria are 1st examination at chronological
included (e.g. age of 4 weeks.
retinoblastoma,
persistent fetal
vasculature,
toxocariasis, etc.
EYE DISEASES IN INFANTS
EPIDEMIOLOGY CLINICAL DIAGNOSIS and MANAGEMENT
MANIFESTATIONS DIFFERENTIAL
DIAGNOSIS
8.1 % of all Eye-crossing in birth Complete eye exam w/ Strabismus surgery, frequently
esodeviations and this anterior segment bilateral medial rectus
examination recessions.
 Those with cerebral palsy.
Infants with a family history
of esotropia and or
strabismus.
The exact cause of infantile
esotropia remains
unknown. While some
opine that esotropia is due
to excessive tonic
convergence, few agree on
what accounts for such
conditions. Worth strongly
believed that esotropia is
an inborn and irreversible
defect of fusion. As such, it
is a primary dysfunction in
the normal development of
binocular sensitivity.
Congenital most commonly a
Nasolacrimal membranous obstruction at
Duct the valve of Hasner at the
Obstruction distal end of the
nasolacrimal duct. General
stenosis of the duct is the
second most common
cause of duct obstruction.
Congenital proximal
lacrimal outflow dysgenesis
involves maldevelopment
of the punctum and
canaliculus. Proximal
outflow dysgenesis can
occur concurrently with
distal obstruction.
Congenital lacrimal sac
mucocele or
dacryocystocele occurs
when there is a
membranous cyst
extending from the distal
end of the duct into the
nose.
can happen in 1 out of Variable angle
403 live births intermittent esotropia Dilated fundus exam Amblyopia therapy
in first few months
Cycloplegic refraction Miotics, patching and glasses.
Latent nystagmus
(Bilateral& Jerky) Cover testing
Other signs
Amblyopia, Motor DDx:
abnormalities (Inf. Duane syndrome, 6th
Oblique overaction & nerve paresis, sensory
dissociated vertical esotropia and
deviation) accomodative
esotropia.
Present in 5% of term Regurgitation of Dye disappearance test Conservative: Crigler massage
babies purulent material into
the eye can cause DDx: NLD probing
conjunctivitis and a The differential
history of recurrent diagnosis of if failed NLD probing, balloon
"pink eye" in an infant nasolacrimal duct catheter dilation % silicone
or young child obstruction includes intubation.
acute conjunctivitis,
Epiphora. Pressure on glaucoma, congenital External dacryocystorhinostomy
lacrimal sac anomalies of the upper for only 5 years and above
lacrimal drainage
Repeated infections system (punctal or Endoscopic DCR for younger
canalicular atresia or children.
agenesis), entropion
and triachiasis.
 The fluid becomes purulent
within days of birth and
neonatal dacryocystitis
occurs
ETIOLOGY and
PATHOPHYSIOLOGY
Amblyopia Amblyopia is believed to
result from disuse from
inadequate fovea or
peripheral retinal
stimulation and or
abnormal binocular
interaction that causes
different visual input from
the fovea
Leading cause of
preventable blindness in
developed countries.
EYE DISEASES IN TODDLERS
EPIDEMIOLOGY CLINICAL DIAGNOSIS and MANAGEMENT
MANIFESTATIONS DIFFERENTIAL
DIAGNOSIS
Not firmly established The presence or Crowding phenomenon Anisometropic amblyopia &
retinocortical absence of signs of or better visual acquity ammetropic : Prescription glasses
connections amblyopia would when using a single
depend on what the optotype versus Strabismis ammetropic
underlying etiology for reading a line. Surgery & glasses
the amblyopia is.
• Deprivational Vision better in dark Deprivational amblyopia
amblyopia could settings than in bright Lensectomy
manifest with ones Intralesional injection of steroid
ptosis, an eyelid Corneal transplant
hemangioma, or a DDx: all within 2-3months.
cataract for • A-Pattern Esotropia
example. and Exotropia Occlusion therapy ex. Eye patch
• Strabismic • Accommodative and or atropine
amblyopia may Esotropia
show a constant or • Acquired Esotropia
intermittent ocular • Acquired Exotropia
deviation. • Congenital
• Anisometropic Exotropia
amblyopia often • Congenial Ptosis
shows no obvious • Esotropia with High
signs when AC/A Ratio
observing the • Infantile Esotropia
patient, but • Monofixation
cycloplegic Syndrome
retinoscopy will • V-Pattern Esotropia
reveal the and Exotropi
anisometropia.
• On clinical
examination,
unilateral
amblyopia will
show asymmetric
visual behavior or
acuity testing
results (although
not all patients with
asymmetric acuity

Strabismus Any misalignment of the
eyes from the visual axis.
Horizontal: medial rectus
and lateral rectus
Vertical: superior rectus,
inferior rectus, superior
oblique and inferior oblique
muscles
have amblyopia).
Severe cases may
have a mild
afferent pupillary
defect.
• The crowding
phenomenon is
important to be
aware of when
testing visual
acuity in an
amblyope. The
amblyopic eye of
these patients will
visualize individual
letters better than
a whole line of
letters.
• Therefore if the
visual acuity tester
uses individual
letters (sans
crowding bar), then
they may
underestimate the
degree of
amblyopia that is
present or miss it
entirely. A neutral
density filter
significantly
reduces vision in
organic disease,
but generally does
not in pure
amblyopia
Caucasians: Commitant Esotropia Pseudoesotropia Accommodative Esotropia
esotropia more The degree of crossing • Hirschberg’s test: • Giving the full hyperopic
common than is the same whether the corneal light correction clears the retinal
exotropia among measured in the reflexes are in the image which then relaxes
Caucasians. fixating eye (straight) center of both accommodation/convergence
or in the deviated eye pupils , causing the eye to align.
Americans > 19 y/o: (crossed); the degree
Esotropia:Exotropia is the same from the Acquired esotropia: • Amblyopia of any type should
ratio (65:35) primary gaze (straight) • Usually presents be treated with atropine
to right and left gaze. with diplopia penalization.
Congenital or acquired
structural anomalies of the
extraocular muscles and
adjacent orbital structures
can cause strabismus
Incommitant esotropia:
secondary to a weak lateral
rectus muscle or restriction
of the medial rectus. It may
be congenital or acquired.
Cranial Nerve VI Palsy:
Complete or incomplete
paralysis of the abduscens
nerve manifests as
weakness of the lateral
rectus muscle, causing
horizontal misalignment.
Duane’s Syndrome:
Congenital absence of CN
VI and an aberrant
regeneration of the
developing CN III.
Moebius Syndrome:
Bilateral symmetrical or
asymmetrical paralysis of
the facial nerves and
horizontal gaze palsy, with
marked bilateral abduction
limitation and a variable
limitation of adduction.
Intermittent exotropia:
divergent strabismus that
has a phoric (controlled by
fusional convergence
mechanisms) and trophic
(manifests as divergent
strabismus) phase.
Asians: • To rule out vascular
Exotropia 2.5x more Accommodative causes: • For any crossing that persists
common than Esotropia ✓ Ophthalmologic despite the use of
esotropia It initially occurs exam eyeglasses, correction and
intermittently, and then ✓ Neurologic surgery may be needed as an
Accommodative becomes more exam adjunct treatment
Esotropia: constant. The crossing ✓ MRI or CT scan
Convergent is more notable when of the brain Cranial Nerve VI Palsy:
strabismus that the child focuses at • Depends on the remaining
presents most near distances. Cranial Nerve VI function of the lateral rectus
frequently when the Palsy: muscle
child is 2 to 3 years Pseudoesotropia Confirmed by negative • Complete paralysis:
old. Prominent epicanthal forced duction test transposition procedure
folds give the which indicates the • Incomplete paralysis:
Duane’s Syndrome: impression that the lateral rectus muscle strengthening procedure
Most individuals with eyes are crossed function is absent or
isolated Duane’s because the excess deficient Intermittent exotropia:
syndrome are simplex skin hides the nasal • Strabismus surgery before
cases (i.e., single sclera the loss or decline of depth
occurrence in a family) • Incommitant perception. Early surgery:
of unknown cause. esotropia: superior sensory outcome
convergent
Isolated Duane’s strabismus • Non-surgical: over minus
syndrome resulting wherein the degree lenses, prisms, and alternate
from a heterogenous of crossing patching (temporizing
mutation in CHN1 is changes as the procedures).
inherited in an patient shifts from
autosomal dominant straight gaze to Convergence insufficiency:
manner with right to left gaze Orthoptic exercises to increase
incomplete convergence amplitude
penetrance. Cranial Nerve VI
Palsy:
• Presents with
Convergence esotropia that
insufficiency: increases when
Accounted for 10% of looking towards
all cases of exotropia. the side of the
Presents at an weak muscle.
average of 6 to 8 There is abduction
years of age and are deficit.
more myopic and
astigmatic. Duane’s Syndrome:
• Lid fissure
narrowing on
attempted
adduction and can
 Convergence
insufficiency:
Inability to maintain
convergence on objects as
they approach from
distance to near.
Sensory Strabismus
(Esotropia/Exotropia):
Results from the loss of
vision secondary to optic
and retinal pathology. It can
also occur secondary to
poor vision from amblyopia
secondary to congenital
cataracts and uncorrected
high errors of refraction.
Retinoblastom 94% of cases: arise from
a somatic non-hereditary
mutations in retinal cells,
resulting in unilateral
tumors.
6% of cases: inheritable
form; autosomal dominant
sometimes be
accompanied by
globe retraction.
• Present with the
face turned
towards the
affected side.
Moebius Syndrome:
Esotropia with absent
abduction and no facial
expression
Intermittent
exotropia:
• Child looks at a
distance that
progresses to a
constant deviation,
and then moves to
a near deviation.
• Patients complain
of blurring of
vision, asthenopia,
photophobia, and
squinting when
exposed to bright
sunlight.
Convergence
insufficiency:
Presents with
symptoms of reading
difficulty, blurred near
vision and diplopia.
Most common primary Retinoblastoma: Dilated eye Mode of treatment is based on
intraocular tumor in • presents as a examination: indirect the stage of the disease.
the Philippines and 2nd “white pupil” or ophthalmoscope with
most common cat’s eye reflex. scleral depression Small tumors: cryotherapy and
intraocular malignancy Leucocoria is the ✓ white to grayish laser photoablation
in all age groups. most common mass with or
presentation (77%) without overlaying
retinal vessels
 pattern with complete Family incidence: 7- followed by Tumors that occupy more than
penetrance 8% in the Philippines. strabismus (11%). B scan ultrasound: 50% of the eye: enucleation of
✓ presence of the involved eye
Normal parents w/ 1 STAGES: intraocular
affected child: 5% Stage 1: Intraocular calcium deposits Bilateral cases: External beam
chance of having a 2nd stage (tumor confined radiation (if not amenable to
child with within the retina) CT scan: cryotherapy and laser
retinoblastoma ✓ to assess the photocoagulation) but may induce
Stage 1A: Early extent of the a secondary nonocular tumor.
Parents with affected intraocular tumor disease
2nd child: 45% chance (tumor less than half of Chemotherapy: to reduce the
of having a 3rd child the retinal surface) CT scan or MRI: tumor size prior to cryotherapy or
with the condition. confirmatory laser photocoagulation; also used
A1: tumor size <4 DD in treatment of metastatic
Retinoblastoma A2: tumor size 4 DD to Lumbar puncture: diseases.
survivor: 50% chance 10 DD done in patients with
of having the child with A3: tumor size >10 DD metastatic disease prior Brachytherapy: recommended
the same disease to 15 DD to chemotherapy in treating small to medium-sized
eye tumors but it may lead to
Male to Female ratio: Stage 1B: Late radiation optic neuropathy.
1.2:1 (Philippines); 1:1 intraocular tumor
(worldwide) (tumor more than half Genetic counseling of the
of the retinal surface or family: part of the therapy if case
Diagnosed between 1 >15 DD) is heritable type
to 3 years in sporadic
unilateral cases and Stage 2: Intraocular far
during 1st year of life advanced stage.
in familial and bilateral Tumor and/or
cases. pathologic changes
have spread to ocular
Average onset of structures
symptoms: 14
months Stage 3: Intraocular
and/or metastatic
spread. Tumors has
extended out to the
eyeball into the orbit
(intraorbital) or to
distant tissues
(metastatic)

OCULAR INFECTIONS AND INFLAMMATION

DISEASE ETIOLOGY and EPIDEMIOLOGY CLINICAL DIAGNOSIS and MANAGEMENT
PATHOPHYSIOLOGY MANIFESTATIONS DIFFERENTIAL
DIAGNOSIS
Acute Bacterial Hyperemia of the Patients present with Topical antibacterial drops may
Conjunctivitis conjunctiva of less than 3 unilateral or bilateral shorten the course of disease. If
weeks in duration. conjunctival left untreated, will last 2 weeks.
hyperemia,
Most common etiologic mucopurulent
organisms: Steptococcus discharge, morning lid
pneumoniae, sealing, and foreign
Haemophilus sp., body sensation.
Moraxella spp.
Hyperacute Occur when the duration of High index of Conjunctival scrapings Prompt treatment.
and Chronic symptoms is from 24 hours suspicion: explosive should be obtained for If no corneal perforation: 1g IM
Bacterial to a few days. Chronic onset of copious culture and sensitivity Ceftriaxone
Conjunctivitis hyperemia: if lasting > 4 discharge, morning lid studies
weeks sealing, and foreign If with corneal perforation: 1g
body sensation IV Ceftriaxone q 12 hours should
Possible pathogens: be given for 3 days.
Neisseria gonorrhea,
Neisseria meningitidis,
Streptococcus and
Staphylococcus
Blepharokerato Etiologic agents: Syndrome associated Diagnosis requires the Lid hygiene, topical antibacterials
conjunctivitis Staphylococcus aureus, with anterior or following features: and steroids to address
S. epidermidis, posterior lid margin ✓ recurrent inflammation.
Haemophilus influenza, blepharitis, episodes of
Steptococcus accompanied by chronic red eye Macrolides such as erythromycin
pneumoniae and episodes of ✓ tearing appear to penetrate and
Moraxella catarrhalis. conjunctivitis, and a ✓ photophobia accumulate in the Meibomian
keratopathy including ✓ blepharitis glands, affecting sebum
punctate erosions, including composition as well as inhibiting
punctate keratitis, recurrent styes or protein synthesis and lipase
phylctenules, marginal Meibomian cysts production
keratitis and ulceration ✓ keratitis

Definitive diagnosis:
Gram stain and
bacterial culture
Allergic Noninfectious type of Present with an acute, External eye Systemic antihistamines: not
Conjunctivitis conjunctival inflammation bilateral pale examination with slit very effective
characterized by a type 1 conjunctival edema lamp biomicroscopy:
hypersensitivity reaction (pink eye) with little follicles or giant papillae Start patients on topical
discharge, tearing, on palpebral antihistamines and mast cell
TYPES: photophobia and conjunctiva stabilizer, NSAIDS and steroid-
marked itchiness. (+) containing eye drops
a. Seasonal History of allergy; Vernal
keratoconjunctivitis: associated with keratoconjunctivitis:
triggered by asthma, atopic SLIT LAMP
 environmental contact dermatitis, and allergic BIOMICROSCOPY:
with airborne allergens, rhinitis giant papillae in the
dust mites and dander tarsal conjunctiva of the
from pets Seasonal upper eyelid
keratoconjunctivitis:
b. Vernal Hyperemia, watery
keratoconjunctivitis: eyes and itchiness.
seasonal occurrence Children: “allergic
during the vernal shiners”
months
Vernal
Atopic keratoconjunctivitis:
keratoconjunctivitis: intense itching,
associated with atopic blepharospasm,
dermatitis, eczema and foreign body sensation
asthma and photophobia with
palpebral and bulbar
conjunctival
involvement

Atopic
keratoconjunctivitis:
Chronic nature: inferior
palpebral conjunctiva
has papillae and
scarring
Viral TYPES: Epidemic Minimal conjunctival Herpes Simplex Virus Supportive treatment with cool
conjunctivitis a. Epidemic Keratoconjunctivitis: hyperemia and watery Conjunctivitis: compress and artificial tears.
Keratoconjunctivitis: highly contagious and discharge lasting for FLUORESCEIN OR Topical antibacterial drops when
Adenovirus 18, 19, occurs during few days ROSE BENGAL there is secondary bacterial
and 37 epidemics STAIN: dendritic or infection
Epidemic geographic lesions of
b. Pharyngoconjunctival Keratoconjunctivitis: the corneal epithelium Herpes Simplex Virus
Fever (PCF): present with bilateral Conjunctivitis: topical antiviral
secondary to infections follicular conjunctivitis, medications such as Trifluridine
caused by Adenovirus preauricular or Vidarabine
3 and 7 lymphadenopathy and
significant corneal Topical cycloplegics: decrease
Herpes Simplex Virus involvement synechiae formation secondary to
Conjunctivitis inflammation
Pharyngoconjunctiva
l Fever (PCF): Supportive treatment with
conjunctival preservative-free ocular
hyperemia, lubricants is recommended
subconjunctival
hemorrhage, edema,
 tearing, lid swelling, Facial and other mucosal
sore throat, fever and membrane diseases and
preauricular recurrent keratitis: Acyclovir
lymphadenopathy. 15mg/kg per day in divided doses
Symptoms last for 2
weeks

Herpes Simplex Virus

Conjunctivitis: pain,
photophobia, tearing
with conjunctival
hyperemia, watery
discharge and a
decrease in corneal
sensation
Bacterial Develops secondarily to an Not common in Presents with pain, (+) History of trauma Topical antibiotic eye drops and
keratitis antecedent trauma or children photophobia, tearing and topical steroid use cycloplegics
infections caused by due to corneal infiltrate
pathogens: Pseudomonas and/or ulceration SLIT LAMP
aeruginosa and EXAMINATION:
Streptococcus assess pattern of
pneumoniae corneal inflammation
Preseptal Inflammation of tissues Presents with eyelid Complete eye < 1 year old: IV antibiotics should
cellulitis anterior to the orbital edema, taut and examination: Full be started immediately because
septum. inflamed periorbital ocular motility, no pain of risk of sepsis and meningeal
skin when moving involvement
Likely pathogens: extraocular muscles
Staphylococcus aureus, No proptosis or signs > 1 year old: Oral antibiotics:
Streptococcus pyogenes of inflammation on the Severe conjunctivitis: Ampicillin-clavulanic acid
and Streptococcus globe Gram stain, culture and
pneumoniae sensitivity while on
empiric therapy

Orbital and cranial CT

scan: suspected cases
• Lethargy, Fever, a. History and PE Pharmacologic
a. Children less than 9: Eyelid Edema, b. Orbital CT and ✓ IV Cloxacillin and IV
Usually caused by single Rhinorrhea, Cranial CT needed to cefuroxime/cefotaxime
aerobic pathogens such as Headache, Orbital rule out
Infection of the orbit
S. aureus or Bacillus sp. Pain, and • Cavernous Sinus Surgical
Orbital and involves tissue
Tenderness on Thrombosis ✓ Emergency drainage of
Cellulitis posterior to the orbital
b. Older patients: Palpation • Intracranial abscess
septum
Combination of aerobic and • Poor suck in very Extension
anaerobic organisms young patients (Meningitis, Non-pharmacologic
• Limited ocular Periosteal ✓ Frequent handwashing to
rotation and Abscess, and prevent secondary infections
 c. Contiguous spread from proptosis indicates Subdural Abscess) such as conjunctivitis
paranasal sinusitis progression towards
(particularly the development of
cavernous sinus
thrombosis
• Some may have
optic nerve
compression

EYE DISEASES IN SCHOOL-AGE CHILDREN

DISEASE ETIOLOGY and EPIDEMIOLOGY CLINICAL DIAGNOSIS and MANAGEMENT
PATHOPHYSIOLOGY MANIFESTATIONS DIFFERENTIAL
DIAGNOSIS
a. Myopia
(Nearsightedness)
Error of The eyeballs are Blurred vision at
• An eye that is not Correction using biconcave lens
Refractions longer and thus distance
naturally in focus for
focuses in front of the
distance vision, thus
retina
requiring corrective
• Visual Acuity testing
lenses to be in good b. Hyperopia
• headaches from and
focus. (Farsightedness)
extended periods of
• An eye with errors of The eyeballs are short Correction using biconvex or plus
near work blurred • Testing for refractive
refraction is generally and flatter, causing lens
vision at near error using
refered to as an light to focus behind
the retina retinoscopy
ametropic eye

Epidemiology:
c. Astigmatism
Curvature of cornea or
• Myopia 9% lens is not the same in
• Hyperopia 13% • blurred vision in all
different meridians Corrected using cylindrical lens
• Astigmatism 28% distances
causing light to focus
on 2 separate lines or
planes.

Infectious • JIA associated uveitis • Determine best

Inflammation of the uveal Stepwise approach,
• Viruses are the are often corrected visual
tract which is composed of • Begin with topical steroids and
Uveitis most common asymptomatic and acuity
the Choroid, Ciliary Body mydriatics
(Anterior) cause (HSV, VZV, have no pain or • Accessing anterior
and Iris Move to regional steroids,
Mumps) photophobia, but segment
systemic NSAIDs, systemic
eyes appears white Laboratory
 Classified according to area • Previous episodes of examinations such as steroids, immunosuppressives
affected: Non-infectious pink eye or ANA, RF, HLA-B27 and biologic.
• Anterior • More common conjunctivitis, blurry
• Intermediate • Juvenile vision, ocular pain, or
• Posterior Idiopathic abnormal pupil size
Panuveitis Arthritis • Signs of bilateral non-
Spondyloarthropathie granulomatous
s such as Ankylosing iridocyclitis
Spondylitis, Psoriatic • For chronic cases,bnd
Arthritis, IBD, Reactive keratopathy,
Arthritis) Secondary glaucoma,
Hypotony may be
seen.

TRAUMA
• Most common cause of enucleation in children over the age of 3
• 40% of cases occurs at home
• In patients with eye trauma, protective measures (eye shield or disposable coffee cup) should be given to prevent further injury to the
eye if treatment will be done at a later time.
1. Trauma
• Child abuse should also be ruled out, clues includes bilateral black eyes or lid ecchymosis
• Retinal hemorrhages are hallmark of shaken baby syndrome
• In patients under 3, presence of retinal hemorrhages or any traumatic disruptions of the structures around the eye should raise
suspicion of child abuse.
Birth and Prenatal Trauma

Type Common Mechanisms of Injury Clinical Findings Treatment

Descemet’s
Rupture Forceps Delivery Hazy Cone Ambylopia Treatment
(Haab’s Strea)
Injury to Lids and Adnexae
• Cold compresses followed by
warm compresses after 24
Ecchymosis of hours
Blunt Trauma Redness of Eyelids
eyelids
• Evaluate for globe and orbital
injury
• Sharp Objects, • Evaluate for globe injury
Lid Lacerations
• Animal bites, • Primary edge to edge closure
 • Strong blows by blunt objects of lacerations
• Antibiotics and anti-tetanus
• Referral to ophthalmologist if
laceration involves lid margin
and other adnexal structures
like canaliculus and levator
palpebral

Orbital Trauma
• Diplopia
• X-ray and CT-Scan
Blow-out • Limitation of upward gaze
Objects larger than the orbital opening impact the • Antibiotic prophylaxis, ice
fracture of the • Enophthalmos, lid ecchymosis, epistaxis,
orbit (Ball, fist, vehicle dashboard) compress
orbital floor hypesthesia of ipsilateral cheek and upper
• Referral to ophthalmologist
lid
Injuries to the Globe
Injuries to
conjunctiva
In the absence of other
Subconjunctival
Blunt trauma Red eye injuries: ice compress then
Hemorrhage
warm compress
Conjunctival Evaluate for scleral perforation
Swelling of the conjunctiva
edema or foreign body
• Ophthalmoscopy with dilated
pupil to rule out foreign body
• Red eye (subconjunctival hemorrhage)
• Evaluate for sclera
Conjunctival
Sharp object (fingernail, glass) perforation
laceration • Prolapse of white appearing Tenon’s tissue
• Lacerations < 6 mm: topical
or orbital fat
antibiotics
• Lacerations > 6 mm: suture
• Pain, tearing, photophobia • Removal of foreign body
Corneal foreign Inert or organic material
• Foreign body in the cornea • Topical Antibiotics
• Look for occult foreign body,
• Pain, tearing, photophobia
Corneal especially under the eyelids
Cornea scratched by any object, finger • Disruption of smooth glistening corneal
abrasion • Topical Antibiotics
epithelium seen with penlight or slit lamp
• Eye patch
Injuries to the • Red eye, photophobia
Blunt trauma Refer to ophthalmologists
Iris • Traumatic miosis or mydriasis
 • Traumatic iritis
• Iridiodialysis (traumatic disinsertion of iris
at its root)
• If history of trauma is not
elicited, evaluate for bleeding
Traumatic disorders or child abuses
Blunt trauma • Pain and blurring of vision
Hyphema • Refer to ophthalmologist
• Management variable and
controversial
Injuries to the
lens • Refer to ophthalmologists
Cataract Blunt trauma • Blurring of vision • Evaluate for posterior
Subluxation of segment injury
lens
Injuries to the
posterior
segment of the
eye

Commotio
retinae

Choroidal and
Blunt trauma • Blurring of vision Refer to ophthalmologist
chorioretinal
rupture

Retinal tears
and retinal
dialysis

Optic nerve
head avulsion
Sharp objects or high velocity blunt objects smaller
• Pain, blurring of vision Refer to ophthalmologist
than the orbital opening