An Evidence-Based Approach to Nontraumatic Ocular Complaints in Children (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

About This Issue

More than 70% of patients presenting to emergency departments (EDs) with eye complaints have nontraumatic eye disease and, of these, more than 90% are treated and released from the ED. It is important that emergency clinicians have the skills to appropriately evaluate and manage eye disease in children. This issue reviews the presentations of common nontraumatic ocular complaints and provides evidence-based recommendations for management. You will learn:

Age-based milestones for vision development

Ocular and nonocluar etiologies of various eye complaints

Typical presenting signs and symptoms of common pediatric nontraumatic ocular complaints

Key aspects of the history that should be obtained

Common challenges associated with the physical examination and suggestions for addressing those challenges

A stepwise approach to the physical examination that will assess ocular function and structure

Common abbreviations that may be encountered in ophthalmologic documentation

Which complaints are clinical diagnoses and which require diagnostic studies

Disease-specific recommendations for management

Which diagnoses need ophthalmology referral and whether it should be emergent, urgent, or routine

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Eye Anatomy and Vision Development
   1. Eye Anatomy
   2. Vision Development
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Challenges and Suggestions for the Ocular Examination of the Pediatric Patient
         • Topical Anesthetics
      2. Initial Examination
         • External Inspection
         • Pupillary Response
         • Extraocular Movements
         • Visual Fields
         • Visual Acuity
      3. Instrument-Based Examination
         • Ophthalmoscopy
         • Slit Lamp
         • Tonometry
9. Diagnostic Studies
   1. Fluorescein Dye
      1. Infection Testing
   2. Imaging Studies
      1. Ultrasound
      2. Computed Tomography Scan
      3. Magnetic Resonance Imaging
10. Disease-Specific Management
    1. Extraocular Diseases
       1. Periorbital Cellulitis
       2. Orbital Cellulitis
       3. Blepharitis
       4. Hordeola and Chalazia
       5. Lacrimal System Diseases
       6. Conjunctivitis
          • Neonatal Conjunctivitis
          • Childhood Conjunctivitis
            • Bacterial Etiologies
            • Viral Etiologies
            • Noninfectious Etiologies
       7. Subconjunctival Hemorrhage
       8. Episcleritis and Scleritis
    2. Diseases of the Anterior Segment
       1. Anterior Chamber
          • Corneal Abrasion
          • Keratitis
          • Hyphema
          • Glaucoma
          • Uveitis
       2. Posterior Chamber
          • Cataracts
    3. Diseases of the Posterior Segment
       1. Vitreous Hemorrhage
       2. Retinoblastoma
       3. Retinal Detachment
       4. Retinal Artery Occlusion
       5. Orbital Hemorrhage
       6. Optic Neuritis
11. Consulting Ophthalmology
12. Special Populations and Circumstances
    1. Neonates
    2. Solar Retinopathy
    3. Nutritional and Metabolic Disease
    4. Eye Complaints Related to Infectious Etiologies
13. Controversies and Cutting Edge
    1. Transient Smartphone Blindness
    2. Nonmydriatic Fundus Photography
    3. Topical Antibiotics for Childhood Conjunctivitis for Return to School
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls for Pediatric Patients With Nontraumatic Ocular Complaints
18. Case Conclusions
19. Clinical Pathways
    1. Clinical Pathway for Diagnostic Evaluation of the Pediatric Red Eye
    2. Clinical Pathway for Diagnostic Evaluation of Acute Pediatric Vision Loss
20. Tables and Figures
    1. Table 1. Etiologies of Nontraumatic Eye Complaints
    2. Table 2. Ocular Examination
    3. Table 3. Common Abbreviations in Ophthalmologic Documentation
    4. Table 4. Recommendations for Ophthalmology Consultation
    5. Figure 1. Anatomy of the Human Eye
    6. Figure 2. LEA Symbols
    7. Figure 3. Ultrasound of the Eye, With Normal Anatomy Indicated
    8. Figure 4. Right-sided Subperiosteal Abscess in the Setting of Orbital Cellulitis on Computed Tomography
    9. Figure 5. Hordeolum
    10. Figure 6. Chalazion
    11. Figure 7. Nasolacrimal Duct Anatomy
    12. Figure 8. Dacryocystocele
    13. Figure 9. Herpes Simplex Virus Keratitis With Dendritic Pattern on Fluorescein Staining
    14. Figure 10. Hyphema
    15. Figure 11. Retinal Detachment on Ultrasound
21. References

Abstract

Children commonly present to emergency departments with eye complaints in the absence of antecedent trauma. Signs and symptoms of ocular disease are often nonspecific. Red, swollen, or painful eyes may represent benign or vision-threatening processes, making recognition and triage challenging for the emergency clinician. This issue reviews the presentations of common nontraumatic ocular complaints and provides evidence-based recommendations for management in the emergency department.

Case Presentations

A 6-year-old boy with autism is brought to the ED for swelling of his right eye…

• His mother tells you that he has had thick nasal discharge for the past week and has developed progressive redness and fullness of his right eye. He is cranky and holding his head in pain.
• The boy's vital signs are: temperature, 39°C (102.2°F); heart rate, 135 beats/min; respiratory rate, 25 breaths/min; blood pressure, 100/80 mm Hg; and oxygen saturation, 98% on room air. Your examination reveals a tired child with swelling and redness around the right eye. The patient refuses to open his eyes, and you are unable to perform an ocular examination. The boy’s nasal turbinates are swollen.
• You consider both periorbital and orbital cellulitis in your differential diagnosis and wonder whether the boy needs emergent imaging.

On a December afternoon, a 4-year-old girl is brought to the urgent care clinic by her mother for red, matted eyes...

• The mother said she had wiped off the discharge and sent the girl to preschool that morning, but the girl was sent home promptly. The mother tells you, “The school said she needs antibiotics to return.”
• On examination, the child's vital signs are: temperature, 36.5°C (97.9°F); heart rate, 130 beats/min; respiratory rate, 24 breaths/min; and oxygen saturation, 98% on room air. The girl has bilateral conjunctivitis with purulent exudate. Her pupils react normally, and she has full extraocular movements.
• You consider the preponderance of viral infections in this age group and wonder whether treatment with topical antibiotics is appropriate.

A 17-year-old girl presents to the ED with acute left-sided vision loss...

• The girl reports reading on the couch 30 minutes ago when the vision in her left eye suddenly became blurry. She denies associated pain, headache, fever, or trauma. She recently immigrated to the United States and reports a distant history of a heart problem that was not corrected.
• On examination, visual acuity in her right eye is 20/20, and in her left eye she has only light perception. There is a relative afferent pupillary defect in the left eye.
• Given her painless vision loss, you suspect central retinal artery occlusion, and you consider what you should do first: consult ophthalmology, obtain imaging, or call a stroke code?

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Clinical Pathway

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

6. * Prentiss KA, Dorfman DH. Pediatric ophthalmology in the emergency department. Emerg Med Clin North Am. 2008;26(1):181-198. (Review) DOI: 10.1016/j.emc.2007.11.001

18. * Wallace DK, Morse CL, Melia M, et al. Pediatric Eye Evaluations Preferred Practice Pattern^®: I. Vision screening in the primary care and community setting; II. Comprehensive ophthalmic examination. Ophthalmology. 2018;125(1):P184-P227. (Guideline) DOI: 10.1016/j.ophtha.2017.09.032

22. * McLaughlin C, Levin AV. The red reflex. Pediatr Emerg Care. 2006;22(2):137-140. (Review) DOI: 10.1097/01.pec.0000199567.87134.81

32. * Patel KN. Acute vision loss. Clinical Pediatric Emergency Medicine. 2010;11(2):137-142. (Review) DOI: 10.1016/j.cpem.2010.05.001

36. * Seguin J, Le CK, Fischer JW, et al. Ocular point-of-care ultrasound in the pediatric emergency department. Pediatr Emerg Care. 2019;35(3):e53-e58. (Case series) DOI: 10.1097/pec.0000000000001762

41. * Lee JY, Kim JH, Cho HR, et al. Requirement for head magnetic resonance imaging in children who present to the emergency department with acute nontraumatic visual disturbance. Pediatr Emerg Care. 2019;35 (5):341-346. (Retrospective; 39 patients) DOI: 10.1097/pec.0000000000001506

58. * Kiger J, Hanley M, Losek JD. Dacryocystitis: diagnosis and initial management in pediatric emergency medicine. Pediatr Emerg Care. 2009;25(10):667-669. (Review) DOI: 10.1097/PEC.0b013e3181b922f9

66. * Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310(16):1721-1729. (Systematic review; 86 articles) DOI: 10.1001/jama.2013.280318

74. United States Centers for Disease Control and Prevention. “Prevent epidemic keratoconjunctivitis (EKC). “ Accessed January 15, 2020. (CDC guidance)

88. * Ross M, Deschênes J. Practice patterns in the interdisciplinary management of corneal abrasions. Can J Ophthalmol. 2017;52(6):548-551. (Guideline) DOI: 10.1016/j.jcjo.2017.03.016

118. *Congdon NG, Friedman DS, Lietman T. Important causes of visual impairment in the world today. JAMA. 2003;290(15):2057-2060. (Review) DOI: 10.1001/jama.290.15.2057

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Keywords: nontraumatic ocular complaints, nontraumatic ocular conditions, nontraumatic ocular diseases, red eye, red eyes, anterior chamber, blepharitis, eye, eye diseases, eye infections, cataracts, chalazion, chalazia, choroid, ciliary body, conjunctivitis, cornea, fovea, glaucoma, hordeolum, hordeola, hyphema, iris, iritis, Kawasaki, Langerhans cell histiocytosis, macula, nasolacrimal, neuroblastoma, ocular, ophthalmic, optic, pupil, optic nerve, optic neuritis, orbital cellulitis, periorbital cellulitis, pink eye, posterior chamber, retinal artery occlusion, retinal detachment, retrobulbar hemorrhage, retinoblastoma, rhabdosarcoma, sclera, scleritis, stye, uvea, uveitis, vitreous, eye anatomy, vision development, visual acuity, ocular pain, eye discharge, pruritus, photophobia, visual changes, Woods lamp, slit lamp, red reflex, tonometry, ophthalmoscope, ophthalmoscopy, LEA symbols, fluorescein, ocular ultrasound, lacrimal system, dacryostenosis, dacryocystocele, dacryocystitis, dacryoadenitis, neonatal conjunctivitis, childhood conjunctivitis, gonococcal conjunctivitis, chlamydial conjunctivitis, subconjunctival hemorrhage, episcleritis, corneal abrasion, keratitis, vitreous hemorrhage, orbital hemorrhage, transient smartphone blindness