Is it.....

Or isn’t it?Commonly confused

ophthalmologic diagnoses in the

outpatient setting

B. Christian Carter, MD

Albemarle Pediatric Ophthalmology and Strabismus

April 2019

I have no financial

interests to disclose

Adolescent red eye

Toddler red eye

The tearing infant

Preseptal or orbital cellulitis

Strabismus vs pseudostrabismus

Adolescent Red Eye

Acute conjunctivitis

Viral

Follicular response

Thin, watery discharge

Unilateral progressing to bilateral

Concomitant URI

Pre-auricular node

Self-limited, hygiene is key

Adolescent Red Eye

Bacterial

Papillary response

Thick, mucous discharge

Unilateral

Topical antibiotic drops

Beware GC/Chlamydia

Adolescent Red Eye

Allergic

Papillary response

Aqueous based discharge

Bilateral but can be asymmetric

Antihistamine gtts; systemic therapy

Contact lens induced conjunctivitis

More common in soft lenses

Etiology:

Mechanical trauma to superior tarsus by SCL

Hypersensitivity response to SCL polymer

Hypersensitivity response to surface deposits

on SCL

Clinical signs:

Injection, FBS, discharge

Decreased vision

Decreased SCL tolerance

Increased mobility / decentration of lens

Contact lenses

Cornea is avascular

Cornea extracts O2 from environment and returns CO2

as well

Complications

Contact lens induced conjunctivitis

Contact lens overwear (microcystic epitheliopathy)

Contact lens induced conjunctivitis

Papillary conjunctivitis

Papillary hypertrophy

(>0.3mm)

GPC (>1.0mm)

Punctate epithelial

erosions

Peripheral infiltrates

Corneal

neovascularization

Contact lens overwear

Epithelial damage

Central epithelial edema

(Sattler’s veil)

Decreased vision

Acute epithelial necrosis

Microcytic epitheliopathy

(epithelial cysts)

Extended wear

Pain, epiphora

Contact lens overwear

Keratitis

10-20 fold increase with

overnight wear

Gram negative organisms

Multifactorial

Corneal hypoxia

Decreased tear

secretion (20 fold)

Stagnant bacteria laden

tear film behind lens

Contact lens induced conjunctivitis

Medical therapy

Discontinue/decrease contact lens wear

Never overnight!

Consider change to daily disposable

Improve lens hygiene

Vigorous cleaning

Change lenses/cases routinely

Topical therapy

Discuss chronic nature of the condition

Toddler red eye

Corneal abrasion

Trauma may be unknown to parents

Epiphora often with photophobia and eye rubbing

Injected conjunctiva, +/- mucopurulent discharge

Flourescein staining

Lid eversion

Erythromycin ointment TID

Follow up in 1-2 days

Toddler red eye

Foreign body retention

Examine both eyes!

Eyelid eversion

check for hyphema, red reflex

Toddler red eye

HSV epithelial keratitis

Usually HSV-1

Endemic (90%, 2-5% with ocular

involvement)

Unilateral > bilateral

Exposure

Direct contact

Via trigeminal nerve from prior oral

infection

HSV Keratitis

Associated or preceding

blepharoconjunctivitis

Folliculosis, injection

Preauricular node involvement

Epithelial dendrites (“terminal bulbs”)

Preceding punctate keratopathy

Geographic ulcer

Stain with fluorescein or rose bengal

HSV geographic ulcer

HSV keratitis

Photophobia, ocular injection / pain

Clinical diagnosis

Corneal or conjunctival (cul-de-sac) swab

Treatment

Depends on comorbidities (uveitis, stromal disease)

Self limited

Trifluridine 1% 9x/day x 1 week

Not greater than 2 weeks (toxicity)

Oral acyclovir

HSV keratitis

Recurrence

As high as 25%

Immunocompetent status

Sunlight, temperature

Stress, menstruation

Long term low dose acyclovir

Amblyogenic!

The Tearing Infant

Nasolacrimal Duct Obstruction

Membranous obstruction at valve of Hasner

Mucopurulent d/c and epiphora in setting of non-injected conjunctiva

Assoc with angular blepharitis

Present in up to 20% of newborns

50% resolution by 3mo

80% resolution by 6mo

95% resolution by 11mo

Increased rate of recurrence after probing after 12mo (3% vs. 45%)*

Refer prior to 12 months!

Conservative nasolacrimal massage

Probe and irrigation vs. silicone tube

Katowitz JA, Welsh MG. Timing of initial probe and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987; 94:698-705.

Congenital Glaucoma

1:10,000 births; 66% bilateral

VA < 20/50 in 50%; blindness in 2-15%

Epiphora, photophobia, blepharospasm

Corneal edema (presence of Haab striae), increased CD (>11.5 in newborn, >12.5 in 1yo; buphthalmos)

Onset within first year in >80%

5% chance of affected parent having child (same with sibs)

Dacryocele

Proximal and distal obstruction

of tear outflow

Failure of mesodermal

canalization

Mucocele formation within

lacrimal sac (or nasal cavity)

Bluish discoloration inferior to

MCT

Unilateral or bilateral; 1% of all

NLDO

Female > male

Can progress to dacryocystitis

Dacryocele

Dacryocele

Mucocele extension into nasal cavity can impede breathing

DDx

Encephalocele

Hemangioma

Dermoid

Manual decompression

20-25% spontaneous resolution

Coverage with topical antibiotics after decompression

Systemic antibiotic coverage

Dacryocele

Surgical intervention if no

resolution with

conservative measures

By 6-8 weeks of life

Inflammatory Lid Disease

Preseptal cellulitis

Infection/inflammation of the orbital

tissues anterior to the septum

Etiologies

Direct (trauma, localized infection)

Contiguous spread (paranasal

sinuses, hordeolum, dacryocystitis)

Hematogenous (otitis, URI)

Sterile (retinoblastoma)

Gram positive cocci

Preseptal cellulitis

Lid edema, erythema

Absence of ocular injection

Absence of vision loss

Typically afebrile

Outpatient management

Response to oral antibiotics within 48

hours

IM/IV antibiotics for infants/toddlers,

febrile

Orbital cellulitis

Progression of preseptal

infection posterior to

septum

Gram positive cocci

Shared etiology

Ethmoid sinusitis

URI

10% subperiosteal

abscess

Orbital cellulitis

Chemosis

Proptosis

Motility restriction / diplopia

APD

Orbital cellulitis

Prompt neuroimaging

CT

Admission, broad spectrum IV

antibiotics

ENT consultation

Complications

Exposure keratitis

CRVO, optic neuropathy

Cavernous sinus thrombosis

Meningitis

Strabismus

heterotropia: a manifest strabismus

alternate fixation or strong fixation preference

Esotropia = image falls nasal to fovea

Exotropia = image temporal to fovea

Hypertropia = image superior to fovea

by convention, hypertropia unless restrictive

process

Excyclotropia = temporal rotation of 12 o'clock

Incyclotropia = nasal rotation of 12 o'clock

Strabismus

Heterophoria = latent deviation; tendency

for eyes to drift, but held in alignment by

interaction between binocular fusion and

muscular control

motor fusion = ability to keep eyes in

alignment

intermittent tropia = large, difficult to fuse

phoria in which latent deviation becomes

manifest (tired, sick, drunk)

Strabismus vs pseudostrabismus

Epicanthus: bilateral medial canthal fold

Superciliaris: below eyebrow to lacrimal sac

Palpebralis: equally distributed

Tarsalis: most prominent in upper eyelid

Inversus: most prominent in lower eyelid

Fixation Target

Use the smallest age appropriate target that will hold attention

Child’s shoulders square to yours

Head in primary position

Fixation Target

Abnormal Head Posture

Ocular causes

Superior oblique palsy

Abducens palsy

Nystagmus

Vertically incomitant strabismus

(A or V pattern)

Brown’s syndrome

Duane’s syndrome

Abnormal head posture

Cover Test

Good cover-uncover testing technique

Cover-uncover = manifest strabismus (“-tropia”)

Cross-cover = latent strabismus (“-phoria”)

Cover test

Alternate Cover Test

Cover is alternated between the two eyes rapidly breaking down fusion

Elicits phoric deviation

Corneal light reflex

Positive angle kappa

Visual axis slightly

temporal to pupillary

axis

Nasal displacement of

corneal light reflex,

simulating XT

Corneal light reflex

Remember, light is a

nonaccommodative

target

Most common ET is

accommodative

ET

Fixation target will

ensure

accommodation

Multiple choice

A 3 yo boy has a 2 week history of ocular injection

and photophobia. His fluorescein staining reveals

the following image. Appropriate management

would include:

A. Topical erythromycin ophthalmic ointment QID

with instructions to follow up in 1 week

B. HSV conjunctival culture with referral to

ophthalmology

C. Prednisolone 1% gtts QID with 5 day follow up

Multiple choice

A 7 yo boy presents with a 4 day history of increasing

periorbital edema and erythema, and remains

afebrile. Acuity is 20/20 OS and color vision is 12/12

OU. There is no chemosis, proptosis or APD. His only

complaint is pain on attempted adduction OS.

Appropriate next step would include:

A. Topical erythromycin ointment QID to the eye, lids

and lashes with 5 day follow up

B. Augmentin x 14 days with 2 day follow up

C. ED referral for parenteral antibiotics and orbital CT

scan, ophtho consult

Multiple choice

This 6 year old young man presents with

maternal complaints for “lazy eye.” Visual

acuity is 20/20 OU and stereotesting is intact.

Your cover/uncover test is unremarkable, as

well as an alternate cover test. Corneal light

reflex is symmetric OU. The next appropriate

step would be:

A. Reassurance to mom that all is well, RTC in 1

year/PRN

B. Repeat cover testing in forced primary

position

C. Referral to local developmental optometrist

for vision therapy (urgent)

Multiple choice

Thank you!