Lecture 11 Peds Ocular Disease1 .pdf

PEDIATRIC OCULAR DISEASE: TL;DR Matthew T. Vaughn, OD FAAO Pediatric Optometry and Vision Development July 9/11, 2024 1 PEDIATRIC OCULAR DISEASE OUTLINE o Adnexa + Lids + Lashes o Anterior segment o Leukocoria o Retinal...

PEDIATRIC OCULAR DISEASE: TL;DR Matthew T. Vaughn, OD FAAO Pediatric Optometry and Vision Development July 9/11, 2024 1 PEDIATRIC OCULAR DISEASE OUTLINE o Adnexa + Lids + Lashes o Anterior segment o Leukocoria o Retinal diseases in infancy and childhood o Systemic conditions with retinal findings o Optic nerve abnormalities o Nystagmus presenting in infancy 2 ADNEXA + LIDS + LASHES 3 FACIAL HEMANGIOMA Benign vascular tumor Bright red, flat birthmark, present at birth or in the first two weeks of life. May grow to spongy, rubbery-looking bump Face, scalp, chest, or back Usually fades by 10 years of age, most by 5 years of age Risk factors: Caucasian, female, prematurity Complications: bleeding, blocking vision, pain, infection Oral Propranolol can help speed resolution 4  NASOLACRIMAL DUCT OBSTRUCTION Common in pediatric population 5% of infants have some symptoms of NLDO Obstruction commonly at valve of Hasner Where nasolacrimal duct normally enters the nose Treatment Topical antibiotic is bacterial conjunctivitis Massage à every time you change the babies diaper (6-8 times a day) and massage in a downward motion using thumb Probing Observation 66% of infants resolved without surgical intervention 41% >1 yo resolved without surgical intervention -valve of hasner is a little opening into the nose and its not a valve but a thin membrane that usually opens but at that area that membrane isn’t open at birth so the whole system isn’t patent and the tears will build up so you get epiphora -usually unilateral but can be bilateral -can use topical antibiotic such as erythromycin if the child gets bacterial conjunctivitis -if its not opened by 1 year consider getting surgical intervention but most of the time its not needed 5  IMPETIGO o Bacterial skin infection o Highest incidence 2-5 yo “Honey-colored o crusts” o Risk factors o Treatment: topical antibiotics (mupirocin) or oral antibiotic o Sanitize fomites -can get these anywhere in the skin, not necessarily have to be near the eye -common in the face, neck and trunk area -commonly seen in kids who go to daycare -risk factor can be eczema -goes away easily with antibiotics 6  MOLLUSCUM CONTAGIOSUM o Viral skin infection o Highest incidence 1-4 yo o Flesh-colored, dome, “pearly,” umbilicated center o Risk factors o Treatment: monitor, curettage o Sanitize fomites -can get these anywhere in the skin, not necessarily have to be near the eye -its viral so it doesn’t do well with medications -small, circular flesh color, sometimes described as pearly and have a dimple in the center -risk factors can be eczema -can typically take a year for it to go away so its hard to get rid of -contagious à hence the name 7  EPIBLEPHARON Congenital lid variation Can cause lash-cornea contact Lower lid > upper Bilateral > unilateral Treatment Conservative* Surgical -very common in east Asians and Hispanic populations -congenital variation of lid morphology/lid anatomy -normal eyelashes however the skin around it is very tight and that skin is what’s moving the eyelashes towards the cornea causing irritation -if you loosen the skin and pull the skin down you notice the eyelashes are normal -this isn’t trichiasis! -can lubricate the eye a lot if there’s only one eyelash touching the cornea and can epilate that lash every 3 months -CL is another treatment option to use as a bandage and protect the surface of the eye -surgery is typically indicated if all the lashes are touching the cornea and remove a bit of the orbicularis and some skin to loosen the skin -if the pt is complaining of the eyelash touching their eyes and there are no signs indicated, check when the pt is looking in downgaze cause that’s when it typically occurs 8  PHTHIRIASIS PALPEBRARUM oPossible indication of child abuse oPubic lice colonizing eye lashes oNits, feces, bite marks oSmother them with Vaseline or petroleum jelly or epilate oChild Protective Services/Administration for Children’s Services -infestation of pubic lice in the eye lids -can’t assume that its head lice either bc head lice typically prefer hair and eyebrow 9  PRESEPTAL CELLULITIS: SYMPTOMS § Eyelid swelling § Erythema § Warmth § Tenderness § Upper respiratory infection § Obvious skin infection, ex. bug bite § Normal vision § EOMs normal § No pain on eye movement § **Can use CT scan to r/o orbital involvement -typically looks more dramatic -inflammation should be mostly to the eyelid -there can be pain but shouldn’t be exacerbated by EOM movement -if the child is under 5, acting different, malaise, fatigue, not worth the chance and should send them to the ER -call pediatrician to let them know the child’s being put on antibiotics 10  ORBITAL CELLULITIS: SYMPTOMS § Features of preseptal cellulitis § Chemosis of conjunctiva § Limited EOMs with diplopia § Proptosis § Pain § VA loss § Malaise § Symptoms of sinusitis § Fever -inflammation inside the orbit -can be around the optic nerve as well -more dangerous than perseptal à IV needed in ER -typically associated with bacterial not viral 11  BLEPHARO- KERATOCONJUNCTIVITIS (BKC) Etiology Chronic inflammatory eyelid margin disease with secondary conjunctival and corneal involvement -spectrum of disease that is interrelated bc it starts at the eyelid and manifests its way to conj and cornea 12  BKC CORNEAL INVOLVEMENT Stain the cornea!! Superficial punctate keratitis Inferior only: check for lagophthalmos! Corneal ulcer Neovascularization -if the child has mild to moderate bleph with some capped glands à don’t usually stain the cornea -if its more moderate to severe bleph with a decent amount of capped glands à stain the cornea -spk is common in kids but true DE is not seen in children 13 BKC TREATMENT AND MANAGEMENT Treat according to severity Anterior blepharitis: lid hygiene Posterior blepharitis: warm compresses, topical/oral antibiotic Hordeola: warm compresses, oral antibiotic Chalazia: warm compresses, consult for steroid injection or excision Superficial keratitis: lubrication, topical soft steroid Lagophthalmos: nighttime AT ointment Ulcer: topical antibiotic Adjunctive Flaxseed oil, omega 3 14  7 YO F, HX OF BKC, C/O PAIN, PHOTOPHOBIA OD -corneal ulcer with some neo -put the pt on tobradex and PF AT - 15  1 DAY S/P TDEX + PF AT Q1H -1 day after treatment - 16 ANTERIOR SEGMENT 17  OCULAR DERMOID o Choristoma à normal tissue at abnormal area o Inferotemporal most commonly located o Induced astigmatism à leading to ambylopia o Ocular surface disease o Monitor vs surgery oAMT -more congenital malformations -choristomas can sometimes have small hair -can be graded (1,2,3) 18  ANIRIDIA o PAX6 gene, AD o Iris hypoplasia o Aniridia-associated keratopathy o Glaucoma à angle is abnormal, usually bilateral o Cataract o Optic nerve hypoplasia o Nystagmus -aniridia means no iris however there is always some iris tissue -actually a hypoplastic iris 19  PETERS ANOMALY o Corneal opacity due to dysgenesis of the anterior segment during development o Failure of lens vesicle separation from surface ectoderm Shallow A/C, synechiae between iris and cornea, central o corneal leukoma, defect in Descemet’s membrane o Often systemic/ocular associations PAX6-related o o Deprivation amblyopia! Glaucoma o -PAX-6 gene is impt in the embryogenesis and ocular development -very impt to treat this quickly - 20  AXENFELD- RIEGER SYNDROME o PAX6-related o Iris abnormalities – persistence of primordial endothelial layer over anterior iris surface o Polycoria, corectopia, iris hole, ectropion uveae o Often systemic associations o Glaucoma (50%) -polycoria à multiple pupils -coretopia à pupil to the side -ectropian uveae àwhen the posterior iris comes forward 21  AXENFELD-RIEGER SYNDROME -dental abnormalities are noted -problems to the heart -developmental delays 22