The School - Aged Child
Case 4.2 Eye Irritation
94 The School-Aged Child
Social h istory: Tim lives at home with his mother and 5 - year - old brother in an apartment behind the school. He uses the SBHC and the emergency room for his medical care, as the family does not have insurance. He denies tobacco or substance use. He is not sexually active. His mother works part - time as a gas station attendant while he is at school. He sometimes takes care of his younger brother after school before she gets home from work. He has never met his biological father and does not have any contact with him.
Medications: Tim is currently not on any medications and denies use of vitamins or alternative health care remedies.
Allergies: He does not have any known drug allergies and has “ never been diagnosed with seasonal allergies. ”
Additional r eview of s ystems ( ROS ): Further ROS reveals no change in weight or exercise intoler- ance, and he is generally in a good state of health. He does not have any rashes, itching, skin lesions, or skin changes. He reports that he gets headaches once in awhile but not on a normal basis and does not have a headache today. There is no history of vertigo, lightheadedness, or any recent injuries. He does not regularly see a dentist, but he receives dental cleanings from the school ’ s visiting dental hygienist and has had all of his cavities fi lled.
Tim does not have any complaints of neck, joint, or muscle pain or tenderness. He reports that he has never been told that he has a heart problem or murmur and that he has never seen a cardiologist.
He only gets short of breath when he runs the 2 mile during gym class and does not have a history of wheezing. He has never had to use an inhaler for any illness in the past and is not currently on any breathing medications.
OBJECTIVE
General: Tim is polite and dressed appropriately for the season.
Vital s igns: Within normal limits of 118/72 blood pressure in the right arm; 62 pulse at rest; 16 res- pirations per minute; 98.7F measured temporally.
HEENT : On examination, the eyes are erythematous bilaterally with yellow crusting at the ends of his eyelashes and across his lower lid; normal visual acuity of 20/20 on the Snellen test; the pupils are equal and round, reactive to light, with accommodation showing normal papillary refl exes. The eyes are aligned equally bilaterally. Ocular motility is normal bilaterally. Ophthalmoscopic examina- tion reveals normal red refl exes and optic discs without hemorrhage of any vessels. The patient ’ s upper eyelids and lacrimal sacs are within normal limits. The hyperemia is throughout the conjunc- tivae bilaterally with no injection of vessels. Visual fi elds are normal in all four quadrants. Tim ’ s cornea and lens appear within normal limits with no sign of abrasion.
Tim has a normal hairline and scalp with no alopecia or crusting in the hair. He had passed his hearing test at his last examination and external ear and pinnae are normal on examination. Otoscopic examination reveals normal tympanic membranes with no erythema or bulging and all ossicles visible bilaterally. Nasal septum is vertically aligned with normal turbinates and no internal erythema visible. Nasal mucosa is normal. Tim reports no pain or discomfort during palpation of the frontal and maxillary sinuses. Examination of the oral pharynx shows normal tonsil size of 0/4 with no exudates or drainage. Oral mucosa is moist with intact palate and normal uvular size and location.
Tim has several cavities in his mouth and fi llings in both of his mandibular molars. No mouth breath- ing is noted.
Skin: No rashes, scars, or lesions on his skin. Trachea is midline with no lymphadenopathy, normal shoulder shrug, and full range of neck motion in all directions. His neck is easily moveable without resistance in all directions. His spine is straight with no curvature. There are no palpable nodes in the cervical, supraclavicular, or axillary areas.
Eye Irritation 95
Respiratory: Lungs are clear in all fi elds bilaterally with no signs of wheezing, shortness of breath, rales, or crackles.
Cardiovascular: S1/S2 with no murmur, thrill, or irregular beats. PMI is at the fi fth intercostal space at the midclavicular line. No fourth heart sound with rub is heard. There are no masses or nipple discharge on examination of the chest. Patient has equal radial, femoral, and anterior tibial pulses bilaterally. No cyanosis, clubbing, or edema is noted.
Abdomen: Symmetrical without any distention. Bowel sounds heard in all four quadrants of exami- nation are normal and not hyperactive; no organomegaly or hepatomegaly. Rectal exam and exami- nation of genitalia were deferred.
Neuromuscular: Normal muscle strength (5/5) in all extremities; normal bicep, ankle, and knee refl exes; normal toe - to - heel walking; and a negative Romberg test. Cranial nerves II – XII are grossly intact. Motor and sensory examinations of all extremities are within normal limits. Deep tendon refl exes are normal bilaterally.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Gram stain of discharge ___Bulbar conjunctiva biopsy ___Slit lamp examination ___Wood lamp examination
___Dilation of pupil using mydriatic medications ___Dilation tonometry
What is the most likely differential diagnosis and why?
___Viral conjunctivitis ___Bacterial conjunctivitis ___Allergic conjunctivitis ___Blepharitis
___Keratitis ___Iritis
What is your plan of treatment?
What is your plan for follow - up care?
Are any referrals needed?
What if the patient were over age 65 or under age 13?
What patient and family education is important with red eye diagnoses?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: Diagnostic testing is not generally needed in diagnosing conjunctivitis. Laboratory tests to identify bacteria and sensitivity to antibiotics should only be done in severe cases such as in patients who are immunocompromised, contact lens wearers, or neonates, or when initial treatment fails (Hovding, 2008 ). Would you perform any of the following diagnostic tests?
96 The School-Aged Child
1. Gram stain of discharge . If the history and physical examination suggests bacterial conjunctivitis but there is no response to topical antibiotics, a gram stain of discharge swabs for bacterial culture will be necessary.
2. Bulbar conjunctival biopsy . Biopsy of the conjunctivitis is not indicated for red, itchy, dry eyes.
3. Slit lamp examination . A slit lamp examination is used for inspection of anterior eye structures and ocular adnexa and would not be indicated for conjunctivitis differentiation. The slit lamp allows a small beam of light that can be varied in width, height, incident angle, orientation, and color to be passed over the eye. This light beam is narrowed into a vertical slit during examina- tion. Examination of the anterior eye structures is not indicated for erythematous conjunctiva.
4. Wood lamp examination . Fluorescein staining before a slit lamp examination or with a Wood lamp (using ultraviolent light) may reveal corneal abrasions or herpes simplex infection. A Wood lamp exam would be indicated if the patient had reactive miosis, possible foreign body, or severe eye pain but none of these were reported or indicated in the history and review of symptoms.
5. Dilation of pupil using mydriatic medications . Excessive pupil dilation, or mydriasis, can be induced with a mydriatic medication such as tropicamide to examine the retina and deep structures of the eyes. The history, review of systems, and initial physical examination does not indicate that the provider would need to examine the retina. This procedure is usually reserved for the ophthalmologist.
6. Dilation Tonometry . Dilation tonometry measures the intraocular pressure of the aqueous humor of the eye used to determine the intraocular pressure when evaluating glaucoma. This patient did not report throbbing, acute onset eye pain or halos around light, which would lead the prac- titioner to consider a diagnosis of acute angle glaucoma. There was no reduction in visual acuity, poor reaction to light, or tender eyeball that would indicate dilation tonometry would be indicated.
What is the most likely differential diagnosis and why?
Bacterial conjunctivitis:
Acute bacterial conjunctivitis presents abruptly with red eyes, usually bilateral, mild discomfort or pruritus, and purulent drainage. Diagnosis is based on the patient ’ s history and physical symptoms as laboratory investigation is not generally necessary. Patient report of purulent discharge, which may be described as “ extra sleep crusts ” or “ glue ” upon awakening is highly predictive of bacterial conjunctivitis when accompanying red eyes. Mucopurulent discharge is present and mild discomfort may exist but pain is usually absent. Topical antibiotic therapy is indicated because it reduces symp- toms, shortens duration and contagiousness, and reduces risk of complication. Bacterial conjunctivitis should be differentiated from viral and allergic conjunctivitis as well as other acute causes of red eyes (Cronau, Kankanala, & Mauger, 2010 ; Hovding, 2008 ; Leibowitz, 2000 ).
Bacterial conjunctivitis is the most common form of conjunctivitis in primary care. It is often called “ pink eye ” due to the pink appearance of the eye, which results from subconjunctival blood vessel congestion. Symptoms may persist for 3 weeks or more without treatment. Staphylococcus aureus infection is often the cause in adults, whereas Streptococcus pneumonia and Haemophilus infl uenzae infections are the more common causes in children (Hovding, 2008 ; Leibowitz, 2000 ).
Viral conjunctivitis usually presents with upper respiratory symptoms such as cough, rhinorrhea, or nasal congestion. This is usually caused by adenovirus and is highly contagious. Enlarged pre - auricular nodes and history of upper respiratory tract infection would cause the practitioner to con- sider a viral cause of infection. Treatment includes cold compresses, artifi cial tears, and education (Hovding, 2008 ; Leibowitz, 2000 ; Sethuraman & Kamat, 2009 ).
Allergic conjunctivitis is associated with atopic disease such as allergic rhinitis, eczema, and asthma, as well as allergic rhinosinusitis. Itching of the eyes and bilateral tearing are the most appar- ent features of allergic conjunctivitis. Avoiding exposure to allergens and using artifi cial tears are effective methods to alleviate symptoms (Sethuraman & Kamat, 2009 ).
Subconjunctival hemorrhage usually presents unilaterally with localized erythema and adjacent conjunctiva free of infl ammation and no discharge. These are usually painless and do not affect vision.
Subconjunctival hemorrhage is caused by minor trauma (which includes prolonged coughing, vomit- ing, or the Valsalva maneuver), fragile vessels, bleeding disorders, anticoagulation therapy, and
Eye Irritation 97
hypertension. They usually resolve in 2 – 3 weeks, and failure to resolve warrants referral (Leibowitz, 2000 ; Sethuraman & Kamat, 2009 ).
Blepharitis is the acute or chronic infl ammation of the eyelid often associated with conjunctival infl ammation. Caused by infectious agents, including staphylococci bacteria, allergic disorders, and dermatologic diseases, the corneal surface becomes dry and causes microscopic erosions of the corneal epithelium, mild visual distortion, and photophobia. The patient will usually present with crusting of the eyelid margins, swollen eyelids, and erythematous eyes. Corneal involvement and loss of eyelashes may also occur. Treatment includes warm compresses and a topical antibiotic. Severe blepharitis indicates an ophthalmology referral (American Academy of Ophthalmology Cornea/
External Disease Panel, Preferred Practice Patterns Committee, 2008 ; American Academy of Pediatrics, American Association of Certifi ed Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, 2003 ; Sethuraman & Kamat, 2009 ).
More serious causes of red eyes include acute glaucoma, keratitis, and iritis. Clinical symptoms that usually suggest a more serious cause include moderate to severe eye pain, extreme redness, ciliary injection, and reduced visual acuity. If a serious eye disease is suspected, then immediate referral should be made to an emergency eye clinic or to ophthalmology for a same day assessment (AAO, 2008 ).
What is your plan of treatment?
Bacterial and viral conjunctivitis are usually self - limiting, but a topical antibiotic is recommended.
Cultures should be reserved for treatment failure as they are expensive and impractical in the case of bacterial or viral conjunctivitis (AAO, 2008 ). Initial treatment recommendations are broad - spectrum antibiotic such as a combination of polymyxin B sulfate and trimethoprim sulfate, 0.3%
gentamicin, 0.5% erythromycin, and 0.3% tobramycin drops or ointments. These antibiotics are effective against gram negative and positive organisms. Studies have shown no difference in effec- tiveness of different ophthalmic antibiotics. The antibiotic choice should be based on the cost effec- tiveness and local bacterial resistance patterns of the area (Leibowitz, 2000 ). Prescription of ointment or drops is a matter of patient choice. Drops are usually preferred because ointment can cause blurred vision. Some schools will require proof of treatment before readmitting students to school (Cronau et al., 2010 ).
What is your plan for follow - up care?
Patients should be counseled to practice strict hand washing and avoid sharing personal items.
Bacterial and viral conjunctivitis are highly contagious and are spread through direct contact with contaminated fi ngers, medical instruments, or personal items (Cronau et al., 2010 ). Treatment is sup- portive with cold compresses, ocular decongestants, and artifi cial tears. As previously discussed, topical antibiotics are rarely necessary but may decrease time away from work, day care, or school.
If the patient ’ s symptoms do not resolve, the clinician should re - evaluate for possible reinfection or other causes of red eyes (AAO, 2008 ; Sethuraman & Kamat, 2009 ).
Are any referrals needed?
Referral to an ophthalmologist is indicated if the patient has any of the following: visual loss; moder- ate or severe pain; severe, purulent discharge; corneal involvement; conjunctival scarring; lack of response to therapy; recurrent episodes; or history of herpes simplex virus ( HSV ) eye disease or is immunocompromised (AAO, 2008 ; Cronau et al., 2010 ). Suspected ocular herpetic infection also war- rants an immediate ophthalmology referral. Chronic bacterial or viral conjunctivitis should also be referred to an ophthalmologist (Cronau et al., 2010 ).
What if the patient were over age 65 or under age 13?
Erythematous conjunctiva in a neonate indicates smears for cytology and gram stains to rule out infectious neonatal conjunctivitis (AAO, 2008 ). Chlamydia trachomatis is the most common cause of conjunctivitis infection in the neonate and is acquired from the infected genital tract during birth.
Presentation is usually seen 4 – 10 days after birth and consists of mucopurulent unilateral or bilateral discharge. Diagnosis is confi rmed by culture and can differentiate for Neisseria gonorrhoeae . N. gonor- rhoeae usually presents in the fi rst week of life with purulent discharge, chemosis, and lid edema.
Complications lead to blindness. Neonates with either infection should be hospitalized, may need a
98 The School-Aged Child
septic workup, and IV cefotaxime for N. gonorrhoeae or topical erythromycin for C. trachomatis (Sethuraman & Kamat, 2009 ).
Cultures of conjunctiva are indicated in all cases of suspected infectious neonatal conjunctivitis (AAO, 2008 ). Smears for cytology and special stains are recommended in cases of infectious neonatal conjunctivitis, chronic or recurrent conjunctivitis, and suspected gonococcal conjunctivitis in any age group (AAO, 2008 ). The clinician must be alert to the possibility of child abuse in cases of potentially sexually transmitted ocular disease in children. STD and suspected child abuse must be reported to local health authorities and other state agencies (Sethuraman & Kamat, 2009 ). Hyperacute bacterial conjunctivitis is also associated with Neisseria gonorrhoeae in sexually active adults, which has a sudden onset and progresses rapidly leading to corneal perforation (Cronau et al., 2010 ).
Caution should be taken with prescription of myelotoxic drugs in pregnant women in their third trimester because of the possibility of “ gray baby syndrome ” . Gonococcal conjunctivitis is treated with a single IM dose of cefotaxime. Ceftriaxone (Rocephin) should be avoided due to possibility of hyperbilirubinemia (Sethuraman & Kamat, 2009 ). Chlamydial conjunctivitis is treated with oral anti- biotics such as erythromycin.
What patient and family education is important with red eye diagnoses?
The clinician should educate the family and patient about the pathophysiology of bacterial conjunc- tivitis, risk factors, potential complications, treatment benefi ts, and complications. The practitioner should advise the family when to seek medical attention for new or worsening symptoms. The patient should be advised to avoid wearing contact lenses until the infection is resolved. Contact lenses that were worn during the infection should be replaced and new lenses and lens case should be used.
Other family members including close contacts of the patient should use good hygiene and hand washing processes (AAO, 2008 ; Cronau et al., 2010 ).
The practitioner should stress that all family members in the house should use good hand and eye hygiene and avoid close contact with the infected individual.
Are there any standardized guidelines that you should use to assess or treat this case?
The American Academy of Ophthalmology formed a panel to discuss preferred practice patterns of conjunctivitis and created a national guideline which can be found at National Guideline Clearinghouse at http://www.guideline.gov. The guideline reviews the initial evaluation and aspects of a compre- hensive medical eye evaluation including history and physical examination. These guidelines empha- size the importance of a referral to an ophthalmologist with any visual loss, moderate or severe pain, severe purulent discharge, corneal involvement, conjunctival scarring, lack of response to therapy, recurrent episodes, history of HSV, or history of being immunocompromised (AAO, 2008 ).
The American Academy of Pediatrics along with the American Association of Certifi ed Orthoptists, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology, released a policy statement published in Pediatrics on the eye examination in infants, children, and young adults by pediatricians that reviews the eye examination and vision assessments done in children (AAP, 2008 ).
REFERENCES AND RESOURCES
American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee ( 2008 ). Conjunctivitis . San Francisco, CA : American Academy of Ophthalmology (AAO) .
American Academy of Pediatrics, American Association of Certifi ed Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology ( 2003 ). Eye examination in infants, children, and young adults by pediatricians . Pediatrics , 111 ( 4 ), 902 – 907 .
Cronau , H. , Kankanala , R. R. , & Mauger , T. ( 2010 ). Diagnosis and management of red eye in primary care . American Academy of Family Physicians , 81 ( 2 ), 137 – 144 .
Everitt , H. A. , Little , P. S. , & Smith , P. W. ( 2006 ). A randomized controlled trial of management strategies for acute infective conjunctivitis in general practice . British Medical Journal , 333 ( 7563 ), 321 .
Granet , D. ( 2008 ). Allergic rhino conjunctivitis and differential diagnosis of the red eye . Allergy and Asthma Proceedings , 29 ( 6 ), 565 – 574 .
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Hovding , G. ( 2008 ). Acute bacterial conjunctivitis . Acute Ophthalmologica , 86 ( 1 ), 5 – 17 . Leibowitz , H. M. ( 2000 ). The red eye . The New England Journal of Medicine , 343 ( 5 ), 341 – 345 .
Marlin , D. S. ( 2009 ). Conjunctivitis, bacterial . In WebMD ’ s eMedicine Sepcialties. Retrieved from http://
emedicine.medscape.com/article/1191730 - overview
Sethuraman , U. , & Kamat , D. ( 2009 ). The red eye: Evaluation and management . Clinical Pediatrics , 48 ( 6 ), 588 – 600 .