Pediatric emergency medicine trisk 630

Site Lesion Cause Cornea Scar Ulcer Lens Cataracts Metabolic: galactosemia, galactokinase deficiency Viral: Rubella, CMV Traumatic: nonaccidental trauma, birth injury, blunt trauma, perforation of globe Chromosomal: trisomies, Turner syndrome Genetic: aniridia, Treacher Collins, Pierre Robin, Rubinstein–Taybi, Hallermann–Streiff Endocrine: congenital hypoparathyroidism, Albright hereditary osteodystrophy Neurologic: Sjögren syndrome, Smith–Lemli– Opitz Lens Subluxation Fundus Coloboma of fundus Retinoblastoma Persistent hyperplastic primary vitreous Norrie disease Incontinenta pigmenti Retinal dysplasia Marfan syndrome, homocysteinuria, sulfite oxidase deficiency, hyperlysinemia, Ehlers– Danlos, Weill–Marchesani syndrome, trauma Norrie disease-X-linked recessive Retinal fold Retinoschisis Retinopathy of prematurity Optic nerve abnormality Lacrimal Duct Stenosis (Dacryostenosis) Congenital obstruction of the nasolacrimal duct, dacryostenosis, is the most common cause of excessive tearing in the newborn, occurring in 7% of neonates The lacrimal duct system is not fully mature and functional until weeks of age so excessive tearing (epiphora) usually appears at that time Dacryostenosis should be differentiated from congenital or infantile glaucoma, a serious but fortunately rare cause of excessive tearing Most cases of infantile glaucoma presenting during the first months of life are bilateral, whereas dacryostenosis is usually unilateral Other causes of epiphora include dacryocystitis, obstruction, congenital absence of puncta, corneal abrasions, and conjunctivitis Increased wetness of the affected eye relative to the normal eye, excessive tearing, mucoid eye discharge, and crusting along the eyelid margins are the usual presenting symptoms Gentle pressure along the medial canthal region over the lacrimal sac may produce a reflux of tears or purulent material onto the surface of the eye, confirming the diagnosis ( Fig 96.29 ) Infants with glaucoma, in addition to excessive tearing, also present with enlarged cornea, rhinorrhea, photophobia, blepharospasm, and corneal haziness The cornea may be inspected after instillation of fluorescein dye to rule out a corneal abrasion as the reason for the excessive tearing Uncomplicated cases of nasolacrimal duct obstruction should be managed with gentle cleansing of the eyes, followed by local massage of the nasolacrimal duct, several times per day, to prevent stagnation of tears in the lacrimal sac Topical ophthalmologic antibiotic ointments should be prescribed if there is associated conjunctivitis, purulent discharge, or dacryocystitis Systemic antibiotics occasionally may be needed for cases with cellulitis Ninety percent of cases resolve within the first year Referral to an ophthalmologist for probing should be considered for children with a prolonged course Suspected cases of infantile glaucoma require immediate ophthalmologic evaluation under anesthesia Neonates with congenital glaucoma are treated with surgery FIGURE 96.29 Congenital dacryostenosis The child’s parents complained of epiphora of both eyes since the child’s birth The right eye cleared spontaneously, but the left eye continued to tear, with morning crusting and heavy matting (Reprinted with permission from Tasman W, Jaeger E The Wills Eye Hospital Atlas of Clinical Ophthalmology 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2001.) Neonatal Conjunctivitis (Ophthalmia Neonatorum) The major causes of neonatal conjunctivitis, or ophthalmia neonatorum, are chemicals, chlamydia, bacteria, and viruses Chlamydial conjunctivitis is the most common conjunctivitis in neonates The time of onset of symptoms after birth can help identify the causative agent Mild nonpurulent inflammation of the conjunctivae that begins 12 to 24 hours after birth is typically caused by the prophylactic 1% silver nitrate instilled at birth This chemical conjunctivitis usually resolves by 48 hours of age The incidence of chemical conjunctivitis has decreased since erythromycin eye drops (0.5%) have replaced silver nitrate drops in the United States and Canada Chemical conjunctivitis may still be seen in developing countries where silver nitrate is used Neisseria gonorrhoeae conjunctivitis generally appears to days after birth, whereas conjunctivitis caused by Chlamydia trachomatis presents between and 14 days after birth because of its longer incubation period Gonococcal infection may be delayed beyond days of age because of partial suppression by the prophylactic drops instilled at birth Gonococcal infection usually manifests as marked inflammation of the eyelids, chemosis, and copious purulent discharge Gonococcal conjunctivitis is considered a medical emergency because the infection can cause corneal ulceration and perforation Presentation of chlamydial infection, which is primarily localized to the palpebral conjunctiva, can vary from mild inflammation to severe swelling of the eyelids with copious discharge Of neonates with chlamydial conjunctivitis, 10% to 20% have chlamydial pneumonia, which can either occur simultaneously with the eye infection or up to to weeks later HSV is a less common cause of neonatal conjunctivitis The presence of skin lesions can help in the diagnosis Gram stain and cultures are essential in the evaluation of neonatal conjunctivitis Giemsa staining from conjunctival scrapings and direct immunofluorescence antibody test can identify chlamydial disease Gonococcal conjunctivitis should be treated immediately with intravenous penicillin or a third-generation cephalosporin in addition to topical antibiotics and irrigation Chlamydial conjunctivitis should be treated with oral azithromycin Topical drops may be helpful in clearing debris but are not effective (see also Chapter 123 Ophthalmic Emergencies ) Transient Neonatal Strabismus Intermittent esotropia or exotropia may be noted in normal infants during the first to months of life Esotropia (crossed eyes) is more common than exotropia Deviations secondary to neuromuscular immaturity generally resolve spontaneously by to months of age Eye deviations that are constant rather than intermittent, or that not resolve by months of age, warrant referral for a full ophthalmologic examination (including fundus examination) to rule out pathology Esotropia can occur when visual acuity is impaired (e.g., corneal abrasions, cataracts, chorioretinitis, and tumors), or due to paralysis of the lateral rectus muscle In these cases, early treatment of strabismus improves the prognosis for cosmetic appearance and will prevent amblyopia In many infants, a broad, flat nasal bridge and prominent epicanthal folds may obscure a medial portion of the sclera near the nose and create the appearance of esotropia This pseudostrabismus, or apparent deviation of the eyes, is an illusion that can be dispelled by the finding of symmetric corneal light reflexes Disorders of the Neonatal Nose and Mouth Goals of Treatment Many neonatal nose and mouth disorder can be recognized immediately after birth or early in their nursery stay Infants occasionally develop symptoms of acute airway obstruction and respiratory distress after discharge home Airway obstruction can occur at any level from nose to trachea, leading to variable ... eyelids, chemosis, and copious purulent discharge Gonococcal conjunctivitis is considered a medical emergency because the infection can cause corneal ulceration and perforation Presentation of chlamydial