compression and indications for repeat evaluation For patients with specific local abnormalities, such as tumors, polyps, or telangiectasias, referral to an ENT specialist is necessary Such referral might also be considered if bleeding were severe, recurrent, or suspected to be posterior in origin When epistaxis is noted in patients with a recent tonsillectomy/adenoidectomy, ENT consultation should be obtained before determining if it is safe to discharge them home Suggested Readings and Key References Davies K, Batra K, Mehanna R, et al Pediatric epistaxis: epidemiology, management & impact on quality of life Int J Pediatr Otorhinolaryngol 2014;78(8):1294–1297 Elden L, Reinders M, Witmer C Predictors of bleeding disorders in children with epistaxis: value of preoperative tests and clinical screening Int J Pediatr Otorhinolaryngol 2012;76(6):767–771 Eshghi P, Jenabzade A, Habibpanah B A self-controlled comparative clinical trial to explore the effectiveness of three topical hemostatic agents for stopping severe epistaxis in pediatrics with inherited coagulopathies Hematology 2014;19(6):361–364 Kamble P, Saxena S, Kumar S Nasal bacterial colonization in cases of idiopathic epistaxis in children Int J Pediatr Otorhinolaryngol 2015;79(11):1901–1904 Ritter FN Vicarious menstruation In: Strome M, ed Differential Diagnosis in Pediatric Otolaryngology Boston, MA: Little, Brown and Company; 1975:216 Stokhuijzen E, Segbefia C, Biss T, et al Severity and features of epistaxis in children with a mucocutaneous bleeding disorder J Pediatr 2018;193:183–189 Svider P, Arianpour K, Mutchnick S Management of epistaxis in children and adolescents: avoiding a chaotic approach Pediatr Clin North Am 2018;65:607– 621 CHAPTER 27 ■ EYE: RED EYE ATIMA DELANEY, BRUCE M SCHNALL INTRODUCTION “Red eye” is a generic term that refers to any condition in which the “white of the eye” appears red or pink A red eye may be caused by local factors, intraocular disease, or systemic problems Tables 27.1 to 27.3 list common and lifethreatening causes of red eye The cause of a red eye can often be identified by the history alone The history should include the presence or absence of pain, foreign body sensation, itching, discharge, tearing, photophobia, onset, visual disturbances, recent illnesses, and trauma The examination should include visual acuity, pupil shape and reactivity, the gross appearance of the sclera and conjunctiva, extraocular muscle function, and palpation of preauricular nodes The evaluation often requires fluorescein staining and slit-lamp examination by an experienced provider Discussion of chemical conjunctivitis or irritation caused by agents such as smoke or trauma is limited here because the history often makes the diagnosis clear The management of these disorders is discussed in Chapters 114 Ocular Trauma and 123 Ophthalmic Emergencies PATHOPHYSIOLOGY The term conjunctivitis should be reserved for disorders in which the conjunctiva is inflamed Inflammation may be caused by direct irritation, infection, abnormalities of underlying or contiguous structures (e.g., cornea), immune phenomena, or secondary to abnormalities of the lid and lashes Inflammation within the anterior chamber affecting the iris (iritis) may also result in secondary inflammation of the conjunctiva The sclera may become inflamed (scleritis) An intermediate layer, the episclera, lies beneath the conjunctiva’s substantia propria and another largely avascular fascial layer (Tenon fascia), where it is firmly attached to the sclera The episclera is more vascularized than the sclera and may become inflamed either in a diffuse or localized fashion (diffuse, sectorial, or nodular episcleritis) A tear film, which prevents desiccation, is constantly present over the surface of the eye A disruption in the function of the anatomic structures responsible for producing the tear film may cause desiccation of the ocular surface, resulting in irritation and inflammation (dry eye syndrome) Innervation of the conjunctiva and cornea comes from the first division of the trigeminal nerve (V1) Abnormalities on the ocular surface may give rise to pain or a foreign body sensation The reflex arc that involves the afferent trigeminal nerve and the efferent facial nerve results in a rapid blink, with contraction of the orbicularis oculi muscle, to protect the surface of the eye in response to noxious stimuli Two other reactions to noxious stimuli may occur: tearing and discharge Epiphora or tearing may accompany virtually any conjunctival inflammation or irritation Tearing may even be a part of some forms of dry eye syndrome, as the lacrimal gland attempts to compensate for a dry ocular surface Discharge from the eye results either from conjunctival exudation or precipitation of mucus out of the tear film The latter occurs when the tear film is not flowing smoothly such as nasolacrimal duct obstruction, causing misinterpretation as infection when the problem is actually mechanical Although discharge may be a nonspecific finding, the nature of the discharge may be helpful in the cause of an inflammation or infection The presence of membranes or pseudomembranes ( Fig 27.1 ) is more common with adenovirus infection or Stevens–Johnson syndrome These white or white–yellow plaques are caused by loosely or firmly adherent collections of inflammatory cells, cellular debris, and exudate EVALUATION AND DECISION The approach to the child who presents to the emergency department with a red eye is outlined in the flowchart shown in Figure 27.2 Any child with a red eye who wears contact lenses regularly, even if the lens is not in the eye at the time of the examination, should be referred to an ophthalmologist within 12 hours Red, and often painful eyes of a person who wears contact lenses may represent potentially blinding corneal infection (corneal ulcer) or the breakdown of the corneal epithelium, which would predispose the person to subsequent corneal infection Contact lenses should be removed immediately, further diagnostic or therapeutic interventions in these patients should be performed with ophthalmology consultation Decisions regarding starting empiric antibiotic therapy should be made with the consultation of an ophthalmologist, as there may be benefit to waiting until corneal cultures can be obtained The presence of a white spot on the cornea of a contact lens wearer with inflamed conjunctiva is an ominous sign that may represent an ulcer ( Fig 27.3 ) The absence of such a spot does not rule out corneal ulcer Other causes of red eye in a contact lens wearer include contact lens solution allergy (which may develop even after years of using the same regimen), overwearing of contact lenses, overly tight fit, foreign body, or a damaged contact lens Examination by an ophthalmologist can help ensure that a corneal ulcer is not missed by ascribing the red eye to one of these other etiologies It is therefore recommended that all contact lens wearers with a red eye be seen by an ophthalmologist Numerous systemic diseases may be associated with ocular inflammation Select examples can be found in Table 27.3 In some systemic diseases, the associated ocular abnormality involves intraocular inflammation (iritis, vitritis), which can then cause secondary conjunctival infection or inflammation Patients with these diseases may also have coincidental ocular inflammation unrelated to their underlying conditions Ophthalmology consultation may be helpful in making this distinction For example, in Kawasaki disease, the inflammation of the conjunctiva may be associated with mild iritis More often, the conjunctiva is inflamed in isolation as part of the systemic mucous membrane involvement The conjunctivitis of Kawasaki disease is usually confined to the bulbar conjunctiva, often with limbal sparing ( Fig 27.4 ), with little or no discharge In contrast, the bulbar and palpebral conjunctivae are inflamed in infectious conjunctivitis (Fig 123.7 ) ... cellular debris, and exudate EVALUATION AND DECISION The approach to the child who presents to the emergency department with a red eye is outlined in the flowchart shown in Figure 27.2 Any child