Mrs Fiona LeightonPaediatric Dietician

Christchurch

16:30 - 18:30 WS #52: Paediatric Forum (120mins, not repeated)

Dr Antony BedggoodOphthalmologist

Cataract Surgeon

Strabismus Surgeon

Children’s Specialist Centre

Dr Kiki MaoatePaediatric Surgeon

Urologist

Christchurch Public Hospital

Children's Specialist Centre

Dr Tony WallsPaediatric Infectious Disease Specialist

Clinical Senior Lecturer

University of Otago

Christchurch

Dr Kate GibsonGenetic Health Service NZ

Children’s Specialist Centre

Christchurch Hospital

Christchurch

Children: Infections and inflammatory eye problems

Practical management

guidelines

Neonatal conjunctivitis

• Systemic threat: must have PO/systemic antibiotic, Paeds referral

• Ocular threat: can result in corneal ulceration & perforation

• Gonococcal: day 2-5 profuse discharge

• Chlamydia: day 5-14 mucopurulent

• Pneumococcus, Staph, H. flu• Day 4-5, mucopurulent

• Maternal Hx/swab, swab/PCR

• Purulent: refer paeds before result

Nasolacrimal duct obstruction

• Symptoms often from 3-4 weeks, fairly constant• If 2+ week gaps/symptoms only with URTI then not obstructed

• Some children have acquired NLD obstruction• No issues in 1st 2-3 months (due to infection/conjunctivitis)

• Please avoid the term ‘congenital’ when referring

• Range: epiphora to purulent

• Congenital dacryocele• 100% will get infected – dacryocystitis

• Massage usually curative

• Surgery ~ 6 weeks old if non-resolving

Treat a baby’s sticky eye

• No harm in Chlorafast or Oc Chlosig• Often need ongoing bid while waiting for surgery

• Massage works (littler infants, ie <6 months)• 3-4 times/day for 2 weeks

• ‘Just’ watering/sticky: ideal surgery time 1 year

• Constant mucopurulent discharge: don’t wait• Early surgery prevents permanent scarring

How to differentiate the common problems

• Irritated, ‘blinky’ eyes: usually post-viral

• Most acute red, irritated eyes in children are viral• These will settle

• Important: primary HSV vesicles (or VZV in the last 3 months)

• Photophobia

• Clarity of red reflex

Chalasia

• Typical course:• Enlarge over 1-2 weeks, then reduce to a stable smaller size

• Usually an element of inflammation around them initially

• This frequently fluctuates

• Often multiple/sequential

• May spontaneously discharge

• Continued enlargement after 2 weeks not normal• But any chalasia 8mm size is not worrisome

• Core granuloma takes months to resolve

• Treat cellulitis with PO abs

Refer/surgery

• Simple treatments for 1 month• Warm facecloth/heat

• Oral Abs if cellulitis (topical make no difference)

• 3 weeks low dose erythromycin if multiple/recurrent

Then:

• Any large/progressively enlarging (>1.5cm) lid lesion

• Granuloma on the skin• Oc maxidex bid for 2 weeks 1st

• Lesion 8mm or more present 4 months

Periorbital infections

• Refer to paeds forthwith• Febrile/unwell

• Lid closed/can’t examine eye

• Young (<6)

• Treat: early/otherwise well• Broad spectrum to cover nasal flora

• If clear skin lesion: Fluclox

Allergic conjunctivitis

• Common: itch, crusting, atopy, seasonal (hay fever)• Patenol 1-2/day, cool flannel

• Chronic irritation: more important disease• Usually starts from age 4 to 10

• Troubling for child, photosensitive

• Due to papillae inside the upper lid

• Need to be checked

• Adults don’t get this• Vision threatening

• Steroid is very safe if ophthalmologist monitors

• Often needed for years

Why some children need topical steroid

Uveitis in children

• Very different to adults• Red, painful eye is the rare exception

• (Seen in older children)

• White eye, no symptoms

• Your job if a red painful eye in a child:• Check red reflex, vision, systemic exam, cornea

• Lids very swollen, extremely resistant to examination: assume it’s bad

• If all of those are OK, then you are safe to observe +/- Chloramphenicol

A few last tips

• Swab a child’s red or sticky eye? Little use….. (except newborn)• Often grow something, which treating makes no difference

• Nasolacrimal obstruction: chronic overgrowth of odd bugs, the issue though is surgical treatment

• Happily use Chloramphenicol – but don’t expect it to ‘fix’ the problem

• Lubricant drops no use (except to try & keep parents happy)• Wet flannel works

• Topical antihistamines/allergy Rx pointless unless typical symptom/season• Itchy, rubbing, watery, ongoing, in spring/summer

• Patenol is the absolute ‘go-to’: bid, takes up to 1 week to work, effective even od

• Don’t send children <5 to optoms, nor any with signs or real concerns

Summary: the ages of infected/inflamed eyes

• Newborn: Purulent conjunctivitis (STD)

• Infant:• Nasolacrimal duct obstruction

• Young child (1-4):• Post-viral conjunctivitis (mild symptoms)

• Chalasia

• Periorbital cellulitis

• Herpetic

• Corneal inflammation/neovascularisation

• School-aged child:• Allergic disease + any of the above

• Symptomatic anterior uveitis