“don’t panic! when to treat and ... - school of medicine

“Don’t Panic! When to treat and when to refer. Common eye problems for the primary care pediatrician”

Mitchell Strominger, MD, FAAO, FNANOS, FAAPOS, FAAP

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Financial and other disclosures

• I have lots of financial interest in this topic. None of it is commercial• Stole many images from Google• Apologize upfront if I insult anyone's sensibilities

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The Ophthalmic Challenges

• Make the right diagnosis• Don’t worsen• Know when to refer

Case presentations with discussion

• Red Eye• Conjunctivitis• Foreign body / Trauma • Uveitis• Cellulitis, preseptal vs orbital

• Strabismus• Leukocoria• Misc

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6 year old presents to your office with a red eye

• The most important element of your examination is …• A history• B general examination• C ocular examination• D none of the above (Epic in a prescription for eye drops and send the child home

without an examination)• E A, B, and C

All red eye is conjunctivitis?

• A. True• B. False

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What is Red or Pink Eye?

A descriptive term, not a specific diagnosis.

Photo © Alcon Laboratories, Inc.

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Potential Causes of Red Eye

• Conjunctivitis• Bacterial• Allergic• Viral• Chemical

• Foreign body/trauma • Uveitis• Orbital Cellulitis

Photo © 2002 Robert D. Gross, MBA, MD.

Cause and effect. History is important!

• Symptom Cause• Itching Allergy• Scratchiness Foreign body, dry eye• Burning Lid, conjunctival disorders• Localized tenderness Stye, Chalazion• Deep intense pain and photophobia Corneal abrasion, iritis, sinusitis• Halo vision Corneal edema

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Evaluation of the Red Eye:Physical Examination

• Issues to consider• Eyelid involvement • Unilateral or bilateral • Localized or diffuse redness • Discharge:

Watery vs. Mucopurulent• Vision• Pupils • Cornea • Red reflex • Posterior pole and optic

nerve

Subconjunctival HemorrhagePhoto © Alcon Laboratories, Inc.

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Examination

• Non-Vision threatening• Subconjunctival

hemorrhage• Stye or Chalazion• Chalazion• Blepharitis• Conjunctivitis• Dry eyes• Corneal abrasions (most)

• Vision threatening• Corneal infections• Scleritis• Hyphemia• Iritis• Acute glaucoma• Orbital cellulitis

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The Red Eye Opportunities

• Prompt diagnosis• Optimal intervention• Rapid relief• Lower costs• Appreciative patients

Photo © 2002 Robert D. Gross, MBA, MD.

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The conjunctiva is …

• A A pesky embryonic mucous membrane remnant that has no redeeming value, like the appendix

• B The clear part of the eye that you see through• C A protective covering of the eye that has a palpebral and bulbar

component that prevents contact lenses from slipping behind the eye and into the brain

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Ocular Anatomy: Eyelid / Conjunctiva

Managing the Red Eye. Eye Care Skills on CD-ROM. American Academy of Ophthalmology; 2001.

SkinOrbicularis oculi muscle

Hair folliclePerifollicular glands

UPPER EYELID:ANTERIOR ANATOMY

Eyelash

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Types of Conjunctivitis

• Allergic • Bacterial• Viral• Chlamydial• Irritative• Giant papillary• Phlyctenular• Ophthalmia neonatorum

Bacterial ConjunctivitisPhoto © Steven J. Lichtenstein, MD, FAAP

Pre test

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Conjunctivitis associated with … is most likely …

• Pharyngitis• Preauricular adenopathy• Whitish, mucoid discharge

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat

them all the same anyway!

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Conjunctivitis associated with … is most likely …

• Otitis• Sinusitis• Purulent, yellow green

discharge

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat

them all the same anyway!

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Conjunctivitis associated with … is most likely …

• Itching• Stringy, clear discharge

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat

them all the same anyway!

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The major cause of conjunctivitis in children presenting to the primary care physician is …

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat them all the same

anyway !

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Causes of Pediatric Acute Conjunctivitis

1. Weiss A, et al. J Pediatr. 1993;122:10-14. 2. Isenberg SJ, et al. Am J Ophthalmol. 2002;134:681-688.

BacterialInfection1

(n=76) 80%

NoneIdentified1

(n=5) 5%

Allergy1

(n=2) 2%

Viral Infection1

(n=12) 13%

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Conjunctivitis associated with … is most likely …

• Otitis• Sinusitis• Purulent, yellow green

discharge

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat them all

the same anyway!

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Bacterial Conjunctivitis

• Usually occurs in preschool-aged children

• Bilateral but can be unilateral• Mucopurulent discharge with

matting• May be associated with otitis

media1

• Can be highly contagious

1. Bodor FF, et al. Pediatrics. 1985;76:26-28.

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Ocular Pathogens in Bacterial Conjunctivitis

N=76. Weiss A, et al. J Pediatr. 1993;122:10-14.

58.1

27.1

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20

30

40

50

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H influenzae Streptococci M catarrhalis Staphylococci

% o

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s

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Treatment of bacterial conjunctivitis includes …

• A Topical antibiotic• B Lid hygiene• C Do nothing• D None of the above• E A, B, and C

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Why Treat Bacterial Conjunctivitis?

• Achieving an early cure of bacterial conjunctivitis has important implications for1-5

• Reducing contagion • Improving patients’

quality of life• Early return to school

and work• Early identification of

masquerade disease

1.American Academy of Ophthalmology. Preferred Practice Pattern: Conjunctivitis. 1998:9. 2. Gigliotti F. Pediatr Ann. 1993;22:353-356. 3. Gigliotti F, et al. J Pediatr. 1984;104:623-626. 4. Lohr JA, et al. Pediatr Infect Dis J. 1988;7:626-629. 5. Jackson WB, et al. Can J Ophthalmol. 1982;17:153-156.

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Maine Elementary School Epidemic

• Fall 2002 • 101 Cases• Mostly Grades K, 1, 2• Strep. Pneumoniae• Non-encapsulated

strain• Reported to CDC

Pneumococcal conjunctivitis at an elementary school – MaineSept. 20 – Dec. 6, 2002: MMWR 2003;52(04):64-66.

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September 2002 Maine

• 101 students (28%)• 3 classroom teachers• 3 other staff• 37 family members

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September 2002 Maine

• Symptoms• Red eye• Itching, painful or buring• Crusty in the morning• Grey or yellow discharge• Eyelid swelling

• Nontypeable S. pneumoniae

• Resistant to erythromycin

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Ophthalmic Antibiotics Used to Treat Bacterial Conjunctivitis

SulfacetamideBacitracin (ung)Polysporin® (ung)

● Polymyxin B/BacitracinNeosporin®

● Polymyxin B/Bacitracin● Neomycin

Achromycin®

● TetracyclineChloroptic®

● ChloramphenicolIlotycin® (ung)

● ErythromycinGenoptic®

• Gentamicin

Tobrex®

● TobramycinPolytrim®

● Polymyxin B/TrimethoprimChibroxin®

● NorfloxacinCiloxan®

● CiprofloxacinOcuflox®

● OfloxacinQuixin®

● LevofloxacinVigamox™

● MoxifloxacinZymar™

● GatifloxacinBesivanvce

Besifloxacin

Erythromycin – 1 cm 6 x per dayPolymyxin/Trimethoprim – one drop every 3 hours for 7 to 10 days

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Fluroquinolones - bacteriocidal

• Aerobic Gram-positive• Corynebacterium• Staphlylococcus aureus• Staphylococcus

epidermidis• Streptococcus pneumoniae• Streptococcus viridans

group

• Anaerobic• Fusobacterium species

• Other• Chlamydia trachomatis

• Aerobic Gram-negative• Haemophilus influenzae• Esherichia coli• Klebsiella pneumoniae• Moraxella catarrahalis• Proteus mirabilis

Moxifloxacin – 1 drop 2 to 3 x per day for 7 daysOthers – 1 drop q 2 hrs x 24 hrs then 2 to 4 times per day for days 2 - 7

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Conjunctivitis associated with … is most likely …

• Pharyngitis• Preauricular adenopathy• Whitish, mucoid discharge

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat

them all the same anyway!

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Viral Conjunctivitis

• Usually affects older children

• Usually unilateral, then affects fellow eye

• May be associated with pharyngitis

• Associated with preauricularor submandibularadenopathy

• Adenovirus• Supportive treatment

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These children present with eye rubbing. This is most likely …

• A Viral conjunctivitis• B Bacterial conjunctivitis• C Allergic conjunctivitis• D Chemical conjunctivitis

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Conjunctivitis associated with … is most likely …

• Itching• Stringy, clear discharge

• A Viral• B Bacterial• C Allergic• D Chemical• E Who cares, I treat

them all the same anyway!

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Questions that help pinpoint ocular allergy are …

• Are your child's red eyes itchy, watery and are the lids swollen?

• Are you giving your child an over-the-counter eye drop?

• Are they taking oral antihistamine?• Are they taking intranasal steroids?• Do they have Asthma?• Do they have eczema or atopy?

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Allergic Conjunctivitis

SIGNS

Hyperemia

Chemosis

Lid edema

Mucousdischarge

Tearing

SYMPTOM

Itching

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The following are types of ocular allergy

• A Seasonal/Perennial Allergic Conjunctivitis • B Vernal keratoconjunctivitis (VKC)• C Atopic keratoconjunctivitis (AKC)• D Giant papillary conjunctivitis (GPC)• E A only• F A, B, C, D

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Seasonal allergic conjunctivitis

• Lid or conjunctival edema• Watery discharge and white,

stringy mucus• Itching is predominant symptom• Associated with hay fever,

asthma, eczema• Occurs primarily in spring and

fall (Pollens, Outdoor molds)• Contact allergy with drugs,

chemicals, cosmetics

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Perennial Allergic Conjunctivitis

• Causes• Indoor molds• Cockroaches• Dust mites• Pet dander

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Atopic Keratoconjunctivitis

Causes: • Associated with Atopic

Dermatitis• May Be Perennial • Genetic Predisposition • Environmental AntigensSigns / Symptoms: • Itching• Redness• Photophobia• Keratopathy

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Causes: • Genetic Predisposition, Atopy• Seasonal / Perennial Allergens (IgE)• Non-Specific Hypersensitivity

Signs / Symptoms:• Ropy Mucous Discharge• Large, Non-uniform

Cobblestone Papillae• Tanta's Dots• Limbal Nodules• Neovascularization• Shield Ulcers

Vernal Keratoconjunctivitis

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Causes: • Repeated Mechanical Irritation

caused by:• Contact Lens Edge• Ocular Foreign Bodies

• Aggravated by Concomitant Allergy• Can also Aggravate Ocular Allergy

Giant Papillary Conjunctivitis

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Conjunctival mast cells are most similar to …

• A Tryptase containing mast cells of the lungs• B Tryptase containing mast cells of the nasal mucosa• C Tryptase/chymase mast cells of skin connective tissue• D A and B

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Distribution of Human T and TC Mast Cells

Location % T % TC

Skin 12 88

Lung 99 1

Nasal mucosa epithelium

100 0

Conjunctiva 0 100

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Pharmacological management of allergic conjunctivitis includes …

• A Antihistamines• B Antihistamine/Vasoconstrictor Combination• C Mast Cell Stabilizers• D Antihistamine and Mast Cell Stabilizers• E Steroids• F NSAIDs• G All of the above

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The most common topical treatment of allergic conjunctivitis is …

• Antihistamine/ decongestant combinations, Naphazoline/ Pheniramine (Naphcon-A®, Opcon-A®, OcuHist®)

• Topical antihistamines, Levocabastine (Livostin™) Emedastine (Emadine™)

• Antihistamine/ mast cell stabilizers, Olopatadine (Patanol®) Ketotifen (Zaditor™, Alaway) Azelastine (Optivar™)

• Mast cell stabilizersNedocromil (Alocril™) Pemirolast (Alamast™) Lodoxamide (Alomide®), Cromolyn (Crolom®, Opticrom®)

• CorticosteroidsLoteprednol 0.2% (Alrex®) FluorometholonePrednisolone Rimexolone (Vexol®)Loteprednol 0.5% (Lotemax)

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*Who’s Treating our Patients?

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*A.C. Nielsen®, SCANTRACK, FDM 52 Weeks Ending 2/19/00

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Antihistamine/ decongestant combinations, Naphazoline/ Pheniramine

• Naphcon-A®, Opcon-A®, OcuHist®, Visine-A®• These over-the-counter antihistamine/vasoconstrictors are dangerous to children in that the

conjunctiva blood vessels get “dependent” on the vasoconstrictor component. Upon stopping the drug, a rebound vasodilation and hyperemia can occur leading to even worse redness to the eye and irritation. Also the warning label includes that the vasoconstrictor can cause pupil dilatation which can lead to blurry vision, and also central nervous system depression in infants and children.

• The antihistamine compound of these products is very short acting and needs to be dosed every three to four hours which will require having the school nurse give the drops to the children disrupting class.

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Cromolyn sodium - Crolom

• Mast cell stabilizer, but this can take 7 to 10 days before an effect is seen.• Therefore to appropriately treat, two drugs need to be given.

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Olopatadine and ketotifen

• Antihistamine and mast cell stabilizer• Dosage twice per day• Olopatadine formulated specifically for the triptase / chymase mast cell of

the eye • Pataday – once per day• Alaway, Zaditor OTC

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10 year old presents with …

• Watery discharge for two days• Palpable preauricular nodes• URI, sore throat, fever common

• The most likely diagnosis is• A Viral• B Bacterial• C Allergic

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Examination showed …

• Reduced visual acuity• Exam with direct

ophthalmoscope demonstrates

• A tell the patient this is self limited and send home

• B allow the child to return to school

• C refer to an ophthalmologist

• D A and C• E all the above

A child presents with HSV involving the lids. Corneal stain shows dendrites. You decide to …

• A Treat with topical antibiotics• B Treat with topical steroids• C Treat with topical antivirals• D Refer immediately• E No treatment needed since this will

resolve over time

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An 11 month old presents with recurrent morning discharge despite treatment with erythromycin and polytrim. Your advise the parent to

• A. begin a course of a topical fluoroquinolone

• B. begin oral acyclovir• C. obtain an MRI• D. wipe off the discharge and

return next month• E. See a pediatric

ophthalmologist for nasolacrimal duct probing

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Nasolacrimal duct obstruction

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Nasolacrimal duct probing

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A 16 year old presents with this lesion while removing a contact lens. Treatment includes ..

• A Topical antibiotics and patch• B Immediate referral to an ophthalmologist• C Topical antibiotics• D Oral antibiotics• D Corneal transplantation

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This teen shared a cosmetic contact lens with school friends. You call the ophthalmologist to refer a …

• A Hyphema• B Hypopion• C Corneal abrasion• D Conjunctivitis• E Iritis

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This child was playing under the sink and got splashed in the eye with an unknown liquid. The mother calls you on the phone. Youshould …

• A tell mom to let the child continuing playing• B send them to the nearest emergency room for

immediate irrigation and instruct them to bring the bottle

• C refer to an ophthalmologist at the next available appointment

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This child with a URI and cough presents to your office. Visual acuity is normal. You should …

• A refer immediately• B rule out coagulopathy• C reassure parents that this will resolve

spontaneously• D prescribe topical antibiotics• E patch

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This child was playing in the back yard. The most likely cause of this red eye is …

• A Bacterial conjunctivitis• B Allergic conjunctivitis• C Viral conjunctivitis• D Blunt trauma

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This child present with localized redness and discomfort. The history should include questions regarding …

• A Otitis• B Sinusitis• C Bronchitis• D Arthritis

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This child has pain, circumcorneal redness, and decreased vision. Work up should include …

• A ANA• B Rheumatoid factor• C Chest x-ray• D ACE• E GI work up• F A, B, C, D, E• G none of the above

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Evaluation and treatment of this lesion includes ..

• A MRI to rule out intracranial spread• B Warm compress• C Biopsy and node dissection• D Oral antibiotics• E A and C• F B and D

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Chalazion

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A 12 year old was stung by a bee. You …

• A. Prescribe an antihistamine• B. Prescribe an oral antibiotic• C. Apply cool compresses• D. Admit to the hospital emergently for CT

scan and intravenous antibiotics

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Lift the lid and check vision and motility

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The parents of this healthy 1 year old notice the eyes crossing. You …

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• A. Prepare the patient and parents for strabismus surgery

• B. Emergently scan looking for causes of a sixth nerve palsy

• C. Refer the child to the pediatric ophthalmologist at age 6

• D. Comment how cute the baby looks and ask to look at other photographs

Look at the light reflex !

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Pseudoesotropia

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This troubled teen complains of nonspecific headache, stomach ache, wanting to stay home from school. You…

• A. Tell her to get a hair cut• B. Refer her to pediatric GI• C. Refer her to pediatric neurology• D. Refer to pediatric psychiatry• E. None of the above

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You pull her hair back and …

• A. Perform an emergent MRI.• B. Remember that the eye has been crossed

since birth and send her home.• C. Tell her parents to take out a loan to cover

the cost of strabismus repair.• D. Find the vision is reduced and refer for vision

therapy.• E. Discuss with her that even if the vision is

poor, that the eye can be straightened.

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This 4 yo has the relatively acute onset of eye crossing. You…

• A. Discuss that since the child is otherwise healthy that the risk of general anesthesia for strabismus repair is low.

• B. Check for papilledema.• C. Draw Lyme titers.• D. Cover the right eye and ask the child to

look all the way to the left.

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The child returns wearing glasses. The parents are upset since the eyes still cross with the glasses off and want strabismus repair. You …

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• A. Refer them to a pediatric ophthalmologist who has more surgical experience.

• B. Refer them to an optometrist for vision therapy.

• C. Refer them to Costco for contact lenses.

• D. Comment on how cute he looks in the glasses.

A 3yo known child has an urgent visit. The parents note this strange look to the eye. You …

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• A. Immediately draw TORCH titers and check urine amino acids

• B. Have the child return next month to see if this disappears

• C. Ask if the child fights with the older sibling• D. Wait until the child is 10 then refer to an

ophthalmologist for its removal

The eyes of this child have been slowly turning from blue to brown. You notice theses lesions on the iris. You …

• A. Perform a metastatic work up.• B. Refer to an ophthalmologist for iris

biopsy.• C. Check the hearing.• D. Guiac the stool.

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Treatment of this lesion includes …

• A Immediate excision and metastatic work up• B No treatment needed• C Symptomatic treatment with artificial tears, anti

allergics• D A only• E B and C• F none of the above

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The pediatric ophthalmologist calls you describing the fundus findings of this one year old you referred with failure to thrive and poor tracking. You…

• A. Tell the parents to begin pediasure.• B. Perform a long bone series.• C. Draw coagulation studies.• D. Draw a CBC.• E. Obtain blood cultures.

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Treatment indicated – You can treat!

• Chalazion• Conjunctivitis• Corneal abrasions

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Referral required

• Decreased vision• Photophobia• Ocular pain• Circumcorneal redness• Corneal edema• Corneal ulcer or dendrites• Abnormal pupil

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Urgent referral

• Orbital cellulitis• Corneal infections• Episcleritis / scleritis• Hyphemia• Iritis

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Take Home Points

• If prescribing antibiotic drops over the phone, red eyes that are not better within 48 hours (on treatment) need to be reviewed

• Treat bacterial infections with appropriate antibiotics (I prefer fluroquinolones tid x 5 days)

• Do not use topical steroid or antibiotic/steroid combinations

• Treat allergic conjunctivitis with appropriate antihistamine/mast cell stabilizers (Pataday or Alaway) and do not use Visine or other vasoconstrictors

• Always check visual acuity

• Rule out ruptured globe or hyphema

• Check ears for Otitis Media, throat and for preauricular adenopathy

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Conclusion

• Clinical expertise• Cooperation• Communication

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THANK YOU !