Red eye resident survival guide (pediatrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Synonyms and keywords: Approach to red eye in children, Red-eye work-up in kids, Red-eye management in children

Red eye resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Red eye is one of the most common ophthalmologic conditions in the primary care setting in children. Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (unilateral- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for a general practitioner from diseases calling for an elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.

Causes

Life Threatening Causes

Life-threatening causes include conditions that could lead to death or permanent disability within 24 hours if left untreated.

• Globe ruptures or perforations
• Intraocular infections
• Carotid–cavernous sinus fistula

Common Causes

Infectious

• Bacterial conjunctivitis
• Viral conjunctivitis
• Iritis/iridocyclitis
• Anterior uveitis
• Posterior uveitis (choroiditis)
• Endophthalmitis
• Dacrocystitis

Non-infectious

• Acute angle-closure glaucoma
• Disorders of the ocular adnexa(Hordeolum-Eyelid malposition)
• Eyelid malposition
• Intraocular disorders
• Scleritis/Episcleritis
• Photokeratitis
• Corneal erosion/ulceration
• Subconjunctival hemorrhage
• Allergic conjunctivitis
• Non-infectious (kerato-)conjunctivitis
• Contact lens
• Blunt or penetrating trauma
• foreign bodies
• Chemical conjunctivitis
• Blepharitis

FIRE: Focused Initial Rapid Evaluation

Patients with the primary symptom of a red eye are commonly seen in pediatric primary care clinics. The differential diagnoses of a red eye are broad, but with a succinct history and physical examination, the diagnosis can be readily identified in many patients. Identifying conditions that threaten vision and understanding the urgency of referral to an ophthalmologist is paramount. Some systemic diseases such as leukemia, sarcoidosis, and juvenile idiopathic arthritis can present with the chief symptom of a red eye. Finally, trauma, ranging from mild to severe, often precipitates an office visit with a red eye, and thus understanding the signs that raise concern for a ruptured globe is essential . In the primary care setting, with a focused history, a few simple examination techniques, and an appreciation of the differential diagnosis, one can feel confident in managing patients with acute red eyes., or eye emergencies requiring urgent ophthalmic surgery.

History & Physical examination

Emergency

Trauma

Systemic disease

Acute

Mild-severe

Main symptom of red eye

Urgent ophthalmologic evaluation

Rupture of globe

Acute

Office visit

Office visit

Complete Diagnostic Approach

Localized, diffused and perikeratic injection.

Shown below is an algorithm summarizing the diagnosis of red eye according to the Nelson Essentials of Pediatrics guidelines.

Age group

Neonates

Infants and toddlers

School age children

School age children and adolescent

24 hours

<1 week

1-2 weeks

1-5 years

Viral conjunctivitis Allergic conjunctivitis

Chemical conjunctivitis

Neisseria Ghonorrhea

Chlamydia Trachomatis

Herpes Simplex Varicella Zoster

Without otitis

With otitis

Haemophilus Influenzae Streptoccoccus Penumoniae

H. Influenzae

Age Group		Common Etiology
Neonates*	< 24 hrs	Chemical conjunctivitis
	< 1 week	Neisseria gonorrhea
	1-2 wks	Chlamydia trachomatis
Infants and Toddlers	Without otitis	Haemolphilus. influenza, Streptococcus pneumoniae
	With otitis	H. influenza
School Age Children	1-5 years	Herpes simplex virus, varicella-zoster virus
School Age Children and Adolescents		Viral conjunctivitis, allergic conjunctivitis

Treatment

Shown below is an algorithm summarizing the treatment of Red eye according to the American journal of medicine.

Patient with red eye

Emergency

Acute conjunctivitis

Chronic blepharitis

Urgent ophthalmic surgery

•Eyelid hygiene •Topical antibiotics •Oral tetracycline or doxycycline

Severe

Mild

Moderate

Viral

Bacterial

•Over the counter •Antihistamine •Vasocontricter agent or with more effective second generation topical histamine H1 receptor antagonist

•Antiinflammatory agents (eg. topical cyclosporine) •Topical corticosteroids •Systemic omega 3 fatty acids

Hand washing and meticulous hygiene or normal saline spray

Ophthalmic antibiotic such as gentamycin

• Good hygiene, such as meticulous hand washing, is important in decreasing the spread of acute viral conjunctivitis.
• Any ophthalmic antibiotic may be considered for the treatment of acute bacterial conjunctivitis because they have similar cure rates.
• Mild allergic conjunctivitis may be treated with an over-the-counter antihistamine/vasoconstrictor agent, or with a more effective second-generation topical histamine H1 receptor antagonist.
• Anti-inflammatory agents (e.g., topical cyclosporine [Restasis]), topical corticosteroids, and systemic omega-3 fatty acids are appropriate therapies for moderate dry eye.
• Patients with chronic blepharitis who do not respond adequately to eyelid hygiene and topical antibiotics may benefit from an oral tetracycline or doxycycline.

Do's

• The most important task is to detect potentially serious ocular presentations to the immediate referral of the patient to an ophthalmologist and treatment.
• Conditions requiring referral to an ophthalmologist are orbital cellulitis, hyphaema, scleritis, iritis or uveitis, acute angle closure glaucoma, and corneal abrasions (unless very superficial).
• Be cautious when prescribing steroids: You should exclude the possibility of herpetic keratitis.
• Ocular pain and change in vision are two extremely specific warning signs of eye pathology, and unless doctor are absolutely certain of a benign diagnosis doctor must refer him for ophthalmological assessment if he has these.

Don'ts

• Do not miss the pupillary exam in the pediatric population is a vital part of any clinician's workup. In the right clinical setting, pupillary abnormalities such as anisocoria, light-near dissociation, an afferent pupillary defect, and paradoxic pupillary constriction in the dark can be red flags that trigger further examination and workup.
• Through both careful physical examination and detailed history taking and observation, potentially vision- and life-threatening conditions can be detected So eye emergencies requiring urgent ophthalmic surgery.

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