Red eye in children

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

Synonyms and keywords: Red eye in kids, Conjunctivitis, outbreak-epidemic-symptoms.

Overview

Red eye in children is a common consultation purpose. Mostly benign, this sign may also cause visual impairment. We differentiate three kinds of red eye: localised, diffused and perikeratic injection. The last one must be recognized because of its association with severe ocular diseases. Diagnosis must be sure and treatment has to be efficient to not pertubate childrens visual development. Unfortunately, physical examination on children is not always easy. Consultation with an ophthalmologist is justified if a doubt remains, in case of chronic pathology or resistance to first intention treatment. Generally, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications rare.

Historical Perspective

• Red eye in children was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
• In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
• In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

• Red eye may be classified according to classification method into three subtypes/groups:

• localised
• diffused
• perikeratic injection

Pathophysiology

• On microscopic histopathological analysis, viral, bacterial like Streptococcus pneumonia, Haemophilus influenzae, Moraxella catarrhalis, or Staphylococcus aureus and fungal are characteristic findings of red eye.

Causes

Common causes of Red Eye in Children

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

Differentiating Red eye from other Diseases

Red eye is diffrentiated from many disease, the most common is conjunctivitis . Others include: Bacterial conjunctivitis, Viral conjunctivitis, Allergic conjunctivitis,Chemical conjunctivitis, Foreign body, Blepharitis, Hordeola , Keratitis, Endophthalmitis , Dacrocystitis, Anterior uveitis (iridocyclitis) :associated with juvenile RA, Behcet diease and IBS; sudden onset pain, photophobia, blurred vision, irregular pupil, poor vision, Posterior uveitis (choroiditis) and Scleritis/Episcleritis

Differential diagnosis of red eye with no injury

	CONJUNCTIVITIS	CORNEAL ULCER	ACUTE IRITIS	ACUTE GLAUCOMA
Eye	Usually both eyes	Usually one eye	Usually one eye	Usually one eye
Vision	Normal	Usually decreased	Often decreased	Marked decrease
Eye pain	Normal or gritty	Usually painful	Moderate pain, light sensitive	Severe pain (headache and nausea)
Discharge	Sticky or watery	May be sticky	Watering	Watering
Conjunctiva	Generalised (variable) redness	Redness most marked around the cornea	Redness most marked around the cornea	Generalised marked redness
Cornea	Normal	Grey, white spot (fluorescein staining)	Usually clear, (keratitic precipitates may be visible with magnification)	Hazy (due to fluid in the cornea)
Anterior chamber (AC)	Normal	Usually normal (occasionally hypopyon)	Cells will be visible with magnification	Shallow or flat
Pupil size	Normal and round	Normal and round	Small and irregular	Dilated
Pupil response to light	Active	Active	Minimal reaction as already small	Minimal or no reaction
Intraocular pressure (IOP)	Normal (but do not attempt to measure IOP)	Normal (but do not attempt to measure IOP)	Normal	Raised
Useful diagnostic sign/test	Pussy discharge in both eyes	Fluorescein staining of the cornea	Irregular pupil as it dilates with drops	Raised IOP

Epidemiology and Demographics

• The prevalence of red eye in children is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
• Of 840 patients, 525 were men (62.5%) and 315 were women (37.5%). Most of the patients were over 39 years of age. 55.7 percentage of them lived in cities and 44% were from villages. The most common eye symptoms with eye redness were: Eye abrasion (57%), tears in eyes (49%) and swollen eye lid (30%). Red eyes without any symptoms in eyes were diagnosed as runny nose (4.2%) and headaches (3.4%). 11.9% and 19.6% of the patients had a previous history of red eye and had visited doctors for red eyes respectively.

Age

• Patients of all age groups may develop red eye.

Gender

• males are more commonly affected with red eye in children than females.

Race

• There is no racial predilection for red eye in children.

Risk Factors

Common risk factors in the development of red eye in children are

• the Upper Respiratory Infection
• Viral Conjunctivitis (Pink Eye)
• Irritant Conjunctivitis
  1. Smog
  2. Chlorinated pool
• Bacterial Conjunctivitis

Natural History, Complications and Prognosis

• Early clinical features include, tearing, discharge, itching, pain, foreign body sensation, photophobia, and vision changes.
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

• The diagnosis of red eye in children is made when detailed patient history and careful eye examination are token. at least [one] of the following [six] diagnostic criteria are met

• reduced visual acuity
• ciliary flush (circumcorneal injection)
• corneal abnormalities including edema or opacities ("corneal haze")
• corneal staining
• abnormal pupil size
• abnormal intraocular pressure

Symptoms

• Red eye is usually asymptomatic.
• Symptoms of red eye may include the following:

• eye discharge
• pain
• photophobia
• itching
• visual changes and redness

Physical Examination

• Patients with red eye in children usually appear with only red eye .
• Physical examination may be remarkable for:

• 1. Redness of entire Eyelid or swollen Eyelid
     1. Assess for Periorbital Cellulitis
     2. Assess for acute Ethmoiditis
  2. Associated Eye Pain or constant eye tearing, blinking
     1. Assess for Corneal Ulcer
     2. Assess for Herpes Simplex VirusKeratitis
     3. Assess for Eye Foreign Body
  3. Blurred Vision
     1. Assess for Uveitis

Laboratory Findings

• There are no specific laboratory findings associated with red eye in children.
• An [elevated] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of red eye in children.
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with red eye in children.

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

New diagnostic instruments for imaging the anterior segment of the eye have been developed using the corneal topographer as optical coherence tomography (OCT) may be helpful in the diagnosis of red eye. Findings on an OCT suggestive of/diagnostic of keratoconus or pellucid marginal corneal degeneration include epithelial edema in the epithelial layer and stromal layer associated with intraocular pressure elevation.

Other Diagnostic Studies

• Red eye may also be diagnosed using color-Doppler imaging echography of dural carotid-cavernous fistula of ophthalmological manifestation.
• Findings on include color-Doppler imaging echography flow reversal with a systolic component in the superior and inferior enlarged ophthalmic veins and Embolization.

. Computed tomography imaging of the orbits should be performed if a high-velocity penetrating injury is suspected. If acute glaucoma is suspected, intraocular pressure should be measured in the emergency department.

Treatment

treatment is based on the underlying etiology, and Recognizing the need for emergent referral to an ophthalmologist is key in the primary care management of red eye. Referral is necessary when severe pain is not relieved with topical anesthetics; topical steroids are needed; or the patient has vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent infections. clinical signs that require an urgent ophthalmic consultation are chemical burns, intraocular infections, globe ruptures or perforations, and acute glaucoma.

Medical Therapy

• The mainstay of therapy for red eye in children is good hygiene, such as meticulous hand washing, is important in decreasing the spread of acute viral conjunctivitis. and 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. If the cornea is involved, refer to an eye centre where the baby will be treated with intensive antibiotic eye drops and, sometimes, systemic antibiotics.

Surgery

• Surgical procedure can only be performed for patients with emergency case of red eye like intraocular infections, globe ruptures or perforations, and acute glaucoma or traumatic eye injury.

Prevention

Practice good hygiene to control the spread of red eye. For instance:

• Don't touch your eyes with your hands.
• Wash your hands often.
• Use a clean towel and washcloth daily.
• Don't share towels or washcloths.
• Change your pillowcases often.
• Throw away your eye cosmetics, such as mascara.
• Don't share eye cosmetics or personal eye care items.

Keep in mind that red eye is no more contagious than the common cold. It's okay to return to work, school or child care if you're not able to take time off — just stay consistent in practicing good hygiene.

Preventing red eye in newborns

Newborns' eyes are susceptible to bacteria normally present in the mother's birth canal. These bacteria cause no symptoms in the mother. In rare cases, these bacteria can cause infants to develop a serious form of conjunctivitis known as ophthalmia neonatorum, which needs treatment without delay to preserve sight. That's why shortly after birth all babies should have their eyes cleaned immediately, then an antibiotic ointment like tetracycline is applied to every newborn's eyes. The ointment helps prevent eye infection. During antenatal care, all mothers with vaginal infections should be treated. Educate traditional birth attendants, community health workers, and both parents as this is often a sexually transmitted disease.