Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 21

Eye Disorders

Frances K. Porcher

Allergic conjunctivitis, 372.14

Atopic dermatitis, 691.8

Allergic rhinitis, 477.9

Conjunctival hyperemia, 372.71

Allergic rhinitis due to other

 allergens, 477.8

Conjunctivitis, 372.3

Excessive tearing, 375.2

Allergic rhinitis due to pollen

  (seasonal rhinitis), 477

Stringy, mucoid discharge, 372.89

Upper respiratory infection, 465.9

Asthma, 493.9

 

I. ALLERGIC CONJUNCTIVITIS

A. Definition. Conjunctivitis: inflammation or infection of bulbar and/or palpebral conjunctiva.

B. Etiology.

1. Allergens such as pollen, molds, animal dander, smoke, dust.

C. Occurrence.

1. Common in all age groups.

2. Often seasonal.

3. May have had recent upper respiratory infection.

D. Clinical manifestations.

1. Watery, red eyes.

2. Itching or burning bilaterally.

3. Excessive tearing.

E. Physical findings.

1. Diffuse conjunctival hyperemia.

2. Boggy conjunctiva.

3. Stringy, mucoid discharge.

4. May see concurrent asthma, atopic dermatitis, or allergic rhinitis.

F. Diagnostic tests.

1. None.

2. Culture if conjunctivitis is persistent or does not respond to treatment.

G. Differential diagnosis.

Conjunctivitis, bacterial, 372.3

Corneal abrasion, 918.1

Conjunctivitis, viral, 077.99

Nasolacrimal duct obstruction, 375.56

1. Bacterial or viral conjunctivitis.

2. Nasolacrimal duct obstruction.

3. Corneal abrasion.

H. Treatment.

1. Eliminate offending agent.

2. Systemic oral antihistamine (Claritin, Zyrtec).

3. Topical ophthalmic mast-cell stabilizer (Cromolyn, Alomide).

4. Topical ophthalmic antihistamine/mast-cell stabilizer combination (Patanol).

5. Artificial tears.

6. Cool, wet compresses.

I. Follow up.

1. Routine follow up not necessary.

2. Return if fails to improve in 2-3 days or worsens.

J. Complications.

Allergic reaction to medication, 995.5

Secondary bacterial infection, 041.9

1. Allergic reaction to medication.

2. Secondary bacterial infection.

K. Education.

1. Avoid rubbing eyes.

2. Use meticulous handwashing.

3. Avoid wearing eye makeup until resolved.

4. Avoid use of contact lenses until resolved.

5. Will last about 10-14 days.

II. BACTERIAL CONJUNCTIVITIS

Conjunctival hyperemia, 372.71

Conjunctivitis, bacterial, 372.3

Otitis media, 382.9

A. Etiology.

1. Haemophilus influenzae.

2. Streptococcus pneumoniae.

3. Moraxella catarrhalis.

B. Occurrence.

1. Common in school-age children.

2. Accounts for 80% of pediatric acute conjunctivitis.

C. Clinical manifestations.

1. Red eyes.

2. Purulent discharge, with matted eyelids on awakening.

3. May complain of gritty sensation in eye.

4. Usually starts unilaterally, becoming bilateral.

D. Physical findings.

1. Diffuse and marked conjunctival hyperemia.

2. Purulent or mucopurulent discharge.

3. May see concurrent otitis media (especially with H. influenzae).

E. Diagnostic tests.

1. Culture in infants younger than 1 month of age, multiple cases in a daycare/school; unless conjunctivitis is persistent or does not respond to treatment.

F. Differential diagnosis.

Blepharitis, 373

Corneal ulcer, 370

Chlamydial conjunctivitis, 077.98

Herpes simplex, 054.43

Conjunctivitis, viral, 077.99

Nasolacrimal duct obstruction, 375.56

Corneal abrasion, 918.1

Neisseria gonorrhoeae conjunctivitis, 098.4

1. Viral conjunctivitis.

2. Chlamydial conjunctivitis (refer to ophthalmologist).

3. Neisseria gonorrhoeae conjunctivitis (refer to ophthalmologist).

4. Nasolacrimal duct obstruction.

5. Blepharitis.

6. Corneal abrasion or ulcer (refer to ophthalmologist).

7. Herpes simplex (refer to ophthalmologist).

G. Treatment.

1. One year of age, newer generation ophthalmic fluoroquinolones.

a. Levofloxacin (Quixin).

b. Moxifloxacin (Vigamox).

c. Gatifloxacin (Zymar).

2. Younger than 1 year of age.

a. Tobramycin (Tobrex) ophthalmic solution or ointment.

b. Erythromycin ophthalmic ointment.

3. Cool, wet compresses.

H. Follow up.

1. No routine follow up necessary.

2. Recheck if fails to improve in 2-3 days or worsens.

I. Complications.

Blindness, 369

Systemic infection, 038.9

1. Systemic infection.

2. Blindness.

J. Education.

1. Continue treatment for at least 7 days or for at least 3 days after symptoms have resolved.

2. Very contagious; meticulous handwashing and no sharing of linens.

3. No school or daycare until antibiotic treatment for 24 hours.

4. Instillation of ophthalmic ointment will blur vision.

III. CHLAMYDIAL CONJUNCTIVITIS

Chlamydial conjunctivitis, 077.99

Pneumonia, 486.

Chlamydial pneumonia, 483.1

Rhinorrhea, 478.1

Cough, 786.2

Tachypnea, 786.06

Hyperemic conjunctiva, 372.71

 

A. Etiology.

1. Chlamydia trachomatis.

B. Occurrence.

1. Neonatal occurrence, acquired from infected cervix during birth.

2. Adult occurrence, acquired through sexual contact.

C. Clinical manifestations.

1. Purulent discharge.

2. May occur in one or both eyes.

3. Neonatal infection appears from day 2 to week 8.

D. Physical findings.

1. Mucopurulent discharge.

2. Hyperemic conjunctiva.

3. May see Chlamydia pneumonia in infants.

E. Diagnostic tests.

1. Giemsa-stained epithelial cells from conjunctival scraping.

2. Conjunctival culture from swab (requires special tissue culture techniques).

3. Immunofluorescent staining of conjunctival scraping.

4. Chlamydial antigen test.

F. Differential diagnosis.

Congenital glaucoma, 743.2

Conjunctivitis, viral, 077.99

Conjunctivitis, bacterial, 372.3

Neisseria gonorrhoeae conjunctivitis,

 098.4

1. Neisseria gonorrhoeae conjunctivitis (refer to ophthalmologist).

2. Bacterial conjunctivitis.

3. Viral conjunctivitis.

4. Congenital glaucoma (refer to ophthalmologist).

G. Treatment.

1. Refer all neonates for evaluation and treatment (systemic oral erythromycin).

2. Refer mother and mother's sexual partner for evaluation and treatment.

3. Report to appropriate authority (sexually transmitted infection).

H. Follow up.

1. Return in 3 days to monitor eye infection.

2. Return sooner if infant has signs of pneumonia or parental concerns.

I. Complications.

1. Other sexually transmitted infections.

J. Education.

1. Review good handwashing with family.

2. Mother and partner need treatment because disease is usually transmitted vaginally during birth.

3. Eye infection can be associated with pneumonia that started during first 6 weeks with cough, rhinorrhea, tachypnea.

4. Infant may need second round of erythromycin; efficacy is 80%.

IV. VIRAL CONJUNCTIVITIS

Conjunctivitis, viral, 077.99

Pharyngitis, 462

Diffuse conjunctival hyperemia, 372.71

Upper respiratory infection, 465.9

A. Etiology.

1. Adenovirus (most).

2. Herpes simplex.

3. Varicella zoster.

4. Coxsackie.

B. Occurrence.

1. Common in all age groups.

2. Very contagious; 8-day incubation period.

C. Clinical manifestations.

1. Pinkish-red eyes.

2. Watery or serous discharge, with crusty eyelids on awakening.

3. May complain of gritty sensation in eye.

4. May complain of sore throat, upper respiratory infection, flulike symptoms.

5. One or both eyes involved.

6. Vesicles on skin around eye (herpes).

D. Physical findings.

1. Diffuse conjunctival hyperemia with follicles.

2. Watery or serous discharge.

3. Discomfort, not acute pain.

4. Preauricular and submandibular adenopathy.

5. May see concurrent pharyngitis and/or upper respiratory infection.

6. Vesicular lesions on skin around eyes (herpes).

7. Normal vision.

E. Diagnostic tests.

1. None.

2. Culture if conjunctivitis is persistent or does not respond to treatment.

F. Differential diagnosis.

Blepharitis, 373

Corneal abrasion, 918.1

Conjunctivitis, allergic, 372.14

Corneal ulcer, 370

Conjunctivitis, bacterial, 372.3

Nasolacrimal duct obstruction, 375.56

1. Bacterial conjunctivitis.

2. Allergic conjunctivitis.

3. Nasolacrimal duct obstruction.

4. Blepharitis.

5. Corneal abrasion or ulcer (refer to ophthalmologist).

G. Treatment.

1. Antibiotics not indicated.

2. Cool, wet compresses.

3. Artificial tears.

4. Refer if suspect conjunctivitis due to herpes.

H. Follow up.

1. No routine follow up necessary.

2. Recheck if fails to improve in 10-14 days; sooner if worsens.

I. Complications.

Secondary bacterial infection, 041.9

1. Secondary bacterial infection.

J. Education.

1. Very contagious; meticulous handwashing and no sharing of linens.

2. Avoid touching eyes.

3. Will last about 12-14 days.

4. No school or daycare until discharge is resolved.

V. CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION (DACRYOSTENOSIS)

A. Definition. Congenital nasolacrimal duct obstruction (dacryostenosis), 375.56 Defect of lacrimal drainage system resulting in blockage.

B. Etiology.

1. Imperforate membrane at distal end of nasolacrimal duct.

C. Occurrence.

1. Occurs in up to 6% of all newborn infants.

2. Both eyes involved, 33%; one eye involved, 66%.

D. Clinical manifestations.

1. Persistent, excessively watery eyes.

2. Mucopurulent discharge.

3. Matted eyes on awakening.

E. Physical findings.

1. Watery eyes, often overflowing onto cheek.

2. Sclera clear.

3. Reflux of mucopurulent discharge from punctum easily obtained with gentle pressure over nasolacrimal sac.

4. May see concurrent erythema or irritation of skin around eyes.

F. Diagnostic tests.

1. Gentle pressure over nasolacrimal sac produces mucopurulent discharge from punctum.

G. Differential diagnosis.

Blepharitis, 373

Conjunctivitis, viral, 077.99

Conjunctivitis, bacterial, 372.3

Dacryocystitis, 375.3

1. Viral conjunctivitis.

2. Bacterial conjunctivitis.

3. Blepharitis.

4. Dacryocystitis.

H. Treatment.

1. Massage lacrimal sac several times a day.

2. If secondarily infected, treat with anti-infective (see Bacterial Conjunctivitis).

3. Refer to ophthalmologist if not resolved by 12 months of age.

I. Follow up.

1. Recheck at all well-baby exams and as needed.

J. Complications.

Conjunctivitis, bacterial, 372.3

Dacryocystitis, 375.3

Periorbital or orbital cellulites, 376.01

1. Bacterial conjunctivitis.

2. Dacryocystitis.

3. Periorbital or orbital cellulites.

K. Education.

1. Wash hands before touching infant's eyes.

2. Teach massage technique: place index finger over lacrimal sac, exert gentle downward pressure, and slide finger downward toward mouth.

VI. BLEPHARITIS

A. Definition.

Blepharitis, 373

Conjunctivitis, 372.3

Inflammation or infection of margins of eyelid.

B. Etiology.

1. Seborrhea.

2. Staphylococcal.

3. Pediculus pubis or P. capitis.

C. Occurrence.

1. Can occur in all age groups.

D. Clinical manifestations.

1. Red eyelid margin.

2. Itching or burning of eyelid margin.

3. Crusting or scaling of eyelid margin.

4. Commonly bilateral and chronic or recurrent.

E. Physical findings.

1. Seborrhea.

a. Easy-to-remove yellow, greasy scales along base of eyelashes.

b. May see concurrent and similar scales on eyebrows, scalp, external ears.

2. Staphylococcal.

a. Fibrinous, difficult-to-remove scales along base of eyelashes.

b. Inflammation or ulceration of lid margins.

c. Loss of eyelashes.

d. May see concurrent conjunctivitis.

3. Pediculosis.

a. Lice along lid margins.

b. May see concurrent pubic or head lice.

F. Diagnostic tests.

1. Culture of lid margin indicated only if fails to respond to treatment.

G. Differential diagnosis.

Conjunctivitis, allergic, 372.14

Dermatitis, contact, 692.9

Conjunctivitis, bacterial, 372.3

Nasolacrimal duct obstruction, 375.56

Conjunctivitis, viral, 077.99

Seborrheic dermatitis, 690.1

Dermatitis, atopic, 691.8

 

1. Conjunctivitis (allergic, bacterial, or viral).

2. Nasolacrimal duct obstruction.

3. Atopic or contact dermatitis.

4. Seborrheic dermatitis.

H. Treatment.

1. Clean eyelid margins twice a day with diluted baby shampoo.

2. Seborrhea blepharitis: treat eyebrows, scalp, ears with selenium sulfide shampoo.

3. Staphylococcal blepharitis: apply topical anti-infective ointment (erythromycin ophthalmic ointment or bacitracin/polymyxin B ophthalmic ointment).

4. Pediculosis blepharitis: remove parasite by smothering with ophthalmic petrolatum along lid margins.

I. Follow up.

1. No routine follow up necessary.

2. Recheck if fails to improve; sooner if worsens.

J. Complications.

Conjunctivitis, 372.3

Hordeolum, external, 373.11

Hordeolum, internal, 373.12

1. Loss of eyelashes.

2. Conjunctivitis.

3. Hordeolum or chalazion.

K. Education.

1. Frequent handwashing.

2. Discourage rubbing of eyes.

VII. HORDEOLUM

Hordeolum, external, 373.11

Hordeolum, internal, 373.12

A. Definition. Infection of meibomian glands (internal hordeolum) or glands of Zeis or Moll (external hordeolum or stye) of eyelid.

B. Etiology.

1. Usually Staphylococcal aureus.

C. Occurrence.

1. Can occur at any age.

D. Clinical manifestations.

1. Internal: painful and tender eyelid, red eye, usually without pustule.

2. External: painful and tender eyelid, red eye, usually with pustule.

E. Physical findings.

1. Internal: large, erythematous, tender mound of one eyelid with associated mild conjunctival hyperemia.

2. External: smaller, more superficial eyelid pustule with associated mild conjunctival hyperemia.

F. Diagnostic tests.

1. None indicated.

G. Differential diagnosis.

Chalazion, 373.2

Eyelid abscess, 373.13

1. Chalazion.

2. Eyelid abscess.

H. Treatment.

1. Frequent, warm compresses.

2. May use topical antiinfective ointment (erythromycin ophthalmic ointment or bacitracin/polymyxin B ophthalmic ointment).

3. Refer if mass fails to disappear after several weeks (may need surgical incision and drainage).

I. Follow up.

1. No routine follow up necessary.

2. Recheck if fails to resolve or worsens.

J. Complications.

Orbital or eyelid cellulitis, 376.01

1. Orbital or eyelid cellulitis.

K. Education.

1. Frequent handwashing.

2. Avoid rubbing eyes.

VIII. CHALAZION

A. Definition.

Chalazion, 373.2

Inflammation of meibomian glands of eyelid.

B. Etiology.

1. Granulomatous inflammation.

C. Occurrence.

1. Can occur at any age.

D. Clinical manifestations.

1. Hard mass in upper or lower eyelid.

2. Not red or pustular.

3. Chronic appearance.

E. Physical findings.

1. Firm, nontender nodule in upper or lower eyelid.

2. Not erythematous or pustular.

3. No eye discharge.

F. Diagnostic tests.

1. None indicated.

G. Differential diagnosis.

Dacryocystitis, 375.3

Hordeolum, internal, 373.12

Eyelid abscess, 373.13

Orbital cellulitis, 376.01

Hordeolum, external, 373.11

 

1. Hordeolum (internal or external).

2. Orbital cellulitis.

3. Dacryocystitis (inflammation of the lacrimal sac).

4. Eyelid abscess.

H. Treatment.

1. Most spontaneously subside without treatment.

2. Surgical removal if size distorts vision.

I. Follow up.

1. No routine follow up necessary.

2. Recheck if fails to improve or worsens.

J. Complications.

Distorted vision, 368.15

1. Distorted vision secondary to size of lesion.

K. Education.

1. Frequent handwashing.

2. Avoid rubbing eyes.

IX. CHEMICAL BURN

A. Definition.

Burn of the eye, 940.9

Opacity of corneal tissue, 371

Eye pain, 379.91

Photophobia, 368.13

Eyelid burn, 940.9

Swollen corneas, 379.92

Instillation of alkali or acid solution or substance to eye. True emergency needs immediate referral to ophthalmologist.

B. Etiology.

1. Installation of alkali or acid solution or substance into eye.

C. Occurrence.

1. Boys > girls.

2. 11- to 15-year olds have highest rate of injury.

D. Clinical manifestations.

1. Eye pain.

2. Unable to open eye(s).

E. Physical findings.

1. Eyelid burn.

2. Opacity of corneal tissue, pale surrounding tissue.

3. Photophobia.

4. Tearing, swollen corneas.

F. Diagnostic tests.

1. None.

G. Differential diagnosis.

Eyelid injury, 921.1

Foreign body, eye, 930

1. Foreign body.

2. Type of chemical burn.

3. Eyelid injury.

H. Treatment.

1. Emergency treatment is immediate irrigation with copious amounts of water or saline.

2. Emergency referral to ophthalmologist.

I. Follow up.

1. Per ophthalmologist.

J. Complications.

Loss of vision, 369.9

1. Loss of vision.

K. Education.

1. Prevention is most important.

2. Need to know name of chemical in eye; acid burns affect cornea and anterior chamber of eye.

3. Alkali burns can continue for days.

X. CORNEAL ABRASION (SUPERFICIAL)

A. Definition.

Corneal abrasion (superficial), 918.1

Eye pain, 379.91

Decreased vision, 369.9

Photophobia, 368.13

Excessive tearing, 375.2

 

Scratched, abraded, or denuded cornea.

B. Etiology.

1. Usually due to accidental contact with object (fingernail, branches, bushes, paper, contact lens overwear).

C. Occurrence.

1. Can occur at any age.

D. Clinical manifestations.

1. Pain.

2. Excessive tearing.

3. Photophobia.

4. Decreased vision.

E. Physical findings.

1. May see uneven light reflection or cloudiness of cornea.

2. May see foreign body.

3. After staining with fluorescein and using cobalt-blue light or Wood's lamp, will see area of green staining (persists with blinking).

4. Decreased visual acuity.

F. Diagnostic tests.

1. Fluorescein staining and cobalt-blue light or Wood's lamp.

G. Differential diagnosis.

Foreign body, eye, 930

1. Foreign body.

H. Treatment.

1. Instill topical ophthalmic anti-infective ointment (erythromycin ophthalmic ointment or bacitracin/polymyxin B ophthalmic ointment).

2. Patching not recommended.

I. Follow-up.

1. Recheck in 24-48 hours, or sooner if worsens.

J. Complications.

Impaired vision, 369.9

Eye infection, 360

1. Infection.

2. Impaired vision.

K. Education.

1. Frequent handwashing.

2. Avoid use of contact lenses for at least 1 week following healing of abrasion.

XI. FOREIGN BODY (CONJUNCTIVAL, CORNEAL)

A. Definition.

Excessive tearing, 375.2

Photophobia, 368.13

Foreign body, eye, 930

Sensation that something is in eye, 368.9

Presence of abnormal substance or object in eye.

 

B. Etiology.

1. Usually object is airborne.

C. Occurrence.

1. Can occur at any age.

D. Clinical manifestations.

1. Excessive tearing.

2. Photophobia.

3. Sensation that something is in eye.

E. Physical findings.

1. Excessive tearing.

2. Use bright light or magnification to visualize corneal and conjunctival surfaces for foreign body.

3. May need to evert upper eyelid to find foreign body.

F. Diagnostic tests.

1. None.

G. Differential diagnosis.

Eye infection, 360

Perforation of ocular globe, 370.06

1. Infection.

2. Perforation of ocular globe.

H. Treatment.

1. Test visual acuity.

2. Remove foreign body if possible with moistened, cotton-tipped applicator.

3. After removal of foreign body, inspect for corneal abrasion using fluorescein.

4. Refer to ophthalmologist if large abrasion or unable to find foreign body.

I. Follow up.

1. Recheck in 24 hours or sooner if worsens.

J. Complications.

1. Infection.

2. Damage to cornea.

K. Education.

1. Avoid rubbing eyes.

2. Teach prevention of eye injuries (protective eyewear).

XII. HEMORRHAGE (SUBCONJUNCTIVAL)

A. Definition.

Hemorrhage (subconjunctival), 372.72

Ruptured blood vessel in eye, 459

B. Etiology.

1. Sudden increase in intrathoracic pressure (coughing, sneezing).

2. Direct ocular trauma.

C. Occurrence.

1. Can occur at any age.

D. Clinical manifestations.

1. Ruptured blood vessel in eye.

E. Physical findings.

1. Blotchy, bulbar erythema of conjunctiva.

F. Diagnostic tests.

1. None.

G. Differential diagnosis.

1. Ocular trauma.

H. Treatment.

1. None; will spontaneously resolve in 5-7 days.

2. Refer to ophthalmologist if due to trauma.

I. Follow up.

1. No routine follow up necessary.

2. Recheck if fails to disappear in 5-7 days, or worsens.

J. Complications.

1. Usually none.

K. Education.

1. Teach measures to avoid increasing intrathoracic pressure.

XIII. HYPHEMA

A. Definition.

Eye pain, 379.91

Hyphema, 364.41

Impaired vision, 369.9

Blood in anterior chamber of eye.

B. Etiology

1. Usually due to blunt or perforating trauma to eye.

C. Occurrence.

1. Variable.

D. Clinical manifestations.

1. Bright or dark red area near iris.

2. Painful.

E. Physical findings.

1. Bright or dark red fluid level between cornea and iris.

F. Diagnostic tests.

1. X-rays, CT scan for other injuries.

G. Differential diagnosis.

Foreign body, conjunctival, 930.1

1. Type of foreign body.

H. Treatment.

1. Immediate referral to ophthalmologist.

I. Follow up.

1. Per ophthalmologist.

J. Complications.

Impaired vision, 369.9

1. More extensive ocular injury.

2. Rebleeding, which may result in vision impairment.

K. Education.

1. Children sometimes take weeks for vision to return to normal.

2. Prevention is best.

3. Encourage parents to continue follow up as recommended by ophthalmologist.

XIV. OCULAR TRAUMA

A. Definition.

Blurred vision, 368.8

Eye pain, 379.91

Decreased/impaired vision, 369.9

Eye redness, 379.93

Double vision, 368.2

 

Indirect or direct serious injury to eye.

B. Etiology.

1. Fireworks, sticks, stones, BB shots.

2. Sports related.

C. Occurrence.

1. One-third of all causes of acquired blindness.

2. Males > females 4:1.

D. Clinical manifestations.

1. Double, blurred, or decreased vision.

2. Eye pain or pain in surrounding area.

3. Tearing.

E. Physical findings.

1. Unable to open eye.

2. Tearing.

3. Corneal redness.

F. Diagnostic tests.

1. X-rays if orbital fracture or nasal fracture is suspected.

G. Differential diagnosis.

Laceration to ocular globe or orbit, 871.4

Orbital wall fracture, 802.8

Perforation to ocular globe or orbit, 370.06

1. Laceration to ocular globe or orbit.

2. Perforation to ocular globe or orbit.

3. Orbital wall fracture.

H. Treatment.

1. Referral to ophthalmologist.

I. Follow up.

1. Per ophthalmologist.

J. Complications.

Blindness, 369

Eye infection, 360

1. Extensive ocular injury.

2. Blindness.

3. Infection.

K. Education.

1. Prevention: use of goggles or glasses when spraying.

2. Do not instill any medication.

3. Immediate referral to ophthalmologist.

XV. PRESEPTAL CELLULITIS (PERIORBITAL CELLULITIS)

A. Definition.

Dental abscess, 522.5

Periorbital cellulitis, 376.01

Edematous, 782.3

Sinusitis, 473.9

Erythema, unspecified, 695.9

Swelling of the eye, 379.92

Fever, 780.6

 

Inflammation and infection of eyelids and periorbital tissue.

B. Etiology.

1. Staphylococcal aureus.

2. Streptococcus pneumoniae.

3. Streptococcus pyogenes.

4. Haemophilus influenzae type B.

C. Occurrence.

1. Common in young children secondary to trauma, infected wound or insect bite, severe sinusitis, dental abscess.

D. Clinical manifestations.

1. Red, painful swelling around eye.

2. May or may not have fever.

3. History of local trauma to area, insect bite, sinusitis, dental abscess.

E. Physical findings.

1. Erythematous, edematous, tender, warm area around eye.

2. Regional adenopathy.

F. Diagnostic tests.

1. CBC (will indicate leukocytosis in severe cases).

2. Blood culture.

3. Head CT scan (helps delineate extent of disease).

G. Differential diagnosis.

Conjunctivitis, 372.3

Retinoblastoma, 190.5

Contact dermatitis, 692.9

Rhabdomyosarcoma, 171.9

Neuroblastoma, 160

 

1. Severe contact dermatitis.

2. Severe conjunctivitis.

3. Ophthalmic malignancy or tumor (retinoblastoma, rhabdomyosarcoma, neuroblastoma).

H. Treatment.

1. Uncomplicated and older than 2 months of age: ceftriaxone then oral antibiotics, oral antiinfective (amoxicillin-clavulanate, cephalexin, or erythromycin).

2. Complicated/extensive or younger than 2 months of age: requires hospitalization and intravenous antibiotics.

I. Follow up.

1. Daily follow up is necessary to monitor for rapid improvement.

J. Complications.

Eyelid abscess, 373.13

Loss of vision, 369.9

1. Spread of infection with possible abscess formation.

2. Loss of vision.

K. Education.

1. Frequent handwashing.

2. Teach prevention (avoid trauma, use insect repellent, cleanse wounds).

BIBLIOGRAPHY

American Academy of Ophthalmology. Preferred Practice Patterns.http://one.aao.org/CE/PracticeGuidelines/PPP.aspx. Accessed September 8, 2010.

Ehlers JP, Shah CP, eds. The Willis Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008.

Hunter A. Problems related to the head, eyes, ears, nose, throat or mouth. In: Barnes K, ed. Paediatrics–A Clinical Guide for Nurse Practitioners. Philadelphia, PA: Butterworth-Heinemann; 2003.

Kliegman RM, Behrman RE, Jenson HB, et al. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders; 2007.

Nelson LB, Olitsky SE, eds. Harley's Pediatric Ophthalmology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

Trobe JD. The Physician's Guide to Eye Care. 3rd ed. San Francisco, CA: American Academy of Ophthalmology; 2006.



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