Chapters Transcript Common Conditions and Communication Gabrel Burton, OD, presents on strabismus in infants. All right. Well, as always, welcome to Early bird rounds. We're happy to have everyone join us this morning. Today we have Doctor Gabriel Burton, who is specialized in ophthalmology, and today he's speaking on common conditions and communication. Uh, please keep your cameras turned off and your mics muted during the session. There will be time at the end for questions, and you're welcome to unmute at that time. And I'll put the QR code back up at the end for everyone to scan for credit. And with that said, we'll go ahead and give our attention to Doctor Burton. Hi, my name is Gabe Burton, uh, pediatric optometrist in the pediatric ophthalmology department at Wash U in the Saint Louis Children's Hospital. I want to discuss some common things that you have or will encounter, uh, recommendations for those including what to do and when to refer. Um referral touches on the communication aspect of the presentation, but also in those last 15 minutes reserved for questions. Um, I'd also like to pose a question for you. Um, if there's anything that we, pediatric ophthalmology as a department could do better with our communication with you in your office, um, anything you'd like to say, um, could be helpful to improve things over time. And See if I can get that to move. OK. Uh, today we'll cover 4 topics, uh, strabismus in infants, red eyes, irritated but not red eyes, and excess tearing. Let's see, that's still not working. OK. I have uh no disclosures. Uh, so we'll organize this by taking each topic, starting with strabismus and infants, uh, starting with a couple of bullet points on what you should do, then we'll touch on what shouldn't be missed, um, followed by common causes. Then we'll cover the recommended approach to take with the patient including history, examination, and plan. Um, then we'll finish each of the four sections by stressing again what shouldn't be missed, um, just to kind of touch on that again. So, uh, let's start with, uh, strabismus and infants, and this is distinct from strabismus in older children. Um, I wanted to include that as well, but I realized I didn't have quite the time, so maybe we can cover that again at a, uh, a future talk if, if needed. So, um, so first, what should you do? Um, if the child is less than 2 months old and the eyes cross occasionally and there are no visible abnormalities of the eyes, uh, the child should just be rechecked after 2 months of age. Um, patients with constant crossing though, um, constant at any age, or intermittent uh crossing that persists after the two months of age, um, should be referred to pediatric pediatric ophthalmology or your local ophthalmologist depending on where you're at. Um, so what shouldn't be missed, um, although uncommon, abnormalities of the eyes such as, uh, cataract or retinoblastoma, uh, may initially present with strabismus, and I turn, and this is secondary to the decreased vision that's caused by those. Um, the prognosis for those disorders is greatly improved with getting those treated right away. So any child with strabismus and an abnormal red reflex, um, should be referred immediately. Um, some common causes of strabismus in infants, uh, number one is, is just a normal newborn, um, physiological intermittent strabismus of the newborn. Um, intermittent eye crossing is relatively common in the 1st 1 or 2 months of life. Uh, the angle of eye crossing may be quite large, but the duration is brief, uh, only lasting a few seconds, and this resolves in most infants by the 2 months of age. Um, number 2, pseudostrabismus. Uh, if you look at this photo, um, you may notice that normal infants, um, let's see, it looks like both, uh, photos showed up. So the one on the left, uh, if you notice, Uh, normal infants have a, a wider and flatter nasal bridge than adults, and when an infant looks to the side, this tissue may block visualization of the white nasal sclera in the eye that's turned in towards the nose, while the sclera remains visible in the other eye, and this creates asymmetry and creates an optical illusion that makes it appear as if that eye is crossing. Um, examination of the corneal light reflex will reveal that the eyes are straight though. So in the photo on the left, notice the white dot, uh, the corneal light reflex is centered in the pupil on that left eye. Um, contrast that with the picture on the right, um, where the corneal light reflex is displaced temporally on the patient's left eye, showing that that left eye is really turning in. Um, and that brings us to our, uh, third cause of, uh, Strabismus, which is infantile otropia, so it is the, the true eye crossing. Um, it's usually not present at birth, uh, most often begins around the age of 2 months, and initially, it may occur, um, intermittently just some of the time, but usually progresses, uh, rapidly to happening all the time. And when the infant's eye crosses, the brain will stop paying attention to the visual information from that eye, and this may cause amblyopia if that eye is constantly crossed and never addressed and Some children will spontaneously alternate fixation. So if you look at the photos here, the upper photo shows fixation with the left eye, and the bottom photo shows the same patient fix with the right eye. Um, binocular vision though still cannot develop in children if that's constantly happening. Um, early intervention, surgical realignment of the eye, um, will improve the outcome, and infantility trophy is more common in children with, um, developmental delay. And the fourth common cause is decreased vision. Um, any condition that causes decreased vision, particularly if it affects just one eye, may cause a secondary strabismus. And in infants, the strabismus in the poorly seeing eye is most commonly esotropia. Uh, the list of possible causes includes virtually Any ocular disorder that affects vision. So some of these are incurable, such as optic nerve hypoplasia or large retinal colobomas, um, but some are amenable to treatments such as cataracts or retinoblastoma. Um, for the latter, early diagnosis and treatment, um, may dramatically improve the diagnosis. Um, so let's look at the approach to take with the patient. Um, so starting with the history, um, during a well child evaluation, the patient's parents may raise concern about strabismus or you may, as the examiner note, um, possible ocular misalignment during the exam. And if the parents have noted eye misalignment, the history, um, should include the parents' perception of the child's vision. Um, does the baby fixate on their faces? Does the baby respond to lights? Are there other abnormal eye movements present, um, especially if you notice, uh, the stagmus. Uh, if you notice, uh, strabismus during the exam, the parents should be asked whether, um, they've seen it at home, um, and experienced parents may recognize that occasional brief crossing is fairly common in newborns, um, but may not be bothered to mention it, um. However, some parents may mistakenly believe that more severe strabismus, such as constant large angle crossing or crossing that persists beyond the two months of age is also normal, um, and you can figure that out by uh questioning that. Um, the amount and frequency of the eye crossing should be determined. Um, the parents see only brief crossing during the 1st 1 or 2 months of life, and the baby is otherwise developing well, this is slightly normal. Um, if they see constant crossing at any age, um, even in the 1st 2 months of life, this is usually not normal. Um, an important caveat is that true infantileesotropia may initially present with intermittent crossing. Typically worse when the child is tired. Um, usually progresses to constant crossing by 3 to 4 months of age, unlike the normal occasional infant crossing which should um get better by this age. And so If the parents see only mild crossing and it seems worse when the baby looks to the side, this is probably pseudostrabismus. Uh, the condition is often noted in photographs, inspection of which can confirm the diagnosis of the corneal light reflexes are symmetric, and many conditions that cause developmental problems are associated with a higher incidence of infantileotropia. Um, so examples are prematurity, perinatal, um, hypoxia, uh, Down syndrome, hydrocephalus, um. Infantiltroy is not inherited in a Mendelian fashion, but there is a genetic predisposition. So if the children have a first degree relative with strabismus, um, it should be monitored carefully for onset of uh strabismus and other potentially heritable causes of decreased vision that may initially present with strabismus include um the infantile cataracts and retinoblastoma. Um, so during the examination, um, In addition to uh regular well child examination, infants whose parents report the eye crossing or in whom it's noted during the exam should have their vision checked, uh, carefully. Um, it's important to recognize that a child who has decreased vision in one eye, um, but normal vision in the other will appear to seem normal when both eyes are open. Um, in a child with strabismus and decreased vision, the vision loss may be secondary to the strabismus from amblyopia, or the strabismus may be secondary to the decreased vision. So in either case, the infant will ignore the eye with a decreased vision and usually functions well, um, using only the good eye. To check the vision in an infant with strabismus, watch to see whether that strabismus spontaneously alternates like we saw in those photos. Um, if it does, uh, this indicates that the vision's equal or, or at least nearly equal in both eyes. If one eye is constantly crossed though, the examiner should cover the eye that's straight and see whether the child can fixate on a toy or your face, uh, with that strabismic eye. Um, if the child uses this eye well and is not bothered by having the normally straight eye covered, the vision is probably equal or nearly equal on both eyes. Um. The type of strabism should be noted, um, included the, uh, degree and frequency of the crossing. Um, the corneal light reflection test uh is a good way to assess that. Um, the, uh, if the child is isotropic or their eyes are turning in, the light reflection will be centered in the eye that's looking at the pen light and like we saw in that photo, it'll be displaced temporally on the cor and the cross eye, um. Children with uh pseudostrabism isotropic, um, initially, um, they usually have, like we noted before, uh, that wide nasal bridge or the epicampal folds, uh, the corneal light reflex is symmetric though when you're looking at that, indicating that the true esotropy is not present. And as noted before, um brief episodes of crossing which can be um quite marked can are often normal in the 1st 1 or 2 months of life. Um, if an infant's eyes are constantly crossed though, um, go ahead and refer. Um examination findings that indicate there may be other ocular problems in addition to straism include, um, poor vision in both eyes and stagmus or abnormal uh red reflex. So, um, the plan in a healthy child is only, um, occasional brief eye crossing in those 1st 1 to 2 months, um, whether it's by the parent's report, what you're seeing in the exam, or both, and whose vision and eye exam are otherwise normal, um, re-examining them at 2 to 3 months of age is, is just fine. Uh, if the examiner suspects the child has the pseudostribismus, um, just keep in mind that the true esotropia may initially be um, Intermittent and therefore may not be present during that brief period of time when they're in your office. Um, a question that may help distinguishing if it's real esotropia is whether the parents know that the crossing is worse when the baby's tired. Um, if so, uh, true esotropy is more likely. Um, and in addition, there are other concerning historical features such as, um, developmental delay, family history of strabismus like we mentioned, and referral, um, can be considered with, with those as well. Um, an infant with a constant eye crossing at any age, um, an abnormal red red reflex or in whom, uh, decreased vision is suspected should be, uh, referred to, uh, pediatric ophthalmology. Um, and then here's an algorithm that can be useful for uh reference. And so, just to touch on again, so what shouldn't be missed, um, isotropy may be uh the presenting sign of uh serious ocular conditions such as those, uh, infantile cataracts, retinoblastoma, red reflex will usually be abnormal in those patients and since the prognosis for vision and, and life in the case of retinoblastoma is largely dependent on getting those diagnosed and treated as soon as possible, um, those should be referred. To our office or, or similar office and see within a few days and uh for less serious disorders like the strabismus or amblyopia, early diagnosis is also beneficial. Um, in general, if the uh examiner can't be certain whether it's really the strabismus is really present, um, go ahead and err on the side of caution and refer those over. Uh, it's better to have Those referred and found to be normal rather than risk a delay in, in, in diagnosing those. Um, so let's uh switch gears now, um, and let's take a look at red eyes. So, what should you do? Uh, main decision in evaluating a patient with red eye is whether it's likely to recover, um, without sequela or if there's a potentially serious problem. And if the patient has bacterial conjunctivitis, uh, if the cornea is clear, the patient is not significantly uncomfortable, then you can treat with topical antibiotics. Um, uh, culture is usually not necessary unless, um, there's just a lot of discharge going on. Um, patients with allergic conjunctivitis can be treated with an eye drop, um, although oral allergy medications often better tolerated in children. Children just typically don't like drops very much, um, so consider that. And if a patient has a corneal abrasion, but the cornea is otherwise clear and there's no suspicion of an intraocular foreign body, then treatment with um topical antibiotics is, is what would be needed there. Um, small foreign bodies can sometimes be removed um with um uh topical anesthetic and um uh cotton tipped applicator. Uh, if they can't be removed and there's any clotting in the cornea, um, go ahead and refer those. Um, patients with, uh, direct ocular injuries from a ball, fist, uh, um, those should be evaluated for high femur or blood in the anterior chamber or damage to the cornea, um, orbital fracture, those types of things, and, um, referrals indicated for most patients with, uh, kind of non-trivial blunt ocular trauma, so. Um, patients with red eyes who wear, uh, contact lenses should be instructed to stop wearing the lenses immediately. Um, there's an increased risk of, uh, corneal infections in those patients and, um, go ahead and refer those to their local eye care provider. Um, uh, for any of those, uh, conditions, patients with um marked pain, um, that can't be readily explained, for example, from just a minor corneal abrasion or whose vision is, is really decreased, um, go ahead and refer those as well. Um, so, uh, for these, what shouldn't be missed, um, if a patient has a corneal abrasion that doesn't heal within a day or two, it raises the possibility of a foreign body that's still in there. Um, sometimes like small clear plastic or glass can be difficult to see. Um, if the cornea becomes cloudy in any patient with a red eye, um, refer those right away. Um, uh, a rare thing, meningococcal conjunctivitis may present with just hyperpyrulent discharge. Um, that organism has the potential for rapid dissemination which can progress to meningitis and sepsis, so, um, prompt treatments indicated to minimize the risk on that. And Um, so what are some common causes of red-eye? Um, so number one, infectious conjunctivitis, viral conjunctivitis or pink eye is the most common form of infectious conjunctivitis usually develops in association with the systemic viral illness, and there's frequently a history of exposure to other infected individuals. Um, patients with viral conjunctivitis usually have follicles on the inner lower eyelid. Um, if you look at that picture there, you can see those kind of amounts of uh tissue there. Um, bacterial conjunctivitis is less common, um, though potentially could be more severe than the viral. Um, the discharge in the viral conjunctivitis tends to be watery and purulent in the bacterial. Um, number 2, allergic conjunctivitis, and I'll say this many times is the, the hallmark is, as you know, itching, um, and if the patient's old enough to reliably articulate that, it's highly likely that allergic conjunctivitis is the cause. Uh. The conjunctiva may be mildly um swollen, mildly uh edematous or or injected and red, um, but often the symptoms are out of proportion to the exam findings. Those patients frequently have a history of other atopic disease as well. Uh, number 3, trauma. So mild trauma may produce a subconjunctival hemorrhage, a little kind of bruise in the eye and the skin on the eye is clear and it has a white scleral background, so it's pretty striking for those. They look really bad, but they're, they're benign. Um, more severe trauma may produce corneal abrasions, hy femurs, um, blood in the anterior chamber there, um, intraocular damage or damage to the orbit and, and surrounding structures, so. Um, corneal foreign bodies or abrasions are usually visible with a pen light, um, sometimes difficult to see there. Um, so the approach to, uh, to the patient, um, the goal, um, with the red eye is to determine, um, which can be safely managed in your setting and which one, needs the referral. So. Uh, starting with the history, it's very helpful in evaluating patients with red eyes, uh, to look at the history, most common cause of the disorder are infectious conjunctivitis, allergic conjunctivitis, and trauma, um, and you can get a lot from the history. Um, uh, one of the most, or the most common is the viral conjunctivitis, and they typically report that watery discharge that we mentioned, um, frequently, um, having the viral upper respiratory infection. Um, and since it's quite contagious, often they've been exposed to other infected individuals at home or school. Um, patients with bacterial conjunctivitis typically report, um, more of, um, a purulent discharge and may have, uh, uh, uh illness with a fever. Um, allergic conjunctivitis is characterized, uh, again by the itching. Um, it's highly diagnostic that symptom and very helpful in patients who are old enough, as we've mentioned to, to report that well. Um, many, but not all patients with allergic conjunctivitis will have, um, other allergic problems like we mentioned, the seasonal, um, rhinitis, asthma, eczema. And, uh, in most patients with um trauma, the history will match the physical findings. Um, however, uh, specific history may not be available in toddlers who have these acute symptoms but weren't really witnessed during play. Um, and similarly with older children, they may be hesitant to report certain things, um, and if available, the history is useful in assessing the risk of the intraocular injury, um, if there's retained foreign bodies or infection. Um, there was a significant impact from a fist or baseball, for example, the, the risk of that injury is heightened, and if the patient was injured by shattered glass or some other clear material like I mentioned, um, small portions may be in the eye and difficult to, to detect. So if a child develops a corneal abrasion, um, from, uh, Organic vegetable material like that of a plant or playing in a lake, the risk for potentially serious infections increased. Um, if the patient has a history of contact lens use, uh, the patient should be questioned about the, the onset, um, in relation to the lens where, uh, if the patient does not take proper care of the lenses or wears them for longer periods as recommended, many do, um, there's an increased risk. That corneal infection and the risk for complications is greatly increased with the overnight wear, even with the lenses that are marketed for such, um, and the absence of symptoms in a patient with red eye is most suggestive of either um subconjutival hemorrhage or um episcleritis. And so, um, if we look at the examination. Um, before performing an examination. Assess for the level of suspicion that you have for the viral conjunctivitis since it's so um likely to spread. um if the history and description are typical, um, just take appropriate precautions um to decrease the risk of transmission. Um examination is usually limited to that necessary to confirm that diagnosis and rule out other serious problems. So using uh gloves and assessment of vision and pen light, um, to be sure the corneas are clear, um, maybe all that's necessary. Um, if the diagnosis is in question, that inner lining of the lower eyelid, um, try to examine that for, for those follicles, and the presence of, of those follicles will be a strong suggestion for the viral conjunctivitis. Um, for patients in whom transmission of infection is not a concern, um, do the more standard eye exam. Um, vision in patients with bacterial or allergic conjunctivitis should be normal or near normal. Um, the cornea should be clear, anterior structures should be able to be seen as usual. Pupils should react normally, red reflex should be clear. Um, the examination of patients with trauma, um, will be directed by the nature of the injury, um, depending on the severity, injuries occur to the eye itself or the bones or soft tissue surrounding the eye. Um, if a corneal abrasion is suspected. Um, the use of fluorescent dye, um, and the flu, fluorescent light, um, can confirm that diagnosis, and the cornea should be inspected carefully for a retained foreign body. Um, and like we mentioned before, some of those that are hard to see the plastic or clear, um, they can be difficult to see. Um, and it may be easier to see some of those by viewing the red reflex where you're kinda getting uh a retro illumination from behind. Um, and if, uh, high femur where there's blood in the anterior chamber, if that's present, um, go ahead and refer those. Uh, if other serious ocular injuries are found such as, uh, a laceration. Um, maybe best to stop the exam to refer, um, to reduce the risk of further damage, just manipulating the areas there, so. Um, two entities that deserve mention due to their, um, their kind of striking appearance, but really just being benign, like I mentioned before, when the conju subconjunctival hemorrhage, um, and those are usually gonna be either from a direct injury or due to increased venous pressure, usually from a Valsalva maneuver like um lifting a heavy weight, um, something like that. Um, these produce that striking appearance like we mentioned. Um, the second entity though is, um, episcleritis. Um, it's pretty uncommon, um, but it does have kind of a distinctive, uh, look to it, presents with a wedge-shaped area of episcleral erythema, so kind of this wedge shape of redness either medially or laterally. Um, and with both of those conditions, the patients have usually pretty, pretty much a lack of symptoms and their vision is normal. Um, so for the, the plan for the viral conjunctivitis, um, supportive therapy is all that's indicated, so cool compresses, lubricating drops to keep things comfortable. Um, bacterial conjunctivitis should be treated with, um, topical antibiotics. Um, cultures usually aren't necessary unless you have a lot of discharge. Allergic conjunctivitis, um, can be treated with either the systemic or topical. Um, as we mentioned, the oral may be, um, better tolerated in young children. Um, uh, minor trauma can be managed by, uh, you if the examination is otherwise normal. Um, corneal abrasions should be treated with topical antibiotics to prevent that infection. Um, ointment can be more soothing, um, than drops, um, and patching is, is not necessary. Um, it does not improve the healing and it's often just bothersome to the, to the kids. Um, if an abrasion does not heal on the first day or two or a progressive pain or corneal clouding develops, um, go ahead and refer those. Um, management of other trauma depends on the severity. Um, some conjunctival hemorrhages, um, are benign and will go away on their own. Um, children with high femurs or other serious injuries should be referred. Um, patients with, uh, red eyes who wear those contact lenses, um, have them stop the lenses and refer to their, uh, eye care provider due to the potential risk of uh serious complications. And in general for most patients with red eyes, if the vision is normal and there's not significant discomfort and the corneas are clear, um, then go ahead and manage those, um, by yourself. And patients with marked pain or significant decreased vision. Or that corneal clouding again or other progressive problems should be referred. So again, uh, what shouldn't be missed? Occult foreign bodies, um, that may result in non-healing corneal abrasions or ocular infections. So, um, patients with corneal abrasions that don't heal in that 1 to 2 days, um, will need to be referred for a better look with a slit lamp. Um, meningococcal disease is a rare cause of conjunctivitis characterized by, uh, just hyperyrulent discharge. And that um bacteria there um can spread uh systemically causing meningitis and sepsis. Um, systemic antibiotic treatments, therefore necessary for that. Although, um, cultures are not usually necessary for the majority of patients, um, they're indicated if there's a lot of, um, discharge though. OK, and so then let's tackle the topic of irritated, um, but not red eyes. Um, so what should you do? Kind of starting out the etiology of the eye irritation or, or pseudo irritation in a child whose eyes are not red, um, can often be determined by the history. Um, the exam on most children is usually unremarkable. Um, most of the disorders are not dangerous, um, and if you can't identify the etiology with reasonable certainty, go ahead and refer those. Um. And to start off with what shouldn't be missed, um, kind of briefly touching on, uh, ocular tics. They're fairly common, presented as bilateral forceful blinking. We get a lot of those referrals in, um, but looking out for hemi facial spasm, it's rare, but it's characterized by a contraction of the periocular facial muscles on only one half of the face, and that may be associated with brain stem or posterior fossil lesions, and so those will need imaging. Um, so, uh, looking at the common causes of eye irritation without the red eye, um, number one is just idiopathic. Some children are generally more light sensitive to others and they squint in bright light, wanna wear sunglasses, avoid bright situations. Um, those patients tend to have, uh, fair skin and light colored irises. Um, the second cause of irritation is blephritis or dry eyes. Um, blephritis is a condition in which the mybomian glands of the eyelids don't function normally. The eyelid margins are usually, um, red and crusty, um, uh, results in an unstable tear film, and the tears tend to evaporate quickly, creating symptoms of the irritation and frequent blinking. And blephritis is a common cause of dry eyes, although not all patients with dry eyes will have that lephritis, and paradoxically, um, some patients with dry eyes may have symptoms of excess tearing. Um, and that, that's because there's two types of tears. One is the basal tears that keeps the eyes moist and comfortable, and then reflex tears that are produced in response to irritation. So patients with dry eyes have abnormal basal tears and they tend to have cyclic symptoms of eye irritation. Reflex tears temporarily improve the symptoms and then recurrent irritation as those reflex tears evaporate. Mhm. Um, third cause, um, ocular allergy, uh, like it could cause the red eye in the previous section, it can cause um problems without the eye being red. Um, and again, the key historical feature of ocular allergy is itching. Uh, if the child is old enough to reliably articulate that, as we said before, um, it's gonna be very likely, uh, that being the diagnosis and Um, many patients with ocular allergies will have, uh, like we mentioned before, other atopic problems such as reactive airway disease or eczema. Um, and then number 4, ocular tics. So ttic disorders are frequent during childhood. Um, they occur in approximately 10% of children. Um, uh, ocular tics present with, um, like we mentioned, the frequent bilateral forceful blinking, sometimes associated with upward and lateral deviation of the eyes, like when, when, when you're going to sleep. Um, these children don't complain of eye irritation and the eyes are not red. They may, however, be bothered by the symptom which they can't control, and most ocular tics are benign and self-limited, um, but, um, Tourette's syndrome could be considered if the child has other associated vocal or, or motor tics, and ocular tics should be distinguished, like we mentioned before from that hemi facial spasm, um, where it's unilateral. The eyelid contractions are accompanied by facial and periooral contractions as well. Um, hemifacial spasm may be caused by the central nervous system mass lesions, as we mentioned before, we need imaging. Um, uh, number 5, squinting from strabismus. Uh, unilateral squinting and bright light is a common symptom of strabismus, particularly if it's intermittent exotropia where the eyes are turning out just not all the time. Um, it's not associated with eye pain or redness, intermittent exotropia. Um, it's not always easy to, to see that on the exam though. So the approach to take to the patient, um, the differential diagnosis for the child who presents for evaluation of ocular irritation or eyes who appear irritated to the parents is, uh, narrowed down considerably if the eyes are not red. Um, the table to the right summarizes what we've discussed so far. Um, careful history is very useful and can often accurately identify diagnosis and many such patients can be managed without a referral, um. And so for the history, a key point in the history is whether the child is symptomatic. Um, if so, specific questions can be useful to determine the cause. Children with idiopathic light sensitivity typically avoid bright lights, wear sunglasses when outside. They don't develop eye redness or discharge. Many will have those fair complexions and sunburn easily. Um, if the symptoms are severe, such as the child not wanting to leave the house or wanting lights turned off indoors. Um, suspects another ocular problem and, and refer those. Um, children with, um, blephritis or dry eyes usually complain of eye irritation or uh foreign body sensations, saying there's something in their eye. Um, and this symptom is usually worse with activities such as reading or watching television. That's because, um, the blinking rate decreases with concentration. And the tears, therefore have more time to evaporate, and that tear evaporation may produce a temporary blurring that's relieved every time they blink or, or rest the eyes. So children with lephritis may describe Uh, crossing of the eyelashes, uh, which is most notable after they just get up in the morning, and blephritis is a common cause of dry eyes, as we mentioned, but again, um, not all patients with dry eyes have that blephritis. Um, in the absence of the blephritis, most dry eyes in children are idiopathic. Um, they may occur, however, though with um other systemic diseases such as arthritis, Sjogren's uh Sjogren's syndrome, Riley-Day syndrome. Um, therefore, um, the review of systems, um, systems should include questions about joint pain or difficulty eating, um, which may occur due to decreased salivation. Um, the key historical feature of ocular allergies, um, once again is itching, um, and, um, you know, if the patient's old enough, um, uh, that diagnosis is highly likely. And those patients will usually, but not always. Um, again, have those other allergic disorders. Uh, the onset of the ocular tics is usually fairly abrupt. Um, the patients describe bilateral exaggerated eyelid blinking which they mistake for ocular irritation, and the children do not have specific symptoms of pain or irritation though. They sometimes complain their eyes bother them. Um, careful questioning though, um, is, uh, their inability to control those symptoms that's bothersome rather than the blinking itself. And the ocular ticks are often worse in stressful situations, um, usually self-limited, lasting a few weeks to months. Um, squinting and bright lights is a fairly common symptom of strabismus, uh, especially intermittent exotropia, as we mentioned. Um, the children's vision is not affected, and they did not complain of eye irritation, and the key historical element in the squinting is that it's, uh, unilateral. And so for the examination, um, the examination, most children with the disorders discussed, um, in this section is uh fairly unremarkable. Vision is normal except for possible temporary blurring in those patients with dry eyes. Um, children with the blepharitiss usually have crusting on the lashes, the margin of the eyelid may be red. Um, children with um active allergic conjunctivitis may have mild swelling of that conjunctiva and increased hearing. Strabismus may be noted in patients with unilateral squinting, um, but it may be difficult to detect, um, and this is because the intermittent exotrophy is usually most noticeable when the child is fixating on a distant object, but in your office, the eye movements are usually assessed while the child is fixating at near objects. Um, in patients with lateral spasm, it's important, um, as we've said, distinguished benign ocular tics from heavy facial spasm. Uh, patients with ocular tics will have frequent forceful blinking of both eyelids, um, confined to the orbicularis muscle. Um, hemifacial spasm is, is distinctly different though it occurs on only half that face, and the periocular spasm is accompanied by, um, facial and periocular um contractions. So the plan, um, if the disorders um that we've discussed can be reliably identified based on the history and exam and the symptoms are fairly mild, then, um, refer, referral may not be necessary. Um, if the diagnosis is uncertain though, or the symptoms are more marked, um, referral, uh, is certainly indicated. Um, children with uh mild idiopathic light sensitivity can be managed with, uh, the sunglasses or brimmed hats, which they may already be doing. Um, if the child is markedly, um, adverse to light, um, go ahead and refer those to see if there's a more serious, um, disorder going on. Um, blephritis often improves with warm soaks to the eyes and gentle scrubbing with baby shampoo, and this is most conveniently performed during bathing, um. Because the symptoms of dry eyes are often worse during reading, intermittent eye rest or lid closure may help with that. Uh, Older children may benefit from artificial teardrops. Uh, children with ocular allergies are often best treated with the systemic medication, um, although there are several very effective topical medications, um, most children just don't like having drops in their eyes and May be more bothersome than the underlying disorder. Um, if the ocular tick is suspected and the ocular examination is otherwise normal, um, a period of observation is appropriate. Most ticks, ocular tics will resolve within a month or two, and if the child has other vocal or motor tics, um, evaluation by a pediatric neurologist for Tourette's syndrome may be indicated. So, one more time, um, what shouldn't be missed with this? Um, patients with the hemifacial spasm should not be mistaken for benign ocular tics due to the association with the posterior fossa and cerebellar disorders, um, associated with, um, hemifacial spasm, um, and the, uh, imaging may be indicated. And so, um, the last section I wanna um talk about here is excess tearing in infants. And so to start off again, um, what should you do? In the case of lacrimal obstruction, um, larymal massage and topical antibiotics are all that's indicated. Um, if no improvement occurs with age, refer to, um, one of us in, in our office. Uh, if corneal problems or glaucoma are suspected, um, referred to our office immediately. And what shouldn't be missed. So glaucoma, uh, should not be missed. Early treatment um is critical to optimizing vision. Um, if a child has excess hearing, um, and they have corneal clouding or eye size asymmetry, and we'll see a photo here uh in just a couple slides, um, uh, refer those, uh, right away. In common causes, excess tearing um in infants is one of the most common eye problems that pediatricians are likely to encounter. Um, approximately 6% of infants have some symptoms of excess tearing, and most of these spontaneously improve because the symptoms so common. However, um, it's possible to overlook much rare but potentially serious disorders that present with the same picture. Um, number one, so the nasolarymal duct obstruction or NLDO, it's by far the most common cause of excess tearing in infants, results from incomplete opening of the tear ducts with symptoms of overflow tearing, which we call epira, um, periocular crusting, or both. And you can see this in the, the photo to the right. Um, most symptoms of NLDO, um, resolved within the 1st 1 to 2 months of life. Number 2, will include um a couple anatomic abnormalities of the larymal system. The first is absent larymal puncta, um, much less frequently than NLDO infants can be born with absent or imperforate. Larymal puncta and that's the side on the eyelid where the tears enter the larymal system. Um, and you can see that in the photo. The upper photo has an arrow pointing to the lower punctum. Um, the bottom photo shows the absence of the punctum, and these children present with overflow tearing only. There's no tears going into the system, flowing around, creating bacterial discharge and coming back out. Um, it just, just flows over the cheek. Um, unlike most children with NLDO, um, they don't get the crusting, like I just mentioned and other symptoms of the infection. Um, the second anatomic um abnormality is a larymal fistula. Um, this is rare, um, and it's where an accessory larymal duct extends to the skin, usually nasal and inferior to the eye. Um, you can see where that arrow is pointing there. Um, if the fistula is patent. Um, patients may present with symptoms of excess hearing. Um, I had a patient with us recently, Doctor, um, Tyson, one of our surgeons, was there that day and I brought it up to him and um he said he could remove it if it bothered the patient or parents, but it's Typically not a problem. Um, Number 3, misdirected lashes. If the lashes are pointed towards the cornea, um, they may produce chronic irritation with symptoms of excess tearing and muoid discharge. And these symptoms are similar to those of nasolarymal duct obstruction. The most common cause of misdirected lashes is epilephron, and that's an um an extra fold of skin you can see in that picture where the um arrows pointing to the uh skin on the lower eyelid causes the lashes to turn in towards the cornea, kind of scrapes the cornea there, um, and Other, uh, corneal problems, um, corneal abnormalities are typically uncommon in infants and potential ideologies though include inherited disorders, infection, foreign bodies, dry eyes. Um, so going to the one you don't want to miss, glaucoma, um, and try to pay attention to that picture, just kinda look at that a little bit. Um, so glaucoma is gonna result from increased pressure in the eye and, in many infants, the cornea enlarges and becomes edematous. Um, which will cause ocular irritation and it will cause a lot of light sensitivity often. Um, many affected infants, therefore have symptoms of the excess tearing. Um, the photo shows the overflow tearing in the left eye is pointed to by the arrow, and note the left eye appears to be larger than the right. The, so the corneal diameter is greater and look at the lower eyelid crease. It's less distinct uh compared to the right eye, um, due to the forward displacement of the eye. The eye is just larger there. Um, 6, retinal dystrophies. Increased light sensitivity occurs in some inherited retinal dystrophies, which may result in excess hearing, particularly in bright light. Um, most of these disorders have profound effects on vision and concern about that abnormal vision is usually what brings those patients in. Um, so the approach to the patient. Um, because NLDO is so common and the other causes of excess tearing are rare, it's possible that potentially serious problems can be overlooked. Um, and the following approach, um, can help make the distinction. So starting with the history. NLDO affects approximately 6% of patients or uh infants. Uh, therefore, that'll be found on many well child visits, particularly during the 1st 1 or 2 months of life. If the symptoms are mild, the parents may not mention it. Um, if the baby is frequent, obvious overflow tearing or recurrent ocular discharge that requires wiping of the eyes, most parents will express those concerns and have questions about it. The symptoms of NLDL are quite variable though. Um, overflow tearing may be constant or intermittent. Um, if intermittent, it's often worse in windier conditions or if the patient has an upper respiratory infection. And periocular crusting usually um results from low grade infection of the larymal system. Some children have intermittent, um, mild crusting, um, others have marked discharge, um, usually worse when they're getting up in the morning like we mentioned. Um, and these children, the patients need to wipe the eyelashes with a washcloth before the eye will open. In, in severe cases, patients, um, may develop, um, redness and maceration of the eyelid skin due to the constant exposure to moisture. So a key differentiating factor in the history is whether other symptoms are present. Um, children with NLDO typically present with excess tearing and recurrent ocular discharge. However, the eyes themselves are not directly affected and the children are otherwise asymptomatic. Um, the excess tearing in most other disorders results actually from the ocular irritation. Children with those disorders are sensitive to light and blink more frequently and forcefully than normal. Um, if the baby does not appear bothered by the symptoms of excess tearing, NLDO is by far the most likely etiology. Um, and similarly, NLDO has no effects on vision. Um, if the parents have concerns about the vision, one of the other disorders should be, um, suspected. And so for the examination, um, the presence of excess tearing should be verified. Uh, if the obstruction is marked, there may be a lot of overflow tearing on the cheeks. More subtle obstruction may produce enlargement of the lower tier like um between the eyelid and the eyeball kind of gives that appearance where the baby looks like they're about to cry. Um, subtle obstruction is more easily assessed that the patient has it just on one eye cause then you can compare one eye to the other. Um, the presence of the discharge should be noticed. Um, it may range from mild crusting, um, to a lot of discharge that overflows on the cheeks, and you can press on the larymal sac between the eye and the nose, and that may produce a reflux of that material from the sac. Um, that finding, you can't always find that, but it will confirm the diagnosis if that happens. Um, and it's critical on the exam to verify the normal size and clarity of the cornea and the absence of the light sensitivity to rule out the glaucoma. Um. The position of the eyelids and eyelashes should be examined for misdirection, um, like we mentioned before, against the cornea. As with any eye exam, they, uh, the baby's vision and eye movements should be assessed. Uh, these findings are normal, it's very likely that the child has NLDO rather than any of the other potentially serious um problems. Um, so the plan. Uh, after diagnosis of NLDO is established, the treatment plan depends on the patient's age and severity. Um, most will spontaneously resolve in the 1st 1 or 2 months of life. If the patient has mild symptoms, no treatment's necessary. Um, if the symptoms are more marked, periocular discharge is usually more bothersome than the excess tearing. Um, two treatments may be offered. Um, one is lacrymal massage, and the purpose of the massage is, is to produce, um, pressure within that tear sac that forces fluid down the lacrymal duct to the site of the obstruction, which is usually right at the where where it opens into the nose. Um, and that hydraulic pressure can cause that obstruction to open. Um, if the lacrymal massage is recommended, proper technique should be demonstrated. The only site where the sac can be palpated is between the eye and the nose, and by pushing at that site. sac is compressed. If you look at that photo on the, on the right, it can be verified by, like we said before, noting the expression of tears and the uh material onto the eyes through the ducts. Um, moving the finger down the side of the nose is not effective because the tear ducts covered by bone at that site and can't be compressed. Um, number 2, topical antibiotics. If the infant has marked periocular discharge, topical antibiotics can be used. Um, These will often improve the symptoms but not cure the underlying obstruction. Um, it's common for the symptoms to recur when antibiotics are discontinued, and this will continue until either that spontaneously resolves or the patient has a probe. Um, unlike other infections for which antibiotics are prescribed, um, parents of, uh, patients with NLDO may use the topical antibiotics intermittently as, as the child becomes symptomatic. Um, most instances, Um, lacrymal infection will be due to common bacteria rather than significant pathogens, and most topical antibiotics produce some improvement and cultures are usually not necessary. Um, and for the plan, most patients, uh, with NLDO is particularly helpful to educate the parents about the condition it's expected course. Uh, they understand that it'll probably resolve, but the symptoms will vary from day to day until the resolution occurs. They'll be less worried about it when it recurs, um, when it. Uh, they should understand the antibiotics will not cure it, um, but will be a temporizing measure while we're waiting for the duct to open. Um, spontaneous improvement in NLDO occurs in over 90% of patients during the 1st 6 to 12 months of life. Uh, if they remain, um, symptomatic, they can refer over to us. Um, Uh, And let's see, let's go ahead and skip over here to this. So just to touch on this one more time, so what shouldn't be missed is the glaucoma. Um, it is a progressive disease. It can cause that irreversible vision loss, um, early diagnosis and treatment, um, um, will greatly improve the prognosis. Um, it's rare. You may only see one or two of those during your career, but you'll see hundreds of patients with NLDO, um, and just recognize those features, the light sensitivity, corneal clouding, corneal enlargement, um, if in doubt, refer and Um, so I, uh, adapted the information from, um, this, this text, uh, to this PowerPoint to help discuss these topics, um. Uh, written by, um, one of our pediatric ophthalmologists here, Doctor Leeder, and I think maybe he spoke at the last, uh, early bird, uh, rounds. Um, he's really great at, um, discussing things at, at this level, in my opinion, um, and, um, but like I mentioned before, one question, um, I have for you all is, you know, if you have any um concerns about the referral process with, with our, uh, office, um, I'm open to that or, or any other questions that you have, um, we can, we can take those now. Amazing talk. Thank you so much. If you can um find the chat feature, we do have two questions it looks like. OK. uh Let's see, has the referral recommendation changed? I thought that it was physiologic for the eyes to not always be. Uh, conjugate until 4 months of age. Um, seems like I may be referring a lot of infants less than 4 months. You know, um, I will double check with, um, Doctor Leeder and see with some of the other ophthalmologists here as well. Um, cause like I said, I, I, I, I took it from the book that he wrote, um, but let me double check and see, um, cause you, you may, you may be right. Maybe I have things a little bit out of date here, but I'll, I'll double check and see. Um, and then let's see, I had a patient. Recently, who presented with a conjunctivitis, which did not resolve, retinal exam showed inflammation at first diagnosed with scurvy as the explanation for her retinitis and microhemorrhages. Um, this did not get better with vitamin C. Then it was discovered she had vitamin A deficiency as well. These rare vitamin deficiencies were due to a very restrictive diet. Yeah, I've seen um a couple of those come in, um, and I think the vitamin A deficiency also showed up in our office with um cloudy cornea. Uh, so if you see that cloudy cornea, um, that can be, be there as well. And I, though the two that came in. I don't, I don't know if we quite got good enough history to, to realize that right away. Um, and then, OK, the next one, it seems that in office probing may be preferable than going to the OR after 12 months of age. When do you recommend we refer older infants for this eval and possible probing? Um, so, almost every time that I've seen the probing done in our office, it's Basically, the patients will come in. If it doesn't resolve by one year, then we offer to do the probing. Um, I've only seen the in-office probing done at a really young age, one time. It may be done more often than I realized, and I saw Doctor Tyson do that. Um, generally, it's quite painful, so I think they only do that in the very, very young and, you know, they may do that if it's really bad. Um. Yeah, but I'm, I'm not sure if I'm answering your question actually. Um. Up to what age can you do um in office probing, um. I don't think there's an age limit that they will no longer do it. Um, uh, there's a fair number of kids with Down syndrome who have it, and sometimes I feel like they're not quite as um Severe as some of the other ones, and the parents will wait quite a long time, um, and I've never seen An ophthalmologist say, no, they're, they're too old. We're not, we're not gonna do it anymore. Um, so I, I, I don't think there's a There's an upper age limit. Um, let's see, I've had a handful of patients with severe allergic conjunctivitis show up with areas of swelling, serous fluid, uh, fluid collection between the outer layer of cornea and the rest of the eye that does not cross over iris or the pupil. What causes this? Excessive rubbing? Are antihistamine drops enough for treatment for that or other treatments necessary? Um, I think what you're seeing is something called VKC. Um, vernal ketoconjunctivitis, and that can be tough. Um, it, it often will show up with, if, if it's what you're describing where there's little kind of white circles of inflammatory material that are right at the limbus, which is that part where the white part of the eye, uh, hits the, the cornea and It's usually superior, uh, like, probably. A a fair amount of that superior limbus is covered with these little white dots. Um, that's gonna require a referral over to us, um, the over the counter. anti, um, allergy drops just aren't strong enough. They're gonna need One of a few different um treatments. Usually a more uh stronger steroid drop does the trick, like a tapered steroid like 4 times a day for a week and then 3 times a day for a week. That usually gets rid of it, but not always. And sometimes we have to compound cyclosporin to get it, um. And I had one that I referred over to um our corneal department recently cause it, it just, it kept coming back, um, and those, those aren't, those aren't always easy. And I, and I think that's, I think I read that that's a type 1 and type 4 hypersensitivity reaction, um. Some of those are tough. Those are all great questions. Does anybody have anything else for Doctor Burton before we? Go for the weekend. Well, if not, um, thank you so much for spending time with us this morning and sharing all this helpful information. We really appreciate it and um we just want to remind everyone to please take the survey that you'll get with the slides today, and um that will help us to improve early bird rounds for the future. And I'll put in the chat what we can expect for next week. Great. Yeah, thanks everybody for uh for coming out. Thank you. Thank you. Have a good weekend, everyone. You too. Bye. Created by Presenters Gabrel Burton, OD Staff Optometrist, Ophthalmology & Visual Sciences View full profile
