Ophthalmological emergencies

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13.1 Ophthalmological emergencies

1 A history of contact lens use should always be sought.

2 Visual acuity should always be assessed.

3 Neonatal conjunctivitis may have severe sequelae if inadequately treated.

4 The suspicion of keratitis should prompt urgent ophthalmic review.

5 The distinction between orbital and preseptal cellulitis should always be made.

6 Local anaesthetic drops should never be given to a patient to take home.

Introduction

Few ophthalmological emergencies relate exclusively to children. Although the pathology may be the same, the general approach, examination and compliance with treatment is very different depending on the age and development of the child. Also, the long-term sequelae of serious eye injury or disease are much greater.

History

As with other paediatric encounters, it is important to gain the child’s confidence in you whilst obtaining the history from the parents or carers. A detailed history should be obtained from an adult witness. If this is unavailable, injury will be the likely cause of a painful red eye. Other conditions presenting with a red eye are listed in Table 13.1.1. Always enquire about the use of contact lenses or glasses.

Normal visual acuity Conjunctivitis (bacterial, viral, allergic, chemical) Gritty, itchy, injected conjunctiva, discharge Foreign body Pain, grittiness, epiphoria, photophobia Episcleritis Mild pain, localised conjunctival injection Scleritis Severe pain, diffuse conjunctival injection Subconjunctival haemorrhage Consider trauma or pertussis Reduced visual acuity Corneal abrasion Pain, grittiness, epiphoria, photophobia. Corneal defect seen with fluorescein staining Keratitis Photophobia, epiphoria, ciliary injection, flare in anterior chamber, corneal infiltrate Corneal ulcer Photophobia, epiphoria, corneal injection, flare in anterior chamber, defect on fluorescein staining. History of contact lens use? Anterior uveitis Photophobia, epiphoria, ciliary injection flare in anterior chamber, miosis, posterior synechia

Examination

The approach to the examination of a paediatric eye may differ from that of an adult in that an opportunistic strategy should be taken. Leave touching the child until last, particularly if it will result in fear, pain or discomfort.

Some form of assessment of acuity must be made. In pre-verbal children, assess their ability to fix and follow interesting objects and then reach for them. In older children, monocular testing should be carried out using picture cards, single letter matching or a standard Snellen chart. Use of the slit lamp is not essential for a detailed examination, but even small children may co-operate if they remain seated on their parent’s knees.

If the child is compliant, a logical sequence of examination would be from outside to inside thus:

• visual acuity – using Snellen chart with letters or pictures;

• extraocular movements – follow a finger, a small toy or a face;

• visual fields;

• lids, lashes and lacrimal apparatus;

• conjunctiva and sclera;

• anterior chamber;

• pupil and iris;

• red reflex, posterior chamber and retina.

All drops will sting, except for fluorescein. However, once the pain has subsided, the effects of local anaesthetic may allow for a much more meaningful examination than would otherwise have been possible. If, however, this remains impossible, consideration should be given to examination under anaesthetic.

Eyelid disorders

Blepharitis

Blepharitis is an inflammatory process of the eyelids that is characterised by crusting at the base of the eyelashes. There may be oedema of the lids themselves and occasionally the conjunctiva is also injected. Staphylococci are the usual organisms. Treatment should involve the removal of the crusts using a warm flannel, cleansing with dilute baby shampoo and application of antibiotic ointment to the lid margin.

Hordeolum (stye)

A hordeolum is an acute infection, usually staphylococcal, of an eyelash follicle. It causes a small, tender swelling, often with a head of pus, which is seen at the lid margin. Treatment is with warm compresses and chloramphenicol ointment until resolution occurs.

Chalazion (meibomian cyst)

This is caused by inflammation of the lipid-secreting meibomian glands of the lid, probably due to ductal obstruction. It presents as a slowly progressing, mildly painful red lump in the eyelid. Most settle with conservative treatment, namely warm compresses for 10 minutes four times a day with light massage and chloramphenicol ointment for up to 4 weeks. If this treatment fails, or the cyst is excessively large causing visual disturbance, it can be incised. It may become complicated by preseptal cellulitis that may require systemic antibiotics.

Disorders of the lacrimal apparatus

Nasolacrimal duct obstruction

This condition occurs in 6% of infants and almost invariably resolves within the first year. It may cause epiphoria (watering), a mucoid discharge or some erythema of the lids. There may be a minor mucopurulent discharge and rarely a bluish palpable mass will be seen overlying the drainage system, which represents a dacryocele. Treatment of simple obstruction consists of gentle massage four times a day and cleansing. Should spontaneous resolution not occur, the child should be referred for probing of the duct after 6 to 12 months of age. If there is a mucopurulent discharge, topical antibiotics should be added for 2 weeks.

Dacryocystitis

This is defined as infection of the nasal lacrimal duct and presents with pain, redness, swelling and tenderness of the overlying skin and the adjacent nasoperiorbital area. There may also be tearing, discharge and fever. Pressure over the lacrimal sac may express pus from the punctum. This should be sent for culture. Staphylococcus aureus and Staphylococcus epidermidis are the commonest organisms. Treatment should be with cefalexin orally or cefazolin intravenously (IV) if unwell. Gentle massage in the more minor cases may well aid in clearing the infection and unblocking the duct, as dacryocystitis is invariably associated with ductal obstruction that may be congenital or acquired. Probing or irrigation of the lacrimal system should be avoided in the acute setting and in infants less than 6 months old. Complications include preseptal cellulitis; orbital cellulitis and cavernous sinus thrombosis occur very rarely.

Dacryoadenitis

Infection of the lacrimal gland, found in the superotemporal orbit, is called dacryoadenitis. Acute disease is characterised by abrupt onset of pain, swelling and erythema in the superotemporal region. There may also be chemosis, conjunctivitis and a mucopurulent discharge. Rarely there is proptosis, fever, malaise and a reduction in ocular motility, making clinical differentiation from orbital cellulitis difficult, and thus requiring a computerised tomography (CT) scan or magnetic resonance imaging (MRI).

The disease is usually viral in origin but a mucopurulent discharge makes a bacterial infection more likely so swabs should be taken before starting cephalexin.

Conjunctival and scleral disease

Neonatal conjunctivitis (ophthalmia neonatorum)

This condition is defined as conjunctivitis occurring within the first 30 days of life. The causative organisms are usually passed from mother to fetus during passage through the birth canal and are commonly Neisseria gonorrhoeae, Chlamydia trachomatis, staphylococci, streptococci or herpes simplex.

Gonococcal infection presents within 24 to 48 hours of birth with acute eyelid oedema, bulbar conjunctivitis, chemosis and a profound purulent discharge. Both eyes are usually affected. As the presentation may overlap with other infectious agents, a swab should be taken before treatment is commenced. An urgent Gram stain may show Gram-negative intracellular diplococci. Urgent ophthalmology consultation should be sought and treatment should not be delayed due to the risk of rapidly progressive corneal ulceration and perforation. Ceftriaxone 50 mg kg⁻¹ IV for 7 days is used, with the addition of erythromycin orally to cover for infection with C. trachomatis until cultures are negative.

Chlamydial infection is classically associated with a watery then mucopurulent discharge 5 to 14 days after delivery. There is also palpebral conjunctival injection, but less lid oedema is seen than with gonoccocal infection. Swabs are sent for culture and polymerase chain reaction and then treatment is commenced with oral erythromycin 10 mg kg⁻¹ qid for 21 days. This disease is complicated by pneumonitis in 10–20% of cases.

For both of these conditions, the mother will also need treatment and her partner will need screening.

The same organisms that affect older children can also cause neonatal conjunctivitis. These organisms typically present from day 5 to 7. Clinical findings do not distinguish the pathogen so cultures should be taken and treatment commenced with broad-spectrum antibiotic ointment. Herpes simplex virus (HSV) conjunctivitis is the exception and should be suspected if there is a maternal history of infection, vesicular blepharitis or dendritic ulceration. In this instance, treatment should be with topical and systemic aciclovir after urgent ophthalmological consultation.

Conjunctivitis in older children

Conjunctivitis represents the commonest paediatric ophthalmic emergency presentation. Unlike the adult population, bacterial infections predominate.

Bacterial conjunctivitis

This is characterised by epiphoria and a foreign body sensation that progresses to diffuse conjunctival injection and a purulent discharge that may glue the lids together. The onset is usually abrupt and spreads to the other eye within 48 hours. Staphylococci, Streptococcus pneumoniae and Haemophilus influenzae are the commonest organisms. After swabbing, therapy is with chloramphenicol 0.5% 1 to 2 drops every 2 hours initially, tapering to 6-hourly as symptoms improve.

In sexually active teenagers and isolated communities in central and northern Australia, N. gonorrhoeae or N. meningitidis may be the causative organism and will require systemic treatment with ceftriaxone 1 g intramuscularly for 3 to 5 days.

Viral conjunctivitis

This is usually adenoviral in origin and findings include itching or grittiness, tearing, oedematous lids and a characteristic palpable pre-auricular lymph node. It usually spreads to the other eye after a few days. There may be corneal involvement as well, when it is known as epidemic keratoconjunctivitis. Adenovirus can also cause pharyngoconjunctival fever that, intuitively, comprises pharyngitis, conjunctivitis and fever. It is a self-limiting disease but may very rarely disseminate and cause multiorgan failure.

Other viral infections known to cause conjunctivitis include rhinovirus, enterovirus, influenza and respiratory syncytial viruses.

The diagnosis of adenoviral conjunctivitis is clinical but swabs should be taken in most cases to exclude a bacterial cause. It is a highly contagious disease so household or other social contact spread is likely. Treatment should be with cold compresses several times a day, artificial tears and good hygiene. If there is difficulty ruling out bacterial conjunctivitis clinically, antibiotic ointment should be used. Parents should be advised that the child will be contagious for 12 days from onset.

Allergic conjunctivitis, e.g. hay fever

Presentation is similar to viral conjunctivitis although a preauricular lymph node is not present and there is usually a good history of atopy. Treatment should consist of artificial tears, oral antihistamines and removal of the trigger.

Atopic conjunctivitis

This is commonest in male adolescents with a history of atopy. It occurs in spring and summer and causes itching and a thick, ropy discharge. Large subtarsal papillae may also be seen. Treatment should be as for allergic conjunctivitis, with the addition of sodium cromoglycate drops.

Herpes simplex conjunctivitis

Patients complain of a foreign body sensation, pain or burning and may give a history of past ocular or perioral herpetic lesions. Examination will reveal a unilateral conjunctivitis with vesicles on the eyelid or periorbital skin and a palpable preauricular lymph node. Treatment is with topical antiviral medication and close ophthalmic follow up.

Trachoma

Trachoma results from recurrent infections of Chlamydia trachomatis. In Australia, it affects remote indigenous communities, whilst internationally it is a leading cause of blindness in the third world.

Infection manifests as a mild mucopurulent conjunctivitis that is self-limiting. However, recurrent episodes result in a chronic inflammatory state affecting the palpebral conjunctiva and cornea. Eyelid deformities due to scarring include entropion and ectropion whilst corneal complications include scarring (known as cicatrization), vascularisation, ulceration and perforation.

Treatment for children under 6 is by erythromycin 10 mg kg⁻¹ orally qid for 21 days. For older children and adults use azithromycin 1 g (20 mg kg⁻¹ up to 1 g for children) as a single dose. In prevalent areas, consideration should be given to treating all household contacts.

Episcleritis

This condition presents with acute redness to a section of the sclera. There is usually minimal discomfort or tenderness and it is only the more superficial episcleral vessels that are engorged. Although it is associated with connective tissue disorders, HSV, varicella zoster virus (VZV) and inflammatory bowel disease, most presentations are idiopathic in nature.

Treatment is symptomatic with artificial tears and oral non-steroidal anti-inflammatoriy drugs (NSAIDs) but if severe, topical steroids can be used. Ophthalmic follow up should be arranged to ensure resolution.

Scleritis

In contrast to episcleritis, scleritis usually presents with pain that gradually becomes severe and a diffuse redness due to injection of the scleral, episcleral and conjunctival vessels. When viewed in daylight, the affected sclera may have a bluish hue and vision may be reduced. There is a strong association with connective tissue disorders. Treatment consists of oral NSAIDs and steroids and should be initiated by an ophthalmologist.

Corneal disease

Keratitis

Keratitis is defined as inflammation of one or more layers of the cornea. It appears as a focal white corneal opacity without an overlying defect. If ulceration is also present it will stain with the use of fluorescein. Symptoms include pain, redness, photophobia and poor vision. The lids may be erythematous or oedematous whilst chemosis, tearing, conjunctival injection, hypopyon or flare in the anterior chamber may all be seen on examination.

Causes of keratitis

Bacterial infection is the commonest cause of keratitis and this is considered to be one of the leading causes of blindness in the developing world. Organisms include Gram positives, such as staphylococci, streptococci and bacilli, as well as Gram negatives. Of these, Pseudomonas aeruginosa is of significance as it is the commonest cause of keratitis in the contact lens wearer. Other organisms include:

• Fungi, particularly after trauma from vegetable matter. The course is usually more gradual in comparison to bacterial keratitis.

• Acanthamoebic keratitis is a parasitic infection seen in contact lens wearers, especially if they have poor lens hygiene. It is also a complication of a corneal injury contaminated by soil. Patients often present with pain out of proportion to early clinical findings which progress over several weeks.

• HSV may cause a punctate keratitis before the classical dendritic ulcer manifests. It may affect both eyes and corneal scarring may be permanent.

• VZV is associated with a dermatomal skin rash.

Management

All patients with suspected infectious keratitis should be urgently referred to an ophthalmologist for culture by corneal scraping before starting antibiotic treatment.

Recurrent corneal erosion

This manifests with recurrent attacks of pain, photophobia, grittiness and tearing, which occur on waking or rubbing the affected eye. There is often a prior history of corneal abrasion. Examination may often reveal a corneal defect but minor epithelial changes may have resolved by the time the patient is reviewed. Treatment consists of antibiotic ointment and then artificial tears once the corneal defect is healed. Ophthalmic follow up is recommended.

Uveitis

Inflammation of the uveal tract is subdivided according to location of disease (anterior, intermediate or posterior) or structure involved (iris, choroid, retina).

The most frequently encountered of these conditions is that of traumatic iritis. This presents with photophobia, epiphoria, blepharospasm, perilimbal injection and blurring of vision 1 to 3 days after a blunt globe injury. The pupil may be miotic or irregular and cellular flare may be seen in the anterior chamber upon slit lamp examination with an oblique beam. Relief of pain with topical local anaesthetic is a relatively sensitive way of excluding the disease. Other causes include juvenile rheumatoid arthritis, inflammatory bowel disease, and psoriasis. Referral to an ophthalmologist should be made to rule out any involvement of posterior structures. Treatment is with a cycloplegic agent and steroid drops.

Intermediate and posterior uveitis may present with flashes, floaters and decreased vision.

Glaucoma

Glaucoma is very rare in children. An enlarged, clouded cornea is seen associated with tearing (epiphora) and photophobia. It may be associated with a hyphaema, lens subluxation, retinoblastoma or systemic disease (neurofibromatosis or Sturge–Weber syndrome) or high dose steroid use. Ophthalmological referral should be made immediately as prompt diagnosis is essential to prevent visual loss.

Orbital and preseptal (periorbital) cellulitis

The fibrous orbital septum is a continuation of the periosteum of the orbital rim. It connects to the tarsal plates and separates the eyelids and other preseptal structures from the orbital space, acting as a barrier to the spread of infection. It is important to distinguish clinically or radiologically between the two conditions, as missing the diagnosis of orbital cellulitis may have grave sequelae.

Preseptal cellulitis

Of these two conditions, preseptal cellulitis is far more common, accounting for 95% of infections around the eye. It presents with lid oedema and erythema, mild pain and a low-grade fever. The child is unlikely to appear ill. There is usually a portal of entry for the organism such as a nearby wound or insect bite, lid lesion or a pre-existing dacryocystitis. Rarely, haematogenous spread can occur. Staph. aureus, Strep. pneumoniae or H. influenzae in the unvaccinated are the commonest organisms in the under 5s. Cultures should be taken as appropriate and if the child is well and the symptoms minor, treatment can be as an outpatient with augmentin or cefalexin for 7 days as long as appropriate follow up will occur to ensure that symptoms are improving. This is, however, contentious and some advocate admission for IV antibiotics, as for orbital cellulitis, for all cases of presumed preseptal cellulitis, particularly in the under 5s.

Orbital cellulitis

The orbit is surrounded on three sides by paranasal sinuses. The migration of organisms from an infected sinus into the orbital cavity causes orbital cellulitis in the majority of cases. Haematogenous or dental spread can also occur and there may be an associated subperiosteal abscess. Infection is usually poly-microbial and causative organisms are as for preseptal disease, with the addition of Gram negatives and anaerobes. Orbital infection presents with swollen, erythematous lids but, unlike preseptal cellulitis, the swelling should be limited to the orbital rim due to the septum preventing anterior spread. The fever is likely to be higher than that seen with preseptal cellulitis and the child usually appears toxic. There may be chemosis and proptosis and eye movements are likely to be restricted and painful. A raised white count is expected but will not aid differentiation from preseptal infection. Blood culture should be taken and then a CT scan or MRI will confirm the diagnosis and guide drainage of the offending sinus or subperiosteal abscess. Therapy should be with IV flucloxacillin and ceftriaxone and urgent referral should be made to ophthalmology as well as ear, nose and throat for consideration for a sinus drainage procedure. Complications include optic nerve compression, reduced visual acuity, cavernous sinus thrombosis, osteomyelitis, meningitis and cerebral abscess.

Acknowledgement

The contribution of Adrienne Adams as author in the first edition is hereby acknowledged.

Further reading

Bravermann R.S. Eye. In Hay W.W., Levin M.J., Sondheimer J.M., Deterding R.R., editors: Current pediatric diagnosis & treatment, 19th ed., New York: McGraw Hill, 2008.

Christiansen K., Currie B., Ferguson J., et al, editors. Antibiotic Guidelines. Therapeutic Guidelines Limited, 2006. Version 13

Ehlers J.P., Shah C.P. The Wills Eye Manual, 5th ed., Baltimore: Lippincott Williams & Wilkins, 2008.

Greenberg M.F., Pollard Z.F. The red eye in childhood. Paediatr Clin N Am. 2003;50:105-124.

Prentiss K.A., Dorfman D.H. Pediatric ophthalmology in the Emergency Department. Emerg Med Clin N Am. 2008;26:181-198.

Rubenstein J.B., Virasch V. Conjunctival disease. Yanoff & Duker: Ophthalmology, 3rd ed.. New York:Mosby. 2008.

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