STANFORD, CALIF. – Myths about pediatric eye abnormalities often mislead parents into thinking an eye evaluation is not necessary, according to Dr. Deborah M. Alcorn, chief of pediatric ophthalmology at Lucile Packard Children’s Hospital, Stanford.
At a pediatric update sponsored by Stanford University, she debunked the top 10 myths about eye problems in children:
Dr. Deborah M. Alcorn
1. My child is too young for an eye exam. Dr. Alcorn said she frequently gets called to the neonatal unit to evaluate babies who are only a few months old. Infant eye exams are very objective. The child’s age is irrelevant, except that it’s better to treat a problem earlier rather than later, she said.
2. Tearing must be due to a blocked tear duct. Yes, epiphora is most likely to be secondary to a nasolacrimal duct obstruction, but the differential diagnosis includes corneal abrasion and glaucoma.
Placing yellow fluorescein dye in the eye can easily identify nasolacrimal duct obstruction; within 2-3 minutes, the dye will come out the child’s nose. In infants, treatment with warm compresses and massage will open 95% of lacrimal obstructions by 1 year of age.
Persistent, excessive tearing, especially in the first few weeks of life, may be a sign of an associated dacryocystocele. These blue-domed cysts deserve aggressive treatment with systemic antibiotics, warm compresses, and massage, Dr. Alcorn said. Nasolacrimal duct probing may be needed. If the color of the dacryocystocele changes from blue to very red with erythema, hospitalize the child to treat infection, she said.
Tearing and discharge may be due to congenital nasolacrimal duct obstructions. If you see a child with silicone tubing poking out of the tear duct, don’t pull it out – it’s a stent to enlarge the lacrimal duct. "We like to leave it in for 6 months," she said.
Courtesy of the National Eye Institute, National Institutes of Health
A scene as it might be viewed by normal vision.
Tearing from corneal abrasion is accompanied by pain, discomfort, and often photophobia. If you use a topical anesthetic to make the eye exam easier, do not dispense it to parents, Dr. Alcorn said. Repeated use will break down the child’s cornea. Treat a corneal abrasion with a topical antibiotic; children usually prefer drops to ointment, which blurs vision, she noted.
You may see tearing from congenital glaucoma, which produces big eyes on the baby that seem beautiful but are abnormal. Unlike adult glaucoma, congenital glaucoma deserves emergency surgery, she said.
3. All red eyes are contagious. Viral conjunctivitis is highly contagious, but the causes of red eye are diverse. Subconjunctival hemorrhage usually is benign and spontaneously resolves. Episcleritis usually resolves with eye drop therapy. Eyes may be red from pinguecula or pterygium – hyperkeratotic reactions to the sun that are slow growing and not malignant. "We’re starting to see more of these because kids are not wearing sunglasses," Dr. Alcorn said.
Courtesy of the National Eye Institute, National Institutes of Health
A scene as it might be viewed with myopia, which has become "a major global health concern," Dr. Alcorn said.
Treat pinguecula and pterygium with sunglasses, artificial tears, and vasoconstrictors, and consider surgical removal if the lesion is interfering with wearing contact lenses or the pterygium involves the visual axis.
Conjunctivitis can be bacterial, viral, or allergic. The two main clues to differentiate the three kinds of conjunctivitis are the discharge (which is purulent in bacterial conjunctivitis and watery in viral or allergic conjunctivitis) and itching (which is marked in allergic conjunctivitis but minimal with the other two forms).
Viral conjunctivitis is so contagious that Dr. Alcorn said she tries to not let these patients into her examination room, in order to avoid having to wash the room with bleach afterward. These patients usually have bilateral red eyes, preauricular lymphadenopathy, conjunctival inflammation, and watery discharge. Upper respiratory infection, sore throat, and fever are common.
This has been one of the worst years for seasonal allergies causing acute allergic conjunctivitis, in Dr. Alcorn’s experience. Bilateral red eyes, profuse pruritus, chemosis, and ropy mucous discharge are typical.
A variety of topical medications in eye drops can be used to treat allergic conjunctivitis. However, do not prescribe a topical steroid or combination antibiotic-steroid without close follow-up, because steroids can cause glaucoma or cataracts or potentiate infection, she said.