Pediatric emergency medicine trisk 630

Site

Lesion

Cause

Cornea

Scar
Ulcer

Lens

Cataracts

Metabolic: galactosemia,
galactokinase deficiency
Viral: Rubella, CMV
Traumatic: nonaccidental
trauma, birth injury, blunt
trauma, perforation of globe
Chromosomal: trisomies,
Turner syndrome
Genetic: aniridia, Treacher
Collins, Pierre Robin,
Rubinstein–Taybi,
Hallermann–Streiff
Endocrine: congenital
hypoparathyroidism,
Albright hereditary
osteodystrophy

Neurologic: Sjögren
syndrome, Smith–Lemli–
Opitz

Lens

Subluxation

Fundus

Coloboma of fundus
Retinoblastoma
Persistent hyperplastic primary
vitreous
Norrie disease
Incontinenta pigmenti
Retinal dysplasia

Marfan syndrome,
homocysteinuria, sulfite
oxidase deficiency,
hyperlysinemia, Ehlers–
Danlos, Weill–Marchesani
syndrome, trauma
Norrie disease-X-linked
recessive


Retinal fold
Retinoschisis

Retinopathy of prematurity
Optic nerve abnormality
Lacrimal Duct Stenosis (Dacryostenosis)
Congenital obstruction of the nasolacrimal duct, dacryostenosis, is the most
common cause of excessive tearing in the newborn, occurring in 7% of neonates.
The lacrimal duct system is not fully mature and functional until 3 weeks of age
so excessive tearing (epiphora) usually appears at that time. Dacryostenosis
should be differentiated from congenital or infantile glaucoma, a serious but
fortunately rare cause of excessive tearing. Most cases of infantile glaucoma
presenting during the first 3 months of life are bilateral, whereas dacryostenosis is
usually unilateral. Other causes of epiphora include dacryocystitis, obstruction,
congenital absence of puncta, corneal abrasions, and conjunctivitis.
Increased wetness of the affected eye relative to the normal eye, excessive
tearing, mucoid eye discharge, and crusting along the eyelid margins are the usual
presenting symptoms. Gentle pressure along the medial canthal region over the
lacrimal sac may produce a reflux of tears or purulent material onto the surface of
the eye, confirming the diagnosis ( Fig. 96.29 ). Infants with glaucoma, in
addition to excessive tearing, also present with enlarged cornea, rhinorrhea,
photophobia, blepharospasm, and corneal haziness. The cornea may be inspected
after instillation of fluorescein dye to rule out a corneal abrasion as the reason for
the excessive tearing.
Uncomplicated cases of nasolacrimal duct obstruction should be managed with
gentle cleansing of the eyes, followed by local massage of the nasolacrimal duct,
several times per day, to prevent stagnation of tears in the lacrimal sac. Topical
ophthalmologic antibiotic ointments should be prescribed if there is associated
conjunctivitis, purulent discharge, or dacryocystitis. Systemic antibiotics
occasionally may be needed for cases with cellulitis. Ninety percent of cases
resolve within the first year. Referral to an ophthalmologist for probing should be
considered for children with a prolonged course. Suspected cases of infantile
glaucoma require immediate ophthalmologic evaluation under anesthesia.

Neonates with congenital glaucoma are treated with surgery.


FIGURE 96.29 Congenital dacryostenosis. The child’s parents complained of epiphora of both
eyes since the child’s birth. The right eye cleared spontaneously, but the left eye continued to
tear, with morning crusting and heavy matting. (Reprinted with permission from Tasman W,
Jaeger E. The Wills Eye Hospital Atlas of Clinical Ophthalmology . 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2001.)

Neonatal Conjunctivitis (Ophthalmia Neonatorum)
The major causes of neonatal conjunctivitis, or ophthalmia neonatorum, are
chemicals, chlamydia, bacteria, and viruses. Chlamydial conjunctivitis is the most
common conjunctivitis in neonates. The time of onset of symptoms after birth can
help identify the causative agent. Mild nonpurulent inflammation of the
conjunctivae that begins 12 to 24 hours after birth is typically caused by the
prophylactic 1% silver nitrate instilled at birth. This chemical conjunctivitis
usually resolves by 48 hours of age. The incidence of chemical conjunctivitis has
decreased since erythromycin eye drops (0.5%) have replaced silver nitrate drops
in the United States and Canada. Chemical conjunctivitis may still be seen in
developing countries where silver nitrate is used.
Neisseria gonorrhoeae conjunctivitis generally appears 2 to 5 days after birth,
whereas conjunctivitis caused by Chlamydia trachomatis presents between 5 and
14 days after birth because of its longer incubation period. Gonococcal infection
may be delayed beyond 5 days of age because of partial suppression by the
prophylactic drops instilled at birth. Gonococcal infection usually manifests as
marked inflammation of the eyelids, chemosis, and copious purulent discharge.
Gonococcal conjunctivitis is considered a medical emergency because the


infection can cause corneal ulceration and perforation. Presentation of chlamydial

infection, which is primarily localized to the palpebral conjunctiva, can vary from
mild inflammation to severe swelling of the eyelids with copious discharge. Of
neonates with chlamydial conjunctivitis, 10% to 20% have chlamydial
pneumonia, which can either occur simultaneously with the eye infection or up to
4 to 6 weeks later. HSV is a less common cause of neonatal conjunctivitis. The
presence of skin lesions can help in the diagnosis. Gram stain and cultures are
essential in the evaluation of neonatal conjunctivitis. Giemsa staining from
conjunctival scrapings and direct immunofluorescence antibody test can identify
chlamydial disease. Gonococcal conjunctivitis should be treated immediately
with intravenous penicillin or a third-generation cephalosporin in addition to
topical antibiotics and irrigation. Chlamydial conjunctivitis should be treated with
oral azithromycin. Topical drops may be helpful in clearing debris but are not
effective (see also Chapter 123 Ophthalmic Emergencies ).
Transient Neonatal Strabismus
Intermittent esotropia or exotropia may be noted in normal infants during the first
2 to 3 months of life. Esotropia (crossed eyes) is more common than exotropia.
Deviations secondary to neuromuscular immaturity generally resolve
spontaneously by 3 to 4 months of age. Eye deviations that are constant rather
than intermittent, or that do not resolve by 3 months of age, warrant referral for a
full ophthalmologic examination (including fundus examination) to rule out
pathology. Esotropia can occur when visual acuity is impaired (e.g., corneal
abrasions, cataracts, chorioretinitis, and tumors), or due to paralysis of the lateral
rectus muscle. In these cases, early treatment of strabismus improves the
prognosis for cosmetic appearance and will prevent amblyopia.
In many infants, a broad, flat nasal bridge and prominent epicanthal folds may
obscure a medial portion of the sclera near the nose and create the appearance of
esotropia. This pseudostrabismus, or apparent deviation of the eyes, is an illusion
that can be dispelled by the finding of symmetric corneal light reflexes.

Disorders of the Neonatal Nose and Mouth

Goals of Treatment
Many neonatal nose and mouth disorder can be recognized immediately after
birth or early in their nursery stay. Infants occasionally develop symptoms of
acute airway obstruction and respiratory distress after discharge home. Airway
obstruction can occur at any level from nose to trachea, leading to variable