Pediatric emergency medicine trisk 144

compression and indications for repeat evaluation. For patients with specific local
abnormalities, such as tumors, polyps, or telangiectasias, referral to an ENT
specialist is necessary. Such referral might also be considered if bleeding were
severe, recurrent, or suspected to be posterior in origin. When epistaxis is noted in
patients with a recent tonsillectomy/adenoidectomy, ENT consultation should be
obtained before determining if it is safe to discharge them home.
Suggested Readings and Key References
Davies K, Batra K, Mehanna R, et al. Pediatric epistaxis: epidemiology,
management & impact on quality of life. Int J Pediatr Otorhinolaryngol
2014;78(8):1294–1297.
Elden L, Reinders M, Witmer C. Predictors of bleeding disorders in children with
epistaxis: value of preoperative tests and clinical screening. Int J Pediatr
Otorhinolaryngol 2012;76(6):767–771.
Eshghi P, Jenabzade A, Habibpanah B. A self-controlled comparative clinical trial
to explore the effectiveness of three topical hemostatic agents for stopping
severe epistaxis in pediatrics with inherited coagulopathies. Hematology
2014;19(6):361–364.
Kamble P, Saxena S, Kumar S. Nasal bacterial colonization in cases of idiopathic
epistaxis in children. Int J Pediatr Otorhinolaryngol 2015;79(11):1901–1904.
Ritter FN. Vicarious menstruation. In: Strome M, ed. Differential Diagnosis in
Pediatric Otolaryngology . Boston, MA: Little, Brown and Company;
1975:216.
Stokhuijzen E, Segbefia C, Biss T, et al. Severity and features of epistaxis in
children with a mucocutaneous bleeding disorder. J Pediatr 2018;193:183–189.
Svider P, Arianpour K, Mutchnick S. Management of epistaxis in children and
adolescents: avoiding a chaotic approach. Pediatr Clin North Am 2018;65:607–
621.


CHAPTER 27 ■ EYE: RED EYE
ATIMA DELANEY, BRUCE M. SCHNALL

INTRODUCTION
“Red eye” is a generic term that refers to any condition in which the “white of the
eye” appears red or pink. A red eye may be caused by local factors, intraocular
disease, or systemic problems. Tables 27.1 to 27.3 list common and lifethreatening causes of red eye. The cause of a red eye can often be identified by
the history alone. The history should include the presence or absence of pain,
foreign body sensation, itching, discharge, tearing, photophobia, onset, visual
disturbances, recent illnesses, and trauma. The examination should include visual
acuity, pupil shape and reactivity, the gross appearance of the sclera and
conjunctiva, extraocular muscle function, and palpation of preauricular nodes.
The evaluation often requires fluorescein staining and slit-lamp examination by
an experienced provider.
Discussion of chemical conjunctivitis or irritation caused by agents such as
smoke or trauma is limited here because the history often makes the diagnosis
clear. The management of these disorders is discussed in Chapters 114 Ocular
Trauma and 123 Ophthalmic Emergencies .

PATHOPHYSIOLOGY
The term conjunctivitis should be reserved for disorders in which the conjunctiva
is inflamed. Inflammation may be caused by direct irritation, infection,
abnormalities of underlying or contiguous structures (e.g., cornea), immune
phenomena, or secondary to abnormalities of the lid and lashes. Inflammation
within the anterior chamber affecting the iris (iritis) may also result in secondary
inflammation of the conjunctiva.
The sclera may become inflamed (scleritis). An intermediate layer, the
episclera, lies beneath the conjunctiva’s substantia propria and another largely
avascular fascial layer (Tenon fascia), where it is firmly attached to the sclera.
The episclera is more vascularized than the sclera and may become inflamed
either in a diffuse or localized fashion (diffuse, sectorial, or nodular episcleritis).
A tear film, which prevents desiccation, is constantly present over the surface

of the eye. A disruption in the function of the anatomic structures responsible for
producing the tear film may cause desiccation of the ocular surface, resulting in
irritation and inflammation (dry eye syndrome).


Innervation of the conjunctiva and cornea comes from the first division of the
trigeminal nerve (V1). Abnormalities on the ocular surface may give rise to pain
or a foreign body sensation. The reflex arc that involves the afferent trigeminal
nerve and the efferent facial nerve results in a rapid blink, with contraction of the
orbicularis oculi muscle, to protect the surface of the eye in response to noxious
stimuli. Two other reactions to noxious stimuli may occur: tearing and discharge.
Epiphora or tearing may accompany virtually any conjunctival inflammation or
irritation. Tearing may even be a part of some forms of dry eye syndrome, as the
lacrimal gland attempts to compensate for a dry ocular surface. Discharge from
the eye results either from conjunctival exudation or precipitation of mucus out of
the tear film. The latter occurs when the tear film is not flowing smoothly such as
nasolacrimal duct obstruction, causing misinterpretation as infection when the
problem is actually mechanical. Although discharge may be a nonspecific
finding, the nature of the discharge may be helpful in the cause of an
inflammation or infection. The presence of membranes or pseudomembranes (
Fig. 27.1 ) is more common with adenovirus infection or Stevens–Johnson
syndrome. These white or white–yellow plaques are caused by loosely or firmly
adherent collections of inflammatory cells, cellular debris, and exudate.

EVALUATION AND DECISION
The approach to the child who presents to the emergency department with a red
eye is outlined in the flowchart shown in Figure 27.2 .
Any child with a red eye who wears contact lenses regularly, even if the lens is
not in the eye at the time of the examination, should be referred to an
ophthalmologist within 12 hours. Red, and often painful eyes of a person who

wears contact lenses may represent potentially blinding corneal infection (corneal
ulcer) or the breakdown of the corneal epithelium, which would predispose the
person to subsequent corneal infection. Contact lenses should be removed
immediately, further diagnostic or therapeutic interventions in these patients
should be performed with ophthalmology consultation. Decisions regarding
starting empiric antibiotic therapy should be made with the consultation of an
ophthalmologist, as there may be benefit to waiting until corneal cultures can be
obtained. The presence of a white spot on the cornea of a contact lens wearer with
inflamed conjunctiva is an ominous sign that may represent an ulcer ( Fig 27.3 ).
The absence of such a spot does not rule out corneal ulcer. Other causes of red
eye in a contact lens wearer include contact lens solution allergy (which may
develop even after years of using the same regimen), overwearing of contact
lenses, overly tight fit, foreign body, or a damaged contact lens. Examination by


an ophthalmologist can help ensure that a corneal ulcer is not missed by ascribing
the red eye to one of these other etiologies. It is therefore recommended that all
contact lens wearers with a red eye be seen by an ophthalmologist.
Numerous systemic diseases may be associated with ocular inflammation.
Select examples can be found in Table 27.3 . In some systemic diseases, the
associated ocular abnormality involves intraocular inflammation (iritis, vitritis),
which can then cause secondary conjunctival infection or inflammation. Patients
with these diseases may also have coincidental ocular inflammation unrelated to
their underlying conditions. Ophthalmology consultation may be helpful in
making this distinction. For example, in Kawasaki disease, the inflammation of
the conjunctiva may be associated with mild iritis. More often, the conjunctiva is
inflamed in isolation as part of the systemic mucous membrane involvement. The
conjunctivitis of Kawasaki disease is usually confined to the bulbar conjunctiva,
often with limbal sparing ( Fig. 27.4 ), with little or no discharge. In contrast, the
bulbar and palpebral conjunctivae are inflamed in infectious conjunctivitis (Fig.

123.7 ).