Pediatric emergency medicine trisk 1015

FIGURE 123.14 A patient with multiple chalazions, including one in the left upper eyelid
draining spontaneously via the skin.

FIGURE 123.15 Chronic chalazion within left upper lid.

The treatment for both a chalazion and a stye is essentially the same. Eyelash
scrubs once or twice daily are helpful in mechanically establishing drainage.
Baby shampoo is applied to a washcloth and then used to gently scrub the base of
the eyelashes while the eyelids are shut. Warm compresses over closed eyelids
four times daily for 10 minutes may be helpful, but is rarely tolerated well by
younger children. If a washcloth is used it will cool quickly and will need to be


reheated while a gel pack will retain the heat for a longer period of time. There is
minimal evidence for antibiotics in the treatment of stye and chalazion in the
absence of concurrent cellulitis, except in recalcitrant chronic cases. In such cases
a topical antibiotic ointment with coverage for coagulase-negative staphylococcal
species ( Table 123.2 ) can be applied twice daily following eyelash scrubs to
help reduce staphylococcal overgrowth. If there is inadequate resolution after at
least 4 to 6 weeks of medical management, incision and curettage by an
ophthalmologist can be considered.

Nasolacrimal Duct Obstruction and Infection
The nasolacrimal apparatus extends from the puncta in the eyelids to the nose and
is responsible for tear drainage. The most common cause of nasolacrimal duct
(NLD) obstruction is incomplete canalization at the distal end of the system
before it enters the nose. NLD obstruction is the most common cause of persistent
tearing and ocular discharge in children, occurring in up to 20% of all normal
newborns. NLD obstruction may rarely be complicated by inflammation or
bacterial infection of the lacrimal sac (i.e., dacryocystitis), which is an ocular
emergency.

Patients with NLD obstruction are usually younger than 1 year of age, with a
history of symptoms dating back to the first weeks of life. Infants typically
present with intermittent tearing and debris on the eyelashes. The discharge is
mostly mucus that has precipitated out of the tear film because of stagnation of
tear flow, and is usually worse on waking. In contrast to patients with
conjunctivitis-associated discharge, the conjunctiva is rarely inflamed with NLD
obstruction (i.e., no “red eye”) ( Fig. 123.16 ). Older children often have epiphora
(i.e., excess overflow of tears) without discharge. The diagnosis can be confirmed
by placing pressure on the lacrimal sac, which lies under the skin against the
lacrimal bone between the medial canthus and bridge of the nose, which forces
discharge out of the sac back onto the surface of the eye. Dacryocystitis is
characterized by erythema, swelling, warmth and tenderness over the lacrimal sac
often extending into the medial lower lid ( Fig. 123.17 ) and may lead to
periorbital or orbital cellulitis, sepsis, and meningitis. The most common
causative agents include S. aureus, S. epidermidis, and alpha hemolytic
streptococci. It should be noted that almost all infants with dacryocystitis have an
underlying dacryocele (i.e., lacrimal duct mucocele), a cystic dilatation of the
lacrimal sac which is caused by both a distal and proximal obstruction in the
nasolacrimal apparatus. It often presents as a bluish mass before getting infected.


FIGURE 123.16 Left nasolacrimal duct obstruction. Note discharge on medial lower lid and
wet lower lid lashes. The conjunctiva is noninflamed (no “red eye”) indicating that the child
does not have conjunctivitis.

Over 90% of cases of NLD obstruction resolve spontaneously over the first
year of life. Lacrimal duct massage (i.e., applying moderate pressure over the
lacrimal sac) is the first line of treatment. Lacrimal duct probing or stenting may
be required for select resistant cases. Acute dacryocystitis is an ocular emergency
which requires immediate antibiotic treatment and ophthalmology consultation.

FIGURE 123.17 Dacryocystitis in an infant with a dacryocele. Erythematous, tender, swelling
along the inferior medial canthal area representing inflammation of the nasolacrimal sac.

Suggested Readings and Key References
General
Bagheri N, Wajda BN, eds. Wills Eye Manual: Office and Emergency Room
Diagnosis and Treatment of Eye Disease. 7th ed. Philadelphia, PA: Wolters
Kluwer; 2017.
Periorbital and Orbital Cellulitis
Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal periorbital infections are different diseases. A retrospective review of 262 cases.
Int J Pediatr Otorhinolaryngol 2008;72(3):377–383.
Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev
2010;31(6):242–249.
Rudloe TF, Harper MB, Prabhu SP, et al. Acute periorbital infections: who needs
emergent imaging? Pediatrics 2010;125(4):e719–e726.
Santos JC, Pinto S, Ferreira S, et al. Pediatric preseptal and orbital cellulitis: a 10
year experience. Int J Pediatric Otorhinolaryngol 2019;120:82–88.
Conjunctivitis
LaMattina K, Thompson L. Pediatric conjunctivitis. Dis Mon 2014;60:231–238.
Richards A, Guzman-Cottrill J. Conjunctivitis. Pediatr Rev 2010;31(5):196–208.