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True or False. Children are just small adults.
-Children, especially infants, are developing, their systems are not fully matured.
-These differences have an impact on how drugs are tolerated by children.
Skin barrier - in premature babies almost non-existent. Does not fully mature until the age of six.
How can this help us?
If we are struggling to get drops in a child's eye, we can just sqwuert some in.
Skin barrier is not mature in infants, what other systems take a while to develop?
-Blood-brain barrier: newborns have a poor blood brain barrier
-Renal function does not reach adult until age 2
-Liver function does not reach adult until 3 or 4
-GI function does not reach adult levels until ten or twelve
Corneal abrasion is most often diagnosed simply by the history.
What do you need to look carefully?
Blunt traumatic abrasions need to look carefully for hyphen.
How do you treat abrasion in infant?
*patch to ensure their fingers are away from the eye
*See them daily while the patch is on and educate parents about signs of bacterial infection
-For preschoolers and older children use an antibiotic drop and possible bandage CL.
Nasolacrimal duct obstruction occurs due to stenosis and are present in up to 30% of newborns.
What are they due to?
Due to stenosis, chronic infections, acute infections, developmental anomalies, or trauma.
What should be your differential diagnosis if you suspect a nasolacrimal duct obstruction?
1. Bacterial conj.
2. Acute or Chronic dacryocystitis
3. Congential glaucoma
What are these symptoms of?
- Epiphora (unilateral or bilateral) can be continuous
- Breakdown of skin periorbital especially at the lateral canthi
- Mattering of lids with discharge throughout the day
- Can have a concurrent middle ear infection
Nasolacrimal duct obstruction
Surgical treatment typically occurs after having a nasolacrimal duct obstruction for 6 months with: constant discharge and infection and it has been a few months of epiphora with no signs of decreasing.
What occurs with the surgical procedures?
-Balloon catheter dilation
*if the child is too old or weighs too much an in-office procedure may need to be turned into an outpatient procedure.
Why might it be a good idea to monitor nasolacrimal duct obstructions?
Most (90%) congenital NLDO will spontaneously open before the age of one year.
Lacrimal massage is encouraged.
If there is discharge present with a nasolacrimal duct obstruction, what antibiotic drops would you use?
1. For kids <4 months can use Polytrim Ophthalmic Solution up to six times QD for 7-10 days.
2. For kids >4 months Moxeza BID for 7 days
Before prescribing a medication, what things should you consider?
• Need to know the pharmacology of the medication you want to prescribe
• Need to know any possible/potential allergic reactions
• Need to know the relative cost of the medication
• Need to know the Insurance medication formulary
• Need to know the insurance medication formulary
- It is that important it needs to be listed twice!
In order to minimize systemic effects you need to maximize compliance by proper parent education.
What should you educate the parents on?
• Amount of dose and schedule
• Proper technique for administration (how to put drops in the eye)
• Length of course
• Signs of improved symptoms (tell the mom to know if the condition is improving or what it will look like if it is getting worse)
• Signs of adverse reactions
What is polytrim made of and what is it good for treating?
Polytrim: polymyxin B/trimethoprim
*It is an older medication but has a good safety profile.
*Covers gram + and -
*Has been approved for use in infants and children 2 months and older.
*Usual dosage is QID
What is moxeza?
-infants and children >4 mo
-Dosage one drop BID x 7 days
-Gram + & -, bacterial static
What is Vigamox?
-Approved children >1 year old
-One drop TID x 7 days
What is ciloxan?
-sol. for children 1 year or older
-ointment for children 2 years or older
-QID to 8 times daily
Can come in 2 forms:
What is Azasite?
-1 got BID then 1 got QD for 5 days
What is besivance?
1gtt TID for 7 days
What are these S & Sx of?
- Watery eyes
- Boggy conjunctiva
- Conjunctival reaction
Allergies causing epiphoria.
8 year old Referred by pediatrician, Dx with seasonal allergies, no ocular treatment. +whitish discharge in the morning, OU +itching, OU
-Mom has noticed white areas on the front of daughter's eyes
-No major medical conditions, no fhx of medical conditions
-No history of eye problems
-No complications with pregnancy or birth
Vernal keratoconjunctivitis OU
Tx: Cromolynophthalmicsol 1gtt QID OU
-Lotemax Ophthalmic sus 1gtt QUID OU
-RTC 1 week for FU, sooner, if increase redness, pain or discharge
Compare and contrast vernal and seasonal allergies?
Vernal: boys, spring, corneal involvement, giant papillae, mucus
-requires steroid, mast cell stabilizer and antihistamine
Seasonal: equal btwn M&F, spring and autumn, no corneal involvement, small papillae, minimal mucus
-rarely requires steroid
What are some allergy medications?
1. Alocril (neodocromil sodium)
-mast cell stabilizer
2. Cromolyn Opthlamic
-mast cell stabilizer
-mast cell stabilizer
4. Zaditor (ketoifen)
-histamine antagonist and mast cell stabilizer
5. Patanol (olopatadine)
-selective histamine-1 recetor antagonist and mast cell stabilizer
6. Pataday (olopatadine)
What steroids can be used for allergies?
1. Pred-forte (don't use in kids...)
2. Lotamax (loteprednol)
-try to avoid steroids in kids but if you have to, use lotamax.
What antibiotic-steroid combinations can be used?
1. Tobradex (tobramycin and dexamethasone)
2. Tobradex ST
-w/ a newer suspension. Used with MGD and blepharitis.
3. Blephamide (sulfactetamide/prednisone)
Bacterial conjunctivitis occurs most often in what age patients?
clinical signs of bacterial conjunctivitis:
2. Moderate conjunctival hyperemia
3. Mattering in AM.
What bacterial organisms commonly cause bacterial conjunctivitis?
What is the treatment for bacterial conjunctivitis in a child?
1. <4 mo = polytrim
2. >4 mo = Moxeza
3. >1 year = Besivance or Zymaxid
Should you treat hordeolum/chalazion or preseptal cellulitis with topical medications??
Most of the time oral.
complaint of swollen LUL
• VAs unknown
• EOMs full
• No pain
• Running low grade fever
What if there's more to the story?
• Pt. has been on Augmentin for 2 weeks.
• Per parents and grandparents it's getting worse
• What questions should we start to ask?
-This is not a normal clinical course.
Pt had a tumor causing the S-shaped eyelid.
Take home points:
• Always figure out the timeline
• Don't blow off parents when they are saying that something is getting worse
• Ask for pictures- they are the best way to see how something is progressing
• Don't be afraid to order special testing, even when you think it is "nothing"
• Get it to the right person to make the correct Dx
What are these S&Sx of?
• Lid edema can be both superior and
inferior lids and may extend past the
• Chemosis of the conjunctiva
• Concurrent sinus infection or UR
-first rule out orbital cellulitis
-if afebrile may be treated with oral antibiotic
-If febrile or lethargic, hospitalization may be necessary with follow-up with hospital credentialed physicians
How do you treat perceptual cellulitis in a child?
1. Keflex (cephalexin).
-Pediatric dose is 40mg/kg/day (divided q6hr)
2. Augmentin pediatric dosage
-<40kg 20-40mg/kg/day (divided dose every 8 hours)
->40kg one 500mg tablet every 12 hours or one 250mg tablet every 8 your
*if pt has a penicillin allergy, use erythromycin.
What are these S&Sx of?
• Headache and/or fever
• Lid edema
• APD (possible)
• Abnormal EOM with possible diplopia • Pain with eye movement
• Children can be very sick, lethargic
Tx: hospitalization with IV antibiotics.
True or false.
You will treat a child with a hordeolum?
Adults we use warm compresses. But children don't have very good immune syndrome.
-12 year female
-Noticed redness OD 45 days ago
-Started puberty and mense 90 days ago, acne started 60 days ago.
-Went to PCP and had multiple appointments with optometrists.
-Diagnosed with blepharitis and chalazion Previous Tx, compress, -LS and "drops"
• Surgical intervention on the three chalazia
• Will use daily LS, skin treatment for oily skin, blephamide ung each eye and an oral antibiotic daily.
Take home point:
-Hordeolum and chalazion typically not sight or life threatening (unless it turns preseptal cellulitis, or orbital)
-Tx can go to ophthalmologist or MD
-Refer to dermatologist if appearance of acne recurrent hordeolum or multiple hordeolum
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