Sticky eyes in kids… Dead easy to treat, right?
Well… Maybe not.
This post is a little different from the usual posts you’ll find on St Emlyn’s. It includes a clinical topic with a teaching video (see the summary of the clinical topic below) but also some thoughts about teaching challenges in the ED.
EduWars? What’s that then?
As part of the Emergency Medicine Educators’ Conference in Coventry in March, I participated in the first ever EduWars. The aim? To showcase different methods of teaching something tangible in three mins. The topic? “Something to do with ophthalmology”, said Scott Carrington, head of the organising committee. The candidates? Simon Laing, Marius Holmes, Alan Grayson and… me 🙂
So I knocked up a three minute talk on sticky eyes in kids. The recorded version is longer (6mins of clinical content) because it turns out three minutes isn’t very long at all and the original talk I wrote was twice as long as it needed to be – but luckily I realised this during rehearsal, so the live version was shorter.
Hopefully the EMEC versions will also be released in due course, but for now – here’s a taster.
Sticky Eyes in Kids
Why think about kids differently?
Although we commonly see sticky eyes in both children and adults in the ED, there are different pathogens in the paediatric population with sticky eyes so we need to treat them differently. We are more likely to see children with sticky eyes because adults can buy chloramphenicol drops over the counter but this option is not available for children.
We can expect different pathogens in different age groups – read more below.
Ophthalmia neonatorum is our concern in neonates – infection contracted from the birth canal during delivery and presenting in the first 30 days of life. Lid oedema, chemosis, and conjunctival injection are common findings but there is no reliable way to clinically differentiate between conjunctivitis contracted during and after birth.
Sticky eyes presenting on day 1 are usually due to chemical irritation and treated with silver nitrate or erythromycin but this is rare.
There are some big nasty bugs in play here.
Gonococcal infection: presents on day 2-7 with severe conjunctivitis. This is seen in 3.7 per
100,000 live births in UK (according to data from 2003). In <1% disease can become disseminated (sepsis, arthritis, meningitis). For this reason Gonococcal infection is treated with IV antibiotics (usually penicillin/cephalosporin).
Chlamydial infection: presents on day 5-14 with a milder conjunctivitis in 6.9 per 100,000 live births. In 10-20% of cases it leads to Chlamydial pneumonia. There is a risk of infection to you as a healthcare provider if you are prising these sticky eyes open. Chlamydial infection is treated with oral erythromycin
plus topical tetracycline.
Other pathogens usually present on day 5-14; these are more common but still treated with oral antibiotics. Pseudomonas can be very nasty and Herpes simplex (HSV2) is also common (it is treated with intravenous aciclovir).
So: there are some very good reasons to do eye swabs in neonates! These babies will also need consideration of blood culture, PCR for Chlamydia, and gram stain of the discharge for Gonococci. Eye irrigation is an important part of treatment so generally babies with sticky eyes should be referred to paediatrics and also for ophthalmology review.
Unlike older children, toddlers are twice as likely to have a bacterial cause of their sticky eyes as viral cause. In particular they are prone to conjunctivitis/otitis syndrome so remember to look in the ears – if you see coexisting red tympanic membranes, treat with oral antibiotics, not topical ophthalmic antiobiotics (it’s usually Haemophilus influenzae mediated so amoxicillin is a good choice.)
H. influenzae, Strep. pneumoniae & Staphylococcal infections are common so again, there are good reasons to swab the eyes of toddlers for bacteria and viruses and to treat empirically until culture and sensitivities are known.
School Age Kids
When kids reach school age we start to see a viral predominance: 20% are caused by Adenovirus, occurring in typical peaks during autumn and winter. These children often present with a fever and sore throat due to Adenovirus – the clinical course usually lasts around 14/7.
But remember to consider HSV: I would still send swabs for viral and bacterial culture but hold off treatment, advising that things will usually settle within two weeks and suggesting reassessment if things worsen or fail to resolve.
Examination of the Eyes in Kids
Examination can be really tricky! Proxymetacaine is your friend – it doesn’t sting as much as other local anaesthetic drops (you’ll usually find it in the fridge in the ED). Combination drops including fluoroscein are even better. Don’t be afraid to employ all your best distraction techniques and to give analgesia; sometimes you’ll need to be patient, to send the child back to the waiting room after analgesia and reassess a little later to get a better look. Remember to evert the eyelid too, to exclude embedded foreign bodies you might otherwise miss.
There are special charts for assessing visual acuity in children who can’t yet read: record VAs in older kids, and use images in younger (such as the Kay picture test).
Don’t forget – not all sticky eyes are infective!
You need to stain to look for foreign bodies and corneal abrasions – use fluorescein and blue light
Remember other causes of conjunctival irritation, such as allergic/hayfever (antihistamine drops can help)
Chemical irritation is also common so have a low threshold for checking the pH
Remember to consider Measles and Kawasaki disease in the febrile child as both have ocular components to their presentation.
Getting Eye Drops In
In co-operative children, there’s a really easy way to get eye drops in which doesn’t challenge them or stimulate a corneal reflex (you can teach it to parents too!). You usually only need a single drop of fluoroscein to stain the cornea and this method avoids the horrendous yellow mascara faces we often generate in our attempt to get a good look.
- Get the child to sit still and look upwards
- Squeeze the pipette of the eyedrop so that a droplet forms at the end
- Gently pull down the lower lid
- Coming from below the eye, tap the droplet to the inner margin of the lower lid and it will run in
- Ask the child to blink and the fluoroscein or local anaesthetic will be distributed across the front of the eye.
Neonates should be seen by paediatrics and ophthalmology.
Other kids with straightforward infective sticky eyes don’t necessarily need follow-up but if you’re sending swabs for culture make sure you know what will happen to the results (and, as ever, give good quality safety netting advice).
And the winner…?
You’ll have to listen to the podcast to find out 🙂
— Natalie May (@_NMay) March 16, 2015