Pediatric Primary Care (43 page)

3.  Neonatal infection appears from day 2 to week 8.

D.  Physical findings.

1.  Mucopurulent discharge.

2.  Hyperemic conjunctiva.

3.  May see Chlamydia pneumonia in infants.

E.  Diagnostic tests.

1.  Giemsa-stained epithelial cells from conjunctival scraping.

2.  Conjunctival culture from swab (requires special tissue culture techniques).

3.  Immunofluorescent staining of conjunctival scraping.

4.  Chlamydial antigen test.

F.  Differential diagnosis.

1.  Neisseria gonorrhoeae conjunctivitis (refer to ophthalmologist).

2.  Bacterial conjunctivitis.

3.  Viral conjunctivitis.

4.  Congenital glaucoma (refer to ophthalmologist).

G.  Treatment.

1.  Refer all neonates for evaluation and treatment (systemic oral erythromycin).

2.  Refer mother and mother's sexual partner for evaluation and treatment.

3.  Report to appropriate authority (sexually transmitted infection).

H.  Follow up.

1.  Return in 3 days to monitor eye infection.

2.  Return sooner if infant has signs of pneumonia or parental concerns.

I.  Complications.

1.  Other sexually transmitted infections.

J.  Education.

1.  Review good handwashing with family.

2.  Mother and partner need treatment because disease is usually transmitted vaginally during birth.

3.  Eye infection can be associated with pneumonia that started during first 6 weeks with cough, rhinorrhea, tachypnea.

4.  Infant may need second round of erythromycin; efficacy is 80%.

IV. VIRAL CONJUNCTIVITIS

A.  Etiology.

1.  Adenovirus (most).

2.  Herpes simplex.

3.  Varicella zoster.

4.  Coxsackie.

B.  Occurrence.

1.  Common in all age groups.

2.  Very contagious; 8-day incubation period.

C.  Clinical manifestations.

1.  Pinkish-red eyes.

2.  Watery or serous discharge, with crusty eyelids on awakening.

3.  May complain of gritty sensation in eye.

4.  May complain of sore throat, upper respiratory infection, flulike symptoms.

5.  One or both eyes involved.

6.  Vesicles on skin around eye (herpes).

D.  Physical findings.

1.  Diffuse conjunctival hyperemia with follicles.

2.  Watery or serous discharge.

3.  Discomfort, not acute pain.

4.  Preauricular and submandibular adenopathy.

5.  May see concurrent pharyngitis and/or upper respiratory infection.

6.  Vesicular lesions on skin around eyes (herpes).

7.  Normal vision.

E.  Diagnostic tests.

1.  None.

2.  Culture if conjunctivitis is persistent or does not respond to treatment.

F.  Differential diagnosis.

1.  Bacterial conjunctivitis.

2.  Allergic conjunctivitis.

3.  Nasolacrimal duct obstruction.

4.  Blepharitis.

5.  Corneal abrasion or ulcer (refer to ophthalmologist).

G.  Treatment.

1.  Antibiotics not indicated.

2.  Cool, wet compresses.

3.  Artificial tears.

4.  Refer if suspect conjunctivitis due to herpes.

H.  Follow up.

1.  No routine follow up necessary.

2.  Recheck if fails to improve in 10-14 days; sooner if worsens.

I.  Complications.
Secondary bacterial infection, 041.9

1.  Secondary bacterial infection.

J.  Education.

1.  Very contagious; meticulous handwashing and no sharing of linens.

2.  Avoid touching eyes.

3.  Will last about 12-14 days.

4.  No school or daycare until discharge is resolved.

V.  CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION (DACRYOSTENOSIS)

A.  Definition. Congenital nasolacrimal duct obstruction (dacryostenosis), 375.56 Defect of lacrimal drainage system resulting in blockage.

B.  Etiology.

1.  Imperforate membrane at distal end of nasolacrimal duct.

C.  Occurrence.

1.  Occurs in up to 6% of all newborn infants.

2.  Both eyes involved, 33%; one eye involved, 66%.

D.  Clinical manifestations.

1.  Persistent, excessively watery eyes.

2.  Mucopurulent discharge.

3.  Matted eyes on awakening.

E.  Physical findings.

1.  Watery eyes, often overflowing onto cheek.

2.  Sclera clear.

3.  Reflux of mucopurulent discharge from punctum easily obtained with gentle pressure over nasolacrimal sac.

4.  May see concurrent erythema or irritation of skin around eyes.

F.  Diagnostic tests.

1.  Gentle pressure over nasolacrimal sac produces mucopurulent discharge from punctum.

G.  Differential diagnosis.

1.  Viral conjunctivitis.

2.  Bacterial conjunctivitis.

3.  Blepharitis.

4.  Dacryocystitis.

H.  Treatment.

1.  Massage lacrimal sac several times a day.

2.  If secondarily infected, treat with anti-infective (see Bacterial Conjunctivitis).

3.  Refer to ophthalmologist if not resolved by 12 months of age.

I.  Follow up.

1.  Recheck at all well-baby exams and as needed.

J. Complications.

1.  Bacterial conjunctivitis.

2.  Dacryocystitis.

3.  Periorbital or orbital cellulites.

K.  Education.

1.  Wash hands before touching infant's eyes.

2.  Teach massage technique: place index finger over lacrimal sac, exert gentle downward pressure, and slide finger downward toward mouth.

VI. BLEPHARITIS

A.  Definition.

B.  Etiology.

1.  Seborrhea.

2.  Staphylococcal.

3.  Pediculus pubis or P. capitis.

C.  Occurrence.

1.  Can occur in all age groups.

D.  Clinical manifestations.