Microbes are usually introduced into the eye or surrounding tissues including eyelids, eyebrow, and cheeks by direct contact with infected objects. Orbital infections occur secondary to microbial spread from an adjacent sinus, direct inoculation from trauma (insect bites or eyelid injury), surrounding skin infection, or postoperative contamination or, in the case of sepsis or dental infection, from hematogenous spread.
This initiates an inflammatory response that includes dilation of blood vessels, swelling, antibody production, and destruction of the offending agent by white blood cells.
Common bacterial agents include nontypeable Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Staphylococcus aureus. Viral infections are common and are usually caused by adenovirus. Less commonly, herpesvirus may occur.
The infecting agents can be contagious and easily spread from person to person or from infected objects (fomites). Therefore, conjunctivitis may occur in outbreaks in which several children in the same family, classroom, or community are affected.
Allergic reaction from pollen can be a major contributor to conjunctivitis.
Inflammation of palpebral and bulbar conjunctival layer of eyes that leads to dilation of the blood vessels.
Eyelid and conjunctiva edema.
Excessive tearing or exudate.
Gritty feeling in the eye and itching.
Photophobia.
Fluctuating blurring and cloudy vision.
Inflammation of the eyelids and surrounding tissues that does not involve eyeball or internal structures.
No significant fever.
No pain on eye movement.
No impaired vision.
Age less than 5 years.
Red, swollen eyelid with swelling and inflammation of soft tissues surrounding the eye.
Tenderness, pain.
Proptosis (forward displacement of the eye) and, sometimes, chemosis (edema of conjunctiva).
Restrictive eye movement and orbital tension.
Increased temperature of affected areas.
Reduced visual acuity.
Elevated fever.
Age over 5 years.
Table 47-1 Common Causes of Eye Redness in Children | ||||||||||||||||||||||||||||||
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Inflammation of lubricating glands of eyelids and eyelashes.
Unilateral.
Pustule in area of eyelash follicle.
Tenderness, pain.
Localized eyelid swelling and erythema.
“Lump under the eyelid.”
Due to the cost of and the delay in results, laboratory testing is limited to cases which fail to respond to treatment. Appropriate laboratory media must be used to transport a swab of eye exudate for bacterial culture, viral culture, and antigen testing. Swabs should be obtained immediately, but treatment not delayed, especially in the cases of suspected N. gonorrhoea or C. trachomatis.
Screening vision exam may be done; a thorough visual and ocular exam may be done if vision is impaired or if internal involvement is suspected.
A dendritic ulcer caused by herpesvirus can be visualized by instilling fluorescein dye and examining the cornea with a cobalt-filtered blue light, looking for the dendrite lesion.
Clinical evaluation and computed tomography scan are the best methods to distinguish periorbital from orbital cellulitis.
NURSING ALERT
Allergic conjunctivitis may respond to removal of the underlying allergen. Treatment may include systemic or topical agents (depending on severity), including antihistamine, mast cell stabilizer, and corticosteroid.
Antibiotic eyedrops or ointment—such as erythromycin, trimethoprim sulfate and polymyxin B, sulfacetamide, ciprofloxacin, tobramycin, azithromycin, or doxycycline—will shorten the course of bacterial conjunctivitis and make the child more comfortable.
Hordeolum will usually resolve without antibiotic treatment. Warm compresses applied four times daily are recommended. Lid washes of diluted baby shampoo in water aid with drainage. Incision and drainage may be necessary to promote healing.
Systemic antibiotic treatment is indicated for orbital cellulitis. These children may be admitted to the hospital for close observation and aggressive management. A multidisciplinary approach, including an ophthalmologist, pediatrician, otolaryngologist, and, possibly, a neurosurgeon may be indicated.
DRUG ALERT
Permanent scarring of the cornea and visual impairment with herpetic infection, N. gonorrhoeae, and C. trachomatis.
Spread of orbital cellulitis to the central nervous system, with optic nerve damage and vision loss.
Eyelid deformity.
Septicemia.
Ptosis and strabismus after resolution of orbital cellulitis.
Assess nature and extent of symptoms and their effect on child’s activities.
Assess visual acuity.
Determine resources available to family for treatment and rehabilitation.
Risk for Infection (spread, secondary, transmission to others) related to hand-to-hand or hand-to-object contact.
Acute Pain and discomfort related to tissue swelling, inflammation, and light sensitivity.
Perform or teach proper cleansing of drainage.
Use warm water or saline and a disposable applicator, such as cotton balls or gauze.
Use a separate applicator for each eye.
Wipe from inner to outer canthus to avoid contamination of the other eye.
Teach self-care measures to prevent spread to others.
Observe good handwashing practices.
Wipe eyes and nose with tissues and dispose promptly. Do not wipe the nose, then eyes with same tissue.
Avoid rubbing eyes to prevent spread to other eye.
Administer and teach proper instillation of eyedrops or ointment (see page 576).
Administer oral or IV antibiotics, as prescribed.
Advise parents to only use eye drops prescribed or recommended by a health care provider and dispose of leftover medication at end of treatment period.
Apply warm compresses to affected area.
Suggest darkened room and sunglasses for patients with photophobia.
Administer an analgesic, as prescribed.
Administer lubricating eyedrops and ointment, as needed.
Minimize environmental stimulation.
Advise of ways to prevent transmission to others.
Handwashing is the most important factor in infection control.
Do not share washcloths or towels or handkerchief.
Change pillowcases frequently.
Avoid swimming until infection is resolved.
Return child to school only after having received antibiotic treatment for 24 hours.
Dispose of contaminated items in proper receptacles.
Discontinue use of contact lenses until infection is cleared.
Advise parents of indications for reevaluation by health care provider.
Lack of response to antibiotic treatment.
Increased swelling and tendernes; eye pain.
Worsening of visual acuity.
Identification of dry eye.
Development of additional symptoms such as fever.
Encourage routine follow-up visits and vision evaluation.
Advise about proper detection and early treatment of sinus, dental, and other infection.
Recommend updated immunization, including the Haemophilus influenzae type B vaccine in children.
Parents perform treatment correctly; hygiene procedures followed.
Patient verbalizes less pain; tolerates bright light.
Assess for red light reflex, especially in neonates and infants. Absence or asymmetry of the red light reflex may indicate congenital cataract or an intraocular tumor or other eye disease.
Inspect the eyes for redness of conjunctiva, cloudiness of the cornea, excessive tearing, drooping eyelids that partially occlude the pupil, or obvious misalignment, which provide clues to congenital eye problems.
Assess visual acuity routinely in infants and children. Changes in acuity may be the first manifestation of a problem or indication of effectiveness of treatment. Prompt referral to a specialist is necessary.
Perform pupillary light reflex test using a penlight or “muscle light” or use a distant light source to help detect strabismus.
Hirschberg’s test for symmetry of the pupillary light reflexes—normally, the light reflexes are in the same position in each pupil when a light is shone on the bridge of the nose, but asymmetrical reflection will occur with strabismus (positive Hirschberg’s test).
Krimsky test—prism is used to center the light reflex in each eye. It is said to be more accurate than the Hirschberg method.
Perform the cover-uncover test to detect latent strabismus caused by weak eye muscles. When the patient is fixated on
an object approximately 12 inches (30.5 cm) away, cover one eye. The eye with weak muscles will drift when covered and will snap back when uncovered. An eye with normal muscles will remain straight.
Table 47-2 Congenital Eye Problems | ||||||||||||||||||||||||||||||||||||||||||
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Disturbed Sensory Perception (Visual) related to reduction in visual acuity or no visual stimulation.
Disturbed Body Image related to the need for patch or glasses.
Risk for Injury related to reduced visual acuity and modified depth perception.
Delayed Growth and Development related to altered visual stimulation and possible overprotective behavior of parents.
Participate in visual acuity problem identification and encourage prompt treatment to minimize functional impairment. Accurate assessment of (corrected) monocular visual acuity is the single most important element in an examination.
Effective newborn screening in the nursery helps to detect congenital eye problems.
All children should be screened for visual acuity and strabismus. In young children, this is accomplished by physical examination and assessment of developmental milestones (ie, looks at mother’s face, smiles responsively, reaches for objects). Special assessment tools are available to assess preverbal children. By age 3 to 5 years, most children can cooperate for performance of accurate visual acuity screening tests.
Encourage and assist parents in obtaining corrective lenses for the child.
Advise and encourage parents to adhere to the postoperative treatment plan, such as occlusion therapy following cataract surgery or proper use of eyedrops after glaucoma surgery.
Encourage and assist parents in providing normal experiences for child to achieve maximum potential:
Assist parents in locating and accessing resources, such as financial assistance, special education in Braille, or parent support groups.
Remind parents of their child’s right to an education.
Encourage parents to focus on normalization rather than on overprotection. Place expectations on the child’s abilities rather than disabilities, provide opportunities for interaction with peers, and make the child’s life as normal as possible.
Encourage acceptance of appearance and emphasize the positive aspects of treatment.
Encourage the family to be aware of safety in the home, school, and community.
Suggest the use of impact-resistant polycarbonate eyeglasses and devices to keep eyeglasses from falling off.
Advise the family to maintain a consistent and uncluttered furniture arrangement; notify child of planned changes.
Instruct child in the use of a cane or other assistive device, if warranted.
Teach traffic safety and personal security measures.
Orient visually impaired children to their immediate environment.
Orient child to food placement on meal trays.
Assist child with ambulation and use side rails on bed or crib to prevent falls.
Encourage parents to provide many sensory opportunities, such as manipulating objects, hearing various sounds, noting the smells in the environment, and tasting an assortment of substances.
Allow child to perform activities of daily living (ADLs) as independently as possible.
In the interest of hygiene and safety, the patient (if older) and parent should be taught correct handwashing technique before and after instilling eye medication, particularly eyedrops. This must be reinforced before discharge.
Teach about instillation of medications and use of eye shield to prevent injury to the operative eye after surgery.
Teach about activity restrictions after glaucoma surgery.
Bed rest may be required immediately postoperatively.
Older children should not engage in strenuous activity or contact sports for 2 weeks.
Advise that activity is not usually restricted after repair of ptosis.
Following strabismus repair, strenuous activity, contact sports, and swimming are restricted for 2 to 4 weeks.
After cataract surgery due to inflammatory reaction, encourage behaviors to reduce the risk of damage to sutures from increased intraocular pressure (IOP):
Prevent vomiting.
Minimize crying.
Encourage intense occlusion therapy and use of optical correction with glasses or contact lenses as advised.
Encourage parents to remove eye discharge or crusts on lashes regularly by wiping the eyes with warm water. Separate washcloths should be used for each eye and each child. Moistened cotton balls may be used.
Advise and encourage about the importance of keeping postoperative follow-up appointments.
Advise of indications that would require reevaluation by health care provider:
Worsening of visual acuity.
Evidence of inflammation and infection, such as pain, redness, swelling, drainage, and increased temperature.
Refer family to Prevent Blindness America (www.preventblindness.org) for information on eye disease and safety measures. For cataract and glaucoma patients, refer to the Pediatric Glaucoma and Cataract Family Association (www.pgcfa.org). Lighthouse International (www.lighthouse.org) aids with rehabilitation of visual impairment.
Child wears glasses or contact lens, as prescribed; good visual outcome with adequate optical rehabilitation.
Parents and child report involvement in activities, satisfactory school performance, and positive peer interactions.
No injuries reported.
Achieves age-appropriate developmental milestones.
Evidence Base
Injury to corneal epithelium.
This may happen when a foreign object becomes lodged in the eye (eg, flying dust particle; contact lens rubbing against the eye because of inadequate tear production; injury from a fingernail, tree branch, or other sharp object entering the eye and scraping the cornea).
May occur from the effects of general anesthetic, which cause decreased tear production, decreased eyelid reflexes, decreased perception of pain, and failure of the eye to close properly.
May result from corneal exposure with such conditions as ptosis or pressure on the globe, especially in the presence of dry eyes.
May result from contact with household or industrial chemicals.
Occurs when the eye or surrounding tissues are struck by a blunt object such as a ball, a hockey puck, a bat, or a stick.
The resulting injury depends on the size, hardness, and velocity of the blunt object and the force imparted. Injury may include tissue swelling and seepage of blood into the surrounding tissues.
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