Clinical Evaluation of Red Eyes in Pediatric Patients

Casey Beal, MD; Beverly Giordano, MS, RN, CPNP, PMHS

Disclosures

J Pediatr Health Care. 2016;30(5):506-514. 

In This Article

Inflammatory Eye Conditions

Blepharitis

Definition. Blepharitis, an inflammation of the eyelid margins involving the eyelashes, is very common in the pediatric patient population. Most patients are completely asymptomatic, but blepharitis can cause significant eye pain and even vision loss in some children. Blepharitis is a type 3 hypersensitivity reaction to bacterial exotoxins, most commonly staphylococcal skin flora located at the lid margin.

History of the Present Illness

  • Chronic burning, itching, and tearing of the eyes that is worse toward the end of the day; it is always bilateral but can be asymmetric

  • Typical age of onset is between 6 and 10 years (Gupta, Dhawan, Beri, & D'souza, 2010; Teo, Mehta, Htoon, & Tan, 2012)

  • Recurrent chalazia or red, swollen areas of the eyelids also are common in these patients

Physical Examination

  • Crusting at the base of the eyelashes and erythema of the eyelid margins with diffuse reactive conjunctival erythema

  • An examination with a Wood's lamp and fluorescein staining should be performed to evaluate for corneal abrasions

In severe forms, corneal scarring and neovascularization can be seen as white areas on the otherwise translucent cornea. Although these lesions might be seen without use of a Wood's lamp, they become more apparent upon its use with fluorescein.

Treatment

  • Wash the eyelashes daily with a mild baby shampoo

  • Apply warm compresses to the eyelids twice daily or more often for associated chalazia

  • Apply topical erythromycin ointment to the eyelashes nightly as needed

  • Provide a referral to ophthalmology if no improvement occurs with conservative treatment or if corneal scarring is noted

Episcleritis and Scleritis

Definition. Episcleritis is inflammation of the episclera (which lies just posterior to the conjunctiva), and scleritis is inflammation of the deeper, avascular, white sclera. These conditions are commonly idiopathic in origin but can be associated with a systemic autoimmune disorder. Thirty-seven percent of patients with scleritis have an associated systemic connective tissue disease (Wieringa, Wieringa, ten Dam-van Loon, & Los, 2013). Scleritis, as opposed to episcleritis, is exceedingly rare in the pediatric population, with the largest case series consisting of only 13 patients (Cheung & Chee, 2012).

History of the Present Illness

  • Eye pain that is acute to subacute in onset along with redness, which is usually unilateral

Physical Examination

  • Persons with episcleritis will have localized or diffuse conjunctival erythema that is tender to palpation (Figure 5); in contrast, simple conjunctivitis is more "irritating" rather than "tender to palpation"

  • Scleritis is characterized by inflammation of the deeper eye structures and will have localized erythema, tenderness to palpation, and a bluish discoloration underlying it

Figure 5.

Nodular scleritis. A discrete raised conjunctival nodule with surrounding erythema.
Photo courtesy of Phuchong Choksamai. ©123rf.com. This figure appears in color online at www.jpedhc.org.

Treatment

  • Patients should be referred to ophthalmology for treatment and management; artificial tears, steroid eye drops, oral nonsteroidal anti-inflammatory drugs (NSAIDs), and sometimes systemic immunosuppression are the treatments of choice

Uveitis

Definition. Uveitis is an inflammatory disorder of the uveal tract that includes the iris, ciliary body, and choroid. It is classified as anterior, intermediate, posterior, or pan uveitis based on the portion of the eye that is involved. Anterior uveitis, also known as iritis, is the most common type that should be considered when a pediatric patient presents with an acute red eye, and therefore we will focus on that type or uveitis in this article. Uveitis occurs in 11% to 13% of all patients with juvenile idiopathic arthritis (JIA) and can cause significant ophthalmic morbidity (Tappeiner et al., 2015). It is more common in patients with pauciarticular JIA and those who are positive for antinuclear antibodies. The uveitis associated with JIA can be low grade and asymptomatic, and thus these patients require frequent routine eye examinations by an ophthalmologist.

History of the Present Illness

  • Acute or subacute onset severe photophobia, eye redness, and a "boring" type pain with blurry vision

Physical Examination

  • Diffuse conjunctival erythema that is most prominent near the cornea

  • Direct and consensual photophobia (i.e., pain in the affected eye when light is shown in the normal eye)

  • Most cases are unilateral, although uveitis can be bilateral

Diagnostic Tests

  • If recurrent or severe disease is present, rule out infectious/inflammatory causes, including syphilis, sarcoidosis, Lyme disease, tuberculosis, and HLA-B27 seropositivity

Treatment

  • If uveitis is suspected, the patient should be referred to an ophthalmologist for evaluation and treatment including topical steroids, cycloplegic drops, and systemic immunomodulators

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