Lecture: Anterior Segment Pediatric Disease

This live webinar will discuss the etiology of common anterior segment findings in pediatric patients and review the treatment and management options considered for each diagnosis. Live questions will be answered at the end of the webinar.

Lecturer: Jenelle L. Mallios, OD, FAAO, Dipl of ABO, Associate Dean of Clinical Affairs, Associate Professor, Midwestern University | Chicago College of Optometry, USA


DR MALLIOS: Hello, everyone. My name is Dr. Jenelle Mallios. I am going to be giving you a lecture today on common anterior segment diseases in pediatric patients. I’m honored to be here and giving you this lecture today. A little bit about myself: I went to optometry school in Boston, at the New England College of Optometry. And after I finished my four years, I did a residency in pediatrics. And after my residency, I ended up working at a hospital in Boston called Tufts Medical Center. From there, I moved to New York, and I worked at the SUNY College of Optometry, teaching pediatrics. And also was the chief of the pediatrics department. After about four years there, I moved to Chicago. Which is where I’m currently living. And I am the associate dean of clinical affairs at the Chicago College of Optometry. A lot of sort of the practice that I’ve been doing over the years, as you can probably tell from the lecture, is pediatrics, special needs, and really focusing on primary care and the medical side of pediatrics. But I have also done plenty of binocular vision as well. But this lecture today is really focusing on the medical side. And so I’m excited to start. So let me go ahead and share my screen. I know you’re all seeing the Eiffel Tower at the moment. One second. Okay. So you should be able to see my screen. And like I mentioned, the title of today’s lecture is common pediatric anterior segment disorders and diseases. My email address is there if you need it. I have nothing to disclose. The objectives today are to understand the etiology of common anterior segment disorders, and understand the treatment and management or co-management options for these disorders and diseases. You know, what’s common here in the states that I’ve lived in might not be as common or might be more common in the areas that you all live in, around the world. So I guess “common” is a pretty relative term. But please feel free to ask me questions throughout the lecture. Here’s the outline of what we’ll be covering. In the eyelid, we’re gonna be discovering epiblepharon, lacrimal system, nasolacrimal duct obstruction, dacryocystoceles, lacrimal fistula, iris and pupil will be coloboma and aniridia, for infectious disease, herpes simplex and molluscum, and inflammatory disease, blepharokeratoconjunctivitis and vernal conjunctivitis. So let’s start with the eyelid. Like I mentioned, we’ll be discussing epiblepharon first. Epiblepharon is a variation of the eyelid. It’s congenital. You can see in this photo here there’s a horizontal fold of the skin. That stretches across the eyelid margin. So you can see that here. This sort of lower lid — there’s a horizontal fold. The lashes brush against the ocular surface, causing conjunctival and corneal irritation and erosion. So you’ll see it in other photos as well, but you can see that here — how it’s brushing along the cornea. The prevalence varies depending on, again, where you’re living. It’s very highly prevalent in East Asian populations. It’s also seen in some Hispanic populations. There was a prevalence study that showed about 20% of Japanese children that were one year of age had an epiblepharon. But at 12 years of age, only 2% of pediatric patients — of the same population — had the epiblepharon. So we know that as a child gets older, their anatomy changes, their face anatomy changes. Just the growth of the structures. While a patient might have had it when they were younger, and through adolescence, this might change as they get older. With regard to laterality, 90% of the time it’s bilateral, 75% of the time it would be the lower lids only, and 15% of the time it would be both the upper and the lower lids. So what are some of the symptoms that the patient might experience? Irritation or itchiness, discomfort, eye rubbing, persistent tearing, blurred vision, frequent blinking, pain. And what I didn’t mention but I probably should have is also nothing. Just last week, I had another patient who had an epiblepharon, and it was so minor in the sense that mild symptoms and signs — that they were completely asymptomatic. And it’s just something that we were looking for when we were doing our slit lamp examination. What are the signs that we’ll be looking for? Lashes contacting the ocular surface. Punctate keratopathy. 82% of the time. And this could induce astigmatism, depending on the severity. Which could cause amblyopia. Again, we’re noticing that the epiblepharon typically happens in the younger age group. And so depending on how severe it is, and their induced astigmatism, we should be watching for the amblyopia. One thing that I would suggest when you’re seeing a patient that could have an epiblepharon — again, this is just me thinking about the patient I had last week — you know, in primary gaze, they might not have any lashes contacting the cornea. But as you’re having them look from side to side during their slit lamp examination, specifically I would say nasally more than temporally, they might see that the lashes are scratching the cornea, just in a specific gaze. So even if it’s not in primary gaze, make sure that you’re looking at all the gazes, to see: How are the lashes contacting the cornea? Depending on where they’re looking. With that, additionally, we say here that punctate keratopathy happens 82% of the time. And while sometimes in severe cases of SPK we could see that without staining, I’m just going to stress the importance of staining in these patients. So sometimes the SPK or the punctate keratopathy might be so mild that you can’t see it unless you’re staining. And that’s exactly what happened in our case last week. And I think about this, because I work with students. And this is a really good learning experience for the students, because they hadn’t even considered this. All of a sudden we stained, and we could see mild SPK in the inferior cornea. So keep those things in mind when you’re seeing a patient who potentially might have an epiblepharon. So again, I mentioned that there’s a spectrum of the severity. Here you can see that it is a severe case. And 68% of the time, it is severe. So these patients would be more symptomatic. As you would expect. But know that there is a range of severity that we’re working with. One second. There we go. 24% of the time it will be moderate. In the severity. And you can see a photo here of what would be considered more moderate. And then we have the mild cases, which would be more like 7% of the time. Based on previous studies. So what are our treatment options for these patients? So the more conservative treatment — or I guess also depending on the severity, you can start with lubrication. So my patient last week, who had a really mild case, I just started them on artificial tears and I saw them a month later. If it is mild and there’s only one or two lashes that are affecting the cornea, you can always epilate the lashes, and that can help, obviously, in the mean time, to ensure there’s no increased severity in the punctate keratopathy. Also contact lenses are a really great option. When I’ve had patients who had more severe cases of epiblepharon and really had trichiasis, you can’t epilate all of their lashes, so using something like a soft contact lens for them, until their cornea heals, is a really great option. In the more severe cases, you might have to refer to an ophthalmologist for surgical modification of their eyelid. And this can really help, so that the lid will then be folded back, so that it’s not brushing along their corneas. So now we have our first poll question. Which is not a treatment for epiblepharon? Great. So antibiotic was something we discussed as a treatment option. As we mentioned, contact lens could be a really great option, artificial tears for lubrication, and surgical management in severe cases. So moving on to the lacrimal drainage system abnormalities… So I’m going to mention the acronym NLDO. It stands for nasolacrimal duct obstruction. That’s the first one we’re going to be discussing. And kind of back to back, I’m already gonna be asking a second poll question. So wherever you live, how do you typically treat nasolacrimal duct obstructions in your current practice? Do you tell your patients just to massage near the nasolacrimal sac? Do you prescribe an antibiotic the first time you see them? Do you send for probing immediately? Or do you tend to watch and wait and have them come back? Massaging near the nasolacrimal sac is 80% of the time. Antibiotic a couple of times, send for probing. And this is pretty, I think, typical of what I’ll be explaining over the next few slides. There’s really no wrong answer. It just depends on the timeline of the patient that you’re seeing. So just for a quick overview, again, of the anatomy, and the one thing I really want to make sure that you guys are seeing is: Right here, the valve of Hasner, you can see the bottom of the nose, so if we’re looking at a human person — that valve of Hasner is a really important aspect of what we’re gonna be discussing. Especially for the massages that will be the treatment for NLDOs. I circled it in this image here. So what are the NLDO signs and symptoms? You might see increased tearing. An increased tear lake at the bottom of the lid margin. Matting of the lashes. Overgrowth of bacteria in the nasolacrimal duct. So with that could cause mucous discharge, crusting on the lashes, reddening along the lid margin, and occasional conjunctivitis. What are the treatment options that we have? Compression or massage of the nasolacrimal sac. I think one of the biggest things that I’ve noticed in practice, or from hearing other patients who might get referred to me, is: How we’re describing the massage for the patient, in order to really help the obstruction. So it’s not that we’re just telling people to just do a little massage here in the corner. The really important part is that we’re rupturing that membrane obstruction at the valve. So remember, we mentioned that the valve is down here. And we want the sort of hydrostatic pressure that we’re creating to help rupture that membrane. Doing a little circle massage here isn’t gonna help. What’s really important is the downward fashion during the massage or while we’re educating our patients. The downward fashion is going to increase the pressure there to help rupture that membrane. So again, a circular massage in the corner of the puncta isn’t gonna be as beneficial as telling them to do that motion to rupture the membrane at the valve of Hasner. You want to tell them to do this for up to five minutes a day, two to four times a day if they can. Obviously with an infant, that can be really difficult. But the more they can do it, the better chance they have of having that rupture. Topical antibiotics, when discharge is present — so the topical antibiotic isn’t necessarily going to fix the NLDO. But it is gonna help those secondary symptoms that we discussed in the last slide. If there’s redness, matting, mucous discharge. So sometimes if I have a patient who is coming around 7 months of age and I’m not sending for probing, I have a prophylactic antibiotic on hand for the parent in case they see any injection. The parent likes to have that as a backup. Sometimes you can also have them come back if there’s any injection or mucus, so you can prescribe the antibiotic at that point. But also keeping in mind which antibiotics are safe in this age. Again, in the United States, something like erythromycin is a really good option for these patients, or maybe Polytrim. It depends on where you live and what’s available in the countries you’re all in. But that’s sort of my go-to in this age, since they are typically so young. For surgical management, probing and dilation — that can really be a successful option, especially through three years of age. However, probing can sometimes fail, and then they’ll have return of symptoms. If there’s a failed probing, that will typically happen within the six weeks of the procedure. So just keeping that in mind, if you are referring it. You can also do a stent insertion. So there’s a silicone tubing connecting the upper and the lower puncta. It’s called the Crawford stent. And that could be really beneficial, especially with craniofacial malformations or past trauma. So when would you refer for surgical management? First let’s talk about how often NLDOs or nasolacrimal duct obstructions resolve within six months of non-surgical management? So there was a study that was done that looked at around 100 infants. They had never had surgery prior, and they were prescribed six months of massage with antibiotics as needed. The resolution was absence of all signs and not having to go through surgery. And they saw that 66% of infants had resolved without surgical treatment. So two thirds of these patients did not need to go on to surgery. So I would say that even based on this, having that initial management just be through you as the provider, not having to go into surgery, I think is a really great option, since two thirds of the time the patient will resolve at that point, not needing to go through any extra additional surgical management. With that being said, there are times that the patient still might need it. It really depends on the ophthalmologist that you’re working with. Some ophthalmologists really won’t do an NLDO dilation and probing, until they’re maybe at least 12 months of age. Or 18 months of age. So that’s always something to discuss with the local doctor that you are working with. So what are some of the NLDO surgical philosophies? There is this philosophy about early probing. Some people do prefer it. I haven’t seen that really with any of the doctors I’ve worked with. But there’s this idea where you could do this in office. It avoids general anesthesia, and it decreases the duration of the symptoms. More often than not, it’s late probing. So greater than 1 year of age. It does allow for that greater spontaneous resolution that we discussed. Again, two thirds of the patients will find that there’s resolution. Sometimes, again, even spontaneously, without that massage. Fewer children needing probing with general anesthesia. Again, most surgeons would prefer doing probing with anesthesia, which is why they would prefer to wait until the child’s a little bit older. And I know I mentioned failed probing beforehand. But this usually would occur within the first six weeks of the procedure. You’ll see the return of crusting and epiphora. And success rates for repeat procedures — 56% for repeat probing, 77% with balloon catheter dilation and 84% with nasolacrimal duct intubation. I think I’ve answered some of these questions. I’m looking at the Q and A. At what age do we stop probing? Like I mentioned, typically around 3 years of age is when we’re the most successful. But you would probably be able to — you would be managing it sooner, because these patients would be coming in to you for sure prior to that anyway. So what are some things that we want to be keeping in mind as differentials? Dacryoceles or dacryocystoceles would be some differentials to keep in mind. Also congenital glaucoma. I put those in the red box, because those are probably two of the bigger ones to make sure you’re ruling out. And why congenital glaucoma? Well, when you see epiphora, especially in an infant, you want to make sure that you are differentiating between congenital glaucoma and NLDO. However, with congenital glaucoma, those patients will have associated pain, photophobia, corneal opacities, megalocornea. So there are differentiating factors between those two. But you just want to make sure that you’re ruling that out. We’re gonna talk about dacryocystoceles in a moment. Entropion, ectropion, even epiblepharon, like we mentioned in the previous slides, could cause there to be an increase in light sensitivity. If there’s corneal involvement or even epiphora. So just mentioning some of the differentials to keep in mind. And next we’re gonna talk about congenital lacrimal fistulas. So there is a tract extending from the canaliculus or the lacrimal sac to the overlying skin surface. And what will happen is that you’ll see discharges associated with nasolacrimal duct obstruction, but it might cease after the lower drainage system becomes patent. And there’s gonna be a photo of it in the next slide. It’s a little bit more obvious of what we’re talking about with this tract. So you can see that in this photo here. This is where it sort of came out through the skin. As opposed to the typical drainage system. So what are signs and symptoms of a congenital lacrimal fistula? There would be a small dimple, medial to the eye. It would be inferonasal to the medial canthus. It’s typically unilateral. Again, you might see epiphora. You also might see mucous discharge through this opening. The incidence is about 1 in 2,000. And you might see it more often in patients who have Down syndrome or CHARGE syndrome. CHARGE syndrome — actually, we’re gonna be discussing it in a little bit when we start talking about coloboma as well. The diagnosis — you would have this diagnosis clinically, obviously, on observation through slit lamp. You may be able to do a dacryoendoscopy or a CT scan. The treatment, if they’re asymptomatic, you don’t need to do anything, which is really nice. If they are symptomatic, you could do probing. As you would do for an NLDO, or surgical excision. They would do a fistulectomy and a dacryocystorhinostomy, when you see persistence of discharge despite adequate drainage. If they’re not complaining, if there’s no discharge, you can just leave it. A dacryocystocele or dacryocele, this is what we’re gonna be discussing next. So a dacryocystocele is distension of the lacrimal sac with distal blockage. Mucoceles will form within the lacrimal sac as a consequence of a congenital NLDO. And in the lacrimal sac we have goblet cells, which is why these mucoceles are forming. And then you will see an associated cyst due to this distension. What are the clinical features? It’s present at birth or soon after. They can do an ultrasound to also — through ultrasound, they may even be able to tell if the child will have a dacryocystocele. Bluish swelling inferior and nasal to the medial canthus. It almost looks like a really large bruise, but you can also see there’s elevation. Typically unilateral. And some of the differential diagnoses would be hemangioma, dermoid cyst, or encephalocele. Initially sterile. So it may respond to an antibiotic or massage. But… If it doesn’t within the first week or if you’re noticing an infection, it’s really best to send for a consult. So again prophylactically, antibiotic, massage. But really, these patients will need to do a consultation with pediatric ophthalmologists or oculoplastics. They’ll do a decompression with digital massage and then antibiotic. They may need to do a nasolacrimal probing with endoscopy for cyst removal. If you’re seeing that it is bilateral, that’s gonna be considered more urgent. So just refer accordingly. So moving on to congenital anomalies of the iris and the pupil. First we’re gonna discuss iris coloboma. So we know coloboma refers to the malformations that result from the failure of closure of the optic fissure. We can have different types of colobomas. Chorioretinal coloboma, which would be the retina and the choroid, which is what we’re seeing more in this photo, or iris, uveal coloboma, which is keyhole shaped, which is more applicable to this lecture, since we’re doing anterior segment disorders. But you really can have a coloboma anywhere. Macula, eyelid, lens, optic nerve. So again, from an embryology standpoint, like I mentioned, it’s when the choroidal fissure fails to close. It depends on whether it’s the top or the bottom of the fissure. If it’s the top, it would be anterior, versus posterior coloboma. This tends to happen around the 5th to 7th week of pregnancy. So what we typically see is that it’s in the inferonasal quadrant. So just based on how that fissure closes, the last part would be the inferonasal quadrant. So this is why the colobomas that we see tend to be inferonasal. It typically can be involved with other parts of the eye, like I mentioned. Anywhere from the choroid, retina, macula, iris, et cetera. What’s more atypical is if it’s in another area besides the inferonasal quadrant. Or if it’s not associated with a posterior coloboma. One second. So there was a study that looked at the incidence, ocular findings, and systemic associations with ocular coloboma. And they saw that 36% of the time it was anterior, 40% posterior, 24% both. 58%, around 60%, had additional ocular disorders. And you can see here that what’s also interesting is that we may also see amblyopia or strabismus in patients who have colobomas as well. So you can see out of all of the patients 10 to 11 had some form of — 11 had amblyopia. And 10 had strabismus. Around 70% had non-ocular diagnoses as well. And that could include something like CHARGE syndrome, which we’re gonna talk about more in just a moment. So we have to think about what other associations the patient might have if we do find that they have a coloboma, and making sure that we’re testing for any additional syndromes, for example, like CHARGE syndrome, because we’re seeing this initial diagnosis of a coloboma. I’m sorry this showed up so small. This did not look like this when I was doing the study — when I wrote the PowerPoint originally. Let me read this for you, since that is so tiny. So here’s where I’m describing what CHARGE syndrome is. So CHARGE is just an acronym for — the C stands for coloboma. The H is for heart anomaly. The A is for atresia of the choanae, a narrow blockage of the nasal package. This is nasal related. R stands for retardations, G for genital anomalies, and E for ear or hearing abnormalities. So the C stands for coloboma. So one thing we want to rule out is if the patient does perhaps have CHARGE syndrome, but they would have other associated signs, again, that are the ones I just mentioned. A lot of these patients, if they do have CHARGE syndrome, tend to be visually and hearing impaired, since those are both associated with CHARGE. So just keeping that in mind when you have a patient who has coloboma. You’re ruling out any other genetic conditions. Some of the other ones that are listed here, that are obviously still too small to see, are cat eye syndrome, kabuki syndrome, Goldenhar syndrome, so there are other syndromes associated with colobomas. And we mentioned there are other ocular conditions to keep in mind. I pointed out amblyopia and strabismus. There’s also heterochromia, microphthalmia, cataracts, glaucoma, nystagmus, and staphylomas. So how do we treat these patients? It really depends on where the coloboma is. So if you have a patient who again for this study… Or this lecture we’re talking about anterior segment disorders… We’re gonna think that they’re gonna have a lot of light sensitivity. So for light sensitivity, we can always do a tinted contact lens, or surgery for the iris coloboma, if there’s amblyopia, we’re gonna treat the amblyopia. Obviously we want to still prescribe glasses for any refractive error, potentially you could put a tint in their glasses, if they have that extra light sensitivity. If there’s issues with retinal colobomas, then you’re gonna again treat accordingly, depending on where the coloboma is. So we’re on to question three. In which quadrant do we expect to see a coloboma? Inferotemporal, nasal, superotemporal, or superonasal? So just based on, again, embryology, and how the choroidal fissure is closing, we would typically tend to see these inferonasally. Now on to aniridia. Aniridia is a genetic disorder with variable degrees of hypoplasia and absence of the iris associated with other ocular features. There’s really no gender or ethnic predilection. Some features are present at birth and others may arise progressively over time. This can really affect the cornea, iris, lens, angle, ciliary body, optic nerve, macula, retina, pretty much the entire eye. So I’ll be discussing different parts of how this will really affect the patient and how to treat them. So for iris hypoplasia, we will see visual acuity reduction, photophobia, and of course, there are aesthetic concerns as well. There’s almost always some tissue remaining. And when there’s a mild case, you will still see iris is present, but there will be transillumination defects. In severe cases, you really might not see as much of the tissue. You would have to do gonio or B scan to see what part of the structures are still visible. There may be a coloboma-like lesion, eccentric pupil, again, depending on how the aniridia’s severity is, and how much tissue is remaining. So what are some of the treatments for an iris when you’re seeing the aniridia? It’s sort of similar in some ways to what we mentioned with the coloboma. But again, it could be more severe in these cases. So you might want to use colored contact lenses. However, sometimes the patient might not be able to tolerate a colored contact lens. Just because their cornea is a little bit more sensitive. There’s also this idea of corneal tattooing. Again, that can be complicated, because of the keratopathy that these patients already have. You may be able to do an artificial iris device. And that can improve visual acuity, reduces photophobia, decreases nystagmus. And you can even add an IOL to the back of it. But the complication here is that you’re still doing something surgical. So with any surgery, there are complications. But this can be a really great help to the patients who have aniridia. And then endocapsular ring. So there would be a smaller incision with these rings. And you need to have an intact capsule in order to do an endocapsular ring. So I mentioned keratopathy a couple of times, because I mentioned how sometimes a colored contact lens might not be the best option. But it is still an option depending on the patient. And that’s because there’s an aniridia associated keratopathy, or AAK. So there’s ocular surface changes in about 90% of the patients who have aniridia. And that’s because there’s a deficiency in the corneal limbal stem cells. And so when there’s this deficiency in the corneal limbal stem cells, there’s an irregular thickening and neovascularization of the peripheral cornea. Which may progress to involve the central cornea. And so some of the signs that you might notice in these patients that have AAK are recurrent corneal erosions, ulcers, subepithelial fibrosis, increased central corneal thickness, neovascularization, so you can just tell that these patients have — again, the severity, the degree can change depending on the patient, but you’re gonna see that the corneas are not as healthy, due to all of these complications. So what are the symptoms that you would note? Dry eye, red eye, photophobia, epiphora. So you can see why adding a soft contact lens on top of this sort of cornea is not gonna be the most beneficial. Especially if they are colored contact lenses, and depending on the DK of the lens. So what are some treatments for AAK? Again, it’s based on severity. Amount or frequency of the ulcers that they’re seeing. Erosions. Presence of epiphora, redness, or photophobia. When it’s just mild, you can do preservative-free artificial tears. You might need to do dark glasses, or if they’re having light sensitivity, or topical antibiotics. For moderate AAK, you can do autologous serum eye drops, and for severe cases, you may need to refer for limbal stem cell therapy or artificial corneal prosthesis implants. I’m trying to manage the Q and A. So give me one second. I want to make sure if there is anything directly related to this topic. Okay. I’ll try to answer some of these at the end as well. Okay. So with aniridia, there are other, again, complications, like glaucoma. 50% have this risk of development. Usually in the first two decades. It is where there is this progressive angle change in the first two decades, which is what is causing there to be this glaucoma. And we have this abnormal development of the anterior chamber and angle. How would we treat the glaucoma? Miotics, oral CAIs, there are some surgical managements as well. Just like any other juvenile congenital glaucoma. The way we treat these glaucomas in these kids is gonna be a little bit more seemingly aggressive than it would be for an adult. For the lens, there may be a cataract in 50% to 85% of the patients. Mostly adolescents and young adults. Polar cataracts are the most common. The lens capsule is very fragile in these patients. And subluxation or positional changes may occur. What is the treatment? A cataract extraction may be recommended, with or without the IOL. Or an artificial iris device, as mentioned earlier. For the optic nerve, we can have hypoplasia, it may be difficult to assess if they have nystagmus, keratopathy, or cataracts. And then the retina, macular/foveal hypoplasia, general retinal dysfunction, because there may be so much sunlight coming in it can damage the retina, and higher probability of retinal tears. I’m not gonna focus on this, since this is an anterior segment lecture, but for completion, I wanted to include that in this section. There are a lot of differential diagnoses for anything that has sort of an anterior segment condition, like aniridia. So we have Rieger’s, Peters anomaly, iris coloboma, like we just mentioned, albinism, and for nystagmus or reduced visual acuities with iris abnormalities, there’s retinal dysplasias, congenital cataracts, lots of things that can cause nystagmus with reduced visual acuities and iris abnormalities as well. So moving on to infectious diseases, first I’m gonna talk about herpes simplex virus. So herpes simplex virus can have different triggers. And 30% of the time, it could be just stress, fever, menstruation, extremes in temperature, sunlight exposure, and sometimes we don’t think about pediatric patients having stress, but they do. You know? This is something that’s actually really common. Well, herpes simplex isn’t very common, but stress is very common in kids these days, and sometimes we forget that they also have stress in their lives. So again, if they have a fever, that could be a trigger. If they’re menstruating, in young females, depending on where you’re living, there might be extremes in temperature. What are some of the systemic effects? It can affect the lungs, liver, adrenal glands, and central nervous system. What is the ocular presentation? It’s mostly unilateral. 90% plus of the time it would be unilateral. You might see a conjunctivitis with edema and vesicles, you might see a uveitis, again, the keratitis, we might see epithelial, interstitial, disciform, neurotrophic, but one thing to keep in mind is children are more likely to have inflammation and stromal keratitis, as opposed to the classic dendrites you might see in adults. You might not see the typical presentation in these kids. It still would be herpes simplex. A lot of times we have an idea of what a disease is supposed to look like, but in pediatric patients, it’s not always the same. So please keep that in mind. Especially because herpes simplex is often misdiagnosed in adults, but also in pediatric patients. We also may have decreased corneal sensitivity. In, again, about two thirds of the time. There’s a study that looked at… Just looking at pediatric herpes simplex, and the recurrence rate was about 45%, and it was independent of age, type of keratitis, or gender. So you’re gonna want to look at these patients or hold on to these patients a little bit more closely, to make sure there’s no recurrence. 60% of the time, there’s residual central corneal opacity. And then 70% of the time, there’s this induced astigmatism of greater than 2 diopters. As we know, depending on if it’s unilateral — that could definitely be amblyogenic, anisometropic amblyogenic. So keep that in mind as you’re treating these children. So what are some of the treatments that we have? There’s oral versus topical, you might want to co-manage these patients, and then visual rehabilitation, depending on what the sequelae have been, if there’s a scarred cornea, for example. Do they have amblyopia, do they need contact lenses or glasses, so all of the treatment options, depending on what you’re seeing during your exam. For oral acyclovir, again, this is really more based in the United States. I’m not as familiar with what’s available around the world, where all of you guys are currently working. But you want to be able to prescribe, based on the weight of the child, so you might have to adjust your dose accordingly, as the child is growing, for any oral medication. We do have Zirgan and Viroptic for patients who have… For herpes as well. So again, if this is available for you, Zirgan gel is great, because it’s fewer times during the day. Five times a day, versus a drop that’s nine times a day is really preferred in a child. And you can use it in two years of age and older. Versus Viroptic is really for six years of age and older. Recurrence is more common in children than adults. So you might even need to be doing treatments prophylactically. And so what would you change prophylactically, versus during treatment? And here there is this indication of treatment three times a day, versus prophylactically, which would be twice a day. And so that’s really the difference that you would be prescribing for these patients. So now we’re gonna be moving on to molluscum. It’s a common skin condition that affects primarily children. We typically see the highest incidences between the ages of 1 and 4 years of age. It’s a pox virus. So this is a virus. It’s an asymptomatic lesion on the skin. It occasionally can cause pruritus, erythema, inflammation, and pain. So what does it look like on clinical presentation? We’re gonna see these firm small papular lesions, with an umbilicated center. It’s really flesh colored, you can see that dome shape. And it has this pearly presentation as well. You might see redness around the area. And it can occur anywhere on the body. It may be even more common in immunocompromised patients, but pediatric patients as well. What are some of the risk factors? Swimming or atopic dermatitis, such as eczema. What is the treatment? So resolved within two years without treatment. On average, it can take eight months for it to resolve. I think that’s an important thing to tell parents, just so they have expectations of the condition. If a patient has come and they’re telling us that they’ve had this for six months and they’re really concerned, well, you can tell them that it might take up to two years, and on average, it’s eight months. And I think because these can spread fairly easily, you want to make sure that that education is made. Parents are often uncomfortable with management. Right? Because they want to do something. They’re seeing these papules all over their child’s body and face. And they don’t want to do nothing. But that’s kind of — with a virus, we can’t really do much. If there’s a viral conjunctivitis, again, treating the viral conjunctivitis as you normally would. You want to try to keep the lesions covered, to avoid spreading. If there’s other family members in the household, make sure that they’re not sharing their clothing or linens with their siblings. Or any other fomites. So maybe if they have a stuffed animal that they love to play with, and it’s all over their face, and that’s where you’re seeing the molluscum, they’re not sharing those toys with their little brother or sister. Avoid behavior that could open the lesions. Trying to have the child not scratch, no shaving or electrolysis. We don’t want anything that can really expose this. There may be surgical management, but again, that’s not as common. Since this does resolve on its own within two years. So now we’re gonna be moving on to the inflammatory diseases and conditions. First we’re gonna be talking about blepharokeratoconjunctivitis. And just because that is a really long word, I’m just gonna be saying BKC. In reference to blepharokeratoconjunctivitis. So first we have this paper that discussed really all the different areas of etiology and epidemiology for BKC in children. It’s a chronic inflammatory condition of the eyelid margin, and there are secondary conjunctival and corneal involvements. So we have — it’s blepharokeratoconjunctivitis. So it does involve the lid, the kerato being the cornea, conjunctivitis the conjunctiva as well. So it’s affecting all the different parts. It’s not just blepharitis. So the epidemiology is 15% of the US pediatric population. But I would actually say that it’s probably higher. It’s just a lot of people don’t know to look for it. The average age of onset is around 7 years of age. But I’ve seen it in as young as two years of age. So there is really a large spectrum here. And the disease is also — just like any other disease — there’s a range of severity. So 70% of the time, it’s mild. Moderate in 25% of the cases, and severe in 4% of the cases. But however… I think the one thing to mention too is that this disease can worsen if it’s left untreated. Especially because it does involve the cornea. And there can be corneal scarring, ulcers, et cetera. So what are some of the signs and symptoms? So the symptoms would be really chronic ocular discomfort, eye rubbing, burning, itching, redness, tearing. You may have reduced vision. And photophobia. If the patient has reduced vision and photophobia, that leads you to believe that there’s more corneal involvement. You typically would see this bilateral. So if you have — a lot of these symptoms sound like some of the other diseases that we discussed. It does sound like herpes, for example. So what’s one of the differences that we discussed with herpes versus BKC? Herpes tends to be unilateral. So if you’re having a patient with reduced vision, photophobia unilaterally, maybe you’re thinking more herpes simplex, versus someone who has this bilaterally. Then you might think BKC. So what are some of the signs that we’re gonna see? Inflamed eyelids. Lid margin telangiectasias, collarettes, meibomian gland inspissation, you might see hordeola, chalazia, keratitis, and scurf. When I have a patient with blepharitis, I do tend to stain the cornea, because blepharitis is very, very common to have with BKC. So you really are looking to see if there’s corneal involvement. Or if you have a patient — any time I have a child who has hordeola or especially if they’re frequent — but even if not, I like to stain the cornea to make sure: Is there corneal involvement? Because sometimes you won’t know unless you’re staining the cornea. And this is a point that I’m gonna be sort of beating down, because I do think it’s really important. And like I said, I think this is underdiagnosed. You can see it’s bolded. First line. Stain the cornea! It’s really important. Because you won’t know what the corneal involvement is a lot of the time if you don’t stain. Superficial punctate keratitis. You might see it — if it’s inferior only, you might want to make sure it’s not from lagophthalmos. There are other things that can cause SPK in a child. Epiblepharon, trichiasis, lagophthalmos. But you’re looking for associated signs as well. If there’s really bad blepharitis and corneal involvement, you might be thinking it’s really more BKC. In severe cases you might have corneal ulcers and neovascularization. So what is the treatment and management? You’re really gonna do it depending on the severity. So if you have anterior blepharitis, you’re gonna discuss lid hygiene. And what does lid hygiene mean? You can use something like the wipes that exist. Or you can do just baby shampoo, diluted with water. And having them scrub the lids maybe morning and night. Or every time they take a shower or bath, depending on… Again… The severity of what you’re seeing. Posterior blepharitis or hordeola — warm compress, you might want to do a systemic antibiotic, especially if the child is a little bit older. One of my favorite things — again, I have no financial disclosures — we have here what’s called the Bruder mask. It’s a mask that sort of has beads in it already. And it comes bilateral or it comes unilateral. And I really love the unilateral Bruder mask, because — one, it also velcros around their head. And you can heat this… I think it takes 10 seconds to heat it up, and it stays warm for five to ten minutes, which is what you want. Extended heat. And because it’s unilateral, the child can still do other things. Because typically, when there’s a mask that has both — blocks both of their eyes, the child won’t sit with it on for more than two minutes. They want to be able to do other things. So the unilateral ones are really nice, because they can still play video games or read a book or play outside. Being able to be functional still. While being able to treat the hordeola or chalazia. So that’s a personal favorite of mine. The patients do report that it’s significantly easier to use. And also really great results from treatment. Chalazia — warm compresses. You may have to consult if it’s a really large chalazion or not improving. Superficial keratitis, especially if it’s pretty mild, I’ll start with lubrication and topical steroids. If needed. That’s a little later. If there’s a lagophthalmos, you might need to use an ointment as well, especially in the evenings. That’s usually only when I’ll do an ointment for pediatric patients, especially with the lagophthalmos. And of course, if there’s an ulcer, you’re gonna treat accordingly as well. There are some ideas that adjunctive therapies like flaxseed oil or Omega-3 can be really helpful with this lid disease as well. So that brings us to… Our next question. How frequently do you all see BKC in your practice? Okay. So… 25% of you see it very often. Around 50%, 60% of you sometimes see it. Never — or maybe you just learned about it a little bit more and are gonna start looking for it more often. There’s nothing wrong with that. One question was: What type of wipes do I use for BKC? Here we have OCuSOFT, and that is just something specific that we have for blepharitis, that is over the counter. Something similar — and again, in whatever countries you guys are working in — would be just as beneficial. They might be a little bit pricey. At least here in the United States. So that’s why I also give… But they’re so much easier to use, which is why parents like it. You just open it up and swipe it around the lids. But using something like… Baby shampoo, or something that’s really sensitive for the eyes, and diluting it with water, and then taking a clean washcloth and scrubbing the lids as well is also a really good option. Another question is: What is scurf? So scurf is sort of similar to, like, blepharitis, I guess, it’s gonna probably be the easiest way to describe it. So when you’re seeing really any accumulated material along the lashes, you can think of that as scurf. So now we’re moving on to vernal. And I feel like this is a really popular topic, because when I saw the list of questions ahead of time, VKC was one of the more popular questions that had come up. So what is VKC or vernal keratoconjunctivitis? I’ll be saying VKC again just because it’s shorter and faster to say. We tend to see this more often in males. It’s three times more likely to happen in males than females. We typically see this in younger children. So before age ten. It’s common and often more severe cases happen in hot environments. Maybe along the equator, Mediterranean, and those areas. 23% of these patients may be symptomatic all year round. We do see recurrence in more than 50% of the patients. And one third of these patients who have VKC have atopy. So they might have another version of some sort of allergic reaction. Maybe atopic dermatitis, allergic rhinitis. That’s when they have a runny nose. Or asthma. So here’s a few studies, again, to look at, if you have more questions. So what are some of the signs and symptoms? Some of the symptoms include itching, watering, redness, foreign body sensation, and photophobia. The signs that we see are giant papillae, especially on the upper tarsal, so these patients — you would have to flip the upper lid in order to see what the upper tarsal looks like, to see these giant papillae. They’re typically more than 1 millimeter in diameter. You will see these Horner-Trantas dots. They’re right here. You can see that on the superior limbus. You’ll see injection or redness, keratitis, you may see shield ulcer. So there is a range of signs that you will see. These patients are just really uncomfortable. And so giving them appropriate treatment is really important. So that could be anything like daily hygiene, limiting their contact with known allergens, if they have a specific allergen that they know about, during allergy season — this is really in more mild cases — but during allergy season, especially here in the United States, I’ll tell the patients, keeping in mind if they’re outside all day, you want to try to make sure that you’re giving the child a bath at nighttime, so that when they’re going to bed, all of the allergens in their hair doesn’t go on their pillowcase and their bed. And they typically will wake up with puffier lids. Or maybe you’re using artificial tears more often to remove the allergen. So things like that, that are just really daily things that can help minimize these signs and symptoms. Like I said, artificial tears or cool compresses. Steroids. When patients really have — especially the giant papillae on the upper tarsal or the Horner-Trantas dots and it’s really severe, don’t be afraid to give steroid in these patients. Especially steroid that’s a little bit stronger. Maybe it’s not necessarily FDA approved for the age group. So I tend to use prednisolone. Again, even though it’s not something that is approved for this age. But it works. If you’re gonna start them on something really soft, like a soft steroid, and it’s going to take them longer, it’s probably not gonna work in the beginning, and then it’ll just take longer for them to have those improved symptoms. So you can just hit it hard from the beginning. You might want to supplement it with an allergy medication. Maybe you’ve already prescribed them a twice a day Patanol or Pataday, whatever you guys have, and also have them on the steroid. You don’t want to be on the steroid longstanding. There are a lot of side effects to steroids that we have to keep in mind. But at least to minimize those symptoms initially. So then once you are tapering the steroid, then you can have them on another allergy medication long-term. Another medication like a steroid that you can use is loteprednol. There typically tends to be fewer side effects from an intraocular pressure standpoint. But one thing to keep in mind any time you have a patient on a steroid, a pediatric patient on a steroid, is again, the IOP effects. Just because they’re kids it doesn’t mean that they won’t have the increased risk for high IOPs. And just in general, keeping a child on a steroid for a long time or any patient on a steroid for a long time, the side effects of glaucoma, cataracts, those are the types of things that you’re still gonna want to monitor in these patients. And I’ve had instances when I’ve seen patients — and I’ve started them on a steroid. I might be tapering it over a month period. But they also have an IOP increase, so then I have to add a glaucoma medication to their treatment. In order to decrease their pressure. So you might have to add these types of medications in order to treat the patient entirely. But that’s okay. I mean, again, you’re not hoping to keep the patient on the steroid for a really extended period of time. Knowing what their triggering factors are is going to be important too. Or also — like, I have patients who I just know every spring, it’s gonna hit. So maybe we start them on the steroid ahead of time. Knowing that this is going to hit. And then they’re on supplemental medication as well. Most of the medications are palliative and don’t eliminate the complex immune response. Which is why it recurs. So again, you’re sort of treating it as it comes to you. You’re not treating it for the long run. So you might have to refer to an immunologist or someone… Another provider as well. To be able to treat any other — especially if they have severe allergic reactions. So that was my entire lecture! Thank you so much. Let me see. Okay. Thank you, everyone. If you had any questions that I didn’t get to answer, please feel free to email me at the email address that is indicated on your screen. I’m happy to answer them. And I just really appreciated being able to lecture to everyone. So thank you so much.

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March 12, 2021

Last Updated: October 31, 2022

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