Pediatric Clinical Practice Guidelines for Nurses in Primary Care

Chapter 8 - The Eyes

Assessment of The Eyes

• History of Present Illness and Review of System
• Physical Examination

Common Problems of the Eye

• Red Eye
• Conjunctivitis
• Allergic Conjunctivitis
• Ophthalmia Neonatorum
• Nasolacrimal Duct Obstruction (Dacryostenosis)
• Strabismus (Squinting)
• Hordeolum or Stye
• Chalazion

Emergency Problems of the Eye

• Orbital Cellulitis
• Periorbital Cellulitis (Preseptal)
• Corneal Abrasion
• Conjunctival, Corneal or Intraocular Foreign Bodies
• Acute Angle-Closure Glaucoma
• Chemical Burns
• Blunt or Lacerating Ocular Trauma
• Uveitis (Iritis)

For more information on the history and physical examination of the eyes in older children and adolescents, see chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

• For many ocular diseases and conditions, clinical presentation and management are the same in adults and children. For information on the following conditions, see chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).
• Allergic conjunctivitis
• Hordeolum or stye
• Chalazion
• Corneal abrasion
• Conjunctival, corneal or intraocular foreign bodies
• Acute angle-closure glaucoma
• Chemical burns
• Blunt or lacerating ocular trauma
• Uveitis (iritis)

Assessment of The Eyes

History of Present Illness and Review of System

General

The following characteristics of each symptom should be elicited and explored:

Onset (sudden or gradual)

• Chronology
• Current situation (improving or deteriorating)
• Location
• Radiation
• Quality
• Timing (frequency, duration)
• Severity
• Precipitating and aggravating factors
• Relieving factors
• Associated symptoms
• Effects on daily activities
• Previous diagnosis of similar episodes
• Previous treatments
• Efficacy of previous treatments

Cardinal Symptoms

In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited as follows.

Vision

• Recent changes
• Blurring
• Corrective measures (glasses, contact lenses)

Other Associated Symptoms

• Pain
• Irritation
• Foreign-body sensation
• Photophobia
• Diplopia
• Lacrimation
• Itching
• Discharge
• Ear pain
• Nasal discharge
• Sore throat
• Cough
• Nausea or vomiting

Medical History (Specific to Eyes)

• Eye diseases or injuries
• Eye surgery
• Use of corrective eyeglasses or contact lenses
• Concurrent URTI
• Immunocompromise from other illness or medications
• Environmental exposure to eye irritants
• Systemic inflammatory disease (e.g., juvenile rheumatoid arthritis)
• Diabetes mellitus
• Chronic renal disease
• Bleeding disorders
• Allergies (especially seasonal)
• Current medications

Personal and Social History (Specific to Eyes)

• Concerns reported by parent, caregiver or teacher about child's vision (e.g., squinting, headaches caused by reading)
• Use of protective eyewearfor sports and other activities
• Housing and sanitation conditions
• School or daycare exposureto eye infection

Physical Examination

Eye

Examine the bony orbit, lids, lacrimal apparatus, conjunctiva, sclera, cornea, iris, pupil, lens and fundi. Note the following:

• Visual acuity (which is decreased in keratitis, uveitis and acute glaucoma)
• Swelling
• Discharge or crusting
• Discoloration (erythema, bruising or hemorrhage)
• Position and alignment of eyes (e.g., strabismus): use corneal light reflex test, cover-uncover test
• Reaction of pupil to light
• Extraocular movements (which are associated with pain in uveitis)
• Visual field (test in older children if there is concern about glaucoma)
• Corneal clarity, abrasions and lacerations
• Lens opacities (cataracts)
• Red reflex (which is abnormal if there is retinal detachment, glaucoma or cataract)
• Hemorrhage or exudate
• Optic disk and retinal vasculature

Palpate the bony orbit, eyebrows, lacrimal apparatus and pre-auricular lymph nodes for tenderness, swelling or masses.

Apply fluorescein stain to test for corneal integrity (if there is a possibility that trauma has occurred).

An ENT examination, including the lymph nodes of the head and neck, should also be performed if there are symptoms of a systemic condition, such as viral URTI

Common Problems of the Eye

Red Eye

Definition

Inflammation in and around the structures of the eye.

Causes

There are numerous causes of red eye in children (Table 8-1).

Note: +, present (to various degrees); --, absent; +/--, may be present.
*Hyperthyroidism may cause conjunctival injection.

History

• An accurate history is very important
• History may point to a systemic illness such as juvenile rheumatoid arthritis or the possibility of trauma
• Ask about preceding viral URTI (which would indicate infectious conjunctivitis)
• Ask the child (if of an appropriate age) about visual acuity, pain on movement of the eye and contact with chemical agents or makeup (the last of which might indicate allergic conjunctivitis)
• For newborns, inquire about exposure to silver nitrate or the possibility of maternally acquired infections such as gonorrhea

Physical Findings

• Assess both eyes for symmetry
• Carefully document any evidence of external trauma
• Assess visual acuity and pupillary reaction, essential for measuring improvement or deterioration
• Examine the anterior segment of the globe with a small penlight, and use a fluorescent stain to assess for corneal abrasion or ulcers
• Assess ocular mobility by checking range of movement

Features of Dangerous Red Eye

The first step is to differentiate major or serious causes of red eye from minor causes. The following danger signs call for urgent consultation and/or referral to a physician.

• Severe ocular pain, especially if unilateral
• Photophobia
• Persistent blurring of vision
• Exophthalmos (proptosis)
• Reduction of ocular movements
• Ciliary flush
• Irregular corneal reflection of light
• Corneal epithelial defect or opacity
• Pupil unreactive to direct light
• Worsening of signs after 3 days of pharmacologic treatment for conjunctivitis
• Immunocompromise (e.g., neonate, immunosuppression)

Differential Diagnosis

See Fig. 8-1.

• Ophthalmia neonatorum
• Conjunctivitis (bacterial, viral or allergic)
• Traumatic injury (e.g., corneal abrasion)
• Foreign body
• Glaucoma
• Uveitis (iritis)
• Periorbital or orbital cellulitis

Management

Some of the diseases (e.g., ophthalmia neonatorum) associated with red eye are covered in detail elsewhere in this chapter. See table of contents of the chapter for topic headings.

Referral

When in doubt about the diagnosis or if there is significant associated ocular trauma or decreased visual acuity, urgent consultation with and referral to a physician is indicated.

For more details about the causes, assessment and management of conditions associated with red eye, see "Red Eye," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Conjunctivitis

Definition

Inflammation of the conjunctival membrane of the eye. This is one of the most common causes of red eye in children.

Causes

Viral or bacterial conjunctivitis is common in children.

The allergic form is more common in adolescents. See "Conjunctivitis" (allergic type), in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Bacterial Pathogens

• Chlamydia
• Hemophilus influenzae (non-typable)
• Neisseria gonorrhoeae
• Staphylococcus aureus
• Streptococcus pneumoniae
• In an adolescent, gonococcal or chlamydial infection should be considered if the history is supportive of this diagnosis and the adolescent is sexually active

Viral Pathogens

• Adenovirus
• Enterovirus
• Epstein-Barr virus and herpes zoster virus (less common)
• Measles and rubella viruses

History

• Eye red and itchy
• Discharge or sticky eye common upon waking in the morning
• Sensation like that of sand in the eye
• Commonly, a viral URTI has preceded the eye infection
• Complicating bacterial infections, such as otitis media, may be evident
• Perform a general assessment if the child appears systemically ill (e.g., fever)

Children with mild viral or superficial bacterial conjunctivitis do not usually have significant systemic symptoms.

Physical Findings

• Assess both eyes for symmetry
• Carefully document all evidence of external trauma
• Assess visual acuity and pupillary reaction, essential for measuring improvement or deterioration--both should be normal
• Examine the anterior segment of the globe with a small penlight, and use a fluorescent stain to assess for corneal abrasion or ulcers if history or physical findings suggest corneal abrasion
• Assess ocular mobility by checking range of movemen
• Check for reddened conjunctiva(unilateral or bilateral
• Check for discharge (purulent, watery, milky), which is usually presen
• Check for white granules (phlyctenules) on the edge of the cornea surrounded by erythem

Differential Diagnosis

• Infectious conjunctivitis
• Trauma
• Foreign body
• Allergic conjunctivitis
• Keratitis
• Glaucoma
• Uveitis (iritis)
• Periorbital or orbital cellulitis
• Measles-associated conjunctivitis

Complications

• Spread of infection to other eye structures
• Spread of infection to others

Diagnostic Tests

• Measure visual acuity if >3 years old
• Swab any drainage for culture and sensitivity

Management

Goals of Treatment

• Relieve symptoms
• Rule out more serious infections (e.g., uveitis)
• Prevent complications
• Prevent spread of infection to other

Appropriate Consultation

Consult a physician if any of the following occur:

• Significant associated eye pain
• Any deficit in visual acuity or color vision
• Suspicion of keratoconjunctivitis or other more serious cause of red eye
• Evidence of periorbital cellulitis
• No improvement after 48-72 hours of treatment

Nonpharmacologic Interventions

• Supportive care and good hygiene for both forms of infectious conjunctivitis
• Cleansing of eyelids qid by application of compresses of saline or plain water
• Public health measures that support good hygiene (e.g., frequent hand-washing, use of separate clean face cloth and towels), because the condition is highly contagious

Client Education

• Counsel parents or caregiver about appropriate use of medications (dose, frequency, instillation)
• Advise parents or caregiver to avoid contamination of the tube or bottle of medication with the infecting organisms
• Suggest ways to prevent spread of infection to other household members
• Instruct parents or caregiver (and child, if of a suitable age) about proper hygiene, especially of hands and eyes
• For bacterial form: child may need school or daycare restrictions for 24-48 hours after treatment is initiated
• For viral form: contagious for 48-72 hours, but condition may last for 2 weeks
• For allergic form: recommend that child avoid going outside when pollen count is high and that protective glasses be worn to prevent pollen from entering the eyes
• Do not use a patch for conjunctivitis

Pharmacologic Interventions

Never use steroid or steroid-and-antibiotic combination eye drops, because the infection may progress or a corneal ulcer may rapidly form and cause perforation.

Bacterial Conjunctivitis

Topical antibiotic eye drop:

polymyxin B gramicidin eye drops (Polysporin) (A class drug), 2 or 3 drops qid for 5-7 days

An antibiotic eye ointment may be used at bedtime in addition to the antibiotic eye drops prn:

erythromycin 0.5% (Ilotycin) (A class drug), hs

These treatments should not be used for gonorrheal or herpetic eye infections, for which consultation is required.

Viral Conjunctivitis

Antibiotics are not helpful and are not indicated.

Normal saline washes often provide excellent symptomatic relief.

Monitoring and Follow-Up

Follow up appropriately in 2 or 3 days, or sooner if symptoms worsen.

Referral

Referral is indicated under the following circumstances:

• The diagnosis is in doubt and significant ocular infections (e.g., uveitis) cannot be ruled out
• There is associated trauma
• Visual acuity is decreased
• There is significant associated ocular pain
• The child's condition deteriorates or the symptoms persist despite treatment
• The condition recurs frequently

Allergic Conjunctivitis

See "Conjunctivitis" (allergic type), in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Ophthalmia Neonatorum

Definition

Severe conjunctivitis in newborns (<28 days of age).

This condition must be differentiated from the more common mild conjunctivitis, which has the same causes; see "Conjunctivitis," above, this chapter.

Causes

• Generally acquired from the maternal genital tract
• Bacterial organisms include Chlamydia and Neisseria gonorrhoeae
• Chlamydial infection is a very common STD in North America and is thus the more common cause of neonatal conjunctivitis
• Less commonly, Hemophilus strains, Staphylococcus aureus, Streptococcus pneumoniae and other gram-negative organisms may be involved

History

• Depends on causative organism

Gonorrhea

• Generally presents early (day 3-5 of life)
• Should be considered in any infant who presents with conjunctivitis at less than 2 weeks of age

Chlamydial Infection

• Children present with a history of eye redness and discharge after incubation period of 1-2 weeks
• Should be considered in any child who presents with conjunctivitis in the first 3 months of life and who does not respond to usual topical antibiotics for mild conjunctivitis

Physical Findings

The child may appear severely ill, but the physical findings are generally limited to the eye examination:

• Edema or erythema of the conjunctiva
• Purulent secretion
• Eyelids may be stuck together secondary to the purulent secretions

Differential Diagnosis

• Infectious conjunctivitis
• Trauma
• Nasolacrimal duct obstruction (dacryostenosis)

Complications

• Gonorrheal conjunctivitis (also known as GC conjunctivitis) may be fulminant, leading rapidly to extensive orbital infection and possibly blindness
• Systemic infections, including blood, joint and CNS infections, may occur secondary to N. gonorrhoeae infection

Diagnostic Tests

• Swab drainage for culture and sensitivity, N. gonorrhoeae and Chlamydia

It is important to rule out chlamydial infection by means of a Chlamydia antigen swab.

Management

Goals of Treatment

• Treat infection
• Prevent complications

Appropriate Consultation

Consult a physician immediately, before commencing treatment, especially if you suspect gonorrheal or chlamydial infection.

See also "Conjunctivitis," above, this chapter.

Nonpharmacologic Interventions

• Prevention of perinatally acquired infections through prenatal clinics and screening and through STD control
• Appropriate follow-up of infected mother and her partner

Pharmacologic Interventions

Prevention

Routine prophylaxis with erythromycin ointment (Ilotycin; A class drug) for all newborns at birth.

Treatment of Chlamydia Infection

erythromycin ethylsuccinate suspension (EES-200) (A class drug), 40-50 mg/kg daily, divided qid, PO for 10 days

Topical erythromycin ointment alone is not effective in eliminating nasopharyngeal colonization.

Referral

Refer all suspected cases of gonorrheal ophthalmia to a physician immediately. The child must usually be admitted to hospital for IV administration of antibiotics (e.g., penicillin or cefotaxime) for 7 days.

Refer all cases of Chlamydia infection to a physician if there is no improvement after 2 or 3 days of oral treatment.

Nasolacrimal Duct Obstruction (Dacryostenosis)

Definition

A congenital disorder of the lacrimal system characterized by blockage of the nasolacrimal duct and resulting in excessive tearing and mucopurulent discharge from the affected eye.

The condition occurs in approximately 2% to 6% of newborns. Onset is usually within the first few weeks of life.

Cause

Persistence of a membrane at the lower end of the nasolacrimal duct results in incomplete canalization of the duct and its consequent obstruction.

History and Physical Findings

• Usually unilateral but may be bilateral
• Conjunctival erythema and irritation minimal
• Tearing within the affected eye
• Pooling or puddling of tears
• Epiphora (frank overflow of tears)
• Accumulation of mucoid or mucopurulent discharge in the affected eye, which results in crusting (usually evident upon awakening)
• Erythema or maceration of the skin under the eye
• Expression of clear fluid or mucopurulent discharge when the area of the nasolacrimal sac is massaged, which may be intermittent or continuous over several months
• URTI may exacerbate the condition

Differential Diagnosis

• Early signs of congenital glaucoma
• Photophobia
• Cloudy cornea
• Excessive lacrimation

Complications

• Dacryocystitis: inflammation of the nasolacrimal sac, accompanied by edema, erythema and tenderness of the skin over the area of the affected duct (acute or chronic)
• Pericystitis: inflammation of the tissues surrounding the affected duct
• Mucocele: a bluish, subcutaneous mass below the medial canthal tendon
• Periorbital cellulitis: inflammation around the ipsilateral eye (this is an eye emergency)

Diagnostic Tests

• Eye swab for culture and sensitivity (if purulent discharge present)

Management

In 90% of cases, the condition resolves, with conservative management, once the child reaches 1 year of age.

Goals of Treatment

• Observe, to monitor for and prevent complications

Nonpharmacologic Interventions

• Provide reassurance to parents or caregiver
• Offer support and encouragement, as condition may take many months to resolve
• Recommend nasolacrimal massage two or three times daily, followed by cleansing of the eyelid with warm water
• Suggest gentle massage of lacrimal sac toward the nose, to clear the passage
• Teach parents or caregiver the signs and symptoms of complications, and instruct them to report any that occur

Pharmacologic Interventions

Topical antibiotics for mucopurulent drainage:

erythromycin 0.5% eye ointment (Ilotycin) (A class drug), hs

Referral

Refer to a physician if the condition has not responded to conservative management by the time the child reaches 6 months of age or any time there are complications (e.g., dacryocystitis, pericystitis or periorbital cellulitis, an eye emergency).

A surgery consult may be necessary for lacrimal probing, which may be repeated once or twice. Definitive surgery is indicated if lacrimal probing (performed up to three times) fails to resolve the problem.

Strabismus (Squinting)

Definition

Any abnormality in the alignment of the eyes.

The classification of strabismus is complex. On an etiologic basis, it may be paralytic or non-paralytic, but it can also be classified as congenital or acquired, intermittent or constant, or convergent or divergent.

Pathogenesis

When the eyes are positioned so that an image falls on the fovea (the area of best visual acuity) of one eye, but not the other, the second eye will deviate so that the image falls on its fovea as well. This deviation may be up, down, in or out and results in strabismus.

• Esotropia: both eyes converge medially (crossed eyes)
• Esotrophia: one eye deviates medially
• Exotrophia: one eye deviates laterally
• Hypertrophia: one eye deviates upward
• Hypotrophia: one eye deviates downward

Early recognition and treatment are important for the development of both normal binocular vision and good cosmetic results. Persistent, untreated strabismus may lead to decreased visual acuity of the deviating eye. For best results, strabismus must be treated before the child reaches 5 years of age.

Main Types

Heterophoria

Intermittent (latent) tendency to misalignment.

• Eyes deviate only under certain conditions (e.g., stress, fatigue, illness)
• Common
• May be associated with transient double vision, headaches, eye strain

Heterotropia

Constant misalignment of eyes.

• Occurs because normal fusional mechanisms are unable to control eye deviation
• Child is unable to use both eyes to fixate on an object and learns to suppress the image in the deviating (non-fixating) eye

• Alternating: child uses either eye for fixating and the other eye deviates; vision develops normally in both eyes because there is no preference for fixation
• Consistent: one eye is used consistently for fixating, and the other eye consistently deviates; child is prone to defective development of vision in the deviating eye (because of constant suppression of the visual image)

Causes

Paralytic

• Weakness or paralysis of one or more ocular muscles
• Deviation is asymmetric
• Congenital: secondary to developmental defect in muscle or nerves or to congenital infection
• Acquired: due to extraocular nerve palsies; indicates a serious underlying problem (e.g., fracture of facial bone, CNS tumor, neurodegenerative disease, myasthenia gravis, CNS infection)

Non-paralytic

• Most common type of strabismus
• Extraocular muscles and the nerves that control them are normal
• Occasionally, this form may be secondary to underlying ocular or visual defects such as cataracts or refraction errors
• Overall, seen in 3% of children

Pseudostrabismus

Young infants have a broad nasal bridge; therefore, less of the inner eye is seen, which may give the impression of squinting.

Intermittent eye convergence (crossed eyes) in infants 3-4 months of age is usually normal but should be monitored. If it persists, the child should be evaluated by a physician.

History

• Family history (about 50% of cases are hereditary)
• Constant or variable squint in one or both eyes
• Squinting worse with fatigue or stress
• Child tilts head or closes one eye (compensatory mechanisms for weak eye)

Physical Findings

First assess the following:

• Extraocular eye movements (by having child visually follow an object): watch for asymmetry of movement
• Visual acuity (with Snellen or similar chart)

Then assess alignment with the following two main techniques.

Corneal Light Reflex Test (Hirschberg Test)

Direct a small, focal light toward the child's face, and observe the reflections in each cornea. If the eyes are aligned, the reflection should be on symmetric points of the corneas.

Cover-Uncover Test

Child is asked to fix gaze on an object. Examiner alternately covers each eye, after allowing time for the eyes to drift.

• Normal alignment: no movement of either eye
• Phoria: when deviating eye is covered, it tends to move; therefore, when the deviating eye is uncovered, the examiner can observe the eye as it resumes its former position (Fig. 8-2), i.e., movement is seen on uncovering the deviating eye
• Tropia: when fixating eye is covered, the deviating (uncovered) eye moves, i.e., movement is seen on covering the deviating eye

Fig. 8-2: Cover-Uncover Test (what practitioner sees when facing child)

Complications

• Amblyopia

Diagnostic Tests

None.

Management

Goals of Treatment

• Prevent complications

Monitoring and Follow-Up

A young infant with intermittent, non-paralytic strabismus may be kept under observation until he or she reaches 6 months of age, when referral may become necessary.

Referral

• Refer all children with suspected strabismus to a physician for evaluation
• All children with fixed (paralytic) strabismus need more urgent referral, particularly if the paralytic strabismus is acquired

Early referral and treatment give the best chance for good vision in both eyes and good ocular alignment.

Hordeolum or Stye

See "Hordeolum or Stye," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Chalazion

See "Chalazion," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Emergency Problems of the Eye

Orbital Cellulitis

Definition

Bacterial infection of the deep tissues of the posterior orbital space.

Orbital cellulitis and periorbital cellulitis (see next section) may coexist in the same person.

Causes

Usually a serious complication of acute sinusitis or other facial infection or trauma.

• Streptococcus pneumoniae
• Hemophilus influenzae (non-typable)
• Branhamella catarrhalis
• Staphylococcus (less common)

History

• Preceding history of acute sinusitis (although such a history is not often present in young children, i.e., <6 years old)
• Often no obvious antecedent event in children
• Low- to high-grade fever
• Mild or marked swelling and pain on movement of the eye
• Mild to marked visual impairment

Physical Findings

• Inflammation and swelling of the surrounding orbital tissues and eyelids
• Exophthalmos (proptosis) may be present in severe cases
• Mild to moderate ophthalmoplegia (inability to move eye)
• Mild to significant decrease in visual acuity
• Child may appear mildly ill to moribund, depending on severity of infection

Assess for any neurologic complications and level of consciousness (see pediatric Glasgow coma scale, Table 15-1, in chapter 15, "Central Nervous System").

Differential Diagnosis

• Periorbital cellulitis
• Insect bite
• Allergic reaction
• Conjunctivitis
• Dacryocystitis
• Eczematoid dermatitis
• Rhabdomyosarcoma

Complications

• Intracranial cavernous sinus thrombosis (associated with signs of CNS irritation, puffiness of the face, deterioration in level of consciousness)
• Orbital or subperiosteal abscess
• Infection of other orbital structures
• Meningitis
• Intracranial abscess
• Blindness

Diagnostic Tests

• Swab any discharge for culture and sensitivity before starting antibiotics

Management

Goals of Treatment

• Treat infection
• Prevent complications

Appropriate Consultation

Consult a physician immediately.

Adjuvant Therapy

• Start IV therapy with normal saline to keep vein open

Nonpharmacologic Interventions

Client Education

• Explain to the parents or caregiver the nature, course, expected treatment and outcomes of disease

Pharmacologic Interventions

• IV antibiotics should be started urgently, before transport
• Discuss choice of antibiotics with a physician
• Antibiotic of choice: cefuroxime (Zinacef) (B class drug)

Referral

Medevac to hospital.

Periorbital Cellulitis (Preseptal)

Definition

Infection of the tissues anterior to the orbital septum.

Periorbital cellulitis and orbital cellulitis (see previous section) may coexist in the same person.

Causes

Bacteria gain access to the tissues around the orbit through trauma, skin pustules, insect bites, URTIs, infections of the teeth and occasionally sinusitis.

• Hemophilus influenzae (type B) -- very important in children <5 years old
• Staphylococcus aureus
• Streptococcus pyogenes

History

• May be a preceding history of trauma or insect bites to the eye area, but frequently there is no antecedent history
• Child may have other systemic features, such as fever and irritability
• Parents or caregiver may have noticed that the eyes are swollen to the point of shutting
• Examination of the child may be very difficult, because of edema, pain and anxiety

Physical Findings

• Child febrile, ill-looking
• No pain on movement of the eye
• Visual acuity usually normal (if it can be assessed)
• Orbital edema and erythema
• Discharge from the eyelid and surrounding tissues

Unless other complications have occurred, the child should show no evidence of neurologic problems.

Differential Diagnosis

• Orbital cellulitis

Complications

• CNS infection
• Meningitis

Diagnostic Tests

• Swab any discharge for culture and sensitivity before starting antibiotics

Management

Appropriate Consultation

Consult a physician for all cases of suspected periorbital cellulitis.

Nonpharmacologic Interventions

Client Education

• Explain to parents or caregiver the nature, course, expected treatment and outcomes of the disease
• If child is being treated on an outpatient basis, counsel parents or caregiver about appropriate use of medications (dose, route, side effects)

Pharmacologic Interventions

Discuss with a physician. If the infection is extensive, IV antibiotics may have to be started before transfer to hospital. If the infection is mild or moderate, the physician may decide to treat the child as an outpatient, using oral antibiotics (e.g., amoxicillin/clavulanate [Clavulin])

Referral

Medevac for admission to hospital and treatment with IV antibiotics may be needed for more severe infections.

Corneal Abrasion

See "Corneal Abrasion," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Conjunctival, Corneal or Intraocular Foreign Bodies

See "Conjunctival, Corneal or Intraocular Foreign Bodies," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Acute Angle-Closure Glaucoma

See "Acute Angle-Closure Glaucoma," in chapter 1, "The Eyes,"in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Chemical Burns

See "Chemical Burns," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Blunt or Lacerating Ocular Trauma

See "Blunt or Lacerating Ocular Trauma," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).

Uveitis (Iritis)

See "Uveitis (Iritis)," in chapter 1, "The Eyes," in the adult clinical guidelines (First Nations and Inuit Health Branch 2000).