Pediatric emergency medicine trisk 0584 0584
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present, the red eye may be caused by periorbital or orbital cellulitis which is
emergent condition (see Chapter 123 Ophthalmic Emergencies ). Eye pain,
watery discharge, hyperemia, chemosis, and marked lid swelling also may be
associated with epidemic keratoconjunctivitis (EKC) secondary to adenovirus
(Fig. 123.7 ). When questioned further, patients may reveal that they actually
have a sandy foreign body sensation rather than true ocular pain.
Pseudomembranes are a fairly diagnostic sign when present ( Fig. 27.1 ). Lowgrade fever and tender preauricular adenopathy may also occur, making it
difficult to distinguish EKC from periorbital cellulitis. EKC usually affects the
eyes consecutively and bilaterally as opposed to the unilateral nature of
periorbital cellulitis. There also may be associated prominent photophobia and
tearing in adenoviral conjunctivitis, which is not usually seen in cellulitis.
Itching is another important diagnostic symptom. When it is associated with
conjunctival edema, giving it the appearance of a blister-like elevation (chemosis,
Fig. 123.10 ), one should suspect allergic conjunctivitis. Seasonal allergic
conjunctivitis, a type I, IgE-mediated hypersensitivity reaction to allergens such
as pollen, is the most common type of ocular allergy. It is often seen in patients
with atopic disease. Both eyes are usually affected. Tearing, burning, and mild
eyelid swelling may be present.
Itching and a burning sensation can be associated with blepharitis, an
idiopathic disorder in which there is suboptimal flow of secretions from the
meibomian glands in the eyelids resulting in an abnormal tear film and rapid
corneal desiccation. Blepharitis may present as acute or chronic bilateral eye
irritation. Symptoms are aggravated by activities associated with prolonged
staring and decreased blinking such as reading, television or computer viewing,
and playing video games. Spending time outside on windy days can also provoke
symptoms. To compensate for the tear film deficiency, reflexive excess tearing
may occur from the lacrimal gland. Patients may have photophobia and a sandy
foreign body sensation. The most characteristic sign is erythema of the eyelid
margins and flaking and crusting at the base of the eyelashes ( Fig. 27.6 ).
Chronic skin changes also include eyelid thickening. Left untreated, the reduced
flow of the meibomian glands may allow for proliferation of the coagulasenegative staphylococci that normally colonize the area. This overgrowth may lead
to an immune response causing an inflamed elevated white spot(s) on the
conjunctiva (phlyctenule) or peripheral corneal infiltrates associated with a red
eye. Slit-lamp examination is helpful in making these diagnoses, particularly to
assess for corneal involvement.
