positive if inequality of color, intensity or clarity of the reflection, or the presence of opacities or whites spots
If red reflex positive…
Refer to opthamologist
- Congenital cataract requires surgery before 3-4 months of age
- Congenital cloudy cornea is considered an ophthalmic emergency–leads to vision loss.
- due to glaucoma, trauma, scleroderma, dermoid cyst, infections, retinoblastoma, rhabdomyosarcoma
- Coordinated movement of the eye develops by 3-6months, when infants begin using binocular vision
- If deviation from coordinated movement persists beyond six months, refer for evaluation
eyes are divergent
Eyes are crossed
Causes of strabismus
Supranuclear (visual cortex)
Infranuclear (extraocular muscles or their respective nerves)
Complications of strabismus
Approx. 50% of children with strabismus under 9 years of age will develop amblyopia (loss of vision) in the eye if left untreated
Chronic strabismus can be disfiguring
Treatment of strabismus
Refer to opthlamologist
Correction of refractive errors, penalization of preferred eye by patching, and extraocular muscle surgery
Red eye/eye discharge questions
Unilateral or bilateral
Onset, spreading, location
Red eye with discharge: Dacrostenosis
-Stricture of the nasolacrimal duct, often resulting from a congenital abnormality. Presents between ages 3-12 weeks as a persistent tearing of one eye
Self-limiting: resolves by 6 months
Red eye with discharge: Dacrocystitis
infection of the lacrimal sac, secondary to dacrostenosis. Sxs: pain, erythema and edema about the lacrimal sac; tearing and conjunctivitis
Tx: warm compress, milk the contents of the lacrimal sac
OR the punctum can be dilated and the nasolacrimal canal probed
Injection of conjunctiva, tearing, mucopurulent discharge, swelling of eyelid
unilateral, but may spread to other eye
TX: Warm compresses, herbal eye wash, topical antibiotics
(if mom is breastfeeding…breast milk!)
Associated with URI
Watery clear discharge, minimal lid swelling
TX: Warm compresses, herbal eye wash
Clear, mucoid, ropy discharge, moderate to severe lid edema, itchy
TX: Treat allergies, modify environment
involves the eyelid and surrounding skin
sxs: edema and erythema of upper and lower eyelid, usually unilateral; fever; pain
TX: IV abx, outpt if parents compliant
periorbital and orbital contents
cause: 1. Breach of skin-bug bite, trauma; s aureus, s pyogenes
2. Internal infections-sinusitis, bacteremia; h. influenza type b or strep pneumoniae
sxs: eyeball becomes swollen and bulges, decreased ability to move eye, decrease vision
TX: EMERGENT. IV Abx
Complications of peri/orbital cellulitis
- Retinal damage secondary to ischemia
2. Meningitis, brain abscess
Inflammation of the lid margins with erythema, thickening and crusts, scales or shallow marginal ulcers; may see loss of lashes
TX: daily cleansing with baby shampoo; antibiotic ointment or herbal eyewash for infection as needed; homeopathy
(herbal eyewash: sterile eye saline with calendula, echinacea, goldenseal, eye bright; 3-4 drops of each herb in __oz tincture bottle)
Acute localized, pyogenic infection of one or more of the glands of Zeis or Moll or of the meibomian glands generally caused by staph
internal or external
sxs: pain, redness and tenderness; may find small, tender area of induration
TX-hot packs 10 min TID to QID; homeopathy; (antibiotics rarely if ever indicated)
Remove envl and dietary cause
Clean windowsills, run humidifier, avoid food sensitivities, vitamin C, bioflavinoids, herbs.
[If allergic–wash hands and face frequently!! Sleep with bedroom window closed, air purifier]
Immune glycerin by WWH
bacterial causes include strep, pneumococci, hemophilus, or staph species (but can be viral, allergic)
Hx: recent URI with a late onset fever.
Tx: 1/2 self-limited; saline rinses, humidifier, steam, compresses. Mucolytic- water and NAC.
Glycerite herbs with added amoracia, mahonia. Wet socks. Abx: amoxicillin 40 mg/kg in 3 divided doses. [augmentin if you suspect h. influenza]
Sore throats- common viruses
adenovirus, influenza, parainfluenza, rhinovirus, RSV
Sxs: Coryza, conjunctivitis, malaise, hoarseness, low-grade fever suggest viral pharyngitis. [mouth-breathing, vomiting, abdominal pain and diarrhea]
Hand, foot, and mouth
small red papules, vesicles and ulcers on tongue, buccal mucosa, palate, gingival and uvulotonsillar pillars. Often see 2-10 lesions that persist one week
small red papules, vesicles and ulcers on posterior oropharynx. High fever common.
due to Coxsackie virus
VERY painful, consider topical lidocaine
Pharyngeal injection with exudates, posterior cervical lymphadenopathy, hepatosplenomegaly.
Bacterial sore throat:
Group A beta hemolytic strep
Sxs: mod to several pharyngeal erythema, edema and tonsillar enlargement; exudate in crypts of tonsils, cervical lymphadenopathy, palatine petechiae
TX: Oral Pen V, amoxicillin, cephalosporins, erythromycin
BEMP Tincture, hydrotherapy, homeopathy
Children on antibiotics can return to school after 24 hours of treatment
No need to reculture; watch for suppurative complications
Strep throat sequalae: Scarlet Fever
sandpaper rash due to hypersensitivity to strep pyrogenic toxin. Begins on trunk and spreads over body. Rash blanches with pressure and desquamates after 7-21 days.
Strep throat sequalae: Acute post-infectious glomerulonephritis
from the antibodies!
Strep throat sequalae: Rheumatic Fever
Should be suspected in any patient with joint swelling, subcutaneous nodules, erythema marginatum or heart murmur, with concomitant strep within the past month.
Strep throat sequalae: peritonisilla abscess
Results from accumulation of purulence in the tonsilar fossa. Peritonsilar edema may lead to compromise of the upper airway.
PE: unilateral peritonsilar fullness/bulging of the posterior, superior soft palate with uvular deviation.
Refer immediately for drainage of abscess and IV antibiotics
Strep throat sequalae: Retropharyngeal abscess
Abscess occurs subsequent to lymph drainage or localized spread of bacteria. Sxs: sore throat, fever, neck pain or stiffness, poor oral intake. PE: exam will also reveal neck mass or retropharyngeal bulge. Refer immediately!!
Bacteria are H. influenza, staph and strep.
History: abrupt onset of high fever, sore throat without URI symptoms.
Child appears TOXIC
PE: anxious child with chin hyperextended, drooling, slow and labored respiratory effort with stridor and retractions. DO NOT examine pharynx
Refer to ER with oxygen
Acute purulent otitis media
Abx for children under 2 yrs
otherwise watch and wait, garlic and mullein
Homeopathy: belladonna, chamomilla, pulsatilla, kali bic, aconite, calc carb
Otitis media with effusion
TM clear, amber or gray, retracted. May see fluid line or bubbles.
May lead to hearing loss
Early treatment with antibiotics.
Identify food sensitivities, environmental sensitivities, decrease inflammation, endonasal treatments
complication from OM
Indications for tympanostomy
hearing loss, speech delays, concomitant infections or infections (tonsillitis, enlarged adenoids, snoring, frequent severe URIs, apnea)
Complications of OM
- Mastoiditis-fever, OM and post-auricular swelling and tenderness (ear lifts away from head). Refer to ER for IV antibiotics.
- Delayed speech development, hearing loss
- Chronic perforation can require surgery
- Tympanosclerosis-generally not a problem unless it involves the entire TM
- Cholesteatoma-appears as a white lesions behind the TM
- Meningitis, brain abscess, subdural empyema, and epidural abscess
Chronic serous OM
aka mucoid aka glue ear
wrinkled/retracted appearance, no bony landmarks; chronic fluid/bubbles behind ear, amber TM
Management: tx eustachian tube dysfunction, tx allergies, refer to chiropractor/craniosacral
J tug on ear lobe; downward massage on posterior SCM