Common Eye Problems

Blocked Tear Ducts: Pediatricians are familiar with blocked tear ducts: they occur in 2-4% of newborns with onset usually within the first few weeks of life. 90% of cases resolve spontaneously. Treatment consists of antibiotic drops every 4-6 hours for purulent discharge, digital pressure (NOT massage: parents often end up pressing on the orbital rim, not the lacrimal sac which lies between the inferonasal orbital rim and the globe), and time. However, some cases do not clear and surgical intervention is needed. It is well established that a tear duct probe works in about 90 percent of cases if performed before age thirteen months of age, but in a much lower percentage of cases if the procedure is performed after thirteen months of age.

For this reason, if a blocked tear duct has not resolved by age eight months, referral is recommended so that a timely tear duct probe may be performed if spontaneous resolution does not occur. Also, if purulent discharge cannot be well controlled with topical antibiotics and digital pressure, a tear duct probe can be performed earlier. A tear duct probe can be performed under topical anesthesia without going to the operating room if the child is under one year of age and weighs 20lbs. or less. If a child has had a significant lid cellulitis due to a blocked tear duct, a tear duct probe should probably be performed after the infection has been controlled with oral or parenteral antibiotics.

A new procedure called balloon catheter dacryoplasty is available for children older than thirteen months in whom a tear duct probe either has not been performed or a tear duct probe has been unsuccessful.

Antibiotics: Many antibiotics are effective when placed topically in the eye even though susceptibility studies might show resistance. The concentration of antibiotics placed topically in the eye is very large compared to blood levels. At this time, tobramycin can be purchased generically at very low cost and is a good first line agent as is polytrim. Antibiotics containing neomycin should generally be avoided due to the very high rate of allergic reaction, as high as 10-15%. There has been an alarming trend of the use of combined antibiotic-steroid eyedrops among pediatricians. I have seen two cases in which infantile glaucoma was induced in two different infants treated with topical steroids: children develop intraocular pressure elevation very commonly after treatment with topical steroids in as little as two weeks. Also, topical steroids will worsen herpes simplex keratitis, which is a very common cause of red eye in children (We often see 3-5 new cases weekly). One child treated with topical steroids for a red eye developed a large corneal scar due to worsening of the herpes infection in the cornea while on topical steroids. We strongly advise against the use of topical steroids by any primary care physician: you must be certain the child does not have herpes simplex and you must be capable of measuring intraocular pressure or the child can have significant ocular damage and the primary care physician will have significant liability.

With an acute red eye without injury, inspect the cornea carefully with a hand light for a foreign body. If a child has redness with significant pain and or photophobia, suspect iritis or corneal problem such as herpes simplex, corneal abrasion or foreign body. If the cornea is clear and no pain or photophobia is present, treat with a topical antibiotics QID. If no improvement occurs within 3-5 days, referral to an ophthalmologist is recommended.

Allergic Conjunctivitis: This entity is well known in the spring and fall: watery, itchy eyes, often with mucoid discharge and usually seen in patients with other allergic conditions such as chronic allergic rhinitis, asthma or contact dermatitis. This condition is invariably bilateral: a unilateral red eye with a clear watery discharge should raise suspicion for herpes simplex conjunctivitis and /or keratitis or corneal abrasion or foreign body. A purulent discharge usually indicates bacterial infection which often occurs in patients with ocular surface disease such as allergic conjunctivitis. Antibiotics are ineffective in pure allergic conjunctivitis and often worsen symptoms, particularly when aminoglycosides are used as the patient is often allergic to the eyedrop. Naphcon-A, a combined topical antihistamine and vasoconstrictor is now OTC and is inexpensive: it is a good first line agent for mild allergic conjunctivitis. Alomide is a mast cell stabilizer but must be used daily for 7- 10 days for any significant effect and is thus best reserved for chronic, fairly severe cases. Patanol, which has both immediate antihistamine properties and longer-term mast cell stabilization, is useful for patients with significant symptoms. This drug is fairly expensive and must be used daily (BID) and regularly for best results. Oral antihistamines such as Zyrtec are effective in about two thirds of patients and are good agents for younger children in whom installation of eyedrops is a real chore.