NR 602 Midterm Review
Chalazion
Chalazion is a chronic sterile inflammation of the eyelid resulting from a lipogranuloma of
the meibomian glands that line the posterior margins of the eyelids (see Fig. 29-7). It is
deeper in the eyelid tissue than a hordeolum and may result from an internal hordeolum or
retained lipid granular secretions.
Clinical Findings
Initially, mild erythema and slight swelling of the involved eyelid are seen. After a few days
the inflammation resolves, and a slow growing, round, nonpigmented, painless (key finding)
mass remains. It may persist for a long time and is a commonly acquired lid lesion seen in
children (see Fig. 29-7).
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Management
• Acute lesions are treated with hot compresses.
• Refer to an ophthalmologist for surgical incision or topical intralesional corticosteroid
injections if the condition is unresolved or if the lesion causes cosmetic concerns. A
chalazion can distort vision by causing astigmatism as a result of pressure on the orbit.
Complications
Recurrence is common. Fragile, vascular granulation tissue called pyogenic granuloma
that enlarges and bleeds rapidly can occur if a chalazion breaks through the conjunctival
surface.
Types of Conjunctivitis
Type Incidence/Etiology Clinical Findings Diagnosis Management*
Ophthalmia
neonatorum
Neonates: Chlamydia
trachomatis, Staphylococcus
aureus, Neisseria
gonorrhoeae, HSV (silver
nitrate reaction occurs in
10% of neonates)
Erythema, chemosis,
purulent exudate
with N. gonorrhoeae
; clear to mucoid
exudate with
chlamydia
Culture (ELISA, PCR),
Gram stain, R/O
N. gonorrhoeae,
chlamydia
Saline irrigation to eyes until
exudate gone; follow with
erythromycin ointment
For N. gonorrhoeae:
ceftriaxone or IM or IV
For chlamydia: erythromycin
or possibly azithromycin PO
For HSV: antivirals IV or PO
Bacterial
conjunctivitis
In neonates 5 to 14 days old,
preschoolers, and sexually
active teens: Haemophilus
influenzae(nontypeable),
Streptococcus pneumoniae,
S. aureus, N. gonorrhoeae
Erythema, chemosis,
itching, burning,
mucopurulent
exudate, matter in
eyelashes; ? in winter
Cultures (required in
neonate); Gram stain
(optional); chocolate
agar (for N.
gonorrhoeae
) R/O pharyngitis,
N. gonorrhoeae
, AOM, URI, seborrhea
Neonates: Erythromycin 0.5%
ophthalmic ointment
?1 year old: Fourth-generation
fluoroquinolone
For concurrent AOM: Treat
accordingly for AOM
Warm soaks to eyes three
times a day until clear
No sharing towels, pillows
No school until treatment
begins
Chronic bacterial
conjunctivitis
(unresponsive
conjunctivitis
previously treated
as bacterial in
etiology)
School-age children and
teens: Bacteria, viruses,
C. trachomatis
Same as above;
foreign body
sensation
Cultures, Gram stain;
R/O dacryostenosis,
blepharitis, corneal
ulcers, trachoma
Depends on prior treatment,
laboratory results, and
differential diagnoses
Review compliance and prior
drug choices of conjunctivitis
treatment
Consult with ophthalmologist
Inclusion
conjunctivitis
Neonates 5 to 14 days old
and sexually active teens:
C. trachomatis
Erythema, chemosis,
clear or mucoid
exudate, palpebral
follicles
Cultures (ELISA,
PCR), R/O sexual
activity
Neonates: Erythromycin or
azithromycin PO
Adolescents: Doxycycline,
azithromycin, EES,
erythromycin base,
levofloxacin PO
Viral conjunctivitis Adenovirus 3, 4, 7; HSV,
herpes zoster, varicella
Erythema, chemosis,
tearing (bilateral);
HSV and herpes
zoster: unilateral
with photophobia,
fever; zoster: nose
lesion; spring and fall
Cultures, R/O corneal
infiltration
Refer to ophthalmologist if
HSV or photophobia present
Cool compresses three or four
times a day
Allergic and vernal
conjunctivitis Atopy sufferers, seasonal
Stringy, mucoid
exudate, swollen
eyelids and
conjunctivae, itching
(key finding),
tearing, palpebral
follicles, headache,
rhinitis
Eosinophils in
conjunctival scrapings
Naphazoline/pheniramine,
naphazoline/antazoline
ophthalmic solution (see text)
Mast cell stabilizer (see text)
Refer to allergist if needed
*See text for dosages.
Blepharitis
Blepharitis is an acute or chronic inflammation of the eyelash follicles or meibomian
sebaceous glands of the eyelids (or both). It is usually bilateral. There may be a history of
contact lens wear or physical contact with another symptomatic person. It is commonly
caused by contaminated makeup or contact lens solution. Poor hygiene, tear deficiency,
rosacea, and seborrheic dermatitis of the scalp and face are also possible etiologic factors.
The ulcerative form of blepharitis is usually caused by S. aureus. Nonulcerative blepharitis is
occasionally seen in children with psoriasis, seborrhea, eczema, allergies, lice infestation, or
in children with trisomy 21.
Clinical Findings
• Swelling and erythema of the eyelid margins and palpebral conjunctiva
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• Flaky, scaly debris over eyelid margins on awakening; presence of lice
• Gritty, burning feeling in eyes
• Mild bulbar conjunctival injection
• Ulcerative form: Hard scales at the base of the lashes (if the crust is removed, ulceration is
seen at the hair follicles, the lashes fall out, and an associated conjunctivitis is present)
Differential Diagnosis
Pediculosis of the eyelashes.
Management
Explain to the patient that this may be chronic or relapsing. Instructions for the patient
include:
• Scrub the eyelashes and eyelids with a cotton-tipped applicator containing a weak (50%)
solution of no-tears shampoo to maintain proper hygiene and debride the scales.
• Use warm compresses for 5 to 10 minutes at a time two to four times a day and wipe away
lid debris.
• At times antistaphylococcal antibiotic (e.g., erythromycin 0.5% ophthalmic ointment) is
used until symptoms subside and for at least 1 week thereafter. Ointment is preferable to eye
drops because of increased duration of contact with the ocular tissue. Azithromycin 1%
ophthalmic solution for 4 weeks may also be used (Shtein, 2014).
• Treat associated seborrhea, psoriasis, eczema, or allergies as indicated.
• Remove contact lenses and wear eyeglasses for the duration of the treatment period.
Sterilize or clean lenses before reinserting.
• Purchase new eye makeup; minimize use of mascara and eyeliner.
• Use artificial tears for patients with inadequate tear pools.
Chronic staphylococcal blepharitis and meibomian keratoconjunctivitis respond to oral
erythromycin. Doxycycline, tetracycline, or minocycline can be used chronically in children
older than 8 years old.
Hand-Foot-Mouth Syndrome
Enteroviruses
Nonpolio Enteroviruses
Of the more than 100 serotypes of nonpolio RNA enteroviruses, 10 to 15 serotypes account
for most diseases. They are grouped into four genomic classifications: human 495
enteroviruses (HEVs) A, B, C, and D. Coxsackieviruses and echoviruses are subgroups of
HEVs. Hand-foot-mouth, herpangina, pleurodynia, acute hemorrhagic conjuncti
vitis, myocarditis, pericarditis, pancreatitis, orchitis, and dermatomyositis-like syndrome are
manifestations of infection. These enteroviruses are the most common cause of aseptic
meningitis and have also been associated with paralysis, neonatal sepsis, encephalitis, and
other respiratory and GI symptoms. The specific serotype may not be unique to any given
disease (Abzug, 2011).
As evidenced by the name, enteroviruses concentrate on the GI tract as their primary
invasion, replication, and transmission site; they spread by fecal-oral contamination,
especially in diapered infants. They are also transmitted via the respiratory route and
vertically either prenatally, during parturition, or possibly by way of breastfeeding by an
infected mother who lacks antibodies to that particular serotype. Transplacental infection can
lead to serious disseminated disease in the neonate that involves multiorgan systems (liver,
heart, meninges, and adrenal cortex).
Enteroviruses have worldwide distribution, occurring in temperate climates during the
summer and fall and in tropical climates year round. In known cases, infants younger than 12
months old have the highest prevalence rate (>25%), and HEVs account for 55% to 65% of
hospitalizations for suspected infant sepsis. Illness occurs more frequently in males; those
living in crowded, unsanitary conditions; and in those of lower socioeconomic status (Abzug,
2011). Infection can range from asymptomatic to undifferentiated febrile illness to severe
illness. Young children are more likely to be symptomatic. The incubation period is 3 to 6
days (less for hemorrhagic conjunctivitis). After infection, the virus is shed from the
respiratory tract for up to 3 weeks and from the GI tract for up to 7 to 11 weeks; it is viable
on environmental surfaces for long periods.
Nonpolio enteroviral infection is not a reportable disease, nor is it routinely tested for in the
clinical setting, so the overall incidence rate is not known. The CDC administers the National
Respiratory and Enteric Virus Surveillance System (NREVSS) and the National Enterovirus
496Surveillance System (NESS) to monitor detection patterns of respiratory and enteric
adenoviruses. The 2014 outbreak of an illness in children referred to as acute flaccid myelitis
bears some similarity to infections caused by viruses, including enterovirus; epidemiologic
studies are ongoing (CDC, 2015f).
Clinical Findings
History.
General symptoms include:
• A mild upper respiratory infection (URI) is common and may include complaints of sore
throat, fever, vomiting, diarrhea, anorexia, coryza, abdominal pain, rash, and headache.
• Nonspecific febrile illness of at least 3 days: In young children, there is an undifferentiated
abrupt-onset febrile illness (101° to 104° F [38.5° to 40° C]) associated with myalgias,
malaise, irritability; fever may wax and wane over several days.
• Onset of viral symptoms within 1 to 2 weeks after delivery for neonates infected
transplacentally.
Physical Examination.
General findings include mild conjunctivitis, pharyngeal infection, and/or cervical
adenopathy. Other findings include:
• Skin: Rash may be macular, macular-papular, urticarial, vesicular, or petechial. May
imitate the rash of meningitis, measles, or rubella.
• Herpangina: There is a sudden onset of high fever (up to 106° F [41° C]) lasting 1 to 4
days. Loss of appetite, sore throat, and dysphagia are common, with vomiting and abdominal
pain in 25% of cases. Small vesicles (from one to more than 15 lesions of 1 to 2?mm each)
appear and enlarge to ulcers (3 to 4?mm) on the anterior pillars of the fauces, tonsils, uvula,
and pharynx and the edge of the soft palate. The vesicles commonly have red areolas up to
10?mm in diameter. This self-limiting infection usually lasts 3 to 7 days.
• Acute lymphonodular pharyngitis: This manifests as an acute sore throat lasting
approximately 1 week.
• Hand-foot-mouth disease: This is a clinical entity evidenced by fever, vesicular eruptions in
the oropharynx that may ulcerate, and a maculopapular rash involving the hands and feet.
The rash evolves to vesicles, especially on the dorsa of the hands and the soles of the feet,
and lasts 1 to 2 weeks (Fig. 24-1).
Pharyngitis
Pharyngitis, Tonsillitis, and Tonsillopharyngitis
Pharyngitis is an inflammation of the mucosa lining the structures of the throat, including the
tonsils, pharynx, uvula, soft palate, and nasopharynx. It can be due to infectious agents or
noninfectious causes, such as smoke or other air irritants. The illness is generally acute and
involves an inflammatory response, including erythema, exudate, or ulceration.
The etiology could include a number of viruses and bacteria. If there are nasal symptoms, it
is called nasopharyngitis, but if there are no nasal symptoms, the disease is called pharyngitis
or tonsillopharyngitis. Most cases of pharyngitis are caused by viruses (Gereige and Cunill-De
Sautu, 2011). Adenovirus is the most common cause of nasopharyngitis (Cherry, 2009c
). Other viruses include Epstein-Barr virus (EBV), herpes simplex virus (HSV),
cytomegalovirus (CMV), enterovirus, influenza virus, parainfluenza, and human
immunodeficiency virus (HIV). The viral organisms generally present with upper nasal
symptoms. The common bacterial etiology is GABHS in children between 5 and 11 years
old, whereas 40% of reported cases of gonococcal infections occur in females 15 to 19 years
old. Other organisms include Corynebacterium diphtheriae, Arcanobacterium haemolyticum,
Neisseria gonorrhoeae, group C and group G streptococci, Chlamydia trachomatis,
Francisella tularensis, and Mycoplasma pneumonia (Gereige and Cunill-De Sautu, 2011).
Acute Viral Pharyngitis, Tonsillitis, or Tonsillopharyngitis
Adenoviruses are more likely to cause pharyngitis as a prominent symptom. Other viruses
(e.g., rhinovirus) are associated with pharyngitis as a minor symptom and rhinorrhea or
cough as predominant features. The enterovirus (coxsackievirus, echovirus), herpesvirus, and
EBV are also common. Viral infections occur year-round, but adenovirus presenting as
pharyngoconjunctival fever occurs in outbreaks during the summer due to contaminated
swimming pools (Gereige and Cunill-De Sautu, 2011). It is helpful to know what agents are currently
infecting children in the community. However, when a patient only has a sore throat, it is
difficult to differentiate viral from bacterial causes. Hoarseness, cough, coryza,
conjunctivitis, and diarrhea are classic features of a viral infection (
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