Conjunctivitis (peds)

This page is for pediatric patients (non-neonatal); for neonatal patients see Neonatal conjunctivitis and adult patients see conjunctivitis

Background

• Most common cause of acute red eye
• One review with limited evidence found that bacterial conjunctivitis was more common than viral conjunctivitis in children.

Conjunctivitis Types

• Viral conjunctivitis
  • Epidemic keratoconjunctivitis
  • Herpes zoster ophthalmicus
  • Herpes simplex keratitis
• Bacterial conjunctivitis
  • Gonorrheal conjunctivitis
  • Chlamydia conjunctivitis
• Allergic conjunctivitis
• Caustic keratoconjunctivitis

Clinical Features

• Can have pain, itching, photophobia, visual disturbance, tearing, edema, discharge, fever
• Injected conjunctiva with perilimbal sparing
• Rarely painful; more irritated

Conjunctivitis Images

• 

  Bacterial conjunctivitis

• 

  Viral conjunctivitis

• 

  Epidemic keratoconjunctivitis

• 

  Herpes zoster ophthalmicus

• 

  Herpes simplex keratitis

• 

  Chlamydial conjunctivitis

• 

  Gonorrheal conjunctivitis

• 

  Acute allergic conjunctivitis

• 

  Chronic allergic conjunctivitis

• 

  Contact blepharoconjunctivitis

Differential Diagnosis

• Kawasaki Disease
• Pediculosis

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses
^^Critical diagnoses

Evaluation

Conjunctivitis with limbus sparing

• Typically clinical
  • However, a literature review attempting to differentiate bacterial vs viral concludes: No single symptom or sign differentiated the two conditions with high certainty.

Clinical diagnosis of conjunctivitis^

Conjunctivitis

	Bacterial	Viral	Allergic
Bilateral	50%	25%	Mostly
Discharge	Mucopurulent	Clear, Watery	Cobblestoning, none
Redness	Yes	Yes	Yes
Pruritis	Rarely	Rarely	Yes
Increased Likelihood	Presence of mucopurulent discharge; otitis media	Concomitant pharyngitis; an enlarged preauricular node; contact with another person with red eye	NA
Additional	Treatment: Antibiotics	Treatment: Hygiene	Seasonal

Management

• Viral infections - most common cause of conjunctivitis, but difficult to differentiate viral from bacterial
• Some clinicians treat all possible viral presentations as bacterial conjunctivitis
• Treatment considerations:
  • Ointments - soothing effect, but interfere with vision
  • Drops - no interference with vision

Bacterial Causes

Newborn, see Neonatal conjunctivitis

Chlamydial

• Doxycycline 100mg PO BID for 7 days OR
• Azithromycin 1g (20mg/kg) PO one time dose
• Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

• Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
• Ceftriaxone 1g IM single dose PLUS
• Azithromycin 1g PO one dose
• Newborn Treatment:
  • Prophylaxis: Erythromycin ophthalmic 0.5% x1
  • Disease manifests 1st 5 days post delivery (early onset)
  • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
  • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)

Bacterial Conjunctivitis

• Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
• Apply warm or cool compresses (for comfort and cleansing) every 4 hours, followed by instillation of ophthalmic antibiotic solutions

These options do not cover gonococcal or chlamydial infections

• Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
• Erythromycin applied to the conjunctiva q6hrs for 7 days OR
• Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
• Chloramphenicol 0.5% ophthalmic solution 1 drop QID for 7 days

NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment

Pediatric

Same topical regimens as adults; erythromycin ointment preferred in neonates and young infants

• Erythromycin 0.5% ophthalmic ointment applied q6hrs x 7 days (preferred in neonates/infants) OR
• Moxifloxacin 0.5% ophthalmic 1 drop TID x 7 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID x 2 days then daily x 5 days

Viral Causes

• Non-herpetic: supportive care
• Herpetic: Acyclovir, ophto referral

Allergic

• Artificial tears and avoidance of allergens
• Consider topical antihistamines for severe symptoms

Antihistamines

• Ketotifen 1 drop q8-12hr OR
• Olopatadine 1-2 drop daily

Disposition

• Typically outpatient

See Also

• Conjunctivitis
• Neonatal conjunctivitis