Conjunctivitis (peds): Difference between revisions
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==Neonatal Conjunctivitis==
''This page is for pediatric patients (non-neonatal); for neonatal patients see [[Neonatal conjunctivitis]] and adult patients see [[conjunctivitis]]''
===Background===
==Background==
*Vesicles + conjunctivitis = full sepsis eval + acyclovir
*Most common cause of [[acute red eye]]
*Viral infection is usual etiology


===Diagnosis===
{{Conjunctivitis DDX}}
*Chlamydial
**Can range from mild to severe hyperemia w/ thick mucopurulent discharge
*Gonococcal
**May present as typical conjunctivitis or w/ severe lid edema, cornea ulceration
===Work-Up===
*Gram stain/culture to r/o gonorrhea


===DDx===
==Clinical Features==
*Chemical
*Injected conjunctiva with perilimbal sparing
**Due to ocular prophylaxis
*Rarely painful; more irritated
**Occurs on 1st day of life
*Gonococcal
**Peaks at 3-5 days after birth
**Has potential to cause loss of vision
*Chlamydia
**Peaks from 1wk to 1 month after birth
*Herpetic
**Peaks at 6-14 days of life
**May lead to keratitis and disseminated infection


===Treatment===
{{Conjunctivitis images}}
*Gonococcal
**Cefotaxime 100mg/kg IV or IM OR [[ceftriaxone]] 25-50mg/kg IV or IM x1 (not to exceed 125mg)
***Cefotaxime is preferred b/c does not displace bilirubin
**Disseminated disease should be suspected until CSF is negative
**Topical tx is unnecessary
*Chlamydial
**Erythromycin 50mg/kg PO QD in 4 divided doses x 14 days
**Topical tx is unnecessary
*Herpetic
**Acyclovir 20mg/kg IV q8hr x 14-21d
**Topical antiviral
**Full sepsis evaluation
*Chemical
**Watchful waiting


===Disposition===
==Differential Diagnosis==
*Gonococcal
*[[Kawasaki Disease]]
**Admit
*[[Lice|Pediculosis]]
*Herpetic
**Admit


==Childhood Conjunctivitis==
{{Unilateral red eye DDX}}
===DDX===
*Viral
**Most frequently caused by adenovirus
**Herpes infection requires immediate treatment
*Bacterial
**Consider chlamydial and gonococcal, esp in adolescents
*Allergic
*Kawasaki Disease
*Pediculosis


===Treatment===
==Evaluation==
*Viral
[[File:Conjunctivitis.jpg|thumb|Conjunctivitis with limbus sparing]]
**Non-herpetic: supportive care
*Typically clinical
**Herpetic: Acyclovir, ophto referral
{{Clinical diagnosis of conjunctivitis}}
*Bacterial
**If otitis media + conj give PO abx
**If conj only give topical abx
***Erythromycin ointment
****Note: does not adequately cover H. flu and Moraxella
*****If tx failure switch to fluoroquinolone drops
*Allergic
**Ketotifen 1 drop q8-12hr OR olopatadine 1-2 drop QD


==Source==
==Management==
Tintinalli
*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


[[Category:Peds]]
===Bacterial Causes===
Newborn, see [[Neonatal conjunctivitis]]
 
{{GC Conjunctivitis Treatment}}
 
{{Bacterial Conjunctivitis Treatment}}
 
===Viral Causes===
*Non-herpetic: supportive care
*Herpetic: [[Acyclovir]], ophto referral
 
===[[Allergic conjunctivitis|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]]
 
==References==
<references/>
 
 
[[Category:Pediatrics]]
[[Category:Ophthalmology]]
[[Category:ID]]

Revision as of 19:25, 26 September 2020

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
  • Viral infection is usual etiology

Conjunctivitis Types

Clinical Features

  • Injected conjunctiva with perilimbal sparing
  • Rarely painful; more irritated

Conjunctivitis Images

Differential Diagnosis

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Evaluation

Conjunctivitis with limbus sparing
  • Typically clinical

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
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 [1]
    • 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 250mg IM one 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

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

References

  1. ↑ Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N. Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis. J Pediatric Infect Dis Soc. 2018 Aug 17;7(3):e107-e115. doi: 10.1093/jpids/piy060. PMID: 30007329; PMCID: PMC6097578.
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