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
• Viral infection is usual etiology

Conjunctivitis Types

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

Clinical Features

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

Differential Diagnosis

• Kawasaki Disease
• Pediculosis

Unilateral red eye

• 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
  • Conjunctival laceration
  • Globe rupture^
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic optic neuropathy
  • Ultraviolet keratitis

^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
  • 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

Bacterial Conjunctivitis

• Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!

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

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

• Conjunctivitis
• Neonatal conjunctivitis