Diagnosis and management of pediatric conjunctivitis

2. Introduction
• One of the most common ophthalmologic complaints
managed in the pediatric emergency department (ED) is
conjunctivitis.
• Conjunctivitis is common in childhood and may be
infectious or noninfectious.
 Most commonly, conjunctivitis is due to:
• bacterial infection,
• viral infection, or
• allergic hypersensitivity.
• The etiology of conjunctivitis varies with the age of the
child.

3. • The approach to a patient with conjunctivitis
should begin by eliminating other causes of a red
eye, such as
• iritis,
• keratitis,
• glaucoma,
• corneal abrasion,
• measles,
• Kawasaki disease, and others

4. According to Age?
• The evaluation then varies with the age of the
child.
• If conjunctivitis develops in the first 24 hours of
life, it is most likely due to chemical irritation
from an agent used for prophylaxis of gonorrhea.
• However, all neonates with conjunctivitis should
be evaluated for both N. gonorrhea and C.
trachomatis with Gram stains and culture.

5. • If gram-negative diplococci are seen, infection
with gonorrhea is assumed and should be
treated with systemic antibiotics.

6. • Infants younger than 30 days that do not have
gonorrhea should be treated with oral
erythromycin for presumed chlamydia
infection.

7. • Older infants and toddlers are more likely to
have bacterial conjunctivitis.
• Their ears must be checked for otitis media,
which, if present, should be treated with oral
antibiotics.

8. • Patients with hyperacute conjunctivitis with
rapidly progressive hyperemia, edema, and
copious, purulent discharge should be evaluated
for N. gonorrhea and N. meningitidis with Gram
staining and culture.
• Both of these organisms are treated with
systemic antibiotics and frequent irrigation of
the eyes.

9. • If the child does not have otitis media or
hyperacute conjunctivitis, empiric topical
antibiotics should be prescribed.

10. • Isolation is usually not needed for most cases
of bacterial conjunctivitis, except those that
involve Neisseria species and conjunctivitis–
otitis media syndrome.

11. • Conjunctivitis in school-aged children and
adolescents is most likely to be of viral or allergic
origin.
• Associated findings that can help differentiate the
two are preauricular lymphadenopathy,
pharyngitis, upper respiratory tract infection,
history of asthma, eczema or rhinitis, and
history of recurrent conjunctivitis.
• Also, if any vesicles are seen in the vicinity, HSV or
varicella–zoster virus is the likely etiologic agent.

12. • If either of these is suspected, a fluorescein
examination of the eye must be performed to
look for the characteristic dendritic pattern of
herpes keratitis.
• Ophthalmologic consultation is needed for both
herpes and zoster involvement of the
conjunctiva.
• Other viral forms of conjunctivitis require only
supportive care but are highly contagious and
require approximately 1 week of isolation.

13. • Allergic conjunctivitis is not contagious,
requires no isolation, and can be treated with
antihistamines, decongestants, H1- receptor
antagonists, mast cell stabilizers, or
nonsteroidal anti-inflammatory drugs.

14. Age groups Common etiology Treatment
Neonates < 24 hours Chemical
conjunctivitis
Observation
< 1 week Neisseria gonorrhea Hospitalize,
ceftriaxone
1–2 weeks Chlamydia
trachomatis
Oral erythromycin
Infants and toddlers Without otitis Haemophilus
influenzae,
Streptococcus
pneumoniae,
Branhamella
catarrhalis
Topical antibiotics
(Polysporin* or
Polytrim†)
With otitis H. influenzae Oral antibiotics
School-age children 3–5 years HSV, varicella–zoster
conjunctivitis
Topical antivirals, oral
acyclovir
School-age children
and adolescents
Viral conjunctivitis Supportive care,
artificial tears
Allergic conjunctivitis Antihistamines,
decongestants, H1,
antagonists, mast cell
stabilizers, NSAIDS

15. CLINICAL MANIFESTATIONS
• The signs and symptoms of conjunctivitis are
similar with each of these etiologies:

16. Bacterial Viral Allergic
Common etiologic
agent
Haemophilus
influenzae,
Streptococcus
pneumoniae,
Staphylococcus
aureus, Neisseria
gonorrhea,
Chlamydia
trachomatis
Adenovirus, HSV,
HZV, enterovirus
Pollens, allergens
Prevalent age Neonates to toddlers School age to adults Late childhood to
early adulthood
Character of discharge Purulent Watery Mucoid
Amount of discharge 1+ to 3+ 1+ to 2+ 1+
Injection 3+ 2+ 1+
Lymphadenopathy Occasional Common None
Smear of exudate Bacteria, PMNs Lymphocytes Eosinophils
Associated symptoms Papillary response Follicular response Chemosis
Associated disorders Otitis media Pharyngitis, URI Rhinitis, asthma,
eczema
Treatment Antibiotics Artificial tears,
acyclovir
Antihistamines,
decongestants, mast
cell stabilizers,
NSAIDS

17. CONDITION ETIOLOGY SIGNS AND SYMPTOMS TREATMENT
Bacterial conjunctivitis
Haemophilus influenzae,
Haemophilus aegyptius,
Streptococcus
pneumoniae
Mucopurulent unilateral
or bilateral discharge,
normal vision,
photophobia
Topical antibiotics,
parenteral ceftriaxone
for gonococcus, H.
influenzae
Neisseria gonorrhoeae
Conjunctival injection
and edema (chemosis);
gritty sensation
Viral conjunctivitis
Adenovirus, ECHO virus,
coxsackievirus
As above; may be
hemorrhagic, unilateral
Self-limited
Neonatal conjunctivitis
Chlamydia trachomatis,
gonococcus, chemical
(silver nitrate),
Staphylococcus aureus
Palpebral conjunctival
follicle or papillae; as
above
Ceftriaxone for
gonococcus and
erythromycin for C.
trachomatis
Allergic conjunctivitis
Seasonal pollens or
allergen exposure
Itching, incidence of
bilateral chemosis
(edema) greater than
that of erythema, tarsal
papillae
Antihistamines, topical
mast cell stabilizers or
prostaglandin inhibitors,
steroids

18. Acute Bacterial Conjunctivitis
• Beyond the neonatal period, acute conjunctivitis
is twice as likely to be due to bacteria than to
viruses.
• H. influenzae is the most commonly isolated
organism, followed by S. pneumoniae and
Moraxella catarrhalis.
• Staphylococcal species were isolated from the
conjunctivae of children with conjunctivitis and
from those of asymptomatic children at equal
rates; thus, their role in the pathogenesis of
conjunctivitis remains controversial.

19. • Other bacteria were isolated from conjunctival
cultures but at very small frequencies.
• The child may present with any of the following
signs and symptoms:
• itching,
• burning,
• mucopurulent or purulent discharge,
• eyelid edema, or
• conjunctival erythema.

21. • There are no pathognomonic signs to
distinguish bacterial from viral conjunctivitis;
however, there are some clues that may help
differentiate the two.
• Preschool-aged children are more likely to
have bacterial etiologies, although there is
considerable overlap in age ranges.

22. • The development of papillae, a papillary response, on
the conjunctiva and bilateral disease are also more
likely when the conjunctivitis is bacterial in origin.
• Associated otitis media is highly suggestive of a
bacterial etiology.
• However, given the significant overlap in the signs and
symptoms of bacterial and viral conjunctivitis,
clinicians cannot reliably predict etiology based on
clinical examination.
• Gram stain of conjunctival exudates may be helpful,
but some studies show poor sensitivity.

23. • Acute bacterial conjunctivitis is a self-limited disease,
although it is frequently treated with topical
antibiotics
• There are many topical antimicrobial agents available.
• Three inexpensive, commonly prescribed topical
antibiotics, trimethoprim , gentamicin, and sodium
sulfacetamide, were compared in a doubleblind study,
which showed no difference in rate or speed of cure.

24. • In general, when choosing an antibiotic, one
should consider the antibiotic’s spectrum of
activity, side effects, and cost.
• trimethoprim–polymyxin (Polytrim) are
inexpensive, have few side effects, and have good
broad-spectrum coverage.
• Sodium sulfacetamide is inexpensive and has
good gram-positive coverage, but it stings when
applied.
• Aminoglycosides have good gram-negative
coverage, but they are expensive and cover
streptococci poorly. Epithelial toxicity and
corneal ulceration can occur, especially with
prolonged use of aminoglycosides.

25. • Erythromycin is inexpensive and has good
gram-positive and Chlamydia coverage, but it
has poor activity against Haemophilus
species, B. catarrhalis, staphylococcal
species, and gram-negative organisms.
• Fluoroquinolones are expensive but have
broad-spectrum coverage and few side effects
other than local irritation.

26. • Chloramphenicol is inexpensive and has broad-
spectrum coverage, but there are case reports of
associated aplastic anemia with topical
ophthalmic administration.
• Corticosteroids are sometimes combined with
ophthalmic antibiotic preparations. Use of these
agents should be avoided because the
corticosteroid may impede eradication of the
bacteria; worsen herpes keratitis, which may
have been mistaken for conjunctivitis; and
increase intraocular pressure.

28. Ointments VS Drops
• Antimicrobial medications for conjunctivitis are typically
given as one drop (or one-half inch of ointment) four times
daily for 5-7 days.
• It is important to use one drop at a time. Otherwise, the
second eye drop will wash the first one out of the eye.
• If you use more than one types of eye drops, wait at least 5
minutes between each drop.
• If you use eye drops as well as eye ointment, apply the eye
drops first, and then apply the eye ointment 5 minutes
later.
• Ointments have the advantage of increased dwell time in
the eye, but often patients and parents of children prefer
drops, and no therapeutic advantage of one over the other
has been demonstrated.

29. • the texture of eye
drops is somewhat
thinner and more
watery. Drops are
also formulated for
application directly
to the eye, and not
to the eyelid.
• In contrast, the
consistency of most
eye ointments is
thicker and includes
antibiotics to aid in
treating an infection
as well as alleviating
the pain associated
with the particular
ailment.
• Another important
difference involves the
introduction of moisture
along the surface of the
eye.
• Drops primarily aid in the
process of treating rough,
dry eyes by adding
additional fluid to the
surface of the eye.
• While many eye ointments
do provide some type of
moisture, the products also
provide a more aggressive
treatment for redness due
to eyestrain or allergies,
ease pain associated with
dryness, and in general
reduce just about any type
of irritation to a greater
degree than simple drops.
• Depending on the type
of eye condition that
exists, both eye
ointments and drops
may be used.
• In general, the drops will
help to ease discomfort,
while ointments treat
the underlying condition.
• However, many
ointments also include
properties that are
intended to treat pain as
well as minimize
bacterial and other types
of infections.
• In some cases, the
ointments also provide a
barrier that protects the
eye as it recovers from
injury or some type of
surgical procedure.
Ointments VS Drops

30. VIRAL CONJUNCTIVITIS
• Adenoviral Conjunctivitis. Most viral conjunctivitis is
caused by adenovirus. Approximately 20% of all cases
of conjunctivitis are caused by adenovirus, with a
seasonal predilection for fall and winter months.
• Several forms of adenoviral infection occur:
 follicular conjunctivitis,
 pharyngoconjunctival fever,
 epidemic keratoconjunctivitis, and, occasionally,
 acute hemorrhagic conjunctivitis.
• All forms of adenoviral conjunctivitis are extremely
contagious.

31. • Transmission of infection is usually through
direct contact with infected persons or contact
with contaminated instruments.
• Thus, healthcare workers who manipulate the
eyes should wear gloves and practice good hand-
washing techniques.
• Instruments used to examine patients should
also be cleaned after use.
• Families must be instructed to separate the
towels and bed sheets of the patient from other
family members.

32. • The affected child should be kept home for
approximately 1 week after the onset of
symptoms.
• Treatment is supportive regardless of the type of
adenoviral conjunctivitis.
• Cold compresses, artificial tears, and topical
vasoconstrictors may provide comfort.
• Studies comparing antiviral agents and anti-
inflammatory medications with artificial tears
show no significant difference between these
medications and artificial tears.

33. • Topical steroids should be avoided because
they have significant side effects, such as
superinfection, glaucoma, and cataract .
• Topical steroids also may exacerbate a missed
diagnosis of herpes conjunctivitis, may
enhance adenoviral replication, and may
increase the duration of adenoviral shedding.
• Topical antibiotics are usually unnecessary, as
secondary bacterial infections are rare.

35. THANKS FOR YOUR ATTENTION