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Conjunctivitis, Pediatric

Basics

Description

- Gram stain - Note: always for ophthalmia neonatorum - Gonococcus: gram-negative intracellular diplococcus - Chlamydia: intracytoplasmic, paranuclear inclusion bodies on Gram stain and conjunctival scraping with Giemsa stain for basophilic intracytoplasmic inclusion bodies - Viral or chemical: polymorphonuclear leukocytes without bacteria

- Ophthalmia neonatorum - Chemical conjunctivitis: noninfectious, mild, self-limited; result of silver nitrate or povidone-iodine administration - Birth trauma: often unilateral subconjunctival hemorrhage, may have associated eyelid contusion, history of forceps use or difficult delivery - Congenital glaucoma: mild redness, minimal discharge. Look for enlarged eye, cloudy cornea, tearing, and photophobia. - Nasolacrimal duct obstruction: unilateral or bilateral discharge, may be clear to mucopurulent with reflux from nasolacrimal sac. Conjunctiva is usually white and nonerythematous.

- All conjunctivitis - Preseptal cellulitis: early eyelid edema/erythema; looks like conjunctivitis, especially in young children with a difficult exam. Motility deficit, proptosis, decreased vision, and afferent pupillary defect are consistent with orbital cellulitis. - Foreign body - Blepharitis: inflammation of eyelids, history of gritty/burning sensation, excessive tearing, significant eyelid swelling - Corneal abrasion: history of pain, associated trauma; significant tearing, photophobia, erythema. Diagnose with fluorescein and blue light. - Keratitis: signifies corneal infection; may have associated conjunctivitis. Primary herpes keratitis is associated with vesicular eyelid rash and pain. Consult an ophthalmologist. Bacterial keratitis may be caused by staphylococci, streptococci, and Pseudomonas; Lyme spirochete; or vitamin A deficiency. - Episcleritis: inflammation of the thick loose connective tissue between the clear conjunctiva and the white-appearing stroma of the sclera; rare disease in childhood; can be associated with rheumatologic disease - Scleritis: presents as red eye; severe disease involving inflammation of the sclera; rare in childhood; associated with systemic disease; requires oral or IV steroids - Iritis/uveitis: frequently unilateral, with or without a history of trauma; photophobia, decreased vision, and constant pain (except if associated with juvenile rheumatoid arthritis). Contagious history is rare. Consult an ophthalmologist for full evaluation, including pupillary dilation.

An inflammatory process of the conjunctiva, the membrane covering the eye and inside of the eyelids, manifested by erythema and edema, frequently with tearing and discharge. There is a wide range in severity and many potential causes. It is critical to rule out gonococcus infection because of the destructive nature of the eye disease and potential for vision loss.

Epidemiology

Incidence

  • Children: Viral infection is the most common cause and is highly contagious.
  • Neonates: Ophthalmia neonatorum, conjunctivitis in the 1st month of life, is the most common infection in neonates. Remains a significant cause of blindness in children worldwide. Chlamydia trachomatis is the most common infectious cause.

Pathophysiology

  • Results from bacterial, viral, allergic, or toxic activation of the inflammatory response that causes dilation and exudation from conjunctival blood vessels
  • Pathology involves dilated conjunctival capillaries with leukocytic infiltration and edema of conjunctiva and substantia propria.

Etiology

  • Ophthalmia neonatorumIf present in the first 24 hours of life, most likely due to chemical irritation from silver nitrate or povidone-iodine (e.g., Wokadine, Betadine) eyedropsGonococcal conjunctivitis is treatable if recognized early but devastating if diagnosis is delayed or missed.Chronic Chlamydia infection can lead to scarring and corneal opacity. Chlamydial pneumonia develops in 20% of patients with chlamydial conjunctivitis.
  • BacterialAgents include staphylococci, streptococci, Haemophilus, Moraxella, and Pseudomonas.Serious complications of these are rare.
  • ViralAdenovirus is the most common agent.Recurrent herpes simplex virus infection can lead to significant visual loss from corneal scarring, even with proper therapy.Other viral etiologies usually follow a benign course but rarely can lead to conjunctival scarring.
  • AllergicIgE-mediated hypersensitivity response

Diagnosis

History

  • Ophthalmia neonatorumGonococcus: typically presents 2-4 days after birth with mucopurulent dischargeChlamydia: typically presents 4-14 days after birth with mucopurulent discharge
  • BacterialEye redness and mucopurulent discharge. Patient may complain of sticky eyelids upon waking. Mild photophobia and discomfort may be present but are typically not painful.
  • ViralHSV ocular infection may present as conjunctivitis; often associated with corneal anesthesia, so painless. In neonates, it occurs 1-2 weeks after birth as unilateral serous discharge and conjunctival injection.Other viral causes often present with upper respiratory symptoms, fever, sore throat, eye redness, tearing, serous discharge, eyelid edema, and photophobia. Typically begins in one eye but spreads to the other within a few days. History of similar infection in siblings or contacts is common.
  • AllergicBilateral itching and tearing; classically, a complaint of itching or foreign body sensation in an older child with red eyes

Physical Exam

  • GeneralCornea is clear.Vision, pupils, and ocular motility are normal.Refer to an ophthalmologist for vesicular rash on eyelids or corneal changes, as the condition may be caused by herpes simplex virus and can be vision threatening.
  • BacterialWide range of clinical presentation, from mild hyperemia to significant injection and mucopurulent discharge (opaque and thick)Injected conjunctiva, episcleral vessels, palpebral conjunctival papillaePreauricular lymphadenopathy less common
  • ViralHSV ocular infection may involve corneal ulceration or dendritic or disciform keratitis.Serous discharge (clear and watery)May involve pseudomembrane formation, pinpoint subconjunctival hemorrhages, and palpable preauricular lymph nodes
  • AllergicBilateral conjunctival edema and chemosis

Alert

  • Failure to diagnose gonococcal conjunctivitis may lead to corneal perforation or visual loss.
  • HSV ocular infection is associated with a significant risk of blindness; have high suspicion for HSV with any recurrent unilateral eye redness, corneal changes, or vesicular rash on eyelids.
  • Steroids can activate or accelerate unrecognized herpes simplex virus infection, and chronic use can lead to raised intraocular pressure or cataract formation.
  • Chronic use of empiric broad-spectrum antibiotics for self-limited conjunctivitis can promote bacterial resistance, although less so than for systemic antibiotic administration.

Diagnostic Tests & Interpretation

Lab

  • Gram stainNote: always for ophthalmia neonatorumGonococcus: gram-negative intracellular diplococcusChlamydia: intracytoplasmic, paranuclear inclusion bodies on Gram stain and conjunctival scraping with Giemsa stain for basophilic intracytoplasmic inclusion bodiesViral or chemical: polymorphonuclear leukocytes without bacteria
  • CultureViral: Cultures for HSV and adenovirus are not clinically useful.Bacterial: blood agar and chocolate agarGonococcus: Thayer-Martin mediaChlamydia: Culture techniques are not widely available. However, they remain the gold standard for diagnosis. Specimens should be obtained using an aluminum-shafted Dacron-tipped swab and processed within 24 hours. A positive test is confirmed when the organism is identified using fluorescein-conjugated monoclonal antibody. Other equally effective methods involve polymerase chain reaction or direct fluorescent antibody.
  • Conjunctival scrapingsAllergic: mast cells and eosinophils
  • Serum testsAllergic: IgE may be elevated.Chlamydia: The diagnosis of chlamydial pneumonia can be made with a serum test but is not reliable for chlamydial conjunctivitis.

Differential Diagnosis

  • Ophthalmia neonatorumChemical conjunctivitis: noninfectious, mild, self-limited; result of silver nitrate or povidone-iodine administrationBirth trauma: often unilateral subconjunctival hemorrhage, may have associated eyelid contusion, history of forceps use or difficult deliveryCongenital glaucoma: mild redness, minimal discharge. Look for enlarged eye, cloudy cornea, tearing, and photophobia.Nasolacrimal duct obstruction: unilateral or bilateral discharge, may be clear to mucopurulent with reflux from nasolacrimal sac. Conjunctiva is usually white and nonerythematous.
  • All conjunctivitisPreseptal cellulitis: early eyelid edema/erythema; looks like conjunctivitis, especially in young children with a difficult exam. Motility deficit, proptosis, decreased vision, and afferent pupillary defect are consistent with orbital cellulitis.Foreign bodyBlepharitis: inflammation of eyelids, history of gritty/burning sensation, excessive tearing, significant eyelid swellingCorneal abrasion: history of pain, associated trauma; significant tearing, photophobia, erythema. Diagnose with fluorescein and blue light.Keratitis: signifies corneal infection; may have associated conjunctivitis. Primary herpes keratitis is associated with vesicular eyelid rash and pain. Consult an ophthalmologist. Bacterial keratitis may be caused by staphylococci, streptococci, and Pseudomonas; Lyme spirochete; or vitamin A deficiency.Episcleritis: inflammation of the thick loose connective tissue between the clear conjunctiva and the white-appearing stroma of the sclera; rare disease in childhood; can be associated with rheumatologic diseaseScleritis: presents as red eye; severe disease involving inflammation of the sclera; rare in childhood; associated with systemic disease; requires oral or IV steroidsIritis/uveitis: frequently unilateral, with or without a history of trauma; photophobia, decreased vision, and constant pain (except if associated with juvenile rheumatoid arthritis). Contagious history is rare. Consult an ophthalmologist for full evaluation, including pupillary dilation.
  • Systemic diseases with red eyeVaricella: ocular involvement in rare cases. Treat with antiviral medications.Stevens-Johnson syndrome: secondary to viruses, mycoplasma, or adverse drug reaction. Mucous membrane involvement may lead to conjunctival bullae with risk of rupture and subsequent scarring.Kawasaki disease: acute vasculitis. Classic symptoms include fever 5 days, plus 4 out of 5 of the following: bilateral, limbic-sparing nonexudative conjunctivitis; oropharyngeal changes (including strawberry tongue); cervical adenopathy; polymorphous rash; and extremity changes/swelling of palms and soles with peeling around nail beds.Measles: presents with fever, rash, cough coryza, and conjunctivitisCat-scratch disease: Parinaud syndrome includes granulomatous conjunctivitis and adenopathy.

Treatment

Medication

  • Ophthalmia neonatorumGonococcus: ceftriaxone, 25-50 mg/kg/dose (max 125 mg) IV or IM as a single dose and ocular irrigation followed by topical 0.5% erythromycin ophthalmic ointment q.i.d. for 14 days. Also treat for Chlamydia.Chlamydia: oral erythromycin suspension, 12.5 mg/kg/dose q6h for 14 days. Topical 0.5% erythromycin ophthalmic ointment q.i.d. both eyes for 14 days as above. (Povidone-iodine 1.25% ophthalmic drops q.i.d. can be used if other antibiotics are not readily available.)Important to treat both of these conditions systemically as well as topically
  • BacterialOften self-limited; however, studies have shown empiric antibiotic treatment can shorten duration of symptoms and reduce transmission.Treatment includes erythromycin ointment, sulfacetamide 10%, polymyxin-trimethoprim, fluoroquinolone, or azithromycin drops.
  • ViralHerpes simplex: topical trifluorothymidine (Viroptic solution), 1 drop q2h while awake (max 9 drops/24 h) until reepithelialization of ulcer; then 1 drop q4h for 7 days (do not exceed 21 days of treatment) with or without systemic acyclovirTopical glucocorticoid therapy is contraindicated.Other viral: over-the-counter antihistamine or decongestant drops for comfortCidofovir has recently been considered as a potential antiadenoviral therapy, but its clinical use is limited by local toxicity to the skin, eyelids, and conjunctiva.
  • AllergicA new class of topical mast cell stabilizers such as olopatadine b.i.d. is effective for more involved cases.

Additional Treatment

General Measures

  • Ophthalmia neonatorumCases of suspected gonococcal conjunctivitis should be hospitalized for IV antibiotics and workup for sepsis.For suspected chlamydial infection, topical and oral therapy is usually appropriate.
  • BacterialUsually self-limited, but treatment may help shorten course and prevent spread of infection. Contact lens users should remove lenses until infection clears and consider use of fluoroquinolone.
  • ViralSuspected HSV warrants hospitalization for IV antiviral therapy.For suspected adenovirus, children should stay home from school until discharge is minimal and discomfort has subsided; cool compresses for comfort
  • AllergicRemove offending allergen if possible.Mild symptoms can be treated with preservative-free artificial tears. Consider topical or systemic antiallergy medicine if symptoms persist.Consider treating other atopic conditions which are often present.
  • ChemicalClose observation only. Remove offending agent; self-limited

Ongoing Care

Follow-up Recommendations

Patient Monitoring

  • Daily follow-up is necessary for gonococcus, Chlamydia, and herpes simplex virus.
  • For epidemic viral conjunctivitis, frequency is dictated by severity (daily to weekly).
  • For allergic conjunctivitis, follow-up can be made after a few weeks of treatment.
  • No office follow-up is recommended for routine conjunctivitis.
  • Follow atypical conjunctivitis closely until a more serious disease can be excluded.
  • A nonresponsive or worsening condition needs ophthalmic consultation.

Complications

  • Significant complications are extremely rare for common bacterial, viral, or allergic conjunctivitis.
  • Blindness may result from untreated neonatal conjunctivitis or from recurrent HSV ocular infection.

Additional Reading

  • American Academy of Ophthalmology. Conjunctivitis. Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2013.
  • Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310(16):1721-1729. [View Abstract]
  • Bielory L, Mongia A. Current opinion of immunotherapy for ocular allergy. Curr Opin Allergy Clin Immunol. 2002;2(5):447-452. [View Abstract]
  • Brook I. Ocular infections due to anaerobic bacteria in children. J Pediatr Ophthalmol Strabismus. 2008;45(2):78-84. [View Abstract]
  • Crede CSF. Reports from the obstetrical clinic in Leipzig: prevention of eye inflammation in the newborn. Am J Dis Child. 1971;121(1):3-4. [View Abstract]
  • Greenberg MF, Pollard ZF. The red eye in childhood. Pediatr Clin North Am. 2003;50(1):105-124. [View Abstract]
  • Hillenkamp J, Reinhard T, Ross RS, et al. The effects of cidofovir 1% with and without cyclosporin a 1% as a topical treatment of acute adenoviral keratoconjunctivitis: a controlled clinical pilot study. Ophthalmology. 2002;109(5):845-850. [View Abstract]
  • Isenberg SJ, Apt L, Valenton M, et al. A controlled trial of povidone-iodine to treat infectious conjunctivitis in children. Am J Ophthalmol. 2002;134(5):861-868. [View Abstract]
  • Rietveld RP, van Weert HC, ter Riet G, et al. Diagnostic impact of signs and symptoms in acute infectious conjunctivitis: systematic literature search. BMJ. 2003;327(7418):789. [View Abstract]
  • Sethuraman US, Kamat D. The red eye: evaluation and management. Clin Pediatr. 2009;48(6):588-600. [View Abstract]
  • Sheikh A, Hurwitz B, van Schayck CP, et al. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012:9:CD001211. [View Abstract]
  • Strauss EC, Foster CS. Atopic ocular disease. Ophthalmol Clin North Am. 2002;15(1):1-5. [View Abstract]
  • Teoh DL, Reynolds S. Diagnosis and management of pediatric conjunctivitis. Pediatr Emerg Care. 2003;19(1):48-55. [View Abstract]
  • Trocme SD, Sra KK. Spectrum of ocular allergy. Curr Opin Allergy Clin Immunol. 2002;2(5):423-427. [View Abstract]

Codes

ICD09

  • 372.30 Conjunctivitis, unspecified
  • 077.99 Unspecified diseases of conjunctiva due to viruses
  • 771.6 Neonatal conjunctivitis and dacryocystitis
  • 098.40 Gonococcal conjunctivitis (neonatorum)
  • 372.05 Acute atopic conjunctivitis
  • 372.30 Conjunctivitis, unspecified
  • 372.03 Other mucopurulent conjunctivitis
  • 077.98 Unspecified diseases of conjunctiva due to chlamydiae

ICD10

  • H10.9 Unspecified conjunctivitis
  • B30.9 Viral conjunctivitis, unspecified
  • P39.1 Neonatal conjunctivitis and dacryocystitis
  • A54.31 Gonococcal conjunctivitis
  • A74.0 Chlamydial conjunctivitis

SNOMED

  • 9826008 Conjunctivitis (disorder)
  • 45261009 Viral conjunctivitis (disorder)
  • 34298002 Neonatal conjunctivitis (disorder)
  • 231858009 Gonococcal conjunctivitis (disorder)
  • 231861005 Chlamydial conjunctivitis (disorder)

FAQ

  • Q: Is conjunctivitis contagious?
  • A: All infectious conjunctivitis is contagious but to varying degrees. Viral or epidemic keratoconjunctivitis (EKC) is the most contagious. Careful handling of secretions, tissues, towels, and bed linens and strict hand washing usually prevent spread. Wipe surfaces with isopropyl alcohol or dilute bleach to prevent recontamination. Gonococcus, Chlamydia, and herpes simplex virus can be transmitted through infected discharge or secretions, but this is less common. The most common source is the infected birth canal.
  • Q: Should the patient with "pink eye" (non-Gonococcus, non-Chlamydia, non-herpes simplex virus conjunctivitis) be treated with empiric antibiotics?
  • A: There is some benefit to empiric antibiotic treatment in bacterial conjunctivitis but not in viral or allergic etiologies. Practically, it is often difficult to distinguish viral and bacterial conjunctivitis based on symptoms alone, and return to school is often contingent on initiation of antibiotic therapy. Providers should be aware that empiric treatment with topical antibiotics can cause harm in the case of sulfa-containing compounds. Antibiotic toxicity, including Stevens-Johnson reactions, can occur from sulfa antibiotics, and use of antibiotics long term promotes selection of resistant strains of bacteria. Empiric treatment also increases manipulation of the infected eye and thus increases the risk of spread.
  • Q: How long is the patient with pink eye (non-Gonococcus, non-Chlamydia, non-herpes simplex virus conjunctivitis) contagious, and when can the patient return to school?
  • A: The organism can be recovered from the eye for up 2 weeks after onset of symptoms, demonstrating that patients are infectious during this time. Practically, children should probably be kept out of school at least 24 hours after onset of therapy, if indicated, ideally until discharge is minimal and discomfort has subsided.