Conjunctivitis in children

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]

Synonyms and keywords: Madras eye, pink-eye, pinkeye, conjunctivitis, ophthalmia, rubor, inflammation, ophthalmitis, redness, neonatal conjunctivitis

Overview

Conjunctivitis is characterized by inflammation and swelling of the conjunctival tissue which can be associated with engorgement of the blood vessels, ocular discharge, and pain. Neonatal conjunctivitis is a red eye in a newborn caused by infection, irritation, or a blocked tear duct. When caused by an infection, neonatal conjunctivitis can be very serious.

Historical Perspective

• In 1750, Neonatal conjunctivitis was first described by S.T. Quellmaz.
• In 1881, Crédé introduced 2% silver nitrate for the first time as a prophylaxis treatment method for conjunctivitis in the newborns.
• In 1883, Koch discovered the bacilli of two different forms of infectious conjunctivitis.
• In 1953, Micheal Hogan first described the association between atopic dermatitis and conjunctivitis.

Classification

Conjunctivitis can be classified into subtypes:

• Bacterial conjunctivitis
• Viral conjunctivitis
• Allergic conjunctivitis
• Chemical conjunctivitis
• Immune mediated conjunctivitis

Pathophysiology

• The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as streptococci, staphylococci, and corynebacteria. Alterations in the bacterial titer, or in the species of bacteria can lead to clinical infection.
• Alteration in the flora can also result from external contamination, the use of topical or systemic antibiotics, or spread from adjacent infectious sites.
• Disruption of defense barriers can lead to infection. The primary defense against infection is the epithelial layer covering the conjunctiva.
• Secondary defense include hematologic immune mechanisms carried by the conjunctival vessels, tear film immunoglobulins and lysozyme and the rinsing action of lacrimation and blinking.

Causes

• Common causes of neonatal conjunctivitis include:
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Herpes zoster virus, HSV

• Common causes of Conjunctivitis in children inculde:
  • Haemophilus influenzae
  • Streptococcus pneumoniae
  • Adenovirus
  • Moraxella catarrhalis (rarely)

Differentiating conjunctivitis from other Diseases

In children with red eye and conjunctivitis symptoms, mentioned diagnosis should be excluded:

• Corneal abrasion
• Subconjunctival haemorrhage
• Blepharitis
• Periorbital cellulitis
• Uveitis
• Episcleritis

Epidemiology and Demographics

• Bacterial conjunctivitis most commonly affects individuals younger than <6 years of age. Recent studies have shown that haemophilus influenzae and streptococcus pneumoniae are the two organisms most commonly responsible for bacterial conjunctivitis in children.
• Viral conjunctivitis occurs most often in the fall and winter and usually affects children older than 6 years.
• Children age 0-4 years shows a peak of conjunctivitis during the month of March.
• Boys and girls are affected in similar proportions.

Risk Factors

Risk factors of neonatal conjunctivitis includes:

• STDs in mother
• HIV infected mothers
• Exposure of the infant to infectious organisms
• Prematurity
• Poor hygienic delivery conditions
• Ocular trauma during delivery

Natural History, Complications and Prognosis

Natural history

• Chlamydial conjunctivitis is cuased by chlamydia trachomatis which is one of the most common causes in neonatal conjunctivitis. Women with untreated chlamydia can pass the bacteria to her baby during childbirth. Symptoms include red eye, swelling of the eyelids, and purulent discharge. Symptoms are likely to appear 5 to 12 days after birth. About half ofnewborns with chlamydial conjunctivitis also have the infection in other parts of their bodies.
• Gonococcal conjunctivitis is caused by neisseria gonorrhoeae. Women with untreated gonorrhea can pass the bacteria to her baby during childbirth. Symptoms usually include red eye, thick pus in the eyes, and swelling of the eyelids. This type of conjunctivitis usually begins about 2 to 4 days after birth. It can be associated with bacteremia and meningitis in newborns.
• Chemical conjunctivitis can occur when eye drops are given to newborns or children to help prevent a bacterial infections. Symptoms of chemical conjunctivitis usually include mildly red eye and some swelling of the eyelids. Symptoms are likely to last for only 24 to 36 hours.
• Conjunctivitis caused by adenovirus is frequently hemorrhagic, and cases of adenovirus keratoconjunctivitis are often accompanied by dramatic degrees of periorbital swelling.

Complications

Complications to neonatal conjunctivitis include:

• Pseudomembrane formation
• Corneal edema
• Peripheral pannus formation
• Corneal opacification
• Corneal perforation
• Endophthalmitis
• Loss of eye and blindness
• Infantile pneumonia
• Nasopharyngeal, rectaland vaginal colonization
• Some systemic complications particularly in gonococcal conjunctivitis including:
  • Stomatitis
  • Arthritis
  • Rhinitis
  • [Septicemia]]
  • Meningitis

Complications of viral conjunctivitis in children including:

• Keratitis
• Corneal ulceration with keratoconjunctivitis

Prognosis

• Early detection and early treatment of extremely pathogenic bacteria, such as Chlamydia trachomatis or Neisseria gonorrhoeae, is associated with a good prognosis.

Diagnosis

Diagnostic Criteria

• The diagnosis of conjunctivitis in children is based on the clinical physical findings which include:
  • Redness, excessive tearing, and irritation are symptoms common to all forms of conjunctivitis.
  • Photophobia, itching, mucopurulent or non-purulent discharge, chemosis, burning eyes, blurred vision and eyelid swelling are variable depending on the pathogen.
  • Broad generalizations can be made about the clinical characteristics of bacterial conjunctivitis as compared to viral conjunctivitis but distinguishing them clinically in individual children may be difficult.

Symptoms

Gonococcal Conjunctivitis

Gonococcal conjunctivitis is more severe than chlamydial conjunctivitis. The incubation period is 2-5 days and it is usually bilateral.

• Purulent discharge
• Eyelid oedema
• Chemosis
• Red eye

Chlamydial conjunctivitis

Chlamydial conjunctivitis has a later onset than gonococcal conjunctivitis. The incubation period is 5-14 days. Most of the cases are mild and self-limited, but occasionally may be severe.

• Eyelid swelling
• Watery or mild mucoid discharge
• Red eye

Chemical conjunctivitis

Chemical conjunctivitis usually occurs within 24 hours of instillation of silver nitrate solution and resolves spontaneously within a few days.

• Eyelids swelling
• Red eye

Herpes simplex keratoconjunctivitis

Herpes simplex keratoconjunctivitis in an infant usually presents with generalized herpes infection.

• Vesicles around the eye
• corneal involvement
• Watery discharge
• Itchy eyes
• Eye redness

Bacterial Conjunctivitis

Bacterial conjunctivitis more than viral conjunctivitis tend to cause bilateral rather than unilateral involvement.

• Mucopurulent discharge
• Eyelids swelling
• Red eye

Physical Examination

Ophthalmologic examination of children with conjunctivitis is usually remarkable for:

• Chemosis
• Mucopurulent or watery discharge
• Eye lid oedema
• Mild to moderate hyperemia

Laboratory Findings

• Conjunctivitis is essentially a clinical diagnosis made by observation of signs and symptoms. However, lab diagnosis is of paramount importance in establishing the correct diagnosis and initiating the best treatment.

Bacterial Conjunctivitis

Laboratory tests usually are not required in patients with mild bacterial conjunctivitis. However, specimens for bacterial cultures should be obtained in patients who have severe inflammation with mucopurulent discharge or in patients who do not respond to treatment.

• Chlamydial conjunctivitis
  • Positive polymerase chain reaction (PCR) of conjunctival scraping
  • Positive gram staining or giemsa staining of conjunctival scraping
  • Positive enzyme immuno-assays for chlamydia organisms

• Gonococcal conjunctivitis
  • Positive gram staining of conjunctival scraping for gram-negative intra-cellular diplococci
  • Positive special cultures for neisseria species on chocolate agar or Thayer-Martin agar

Viral conjunctivitis

• Positive conjunctival scraping for polymerase chain reaction (PCR)
• Positive viral culture of corneal epithelial cells for HSV

Neonatal conjunctivitis

• Positive gram staining or giemsa staining of conjunctival scraping
• Positive polymerase chain reaction (PCR) of conjunctival scraping
• Positive special cultures for neisseria species on chocolate agar or Thayer-Martin
• Positive culture on blood agar

Electrocardiogram

• There are no ECG findings associated with conjunctivitis.

X-ray

• There are no x-ray findings associated with conjunctivitis.

Echocardiography or Ultrasound

• There are no echocardiography or ultrasound findings associated with conjunctivitis.

CT scan

• There are no CT scan findings associated with conjunctivitis.

MRI

• There are no MRI findings associated with conjunctivitis.

Other Imaging Findings

• There are no other imaging findings associated with conjunctivitis.

Other Diagnostic Studies

• There are no other diagnostic findings associated with conjunctivitis.

Treatment

Medical Therapy

Neonatal conjunctivitis

Ophthalmia neonatorum is an ocular emergency so all infants with this condition should be admitted immediately. Clinical treatment should be based on clinical features and laboratory results. However, it is essential to treat ophthalmia neonartum with systemic drugs rather than topical to prevent systemic dissemination.

• Chlamydial conjunctivitis
  • Oral erythromycin syrup, 50 mg/kg/day, in 4 divided doses for 14 days
  • Topical erythromycin or tetracycline as an adjunct therapy

• Gonococcal conjunctivitis
  • Intravenous Penicillin G 100,000 Units /kg/day for 1 week
  • Ceftriaxone 50 mg/kg as a single dose in case of resistance to penicillin
  • Spectinomycin 25 mg/kg (maximum 75 mg) as a single IM dose as an alternative option
  • Kanamycin 25 mg/kg (maximum 75 mg) as an alternative option

• Herpetic conjunctivitis
  • Low dose systemic acyclovir (30mg/kg/ day IV divided tid) Or
  • Vidarabine (30 mg /kg/day in divided doses IV) for at least 2 weeks
  • Trifluridine eye drops

Conjunctivitis in children

Bacterial conjunctivitis

Although bacterial conjunctivitis generally resolves spontaneously in a few days, there is broad agreement that topical antibiotics are worthwhile, particularly in moderate to severe infection.

• Azithromycin 1.5% ocular solution
• Polymyxin B with Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution for 1 week
• Gentamicin 0.3% ophthalmic ointment for 1 week
• Sodium sulfacetamide 10%-30% ophthalmic solution for 1 week

Viral conjunctivitis

The purpose of the treatment in children with viral conjunctivitis is to reduce virus dissemination and the chance of the development of keratitis

• Ganciclovir 0.15% ophthlamic gel for 1 week
• Trifluridine 1% solution q4h for 1 week

Allergic conjunctivitis

Most cases do not need therapeutic interaction. However, in severe cases below can be used

• Topical antihistamines
• Topical mast cell stabilizers like diclofenacor ketorolac

Surgery

• Surgical intervention is not recommended for the management of conjunctivitis in children and neonates.

Prevention

Neonatal conjunctivitis

• Ocular prophylaxis with 0.5% erythromycin ointment or 1% tetracycline hydrochloride can be given to all newborns.
• To prevent neonatal conjunctivitis, women with STDs should consult with their physician about ways to minimize the chances of spread to their newborn baby.
• Avoid vaginal delivery in mothers with STDs (HSV transmission rates are high for women who acquire genital herpes in the last few weeks of pregnancy).

Conjunctivitis in children

Effective measures to prevent conjunctivitis in children include:

• Washing hands
• Change towels and wash cloths daily