This article is more than 5 years old. Information may no longer be current.
Acute Pediatric Conjunctivitis
Click Here to Manage Email Alerts
Introduction
Acute conjunctivitis in children is usually caused by bacteria, viruses, or allergy. The differential diagnosis of conjunctival inflammation includes nasolacrimal duct obstruction, trauma, corneal abrasions, ulcers, and iritis. Herpes simplex infection and infantile glaucoma also must be considered. Allowing these conditions to remain undetected may result in serious visual consequences. On rare occasions, conjunctivitis has been associated with serious systemic diseases, such as Kawasaki syndrome and Lyme disease.
Bacterial Conjunctivitis
Haemophilus influenzae and Streptococcus pneumoniae have been found to be the most frequent causative organisms in acute bacterial conjunctivitis. In an important prospective study, Gigliotti and coworkers at the University of Virginia cultured conjunctival samples from 99 patients with conjunctivitis and 102 age-matched and season-matched controls.1 Three organisms were isolated more often from patients with conjunctivitis than from the controls: H. influenzae was found in 42% of patients and not obtained from controls; S. pneumoniae was obtained from 12% of patients and three controls; and an adenovirus was found in 20 patients and in no controls. At least one of these three organisms was isolated on culture in 71 patients (72%) with conjunctivitis
The Charlottesville investigators found that H. influenzae was responsible for most cases of conjunctivitis seen during January, February, and March. Conjunctivitis caused by an adenovirus predominated during September. Pneumococcal conjunctivitis occurred during these months at a relatively low rate.
Patients in this study ranged in age from 1 month old to 18 years old, with a mean age of 4.4 years for patients and 4.9 years for controls. The mean ages of the children who were culture-positive for H. influenzae and S. pneumoniae were 3.6 years and 3.1 years, respectively. This indicates that the younger the child is, the more likely the conjunctivitis will be bacterial.
Other studies confirm that bacteria are the predominant cause of acute conjunctivitis, with H. influenzae and S. pneumoniae being the most frequently isolated pathogens (Table 1).
Table 1. Commonly found bacterial pathogens in pediatric conjunctivitis.21
| Pathogen | Cell Type | Onset | Associated Findings |
| Haemophilus influenzae* | Gram(-) bacilli | Acute | Otitis media; periorbital cellulitis |
| Streptococcus pneumoniae* | Gram(+) cocci | Acute | Sinusitis; rhinitis; otitis media |
| Moraxella catarrhalis* | Gram(-) diplococci | Subacute | External angular conjunctivitis |
| Staphylococcus aureus | Gram(+) cocci | Subacute; chronic | Concurrent lid disease |
| S. epidermidis | Gram(+) cocci | Subacute; chronic | Concurrent lid disease |
| Neisseria gonorrhoeae | Gram(-) diplococci | Hyperacute | Corneal perforation; septicemia |
| Neisseria meningitidis | Gram(-) diplococci | Hyperacute | Septicemia and meningitis |
| Haemophilus aegyptius | Gram(-) bacilli | Acute | Brazilian purpuric fever |
In a 1991 study in Seattle by Weiss and colleagues, H. influenzae and S. pneumoniae organisms were recovered at a rate comparable to that found in the Charlottesville study. Moraxella catarrhalis was the third most frequent bacterial isolate in patients with conjunctivitis.2 The H. influenzae isolates tended to be either nontypable or serotype A organisms. H. influenzae type B organisms are usually associated with more invasive disease as in periorbital cellulitis.
Epidemic conjunctivitis has been typically attributed to adenovirus infection, but a recent outbreak in Maine serves as a reminder that S. pneumoniae can also be an etiologic agent. As reported in the MMWR, between late September through early December 2002, 101 school children (mostly in kindergarten, first and second grades with a median age of 6 years, range 5 to 8 years) were infected with a nontypeable strain of S. pneumoniae.3
The clinical spectrum varied from eyes with mild conjunctival vascular injection to some with a profuse mucopurulent discharge, making the clinical diagnosis (viral versus bacterial) difficult. No symptoms of systemic pneumococcal infection were reported in students or their contacts. This outbreak was caused by the same nontypeable strain of pneumococcus that caused an epidemic of conjunctivitis among college students in New Hampshire during January through March 2002.4
The University of Washington investigators also looked at the diagnostic value of staining material from conjunctival scrapings with Gram's and Giemsa stains (Table 2).
Table 2. Cytologic findings in conjunctivitis.2
| Findings | Associated Findings |
| Neutrophils | Bacterial, chemical |
| Lymphocytes | Viral, sllergic, toxic (medicamentosa) |
| Eosinophils | Allergic, Parasitic |
| Mixed neutrophils, lymphocytes, plasma cells, and multi-enucleated epithelial cells, plus intracytoplasmic inclusion bodies within epithelial cells |
Chlamydial |
They found that in 51 of 52 cases, the observed Gram's stain agreed with the known staining properties of the cultured pathogen. Gram's staining, therefore, offers a rapid, sensitive means of identifying pathogens in bacterial conjunctivitis.
Giemsa stains provide information about the type of inflammatory cells present in the erythema, sinusitis blepharitis, and secondary conjunctivitis. The findings of flaky scales along the anterior lid margin and fibrinous debris along the eyelashes are signs of staphylococcal blepharoconjunctivitis. This condition is a frequent cause of chronic conjunctivitis in children.
Gram-negative bacilli, other than H. influenzae, have been isolated in cases of pediatric conjunctivitis.5 Organisms such as Escherichia coli have been cultured in situations where poor personal hygiene exists. Children may rub their eyes with contaminated fingers. These organisms can also produce conjunctivitis in chronically ill, hospitalized patients. Overtreatment with antibiotics predominantly active against gram-positive bacteria may encourage the growth of some gram-negative organisms.
Clinical Features
It often is difficult to distinguish bacterial from viral conjunctivitis on clinical grounds
alone, but the child's age can offer a significant guideline. In children younger than 6
years of age, the infection is more often bacterial, while children older than 6 years of
age are more likely to have an adenoviral conjunctivitis. In addition, bacterial conjunctivitis
occurs more frequently during the winter months and viral more frequently during the fall.
Because acute conjunctivitis is not routinely cultured, knowledge of the most common pathogens
generally provides the basis for therapeutic decisions.
|
When a child has conjunctival hyperemia with a purulent exudate in both eyes, the infection is most likely bacterial (Slide 1). Symptoms are frequently nonspecific and include itching, burning or stinging, photophobia, or foreign body sensation. Concurrent otitis media often is associated with bacterial conjunctivitis cause by H. influenzae. Indeed, a child with mild conjunctivitis, otitis media, fever, and mucopurulent rhinorrhea may have conjunctivitis-otitis syndrome.6
Sinusitis and rhinitis may accompany conjunctivitis caused by Pneumococcus. A pneumococcal infection usually affects only one eye. Cultures of the conjunctiva reveal S. pneumoniae. Sinus involvement is a cause for concern because it can lead to orbital cellulitis, which is an acute swelling of the orbital contents. This condition should be treated aggressively.
Treatment
A topical anti-infective known to be effective against the suspected or culture-proven pathogen
should be selected for treatment. Also, patient compliance should be considered. It is not easy
to instill drops or ointment into the eyes of a squirming, crying child. If the medication stings
or burns, it will be even more difficult to administer the next dose and compliance will be poor.
Some preferred therapeutic choices for bacterial conjunctivitis include sodium sulfacetamide, erythromycin ointment, and the combination ointments such as trimethoprim sulfate and polymyxin B sulfate and polymyxin B-bacitracin. Polymyxin B-bacitracin provides good activity against H. influenzae and S. pneumoniae, as well as organisms that cause blepharitis.7,8 This combination medication is comfortable upon application, and infrequently causes hypersensitivity reactions.7 Polymyxin B-bacitracin ointment has been shown to be safe and effective in children and is approved by the U.S. Food and Drug Administration (FDA) for use in infants as young as 2 months of age.
Many other topical products are available. Aminoglycosides, such as tobramycin and gentamicin, are among the most frequently prescribed antibiotics for treatment of conjunctivitis. Tobramycin has a broader bacterial coverage and is less toxic to the epithelium than gentamicin.
Sulfonamides provide good antimicrobial coverage of conjunctival organisms and are inexpensive. However, these agents may cause significant irritation and stinging upon instillation.
Because sensitivity to neomycin occurs frequently, it is wise to avoid neomycin-containing products. Often, it is not clear if conjunctival irritation results from neomycin-induced sensitivity or failure of the drug to eradicate the pathogen.
Available topical antibiotics include ofloxacin (Ocuflox, Allergan), ciprofloxacin (Ciloxan, Alcon), norfloxacin (Chibroxin, Merck Co & Co) and levofloxacin (Quixen, Santen). These fluoroquinolones are approved for use in children at least 1 year old. These medications exhibit a broad spectrum of activity against gram-positive and gram-negative organisms, and are proving to be useful in treating pediatric conjunctivitis, particularly in resistant cases.10,11 This group of medications is highly effective in rapidly eradicating the organisms that frequently cause bacterial conjunctivitis in children.12-14
Ophthalmologists have become comfortable with the use of topical fluoroquinolones, which have supplanted other antibiotics as first line therapy for pediatric bacterial conjunctivitis in most cases. There have been no reported systemic side effects and these drops are well tolerated. A gap in gram-positive coverage of the second and third-generation fluoroquinolones led to the development of fourth-generation topical antibiotics.
Recently, gatifloxacin (Zymar, Allergan) and moxifloxacin (Vigamox, Alcon) were approved for the treatment of bacterial conjunctivitis in children 1 year of age and older. Both have improved gram-positive coverage and disrupt the action of two bacterial enzymes essential in DNA replication (topoisomerase II — also known as DNA gyrase — and topoisomerase IV). For resistance to develop, separate mutations in two bacterial genes would have to occur simultaneously, an event that might transpire in one organism in 10 trillion. Resistance to these highly effective antibiotics is therefore extremely unlikely.
Whether the medication is used in a drop or ointment vehicle is not a significant issue. However, repeated administration is slightly easier with drops, and drops do not blur vision as ointments do. This may be an important consideration in school-age children.
It is important not to prescribe topical antibiotic/corticosteroid combination medications, unless the patient's condition is confirmed. Ophthalmologists are familiar with the adverse effect of prolonged steroid use, as well as its effects on an ocular herpes simplex infection. The use of a steroid can cause the virus to proliferate, causing a small dendritic ulceration to worsen dramatically and rapidly.
Because ideal duration of treatment for bacterial conjunctivitis has not been determined, a 7- to 10-day course usually is recommended. Studies have shown, however, that 3 to 4 days of therapy with an appropriate agent usually eradicates infection.15 After 2 days of seemingly successful treatment, the child may return to school. A poor clinical response after several days of treatment may indicate that a resistant organism is present or that the infection is viral or allergic.
The need for systemic antibiotic treatment depends on the severity of the child's symptoms and associated problems, such as development of conjunctivitis-otitis syndrome.6 This syndrome begins with a low-grade fever. A mucopurulent rhinorrhea initially develops, followed in a few days by mild conjunctivitis and otitis media. H. influenzae and S. pneumoniae are the usual causative organisms, and systemic therapy should target them.16 Topical antibiotics may not be necessary, but some clinicians prescribe it for symptomatic relief.
For children who have an upper respiratory infection and conjunctivitis, the decision to use systemic therapy is not as definitive. Although overtreatment with systemic antibiotics should be avoided, systemic medication may be prudent in a younger child who is prone to otitis media infections.
Neonatal Conjunctivitis
Chemical conjunctivitis is a major cause of conjunctivitis in neonates. It generally occurs 6 to 8 hours after prophylactic silver nitrate drops are administered. Chemical conjunctivitis resolves spontaneously within 1 to 2 days. Many hospital nurseries now use erythromycin ointment rather than silver nitrate to avoid this problem.
|
The most common infectious cause of neonatal conjunctivitis is Chlamydia trachomatis, which the infant acquires from the mother during birth. Symptoms usually begin 5 to 14 days after birth and may range from mild conjunctival inflammation with minimal mucopurulent discharge to severe eyelid edema with profuse drainage. Pseudomembranes may form in the palpebral conjunctiva and can be seen by everting the eyelid (Slide 2). Direct culture of the conjunctiva is the most sensitive method to diagnose chlamydial conjunctivitis. Several other diagnostic tests for chlamydia also are available, such as chlamydial spot tests (e.g., enzyme-linked immunosorbent assay, ELISA) and polymerase chain reaction tests.17 In addition, Giemsa-stained conjunctival epithelial scrapings can be examined for chlamydial intranuclear and intracytoplasmic inclusion bodies. The usual treatment is systemic erythromycin, which covers both the conjunctivitis and the pneumonitis that often accompany neonatal conjunctivitis.
Trachoma, the main cause of preventable blindness in the world, is rarely found in North America. This chlamydial infection produces lymphoid follicles on the upper lid palpebral conjunctiva and eventually chronic inflammation and scarring. Trachoma is treated with a 3-week course of oral erythromycin. Inclusion conjunctivitis may occur in older sexually active adolescents or in abused children. It frequently manifests as a unilateral follicular conjunctivitis, but can be associated with keratitis and micropannus formation. Systemic erythromycin or tetracycline is used for treatment.
Gonococcal conjunctivitis in newborns is much less common that it was in the past, due to prophylactic use of silver nitrate and erythromycin.18 However, it remains important to recognize this fulminant infection because the cornea can ulcerate or even perforate if treatment is delayed. Typically, gonococcal ophthalmia appears 2 to 5 days after birth, presenting as a profuse purulent discharge and severe eyelid edema. Culture and Gram's stain of the conjunctiva identify Neisseria gonorrhoeae. The hospitalized neonate is aggressively treated with intramuscular aqueous penicillin G or, for penicillinase-producing strains of gonococci, cefotaxime or ceftriaxone.
Viral Conjunctivitis
|
Viral conjunctivitis is characterized by redness, itchiness, and sometimes a nonpurulent, serous discharge in one or both eyes (Slide 3). Adenovirus types 8, 19, and 37 most often cause viral conjunctivitis in school-age children.19 Periauricular adenopathy or pharyngitis may accompany the conjunctivitis. Some children have pharyngitis, conjunctivitis, and fever, the so-called PCF triad.20 Adenovirus types 3, 4, and 7 produce this condition. Epidemic keratoconjunctivitis may also occur in children. Adenoviral infection is self-limited and lasts for 7 to 10 days. Frequent hand-washing is the best way to prevent dissemination of the infection. Treatment is symptomatic (Table 3).
Table 3. Clinical findings in pediatric conjunctivitis.21
| Conjunctivitis | Discharge Type | Conjunctival Response | Other Findings |
| Bacterial | Mucopurulent | Papillary | Matting of eyelids Otitis media |
| Viral | Serous | Follicular | Preauricular adenopathy Pharyngitis |
| Chlamydial | Mucoid; purulent | Follicular | Pseudomembranes |
| Allergic | Serous; mucoid | Papillary (giant) | Itching, bilateral |
| Chemical | Serous; mucoid | Follicular | Exposure, lids involved |
Herpes Simplex Infection
The most serious form of viral conjunctivitis is herpes simplex infection. Although primary
herpes infection is self-limited, secondary infection or recurrence can result in corneal
opacification and loss of vision.
|
Most ocular herpetic infections in children are caused by herpesvirus type 1 rather than by herpesvirus type 2, which neonates acquire via the birth canal.21 In primary type 1 infection, the child usually presents with a nonspecific bilateral conjunctivitis, as seen in Slide 4. Vesicles may be present on the surrounding skin or eyelids (Slide 4); these vesicles can help make a difficult diagnosis easier. When no vesicles are present, the appearance of the infection may be indistinguishable from other types of viral or bacterial infection.
Obtaining a child's history is important, because a recent viral illness or contact with an infected person may precede ocular herpes. If the herpesvirus invades the trigeminal ganglion, secondary herpes infection may develop. This reactivation or recurrence may be seen in a child who had an undetected primary herpes infection.
A febrile illness or other physical stress may precipitate secondary herpes infection. It is almost always unilateral. Children infected with secondary herpes infection present with a red eye, severe pain, and sensations associated with an abrasion or other eye trauma, but have no history of trauma or contact with a foreign body. This intense unilateral eye pain is often a diagnostic sign. Vesicles may be present but usually are not pronounced.
A dendritic ulcer on the corneal epithelium is characteristic of a herpesvirus infection. The ulcer can be visualized by instilling fluorescein dye and examining the cornea with a cobalt-filtered blue light. The irregular surface of the cornea, possibly with a hazy appearance, may lead the clinician to suspect herpes keratitis. These lesions are sometimes mistaken for a corneal abrasion and may be treated as such with an eye patch for a short period.
As mentioned, a topical corticosteroid/antibiotic combination should never be used in herpesvirus infections. The antibiotic will not be effective, and the steroid will significantly increase the width of individual branches as well as the overall size of the dendritic lesions caused by herpes simplex, resulting in an irreversibly opaque cornea.
Effective topical antiviral medications are available for treating ocular herpes, including trifluridine and vidarabine. Because these agents may be difficult to administer to children and require frequent dosing, compliance may be a problem. The parents and child must understand the importance of using the medication for the prescribed period. Resistant infections and herpetic keratitis may require systemic treatment with acyclovir.
Varicella zoster, or chickenpox, may also produce a conjunctivitis. Children with chickenpox frequently have painful focal vesicles on the palpebral and bulbar conjunctiva. These lesions usually are self-limited and require no treatment. Treatment with topical steroids should generally be avoided in these cases.
Molloscum contagiosum lesions on the eyelid margin can produce a chronic follicular conjunctivitis and may require surgical excision of the lesions if symptoms persist. There is no optimal medical treatment for this condition.
Parinaud oculoglandular syndrome consists of granulomatous conjunctivitis and ipsilateral preauricular or submandibular nodes. Causes include cat scratch disease (Bartonella henselae) and, less frequently, Lyme disease and Tularemia. Parinaud oculoglandular syndrome is self-limited and will respond to the underlying disease if treatable.
Kawasaki syndrome may present with bilateral conjunctival injection along with the more common mucous membrane and cutaneous findings usually associated with this febrile illness. Typically, there is a discrete bulbar conjunctival injection without exudate.22 The cause is unknown and treatment is mainly supportive. Aspirin is considered the drug of choice.
Allergic Conjunctivitis
An allergic etiology should always be considered in a child who has red, watery eyes. Children with allergies primarily complain about itchy and irritated eyes. They often have a history of hypersensitivity reactions to seasonal allergens, such as pollens and molds, or to perennial allergens, such as dust mites and animal dander. Symptoms usually occur in both eyes, but a unilateral reaction may result if one eye is inoculated with animal hair or dander. Although atopic conjunctivitis is usually part of a larger allergic syndrome, such as hay fever, it may develop alone through direct contact with an airborne allergen.
|
Other signs and symptoms of seasonal allergy include nasal symptoms (allergic rhinitis); swollen, chronically inflamed, ecchymotic eyelids (allergic shiner); and a nasal crease. Occasionally, the conjunctiva becomes so chemotic that the cornea appears to be sitting in a depression or crater (Slide 5).
Treatment of allergic conjunctivitis includes avoiding the allergen whenever possible. Cold compresses applied to the eyes can relieve itching and help reduce conjunctival edema. Desensitization treatment is a rather drastic remedy for ocular allergies.
Many topical medications are available and should be selected carefully. A combination antihistamine/vasoconstrictor may help some patients, but should not be used chronically in children. Long-term use may be associated with drowsiness and bradycardia. Topical steroids and mast cell stabilizers, such as lodoximide tromethamine and cromolyn sodium, generally should be reserved for severe allergic conditions such as vernal conjunctivitis, which is a chronic, seasonal allergy in which the palpebral conjunctiva has a cobblestone appearance. Topical nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac tromethamine and diclofenac sodium are alternatives, although NSAID drops may sting and are not approved for use in children younger than 12 years old. NSAIDs inhibit prostaglandin synthesis. Nedocromil sodium is a mast cell stabilizer and also decreases chemotaxis and activation of eosinophils. Olopatadine hydrochloride and ketotifen fumarate ophthalmic solution are effective medications that have an antihistamine and mast cell stabilizing effect. Azelastine, emedastine difumarate, and levocabastin hydrochloride are selective H1-receptor antagonists and inhibit the release of histamine. These medications are only approved for use in children 3 years of age and older. Recently, mild steroids have been introduced for the treatment of allergic conjunctivitis (lodeprednol etabonate ophthalmic suspension 0.2%). The inherent side effects of topical steroid use must be considered when any topical corticosteroids are used.23
Conclusion
Although there are many causes of conjunctivitis in children, most cases are due to infectious organisms. In the past, the adenovirus was considered to be the most likely agent in conjunctivitis. However, recent studies have shown that bacterial conjunctivitis is more common then was previously believed. In fact, H. influenzae and S. pneumoniae are the most common causes of conjunctivitis in children. An understanding of the various causes of conjunctivitis will allow the ophthalmologist to make appropriate decisions regarding management and selection of therapeutic agents.
References
- Gigliotti F, Williams WT, Hatden FG,et al. Etiology of acute conjunctivitis in children. J Pediatrics. 1981;98:531-536.
- Weiss A, Brinsor JH, Nazar-Stewart V. Acute conjunctivitis in childhood. J Pediatrics. 1993;122:10-14.
- Pneumococcal conjunctivitis at an elementary school – Maine. Sept. 20 - Dec. 6, 2002. MMWR, 2003;52(4):64-66.
- Martin M, Turco JH, Zegans ME, et al. An outbreak of conjunctivitis due to atypical Streptococcus pneumoniae. N Engl J Med. 2003;348:1112-1121.
- Weiss A. Acute conjunctivitis in childhood. Current Problems in Pediatrics. 1994;24:4-11.
- Bodor FF. Conjunctivitis-otitis syndrome. Pediatrics. 1982;69:695-698.
- Lohr JA, Austin RA, Grossman M, et al. Comparison of three topical antimicrobials for acute bacterial conjunctivitis. Pediatr Infect Dis J. 1988;7:626-629.
- Gibson JR. Trimethoprim-polymyxin B ophthalmic solution in the treatment of presumptive bacterial conjunctivitis. J Chemotherapy. 1983;11:217-221.
- Wagner RS. Results of a survey of children with acute bacterial conjunctivitis treated with trimethoprim-polymyxin B ophthalmic solution. Clinical Therapeutics. 1995;17:875-881.
- Ophthalmic ciprofloxacin. Medical Letter. 1991;33:52-53.
- Huber-Spitzy V, Avocker-Mettinger E, Baumgartner I. Efficacy of norfloxacin in bacterial conjunctivitis. Eur J Ophthalmol. 1991;1:69-72.
- Leibowitz HM. Antibacterial effectiveness of ciprofloxacin 0.3% ophthalmic solution in the treatment of bacterial conjunctivitis. Am J Ophthalmol. 1991;112:295-335.
- Jensen HG, Felix C, et al. In vitro antibiotic susceptibilities of ocular isolates in North and South America. Cornea. 1998;17:79-87.
- Gwon A. Ofloxacin vs. tobramycin for the treatment of external ocular infection. Arch Ophthalmol. 1992;110:1234.
- Gigliotti F, Hendley JO, Morgan J, et al. Efficacy of topical antibiotic therapy in acute conjunctivitis in children. J Pediatr. 1984;104:623-626.
- Bodor FF, Marchant CD, Shurin PA, et al. Bacterial etiology of conjunctivitis-otitis media syndrome. Pediatrics. 1985;76:26-28.
- Hammerschlag MR, Herrmann JE, Cox P, et al. Enzyme immunoassay for diagnosis of neonatal chlamydial conjunctivitis. J Pediatr. 1985;107:741-745.
- Lewis LS, Glauser TA, Joffe MD. Gonococcal conjunctivitis in prepubertal children. Am J Dis Child. 1990;144:548-548.
- Ford E, Nelson KE, Warren D. Epidemiology of epidemic keratoconjunctivitis. Epidemiol Rev. 1987;9:244-261.
- Giladi N, Herman J. Pharyngoconjunctival fever. Arch Dis Child. 1984;59:1182-1186.
- Nahmias AJ, Hagler WS. Ocular manifestations of herpes simplex in the newborn. Int Ophthalmol Clin. 1972;12:191-199.
- Melish ME. Kawasaki syndrome. A new infectious disease? J infect Dis. 1981;143:317-325.
- Wagner RS, DeRespinis PA. Pediatric conjunctivitis. Clinical Signs in Ophthalmology. 1996;17:2-11.