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Managing pediatric conjunctivitis

At Issue posed the following question to a panel of experts: How do you manage a pediatric patient with conjunctivitis?

Issue: August 15, 2005

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ROBERT S. GOLD, MD:
Accurate history essential

As summer is in full swing, one of the most common presentations of conjunctivitis we are seeing is red eyes associated with burning and stinging, and sometimes a whitish stringy discharge secondary to a chemical reaction to the chlorine in pools. Some children when examined at the slit lamp actually have a chemical conjunctivitis or keratoconjunctivitis. This condition is often self-limiting, and treating the symptoms with cool compresses, artificial tears or antihistamine-type ophthalmic preparations is appropriate. The specific drops include Patanol (olopatadine HCl, Alcon), Optivar (azelastine HCl ophthalmic solution 0.05%, Bausch & Lomb), Zaditor (ketotifen fumarate ophthalmic solution 0.025%, Novartis Ophthalmics) and Elestat (0.5% epinastine HCl, Inspire Pharmaceuticals), among others. Rarely, for severe conjuctival chemosis, a topical steroid such as Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb) or Lotemax (loteprednol etabonate, Bausch & Lomb) can be used for a short course of therapy.

	Robert S. Gold

Once the summer comes to an end and children return to school and day care situations, viral and bacterial conjunctivitis become more prevalent. For those that present with purulent discharge, usually yellow or green in color, antibiotic drops, usually Vigamox (moxifloxacin HCl ophthalmic solution 0.5%, Alcon), Zymar (gatifloxacin ophthalmic solution 0.3%, Allergan) or Quixin (levofloxacin, Santen), the 4th generation fluorquinolones, are prescribed, usually three times a day for 5 to 7 days. I normally do not culture these patients, and often they have been on other eye drops for several days from their primary physician and are not responding to that form of therapy.

It is extremely important to take an accurate history in regard to the characteristics of the conjunctivitis, including unilaterality or bilaterality, type of discharge, history of upper respiratory infection, viral illness or other concurrent illness, and if eye pain or photophobia are present (as this can mimic as an iritis rather than a conjunctivitis).

• Robert S. Gold, MD, can be reached at Eye Physicians of Central Florida, 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407-767-8160; e-mail: rsgeye@aol.com. Ocular Surgery News could not confirm whether Dr. Gold has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.

DAVID B. GRANET, MD, FAAP, FACS, AND CINTIA F. GOMI, MD:
Treatment based on etiology

	Cintia F. Gomi

	David B. Granet

Acute conjunctivitis is the most common ocular infection in childhood. Fortunately, the pediatrician or primary care physician handles most cases of red eyes in children. For most pediatric cases, the etiology of these infections has been documented as bacterial. Even in epidemics — like the recent Ivy League conjunctivitis — the cause may be bacterial. Diagnosis is essentially clinical, made by observations of the signs and symptoms presented. In most cases, laboratory exams are not necessary. They are expensive, time-consuming and should usually be reserved for cases refractory to treatment, severe conjunctivitis or cases suspected to be caused by Neisseria.

Appropriate treatment is based on the etiology of the conjunctivitis. For allergic conjunctivitis, a combination antihistamine/mast cell stabilizer able to address all the signs and symptoms of allergic conjunctivitis (ie, itching, chemosis, injection, lid swelling and tearing) can be used, along with avoidance measures. In children, a true combination drop is important because of the need for immediate relief to stop eye rubbing.

For infectious conjunctivitis, timing matters. Neonatal conjunctivitis, for example, affects infants during the first month after birth. The period of time from birth until the onset of the conjunctivitis is variable, but it may be helpful in suggesting the etiology by correlating it to the incubation time of the possible agent.

In typical acute conjunctivitis, bilateral disease is common with the second eye becoming affected within 1 week after the initial symptoms appear. It is self-limited, with symptoms generally subsiding in about 14 days, even without treatment. Shortening the course of a bacterial conjunctivitis with the use of topical antibiotics can reduce contagiousness, decrease patient morbidity and allows prompt return to work for the parents, and school or daycare for the child. By utilizing an antibiotic expected to work quickly, more worrisome diseases, like herpes, will be unmasked. Thus the newer fourth-generation fluoroquinolones provide the best choice. Further, in children especially, use of a drug dosed with least frequency improves compliance. There is no evidence of resistance caused by short courses of these antibiotics properly used.

Adenovirus is by far the most common viral pathogen. It can manifest itself in many forms, ranging from self-limited conjunctivitis to keratitis, which can be prolonged. Treatment for viral conjunctivitis is palliative but secondary bacterial infection can be seen and then treated.

• David B. Granet, MD, FAAP, FACS, is an Anne F. Ratner Professor of Ophthalmology and Pediatrics and is the director of the UCSD Ratner Children’s Eye Center. He can be reached at UCSD Ratner Children’s Eye Center, 9415 Campus Point Dr., La Jolla, CA 92093-0946; 858-534-7440; fax: 858-534-5695; e-mail: dgranet@ucsd.edu.
• Cintia F. Gomi, MD, is a pediatric ophthalmology research fellow at the UCSD Ratner Children’s Eye Center. She can be reached at UCSD Ratner Children’s Eye Center, 9415 Campus Point Dr., La Jolla, CA 92093-0946. Ocular Surgery News could not confirm whether Drs. Granet and Gomi have a direct financial interest in the products mentioned in this article or if they are paid consultants for any companies mentioned.

RUDOLPH S. WAGNER, MD:
Fluoroquinolones if bacterial

	Rudolph S. Wagner

Making the diagnosis of an acute infectious conjunctivitis in pediatric patients is not difficult for most ophthalmologists. Some might not be aware that bacterial conjunctivitis is more common in younger children (6 years old and younger) than is viral conjunctivitis. The classic articles by Gigliotti and co-authors and Weiss and associates have shown that Streptococcus pneumoniae and Haemophilus influenzae (nontypable strains) are the most common organisms causing infectious conjunctivitis in children. The recent outbreak of an epidemic of bacterial conjunctivitis in Maine attributed to a non-encapsulated strain of S. pneumoniae supports their findings. With this information in mind, I assume that an acute infectious conjunctivitis occurring in children 6 years old or younger is bacterial and should be treated appropriately. It is important to determine if the child is febrile or has the signs and symptoms of otitis media or pharyngitis. Such children need to be evaluated by a pediatrician to institute appropriate systemic therapy. The presence of pre-auricular lymph adenopathy suggests a viral etiology, for which there is only supportive therapy available, such as liquid tear preparations. In all cases, frequent hand washing by contacts is important. When I decide to treat a suspected bacterial conjunctivitis, I prefer to use a topical antibiotic solution that is well-tolerated by children and has good coverage for gram-positive organisms and is not likely to produce resistant organisms. The fourth-generation fluoroquinolones, which include gatifloxacin and moxifloxacin, are my first choice for treatment. They have been shown to rapidly eradicate the pathogens and lead to clinical cures after only a few days of therapy. I find that busy parents prefer to get their children back to school as soon as possible to avoid loss of time and income for themselves and loss of educational opportunities for their children. I have most experience with moxifloxacin and prefer to use it as it is the only topical ophthalmic fluoroquinolone approved for dosing three times daily. I instruct the parents to instill the drops for at least 4 days. The less frequently the parents have to instill the drops, the better off everyone is. I find that I am often co-managing these kids with the pediatrician and that they are concerned with using ophthalmic medications according to the dosing schedule found in the package inserts.

• Rudolph S. Wagner, MD, is the director of pediatric ophthalmology at the Institute for Ophthalmology and Visual Science, UMDNJ - New Jersey Medical School, Newark. He can be reached at the Children’s Eye Care Center of NJ, 495 N. 13th Street, Newark, NJ 07107; 973-485-3186; fax: 973-497-5674; e-mail: wagdoc@comcast.net. Dr. Wagner has no financial interest in the products mentioned. He is on the speaker’s bureau of Alcon and has participated in CME activities supported by Alcon and Allergan.

References:

• Centers for Disease Control and Prevention. Pneumococcal conjunctivitis at an elementary school. MMWR Morb Mortal Wkly Rep. January 31, 2003; 52(04);64-66.
• Gigliotti, et al. Etiology of acute conjunctivitis in children. J Pediatr. 1981;98:531-536.
• Weiss, et al. Acute conjunctivitis in childhood. J Pediatr. 1993;122;10-14.

ROBERTO WARMAN, MD:
Age as diagnostic tool

	Roberto Warman

I like to think of three different age groups regarding pediatric infectious conjunctivitis: neonatal, up to 5 to 6 years old and older children.

Neonatal conjunctivitis should always be cultured, and if practical, obtain gram and giemsa stains. The most common neonatal conjunctivitis still is chemical even now that silver nitrate has been mostly substituted for erythromycin ointment prophylaxis. The most common microbial neonatal conjunctivitis is chlamydia. It is a self-limiting disease, but it has to be treated systemically to avoid the serious complication of pneumonitis, and erythromycin is still the drug of choice. Zithromax (azithromycin, Pfizer) is a possible alternative. Additional erythromycin ointment is usually given but may not even be necessary. If there is a hyperacute purulent conjunctivitis, gonoccocal conjunctivitis has to be considered and can rapidly penetrate the cornea. It also is treated systemically with penicillin or Rocephin (ceftriaxone, Roche Pharmaceuticals) and frequent ocular irrigation with saline or artifical tears. Once confirmed, both of these require culture in parents and other close family members or the cycle can be recurrent.

During the first 6 years of life, bacterial conjunctivitis is more frequent than viral. Differential diagnosis with nasolacrimal duct obstruction is needed as management differs. H. influenza, S. pneumonia and Moraxella catarrhalis are the predominant organisms. This compares with adults where S. aureus is more common but of course other organisms can be involved including gram-negative rods. I prefer to treat with a fourth-generation fluoroquinalone so the process is stopped rapidly in 2 to 3 days, but I advise against longer-term use of these medications. (Frequently patients are seen with 2-week courses of antibiotics.) There are definitive advantages to using these medications but for the majority of the cases in the community, Polytrim (polymyxin B, trimethoprim sulfate, Allergan) or gentamicin are more economical and will be almost as effective; I have no objection to using them as primary drugs. If the infection involves a hospital setting, possible corneal compromise, association with contact lens use or other factors, I would be directed more toward the fluoroquinalones.

After age 6, viral conjunctivitis is more common than bacterial, and the use of antimicrobial treatment is directed more to avoid superinfection and is not even necessary in many cases. The most important issue is to make sure we have no corneal involvement and to determine if we are dealing with herpes strains and not with adenovirus. They are highly contagious, and epidemics are seen frequently. It is important to keep in mind that allergic conjunctivitis is prevalent, and if symptoms are itching and mild mucous discharge, most probably the process is allergic and not infectious. The management of which belongs to a different discussion.

• Roberto Warman, MD, is the chief of pediatric ophthalmology at Miami Children’s Hospital. He can be reached at 3200 S.W. 60 Court, Suite 103, Miami, FL 3155-4072; 305-662-8390; fax: 305-661-7862; e-mail: rwarman@eyes4kids.com. Ocular Surgery News could not confirm whether Dr. Warman has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.