There are many problems that may produce a red eye in a child. In this section, we focus on the most common pediatric complaints, corneal abrasion and conjunctivitis, and then discuss other pertinent pediatric problems, including Kawasaki's disease and pediculosis. Inflammatory conditions including scleritis, episcleritis, uveitis, and iritis are covered in chapter 241.
Corneal abrasions in older children are characterized by a foreign body sensation, pain, photophobia, injection, and a history of direct trauma, ultraviolet light exposure, or pain from windblown particulate matter in the eye. Smaller children and infants often lack a history of trauma to the eye and may present with a chief complaint of inconsolable crying and an otherwise normal physical examination. If instillation of an anesthetic drop such as tetracaine 0.5% onto the surface of the eye calms the child, it strongly suggests that injury to the surface of the eye may be the source of the child's distress.
A thorough eye examination with instillation of fluorescein confirms the diagnosis of corneal abrasion. An abrasion will fluoresce to a yellow-green color under the cobalt blue filter in the slit lamp or handheld Wood's lamp. The presence of a vertical linear abrasion suggests the presence of a retained foreign body, and the upper eyelid should be everted and the superior conjunctiva examined. If details on the iris are not visible due to corneal opacification, this may indicate a corneal ulcer, and the patient should be seen by an ophthalmologist the same day.13
Treatment of a corneal abrasion is erythromycin or bacitracin-polymyxin ophthalmic ointment to help avoid superinfection and provide lubrication.13 Avoid ointments containing neomycin due to hypersensitivity reactions.14 Cyclopentolate 0.5% drops may alleviate pain by reducing ciliary spasm. Occasionally nonsteroidal anti-inflammatory drops are also used (such as ketorolac), but the evidence is not robust.15 Eye patching is not routinely recommended but may be useful for any child who frequently attempts to scratch or rub the injured eye. Although the need for tetanus prophylaxis of a corneal abrasion is debatable, the ED visit should be used to remind the caregiver to check the child's tetanus status with the primary care provider. In a tetanus-prone injury, using the same criteria as a standard skin abrasion, updating unknown tetanus status is recommended.16
For uncomplicated and simple corneal abrasions, recommend follow-up in 48 hours with the pediatrician or other primary care provider. Children with involvement of the visual axis should follow up the next day with ophthalmology. Children or adolescents who use contact lenses, have a history of herpes, or may have a retained foreign body should also be evaluated by an ophthalmologist. Contact lenses should not be worn until all symptoms have resolved. Corneal abrasions heal quickly, and patients who continue to have a foreign body sensation 2 to 3 days after initial presentation require urgent ophthalmologic reevaluation.
Ophthalmia neonatorum is conjunctivitis in neonates up to 30 days old. The five primary categories of neonatal conjunctivitis are chemical, gonococcal, chlamydial, other bacterial, and viral (Table 119-2). Gonococcal, chlamydial, and viral neonatal conjunctivitis can all lead to severe morbidity. Although specific diagnoses and treatments are discussed in the following sections, in the ED, it may not be possible to determine the specific etiology. A rapid Gram stain of discharge should be obtained in all cases and will aid in management.
TABLE 119-2Ophthalmia Neonatorum ||Download (.pdf) TABLE 119-2 Ophthalmia Neonatorum
|Type ||Cause ||Age of Presentation ||Key Findings ||Treatment |
|Chemical ||Erythromycin ointment prophylaxis ||24 h ||Bilateral, watery discharge, negative Gram stain ||Watchful waiting |
|Gonococcal ||Neisseria gonorrhoeae ||2–7 d ||Intense chemosis, copious discharge, gram-negative diplococci on Gram stain ||Admission, IV antibiotics |
|Chlamydial ||Chlamydia trachomatis ||7–14 d ||Intense erythema, purulent discharge ||Admission, PO and topical antibiotics |
|Other bacterial ||Staphylococcus aureus, nontypeable Haemophilus influenzae, Staphylococcus epidermidis, Escherichia coli, Pseudomonas ||7–14 d ||Identify etiology on Gram stain ||Topical antibiotics |
|Viral ||HSV-2, less commonly HSV-1 ||14–28 d ||Dendrites on fluorescein exam ||Admission, IV and topical antivirals |
CHEMICAL OPHTHALMIA NEONATORUM
Chemical conjunctivitis occurs in the first 24 hours of life following erythromycin ointment prophylaxis.13 Infants present with bilateral conjunctivitis, inflamed eyelids, and watery discharge. Gram stain of the discharge would reveal the absence of pathologic bacteria and only a few WBCs. Treatment of neonatal chemical conjunctivitis is watchful waiting. Symptoms should resolve within 48 hours.
GONOCOCCAL OPHTHALMIA NEONATORUM
Erythromycin ophthalmic ointment prophylaxis is used at birth in all babies to diminish the risk of conjunctivitis caused by Neisseria gonorrhoeae. Gonococcal conjunctivitis usually presents at 2 to 7 days of life with intense bilateral bulbar conjunctival erythema, chemosis, and a copious purulent discharge (Figure 119-11). The diagnosis is made by Gram stain, revealing gram-negative diplococci, and culture using chocolate agar. Admit all infants with gonococcal conjunctivitis and obtain ophthalmology consultation, and evaluate for disseminated disease.17 Test blood, urine, cerebrospinal fluid, and any other sites with suspected infection. Therapy for isolated conjunctivitis in a neonate without hyperbilirubinemia is a single dose of parenteral ceftriaxone (50 milligrams/kg IV; maximum, 125 milligrams). To avoid exacerbation of hyperbilirubinemia or if disseminated infection is suspected and longer-term antibiotics are required, use cefotaxime (50 milligrams/kg IV every 8 hours). Irrigate the infant's eyes with normal saline frequently to eliminate the purulent discharge. Gonococcal ophthalmia neonatorum may progress to ulceration and perforation of the cornea if improperly treated.
Gonococcal ophthalmia. [Reproduced with permission from Shah BR, Lucchesi M: Atlas of Pediatric Emergency Medicine. © 2006, McGraw-Hill, New York, Figure 8-1.]
CHLAMYDIAL OPHTHALMIA NEONATORUM
Symptoms of chlamydial conjunctivitis present slightly later than those caused by gonorrhea, typically around 7 to 14 days of age. Signs are unilateral or bilateral purulent discharge with intense erythema of the palpebral conjunctiva (Figure 119-12). Chlamydial ophthalmia may be associated with chlamydial pneumonia. Diagnosis is confirmed with Giemsa stain, culture, or nucleic acid amplification of conjunctival scrapings. Treat chlamydial conjunctivitis with or without associated pneumonia with a 14-day course of oral erythromycin (12.5 milligrams/kg PO every 6 hours) and erythromycin ophthalmic ointment.13 Ophthalmology consultation is recommended. Patients with isolated chlamydial ophthalmia who do not have respiratory symptoms or evidence of pneumonia may be safely discharged to home with follow-up in 24 hours.
A and B. Chlamydial ophthalmia. [Reproduced with permission from Shah BR, Lucchesi M: Atlas of Pediatric Emergency Medicine. © 2006, McGraw-Hill, New York, Figure 8-2.]
OTHER BACTERIAL OPHTHALMIA NEONATORUM
Bacterial conjunctivitis due to bacteria other than chlamydia and gonorrhea is also less common when erythromycin topical prophylaxis has been given.17 The most common bacterial pathogens are S. aureus, nontypeable H. influenzae, Staphylococcus epidermidis, Escherichia coli, and Pseudomonas.4 Symptoms are variable and usually begin within 2 weeks of birth with hyperemia, purulent discharge, and edema. Gram stain and culture will identify the cause. Parenteral or oral therapy is not necessary in almost all cases, except nontypeable H. influenzae, and topical therapy with bacitracin-polymyxin ointment is sufficient.4 Nontypeable H. influenzae requires admission to the hospital, a full septic workup, and parenteral antibiotics.
VIRAL OPHTHALMIA NEONATORUM
Viral neonatal ophthalmia, caused by herpes simplex virus types 1 and 2, is a rare cause of neonatal conjunctivitis. Because there is a significant risk of keratitis and devastating disseminated infection, early identification and treatment are critical. Symptoms develop at 14 to 28 days of life with bilateral lid edema and conjunctival erythema. Suspect herpes infection in a neonate with associated mucocutaneous lesions and a maternal history of herpes; however, a history of maternal infection is not necessary for the diagnosis. Herpes conjunctivitis is confirmed with the presence of keratitis or corneal dendrites on fluorescein examination and viral culture or nucleic amplification tests. Neonates with suspected herpetic ophthalmia require hospital admission, full septic evaluation (including lumbar puncture with herpes polymerase chain reaction testing of cerebrospinal fluid), IV acyclovir (20 milligrams/kg IV every 8 hours for 14 to 21 days), and topical antivirals (1% trifluridine, 0.1% iododeoxyuridine, or 3% vidarabine).17 Steroid drops should be strictly avoided in herpes conjunctivitis.
Conjunctivitis, or inflammation of the conjunctiva, is very common in children and may be caused by viruses, bacteria, or allergy; less commonly, it may be a symptom of a systemic disease. Each type of conjunctivitis is discussed in the following sections.
Viral conjunctivitis in childhood is most frequently caused by adenovirus. Less frequent pathogens are rhinovirus, enteroviruses, influenza, and Epstein-Barr virus.4 Measles virus can also cause conjunctivitis but is an unlikely diagnosis with proper childhood immunization. Measles outbreaks can occur among unimmunized populations. Conjunctivitis caused by the herpes viruses requires immediate therapy to prevent permanent vision loss and is covered separately below.
Viral conjunctivitis has several distinct presentations. Pharyngoconjunctival fever presents with fever, acute onset of conjunctivitis, pharyngitis, and preauricular adenopathy, and may be unilateral or bilateral. Epidemic keratoconjunctivitis can present with pain, photophobia, subepithelial defects, and pseudomembranes over the conjunctiva, and is usually bilateral. Follicular conjunctivitis often presents with a foreign body sensation and erythema of the conjunctiva. On examination, an aggregation of lymphocytes around networks of blood vessels in the conjunctiva will give the appearance of follicles. Finally, acute hemorrhagic conjunctivitis presents with hyperemic conjunctiva, subconjunctival hemorrhages, chemosis, swelling, photophobia, and pain. Figure 119-13 shows a child with adenoviral conjunctivitis.
A and B. Adenoviral conjunctivitis. [Reproduced with permission from Shah BR, Lucchesi M: Atlas of Pediatric Emergency Medicine. © 2006, McGraw-Hill, New York, Figure 8-3.]
The treatment of these categories of viral conjunctivitis is supportive only. Cool compresses may offer patients symptomatic relief. Artificial tears and topical vasoconstrictors may improve redness and the sensation of dryness. Topical antibiotics should not be prescribed because there is no evidence of protection against secondary infections and there is suspicion of harm.18 Symptoms may last 2 to 3 weeks, and patients should be referred to ophthalmology if conjunctivitis is persistent or worsening. Viral conjunctivitis is very contagious, and families should not share face cloths, towels, or pillows.
CONJUNCTIVITIS CAUSED BY HERPES VIRUSES
Conjunctivitis caused by varicella most often occurs during primary infections. However, it can also occur with herpes zoster ophthalmicus, which is when the varicella virus lies dormant in the trigeminal nerve and causes recurrent vesicles in the V1 distribution. Herpes simplex virus type 1 may also present similarly with unilateral vesicles in the same distribution. A typical dendritic pattern will be seen on the cornea with fluorescein examination.
Treat both primary and secondary varicella conjunctivitis presenting in the first 72 hours of symptoms with oral acyclovir (for age >2 years old: 20 milligrams/kg PO every 6 hours for 5 days; maximum dose, 3200 milligrams/d) and obtain ophthalmology consultation.19 Similarly, herpes simplex infections of the eye in children also require ophthalmology consultation but may be treated with topical antivirals such as trifluridine, iododeoxyuridine, or vidarabine.17 Topical steroids may be prescribed by an ophthalmologist for both varicella and herpes simplex infections of the eye but should not be prescribed by the emergency physician.
CHILDHOOD BACTERIAL CONJUNCTIVITIS
Bacterial conjunctivitis in childhood is most frequently caused by Haemophilus species, S. pneumoniae, M. catarrhalis, and S. aureus.4 Less common pathogens include Pseudomonas aeruginosa, group B Streptococcus, E. coli, and Neisseria meningitidis. Oculoglandular syndrome is a rare infection often caused by Bartonella henselae (cat-scratch disease) or tularemia, which causes ipsilateral conjunctivitis and lymphadenopathy, often axillary. Physical exam findings include normal vision, mucopurulent matting of the lashes (especially after sleep), and eyelid edema. Photophobia and eye pain are not present, although patients will have some discomfort. Consider chlamydial and gonococcal conjunctivitis in the differential diagnosis, especially in sexually active adolescents and neonates, as mentioned above.
The diagnosis of bacterial conjunctivitis is primarily clinical. If patients have concomitant otitis media, the diagnosis is most likely conjunctivitis-otitis syndrome caused by nontypeable H. influenzae, and oral antibiotics should be prescribed. Otherwise, treat with a broad-spectrum topical antibiotic such as a fluoroquinolone (ciprofloxacin or ofloxacin ophthalmic, which, due to limited absorption, are accepTable for use in children), bacitracin-polymyxin, or trimethoprim-polymyxin.4 An ointment is preferable to eye drops. Although erythromycin ointment is inexpensive, it does not provide adequate coverage for H. influenzae or M. catarrhalis. Therefore, if erythromycin ointment has been prescribed and the patient is not clinically improving, change the topical antibiotic ointment.
Patients with isolated bacterial conjunctivitis or conjunctivitis-otitis syndrome may be safely discharged to home. Symptoms that do not improve after 7 days of therapy merit ophthalmology referral.
It may be difficult in the ED to differentiate bacterial from viral conjunctivitis. In addition to the earlier noted differences, clues to bacterial etiology include history of discharge causing eyelash matting and mucoid or mucopurulent discharge on exam. Viral conjunctivitis is likely in the presence of preauricular lymphadenopathy, recent respiratory illness, and conjunctivitis that spreads among close contacts.9 Consider a swab of the conjunctiva for severe or recurrent cases.
Children with a history of atopy are most likely to suffer allergic conjunctivitis, but almost any child can be affected. Children with allergic conjunctivitis may have bilateral itchy eyes, tearing, thin mucoid discharge, mild redness, and eyelid edema, as well as chemosis. In severe cases, patients may have mild photophobia. Treat allergic conjunctivitis with allergen avoidance, topical antihistamines, and mast cell stabilizers. Ketotifen (one drop to each eye every 8 to 12 hours) and olopatadine (one to two drops to each eye daily), which are both antihistamines and mast cell stabilizers, are very effective.20,21 Topical nonsteroidal anti-inflammatory drugs, vasoconstrictors, and lubricants may provide symptomatic relief. Cool compresses may also be beneficial. Oral antihistamines are discouraged because they can cause eye dryness, exacerbating symptoms.
OTHER CAUSES OF CHILDHOOD CONJUNCTIVITIS
Although almost all pediatric conjunctivitis is due to bacterial, viral, or allergic causes, a differential diagnosis of the red eye includes iritis, keratitis, uveitis, glaucoma, corneal abrasion, Kawasaki's disease, and pediculosis. Kawasaki's disease, glaucoma, and pediculosis of the eyelashes are discussed in the following sections.
Kawasaki's disease, a severe medium-sized vessel vasculitis that can cause coronary artery aneurysms, predominantly presents in children 1 to 8 years of age (see chapter 141, "Rashes in Infants and Children"). Nonpurulent bilateral conjunctivitis is a key diagnostic feature of Kawasaki's disease. In typical cases, patients have a fever (>5 days), dry and erythematous lips and oropharynx, enlarged cervical lymph node (>1.5 cm), nonvesicular rash, edema, or peeling of the hands and feet. A diagnosis of Kawasaki's disease requires inpatient admission, IV γ-globulin, aspirin therapy, cardiology consult, and, in most institutions, either infectious disease or rheumatology consultations.
Lice can infest the eyelashes of a child of any age, leading to itching and scratching, with a mild conjunctivitis caused by the louse's saliva. Occasionally by scratching, children can cause a secondary bacterial infection or corneal abrasion.
Do not use pediculicide shampoos to treat pediculosis of the eyelashes because the shampoo is toxic to the eyes. Rather, attempt to remove nits (eggs) and then smother the lice with petroleum jelly or other ophthalmic ointment three times a day. Although the head and body louse may frequently involve the eyelashes of children, if Pthirus pubis (pubic louse) is identified, consider sexual abuse.