A two year old child comes to your office with the onset of URI symptoms. There is a low grade fever and a runny right eye. Physical exam demonstrates some erythema of the bulbar conjunctiva and a clear nasal discharge. The ears are difficult to see because of cerumen. The throat is red without exudate. How would you treat this child?
A patient with viral conjunctivitis.
What is conjunctivitis?
- Inflammation of the conjunctiva – comprised of a squamous epithelium with goblet cells and a highly vascularized substania propria
- Palpebral or tarsal conjunctiva: lines the upper and lower lids
- Bulbar or ocular conjunctiva: tightly adherent to the sclera
- Fornix conjunctiva: junction between palpebral and bulbar conjunctiva
- The redness/injection in conjunctivitis should:
- Involve the bulbar conjunctiva for 360 degrees and the palpebral conjunctiva
- If injection is localized, consider an alternative diagnosis
Common infectious etiologies of conjunctivitis
- Greater than 70% are Streptococcus pneumoniae, non typable Hemophilus influenzae, and adenoviruses
- Clinical experience suggests viral the most common
- Bacterial is more common in children than adults
- In the neonate and young infant -Chlamydia and N. gonorrhea
- Type b Hemophilus often associated with periorbital cellulitis
- Staphlococcus aureus is usually normal flora
- Adenovirus type 3&7 associated with pharyngeal conjunctival fever
- Adenovirus 8,19, and 37 associated with epidemic keratoconjunctivitis
A patient with bacterial conjunctivitis, note the exudate.
Other causes of red eyes that must be considered
- Allergic reactions- often seasonal
- Irritation from chemicals
- Foreign bodies and corneal abrasions.
- Infants may have nasolacrimal duct obstruction and will have discharge but conjunctiva not injected
- Kawasaki's syndrome-watery discharge
- JRA, Lyme disease, ataxia telangectasia
- Subconjunctival hemorrhage- common after birth
A patient with allergic conjunctivitis, note swelling and redness but lack of exudate. https://en.wikipedia.org/wiki/Conjunctivitis
Physical findings and historical information helpful in establishing an etiology
- Viral conjunctivitis: viral prodrome; presents with watery eye, some mucous but no purulent drainage; “burning” or “gritty” feeling; second eye involved within 24 -48 hours
- Bacterial conjunctivitis: often presents with purulent discharge at the lid margins
- Time of year and history of atopy associated with allergic conjunctivitis as does a “burning” or “gritty” feeling to the eye
- Presence of otitis diagnostic for otitis/conjunctivitis syndrome that is caused by non-typable H. flu.
- Presence of exudate on tonsils may indicate adenoviral infection
- Acute onset or feeling of something in eye may indicate foreign body or corneal abrasion
- "Bloody" discharge often seen with N. gonorrhea
- Preauricular lymph node associated with viral etiology
- Vesicular lesions around the eye suggestive of Herpes simplex and chickenpox
- Age > 6, April through November, no or watery discharge, and abscence of glued eyes in morning, makes bacterial etiology less likely (ref 9)
- Infectious conjunctivitis is a diagnosis of exclusion
- In general, culturing and gram staining the discharge is not recommended unless you suspect N. gonorrhea.
- Staining for viruses may be helpful diagnosing herpes infections.
- Treatment with topical antibiotics may increase the clinical response but after 8-10 days there will be no difference between the treated and untreated cases. Most cases will resolve without treatment.
Otitis/conjunctivitis should be treated with oral beta-lactamase resistant antibiotic.
a. Quinolones, Polytrim.
- Viral: self-limited, supportive care; symptom relief from topical antihistamine/decongestants
- Failure of resolution of symptoms or worsening needs ophthalmologic evaluation for possible corneal involvement
- N. gonorrhea and chlamydia may need IV therapy
- Viral conjunctivitis is highly contagious by direct contact with patient, his/her secretions, and contaminated objects and surfaces
- There is no scientific evidence that children with conjunctivitis need to be out of school. Most schools are insistent that the child not be allowed to return to school without a doctor's note signifying that the child has been treated and is no longer contagious.
- Good hand washing and separate towels.
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