Conjunctivitis (Pink Eye)

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.
https://en.wikipedia.org/wiki/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

1. Greater than 70% are Streptococcus pneumoniae, non typable Hemophilus influenzae, and adenoviruses
   1. Clinical experience suggests viral the most common
   2. Bacterial is more common in children than adults
2. In the neonate and young infant -Chlamydia and N. gonorrhea
3. Type b Hemophilus often associated with periorbital cellulitis
4. Staphlococcus aureus is usually normal flora
5. Adenovirus type 3&7 associated with pharyngeal conjunctival fever
6. Adenovirus 8,19, and 37 associated with epidemic keratoconjunctivitis
    

A patient with bacterial conjunctivitis, note the exudate.
https://en.wikipedia.org/wiki/Conjunctivitis

Other causes of red eyes that must be considered

1. Allergic reactions- often seasonal
2. Irritation from chemicals
3. Foreign bodies and corneal abrasions.
4. Infants may have nasolacrimal duct obstruction and will have discharge but conjunctiva not injected
5. Trauma
6. Kawasaki's syndrome-watery discharge
7. JRA, Lyme disease, ataxia telangectasia
8. 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

1. 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
2. Bacterial conjunctivitis: often presents with purulent discharge at the lid margins
3. Time of year and history of atopy associated with allergic conjunctivitis as does a “burning” or “gritty” feeling to the eye
4. Presence of otitis diagnostic for otitis/conjunctivitis syndrome that is caused by non-typable H. flu.
5. Presence of exudate on tonsils may indicate adenoviral infection
6. Acute onset or feeling of something in eye may indicate foreign body or corneal abrasion
7. "Bloody" discharge often seen with N. gonorrhea
8. Preauricular lymph node associated with viral etiology
9. Vesicular lesions around the eye suggestive of Herpes simplex and chickenpox
10. Age > 6, April through November, no or watery discharge, and abscence of glued eyes in morning, makes bacterial etiology less likely (ref 9)

Diagnostic tests

1. Infectious conjunctivitis is a diagnosis of exclusion
2. In general, culturing and gram staining the discharge is not recommended unless you suspect N. gonorrhea.
3. Staining for viruses may be helpful diagnosing herpes infections.

Treatment

1. 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.
2. Viral: self-limited, supportive care; symptom relief from topical antihistamine/decongestants
3. Failure of resolution of symptoms or worsening needs ophthalmologic evaluation for possible corneal involvement
4. N. gonorrhea and chlamydia may need IV therapy

Contagiousness

1. Viral conjunctivitis is highly contagious by direct contact with patient, his/her secretions, and contaminated objects and surfaces
2. 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.
3. Good hand washing and separate towels.

References

1. Gigliottii,F Acute conjunctivitis of childhood. Pediatric Annals. June 1993 353-374.
2. Gigliotti,F Management of the child with conjunctivitis. The Pediatric Infectious Disease Journal. Vol 13, No12 1161-1162 December 1994.
3. Persaud D, Moss WJ and Munoz JL Serious Eye Infections in Children. Pediatric Annals. 1993; 22(6):379-383.
4. Wagner, R. The differential diagnosis of the red eye. Contemporary Pediatrics. July 1991 26-48.
5. Wagner Ralph.  Eye Infections:  Issues for the Pediatrician. Contemporary Pediatrics June 1997
6. Liebowitz H. M. Primary Care: The Red Eye NEJM Vol 343 No. 5 Aug. 3 2000 pg. 345
7. Rose PW. Chloramphenicol treatment of Acute Infective Conjunctivitis in Primary Care Children.  Lancet 2005
8. Conjunctivitis.  Peditrics in Review. May 2010
9. Kunkov S et al. Clinical Prediction Rules Adequately Predict Non-bacterial Conjunctivitis.  Archives Disease of Pediatrics and Adolescents.  2010
10.  Azar MJ, Dhaliwal DK, Bower KS, Kowalski RP, and Gordon YJ, “Possible consequences of shaking hands wit hyour patients with epidemic keratoconjunctivitis,” Am J Ophthalmol 1996; 121(6): 711.