CONJUNCTIVITIS IN CHILDHOOD

What are the most common causes of conjunctivitis in childhood?

Conjunctivitis is an inflammation of the conjunctiva which is usually caused by infection or allergy. It is frequently referred to as “pink eye” and is the most common acute eye disorder seen by primary care pediatricians and family physicians.

What are the characteristics of allergic conjunctivitis?

Allergic conjunctivitis is characterized by ocular redness and itching. Tearing (clear tears), crusting of the eye lids and photophobia may also be seen. The condition is often recurrent, and seasonal. Children who have allergic conjunctivitis often have a history of other atopic diseases, particularly allergic rhinitis, eczema or asthma.

What are the characteristics of an infectious conjunctivitis?

Infectious conjunctivitis may be bacterial or viral. Bacterial conjunctivitis is twice as common as viral conjunctivitis. Typically in bacterial conjunctivitis the eye is red, there is a purulent discharge, the affected child is often a pre-schooler and there may be an associated otitis media. In viral conjunctivitis there is redness, clear tearing or crusting, usually occurs in an older school age child, and is often associated with pharyngitis.

What organisms are commonly involved in bacterial conjunctivitis?

The most common bacterial organisms causing conjunctivitis are Haemophilus Influenzae and Streptococcus pneumoniae. H. Influenzae conjunctivitis occurs in 40 to 50% of cases and is more likely to be associated with an accompanying otitis media than other organisms. S. Pneumoniae accounts for about 10% of cases and other organisms (Staphylococcus aureus, Bacteroides and Moraxella catarrhalis) account for the remainder.

What is the most common cause of viral conjunctivitis?

Adenovirus conjunctivitis is the most common cause of viral conjunctivitis and may account for up to 20% of infectious conjunctivitis. Outbreaks of adenoviral conjunctivitis have been linked to contaminated equipment in ophthalmology clinics and to swimming pools.

Why is there a need to distinguish viral from bacterial conjunctivitis?

Viral and other non-purulent types of conjunctivitis do not require antimicrobial treatment. Often these children are treated mistakenly for prolonged periods of time with both topical and systemic antibiotics with persistence of the red eye. In some situations the topical antibiotic itself may cause an allergic reaction resulting in a persistent red eye.

What is the pathogenesis of infectious conjunctivitis?

In children the joint communication of the conjunctival sac with the middle ear and nasopharynx probably accounts for the frequent association of otitis media and pharyngitis with acute conjunctivitis.

What is the differential diagnosis of acute conjunctivitis?

In the child with a non-purulent conjunctivitis, one should think of Kawasaki disease, Lyme disease, juvenile rheumatoid arthritis or Steven’s Johnson syndrome. When there is decreased vision and light sensitivity the physician must think of uveitis. Trauma and allergic conjunctivitis account for the remainder of the differential diagnosis.

What is the treatment of choice for acute bacterial conjunctivitis?

Acute bacterial conjunctivitis is a self limited condition. However, the use of antibiotic treatment is recommended because it hastens healing considerably and it eradicates the bacterial pathogen allowing children to return to daycare centers and schools within 24 hours of treatment. Topical treatment with polymyxin-bacitracin, garamycin or other suitable topical antimicrobials should be used. There is usually no need to use topical treatment for more than 2 to 5 days when complete resolution should have occurred. Treatment should be applied to both eyes, even if only one eye appears to be infected. Topical application should be applied four times a day.

What approach should be used if the purulent discharge persists despite topical treatment?

If there is persistent eye discharge after Day 4 or 5 of treatment then one needs to consider an alternative diagnosis. The most common occurrence is that of an associated otitis media which has not been recognized or has subsequently developed and requires the use of an oral systemic antibiotic. This occurs most frequently in H. influenzae conjunctivitis. An oral antibiotic which has activity against beta lactamase producing organisms should be used.

What is the treatment for viral conjunctivitis?

Non-purulent viral conjunctivitis requires no treatment.

What is the treatment for allergic conjunctivitis?

Allergic conjunctivitis can be treated with an ophthalmic preparation containing a topical decongestant with or without antihistamine. Prevention of allergic conjunctivitis in susceptible individuals is best treated with topical sodium chromoglycate.