Abstract
Eye complaints in children can differ significantly from those seen in adults. Not only is there the challenge in performing a complete ophthalmic examination, which can vary in success based on age and cooperation, but also knowing when to refer to the emergency department or to an ophthalmologist. These secrets will help improve a practitioner’s comfort level and also cover some of the common pitfalls one may encounter when managing pediatric ophthalmic problems in the urgent care setting.
Keywords
conjunctivitis, ophthalmia neonatorum, pediatric eye exam, preseptal cellulitis, red eye
1
A 3-year-old female patient presents to your urgent care center with “pink eye.” What are the classic signs and symptoms of viral conjunctivitis and how can it be distinguished from bacterial conjunctivitis?
See Table 14.1 .
| Viral conjunctivitis | Bacterial conjunctivitis | |
|---|---|---|
| Discharge | Commonly nonpurulent | Purulent |
| Conjunctival injection and chemosis | + | + |
| Foreign body sensation, tearing, and photophobia | + | + |
| Unilateral or bilateral | Unilateral but can become bilateral | Commonly unilateral |
| Common etiologies and variants |
|
|
| Duration | Up to 2–3 weeks | Less than 3 weeks’ duration |
| Additional features |
|
|
| Important considerations for immediate referral |
|
|
| Treatment and supportive management |
|
|
2
How can you differentiate between the causes of ophthalmia neonatorum (neonatal conjunctivitis)?
Chemical conjunctivitis: This occurs within the first 24 hours of life and is caused by a reaction to topical ophthalmic bactericidal agent (e.g., silver nitrate) applied at birth. It is self-limited and typically resolves within 24–48 hours. Routine use of erythromycin ointment has made this etiology uncommon
N. gonorrhoeae –associated conjunctivitis: Patients usually present with sudden, severe, and grossly purulent discharge between 2 and 5 days of life. This disease is vision threatening due to the high risk of ulceration and globe perforation. Gonococcal meningitis is an associated disease. Treatment involves hospital admission and systemic antibiotics covering both N. gonorrhoeae and C. trachomatis.
C. trachomatis –associated conjunctivitis: Usually occurs between 1–2 weeks of life (but should be suspected in infants <30 days old). Common presentation includes a beefy red conjuctiva with mucoid “ropy” discharge. This disease can cause permanent scarring and is associated with chlamydial pneumonitis. Treatment involves systemic antibiotics with concurrent treatment for N. gonorrhoeae. As with N. gonorrhoeae– associated conjunctivitis the patient’s mother and her sexual partners also require treatment.
Nasolacrimal duct obstruction: Only half of all nasolacrimal ducts are patent at birth. Obstruction causes tearing and discharge without redness. Treatment of this condition involves digital massage over the lacrimal sac. Most cases resolve spontaneously by 1 year of age.
3
Name indications to culture and Gram stain eye discharge
- •
Marked purulence.
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Hyperacute onset of symptoms (over 12–24 hours).
- •
Immunocompromised state.
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Suspicion of N. gonorrhoeae or C. trachomatis.
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