LAS VEGAS – Few conditions worry parents or school nurses more than when a child develops red eye, but how do you as the treating clinician know when to worry?
“Our challenge is to make the right diagnosis, not to worsen the problem, to figure when to refer, and to make that mother who had to take off from work to bring her child into the office – somehow we have to make her happy,” Dr. David B. Granet said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.
Dr. David B. Granet
Concomitant pain or photophobia typically means that something other than bacterial conjunctivitis is at play, said Dr. Granet, professor of ophthalmology and pediatrics at the University of California, San Diego. “Is there contact lens use?” he asked. “Is there proptosis or a history of trauma or injury? How long has it been going on? Most bacterial and viral infections will eventually go away. Is there a corneal opacity? Is there cellulitis, loss of vision, or herpes simplex virus?”
If parents call in suspecting that their child’s eye has been contaminated with a chemical, instruct them to irrigate the eye before they head to the emergency department, he advised. “Whoever’s answering the phone in your office ought to be able to separate out what’s worrisome and what’s not,” he said. “Like everything else we do, the history matters.”
For children who present to your office, consider “anything that can go wrong to make the eye red,” he continued, including nasolacrimal duct obstruction, adnexal disease, foreign body/trauma, uveitis, neoplasm, structural change, or conjunctivitis. “Has the vision changed? If so, that’s your vital sign for referral,” he said. “It’s generally a better sign to have both eyes involved with redness than just one. One eye involved means herpes simplex virus, uveitis, or trauma. Both eyes involved usually means infective or allergic conjunctivitis.”
The three most common conditions that cause a red or pink eye are allergic, bacterial, and viral conjunctivitis. Allergic conjunctivitis “is not just itching; that’s the symptom,” Dr. Granet said. “You get redness, swelling of the conjunctiva, lid edema, mucous discharge, and tearing. All of these occur when the patient rubs their eye. The best treatment for allergic conjunctivitis is avoidance of the allergen.”
He also recommended that affected children wash their hair before they go to sleep. “If their hair has been catching allergen all day long and they lie down on their pillow and start to roll [their head around in] it, that can cause a reaction,” he said.
Ketotifen fumarate (Zaditor) is an available over-the-counter treatment option, but olopatadine HCl (Pataday) is the most popular prescription written by pediatricians. “If you give any antihistamine, in low doses you start to prevent the release of histamine,” Dr. Granet said. “As the dose increases, you have a catastrophic event and you start to destruct the mast cell.”
Viral conjunctivitis usually affects older children and presents as a unilateral condition, then affects the fellow eye. It may be associated with pharyngitis and preauricular or submandibular adenopathy. Bacterial conjunctivitis, on the other hand, typically affects preschool-aged children, is often bilateral but can be unilateral, and yields mucopurulent discharge with matting. It is not associated with adenopathy, but it may be associated with otitis media, and it’s highly contagious. Topical antibiotic ointment therapy is indicated for bacterial conjunctivitis “not because this is a deadly disease, but because we want to reduce the chance for spread,” Dr. Granet said. “We know that communicable diseases are responsible for loss of 164 million school days each year. Additionally, there is a significant cost to a family when a parent misses work. Finally, if the diagnosis is in doubt, treatment with an antibiotic geared to work within a few days will help identify masquerade diseases early.”
Because of concerns about antibiotic resistance, fluoroquinolones are often the first choice for treating bacterial conjunctivitis. Dr. Granet led a multicenter comparison of moxifloxacin versus polymyxin B sulfate–trimethoprim ophthalmic solution in the speed of clinical efficacy for the treatment of bacterial conjunctivitis (J. Pediatr. Ophthalmol. Strabismus 2008;45:340-9). The investigators found that after day 2 of treatment, clinical cure was achieved by 81% of kids in the moxifloxacin group, compared with 44% of those in the polymyxin B sulfate–trimethoprim group. In addition, only 2.3% of kids in the moxifloxacin group were nonresponders, compared with 19.5% of those in the polymyxin B sulfate–trimethoprim group.
Common treatments for viral conjunctivitis include hygiene-related approaches like hand washing and not sharing towels and glasses. But these only prevent spread and don’t make the disease go away faster. The infection usually resolves in about 2 weeks.