Conjunctivitis in Children

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of conjunctivitis in children. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose and treat conjunctivitis caused by adnexal diseases.

2. Identify children at risk for uveitis.

3. Manage viral, allergic, and irritative conjunctivitis.

Summary

“Pink eye”: description rather than diagnosis; typically, viral conjunctivitis with no long-term ocular consequences

Ocular anatomy: almost any inflammatory, infectious, traumatic, or allergic response can cause redness of eye; can be focal or diffuse; use of slit lamp necessary to see anterior segment

Potential causes of red eye: adnexal disease; foreign body or trauma; uveitis; neoplastic or structural changes; glaucoma

Adnexal Diseases

Sturge-Weber syndrome: characterized by port-wine stain and injection of conjunctiva

Orbital cellulitis: case example — eyelids tense and difficult to pull open; child fussy and febrile; has history of upper respiratory tract infection; computed tomography shows almost completely obliterated ethmoid sinuses

Chalazion: focal and tender; treat immediately with hot compresses and eyelid scrubs (50% baby shampoo); caused by plugged meibomian gland; oil leaks into surrounding tissue and causes foreign body reaction; hordeolum (ie, stye) focal at eyelid margin; chalazia higher, deeper, darker, and may point; treatment — indicated if chalazia large and chronic; invert eyelid and place clamp around it; incise with #11 blade scalpel and scoop out granulation tissue; leave wound open; treat with topical antibiotic plus steroid; recurrence common, particularly in children with Down syndrome (have abnormal meibomian glands and tend to rub eyes); eye rubbing may indicate refractive error; eyeglasses correct myopia and may prevent rubbing of eyes

Chronic blepharitis: associated with redness, mattering of eyelid margins, and honey-colored crusting; caused by chronic marginal infection with Staphylococcus aureus; patient may have marginal ulcers or small scars in corneal stroma; may cause degradation of visual acuity if scars central in visual axis; treat aggressively with hot compresses and eyelid hygiene; do not use oral antibiotics; other causes — lice; sexual transmission in adolescents; in young child, consider possibility of child abuse

Blocked tear duct: presents as swollen lump on lower eyelid; obstruction in nasolacrimal duct leads to chronic overgrowth of bacteria in fluid-filled lacrimal sac and causes inflammation at common or proximal canaliculus; loculated area of pus develops; requires early probing; has potential for localized cellulitis; membrane over Hasner valve (opening of lacrimal duct beneath inferior turbinate) usually disappears by 40 wk of gestation; persists to 2 to 3 mo of age in ≈10% of babies; if not resolved by 9 to 12 mo of age, probing required

Adnexal neoplasia: lipodermoid — ocular tumor, typically in superior temporal quadrant; differential diagnosis includes lymphoma and (less commonly) leukemia; often slightly mobile; highly focal, localized, and sharply demarcated; does not grow substantially over time; do not resect (may compromise lacrimal gland or extraocular muscles); lymphangioma — often diffuse and poorly demarcated in orbit; difficult to ablate or excise; sclerosing agents used conservatively (may cause optic neuropathy)

Uveitis

Anterior: consequence of trauma, local ocular surface infection, or juvenile idiopathic arthritis (JIA); ≈40% of children with JIA have ocular involvement; many respond to topical treatment; some require immunosuppressive therapy

Posterior: more visually threatening; occurs in immunocompromised children with vitreitis, retinitis, or choroiditis

Case example: child with uncontrolled inflammation due to JIA; has posterior synechiae of pupillary margins to lens surface (can form centrally and must be broken down); child can develop cataract; implantation of intraocular lens challenging due to ongoing inflammation; slit lamp examination of anterior chamber reveals “cell” (ie, white blood cells) and “flare” (indicative of inflammation); cells graded from trace (<5 cells) to 4+ (many cells)

Viral Conjunctivitis

Adenoviral: typically seen in older children; usually unilateral or highly asymmetric (but bilateral disease occurs); often associated with pharyngitis; often associated with palpable preauricular and submandibular nodes; highly contagious

Pharyngoconjunctival fever: type 3 adenovirus; causes fever; preauricular lymph nodes common; cornea typically spared; highly contagious

Epidemic keratoconjunctivitis: has protracted course; subepithelial corneal infiltrates develop over time; initial presentation bright red eyes (bilaterally); eyelids swollen and pink, with significant discharge; duration of immediate symptoms 7 to 14 days; subepithelial infiltrates require 3 mo to 3 yr to clear; highly contagious

Acute hemorrhagic: caused by enterovirus or coxsackievirus; unilateral or bilateral; often associated with viral prodrome and subconjunctival hemorrhage; highly contagious

Management: instruct parent to keep child home from school; antibiotic drops not recommended as first-line treatment; child can return to school after discharge cleared and tearing resolved, or ≥24 hr after resolution of fever; usually resolves in few days; cool compresses may be used; artificial tears may help with irritation of ocular surface

Herpes simplex virus (HSV): vesicles seen on eyelid margins and sometimes tip of nose; not painful, but potentially vision threatening; primary infection characterized by multilobed multiple-branching dendritic epithelial defect; some patients develop scarring of anterior stromal cells through Bowman membrane; primary infection can occur at any age; generally unilateral; bilateral HSV indicates immunocompromise; keratitis worsens with topical steroids; reactivation may lead to dendritic lesion or disciform keratopathy, which causes disciform scar, sometimes centrally; vascularization of cornea may occur, possibly requiring corneal transplant (transplantation often unsuccessful due to recurrent erosions, graft failure, and vascular ingrowth into graft); treat with cool compresses; for corneal involvement, use trifluridine ophthalmic (Viroptic) and cycloplegic agents

Herpes zoster: Hutchinson sign — vesicle on tip of nose sign of ocular surface involvement (pseudodendritic epithelial defect); refer to ophthalmologist

Varicella: usually associated with clinical chickenpox; papular lesions present on eyelid margin, with focal involvement near area of ocular surface in which viral particles shedding; not sight threatening; self-limited

Molluscum contagiosum: can cause follicular conjunctivitis; treated with curettage (under anesthesia) to remove lesions

Allergic Conjunctivitis

Background: always itch, often intensely

Seasonal or perennial: signs — hyperemia; chemosis; “boggy-looking” conjunctiva; ropey mucoid discharge; tearing; itching; treat with cool compresses, mast cell stabilizers (eg, olopatadine ophthalmic [eg, Pataday, Patanol]), and topical antihistamine

Vernal: typically seen in southern United States; worse in hot weather; patients develop large papillary forms of conjunctivitis; excision of papules may be necessary; can be tarsal or limbal; limbal form diagnosed by observation of fine vessels coming into surface of cornea, particularly superiorly; shield ulcer may develop due to erosion of cornea from large papules; ≤5% of children have permanent vision change from scarring; treatment — cool compresses; topical steroids (even low-dose steroids effective)

Giant papillary conjunctivitis: usually from protein deposits on contact lenses (particularly hard lenses); can develop vascularization of superior cornea; instruct children to wear eyeglasses instead of contact lenses

Irritative Conjunctivitis

Causes: environmental pollutants; smoke; pet dander; occupational exposure

Readings

Berry-Brincat A, Rose GE: Idiopathic orbital inflammation: a new dimension with the discovery of immunoglobulin G4-related disease. Curr Opin Ophthalmol 23:415, 2012; Bijlsma WR et al: The role of biopsy in diagnosing patients suspected of idiopathic orbital inflammation. Curr Eye Res 37:251, 2012; Carruth BP, Wladis EJ: Inflammatory modulators and biologic agents in the treatment of idiopathic orbital inflammation. Curr Opin Ophthalmol 23:420, 2012; Cronau H et al: Diagnosis and management of red eye in primary care. Am Fam Physician 2010;81:137-44; Dugel PU et al: Macular epiretinal brachytherapy in treated age-related macular degeneration: MERITAGE study: twelve-month safety and efficacy results. Ophthalmology 119:1425, 2012; Heier JS et al: The 1-yr results of CLEAR-IT 2, a phase 2 study of vascular endothelial growth factor trap-eye dosed as-needed after 12-week fixed dosing. Ophthalmology 118:1098, 2011; Kari O, Saari KM: Diagnostics and new developments in the treatment of ocular allergies. Curr Allergy Asthma Rep 2012;12:232-9; Kubota T, Moritani S: Orbital IgG4-related disease: clinical features and diagnosis. ISRN Rheumatol 2012:412896, 2012; Li F et al: Controlled release of bevacizumab through nanospheres for extended treatment of age-related macular degeneration. Open Ophthalmol J 6:54, 2012; Shinder R et al: Idiopathic inflammation of the orbit and contiguous structures. Ophthal Plast Reconstr Surg 28:e82, 2012; Soderberg AC et al: Combination therapy with low-dose transpupillary thermotherapy and intravitreal ranibizumab for neovascular age-related macular degeneration: a 24-month prospective randomised clinical study. Br J Ophthalmol 96:714, 2012; Wagner RS, Aquino M: Pediatric ocular inflammation. Immunol Allergy Clin North Am 2008;28:169-88

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In this lecture, Dr. Christiansen presents information related to the off-label use of a therapy, product, or device.

 

Acknowledgements

Dr. Christiansen spoke at Current Clinical Pediatrics 2012, held April 16-20, 2012, in Hilton Head Island, SC, and presented by Boston University School of Medicine, Department of Pediatrics and Office Continuing Medical Education (to learn more about CME activities at Boston University School of Medicine, visit www.bumc.bu.edu/cme). The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP502301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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