• Red eye, pink eye, or conjunctivitis
  • A nonspecific finding that indicates conjunctival inflammation
  • A variety of disease processes can cause conjunctival inflammation.
  • In most children, it is a benign, self-limiting condition.

• Neonatal infections can be acquired from:
  • Vaginal microorganisms during birth
    • Vaginal delivery
    • Cesarean delivery, if amniotic membranes rupture before delivery
  • Hand-to-eye contamination from hospital workers.
  • Infectious causes of neonatal conjunctivitis usually develop at least 48 hours after birth (see Table 215-2).
    • Chlamydia trachomatis
    • Neisseria gonorrhoeae
    • Group B Streptococcus
    • Staphylococcus aureus
    • Escherichia coli
    • Haemophilus influenzae
    • Herpes simplex virus (HSV) type 2
• Before the use of topical prophylaxis, ophthalmia neonatorum was a devastating disease associated with high morbidity.
  
  • Routine topical prophylaxis with silver nitrate, tetracycline ointment, or erythromycin ointment has dramatically reduced its incidence.

• Nasolacrimal duct (NLD) obstruction
  • At birth, tear production by the lacrimal gland is minimal.
  • Normal tearing develops several days to 2 weeks after birth.
  • Normally, the process of nasolacrimal canalization is completed by the end of the 9th month of gestation.
  • When canalization is incomplete, failure most often occurs at the distal end of the NLD at the Hasner valve.
    • Outflow obstruction at the Hasner valve is the most common cause of NLD obstruction.
  • Other, less common anatomic variations within the nasolacrimal system can cause obstruction of tear outflow.
    • Agenesis of the canaliculus
    • Crowding of the NLD opening by the inferior turbinate
• The most common bacteria causing conjunctivitis in children include:
  • H influenzae
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
  • Staphylococcus

• A history of friends or family members with conjunctivitis usually indicates a contagious origin.
  • Viral conjunctivitis is usually caused by an adenovirus and is extremely contagious.
• Ask about itching.
  • Hallmark sign of allergic conjunctivitis
• Eye discharge
  • 1 or both eyes

• Watery
  • Allergic or viral conjunctivitis
• Purulent
  • Bacterial infections
• Infectious conjunctivitis usually begins in one eye, then spreads to the second eye after a few days.
• If only 1 eye is affected, consider:
  • Foreign body
  • Corneal ulcer
  • Herpes simplex keratitis

• The pediatric patient should receive an ocular examination using the mnemonic I-ARM.
  • Inspection
  • Acuity
  • Red reflex
    • The red reflex test should also be performed on older children with conjunctivitis because an abnormal red reflex may indicate a serious disease process.
    • Benign pediatric conjunctivitis almost never interferes with vision.
  • Motility
• Note whether conjunctivitis is unilateral or bilateral.
  • Unilateral conjunctivitis may be caused by
    • Foreign body
    • Corneal ulcer
    • Herpes simplex keratitis
• Note whether there is any discharge.
  • Minimal
    • Blepharitis
  • Watery
    • Allergic reaction
    • Viral conjunctivitis
  • Purulent
    • Bacterial conjunctivitis
• Note presence of preauricular lymph adenopathy.
  • Indicative of viral conjunctivitis
• Distinguishing features of conjunctivitis in children (see Table 215-1)
  
  • Blepharitis
    • Minimal discharge
    • Minimal itching (real irritation, not itching)
    • Staphylococcus on culture common
  • Allergic reaction
    • Watery discharge
    • Marked itching
    • Eosinophils on conjunctival scraping
  • Bacterial
    • Purulent discharge
    • Minimal itching
    • Children with a bacterial conjunctivitis often complain that their eyelids stick together in the morning.
    • Most often, one eye is initially involved, with subsequent involvement of the other.
    • The bulbar conjunctiva is diffusely injected, and a mucopurulent exudate is present in the inferior conjunctival fornix.
  • Viral
    • Watery discharge
    • Minimal itching
    • Commonly preauricular lymph adenopathy
    • Patients often begin with infection in one eye that then spreads to the other.
    • Eyelids may be swollen, and they may produce reactive ptosis, severe conjunctival hyperemia, and hemorrhagic conjunctivitis.
    • The cornea may be involved; such patients are sensitive to light.
    • Tearing, redness, and the sensation of having a foreign body lodged in the eye are the extreme (termed catarrhal conjunctivitis).
• Neonatal conjunctivitis
  • As for all newborns, the ophthalmic examination should start with the red reflex test.
    • The red reflex should be normal, if the abnormality is isolated to the conjunctiva and does not involve the cornea or intraocular structures.
    • Conditions that have an abnormal red reflex test finding and require immediate consultation with an ophthalmologist
      • Endophthalmitis
      • Congenital glaucoma
      • Corneal infections
  • An urgent consultation is indicated if the neonatal patient has marked lid swelling or unilateral conjunctivitis that does not improve over 1 or 2 days.
    • This condition may be HSV-2 keratitis.

Conjunctivitis

Neonatal conjunctivitis

• Other causes of a red, teary eye in a newborn include:
  • Congenital herpes keratitis
  • Congenital glaucoma, characterized by clear tears, large cornea, hazy cornea due to corneal edema
  • Dacryocystitis, an infection of the nasolacrimal sac that causes swelling in medial canthal area of lower lid

Gonococcal conjunctivitis

• Occurs approximately 48 hours after birth
• It may appear even earlier if rupture of the amniotic membranes occurs several hours before delivery.
• Typically bilateral, purulent conjunctivitis with copious discharge and lid edema
  • N gonorrhoeae is one of the few bacteria that can penetrate intact corneal epithelium, causing corneal ulceration and even corneal perforation.
  • Diagnosis is usually made by identifying gram-negative intracellular diplococci on conjunctival scrapings and verifying by culture.

Chlamydial conjunctivitis

• Typically bilateral and mild to moderate in severity
• Approximately 4–10 days after birth
• Eyelid swelling and a tarsal conjunctival pseudomembrane may be present.
  
  • A conjunctival pseudomembrane is an accumulation of debris, not a true vascular tissue.
• The diagnosis is confirmed by conjunctival scrapings identifying cytoplasmic inclusion bodies in corneal epithelial cells (Giemsa stain) or by indirect immunofluorescence assay or culture.

Viral conjunctivitis

• Pharyngoconjunctival fever consists of an upper respiratory infection (pharyngitis and fever) with bilateral conjunctivitis.
  • Most commonly associated with adenovirus type 3 and type 7
  • Pharyngoconjunctival fever produces:
    • A severe, watery conjunctival discharge
    • Hyperemic conjunctivitis
    • Chemosis (conjunctival edema)
    • Preauricular lymph adenopathy
    • Quite often, a foreign-body sensation that results from corneal involvement
  • Disease is highly contagious and lasts approximately 2–3 weeks.
• Epidemic keratoconjunctivitis (EKC)
  • EKC is caused by adenovirus types 8, 19, and 37.
  • It occurs most often in older children and adolescents.
  • In contrast to pharyngoconjunctival fever, EKC is isolated to the eyes.
  • The virus causes a severe bilateral conjunctivitis with:
    • Conjunctival hyperemia
    • Watery discharge
    • Eyelid swelling
    • A reactive ptosis
    • Petechial conjunctival hemorrhages are common.
    • Pseudomembrane may be found along the conjunctiva.
    • Preauricular adenopathy may be present.
  • In many instances, one eye is involved first, and the second eye becomes affected several days later.
  • Approximately one-third of patients develop corneal inflammation (keratitis) with subepithelial infiltrates 7–10 days after onset of the conjunctivitis.
  • Keratitis is a hypersensitive reaction to the virus, not a true viral infection.
  • Corneal infiltrates cause severe photophobia and irritation.

Hemorrhagic conjunctivitis (conjunctivitis with subconjunctival hemorrhage)

• Common causes include:
  • Infection with H influenzae, adenovirus, or picornavirus
  • H influenzae hemorrhagic conjunctivitis is associated with a purplish discoloration of the eyelids, caused by multiple tiny subcutaneous hemorrhages.
  • Spontaneous subconjunctival hemorrhage is a painless rupture of a small conjunctival vessel.
    • Usually no known reason
    • Conjunctiva surrounding the hemorrhage will be normal.
    • No tearing or exudate is present.
    • Hemorrhage resolves without treatment.
    • A systemic work-up is not usually necessary unless:
      • Hemorrhage becomes recurrent.
      • History of prior bleeding or bruising exists.

Phlyctenular conjunctivitis

• A delayed hypersensitivity reaction to bacterial protein usually associated with staphylococcal blepharitis
• Creamy white or yellowish elevated nodules with a surrounding erythematous base
• Usually located at 3 and 9 o’clock around the limbus
• When tuberculosis was prevalent, it was a major cause of phlyctenulosis.

Seasonal allergic conjunctivitis

• Seasonal allergic (hay fever) conjunctivitis is common and affects approximately 10% of the general population.
  • The hallmark is itching and tearing.
  • Seasonal allergic rhinitis often accompanies seasonal allergic conjunctivitis, which is a type-1 hypersensitivity reaction.
  • Conjunctival scrapings or biopsy samples reveal mast cells and eosinophils.
  • Serum quantitative immunoglobulin E levels are usually high.
  • Skin tests may be positive for environmental allergens.
  • Allergic conjunctivitis is most common in the spring, when pollen levels are high.
  • Many cases occur during the winter, when forced-air heating is turned on and filters have not been cleaned or replaced.
  • Diagnosis usually can be made through clinical signs and symptoms.
    • A family history of allergies, atopic disease, or asthma may be found.

Vernal conjunctivitis

• Severe allergic condition characterized by:
  
  • Severe itching
  • Tearing
  • Mucus production
  • Giant papillae of the upper tarsal conjunctiva
  • Most commonly affects young boys from the Mediterranean basin and from Central and South America
  • Patients often have reactive ptosis and squint in bright light.
    • The result of secondary keratitis caused by the giant papillae scraping the cornea
      • Papillae may be found around the limbus (junction of the sclera and cornea) with characteristic white centers (Horner-Trantas dots representing an accumulation of inflammatory cells, predominantly eosinophils).
      • Conjunctival scrapings of the papillae show many eosinophils.

• Full-blown vernal conjunctivitis is a vision-threatening disease; however, with the advent of topical mast cell stabilizers and antihistamines, this outcome is now rare.

Giant papillary conjunctivitis

• Large papillae develop underneath the superior tarsal conjunctiva as a result of wearing soft contact lenses.
  • Similar to vernal conjunctivitis
  • Reaction results from sensitization of the conjunctiva to allergic materials present on the surface of the contact lens or in contact lens solutions.

Atopic conjunctivitis

• Atopic conjunctivitis is a form of allergic conjunctivitis associated with eczema.
• Serum immunoglobulin E concentrations are often high in these patients.
• Patients with atopic dermatitis often have associated conjunctivitis, with itching, burning, and mucus discharge.

Conjunctivitis associated with systemic disease

• Stevens-Johnson syndrome (erythema multiforme major)
  • Most likely a type-III hypersensitivity reaction associated with mycoplasmal and HSV infections and with many drugs, especially antibiotics and anticonvulsants
  • Patients have fever, malaise, headache, loss of appetite, and nausea.
  • Generalized erythematous papular rash
  • The skin is friable, and traction on it can produce tears.
  • Mucous membranes are most severely affected, including nose, mouth, vagina, anus, and conjunctiva.
  • Eye involvement consists of conjunctival injection and the formation of bullae that can rupture and lead to scarring.
  • Conjunctival scarring can distort eyelids and turn lashes toward the cornea, causing corneal damage.

Herpes infections

• HSV-2
  • Usually associated with keratitis
  • Herpes keratoconjunctivitis may be associated with systemic disease and encephalitis, although it can occur as an isolated eye infection.
  • Onset is usually between 1 and 2 weeks after birth.
  • Serous discharge with moderate conjunctival injection
  • Almost always occurs in only 1 eye
  • Breakdown of the normal epithelial barrier can result in a secondary bacterial corneal ulcer.
  • Early stages of keratitis are detected by corneal fluorescein staining with a geographic or dendritic pattern.
  • Diagnosis is confirmed by viral cultures.
    • May take up to 7–10 days to become positive
• Recurrent ocular HSV
  
  • After initial cutaneous facial infection or infection of mucus membranes, HSV gains access to the sensory nerve endings and travels up the axons to the trigeminal ganglion.
  • The virus remains sequestered and protected within the ganglion.
  • Recurrent ocular herpes infections occurs when virus from the ganglion travels down the sensory nerve and infects the cornea or eyelids.
  • Cutaneous eyelid disease consists of a vesicular reaction similar to primary herpes simplex.
  • Corneal disease from recurrent HSV affects the corneal surface epithelium.
    • Active virus replication causes punctate, dendritic, or geographic epithelial defects.
  • The dendritic pattern is a classic sign of herpes keratitis (corneal infection).
  • Recurrent herpes keratitis is almost always unilateral.
  • Cornea becomes anesthetized as a result of sensory nerve damage.
  • With recurrent herpes, the cornea can scar, and a secondary inflammatory reaction can occur in response to the viral antigen.
• Herpes zoster and varicella-zoster virus
  • Chickenpox, or varicella-zoster virus, rarely affects the eye, even when vesicular lesions occur on the eyelid or eyelid margin.
  • Some physicians administer topical trifluorothymidine if the conjunctiva becomes involved.
  • In immunocompromised patients, herpes zoster can present a high risk.
    • These patients especially should be treated with antiviral therapy.
  • Secondary, or recurrent, herpes zoster ophthalmicus affects patients > 50 years or immunocompromised patients.
    • This severe ocular inflammation can affect all layers of the eye.

NLD obstruction and aminotocele

• NLD obstruction
  • A watery eye and an increased tear lake
  • Eyelash matting
  • Mucus in the medial canthal area
  • Congenital NLD obstruction is common and occurs in 1–5% of the population.
    • Approximately a third are bilateral.
  • If left untreated, NLD blockage spontaneously opens by 6 months of age in almost one-half of cases.
    • The incidence of spontaneous resolution after 13 months of age decreases to only 15%.
• Amniotocele (dacryocystocele)
  • Swelling of the nasal lacrimal sac from an accumulation of fluid within the sac as a result of punctal and NLD obstruction
  • A few days after birth, a bluish swelling appears in the medial canthal area, representing fluid that is sequestered within a distended nasolacrimal sac.

Congenital glaucoma

• Primary congenital glaucoma refers to increased intraocular pressure occurring at birth or shortly thereafter.
  • Normal intraocular pressure in infants is approximately 10–15 mm Hg.
  • Intraocular pressure in infants with congenital glaucoma is often > 30 mm Hg.
• Congenital glaucoma differs from adult glaucoma by causing enlargement of the eye in addition to damaging the optic nerve.
  • The eye enlarges because, in infants, the eye wall is elastic and stretches.
  • Normal corneas at birth are approximately 10.5 mm in diameter.
  • Corneal diameters > 12 mm are considered abnormally large (megalocornea).
  • As the cornea enlarges, breaks of the basement membrane of the corneal endothelium (Haab striae) occur, resulting in corneal edema that reduces vision and can lead to amblyopia.
  • After 3 years of age, the eye wall becomes fairly rigid, and ocular enlargement resulting from glaucoma does not occur.
• Features of congenital glaucoma include:
  • Tearing
  • Photophobia
  • Blepharospasm
  • Large cornea
  • Corneal clouding
  • Edema
  • Bilateral in approximately 70% of cases
• The classic findings of congenital glaucoma are not always present.
  • Signs of ocular enlargement and corneal edema may be subtle.
• In cases with tearing, diagnosis of congenital glaucoma may be misdiagnosed as NLD obstruction.
  • In contrast to NLD obstruction, however, the tearing associated with congenital glaucoma is caused by corneal edema.
  • Can be seen as a dull red reflex with an ophthalmoscope
• Primary ocular HSV-1
  
  • Most adults have been exposed to HSV-1, and unless immunocompromised, have circulating antibodies to the virus.
  • Only 1% of the population will exhibit clinical HSV-1 infection.
  • Most infections are asymptomatic.
  • Primary ocular herpes represents the first exposure to HSV-1.
    • Occurs initially as a skin eruption with multiple vesicular lesions
    • Virus can be cultured from vesicle fluid.

Blepharitis

• Blepharitis, or eyelid inflammation, is one of the most common causes of pink eye in children.
• The 2 most common types of blepharitis are staphylococcal blepharitis and meibomian gland dysfunction.
  • Both types of blepharitis are treated with lid hygiene (lid scrubs with baby shampoo) and topical antibiotics.
• Complaints of itching and burning
• Children often awake with eyelids stuck together with crusting.
• The eyes are irritated, but true itching is not present.
• Crusting and scales at the base of the eyelashes
• The eyelid margins are thickened and hyperemic.
• Vascularization of the eyelid margin
• Lashes may become misdirected, broken, or absent (madarosis).
• Sties, or external hordeolums, are common.
  • An external hordeolum is an abscess of the gland of Zeis on the anterior eyelid margin.
  • In contrast to a chalazion, which is deeper and an inflammation of the meibomian gland that results from breakdown of the fatty secretions
• Blepharitis may be associated with corneal changes that cause severe photophobia.

Meibomian gland dysfunction

• Meibomian glands are sebaceous glands with orifices at the eyelid margins.
• Secretions consist of sterol esters and waxes that provide a covering to the tear film, thereby preventing evaporation
• Dysfunction or blockage of the meibomian gland orifice by desquamated epithelial cells results in stagnation of the lipids and causes a secondary local inflammation.
• Microbial lipases from Propionibacterium acnes and other bacteria contribute to producing irritating fatty acids that increase the inflammatory response.
• Obstruction of the meibomian gland orifices may result in a chalazion or sty.
  • Chalazion appears as a lump near the upper or lower eyelid margin.
    • Swelling can occur externally as a lump on the skin or internally as a lump underneath the conjunctiva.
    • Chalazion is not an infection, but a granulomatous inflammation that results from the irritating lipids within the meibomian gland.

Molluscum contagiosum

• Molluscum contagiosum is a viral disease of the skin caused by a DNA virus of the poxvirus group often occurring on the eyelids.
• Lesions are small, round, discrete bumps with a central pit.
• Presumed to be contagious and are transmitted by direct touch
• When present on the eyelid margin, they can cause a conjunctival reaction and a follicular conjunctivitis.

Kawasaki disease

• Kawasaki disease is a systemic vasculitis occurring in children usually < 8 years.
• Onset of fever, present for > 5 days, along with 4 of the following 5 criteria:
  • Nonpurulent conjunctivitis
  • Oral mucus membrane injection or swelling (or both)
  • Erythema and edema of the hands and feet
  • Polymorphous rash
  • Cervical lymphadenopathy
• Vasculitis may involve coronary arteries and cause a coronary aneurysm or a thrombosis that may lead to sudden death.
• The cause of Kawasaki disease is unknown.

Graft-versus-host disease

• Approximately 40% of patients who receive a bone marrow transplant will have graft-versus-host disease.
  • Donor T lymphocytes attack the recipient cells, primarily affecting the skin, liver, intestine, oral mucosa, conjunctiva, lacrimal gland, vaginal mucosa, and esophageal mucosa.
  • Ocular effects of graft-versus-host disease consist of conjunctivitis, dry eye, corneal epithelial erosions, and corneal ulcerations.

Conjunctival nevi

• Congenital or acquired lesions of the conjunctiva are usually located near the corneal limbus.
• They appear as pink or inflamed conjunctiva.
• Nevi come from melanocytes, but they have varying amounts of pigmentation.
• 30% of patients have minimal pigmentation.
• The most common types include junctional, compound, and subepithelial nevi.
• All types have low malignant potential and usually become noticeable in the 1st decade of life through puberty.

• The initial work-up for presumed infectious neonatal conjunctivitis includes conjunctival cultures on:
  • Chocolate agar
  • Thayer-Martin agar
  • Blood agar
• Conjunctival scrapings should be obtained and examined.
  • Gram stain
  • Giemsa stain
  • Indirect immunofluorescent antibody assay for Chlamydia
• If herpes keratitis is suspected (unilateral conjunctivitis with corneal fluorescein staining) then a corneal scraping for herpes culture should be obtained.

• A serologic test for concurrent congenital syphilis infection is advised for venereal-transmitted neonatal conjunctivitis.
• Fluorescein staining of the corneal epithelium is indicated if a corneal abrasion is the suspected cause of the pink eye.
  • Fluorescein staining indicates a defect of the corneal epithelium most commonly caused by a traumatic abrasion, less frequently, an infectious process.
  • Bacterial corneal ulcer
  • Herpes simplex keratitis
• Blepharitis
  • Staphylococcus is common on culture.
• Allergic reaction
  • Eosinophils likely on conjunctival scraping

• Bacterial conjunctivitis
  • Polymorphonuclear neutrophils are present.
  • Bacteria on Gram stain
• Viral conjunctivitis
  • Lymphocytes and monocytes are present.

• Neonatal conjunctivitis
  • Treatment of presumed infectious neonatal conjunctivitis before receiving laboratory results includes the use of topical erythromycin ointment and intravenous (IV) cephalosporin, such as cefotaxime.
    • Ceftriaxone is usually avoided in neonates because it may result in hyperbilirubinemia.
  • Antibiotic treatment should be provided immediately after samples are taken for culture.
  • Topical trifluorothymidine (Viroptic) and IV acyclovir should be provided if herpes is suspected.
  • Once laboratory results are known, therapy is tailored to treat the identified organism.
• NLD obstruction
  • Optimal timing for initial NLD probing is controversial.
  • Some experts advocate probing even when the patient is only a few months of age.
  • Most pediatric ophthalmologists suggest waiting until the child is ≥ 6 months of age.
    • Almost one-half the cases will have spontaneously resolved by then.
  • Other experts suggest waiting until the child is 1 or 2 years of age for probing.
    • Evidence indicates that delaying probing until 1.5–2 years of age means that a single probing will be less successful.
  • Performing initial probing when the patient is between 6 months and 1 year of age allows time for most cases to resolve spontaneously, but it also offers the highest opportunity for success.
  • Probing should be performed on an urgent basis in the case of amniotocele.
  • Probing should be performed in the office without anesthesia.
  • Medical management during the observational period is a combination of nasolacrimal sac massage and intermittent topical antibiotics.
    • Initial massage is directed inferiorly to push the tears in the normal direction, out the NLD.
    • Subsequent massage is directed superiorly so that any tears that did not exit are cleared from the punctum.
    • Occasionally, inferior pressure itself will open a mild NLD obstruction.
    • Topical antibiotic eyedrops or ointments may be provided if signs of infection are present, eg, mucopurulent discharge.
      • For example, moxifloxacin (Vigamox) or trimethoprim-polymyxin B
      • Drops should be prescribed only when evidence of a true infection exists.
• Congenital glaucoma
  • Treatment is based on decreasing the intraocular pressure.
    • Prevent optic nerve damage
    • Prevent progressive expansion of the eye
    • Reduce corneal edema
  • Medications used to lower intraocular pressures include:
    • β-Adrenergic inhibitors, such as timolol
    • Carbonic-anhydrase inhibitors, such as acetazolamide an be administered topically or systemically.
    • Adrenergic agonists, such as apraclonidine
  • Medical treatment is not effective in most cases of congenital glaucoma, which is almost always treated with surgery directed at opening the outflow channels at the trabecular meshwork.
• Bacterial conjunctivitis
  • In general, cultures and Gram stain are not routinely performed for mild to moderate conjunctivitis.
  • Patients are treated with antibiotic eyedrops, including the quinolones.
    • Moxifloxacin
    • Levofloxacin
    • Gatifloxacin
    • Ofloxacin
  • Other antibiotic eyedrops include:
    • Sulfacetamide
    • Trimethoprim sulfate
    • Trimethoprim-polymyxin B (Polytrim)
    • Gentamicin
    • Tobramycin
  • Erythromycin ointment may also be applied.
  • An ophthalmology referral should be considered for severe conjunctivitis or chronic conjunctivitis that does not improve after 7 days of treatment.

Gonococcal conjunctivitis

• Treatment for gonococcal conjunctivitis is topical erythromycin ointment and IV cefotaxime.
• Parents may also need to be evaluated for possible treatment.

Chlamydial conjunctivitis

• The first-line treatment is topical erythromycin ointment.
• Along with oral erythromycin to remove Chlamydia organisms from the nasopharynx at 1–3 months of age
  • To decrease the risk of subsequent Chlamydia pneumonia
  • Because pneumonitis can occur after neonatal conjunctivitis, parents should be warned of this possibility.
    • Parents harbor the infection and should be treated with oral erythromycin or tetracycline even if they do not have any symptoms.

HSV-2

• If herpes neonatal conjunctivitis is suspected, the treatment of choice is topical trifluorothymidine (trifluridine) combined with IV acyclovir.
• Topical antibiotics should be used to prevent a secondary bacterial infection.

NLD obstruction

• NLD probing is a simple but delicate procedure.
• A small steel wire is passed through the nasolacrimal system, through the Hasner valve, and into the nose.
  • In some cases, the inferior turbinate is infractured to relieve crowding.
• The success rate for NLD probing is > 90% when performed before 1.5 years of age.
• In cases in which NLD probing fails, intubation with silicone tubes is indicated to establish a patent system.
  • In general, tubes are used only when the probing procedure fails.
• Amniotocele

• Treatment for a noninfected amniotocele is local massage.
• If decompression does not occur within a few days, then infection (ie, dacryocystitis) is almost certain.
• Because of this likelihood, probing the NLD to open the obstruction may be performed.
• An infected amniotocele is red, warm, and large, approximately 1 cm in diameter.
• Treatment of the infection consists of IV antibiotics (cephalosporin).
• Urgent NLD probing should be performed to relieve the obstruction and drain the abscess.
• Although a cutaneous incision into the sac to decompress the abscess may be performed, this procedure leaves a scar and may produce an external fistula.
• NLD probing does not leave a scar and avoids fistulae.
• Probing has the advantage of directly addressing the primary cause of the abscess by opening the NLD obstruction.
• If the abscess is not drained, then an infected amniotocele can result in cellulitis and even sepsis.

Congenital glaucoma

• The 2 most frequently used procedures are goniotomy and trabeculotomy ab externum.
  • Goniotomy
    • A microscopic knife is used to lyse the abnormal trabecular meshwork to open up the angle.
  • Trabeculotomy ab externum
    • A microscopic probe is placed in the Schlemm canal and then swept through the trabecular meshwork and into the anterior chamber to open up the angle.
  • The success rate of these procedures for congenital glaucoma is approximately 60–70%.
  • If the first procedure fails, a second one may be performed.
  • When these procedures are not successful, a trabeculectomy is usually performed.
    • Trabeculectomy is a filtering procedure in which aqueous fluid is filtered through a small hole in the eye to the subconjunctival space.
• If all these procedures fail, congenital glaucoma can sometimes be managed by ciliary body destructive procedures, such as cryotherapy and laser surgery.
  • Eliminate the ciliary body epithelium that produces aqueous fluid
  • These end-stage procedures have a high failure rate.
• The prognosis for congenital glaucoma is fair, with approximately 70% of patients maintaining good, long-term visual acuity.
  • Unfortunately, patients with unfavorable outcomes often become blind.
  • The most important cause of visual loss is attributed to optic nerve damage, which is not reversible.
  • Other causes include chronic corneal edema with corneal scarring, refractive errors, and, importantly, dense irreversible amblyopia.
• Juvenile glaucoma is more amenable to medical treatment.
  • In many cases, however, juvenile glaucoma must also be treated with surgical techniques.

EKC

• EKC is caused by adenovirus types 8, 19, and 37; the treatment of adenovirus conjunctivitis is prevention of further transmission.
• The clinician must thoroughly wash everything before seeing another patient, if a patient seems to have adenoviral conjunctivitis.
• A patient with this disease will be contagious for up to 2 weeks and should observe isolation precautions during this time.
• Patients with adenoviral conjunctivitis should be referred to an ophthalmologist because of the possibility of corneal involvement.
• No effective antiviral treatment for EKC exists.
  • Cold compresses and topical nonsteroidal antiinflammatory drugs may reduce symptoms.
• A scraping for viral antigen quick preparation is indicated.
• Because of the contagious nature of the adenoviral conjunctivitis, if results are positive, then patients should not return to school for 1–2 weeks.
• Corticosteroids are discouraged except for the treatment of keratitis and should be administered only by an ophthalmologist.

Primary ocular HSV-1

• The use of antiviral medications is controversial.
• Oral acyclovir may be used for severe skin involvement.
• Systemic or topical acyclovir may speed recovery if provided within 1 or 2 days of onset.
• Topical antibiotics applied to the skin may be useful for preventing secondary bacterial infection.
• Over several days to 2 weeks, the skin lesions heal, with or without treatment, usually without much scarring.
• The cornea is involved in 30% of patients with primary ocular HSV-1 infection.
• Topical ophthalmic antiviral medications, such as trifluorothymidine, may be provided to prevent secondary corneal involvement.
• Primary ocular HSV rarely causes intraocular inflammation or uveitis.

Recurrent ocular HSV

• The treatment for acute recurrent herpes keratitis is topical antiviral therapy.
  • Usually with trifluorothymidine (trifluridine).
• Systemic treatment with oral acyclovir has proven to be effective, especially in cases of multiple recurrences or in immunocompromised children.
  • Treatment must sometimes last 6 months to 1 year to prevent recurrence.
  • Topical corticosteroids are not indicated for active herpes keratitis because they will decrease the body’s immune response.
  • The clinician needs to be careful about unilateral pink eye because some of these cases may be herpes keratitis.
  • Topical corticosteroids in conjunction with antiviral therapy may be used by ophthalmologists to reduce corneal scarring.

Blepharitis

• Treatment of staphylococcal blepharitis includes eyelid hygiene and topical antibiotic ointment, usually erythromycin.
• In severe cases, systemic erythromycin may be indicated.
• Eyelid cultures are not routinely performed because most eyelids normally are colonized with Staphylococcus organisms.
• Eyelid hygiene includes lid scrubs with baby shampoo once or twice a day.
  • Prevention of recurrent blepharitis consists of ongoing lid hygiene.

Phlyctenular conjunctivitis

• Treatment consists of treating the blepharitis (lid scrubs and topical antibiotics) and the use of topical corticosteroids.
  • If topical corticosteroids are to be administered, then treatment should be monitored by an ophthalmologist.
• When tuberculosis was prevalent, it was a major cause of phlyctenulosis.
  • Patients with phlyctenular conjunctivitis who are at risk should be evaluated for tuberculosis.

Meibomian gland dysfunction

• Chalazia may resolve without treatment.
• Applying hot soaks several times a day helps the drainage of lipid material.
• If the chalazion does not resolve over several weeks of treatment, then incision and drainage may be necessary.
• An external hordeolum is an acute infection of an accessory gland, which can be treated with:
  • Erythromycin ointment
  • Hot soaks
  • Eyewashes with baby shampoo
• Chalazia may be prevented by eyelid hygiene with eye wipes or a baby shampoo eyewash each day.

Molluscum contagiosum

• Lesions can be treated by excising the central core.
• Rarely, through the use of cryotherapy or application of chemical caustics, such as trichloroacetic acid or aqueous phenol

Seasonal allergic conjunctivitis

• Treatment has greatly improved with the advent of combination mast cell stabilizer–antihistamine eyedrops, such as olopatadine.
  
  • Mast cell stabilizers require 2–3 days of continued use to reduce symptoms
  • Because they do not inhibit activity of already-circulating histamines, combination mast cell stabilizer–antihistamine eyedrops have a double effect.
  • They provide immediate relief because they directly block histamine receptors and prevent the release of histamine by mast cells.
  • Patients with chronic allergic conjunctivitis can use the eyedrops every day, year round.
  • Side effects are rare.
• In cases of severe allergic conjunctivitis, an oral antihistamine may be added to the eyedrops.
• Topical corticosteroids are reserved for severe allergic conjunctivitis not responsive to other treatment.
  • They are only used for a few days.
  • If corticosteroids are used, then an ophthalmologist should monitor the patient for potential side effects of glaucoma and cataracts.
  • Fluorometholone, a mild topical corticosteroid, is a good choice because it does not penetrate the cornea, thus reducing the likelihood of glaucoma and cataracts.

Vernal conjunctivitis

• Treatment is based on avoiding allergens and using combination mast cell stabilizer–antihistamine eyedrops, such as olopatadine.
  • Patients need to use the eyedrops daily during the allergy season.
  • In temperate climates, patients with vernal conjunctivitis may need treatment year round.
• An oral antihistamine can be added to the use of the eye drops if necessary.
• In some instances, severe episodes of inflammation can be controlled only with intermittent short courses of topical corticosteroids.
  • They should be administered and supervised by an ophthalmologist.

Giant papillary conjunctivitis

• Treatment consists of:
  • Using mast cell stabilizers
  • Discontinuing contact lens wear
  • Changing to a regimen of frequent contact lens replacement
• Prognosis is good.

Atopic conjunctivitis

• Treatment of eye symptoms includes:
  • Use of cold compresses
  • Topical vasoconstrictors
  • Topical antihistamines
  • Topical mast cell stabilizers
  • Topical corticosteroids should be used only for short periods while being monitored by an ophthalmologist.

Stevens-Johnson syndrome

• Therapy remains controversial.
• Topical corticosteroids may be administered early, before advanced disease leads to conjunctival scarring.
  • Their use may prevent severe ocular sequelae.
  • Once conjunctival scarring occurs, however, no effective treatment exists.
  • Patients with Stevens-Johnson syndrome should be referred immediately to an ophthalmologist for consultation.

Graft-versus-host disease

• Treatment with topical artificial tears, short courses of topical corticosteroids, and, in severe cases, cyclosporine may improve symptoms.
  • These patients should be referred to an ophthalmologist for careful follow-up.

Conjunctival nevi

• Treatment is controversial, but growth or change in pigmentation of the nevus may be an indication for surgical removal.
• Malignant melanoma is rare in children.

• Severe neonatal conjunctivitis
• Conjunctivitis with poor red reflex
• Conjunctivitis not improving after 1 week of treatment
• Recurrent conjunctivitis, unilateral or bilateral
• Conjunctivitis with positive corneal fluorescein staining
• Conjunctivitis with decreased visual acuity (20/50 or worse)
• Unilateral conjunctivitis in a contact lens user
• Neonatal swollen nasolacrimal sac (amniotocele)
• Tearing with a poor red reflex
• Tearing with large eye (buphthalmos)
• Patients with conjunctivitis associated with contact lens use should be immediately referred to an ophthalmologist.

• Patients with suspected Stevens-Johnson syndrome
• Neonates with gonococcal conjunctivitis

• Patients with corneal involvement need to be closely followed for development of corneal scars.
• Patients with congenital glaucoma need to be monitored for pressure changes, as well as visual acuity, by the pediatric ophthalmologist.

• Corneal scarring due to keratitis
• Loss of vision in patients with congenital glaucoma

• The best agent to use to prevent neonatal conjunctivitis is controversial.
  • The efficacies of erythromycin ointment, tetracycline ointment, and silver nitrate are approximately the same.
  • The use of povidone iodine as prophylaxis has also been advocated.
    • Effective coverage of a broad spectrum of bacteria
    • Coverage for such viruses as HSV and HIV
    • Little chemical irritation reaction

• Pediatric Ophthalmology for Primary Care, 3rd edition (book), American Academy of Pediatrics.
• The Physician’s Guide to Eye Care, 3rd edition (book), American Academy of Ophthalmology.

• American Academy of Pediatrics, Section on Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, and American Association of Certified Orthoptists. Red reflex examination in neonates, infants, and children. Pediatrics. 2008;122(6):1401-1404.  [PMID:19047263]

• Greenberg MF, Pollard ZF. The red eye in childhood. Pediatr Clin North Am. 2003;50:105-124.  [PMID:12713107]