Conjunctivitis in children
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]
Synonyms and keywords: Madras eye, pink-eye, pinkeye, conjunctivitis, ophthalmia, rubor, inflammation, ophthalmitis, redness, neonatal conjunctivitis
Overview
Conjunctivitis is characterized by inflammation and swelling of the conjunctival tissue which can be associated with engorgement of the blood vessels, ocular discharge, and pain. Neonatal conjunctivitis is a red eye in a newborn caused by infection, irritation, or a blocked tear duct. When caused by an infection, neonatal conjunctivitis can be very serious.
Historical Perspective
- In 1750, Neonatal conjunctivitis was first described by S.T. Quellmaz.[1][2]
- In 1881, Crédé introduced 2% silver nitrate for the first time as a prophylaxis treatment method for conjunctivitis in the newborns.[3]
- In 1883, Koch discovered the bacilli of two different forms of infectious conjunctivitis.
- In 1953, Micheal Hogan first described the association between atopic dermatitis and conjunctivitis.
Classification
Conjunctivitis can be classified into subtypes:[4][5]
- Bacterial conjunctivitis
- Viral conjunctivitis
- Allergic conjunctivitis
- Chemical conjunctivitis
- Immune mediated conjunctivitis
Pathophysiology
- The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as streptococci, staphylococci, and corynebacteria. Alterations in the bacterial titer, or in the species of bacteria can lead to clinical infection.
- Alteration in the flora can also result from external contamination, the use of topical or systemic antibiotics, or spread from adjacent infectious sites.
- Disruption of defense barriers can lead to infection. The primary defense against infection is the epithelial layer covering the conjunctiva.
- Secondary defense include hematologic immune mechanisms carried by the conjunctival vessels, tear film immunoglobulins and lysozyme and the rinsing action of lacrimation and blinking.[6]
Causes
- Common causes of neonatal conjunctivitis include:[7]
- Common causes of Conjunctivitis in children inculde:[7][8]
Differentiating conjunctivitis from other Diseases
In children with red eye and conjunctivitis symptoms, mentioned diagnosis should be excluded:[9]
- Corneal abrasion
- Subconjunctival haemorrhage
- Blepharitis
- Periorbital cellulitis
- Uveitis
- Episcleritis
Epidemiology and Demographics
- Bacterial conjunctivitis most commonly affects individuals younger than <6 years of age. Recent studies have shown that haemophilus influenzae and streptococcus pneumoniae are the two organisms most commonly responsible for bacterial conjunctivitis in children.
- Viral conjunctivitis occurs most often in the fall and winter and usually affects children older than 6 years.
- Children age 0-4 years shows a peak of conjunctivitis during the month of March.[10]
- Boys and girls are affected in similar proportions.[7]
Risk Factors
Risk factors of neonatal conjunctivitis includes:[11][12]
- STDs in mother
- HIV infected mothers
- Exposure of the infant to infectious organisms
- Prematurity
- Poor hygienic delivery conditions
- Ocular trauma during delivery
Natural History, Complications and Prognosis
Natural history
- Chlamydial conjunctivitis is cuased by chlamydia trachomatis which is one of the most common causes in neonatal conjunctivitis. Women with untreated chlamydia can pass the bacteria to her baby during childbirth. Symptoms include red eye, swelling of the eyelids, and purulent discharge. Symptoms are likely to appear 5 to 12 days after birth. About half ofnewborns with chlamydial conjunctivitis also have the infection in other parts of their bodies.[13][2][7]
- Gonococcal conjunctivitis is caused by neisseria gonorrhoeae. Women with untreated gonorrhea can pass the bacteria to her baby during childbirth. Symptoms usually include red eye, thick pus in the eyes, and swelling of the eyelids. This type of conjunctivitis usually begins about 2 to 4 days after birth. It can be associated with bacteremia and meningitis in newborns.
- Chemical conjunctivitis can occur when eye drops are given to newborns or children to help prevent a bacterial infections. Symptoms of chemical conjunctivitis usually include mildly red eye and some swelling of the eyelids. Symptoms are likely to last for only 24 to 36 hours.
- Conjunctivitis caused by adenovirus is frequently hemorrhagic, and cases of adenovirus keratoconjunctivitis are often accompanied by dramatic degrees of periorbital swelling.
Complications
Complications to neonatal conjunctivitis include:[14][15]
- Pseudomembrane formation
- Corneal edema
- Peripheral pannus formation
- Corneal opacification
- Corneal perforation
- Endophthalmitis
- Loss of eye and blindness
- Infantile pneumonia
- Nasopharyngeal, rectaland vaginal colonization
- Some systemic complications particularly in gonococcal conjunctivitis including:
- Stomatitis
- Arthritis
- Rhinitis
- [Septicemia]]
- Meningitis
Complications of viral conjunctivitis in children including:[2]
Prognosis
- Early detection and early treatment of extremely pathogenic bacteria, such as Chlamydia trachomatis or Neisseria gonorrhoeae, is associated with a good prognosis. [2]
Diagnosis
Diagnostic Criteria
- The diagnosis of conjunctivitis in children is based on the clinical physical findings which include:
- Redness, excessive tearing, and irritation are symptoms common to all forms of conjunctivitis.
- Photophobia, itching, mucopurulent or non-purulent discharge, chemosis, burning eyes, blurred vision and eyelid swelling are variable depending on the pathogen.
- Broad generalizations can be made about the clinical characteristics of bacterial conjunctivitis as compared to viral conjunctivitis but distinguishing them clinically in individual children may be difficult.[16]
Symptoms
Gonococcal Conjunctivitis
Gonococcal conjunctivitis is more severe than chlamydial conjunctivitis. The incubation period is 2-5 days and it is usually bilateral.[2]
Chlamydial conjunctivitis
Chlamydial conjunctivitis has a later onset than gonococcal conjunctivitis. The incubation period is 5-14 days. Most of the cases are mild and self-limited, but occasionally may be severe.[2]
Chemical conjunctivitis
Chemical conjunctivitis usually occurs within 24 hours of instillation of silver nitrate solution and resolves spontaneously within a few days.[4]
Herpes simplex keratoconjunctivitis
Herpes simplex keratoconjunctivitis in an infant usually presents with generalized herpes infection.[4]
Bacterial Conjunctivitis
Bacterial conjunctivitis more than viral conjunctivitis tend to cause bilateral rather than unilateral involvement.[4]
- Mucopurulent discharge
- Eyelids swelling
- Red eye
Physical Examination
Ophthalmologic examination of children with conjunctivitis is usually remarkable for:[4][17]
- Chemosis
- Mucopurulent or watery discharge
- Eye lid oedema
- Mild to moderate hyperemia
Laboratory Findings
- Conjunctivitis is essentially a clinical diagnosis made by observation of signs and symptoms. However, lab diagnosis is of paramount importance in establishing the correct diagnosis and initiating the best treatment.
Bacterial Conjunctivitis
Laboratory tests usually are not required in patients with mild bacterial conjunctivitis. However, specimens for bacterial cultures should be obtained in patients who have severe inflammation with mucopurulent discharge or in patients who do not respond to treatment.[14][8][18]
- Chlamydial conjunctivitis
- Positive polymerase chain reaction (PCR) of conjunctival scraping
- Positive gram staining or giemsa staining of conjunctival scraping
- Positive enzyme immuno-assays for chlamydia organisms
- Gonococcal conjunctivitis
- Positive gram staining of conjunctival scraping for gram-negative intra-cellular diplococci
- Positive special cultures for neisseria species on chocolate agar or Thayer-Martin agar
Viral conjunctivitis
- Positive conjunctival scraping for polymerase chain reaction (PCR)[19]
- Positive viral culture of corneal epithelial cells for HSV
Neonatal conjunctivitis
- Positive gram staining or giemsa staining of conjunctival scraping[2]
- Positive polymerase chain reaction (PCR) of conjunctival scraping
- Positive special cultures for neisseria species on chocolate agar or Thayer-Martin
- Positive culture on blood agar
Electrocardiogram
- There are no ECG findings associated with conjunctivitis.
X-ray
- There are no x-ray findings associated with conjunctivitis.
Echocardiography or Ultrasound
- There are no echocardiography or ultrasound findings associated with conjunctivitis.
CT scan
- There are no CT scan findings associated with conjunctivitis.
MRI
- There are no MRI findings associated with conjunctivitis.
Other Imaging Findings
- There are no other imaging findings associated with conjunctivitis.
Other Diagnostic Studies
- There are no other diagnostic findings associated with conjunctivitis.
Treatment
Medical Therapy
Neonatal conjunctivitis
Ophthalmia neonatorum is an ocular emergency so all infants with this condition should be admitted immediately. Clinical treatment should be based on clinical features and laboratory results. However, it is essential to treat ophthalmia neonartum with systemic drugs rather than topical to prevent systemic dissemination.[2][20][13]
- Chlamydial conjunctivitis
- Oral erythromycin syrup, 50 mg/kg/day, in 4 divided doses for 14 days
- Topical erythromycin or tetracycline as an adjunct therapy
- Gonococcal conjunctivitis
- Intravenous Penicillin G 100,000 Units /kg/day for 1 week
- Ceftriaxone 50 mg/kg as a single dose in case of resistance to penicillin
- Spectinomycin 25 mg/kg (maximum 75 mg) as a single IM dose as an alternative option
- Kanamycin 25 mg/kg (maximum 75 mg) as an alternative option
- Herpetic conjunctivitis
- Low dose systemic acyclovir (30mg/kg/ day IV divided tid) Or
- Vidarabine (30 mg /kg/day in divided doses IV) for at least 2 weeks
- Trifluridine eye drops
Conjunctivitis in children
Bacterial conjunctivitis
Although bacterial conjunctivitis generally resolves spontaneously in a few days, there is broad agreement that topical antibiotics are worthwhile, particularly in moderate to severe infection.[21]
- Azithromycin 1.5% ocular solution
- Polymyxin B with Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution for 1 week
- Gentamicin 0.3% ophthalmic ointment for 1 week
- Sodium sulfacetamide 10%-30% ophthalmic solution for 1 week
Viral conjunctivitis
The purpose of the treatment in children with viral conjunctivitis is to reduce virus dissemination and the chance of the development of keratitis[22]
- Ganciclovir 0.15% ophthlamic gel for 1 week
- Trifluridine 1% solution q4h for 1 week
Allergic conjunctivitis
Most cases do not need therapeutic interaction. However, in severe cases below can be used[6]
- Topical antihistamines
- Topical mast cell stabilizers like diclofenacor ketorolac
Surgery
- Surgical intervention is not recommended for the management of conjunctivitis in children and neonates.
Prevention
Neonatal conjunctivitis
- Ocular prophylaxis with 0.5% erythromycin ointment or 1% tetracycline hydrochloride can be given to all newborns.[2]
- To prevent neonatal conjunctivitis, women with STDs should consult with their physician about ways to minimize the chances of spread to their newborn baby.
- Avoid vaginal delivery in mothers with STDs (HSV transmission rates are high for women who acquire genital herpes in the last few weeks of pregnancy).
Conjunctivitis in children
Effective measures to prevent conjunctivitis in children include:[6]
- Washing hands
- Change towels and wash cloths daily
References
- ↑ "Reports from the obstetrical clinic in Leipzig. Prevention of eye inflammation in the newborn". Am J Dis Child. 121 (1): 3–4. 1971. PMID 5543850.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Mallika P, Asok T, Faisal H, Aziz S, Tan A, Intan G (2008). "Neonatal conjunctivitis - a review". Malays Fam Physician. 3 (2): 77–81. PMC 4170304. PMID 25606121.
- ↑ "INTRODUCTION". Acta Paediatrica. 75 (s330): 7–27. 1986. doi:10.1111/j.1651-2227.1986.tb10403.x. ISSN 0803-5253.
- ↑ 4.0 4.1 4.2 4.3 4.4 Gigliotti F, Williams WT, Hayden FG, Hendley JO, Benjamin J, Dickens M; et al. (1981). "Etiology of acute conjunctivitis in children". J Pediatr. 98 (4): 531–6. doi:10.1016/s0022-3476(81)80754-8. PMID 6970802.
- ↑ "StatPearls". 2020. PMID 28722870.
- ↑ 6.0 6.1 6.2 Azari AA, Arabi A (2020). "Conjunctivitis: A Systematic Review". J Ophthalmic Vis Res. 15 (3): 372–395. doi:10.18502/jovr.v15i3.7456. PMC 7431717 Check
|pmc=value (help). PMID 32864068 Check|pmid=value (help). - ↑ 7.0 7.1 7.2 7.3 Weiss A (1994). "Acute conjunctivitis in childhood". Curr Probl Pediatr. 24 (1): 4–11. doi:10.1016/0045-9380(94)90022-1. PMID 8174390.
- ↑ 8.0 8.1 Bodor FF, Marchant CD, Shurin PA, Barenkamp SJ (1985). "Bacterial etiology of conjunctivitis-otitis media syndrome". Pediatrics. 76 (1): 26–8. PMID 3874389.
- ↑ Rainsbury PG, Cambridge K, Selby S, Lochhead J (2016). "Red eyes in children: red flags and a case to learn from". Br J Gen Pract. 66 (653): 633–634. doi:10.3399/bjgp16X688309. PMC 5198670. PMID 27884914.
- ↑ Ramirez, David A.; Porco, Travis C.; Lietman, Thomas M.; Keenan, Jeremy D. (2017). "Epidemiology of Conjunctivitis in US Emergency Departments". JAMA Ophthalmology. 135 (10): 1119. doi:10.1001/jamaophthalmol.2017.3319. ISSN 2168-6165.
- ↑ Gichuhi S, Bosire R, Mbori-Ngacha D, Gichuhi C, Wamalwa D, Maleche-Obimbo E; et al. (2009). "Risk factors for neonatal conjunctivitis in babies of HIV-1 infected mothers". Ophthalmic Epidemiol. 16 (6): 337–45. doi:10.3109/09286580903144746. PMC 3223245. PMID 19995198.
- ↑ Honkila M, Renko M, Ikäheimo I, Pokka T, Uhari M, Tapiainen T (2018). "Aetiology of neonatal conjunctivitis evaluated in a population-based setting". Acta Paediatr. 107 (5): 774–779. doi:10.1111/apa.14227. PMC 7159510 Check
|pmc=value (help). PMID 29345007. - ↑ 13.0 13.1 Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N (2018). "Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis". J Pediatric Infect Dis Soc. 7 (3): e107–e115. doi:10.1093/jpids/piy060. PMC 6097578. PMID 30007329.
- ↑ 14.0 14.1 Fransen L, Nsanze H, Klauss V, Van der Stuyft P, D'Costa L, Brunham RC; et al. (1986). "Ophthalmia neonatorum in Nairobi, Kenya: the roles of Neisseria gonorrhoeae and Chlamydia trachomatis". J Infect Dis. 153 (5): 862–9. doi:10.1093/infdis/153.5.862. PMID 3084664.
- ↑ Drug and Therapeutics Bulletin (2011). "Management of acute infective conjunctivitis". Drug Ther Bull. 49 (7): 78–81. doi:10.1136/dtb.2011.02.0043. PMID 21733975.
- ↑ Rose P (2007). "Management strategies for acute infective conjunctivitis in primary care: a systematic review". Expert Opin Pharmacother. 8 (12): 1903–21. doi:10.1517/14656566.8.12.1903. PMID 17696792.
- ↑ Azari AA, Barney NP (2013). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMC 4049531. PMID 24150468.
- ↑ Høvding G (2004). "[Acute bacterial conjunctivitis]". Tidsskr Nor Laegeforen. 124 (11): 1518–20. PMID 15195156.
- ↑ Pinto RD, Lira RP, Arieta CE, Castro RS, Bonon SH (2015). "The prevalence of adenoviral conjunctivitis at the Clinical Hospital of the State University of Campinas, Brazil". Clinics (Sao Paulo). 70 (11): 748–50. doi:10.6061/clinics/2015(11)06. PMC 4642493. PMID 26602522.
- ↑ Matejcek A, Goldman RD (2013). "Treatment and prevention of ophthalmia neonatorum". Can Fam Physician. 59 (11): 1187–90. PMC 3828094. PMID 24235191.
- ↑ Oikonomakou MZ, Makri OE, Panoutsou E, Kagkelaris K, Plotas P, Garatziotou D; et al. (2019). "Bacteriology and Antimicrobial Susceptibility Patterns of Childhood Acute Bacterial Conjunctivitis in Western Greece". Med Hypothesis Discov Innov Ophthalmol. 8 (4): 266–271. PMC 6778672 Check
|pmc=value (help). PMID 31788487. - ↑ Bremond-Gignac D, Messaoud R, Lazreg S, Speeg-Schatz C, Renault D, Chiambaretta F (2015). "A 3-day regimen with azithromycin 1.5% eyedrops for the treatment of purulent bacterial conjunctivitis in children: efficacy on clinical signs and impact on the burden of illness". Clin Ophthalmol. 9: 725–32. doi:10.2147/OPTH.S78747. PMC 4408937. PMID 25945033.