Conjunctivitis resident survival guide (pediatrics)

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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]

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Conjunctivitis resident survival guide (pediatrics) Microchapters


Conjunctivitis is a commonly encountered disorder in children and adults in both primary care and specialty eye care settings. The predominant causes of infectious conjunctivitis are viral and bacterial pathogens. Infectious conjunctivitis typically presents as a red eye with purulent or watery discharge and is usually self-limiting, but in rare cases can lead to complications such as keratitis and blindness. Conjunctivitis can occur in a newborn during the first month of life which is known as neonatal conjunctivitis or ophthalmia neonatorum with clinical signs of erythema and oedema of the eyelids and the palpebral conjunctivae, purulent eye discharge. The major causes of ophthalmia neonatorum are chemical inflammation, bacterial infection and viral infection.


Neonatal conjunctivitis

Life Threatening Causes

Most cases of neonatal conjunctivitis are relatively mild, self-limited and will not cause eye damage of any sort. However, if it left untreated it can lead to sight-treathening or even systemic complications.[1]

Common Causes

Conjunctivitis in children

Life Threatening Causes

Most cases of conjunctivitis in children are relatively mild and self-limited, although untreated bacterial conjunctivitis may be associated with complications such as:[2]

Common causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[3][4]

Newborn with suspected gonococcal conjunctivitis
❑ An urgent eye swab should be taken
❑ Urgent gram stain should be requested
Polymerase chain reaction (PCR) can also be used
❑ Definitive diagnosis is made by subsequent bacteriological culture or Nucleic Acid Amplification Test (NAAT)
❑ Gram-negative intracellular diplococci is highly suggestive of gonococcal conjunctivitis
Further investigation including :
❑ Screening for other STDs in both mothers and neonates
❑ Genital and throat swabs in patients with risk factors

Complete Diagnostic Approach

Neonatal conjunctivitis

Ophthalmia neonatorum is essentially a clinical diagnosis made by observation of signs and symptoms.[1][3][5]

Neonate with eye discharge
Take a full history and examine
❑ Bilateral or unilateral red eye
Purulent discharge
❑ Eyelid swelling
❑ Reassure mother
❑ Advise to return if not better
Culture for chlamydia and gonorrhea
HSV is suspected
❑ Oral antibiotics
❑ Treat mother and her partner

Conjunctivitis in children

Most cases are diagnosed on the basis of clinical features[2]

Child with acute red eye
No discharge
Stringy or watery
Other symptoms and signs
Trial of topical antibiotics
Advise self-limiting condition
Refer to ophthalmologist


Neonatal conjunctivitis

Ophthalmia neonatorum is an ocular emergency so all infants with neonatal conjunctivitis should be admitted.[6][7][8]

Category Symptoms DDx Treatment Parents treatment
Gonococcal conjunctivitis Infected mother single dose of ceftriaxone (25-50 mg/kg)
Chlamydial conjunctivitis Infected mother
Herpetic conjunctivitis Oral acyclovir 400 mg daily for 1 week

Conjunctivitis in children

In most cases, conjunctivitis is self-limited and some supportive treatment would be needed. However, some cases require medical intervention.[2][9]

Category Symptoms Causes Treatment
Bacterial conjunctivitis
Viral conjunctivitis
Allergic conjunctivitis
  • Itching
  • Watery discharge


  • Neonatal conjunctivitis[8][10][11][12]
    • The majority of newborns with conjunctivitis would be infected when pass through the birth canal. Hence, the most common strategies for preventing transmission seek to reduce neonatal exposure to active genital lesions.
    • All pregnant women aged <25 years and older women at increased risk for infection for instance those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection, should be routinely screened for chlamydia trachomatis and N.gonorrhea at the first prenatal visit.
    • Pregnant women found to have chlamydial infection should have a test-of-cure to document chlamydial eradication (preferably by nucleic acid amplification testing NAAT) 3–4 weeks after treatment and then retested within 3 months.
    • Women found to have gonococcal infection should be treated immediately and retested within 3 months.
    • Pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester to prevent maternal postnatal complications and gonococcal infection in the neonate.
    • Accurate risk assessment and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services.
    • In mother with active recurrent genital HSV lesions, antiviral suppressive therapy with oral acyclovir or valacyclovir can mitigate the risk of neonatal conjunctivitis.
    • Prophylaxis with silver nitrate 1% or erythromycin ointment 0.5% is part of the routine newborn care for ophthalmia neonatorum prevention.
  • Conjunctivitis in children
    • In assessment of a child presenting with red eye, serious causes (such as acute glaucoma, keratitis, iritis and trauma must be excluded.
    • Reassuring the parents that most cases are self-limiting.
    • Advising self-care measures such as cleaning the eyelids, cool compresses, lubricating drops or artificial tears.
    • Any patient treated for suspected bacterial or viral conjunctivitis that does not improve significantly with initial therapy should be referred to an ophthalmologist for further evaluation.


  • Do not share personal articles that come in contact with the eyes (e.g. eye make-up applicators, towels, wash cloths, eye droppers).[13]
  • Avoid vaginal delivery in mothers with STDs.


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  2. 2.0 2.1 2.2 Chawla R, Kellner JD, Astle WF (2001). "Acute infectious conjunctivitis in childhood". Paediatr Child Health. 6 (6): 329–35. doi:10.1093/pch/6.6.329. PMC 2804756. PMID 20084257.
  3. 3.0 3.1 Gonçalves Dos Santos Martins T, Fontes de Azevedo Costa AL (2018). "A rare ocular complication of neisseria gonorrhoeae". Ir J Med Sci. 187 (3): 815–816. doi:10.1007/s11845-018-1740-2. PMID 29349557.
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  5. Rapoza, Peter A.; Quinn, Thomas C.; Kiessling, Lou Ann; Taylor, Hugh R. (1986). "Epidemiology of Neonatal Conjunctivitis". Ophthalmology. 93 (4): 456–461. doi:10.1016/S0161-6420(86)33716-3. ISSN 0161-6420.
  6. Ellsworth RM (1969). "The practical management of retinoblastoma". Trans Am Ophthalmol Soc. 67: 462–534. PMC 1310351. PMID 5381307.
  7. Straface G, Selmin A, Zanardo V, De Santis M, Ercoli A, Scambia G (2012). "Herpes simplex virus infection in pregnancy". Infect Dis Obstet Gynecol. 2012: 385697. doi:10.1155/2012/385697. PMC 3332182. PMID 22566740.
  8. 8.0 8.1 James SH, Sheffield JS, Kimberlin DW (2014). "Mother-to-Child Transmission of Herpes Simplex Virus". J Pediatric Infect Dis Soc. 3 Suppl 1: S19–23. doi:10.1093/jpids/piu050. PMC 4164179. PMID 25232472.
  9. Quinto GG, Campos M, Behrens A (2008). "Autologous serum for ocular surface diseases". Arq Bras Oftalmol. 71 (6 Suppl): 47–54. PMID 19274411.
  10. Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMC 5885289. PMID 26042815.
  11. Laga M, Meheus A, Piot P (1989). "Epidemiology and control of gonococcal ophthalmia neonatorum". Bull World Health Organ. 67 (5): 471–7. PMC 2491298. PMID 2611972.
  12. Ramirez DA, Porco TC, Lietman TM, Keenan JD (2017). "Epidemiology of Conjunctivitis in US Emergency Departments". JAMA Ophthalmol. 135 (10): 1119–1121. doi:10.1001/jamaophthalmol.2017.3319. PMC 5773254. PMID 28910427.
  13. Matejcek A, Goldman RD (2013). "Treatment and prevention of ophthalmia neonatorum". Can Fam Physician. 59 (11): 1187–90. PMC 3828094. PMID 24235191.