diagnosis and management of pediatric conjunctivitis
TRANSCRIPT
Dr.Azad A Haleem AL.MezoriDCH, FIBMS
Lecturer University Of DuhokColleg of Medicine
Pediatrics Department2016
Diagnosis and Management of Pediatric Conjunctivitis
Introduction • One of the most common ophthalmologic complaints managed
in the pediatric emergency department (ED) is conjunctivitis. • Conjunctivitis is common in childhood and may be infectious
or noninfectious. Most commonly, conjunctivitis is due to:• bacterial infection, • viral infection, or • allergic hypersensitivity. • The etiology of conjunctivitis varies with the age of the child.
• The approach to a patient with conjunctivitis should begin by eliminating other causes of a red eye, such as
• iritis, • keratitis, • glaucoma, • corneal abrasion, • measles, • Kawasaki disease, and others
According to Age?
• The evaluation then varies with the age of the child.
• If conjunctivitis develops in the first 24 hours of life, it is most likely due to chemical irritation from an agent used for prophylaxis of gonorrhea.
• However, all neonates with conjunctivitis should be evaluated for both N. gonorrhea and C. trachomatis with Gram stains and culture.
• If gram-negative diplococci are seen, infection with gonorrhea is assumed and should be treated with systemic antibiotics.
• Infants younger than 30 days that do not have gonorrhea should be treated with oral erythromycin for presumed chlamydia infection.
• Older infants and toddlers are more likely to have bacterial conjunctivitis.
• Their ears must be checked for otitis media, which, if present, should be treated with oral antibiotics.
• Patients with hyperacute conjunctivitis with rapidly progressive hyperemia, edema, and copious, purulent discharge should be evaluated for N. gonorrhea and N. meningitidis with Gram staining and culture.
• Both of these organisms are treated with systemic antibiotics and frequent irrigation of the eyes.
• If the child does not have otitis media or hyperacute conjunctivitis, empiric topical antibiotics should be prescribed.
• Isolation is usually not needed for most cases of bacterial conjunctivitis, except those that involve Neisseria species and conjunctivitis–otitis media syndrome.
• Conjunctivitis in school-aged children and adolescents is most likely to be of viral or allergic origin.
• Associated findings that can help differentiate the two are preauricular lymphadenopathy, pharyngitis, upper respiratory tract infection, history of asthma, eczema or rhinitis, and history of recurrent conjunctivitis.
• Also, if any vesicles are seen in the vicinity, HSV or varicella–zoster virus is the likely etiologic agent.
• If either of these is suspected, a fluorescein examination of the eye must be performed to look for the characteristic dendritic pattern of herpes keratitis.
• Ophthalmologic consultation is needed for both herpes and zoster involvement of the conjunctiva.
• Other viral forms of conjunctivitis require only supportive care but are highly contagious and require approximately 1 week of isolation.
• Allergic conjunctivitis is not contagious, requires no isolation, and can be treated with antihistamines, decongestants, H1- receptor antagonists, mast cell stabilizers, or nonsteroidal anti-inflammatory drugs.
Age groups Common etiology TreatmentNeonates < 24 hours Chemical
conjunctivitisObservation
< 1 week Neisseria gonorrhea Hospitalize, ceftriaxone
1–2 weeks Chlamydia trachomatis
Oral erythromycin
Infants and toddlers Without otitis Haemophilus influenzae, Streptococcus pneumoniae, Branhamella catarrhalis
Topical antibiotics (Polysporin* or Polytrim†)
With otitis H. influenzae Oral antibioticsSchool-age children 3–5 years HSV, varicella–zoster
conjunctivitisTopical antivirals, oral acyclovir
School-age children and adolescents
Viral conjunctivitis Supportive care, artificial tears
Allergic conjunctivitis Antihistamines, decongestants, H1, antagonists, mast cellstabilizers, NSAIDS
CLINICAL MANIFESTATIONS
• The signs and symptoms of conjunctivitis are similar with each of these etiologies:
Bacterial Viral AllergicCommon etiologic agent
Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, Neisseria gonorrhea, Chlamydia trachomatis
Adenovirus, HSV, HZV, enterovirus
Pollens, allergens
Prevalent age Neonates to toddlers School age to adults Late childhood to early adulthood
Character of discharge Purulent Watery MucoidAmount of discharge 1+ to 3+ 1+ to 2+ 1+Injection 3+ 2+ 1+Lymphadenopathy Occasional Common NoneSmear of exudate Bacteria, PMNs Lymphocytes EosinophilsAssociated symptoms Papillary response Follicular response ChemosisAssociated disorders Otitis media Pharyngitis, URI Rhinitis, asthma,
eczemaTreatment Antibiotics Artificial tears,
acyclovirAntihistamines, decongestants, mastcell stabilizers, NSAIDS
CONDITION ETIOLOGY SIGNS AND SYMPTOMS TREATMENT
Bacterial conjunctivitis
Haemophilus influenzae, Haemophilus aegyptius, Streptococcus pneumoniae
Mucopurulent unilateral or bilateral discharge, normal vision, photophobia
Topical antibiotics, parenteral ceftriaxone for gonococcus, H. influenzae
Neisseria gonorrhoeaeConjunctival injection and edema (chemosis); gritty sensation
Viral conjunctivitis Adenovirus, ECHO virus, coxsackievirus
As above; may be hemorrhagic, unilateral Self-limited
Neonatal conjunctivitisChlamydia trachomatis, gonococcus, chemical (silver nitrate), Staphylococcus aureus
Palpebral conjunctival follicle or papillae; as above
Ceftriaxone for gonococcus and erythromycin for C. trachomatis
Allergic conjunctivitis Seasonal pollens or allergen exposure
Itching, incidence of bilateral chemosis (edema) greater than that of erythema, tarsal papillae
Antihistamines, topical mast cell stabilizers or prostaglandin inhibitors, steroids
Acute Bacterial Conjunctivitis
• Beyond the neonatal period, acute conjunctivitis is twice as likely to be due to bacteria than to viruses.
• H. influenzae is the most commonly isolated organism, followed by S. pneumoniae and Moraxella catarrhalis.
• Staphylococcal species were isolated from the conjunctivae of children with conjunctivitis and from those of asymptomatic children at equal rates; thus, their role in the pathogenesis of conjunctivitis remains controversial.
• Other bacteria were isolated from conjunctival cultures but at very small frequencies.
• The child may present with any of the following signs and symptoms:
• itching, • burning, • mucopurulent or purulent discharge, • eyelid edema, or • conjunctival erythema.
• There are no pathognomonic signs to distinguish bacterial from viral conjunctivitis; however, there are some clues that may help differentiate the two.
• Preschool-aged children are more likely to have bacterial etiologies, although there is considerable overlap in age ranges.
• The development of papillae, a papillary response, on the conjunctiva and bilateral disease are also more likely when the conjunctivitis is bacterial in origin.
• Associated otitis media is highly suggestive of a bacterial etiology.
• However, given the significant overlap in the signs and symptoms of bacterial and viral conjunctivitis, clinicians cannot reliably predict etiology based on clinical examination.
• Gram stain of conjunctival exudates may be helpful, but some studies show poor sensitivity.
• Acute bacterial conjunctivitis is a self-limited disease, although it is frequently treated with topical antibiotics
• There are many topical antimicrobial agents available. • Three inexpensive, commonly prescribed topical
antibiotics, trimethoprim , gentamicin, and sodium sulfacetamide, were compared in a doubleblind study, which showed no difference in rate or speed of cure.
• In general, when choosing an antibiotic, one should consider the antibiotic’s spectrum of activity, side effects, and cost.
• trimethoprim–polymyxin (Polytrim) are inexpensive, have few side effects, and have good broad-spectrum coverage.
• Sodium sulfacetamide is inexpensive and has good gram-positive coverage, but it stings when applied.
• Aminoglycosides have good gram-negative coverage, but they are expensive and cover streptococci poorly. Epithelial toxicity and corneal ulceration can occur, especially with prolonged use of aminoglycosides.
• Erythromycin is inexpensive and has good gram-positive and Chlamydia coverage, but it has poor activity against Haemophilus species, B. catarrhalis, staphylococcal species, and gram-negative organisms.
• Fluoroquinolones are expensive but have broad-spectrum coverage and few side effects other than local irritation.
• Chloramphenicol is inexpensive and has broad-spectrum coverage, but there are case reports of associated aplastic anemia with topical ophthalmic administration.
• Corticosteroids are sometimes combined with ophthalmic antibiotic preparations. Use of these agents should be avoided because the corticosteroid may impede eradication of the bacteria; worsen herpes keratitis, which may have been mistaken for conjunctivitis; and increase intraocular pressure.
Ointments VS Drops • Antimicrobial medications for conjunctivitis are typically given
as one drop (or one-half inch of ointment) four times daily for 5-7 days.
• It is important to use one drop at a time. Otherwise, the second eye drop will wash the first one out of the eye.
• If you use more than one types of eye drops, wait at least 5 minutes between each drop.
• If you use eye drops as well as eye ointment, apply the eye drops first, and then apply the eye ointment 5 minutes later.
• Ointments have the advantage of increased dwell time in the eye, but often patients and parents of children prefer drops, and no therapeutic advantage of one over the other has been demonstrated.
• the texture of eye drops is somewhat thinner and more watery. Drops are also formulated for application directly to the eye, and not to the eyelid.
• In contrast, the consistency of most eye ointments is thicker and includes antibiotics to aid in treating an infection as well as alleviating the pain associated with the particular ailment.
• Another important difference involves the introduction of moisture along the surface of the eye.
• Drops primarily aid in the process of treating rough, dry eyes by adding additional fluid to the surface of the eye.
• While many eye ointments do provide some type of moisture, the products also provide a more aggressive treatment for redness due to eyestrain or allergies, ease pain associated with dryness, and in general reduce just about any type of irritation to a greater degree than simple drops.
• Depending on the type of eye condition that exists, both eye ointments and drops may be used.
• In general, the drops will help to ease discomfort, while ointments treat the underlying condition.
• However, many ointments also include properties that are intended to treat pain as well as minimize bacterial and other types of infections.
• In some cases, the ointments also provide a barrier that protects the eye as it recovers from injury or some type of surgical procedure.
Ointments VS Drops
VIRAL CONJUNCTIVITIS• Adenoviral Conjunctivitis. Most viral conjunctivitis is caused
by adenovirus. Approximately 20% of all cases of conjunctivitis are caused by adenovirus, with a seasonal predilection for fall and winter months.
• Several forms of adenoviral infection occur: follicular conjunctivitis, pharyngoconjunctival fever, epidemic keratoconjunctivitis, and, occasionally, acute hemorrhagic conjunctivitis. • All forms of adenoviral conjunctivitis are extremely
contagious.
• Transmission of infection is usually through direct contact with infected persons or contact with contaminated instruments.
• Thus, healthcare workers who manipulate the eyes should wear gloves and practice good hand-washing techniques.
• Instruments used to examine patients should also be cleaned after use.
• Families must be instructed to separate the towels and bed sheets of the patient from other family members.
• The affected child should be kept home for approximately 1 week after the onset of symptoms.
• Treatment is supportive regardless of the type of adenoviral conjunctivitis.
• Cold compresses, artificial tears, and topical vasoconstrictors may provide comfort.
• Studies comparing antiviral agents and anti-inflammatory medications with artificial tears show no significant difference between these medications and artificial tears.
• Topical steroids should be avoided because they have significant side effects, such as superinfection, glaucoma, and cataract .
• Topical steroids also may exacerbate a missed diagnosis of herpes conjunctivitis, may enhance adenoviral replication, and may increase the duration of adenoviral shedding.
• Topical antibiotics are usually unnecessary, as secondary bacterial infections are rare.
THANKS FOR YOUR ATTENTION