Conjunctivitis: A practice guideline

-1 I ! Robert

J. Yetman

& Deborah

CONJUNCTIVITIS Defirzition: Inflammation of the palpebral conjunctiva (the lining of the upper and lower eyelids) and occasionally the bulbar conjunctiva (layer of conjunctival tissue over the sclera). Incidence/Cause: Conjunctivitis is the most common ocular disorder in childhood. Causes include viral, bacterial, allergic, and chemical.

ALLERGIC ORVERNAL CONJUNCTIVITIS IncidencelCause: l Allergic cause. l Also known as “hay fever conjunctivitis.” l Attacks are acute and are precipitated by allergens (pollens, animal hair, fungi, dust, and ingestion of some foods). HiSt0t-J.j: l Severe itching and tearing. l RUMY nose. l Swollen lids. l Defined allergens. l Family history of seasonal allergies. Physicalfindings (see Table 2): l Palpebral and bulbar conjunctival injection and cobblestoning. l Bulbar conjunctival edema.

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K. Coody

l l l

l

Mucoid eye discharge. Rhinitis. Chemosis.

l

Diagnostic Testing: l Scrapings or smears of the conjunctiva reveal eosinophils. Management: l Control known allergens. l Apply cold compresses to eyes p.r.n. for symptomatic relief. l Topical vasoconstrictor-antihistamine (Naphcon A)-one drop in each eye q.i.d. l Nonsteroidal antiinflammatory -Acular (ketorolac tromethamine 0.5%) one drop q.i.d. up to 1 week in children older than 12 years of age. l Topical mast cell stabilizersCromolyn sodium 4% ophthalmic solution (Crolom) or Alomide 0.1% (Lodoxamide

Teline

tromethamine) one or two drops on each eye q.i.d. Oral antihistamines (Benadryl, Tavist D, Claritin) and / or nasal steroids (Flonase, Beconase) for associated allergic symptoms.

VIRAL CONJUNCTIVITIS IncidencelCause: l Adenovirus, by far the most common cause, is very contagious. l Transmission is by exposure to airborne, aerosolized particles or by hand contact with eye. l Herpes (simplex, zoster or varicella), mumps, and rubella infections are also causes of conjunctivitis, although less common. Histo y: l Acute onset of profuse, watery discharge.

clear,

This guideline was adapted for use in the Department of Pediatrics at the University of Texas-Houston Health Science Center; its use should in no way be construed as an endorsement by NAPNAP. Adaption may be required (a) to fit the needs of one’s practice setting or (b) to meet state legislative requirements. Robert J. Yetman is an Associate Houston, Texas.

Professor of Pediatrics at the University

Deborah K. Coody is an Associate Houston, Texas. Reprint requests: Robertj. 77030. Copyright

Professor of Pediatrics at the University

Yetman, MD, Department

] Pediatr Health Care. (1997). + 0

of Texas-Houston

Medical School in Medical

of Pediatrics, 6431 Fannin, MS6 3.140, Houston,

School in TX

II, 238-241.

0 1997 by the National Association

0891.5245/97/$5.00

of Texas-Houston

of Pediatric Nurse Associates

& Practitioners.

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Yetman & Coody

ipHi PRACTICE GUIDELINES

TABLE 1 Clinical and laboratory features of conjunctivitis Viral Minimal Generalized Profuse Minimal, mucoid

Bacterial Minimal Generalized Moderate Profuse, purulent

Preauricular adenopathy

Common

Uncommon

Stained conjunctival smears & scrapings

Lymphocytes, plasma cells, multinucleated giant cells, eosinophilic intranuclear inclusions Occasionally

Neutrophils,

Itching Hyperemia Tearing Exudation

Associated sore throat & fever

Modified from Vaughan, D., Asbuty, T., & Riordan-Eva,

l

l

Commonly associated with pharyngitis and/or fever. Close personal contacts may have history of similar conjunctivitis.

Physicalfindings (see Table 2): l Conjunctival injection. l Watery discharge. l Preauricular or submaxillary lymphadenopathy. l Primary herpes simplex presents with acute unilateral follicular conjunctivitis with regional lympadenopathy; vesicular ulcerations of the eyelids; cornea1 involvement not uncommon. Management: l Cool compresses to eye t.i.d.q.i.d. l Refer to ophthalmologist if a viral infection other than adenovirus is suspected.

OPHTHALMIA NEONATORUM (CONJUNCTIVITIS THE NEWBORN)

IN

Cause: l

Viral (herpes simplex), bacterial (gonococcal, staphylococcal, pneumococcal), chlamydial, or chemical (silver nitrate).

JOURNAL

OF PEDIATRIC

HEALTH

CARE

P. (1995).

l

bacteria

Occasionally

General ophthalmology

(14th ed.). Appleton

Cesarean section can reduce the incidence of ophthalmia neonatorum caused by active maternal herpetic infection.

Histo y: l Premature rupture of maternal amniotic membranes. l Documented or suspected sexually transmitted disease (gonorrhea, chlamydia, herpes). l Local injury to the eye during delivery. l Infected health care personnel or family members. l The use of silver nitrate as prophylaxis against Neisseria gonorrhea. Physical findings: l Redness and swelling of the bulbar and palpebral conjunctiva. l Chemosis. l Purulent exudate. Diagnostic tests: l Quick screen: Gram stain, Giemsa stain. l Definitive diagnostic tests: DNA probe for Chlamydia, chocolate agar for gonorrhea, herpes simplex virus cultures, routine bacterial cultures.

Chlamydial Minimal Generalized Moderate Profuse, mucoid or mucopurulent Common only in inclusion conjunctivitis Neutrophils, plasma cells, basophilic intracytoplasmic inclusions Never

Allergic Severe Generalized Moderate Minimal, slight mucus None

Eosinophils

Never

8! Lange, 1995

Management: See Table 2.

BACTERIAL CONJUNCTIVITIS >l MONTH OF AGE IncidenceJCause: l Staphylococcal, pneumococcal, and Haemophilus conjuctivitis predominate between the ages of 3 months and 8 years. l Consider Neisseria gonorrheae in a sexually active teen or in a child who has been sexually abused. Nontypable Haemophilus in+erzzae is seen more in warmer climates between May and October. Streptococcus pxeumoniae is seen in colder climates during the winter. Staphylococcus aweus shows no geographic or seasonal predilection. Histo y: l Erythema and irritation of the eye. l Sticky purulent or mucopurulent discharge. * Matted or crusted eyelashes upon awakening. l Mild photophobia.

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~PRACTKE

TABLE 2

Yetman

GUIDELINES

Management

of ophthalmia

neonatorum

(conjunctivitis

in the

newborn) Etiologic

Agent

Treatment

Prophylaxis Chemical conjunctivitis Gonococcal conjunctivitis Without extraocular manifestations With extraocular manifestations

Ceftriaxone

Bacterial conjunctivitis Gram-positive cocci

Herpetic conjunctivitis

History of sick contacts or symptoms of upper respiratory infection, otitis media, acute pharyngitis. Infants with dacryostenosis may get a bacterial conjunctivitis as a result of increased moisture in the eye.

Physical Findings: l Palpebral and conjunctival redness. l Purulent or mucopurulent discharge (acute, profuse exudate with conjunctival and lid edema is suggestive of AJeisseriu conjunctivitis). Diagnostic Testing: Usually not indicated. culture, Gram stain, routine chocolate agar for gonorrhea, Giemsa stain, and DNA probe for Chlamydia if poor response to ini-

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Volume

11 Number

50 mg/kg in a single dose (max 125 mg)

0.5% erythromycin ointment every 2-4 hours 0.3% gentamicin or tobramycin ointment every l-3 hours; and/or systemic therapy 0.5% erythromycin ointment every 2-4 hours Oral erythromycin ethylsuccinate 50 mg/kg/day in 4 divided doses for 2 weeks Systemic acyclovir plus topical 1% trifluridine, 6 times per day x 5-l 4 days

Gram-negative rods Chlamydial conjunctivitis

l

or 1% tetracy-

Ceftriaxone 25-50 mg/kg/day intravenously or intramuscularly x 7 days; or cefotaxime 25 mg/kg/day, intravenously or intramuscularly every 12 hours Penicillin G 50,000 U/kg/day divided in 2 intravenous doses x 7 days In severe infections add Bacitracin ointment 500 U/g every 2 hours for 2 days and 5 times daily thereafter

With known susceptibility

l

l

1% silver nitrate; or 0.5% erythromycin; cline ointment Observation x 24 hours

5

tial therapy or possibility of sexually transmitted disease. Management: l Warm soaks to eyes with water, ocular saline solution or boric acid solution t.i.d. l Good hygiene including hand washing and avoidance of mucosal touching. No sharing of towels, pillows, or blankets. l Return to school after antibiotic treatment is initiated. l Although bacterial conjunctivitis is often self-limited unless caused by gonorrhea, children who receive topical antibiotics more quickly, and improve most schools require treatment before the child’s return to class. l Antibiotic drops: sulfacetamide sodium 10% ophthalmic solution (Sulamyd) or trimethoprim sulfate and polymyxin B sulfate

l

& Coody

(Polytrim); or antibiotic ointment: erythromycin 0.5% ophthalmic ointment or polymyxinbacitracin ophthalmic ointment. Bacterial conjunctivitis caused by dacryostenosis may be treated with an erythromycin-based ophthalmic ointment or drops. Acute dacryostenosis may require surgical relief after the acute episode resolves. Treat associated otitis media, pharyngitis, or upper respiratory infection. If oral antibiotics are prescribed for associated infection, topical ophthalmic treatment is usually not indicated.

INCLUSION CONJUNCTIVITIS (CHLAMYDIA) Cause: l Usually caused by chlamydia and is most often seen in the neonate or the sexually active adolescent. Histo y: l Mother with history of untreated chlamydia. l Sexual partner of adolescent with history of chlamydia. Physical findings: l Conjunctival erythema. l Follicular reaction (large, round elevations) in the conjunctiva of the lower eyelids. l Clear or mucoid discharge. l Cervicitis and urethritis are often associated. Laborato y studies: l Culture or rapid screening test of the exudate for chlamydia Management: l Oral erythromycin (30 to 50 mg / kg/ day) in 3 to 4 divided doses. l Tetracycline (25 to 50 mg/ kg/ day) in divided doses every 6 hours for adolescents older than 12 years of age. l Partners of sexually active adolescents are examined and treated.

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Yetman & Coody

PRACTICE GUIDELINES

INDICATIONS FOR REFERRAL OF INFANTS AND CHILDREN WITH CONJUNCTIVITIS l

l l l l l

l l l

Restriction in ocular movement. Cornea1 changes. Lacrimal infection.

Hay,

W.,

Groothius,

Levin,

REFERENCES Apt,

L., & Miller, Rudolph, (Eds.),

J. Hoffman, Rudolph’s

Stamford, Catalano,

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nurse

Taylor,

301-28).

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(pp. 383-4).

primary

MA.:

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& A. Dunn (pp.

C. (1997).

ophthalmology

bridge,

Stamford,

care: A handbook

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D., & Hoyt,

atric

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diag-

Eye problems. M. Brady,

practitioners

Philadelphia:

Pediatric

A text atlas (pp.

N. Barber,

(Eds.), for

(pp. 2076-82).

A.,

pediatric

& Lange.

M. (1996).

Bums,

& C. Rudolph

pediatrics

CT: Appleton

ophthalmology: Stamford,

Macdonald,

K. (1996).

Currenf

nosis and tveafment CT: Appleton

Failure to respond to treatment after 48-72 hours. Reduced visual acuity. Severe photophobia. Severe pain. Orbital involvement. Asymmetric pupillary size.

J., Hayward,

M. (1993).

(pp.

579-82). Co.

Practical 28-40).

Blackwell

Science,

September/October

1997

pediCamInc.

DISCUSSION LEADERS NEEDED

NAPNAP’s 19th Annual Conference on Pediatric Primary Care Chicago, Illinois March 19-22,1998 Please consider serving as a discussion leader at the breakfast roundtable session. You do not need to be an expert in the topic to participate, just have an interest in learning and sharing information with your colleagues. If interested, please send a note indicating your choice of topic and a brief (l- to 2-page maximum) resume to NAPNAP’s National Office (Attention: Kathy Watson). 1998 Topics include: Breastfeeding Update Toddler Nutrition Early Newborn Discharge Early Childhood Behavior Problems Immunizations-1998 Guidelines Smoking Cessation-Programs and Medications PNP’s in Specialty Practice--Challenges and Benefits Childhood Diabetes-Insulin or Not? Child Abuse-Recognition and Follow Up by PNP School-Based Clinics-Successes and Concerns NAPNAP National Office 1101 Kings Highway, North, Suite 206 Cherry Hill, NJ 08034 Phone: (609) 667-1773 FAX: (609) 667-7187

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