Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter XVII.4. Eye Infections and Conjunctivitis
Peggy M. Liao, MD
April 2002

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A 28 month old female presents to the pediatrician with a swollen right upper eyelid for one day. Her mother says that the eyelid had a small red lump 2 days prior, but the eyelid became progressively swollen. The patient has a low grade fever, but she is otherwise still playful. The pediatrician diagnoses that the patient has right upper eyelid cellulitis and prescribes oral antibiotics and warm compresses. After 2 days of antibiotics, the eyelid is still swollen and red. The patient is admitted to the hospital for intravenous antibiotics and within 48 hours, and eyelid is less swollen and the patient is discharged for a total of 14 days of systemic antibiotics.


Preseptal eyelid cellulitis (periorbital cellulitis) is an infection confined to the tissues anterior to the orbital septum. External trauma, such as cuts and insect bites, as well as internal inflammation, such as hordeolum and dacryocystitis can cause eyelid cellulitis. Symptoms include tenderness, swelling and redness of the involved eyelid. Young children may also present with fever. Signs include edema, erythema, warmth and pain of the eyelid. Visual acuity, eye motility, and pupillary reaction are normal. The conjunctiva can be injected, and there should be very little pain on eye movement.

Teenagers and adults can be treated with oral antibiotics, and followed as outpatients. Preseptal cellulitis in infants and children caused by Haemophilus influenzae type B, can spread to septicemia and meningitis, therefore all febrile children with preseptal cellulitis were hospitalized in the past and treated with IV antibiotics. However, since widespread Haemophilus influenzae type B vaccine has virtually eliminated this pathogen, cellulitis with group A strep and Staph aureus are less likely to cause septicemia, thus, they can usually be treated as outpatients with clindamycin. Cultures from conjunctiva and blood can be obtained, but the yield is not high. Conjunctival cultures do not necessarily reflect the etiology of the cellulitis and blood cultures are only positive in bacteremic or septic patients. CSF should be obtained via a lumbar puncture if meningitis is suspected. Diagnostic imaging may be necessary if the patient does not respond to treatment or a subcutaneous abscess is suspected. Antibiotic selection is based on history and examination, but staphylococcus aureus and streptococcus are the most common organisms in patients with eyelid cellulitis caused by trauma.

When the orbital structures posterior to the orbital septum are infected, it implies orbital cellulitis (as opposed to periorbital cellulitis). Signs include proptosis, restricted ocular motility (or pain with eye movement), decrease in visual acuity and sometimes, abnormal pupillary reaction. CT scan is mandatory in these patients to detect possible subperiosteal abscesses. Diagnostic imaging also helps in detecting infections extending from periorbital sites which are not uncommon. They include paranasal sinuses, dental infections and trauma with retained orbital foreign bodies. Draining of abscesses may be necessary for the patient to improve. Otolaryngology consultation should be sought if sinusitis is present to consider draining the sinuses as well.

A chalazion is a granulomatous mass results from an obstruction of the meibomian gland. Meibomian glands are oil-producing glands with openings just posterior to the eyelash line (the tarsal margin). When the openings of the glands are plugged, the sebum is released into the surrounding tissue, inciting an inflammatory response with pain, erythema and a mass. They are not considered infectious, unless eyelid cellulitis ensues. The main treatment includes warm compresses, topical and/or systemic antibiotics, topical anti-inflammatory medications and eyelid hygiene. The term "hordeolum" usually refers to the acute phase of a chalazion.

The conjunctiva is a thin layer of non-keratinized mucous membrane which covers the surface of the eyeball (bulbar conjunctiva) and inner layers of the eyelids (tarsal or palpebral conjunctiva). Conjunctivitis describes inflammation of the conjunctiva and is a nonspecific entity. It is easiest to classify conjunctivitis into infectious versus non-infectious.

Infectious conjunctivitis can be further sub-classified into etiologies, such as viral, bacterial, chlamydial (or trachoma), and others. Non-infectious conjunctivitis can include allergic, chemical, or toxic conjunctivitis.

Watery and thin mucus discharge accompanied by red and swollen eyelids are signs of viral conjunctivitis, usually caused by adenovirus. Onset can be acute, and bilateral involvement is usual, but one eye can be involved first. Preauricular adenopathy is common, along with conjunctival membranes or pseudomembranes. Patients may have URI symptoms prior to the onset of the conjunctivitis. Treatment is supportive, with cool compresses and artificial tears. Conjunctivitis may take up to 21 days to resolve. Viral conjunctivitis is very contagious, especially for the first few days. Patients should be told to wash their hands, avoid touching their eyes, sharing towel, bedsheets or pillow cases. Similarly, other household members should wash their hands frequently and avoid touching their eyes to reduce their likelihood of acquiring the infection from the household. Children should stay away from school for at least the first 3 to 7 days.

Herpes simplex can cause conjunctivitis indistinguishable from other viral conjunctivitis, but herpetic skin vesicles along the eyelids should raise the suspicion. Topical antiviral therapy and sometimes systemic antiviral therapy are recommended.

Purulent discharge is an important sign of bacterial conjunctivitis. If the onset is hyperacute, i.e., within 12 hours, a smear should be taken from the eye to rule out gonococcal conjunctivitis. Otherwise, a routine culture should be taken and a topical broad-spectrum antibiotic, such as erythromycin ointment or sulfacetamide drops can be used for 5 to 7 days.

Chlamydial inclusion conjunctivitis is a sexually transmitted infection, typically occurring in teenagers and young adults. It is usually chronic with typical tarsal conjunctival follicles. A definitive diagnosis can be made by direct chlamydial immunofluorescent test and or chlamydial culture. Both the patient and the sexual partners must be treated with oral erythromycin or doxycycline for 3 weeks.

Trachoma can present in a similar fashion to chlamydial conjunctivitis, but this principally occurs in immigrants from underprivileged countries. Trachoma (due to chlamydia trachomatis) is the leading cause of acquired blindness in many countries, but it is rare in the U.S. Trachoma is classically acquired by workers in rug factories where the occupational risk of poor air quality (dust and rug fibers presumably) places the factory workers at risk for trachoma.

Allergic conjunctivitis is the most common non-infectious conjunctivitis. Itching, watery discharge, chronicity, red eyes and a history of allergies are typical symptoms. Some allergic conjunctivitis are seasonal, but others can be year-long. If the inciting agent can be identified, such as cat fur and animal dander, it should be eliminated. Cool compresses help decrease itchiness, and are preferable to rubbing the eyes. Over-the-counter artificial tears and vasoconstrictor drops (naphazoline/pheniramine) can be used for mild cases.

Topical mast-cell stabilizers (cromolyn, Alomide) work well as preventive measures if the patient's allergies are seasonal. Topical antihistamines have a faster onset of action. In severe cases, topical corticosteroids may be needed, but patients must be monitored for side effects associated with prolonged topical steroid use, such as cataracts, and glaucoma. Concomitant oral antihistamines are helpful if the patient has systemic allergies.

Acute allergic conjunctivitis frequently presents with impressive edema of the conjunctiva. The conjunctiva can become so edematous that it lifts off the sclera and frequently protrudes out. The pale, watery edema resembles a lychee fruit (without the skin). Topical vasoconstrictors and antihistamines are used to treat this.

When an eye is exposed to acidic or basic chemicals, copious irrigation with water or normal saline should be started as soon as possible. Litmus paper can be used to test the tears for neutrality. If the cornea has been burned with the chemical, an ophthalmology consult needs to be obtained. Otherwise, the conjunctivitis can be treated with frequent artificial tears and moisturizing eye ointments.

Occasionally, prolonged exposure to topical eye medications can cause conjunctivitis, especially the aminoglycosides, such as gentamicin and tobramycin, and certain glaucoma medications. Additionally, patients may have allergic reactions to other topical antibiotics such as sulfonamides.


Questions

1. Herpes simplex conjunctivitis:
. . . . . a. may be chronic.
. . . . . b. may be associated with skin vesicles.
. . . . . c. may recur.
. . . . . d. all of the above.

2. Common causes of periorbital cellulitis include the following:
. . . . . a. sinusitis
. . . . . b. chalazion
. . . . . c. dental infection
. . . . . d. eyelid skin laceration

3. A three-year old boy presents with an acute red lump in his right upper eyelid, the pediatrician diagnoses that it is an acute chalazion. What are the proper treatments?
. . . . . a. warm compress
. . . . . b. antibiotic eyedrops
. . . . . c. oral antibiotics
. . . . . d. topical corticosteroid

4. An 18 year old female presents with a chronic follicular conjunctivitis and a diagnosis of chlamydial conjunctivitis is made. What is the proper treatment?

5. A four month old male has congenital tear duct obstructions and has symptoms of chronic tearing and mucus. His primary care physician prescribes topical sulfacetamide drops three times a day to clear up the mucus, but after using the drops for one month, his eyelids are more erythematous than ever and the conjunctiva is more swollen and he constantly rubs his eyes. What should be done?


References

1. Friedberg MA, Rapuano CJ. Wills Eye Hospital Office and Emergency Room Diagnosis and Treatment of Eye Disease. 1990, Philadelphia: J.B. Lippincott Company.

2. Orbits, Eyelids, and Lacrimal System. Basic and Clinical Science Course, Section 9., American Academy of Ophthalmology.


Answers to questions

1. The answer is d. Herpes simplex conjunctivitis can present with all of the above.

2. The answer is all of the above. Although a skin laceration is easily diagnosed, a sinusitis needs to be confirmed with a CT scan. A chalazion is usually diagnosed by history or a fluctuant skin mass in the eyelid. A dental infection involving the upper teeth can easily spread itself into the orbit.

3. Topical corticosteroid is the only choice that is not appropriate for a primary care physician to prescribe. The rest of the choices are appropriate, although most chalazia do not require oral antibiotics.

4. Topical erythromycin for two weeks and oral erythromycin for two weeks for the patient AND oral erythromycin for two weeks for her sexual partner.

5. The baby is probably developing an allergic reaction to the long-term use of topical sulfacetamide. The eyedrops should be discontinued right away and patient can be treated with tear duct massage and another antibiotic eyedrop on an as-needed basis.


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