Recognize Common Anterior Segment Infections in Children

In children, “pink eye” is an umbrella term for a number of anterior segment infections. Credit: Getty Images
Julius Oatts, MD, reviews the common presentations of anterior segment infections in pediatric patients.

Any parent will tell you: children can be magnets for infection. At schools and day care centers — where children’s top priorities usually do not include strict hygiene — disease spreads like wildfire. While most parents are equipped to help their young ones battle common colds and other mild respiratory infections, ocular presentations might raise their red flags. In fact, infections in the front of the eye in children are relatively common. They include several types of conjunctivitis — contrary to what parents may believe, only some are contagious — as well as more severe pathogens. Additionally, ocular injuries, irritation, eye rubbing, and other behaviors might lead to corneal epithelial defect, setting the stage for later infections. And children need not pick up infections on the playground. Infants can be born with infections that require early treatment.

Any ophthalmologist can help resolve these issues with careful differential diagnoses, clear parent education, and by delivering appropriate treatments to help keep young patients in the pink, without the pink eye.

Types of Conjunctivitis 

Although patients may colloquially refer to any number of infectious or inflammatory presentations in children as “pink eye,” they are usually referring to 1 of 3 primary and common types of conjunctivitis: bacterial, viral, or allergic. 

The prevalence of conjunctivitis is difficult to study, though it has been reported to affect approximately 2% of the United States population.1 Conjunctivitis is most often bacterial or viral, with the most common bacterial pathogens being Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus.2 

The most common viral pathogen is adenovirus, but other viral pathogens, such as herpes simplex virus and varicella zoster virus, can cause conjunctivitis as well.3 While researchers have attempted to create guidelines to differentiate  bacterial and viral conjunctivitis based on signs and symptoms, significant overlap in clinical presentation makes this difficult. Several point of care tests for adenovirus exist, but their sensitivity can be low and their utility in conjunctivitis management remains a topic of academic debatabe.4,5 Both research and clinical experience have brought some distinctive clinical features to light. Patients with either viral or bacterial conjunctivitis may present with sudden onset foreign body sensation, conjunctival injection, itching, light sensitivity, burning, and watery discharge. But mucopurulent discharge and mattering of the eyelids upon waking is the classic sign that the infection is bacterial in nature.6 Clinical findings such as preauricular lymphadenopathy or hemorrhage conjunctivitis (characterized by subconjunctival hemorrhage) may suggest a viral etiology.7

The typical course of conjunctivitis in children (bacterial or viral) is self-limited and symptoms often improve and resolve without treatment within 7 to 10 days.2 Despite this, antibiotic eye drops are often prescribed, though may ultimately not affect the course of the condition; however, they can be helpful in giving worried parents a sense of control and possibly decrease the duration of the symptoms. There is also the concern that over-prescribing antibiotics may contribute to higher levels of antibiotic resistance.8,9

Topical antibiotics options for these patients can include erythromycin ointment and trimethoprim-polymyxin B drops. Each of these is typically prescribed 3 to 4 times daily for 7 to 10 days, or until symptoms resolve. Other treatments to consider are supportive and include artificial tears, to be used up to 4 times daily as needed for discomfort. Additionally, children should be counseled to wash their hands frequently and avoid rubbing the eyes or touching the contralateral eye in unilateral cases.10     

Finally, allergic conjunctivitis, a non-infectious conjunctivitis, is typically bilateral, chronic, and may vary with the seasons, though the symptoms themselves (including redness and watery discharge) may be difficult to differentiate from infectious conjunctivitis on examination.11 Compared to acute infectious conjunctivitis, allergic conjunctivitis is more likely to be bilateral, seasonal, and seen in children with other atopic conditions such as eczema, asthma, or rhinitis.12

Neonate Presentations

While the aforementioned 3 types of conjunctivitis are common in children, conjunctivitis in neonates requires a unique differential diagnosis.

Conjunctivitis that occurs in the first month of life is called ophthalmia neonatorum and requires a different approach than that of conjunctivitis in older children. Ophthalmia neonatorum is the most common eye infection in the first month of life and worldwide, the incidence varies but is as high as 10% in areas with high rates of sexually transmitted illnesses.13 

The most important treatment for this condition is prophylaxis and multiple agents have been used. The idea of using silver nitrate was introduced in 1880s and is still used in some parts of the world. Silver nitrate is not effective against chlamydia, so in most places, the transition to erythromycin or tetracycline ointments was made, as both cover both gonorrhea and chlamydia.13 There was a study looking at povidone-iodine in Kenya which showed equal efficacy to antibiotic ointment.14 Overall, the scientific data supporting different types of neonatal conjunctivitis prophylaxis vary from country to country and the most commonly used agent is erythromycin. In areas with poor health or medication access, other lower cost agents such as povidone-iodine have shown promise, but ultimately additional studies are needed to determine the ideal prophylactic agent.15 

The cause of ophthalmia neonatorum can be classified based on time of presentation and symptoms. Chemical conjunctivitis typically occurs in the first 24 hours and is in reaction to the prophylactic medication given at birth. Chemical conjunctivitis is typically mild, self-limited irritation and redness of the conjunctiva occurring in the first 24 hours of life which improves spontaneously without treatment by the second day of life.16

Gonococcal conjunctivitis presents between 2 and 7 days of life and manifests with conjunctival hyperemia and often copious discharge and marked chemosis. This can lead to rapid corneal ulceration and perforation and  should be treated with a 1-time dose of ceftriaxone 25 to 50 mg/kg intramuscular or intravenous. Topical antibiotics such as erythromycin may be indicated if there is corneal involvement.13 

Chlamydial infections usually occur at approximately 1 week of age, although the onset can be earlier, especially in children with premature rupture of membranes. Chlamydial conjunctivitis typically has less discharge than gonorrhea and is characterized by occasional pseudomembrane formation. This should be treated with a 14-day course of oral erythromycin 50 mg/kg/day divided q6h and the child must be treated systemically with due to risk of pneumonia and otitis media.13 

Finally, HSV conjunctivitis usually presents in the second week of life and requires treatment with intravenous acyclovir 60 mg/kg/day for 14 to 21 days, given the risk of systemic disease.13

Corneal Abrasions and Ulcers

Children’s eyes also face risk of infection that results from injuries which can be incurred during contact lens insertion or removal, organized sports, or playtime mishaps.

The most common cause of a corneal abrasion (also known as a corneal epithelial defect) in children is trauma. The true prevalence of corneal abrasion is unknown, as many are managed by urgent care providers or do not present to care at all. Periocular trauma causing a corneal abrasion can range from minor (such as scratching the eye with a fingernail) to major (such as exposure to a chemical or a sharp object). For children who wear contact lenses, contact lens insertion or removal can also serve as another risk factor for corneal abrasion. Other causes such as lagophthalmos (a gap between the eyelids leading to prolonged corneal exposure) or absent corneal sensation are uncommon in the population. 

While a corneal abrasion itself does not represent an ocular infection, the disruption of the corneal epithelium predisposes the patient to an infection of the cornea, known as a corneal ulcer or infectious keratitis, and should be treated with antimicrobial prophylaxis until the corneal epithelium has healed. For contact lens wearers specifically, history should include details about contact lens hygiene including how often the contact lenses are removed/replaced and whether the child sleeps, swims, or showers in their contact lenses. If there is visible evidence of opacification on the cornea, this could represent a corneal ulcer and a referral should be made for prompt evaluation by an ophthalmologist. Corneal ulcers can progress rapidly and if large or central, can be associated with significant visual morbidity and may require more intense treatment such as compounded fortified antibiotic eye drops.17

The most common topical antibiotics used for corneal abrasions are the same as used for conjunctivitis including erythromycin ointment and trimethoprim-polymyxin B drops, each prescribed 3 to 4 times daily for 7 to 10 days, or until symptom resolution. Contact lens wearers have a higher risk of P. aeruginosa, thus the preferred topical antibiotic eye drop in this case would be a fluoroquinolone such as moxifloxacin or ofloxacin to cover this pathogen.17,18

With deft diagnoses, patient/parent education, and careful observation, ophthalmology can combat these infectious pathogens and, in some cases, prevent them altogether. Published research has a wealth of guidance for managing infants and older children to keep their eyes clear and their vision sharp.

Dr Oatts is a pediatric ophthalmologist, a pediatric glaucoma specialist, and an assistant professor at the University of California, San Francisco.

References:

  1. Schneider JE, Scheibling CM, Segall D, Sambursky R, Ohsfeldt RL, Lovejoy L. Epidemiology and economic burden of conjunctivitis: a managed care perspective. J Managed Care Med. 2014;17(1):78-83. 
  2. Feldman BH, Epley KD, Bunya VY, Prakalapakorn G, Grigorian AP, Chen M. Bacterial Conjunctivitis. Eyewiki. Updated November 1, 2022. Accessed December 20, 2022. https://eyewiki.aao.org/Bacterial_Conjunctivitis 
  3. American Academy of Ophthalmology Cornea/External Disease Preferred Practice Pattern Panel. Conjunctivitis Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2018. Available from https://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp-2018. Accessed November 26, 2018.
  4. Holtz KK, Townsend KR, Furst JW, et al. An assessment of the adenoplus point-of-care test for diagnosing adenoviral conjunctivitis and its effect on antibiotic stewardship. Mayo Clin Proc Innov Qual Outcomes. 2017;1(2):170-175. doi:10.1016/j.mayocpiqo.2017.06.001
  5. Burr SE, Sillah A, Joof H, Bailey RL, Holland MJ. An outbreak of acute haemorrhagic conjunctivitis associated with coxsackievirus A24 variant in The Gambia, West Africa. BMC Res Notes. 2017;10:692. doi:10.1186/s13104-017-3007-9
  6. Solano D, Fu L, Czyz CN. Viral conjunctivitis. In: StatPearls. Treasure Island, FL: StatPearls Publishing (2021). Available online at: https://www.ncbi.nlm.nih.gov/book 
  7. Aoki K, Gonzalez G, Hinokuma R, et al. Assessment of clinical signs associated with adenoviral epidemic keratoconjunctivitis cases in southern Japan between 2011 and 2014. Diagn Microbiol Infect Dis. 2019;95(4):114885.doi:10.1016/j.diagmicrobio.2019.114885.
  8. Honkila M, Koskela U, Kontiokari T, et al. Effect of topical antibiotics on duration of acute infective conjunctivitis in children: a randomized clinical trial and a systematic review and meta-analysis. JAMA Netw Open. 2022;5(10):e2234459- doi:10.1001/jamanetworkopen.2022.34459.
  9. Buznach N, Dagan R, Greenberg D. Clinical and bacterial characteristics of acute bacterial conjunctivitis in children in the antibiotic resistance era. Pediatr Infect Dis J. 2005;24(9):823-8. doi:10.1097/01.inf.0000178066.24569.98 
  10. Chan VF, Yong AC, Azuara-Blanco A, et al. A systematic review of clinical practice guidelines for infectious and non-infectious conjunctivitis. Ophthalmic Epidemiol. 2021;29:1-0. doi:10.1080/09286586.2021.1971262
  11. Yeu E , Hauswirth S. A review of the differential diagnosis of acute infectious conjunctivitis: implications for treatment and management. Clin Ophthalmol. 2020;14(3):805-813. doi:10.2147/OPTH.S236571
  12. La Rosa M, Lionetti E, Reibaldi M, et al. Allergic conjunctivitis: a comprehensive review of the literature. Ital J Pediatr. 2013;39(1):1-8. doi:10.1186/1824-7288-39-18
  13. Matejcek A, Goldman RD. Treatment and prevention of ophthalmia neonatorum. Can Fam Physician. 2013;59(11):1187-1190. 
  14. Isenberg SJ, Apt L, Del Signore M, Gichuhi S, Berman NG. A double application approach to ophthalmia neonatorum prophylaxis. Br J Ophthalmol. 2003;87(12):1449–1452. doi:10.1136/bjo.87.12.1449
  15. Celik M, Koroglu OA. Ocular prophylaxis in the newborn. Eur Eye Res. 2022;2(2):80-3. doi:10.14744/eer.2022.40085
  16. Makker K, Nassar GN, Kaufman EJ. Neonatal Conjunctivitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing (2020). Updated July 21, 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441840/
  17. Stretton S, Gopinathan U, Willcox MDP. Corneal ulceration in pediatric patients: a brief overview of progress in topical treatment. Paediatr Drugs. 2002;4(2):95-110.  doi:10.2165/00128072-200204020-00003
  18. Song X, Xu L, Sun S, Zhao J, Xie L. Pediatric microbial keratitis: a tertiary hospital study. Eur J Ophthalmol. 2011;22(2). doi:10.5301/EJO.2011.8338