Red Eye

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Chapter 22 Red Eye

Kathy Palmer, MD

3 What systemic conditions are associated with red eyes?

Collagen vascular disorders, juvenile rheumatoid arthritis, infectious diseases (varicella, measles, mumps, otitis media), Kawasaki disease, inflammatory bowel disease, cystic fibrosis, Stevens-Johnson syndrome.

Levin AV: Eye—Red. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 267–271.

4 Describe the characteristics of bacterial conjunctivitis

Mucopurulent discharge that involves one eye and usually spreads to the second eye associated with injection of the bulbar conjunctiva. Haemophilus influenzae, Streptococcus pneumoniae, and staphylococci are the most common pathogens. Treat with topical antibiotic drops every 4–6 hours or ointment three times daily for younger children. Trimethoprim sulfate and polymyxin B sulfate (Polytrim) is a good choice because it provides broad-spectrum coverage and is well tolerated (minimal stinging with application).

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

5 What is epidemic keratoconjunctivitis (EKC)?

EKC is a specific type of viral conjunctivitis caused by adenovirus types 8, 19, and 37. It usually affects older children and adolescents. Physical examination findings include severe bilateral conjunctivitis with conjunctival hyperemia, watery discharge, eyelid swelling, petechial conjunctival hemorrhages, pseudomembrane along the conjunctiva, and preauricular adenopathy. One third of patients develop corneal inflammation (keratitis) associated with severe photophobia. EKC is extremely contagious, and patients may need to be isolated for as long as 2 weeks. Because of the risk for keratitis, refer all patients with EKC to an ophthalmologist.

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

6 How do a stye and a chalazion differ?

A stye or external hordeolum is an inflammation of the ciliary follicles or accessory glands of the anterior lid margin. A chalazion or internal hordeolum is an inflammation of the meibomian glands and involves deeper eyelid tissues than does a stye. Both conditions cause painful focal tenderness of an eyelid and are treated with warm compresses. If they fail to resolve after several months, refer the patient to an ophthalmologist.

Levin AV: Ophthalmic emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1653–1661.

7 What is blepharitis? How is it treated?

Blepharitis is an inflammation of the eyelids. Anterior blepharitis affects the skin, cilia follicles, or accessory glands of the eyelids. Posterior blepharitis is an infection of the meibomian sebaceous glands. Clinical findings include swollen, erythematous lid margins with crusting, a gritty or burning sensation of the eyes, and mild conjunctival injection. Scrubbing the eyelid margins with diluted baby shampoo and applying bacitracin or erythromycin ointment are done to treat anterior disease. Posterior disease is treated with eyelid hygiene and oral antibiotics.

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

8 What is the most common cause of conjunctivitis in the newborn period?

Red, watery eyes in an infant who is only a few hours old is almost always a chemical conjunctivitis secondary to the use of topical prophylaxis (1% silver nitrate, 1% tetracycline ointment, or 0.5% erythromycin ointment) for ophthalmia neonatorum. True neonatal conjunctivitis rarely presents prior to 48 hours of age. The infectious organisms associated with neonatal conjunctivitis include Neisseria gonorrhoeae (onset, 2–4 days of age), staphylococci or streptococci (onset, 4–7 days of age), chlamydia (onset, 4–10 days of age), haemophilus (onset, 5–10 days of age), and herpes simplex virus type II (onset, 6 days–2 weeks).

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

9 List the differential diagnosis of red, teary eyes in a newborn

Neonatal conjunctivitis

Congenital glaucoma

Endophthalmitis

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

10 What is endophthalmitis?

Endophthalmitis is a devastating intraocular infection that can be either bacterial or fungal in origin. It can be caused by traumatic intraocular introduction of organisms or result from hematogenous spread. The prognosis is poor, even with high-dose antimicrobial therapy and vitrectomy to remove the infection.

Wright KW: Ocular inflammation and uveitis. In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 195–211.

11 Describe the clinical features of gonococcal conjunctivitis

This condition usually occurs in infants at least 48 hours old, and even earlier in infants born to mothers with prolonged rupture of membranes. Physical examination findings include unilateral or bilateral, purulent conjunctivitis with copious discharge and lid edema. The onset of the disease is often hyperacute. N. gonorrhoeae infection can cause corneal ulceration or perforation. Gram stain of conjunctival scrapings reveals gram-negative intracellular diplococci. Treat with topical erythromycin and IV cefotaxime. Ophthalmology consultation is required. If left untreated, gonococcal conjunctivitis can lead to septicemia and meningitis.

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

12 Which groups of patients are most often diagnosed with gonococcal conjunctivitis?

Neonates and sexually active adolescents.

13 When are systemic antibiotics indicated in neonatal conjunctivitis?

Systemic antibiotics are used in chlamydial and gonococcal disease to control the risk of systemic involvement.

14 What is dacryocystitis?

This is an inflammation of the lacrimal sac in patients with an obstructed nasolacrimal passage. It causes erythema and swelling of the medial lower lid, excessive tearing, and mucopurulent discharge. It is found commonly in infants with a blocked nasolacrimal duct or in older patients with chronic sinusitis or facial trauma. It is treated with oral and topical antibiotics.

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

15 What are the classic signs of orbital cellulitis?

Orbital cellulitis is an infection of the tissues posterior to the orbital septum. Erythema and edema of the eyelids, decreased eye movement, proptosis, decreased vision, and papilledema are the classic signs of this infection.

16 List the causes of orbital cellulitis

Most common is sinusitis invading the orbit. It can also occur as sequelae of an orbital fracture, a skin or lacrimal sac infection, hematogenous spread of organisms seeding the orbit, or even an ascending dental infection.

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

17 What other noninfectious conditions can mimic the physical findings of orbital cellulitis?

Orbital tumors (rhabdomyosarcomas, lymphangiomas, neuroblastomas)

Orbital pseudotumor (an autoimmune process)

Graves’ disease

Ruptured dermoid cyst

18 Do all patients with orbital cellulitis require hospital admission?

Yes, orbital cellulitis is a potentially vision- or life-threatening condition.

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

19 What are the potential complications of orbital cellulitis?

Vision loss, meningitis, cavernous sinus thrombosis, brain abscess, and death.

20 What are the causative organisms for orbital cellulitis?

In younger children (< 8 years old), infections are most often caused by a single organism, either staphylococcus or streptococcus. In older children, infections can include multiple bacterial strains and even anaerobes. Mucormycosis and aspergillosis can be seen in immunocompromised hosts. These guidelines should be used to select initial empiric antimicrobial coverage.

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

21 How is orbital cellulitis treated?

With IV antibiotics, many cases can be managed medically but others require surgical drainage. Computed tomography should be performed to look for evidence of abscess formation and sinusitis, which are most often the inciting process. Urgent ophthalmologic consultation is indicated once the diagnosis of orbital cellulitis is considered. If operative drainage is necessary, an otolaryngologist often consults in conjunction with the ophthalmologist to drain the sinuses.

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

22 Which cases of orbital cellulitis are more likely to require surgical intervention and drainage?

Infections in older children and adults and those resulting from an extension of frontal sinusitis. Infections extending from ethmoid sinus disease are often amenable to medical management.

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

23 What is periorbital cellulitis?

Periorbital or preseptal cellulitis is an infection of the tissues of the eyelids that does not involve the posterior orbit. Periorbital cellulitis is associated with predominantly unilateral swelling, erythema, and tenderness of the eyelids but normal visual acuity and eye motility. Computed tomography is often useful in distinguishing between periorbital and orbital cellulitis, especially when severe eyelid edema precludes an adequate eye examination to ensure normal eye motility.

Levin AV: Ophthalmic emergencies. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1653–1661.

24 What problems can lead to the development of preseptal cellulitis?

Dacryocystitis (infection of the tear sac)

Infections of the oil glands or hair follicles on the lid margins

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

25 Which conditions can mimic periorbital cellulitis?

Insect bites (punctum can often be seen with direct ophthalmoscope)

Contact dermatitis (poison ivy)

Allergic reactions (usually bilateral swelling)

Underlying sinusitis

Severe conjunctivitis (adenoviral or chlamydial and gonococcal)

Eyelid tumors (capillary hemangiomas and nevus flammeus hemangiomas)

26 Do all patients with periorbital cellulitis require hospitalization?

No. Children beyond infancy who are otherwise healthy and have no signs of systemic infection may be treated with intramuscular or oral antibiotics as outpatients. They require close follow-up for at least 24–48 hours. Patients who demonstrate no improvement or worsening disease should be admitted for IV therapy.

Levin AV: Ophthalmic emergencies. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1653–1661.

27 How should you treat a red eye in a contact lens wearer?

A red eye in a contact lens wearer may signify a sight-threatening condition (infection or a breakdown of corneal epithelium). Remove the contact lens and refer the patient for urgent ophthalmologic examination (within 12 hours). Do not treat empirically with antibiotics; it will prevent the ophthalmologist from obtaining an accurate culture.

Levin AV: Eye—red. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 267–271.

KEY POINTS: RED EYE

1 Red, watery eyes in an infant less than 24–48 hours of age are almost exclusively due to chemical conjunctivitis from topical antibiotics used to prevent ophthalmia neonatorum.

2 A red eye in a contact lens wearer is an emergent problem requiring consultation with an ophthalmologist.

3 Orbital cellulitis is a potentially vision- or life-threatening condition that requires hospital admission and emergent consultation with an ophthalmologist.

4 Orbital cellulitis in children younger than 8 years is often amenable to medical therapy; infections in older children often require surgical intervention.

5 Many systemic conditions are associated with “red eyes.”

28 What are the common causes of conjunctivitis?

Infectious (viral, bacterial, or chlamydial), allergic or seasonal, and chemical.

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

29 Describe the different types of allergic conjunctivitis

Seasonal allergic conjunctivitis (hay fever) is associated with itchy, tearing eyes, and relatively minor eye irritation. Chemosis (a blisterlike swelling of the bulbar conjunctivae) is sometimes present. Conjunctival scrapings reveal increased mast cells and eosinophils. Treatment includes topical antihistamines and mast cell–stabilizing agents.

Vernal conjunctivitis is an allergic condition associated with severe itching, tearing, and mucous production and giant papillae of the upper tarsal conjunctiva. Some patients have corneal involvement (keratitis) secondary to scraping by the enlarged papillae. Treatment includes topical antihistamines and mast cell stabilizers. Topical steroids are reserved for the most severe cases, and an ophthalmologist should supervise use. Of affected patients, 20% have permanent vision loss from keratitis.

Giant papillary conjunctivitis is similar to vernal conjunctivitis but is secondary to soft contact lens use. It represents a sensitization to components of the lenses and/or cleaning solutions. Treatment includes topical mast cell stabilizers and temporary discontinuation of contact lens use.

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

30 Describe the different types of antiallergy eye drops available for treating ocular allergies

Ketorolac (a nonsteroidal anti-inflammatory eye drop: may cause stinging on installation)

Levocabastine (antihistamine)

Lodoxamide and cromolyn sodium (mast cell stabilizers)

Olopatadine (antihistamine and mast cell stabilizer)

Nedocromil and pemirolast (mast cell stabilizers that inhibit eosinophil activation and chemotaxis)

Ketotifen and azelastine (antihistamine, mast cell stabilizing, and eosinophil chemotaxis–inhibiting effects)

Greenberg MF: The red eye in childhood. Pediatr Clin North Am 50:105–124, 2003.

31 What are the characteristics of herpes simplex keratoconjunctivitis?

The ocular involvement with herpes simplex virus is characterized by an episode of primary ocular herpes (skin eruption with multiple vesicles) that lasts for 2–3 weeks, followed later by recurrent corneal disease. The recurrences are almost always unilateral and associated with preauricular adenopathy. A dendritic pattern of corneal defects is a classic sign of recurrent herpes simplex keratitis. Viral replication causes punctate, dendritic, or geographic epithelial defects. Treatment is topical antivirals, usually Viroptic 1% every 2 hours while awake. Corticosteroids are contraindicated because they diminish the body’s immune response. The cumulative effect of repeated infections can lead to corneal clouding and vision loss.

Wright KW: Pediatric “pink eye.” In Pediatric Ophthalmology for Pediatricians. Baltimore, Williams & Wilkins, 1999, pp 165–193.

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