For the pediatrician, a child with a red eye can be a significant challenge; the key decision is whether to refer to a pediatric ophthalmologist. The diagnosis is often reasonably clear after a careful history has been obtained. The examination may be challenging without the availability of an accurate visual acuity test for each eye, appropriate diagnostic eye drops, microscopic examination, and the distraction devices that pediatric ophthalmologists often use. Making an incorrect diagnosis in a child with a red eye can result in vision loss, and inappropriate treatment can have vision-threatening side effects. The pediatrician is occasionally tempted to treat a red eye with steroid eye drops, but this should only be prescribed by a physician able to do a complete eye examination and measure intraocular pressure. Therefore, in practice, steroids should not be prescribed by pediatricians or family physicians.
Conjunctivitis is a common problem in childhood. The conjunctiva becomes red and inflamed in response to a wide range of inciting agents, such as infections, allergens, chemicals, smoke, trauma, toxins, and systemic diseases. Red eye is not a common feature of congenital glaucoma or nasolacrimal duct obstruction. This chapter focuses on diagnosis and treatment of injected or red conjunctiva. The differential diagnosis and management of a red eye are outlined in Tables 578-1, 578-2, 578-3, 578-4. These tables do not provide exhaustive lists, but rather present the scope of problems that may lead to a red eye. History taking is more likely to lead to the correct diagnosis if this broad range of possible diagnoses is considered. Figure 578-1 provides a useful guide to evaluating a child with a red eye.
TABLE 578-1INFECTIVE CAUSES OF A RED EYE ||Download (.pdf) TABLE 578-1INFECTIVE CAUSES OF A RED EYE
|Condition ||Etiology ||Symptoms and Signs ||Diagnosis and Treatment |
|Conjunctivitis of the newborn (neonatal conjunctivitis, ophthalmia neonatorum) ||Gonococcus, Chlamydia trachomatis, Staphylococcus aureus, herpes simplex, chemical (from silver nitrate prophylaxis), gram-negative and other bacteria ||Purulent discharge, lid swelling (hyperacute, with possible keratitis, in gonococcal infection), brain and skin involvement with herpes ||Cultures, polymerase chain reaction (PCR), antibiotics/antivirals, irrigation (gonococcus); if gonorrhea, must have ophthalmology consultation |
|Viral conjunctivitis (acute follicular conjunctivitis) ||Adenovirus, rarely enteroviruses, coxsackieviruses ||Acute, often associated with upper respiratory infection, may have preauricular or submandibular adenopathy lymphadenopathy; conjunctival edema, discomfort, mild photophobia, small subconjunctival hemorrhages. Spreads to second eye over days. May have discrete corneal infiltrates visible at slit lamp. ||Consider viral cultures/PCR, no treatment for mild cases |
|Chlamydia conjunctivitis ||C trachomatis ||Follicular and papillary conjunctivitis, mucopurulent discharge, sometimes mild ptosis || |
Treat with a single dose of azithromycin or 2 weeks of oral erythromycin. Trace contacts; consider child sexual abuse if other indicators
|Trachoma is the leading cause of preventable blindness worldwide. It is endemic to North Africa, the Middle East, India, and Southeast Asia. ||C trachomatis ||Transmission is by direct person-to-person ...|