Chapter 588. Red Eye

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 eyedrops, 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 eyedrops, 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.1,2

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 588-1, 588-2, 588-3, and 588-4. 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 588-1 provides a useful guide to evaluating a child with a red eye.

Conjunctivitis of the newborn (ophthalmia neonatorum) is one of the most common infections in the first month of life. Time of onset is an unreliable predictor of etiology. The primary objective in evaluating a neonate with conjunctivitis is to rule out gonorrhea, as this organism can cause corneal perforation. Neonatal gonococcal conjunctivitis is usually “hyperacute,” with extremely purulent, copious discharge and marked lid swelling. An emergency Gram stain is indicated, along with appropriate culture and sensitivity testing. Treatment may be started on the basis of the Gram stain alone. Some bacteria may be resistant to penicillin; therefore, third-generation cephalosporins, administered systemically, are recommended. Frequent topical lavage with normal saline may be useful in decreasing bacterial count. Parents and contacts should be referred for testing, and the child and others screened for other sexually transmitted diseases such as chlamydia. An ophthalmologist should comanage the child with the pediatrician.3

Chlamydia conjunctivitis typically presents 5 to 25 days after birth but may occur earlier or later. It is more common than other causes of conjunctivitis in newborns, with a prevalence of 3 to 4 per 1000 live births. It usually presents unilaterally but often becomes bilateral. It is diagnosed using nonculture tests—enzyme assay, direct fluorescent antibody, and polymerase chain reaction (PCR)—and culture. Discharge may be mild or more prominent. Treatment of the infant, the mother, and the mother’s sexual contacts, usually with erythromycin or azithromycin, is indicated. This should be augmented with topical erythromycin ointment for the child with conjunctivitis. If this condition is left untreated, pneumonitis may develop in 20% to 40% of affected children in the first 3 months after birth. Though commonly used in the past, prophylaxis against ophthalmia neonatorum with topical silver nitrate solution is now rarely used, as it may cause a chemical conjunctivitis in the first few days after birth. Less toxic forms of prophylaxis are used currently, such as topical povidone-iodine or erythromycin eye ointment (see Chapter 582).

Other causes of neonatal conjunctivitis are less common. Herpes simplex conjunctivitis occurs infrequently in neonates who are exposed to maternal herpes during birth. Herpes keratitis may cause vision-threatening scarring of the cornea. Skin lesions are almost always present, and the child may develop herpetic encephalopathy.

Contact lens wearers are at an increased risk of microbial keratitis and should be presumed to have this if they present with a red eye, even if the lens has already been removed. They should be referred urgently (within 12 hours) to an ophthalmologist. If possible, the contact lens should be removed. Usually the child (or parents) will be expert at this, but topical anesthetic may make it easier for the patient or the physician to remove the lens. Once removed, fluorescein staining may help to show an obvious area of corneal epithelial defect or ulcer.

In a cooperative child, it may be possible to evert the upper eyelid, allowing inspection of the palpebral conjunctiva for a lost contact lens or enlarged subconjunctival lymphoid tissue (“giant papillae”) that sometimes occur in contact lens wearers.

The sensation of a foreign body in the eye is a nonspecific symptom that may be caused by any disturbance of the cornea or conjunctiva. Tiny foreign bodies may be difficult to see and require a magnified view with a slit lamp or direct ophthalmoscope. Fluorescein staining may facilitate detection of a foreign body (see Chapter 581). A foreign body under the upper lid will sometimes produce vertical, linear scratches on the cornea that stain with fluorescein. These are a good clue to the etiology of the red eye.

A cooperative child may allow removal of a foreign body with topical anesthesia and a sterile cotton swab or forceps, but sometimes removal under general anesthesia and use of a needle is necessary, in which case ophthalmology consultation is indicated.

Conjunctival and corneal abrasions are reasonably common, sometimes caused by a fingernail or other sharp object coming in contact with the eye. A careful and detailed history of any trauma to the eye is essential. Topical anesthetic drops can be used diagnostically; if pain is relieved, the irritation is arising from the ocular surface. Fluorescein staining will identify the abrasion (see Chapter 583).

Conjunctivitis can be infectious, allergic, or chemical. Typically, there is a watery or mucous discharge and diffuse injection of the conjunctiva, and there may be associated eyelid edema. The most common infectious cause is viral conjunctivitis, most often due by adenoviruses. There may be an associated upper respiratory tract infection or otitis media. Viral conjunctivitis is highly contagious and spreads by eye-to-hand contact. Parents are advised to use a separate hand towel for their child and to wash their hands after touching the child’s eye, hands, or secretions The cornea may be affected, initially with a fine, diffusely spread, punctate epithelial disturbance, followed by subepithelial infiltrates. Both can produce photophobia. It may be appropriate to seek ophthalmology consultation, because photophobia with corneal pathology may require specialized treatment. Steroid eyedrops are not indicated, except in the most severe cases, and then only under the care of an ophthalmologist, who must exclude herpes simplex keratitis and monitor for steroid-induced side effects.

Viral conjunctivitis is typically self-limited and can last from a few days to 4 weeks or more. If the course is prolonged, the condition is most likely epidemic keratoconjunctivitis, due to adenovirus serotypes. Viral conjunctivitis often begins with unilateral involvement, becoming bilateral after a few days. There is often a swollen preauricular or submandibular lymph node. Other viruses that can cause conjunctivitis include coxsackieviruses and echoviruses. Primary herpes simplex infection can cause conjunctivitis, and while this is usually accompanied by skin lesions, it can occur without skin involvement. More typically, the first infection involves the skin only and later recurrences involve the eye. Herpes simplex is almost always unilateral; it is characterized by a dendritic corneal lesion, revealed by fluorescein staining. This lesion may not be noted with later recurrences. Ophthalmology consultation is indicated in any child with possible herpetic infection or in any child with a red eye in which there is a history of herpetic infection.

Bacterial conjunctivitis is typically more purulent than viral conjunctivitis and becomes bilateral within a very short period. It is a common disorder in young children, and typical organisms include Streptococcus pneumoniae, Moraxella, and non-typable Haemophilus influenzae. In teenagers, it is important to rule out sexually transmitted organisms, such as gonococcus, chlamydia, and herpes simplex, although there is some evidence that the unique external nature of the conjunctival mucous membrane may allow for nonsexual transmission. Cultures may be helpful, but many pathogenic organisms can be found in conjunctival cultures of asymptomatic children. The choice of antibiotic depends on the cause, but often a broad-spectrum drug such as combined trimethoprim sulfate and polymyxin B sulfate ophthalmic solution is used. Outside North America, chloramphenicol is still used commonly. In general, antibiotic drops are used 4 to 6 times daily, or ointment 2 to 4 times daily, for approximately 1 week. The choice between drops or ointment is that of the physician and parent.

Eyedrops can be applied while the child is lying or sitting up and having the child look at the ceiling. In children who do not easily allow direct application, drops can be placed in the medial canthus area (at the medial junction of the eyelids) and gravity allows the drops to enter the conjunctival sac. The child can close the eyes as the drops are applied, which reduces anxiety, and is told to expect a “wet feeling” on the lids. The child is then asked to blink, allowing the drops to enter the conjunctival sac. It is worth remembering that the conjunctival sac can accommodate only about 1/4 of an eyedrop, so some excess is expected to spill out of the sac.

Allergic conjunctivitis is common and typically seasonal, being worse in spring and summer. It is often accompanied by nasal congestion (rhinoconjunctivitis). It is also known as “hay fever” conjunctivitis and represents a type I hypersensitivity response to a seasonal allergen. Onset is subacute and attacks may be short-lived. A hyperemic reaction of the tarsal and bulbar conjunctiva is accompanied by edema of the conjunctiva and lids and results in profuse lacrimation and itching. The itching is usually far more conspicuous than in infectious conjunctivitis. There may be a scant, stringy mucoid discharge containing a variable number of eosinophils. Histamine and IgE levels in tears are elevated, but this test is rarely used.

The initial approach to management includes educating the parents and child to avoid allergens and cigarette smoke, applying cold compresses, and using pharmacotherapy. There is little data on the effect of allergen avoidance or how much allergen exposure needs to be reduced to help resolve the disorder. It is also unclear whether sufficient allergen reduction can be achieved in the child’s environment to be clinically useful. The effect of avoiding pet allergens is also unclear from currently available evidence.

There are several options in treating allergic rhinoconjunctivitis. A topical antihistamine-decongestant agent (eg, antazoline with xylometazoline) may be helpful in mild disease. For relief of seasonal or refractory allergic conjunctivitis, the following topical agents are available: H1 antagonists (levocabastine, epinastine, emadastine), mast-cell inhibitors (sodium chromoglycate, nedocromil, lodoxamide), H1 antagonist/mast-cell inhibitor combination (olopatadine, azelastine, ketotifen), nonsteroidal anti-inflammatory agent (ketorolac), and corticosteroids (used short-term and only under the supervision of an ophthalmologist). Reduced daily dosage of longer-acting agents (eg, olopatadine) may improve compliance and effectiveness. Systematic reviews on immunotherapy in children and adolescents with allergic rhinoconjunctivitis have found no convincing evidence that any form of systemic treatment improves symptoms or outcomes.

Vernal conjunctivitis represents the severe end of the spectrum of allergic eye disease, typically presenting between ages 3 to 5 years. It is a problem throughout the year but is typically worse in spring and summer. In addition to the symptoms above, there is usually a significant problem with photophobia, due to limbal or corneal inflammation. “Shield ulcers” caused by large, upper tarsal conjunctival giant papillae, which are so big they abrade the cornea, may also occur. Another form of vernal conjunctivitis affects the limbus around the corneal edge and presents as fleshy gelatinous elevations. Children with chronic allergic conjunctivitis or abnormalities on upper lid eversion, suggestive of vernal conjunctivitis, should be referred to an ophthalmologist.

4Oculocutaneous disorders that can cause conjunctivitis include Stevens-Johnson syndrome (erythema multiforme major), toxic epidermal necrolysis, and graft-versus-host disease. These all can cause blindness due to corneal scarring. Involvement of an ophthalmologist is essential.

Blepharoconjunctivitis, with or without rosacea, is caused by an inflammation of the eyelid margins secondary to suboptimal flow from the meibomian glands of the eyelids. There are 20 to 25 of these glands in each upper and lower eyelid, lying vertically within the fibrous tarsal plate of the lid and opening onto the eyelid margin posterior to the eyelashes. Suboptimal flow of the glands is associated with thickening and redness of the lid margins, along with crusting and flaking at the base of the lashes. Hordeolum, either external (sty) or internal (chalazion), represents a completely blocked gland. Sties and chalazia are often recurrent and affect more than one lid. The conjunctiva can be red because of the associated dry eye caused by the relative lack of lipid in the tear film or because of the poorly understood hypersensitivity reaction thought to occur as a result of staphylococcal toxins released into the tear film by excess lid-margin bacteria.

Treatment mainly consists of eyelash scrubs with baby shampoo once or twice daily. A thin line of full strength “no tears” shampoo is placed on a washcloth and the lashes gently scrubbed while the lids are closed. This soapy preparation helps to unblock the meibomian gland orifices. A nonsoaped wet cloth is then used to wipe away the suds. In more severe cases, erythromycin ointment can be applied to the lashes immediately after the scrub. This condition is chronic and requires long-term daily treatments, although the use of antibiotics is usually indicated for only 1 to 2 weeks. If the problems of red eye and photophobia persist, referral to an ophthalmologist is advised. Presence of a phlyctenule, an elevated white nodule within the surrounding injected conjunctiva that results from a hypersensitivity reaction to staphylococcus, also requires ophthalmology consultation. In children with rosacea or severe aggressive blepharoconjunctivitis, systemic treatment with erythromycin (or tetracyclines in older children) may be helpful.

Focal or sectoral conjunctival injection can be due to a variety of disorders, including episcleritis; scleritis; ingrowing eyelashes (trichiasis); foreign bodies; herpes simplex or varicella (chickenpox) lesions on the conjunctiva; and rarely such conditions as conjunctival nevi, warts (human papillomavirus), or conjunctival telangiectatic blood vessels associated with ataxia telangiectasia (Louis-Barr syndrome).

Older adolescents exposed to significant amounts of ultraviolet light may develop pingueculae of the nasal (and sometimes temporal) conjunctiva. These are elevated areas of conjunctival degeneration from sun damage. They are wedge-shaped, yellow-white in color, and located adjacent to the limbus. When inflamed or dry, they appear as a focal area of conjunctival redness. They are rare in young children.

Episcleritis is a self-limiting disorder, with attacks lasting up to a month and often recurring. There is a circumscribed area of redness deep to the conjunctiva, which can become elevated or nodular. No cause is usually found in children, but some children may have this disorder in combination with autoimmune systemic disease. Scleritis is much more likely associated with underlying collagen vascular disorders or herpes zoster and can have sight-threatening consequences. Like episcleritis, it can present as a localized or a generalized red eye, but it is a painful disorder and gives the sclera a purple hue. Referral to an ophthalmologist is indicated if either episcleritis or scleritis is suspected.

Photophobia and red eye are prominent features of anterior uveitis (iritis; see Chapter 590), except when the iritis is associated with juvenile idiopathic arthritis (JIA) and related disorders such as enthesitis, or with psoriasis. Children with JIA may be asymptomatic and detected only at screening by an ophthalmologist. In severe disease, red eye, along with a distorted pupil due to posterior synechiae (adherence of the iris [pupil] margin to the anterior surface of the lens) may occur, but a lack of symptoms does not exclude the presence of uveitis. Other forms of uveitis may present with red eye, miosis (small pupil), and pain. Ophthalmology consultation is required.