What is the management approach for a pediatric patient presenting with sore eyes?

Management of Pediatric Sore Eyes (Conjunctivitis)

The most effective approach for managing pediatric conjunctivitis is to identify the specific cause and provide targeted treatment, with broad-spectrum topical antibiotics being appropriate for bacterial cases, while viral cases are typically self-limiting and may only require supportive care. 1

Diagnosis and Assessment

• Determine the likely etiology through clinical presentation:

  • Bacterial conjunctivitis: characterized by purulent discharge, "sticky eyes" upon awakening, and conjunctival injection (pink eye) 2
  • Viral conjunctivitis: typically presents with watery discharge, lymphocytosis on conjunctival scrapings, and may be associated with pharyngitis 3, 4
  • Allergic conjunctivitis: presents with itching, bilateral involvement, and sometimes eosinophilia on conjunctival scrapings 4

• Common bacterial pathogens in pediatric patients include:

  • Haemophilus influenzae (most common)
  • Streptococcus pneumoniae
  • Moraxella catarrhalis 2, 3, 4

Treatment Approach

Bacterial Conjunctivitis

• For mild bacterial conjunctivitis:

  • Apply a broad-spectrum topical antibiotic 4 times daily for 5-7 days 5
  • Options include erythromycin ophthalmic ointment (apply approximately 1 cm directly to infected eye up to six times daily depending on severity) 6
  • Bacitracin ointment can be applied directly into the conjunctival sac 1-3 times daily 7

• For moderate to severe bacterial conjunctivitis:

  • Consider obtaining conjunctival cultures before initiating treatment if severe purulent discharge is present 5
  • More frequent application of antibiotics may be necessary initially 5
  • Daily follow-up until improvement is noted 5

Viral Conjunctivitis

• Most cases are self-limiting and resolve without specific treatment 1
• Supportive measures include:
  • Cold compresses to reduce inflammation 1
  • Artificial tears for comfort 1
  • Patient education on hygiene measures to prevent transmission 1
  • Counsel patients to wash hands frequently with soap and water, use separate towels and pillows, and avoid close contact with others for approximately 7 days from symptom onset 1

Herpes Simplex Virus (HSV) Conjunctivitis

• If HSV is suspected:
  • Topical ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily 1
  • Avoid topical corticosteroids as they potentiate HSV epithelial infections 1
  • Neonates with HSV conjunctivitis require prompt consultation with a pediatrician due to risk of life-threatening systemic infection 1

Varicella Zoster Virus (VZV) Conjunctivitis

• For children with chicken pox and conjunctivitis:
  • Topical antibiotics may be used to prevent secondary infection of vesicles 1, 8
  • For persistent cases, oral antivirals may be beneficial (dosing adjusted for pediatric patients) 1, 8

Allergic Conjunctivitis

• Initial management includes:
  • Cold compresses and ocular lubricants 1
  • Topical antihistamines and mast-cell stabilizers 1
  • For severe cases, short-term topical corticosteroids may be necessary 1

Follow-Up Care

• Schedule follow-up based on severity and etiology 1
• For bacterial conjunctivitis, improvement should be seen within 2-3 days of antibiotic treatment 5
• For viral conjunctivitis, symptoms typically resolve within 1-2 weeks 1
• For HSV conjunctivitis, follow-up within one week with visual acuity measurement and slit-lamp biomicroscopy 1

Indications for Referral to Ophthalmologist

• Severe pain not relieved with topical anesthetics
• Vision loss
• Corneal involvement
• Traumatic eye injury
• Distorted pupil
• Herpes infection
• No improvement after 2-3 days of appropriate treatment 9

Prevention

• Educate patients and caregivers about proper hand hygiene 1
• For infectious conjunctivitis, advise avoiding sharing towels, pillows, and close contact during the contagious period 1
• For allergic conjunctivitis, allergen avoidance and possibly allergen-specific immunotherapy for recurrent cases 1

Common Pitfalls

• Failure to differentiate between viral and bacterial causes, leading to unnecessary antibiotic use 2, 9
• Missing herpes infections, which require specific antiviral treatment 1
• Not recognizing signs of more serious conditions that require referral, such as keratitis or corneal ulceration 10
• Prolonged use of topical corticosteroids without ophthalmology supervision, which can lead to complications including elevated intraocular pressure and cataract formation 1