What is the appropriate treatment for a 15-week-old infant with left eye discharge?

Treatment of Eye Discharge in a 15-Week-Old Infant

For a 15-week-old infant with unilateral eye discharge, initiate topical erythromycin ophthalmic ointment (approximately 1 cm applied to the affected eye up to 6 times daily depending on severity) while simultaneously evaluating for nasolacrimal duct obstruction, which is the most common cause of persistent tearing and discharge in infants under 1 year of age. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, you must immediately evaluate for vision-threatening conditions that require urgent ophthalmology referral:

• Examine for purulent discharge - Any severe, purulent discharge that rapidly reaccumulates after cleaning requires immediate evaluation to rule out gonococcal conjunctivitis, which can cause corneal perforation within 24-48 hours 3, 4
• Check the cornea with fluorescein staining - This is mandatory in any case of purulent conjunctivitis to detect early corneal involvement 3
• Assess for moderate to severe pain - This warrants immediate ophthalmology referral 5
• Look for eyelid vesicles or rash - Herpes simplex virus can progress to keratitis, corneal scarring, and perforation 3

Differential Diagnosis by Clinical Presentation

Bacterial Conjunctivitis (Most Common in Infants)

• Presents with mucopurulent discharge and matted eyelids 6, 7
• Treatment: Erythromycin ophthalmic ointment approximately 1 cm applied directly to the infected eye up to 6 times daily 1
• Remains infectious until 24-48 hours after starting antibiotics - Keep infant out of daycare during this period 4
• Expected improvement within 3-4 days - If no improvement, refer to pediatric ophthalmology 4

Nasolacrimal Duct Obstruction (Most Common Cause of Persistent Tearing in Infants)

• Presents with persistent tearing, mucoid discharge, and crusting without significant conjunctival injection 2
• Management: Conservative approach with nasolacrimal massage and observation, as spontaneous resolution occurs in approximately 90% by 6 months of age and more than 99% by 12 months 2
• Defer ophthalmology referral until 6-9 months of age unless complications develop 2
• Watch for dacryocystitis - If erythema, swelling, warmth, and tenderness develop over the lacrimal sac, this requires urgent ophthalmology referral due to risk of periorbital cellulitis, meningitis, and sepsis 2

Viral Conjunctivitis

• Presents with watery discharge, conjunctival injection, and may have preauricular lymphadenopathy 5, 6
• Treatment is supportive only - Artificial tears, cold compresses, and strict hand hygiene 7
• Self-limited within 5-14 days 5

Critical Pitfalls to Avoid

Never miss gonococcal or chlamydial conjunctivitis in this age group:

• Gonococcal conjunctivitis manifests within 1-7 days after birth (but can present later if prophylaxis was given) with marked eyelid edema, marked purulent discharge, and can cause corneal perforation, septicemia, meningitis, and death 5, 3
• Chlamydial conjunctivitis manifests 5-19 days following birth and can persist for 3-12 months untreated, with up to 50% having associated nasopharyngeal or pulmonary infection 5, 4
• Both require systemic antibiotics, not just topical therapy 5, 1

Consider sexual abuse in any infant or child presenting with gonococcal or chlamydial conjunctivitis 5, 3

When to Refer to Pediatric Ophthalmology

Immediate referral is required for: 5

• Severe, purulent discharge
• Moderate or severe pain
• Corneal involvement on fluorescein examination
• Visual concerns
• No improvement after 3-4 days of appropriate antibiotic treatment
• Suspected herpes simplex or varicella zoster infection

Infants, children, and adolescents with ocular or periocular inflammation not responding to initial topical and/or systemic antibiotic therapy or not clearing within 3 weeks of treatment should be referred to a pediatric ophthalmologist. 5

Practical Treatment Algorithm

1. Rule out emergencies (purulent discharge, corneal involvement, pain, vesicular rash)
2. If simple bacterial conjunctivitis suspected: Start erythromycin ophthalmic ointment up to 6 times daily 1
3. If nasolacrimal duct obstruction suspected: Teach nasolacrimal massage, observe, and reassure parents about high spontaneous resolution rate 2
4. Counsel on hand hygiene to prevent transmission 4
5. Follow up in 3-4 days - If not improving, refer to pediatric ophthalmology 4
6. Keep infant out of daycare for 24-48 hours after starting antibiotics if bacterial conjunctivitis 4