What are the key assessment questions and signs to look for in a 3-year-old with red, itchy, crusty eyes?

Assessment of a 3-Year-Old with Red, Itchy, Crusty Eye

For a 3-year-old presenting with red, itchy, crusty eyes, your assessment must immediately differentiate benign conjunctivitis from vision-threatening conditions requiring urgent ophthalmology referral, focusing on visual acuity, discharge character, corneal involvement, and pain severity. 1

Critical Red Flags Requiring Immediate Ophthalmology Referral

Before proceeding with routine assessment, identify any of these urgent findings 2:

• Visual loss or decreased visual acuity 2
• Moderate-to-severe pain (not just irritation) 2
• Corneal involvement (opacity, infiltrate, ulcer) 1, 2
• Severe purulent discharge (especially copious, suggesting gonococcal infection) 1, 2
• History of herpes simplex virus eye disease 2
• Immunocompromise 2
• Conjunctival scarring or symblepharon 2
• Lack of response to initial therapy 2

Essential History Questions

Symptom Characterization

• Duration and time course: Acute (days) versus chronic (weeks to months) 1
• Unilateral versus bilateral presentation: Bacterial often starts unilateral; viral and allergic typically bilateral 1
• Character of discharge: Purulent (bacterial), watery (viral), mucoid (allergic), or blood-tinged (chlamydial in neonates) 1
• Morning crusting: "Mattering and adherence of eyelids" suggests bacterial etiology 1
• Itching intensity: Prominent itching strongly suggests allergic conjunctivitis 1
• Pain versus irritation: True pain suggests corneal involvement or more serious pathology 1, 2
• Photophobia: Indicates possible corneal or intraocular involvement 1, 2

Exposure and Risk Factors

• Recent exposure to infected individuals: Viral conjunctivitis is highly contagious 1
• Upper respiratory infection symptoms: Suggests viral etiology 1
• Allergy, asthma, or eczema history: Points toward allergic conjunctivitis 1
• Trauma history: Mechanical, chemical, or ultraviolet exposure 1
• Skin conditions: Rosacea, eczema, seborrhea can cause associated conjunctivitis 1
• Recent travel or unusual exposures: Consider less common viral causes 1
• Daycare attendance: Increases risk of infectious conjunctivitis 3

Neonatal-Specific Considerations (if applicable)

For infants, always ask about 1:

• Timing of onset after birth: Gonococcal (1-7 days), chlamydial (5-19 days) 1
• Maternal sexually transmitted infection history: Risk for gonococcal or chlamydial ophthalmia neonatorum 1

Physical Examination Components

Visual Acuity Assessment

• Perform monocular visual acuity testing using age-appropriate optotypes (LEA SYMBOLS or HOTV letters for 3-year-olds) 1, 2
• Occlude the fellow eye with adhesive patch or tape to prevent peeking 1
• Document if child is untestable: These children are at twice the risk for vision disorders and require rescreening within 6 months or referral 1, 2

External Examination

Preauricular Lymphadenopathy

• Palpate for enlarged preauricular nodes: Present in viral (especially adenoviral), gonococcal, and chlamydial conjunctivitis 1

Eyelid Assessment

• Swelling and edema: Marked edema suggests gonococcal or severe bacterial infection 1
• Eyelid margin inflammation: Indicates blepharitis as contributing factor 1
• Vesicles or ulceration: Suggests herpes simplex or varicella zoster virus 1
• Umbilicated lesions: Pathognomonic for molluscum contagiosum 1

Eyelash Examination

• Crusting at lash base: Bacterial or seborrheic blepharitis 1
• Nits or lice: Pediculosis palpebrarum (consider sexual abuse in children) 1

Conjunctival Assessment

• Type of reaction: Follicular (viral, chlamydial) versus papillary (bacterial, allergic) 1
• Distribution: Diffuse versus sectoral involvement 1
• Discharge character: Purulent, mucopurulent, watery, or mucoid 1
• Chemosis (conjunctival edema): Suggests more severe inflammation 1
• Subconjunctival hemorrhage: Can occur with viral conjunctivitis or trauma 1

Corneal Examination

• Corneal clarity: Any opacity, infiltrate, or ulcer requires immediate referral 1, 2
• Fluorescein staining pattern (if available): Dendritic pattern suggests HSV; punctate staining suggests viral or toxic keratitis 1
• Superior corneal involvement: Gonococcal infection characteristically begins superiorly 1

Red Reflex Examination

• Perform with direct ophthalmoscope in darkened room: Any white pupil, dark spots, or absent/asymmetric reflex requires immediate referral 1, 2

Pupillary Examination

• Assess pupil size, shape, and reactivity: Distorted pupil suggests intraocular inflammation or trauma 2, 4

Diagnostic Testing Considerations

When Cultures Are Indicated

Cultures are not routinely needed for typical conjunctivitis but are indicated for 1:

• All cases of suspected neonatal conjunctivitis 1
• Recurrent, severe, or chronic purulent conjunctivitis 1
• Cases not responding to initial treatment 1
• Suspected gonococcal infection (requires immediate culture and treatment) 1

Rapid Testing

• Adenovirus rapid immunodiagnostic test: Available in some settings with 88-89% sensitivity and 91-94% specificity, though not routinely necessary 1

Common Pitfalls to Avoid

• Dismissing complaints without thorough examination: Can miss serious pathology including corneal ulcers, iritis, or even retinoblastoma 2
• Inadequate occlusion during visual acuity testing: Leads to false reassurance if child is peeking 1, 2
• Missing subtle corneal involvement: Always assess corneal clarity carefully; any opacity warrants referral 1, 2
• Assuming all red, crusty eyes are bacterial: Viral conjunctivitis is extremely common and doesn't require antibiotics 5, 3
• Overlooking allergic etiology: Prominent itching with bilateral involvement suggests allergy, not infection 1
• Failing to consider child abuse: Pediculosis palpebrarum or gonococcal infection in children should raise concern 1
• Delaying referral for persistent symptoms: Lack of response to therapy is itself an indication for ophthalmology referral 2