Is membrane removal necessary in a pediatric patient with pseudomembranous conjunctivitis?

Membrane Removal in Pediatric Pseudomembranous Conjunctivitis

In most cases of pseudomembranous conjunctivitis in children, membrane removal is NOT necessary and should be avoided, as surgical excision can trigger recurrence and worsen the condition—focus instead on treating the underlying cause with appropriate medical therapy. 1

Treatment Approach Based on Etiology

For Bacterial Pseudomembranous Conjunctivitis

• Initiate broad-spectrum topical antibiotics (polymyxin-bacitracin or erythromycin) applied 4 times daily for 5-7 days without membrane removal 2, 3
• If severe purulent discharge is present, rule out gonococcal infection immediately, which requires systemic ceftriaxone plus daily follow-up—this can cause corneal perforation within 24-48 hours 3
• Membrane removal is unnecessary as antibiotic therapy addresses the underlying infection 2

For Ligneous Conjunctivitis (Plasminogen Deficiency)

• Surgical excision should be avoided as it triggers membrane recurrence and can worsen the condition 1
• The American Academy of Ophthalmology recommends topical plasminogen drops or intravenous plasminogen as first-line treatment 1
• Alternative medical therapies include topical heparin-containing artificial tears, which have shown effectiveness in milder cases 4
• If surgical excision is performed, immediate anticoagulation and immunosuppression are mandatory to prevent recurrence 1

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present:

• Visual loss 2, 3
• Moderate or severe pain 2
• Severe purulent discharge (possible gonococcal infection) 2, 3
• Corneal involvement on fluorescein staining 3
• Lack of response to therapy after 3-4 days 2, 3
• History of immunocompromise 2

Common Pitfalls to Avoid

• Do not surgically remove membranes without identifying the underlying cause first—this can trigger severe recurrence, especially in ligneous conjunctivitis 1, 5
• Avoid indiscriminate use of topical corticosteroids before ruling out infectious causes 2
• Do not miss gonococcal or chlamydial infection in children, which requires systemic (not just topical) treatment and consideration of sexual abuse 2, 3
• In cases resembling preseptal cellulitis that don't respond to antibiotics, consider ligneous conjunctivitis and arrange examination under anesthesia 4

Supportive Care Measures

• Strict hand hygiene to prevent transmission to the unaffected eye or others 2, 3
• Preservative-free artificial tears for comfort 2
• Keep child home from daycare until discharge resolves or after 24 hours of antibiotic treatment 3

Follow-Up Protocol

• Return for evaluation if no improvement after 3-4 days of treatment 2, 3
• For gonococcal conjunctivitis, daily follow-up is mandatory until complete resolution 2
• Most cases can be managed in outpatient settings; hospitalization is reserved for severe gonococcal cases or neonatal conjunctivitis 2