What treatment is recommended for a pediatric patient with suspected sore eyes?

Treatment of Pediatric Sore Eyes (Suspected Conjunctivitis)

For a pediatric patient with suspected sore eyes (conjunctivitis), start with supportive care including artificial tears and cold compresses while determining the etiology, then treat bacterial cases with topical erythromycin ointment or fluoroquinolones (if >12 months old) for 5-7 days, avoid antibiotics entirely for viral conjunctivitis, and use topical antihistamines with mast cell stabilizers for allergic cases. 1, 2, 3

Initial Assessment: Determine the Etiology

The treatment fundamentally differs based on whether the conjunctivitis is bacterial, viral, or allergic, so accurate diagnosis is critical before prescribing therapy. 1, 3

Key Clinical Features to Distinguish Etiology:

Bacterial Conjunctivitis:

• Purulent or mucopurulent discharge with matted eyelids upon waking 1, 4
• Papillary reaction (not follicular) 1
• May be unilateral or bilateral 1
• Often associated with concurrent otitis media in children 1, 3
• Lack of itching 4

Viral Conjunctivitis:

• Watery discharge with abrupt onset 1
• Follicular reaction on inferior tarsal conjunctiva 1
• Preauricular lymphadenopathy 1
• Often starts unilateral but becomes sequentially bilateral 1
• May have concurrent upper respiratory infection 1

Allergic Conjunctivitis:

• Itching is the most consistent and distinguishing feature 1, 4
• Bilateral presentation 1
• Watery discharge 1
• History of atopy, asthma, or eczema 2
• Seasonal or perennial pattern 1

Treatment by Etiology

Bacterial Conjunctivitis

First-Line Treatment:

• For children >12 months: Topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) applied 4 times daily for 5-7 days 2, 3
• For infants and all ages: Erythromycin ophthalmic ointment 0.5%, approximately 1 cm applied to infected eye(s) up to 6 times daily depending on severity 5
• Alternative option: Polymyxin B/trimethoprim if fluoroquinolones unavailable 1, 3

Expected Course:

• Topical antibiotics shorten clinical disease duration from 7 days to approximately 5 days 3, 6
• Bacterial eradication occurs in 71% by days 3-5 and 79% by days 8-10 with antibiotic treatment 6
• Clinical cure rate at 3-5 days: 62% with antibiotics vs 28% with placebo 6
• Child may return to daycare/school after 24 hours of therapy once symptoms begin improving 3

Viral Conjunctivitis

Primary Management:

• No antibiotics should be prescribed - viral conjunctivitis will not respond to antibacterial agents and antibiotics cause unnecessary toxicity and resistance 1, 2
• Supportive care with preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 2
• Cold compresses for comfort and inflammation reduction 2, 3
• Topical antihistamines for symptomatic relief of itching and discomfort 1, 2

Special Viral Considerations:

• Herpes Simplex Virus (HSV) conjunctivitis: Requires topical ganciclovir 0.15% gel or trifluridine 1% solution, plus oral antivirals (acyclovir, valacyclovir, or famciclovir) 2
• Never use topical corticosteroids in HSV without antiviral coverage - they potentiate infection 2
• Neonates with suspected HSV require immediate pediatric consultation due to risk of life-threatening systemic infection 3

Infection Control:

• Patients should minimize contact with others for 10-14 days from symptom onset 1
• Strict hand hygiene with soap and water 1, 3
• Avoid sharing towels, pillows, or close contact 3

Allergic Conjunctivitis

First-Line Treatment:

• Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1, 2
• Environmental modifications: sunglasses as allergen barrier, cold compresses, refrigerated preservative-free artificial tears 1, 2
• Avoid eye rubbing 1

Second-Line Treatment:

• If symptoms persist, add brief 1-2 week course of low side-effect profile topical corticosteroids with monitoring of intraocular pressure 2

Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present:

• Visual loss or decreased vision 1, 2, 3
• Moderate to severe pain 1, 2, 3
• Severe purulent discharge (suggests gonococcal infection) 1, 2, 3
• Corneal involvement (infiltrate, ulcer, opacity) 1, 2, 3
• Conjunctival scarring 1, 2
• Lack of response to therapy after 3-4 days 1, 3
• Recurrent episodes 1, 2
• History of HSV eye disease 1, 2, 3
• Immunocompromised state 1, 2, 3
• Neonatal conjunctivitis (requires systemic treatment) 2, 3

Special Infection Considerations Requiring Systemic Therapy

Gonococcal Conjunctivitis:

• Presents with marked eyelid edema, bulbar conjunctival injection, and copious purulent discharge 1
• Treatment: Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 2
• Neonatal dosing: Ceftriaxone 25-50 mg/kg IV or IM single dose 2
• Requires daily follow-up until resolution 2, 3
• Can cause corneal perforation if untreated 1, 2
• Obtain conjunctival cultures and Gram staining before treatment 2, 3
• Must evaluate for sexual abuse in children 1, 2

Chlamydial Conjunctivitis:

• Neonatal treatment: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses for 14 days 2, 5
• Children <45 kg: Erythromycin 50 mg/kg/day divided into 4 doses for 14 days 2
• Children ≥45 kg but <8 years: Azithromycin 1 g oral single dose 2
• Children ≥8 years: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 2
• Topical therapy alone is inadequate 1, 2
• Must treat sexual partners and consider sexual abuse in preadolescent children 1, 2
• Monitor infants <6 weeks on erythromycin for infantile hypertrophic pyloric stenosis 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics indiscriminately for viral conjunctivitis - this contributes to resistance and causes unnecessary toxicity 1, 2
• Do not use topical corticosteroids without ophthalmology consultation - they prolong adenoviral infections, worsen HSV infections, and can cause increased intraocular pressure and cataracts 1, 2, 3
• Do not miss gonococcal or chlamydial infection - these require systemic therapy and delayed treatment leads to vision loss 1, 2, 3
• Do not overlook concurrent otitis media - check ears in children with bacterial conjunctivitis 1, 3
• Be aware of MRSA - if no improvement after 3-4 days, consider culture and alternative therapy 3
• Do not use doxycycline in children <8 years or pregnant women - use erythromycin or azithromycin instead 2

Follow-Up Recommendations

• Return for re-evaluation if no improvement after 3-4 days of antibiotic treatment 3
• Patients with severe viral conjunctivitis should be re-evaluated within 1 week 1
• Those not on corticosteroids should return if symptoms persist beyond 2-3 weeks 1
• Patients on topical corticosteroids require regular monitoring of intraocular pressure and periodic pupillary dilation 1, 2