Treatment of Baby's Crusty Eye
For a baby with a crusty eye, start with a 5-7 day course of broad-spectrum topical antibiotic (such as erythromycin or bacitracin ointment) applied 4 times daily, while implementing strict hand hygiene and monitoring closely for red flags that require immediate ophthalmology referral. 1
Initial Assessment and Red Flags
Before initiating treatment, you must evaluate for life-threatening conditions:
- Any purulent conjunctivitis in a neonate is an emergency until gonococcal causes are ruled out, as this can cause corneal perforation within 24-48 hours, septicemia, meningitis, and death 2
- Look for severe or rapidly reaccumulating purulent discharge with marked eyelid swelling—this suggests gonococcal infection requiring immediate systemic antibiotics 2
- Check for eyelid vesicles, which are pathognomonic for herpes simplex virus and require immediate ophthalmology referral 2
- Perform fluorescein staining to detect corneal involvement (infiltrate, ulcer, or opacity), which mandates urgent ophthalmology referral 1, 2
Standard Treatment Protocol
For uncomplicated bacterial conjunctivitis:
- Apply topical antibiotic ointment (erythromycin approximately 1 cm in length or bacitracin) directly into the conjunctival sac 4 times daily for 5-7 days 1, 3, 4
- Before applying ointment, carefully remove all scales and crusts from the eyelids 3
- Instruct caregivers to avoid contaminating the ointment tube when applying 3
- Implement strict hand hygiene to prevent transmission to others or the unaffected eye 1
- Avoid sharing towels or close contact during the contagious period 1
Special Situations Requiring Systemic Antibiotics
Gonococcal Conjunctivitis
If you suspect gonococcal infection (marked eyelid edema, severe purulent discharge, preauricular lymphadenopathy, rapid progression):
- Obtain conjunctival cultures and Gram stain before treatment 1
- Administer Ceftriaxone 125 mg IM for infants weighing less than 45 kg 1
- Add topical antibiotics and saline lavage for comfort and faster resolution 1
- Require daily follow-up until complete resolution 1
- Evaluate and treat mothers and sexual partners 1
- Consider sexual abuse in all cases 1
Chlamydial Conjunctivitis
If you suspect chlamydial infection (follicular conjunctivitis):
- Prescribe erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses for 14 days 1
- Topical antibiotics are unnecessary when systemic treatment is given 1
- Treatment efficacy is approximately 80%; a second course may be required 1
- More than 50% of infants may also be infected at other sites (nasopharynx, genital tract, lungs) 1
- Consider sexual abuse in children with this condition 1
- Evaluate and treat mothers and sexual partners 1
When to Refer Immediately to Ophthalmology
Refer immediately if the baby has any of the following: 1, 5
- Visual loss or change in visual behavior
- Moderate or severe pain causing significant distress
- Severe purulent discharge that rapidly reaccumulates after cleaning
- Corneal involvement (infiltrates, ulceration, opacity)
- Conjunctival scarring
- Proptosis or impaired extraocular muscle function (suggests orbital cellulitis)
- History of immunocompromise
- Eyelid vesicles (herpes simplex virus)
Follow-Up and Monitoring
- Return for evaluation if no improvement after 3-4 days of treatment 1, 5
- Lack of response suggests resistant organisms, alternative diagnoses, or need for systemic therapy 1
- Most cases of bacterial conjunctivitis can be treated effectively in an outpatient setting 1
Critical Pitfalls to Avoid
- Never use topical corticosteroids indiscriminately, as this can worsen infection 1
- Do not miss gonococcal or chlamydial infection, which require systemic therapy and can cause corneal scarring and perforation 1
- Do not delay referral for severe cases, as this can lead to vision-threatening complications 5
- Remember that nasolacrimal duct obstruction is a common predisposing factor for bacterial conjunctivitis in infants 1