What is the appropriate management of acute hemorrhagic conjunctivitis in a 2½-year-old child?

Management of Acute Hemorrhagic Conjunctivitis in a 2.5-Year-Old

Acute hemorrhagic conjunctivitis (AHC) in a 2.5-year-old requires supportive care only—no antibiotics, no antivirals, and strict infection control measures to prevent household and school transmission. 1, 2

Clinical Recognition and Diagnosis

AHC is a highly contagious viral conjunctivitis caused by enterovirus 70 or coxsackievirus A24 variant, presenting with distinctive features that differentiate it from bacterial or other viral causes: 1, 3

• Rapid onset of bilateral swollen eyelids, foreign-body sensation, burning, and watery (not purulent) discharge 2
• Distinctive bulbar conjunctival hemorrhages—the hallmark finding that gives this condition its name 2
• Follicular conjunctival reaction with only mild and infrequent corneal involvement 2
• Symptoms typically resolve within 5-7 days without significant ocular sequelae 2

Critical distinction: The presence of subconjunctival hemorrhages with watery discharge (not purulent) in an epidemic context strongly suggests AHC rather than bacterial conjunctivitis, which would show purulent discharge and mattering of eyelids. 4, 2

Treatment Approach

Primary Management: Supportive Care Only

No specific antiviral therapy exists for enterovirus-associated AHC, making supportive care the only evidence-based approach. 1, 2

• Cold compresses applied to closed eyelids for comfort and to reduce inflammation 5, 6
• Refrigerated preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 6
• Topical antihistamines (second-generation) may be used for symptomatic relief of itching and discomfort 6

What NOT to Do

Avoid topical antibiotics entirely—they provide no benefit for viral AHC, risk inducing ocular toxicity, and promote antimicrobial resistance. 5, 6, 2 The 1983 Florida outbreak study demonstrated that symptomatic treatment was as effective as various topical medical regimens, including antibiotics. 2

Never use topical corticosteroids in suspected viral conjunctivitis without definitively excluding herpes simplex virus, as steroids potentiate HSV infection and prolong adenoviral infections. 5, 6

Infection Control: The Critical Component

AHC spreads with extraordinary efficiency through direct person-to-person contact, contaminated fomites, and possibly airborne transmission. 1, 3

Mandatory Household Measures

• Strict hand hygiene with soap and water after any eye contact—this is the single most important intervention 6, 3
• Avoid sharing towels, pillowcases, or any items that contact the face 3
• Discard or thoroughly disinfect any eyedrop containers to prevent cross-contamination 6
• Avoid close contact for 7-14 days from symptom onset 6

School Exclusion

Exclude the child from daycare or preschool immediately and keep them home for at least 7 days or until discharge resolves. 3 The 1981 Florida outbreak demonstrated a dramatic reduction in cases after excluding affected schoolchildren, with attack rates declining more rapidly for school-aged children than other age groups. 3 Schoolchildren are the most likely to introduce AHC into households. 3

Red Flags Requiring Immediate Ophthalmology Referral

While AHC is typically self-limited, refer urgently if any of the following develop: 5, 6

• Visual loss or significant change in vision 6
• Moderate to severe eye pain (beyond mild irritation) 6
• Corneal opacity, infiltrate, or ulcer on examination 6
• Lack of improvement after 7 days or worsening symptoms 6
• Immunocompromised state 6

Expected Natural History and Follow-Up

• Duration: Symptoms typically last 5-7 days and are self-limited 1, 2
• Complications: Rare—the Florida outbreak showed AHC was free of significant ocular sequelae, with secondary bacterial infections occurring only in individuals who used contaminated substances (urine) as eyewash 2
• Neurologic complications: One case of transient Bell's palsy was reported in the Florida outbreak, though this is exceedingly rare 2

Instruct parents to return if symptoms worsen, persist beyond 7 days, or if the child develops severe pain or vision changes. 6

Common Pitfalls to Avoid

• Misdiagnosing as bacterial conjunctivitis and prescribing unnecessary antibiotics—look for the distinctive subconjunctival hemorrhages and watery (not purulent) discharge 4, 2
• Failing to implement strict infection control—younger age groups and members of larger households are at significantly greater risk, making household education critical 3
• Using combination antibiotic-steroid drops (e.g., Tobradex) without excluding HSV, which can cause devastating corneal complications 6
• Underestimating contagiousness—AHC has an extremely high transmission rate, and inadequate infection control can lead to household and community outbreaks 1, 3