Conjunctivitis in Children

Aetiology

Clinical Features by Type

1. Bacterial Conjunctivitis

• Discharge: mucopurulent, often causing eyelid adherence on waking
• Usually painless; starts unilateral, may become bilateral
• Conjunctiva injected; cornea clear
• Chemosis (conjunctival oedema) is common
• Preauricular lymphadenopathy is absent (except in gonococcal infection)
• Typical pathogens: Staphylococcus and Streptococcus spp.
• H. influenzae is a common childhood pathogen

Bacterial conjunctivitis (H. influenzae) in a paediatric patient — Tintinalli's Emergency Medicine

2. Viral Conjunctivitis

• Often preceded by upper respiratory infection or systemic viral illness
• Watery discharge, "red eye," mild to moderate
• One eye involved initially → other eye within days
• Physical exam: conjunctival injection ± chemosis, small subconjunctival haemorrhages, preauricular lymphadenopathy, follicles on inferior palpebral conjunctiva
• Epidemic keratoconjunctivitis (EKC): severe adenoviral form — high fever, malaise, myalgias, photophobia, marked redness; highly contagious
• Always examine cornea with fluorescein to exclude herpetic dendrite

3. Allergic Conjunctivitis

• Watery discharge + itching (hallmark symptom)
• Erythematous swollen eyelids, injected/oedematous conjunctiva
• Papillae on inferior conjunctival fornix (vs. follicles in viral)
• Prominent chemosis may be seen
• Associated with atopy/allergic rhinitis

4. Neonatal Conjunctivitis (Ophthalmia Neonatorum) — special case

• Gonococcal: profuse purulent discharge, requires systemic treatment
• Chlamydial: most common infectious cause in neonates — requires systemic antibiotics (not just topical)

Diagnosis

• Primarily clinical
• Always perform fluorescein staining — especially in infants — to exclude corneal abrasion, ulcer, or herpetic dendrite
• Culture and sensitivity in severe bacterial cases
• Key distinguishing features:
  • Itching → allergic
  • Watery discharge + lymphadenopathy → viral
  • Purulent discharge + lid adherence, no itch → bacterial
  • Fever + purulent discharge → bacterial

Management

Bacterial Conjunctivitis

• Most cases are self-limited but antibiotics shorten duration
• First-line: Trimethoprim–polymyxin B eye drops — effective, avoids sulfa/neomycin allergy risks
• Ophthalmic ointments are preferred in young children (easier to administer)
• Contact lens wearers → treat with a fluoroquinolone (besifloxacin, gatifloxacin, moxifloxacin, ofloxacin) or tobramycin to cover Pseudomonas
• Gonococcal/chlamydial: requires systemic antibiotics in addition to topical therapy

Viral Conjunctivitis

• Supportive care — no antivirals for adenovirus
• Cool compresses; artificial tears 5–6×/day
• Ocular decongestants (e.g., Naphcon-A) for redness/congestion
• Course: 1–3 weeks; very contagious → strict hand hygiene, separate towels
• If viral vs. bacterial is uncertain → prescribe topical antibiotics empirically and reassess

Allergic Conjunctivitis

• Identify and eliminate the offending allergen
• Cool compresses 4× daily
• Mild: artificial tears alone
• Moderate–severe: topical antihistamine/mast cell stabilisers (olopatadine, ketotifen, azelastine, bepotastine, emedastine)
• Avoid topical steroids unless directed by ophthalmologist

When to Refer to Ophthalmology

• Photophobia or vision loss
• Severe pain
• Recurrent episodes
• Suspected gonococcal infection
• No improvement with treatment
• Contact lens wearer with worsening symptoms

Key Differences from Adult Presentation

• H. influenzae is a more prominent pathogen in children
• Ointment formulations are preferred over drops in young children
• Neonatal conjunctivitis is a distinct entity requiring specific workup and systemic treatment
• School exclusion should follow local policy — bacterial/viral forms are highly contagious