Philip A. Brunell, MD: I am joined by a distinguished panel comprising a pediatrician, ophthalmologists and allergists, to consider the diagnosis and management of red eye in children. Our discussion will include the most common types of red eye in children, differential diagnosis of conjunctivitis and management options. What types of red eye commonly present to a pediatrician’s office?
Frederick N. Friedman, MD, FAAP: Bacterial, viral and allergic conjunctivitis are seen in children from two to five times a week, depending on the season. Patients come to the office with red eye from foreign bodies or corneal abrasions. One of the most “serious looking” but not serious causes of red eye is a significant subconjunctival hemorrhage due to coughing, vomiting or straining with constipation. Many eye diseases can be treated by a pediatrician and do not require referral to an ophthalmologist. However, cases such as hyphemas and corneal foreign bodies must be referred to an ophthalmologist.
Brunell: What cases of red eye do you consider handling over the phone?
Friedman: One of the few cases of red eye I will treat over the phone is a child with eye symptoms such as redness and mucousy discharge who has a cold, but is able to open the eye wide and does not seem to be experiencing pain, earache or a sore throat. I prescribe antibiotic eye drops or ointment and stress the importance of good hand washing practices of parents and child. If the child has improved in 24 to 48 hours, he or she can return to day care or school. If the child does not show improvement in 24 to 48 hours, he or she should come in to the office to be examined.
A patient who has pain, high fever or photophobia, or will not open or use the eye must be examined in the office.
Brunell: How is the cause of infection determined over the phone?
David B. Granet, MD, FACS, FAAP, FAAO: The following questions should be asked over the phone prior to calling in a prescription or suggesting an office examination:
Mark B. Abelson, MD, FRCS: The depth of redness is another clue. Red eye ranges from pale pink indicating conjunctivitis, to fire engine red indicating more severe and deeper inflammation, such as a corneal ulcer, scleritis or an intraocular infection. Therefore, I suggest asking the parent over the phone questions to determine the actual depth of redness of the eye.
Granet: It is possible that a staff member in the office may forget a critical question or fail to obtain accurate information. Therefore, I have compiled an algorithm for help during phone interviews ( see the Pediatric Red Eye Triage Algorithm ). The list of questions can serve as an aid during the phone conversation. But, in addition to asking appropriate questions, it is important to listen carefully to the parent.
Friedman: One of the advantages of my pediatric practice is knowing most of the parents. I know whose description I can trust and whose I cannot. If the physician is not comfortable with the answers to the questions, he/she must insist that the child come to the office for an examination.
Granet: Patients with routine bacterial conjunctivitis usually do not present to the ophthalmologist because these patients are treated at the pediatrician’s office. By the time I examine the patient, the symptoms usually are severe. Thus, as a pediatric ophthalmologist, I do not prescribe medications over the phone.
Friedman: In our practice, we will diagnose and treat a patient over the phone only if the symptoms unquestionably describe bacterial conjunctivitis. If I suspect a subconjunctival hemorrhage or another possibly serious condition, I must see the patient. Ninety percent of children with eye problems who present to the pediatrician’s office are treated by a pediatrician and referral to the ophthalmologist is not necessary.
Brunell: A cardinal treatment principle of pediatrics is listening to the parent. Problems may occur when the clinician ignores what the parent is saying.
Dennis L. Spangler, MD: Most of the patients a pediatrician treats over the phone have clear-cut, mild symptoms. If a pediatrician sees every patient who has an eye symptom, the pediatrician will not have time for other patients. So there is a certain amount of practicality with pediatricians treating some cases over the phone, as long as the parent understands to call back if the child does not improve within 24 hours.
Granet: We all agree that there are certain questions that must be asked to ensure that the condition is on the milder end of severity. The case may be treatable over the phone with the caveat that it should be improving and not worsening, and that the physician will continue to have contact with the patient.
Brunell: What steps are performed in the examination of a child who presents with eye complaints?
Friedman: First, a complete history must be obtained, including questions to determine if the child is in pain, when the symptoms started and systemic symptoms. I recommend observing the child while taking the history. A child who will not open the eye does not have bacterial, viral or allergic conjunctivitis. The problem is more serious, such as a foreign body or an ocular trauma. In addition to a routine physical examination, the eye must be examined for swelling, redness of the eyelids or conjunctiva, and enlarged lymph nodes, as well as proper functioning. The ear and throat should also be examined. I do not perform cultures, Gram’s stains or histologic stains from the eye in my pediatric office.
Granet: From a pediatrician’s perspective, it is important to determine a significant change in the vision during the examination. Therefore, the child’s vision should also be checked. In patients <5 years old, the vision can be tested in the same manner as checking for amblyopia. The physician holds a toy and observes if the child is reacting differently when looking out of each eye. Don’t forget to check the red reflex and the pupils.
Peter A. D’Arienzo, MD: The history is going to affect the diagnosis. For example, a child with a crusted eyelid who was recently swimming in a pool most likely has viral conjunctivitis. If a child was hit by a tree branch, a corneal abrasion may be the diagnosis.
Brunell: During an examination, should a pediatrician use anesthetic drops and fluorescein strips to detect a corneal abrasion?
Friedman: I use fluorescein strips without anesthetic drops.
Abelson: The following procedure should be followed when using fluorescein strips. First, apply a drop of saline to the tip of the strip. Then, pull down the lower lid and apply the drop to the conjunctival cul-de-sac. Finally, after one minute, examine the eye under blue light.
Granet: Linear abrasions can indicate a foreign body beneath the lid, which can potentially cause damage with every blink of the eye. Therefore, the pediatrician should attempt to check under the lid for the presence of a foreign body.
Friedman: My colleagues and I treat 80% to 90% of patients with corneal abrasions in our office. All children with corneal abrasions are patched after applying an antibiotic topical ointment. We examine patients again in a follow-up visit the next day to ensure that the abrasion has healed.
D’Arienzo: According to ophthalmic literature, ophthalmologists only patch the eye if the abrasion is >10 mm or if a child is in severe pain. Studies have shown that the smaller lesions heal better because of the eye’s natural blinking phenomenon, tear lysozymes and immunoglobulins.1
Granet: Once the diagnosis of fungal infection has been ruled out, I prefer to patch the eye of a child with a corneal abrasion simply to keep his/her hands away from the eye. Generally, most corneal abrasions in young children heal within 24 hours. I explain to children that the patch will help them feel better. I also tell the parents not to attempt to reapply the patch if it falls off, because a parent putting a patch on at home can cause more damage than good. Generally, most children keep the patch on for the required amount of time while they are healing, even if it is a few hours. In addition, their hands are kept away from their eyes during the healing phase.
Abelson: It is important to remember that patching may increase the likelihood of an abrasion becoming a corneal ulcer due to increased levels of bacteria.
Friedman: To avoid infection, I apply antibiotic ointment to the eye and leave a patch on for 24 hours.
Abelson: Corneal abrasions create a significant risk for corneal ulcers. Therefore, the antibiotic should be broad spectrum, with rapid onset and high minimal inhibitory concentrations, such as the topical fluoroquinolones. Do you instruct parents to remove the patch at night to apply more antibiotic ointment?
Friedman: No. The patch remains on the eye for 24 hours. I remove it the next day, and generally, the cornea has healed. If the corneal abrasion has not healed or the eye becomes red again after a few days, I refer patients to an ophthalmologist.
D’Arienzo: Patching helps photophobia because it prevents light from entering the eye, but it does not relieve brow pain. Should a pediatrician commonly insert a cycloplegic to relax the ciliary body muscle spasm and to relieve photophobia and pain?
Abelson: I do not believe pediatricians should use a cycloplegic. Most of the cycloplegics do not last for more than four hours, and the long-acting cycloplegics are effective primarily for iritis.
Friedman: The majority of children have a simple corneal abrasion that usually will resolve within 24 hours with antibiotic ointment and a patch. I also administer acetaminophen or ibuprofen for pain. The rare cases that do not improve after 24 hours are referred to an ophthalmologist.
D’Arienzo: Cases of corneal melts, when superficial corneal layers melt away, can occur with patching of corneal abrasions, especially in patients wearing contact lenses. Therefore, I do not believe a pediatrician should patch any corneal abrasion in a contact lens wearer because Pseudomonas is a concern.
Friedman: I would immediately refer a contact lens patient who acquired a corneal abrasion while wearing the lens to an ophthalmologist.
D’Arienzo: I suggest using a fluoroquinolone such as Ciloxan (ciprofloxacin, Alcon), which has excellent pseudomonal coverage.
Brunell: How can a clinician differentiate between viral and bacterial conjunctivitis?
Friedman: Differentiating viral conjunctivitis from bacterial conjunctivitis is challenging. Typically, the symptoms of viral conjunctivitis include a teary to slightly milky discharge that is not purulent looking. Patients may also have systemic manifestations such as high fever, pharyngitis, enlarged lymph nodes and an inflamed ear with clear fluid. If the child has a sore throat, I will culture for group A and group beta Streptococcus. If the culture is negative but the eardrum is red with clear fluid, the conjunctivitis is usually viral. If I am confident that the infection is viral, I will not treat with antibiotics. Rather, I will prescribe decongestants and antihistamines. If I cannot rule out a bacterial infection, I will treat with antibiotics. I treat most cases with antibiotic drops or ointment.
Spangler: Most of the time, because the child is going to be significantly sick and uncomfortable, the parent will not be satisfied unless medications are prescribed.
Brunell: Upon review of data on the diagnosis and clinical findings of viral conjunctivitis vs. bacterial conjunctivitis, I find the two conditions are often indistinguishable. Statistically, statements can be made about the likelihood of a disease being bacterial and viral, but it is interesting how many cases of proven adenovirus conjunctivitis had purulent conjunctivitis.2
D’Arienzo: Even for an ophthalmologist, it is difficult to determine whether an infection is bacterial or viral. Bacterial conjunctivitis tends to be more bilateral and occurs in preschool children, whereas viral conjunctivitis can be unilateral and may occur in older, school-aged children. If a patient has a red eye and otitis media (OM), the infection is most likely bacterial. If a patient has a red eye and an enlarged lymph node, the infection is most likely viral. Therefore, checking for preauricular nodes and submandibular nodes is important.
Granet: Even in studies, the “hit rate” on clinically distinguishing viral from bacterial conjunctivitis is low. Therefore, from a practical standpoint, the majority of viral conjunctivitis cases are most likely treated with an antibiotic, which goes against the principles taught to medical students — antibiotics should not be prescribed for all patients who present with colds. However, relating to the eye, treating viruses with antibiotics is common practice, because the antibiotic drops are safe and do not cause resistance. Additionally, cases of bacterial superinfection may be prevented.
Spangler: The severity of disease is also an issue in terms of the potential consequences of mistreated conditions. If cold symptoms are missed initially, problems such as an ear infection or sinusitis are manageable. However, the potential results from a mistreated eye problem, such as a corneal melt, are more serious.
D’Arienzo: It is important to differentiate between typical viral conjunctivitis and more serious viral infections. Types 8, 11 and 19 adenovirus cause epidemic keratoconjunctivitis (EKC). Although rare in children, patients with EKC present with corneal findings such as subepithelial infiltrates and may develop pseudomembranes. These patients may experience decreased vision and will sometimes require a topical steroid.
Granet: Also, on physical examination, the cornea is not crystal clear.
D’Arienzo: Other types of viruses, such as enterovirus 70 and coxsackievirus A24, cause acute hemorrhagic conjunctivitis. Manifestations include a mucopurulent discharge, chemosis and bulbar and tarsal conjunctival hemorrhages.
Abelson: I allow each patient one unexplained subconjunctival hemorrhage. However, if patients experience subsequent subconjunctival hemorrhages within a short time, the underlying cause must be examined.
Granet: Although uncommon, neuroblastoma can also cause subconjunctival ecchymosis in children.
D’Arienzo: It is important to examine the ear of a child who has conjunctivitis. Studies have shown that if patients have a combination of red eye and OM, 75% of the cases will be a Haemophilus bacterial infection. But if a child presents with red eye and pharyngitis, over 50% of the cases will be viral.2
Abelson: In a survey of studies on the relationship between OM and conjunctivitis, Harrison stated, “Patients presenting with conjunctivitis and acute otitis media (AOM) were most often <3 years of age and had a history of increased episodes of AOM in the previous year. Thus, we postulate the underlying age-related immunologic immaturity in response to polysaccharide challenge and anatomic dysfunction may lead to AOM during any inflammatory upper respiratory disease in these patients including keratoconjunctivitis.”3
Brunell: What is the recommended treatment for conjunctivitis and OM?
Abelson: In 3- to 4-year-old children, 5% of cases of conjunctivitis are associated with OM. In this age group, we strongly believe in treating topical diseases topically. However, if patients in this age group have a high incidence and high risk of OM infections, systemic medications may also be used.3
A history of OM was shown to be associated with the increased risk of developing a concurrent or secondary OM from bacterial conjunctivitis. However, the combination of systemic and topical medications should be used only in patients <4 years old. Patients without previous history of OM or problems related to conjunctivitis, and with the potential to follow-up, can be treated topically. These patients need not be subjected to the over use of systemic antibiotics.3
D’Arienzo: In a pilot study by Wald,4 20 patients with bacterial conjunctivitis were randomized to receive an oral antibiotic plus a topical placebo or an oral placebo plus topical polymyxin-bacitracin. All of the eight patients receiving oral antibiotics had a clinical cure of their conjunctivitis, and none developed OM. In contrast, 11 of the 12 patients receiving topical therapy had a clinical cure. However, five patients developed OM. Therefore, oral antibiotics are most likely effective in the treatment of bacterial conjunctivitis and the prevention of OM. However, I recommend that pediatricians use a topical and a systemic antibiotic if a child has conjunctivitis and OM. The topical antibiotic will eradicate the pathogen faster than the systemic antibiotic, even within one day. I would not treat conjunctivitis/OM syndrome with an oral agent alone. Moreover, I do not treat conjunctivitis with oral medications, because of the concerns with resistance and adverse effects.
Brunell: In a similar study by Harrison,3 children with conjunctivitis who were treated with topical antibiotics alone developed OM at a significantly higher rate than the patients treated with both topical and systemic antibiotics.
| ALLERGIC CONJUNCTIVITIS |
 Figure 1. The causes, clinical finding and signs and symptoms of allergic conjunctivitis. (Photograph courtesy of Mark B. Abelson, MD.) |
Brunell: How can a physician differentiate between allergic conjunctivitis and viral conjunctivitis?
Friedman: The time of year is a significant factor in differentiating between allergic and viral conjunctivitis. For example, in southern California, allergic conjunctivitis almost always occurs in the spring and summer. With allergic conjunctivitis, the eye is slightly pink with no mucopurulent discharge. The primary patient complaints are itching and excessive tearing, in addition to difficulty breathing and nasal congestion (Figure 1). Typically, a family history of allergy exists, and upon examination, the pupils are normal and the corneas are clear.
Brunell: Is conjunctivitis part of a general allergic disease?
Friedman: Yes. The majority of conjunctivitis cases are part of the allergic rhinitis/conjunctivitis picture. But sometimes a case of isolated conjunctivitis will occur, for example, a teenage girl’s allergic reaction to eye make-up.
Brunell: How is allergic conjunctivitis managed?
Friedman: My first-line treatment for allergic conjunctivitis is an oral antihistamine, such as Zyrtec (cetirizine, Pfizer Inc.) or Claritin (loratadine, Schering Plough), once a day. If the oral antihistamine is not effective, Patanol ophthalmic solution (olopatadine hydrochloride 0.1%, Alcon) twice a day is effective and well tolerated.
Brunell: It is important to emphasize that oral antihistamines dry not only the nasal and oral mucosa, but also the conjunctiva.
Spangler: In cases of allergic conjunctivitis, I prefer to treat the area topically, if possible. Even in patients with allergic rhinitis, the trend is moving more toward topical treatments than systemic treatments.
Bob Q. Lanier, MD: Most patients connect antihistamines and allergy together, and so even if the eye symptoms are the major complaint, they use an antihistamine. When patients use Patanol, their symptoms are relieved without the use of an oral antihistamine.
Abelson: In addition to Patanol’s high receptor affinity, when using topical Patanol, high concentrations are applied directly to conjunctival mast cells and H1 receptors. Patanol is prescribed twice a day. There are few adverse effects with Patanol, and it has favorable safety and efficacy profiles.5-7 In studies comparing Patanol vs. Claritin, Patanol has been shown to be clinically more effective for managing ocular allergic symptoms. However, combining Patanol and Claritin is an effective way to simultaneously treat both ocular and systemic manifestations of allergy and may reduce the amount of systemic medication required.5-7
Spangler: Contact lens wearers also benefit from topical treatments. Many contact lens wearers treated with oral antihistamines complain of the drying effects of antihistamines on their eyes. But using long-acting topical products that can be applied twice daily will allow patients to wear their lenses without symptoms for a long time.
Granet: Younger children also benefit from a drop that is dosed twice a day. Patanol is practical and cost effective because one bottle of drops replaces four bottles (two bottles each of the antihistamines and the mast cell stabilizers). To me, cost effective means cost per treatment, not cost per bottle. It is important to remind patients not to rub their eyes, because they auto-inoculate the eye with the antigen. The mechanical rubbing of the eye can trigger the allergic response indistinguishably from an antigen causing it. As mast cells migrate from deep to superficial, less antigen is required to trigger the same response, and the cycle becomes worse.
Spangler: If a patient has chronic allergy problems, the patient should be referred to an allergist for evaluation.
Granet: What is the role of over-the-counter (OTC) eye drops in the management of allergic conjunctivitis?
Abelson: Ninety percent of our patients self medicate with OTC anti-allergic eye drops.
Lanier: I recommend that patients use OTC drops for only a few days because OTC drops do not treat the basic disease.
Abelson: Although the recommended dose for OTC drops is four times a day, most OTC drops have no effect beyond two hours. If the instructions indicate two hours’ duration of action up to four times a day, there is a period when the eye continues to itch, so the drops will most likely be used more frequently. The drops that contain benzalkonium chloride preservatives should not be used six to eight times a day.
Spangler: The OTC eye drops are only appropriate for short-term use. Physicians must realize that these drugs are available to the patients and should ask all patients which OTC eye drops they are using. There are safer and better solutions to these patients’ problems. Most of my patients who have been using OTC eye drops on a regular basis do not object to switching to a more effective and more comfortable treatment that is used only once or twice a day.
Brunell: It is important to remember that the preservatives such as benzalkonium chloride in OTC eye drops can sensitize the eye.
| VERNAL KERATOCONJUNCTIVITIS |
 Figure 2. Images showing the clinical presentations of vernal keratoconjunctivitis, including corneal haze, severe redness and papillae. (Photographs courtesy of Mark B. Abelson, MD.) |
Brunell: What is the difference in management between seasonal and perennial allergy?
Spangler: Allergy management depends upon the individual patient. Typically, if a patient has symptoms two or three weeks in a certain season, I will prescribe topical ocular and intranasal medications. I also recommend driving with the windows closed when the child is in the car, washing hair before going to bed, using central heating and air conditioning and frequently changing air filters in heating and air conditioning units. I may modify the regimen when allergy symptoms are chronic and incapacitating or when patients cannot tolerate medications.
Friedman: When children come to the office with chronic allergies, I recommend changes to the home environment especially the child’s bedroom, such as removing the carpet, eliminating dust and closing the air vents.
D’Arienzo: It is important to look for vernal keratoconjunctivitis (VKC) in the pediatric population, which is a seasonal conjunctivitis that must be managed by an ophthalmologist (Figure 2). VKC can mimic bacterial conjunctivitis when a child rubs the eyes and awakens in the morning with eyelids that are crusted together. Eye rubbing degranulates mast cells. So it is important for the pediatrician to ask about eye rubbing and try to have the child refrain from that. For treatment, in addition to cool compresses, I recommend refrigerated artificial tears, which act as a diluent, alleviate some of the allergen from the cul-de-sac and reduce redness. Topical medications may also be required, such as mast cell stabilizers, antihistamines and corticosteroids. Of all the allergy drops, Patanol is the only mast cell antihistamine that is approved for treating the signs and symptoms of allergic conjunctivitis, which include chemosis, hyperemia, itching, tearing and lid swelling. The other medications are approved only for itching.
Brunell: The Red Book states that patients with “purulent conjunctivitis, defined as pink or red conjunctiva with white or yellow eye discharge, often with matted eyelids after sleep and eye pain or redness of the eye lids or skin surrounding the eye, until examined by a physician and approved for readmission with treatment, must be withheld from school.”8 When is readmission to school or day care approved once topical antibiotics have been started for treatment of conjunctivitis?
Friedman: Generally, once the child begins treatment for bacterial conjunctivitis, the child can return to school if the eye discharge is significantly reduced within 24 to 48 hours. I spend time talking with parents about hand washing and the use of antibacterial hand gel for washing the hands each time they touch the child’s eye.
Granet: Typically, viral conjunctivitis is considered more likely to spread than bacterial conjunctivitis, and, therefore, more cause for concern because of lack of good treatment.
Brunell: Most of the children in day care are colonized with the organisms that cause bacterial conjunctivitis, for example Haemophilus or Pneumococcus. Viral conjunctivitis is different because it requires contact with an infected person, whereas the organisms that cause purulent conjunctivitis are resident flora in the children.
Friedman: Bacterial infections spread within families and schools, but not as aggressively as viral conjunctivitis. If the student remains out of school for 24 to 48 hours, and the eye looks better, usually, the child will be readmitted. But with allergic conjunctivitis, a note from the pediatrician is required because the eye is going to be red for a while and the school will want a note that the child is not contagious.
D’Arienzo: If a child with bacterial conjunctivitis returns to school within 24 hours, it is important to use a bactericidal agent that will quickly eradicate the pathogen. If a medication that is bacteriostatic is prescribed, a microbiological cure cannot be confirmed.
Granet: What are the common eye problems seen in newborn infants?
D’Arienzo: The time of symptom onset is important in newborn infants. Within 24 hours after birth, chemical conjunctivitis manifests. Neisseria gonorrhea typically occurs on the second to fourth day of life, Chlamydia on day five to day 14 and herpes on day seven to day 14. I believe that any case of ophthalmia neonatorum must be cultured to rule out Chlamydia due to the potential systemic complications that may occur if Chlamydia remains untreated.
Brunell: Are you concerned that an infection may be gonococcal conjunctivitis?
Granet: Clinically, the classic symptom of gonococcal conjunctivitis is a constant purulent discharge. However, I always assume that a newborn has Chlamydia if gonococcal conjunctivitis is present, even though Chlamydia may not show on the culture. Therefore, both must be treated.
D’Arienzo: Clinically, the symptoms of Neisseria include a copious purulent discharge, marked conjunctival hyperemia and chemosis and eyelid edema. Chlamydia is significantly different in appearance than N. gonorrhea. Chlamydia causes minimal swelling and discharge, pseudomembranes and subconjunctival hemorrhage. The treatment for Chlamydia is oral antibiotics for 14 to 21 days.
Brunell: When chlamydial conjunctivitis was first recognized, it was treated topically and many infants developed chlamydial pneumonia. Today, young infants with chlamydial conjunctivitis and pneumonia are treated with oral erythromycin. The Red Book recommends oral erythromycin, 50 mg/kg/day, and four divided doses over 14 days. Topical therapy does not eliminate pharyngeal carriage. Thus, by treating systemically, the progression to pneumonia can most likely be diminished.9
According to the Red Book, the standard of care for infants with gonococcal ophthalmia includes systemic antibiotics and eye irrigation with saline immediately and at frequent intervals until purulent discharge is eliminated. How do ophthalmologists treat gonococcal conjunctivitis?10
D’Arienzo: The preferred practice pattern from the American Academy of Ophthalmology for treatment of gonococcal conjunctivitis is single injection of ceftriaxone (Rocephin, Roche), 25 to 50 mg/kg intravenously or intramuscularly. In my opinion, because certain pathogens such as Neisseria and Haemophilus can invade an intact corneal epithelium, it is prudent to treat with a topical agent, as well.11
Granet: In a 2-month-old infant, a nasolacrimal duct obstruction can cause what appears to be a bacterial conjunctivitis with discharge. Does the presence of a nasolacrimal duct obstruction change your management?
Friedman: We commonly diagnose nasolacrimal duct obstruction at the two-week or the two-month check-up. We explain to the parent the cause of the obstruction, the possibility of recurrence, how to treat and when to bring the child to the pediatrician’s office. Because we can successfully treat 99% of nasolacrimal duct obstruction cases, we usually do not refer these patients to an ophthalmologist until they are close to 1 year old. However, some ophthalmologists in our community prefer to see infants with a nasolacrimal duct obstruction at 2- or 3-months of age.
Granet: I am concerned that bacterial conjunctivitis will become uncontrollable in infants. Because these patients do not have a formed septum, if bacterial conjunctivitis becomes an orbital cellulitis, they are at significant risk of comorbidities. Therefore, it is important to treat with an antibiotic that will achieve the most immediate complete kill, because you do not want infection lingering in that child if there is a significant risk of orbital cellulitis. I immediately admit these very young patients into the hospital, begin treatment with topical fluoroquinolones and either IV or parenteral antibiotics, and closely monitor the patient each day. My topical treatment is off-label. Medications that work quickly in that young age group are important. By using a broad-spectrum antibiotic such as Ciloxan, which is the only fluoroquinolone available in an ointment vehicle, the infection resolves quickly, and the infant is at less risk of comorbidities.
Friedman: We have been using Ciloxan drops and ointment more often because of its rapid action. It is well tolerated by children.
Granet: Your comment is important. Explaining to children that a
drop is good for them although it may feel uncomfortable or sting, does not
help. The first drop is always a “free shot” in children. If it
hurts, then the battle to administer the drop again begins. So a comfortable
drop is essential. All of the fluoroquinolones are comfortable. Do not be
concerned with the pH, because even drops with a pH near tears still sting. I
advise everyone to first try the drops on themselves.
Brunell: What is the recommended treatment for blepharitis and styes?
Friedman: For the treatment of blepharitis, I recommend warm compresses and lid scrubs with no-tear baby shampoo to remove the eyelid crust. If that treatment does not work, the patient is referred to an ophthalmologist.
Granet: The most effective treatment for blepharitis is lid scrubs. I have the parent scrub the lid with a combination of one capful of no-tear baby shampoo in eight ounces of water.
Abelson: A stye can be classified into two groups — hordeolum and chalazion. Classically, the hordeolum is an acute, red and purulent bacterial infection of one or more sebaceous glands. Optimal treatment is a warm compress. Also, antibiotics are useful because when the hordeolum drains, it will release bacteria and white cells into the cul-de-sac. The chalazion is a chronic, foreign body-type granulomatous inflammation in the meibomian gland. Because no bacteria are present and it is noninfectious, antibiotics are not necessary. Warm compresses will dilate vessels and help remove any build-up of the meibomian material.
D’Arienzo: A hordeolum occurs in the glands of Zeis or Moll and can be either external or internal. A chalazion is an eyelid mass that results from chronic inflammation of a meibomian gland. It is not infectious, but ophthalmologists may treat a chalazion with an antibiotic/steroid ointment to quiet the lid and reduce inflammation resulting from the contents that can be toxic to the surrounding tissue.
Abelson: In patients with a resistant or recurrent chalazion, steroid injections into the lid have been reported as being successful.12
Granet: I tend not to use antibiotics to treat the majority of patients with styes. I may consider antibiotics when the chalazion or stye begins to spread or it appears to be progressing to preceptal cellulitis. I tell the parents to apply warm compresses multiple times per day, so that the parents will likely apply the compresses four or five times. If a parent is told to apply compresses four or five times per day, they may actually only apply them one or two times.
D’Arienzo: Studies have shown that tetracycline or doxycycline can be useful in improving symptoms in patients with rosacea and improving tear break-up time. It is based on studies showing that tetracycline decreases lipase production in both Staphylococcus epidermidis and S. aureus. What is the age cutoff for tetracycline in a patient with recurrent chalazion?
Brunell: Tetracycline can be given to patients 8 years old or older.
Friedman: Patients with recurrent styes must be referred to an ophthalmologist to determine the underlying cause.
Abelson: Do pediatricians most commonly use ointments or drops?
Friedman: I use the vehicle that the parent will be able to get into the child’s eye. Typically, I use an ointment in children <2 years old, because crying washes drops out. Children 2 to 5 years old usually will tolerate drops. I have the child lie down with eyes closed, and I place the drops in the corner of each eye. Finally, I tell the child to open the eye, and the drops go in.
D’Arienzo: Parents prefer to use drops because they believe they are not able to apply the ointment into the cul-de-sac. But studies have shown that ointment is not needed in the fornix of the conjunctiva. The same level of concentration of topical drops can be achieved with ointment, if a strip is applied to the outer surface of the lower lid.13,14
Friedman: Because ointment melts at body temperature, its petrolatum base will allow the medication to get in the eye. Also, once the ointment is applied, the child immediately rubs the eye, and, therefore, promotes distribution.
Abelson: An ointment is preferred if the child will tolerate it, because the dwell time of an ointment is usually three hours as opposed to a drop that has a dwell time of only a few minutes.
Brunell: I am concerned that some physicians have been prescribing eye drops every two hours, has anyone heard of such practices?
Friedman: In pediatrics, there is no rationale to prescribe any medication every two hours. Moreover, few parents will comply with a regimen of every two hours. At best, parents may instill drops three times a day, for a maximum of five days.
Brunell: Is comfort a factor when selecting a medication?
Friedman: Comfort of a medication is critical to compliance in children because if a medication stings or burns, the child will not allow the parent to administer the medication again.
Granet: It is a pediatrician’s responsibility to maximize the chance for a successful treatment. The spectrum and speed of action and likelihood of compliance must be considered. Fluoroquinolones have the desired spectrum, and even cover the worrisome but uncommon Pseudomonas.
Since the time any drop is in contact with the eye is just minutes (especially in children), a bactericidal agent must work quickly. The faster the better. Therefore, a drop that clings to the epithelium, such as Ciloxan, becomes a real advantage. For example, in the worst situations — corneal ulcers — ophthalmologists will use drops multiple times, even per hour. In this extreme case, Ciloxan can form active collections of antibiotics called precipitates, a benefit of its tendency to stick to the eye. The advantage of this for the pediatrician, who would never see a precipitate, is that the drop wants to stick to the eye giving it vital extra time to work. That's a true bonus. From a compliance standpoint, dosing two or three times a day is crucial. I recommend Ciloxan three times a day, hoping for at least twice a day dosing, for three to five days. It has a broad spectrum and fast killing time, and it clings to the eye and is comfortable. All this adds up to less morbidity to the family and less call backs for the doctor.
Abelson: In a study of 750 patients, Leibowitz15 found that 288 patients had positive cultures. After three days of receiving ciprofloxacin, bacteria were either totally or almost completely eliminated in 93% of patients.
Brunell: Most antibiotic ointments such as polymyxin are less expensive than fluoroquinolone drops. Should cost be a significant issue when choosing treatment?
Abelson: The cost differential between antibiotic ointments and fluoroquinolones is insignificant when compared to the cost of potential adverse events and bacterial spreading. Why would you not prescribe a medication that will achieve a more rapid kill rate and reduce the likelihood of a corneal ulcer and spread to friends and family? The package insert of fluoroquinolones indicates treatment for six or seven days. However, three to five days should provide total clearing by culture and by relief of signs and symptoms. That has not been the case with polymyxin ointment. What is the success rate of your patients using polymyxin ointment?
Friedman: In 24 to 48 hours, 90% to 95% of patients show improvement using polymyxin ointment. The patients who do not respond either return to the office or call, at which time they will be switched to a fluoroquinolone.
Granet: Physicians must consider the cost to the family, as well. Even if a cure takes only one day longer, the family can be affected economically because a parent may be out of work an additional day. In a recent study of Tobrex (tobramycin, Alcon) vs. Ciloxan, Tobrex had an 84.3% success rate, and Ciloxan had a 90.1% success rate. The number of failures is reduced by 50% when ciprofloxacin is used. So although both medications are effective, I prefer to reduce the number of failures when I have the choice.16
Brunell: What is the role of topical ocular steroids in the hands of a pediatrician or an allergist to treat eye diseases?
Friedman: I do not prescribe topical steroids for ocular disease. Patients who require topical steroids must see an ophthalmologist.
Lanier: As an allergist, any time I prescribe medications such as steroids, I recommend follow-up with an ophthalmologist for a slit lamp examination.
Spangler: With the new highly effective medications for allergy management that are available, I have little need for ocular steroids. Patients who are well managed will not need steroids. The risks of ocular steroids far outweigh the small amount of additional benefits they offer. In cases in which red eyes are a manifestation of systemic problems, instead of topical steroidal eye drops, I prescribe systemic steroids for six or 10 days, which resolve both the systemic and eye problems.
Brunell: Because red eye is a manifestation of many conditions and is commonly seen in children, diagnosis can be challenging. The clinicians presented valuable information and tips that we hope will be useful for accurate diagnosis and effective treatment of red eye. I would like to thank the faculty for their insightful comments and Alcon Laboratories for sponsoring this Infectious Diseases in Children symposium and monograph project.
| PEDIATRIC RED EYE TRIAGE ALGORITHM |
Algorithm. The pediatric red eye triage algorithm is a useful tool to obtain accurate information during phone interviews with parents of children with red eye. (Algorithm provided by David B. Granet, MD, and Ricardo Ventura, MD.) |
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