The Pediatric Red Eye: Ophthalmia Neonatorum, Conjunctivitis, and Uveitis
Ashley A. Foster
Tamiesha A. Frempong
A red eye is one of the most common pediatric eye conditions evaluated in the emergency department (ED). Careful diagnosis is critical because the causes vary by age and presentation. Neonatal conjunctivitis carries some of the most significant potential for morbidity and mortality because it may progress to sepsis and death. Conjunctivitis beyond the neonatal period, commonly referred to as pink eye, is broadly defined as inflammation of the conjunctiva and has many distinct causes.
THE CLINICAL CHALLENGE
Neonatal conjunctivitis, or ophthalmia neonatorum, is defined as conjunctivitis that occurs in a newborn less than 1 month of age. Causes include chemical, bacterial, or viral agents.1 The risk of morbidity from the infection is severe, because the infection can rapidly destroy the eyes and cause corneal ulceration, endophthalmitis, and subsequent blindness.2 It can also disseminate and lead to sepsis, meningitis, arthritis, or other severe manifestations of invasive disease. Fortunately, rates of ophthalmia neonatorum have been declining since initiation of preventative measures, including neonatal prophylaxis and identification and treatment of maternal infections during pregnancy (Table 37.1). Nevertheless, this diagnosis should not be missed.
Conjunctivitis beyond the neonatal period is a relatively benign condition. The etiologic causes fall into two categories: infectious (bacterial/viral) and noninfectious (allergic/toxic). Although infectious conjunctivitis is highly contagious and inconvenient owing to discomfort and missed days from school or work, it is self-limiting or manageable with medications. However, notable exceptions with high morbidity cannot be overlooked. Neisseria gonorrhoeae (NG) conjunctivitis that can occur in adolescents and adults carries the risk of corneal ulceration, endophthalmitis, or subsequent blindness. Chemical conjunctivitis caused by acid or alkali burns to the eye are true ocular emergencies. Because alkali agents penetrate ocular tissue deeper than acidic chemicals, they are potentially more devastating to the eye and vision.
TABLE 37.1 Etiology of Ophthalmia Neonatorum and Time Frame of Onset of Symptoms
Uveitis is often accompanied by conjunctivitis, causing a red eye. It can be extremely challenging to diagnose because children may have a range of symptoms, including severe pain or vision loss, or they may be completely asymptomatic. Uveitis can occur as anterior (iris and ciliary body), intermediate (vitreous and pars plana), posterior (choroid or retina), or pan uveitis (all structures). Uveitis can be infectious or noninfectious or represent a masquerade syndrome (eg, leukemia).3 Pediatric uveitis denotes an important disease to detect because of the risk of poor visual outcomes if there is a delay to diagnosis or treatment. Noninfectious anterior uveitis is the most common type in the United States, representing a majority of cases (61.9%).4 Although most cases of anterior uveitis are idiopathic, more than ¼ of patients have underlying systemic disease.2 Early diagnosis and aggressive treatment improve morbidity associated with this disease. Uveitis can also develop after nonpenetrating or penetrating trauma to the eye, especially in males.
The underlying cause of conjunctivitis in the pediatric population is influenced by the age of the child (Figure 37.1). Clinical signs and symptoms can help in distinguishing among the various causes of conjunctivitis (Table 37.2).
Viral and allergic causes are more common in school-aged children, whereas bacterial causes of acute conjunctivitis are twice as likely in infants and toddlers. The exception is in adolescents with copious, mucopurulent discharge associated with conjunctivitis concerning for NG or Chlamydia trachomatis (CT) infection.
The most implicated bacteria in the younger cohorts are Haemophilus influenza, Streptococcus pneumonia, Staphylococcus aureus, and Moraxella catarrhalis. Notably, otitis media occurs in 25% of patients with conjunctivitis even in the absence of ear pain.1 Therefore, every child with conjunctivitis also requires an ear exam owing to the risk of concurrent infection, most commonly caused by H influenza.
Adenovirus is the most common viral cause of infectious conjunctivitis, accounting for 20% of all cases, particularly in the fall and winter months.1 Primary herpes virus conjunctivitis occurs between the ages of 1 and 5 years.1 Eighty percent of cases are unilateral. Fifty percent of patients have corneal involvement evidenced by corneal dendrite.1 Contact with another person with an active lesion may also be elicited in the history of present illness.
Uveitis can be divided into isolated uveitis or a manifestation of systemic disease. Juvenile idiopathic arthritis represents the most common systemic disease to cause anterior uveitis.5 Additional systemic diseases associated with uveitis are listed in Table 37.3.
Uveitis can present with eye pain, redness, or light sensitivity and is more likely to have bilateral eye involvement. Patients may have conjunctival injection with photophobia or vision changes. Slit lamp examination is recommended and will often reveal white blood cells in the anterior chamber, described as “cell and flare” (Figure 37.2).2 Cells may settle in the front of the eye, forming a hypopyon.2
Figure 37.1: A, Neonatal gonorrheal conjunctivitis with associated lid swelling and significant purulent discharge. (From Bachur RG, Shaw KN, Chamberlain J, Lavelle J, Nagler J, Shook JE, eds. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 8th ed. Wolters Kluwer; 2021. Figure 123.6.) B, Neonatal conjunctivitis caused by Chlamydia trachomatis with pseudomembrane formation. (From Nelson LB, Olitsky SE. Harley’s Pediatric Ophthalmology. 6th ed. Wolters Kluwer; 2014. Figure 9.12.) C, Neonatal conjunctivitis and keratitis caused by HSV in a neonate. A corneal dendrite is seen with associated epithelial defect. (From Taylor and Hoyt’s Pediatric Ophthalmology and Strabismus. 5th ed. Elsevier; 2017:109-112. Figure 13.1.C.)
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