The Pediatric Red Eye: Ophthalmia Neonatorum, Conjunctivitis, and Uveitis

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.


Ophthalmia Neonatorum

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.


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.