Red eye (peds)

Background

Eye anatomy.

• This page describes a general approach to the complaint of eye redness for pediatric patients
• Red eye is extremely common in pediatrics — the vast majority is caused by viral conjunctivitis
• Key EM considerations: distinguish benign causes from sight-threatening or systemic diseases
• Neonatal conjunctivitis (ophthalmia neonatorum) requires special attention due to gonococcal and chlamydial etiologies
• Consider non-accidental trauma in any child with unexplained eye findings

Clinical Features

History

• Age of child (neonatal conjunctivitis has specific pathogens by timing)
• Unilateral vs. bilateral
• Duration of symptoms
• Type of discharge: watery (viral, allergic), purulent (bacterial), mucopurulent
• Associated symptoms: fever, URI symptoms, ear pain, photophobia, pain
• Contact with sick individuals (viral conjunctivitis is highly contagious)
• Seasonal pattern (allergic conjunctivitis)
• Trauma history, foreign body exposure
• Contact lens use (in adolescents — corneal ulcer risk)
• Neonatal: maternal STI history, prophylaxis received

Physical Exam

• Visual acuity (age-appropriate testing) — decreased acuity is a red flag
• Pupillary exam
• Extraocular movements
• Pattern of injection: diffuse (conjunctivitis), ciliary flush/limbal injection (iritis, glaucoma)
• Type of discharge
• Lid swelling, chemosis
• Corneal clarity (cloudy cornea = concerning for keratitis or glaucoma)
• Fluorescein staining (corneal abrasion, dendrites of herpes keratitis)
• Preauricular lymphadenopathy (viral conjunctivitis, chlamydia)

Red Flags

• Neonatal purulent discharge (gonococcal ophthalmia — can perforate cornea within hours)
• Decreased visual acuity
• Photophobia + pain (iritis, keratitis)
• Cloudy cornea (glaucoma, keratitis)
• Fixed/irregular pupil (iritis, glaucoma)
• Periorbital swelling with restricted eye movements (orbital cellulitis)
• Dendritic pattern on fluorescein (herpes keratitis — do NOT use steroids)
• Hypopyon (layered white cells in anterior chamber — endophthalmitis, severe iritis)

Neonatal Conjunctivitis by Timing

• Day 1: chemical conjunctivitis (from erythromycin prophylaxis) — self-limited
• Day 2-5: Neisseria gonorrhoeae — emergent, can rapidly perforate
• Day 5-14: Chlamydia trachomatis — most common infectious cause of neonatal conjunctivitis
• Day 6-14: Herpes simplex virus — vesicles, keratoconjunctivitis

Differential Diagnosis

Infectious

• Viral conjunctivitis (adenovirus most common — bilateral watery discharge, preauricular LAD)
• Bacterial conjunctivitis (purulent discharge, H. flu, S. pneumo, Moraxella)
• Gonococcal ophthalmia neonatorum (hyperacute, profuse purulent discharge in neonate)
• Chlamydial conjunctivitis (neonate or sexually active adolescent)
• Herpes keratitis (dendritic ulcer on fluorescein)
• Corneal ulcer (contact lens users)
• Orbital cellulitis (lid swelling, proptosis, restricted EOM)
• Preseptal cellulitis (lid swelling, but normal EOM and vision)

Non-Infectious

• Corneal abrasion and foreign body (tearing, pain, fluorescein uptake)
• Allergic conjunctivitis (bilateral itching, watery, seasonal)
• Chemical/irritant exposure
• Iritis/uveitis (photophobia, pain, ciliary flush)
• Congenital/infantile glaucoma (epiphora, photophobia, cloudy/enlarged cornea)
• Kawasaki disease (bilateral non-exudative conjunctivitis with other features)
• Subconjunctival hemorrhage (traumatic or spontaneous — benign)
• Non-accidental trauma (unexplained subconjunctival hemorrhage, retinal hemorrhages)

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses
^^Critical diagnoses

Bilateral red eyes

• Painful
  • Caustic keratoconjunctivitis
  • Ocular foreign body
  • Orbital trauma
  • Contact lens problems
  • Conjunctivitis
  • Blepharitis
  • Allergic reaction
  • Thyroid disease
  • Carotid-cavernous fistula
• Painless
  • Conjunctivitis
  • Blepharitis
  • Allergic reaction
  • Thyroid disease

Evaluation

Bedside

• Visual acuity (age-appropriate)
• Fluorescein exam with Wood's lamp or slit lamp: rule out corneal abrasion, dendrites (herpes keratitis), corneal ulcer
• Pupillary exam
• IOP measurement if concern for glaucoma (tonometry)

Laboratory/Cultures

• Not routinely needed for typical viral or bacterial conjunctivitis
• Neonatal conjunctivitis: Gram stain and culture of discharge (specifically request for N. gonorrhoeae and Chlamydia), chlamydia NAAT
• Culture if: neonatal, severe/hyperacute, not responding to empiric therapy, suspected gonococcal

Management

Viral Conjunctivitis (Most Common)

• Supportive care: cool compresses, artificial tears
• Highly contagious — hand hygiene education, avoid sharing towels
• No antibiotics needed (self-limited in 1-2 weeks)
• Consider erythromycin ointment if unable to distinguish from bacterial

Bacterial Conjunctivitis

• Topical antibiotic drops or ointment: erythromycin ointment, polymyxin B-trimethoprim drops
• Ointment preferred in younger children (easier to apply)

Neonatal Conjunctivitis

• Gonococcal: emergent — ceftriaxone 25-50 mg/kg IV/IM (max 125mg) single dose; frequent saline irrigation; ophthalmology consultation
• Chlamydial: oral erythromycin 50 mg/kg/day divided QID x 14 days (topical alone insufficient — risk of chlamydial pneumonia)
• HSV: IV acyclovir, ophthalmology consultation

Herpes Keratitis

• Ophthalmology referral — do NOT prescribe topical corticosteroids (worsens herpes keratitis)
• Topical antivirals (trifluridine, ganciclovir gel)
• See Herpes keratitis

Other

• Allergic: topical antihistamine/mast cell stabilizer drops, cool compresses, oral antihistamines
• Corneal abrasion: topical antibiotics, pain management (see Corneal abrasion and foreign body)
• Iritis: ophthalmology referral, cycloplegics for pain
• Orbital cellulitis: IV antibiotics, CT orbits, ophthalmology/ENT consultation (see Orbital cellulitis)

Disposition

Emergent Ophthalmology Consultation

• Gonococcal ophthalmia neonatorum
• Herpes keratitis
• Corneal ulcer
• Suspected orbital cellulitis
• Congenital glaucoma

Discharge (Most Patients)

• Viral conjunctivitis with return precautions
• Mild bacterial conjunctivitis with topical antibiotics
• Corneal abrasion with close follow-up
• Allergic conjunctivitis
• Return precautions: worsening redness, increased pain, decreased vision, sensitivity to light, swelling around the eye, high fever

See Also

Eye Algorithms

• Red eye
  • Bilateral red eyes
  • Unilateral red eye
  • Red eye (by symptoms)
  • Red eye (peds)
    • Neonatal conjunctivitis
• Periorbital swelling
• Acute vision loss (noninflamed)
• Acute onset flashers and floaters
• Painful eyes with normal exam
• Neonatal eye problems
• Conjunctivitis
• Neonatal conjunctivitis
• Periorbital vs Orbital Cellulitis
• Herpes keratitis
• Corneal abrasion and foreign body