Paediatric medicine - Eye infections in children

Presentation of conjunctivitis varies according to the age of the child, explains Dr Alaa Attawan.

Swab conjunctiva for immediate Gram staining, immunofluorescent staining, culture and sensitivity and viral PCR (Photograph: SPL)
Swab conjunctiva for immediate Gram staining, immunofluorescent staining, culture and sensitivity and viral PCR (Photograph: SPL)

Ophthalmic infections occur frequently in both neonates and children and they can be of high ocular and systemic morbidity.

This article discusses the most common ocular infections in children and how they can be managed.

Conjunctivitis
Acute bacterial conjunctivitis is an acute bacterial unilateral or bilateral infection caused by many bacteria such as the gonococcus (Neisseria gonorrhoeae), chlamydia and streptococcus species.

Causative agents vary with age; for example, gonorrhoea is the commonest cause in the first three days after birth and chlamydia is a common cause after the first week of life.

Ophthalmia neonatorum is a term used to describe acute bacterial conjunctivitis occurring within the first month of life. This is an ophthalmic emergency and patients should be referred immediately.

Presentation varies according to the age of the child.Hyperacute ophthalmia neonatorum occurs within one to three days of birth and presents with severe purulent discharge, lid oedema, chemosis and pseudomembrane or membrane formation. The most common causative bacterium is gonococcus.

Subacute ophthalmia neonatorum is within four to 28 days of birth and presents with mucopurulent discharge, preseptal cellulitis and systemic features such as rhinitis, otitis or pneumonitis.

This is the most common type of neonatal conjunctivitis and the most common causative organism is chlamydia.

Acute onset of herpes simplex virus neonatal conjunctivitis is within one to 14 days of birth. Although it is an uncommon infection, it may cause serious ocular and systemic morbidity.

It is characterised by vesicular lid lesion with mucoid discharge and red eye. Systemic features include hepatosplenomegaly, jaundice, pneumonitis, and meningoencephalitis.

Management of conjunctivitis
The management strategies for the different types of neonatal conjunctivitis are alike and each should be dealt with as an emergency:

  • Conjunctival swabs for immediate Gram stain, immunofluorescent staining, culture and sensitivity and viral PCR.
  • Frequent irrigation of discharge with saline solution.
  • Discuss with paediatrician for admission.
  • For gonococcal infection, prescribe IV ceftriaxone 50mg/kg once daily for one week.
  • For chlamydia give oral erythromycin 25mg/kg twice daily for two weeks.
  • For herpetic infection give topical aciclovir eye ointment five times daily for one week, with or without oral aciclovir 10mg/kg three times daily for 10 days. Discuss with an ophthalmologist to exclude corneal ulcer (high risk of perforation) especially in gonococcal infection.
  • After counselling, refer parents to genitourinary physician.

Conjunctivitis in older children behaves in a similar manner to adult infections and can be dealt with accordingly.

Stye
A stye (hordeolum) is an acute, localised abscess situated on the eyelid. It is usually caused by a staphylococcal infection. There are two types of stye: external and internal.

The external stye (also known as an external hordeolum or a common stye) appears along the edge of the eyelid and is caused by an infection of an eyelash follicle and/or associated sebaceous (Zeis) or aprocrine (Moll) glands.

The internal stye (also known as an internal hordeolum, meibomian stye or acute meibomianitis) occurs on the conjunctival surface of the eyelid. It is caused by an infection of the meibomian glands situated on the interior eyelid surface.

Children present with acute painful localised eyelid swelling over a few days. Blepharitis and rosacea are common associations and risk factors for its development. Visual acuity is unaffected.

Management of styes
Styes are self-limiting and rarely cause serious complications. Consider eyelash epilation for painful external sties.

Apply a warm compress to the affected eye for five to 10 minutes, repeating three to four times daily until the stye drains or resolves. Use of topical antibiotics is controversial because there is no evidence to suggest that they help unless there is associated preseptal cellulitis.

Treat associated blepharitis by bathing the eyelids with warm saline. Referral to an ophthalmologist is advised if there is no response to treatment.

Chalazion
Chalazion (meibomian cyst) is a chronic inflammatory granuloma caused by meibomian gland obstruction and presents as a lump on the interior surface of the eyelid. It is painless - unlike an acute internal stye, which is painful.

Management includes warm compresses and considering referral to an ophthalmologist for incision and drainage.

Nasolacrimal duct infection
Children with delayed canalisation of the nasolacrimal duct present with epiphora and recurrent discharge and this group of patients are advised to continuously massage the side of the nose to enhance canalisation of the nasolacrimal duct until the age of 12-18 months.

Referral to an ophthalmologist is indicated for probing and syringing of the nasolacrimal duct before the age of two years if symptoms persist.

Acute dacryocystitis
This is an acute staphylococcal or streptococcal infection of the incompletely canalised nasolacrimal duct in children.

Symptoms of acute dacryocystitis include worsening epiphora, fever, a tender erythematous lump inferior to the medial canthus, pus and possibly preseptal cellulitis.

Any expressed discharge should be sent to microbiology for Gram staining, culture and sensitivity. Treat with broad spectrum systemic antibiotics and warm compresses and refer to an ophthalmologist for further management.

Orbital and preseptal cellulitis
It is crucial to clinically differentiate between orbital and preseptal cellulitis in children as their management and outcome differs (see b ox).

  • Dr Attawan is a specialist registrar in ophthalmology at Royal Victoria Infirmary, Newcastle.
Cellulitis risk factors
  • Male/female
  • Pre-existing sinusitis (mainly ethmoidal)
  • Pre-exisiting dacryocystitis
  • Pre-exisiting stye
  • Recent trauma

 

Presentation of orbital and preseptal cellulitis
Orbital cellulitisPreseptal cellulitis
GeneralFever, malaise, swollen lid and orbitFever, malaise, swollen lid and orbit
ProptosisPresentAbsent
Ocular movementPainful + restrictedNormal
Visual acuityReducedNormal
Colour visionReducedNormal
ComplicationMore common meningitis,
cerebral abscess, optic
neuropathy
Unlikely

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