PEM Playbook – Conjunctivitis

Originally published at Pediatric Emergency Playbook on December 1, 2020 – Visit to listen to accompanying podcast. Reposted with permission.

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Straightforward, until it’s not — know when to treat, when to test, and when to pull out all the stops…

 

Neonatal Conjunctivitis

Within 24 hours of birthchemical.

1-2 days of birthgonorrheal.

1-2 weeks of birth, chlamydial.

These of course are general timelines, and there is much overlap; assume gonorrhea and rule-out sepsis in the neonate with conjunctivitis until proven otherwise.  [Explanation, nuance, and strategy in Audio]

Gonococcal conjunctivitis in a neonate.
Tigchelaar H, Kannikeswaran N, Kamat DM. Gonococcal conjunctivitis. Consultant for Pediatricians. 2008;7(6):241-24

General Tip

In infants, toddlers, and young children, assume bacterial and treat.  Signs and symptoms are unreliable to distinguish viral from bacterial.

General Tip

In children: more likely bacterial.

In adults: more likely viral.

Typical Bacterial Conjunctivitis in a Toddler.
Chawla R, Kellner JD, Astle WF. Acute infectious conjunctivitis in childhood. Paediatr Child Health. 2001;6(6):329-335. doi:10.1093/pch/6.6.329
Typical Viral Conjunctivitis.
Chawla R, Kellner JD, Astle WF. Acute infectious conjunctivitis in childhood. Paediatr Child Health. 2001;6(6):329-335. doi:10.1093/pch/6.6.329

General Tip

Chronic allergic conjunctivitis may need ophthalmology referral: vernal conjunctivitis and giant papillae.

Vernal conjunctivitis with giant papillae.
Kraus CL. Vernal Keratoconjunctivitis. American Academy of Ophthalmology.

General Tip

Mostly conjunctivitis is a clinical diagnosis and no testing is required.

Exception: Beware of Hyperacute Conjunctivitis in any age — think gonococcus and aggressive empiric treatment and testing.

Comparison: Bacterial v Hyperacute Bacterial v Viral.
Azari AA et al. Conjunctivitis: A Systematic Review of Diagnosis and Treatment. JAMA. 2013 Oct 23;310(16):1721-9
Pseudomembranous Conjunctivitis as seen in Chlamydia.
Sahay P, Nair S, Maharana PK, et al. Pseudomembranous conjunctivitis: unveil the curtain. BMJ Case Reports CP 2019;12:e228538.
Proposed Algorithm for Adolescents and Adults.
Azari AA et al. Conjunctivitis: A Systematic Review of Diagnosis and Treatment. JAMA. 2013 Oct 23;310(16):1721-9

Selected References

Azari AA et al. Conjunctivitis: A Systematic Review of Diagnosis and Treatment. JAMA. 2013 Oct 23;310(16):1721-9

Chawla R, Kellner JD, Astle WF. Acute infectious conjunctivitis in childhood. Paediatr Child Health. 2001;6(6):329-335.

Ho D, Lim S, Kim Teck Y. Pseudomembranous Conjunctivitis: A Possible Conjunctival Foreign Body Aetiology. Cureus. 2020;12(5):e8176.

Kraus CL. Vernal Keratoconjunctivitis. American Academy of Ophthalmology.

Makker K, Nassar GN, Kaufman EJ. Neonatal Conjunctivitis. StatPearls Publishing; 2020 Jan.

Matejcek A, Goldman RD. Treatment and prevention of ophthalmia neonatorum. Can Fam Physician. 2013;59(11):1187-1190.

Perez Y, Patel BC, Mendez MD. Nasolacrimal Duct Obstruction. StatPearls Publishing; 2020 Jan.

Recine H et al. Ocular Emergencies in Children: Demographics, Origin, Symptoms, and Most Frequent Diagnoses. Journal of Ophthalmology. 2020.

Rietveld RP, ter Riet G, Bindels PJ, Schellevis FG, van Weert HC. Do general practitioners adhere to the guideline on infectious conjunctivitis? Results of the Second Dutch National Survey of General Practice. BMC Fam Pract. 2007 Sep 16;8:54.

Sahay P, Nair S, Maharana PK, et al. Pseudomembranous conjunctivitis: unveil the curtain. BMJ Case Reports CP 2019;12:e228538.

Solmaz N et al. Primary Conjunctival Tuberculosis. Turk J Ophthalmol 2018;48:39-41

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