Approach to a Child With Eye Discharge and Swelling

Introduction

Conjunctivitis is a common infection especially among children under five. Children with conjunctivitis must be kept home from school or day care until the discharge from their eyes has stopped. This will prevent the spread of infection to other children. The incidence of conjunctivitis decreases with age.

Conjunctivitis leads to:

• Eye irritation and redness
• Excessive tears in the eyes
• A discharge with pus
• Swelling of the eyelids
• Photophobia

History Taking

Age
Age of the child is important in determining the etiology of conjuctivitis. In newborns typical cause is chemical, chalmyadial or bacterial. In older children bacteria , viruses and allergies are more likely causes.

Onset of Symptoms
Time of onset is especially important in the neonatal period. With chemical conjunctivitis inflammation begins a few hours after drops have been placed and lasts for 24 to 36 hrs. Gonococccol conjunctivitis develops between 2 and 5 days of life.

Characteristic of discharge

• Viral conjunctivitis usually causes watery or serous discharge.
• Bacteria causes purulent or mucopurulent discharges.
• Allergies produce serous or mucoid discharge often very stringy.

Associated Symptoms
Viral conjunctivitis is often associated with upper respiratory symptoms or other systemic complains like pharyngitis . Preauricular adenopathy and rashes may also be present. With vesicles or corneal ulceration HSV must be rules out. Pain on movement of the eyes is never normal and orbital cellulitis should be ruled out.

Physical Examination
A complete physical examination should always be done to rule out signs of systmic infection. Particular attention should be payed on oropharynx and ear.

Ophthalmic Examination
Check both eyes for swelling of eyelids, redness of conjunctiva, movements and associated pain if any, bulging ( proptosis ). Note any discharge, check vision and pupil.

Differential Diagnosis

• Keratitis : Inflammation of the cornea.
• Uveitis: Inflammation of the iris and ciliary muscle typically caused by an autoimmune response seen in juvenile rheumatoid arthritis.
• Scleritis: Focal or diffuse scleral inflammation
• Episcleritis: Focal inflammation of the deep subconjunctivial tissues similar to scleritis
• Foreign body:Usually there is a history of exposure and the object may be visible
• Periorbital cellulitis: Infection of the anterior eye and eyelid
• Orbital cellulitis: Caused by same organisms reponsible for sinusitis but it involves the back of the eye and is a serious condition

Workup
Diagnosis is usually based on history and physical examination. Gram stain and culture are obtained in neonates to rule out gonococcal and chlamydial disease.

CT scan may be useful in patients in whom orbital cellulitis is suspected .

Treatment

Non pharmacological Measures
Apply warm or cool compresses on eye for comfort

Pharmacological measures

Antibiotics: uses to prevent complications of gonococcal , chlamydial and herpes conjunctivitis in neonates.
Gonococal: Aqueous Penicillin G or cefriaxone for 1 – 7 days.
Chlamydial: Oral erythromycin for 14 days

Topical Antibiotics: Erythromycin , tetracycline or polymyxin B solution helps early recovery of symptoms in bacterial conjunctivitis.

Preventive Measures

• Good hand washing to decrease transmission
• Avoidance of allergen or irritant if allergic
• Neonatal prophylaxis with 1% Silver nitrate, 0.5% erythromycin or 1% tetracycline.