John is a 15-year-old freshman in high school. He played football in the fall, and wrestled in the winter. He is a solid B student, and an all-around neat kid. This spring he wasn’t involved in any sports and seemed to enjoy blending in with the rest of the freshman class. His mom was particularly concerned when she got a phone call from the school nurse. “I would like you to pick John up from school because I’m afraid that he might have Pink Eye,” the nurse said. “Both of his eyes are red and watery, and he can’t stop rubbing them...or his nose,” she added.
Mom got right in the car and hurried to the school. When she arrived the nurse told John to go ahead as she wanted to talk to mom. The nurse pulled her aside and in a soft voice, almost a whisper, she said, “I am a bit worried about your boy. For the past few weeks I have noticed that his eyes are blood-shot and red, and he is constantly rubbing his nose or eyes. Have you ever thought that he might be taking drugs?”
Anna is an 18-month-old day care toddler who was just fine until two days age. When her mother woke her up one morning she noticed that Anna’s left eye was “goopy” with a yellowish matter that stuck her eyelashes together. After a warm bath the child looked much better. Other than a slight redness to the left eye she was her normal self. There was no fever and mom thought it was safe to take her to day care. Mom got a phone call at 11:30 a.m. requesting her to pick Anna up because both eyes were blood-shot and full of discharge.
JP is in the fourth grade. He, along with just about every other family member has been fighting off a cold for the past week. He wakes up with a slightly sore throat, nasal congestion and a cough. The cough is much worse at night, to the point of keeping him awake. But it is not a deep chesty cough. It probably is from the postnasal drip, causing it to be worse when he lays down. There has been no fever, and actually he does not feel that bad. But for the past two days his eyes have been red and blood-shot. There has not been much discharge. In the morning it is as if he has a lot of dried sleep in the corner of his eyes.
All three of these patients have a form of “pink eye”, or conjunctivitis. In general, there are three main types in pediatrics: allergic, viral and bacterial. John clearly had an allergic type of conjunctivitis and was certainly not abusing drugs. His red eyes occurred seasonally. After further questioning of mom and review of John’s medical chart it became more apparent. He had been seen at least once in each of the past three Spring months for conjunctivitis.
In allergic conjunctivitis there is usually a seasonal component involved. The course of the red eyes can be prolonged or intermittent. Although the eyes are red there is very little discharge. It is not uncommon for both eyes and the nose to itch. This is in no way infectious or contagious. It can be successfully treated with topical anti-histamine eye drops. This was done for John, and he had a tremendous response. He stayed on the drops until August.
The other two causes of conjunctivitis in the pediatric patient are bacterial and viral infections. Bacterial conjunctivitis is by far the most common of all three, accounting for up to 70-80 percent of all cases. Generally speaking, bacterial conjunctivitis affects both eyes but often begins in one eye and quickly spreads to the other. It produces a heavy and thick muco-purulent discharge that mats the eyelashes making them stick together. It also causes obvious inflammatory changes to the underside of the eyelids. Bacterial conjunctivitis is highly contagious and, if suspected, should be treated with antibiotic drops immediately. Good hand washing is critical in preventing the spread of the disease. If more than one family member comes down with conjunctivitis, have them use their own antibiotic drops and discard them when the treatment is done. If left untreated, bacterial conjunctivitis will finally resolve on it’s own after 8-10 days...but that is 8-10 days that the patient is highly contagious to others.
Viral conjunctivitis is not as aggressive as bacterial. It quite often develops while the patient has an intercurrent upper respiratory tract infection. Just as in the bacterial form, it may start in one eye and then spread to the other eye. Although the eyes are red and blood-shot, there is minimal discharge. In some cases there may be an enlarged lymph node around the ear. The lymph node enlargement is reported in 20 percent of all viral cases. If one is absolutely certain that they are dealing with a viral infection and not bacterial, conservative measures such as artificial tears or cool compresses are all that are needed. Quite often, however, it is not so readily obvious. Studies have shown that in bacterial conjunctivitis, once the antibiotic drops have been started, the patient may safely return to school and not be at risk to infect others. Certainly the decision to treat or not must be made on an individual basis. But most physicians would elect to error on the safe side and treat with antibiotics if there were ANY question.
In the cases of Anna and JP both were treated with antibiotic drops. Anna’s case was fairly classic for bacterial conjunctivitis and it was easy to decide to treat her. JP’s case, however, was not so clear cut. Superficially, it looked like he had a viral type of infection. But there was no way to prove beyond a reasonable doubt that the viral infection had not become secondarily infected, especially since he had been sick for over a week. Both were treated with antibiotic drops, and both reported complete resolution of their pink eyes within two days.
When a patient is being evaluated for red eye, it is critical that the physician rules out other potentially serious eye problems such as a foreign body, scratched cornea, blunt eye trauma or a herpes infection of the eye. This can be accomplished with a detailed history and a thorough physical exam.
Some advice that was passed on to me by an ophthalmologist in regard to getting eye drops into the eyes of a squeamish or frightened child: have the child lay flat on his back and shut the eyes as tight as he can. Put the drops of medicine in the corner of the eye near the nose telling him to keep those eyes shut! On the count of three, tell him to open his eyes as big as he can. That will deliver the medication to the eyes immediately. It is absolutely futile to sit there trying to pry the eyelids open while he is squirming and fighting you the whole way. It can also be dangerous.