Pediatric emergency medicine trisk 1013

FIGURE 123.10 Nonseasonal acute allergic conjunctivitis. Acutely swollen conjunctiva
(chemosis) is indicated (arrow ).

FIGURE 123.11 Fluorescein staining pattern of herpes simplex virus corneal infection. Eye is
illuminated with blue light to demonstrate yellow/green branching fluorescein staining pattern
of herpetic dendrite.

Management. Neonatal purulent conjunctivitis should be treated as gonorrheal
conjunctivitis until proven otherwise. If a Gram stain of the purulent discharge


demonstrates gram-negative diplococci, the patient should be hospitalized for
parenteral ceftriaxone or ceftazidime, while awaiting results of cultures.
Ophthalmology consultation is indicated. Hourly ocular lavage with saline should
be performed to decrease bacterial burden. Topical treatment is insufficient for
both gonorrhea and chlamydia. The neonate should be tested for chlamydial
conjunctivitis as this is treated with a 14-day course of oral erythromycin. Sexual
abuse should be considered for postneonatal or prepubertal children with
gonorrhea or chlamydia conjunctivitis, although there is evidence that nonsexual
transmission to these sites may occur (unlike infection of the vagina, urethra,
anus, or throat).
Outside the neonatal period, bacterial conjunctivitis can be treated with
inexpensive nontoxic topical antimicrobials such as erythromycin or
trimethoprim/polymyxin B. Table 123.2 provides some guidelines regarding the
prescription and use of ophthalmic medications. The table also includes
medications that should be avoided because of problems with ocular toxicity,
systemic toxicity, undesirable selection of resistant organisms, or the need for
ophthalmology consultation with their use. In the first 3 months of life, topical
aminoglycosides might be a reasonable choice because gram-negative and enteric
organisms are more common. In older children, without strong evidence to
suspect such organisms, aminoglycosides should be avoided because they may be

toxic to the corneal epithelium and may select for resistant organisms. Ointment
may be preferred to drops in pediatric patients in whom instillation of medication
is difficult. Ophthalmic ointments are applied by placing a strip of ointment along
the conjunctiva of the lower lid without touching the tip of the applicator to the
eye. Antibiotic ointment doses are usually twice daily whereas drops are usually
four times daily. Ultimately the choice of ointment versus drops may be a matter
of patient or parental preference. Improvement should be seen within 2 days and
children can return to school within 24 hours of treatment. Corticosteroids should
be avoided in the treatment of conjunctivitis as they can be devastating in the
presence of herpetic infections. Treatment of herpetic conjunctivitis typically
involves a topic antiviral and ophthalmology consultation.


TABLE 123.2
PEDIATRIC EMERGENCY DEPARTMENT OPHTHALMIC DRUG
GUIDELINES
Use

Avoid

Dilating drops
Phenylephrine 2.5%
Tropicamide 1%
Cyclopentolate 1%

Scopolamine
Atropine
Homatropine
Cyclopentolate 2%

Antibiotics
Bacitracin ointment
Neomycin
Erythromycin ointment
Sulfacetamide
Polysporin drops or ointment
Aminoglycosides (except
neonate)
Polytrim (trimethoprim/ polymyxin B) drops
Lubricants
Artificial tear drops or ointment
Vasoconstrictors/antihistamines
Naphazoline/antazoline
Diagnostic agents
Topical fluorescein
Anesthetic agents
Proparacaine, tetracaine
The ER clinicians should avoid the use/prescription of any of the following
without ophthalmology consultation:
ANTIVIRALS, MIOTICS, STEROIDS, a and ANTIGLAUCOMA AGENTS.
a Including

steroid-containing preparations, such as combination antibiotic-steroids.

There is no evidence to support the routine use of antimicrobials or antivirals in
the majority of viral conjunctivitis cases. Contrary to popular belief, “secondary
bacterial infection” is not a clinically significant problem in immunocompetent
children. Rather, these patients can be treated symptomatically with cool
compresses and over-the-counter lubricating agents (e.g., artificial tears) which

can be used as often as hourly. Depending on the virus, symptoms may last for up
to 2 to 3 weeks. Patients with symptoms that appear to be getting worse or
persisting for longer than 1 week may benefit from ophthalmology consultation.
If a herpetic ocular infection is suspected, urgent ophthalmologic consultation is
required. Skin lesions not involving the eye lid margins or without any
conjunctival injection do not require ophthalmology consultation.
Allergic conjunctivitis is soothed by topical lubricants and cool compresses.
The combination vasoconstrictor/antihistamine preparations listed in Table 123.2
may also be prescribed. Patients with recurrent allergic conjunctivitis, atopy, or
asthma may benefit from long-term or seasonal topical mast cell stabilizers. A
host of antiallergy eye drops are now available, the review of which is beyond the
scope of this chapter. Topical glucocorticoids should not be prescribed by the ED
clinician without consultation with an ophthalmologist. Inappropriate use of
steroids may lead to glaucoma, cataracts, and can promote herpes virus
replication and corneal scarring. Finally, any patient who wears contact lenses
and has conjunctivitis, should remove their contact lenses immediately and be
referred for ophthalmology consultation. No topical drugs should be prescribed in
these cases without the supervision and consultation of an ophthalmologist.

Ocular Chemical Injury
CLINICAL PEARLS AND PITFALLS
Alkali ocular burns are more common and typically more severe than
acid burns.
Ocular irrigation involves continuous irrigation with saline or water (for
at least 20 minutes) until a neutral pH is achieved in the eye.
Ocular irrigation should never be delayed for sedation, examination, or
consultation purposes.
Current Evidence
Pediatric ocular chemical exposures often occur in preschool-aged children due to

accidental contact with household products such as organic solvents and other
cleaning agents. Chemical burns to the eye can cause extensive damage to the
ocular surface epithelium and cornea leading to blindness. The severity of
damage depends on the agent involved, the duration of contact, and the depth of
penetration. Acidic substances can cause significant damage on impact but
ultimately produce a “coagulum” that can create a barrier to further ocular