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 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 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 to weeks Patients with symptoms that appear to be getting worse or persisting for longer than 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 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 ... 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%... 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... 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