Eye Discharge

The most common cause of eye discharge in pediatric patients is viral conjunctivitis. Many clinicians treat viral conjunctivitis as bacterial conjunctivitis because the similarities in history and physical examination make a definitive diagnosis difficult without a culture, which is expensive and may take 2–3 days. Additionally, small children frequently acquire superinfection and contagion by repeated rubbing of the eyes, justifying antibiotic prophylaxis.

Differential Diagnosis

• Blocked tear duct (nasolacrimal duct stenosis)
  –Occurs in 5–10% of normal newborns
  –Tearing and mucus discharge secreted to lubricate the eye accumulate at the medial canthus because it cannot drain through the fused nasolacrimal duct
  –Frequently the discharge is mistaken for pus; also superinfection and conjunctivitis may occur

• Allergic conjunctivitis
  –Mucoid discharge, injection, and pruritus are the typical symptoms
  –Symptoms may be seasonal or perennial, depending on the allergy (ragweed vs dust)
  –Patients frequently have a history of other atopic disease (e.g., allergic rhinitis, asthma, or eczema)

• Viral conjunctivitis
  –Adenovirus: Frequently associated with fever and pharyngitis, very contagious, and may have preauricular nodes
  –Human herpesvirus: HSV1 may cause conjunctivitis, frequently accompanied by herpetic lesions on the face

• Bacterial conjunctivitis
  –Staphylococcus aureus
  –Haemophilus influenzae (non-typable): May cause simultaneous otitis, should be treated for penicillin-resistant organisms
  –Chlamydia trachomatis and Neisseria gonorrhoeae (newborn): Suspect in an infant of a mother with a history of inadequate prenatal care or any sexually transmitted disease; physical signs are usually impressive; C. trachomatis may also cause pneumonia; must be treated systemically

• Foreign body
  –Patient usually relates a history consistent with FB
• Corneal abrasion
  –May manifest as an FB sensation
• Glaucoma
  –May be congenital, acquired, or syndrome-associated; in young children it presents with tearing, progressive enlargement of the eye, and corneal changes

Workup and Diagnosis

• History
  –Onset, duration, character, unilateral or bilateral
  –Painful or painless
  –Presence or absence of FB sensation (corneal abrasion or actual foreign body)
  –Presence or absence of pruritus
  –Presence or absence of allergic/atopic symptoms
  –History of contact with person with eye discharge
  –History of trauma to the eye

• Physical exam
  –Inspection of the sclera, conjunctiva, lids, and lashes
  –Erythema, edema, and injection may occur with allergy, infection, FB, or trauma
  –Bacterial infections are associated with systemic symptoms such as fever, are more likely to be unilateral, and have purulent discharge
  –Viral infections are more likely to be bilateral, have more mucoid discharge, and the conjunctiva may have a granular appearance
  –Fluorescein examination for corneal abrasion or FB
  –Herpetic lesions have a spidery appearance
  –Slit-lamp examination to detect changes consistent with uveitis/iritis
• Studies
  –MRI may be indicated for suspected FB; however, it is contraindicated if FB may be metallic

Treatment

• Blocked tear duct: Supportive care with massage and warm compresses; surgical probe or stent may be indicated if stenosis persists beyond 9 months of age
• Allergic conjunctivitis: Intraocular anti-inflammatory agents, antihistamines, or mast cell stabilizers
• Viral conjunctivitis: Supportive care for most routine viral infections; herpetic lesions should be referred to an ophthalmologist and must be treated with systemic acyclovir and intraocular steroids
• Bacterial conjunctivitis: Usual pathogens are susceptible to polysporin/trimethoprim, may also be treated with quinolones; newborn STD pathogens must be treated systemically
  
• Foreign body: Removal may require referral to an ophthalmologist
• Corneal abrasion: Routine antibiotics and patching are no longer recommended, but may be used in more severe cases

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Wide-set eyes

• Back to symptom: Wide-set eyes: Introduction (review 411 causes)
• Next Book Extract About Wide-set eyes: EYE PAIN (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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