Bacterial Conjunctivitis in Children and Adolescents
The most common causes of bacterial conjunctivitis in school-aged children are Streptococcus pneumoniae, Haemophilus species, Staphylococcus aureus, and Moraxella. The incidence of infection from Haemophilus has decreased because of widespread immunization, whereas the incidence of methicillin-resistant S aureus (MRSA) conjunctivitis has increased. More severe forms of bacterial conjunctivitis accompanied by copious discharge suggest infection with more virulent organisms, including N gonorrhoeae and N meningitidis.
Diagnosis is by clinical presentation. Culture to identify the offending agent is usually not necessary in mild cases but should be performed in severe cases. If the infection is untreated, symptoms are self-limited but may last up to 2 weeks. A broad-spectrum topical ophthalmic drop or ointment should shorten the course to a few days. Topical medications that are usually effective include polymyxin combinations, aminoglycosides, erythromycin, bacitracin, fluoroquinolones, and azithromycin. Fluoroquinolones may be considerably more expensive than other medications and may increase the risk of promoting drug-resistant organisms. Patients with N meningitidis conjunctivitis, and others exposed to these patients, require systemic treatment because of the high risk of meningitis.
Parinaud oculoglandular syndrome
Parinaud oculoglandular syndrome (POS) manifests as unilateral granulomatous conjunctivitis associated with preauricular and submandibular lymphadenopathy that can be very marked (Fig 20-3). MRSA conjunctivitis can have a similar presentation. Bartonella henselae, a pleomorphic gram-negative bacillus that is endemic in cats and causes cat-scratch disease, is the most common cause of POS. Other causative organisms include Mycobacterium tuberculosis, Mycobacterium leprae, Francisella tularensis, Yersinia pseudotuberculosis, Treponema pallidum, and C trachomatis. Cat-scratch disease is usually associated with a scratch from a kitten, but a cat bite or even touching the eye with a hand that has been licked by an infected kitten can cause the disease.
Figure 20-3 Parinaud oculoglandular syndrome. A, Marked follicular reaction in the lower fornix. B, Massive enlargement of submandibular lymph node on the affected right side.
(Courtesy of David A. Plager, MD.)
Serologic testing is an effective means of diagnosing POS. Presence of antibodies to B henselae, detected by indirect fluorescent antibody testing or enzyme immunoassay, can confirm a diagnosis of cat-scratch disease. Treatment can be supportive in mild cases of cat-scratch disease because the disease is self-limited. In more severe cases systemic treatment, usually with azithromycin, may be indicated. Appropriate systemic antibiotics are used to treat the other organisms that cause POS.
Two different diseases can be caused by C trachomatis in children and adolescents: trachoma (serotypes A–C) and adult inclusion conjunctivitis (serotypes D–K).
Trachoma is the most common cause of preventable blindness in the world. This disease is uncommon in Europe and the United States, except in areas of the southern United States and on Native American reservations. It is caused by poor hygiene and inadequate sanitation and is spread from eye to eye or by flies or fomites. Clinical manifestations include acute purulent conjunctivitis, a follicular reaction, papillary hypertrophy, vascularization of the cornea, and progressive cicatricial changes of the cornea and conjunctiva. Diagnosis is made by Giemsa stain, cell culture, or polymerase chain reaction. Treatment includes both topical and systemic erythromycin. Tetracycline can be used in children 8 years of age and older.
Adult inclusion conjunctivitis
Adult inclusion conjunctivitis is a sexually transmitted disease that can be found in sexually active adolescents in association with chlamydial urethritis or cervicitis. However, there are nonsexual modes of transmission, including shared eye cosmetics and contaminated swimming pools. Patients present with follicular conjunctivitis, scant mucopurulent discharge, and preauricular lymphadenopathy. There is no membrane formation. This condition can be diagnosed by culture of conjunctival scrapings, polymerase chain reaction, direct fluorescent antibody tests, and enzyme immunoassays. If untreated, inclusion conjunctivitis resolves spontaneously in 6–18 months. The recommended treatment is oral tetracycline, doxycycline, azithromycin, or erythromycin. The clinician should consider whether the patient has been sexually abused, especially if adult inclusion conjunctivitis is found in a young child.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.