Short, guided case covering common 'pink eye' complaints, including some must-not-miss differentials.

1. Children’s Hospital of Pittsburgh
Physician Assistant Curriculum
Created by Sondra Baumcratz, PA-C, August 2019
Topic: Ophthalmic Infections
Learning Objectives:
After reviewing these materials, viewers will be able to:
1. Know how to differentiate neonatal conjunctivitis (which is serious) from
dacyrostenosis/cystitis, (which is not) and understand the management of each.
2. Discuss the diagnosis and treatment of ‘pink eye’ and be able to differentiate when
no antibiotics/topical antibiotics/oral antibiotics are needed.
3. Recognize septal (orbital) and pre-septal cellulitis, and make a management and
contingency plan for each.
Original module developed by S Baumcratz, PA-C. August 2019, revised August 2020. All rights
reserved.
CASE 1: Jessica is a 5 day old infant here for a post-hospital discharge check. Her mom
mentions that she thinks the baby has pink eye, because her right eye is crusted shut in the
mornings.
QUESTION 1: Does crusting always mean pink eye?
• In conjunctival infections, crusting is often present because 1) infection is inflammatory
and inflammatory process tend to seep, and 2) in BACTERIAL infections, there is pus,
which pools in the eye overnight and dries there. But crusting can be present in NON
inflammatory conditions also, if normal tears have a chance to pool and dry. This
happens frequently in infants, due to dacyrostenosis, a narrowing of the tear DUCT at
the medial canthus. This prohibits the tears from draining into the nasopharynx, and
they fall off the lower lid instead. At night, they pool there, and in the am, there’s dried,
crusted discharge that causes concern for conjunctivitis.
• In an infant with dacyrostenosis, the eye will be runny all the time, even while awake; the
drainage will be clear to serous in color; the conjunctivae will be clear. There may or
may not be a palpable thickening of the duct on exam. Treatment is watchful waiting;
most cases self-resolve by a year of age as the child continues to grow. Warm
washcloths can be used to clear the crust, and massage of the duct can be done to
encourage the planes to separate. If there’s still evidence of blockage at a year of age,
refer to ophthalmology for probing.

2. • Occasionally, while you wait, the duct itself becomes inflamed, red, and tender, and may
have some purulent drainage when you massage it. This is dacryocystitis, and
requires topical antibiotics.
TRUE neonatal conjunctivitis (meaning injection of the conjunctivae) has a somewhat wide
differential.
• Irritant conjunctivitis from the drops used for prophylaxis at birth usually has an onset
within 24-48 hours and then resolves within a day or two.
• Vaginal flora to include: chlamydia, gonorrhea, and herpes, as well as normal flora.
• Gonorrhea usually presents within the first 2-4 days, and has swollen lids and purulent
discharge as well as the conjunctivitis. Tx is IV antibiotics, so culture this eye and refer
the baby to the ED. Disseminated disease is common so the baby will need ophthy
consult, and further workup to assess for systemic spread.
• Chlamydia usually presents a few days later, at around day 5-12. It also has
conjunctival redness, lid swelling and purulent discharge. About half of these babies
have pharyngeal and pulmonary seeding also, so culture the eye AND the oropharynx.
Keep in mind that chlamydia is an obligate intracellular organism, so you must get cells
in your sample. Collect from the palpebral conjunctivae. You should also collect a
second swab from the oropharynx to identify OP chlamydia). po abx are needed.
• Herpes has the same sxs: redness, swelling, and +/- pus (it’s viral) but it should be very
painful so the baby may be inconsolable. Suspect this if mom has a hx, even if she was
on appropriate suppression therapy I the third trimester. Fluorescein staining may be
needed to visualize the lesions. This is also an ED referral for 1. ophthalmology consult,
and 2. neuro workup to rule out systemic spread.
NOTE: “Culture” in this sense means two things. It means a regular aerobic culture swab of the
discharge, which should grow normal respiratory/vaginal flora, AND separate swab for the
GC/Chlam. Collect on an Aptima white and send it for DNA amplification. (That’s the same test
used for genital gonorrhea. The container is white because it’s a different source. Please label
tubes, NOT lids.
CASE, continued:
• You continue the history and discover that Jessica was born via cesarean section due to
breech presentation. Mom was routinely tested for STD as per normal OB protocol and
was negative. She says the eye does seem runnier than the other side, now that you
mention it. On exam, the conjunctiva is clear, there are tears in the lower lid, and the
tear duct and nasal bridge don’t appear red or feel hot. There’s no apparent tenderness
on palpation of the duct. You diagnose dacryostenosis.
• You reassure mom that this is a normal variant; explain about the crusting, and what to
look for that would be suspicious for infection, so she can call. Demonstrate the
massage technique. Follow up is as needed or at the next routine well visit, which in this
case is at two weeks of age.
• Be sure to put the diagnosis in the note so whoever sees her next can check it.

3. CASE 2: Jessica returns:
You next see Jessica for a sick visit at 9 months of age. She is here with her 6 year-old brother
today. Jessica has had 2 days of cold sxs. There was fever initially which is now resolved.
She now c/o rhinorrhea, sneezing, cough, and glassy eyes. Jake has an isolated unilateral red
eye with no other sxs that appeared 3 days ago. He was sent home from school.
On exam, neither child is febrile. Jessica has obvious conjunctival redness, some swelling of
the lids, and watery discharge. There is green-yellow mucus in the nose. The pharynx is red,
and the lungs are clear. Jake has an injected right eye, with watery discharge. There is some
prominence to the preauricular lymph node on that side. He is rubbing the eye. He has no other
findings.
QUESTION: Do these pink eyes need drops?
• No. Jessica’s is clearly part of a viral URI, without purulent drainage or fever. There is
no treatment for Viral URI. Jake’s is also likely viral; it’s unilateral with watery discharge,
has a pre-auricular node, and he has a sick contact. Both of these conditions will self-
resolve.
• Give good return instructions: if pus develops, if fever develops, if they start complaining
of pain or headache, or if the pink eyes last longer than a week.
• Children should be able to return to school or child care when the eye discharge either
has resolved completely or is visible only on morning waking and the discomfort has
subsided so the child is not repeatedly touching or rubbing his or her eyes throughout
the day.
• https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-
childcare/Documents/M3_Pinkeye.pdf
CASE 2, continued
Jessica returns 10 days later. Mom says her cold was unconcerning until yesterday when she
developed fever to 101 at home, and had a worsening of her nasal discharge. She seems
fussier than usual, and interrupts bottle feedings to cry.
QUESTION: What’s changed? What’s to worry about here?
• Fever and worsening sxs around the time you expect something to be going AWAY is
often an indicator that there’s now a secondary bacterial infection. Her nasal discharge
has worsened, indicating the source of the overgrowth. Pain with swallowing is often
due to a sore throat or ear pain. In this age child, I’d be more concerned about an otitis
than a tonsillitis, but look at both.

4. CASE 2, continued
The (RECTAL!) temp is 100.9. There is now purulent drainage from bilateral eyes in addition to
bilateral conjunctivitis. There are bilateral otitis media. The tonsils and pharynx are normal and
the lungs are clear.
DISCUSSION:
• This is otitis-conjunctivitis syndrome. It is important to check the ears for two reasons.
First, treating the eyes without the ears won’t fix the underlying problem in this case.
Second, this particular constellation of sxs implies a Haemophilus Influenza infection,
which requires a beta-lactam antibiotic as opposed to plain amoxicillin.
• Treat this with Augmentin at a dose appropriate for the otitis. You do not need an eye
drop. Fever should resolve in 2 days and there should be a noticeable improvement in
other sxs of pain and discharge, also.
• IF the ears were normal AND the child were afebrile, she would need an antibiotic eye
drop.
CASE 2, continued some more
Jessica returns on day 3/10 of her Augmentin. She still has a temperature, and now the left
side of her nose near the eye seems red and swollen. The lids on the left eye are swollen and
there is some bulging of the eye on the left when viewed from below. (see attached article for
pictures.) You immediately call the Pediatric Ophthalmologist, who instructs you to send the
baby to the ED. In the ED, she has IV antibiotics, and imaging reveals a post-septal abscess.
She is admitted to ophthalmology, and they discuss indications for surgical drainage.
QUESTION: What just happened?
• This is orbital cellulitis. Occasionally, simple infections become complicated. Ear
infections extend to the mastoid. Tonsillitis extends to deep space soft tissue infections.
Pneumonias get septic. In this case, the orbital space was invaded by the bacteria from
the sinuses and the eye.
• Pre-Septal cellulitis is cellulitis that is limited to the lids in front of the septum. This is
equivalent to a cellulitis on the skin; a bug bite, scratch, or stye, etc., got infected under
the skin. BE SURE you document a history of the definite event.
https://o.quizlet.com/i/Ps4koWZIr5vGIedNo0X3hQ.jpg
https://pedclerk.bsd.uchicago.edu//page/periorbital-and-orbital-cellulitis
• Orbital Cellulitis is extension of infection into the orbit proper. It is usually an extension
of an ethmoid sinusitis. It requires, depending on the extent of cellulitis vs abscess, IV
abx and/or surgical drainage. Suspect this if there is NO definite injury, there is
antecedent cold/sinus sxs, there are signs of increased ocular pressure.
• https://webeye.ophth.uiowa.edu/eyeforum/cases/103-Pediatric-Orbital-Cellulitis.htm

5. LINKS
https://pedsinreview.aappublications.org/content/31/5/196?sso=1&sso_redirect_count=5&nfstat
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https://www.ncbi.nlm.nih.gov/books/NBK441840/#article-19893.s1