Clinical Evaluation of Red Eyes in Pediatric Patients

Casey Beal, MD; Beverly Giordano, MS, RN, CPNP, PMHS


J Pediatr Health Care. 2016;30(5):506-514. 

In This Article


Conjunctivitis is one of the most common ophthalmologic disorders encountered by pediatric primary care practitioners. The eye becomes red as a result of dilation of the conjunctival blood vessels, which is sometimes associated with discharge and edema. When edema accumulates under the conjunctiva, the conjunctiva begins to look "boggy"; this appearance is referred to as chemosis (Figure 1). It is important to examine the palpebral conjunctiva—that is, the portion that covers the inside of the eyelid—which can be seen by pulling down on the lower eyelid or everting the upper eyelid. A papillary or follicular reaction may be observed, depending on the underlying cause of the conjunctivitis. A papillary reaction creates large, flat nodules with a central vessel that is commonly described as "cobblestoning." A follicular reaction creates smaller, dome-shaped, gelatinous-appearing lesions that are best seen on the palpebral conjunctiva (Figure 2). Conjunctivitis can be caused by viral or bacterial infections, allergies, or chemical exposure; viruses and allergies are the most commonly encountered causes.

Figure 1.

Chemosis—edema of the conjunctiva.
Photo courtesy of Phuchong Choksamai. © This figure appears in color online at

Figure 2.

Follicular conjunctival reaction of the inferior palpebral conjunctiva seen here by everting the lower eyelid with a cotton tip applicator.
Photo courtesy of Phuchong Choksamai. © This figure appears in color online at

Viral Conjunctivitis

Definition. Viral conjunctival infection is most commonly caused by adenovirus types 8, 19, and 37 (LaMattina & Thompson, 2014). Some common variants of the classic viral conjunctivitis are pharyngoconjunctival fever and acute hemorrhagic conjunctivitis. Pharyngoconjunctival fever presents with a triad of sore throat, fever, and conjunctivitis and is caused by adenovirus type 3 or 7 (LaMattina & Thompson, 2014). Acute hemorrhagic conjunctivitis, although not common, is significant for extensive subconjunctival hemorrhages in addition to conjunctival injection. These cases are commonly caused by Coxsackie virus A2 and enterovirus 70 (Wong, Lai, Chi, & Lam, 2011). Zika virus, which has recently emerged in the Western hemisphere, also can cause a viral conjunctivitis along with fever, rash, and arthralgias (Petersen et al., 2016). Infection with Zika virus should be suspected in a patient with a recent history of travel to an endemic country.

History of the Present Illness

  • Acute-onset eye redness, irritation, tearing, and a burning sensation

  • Contact with people who are sick

  • One eye is often affected first, followed by the other eye in a few days

Physical Examination

  • Examine the inferior conjunctiva by pulling down on the lower eyelid to evert it, which usually shows a follicular conjunctival reaction (Figure 2)

  • External examination shows diffuse conjunctival erythema (Figure 3)

  • An enlarged preauricular lymph node is almost always noted

Figure 3.

Viral conjunctivitis—diffuse conjunctival injection and tearing.
Photo courtesy of Phuchong Choksamai. © This figure appears in color online at

Diagnostic Tests

  • A Wood's lamp (i.e., a lamp emitting long-wave ultraviolet light named for Robert W. Wood) or a direct ophthalmoscope switched to its cobalt blue light setting and fluorescein are used to evaluate for corneal abrasions

  • No cultures are needed in these cases


  • Symptomatic care

    • Artificial tears as needed

    • Cool compresses

  • Counsel patient and families on contagious nature of the disease

    • Wash hands frequently and don't share towels or pillows

    • Conjunctivitis can be contagious from 10 days to 3 weeks or as long as the eyes are red (Pinto et al., 2014). It has been recommended that persons who are infected stay home for 2 weeks to prevent spread of the virus (Kaufman, 2011), although this recommendation is often unrealistic for working parents or patients in school. Simple precautions such as frequent hand washing and avoiding direct contact with the eyes are more realistic and will decrease the risk of transmission. The viral load decreases exponentially as healing occurs, and thus the infectivity will drop significantly during the first 7 days.

    • Antibiotics have shown no value in treating viral conjunctivitis and should not be prescribed (Rose et al., 2005)

    • All contact lenses, solutions, cases, and eye makeup should be discarded

Ophthalmology Referral

  • Refer for vision changes, corneal abrasions as identified with the fluorescein examination previously described, significant discharge that is more likely to be bacterial, or no improvement in 5 to 7 days

  • Other viral causes of conjunctivitis include herpes simplex virus and varicella zoster virus, which frequently manifest with skin findings as well. These patients should be referred to ophthalmology immediately for close follow-up.

Allergic Conjunctivitis

Definition. Simple allergic conjunctivitis is extremely common, affecting 15% to 40% of the population (Bielory, O'Brien, & Bielory, 2012). It is caused by an inflammatory reaction to allergens in the environment.

History of Present Illness

  • Significant eye itching bilaterally

  • Usually a seasonal component is present, and it is commonly seen in conjunction with allergic rhinitis and/or asthma

Physical Examination

  • "Allergic shiners" or dark circles under the eyes are frequently present

  • Excessive tearing is present with diffuse conjunctival erythema, variable amounts of chemosis, and a papillary reaction or "cobblestoning" appearance to the conjunctiva


  • Limit exposure to the inciting agent, if it is known

  • Artificial tears are helpful for rinsing out any allergens

  • Combination mast cell stabilizer/antihistamine eyedrops (e.g., olopatadine, 0.1% or 0.2%, or ketotifen, 0.035%) are the first-line treatments; these drops can take up to 2 weeks to have their full effect, so patients are encouraged to continue using them for this period before evaluating their effectiveness

  • Oral antihistamines

  • Topical steroids or immunomodulators should only be prescribed by an ophthalmologist

Bacterial Conjunctivitis

Definition. Bacterial conjunctival infection is less common than viral conjunctivitis but can have significant morbidity. The most common causes are Staphylococcus aureus, Streptococcus pneumonia, and Haemophilus influenza. (See the subsequent "Ophthalmia Neonatorum" section as well, because conjunctivitis caused by Neisseria gonorrhoeae and Chlamydia trachomatis also can occur in adolescents.)

History of the Present Illness

  • Acute onset conjunctival redness, tearing, and discharge

  • Unilateral or bilateral

Physical Examination

  • The hallmark finding is copious, usually white, discharge (Figure 4), along with conjunctival erythema; the presence of this significant discharge helps distinguish bacterial from viral conjunctivitis

Figure 4.

Bacterial conjunctivitis. White discharge is present on the conjunctiva, seen with eversion of the upper eyelid.
Photo courtesy of Phuchong Choksamai. © This figure appears in color online at

Diagnostic Tests

  • A culture can be obtained if significant discharge is noted

  • A Wood's lamp and fluorescein are used to evaluate for corneal abrasions


  • Empiric treatment consists of polymyxin B sulfate/trimethoprim drops or a fluoroquinolone eyedrop such as ofloxacin, ciprofloxacin, or moxifloxacin four times daily for 5 to 7 days; antibiotic choices can be adjusted on the basis of culture results if they are available

Ophthalmology Referral

  • If corneal involvement is suspected, changes in vision occur, or no improvement is noted with topical antibiotics, then a corneal ulcer is suspected and the patient should be referred immediately to an ophthalmologist

Ophthalmia Neonatorum

Definition. Bacterial conjunctivitis in the neonatal period is most commonly caused by C. trachomatis or N. gonorrhoeae and can cause significant morbidity and even mortality.

History of the Present Illness

  • Conjunctival redness, discharge, and eyelid edema in the first 14 days of life

  • N. gonorrhoeae classically presents in the first 3 to 4 days of life

  • C. trachomatis classically presents a little later than N. gonorrhoeae, at around 1 week of life

Physical Examination

  • Significant conjunctival erythema, edema, and discharge

  • C. trachomatis typically results in thin, "ropy" white discharge, whereas N. gonorrhoeae results in exuberant purulent white discharge

Diagnostic Tests. Gram stain with culture or polymerase chain reaction for C. trachomatis and N. gonorrhoeae should be obtained from conjunctival discharge.


  • Treatment for C. trachomatis includes administration of oral or intravenous (IV) erythromycin and use of erythromycin ophthalmic ointment four times daily for 14 days, and an ophthalmology consultation should be obtained

  • Treatment for N. gonorrhoeae infection requires hospital admission, saline solution irrigation of the eyes every hour until the discharge clears, administration of ceftriaxone IV or intramuscularly, and an ophthalmology consultation (American Academy of Pediatrics, 2015)

  • The mother and her sexual partner(s) also should be treated

  • The infection should be reported to the local health department

  • N. gonorrhoeae and C. trachomatis conjunctivitis can also occur in adolescents and should be suspected if severe or chronic discharge is present. C. trachomatis conjunctivitis in the adolescent is treated with oral doxycycline, azithromycin, or erythromycin in addition to topical erythromycin ophthalmic ointment. N. gonorrhoeae conjunctivitis in the adolescent is treated with intramuscular ceftriaxone, oral azithromycin, or doxycycline, as well as saline solution lavage of the conjunctiva.