Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. And today, i'm joined by Jennifer Qayum, pediatric optometrist practicing at Children's Mercy in Kansas City. Today, we're discussing pink eye. Dr. Qayum, thank you so much for taking the time to join us this morning.

Dr. Jennifer Qayum: Well, thank you for having me.

Host: So when we're talking about pink eye, what are the most common causes of pink eye in children?

Dr. Jennifer Qayum: When we're talking about pink eye or conjunctivitis, the most common causes are virus, bacteria, or allergies. With virus, we're thinking typically an adenovirus or molluscum or maybe a herpetic infection. Bacteria in kids is typically a strep or a staph infection, and then allergies typically come with the season changes.

Host: That makes a lot of sense. How can pediatricians distinguish between these different types, the viral, bacterial, and allergic conjunctivitis?

Dr. Jennifer Qayum: The first thing I like to do with a patient who has conjunctivitis is discuss with their caregivers the presentation of the conjunctivitis. Did it start in one eye and then move to the other? If this is the case where it starts unilaterally and then moves to the other eye, it is likely bacterial or viral. In contrast, allergic conjunctivitis is typically presenting bilaterally.

Another question I like to ask families is, did the patient have any other systemic symptoms, such as an upper respiratory infection or an ear infection? If that's the case, I would be leaning more towards a diagnosis of a viral or bacterial infection. But if the patient's been sneezing a lot and has an itchy throat, I'm thinking more about allergies.

Other things I ask the family, you know, did the patient have contact with anyone who has conjunctivitis? Because again, then I'm thinking more of a contagion, which would be a bacteria or virus. Or did the red eyes occur with the season change? Again, that would be allergic. Are there any associated rashes around the eye? Then, I'm thinking of maybe a herpetic infection or a molluscum or impetigo. Are there styes? If there are styes associated with the red eye, often I'm thinking of a condition called blepharokeratoconjunctivitis, or we shorten that to BKC. And that's an inflammation of the oil glands of the eyelids that causes a recurrent red eye.

So once I've talked to the family more about the presentation of the conjunctivitis and how the patient is feeling, then I'm going to try to examine the patient. And the presenting signs of conjunctivitis can differ slightly based on the cause. If the pediatrician is able to look at the inside of the eyelid, this is called the palpebral conjunctiva, then the types of bumps that you see on the inside of the eyelid are slightly different. Now, for me as an eye care provider, I have extra tools in my exam room that makes it easier to see these. So, it can be tricky as a pediatrician to view these. But for a bacterial and allergic conjunctivitis, the bumps on the inside of the eyelid on that palpebral conch are typically more red overall because the vasculature of those bumps goes over the whole bump. These are called papillae. In contrast, a viral conjunctivitis typically presents with follicles, and these look like little blisters on the inside of the eyelid. Because for follicles, the vasculature goes around the bump instead of over the bump.

Now, realistically, like I said, I have extra tools in my exam room to help me visualize these. And also, pediatric patients don't love having their eyelids pulled on. So then, I'm observing for any discharge associated with the conjunctivitis. A bacterial conjunctivitis typically presents with a yellow or green mucus discharge, while the viral conjunctivitis and the allergic conjunctivitis are both usually more watery or teary.

So, those are the main things that I'm looking at trying to help me determine what the cause of this conjunctivitis is. It's kind of a funny branching graph in my head of unilateral versus bilateral, what type of discharge, when did it start? But those types of things can help us distinguish between the types of conjunctivitis.

Host: Thank you for walking us through the different parts and how to distinguish between them. When are antibiotic eye drops actually needed? Does it depend on the type of conjunctivitis?

Dr. Jennifer Qayum: Yes. Really, we want to reserve antibiotic eye drops for when there is a bacterial conjunctivitis. So, that would be the patient who they have a pink eye that started in one eye and maybe it moved to the other eye. It typically has that yellow or green mucus discharge. Antibiotics really are not needed for viral or allergic conjunctivitis. And in fact, using antibiotics unnecessarily can really lead to antibiotic resistance in the future

Host: What guidance, Dr. Qayum, should we give families about returning to school or daycare? Because it's that season.

Dr. Jennifer Qayum: It is. And this is tough. You know, the easy one, if it's allergic, there are no restrictions on returning to school or daycare. You just need to start some allergy eye drops, maybe some cool compresses, and you're good to go. If it's bacterial, again, that one's not too tough because the patient is not contagious after being on an antibiotic for 24 hours. So, they can easily go back to school after starting the antibiotic. Where things get really tricky is viral conjunctivitis, because these children can be contagious for seven to 14 days, if not longer, depending on the type of conjunctivitis. But really, let's talk about how it's contagious. Because, you know, there are ways to prevent spreading this viral conjunctivitis.

For the conjunctivitis to spread, the patient has to rub their eye, get the virus on their hand, then touch something like a pencil, then their friend uses that same pencil and touches their own eye. So, for older patients, I counsel them on how this conjunctivitis is spread, and I advise them on how to have proper hand hygiene, wash hands frequently, don't touch their eyes. And within the household, I really recommend that families change all the sheets on the beds, wash all the towels, make sure that siblings aren't sharing any of those things or stuffies or clothes.

But, you know, for younger patients, it gets really tricky. So, I'm thinking of, like, the toddlers, the infants because often these viral conjunctivitis, they're just getting passed around the classroom. And realistically, most parents can't be out of work for two weeks while their child gets rid of the contagion. So, I give them as much education as I can and advise them to use their best judgment possible.

Host: I love that. Education is so important. What red flags warrant a referral to an eye specialist when it kind of goes above and beyond?

Dr. Jennifer Qayum: The times when I become concerned with a pink eye is if the cornea, that clear front part of the eye, becomes cloudy either in one section or over the entire part. That warrants an immediate referral, because we're thinking at that point maybe there's a corneal ulcer or maybe there's a uveitis. Maybe this is more than just conjunctivitis. Also, if the patient is describing decreased vision, that would be concerning because a typical conjunctivitis or pink eye should not cause decreased vision.

And another note is if the treatment you have initiated does not seem to be working or if the pink eye is recurrent, that is again concerning and I think would warrant a referral to an eye care provider. Because again, we just have more tools in our exam rooms to help us look more closely at the eye to maybe help identify what's going on with the eye.

Host: Thank you so much for sharing all of this wonderful information with us. We are thrilled to have you.

Dr. Jennifer Qayum: Thank you very much.

Host: And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You could do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara. And this has been Pediatrics in Practice, a CME podcast.