Eye Infections in Children – the full guide

What are eye infections in children?

Eye infections in children usually present as a red eye. When we say ‘eye infection’ we are referring to an infection of the conjunctiva or simply ‘conjunctivitis’.

The conjunctiva is the white part of the eye (the layer that covers the white part of the eye which surrounds the coloured circle around the pupil). When the conjunctiva is infected, the white part of the eye turns red, and sometimes it is swollen and causes the secretion of fluids.
The most common causes of conjunctivitis in children are infections (viruses, bacteria, see more below). The condition can be one sided or may be seen in both eyes. In most cases the infection will start in one eye and then spread to the other, because of the children’s tendency to itch the infected eye.
Note that the eye has other parts to it, as well (I won’t be going into the detailed anatomy of the eye) and different conditions may cause the conjunctiva to turn red. So, just keep in mind that sometimes a red eye could be an indication of a completely different illness in one of the other structures in the eye. And so, if things aren’t clear and the symptoms persist, make sure to consult with a pediatrician or an ophthalmologist. More about this below.

What are the most common causes of eye infections in children?

In children, the most common causes are infections, i.e., viruses and bacteria. In infectious cases, it is important to differentiate between a simple viral infection, a bacterial infection or a more serious infection that requires treatment and more rigid monitoring.

Viral conjunctivitis

Even though this term has the magic word “viral” in it, it can still be very painful, irritable, and itchy. This infection is characterised by a watery secretion, it is often unilateral but when it is bilateral the medical history will often reveal that it had started in one eye and only then spread to the other. How does this happen? When the child itches the first eye affected, they cause the infection to spread from one eye to the other and often to other kids’ eyes as well. Sometimes, you will see swelling of the neighboring lymph nodes surrounding the ear on the same side of the infected eye.
One of the most common viruses that causes conjunctivitis is called adenovirus (you can learn more about it here), and in addition to eye infections it can also cause a characteristic infection that presents with runny nose, throat pain and fever. Many times, one of the parents will catch it as well and will find themselves walking around with a red eye for a few days.
Some of the adenovirus species can cause a severe infection that involves the cornea (the most external transparent part of the eye that covers the pupil). Patients will feel the sensation of a foreign object in their eye, will suffer from photophobia (eye discomfort in bright light) and will have blurred vision.
Viral conjunctivitis symptoms will usually worsen during the first 3-5 days and then improve within 1-2 weeks. What is frustrating about this condition is that on the one hand, there is no real treatment that can significantly shorten the duration of the symptoms (unlike bacterial infections, antibiotics aren’t useful here) and on the other hand, it is a very infectious condition. Therefore, maintaining good hygiene, including hand washing for both children and parents, is very important. To avoid infecting other household members or children at day-care we recommend ensuring that the child sleeps only on his own pillow and does not share it with other members of the house and that they use a towel reserved only for them (also when using the hand towel in the kitchen). I will provide more details about when the child can return to day-care and what treatment options exist below.

It is also important to discuss about herpes infection in this section (more about herpes virus here). Herpes usually causes a corneal infection (the transparent layer that I mentioned earlier) but sometimes there will also be a reactive redness and irritation of the conjunctiva (the white part of the eye), especially in the area around the iris (the part of the eye with the colour). When herpes involves the eye, it is considered a serious condition that may cause vision loss. The treatment of herpes is different to the treatment of other viral infections and therefore if vesicles appear in or around the eyelids, or when there is any other reason to suspect a herpetic infection – seek medical attention ASAP (and make sure to avoid the use of ointments or drops that may contain steroids).

Acute purulent conjunctivitis

This is usually a bacterial infection. It is not always possible to distinguish between a viral infection and a bacterial infection based on the external appearance. Nonetheless, what are signs that can aid in making that differentiation? In bacterial infections the secretion is thick and contains pus, it is sticky and many times its presence makes it difficult to open the eye because the eyelids are stuck to each other. Most of the time, this infection affects both eyes.
The common bacteria that can cause this infection are Staph aureus (read more about this in the section about skin infections here), Hemophilus influenza, Pneumococcus (these are both familiar to you from the post about ear infections and respiratory infections) and Moraxella catarrhalis.
When it comes to treatment, most of these infections will react well to warm compresses and topical antibiotics in the form of eye drops or ointments. It is true that hypothetically speaking, this infection could resolve on its own but because adequate treatment can shorten the duration of the illness, the doctor will usually recommend treatment with antibiotic drops or ointments. See more about the optional treatments below.

Allergic conjunctivitis

As the name implies, it is conjunctivitis due to an allergic cause. It is characterized by a feeling of itchiness that is very disturbing (unlike the pain felt in infections) and it is accompanied by a watery secretion, tearing and sensitivity to light. It usually affects both eyes and often the eyelids and the area around the eyes are swollen and red. Bumps may appear on the inner side of the eyelids.
Allergic conjunctivitis is often seen in children that have other allergies such as allergic rhinitis, asthma, and atopic dermatitis. Sometimes, the allergy may appear suddenly after exposure to an allergic trigger such as dust or cats but what it is also very common to see the seasonal type that has much less of a dramatic presentation; it develops over a few days and returns during the same time, every year. It is therefore important for parents to follow up on eye infections that tend to recur seasonally, and to consider preventive treatment for the following year.
Treatment of allergic conjunctivitis is different, and it includes cold compresses, topical antihistamines, and other anti-allergic medications. Only in very rare cases, and under stringent monitoring, will eye drops that contains steroids be offered.
This is obviously non-infectious and as long as this is the diagnosis, the child will have no restrictions in returning to his/her daily activities with other children.

Conjunctivitis due to other reasons

Other conditions that are non-infectious include different exposures – exposure to smoke, industrial pollution, haze, and different domestic detergents may cause irritation and a chemical infection in the conjunctiva. Be aware, if the eye was exposed to acidic or basic chemicals, this is very serious, and it could lead to vision loss. Wash the eye well under running tap water or mineral water for 5 minutes and refer to emergency medical care, immediately.
Subconjunctival bleeding – most of the time this isn’t dangerous, and it resolves spontaneously. It appears as a red spot, and it can happen for no special reason or it may follow a cough or a sneeze.
Eye injury or suspected foreign object – such cases may be serious and require a prompt medical examination.

What are other important causes of a red eye that one should be familiar with that isn’t conjunctivitis?

Corneal infection – the cornea, as I mentioned above, is a layer that covers the orbit. The conjunctiva surrounds the cornea, and any injury to the cornea leads to a sense of foreign object in the eye, pain, decrease in vision, significant irritation, and photophobia. An infection of the cornea can be caused by a virus, bacteria, fungus, or parasite. There could be whitish/yellowish spotting over this layer. Treatment of this condition is intense as this infection could lead to vision loss. Adolescents that wear contact lenses are at high risk of developing such an infection and so if your child has a red eye and wears contact lenses, see an ophthalmologist immediately.
Uveitis – this is an inflammation of the deeper structures of the eye. Sometimes uveitis can be asymptomatic, and the diagnosis may be missed, but in other situations the patients will present with unilateral or bilateral red eyes. This could be a condition that is strictly in the eyes or part of a larger systemic disease. It is important to treat it and treatment usually entails topical drops that contain steroids. Further workup may be needed, depending on the physicians’ discretion.
Blockage or congenital narrowing of the tear-ducts – read more about this in the link here.

Do I need to see a pediatrician or ophthalmologist every time my child has an eye infection?

Do I need to see a doctor at all? Most of the cases are very mild, and an experienced parent will know what needs to be done without referring to a doctor (maybe just to get the doctor’s consent for the child to return to day-care). In practice, most parents do not see an ophthalmologist every time there is a mild infection in their child’s eye.
On the other hand, if the infection presents differently, or does not resolve quickly, it is important to seek medical attention. The physician’s main job, in such cases, is to identify conditions that present atypically. It is true that pediatricians do not have all the special equipment required for eye examinations, but the medical history of the current illness (for example: When and how did it start? Were there symptoms in both eyes or just one of the eyes at the beginning? Was there fever or any other symptoms? Was there any exposure to smoke or allergens? Did someone else catch it at home? And also questions directed at ruling out dangerous conditions – is the pain severe? Have there been any changes in vision? Was there a trauma prior to the onset of symptoms?) and the appearance of the eye will help distinguish between the different causes and identify the worrisome causes.
Should you be seeing a pediatrician or an ophthalmologist? Considering the waiting times in most countries around the world for ophthalmologist appointments, I presume that by the time you make it to your appointment, the symptoms will be long gone and so practically speaking, seeing your pediatrician would be the better option. If you and your pediatrician think that your case requires examination by an ophthalmologist, your primary care physician will refer you to one.

What is periorbital cellulitis?

This is a potential complication of an eye infection, a stye or any other lesion found on the eyelids (such as molluscum).
Peri – means surrounding. Orbital – the eye. Cellulitis – infection of the skin.
If you put this together, you get a skin infection surrounding the eye. Often it starts off as an eye infection but when the child itches their infected eye, they injure the skin around it and allow for bacteria to enter the soft tissue. This is a unilateral infection that presents as redness around the eye and is sometimes accompanied by fever.
If you suspect your child may have periorbital cellulitis, see your pediatrician for an examination and a consult regarding the appropriate treatment.
Complications to this infection may include further spread of the infection into the deeper tissues surrounding the orbit and this condition requires emergent intervention and treatment.

What about eye infections in infants under the age of 1 month?

Most of the infections that occur at this age are due to blocked tear-ducts and are not serious infections (medical examination will reveal secretions but not so much irritation of the conjunctiva). Read more about blocked tear ducts here.
Nonetheless, there is an eye infection that occurs during delivery, when the child passes through the birth canal.
Therefore, one should always get their child checked by a medical professional if he/she presents with a red eye and secretions at infancy so that they can determine whether it is a serious infection that needs to be treated promptly and effectively to avoid long-term consequences.

When should I be worried about my child’s eye condition and when should I refer to an urgent care clinic for medical examination? (What are the red flags?)

The answer to this can be divided into the reasons behind the appearance of the red eye, the accompanying symptoms, the child’s characteristics such as age and/or other symptoms and absence of improvement after onset of treatment.
Age – as I mentioned above, infants under the age of 1 month
Injury, especially if it is penetrating – this is an emergency, cover your child’s eye and refer to the nearest emergency room.
Exposure to a burning, acidic or basic chemical – risk of chemical burn of the cornea. Wash the child’s eye and refer to the nearest emergency room.
Suspected foreign object, or a sensation of foreign object – this can lead to corneal abrasions, infection or pose serious risk to the eye.
Infection in adolescents that wear contact lenses – risk of abscess formation in the cornea.
Severe pain, especially on movement of the eye – could indicate an infection in the deeper tissues of the eye.
Blurry vision – this is always concerning.
Photophobia – suggests corneal infection.
Inability to open the eye – suggests severe irritation of the eye.
Large quantity of secretions.
A lesion or spotting of the cornea.
Redness that is emphasized around the iris – suggests herpetic infection.
Any other reason to suspect herpes.
A child, any age, with signs such as fever, headache, generally unwell or appearing unwell.

How should eye infections in children be treated?

First of all, keep in mind that not all eye infections require treatment.
In mild cases, wiping the tears or the secretions may be sufficient and no further intervention is necessary.
A cotton pad, dunked in warm water that has been boiled and left to cool is cheap and work perfectly.
If an intervention is required, we will have to divide the drops and ointments into 2 types:
Those that only contain antibiotics – such as chloramphenicol 5%.
And those that contain both antibiotics and steroids – for example Maxitrol (dexamethasone, neomycin and polymyxin).
If the infection is bacteria, antibiotics are important. If the infection is viral, antibiotic treatment is not helpful.
The combination of antibiotics and steroids helps reduce the local swelling seen in both bacterial and viral infections.
And therefore, in certain conditions, and if your pediatrician approves, the recommended treatment will include steroids.
Always remember that steroids are not to be used for longer than a few days, unless your pediatrician instructs you to do so, and you should never use ointments or eye drops that contain steroids when herpes is suspected.

When should eye drops be used and when is ointment preferred?

Some of the products, such as chloramphenicol, are only available as an ointment.
Other products are, such as maxitrol, are available in both ointment and drop form.
The formulation of the drug will be determined depending on the diagnosis and parents’ preference. Some parents find it difficult to administer eye drops and prefer ointments and for others it may be the opposite way around. Both options are good, as long as the drug comes in contact with the eye so it can produce an effect.
Some parents prefer combining the two. When the child is awake, they prefer using eye drops and when they are asleep – ointment. Everything works.
Refer to this link to learn more about how to apply eye drops properly and here to learn about the application of eye ointments.

The million-dollar question – when can my child return to daycare?

This is probably what concerns parents the most…
It is difficult to miss work for a child who is sitting at home, is happy and only needs their eyes wiped every now and then.
It is obvious to all of us that eye infections, even when they are mild, can spread among all the children at day care. In addition, sometimes the virus that causes an eye infection in one child can cause a more significant infection in another. This is the reason behind why teachers are very strict about eye infections, but this is not always justified.
In my chapter about “Returning to educational institutions” I mention that if the child has an eye infection but no pus, they can continue going to school (this includes a red eye with or without transparent secretions). But as I just explained above, even among those kids who have a red eye with or without transparent secretions, there may exist infectious conditions. Also, you’ll find that some parents wipe the pus of their child’s eyes in the morning and send them off to school. So, lots of teachers require a doctor’s note confirming that the kid is not infectious anymore.
Unfortunately, I don’t have a clear-cut answer to all the cases of red eyes, some of which may have an underlying infectious cause and may infect others through direct or indirect contact.
Generally speaking, one can say that once the secretions have resolved, the child may go back to school/daycare.

Summary and take-home message

In most cases of red eyes, the cause is either a viral or bacterial infection. These will usually resolve spontaneously, within a few days, without any serious complications.
Nonetheless, there are dangerous situations that one should not disregard, and if one of the red flags that I mentioned above is present, one should seek medical attention immediately.
If your child has an eye infection, it is important that all the family members wash their hands frequently and use separate bed linen and separate towels to prevent the spread of infection.
So, let’s just hope that despite having to avoid day-care/school for several days, you remain keep in mind that this is a mild infection and is usually not serious or dangerous in most children.