Round table: Experts approach treatments for pediatric conjunctivitis, nevi and papilledema

After viral causes, bacteria are the next most common cause of infectious conjunctivitis. Relatively short courses of treatment can resolve bacterial conjunctivitis, whereas chronic or seasonal allergic conjunctivitis requires longer therapy.

Members of the OSN Pediatrics/Strabismus Board met in a round table session led by Section Editor Robert S. Gold, MD, to discuss their approaches to treatment of bacterial and allergic conjunctivitis in children, as well as more rare conditions of conjunctival nevi and papilledema.

Roundtable Participants

  • Robert S. Gold, MD
  • Moderator

  • Kenneth P. Cheng, MD
  • Moderator
  • Kenneth P. Cheng, MD
  • Kenneth P. Cheng, MD
  • Rudolph S. Wagner, MD
  • Rudolph S. Wagner, MD
  • Roberto Warman, MD
  • Roberto Warman, MD

Robert S. Gold, MD: What is your choice for antibiotic eye drops for bacterial conjunctivitis in children?

Rudolph S. Wagner, MD: Most of the information that we have about bacterial pediatric conjunctivitis is that it occurs in children 3 years of age and younger, and most cases are caused by Streptococcus pneumoniae or often non-typeable Haemophilus. These organisms do respond to certain antibiotics. Recently, I have been using a combination of polymyxin B and trimethoprim sulfate.

There have been cases reported of methicillin-resistant pediatric conjunctivitis. There was no associated morbidity, and the cases presented like typical bacterial conjunctivitis. The recommended systemic medication for MRSA infections is usually trimethoprim or Bactrim (sulfamethoxazole/trimethoprim, Sun Pharmaceutical Industries). So the combination of polymyxin B and trimethoprim sulfate, or Polytrim (Allergan), seems to work, especially if you have any concerns about MRSA infection.

Roberto Warman, MD: I use Polytrim also. The generic is easily available, and a lot of our patients are in Medicaid programs that will not accept easily the other treatments. And because of the broad spectrum of coverage, that is my first choice.

Gold: There are many times when we would prescribe “X” antibiotic, not Polytrim or a generic, and we would get phone calls from the pharmacy or from the patient that it is too expensive. We do have to be cost conscious and compassionate to the families.

Wagner: Even some of the generics now are becoming prohibitively expensive. It is a major concern.

One thing I have learned is that when you use a topical antibiotic in the eye, you are delivering such a high concentration that is far above the minimum inhibitory concentration, which is based on serum levels, that you will likely have success treating a bacterial infection. Unfortunately, many of these cases are viral not bacterial, so the treatment does not work and the infection has to run a longer time course.

Gold: Let’s talk about diagnosis and treatment preferences for allergic conjunctivitis.

Kenneth P. Cheng, MD: I like Patanol (olopatadine hydrochloride ophthalmic solution 0.1%, Novartis) or variations thereof. It has been effective in my experience.

The biggest issue in addressing allergic conjunctivitis is insurance coverage. The majority of insurance companies, certainly all the Medicaid insurance companies and their HMO products, at least in my area, do not cover treatments that work. They will cover cromolyn, which is effective, but it takes a long time to work. So, it is an issue, but my first line is Patanol products.

Warman: Regarding Patanol, olopatadine 0.1%, it did come out in generic recently. At least in my area in south Florida, interestingly enough, the Medicaid HMOs do not cover it, but they do cover Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%, Novartis), so who can explain it? Commercial insurers, of course, are not covering the 0.7% and are covering the 0.1%, which is good because I do think that is choice No. 1.

The other comment I would make is that everybody tends to stay away from the steroids because of the side effects, and you do have to be careful, but there is a lot of severe allergic conjunctivitis out there and you need steroids. There can be incredible side effects from not treating severe vernal conjunctivitis. When we use steroids, we need to have the patients come back and check their IOP. There is a strong need for a combination of antihistamine and low-dose — and sometimes the stronger dose — steroids.

Gold: One of the things that sometimes we overlook is that these young patients may be on olopatadine as well as oral antihistamines, and they can have dry eyes. The steroid is going to make that a little better, and sometimes just putting them on cold compress and artificial tears in the interim of the drops will help some of their symptoms.

Wagner: I tell people to take the tears and keep them in the refrigerator. They feel better and maybe they work better when they are instilled that way. But I do like to use olopatadine derivatives because I find that they work well. We do encounter some insurance coverage issues at times.

Cheng: I would add that if a patient has bad enough ocular allergies to require a frequent or continuous use of a topical drop during a season, I make sure that the patient is also taking an oral antihistamine such as cetirizine or loratadine or a fluticasone nasal spray to relieve nasal symptoms, which can in turn help their eye symptoms significantly. Those additions can help significantly and frequently alleviate the need for additional eye drops or topical steroids.

Conjunctival nevi

Gold: Another thing I would like to talk about is conjunctival nevi. We see quite a lot of this in our office in Florida. What do you do about them?

Warman: The data are clear. Change for malignancy in conjunctival nevi in children is extremely rare, so you just reassure the family. But the real question is, how often do we need to see them? We do know that the nevi become elevated and change pigmentation, particularly during hormonal changes in puberty. So, I tend to see them, if not every year, then every couple of years. I do not send them to an anterior conjunctival expert.

Wagner: I manage it the same way. I have them come back, not more than yearly, to see if there is any change in progression. We do see a lot of them. I have biopsied a few, and I have removed a few when they were cosmetically an issue to the family or the child. I did get back one pathology report that was a little frightening, but upon review there were no malignant cells. It was just a benign nevus.

Cheng: As long as they do not have any concerning characteristics and as long as they are not getting irritated cosmetically, I leave them alone and watch them. I tell the parents to let me know if it looks like it is getting red or irritated, or enlarging significantly, and I do have them come back yearly.

For nevi that are in a prominent spot that shows or will show as they enlarge, say located laterally at the limbus, especially in girls before puberty, I have removed a few of those, even though they remain perfectly benign looking. I do that so my excision is smaller and there is not much problem with healing. However, there can be some redness when you excise one of these and you disturb the conjunctiva, so I do warn parents about that.

Warman: One more comment. When you remove them, send the specimen to a good ophthalmic pathologist or trusted pathology lab. Otherwise, getting back a false-positive reading only opens up Pandora’s box and creates headaches.

Optic nerve edema

Gold: Moving on to a neuro-ophthalmic situation, how do you approach evaluation, workup and management of possible optic nerve edema? This I know is not a 2-minute conversation.

Warman: We get an incredible number of mostly optometry referrals for what sounds like subtle edema, and the patients are sent straight for neuroimaging at our children’s hospital emergency room. However, the important cases of real papilledema are usually quite clear. Those clear-cut cases do need the appropriate workup with neuroimaging and lumbar puncture. The tricky cases are not clear-cut, when findings are borderline. For those, you have to pay much more attention to the child’s history. Patients who are asymptomatic and are just found to have “disc swelling” most probably do not have disc swelling. But those are the hard cases. Those are the ones in which we do the extra testing.

Wagner: When there is history of pseudotumor cerebri or headaches, it is easier to make the diagnosis, but when “papilledema” appears on the chart, the level of concern rises. Most of those children do end up having brain imaging.

Warman: One other caveat here is that lately I have seen more patients being started on Diamox (acetazolamide, Zydus Pharmaceuticals) without a lumbar puncture. That creates a headache for a neuro-ophthalmologist. A real diagnosis of idiopathic increased intracranial pressure requires a lumbar puncture with normal study to make the diagnosis. Once the patient is on Diamox, you cannot stop it immediately. It will be a long, protracted follow-up of patients, many of whom did not have anything.

Disclosures: The round table participants report no relevant financial disclosures.

After viral causes, bacteria are the next most common cause of infectious conjunctivitis. Relatively short courses of treatment can resolve bacterial conjunctivitis, whereas chronic or seasonal allergic conjunctivitis requires longer therapy.

Members of the OSN Pediatrics/Strabismus Board met in a round table session led by Section Editor Robert S. Gold, MD, to discuss their approaches to treatment of bacterial and allergic conjunctivitis in children, as well as more rare conditions of conjunctival nevi and papilledema.

Roundtable Participants

  • Robert S. Gold, MD
  • Moderator

  • Kenneth P. Cheng, MD
  • Moderator
  • Kenneth P. Cheng, MD
  • Kenneth P. Cheng, MD
  • Rudolph S. Wagner, MD
  • Rudolph S. Wagner, MD
  • Roberto Warman, MD
  • Roberto Warman, MD

Robert S. Gold, MD: What is your choice for antibiotic eye drops for bacterial conjunctivitis in children?

Rudolph S. Wagner, MD: Most of the information that we have about bacterial pediatric conjunctivitis is that it occurs in children 3 years of age and younger, and most cases are caused by Streptococcus pneumoniae or often non-typeable Haemophilus. These organisms do respond to certain antibiotics. Recently, I have been using a combination of polymyxin B and trimethoprim sulfate.

There have been cases reported of methicillin-resistant pediatric conjunctivitis. There was no associated morbidity, and the cases presented like typical bacterial conjunctivitis. The recommended systemic medication for MRSA infections is usually trimethoprim or Bactrim (sulfamethoxazole/trimethoprim, Sun Pharmaceutical Industries). So the combination of polymyxin B and trimethoprim sulfate, or Polytrim (Allergan), seems to work, especially if you have any concerns about MRSA infection.

Roberto Warman, MD: I use Polytrim also. The generic is easily available, and a lot of our patients are in Medicaid programs that will not accept easily the other treatments. And because of the broad spectrum of coverage, that is my first choice.

Gold: There are many times when we would prescribe “X” antibiotic, not Polytrim or a generic, and we would get phone calls from the pharmacy or from the patient that it is too expensive. We do have to be cost conscious and compassionate to the families.

Wagner: Even some of the generics now are becoming prohibitively expensive. It is a major concern.

One thing I have learned is that when you use a topical antibiotic in the eye, you are delivering such a high concentration that is far above the minimum inhibitory concentration, which is based on serum levels, that you will likely have success treating a bacterial infection. Unfortunately, many of these cases are viral not bacterial, so the treatment does not work and the infection has to run a longer time course.

Gold: Let’s talk about diagnosis and treatment preferences for allergic conjunctivitis.

Kenneth P. Cheng, MD: I like Patanol (olopatadine hydrochloride ophthalmic solution 0.1%, Novartis) or variations thereof. It has been effective in my experience.

PAGE BREAK

The biggest issue in addressing allergic conjunctivitis is insurance coverage. The majority of insurance companies, certainly all the Medicaid insurance companies and their HMO products, at least in my area, do not cover treatments that work. They will cover cromolyn, which is effective, but it takes a long time to work. So, it is an issue, but my first line is Patanol products.

Warman: Regarding Patanol, olopatadine 0.1%, it did come out in generic recently. At least in my area in south Florida, interestingly enough, the Medicaid HMOs do not cover it, but they do cover Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%, Novartis), so who can explain it? Commercial insurers, of course, are not covering the 0.7% and are covering the 0.1%, which is good because I do think that is choice No. 1.

The other comment I would make is that everybody tends to stay away from the steroids because of the side effects, and you do have to be careful, but there is a lot of severe allergic conjunctivitis out there and you need steroids. There can be incredible side effects from not treating severe vernal conjunctivitis. When we use steroids, we need to have the patients come back and check their IOP. There is a strong need for a combination of antihistamine and low-dose — and sometimes the stronger dose — steroids.

Gold: One of the things that sometimes we overlook is that these young patients may be on olopatadine as well as oral antihistamines, and they can have dry eyes. The steroid is going to make that a little better, and sometimes just putting them on cold compress and artificial tears in the interim of the drops will help some of their symptoms.

Wagner: I tell people to take the tears and keep them in the refrigerator. They feel better and maybe they work better when they are instilled that way. But I do like to use olopatadine derivatives because I find that they work well. We do encounter some insurance coverage issues at times.

Cheng: I would add that if a patient has bad enough ocular allergies to require a frequent or continuous use of a topical drop during a season, I make sure that the patient is also taking an oral antihistamine such as cetirizine or loratadine or a fluticasone nasal spray to relieve nasal symptoms, which can in turn help their eye symptoms significantly. Those additions can help significantly and frequently alleviate the need for additional eye drops or topical steroids.

PAGE BREAK

Conjunctival nevi

Gold: Another thing I would like to talk about is conjunctival nevi. We see quite a lot of this in our office in Florida. What do you do about them?

Warman: The data are clear. Change for malignancy in conjunctival nevi in children is extremely rare, so you just reassure the family. But the real question is, how often do we need to see them? We do know that the nevi become elevated and change pigmentation, particularly during hormonal changes in puberty. So, I tend to see them, if not every year, then every couple of years. I do not send them to an anterior conjunctival expert.

Wagner: I manage it the same way. I have them come back, not more than yearly, to see if there is any change in progression. We do see a lot of them. I have biopsied a few, and I have removed a few when they were cosmetically an issue to the family or the child. I did get back one pathology report that was a little frightening, but upon review there were no malignant cells. It was just a benign nevus.

Cheng: As long as they do not have any concerning characteristics and as long as they are not getting irritated cosmetically, I leave them alone and watch them. I tell the parents to let me know if it looks like it is getting red or irritated, or enlarging significantly, and I do have them come back yearly.

For nevi that are in a prominent spot that shows or will show as they enlarge, say located laterally at the limbus, especially in girls before puberty, I have removed a few of those, even though they remain perfectly benign looking. I do that so my excision is smaller and there is not much problem with healing. However, there can be some redness when you excise one of these and you disturb the conjunctiva, so I do warn parents about that.

Warman: One more comment. When you remove them, send the specimen to a good ophthalmic pathologist or trusted pathology lab. Otherwise, getting back a false-positive reading only opens up Pandora’s box and creates headaches.

Optic nerve edema

Gold: Moving on to a neuro-ophthalmic situation, how do you approach evaluation, workup and management of possible optic nerve edema? This I know is not a 2-minute conversation.

Warman: We get an incredible number of mostly optometry referrals for what sounds like subtle edema, and the patients are sent straight for neuroimaging at our children’s hospital emergency room. However, the important cases of real papilledema are usually quite clear. Those clear-cut cases do need the appropriate workup with neuroimaging and lumbar puncture. The tricky cases are not clear-cut, when findings are borderline. For those, you have to pay much more attention to the child’s history. Patients who are asymptomatic and are just found to have “disc swelling” most probably do not have disc swelling. But those are the hard cases. Those are the ones in which we do the extra testing.

PAGE BREAK

Wagner: When there is history of pseudotumor cerebri or headaches, it is easier to make the diagnosis, but when “papilledema” appears on the chart, the level of concern rises. Most of those children do end up having brain imaging.

Warman: One other caveat here is that lately I have seen more patients being started on Diamox (acetazolamide, Zydus Pharmaceuticals) without a lumbar puncture. That creates a headache for a neuro-ophthalmologist. A real diagnosis of idiopathic increased intracranial pressure requires a lumbar puncture with normal study to make the diagnosis. Once the patient is on Diamox, you cannot stop it immediately. It will be a long, protracted follow-up of patients, many of whom did not have anything.

Disclosures: The round table participants report no relevant financial disclosures.