School Nurse’s Guide to Pink Eye (Conjunctivitis) - One of my first job interviews was in Phoenix, Arizona for a school nurse position...well...kinda like a school nurse position. During my interview, the director shared this story:
Two girls are up and dressed and ready for school. This is not a normal school; it’s a dormitory for children with “challenges” and sort of an inpatient type of arrangement (this was years ago). They go to the nurse, and one reports, “I think we have pink eye.”
The two girls had awakened and gotten ready for school, and then they came to the health office to complain about their crusty, red, and itchy eyes. ‘Well, I guess you two get to stay in today; no school for you two,” the nurse said. Though their eyes looked terrible, the two girls were a bit giddy to learn they had the day off.
The other 28 students seem a tad bit more depressed than normal about their pending school day; these two red-eyed gals were only “suffering” from itchy, gritty-feeling, oozing, and crusty eyes. Nonetheless, off the children went...the two ill girls back to their rooms and the other 28 on to school to get smarter than they were the day before. A few days later the two girls with pink-eye-like symptoms were resolving well. However, the other 28 students all had (surprise!) symptoms including red, itchy, gunky eyes. What-da-ya-know...two students were on the mend, and 28 now had a fresh case of conjunctivitis. “Nurse So-And-So,” the unofficial ‘spokesperson’ for the ‘suffering 28’ asked, “Since we all have pink eye, can we stay in from school today.” Needless to say, 28 infected cannot infect the infected** and...well...a decision was made…The end verdict was 28 red, itchy, gunky-eyed students were to go to school and the two now-healing students were to go back in their quarters.
I’ll fill you in on what happened later in this article.
The conjunctiva of the eye is like a flat sack (sac) that starts just behind the eyelashes toward the inner part of the upper eyelid, opening up and inside the eyelid (palpebral conjunctiva), up and at the bend of the conjunctiva (conjunctival fornix), then over the top of the eyeball (conjunctiva bulbar), then over the surface of the eye's sclera (white part of the eye) and cornea (transparent layer forming the front of the eye), down toward the lower bulbar conjunctiva, at the lower bed of the conjunctival sac (conjunctival fornix), and ending at the lower eyelashes at the palpebral conjunctiva.
What is Pink Eye (Conjunctivitis)?
All forms of pink eye (conjunctivitis) is the inflammation (secondary to infection or irritation) of that “flat sack” tissue called the conjunctiva. They call it “pink eye” because of the pink and red color that is most notable over the sclera.
There are several kinds of pink eye, though the condition is commonly caused by one of three things (not all incidents of pink eye are caused by infection):
- Bacterial infection
- Viral infection
You will find this to be a sticky mess. Even after wiping the eye clean, the thick, purulent eye drainage may goo-up again just a second or two later. During the night and while the child is sleeping, the drainage may seep out and dry. In a sense, the eyes will be “glued” and difficult to open without washing away dried green and yellow “eyeball boogers” (as the children like to describe the dry drainage).
Funny thing about bacterial conjunctivitis is that most of us have the bacteria that causes pink eye there in our eye already. For some of us, this bacteria is part of our normal flora. Wah? Yep. Then...POW. Pink eye. (Managing Infectious Diseases in Child Care and Schools)
However, bacterial pink eye is likely contracted through various sources of contamination that have come into contact with an infected individual’s secretions. The child touches a contaminated surface, then touches his or her eye, and then...eyeball-booger city!
Some of the bacterial cooties that cause pink eye are:
Symptoms of Bacterial Conjunctivitis
It’s hard to miss. The child will have red and painful eyes. Unlike what we commonly believe, itching may or may not occur. Green and/or yellow drainage (but sometimes just white) is sure to cause some issues. One child came to me and said, “Nurse Kevin, my eyeball boogers are causing my eyes to hurt and itch.” He thought the “crusties” were causing his eyes to become red and inflamed (though this out-of-the-box thinking had a lot of merits). Often this drainage will ooze during the night while the child is sleeping, then thicken up and dry out as the drainage makes its way out onto the eyelashes and kinda “glue” the eye shut in the mornings.
These children are contagious until the course of antibiotics is started or when there are no longer any symptoms. In the meantime, awesome handwashing is vital. Like an itch on their little heads, they will eventually touch their eyes (and “cooties” can “swim” right through a wet tissue). The bacteria go from tear to finger...then finger to surface...then surface to another’s eye.
Sometimes parents will not take the child to the doctor. The child’s body will fight off the infection...eventually...in about two weeks (give or take). This is a good time (as is anytime) to promote handwashing to that classroom (see here for Nurse Kevin’s FREE handwashing PowerPoint presentation).
Treatment of Bacterial Conjunctivitis
We school nurses could offer a warm or cool compress for the children. Teaching the younger children not to press the compress into the eye can be a bit challenging because this may help their eye “feel” better (like scratching or rubbing). And, if only one eye has the infection, keep that compress away from the other eye.
If you have them (and if mamma and daddy say it’s okay), use eye drops that are of the “lubricating” or “natural tear” variety. The eye drops that are for “red eyes” shouldn’t be used. The active ingredients such as tetrahydrozoline could be counter-productive and may even interact with other medications being used.
If the pink eye-like symptoms (how we nurses “chart” our findings) motivate the parent to seek the care of a physician, NP, or PA, the child will likely receive a topical antibiotic that will be in the form of drops or an ointment.
The symptoms will gradually worsen during the first 3-5 days (when the child finally makes his or her way down to our offices) and gradually subside afterwards. It’ll probably take a week or two to clear up.
Like bacterial conjunctivitis, this is a common type of pink eye that is highly contagious. Sometimes the child will “just get” a case of viral conjunctivitis secondary to their own respiratory illnesses such as measles, flu, cold, or other nasal infections. Y’all ever get an ill child in your office that “open-air” sneezes or coughs? That sputum spray can leave their little mouths and noses at (an estimated 100 miles per hour (about 161 kilometers per hour)).
And with (an estimated) cough-spray of 3,000 droplets and a sneeze-spray of 100,000 droplets, those viruses will surely find their way to a soon-to-be-touched surface or make their way directly into another’s eyes.
Viral conjunctivitis is usually caused by adenoviruses (cold, sore throat, bronchitis, pneumonia) or enteroviruses (more severe respiratory illnesses).
Symptoms of Viral Conjunctivitis
Young-‘uns with a case of viral conjunctivitis will likely have a watery discharge from one or both eyes. The sclera will appear pink and red and very similar to that seen in bacterial conjunctivitis.
The symptoms of viral conjunctivitis and bacterial conjunctivitis are very similar. So, how do you know the difference? Well, you won't be able to...not 100% anyway. But, you can do some guessing. Not that it matters; we nurses can’t diagnose or prescribe medications. And you and I both know that topical antibiotics are not going to help if the “cootie” is a virus.
Treatment of Viral Conjunctivitis
Unlike with bacterial infections, antibiotics will not work against viruses. No eye drops or ointments are effective against the common viruses that cause viral conjunctivitis. But viral conjunctivitis is self-limited, which means it will go away by itself after a short time.
If the viral conjunctivitis is severe enough, the doctor may order a corticosteroid. However, if the viral conjunctivitis is so debilitating where the use of corticosteroids is necessary, the child may need to remain home until symptoms subside to the point where learning can occur. Keep in mind that steroids may prolong the illness.
In a nutshell, here’s what happens: An allergen triggers the allergic response in the body. The eyes become inflamed and irritated because of the immune system’s response to the allergen. The body dumps all that histamine through our mast cells. “This-That-and-the-Other” happens. Then POW! Itchy, watery eyes that get all red and pink-like. There’s a more “medical” and “professional” way of explaining this; I am sure. But…
Things that can trigger an immune response resulting in allergic conjunctivitis are just like any allergen, such as pet dander and the oils in pet hair, motor exhaust, perfumes, and pollen (to name a few). For me personally, if I pet a dog or cat, and then touch my eyes, my eyes get all red and swollen and it’ll look like I am “crying a river.” But Nurse Kevin don’t cry...I’m too tough. I am so tough… Well, I’d tell ya’ how tough I am but my wife won’t let me, “Gross, don’t tell them that old Army thing you tell.” Anyway...I digress...
Treatment of Allergic Conjunctivitis
With watery, itchy eyes being the main symptoms to deal with, eye drops that contain an antihistamine specifically for allergic reactions would be the thing to use. If the parent were to call the doctor and get an OTC (over-the-counter) suggestion, he or she may suggest something like Visine-A Antihistamine drops. *
Rest and a nice cold or warm compress (child’s preference) will do just fine. Non-medicated eyewash or natural tears should be okay to use.* Antihistamine drops are like any other medication and should not be used unless the parent/guardian gives their blessing.
Allergic conjunctivitis is kinda like plants in my garden: annuals and perennials. Allergic conjunctivitis can be seasonal (annuals) or perennial (happen anytime during the year). This all depends on what allergen is causing the ailment. So, avoiding the allergen (whatever that may be) is the best treatment.
Sweet-talk the custodian or other persons who keep the schoolhouse clean and tidy. Request a bit of extra sanitation of the classroom the child with pink eye is assigned to. I know our custodian is a rock star! Those rooms are already in ship-shape.
The school nurse can do a nice handwashing teaching session with the child (get Nurse Kevin’s Handwashing PowerPoint HERE).
Educate the teacher to keep an “eye” (pun intended) on the child and promote frequent handwashing and surface sanitation after the child touches his or her eyes, mouth, or nose. It’s a hassle, but these children may not need to be excluded from school.
To Exclude or Not?
I’ve worked in medical facilities before that have had policies to send employees home who have pink eye. However, in school children...like with the rest of the population...most cases of pink eye are about as serious as the cold. (https://amzn.to/2q71hZz )
Here are some questions to ask if the child has pink eye-like symptoms:
1) What does your district’s policy say? Follow that. Policies and procedures are in place and there to reduce all the “why” questions that will come your way.
If your district’s policy suggests that the child is able to remain in school but your “nurse-ey senses” say “not with the symptoms I am finding,” then use your best nursing judgment.
2) Is the child able to participate in school activities and required school work...comfortably and where learning is actually happening?
3) Is the child back-and-forth to the health office? The subjective complaints are very important to “hear.”
4) Are there other symptoms of illness? After all, as we mentioned above, pink eye can be secondary to a respiratory illness or other illness. Fever? Irritability? Crying? Lethargy (maybe the child didn’t sleep well last night due to irritating symptoms)?
5) Here’s a big one: Is the child able to “safely” participate in group activities (i.e. school)? If the infected child is not able to manage the secretions (or not willing to manage the secretions), then exclusion is to be considered. The second case of pink eye in once class will definitely generate a few “why” questions.
6) Pay special attention if you suspect viral conjunctivitis. The American Academy of Pediatrics suggests that adenoviruses caused pink eye can cause epidemics. So, if you have two or more cases in a group, you’ll need to consult “the advice of” your school’s or district’s “health consultant.” In middle school and high schools (even some elementary schools), it is sometimes hard to tell what is the “official” group is. Again, here’s where both common sense and your “nurse-ey senses” help guide you to a decision and to avoid all the “why” questions.
Another type of allergic conjunctivitis is called giant papillary conjunctivitis (GPC). GPC is when some kind of foreign object in the eye causes irritation and subsequently pink eye. This is more common in folks who wear soft contact lenses.
The solutions are both easy and difficult: The student will need to stop wearing the contact lenses. This may be permanently (just with this type of contact lens) or just for a period of time while the eye symptoms subside. I encourage the parents to seek care with their eye doctor who may very well prescribe a different type of contact lens. But, for the time being, the student may have to dust off their old glasses.
Here’s one more out-of-the-box consideration:
If the student has been using eye drops, and symptoms just seem to persist and persist, consider the preservatives in eye drops. Sometimes toxic conjunctivitis can occur as a reaction to the preservatives in the very solution that is supposed to be soothing, cooling, and relieving.
Outside of the scope of this article is gonococcal and chlamydial conjunctivitis.
If you are a school nurse at a high school, you may have a pregnant student with an STD (sexually transmitted disease). Here in the U.S., an antibiotic ointment often is applied to the eyes of newborn infants to help prevent the possibility of certain eye infections. This is just FYI...you’ll likely have no say-so in this matter.
Those Poor 28 Students
So...to follow up on the school in Arizona with the two-cases-then-turned-into-30-cases-of-pink-eye at the start of this article: Apparently, the two girls that had first come down with pink-eye were greatly envied by the other 28. We like to think children “don’t know nothin’.” But, little do we know that they know... And they knew… The whole group used a damp wash rag and literally wiped the eyes of the two girls that originally had contracted pink eye (with their permission mind you) and purposely self-infected themselves in order to get out of school. Hey, if one was gonna do it, they all were going to do it. (I’m just glad the first two girls didn’t get out of school by jumping off a bridge or eating doggy poo.)
And the Arizona job? Well, I passed it up. Not because of this story...but because I ended up working in Alaska. Yep...a whole different story for a whole different day.
May your splinters always be shallow,
P.S.: These children were the only 30 children in that school.
*I am a registered nurse and not a physician. I cannot prescribe medications. My reference to any medication in this article or any article on Go See The Nurse is what I would do for myself and my own family. My reference to medications and treatments in this article or any article/post on Go See The Nurse is not meant to be followed unless under the supervision/advice of a practitioner with prescribing privileges.