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conjunctivitis

Inflammation of the conjunctiva. Etiology: 1) allergic (atopic) a) grass pollens in May & June b) ragweed pollens in August & September 2) viral conjunctivitis (see History:) [2] a) Herpes simplex (generally type 1) b) Adenovirus (most common) [7] c) Enterovirus 70 - acute hemorrhagic conjunctivitis d) Varicella zoster - virus spreads along the optic nerve 3) bacterial conjunctivitis a) Staphylococcus aureus b) Streptococcus pneumoniae c) Haemophilus influenzae d) Neisseria gonorrhoeae (hyperacute bacterial conjunctivitis) e) Klebsiella pneumoniae f) Proteus g) Borrelia burgdorferi (Lyme disease) h) Pseudomonas 4) Chlamydia a) adult inclusion conjunctivitis b) ophthalmia neonatorum c) trachoma d) transmission: sexual or passage through the birth canal e) symptoms develop 7-10 days after exposure 5) complication of rosacea Epidemiology: - bacterial & viral conjunctivitis are highly contagious [2] - transmission may be through hand to eye or oral-genital contact - infectivity up to 2 weeks for viral conjunctivitis [2] - bacterial conjunctivitis most often in winter & spring [7] History: - history of exposure to infected persons suggests viral conjunctivitis [2] - antecedent upper respiratory tract infection suggests viral conjunctivitis [2] Clinical manifestations: 1) itching: a) minimal in bacterial, viral & chlamydial conjunctivitis b) severe in allergic conjunctivitis 2) sensation of foreign body 3) hyperemia, redness: generalized in distribution 4) tearing, watery eyes: a) profuse in viral conjunctivitis b) moderate in bacterial, chlamydial & allergic conjunctivitis 5) discharge, exudates a) minimal in viral & allergic conjunctivitis b) profuse in bacterial & chlamydial conjunctivitis - mucopurulent discharge described as yellow crusting on eyelashes [2] c) may awaken with eyelids stuck together 6) eyelid swelling 7) periauricular adenopathy a) common in viral & chlamydial inclusion conjunctivitis b) uncommon in bacterial conjunctivitis - noted in Bartonella infections [7] c) none in allergic conjunctivitis 8) sore throat a) occasionally in viral & bacterial conjunctivitis b) not associated with chlamydial or allergic conjunctivitis 9) fever a) occasionally in viral & bacterial conjunctivitis b) not associated with chlamydial or allergic conjunctivitis 1O) subconjunctival hemorrhage a) bacterial conjunctivitis b) enterovirus 70 conjunctivitis 11) membrane formation a) a thin film adhering to the conjunctival epithelium b) bleeding occurs if membrane is removed c) Herpes simplex, S. pneumoniae, N. gonorrhoeae 12) follicle formation a) lymphoid tissue hyperplasia b) dome-shaped elevation with blood vessels in their surface 13) papillae formation 14) unilateral with viral conjunctivitis [2,7] - may spread to the other eye in a few days [7] - spontaneous resolution within 2 weeks [7] Laboratory: 1) gram stain a) suspected Neisseria gonorrhoeae b) conjunctivitis that fails to respond to antibiotic therapy c) membranous conjunctivitis d) severe or prolonged conjunctivitis 2) culture a) purulent discharge b) suspected Neisseria gonorrhoeae 3) giemsa stain a) tarsal plate scrapings b) neutrophils - bacterial c) mononuclear leukocytes - viral d) eosinophils - allergic 4) fluorescent antibody for Chlamydia 5) GenProbe for gonorrhea & Chlamydia Special laboratory: 1) visual acuity testing: Snellen visual acuity test (all) 2) examination of eye with blue penlight after fluorescein stain of conjunctiva a) corneal scratches b) corneal dendrites - Herpes simplex c) corneal ulceration Differential diagnosis: 1) blepharitis - inflammation of eyelid margins - itching, tearing, burning, crusting - chronic condition affecting both eyes - associate with rosacea 2) anterior uveitis (iritis) (indication for referral) - may be associated with connective tissue disorder or autoimmune disease 3) acute angle-closure glaucoma (indication for referral) - deep eye pain, nausea/vomiting 4) keratitis, iritis, scleritis (indication for referral) - photophobia, eye pain, foreign body sensation 5) chalazion - eyelid discomfort followed by acute inflammation Management: 1) general measures a) warm compresses; cool compresses for viral conjunctivitis b) lubrication of eyes with artificial tears c) cleaning of eyelid margins d) avoid contact lenses e) avoid topical anesthetics except - before fluorescein staining - obtaining intraocular pressure measurements f) treat suspected bacterial conjunctivitis empirically before results of culture are available g) do not patch affected eye h) Follow-up within 24-72 hours 2) pharmacologic agents a) topical antibiotics for bacterial conjunctivitis - polymixin-B/trimethoprim (Polytrim) or erythromycin ophthalmic [2] - Neosporin, Opthneosporin, or Polysporin - gentamicin ophthalmic ointment every 2 hours day 1, then every 4 hours - sulfacetamide 10% ophthalmic every 2 hours day 1, then every 4 hours - fluoroquinolone ophthalmics - reserve for refractory conjunctivitis, contact lens wearers, suspected Pseudomonas [3] - ciprofloxacin (Ciloxan), norfloxacin, gatifloxacin (Zymar) moxifloxacin (Vigamox), levofloxacin, prednisolone/gatifloxacin rates of clinical & microbiological remission [6]; NNT = 7 [6] - dexamethasone/neomycin/polymixin-B (Maxitrol, Dexasporin) - prednisolone (Pred-Forte) + neomycin/polymixin-B - chloramphenicol eyedrops of no benefit [5] b) Neisseria gonorrhoeae in adults requires systemic agents - ceftriaxone 1 gm IM once - penicillin G - 10 million units IM QD for 5 days c) Chlamydia in adults requires systemic agents - tetracycline 500 mg TID for 3 weeks - doxycycline 100 mg BID for 3 weeks - erythromycin 250 mg QID for 3 weeks - erythromycin ointment ou may be added d) viral conjunctivitis - supportive, see general measures - antiviral ophthalmic agents - idoxuridine, vidarabine, trifluridine e) allergic conjunctivitis - avoidance of offending agent - 0.1% naphazoline (topical vasoconstrictor) 1-2 drops OU every 3-4 hours - Naphcon-A (topical vasoconstrictor plus antihistamine) 1-2 drops OU every 3-4 hours - vasoconstrictors for short-term use only - topical NSAIDs - ketorolac tromethamine (Acular) 1 drop OU QID - diclofenac (Voltaren) ophthalmic 1-2 drops OU QID - up to 1 week of use - topical steroids (prednisolone ophthalmic) - confirmed allergic conjunctivitis refractory to more conservative measures - failure of ophthalmic antihistamine - evidence of iritis [10] - oral antihistamines may be used in conjunction with ophthalmic agent [4] - ophthalmic antihistamine if oral antihistamine insufficiently effective [10] - mast cell stabilizers for prophylaxis during allergy season - Alocril, Alamast, cromolyn - Elestat, Optivar, Zaditor, olopatadine, azelastine, cetirizine, ketotifen work as both antihistamine & mast cell stabilizers [8] - treatment of choice for repeated exposure to outdoor allergens [8] 3) patient education - patient should stay home form work or school during acute infectious conjunctivitis - importance of good hygiene - viral conjunctivitis may persist for 3-4 weeks before improving 4) indications for referral to ophthalmologist - symptoms do not improve with treatment (> 2 weeks) - suspected keratitis, iritis or scleritis - photophobia, eye pain, foreign body sensation - immunosuppressed patients - recent eye surgery - recent eye trauma - hyperacute, purulent conjunctivitis - orbital cellulitis - decreasing visual acuity, blurred vision - membrane development across upper tarsal plate - increasing corneal opacities - conjunctivitis associated with shingles (Herpes zoster) - angle-closure glaucoma - deep eye pain, nausea/vomiting

Related

blepharitis

Specific

allergic conjunctivitis; Angelucci's syndrome bacterial conjunctivitis blepharoconjunctivitis inclusion conjunctivitis keratoconjunctivitis ophthalmia neonatorum pharyngoconjunctional fever (PCF) pingueculitis vernal conjunctivitis

General

conjunctival disease eye infection (ocular inflammation including eyelid inflammation)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 69-71
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2022.
  3. Prescriber's Letter 10(5):27 2003
  4. Ophthalmic Medications for Allergic Conjunctivitis Prescriber's Letter 11(3):15 2004 Detail-Document#: 200313 (subscription needed) http://www.prescribersletter.com
  5. Journal Watch 25(17):139, 2005 Rose PW, Harnden A, Brueggemann AB, Perera R, Sheikh A, Crook D, Mant D. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet. 2005 Jul 2-8;366(9479):37-43. PMID: 15993231
  6. The NNT: Topical Antibiotics for Clinical Cure of Bacterial Conjunctivitis http://www.thennt.com/nnt/topical-antibiotics-for-bacterial-conjunctivitis/ - Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012 Sep 12;9:CD001211 PMID: 22972049
  7. NEJM Knowledge+ Ophthalmology
  8. NEJM Knowledge+ Allergy/Immunology
  9. Varu DM, Rhee MK, Akpek EK, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Conjunctivitis Preferred Practice Pattern. Ophthalmology. 2019;126:P94-169. PMID: 30366797
  10. Bilkhu PS, Wolffsohn JS, Naroo SA, Robertson L, Kennedy R. Effectiveness of nonpharmacologic treatments for acute seasonal allergic conjunctivitis. Ophthalmology. 2014 Jan;121(1):72-78. PMID: 24070810 Clinical Trial.