conjunctivitis
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Introduction
Inflammation of the conjunctiva.
Etiology
- allergic (atopic)
- viral conjunctivitis (see History:)[2]
- Herpes simplex (generally type 1)
- Adenovirus (most common)[7]
- Enterovirus 70 - acute hemorrhagic conjunctivitis
- Varicella zoster - virus spreads along the optic nerve
- bacterial conjunctivitis
- Chlamydia
- adult inclusion conjunctivitis
- ophthalmia neonatorum
- trachoma
- transmission: sexual or passage through the birth canal
- symptoms develop 7-10 days after exposure
- 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
- itching:
- minimal in bacterial, viral & chlamydial conjunctivitis
- severe in allergic conjunctivitis
- sensation of foreign body
- hyperemia, redness: generalized in distribution
- tearing, watery eyes:
- profuse in viral conjunctivitis
- moderate in bacterial, chlamydial & allergic conjunctivitis
- discharge, exudates
- minimal in viral & allergic conjunctivitis
- profuse in bacterial & chlamydial conjunctivitis
- may awaken with eyelids stuck together
- eyelid swelling
- periauricular adenopathy
- common in viral & chlamydial inclusion conjunctivitis
- uncommon in bacterial conjunctivitis
- noted in Bartonella infections[7]
- none in allergic conjunctivitis
- sore throat
- occasionally in viral & bacterial conjunctivitis
- not associated with chlamydial or allergic conjunctivitis
- fever
- occasionally in viral & bacterial conjunctivitis
- not associated with chlamydial or allergic conjunctivitis 1O) subconjunctival hemorrhage
- bacterial conjunctivitis
- enterovirus 70 conjunctivitis
- membrane formation
- a thin film adhering to the conjunctival epithelium
- bleeding occurs if membrane is removed
- Herpes simplex, S. pneumoniae, N. gonorrhoeae
- follicle formation
- lymphoid tissue hyperplasia
- dome-shaped elevation with blood vessels in their surface
- papillae formation
- unilateral with viral conjunctivitis[2][7]
Laboratory
- gram stain
- suspected Neisseria gonorrhoeae
- conjunctivitis that fails to respond to antibiotic therapy
- membranous conjunctivitis
- severe or prolonged conjunctivitis
- culture
- purulent discharge
- suspected Neisseria gonorrhoeae
- giemsa stain
- tarsal plate scrapings
- neutrophils - bacterial
- mononuclear leukocytes - viral
- eosinophils - allergic
- fluorescent antibody for Chlamydia
- GenProbe for gonorrhea & Chlamydia
Diagnostic procedures
- visual acuity testing: Snellen visual acuity test (all)
- examination of eye with blue penlight after fluorescein stain of conjunctiva
- corneal scratches
- corneal dendrites - Herpes simplex
- corneal ulceration
Differential diagnosis
- blepharitis
- anterior uveitis (iritis) (indication for referral)
- may be associated with connective tissue disorder or autoimmune disease
- acute angle-closure glaucoma (indication for referral)
- keratitis, iritis, scleritis (indication for referral)
- chalazion
- eyelid discomfort followed by acute inflammation
Management
- general measures
- warm compresses; cool compresses for viral conjunctivitis
- lubrication of eyes with artificial tears
- cleaning of eyelid margins
- avoid contact lenses
- avoid topical anesthetics except
- before fluorescein staining
- obtaining intraocular pressure measurements
- treat suspected bacterial conjunctivitis empirically before results of culture are available
- do not patch affected eye
- Follow-up within 24-72 hours
- pharmacologic agents
- 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]
- Neisseria gonorrhoeae in adults requires systemic agents
- ceftriaxone 1 gm IM once
- penicillin G - 10 million units IM QD for 5 days
- 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
- viral conjunctivitis
- supportive, see general measures
- antiviral ophthalmic agents
- 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]
- topical antibiotics for bacterial conjunctivitis
- 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
- indications for referral to ophthalmologist
- symptoms do not improve with treatment (> 2 weeks)
- suspected keratitis, iritis or scleritis
- 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
More general terms
More specific terms
- allergic conjunctivitis; Angelucci's syndrome
- bacterial conjunctivitis
- blepharoconjunctivitis
- inclusion conjunctivitis
- keratoconjunctivitis
- ophthalmia neonatorum
- pharyngoconjunctional fever (PCF)
- pingueculitis
- vernal conjunctivitis
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 69-71
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2022.
- ↑ 3.0 3.1 Prescriber's Letter 10(5):27 2003
- ↑ 4.0 4.1 Ophthalmic Medications for Allergic Conjunctivitis Prescriber's Letter 11(3):15 2004 Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=200313&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 5.0 5.1 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: https://www.ncbi.nlm.nih.gov/pubmed/15993231
- ↑ 6.0 6.1 6.2 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: https://www.ncbi.nlm.nih.gov/pubmed/22972049 - ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 NEJM Knowledge+ Ophthalmology
- ↑ 8.0 8.1 8.2 NEJM Knowledge+ Allergy/Immunology
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/30366797
- ↑ 10.0 10.1 10.2 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: https://www.ncbi.nlm.nih.gov/pubmed/24070810 Clinical Trial.