Conjunctivitis
Conjunctivitis or inflammation of the conjunctiva is a general term that refers to a diverse group of diseases/ disorders that affect the conjunctiva primarily.
Conjunctiva is a thin translucent membrane that lines the anterior part of the sclera It has bulbar and palpebral parts ( under surface of eyelids ) Inflammation or infection leads to dilatation of conjunctival vessels leading to hypermaemia and oedema – typically associated with discharge Conjunctivitis may also occur secondary to other ocular or systemic conditions that produce conjunctival inflammation It is estimated it affects 6 million people annually in the US
Allergic -immunoglobulin hypersensitivity reaction. Seasonal allergic conjunctivitis Perennial allergic conjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis Giant cell papillary conjunctivitis
All forms bilateral Type 1 immune response to an allergen Can be made worse by problems with eyebrows , eyelids or eyelashes which act as barriers to allergens Redness and itching are most consistent symptoms Itching is hallmark – can also be described as burning or stinging If not present consider alternative cause Discharge – watery or mucoid can be stringy or ropey due to small amount of mucous Seasonal allergic conjunctivitis is the most common type seen May present with other systemic atopic manifestations as ○ rhinoconjunctivitis ○ rhinosinusitis ○ asthma ○ urticaria ○ atopic dermatitis More common in spring / late summer
Identification of specific antigens and elimination of specific pathogens ( when practical ) Use of medications that decrease or mediate the immune response to minimize and control signs and symptoms
Topical ocular antihistamines and mast cell stabilizers for eg ○ Antihistamine action -Emedastine – for seasonal allergic conjunctivitis above age 3 bd ○ Dual antihistamine + mast cell stabilizer action Azelastine , Epinastine , Ketotifen , Olopatadine , Nedocromil Topical ocular decongestants ○ synthetic adrenergic agonists ○ can cause rebound hyperemia when stopped ○ contra-indicated in people with glaucoma and CVD , hyperthyroidism and diabetes Topical NSAIDs – Ketorolac Topical corticosteroids Systemic antihistamines Immunotherapy
Bacterial-Hyperacute Bacterial conjunctivitis Acute bacterial conjunctivitis Chronic bacterial conjunctivitis
Most common causes are ○ Streptococcus pneumonia ○ Staphylococcus aureus ○ Haemophilus influenae Other causes include Moraxella catarrhalis , Chlamydia trachomatis and Neisseria gonorrhea Mild or no pruritus Papillary conjunctival reaction , eyelid matting and purulent discharge If caused by Chamydia trachomatis or Neisseria gonorrhoea – its termed hyperacute conjunctivitis and the symptoms will be more severe and persistent and decreased vision. Pre-airicual lymphadenopathy can be seen. This requires systemic treatment. This needs urgent attention as inadequately treated gonoccoccal infection can lead to blindness Conjunctivitis lasting > 4 weeks is chronic conjunctivitis
Most cases are self limiting- resolve in 5-7 days without treatment Consider topical antibiotics if severe or circumstances require rapid resolution Delayed Rx- use antibiotics if no better in 3 days No recommended exclusion period from school , nursery or child minders for isolated cases If not resolving and patient re-attends - ○ consider swabs for viral PCR ○ bacterial culture ○ empirical topical antibiotic Consider ophthalmology referral if symptoms persist for > 7-10 days after initiating Rx Choice of agents ○ Chloramphenicol drops 0.5 % 1 drop 2 hrly x 2 days then 4/D x 5 days ○ Chloramphenicol 1 % oint 4/D x 2 days then 2/D x 5 days ○ Fusidic acid eye drops 1 % bd x 7 days second line ○ Topical fluoroquinolones Aminoglycosides ( eg gentamycin and tobramycin ) not recommended – corneal toxic and may delay healing and cause hyperaemia
History-Onset , duration , time course Uni or bilateral Recent exposure to an infected individual Discharge ○ watery purulent or mucopurulent ○ when is it worse eg on waking up Itching ○ severity ○ persistent or intermittent Vision ○ VA – check ○ blurring Pain Photophobia Burning Foreign body sensation Exposure to chemicals irritants FB or trauma Contact lens use – lens type , hygiene and use regimen Past ocular hx and associated medical conditions
Examination-Extent , location and nature of redness try and note pattern of redness ○ conjunctival injection ○ ciliary injection – ring like pattern of dilated blood vessels usually indicated intraocular inflammation Examine conjunctiva- pay attention to ○ swelling ○ follicles ○ papillae – inflamed vesicular elevations ○ membranes Character of discharge Cornea – look for ulceration , opacities Pupil – shape , size , pupillary reaction Eyelids Periorbital area Visual acuity Lymph nodes ( can be found in 50 % of viral conjunctivitis )
Red flags-Reduced visual acuity Marked eye pain , headache or photophobia ○ consider systemic cause for eg meningitis Inability to open the eye or keep it open Red sticky eye in a neonate ( within 30 days of birth ) Trauma including ○ mechanical ○ chemical ○ ultra violet Copious rapidly progressive discharge consider gonococcal infection Herpes virus infection ○ Herpes simlex – U/L red eye with vesicular lesions on eyelid ○ Herpes zoster – look for Hutchinson’s sign ( lesions present on tip of nose ) Soft contact lens use with corneal symptoms as photophobia and watering
Viral conjunctivitis-Viruses cause up to 80 % of all cases of acute conjunctivitis Most commonly caused by adenovirus Usually starts in one eye and spreads to another Presentation can be with a red eye , itching , burning or a FB sensation with a watery to mucous discharge and periauricular lymphadenopathy May be associated with a recent URTI or exposure to an infected person Mild to moderate erythema of the palpebral bulbar conjunctiva , follicles on eyelid eversion and lid oedema Adenovirus infection can cause 2 of the common clinical entities associated with viral conjunctivitis ♦ pharyngoconjunctival fever ♦ epidemic keratoconjunctivitis
Self limiting – reassure resolves within 1-2 wks and antibiotic Rx is not required No specific antiviral agent to Rx viral conjunctivitis Self care as cool compress , remove discharge with cotton wool soaked in sterile saline or boiled and cooled eater Lubricating drops or artificial tears Very contagious – avoid close contact with others particularly if they are healthcare professionals or child care providers (may be infectious up to 14 days from onset ) Advice to return- seek help if symptoms persist beyond 10 D If patient re-attends with symptoms of conjunctivitis -Consider swab for viral PCR and bacterial culture and empirical topical antibiotics Consider referral / discussion with ophthalmology if symptoms persist 7-10 D after starting Rx
May be indistinguishable from other viral infections Usually unilateral Thin watery discharge with accompanying vesicular lesions Look for Hutchinsons sign Avoid using topical steroids – may potentate the virus and can cause harm Topical and oral antivirals can shorten the duration of course ( seek ophthalmology adv – see Red flag)
Refer eye clinic-A red flag indicating a serious cause Opthalmia neonatorum- sticky eyes with redness in a neonate Suspected gonococcal or chlamydial conjunctivitis will need topical + oral antibiotics Possible herpes conjunctivitis Features suggestive of periorbital or orbital cellulitis Corneal ulceration Significant keratitis Pseudomembrane ( can suggest epidemic keratoconjunctivitis ) Recent surgery on eye Associated systemic condition as rh arthritis or immunocompromise Soft contact lens use with corneal involvement Fluorescein staining is required to show corneal involvement ○ antibiotics can interfere with corneal culture result ○ refer eye casualty and ask them to take the lenses with them Recurrent or persistent conjunctivitis Conjunctivitis due to molluscum contagiosum
There can be significant overlap in symptoms making differentiation between different types difficult
References
- Conjunctivitis A Systematic Review of Diagnosis and Treatment Amir A Azari et al JAMA. 2013 Oct 23;310(16):1721-9. doi: 10.1001/jama.2013.280318
- Causes Complications & Treatment of a Red Eye BPJ Issue 54 https://bpac.org.nz/bpj/2013/august/redeye.aspx
- Stop demanding antibiotics for children with conjunctivitis , royal college tells schools BMJ 2016 ; 355 : i6109
- Quick Reference guide Care of Patient with Conjunctivitis American Optometric Association https://www.aoa.org/documents/optometrists/QRG-11.pdf
- Optometric Clinical Practice Guideline Care of the People with Conjunctivitis American Optometric Association Christopher J. Quinn et al https://www.aoa.org/documents/optometrists/CPG-11.pdf
- Acute Conjunctivitis BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/68
- CKS NHS Conjunctivitis Allergic May 2017
- CKS NHS Conjunctivitis – Infective April 2018
- An algorithm for the management of allergic conjunctivitis. Bielory L1, Meltzer EO, Nichols KK, Melton R, Thomas RK, Bartlett JD. Allergy Asthma Proc. 2013 Sep-Oct;34(5):408-20. doi: 10.2500/aap.2013.34.3695
- Ryder EC, Benson S. Conjunctivitis. [Updated 2020 Apr 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541034/
- Ramirez DA, Porco TC, Lietman TM, Keenan JD. Epidemiology of Conjunctivitis in US Emergency Departments. JAMA Ophthalmol. 2017;135(10):1119–1121. doi:10.1001/jamaophthalmol.2017.3319