Conjunctivitis Acute

Description of Medical Condition

Inflammation of the bulbarand/ or palpebral conjunctiva of less than 4 weeks duration

System(s) affected: Nervous, Skin/Exocrine

Genetics: N/A

Incidence/Prevalence in USA: Variable, but accounts for 1 -2% of all ambulatory office visits

Predominant age: Depends on cause

Predominant sex: Male = Female

Medical Symptoms and Signs of Disease

• General: for viral, bacterial, allergic, atopicand nonspecific

– Red eye, conjunctival injection

– Discharge

– Foreign body sensation

– Eyelid sticking or crusting

– Normal visual acuity and papillary reactivity, otherwise, see Differential Diagnosis

• Viral, adenoviral or enteroviral most common sporadically in children, or may be associated with influenza, measles or mumps

– History of upper respiratory infection or systemic viral symptoms

– May start with 1 eye, then progresses to both eyes in 1-2 days

– Watery mucous discharge

– Inferior palpebral conjunctival follicles

– Palpable preauricular lymphadenopathy

• Viral, herpes simplex or zoster

– May have history of recurrent ocular herpes simplex

– Burning sensation, rarely itching

– Unilateral, with concurrent herpetic skin vesicles on eyelid or in distribution of ophthalmic branch of trigeminal nerve if herpes zoster

– Palpable preauricular node

• Bacterial, gonococcal hyperacute infection

– Rapid onset 12-24 hours

– Severe purulent discharge

– Chemosis-conjunctival edema

– May have rapid growth of superior corneal ulceration

– Eyelid swelling

– Preauricular adenopathy

– ? History or signs of other sexually transmitted diseases (chlamydia, HIV, etc.)

• Bacterial, nongonococcal: may be epidemic

– Mild pruritus

– Mild purulent discharge

– Conjunctival chemosisedema

– No preauricular adenopathy

– If contact lens user, must rule out pseudomonal keratitis

• Allergic

– Itching most dominant symptom

– Watery discharge

– History of seasonal or dander allergies

– Chemosis-conjunctival edema

– Eyelids edematous and red

– No preauricular adenopathy

• Atopic/vernal recurrent

– History of atopy

– Itching

– Thick sticky discharge

– Seasonal recurrences

– Large conjunctival papillae (bumps) under upper eyelid

– Sometimes superior corneal “shield” ulcer (sterile gray-white infiltrate)

– Sometimes raised white dots on inner lids or limbus

– Sometimes superficial punctate keratopathy on fluorescein staining

• Nonspecific irritative

– Dry eyes with intermittent redness and mucus

– Irritation after a chemical exposure or drug reaction

– Foreign body: may still have redness and discharge 24 hours after removal

What Causes Disease?

• Viral

– Adenovirus (common cold)

– Coxsackie

– Enterovirus (acute hemorrhagic conjunctivitis)

– Herpes simplex, primary and recurrent

– Herpes zoster or varicella

– Molluscum contagiosum

– Measles, mumps or influenza

• Bacterial

– Staphylococcus aureus

– S. epidermidis

– Streptococcus pneumoniae

– Haemophilus influenzae (especially in children)

– Pseudomonas species (must rule out in contact lens users; frequently progresses to corneal ulcers)

Oneisseria gonorrhoeae

Oneisseria meningitidis

– Chlamydia trachomatis causes a chronic conjunctivitis — gradual onset over 4 weeks

• Allergic

– Hay fever, seasonal allergies

– Vernal conjunctivitis/atopy

• Nonspecific

– Irritative: topical medications, wind, or dry eye ultraviolet light exposure, smoke

– Autoimmune: Sjogren’s, pemphigoid, Wegener granulomatosis

– Rare: Rickettsial, fungal, parasitic, tuberculosis, syphilis, Kawasaki disease, Grave disease, gout carcinoid, sarcoid, psoriasis, Stevens-Johnson,

Reiter syndrome

Risk Factors

• History of contact with infected persons; epidemic bacterial or viral conjunctivitis

• Sexually transmitted disease contact: gonococcal chlamydial, syphilis, herpes

• Use of contact lenses: pseudomonal

Diagnosis of Disease

Differential Diagnosis

• Uveitis (iritis, iridocyclitis, choroiditis): limbal flush (red band at corneal margin, less on other areas of conjunctiva) hazy anterior chamber, decreased visual acuity

• Penetrating ocular trauma: ophthalmologic emergency; hospitalize

• Acute glaucoma (ophthalmologic emergency) headache, corneal clouding, decreased visual acuity

• Corneal ulcer(s) or foreign body: abnormal fluorescein exam

• Dacryocystitis: tenderness and swelling over tear sac (near nasal bridge)

• Scleritis and episcieritis: red injected vessels are radially oriented, sectoral (pie wedge) inflammation, sometimes with nodularity of sclera

• Ophthalmia neonatorum: neonates in first 2 days of life — gonococcal; 5-12 days of life — chlamydial, consider HSV if maternal cultures were positive for herpes simplex. Consider specialty consultation. All of these require systemic therapy as well as topical.

Laboratory

• Usually not needed initially for the most common causes of conjunctivitis

• Culture swab if thought to be bacterial or if contact lens user

• Gram stain of discharge if thought to be gonococcal

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Pathological Findings

N/A

Special Tests

• Pap stain for giant cells of herpes simplex.

• Viral culture or immunofluorescence for herpes simplex

Diagnostic Procedures

• Document visual acuity/Snellen Chart

• Fluorescein staining to detect foreign bodies, corneal ulcers or punctate keratitis, and look for dendritic lesions of herpes simplex or zoster

• Examine eyelid skin also for herpetic vesicles, lice or nits, blepharitis or styes

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient

General Measures

• Cool compresses and eyelid cleansing with wet cloth up to 4 times per day

• Discontinue use of contact lenses for duration of inflammation

• Patching of eye not beneficial

• Try to avoid irritants such as smoke, dry wind, prolonged sun exposure

Activity

No restrictions

Diet

No restrictions

Patient Education

• Discuss handwashing techniques to decrease transmission of disease

• Do not re-use eye cosmetics after an infection. They should be discarded.

• Demonstrate eye dropper techniques: while eye is closed, and head tipped back, drop several drops in a lake at nasal margin then patient can open eyes to allow liquid to enter. Never touch tip of applicator to skin or eye.

• Demonstrate ointment techniques; apply 1/2 inch to edqe of lower lid

Medications (Drugs, Medicines)

Drug(s) of Choice

• Viral: nonherpetic

– Artificial tears for symptomatic relief

– Vasoconstrictor/antihistamine (e.g. naphazoline/pheniramine) qid for severe itching

– Consider bland, inexpensive, topical antibiotic ointments in an empiric approach “in case” a viral infection is complicated by skin flora:

– Erythromycin ophthalmic ointment 1/2 inch twice a day for 5 days, or

– 10% sodium sulfacetamide ophthalmic drops 2 gtts every 4 hours for 5 days.

• Viral: herpetic

– Trifluorothymidine 1% drops one drop 5 times a day or vidarabine 3% ointment 5 times per day.

– Acyclovir oral, consult drug reference

– If corneal lesions seen, consider ophthalmologist referral

• Bacterial: gonorrheal

– If ulceration visible, or can not be ruled out consider emergent ophthalmologic consultation and hospitalization for IV ceftriaxone

– If no corneal lesions, ceftriaxone 1 gm IM, as single dose and topical bacitracin ophthalmic ointment ½ inch, 4 times per day.

• Bacterial: non-gonococcal

– Bacitracin ophthalmic 1/2 inch 2-4 times per day for 5 days or

– Erythromycin ophthalmic ointment, 1/2 inch 2-4 times per day for 5 days, or

– Sodium sulfacetamide 10% solution, 2 drops every 4 hours (while awake) for 5 days

– Fluoroquinolone eye drops (such as ciprofloxacin) are more expensive but also are acceptable

– Avoid aminoglycoside drops and neomycin ointments as they can cause a reactive keratoconjunctivitis after a few days of use

• Allergic and atopic

– Artificial tears 4 to 8 times per day

– Vasoconstrictor/antihistamine qid

– azelastine (Optivar) 0.05% bid

– epinastine (Elestat) 0.05% bid

– NSAID (anti-inflammatories)

– Ketorolac (Acular) 0.5%

– levocabastine (Livostin) qid

– Mast cell stabilizers:

– ketotifen (Zatidor) 0.025% bid

– cromolyn (Opticrom) 4% qid

– olopatadine (Patanol) tid

– Oral antihistamine (e.g., diphenhydramine 25 mgtid) in severe cases

Contraindications: Avoid use of topical steroids unless in ophthalmologic setting and able to monitor intraocular pressure

Precautions:

• Do not allow dropper to touch eye or skin to avoid contamination. Do not re-use same eye cosmetics after an infection — they should be discarded

• Vasoconstrictor/antihistamine — rebound vasodilation after prolonged use

• Avoid topical steroids in non-ophthalmologic setting as patients must be monitored for development of steroid related cataracts and glaucoma. If superior shield ulcer of vernal conjunctivitis is present, refer to ophthalmology for steroids.

Significant possible interactions: N/A

Alternative Drugs

• Viral — numerous over-the-counter and prescription topical vasoconstrictors and antihistamines

• Bacterial

– Polymyxin-gramicidin

Oneomycin-polymyxin b-bacitracin (Neosporin) (15% of people have reaction to neomycin)

– Ciprofloxacin

– Norfloxacin

– Chloramphenicol (warning: slight hematological adverse effect risk)

– Oral erythromycin for chlamydia in neonate (see drug reference for dosing)

• Allergic

– Numerous topical vasoconstrictors and antihistamines

– Numerous oral antihistamines

Patient Monitoring

Referral if worse in 24 hours. Bacterial: expect improvement in 24 hours and resolution in 2-5 days.

Prevention / Avoidance

• Avoid listed causes when possible

• Wash hands frequently

Possible Complications

• Viral

– Corneal scars with herpes simplex

Oneonatal herpes simplex could include encephalitis

– Lid scars or entropion with Varicella zoster

– Bacterial superinfection

• Bacterial

– Chronic marginal blepharitis

– Conjunctival scar if membrane develops.

– Corneal ulcers or perforation, very rapid with gonococcal

– Hypopyon: pus in anterior chamber

– Chlamydial neonatal ophthalmia: could have concomitant pneumonia

• Allergic, chemical or nonspecific

– Bacterial superinfection

Expected Course / Prognosis

• Viral

10 days for pharyngitis with conjunctivitis

– Several weeks for epidemic keratoconjunctivitis

– 2-3 weeks for herpes simplex

• Bacterial

2-4 days with treatment 010-14 days if untreated

Miscellaneous

Associated Conditions

• Viral infection (e.g., common cold)

• Sexually transmitted diseases

Age-Related Factors

Pediatric: Neonatal conjunctivitis may be gonococcal, chlamydial, irritative or related to dacryocystitis. Gonococcal ophthalmia neonatorum is an emergency.

Geriatric: More likely to have autoimmune, systemic or irritative conditions

Others: Epidemic bacterial (streptococcal) conjunctivitis reported on college campuses

Pregnancy

N/A

Synonyms

Pinkeye

International Classification of Diseases

077.99 Unspecified diseases of conjunctiva due to viruses

372.50 Conjunctival degeneration, unspecified

372.14 Other chronic allergic conjunctivitis

See Also

Rhinitis, allergic

Vernal keratoconjunctivitis

Sjogren syndrome