Conjunctivitis resident survival guide

Conjunctivitis Resident Survival Guide Microchapters

Overview
Causes
Diagnosis
Differential Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Seyed Arash Javadmoosavi, MD[2]

## Overview

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Conjunctivitis is the most common eye infection in which inflammation causes dilation of conjunctival blood vessels giving the eye a reddish aspect. The most common cause of conjunctivitis is infection of which viral infections are the commonest cause, followed by bacterial. The non-infection forms are allergic, mechanical, toxic and neoplastic. Among noninfectious conjunctivitis, the allergic form is more common. Infectious conjunctivitis presents with many similar symptoms regardless of the cause, such as: red eye, foreign body sensation, itching, light sensitivity, burning. Watery discharge is common in viral conjunctivitis while mucopurulent discharge is more suggestive of bacterial cause. Regarding the onset and severity of clinical symptoms, conjunctivitis is classified as acute, chronic, and recurrent. Most cases of infectious conjunctivitis are considered as acute conjunctivitis. Allergic conjunctivitis can be chronic while it can be present with acute exacerbations related to seasonal factors or contact lens use. It is important to differentiate conjunctivitis from other sight-threatening eye diseases that have similar clinical presentation.

## Causes

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### Life Threatening Causes

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Most cases of conjunctivitis are relatively mild and will not cause eye damage of any sort. However, if it left untreated it can lead to sight-treathening complications including:[1]

* keratitis \- which occurs mostly on contact-lens wearers
* keratoconjunctivitis
* Scarring of the eye \- especially associated with trachoma[2]
* Uveitis \- especially associated with herpes simplex virus[2]

### Viral conjunctivitis

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* Adenoviruses are the most common cause of viral conjunctivitis[3]
* Herpes simplex virus (HSV)
* Varicella zoster virus (VZV)
* Picornaviruses[4]

### Bacterial conjunctivitis

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* Staphylococcus aureus[2]
* Haemophilus influenza
* Streptococcus pneumoniae
* Moraxella catarrhalis

## Diagnosis

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Some initial diagnosis should be excluded for which physicians should manage patients by a systematic approach.[5]

Suspected acute conjunctivitis
(<4 weeks duration)

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Associated with pain, blurred vision, photophobia

Yes

Ophthalmology referral

Any discharge

Yes

Hyperpurulent

Mucopurulent

Serous

Ophthalmology referral

Gonococcal conjunctivitis

Bacterial conjunctivitis

Itiching

Ophthalmology referral

Yes

Allergic conjunctivitis

Viral conjunctivitis

### Differential Diagnosis

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Differential diagnosis  | Manifestation  | Examination findings

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Blepharitis |

* Burning and foreign-body sensation, symptoms worse with prolonged reading or watching[6]

* Bilateral redness

Uveitis |

* Photophobia, pain, blurred vision[7][7][7][7][7][7][7][7][7][7][7][7][7][7]

* Decreased vision, poorly reacting pupils, constant eye pain radiating to temple and brow, red-eye

Angle closure glaucoma |

* Headache, nausea, vomiting, ocular pain, decreased vision, light sensitivity[8][8][8][8][8][8][8][8][8][8][8][8][8]

* Firm eye on palpation, ocular redness, steamy cornea

Endophthalmitis[9][9][9] |

* Severe pain, photophobia[9][9][9][9][9][9][9][9][9][9][9][9][9][9]

* Red-eye, pus in the anterior chamber, history of eye surgery or ocular trauma

Scleritis |

* Decreased vision, moderate to severe pain[10]

* Redness, bluish sclera

Subconjunctival hemorrhage |

* Foreign-body sensation and tearing or be asymptomatic[11][11][11][11][11][11][11][11][11][11][11][11]

* Blood under the conjunctival membrane

Corneal abrasion |

* Red-eye, pain, foreign-body sensation and tearing[1]

* If caused by a foreign-body, it can be found on biomicroscopic exam

## Treatment

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Medical therapy for conjunctivitis[5] Category  |  Epidemiology  |  Type of discharge  |  Cause  |  Treatment

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Viral conjunctivitis |

* 80% of all acute conjunctivitis

* Serous

* Adenovirus in 65% of cases

* Cold compress

* Artificial tears

* Antihistamines

HSV |

* 1.3-4.8% of all acute conjunctivitis

* Variable

* Herpes simplex virus

* Topical acyclovir 1 drop 9x per day for 7-10 days

Acute bacterial conjunctivitis |

* 18.3%-57% of all acute conjunctivitis

* Mucopurulent

* Staphylococcus aureus
* Staphylococcus epidermidis

* Haemophilus influenzae
* Streptococcus pneumoniae

* Aminoglycosides
* Gentamicin

* Ointment: qid for 1 wk
* Solution: 1-2 drops qid for 1 week
Fluoroquinolones

* Ciprofloxacin

* Ointment: Tid (three times a day) for 1 wk
* Solution: 1-2 drops Qid (four times a day) for 1 week

Allergic conjunctivitis |

* Up to 40% of the population may be affected

* Serous or mucoid

* Pollen

* Topical antihistamines
* Azelastine 0.05%: 1 drop bid

* Topical mast cell inhibitors
* Cromolyn sodium 4%: 1-2 drops every 4-6 h

## Do's

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* In assessment of a person presenting with red eye, serious causes (such as acute glaucoma, keratitis, iritis and trauma) must be excluded.[12][13]
* Urgent referral to ophthalmology should be arranged if the person has:
* A red flag indicating a serious cause of red eye
* Suspected gonococcal or chlamydial conjunctivitis
* Suspected periorbital or orbital cellulitis
* Had recent intraocular surgery
* Conjunctivitis associated with a severe systemic condition or is immunocompromised
* Corneal involvement
* Possible herpes infection
* Reassuring the person that most cases are self-limiting
* Advising self-care measures such as cleaning the eyelids, cool compresses, lubricating drops or artificial tears and avoidance of contact lenses
* In most cases of bacterial conjunctivitis, observation can be the only option because they often resolve spontaneously and no treatment is necessary. However, using topical antibiotics is are effective in reducing the duration of conjunctivitis
* Topical antihistamines and mast cell stabilizers in allergic conjunctivitis is recommended
* In cases of severely purulent conjunctivitis or chronic conjunctivitis bacterial culture is useful

## Don'ts

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* People with weaker immune systems such as those with diabetes and people who don’t wash their hands before inserting or removing contact lenses are more at risk of bacterial conjunctivitis.[14]
* Patients with any form of conjunctivitis should refrain from wearing contact lenses until the conjunctivitis has completely cleared up.
* Both types of infectious conjunctivitis are very contagious and easily spread. It is important to avoid contacting others or sharing equipment with other people to help prevent spreading the infection.

## References

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1. ↑ 1.0 1.1 Epling J (2012). "Bacterial conjunctivitis". BMJ Clin Evid. 2012. PMC 3635545. PMID 22348418.
2. ↑ 2.0 2.1 2.2 Azari AA, Arabi A (2020). "Conjunctivitis: A Systematic Review". J Ophthalmic Vis Res. 15 (3): 372–395. doi:10.18502/jovr.v15i3.7456. PMC 7431717 Check `|pmc=` value (help). PMID 32864068 Check `|pmid=` value (help).
3. ↑ Yeu E, Hauswirth S (2020). "A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management". Clin Ophthalmol. 14: 805–813. doi:10.2147/OPTH.S236571. PMC 7075432 Check `|pmc=` value (help). PMID 32210533 Check `|pmid=` value (help).
4. ↑ Chaturvedi UC, Mathur A, Singh UK, Kapoor AK, Mehrotra RM, Saxena RC (1975). "An epidemic of picornavirus and adenovirus conjunctivitis". Br J Ophthalmol. 59 (8): 439–43. doi:10.1136/bjo.59.8.439. PMC 1017389. PMID 173388.CS1 maint: Multiple names: authors list (link)
5. ↑ 5.0 5.1 Azari AA, Barney NP (2013). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMC 4049531. PMID 24150468.
6. ↑ Amescua, Guillermo; Akpek, Esen K.; Farid, Marjan; Garcia-Ferrer, Francisco J.; Lin, Amy; Rhee, Michelle K.; Varu, Divya M.; Musch, David C.; Dunn, Steven P.; Mah, Francis S. (2019). "Blepharitis Preferred Practice Pattern®". Ophthalmology. 126 (1): P56–P93. doi:10.1016/j.ophtha.2018.10.019. ISSN 0161-6420.
7. ↑ Harthan JS, Opitz DL, Fromstein SR, Morettin CE (2016). "Diagnosis and treatment of anterior uveitis: optometric management". Clin Optom (Auckl). 8: 23–35. doi:10.2147/OPTO.S72079. PMC 6095364. PMID 30214346.CS1 maint: Multiple names: authors list (link)
8. ↑ Weinreb RN, Aung T, Medeiros FA (2014). "The pathophysiology and treatment of glaucoma: a review". JAMA. 311 (18): 1901–11. doi:10.1001/jama.2014.3192. PMC 4523637. PMID 24825645.CS1 maint: Multiple names: authors list (link)
9. ↑ Callegan MC, Engelbert M, Parke DW, Jett BD, Gilmore MS (2002). "Bacterial endophthalmitis: epidemiology, therapeutics, and bacterium-host interactions". Clin Microbiol Rev. 15 (1): 111–24. doi:10.1128/cmr.15.1.111-124.2002. PMC 118063. PMID 11781270.CS1 maint: Multiple names: authors list (link)
10. ↑ Al Barqi M, Behrens A, Alfawaz AM (2015). "Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia". Int J Ophthalmol. 8 (6): 1215–9. doi:10.3980/j.issn.2222-3959.2015.06.25. PMC 4651892. PMID 26682176.CS1 maint: Multiple names: authors list (link)
11. ↑ Tarlan B, Kiratli H (2013). "Subconjunctival hemorrhage: risk factors and potential indicators". Clin Ophthalmol. 7: 1163–70. doi:10.2147/OPTH.S35062. PMC 3702240. PMID 23843690.
12. ↑ Owen CG, Shah A, Henshaw K, Smeeth L, Sheikh A (2004). "Topical treatments for seasonal allergic conjunctivitis: systematic review and meta-analysis of efficacy and effectiveness". Br J Gen Pract. 54 (503): 451–6. PMC 1266207. PMID 15186569.CS1 maint: Multiple names: authors list (link)
13. ↑ Leibowitz HM (2000). "The red eye". N Engl J Med. 343 (5): 345–51. doi:10.1056/NEJM200008033430507. PMID 10922425.
14. ↑ Tarabishy AB, Jeng BH (2008). "Bacterial conjunctivitis: a review for internists". Cleve Clin J Med. 75 (7): 507–12. doi:10.3949/ccjm.75.7.507. PMID 18646586.