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  1. 1. CONJUNCTIVITIS and other eye lesions October 2003 Claire Gogal
  2. 2. Definition • Conjunctivitis: inflammation of the conjunctiva • Conjunctiva: thin, translucent, elastic tissue layer with bulbar and palpebral portions • Bulbar: lines the outer surface of the globe to the limbus (junction of sclera and cornea) • Palpebral: covers the inside of the eyelids • Two layers: epithelium, substantia propria
  3. 3. Eye Anatomy
  4. 4. Classification of Conjunctivitis Viral • Infectious → Hyperacute Bacterial → Acute Chronic • Noninfectious → Allergic, Toxins/ Chemicals, Foreign body, Trauma, Neoplasm
  5. 5. Prevalence
  6. 6. Viral Conjunctivitis • Most common viral cause is adenovirus (enterovirus, HSV) • Occurs in community epidemics (schools, workplaces, physicians’ offices) • Usual modes of transmission: contaminated fingers, medical instruments, swimming pool water
  7. 7. Viral Conjunctivitis • Presentation: unilateral or bilateral, acutely red eye, watery or mucoserous discharge, chemosis, tender preauricular node, burning/ sanding/gritty feeling in eye(s), rarely photophobia • May be part of viral prodrome: adenopathy, fever, pharyngitis, cough, rhinorrhea
  8. 8. Acute Bacterial Conjunctivitis • Common causes in neonates: Chlamydia trachomatis, Neisseria gonorrhoeae • In children: Haemophilus influenzae (80%), Streptococcus pneumoniae (20%), and Moraxella catarrhalis. Concurrent OM seen in 25%. • In adults: Staphylococcus aureus
  9. 9. Acute Bacterial Conjunctivitis • Presentation: Unilateral or bilateral, red eye, mucopurulent or purulent discharge continuously throughout the day, burning, irritation, mild chemosis • Neonates: symptoms appear 5-14d after birth (inclusion conjunctivitis of the newborn) • Highly contagious: spread by direct contact or by contaminated objects
  10. 10. Hyperacute Bacterial Conjunctivitis • Etiology: Neisseria species, most commonly N. gonorrhoeae • Presentation: profuse, purulent discharge with rapidly progressive symptoms of marked conjunctival injection, irritation, tenderness to palpation, chemosis, lid swelling, and tender preauricular adenopathy • Ophthalmia neonatorum: gonococcal ocular infection with bilateral discharge 3-5d after birth from vaginal transmission • Sexually active teens: transmitted from genitalia to hands to eyes, commonly see concurrent urethritis • Sight-threatening
  11. 11. Chronic Bacterial Conjunctivitis • Most common etiology: Staphylococcus species • More common in adults and patients with acne rosacea or facial seborrhea • Presentation varies: redness, itching, burning, foreign-body sensation, flaky debris, blepharitis (common), eyelash loss • Concurrently see styes and chalazia of the lid margin from chronic inflammation of the meibomian glands
  12. 12. Allergic Conjunctivitis • Most commonly seasonal allergic rhinoconjunctivitis, also called hay fever rhinoconjunctivitis • IgE mediated hypersensitivity reaction precipitated by small airborne allergens→ local mast cell degranulation → release of chemical mediators (histamine, eosinophil chemotactic factors, PAF, etc.) • Presentation: bilateral, pruritis, redness, watery discharge, rhinorrhea/congestion • Patients often have h/o atopy, seasonal allergy or specific allergy
  13. 13. Discharge Discharge Associated with Conjunctivitis Etiology Serous Mucoid Mucopurulent Purulent Viral Chlamydial Bacterial Allergic Toxic + - - + + - + - + + - + + - + - - + - - +=Present; -=absent. Adapted with permission from Jackson WB. Differentiating conjunctivitis of diverse origins. Surv Ophthalmol 1993;38(Suppl):91-104
  14. 14. Diagnosis of Conjunctivitis • Clinical diagnosis of exclusion • Morning crusting of eye unreliable for determining etiology • If focal pathology (hordeolum, cancerous lesion or blepharitis), conjunctivitis is reactive rather than primary • If redness is localized rather than diffuse, consider foreign body, pterygium or episcleritis
  15. 15. “Pink Eye” Differential
  16. 16. Cultures • Not necessary for initial diagnosis and therapy of acute conjunctivitis • When to culture: 1. Neonates 2. Hyperacute purulent conjunctivitis (immediate Gram staining) 3. Chronic or recurrent conjunctivitis
  17. 17. Treatment • Viral, allergic, and nonspecific conjunctivitis are self-limited • Bacterial conjunctivitis is also likely to be self-limited but abx treatment shortens the course, reduces person-to-person spread, and lowers the risk of sight-threatening complications
  18. 18. Treatment of Viral Conjunctivitis • Topical antibiotics not necessary because secondary bacterial infection is uncommon • Reassurance that the sxs may get worse for 3-5d before getting better and persist for 2-3 weeks • Some relief from cold compresses and topical antihistamines/decongestants • Do not use topical corticosteroids due to risk of sight-threatening complications (scarring, corneal melting, perforation), especially if etiology is herpes simplex virus or bacterial keratitis
  19. 19. Treatment of Acute Bacterial Conjunctivitis • Topical broad-spectrum antibiotics: erythromycin ointment, bacitracin-polymyxin B ointment (Polysporin), trimethropim-polymyxin B (Polytrim), sulfa drops • Most H. flu and S. pneumoniae resistant to macrolides • Sulfa drops (Bleph-10): less effective and rare side effect of Stevens-Johnson syndrome • Rx: 1/2” ointment inside lower lid or 1-2 drops QID for 5- 7 days (response seen typically within 1-2d) • Inclusion Conjunctivitis of the Newborn: treat with 2 week course of erythromycin (50mg/kg/d po divided QID) or sulfisoxazole (150mg/kg/d po divided QID), topical unnecessary with systemic
  20. 20. Treatment of Hyperacute Bacterial Conjunctivitis • Immediate ophthalmic referral • Systemic and topical antibiotics and saline irrigation • Systemic antibiotic of choice due to penicillin-resistant N. gonorrhoeae is single-dose Ceftriaxone (25-50mg/kg IV or IM, not to exceed 125mg) or single-dose Cefotaxime (100mg/kg IV or IM) in neonates • If venereal disease present in teens, also treat with single- dose of azithromycin (1g) because over 30% of these patients will have concurrent chlamydial disease • AAP and CDC recommendations for prevention of ophthalmia neonatorum: silver nitrate 1% aqueous solution (side effect of chemical conjunctivitis), erythromycin 0.5% ophthalmic ointment, tetracycline 1% ophthalmic ointment
  21. 21. Treatment of Allergic Conjunctivitis • Self-limited • Allergen avoidance, cold compresses, topical antihistamines/vasoconstrictors (do not use for greater than 2 weeks), artificial tears, topical NSAIDS (low efficacy) • Prophylaxis: oral antihistamines (onset of action=days), mast cell stabilizers (onset of action=5-14d)
  22. 22. When to Refer to Ophthalmology • Neonates • Hyperacute Purulent Conjunctivitis • Chronic Conjunctivitis • Sxs of pain, blurred vision, and photophobia • Reactive conjunctivitis vs. primary
  23. 23. School/Daycare • Bacterial and viral conjunctivitis are highly contagious • Red Book 2003: Except when viral or bacterial conjunctivitis is accompanied by systemic signs of illness, infected children should be allowed to remain in school once any indicated therapy is implemented, unless their behavior is such that close contact with other students cannot be avoided. Exclude from daycare if purulent d/c. • Safest approach for a child with bacterial conjunctivitis is to stay home until there is no longer purulent discharge (1- 2d after Rx started).
  24. 24. Eye Anatomy
  25. 25. Other Eye Lesions Anterior Uveitis • Iridocyclitis • Etiology: CMV, Cat scratch disease, JRA, Kawasaki disease, IBD, sarcoidosis • Presentation: Unilateral/Bilateral, erythema, irregular pupil, iris adhesions, pain, photophobia, poor vision • Tx: topical steroids, therapy for primary dx Posterior Uveitis • Choroiditis • Etiology: Toxoplasmosis, histoplasmosis, Toxocara canis • Presentation: No signs of erythema, decreased vision • Tx: specific therapy for pathogen
  26. 26. Uveitis
  27. 27. Other Eye Lesions Keratitis • Etiology: HSV, adenovirus, Streptococcus, Pseudomonas, Acanthamoeba, chemicals • Presentation: severe pain, corneal swelling, clouding, limbus erythema, hypopyon, h/o contact lens use • Tx: specific abxs; keratoplasty; acyclovir for HSV
  28. 28. Eye Anatomy
  29. 29. Other Eye Lesions Episcleritis • Etiology: Idiopathic, rarely seen with arthropathies • Presentation: young woman, acute, unilateral, intense erythema, large blood vessels, serous d/c • Tx: self-limiting (2-21d), no threat to vision, topical lubricants Scleritis • Etiology: systemic disease (RA, IBD, SLE, HSP, sarcoidosis, Wegener’s) • Presentation: all ages, more common in women, painful, photophobia, perforation, vision changes • Tx: systemic NSAIDS, steroids, treat underlying condition
  30. 30. Episcleritis/Scleritis
  31. 31. Other Eye Lesions Hordoleum (sty) • swelling of one or more sebaceous glands of the eyelid from bacterial infxn, internal or external • tx: warm compresses, I&D if no drainage occurs, topical abx Chalazion • hard tumor formed by distention of a meibomian gland with secretion • tx: warm compresses
  32. 32. Other Eye Lesions Pterygium • triangular thickening of bulbar conjunctiva extending from inner canthus to border of cornea with the apex towards the pupil • Tx: avoid UV radiation and dust, lubricating eye drops
  33. 33. References • Conjunctivitis. UpToDate 4/23/03 • Conjunctivitis. American Family Physician, 2/15/98 • Red Book. 2003 Report of the Committee on Infectious Diseases • Gonococcal infection in the newborn. UpToDate 7/22/02 • Chlamydia trachomatis infections in the newborn. UpToDate 3/27/03 • Rudolph’s Fundamentals of Pediatrics. 2nd edition, 1998 • Nelson’s Essentials of Pediatrics. 3rd edition, 1998 • “Should we prescribe antibiotics for acute conjunctivitis?”. Cochrane for Clinicians: Putting Evidence into Practice, 10/03. • Uveitis: Etiology; diagnosis; and treatment. UpToDate, 9/9/03. • Episcleritis and scleritis. UpToDate, 6/8/01. • Sexually Transmitted Diseases Treatment Guidelines. CDC, MMWR, 2002.