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結膜炎 JAMA 2013

Ceftriaxone: 1 g IM once C16,47 Lavage of the infected eye C16 Treatment to cover chlamydia is indicated C16,50 Dual therapy C16 1) Conjunctivitis is inflammation of the conjunctiva that covers the sclera and inside of the eyelids. 2) Causes of conjunctivitis include viral (most common), bacterial, allergic, toxic, autoimmune, and tumoral. The most common viruses are adenoviruses. 3) Treatment depends on the cause but may include antibiotics, antivirals, cold compresses

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結膜炎 Conjunctivitis JAMA. 2013;310(16):1721-1729. 13年10月24日木曜日
結膜 • 結膜は強膜と眼瞼部分を覆う薄い膜. Review of Conjunctivitis Diagnosis and Treatment 強膜部位をBulbar conjunctiva, 眼瞼部位をPalpebral conjunctivaと呼ぶ Clinical Review & Education Review • Figure 1. Normal Conjunctival Anatomy Eyelid Limbus Bulbar conjunctiva Sclera Bulbar conjunctiva Cornea Iris Palpebral conjunctiva Palpebral conjunctiva S AG I T TA L C R O SS S EC T I O N 13年10月24日木曜日 The conjunctiva is a thin membrane covering the sclera (bulbar conjunctiva, labeled with purple) and the inside of the eyelids (palpebral conjunctiva, labeled with blue).
結膜炎 • 名前の通り結膜の炎症. Conjunctivitisと呼び, 結膜の血管拡張を認め, 浮腫や浸出液を認める. • 一般的な感染症であり, 眼科よりは一般外来で対応することが多い. • 感染性ウイルス性が最も多く, 夏場で多い. 細菌性は2番目. 小児例が50-75%を占め, 12月~4月に多い. アレルギー性は全体で15-40%を占める最多の原因. 春~夏に多い. • 非感染性ではアレルギー性以外に, 毒素性, 瘢痕性, 自己免疫性, 腫瘍性が挙げられる. • 全身性疾患に付随するものとして, 淋菌, クラミジア, GVHD, Reiter症候群等. 13年10月24日木曜日
Figure 2. Suggested Algorithm for Clinical Approach to Suspected Acute Conjunctivitis Suspected acute conjunctivitis (≤ 4 wk duration) アプローチ. • No No Blurred vision? Yes Constant blurred vision? Yes No No Hyperpurulent Yes Gonococcal conjunctivitis Mucopurulent Bacterial conjunctivitis (nongonococcal) Serous No Yes 眼痛や羞明, 複視があれば Methods 眼科診察が必要. Yes Photophobia? Itching? プライマリケアでの Yes Pain? Discharge? • referral. An algorithmic approach (Figure 2) using a focused history along with a penlight eye examination may be helpf agnosis and treatment. Because conjunctivitis and many oth lar diseases can present as “red eye,” the differential diagnos eye and knowledge about the typical features of each diseas category are important (Table 1). Allergic conjunctivitis Dry eye disease No Ophthalmology referral Conjunctivitis can be divided into infectious and noninfectious causes. Viruses and bacteria are the most common infectious causes. Noninfectious conjunctivitis includes allergic, toxic, and cicatricial 13年10月24日木曜日 TheliteraturepublishedthroughMarch2013wasreviewedby ing PubMed, the ISI Web of Knowledge database, and the Co Library. The following keywords were used: bacterial conjun • 膿性分泌物の場合は viral conjunctivitis, allergic conjunctivitis, treatment of bacte junctivitis, and treatment of viral conjunctivitis. No language 淋菌や細菌性を考慮. tion was applied. Articles published between March 2003 an 2013 were initially screened. After review of titles, abstrac and 掻痒感が強ければ were identified and sc • references for the articles, more Articles and meta-analyses that provided evidence-based in tionアレルギー性を考慮. treatment of variou about the cause, management, and of conjunctivitis were selected. A total of 86 articles were in in this review. The first study8 was published in 1982 and th in 2012. A level of evidence was assigned to the recommen • ただし, 細菌性結膜炎の presented in Table 2 and Table 3 with the American Heart A tion58%は掻痒感(+), grading system: “The strongest weight65%, 熱感 of evidence (A signed if there are multiple randomized trials with large num patients. An intermediate weight (B) is assigned if there ar 漿液性浸出液 or 無し が35% ited number of randomized trials with small numbers of p careful analyses of non-randomized studies, or observatio
• 結膜炎意外のRed eyeを来す疾患群 Review Clinical Review & Education Review of Conjunctivitis Diagnosis and Treatment Table 1. Selected Nonconjunctivitis Causes of Red Eyea Differential Diagnosis Symptoms Penlight Examination Findings Dry eye disease Burning and foreign-body sensation. Symptoms are usually transient, worse with prolonged reading or watching television because of decreased blinking. Symptoms are worse in dry, cold, and windy environments because of increased evaporation. Bilateral redness Blepharitis Similar to dry eyes Redness greater at the margins of eyelids Uveitis Photophobia, pain, blurred vision. Symptoms are usually bilateral. Decreased vision, poorly reacting pupils, constant eye pain radiating to temple and brow. Redness, severe photophobia, presence of inflammatory cells in the anterior chamber. Angle closure glaucoma Headaches, nausea, vomiting, ocular pain, decreased vision, light sensitivity, and seeing haloes around lights. Symptoms are usually unilateral. Firm eye on palpation, ocular redness with limbal injection. Appearance of a hazy/steamy cornea, moderately dilated pupils that are unreactive to light. Carotid cavernous fistula Chronic red eye; may have a history of head trauma Dilated tortuous vessels (corkscrew vessels), bruits on auscultation with a stethoscope Endophthalmitis Severe pain, photophobia, may have a history of eye surgery or ocular trauma Redness, pus in the anterior chamber, and photophobia Cellulitis Pain, double vision, and fullness Redness and swelling of lids, may have restriction of the eye movements, may have a history of preceding sinusitis (usually ethmoiditis) Anterior segment tumors Variable Abnormal growth inside or on the surface of the eye Scleritis Decreased vision, moderate to severe pain Redness, bluish sclera hue Subconjunctival hemorrhage May have foreign-body sensation and tearing or be asymptomatic Blood under the conjunctival membrane a Data are from Cronau et al18 and Leibowitz.1 The examination can be done by shining a penlight in the patient’s affected eye(s). 13年10月24日木曜日
感染性結膜炎 • Viral conjunctivitis;  • 急性結膜炎の80%はウイルス性. 65-90%はAdenovirusによるものであり, 2つの臨床型がある.  > Pharyngoconjunctival FeverとEpidemic keratoconjunctivitis. • Pharyngoconjucnctival Feverとは, 急性の発熱, 咽頭痛, 両側性の結膜炎,  耳介周囲リンパ節腫大を呈する病態 • Epidemic keratoconjunctivitisはもっと高度な結膜炎を呈し,  多量の水様の浸出液, 浮腫, 充血, 同側のリンパ節腫大を呈する. • リンパ節腫大は50%で認められ, 細菌性よりも頻度は高い. 13年10月24日木曜日
Table 2. Ophthalmic Therapies for Conjunctivitis Category Epidemiology Acute bacterial conjunctivitis 135 case per 10 000 population in US3 18.3%-57% of all acute conjunctivitis7-9,12,13 Type of Discharge Mucopurulent Cause Treatment S aureus, S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp Level of Evidence for Treatment Aminoglycosides B20-22 Tobramycin ointment: 3 ×/d for 1 wk A23-30 Besifloxacin: 1 drop 3 ×/d for 1 wk • Gentamicin Ointment: 4 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk A31-34 Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk A24,28,29 Adenovirusによる結膜炎は10-50%で感染播種する. Fluoroquinolones • 感染経路は浸出液が付いた手, 物, 医療機器, プール等. Gatifloxacin: 3 ×/d for 1 week Levofloxacin: 1-2 drops 4 ×/d for 1 wk 潜伏期間は5-12日間で, 排菌期間は10-14日間. 3 ×/d for 1 wk Moxifloxacin: Ofloxacin: 1-2 drops 4 ×/d for 1 wk B35 B36-38 A34,39,40 A37,38,41,42 Macrolides 特異的な治療は無く, 冷やしたり, 人工涙を使用したり, 1 drop Azithromycin: 2 ×/d for 2 d; then A27,30,43,44 Erythromycin:  抗ヒスタミンを使用する等対症療法を行う. 4 ×/d for 1 wk • B45 daily for 5 d Sulfonamides • 7-10日で改善しない場合や, Clinical Review & Education Review B22 Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk Review of Conjunctivitis Diagnosis and Treatment Combination drops  合併症を生じた場合は眼科コンサルトの必要がある. Trimethoprim/polymyxin B: 1 or 2 drops 4 ×/d for 1 wk NA Purulent Hyperacute Table 2. Ophthalmic Therapies for Conjunctivitis bacterial conjunctivitis in adults Category Acute Viral bacterial conjunctivitis conjunctivitis Herpes zoster virus 13年10月24日木曜日 Epidemiology 135 case per all 000 9%-80.3% of 10 acute population in US3 conjunctivitis8-13 18.3%-57% of all acute conjunctivitis7-9,12,13 NA Type of Discharge Mucopurulent Serous Variable Cause S aureus, are due to Up to 65% S epidermidis, H influenzae, adenovirus strains49 S pneumoniae, S viridans, Moraxella spp Herpes zoster virus Ceftriaxone: 1 g IM once C16,47 Lavage of the infected eye Neisseria gonorrhoeae A22,40,46 C16 Level of Evidence for Treatment C48 Treatment to cover chlamydia is indicated Dual therapy Aminoglycosides Cold compress Artificial tears Gentamicin Antihistamines Ointment: 4 ×/d for 1 wk Solution: 1-2 dropsmg: 5 ×/d 1 wk Oral acyclovir 800 4 ×/d for for 7-10 d Tobramycin ointment: 3 ×/d for 1 wk C16,50 B20-22 C16 16 A23-30
Tobramycin ointment: 3 ×/d for 1 wk • A23-30 Fluoroquinolones Herpes Conjunctivitis; ヘルペス結膜炎 Besifloxacin: 1 drop 3 ×/d for 1 wk A31-34 Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk • A24,28,29 Gatifloxacin: 3 ×/d for 1 week B35 HSVは急性結膜炎の1.3-4.8%を占める原因. Levofloxacin: 1-2 drops 4 ×/d for 1 wk Moxifloxacin: 3 ×/d for 1 wk B36-38 A34,39,40  通常片側で浸出液は水様で, 眼瞼結膜に小水疱性眼瞼炎を生じる. Ofloxacin: 1-2 drops 4 ×/d for 1 wk A 37,38,41,42 Macrolides  局所, 経口の抗ウイルス薬は病期を短縮し得る. for 2 d; then 1 drop Azithromycin: 2 ×/d daily for 5 d Erythromycin: 4 ×/d for 1 wk • Sulfonamides VZVも原因となる. V1,2を含む帯状疱疹の場合に生じ, Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk A27,30,43,44 B45 B22  眼瞼に生じることが多い(45.8%). 次いで結膜に生じる(41.1%) Combination drops  角膜の障害を38.2%, ぶどう膜炎を19.1%で生じる. B: 1 or 2 drops Trimethoprim/polymyxin Clinical Review & Education Review NA Hyperacute bacterial conjunctivitis in adults Purulent Neisseria gonorrhoeae Lavage of the infected eye Table 2. Ophthalmic Therapies for Conjunctivitis 9%-80.3% of all acute conjunctivitis8-13 Epidemiology Serous Type of Discharge Up to 65% are due to adenovirus strains49 Cause Acute zoster Herpes bacterial conjunctivitis virus 135 NA case per 10 000 population in US3 18.3%-57% of all acute conjunctivitis7-9,12,13 Mucopurulent Variable S aureus, Herpes zoster virus S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp 1.3-4.8 of all acute conjunctivitis9-12 Variable Herpes simplex virus C16 Dual therapy to cover chlamydia is indicated Viral conjunctivitis Category Herpes simplex virus A22,40,46 4 ×/d for 1 wk Review of Conjunctivitis Diagnosis and Treatment Ceftriaxone: 1 g IM once C16,47 C48 Cold compress Artificial tears Treatment Antihistamines Aminoglycosides mg: 5 ×/d for 7-10 d Oral acyclovir 800 Level of Evidence C16,50 for Treatment C16 Gentamicin Oral famciclovir 500 mg: 3 ×/d for 7-10 d Ointment: 4 ×/d for 1 wk Oral valacyclovir 1000 mg: 3 wk Solution: 1-2 drops 4 ×/d for 1×/d for 7-10 d 20-22 BC16 Topical acyclovir: 1 drop 9 for Tobramycin ointment: 3 ×/d×/d 1 wk 23-30 AC16 Fluoroquinolones mg: 7-10 d Oral acyclovir 400 C16 C16 Besifloxacin: 1 drop 3 ×/d for×/d for 7-10 d Oral valacyclovir 500 mg: 3 1 wk 13年10月24日木曜日1.8%-5.6% of all acute Adult inclusion Variable Chlamydia trachomatis 31-34 AC16 Ciprofloxacin ointment: 3once for 1 wk Azithromycin 1 g: orally ×/d 24,28,29 AB16,51
• Bacterial Conjunctivitis; 細菌性結膜炎 • 細菌性結膜炎の頻度は135/10000. 感染経路は直接感染, 手指を介した感染, 汚染された媒介物より. また, 外傷や眼球の傷, 免疫抑制状態といった患者側の要素も重要. • 原因菌としては, Staphylococcal spp > S pneumoniae > H influenzae.  小児ではH influenzae > S pneumoniae > Moraxella catarrhalis. • 潜伏期間は1-7日, 排菌期間は2-7日程度. 結膜炎は通常7-10日持続する. • 眼瞼に膿性物質があること, 眼瞼の癒着, 掻痒感(-), 結膜炎の病歴が無い点は細菌性結膜炎を示唆する情報となる. コンタクトレンズもHigh-riskとなり, Abx点眼を考慮する. 13年10月24日木曜日
• Hyperacute bacterial conjunctivitis;  • 重度の膿性浸出液と視力の低下を伴う結膜炎. 眼瞼の腫脹, 眼圧痛, 耳介周囲リンパ節腫大を伴い, 淋菌が原因となることが多い. 角膜損傷や • 孔を伴うこともある. 治療はCTRXの筋注. 重度の膿性浸出液がある場合は必ず淋菌をチェックすること. また, 抗生剤に反応しない例はクラミジアをチェック. • Chronic bacterial conjunctivitis;  • 4wk以上持続する結膜炎で, Staphylococcus aureus, Moraxella lacunata,  腸管内細菌が原因として多い. 13年10月24日木曜日
rus and may cause harm.16,71 Herpes zoster virus, responsible for shingles, can involve ocular tissue, especially if the first and second branches of the trigeminal nerve are involved. Eyelids (45.8%) are the most common site of ocular involvement, followed by the conjunctiva (41.1%).72 Corneal complication and uveitis may be present in 38.2% and 19.1% Good hand hygiene can be used to decrease the spread of acute viral conjunctivitis. C16 Bacterial cultures can be useful in cases of severely purulent conjunctivitis or cases that are recalcitrant to therapy. C16 It may be helpful to treat viral conjunctivitis with artificial tears, topical antihistamines, or cold compresses. C16 Topical steroids are not recommended for bacterial conjunctivitis. C65 Figure 3. Characteristic Appearance of Bacterial and Viral Conjunctivitis A Bacterial conjunctivitis B Hyperacute bacterial conjunctivitis A, Bacterial conjunctivitis characterized by mucopurulent discharge and conjunctival hyperemia. B, Severe purulent discharge seen in hyperacute bacterial conjunctivitis secondary to gonorrhea. C, Intensely hyperemic jama.com m: http://jama.jamanetwork.com/ by JUNKO NAGASUE on 10/22/2013 13年10月24日木曜日 C Viral conjunctivitis response with thin, watery discharge characteristic of viral conjunctivitis. Images reproduced with permission: © 2013 American Academy of Ophthalmology. JAMA October 23/30, 2013 Volume 310, Number 16
• 細菌性結膜炎の治療 • 60%は1-2wkで自然に治癒する経過となる. • 抗生剤の点眼は病期を短縮し得るが, 臨床的アウトカムには影響しない. 一部では10%程度の予後改善効果があるとのことで, 通常使用される. • S pneumoniae, N gonorrhoeae, H influenzaeは毒性も強く, 組織への侵襲も強い為, 重症化し易い傾向がある. 13年10月24日木曜日
Fluoroquinolones Table 2. Ophthalmic Therapies for Conjunctivitis Category Acute bacterial conjunctivitis Epidemiology 135 case per 10 000 population in US3 18.3%-57% of all acute conjunctivitis7-9,12,13 Type of Discharge Mucopurulent Cause S aureus, S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp Hyperacute bacterial conjunctivitis in adults NA Viral conjunctivitis 9%-80.3% of all acute conjunctivitis8-13 Serous Up to 65% are due to adenovirus strains49 Herpes zoster virus NA Variable Herpes zoster virus Hyperacute Herpes simplex bacterial virus conjunctivitis in adults NA 1.3-4.8 of all acute conjunctivitis9-12 Viral Adult inclusion conjunctivitis 9%-80.3% of all acute 1.8%-5.6%of all acute 8-13 conjunctivitis5,8-11 Serous Variable Up to 65% are due to Chlamydia trachomatis adenovirus strains49 Allergic 90% of all allergic NA 15 Serous or Variable Pollens zoster virus Herpes Herpes zoster 13年10月24日木曜日 Purulent Besifloxacin: 1 drop 3 ×/d for 1 wk Neisseria gonorrhoeae A31-34 Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk Treatment Gatifloxacin: 3 ×/d for 1 week Aminoglycosides A24,28,29Evidence Level of for Treatment B35 Levofloxacin: 1-2 drops 4 ×/d for 1 wk Gentamicin Ointment: 4 3 for 1 wk Moxifloxacin:×/d×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk Ofloxacin: 1-2 drops 4 ×/d for 1 wk Tobramycin ointment: 3 ×/d for 1 wk Macrolides Fluoroquinolones Azithromycin: 2 ×/d for 2 d; then 1 drop Besifloxacin: daily for 5 d 1 drop 3 ×/d for 1 wk Ciprofloxacin 4 ×/d for 3 ×/d Erythromycin:ointment: 1 wk for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk Sulfonamides Gatifloxacin: 3 ×/d for 1 week Sulfacetamide ointment: 4 ×/d and at Levofloxacin: 1-2 bedtime for 1 wk drops 4 ×/d for 1 wk Solution: 1-2 drops every wk h for 1 wk Moxifloxacin: 3 ×/d for 1 2-3 Combination drops Ofloxacin: 1-2 drops 4 ×/d for 1 wk Trimethoprim/polymyxin B: 1 or 2 drops Macrolides 4 ×/d for 1 wk Azithromycin: 2 ×/d for Ceftriaxone: 1 g IM once2 d; then 1 drop daily for 5 d Lavage of the infected eye Erythromycin: 4 ×/d for 1 wk Dual therapy to cover chlamydia is indicated Sulfonamides Cold compress Sulfacetamide Artificial tears ointment: 4 ×/d and at bedtime for 1 wk Antihistamines Solution: 1-2 drops every 2-3 h for 1 wk Oral acyclovir 800 mg: 5 ×/d for 7-10 d Combination drops Oral famciclovir 500 mg: 3 ×/d for 7-10 d Trimethoprim/polymyxin B: 1 or 2 drops Oral valacyclovir 1000 mg: 3 ×/d for 7-10 d 4 ×/d for 1 wk B36-38 B20-22 A34,39,40 A37,38,41,42 A23-30 A27,30,43,44 A31-34 A24,28,29 B45 B35 B22 B36-38 A34,39,40 A37,38,41,42 A22,40,46 A27,30,43,44 C16,47 C16 B45 C48 B22 C16,50 C16 C16 A22,40,46 C16 C16,47 C16 C16 C16 Dual therapy to cover chlamydia is 7-10 d Oral valacyclovir 500 mg: 3 ×/d forindicated Neisseria gonorrhoeae Herpes simplex virus Ceftriaxone: 1 g IM once Topical acyclovir: 1 drop 9 ×/d Lavage of the 400 mg: 7-10 Oral acyclovir infected eye d Purulent Variable C48 C16 Cold compress Azithromycin 1 g: orally once Artificial tears Doxycycline 100 mg: orally 2 ×/d for 7 d Antihistamines Topical antihistamines 5 ×/d for 7-10 d Oral acyclovir 800 mg: B16,51 16,50 C16,51 B C16
• 特殊な細菌性結膜炎; • MRSA結膜炎; 特殊な例であり, 眼科診察が必要.  VCMによる治療が必要となる. • クラミジア結膜炎; 1.8-5.6%を占める.  片側性であり, 陰部感染症も併発(男性54% 女性74%).  結膜充血, 粘性膿性分泌物, Lymphoid follicle formationが  特徴的な所見. • 淋菌性結膜炎; Hyperacute conjunctivitisの主な原因. 13年10月24日木曜日
• Trachomaによる結膜炎;  TrachomaはChlamydia trachomatis subtypes A~Cによる感染症で  失明の原因となる病態.  粘性膿性分泌物と眼球の異常が主な症状, 所見となる.  晩期の眼球損傷, 結膜炎, 角膜障害が失明の主な原因.  Azithromycin 20mg/kgの単回投与が効果的. Abx点眼は6wk程度使用  TC, EMを3wk使用すること選択肢. 13年10月24日木曜日
• Allergic Conjunctivitis; アレルギー性結膜炎 • 花粉や動物由来抗原等に反応し生じる炎症. 結膜炎の40%を占めるが, 未受診の患者も多い. • 結膜充血と掻痒感が強いのが特徴. • 治療は抗原暴露の回避と生理食塩水や人工涙で抗原を薄める. 薬剤では点眼のDecongestant, 抗ヒスタミン, Mast cell stabilizer, NSAID, ステロイド薬の使用. • 抗ヒスタミンやDecongestantの長期使用は 反動性血管充血を来す為に注意が必要. • ステロイド点眼は白内障や緑内障のリスクを上げる. 13年10月24日木曜日
Herpes zoster virus NA Variable Herpes zoster virus 1.3-4.8 of all acute conjunctivitis9-12 C16 Oral famciclovir 500 mg: 3 ×/d for 7-10 d C16 Review of ×/d for 7-10 Diagnosis and Treatment Oral valacyclovir 1000 mg: 3Conjunctivitis d C16 Clinical Review & Education Review Herpes simplex virus Oral acyclovir 800 mg: 5 ×/d for 7-10 d Table 2. Ophthalmic Therapies for Conjunctivitis Adult inclusion conjunctivitis Category 1.8%-5.6% of all acute conjunctivitis5,8-11 Epidemiology Variable Type of Discharge Chlamydia trachomatis Cause Acute bacterial Allergic conjunctivitis conjunctivitis 135 case per 10 000 90% of all allergic population in 15 3 US conjunctivitis ; 18.3%-57% of all acute up to 40% of 7-9,12,13 conjunctivitis population may be affected15 Mucopurulent Serous or mucoid S aureus, Pollens S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp C16 C16 Oral valacyclovir 500 mg: 3 ×/d for 7-10 d Herpes simplex virus Topical acyclovir: 1 drop 9 ×/d Oral acyclovir 400 mg: 7-10 d Variable C16 Azithromycin 1 g: orally once Treatment Doxycycline 100 mg: orally 2 ×/d for 7 d B16,51of Evidence Level for Treatment B16,51 Aminoglycosides Topical antihistamines Gentamicin Azelastine 0.05%: 1 drop 2 ×/d Ointment: 4 ×/d for 1 wk Solution: 1-2 drops 4 ×/d 4 1 wk Emedastine 0.05%: 1 dropfor×/d Tobramycin cell inhibitors Topical mastointment: 3 ×/d for 1 wk 20-22 B52 A A52 A23-30 Fluoroquinolones Cromolyn sodium 4%: 1-2 drops every 4-6 h Besifloxacin: 1 drop 3 drops 1 wk Lodoxamide 0.1%: 1-2×/d for4 ×/d A52 A31-34 A52 Ciprofloxacin ointment: 3 2 ×/d Nedocromil 2%: 1-2 drops ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk NSAIDs Gatifloxacin: 3 ×/d for 1 week Ketorolac: 1 drop 4 ×/d Levofloxacin: 1-2 drops 4 ×/d for 1 wk Vasoconstrictor/antihistamine Moxifloxacin: 3 ×/d for 1 wk Naphazoline/pheniramine: 1-2 drops up to Ofloxacin: 1-2 drops 4 ×/d for 1 wk 4 ×/d Macrolides Combination drops A24,28,29 A52 Azithromycin: 2 ×/d drop d; then Ketotifen 0.025%: 1 for 2 2-3 ×/d1 drop daily for 5 d Olopatadine 0.1%: 1 drop 2 ×/d Erythromycin: 4 ×/d for 1 wk Abbreviations: IM, intramuscularly; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs. Sulfonamides Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk B35 B53,54 B36-38 A34,39,40 B55 A37,38,41,42 A27,30,43,44 A56,57 A58,59 B45 B22 Combination drops Trimethoprim/polymyxin B: 1 or 2 drops 4 ×/d for 1 wk JAMA October 23/30, 2013 Volume 310, Number 16 Hyperacute bacterial 13年10月24日木曜日 NA Purulent Neisseria gonorrhoeae A22,40,46 Ceftriaxone: 1 g IM once C16,47 Lavage of the infected eye C16 jama.com
• 薬剤, 化学, 毒性結膜炎 • 抗生剤点眼, 抗ウイルス薬点眼, 潤滑性点眼薬は, 塩化ベンザルコニウムが含まれており, それによるアレルギー性結膜炎を来すことがある. • 結膜炎を来す全身疾患 • Mucous membrane pemphigoid, Sjogren syndrome, 川崎病, Stevens-Johnson syndrome, Carotid cavernous fistulaで結膜炎を来す. • 軽症の頸動脈-静脈洞瘻では慢性の結膜炎のみ呈することがある. 13年10月24日木曜日
• 抗生剤/ステロイド合剤点眼 不使用ノススメ • アデノウイルスによる結膜炎にステロイドを使用することで, 感染が長期化するリスクがあがる. • また, 角膜潰瘍を見逃した状態でステロイド点眼を使用すると, ステロイドにより角膜が溶解し失明に至る可能性もあるため, 容易に抗生剤/ステロイド合剤は使用すべきでない. 13年10月24日木曜日

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結膜炎 JAMA 2013

  • 1.
  • 2.
    結膜 • 結膜は強膜と眼瞼部分を覆う薄い膜. Review of ConjunctivitisDiagnosis and Treatment 強膜部位をBulbar conjunctiva, 眼瞼部位をPalpebral conjunctivaと呼ぶ Clinical Review & Education Review • Figure 1. Normal Conjunctival Anatomy Eyelid Limbus Bulbar conjunctiva Sclera Bulbar conjunctiva Cornea Iris Palpebral conjunctiva Palpebral conjunctiva S AG I T TA L C R O SS S EC T I O N 13年10月24日木曜日 The conjunctiva is a thin membrane covering the sclera (bulbar conjunctiva, labeled with purple) and the inside of the eyelids (palpebral conjunctiva, labeled with blue).
  • 3.
    結膜炎 • 名前の通り結膜の炎症. Conjunctivitisと呼び, 結膜の血管拡張を認め, 浮腫や浸出液を認める. • 一般的な感染症であり,眼科よりは一般外来で対応することが多い. • 感染性ウイルス性が最も多く, 夏場で多い. 細菌性は2番目. 小児例が50-75%を占め, 12月~4月に多い. アレルギー性は全体で15-40%を占める最多の原因. 春~夏に多い. • 非感染性ではアレルギー性以外に, 毒素性, 瘢痕性, 自己免疫性, 腫瘍性が挙げられる. • 全身性疾患に付随するものとして, 淋菌, クラミジア, GVHD, Reiter症候群等. 13年10月24日木曜日
  • 4.
    Figure 2. SuggestedAlgorithm for Clinical Approach to Suspected Acute Conjunctivitis Suspected acute conjunctivitis (≤ 4 wk duration) アプローチ. • No No Blurred vision? Yes Constant blurred vision? Yes No No Hyperpurulent Yes Gonococcal conjunctivitis Mucopurulent Bacterial conjunctivitis (nongonococcal) Serous No Yes 眼痛や羞明, 複視があれば Methods 眼科診察が必要. Yes Photophobia? Itching? プライマリケアでの Yes Pain? Discharge? • referral. An algorithmic approach (Figure 2) using a focused history along with a penlight eye examination may be helpf agnosis and treatment. Because conjunctivitis and many oth lar diseases can present as “red eye,” the differential diagnos eye and knowledge about the typical features of each diseas category are important (Table 1). Allergic conjunctivitis Dry eye disease No Ophthalmology referral Conjunctivitis can be divided into infectious and noninfectious causes. Viruses and bacteria are the most common infectious causes. Noninfectious conjunctivitis includes allergic, toxic, and cicatricial 13年10月24日木曜日 TheliteraturepublishedthroughMarch2013wasreviewedby ing PubMed, the ISI Web of Knowledge database, and the Co Library. The following keywords were used: bacterial conjun • 膿性分泌物の場合は viral conjunctivitis, allergic conjunctivitis, treatment of bacte junctivitis, and treatment of viral conjunctivitis. No language 淋菌や細菌性を考慮. tion was applied. Articles published between March 2003 an 2013 were initially screened. After review of titles, abstrac and 掻痒感が強ければ were identified and sc • references for the articles, more Articles and meta-analyses that provided evidence-based in tionアレルギー性を考慮. treatment of variou about the cause, management, and of conjunctivitis were selected. A total of 86 articles were in in this review. The first study8 was published in 1982 and th in 2012. A level of evidence was assigned to the recommen • ただし, 細菌性結膜炎の presented in Table 2 and Table 3 with the American Heart A tion58%は掻痒感(+), grading system: “The strongest weight65%, 熱感 of evidence (A signed if there are multiple randomized trials with large num patients. An intermediate weight (B) is assigned if there ar 漿液性浸出液 or 無し が35% ited number of randomized trials with small numbers of p careful analyses of non-randomized studies, or observatio
  • 5.
    • 結膜炎意外のRed eyeを来す疾患群 Review ClinicalReview & Education Review of Conjunctivitis Diagnosis and Treatment Table 1. Selected Nonconjunctivitis Causes of Red Eyea Differential Diagnosis Symptoms Penlight Examination Findings Dry eye disease Burning and foreign-body sensation. Symptoms are usually transient, worse with prolonged reading or watching television because of decreased blinking. Symptoms are worse in dry, cold, and windy environments because of increased evaporation. Bilateral redness Blepharitis Similar to dry eyes Redness greater at the margins of eyelids Uveitis Photophobia, pain, blurred vision. Symptoms are usually bilateral. Decreased vision, poorly reacting pupils, constant eye pain radiating to temple and brow. Redness, severe photophobia, presence of inflammatory cells in the anterior chamber. Angle closure glaucoma Headaches, nausea, vomiting, ocular pain, decreased vision, light sensitivity, and seeing haloes around lights. Symptoms are usually unilateral. Firm eye on palpation, ocular redness with limbal injection. Appearance of a hazy/steamy cornea, moderately dilated pupils that are unreactive to light. Carotid cavernous fistula Chronic red eye; may have a history of head trauma Dilated tortuous vessels (corkscrew vessels), bruits on auscultation with a stethoscope Endophthalmitis Severe pain, photophobia, may have a history of eye surgery or ocular trauma Redness, pus in the anterior chamber, and photophobia Cellulitis Pain, double vision, and fullness Redness and swelling of lids, may have restriction of the eye movements, may have a history of preceding sinusitis (usually ethmoiditis) Anterior segment tumors Variable Abnormal growth inside or on the surface of the eye Scleritis Decreased vision, moderate to severe pain Redness, bluish sclera hue Subconjunctival hemorrhage May have foreign-body sensation and tearing or be asymptomatic Blood under the conjunctival membrane a Data are from Cronau et al18 and Leibowitz.1 The examination can be done by shining a penlight in the patient’s affected eye(s). 13年10月24日木曜日
  • 6.
    感染性結膜炎 • Viral conjunctivitis;  • 急性結膜炎の80%はウイルス性. 65-90%はAdenovirusによるものであり, 2つの臨床型がある.  >Pharyngoconjunctival FeverとEpidemic keratoconjunctivitis. • Pharyngoconjucnctival Feverとは, 急性の発熱, 咽頭痛, 両側性の結膜炎,  耳介周囲リンパ節腫大を呈する病態 • Epidemic keratoconjunctivitisはもっと高度な結膜炎を呈し,  多量の水様の浸出液, 浮腫, 充血, 同側のリンパ節腫大を呈する. • リンパ節腫大は50%で認められ, 細菌性よりも頻度は高い. 13年10月24日木曜日
  • 7.
    Table 2. OphthalmicTherapies for Conjunctivitis Category Epidemiology Acute bacterial conjunctivitis 135 case per 10 000 population in US3 18.3%-57% of all acute conjunctivitis7-9,12,13 Type of Discharge Mucopurulent Cause Treatment S aureus, S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp Level of Evidence for Treatment Aminoglycosides B20-22 Tobramycin ointment: 3 ×/d for 1 wk A23-30 Besifloxacin: 1 drop 3 ×/d for 1 wk • Gentamicin Ointment: 4 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk A31-34 Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk A24,28,29 Adenovirusによる結膜炎は10-50%で感染播種する. Fluoroquinolones • 感染経路は浸出液が付いた手, 物, 医療機器, プール等. Gatifloxacin: 3 ×/d for 1 week Levofloxacin: 1-2 drops 4 ×/d for 1 wk 潜伏期間は5-12日間で, 排菌期間は10-14日間. 3 ×/d for 1 wk Moxifloxacin: Ofloxacin: 1-2 drops 4 ×/d for 1 wk B35 B36-38 A34,39,40 A37,38,41,42 Macrolides 特異的な治療は無く, 冷やしたり, 人工涙を使用したり, 1 drop Azithromycin: 2 ×/d for 2 d; then A27,30,43,44 Erythromycin:  抗ヒスタミンを使用する等対症療法を行う. 4 ×/d for 1 wk • B45 daily for 5 d Sulfonamides • 7-10日で改善しない場合や, Clinical Review & Education Review B22 Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk Review of Conjunctivitis Diagnosis and Treatment Combination drops  合併症を生じた場合は眼科コンサルトの必要がある. Trimethoprim/polymyxin B: 1 or 2 drops 4 ×/d for 1 wk NA Purulent Hyperacute Table 2. Ophthalmic Therapies for Conjunctivitis bacterial conjunctivitis in adults Category Acute Viral bacterial conjunctivitis conjunctivitis Herpes zoster virus 13年10月24日木曜日 Epidemiology 135 case per all 000 9%-80.3% of 10 acute population in US3 conjunctivitis8-13 18.3%-57% of all acute conjunctivitis7-9,12,13 NA Type of Discharge Mucopurulent Serous Variable Cause S aureus, are due to Up to 65% S epidermidis, H influenzae, adenovirus strains49 S pneumoniae, S viridans, Moraxella spp Herpes zoster virus Ceftriaxone: 1 g IM once C16,47 Lavage of the infected eye Neisseria gonorrhoeae A22,40,46 C16 Level of Evidence for Treatment C48 Treatment to cover chlamydia is indicated Dual therapy Aminoglycosides Cold compress Artificial tears Gentamicin Antihistamines Ointment: 4 ×/d for 1 wk Solution: 1-2 dropsmg: 5 ×/d 1 wk Oral acyclovir 800 4 ×/d for for 7-10 d Tobramycin ointment: 3 ×/d for 1 wk C16,50 B20-22 C16 16 A23-30
  • 8.
    Tobramycin ointment: 3×/d for 1 wk • A23-30 Fluoroquinolones Herpes Conjunctivitis; ヘルペス結膜炎 Besifloxacin: 1 drop 3 ×/d for 1 wk A31-34 Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk • A24,28,29 Gatifloxacin: 3 ×/d for 1 week B35 HSVは急性結膜炎の1.3-4.8%を占める原因. Levofloxacin: 1-2 drops 4 ×/d for 1 wk Moxifloxacin: 3 ×/d for 1 wk B36-38 A34,39,40  通常片側で浸出液は水様で, 眼瞼結膜に小水疱性眼瞼炎を生じる. Ofloxacin: 1-2 drops 4 ×/d for 1 wk A 37,38,41,42 Macrolides  局所, 経口の抗ウイルス薬は病期を短縮し得る. for 2 d; then 1 drop Azithromycin: 2 ×/d daily for 5 d Erythromycin: 4 ×/d for 1 wk • Sulfonamides VZVも原因となる. V1,2を含む帯状疱疹の場合に生じ, Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk A27,30,43,44 B45 B22  眼瞼に生じることが多い(45.8%). 次いで結膜に生じる(41.1%) Combination drops  角膜の障害を38.2%, ぶどう膜炎を19.1%で生じる. B: 1 or 2 drops Trimethoprim/polymyxin Clinical Review & Education Review NA Hyperacute bacterial conjunctivitis in adults Purulent Neisseria gonorrhoeae Lavage of the infected eye Table 2. Ophthalmic Therapies for Conjunctivitis 9%-80.3% of all acute conjunctivitis8-13 Epidemiology Serous Type of Discharge Up to 65% are due to adenovirus strains49 Cause Acute zoster Herpes bacterial conjunctivitis virus 135 NA case per 10 000 population in US3 18.3%-57% of all acute conjunctivitis7-9,12,13 Mucopurulent Variable S aureus, Herpes zoster virus S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp 1.3-4.8 of all acute conjunctivitis9-12 Variable Herpes simplex virus C16 Dual therapy to cover chlamydia is indicated Viral conjunctivitis Category Herpes simplex virus A22,40,46 4 ×/d for 1 wk Review of Conjunctivitis Diagnosis and Treatment Ceftriaxone: 1 g IM once C16,47 C48 Cold compress Artificial tears Treatment Antihistamines Aminoglycosides mg: 5 ×/d for 7-10 d Oral acyclovir 800 Level of Evidence C16,50 for Treatment C16 Gentamicin Oral famciclovir 500 mg: 3 ×/d for 7-10 d Ointment: 4 ×/d for 1 wk Oral valacyclovir 1000 mg: 3 wk Solution: 1-2 drops 4 ×/d for 1×/d for 7-10 d 20-22 BC16 Topical acyclovir: 1 drop 9 for Tobramycin ointment: 3 ×/d×/d 1 wk 23-30 AC16 Fluoroquinolones mg: 7-10 d Oral acyclovir 400 C16 C16 Besifloxacin: 1 drop 3 ×/d for×/d for 7-10 d Oral valacyclovir 500 mg: 3 1 wk 13年10月24日木曜日1.8%-5.6% of all acute Adult inclusion Variable Chlamydia trachomatis 31-34 AC16 Ciprofloxacin ointment: 3once for 1 wk Azithromycin 1 g: orally ×/d 24,28,29 AB16,51
  • 9.
    • Bacterial Conjunctivitis; 細菌性結膜炎 • 細菌性結膜炎の頻度は135/10000. 感染経路は直接感染,手指を介した感染, 汚染された媒介物より. また, 外傷や眼球の傷, 免疫抑制状態といった患者側の要素も重要. • 原因菌としては, Staphylococcal spp > S pneumoniae > H influenzae.  小児ではH influenzae > S pneumoniae > Moraxella catarrhalis. • 潜伏期間は1-7日, 排菌期間は2-7日程度. 結膜炎は通常7-10日持続する. • 眼瞼に膿性物質があること, 眼瞼の癒着, 掻痒感(-), 結膜炎の病歴が無い点は細菌性結膜炎を示唆する情報となる. コンタクトレンズもHigh-riskとなり, Abx点眼を考慮する. 13年10月24日木曜日
  • 10.
    • Hyperacute bacterial conjunctivitis;  • 重度の膿性浸出液と視力の低下を伴う結膜炎. 眼瞼の腫脹,眼圧痛, 耳介周囲リンパ節腫大を伴い, 淋菌が原因となることが多い. 角膜損傷や • 孔を伴うこともある. 治療はCTRXの筋注. 重度の膿性浸出液がある場合は必ず淋菌をチェックすること. また, 抗生剤に反応しない例はクラミジアをチェック. • Chronic bacterial conjunctivitis;  • 4wk以上持続する結膜炎で, Staphylococcus aureus, Moraxella lacunata,  腸管内細菌が原因として多い. 13年10月24日木曜日
  • 11.
    rus and maycause harm.16,71 Herpes zoster virus, responsible for shingles, can involve ocular tissue, especially if the first and second branches of the trigeminal nerve are involved. Eyelids (45.8%) are the most common site of ocular involvement, followed by the conjunctiva (41.1%).72 Corneal complication and uveitis may be present in 38.2% and 19.1% Good hand hygiene can be used to decrease the spread of acute viral conjunctivitis. C16 Bacterial cultures can be useful in cases of severely purulent conjunctivitis or cases that are recalcitrant to therapy. C16 It may be helpful to treat viral conjunctivitis with artificial tears, topical antihistamines, or cold compresses. C16 Topical steroids are not recommended for bacterial conjunctivitis. C65 Figure 3. Characteristic Appearance of Bacterial and Viral Conjunctivitis A Bacterial conjunctivitis B Hyperacute bacterial conjunctivitis A, Bacterial conjunctivitis characterized by mucopurulent discharge and conjunctival hyperemia. B, Severe purulent discharge seen in hyperacute bacterial conjunctivitis secondary to gonorrhea. C, Intensely hyperemic jama.com m: http://jama.jamanetwork.com/ by JUNKO NAGASUE on 10/22/2013 13年10月24日木曜日 C Viral conjunctivitis response with thin, watery discharge characteristic of viral conjunctivitis. Images reproduced with permission: © 2013 American Academy of Ophthalmology. JAMA October 23/30, 2013 Volume 310, Number 16
  • 12.
  • 13.
    Fluoroquinolones Table 2. OphthalmicTherapies for Conjunctivitis Category Acute bacterial conjunctivitis Epidemiology 135 case per 10 000 population in US3 18.3%-57% of all acute conjunctivitis7-9,12,13 Type of Discharge Mucopurulent Cause S aureus, S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp Hyperacute bacterial conjunctivitis in adults NA Viral conjunctivitis 9%-80.3% of all acute conjunctivitis8-13 Serous Up to 65% are due to adenovirus strains49 Herpes zoster virus NA Variable Herpes zoster virus Hyperacute Herpes simplex bacterial virus conjunctivitis in adults NA 1.3-4.8 of all acute conjunctivitis9-12 Viral Adult inclusion conjunctivitis 9%-80.3% of all acute 1.8%-5.6%of all acute 8-13 conjunctivitis5,8-11 Serous Variable Up to 65% are due to Chlamydia trachomatis adenovirus strains49 Allergic 90% of all allergic NA 15 Serous or Variable Pollens zoster virus Herpes Herpes zoster 13年10月24日木曜日 Purulent Besifloxacin: 1 drop 3 ×/d for 1 wk Neisseria gonorrhoeae A31-34 Ciprofloxacin ointment: 3 ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk Treatment Gatifloxacin: 3 ×/d for 1 week Aminoglycosides A24,28,29Evidence Level of for Treatment B35 Levofloxacin: 1-2 drops 4 ×/d for 1 wk Gentamicin Ointment: 4 3 for 1 wk Moxifloxacin:×/d×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk Ofloxacin: 1-2 drops 4 ×/d for 1 wk Tobramycin ointment: 3 ×/d for 1 wk Macrolides Fluoroquinolones Azithromycin: 2 ×/d for 2 d; then 1 drop Besifloxacin: daily for 5 d 1 drop 3 ×/d for 1 wk Ciprofloxacin 4 ×/d for 3 ×/d Erythromycin:ointment: 1 wk for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk Sulfonamides Gatifloxacin: 3 ×/d for 1 week Sulfacetamide ointment: 4 ×/d and at Levofloxacin: 1-2 bedtime for 1 wk drops 4 ×/d for 1 wk Solution: 1-2 drops every wk h for 1 wk Moxifloxacin: 3 ×/d for 1 2-3 Combination drops Ofloxacin: 1-2 drops 4 ×/d for 1 wk Trimethoprim/polymyxin B: 1 or 2 drops Macrolides 4 ×/d for 1 wk Azithromycin: 2 ×/d for Ceftriaxone: 1 g IM once2 d; then 1 drop daily for 5 d Lavage of the infected eye Erythromycin: 4 ×/d for 1 wk Dual therapy to cover chlamydia is indicated Sulfonamides Cold compress Sulfacetamide Artificial tears ointment: 4 ×/d and at bedtime for 1 wk Antihistamines Solution: 1-2 drops every 2-3 h for 1 wk Oral acyclovir 800 mg: 5 ×/d for 7-10 d Combination drops Oral famciclovir 500 mg: 3 ×/d for 7-10 d Trimethoprim/polymyxin B: 1 or 2 drops Oral valacyclovir 1000 mg: 3 ×/d for 7-10 d 4 ×/d for 1 wk B36-38 B20-22 A34,39,40 A37,38,41,42 A23-30 A27,30,43,44 A31-34 A24,28,29 B45 B35 B22 B36-38 A34,39,40 A37,38,41,42 A22,40,46 A27,30,43,44 C16,47 C16 B45 C48 B22 C16,50 C16 C16 A22,40,46 C16 C16,47 C16 C16 C16 Dual therapy to cover chlamydia is 7-10 d Oral valacyclovir 500 mg: 3 ×/d forindicated Neisseria gonorrhoeae Herpes simplex virus Ceftriaxone: 1 g IM once Topical acyclovir: 1 drop 9 ×/d Lavage of the 400 mg: 7-10 Oral acyclovir infected eye d Purulent Variable C48 C16 Cold compress Azithromycin 1 g: orally once Artificial tears Doxycycline 100 mg: orally 2 ×/d for 7 d Antihistamines Topical antihistamines 5 ×/d for 7-10 d Oral acyclovir 800 mg: B16,51 16,50 C16,51 B C16
  • 14.
    • 特殊な細菌性結膜炎; • MRSA結膜炎; 特殊な例であり, 眼科診察が必要.  VCMによる治療が必要となる. • クラミジア結膜炎;1.8-5.6%を占める.  片側性であり, 陰部感染症も併発(男性54% 女性74%).  結膜充血, 粘性膿性分泌物, Lymphoid follicle formationが  特徴的な所見. • 淋菌性結膜炎; Hyperacute conjunctivitisの主な原因. 13年10月24日木曜日
  • 15.
    • Trachomaによる結膜炎;  TrachomaはChlamydia trachomatis subtypesA~Cによる感染症で  失明の原因となる病態.  粘性膿性分泌物と眼球の異常が主な症状, 所見となる.  晩期の眼球損傷, 結膜炎, 角膜障害が失明の主な原因.  Azithromycin 20mg/kgの単回投与が効果的. Abx点眼は6wk程度使用  TC, EMを3wk使用すること選択肢. 13年10月24日木曜日
  • 16.
    • Allergic Conjunctivitis; アレルギー性結膜炎 • 花粉や動物由来抗原等に反応し生じる炎症. 結膜炎の40%を占めるが,未受診の患者も多い. • 結膜充血と掻痒感が強いのが特徴. • 治療は抗原暴露の回避と生理食塩水や人工涙で抗原を薄める. 薬剤では点眼のDecongestant, 抗ヒスタミン, Mast cell stabilizer, NSAID, ステロイド薬の使用. • 抗ヒスタミンやDecongestantの長期使用は 反動性血管充血を来す為に注意が必要. • ステロイド点眼は白内障や緑内障のリスクを上げる. 13年10月24日木曜日
  • 17.
    Herpes zoster virus NA Variable Herpes zostervirus 1.3-4.8 of all acute conjunctivitis9-12 C16 Oral famciclovir 500 mg: 3 ×/d for 7-10 d C16 Review of ×/d for 7-10 Diagnosis and Treatment Oral valacyclovir 1000 mg: 3Conjunctivitis d C16 Clinical Review & Education Review Herpes simplex virus Oral acyclovir 800 mg: 5 ×/d for 7-10 d Table 2. Ophthalmic Therapies for Conjunctivitis Adult inclusion conjunctivitis Category 1.8%-5.6% of all acute conjunctivitis5,8-11 Epidemiology Variable Type of Discharge Chlamydia trachomatis Cause Acute bacterial Allergic conjunctivitis conjunctivitis 135 case per 10 000 90% of all allergic population in 15 3 US conjunctivitis ; 18.3%-57% of all acute up to 40% of 7-9,12,13 conjunctivitis population may be affected15 Mucopurulent Serous or mucoid S aureus, Pollens S epidermidis, H influenzae, S pneumoniae, S viridans, Moraxella spp C16 C16 Oral valacyclovir 500 mg: 3 ×/d for 7-10 d Herpes simplex virus Topical acyclovir: 1 drop 9 ×/d Oral acyclovir 400 mg: 7-10 d Variable C16 Azithromycin 1 g: orally once Treatment Doxycycline 100 mg: orally 2 ×/d for 7 d B16,51of Evidence Level for Treatment B16,51 Aminoglycosides Topical antihistamines Gentamicin Azelastine 0.05%: 1 drop 2 ×/d Ointment: 4 ×/d for 1 wk Solution: 1-2 drops 4 ×/d 4 1 wk Emedastine 0.05%: 1 dropfor×/d Tobramycin cell inhibitors Topical mastointment: 3 ×/d for 1 wk 20-22 B52 A A52 A23-30 Fluoroquinolones Cromolyn sodium 4%: 1-2 drops every 4-6 h Besifloxacin: 1 drop 3 drops 1 wk Lodoxamide 0.1%: 1-2×/d for4 ×/d A52 A31-34 A52 Ciprofloxacin ointment: 3 2 ×/d Nedocromil 2%: 1-2 drops ×/d for 1 wk Solution: 1-2 drops 4 ×/d for 1 wk NSAIDs Gatifloxacin: 3 ×/d for 1 week Ketorolac: 1 drop 4 ×/d Levofloxacin: 1-2 drops 4 ×/d for 1 wk Vasoconstrictor/antihistamine Moxifloxacin: 3 ×/d for 1 wk Naphazoline/pheniramine: 1-2 drops up to Ofloxacin: 1-2 drops 4 ×/d for 1 wk 4 ×/d Macrolides Combination drops A24,28,29 A52 Azithromycin: 2 ×/d drop d; then Ketotifen 0.025%: 1 for 2 2-3 ×/d1 drop daily for 5 d Olopatadine 0.1%: 1 drop 2 ×/d Erythromycin: 4 ×/d for 1 wk Abbreviations: IM, intramuscularly; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs. Sulfonamides Sulfacetamide ointment: 4 ×/d and at bedtime for 1 wk Solution: 1-2 drops every 2-3 h for 1 wk B35 B53,54 B36-38 A34,39,40 B55 A37,38,41,42 A27,30,43,44 A56,57 A58,59 B45 B22 Combination drops Trimethoprim/polymyxin B: 1 or 2 drops 4 ×/d for 1 wk JAMA October 23/30, 2013 Volume 310, Number 16 Hyperacute bacterial 13年10月24日木曜日 NA Purulent Neisseria gonorrhoeae A22,40,46 Ceftriaxone: 1 g IM once C16,47 Lavage of the infected eye C16 jama.com
  • 18.
    • 薬剤, 化学, 毒性結膜炎 • 抗生剤点眼,抗ウイルス薬点眼, 潤滑性点眼薬は, 塩化ベンザルコニウムが含まれており, それによるアレルギー性結膜炎を来すことがある. • 結膜炎を来す全身疾患 • Mucous membrane pemphigoid, Sjogren syndrome, 川崎病, Stevens-Johnson syndrome, Carotid cavernous fistulaで結膜炎を来す. • 軽症の頸動脈-静脈洞瘻では慢性の結膜炎のみ呈することがある. 13年10月24日木曜日
  • 19.