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MattiSeppänen

Conjunctivitis

Essentials

  • The most common ophthalmologic disease encountered and treatable within primary care
  • Main symptoms: conjunctival injection, discharge, feeling of a foreign body, smarting, in association with an allergic reaction: itching
  • If purulent discharge is present, the infection is most likely bacterial.
  • Watery, copious discharge often suggests viral infection.
  • Differentiate conjunctivitis from the following conditions usually requiring investigation and treatment by an ophthalmologist:
  • Recognize dry eye syndrome Dry Eye Syndrome and allergic conjunctivitis Allergic Conjunctivitis and avoid unnecessary use of antimicrobials in their treatment.

Aetiology

Causes of conjunctivitis

BacteriaMost common:
  • Staphylococci
  • Streptococci
  • Moraxella
  • Haemophilus
Rare:
  • Pseudomonas (in contact lense users may lead to corneal perforation)
  • Chlamydia, gonococci, Francisella tularensis
VirusesAdenoviruses the most common; others: Herpes simplex 1 and 2, H. varicella-zoster, EBV
FungiCandida albicans the most common (associated primarily with immunodeficiency or long-term use of topical glucocorticoids)
ParasitesItch mites, pubic lice (in eyelashes), lice (in eyebrows); in tropical countries loiasis, onchocerciasis , among others
AllergyPollen, food substances, eye drops in long-term use
Dry eye syndrome Dry Eye SyndromeOften caused by an underlying eyelid dysfunction. Predisposing factors may also include systemic diseases or pharmaceuticals.

Symptoms and findings

  • The most common eye symptoms
    • Red eye, particularly what is called conjunctival injection
    • Purulent or watery discharge
    • Itching and gritty sensation
    • Conjunctival oedema (chemosis)
  • In case of bacterial infection, purulent, yellowish discharge and gluing together of the eyelashes (particularly in the morning)
  • Chlamydial conjunctivitis
    • Often bilateral follicular conjunctivitis with severe symptoms (small yellow or transparent follicles on the conjunctiva; picture 1 )
    • Caused by Chlamydia trachomatis (serotypes D-K and B), sexually transmitted, may be transmitted to the baby in childbirth (causing ocular irritation that appears at around the end of the first week)
  • Watery discharge, erythema and oedema of the eyelids suggest viral infection.
    • General symptoms often include upper respiratory tract symptoms, sore throat, enlarged preauricular and cervical lymph nodes.
    • Blisters on eyelids or the conjunctiva and swollen lymph nodes around the eye(s) suggest herpes simplex infection.
    • Skin symptoms that do not cross the midline suggest shingles (herpes zoster).
    • In adenovirus conjunctivitis often only one eye is affected at first and the other eye with delay. The symptoms are often clearly more severe in the eye that became ill first.
      • Pain and photophobia are often relatively mild in relation to the appearance of the eye.
      • In more severe cases the whole eye region and eyelid become swollen and the eye may become scarlet red. Complications may include conjunctival pseudomembranes, conjunctival adhesions and corneal problems requiring consultation of an ophthalmologist.
      • Lengthy duration, often 2-3 weeks.
    • In case of fungal infection, there are pale, flat lesions, conjunctival granulomas.

DiagnosisCombinations of Signs and Symptoms in the Diagnosis of Bacterial Conjunctivitis

  • A slightly purulent or non-discharging inflammation can be considered conjunctivitis if the patient does not have any symptoms suggesting keratitis, iritis or acute glaucoma (see Differential diagnosis).
  • If the patient has a concomitant upper respiratory infection he/she probably has viral or bacterial conjunctivitis.
  • Basic investigations
    • Visual acuity, fluorescein staining, corneal examination using a loupe or an ophthalmoscope
    • Intraocular pressure (unless a corneal ulcer is suspected)
  • The treatment of ordinary bacterial conjunctivitis can be started based on clinical diagnosis without taking samples. If symptoms are prolonged, a specimen for bacteriological culture should be obtained from the conjunctiva. If the diagnosis remains unclear, perform examinations for chlamydia and gonococci, as necessary (including urine samples).
  • Samples for viral culture and fungal staining or culture can also be taken, as necessary.
    • The diagnosis of adenovirus conjunctivitis is based mainly on the clinical picture, but some ophthalmological outpatient clinics may have a rapid test for detecting adenovirus in the tear fluid.

Differential diagnosis

  • The following symptoms may suggest keratitis, iritis or acute glaucoma, which usually require examination and treatment by an ophthalmologist:
    • severe or dull pain
    • photophobia (occurs in iritis and allergic conjunctivitis)
    • tenderness on pressure
    • impaired visual acuity
    • opacified, mottled, or ulcerating cornea
    • small or distorted pupil.
  • Iritis: photophobia, pain, pericorneal redness
  • Keratitis: fluorescein staining often shows inflammatory foci; decreased visual acuity
    • In herpes infection, often dendritic lesions
  • Acute angle-closure glaucoma: high intraocular pressure, often exceeding 50 mmHg, mid-dilated pupil, severe pain
  • If antimicrobial treatment is not effective against conjunctivitis considered to be bacterial, it should be discontinued and the case reconsidered. The patient may have
    • a viral infection
    • an infection caused by resistant bacteria (remember gonococci in patients with copious purulent discharge)
    • a chlamydial infection
    • lacrimal stenosis, which is a common cause for recurrent conjunctivitis in children below six months of age Lacrimal Duct Stenosis
    • entropion or ectropion ( Entropion and Ectropion; a common cause in elderly patients)
    • dryness of the eyes Dry Eye Syndrome
    • problems with indoor air (excessive ventilation, microbial growth in the ventilation system)
    • an incorrect initial diagnosis, see Table T1.
  • Remember the possibility of a conjunctival foreign body: evert the upper eyelid, too, with topical anaesthesia and check this.
  • Dry eye syndrome: fluorescein staining shows reduced tear film stability, and corneal laceration may be seen particularly in the lower medial area
  • If the patient has atopy with other concomitant allergic symptoms (clear rhinorrhoea, prolonged cough, atopic eczema) the patient probably has atopic conjunctivitis. Exposure to pollen or animals is not always evident from the history. Stringy mucus occurs only in patients with allergy.
  • Vernal conjunctivitis is a rare but chronic conjunctivitis with severe symptoms occurring in children. It should be treated and followed up by an ophthalmologist.
  • If the cheek or eyelid is red or if one eye is shut because of oedema consider the possibility of cellulitis Preseptal and Orbital Cellulitis Facial Cellulitis in a Child.
  • Chronic dacryocystitis is a rare cause of discharge from the eye.
    • The disease most frequently occurs in middle-aged or elderly women.
    • Pressure on the lacrimal sac expresses inflammatory secretions from the lacrimal punctum.
    • Should be treated by an ophthalmologist.

Treatment Antibiotics for Acute Bacterial Conjunctivitis, Delayed Prescribing for Acute Conjunctivitis

  • In case of bacterial infection, cleansing is essential: all visible discharge should be removed.
  • Purulent conjunctivitis (caused by a virus or bacteria) should be treated with topical antimicrobial preparations.
  • The drug of choice is chloramphenicol, 5 mg/ml.
    • 6-8 drops per day should be administered for 5 days (and for 1-2 days after the symptoms have subsided), and an eye ointment should be used for the night. Drops should be administered by pulling down the lower lid and instilling them into the space between the lower lid and the eye.
  • Other drugs
    • Fusidic acid, 10 mg/ml, 1 drop twice daily
      • Fusidic acid has the advantage that it is given only twice a day, but it causes smarting of the eye more often than the water- or oil-based chloramphenicol drops.
      • Fusidic acid has a narrow spectrum, being mostly effective against staphylococci.
      • It is effective against most cases of bacterial conjunctivitis in small children.
    • Quinolone drops (levofloxacin or ofloxacin) are recommended for use only as prescribed by an ophthalmologist or after consulting an ophthalmologist.
  • The duration of drug treatment is one week or until the patient has had at least 2 symptomless days.
  • Because spontaneous resolution is very common in bacterial conjunctivitis with mild symptoms, medication need not necessarily be started immediately. Antimicrobial use can be reduced by giving the patient a prescription but asking them to start taking the eye drops only if the symptoms are not alleviated in 2-3 days.
  • A general practitioner should not prescribe glucocorticoid drops or ointments.
  • Chlamydial infection
    • Note also the need to treat the sexually transmitted disease (at an outpatient STD clinic, as necessary).
    • Do not hesitate to consult an ophthalmologist on the treatment of the eye infection.
    • Pharmacotherapy
      • If an adult patient has typical follicular conjunctivitis, prescribe oral azithromycin or doxycycline for both the patient and his/her partner.
      • For topical treatment, azithromycin or fluoroquinolone eye drops
  • An acute conjunctivitis associated with viral respiratory infection can be treated with moisturizing eye drops without preservative, as necessary. If there are signs of secondary bacterial infection, topical antimicrobials should also be started.
  • Herpes simplex conjunctivitis: consult an ophthalmologist about starting the treatment, and refer the patient to an ophthalmologist.
  • Herpes zoster: consult an ophthalmologist, and start systemic medication (for 7 days), such as
  • Adenovirus
    • In mild cases moisturizing eye drops, in moderate cases topical antimicrobial drops and ointments to prevent secondary infections
    • Treatment by an ophthalmologist includes e.g. mechanical removal of pseudomembranes and adhesions.
    • Special emphasis should be placed on the hygiene of one's own working space, as the virus is highly contagious and may survive on surfaces for up to two weeks.
      • Use gloves and mask.
      • After examining the patient, do not touch instruments or computer keyboard with the same gloves.
      • Disinfect surfaces.
    • If a fungal infection of the eye is suspected or has been diagnosed, consult or refer the patient to an ophthalmologist.
    • Dacryocystitis should be treated by an ophthalmologist.
      • The treatment consists of periodic administration of topical antimicrobials, and later usually surgery where the communication between the lacrimal sac and the nasal cavity is restored.
      • Oral antimicrobials should be prescribed for acute infection. Severe symptoms may warrant surgical treatment.

Ophthalmological consultation and treatment

  • If there are atypical or very severe symptoms or inflammation is prolonged, an ophthalmologist should be consulted.
  • Differentiate conjunctivitis from the following conditions usually requiring investigation and treatment by an ophthalmologist: iritis Iridocyclitis (Iritis); keratitis Corneal Ulcers; glaucoma attack Glaucoma.
  • Ophthalmological consultation or referral
    • Chlamydia, herpes simplex or herpes zoster infections
    • Suspected or diagnosed fungal infection of the eye
    • Dacryocystitis
  • In adenovirus infection, symptoms persisting for more than 2 weeks, painfulness and reduced visual acuity after the acute phase require consultation of an ophthalmologist. Treatment by an ophthalmologist may be needed for mechanical removal of pseudomembranes or adhesions, for instance.