Conjunctivitis Flashcards
What is conjunctivitis
- Inflammation of conjunctiva
- Most common cause of red eye worldwide
- Inflammation can be hyperacute, acute or chronic
- Acute (less than 3-4 weeks) vs chronic (> 4 weeks)
- Usually self limiting
What is the most common cause
Viruses (80%)
• Peak prevalence in summer
• Adenovirus infections most common (65-90%) followed by herpes simplex
• Other viruses: varicella zoster, Molluscum contagiousum
• Many viral conjunctivitis cases are misdiagnosed as bacterial conjunctivitis
What is the second most common cause
Bacterial
• 50-75% cases in children in winter months
• Staphylococcal species most common followed by Streptococcus pneumoniae and Haemophilus influenza
• Neisseria gonorrhoeae or Chlamydia rachomatic cause a more serious hyperacute infection
When does allergic conjunctivitis occur and how does it occur
- Peak in spring and summer
- Immediate hypersensitivity, allergy to seasonal pollens or allergic reactions to eye products
- Chemical or irritative causes include dry eyes, drug-induced dry eye
What is the clinical presentation of viral conjunctivitis
redness serous (watery) discharge burning foreign body sensation itching unilateral symptoms initially that may progress bilaterally
adenovirus is more severe (fever, large lymph nodes, etc)
What is the clinical presentation of bacterial conjunctivitis
redness
purulent (viscous, yellow/green colour) secretion
sticky eyelids in the morning
minimal itching
• Hyperacute bacteria conjunctivitis (caused by N gonorrhoea) symptoms include rapid onset, purulent discharge, diminished visual acuity, eye tenderness and swollen lymph nodes
What is the clinical presentation of allergic conjunctivitis
Mild to severe ocular itching redness watery or mucoid discharge mild eyelid swelling bilateral presentation
How to differentiate between Viral, Bacterial & Allergic Conjunctivitis
- Allergic has SEVERE itching (others have minimal)
- bacterial has purulent discharge
- sore throat and fever most common in viral
- lymphadenopathy most common in viral
- viral usually occurs in one eye only
What are the Risk factors for Conjunctivitis
● Exposure to someone infected with active viral or bacterial conjunctivitis
● Contact lens use, poor contact lens hygiene
● Foreign body exposure
● Use of contaminated cosmetic eye products
● Chronic dry eye or blepharitis
● Use of ophthalmic or other medications that might cause allergic reactions or dry eyes
● Immunosuppression, rheumatological disease, allergic rhinitis
What is S in SCHOLAR
S: redness discharge (purulent or watery) itching (severe or minimal) fever, sore throat
What is C in SCHOLAR
C: water, serous, purulent, mucopurulent, hyperpurulent discharge
What is H in SCHOLAR
History of contact lens use, exposure to person with red eye, URI, exposed to allergens, past history of conjunctivitis
what is O in SCHOLAR
O: acute presentation 1-2 days vs chronic
what is L in SCHOLAR
L: conjunctiva vs eyelid or around the eye
What is A in SCHOLAR
A: risk factors for dry eyes, blunt trauma, chemical exposure
what is R in SCHOLAR
R: what has been tried before
what is H in HAMS
H: history of ocular disease, intermittent episodes of red eye, history of atopy, current URI, Sjogren’s, rheumatoid arthritis, thyroid disorder, rosacea
history of herpes (herpes conjunctivitis)
STI
what is A in HAMS
A: allergies to medications or environment
what is M in HAMS
M: medications with anticholinergic side effects, beta blockers, hormone-based therapy (common causes of dry eye), antineoplastics (cause allergic reactions), allergy medications, nonprescription or natural medications, recreational drugs/opiates
what is S in HAMS
S: history of smoking, alcohol use and caffeine use, hobbies, travel, sexual history, use of illicit drugs
Red flags
● Contact lens wearer due to the high risk of corneal ulcer
● Visual loss, blurred vision, halos
● Moderate to severe pain or ocular trauma
● Severe or hyperpurulent discharge or any corneal involvement
● Photophobia or coloured halos around lights
● Irregular pupils-fixed, smaller, larger
● Visible corneal opacity or haze
● Rash +/- blisters around eye or redness at the corneoscleral junction, ciliary flush
● Foreign body sensation
● Severe headache with nausea, vomiting
● Bacterial ophthalmic infections in children
What to do during assess phase of PPCP
- ascertain symptoms align with conjunctivitis and differentiate between viral, bacterial, allergic
- identify red flags and refer
- refer if differential diagnosis
What is dry eye (differential diagnosis)
Burning, foreign body sensation
Rule out medication caused
non urgent referral
What is blepharitis (differential diagnosis)
Similar to dry eye disease
Redness greater at eyelid margins
Non urgent referral
What is uveitis (differential diagnosis)
Photophobia, pain, blurred vision
Urgent referral
What is angle closure glaucoma (differential diagnosis)
Headaches, nausea, vomiting, ocular pain, decreased vision, light sensitivity, halos
Urgent referral
What is carotid cavernous fistula (differential diagnosis)
Chronic red eye, may have history of head trauma
Urgent referral
What is endophthalmitis (differential diagnosis)
Severe pain, photophobia
Urgent referral
What is cellulitis (differential diagnosis)
Pain, double vision, fullness
Urgent referral
What is anterior segment tumors (differential diagnosis)
Symptoms vary
Urgent referral
What is scleritis (differential diagnosis)
Decreased vision, moderate to severe pain
Urgent referral
What is subconjunctival hemorrhage (differential diagnosis)
May have foreign body sensation
Urgent referral
Goals of therapy
- Eliminate or reduce signs and symptoms
- Restore or maintain normal vision
- Prevent complications (preserve eyesight)
- Prevent recurrence
- Cure or control infection where present and prevent transmission of infection to others
Non-Pharm Recommendations
- Cold compresses for allergic or viral conjunctivitis
- Warm compresses or soak for bacterial conjunctivitis
- Sterile saline irrigation or refrigerated commercial eye wash
- Eyelid wipes for blepharitis
- Infection prevention and control measures
- Contact lens wears should stop using contact lens and seek medical advice
- Avoid environmental triggers for allergic conjunctivitis
- Encourage proper use of eye drops and recommend discarding contaminated or older eye drop bottles
- Discard old eye cosmetic/eye make up products being used
- Review use of other medications that can worsen eye conditions
What is the pharm treatment for viral conjunctivitis
No proven treatment for virus
Adenoviral conjunctivitis is usually self limiting (within 5-14 days, refer if after 14 days)
Can use supportive therapies (artificial tears, ophthalmic decongestants, antihistamine/decongestant combinations
What are examples of artificial tears (optical lubricants) and what is the dosing
Carboxymethylcellulose, polyvinyl alcohol, carbomer 940, polyethylene glycol, sodium hyaluronate
Preferable to use preservative free
1-2 drops TID to QID
What are examples of ophthalmic vasoconstrictors and what is the dosing
Naphazoline, oxymetazoline, phenylephrine, tetrahydrozoline
1-2 drops every 3 to 4 hours
are meant for occasional and short-term use (3/4 times a month or 3 days in a row)
What are examples of antihistamine/decongestants combinations and what is the dosing
Antazoline/naphazoline, Pheniramine/naphazoline
1-2 drops every 3 to 4 hours
are meant for occasional and short-term use (3/4 times a month or 3 days in a row)
What is the pharm treatment for Bacterial Conjunctivitis
usually self-limiting and resolves within 7 to 10 days
• Refer children to primary care provider or optometrist
mild infection (small amounts of discharge, tearing mild burning) can use OTC treatment moderate infection (copious amounts of discharge and tearing, moderate burning) can use Rx treatment
OTC treatment for bacterial conjunctivitis
Polymyxin B gramicidin eye/ear drops
1-2 drops 4-6 times per day for 5 to 7 days
If no improvement in 2 days, refer
Rx treatment for bacterial conjunctivitis
Erythromycin 0.5% ointment
Fusidic acid 1% viscous eye drops
Trimethoprim/polymyxin B 0.1%- 10,000 units/ml
Tobramycin 0.3% ophthalmic drops
Fluoroquinolones: Besifloxacin 0.6%, Ciprofloxacin 0.3%,
Gatifloxacin 0.3%, Moxifloxacin 0.5%, Ofloxacin 0.3%
What is the Pharm treatment for allergic conjunctivitis
- First line treatment is to identify and remove allergens
- OTC Treatment options
* Artificial tears or saline solution
* Antihistamine/decongestant drops (like viral)
* Mast cell stabilizers - Rx treatment options
* Dual acting antihistamines with mast cell stabilizing properties if OTC products have failed
Mast cell stabilizer for OTC treatment
Sodium cromoglycate 2%
1-2 drops QID
Takes 2-3 days to see improvement. Age > 5 yrs
Rx treatment for allergic conjunctivitis
Dual acting with antihistamine and secondary mast cell stabilizing properties
Ketotifen 0.025%
Olopatadine 0.1% (also 0.2% and 0.7% available)
When should a child return to school if they have bacterial conjunctivitis
Return to school 24 hours after starting treatment for bacterial injections
When should a child return to school if they have viral conjunctivitis
Viral conjunctivitis is contagious
Return to school once there is no discharge (min 1 week)
When should you follow up for bacterial conjunctivitis
2 days
When should you follow up for allergic conjunctivitis
3 days
When should you follow up for viral conjunctivitis
1 week
