conjunctivitis

Question 1

a difference between chlamydial conjunctivitis and other conjunctivitis

Answer 1

rare
so much mucus that they can taste it in their mouth

Question 2

VKC management done by who

Answer 2

usually managed by HES
paedriatic ophthalmologist usually manages this

Question 3

AKC management

Answer 3

corneal then urgent referral
if just conjunctival then routine

Question 4

differential diagnosis of acute allergic conjunctivitis

Answer 4

Seasonal allergic conjunctivitis
Chemical trauma
Preseptal cellulitis
Orbital cellulitis

Question 5

management of acute allergic conjucntivits

Answer 5

reassure most cases resolve spontanousely in few hours, adv against rubbing eyes, cold compress, identify allergen, eye wash/ drops to flush out allergen
oral antihistamines
if diagnosis unsure then review 24hrs - should have been some improvement in this time

Question 6

recurrent acute allergic conjunctivitis

Answer 6

sodium cromoglicate 2% eye drops - 4x a day
or lodozamide 0.1%
or dual action (antihistamine and mast cell stabiliser) olopatadine 0.1%, 1 drop twice daily (8 hour interval whilst symptomatic)- off label use

Question 7

contraindications for olopatadine

Answer 7

Contraindicated in
- breastfeeding/pregnancy
- women of childbearing age not using contraception
- Caution in dry eye/compromised ocular surface if prolonged use planned

Question 8

when would refer occur with acute allergic conjunctivitis

Answer 8

If associated hay fever / asthma / eczema, discuss referral to GP or pharmacist for an oral antihistamine
Refer to ophthalmology if
Corneal epithelial defect
Corneal stromal infiltrate

Question 9

what is Conjunctivitis medicamentosa

Answer 9

condition in which a drug applied to the eye as drops or ointment, contact lens solutions or a cosmetic, or some other substance reaching the eye surface, causes an irritative or allergic reaction.

Question 10

management of seasonal/ perennial allergic conjunctivitis

Answer 10

identify the allergen, cool compress, adv no eye rubbing
systemic antihistamines
ocular lubricants for symptomatic relief

Question 11

further management of seasonal or perennial allergic conjunctivitis (entry)

Answer 11

mast cell stabiliser sodium cromoglicate 2% 4x a day
or lodoxamide 0.1% (effects of drops can take 2 weeks to show)

Question 12

further management of seasonal or perennial allergic conjunctivitis (IP)

Answer 12

topical antihistamine and mast cell stabilizer - olopatadine 0.1% 2x a day (less side effects, better and faster), ketotifen 0.025%

Topical NSAIDs, dicofenac sodium 0.1%

topical antihistamine, antazoline 0.5% -PoM,[Otrivine-Antistin] also contains xylometazoline 0.05%)

Question 13

can systemic and topical antihistamines be used together

Answer 13

yes

Question 14

types of non sedating systemic antihistamines (newer class)

Answer 14

cetrizine and loradine
use especially if other allergy symptoms

Question 15

systemic antihistamines for children

Answer 15

under 12
lower concentration of active ingredient, liquid syrup
chlorphenamine
cetirizine

Question 16

sedating systemic antihistamines

Answer 16

chlorphenamine
clemastine (older class of drugs)

Question 17

what effects may systemic antihistamines have

Answer 17

dry mouth
headaches
gastro intestinal distrubances

Question 18

VKC referral

Answer 18

Routine referral for PoM for milder cases (without active limbal or corneal involvement) and when topical meds fail to provide symptomatic relief

Urgent referral (within one week) if there is active limbal or corneal involvement

Low threshold for referral to ophthalmology as significant corneal involvement common

no referral when initial management with mast cell stabilisers - needs very careful monitoring

Question 19

VKC management when mild disease (no limbal or corneal involvement)

Answer 19

avoid enviromental trigger and cold compress use
topical mast cell stabilisers - sodium cromoglicate, lodoxamide or dual acting agents - olopatidine 0.1%, ketefiden 0.025% (off label use) for symptomatic relief

Question 20

symptoms of VKC

Answer 20

Ocular itching, burning or foreign body sensation
Watering
Mucoid stringy discharge
Blurred vision
Pain (if cornea affected)
Photophobia (may be intense)
Difficulty opening eyes on waking
bilateral but often asymmetrical

Question 21

Predisposing factors of VKC

Answer 21

Onset usually before 10 years of age; M:F = 2-4:1 and typically resolves during puberty

Seasonal exacerbations but condition may be active year-round if severe

Patients usually atopic with a history of eczema and asthma
Often a family history of atopic disease

Question 22

signs of VKC

Answer 22

cobblestone appearance of papillae
hyperaemia and chemosis of conjunctiva when active
limbal hyperaemia and oedematous, thickened limbus
Trantas dots
SPK
mucoid stringy discharge
plaque (deposited on Bowman’s layer, preventing re-epithelialisation)

Question 23

which type of allergic conjunctivitis can be unilateral

Answer 23

acute allergic conjunctivits

Question 24

AKC predisposing factors

Answer 24

• majority of patients have a personal history of asthma, and eczema
  (atopic dermatitis)
• family history of atopic disease
• Most patients have eczema affecting the eyelids and periorbital skin
• strong association with staphylococcal lid margin disease
• Specific allergens may exacerbate the condition
• affects patients in 20-50s

Question 25

symptoms of AKC

Answer 25

Ocular itching, burning, watering,
usually bilateral
Blurred vision, photophobia
White stringy mucoid discharge
Onset of ocular symptoms may occur several years after onset of atopy
Symptoms are typically bilateral, occur year-round, with exacerbations

Question 26

signs of AKC

Answer 26

Eyelids may be thickened, crusted and fissured
Associated chronic staphylococcal blepharitis
Tarsal conjunctiva: giant papillary hypertrophy, subepithelial fibrosis, scarring and shrinkage
Entire conjunctiva hyperaemic
Limbal inflammation
Corneal involvement is common and may be sight-threatening: beginning with punctate epitheliopathy that may progress to macro-erosion, plaque formation (usually upper half), progressive corneal subepithelial scarring, neovascularisation/pannus, thinning, and rarely spontaneous perforation
papillae (smaller than VKC but larger than seasonal)
symblepharon - abnormal attachment between the conj and eyelid

Question 27

AKC patient prone to develop what

Answer 27

herpes simplex keratitis (which may
be bilateral), corneal ectasia such as keratoconus, atopic (anterior or posterior polar) cataracts, retinal detachment

Question 28

management of AKC

Answer 28

lid hygiene and tx of associated staph bleph
cool compresses
avoid allergens
ocular lubricants - symptomatic relief - ointment for bedtime.
systemic antihistamines while waiting on referral

topical mast cell stabiliser - sodium cromo, lodoxamide, olopatadine, ketofiden

Question 29

referral for AKC

Answer 29

Urgent referral (within one week) if corneal involvement

Routine referral for Milder cases

Question 30

What is CLAPC more common in

Answer 30

contact lens wear
more common in reuseable CLs, over night cls, lens deposits, MGD, preservatives in cls care products, high modulus SiHi

Question 31

symptoms of CLAPC

Answer 31

itchy irritated, burning FB sensation
may increase on removal of Cls - physical action of removing cls may increase degranulation os mast cells or acts as a barrier
white mucus discharge
increased lens movement
loss of lens tolerance
decreased comfort
blurry vision
poor correlation of severity with signs and symptoms

Question 32

management CLAPC non pharm

Answer 32

lens changes - replace more, better hygiene, reduce wear time , break from cls for 2-4weeks.
RGPs reduce edge clearance and edge thicknes, SCLs change material with lower modulus
stop extended wear.

Question 33

management of CLAPC pharm

Answer 33

sodium cromoglicate 2%, qds, can be used while lens wear continues, but preserved drops should not be instilled with SCLs in
olopadine - off license, if no reponse then soft topical steroid - FML 0.1%, loteprednol 0.5%, monitor IOPs

Question 34

bacterial conjunctivitis initial management

Answer 34

Often resolves in 5-7 days without treatment
adv contagious nature
Bathe/clean the eyelids with proprietary sterile wipes, lint or cotton wool dipped in sterile saline or boiled (cooled) water to remove crusting
adv to return if no improvement in 4-5 days

Question 35

why do we not treat bacterial infections with antibiotics straight away

Answer 35

Treatment with topical antibiotics may modestly improve short-term clinical remission and render patient less infectious to others; however the potential benefit of antibiotics needs to be balanced against the risk of antibiotic resistance

Question 36

management of bacterial conjunctivitis entry level (if not self resolved)

Answer 36

Chloramphenicol 1% eye ointment 3 times daily for a week
If allergic to Chloramphenicol, or pregnant, supply Fuscidic acid 1% liquid gel twice a day for a week

Question 37

management of bacterial conjunctivitis IP if not self resolved

Answer 37

azithromycin 1.5% eye drops
(one drop twice daily for 3 days- found from study)
Or chloramphenicol 0.5% qds 5 days

Question 38

contact lens wearers and bacterial conjunctivitis

Answer 38

Contact lens wearers with a diagnosis of bacterial conjunctivitis should be treated with a topical antibiotic effective against Gram –ve organisms, such as an aminoglycoside (e.g. gentamycin) or a quinolone (e.g. levofloxacin or moxifloxacin) Contact lenses should not be worn until the condition has resolved.

Question 39

bacterial conjunctivitis - when would we refer to HES

Answer 39

B3: management to resolution. Refer if condition fails to resolve, or if there is corneal involvement.

A3: If condition fails to resolve, or if there is corneal involvement, urgent referral (within one week) to ophthalmologist

if cls wearer - even if IP

Question 40

adenoviral conjunctivitis management

Answer 40

Normally self-limiting, resolving within one to two weeks
Highly contagious for family, friends and work colleagues (do not share towels)

Infection with adenovirus does not require time off work or school unless patient feels particularly unwell, or if working in close contact with others, or sharing equipment (in which case stay off work until discharge has cleared)

Cold compresses may give symptomatic relief

Discontinue contact lens wear in acute phase

Ask patient to return if symptoms do not resolve or symptoms worsen - in 4-5 days

Artificial tears and lubricating ointments (drops for use during the day, unmedicated ointment for use at bedtime) may relieve symptoms

Topical antihistamines may be used for severe itching

Can use adenoplus swab test which is diagnostic

Question 41

when would we refer for adenoviral conjunctivitis

Answer 41

Normally no referral
Emergency referral (same day):
Visual loss
Severe pain
Significant keratitis
Pseudomembrane

Question 42

controversial management of adenoviral conjunctivits

Answer 42

Topical steroids are sometimes used for the treatment of subepithelial infiltrates (SEI). Although SEI are typically self-limiting, steroids may be indicated in symptomatic patients with persistent SEI after >6 weeks duration. Low potency (non-penetrating) steroids (e.g. fluorometholone) with a higher frequency initially and then tapered e.g. four times per day (QDS) for 1-month, three times per day (TDS) for 1-month and twice per day (BD) for 4-months).

Question 43

tx for internal hordeolum with copious discharge - entry

Answer 43

chloramphenicol
chloramphenicol ointment as longer residency time and it is a lid disorder , normally twice daily for a week

Question 44

how would entry level get chloramphenicol for hordeolums

Answer 44

written order for the medicaion to take to the pharmacy

Written order as can only directly supply chloramphenicol for bacterial conjunctivitis as a P Med