conjunctivitis Flashcards
a difference between chlamydial conjunctivitis and other conjunctivitis
rare
so much mucus that they can taste it in their mouth
VKC management done by who
usually managed by HES
paedriatic ophthalmologist usually manages this
AKC management
corneal then urgent referral
if just conjunctival then routine
differential diagnosis of acute allergic conjunctivitis
Seasonal allergic conjunctivitis
Chemical trauma
Preseptal cellulitis
Orbital cellulitis
management of acute allergic conjucntivits
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
recurrent acute allergic conjunctivitis
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
contraindications for olopatadine
Contraindicated in
- breastfeeding/pregnancy
- women of childbearing age not using contraception
- Caution in dry eye/compromised ocular surface if prolonged use planned
when would refer occur with acute allergic conjunctivitis
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
what is Conjunctivitis medicamentosa
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.
management of seasonal/ perennial allergic conjunctivitis
identify the allergen, cool compress, adv no eye rubbing
systemic antihistamines
ocular lubricants for symptomatic relief
further management of seasonal or perennial allergic conjunctivitis (entry)
mast cell stabiliser sodium cromoglicate 2% 4x a day
or lodoxamide 0.1% (effects of drops can take 2 weeks to show)
further management of seasonal or perennial allergic conjunctivitis (IP)
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%)
can systemic and topical antihistamines be used together
yes
types of non sedating systemic antihistamines (newer class)
cetrizine and loradine
use especially if other allergy symptoms
systemic antihistamines for children
under 12
lower concentration of active ingredient, liquid syrup
chlorphenamine
cetirizine
sedating systemic antihistamines
chlorphenamine
clemastine (older class of drugs)
what effects may systemic antihistamines have
dry mouth
headaches
gastro intestinal distrubances
VKC referral
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
VKC management when mild disease (no limbal or corneal involvement)
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
symptoms of VKC
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
Predisposing factors of VKC
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
signs of VKC
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)
which type of allergic conjunctivitis can be unilateral
acute allergic conjunctivits
AKC predisposing factors
- 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
symptoms of AKC
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
signs of AKC
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
AKC patient prone to develop what
herpes simplex keratitis (which may
be bilateral), corneal ectasia such as keratoconus, atopic (anterior or posterior polar) cataracts, retinal detachment
management of AKC
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
referral for AKC
Urgent referral (within one week) if corneal involvement
Routine referral for Milder cases
What is CLAPC more common in
contact lens wear
more common in reuseable CLs, over night cls, lens deposits, MGD, preservatives in cls care products, high modulus SiHi
symptoms of CLAPC
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
management CLAPC non pharm
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.
management of CLAPC pharm
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
bacterial conjunctivitis initial management
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
why do we not treat bacterial infections with antibiotics straight away
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
management of bacterial conjunctivitis entry level (if not self resolved)
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
management of bacterial conjunctivitis IP if not self resolved
azithromycin 1.5% eye drops
(one drop twice daily for 3 days- found from study)
Or chloramphenicol 0.5% qds 5 days
contact lens wearers and bacterial conjunctivitis
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.
bacterial conjunctivitis - when would we refer to HES
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
adenoviral conjunctivitis management
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
when would we refer for adenoviral conjunctivitis
Normally no referral
Emergency referral (same day):
Visual loss
Severe pain
Significant keratitis
Pseudomembrane
controversial management of adenoviral conjunctivits
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).
tx for internal hordeolum with copious discharge - entry
chloramphenicol
chloramphenicol ointment as longer residency time and it is a lid disorder , normally twice daily for a week
how would entry level get chloramphenicol for hordeolums
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
