Conjunctivitis

Question 0

What is the cause of hyper acute bacterial conjunctivitis?

Answer 0

Hyperacute bacterial conjunctivitis
Neisseria species, particularly N. gonorrhoeae, can cause a hyperacute bacterial conjunctivitis that is severe and sight-threatening, requiring immediate ophthalmologic referral [8]. The organism is usually transmitted from the genitalia to the hands and then to the eyes. Concurrent urethritis is typically present.

The eye infection is characterized by a profuse purulent discharge present within 12 hours of inoculation [9]; the amount of discharge is striking. Other symptoms are rapidly progressive and include redness, irritation, and tenderness to palpation. There is typically marked chemosis, lid swelling, and tender preauricular adenopathy. Gram negative diplococci can be identified on Gram stain of the discharge.

These patients require hospitalization for systemic and topical therapy and for monitoring of the ocular component. Keratitis and perforation can occur.

Question 1

What are the key differentiating points diagnosing viral versus bacterial conjunctivitis?

Answer 1

• The majority of cases are viral(adenovirus).
• Viral conjunctivitis may or may not be associated with URI symptoms.
• Viral usually spreads to the other eye within 12 to 24 hours.
• In Viral the discharge is watery and not copious. There may be a stringy mucus component but not actual pus. (Patients will often misinterpret this mucousy discharge as pus) One or both lids often stuck together in the morning. Often with gritty or itchy sensation

-In bacterial conjunctivitis there is usually a heavy pussy exudate which reappears quickly after the lids are wiped

Question 2

In what conjunctivitis due patients typically have a severe foreign body sensation and difficulty opening the eyes?

Answer 2

One form of viral conjunctivitis, Epidemic Keratoconjunctivitis (EKC), is particularly fulminant, causing a keratitis (inflammation of the cornea) in addition to conjunctivitis. It is typically caused by adenovirus .

multiple corneal infiltrates barely visible with a penlight to the skilled observer>the infiltrates typically degrade acuity by two or three lines to the 20/40 range.

**Keratitis is potentially vision-threatening, and these patients should be referred to an ophthalmologist to confirm the diagnosis and to decide if a course of topical glucocorticoids is warranted.

Question 3

How should you handle “conjunctivitis” in a patient who wears contact lenses particularly soft contact extended wear lenses?

Answer 3

*Don’t prescribe antibiotics without the patient first seeing an ophthalmologist!
More importantly, soft contact lens wearers have a high risk of Pseudomonal keratitis, especially with use of extended-wear lenses [15,16]. This causes an acute red eye and discharge in association with an ulcerative keratitis. The ulcerative keratitis can lead to ocular perforation within 24 hours if it is not recognized and treated appropriately. Thus, the presence of keratitis should be ruled out prior to presuming and treating conjunctivitis. *Keratitis causes objective foreign body sensation, and the patient is usually unable to spontaneously open the eye or keep it open.

A contact lens wearer with an acute red eye and discharge should be advised to discontinue contact lens wear immediately and to be seen by an eye care provider if the symptoms do not improve in 12 to 24 hours. The patient may be treated for acute conjunctivitis only if there is no evidence of keratitis.

Question 4

What are some red flags in evaluating a Red eye?

Answer 4

Red flags
Warning signs of more serious problems that should prompt evaluation by an ophthalmologist include:

●Reduction of visual acuity (concerns about infectious keratitis, iritis, angle closure glaucoma)
●Ciliary flush: A pattern of injection in which the redness is most pronounced in a ring at the limbus (the limbus is the transition zone between the cornea and the sclera) (concerns about infectious keratitis, iritis, angle closure glaucoma)
●Photophobia (concerns about infectious keratitis, iritis)
●Severe foreign body sensation that prevents the patient from keeping the eye open (concerns about infectious keratitis)
●Corneal opacity (concerns about infectious keratitis)
●Fixed pupil (concerns about angle-closure glaucoma)
●Severe headache with nausea (concerns about angle closure glaucoma)
Note that photophobia may also indicate corneal abrasion, a condition that can be initially treated in the primary care or emergency care setting, with referral to ophthalmology if symptoms persist. (See “Corneal abrasions and corneal foreign bodies: Management” and “Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis”.)

Question 5

What are the therapeutic options for conjunctivitis?

Answer 5

Dosage
Empiric approach
Erythromycin ophthalmic ointment One-half inch (1.25 cm) four times daily for 5 to 7 days*
OR. can decrease to BID after 2-3 days if improving
Trimethoprim-polymyxin B ophthalmic drops. 1 to 2 drops four times daily for 5 to 7 days
Specific approach
Bacterial conjunctivitis
Erythromycin ophthalmic ointment One-half inch (1.25 cm) four times daily for 5 to 7 days
OR
Trimethoprim-polymyxin B ophthalmic drops 1 to 2 drops four times daily for 5 to 7 days
OR
Fluoroquinolone ophthalmic drops (preferred agent in **contact lens wearers) Generally, 1 to 2 drops four times daily for 5 to 7 days (regimens vary by medication)
OR
Azithromycin drops 1 drop twice a day for 2 days; then 1 drop daily for 5 days
OR
Bacitracin ophthalmic ointment One-half inch (1.25 cm) four to six times daily for 5 to 7 days
OR
Bacitracin-polymyxin B ophthalmic ointment One-half inch (1.25 cm) four to six times daily for 5 to 7 days
Viral conjunctivitis
Antihistamine/decongestant drops (OTC) 1 to 2 drops four times daily as beeded for no more than three weeks
Allergic conjunctivitis
Antihistamine/decongestant drops (OTC) 1 to 2 drops four times daily as needed for no more than three weeks
Mast cell stabilizer/antihistamine drops Generally, 1 to 2 drops one to three times daily (regimens vary by medication)
Non-specific conjunctivitis
Eye lubricant drops (OTC) 1 to 2 drops every 1 to 6 hours as needed
AND/OR
Eye lubricant ointment (OTC) One-half inch (1.25 cm) at bedtime or four times daily as needed