Painless red eye

Question 1

What is conjunctivitis?

Answer 1

Conjunctivits is inflammation of the conjunctiva over the sclera (bulbar) and inner eyelids (tarsal) due to allergic or immunological reactions, infections (viral, bacterial or parasitic), mechanical irritation, neoplasia, or contact with toxic substances

• The conjunctiva is a thin, transparent mucous membrane lining the anterior part of the sclera (bulba conjunctiva) and the under-surface of the eyelids (palpebral conjunctiva)
• Inflammation or infection of the conjunctiva causes dilatation of conjunctival vessels leading to hyperaemia and oedema of the conjunctiva +/- discharge

Most cases are bilateral, due either to symmetrical pathologies (allergy, eye drop toxicity and other chemical exposure) or cross-infection from one eye to the other

Question 2

What are the different types of conjunctivitis?

Answer 2

Conjunctivitis can be divided into:

• Infectious
  
  • Bacterial conjunctivitis
  • Chlamydial conjunctivitis
  • Gonorrhoeal conjunctivitis
  • Neonatal conjunctivitis
  • Viral conjunctivitis
• Non-infectious
  
  • Allergic conjunctivitis

Question 3

Infective conjunctivitis refers to conjunctival inflammation occurring secondary to viral, bacterial and parasitic infection.

Infective conjunctivitis can be acute, chronic or recurrent

How long are the duration for acute and chronic infective conjunctivitis?

Answer 3

Acute infective conjunctivitis resolves within 4 weeks

Chronic infective conjunctivitis persists for > 4 weeks

There is also a hyperacute conjunctivitis, which is a rapidly developing severe conjunctivitis typically caused by infection with Neisseria gonorrhoeae

Question 4

Which bacteria cause hyperacute (rapidly developing) infective conjunctivitis?

Answer 4

Neisseria gonorrhoeae and Neisseria meningitidis

They cause hyperacute conjunctivitis which is a rapidly progressive (within 12-24 hrs) and severe bacterial conjunctivitis characterised by *large volume of purulent discharge in the eye. It’s potentially sight-threatening

Question 5

a) . What is Neonatal conjunctivitis (Ophthalmia neonatorum)?
b) . What bacteria most commonly cause neonatal conjunctivitis?

Answer 5

a) . Neonatal conjunctivitis is conjunctivitis occuring within the first 4 weeks of life. It can be infectious (often from contamination from the maternal genital tract) or non-infectious
b) . Infectious neonatal conjunctivitis are usually caused by Chlamydia trachomatis (more common) or Neisseria gonorrhoea. Non-sexually transmitted bacteria account for up to 50% of cases with common pathogens like streptococcus spp, staphylococcus spp and haemophilus influenzae

Question 6

Epidemiology of Infective conjunctivitis:

a) . How common is infective conjunctivitis in primary care?
b) . Bacterial conjunctivitis is the most common form of infectious conjunctivitis - True or False
c) . Most cases of infective conjunctivitis in children are viral - True or False

Answer 6

a) . Infective conjunctivitis is common, accounting for 1% of all GP consultations in the UK
b) . FALSE - viral conjunctivitis is the most common form, accounting for 80% of all cases of acute conjunctivitis. Bacterial conjunctivitis is the 2nd most common cause
c) . FALSE - Up to 75% of cases of infective conjunctivitis in children are caused by a bacterial infection

Question 7

What age group is most commonly affected by bacterial conjunctivitis?

Answer 7

Children (and the elderly too)

Question 8

How is bacterial conjunctivitis transmitted?

Answer 8

Direct contact with infected secretions

Question 9

What are the causative agents for viral and bacterial conjunctivitis?

(Please specify which is the most common causative agent)

Answer 9

Viral conjunctivitis

• Adenovirus types (up to 90% of all cases of viral conjunctivitis)
  
  • Adenovirus types 3, 4 and 7 –> pharyngoconjunctival fever
  • Adenovirus types 8 and 9 –> epidemic keratoconjunctivitis
• Herpes - HSV, VZV, EBV
• Coxsackie virus
• Enteroviruses
• Molluscum contagiosum

Bacterial conjunctivitis

• Staphylococcus aureus
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Chlamydia trachomatis
• Neisseria gonorrhoea

Question 10

Give 5 complications of infective conjunctivitis

Answer 10

Complications due to infective conjunctivitis are rare. However:

• Epidermic keratoconjunctivitis (inflammation of both the cornea and the conjunctiva) - a complication of adenovirus infection
  
  • Up to 50% of people develop corneal subepithelial infiltrates –> visual loss and photophobia
    
    • Inflammation of the cornea produces chemokines which draw WBCs from the limbal vasculature into the avasular cornea. These WBCs coalesce to form spots i.e. infiltrates inside the cornea
  • Super infectious –> epidemics
• Keratitis in people who wear contact lenses or those who are immunocompromised - a complication of bacterial conjunctivitis
• Corneal perforation - a complication of infection with Neisseria gonorrhoeae
• Superficial corneal vascularisation, conjunctival scarring, pneumonia –> a complication of chlamydial neonatal conjunctivitis
• Corneal scarring and ulceration, panophthalmitis, perforation of eyeball, permanent visual loss - a complication of gonorrhoeal neonatal conjunctivitis
  
  • Panophthalmitis is inflammation of both internal and external ocular structures, while endophthalmitis is inflammation of internal ocular structures
• Trachoma (chronic keratoconjunctivitis) - a complication of recurrent infection with Chlamydia trachomatis in children, found mostly in sub-Saharan Africa –> scarring of eyelid, conjunctiva and cornea
  
  • The leading cause of infectious blindness worldwide

Question 11

Prognosis of infective conjunctivitis:

How long does it take for viral and bacterial conjunctivitis to resolve?

What is the prognosis of neonatal conjunctivitis?

Answer 11

Viral conjunctivitis - 7 days

Bacterial conjunctivitis - 5-10 days

Question 12

What are the clinical features of viral conjunctivitis?

Answer 12

Common features shared by all forms of conjunctivitis:

• Acute onset of diffuse conjunctival erythema/ injection (red eye) - usually progresses from unilateral to bilateral due to cross-infection from one eye to the other
• Discomfort which maybe described as ‘grittiness’, ‘foreign body’ or ‘burning’ sensation
• Watering and discharge which may cause transient blurring of vision
• Eyelids crusted shut in the morning

Features specific for viral conjunctivitis:

• Mild to moderate erythema of the bulbar or palpebral conjunctiva, follicles on eyelid eversion and lid oedema
• Petechial (pin-point) subconjunctival haemorrhages
• Pseudomembrane formation on tarsal conjunctival surfaces in severe cases, indicating epidemic keratoconjunctivitis (caused by adenovirus type 8 and 9), which is usually accompanied by severe pain, subconjunctival haemorrhage, visual changes and photophobia
• Less discharge compared to bacterial conjunctivitis and is usually watery (serous)
• Pruritus (absent in bacterial conjunctivitis)
• Hx of URTI (coryzal symptoms) and pre-auricular lymphadenopathy
  
  • Pharyngoconjunctival fever (caused by adenovirus type 3, 4 and 7) can lead to high fever, sore throat (pharyngitis), periauricular lymphadenopathy, and bilateral conjunctivitis
• Microscopic subepithelial corneal infiltrates may develop under epithelial erosions and result in glare, which can persist following resolution of acute conjunctivitis
• If caused by HSV –> unilateral red eye + vesicular rash on eyelid + watery discharge
• If caused by VZV (herpes zoster ophthalmicus) –> ophthalmic shingles
  
  • ​If the rashin involves the tip or the side of the nose (+ Hutchinson’s sign), assume there is ocular involvement (conjunctivitis, herpes zoster keratitis)
• If caused by molluscum contagiosum –> tiny white papillomatous lump on eyelid margin (follicular conjunctivitis)
• Extremely contagious (wash hands thoroughly)

Question 13

What does the image below show?

Which condition do you see that in a patient?

Answer 13

Pseudomembranes –> severe viral conjunctivitis

Question 14

Patient comes to see you with itchy red eyes. On examination, you see these (see image) on the lower eyelids. What are they?

Answer 14

Follicles (resembling grains of rice) –> viral conjunctivitis

Question 15

What are the clinical features of bacterial conjunctivitis?

Answer 15

Presentations:

Common features shared by all forms of conjunctivitis:

• Acute onset of diffuse conjunctival erythema (red eye) - usually progresses from unilateral to bilateral due to cross-infection from one eye to the other
• Discomfort which maybe described as ‘grittiness’, ‘foreign body’ or ‘burning’ sensation
• Watering and discharge which may cause transient blurring of vision
• Eyelids crusted shut in the morning

Features specific to bacterial conjunctivitis (staphylococcus aureus, streptococcus pneumoniae, haemophilus influenzae)

• More extensive conjunctival erythema, discharge and lid swelling compared to viral conjunctivitis
• Purulent/ mucopurulent discharge with crusting of the eyelids which maybe stuck together on waking
• Mild/ absent pruritus
• Conjunctival papillae, giving a velvet-like appearance
• If red eye + mucopurulent discharge in large volumes + pre-auricular lymphadenopathy –> hyperacute bacterial conjunctivitis (caused by Neisseria gonorrhoea or Neisseria meningitidis)

Question 16

Patient comes to see you with a red eye with purulent discharge, you examine his eye and you see this? (see image)

What is that? and What does it indicate?

Answer 16

Papillae in conjunctiva –> velvet-like appearance

Bacterial conjunctivitis

Question 17

What are the clinical features of chlamydial conjunctivitis?

Answer 17

Presentations:

Common features shared by all forms of conjunctivitis:

• Acute onset of diffuse conjunctival erythema (red eye) - usually progresses from unilateral to bilateral due to cross-infection from one eye to the other
• Discomfort which maybe described as ‘grittiness’, ‘foreign body’ or ‘burning’ sensation
• Watering and discharge which may cause transient blurring of vision
• Eyelids crusted shut with sticky discharge in the morning

Features specific to chlamydial conjunctivitis

• Usually present in young adults as they are more sexually active, so higher risk of catching STIs!
• Chronic (> 2 weeks) low-grade irritation + prolonged mucopurulent discharge that usually affects one eye (unilateral) in a sexually active person + pre-auricular lymphadenopathy
• Conjunctival follicles on lower eyelids
• Urethral or vaginal symptoms
• No response to topical Abx

Trachoma (chronic keratoconjunctivitis)

• Usually affect children esp in sub-Saharan Africa due to inadequate sanitary facilities
• Follows a chronic course leading to severe conjunctival cicatricial change with entropion, trichiasis, dry eye and secondary corneal ulceration and scarring

Question 18

What are the clinical features of gonorrhoeal conjunctivitis?

Answer 18

Common features shared by all forms of conjunctivitis:

• Acute onset of diffuse conjunctival erythema (red eye) - usually progresses from unilateral to bilateral due to cross-infection from one eye to the other
• Discomfort which maybe described as ‘grittiness’, ‘foreign body‘or ‘burning’ sensation
• Watering and discharge which may cause transient blurring of vision
• Eyelids crusted shut in the morning

Features specific to gonorrhoeal conjunctivitis

• Usually affects young adults as they are more sexually active!
• Hyperacute - rapidly developing over 12-24 hrs
• Large volume of mucopurulent discharge
• Lid swelling
• Tender preauricular lymphadenopathy

Question 19

Give 3 complications of gonorrhoeal conjunctivitis?

Answer 19

Keratitis

Anterior uveitis

Corneal ulceration and scarring

_*Corneal perforation_

Question 20

How do the presentations in chlamydial neonatal conjunctivitis differ from that in gonococcal neonatal conjunctivitis?

Answer 20

Common features

• Acute onset of diffuse conjunctival erythema (red eye) - usually progresses from unilateral to bilateral due to cross-infection from one eye to the other
• Discomfort which maybe described as ‘grittiness’, ‘foreign body’or ‘burning’ sensation
• Watering and discharge which may cause transient blurring of vision
• Eyelids crusted shut with sticky discharge in the morning

Features specific to Chlamydial neonatal conjunctivitis

• Watery/ mucopurulent discharge about 5-14 days after birth

Features specific to Gonorrhoeal neonatal conjunctivitis

• Large volume of purulent discharge and severe eyelid swelling that typically present within the first 5 days of life (tho they can present up to 3 weeks after delivery)

Question 21

What are the red flag symptoms that warrant urgent ophthalmological assessment?

Answer 21

Red flag symptoms that warrant URGENT OPHTHALMOLOGICAL ASSESSMENT:

• Reduced visual acuity
• Severe eye pain, headache or photophobia - always consider serious conditions e.g. meningitis or encephalitis
• Red sticky eye in a neonate (within 30 days of birth) suggestive of neonatal conjunctivits
• Hx of trauma (mechanical, chemical or UV) or possible FB
• Recent intraocular surgery
• Large volume of rapidly progressive discharge –> gonococcal infection
• Infection with herpes virus (HSV, VZV, EBV)
• Soft contact lens use with corneal symptoms e.g. photophobia and watering)
• Suspected periorbital or orbital cellulitis
• Severe disease e.g. corneal ulceration, significant keratitis or presence of pseudomembrane

Question 22

What investigations would you consider doing for infective conjunctivitis?

Answer 22

Ix:

• Viral conjunctivits - no Ix needed usually, however, if the person re-attends with symptoms of conjunctivitis, consider sending swabs for viral PCR (for adenovirus and HSV) and bacterial culture and empirical topical Abx
• Bacterial conjunctivitis
  
  • Swabs are NOT routinely performed except:
    
    • When diagnosis is uncertain
    • If the person fails to respond to initial treatment
    • If there is severe purulent discharge (which may indicate gonococcal infection) - performed in secondary care
• Chlamydial conjunctivitis
  
  • Swab/ smear and sent for direct monoclonal fluorescent antibody microscopy and PCR
• Gonorrhoeal conjunctivitis or neonatal conjunctivitis
  
  • Swabs should be carried out urgently in secondary care for severe purulent discharge

Question 23

How do you manage infective conjunctivitis?

Answer 23

Mx:

• Primary care
  
  • Urgent referral to an ophthalmologist for same-day assessment for patients with:
    
    • Red flag symptoms:
      
      • Reduced visual acuity
      • Severe eye pain, headache or photophobia - always consider serious conditions e.g. meningitis or encephalitis
      • Red sticky eye in a neonate (within 30 days of birth) suggestive of neonatal conjunctivits
      • Hx of trauma (mechanical, chemical or UV) or possible FB
      • Large volume of rapidly progressive discharge –> gonococcal infection
      • Infection with herpes virus (HSV, VZV, EBV)
      • Soft contact lens use with corneal symptoms e.g. photophobia and watering)
      • Recent intraocular surgery
      • Suspected periorbital or orbital cellulitis
      • Suspected gonococcal or chlamydial conjunctivitis
      • Severe disease e.g. corneal ulceration, significant keratitis or presence of pseudomembrane
      • Conjunctivitis associated with a severe systemic condition e.g. RA or immunocompromise
  • If the patient does not need referral, manage infective conjunctivitis according to likely cause:
    • Viral conjunctivitis:
      
      • Most are self-limiting, usually resolves within 1-2 weeks without treatment
      • Advice
        
        • Explain to the patient that Abx are useless against viral infections and it could lead to resistance
        • Self care measures:
          
          • Bathing/ cleaning the eyelids with cotton wool soaked in boiled cooled water to remove any crusting or discharge
          • Cool compresses applied gently around affected eye
          • Lubricating drops or artificial tears
          • Stop contact lens use if wearing one
        • Inform the patient that infective conjunctivitis is HIGHLY CONTAGIOUS and they should try to prevent spread of infection to their other eye and other people by:
          
          • Washing hands frequently with soap and water
          • Using separate towels and flannels
          • Avoiding close contact with others esp if they are a healthcare professional or child care provider - they maybe infectious for up to 14 days from onset
        • Safety netting - explain red flags for urgent review and advise the person to seek further help if symptoms persist for > 7 days
      • If the person re-attends with symptoms of conjunctivitis, consider sending swabs for viral PCR (for adenovirus and HSV) and bacterial culture and empirical topical antibiotics (if not already prescribed)
    • Bacterial conjunctivitis:
      
      • Most are self-limiting and resolve within 5-7 days without treatment
      • Offer topical Abx only if severe
        
        • 1st line - Chloramphenicol 0.5% drops apply 2 hourly for 2 days then 4 hourly (while awake). Continue until 48 hrs after resolution
        • 2nd line or if penicillin allergic - Fusidic acid 1% eye gels apply BD until 48 hrs after resolution
      • Advice
        
        • Self-care measures
          
          • Bathing/ cleaning the eyelids with cotton wool soaked in boiled cooled water to remove any crusting or discharge
          • Educate patients on red flags and explain the need for urgent review
          • Stop contact lens use if wearing one
      • If the person re-attends with symptoms of conjunctivitis, consider sending swabs for viral PCR (for adenovirus and HSV) and bacterial culture and empirical topical antibiotics (if not already prescribed)
    • Chlamydial conjunctivitis:
      
      • Topical tetracycline/ oral doxycycline/ azithromycin
      • Contact trace
      • Referral to GUM clinic
    • Congenital chlamydial conjunctivitis:
      
      • Oral erythromycin
    • Congenital gonococcal conjunctivitis:
      
      • IM cefotaxime

Question 24

When should you do a routine referral for a patient with infective conjunctivitis?

(Not urgent referral, but routine referral!)

Answer 24

When symptoms persist for > 7-10 days after starting treatment

Question 25

How do you manage contact lens wearers with conjunctivitis?

Answer 25

Mx:

• Assess the cornea using topical fluorescein drops under cobalt blue light and refer them if cornea is involved
• Stops contact lenses use immediately until the condition has completely resolved
• Advise regular bathing/cleaning of the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge
• Treat as described previously
  
  • Viral and bacterial conjunctivitis are mostly self-limiting, so no treatment needed
  • Offer topical chloramphenicol if severe bacterial conjunctivitis

Question 26

Are school exclusion necessary for infective conjunctivitis?

Answer 26

NO!

Question 27

What is the pathophysiology of allergic conjunctivitis?

Answer 27

Pathophysiology:

• Due to IgE response to an allergen
  
  • Allergen binds to mast cells in the conjunctiva causing them to degranulate, which initiates an inflammatory cascade. This releases histamine and other inflammatory mediators
  • Activation of Histamine H1 receptors in the conjunctiva leads to itching of the eyes
  • Redness and swelling (chemosis) of the conjunctiva and eyelids are due to stimulation of H1 and H2 receptors on blood vessels
• Problems with eyebrows, eyelashes, eyelids or production of tears can exacerbate allergic conjunctivitis as they act as barriers to allergens

Question 28

Give 4 complications of allergic conjunctivitis

Answer 28

Irritability, decreased concentration and daytime fatigue

Impaired performance at school/ work

Reduced quality of life

Vernal and atopic keratoconjunctivitis are more severe forms of allergic conjunctivitis which can cause thickening of eyelids, corneal neovascularisation, conjunctival scarring, thinning, ulceration and infection, and loss of vision

Question 29

What are the clinical features of allergic conjunctivitis?

Answer 29

Presentations:

Symptoms

• Bilateral conjunctival erythema and swelling (chemosis)
  
  • Chemosis - bulbar and palpebral conjunctiva may bulge over lid margin or limbus
• Very itchy eyes
• Watery or mucoid discharge (tearing)
• Swollen eyelids
• Hx of atopy - asthma, allergic rhinitis (coryzal symptoms), eczema, urticaria
• Maybe seasonal (due to pollen) or perennial (due to dust mites, moulding spores, animal dander and washing powder)

Signs

• Cobblestone papillae in chronic cases, most commonly found on the superior tarsal conjunctiva (the inferior tarsal conjunctiva is unaffected)

Question 30

What investigations do you do for allergic conjunctivitis?

Answer 30

Clinical diagnosis

(Ix are NOT normally required)

If diagnosis is uncertain, exclude infection, check IgE levels and patch resting

Question 31

How do you manage a patient with allergic conjunctivitis?

Answer 31

Mx:

• Primary care
  
  • Non-pharmacological management
    
    • Allergen avoidance
      
      • For grass pollen allergy:
        
        • Avoid walking in open grassy areas, particularly during early morning and early evening
        • Keep windows shut in cars and buildings
      • For dust mite allergy:
        
        • Wash bedding and furry toys at least once a week at high temperatures
        • Fit blinds that can be wiped clean instead of curtains
        • Avoid use of carpets
      • For animal allergy:
        
        • Don’t allow animal in the house, if not possible, restrict their presence to bedrooms and kitchen
        • Wash the animal and any surfaces they are in contact with regularly
    • Avoid rubbing eyes
    • Apply cold compresses to the eyes
    • Apply eye lubricants such as saline or artificial tears
    • Advise that after using eye drops, they should not drive or perform other skilled tasks until vision is clear
  • Pharmacological management
    
    • 1st line - topical antihistamine e.g. olopatidine
    • If symptoms are recurrent or persistent, 2nd line - topical mast cell stabilisers e.g. sodium cromoglicate
      
      • Advise the person that a long loading period is required and mast cell stabilisers need to be applied routinely for several weeks to provide prophylactic benefit
        
        • Long loading period means that it takes a long time for the drug to teach appropriate therapeutic level
  • Arrange review in 1 week to assess response

Question 32

A patient who’s been sneezing quite a lot recently presented to you with a red itchy eye. On examination, you see this. What does the image show? and What condition does it suggest?

Answer 32

Cobblestone papillae

• Seen in allergic conjunctivitis