CONJUNCTIVITIS and other eye lesions

October 2003

Claire Gogal

Definition

• Conjunctivitis: inflammation of the conjunctiva

• Conjunctiva: thin, translucent, elastic tissue layer with bulbar and palpebral portions

• Bulbar: lines the outer surface of the globe to the limbus (junction of sclera and cornea)

• Palpebral: covers the inside of the eyelids• Two layers: epithelium, substantia propria

Eye Anatomy

Classification of Conjunctivitis

Viral• Infectious Hyperacute

Bacterial Acute

Chronic

• Noninfectious Allergic, Toxins/ Chemicals, Foreign body, Trauma, Neoplasm

Prevalence

Viral Conjunctivitis

• Most common viral cause is adenovirus (enterovirus, HSV)

• Occurs in community epidemics (schools, workplaces, physicians’ offices)

• Usual modes of transmission: contaminated fingers, medical instruments, swimming pool water

Viral Conjunctivitis

• Presentation: unilateral or bilateral, acutely red eye, watery or mucoserous discharge, chemosis, tender preauricular node, burning/ sanding/gritty feeling in eye(s), rarely photophobia

• May be part of viral prodrome: adenopathy, fever, pharyngitis, cough, rhinorrhea

Acute Bacterial Conjunctivitis

• Common causes in neonates: Chlamydia trachomatis, Neisseria gonorrhoeae

• In children: Haemophilus influenzae (80%), Streptococcus pneumoniae (20%), and Moraxella catarrhalis. Concurrent OM seen in 25%.

• In adults: Staphylococcus aureus

Acute Bacterial Conjunctivitis

• Presentation: Unilateral or bilateral, red eye, mucopurulent or purulent discharge continuously throughout the day, burning, irritation, mild chemosis

• Neonates: symptoms appear 5-14d after birth (inclusion conjunctivitis of the newborn)

• Highly contagious: spread by direct contact or by contaminated objects

Hyperacute Bacterial Conjunctivitis

• Etiology: Neisseria species, most commonly N. gonorrhoeae

• Presentation: profuse, purulent discharge with rapidly progressive symptoms of marked conjunctival injection, irritation, tenderness to palpation, chemosis, lid swelling, and tender preauricular adenopathy

• Ophthalmia neonatorum: gonococcal ocular infection with bilateral discharge 3-5d after birth from vaginal transmission

• Sexually active teens: transmitted from genitalia to hands to eyes, commonly see concurrent urethritis

• Sight-threatening

Chronic Bacterial Conjunctivitis

• Most common etiology: Staphylococcus species• More common in adults and patients with acne

rosacea or facial seborrhea• Presentation varies: redness, itching, burning,

foreign-body sensation, flaky debris, blepharitis (common), eyelash loss

• Concurrently see styes and chalazia of the lid margin from chronic inflammation of the meibomian glands

Allergic Conjunctivitis

• Most commonly seasonal allergic rhinoconjunctivitis, also called hay fever rhinoconjunctivitis

• IgE mediated hypersensitivity reaction precipitated by small airborne allergens local mast cell degranulation release of chemical mediators (histamine, eosinophil chemotactic factors, PAF, etc.)

• Presentation: bilateral, pruritis, redness, watery discharge, rhinorrhea/congestion

• Patients often have h/o atopy, seasonal allergy or specific allergy

DischargeDischarge Associated with Conjunctivitis

Etiology Serous Mucoid Mucopurulent Purulent

ViralChlamydialBacterialAllergicToxic

+--++

-+-++

-++-+

--+--

+=Present; =absent.

Adapted with permission from Jackson WB. Differentiating conjunctivitis of diverse origins. Surv Ophthalmol1993;38(Suppl):91-104

Diagnosis of Conjunctivitis

• Clinical diagnosis of exclusion• Morning crusting of eye

unreliable for determining

etiology • If focal pathology (hordeolum, cancerous lesion or

blepharitis), conjunctivitis is reactive rather than primary

• If redness is localized rather than diffuse, consider foreign body, pterygium or episcleritis

“Pink Eye” Differential

Cultures

• Not necessary for initial diagnosis and therapy of acute conjunctivitis

• When to culture:

1. Neonates

2. Hyperacute purulent conjunctivitis (immediate Gram staining)

3. Chronic or recurrent conjunctivitis

Treatment

• Viral, allergic, and nonspecific conjunctivitis are self-limited

• Bacterial conjunctivitis is also likely to be self-limited but abx treatment shortens the course, reduces person-to-person spread, and lowers the risk of sight-threatening complications

Treatment of Viral Conjunctivitis

• Topical antibiotics not necessary because secondary bacterial infection is uncommon

• Reassurance that the sxs may get worse for 3-5d before getting better and persist for 2-3 weeks

• Some relief from cold compresses and topical antihistamines/decongestants

• Do not use topical corticosteroids due to risk of sight-threatening complications (scarring, corneal melting, perforation), especially if etiology is herpes simplex virus or bacterial keratitis

Treatment of Acute Bacterial Conjunctivitis

• Topical broad-spectrum antibiotics: erythromycin ointment, bacitracin-polymyxin B ointment (Polysporin), trimethropim-polymyxin B (Polytrim), sulfa drops

• Most H. flu and S. pneumoniae resistant to macrolides• Sulfa drops (Bleph-10): less effective and rare side effect of

Stevens-Johnson syndrome • Rx: 1/2” ointment inside lower lid or 1-2 drops QID for 5-7

days (response seen typically within 1-2d)• Inclusion Conjunctivitis of the Newborn: treat with 2 week

course of erythromycin (50mg/kg/d po divided QID) or sulfisoxazole (150mg/kg/d po divided QID), topical unnecessary with systemic

Treatment of Hyperacute Bacterial Conjunctivitis

• Immediate ophthalmic referral• Systemic and topical antibiotics and saline irrigation• Systemic antibiotic of choice due to penicillin-resistant N.

gonorrhoeae is single-dose Ceftriaxone (25-50mg/kg IV or IM, not to exceed 125mg) or single-dose Cefotaxime (100mg/kg IV or IM) in neonates

• If venereal disease present in teens, also treat with single-dose of azithromycin (1g) because over 30% of these patients will have concurrent chlamydial disease

• AAP and CDC recommendations for prevention of ophthalmia neonatorum: silver nitrate 1% aqueous solution (side effect of chemical conjunctivitis), erythromycin 0.5% ophthalmic ointment, tetracycline 1% ophthalmic ointment

Treatment of Allergic Conjunctivitis

• Self-limited

• Allergen avoidance, cold compresses, topical antihistamines/vasoconstrictors (do not use for greater than 2 weeks), artificial tears, topical NSAIDS (low efficacy)

• Prophylaxis: oral antihistamines (onset of action=days), mast cell stabilizers (onset of action=5-14d)

When to Refer to Ophthalmology

• Neonates

• Hyperacute Purulent Conjunctivitis

• Chronic Conjunctivitis

• Sxs of pain, blurred vision, and photophobia

• Reactive conjunctivitis vs. primary

School/Daycare• Bacterial and viral conjunctivitis are highly contagious

• Red Book 2003: Except when viral or bacterial conjunctivitis is accompanied by systemic signs of illness, infected children should be allowed to remain in school once any indicated therapy is implemented, unless their behavior is such that close contact with other students cannot be avoided. Exclude from daycare if purulent d/c.

• Safest approach for a child with bacterial conjunctivitis is to stay home until there is no longer purulent discharge (1-2d after Rx started).

Eye Anatomy

Other Eye Lesions

Anterior Uveitis• Iridocyclitis

• Etiology: CMV, Cat scratch disease, JRA, Kawasaki disease, IBD, sarcoidosis

• Presentation: Unilateral/Bilateral, erythema, irregular pupil, iris adhesions, pain, photophobia, poor vision

• Tx: topical steroids, therapy for primary dx

Posterior Uveitis• Choroiditis

• Etiology: Toxoplasmosis, histoplasmosis, Toxocara canis

• Presentation: No signs of erythema, decreased vision

• Tx: specific therapy for pathogen

Uveitis

Other Eye Lesions

Keratitis• Etiology: HSV, adenovirus, Streptococcus, Pseudomonas,

Acanthamoeba, chemicals

• Presentation: severe pain, corneal swelling, clouding, limbus erythema, hypopyon, h/o contact lens use

• Tx: specific abxs; keratoplasty; acyclovir for HSV

Eye Anatomy

Other Eye Lesions

Episcleritis• Etiology: Idiopathic, rarely seen

with arthropathies

• Presentation: young woman, acute, unilateral, intense erythema, large blood vessels, serous d/c

• Tx: self-limiting (2-21d), no threat to vision, topical lubricants

Scleritis• Etiology: systemic disease (RA,

IBD, SLE, HSP, sarcoidosis, Wegener’s)

• Presentation: all ages, more common in women, painful, photophobia, perforation, vision changes

• Tx: systemic NSAIDS, steroids, treat underlying condition

Episcleritis/Scleritis

Other Eye Lesions

Hordoleum (sty)• swelling of one or more

sebaceous glands of the eyelid from bacterial infxn, internal or external

• tx: warm compresses, I&D if no drainage occurs, topical abx

Chalazion• hard tumor formed by distention

of a meibomian gland with secretion

• tx: warm compresses

Other Eye Lesions

Pterygium• triangular thickening

of bulbar conjunctiva extending from inner canthus to border of cornea with the apex towards the pupil

• Tx: avoid UV radiation and dust, lubricating eye drops

References

• Conjunctivitis. UpToDate 4/23/03• Conjunctivitis. American Family Physician, 2/15/98• Red Book. 2003 Report of the Committee on Infectious Diseases• Gonococcal infection in the newborn. UpToDate 7/22/02• Chlamydia trachomatis infections in the newborn. UpToDate 3/27/03• Rudolph’s Fundamentals of Pediatrics. 2nd edition, 1998• Nelson’s Essentials of Pediatrics. 3rd edition, 1998• “Should we prescribe antibiotics for acute conjunctivitis?”. Cochrane for

Clinicians: Putting Evidence into Practice, 10/03.• Uveitis: Etiology; diagnosis; and treatment. UpToDate, 9/9/03.• Episcleritis and scleritis. UpToDate, 6/8/01.• Sexually Transmitted Diseases Treatment Guidelines. CDC, MMWR, 2002.