OVERVIEW: What every practitioner needs to know
Are you sure your patient has conjunctivitis? What are the typical findings for this disease?
Conjunctivitis is arguably the most common pediatric eye disease seen in practice. Most cases will resolve without intervention. Children will typically experience a number of episodes throughout childhood. Although many cases are self-limited, some will require timely diagnosis and treatment. Vision is rarely affected and the associated pain is generally mild. Causes of conjunctivitis are viral, bacterial, allergic, chemical, and toxic. Viral conjunctivitis is highly contagious. The key symptoms follow:
Discharge
Irritation
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Conjunctival redness
What other disease/condition shares some of these symptoms?
A corneal foreign body, corneal infection, or corneal/conjunctival abrasion may induce redness and copious tearing, although vision is not usually affected. Pain is superficial. Examination with magnification and a fluorescein drop can be instrumental in the diagnosis. These conditions are typically unilateral.
Nasolacrimal duct obstruction may produce a discharge, but usually the eye is not red. The discharge ranges from watery to mucopurulent. In addition, nasolacrimal duct obstruction is a chronic condition and history of previous episodes is typical. There is usually little pain unless it is associated with a purulent collection in the lacrimal sac. There is often a history of bilaterality, even if the current symptoms are unilateral.
A key consideration is infantile or juvenile-onset glaucoma. There will be redness and watery discharge, vision will be reduced, and there will be extensive conjunctival injection especially on the surface of the eye. There is often photosensitivity and clouding of the cornea. This does need urgent evaluation. Nausea and vomiting may be associated. This glaucoma may be unilateral or bilateral.
Much less common are iritis and endophthalmitis. Iritis is inflammation in the interior of the eye.
What caused this disease to develop at this time?
Predisposing factors and clinical signs depend on the type of conjunctivitis.
Allergic conjunctivitis typically has a history of eye irritation or respiratory symptoms (e.g., hay fever) with an exposure to pollen or a pet. Chronicity is typical.
Viral conjunctivitis has a history of family or school episodes of “pink eye,” which is essentially epidemic viral conjunctivitis. Symptoms are acute.
Bacterial conjunctivitis is associated with a history of nasolacrimal obstruction that leads to bacteria being continuously refluxed into the tear film. Also consider the use of soft contact lenses to be a common cause among users, both with and without good lens hygiene practices. Lastly, contaminated eye make-up is often implicated.
Chlamydia-associated conjunctivitis may be seen among newborns and in older sexually active patients in whom there has been hand-to-eye transmission of genital secretions. Usually it is chronic and has not responded to antibiotics.
Toxic conjunctivitis (also called chemical conjunctivitis) implies some exposure to a foreign substance introduced into the tear film. History is key to the diagnosis. There may be use of home remedies or over-the-counter medications.
Contact lens–associated conjunctivitis occurs from poor lens hygiene or reaction to protein on the surface of the lens, producing an allergic reaction.
What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
In most cases, laboratory studies are not performed. In infants or very serious-appearing cases, conjunctival cultures may be obtained. For infants it is crucial to exclude Neisseria gonorrheae with culture and history of onset 2-4 days after delivery. Swab for DNA.
Gram staining can be helpful in limited circumstances.
In some instances to delay transmission in the health care or school setting, viral conjunctivitis needs to be excluded. A polymerase chain reaction–based test of the tear for adenoviral presence is performed.
Chronic or persistent conjunctivitis includes the consideration of eyelid or meibomian gland infection. Chlamydia trachomatis may with the need to swab for DNA.
Typical viral infections are not cultured or tested, as the appearance is typical. However, new rapid screening tests of the conjunctiva for adenovirus are being developed to obviate the need for empirical antibiotic treatment.
Would imaging studies be helpful? If so, which ones?
Imaging studies are not necessary.
Confirming the diagnosis
The symptoms and nature of the discharge can be key to clinical diagnosis. There are no published preferred practice patterns.
Allergic conjunctivitis: Irritation and itching are in excess to the signs, with only slight redness and no to scant discharge. Usually both eyes are affected and there is a history of multiple episodes in a seasonal distribution. There is no preauricular lymphadenopathy. With a handlight, the conjunctival surface of the lower lid will have many small bumps, typically <1 mm, termed papillae. There is a history of chronic symptoms. The symptoms are typically in excess of the findings.
Viral conjunctivis: The tearing is watery and copious. Severe cases will show photosensitivity. The bulbar conjunctiva is usually unaffected, so the eye is not particularly red. The palpebral conjunctiva is very injected; if the lower lid is everted, that conjunctival surface will be very red, and a cobblestone pattern of larger bumps will be visibile with side illumination and without magnification (>2 mm). They are called follicles. There is a nontender enlarged preauricular lymph node. Viral conjunctivitis typically spreads from one eye to the fellow eye in 3-4 days. It will last from 3-14 days.
Bacterial conjunctivitis: The eye is red, there is no lymphadenopathy, and the discharge is mucoid or purulent. The palpebral conjunctiva is inflamed and there are much smaller bumps on the surface compared with viral conjunctivitis. They are like those seen in allergic conjunctivitis.
Chlamydia: In the United States, Chlamydiais seen in the perinatal period and in adolescents and adults. Both groups may have follicles. Newborns will have significant discharge, whereas adults will have minimal discharge.
If you are able to confirm that the patient has conjunctivitis, what treatment should be initiated?
Viral conjunctivitis: cool compresses, systemic decongestants, topical antihistamines, topical nonsteroidal antiinflammatory agents, surface lubricants (e.g., artificial tears)
Bacterial conjunctivitis: topical antibiotics—for intial treatment, older classes of antibiotics are recommended.
Neisseria gonorrheae: neonatal—determine whether it is localized or disseminated; ceftriaxone 25-50 mg/kg daily for 7 days
Chlamydia: topical erythyromycin ointment along with a single dose of azithromycin. Longer courses of tetracycline and erythromycin were used in the past.
Allergic conjunctivitis: topical antihistamines and mast cell stabilizers, artificial tears, oral antihistamines. Nasal treatment has been shown to improve the ocular course.
What are the adverse effects associated with each treatment option?
Antibiotics are associated with nausea and vomiting.
What are the possible outcomes of conjunctivitis?
Most cases resolve without therapy. Viral conjunctivitis, including acute Herpes simplex conjunctivitis, runs a 7- to 14-day course. These cases may develop corneal involvement, scarring, and visual loss.
The most important consideration is bacterial conjunctivitis caused by Neisseria gonorrheae, which can infrequently cause a corneal perforation if not recognized and managed quickly.
What causes this disease and how frequent is it?
Allergic conjunctivitis: exposure to allergens. Reduce the exposure and try to not rub eyes. Most children with allergic conjunctivitis have allergic rhinitis.
Viral conjunctivitis: hand or droplet transmission from infected tears to patient. Prevented by hand hygiene and cleaning infected surfaces.
Contact lens use
Infection of eyelid glands
Bacterial conjunctivitis: both endogenous and exogenous. Transmitted by genital secretions.
What complications might you expect from the disease or treatment of the disease?
Most forms of conjunctivitis typically have no adverse sequelae.
Neisseria gonorrheae may damage the corneal surface with scarring.
Recurrent herpes simplex conjunctivitis can become keratitis, which can cause scarring of the cornea with a reduction in vision.
How can conjunctivitis be prevented?
Viral conjunctivitis may be prevented by mandating sound hand hygiene when working with affected children or adults. Disinfect surfaces that affected patients have touched.
Prenatal care must be given for gonorrhea and neonatal chlamydial infections.
Bacterial conjunctivitis can be reduced by clearing any nasolacrimal duct obstructions and asking contact lens users to be scrupulous in their adherence to best lens handling practices.
Allergic conjunctivitis is reduced by avoiding exposure to known pathogens and bathing after an exposure.
What is the evidence?
Naclerio, R. “Intranasal corticosteroids reduce ocular symptoms associated with allergic rhinitis”. Otolaryngol Head Neck Surg. vol. 138. 2008. pp. 129-39. (A review article that shows that intranasal corticosteroids in patients with allergic rhinitis show improvement in their ocular symptoms. Mechanism of action is uncertain.)
Gigliotti, F. “Acute conjunctivitis of childhood”. Pediatric Ann. vol. 22. 1993. pp. 353-6. (A review of causes of conjunctivitis in childhood. The epidemiology has not changed since this survey.)
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