Module 8.0 - Conjunctivitis

Question 1

What is conjunctivitis?

Answer 1

An inflammation or swelling of the conjunctiva, commonly known as ‘pink eye’. The conjunctiva is the thin transparent layer of tissue that lines the inner surface of the eyelid and covers the white part of the eye. Spread by direct inoculation via fingers or droplets.

Question 2

What are the 4 types of conjunctivitis?

Answer 2

1. Infectious
2. Allergic conjunctivitis
3. Chemical Conjunctivitis
4. Miscellaneous types of conjunctivitis

Question 3

What are the 3 causes of infectious conjunctivitis?

Answer 3

1. Bacterial conjunctivitis: Common organisms include Staphylococcus aureus, Pseudomonas, Haemophilus influenza, Streptococcus pneumoniae, Moraxella, Gonorrhea and chlamydia.
2. Viral conjunctivitis: common organisms include adenovirus and herpes virus, which can be vision threatening.
3. Ophthalmia neonatorum – severe form of bacterial conjunctivitis that occurs in newborn babies from exposure in the birth canal to chlamydia or gonorrhea.

Question 4

What are the 2 causes of allergic conjunctivitis?

Answer 4

1. Allergic conjunctivitis – ​caused by exposure to pollen (seasonal allergies), dust, make-up, etc., noninfectious.
2. Giant papillary conjunctivitis – type of allergic conjunctivitis caused by the chronic presence of a foreign body in the eye, such as contact lenses.

Question 5

What causes chemical conjunctivitis?

Answer 5

Caused by irritants such as air pollution, chlorine in swimming pools, and exposure to noxious chemicals.

Question 6

What are some miscellaneous causes of conjunctivitis?

Answer 6

Includes Trauma, Keratoconjunctivities sicca (dry eye), parasitic infestation (pediculosis pubis), Systemic Disease (Reiter syndrome, temporal arteritis, thyroid exophthalmos, and Sjogren syndrome), Medication adverse effects (antihistamines, anticholinergics) or Environmental insults (wind, heat, sun and smoke).

Question 7

What are the subjective/physical exam findings associated with conjunctivitis?

Answer 7

• Redness
• Swelling or itching
• History of allergenic/infectious/traumatic exposure
• Discharge
• Visual acuity may be decreased and may indicate a more serious condition
• Edema of external eye or lid
• Extraocular movement, visual fields, pupillary response, cornea and anterior chamber are usually normal. The presence of photophobia rules out conjunctivitis.
• Conjunctival injection/swelling (chemosis)/foreign body
• Drainage may be purulent or serous. If intent is to culture, a specimen should be taken before drops or irrigation is instilled.

Question 8

How do you assess a patient with a conjunctival injection?

Answer 8

While wearing gloves, evert the upper lid by rolling it externally along the cotton end of a swab and inspect for foreign bodies or papillary changes.

• Normal internal lid is pink and smooth.
• With injection, “bumpy’ flesh or cobblestone appearance (i.e., giant papillary conjunctivae) indicates tissue changes induced by chronic irritation, as from the following:
  
  • Poor hygiene
  • Improper use of extended wear contacts
  • Allergic response to ophthalmic solution
• Examine for obvious foreign body

Question 9

What lab tests can you conduct for conjunctivitis?

Answer 9

Consider a culture of secretions: Giemsa stain for possible infection with chlamydia or gonorrhea.

Question 10

In general, how do you manage conjunctivitis?

Answer 10

1. Nonpharmacological

• Eye compresses- cool for itching/irritation; warm for crusting.
• Discontinue wearing contact lens and eye makeup until resolved.

2. Rule out corneal abrasion or foreign body

• Instill topical anesthetic (2 drops tetracaine [Pontocaine], 0.5% or proparacaine, 0.5%
• Stain the eye with fluorescein with the use of drops or paper
• Examine under ultraviolet light or slit lamp

3. Specific treatments based on cause

Question 11

How do you treat bacterial conjunctivitis?

Answer 11

Topical antibiotic ophthalmic solutions or ointments:

• Gentamycin (Garamycin), 3mg/ml solution, 1-2 drops every 4 hours while awake for 5 days.
• Neomycin (Neosporin) 1-2 drops solution every 1-6 hours; ointment ½ inch ribbon every 3-4 hours; for 7-10 days. *Note: a 15% potential for an adverse reaction to Neomycin-containing products has been reported.
• Polymycin, apply ointment every 3-4 hours for 7-10 days.
• Sulfacetamide sodium (sodium sulamyd) 10% solution, 1-2 drops into affected eye every 2-6 hours while awake; or ½ inch ribbon of ointment every 3-8 hours; for 7-10 days.
• Ofloxacin (Ocuflox), 0.3% solution, 1-2 drops into affected eye every 1-6 hours depending on severity.

Question 12

How do you treat chlamydial conjunctivitis?

Answer 12

1. Oral tetracycline or erythromycin, 250mg 4 times daily, or doxycycline, 100mg bid for 3-4 weeks or,
2. Single dose of azithromycin, 1 gram po
3. Local antibiotics generally are not indicated.

Question 13

How do you treat gonorrheal conjunctivitis?

Answer 13

1. A single dose of ceftriaxone, 1 gram IM
2. Gonococcal conjunctivitis should be confirmed by Gram stain and culture.
3. Patients suspected of ophthalmic infection should be immediately referred to an ophthalmologist because of the risk of corneal perforation.

Question 14

What is vernal conjunctivitis?

Answer 14

• It is a chronic, bilateral, and seasonal conjunctivitis that affects adolescents and young adults predominantly.
• Atopic keratoconjunctivitis affects older adults more commonly and may manifest with lid structural changes and blepharitis (with or without bacterial infection).

Question 15

How do you treat allergic conjunctivitis?

Answer 15

1. Over the counter:

• naphazoline, instill 1-2 drops of 0.012% or 0.1% ophthalmic solution into each eye every 3-4 hours or 4 times daily, prn.

2. H1-receptor antagonists:

• a. Ketotifen, 0.025% 2 drops 2-4 times daily
• b. Loratadine, 10mg po, once daily
• c. Fexofenadine, 180mg po, once daily
• d. Cetirizine, 5-10 mg po, once daily

3. NSAIDS:

• Ketorolac tromethiamine, 2 drops every 6 hours.

4. Topical mast cell stabilizers, cromolyn, vasoconstrictors, and antihistamines should be considered for vernal type.

5. Ophthalmic corticosteroids

• should be considered for acute exacerbations. *Note: Cataracts, glaucoma, and worsening of infections, such as herpes, may occur with the use of steroids.

If pertinent, and allergy to contacts or contact solution is suspected, discontinue agent and refer to an ophthalmologist. Change in contact type or cleaning solution (e.g. Hydrogen peroxide based), discontinuance of one or both, or simply a more judicious cleaning protocol may be indicated.

Question 16

What do you do if a patient has herpes simplex conjunctivitis?

Answer 16

Refer to Ophthalmologist.