PANCE Blueprint EENT (7%)

Conjunctival disorders (PEARLS)

Conjunctivitis (ReelDx + Lecture)
ReelDx Virtual Rounds (Conjunctivitis)
Patient will present as → a 6-year-old boy complaining of itchy eyes. The mother states that she has noted that he has been tearing up and that both of his eyes have been red for the past 4 days. The patient denies any pain but has had a runny nose for the past week. The mother states that he has not had any sick contacts, and he has been home from school for summer vacation. On exam, there is marked redness, tearing, and eyelid edema in both eyes.

Viral conjunctivitis - copious watery discharge, scant mucoid discharge. Adenovirus (most common). Self-limiting associated with URI

Bacterial conjunctivitis - will present with purulent (yellow) discharge, crusting, usually worse in the morning. It may be unilateral.

  • S. pneumonia, S. aureus – acute mucopurulent
  • M. catarrhalis, Gonococcal – copious purulent discharge in a patient who is not responding to conventional treatment
  • Chlamydia– newborn, Giemsa stain - inclusion body, scant mucopurulent discharge

Allergic conjunctivitis - red eyes, itching and tearing, usually bilateral, cobblestone mucosa on the inner/upper eyelid


Bacterial: Treatment(s) in order of suggested use - the dose is 0.5 inches (1.25 cm) of ointment (preferable in children) deposited inside the lower lid or 1 to 2 drops instilled four times daily for five to seven days.

  1. Gentamicin/tobramycin (Tobrex): aminoglycoside antibiotic used for gram-negative bacterial coverage. Most cases of bacterial conjunctivitis will respond to this agent
  2. Erythromycin ointment (E-Mycin) Chlamydia for newborns
  3. Trimethoprim and polymyxin B (Polytrim) This combination is used for ocular infections involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic.
  4. Ciprofloxacin (Ciloxan)

Contact lenses use = pseudomonas tx=fluoroquinolone (ciprofloxacin / Ciloxan drops) 

  • Neisseria conjunctivitis warrants prompt referral and topical + systemic antibiotics
  • Chlamydial conjunctivitis systemic tetracycline or erythromycin x 3 weeks, topical ointments as well, assess for STD or child abuse

Viral: There is no specific antiviral agent for the treatment of viral conjunctivitis. Some patients derive symptomatic relief from topical antihistamines/decongestants. Warm or cool compresses may provide additional symptomatic relief.

Allergic conjunctivitis systemic antihistamines and topical antihistamines or mast cell stabilizers. (Naphcon-A, Ocuhist, generics)

  • Epinastine (Elestat)
  • Azelastine (Optivar)
  • Emedastine difumarate (Emadine)
  • Levocabastine (Livostin)

A Comparison of Bacterial, Viral, and Allergic Conjunctivitis

Subconjunctival hemorrhage
Patient will present as → a 45-year-old individual who noticed a bright red patch on the white of one eye upon waking up this morning. The patient reports no pain, vision changes, or recent injury to the eye but feels self-conscious about the appearance. The red patch does not extend to the iris, and there is no discharge or photophobia.

Subconjunctival hemorrhage is a benign condition characterized by a sudden onset of a unilateral bright red patch on the sclera due to the rupture of small blood vessels under the conjunctiva

  • It can occur spontaneously or be triggered by coughingsneezingheavy liftingvomiting, or even rubbing the eye too hard
  • While it may look alarming, it typically causes no pain, no vision changes, and no discharge
  • Risk factors include hypertension, diabetes, blood thinning medications, and certain blood clotting disorders


Diagnosis is primarily clinical, based on the characteristic appearance of a bright red or dark red patch on the sclera, with clear demarcation, and absence of other symptoms such as pain, vision loss, or discharge

  • No specific tests are usually required unless recurrent hemorrhages suggest an underlying systemic condition


Treatment is generally not required as the condition resolves on its own within two weeks. Artificial tears can help with any mild irritation

Subconjunctival hemorrhage eye

Subconjunctival hemorrhage eye. Broken blood vessel.

Brian Wallace PA-C Podcast: Disorders of the Eye Parts 1-4 (Prev Lesson)
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