Lecture
1-year-old with inflamed conjunctiva
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 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 of both eyes.
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I. Viral: Pt will likely present with bilateral preauricular lymphadenopathy, copious watery discharge, and scant mucoid discharge. Cobblestoning of palpebral conjunctiva. The most common viral agent is adenovirus.
- Treat with cool compresses, artificial tears, and antihistamines for itching/redness (e.g. olopatadine)
II. Bacterial: acute onset of copious purulent D/C from both eyes. Eyes “glued” shut in the AM.
- Staphylococcus aureus is most common in adults
- Staphylococcus epidermidis, Streptococcus pneumoniae, Haemophilus influenzae
- Moraxella catarrhalis/gonococcal - copious purulent discharge in a patient who is not responding to conventional treatment
- H influenzae most common cause in young preschool children
- School-aged children and adolescents bacterial - strep pneumoniae, staph aureus, H. flu, Moraxella
- C. trachomatis is the most common causative organism in neonates.
- The presence of acute follicular conjunctivitis is most consistent with inclusion conjunctivitis resulting from chlamydial infection
- Giemsa stain - inclusion body, scant mucopurulent discharge
III. Allergic conjunctivitis: Patients will present with red eyes, itching, and tearing. Usually bilateral. Will also see cobblestone mucosa on the inner/upper eyelid
Chlamydial conjunctivitis - Giemsa stain - inclusion body
Neisseria conjunctivitis - gram stain and culture if suspected
Red flags — Warning signs of more serious problems that should prompt evaluation by an ophthalmologist include:
- Reduction of visual acuity (concerns about infectious keratitis, iritis, angle-closure glaucoma)
- Ciliary flush: A pattern of injection in which the redness is most pronounced in a ring at the limbus (the limbus is the transition zone between the cornea and the sclera) (concerns about infectious keratitis, iritis, angle-closure glaucoma)
- Photophobia (concerns about infectious keratitis, iritis)
- Severe foreign body sensation that prevents the patient from keeping the eye open (concerns about infectious keratitis)
- Corneal opacity (concerns about infectious keratitis)
- Fixed pupil (concerns about angle-closure glaucoma)
- Severe headache with nausea (concerns about angle closure glaucoma)
Bacterial: Treatment(s) in order of suggested use - the dose is 0.5 inch (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.
- Gentamicin/tobramycin (Tobrex): aminoglycoside antibiotic used for gram-negative bacterial coverage. Most cases of bacterial conjunctivitis will respond to this agent
- Erythromycin ointment (E-Mycin) Chlamydia for newborns
- 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.
- Ciprofloxacin (Ciloxan)
Contact lenses use = pseudomonas tx=fluoroquinolone (ciprofloxacin/Ciloxan drops)
- Neisseria conjunctivitis warrants prompt referral and topical + systemic antibiotics
- Chlamydial conjunctivitis in neonates: This infection is treated with oral erythromycin (50 mg/kg/d divided qid) for 14 days. Topical erythromycin ointment may be beneficial as adjunctive therapy, but alone is ineffective. 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)
* Most daycare centers and schools require that students receive 24 hours of topical therapy before returning to school.
Question 1 |
Which of the following organisms is not a common pathogen causing bacterial conjunctivitis?
Streptococcus pneumoniae Hint: This is a common cause | |
Staphylococcus aureus Hint: This is a common cause | |
Haemophilus aegyptius Hint: This is a common cause | |
Moraxella sp. Hint: This is a common cause | |
Chlamydia trachomotis |
Question 1 Explanation:
Chlamydia trachomatis (and Neisseria gonorrhea) can cause bacterial conjunctivitis but unlike the other 4 listed here is a rare cause. The natural history of infections caused by these rare pathogens is severe conjunctivitis and keratitis with development of permanent isual impairment.
Question 2 |
A 32-year-old woman comes to your office with a 1-week history of bilateral red eyes associated with tearing and crusting, a sore throat with difficulty swallowing, and a cough that was initially nonproductive but has become productive during the past few days. The patient displays significant fatigue and lethargy, is hoarse, and is having great difficulty performing any of her routine daily chores.
On physical examination, there is bilateral conjunctival injection. Her visual acuity is normal. There is significant pharyngeal erythema but no exudate. Cervical lymphadenitis is not present. Examination of the chest reveals a few expiratory crackles bilaterally.
What is the most likely organism or condition responsible for the constellation of symptoms in this patient?endotoxin-producing Staphylococcus | |
endotoxin-producing Streptococcus | |
exotoxin-producing Staphylococcus | |
activation of the autoimmune system | |
none of the above |
Question 2 Explanation:
This picture is completely consistent with adenovirus infection and a primary viral conjunctivitis. Viral agents, especially adenovirus, produce signs and symptoms of upper respiratory tract infection, with the red eye being prominent among those symptoms.
With adenovirus, there is often associated conjunctival hyperemia, eyelid edema, and a serous or seropurulent discharge. Viral conjunctivitis is self-limited, lasting 1 to 3 weeks. If the conjunctivitis is definitely caused by a virus, no antibiotic treatment is necessary.
There is no indication to perform a throat culture or any other test at this time. The only theoretical concerns are the “rales” that are present in both lung bases; you could argue that if the patient is sick enough, a chest radiograph may be indicated.
Question 3 |
A 7 year old boy presents to your clinic with thick purulent discharge from her right eye which was significantly worse this morning. What should you do next?
take a sample of the discharge and send it to the lab for culture. Hint: In this case it would be appropriate to begin antibiotic treatment immediately. A poor clinical response after 2 or 3 days indicates that the cause is resistant bacteria, a virus, or an allergy. Culture and sensitivity studies should then be done | |
send the patient home to perform warm compresses for 20 minutes 3 times daily tell them to come back if symptoms become worse Hint: warm compresses can help but this patient would benefit from antibiotic ointment and should not be sent home without treatment | |
moxifloxacin 0.5% drops tid for 7 to 10 days | |
topical 1% prednisolone acetate qid Hint: steroids are not indicated in the treatment of bacterial conjuntivitis |
Question 3 Explanation:
If neither gonococcal nor chlamydial infection is suspected, most clinicians treat presumptively with moxifloxacin 0.5% drops tid for 7 to 10 days or another fluoroquinolone or trimethoprim/polymyxin B qid. A poor clinical response after 2 or 3 days indicates that the cause is resistant bacteria, a virus, or an allergy. Culture and sensitivity studies should then be done (if not done previously); results direct subsequent treatment.
Question 4 |
A 12 year old present to your office with red eyes, itching and tearing bilaterally. He has a past medical history significant for asthma. As you examine the inner eyelid what finding do you expect to see?
cobblestone mucosa | |
Kayser–Fleischer rings Hint: this finding is associated with copper deposition in Wilson's disease | |
mucopurulent discharge Hint: this finding is associated with bacterial conjunctivitis | |
dendritic ulcerations Hint: this finding is associated with Herpes Simplex Keratitis |
Question 4 Explanation:
A classic finding of allergic conjunctivitis is cobblestone mucosa on the inner/upper eyelid.
Question 5 |
A 17-year-old girl comes to your office with a 1-day history of red eye. She describes not being able to open her right eye in the morning because of crusting and discharge. The right eye feels swollen and uncomfortable, although there is no pain.
On examination, she has a significant redness and injection of the right bulbar and palpebral conjunctivae. There is a mucopurulent discharge present. No other abnormalities are present on physical examination. Her visual acuity is normal.
bacterial conjunctivitis | |
viral conjunctivitis | |
allergic conjunctivitis | |
autoimmune conjunctivitis |
Question 5 Explanation:
This patient has a primary bacterial conjunctivitis. Unlike viral conjunctivitis, bacterial conjunctivitis will produce a mucopurulent discharge from the beginning. Symptoms are more often unilateral, and associated eye discomfort is common.
In bacterial conjunctivitis, normal visual acuity is always maintained. There is usually uniform engorgement of all the conjunctival blood vessels. There is no staining of the cornea with fluorescein. Bacterial conjunctivitis should be treated with antibiotic drops such as sodium sulfacetamide, gentamicin, or fluoroquinolones.
Question 6 |
A 12 year-old presents with complaint of both eyes "watering." He also complains of sinus congestion and sneezing for two weeks. On exam vital signs are T-38°C, P-80/minute, and RR-20/minute. The eyes reveal mild conjunctival injection bilaterally, clear watery discharge, and no matting. Pupils are equal, round, and reactive to light and accommodation. The extraocular movements are intact. The funduscopic exam shows normal disc and vessels. The TMs are normal and the canals are clear. The nasal mucosa is boggy, with clear rhinorrhea. Which of the following is the most helpful pharmacologic agent?
Artificial tears Hint: Artificial tears are used for dry eyes. | |
Tobramycin drops Hint: Tobramycin drops and erythromycin ointment are used to treat bacterial infections. | |
Erythromycin ointment Hint: See B for explanation. | |
Naphazoline (Naphcon-A) drops |
Question 6 Explanation:
Naphazoline is a topical antihistamine that relieves symptoms of allergic conjunctivitis.
Question 7 |
A patient is evaluated in the office with a red eye. The patient awoke with redness and a watery discharge from the eye. The eyelids were not matted together. Examination reveals a palpable preauricular node. Which of the following is the most likely diagnosis?
bacterial conjunctivitis Hint: Bacterial conjunctivitis is associated with purulent, not watery eye discharge. | |
viral conjunctivitis | |
allergic conjunctivitis Hint: Allergic conjunctivitis is associated with symptoms limited to the conjunctiva with hyperemia and edema. | |
gonococcal conjunctivitis Hint: Gonococcal conjunctivitis is associated with copious purulent discharge and no preauricular adenopathy. |
Question 7 Explanation:
Viral conjunctivitis is associated with copious watery discharge and preauricular adenopathy.
Question 8 |
A 23 year-old sexually active female presents with a 4 day history of painless bilateral eye exudates which she describes as copious. Visual acuity is 20/20, generalized conjunctival inflammation with sparing of the cornea is noted on physical examination. Gram stain of the exudate reveals gram negative diplococci. Appropriate management of this case is
ceftriaxone (Rocephin) | |
polymyxin ophthalmic drops (Aerosporin) Hint: Polymyxin is ineffective against gonococcus. | |
ciprofloxacin (Cipro) Hint: Oral ciprofloxacin is not used in cases of gonococcal conjunctivitis. | |
doxycycline (Doryx) Hint: Doxycycline is ineffective against gonococcus. |
Question 8 Explanation:
With sparing of the cornea, as in this case, a single 1 gram IM dose of ceftriaxone is sufficient treatment for ophthalmic gonorrhea. If the cornea is involved, 5 days of IM ceftriaxone would be required.
Question 9 |
A patient presents complaining of left eye discharge and eyes that were matted shut this morning. The patient denies changes in visual acuity, but states that he is afraid to put his contacts in. On physical examination you note erythematous conjunctivae and mucopurulent discharge of the left eye. The cornea is clear. Which of the following topical agents is the treatment of choice in this patient?
Aminoglycoside (Tobrex) | |
Olopatadine (Patanol) Hint: Patanol is indicated in patients with allergic, not bacterial, conjunctivitis. | |
Cycloplegic Hint: Topical cycloplegic agents and corticosteroids are not indicated in the treatment of bacterial conjunctivitis. | |
Prednisolone acetate Hint: See C for explanation. |
Question 9 Explanation:
Topical aminoglycoside or fluoroquinolones are indicated in contact lens wearers with conjunctivitis to cover for Pseudomonas infection.
Question 10 |
A 9 year-old patient presents with conjunctivitis after swimming at the local pool. On examination, there is visible lid edema with redness of the palpebral conjunctiva, copious watery discharge, and scanty exudate. The sanitation system of the public pool is through the use of a salt water system; therefore, the possibility of a chemical induced conjunctivitis is almost non-existent. Which of the following should be instituted to prevent the sequalae of the condition
Ketorolac tromethamine (Acular) Hint: See D for explanation. | |
Dexamethasone ophthalmic Hint: See D for explanation. | |
Naphazoline HCL (Naphcon A) Hint: See D for explanation. | |
Sulfacetamide ophthalmic |
Question 10 Explanation:
One of the most common causes of viral conjunctivitis is adenovirus type 3. Contaminated swimming pools can be source of infection. Topical sulfonamides prevent secondary bacterial infection.
There are 10 questions to complete.
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References: Merck Manual · UpToDate