Conjunctivitis

Conjunctivitis: Excerpt from The 5-Minute Pediatric Consult

Brian J. R. Forbes, MD, PhDWilliam R. Katowitz, MD

Conjunctivitis - BASICS

Conjunctivitis - description

Conjunctivitis is an inflammatory process involving the external membrane of the eye or the conjunctiva that is manifested by redness and edema of the conjunctiva, frequently with associated discharge.

It is critical to rule out Gonococcus infection because of the destructive nature of eye disease and associated systemic infection.

Conjunctivitis - epidemiology

Ophthalmia neonatorum or neonatal conjunctivitis remains a significant cause of blindness worldwide.

Conjunctivitis - incidence

Viral conjunctivitis is extremely common and highly contagious. Adenovirus is the common cause of viral conjunctivitis.

Conjunctivitis - pathophysiology

• A bacterial, viral, allergic, or toxic activation of the inflammatory response that causes dilation and exudation from conjunctival blood vessels or conjunctivitis
• Pathology:
  • Dilated conjunctival capillaries with leukocytic infiltration and edema of conjunctiva and substantia propria
  • In children with competent lymphocyte function (>3 months of age), visible conjunctival aggregates of lymphoid tissue (follicles) or smaller infiltrates of inflammatory cells (papillae) may develop.

Conjunctivitis - etiology

• Gonococcus (GC) conjunctivitis is benign if recognized early and devastating if misdiagnosed or delayed.
• Chronic Chlamydia infection leads to scarring and corneal opacity; chlamydial pneumonia develops in 20% of these patients.
• Viral: Usually benign course, but may rarely lead to conjunctival scarring
• Herpes simplex virus may lead to significant visual loss from recurrence and corneal scarring, even with proper therapy.
• Conjunctivitis is also caused by bacteria (staphylococci, streptococci, and Haemophilus) and serious complications of these are rare.

Conjunctivitis - DIAGNOSIS

Conjunctivitis - signs & symptoms

Conjunctivitis - history

• Type I ophthalmia neonatorum (<40–60 days of age):
  • Acute perinatal conjunctivitis with purulent discharge
• Type 2 ophthalmia neonatorum:
  • Pink eye: Red, watery eyes with acute onset, with or without upper respiratory tract infection; often, history of similar infection in siblings or contacts; usually viral, occasionally bacterial, commonly self-limited; classically, a complaint of itching in an older child is associated with red eyes, often owing to some noninfectious offending agent such as an allergen or a chemical exposure

Conjunctivitis - physical exam

• Discharge ranges from clear, watery (often viral) to mucopurulent (often bacterial)
• Conjunctiva is inflamed and edematous.
• May have eyelid swelling or submandibular or preauricular lymphadenopathy
• Cornea is clear.
• Vision, pupils, and motility are normal.
• Refer to an ophthalmologist if vesicular rash is present on eyelids and corneal changes are present, as the condition may be caused by herpes simplex which can be vision threatening if not appropriately treated.

• Failure to diagnose Gonococcus conjunctivitis may lead to corneal perforation.
• No office follow-up recommended for routine conjunctivitis:
  • Follow atypical conjunctivitis closely until a more serious disease can be excluded.
  • A nonresponsive or worsening condition needs ophthalmic consultation.
• Treating any red eye with steroids:
  • Can activate or accelerate unrecognized herpes simplex virus infection
  • Chronic administration may raise intraocular pressure or cause cataracts
• Chronic use of empiric broad-spectrum antibiotics for self-limited conjunctivitis can promote bacterial resistance though less so than for systemic antibiotic administration.

Conjunctivitis - tests

Conjunctivitis - lab

• Gram stain of discharge (always in ophthalmia neonatorum):
  • Gonococcus: Gram-negative intracellular diplococcus
  • Polymorphonuclear leukocytes without bacteria likely chemical (neonatal) or viral conjunctivitis
  • Chlamydia: Intracytoplasmic, paranuclear inclusion bodies on gram stain and conjunctival scraping with Giemsa stain for basophilic intracytoplasmic inclusion bodies
• Culture:
  • Thayer-Martin test for Gonococcus
  • Blood agar, chocolate agar for bacterial
  • Viral cultures for herpesvirus and adenovirus are not clinically useful.
  • Chlamydia culture techniques are not widely available.
• Immunofluorescence staining:
  • May be useful in identifying Chlamydia infection

Conjunctivitis - differencial diagnosis

• For neonatal conjunctivitis:
  • Chemical conjunctivitis: Noninfectious, mild, self-limited; result of silver nitrate or povidone iodine administration
  • Birth trauma: Unilateral, often with associated eyelid contusion, history of forceps use or difficult delivery
  • Congenital glaucoma: Mild conjunctival redness, minimal discharge; look for enlarged eye, cloudy cornea, tearing, and photophobia.
  • Nasolacrimal duct obstruction: Unilateral or bilateral discharge, may be clear to mucopurulent with reflux from nasolacrimal sac; the conjunctiva is usually white and nonerythematous.
• For all conjunctivitis:
  • Preseptal cellulitis: Early eyelid edema/erythema; looks like conjunctivitis, especially in young children, with the difficulty of examination; motility deficit, proptosis, decreased vision, afferent pupillary defect are consistent with orbital cellulitis.
  • Keratitis: Keratitis signifies corneal infection and may have associated conjunctivitis; primary herpes keratitis is associated with vesicular eyelid rash and pain; consult an ophthalmologist for specific treatment. Bacterial keratitis may be caused by staphylococci, streptococci, and Pseudomonas; Lyme spirochete; or vitamin A deficiency.
  • Episcleritis: Presents as a red eye and consists of inflammation of the thick loose connective tissue, which lies between the clear conjunctiva and the white appearing stroma of the sclera; rare disease in childhood and can be associated with rheumatologic disease
  • Scleritits: Presents as a red eye. More severe disease involving inflammation of the sclera. Rare disease in childhood and associated with systemic disease. Requires oral or IV steroids.
  • Iritis: Frequently unilateral, with or without a history of trauma; photophobia, decreased vision, and constant pain (except if associated with juvenile rheumatoid arthritis); contagious history is rare; consult an ophthalmologist for full evaluation, including pupillary dilation.

Conjunctivitis - TREATMENT

Conjunctivitis - general measures

• Allergic: Remove offending allergen (if possible). Mild symptoms can be treated with artificial tears (make sure tears are preservative free). A new class of topical mast cell stabilizers such as olopatadine b.i.d. a day is effective for more involved cases.
• Chemical:
  • Close observation only
  • Self-limited
• Viral or epidemic keratoconjunctivitis:
  • Cool compresses
  • No specific antiadenovirus treatment is available.

Conjunctivitis - medication

• Gonococcus: Ceftriaxone, 30–50 mg/kg/d IV q8–12h and ocular irrigation followed by topical 0.5% erythromycin or 1.0% tetracycline ophthalmic ointments q.i.d. for 14 days. Also treat for Chlamydia.
• Chlamydia: Oral erythromycin syrup, 12.5 mg/kg/d in 4 doses for 14 days. Topical 0.5% erythromycin or 1.0% tetracycline ophthalmic ointment q.i.d. both eyes for 14 days as above. (Povidone-iodine 1.25% ophthalmic drops q.i.d. can be used if other antibiotics are not readily available.)
• Bacterial: Empiric antibiotic treatment if bacterial infection is suspected, including erythromycin 0.5%, levofloxacin 0.5%, tetracycline 1% ointment, or polymyxin B solution q.i.d. a day
• Herpes simplex: Topical trifluorothymidine (viroptic solution), 9 times a day for at least 14 days with or without systemic acyclovir (IV solution)

Conjunctivitis - FOLLOW UP

Conjunctivitis - complications

• Significant complications are extremely rare for common bacterial, viral, or allergic conjunctivitis.
• Blindness may result from untreated neonatal conjunctivitis.

Conjunctivitis - patient monitoring

• Daily follow-up is necessary for Gonococcus, Chlamydia, and herpes simplex virus.
• For epidemic viral conjunctivitis, frequency is dictated by severity (daily to weekly). For allergic conjunctivitis, follow-up can be made after a few weeks of treatment.

Conjunctivitis - bibliography

1. Bielory L, Mongia A. Current opinion of immunotherapy for ocular allergy. Curr Opin Allergy Clin Immunol. 2002;2:447–452.
2. Crede CSF. Reports from the obstetrical clinic in Leipzig: Prevention of eye inflammation in the newborn. Am J Dis Child. 1971;121:3–4.
3. Greenberg MF, Pollard ZF. The red eye in childhood. Pediatr Clin North Am. 2003;50:105–124.
4. Isenberg SJ, et al. A controlled trial of povidone-iodine to treat infectious conjunctivitis in children. Am J Ophthalmol. 2002;134:861–868.
5. Lepage P, Bogaerts J, Kestelyn P, et al. Single-dose cefoxamine intramuscularly cures gonococcal ophthalmia neonatorum. Br J Ophthalmol. 1988;72:518–520.
6. Rietveld RP, van Weert HC, ter Riet G, et al. Diagnostic impact of signs and symptoms in acute infectious conjunctivitis: Systematic literature search. BMJ. 2003;327:789.
7. Strauss EC, Foster CS. Atopic ocular disease. Ophthalmol Clin North Am. 2002;15:1–5.
8. Trocme SD, Sra KK. Spectrum of ocular allergy. Curr Opin Allergy Clin Immunol. 2002;2:423–427.

Conjunctivitis - CODES

Conjunctivitis - icd9

• 372.03 Acute purulent conjunctivitis
• 372.05 Allergic conjunctivitis
• 372.30 Conjunctivitis, unspecified

Conjunctivitis - FAQ

• Q: Is conjunctivitis contagious?
• A: All infectious conjunctivitis is contagious, but to varying degrees. Viral or epidemic keratoconjunctivitis (EKC) is the most contagious. Careful handling of secretions, tissues, towels, bed linens, and strict handwashing usually prevent spread. Wipe surfaces with isopropyl alcohol or dilute bleach to prevent recontamination. Gonococcus, Chlamydia, and herpes simplex virus can be transmitted through infected discharge or secretions, but this is less common. The most common source is the infected birth canal.
• Q: Should the patient with “pink eye” (non-Gonococcus, non-Chlamydia, non-herpes simplex virus conjunctivitis) be treated with empiric antibiotics?
• A: Empiric treatment with topical antibiotics can cause harm in the case of sulfa-containing compounds. Antibiotic toxicity, including Stevens-Johnson reactions, can occur from sulfa antibiotics, and use of antibiotics long term promotes selection of resistant strains of bacteria. Empiric treatment also increases manipulation of the infected eye and thus increases the risk of spread.
• Q: How long is the patient with “pink eye” (non-Gonococcus, non-Chlamydia, non-herpes simplex virus conjunctivitis) contagious and when can the patient return to school?
• A: The organism can be recovered from the eye for up 2 weeks after onset of symptoms, demonstrating that patients are infectious during this time. Practically, children should probably be kept out of school for at least 1 week.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Conjunctivitis

• Back to disease: Conjunctivitis: Introduction
• Next Book Extract About Conjunctivitis: Surveys relating to Conjunctivitis
• More Book Extracts: All Online Books for Conjunctivitis

More Medical Textbooks Online about Conjunctivitis

Review other book chapters online related to Conjunctivitis:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Surveys relating to Conjunctivitis

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Surveys relating to Conjunctivitis
• Ask Question about Conjunctivitis

Tools & Services:

• Bookmark this page
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City