Conjunctival injection
Conjunctival injection: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
A common ocular sign associated with inflammation, conjunctival injection is nonuniform redness of the conjunctiva from hyperemia. This redness can be diffuse, localized, or peripheral, or it may encircle a clear cornea.
Conjunctival injection usually results from bacterial or viral conjunctivitis, but it can also signal a severe ocular disorder that, if untreated, may lead to permanent blindness. Conjunctival injection can also result from minor eye irritation due to inadequate sleep, overuse of contact lenses, environmental irritants, and excessive eye rubbing.
Emergency interventions
If the patient with conjunctival injection reports a chemical splash to the eye, quickly irrigate the eye with copious amounts of normal saline solution. (First, remove contact lenses.) Evert the lids and wipe the fornices with a cotton-tipped applicator to remove any foreign body particles and as much of the chemical as possible.
History and physical examination
When you take the patient’s history, always ask if he has associated pain. If so, when did the pain begin, and where is it located? Is it constant or intermittent? Also, ask about itching, burning, photophobia, blurred vision, halo vision, excessive tearing, or a foreign body sensation in his eye. Does the patient have a history of eye disease or trauma? If he has suffered ocular trauma, avoid touching the affected eye. Test his visual acuity and intraocular pressure (IOP) only if his eyelids can be opened without applying pressure. Place a metal shield over the affected eye to protect it, if necessary.
If the patient’s condition permits, examine the affected eye. First, determine the location and severity of conjunctival injection. Is it circumcorneal or localized? Peripheral or diffuse? Note any conjunctival or lid edema, ocular deviation, conjunctival follicles, ptosis, or exophthalmos. Also note the type and amount of any discharge.
Test the patient’s visual acuity to establish a baseline. Note if the patient has had vision changes: Is his vision blurred or his visual acuity markedly decreased? Next, test pupillary reaction to light.
Perform IOP measurements. To gauge increased IOP without a tonometer, gently place your index finger over the closed eyelid; if the globe feels rock-hard, IOP is elevated.
Medical causes
Blepharitis
This disorder produces diffuse conjunctival injection. Ulcerations appear on the eyelids, which burn, itch, and have no lashes.
Chemical burns
Diffuse conjunctival injection occurs in this ocular emergency, but severe pain is the main symptom. The patient also displays photophobia, blepharospasm, and decreased visual acuity in the affected eye; the cornea may appear gray, and the pupil may be unilaterally smaller.
Conjunctival foreign bodies and abrasions
These conditions feature localized conjunctival injection with sudden, severe eye pain. The patient may have increased tearing and photophobia, but his visual acuity usually isn’t impaired.
Conjunctivitis
Allergic conjunctivitis produces milky, diffuse peripheral conjunctival injection. Related findings include a watery, stringy eye discharge; increased tearing; itching; palpebral conjunctival follicles; and (with hay fever) conjunctival edema, photophobia, and a feeling of fullness around the eyes.
Bacterial conjunctivitis causes diffuse peripheral conjunctival injection along with a thick, purulent eye discharge that contains mucous threads. The patient’s lids and lashes stick together, and he has excessive tearing, photophobia, burning, and itching. He may have pain and a foreign body sensation if the cornea is involved.
Besides diffuse peripheral conjunctival injection, the patient with fungal conjunctivitis complains of photophobia and increased tearing, itching, and burning. The discharge is thick and purulent, making his eyelids crusted, sticky, and swollen. Corneal involvement causes pain.
In viral conjunctivitis, the conjunctival injection is bright red, diffuse, and peripheral. The patient may also have conjunctival edema, follicles on the palpebral conjunctiva, and lid edema; a local viral rash; and signs of upper respiratory tract infection. He complains of itching, increased tearing and, possibly, a foreign body sensation.
Corneal abrasion
Diffuse conjunctival injection is extremely painful in this disorder, especially when the eyelids move over the abrasion. The patient may also report photophobia, excessive tearing, blurred vision, and a foreign body sensation.
Corneal erosion
Recurrent corneal erosion produces diffuse conjunctival injection; severe, continuous pain from rubbing of the eyelid over the eroded area of the cornea; and photophobia.
Corneal ulcer
Bacterial, viral, and fungal corneal ulcers produce diffuse conjunctival injection that increases in the circumcorneal area. Accompanying findings include severe photophobia, severe pain in and around the eye, markedly decreased visual acuity, and a copious amount of purulent eye discharge and crusting. If the patient develops associated iritis, a physical examination will also reveal corneal opacities and an abnormal pupillary response to light.
Dacryoadenitis
This disorder produces diffuse conjunctival injection, pain over the temporal part of the eye, considerable lid swelling and, possibly, a purulent eye discharge.
Episcleritis
Conjunctival injection is localized and raised and may be violet or purplish pink in patients with episcleritis. Associated signs and symptoms include an inflamed sclera, deep pain, photophobia, increased tearing, and conjunctival edema.
Glaucoma
In acute angle-closure glaucoma, conjunctival injection is typically circumcorneal. Other signs and symptoms include severe eye pain, nausea and vomiting, severely elevated IOP, blurred vision, and the perception of rainbow-colored halos around lights. Corneas appear steamy because of corneal edema. The pupil of the affected eye is moderately dilated and completely unresponsive to light.
Hyphema
Depending on the type and extent of traumatic injury, a hyphema may produce diffuse conjunctival injection, possibly with lid and orbital edema. The patient may complain of pain in and around the eye. The extent of visual impairment depends on the hyphema’s size and location.
Iritis
In acute iritis, marked conjunctival injection is found mainly around the cornea. Other findings include moderate to severe pain, photophobia, blurred vision, constricted pupils, and poor pupillary response to light.
Kawasaki syndrome
Conjunctival injection is a characteristic sign of Kawasaki syndrome and usually occurs bilaterally. This febrile illness, which primarily affects children under age 5, also causes erythema, lymphadenopathy, and swelling in the peripheral extremities. Treatment with I.V. gamma globulin is extremely effective if given immediately, so early detection is essential. Delaying treatment may cause coronary artery dilation and aneurysm, resulting in ischemic heart disease and, possibly, sudden death.
Keratoconjunctivitis sicca
This disorder produces severe diffuse conjunctival injection. The patient reports generalized eye pain along with burning, itching, a foreign body sensation, excessive mucus secretion from the eye, absence of tears, and photophobia.
Lyme disease
Spread by tick bites, Lyme disease may cause conjunctival injection, diffuse urticaria, malaise, fatigue, headache, fever, chills, aches, and lymphadenopathy.
Ocular lacerations and intraocular foreign bodies
Diffuse conjunctival injection may be increased in the area of injury. The patient experiences impaired visual acuity and moderate to severe pain that varies with the type and extent of injury. He may also develop lid edema, photophobia, excessive tearing, and an abnormal pupillary response to light.
Ocular tumors
A tumor located in the orbit behind the globe may produce conjunctival injection together with exophthalmos. Conjunctival edema, ocular deviation, and diplopia usually occur if muscles are involved.
Refractive error
An uncorrected or poorly corrected refractive error can produce conjunctival injection. The patient may complain of headache, eye pain, and eye fatigue.
Scleritis
In this relatively rare disorder, conjunctival injection can be diffuse or localized over the area of the scleritis nodule. The patient has severe pain on moving the eye, photophobia, tenderness, and tearing.
Stevens-Johnson syndrome
This disorder produces diffuse conjunctival injection, a purulent eye discharge, severe eye pain, photophobia, decreased tearing, entropion, and trichiasis.
Trachoma
Conjunctival injection is an early sign of trachoma, a leading cause of blindness in Third World countries and among Native Americans in the southwestern United States. Caused by a bacterial infection, trachoma may also produce eyelid swelling and corneal cloudiness.
Uveitis
Diffuse conjunctival injection, which may be increased in the circumcorneal area, characterizes this disorder. Accompanying signs and symptoms include constricted, irregularly shaped pupils; blurred vision; tenderness; photophobia; and possibly sudden, severe ocular pain.
Special considerations
As indicated, prepare the patient for such diagnostic tests as orbital X-rays, ocular ultrasonography, and fluorescein staining. Obtain cultures of any eye discharge, and record its appearance, consistency, and amount.
Most forms of conjunctivitis are contagious and can easily spread to the other eye or to family members. Stress the importance of frequent hand washing and of not touching the affected eye to prevent contagion.
Pediatric pointers
An infant can develop self-limiting chemical conjunctivitis at birth from the ocular instillation of silver nitrate. He may also develop bacterial conjunctivitis 2 to 5 days after birth from contamination of the birth canal. An infant with congenital syphilis has prominent conjunctival injection and grayish pink corneas.
Patient counseling
If the patient complains of photophobia, darken the room or suggest that he wear sunglasses. If the patient’s visual acuity is markedly decreased, orient him to his environment to ensure his comfort and safety.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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