In many encounters in medicine, tests exist to confirm the diagnosis; however, the test results may not be readily available, thus leaving the practitioner to make a diagnosis as well as treatment recommendations based on the history and physical alone. By putting together the signs and symptoms based on the history and physical exam, the practitioner is able to make a diagnosis and treatment plan without the confirmatory test.
1. Identify the distinguishing signs and symptoms of bacterial, viral, and allergic conjunctivitis.
2. Discuss the different treatments of bacterial, viral, and allergic conjunctivitis.
3. Identify when patients need to be referred to an ophthalmologist for treatment of conjunctivitis.
Case Presentation and Discussion
Jack Cho is a 5-year-old Asian American boy who presents to your office because he was sent home from school today by the school nurse who said he had “pink eye.” He is accompanied by his pregnant mother and his 19-month-old sister.
You talk with Jack and his mother about his symptoms and plan to complete a physical examination.
What questions will you ask Jack and his mother related to his “pink eye”?
Your symptom analysis reveals the following information: He woke up this morning with a crusted shut right eye. After his mother applied a warm washcloth to his face, the crusting disappeared. He had more yellow drainage out of his right eye while on the bus to school. He continued to have yellow drainage and a red eye at school, so his teacher sent him to the school nurse. He states his eye is not itchy or burning. Jack and his mother do not recall any trauma to the eye. Jack does not have any cough, rhinorrhea, fever, or ear or throat pain. He does not have any history of allergic rhinitis either. Upon further questioning, he tells you other children have been sent home from his class for “pink eye” this week, including the boy who sits next to him.
What other questions do you need to ask Jack?
Before answering this question, here is some more information about “pink eye” that you need to consider.
Information about “Pink Eye”
Conjunctivitis is the most common pediatric eye disorder that primary care practitioners will encounter (Wald, 2004). In developed countries worldwide, acute bacterial or viral conjunctivitis has an annual incidence in adults and children of 1.5–2%, with one in eight school-age children affected each year (Rietveld, ter Riet, Bindels, Sloos, & van Weert, 2004; Rose et al., 2005). Bacterial pathogens account for 54–73% of conjunctivitis, with nontypable Haemophilus influenzae and Streptococcus pneumoniae as the most common bacterial pathogens (Buznach, Dugan, & Greenberg, 2005). Viral conjunctivitis can be caused by many different viruses, the most common being adenovirus (Langley, 2005). Enterovirus and influenza are also considered to be important causes of viral conjunctivitis (Pickering, Baker, Long, & McMillan, 2006).
Data for the Diagnosis
The differential diagnoses include bacterial, viral, and allergic conjunctivitis; hyperacute bacterial conjunctivitis; ophthalmia neonatorum; epidemic keratoconjunctivitis; chemical conjunctivitis; ocular foreign body; periorbital and orbital cellulitis; keratitis; uveitis; glaucoma; or possible systemic disease processes such as Kawasaki disease, Stevens-Johnson syndrome, juvenile idiopathic arthritis, inflammatory bowel disease, or lupus. (See Table 21-1.)
In this situation, the information that needs to be gathered includes the following:
• How old is the patient? (Certain causes for conjunctivitis are included and excluded based on age.)
• Is there drainage from the eye, what color, and how much? (Helps to distinguish among bacterial, viral, and allergic conjunctivitis, as well as hyperacute bacterial conjunctivitis and some of the systemic causes of red eye)
• Is the drainage persistent and yellow in color? (Bacterial conjunctivitis)
• Is the drainage watery in nature? (Viral conjunctivitis, allergic conjunctivitis)
• Does the patient wake up with the affected eye matted shut due to discharge? (Bacterial conjunctivitis)
• Is there associated itching of the eye? (Allergic conjunctivitis)
• Is the eye painful? (Keratitis, uveitis, orbital cellulitis, foreign body)
• Is there vision loss? (Uveitis, orbital cellulitis)
• Is there photophobia? (Bacterial conjunctivitis, viral conjunctivitis, epidemic keratoconjunctivitis, uveitis, keratitis)
Table 21–1 Distinguishing Causes of Red Eye
• Does the patient wear contact lenses? (Keratitis)
• Has there been any trauma or toxin exposure to the eye? (Chemical conjunctivitis, foreign body)
• Does the patient have otitis media and conjunctivitis? (Nontypable H. influenzae conjunctivitis)
• Does the patient have associated symptoms such as sore throat and fever? (Viral conjunctivitis)
• Does the patient have significant swelling and erythema of the eyelids with or without proptosis? (Periorbital and orbital cellulitis, epidemic keratoconjunctivitis)
• Does the patient have clouding of the cornea? (Glaucoma, keratitis, epidemic keratoconjunctivitis)
• Does the patient have a nonpurulent conjunctivitis associated with fever for at least 5 days, perineal diaper rash, pharyngitis, strawberry tongue, or cervical lymphadenopathy? (Kawasaki disease)
• Does the patient have associated symptoms suggesting a systemic illness such as fever, weight loss, diarrhea, or arthritis? (Juvenile idiopathic arthritis, inflammatory bowel disease, lupus)
• Does the patient have associated symptoms such as bullae of skin and aphthous ulcers of oral mucosa? (Stevens-Johnson syndrome)
Data from your physical examination will give you the remaining information that you need to make a reasonable diagnosis.
Upon physical examination, Jack is nontoxic in appearance and cooperative with your exam. His right eyelid margin and corners of his eye have purulent yellow discharge. His right eye has an injected, red conjunctiva. His left eye is normal without discharge or conjunctival injection. He has 20/20 vision in both eyes. His pupils are both equal and reactive to light and his extraocular muscles are intact without any pain upon movement of either eye. He does not have any photophobia. His ear exam is normal without any bulging or erythema of his tympanic membranes. Examination of his nose does not reveal any bogginess of the mucosa or nasal drainage. His oropharynx is normal without any erythema or cobblestoning. He does not have any lymphadenopathy.
Making the Diagnosis
This history and physical examination are consistent with a diagnosis of bacterial conjunctivitis. The combination of crusted eyelid in the morning, a red eye, and purulent discharge on physical exam are indicative of bacterial conjunctivitis (Patel, Diaz, Bennett, & Attia, 2007). Acute infectious conjunctivitis is defined as conjunctival injection with eye discharge (Wald, 2004); however, there are multiple causes of a red eye that must be included in the differential diagnosis of conjunctivitis.
Usually the diagnosis of conjunctivitis is not complicated and is based on the history and physical examination findings. The history and physical examination are important to help guide one down the right path on the differential diagnosis. When evaluating a patient with suspected conjunctivitis, the healthcare provider needs to consider the following characteristic clinical findings to point to the causative agent.
Bacterial conjunctivitis is usually characterized by unilateral injected conjunctiva, purulent drainage, and matted eye upon awakening, and is most commonly caused by either nontypable H. influenzae or S. pneumoniae (Patel et al., 2007). Bacterial conjunctivitis due to H. influenzae may also be present with otitis media. Infants may also have lacrimal duct stenosis, which can present with unilateral or bilateral yellow drainage and is often confused with conjunctivitis. Usually the conjunctiva is not injected, and the drainage will often persist despite the use of topical ophthalmic antibiotic drops. Ophthalmia neonatorium occurs in infants less than 1 month of age and is usually due to Neisseria gonorrhoeae or Chlamydia trachomatis. It is acquired during vaginal delivery by a mother who is infected with N. gonorrhoea or C. trachomatis as a sexually transmitted infection. It is characterized by purulent drainage from the eye after 48 hours of life (Olitsky, Hug, & Smith, 2007). Older children, especially adolescents, may also develop an acute purulent conjunctivitis secondary to infection with N. gonorrheae or C. trachomatis.
Viral conjunctivitis is often characterized by watery discharge, burning, itching, and injection of the conjunctiva. Conjunctivitis due to adenovirus may also be associated with pharyngitis and fever called pharyngoconjunctival fever. Outbreaks have occurred in contaminated swimming pools and ponds. Adenovirus can also lead to epidemic keratoconjunctivitis, which usually is characterized by conjunctivitis with a foreign body sensation, discharge, photophobia, itching, burning, edema of the lid, and associated upper respiratory infection (URI) symptoms. Outbreaks have occurred in ophthalmology offices and neonatal intensive care units (Langley, 2005). Acute hemorrhagic conjunctivitis, caused by enterovirus, includes symptoms such as watery hemorrhagic discharge with painful eyes (Pickering et al., 2006; Olitsky et al., 2007). Influenza infection may also lead to conjunctivitis, which is often associated with sudden onset of fever, malaise, sore throat, myalgias, and cough and has a seasonal epidemic period in the winter months (Pickering et al.).
Bilateral conjunctival injection with watery discharge and itching rather than pain characterizes allergic conjunctivitis. It also may be associated with allergic rhinitis. Often there is a seasonal pattern, most commonly in the spring, summer, and fall with recurrence each year. Vernal conjunctivitis may develop due to severe allergic conjunctivitis. Patients will have cobblestoning on the upper tarsal plate due to giant papillae. This most commonly occurs in prepubertal children and boys more often than girls (Gigliotti, 1995).
Ocular foreign body is commonly characterized by unilateral conjunctival injection, watery discharge, and a foreign body sensation. Chemical conjunctivitis results when an irritating substance comes in contact with the conjunctiva. Common agents include silver nitrate used in newborns for prophylaxis of ophthalmia neonatorium, household cleaners, pesticides, and smoke (Olitsky et al., 2007).
Patients with periorbital and orbital cellulitis will have conjunctival injection as well. However, in both of these infections, patients will have significant unilateral eyelid edema, erythema, and chemosis or swelling of the bulbar conjunctiva. Often they are unable to open the eyelid due to swelling. They may have fever and will often appear ill with orbital cellulitis as well as have proptosis of the affected eye, pain with movement of the eye, impaired eye movement, and visual impairment (Wald, 2004).
Keratitis and uveitis are often associated with a red eye. Patients with keratitis may present with intense pain, photophobia, and corneal clouding. Patients may have a history of contact lens use. Herpes simplex virus can cause keratitis, as can S. pneumoniae, S. aureus, and Pseudomonas. Uveitis in children is often due to a systemic illness such as juvenile idiopathic arthritis, inflammatory bowel disease, lupus, Kawasaki disease, or Stevens-Johnson syndrome. Patients often complain of pain, vision loss, and photophobia in addition to conjunctival injection (Gigliotti, 1995). Kawasaki disease is characteristically associated with a bilateral bulbar, nonpurulent conjunctivitis, fever for 5 days or longer, rash, oral mucosal involvement, swelling of hands and feet, and lymphadenopathy (Pickering et al., 2006). In addition to widespread vesicles and bullae of the face, trunk, and extremities, patients with Stevens-Johnson syndrome often have eye involvement characterized by uveitis and corneal abrasion as well as oral mucosal involvement. Glaucoma may present with a red eye, corneal clouding, and pain; however, outside of the neonatal period, it is not a common disorder in children (Gigliotti).
Do you need to do anything to confirm the diagnosis, such as laboratory studies?
Laboratory studies usually are not needed to confirm the diagnosis of bacterial conjunctivitis. Culture of the eye drainage may be obtained, but patients are usually treated presumptively based on the history and physical examination findings, which suggest bacterial conjunctivitis. In neonates, bacterial culture may be warranted because N. gonorrhoea or C. trachomatis require systemic treatment, not just topical treatment.
Therapeutic plan: What will you do therapeutically?
The plan is determined by the type of conjunctivitis the patient has. Different treatments exist for the various causes of conjunctivitis.
Bacterial, viral, and allergic conjunctivitis are all generally self-limited illnesses. Treatment of bacterial conjunctivitis has some advantages because it will decrease the length of illness, possibly prevent the spread of the bacteria, and decrease the risk of complications. In addition, children are usually not allowed to return to the daycare or school setting unless treatment has been initiated. The mainstay of treatment of bacterial conjunctivitis is topical antibiotics. Because a culture is not usually obtained, a broad-spectrum topical antibiotic is usually the choice for treatment (Hwang, Schanzlin, Rotberg, Foulks, & Raizman, 2003). Topical antibiotics can be either drops or ointment, with ointment commonly used for infants. Typically older children do not tolerate ointment as well because it can cause distorted vision. Common antibiotics prescribed include erythromycin ointment, trimethoprim sulfate/polymyxin drops, or sulfacetamide drops. Fluoroquinolone drops and azithromycin drops are also used but may promote resistance and are generally more expensive than the other choices because they are relatively newer preparations. (See Table 21-2.) In cases of ophthalmia neonatorum, systemic treatment with intravenous antibiotics is required. In children who present with conjunctivitis with ipsilateral otitis media, oral antibiotics should be used such as amoxicillin/clavulanate. Patients who wear contact lenses need to be instructed to refrain from wearing their contacts until the conjunctivitis has resolved. If the lenses are disposable, they should be discarded along with the lens case (Olitsky et al., 2007).
Viral conjunctivitis does not generally require any treatment. The symptoms may last for up to 2 to 3 weeks. The emphasis should be placed on prevention of the spread of viral conjunctivitis. In cases of adenoviral conjunctivitis associated with swimming pools, adequate chlorination of the water will prevent the spread of adenovirus (Gigliotti, 1995).
Treatment of allergic conjunctivitis should include avoidance of the inciting allergen; however, this may be difficult to do because many allergens are pervasive and difficult for patients to avoid. Cold compresses and lubricating eye drops can also provide relief. Patients can use either topical or oral preparations to help manage allergic conjunctivitis. In cases when allergic conjunctivitis is present in combination with allergic rhinitis, patients will benefit from oral, nonsedating antihistamines such as cetirizine, loratadine, or fexofenadine. Topical ophthalmic medications include antihistamines, antihistamines and mast cell blockers, decongestants, and corticosteroids. Decongestants are not recommended because although they may reduce symptoms, they do not help stop the allergic reaction. Repeated use of these can cause a rebound conjunctival injection or conjunctivitis medicamentosa. The combination of an antihistamine and mast cell blocker offers quick relief of the symptoms and helps stop the allergic reaction. Examples of this are epinastine hydrochloride 0.05%, ketotifen fumarate 0.025%, or olopatadine hydrochloride 0.1%. These medications are given twice daily, but sometimes cause burning. Refrigerating the medications can sometimes decrease the burning sensation. Corticosteroids should be used only in consultation with an ophthalmologist (Boguniewicz & Leung, 2007; Ono & Abelson, 2005).
Table 21–2 Topical Antibiotics for Bacterial Conjunctivitis
Both chemical conjunctivitis and ocular foreign body require removal of the offending agent. Immediate irrigation of the eye with profuse amounts of water is necessary to help prevent the effects of chemical exposure of the eye. Conjunctival injection, edema, and irritation may persist even if the chemical or foreign body is removed. Consultation with an ophthalmologist may be necessary in certain cases of chemical exposure and foreign body.
Both periorbital and orbital cellulitis require treatment with systemic antibiotics and may require hospitalization. Orbital cellulitis requires intravenous antibiotics, and an ophthalmologist should be consulted to help manage the patient because surgery may be required (Wald, 2004). In patients with suspected uveitis and keratitis, referral to an ophthalmologist for evaluation and management is required.
The summary of treatments of different types of conjunctivitis is found in Table 21-3.
Table 21–3 Treatments for Allergic Conjunctivitis
In Jack’s case, you decide to prescribe trimethoprim/polymyxin drops. His mother is instructed to instill two drops into the affected eye four times daily for 7 days.
Educational plan: What will you do to educate Jack and his mother about bacterial conjunctivitis and its management?
Points to make through discussion:
Explain the diagnosis of bacterial conjunctivitis.
Explain the use of the topical antibiotic drops and the benefit of treating bacterial conjunctivitis.
Reassure them that his symptoms should decrease 1 to 2 days after treatment with complete resolution in about 7–10 days.
Advise him to:
Either wash his hands with antibacterial soap or use hand sanitizer after touching his eyes, nose, or mouth to reduce the spread of the bacteria (Aronson & Shope, 2005).
Avoid sharing towels with other family members.
Stay out of school or daycare until antibiotics are initiated (Aronson & Shope, 2005). If his school is in the midst of an epidemic, he may be required to stay home until his conjunctivitis has resolved (Centers for Disease Control and Prevention, 2003).
When do you want to see this patient back again?
Usually patients are not seen in follow-up for bacterial or viral conjunctivitis unless symptoms do not resolve as expected. Patients should return if pain, vision changes, fever, or increased swelling of eyelids develop. If symptoms do not decrease as expected within 2 days of treatment, further evaluation is needed with possible referral to an ophthalmologist. In cases of allergic conjunctivitis and allergic rhinitis, patients should be instructed to return if the prescribed medications do not alleviate the symptoms or the symptoms worsen. These patients may need referral to an ophthalmologist for additional evaluation and treatment.
Key Points from the Case Study
1. Bacterial conjunctivitis is a diagnosis made based on clinical suspicion and exclusion of other causes of conjunctivitis.
2. Treatment of conjunctivitis varies based on the type of conjunctivitis the patient has.
3. The majority of cases of conjunctivitis can be managed by the primary care practitioner, but referral to an ophthalmologist may be required in certain cases.
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