Conjunctivitis, Emergency Medicine

Basics

Description

Inflammation of the conjunctiva arising from a broad group of etiologies. Commonly referred to as "pink eye."

Etiology

Bacterial:
- Staphylococcus aureus
- Streptococcus pneumoniae
- Haemophilus influenzae
- Gonococcal:
  - Ophthalmic emergency
- Chlamydia:
  - Transmission occurs via autoinoculation from genital secretions.
  - Often occurs in newborns
Viral:
- Adenovirus most common
- Epidemic keratoconjunctivitis (EKC) is caused by adenovirus subtypes.
- Frequently associated with upper respiratory infections or exposure to someone with a red eye
- Most commonly referred to as "pink eye"
- Herpes simplex virus (HSV)
- Recurrent ocular infection occurs in 25% patients within 2 yr.
- Use of steroids is contraindicated:
  - Allergic
- Frequent history of allergy, atopy, nasal symptoms
- Contact related
- May be due to chemical irritation, hypersensitivity from preservatives, medications, shampoo, chlorine, dust, smoke
- Pseudomonas commonly implicated organism:
  - May be found in patients using saliva to clean contact lenses

Diagnosis

Signs and Symptoms

General:
- Red eye (conjunctival irritation)
- Gritty, foreign body sensation
- Sensation of eyes burning
- Discharge
- Eyelid sticking (worse upon awakening)
- Conjunctival edema (chemosis) and eyelid edema
- Itchy eyes
- Increased tearing
Bacterial:
- Mucopurulent or purulent discharge
Gonococcal:
- Hyperacute, copious purulent discharge:
  - Discharge starts 12 hr after inoculation.
- Severe chemosis
- Eyelid swelling
- Preauricular lymphadenopathy typically absent
- Invades intact conjunctiva and cornea within 24 hr and causes ulcerations, scarring, and perforations leading to blindness
Chlamydia:
- Lacrimation
- Mucopurulent discharge
- With or without photophobia
- Concomitant genital infection (>50%)
- Transmission occurs via autoinoculation from genital secretions
Viral-general:
- Preauricular adenopathy
Viral syndrome:
- Watery, mucous discharge, lacrimation
- Gritty feeling or foreign body sensation in eye
- Spreads to other eye in 24-48 hr
- Pinpoint subconjunctival hemorrhages:
  - Tarsal conjunctiva may have a bumpy appearance.
EKC:
- Conjunctival hyperemia
- Chemosis
- Corneal infiltrates
- Decreased vision
HSV:
- Acute follicular conjunctival reaction
- Skin lesions or vesicles along eyelid margin or periocular skin
- Corneal involvement-dendritic lesion
Herpes zoster virus (HZV):
- Associated with pain or paresthesia of the skin
- Rash or vesicles involving the distribution of cranial nerve V1
- Dendritic characters on cornea
- Rarely vesicles or ulcers form on the conjunctiva.
Allergic:
- Hallmark: Itching
- Red conjunctiva
- Watery discharge
- Papillary hypertrophy
- Frequent history of allergy, atopy, nasal symptoms
Contact related:
- Acute symptoms result of corneal ulceration
- Normal visual acuity and intraocular pressures

Essential Workup

History for:
- Onset of inflammation
- Environmental or work-related exposure
- Ill contacts
- Sexual activity, discharge, rash
- Use of over-the-counter medicines or cosmetics
- Systemic diseases
Careful physical exam including slit-lamp exam including fluorescein staining

Diagnosis Tests & Interpretation

Lab

Bacteriologic studies:
- Not indicated in routine cases
- Indications:
  - Ophthalmia neonatorum (except chemical)
  - Suspected gonococcal ophthalmia
  - Compromised host
  - Signs and symptoms of systemic disease
  - Refractory to treatment within 48-72 hr (with good compliance)
Positive Gram stain for gram-negative intracellular diplococci:
- Sufficient to initiate systemic and topical treatment for gonococcal disease
Rapid plasma reagent (RPR):
- For suspected cases of sexually transmitted disease

Differential Diagnosis

Acute angle-closure glaucoma (most serious cause)
Allergies or hypersensitivity
Anterior uveitis
Corneal abrasion
Dry eye
Foreign body
Keratitis
Nasolacrimal obstruction
Scleritis or episcleritis
Subconjunctival hemorrhage

Treatment

Initial Stabilization/Therapy

Initiate empiric antibiotic therapy with broad-spectrum topical agent.
Systemic therapy for gonococcal, chlamydial, and meningococcal conjunctivitis, ophthalmia neonatorum, and all severe infections regardless of cause
Manage herpetic eye infections in consultation with an ophthalmologist.

Ed Treatment/Procedures

Remove discharge from the eye(s):
- Contact lens wearers should discontinue use and throw away affected contact lenses.
- Contact lens wearers should discontinue use until:
  - Eye is white.
  - Antibiotic therapy is completed.
  - No discharge for 24 hr
- Frequent handwashing
- No sharing of towels, tissues, cosmetics, linens
- Frequent warm soaks until lashes and eyes free of debris
Bacterial conjunctivitis:
- Antibiotics-topical:
- Can use ointment or drops
- Continue therapy for 48 hr after clearing of symptoms.
- Discontinue therapy and obtain cultures if no improvement in 48-72 hr (with good compliance).
Antibiotics-systemic:
- Parenteral therapy mandatory for gonococcal infection
- Chlamydia requires systemic treatment of sexual partners and parents of neonates.
Viral conjunctivitis:
- No specific antiviral therapy
- Limited use of topical antihistamine or decongestant
EKC may require steroids and should be prescribed in consult with ophthalmology.
Allergic conjunctivitis (there may be a lag time of up to 2 wk for improvement with these agents):
- Antihistamine or decongestant drops (naphazoline [Naphcon-A])
- Mast cell stabilizer/antihistamine or NSAID ophthalmic drops as 2nd line
- Artificial tears
Noninfectious:
- Eye lubricant drops or ointment
Empiric treatment:
- Topical antibiotic ointment or drops

Medication

General:
- All contact lens wearers require pseudomonal coverage.
- Bacterial:
- Bacitracin ophthalmologic ointment (no pseudomonal coverage)
- Ciprofloxacin: 0.35% 1 drop q1-6h (has antipseudomonal properties; may be used in children)
- Erythromycin: 0.5% ointment
- Gentamicin: 0.3% ointment q3-4h or drops q1-4h (has antipseudomonal coverage)
- Sulfacetamide: 10% 1 drop q1-6h (lacks pseudomonal coverage)
- Tobramycin ointment
Chlamydia:
- Doxycycline: 100 mg PO BID for 3 wk
- Erythromycin: 250-500 mg PO QID for 3 wk (peds: 50 mg/kg/d PO in 4 div. doses for 14 days)
- Sulfisoxazole 500-1,000 mg QID for 3 wk
Gonococcal:
- Adults:
  - Ceftriaxone: 1 g IV or IM daily for 3-5 days or PRN
  - Erythromycin: 500 mg PO QID for 2-3 wk or doxycycline 100 mg PO BID for 2-3 wk
  - + topical antibiotics as above
- Neonates:
  - Penicillin G 100,000 U/kg/d in 4 div. doses for 7 days or ceftriaxone 25-50 mg/kg/d IV for 7 days
Viral:
- Artificial tears
- Naphcon-A or Visine AC 1 or 2 drops QID PRN for no more than 1 wk
HSV or HZV:
- Trifluorothymidine: 1% 5 times per day
- Vidarabine: 3% ointment 5 times per day
Allergic:
- Naphazoline (Naphcon-A): 1 drop BID-QID or Visine AC
- Acular: 1 or 2 drops BID
- Cromolyn sodium 4% (Crolom): 1 drop QID
Noninfectious and nonallergic:
- Eye lubricant drops or ointment: Artificial tears or Lacri-Lube
Empiric treatment:
- Erythromycin ointment 0.5% (half in QID)
- Sulfacetamide 10% ophthalmic drops (1 or 2 drops QID) for 5-7 days

Often a manifestation of systemic disease in infants
Conjunctivitis in the 1st 36 hr of life usually chemically induced caused by silver nitrate applied at birth.
Neonates become infected during passage through the birth canal.
Gonococcal, herpetic, chlamydial organisms most common
Ophthalmia neonatorum is conjunctivitis within the 1st 4 wk of life.
Chlamydia trachomatis is not eradicated by silver nitrate.
Some newborns treated with erythromycin still develop conjunctivitis.
Ointment is preferred over drops because of difficulty with administration of drops.

Follow-Up

Disposition

Admission Criteria
Known or suspected gonococcal infection (any age group)
Discharge Criteria
Close follow-up for all cases
Issues for Referral
Diagnosis of EKC and bacterial conjunctivitis requires ophthalmology referral.

Followup Recommendations

All patients with bacterial conjunctivitis require ophthalmology follow-up.

Pearls and Pitfalls

Be sure to disinfect slit lamp and chair used for patients to avoid contamination.
Conjunctivitis is extremely contagious.
Viral conjunctivitis contagious for up to 2 wk.
EKC is especially contagious.
Extreme caution should be taken when using corticosteroids, as they may worsen an underlying HSV infection.

Additional Reading

Alteveer JG, McCans KM. The red eye, the swollen eye, and acute vision loss. Emerg Med Pract. 2002;4(6):27.
Bertolini J, Pelucio M. The red eye. Emerg Med Clin North Am. 1995;13(3):561-579.
Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
Leibowitz HM. The red eye. New Engl J Med. 2000;343:345.
Mueller JB, McStay C. Ocular infection and inflammation. Emerg Med Clin North Am. 2008;26(1).
Sethuraman U, Kamat D. The red eye: Evaluation and management. Clin Pediat. 2009;48(6):588-600.

Codes

ICD9

077.99 Unspecified diseases of conjunctiva due to viruses
372.03 Other mucopurulent conjunctivitis
372.30 Conjunctivitis, unspecified
771.6 Neonatal conjunctivitis and dacryocystitis
054.43 Herpes simplex disciform keratitis
077.3 Other adenoviral conjunctivitis
077.98 Unspecified diseases of conjunctiva due to chlamydiae
098.40 Gonococcal conjunctivitis (neonatorum)

ICD10

B30.9 Viral conjunctivitis, unspecified
H10.029 Other mucopurulent conjunctivitis, unspecified eye
H10.9 Unspecified conjunctivitis
P39.1 Neonatal conjunctivitis and dacryocystitis
A54.31 Gonococcal conjunctivitis
A74.0 Chlamydial conjunctivitis
B00.53 Herpesviral conjunctivitis
H10.89 Other conjunctivitis

SNOMED

9826008 Conjunctivitis (disorder)
241759005 Pink eye disease (disorder)
128350005 Bacterial conjunctivitis (disorder)
276680000 Neonatal bacterial conjunctivitis (disorder)
186679007 Conjunctivitis due to adenovirus
231858009 Gonococcal conjunctivitis (disorder)
231861005 Chlamydial conjunctivitis (disorder)
276691007 Staphylococcal ophthalmia neonatorum
410508006 Herpes simplex conjunctivitis
45261009 Viral conjunctivitis (disorder)

Home

Erectile Dysfunction

Doctor123.org