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Conjunctivitis, Emergency Medicine

Basics

Description

- Bacterial: - Staphylococcus aureus - Streptococcus pneumoniae - Haemophilus influenzae - Gonococcal: - 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: - 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

- 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

- 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: - 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.

- Contact related: - Acute symptoms result of corneal ulceration - Normal visual acuity and intraocular pressures

- 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

- 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)

- Frequent handwashing - No sharing of towels, tissues, cosmetics, linens - Frequent warm soaks until lashes and eyes free of debris

- Allergic: - Naphazoline (Naphcon-A): 1 drop BID-QID or Visine AC - Acular: 1 or 2 drops BID - Cromolyn sodium 4% (Crolom): 1 drop QID

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

Etiology

  • Bacterial:Staphylococcus aureusStreptococcus pneumoniaeHaemophilus influenzaeGonococcal:Chlamydia:Transmission occurs via autoinoculation from genital secretions.Often occurs in newborns
  • Viral:Adenovirus most commonEpidemic keratoconjunctivitis (EKC) is caused by adenovirus subtypes.Frequently associated with upper respiratory infections or exposure to someone with a red eyeMost 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:Frequent history of allergy, atopy, nasal symptomsContact relatedMay be due to chemical irritation, hypersensitivity from preservatives, medications, shampoo, chlorine, dust, smokePseudomonas 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 sensationSensation of eyes burningDischargeEyelid sticking (worse upon awakening)Conjunctival edema (chemosis) and eyelid edemaItchy eyesIncreased tearing
  • Bacterial:Mucopurulent or purulent discharge
  • Gonococcal:Hyperacute, copious purulent discharge:Discharge starts 12 hr after inoculation.Severe chemosisEyelid swellingPreauricular lymphadenopathy typically absentInvades intact conjunctiva and cornea within 24 hr and causes ulcerations, scarring, and perforations leading to blindness
  • Chlamydia:LacrimationMucopurulent dischargeWith or without photophobiaConcomitant genital infection (>50%)Transmission occurs via autoinoculation from genital secretions
  • Viral-general:
  • Viral syndrome:Watery, mucous discharge, lacrimationGritty feeling or foreign body sensation in eyeSpreads to other eye in 24-48 hrPinpoint subconjunctival hemorrhages:Tarsal conjunctiva may have a bumpy appearance.
  • EKC:Conjunctival hyperemiaChemosisCorneal infiltratesDecreased vision
  • HSV:Acute follicular conjunctival reactionSkin lesions or vesicles along eyelid margin or periocular skinCorneal involvement-dendritic lesion
  • Herpes zoster virus (HZV):Associated with pain or paresthesia of the skinRash or vesicles involving the distribution of cranial nerve V1Dendritic characters on corneaRarely vesicles or ulcers form on the conjunctiva.
  • Allergic:Hallmark: ItchingRed conjunctivaWatery dischargePapillary hypertrophyFrequent history of allergy, atopy, nasal symptoms
  • Contact related:Acute symptoms result of corneal ulcerationNormal visual acuity and intraocular pressures

Essential Workup

  • History for:Onset of inflammationEnvironmental or work-related exposureIll contactsSexual activity, discharge, rashUse of over-the-counter medicines or cosmeticsSystemic diseases
  • Careful physical exam including slit-lamp exam including fluorescein staining

Diagnosis Tests & Interpretation

Lab

  • Bacteriologic studies:Not indicated in routine casesIndications:Ophthalmia neonatorum (except chemical)Suspected gonococcal ophthalmiaCompromised hostSigns and symptoms of systemic diseaseRefractory 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 hrFrequent handwashingNo sharing of towels, tissues, cosmetics, linensFrequent warm soaks until lashes and eyes free of debris
  • Bacterial conjunctivitis:Antibiotics-topical:Can use ointment or dropsContinue 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 infectionChlamydia requires systemic treatment of sexual partners and parents of neonates.
  • Viral conjunctivitis:No specific antiviral therapyLimited 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 lineArtificial 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% ointmentGentamicin: 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 wkErythromycin: 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 PRNErythromycin: 500 mg PO QID for 2-3 wk or doxycycline 100 mg PO BID for 2-3 wk+ topical antibiotics as aboveNeonates: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 tearsNaphcon-A or Visine AC 1 or 2 drops QID PRN for no more than 1 wk
  • HSV or HZV:Trifluorothymidine: 1% 5 times per dayVidarabine: 3% ointment 5 times per day
  • Allergic:Naphazoline (Naphcon-A): 1 drop BID-QID or Visine ACAcular: 1 or 2 drops BIDCromolyn 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.

See Also (Topic, Algorithm, Electronic Media Element)

Red eye

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)