Conjunctivitis

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Conjunctivitis

An eye with viral conjunctivitis
Classification and external resources
Specialty Ophthalmology
ICD-10 H10
ICD-9-CM 372.0
DiseasesDB 3067
MedlinePlus 001010
eMedicine emerg/110
Patient UK Conjunctivitis
MeSH D003231

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid.[1] It makes the eye appear pink or reddish. There may also be pain, burning, scratchiness, or itchiness. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur.[2] Itching of the eye is more common in cases due to allergies.[3] Conjunctivitis can affect one or both eyes.[2]

The most common infectious causes are viral followed by a bacterial infections.[3] The viral infection may occur along with other symptoms of a common cold. Viral and bacterial cases are easily spread between people.[2] Allergies to pollen or animal hair is also a common cause.[3] Diagnosis is often based on signs and symptoms. Occasionally a sample of the discharge is sent for culture.[2]

Prevention is partly by handwashing. Treatment depends on the underlying cause.[2] In the majority of viral cases, there is no specific treatment.[3] Most cases due to a bacterial infection will also resolve without treatment; however, antibiotics can shorten the illness.[2][3] Those who wear contact lens and those with either gonorrhea or chlamydia as the cause should be treated. Allergic cases can be treated with antihistamine or mast cell inhibitor drops.[3]

About 3 to 6 million people get conjunctivitis each year in the United States.[2][3] In adults viral causes are more common, while in children bacterial causes are more common.[3] Typically people get better in one or two weeks.[2][3] If there is visual loss, significant pain, sensitivity to light, signs of herpes, or a person is not improving after a week, further diagnosis and treatment may be required.[3] Conjunctivitis in a newborn, known as neonatal conjunctivitis, may also require specific treatment.[2]

Signs and symptoms

Red eye, swelling of conjunctiva and watering of the eyes are symptoms common to all forms of conjunctivitis. However, the pupils should be normally reactive, and the visual acuity normal.

Viral

Conjunctivitis due to a viral infection resulting in some bleeding

Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold, and/or a sore throat. Its symptoms include excessive watering and itching. The infection usually begins with one eye, but may spread easily to the other.

Viral conjunctivitis shows a fine, diffuse pinkness of the conjunctiva, which is easily mistaken for the ciliary infection of Iris (Iritis), but there are usually corroborative signs on microscopy, particularly numerous lymphoid follicles on the tarsal conjunctiva, and sometimes a punctate keratitis.

Some other viruses that can infect the eye include Herpes simplex virus and Varicella zoster.[4]

Allergic

An eye with allergic conjunctivitis showing conjunctival edema

Allergic conjunctivitis is inflammation of the conjunctiva (the membrane covering the white part of the eye) due to allergy.[5] Allergens differ among patients.

Symptoms consist of redness (mainly due to vasodilation of the peripheral small blood vessels), swelling of the conjunctiva, itching, and increased lacrimation (production of tears). If this is combined with rhinitis, the condition is termed "allergic rhinoconjunctivitis". The symptoms are due to release of histamine and other active substances by mast cells, which stimulate dilation of blood vessels, irritate nerve endings, and increase secretion of tears.

Bacterial

An eye with bacterial conjunctivitis

Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and mucopurulent discharge. Typically, symptoms develop first in one eye, but may spread to the other eye within 2–5 days. Bacterial conjunctivitis due to common pyogenic (pus-producing) bacteria causes marked grittiness/irritation and a stringy, opaque, greyish or yellowish mucopurulent discharge that may cause the lids to stick together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may also occur. The gritty and/or scratchy feeling is sometimes localized enough for patients to insist they must have a foreign body in the eye. The more acute pyogenic infections can be painful. Common bacteria responsible for non-acute bacterial conjunctivitis are Staphylococci and Streptococci.[6]

Bacteria such as Chlamydia trachomatis or Moraxella can cause a non-exudative but persistent conjunctivitis without much redness. Bacterial conjunctivitis may cause the production of membranes or pseudomembranes that cover the conjunctiva. Pseudomembranes consist of a combination of inflammatory cells and exudates, and are loosely adherent to the conjunctiva, while true membranes are more tightly adherent and cannot be easily peeled away. Cases of bacterial conjunctivitis that involve the production of membranes or pseudomembranes are associated with Neisseria gonorrhoeae, β-hemolytic streptococci, and C. diphtheriae. Corynebacterium diphtheriae causes membrane formation in conjunctiva of non-immunized children.

Chemical

Chemical eye injury is due to either an acidic or alkali substance getting in the eye.[7] Alkalis are typically worse than acidic burns.[8] Mild burns will produce conjunctivitis, while more severe burns may cause the cornea to turn white.[8] Litmus paper is an easy way to rule out the diagnosis by verifying that the pH is within the normal range of 7.0—7.2.[7] Large volumes of irrigation is the treatment of choice and should continue until the pH is 6—8.[8] Local anaesthetic eye drops can be used to decrease the pain.[8]

Irritant or toxic conjunctivitis show primarily marked redness. If due to splash injury, it is often present in only the lower conjunctival sac. With some chemicals, above all with caustic alkalis such as sodium hydroxide, there may be necrosis of the conjunctiva with a deceptively white eye due to vascular closure, followed by sloughing of the dead epithelium. This is likely to be associated with slit-lamp evidence of anterior uveitis.

Other

An eye with chlamydial conjunctivitis

Inclusion conjunctivitis of the newborn (ICN) is a conjunctivitis that may be caused by the bacteria Chlamydia trachomatis, and may lead to acute, purulent conjunctivitis.[9] However, it is usually self-healing.[9]

Conjunctivitis is identified by irritation and redness of the conjunctiva. Except in obvious pyogenic or toxic/chemical conjunctivitis, a slit lamp (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.

Causes

Conjunctivitis when caused by an infection is most commonly caused by a viral infection.[10] Bacterial infections, allergies, other irritants and dryness are also common causes. Both bacterial and viral infections are contagious and passed from person to person, but can also spread through contaminated objects or water.

The most common cause of viral conjunctivitis is adenoviruses (see: Adenoviral keratoconjunctivitis).[11] Herpetic keratoconjunctivitis (caused by herpes simplex viruses) can be serious and requires treatment with acyclovir. Acute hemorrhagic conjunctivitis is a highly contagious disease caused by one of two enteroviruses, Enterovirus 70 and Coxsackievirus A24. These were first identified in an outbreak in Ghana in 1969, and have spread worldwide since then, causing several epidemics.[12]

The most common causes of acute bacterial conjunctivitis are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.[11] Though very rare, hyperacute cases are usually caused by Neisseria gonorrhoeae or N. meningitidis. Chronic cases of bacterial conjunctivitis are those lasting longer than 3 weeks, and are typically caused by Staphylococcus aureus, Moraxella lacunata, or gram-negative enteric flora.

Conjunctivitis may also be caused by allergens such as pollen, perfumes, cosmetics, smoke,[13] dust mites, Balsam of Peru,[14] and eye drops.[15]

Conjunctivitis is part of the triad of reactive arthritis, which is thought to be caused by autoimmune cross-reactivity following certain bacterial infections. Reactive arthritis is highly associated with HLA-B27. Conjunctivitis is associated with the autoimmune disease relapsing polychondritis.[16][17]

Diagnosis

Cultures are not often taken or needed as most cases resolve either with time or typical antibiotics. Swabs for bacterial culture are necessary if the history and signs suggest bacterial conjunctivitis but there is no response to topical antibiotics. Viral culture may be appropriate in epidemic case clusters.

A patch test is used to identify the causative allergen in the case where conjunctivitis is caused by allergy.[18]

Conjunctival scrapes for cytology can be useful in detecting chlamydial and fungal infections, allergy, and dysplasia, but are rarely done because of the cost and the general lack of laboratory staff experienced in handling ocular specimens. Conjunctival incisional biopsy is occasionally done when granulomatous diseases (e.g., sarcoidosis) or dysplasia are suspected.

Classification

Classification can be either by cause or by extent of the inflamed area.

Causes

By extent of involvement

Blepharoconjunctivitis is the dual combination of conjunctivitis with blepharitis (inflammation of the eyelids).

Keratoconjunctivitis is the combination of conjunctivitis and keratitis (corneal inflammation).

Differential diagnosis

There are more serious conditions that can present with a red eye such as infectious keratitis, angle closure glaucoma, or iritis. These conditions require the urgent attention of an ophthalmologist. Signs of such conditions include decreased vision, significantly increased sensitivity to light, inability to keep eye open, a pupil that does not respond to light, or a severe headache with nausea.[19] Fluctuating blurring is common, due to tearing and mucoid discharge. Mild photophobia is common. However, if any of these symptoms are prominent, it is important to consider other diseases such as glaucoma, uveitis, keratitis and even meningitis or carotico-cavernous fistula.

A more comprehensive differential diagnosis for the red or painful eye includes:[19]

Prevention

The best effective prevention is hygiene and not rubbing the eyes by infected hands. Vaccination against adenovirus, haemophilus influenzae, pneumococcus, and neisseria meningitidis is also effective.

Povidone-iodine eye solution has been found to prevent conjunctivitis follow birth.[20] As it is less expensive it is being more commonly used for this purpose globally.[20]

Management

Conjunctivitis resolves in 65% of cases without treatment, within two to five days. The prescription of antibiotics is not necessary in most cases.[21]

Viral

Viral conjunctivitis usually resolves on its own and does not require any specific treatment.[10] Antihistamines (e.g., promethazine) or mast cell stabilizers (e.g., cromolyn) may be used to help with the symptoms.[10] Povidone iodine has been suggested as a treatment, but as of 2008 evidence to support it was poor.[22]

Allergic

For the allergic type, cool water poured over the face with the head inclined downward constricts capillaries, and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, nonsteroidal anti-inflammatory medications and antihistamines may be prescribed. Persistent allergic conjunctivitis may also require topical steroid drops.

Bacterial

Bacterial conjunctivitis usually resolves without treatment.[10] Topical antibiotics may be needed only if no improvement is observed after three days.[23] In people who received no antibiotics, recovery was in 4.8 days, with immediate antibiotics it was 3.3 days, and with delayed antibiotics 3.9 days. No serious effects were noted either with or without treatment.[24] As they do speed healing in bacterial conjunctivitis, their use is also reasonable.[25]

In those who wear contact lenses, are immunocompromised, have disease which is thought to be due to chlamydia or gonorrhea, have a fair bit of pain, or who have lots of discharge, antibiotics are recommended.[10] Gonorrhea or chlamydia infections require both oral and topical antibiotics.[10]

When appropriate, the choice of antibiotic varies, differing based on the cause (if known) or the likely cause of the conjunctivitis. Fluoroquinolones, sodium sulfacetamide, or trimethoprim/polymyxin may be used, typically for 7–10 days.[11] Cases of meningococcal conjunctivitis can be treated with systemic penicillin, as long as the strain is sensitive to penicillin.

When investigated as a treatment, Povidone-iodine ophthalmic solution has also been observed to have some effectiveness against bacterial and chlamydial conjunctivitis, with a possible role suggested in locations where topical antibiotics are unavailable or costly.[26]

Chemical

Conjunctivitis due to chemicals is treated via irrigation with Ringer's lactate or saline solution. Chemical injuries (particularly alkali burns) are medical emergencies, as they can lead to severe scarring and intraocular damage. People with chemically induced conjunctivitis should not touch their eyes, regardless of whether or not their hands are clean, as they run the risk of spreading the condition to another eye.

Epidemiology

Conjunctivitis is the most common eye disease.[27]

History

A former superintendent of the Regional Institute of Ophthalmology in the city of Madras (the present-day Chennai) Tamil Nadu in India, Kirk Patrick, was the first to have found the adenovirus that caused conjunctivitis, leading to the name Madras eye for the disease.[28]

See also

References

  1. ↑ Richards A, Guzman-Cottrill JA (May 2010). "Conjunctivitis". Pediatr Rev 31 (5): 196–208. doi:10.1542/pir.31-5-196. PMID 20435711.
  2. 1 2 3 4 5 6 7 8 9 "Facts About Pink Eye". National Eye Institute. November 2015. Retrieved 8 March 2016.
  3. 1 2 3 4 5 6 7 8 9 10 Azari, AA; Barney, NP (23 October 2013). "Conjunctivitis: a systematic review of diagnosis and treatment.". JAMA 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMID 24150468.
  4. ↑ Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott's Diagnostic Microbiology. 12th Edition. Mosby Elsevier, 2007. p. 834.
  5. ↑ Bielory L, Friedlaender MH (February 2008). "Allergic conjunctivitis". Immunol Allergy Clin North Am 28 (1): 43–58, vi. doi:10.1016/j.iac.2007.12.005. PMID 18282545.
  6. ↑ "Pink Eye (Conjunctivitis)". MedicineNet.
  7. 1 2 Zentani A, Burslem J (December 2009). "Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: use of litmus paper in chemical eye injury". Emerg Med J 26 (12): 887. doi:10.1136/emj.2009.086124. PMID 19934140.
  8. 1 2 3 4 Hodge C, Lawless M (July 2008). "Ocular emergencies". Aust Fam Physician 37 (7): 506–9. PMID 18592066.
  9. 1 2 Fisher, Bruce; Harvey, Richard P.; Champe, Pamela C. (2007). Lippincott's Illustrated Reviews: Microbiology (Lippincott's Illustrated Reviews Series). Hagerstown MD: Lippincott Williams & Wilkins. ISBN 0-7817-8215-5.
  10. 1 2 3 4 5 6 Azari, AA; Barney, NP (23 October 2013). "Conjunctivitis: a systematic review of diagnosis and treatment.". JAMA: the Journal of the American Medical Association 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMID 24150468.
  11. 1 2 3 Yanoff, Myron; Duker, Jay S. (2008). Ophthalmology (3rd ed.). Edinburgh: Mosby. pp. 227–236. ISBN 978-0-323-05751-6.
  12. ↑ Lévêque N, Huguet P, Norder H, Chomel JJ (April 2010). "[Enteroviruses responsible for acute hemorrhagic conjunctivitis]". Med Mal Infect (in French) 40 (4): 212–8. doi:10.1016/j.medmal.2009.09.006. PMID 19836177.
  13. 1 2 "Allergic Conjunctivitis". familydoctor.org. Retrieved 2015-09-18.
  14. 1 2 Pamela Brooks – (2012-10-25). The Daily Telegraph: Complete Guide to Allergies. Retrieved 2014-04-15.
  15. 1 2 "What Is Allergic Conjunctivitis? What Causes Allergic Conjunctivitis?". medicalnewstoday.com. Retrieved 2010-04-06.
  16. ↑ Puéchal, X; Terrier, B; Mouthon, L; Costedoat-Chalumeau, N; Guillevin, L; Le Jeunne, C (March 2014). "Relapsing polychondritis.". Joint, bone, spine : revue du rhumatisme 81 (2): 118–24. doi:10.1016/j.jbspin.2014.01.001. PMID 24556284.
  17. ↑ Cantarini, Luca; Vitale, Antonio; Brizi, Maria Giuseppina; Caso, Francesco; Frediani, Bruno; Punzi, Leonardo; Galeazzi, Mauro; Rigante, Donato (2014). "Diagnosis and classification of relapsing polychondritis". Journal of Autoimmunity. 48-49: 53–59. doi:10.1016/j.jaut.2014.01.026. ISSN 0896-8411. PMID 24461536.
  18. 1 2 Mark J. Mannis, Marian S. Macsai, Arthur C. Huntley (1996). Eye and skin disease. Lippincott-Raven. Retrieved 2014-04-23.
  19. 1 2 Longo, DL (2012). "Disorders of the Eye(Horton JC)". Harrison's Principles of Internal Medicine. McGra-Hill.
  20. 1 2 Isenberg, SJ (2003). "The ocular application of povidone-iodine.". Community eye health / International Centre for Eye Health 16 (46): 30–1. PMID 17491857.
  21. ↑ Rose P (August 2007). "Management strategies for acute infective conjunctivitis in primary care: a systematic review". Expert Opin Pharmacother 8 (12): 1903–21. doi:10.1517/14656566.8.12.1903. PMID 17696792.
  22. ↑ Jimmy D. Bartlett; Siret D. Jaanus (2008). Clinical Ocular Pharmacology. Elsevier Health Sciences. pp. 454–. ISBN 0-7506-7576-4.
  23. ↑ Visscher, KL; Hutnik, CM; Thomas, M (November 2009). "Evidence-based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing.". Canadian Family Physician 55 (11): 1071–5. PMC 2776793. PMID 19910590.
  24. ↑ Sheikh A, Hurwitz B (2006). Sheikh, Aziz, ed. "Antibiotics versus placebo for acute bacterial conjunctivitis". Cochrane Database Syst Rev (2): CD001211. doi:10.1002/14651858.CD001211.pub2. PMID 16625540.
  25. ↑ Sheikh, A; Hurwitz, B; van Schayck, CP; McLean, S; Nurmatov, U (12 September 2012). "Antibiotics versus placebo for acute bacterial conjunctivitis.". Cochrane database of systematic reviews (Online) 9: CD001211. doi:10.1002/14651858.CD001211.pub3. PMID 22972049.
  26. ↑ Isenberg, SJ; Apt, L; Valenton, M; Del Signore, M; Cubillan, L; Labrador, MA; Chan, P; Berman, NG (November 2002). "A controlled trial of povidone-iodine to treat infectious conjunctivitis in children". American Journal of Ophthalmology 134 (5): 681–688. doi:10.1016/S0002-9394(02)01701-4. PMID 12429243.
  27. ↑ Smeltzer, Suzanne C. (2010). Brunner & Suddarth's textbook of medical-surgical nursing. (12th ed. ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1787. ISBN 9780781785891.
  28. ↑ "Chennai's medical history unveiled". The Times of India (Chennai). 23 August 2011. Retrieved 16 September 2012.

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