BASICS
DESCRIPTION
Acute conjunctivitis defines an inflammation of the conjunctiva, or the mucous membrane lining the inner surface of the eyelids and the outer surface of the eyeball extending over the sclera. Bacterial conjunctivitis is a very common condition.
EPIDEMIOLOGY
• Affects both children and adults of all ages
• No sex predominance
Incidence
• Acute conjunctivitis comprises about 1–2% of a primary care office visits.
• 1 in 8 schoolchildren has an episode of acute infective conjunctivitis every year.
• There are approximately 6 million cases of conjunctivitis annually.
Prevalence
Bacteria are responsible for about 50–75% of all cases of acute conjunctivitis in young children.
RISK FACTORS
• Bacterial conjunctivitis occurs in otherwise healthy individuals.
• Risk factors include exposure to infected individuals, sinusitis, and immunodeficiency states.
Genetics
No genetic predisposition
GENERAL PREVENTION
Isolation of contagious patients for 24–48 h after initiation of antibiotic therapy
PATHOPHYSIOLOGY
Inflammation of the conjunctiva, or the mucous membrane lining the inner surface of the eyelids, and outer surface of the eyeball extending over the sclera
ETIOLOGY
• Acute bacterial conjunctivitis:
– Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumonia, Moraxella catarrhalis, Staphylococcus epidermidis:
H. influenzae and S. pneumonia are most common in children.
S. aureus are most common in adults.
• Hyperacute bacterial conjunctivitis:
– Neisseria gonorrhea
• Chronic bacterial conjunctivitis:
– Chlamydia
COMMONLY ASSOCIATED CONDITIONS
• Otitis media:
– Frequently caused by H. influenzae
DIAGNOSIS
There is considerable overlap in clinical signs and symptoms between viral and bacterial conjunctivitis; clinical accuracy of 50%. Four clinical factors were independently associated with negative cultures: 1) age ≥6 years, 2) presentation during April through November, 3) watery or no discharge, 4) no glued eye in the morning. A child who presented with all four clinical factors would have a negative culture 92% of the time, whereas a child who presented with none of these factors would have a negative culture 12% of the time (2).
HISTORY
• More commonly associated with a bilateral > unilateral red eye
• Eyelash matting
• Purulent yellow-green discharge
• Copious discharge associated with hyperacute bacterial conjunctivitis
• History of sexual activity associated with hyperacute and chronic conjunctivitis
• Exposure to a sick contact
PHYSICAL EXAM
• Palpebral papillary reaction
• Follicles develop with Chlamydia.
• Only 10% have associated a preauricular lymphadenopathy.
• Moraxella species, Chlamydia, and N. gonorrhea
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Initial lab tests
• Cell culture:
– “Gold Standard”; Not routinely performed
– Blood agar and chocolate agar
– Recommended for patients not responding to therapy, immune compromised patients, contact lens wearers, in the setting of an outbreak, sexual active person with copious discharge
– Copious discharge suggests N. gonorrhea; requires culture on chocolate agar.
– Copious discharge suggests N. gonorrhea; intracellular diplococci are suggestive.
• Polymerase chain reaction:
– Usually a send-out test; expensive
– Not FDA cleared
– Available for confirmation of Chlamydia and N. gonorrhea
Follow-up & special considerations
• Follow-up in 5–7 days
• 70% of patients with confirmed ocular chlamydia have a coexistent chlamydia genital infection.
• Follow-up should be in 5–7 days. N. gonorrhea needs daily follow-up in the first 3 days.
– High risk of corneal ulceration with perforation
Diagnostic Procedures/Other
Immunoassay to rule out adenovirus
DIFFERENTIAL DIAGNOSIS
Acute viral conjunctivitis (HSV and adenovirus), allergic conjunctivitis, episcleritis/scleritis, blepharitis, infectious or inflammatory keratitis, uveitis, and angle closure glaucoma
TREATMENT
MEDICATION
• A meta-analysis of antibiotics versus placebo for acute bacterial conjunctivitis was published in a Cochrane review in 2006. 5 randomized trials including a total of 1034 participants were analyzed and it was determined that clinical recovery with antibiotics was faster in the first 2–5 days after presentation (relative risk of clinical cure 1.24; 6 patients needed treatment in order to achieve one more clinical cure than with placebo) (1,3)[A].
• 6–10 days after presentation the benefit of antibiotics was less (relative risk of clinical cure 1.11; 13 patients needed treatment) (1,3)[A].
• The benefit of topical antibiotics versus placebo was greater on microbiological cure than on clinical cure. At 2–5 days after presentation the relative risk of microbiological cure was 1.77; at 6 to 10 days the relative risk was 1.56 (1,3)[A].
• Delayed therapy for 3 days is an option but forces isolation of contagious persons.
First Line
• Acute bacterial conjunctivitis:
– Polytrim 1 drop every 4–6 h for 7 days
– Fluoroquinolone 1 drop every 4–6 h for 7 days
i.e., moxifloxacin, gatifloxacinlevofloxacin, besifloxacin
• Hyperacute bacterial conjunctivitis:
– Ceftriaxone 1 g intramuscularly (i.m.) in a single dose for presumed N. gonorrhea
– If corneal involvement exists, treat with ceftriaxone 1 g intravenously (i.v.) every 12–24 h
– Topical fluoroquinolone q.i.d. without corneal involvement and q1–2h with corneal involvement
– In penicillin-allergic patients, consider an oral fluoroquinolone (e.g., ciprofloxacin 500 mg p.o., for 5 days.
Second Line
• Azithromycin 1 drop twice daily for 2 days and then once daily for 3 additional days
• Older generation medications suffer from high rates of antibiotic resistance.
• Medications such as topical Tobramycin and Gentamycin may be associated with corneal toxicity. Other antibiotics such as Sulfa and Neomycin are associated with increased rates of allergic reactions and should be avoided.
ADDITIONAL TREATMENT
General Measures
• Supportive care:
– Refrigerated preservative-free artificial tears
– Frequent hand washing
– Limit sharing of towels and linens
Issues for Referral
• Severe eye pain or headache, photophobia, decreased vision acuity, trauma, or contact lens use
• Mid-dilated fixed pupil, hazy cornea
• No improvement after 7 days of antibiotic treatment
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow-up is recommended for patients who develop reduced vision, pain, light sensitivity or if symptoms persist beyond 7 days.
PATIENT EDUCATION
Educate patients on contagiousness.
PROGNOSIS
Self-limiting; most patients recover spontaneously.
COMPLICATIONS
Complications are rare.
ADDITIONAL READING
• O’Brien TP, Jeng BH, McDonald M, et al. Acute conjunctivitis: Truth and misconceptions. Curr Med Res Opin 2009;25:1953–1961.
• Høvding G. Acute bacterial conjunctivitis. Acta Ophthalmol 2008;86:5–17.
• Meltzer JA, Kunkov S, Crain EF. Identifying children at low risk for bacterial conjunctivitis. Arch Pediatr Adolesc Med 2010;164:263–267.
• Oliver GF, Wilson GA, Everts RJ. Acute infective conjunctivitis: evidence review and management advice for New Zealand practitioners. N Z Med J 2009;122:69–75.
• Tarabishy AB, Jeng BH. Bacterial conjunctivitis: A review for internists. Cleve Clin J Med 2008;75:507–512.
• American Academy of Ophthalmology. Conjunctivitis Preferred Practice Patterns 2008.
CODES
ICD9
• 372.00 Acute conjunctivitis, unspecified
• 372.03 Other mucopurulent conjunctivitis
• 372.30 Conjunctivitis, unspecified
CLINICAL PEARLS
• Consider more serious eye disease if there is a unilateral red eye, reduced visual acuity, severe pain, significant photophobia, contact lens wear, or recent ocular surgery or trauma. Purulent discharge is associated with bacterial conjunctivitis.
• Negative cultures are associated with: 1) age ≥6 years, 2) presentation during April through November, 3) watery or no discharge, and 4) no glued eye in the morning.
• Antibiotic treatment of bacterial conjunctivitis reduces the duration of clinical illness by 0.5–1.5 days and hastens microbiological cure.
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