BASICS

DESCRIPTION

Acute conjunctivitis defines an 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. Viral conjunctivitis is a very common condition and adenovirus is the most frequent cause of conjunctivitis worldwide.

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.

• There are approximately 6 million cases of conjunctivitis annually.

Prevalence

20–70% of acute conjunctivitis is viral.

RISK FACTORS

• <5% of the US population shows natural immunity against adenovirus.

• Adenovirus can live on inanimate surfaces for 5 weeks:

– Overcrowding or close quarters

– Urban setting

– Exposure to a sick contact

Genetics

No genetic predisposition

GENERAL PREVENTION

• Isolation of contagious patients:

– Adenoviral conjunctivitis shows close contact and intrafamilial spread of 20–40%.

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

• Viral conjunctivitis represents 20–70% of all acute conjunctivitis.

– Adenovirus accounts for 65–90% of viral conjunctivitis.

– Presents as 1 of 4 clinical conditions: Epidemic keratoconjunctivitis (EKC), acute hemorrhagic conjunctivitis (AHC), pharyngoconjunctival fever (PCF), and nonspecific follicular conjunctivitis (NFC)

– Herpes simplex virus (HSV) accounts for 1.3–21% of viral conjunctivitis.

– These cases occur without associated skin vesicles or keratitis.

– Other less common viruses include Molluscum contagiosum, varicella-zoster virus (VZV), coxsackie virus, enterovirus, echovirus, Epstein-Barr virus, human immunodeficiency virus, and cytomegalovirus.

COMMONLY ASSOCIATED CONDITIONS

• Adenovirus may be associated with viral prodrome followed by adenopathy, fever, pharyngitis, or an upper respiratory tract infection.

• HSV and VZV may be associated with a vesicular skin rash and/or keratitis.

DIAGNOSIS

HISTORY

• More commonly associated with a bilateral red eye

• Starts in one eye and then moves to the other several days later

• Watery to mucoid discharge

• Recent upper respiratory symptoms

• Exposure to a sick contact

PHYSICAL EXAM

• Injection

• Palpebral follicular reaction

• Microhemorrhages

• Pseudomembranes

• Superficial punctuate keratopathy

• Subepithelial infiltrates:

– Only occurs after 7–10 days

• Pre-auricular lymphadenopathy:

– Only present in 30–50%

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Point of care immunoassay for adenovirus with a sensitivity of 88–89% and a specificity of 91–94% (1)[A]:

– 10 min in office test

– Detects viable and nonviable virus fragments

– Antigen levels diminish after 7 days

• Viral cell culture (3)[A]:

– May take 3–21 days to grow

– “Gold Standard”

– Only detects live virus

• Polymerase chain reaction (3)[A]:

– Usually a send-out test; expensive

– Not FDA cleared

– Detects both viable and nonviable viral fragments

Diagnostic Procedures/Other

Serological tests for HSV IgM and IgG

DIFFERENTIAL DIAGNOSIS

Acute bacterial conjunctivitis, allergic conjunctivitis, episcleritis/scleritis, blepharitis, dry eyes, infectious or inflammatory keratitis, uveitis, and angle closure glaucoma

TREATMENT

MEDICATION

First Line

• Adenoviral conjunctivitis has no FDA approved antiviral agents.

– Refrigerated preservative-free artificial tears every 2 h

– Topical antihistamines twice daily for significant itching

– Topical ganciclovir gel:

Small, randomized, controlled, masked series of 18 patients showed decreased duration of disease (4)[A].

• HSV should be treated with topical antiviral:

– Topical ganciclovir gel 0.15% 5 times per day (4)[B]

– Trifluridine 1% (Viroptic) drops 5 times per day (4)[B]

Second Line

• Topical steroids may be considered in the presence of pseudomembranes or subepithelial infiltrates.

– Steroids should be avoided except in severe disease because of associated increased viral replication and prolonged infectivity.

Consider loteprednol twice to 4 times daily or a steroid ointment such as fluorometholone 0.1% or dexamethasone/tobramycin 4 times daily.

ADDITIONAL TREATMENT

General Measures

• Supportive care:

– Refrigerated preservative-free artificial tears

– Frequent hand washing

– Limit sharing of towels and linens

– Home disinfection

Issues for Referral

• After 7–10 days patients may develop subepithelial infiltrates (corneal deposits).

– Manifest as reduced vision or photosensitivity

Additional Therapies

Analytical laboratory studies and anecdotal support for povidone iodine therapy exist.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Follow-up is recommended for patients who develop reduced vision, light sensitivity, or if symptoms persist beyond 10 days.

PATIENT EDUCATION

• Educate patients on extreme contagiousness.

• Educate patients on the ineffectiveness of topical antibiotics.

PROGNOSIS

• Most patients recover spontaneously.

• 20–50% of patients with EKC develop SEIs or chronic dry eyes.

COMPLICATIONS

• Corneal subepithelial infiltrates (inflammatory deposits)

• Chronic dry eye

• Conjunctival scarring

• Chronic epiphora (tearing)

ADDITIONAL READING

• American Academy of Ophthalmology. Conjunctivitis Preferred Practice Patterns. 2008.

• Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for adenoviral conjunctivitis. Am J Med Sci 2008;336:254–264.

• Sambursky R, Tauber S, Schirra F, et al. The RPS adeno detector for diagnosing adenoviral conjunctivitis. Ophthalmology 2006;113:1758–1764.

• Rietveld RP, van Weert HC, ter Riet G, et al. Diagnostic impact of signs and symptoms in acute infectious conjunctivitis: Systematic literature search. BMJ 2003;327:789.

• O’Brien TP, Jeng BH, McDonald M, et al. Acute conjunctivitis: truth and misconceptions. Curr Med Res Opin 2009;25:1953–1961.

• Colin J. Ganciclovir ophthalmic gel, 0.15%: A valuable tool for treating ocular herpes. Clin Ophthalmol 2007;1:441–453.

CODES

ICD9

• 077.3 Other adenoviral conjunctivitis

• 077.99 Unspecified diseases of conjunctiva due to viruses

• 372.00 Acute conjunctivitis, unspecified

CLINICAL PEARLS

• A 50% clinical accuracy was found compared to laboratory diagnosis.

• HSV may present with EKC that is indistinguishable from adenovirus.

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