Staphylococcal infection, acne rosacea, seborrheic dermatitis
Burning, itching, discomfort, foreign-body sensation, tearing, crusting, mild discharge, fluctuation in vision
Associated atopic and seborrheic dermatitis, and ocular rosacea
Hyperemia, telangiectasias, crusting, scaling, formation of collarettes around bases of lashes (staphylococcal), sleeves along eyelashes (seborrheic), and pouting of meibomian gland orifices, which can be expressed to produce a thickened lipid secretion, sometimes of toothpaste-like consistency (Fig. 1-1)
Frothy and foamy tear film, conjunctival injection, inferior superficial punctate keratopathy, phlyctenulosis, corneal infiltrates
Warm compresses 5 to 10 minutes b.i.d., eyelid margin scrubs with mild commercially available cleansers (e.g., Ocusoft Lid Scrub, Advanced Vision Research Sterilid)
Tear supplements while awake, topical azithromycin drops or erythromycin, bacitracin, or tetracycline ointment at bedtime
Oral tetracycline 250 mg b.i.d. to q.i.d. or doxycycline 100 mg q.d. to b.i.d. in severe or recurrent cases. These medications can often be tapered to a much lower dose for long-term use (e.g., doxycycline 20 mg b.i.d. or 50 mg q.d.). Oral erythromycin (approximately 200 mg/day) can be used for children.
Judicious short-term use of topical corticosteroids for phlyctenulosis or infiltrates
Good for significant improvement in symptoms over weeks, but patients need to understand that the condition is controlled rather than cured.
CHALAZION (INTERNAL HORDEOLUM, STYE)
A chalazion is a tender eyelid mass, often with surrounding erythema and swelling. It may be small or large, and can cause significant eyelid inflammation when severe.
Blockage of meibomian gland orifices and stagnation of sebaceous secretions
Associated with blepharitis/meibomitis and acne rosacea
Eyelid swelling, pain, and redness
Often a history of previous chalazia
Rarely, large, central chalazia can cause corneal flattening, especially after refractive surgery, or induced astigmatism.
Subcutaneous round, firm, swelling in the tarsal plate (Fig. 1-2)
May have an associated pyogenic granuloma on eversion of eyelid
Sometimes may be associated with significant eyelid inflammation (preseptal cellulitis)
External hordeolum: an acute staphylococcal infection of a lash follicle and its associated gland of Zeis or Moll
Pyogenic granuloma: a vascularized mass protruding from the conjunctiva
Sebaceous carcinoma: suspect in recurrent chalazia, eyelid margin excoriation, or loss of lashes, especially if unilateral
Eyelid biopsy if suspicious for sebaceous carcinoma
Warm compresses, eyelid massage, and hygiene (see Blepharitis/Meibomitis above)
Topical azithromycin drops or erythromycin, bacitracin, or tetracycline ointment for blepharitis/meibomitis
Oral tetracycline 250 mg b.i.d. to q.i.d. or doxycycline 100 mg q.d. to b.i.d. in inflamed, severe, or recurrent cases, to prevent recurrent chalazia
Corticosteroid injection can be considered to reduce scarring in recalcitrant cases.
Incision and curettage if no improvement with medical treatment.
Very good with medical treatment
If medical treatment is unsuccessful, surgical treatment is quite effective.
BACTERIAL CONJUNCTIVITIS (NONGONOCOCCAL)
Bacterial conjunctivitis is a relatively uncommon, usually bilateral condition, characterized by a mucopurulent or purulent discharge.
Staphylococcus aureus, Staphylococcus epidermidis
Haemophilus influenzae (especially in children), others
Redness, discharge, foreign-body sensation, burning, itchiness, photophobia
Purulent or mucopurulent discharge (Fig. 1-3)
Conjunctival hyperemia, maximal in the fornices
Pseudomembranes may be present in severe infections.
Corneal punctate epitheliopathy
Preauricular lymphadenopathy is usually absent.
Conjunctival swab for Gram stain, cultures, and sensitivities if severe or recurrent
Spontaneous resolution in days to 1 to 2 weeks is usual.
Artificial tears to wash away discharge
Empiric broad-spectrum topical antibiotic drops (e.g., polymyxin B/trimethoprim, fluoroquinolones, gentamicin, tobramycin, neomycin/gramicidin/bacitracin) q.i.d. for 1 week or azithromycin b.i.d. for 2 days then q.d. for 5 days
Antibiotic ointments (e.g., ciprofloxacin, tobramycin, gentamicin, tetracycline, bacitracin, polymyxin B/bacitracin) can be used q.i.d. for 1 week in patients in whom the drops wash out very quickly, such as crying children.
Severe infections can cause permanent conjunctival scarring.
GONOCOCCAL BACTERIAL CONJUNCTIVITIS
Gonococcal conjunctivitis is a rare, occasionally bilateral condition, characterized by acute onset of a severe purulent discharge.
Primarily Neisseria gonorrhoeae
Occasionally Neisseria meningitidis
It is typically sexually transmitted.
Redness, severe purulent discharge, foreign-body sensation, burning, photophobia
Hyperacute onset (within 12 to 24 hours)
Severe purulent discharge; pseudomembranes may be present
Marked conjunctival inflammation and chemosis (Fig. 1-4A)
Preauricular lymphadenopathy often present
Corneal punctate epitheliopathy, epithelial defect, infiltrate, ulcer, or perforation (Fig. 1-4B)
Conjunctival scraping for immediate Gram stain, cultures, and sensitivities. The diagnosis is confirmed if the Gram stain demonstrates gram-negative intracellular diplococci.
Systemic ceftriaxone 1 g IM in a single dose if there is no corneal involvement. If the patient is allergic to cephalosporins, fluoroquinolones are the drugs of choice.
If there is corneal involvement or corneal involvement cannot be excluded because of a limited slit-lamp examination, the patient should be treated with ceftriaxone 1 g IV q12h to q24h for 3 days.
Topical fluoroquinolone (e.g., ciprofloxacin) drops q2h, or q1h if the cornea is involved.
Ocular irrigation with saline q.i.d. to q2h to eliminate the discharge.
Evaluate and treat for possible coinfection with Chlamydia (e.g., azithromycin 1 g PO once).
Evaluate sexual partners for sexually transmitted infections.
Very good if diagnosed and treated appropriately before corneal involvement occurs. If the cornea is involved, the prognosis is guarded.
VIRAL CONJUNCTIVITIS (TYPICALLY ADENOVIRUS)
Viral conjunctivitis is a common, highly contagious, usually bilateral condition, characterized by the rapid onset of redness, itchiness, and tearing, first in one eye and then the other.
Adenovirus serotypes 8, 19, 37: epidemic keratoconjunctivitis
Adenovirus serotypes 3, 7: pharyngoconjunctival fever, usually in children
Others: herpes simplex virus, enteroviruses, Newcastle disease virus, Epstein-Barr virus
Tearing, itching, burning, redness, foreign-body sensation, photophobia
History of contact with someone with a red eye, recent upper respiratory tract infection, or recent eye examination
Generalized conjunctival hyperemia, subconjunctival hemorrhages
Conjunctival follicles, which are frequently most apparent in the inferior fornices (Fig. 1-5A)
Membranes or pseudomembranes in severe cases
Conjunctival membranes consist of coagulated exudate adherent to inflamed conjunctival epithelium. Clinically, a true membrane causes bleeding on attempted removal and a pseudomembrane does not, but this rule is not universal. The causes of true membranes and pseudomembranes are similar.
Central punctate epithelial keratitis, and occasionally an epithelial defect (Fig. 1-5B).
Multiple small corneal infiltrates with overlying punctate staining may also be seen in the acute phase of severe infections (Fig. 1-5C).
Preauricular lymphadenopathy is often present.
Subepithelial infiltrates (SEIs) can occur weeks after the onset of the acute infection and may persist for months to years (Fig. 1-5D)
Artificial tears and cool compresses four to eight times a day
Antihistamines (e.g., antazoline, naphazoline) q.i.d. for itching
Removal of membranes or pseudomembranes
Corticosteroid drops in severe cases with membranes or pseudomembranes or erosions. A long, slow taper of mild corticosteroid drops can be used in eyes with SEIs that affect visual function.
Strict observation of hygienic measures is needed to avoid spreading the infection.
Very good. If clinically significant subepithelial infiltrates develop, the treatment course can be prolonged. Severe infections with membranes or pseudomembranes can cause permanent conjunctival scarring (Fig. 1-5E).
CHLAMYDIAL CONJUNCTIVITIS (ADULT INCLUSION CONJUNCTIVITIS)
Adult chlamydial conjunctivitis is a relatively common, usually unilateral condition that is typically transmitted sexually and generally affects young adults.
Chlamydia trachomatis serotypes D through K
Typically sexually transmitted
Tearing, itching, burning, redness, foreign-body sensation, photophobia, discharge of longer than 3 to 4 weeks in duration
May be associated with urethritis, vaginitis, or cervicitis
Stringy, white mucopurulent discharge
Large follicles in the inferior fornices (Fig. 1-6)
Superior tarsal follicles, occasionally follicles at the limbus
Superior limbal or peripheral nummular corneal infiltrates and pannus
Mild preauricular lymphadenopathy may be present.
History of sexual exposure; patient may have concomitant genitourinary symptoms
Direct immunofluorescent antibody test of conjunctival smears
Giemsa stain cytology for basophilic cytoplasmic inclusion bodies of Halberstaedter-Prowazek; more common in newborns than adults
McCoy chlamydial cell culture
Azithromycin 1 g PO once, doxycycline 100 mg PO b.i.d., or tetracycline, erythromycin or clarithromycin 250 mg q.i.d. for 2 to 6 weeks
Topical azithromycin drops b.i.d. for 2 days, then q.i.d. for 1 to 6 weeks, or tetracycline or erythromycin ointment q.i.d. for 4 to 6 weeks
Referral for treatment of sexual partners and other sexually transmitted infections should be done.