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Pathophysiology

 

The conjunctiva is a mucous membrane that that lines the surface of the eyelids (palpebral) and globe up to the limbus (bulbar).

 

The conjunctiva itself is made up of non-keratinized squamous epithelium with goblet cells and substantia propria, which is highly vascularized.

The important thing to remember is that the conjunctiva is transparent, unless inflamed (which is termed “injected”).

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Bacterial Conjunctivitis

 

• Bacterial conjunctivitis is more common in children than adults (though viral is most common overall).
• Transmission is spread from direct contact with infected drainage or contaminated objects
• Pathogens
  • S. aureus, S. pneumoniae, H. influenza, M. catarrhalis
• Signs and Symptoms
  • Redness and drainage in one eye
  • Matted shut in the morning
  • Drainage
    • Continues throughout the day
    • Thick and purulent
• Special Concerns
  • Neisseria gonorrhoeae
    • Concurrent STI symptoms
    • Rapid onset of symptoms (< 12 hours)
    • More pain and tenderness with marked chemosis and lymphadenopathy
    • Admission with emergency ophthalmology evaluation
      • Keratitis and perforation may occur

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Viral Conjunctivitis

 

• Most common cause of acute conjunctivitis
• Highly contagious and is spread through direct contact with drainage or contaminated objects
• Pathogens
  • Adenovirus is the most common
• Viral prodrome
  • Fever, adenopathy, pharyngitis, URI, conjunctivitis
• Drainage
  • Watery, mucoserous drainage
  • Matted/thick in the morning with scant, watery drainage throughout the day
• Corneal injection with burning/gritty sensation
• Starts unilateral and spreads to contralateral eye within 48 hours of symptoms onset
• Follicular pattern on palpebral conjunctiva
• 
• Self-limiting process
  • Worsens for 3-5 days with gradual resolution over the next 7-10 days

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Allergic Conjunctivitis

 

• Caused by airborne allergens that initiate an IgE-mediated local response with mast cell degranulation and release of histamine
• Drainage
  • Watery and stringy
• Signs and Symptoms
  • Bilateral eye involvement
  • Periorbital edema
  • Allergic symptoms
    • Sneezing, coughing, rash, sore throat
  • Profuse itching
  • Marked chemosis and injection
    • Bullous chemosis may occur in severe causes or as a result of itching
    • 

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Non-Infectious/Non-Allergic Conjunctivitis

 

• Causes
  • Mechanical or chemical insult
    • Patients with chronic dry eyes
    • Patients s/p irrigation from chemical splash
    • Transient foreign body
• Self-limiting and spontaneously improve within 24 hours

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Distinguishing Between The Types

 

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Special Considerations for Contact Lens Wearers

 

These patients are at an increased risk for Pseudomonas infections and should be advised to refrain from wearing their contacts and to have a formal evaluation by an ophthalmologist to rule-out serious infection.  Any antibacterial treatment in these patients should also cover for Pseudomonas.

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Treatment

 

With the exception of gonococcal conjunctivitis, all types are self-limiting and will improve on their own.  Having said that, bacterial conjunctivitis will improve faster with topical antibiotics.

 

Bacterial

• Erythromycin 5mg/gram ointment – 1cm ribbon 4x/day for 5-7 days
• Trimethoprim-polymyxin B 0.1%-10,000 units/mL – 1-2 drops 4x/day for 5-7 days
• Ciprofloxacin 0.3% – 1-2 drops 4x/day for 5-7 days

 

Viral and Allergic

• Antihistamine/decongestant drops
  • Pheniramine/naphazoline – 1-2 drops 4x/day
  • Olopatadine 0.2% – 1 drop daily
  • Azelastine 0.05% – 1 drop 2x/day

 

Non-Infectious/Non-Allergic

• Eye lubricants

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Return to Work/School Issues

 

The safest recommendation is to be out until there is no longer any discharge, but this is not practical since it could last for up to 2 weeks.

 

Viral

• I tell patients that you treat it like the common cold and practice good hand hygiene to limit the spread of any infectious drainage

Bacterial

• Most schools require 24 hours of therapy before children are allowed to return to school

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Cottage Physician

 

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References

1. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clinical therapeutics. 1995;17(5):800-10; discussion 779. [pubmed]
2. Ullman S, Roussel TJ, Culbertson WW. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. 1987; 94(5):525-31. [pubmed]
3. Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. American journal of ophthalmology. 1986; 102(5):575-83. [pubmed]
4. Azar MJ, Dhaliwal DK, Bower KS, Kowalski RP, Gordon YJ. Possible consequences of shaking hands with your patients with epidemic keratoconjunctivitis. American journal of ophthalmology. 1996; 121(6):711-2. [pubmed]
5. Roba LA, Kowalski RP, Gordon AT, Romanowski EG, Gordon YJ. Adenoviral ocular isolates demonstrate serotype-dependent differences in in vitro infectivity titers and clinical course. Cornea. 1995; 14(4):388-93. [pubmed]
6. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. The Cochrane database of systematic reviews. 2012; [pubmed]
7. Rose PW, Harnden A, Brueggemann AB. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet (London, England). ; 366(9479):37-43. [pubmed]