#37 – Conjunctivitis



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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”).


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

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

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

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

Distinguishing Between The Types

 


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.


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

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

Cottage Physician

 


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]

Ep-PAINE-nym



Ishihara Test

 

Other Known AliasesPseudo-isochromatic plates

DefinitionTest for detecting color blindness using different color dots to outline numbers

Ishihara 9.png

Clinical SignificanceAllows for quick assessment of color blindness using different styles plates (a full test is 38 plates) and even differentiate between different types of color blindness.  Research has proven that a score of 12 out of 14 red/green plates indicates normal color vision with a sensitivity of 97% and a specificity of 100%.

History – Named after Shinobu Ishihara (1879-1963), who developed these while working as a military surgeon for the Japanese army during World War I as a better way of assessing color blindness in troops.  He first published these findings in 1917 in Japan and it was first translated and reviewed in the American Journal of Ophthalmology in June 1918 extolling its usefulness.


 


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Ishihara S.  Tests for Color Blindness.  AJO. 1918;1(6):457 [article]
  6. Ishihara S.  Tests for Color Blindness.  1972 [book]
  7. http://www.eyemagazine.com/feature/article/ishihara

PAINE #PANCE Pearl – HEENT



Question

 

What do you expect to find on Weber and Rinne tests in sensorineural hearing loss (SSNHL)?

 



Answer

 

Both of these tests are easy bedside maneuvers to perform in the early evaluation of hearing loss and only require a 256 Hz tuning fork.  The main thing to remember is that in the Rinne test, air conduction is supposed to be greater than bone conduction….but because the problem with SSNHL is the conversion of sound waves to neural impulses, AC will still be greater than BC because the sound waves can still travel through the canal uninhibited.  So AC>BC can be both normal and abnormal, which is why it always done in tandem with the Weber to help figure out which side is affected.

Ep-PAINE-nym



Epstein’s Pearls

 

Other Known Aliasesnone

DefinitionSmall, fluid filled cysts on the hard palate of newborns that are most commonly found along the median palatal raphae.

Image result for epstein's pearls

 

Clinical SignificanceNone.  These are completely normal and occur in 65-80% of newborns.  The are formed by epithelium that becomes trapped during palatal development.

Image result for epstein's pearls

 

History – Named after Alois Epstein (1849-1918), who was a Czechoslovakian pediatrician, graduating from the University of Prague in 1873.  His career was highlighted by becoming the first physician-in-chief for the University of Prague hospital in 1873 and being appointed to professor at the University of Prague in 1884.  He first described these findings in 1880.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Lewis DM. Bohn’s nodules, Epstein’s pearls, and gingival cysts of the newborn: a new etiology and classification. Journal – Oklahoma Dental Association. ; 101(3):32-3. [pubmed]
  6. Singh RK, Kumar R, Pandey RK, Singh K. Dental lamina cysts in a newborn infant. BMJ case reports. 2012; 2012:. [pubmed]
  7. Epstein A. Ueber die Gelbsucht bei Neugeborenen Kindern. Leipsic. 1880. [book]

PAINE #PANCE Pearl – HEENT



For HEENT block, lets talk a little about about hearing loss:

 

Ep-PAINE-nym



Tullio’s Phenomenon

 

Other Known AliasesSound-induced vestibular activation.

Definition – Vertigo, dizziness, nausea, and nystagmus caused by a load noise.

Clinical Significance This pathology is due to a communication between the middle and inner ear classically associated with congenital syphilis.  Recently, it has been associated with superior canal dehiscence syndrome (SCDS).  This can also be elicited with nose-blowing, valsalva, and heavy lifting.

History – Named after Italian biologist Pietro Tullio, Ph.D. (1881-1941), who originally studied this finding in pigeons and published it in 1929. 

Tullio blowing a whistle in the ear of rabbit test subject


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com/
  5. Tullio, Pietro: Das Ohr und die Entstehung der Sprache und Schrift. Berlin, Germany: Urban & Schwarzenberg; 1929.
  6. Kaski D, Davies R, Luxon L, Bronstein AM, Rudge P. The Tullio phenomenon: a neurologically neglected presentation. Journal of Neurology. 2012; 259(1):4-21. [pubmed]
  7. Halmagyi GM, Curthoys IS, Colebatch JG, Aw ST. Vestibular responses to sound. Annals of the New York Academy of Sciences. 2005; 1039:54-67. [pubmed]

Ep-PAINE-nym



Argyll Robertson Pupils

 

Other Known Aliases – Prostitute’s Pupil

Definition – Small, bilateral pupils with an absence of miotic reaction to light, both direct and consensual, with preservation of miotic reaction to near stimulus.  In other words, they accommodate, but do not react light (light-near dissociation).

Clinical Significance Classically associated with tabes dorsalis of neurosyphylis, but can also be seen in diabetic neuropathy.  Rare now due to the widespread of antibiotics and treating early syphilis infections

History – Named after Douglas Moray Cooper Lamb Argyll Robertson (1837-1909), who was a Scottish surgeon and ophthalmologist and one of the first to specialize in the eye.  He published his findings of several case reports in two articles in the “Edinburgh Medical Journal” in 1869.  Previous to this however, he was also the first to discover and use the extract of the Calabar bean (otherwise known as physostigmine) for treatment of various eye disorders.

“Dougie”, as his friends called him****


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com/
  5. Robertson DA. On an interesting series of eye symptoms in a case of spinal disease, with remarks on the action of belladonna on the iris. Edinb Med J. 1869;14:696–708.
  6. Robertson DA. Four cases of spinal myosis with remarks on the action of light on the pupil. Edinb Med J. 1869;15:487–493
  7. Robertson, D. A.:  On the Calabar Bean as a New Agent in Ophthalmic Medicine.  Edinb Med J. 1863;93:815-820.

****I have no source for this but he looks like a Dougie….plus with a name like Douglas Moray Cooper Lamb Argyll Robertson, you have to have a nickname, right?