Conjunctivitis

for the 2008 film see Pink Eye (film)

Conjunctivitis
Classification and external resources
An eye with viral conjunctivitis.
ICD-10	H10.
ICD-9	372.0
DiseasesDB	3067
MedlinePlus	001010
eMedicine	emerg/110
MeSH	D003231

Conjunctivitis (also called "madras eye" in India^[1] or "pink eye") is an acute inflammation of the conjunctiva (the outermost layer of the eye and the inner surface of the eyelids), most commonly due to an allergic reaction or an infection (usually viral, but sometimes bacterial^[2]).

Classification

Classification can be either by cause or by extent of the inflamed area.

By cause

• Allergic conjunctivitis
• Bacterial conjunctivitis
• Viral conjunctivitis
• Chemical conjunctivitis
• Neonatal conjunctivitis is often defined separately due to different organisms

By extent of involvement

Blepharoconjunctivitis is the dual combination of conjunctivitis with blepharitis (inflammation of the eyelids).

Keratoconjunctivitis is the combination of conjunctivitis and keratitis (corneal inflammation).

Episcleritis is an inflammatory condition that produces a similar appearance to conjunctivitis, but without discharge or tearing.

Signs and symptoms

Eyes with conjunctivitis

An eye, red due to acute conjunctivitis.

An eye with bacterial conjunctivitis.

Redness (hyperaemia), irritation (chemosis) and watering (epiphora) of the eyes are symptoms common to all forms of conjunctivitis.

Acute Conjunctivitis

Acute conjunctivitis is typically caused by either an allergy, virus, or bacteria. Typically, it is associated with a red eye and discharge.

Allergic

Allergic conjunctivitis is typically itchy, sometimes distressingly so, and often involves some eye swelling. Chronic allergy often causes just itching or irritation.

Allergic conjunctivitis shows pale watery swelling or edema of the conjunctiva and sometimes the whole eyelid, often with a ropy, non-purulent mucoid discharge. There is variable redness.

Itching must be a primary symptom to make this diagnosis.

Viral

Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold, and/or a sore throat. Its symptoms include watery discharge and variable itch. The infection usually begins with one eye, but may spread easily to the other.

Viral conjunctivitis, commonly known as "pink eye,"^[3] shows a fine diffuse pinkness of the conjunctiva which is easily mistaken for the 'ciliary injection' of iritis, but there are usually corroborative signs on microscopy, particularly numerous lymphoid follicles on the tarsal conjunctiva, and sometimes a punctate keratitis.

Bacterial

Bacterial conjunctivitis due to the common pyogenic (pus-producing) bacteria causes marked grittiness/irritation and a stringy, opaque, grey or yellowish mucopurulent discharge (mucus, gowl, goop, gunk, googies, eye crust, or other regional names, officially known as 'gound') that may cause the lids to stick together (matting), especially after sleeping. Another symptom that could be caused by bacterial conjunctivitis is severe crusting of the infected eye and the surrounding skin. However discharge is not essential to the diagnosis, contrary to popular belief. Bacteria such as Chlamydia trachomatis or Moraxella can cause a non-exudative but persistent conjunctivitis without much redness. The gritty and/or scratchy feeling is sometimes localized enough for patients to insist they must have a foreign body in the eye. The more acute pyogenic infections can be painful. Like viral conjunctivitis, it usually affects only one eye but may spread easily to the other eye. However, it is dormant in the eye for three days before the patient shows signs of symptoms.

Pyogenic bacterial conjunctivitis shows an opaque purulent discharge, a very red eye, and on bio microscopy there are numerous white cells and desquamated epithelial cells seen in the tear duct along the lid margin. The tarsal conjunctiva is a velvety red and not particularly follicular. Non-pyogenic infections can show just mild infection and be difficult to diagnose. Scarring of the tarsal conjunctiva is occasionally seen in chronic infections, especially in trachoma.

Chemical

Irritant or toxic conjunctivitis is irritable or painful when the infected eye is pointed far down or far up. Discharge and itch are usually absent. This is the only group in which severe pain and discomfort may occur.

Irritant or toxic conjunctivitis show primarily marked redness. If due to splash injury, it is often present only in the lower conjunctival sac. With some chemicals, above all, with caustic alkalis such as sodium hydroxide—there may be necrosis of the conjunctiva with a deceptively white eye due to vascular closure, followed by sloughing of the dead epithelium. This is likely to be associated with slit-lamp evidence of anterior uveitis.

Other

Inclusion conjunctivitis of the newborn (ICN) is a conjunctivitis that may be caused by the bacteria Chlamydia trachomatis, and may lead to acute, purulent conjunctivitis.^[4] However, it is usually self-healing.^[4]

Conjunctivitis is identified by irritation and redness of the conjunctiva. Except in obvious pyogenic or toxic/chemical conjunctivitis, a slit lamp (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.

Causes

Conjunctivitis is most commonly caused by viral infection, but bacterial infections, allergies, other irritants and dryness are also common etiologies for its occurrence. Both bacterial and viral infections are contagious. Commonly, conjunctival infections are passed from person-to-person, but can also spread through contaminated objects or water.

The most common cause of viral conjunctivitis is adenoviruses . Herpetic keratoconjunctivitis (caused by herpes simplex viruses) can be serious and requires treatment with acyclovir. Acute Hemorrhagic Conjunctivitis is a highly contagious disease caused by two enteroviruses, Enterovirus 70 and Coxsackievirus A24. These were first identified in an outbreak in Ghana in 1969 and have spread worldwide since then, causing several epidemics.^[5]

Differential diagnosis

Conjunctivitis symptoms and signs are relatively non-specific. Even after bio microscopy, laboratory tests are often necessary if proof of etiology is needed.

A purulent discharge (a whitish-yellow, yellow or yellow-brown substance more commonly known as pus) strongly suggests a cause from fecal matter, unless there is known exposure to toxins. It can also be caused by bacteria from faeces, pet hair, or by smoke or other fumes. Infection with Neisseria gonorrhoeae should be suspected if the discharge is particularly thick and copious.

Itching (rubbing eyes) is the hallmark symptom of allergic conjunctivitis. Other symptoms include past history of eczema, or asthma.

A diffuse, less "injected" conjunctivitis (looking pink rather than red) suggests a viral cause, especially if numerous follicles are present on the lower tarsal conjunctiva on bio microscopy.

Scarring of the tarsal conjunctiva suggests trachoma, especially if seen in endemic areas, if the scarring is linear (von Arlt's line), or if there is also corneal vascularisation.

Clinical tests for lagophthalmos, dry eye (Schirmer test) and unstable tear film may help distinguish the various types of conjunctivitis.

Other symptoms including pain, blurring of vision and photophobia should not be prominent in conjunctivitis. Fluctuating blurring is common, due to tearing and mucoid discharge. Mild photophobia is common. However, if any of these symptoms are prominent, it is important to exclude other diseases such as glaucoma, uveitis, keratitis and even meningitis or caroticocavernous fistula.

Many people who have conjunctivitis have trouble opening their eyes in the morning because of the dried mucus on their eyelids. There is often excess mucus over the eye after sleeping for an extended period.

Diagnosis

These are done infrequently because most cases of conjunctivitis are treated empirically and (eventually) successfully, but often only after running the gamut of the common possibilities.

Swabs for bacterial culture are necessary if the history and signs suggest bacterial conjunctivitis, but there is no response to topical antibiotics. Research studies indicate that many bacteria implicated in low-grade conjunctivitis are not detected by the usual culture methods of medical microbiology labs, so negative results are common. Viral culture may be appropriate in epidemic case clusters. Conjunctival scrapes for cytology can be useful in detecting chlamydial and fungal infections, allergy and dysplasia, but are rarely done because of the cost and the general lack of laboratory staff experienced in handling ocular specimens. Conjunctival incisional biopsy is occasionally done when granulomatous diseases (e.g., sarcoidosis) or dysplasia are suspected.

Management

Conjunctivitis resolves in 65% of cases without treatment, within 2 – 5 days. The prescribing of antibiotics to most cases is not necessary.^[6]

Allergic

For the allergic type, cool water poured over the face with the head inclined downward constricts capillaries, and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, non-steroidal anti-inflammatory medications and antihistamines may be prescribed. Persistent allergic conjunctivitis may also require topical steroid drops.

Bacterial

Bacterial conjunctivitis usually resolves without treatment. Antibiotics, eye drops, or ointment are thus only needed if no improvement is observed after 3 days.^[7] In patients receiving no antibiotics recovery was in 4.8 days, immediate antibiotics 3.3 days, delayed antibiotics 3.9 days. No serious effects were noted either with or without treatment.^[8][9]

Viral

Although there is no specific treatment for viral conjunctivitis, symptomatic relief may be achieved with cold compresses^[10] and artificial tears. People are often advised to avoid touching their eyes or sharing towels and washcloths.

Chemical

Conjunctivitis due to chemicals is treated via irrigation with Ringer's lactate or saline solution. Chemical injuries (particularly alkali burns) are medical emergencies as they can lead to severe scarring, and intraocular damage.

References

External links

• Facts About the Cornea and Corneal Disease The National Eye Institute (NEI).
• Conjunctivitis Mayo Clinic website.
• Comparison of symptoms of Conjunctivitis versus Orbital Cellulitis Medical notes and photographs of a real patient experience.
• Differentiating Viral and Bacterial conjunctivitis Medscape Article