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Acute conjunctivitis
Clinical Lecturer in General Practice, Primary Medical Care, School of Medicine, University of Southampton, UK
E-mail: hae1{at}soton.ac.uk
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Abstract |
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Acute conjunctivitis is common. About 2–5% of general practice consultations are related to eye conditions and approximately 40% of these are concerned with conjunctivitis. Thus, on average, a full-time general practitioner sees a patient with conjunctivitis every week. The most common presentation is with a red eye. The main tasks are to exclude potentially serious causes of a red eye and then decide whether the conjunctivitis is infective, allergic or due to other causes so that suitable management can be initiated.
The GP curriculum statement 15.5 outlines GPs roles and responsibilities in eye problems. It states that GPs in training must:
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Definition |
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The conjunctiva is a thin flexible epithelial layer that covers the inner surface of the eyelids and anterior sclera. It contributes to the tear film with the production of mucus and acts together with its secretions to form a barrier to foreign matter and infection. It is sterile at birth but is rapidly colonized by bacteria. Conjunctivitis is inflammation of the conjunctiva indicated by conjunctival injection and oedema.
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Aetiology |
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Conjunctivitis is the commonest eye problem seen in general practice. It may present at any age but infective conjunctivitis is most common in preschool children. It affects both sexes and all races. The Morbidity Statistics for General Practice: Fourth National Study 1991–92 gave a prevalence for conjunctivitis (infective and allergic) of 396 per 10 000 person years at risk. This is a 39% increase on the level of 284 per 10 000 found in the 1981–82 study.
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Assessment |
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Take a history—concurrent viral illness symptoms, a past medical history of hay fever, atopy or allergies, exposure to chemicals, recent surgery or a potential foreign body can help make the diagnosis. Enquire about previous eye problems (some important differential diagnoses, e.g. iritis may be recurrent). Ask about current symptoms including vision, pain, itch, photophobia and eye discharge. Examine the eye by undertaking a careful inspection with a good light and stain with fluorescein if there is any indication that a foreign body or corneal damage may be present. Check visual acuity, pupil reactions and eye movements.
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Symptoms and signs |
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In conjunctivitis, the eye may be red with surface irritation, discharge (may be clear, mucoid or mucopurulent), sticking of eyelids (especially on waking) and enlarged papillae under the upper eyelid. There may also be preauricular lymph node enlargement. Visual acuity should not be affected (once any discharge has been cleared away) and if vision is affected, other causes of red eye should be considered. See Box 1.
Box 1. Signs of a potentially dangerous red eye
Refer for a specialist opinion on the same day as these signs may indicate serious conditions such as keratitis, iritis or orbital cellulitis.
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Differential diagnosis of conjunctivitis |
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The main types of conjunctivitis are: infective conjunctivitis (including ophthalmia neonatorum), allergic conjunctivitis or chemical conjunctivitis.
Infective conjunctivitis
Symptoms and signs
Acute infective conjunctivitis usually presents with acute onset of a vague foreign body sensation or a surface irritation in the eye/eyes accompanied by tear production. It may start in one eye and then affect both. There is no severe or deep pain in the eye but there may be itching. Conjunctival injection causes the appearance of a red eye and conjunctival oedema and mild eyelid swelling may occur. Mucopurulent discharge may accumulate in the nasal palpebral fissure and on the eyelid margins. The discharge can accumulate while sleeping and the eye lids be stuck together upon awakening. There should be no significant photophobia and visual acuity should be normal once any discharge has been wiped away.
Aetiology
Infective conjunctivitis may be bacterial or viral. It is likely that at least 50% of acute infective conjunctivitis presenting to general practice is viral in origin. Clinically, it is difficult to distinguish between bacterial and viral conjunctivitis. In textbooks, a variety of signs and symptoms are proposed as potential discriminators between viral and bacterial conjunctivitis but their usefulness is uncertain. For instance, it has been suggested that unilateral infection followed a few days later by involvement of the other eye, watery eye discharge and/or the presence of a periauricular lymph node may indicate a viral cause, whereas involvement of the second eye within 24–48 hours, purulent eye discharge and/or a papillary or pseudomembraneous conjunctivitis may be suggestive of a bacterial infection. However, there has been little scientific evidence behind these assertions and in research studies, consultant ophthalmologists can correctly identify a bacterial versus viral aetiology 50% of the time.
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Viral conjunctivitis is most commonly caused by an adenovirus or picornavirus infection. It often presents concurrently with upper respiratory tract symptoms but may also cause epidemics of conjunctivitis especially in school-aged children.
Bacterial conjunctivitis is most often caused by Streptococcus pneumoniae, Haemophilus influenzae or Staphylococcus aureus. Haemophilus influenzae is the most common organism in children.
Chronic infective conjunctivitis (ongoing infection for greater than 4 weeks) is most commonly caused by S. aureus because of its ability to establish and maintain growth on the eyelid and in the associated glands. Long-term infection can result in eyelid disorders such as trichiasis, hordeola and chalazia.
Natural history
Acute bacterial conjunctivitis is commonly a self-limiting condition. A Cochrane systematic review of the literature on topical antibiotics for acute bacterial conjunctivitis showed that clinical remission occurs in 64% (99% CI 54– 73%) of microbiologically confirmed cases of bacterial conjunctivitis treated with placebo by days 2–5.
Viral conjunctivitis is also self-limiting but has a more uncertain course. It may be transitory with an upper respiratory tract infection or last several weeks.
Management
Traditionally, acute infective conjunctivitis has been treated with topical antibiotics, most commonly chloramphenicol eye drops or fusidic acid (Fucithalmic) in the UK. However, with increasing concerns regarding antibiotic resistance and encouragement of patients to manage minor self-limiting conditions, this has been questioned in recent years. A number of research studies have been undertaken to assess the potential benefit of topical antibiotics. The Cochrane review showed a small improvement in symptom severity and duration with topical antibiotics but this needs to be balanced against the time and effort for patients in gaining and attending a general practice appointment, administering the drops (especially problematic in young children) and the potential side effects of topical antibiotics (sensitivity reactions to the drops are quite common).
Topical chloramphenicol used to be a prescription-only medicine but has recently been made available over the counter for those over 2 years old. Thus, patients can directly access treatment via a pharmacist if they wish. This may reduce the number of GP consultations for acute infective conjunctivitis but may have implications for antibiotic resistance. The British Pharmacological Society's Practice Guidance for Pharmacists on OTC chloramphenicol can be accessed at: www.rpsgb.org.uk/pdfs/otcchlorampheneyedropsguid.pdf.
A pragmatic approach to the management of those that present to general practice may be to advise bathing of the eyes to remove any discharge and consider a delayed prescription of antibiotic eye drops (e.g. chloramphenicol, two drops four times a day for 5 days) for the patient to start after 3 days if symptoms are not improving. This approach encourages discussion of the natural history of conjunctivitis and allows time for cases to settle without treatment, but avoids the need for the patient to reattend if symptoms are not improving. It has the potential to reduce the amount of antibiotics used and reduce medicalization of patients (i.e. they may feel more able to self-care for conjunctivitis and not seek medical help for this self-limiting condition). Various patient advice leaflets are available on the Internet (e.g. at: www.patient.co.uk).
Patients should be advised that if symptoms are not settling by day 7 or there is visual disturbance, significant eye lid swelling or pain in the eye, they should seek further medical advice (refer to ophthalmology if any potentially serious signs; see Box 1). If symptoms are ongoing, reassess to exclude other diagnoses. An eye swab may help exclude a bacterial cause.
Ophthalmia neonatorum
Ophthalmia neonatorum is a bacterial eye infection seen in neonates, usually within a few days of birth. It presents as a purulent discharge from the eyes of an infant less than 21days old (see Fig. 2). It may be caused by Escherichia coli, S. aureus and H. influenzae but the most virulent form is caused but Neisseria gonorrhoea. It can cause extensive infection and damage to the eye with the potential for secondary meningitis, cellulitis and septicaemia. Swabs should be sent for microscopy and culture and the infant referred for an ophthalmology opinion. Treatment is usually with topical antibiotics.
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Allergic conjunctivitis
Allergic conjunctivitis can often be distinguished from infective conjunctivitis by the presence of severe itching, allergen exposure (e.g. pollen) and a marked seasonal variation. It is useful to take a history for atopy, family history of atopy and past allergies and exposures.
Symptoms and signs
Bilateral symptoms appear seasonally (e.g. hay fever) or on contact with an allergen (e.g. animal fur). The main symptoms are red, watery, itchy eyes. There may also be mild photophobia. Examination may reveal follicles in the lower tarsal conjunctiva and ‘cobblestones’ under the upper lid (see Fig. 3). Related symptoms may include an itchy runny nose.
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Aetiology
Allergic conjunctivitis is mediated primarily by type 1 hypersensitivity reactions and may be seasonal, perennial or atopic.
Seasonal allergic conjunctivitis is most commonly caused by pollen in the hay fever season. Grass pollens are the most important cause of hay fever in the UK, with a season lasting from May to August, with peaks in June and July. Tree pollens, other pollens and fungal spores can also be responsible for symptoms, and these may present as early as January and as late as September. Pollen counts (particularly grass pollen) may vary greatly from day to day and information on current counts is published (e.g. on the BBC website).
Perennial conjunctivitis lasts all year and house dust mite allergy is the main cause.
Atopic conjunctivitis is related to allergy, for example to cosmetics, animals or chemicals.
Management
Treatment is similar for all types of allergic conjunctivitis.
First-line treatment is to try and avoid exposure:
- Wearing glasses when outside and keeping windows closed to avoid pollen exposure and avoiding known allergens, e.g. recently cut grass, animal fur or smoke
- Pollen counts vary according to the weather and they are often reported with weather forecasts
- House dust mite can be reduced by restricting the amount of soft furnishing in houses (e.g. carpets, curtains and soft toys) and by protective bed mattress and pillow covers, regular vacuuming and high-temperature laundering of sheets. However, the practicality of maintaining this type of regime means that it often only has a marginal effect on symptoms.
Medication
Topical antihistamines (e.g. sodium cromoglycate eye drops) can be beneficial and can be used in combination with systemic antihistamines (e.g. loratadine) if required.
Topical steroids should be avoided due to potential long-term complications (e.g. cataract, glaucoma and fungal infection) and should only be prescribed under the supervision of an ophthalmologist.
Intramuscular steroids (e.g. triamcinolone) are not recommended for routine management of hay fever but may be of use in exceptional circumstances, for example during exams or when getting married if other treatments fail to adequately control symptoms.
Allergy testing may be useful to help advise patients on allergen avoidance when the cause is not clear. Standard tests include those for house dust mite, grass and tree pollen and pet allergens. These can be done in general practice but are most commonly undertaken in hospital-based allergy clinics. Testing may involve skin prick tests and/or the measurement of specific IgE antibodies in blood.
Immunotherapy has had some success for hay fever sufferers but availability is variable across the country.
Chemical irritation
Conjunctivitis caused by chemical irritation usually has a history of exposure to a noxious substance. Many substances can cause chemical irritation to the eye, for example household cleaning products, alkalis and contact lens solutions. It usually presents with symptoms similar to allergic conjunctivitis.
If a known exposure occurs, the eye should be washed with copious amounts of clean water and the patient reviewed in eye casualty.
Giant papillary conjunctivitis is associated with chronic contact lens wear with sensitivity to lens and cleaning agents (Fig. 4). Advise to stop contact lens use and refer urgently to ophthalmology.
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Differential diagnosis of a red eye |
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Foreign body in the eye is commonly unilateral and often has a clear history, although this may not be the case in young children. It should always be considered as a differential diagnosis in unilateral red eye. Fluorescein should be instilled into the eye and a careful inspection made—including everting the eyelids.
Blepharitis is an inflammation of the lid margins that causes chronically irritable red eyes. Eyelids have red margins and there may be scales on the eyelashes, a burning sensation on the lids and concurrent conjunctivitis.
Orbital cellulitis is an infection of the tissues of the orbit and is usually due to spread of infection from the paranasal sinuses. Signs include fever, eyelid swelling, proptosis and unwillingness to move the eye but it can start with subtle signs similar to acute infective conjunctivitis. If orbital cellulitis is suspected, refer immediately for an ophthalmology opinion. Treatment is with intravenous antibiotics. Complications include meningitis, cavernous sinus thrombosis and blindness.
Subconjunctival haemorrhage is a spontaneous painless localized haemorrhage. It is common in the elderly and often recurrent. It looks alarming but clears spontaneously in 1–2 weeks. It may be associated with high blood pressure, clotting disorders and increased venous pressure. Consider referral if it follows trauma—especially if the posterior edge of the haemorrhage cannot be seen as it may be associated with orbital haematoma, penetrating injury or orbital or basal skull fracture.
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Ophthalmic shingles is caused by zoster in the ophthalmic branch of the trigeminal nerve. Symptoms include pain, tingling or numbness around the eye which precedes a blistering rash and inflammation. In 50%, the eye is affected with conjunctivitis, scleritis, episcleritis, iritis, keratitis, visual loss and/or visual nerve palsy. Nose tip involvement makes eye involvement likely (nerve supply is the same as the globe). Prescribe oral aciclovir (800 mg 5 times a day) and refer immediately to ophthalmology.
Episcleritis is inflammation of the episclera. It presents with a dull ache in the eye. Examination reveals tenderness of the inflamed area, a bluish tint to the sclera and engorged vessels. If suspected, patients should be referred to ophthalmology. Treatment is with steroid drops.
Scleritis is a generalized inflammation of the eye, conjunctival oedema and scleral thinning (globe perforation is a complication). It is associated with connective tissue disorders. Refer urgently to ophthalmology. Patients may need oral steroids.
Iritis (anterior uveitis) is indicated by acute onset of pain, photophobia, blurred vision, watering, circumcorneal redness, small or irregular pupil and there may be a hypopyon (anterior chamber pus). Pain increases as eyes converge and pupils constrict. It is most commonly seen in young and middle-aged adults and may be associated with ankylosing spondylitis or inflammatory bowel disease. If suspected, refer urgently to ophthalmology. Treatment is with steroid drops to reduce the inflammation and mydriatics to dilate the pupil and prevent adhesions. Relapses are common.
Acute glaucoma may present with severe eye pain and decreased vision with coloured haloes around lights. Examination shows a fixed, mid-dilated pupil and cloudy cornea.
Dry eye (sicca) syndrome causes eye irritation and redness due to reduced tear secretion or mucin deficiency in the tears. It is more common with increasing age. Symptoms can be helped with artificial tears.
Corneal abrasion/ulceration can cause severe pain, photophobia, watering eye and blurred vision. Conjunctival defects show up green when examining with a blue light after staining the eye with fluorescein. Refer all but the most minor abrasions for an ophthalmology opinion.
Arc eye is found when the eyes are exposed to bright light without adequate protection. It can cause severe pain, watering and blepharospasm. The eye needs padding and analgesics should be given—refer if not better after 24 hours.
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| Patient information Patient UK, website: www.patient.co.uk, Information sheets on infective, allergic conjunctivitis and ophthalmia neonatorum. Good Hope NHS Hospital, Eye Department website: www.goodhope.org.uk/departments/eyedept, Information on allergic conjunctivitis. BBC pollen index, website: www.bbc.co.uk/weather/pollen. AllergyUK, website: www.allergyuk.org, Tel: 01322 619898.
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| Key points Acute conjunctivitis is:
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References |
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TOPAbstractThe GP curriculum and...DefinitionAetiologyAssessmentSymptoms and signsDifferential diagnosis of...Differential diagnosis of a...References |
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British Society for Allergy and Clinical Immunology. Accessed via www.bsaci.org.
Everitt H, Little P, Smith P. A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. British Medical Journal (2006) 333:321. DOI: 10.1136/bmj.38891.551088.7C.
McCormick A, Fleming D, Charlton J. Morbidity statistics from general practice. Fourth national study, 1991–2 (1995) London: HMSO. Accessed via www.statistics.gov.uk/downloads/theme_health/MB5No3.pdf [date last accessed 02.09.2008].
Newsome R, Everitt H, Simon C. Oxford General Practice Library: ENT and ophthalmology. Oxford: Oxford University Press. (in press).
RCGP. Curriculum statement 15.5: Eye problems. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_15_5_Eye_problems.pdf [date last accessed 08.01.2009].
Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: Cochrane systematic review and meta-analysis update. British Journal of General Practice (2005) 55(521):962–964.[Web of Science][Medline]
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