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| Conjunctivitis |
| Classification and external resources |
An eye with conjunctivitis.
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| ICD-10 |
H10 |
| ICD-9 |
372.0 |
| DiseasesDB |
3067 |
| MedlinePlus |
001010 |
| eMedicine |
emerg/110 |
| MeSH |
D003231 |
Conjunctivitis (also called pink eye[1] or madras eye[2] in India) is inflammation of the conjunctiva (the outermost layer of the eye and the inner surface of the eyelids).[1] It is most commonly due to an infection (usually viral, but sometimes bacterial[3]) or an allergic reaction.
Contents
- 1 Classification
- 1.1 By cause
- 1.2 By extent of involvement
- 2 Signs and symptoms
- 2.1 Viral
- 2.2 Bacterial
- 2.3 Chemical
- 2.4 Other
- 3 Causes
- 4 Diagnosis
- 4.1 Differential diagnosis
- 5 Prevention
- 6 Management
- 6.1 Allergic
- 6.2 Bacterial
- 6.3 Viral
- 6.4 Chemical
- 7 History
- 8 See also
- 9 References
- 10 External links
Classification[edit]
Classification can be either by cause or by extent of the inflamed area.
By cause[edit]
- Allergic conjunctivitis
- Bacterial conjunctivitis
- Viral conjunctivitis
- Chemical conjunctivitis
- Neonatal conjunctivitis is often defined separately due to different organisms.
By extent of involvement[edit]
Blepharoconjunctivitis is the dual combination of conjunctivitis with blepharitis (inflammation of the eyelids).
Keratoconjunctivitis is the combination of conjunctivitis and keratitis (corneal inflammation).
Signs and symptoms[edit]
Eye with allergic conjunctivitis
An eye with bacterial conjunctivitis.
An eye with chlamydial conjunctivitis.
Red eye (hyperaemia), swelling of conjunctiva (chemosis) and watering (epiphora) of the eyes are symptoms common to all forms of conjunctivitis. However, the pupils should be normally reactive and the visual acuity normal.
Viral[edit]
Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold, and/or a sore throat. Its symptoms include excessive watering and itching. The infection usually begins with one eye, but may spread easily to the other.
Viral conjunctivitis, commonly known as pink eye, 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[edit]
Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and mucopurulent discharge. Typically, symptoms develop first in one eye, but may spread to the other eye within 2–5 days. Bacterial conjunctivitis due to common pyogenic (pus-producing) bacteria causes marked grittiness/irritation and a stringy, opaque, greyish or yellowish mucopurulent discharge that may cause the lids to stick together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may also occur, but, contrary to popular belief[citation needed], discharge is not essential to the diagnosis. 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.[citation needed]. Common bacteria responsible for non-acute bacterial conjunctivitis are Staphylococci and Streptococci.[4]
Bacteria such as Chlamydia trachomatis or Moraxella can cause a non-exudative but persistent conjunctivitis without much redness. Bacterial conjunctivitis may cause the production of membranes or pseudomembranes that cover the conjunctiva. Pseudomembranes consist of a combination of inflammatory cells and exudates, and are loosely adherent to the conjunctiva, while true membranes are more tightly adherent and cannot be easily peeled away. Cases of bacterial conjunctivitis that involve the production of membranes or pseudomembranes are associated with Neisseria gonorrhoeae, β-hemolytic streptococci, and C. diphtheriae. Corynebacterium diphtheriae causes membrane formation in conjunctiva of non immunized children.[citation needed]
Chemical[edit]
Chemical eye injury is due to either an acidic or alkali substance getting in the eye.[5] Alkalis are typically worse than acidic burns.[6] Mild burns will produce conjunctivitis while more severe burns may cause the cornea to turn white.[6] Litmus paper is an easy way to rule out the diagnosis by verifying that the pH is within the normal range of 7.0—7.2.[5] Large volumes of irrigation is the treatment of choice and should continue until the pH is 6—8.[6] Local anaesthetic eye drops can be used to decrease the pain.[6]
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[edit]
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.[7] However, it is usually self-healing.[7]
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[edit]
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.[8] 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 one of 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.[9]
The most common causes of acute bacterial conjunctivitis are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.[8] Though very rare, hyperacute cases are usually caused by Neisseria gonorrhoeae or N. meningitidis. Chronic cases of bacterial conjunctivitis are those lasting longer than 3 weeks, and are typically caused by Staphylococcus aureus, Moraxella lacunata, or gram-negative enteric flora.
Diagnosis[edit]
Cultures 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. 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.
Differential diagnosis[edit]
Conjunctivitis causes relatively nonspecific symptoms.[1] Even after biomicroscopy, 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) suggests a bacterial infection. It can also be caused by bacteria from feces, 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 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 biomicroscopy.
Scarring of the tarsal conjunctiva suggests trachoma, especially if seen in endemic areas, if the scarring is linear (Arlt's line), or if there is also corneal vascularization.
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 with 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.
Episcleritis is an inflammatory condition that produces a similar appearance to conjunctivitis, but without discharge or tearing.
Prevention[edit]
The best effective prevention is hygiene and not rubbing the eyes by infected hands. Vaccination against adenovirus, haemophilus influenzae, pneumococcus, and neisseria meningitidis is also effective.[citation needed]
Management[edit]
Conjunctivitis resolves in 65% of cases without treatment, within two to five days. The prescription of antibiotics is not necessary in most cases.[10]
Allergic[edit]
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, nonsteroidal anti-inflammatory medications and antihistamines may be prescribed. Persistent allergic conjunctivitis may also require topical steroid drops.
Bacterial[edit]
Bacterial conjunctivitis usually resolves without treatment. Antibiotics, eye drops, or ointment may only be needed if no improvement is observed after three days.[11] In people receiving no antibiotics, recovery was in 4.8 days, with immediate antibiotics it was 3.3 days, and with delayed antibiotics 3.9 days. No serious effects were noted either with or without treatment.[12] As they do speed healing in bacterial conjunctivitis, their use is also reasonable.[13]
When appropriate, the choice of antibiotic varies, differing based on the cause (if known) or the likely cause of the conjunctivitis. For acute cases, 3rd or 4th generation fluoroquinolones, sodium sulfacetamide, or trimethoprim/polymyxin may be used, typically for 7–10 days.[8] Cases of meningococcal conjunctivitis can be treated with systemic penicillin, as long as the strain is sensitive to penicillin.
The number of bacterial eye infections related to sexually transmitted disease is steadily rising. Chlamydial eye infections are the world's leading cause of blindness, and these cases will not resolve without antibiotics. If the conjunctivitis is known to be caused by gonorrhea, then it may be treated with a one-time injection of ceftriaxone, followed by 2–3 weeks of oral tetracycline or erythromycin.[citation needed]
Viral[edit]
In 2001, a stir was created when an ophthalmologist published anecdotal evidence that a brief povidone iodine eye wash in patients known to be suffering from viral conjunctivitis successfully helped to resolve the malady far faster than observation and supportive therapy alone.[14] Since that time, investigators have been evaluating the agent to officially validate its use in this regard as well as potentially expand its role in the management of ocular disease. In the Review of Optometry 2002 Clinical Guide to Ophthalmic Drugs, Melton and Thomas present an "off-label" use of Betadine 5% solution to treat viral conjunctivitis.[15]
However, in one study, though povidone iodine 1.25% ophthalmic solution was as effective as neomycin-polymyxin B-gramicidin for treating bacterial conjunctivitis and was somewhat more effective against Chlamydia, it was judged ineffective against viral conjunctivitis.[16]
In 2011, Derek Cunningham, O.D., of Dell Laser Consultants Austin, noted that almost all published studies on povidone-iodine to that date have been from animal models or conjunctival isolates from normal eyes, and that there is a lack of well-controlled studies on the clinical effects of povidone-iodine mono-treatment on infected eyes.[17]
The new treatment for viral eye infection involves a single treatment of Iodine solution (Betadine 2.5–5% concentration). After ocular anaesthetization, made necessary by the Iodine solution's irritating nature to the eye, a series of drops are instilled in the patient's eye.[18][unreliable medical source?] It is generally advisable to avoid touching the eyes or sharing towels and washcloths in the case of viral Conjunctivitis infection.
Because a topical anesthetic must be used, this should be an in-office procedure only, says Dr. Cunningham. Using Betadine as an at-home remedy could be dangerous for several reasons, especially because Betadine is a trade name for different solutions containing povidone-iodine, "Many commercially available [non-ophthalmic] preparations can contain detergents that are disruptive to tissue and can cause considerable cornea and conjunctiva damage," he says. "Time of exposure and possible adverse reactions need to be monitored [in office]."
Chemical[edit]
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. People with chemically induced conjunctivitis should not touch their eyes, regardless of whether or not their hands are clean, as they run the risk of spreading the condition to another eye.
History[edit]
A former superintendent of the Regional Institute of Ophthalmology in the city of Madras (the present-day Chennai) in India, Kirk Patrick, was the first to have found the adenovirus that caused conjunctivitis, leading to the name Madras eye for the disease.[19]
See also[edit]
References[edit]
- ^ a b c Richards A, Guzman-Cottrill JA (May 2010). "Conjunctivitis". Pediatr Rev 31 (5): 196–208. doi:10.1542/pir.31-5-196. PMID 20435711.
- ^ "Beware, 'Madras eye' is here!". The Hindu. 12 October 2001. Retrieved 30 October 2008.
- ^ Langley JM (July 2005). "Adenoviruses". Pediatr Rev 26 (7): 244–9. PMID 15994994.
- ^ "Pink Eye (Conjunctivitis)". MedicineNet.
- ^ a b Zentani A, Burslem J (December 2009). "Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: use of litmus paper in chemical eye injury". Emerg Med J 26 (12): 887. doi:10.1136/emj.2009.086124. PMID 19934140.
- ^ a b c d Hodge C, Lawless M (July 2008). "Ocular emergencies". Aust Fam Physician 37 (7): 506–9. PMID 18592066.
- ^ a b Fisher, Bruce; Harvey, Richard P.; Champe, Pamela C. (2007). Lippincott's Illustrated Reviews: Microbiology (Lippincott's Illustrated Reviews Series). Hagerstown MD: Lippincott Williams & Wilkins. ISBN 0-7817-8215-5.
- ^ a b c Yanoff, Myron; Duker, Jay S. (2008). Ophthalmology (3rd ed.). Edinburgh: Mosby. pp. 227–236. ISBN 978-0-323-05751-6.
- ^ Lévêque N, Huguet P, Norder H, Chomel JJ (April 2010). "[Enteroviruses responsible for acute hemorrhagic conjunctivitis]". Med Mal Infect (in French) 40 (4): 212–8. doi:10.1016/j.medmal.2009.09.006. PMID 19836177.
- ^ Rose P (August 2007). "Management strategies for acute infective conjunctivitis in primary care: a systematic review". Expert Opin Pharmacother 8 (12): 1903–21. doi:10.1517/14656566.8.12.1903. PMID 17696792.
- ^ Visscher, KL; Hutnik, CM; Thomas, M (November 2009). "Evidence-based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing.". Canadian family physician 55 (11): 1071–5. PMID 19910590.
- ^ Sheikh A, Hurwitz B (2006). "Antibiotics versus placebo for acute bacterial conjunctivitis". In Sheikh, Aziz. Cochrane Database Syst Rev (2): CD001211. doi:10.1002/14651858.CD001211.pub2. PMID 16625540.
- ^ Sheikh, A; Hurwitz, B; van Schayck, CP; McLean, S; Nurmatov, U (2012 Sep 12). "Antibiotics versus placebo for acute bacterial conjunctivitis.". Cochrane database of systematic reviews (Online) 9: CD001211. PMID 22972049.
- ^ Shovlin JP, Abel R (2001). "Steroids, povidone iodine recommended for adenoviral keratoconjunctivitis". Primary Care Optometry News 6 (6): 22–23.
- ^ Melton R, Thomas RK (2002). "2002 Clinical Guide to Ophthalmic Drugs". Review of Optometry 139 (6 Suppl): 40s.
- ^ Isenberg SJ, Apt L, Valenton M, et al. (November 2002). "A controlled trial of povidone-iodine to treat infectious conjunctivitis in children". Am. J. Ophthalmol. 134 (5): 681–8. PMID 12429243.
- ^ Shovlin JP (2011-09-15). "What's the Buzz About Betadine?". Review of Optometry.
- ^ "CONJUNCTIVITIS: Caused by Viruses". Theeyepractice.com.au. 2011-12-18. Retrieved 2012-12-01.
- ^ "Chennai's medical history unveiled". The Times of India (Chennai). 23 August 2011. Retrieved 16 September 2012.
External links[edit]
- Complete information on Conjunctivitis and its types. Conjunctivitis.Co
- Facts About the Cornea and Corneal Disease The National Eye Institute (NEI).
- Eye burning — itching and discharge. U.S. National Library of Medicine
- Conjunctivitis: Do antibiotics make a difference? U.S. National Library of Medicine
- Conjunctivitis Mayo Clinic website.
- Differentiating Viral and Bacterial conjunctivitis Medscape Article.
- Tarabishy AB, Jeng BH (July 2008). "Bacterial conjunctivitis: a review for internists". Cleve Clin J Med 75 (7): 507–12. PMID 18646586.
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Inflammation
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| Acute |
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Plasma derived mediators
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Bradykinin · complement (C3, C5a, MAC) · coagulation (Factor XII, Plasmin, Thrombin)
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Cell derived mediators
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preformed: Lysosome granules · vasoactive amines (Histamine, Serotonin)
synthesized on demand: cytokines (IFN-γ, IL-8, TNF-α, IL-1) · eicosanoids (Leukotriene B4, Prostaglandins) · Nitric oxide · Kinins
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| Chronic |
Macrophage · Epithelioid cell · Giant cell · Granuloma
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| Processes |
Traditional: Rubor · Calor · Tumor · Dolor (pain) · Functio laesa
Modern: Acute-phase reaction/Fever · Vasodilation · Increased vascular permeability · Exudate · Leukocyte extravasation · Chemotaxis
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Nervous
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CNS (Encephalitis, Myelitis) · Meningitis (Arachnoiditis) · PNS (Neuritis) · eye (Dacryoadenitis, Scleritis, Episcleritis, Keratitis, Choroiditis, Retinitis, Chorioretinitis, Blepharitis, Conjunctivitis, Uveitis) · ear (Otitis, Labyrinthitis, Mastoiditis)
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Carditis (Endocarditis, Myocarditis, Pericarditis) · Vasculitis (Arteritis, Phlebitis, Capillaritis)
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upper (Sinusitis, Rhinitis, Pharyngitis, Laryngitis) · lower (Tracheitis, Bronchitis, Bronchiolitis, Pneumonitis, Pleuritis) · Mediastinitis
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female: Oophoritis · Salpingitis · Endometritis · Parametritis · Cervicitis · Vaginitis · Vulvitis · Mastitis
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