N. gonorrhea is one of the most severe and feared causes of are considered equally effective for prophylaxis of ocular gonorrhea infection. is directed at correcting the underlying problems.8,9 Systemic diseases such as gonorrhea or atopy may also cause conjunctival inflammation. According to the Public Health Agency of Canada (PHAC), the incidence of gonorrhea has more than doubled, from approximately 15 cases per , in.
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To examine the diagnosis, management, and treatment of conjunctivitis, including various antibiotics and alternatives to antibiotic use in infectious conjunctivitis and use of antihistamines and mast cell stabilizers in allergic conjunctivitis. Eligible articles were selected after review of titles, abstracts, and references.
Viral conjunctivitis is the most common overall cause of infectious conjunctivitis and usually does not require treatment; the signs and symptoms at presentation are variable. Bacterial conjunctivitis is the second most common cause gonoore infectious conjunctivitis, with most uncomplicated cases resolving in 1 to 2 weeks.
Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are the strongest factors associated with bacterial conjunctivitis.
Topical antibiotics decrease the duration of bacterial conjunctivitis and allow earlier gobore to school or work. Conjunctivitis secondary to sexually transmitted diseases such as chlamydia and gonorrhea requires systemic treatment in addition to topical antibiotic therapy.
The majority of cases in bacterial conjunctivitis are self-limiting and no treatment is necessary kobjungtivitis uncomplicated cases. However, conjunctivitis caused by gonorrhea or chlamydia and conjunctivitis in contact lens wearers should be treated with antibiotics. Treatment for viral conjunctivitis is supportive. Treatment with antihistamines gonpre mast cell stabilizers alleviates the symptoms of allergic conjunctivitis. Conjunctiva is a thin, translucent membrane lining the anterior part of the sclera and inside of the eyelids.
It has 2 parts, bulbar and palpebral. The konjungtivitks portion begins at the edge of the cornea and covers the visible part of the sclera; the palpebral part lines the inside of the eyelids Figure 1. Inflammation or infection of the conjunctiva is known as conjunctivitis and is characterized by gonoer of the conjunctival vessels, resulting in hyperemia and edema of the conjunctiva, typically with associated discharge.
The conjunctiva is a thin membrane covering the sclera bulbar conjunctiva, labeled with purple and the inside of the eyelids palpebral conjunctiva, labeled with blue. Conjunctivitis affects many people and imposes economic and social burdens. It is estimated that acute conjunctivitis affects 6 million people annually in the United States. A majority of conjunctivitis patients are initially treated by primary care physicians rather than eye care professionals. Viral conjunctivitis is the most common cause of infectious conjunctivitis both overall and in the adult population 7 – 13 and is more prevalent in summer.
Conjunctivitis can be divided into infectious and noninfectious causes. Viruses and bacteria are the most common infectious causes. Noninfectious conjunctivitis includes allergic, toxic, and cicatricial konjunbtivitis, as well as inflammation secondary to immune-mediated diseases and neoplastic processes. It is important to differentiate conjunctivitis from other sight-threatening eye diseases that have similar clinical presentation and to make appropriate decisions about further testing, treatment, or referral.
An algorithmic approach Figure 2 using a focused konjungticitis history along with a penlight eye examination may be helpful in diagnosis and treatment.
The following keywords were used: No language restriction was applied. Articles published between March and March were initially screened. After review of titles, abstracts, text, and references for the articles, more were identified and screened.
Articles and meta-analyses that provided evidence-based information about the cause, management, and treatment of various types of conjunctivitis were selected. A total of 86 articles were included in this review.
The first study 8 was published in and the last 19 in A level of evidence was assigned to the recommendations presented in Table 2 and Table 3 with the American Heart Association grading system: An intermediate weight B is assigned if there are a limited number of randomized trials with small numbers of patients, careful analyses of non-randomized studies, or observational registries.
The lowest rank of evidence C is assigned when expert consensus is the primary basis for the recommendation. Focused ocular examination and history are crucial for making appropriate decisions about the treatment and management of any konuungtivitis condition, including conjunctivitis.
Eye discharge type and ocular symptoms can be used to determine the cause of the conjunctivitis. A, Bacterial conjunctivitis characterized by mucopurulent discharge and conjunctival hyperemia. B, Severe purulent discharge seen in hyperacute bacterial conjunctivitis secondary to gonorrhea.
C, Intensely hyperemic response with thin, watery discharge characteristic of viral conjunctivitis. Images reproduced with permission: However, the clinical presentation is often nonspecific. Relying on konjumgtivitis type of discharge and patient symptoms does not always lead to an accurate diagnosis. Furthermore, scientific evidence correlating conjunctivitis signs and symptoms with the underlying cause is often lacking.
Ina large meta-analysis failed to find any clinical studies correlating the signs and symptoms of conjunctivitis with the underlying cause 61 ; later, the same authors conducted a prospective study 61 and found that a combination of 3 signs—bilateral mattering of the eyelids, lack of itching, and no history of conjunctivitis—strongly predicted bacterial conjunctivitis.
Having both eyes matter and the lids adhere in the morning was a stronger predictor for positive bacterial culture result, and either itching or a previous episode of conjunctivitis made a positive bacterial culture result less likely. Although in the primary care setting an ocular examination is often limited because of lack of a slitlamp, useful information may be obtained with a simple penlight.
The eye examination should focus on the assessment of the visual acuity, type of discharge, cor-neal opacity, shape and size of the pupil, eyelid swelling, and presence of proptosis. Obtaining conjunctival cultures is generally reserved for cases of suspected infectious neonatal conjunctivitis, recurrent conjunctivitis, conjunctivitis recalcitrant to therapy, conjunctivitis presenting with severe purulent discharge, and cases suspicious for gonococcal or chlamydial infection. Thirty-six percent of conjunctivitis cases are due to adenoviruses, and one study estimated that in-office rapid antigen testing could prevent 1.
Although no effective treatment exists, artificial tears, topical antihistamines, or cold compresses may be useful in alleviating some of the symptoms Table 2. Herpes simplex virus comprises 1. The discharge is thin and watery, and accompanying vesicular eyelid lesions may be present. Topical and oral antivirals are recommended Table 2 to shorten the course of the disease. Herpes zoster virus, responsible for shingles, can involve ocular tissue, especially if the first and second branches of the trigeminal nerve are involved.
Treatment usually consists of a combination of oral antivirals and topical steroids. The incidence of bacterial conjunctivitis was estimated to be in 10 in one study. In addition, certain conditions such as compromised tear production, disruption of the natural epithelial barrier, abnormality of adnexal structures, trauma, and immunosup-pressed status predispose to bacterial conjunctivitis.
Hyperacute bacterial conjunctivitis presents with a severe copious purulent discharge and decreased vision Figure 3. There is often accompanying eyelid swelling, eye pain on palpation, and preauricular adenopathy. It is often caused by Neisseria gonorrhoeae and carries a high risk for corneal involvement and subsequent corneal perforation.
Chronic bacterial conjunctivitis is used to describe any conjunctivitis lasting more than 4 weeks, with Staphylococcus aureusMoraxellalacunataand enteric bacteria being the most common causes in this setting 62 ; ophthalmologic consultation should be sought for management. Signs and symptoms include red eye, purulent or mucopurulent discharge, and chemosis Figure 3. A patient wearing contact lenses should be asked to immediately remove them. No serious sight-threatening out comes were reported in any of the placebo groups.
Topical antibiotics seem to be more effective in patients who have positive bacterial culture results. In a large systemic review, they were found to be effective at konjungtjvitis both the clinical and micro-biological cure rate in the group of patients with culture-proven bacterial conjunctivitis, whereas only an improved microbial cure rate was observed in the group of patients with clinically suspected bacterial conjunctivitis.
All broad-spectrum antibiotic eyedrops seem in general to be effective in treating gonlre conjunctivitis. There are no significant differences in achieving clinical cure between any of the broad-spectrum topical antibiotics. Konjhngtivitis that influence antibiotic choice are local availability, patient allergies, resistance pat terns, and cost. Initial therapy for acute nonsevere bacterial conjunctivitis is listed in Table 2.
Tonore our knowledge, no studies have been conducted to evaluate the efficacy of ocular decongestant, topical saline, or warm compresses for treating bacterial conjunctivitis. In conclusion, benefits of antibiotic treatment include quicker recovery, decrease in transmissibility, 49 and early return to school. Therefore, no treatment, a wait-and-see policy, and immediate treatment all appear to be reasonable approaches in cases of uncomplicated conjunctivitis.
Antibiotic therapy should be considered in cases of purulent or mucopurulent konjuntgivitis and for patients who have distinct discomfort, who wear contact lenses, 1418 who are immunocompromised, and who have suspected chlamydial and gonococcal conjunctivitis. It is estimated that 1. Discharge is often purulent or mucopurulent.
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No data support the use of topical antibiotic therapy in addition to systemic treatment. Conjunctivitis caused by N gonorrhoeae is a frequent source of hyperacute conjunctivas in neonates and sexually active adults and young adolescents. Neisseria gonorrhoeae is associated with a high risk of cor-neal perforation. Trachoma is caused by Chlamydia trachomatis subtypes A through C and is the leading cause of blindness, affecting 40 million people worldwide in areas with poor hygiene.
Late complications such as scarring of the eyelid, conjunctiva, and cornea may lead to loss of vision. Patients may also be treated with topical antibiotic ointments for 6 weeks ie, tetracycline or erythromycin. Systemic antibiotics other than azithromycin, such as tetracycline or erythromycin for 3 weeks, may be used alternatively. Treatment consists of avoidance of the offending antigen 52 and use of saline solution or artificial tears to physically dilute and remove the allergens.
In a large systemic review, both antihistamines and mast cell stabilizers were superior to placebo in reducing the symptoms of allergic conjunctivitis; researchers also found that antihistamines were superior to mast cell stabilizers in providing short-term benefits. Topical steroids are associated with formation of cataract and can cause an increase in eye pressure, leading to glaucoma. A variety of topical medications such as antibiotic eyedrops, topical antiviral medications, and lubricating eyedrops can induce allergic conjunctival responses largely because of the presence of benzalkonium chloride in eye drop preparations.
Therefore, the above causes should be considered in patients presenting with conjunctivitis. For example, patients with low-grade carotid cavernous fistula can present with chronic conjunctivitis recalcitrant to medical therapy, which, if left untreated, can lead to death.
As recommended by the American Academy of Ophthalmology, 16 patients with conjunctivitis who are evaluated by nonophthalmologist health care practitioners should be referred promptly to an ophthalmologist if any of the following develops: In addition, the following patients should be considered for referral: Patients should be referred to an ophthalmologist if there is no improvement after 1 week.
Steroid drops or combination drops containing steroids should not be used routinely. Steroids can increase the latency of the adeno-viruses, the refore prolonging the course of viral conjunctivitis.
In addition, if an undiagnosed corneal ulcer secondary to herpes, bacteria, or fungus is present, steroids can worsen the condition, leading to corneal melt and blindness. Nonherpetic viral conjunctivitis followed by bacterial conjunctivitis is the most common cause for infectious conjunctivitis.
Physicians must be vigilant to not overlook sight-threatening conditions with similarities to conjunctivitis, as summarized in Table 1. Role of the Sponsor: