Appendix C: Overview of Diagnosis and Treatment of Conjunctivitis

Diagnosis:

Type	Picture/Description	Severity of Sx	Onset	D/C	Later- ality	Pre-auricular lymphadenopathy	Itching	Other
Hyperacute bacterial		Severe	less than 24 hrs	Purulent	U/L	+ (if gonococcal)	-	N.gonorrhea or meningitidis
Acute bacterial		Mild-Moderate	Days-Weeks	Muco- purulent	U/L	-	-	Many bacterial species: Strep pneumo, H. flu, Staph aureus
Chronic bacterial		Mild	Weeks-Months	Scant	May be B/L	-	-	Freq due to Staph aureus, Proteus, Staph epi. Staph aureus results in inflammation of the eyelids as well as the conjunctiva (blepharoconjunctivitis). Sticky, mucoid D/C/flakes along base of eyelashes
Herpes Simplex		Mild-Moderate	Days	Watery	U/L	+	-	May have eyelid herpetic vesicles
Acute Hemorrhagic			Acute	Muco-purulent	U/L or B/L			Conjunctival hemorrhages. Caused by enterovirus or coxsackievirus
Other Viral (at right: adenoviral)		Mild-Moderate	Days	Watery	Starts U/L => B/L	+	+	Often recent exposure to someone with "pink eye"
Adult inclusion (eg, via Chlamydia)		Mild-Moderate	Weeks	Scant mucopurulent	U/L	+	-	STD due to Chlamydia trachomatis. Usually seen in pts w/ chlamydial urethritis or cervicitis.
Trachoma		May be severe	Days to weeks	Muco-purulent	May be B/L	-	-	Assoc'd w/ poor hygiene. Leading cause of blindness in world
Allergic		Mild-Moderate	Weeks	Ropy	B/L	-	+	Exposure to environmental allergen
Dry Eye		Mild-Moderate	Variable	Watery	May be B/L	-	-	Common in post-menopausal women
Toxic		Mild-Moderate	Variable	Watery	May be B/L	-	-	Use of ocular medications
Pediculosis	Infestation of the eyelashes with pubic lice.	Mild	Days to Weeks	None	May be B/L	-	-	Nits visible at eyelash base
Vernal Kerato-conjunctivitis				Thick, Ropy	B/L		+	Seasonal allergic disorder. Usually chidlren and young adults. Pt may also complain of tearing, mild light sensitivity and foreign body sensation

Treatment:

Cause	Picture/Description	Tx
Hyperacute bacterial		Ophthalmic emergency - prompt referral to ophthalmologist - Copious irrigation - systemic and topical ABx
Acute bacterial		Topical Abx: Mild cases, can empirically treat (don't yet need Gram stain) trimethoprim-polymyxin B solution (Polytrim) or sulfacetamide 10% QID for 7-10 days. Should re-evaluate (1-3 d) should improve in 48 hrs, if not, do a gram stain
Chronic bacterial		Topical Abx: If blepharoconjunctivitis (usually Staph aureus): topical bacitracin QID for 7-10 days else Trimethoprim-polymyxin B solution (Polytrim) or Bacitracin-polymyxin B QID for 7-10 days. Should re-evaluate if no improvement in 1-2 wks, refer to ophthalmologist
Herpes Simplex		Referral to an ophthalmologist is a good idea. Herpes Simplex: topical antiviral such as Viroptic (trifluorothymidine). Varicella-Zoster: systemic anti-viral therapy such as acyclovir/famciclovir. Never topical steroids. That can lead to rapid destruction of the cornea.
Acute Hemorrhagic		Same as for adenoviral.
Other Viral (at right: adenoviral)		Sx may persist up to 3 wks. Good hand washing, do not touch eyes, avoid sharing towels/soap, wash sheets, towels, and pillowcases. Cool compresses QID may help w/ sx (Cidofovir is a topical antiviral eye drop that may be available in the future)
Adult inclusion (eg, via Chlamydia)		Same as for the STD: oral tetracycline, coxycycline or erythromycin for 3 weeks or 1 gm of azithromycin. Also concurrent topical therapy of erythromycin, tetracycline or sulfacetamide ointment BID-TID for 2-3 wks.
Trachoma
Allergic		Topical vasoconstrictor and/or antihistamine combination such as naphazoline 0.05% or antazoline (Albalon-A, Vasocon-A) 0.5% Oral antihistamine Topical cromolyn sodium (Opticom) 2%,4% QID starting 2 weeks before the season.
Dry Eye		Primary or Secondary (eg, RA or Sjogren's syndrome). Sx relief via artificial tears. May need to recommend preservative-free solutions if sensitivity develops. If moderate/severe, punctal occlusion may be necessary.
Pediculosis	Infestation of the eyelashes with pubic lice.	Mechanical removal and smothering of parasites with any bland ophthalmic ointment (eg, erythromycin) TID for 10 days
Vernal Kerato-conjunctivitis		Seasonal allergic disorder.

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