Conjunctivitis: Differential Diagnosis

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Mervin May
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1 Conjunctivitis: Differential Diagnosis Signs/ Symptoms Hyperemia Discharge Allergic Mild-tomoderate Ropy, mucoid Bacterial Hyperacute Bacterial Viral Moderate Severe Mild-to-moderate Mucopurulent, awakening glued eyes Copious, thick, purulent Watery (may be thicker upon arising) Pain No Mild-to-moderate Severe Mild to none Itching Yes Mild Mild Some Vision change None usually Blurry Diminished Possible Eye involvement Bilateral Starts unilateral, with second eye involvement Starts unilateral, with second eye involvement Bilateral with less severe second eye involvement 1 American Academy of Ophthalmology. Accessed February 18, 2014; American Optometric Association. Accessed February 18, 2014; Cronau H, et al. Am Fam Physician. 2010;81:

2 Conjunctivitis Can Mask Conditions Requiring Urgent or Emergent Referral Conditions for Referral Within 48 Hours Acute anterior uveitis Canaliculitis Dacryocystitis Scleritis Pain, photophobia Pain, swelling, discharge from punctum Pain, swelling, redness over lacrimal sac Conditions for Immediate Referral Acute angle-closure glaucoma Foreign body in eye Keratitis Thyroid-related eye disease Cellulitis Deep pain that can awaken patient Pain, watering, halos around lights, headache, nausea, vomiting Pain, irritation, watering Pain, photophobia, watering, blurred vision Burning, watering, foreign body sensation, double vision, decreased vision Eyelid swelling, redness, tenderness Uveitis Keratitis 2 Photos courtesy of Stephen E. Orlin, MD. American Optometric Association. Accessed February 18, 2014; Galor A, et al. Cleve Clin J Med. 2008;75:

3 Checklist for Evaluation of Conjunctivitis: Patient History Category General health Ask the Patient About: Atopy, autoimmune diseases, dermatologic conditions, diabetes, STD, thyroid disease, recent URTI Ocular Social Medications Family Prior episodes of conjunctivitis, exposure to infected person, eye trauma, contact lens use, surgery Environmental exposures, sexual history (if appropriate) Use of agents with ocular effects (eg, anticholinergics, corticosteroids, tamoxifen, thioridazine, topical vasoconstrictors, vincristine) Current or past episodes of conjunctivitis, infections, autoimmune diseases, acute angle-closure glaucoma 3 STD = sexually transmitted disease; URTI = upper respiratory tract infection. Cronau H, et al. Am Fam Physician. 2010;81: ; Galor A, et al. Cleve Clin J Med. 2008;75:

4 Checklist for Evaluation of Conjunctivitis: Symptom Characterization and Eye Examination Characterize symptoms Perform basic eye examination Palpate preauricular lymph nodes Itching Burning Tearing Pain Foreign body sensation Visual acuity Eyelids, lacrimal sac Cornea Lymphadenopathy Photophobia Unilateral or bilateral Acute onset or chronic Progressive or stable Purulent, mucous, serous, or mixed discharge Pupil size, symmetry, reactivity Hyperemia pattern, location 4 American Academy of Ophthalmology. Accessed February 18, 2014; American Optometric Association. Accessed February 18, 2014; Cronau H, et al. Am Fam Physician. 2010;81: ; Galor A, et al. Cleve Clin J Med. 2008;75:

5 Red Flags for Ophthalmologic Referral Moderate or severe pain a Diminished visual acuity Severe mucopurulent discharge Firm eye palpation Blood or pus in anterior chamber Corneal involvement Trauma Photophobia Worsening of condition after 3 days of topical therapy Unreactive or irregularly shaped pupil Proptosis Reduced ocular motility Nausea, vomiting Headache 5 a Patients with corneal abrasion may present with severe pain but can be treated by a primary care clinician. American Optometric Association. Accessed February 18, 2014; Cronau H, et al. Am Fam Physician. 2010;81: ; Galor A, et al. Cleve Clin J Med. 2008;75:

6 Allergic Conjunctivitis: Subtypes and Clinical Manifestations Type Causes Signs Symptoms Hyperemia Atopic keratoconjunctivitis Atopic dermatitis Chemotic bulbar conjunctiva Seasonal/ perennial Vernal Giant papillary Ragweed, pollen, dust, mold spores Dry, warm climates Bilateral seasonal Contact lens, ocular prostheses Exposed sutures Seasonal/recurrent Mild hyperemia Chemosis Mixed papillae, follicles Conjunctival scraping shows eosinophils Acute/chronic, giant papillae Painless tearing Intense itching Redness Tearing Mucoid discharge Itching Burning Photophobia Contact lens intolerance Mucous discharge 6 American Academy of Ophthalmology. Accessed February 18, 2014; American Optometric Association. Accessed February 18, 2014; Cronau H, et al. Am Fam Physician. 2010;81:

7 Allergic Conjunctivitis: Treatment Options Nonpharmacologic Identification of allergen or irritant; counseling on avoidance Supportive care: unpreserved lubricants and cold compresses Pharmacologic Class H 1 receptor antagonist Mast cell stabilizer Mast cell stabilizer plus H 1 receptor antagonist Vasoconstrictor/ antihistamine NSAID (topical) Agents Emedastine, levocabastine Cromolyn, lodoxamide, nedocromil, pemirolast Alcaftadine 0.25%, bepotastine 1.5%, ketotifen 0.025%, olopatadine 0.2% or 0.1% Naphazoline/antazoline, naphazoline/pheniramine Ketorolac 7 NSAID = nonsteroidal anti-inflammatory drug. American Academy of Ophthalmology. Accessed February 18, 2014; American Optometric Association. Accessed February 18, 2014; Butcher JM, et al. BMJ. 1994;309:43; Cronau H, et al. Am Fam Physician. 2010;81:

8 Bacterial Conjunctivitis: Pathogens Pathogen Chlamydia trachomatis Coagulase-negative staphylococci Haemophilus influenzae Neisseria gonorrhoeae Staphylococcus aureus Streptococcus pneumoniae Patients Affected Neonates, children (suspect sexual abuse), sexually active adolescents and adults Adults Neonates, children, adults Neonates (rare), sexually active adolescents and adults Neonates, children, adults Neonates, children, adults 8 American Academy of Ophthalmology. Accessed February 18, 2014; American Optometric Association. Accessed February 18, 2014; Cronau H, et al. Am Fam Physician. 2010;81: ; Tarabishy AB, et al. Cleve Clin J Med. 2008;75:

9 Cataracts: Risk Factors Age Corticosteroid use Diabetes mellitus Heredity Race Smoking Sunlight exposure 9 Cumming RG, et al. N Engl J Med. 1997;337:8-14; Goldzweig CL, et al. JAMA. 2004;291: ; Hodge WG, et al. Epidemiol Rev. 1995;17: ; Rowe S, et al. JAMA. 2004;291: ; Weintraub JM, et al. Am J Epidemiol. 2002;155:72-79; West SK, et al. Surv Ophthalmol. 1995;39:

10 Components of Age-Related Cataracts by Affected Anatomic Location Cortical spoking Posterior subcapsular haze Nuclear sclerosis 10 Illustration courtesy of the National Eye Institute, National Institutes of Health.

11 Age-Related Cataracts: Common Signs and Symptoms Nuclear cataract Cortical cataract Posterior subcapsular cataract Clouds central portion of the lens Affects distance vision more than near vision Dulls colors and whites Progresses slowly Extends from lens rim to central core as spoke-like opacities Does not degrade vision substantially but may cause glare Clouds back surface of the lens Tends to cause disabling glare in bright sunlight or from street lights or automobile headlights at night, even if it degrades visual acuity only slightly Associated with corticosteroid use Tends to progress more quickly than a nuclear cataract 11 Jacobs DS. Accessed February 18, 2014.

Eye Trauma: Incidence

Ocular Emergencies and Trauma Stuart Fourman, MD Director, Glaucoma Center Department of Ophthalmology Stony Brook University Eye Trauma: Incidence 1.3 million eye injuries per year in the United States.