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Snapshot
  • A 24-year-old man presents to his primary care phyisician for discomfort and redness in his eyes. He notes these symptoms began 2 days prior to presentation and is associated with a "sandy" or "gritty" sensation in his eyes. He also notes some discharge that makes his eyes difficult to open in the morning. A few days ago, he developed a cough with fever and pharyngitis that was managed with tea, analgesics, and antipyretics. On physical exam, there is bilateral conjunctival injection with watery discharge. There is no evidence of pus. (Acute viral conjunctivitis)
Introduction
  • Overview
    • inflammation of the conjunctiva
Anatomy
  • Conjunctiva
    • transparent tissue that adheres to the anterior portion of the sclera and lines the eyelids
    • divided into 2 sections
      • bulbar conjunctiva
        • covers the sclera
      • tarsal conjunctiva
        • covers the inner eyelids
    • covers up to the limbus
 
Conjunctivitis
Type
Etiology
Pathophysiology Presentation Diagnosis Management
Bacterial conjunctivitis
  • Staphylococcus aureus
    • most common in adults
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Neisseria gonorrhoeae
    • associated with hyperacute bacterial conjunctivitis
      • this is a sight-treatening organism
  • Direct contact with an infected substance
  • Symptoms 
    • erythema
    • pruritus
    • the eye is "stuck shut" in the morning
  • Physical exam
    • purulent discharge 
      • the discharge is thick and globular
      • found on the lid margins and corners of the eye
  • Clinical diagnosis
  • Medical and pharmacologic 
    • topical erythromycin ointment or trimethoprim-polymyxin B drops
      • indication
        • first-line treatment for bacterial conjunctivitis
Hyperacute bacterial conjunctivitis
  • Neisseria gonorrhoeae
    • this is a sight-treatening organism
  • Microorganism is transmitted from the genitalia to the hands and then to the eyes
  • Symptoms
    • erythema
    • pruritus
  • Physical exam
    • profuse purulent discharge
    • tenderness to palpation of the eye
    • chemosis
    • eyelid swelling
    • periauricular adenopathy
    • patients commonly have a concomitant urethritis
  • Gram stain of the discharge demonstrating gram-negative diplococci
  • Medical and pharmacologic
    • topical and systemic antibiotics
      • indication
        • first-line treatment
Viral conjunctivitis
  • Adenovirus
    • most common cause
  • Direct contact with an infected substance
  • Symptoms 
    • sandy, burning, or gritty sensation in the eye
  • Physical exam 
    • watery or mucoserous discharge
    • patients may have a concomitant upper respiratory tract infection
  • Clinical diagnosis
  • Conservative and lifestyles
    • supportive management 
      • indication
        • initial management
          • viral conjunctivitis self-resolves

 

Allergic conjunctivitis 

  • Allergen
  • Airborne allergen interacts with IgE within the eye, leading to mast cell degranulation
  • Symptoms  
    • erythema
    • pruritus
  • Physical exam
    • watery or mucoserous discharge
  • Clinical diagnosis
  • Conservative and lifestyle
    • allergen avoidance
      • indication
        • recommended in all types of allergic reactions
  • Medical and pharmacologic
    • eye drops
      • indication
        • first-line treatment
      • medications
        • mast cell stabilizers
          • cromolyn
        • antihistamines 
          • olopatadine
          • alcaftadine
        • dual-action medications
          • pheniramine
          • naphazoline 
Vernal conjunctivitis 
  • Allergic response that occurs in response to allergens or seasonally
  • IgE and non-IgE mediated pathophysiology
  • Physical exam
    • papillae and pruritus in a seasonal pattern suggestive of vernal conjunctivitis
  • Clinical diagnosis

 

 

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(M2.OP.17.4868) A 22-year-old man presents to his primary care physician with itchy eyes. The patient recently moved to the northern US and states that he has experienced bilateral itching and watering of his eyes. He states that it is very distracting and is making it hard for him to work. The patient denies any recent sick contacts and lives alone. He works as a machinist and is currently struggling with his finances. The patient has a past medical history of asthma, and his current medications include albuterol, fluticasone, fish oil, and whey protein supplements. His temperature is 99.5°F (37.5°C), blood pressure is 100/65 mmHg, pulse is 60/min, respirations are 15/min, and oxygen saturation is 99% on room air. Cardiopulmonary exam is within normal limits. You notice the bilateral findings seen in Figure A. Otoscopy reveals bilateral clear tympanic membranes. The rest of the patient's physical exam is within normal limits. Which of the following is the most likely diagnosis? Tested Concept

QID: 109561
FIGURES:
1

Viral conjunctivitis

11%

(5/46)

2

Bacterial conjunctivitis

0%

(0/46)

3

Allergic conjunctivitis

85%

(39/46)

4

Corneal abrasion

2%

(1/46)

5

Foreign body

2%

(1/46)

M 6 C

Select Answer to see Preferred Response

(M3.PH.14.11) A 45-year-old truck driver complains of itchy eyes. He states his symptoms are worse when he goes outside and better when he takes a shower. His past medical history is significant for hypercholesterolemia, type II diabetes mellitus, and hypertension for which he takes atorvastatin, metformin, and lisinopril. His temperature is 98.1°F (36.7°C), blood pressure is 174/104 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man with the findings in Figure A which are seen in both eyes. Which of the following is the most appropriate next step in management? Tested Concept

QID: 102610
FIGURES:
1

Cetirizine

14%

(2/14)

2

Diphenhydramine

21%

(3/14)

3

Olopatadine

14%

(2/14)

4

Reassurance

0%

(0/14)

5

Topical erythromycin

50%

(7/14)

M 12 E

Select Answer to see Preferred Response

(M2.OP.14.3) A 6-year-old boy is brought to the pediatrician complaining of itchy eyes. The mother states that she has noted that he has been tearing and that both of his eyes have been red for the past 4 days. The patient denies any pain but has had a runny nose for the past week. The mother states that he has not had any sick contacts, and he has been home from school for summer vacation. She notices that his symptoms seem to improve in the evening after he showers. His temperature is 97.0°F (36.1°C), blood pressure is 100/66 mmHg, pulse is 90/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the most likely diagnosis?
Tested Concept

QID: 105369
FIGURES:
1

Allergic conjunctivitis

11%

(4/38)

2

Bacterial conjunctivitis

61%

(23/38)

3

Corneal abrasion

0%

(0/38)

4

Endophthalmitis

26%

(10/38)

5

Viral conjunctivitis

0%

(0/38)

M 6 E

Select Answer to see Preferred Response

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