Intensity of injection around the periphery suggests conjunctival inflammation whereas injection around the cornea suggests corneal or intra-ocular inflammation.
History of contact with other with conjunctivitis – especially if young children at home!
Often bilateral
Infective causes:
Bacteria – more purulent discharge where eyelids may stick together
Viruses – adenovirus is very infectious, small lymphoid aggregates appear as follicles on conjunctiva, pre-auricular lymph node enlargement
Chlamydia – young adults or newborns (opthalmia neonatorium is caused by bacteria in the birth canal and must be treated immediately to preserve eyesight)
Infective causes typically accompanied by a purulent discharge (but not always)
Bacterial conjunctivitis may have more copious amounts of discharge, and viral conjunctivitis tends to have a watery as opposed to bacterial discharge
Most cases are viral – usually adenovirus. Consider herpes zoster virus and herpes simplex virus
Allergy
Very itchy and often watery
Vision is normal or very mildly reduced
Acuity will always improve with pinhole
Treatment depends on the cause: allergic conjunctivitis may respond to antihistamines or self resolve when the allergen is removed, antibiotics clear bacterial conjunctivitis, and viral conjunctivitis will disappear on its own.
Many bacterial cases will not require antibiotics
Advise patients to wash the eye frequently with either cool boiled water or saline, using cotton wool balls to wipe the eye once before disposing. I advise patients to do this whenever any discharge is present – and to do 5 wipes – with 5 individual cotton wool balls. This can be a lot of wiping!
Advised about hygiene measures to reduce the risk of transmission – frequent hand washing at home, avoid sharing of towels and pillows, consider disinfecting surfaces around the house
Patients with allergic conjunctivitis may also benefit from lubricating eye drops
If marked decrease in visual acuity (<6/9 with pinhole) or photophobia – consider ophthalmology assessment within 24 hours (could represent scleritis or iritis)
Corneal Abrasion
This occurs when the surface epithelium is sloughed off – usually due to trauma
Pain, foreign body sensation, tearing, red eye
Variable reduction in vision
Stains with fluorescein
Treatment: Analgesia (paracetamol or ibuprofen), Prevention of secondary infection with tetanus prophylaxis and a topical antibiotic for 7 days (chloramphenicol or fusidic acid)
Exclude a foreign body which may be trapped under the inside of the upper eyelid. (Invert the upper eyelid over a cotton bud or orange stick.)
Chemical:Alkali injuries are worse than acid – seconds count
Ulceration with keratitis (inflammation of the cornea) is known as ulcerative keratitis and must be treated as an emergency to prevent permanent scarring or visual loss.
Anterior uveitis (iritis)
Inflammation of the anterior uvea, comprising the coloured iris and ciliary body.
Photophobia, circumcorneal redness (due to ciliary congestion), acute pain, lacrimation, decreased vision (due to precipitates in the aqueous), small pupil (due to iris spasms and adhesions) Most commonly idiopathic.
The pain is often significant and feels like a “deep burning pain” in the eye. Associated with systemic diseases:
The exudate in the cornea seen in anterior uveitis – known as hypopyon. Image from wikipedia
The pupil is often smaller than the unaffected side, and may be irregular due to adhesions.
Initial management
Refer urgently to ophthalmology – call you local on-call ophthalmology service
Steroid eyedrops are often recommended but you MUST ensure you have the diagnosis right, because they can precipitate or worsen glaucoma, cause cataracts and lead to infections such as a keratitis – and all of these potential complications are sight threatening
Do NOT start steroid eye drops without the consent and advice of an ophthalmologist
Episcleritis
Superficial irritation and inflammation of the episclera, a thin layer of tissue covering the sclera of the eye.
Idiopathic, collagen vascular disorder (Rheumatoid Arthritis). It occurs without an infection.
Asymptomatic, mild pain
Self-limiting without treatment within 1-2 weeks or topical corticosteroid eye drops may relieve the symptoms faster. Rarely, scleritis may develop.
Scleritis
Inflammation of the sclera causes a severely deep boring pain that wakes the patient at night, lacrimation, photophobia Causes:
Systemic treatment with NSAIDs (or oral Prednisolone if severe)
Corticosteroid eye drops/ oral corticosteroids help reduce the inflammation. Consider investigating for or treating the underlying cause to prevent recurrence.
Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio
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