Rosen & Barkin's 5-Minute Emergency Medicine Consult (172 page)

• General:
  
  • Red eye (conjunctival irritation)
    
  • Gritty, foreign body sensation
    
  • Sensation of eyes burning
    
  • Discharge
    
  • Eyelid sticking (worse upon awakening)
    
  • Conjunctival edema (chemosis) and eyelid edema
    
  • Itchy eyes
    
  • Increased tearing
    
• Bacterial:
  
  • Mucopurulent or purulent discharge
    
• Gonococcal:
  
  • Hyperacute, copious purulent discharge:
    
    • Discharge starts 12 hr after inoculation.
      
  • Severe chemosis
    
  • Eyelid swelling
    
  • Preauricular lymphadenopathy typically absent
    
  • Invades intact conjunctiva and cornea within 24 hr and causes ulcerations, scarring, and perforations leading to blindness
    
• Chlamydia:
  
  • Lacrimation
    
  • Mucopurulent discharge
    
  • With or without photophobia
    
  • Concomitant genital infection (>50%)
    
  • Transmission occurs via autoinoculation from genital secretions
    
• Viral—general:
  
  • Preauricular adenopathy
    
• Viral syndrome:
  
  • Watery, mucous discharge, lacrimation
    
  • Gritty feeling or foreign body sensation in eye
    
  • Spreads to other eye in 24–48 hr
    
  • Pinpoint subconjunctival hemorrhages:
    
    • Tarsal conjunctiva may have a bumpy appearance.
      
• EKC:
  
  • Conjunctival hyperemia
    
  • Chemosis
    
  • Corneal infiltrates
    
  • Decreased vision
    
• HSV:
  
  • Acute follicular conjunctival reaction
    
  • Skin lesions or vesicles along eyelid margin or periocular skin
    
  • Corneal involvement—dendritic lesion
    
• Herpes zoster virus (HZV):
  
  • Associated with pain or paresthesia of the skin
    
  • Rash or vesicles involving the distribution of cranial nerve V1
    
  • Dendritic characters on cornea
    
  • Rarely vesicles or ulcers form on the conjunctiva.
    
• Allergic:
  
  • Hallmark: Itching
    
  • Red conjunctiva
    
  • Watery discharge
    
  • Papillary hypertrophy
    
  • Frequent history of allergy, atopy, nasal symptoms
    
• Contact related:
  
  • Acute symptoms result of corneal ulceration
    
  • Normal visual acuity and intraocular pressures
    

• History for:
  
  • Onset of inflammation
    
  • Environmental or work-related exposure
    
  • Ill contacts
    
  • Sexual activity, discharge, rash
    
  • Use of over-the-counter medicines or cosmetics
    
  • Systemic diseases
    
• Careful physical exam including slit-lamp exam including fluorescein staining
  

• Bacteriologic studies:
  
  • Not indicated in routine cases
    
  • Indications:
    
    • Ophthalmia neonatorum (except chemical)
      
    • Suspected gonococcal ophthalmia
      
    • Compromised host
      
    • Signs and symptoms of systemic disease
      
    • Refractory to treatment within 48–72 hr (with good compliance)
      
• Positive Gram stain for gram-negative intracellular diplococci:
  
  • Sufficient to initiate systemic and topical treatment for gonococcal disease
    
• Rapid plasma reagent (RPR):
  
  • For suspected cases of sexually transmitted disease
    

• Acute angle-closure glaucoma (most serious cause)
  
• Allergies or hypersensitivity
  
• Anterior uveitis
  
• Corneal abrasion
  
• Dry eye
  
• Foreign body
  
• Keratitis
  
• Nasolacrimal obstruction
  
• Scleritis or episcleritis
  
• Subconjunctival hemorrhage
  

TREATMENT

• Initiate empiric antibiotic therapy with broad-spectrum topical agent.
  
• Systemic therapy for gonococcal, chlamydial, and meningococcal conjunctivitis, ophthalmia neonatorum, and all severe infections regardless of cause
  
• Manage herpetic eye infections in consultation with an ophthalmologist.
  

• Remove discharge from the eye(s):
  
  • Contact lens wearers should discontinue use and throw away affected contact lenses.
    
  • Contact lens wearers should discontinue use until:
    
    • Eye is white.
      
    • Antibiotic therapy is completed.
      
    • No discharge for 24 hr
      
  • Frequent handwashing
    
  • No sharing of towels, tissues, cosmetics, linens
    
  • Frequent warm soaks until lashes and eyes free of debris
    
• Bacterial conjunctivitis:
  
  • Antibiotics—topical:
    
  • Can use ointment or drops
    
  • Continue therapy for 48 hr after clearing of symptoms.
    
  • Discontinue therapy and obtain cultures if no improvement in 48–72 hr (with good compliance).
    
• Antibiotics—systemic:
  
  • Parenteral therapy mandatory for gonococcal infection
    
  • Chlamydia requires systemic treatment of sexual partners and parents of neonates.
    
• Viral conjunctivitis:
  
  • No specific antiviral therapy
    
  • Limited use of topical antihistamine or decongestant
    
• EKC may require steroids and should be prescribed in consult with ophthalmology.
  
• Allergic conjunctivitis (there may be a lag time of up to 2 wk for improvement with these agents):
  
  • Antihistamine or decongestant drops (naphazoline [Naphcon-A])
    
  • Mast cell stabilizer/antihistamine or NSAID ophthalmic drops as 2nd line
    
  • Artificial tears
    
• Noninfectious:
  
  • Eye lubricant drops or ointment
    
• Empiric treatment:
  
  • Topical antibiotic ointment or drops
    

• General:
  
  • All contact lens wearers require pseudomonal coverage.
    
  • Bacterial:
    
  • Bacitracin ophthalmologic ointment (no pseudomonal coverage)
    
  • Ciprofloxacin: 0.35% 1 drop q1–6h (has antipseudomonal properties; may be used in children)
    
  • Erythromycin: 0.5% ointment
    
  • Gentamicin: 0.3% ointment q3–4h or drops q1–4h (has antipseudomonal coverage)
    
  • Sulfacetamide: 10% 1 drop q1–6h (lacks pseudomonal coverage)
    
  • Tobramycin ointment
    
• Chlamydia:
  
  • Doxycycline: 100 mg PO BID for 3 wk
    
  • Erythromycin: 250–500 mg PO QID for 3 wk (peds: 50 mg/kg/d PO in 4 div. doses for 14 days)
    
  • Sulfisoxazole 500–1,000 mg QID for 3 wk
    
• Gonococcal:
  
  • Adults:
    
    • Ceftriaxone: 1 g IV or IM daily for 3–5 days or PRN
      
    • Erythromycin: 500 mg PO QID for 2–3 wk or doxycycline 100 mg PO BID for 2–3 wk
      
    • + topical antibiotics as above
      
  • Neonates:
    
    • Penicillin G 100,000 U/kg/d in 4 div. doses for 7 days or ceftriaxone 25–50 mg/kg/d IV for 7 days
      
• Viral:
  
  • Artificial tears
    
  • Naphcon-A or Visine AC 1 or 2 drops QID PRN for no more than 1 wk
    
• HSV or HZV:
  
  • Trifluorothymidine: 1% 5 times per day
    
  • Vidarabine: 3% ointment 5 times per day
    
• Allergic:
  
  • Naphazoline (Naphcon-A): 1 drop BID–QID or Visine AC
    
  • Acular: 1 or 2 drops BID
    
  • Cromolyn sodium 4% (Crolom): 1 drop QID
    
• Noninfectious and nonallergic:
  
  • Eye lubricant drops or ointment: Artificial tears or Lacri-Lube
    
• Empiric treatment:
  
  • Erythromycin ointment 0.5% (half in QID)
    
  • Sulfacetamide 10% ophthalmic drops (1 or 2 drops QID) for 5–7 days
    

• Often a manifestation of systemic disease in infants
  
• Conjunctivitis in the 1st 36 hr of life usually chemically induced caused by silver nitrate applied at birth.
  
• Neonates become infected during passage through the birth canal.
  
• Gonococcal, herpetic, chlamydial organisms most common
  
• Ophthalmia neonatorum is conjunctivitis within the 1st 4 wk of life.
  
• Chlamydia trachomatis is not eradicated by silver nitrate.
  
• Some newborns treated with erythromycin still develop conjunctivitis.
  
• Ointment is preferred over drops because of difficulty with administration of drops.
  

FOLLOW-UP

Known or suspected gonococcal infection (any age group)

Close follow-up for all cases

Diagnosis of EKC and bacterial conjunctivitis requires ophthalmology referral.

All patients with bacterial conjunctivitis require ophthalmology follow-up.

• Be sure to disinfect slit lamp and chair used for patients to avoid contamination.
  
• Conjunctivitis is extremely contagious.
  
• Viral conjunctivitis contagious for up to 2 wk.
  
• EKC is especially contagious.
  
• Extreme caution should be taken when using corticosteroids, as they may worsen an underlying HSV infection.
  

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