​Kembara Xtra - Medicine - Acute Conjunctivitis

​Kembara Xtra - Medicine - Acute Conjunctivitis 
Inflammation of the bulbar and/or palpebral conjunctiva that has lasted for less than four weeks; the nerve and skin/exocrine systems are both impacted; the condition is commonly referred to as pink eye.

Considerations Regarding the Aged
Investigate the possibility of a bacterial, autoimmune, or irritative process.  If the infection is purulent, the likelihood that it was caused by bacteria rises with age, residence in a long-term care facility, age over 65 years, and bilateral lid adhesion. There is a greater than 70% chance of bacterial infection.

Considerations Relating to Children
Neonatal conjunctivitis could be caused by gonococcus, chlamydia, irritation, or it could be associated with dacryocystitis.
Study conducted in a pediatric emergency room; 78% of samples had a positive bacterial culture, most of which were Haemophilus influenzae; 13% of samples showed no growth; other investigations found that more than 50% of samples were adenovirus.
Despite the lack of proof, daycare standards may require a kid with suspected conjunctivitis to be treated with a topical antibiotic before returning. This is especially true for children between the ages of 5 and 7, who are more likely to have bacterial involvement than older patients.


EPIDEMIOLOGY ● Predominant age – Pediatric: viral, bacterial – Adult: viral, bacterial, allergic ● Predominant sex: male = female
1–2% of ambulatory office visits and up to 3% of emergency room visits are affected.

Causes and effects: etiology and pathophysiology 
Viral: Adenovirus (which causes the common cold), Coxsackievirus (which has been linked to recent outbreaks of hemorrhagic conjunctivitis in Asia and the Middle East). — Infection with enterovirus, which causes acute hemorrhagic conjunctivitis
- Herpes simplex; herpes zoster or varicella
- Measles, mumps, or influenza
– COVID-19
Bacterial: Staphylococcus aureus, MRSA, or Staphylococcus epidermidis; Streptococcus pneumoniae; and Haemophilus influenzae (children);
- Pseudomonas spp. or anaerobes (contact lens users) – Acanthamoeba in contact lens solution (very rare; fewer than 30 instances reported annually in the US).
– Neisseria gonorrhoeae – Chlamydia trachomatis: slow onset between one and four weeks Allergic – Hay fever, seasonal allergies, atopy Nonspecific – Irritative: topical medicines, wind, dry eye, UV light exposure, smoke, chlorine Irritating: – Autoimmune: Sjogren syndrome, pemphigoid, Wegener granulomatosis, Reiter syndrome, sarcoid Rickettsia, fungal, and parasite infections, TB, syphilis, Kawasaki illness, chikungunya, Graves disease, gout, carcinoid, psoriasis, Stevens-Johnson syndrome, molluscum contagiosum, rosacea, and squamous neoplasia are examples of diseases that are extremely uncommon.

History of contact with infected individuals Sexually transmitted disease (STD) contact: gonococcal, chlamydial, syphilis, or herpes Contact lenses: pseudomonal or acanthamoeba keratitis Epidemic bacterial (streptococcal) conjunctivitis reported in school settings, epidemic adenoviral transmission in crowded settings Risk factors History of contact with infected individuals Sexually transmitted disease (STD

Prevention 

Always be sure to wash your hands.
The eyedropper technique involves placing several drops over the nasal canthus while the eye is closed and the head is tilted back. After this, the eyes are opened so that the liquid can enter. Never contact the tip of the dropper to your skin or your eye.
Adults between the ages of 50 and 70 should get vaccinated against herpes zoster (shingles) to prevent getting the disease.

Conditions that may be associated with it include: a viral infection (like the cold), and the possibility of a sexually transmitted infection.


Diagnosis Caution 

Warning sign: a decrease in visual acuity is not consistent with conjunctivitis by itself; normal vision must be documented for the diagnosis of true isolated conjunctivitis.
Viral: contact or travel May start with one eye and later both If herpetic: recurrences or vesicles on skin Bacterial: difficult to identify from viral because of similarities in symptoms. Assume the patient is infected with germs unless the culture results come back negative. When a recent STD is present, chlamydia or gonococcal infection should be suspected. Residents of nursing homes may get MRSA conjunctivitis; therefore, they ought to have their eyes cultured.
Allergic reactions include hives, atopy, seasonal allergies, and dander 
Irritative: feels dry, exposure to wind, tear-film deficit may persist 30 days after acute conjunctivitis, chemicals such as chlorine from pools or drug: atropine, aminoglycosides, iodide, phenylephrine, antivirals, bisphosphonates, retinoids, topiramate, chamomile, COX-2 inhibitors, immune modulators. Allergic: atropine, aminoglycoside 
Redness may continue to appear even 24 hours after the removal of the foreign body.

The Patient's Clinical Examination 
General: red eye and conjunctival injection are symptoms that are present in all forms of conjunctivitis
- Foreign body sensation
- Eyelids that are crusty or stick together, discharge from the eye
- Visual acuity and pupillary responsiveness that are both normal
Viral: Symptoms of a "cold" in the upper respiratory tract and preauricular lymphadenopathy may be present.
- Epidemics of hemorrhagic coxsackievirus and adenoviral diseases observed in health care facilities and in the community - A serious viral illness, such as herpes simplex or zoster:
– Burning sensation, rarely itching – Unilateral, dermatomal distribution herpetic skin vesicles in zoster – Palpable preauricular node – Bacterial (non-STD): may be epidemic – Mild pruritus, discharge mild to heavy – Conjunctival chemosis/edema – If contact lens user, must rule out pseudomonal (or other bacterial) keratitis. Obtain a culture to rule out MRSA if the patient is a resident of a long-term care facility.
Bacterial: gonococcal (or meningococcal) hyperacute infection – Rapid onset 12 to 24 hours – Severe purulent discharge – Chemosis/conjunctival/eyelid edema – Rapid growth of superior corneal ulceration – Preauricular adenopathy – Signs of STDs (chlamydia, GC, HIV, etc.) – Rapid growth of superior corneal ulceration
Allergic: Itching is the major symptom, chemosis and edema are present
– Allergies caused by the changing of the seasons or by animal dander Nonspecific irritative – Dry eyes, intermittent redness, chemical or drug exposure – Foreign body: may have redness and discharge 24 hours after removal Must document normal visual acuity Cornea should be clear and without fluorescein absorption in the corneal tissue.
Keratitis is indicated by a cloudy or ulcerated cornea; an ophthalmologist should be consulted.
It is suggested that you get a fluorescein stain exam. Turn the top upside down and look inside for any foreign objects.
Check the skin for herpetic vesicles, nits on the lashes (which are caused by lice), scaliness (which is caused by seborrhea), and lid inflammation (which can be caused by blepharitis, rosacea, or styes).
Flushing of the limbus at the corneal border of uveitis 
If the pupil is irregular (for example, if there is a foreign body piercing the eye), an urgent referral is required.
Blepharitis is diagnosed when there is discharge on the lid edge but there is no conjunctival injection.


Differential Diagnosis Punctate keratitis as a result of prolonged contact lens wear Phlyctenular conjunctivitis: localized nodules with hyperemia as a result of the immunological response to Staphylococcus and TB in the eye
Uveitis, also known as iritis, iridocyclitis, and choroiditis, is characterized by decreased visual acuity, a hazy anterior chamber, and a limbal flush (a red band at the corneal edge). Acute glaucoma, often known as an emergency, is characterized by headaches, corneal clouding, and poor vision. 
Dacryocystitis: soreness and swelling above the tear sac (behind the medial canthus). Corneal ulcer, keratitis, or foreign body: lesions or tear-film deficits on fluorescein exam. 
scleritis and episcleritis are characterized by red injected vessels that are radially orientated, sectoral (pie wedge), and nodularity of the sclera. 
Inflammation of a yellow nodular or wedge-shaped area of chronic conjunctival degeneration (pinguecula) is known as pingueculitis. 
Ophthalmia neonatorum: affecting neonates within the first two days of life (gonococcal; 5 to 12 days of life): chlamydial, herpes simplex virus (HSV). 
Blepharitis is an inflammation of the lid margins that might cause itching, scaling, or discharge but does not include conjunctival injection.

Results From the Laboratory 

 In most cases, this step is not required initially for the most prevalent causes; however, if COVID-19 is associated to the pandemic, consider using viral PCR or antigen.
A culture should be taken if you have severe symptoms, wear contact lenses, or have failed previous treatment for an STD.
The viral swab test for adenovirus, which only takes 10 minutes, is expensive and may not be well tolerated by youngsters.

Diagnostic Methods and Other Procedures
a fluorescein exam to rule out the possibility of an abrasion, herpes zoster, or corneal ulcer.
Using irrigation or a swab that has been wet, remove any small, superficial foreign bodies.
Symptoms that last for more than seven days should be referred to a specialist to confirm the diagnosis and rule out the necessity for a biopsy.

Management ● Viral conjunctivitis does not require antibiotics, most resolve spontaneously.
Using a damp towel, wipe the outside of your eyelid up to four times per day.
Please refrain from wearing contact lenses while your eye is red.
The use of eyepatch is not advantageous in any way.

The First Line Of Defense Is Medication
A virus that does not cause herpes
– Tear substitutes for symptomatic alleviation – Vasoconstrictor/antihistamine medications (such naphazoline and pheniramine, for example) QID for itching that is quite intense – May use topical antibiotic (see bacterial below) if return to daycare requires treatment. – Refer to an ophthalmologist for possible steroid medication if the condition is really severe or lasts a very long time.
Herpes simplex virus (consulting with an ophthalmologist)
- Ganciclovir gel: 0.15%, 5 times per day for 7 days- Oral acyclovir doses of 400 mg five times daily for HSV and 800 mg once day for zoster for a period of seven days. 
Bacterial infections that are not transmitted sexually: Applying cool compresses for three days prior to starting antibiotic treatment helps lessen the need for antibiotic treatment.
– If desired, one may apply topical antibiotics (NNT 7 by day 6); using immediate topical antibiotics may enable some children to return to school sooner. - Bacitracin ophthalmic ointment (available without a prescription): Apply the ointment three to four times per day for five to seven days.
– Povidone-iodine 1.25 percent ophthalmic solution (an antibacterial lubricant available over-the-counter). 1 gtt, four times a day, for between five and seven days (1)[A]
– A solution of polymyxin B and trimethoprim 1 gtt, six times a day, for between five and seven days
– Erythromycin ophthalmic ointment: one-half of an inch, twice to four times daily, for five days – Sodium sulfacetamide (Bleph-10) (10% solution): two drops every four hours (when awake) for a period of five days. - Tobramycin or gentamicin: 0.3% ophthalmic drops or ointment once every four hours to once every eight hours for a period of seven days.
● Bacterial (gonococcal)
- Hospitalize neonates and provide ceftriaxone or cefotaxime intravenously.
- For adults, the recommended dosages of ceftriaxone are as follows: 1 gram intramuscularly (IM) as a single dose and topical bacitracin ophthalmic ointment 1/2 inch twice day. Neonatal patients should receive 25 to 50 mg/kg intravenously or intramuscularly, with a maximum single dose of 125 mg. Oral erythromycin at a dosage of 50 mg/kg/day, split every six hours, is the treatment of choice for chlamydia in newborns. The daily dosage should not exceed three grams.
Allergic and atopic conditions: over-the-counter (OTC) drugs are effective, there is no conclusive evidence favoring one over another, and the cost varies greatly [A].
– Ketotifen (Zaditor, Alaway, and other generics available over-the-counter): 0.25% one drop, twice daily – Ketorolac (Acular): 0.1% one drop four times daily; – Cetirizine (Zerviate): 24% one drop twice daily; – Olopatadine (Pataday, Patanol): 0.1% one drop twice daily or 0.2% one drop daily; – Cromolyn (Opticrom): 4% one drop, four times daily. – Naphazoline (Vasocon-A, Naphcon-A, Opcon-A, and Visine-A: over-the-counter) 1 drop four times day for azelastine (Astelin): 0.05% 1 drop twice daily for astelin (0.1%)
– Nedocromil (Alocril): 2% 1 drop 2 times per day – Alcaftadine (Lastacaft): 0.25% 1 drop of emedastine (Emadine) once per day contains 0.05% of the drug. Oral nonsedating antihistamines (such as cetirizine [Zyrtec] 10 mg/day or fexofenadine [Allegra] 60 mg BID, etc.) may relieve nasal symptoms but cause eye dryness. Oral antihistamines (such as diphenhydramine 25 mg TID) are recommended for severe cases of itching.
Steroids should not be used as a treatment for bacterial keratitis since they have several contraindications. Any topical steroid should be accompanied with a baseline and periodic examination by a specialist to check for corneal ulcers, glaucoma, and cataracts, particularly in children younger than 10 years old.
Tacrolimus and cyclosporine are two examples of topical immune modulators that should only be used by trained professionals in the most challenging of instances.
Do not allow the dropper to come into contact with the eye. There have been reports of eye irritation caused by gentamicin in newborns, moxifloxacin in adults, and sulfacetamide in allergic individuals. Precautions - Do not allow the dropper to come into contact with the eye. - Rebound vasodilation in the case of vasoconstrictors and antihistamines following extended usage

Second Line Viral and allergic: many over-the-counter medications and oral montelukast 10 mg once daily Bacterial: second line (quinolones used as postoperative treatment or for known resistant organisms) - Ofloxacin: 0.3% 1 gtt QID for 7 days Ciprofloxacin: 0.3% 1 gtt QID for 7 days Both drugs should be taken for a total of 7 days.
– Levofloxacin: 0.3% one gram taken three times daily for seven days. – Azithromycin: 1.5% twice daily for three days.


There are conditions that call for additional consultation. 
If you have impaired visual acuity, a suspected case of herpetic keratitis or contact lens-related conjunctivitis, or if you are immunocompromised (HIV), you should see an ophthalmologist.
Symptoms that have persisted for more than a week or have gotten worse may raise concerns about severe adenoviral keratitis.

Alternative Medicine 
Saline flushes, cool compresses, and other similar therapies are helpful, and the condition is typically harmless and self-limiting.
A mandarin orange yogurt oral treatment exhibited improvement in allergy pollen conjunctivitis during the course of a small research that lasted for two weeks.

Admission 
Acute gonococcal conjunctivitis (or in extremely rare cases, meningococcal conjunctivitis) calls for inpatient therapy with ceftriaxone at a dosage of 50 mg/kg IV per day (for pediatric patients), or 1 g IM for one adult patient, in addition to ophthalmologic evaluation.
● Admission criteria/initial stabilization – Penetrating ocular trauma, gonococcal conjunctivitis


Conjunctivitis caused by epidemic keratoconjunctivitis and other adenoviral conjunctivitis normally lasts between one and two weeks. If symptoms have not improved within five to seven days, the diagnosis should be reevaluated or a specialist should be seen.
Depending on the rules of the school, children may be barred from attending classes until the redness in their eye has subsided. Students with allergic conjunctivitis, which is not contagious, are permitted to return to school with a note from their doctor.
Monitoring of the Patient
If there is any sign of deterioration, the patient should return in one day.

No contact lenses until the eyes have completely healed, which should take around a week.
Discard current contact lenses.
Adenovirus may remain on surfaces for up to 28 days; urge patients to wash their hands with soap and use hypochlorite wipes on surfaces. Old eye makeup, especially mascara, should be thrown away. Cool, moist compresses help alleviate irritation and itch.

Herpes simplex: 2 to 3 weeks of symptoms Most common bacterial—H. influenzae, Staphylococcus, Streptococcus: self-limited; 74–80% remission after 7 days, whether treated or not Prognosis Viral: 5 to 10 days of symptoms for pharyngitis with conjunctivitis, 2 weeks with adenovirus Herpes simplex: 2 to 3 weeks of symptoms Most common bacterial: H. influenzae, Sta

Complications 

Scars on the cornea caused by herpes simplex
Scarring of the lids, the conjunctiva, symblepharon, or entropion can occur as a result of varicella zoster, chlamydia, or any other condition that causes significant inflammation.
Ulcers of the cornea or perforations in the cornea
Hypopyon is characterized by the presence of pus in the anterior chamber. Chlamydial neonatal (ophthalmic) infection may be accompanied with pneumonia. Otitis medium may be the result of H. influenzae conjunctivitis.
Meningitis can sometimes develop after a case of N. meningitidis conjunctivitis, but this only happens very infrequently.

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