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Conjunctivitis: diagnosis and management

Gill Bedson
RGN DPSN NPDip BScHealthStudies
Lead Nurse
Luton Walk-in Centre
Luton, Bedfordshire
E:gill.bedson@luton-pct.nhs.uk

Conjunctivitis is any inflammation of the conjunctiva (the mucous membrane that lines the eyelids and is reflected onto the eyeball), usually characterised by irritation, itching, gritty foreign body sensation, discharge or excessive tearing.(1)
Conjunctivitis falls into three categories:

  • Bacterial conjunctivitis - usually distinguished from other types of conjunctivitis by the presence of mucopurulent discharge (see Figure 1).
  • Viral conjunctivitis - often seen in conjunction with, or shortly after, upper respiratory tract ­infections with no history of discharge from the eye (see Figures 2 and 3).
  • Allergic conjunctivitis - usually seasonal (see Figure 4).

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Causative organisms
Staphylococcus species are the most common bacterial pathogens, followed by Streptococcus pneumoniae and Haemophilus influenzae.
In children, bacterial infection is more common than viral infection, the most common pathogens being H influenzae, S pneumoniae and Moraxella catarrhalis.(2)

Presentation
Conjunctivitis is the commonest cause of "red eye". Infective conjunctivitis is responsible for about 35% of all eye problem presentations in general practice.(3)
The patient usually presents with:

  • Eye discomfort.
  • Discharge.
  • Irritation of the eye.

Certain individuals are more prone to conjunctivitis: for example, the elderly and children, contact lens wearers, and those with a history of contact with an infected individual.

Diagnosis
On examination:

  • The patient will have "red eye" with uniform engorgement of all the conjunctival blood vessels.
  • Mucopurulent discharge is usually indicative of bacterial infection; this may cause difficulty in opening the eye after sleep as the lids get stuck together.
  • Unilateral or bilateral infection may be seen, although on closer questioning it is often found to start in one eye and spread to the other.
  • Presence of a watery discharge, preauricular ­lymphadenopathy and cobblestone appearance of the tarsal conjunctiva are all associated with viral infection.

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Treatment
Topical antibiotic treatment will relieve symptoms and shorten the length of the illness. This in turn reduces spread of the infection and the incidence of ­complications such as corneal ulceration. Treatment with antibiotic drops/ointment will also prevent the risk of more widespread extraocular disease.
Although conjunctivitis is thought to be self-limiting in nature, delaying treatment to ascertain resolution of symptoms is not recommended as it could compromise the safety of a small number of people.(4)
Chloramphenicol, as eye drops or ointment, is the drug of choice in the UK today. The drops are instilled every two hours to begin with, then reduced in frequency as infection is controlled. Treatment should continue for 48 hours after infection has cleared. The ointment should be used at night and may be more appropriate altogether for young children.
Fusidic acid is an alternative antibiotic to chloramphenicol and comes in a viscous drop formulation; this need be applied only twice a day and may be more appropriate for those who need assistance to apply their drops, or for children.

Management
Conjunctivitis is extremely infectious, especially adenoviral infection. Advice should be given about hygiene measures to prevent the spread of infection, such as:

  • Not sharing face cloths and towels.
  • Trying not to touch the eye.
  • Handwashing after touching the eye.
  • Handwashing before and after administration of medication.

Contact lenses should not be worn while the infection is present and until treatment is completed. Thorough cleaning of the lenses must be undertaken before reintroduction into the eye.
Corneal infection is the complication associated with contact lenses that causes most concern; it can present with discharge but is usually also associated with ocular pain and photophobia.

Conclusion
Conjunctivitis is a minor ailment that is self-limiting; however, it is recommended that antibiotic treatment continue to be prescribed until further studies have been carried out.

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References

  1. Chung C, Cohen E, Smith J. Bacterial conjunctivitis. Clin Evid 2002;7:575-9.
  2. Prodigy. Prodigy Guidance - Conjunctivitis ­- Infective; 2002. Available from URL: http://www. prodigy.nhs.uk/guidance.asp?gt
  3. Royal College of General Practitioners and Royal College of Ophthalmologists. Ophthalmology for general practice trainees. London: Medical Protection Society; 2001.
  4. Sheikh A, Hurwitz B. Topical ­antibiotics for acute bacterial ­conjunctivitis: a systematic review. Br J Gen Pract 2002;51:473-7.

Resources
Prodigy A broad concept to support general practice in ­developing the quality of clinical practice
W:www.prodigy.nhs.uk

Clinical Evidence from the BMJ Publishing Group
W:www.clinicalevidence.com

Further ­reading
Batterbury M, Bowling B. Ophthalmology: an illustrated colour text. Edinburgh: Churchill Livingstone; 1999

Khaw PT, Elkington AR. ABC of eyes. London: BMJ Publications; 1999