Conjunctival disorders: Clinical sciences

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Introduction 0:00–0:37

Conjunctival disorders occur when the lubricating mucous membrane covering the eye becomes infected, damaged, or inflamed, and they're the most common causes of a red eye encountered in the primary care setting.
Emergent vision-threatening conjunctival disorders include chemical injury and hyper acute bacterial conjunctivitis. Well, non-vision threatening conjunctival disorders include acute bacterial conjunctivitis, viral conjunctivitis, allergic conjunctivitis, and keratoconjunctivitis sica.
Now, if a patient presents with a chief concern suggesting a conjunctival disorder, first obtain a focused history and physical examination.

H&P 0:37–1:06

Your patient will typically report redness of one or both eyes, while a physical exam will reveal conjunctival injection, commonly referred to as bloodshot eyes, which is caused by dilation of the conjunctival blood vessels.
With these findings, diagnose a conjunctival disorder. Next, assess for red flags, which indicate vision threatening emergencies.

Red Flags Present1:06–1:27

Red flags include severe pain, decreased visual acuity, photophobia, anterior chamber inflammation, and corneal epithelial defects.
If any of these red flags are present, assess for the emergent underlying cause. First up is chemical injury.
Your patient will report a chemical or toxic exposure to something like household cleaners, for example, bleach or ammonia.

Chemical Injury 1:27–2:38

Other symptoms include pain and blurry vision. Your physical exam will reveal conjunctival injection, decreased visual acuity, and possibly eyelid edema.
With these findings, diagnose chemical injury. Treat with supportive care by removing any offending agents and providing adequate ocular irrigation for at least 30 minutes to reach a neutral pH.
Also, be sure to use artificial tears throughout all stages of healing, and combine with medical therapy, such as topical antibiotics for infection prophylaxis, and topical steroids to reduce inflammation.
Here's a clinical pearl. The main pitfall in the initial management of chemical injury of the conjunctiva is inadequate irrigation, which results in ongoing exposure to the chemical.
You can manage irrigation by applying a lens-like device to the eye, which connects to intravenous tubing for continuous hands-free irrigation.
OK, let's move on to hyper acute bacterial conjunctivitis. These patients will report an abrupt onset of copious purulent discharge associated with pain and blurry vision.

Hyperacute Bacterial Conjunctivitis 2:38–4:14

Adult patients are generally either sexually active or are immunocompromised. But don't forget, this can also affect neonates who can be exposed to infectious agents during a vaginal delivery.
Here's a clinical pearl. Hyper acute bacterial conjunctivitis is a rare cause of blindness in neonates.
Prophylactic treatment with erythromycin eye ointment can be used to prevent this condition, if there's a risk that the neonate was exposed to infectious agents like Nisseria gonorrhea during vaginal delivery.
Your physical exam may reveal conjunctival kemosis, which is a swelling of the conjunctiva, eyelid edema, or preauricular lymphadenopathy.
With these findings, suspect hyper-acute bacterial conjunctivitis, which is most commonly caused by neisseria gonorrhea.
So obtain a culture, PCR and nucleic acid amplification testing, or NAT for short. If testing comes back positive for gonorrhea, diagnose hyper acute bacterial conjunctivitis.
Treatment includes supportive care with saline irrigation and medical therapy with IV ceftriaxone. On the other hand, if red flags are not present, assess for a non-emergent underlying cause of conjunctival disorder.
First up is bacterial conjunctivitis. These patients typically report drainage of mucus or pus, morning matting of their eyes, and a foreign body sensation.

Bacterial conjunctivitis4:14–5:33

These symptoms are unilateral, but may spread to the other eye through contact from unwashed hands. Physical exam reveals mucopurulent discharge.
With these findings, diagnose bacterial conjunctivitis and treat with topical antibiotics. The most common pathogens causing bacterial conjunctivitis include Haemophilus influenza, Streptococcus pneumonia, Marraxella catalis, and Staphylococcus aureus.
Good choices to provide adequate antimicrobial coverage include amino glycosides, macrolides, fluoroquinolones, or polymixin B combination medications.
Here's a clinical pearl to keep in mind. Bacterial conjunctivitis is a much more common and less severe condition compared to hyper acute bacterial conjunctivitis.
It's important to make this distinction early in the workup, because the severe inflammation seen in hyper acute bacterial conjunctivitis can lead to corneal ulcers, perforation of the eyeball, and permanent vision loss if not treated promptly.
Next up is viral conjunctivitis. These patients will report itchy eyes, watery drainage, and often have a history of a recent upper respiratory infection.

Viral conjunctivitis 5:33–7:08

Physical exam reveals watery discharge, and you may even see pre-auricular adenopathy. With these findings, diagnose viral conjunctivitis and treat with supportive care, including artificial tears and cold compresses for symptomatic relief.
Antivirals are not required, as this infection is generally self-limited. Here's a high yield fact.
Adenoviruses cause up to 90% of viral conjunctivitis cases. Counsel patients on measures to prevent the spread of the infection to the other eye, or close contacts by practicing good hygiene with frequent hand washing and discouraging eye-touching and sharing towels.
The potential for transmission is highest while the eyes are red and tearing. And while we're at it, back to back high-yield facts.
Herpes simplex virus causes up to 5% of viral conjunctivitis cases. In addition to the typical eye redness you'll see with conjunctivitis, your patient might also report oral sores, or may have a history of a sexually transmitted infection.
In this situation, immediately treat with topical antiviral agents to reduce transmission potential and the development of keratitis.
Also, keep in mind, topical steroids are contraindicated in treating herpes simplex conjunctivitis, since they're associated with prolonged viral shedding and infection.
Let's move on to allergic conjunctivitis. Your patient will report bilateral itchy, burning eyes, watery drainage, and a history of environmental allergies, such as pollen or pet dander.

Allergic conjunctivitis 7:08–8:00

The physical exam will show watery discharge and infraorbital discoloration, often with signs of allergic rhinitis, like a clear nasal discharge, swelling of the turbinates, and pharyngeal cobblestoning.
With these findings, diagnose allergic conjunctivitis. Treatment includes supportive care with allergen avoidance.
Medical therapy includes oral mast cell stabilizers, but keep in mind, this medication may take days to weeks to take effect.
For immediate symptomatic relief, you can add topical antihistamines and anti-inflammatories, or oral antihistamines. Last up is keratoconjunctivitis sica, also known as dry eye disease.

Keratoconjunctivitis sicca 8:00–10:03

Your patient might report photophobia and a foreign body sensation. They may have a history of Sjogren's syndrome, or they might be taking medications with a drying effect on the eyes, like antihistamines or diuretics.
Your physical exam might reveal conjunctival injection or a mucoid discharge. With these findings, suspect keratoconjunctivitis sica and perform a Shermer test, which if positive, confirms the diagnosis of keratoconjunctivitis sica.
Keep in mind that this condition is not always a result of medications or Sjogren's syndrome, but might be aggravated by contact lenses or prolonged staring at computer screens.
Here's one last clinical pearl. The Shermer test involves placing filter paper between the lower lid of the eye and the conjunctiva in order to detect a deficiency of tear production.
After 5 minutes, the paper is removed and tested for its moisture content. Treatment includes supportive care with ocular lubricants for symptomatic relief.
You should also reduce the dosage of any offending medications like antihistamines and diuretics, or completely discontinue them if possible.
And don't forget to treat any associated systemic diseases such as Sjogren's syndrome. Depending on the severity of symptoms, you may need to add medications such as topical anti-inflammatories or topical immunosuppressants like cyclosporine.
Here's a high yield fact. Sjogren's syndrome is a systemic autoimmune disease that most often presents with sicka symptoms like dry eyes and mouth, which is due to inflammation of the lacrimal and salivary glands.
If you suspect your patient has keratoconjunctivitis sica due to Sjogren's syndrome, test autoantibodies RSSA or LSSB to confirm the diagnosis.
All right, as a quick recap. Conjunctival disorders occur when the lubricating mucous membrane covering the eye becomes infected, damaged, or inflamed.

Review 10:03–10:56

And they're the most common causes of a red eye encountered in the primary care setting. Emergent vision-threatening conjunctival disorders include chemical injury and hyper-acute bacterial conjunctivitis.
Treatment involves prompt ocular irrigation and topical medications for chemical injury, and IV ceftriaxone and saline irrigation for hyper acute bacterial conjunctivitis.
On the other hand, non-vision threatening conjunctival disorders include acute bacterial conjunctivitis, viral conjunctivitis, allergic conjunctivitis, and keratoconjunctivitis sica.
Treatment includes a combination of supportive care and medical therapy, depending on the underlying cause.