Eyeworld

EW FEATURE 50 Navigating the red eye • May 2018 AT A GLANCE • The appropriate historical questions are key to determining if acute conjunctivitis is hemolytic, toxic, traumatic, or infectious in nature. • Follow the "SAFE" protocol: Surgical care (of secondary issues), Antibiot- ics, Facial hygiene, and Environmen- tal improvement. • Chronic conjunctivitis is less com- mon than acute conjunctivitis, but it is often missed or misdiagnosed. by Rich Daly EyeWorld Contributing Writer logic in origin, or even factitious," Dr. Mannis said. In addition, ocular surface neoplasms can mimic chron- ic conjunctivitis. When dealing with acute con- junctivitis, the appropriate historical questions are key to determining if it is infectious or toxic in nature. "This becomes very important; you need to know about the onset, symptoms, and type of discharge," Dr. Mannis said. "Moreover you need to know if there are any other contiguous problems, such as con- comitant upper respiratory infection or periocular skin disease." Other questions include wheth- er the patient has had exposure to toxins, such as creams, hair sprays, and over-the-counter drops, which are potentially toxic agents. Phy- sicians should also examine other parts of the eye and face to identify conjunctivitis. Close attention to the lid margins and periocular skin is important. Palpable preauricular or submandibular nodes may indi- cate viral or chlamydial infection. A loss of lashes suggests chronic lid disease. "History and the examina- tion become important in trying to figure out into which of these categories the conjunctivitis falls," Dr. Mannis said. "Most of the time you can hone in on a diagnosis with a careful set of questions. Once you have an idea of what you are deal- ing with, there may also be relevant diagnostic tests." Additional differentiation Vincent de Luise, MD, assistant clinical professor of ophthalmology, Yale University School of Medicine, New Haven, Connecticut, noted that allergic conjunctivitis is usually acute, although it can recur. Allergic conjunctivitis is usually papillary in nature—that is, it presents more often with conjunctival papillae and not follicles. However, an exception is some types of allergic drug-induced medicamentosa, with follicular reactions. Dr. de Luise said toxic follicular conjunctivitis can be caused by sev- eral different medications: antivirals such as vidarabine and trifluridine; glaucoma medications such as pilocarpine, carbachol, epinephrine, and apraclonidine; topical ocular antibiotics such as neomycin, genta- micin, sulfonamides and amphoter- icin B; and agents such as atropine, scopolamine, and neostigmine. Primary chronic papillary conjunctivitis is commonly seen in vernal keratoconjunctivitis or atopic keratoconjunctivitis. Secondary giant papillary conjunctivitis is seen in contact lens wearers, ocular pros- theses, and with exposed sutures, Dr. de Luise noted. Meanwhile, chronic cicatrizing conjunctivitis can be due to a toxic medicamentosa reaction or to ocular cicatricial pemphigoid. Best approaches for detection, treatment, and follow-up T he right questions can be key to the early and correct diagnosis of various types of conjunctivitis. Conjunctivitis treat- ments begin with differentiating between acute and chronic versions of the condition. The acute form generally has a rapid onset and lasts 3 weeks or less. Conjunctivitis lasting longer than 3 weeks can be considered chronic conjunctivitis, said Mark Mannis, MD, professor and chair, Department of Ophthal- mology & Vision Science, Davis Eye Center, University of California, Sacramento. "Chronic conjunctivitis can be infectious, toxic, immune, dermato- Understanding chronic conjunctivitis Inferior follicles in a chronic follicular conjunctivitis case Source: Vincent de Luise, MD Monthly Pulse Navigating the red eye EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthal- mologist. Each month we send an online survey covering different topics so readers can see how they compare to our survey. If you would like to join the physicians who take a minute a month to share their views, please send us an email and we will add your name. Email anne@eyeworld. org and put "EW Pulse" in the subject line. If I suspect viral epidemic keratoconjunctivitis and the patient has developed membranes and corneal subepithelial infiltrates, I would likely: Treat with topical povidone iodine Treat with topical ganciclovir Treat with topical steroids Treat with artificial tears When I encounter a patient with allergic conjunctivitis, the first step in my management plan would likely be: Refer the patient to an allergist Plan to treat the patient's dry eye disease Start a topical antihistamine/ mast cell stabilizer Start a topical steroid

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