Eyeworld

51 EW FEATURE May 2018 • Navigating the red eye "While most cases of chronic conjunctivitis are follicular and bilateral in nature, some conditions, such as molluscum contagiosum, are more often unilateral," Dr. de Luise said. Other causes for unilateral chronic papillary conjunctivitis include lacrimal drainage infections (chronic dacryocystitis and cana- liculitis); giant fornix syndrome; masquerade syndrome, due most commonly to sebaceous carcinoma; and factitious conjunctivitis. "These are uncommon condi- tions but should be in the differen- tial diagnosis," Dr. de Luise said. Anat Galor, MD, associate professor of clinical ophthalmol- ogy, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, differentiates the medi- cal cause as trachoma, chlamydial conjunctivitis, or toxic follicular conjunctivitis by the pattern of con- junctival and cornea involvement. For example, in cases with su- perior cicatricial changes, Dr. Galor worries about trachoma, while in cases with inferior cicatricial chang- es, Dr. Galor worries about mucous membrane pemphigoid. In cases of a chronic bilateral follicular conjunc- tivitis involving the inferior con- junctivae, Dr. Galor will review the medication list (especially the use of glaucoma medications), examine the periocular skin for molluscum lesions, and swab for chlamydia. If negative, she will biopsy to rule out lymphoma. Chronic papillary changes of the inferior conjunctivae can be seen in allergy and with in- tolerance to glaucoma medications. In addition, an atypical infectious organism should be considered. The appearance of a diffuse corneal staining pattern in the setting of a chronic conjunctivitis suggests toxicity, typically to a topical med- ication. Treatments available The treatment Dr. de Luise rec- ommends in cases of chlamydial inclusion conjunctivitis is oral doxycycline 100 mg po twice daily for 4–6 weeks. Alternatively, oral erythromycin stearate 500 mg po twice daily for 4–6 weeks or 1 gram of azithromycin po as a single dose can be used. Dr. de Luise urges ophthalmolo- gists to avoid the use of tetracycline due to less bioavailability and its contraindication in children under 8 years old. Also important is the need to identify and treat all sexual partners to prevent reinfection. For trachoma, Dr. de Luise rec- ommends 1 gram po of oral azith- romycin in adults and 20 mg of oral azithromycin in children. Another option is topical tetracycline oint- ment 1% twice daily for 6 weeks. Dr. de Luise recommends fol- lowing the "SAFE" protocol: Surgical care (of secondary issues), Antibi- otics, Facial hygiene, and Environ- mental improvement. For toxic medicamentosa chronic conjunctivitis, immediate cessation of the medication is usual- ly efficacious. However, it may take weeks for the conjunctival inflam- mation to disappear. A short course of topical ester corticosteroids can help reduce inflammation. "This requires close slit lamp follow-up," Dr. de Luise said. Molluscum contagiosum is usually a self-limited condition. Dr. de Luise recommends following the patient closely and considers curettage of the lesion to reduce the viral load. No antivirals are available for this virus. Giant papillary conjunctivitis caused by contact lenses is ad- dressed through ceasing the use of the lenses, and sometimes a short course of a topical ester corticoste- roid helps. Cases of vernal keratoconjuncti- vitis and atopic keratoconjunctivitis (AKC) require ongoing care, with topical antihistamine mast cell sta- bilizers, the judicious use of topical corticosteroids, and careful and frequent slit lamp follow-up. Topical cyclosporine has proven effective in some cases. Patients with AKC should be followed by an allergist/ immunologist as well as an ophthal- mologist, Dr. de Luise said. Patient follow-up Once physicians identify the cause and start the treatment, they have to give the condition some time to regress, Dr. Mannis said. A biopsy may be needed if there are indica- tions of some type of tumor. "Once those things are done you are going to see the patient in 2–4 weeks, and the conjunctivitis is resolving," Dr. Mannis said. "You may not see the patient for months after that but generally it is the ini- tial visit, a scraping for a biopsy, and a month follow-up." Dr. de Luise said in his experi- ence chronic conjunctivitis is less common than acute conjunctivitis, but it is often missed or misdiag- nosed. "Ophthalmologists should have a high index of clinical suspicion for" chronic conjunctivitis, Dr. de Luise said. Dr. Mannis agreed that chronic conjunctivitis is moderately rare but its common causes are commonly missed. "For example, chronic lid disease is a very common cause of chronic blepharoconjunctivitis," Dr. Mannis said. "It's often simply overlooked as a cause." EW Editors' note: The physicians have no financial interests related to their comments. Contact information de Luise: vdeluisemd@gmail.com Galor: agalor@med.miami.edu Mannis: mjmannis@ucdavis.edu Poll size: 121 For patients with lagophthalmos and exposure keratitis causing a red eye in the morning, I will: Refer them to an oculoplastics specialist Prescribe topical lubrication ointment before bed Encourage them to increase their blinking frequency Recommend that they tape their eyelids closed at night In a patient complaining of having a red eye for more than 3 weeks, the most likely etiology I would consider to be the cause of the chronic conjunctivitis is: Infectious Toxicity Inflammatory Neoplastic

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