Ocular Symptoms and Signs

RED EYE, DISCHARGE PRESENT

    Infectious Conjunctivitis

               Infectious conjunctivitis comes in two varieties: viral and bacterial (See Table 2). Viral conjunctivitis is more common and is typically adenoviral in etiology. Herpes simplex conjunctivitis is seen less frequently. The usual organisms implicated in bacterial conjunctivitis are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Haemophilus influenza. An acute, hyperpurulent conjunctivitis is typically gonococcal. Chlamydia classically causes a chronic conjunctivitis.

Table 2. Viral vs. Bacterial Conjunctivitis

	Viral Conjunctivitis	Bacterial Conjuncitivitis
Discharge	Watery, mucous	Purulent
Conjunctival pathology	Follicles	Papillae
Preauricular adenopathy	Common	Uncommon
Itching	Common	Less Common

               Patients with conjunctivitis may have a clear history of recent contact with individuals who had red eyes. The viral variety can be accompanied by an upper respiratory infection or sore throat and typically begins in one eye and then involves the second eye a few days later. A history of awakening with eyelids stuck together is often elicited. General physical exam can reveal preauricular lymphadenopathy, especially with the viral variety. Slit lamp examination can help to distinguish between viral and bacterial causes. Conjunctival follicles are more commonly seen with viruses while papillae are seen in bacterial conjunctivitis. There are exceptions to this rule, however, and often a mixed picture with both papillae and follicles can be seen. Clear, mucoid discharge is more indicative of a virus while purulent discharge is associated with bacteria. For herpetic disease, finding periocular vesicles is a key to the diagnosis.

There is a follicular conjunctivitis of the right eye. The red “lumpy” appearance could be seen with adenoviral or allergic conjunctivitis. In this case it was due to infection with Bartonella henselae (cat-scratch disease).

               Clear cases of viral conjunctivitis do not require a work-up, but if there is any doubt as to the diagnosis, cultures of ocular discharge are required. Viral disease is treated conservatively with artificial tears and cold compresses. It often takes one to two weeks for symptoms to resolve. If the patient describes loss of vision, he or she should be referred to an ophthalmologist to ensure they have not developed subepithelial corneal infiltrates that require topical steroid therapy. Cases of herpetic conjunctivitis can be treated with vidarabine ointment four to six times per day.

               Therapy of bacterial conjunctivitis should be guided by culture results. In general topical antibiotics are given for seven days. Some specific medications that cover most pathogens are moxifloxacin, gatifloxacin and polymyxin B/trimethoprim drops four to six times per day. Bacitracin and erythromycin ointment four times per day will also be sufficient in most cases. A few bacterial etiologies will require systemic medication. If the history or gram stain is suggestive of gonococcal disease, one gram of intramuscular ceftriaxone should be given promptly. If chlamydial disease is present, oral doxycycline or azithromycin therapy are acceptable therapies. Haemophilus influenzae conjunctivitis requires oral amoxicillin/clavunalate because of potential for concomitant nonocular involvement. With more virulent cases, especially gonococcal disease, referral to an ophthalmologist to rule out corneal involvement is imperative. Bacterial conjunctivitis should resolve within days of starting appropriate antibiotic therapy.

    Allergic Conjunctivitis

               Allergic conjunctivitis is common in patients with a history of seasonal allergies, atopy, and eczema. The most prominent symptom is itching. Both eyes are typically involved and have a watery discharge. Slit lamp exam shows conjunctival papillae which may be most prominent upon flipping the upper lid, especially in vernal disease. Collaboration with an allergist to identify causative allergens is necessary in severe or persistent cases. The best treatment is to eliminate the allergen. Many different topical anti-allergy regimens are effective, including olapatadine twice daily and cromolyn sodium four times daily. Fluoromethalone or another similar mild topical steroid is necessary for severe cases. Oral histamines are a good adjunctive treatment. Allergic conjunctivitis is a chronic condition that may require ongoing therapy with particular attention to prophylactic therapy prior to seasons when the disease tends to reactivate.

    Dacryocystitis

               Dacryocystitis, inflammation of the lacrimal sac, is most often related to nasolacrimal duct obstruction. It is less commonly related to nasal surgery, trauma, lacrimal sac diverticulum, or sinus surgery. The typically-implicated organisms are staphylococci, streptococci, and diphteroids. Patients will complain of tearing, discharge and swelling over medial aspect of lower eyelid. Examination reveals red, tender edema over medial aspect of lower eyelid and discharge from the punctum when pressure is applied over the lacrimal sac. Any discharge expressed from the punctum should be cultured. Additionally, proptosis and restriction of ocular motility should be looked for as signs of progression to orbital cellulitis. Oral cephalexin, amoxicillin/clavunalate, ciprofloxacin or cefaclor for ten days are the typical antibiotic choices. If the patient is febrile or acutely ill, one should consider admission for intravenous antibiotics. In additional to systemic therapy, topical trimethoprim/polymyxin or moxifloxacin 4 times per day should be given. Dacrocystitis resolves within one to two weeks with appropriate oral antimicrobials. Cases that do not improve with medical treatment should be referred to an ophthalmologist for incision and drainage. Surgical correction of nasolacrimal duct obstruction is often needed to prevent recurrences even in cases that respond to antibiotics.

    Canaliculitis

               Canaliculitis, inflammation of the canaliculus which leads from the punctum to the lacrimal sac is caused most commonly by Actinomyces israeili and less commonly by Fusobacterium, Nocardia, and various fungi. Patients describe tearing, discharge and swelling over medial aspect of the upper or lower eyelid. The classic sign on slit lamp examination is a “pouting punctum,” swelling and erythema of the punctum in medial most aspect of eyelid margin. Discharge may be expressed from the punctum with pressure and should be cultured. These patients should be referred to an ophthalmologist as surgical removal of the obstructing secretions and irrigation with antifungal or antibacterial solution is often required and curative.