Conjunctivitis

There is significant overlap among conditions that cause a red, painful or

red and painful eye. Here are additional cards that may help in your
evaluation:

Allergic

IgE mediated, usually associated with itching

Treatment: Cold compresses, over-the-counter topical
vasoconstrictors, histamine-blocking eyedrops

Viral

Most common form of infectious conjunctivitis (usually adenovirus)

Preauricular lymphadenopathy, global conjunctival injection
Watery discharge
Follicular reaction of inferior tarsal conjunctiva
Treatment: Cold compresses, artificial tears, topicaldecongestants,
+/- topical antibiotics, if not able to discern from bacterial etiology
Viral: Epidemic keratoconjunctivitis

Adenovirus
Symptoms: Eye pain, decreased visual acuity
Findings: Corneal subepithelial infiltrates (1-2 mm gray-white crumb-
like defects)

Viral: HSV conjunctivitis

More prevalent in HIV patients

Foreign body sensation in eye (unlike typical viral conjunctivitis)
Treatment:
If no skin or corneal involvement, topical antivirals (trifluridine or
vidarabine) x 10-14 days
If corneal involvement (dendrites seen), topical trifluridine and
oral acyclovir x 7-10 days. NO STEROIDS.

Viral: HZV ophthalmicus

VZV virus: Reactivation through V1 nerve

Findings:

Hutchinson sign: Herpes pustules at nose tip and is predictive of ocular

involvement
Dendrites on eye exam
Treatment: Systemic vs topical antiviral agents, +/- steroids only with
ophthalmology consult

Bacterial

Often association with morning crusting

Injection more pronounced at fornices
Contact lens wearer: Pseudomonas risk
Treatment: Topical fluoroquinolone, cycloplegic

Gonorrheal conjunctivitis:

Sexually active patients and neonates (from birthcanal)

“hyperacute conjunctivitis”, abrupt onset
copious purulent discharge
Treatment: Topical antibiotics, usually with systemic antibitics
because associated with venereal disease

Inclusion or Chlamydial conjunctivitis:

Sexually active patients and neonates

mucopurulent discharge
foreign body sensation
Check for concurrent sexually transmitted infections (symptomatic
only 1⁄2 patients).
Treatment: Topical erythromycin and po azithromycin x 1

Subconjunctival Hemorrhage
 In setting of trauma and large hemorrhage, consider globe rupture
Treatment: Warm compresses, lubrication drops

Episcleritis

Episclera: Thin membrane over the sclera and beneath conjunctiva

Benign self-limited inflammatory cond with focal area of dilated
episceral vessels
Seen with rheumatoid arthritis, polyarteritis nodosa, lupus, inflam
bowel disease, sarcoid, Wegener’s, gout, herpes zoster virus, syphilis
Treatment: Oral NSAIDs

Scleritis
 Most common immune cause: Rheumatoid arthritis
Most common vasculitis cause: Wegener’s
Symptoms: Severe eye pain radiating to ear, scalp, face, and jaw. Dull
pain. Photophobia.
Exam: Deep episcleral plexus is vascularly engorged – appears blue-
violet, vessels non-blanching with vasoconstrictor, scleral edema
Treatment:
Oral NSAIDs
Consider oral steroids, but with ophthalmology consultation

Uveitis
Divided into anterior (iris, ciliary body) vs posterior (retinochoroiditis)
Etiologies: Inflammatory (50% assoc w/ systemic inflam disease),
traumatic, infectious
Consider CMV in posterior uveitis in HIV patients
Anterior uveitis: Sudden, severe, painful eye; photophobia; perilimbal
injection, consensual photophobia from unaffected eye
Posterior uveitis: “Floaters”, flashing light – no redness or pain
Exam: Inflammatory cells, proteinaceous flare
 Complications: Cataracts, glaucoma, retinal detachment
Treatment:
Mydriatic or cycloplegic drops
Consider oral steroids, but with ophthalmology consult

Acute Angle Closure Glaucoma

Symptoms: Blurred vision, halos around lights, nausea/vomiting,

headache
Pearl: Consider in all patients with “migraine HA’s” – check pupil
reactivity
Exam: Corneal edema, mid-dilated NON-reactive pupil
Intraocular pressure >30 mmHg requires prompt treatment
Treatment:
Topicals: Timolol, prednisolone, apraclonidine
Oral: Acetazolamide

References
Mahmood AR, Narang AT. Diagnosis and management of the acute red
eye. Emerg Med Clin North Am. 2008 Feb;26(1):35-55, vi. [PubMed]