Conjunctivitis: A Systematic Review of Diagnosis and Treatment

Post on November 4, 2013 by André Broussard, D.C.

AA Azari, NP Barney
JAMA 2013 Oct 01;310(16)1721-1729,

TAKE-HOME MESSAGE

  • What is the current management and treatment of conjunctivitis?
  • Viral conjunctivitis is the most common infectious conjunctivitis and requires no treatment. Bacteria are the second most common cause, and bacterial conjunctivitis can be treated with topical antibiotics to decrease the duration. Allergic conjunctivitis can be treated with topical antihistamines. Conjunctivitis caused by chlamydia and gonorrhea requires systemic treatment.

Commentary By:  David Rakel, MD, FAAFP

Azari and Barney provide a good review of a common problem affecting about 1% of patients who walk in our clinic doors. The main take-home message is that no negative consequences occur if we do not treat bacterial conjunctivitis—unless it is caused by chlamydia or gonorrhea. Antibiotics will shorten the duration; however, if given time, it will get better on its own.

The article summarizes the following causes of conjunctivitis:

  • For red and itchy eyes, it is likely allergic. Use an antihistamine (azelastine or olopatadine) or a mast-cell stabilizer (cromolyn).
  • For watery discharge with or without a swollen preauricular node, it is likely viral. Wash your hands!
  • For discharge and mattering with no itching, it could be bacterial. Wash your hands and prescribe nothing or prescribe antibiotic drops to shorten the duration and reduce transmission. The choice of antibiotic doesn’t matter, as they all appear to be efficacious. I like gentamicin ophthalmic drops, which do not burn as much as others (sulfacetamide). Avoid neomycin preparations due to the high risk of hypersensitivity.
  • For excessive mucopurulent discharge, think chlamydia or gonorrhea. Take a culture and cover with both systemic (azithromycin 1 gm x 1) and topical antibiotics (erythromycin or doxycycline) due to the risk of corneal damage.

Note: The type of discharge can fool us and is not always predictive. If in doubt, culture.

For those who have had trouble putting eye drops in kids, have them close their eyes and put a puddle of 3 to 4 drops in the corner of the eye and then simply pull down on the lower lid with your finger allowing the fluid to flood the eye. This is much easier than trying to pry the eye open, and the child will be grateful!

ABSTRACT

Importance: Conjunctivitis is a common problem.

Objective: To examine the diagnosis, management, and treatment of conjunctivitis, including various antibiotics and alternatives to antibiotic use in infectious conjunctivitis and use of antihistamines and mast cell stabilizers in allergic conjunctivitis.

Evidence Review: A search of the literature published through March 2013, using PubMed, the ISI Web of Knowledge database, and the Cochrane Library was performed. Eligible articles were selected after review of titles, abstracts, and references.

Findings: Viral conjunctivitis is the most common overall cause of infectious conjunctivitis and usually does not require treatment; the signs and symptoms at presentation are variable. Bacterial conjunctivitis is the second most common cause of infectious conjunctivitis, with most uncomplicated cases resolving in 1 to 2 weeks. Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are the strongest factors associated with bacterial conjunctivitis. Topical antibiotics decrease the duration of bacterial conjunctivitis and allow earlier return to school or work. Conjunctivitis secondary to sexually transmitted diseases such as chlamydia and gonorrhea requires systemic treatment in addition to topical antibiotic therapy. Allergic conjunctivitis is encountered in up to 40% of the population, but only a small proportion of these individuals seek medical help; itching is the most consistent sign in allergic conjunctivitis, and treatment consists of topical antihistamines and mast cell inhibitors.

Conclusions and Relevance: The majority of cases in bacterial conjunctivitis are self-limiting and no treatment is necessary in uncomplicated cases. However, conjunctivitis caused by gonorrhea or chlamydia and conjunctivitis in contact lens wearers should be treated with antibiotics. Treatment for viral conjunctivitis is supportive. Treatment with antihistamines and mast cell stabilizers alleviates the symptoms of allergic conjunctivitis.

Journal Abstract:  http://jama.jamanetwork.com/article.aspx?articleid=1758756

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