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Conjunctivitis
Secretary for Quality of Care
Anne L
...
Emptage, MAE
Nancy Collins, RN, MPH
Doris Mizuiri
Jessica Ravetto
Flora C
...
All other trademarks are the property of
their respective owners
...
Preferred Practice Pattern®
Guidelines
...
San Francisco, CA: American Academy of Ophthalmology; 2013
...
aao
...
Preferred Practice Pattern® guidelines are developed by the Academy’s H
...
, MD Center
for Quality Eye Care without any external financial support
...
The
guidelines are externally reviewed by experts and stakeholders before publication
...
The PPP Panel members discussed
and reviewed successive drafts of the document, meeting in person twice and conducting other
review by e-mail discussion, to develop a consensus over the final version of the document
...
Feder, MD, Co-chair
Stephen D
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Akpek, MD, Cornea Society Representative
Steven P
...
Garcia-Ferrer, MD
Amy Lin, MD
Francis S
...
Talley-Rostov, MD
Divya M
...
Musch, PhD, MPH, Methodologist
The Preferred Practice Patterns Committee members reviewed and discussed the document
during a meeting in March 2013
...
Preferred Practice Patterns Committee 2013
Stephen D
...
Chang, MD
Robert S
...
Olsen, MD
Bruce E
...
, MD
C
...
Musch, PhD, MPH, Methodologist
The Conjunctivitis PPP was then sent for review to additional internal and external groups and
individuals in June 2013
...
Members of the
Cornea/External Disease Preferred Practice Pattern Panel reviewed and discussed these
comments and determined revisions to the document
...
Karp, MD
David B
...
cmss
...
aspx), relevant relationships with industry are listed
...
aao
...
aspx)
...
Cornea/External Disease Preferred Practice Pattern Panel 2012–2013
Esen K
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Dunn, MD: No financial relationships to disclose
Robert S
...
Garcia-Ferrer: No financial relationships to disclose
Amy Lin, MD: No financial relationships to disclose
Francis S
...
– Consultant/Advisor; Allergan, Inc
...
McLeod, MD: No financial relationships to disclose
David C
...
– Consultant/Advisor
Audrey R
...
– Lecture fees
Divya M
...
Chang, MD: Abbott Medical Optics – Consultant/Advisor; Allergan, Inc
...
– Patent/Royalty
Robert S
...
McLeod, MD: No financial relationships to disclose
David C
...
– Consultant/Advisor
Timothy W
...
Prum, Jr
...
Gail Summers, MD: No financial relationships to disclose
Secretary for Quality of Care
Anne L
...
– Consultant/Advisor; Pfizer Ophthalmics – Consultant/Advisor
Academy Staff
Nicholas P
...
Lum, MD: No financial relationships to disclose
Doris Mizuiri: No financial relationships to disclose
Jessica Ravetto: No financial relationships to disclose
The disclosures of relevant relationships to industry of other reviewers of the document from January to
August 2013 are available online at www
...
org/ppp
...
2
METHODS AND KEY TO RATINGS
...
4
INTRODUCTION
...
5
Patient Population
...
5
BACKGROUND
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6
Natural History
...
10
Patient Outcome Criteria
...
10
History
...
10
Diagnostic Tests
...
14
Prevention
...
15
Provider and Setting
...
24
Socioeconomic Considerations
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QUALITY OF OPHTHALMIC CARE CORE CRITERIA
...
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS (ICD) CODES
...
PREFERRED PRACTICE PATTERN RECOMMENDATION GRADING
...
OCULAR SURFACE DYE STAINING
...
42
REFERENCES
...
Appendix 1 describes the core criteria of quality eye care
...
In some instances, such as when results of carefully conducted
clinical trials are available, the data are particularly persuasive and provide clear guidance
...
These documents provide guidance for the pattern of practice, not for the care of a particular
individual
...
Adherence to these PPPs will not ensure a successful outcome in every situation
...
It may be necessary to approach different patients’
needs in different ways
...
The American Academy of
Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of
ophthalmic practice
...
The Academy specifically disclaims any and all liability for injury or other damages of any kind,
from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or
other information contained herein
...
Such material may include information on applications
that are not considered community standard, that reflect indications not included in approved U
...
Food and
Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings
...
Innovation in medicine is essential to ensure the future health of the American public, and the Academy
encourages the development of new diagnostic and therapeutic methods that will improve eye care
...
All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if
developments warrant and updated accordingly
...
Preferred Practice Pattern guidelines are
funded by the Academy without commercial support
...
The PPPs are externally
reviewed by experts and stakeholders, including consumer representatives, before publication
...
The Academy has Relationship with Industry Procedures (available at
http://one
...
org/CE/PracticeGuidelines/PPP
...
Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems
(ICD) codes for the disease entities that this PPP covers
...
2
Conjunctivitis PPP
METHODS AND KEY TO RATINGS
Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful
information to practitioners
...
To accomplish these
aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of
Recommendations Assessment, Development and Evaluation2 (GRADE) group are used
...
Organizations that have adopted GRADE include
SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American
College of Physicians
...
To rate individual studies, a scale based on SIGN1 is used
...
g
...
The body of evidence quality
ratings are defined by GRADE2 as follows:
Good quality
Moderate quality
Insufficient quality
Key recommendations for care are defined by GRADE2 as follows:
Strong
recommendation
Discretionary
recommendation
Further research is very unlikely to change our confidence in the estimate of
effect
Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate
Further research is very likely to have an important impact on our confidence in
the estimate of effect and is likely to change the estimate
Any estimate of effect is very uncertain
Used when the desirable effects of an intervention clearly outweigh the
undesirable effects or clearly do not
Used when the trade-offs are less certain—either because of low-quality
evidence or because evidence suggests that desirable and undesirable effects are
closely balanced
The Highlighted Findings and Recommendations for Care section lists points determined by the PPP
panel to be of particular importance to vision and quality of life outcomes
...
To locate ratings
for specific recommendations, see Appendix 3 for additional information
...
Complete details of the literature search are available at www
...
org/ppp
...
4 Conjunctivitis
infrequently causes permanent visual loss or structural damage, but the economic impact of the disease in
terms of lost work time, cost of medical visits, diagnostic testing, and medication is considerable
...
The ophthalmologist plays a critical role in breaking the chain of transmission of epidemic adenoviral
conjunctivitis, primarily by educating the patient and family about proper hygiene
...
Wiping with 70% alcohol may not be effective in eliminating adenovirus from tonometer tips
...
Treatment of conjunctivitis is ideally directed at the root cause
...
Viral conjunctivitis will not
respond to anti-bacterial agents, and mild bacterial conjunctivitis is likely to be self-limited
...
In adults, conjunctivitis caused by ocular mucous membrane pemphigoid (OMMP), graft-versus-host disease
(GVHD), gonococcus, and chlamydia is important to detect early because it is necessary to treat the
concomitant systemic disorder
...
Early detection of conjunctivitis associated with neoplasms may
be lifesaving
...
PATIENT POPULATION
The patient population includes individuals of all ages who present with symptoms and signs
suggestive of conjunctivitis, such as red eye or discharge
...
Most varieties of conjunctivitis are self-limited, but
some progress and may cause serious ocular and extraocular complications
...
The types
of noninfectious conjunctivitis are allergic, mechanical/irritative/toxic, immune-mediated, and neoplastic
...
The causes of infectious conjunctivitis include
viruses and bacteria
...
For example, although dry eye and
blepharitis are the most frequent causes of conjunctival inflammation, the treatment for each of these entities
is directed at correcting the underlying problems
...
Ligneous conjunctivitis is caused by plasminogen deficiency resulting in multiorgan
pseudomembranous disease of mucous membranes in the mouth, nasopharynx, trachea, and female genital
tract
...
11
This Preferred Practice Pattern addresses the following types of conjunctivitis that are most common or are
particularly important to detect and treat:
Allergic
Seasonal allergic conjunctivitis
Vernal conjunctivitis
Atopic conjunctivitis
Giant papillary conjunctivitis (GPC), which also has a mechanical component
Mechanical/Irritative/Toxic
Superior limbic keratoconjunctivitis (SLK)
Contact-lens-related keratoconjunctivitis
Floppy eyelid syndrome
Giant fornix syndrome
Pediculosis palpebrarum (Phthirus pubis)
Medication-induced keratoconjunctivitis
Conjunctival chalasis
5
Conjunctivitis PPP:
Prevalence and Risk Factors
Viral
Adenoviral conjunctivitis
Herpes simplex virus (HSV) conjunctivitis
Varicella (herpes) zoster virus (VZV) conjunctivitis
Molluscum contagiosum
Bacterial
Bacterial conjunctivitis (including nongonococcal and gonococcal)
Chlamydial conjunctivitis
Immune-mediated
Ocular mucous membrane pemphigoid (OMMP)
Graft-versus-host disease (GVHD)
Stevens-Johnson syndrome
Neoplastic
Sebaceous carcinoma
Ocular surface squamous neoplasia
Melanoma
PREVALENCE AND RISK FACTORS
Conjunctivitis is a diagnosis that encompasses a diverse group of diseases that occur worldwide and
affect all ages, all social strata, and both genders
...
4 Conjunctivitis infrequently causes permanent visual loss
or structural damage, but the economic impact of the disease in terms of lost work time, cost of
medical visits, diagnostic testing, and medication is considerable
...
The associated and predisposing
factors for the types of conjunctivitis that are most common or most important to treat are listed in
Table 1
...
TABLE 1 ASSOCIATED/PREDISPOSING FACTORS FOR CONJUNCTIVITIS
Type of Conjunctivitis
Associated/Predisposing Factors
Allergic
Seasonal
• Environmental allergens
Vernal
• Hot, dry environments such as West Africa; parts of India, Mexico, Central, North, and
South America; and the Mediterranean area
• Environmental allergens for acute exacerbations
Atopic
• Genetic predisposition to atopy
• Environmental allergens and irritants for acute exacerbations
Giant papillary conjunctivitis (GPC)
• Contact lens wear
...
) Also occurs with irritation from exposed sutures and
prostheses
...
May have associated pubic lice or other sexually
transmitted diseases
...
6
Conjunctivitis PPP:
Prevalence and Risk Factors
TABLE 1 ASSOCIATED/PREDISPOSING FACTORS FOR CONJUNCTIVITIS (CONTINUED)
Type of Conjunctivitis
Associated/Predisposing Factors
Mechanical/Irritative/Toxic (continued)
Medication-induced keratoconjunctivitis
• Glaucoma medications, antibiotics, antivirals, others; may be associated with
preservatives in all eye medications
...
Conjunctival chalasis
• Previous eye surgery
• Dry eye
• Redundant conjunctivitis
Viral
Adenoviral
• Exposure to infected individual (especially in school setting), recent ocular testing,
concurrent upper respiratory infection
Herpes simplex virus (HSV)
• Prior infection with HSV: trigger for reactivation such as stress, other acute viral or febrile
illnesses, ultraviolet exposure, or trauma
• Primary HSV infection: exposure to infected individual
Varicella (herpes) zoster virus (VZV)
• Acute chicken pox, exposure to an individual with active chicken pox or recurrent VZV
(shingles)
Molluscum contagiosum
• Predominantly older children and young adults
...
g
...
Associated drugs
include pilocarpine and timolol
...
14,15
• Prior infection (e
...
, HSV, mumps, mycoplasma pneumoniae)
• Systemic medications (e
...
, sulfonamides, barbiturates, or phenytoin) produce
inflammation and cicatricial changes of the various mucous membranes of the body
including the bulbar and palpebral conjunctiva
Neoplastic
Sebaceous carcinoma
• Unknown (rarely follows radiation therapy)
Ocular surface squamous neoplasia
• Associated with human papillomavirus (HPV); associated with significant exposure to
ultraviolet (UV) light; longstanding chronic inflammation may be associated16
Melanoma
• Associated with significant exposure to UV light; a history of systemic melanoma may
exist; previous pigmented lesions such as primary acquired melanosis (PAM) or nevus of
Ota
7
Conjunctivitis PPP
NATURAL HISTORY
The natural history of each type of conjunctivitis depends on its etiology
...
TABLE 2 NATURAL HISTORY OF CONJUNCTIVITIS
Type of Conjunctivitis
Natural History
Potential Sequelae
Seasonal
Recurrent
Minimal, local
Vernal
Onset in childhood; chronic course with
acute exacerbations during spring and
summer
...
Eyelid thickening; ptosis; conjunctival scarring;
corneal neovascularization, thinning, ulceration,
infection; visual loss; keratoconus
Atopic
Onset in childhood; chronic course with
acute exacerbations
Eyelid thickening or tightening, loss of lashes;
conjunctival scarring; corneal scarring,
neovascularization, thinning, keratoconus,
infection, ulceration; cataract; visual loss
Giant papillary conjunctivitis (GPC)
Chronic gradual increase in symptoms and
signs with contact lens wear, exposed
corneal or scleral sutures, ocular
prosthesis
Ptosis
Superior limbic keratoconjunctivitis (SLK)
Subacute onset of symptoms, usually
bilateral
...
Superior conjunctival keratinization, pannus,
filamentary keratitis
Contact-lens-related keratoconjunctivitis
Subacute to acute onset of symptoms
...
Superior epitheliopathy and corneal scarring;
limbal stem cell deficiency; may progress
centrally into the pupillary area
Floppy eyelid syndrome
Chronic ocular irritation due to nocturnal
eyelid ectropion causing upper-tarsal
conjunctiva to come in contact with
bedding
Punctate epithelial keratitis; corneal
neovascularization, ulceration, and scarring;
keratoconus
Giant fornix syndrome
Chronic mucopurulent conjunctivitis, which
waxes and wanes with typical short
courses of topical antibiotic therapy
Elderly women, ptosis, superior hyperemia,
chronic conjunctivitis, large superior fornix with
coagulum of mucopurulent material
Pediculosis palpebrarum (Phthirus pubis)
Blepharitis and conjunctivitis persist until
treated
Chronic blepharitis, conjunctivitis, and, rarely,
marginal keratitis
Medication-induced keratoconjunctivitis
Gradual worsening with continued use
Corneal epithelial erosion, persistent epithelial
defect, corneal ulceration, pannus, corneal and
conjunctival scarring
Conjunctival chalasis17
Chronic irritation; dry eye
Redundant conjunctiva
Adenoviral
Self-limited, with improvement of
symptoms and signs within 5–14 days
Mild cases: none
...
Vesicles
can form at the limbus, especially in
primary infection
...
Necrosis and scarring from vesicles on the
eyelid margins, conjunctiva, and in the corneal
stroma in primary disease in children
...
In recurrent
disease, keratitis of the epithelium or stroma and
late corneal anesthesia or dry eye
Molluscum contagiosum
Conjunctivitis is associated with eyelid
lesions, which can spontaneously resolve
or persist for months to years
Conjunctival scarring, epithelial keratitis, pannus;
less commonly subepithelial infiltrates/haze/scar,
occlusion of the puncta, follicular conjunctivitis
Allergic
Mechanical/Irritative/Toxic
Viral
8
Conjunctivitis PPP:
Natural History
TABLE 2 NATURAL HISTORY OF CONJUNCTIVITIS (CONTINUED)
Type of Conjunctivitis
Natural History
Potential Sequelae
Mild: self-limited in adults
...
Rare, but possibly corneal infection, preseptal
cellulitis
Severe: may persist without treatment,
rarely hyperacute
Corneal infection; may be associated with
pharyngitis, otitis media, meningitis
Neonate
Manifests within 1–7 days after birth, later
if a topical antibiotic was used
...
Corneal infection, corneal scarring, corneal
perforation, septicemia with arthritis, meningitis
Adult
Rapid development of severe
hyperpurulent conjunctivitis
Corneal infection, corneal scarring, corneal
perforation, urethritis, pelvic inflammatory disease,
septicemia, arthritis
Neonate
Manifests 5–19 days following birth, earlier
if placental membranes have ruptured
prior to delivery
...
Corneal scarring, conjunctival scarring; up to 50%
have associated nasopharyngeal, genital, or
pulmonary infection
Adult
May persist if untreated
Corneal scarring, neovascularization, conjunctival
scarring, urethritis, salpingitis, endometritis,
perihepatitis, follicular conjunctivitis
Ocular mucous membrane pemphigoid
(OMMP)
Onset generally over age 60
...
Conjunctival scarring and shrinkage; symblepharon;
trichiasis; corneal scarring, neovascularization,
ulceration; ocular surface keratinization; bacterial
conjunctivitis; cicatricial lid changes; severe tear
deficiency; severe vision loss
Graft-versus-host disease
Can involve multiple tissues including skin,
liver, gastrointestinal system, lung, and
eye
...
Conjunctivitis; subconjunctival fibrosis;
symblepharon; lacrimal gland involvement;
keratoconjunctivitis sicca; cicatricial lid disease
...
Involves the various mucous membranes
including the gastrointestinal system, lung
and eye following the systemic use of
sensitizing medication
Conjunctival scarring and shrinkage;
symblepharon; trichiasis; corneal scarring,
neovascularization, ulceration; limbal stem cell
deficiency; ocular surface keratinization; bacterial
conjunctivitis; cicatricial lid changes; severe tear
deficiency; severe vision loss
Sebaceous carcinoma
Occurs in fifth to ninth decades of life with
fairly rapid progression18
Orbital invasion, regional or distant metastases,
melanoma
Ocular surface squamous neoplasia
May be history of HPV, significant UV
exposure, chronic inflammation; may be
mistreated as an unresponsive
blepharoconjunctivitis
Conjunctival hyperemia, carcinoma in situ, or
ocular surface squamous neoplasia, which can be
locally invasive with regional metastases
Melanoma
Significant UV exposure, previous history
of melanoma, previous primary acquired
melanosis (PAM) or nevus of Ota
Pigmented, or non-pigmented lesion, invasive
regional metastases, history of previous
melanoma, primary may not be conjunctiva
Bacterial
Nongonococcal
Gonococcal
Chlamydial
Immune-mediated
(GVHD)
Stevens-Johnson syndrome
Neoplastic
9
Conjunctivitis PPP
CARE PROCESS
PATIENT OUTCOME CRITERIA
Outcome criteria for treating conjunctivitis include the following:
Eliminate or reduce signs and symptoms of conjunctivitis
Restore or maintain normal visual function
Detect and treat the underlying systemic disease process when applicable
Prevent or reduce the likelihood of damage to the ocular surface
DIAGNOSIS
The initial evaluation of a patient should include the relevant aspects of the comprehensive medical
eye evaluation,19,20 but some elements of the evaluation may be deferred in patients with symptoms
and signs suggestive of infectious conjunctivitis
...
g
...
e
...
g
...
The medical history takes into account the following:
Compromised immune status (e
...
, human immunodeficiency virus (HIV), chemotherapy,
immunosuppressants)
Current or prior systemic diseases (e
...
, atopy, Stevens-Johnson syndrome, carcinoma,
leukemia, chicken pox, GVHD)
The social history should include smoking habits, occupation and hobbies, travel, and sexual
activity
...
The typical clinical signs for the types of conjunctivitis that are
most common or most important to treat are listed in Table 3
...
Conjunctival injection, chemosis, watery discharge, mild mucous discharge
...
Giant papillary hypertrophy of superior tarsal conjunctiva, bulbar conjunctival
injection, conjunctival scarring, watery and mucoid discharge, limbal Trantas dots,
limbal "papillae", corneal epithelial erosions, corneal neovascularization and scarring,
corneal vernal plaque/shield ulcer
...
Eczematoid blepharitis; eyelid thickening, scarring; lash loss; papillary
hypertrophy of superior and inferior tarsal conjunctiva; conjunctival scarring; watery or
mucoid discharge; boggy edema; corneal neovascularization, ulcers and scarring;
punctate epithelial keratitis
...
Giant papillary conjunctivitis (GPC)
• Laterality associated with contact lens wear pattern
...
Papillae with white fibrotic centers can be seen in
patients with long-standing disease
...
Mechanical/Irritative/Toxic
Superior limbic keratoconjunctivitis (SLK)
• Bilateral superior bulbar injection, laxity, edema, and keratinization
...
Contact-lens-related keratoconjunctivitis
• Ranges from mild to diffuse conjunctival injection, focal or diffuse corneal
neovascularization, peripheral or circumferential corneal neovascularization, focal or
diffuse superficial punctate keratopathy
...
May result from limbal stem cell deficiency
...
Bilateral often asymmetric
...
Pediculosis palpebrarum (Phthirus pubis)
• Unilateral or bilateral follicular conjunctivitis
...
Medication-induced keratoconjunctivitis
• Laterality based on drug use
...
• Distinctive signs: contact dermatitis of eyelids with erythema, scaling in some cases
...
Adenoviral
• Abrupt onset
...
Varies in severity
...
Viral
• Distinctive signs: preauricular lymphadenopathy, petechial and subconjunctival
hemorrhage, corneal epithelial defect, multifocal epithelial punctate keratitis evolving to
anterior stromal keratitis, membrane/pseudomembrane formation, eyelid ecchymosis
...
Bulbar conjunctival injection, watery discharge, mild follicular reaction of
conjunctiva
...
• Distinctive signs: vesicular rash or ulceration of eyelids, pleomorphic or dendritic
epithelial keratitis of cornea or conjunctiva
...
Bulbar conjunctival injection, watery discharge, mild follicular
reaction of conjunctiva
...
Typically punctate
keratitis in primary disease; punctate or dendritic keratitis in recurrent disease
...
Molluscum contagiosum
• Typically unilateral, but can be bilateral
...
May have corneal pannus, especially if longstanding
...
Bacterial
Nongonococcal
• Unilateral or bilateral
...
Gonococcal
• Unilateral or bilateral
...
• Important sign to detect: corneal infiltrate or ulcer, which often begins superiorly
...
Eyelid edema, bulbar conjunctival injection, discharge may be
purulent or mucopurulent, no follicles
...
Bulbar conjunctival injection, follicular reaction of tarsal
conjunctiva, mucoid discharge, corneal pannus, punctate epithelial keratitis,
preauricular lymphadenopathy
...
Immune-mediated
Ocular mucous membrane pemphigoid (OMMP)
• Bilateral
...
Graft-versus-host disease (GVHD)
• Bilateral
...
Stevens-Johnson syndrome
• Unilateral or bilateral
...
12
Conjunctivitis PPP:
Diagnostic Tests
TABLE 3 TYPICAL CLINICAL SIGNS OF CONJUNCTIVITIS (CONTINUED)
Type of Conjunctivitis
Clinical Signs
Neoplastic
Sebaceous carcinoma
• Unilateral
...
May have a
mucopurulent discharge
...
• Eyelids may exhibit a hard nodular, nonmobile mass of the tarsal plate with yellowish
discoloration; may appear as a subconjunctival, multilobulated yellow mass, may
resemble a chalazion
...
Melanoma
• Unilateral
...
Sentinel vessel
...
NOTE: Typical clinical signs may not be present in all cases
...
In all entities, laterality may vary and may be asymmetrical
...
g
...
In other cases, however,
additional diagnostic tests may be helpful
...
24 Bacterial cultures also may be helpful for recurrent, severe, or chronic purulent
conjunctivitis in any age group and in cases where the conjunctivitis has not responded to
medication
...
A rapid, in-office
immunodiagnostic test using antigen detection is available for adenovirus conjunctivitis
...
25 More recently, a study of 128 patients with acute viral
conjunctivitis found that a newer test had a sensitivity between 85% and 93% and a specificity
between 96% and 99%
...
Polymerase chain reaction (PCR) may be used to detect
viral deoxyribonucleic acid
...
Chlamydial Diagnostic Tests
Suspected cases of adult and neonatal chlamydial conjunctivitis can be confirmed by laboratory
testing
...
28,29 These tests have
been largely supplanted by PCR for genital specimens, and, therefore, their availability for
conjunctival specimens is more limited
...
Although specimens from the eye have been used with satisfactory performance,30-32
these applications have not been approved by the Food and Drug Administration (FDA)
...
g
...
18,24
Biopsy
Conjunctival biopsy may be helpful in cases of conjunctivitis unresponsive to therapy
...
16
Conjunctival biopsy and immunofluorescent staining diagnostic tests may be helpful to
establish the diagnosis of diseases such as OMMP and paraneoplastic syndromes
...
33 Biopsy itself may cause
further conjunctival scarring in OMMP, so arrangements should be made in advance for
appropriate immune staining
...
In cases of suspected
sebaceous carcinoma, a full-thickness lid biopsy is indicated
...
Confocal Microscopy
Confocal microscopy may be helpful as a non-invasive tool to evaluate some forms of
conjunctivitis (e
...
, atopic, SLK)
...
38
MANAGEMENT
Prevention
The most important reason for early detection of conjunctivitis is that prompt, appropriate
treatment, available for most types of conjunctivitis, speeds resolution of the disease,
minimizing both the sequelae of untreated conjunctivitis and time away from work or school
...
For example, some types of neonatal conjunctivitis are associated with
pneumonia, otitis media, or Kawasaki disease
...
Diagnosis of SLK may lead to further investigations that
reveal a thyroid disorder
...
Individuals can protect against some chemical and toxin exposures by using adequate eye
protection
...
Infectious conjunctivitis in neonates can be prevented by means of prenatal screening and
treatment of the expectant mother and prophylactic treatment of the infant at birth
...
5% erythromycin are used as the standard
prophylactic agent to prevent ophthalmia neonatorum
...
5% has
been suggested as an alternative to antibiotic ointments for the prevention of neonatal
conjunctivitis,40,41 but it may be less effective and more toxic to the ocular surface
...
The use of a 7-day course of antibiotics has been shown to eradicate bacteria
within 5 days
...
Infected individuals should be counseled to wash hands frequently with soap and water (as
opposed to sanitizer only) and use separate towels, and to avoid close contact with others during
the period of contagion
...
While the exact length of the period of infectivity is variable, many consider 7 days
from the onset of symptoms as the contagious period, because the recovery of virus from
infected cases drops off after 7 days of infection
...
44,45
Health care facilities have occasionally been associated with epidemic outbreaks of adenoviral
keratoconjunctivitis
...
48 Hand-washing
procedures with antimicrobial soap and water49 and disinfecting ophthalmic equipment may
reduce the risk of transmission of viral infection, as the virus can remain infectious in a
14
Conjunctivitis PPP:
Treatment
desiccated state on surfaces for up to 28 days
...
48,49,52 Disinfecting agents recommended for routine
decontamination of tonometer tips include 70% ethyl alcohol and sodium hypochlorite (a 1:10
dilution of household chlorine bleach)
...
7 After disinfection, the tonometer
should be thoroughly rinsed in tap water and air dried before use
...
Any
disinfecting agent can result in iatrogenic corneal de-epithelialization and haze if not properly
removed from the tonometer tip before use by thorough rinsing in tap water and air drying
...
Though not in wide use,
disposable tonometer tips can also be considered to eliminate cross infections
...
Despite the use of reasonable measures, it may not be possible to prevent all transmission of
viral infection
...
In addition to tonometer tips, attention
should be paid to disinfecting other items that may have come in contact with the patient’s
secretions
...
”
Treatment
Treatment of conjunctivitis is ideally directed at the root cause
...
Treatment methods are described below for the most common types of conjunctivitis and for
those types that are particularly important to treat
...
54 Chronic use of vasoconstrictor agents can be associated with rebound
vasodilation once the agent is stopped
...
54 Many new medications combine antihistamine activity
with mast-cell stabilizing properties and can be utilized for either acute or chronic disease
...
The lowest potency and frequency of
corticosteroid administration that relieves the patient’s symptoms should be used
...
61 Table 4 lists topical medications that can be used for
seasonal allergic conjunctivitis
...
Frequent clothes washing and bathing/showering before bedtime may also
be helpful
...
The use of topical mast cell inhibitors can also be helpful in alleviating the symptoms of
allergic rhinitis
...
A follow-up visit should include an interval history, measurement of visual acuity,
and slit-lamp biomicroscopy
...
15
Conjunctivitis PPP:
Treatment
TABLE 4 TOPICAL MEDICATIONS FOR SEASONAL ALLERGIC CONJUNCTIVITIS
Generic Name
Trade Name
Class
Typical Daily
Dose
Alcaftadine
Lastacaft
H1-antagonist
1
Azelastine HCI
Optivar
H1-antagonist/mast-cell inhibitor
2
Available generically
Bepotastine besilate
Bepreve
H1-antagonist/mast-cell inhibitor
Cromolyn sodium
Crolom
Mast-cell inhibitor
2
4–6
Available generically
Emedastine difumarate
Emadine
H1-antagonist
4
Epinastine HCI
Elestat
H1- and H2-antagonist/mast-cell inhibitor
2
Ketoralac tromethamine
Acular, Acular LS, Acular PF
NSAID
4
Ketotifen fumarate
Alaway, Zaditor (OTC)
H1-antagonist/mast-cell inhibitor
2
Lodoxamide tromethamine
Alomide
Mast-cell inhibitor
4
Loteprednol etabonate
Alrex
Corticosteroid
4
Naphazoline/antazoline
Vasocon-A (OTC)
Antihistamine/decongestant
4
Naphazoline/pheniramine
Naphcon-A (OTC)
Antihistamine/decongestant
4
Opcon-A (OTC)
Visine-A (OTC)
Nedocromil sodium
Alocril
Mast-cell inhibitor
2
Olopatadine HCI 0
...
2%
Pataday
H1-antagonist/mast-cell inhibitor
1
Pemirolast potassium
Alamast
Mast-cell inhibitor
4
Adapted with permission from PDR Network LLC
...
40th ed
...
Montvale, NJ: PDR Network LLC; 2011:9
...
Agents for Relief of Seasonal Allergic Conjunctivitis
...
pdrbooks
...
NSAID = nonsteroidal anti-inflammatory drug; OTC = over the counter
Vernal/Atopic Conjunctivitis
General treatment measures include modifying the environment to minimize exposure to
allergens or irritants, and using cool compresses and ocular lubricants
...
For acute exacerbations of vernal/atopic conjunctivitis, topical corticosteroids are usually
necessary to control severe symptoms and signs
...
Topical cyclosporine 2% is effective as
adjunctive therapy to reduce the amount of topical corticosteroid used to treat severe atopic
keratoconjunctivitis
...
05% had fewer signs and symptoms than patients
using artificial tears
...
1% ophthalmic solution and
found that 30% of topical corticosteroid users were able to discontinue their use when using
adjunctive topical cyclosporine 0
...
68 As such, commercially available topical cyclosporine
0
...
For entities such
as vernal keratoconjunctivitis, which may require repeat short-term therapy with topical
corticosteroids, patients should be informed about potential complications of corticosteroid
therapy, and general strategies to minimize corticosteroid use should be discussed
...
69
Systemic immunosuppression rarely warranted
...
70-73 Tacrolimus ointment 0
...
03% or 0
...
A randomized, placebocontrolled clinical trial of topical tacrolimus 0
...
74 Tacrolimus or
pimecrolimus are rarely associated with development of skin cancer or lymphoma
...
Consultation with a dermatologist is often helpful
...
If
corticosteroids are prescribed, baseline and periodic measurement of IOP and pupillary dilation
should be performed to evaluate for glaucoma and cataract
...
Keratoconus, which is also associated with vernal conjunctivitis, is discussed in much more
detail in the Corneal Ectasia PPP
...
Protruding suture
knots can be treated by removing or replacing the sutures, rotating the knots, or using a
therapeutic contact lens
...
Ocular prostheses that cause
GPC can be cleaned, polished, or replaced
...
Associated abnormalities
such as aqueous tear deficiency and MGD should be treated
...
If corticosteroids are used for
conjunctivitis, baseline and periodic measurement of IOP and pupillary dilation should be
performed to evaluate for cataract and glaucoma
...
At the
follow-up visit, an interval history, measurement of visual acuity, and slit-lamp biomicroscopy
should be performed
...
Associated filamentary keratitis may occasionally respond to
topical 10% acetylcysteine80 or hypertonic (5%) saline
...
This tight eyelid drags the loose conjunctiva
down chronically with every blink over the superior cornea, creating chronic irritation and
inflammation
...
82 Up to 65%
of patients with SLK may have underlying thyroid dysfunction, and many of these have
associated ophthalmopathy
...
38,83 Because SLK may persist with exacerbations over a period of
years, treatment and frequency of follow-up are driven by the patient’s symptoms
...
Contact-Lens-Related Keratoconjunctivitis
This phenomenon is essentially hypoxia of the limbal stem cells creating punctate epithelial
keratitis, pannus, neovascularization, inflammation, edema, and ultimately epitheliopathy
...
A brief (1 to 2 weeks) course of topical
corticosteroids may be prescribed, in addition to more long-term topical cyclosporine 0
...
If
related to limbal stem cell failure, symptoms may be prolonged, but usually will ultimately
clear with contact lens abstinence
...
g
...
g
...
17
Conjunctivitis PPP:
Treatment
Floppy Eyelid Syndrome
Temporary relief of floppy eyelid syndrome is afforded by taping the patient’s eyelids shut or
by having the patient wear a protective shield while sleeping
...
Definitive therapy involves surgical procedures such as full-thickness
horizontal shortening of the upper eyelid to prevent it from everting
...
Floppy eyelid syndrome has been associated with keratoconus,
mitral valve prolapse (MVP), and sleep apnea,87,88 and referral for evaluation of the MVP and
sleep apnea should be considered
...
Many patients have concomitant nasolacrimal duct obstruction and chronic
dacryocystitis, which may need to be addressed surgically
...
Recommended treatment strategies include the prolonged use of systemic antistaphylococcal antibiotics and intensive topical antibiotics and corticosteroids
...
Given the increasing frequency
of methicillin-resistant Staphylococcus aureus (MRSA) in the general population, conjunctival
cultures before starting treatment can help guide the appropriate choice of antibiotic
...
Pediculosis Palpebrarum (Phthirus pubis)
Jeweler’s forceps can be used to remove the adult lice and nits (eggs) mechanically from the
eyelids and eyelashes
...
A bland
ophthalmic ointment (e
...
, petrolatum, erythromycin, bacitracin) applied 2 to 3 times a day for
10 days will smother the adult lice and nits
...
Patients
and close contacts should be advised to use anti-lice lotion and shampoo for nonocular areas
and to wash and dry clothing and bedding thoroughly (using the highest temperature of the
dryer for 30 minutes)
...
Sexual abuse should be considered in
children with this condition
...
g
...
Medication-Induced Keratoconjunctivitis
Discontinuation of the agent responsible for medication-induced keratoconjunctivitis results in
resolution over a period of weeks to months
...
Nonpreserved artificial tears
may be beneficial
...
A recent study showed conjunctival cicatricial changes after chronic use of glaucoma
medications
...
Adenoviral Conjunctivitis
The majority of cases of acute, infectious conjunctivitis in the adult population are viral and
self-limited; these cases do not require antimicrobial treatment
...
7 Because of its ability to infect multiple members of a family or a classroom,
this infection is often termed epidemic keratoconjunctivitis
...
There is inadequate
evidence to support the use of available antiviral agents for treating adenoviral conjunctivitis
...
Close follow-up is warranted for patients with adenoviral
18
Conjunctivitis PPP:
Treatment
conjunctivitis who are being treated with corticosteroids
...
90
Patients who use topical corticosteroids should be instructed to maintain precautions against the
spread of the virus for 2 additional weeks after symptoms resolve
...
g
...
Patients with severe disease who have corneal epithelial ulceration or membranous
conjunctivitis should be re-evaluated within 1 week
...
Topical corticosteroids should be tapered once
inflammation is controlled
...
This follow-up visit should include an interval history, measurement of visual
acuity, and slit-lamp biomicroscopy
...
Treatment of
subepithelial infiltrates varies with the severity of the disease
...
In cases with blurring, photophobia, and decreased vision, topical corticosteroids at
the minimum effective dose may be considered
...
Corticosteroids with poor ocular penetration, including
fluorometholone or site-specific corticosteroids such as rimexolone or loteprednol, may be less
likely to result in elevated IOP or cataract formation
...
Visits should include an
interval history, measurement of visual acuity and IOP, and slit-lamp biomicroscopy
...
91,92
Herpes Simplex Virus Conjunctivitis
Topical and/or oral antiviral treatment is recommended for HSV conjunctivitis to prevent
corneal infection
...
15% gel used 3 to 5 times per
day,93-96 trifluridine 1% solution 5 to 8 times per day or oral acyclovir 200 to 400 mg 5 times
per day
...
98,99 Topical trifluridine inevitably causes epithelial toxicity if used for more
than 2 weeks
...
Topical corticosteroids potentiate HSV infection
and should be avoided
...
Neonates require prompt consultation with the pediatrician or primary care physician, because
systemic HSV infection is a life-threatening condition
...
Many clinicians treat such patients with topical antibiotics to prevent secondary
infection, because the vesicles will undergo necrosis before healing
...
101 Topical
antivirals have not been shown to be helpful in treating VZV conjunctivitis
...
Recurrent cases of VZV conjunctivitis are generally
also papillary, but they can be pseudomembranous or vesicular
...
103 When treatment seems justified for the
immunocompetent patient, oral antivirals are recommended at a dose of 800 mg five times daily
for 7 days for acyclovir, 1000 mg every 8 hours for 7 days for valacyclovir, or 500 mg three
times daily for 7 days for famciclovir
...
Caution is advised in patients with impaired renal clearance
...
100
19
Conjunctivitis PPP:
Treatment
Molluscum Contagiosum
Conjunctivitis and keratitis from molluscum contagiosum are due to viral shedding from the
eyelid lesion(s) onto the surface of the eye
...
Treatment to remove the lesions is indicated in
symptomatic patients
...
The conjunctivitis may
require weeks to resolve after elimination of the lesion
...
104 Follow-up is not usually necessary unless the conjunctivitis persists
...
105 Use of topical antibacterial therapy
is associated with earlier clinical and microbiological remission compared with placebo in days
2 to 5 of treatment
...
105 The choice of antibiotic is usually empiric
...
Severe bacterial conjunctivitis is characterized by copious purulent discharge, pain, and marked
inflammation of the eye
...
In these cases, the choice of antibiotic is guided by the
results of laboratory tests
...
106,107 Increasing colonization of
MRSA has been found in nursing home residents,108 and the incidence of community-acquired
MRSA infections also has risen
...
aureus organisms are resistant to
many commercially available topical antibiotics
...
18 Topical therapy, while not necessary, is usually also used
...
If
corneal involvement is present, the patient should also be treated topically as for bacterial
keratitis (see Bacterial Keratitis PPP111)
...
Sexual abuse should be
considered in children with this condition
...
At each follow-up visit, an interval history, visual acuity measurement, and slitlamp biomicroscopy should be performed
...
N
...
gonorrhoeae is
responsible
...
112
Chlamydial Conjunctivitis
Table 5 contains recommendations for the treatment of chlamydial conjunctivitis
...
18 Empiric antibiotic
therapy can be considered in patients with symptoms and signs highly suggestive of chlamydia
(e
...
, follicular conjunctivitis that persists for several weeks)
...
Because the incidence of treatment
failure can be as high as 19%,24 patients should be re-evaluated following treatment
...
Adult conjunctivitis usually responds to systemic therapy, and sexual contacts
should be treated at the same time
...
Sexual abuse should be
considered in children with this condition
...
gonorrhoeae
Ceftriaxone
25–50 mg/kg intravenous or IM, single dose,
not to exceed 125 mg
Chlamydia
Erythromycin base or ethylsuccinate
50 mg/kg/day orally divided into four doses
daily for 14 days**
Neonates
NOTE: Pregnant women should not be treated with doxycycline, quinolones, or tetracyclines
...
Data from:
Centers for Disease Control and Prevention
...
MMWR Morb Mortal Wkly Rep 2010;59 (No
...
Update in: Centers for Disease Control and Prevention
...
Oral
cephalosporins no longer a recommended treatment for gonococcal infections
...
31):590–4
...
trachomatis
...
Consider lavage of
infected eyes with saline solution once
...
Because data are limited regarding alternative regimens for
treating gonorrhea among persons who have severe cephalosporin allergy, providers treating such patients should consult infectious disease
specialists
...
Sexual abuse must be considered a cause of infection in preadolescent children
...
trachomatis or N
...
║
¶
Spectinomycin is not available in the United States; updated information from the CDC on the availability of spectinomycin will be available at
www
...
gov/std/treatment
...
Infants treated with erythromycin should be followed for signs and symptoms of infantile hypertrophic pyloric stenosis
...
Early symptoms may be very non-specific ocular surface complaints such as
redness, foreign body sensation, dryness, tearing, discharge, and the like
...
As the condition progresses, the
inflammation may increase and the complaints may persist and worsen
...
As a result of the conjunctival scarring, entropion occurs, and trichiasis and acquired
distichiasis cause corneal trauma with eventual scarring
...
The diagnosis is typically one of exclusion, and a conjunctival biopsy for
immunopathology confirms the diagnosis
...
Medications include epinephrine
and glaucoma medications, especially the miotics
...
Grading systems and photographic documentation of the
conjunctiva may be helpful to assess disease progression
...
114 The rate of disease progression, age and general condition of the patient, and the
potential complications of immunosuppressive therapy should be considered and discussed with
the patient before initiating therapy
...
Mild and slowly
progressive disease may be treated using mycophenolate mofetil, dapsone, azathioprine, or
methotrexate
...
117 For severe inflammation or for inflammation
unresponsive to treatment with other agents, cyclophosphamide should be considered
...
In general, a physician with expertise in
immunosuppressive therapy should administer and monitor the treatment to minimize and
manage side effects
...
123 Associated dry eye state, trichiasis, distichiasis, and
entropion should be treated
...
In
advanced disease with corneal blindness, keratoprosthesis surgery may improve vision
...
A follow-up visit should include an interval history, visual acuity
measurement, slit-lamp biomicroscopy, and documentation of corneal and conjunctival changes
to monitor progression
...
Perioperative immunosuppression and close postoperative follow-up are warranted in such
cases
...
Systemic corticosteroids are the mainstay of initial treatment and are commonly used in
conjunction with cyclosporine or tacrolimus
...
22
Conjunctivitis PPP:
Provider and Setting
For ocular GVHD, aggressive lubrication and punctal occlusion are particularly useful in
treating patients with secondary keratoconjunctivitis sicca, which is very common
...
125
Topical cyclosporine or autologous serum tears can be used to treat dry eye syndrome
associated with GVHD
...
129 Treating the underlying inflammatory
process with topical corticosteroids and cyclosporine may help to reduce conjunctival damage
leading to dry eye disease
...
130 Other secondary complications of ocular
GVHD such as cicatricial eyelid malposition, SLK, or limbal stem cell failure should be
managed on a case-by-case basis
...
Sebaceous Carcinoma
When a diagnosis of sebaceous carcinoma is confirmed by an eyelid biopsy, local excision is
indicated
...
Ocular Surface Squamous Neoplasia
When a diagnosis of ocular surface squamous neoplasia is confirmed by biopsy, treatment may
consist of local excision with or without chemotherapeutics
...
The
optimal treatment is still under debate, and, therefore, management should be done by an
experienced specialist
...
PROVIDER AND SETTING
Because there is a spectrum of etiologies and treatment, optimal diagnosis and management of
conjunctivitis require broad medical skills and experience
...
Patients with conjunctivitis who are evaluated by non-ophthalmologist health care providers should be
referred promptly to the ophthalmologist in any of the following circumstances:
Visual loss
Moderate or severe pain
Severe, purulent discharge
Corneal involvement
Conjunctival scarring
Lack of response to therapy
Recurrent episodes
History of HSV eye disease
History of immunocompromise
A majority of patients with conjunctivitis can be treated effectively in an outpatient setting
...
COUNSELING AND REFERRAL
Counseling is imperative for all contagious varieties of conjunctivitis to minimize or prevent spread of
the disease in the community
...
Hand-washing is important to
reduce the risk of transmission of viral infection
...
When conjunctivitis is associated with sexually transmitted disease, treatment of sexual partners is
essential to minimize recurrence and spread of the disease
...
The physician must remain alert to the
23
Conjunctivitis PPP:
Socioeconomic Considerations
possibility of child abuse in cases of potentially sexually transmitted ocular disease in children
...
In cases of ophthalmia neonatorum due to gonococcus, chlamydia, and HSV, the infant should be
referred to an appropriate specialist
...
When conjunctivitis appears to be a manifestation of systemic disease, patients should be referred to
an appropriate medical specialist for evaluation
...
There have been multiple studies that have examined how allergic
conjunctivitis causes a reduction in quality of life132-135 and increases economic costs
...
An
observational cross-sectional study on allergic rhinitis in four European countries showed that
the presence of ocular symptoms reduces quality of life, reduces work productivity, and
increases resource utilization regardless of the severity of nasal symptoms
...
It found that 59% of patients had year-round symptoms, and that 46%
had significant impairment in their quality of life during an acute episode
...
136 Among students with nasal
and ocular symptoms, 42%, 24%, 36%, and 28% reported moderate to severe interference of
daily activities, at least 1 day of absence from school, a visit to a health care professional, and
drug usage for rhinitis, respectively
...
137 Similar decreases in quality of life and progressively
increasing economic costs for seasonal allergic conjunctivitis were also found in Spain and
Oxfordshire, England
...
133
Vernal keratoconjunctivitis (VKC) is a rarer form of allergic conjunctivitis that is more
common in children and young adults and is more prevalent in hot, dry climates
...
It not only
found that hot climate and male gender were risk factors for the disease but that higher
socioeconomic status was also a risk factor
...
Bacterial Conjunctivitis
The economic impact of bacterial conjunctivitis is also substantial
...
6 Even though the course of the disease was very short and there were no long-term
ocular sequelae, the estimated cost, including doctors’ visits, cultures, and antibiotics, ranged
from $66,468 to $120,583
...
5 The
estimated number of cases of bacterial conjunctivitis in the United States in 2005 was 4 million,
and the total direct and indirect cost of treating patients with bacterial conjunctivitis was $589
million
...
24
Conjunctivitis PPP:
Socioeconomic Considerations
Adenoviral Conjunctivitis
While adenoviral conjunctivitis is a common condition that often results in several missed days
of work and can lead to painful and visually debilitating keratoconjunctivitis, there have not
been any published studies yet on its overall economic impact in the general population
...
140 Preventive
infection-control measures can be extremely cost-effective if such an outbreak is avoided
...
The cost per case of adenoviral conjunctivitis is
$111
...
25 with the test, implying a cost savings of $71
...
141 If these costs are
extrapolated to include the entire U
...
population, it is estimated that nearly $430 million in
unnecessary medical care could be saved and that over 1 million cases of unnecessary antibiotic
treatment could be avoided
...
QUALITY OF OPHTHALMIC
CARE CORE CRITERIA
Providing quality care
is the physician's foremost ethical obligation, and is
the basis of public trust in physicians
...
The discussion that follows characterizes the core elements of such care
...
As such, the ophthalmologist demonstrates
compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate
patient fear and suffering
...
The
ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and
responds accordingly
...
The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state
...
Quality ophthalmic care has the following optimal attributes, among others
...
The
ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their
needs and concerns
...
This is to ensure
their meaningful participation (appropriate to their unique physical, intellectual and emotional state) in
decisions affecting their management and care, to improve their motivation and compliance with the
agreed plan of treatment, and to help alleviate their fears and concerns
...
The ophthalmologist carries out only those procedures for which he or she is adequately trained,
experienced and competent, or, when necessary, is assisted by someone who is, depending on the urgency
of the problem and availability and accessibility of alternative providers
...
The ophthalmologist treats patients with due regard to timeliness, appropriateness, and his or her own
ability to provide such care
...
When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate
ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and
procedures for obtaining it
...
The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other
medical or surgical problem
...
They receive as complete and accurate an accounting of the problem as necessary to provide efficient
and effective advice or intervention, and in turn respond in an adequate and timely manner
...
Quality of Ophthalmic Care Core Criteria
The ophthalmologist maintains complete and accurate medical records
...
The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective
manner and takes appropriate actions
...
For patients whose conditions fail to respond to treatment and for whom further treatment is
unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and
social services, and referral as appropriate and accessible
...
Additionally, he or she enables the patient to reach a fully informed
decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks,
benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks
and benefits of no treatment
...
g
...
The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and
assessing his or her personal performance in relation to established standards, and by revising or altering
his or her practices and techniques appropriately
...
This includes alerting
colleagues of instances of unusual or unexpected rates of complications and problems related to new
drugs, devices or procedures
...
The ophthalmologist also provides ophthalmic care in a manner that is cost effective without
unacceptably compromising accepted standards of quality
...
INTERNATIONAL STATISTICAL
CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS (ICD) CODES
Conjunctivitis includes entities with the following ICD-9 and ICD-10 classifications:
ICD-9 CM
Conjunctivitis, other diseases of conjunctiva
caused by viruses
ICD-10 CM
Code first underlying virus or
chemical and intent
372
...
39
H10
...
813
(approximately 65 codes in
this range)
Chlamydia
077
...
99
A74
...
0 – B30
...
40
A54
...
The applicable 7th character is required for all codes within the category, or as the
notes in the Tabular List instruct
...
If a code that requires a 7th character is not
6 characters, a placeholder X must be used to fill in the empty characters
...
If no bilateral code is provided and the condition is
bilateral, separate codes for both the left and right side should be assigned
...
• When the diagnosis code specifies laterality, regardless of which digit it is found in (i
...
, 4th digit, 5th digit, or 6th digit):
• Right is always 1
• Left is always 2
• Bilateral is always 3
28
Conjunctivitis PPP
APPENDIX 3
...
Details of these grading systems are reported in the Methods and Key to Ratings section at the
beginning of this document
...
g
...
PPP Recommendation Grading
Page 13: Conjunctival biopsy and immunofluorescent staining diagnostic tests may be helpful to establish the
diagnosis of diseases such as OMMP and paraneoplastic syndromes: II-; Insufficient; Discretionary
Page 13: A biopsy of bulbar conjunctiva should be performed and a sample should be taken from an
uninvolved area in an eye with active inflammation when OMMP is suspected: II-; Insufficient; Discretionary
Page 14: In cases of suspected sebaceous carcinoma, a full-thickness lid biopsy is indicated: III; Insufficient;
Discretionary
Page 14: When considering a biopsy, a preoperative consultation with the pathologist is advised to ensure
proper handling and staining of specimens: III; Insufficient; Strong
Page 14: Confocal microscopy may be helpful as a non-invasive tool to evaluate some forms of conjunctivitis
(e
...
, atopic, SLK): II-; Moderate; Discretionary
Page 14: Thyroid function tests are indicated for patients with SLK who do not have known thyroid disease:
III; Insufficient; Discretionary
Care Process – Management
Page 14: Individuals can protect against some chemical and toxin exposures by using adequate eye
protection: III; Good; Strong
Page 14: Contact lens wearers can be instructed in appropriate lens care and frequent lens replacement to
reduce the risk or severity of GPC: III; Good; Strong
Page 14: Infectious conjunctivitis in neonates can be prevented by prenatal screening and treatment of the
expectant mother and by prophylactic treatment of the infant at birth: III; Moderate; Strong
Page 14: Single-use tubes of ophthalmic ointment containing 0
...
5% may be less effective and more toxic to the ocular surface: I+;
Moderate; Discretionary
Page 14: The use of a 7-day course of antibiotics has been shown to eradicate bacteria within 5 days: III;
Good; Strong
Page 14: Infected individuals should be counseled to wash hands frequently with soap and water (as opposed
to sanitizer only) and use separate towels, and to avoid close contact with others during the period of
contagion: II++; Good; Strong
Page 14: Avoiding contact with others is especially important for individuals in professions with high
potential for transmission, such as health care workers and child care providers: III; Good; Strong
Page 14: To avoid cross-contamination, multiple-dose eyedrop containers should be discarded when
inadvertent contact with the ocular surface occurs: III; Good; Strong
Page 14: Hand-washing procedures with antimicrobial soap and water49 and disinfecting ophthalmic
equipment may reduce the risk of transmission of viral infection: III; Good; Strong
Page 15: Exposed surfaces on equipment can be decontaminated by wiping with sodium hypochlorite or other
appropriate disinfectants: III; Insufficient; Discretionary
Page 15: Disinfecting agents recommended for routine decontamination of tonometer tips include 70% ethyl
alcohol and sodium hypochlorite: III; Good; Strong
Page 15: Tonometer tips should be wiped clean and then disinfected by immersing them for 5 to 10 minutes
in either 70% ethyl ethanol or 1:10 sodium hypochlorite: II+; Good; Strong
30
Conjunctivitis PPP:
Appendix 3
...
PPP Recommendation Grading
Page 15: A follow-up visit should include an interval history, measurement of visual acuity, and slit-lamp
biomicroscopy: III; Insufficient; Discretionary
Page 15: If corticosteroids are used in chronic or recurrent conjunctivitis, baseline and periodic measurement
of IOP and pupillary dilation should be performed to evaluate for cataract and glaucoma: III; Insufficient;
Discretionary
Page 16: General treatment measures include modifying the environment to minimize exposure to allergens
or irritants, and using cool compresses and ocular lubricants: III; Insufficient; Discretionary
Page 16: Topical and oral antihistamines and topical mast-cell stabilizers can be useful to maintain comfort:
III; Insufficient; Discretionary
Page 16: For acute exacerbations of vernal/atopic conjunctivitis, topical corticosteroids are usually necessary
to control severe symptoms and signs: III; Insufficient; Discretionary
Page 16: The minimal amount of corticosteroid should be used based on patient response and tolerance: III;
Insufficient; Discretionary
Page 16: Topical cyclosporine 2% is effective as adjunctive therapy to reduce the amount of topical
corticosteroid used to treat severe atopic keratoconjunctivitis: I-; Moderate; Discretionary
Page 16: Commercially available topical cyclosporine may be a useful adjunct in the treatment of
vernal/atopic conjunctivitis: I++; Good; Strong
Page 16: For entities such as vernal keratoconjunctivitis, patients should be informed about potential
complications of corticosteroid therapy, and general strategies to minimize corticosteroid use should be
discussed: III; Good; Strong
Page 16: For severe sight-threatening atopic keratoconjunctivitis that is not responsive to topical therapy,
systemic immunosuppression may be warranted rarely: I+; Moderate; Discretionary for tacrolimus 0
...
PPP Recommendation Grading
Page 17: Mild contact-lens-related GPC may respond to using preservative-free lens-care systems: III;
Insufficient; Discretionary
Page 17: Mild contact-lens-related GPC may respond to administering mast-cell stabilizing agents: I+;
Moderate; Discretionary
Page 17: Mild contact-lens-related GPC may respond to refitting contact lenses: III; Insufficient;
Discretionary
Page 17: Mild contact-lens-related GPC may respond to switching to daily-wear disposable lenses: III;
Insufficient; Discretionary
Page 17: Mild contact-lens-related GPC may respond to changing the contact lens polymer: III; Insufficient;
Discretionary
Page 17: Associated abnormalities such as aqueous tear deficiency and MGD should be treated: III;
Insufficient; Discretionary
Page 17: For patients with moderate or severe GPC, discontinuation of contact lens wear for several weeks to
months and a brief course of topical corticosteroid treatment may also rarely be necessary: III; Insufficient;
Discretionary
Page 17: If corticosteroids are used for conjunctivitis, baseline and periodic measurement of IOP and
pupillary dilation should be performed to evaluate for cataract and glaucoma: III; Insufficient; Discretionary
Page 17: Frequency of follow-up visits is based on the severity of disease and treatment used: III;
Insufficient; Discretionary
Page 17: At the follow-up visit, an interval history, measurement of visual acuity, and slit-lamp
biomicroscopy should be performed: III; Insufficient; Discretionary
Page 17: Mild cases of SLK may respond to treatment of concomitant dry eye syndrome with lubricants: III;
Insufficient; Discretionary
Page 17: Mild cases of SLK may respond to treatment of concomitant dry eye syndrome with mast-cell
stabilizers: III; Insufficient; Discretionary
Page 17: Mild cases of SLK may respond to treatment of concomitant dry eye syndrome with cyclosporine:
III; Insufficient; Discretionary
Page 17: Mild cases of SLK may respond to treatment of concomitant dry eye syndrome with soft contact
lenses: III; Insufficient; Discretionary
Page 17: Mild cases of SLK may respond to treatment of concomitant dry eye syndrome with punctal
occlusion: III; Insufficient; Discretionary
Page 17: Associated filamentary keratitis may occasionally respond to topical 10% acetylcysteine: III;
Insufficient; Discretionary
Page 17: Persistent symptoms may necessitate surgical intervention such as cautery (chemical or thermal) to
tighten redundant conjunctiva or conjunctival resection: III; Insufficient; Discretionary
Page 17: An underlying thyroid disorder should be investigated by means of thyroid function tests: III;
Insufficient; Discretionary
Page 17: Because SLK may persist with exacerbations over a period of years, treatment and frequency of
follow-up are driven by the patient’s symptoms: III; Insufficient; Discretionary
33
Conjunctivitis PPP:
Appendix 3
...
05%: III; Insufficient; Discretionary
Page 17: At the follow-up evaluation, the contact lens fit, type, and lens-care regimen should be reviewed: III;
Insufficient; Discretionary
Page 17: At the follow-up evaluation, consideration should be given to alternatives to contact lenses once the
keratoconjunctivitis has resolved: III; Insufficient; Discretionary
Page 18: Temporary relief of floppy eyelid syndrome is afforded by taping the patient’s eyelids shut or by
having the patient wear a protective shield while sleeping: III; Insufficient; Discretionary
Page 18: Lubricants may help in managing mild cases: III; Insufficient; Discretionary
Page 18: Definitive therapy involves surgical procedures such as full-thickness horizontal shortening of the
upper eyelid to prevent the upper eyelid from everting: III; Insufficient; Discretionary
Page 18: Follow-up depends on the patient’s clinical course: III; Insufficient; Discretionary
Page 18: Referral for evaluation of the mitral valve prolapse and sleep apnea should be considered: III;
Insufficient; Discretionary
Page 18: Concomitant nasolacrimal duct obstruction and chronic dacryocystitis may need to be addressed
surgically: III; Insufficient; Discretionary
Page 18: Treatment with antibiotic regimens used for routine cases of bacterial conjunctivitis generally results
in only temporary improvement: III; Insufficient; Discretionary
Page 18: Recommended treatment strategies include prolonged use of systemic anti-staphylococcal
antibiotics: III; Insufficient; Discretionary
Page 18: Recommended treatment strategies include intensive topical antibiotics and corticosteroids: III;
Insufficient; Discretionary
Page 18: Supratarsal injections of antibiotics and corticosteroids, along with irrigation and sweeping of the
fornix with povidone-iodine solution, have been advocated: III; Insufficient; Discretionary
Page 18: Conjunctival cultures before starting treatment can help guide the appropriate choice of antibiotic:
III; Insufficient; Discretionary
Page 18: Surgical correction of the ptosis may play a role: III; Insufficient; Discretionary
Page 18: Jeweler’s forceps can be used to remove the adult lice and nits mechanically from the eyelids and
eyelashes: III; Insufficient; Discretionary
Page 18: Adherent nits may require epilation of the involved lashes: III; Insufficient; Discretionary
Page 18: A bland ophthalmic ointment applied 2 to 3 times a day for 10 days will smother the adult lice and
nits: III; Insufficient; Discretionary
Page 18: Patients and close contacts should be advised to use anti-lice lotion and shampoo for non-ocular
areas and to wash and dry clothing and bedding thoroughly: III; Good; Strong
34
Conjunctivitis PPP:
Appendix 3
...
PPP Recommendation Grading
Page 19 This follow-up visit should include an interval history, measurement of visual acuity, and slit-lamp
biomicroscopy: III; Insufficient; Discretionary
Page 19: During follow-up, patients should be evaluated for the presence of corneal subepithelial infiltrates,
which typically occur 1 or more weeks after the onset of conjunctivitis: III; Insufficient; Discretionary
Page 19: In mild cases, observation is sufficient: III; Insufficient; Discretionary
Page 19: In cases with blurring, photophobia, and decreased vision, topical corticosteroids at the minimum
effective dose may be considered: III; Insufficient; Discretionary
Page 19: Cyclosporine 1% may be a corticosteroid-sparing agent that is useful in the management of this
post-EKC condition: II-; Insufficient; Discretionary
Page 19: Patients who are being treated with topical corticosteroids should have the dosage slowly tapered to
the minimum effective dose: III; Insufficient; Discretionary
Page 19: A follow-up examination should be conducted every 4 to 8 weeks, and visits should include an
interval history, measurement of visual acuity and IOP, and slit-lamp biomicroscopy: III; Insufficient;
Discretionary
Page 19: Topical and/or oral antiviral treatment is recommended for HSV conjunctivitis to prevent corneal
infection: I++; Good; Strong
Page 19: Topical antiviral agents may cause toxicity if used for more than 2 weeks: III; Insufficient;
Discretionary
Page 19: Topical corticosteroids potentiate HSV infection and should be avoided: III; Insufficient;
Discretionary
Page 19: Within 1 week of treatment, patients should have a follow-up visit consisting of an interval history,
visual acuity measurement, and slit-lamp biomicroscopy: III; Insufficient; Discretionary
Page 19: Neonates require prompt consultation with the pediatrician or primary care physician, because
systemic HSV infection is a life-threatening condition: III; Insufficient; Discretionary
Page 19: Many clinicians treat VZV conjunctivitis patients with topical antibiotics to prevent secondary
infection, since the vesicles will undergo necrosis before healing: III; Insufficient; Discretionary
Page 19: Topical antivirals have not been shown to be helpful in treating VZV conjunctivitis: III; Insufficient;
Discretionary
Page 19: When treatment seems justified for the immunocompetent patient, oral antivirals are recommended
at a dose of 800 mg five times daily for 7 days for acyclovir, 1000 mg every 8 hours for 7 days for
valacyclovir, or 500 mg three times daily for 7 days for famciclovir: III; Insufficient; Discretionary
Page 19: Immunocompromised patients may need to be treated more aggressively: III; Insufficient;
Discretionary
Page 19: Caution is advised in patients with impaired renal clearance: III; Insufficient; Discretionary
Page 20: Treatment to remove the lesions is indicated in symptomatic molluscum contagiosum patients: III;
Insufficient; Discretionary
Page 20: Treatment options include incision and curettage, simple excision, excision and cautery, and
cryotherapy: III; Insufficient; Discretionary
Page 20: Follow-up is not usually necessary unless the conjunctivitis persists: III; Insufficient; Discretionary
36
Conjunctivitis PPP:
Appendix 3
...
PPP Recommendation Grading
Page 20: Sexual abuse should be considered in children with this condition: III; Good; Strong
Page 22: The diagnosis of OMMP is typically one of exclusion, and a conjunctival biopsy for
immunopathology confirms the diagnosis: III; Insufficient; Discretionary
Page 22: If the patient is using any of the drugs associated with medication-induced mucous membrane
pemphigoid, OMMP should be considered, and trial discontinuation of the medication should be attempted:
III; Insufficient; Discretionary
Page 22: Grading systems and photographic documentation of the conjunctiva may be helpful to assess
disease progression: III; Insufficient; Discretionary
Page 22: Although topical corticosteroid therapy may aid in controlling acute conjunctival inflammation,
systemic immunosuppressive therapy is usually required to inhibit inflammation and prevent progression of
conjunctival scarring: III; Insufficient; Discretionary
Page 22: The rate of disease progression, age and general condition of the patient, and the potential
complications of immunosuppressive therapy should be considered and discussed with the patient before
initiating therapy: III; Insufficient; Discretionary
Page 22: Systemic corticosteroids may be indicated to control inflammation initially, but they should be
weaned as other immunosuppressive therapy becomes effective to avoid complications of chronic
corticosteroid use: III; Good; Strong
Page 22: Mild and slowly progressive disease may be treated using mycophenolate mofetil, dapsone,
azathioprine, or methotrexate: III; Insufficient; Discretionary
Page 22: If dapsone is considered, caution should be taken in patients with glucose-6-phosphate
dehydrogenase (G6PD) deficiency: I-; Moderate; Discretionary
Page 22: For severe inflammation or for inflammation unresponsive to treatment with other agents,
cyclophosphamide should be considered: III; Insufficient; Discretionary
Page 22: These therapies can be used alone or in combination: III; Insufficient; Discretionary
Page 22: A physician with expertise in immunosuppressive therapy should administer and monitor the
treatment to minimize and manage side effects: III; Good; Strong
Page 22: Other less commonly used therapies that may be effective for treatment or adjunctive therapy
include oral tetracycline and niacinamide: III; Insufficient; Discretionary
Page 22: Other less commonly used therapies that may be effective for treatment or adjunctive therapy
include sulfasalazine: III; Insufficient; Discretionary
Page 22: Other less commonly used therapies that may be effective for treatment or adjunctive therapy
include intravenous immunoglobulin: III; Insufficient; Discretionary
Page 22: Associated dry eye state, trichiasis, distichiasis, and entropion should be treated: III; Insufficient;
Discretionary
Page 22: Mucous membrane or amniotic membrane grafting for fornix reconstruction is possible if eyes are
not severely dry and inflammation is under control: III; Insufficient; Discretionary
Page 22: In advanced disease with corneal blindness, keratoprosthesis surgery may improve vision: II-;
Insufficient; Discretionary
Page 22: The timing and frequency of follow-up visits is based on the severity of disease presentation,
etiology, and treatment: III; Insufficient; Discretionary
38
Conjunctivitis PPP:
Appendix 3
...
PPP Recommendation Grading
Counseling and Referral
Page 23: Counseling is imperative for all contagious varieties of conjunctivitis to minimize or prevent spread
of the disease in the community: III; Insufficient; Discretionary
Page 23: Hand-washing is important to reduce the risk of transmission of viral infection: III; Good; Strong
Page 24: Return to school or work depends on the age of the patient, occupation, and type and severity of
conjunctivitis: III; Insufficient; Discretionary
Page 23: When conjunctivitis is associated with sexually transmitted disease, treatment of sexual partners is
essential to minimize recurrence and spread of the disease: III; Good; Strong
Page 23: Patients as well as their sexual partners should be referred to an appropriate medical specialist: III;
Good; Strong
Page 23: The physician must remain alert to the possibility of child abuse in cases of potentially sexually
transmitted ocular disease in children: III; Good; Strong
Page 24: In cases of ophthalmia neonatorum due to gonococcus, chlamydia, and HSV, the infant should be
referred to an appropriate specialist: III; Good; Strong
Page 24: Infants who require systemic treatment are best managed in conjunction with a pediatrician: III;
Insufficient; Discretionary
Page 24: When conjunctivitis appears to be a manifestation of systemic disease, patients should be referred
for evaluation by an appropriate medical specialist: III; Good; Strong
APPENDIX 4: Ocular Surface Dye Staining
Page 41: Fluorescein, rose bengal, or lissamine green dyes may be used to assess the ocular surface: III;
Insufficient; Discretionary
Page 41: Lissamine green dye is not recommended for evaluating corneal epithelial disease: III; Insufficient;
Discretionary
40
Conjunctivitis PPP
APPENDIX 4
...
Fluorescein dye stains areas of the corneal and conjunctival epithelium where there is sufficient disruption of
intercellular junctions to allow the dye to permeate into the tissue
...
After instilling the dye, the ocular surface
is examined through a biomicroscope using a cobalt blue filter
...
Staining is more intense when it is observed using a yellow filter
...
Exposure-zone punctate or blotchy
fluorescein staining is observed in dry eye, and staining is more easily visualized on the cornea than on the
conjunctiva
...
Rose bengal staining of the tear film may be
performed using a saline-moistened strip or 1% solution
...
) The saline drop used to moisten the strip should remain in contact with the strip for at least a
minute to achieve an adequate concentration of rose bengal to stain the ocular surface
...
Lissamine green dye has a staining profile similar to that of rose bengal143 and may cause less ocular
irritation
...
Diffuse corneal and conjunctival staining is commonly seen in viral keratoconjunctivitis and medicamentosa
...
A pattern of exposure zone
(interpalpebral) corneal and bulbar conjunctival staining is typically seen with aqueous tear deficiency
...
aao
...
Comprehensive Adult Medical Eye Evaluation (2010)
To order any of these products, except for the free materials, please contact the Academy’s Customer Service
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only) or 415
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2
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6
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8
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10
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12
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Annex B: key to evidence statements and grades of
recommendations
...
Available at:
www
...
ac
...
html
...
GRADE: an emerging consensus on rating quality of evidence
and strength of recommendations
...
GRADE Working Group
...
Available at:
www
...
org/society/index
...
Accessed October 2, 2012
...
Office visits to ophthalmologists and other physicians for eye care
among the U
...
population, 1990
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Smith AF, Waycaster C
...
BMC Ophthalmol 2009;9:13
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Rutala WA, Weber DJ
...
Guideline for disinfection and sterilization in healthcare facilities, 2008
...
Available at:
www
...
gov/hicpac/pdf/guidelines/disinfection_Nov_2008
...
Accessed April 5, 2013
...
Preferred Practice Pattern®
Guidelines
...
San Francisco, CA: American Academy of Ophthalmology; 2013
...
aao
...
American Academy of Ophthalmology Cornea/External Disease Panel
...
Dry Eye Syndrome
...
Available at: www
...
org/ppp
...
Ligneous conjunctivitis in a girl with severe type I plasminogen
deficiency
...
Watts P, Suresh P, Mezer E, et al
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Am J Ophthalmol 2002;133:451-5
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Chronic conjunctivitis, part 2
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Module
3
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U
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Food and Drug Administration Center for Drug Evaluation and Research
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Acular®
(ketorolac tromethamine ophthalmic solution), 0
...
NDA 19-700/S-023 & S024
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Available at: www
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fda
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Topical tacrolimus and pimecrolimus and the risk of cancer: how much cause for
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Guidelines
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San Francisco, CA: American Academy of Ophthalmology; 2013
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Clinical Science Course
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