Chapter XVII.4. Conjunctivitis and Eyelid Infections
Jaxon J. Huang
Peggy M. Liao, MD
December 2022

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A 6 year old female presents to the pediatrician with red eyes bilaterally and watery mucous discharge for 2 days. Her mother reports that the symptoms started in her right eye and progressed to involve the left eye. The patient complains of an itching and burning sensation, stating that it feels like there is "sand in her eye". She had been in good health until 1 week ago, when she developed rhinorrhea, cough, and sore throat after visiting a water park. Her two older brothers also had similar symptoms.

Exam: VS T 37.2, P 80, RR 13, BP 95/65. She is in mild distress, rubbing at her eyes. The inner eyelids (palpebral conjunctivae) are red and edematous, there is mild bulbar conjunctival injection (over the sclera/glove), moderate watery discharge bilaterally, and preauricular adenopathy. A fluorescein exam is done which shows smooth corneas bilaterally.

The patient and her mother are counseled on the self-limited nature of viral conjunctivitis and her symptoms are treated with a cool compress and artificial tears several times a day. Since it is highly contagious, they are advised to avoid sharing of linens, practice frequent handwashing, and to avoid rubbing or touching the eyes. The patient is also advised to stay home from school until symptoms resolve. Her mother asks several additional questions: 1) My niece had this and she was put on antibiotic eye drops, specifically a product called Ciprodex (ciprofloxacin and dexamethasone). You reply that antibiotics will not help this type of viral infection, it will not reduce the contagious potential, and that some patients can be sensitive to antibiotic eye drops. 2) My niece was told that she could have bacterial conjunctivitis. You reply that you expect this viral infection to get better in 1 to 2 days. The mucus in her eyes could encourage bacterial growth so please wipe the mucus from her eyes with a moist soft tissue. If there is more mucus in the eyes, or the eyes appear to be worse, please call me so that we can determine if antibiotic eye drops are necessary.

The conjunctiva is a thin, semitransparent layer of non-keratinized mucous membrane that covers the sclera of the eyeball (bulbar conjunctiva) and inner layers of the eyelids (tarsal or palpebral conjunctiva) (1). Inflammation of the conjunctiva is referred to as conjunctivitis, which can be classified as infectious or non-infectious. The examination documentation generally uses the term conjunctival injection. While some practitioners will describe the sclera as being injected (scleral injection, redness, or inflammation), it is usually the conjunctiva that is injected and not the sclera. Infectious conjunctivitis can be further sub-classified into viral, bacterial, or chlamydial causes. Non-infectious conjunctivitis includes allergic, chemical, toxic conjunctivitis, and other causes (2,3). Conjunctivitis is a common condition and more than 80% of acute cases are diagnosed by non-ophthalmologists, including pediatricians (4).

The most common cause of infectious conjunctivitis overall is viral, with many (perhaps most) of these cases due to adenoviruses. Less common causes of viral conjunctivitis includes herpes simplex virus (HSV), varicella zoster virus (VZV), and enteroviruses. More recently, the COVID-19 strain of coronavirus has been reported to cause conjunctivitis in 1% to 6% of patients infected with the virus (4). Viral conjunctivitis is seen more often in the summer months and usually occurs in older children above the age of 5 years (3). Viral conjunctivitis is highly contagious for 10 to 14 days and can spread through contaminated fingers, water at swimming pools, through sharing of items (e.g., towel), or other fomites. The onset can be acute and bilateral involvement is common, but one eye can be involved first. Symptoms include watery mucus discharge, red eyes, foreign body sensation, burning, itching, and light sensitivity. Preauricular adenopathy is common, along with conjunctival membranes or pseudomembranes. Patients may have upper respiratory symptoms or a recent sick contact prior to the onset of the conjunctivitis. Laboratory tests are usually not indicated; however in patients with persistent infection for over four weeks, specific viral polymerase chain reaction (PCR) testing can be conducted. Due to its self-limited nature, treatment is supportive with artificial tears, antihistamine eye drops, and cool compresses. Conjunctivitis may take up to 21 days to resolve. Spread of infection should be prevented with frequent hand washing, avoidance of eye rubbing or touching, and avoidance of towel or linen sharing. Children should stay away from school for at least the first 3 to 7 days until symptoms resolve (4,5).

In children, the most common variant of adenovirus infection is pharyngoconjunctival fever. This manifestation is highly contagious and presents with bilateral conjunctivitis, high fever, pharyngitis, and periauricular lymphadenopathy (3-5). Epidemic keratoconjunctivitis (EKC) is the most severe ocular manifestation of adenovirus infection, presenting as itching, burning, and foreign body sensation. Corneal infiltrates can develop leading to blurred vision that usually resolves, but in some cases can cause permanent visual disturbances (3,4). Herpetic conjunctivitis can be indistinguishable from conjunctivitis caused by other viruses, but the presence of herpetic vesicular skin lesions along the eyelids should raise the suspicion for HSV. Treatment includes topical antiviral therapy such as ganciclovir or trifluridine, and in some cases, systemic antiviral therapy such as acyclovir (4,5).

The second most common cause of infectious conjunctivitis is bacterial conjunctivitis. Bacterial conjunctivitis is encountered more frequently in children less than 5 years of age, with peak season between December and April. The most common pathogens in children are Haemophilus influenzae (60% to 80%), followed by Streptococcus pneumoniae (20%), Staphylococcus aureus (5% to 10%) and Moraxella catarrhalis. It can often be difficult to distinguish between bacterial and viral conjunctivitis based on signs and symptoms alone. Previous studies have found no correlation between the clinical presentation and the underlying etiology, despite traditional belief that specific signs/symptoms (e.g., itching, discharge, involvement of the second eye, lymph node involvement, papillae/follicles) could differentiate between a bacterial versus a viral cause. Recent studies have suggested that the three signs in combination could be a predictor of bacterial conjunctivitis: bilateral eyelid secretions, absence of itching, and no previous history of conjunctivitis. Mucopurulent discharge and unilateral involvement that becomes bilateral 1 to 2 days later could also help to distinguish bacterial conjunctivitis rather than viral conjunctivitis; however, these associations have not been proven to be accurate in the literature (4). Other signs may include sticky eyelids, conjunctival erythema, and foreign body sensation. If the onset of symptoms is hyperacute (within 12 to 24 hours) with significant discharge, a conjunctival scraping for gram stain and culture should be obtained to rule out gonococcal conjunctivitis. Otherwise, gram stain and culture are typically only done in cases that are severe, recurrent, have not responded to therapy, or for suspected infectious neonatal conjunctivitis. Bacterial conjunctivitis is normally self-limiting with spontaneous resolution in 7 to 10 days. However, antibiotic therapy can be prescribed to speed resolution, reduce symptom severity, and decrease transmission. Broad-spectrum antibiotics such as topical aminoglycosides, trimethoprim/polymyxin B, fluoroquinolones, or macrolides can be used for 5 to 7 days. Although complications and adverse events are rare, severe infections can lead to keratitis, corneal ulceration and perforation, and blindness (2-5).

Chlamydia trachomatis causes a number of ocular infections including inclusion conjunctivitis, trachoma, and neonatal conjunctivitis. Inclusion conjunctivitis is a sexually transmitted infection spread through oculogenital contact, typically in young adults. The infection is usually chronic, with mucous discharge and tarsal conjunctival follicles occurring for weeks to months. In most cases there is concurrent genital infection (4). A definitive diagnosis can be made by direct chlamydial immunofluorescent test, DNA probe, PCR of a conjunctival sample, or chlamydial culture. Treatment includes oral azithromycin, erythromycin, or doxycycline for 7 days for both the patient and any sexual partners. Topical erythromycin or tetracycline ointment is also prescribed for 2 to 3 weeks.

Trachoma is a more severe eye infection due to C. trachomatis that affects 40 million individuals globally and is the leading cause of infectious blindness in the world. It is rare in the United States due to more controlled occupational workplace standards. Trachoma typically occurs in underprivileged countries with crowded conditions, poor hygiene, and occupational conditions that spread the disease. Mucopurulent discharge and tender preauricular nodes are seen initially, which then progresses to extensive eyelid, conjunctival, and corneal scarring. Eventually, loss of vision can occur. Patients are treated with oral azithromycin, erythromycin, or doxycycline for 2 weeks, in addition to topical tetracycline, erythromycin, or sulfacetamide ointments for 3 to 4 weeks in some cases. It is important to note that tetracyclines should only be given to children above the age of 8 years due to the risk of tooth discoloration and enamel hypoplasia in younger children (4,5).

Allergic conjunctivitis is a common non-infectious conjunctivitis, affecting 15% to 20% of the population (4). Seasonal allergic conjunctivitis occurs predominately in the spring and summer months due to pollen from plants and trees. Perennial allergic conjunctivitis occurs year-round due to common allergens such as mites or animal hair. Typical symptoms include bilateral intense itching of the eyes, watery discharge, red eyes, rhinorrhea and a history of allergies (4). First-line treatment is aimed at eliminating the inciting agent, if one can be identified. Cool compresses several times a day can decrease itchiness and provide symptomatic relief. In mild cases, artificial tears 4 to 8 times a day can be used. In moderate cases, topical antihistamine, mast-cell stabilizers, or prostaglandin inhibitors may help. Topical mast-cell stabilizers also work well as a preventive measure if the patient's allergies are seasonal. In more severe cases, mild topical corticosteroids can be added to the current regimen, but patients must be monitored for side effects associated with prolonged topical corticosteroid use such as cataracts and glaucoma. Concomitant oral antihistamines are helpful if the patient has systemic allergies (3,5).

Chemosis is the term used for more severe conjunctival edema in which the conjunctiva separates from the underlying sclera. The fluid is often clear or lightly pink. In Hawai`i this is known as "lychee eye" because it resembles white inner lychee fruit. The edema severity can be quite remarkable since it can actually protrude from the eye in severe cases. The conjunctiva fuses with the cornea/globe at the limbus, which confirms that the swelling is limited to the conjunctiva. This is almost always due to contact hypersensitivity. The treatment is antihistamines (systemic and or topical) and topical vasoconstrictors.

Chemical conjunctivitis occurs when the eye is exposed to acidic or basic chemicals, such as household cleaning products, industrial pollutants, sprays, and smoke. Alkaline substances are more serious due to their ability to remain in the conjunctival tissues and cause damage for hours to days, whereas acidic substances cause damage immediately. Litmus paper can be used to test the tears for neutrality. Treatment includes copious irrigation of the eyes with water or normal saline as soon as possible, frequent artificial tears, and moisturizing eye ointments. If the cornea has been burned with the chemical, an ophthalmology consult needs to be obtained. In severe cases, the loss of the eye can occur due to extensive tissue damage (3). More mild conjunctivitis is caused by mild irritants such as soap in children and silver nitrate in newborns which used to be used for gonococcal eye prophylaxis.

Toxic conjunctivitis occurs due to prolonged exposure to foreign substances such as eye cosmetics or eye medications. Topical eye medications are the most common cause, most notably the aminoglycosides (neomycin, gentamicin, tobramycin), glaucoma medications (brimonidine, pilocarpine), antivirals, and drops with preservatives such as benzalkonium chloride. Treatment includes discontinuing the offending eye drop and using preservative-free artificial tears 4 to 8 times a day if needed. In severe cases, topical corticosteroids can be used to reduce conjunctival inflammation (2,5).

A chalazion and a hordeolum are two inflammatory lesions of the eyelid. A chalazion results from the obstruction of a Meibomian gland, located just posterior to the eyelash line, or a gland of Zeis, located near the base of each eyelash follicle. Both glands are sebaceous glands that produce an oily secretion (6). When the glands are occluded, the glandular sebum is trapped and expands into the surrounding tissue, causing an inflammatory response and a chronic, firm, erythematous, tender or nontender nodule in the eyelid. They are not considered infectious unless eyelid cellulitis ensues. When the lesion is acute and infectious, it is termed a hordeolum. An external hordeolum involves the blockage of the gland of Zeis, whereas an internal hordeolum involves the Meibomian gland. A hordeolum will be acute, painful, edematous, and erythematous, and can progress into cellulitis of the surrounding soft tissue. The usual causal agent is Staphylococcus aureus. The diagnosis of a chalazion and a hordeolum is based on clinical features during external and slip lamp examination and culture if a hordeolum is suspected. They are often difficult to distinguish. The main treatment includes warm compresses with gentle massage, as they are often self-limited and resolve spontaneously. For a hordeolum, a short course of topical antibiotics (bacitracin, tobramycin, erythromycin) can be considered. In severe cases, incision and drainage may be needed. For a chalazion, a short course of topical antibiotic/corticosteroid (neomycin/polymyxin B/dexamethasone) can be considered. If the chalazion persists, incision and curettage or an intralesional corticosteroid injection may be performed. It is best for ophthalmic corticosteroids to be prescribed by an ophthalmologist so that any ocular side effects can be monitored (5 to 8).

Instructions for warm compresses over the eye should be given to patients. A small towel (wash cloth) moistened with very warm water over the affected eye stays warm for a few minutes at the most, rendering it fairly ineffective. Classically, boiling an egg and wrapping this in a moist wash cloth will maintain warmth for a longer period of time. When the egg cools, the same egg can be re-used and boiled again; however, boiling water can be time consuming and the boiling temperature can sometimes be too hot. Microwaving an egg can be tried, but this can result in the egg exploding. An easier solution is to make a ball of cooked sticky rice. Wrap this in plastic wrap, microwave it, then wrap it in a moist wash cloth. This maintains the warmth of the compress for a long period of time. When the ball of rice cools, it can be re-microwaved to be reused again. Theoretically, other sludgy materials can be used such as mashed potatoes or moistened bread.

1. The most common cause of viral conjunctivitis is:
   a. Enterovirus
   b. Adenovirus
   c. Herpes simplex virus
   d. Varicella zoster virus

2. What is the treatment for bacterial conjunctivitis?

3. An 18 year old female presents with a chronic follicular conjunctivitis and a diagnosis of chlamydial conjunctivitis is made. What is the proper treatment?

4. A 2 year old male presents to the emergency department after his mother found him playing with an open bottle of household cleaner. He is crying, his eyelids are erythematous, the conjunctiva are swollen, and he is constantly rubbing his eyes. What should be done immediately?

5. A 13 year old female presents with an acute red lump in her right upper eyelid. She notes that the lump appeared yesterday and is very tender. What is the recommended treatment? Should a culture be obtained?

1. Ma K, Morrison JC. Chapter 5. The Conjunctiva and the Limbus. In: Freddo TF, Chaum E (eds). Anatomy of the Eye and Orbit: the Clinical Essentials. 2018. Wolters Kluwer, Philadelphia. pp: 151-169.
2. Rubenstein JB, Spektor T. Chapter 4.6. Conjunctivitis: Infectious and Noninfectious. In: Yanoff M, Duker JS (eds). Ophthalmology, 5th edition. 2018. Elsevier Saunders, Edinburgh. pp: 183-191.
3. Olitsky SE, Marsh JD. Chapter 644. Disorders of the Conjunctiva. In: Kliegman RM, St. Geme JW, Blum NJ, et al (eds). Nelson Textbook of Pediatrics, 21st edition. 2020. Elsevier, Philadelphia, PA. pp: 3364-3368.
4. Azari AA, Arabi A. Conjunctivitis: A Systematic Review. J Ophthalmic Vis Res. 2020;15(3):372-395. doi: 10.18502/jovr.v15i3.7456.
5. Chapter 5. Conjunctiva/Sclera/Iris/External Disease. In: Gervasio KA, Peck TJ (eds). The Wills Eye Manual: Office and Emergency Room Diagnosis Disease and Treatment of Eye, 8th edition. 2022. Wolters Kluwer, Philadelphia. pp: 109-135.
6. Chapter 2. The Eyelids and Adenexa. In: Freddo TF, Chaum E (eds). Anatomy of the Eye and Orbit: the Clinical Essentials. 2018. Wolters Kluwer, Philadelphia, PA. pp: 62-95.
7. Neff AG, Chahal HS, Carter KD. Chapter 12.7. Benign Eyelid Lesions. In: Yanoff M, Duker JS (eds). Ophthalmology, 5th edition. 2018. Elsevier Saunders, Edinburgh. pp: 1293-1303.
8. Olitsky SE, Marsh JD. Chapter 642. Abnormalities of the Lids. In: Kliegman RM, St. Geme JW, Blum NJ, et al (eds). Nelson Textbook of Pediatrics, 21st edition. 2020. Elsevier, Philadelphia, PA. pp: 3360-3362.

Answers to questions
1. b. Adenovirus causes many or perhaps most of viral conjunctivitis.
2. Bacterial conjunctivitis is normally self-limiting with spontaneous resolution in 7 to 10 days. Broad-spectrum topical antibiotics such as topical aminoglycosides, trimethoprim/polymyxin B, fluoroquinolones, or macrolides can be used for 5 to 7 days to speed resolution, and reduce symptom severity.
3. Oral azithromycin, erythromycin, or doxycycline for 7 days for both the patient and any sexual partners. Consider that there might be other sexually transmitted infections that would require other antibiotics. Topical erythromycin or tetracycline ointment is also used for 2 to 3 weeks.
4. The patient most likely has chemical conjunctivitis. Copious irrigation of the eyes with water or normal saline should be done as soon as possible.
5. A hordeolum will present acutely and the lesion will be erythematous and tender, whereas a chalazion is more chronic and can be non-tender. A culture can be done, but it will take several days for the result to help with managing its treatment. A culture revealing Staphylococcus aureus would indicate that the lesion is more likely to be a hordeolum since it is due to an infectious process, whereas a chalazion is an inflammatory process. Frequent prolonged warm compresses are recommended to help open the occluded pores. You describe wrapping cooked sticky rice in plastic wrap, then wrapping this in a moist wash cloth to maintain the warmth of the compress for a longer period of time.

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