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BLOG: Viral conjunctivitis: Still thinking about goblet cells
Not a day goes by at SkyVision during which I don’t see at least one patient who is weeks, sometimes months, out from a case of infectious conjunctivitis and is still having symptoms. Their history is almost always filled with a veritable cornucopia of antibiotics prescribed most often by either their primary care doctor or the well-meaning but overmatched nurse practitioner at a minute clinic. “Why are my eyes still red? Am I infected again? My eyes just don’t feel right since the infection.”
I’m betting it’s the same thing in your neck of the woods, right?
Whether it be viral or bacterial, infectious conjunctivitis involves our immune system in response to the replication of the invading organism. In the early stages of infection there is swelling of the tissues in response to the infection, as well as an influx of lymphocytes targeting the bacteria or virus. Happily, this response usually results in the eradication of the infection, with or without the assistance of antibiotics or antivirals. Less happily we get collateral damage to both the accessory lacrimal glands of Moll and Zeis, as well as — wait for it — goblet cells.
When we see these patients in the office weeks after the infection, are we seeing ongoing inflammation or delayed recovery from prior inflammation? The answer, of course, is “yes.” We rarely see a decrease in tear volume, though; it is unlikely that aqueous production is reduced and thus causing those chronic symptoms. More likely is the case that the goblet cells are still underperforming and that our patient’s symptoms are caused by inadequate mucin.
In general we are better off, and so are our patients, if we can simply support them through this phase with palliative care. Artificial tears are often all that is necessary. I like those “utility infielder” tears like Refresh Optive (Allergan) and Systane Ultra (Alcon) here, but your mileage may vary. When necessary, though, I pull a pretty quick trigger on steroid treatment in the ultra-symptomatic. Fluorometholone and loteprednol have a more favorable safety profile so I lean toward them if I can.
The goblet cells are the sensitive souls of the ocular surface. We need to carve out a “safe space” medication to mimic mucin when they are too offended to work. Until then we will need to be comfortable treating with anti-inflammatory agents.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.