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Update your viral conjunctivitis protocol for better outcomes
Patients suspicious for this highly contagious condition should be handled carefully and diagnosed quickly.
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There are an estimated 6 million cases of acute conjunctivitis in the U.S. each year. Twenty percent of these cases first present to either an optometrist or ophthalmologist, according to Udeh and colleagues, and are spread across three major subtypes of conjunctivitis: allergic, bacterial and viral.
Viral etiology is thought to make up 20% to 70% of infectious conjunctivitis, O’Brien and colleagues reported. The enormity of this range, which would certainly reduce patient confidence were they aware of it, is largely due to the historic lack of a point-of-care diagnostic to differentiate among etiologies. By implementing a red eye protocol for conjunctivitis – designed to achieve a differential diagnosis of acute conjunctivitis, as well as reduce the risk of potential infection in the practice – my practice has improved clinical results and increased patient satisfaction.
As much as 90% of viral conjunctivitis cases may be caused by adenovirus, which is highly contagious and has a transmission rate of up to 50%. Viral conjunctivitis can be associated with decreased visual acuity or light sensitivity from persistent subepithelial infiltrates, chronic dry eye and visual loss from conjunctival foreshortening and scarring (Kaufman and Gordon et al.).
Mile Brujic
Patient isolation protocol
Common modes of transmission include hand-to-eye and airborne respiratory droplets. This high level of contagion makes it imperative to isolate any patient that presents in the waiting room with the appearance of acute conjunctivitis.
Paraoptometrics can easily be trained to take the lead on this. In our office, these patients are sent to any open exam lane as quickly as possible. We call that lane the “red eye room” until the patient is confirmed as not infected with adenovirus. After the patient leaves, we thoroughly swab the entire area with alcohol, regardless of whether the test is positive for viral conjunctivitis.
Differentiating between viral, allergic, bacterial
An initial patient history should include symptoms as well as questions regarding contact with anyone who manifested signs of red eye recently. Patients that report an origin of pain associated with some kind of physical event – such as something flying into their eye – can generally be eliminated from a possible conjunctivitis diagnosis.
All patients with red eye should be treated as contagious until the absence of adenovirus is confirmed.
Image: Brujic M
All others are administered the AdenoPlus (Nicox, Dallas) immunoassay. This unique point-of-care diagnostic provides a rapid, differential diagnosis of viral conjunctivitis before the patient leaves the office.
If the test is negative for adenovirus, I continue with a differential diagnosis to determine if the conjunctivitis is bacterial or allergic. One clue is if the conjunctivitis is unilateral. Allergic reactions are more likely to be bilateral but can be asymmetric in their presentation.
I would suspect a bacterial infection if there were a significant discrepancy between the two eyes in the appearance of the injection. I also try to differentiate between purulent and mucoid discharge. Purulent discharge tends to be whiter in color and is considered to be the thicker byproduct of bacteria. Purulent discharge also tends to produce more “caking” around the eye, creating a mattered lashes appearance. Although this rule generally applies for most cases, there are a number of clinical examples where the signs were inconsistent with the final diagnosis.
Mucoid discharge, a symptom of allergic conjunctivitis, is more of a yellow color and is similar to what you may see from the nose. Mucoid discharge tends to pool in the corner of the eye and, while the patient may be regularly wiping it away, it continues to be produced.
I also find it helpful to ask specific questions about itching. Patients with seasonal allergic conjunctivitis generally report that the whole eye itches, with symptoms being greater in the nasal canthal area. They will oftentimes demonstrate how they rub their eyes by utilizing a fist and really trying to get to the nasal canthal regions.
In the case of bacterial conjunctivitis, although they can present with bilateral disease, they will usually be itchy or uncomfortable in primarily one eye. A close examination of this complaint can differentiate between other pathologies as well. If patients close their eyes and scratch their eyelids, that may be dermatitis. If they close their eyes and itch the lid margins, that is probably blepharitis. If they scratch the inside lower eyelid, they may potentially have mucous fishing syndrome.
The final diagnostic technique I use is to place fluorescein dye on every patient, as it reveals clinical findings that are virtually invisible without the dye. Patients with bacterial conjunctivitis may have an irritated corneal surface as manifested through the presence of corneal staining. Seasonal allergic conjunctivitis patients do not tend to show punctate staining. Keep in mind that other forms of chronic allergies can manifest in the cornea, including vernal keratoconjunctivitis and atopic keratoconjunctivitis.
Differential treatment
No clinical treatment for viral conjunctivitis is approved by the U.S. Food and Drug Administration. Recommendations include patient counseling about contagion and isolation, especially for school-age children. Patients may also use artificial tears, antihistamines and cool compresses to increase comfort. Topical corticosteroids can be used, when warranted, if corneal involvement is present.
A number of off-label treatments have invigorated interest in a new protocol for treating viral conjunctivitis. Some practitioners have embraced Betadine 5% ophthalmic solution (povidone-iodine, Alcon). Studies have confirmed high microbial kill rates with Betadine (Chronister et al.), and using it in cases of adenovirus can help reduce the viral load in the eye.
A topical anesthetic is initially applied to the eye to mitigate stinging, then a drop of a topical nonsteroidal anti-inflammatory drug is followed by several drops of 5% povidone-iodine on the eye and lids. Patients then roll their eye for 2 minutes to distribute the Betadine. A sterile irrigating solution is then used to thoroughly rinse the eye, and another drop of NSAID is applied.
Another potential treatment for viral conjunctivitis is Zirgan (ganciclovir 0.15% gel, Bausch + Lomb). It is approved for use against herpetic keratitis but has shown efficacy in vitro against adenovirus, and small pilot studies are demonstrating success (Tabbara et al., Trousdale et al.). Patients apply it five times per day for the first week, which is generally reduced to three times per day for a second week.
Clinically I limit the use of steroids to those patients who have epithelial keratoconjunctivitis (EKC) with an infiltrative response. I will usually reserve steroids for those who are most symptomatic.
For example, if someone comes in with early EKC and a mild infiltrative response, I will usually begin them on Zirgan and monitor their response to that medication. In 3 days, if the infiltrates are the same or have gotten worse, I will begin a steroid four times daily. On the other hand, if someone has significant symptoms along with an infiltrative response, I will be more likely to initially start them on steroids in addition to the Zirgan.
Bacterial conjunctivitis is usually a self-limiting infection, but most practitioners have embraced the treatment of these patients with topical antibiotics to significantly shorten the course of the disease, reduce the chances of any permanent clinical sequelae and reduce contagion.
Allergic pathologies are treated with topical antihistamines/mast-cell stabilizing combinations. New medications are now approved for once-a-day dosing regimens, which is particularly attractive from a convenience and compliance perspective. Olopatadine 0.2% and alcaftadine 0.25% are two topically available antihistamine/mast-cell stabilizing agents approved for a once-daily dosing regimen.