• American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee. Conjunctivitis. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 25 p. [67 references]

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology (AAO), Preferred Practice Patterns Committee, Cornea/External Disease. Conjunctivitis. San Francisco (CA): American Academy of Ophthalmology (AAO); 1998. 24 p.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant.

The ratings of importance to the care process (A, B, C) and the ratings for strength of evidence (I, II, III) are defined at the end of the "Major Recommendations" field.

Diagnosis

The initial evaluation of a patient should include the relevant aspects of the comprehensive medical eye evaluation. [A:III]

History

Questions about the following elements of the patient history may elicit helpful information:

• Symptoms and signs [A:III]
• Duration of symptoms [A:III]
• Unilateral or bilateral presentation [A:III]
• Character of discharge [A:III]
• Recent exposure to an infected individual [A:III]
• Trauma [A:III]
• Contact lens wear [A:III]
• Symptoms and signs potentially related to systemic diseases [A:III]
• Allergy, asthma, eczema [A:III]
• Use of topical and systemic medications [A:III]

The ocular history includes details about previous episodes of conjunctivitis [A:III] and previous ophthalmic surgery. [B:III]

The medical history takes into account the following:

• Compromised immune status [B:III]
• Prior systemic diseases [B:III]

The social history incorporates pertinent information about the patient's lifestyle, which may include smoking habits, [C:III] occupation and hobbies, [C:III] travel, [C:III] and sexual activity. [C:III]

Examination

The initial eye examination includes measurement of visual acuity, [A:III] external examination, and slit-lamp biomicroscopy.

The external examination should include the following elements:

• Regional lymphadenopathy [A:III]
• Skin [A:III]
• Abnormalities of the eyelids and adnexae [A:III]
• Conjunctiva [A:III]

The slit-lamp biomicroscopy should include careful evaluation of the following:

• Eyelid margins [A:III]
• Eyelashes [A:III]
• Lacrimal puncta and canaliculi [B:III]
• Tarsal and forniceal conjunctiva [A:III]
• Bulbar conjunctiva/limbus [A:III]
• Cornea [A:III]
• Anterior chamber/iris [A:III]
• Dye-staining pattern [A:III]

Diagnostic Tests

Cultures of the conjunctiva are indicated in all cases of suspected infectious neonatal conjunctivitis. [A:I] Smears for cytology and special stains (e.g., gram, giemsa) are recommended in cases of suspected infectious neonatal conjunctivitis and in cases of suspected gonococcal conjunctivitis in any age group. [A:II]

A biopsy of bulbar conjunctiva should be performed and a sample should be taken from an uninvolved area adjacent to the limbus in an eye with active inflammation when ocular cicatricial pemphigoid (OCP) is suspected. [A:III] In cases of suspected sebaceous gland carcinoma, a full-thickness lid biopsy is indicated. [A:II]

Treatment and Follow-up

Specific treatment and follow-up recommendations are contained in the main body of the original guideline document.

Frequency of follow-up visits is based on the severity of disease and treatment used. A follow-up visit should include an interval history, measurement of visual acuity, and slit-lamp biomicroscopy. [A:III] If corticosteroids are used in chronic or recurrent conjunctivitis, baseline and periodic measurement of intraocular pressure and pupillary dilation should be performed to evaluate for cataract and glaucoma. [A:III]

Associated abnormalities such as aqueous tear deficiency and meibomian gland dysfunction should be treated. [A:III]

Provider and Setting

Patients with conjunctivitis who are evaluated by non-ophthalmologist health care providers should be referred promptly to the ophthalmologist when any of the following occur: [A:III]

• Visual loss
• Moderate or severe pain
• Severe, purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy
• Recurrent episodes
• History of herpes simplex virus (HSV) eye disease

Counseling/Referral

When conjunctivitis is associated with sexually transmitted disease, patients, as well as their sexual partners, should be referred to an appropriate medical specialist. [A:III] In cases of ophthalmia neonatorum due to gonococcus, Chlamydia, and herpes simplex virus, the infant's parents should be referred to an appropriate pediatric specialist. [A:III] When conjunctivitis appears to be a manifestation of systemic disease, patients should be referred for evaluation by an appropriate medical specialist. [A:III]

Definitions:

Ratings of importance to care process

Level A, most important
Level B, moderately important
Level C, relevant but not critical

Ratings of strength of evidence

1. Level I includes evidence obtained from at least one properly conducted, well-designed, randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
2. Level II includes evidence obtained from the following:
   • Well-designed controlled trials without randomization
   • Well-designed cohort or case-control analytic studies, preferably from more than one center
   • Multiple-time series with or without the intervention
3. Level III includes evidence obtained from one of the following:
   • Descriptive studies
   • Case reports
   • Reports of expert committees/organization
   • Expert opinion (e.g., Preferred Practice Pattern panel consensus)

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee. Conjunctivitis. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 25 p. [67 references]

Not applicable: The guideline was not adapted from another source.

1998 Sep (revised 2003)

American Academy of Ophthalmology - Medical Specialty Society

American Academy of Ophthalmology

Preferred Practice Patterns Committee, Cornea/External Disease Panel

Cornea/External Disease Panel Members: Alice Y. Matoba, MD (Chair); David J. Harris, Jr., MD; David M. Meisler, MD, Stephen C. Pflugfelder, MD, Christopher J. Rapuano, MD; Jayne S. Weiss, MD; David C. Musch, PhD, MPH (Methodologist)

Preferred Practice Patterns Committee Members: Joseph Caprioli, MD (Chair); J. Bronwyn Bateman, MD; Emily Y. Chew, MD; Douglas E. Gaasterland, MD; Sid Mandelbaum, MD; Samuel Masket, MD; Alice Y. Matoba, MD, Donald S. Fong, MD, MPH

The following authors have received compensation within the past 3 years up to and including June 2003 for consulting services regarding the equipment, process, or product presented or competing equipment, process, or product presented:

Jayne S. Weiss, MD: Alcon, Allergan - Reimbursement of travel expenses for presentation at meetings or courses.

Other authors have no financial interest in the equipment, process, or product presented or competing equipment, process, or product presented.

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology (AAO), Preferred Practice Patterns Committee, Cornea/External Disease. Conjunctivitis. San Francisco (CA): American Academy of Ophthalmology (AAO); 1998. 24 p.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant.

None available

This NGC summary was completed by ECRI on February 20, 1999. The information was verified by the guideline developer on April 23, 1999. This summary was updated by ECRI on April 9, 2004. The information was verified by the guideline developer on May 20, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Information about the content, ordering, and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500.