The ratings of importance to the care process (A-C) and the ratings for strength of evidence (I-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 (American Academy of Ophthalmology Preferred Practice Patterns Committee, 2005; American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel, 2007), [A:III] but some elements of the evaluation may be deferred in patients with symptoms and signs suggestive of infectious conjunctivitis.
History
- Symptoms and signs [A:III]
- Duration of symptoms [A:III]
- Exacerbating factors [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, [A:III] and slit-lamp biomicroscopy. [A:III]
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 (Tullo, 1980; Dawson, Hanna, & Togni, 1972) [A:III]
- Bulbar conjunctiva/limbus (Tullo, 1980; Dawson, Hanna, & Togni, 1972) [A:III]
- Cornea (Dawson, Hanna, & Togni, 1972) [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 (Rapoza et al., 1986). [A:I] Smears for cytology and special stains (e.g., gram, Giemsa) are recommended in cases of suspected infectious neonatal conjunctivitis, chronic or recurrent conjunctivitis, and in cases of suspected gonococcal conjunctivitis in any age group (Rapoza et al., 1986; Centers for Disease Control and Prevention, 2006). [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 mucous membrane pemphigoid (OMMP) is suspected (Power et al., 1995). [A:III] In cases of suspected sebaceous gland carcinoma, a full-thickness lid biopsy is indicated (Gilberg & Tse, 1992). [A:II]
Treatment
Indiscriminate use of topical antibiotics or corticosteroids should be avoided, because antibiotics can induce toxicity and corticosteroids can prolong adenoviral infections and worsen herpes simplex virus infections. [A:III] 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 presentation, etiology, and treatment. 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]
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
- History of immune compromise
Counseling/Referral
When conjunctivitis is associated with sexually transmitted disease, treatment of sexual partners is essential to minimize recurrence and spread of the disease.[A:III] Patients, as well as their sexual partners, should be referred to an appropriate medical specialist. [A:III] The physician must remain alert to the possibility of child abuse in cases of potentially sexually transmitted ocular disease in children. In many states, sexually transmitted diseases and suspected child abuse must be reported to local health authorities or other state agencies.
In cases of ophthalmia neonatorum due to gonococcus, Chlamydia, and herpes simplex virus, the infant should be referred to an appropriate pediatric specialist. [A:III] Infants who require systemic treatment are best managed in conjunction with a pediatrician.
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, defined as most important
Level B, defined as moderately important
Level C, defined as relevant but not critical
Ratings of Strength of Evidence
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.
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
Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)
