Case Study 2 - CC: Red, itchy eyes

Disclaimer: This original case study has been revised in January 2025 to align with layout and description of new cases studies added to our repository. In addition, this specific case study was adjusted to include minor copy changes, more details provided within the diagnosis and discussion section, updates to the Q&A section and sources listed.

Patient History

HPI:
An 11-year-old male reports to your clinic after a 4-day history of eye irritation and itching. The symptoms started in the left eye followed by the right eye one day later. Both eyes have a mild yellow discharge and mattering of the eyelids making it difficult to open the eyes in the morning. There is minimal eye redness. He denies foreign body sensation, flashes, floaters, decreased vision, diplopia, or environmental exposures to the eyes. He is not using any drops.

Past Ocular History:
No history of eye trauma, surgery, amblyopia or strabismus. No history of contact lens use.

Ocular Medications:
None

Past Medical History:
Born at term without complications

Surgical History:
None

Past Family Ocular History:
No history of glaucoma, macular degeneration or other blinding diseases

Social History:
No smokers at home

Medications:
None

Allergies:
No known drug allergies

ROS:
Was exposed to the common cold via a neighborhood friend. No history of environmental allergies, recent cold, CNS, heart, lung, GI, skin, or joint problems.

Ocular Exam

Visual Acuity (cc):
OD: 20/20
OS: 20/25

IOP (iCare tonometry):
OD: 17 mmHg
OS: 14 mmHg

Pupils:
OD: Equal, Round and reactive in dark and light settings, no APD
OS: Equal, Round, and reactive in dark and light settings, no APD

Extraocular Movements:
OD: Full, no nystagmus noted at distance or at near
OS: Full, no nystagmus noted at distance or at near

Confrontational Visual Fields:
OD: Full to finger counting
OS: Full to finger counting 

Slit Lamp Exam:

	RIGHT EYE	LEFT EYE
External	Normal	Normal
Lids and Lashes	Crusted mucoid discharge on eyelashes. No meibomian gland dysfunction.	Crusted mucoid discharge on eyelashes. No meibomian gland dysfunction.
Conjunctiva/Sclera	Trace follicles. Trace injection, no chemosis.	Trace follicles. Trace injection, no chemosis.
Cornea	Clear, no infiltrates	Clear, no infiltrates
Anterior Chamber	Deep and quiet	Deep and quiet
Iris	Flat and color varies	Flat and color varies
Lens	Normal	Normal
Anterior Vitreous	Normal	Normal

Dilated Fundus Examination:

	RIGHT EYE	LEFT EYE
Disc	Normal with sharp margins	Normal with sharp margins
C/D Ratio	0.2	0.2
Macula	Flat with normal foveal light reflex	Flat with normal foveal light reflex
Vessels	Normal	Normal
Periphery	Normal	Normal

Other Exam Findings:
+ Preauricular and submandibular lymph node enlargement

Diagnosis
Acute conjunctivitis of both eyes

Discussion

Definition:

 Acute viral conjunctivitis
Viral conjunctivitis, also known as “pink eye,” is highly contagious and can spread through direct or indirect contact with the infected person’s eye secretions. It is responsible for the majority of infectious conjunctivitis cases, accounting for up to 75% of these cases. The most common cause is adenovirus, but other viral causes include herpes simplex virus (HSV), COVID-19, and other picornaviruses.¹ Signs of viral conjunctivitis include foreign body sensation, itching, burning, and “watery” discharge. The history of viral conjunctivitis is often characterized by a gradual onset of symptoms, with one eye becoming infected first, followed by the second eye. On general physical exam, preauricular or submandibular lymphadenopathy may be present. On slit lamp examination, several findings can help confirm the diagnosis: the cornea may have subepithelial infiltrates that can cause light sensitivity, a pseudomembrane may be seen in the tarsal conjunctiva, and follicles (round collections of lymphocytes) can present on the palpebral conjunctiva. It is important to note that papillae (fibrovascular mounds) on the conjunctiva do not rule out a viral etiology.¹

Differential Diagnosis:

Allergic conjunctivitis
Allergic conjunctivitis is an inflammatory condition of the conjunctiva often associated with a history of systemic allergies. It typically manifests as bilateral itching and watery discharge in individuals with a history of allergies. The condition is due to the body’s immune system reacting to certain substances, known as allergens. Common allergens include pollen, dust mites, animal dander, mold, contact lenses/solution, and cosmetics. Clinical presentation involves various allergic symptoms, and the severity may vary. Notably, allergic conjunctivitis can be further classified based on corneal involvement.³ Physical exam may present with conjunctival redness (injection), swelling (chemosis), and watery discharge. Papillary hypertrophy, characterized by raised bumps on the superior or inferior tarsal conjunctiva, is a notable feature. First line treatment would include over the counter antihistamines or mast-cell stabilizers.³ Sometimes topical steroids are used and necessary for treating severe cases of allergic conjunctivitis. Prevention often involves avoiding the causative agent.

Bacterial conjunctivitis
Bacterial conjunctivitis is primarily caused by bacterial pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae.⁴ These organisms commonly spread through hand-to-eye contact or through contact with adjacent tissue. Clinical signs indicative of bacterial conjunctivitis includes red eye, significant yellow or green mucopurulent discharge, photophobia, decreased vision, and “gluing” of the eyelids shut in the morning. During a slit lamp exam, a palpebral conjunctival papillary (fibrovascular mounds) reaction may be observed.⁴ Differentiating between viral and bacterial conjunctivitis can be challenging; however, bacterial conjunctivitis typically presents with more viscous purulent discharge. In severe or atypical cases of conjunctivitis, PCR may be indicated to identify the causative organism. Supportive therapy consists of cool compresses and preservative free artificial tears 2 to 6 times a day. Topical antibiotics can also be prescribed and may lead to quicker remission of the disease and decreased transmission of the disease.⁴ Good hygiene practices and not sharing personal items such as towels and cosmetics can help prevent transmission.

Blepharitis
Blepharitis is the inflammation of the eyelids causing irritation to the lid margins and flaking and crusting of the lashes. Blepharitis can be an acute or chronic condition affecting either the front of the eyelid where the eyelashes are attached or the inner eyelid where the meibomian glands are located. Blepharitis often presents with itchiness, tearing, foreign body sensation, and blurred vision. Symptoms often occur or are exacerbated in the morning upon waking up. On slit lamp examination, erythema and edema of the eyelid margin, telangiectasia, scaling at the base of the eyelashes forming "collarettes", loss of lashes (madarosis), depigmentation of lashes (poliosis), and misdirection of lashes (trichiasis) can all be seen. An abnormal tear break-up time test (<10 seconds) can also help confirm the diagnosis. Treatment if indicated would include eyelid hygiene (warm compresses, washing of the lids with gentle soap) and sometimes topical antibiotics and/or topical steroids for acute cases to help with the bacteria at the lid margins.⁵

Medication toxicity
Ocular medication toxicity is normally diagnostic based on a HPI. Patients typically complain of chronic itching and burning of the eyes and use of specific eyes drops or exposure to potential irritants. Slit lamp examination can show conjunctival injection, chemosis, eyelid swelling, thickening, and excoriations. Involvement is usually bilateral unless the offending agent was only used in one eye. Treatment involves discontinuing the offending eye drop or avoiding the causative agent. Toxicity is commonly found in medications such as in gentamicin, tobramycin, trifluorothymidine, idoxuridine, brimonidine, timolol, and pilocarpine; Preservatives such as benzalkonium chloride (BAK or BAC), thimerosal, chlorobutanol, sodium perborate, stabilized oxychloro complex (SOC), polyquaternium-1, sorbitol, propylene, glycol, and zinc; Or cosmetics such mascara, creams, and hair spray.6 Prevention generally involves education about their medications and current products.

Giant Papillary Conjunctivitis
Giant papillary conjunctivitis (GPC) is characterized by erythema, edema and the presence of giant papillae (papillae with diameter > 1mm) on the upper tarsal conjunctiva due to a natural foreign body reaction. It is suspected that GPC is mediated mainly by a basophil-rich delayed hypersensitivity reaction with a possible IgE humoral component.⁷ GPC is most commonly associated with contact lens wear but is also seen with exposed suture ends after surgery. Early diagnosis of GPC includes increased mucus production and itching, most patients ignore these symptoms thinking them as normal. As the GPC advances, patients can develop excess mucus production and eventually pain associated with the foreign body.⁷ On exam, the conjunctiva may appear hyperemic, the conjunctiva can lose its translucency becoming opaque with central vessels (due to cellular infiltrate) and marcopapillae (0.3-1 mm)/giant papillae (>1mm) can be seen.⁷ Treatment is started right away to prevent serious damage to the eyelid and cornea. Recommendations include treating the underlying cause such as shorten exposed suture ends or stopping contact lens wear and giving the eye time to heal. Otherwise, education on proper lens care and use need to be performed in addition to changing the type of contact lens.⁸

Examination:
Ocular findings of viral conjunctivitis (VC) include conjunctival hyperemia, chemosis and hemorrhages, follicular conjunctival reaction, epiphora, preauricular/submandibular adenopathy, corneal subepithelial infiltrates, edematous eyelids, conjunctival membranes or pseudomembranes and/or corneal epithelial defects. In VC, visual acuity is usually minimally affected. Diagnosis of VC is usually based on history and exam findings. Fluorescein can help detect corneal epithelial defects. In addition to the clinical presentation, further workup for viral conjunctivitis may include conjunctival swabs/PCR for adenovirus or herpes simplex virus and conjunctival scrapings to examine for eosinophils if an allergic conjunctivitis is suspected.1,3,4 Cultures (to detect bacterial conjunctivitis) should be performed in cases of severe purulent discharge, chronic signs and symptoms, or severe corneal findings to rule out bacterial conjunctivitis.

Treatment:
Treatment of viral conjunctivitis is supportive with artificial tears and cool compresses. For conjunctivitis caused by herpes simplex virus (HSV), and varicella-zoster virus (VZV), antiviral treatment is recommended.² Topical antibiotics are not needed unless a bacterial etiology is suspected. Corticosteroid drops are usually avoided but can be helpful in the convalescent period in the most severe cases (evidence of membranes/pseudomembranes). Topical anesthetics should not be used as these can impede healing. Patients that use contact lenses should avoid lens wear until signs and symptoms have resolved. Prognosis of viral conjunctivitis is very good as most patients will have spontaneous resolution in two weeks.

Membranes/pseudomembranes may cause permanent conjunctival scarring and chronic subepithelial corneal infiltrates in the visual axis that can impair vision. Reassessment by an eye care provider would be important in this case. Hand washing and other disinfectant techniques (changing pillowcases and towels) are important to prevent transmission.

What is not a typical exam finding of conjunctivitis?
a. Eyelid erythema
b. Conjunctival injection
c. Subepithelial corneal infiltrates
d. Cells in the Anterior chamber
e. Mucous in the canthus

A 30-year-old male presents with unilateral red eye. He has associated pain, photophobia, and decreased vision. On slit lamp exam you observe conjunctival injection and a small corneal infiltrate. On further examination with fluorescein staining, you see a dendritic like ulcer. The patient denies any recent trauma to the eye. What is the most likely etiology of this patient’s conjunctivitis, and what specific treatments would be indicated?
a. Allergic conjunctivitis with oral antihistamines
b. Bacterial conjunctivitis with ciprofloxacin eye drops
c. Giant papillary conjunctivitis with mast cell stabilizers
d. Herpetic keratitis with topical acyclovir ointment

Label the anatomy (part of it is cornea):

Image source: https://www.sciencephoto.com/media/703697/view/conjunctiva-illustration-illustration

A 15 year-old female presents to the clinic with bilateral red eyes and itchiness for 4 days. She reports matting of her eyelashes in the morning that she washes/rubs off. She endorses watery discharge but no mucopurulent discharge. Upon flipping her eyelids up and down, clusters of bumps with a central vessel (as below, hoping to get picture). Which of the following most likely led to this exam finding?
a. She is a contact lens wearer
b. Active HSV infection
c. Recent contact with a sick loved one
d. Recent staph infection

What is not a typical exam finding of conjunctivitis?
d. Cells in the Anterior chamber

Most pathology in typical conjunctivitis is in the surface of the eye and not intraocular

A 30-year-old male presents with unilateral red eye. He has associated pain, photophobia, and decreased vision. On slit lamp exam you observe conjunctival injection and a small corneal infiltrate. On further examination with fluorescein staining, you see a dendritic like ulcer. The patient denies any recent trauma to the eye. What is the most likely etiology of this patient’s conjunctivitis, and what specific treatments would be indicated?
d. Herpetic keratitis with topical acyclovir ointment

A dendritic like ulcer on fluorescein stain is a classic type of ulcer seen with HSV-1. This is due to the epithelial manifestation of HSV.

Label the anatomy (part of it is cornea):

Image source: https://www.sciencephoto.com/media/703697/view/conjunctiva-illustration-illustration

A 15 year-old female presents to the clinic with bilateral red eyes and itchiness for 4 days. She reports matting of her eyelashes in the morning that she washes/rubs off. She endorses watery discharge but no mucopurulent discharge. Upon flipping her eyelids up and down, clusters of bumps with a central vessel (as below, hoping to get picture). Which of the following most likely led to this exam finding?
a. She is a contact lens wearer

The bumps on exam are papillae (central vessel) which are often associated with allergies, contact lens intolerance, or bacterial conjunctivitis.¹⁰

References/Resources

1. Solano, D., Fu, L., & Czyz, C. N. (2023, August 18). Viral conjunctivitis - statpearls - NCBI bookshelf. Viral Conjunctivitis. https://www.ncbi.nlm.nih.gov/books/NBK470271/
2. López Montero, M. C., & Prakalapakorn, S. G. (2023, October). Conjunctivitis. EyeWiki. https://eyewiki.aao.org/Conjunctivitis
3. Umfress, A., & Patel, R. (Eds.). (2023, September 4). Allergic conjunctivitis. EyeWiki. https://eyewiki.aao.org/Allergic_Conjunctivitis
4. Chen, M. (Ed.). (2023, June 30). Bacterial conjunctivitis. EyeWiki. https://eyewiki.aao.org/Bacterial_Conjunctivitis#Disease_Entity
5. Eberhardt, M., & Rammohan, G. (2023, January 23). Blepharitis - StatPearls - NCBI Bookshelf. Blepharitis. https://www.ncbi.nlm.nih.gov/books/NBK459305/
6. Hamrah, P. (2023, December 4). Toxic conjunctivits. UpToDate. https://www.uptodate.com/contents/toxic-conjunctivitis/print
7. Allansmith, M. R. (1991, January 1). Treatment of giant papillary conjunctivitis. Considerations in Contact Lens Use Under Adverse Conditions: Proceedings of a Symposium. https://www.ncbi.nlm.nih.gov/books/NBK234094/
8. Boyd, K. (2023, April 27). Giant papillary conjunctivitis. American Academy of Ophthalmology. https://www.aao.org/eye-health/diseases/what-is-giant-papillary-conjunctivitis
9. Centers for Disease Control and Prevention. (2021, August 4). Conjunctivitis information for clinicians. Centers for Disease Control and Prevention. https://www.cdc.gov/conjunctivitis/clinical.html
10. Hashmi, M., Gurnani, B., & Benson, S. (2022, December 6). Conjunctivitis - statpearls - NCBI bookshelf. Conjunctivitis. https://www.ncbi.nlm.nih.gov/books/NBK541034/
11. Azari, A. A., & Barney, N. P. (2013, October 23). Conjunctivitis: A systematic review of diagnosis and treatment. JAMA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049531/