Case Study 2 - CC: Red, itchy eyes

Patient History

HPI:
The patient is an 11-year-old male who reports a 4-day history of irritation and itching, first in the L eye followed by the R eye one day later. Both eyes also 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 but no foreign body sensation, flashes, floaters, decreased vision or diplopia. Not using any drops. No environmental exposures to the eyes.

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:
None

ROS:
Exposure to the common cold (neighbor 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 (tonoapplantation):
OD: 17 mmHg
OS: 14 mmHg

Pupils:
Equal, round and reactive OU, no APD

Extraocular Movements:
Full OU, no nystagmus

Confrontational Visual Fields:
Full to finger counting OU

External:
Normal-appearing orbital structures; no redness or swelling either eye

Slit Lamp:

Lids and Lashes	Crusted dry flaky material on eyelashes OU, no follicles in inferior or superior fornix OU. No foreign body in fornices OU
Conjunctiva/Sclera	Mild conjunctival injection OU, no chemosis
Cornea	Clear OU, no infiltrates
Anterior Chamber	Deep and quiet OU
Iris	Normal OU
Lens	Normal OU
Anterior Vitreous	Clear OU

Dilated Fundus Examination:

OD	Clear view, CDR 0.2 with sharp optic disc margins, flat macula with normal foveal light reflex, normal vessels and peripheral retina
OS	Clear view, CDR 0.2 with sharp optic disc margins, flat macula with normal foveal light reflex, normal vessels and peripheral retina

Other:
No preauricular or submandibular lymph node enlargement

Diagnosis
Acute conjunctivitis of both eyes

Discussion

Differential Diagnosis:
The above presentation is consistent with viral conjunctivitis. Other possible diagnoses include allergic conjunctivitis (usually with pruritus), atopic conjunctivitis (usually with a history of eczema), bacterial conjunctivitis (usually with purulent discharge and severe redness), medication toxicity (ex. patient on chronic drops), exposure toxicity (ex. exposed to fire fumes or other toxic fumes/chemicals) and pediculosis (eyelash lice infestation with chronic follicular conjunctivitis).

Definition:
Viral conjunctivitis is an inflammatory response to infection of the conjunctival tissues surrounding the globe and lids by a virus. The most common cause of viral conjunctivitis is adenovirus. Other causes include coxsackie virus, enterovirus, molluscum contagiosum and systemic viral syndromes such as measles, mumps, influenza and rhinovirus. Viral conjunctivitis most commonly affects patients with upper respiratory infection symptoms or with a history of sick contacts. It usually starts in one eye and develops in the other eye a few days later. Herpetic conjunctivitis has distinct findings but in its mildest form can mimic typical viral conjunctivitis.

Examination:
Ocular findings include conjunctival hyperemia, chemosis and hemorrhages, follicular conjunctival reaction, epiphora, preauricular adenopathy, corneal subepithelial infiltrates, edematous eyelids, conjunctival membranes or pseudomembranes and/or corneal epithelial defects. Visual acuity is minimally affected in viral conjunctivitis. Diagnosis of viral conjunctivitis is usually based on history and exam findings. Fluorescein can help detect corneal epithelial defects. Cultures (to detect bacterial conjunctivitis) should be performed in cases of severe purulent discharge, chronic signs and symptoms or severe corneal findings.

Treatment:
Treatment of viral conjunctivitis is supportive with artificial tears and cool compresses. 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.

1. What is not a typical exam finding of conjunctivitis?
   • Eyelid erythema
   • Red conjunctiva
   • Subepithelial corneal infiltrates
   • Anterior chamber cell
   • Mucous in the canthus
2. A patient with a recent head cold presents with a 2-day history of a left red eye. Today the right eye is also red. The patient complaints of a lot of watery discharge, burning, and slight blurring of the vision. She denies significant discharge or extreme itchiness. What is the most likely diagnosis?
   • Viral
   • Bacterial
   • Allergic
   • Not conjunctivitis – consider another diagnosis
3. What treatment would you recommend?
   • Start a topical antibiotic and contact precautions
   • Admit to hospital for further work-up and treatment
   • Recommend cold compresses, artificial tears for comfort, contact precautions
   • Start an anti-histamine drop

References/Resources

1. What is not a typical exam finding of conjunctivitis?

d. Anterior chamber cell

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

2. A patient with a recent head cold presents with a 2-day history of a left red eye. Today the right eye is also red. The patient complaints of a lot of watery discharge, burning, and slight blurring of the vision. She denies significant discharge or extreme itchiness. What is the most likely diagnosis?

a. Viral

The presentation is typical of viral or mild conjunctivitis.

3. What treatment would you recommend?

c. Recommend cold compress, artificial tears for comfort and contact precautions

Since the possible agent is not bacterial supportive measures are recommended (cold compresses, artificial tears and washing hands/sheets/towels, etc.).