May 2018

COVER FEATURE

Navigating the red eye
Understanding chronic conjunctivitis


by Rich Daly EyeWorld Contributing Writer


Inferior follicles in a chronic follicular conjunctivitis case
Source: Vincent de Luise, MD

Best approaches for detection, treatment, and follow-up

The right questions can be key to the early and correct diagnosis of various types of conjunctivitis.
Conjunctivitis treatments begin with differentiating between acute and chronic versions of the condition. The acute form generally has a rapid onset and lasts 3 weeks or less. Conjunctivitis lasting longer than 3 weeks can be considered chronic conjunctivitis, said Mark Mannis, MD, professor and chair, Department of Ophthalmology & Vision Science, Davis Eye Center, University of California, Sacramento.
“Chronic conjunctivitis can be infectious, toxic, immune, dermatologic in origin, or even factitious,” Dr. Mannis said. In addition, ocular surface neoplasms can mimic chronic conjunctivitis.
When dealing with acute conjunctivitis, the appropriate historical questions are key to determining if it is infectious or toxic in nature.
“This becomes very important; you need to know about the onset, symptoms, and type of discharge,” Dr. Mannis said. “Moreover you need to know if there are any other contiguous problems, such as concomitant upper respiratory infection or periocular skin disease.”
Other questions include whether the patient has had exposure to toxins, such as creams, hair sprays, and over-the-counter drops, which are potentially toxic agents. Physicians should also examine other parts of the eye and face to identify conjunctivitis. Close attention to the lid margins and periocular skin is important. Palpable preauricular or submandibular nodes may indicate viral or chlamydial infection. A loss of lashes suggests chronic lid disease.
“History and the examination become important in trying to figure out into which of these categories the conjunctivitis falls,” Dr. Mannis said. “Most of the time you can hone in on a diagnosis with a careful set of questions. Once you have an idea of what you are dealing with, there may also be relevant diagnostic tests.”
Additional differentiation
Vincent de Luise, MD, assistant clinical professor of ophthalmology, Yale University School of Medicine, New Haven, Connecticut, noted that allergic conjunctivitis is usually acute, although it can recur. Allergic conjunctivitis is usually papillary in nature—that is, it presents more often with conjunctival papillae and not follicles. However, an exception is some types of allergic drug-induced medicamentosa, with follicular reactions.
Dr. de Luise said toxic follicular conjunctivitis can be caused by several different medications: antivirals such as vidarabine and trifluridine; glaucoma medications such as pilocarpine, carbachol, epinephrine, and apraclonidine; topical ocular antibiotics such as neomycin, gentamicin, sulfonamides and amphotericin B; and agents such as atropine, scopolamine, and neostigmine.
Primary chronic papillary conjunctivitis is commonly seen in vernal keratoconjunctivitis or atopic keratoconjunctivitis. Secondary giant papillary conjunctivitis is seen in contact lens wearers, ocular prostheses, and with exposed sutures, Dr. de Luise noted.
Meanwhile, chronic cicatrizing conjunctivitis can be due to a toxic medicamentosa reaction or to ocular cicatricial pemphigoid.
“While most cases of chronic conjunctivitis are follicular and bilateral in nature, some conditions, such as molluscum contagiosum, are more often unilateral,” Dr. de Luise said.
Other causes for unilateral chronic papillary conjunctivitis include lacrimal drainage infections (chronic dacryocystitis and canaliculitis); giant fornix syndrome; masquerade syndrome, due most commonly to sebaceous carcinoma; and factitious conjunctivitis.
“These are uncommon conditions but should be in the differential diagnosis,” Dr. de Luise said.
Anat Galor, MD, associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, differentiates the medical cause as trachoma, chlamydial conjunctivitis, or toxic follicular conjunctivitis by the pattern of conjunctival and cornea involvement.
For example, in cases with superior cicatricial changes, Dr. Galor worries about trachoma, while in cases with inferior cicatricial changes, Dr. Galor worries about mucous membrane pemphigoid. In cases of a chronic bilateral follicular conjunctivitis involving the inferior conjunctivae, Dr. Galor will review the medication list (especially the use of glaucoma medications), examine the periocular skin for molluscum lesions, and swab for chlamydia. If negative, she will biopsy to rule out lymphoma. Chronic papillary changes of the inferior conjunctivae can be seen in allergy and with intolerance to glaucoma medications. In addition, an atypical infectious organism should be considered. The appearance of a diffuse corneal staining pattern in the setting of a chronic conjunctivitis suggests toxicity, typically to a topical medication.

Treatments available

The treatment Dr. de Luise recommends in cases of chlamydial inclusion conjunctivitis is oral doxycycline 100 mg po twice daily for 4–6 weeks. Alternatively, oral erythromycin stearate 500 mg po twice daily for 4–6 weeks or 1 gram of azithromycin po as a single dose can be used.
Dr. de Luise urges ophthalmologists to avoid the use of tetracycline due to less bioavailability and its contraindication in children under 8 years old. Also important is the need to identify and treat all sexual partners to prevent reinfection.
For trachoma, Dr. de Luise recommends 1 gram po of oral azithromycin in adults and 20 mg of oral azithromycin in children. Another option is topical tetracycline ointment 1% twice daily for 6 weeks.
Dr. de Luise recommends following the “SAFE” protocol: Surgical care (of secondary issues), Antibiotics, Facial hygiene, and Environmental improvement.
For toxic medicamentosa chronic conjunctivitis, immediate cessation of the medication is usually efficacious. However, it may take weeks for the conjunctival inflammation to disappear. A short course of topical ester corticosteroids can help reduce inflammation.
“This requires close slit lamp follow-up,” Dr. de Luise said.
Molluscum contagiosum is usually a self-limited condition. Dr. de Luise recommends following the patient closely and considers curettage of the lesion to reduce the viral load. No antivirals are available for this virus.
Giant papillary conjunctivitis caused by contact lenses is addressed through ceasing the use of the lenses, and sometimes a short course of a topical ester corticosteroid helps.  
Cases of vernal keratoconjunctivitis and atopic keratoconjunctivitis (AKC) require ongoing care, with topical antihistamine mast cell stabilizers, the judicious use of topical corticosteroids, and careful and frequent slit lamp follow-up. Topical cyclosporine has proven effective in some cases. Patients with AKC should be followed by an allergist/immunologist as well as an ophthalmologist, Dr. de Luise said.

Patient follow-up

Once physicians identify the cause and start the treatment, they have to give the condition some time to regress, Dr. Mannis said. A biopsy may be needed if there are indications of some type of tumor.
“Once those things are done you are going to see the patient in 2–4 weeks, and the conjunctivitis is resolving,” Dr. Mannis said. “You may not see the patient for months after that but generally it is the initial visit, a scraping for a biopsy, and a month follow-up.”
Dr. de Luise said in his experience chronic conjunctivitis is less common than acute conjunctivitis, but it is often missed or misdiagnosed. 
“Ophthalmologists should have a high index of clinical suspicion for” chronic conjunctivitis, Dr. de Luise said.
Dr. Mannis agreed that chronic conjunctivitis is moderately rare but its common causes are commonly missed.
“For example, chronic lid disease is a very common cause of chronic blepharoconjunctivitis,” Dr. Mannis said. “It’s often simply overlooked as a cause.”

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

de Luise
: vdeluisemd@gmail.com
Galor: agalor@med.miami.edu
Mannis: mjmannis@ucdavis.edu

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