Case # 34

1. Case # 34 By Yang, Joseph

2. Case • Miss Saigon, 25 y/o, single, officer executive was seen at the OPD because of red eyes for almost 2 weeks without accompanying fever except for itchiness and moderate sensation of pain on both eyes with blurred vision

3. Patient’s symptoms - red eyes for 2 weeks - Itchiness - moderate pain on both eyes - blurred vision - no discharge - no fever - no dry eyes

4. Main diagnosis • Main diagnosis – Chronic Allergic Conjunctivitis due to the patient’s overuse of cosmetics (i.e. mascara) • Reasons for this dx - The pt’s dx was done at the OPD (out patient dep.), which indicates a Non-emergency case. (mild symptoms) - Allergic conjuctivitis has a intense itchiness without fever and - She is an executive officer for Miss Saigon musical performance so that she tends to overuse of cosmetics (mascara)

5. Main diagnosis: Allergic conjunctivitis - Allergic conjunctivitis usually lasts long before the original allergen is removed - There is no yellowish dischare, usually seen in a bacterial infection - There is no signs and symptoms of dry eyes, usually insufficient tears production due to autoimmune diseases affecting lacrimal glands

6. Eyes with conjunctivitis

7. Conjuntiva (Definition) - Conjunctivitis is the inflammation of the conjunctiva (the membrane that lines the eyelids and covers the exposed surface of the eyeball). - Eyes are susceptible to infection because they are not sterile. They rely on lysozyme (an enzyme found in the tears) to destroy bacteria. But, for some reasons, (bacteria infection, viral infection, allergic condition, chemical irritation, insufficient of tears due to obstruction or autoimmune dx of lacrimal gland, or etc) an inflammatory reaction occurs on the outermost membrane of exposed surface of the eyeball.

9. Conjunctivitis (Etiology) • There are three common varieties of conjunctivitis, which are bacterial, viral and allergic. • Other causes of conjunctivitis include thermal and ultraviolet burns, chemicals, toxins, overuse of contact lenses, foreign bodies, vitamin deficiency, dry eye, dryness due to inadequate lid closure, exposure to chickens infected with Newcastle disease, epithelial dysplasia (pre-cancerous changes), and some conditions of unknown cause such as sarcoidosis.

10. Variants of Conjunctivitis • A. Bacterial conjunctivitis (most common – 50 % of total conjunctivitis) - most often caused by pyogenic bacteria such as Staphylococcus or Streptococcus from the patient's own skin or respiratory flora. Others are due to infection from the environment (e.g. insect-borne), from other people (usually by touch - especially in children), or another bactierial conjunctivitis due to the bacteria Haemophilus influenzae.

11. Variants of Conjunctivitis • B. Viral conjunctivitis (20 % of total conjunctivitis) - It is spread by aerosol or contact of a variety of contagious viruses, including many that cause the common cold, so that it is often associated with upper respiratory tract symptoms. (The common cold is caused by numerous viruses (mainly rhinoviruses, coronaviruses, and also certain echoviruses, paramyxoviruses, and coxsackieviruses) infecting the upper inspiratory system.It may also be caused by adenovirus.

12. Variants of Conjunctivitis C. Allergic conjunctivitis (30 % of total conjunctivitis) - occurs more frequently among those with allergic conditions, with the symptoms having a seasonal correlation. It can also be caused by allergies to substances such as cosmetics, perfume, protein deposits on contact lenses, or drugs. It usually affects both eyes, and is accompanied by swollen eyelids.

13. Variants of Conjunctivitis D. Irritant, toxic, thermal and chemical conjunctivitis - they are associated with exposure to the specific agents, such as flame burns, irritant plant saps, irritant gases or liquid (e.g., chlorine or hydrochloric acid (‘swimming pool acid') fumes or liquid), natural toxins, or splash injury from an enormous variety of industrial chemicals, the most dangerous being strongly alkaline materials.

14. Variants of Conjunctivitis E. Xerophthalmia - It is a destructive dryness of the conjunctival epithelium due to 1.dietary vitamin A deficiency— usually in developing countries. 2. Other forms of dry eye are associated with aging, poor lid closure,obstruction (children) scarring from previous injury, or autoimmune diseases such as rheumatoid arthritis or Sjogren’s syndrom, and these can all cause chronic conjunctivitis.

15. Screening and diagnosis • History taking and physical examination • Lab procedure - a sample of eye secretions from the conjunctiva for laboratory analysis to determine which form of infection you have and how best to treat it. • Close monitoring of the patient

16. Exam. equipment • A pen light – providing a good bright light • A low powered magnifying glass (2 -3x) • A Snellen chart – for testing distance acuity (6m is standard) • A reading test type book • A bright red target • An ophthalmoscope

17. Differential Diagnosis A. Bacterial or viral conjunctivitis (Probably, the patient has the chronic allergic conjunctivitis. However, the lab diagnostic procedure is necessary to figure out the etiologic agent and its corresponding treatment) B. Irritant, toxic, thermal and chemical conjunctivitis(The patient has no history of being exposured to those materials)

18. Differential diagnosis C. Keratitis (cloudy cornea due to inflammed cornea)- Symptoms are very similar to conjunctivitis, but more painful and serious effects, such as ulcerative cornea and blindness – Etiology (Amoebic infection, Viral infection (herpes simplex or herpes zoster), fungal infection and wearing contact lens D. Scleritis (usually associated with underlying systemic diseases (i.e. autoimmune dx) in about half of the cases. Rarely, scleritis is associated with an infectious problem.) – Usually lack of itchiness and intense pain

19. Differential diagnosis E. Uveitis/Iritis (They may have similar symptoms with conjunctivitis (such as redness of the eye, blurred vision, sensitivity to light,dark, floating spots in the vision,eye pain), exept itchiness. It is caused by more systemic infection or autoimmune disease because uvea layer is located between sclera and retina layer. Where it is highly vascularized. I. Intraocular pathology/retinopathy – glaucoma, cataract, papiledema or etc

20. Differential diagnosis • G. Other systemic autoimmune diseases (such as rheumatoid arthritis, lupus, Kawasaki's disease, ulcerative colitis or Crohn's disease. • H. Immune – compromised HIV related case- cytomegalovirus infection • I. Xerophthalmia – dry eyes (vit. A def, aging, obstruction in tears flow, or Sjogren’s syndrome due to autoimmune dx) • J. Subarachnoid hemorrage or increased ICP – can cause red eyes • K. complication of other systemic disease

21. Treatment • Treatment varies depending on the cause. When treating allergic and chemical forms of conjunctivitis, the cause of the allergy or irritation must first be removed. • For the allergic type, cool compresses and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, non-steroidal anti-inflammatory medications and antihistamines may be prescribed. Some patients with persistent allergic conjunctivitis may also require topical steroid drops.

22. Treatment • Bacterial conjunctivitis is usually treated with antibiotic eye drops or ointments. • Viral conjunctivitis can be relieved with cool compresses and artificial tears. For the worst cases, topical steroid drops may be prescribed to reduce the discomfort from inflammation.

23. Treatment (Anitbacterials) • Antibactic eye drop preparation based upon the etiological agent, but usually wide ranged antibiotic (chloramphenicol) is commonly used • Chloramphenicol (50s inhibitor) – Most wide spectrum, most commonly used • Fusidic acid • Chlortetracycline – 30s inhibitor - Gentamicin – 30s inhibitor (Gram (–) aerobic bacilli, staph. aureus, N. gonorrhea, mycobacteria.) • Neomycin - 30s inhibitor • sulphate - sulfonamide • Ciprofloxacin/Ofloxacin • Polymyxin B sulphate

24. Antiviral agents/corticosteroids • Antiviral agent - Aciclovir - Ganciclovir • Corticosteroids - Betamethasone - Butyrate - Dexamethasone - Flourometholone - Hydrocortisone acetate - Prednisolone

25. Anti-inflammatory - Diphenhydramine hydrochloride . • Azelastine hydrochloride • Emedastine • Levocabastine • Lodoxamide • Nedocromil sodium • Sodium cromoglycate Artificial tears and lubricants are also used.

26. Prevention • Don’t touch or rub the infected eye(s). • Wash your hands often with soap and warm water. • Wash any discharge from your eyes twice a day using a fresh cotton ball or paper towel. Afterwards, discard the cotton ball and wash your hands with soap and warm water. • Wash your bed linens, pillowcases, and towels in hot water and detergent.

27. Prevention • Avoid wearing eye makeup. • Don’t share eye makeup with anyone else. • Never wear another person’s contact lens. • Wear glasses instead of contact lenses. Throw away disposable lenses or be sure to clean extended wear lenses and all eyewear cases.

28. Prevention • Avoid sharing common articles such as unwashed towels, cups, and glasses. • Wash your hands after applying the eye drops or ointment to your eye or your child’s eye. • Do not use eye drops in a non-infected eye that were used for an infected one.