Conjunctivitis physical examination: Difference between revisions

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{{Conjunctivitis}}
{{Conjunctivitis}}
{{CMG}} {{AE}} {{SaraM}}
{{CMG}}; {{AE}} {{SaraM}}


==Overview==
==Overview==
Infection (redness) of the conjunctiva on one or both eyes should be apparent, but may be quite mild. Except in obvious pyogenic or toxic/chemical conjunctivitis, a [[slit lamp]] (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.
Physical examination of patients with conjunctivitis is usually remarkable for [[conjunctival]] [[injections]], [[epiphora]], [[hyperemia]], [[chemosis]], and muco-purulent or watery discharge. However, [[ophthalmologic]] examination may be varies based on conjunctivitis subtypes.<ref name="pmid26077630">{{cite journal| author=Jhanji V, Chan TC, Li EY, Agarwal K, Vajpayee RB| title=Adenoviral keratoconjunctivitis. | journal=Surv Ophthalmol | year= 2015 | volume= 60 | issue= 5 | pages= 435-43 | pmid=26077630 | doi=10.1016/j.survophthal.2015.04.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26077630  }} </ref><ref name="pmid24150468">{{cite journal| author=Azari AA, Barney NP| title=Conjunctivitis: a systematic review of diagnosis and treatment. | journal=JAMA | year= 2013 | volume= 310 | issue= 16 | pages= 1721-9 | pmid=24150468 | doi=10.1001/jama.2013.280318 | pmc=4049531 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24150468  }} </ref>


==Physical Examination==
==Physical Examination==
===Viral Conjunctivitis===
===Viral Conjunctivitis===
Patients with [[viral conjunctivitis]] usually appear [[febrile]], and they have Preauricular [[adenopathy]]. Eye examination of patients with viral conjunctivitis is usually remarkable for:
Patients with viral conjunctivitis usually appear [[febrile]], and they have preauricular [[adenopathy]]. [[Ophthalmologic]] examination of patients with viral conjunctivitis is usually remarkable for:<ref name="pmid26077630">{{cite journal| author=Jhanji V, Chan TC, Li EY, Agarwal K, Vajpayee RB| title=Adenoviral keratoconjunctivitis. | journal=Surv Ophthalmol | year= 2015 | volume= 60 | issue= 5 | pages= 435-43 | pmid=26077630 | doi=10.1016/j.survophthal.2015.04.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26077630  }} </ref><ref name="pmid24150468">{{cite journal| author=Azari AA, Barney NP| title=Conjunctivitis: a systematic review of diagnosis and treatment. | journal=JAMA | year= 2013 | volume= 310 | issue= 16 | pages= 1721-9 | pmid=24150468 | doi=10.1001/jama.2013.280318 | pmc=4049531 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24150468  }} </ref>
*[[Epiphora]]
*[[Epiphora]]
*[[Hyperemia]]
*[[Hyperemia]]
*[[Chemosis]]
*[[Chemosis]]
*Lymphoid follicle on the under-surface of the eyelid
*Follicular conjunctival reaction
*Follicular conjunctival reaction
*Pseudomembranous (occasionally)
*Pseudomembrane formation (occasionally)
*[[Cicatricial]] [[conjunctival]] reaction
*[[Cicatricial]] conjunctival reaction
*[[Edematous]] and [[ecchymotic]] [[eyelids]]
*Eyelids [[ecchymosis]]
*[[Corneal]] [[epithelial]] defect (severe cases)
*Corneal epithelial defect (in severe cases)
 
===Acute Hemorrhagic Conjunctivitis===
===Acute Hemorrhagic Conjunctivitis===
Eye examination of patients with [[acute]] hemorrhagic conjunctivitis is usually remarkable for:
[[Ophthalmologic]] examination of patients with acute hemorrhagic conjunctivitis is usually remarkable for:<ref name="pmid1088513">{{cite journal| author=Yin-Murphy M| title=Simple tests for the diagnosis of picornavirus epidemic conjunctivitis (acute haemorrhagic conjunctivitis). | journal=Bull World Health Organ | year= 1976 | volume= 54 | issue= 6 | pages= 675-9 | pmid=1088513 | doi= | pmc=2366581 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1088513  }} </ref>
*[[Swollen]], Edematous [[Eyelid]]
*Eyelid [[edema]]
*Eye pain in [[palpation]]
*[[Eye pain]] in palpation
*[[Bulbar]] [[conjunctiva]] [[hemorrhage]]
*Bulbar conjunctival [[hemorrhage]]
 
===Bacterial Conjunctivitis===
===Bacterial Conjunctivitis===
Eye examination of patients with [[bacterial]] conjunctivitis is usually remarkable for:
Ophthalmologic examination of patients with bacterial conjunctivitis is usually remarkable for:<ref name="pmid10922425">{{cite journal| author=Leibowitz HM| title=The red eye. | journal=N Engl J Med | year= 2000 | volume= 343 | issue= 5 | pages= 345-51 | pmid=10922425 | doi=10.1056/NEJM200008033430507 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10922425  }} </ref><ref name="pmid21160459">{{cite journal| author=Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC)| title=Sexually transmitted diseases treatment guidelines, 2010. | journal=MMWR Recomm Rep | year= 2010 | volume= 59 | issue= RR-12 | pages= 1-110 | pmid=21160459 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21160459  }} </ref>
*[[Bulbar]] [[conjunctival]] injection
*Bulbar conjunctival injection
*Palpebral [[conjunctival]] [[papillary]] reaction
*Palpebral conjunctival papillary reaction
*Muco-purulent or watery discharge
*Watery or [[mucopurulent discharge]]
*[[Chemosis]]
*[[Chemosis]]
*Lid [[erythema]]
*Lid [[erythema]]
*Corneal involvement (''[[Neisseria gonorrhea]]'')
===Neonatal Conjunctivitis===
===Neonatal Conjunctivitis===
Eye examination of patients with [[neonatal]] conjunctivitis is usually remarkable for:
Ophthalmologic examination of patients with neonatal conjunctivitis or [[ophthalmia neonatorum]] is usually remarkable for:<ref name="pmid25606121">{{cite journal| author=Mallika P, Asok T, Faisal H, Aziz S, Tan A, Intan G| title=Neonatal conjunctivitis - a review. | journal=Malays Fam Physician | year= 2008 | volume= 3 | issue= 2 | pages= 77-81 | pmid=25606121 | doi= | pmc=4170304 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25606121  }} </ref><ref name=ophthalmia-two>Rours, Ingrid GIJG, et al. "Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants." Pediatrics 121.2 (2008): e321-e326.</ref><ref name=Ophthalmia-three>Pickering, Larry K. Red book®: 2003 report of the committee on infectious diseases. No. Ed. 26. American Academy of Pediatrics, 2003.</ref>
*''[[Neisseria gonorrhea]]''
*''[[Neisseria gonorrhea]]''
**Chemosis
**[[Chemosis]]
**[[Severe]] [[lid edema]] and
**Severe lid edema  
**[[Mucopurulent]] discharge
**[[Mucopurulent discharge]]
**[[Corneal]] involvement (diffuse [[epithelial edema]], [[ulceration]], corneal [[perforation]], and [[endophthalmitis]]
**[[Corneal]] involvement (diffuse epithelial edema, [[ulceration]], corneal perforation, and [[endophthalmitis]]
*''[[Chlamydia trachomatis]]''
*''[[Chlamydia trachomatis]]''
**Mild [[hyperemia]]  
**Mild [[hyperemia]]  
Line 41: Line 46:
**[[Chemosis]]  
**[[Chemosis]]  
**Pseudomembrane formation
**Pseudomembrane formation
*Chemical
*[[Chemical]]
**Mild conjunctival [[injection]]  
**Mild conjunctival injection
**Tearing
**[[Epiphora]]


===Allergic Conjunctivitis===
Ophthalmologic examination of patients with [[allergic conjunctivitis]] is usually remarkable for:<ref name="pmid10922425">{{cite journal| author=Leibowitz HM| title=The red eye. | journal=N Engl J Med | year= 2000 | volume= 343 | issue= 5 | pages= 345-51 | pmid=10922425 | doi=10.1056/NEJM200008033430507 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10922425  }} </ref><ref name="pmid23497516">{{cite journal| author=La Rosa M, Lionetti E, Reibaldi M, Russo A, Longo A, Leonardi S et al.| title=Allergic conjunctivitis: a comprehensive review of the literature. | journal=Ital J Pediatr | year= 2013 | volume= 39 | issue=  | pages= 18 | pmid=23497516 | doi=10.1186/1824-7288-39-18 | pmc=3640929 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23497516  }} </ref>
*[[Bilateral]] conjunctival injection
*[[Chemosis]]
*Watery discharge or mild mucous discharge
*Large cobblestone papillae under upper eyelid


[[Redness]] of the [[conjunctiva]] on one or both eyes should be apparent, but may be quite mild. Except in obvious pyogenic or toxic/chemical conjunctivitis, a [[slit lamp]] (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.
===Keratoconjunctivitis Sicaa===
Examination should include evaluation of the face, eyelids, blinking patterns, eyelid margins, [[eyelashes]], [[conjunctiva]], [[cornea]], and tear film.
Examination of patients with [[keratoconjunctivitis sicaa]] is usually remarkable for:<ref name="pmid9820935">{{cite journal| author=Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC| title=The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. | journal=Cornea | year= 1998 | volume= 17 | issue= 6 | pages= 584-9 | pmid=9820935 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9820935  }} </ref><ref name="pmid19506195">{{cite journal| author=Schaumberg DA, Dana R, Buring JE, Sullivan DA| title=Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies. | journal=Arch Ophthalmol | year= 2009 | volume= 127 | issue= 6 | pages= 763-8 | pmid=19506195 | doi=10.1001/archophthalmol.2009.103 | pmc=2836718 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19506195  }} </ref>
*Conjunctival redness
*Damage to the ocular surface with punctate epithelial
*Thickened eyelid margins and [[telangiectasia]] (signs of [[meibomian gland]] [[dysfunction]])
*[[Meibomian gland]] orifices are obstructed with a cloudy or granular [[secretion]] (expressed by exerting considerable pressure on the lower lid)
*[[Blepharitis]] (associated with meibomian gland dysfunction)
*Meibomitis ([[inflammation]] of the meibomian glands)


'''Allergic conjunctivitis'''shows pale watery swelling or [[edema]] of the conjunctiva and sometimes the whole eyelid, often with a ropy, ''non-purulent'' mucoid discharge. There is variable redness.
===Superior Limbic Keratoconjunctivitis===
''Viral conjunctivitis'', commonly known as "pink eye", shows a fine diffuse pinkness of the conjunctiva which is easily mistaken for the 'ciliary infection' of [[iritis]], but there are usually corroborative signs on biomicroscopy, particularly numerous lymphoid follicle12:02, 22 January 2008 (EST)12:02, 22 January 2008 (EST)~~s on the tarsal conjunctiva, and sometimes a punctate keratitis.
Ophthalmologic examination of patients with [[superior limbic keratoconjunctivitis|superior limbic keratoconjunctivitis (SLK)]] is usually remarkable for:<ref name="pmid2695351">{{cite journal| author=Nelson JD| title=Superior limbic keratoconjunctivitis (SLK). | journal=Eye (Lond) | year= 1989 | volume= 3 ( Pt 2) | issue= | pages= 180-9 | pmid=2695351 | doi=10.1038/eye.1989.26 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2695351  }} </ref>
 
*[[Hyperemia]]
Pyogenic ''bacterial conjunctivitis'' shows an opaque purulent discharge, a very red eye, and on biomicroscopy there are numerous white cells and desquamated [[epithelial cell]]s seen in the 'tear gutter' along the lid margin. The tarsal conjunctiva is a velvety red and not particularly follicular. Non-pyogenic infections can show just mild injection and be difficult to diagnose. Scarring of the tarsal conjunctiva is occasionally seen in chronic infections, especially in trachoma.
*Micro-papillary reaction in the upper tarsal conjunctiva
 
*Thickening of the superior bulbar conjunctiva
''Irritant'' or ''toxic conjunctivitis'' show primarily marked redness. If due to splash injury, it is often present only in the lower conjunctival sac.  With some chemicals—above all with caustic alkalis such as sodium hydroxide&mdash;there may be necrosis of the conjunctiva with a deceptively white eye due to vascular closure, followed by sloughing of the dead epithelium. This is likely to be associated with slit-lamp evidence of [[iritis|anterior uveitis]].
*Ciliary injection in the upper bulbar conjunctiva
 
*Corneal erosion in the upper quadrants
===Images===
*Diffuse superficial corneal erosions
The following are gross images associated with rheumatic fever.<ref>http://picasaweb.google.com/mcmumbi/USMLEIIImages/</ref>
*Eyelid edema
 
<div align="left">
<gallery heights="175" widths="175">
Image:Conjunctivitis-giardiacorp-xs.jpg|One eye with conjunctivitis.
Image:Bacterial_Conjunctivitis.jpg|Bacterial Conjunctivitis
Image:chemical conjunctivits (day1-2).jpg|Chemical Conjunctivitis
</gallery>
</div>
 
(Images shown below are courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)
 
<div align="left">
<gallery heights="175" widths="175">
Image:eyes_conjunctivitis.jpg|Conjunctivitis: Note inflamed conjunctiva of sclera and reflection onto underside of eyelid.
Image:eyes_conjunctivitis2.jpg|Conjunctivitis: Marked bilateral inflammation involving conjunctiva that covers sclera and under surface of eyelid. Thick exudate can also be seen.
Image:eyes_conjunctivitis3.jpg|Conjunctivitis: Inflammation of conjunctiva covering sclera and under surface of eyelid.
</gallery>
</div>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Ophthalmology]]
[[Category:Immunology]]
[[Category:Pediatrics]]
[[Category:FinalQCRequired]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Latest revision as of 21:07, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Physical examination of patients with conjunctivitis is usually remarkable for conjunctival injections, epiphora, hyperemia, chemosis, and muco-purulent or watery discharge. However, ophthalmologic examination may be varies based on conjunctivitis subtypes.[1][2]

Physical Examination

Viral Conjunctivitis

Patients with viral conjunctivitis usually appear febrile, and they have preauricular adenopathy. Ophthalmologic examination of patients with viral conjunctivitis is usually remarkable for:[1][2]

  • Epiphora
  • Hyperemia
  • Chemosis
  • Lymphoid follicle on the under-surface of the eyelid
  • Follicular conjunctival reaction
  • Pseudomembrane formation (occasionally)
  • Cicatricial conjunctival reaction
  • Eyelids ecchymosis
  • Corneal epithelial defect (in severe cases)

Acute Hemorrhagic Conjunctivitis

Ophthalmologic examination of patients with acute hemorrhagic conjunctivitis is usually remarkable for:[3]

Bacterial Conjunctivitis

Ophthalmologic examination of patients with bacterial conjunctivitis is usually remarkable for:[4][5]

Neonatal Conjunctivitis

Ophthalmologic examination of patients with neonatal conjunctivitis or ophthalmia neonatorum is usually remarkable for:[6][7][8]

Allergic Conjunctivitis

Ophthalmologic examination of patients with allergic conjunctivitis is usually remarkable for:[4][9]

  • Bilateral conjunctival injection
  • Chemosis
  • Watery discharge or mild mucous discharge
  • Large cobblestone papillae under upper eyelid

Keratoconjunctivitis Sicaa

Examination should include evaluation of the face, eyelids, blinking patterns, eyelid margins, eyelashes, conjunctiva, cornea, and tear film. Examination of patients with keratoconjunctivitis sicaa is usually remarkable for:[10][11]

Superior Limbic Keratoconjunctivitis

Ophthalmologic examination of patients with superior limbic keratoconjunctivitis (SLK) is usually remarkable for:[12]

  • Hyperemia
  • Micro-papillary reaction in the upper tarsal conjunctiva
  • Thickening of the superior bulbar conjunctiva
  • Ciliary injection in the upper bulbar conjunctiva
  • Corneal erosion in the upper quadrants
  • Diffuse superficial corneal erosions
  • Eyelid edema

References

  1. ↑ 1.0 1.1 Jhanji V, Chan TC, Li EY, Agarwal K, Vajpayee RB (2015). "Adenoviral keratoconjunctivitis". Surv Ophthalmol. 60 (5): 435–43. doi:10.1016/j.survophthal.2015.04.001. PMID 26077630.
  2. ↑ 2.0 2.1 Azari AA, Barney NP (2013). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMC 4049531. PMID 24150468.
  3. ↑ Yin-Murphy M (1976). "Simple tests for the diagnosis of picornavirus epidemic conjunctivitis (acute haemorrhagic conjunctivitis)". Bull World Health Organ. 54 (6): 675–9. PMC 2366581. PMID 1088513.
  4. ↑ 4.0 4.1 Leibowitz HM (2000). "The red eye". N Engl J Med. 343 (5): 345–51. doi:10.1056/NEJM200008033430507. PMID 10922425.
  5. ↑ Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC) (2010). "Sexually transmitted diseases treatment guidelines, 2010". MMWR Recomm Rep. 59 (RR-12): 1–110. PMID 21160459.
  6. ↑ Mallika P, Asok T, Faisal H, Aziz S, Tan A, Intan G (2008). "Neonatal conjunctivitis - a review". Malays Fam Physician. 3 (2): 77–81. PMC 4170304. PMID 25606121.
  7. ↑ Rours, Ingrid GIJG, et al. "Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants." Pediatrics 121.2 (2008): e321-e326.
  8. ↑ Pickering, Larry K. Red book®: 2003 report of the committee on infectious diseases. No. Ed. 26. American Academy of Pediatrics, 2003.
  9. ↑ La Rosa M, Lionetti E, Reibaldi M, Russo A, Longo A, Leonardi S; et al. (2013). "Allergic conjunctivitis: a comprehensive review of the literature". Ital J Pediatr. 39: 18. doi:10.1186/1824-7288-39-18. PMC 3640929. PMID 23497516.
  10. ↑ Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC (1998). "The pathology of dry eye: the interaction between the ocular surface and lacrimal glands". Cornea. 17 (6): 584–9. PMID 9820935.
  11. ↑ Schaumberg DA, Dana R, Buring JE, Sullivan DA (2009). "Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies". Arch Ophthalmol. 127 (6): 763–8. doi:10.1001/archophthalmol.2009.103. PMC 2836718. PMID 19506195.
  12. ↑ Nelson JD (1989). "Superior limbic keratoconjunctivitis (SLK)". Eye (Lond). 3 ( Pt 2): 180–9. doi:10.1038/eye.1989.26. PMID 2695351.
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