Conjunctivitis

[Jason09]

So I am currently a PA student about to graduate and go into EM. I had a question about the approach to patients with Conjunctivitis. A preceptor once told me to always treat for bacterial unless can clearly be proven otherwise because you don't want to miss bacterial. From a practitioner standpoint do you find yourselves always rx antibiotic eye drops "in case" it is atypical bacterial conjunctivitis?

[marilynpac]

As someone who gets frequent attacks of conjunctivitis, I always have a large bottle of ABX gtts handy....it spreads very rapidly, even w/o touching it...BTW, I prefer the gtts over the ointment.

[rcdavis]

Like anything else, you do a hx and pe, make a differential, and then tx appropriately. Cobblestones? Vesicles? Pre auricular lymph nodes? Scleral episcleral injections, chemosis?

Abx make no dif in allergic or viral conjunctivities, and corneal abrasions or keratitis are tx'd differently than iritis.

 

Allergic or vernal conjunctivitis is best tx'd w ocular antihistamines, or mast stabilizers.

 

Adenoviral infections, hemorrhgic conjunctivitis do notvrespond to abs at all, but need sx relief.

 

Steroids help if episceritis, or severe allergic fxn.

 

With a normal cornea, negative purulent drainage, abd rarely are needed...

 

Yes the tendency is to tx w/ abx x but like abx in dental cavities, they really are not needed... and are more often given simply to move the patient out ... And do not represent critical thinking.

 

And, other than herpetic keratitis, what is the danger of" missing" a bacterial conjunctivitis?

 

Unilateral mucopurulent drainage, periorbital cellulitis, maybe good indications.. But if you delay tx... Where is the urgent risk? I am excluding the neonate here... And the PT with possible c. Trachoma ...

 

The things that you cannot miss are h. Simplex keratitis, glaucoma, corneal foreign body, retrobulbar cellulitis... Just about everything else can be treated without topical abx.

 

Until you are really good with ddx ocular infections, get good at the dx, then treat the accurate dx appropriately and use abx only when necessary.. Don't succumb to a " move the meat, and give vigamox ( !!!) to any eye irritation complaint".

 

Though a common (mis) perception by multiple Ed attendings, the giving ocular abxs to viral illnesses, is, simply, a wrong approach.

 

Vr

davis

[EMEDPA]

for conjunctivitis that is clearly allergic(clear d/c, runny nose, seasonal, chemosis) our local ophthos like a product called zaditor which is an otc combo mast cell stabilizer and antihistamine.

for regular conjunctivitis with yellow am d/c etc I typically use ery oint unless they are contact lens wearers then I use gent oint to cover pseudomonas.

[mdebord]

I had an interesting lesson in this recently, granted it was in Peds not EM. We gave almost everyone with conjunctivitis Abx drops because the local schools mandate them. On the one hand, I resent having my best-practice influenced by people without medical training. But does that mean we shouldn't give them? Seems like that would put the patient in a tougher spot.

[marilynpac]

What about viral conjunctivitis???? you don't Rx ABX...what about saline gtts?? Does that provide any comfort???

[Jason09]

Thanks for the responses. All interesting points. I guess what I am trying to say is from a student standpoint it can be very easy to slip into "common practice/ defensive medicine" treatment from what we observe in the field. Having said that I guess this reaffirms take everything we learn in the field with a grain of salt.

[Emerson]

Bacterial conjunctivitis is usually self-limiting. Treatment does shorten the course, reduce person-to-person contact and lowers the risk for ulceration. If it's unilateral with purulent d/c I will treat, as E mentioned the difference with contact lens wearer. If it's clearly viral/allergenic I don't prescribe abx. Early in your career you can expect to practice 'defensive medicine' as your practice evolves and you become more secure with your decision making with each case you encounter.

[cbrsmurf]

I had an interesting lesson in this recently, granted it was in Peds not EM. We gave almost everyone with conjunctivitis Abx drops because the local schools mandate them. On the one hand, I resent having my best-practice influenced by people without medical training. But does that mean we shouldn't give them? Seems like that would put the patient in a tougher spot.

 

My experience as well. Day care requires abx for any type of pink eye in order to allow the kid back into day care. Doc will prescribe even if she doesn't think it's bacterial.

[dm123]

You can always get with your supervising physician. Some are not comfortable dealing with most basic eye problems. A slit lamp should be require equipment for eyes. I'm not real comfortable with eye stuff as I've never had a supervisor who was. I missed an ocular herpes once that was thankfully saved by someone covering my butt. Scared me to death. It was an ER without a slit lamp and was using eye dye and a hand held black light with a set of blurry magnification lenses on a pair of glasses. Taught me that if you can't do it right turf it out.

 

And check visual acuity before messing with someones eye. CYA move.

[bradtPA]

I sure wish I could convince my SP to buy me even a simple woods lamp....

[medic25]

It was an ER without a slit lamp and was using eye dye and a hand held black light with a set of blurry magnification lenses on a pair of glasses. Taught me that if you can't do it right turf it out.

 

And check visual acuity before messing with someones eye. CYA move.

 

Are there many ED's out there that do not have a slit lamp? I figured this was standard equipment in this day.

Totally agree with checking visual acuity before messing with the eye; it's one of the most important parts of the eye exam. My only caveat is that I'll sometimes re-document the visual acuity after providing some form of analgesia; that big corneal abrasion might have much better vision after a couple of drops of tetracaine when the patient can actually open their eye.

[Hemegroup]

I saw a kid last week who had been sent home because the girl at the desk next to her had 'pink eye'. Both her mom and I couldn't tell if her left eye was truly red or if it was our imaginations or if it was just from the mom poking and pulling. But since there was a newborn at home, I went ahead and treated to be on the safe side.

[Febrifuge]

Saw a neonate today in my Urgent Care with one goopy, mattery eye every day since birth. Looked okay to me, but I told the parents they should get directly to the ER at the children's hospital. Five weeks old I feel okay about, five months is no problem, but at less than a week old I feel like I have ZERO margin for error. The DDx for eye stuff and the potential complications at that age are pants-crappingly serious.

 

I'm not second-guessing myself. I don't feel like I wimped out. But how many of you would do the same, and what would you do differently?

[EMEDPA]

with a single persistently goopy eye in a newborn you have to worry about an fb or something really ugly like congenital occular chlamydia or herpes.

[Febrifuge]

Exactly. Which is why I printed out my pre-written "this may be nothing but we don't have the resources to be confident enough it's not something serious" instruction sheet and sent them on their way.

 

Thanks for backing me up. Always good to know I was thinking what the pros would be thinking.