Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Conjunctivitis
CONJUNCTIVITIS
An inflammation of the bulbar or palpebral conjunctiva or both which is characterized by irritation, pruritis, tearing, discharge, or foreign body sensation. It is a selflimited disease in older children and adults.
I. Etiology
A. Viral, predominantly adenoviruses
B. Bacterial
1. Haemophilus influenzae accounts for 40% to 50% of conjunctivitis in older infants and children.
2. Streptococcus pneumoniae is the second most common cause, accounting for 10% of cases.
3. Moraxella catarrhalis is the third most common cause.
4. S. aureus is unlikely to be a significant cause of uncomplicated acute conjunctivitis because it is isolated not only from eyes with conjunctivitis, but healthy eyes as well.
5. Chlamydia trachomatis is a diagnostic consideration in the neonate and sexually active adolescent.
6. Neisseria gonorrhoeae should also be considered in the neonate. (Antimicrobial prophylactic failure rate is about 1% in the neonate.)
C. Allergy: Allergens, such as pollens, molds, animal dander, dust
D. Chemicals and other irritants: Commonly seen after chemical prophylaxis in newborns
II. Incidence
A. Common in all age groups, but infants and young children are particularly susceptible.
B. Bacterial conjunctivitis is highly contagious and therefore prone to epidemics.
C. In older infants and children, conjunctivitis is twice as likely to be bacterial rather than viral.
III. Incubation period
A. Viral: 5 to 14 days
B. Bacterial: 2 to 3 days
IV. Communicability
Bacterial and viral conjunctivitis are highly communicable—by both direct and indirect contact.
V. Subjective data
A. Photophobia
B. Itching of eyes
C. Burning of eyes
D. Feeling of roughness under eyelids
E. Discharge from eyes
F. Eyelids stuck together
G. Eyelids swollen
H. Pertinent subjective data to obtain
1. History of upper respiratory infection
2. Any associated signs or symptoms (e.g., runny nose, sore throat, earache)
3. History of exposure to conjunctivitis
4. Prevalence of conjunctivitis in the community
5. History of swimming in a chlorinated pool or contaminated pond
6. History of foreign body or trauma to the eye
7. History of exposure to herpes simplex or concurrent cold sore
8. History of exposure to volatile chemicals or other irritants
9. History of atopy
I. No complaints of decreased vision
VI. Objective data
A. Viral conjunctivitis
1. Conjunctiva hyperemic
2. Hypertrophy of lymphoid follicles in lower palpebral conjunctiva
3. Tearing or watery, slightly milky discharge
4. Pupils: Normal and reactive to light
5. Cornea: Clear
6. Vision: Normal
7. May have associated pharyngitis, preauricular adenopathy, or edema of lower eyelids
8. Pruritis
B. Bacterial conjunctivitis
1. Conjunctiva mildly injected to markedly inflamed; discharge purulent or mucopurulent
2. Pupils: Normal and reactive to light
3. Vision: Normal
4. Cornea: Clear; check for ulcerations.
5. Eyelid margins: May be ulcerated
6. Pruritis not a prominent symptom.
7. Skin: Occasionally, impetigo is found on the face with a staphylococcal conjunctivitis.
8. Examine ears, nose, and throat for concomitant infection.
C. Allergic conjunctivitis
1. Conjunctiva edematous and moderately inflamed
2. Watery or stringy mucoid discharge
3. Vision: Normal
4. Pruritis
5. Associated symptoms of allergic rhinitis (see Allergic Rhinitis and Conjunctivitis, p. 218)
6. Symptoms worse than inflammation would indicate
7. History of atopy.
D. Chemical conjunctivitis
1. Conjunctiva inflamed and edematous
2. Tearing
3. Diagnosis made by history of exposure
E. A thorough ENT exam should be done; 75% of cases of conjunctivitis with concurrent otitis media will be a Haemophilus infection.
F. Laboratory studies: Culture of conjunctival exudate should be done on all infants younger than 1 month.
G. If unilateral or any question of diagnosis, examine eye with fluorescein to rule out corneal ulcer or abrasion.
H. Laboratory studies
1. Culture of conjunctival exudate on all infants younger than 1 month
2. Culture of conjunctival exudate if there are multiple cases in a school, day care, or college setting
VII. Assessment
A. Diagnosis is made by evaluation of subjective and objective data.
1. Viral conjunctivitis: Inflamed, watery discharge
2. Bacterial conjunctivitis: Inflamed, purulent discharge, eyes matted shut
3. Allergic conjunctivitis: Inflamed, watery discharge, pruritis
4. Chemical conjunctivitis: Inflamed, edematous, history of exposure
B. Differential diagnosis
1. Herpes simplex blepharitis: History of clinical findings of primary or secondary infection; generally unilateral
2. Herpetic keratitis: Corneal inflammation and presence of dendritic figure on staining with fluorescein
3. Trachoma (rare in the United States): Upper eyelid and upper portion of globe more severely involved than lower; conjunctiva thickened, with papillary hypertrophy and formation of follicles
4. Dacryostenosis: Chronic tearing with or without discharge; generally unilateral; naris on affected side dry
5. Ophthalmia neonatorum: Diagnosis established by culture of exudate
6. Corneal abrasion or ulcer: Severe pain and tearing, decreased vision, cornea may be hazy
7. Iritis: Moderate pain, no discharge, diminished vision, cornea possibly cloudy, poor pupillary reaction
8. Uveitis: Light sensitivity, pain, decreased vision
VIII. Plan: Treatment is often based on assumption that conjunctivitis is bacterial.
A. Viral conjunctivitis
1. Usually associated with upper respiratory infection and selflimited
2. Medication of value only to prevent secondary infection
a. Sodium Sulamyd ophthalmic ointment or solution 10%, 5 times daily
b. Cool compresses
B. Bacterial conjunctivitis
1. Vigamox 0.5% ophthalmic solution, over 1 year of age: 1 drop tid for 7 days
or
2. Tobrex ophthalmic ointment or solution, bid–qid for 7 days or
3. Polytrim ophthalmic solution, every 3 hours, maximum 6 doses a day
or
4. Ciloxin ophthalmic solution, over 1 year of age: 1 to 2 drops every 2 hours during day for 2 days, then 1 to 2 drops every 4 hours for 5 days
5. Warm compresses
C. Allergic conjunctivitis
1. Treatment of underlying allergy and allergic rhinitis (see Allergic Rhinitis and Conjunctivitis, p. 218.)
2. Cool compresses
3. Alocril ophthalmic solution, for children over 3 years of age: 1 to 2 drops in each eye bid for up to 3 months
or
4. Optivar ophthalmic solution, for children over 3 years of age: 1 drop in each eye, bid
or
5. Patanol ophthalmic solution, for children over 3 years of age: 1 drop in each eye, bid
D. Chemical conjunctivitis
1. Immediately flush eye with copious amounts of tepid water, preferably normal saline.
2. Consult with ophthalmologist for further treatment.
IX. Education
A. Viral conjunctivitis lasts about 12 to 14 days. It is generally self-limited, but secondary bacterial infection may occur.
B. Bacterial conjunctivitis should respond to treatment within 2 to 3 days. Continue treatment for 1 week or for at least 3 days after symptoms have subsided; otherwise it may recur.
C. Cool, wet compresses: Use cooled boiled water to moisten cotton ball; use a fresh cotton ball each time.
D. Wipe eyes gently from inner canthus to outer canthus to avoid spread to unaffected eye. Eyes should be cleaned before instillation of medication.
E. To instill ointment or drops, pull down inner canthus of lower eyelid toward center of eye; apply thin ribbon of ointment or drops to the “pocket.” Do not allow applicator tip to touch eyelid or fingers.
F. Instillation of ointment will cause blurring of vision.
G. Continue medication for recommended treatment time. Discontinuing use too soon will lead to resistance.
H. Rubbing of eyes can cause spread to other eye.
I. Discontinue use of contact lenses because of increased risk of bacterial keratitis.
J. Hygiene
1. Keep child’s face cloth and towels separate to avoid spread of infection.
2. Use careful handwashing technique to help prevent spread of infection.
3. Provide hand sanitizers for classrooms.
J. Ophthalmic medications, particularly in allergic conjunctivitis, help stop the cycle of itching and rubbing that can cause substantial irritation of the eyes.
K. With purulent conjunctivitis, exclude child from day care and school until treatment has been instituted and the discharge is significantly reduced.
X. Follow-up
A. Call back if no improvement noted in 2 to 3 days.
B. Call back immediately if symptoms become worse or child complains of pain.
C. Call back if child initially responds to treatment but then seems worse; this may be an allergic reaction to the medication.
D. No routine follow-up is necessary if child responds well to medication. Resolution should be complete in 1 week for bacterial infections,
2 weeks for viral.
XI. Complications
A. Blepharitis or corneal ulcers with bacterial conjunctivitis
B. Secondary bacterial infection with viral conjunctivitis
C. Sloughing of cornea or ulcer due to chemical irritation
XII. Consultation/referral
A. Corneal ulcer
B. Corneal inflammation
C. Suspicion of herpes simplex
D. No response to treatment within 3 days
E. Complaints of pain, severe photophobia, or decreased vision
F. Infants younger than 1 month
G. Any irregularities of pupil size or reaction to light
H. Chemical conjunctivitis