Case scenario

Kaia is a 22-year-old student and resident of a shared university dormitory who has come into your community pharmacy complaining of ‘icky’ eyes. She mentions her roommate had the same issue last week, went to the pharmacy and it has now cleared up. On further questioning, she mentions it started yesterday and that it was a little difficult to open her eyes this morning, and describes some discomfort but not pain. You rule out other red-flag symptoms such as photophobia or vision changes and ensure she does not have symptoms suggestive of more sinister bacterial infection. Kaia is usually otherwise well (does not use corrective eyewear) but is concerned that this will affect her studies.

Learning objectives

After successful completion of this CPD activity, pharmacists should be able to:

  • Discuss conjunctivitis
  • Recognise symptoms of conjunctivitis, differential diagnoses and when to refer
  • Explain treatment options for conjunctivitis.

Competency (2016) Standards addressed: 1.1, 1.3, 1.4, 1.5, 3.1, 3.5

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Introduction

Conjunctivitis is a common ophthalmic condition characterised by inflammation of the conjunctiva.1,2 Causes of conjunctivitis can either be infective (e.g. bacterial, viral) or non-infective (e.g. allergic, chemical irritation). Although most cases are self-limiting and the condition does not typically endanger vision, treatment and/or further referral may be appropriate in some cases.1,3–6 Management may involve the use of antimicrobials, antihistamines and lubricating topical preparations, and non-pharmacological strategies such as eyelid bathing, allergen avoidance and good hygiene practice.1,7 Correct diagnosis is important for effective management and to reduce inappropriate antibiotic use.1 Pharmacists may be heavily involved in the management of conjunctivitis, including the diagnosis, treatment, medicine and condition counselling, and follow-up.

Background

Made up of a thin mucous membrane, the conjunctiva lines the inside of the upper and lower eyelids.7,8 Dilation of blood vessels found in this membrane can occur secondary to infection or inflammation which often leads to hyperaemia (causing red eye) and oedema, which may be associated with discharge.7,8 Conjunctivitis may be acute or chronic (less or more than 4 weeks respectively), or recurrent.7,8 See common causes of conjunctivitis in Table 1.

TABLE 1 – Common causes of conjunctivitis

 

ALLERGIC

 

VIRAL

 

BACTERIAL

Age group Children or adults More often in adults More often in children
Aetiology Allergen response Usually associated with upper respiratory tract infections and commonly caused by adenovirus Usually caused by Staphylococcus aureus, Streptococcus pneumoniae, or Haemophilus influenzae
Clinical features Usually bilateral

 

Common symptoms include itchy and watery or mucoid discharge

Usually unilateral,

often becoming bilateral within days

 

Common symptoms include red eye, watery or mucoid discharge and irritation

Usually unilateral but can be bilateral

 

Common symptoms include red eye, purulent discharge and eyelid crusting

Reproduced with permission from Introduction to conjunctivitis [published April 2019]. In: eTG complete [digital]. Melbourne: Therapeutic Guidelines Limited; 2020. At: www.tg.org.au1

Infective causes

Bacterial conjunctivitis

Bacterial conjunctivitis often presents with unilateral symptoms of rapid onset, which frequently becomes bilateral.1,3 It is more common in children, with the elderly also having an increased risk.3 Symptoms include red eye, purulent discharge, discomfort (may be described as grittiness) and eyelid crusting. Predisposing factors include previous superficial trauma, diabetes, steroid treatment and blepharitis.1,3 It is commonly caused by Staphylococcus aureus, Streptococcus pneumoniae or Haemophilus influenzae, however most cases resolve within 7 days and antibiotic treatment may only modestly improve symptoms.1

Gonococcal conjunctivitis

Gonococcal conjunctivitis presents with a rapid onset of copious, purulent discharge.1 It is an ophthalmic medical emergency, as ulceration and perforation of the cornea may develop, so patients should be treated on the advice of an ophthalmologist.1 It is caused by the bacteria Neisseria gonorrhoeae and laboratory testing (e.g. culture and Gram-stain testing) of a conjunctival swab is required to confirm diagnosis.1 Infection in children, including infants and neonates, may occur via mother to child, or may be a sign of sexual abuse.1 Treatment with systemic antibiotics and saline lavage is required. For further information on the management of gonococcal conjunctivitis, see Therapeutic Guidelines: Antibiotic (see Helpful links).1,2

Viral conjunctivitis

Viral conjunctivitis usually presents with unilateral symptoms that often become bilateral and is more common in adults (usually aged 20–40 years).1,4 Symptoms may include red eye, watery or mucoid discharge, local irritation and systemic malaise.1 It is most commonly caused by the highly contagious pathogen, adenovirus (65–90% of cases) and is often associated with an upper viral respiratory tract infection. Other predisposing factors include crowded conditions and poor hygiene.1,2,4 Less common causes (very rare) include enterovirus 70 (EV70), Coxsackievirus A24 (CA24v) and SARS- CoV-2 coronavirus (COVID-19).4

Helpful links

Non-infective causes

Allergic conjunctivitis

Allergic conjunctivitis is the result of a type I hypersensitivity reaction to an allergen, creating a localised response.1 Symptoms are usually bilateral, and include itch and watery discharge, and are either acute or chronic in nature.1 Allergic conjunctivitis can be seasonal, caused by allergens such as grass pollen, typically occurring in spring or autumn; or it can be perennial, non-seasonally specific, caused by allergens such as animal dander or dust mites.6 It can also be due to a contact hypersensitivity reaction to a compound (e.g. preservatives in eye drops).1 Predisposing factors include patients with an atopic disposition, personal or family history of allergies, and exposure to the allergen.6

What are the differential diagnoses?

Differential diagnoses typically relate to the most prominent symptoms seen, and consideration of other possible causes.3–6 For example, other causes of an acute red eye include angle-closure glaucoma, infective keratitis and anterior uveitis.3,7,8 Causes of ocular discharge include all forms of conjunctivitis, Acanthamoeba keratitis, allergy and herpes zoster.3–6

Assessment may include checking visual acuity and examining the eyeball under torch or slit lamp to rule out signs of corneal ulceration or sinister infection.2 Possible diagnosis of cold sores or shingles should be considered to rule out a herpetic cause of conjunctivitis.2

When is referral required?

Timely referral to an ophthalmologist is required in patients with any type of conjunctivitis that is associated with a ‘red-flag’ symptom, as this may suggest a more severe condition.1,7,10 Red-flag symptoms include significant pain, vision changes, severe foreign body sensation, corneal opacity or photophobia.1,8,10–12 Urgent referral is also required in some patients such as those with suspected gonococcal or chlamydial conjunctivitis, herpetic infection, ocular cellulitis, suspected corneal involvement in a contact lens wearer, and those who have had recent intraocular surgery.8

It is important to note that sticky eyes seen in children aged 2–12 months may be due to built-up mucus from the tear film secondary to having blocked lacrimal ducts (tear ducts) rather than pus from conjunctivitis.1

For acute viral and bacterial conjunctivitis, if symptoms persist beyond 7 days after initiating treatment, advise the patient to seek further help.7

Management

Most cases of viral, bacterial and allergic conjunctivitis are self-limiting and resolve without treatment.3,6,7,12 Bacterial conjunctivitis usually resolves within 5–7 days, while viral conjunctivitis often worsens for 3–5 days then resolves within 1–2 weeks.7,12 Most cases of acute allergic conjunctivitis resolve spontaneously within a few hours.5 Contact lenses should be discontinued during the acute phase of conjunctivitis; particularly during topical treatment. Contact lens solution compatibility with some eye drops/lubricants are uncertain, therefore individual manufacturer advice should be sought.3,4,7,8

Non-pharmacological treatment options

Bacterial conjunctivitis

As bacterial conjunctivitis is contagious, hygiene education is vital when informing patients on how to reduce contamination risk (between eyes and among individuals).11 Good hygiene practice includes washing hands often, avoiding hand-to-eye contact, and discarding used make-up, contact-lens solution and disposable contact lenses.11 Patients should also avoid sharing towels and using public swimming pools while infected.11

Patients may bathe/cleanse the eyelids to wash discharge or ‘grit’ using sterile wipes, or cotton dipped in saline or sterile water (boiled, then cooled).7,11

Viral conjunctivitis

Self-care strategies may help alleviate symptoms and include bathing/cleansing the eyelids using sterile wipes, or cotton dipped in saline or sterile water (boiled, then cooled), cool compresses, and the use of lubricating eye drops.7

As the infection is highly contagious and patients may be contagious for 14 days from symptom onset, patients should be advised to practice good hygiene, including washing hands often and avoiding sharing towels.7

Allergic conjunctivitis

Patients should be advised to avoid eye rubbing as this can cause mechanical mast-cell degranulation and worsening of the condition.6 Avoidance of allergens/triggers, if known, should be advised.

Other self-care strategies include cold compresses for symptomatic relief and/or ocular lubricants such as saline drops or artificial tears.6,8

Pharmacological treatment options

Bacterial infections

Treatment with a topical antibiotic may be appropriate if symptoms of infection are pronounced (e.g. purulent discharge) or if the infection occurs in a neonate or young infant.1

Antibiotic treatment may improve the short-term outcome and cause the patient to become less contagious.3 It is important that the patient discard the bottle after use.11

Topical antibiotic options include1,13,14:

  • Chloramphenicol 0.5% eye drops: one drop into the affected eye, four times a day for up to 7 days, OR
  • Chloramphenicol 1% eye ointment: apply approximately 1.5 cm into lower eyelid of affected eye, four times a day for up to 7 days, OR
  • Framycetin 0.5% eye drops: one drop into the affected eye, four times daily for up to 7 days.

Chloramphenicol is an S3 medicine (pharmacist only), while framycetin is S4 (prescription only).13,14

If treatment fails to resolve symptoms but the patient does not require referral to an ophthalmologist, swabs may be appropriate.7

Viral infections

Viral conjunctivitis does not require antimicrobial treatment, however symptomatic management is recommended.1,7 Along with self-care measures, symptomatic treatment may involve topical antihistamines to relieve severe itching and systemic analgesics for pain relief.2,4,12 Medicated eye drops should be used during the day, while unmedicated/lubricating preparations can be used before bedtime.4

For examples of topical antihistamines, see Allergic conjunctivitis.

Allergic conjunctivitis

For the symptomatic management of allergic conjunctivitis, topical antihistamines with or without mast-cell stabilisers may be used.6,15 Topical antihistamines provide short-term relief, while mast-cell stabilisers provide prophylactic cover.15 Mast-cell stabilisers may be used if symptoms are recurrent or persistent but can take several weeks of regular use to provide any prophylactic benefit.8

Other treatment options, particularly when symptoms of allergy are not restricted to the eye, may include oral antihistamines and/or intranasal corticosteroids.10 Some topical antihistamine preparations may be combined with a vasoconstricting medicine. Chronic use may cause vasodilation upon discontinuation.8

Examples of topical preparations available include15–20:

  • Topical antihistamines:
    • Azelastine 0.05% eye drops: one drop into each eye, twice a day and may be increased to four times a day (use of up to 6 weeks has been studied).
  • Topical antihistamines (some mast-cell stabiliser action):
    • Ketotifen 0.025% eye drops: one drop into each eye, twice a day (maximum duration not specified).
    • Olopatadine 0.1% eye drops: 1–2 drops into each eye, twice a day (up to 14 weeks).
  • Mast-cell stabilisers:
    • Sodium cromoglycate 2% eye drops: 1–2 drops into each eye 4–6 times a day.
    • Lodoxamide 0.1% eye drops: one drop into each eye, four times daily.

Ketotifen, azelastine, sodium cromoglycate and lodoxamide are S2 medicines ‘Pharmacy Medicine’, while olopatadine is an S4 medicine ‘Prescription Only Medicine’.16–20

Potential interactions and adverse effects

Generally, very few interactions are reported with eye drops used in the treatment of conjunctivitis.16–20 This is likely due to minimal systemic absorption with ocular use.16,18

  • Chloramphenicol eye drops/ointment may be absorbed systemically and cause toxicity with chronic use. Dose-related toxicity is unlikely following a single course.13
  • Framycetin, an aminoglycoside, may cause irreversible deafness when applied to open wounds where the likelihood increases in patients with renal/hepatic impairment and prolonged use.14

See Table 2 for adverse effects associated with topical eye preparations.

TABLE 2 – Adverse effects

 

TOPICAL EYE PREPARATION

 

ADVERSE DRUG REACTIONS

Chloramphenicol Hypersensitivity, burning, itching, dermatitis, aplastic anaemia (rarely)
Framycetin Hypersensitivity, hearing impairment (rarely)
Ketotifen Hypersensitivity, headache, punctuate keratitis, corneal erosion, irritation, pain, dry mouth, rash
Azelastine Hypersensitivity, bitter taste, local irritation (burning and stinging)
Olopatadine Hypersensitivity, headaches, local irritation, taste perversion, rhinitis, eyelid oedema, keratitis
Sodium cromoglycate Hypersensitivity, eyelid swelling, transient stinging and burning, local irritation
Lodoxamide Hypersensitivity, dizziness, headache, ocular discomfort, dry eye, pruritus, ocular hyperaemia

References: Therapeutic Guidelines,1 Aspen Pharma,13 Sanofi-aventis,14 Randall L K et al,15 Mylan,16 Sanofi-aventis,17 Apotex,18 Novartis,19 Novartis20

Note: Patients requiring treatment with eye drops or ointment should be advised that blurred vision may occur and that driving or performing other such skills/tasks should be avoided until it resolves.8

Role of the pharmacist

As conjunctivitis is a commonly occurring condition, pharmacists can diagnose, educate and treat the patient as appropriate. Pharmacists should recognise ‘red-flag’ symptoms and other causes that require referral to a medical practitioner. Pharmacists can provide education on the self-limiting nature of conjunctivitis, expectations of resolution, management advice including good hygiene practices, trigger avoidance for prevention, and what to do should resolution not occur.

Conclusion

Conjunctivitis is a common eye condition that is often self-limiting, however it may require antimicrobial or symptomatic treatment and/ or appropriate referral. Self-care measures play a vital role in alleviating symptoms and, in many cases, minimising contractibility and spread.

Pharmacies are often the first port of call for patients with conjunctivitis due to the accessibility, availability and expertise that pharmacists are able to provide, not only in diagnosis, but also treatment and appropriate referral. Furthermore, treatment options are often available over the counter, following a pharmacist consultation.

Key points

  • Conjunctivitis is the inflammation of the conjunctival lining in the upper and lower lids; it can be infective or non-infective.
  • Symptoms, usually localised, include red eye, itch, watery or mucoid discharge and purulent discharge with or without eyelid crusting.
  • Conjunctivitis is treated through the use of self-care measures and topical eye preparations as appropriate.
  • Pharmacists have a role in diagnosis, education, treatment and referral as appropriate.
  • Referral is required in those with chlamydial, gonorrhoeal and herpetic conjunctivitis, and in those who have had recent ocular surgery, and where treatment is refractory.

Case scenario continued

You advise Kaia that she has likely contracted bacterial conjunctivitis but reassure her this is a common infection that is often self-limiting and usually resolves without treatment. As she is living in a shared space, experiencing marked purulent discharge, and has concerns over upcoming studies, you advise she can also use a course of chloramphenicol eye drops or ointment. You discuss the importance of self-care measures such as eye cleansing, and prevention strategies such as good hygiene practices, particularly in a dormitory living space. You discuss the antibiotic use, frequency, duration and when to discard the bottle, and advise her to visit the GP if symptoms do not resolve within approximately one week, or ‘red-flag’ symptoms develop. In the meantime, she is able to contact you should she need further help.

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References

  1. Conjunctivitis [revised April 2019]. In: eTG complete. Melbourne: Therapeutic Guidelines; 2020. At: https://www.tg.org.au/
  2. Watson S, Carbrera-Aguas M, Khoo P. Common eye infections. Australian prescriber 2018;41:67–72. At: nps.org.au/assets/d1e1894daab433a1- 9ed1066742d1-p67-Watson-et- al-v3.pdf
  3. The College of Optometrists. Conjunctivitis (bacterial). 2018. At: college-optometrists.org/guidance/clinical-management-guidelines/conjunctivitis-bacterial-.html
  4. The College of Optometrists. Conjunctivitis (viral, non-herpetic). 2020. At: college-optometrists.org/guidance/clinical-management-guidelines/conjunctivitis-viral-non-herpetic-.html
  5. The College of Optometrists. Conjunctivitis (acute allergic). 2019. At: college-optometrists.org/guidance/clinical-management-guidelines/conjunctivitis-acute-allergic-.html
  6. The College of Optometrists. Seasonal allergic conjunctivitis; perennial allergic conjunctivitis 2018. At: college-optometrists.org/guidance/clinical-management-guidelines/seasonal-allergic-conjunctivitis.html
  7. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Conjunctivitis – infective. 2018. At: https://cks.nice.org.uk/topics/conjunctivitis-infective/management/management-in-primary-care/
  8. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Conjunctivitis – allergic. 2017. At: https://cks.nice.org.uk/topics/conjunctivitis-allergic/management/management-in-primary-care/#management-in-primary-care
  9. The College of Optometrists. Conjunctivitis, chlamydial (adult incision conjunctivitis). 2018. At: college-optometrists.org/guidance/clinical-management-guidelines/conjunctivitis-chlamydial.html
  10. Dermnet NZ. Allergic conjunctivitis. 2015. At: https://dermnetnz.org/topics/allergic-conjunctivitis/
  11. Dermnet NZ. Bacterial conjunctivitis. 2015. At: https://dermnetnz.org/topics/bacterial-conjunctivitis/
  12. Dermnet NZ. Viral conjunctivitis 2015. At: https://dermnetnz.org/topics/viral-conjunctivitis/
  13. Aspen Pharma. Chlorsig product information chloramphenicol 0.5% eye drops, 1% eye ointment. 2010. At: aspenpharma.com.au/wp-content/uploads/PICMI/PI/PI_Chlorsig.pdf
  14. Sanofi-aventis. Australian product information framycetin 5mg/mL eye/ear drops. 2019. At: https://apps.medicines.org.au/files/swpsofra.pdf
  15. Randall L K et al. Antihistamines and allergy. Australian prescriber 2018;41:42–5. At: https://www.nps.org.au/australian-prescriber/articles/antihistamines-and-allergy
  16. Australian product information azelastine hydrochloride 0.5mg/mL eye drops. 2018. At: https://apps.medicines.org.au/files/gopeyeze.pdf
  17. Sanofi-aventis. Australian product information sodium cromoglycate 2% eye drops. 2018. At: https://apps.medicines.org.au/files/swpoptic.pdf
  18. Australian product information olopatadine 1mg/mL eye drops. 2016. At: https://apps.medicines.org.au/files/txpolopa.pdf
  19. New Zealand data sheet ketotifen 0.25mg/mL eye drops. 2018. At: www.medsafe.govt.nz/profs/Datasheet/z/Zaditeneyedrops.pdf
  20. New Zealand data sheet lodoxamide trometamol 0.1% eye drops. 2020. At: www.medsafe.govt.nz/Profs/Datasheet/l/lomideeyedrops.pdf

HANA NUMAN BPharm, PGDipClinPharm is an experienced community, hospital and aged-care facility pharmacist with an interest in multiple specialisations, including endocrinology. She is currently working as a freelance writer on a number of international pharmaceutical publications, and as a locum pharmacist.