Case 5

A 27-year-old medical student with a red eye

Q1

A 27 yo medical student presents to your office with a chief complaint of redness, itching and foreign body sensation in the left eye.

What additional history do you want to obtain?

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[accordion-item title=”When did these symptoms start? (click to show/hide)”]

4-5 days ago. I really don’t remember. I’ve had some cold symptoms and I’ve been studying really hard for this Neurology exam.

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[accordion-item title=”Any history of eye trauma? (click to show/hide)”]

Not that I can recall.

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[accordion-item title=”Any foreign bodies in eye? (click to show/hide)”]

I don’t think so.

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[accordion-item title=”Any discharge from eye? (click to show/hide)”]

There is some crusting in the mornings, but for the rest of the day, it’s pretty good.

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[accordion-item title=”Is the redness only in the left eye? (click to show/hide)”]

Yeah. Does that mean I have cancer?

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[accordion-item title=”Do you have any associated symptoms? (click to show/hide)”]

Well, the light does bother me, but I don’t have any headache, eye pain, or any problem seeing stuff.

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[accordion-item title=”Do you wear contacts? (click to show/hide)”]

No.

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Q2

A 27 yo medical student presents to your office with a chief complaint of redness, itching and foreign body sensation in the left eye.

What physical examinations would you perform?

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[accordion-item title=”VA (click to show/hide)”]

20/20 both eyes

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[accordion-item title=”Confrontational visual fields (click to show/hide)”]

Full to confrontation each eye.

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[accordion-item title=”Pupil (click to show/hide)”]

Normal direct response each eye. No RAPD

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[accordion-item title=”Motility (click to show/hide)”]

Full range of motion each eye

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[accordion-item title=”External exam (click to show/hide)”]

The right eye is normal. The left eye shows mild injection of the conjunctiva. There is also some mild stringy discharge. The left eye is not painful to touch and feels soft. There is no whiteness of the cornea or foreign body noted on exam. Staining with fluorescein after looking closely with a penlight does not reveal any abrasions, dendrites, or other abnormality.

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Q3

A 27 yo medical student presents to your office with a chief complaint of redness, itching and foreign body sensation in the left eye.

What is the most likely diagnosis?

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[accordion-item title=”Scleritis (click to show/hide)”]

Incorrect: Scleritis is unlikely in this case, as there is no eye pain, and this would likely have been the presenting complaint. Also scleritis is not typically associated with discharge.

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[accordion-item title=”Allergic conjunctivitis (click to show/hide)”]

Incorrect: Allergic conjuncitivitis would most likely be bilateral and is often associated with other symptoms such as sneezing, nasal congestion, and itching.

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[accordion-item title=”Bacterial conjunctivitis (click to show/hide)”]

Incorrect: Bacterial conjunctivitis usually presents with more significant symptoms and more copious discharge. Also the temporal relation to a URI is often longer than a week.

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[accordion-item title=”Viral conjunctivitis (click to show/hide)”]

Correct: Viral conjunctivitis is the most likely answer. Most viral conjuncivitis follows a URI and begins unilaterally. The feeling of a foreign body in the eye and scant discharge also support the diagnosis.

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[accordion-item title=”Foreign body in the eye (click to show/hide)”]

Incorrect: While possible, foreign body in the eye is unlikely if not found on slit lamp examination.

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Q4

Based on the recency of his URI, scant eye discharge, and the unilateral conjunctival injection, you diagnose viral conjunctivitis.

What is the most appropriate treatment for this patient?

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[accordion-item title=”Antibiotic eye drops (click to show/hide)”]

Incorrect: Antibiotic eye drops may be used in the treatment of bacterial conjunctivitis, but have no role in the treatment of viral conjunctivitis.

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[accordion-item title=”Steroid eye drops (click to show/hide)”]

Incorrect: Steroid eye drops typically are not used in treatment of viral conjunctivitis. Use of these types of drops should be limited to eye care professionals.

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[accordion-item title=”Antihistamine eye drops (click to show/hide)”]

Incorrect: Antihistamine eye drops may be used to treat allergic conjunctivitis, but have no role in the treatment of viral conjunctivitis.

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[accordion-item title=”Good eye hygiene and frequent hand washing (click to show/hide)”]

Correct: Good eye hygiene and frequent hand washing is the best way to keep from infecting the other eye and others. Viral conjunctivitis is usually self resolving.

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[accordion-item title=”Oral acyclovir (click to show/hide)”]

Incorrect: Oral acyclovir is not a routine treatment for viral conjunctivitis. Most viral conjunctivitis is self resolving and does not need treatment.

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[accordion-item title=”Prescribe proparacaine (click to show/hide)”]

Incorrect: Prescribing a topical anesthetic for the eye is never appropriate and can lead to corneal melting.

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Summary

Conjunctivitis is a common cause of red eye. There are three common varieties – bacterial, viral, and allergic. Bacterial conjunctivitis is acute, often unilateral, very red, and associated with purulent discharge. Most common pathogens are Streptococcus and Staphylococcus. Viral conjunctivitis is usually subacute, often associated with a viral prodrome, and is associated with a water mucoid discharge. It usually starts off unilateral, but can easily spread to other eye. Adenovirus is the most common pathogen. Allergic conjunctivitis is often associated with other allergic symptoms e.g. runny nose, sneezing. It is usually bilateral and associated with profuse watery discharge from eyes. The redness may be less evident than in other forms of conjunctivitis and it responds to topical antihistamines.

Neonatal conjunctivitis is becoming less common but is still important for boards. Three flavors of neonatal conjunctivitis, with distinct temporal differences. Chemical conjunctivitis is usually secondary to silver nitrate drops and develops within hours of birth. Gonococcal conjunctivitis develops within 2-4 days of birth, and Chlamydia conjunctivitis develops about a week after birth and may be associated with pneumonia.