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INSIDE
Anatomy and
function
Signs and
symptoms
Examination
techniques
Common
conjunctival
conditions
Case studies
The authors
Dr Matthew Oliva, Corneal
Fellow, Royal Victorian Eye
and Ear Hospital,
Melbourne.
Conjunctival
Professor Hugh Taylor
AC, professor of
ophthalmology, University
of Melbourne; director,
Centre for Eye Research
Australia, Royal Victorian
Eye and Ear Hospital,
Melbourne.
conditions
Overview
OCULAR surface problems are one of the most
common reasons patients seek medical care. However,
medical training often invests little time preparing the
GP for the wide variety of eye problems encountered in
clinical practice.
Many ocular symptoms are non-specific and many
clinical entities can lead to inflammation of the conjunctiva and the presentation of a ‘red eye’. While
most conjunctival conditions are benign, some presentations may herald vision-threatening or, rarely,
life-threatening conditions.
For these reasons it is important for GPs to have a
solid framework of knowledge to help them distinguish between common self-limiting conditions, such as
conjunctivitis, and vision-threatening entities requiring
prompt referral, such as corneal ulcers and angleclosure glaucoma.
This review of conjunctival problems emphasises
diagnostic clues, suggested treatments and referral criteria. Some causes of a red eye, such as blepharitis
and pterygium, are beyond the scope of this article, as
are conditions such as neonatal conjunctivitis.
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Anatomy and function
THE conjunctiva is a thin, translucent, mucous membrane-lined sac
covering the anterior portion of the
globe and the undersurfaces of the
eyelids. It protects the eye, allows
unrestricted movement, contributes
products to the tear film and provides a source of immune and
antimicrobial agents to protect the
ocular surface.
The conjunctiva extends from
the upper and lower eyelid margins
onto the back surface of the eyelid
(palpebral portion), into the fornix
(forniceal portion), onto the surface of the globe (bulbar portion),
and up to the corneoscleral limbus
Figure 1: Diagram of the medial
conjunctiva showing the plica
semilunaris.
Punctum
lacrimale
Plica semilunaris
Caruncula
Punctum lacrimale
Opening of
tarsal
glands
The plica semilunaris is a vertical
fold of conjunctiva located in the
medial portion of the bulbar conjunctiva. It may represent a remnant of the nictitating membrane
found in some animals, such as cats
(figure 1).
The conjunctiva, corneal and
intraocular structures derive their
blood supply from terminal branches
of the ophthalmic artery. Hyperaemia of the bulbar conjunctiva and
a red eye is the hallmark of inflammatory processes of the conjunctiva.
Inflammation of the superficial
conjunctival vessels, which tend to
increase in size away from the
(limbal portion).
The stratified squamous and
columnar conjunctival mucosal surface undergoes transition from keratinised skin at the eyelid margin, into
corneal epithelium at the corneoscleral limbus. The tarsal conjunctiva is
tightly adherent to the tarsal plate of
the upper and lower lids. The forniceal portions of the conjunctiva
serve as tear reservoirs.
Special regions of the conjunctiva
include the caruncle and the plica
semilunaris. The caruncle is located
in the medical canthus and contains
dermal structures such as hair follicles and sebaceous glands.
limbus, must be differentiated from
inflammation of the deeper vessels
supplying the sclera and the thin connective tissue layer between the conjunctiva and the sclera, known as the
episclera. These vessels dilate with
inflammation of the cornea, iris, ciliary body and sclera. When there is
inflammation of the conjunctival and
episcleral vessels, white sclera can still
be visualised deep to the redness.
The conjunctiva is rich in lymphatic networks. These join the lymphatics of the eyelids and drain medially to the submandibular lymph
node and laterally to the pre-auricular lymph node system.
Signs and symptoms
A CAREFUL history is important in diagnosing conjunctival conditions and will significantly narrow the differential
diagnosis before examination
begins (see box). The first
impression you have of the
patient is critical in guiding
effective history-taking. Pay
particular attention to their
age, occupational risk factors
and the context of the presentation.
Symptoms not to miss
Pain
Pain can be difficult to assess
given its subjective nature.
Most conjunctival lesions typically produce only mild-tomoderate discomfort. Descriptions of mild burning,
stinging, itching, scratchiness,
aching or foreign body sensation are all common complaints and are typically
caused by ocular surface disturbances.
In the patient who describes
moderate-to-severe pain, consider causes such as corneal
abrasions or ulcers, uveitis,
scleritis, angle-closure glaucoma or, less commonly,
orbital processes such as
orbital cellulitis or pseudotumour. As a general guideline,
a patient with severe pain
should warrant investigation
for a process not involving the
conjunctiva alone.
Important symptoms and associated ocular conditions
Key history points
Pain
Onset and duration — is the condition acute or chronic in
nature? Symptoms lasting more than four weeks are chronic,
while those occurring in the previous 12 hours are
hyperacute.
Laterality — is the condition monocular or binocular? Did it
begin in one eye and then spread to the other?
Course — is the condition improving or worsening, or does
it wax and wane? Is it associated with seasonal variations?
Social history — is there any recent contact with children or
adults with a red eye? Is there a history of long-term sun
exposure (pterygium and pingueculae)? Some patients may
need to be asked specifically about their sexual history,
including current or prior genital tract infection with, or
exposure to, sexually transmitted infections (gonococcal and
chlamydial conjunctivitis).
Occupational history — does the patient work in a situation
that may predispose to trauma or allow environmental
exposures to irritants or allergens such as dust, wind, smoke
or chemicals?
Past medical history and review of systems — has the
patient had a recent upper respiratory illness? Systemic
malignancies, dermatological conditions and inflammatory
disorders such as sarcoidosis and lupus can manifest as
ophthalmic conditions. Pay special attention to immune
status, autoimmune diseases, prior head and neck
pathology, thyroid conditions, history of allergy, and
coagulation status.
Ophthalmic history — does the patient wear contact
lenses? Is there a history of intra- or extra-ocular surgery,
including eyelid surgery? Has there been any prior radiation
treatment to the orbital region?
Medications — many systemic medications may have
ocular side effects, such as antihistamines causing dryness.
Document all topical ocular medications and their actual
frequency and duration of use. Pay special attention to
over-the-counter medicines such as ‘get the red out’
medicines, tear substitutes and contact lens solutions.
Itching
Loss of vision
Relieved with
topical
anaesthetic
Corneal
abrasion,
corneal ulcer,
severe dry eye
Mild
Blepharitis, viral or
bacterial
conjunctivitis, dry
eye, mild allergic
eye disease
Not relieved
with topical
anaesthetic
Scleritis, orbital
process,
anterior uveitis,
angle-closure
glaucoma
Severe
Allergic or atopic
keratoconjunctivitis,
vernal
keratoconjunctivitis
Discharge
Corneal processes
Microbial keratitis (ulcer),
severe dry eye, abrasions
Mucopurulent
Bacterial conjunctivitis
Watery (serous)
Viral conjunctivitis
Intraocular processes
Uveitis, cataract, retinal
pathology, optic
neuropathies, acute
glaucoma
Stringy
Allergic conjunctivitis
Orbital processes
Optic neuropathies, orbital
tumours, orbital infections
Cortical processes
Brain tumours, stroke
Visual disturbance
Another important question
to ask the patient is whether
vision has been affected. It
is critical to determine
whether an intraocular
process is manifesting as an
external inflammation or if
there is involvement of the
cornea, which may also
cause a visual disturbance.
Conjunctivitis unaccompanied by a corneal process
or intraocular inflammation
usually does not affect visual
acuity. If acuity is decreased,
the GP must assume corneal
involvement or an intraocular process such as iritis or
acute angle-closure glaucoma and refer to a collabo-
Guidelines for immediate referral
Severe ocular pain.
■ Any visual deficit associated with an inflamed eye.
■ Any corneal infiltrate or hypopyon.
■ Any unilateral red eye associated with nausea and/or vomiting.
■
rating ophthalmologist.
Discharge
If an infectious cause is suspected, ask about the presence
and type of discharge. In the
acute setting, a history of the
eyelids being stuck closed in
the morning, with greenish or
yellow discharge that adheres
to the lashes and lid margins
and requires a washcloth to
clean them, is usually indicative of bacterial conjunctivitis.
A more watery discharge,
with or without stringy
mucus, is more suggestive of a
viral or allergic cause.
Itching
Itching is a hallmark of allergic
eye disease, although patients
sometimes complain of mild
itching with dry eyes, blepharitis and acute conjunctivitis.
Itching should provide a clue
to the GP to inquire further
regarding allergies.
Examination techniques
BASIC equipment should include a
near and distance acuity chart, pinhole, handheld light source, topical
anaesthetic drops, fluorescein drops,
litmus paper and a magnifying device
such as a slit lamp, loupes or direct
ophthalmoscope.
Visual acuity
Measure acuity in each eye separately
with appropriate correction, or pinhole testing.
Observation
Notice the patient’s level of hygiene
and their body habitus, looking for
signs of an underlying disorder such
as Cushingoid features and any
abnormal habits (such as chronic eye
rubbing). Also, look for any signs of
systemic conditions that may affect
the conjunctiva, such as rheumatoid
arthritis.
Head and neck examination
Avoid the urge to focus attention
immediately on the eye itself. Search
for any pre-auricular or submandibular lymphadenopathy, especially in patients suspected of having
viral conjunctivitis.
Perform a complete cranial nerve
exam with specific focus on cranial
nerves II, III, IV, V and VII. Nerve
palsies may predispose to conjunctival conditions from poor lid closure
or diminished corneal sensation.
Skin examination
Look for chronic skin conditions
such as rosacea and atopic disease. A
rash or cold sore in the distribution
of the fifth cranial nerve could suggest active herpes simplex or zoster
disease. An acute rash could be evidence of contact dermatitis.
and nasolacrimal duct area for
masses as well as for areas of tenderness and warmth.
Pupil examination
Lid examination
Abnormalities in upper or lower
eyelid structure or function may predispose to conjunctival conditions.
Ask the patient to gently close their
eyes. Any lid malposition that allows
a show of sclera could be evidence of
clinically significant corneal exposure. Look for ectropion and entropion.
Also evaluate the spontaneous
blink rate, which should average one
blink per 5-10 seconds, which may
be decreased in neurodegenerative
disorders such as Parkinson’s disease.
Palpate the lids, lacrimal glands
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A fixed large pupil in the setting of a
red painful eye may indicate angleclosure glaucoma. A small pupil suggests uveitis.
Conjunctival examination
One drop of topical anaesthetic in
each eye often helps patient comfort and facilitates examination. If
the topical anaesthetic rapidly
reduces symptoms, an ocular surface aetiology can be assumed.
A thorough examination of the
conjunctiva can be facilitated by
pulling down the lower lid to
examine the inferior fornix. The
presence of follicles (viral process)
or papillae (bacterial or allergic
condition) should be noted. Similarly, the upper lid can be everted
to display the tarsal conjunctiva
and to search for foreign bodies in
the superior fornix.
Try to assess the pattern of redness by distinguishing which layer
of the ocular surface is inflamed.
Fluorescein dye can highlight any
disruption of the conjunctival or
corneal epithelium, such as with an
abrasion, chemical burn or corneal
ulcer.
Ocular examination
If a slit lamp is available, the anterior
chamber should be assessed for cells
and flare — the critical finding in
diagnosing an anterior uveitis.
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how to treat - conjunctival conditions
Common conjunctival conditions
Subconjunctival haemorrhage
SUBCONJUNCTIVAL haemorrhage (figure 2) is a common cause of acute
ocular redness. The bleeding vessel causes a well-circumscribed area of
bright-red blood underneath the conjunctiva, which obscures the view of
the sclera. The condition is unilateral and of sudden onset. The adjacent
conjunctiva is non-injected, pain is absent and visual acuity is unaffected.
Figure 2: Subconjunctival
haemorrhage.
What not to miss
A careful history for antecedent factors should include inquiries about
trauma, bleeding disorders, anticoagulation treatments, hypertension,
prolonged coughing or vomiting episodes, or vigorous Valsalva manoeuvers. Often no explanation for the haemorrhage will be discovered.
Figure 3: Bacterial conjunctivitis.
Treatment
No treatment is necessary and the patient should be advised that resolution will occur gradually over 2-3 weeks. If the haemorrhage fails to
resolve, the patient should be referred to an ophthalmologist.
Conjunctivitis
Conjunctivitis is probably the most common ocular condition presenting
to the GP. Conjunctivitis refers to the non-specific dilation of the superficial conjunctival vessels and may be associated with oedema of the
conjunctiva (chemosis) or discharge.
Conjunctivitis is not typically associated with severe pain or visual
disturbance. Discerning the correct aetiology and treatment often revolves
around taking a careful clinical history.
Figure 4: Gonococcal conjunctivitis.
Viral conjunctivitis
The conjunctiva is the most commonly infected part of the eye and
almost all infectious conjunctivitis is due to viral infection. The typical
clinical history is of a recent URTI or contact with someone with a red
eye. The infection typically starts in one eye and is followed a few days
later with involvement of the contralateral eye.
Viral conjunctivitis is most often caused by adenoviral infection and
may be part of an epidemic. At times, adenoviral conjunctivitis can be
very severe.
Signs and symptoms. Patients may complain of redness, watery discharge or
a burning irritation, but pain or visual disturbance is usually absent. Examination findings may include conjunctival redness, oedema, inferior fornix
follicles and, rarely, pinpoint haemorrhages. Lid swelling is often present.
The spectrum of presentation ranges from mild to severe. A palpable
pre-auricular or submandibular lymph node is highly supportive of the diagnosis but is not always present. If the diagnosis is uncertain, a viral PCR swab
of the inferior fornix can be taken to identify adenoviral DNA.
Treatment. Viral conjunctivitis is typically self-limiting in nature and
there is no substantial evidence that commonly used topical antibiotics or
antiviral treatments improve outcomes. In clinical practice, topical antibiotics are often prescribed with the belief that bacterial superinfection is
prevented or because patients do not readily accept a decision not to treat
any presumed infection without antibiotics.
Supportive treatment should be instituted with tear substitutes and
cool compresses to the eyelids as needed for patient comfort. Patients
often experience a worsening in their symptoms for the first 4-7 days after
onset, and symptoms may not resolve for 2-3 weeks.
Small subsets of patients develop sterile inflammatory corneal infiltrates, which can be visualised as small white opacities in the cornea and
typically require a slit lamp to diagnose. These patients experience a
prolonged disease course, often requiring steroid treatment.
Hygiene. Patients require counselling about the highly infectious nature of
the virus for a two-week period after the appearance of symptoms. They
should avoid close contact, touching their eyes, sharing towels or washcloths, preparing foods, shaking hands, and swimming in communal
pools. Patients may require up to two weeks away from work or school,
depending on the severity of their symptoms and the risk of transmission.
This advice is important to prevent outbreaks and should always be
given. Frequent hand-washing is mandatory. Any surfaces touched during
the examination, the examination room and any instruments should be
decontaminated with topical alcohol.
When to refer. Patients should be reviewed in 10-14 days, or earlier if
their symptoms worsen. Severe cases and those with corneal involvement (keratitis) should be referred to an ophthalmologist for consideration of steroid treatment.
Figure 5: Chlamydial conjunctivitis.
Figure 6: Episcleritis.
Chlamydial inclusion conjunctivitis
Chlamydial infection can cause both
trachoma (serotypes A-C) and inclusion conjunctivitis (serotypes D-K)
(figure 5). Trachoma is a leading
cause of blindness worldwide and
is still endemic in Aboriginal communities in SA, WA, and the NT.
In urban environments, chlamydial
inclusion disease is an important
cause of conjunctivitis. It is an ocular
manifestation of a systemic STI and
often causes chronic symptoms.
Signs and symptoms. Chlaymdial
disease should be strongly considered in chronic conjunctivitis but
may also have an acute presentation. Patients complain of unilateral or bilateral redness, irritation
and a stringy mucoid discharge.
Patients are typically young and
sexually active.
The eye is mildly injected. The
inferior fornix and superior tarsal
conjunctiva will show a characteristic follicular response that can be
appreciated by everting the upper
lid or pulling down the lower lid.
Lymphadenopathy may be present.
The cornea is rarely involved. A
swab of the conjunctiva for PCR to
Bacterial conjunctivitis
Bacterial conjunctivitis (figure 3) typically develops abruptly. Like viral
conjunctivitis, it usually begins in one eye but may spread to the contralateral eye in 1-2 days. Unlike viral conjunctivitis, a mucopurulent discharge is often present, with mucoid inflammatory debris present in the
inferior fornix and crusting along the eyelash base.
Common infective organisms include Streptococcus pneumoniae and
Staphylococcus aureus as well as gram-negative organisms such as
Haemophilus influenzae, especially in children, the elderly and debilitated
patients.
Signs and Symptoms. Patients typically complain of redness, tearing and
irritation, but not pain. Examination shows diffuse redness of the conjunctival vessels and debris in the inferior fornix. Lymphadenopathy is
typically absent. The cornea may have mild punctate staining with fluorescein, which may decrease vision slightly to the 6/7.5-6/9 range.
Treatment. Almost all cases of acute bacterial conjunctivitis are of limited
42
| Australian Doctor | 11 June 2004
duration, even without specific
therapy. With effective topical
treatment, both the morbidity and
duration of disease are reduced.
Treatment consists of a broadspectrum antibiotic such as topical
chloramphenicol (0.5%) qid, which
provides excellent coverage of the
most common pathogens. Newer
fluoroquinolone antibiotics should
be reserved for unresponsive or
severe keratitis.
Conjunctival swabs for culture
are not warranted except for severe
cases and those that fail to respond
to treatment.
When to refer. Patients should be
reviewed in two days initially and
then every 3-5 days until infection
resolves. Severe cases, clinical worsening, corneal involvement, infections in contact-lens wearers, a history of recent eye surgery, or lack
of improvement within one week
warrant prompt referral.
What not to miss. Severe hyperacute bacterial conjunctivitis with
an abrupt onset within 24 hours of
initial discomfort is often associated with gonococcal infection in
sexually active individuals.
This infection is characterised by
a copious purulent discharge, a
bright-red, severely inflamed conjunctiva (figure 4), conjunctival
papillae, marked lid swelling and
tenderness, and lymphadenopathy.
There is often a membrane of
inflammatory material overlying
the tarsal conjunctiva.
Immediate referral to an ophthalmologist is required because
gonococcal bacteria have the ability
to penetrate the cornea and rapidly
cause visual loss. Conjunctival
swabs are mandatory, followed by
the initiation of topical broad-spectrum antibiotics such as a fluoroquinolone (ciprofloxacin, one drop
hourly) in addition to systemic
treatment with a broad-spectrum
antibiotic such as ceftriaxone (1g
IM daily for five days)
A thorough sexual history should
be taken, with appropriate followup and treatment of sexual partners arranged.
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detect the chlamydial antigen can be
used to confirm the diagnosis.
Treatment. Patients require a
workup for evidence of systemic
infection, including urethritis,
vaginitis, or cervicitis. It is essential that sexual partners be identified and treated promptly. Treatment is with oral antibiotics such as
azithromycin (Zithromax) (1g
orally). Topical antibiotics and
steroid treatments are ineffective
and will not treat the underlying
systemic disease.
When to refer. Refer in severe cases
or when the diagnosis is in doubt.
Episcleritis
Episcleritis (figure 6) is a relatively
benign self-limiting condition, presumed to be an autoimmune
process. It most often affects
women aged 20-50.
Signs and symptoms
Episcleritis generally has an acute
onset and is characterised by a mild
ache and focal areas of redness.
Vision is normal and the patient
may be asymptomatic.
Examination shows a focal, nonraised, often well-defined patch of
dilated episcleral vessels with
underlying unaffected sclera. The
condition may be confused with an
inflamed pterygium.
Treatment
Patients should be reassured that the
condition does not threaten vision
and should clear in several weeks.
Prescription of an oral NSAID often
assists with symptoms and may
speed resolution. Artificial tears can
also be prescribed for comfort.
When to refer
Episcleritis that persists, worsens
or frequently recurs should be
referred. Topical corticosteroids
may be considered by an ophthalmologist to speed resolution.
Scleritis
Scleritis is not simply a more severe
form of episcleritis. These two
conditions are quite distinct. Scleritis
is often associated with an underlying connective tissue disease (most
commonly rheumatoid arthritis).
Infectious scleritis, typically with
Gram-negative bacteria, may occur
after beta irradiation after pterygium
removal (figure 7). This can occur
many years after the original surgery
in avascular portions of sclera.
Signs and symptoms
Patients complain of moderate to
severe deep ocular pain, tearing and
photophobia. The eye may be
exquisitely tender to palpation.
There is often fiery or brick-red
inflammation of the sclera,
episclera and conjunctiva that can
be localised or diffuse. The underlying sclera may exhibit a bluish
discoloration. The conjunctival
blood vessels can be seen overlying
the deeper inflammation.
Management
Patients should be referred
promptly to an ophthalmologist,
who may investigate with a systemic workup. Treatment typically
involves systemic corticosteroids or
other forms of immune suppression. Patients are often co-managed
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by the GP or a rheumatologist as
well as the ophthalmologist. Infectious scleritis requires systemic
antibiotic treatment.
Dry-eye syndrome
A stable film of tears is required to
maintain a healthy ocular surface.
Dry eye is typically associated with
a deficiency in aqueous tear production, known as keratoconjunctivitis sicca (KCS).
Other causes such as meibomian
gland dysfunction from blepharitis, or mechanical eyelid problems
such as ectropion causing corneal
exposure, must also be considered.
Dry eye may also be associated
with systemic immune dysfunction
from diseases such as rheumatoid
arthritis and Sjögren’s syndrome.
Dry eyes are common in postmenopausal women and can be
exacerbated by HRT. Drugs such
as tricyclic antidepressants, beta
blockers, oral contraceptives and
antihistamines can also exacerbate
dryness.
Signs and symptoms
Patients often complain of bilateral
constant and disabling eye burning, foreign-body sensation, redness or having “tired” eyes. Paradoxically, some experience copious
reflex tearing and may complain of
watery eyes. Patients with Sjögren’s
syndrome have concurrent dry
mouth symptoms.
Similar symptoms may also
occur after work and reading in
those with inadequately corrected
presbyopia. A new pair of reading
glasses can often help those in their
40s or 50s with symptoms.
Signs of dryness include a
decreased tear film height or
increased mucus production in the
inferior fornix. Tear film height is
best evaluated at a slit lamp, where
the tear meniscus normally measures 0.5mm above the lower
eyelid margin.
Punctate staining of the conjunctiva and the cornea in the interpalpebral zone with either Rose
Bengal or fluorescein dye can be
commonly seen (figure 8).
Treatment
Tear supplements are available as
drops, ointments or gels and should
be started. Most older lubricating
drops (Murine or Tears Naturale)
contain preservatives that can be
toxic to the ocular surface, particularly with often and prolonged use.
Newer products with less toxic
preservatives (GenTeal or Polytears), unpreserved Murine or
Tears Naturale, or single-dose
lubricants (Cellufresh or Celluvisc)
are recommended if prescribed
more than four times a day.
Medications that contribute to
dryness should be discontinued and
patients should be counselled to
avoid dry or windy environments.
Any concurrent blepharitis should
be treated.
A severe dry mouth or systemic
signs of rheumatological disease
should prompt investigation of
serological inflammatory markers
to look for systemic disease.
When to refer
Patient who are refractory to treatment and require excessive
Page 43
amounts of lubricants should be
referred. Temporary or permanent
occlusion of the lacrimal puncti is
often performed by an ophthalmologist, who will also perform
tests to quantify tear production.
Figure 7: Infectious scleritis after
beta irradiation for pterygium.
steroid-sparing systemic treatments
may also be indicated. Recently,
topical cyclosporin has shown
promise as a steroid-sparing agent
for severe allergic eye disease.
Toxic conjunctivitis (figure 10)
Allergy
The eye is a frequent target of
inflammation in both local and systemic allergic reactions, with the
conjunctiva most often involved.
There are several types of allergic
conjunctivitis.
Figure 8: Dry eye stained with Rose
Bengal dye.
Seasonal allergic conjunctivitis
The most common form of ocular
allergy, this condition is a type I
(IgE-mediated) hypersensitivity
response to environmental allergens
such as pollen, dust or animal
dander. It is often associated with
allergic rhinitis and may be associated with eczema or asthma.
Seasonal recurrences are most frequent in the spring and summer
(figure 9).
Signs and symptoms. Patients complain of itching, watery or stringy
discharge, seasonal recurrences,
tearing and nasal discharge and
typically have a history of allergies
or atopy.
Critical signs include bilateral red
and oedematous eyelids, conjunctival oedema and tarsal conjunctival
papillae. Vision is unaffected and
lymphadenopathy is absent.
Treatment. Efforts should be made
to determine and eliminate the
inciting allergen. Cool compresses
and topical artificial tear substitutes will often provide symptomatic relief.
Topical antihistamines such as
levocabastine 0.5% (Livostin) are
useful to limit itching. Mast-cell
stabilisers such as lodoxamide
0.1% (Lomide) can also be useful
for allergy prophylaxis but require
up to two weeks of continued
treatment to gain an effect.
Newer medications such as
olopatadine 0.1% (Patanol) that
combine an antihistamine and a
mast-cell stabiliser are highly effective. Oral antihistamines have little
benefit for ocular symptoms and may
exacerbate a concomitant dry eye.
What not to miss. Atopic keratoconjunctivitis is a sight-threatening
allergic eye disease in people with
severe atopic skin disease. The skin
and lids are always affected, often
being thickened, erythematous and
fissured. Patients are often chronic
eye-rubbers.
Untreated cases can lead to longterm corneal vascularisation and
scarring. Patients should be
referred early to an allergist as well
as an ophthalmologist.
Vernal keratoconjunctivitis,
which can have a seasonal component, occurs most often in male
children. It is characterised by
severe redness of the eye, vascularisation of the cornea and corneal
ulcers. The condition often resolves
in the teenage years.
When to refer. Severe seasonal
allergic eye disease and cases of
atopic keratoconjunctivitis should
be referred to an ophthalmologist.
Topical steroids and mast-cell
stabilisers are typically needed to
control more severe ocular allergy.
Systemic immune suppression
with oral corticosteroids or other
Figure 9: Seasonal allergic
conjunctivitis.
Figure 10: Toxic conjunctivitis.
Figure 11: Conjunctival foreign body.
Conjunctival redness may be
caused by numerous environmental
factors, including smoke, smog or
chemical fumes, wind and ultraviolet radiation.
Topical medications such as
over-the-counter vasoconstrictors,
tear substitutes and glaucoma medications, especially those with
preservatives, can damage ocular
surface cells and inhibit function.
Cosmetic and hair-care products
and contact lens solutions can also
cause ocular surface toxicity.
Signs and symptoms. Take a careful history for use of topical ocular
medications or cosmetics, as these
are the most common offenders
and can be easily overlooked. Irritation, tearing, redness, itching,
burning and aching eyes are
common complaints.
Multiple punctate lesions of the
corneal surface that stain with fluoroscein dye are common but may
require the use of a slit lamp to
visualise. Erythema and swelling of
the lids may be present.
Treatment. Avoiding or minimising exposure is the best remedy.
Tear substitutes, especially those
without preservatives, can be prescribed for symptomatic relief.
What not to miss. Patients often
treat redness with topical vasoconstrictor medicines such as naphazoline to “get the red out”. These
can lead to rebound vasodilation,
requiring a pattern of escalating
frequency of use and resultant surface toxicity. The repetitive longterm use of these agents should be
strongly discouraged.
The frequent application of topical
anaesthetics is highly toxic to the
eye. Anaesthetics should not be prescribed to patients and should only
be used to facilitate examination.
Trauma
Oral antihistamines
have little benefit for
ocular symptoms and
may exacerbate a
concomitant dry eye.
Superficial injuries to the conjunctiva are common and usually heal
rapidly. Common injuries include
metallic foreign bodies from hammering or drilling, glass particles
from shattered spectacles, damage
from sticks or debris while gardening, or from assault, and chemical
splash injuries.
Although superficial conjunctival epithelial injury usually
resolves within 24 hours, a thorough examination is imperative to
look for penetrating eye injuries or
retained foreign bodies. Chemical
injuries are an ocular emergency.
Conjunctival foreign bodies
and lacerations
Signs and symptoms. A conjunctival foreign body causes unilateral
irritation, redness and tearing. A
decrease in vision, a distorted pupil
or shallowing of the anterior chamber should raise suspicion of a penetrating injury (figure 11).
Examination techniques. After
applying topical anaesthetic, the
fornices should be carefully examined. The upper lid should be
everted to facilitate examination of
the superior fornix. A cotton bud
www.australiandoctor.com.au
can be used to sweep the fornices
for any unseen foreign body.
Fluorescein should be applied and
the cornea examined for foreign
bodies.
Treatment. Superficial conjunctival foreign bodies can be irrigated
away, wiped away with a cotton
bud or lifted from the conjunctiva
with the tip of a 25-gauge needle.
If the epithelium of the conjunctiva has been disrupted, such as
with a conjunctival laceration, a
broad-spectrum antibiotic such as
chloramphenicol should be administered qid until the epithelium has
healed. Patching is not required.
When to refer. Any suspicion of a
retained foreign body or penetrating injury necessitates prompt
referral.
What not to miss. A CT scan or
X-ray may be indicated if there is
any concern about a retained foreign body.
Chemical injury
Acute chemical burns with alkali
and acid can permanently damage
the ocular surface function and
constitute an ophthalmic emergency. Splash injuries can occur at
work, in the home from household
cleaning chemicals, or from assault.
They are often bilateral.
The extent of injury and ultimate
outcome depends on the pH of the
chemical, the degree of exposure,
and the timing and quality of the
initial treatment. Alkaline injuries
tend to penetrate tissues more
deeply than acidic injuries and traditionally fare worse.
Signs and symptoms. There is acute
onset of pain, redness, tearing and
photophobia. Vision is often
decreased if the cornea has been
involved. After eye irrigation, assess
the degree of corneal and conjunctival epithelial loss with fluorescein
staining, and the clarity of the
cornea.
Treatment. The most vital aspect
of treatment is immediate and thorough irrigation of the eye. This
cannot be overemphasised and is
hard to overdo. Litmus paper
should be placed in the inferior
fornix to document normalisation
of pH, and pH should be retested
five minutes after stopping the irrigation.
Irrigation should continue for 10
minutes and several litres of fluid
should be used. Remove any particulate matter from the conjunctival fornices with forceps.
When to refer. Small corneal or
conjunctival epithelial defects can
be safely treated with a topical
antibiotic such as chloromycetin
until the epithelium has healed.
Any injury that involves large portions of the ocular surface, crosses
the limbus, reduces corneal clarity,
or has retained particulate matter
requires immediate referral and
possible hospital admission.
What not to miss. Beware of complete corneal epithelial defects,
which may be difficult to appreciate with fluorescein staining
because of lack of a normal-toabnormal transition zone. Large
splash injuries (cement mixing or
spray injuries at close range with
any type of chemical) can cause a
complete loss of the epithelium.
cont’d next page
11 June 2004 | Australian Doctor |
43
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how to treat - conjunctival conditions
Summary
Eye conditions in general,
and conjunctival conditions
in particular, are common
reasons patients visit their
GP. Many of the conditions
reviewed above are selflimiting.
Take-home points:
■ Viral conjunctivitis is highly
contagious and
appropriate hygiene
measures should be taken;
■
Never prescribe a topical
anaesthetic;
■
Topical corticosteroids
should be prescribed in
rare instances only;
■
■
Topical fluoroquinolone
use should be reserved for
severe corneal infections;
Refer promptly cases in
which there is an inflamed
eye with decreased visual
acuity, a corneal infiltrate
or severe pain.
Evidence base for
treatment of bacterial
conjunctivitis*
Evidence for the benefit of
treatment of culturepositive bacterial
conjunctivitis
■ One systematic review
has found that antibiotics
(polymyxin-bacitracin,
ciprofloxacin or ofloxacin)
increase rates of clinical
and microbiological cure,
compared with placebo;
■ Four RCTs comparing use
of antibiotics for culturepositive bacterial conjunctivitis found no significant
difference among antibiotics in clinical or microbiological cure.
Evidence for the benefit
of empirical treatment
of suspected bacterial
conjunctivitis
■ One systematic review
found limited evidence
from one RCT that topical
norfloxacin increased
rates of clinical and microbiological improvement or
cure after five days compared with placebo.
■ RCTs comparing different
topical antibiotics have
found no significant difference in rates of clinical or
microbiological cure.
*Source: Smith J. Bacterial
conjunctivitis. Clinical Evidence Concise 2003; 131.
from previous page
Figure 14: Conjunctival lymphoma.
Figure 15: Conjunctival intraepithelial
neoplasia.
Immediately on presentation the eye
should be irrigated with copious quantities of tap water or sterile saline if
available. Irrigation must continue until
the return of the pH to normal (7.0).
Tumours
Conjunctival tumours can be divided
into lymphoid, epithelial, and pigmented categories. The overall incidence of primary conjunctival malignancy is relatively low, and metastatic
lesions to the conjunctiva are rare.
de novo during or after middle age are
suspicious of malignancy (primaryacquired melanosis). Be especially wary
of new pigmented lesions in fairskinned people. These should always
be referred to an ophthalmologist for
possible biopsy.
Conjunctival naevus
Conjunctival naevi are benign neoplasms, most commonly on the bulbar
conjunctiva, and typically they develop
during puberty. They are usually flat,
well demarcated, mobile and can be
heavily pigmented or amelanotic
(figure 13).
The degree of pigmentation may fluctuate with time and the naevus may
enlarge, especially during puberty. Only
rarely does a naevus malignantly transform into a melanoma.
Treatment. A baseline photograph
should be taken and yearly reviews conducted to monitor for growth. Patients
should be advised to return for examination earlier if there is any change in
the size or colour of the lesion.
When to refer. Flat brown patches of
conjunctival pigmentation that arise
Conjunctival lymphoma
Figure 13: Conjunctival naevus.
Lymphoid tumors of the conjunctiva
are rare (<1/100,000) and occur on a
spectrum from benign lymphoid
hyperplasia to lymphoma. Patients are
typically young to middle aged.
Signs and symptoms. Patients are usually asymptomatic, but the patient or a
relative may notice the enlarging mass.
A unilateral, salmon-coloured diffuse
mass is present in the subconjunctival
space (figure 14).
Treatment. An excisional biopsy is performed by the ophthalmologist, and
immunohistochemical studies initiated.
An oncologist typically conducts a
workup for any systemic lymphoma.
Local radiotherapy may be used if
malignancy is suspected.
Conjunctival intraepithelial neoplasia
Squamous neoplasms of the conjunctiva are associated with excessive sun
exposure. They are typically slow
growing and locally invasive, only
rarely causing metastatic disease. Previous terms for this include Bowen’s
disease, dysplasia and carcinoma in
situ.
Signs and symptoms. Patients often
complain of an enlarging mass on
their eye, which may cause irritation
or blurred vision. On examination a
gelatinous, raised vascular mass is present that is typically grey-white in
colour. It most often originates at the
limbus and may have a ‘stuck-on’
appearance. At other times the
changes are more plaque-like (figure
15).
Treatment. Early referral is warranted to confirm the diagnosis.
The tumour is typically cured by
simple excision. Diffuse lesions
may require supplemental topical
antimetabolite treatments with
agents such as Mitomycin C.
Author’s case study
JIM, 42, presents to his GP
complaining of eye redness,
irritation, mild photophobia
and a watery discharge in
both eyes for three days. He
has had symptoms of a viral
respiratory infection for the
last week.
His symptoms began in the
right eye and were followed
by left eye involvement two
days later. He thinks several
people at his work may have
had “pink eye” recently.
There is no relevant social or
sexual history.
On examination, vision is
6/6 in each eye and each eye
appears as in figure 16. There
is mild lid swelling of both
upper eyelids, and follicles are
noted on the inferior tarsal
conjunctiva. A tender right
pre-auricular lymph node is
palpated.
Acknowledgements:
National Eye Institute
web site: www.nei.nih.gov
| Australian Doctor | 11 June 2004
two weeks later. He notes the
redness, discharge and irritation in both eyes has significantly improved. However,
he complains of a slow deterioration in his visual acuity
in the past few days and that
some light sensitivity and mild
foreign-body sensation persist.
On examination, vision
in each eye is now 6/9. The
conjunctiva appears quiet
and there is minimal follic-
MR M, a 45-year-old engineer, presented to a country doctor with an
acutely “itchy, painful, sore right eye”.
The country doctor recognised there
was something of concern and correctly referred him to an ophthalmologist.
For practitioners
For patients
Comment
The GP correctly diagnoses
a viral conjunctivitis. Jim is
prescribed topical artificial
tears qid for symptomatic
relief, as well as cold compresses. He is counselled
regarding the infectious nature
of viral conjunctivitis and the
need for careful hygiene, and
advised that the disease is selflimiting and should slowly
resolve over the next two
weeks.
Jim returns for follow-up
Case study
Online resources
Wills Eye Manual. Rhee,
1999:
http://pco.ovid.com/lrppco/
index.html
Gills, JP. Ophthalmology.
eMedicine, Inc., 2000:
www.emedicine.com/oph/
index.shtml
to viral conjunctivitis. A
mild topical steroid (fluoromethalone 0.1% [Flarex,
Flucon, FML] qid both eyes)
is prescribed and slowly
tapered over the next few
months. Jim’s vision returns
to normal and the infiltrates
resolve.
Figure 17: Subepithelial infiltrates in viral
conjunctivitis.
Figure 16: Viral conjunctivitis.
ular reaction in each
fornix. Slit-lamp examination reveals several round,
white subepithelial opacities in the central cornea of
each eye (figure 17). There
is no staining with flourescein dye. Jim is referred to
a collaborating ophthalmologist.
He is seen by the ophthalmologist and diagnosed with
decreased vision from subepithelial infiltrates secondary
Almost all viral conjunctivitis resolves without adverse
sequelae. Fewer than 10%
of patients develop an
immunological reaction to
residual viral particles in the
cornea, resulting in the
development of sterile
corneal lymphocytic infiltrates 2-4 weeks after the
onset of infection. Any persistent decrease in vision
after viral conjunctivitis
should prompt referral.
GP’s contribution
All photos generously
supplied by Medical
Photography Imaging Centre,
Royal Victorian Eye and Ear
Hospital, Melbourne.
44
Figure 12: Alkaline burn.
Ocular emergency — chemical burns
(figure 12)
nosed by the ophthalmologist as
having iritis. Is there any link between
iritis and allergy?
No.
Is iritis something that runs in the
family?
It is typically sporadic.
DR JEREMY THOMSON
Fairlight, NSW
From his presenting complaint, what
diagnosis first comes to mind?
Trauma and infection are the primary concerns, given the complaint of
pain.
Mr M had a strong family history of
glaucoma, and a grandfather had iritis.
He had a past and current history of
asthma and hay fever. Mr M was diagwww.australiandoctor.com.au
I had thought that an itchy eye generally meant allergy. Is this true? Can
itch be a symptom of iritis or any other
significant eye condition?
Itching (usually bilateral) is the hallmark of all types of allergic eye disease. Patients sometimes complain of
mild itching with conjunctivitis, blepharitis or dry eye. Iritis usually presents with redness, discomfort, and
photophobia, and itching would be
atypical.
If the country doctor had no access to
an ophthalmologist, would it be appropriate to prescribe steroid drops and, if
so, what should Mr M be careful of?
The diagnosis of iritis requires a slit
lamp examination to check for inflammatory cells in the anterior chamber. If
the diagnosis is confirmed, steroid
drops should be started. Steroids can
elevate intraocular pressure, predispose
to infection and increase the risk of
cataract formation in the long term.
Mr M had no history of any medical
or arthritic conditions apart from
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how to treat - conjunctival conditions
from page 44
some backache. The ophthalmologist ordered extensive
blood tests, which were all
normal. Mr M was treated
with steroids orally and as eye
drops, and recovered fully. Is
it normal practice to prescribe
oral steroids for iritis?
Most iritis can be controlled
with intensive topical steroids.
If this fails, oral steroids or
local steroid injections are typically added. A backache in
the context of iritis could be
suggestive of ankylosing
spondylitis, and radiographs
should be ordered.
A year later Mr M presented
again with possible iritis. The
doctor referred him to an ophthalmologist, who diagnosed
“anterior uveitis and episcleritis”. Two years later Mr M
had similar symptoms but this
time slit-lamp examination
was normal. What is the difference in the terms iritis,
uveitis and scleritis? Do they
share similar pathologies and
treatments? Is it important for
GPs to differentiate between
them?
Uveitis is a general term
describing inflammation anywhere along the uveal tract
(choroid, ciliary body or iris).
Iritis is a type of uveitis implying the ocular inflammation
is confined to the anterior segment of the eye. Scleritis is an
inflammatory condition of the
sclera that is typically severe
and associated with either
infection or a systemic inflammatory condition. It can
occur with or without a coexisting uveitis. Differentiating
and treating types of uveitis
and scleritis requires
advanced examination techniques and is difficult in general practice.
Steroids may
help symptoms
of viral
conjunctivitis but
can also prolong
the disease course
and enhance viral
replication.
bilateral necessitates a
workup for an associated
systemic condition. About
half the time (different studies vary considerably) a systemic condition will be
found, most commonly an
HLA-B27
associated
spondyloarthropathy.
wind. Mild steroid eye drops
can then be added for unresponsive patients on a shortterm basis. Long-term
steroid use necessitates monitoring by an eye care
provider for side effects
(such as high intraocular
pressure).
General questions for the
author
Is there a role for mild steroid
drops for viral conjunctivitis?
Which are the best drops to
use for symptomatic relief?
Cold compresses and tear
substitutes often help with
symptom relief. Steroids may
help symptoms but can also
prolong the course of the
disease and may enhance
viral replication. Steroids are
not typically used except for
severe cases.
I fairly often prescribe FML
eye drops for allergic conjunctivitis and for eye irritation due to pterygia. I realise
this is not without some
risks. What would you suggest as a good approach to
these common conditions?
In both conditions treatment should start with lubricating eye drops for symptomatic relief. A trial of
topical mast-cell stabilisers
and/or antihistamines should
be added for allergic conjunctivitis.
Pterygium
patients should try to avoid
excessive UV exposure and
What percentage of patients
with iritis will have, or
develop, another immune disorder?
Iritis that is recurrent or
When a corneal foreign body
has been removed, is it imperative to completely get rid of
any rust stain that is not close
to the pupil?
Attempts should be made
to remove all the rust
because it will incite a significant
inflammatory
response in the cornea and
delay recovery. A smallgauge needle, spatula or electric burr can be used to
remove residual rust.
Patients who think they have
conjunctivitis often come back
from the chemist with Bleph10 eye drops. Is chloromycetin
a superior treatment?
There is no literature comparing the two. Chloromycetin may be better tolerated by the patient and have
a wider spectrum of antibiotic activity.
In a child with an URTI, otitis
media and conjunctivitis for
which I am going to prescribe
oral antibiotics, should I also
prescribe chloromycetin
drops?
If bacterial conjunctivitis is
suspected, chloromycetin
drops should be added.
Australian Doctor
How To Treat CPD
amount of watery discharge and minimal lid
swelling . . . . . . . . . . . . . . . . . . . . . . . . . .❏
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Note that some questions have more than one correct answer. The mark required for
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January, April, July and October.
1. Jan, 43, has been aware of a red eye
for one day. If the redness is caused by
a condition affecting the conjunctiva,
which TWO statements are most likely
to be true?
a) You would not expect to see hyperaemia of
the bulbar conjunctiva . . . . . . . . . . . . . . . . ❏
b) You would expect to see inflammation of the
superficial conjunctival vessels, which tend to
increase in size away from the limbus . . . .❏
c) You would expect to see white sclera
beneath if there was redness of the eye caused
by inflammation of the conjunctiva . . . . . .❏
d) You may find lymphadenopathy affecting the
occipital nodes . . . . . . . . . . . . . . . . . . . .❏
2. In taking Jane’s history, which ONE factor
is the least likely to help you establish the
diagnosis?
a) Her past medical history . . . . . . . . . . . .❏
b) Her ophthalmic history, such as the use of
contact lenses . . . . . . . . . . . . . . . . . . . . .❏
c) Details of current and recent
medications . . . . . . . . . . . . . . . . . . . . . . .❏
d) Her psychiatric history . . . . . . . . . . . . .❏
3. When assessing Jane’s symptoms, which
ONE statement is correct?
a) If she has pain relieved by a topical
anaesthetic, scleritis is a probable cause of her
symptoms . . . . . . . . . . . . . . . . . . . . . . . .❏
b) If a topical anaesthetic does not relieve her
pain, anterior uveitis is a probable cause of her
symptoms . . . . . . . . . . . . . . . . . . . . . . . .❏
c) If she has severe itch, blepharitis is a
probable cause of her symptoms . . . . . . .❏
46
d) If she has mild itch, vernal
keratoconjunctivitis is a probable cause of her
symptoms . . . . . . . . . . . . . . . . . . . . . . . .❏
4. When you examine Jane you notice
conjunctival inflammation, and a macular
rash with several vesicles affecting the
eyelid. With regard to her rash, which ONE
statement is least likely to be true?
a) If she has herpes zoster ophthalmicus, she
would probably give a history of a flu-like
prodromal illness for about one week . . . .❏
b) If her rash is due to contact dermatitis,
topical creams such as cosmetic products or
sunscreen are unlikely causes . . . . . . . . .❏
c) If she has herpes zoster ophthalmicus, she is
at risk of serious corneal complications and
may require antiviral or steroid therapy . . .❏
d) If her symptoms are caused by rosacea, she
is at risk of other ocular conditions such as
conjunctivitis, blepharitis and chalazion . . .❏
5. Diane, 36, complains of redness affecting
one eye for a day. When considering the
possible causes, which ONE statement is
correct?
a) If the redness is caused by a subconjunctival
haemorrhage, you would expect her eye to be
painful . . . . . . . . . . . . . . . . . . . . . . . . . . .❏
b) If she has viral conjunctivitis you would
expect both eyes to be red at this stage . .❏
c) If she has a bacterial conjunctivitis you
would expect her to have a mucopurulent
discharge . . . . . . . . . . . . . . . . . . . . . . . .❏
d) If the redness is due to a gonococcal
infection, you would expect her to have a small
6. You diagnose viral conjunctivitis and treat
her appropriately. She recovers but sees you
two months later with discomfort in her left
eye, which she thinks may be the start of the
same problem. On examination, you note a
patch of dilated episcleral vessels and
consider she may have episcleritis. If this
diagnosis is correct, which ONE statement
is true?
a) Episcleritis occurs more often in women over
50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .❏
b) If she has episcleritis, you would expect her
visual acuity to be reduced to about 6/9 . .❏
c) If she has episcleritis, NSAIDs may improve
her symptoms . . . . . . . . . . . . . . . . . . . . .❏
d) If she has episcleritis, you can reassure her
that her symptoms will improve over the next
2-3 days . . . . . . . . . . . . . . . . . . . . . . . . .❏
7. You see her again in a year. Now she
complains of deep pain in the left eye, with
watering and some mild photophobia. You
are concerned that she may have scleritis.
Which THREE features in her history,
examination and investigation would support
your diagnosis?
a) A history of rheumatoid arthritis . . . . . .❏
b) The absence of tenderness on palpation of
the eye . . . . . . . . . . . . . . . . . . . . . . . . . .❏
c) A history of previous pterygium treated with
beta irradiation . . . . . . . . . . . . . . . . . . . . .❏
d) A bluish discoloration of the sclera
beneath redness involving the episclera and
conjunctiva . . . . . . . . . . . . . . . . . . . . . . .❏
8. John, 62, has a history of asthma and
allergic rhinitis. His work involves regular
exposure to fumes. His main complaint is of
watery itchy eyes. Which ONE of the
following statements about his possible
diagnoses is correct?
a) When you find that he has enlarged preauricular nodes, you think he is most likely to
have allergic conjunctivitis . . . . . . . . . . . .❏
b) When you notice marked thickening of the
skin on his eyelids and constant eye-rubbing,
you think he may have atopic
keratoconjunctivitis . . . . . . . . . . . . . . . . .❏
c) You suspect seasonal allergic conjunctivitis,
and so would expect this episode to
respond quickly to treatment with a mast-cell
stabiliser . . . . . . . . . . . . . . . . . . . . . . . . .❏
d) You explain that if he has toxic conjunctivitis
he will need to use a topical vasoconstrictor on
a regular ongoing basis . . . . . . . . . . . . . .❏
9. You treat him for seasonal allergic
conjunctivitis. He returns in two weeks and
says his symptoms are worsening. If your
diagnosis is correct, which TWO factors are
most likely to have contributed to delay in
his recovery?
a) He has been using the same type of
lubricating drops he has used intermittently for
the past 15 years . . . . . . . . . . . . . . . . . . .❏
b) He has been regularly using artificial tears to
lubricate the eyes . . . . . . . . . . . . . . . . . . .❏
c) He has been using an oral antihistamine
regularly . . . . . . . . . . . . . . . . . . . . . . . . .❏
d) He has been using antihistamine
drops . . . . . . . . . . . . . . . . . . . . . . . . . . .❏
10. John returns to your surgery a year later
in distress. He has been working at home
changing a battery and has acid burns to his
face and eyes. Which TWO of the following
statements regarding your treatment are
most likely to be correct?
a) You thoroughly irrigate his eye for 10 minutes
using several litres of fluid, then pH test the eye
five minutes after stopping the irrigation . .❏
b) You explain to him that acid injuries to the
eye tend to be more severe than alkaline
injuries . . . . . . . . . . . . . . . . . . . . . . . . . .❏
c) You use fluorescein to confidently exclude all
significant epithelial defects . . . . . . . . . . .❏
d) If you see a small defect on fluorescein
testing, you can safely treat him with a topical
antibiotic such as chloromycetin, and review
him regularly until the epithelium has
healed . . . . . . . . . . . . . . . . . . . . . . . . . . .❏
HOW TO TREAT
NEXT WEEK
Editor: Dr Lynn Buglar
Co-ordinator: Julian McAllan
The next How to Treat enumerates the latest screening procedures and risk assessments of preconception health care. The author, Dr Lesley Cotterell, is
a GP and medical educator with a special interest in reproductive health.
| Australian Doctor | 11 June 2004
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