Conjunctivitis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Infection (redness) of the conjunctiva on one or both eyes should be apparent, but may be quite mild. Except in obvious pyogenic or toxic/chemical conjunctivitis, a slit lamp (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.

Physical Examination

Viral Conjunctivitis

Patients with viral conjunctivitis usually appear febrile, and they have Preauricular adenopathy. Ophthalmologic examination of patients with viral conjunctivitis is usually remarkable for:

• Epiphora
• Hyperemia
• Chemosis
• Follicular conjunctival reaction
• Pseudomembranous (occasionally)
• Cicatricial conjunctival reaction
• Edematous and ecchymotic eyelids
• Corneal epithelial defect (severe cases)

Acute Hemorrhagic Conjunctivitis

Ophthalmologic examination of patients with acute hemorrhagic conjunctivitis is usually remarkable for:

• Swollen, Edematous Eyelid
• Eye pain in palpation
• Bulbar conjunctiva hemorrhage

Bacterial Conjunctivitis

Ophthalmologic examination of patients with bacterial conjunctivitis is usually remarkable for:

• Bulbar conjunctival injection
• Palpebral conjunctival papillary reaction
• Muco-purulent or watery discharge
• Chemosis
• Lid erythema

Neonatal Conjunctivitis

Ophthalmologic examination of patients with neonatal conjunctivitis is usually remarkable for:

• Neisseria gonorrhea
  • Chemosis
  • Severe lid edema and
  • Mucopurulent discharge
  • Corneal involvement (diffuse epithelial edema, ulceration, corneal perforation, and endophthalmitis
• Chlamydia trachomatis
  • Mild hyperemia
  • Mucoid discharge
  • Chemosis
  • Pseudomembrane formation
• Chemical
  • Mild conjunctival injection
  • Tearing

Allergic Conjunctivitis

Ophthalmologic examination of patients with allergic conjunctivitis is usually remarkable for:

• Bilateral conjunctival injection
• Chemosis,
• Watery discharge, or mild mucous discharge

Keratoconjunctivitis Sicaa

Redness Burning Stinging Foreign body sensation Pruritus Photophobia. More or less pronounced conjunctival redness and damage to the ocular surface with punctate epithelial erosions (superficial punctate keratitis) are typical in dry eye; temporal conjunctival folds parallel to the lid margin are indicative. The lower tear meniscus is reduced. In addition, there are often signs of meibomian gland dysfunction with thickened eyelid margins and telangiectasia. The meibomian gland orifices are obstructed with a cloudy, granular or solid secretion that can only be expressed by exerting considerable pressure on the lower lid (15). If the meibomian gland dysfunction is associated with inflammation, blepharitis (inflammation of the lid margin) or meibomitis (inflammation of the meibomian glands) is present

Ophthalmologic examination of patients with superior limbic keratoconjunctivitis is usually remarkable for:

Superior Limbic Keratoconjunctivitis

Ophthalmologic examination of patients with superior limbic keratoconjunctivitis is usually remarkable for:

• Micro-papillary reaction in the upper tarsal conjunctiva,

Hyperemia Thickening of the superior bulbar conjunctiva Ciliary injection in the upper bulbar conjunctiva, Corneal erosions in the upper quadrants Diffuse superficial corneal erosions Eyelid edema

Redness of the conjunctiva on one or both eyes should be apparent, but may be quite mild. Except in obvious pyogenic or toxic/chemical conjunctivitis, a slit lamp (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.

Allergic conjunctivitisshows pale watery swelling or edema of the conjunctiva and sometimes the whole eyelid, often with a ropy, non-purulent mucoid discharge. There is variable redness. Viral conjunctivitis, commonly known as "pink eye", shows a fine diffuse pinkness of the conjunctiva which is easily mistaken for the 'ciliary infection' of iritis, but there are usually corroborative signs on biomicroscopy, particularly numerous lymphoid follicle12:02, 22 January 2008 (EST)12:02, 22 January 2008 (EST)~~s on the tarsal conjunctiva, and sometimes a punctate keratitis.

Pyogenic bacterial conjunctivitis shows an opaque purulent discharge, a very red eye, and on biomicroscopy there are numerous white cells and desquamated epithelial cells seen in the 'tear gutter' along the lid margin. The tarsal conjunctiva is a velvety red and not particularly follicular. Non-pyogenic infections can show just mild injection and be difficult to diagnose. Scarring of the tarsal conjunctiva is occasionally seen in chronic infections, especially in trachoma.

Irritant or toxic conjunctivitis show primarily marked redness. If due to splash injury, it is often present only in the lower conjunctival sac. With some chemicals—above all with caustic alkalis such as sodium hydroxide—there may be necrosis of the conjunctiva with a deceptively white eye due to vascular closure, followed by sloughing of the dead epithelium. This is likely to be associated with slit-lamp evidence of anterior uveitis.

Images

The following are gross images associated with rheumatic fever.

• 
  One eye with conjunctivitis.
• 
  Bacterial Conjunctivitis
• 
  Chemical Conjunctivitis

(Images shown below are courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

• 
  Conjunctivitis: Note inflamed conjunctiva of sclera and reflection onto underside of eyelid.
• 
  Conjunctivitis: Marked bilateral inflammation involving conjunctiva that covers sclera and under surface of eyelid. Thick exudate can also be seen.
• 
  Conjunctivitis: Inflammation of conjunctiva covering sclera and under surface of eyelid.