-
`~~!l~~o~~~Y-PhY-s~~i~~
`
`t+SL
`
`Shoulder Impingement and Rotator Cuff Tears page 667
`
`685 Testicular Masses
`699 Acute Pericarditis
`711 Evaluation of Dyspnea
`719 Occupational Lead Poisoning
`735· Conjunctivitis
`---·•·•··-·-
`
`-- -
`
`--- -· ·--
`
`749 Isoniazid Overdose
`755 Peripheral Neuropathy
`765 Cutaneous Vascular Lesions
`776 Subclinical Hypothyroidism ·
`
`riEALTH SC!~NCES um::.·un
`University of Wisconsin
`
`FEB 1 9 1998
`
`1305 Linden Drive
`Madison, WI 53706
`
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`--
`
`erican Family: P~cian
`
`PEIIRUARY JS, 1998
`
`VOLUME 57, UM888 4
`
`cover
`
`735
`
`685
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`Full text of American Family
`Physician is available online at
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`Articles
`667 Management of Shoulder Impingement Syndrome
`and Rotator Cuff Tears
`ALLEN E. FONGEMIE, M.D., DANIEL D. BUSS, M.D., and SHARON J. ROLNICK, PH.D.
`Rotator cuff impingement and tears are shoulder problems frequently encountered. by family
`physicians. Learning to conduct a thorough, concise examination of the shoulder will help family
`physicians diagnose and treat these problems.
`
`0
`Patient information: "Four Exercises to Strengthen the Muscles of Your Rotator Cuff:' p. 680
`685 Testicular Masses
`JENNIFER JUNNILA, CPT, MC, USA, and PATRICK LASSEN, MAJ, USAF, MC
`A knowledge of normal male genital anatomy and the pathophysiology of major emergency and
`benign processes causing testicular masses allows family physicians to appropriately manage
`patients and refer them to a urologist when indicated.
`699 Electrocardiographlc Manifestations and Differential Diagnosis
`of Acute Pericarditis
`MARK A. MARINELLA, M.D.
`rim Acute pericarditis has a variety of etiologies and produces characteristic findings on ECG,
`including diffuse ST-segment elevatiop that, at times, may be diffic1,Ut to distinguish from changes
`of acute myocardial infarction or other conditions.
`
`711 Diagnostic Evaluation of Dyspnea
`WALTER C. MORGAN, M.D., and HEIDI L. HODGE, M.D.
`Dyspnea, like other-undifferentiated general symptoms, can best be diagnosed with the help of a
`careful history and physical examination. Selective diagnostic testing can be helpful in difficult
`,cases.
`
`PROBLEM-ORIENTED DIAGNOSIS
`719 Occupational Lead Poisoning
`KEVIN C. STAUDINGER, M.D., M.P.H., and VICTORS. ROTH, M.D., M.P.H.
`Despite our increased awareness of the adverse health effects of lead, occupational lead poisoning
`continues to be a major problem, requiring a high index of suspicion for accur,i.te diagnosis.
`Prompt removal of the worker from the source of exposure remains the mainstay of treatment.
`
`0
`
`Patient information: "Lead and Your Health;' p. 731
`
`filR] This article exemplifies the AAFP 1997•98 Annual Clinical Focus on cardiovascular medicine.
`
`FEBRUARY 15, 1998 / VOLUME 57, NUMBER 4
`
`AMERICAN FAMILY PHYSICIAN 597
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`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`Conjunctivitis
`
`@ARY L M RROW, M.D., Toronto East General and Orthopedic Hospital , Toronto, Ontario, C:mad.a
`R[CHARD L. ABB0 11.~ M.D., University of C1Iifornia, San Francisco, and Francis I. Proctor Foundation,
`~ Ft·anci c0, Califor.11ia
`
`co.11j1,mctivitis refers to m1y inflammatory condition of the membrane that lines the eyelids
`n,id co11e,·s the exposed m,face of the sclera. It is the most .common cause of "red eye." The
`etiology can usueilly be determined by a carefi~l history and tm oculnr examinatio.n, but cul(cid:173)
`·w,-e is occasio,uilly necessary to establish the diagnosis or to guide therapy. Conjunctivitis
`'is conmionly caused by bacteria and viruses. Neisseria infe~tion should be suspected when
`;evere, bilatera~ pu.rnlent·co11jun.ctivitis is present in a sexually active adult or in a neonate
`three to five days postpartum. Conjunctivitis ca11sed b)' Chlamydia trachomatis or Neis(cid:173)
`seria gonorrhoeae requi1·es aggressive antibiotic therapy, but conjunctivitis due to other
`,1,pcteria is usually self-limited. Cfiron'ic conjunctivitis is usually associated with blephari(cid:173)
`·tis, rec111:rent styes or meibomianitis. Treatment requires good eyelid hygiene nnd the appli(cid:173)
`'tntion of topical a.ntibiotitzs as determined by culture. Allergic conjunctivitis is distin(cid:173)
`gitisli d by severe itching and allergen expo.sure. This condition. is generally treated with
`Jlopical cmtihistamin.es, 1r1ast-cell stabilizers or unti-inflammatory agents.
`
`T he conjunctiva is a thin, trans(cid:173)
`
`lucent, relatively elastic tissue
`layer with both bulbar and
`palpebral portions. The bulbar
`portion of the conjunctiva lines
`the outer aspect of the globe, while the palpe(cid:173)
`bral portion covers the inside of the eyelids.
`
`Uvea
`
`FIGURE 1. Anatomy of the eye and eyelids.
`
`Underneath the conjunctiva lie the episclera,
`the sclera and the uveal tissue layers (Figure 1).
`The clinical term "red eye" is applied to a
`variety of distinct infectious or inflammatory
`ocular disease processes that involve one or
`more tissue layers of the eye (Table 1). Red eye
`is the most common ocular problem seen by
`primary care physicians.
`The term "conjunctivitis" encompasses a
`broad group of conditions presenting as
`inflammation of the conjunctiva. The inflam(cid:173)
`mation can be hyperacute, acute or chronic in
`presentation and infectious or noninfectious
`in origin. Conjunctivitis is the most common
`cause of red eye.
`Most frequently, conjunctivitis ( and thus
`red eye) is caused by a bacterial or viral infec(cid:173)
`tion. Sexually transmitted diseases such as
`chlamydia! infection and gonorrhea are less
`common causes of conjunctivitis. However,
`these infections are becoming more prevalent
`and are important to recognize because of
`their significant associated systemic, ocular
`and social implications.
`Ocular allergy in its many forms is one of
`the major causes of chronic conjunctivitis.
`Blepharitis (inflammation of the eyelid
`margin), dry eye and the prolonged use of
`ophthalmic medications, contact lenses
`and ophthalmic solutions are also relatively
`
`F~8RUARY 15, 1998 / VoLUME 57, Nm-rnER 4
`
`AMERICAN FAMILY PHYSICIAN 735
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`

`Conjunctivitis
`
`TABLE 1
`Differential Diagnosis of a Red Eye
`
`Conjunctivitis.
`Infectious
`Viral
`Bacterial (e.g., staphylococcus and
`Chlamydia species)
`Noninfectious
`Allergic
`Dry eye
`Toxic or chemical reaction
`Contact lens use
`Occult conjunctiva! neoplasm
`Foreign body
`Factitious
`Idiopathic
`Kera tit is
`Infectious
`Bacterial
`Viral
`Fungal
`Acanthamoeba
`Noninfectious
`Recurrent epithelial erosion
`Foreign body
`Uveitis
`Episcleritis/scleritis
`Acute glaucoma
`Eyelid abnormalities
`Entropion
`Lagophthalmos With globe exposure
`Trichiasis
`Molluscum contagiosum
`Orbital disorders
`Preseptal and orbital cellulitis ·
`Idiopathic orbital inflammation (pseudotumor)
`
`TABLEc2
`Discharge Associated with Conjunctivitis
`
`Etiology
`
`Viral
`Chlamydia!
`Bacterial
`Allergic
`Toxic
`
`Serous
`
`Mucoid
`
`Mucopurulent
`
`Purulent
`
`+
`
`+
`+
`
`+
`
`+
`+
`
`+
`+
`
`+
`
`+
`
`+ = Present,· - = absent.
`Adapted with permission from Jackson WB. Differentiating conjunctivitis of
`diverse origins. Surv Ophthalmol 1993;38(Supp/):91-104.
`·
`
`' I
`
`frequent causes of chronic conjunctiva1
`inflammation.
`This article highlights ·key features in the
`clinical history and ocular examiriation that
`can help family physicians to formulate a di[.
`ferential diagnosis and a management pl!ln
`for patients with conjunctivitis or red eye of
`uncertain etiology (Figure 2). The diagnosis
`and treatment of the most common forms of
`conjunctivitis are also reviewed.
`
`Historical Clues to the Etiology
`of Conjunctivitis
`The history of a patient with conjllllctivifis
`should include a thorough ocular, medi<;al
`and medication history. This should e tablisb
`whether the condition is acute, subacute,
`chronic or recurrent, whether it is tmjJateral
`or bilateral, and whether it is associated witl1
`any i.pecific environmental or work-related
`exposure.
`Many symptoms of conjunctivitis, such cl$
`tearing, irritation, stinging and burning are
`nonspecific. However, certain symptoms-ma)'
`strongly suggest a particular diagnosis.
`
`Itching
`Itching is the hallmark qf allergic conjun·c(cid:173)
`tivitis, as well as other forms of allergic eye
`disease. The itching may be mild to severe. In
`general, a red eye in th~ absence of itching ij
`not caused by ocular allergy.
`A history of recurrent itching or a person~
`or family history of hay fever, allergic rh.i.nitiSi
`asthma or atopic dermatitis is also suggestive
`of ocular allergy. Mild itching can also be a
`feature of blepharitis, dry eyes and, occasion,
`ally, bacterial, or viral conjunctivitis.
`
`Discharge
`The rype of ocular discharge, such as serous
`(watery), mucoid, mucopurulent or gro·s~
`purulent, can be helpful in determining dir
`underlying cause of conjunctiva! infl.ammai
`tion1 (Table 2).2
`A serous discharge is most commonly asso·
`ciated with viral or allergic ocular conditions,
`
`736 AMERICAN FAMILY PH'¥°SICIAN
`
`VOLUME 57, NUMBER 4 / FEBRUARY 15, 19
`
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`

`FIGURE 2. Algorithm for the differential diagnosis of a red eye.
`
`Red eye
`
`!
`
`Pain?
`
`J
`Yes
`
`No
`
`l
`!
`
`Blurred vision?
`
`J
`Yes
`!
`
`-Yes -Photophobia? -
`
`No
`
`l
`!
`No ---.: Discharge?
`I
`
`Ophthalmic
`referral
`
`!
`
`Rule out i ritis/uveitis,
`acute glaucoma;
`keratitis and other
`conditions
`
`J
`Yes ,.
`
`Purulent
`
`!
`!
`
`Bacterial
`conjunctivitis
`
`Watery
`
`l
`!
`
`!
`Itching?
`I
`
`Viral or
`allergic
`conjunctivitis
`
`No
`
`l
`!
`Itching?
`I
`
`No
`
`l
`!
`
`Ophthalmic
`referral
`
`l
`
`Rule out episcleritis,
`scleritis, dry eye,
`blepharitis, topical
`drug toxicity and
`other conditions
`
`J
`Yes
`!
`
`Allergic
`conjunctivitis,
`dry eye or ble(cid:173)
`pharitis
`
`Yes
`
`!
`!
`
`Allergic conjunctivitis
`
`No
`
`l
`!
`
`Viralconjunctivitis
`
`I-
`
`A lllucoid (stringy orropy) discharge is highly
`characteristic of allergy or dry eyes. A muco(cid:173)
`P11ru.lent or purulent discharge, often ai;soci(cid:173)
`ated with morning crusting and difficulty
`0Pening the eyelids, strongly suggests a bactc-
`
`rial infection. The possibility of Neisseria gon(cid:173)
`orrhoeae infection should be considered when
`the discharge is copiously purulent.
`The precedirig generalizations about ocular
`discharges can be helpful in distinguishing
`
`F~hl\lJA RY 15, 1998 / VOLUME 57, NUMBER 4
`
`AMERICAN FAMILY PHYSICIAN 737
`
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`

`Conjunctivitis
`
`Unilateral conjunctivitis may incf,cate keratftis, nasolacrimal
`duct obstruction, occult foreign body or neoplasia.
`
`between viral and simple bacterial conjunc(cid:173)
`tivitis. However, in the absence of a definitive
`diagnosis, many physicians elect to empiri(cid:173)
`cally prescribe topical antibiotics.
`
`Unilateral or Bilateral Conjunctivitis
`Allergic conjunctivitis is almost always sec(cid:173)
`ondary to environmental allergens and, there(cid:173)
`fore, usually presents with bilateral symp(cid:173)
`toms. 2 Infections caused by viruses and
`bacteria (including Chlamydial organisms)
`are transmissible by eye-hand contact. Often,
`these infections initially present in one eye,
`with the second eye becoming involved a few
`days later.
`Since chronic unilateral conjunctivitis can
`have a number of causes, it often presents a
`difficult diagnostic dilemma. Therefore, pa(cid:173)
`tients •with this condition should be referred
`for full ophthalmic assessment to rule out less
`common entities, such as keratitis, naso(cid:173)
`lacrimal duct obstruction, occult foreign body
`and conjunctival neoplasia (Figure 3).
`
`Pain, Photophobia and Blurred Vision
`Pain and photophobia are not typical fea -
`tures of a primary conjunctival inflammatory
`process. If these features are present, the phy(cid:173)
`sician should consider more serious under(cid:173)
`lying ocular or orbital disease processes,
`including uveitis, keratitis, acute glaucoma
`and orbital cellulitis. Similarly, blurred vision
`that fails to clear with a blink is rarely associ(cid:173)
`ated with conjunctivitis. Patients with pain,
`photophobia or blurred vision should be
`referred to an ophthalmologist.
`
`Other Aspects of the History
`A recent upper respiratory tract infection in
`the patient's home, school or workplace sug(cid:173)
`gests a diagnosis of infectious conjunctivitis,
`especially of adenoviral origin. Chlamydia! or
`
`gonococcal infection may be suggested by tfa
`patient's se.xual history, including a history of
`urethral discharge.
`The physician should also inquire about
`the patient's use of systemic and over-the(cid:173)
`counter topical medications (e.g., vasocon,
`strictors or artificial tears), as well as the use
`of cosmetics and contact lenses, since any of
`these can produce acute or chronic conjunc(cid:173)
`tivitis. 2 Most patients do not regard nonpre(cid:173)
`scription eye medications as possible cat1ses
`of ocular problems. Therefore, unless ques(cid:173)
`tioned-directly, they generally do not volun.
`teer information about their use of these
`medications.
`A history of collagen vascular disease or the
`use of diuretics or antidepressant medications.
`should alert the physician to the possibility o£
`dry eyes.
`
`Physical Clues to the Etiology
`of Conjunctivitis
`The patient should be examined in a well(cid:173)
`lit room. Before performing the ocular Cl{am(cid:173)
`ination, the physician should search for
`regional lymphadenopathy and should exam•
`ine the face and eyelids carefully.3
`Viral or chlamydia! inclusion conjanctivitis
`typically presents with a small, tender, pre(cid:173)
`auricular or submandibular lymph node,
`Toxic conjunctivitis secondary to topical med-
`
`FIGURE 3. Sebaceous cell carcinoma that is in•
`vading the conjunctiva and the superficial cof·
`nea. The patient was initially referred for the
`evaluation of chronic unilateral conjunctivitl►
`
`738 AMERICAN FAMILY PHYSICIAN
`
`VOLUME 57, NUMBER 4 / FEBRUARY 15, 1998
`
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`
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`

`•dltton can also produce a palpable, preauric(cid:173)
`~ node. Palpable adenopathy is ra re in acute
`bacterial conjun ctivitis. The exception is
`4-yperacute ~onjun~vitis caused by infection
`-with Neissen a species.
`Other faci,11 clues t o the etiology of conjunc(cid:173)
`tivitis include the presence of herpes labialis or
`a dermatomal vesicular eruption suggestive of
`shingles. Either of these findings may indicate a
`herpetic source of conjunctivitis.
`
`Diagnostic Tests
`Cultures usually are not required in pa(cid:173)
`tients with mild conjunctivitis of suspected
`viral, bacterial or allergic origin. However,
`specimens for bacterial cultures should be
`obtained in patients who have severe inflam(cid:173)
`mation ( e.g., hyperacute purulent conjunc(cid:173)
`tivitis) or chronic or recurrent conjunctivitis.
`Cultures also should be obtained in patients
`who do not respond to treatment.3
`Several laboratory procedures can be used to
`identify chlamydia} infections. These include
`cell culture, direct fluorescent monoclonal
`antibody staining of smears, enzyme immuno(cid:173)
`assays for Chlamydia organisms, DNA hybri(cid:173)
`dization assays and a polymerase chain reac(cid:173)
`tion test to identify chlamydia! antigens.4
`· Many ophthalmologists obtain conjuncti(cid:173)
`val cytology scrapings for Gram's staining
`and/or Giemsa staining to help characterize
`the conjunctiva! inflammatory response. The
`~dings can be helpful, particularly for diag(cid:173)
`nosing allergic, chlamydial and certain atypi(cid:173)
`cal forms of conjunctivitis in which the clini(cid:173)
`cal diagnosis is not immediately apparent.
`
`Bacterial Conjunctivitis
`l:Iyperacute Bacterial Conjunctivitis
`HYPeracute bacterial conjunctivitis is a
`.severe, sight-threatening ocular infection that
`Warrants immediate ophthalmic work-up and
`Illanagement. The infection has an abrupt
`onset and is characterized by a copious yellow(cid:173)
`green purulent discharge that reaccumulates
`_after bemg wiped away.5 The symptoms of
`liyPeracute con junctivitis, which typically are
`
`Hyperacute put'Ufent conjunctivitis Is most often due to
`N. gonorrhoeae aFlfi N. meningltidis infection and req1Jires
`immediate.treatment with systemic antibiotlcs and saline
`irrigatien.
`
`rapidly progressive, also include redness, irri(cid:173)
`tation and tenderness to palpation. Patients
`demonstrate marked conjunctival injection,
`conjunctiva! chemosis (excessive edema), lid
`swelling and tender preauricular adenopathy.
`The most frequent causes of hyperacute
`purulent conjunctivitis are N. gonorrhoeae
`and Neisseria meningitidis, with N. gonor(cid:173)
`rhoeae being by far the more common. These
`two infections have similar clinical presenta(cid:173)
`tions, and they can be distinguished only in
`the microbiology laboratory.
`Gonococcal ocular infection usually presents
`in neonates (ophthalmia neonatorum) and
`sexually active young adults. Affected infants
`typically develop bilateral discharge three to
`five days after birth (Figure 4). Transmission of
`the Neisseria organism to infants occurs during
`vaginal delivery. In adults, the organism is usu(cid:173)
`ally transmitted from the genitalia to the hands
`and then to the eyes.
`If a gonococcal ocular infection is left un(cid:173)
`treated, rapid and severe corneal involvement
`is_ inevitable. 5 The resulting ulceration and,
`ultimately, perforation lead to profound and
`
`FIGURE 4. Neonatal hyperacute purulent con(cid:173)
`junctivitis caused by Neisseria gonorrhoeae.
`
`FEBRUARY 15, 1998 / VOLUME 57, NUMBER 4
`
`AMERICAN FAMILY PHYSI CIAN 739
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`

`Conjunctivitis
`
`'
`sometimes permanent loss of vision. Infected
`infants may also have other· localized go~o(cid:173)
`coccal infections, such as rhinitis or proctitis,
`or they may have disseminated gonococcal
`infection, such as arthritis, meningitis, pneu(cid:173)
`monia or sepsis.
`The diagnostic work-up for a gonococcal
`ocular infection includes immediate Gram
`staining of specimens for gram-negative intra(cid:173)
`cellular diplococci, as well as special cultures
`for Neisseria species. All patients should be
`treated with systemic antibiotics supple(cid:173)
`mented by topical ocular antibiotics and saline
`irrigation. Because of the increasing preva(cid:173)
`lence of penicillin-resistant N. gonorrhoeae in
`the United States, ceftriaxone (Rocephin), a
`third~generation cephalosporin, is currently
`the systemic drug of choice.6 Spectinomycin
`(Trobicin) or oral ciprofloxacin (Cipro) can be
`used in patients who are allergic to penicillin.
`Over 30 percent of patients with gonococ(cid:173)
`cal conjunctivitis have concurrent chlamydial
`venereal disease. For this reason, it is advisable
`to treat patients with supplemental oral
`antibiotics that are effective against Chlamy(cid:173)
`dia species.7
`
`Acute Bacterial Conjunctivitis
`Acute bacterial conjunctivitis typically pre(cid:173)
`sents with burning, irritation, tearing and,
`
`The Authors
`GARY L. MORROW, M. D., is on staff at Toronto East General and Orthopedic Hospi(cid:173)
`tal, Ontario, Canada. Dr. Morrow received his medical degree from the University of
`Toronto and completed a clinical fellowship in cornea, external disease and refractive
`surgery with the Department of Ophthalmology at the University of California, San
`Francisco, and the Francis I. Proctor Foundation, alsq in San Francisco.
`
`RICHARD L. ABBOTT, M.D., is professor of clinical ophthalmology and codirector of
`the cornea, external disease and refractory surgery service in the Department of Oph(cid:173)
`thalmology at the University of California, San Francisco. He is also a research asso(cid:173)
`ciate for the Francis I. Proctor Foundation. Dr. Abbott received his medical degree
`from George Washington University, Washington, D.C. He completed a residency in
`ophthalmology at Pacific Presbyterian Medical Center, San Francisco, and a fel low(cid:173)
`ship in corneal and external diseases at Bascom Palmer Eye Institute, Miami,
`
`Address correspondence to Richard L. Abbott, M.D,, Department of Ophthalmology,
`Beckman Vision Center, 10 Kirkham St., Room K-301, San Francisco, CA 94143-
`0730. Reprints are not available from the author.
`
`FIGURE 5. Acute bacterial conjunctivitis caused
`by Streptococcus pneumoniae.
`
`usually, a mucopurulent or purulent dis,
`charge (Figure 5). Patients with this condition
`often report that their eyelids are matted
`together on awakening. Conjunctiva! swelling
`and mild eyelid edema may be noted. The'
`symptoms of acute bacterial conjunctivitis a.re
`far less severe, less rapid in onset, and pro rress
`at a much slower rate than those of hypera(cid:173)
`cute conjunctivitis.
`The three most common pathogens in bac(cid:173)
`terial conjunctivitis are Streptococcus pneumo(cid:173)
`niae, Haemophilus inf!.uenzae and Staphylococ(cid:173)
`cus aureus. Infections with S. pneumoniae and
`H. infl.uenzae are more common in d1ildren,
`while S. aureusmostfrequentlyaffects adults1"
`(Table 3).
`Although acute bacterial conjunctivitis is
`usually self-limited and does not cause ro1y1
`serious harm, there are several justifications
`for treatment. These include decreasing pa(cid:173)
`tient morbidity by shortening the course ot
`the disease, reducing person-to-person spread,
`lowering the risk of sight-threatening compli(cid:173)
`cations such as corneal ulceration, and eli.roi(cid:173)
`nating the risk of more widespread o.1:raocu(cid:173)
`lar disease.
`Cultures should be obtained in certain
`patients, including young children and debili·
`tated persons. However, empiric treatment
`with a topical medication is a safe and cost·
`effective approach in most patients with clill·
`ically mild acute bacterial conjunctivitis.
`Unfortunately, no single broad-spectrun1
`
`740 AMERICAN FAMILY PHYSICIAN
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`

`'biotic covers all potential conjunctival bac-
`h
`.
`.
`nnu
`I
`, ial pathogens. u c oosmg an apprnpnate
`ltlfnicalantibiotic, the physician should keep in
`,:1. l
`.
`. al
`th
`tc>r
`il;lfnd the most -'=e y con; uncuv pa ogens,
`"eU as the cost and side effects of each med(cid:173)
`os ~~
`i cion- Since most adult cases of acute bacter-
`1! e0njuactivitis are caused by grarn-po itive
`orgallisms, it is best to choose an an.tibioti.c
`with adequate gram-positive coverage (in par(cid:173)
`ticular, good staphylococcal coverage).
`The clinical response to the antibiotic should
`be assessed after the patient has completed a
`short course of therapy. If the inflammation
`has resolved, the antibiotic should be discon(cid:173)
`tinued. However, if the condition has not
`improved, an ophthalmologist should be con(cid:173)
`sulted. In such patients, laboratory test results
`can be used to direct changes in therapy.
`Examples of currently available topical
`broad-spectrum antibiotics include eryth(cid:173)
`romycin ointment and bacitracin-polymyxin
`B ointment ( e.g., Polysporin ophthalmic oint(cid:173)
`ment), as well as combination solutions such
`as trimethoprim-polymyxin B (e.g., Poly(cid:173)
`trim). These medications are well tolerated,
`and they provide excellent coverage for most
`ccmjunctival pathogens in both children and
`adults.9 In general, ointments are better toler(cid:173)
`ated by young children, who are less apt to
`complain about associated blurring of vision.
`
`TABLE 3
`Major Pathogens in Acute
`Bacterial Conjunctivitis
`
`Children
`Slreplococc4s pneumoniae
`Haernophilus influenzae
`Staphylococcus species
`Moraxella species
`Adults
`Staphylococcus species, including Staphylococcus
`aureus, Staphylococcus epidermidis and others
`Streptococcus species
`Gr:am-negative organisms
`Escherichia coli
`Pseudomonas species
`Mora~ella species
`
`Solutions are preferred by most adolescents
`and adults.
`Aminoglycosides, such as gentamicin
`(Garamycin), tobramycin (Tobrex) and neo(cid:173)
`mycin are inexpensive choices for the treat(cid:173)
`ment of acute bacterial conjunctivitis. These
`agents provide good gram-negative coverage,
`but they have relatively poor gram-positive
`coverage, including incomplete coverage of
`Streptococcus and Staphylococcus species.
`Furthermore, aminoglycosides are associated
`with a relatively high incidence of toxicity to
`the corneal epithelium (primarily with pro(cid:173)
`longed use). Neomycin, in particular, can
`cause local oculocutaneous allergic reactions.
`For this reason, topical ophthalmic prepara(cid:173)
`tions containing neomycin probably should
`be avoided as first-line therapy.
`The 10 percent sulfacetamide solution
`(Bleph-10) is still a commonly prescribed top(cid:173)
`ical antibiotic for conjunctivitis. This bacterio(cid:173)
`static agent has weak to moderate activity
`against many gram-positive and gram-nega(cid:173)
`tive organisms, including those that com(cid:173)
`monly cause conjunctivitis. Although sulfac(cid:173)
`etamide is less effective than some of the other
`drugs mentioned in this article, it is inexpen(cid:173)
`sive and well tolerated. A rare potential treat(cid:173)
`ment side effect is Stevens-Johnson syndrome.
`In topical form, tetracycline and chlor(cid:173)
`amphenicol (Chlornmycetin) are commonly
`used to treat bacterial conjunctivitis. Tetra(cid:173)
`cycline is available only in an ointment form.
`Chloramphenicol, which is available in both
`drop and ointment forms, has a broad spec(cid:173)
`trum of antimicrobial activity. Although chlo(cid:173)
`ramphenicol is generally well tolerated, topi(cid:173)
`cal application of this agent has been
`associated with a few cases of aplastic anemia.
`For this reason, chloramphenicol is not widely
`prescribed in the United States. 10
`The fluoroquinolones, which indude
`ciprofloxacin (Ciloxan), ofloxacin (Ocuflox)
`and norfloxacin (Chibroxin), are a new class
`of potent topical antimicrobials. Agents from
`this class are commonly used to treat bacterial
`keratitis. Given the generally benign, self-lim-
`
`FEeR
`DARY 15, 1998 / VOLUME 57, NUMBER 4
`
`AMERICAN FAMILY PHYSICIAN 741
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`

`Conjunctivitis
`
`Chronic bacterial conjunctivitis often occurs wfth eyelid
`abnormalities such as blepharitis and meibomian gland
`inflammation.
`
`ited nature of acute bacterial conjunctivitis,
`the high cost of topical tluoroquinolones,
`their poor coverage of-Streptococcus species
`and the potential for developing resistant
`pathogens with indiscriminate use of this
`antibiotic class, the tluoroquinolones gener(cid:173)
`ally should be reserved for use in more severe
`ocular infections, including bacterial keratitis.
`
`Chronic Bacterial Conjunctivitis
`and Blepharitis
`Chronic bacterial conjunctivitis is most
`commonly caused by Staphylococcus species,
`although other bacteria are occasionally
`involved. This type of conjunctivitis often
`develops in association with blepharitis,
`which is a common but often unrecognized
`inflammatory condition related to bacterial
`colonization of the eyelid margins. Some
`cases of chronic bacterial conjunctivitis are
`also associated with facial seborrhea.
`The symptoms of chronic bacterial con(cid:173)
`junctivitis vary and can include itching, burn(cid:173)
`ing, a foreign-body sensation and morning
`eyelash crusting. Signs of this conjunctival
`condition include flaky debris, erythema and
`warmth along the lid margins, as well as eye(cid:173)
`lash loss and bulbar conjunctival injection:
`Some patients with chronic bacterial conjunc(cid:173)
`tivitis also have recurrent styes and chalazia
`(lipogranulomas) of the lid margin.
`The meibomian glands are sebaceous
`glands that line the posterior lid margin
`behind the eyelashes. These glands secrete an
`important oily component of the tear film.
`Wheri inflamed, the meibomian glands mal(cid:173)
`function, producing chronic inflammation of
`the eyelid margins and the conjunctiva
`(Figure .6), as well as irritating dry-eye symp(cid:173)
`toms. This condition is referred to as meibo-
`
`I
`
`/ mianitis. Chronic inflammation of the mei(cid:173)
`bomian glap.ds and eyelid margins is a prcdis..
`posing factor for the formation of chalazj11
`within the eyelids. ·
`Blepharoconjunctivitis and meibominnitis
`are common associated findings in patients
`with acne rosacea. Thi~ skin disorder typically
`affects adults between 25 and 50 years of ag~
`and occurs more commonly in women than
`in men. Diagnostic dues include a history of
`periodic facial flushing ( usually in response to
`the consumption of certain foods or alcohol)
`and the presence of erythematous and telang_(cid:173)
`iectatic skin changes on the forehead, cheeks,
`chin and nose. Some patients also have
`acneiform lesions and rhinophyma.2 Ocular
`findings include recurrent chalazia and styes
`secondary to chronic blepharitis and meibo(cid:173)
`mianitis, as well as keratitis and dry eyesl1
`(Figur~ 7).
`The work-up of patients with chronic con(cid:173)
`junctivitis and blepharoconjunctivitis involves
`cultttring the conjunctiva and the eyelid mar(cid:173)
`gins to identify the predominant bacterial
`pathogen. Treatment includes the establish(cid:173)
`ment of good eyelid hygiene using warm com(cid:173)
`presses and eyelid margin scrubs and the
`application of appropriate topical antimicro(cid:173)
`bials (e.g., erythromycin).5 Patients with mei(cid:173)
`bomianitis and acne rosacea often beneµl
`from oral tetracycline therapy. Systemic tetra(cid:173)
`cyclines are contraindicated in m.1-rsing moth(cid:173)
`ers, pregnant women and children. Topicttl.
`metronidazole (Metrogel) is helpful in some
`patients with acne rosacea.
`
`Ocular Chlamydial Infections
`Ocular Chlamydia trachornatis infection
`can occur in two distinct clinical forms: tra·
`choma ( associated with serotypes A through
`C) and inclusion· conjunctivitis ( associated
`with serotypes D through K).12
`Trachoma, a chronic keratoconj unctivitis, is
`the most common cause of ocular morbidity
`and preventable blindness throughout tbt
`world. It is a major public health concern iJl
`the rural areas of developing countries, partic·
`
`742 AMERICAN FAMILY PHYSICIAN
`
`VOLUME 57, NUMBER 4 / FEBRUARY 15, 1998
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`

`ularly in Africa, Asia and the Middle East.4•
`13
`Active trachoma is uncommon in North
`America. However, patients who have immi(cid:173)
`grated to North American countries from
`regions in which trachoma is endemic fre(cid:173)
`quently present to ophthalmologists with cica-,
`tricial ocular and eyelid changes secondary to
`previous recurrent infections (Figure 8).
`Inclusion conjunctivitis is a common, pri(cid:173)
`marily sexually transmitted disea~e that occurs
`in both newborns (ophthalmiit neonatorum)
`and adults (adult inclusion conjunctivitis). It is
`the m