Raise the bar for diagnosing, treating acute conjunctivitis

Employing best-in-class management of acute conjunctivitis means abandoning empirical diagnosis in favor of differential diagnosis. Viral, bacterial, and allergic are the most common types of acute conjunctivitis and have similar symptoms.^1,2,3 More importantly, adenovirus causes approximately 1 out of 4 acute conjunctivitis cases seen by eyecare professionals and is often misdiagnosed.^2-6 My practice provides early and accurate diagnosis of acute conjunctivitis via a dedicated red eye protocol for conjunctivitis, a process that I find motivates my staff and satisfies my patients.

I strive to recruit technicians and staff who are passionate about patient care and want to deliver the best results. So it is no surprise to me how well my staff has taken to adopting a red eye protocol for conjunctivitis because it offers them a deeper level of involvement with patient care. For example, my front desk staff identifies patients who may have conjunctivitis, and isolates the patient as soon as he or she enters the office. The technician then performs the preliminary work-up in the isolation room, which includes utilizing a point-of-care diagnostic test, AdenoPlus (Nicox Inc.), to aid in the differential diagnosis of the red eye by either confirming the presence of, or ruling out, adenoviral conjunctivitis. After running the test, my technicians will often peek at the results to see if the patient has adenovirus or not, evidence that the protocol has sparked a deep interest in patient care among my staff.

Evidence-based testing

By the time I see the patient, I have his or her test results, clinical examination, and medical history in front of me. I can then immediately diagnose the patient and develop a treatment plan. I have received positive feedback from conjunctivitis patients because having this protocol offers them efficient management and concrete evidence to support my clinical observation. Many patients are cynical when facing a lack of evidence, so using an evidence-based diagnostic test eliminates much of the skepticism associated with diagnosing acute conjunctivitis.

Within this protocol, having a test to rule out adenovirus greatly benefits patients. If adenovirus is confirmed, I have a clear treatment plan ready, along with instructions for reducing contagion. However, it is equally important to patients when I have proven that adenovirus is not present. I can assure the patient that it is okay to interact with family members and return to work, and that is valuable information. Bacterial and allergic conjunctivitis lack the contagious threat posed by adenovirus, so being able to confidently rule those out lets the patient get back to living his or her life to the fullest sooner.

Activating the treatment plan

Once I have determined the root cause of the conjunctivitis, I can proceed with treatment. For allergic conjunctivitis, I like to prescribe the newer antihistamine-mast cell stabilizer combinations, such as bepotastine besilate (Bepreve, Bausch + Lomb) or alcaftadine (Lastacaft, Allergan.). If a patient has more signs than symptoms, I reach for loteprednol etabonate (Alrex, Bausch + Lomb) to calm the eye quickly. For bacterial conjunctivitis, broad-spectrum fluoroquinolones make the most sense to prescribe, and I favor besifloxacin (Besivance, Bausch + Lomb).

When treating viral conjunctivitis, I have had great success using Betadine 5% (Purdue Products) in the early phases to reduce viral load on the ocular surfaces. After topical anesthesia, I apply two drops of Betadine onto the eye and have the patient swish it around by closing the eye and looking up, then down, then left, and then right for 60 seconds. I also like to spread any excess Betadine onto the lashes. After 60 seconds, I use balanced salt solution to rinse the Betadine off the eye. Finally, I instill two drops of ketorolac 0.45% (Acuvail, Allergan) for patient comfort.

Diagnosing and treating conjunctivitis correctly when the patient first presents with a red eye saves time for my practice and for my patients. This translates into increased efficiency because managing acute conjunctivitis empirically-risking misdiagnosis and, subsequently, mistreatment-can lead to multiple patient visits, directing my time away from other conditions and forcing the patient to return to the practice several times.

Ultimately, by implementing concrete steps designed to better identify, diagnose, and treat patients with conjunctivitis, my practice has improved its standard of care for managing a surprisingly hard-to-manage disease state. As a result of adopting this protocol, I am a more effective clinician, treating more satisfied patients-proof that a little strategy can go a long way.ODT

References

O’Brien TP, Jeng BH, McDonald M, et al. Acute conjunctivitis: truth and misconceptions. Curr Med Res Opin. 2009;25(8):1953-1961.

Leibowitz HM, Pratt MV, Flagstad IJ, et al. Human conjunctivitis. Arch Ophthalmol. 1976;94:1747-1749.

Stenson S, Newman R, Fedukowicz H. Laboratory studies in acute conjunctivitis. Arch Ophthalmol. 1982;100:1275-1277.

Fitch CP, Rapoza PA, Owens S, et al. Epidemiology and diagnosis of acute conjunctivitis at an inner-city hospital. Ophthalmology. 1989;96:1215-1220.

Sambursky R, Tauber S, Schirra F, et al. The RPS Adeno Detector
for diagnosing adenoviral conjunctivitis. Ophthalmology. 2006;113:1758-1764.

Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for adenoviral conjunctivitis. Am J Med Sci. 2008;336(3):254-264.

Dr. Han

Author Info

Scott B. Han, OD, FAAO, is director of optometry and partner in a multi-location practice in West Coast Florida. Dr. Han is a consultant/speaker for Allergan, Bausch + Lomb, and Merck. Contact him at shan@theeyeassociates.com.

Take-Home Message

A dedicated red eye protocol for conjunctivitis can enable a practice to achieve early and accurate diagnosis of acute conjunctivitis. 

PULL-QUOTE 1

By implementing concrete steps designed to better identify, diagnose, and treat patients with conjunctivitis patients, my practice has improved its standard of care.

PULL-QUOTE 2

Diagnosing and treating conjunctivitis correctly when the patient first presents with a red eye saves time for my practice and for my patients.