OCULAR SURFACE DISEASE SERIES: CASE STUDY #2

By Charles B. Slonim, M.D., F.A.C.S.

Pinning Down a Nonspecific Problem

Ruling out the alternatives and evaluating a patient's environment can lead to a diagnosis of nonspecific conjunctivitis.

A patient presents with ocular redness, photosensitivity, mucous discharge, gritty discomfort and watering. He clearly has conjunctivitis, but which type?

Here in Florida, where we have 12 months of "seasonal" allergies, allergy is my most common diagnosis. Viral or bacterial infections are possible. Less frequently, we will see a nonallergic, noninfectious (NANI) or vasomotor conjunctivitis. We wait until we've ruled out a specific conjunctivitis, for example, an acute bacterial infection, a contagious viral infection, a seasonal or perennial allergy or a NANI conjunctivitis before we place the patient into the category of a nonspecific conjunctivitis.

Nonspecific conjunctivitis may occur unilaterally or bilaterally, and ocular redness is a common symptom.

By Process of Elimination

Typically, it is the absence of other types of conjunctivitis that leads to a diagnosis of nonspecific conjunctivitis.

Bilateral itching and nasal or respiratory symptoms suggest allergy, which we can treat effectively with a variety of over-the-counter or prescription antiallergy medications including topical corticosteroids. The absence of itching may rule out an allergic or vasomotor component and indicate infectious conjunctivitis, especially if the symptoms start in one eye and spread to the other or if a true purulent discharge is present. In addition to the common conjunctivitis symptoms, bacterial infection frequently causes a thick, purulent discharge that causes crusting on the eyelids that seems to "glue" the eyelids shut overnight. The lesscommon viral infection often can accompany an upper respiratory infection such as a cold, sore throat or fever. Topical ophthalmic antibiotics are used to treat bacterial conjunctivitis, whereas a virus is usually self-limiting and usually will run its course in less than a week.

Although we need to rule out several other possibilities for a definitive diagnosis, NANI or vasomotor conjunctivitis is quite common. Nonantigenic irritants typically cause the condition. Chemicals can trigger the reaction, as can pollutants like diesel exhaust fumes, perfumes or secondary cigarette smoke. These same triggers can cause a similar nasal condition called vasomotor rhinitis.

Getting 'Nonspecific'

Once "specific" conjunctivitides have been ruled out, there are many cases of red eyes where the conjunctival inflammation is obvious; however, a concomitant infectious process possibly may exist and cannot be completely ruled out. The inflammatory signs and symptoms are frequently reduced and eventually alleviated by treating with an antiinflammatory (e.g., a topical steroid), whereas the suspicion of a primary or secondary infection can be dealt with by employing an antimicrobial (e.g., a topical antibiotic).

A patient who has been wearing his contact lenses beyond the recommended wearing schedule might be experiencing nonspecific conjunctivitis. If a person has dry eye syndrome, this lack of lubrication lowers his defenses against ocular surface debris, which also may cause nonspecific conjunctivitis to develop.

Unlike allergy, nonspecific conjunctivitis may occur unilaterally or bilaterally. If the etiology is not clear, then a broad-spectrum antibiotic with a broad-spectrum anti-inflammatory should give the patient the best opportunity to alleviate his or her symptoms quickly. The presence of pus or mucus is cause to suspect a bacterial component such as Staphylococcus. Instead of a full-blown infection, the patient's eye may have become compromised and opened the door to a minor infection. Frequently, in nonspecific conjunctivitis, topical steroid therapy will suffice to resolve the condition; however, the addition of an antibiotic tends to make most treating physicians sleep better at night.

A combination antibiotic-corticosteroid like loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension (Zylet) is a great choice for treating nonspecific conjunctivitis. The broad-spectrum antibiotic is effective for the most common surface bacteria, and, therefore, one frequently can avoid obtaining a culture. Tobramycin has been proven effective against gram-negative and gram-positive bacteria.

Steroids reduce conjunctival injection and conjunctival edema (chemosis). By ruling out a viral component or any immunologic dysfunction, we ensure the steroid is safe as well as effective. Loteprednol etabonate is an ester steroid that has been proven safe and effective for treating inflammatory disease without raising intraocular pressure, and tapering is rarely required.

Case Study: Work Can Be Irritating

A 39-year-old woman, a new patient, came into my office complaining that her eyes were red and felt dry, gritty and irritated. She was experiencing foreign-body sensation, as well. She had been rubbing her eyes, which only made them look and feel worse. However, she said her eyes did not itch, and she described the problem as bad on one side and worsening on the other, which helped me rule out allergy.

When I examined the patient, her eyes were inflamed. She had some discharge; her vision was slightly compromised by mucus and a small amount of pus was present. The mucus and pus did not seem sufficient for a diagnosis of bacterial conjunctivitis. Under the slit lamp, the cornea looked clear and quiet. There were no corneal infiltrates that would suggest a viral origin and no ulcerations. The absence of preauricular lymph node swelling also helped me rule out viral conjunctivitis.

The patient's history and appearance gave me some important insights into her condition. She was so used to having no problems with her eyes that she came to me before trying an over-the-counter remedy. In her job at a furniture factory, the patient was exposed to chemicals and airborne debris. She had come straight from work and had dirt under her fingernails from her job. When I asked about any changes in her routine, the patient told me she had changed work areas a few weeks ago.

I diagnosed nonspecific conjunctivitis, related to environmental irritants and contaminants, which may or may not have had an infectious component to it. To start, I recommended she wear goggles at work, use wetting drops and keep her hands away from her eyes. I prescribed a combination antibiotic-corticosteroid — loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension — four times a day for 7 days and advised the patient to return in 1 week.

Treatment Outcome

The patient returned in a week, looking and feeling much better. The inflammation had decreased in just a few days, and I could see that the discharge had disappeared. Like most nonspecific conjunctivitis cases, this one resolved without issue. The patient has been following my recommendations for the workplace, and she hasn't had any more episodes. The antibiotic-corticosteroid combination addressed all of her symptoms, as well as any potential for an encroaching infection.

Indication

Zylet is indicated for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists and where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain a diminution in edema and inflammation.

Important Safety Information

As with other steroid anti-infective ophthalmic combination drugs, Zylet is contraindicated in most viral diseases of the cornea and conjunctiva and also in mycobacterial infection of the eye and fungal diseases of ocular structures. Prolonged use of corticosteroids may result in glaucoma, as well as increase the hazard of secondary ocular infections. The incidence of adverse events reported by subjects treated with Zylet included injection (approximately 20%) and superficial punctate keratitis (approximately 15%). The development of secondary infection has occurred after use of combinations containing steroids and antimicrobials. NOT FOR INJECTION INTO THE EYE. Steroids should be used with caution in the presence of glaucoma. The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. If this product is used for 10 days or longer, intraocular pressure should be monitored even though it may be difficult in children and uncooperative patients.