BACKGROUND:

In patients with red eye, traditional teachings suggest that photophobia, visual blurring, and eye pain indicate serious eye disease; in patients with presumed conjunctivitis, the finding of purulent drainage traditionally indicates a bacterial cause. The accuracy of these teachings is unknown.

METHODS:

A MEDLINE search was performed to retrieve articles published between 1966 and April 2014 relevant to the bedside diagnosis of serious eye disease and bacterial conjunctivitis.

RESULTS:

In patients with red eye, the most useful findings indicating serious eye disease are anisocoria (with the smaller pupil in the red eye and difference between pupil diameters >1 mm; likelihood ratio [LR], 6.5; 95% confidence interval [CI], 2.6-16.3) and photophobia, elicited by direct illumination (LR, 8.3; 95% CI, 2.7-25.9), indirect illumination (LR, 28.8; 95% CI, 1.8-459), or near synkinesis test ("finger-to-nose convergence test," LR, 21.4; 95% CI, 12-38.2). In patients with presumed conjunctivitis, complete redness of the conjunctival membrane obscuring tarsal vessels (LR, 4.6; 95% CI, 1.2-17.1), observed purulent discharge (LR, 3.9; 95% CI, 1.7-9.1), and matting of both eyes in the morning (LR, 3.6; 95% CI, 1.9-6.5) increase the probability of a bacterial cause; failure to observe a red eye at 20 feet (LR, 0.2; 95% CI, 0-0.8) and absence of morning gluing of either eye (LR, 0.3; 95% CI, 0.1-0.8) decrease the probability of a bacterial cause.

CONCLUSIONS:

Several bedside findings accurately distinguish serious from benign eye disease in patients with red eye and, in patients with presumed conjunctivitis, distinguish bacterial from viral or allergic causes.

BACKGROUND:

Ocular allergy represents one of the most common conditions encountered by allergists and ophthalmologists. However, there is wide variability of study designs in clinical trials of allergic conjunctivitis, which results in conflicting evidence on their optimal management. We conducted a systematic review of clinical trials to critically evaluate their quality and to highlight biases to be avoided in future clinical research in ocular allergy.

METHODS:

Clinical trials in allergic conjunctivitis performed since 1965 were retrieved, and data on patients, interventions, comparison of interventions, and outcomes were extracted. Four authors independently assessed articles for inclusion in the systematic review and assessed trials' quality using the Jadad scale.

RESULTS:

Three hundred and sixty-two trials were included in the study. Only a minority of trials fulfilled all the criteria of proper clinical trial design. In most of the studies, there was a very limited use of objective (quantifiable) parameters for both patients' selection and evaluation of drug efficacy and safety. Several outcomes of primary importance, such as disease relapses and recurrence rate, were omitted in clinical trials of allergic conjunctivitis.

CONCLUSIONS:

Evidence coming out of clinical trials in ocular allergy is limited, and this affects the strength of recommendations to health care providers and policy makers for optimal management. Standardized diagnostic criteria for patient selection and quantifiable primary outcomes are recommended to improve the design of future clinical trials in allergic conjunctivitis.

From November, 1989, to October, 1991, 4544 neonates were born at our hospital. Neonatal ocular prophylaxis immediately after birth was used with 1% tetracycline ophthalmic ointment in 1156 neonates, 0.5% erythromycin ophthalmic ointment in 1163 neonates and 1% silver nitrate drops in 1082 neonates. No prophylaxis for neonatal conjunctivitis was given to 1143 neonates. A total of 302 infants (6.7%) developed conjunctivitis during the first 4 weeks of life. Between December, 1991, and January, 1992, 425 neonates were born at our hospital and all were given 0.5% erythromycin ophthalmic ointment twice in the first 24 hours after birth for ocular prophylaxis. Thirty-one (7.3%) infants developed conjunctivitis during the neonatal period. The incidence rates of neonatal chlamydial conjuctivitis in the tetracycline, erythromycin, silver nitrate, no prophylaxis and erythromycin twice groups were 1.3, 1.5, 1.7, 1.6 and 1.4%, respectively. We conclude that neonatal ocular prophylaxis with erythromycin (one or two doses) or tetracycline or silver nitrate does not significantly reduce the incidence of neonatal chlamydial conjunctivitis compared with that in those given no prophylaxis.

Chlamydial eye infection was detected in 28 of 983 ophthalmological patients with conjunctivitis or keratoconjunctivitis, with a peak frequency of over 9% in patients aged 16-20 years and with decreasing frequency thereafter. In patients aged 1 to 15 years chlamydial conjunctivitis was not observed. Chlamydial eye infection could not be detected in patients at a venereal diseases clinic, though chlamydial genital infection was rather frequent in these patients. Nor was Chlamydia trachomatis found in the eyes of healthy young adults. In patients with proved chlamydial conjunctivitis unilateral symptoms were the rule. Pseudoptosis was the most conspicuous presentation in two cases. A prolonged course can be expected in chlamydial eye infection if the condition is unrecognised and effective treatment delayed. The venereal background of the condition must also influence the management.

RESUMEN En esta revisión se pretendió abarcar la mayoría de las publicaciones existentes hasta el momento, que informan sobre las afectaciones oftalmológicas de la enfermedad COVID-19, causada por el nuevo coronavirus o síndrome respiratorio agudo severo 2 (SARS-CoV-2). Se realizó una búsqueda en Pubmed/Medline hasta el 28/02/2021, en la que se revisaron las siguientes publicaciones en inglés: cartas al editor, casos clínicos, revisiones bibliográficas y estudios clínicos. En el campo de búsqueda se incluyó tanto el resumen (abstract) como el título de la publicación. Se encontraron como afectaciones oculares producidas por la COVID 19 la conjuntivitis viral, una conjuntivitis inmunomediada, parálisis oculomotoras (POM) y uveítis. Se plantea la posibilidad de retinopatía. Los oftalmólogos presentamos un riesgo considerable de contraer la COVID-19 debido a al contacto estrecho con el paciente, exposición a las lágrimas y secreciones oculares, así como al uso de equipos y aparatos susceptibles de contaminarse.

Red eye is the cardinal sign of ocular inflammation. The condition is usually benign and can be managed by primary care physicians. Conjunctivitis is the most common cause of red eye. Other common causes include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis. Signs and symptoms of red eye include eye discharge, redness, pain, photophobia, itching, and visual changes. Generally, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications are rare. Because there is no specific diagnostic test to differentiate viral from bacterial conjunctivitis, most cases are treated using broad-spectrum antibiotics. Allergies or irritants also may cause conjunctivitis. The cause of red eye can be diagnosed through a detailed patient history and careful eye examination, and treatment is based on the underlying etiology. Recognizing the need for emergent referral to an ophthalmologist is key in the primary care management of red eye. Referral is necessary when severe pain is not relieved with topical anesthetics; topical steroids are needed; or the patient has vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent infections.

BACKGROUND:

Neonatal conjunctivitis (ophthalmia neonatorum) continues to cause blindness because the agents used prophylactically to prevent this condition are not completely effective and are not widely available in many parts of the world. Povidone-iodine ophthalmic solution is an effective antibacterial agent with broad antibacterial and antiviral activity to which no bacteria are known to be resistant, and it is far less expensive and less toxic than the agents currently used to prevent neonatal conjunctivitis.

METHODS:

We conducted a masked, prospective trial involving 3117 infants born over a period of 30 months in a hospital in Kenya. Shortly after birth each infant received a 2.5 percent solution of povidone-iodine (n = 1076), a 1 percent solution of silver nitrate (n = 929), or 0.5 percent erythromycin ointment (n = 1112) in both eyes. Randomization was achieved by rotating the three medications after each was used for a week.

RESULTS:

Of the neonates treated with povidone-iodine, 13.1 percent had infectious conjunctivitis, as compared with 17.5 percent of those treated with silver nitrate (P < 0.001) and 15.2 percent of those treated with erythromycin (P = 0.01). Povidone-iodine was more effective against Chlamydia trachomatis than was silver nitrate (P < 0.001) or erythromycin (P = 0.008). There were 104 cases of noninfectious conjunctivitis (9.7 percent) in the povidone-iodine group, as compared with 129 in the silver nitrate group (13.9 percent, P < 0.001) and 148 in the erythromycin group (13.3 percent, P = 0.004). Many cases of noninfectious conjunctivitis were probably due to a toxic reaction to the treatment itself. The incidence of Neisseria gonorrhoeae and Staphylococcus aureus infections was similar in the three groups.

CONCLUSIONS:

A 2.5 percent ophthalmic solution of povidone-iodine as prophylaxis against ophthalmia neonatorum is more effective than treatment with silver nitrate or erythromycin, and it is less toxic and costs less.

We compared the efficacy of erythromycin ophthalmic ointment vs 1% silver nitrate drops for the prevention of neonatal conjunctivitis or respiratory tract infection from Chlamydia trachomatis. The organism was isolated from the cervix of 67 (12%) of 572 pregnant women. They gave birth to 559 infants who were randomly assigned to either prophylaxis immediately after birth. Thirty-six of 60 infants born to Chlamydia-positive women received silver nitrate; 24 received erythromycin. Twelve (33%) of the 36 infants who received silver nitrate had chlamydial conjunctivitis, but none of the 24 infants who received erythromycin did. Ten (29%) of 36 infants receiving silver nitrate had chlamydial nasopharyngeal infection (three later had pneumonia), as opposed to five (21%) of 24 who received erythromycin (one had pneumonia). Thus, erythromycin ointment is effective in prevention of chlamydial conjunctivitis, but it may not reduce nasopharyngeal infection or subsequent pneumonia.

OBJECTIVES:

Allergic rhinitis is highly prevalent in North America, affecting 20 to 40 percent of the population. Nearly 9 percent of Americans suffer from asthma, with more than half having evidence of atopy. This comparative effectiveness review describes the effectiveness and safety of subcutaneous immunotherapy and sublingual immunotherapy (off-label use of subcutaneous-aqueous allergens for sublingual desensitization) compared with other therapies for treatment of allergic rhinoconjunctivitis and asthma.

DATA SOURCES:

We searched the MEDLINE(®), Embase, LILACS, and CENTRAL databases from the beginning of each database through May 21, 2012.

REVIEW METHODS:

Two reviewers independently selected randomized controlled trials according to established study inclusion criteria. Disagreements were resolved by consensus. Paired reviewers assessed the risk of bias of each study and extracted details about the population, intervention(s), and outcomes of interest. The results were summarized by immunotherapy type (sublingual or subcutaneous), allergen, and outcomes. Studies exclusively enrolling children were reviewed separately. The strength of the body of evidence was graded and summarized.

RESULTS:

We included 74 references that investigated the efficacy and safety of subcutaneous immunotherapy, 60 studies that investigated the efficacy and safety of sublingual immunotherapy, and 8 studies that compared the two modes of delivery. All 142 studies were randomized controlled studies. The majority of studies were at medium risk of bias due to design choices. The strength of evidence is high that subcutaneous immunotherapy reduces asthma symptoms, rhinitis symptoms, conjunctivitis symptoms, asthma medication use, asthma plus rhinoconjunctivitis medication use, and rhinoconjunctivitis-specific quality of life. The strength of evidence is moderate that subcutaneous immunotherapy reduces rhinoconjunctivitis medication use, relative to usual care, which includes pharmacotherapy. Likewise, the strength of evidence is high that sublingual immunotherapy reduces asthma symptoms. The strength of evidence is moderate that sublingual immunotherapy reduces rhinitis/rhinoconjunctivitis symptoms, combined symptom scores, conjunctivitis symptoms, and medication useusage relative to usual care, and improves allergy-specific quality of life. In studies comparing subcutaneous with sublingual immunotherapy, strength of evidence supporting the superiority of subcutaneous immunotherapy for reducing allergic rhinitis and conjunctivitis symptoms, and the superiority of sublingual immunotherapy for reducing medication use, is low. We identified 13 pediatric studies of subcutaneous immunotherapy, 18 pediatric studies of sublingual immunotherapy, and 3 pediatric studies comparing subcutaneous and sublingual immunotherapy. The strength of evidence is moderate that subcutaneous immunotherapy reduces asthma symptoms and rhinitis symptoms in comparison to usual care. The strength of evidence is low that subcutaneous immunotherapy reduces conjunctivitis symptoms, medication scores, combined symptom-medication scores, or improves quality of life relative to usual care. The strength of evidence is high that sublingual immunotherapy reduces asthma symptoms, and moderate that it reduces rhinitis/rhinoconjunctivitis symptoms, combined asthma plus rhinitis/rhinoconjunctivitis symptoms, conjunctivitis symptoms, and decreases medication use. While local reactions were frequent with both treatment regimens, there were rare reports of anaphylaxis in the subcutaneous immunotherapy studies, and no anaphylaxis reported in the sublingual immunotherapy studies.

CONCLUSIONS:

With some variation across outcomes, the overall body of evidence consistently provides moderate to high support for the effectiveness and safety of both subcutaneous and sublingual immunotherapy for the treatment of allergic rhinitis and asthma. The evidence to support the use of immunotherapy in children is somewhat weaker than the evidence supporting its use in adults. The superiority of one route of administration over the other is not known.

BACKGROUND AND OBJECTIVE:

Subcutaneous immunotherapy (SCIT) is approved in the United States for the treatment of pediatric asthma and rhinitis; sublingual immunotherapy (SLIT) does not have regulatory approval but is used in clinical practice. The objective of this study was to systematically review the evidence regarding the efficacy and safety of SCIT and SLIT for the treatment of pediatric asthma and allergic rhinoconjunctivitis.

METHODS:

Two independent reviewers selected articles for inclusion, extracted data, and graded the strength of evidence for each clinical outcome. All studies were randomized controlled trials of children with allergic asthma or rhinoconjunctivitis treated with SCIT or an aqueous formulation of SLIT. Data sources were Medline, Embase, LILACS, CENTRAL, and the Cochrane Central Register of Controlled Trials through May 2012.

RESULTS:

In 13 trials, 920 children received SCIT or usual care; in 18 studies, 1583 children received SLIT or usual care. Three studies compared SCIT with SLIT head-to-head in 135 children. The strength of evidence is moderate that SCIT improves asthma and rhinitis symptoms and low that SCIT improves conjunctivitis symptoms and asthma medication scores. Strength of evidence is high that SLIT improves asthma symptoms and moderate that SLIT improves rhinitis and conjunctivitis symptoms and decreases medication usage. The evidence is low to support SCIT over SUT for improving asthma or rhinitis symptoms or medication usage. Local reactions were frequent with SCIT and SLIT. There was 1 report of anaphylaxis with SCIT.

CONCLUSIONS:

Evidence supports the efficacy of both SCIT and SLIT for the treatment of asthma and rhinitis in children.