An 18-year-old previously healthy woman comes to the office due to redness and discharge from both eyes for the past several days. The patient also has itchiness and irritation in the eyes and has awakened with crusting in the morning. She has had a runny nose and sneezing for the last 4 days but no fever, eye pain, or photophobia. She does not wear contact lenses and her vision is unchanged. The patient is visiting her aunt, who has 2 small children; they are not ill but have a pet cat.
Eye examination reveals diffuse bilateral conjunctival erythema and edema with clear discharge. Pupils are equal and reactive bilaterally. Vision acuity is normal. No corneal opacities are present and the anterior chambers appear grossly normal.
Which of the following is the best next step in management of this patient?

Question

An 18-year-old previously healthy woman comes to the office due to redness and discharge from both eyes for the past several days.  The patient also has itchiness and irritation in the eyes and has awakened with crusting in the morning.  She has had a runny nose and sneezing for the last 4 days but no fever, eye pain, or photophobia.  She does not wear contact lenses and her vision is unchanged.  The patient is visiting her aunt, who has 2 small children; they are not ill but have a pet cat.
Eye examination reveals diffuse bilateral conjunctival erythema and edema with clear discharge.  Pupils are equal and reactive bilaterally.  Vision acuity is normal.  No corneal opacities are present and the anterior chambers appear grossly normal.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_989a_0146_853d_274dc96d3c14_MD0002_00 This patient with conjunctival erythema, edema (chemosis), and clear discharge most likely has allergic conjunctivitis (AC). AC is often associated with other allergic symptoms and can occur in a seasonal (eg, due to pollen) or sporadic (eg, due to animal dander) pattern. Patients with other atopic diseases (eg, allergic rhinitis, asthma, eczema) are at higher risk. Morning crusting and mattering of the lids can be seen in conjunctivitis of any cause, but significant itching is more specific for an allergic etiology. The diagnosis of AC is based primarily on clinical features. Findings that suggest an alternate diagnosis include focal (rather than diffuse) erythema, changes in visual acuity, corneal opacity, photophobia or headache, abnormal pupillary responsiveness, or redness at the cornea-sclera border (ciliary flush). Most cases can be managed with over-the-counter antihistamine/decongestant drops (eg, naphazoline/pheniramine) as needed. Persistent symptoms usually respond to prescription ocular antihistamines (eg, azelastine, olopatadine), mast cell stabilizers (eg, cromolyn), or nonsteroidal anti-inflammatory drugs (eg, ketorolac). (Choice B) Ophthalmic antibiotics are indicated for bacterial conjunctivitis, which is typically unilateral (at least initially) and associated with purulent discharge. This patient's bilateral symptoms and associated itching are more consistent with AC. (Choice D) Topical corticosteroids are indicated for certain steroid-responsive ocular disorders but are not recommended for AC. These agents have significant risk (eg, corneal perforation, cataract formation) and should be used only under the supervision of an ophthalmologist. (Choice E) Ophthalmic cyclosporine is an immunomodulator indicated for the treatment of dry eye symptoms due to keratoconjunctivitis sicca, a chronic condition typically seen in association with certain autoimmune disorders (eg, Sjögren syndrome). Acute discharge and itching suggest AC. Educational objective: Allergic conjunctivitis is characterized by bilateral conjunctival redness, discharge, and itching. It is often associated with other allergic symptoms and atopic conditions (eg, asthma, eczema). Treatment options include topical antihistamines/decongestants, mast cell stabilizers, and nonsteroidal anti-inflammatory drugs. __________ References: Conjunctivitis: a systematic review of diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24150468)

An 18-Year-Old Previously Healthy Woman Comes to the Office Due