A 26-year-old man comes to the physician with sudden onset of redness, watery discharge, and itching of both eyes. His vision is slightly distorted from excess tearing but is not blurred. He otherwise feels fine. The patient's past medical history is significant for obesity, asthma, sleep apnea, and chronic back pain. On eye examination, there is bilateral injection with granular appearance of the conjunctiva. Mild eyelid swelling and clear discharge are also noted. Pupils are equally round and reactive to light. The lungs have a few scattered wheezes. What is the most likely diagnosis in this patient?

Question

A 26-year-old man comes to the physician with sudden onset of redness, watery discharge, and itching of both eyes.  His vision is slightly distorted from excess tearing but is not blurred.  He otherwise feels fine.  The patient's past medical history is significant for obesity, asthma, sleep apnea, and chronic back pain.  On eye examination, there is bilateral injection with granular appearance of the conjunctiva.  Mild eyelid swelling and clear discharge are also noted.  Pupils are equally round and reactive to light.  The lungs have a few scattered wheezes.  What is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d2e6_2e05_bc81_ab6c26b0f8c7_MD0003_00 Allergic conjunctivitis (AC) is an acute hypersensitivity reaction caused by exposure to environmental allergens such as pollen, animal dander, dust, and mold spores. Episodic itching, hyperemia, tearing, and edema of the conjunctiva and eyelids are characteristic. Some patients complain of mild photophobia or a dry-eye sensation. There is often a family or personal history of atopic disorders such as asthma or seasonal allergies. The condition usually subsides in 24 hours, even without treatment. For persistent or recurrent symptoms, AC can be treated with a variety of topical agents, including antihistamines, vasoconstrictors, mast cell stabilizers, and artificial tears, that are available over the counter or by prescription. Oral antihistamines are less effective for acute episodes but can be helpful if taken seasonally, prior to allergen exposure. (Choice B) Anterior uveitis (iritis) is inflammation of the anterior uveal tract, especially the iris. Discharge is uncommon and, if present, is not profuse. Iritis usually has significant pain, miosis, and photophobia; visual loss may be present. A gritty sensation and itching are not present in iritis but are common with AC. Anterior uveitis (Choice C) Atopic keratoconjunctivitis is a severe form of ocular allergy. The most common symptoms are itching, tearing, thick mucus discharge, photophobia, and blurred vision. It can be differentiated from AC by more severe symptoms with a prolonged course, potential visual impairment due to corneal involvement, and thickening of the eyelids and surrounding skin. (Choice D) In contrast to viral conjunctivitis and AC, patients with bacterial conjunctivitis will have a grossly purulent exudate and are likely to have more significant pain, erythema, and possibly fever. (Choice E) Endophthalmitis is an invasive infection of the globe (bacterial or fungal) and is due to disruption of the external surface of the eye (eg, trauma). Endophthalmitis may show conjunctival irritation as well, but patients will usually have purulent haziness of the ocular contents and may have a layering-out of pus in the anterior chamber (hypopyon). Endophthalmitis (Choice F) Kawasaki disease is a vasculitis of medium-sized arteries that affects young children (age usually <5). Symptoms may include conjunctivitis as well as fever, lymphadenopathy, and mucocutaneous inflammation (erythema of lips, tongue, and palate; peripheral edema, desquamation, and generalized rash). Kawasaki disease (Choice G) Symptoms in optic neuritis typically include visual loss, with or without eye pain. Uveitis may occur (uncommonly), but the conjunctiva is not typically affected. (Choice H) Orbital cellulitis is infection of the fat and extraocular muscles surrounding the eye and is a medical emergency. Patients usually have erythema, edema, and tenderness of the eyelids, often with impaired extraocular movement. Orbital cellulitis (Choice I) Viral conjunctivitis ("pink eye") symptoms are similar to those of allergic conjunctivitis but last longer (several days) and usually are preceded by typical nasopharyngeal symptoms. Viral conjunctivitis is most common in the late summer and fall, and may occur in clusters or small epidemics. (Choice J) Viral keratitis is infection of the cornea related to herpes simplex virus or varicella zoster. Patients typically have corneal vesicles, opacification, and/or dendritic ulcers. Viral keratitis Educational objective: Allergic conjunctivitis is an acute hypersensitivity reaction caused by environmental exposure to allergens. It is characterized by intense itching, hyperemia, tearing, and edema of the conjunctiva and eyelids. References: Conjunctivitis: a systematic review of diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24150468)

A 26-Year-Old Man Comes to the Physician with Sudden Onset