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Diagnosis Guide

Overview

Patients with ocular surface diseases such as conjunctivitis, blepharitis have greater potential for discomfort or further ocular damage. Early recognition of the signs of infection and prompt diagnosis minimize the potential for severe or chronic complications.

The evaluation for ocular surface disorders includes a carefully detailed patient history, assessment of associated risk factors, and examination of the anterior ocular structures and their functions.

There are several causes of conjunctivitis and it is important to make the correct diagnosis to avoid complications.

Evaluation of a patient exhibiting blepharitis, dry eye symptoms or signs consistent with blepharitis includes many of the elements of a comprehensive eye and vision examination and a more in-depth evaluation of the ocular surface and adnexa1,2.

Occular Examination

  • External examination of the eye, including lid structure, skin texture, and eyelash appearance
  • Examining lid margins, bases of lashes, meibomian gland and its orifices
  • Comparison of the eyes helps determine the severity of the inflammation1

Patient History

  • Onset and course of condition
  • Thorough medical history
  • Effects of previous treatments and the patient’s compliance in following recommendations1

Differential Diagnosis

Not every 'red eye' is 'bacterial conjunctivitis'. Be wary, particularly in cases that are sub-acute in onset, not responding to treatment or that are associated with other symptoms such as reduced vision, photophobia, double vision or significant eye pain2.

In patients who are contact lens wearers, be alert to the possibility of contact lens-related corneal infection.

Other Forms of Conjunctivitis

  • Viral conjunctivitis
  • Epidemic keratoconjunctivitis (e.g. adenovirus)
  • Chlamydial infection
  • Allergy

Learn about broad differential features of bacterial, viral, chlamydial and allergic conjunctivitis.2

Differential Diagnosis of Chronic Blepharitis Include3:

  • Squamous cell, basal cell, or sebaceous cell carcinoma of the eyelid margin
  • Meibomian cyst (chalazion)
  • Eczema
  • Dry eye syndrome
  • Infection (such as conjunctivitis or impetigo)
  • Infestation (such as pubic lice)
  • Allergy
  • Herpes (simplex or zoster)

Learn more about the signs and symptoms of blepharitis.4,5

Other Causes of Acute Red Eye11

  1. Acute glaucoma
  2. Infective keratitis
  3. Autoimmune causes such as anterior uveitis

Conjunctivitis

This condition varies in severity from mild hyperaemia and tearing to a severe conjunctivitis with copious purulent discharge. Rarely conjunctivitis is sight threatening causing irreversible scarring.

Conjunctivitis has been described as clinically differentiated by symptoms and signs, i.e. discharge, conjunctival reaction, membranes and lymphadenopathy2.

  • Broad Differential Features

    Type Conjunctivital2 Itching Discharge Lymphadenopathy Associated Fever and Sore Throat
    Bacterial Papilliary Minimal Purulent Uncommon Yes
    Viral Follicular Minimal Watery Common Yes
    Allergic Papilliary with chemosis Severe Watery None No
    Chlamydial Follicular Minimal Mucopurulent Common in inclusion conjunctivitis No

  • Chief Complaint of Bacterial Conjunctivitis

    • Redness
    • Itching
    • Burning
    • Tearing
    • Discharge
    • Pain
    • Foreign body sensation
    • Photophobia
    • Discharge: Purulent, mucopurulent, mixed1,3

  • Symptoms

    Acute onset of:

    • Redness
    • Discomfort, usually described as burning or grittiness
    • Discharge (may cause temporary blurring of vision)
    • Crusting of lids (often stuck together after sleep and may have to be bathed open
    • Usually bilateral – one eye may be affected before the other (by one or two days)13

  • Signs

    • Purulent or mucopurulent discharge
    • Conjunctival hyperaemia (redness)
    • Tarsal conjunctiva may show mild papillary reaction
    • Cornea: usually no involvement. If cornea significantly involved, consider possibility of gonococcal infection
    • Lymphadenopathy usually absent13

Blepharitis

Blepharitis is suspected when both the eyelids burn, itch and stick together, with the symptoms becoming worse in the morning. Symptoms are often intermittent, with exacerbation and remissions occurring over long periods3.

Evaluation of a patient exhibiting dry eye symptoms or signs consistent with blepharitis includes many of the elements of a comprehensive eye and vision examination and a more in-depth evaluation of the ocular surface and adnexa1.

Note: Cases of rapid onset of visual loss or an acutely painful red eye if present should be referred to the ophthalmologist for same day evaluation.

Signs & Symptoms of Blepharitis

Conditions Symptoms12 Signs12
Staphylococcal Blepharitis
  • Occular irritation/itching
  • Foreign body sensation
  • Lids sticking together
  • Lid swelling
  • Erythema (redness) of lid margins
  • Scaly collarets at base of lashes
  • Frequent loss of eyelashes
Seborrheic Blepharitis
  • Mild forms often symptom free
  • Possible burning, stinging, itching
  • Oily skin scales and greasy crusting on the lashes
  • Hyperemia (redness) on anterior lid margins
Meibomian gland dysfunction
  • Blockage of the oil glands in the eyelids
  • Poor quality of tears
  • Redness of the lining of the eyelids
Combination of seborrheic Blepharitis and meibomian gland dysfunction
  • Dry eye symptoms
  • Blocked and inflamed meibomian glands
  • Lipid secretions of toothpaste consistency
  • Unstable tear film

References

  1. Care of the Patient with Ocular Surface Disorders. OPTOMETRIC CLINICAL PRACTICE GUIDELINE. American Optometric Association. 2010. Download
  2. Chen, J. Y. and Tey, A. GP guide to the diagnosis and management of conjunctivitis. Prescriber. 2014:25; 22–31. Download
  3. NICE CKS. Blepharitis. October 2015. Download
  4. American Optometric Association. Care of the Patient with Blepharitis. Quick Reference Guide. Download
  5. Blepharitis. American Optometric Association (online). Last accessed on May 2019. https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/blepharitis?sso=y
  6. Dry Eye. American Optometric Association (online). Last accessed on May 2019. https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/dry-eye?sso=y
  7. Uveitis. Diagnostic Approach. BMJ Best Practice (online). Last accessed on May 2019. http://bestpractice.bmj.com/best-practice/monograph/407/diagnosis/step-by-step.html Download
  8. Jean Deschênes. Bacterial Keratitis Clinical Presentation. Bacterial Keratitis Clinical Presentation: History, Physical, Causes. Medscape. May 2017. Download.
  9. Blepharitis (online). Last accessed on May 2019. https://patient.info/doctor/blepharitis-pro
  10. Blepharitis (Lid Margin Disease). The college of optometrists. Last accessed on May 2019. https://www.college-optometrists.org/guidance/clinical-management-guidelines/blepharitis-lid-margin-disease.html
  11. NICE. Conjunctivitis-Infective. 2018. Download.
  12. Care of the Patients with Blepharitis. Quick Reference Guide. American Optometric Association. [Online]. Available at: https://www.aoa.org/documents/optometrists/QRG-10A.pdf. Last accessed on May 2019. Download
  13. Conjunctivitis (bacterial). The College of Optometrists. [Online]. Available at:https://www.college-optometrists.org/guidance/clinical-management-guidelines/conjunctivitis-bacterial-.html Last accessed on May 2019. Download