Noninfectious conjunctivitis

Last updated: December 14, 2022

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Noninfectious conjunctivitis is an inflammation of the conjunctiva caused by mechanical irritation or systemic conditions (e.g., allergy, autoimmune disease). Common symptoms include itching and burning. Clinical history can help to differentiate between the subtypes, e.g., allergic conjunctivitis is associated with allergen exposure, giant papillary conjunctivitis with contact lens use, toxic conjunctivitis with ophthalmic medication use, and keratoconjunctivitis sicca with prolonged screen time. Diagnosis is usually clinical but in cases of diagnostic uncertainty, an ophthalmologist can perform confirmatory studies, including tear osmolarity and conjunctival biopsy. All patients should be started on supportive therapy for conjunctivitis and educated on preventive measures against noninfectious conjunctivitis. If symptoms persist, topical and systemic treatments may be required; these are usually provided in consultation with ophthalmology.

Allergic conjunctivitis is a common cause of conjunctivitis in individuals with a history of atopy.

Epidemiology [1]

  • Affects up to 40% of the population
  • Incidence appears to be increasing.

Pathophysiology [1]

IgE-mediated hypersensitivity (type I) to specific allergens (e.g., pollen, cat dander)

Clinical features [1][2][3]

Diagnostics [1]

Treatment [1][2]

Pharmacological therapy for allergic conjunctivitis

Giant papillary conjunctivitis is a form of noninfectious conjunctivitis associated with mechanical irritation.

Etiology [2][4]

Clinical features [2][4]

Diagnostics [5]

Diagnosis is clinical.

Treatment [2]

  • Treat the underlying cause.
    • Advise patients wearing contact lenses to:
      • Change to disposable lenses or, if already using them, change lenses more frequently (daily disposables are recommended).
      • Decrease wear time.
      • Follow contact lens hygiene precautions.
      • Change the contact lens polymer.
      • Consider discontinuing contact lens use.
    • Remove or replace sutures.
    • Clean or replace prostheses.
  • Consider topical antiinflammatories or corticosteroids if symptoms persist.

Keratoconjunctivitis sicca is a common disorder in which defects in the production or composition of tears cause conjunctival irritation.

Epidemiology [6]

  • Very common in the US, especially in individuals > 40 years of age
  • >

Pathophysiology

Irritation and damage to the ocular surface epithelium is caused by underproduction or changes in the composition of lacrimal fluid or by increased evaporation.

Risk factors [6]

Clinical features [6]

Dry eye is a chronic disease in which symptoms worsen over the course of the day with prolonged eye strain and exposure to dry environments. [6]

Diagnosis [6]

Treatment [6]

Treat dry eye syndrome before certain surgeries (e.g., keratorefractive surgery, cataract), as symptoms can worsen postoperatively. [6]

Ocular cicatricial pemphigoid (a subset of benign mucous membrane pemphigoid) is a chronic autoimmune disorder of the conjunctiva. [8]

Epidemiology

  • Rare condition
  • Predominantly seen in women approx. > 50 years of age [9]

Pathophysiology

Subepithelial blistering may lead to scarring and, in severe cases, blindness.

Clinical features [2]

Diagnostics [2][9]

Ocular cicatricial pemphigoid is a diagnosis of exclusion; as part of the diagnostic process, stop all medications that could be causing toxic conjunctivitis. [2]

Management

Response to treatment is variable and follow-up with a specialist is necessary. [2]

Toxic keratoconjunctivitis is caused by exposure to an environmental irritant (e.g., air pollution, chemicals) or medications.

Etiology

  • Conjunctivitis medicamentosa: a reaction to topical ophthalmic medications [10][11]
  • Environmental factors (e.g., air pollution)
  • Harsh chemicals (e.g., in swimming pools)
  • Contact lenses and/or solutions [10]

Glaucoma medications appear to be particularly prone to causing toxic conjunctivitis and scarring (pseudopemphigoid), even when a preservative-free formulation is used. [10]

Clinical features [10]

Diagnosis [10]

Management

  1. Varu DM, Rhee MK, Akpek EK, et al. Conjunctivitis Preferred Practice Pattern®. Ophthalmology. 2019; 126 (1): p.P94-P169. doi: 10.1016/j.ophtha.2018.10.020 . | Open in Read by QxMD
  2. Elhers WH, Donshik PC. Giant papillary conjunctivitis. Curr Opin Allergy Clin Immunol. 2008; 8 (5): p.445-449. doi: 10.1097/aci.0b013e32830e6af0 . | Open in Read by QxMD
  3. Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. Elsevier Health Sciences ; 2011
  4. Bielory L, et al. ICON: Diagnosis and management of allergic conjunctivitis. Ann Allergy Asthma Immunol. 2020; 124 (2): p.118-134. doi: 10.1016/j.anai.2019.11.014 . | Open in Read by QxMD
  5. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010; 81 (2): p.137-44.
  6. Akpek EK, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019; 126 (1): p.P286-P334. doi: 10.1016/j.ophtha.2018.10.023 . | Open in Read by QxMD
  7. Chakraborty U, Chandra A. Bitot's spots, dry eyes, and night blindness indicate vitamin A deficiency. The Lancet. 2021; 397 (10270): p.e2. doi: 10.1016/s0140-6736(21)00041-6 . | Open in Read by QxMD
  8. Wang K, Seitzman G, Gonzales JA. Ocular cicatricial pemphigoid. Curr Opin Ophthalmol. 2018; 29 (6): p.543-551. doi: 10.1097/icu.0000000000000517 . | Open in Read by QxMD
  9. Azari AA, Barney NP. Conjunctivitis. JAMA. 2013; 310 (16): p.1721. doi: 10.1001/jama.2013.280318 . | Open in Read by QxMD
  10. Paley GL, Lubniewski AJ, Reidy JJ, Farooq AV. Toxic Keratoconjunctivitis. Eye Contact Lens. 2018; 44 (1): p.S8-S15. doi: 10.1097/icl.0000000000000392 . | Open in Read by QxMD
  11. Li J, Tripathi RC, Tripathi BJ. Drug-Induced Ocular Disorders. Drug Saf. 2008; 31 (2): p.127-141. doi: 10.2165/00002018-200831020-00003 . | Open in Read by QxMD

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