Managing the acute red eye

Take-home

To improve clinical accuracy and manage acute conjunctivitis better, one ophthalmologist’s practice has implemented a red eye protocol. This protocol is designed to improve diagnostic confidence and minimize the risk of patients spreading disease.

Evidenced-based treatment, using point-of-care diagnostic testing, is the future of medicine. Having a way to measure and quantify diagnosis objectively allows physicians to diagnose and treat with greater confidence.

In general, the shift away from reflexive empirical treatment based on clinical signs and symptoms and a move toward an evidence-based diagnosis is both beneficial and necessary.

More specifically, the benefits of this approach can be seen in the way my practice manages patients with acute conjunctivitis. Acute conjunctivitis, which often presents as an acute red eye, can have various underlying causes.

The etiology of acute conjunctivitis can range from a simple household allergy to a highly contagious viral infection. Clinicians can often find differentiating the various subtypes of acute conjunctivitis frustrating because of the overlapping signs and symptoms. The clinical presentation can leave eye-care professionals (ECPs) stumped, or treating empirically based on their “best guess.” In fact, studies have shown that ECPs make an accurate differential diagnosis for acute conjunctivitis about 27% to 50% of the time.^1-3

Protocol for red eye

In order to improve clinical accuracy and manage patients with acute conjunctivitis better, my practice has implemented a red eye protocol: a comprehensive, dedicated protocol designed to improve diagnostic confidence and minimize the risk of patients spreading disease. Furthermore, it enables me to focus my time more efficiently with the patient on discussing appropriate management strategies.

So far, I have found this protocol-built around a point-of-care diagnostic device (AdenoPlus, Nicox)-extremely effective in diagnosing adenoviral infections and creating proper expectations and treatment programs for patients. By ruling out or confirming presence of adenovirus with high accuracy, 90% sensitivity and 96% specificity,⁴ the test helps with a more informed, evidence-supported diagnosis.

Any patient who presents with a red eye in my practice immediately undergoes triage by someone at the front desk and is moved to an isolated examination room, where a trained technician confirms the presence of suspected acute conjunctivitis and performs the diagnostic test.

Rapid results

The test is easy to administer and is performed in less than 2 minutes, with results available in 10 minutes. Once the presence of adenovirus is confirmed or denied, the attending physician is informed of the diagnosis, and he or she immediately begins an evaluation. Patients with positive test results are given a written protocol for treatment, which includes applying lubricating drops and cold compresses to the infected eye or eyes. No antibiotics are necessary for the treatment of adenoviral conjunctivitis, and steroids have been shown to increase infectivity and the duration of viral shedding.

We have recently begun to offer patients off-label topical ganciclovir (Zirgan, Bausch + Lomb), an antiviral used for herpetic keratitis, which has also been shown in studies to have activities against epidemic keratoconjunctivitis. Moreover, examination rooms containing patients identified as having adenovirus are vigorously cleaned with a dilute bleach solution to prevent epidemic spread.

Prevention of epidemic spread

One of the biggest concerns that patients and employers have when conjunctivitis is diagnosed is when the patient can return to work. The advent of a simple in-office test to confirm patients with acute adenoviral conjunctivitis prior to allowing their return to the work force or school can help to prevent the epidemic spread of disease, thereby reducing physician medical legal liabilities.

If the test is negative, patients may return to work the same day. If the test is positive, patients are advised to refrain from work until the adenovirus has resolved, and that may be a significant amount of time.

Perhaps the most effective result of implementing this red eye protocol for conjunctivitis is that when the physician sees the patient, an accurate, evidence-based diagnostic process has already been executed, allowing the physician to interpret results quickly and make improved diagnostic and treatment decisions.

Efficient management

Clinicians can move to proper management efficiently, and the patient can leave the office in a timely manner. Patients are asked to return for a follow-up visit at 2 weeks for re-evaluation and examination for any corneal involvement. If patients have any changes in vision or pain, they are asked to follow up immediately.

Since taking an evidence-based approach to acute conjunctivitis, we have reduced dramatically the time patients spend in our office, because we are making the correct diagnoses on a routine basis and are able to advise patients appropriately on treatments. Simply put, implementing the red eye protocol for conjunctivitis is the right thing to do for patient care.

ECPs should consider implementing a similar protocol, designed around evidence-based, point-of-care diagnosis, for managing patients with acute conjunctivitis. It is an approach that will become the standard for care for the management of acute conjunctivitis as clinicians begin to understand the importance and the value of making an accurate diagnosis and “getting it right” the first time.

Eric D. Donnenfeld, MD

E: ericdonnenfeld@gmail.com

Dr. Donnenfeld is clinical professor of ophthalmology, New York University, and founding partner, Ophthalmic Consultants of Long Island and Connecticut, Rockville Centre, NY. He is a consultant for Nicox and Rapid Pathogen Screening Inc.

References

1. O’Brien TP, Jeng BH, McDonald M, et al. Acute conjunctivitis: truth and misconceptions. Curr Med Res Opin. 2009;25:1953-1961.

2. Leibowitz HM, Pratt MV, Flagstad IJ, et al. Human conjunctivitis. Arch Ophthalmol. 1976;94:1747-1749.

3. Stenson S, Newman R, Fedukowicz H. Laboratory studies in acute conjunctivitis. Arch Ophthalmol. 1982;100:1275-1277.

4. Sambursky R, Trattler W, Tauber S, et al. Sensitivity and specificity of the AdenoPlus test for diagnosing adenoviral conjunctivitis. JAMA Ophthalmol. 2013;13117-13122.