Viral conjunctivitis and road safety

Sex and age

A 36-year-old male.

Background

• Non-pathological background: No known allergies to medicines. No toxic habits.
• Medical history: Occasional migraines.
• Surgical history: Tonsillectomy and appendectomy in childhood.
• Family background: Father with high blood pressure; maternal grandmother diabetic.

Regular treatment

None.

Symptoms

The patient attended the clinic with a reddened, itching, burning and constantly weeping left eye which felt gritty inside and had been painful for several days. He mentioned that his 3-year-old daughter had been under treatment for conjunctivitis for several weeks.

• No history of a foreign body or direct trauma to the eye.
• Physical examination: Good general state, afebrile, BP: 110/60 mmHg, pulse 74 bpm.
• Eye examination: Anterior segment. With microscope and tincture of fluorescein negative. Conjunctival irritation. Preserved visual acuity. Pupil: shape, size and reaction to light normal.
• Diagnostic impression: Viral conjunctivitis.

Conjunctivitis

Conjunctivitis is the term used to describe the swelling (inflammation) of the conjunctiva, the thin, transparent membrane that lines the inside of the eyelids and the white part of the eye (known as the sclerotic). This condition is often referred to as “pink eye”.

Typically, conjunctivitis is a short-lived condition which may just require eye drops. However, if the symptoms persist for a long time after treatment, an eye examination should be made by an ophthalmologist (eye specialist), as the symptoms might point to a more serious eye problem. Various eye diseases can cause red eyes, some of which can lead to blindness if they are not diagnosed and treated properly.

Causes

The most common causes of conjunctivitis are infections, allergies and irritation from elements in the atmosphere.

There are three kinds of conjunctivitis:

• Bacterial conjunctivitis
  This is a highly contagious form of conjunctivitis caused by bacterial infections. In general, this type of conjunctivitis causes a red eye effect with a great deal of pus.
• Viral conjunctivitis
  This is the most common form of pink eye and is caused by different viruses, many of which are associated with infections of the upper respiratory tract, colds or throat pain. It is very contagious.
• Allergic conjunctivitis
  This form of conjunctivitis is caused by the body’s reaction to an allergen or irritant and is not contagious.

Diagnosis

Conjunctivitis is frequently diagnosed by its signs and symptoms as well as by the patient’s history. We need to consider whether the symptoms have occurred gradually or suddenly, if the conjunctivitis accompanies a common cold or an infection of the respiratory tract, or whether the eye secretions are liquid or viscous.

The information provided by the patient is important, such as whether they have been in contact with someone with conjunctivitis – this being the case in point – or whether they have allergies, and an eye examination will help to give a more precise diagnosis.

Generally speaking, laboratory tests are not necessary for diagnosis. However, tests can be done if there is any suspicion of the presence of a more serious form of conjunctivitis. These tests are done by analyzing a sample of the secretion from the infected eye; an analysis of the culture will help to determine whether the infection is caused by bacteria or a virus and the type involved, which will then determine the appropriate treatment.

Symptoms

Viral conjunctivitis is characterized by red eyes and possibly a watery discharge. Often the eyelids are very swollen and even the conjunctiva in the white part of the eye can be inflamed, creating a glassy effect. The eyes feel uncomfortable and itchy; there may be painful ulcers, fever, throat pain and congestion, symptoms which are common to most forms of infection. Sometimes there may be lymphatic nodules (inflamed lymph nodes) around the ears or neck.

Conjunctivitis most commonly appears in just one eye and then moves to the other, and normally lasts for about three weeks. However, it can also last for several months and in some cases become permanent, or only disappear after a long time, depending on the immunological response of each individual patient. It can also propagate, affecting the cornea and leading to keratitis.

The most common form of contagion is from direct contact with secretion residue, which in viral conjunctivitis is more watery and can remain on the hands, surfaces or any object the person might have touched. However, as the eye ducts, sinuses and throat are all connected, the contagion can also be caused by the Flügge droplets released when breathing.

Treatment

In the case of viral conjunctivitis, the pink eye symptoms can last between one and two weeks and then disappear on their own. Viral infections are self-limiting and the most important thing is to avoid super-infections. The discomfort can be minimized by applying cold compresses to the eyes and resting them. Usually this is the only treatment necessary.

Severe cases of conjunctivitis can benefit from the use of anti-inflammatory drops, corticosteroids and mydriatics, which can only be prescribed by an ophthalmologist. It is worth knowing that viral conjunctivitis can worsen in spite of the medication and that improvements come in the seventh day of treatment. Contagion must be prevented at all costs.

There are some anti-viral drugs used in ophthalmology such as Acyclovir: these can only be used – under strict medical supervision – when the cause of the conjunctivitis is the herpes virus.

Road Safety Advice

Standard guidelines on conjunctivitis and visual impairments

• Weeping or watery eyes, rhinitis, conjunctivitis, fatigue, general malaise, itching and sneezing fits all reduce drivers’ concentration and performance at the wheel.
• Changes to visual capacity, visual acuity, aphakia, sensitivity to contrast, ocular motility disturbances and other disorders related to age or different systemic diseases, prevent the eyes from capturing stimuli properly and hence affect decision-making, reactions times and psychomotor response. All of these constitute an important risk factor in road safety.
• On this subject, the Spanish Agency for Medicines and Medical Devices has made an anatomical therapeutic chemical (ATC) classification of the groups of medicines with the greatest effect on driving; they are classified under Group S0 corresponding to the sensory organs system, of which the most commonly used in clinical practice for the treatment of viral conjunctivitis are those in sub-groups S01BB and S01CC, which include corticosteroids and mydriatics in combination with ophthalmological treatments.
• Doctors should remember to warn patients about road safety, especially when prescribing eye drops, as the instillation of any ophthalmological solution can cause blurred and/or impaired vision temporarily. These drops can cause discomfort and eye fatigue which can affect the ability to drive.

Advice for drivers with viral conjunctivitis

1. Take care with self-medication, as although there are numerous eye drops containing antibiotics these should not be used in the case of viral conjunctivitis; they must only be used for bacterial conjunctivitis.
2. Preventing contagion of viral and bacterial conjunctivitis, just as with flu, is everyone’s responsibility. If you have an infectious conjunctivitis (whether viral or bacterial), you should help to reduce the chance of infecting other people by following these measures:
   • Wash your hands frequently with soap and warm water. If you don’t have access to them, use an alcohol-based handwash solution.
   • Avoid touching or rubbing your eyes.
   • Clean the eyes of any secretions or discharge several times a day. Wash your hands before and after, using a clean cloth, cotton wool ball or disposable napkin to clean the area around the eye. Throw the cotton wool ball or disposable napkin away once you have used them or wash the cloth in detergent and hot water. Wash your hands with soap and warm water once you have finished.
   • Wash your hands after putting in eye drops or applying an eye cream.
   • Do not use the same bottle of eye drops for healthy eyes if you have used it on an infected eye, even on the same person.
   • Wash pillow slips, sheets, cloths and towels in detergent on a hot wash cycle; after touching these articles, make sure you wash your hands.
   • Do not share items such as towels, sheets and pillow slips.
   • When cleaning spectacles, make sure you do not contaminate articles that may have to be shared with other people (such as towels).
   • Do not share eye or face make-up, make-up brushes, contact lenses, spectacles or spectacle cases.
   • Do not go in a swimming pool.
3. The use of sunglasses is highly recommended as this not only reduces the direct impact of particles in the atmosphere on the mucous membranes but also reduces photophobia.
4. Rest your eyes; keep computer use to a minimum and try to avoid driving while you are still experiencing symptoms and under treatment.

Useful links:

• Crounau H, Kankanala RR, Mauger T. Diagnosis and management of pink eye in primary health care. Am Fam Physician. 2010; 81: 137-44
• Art JK, El-Amir AN, Maddison T, Desai P, S Verma, Hughes A, MacMahon E. Identification and control of a nosocomial outbreak of adenovirus keratoconjunctivitis in an ophthalmology department. Br J Ophthalmol 2009; 93: 18-20. Epub 2008 12 August.
• Rietveld RP, van Weert HC, ter Riet G, Bindels PJ. Impact of diagnosis of the signs and symptoms of acute infectious conjunctivitis: systemic search of the literature. BMJ 2003; 327: 789.
• Health Consensus Guide on Road Safety (DGT.National Observatory on Road Safety)
• Road Safety Recommendations Guide. FAES-SEMERGEN. 2013
• Website of the Spanish Otorhinolaryngology Society
• Clinical Practice guides