2. 結膜
•
結膜は強膜と眼瞼部分を覆う薄い膜.
Review of Conjunctivitis Diagnosis and Treatment
強膜部位をBulbar conjunctiva, 眼瞼部位をPalpebral conjunctivaと呼ぶ
Clinical Review & Education Review
•
Figure 1. Normal Conjunctival Anatomy
Eyelid
Limbus
Bulbar
conjunctiva
Sclera
Bulbar
conjunctiva
Cornea
Iris
Palpebral
conjunctiva
Palpebral
conjunctiva
S AG I T TA L C R O SS S EC T I O N
13年10月24日木曜日
The conjunctiva is a thin membrane
covering the sclera (bulbar
conjunctiva, labeled with purple) and
the inside of the eyelids (palpebral
conjunctiva, labeled with blue).
4. Figure 2. Suggested Algorithm for Clinical Approach to Suspected Acute
Conjunctivitis
Suspected acute conjunctivitis
(≤ 4 wk duration)
アプローチ.
•
No
No
Blurred vision?
Yes
Constant
blurred vision?
Yes
No
No
Hyperpurulent
Yes
Gonococcal conjunctivitis
Mucopurulent
Bacterial conjunctivitis
(nongonococcal)
Serous
No
Yes
眼痛や羞明, 複視があれば
Methods
眼科診察が必要.
Yes
Photophobia?
Itching?
プライマリケアでの
Yes
Pain?
Discharge?
•
referral. An algorithmic approach (Figure 2) using a focused
history along with a penlight eye examination may be helpf
agnosis and treatment. Because conjunctivitis and many oth
lar diseases can present as “red eye,” the differential diagnos
eye and knowledge about the typical features of each diseas
category are important (Table 1).
Allergic conjunctivitis
Dry eye disease
No
Ophthalmology referral
Conjunctivitis can be divided into infectious and noninfectious
causes. Viruses and bacteria are the most common infectious causes.
Noninfectious conjunctivitis includes allergic, toxic, and cicatricial
13年10月24日木曜日
TheliteraturepublishedthroughMarch2013wasreviewedby
ing PubMed, the ISI Web of Knowledge database, and the Co
Library. The following keywords were used: bacterial conjun
• 膿性分泌物の場合は
viral conjunctivitis, allergic conjunctivitis, treatment of bacte
junctivitis, and treatment of viral conjunctivitis. No language
淋菌や細菌性を考慮.
tion was applied. Articles published between March 2003 an
2013 were initially screened. After review of titles, abstrac
and 掻痒感が強ければ were identified and sc
• references for the articles, more
Articles and meta-analyses that provided evidence-based in
tionアレルギー性を考慮. treatment of variou
about the cause, management, and
of conjunctivitis were selected. A total of 86 articles were in
in this review. The first study8 was published in 1982 and th
in 2012. A level of evidence was assigned to the recommen
• ただし, 細菌性結膜炎の
presented in Table 2 and Table 3 with the American Heart A
tion58%は掻痒感(+),
grading system: “The strongest weight65%,
熱感 of evidence (A
signed if there are multiple randomized trials with large num
patients. An intermediate weight (B) is assigned if there ar
漿液性浸出液 or 無し が35%
ited number of randomized trials with small numbers of p
careful analyses of non-randomized studies, or observatio
5. •
結膜炎意外のRed eyeを来す疾患群
Review Clinical Review & Education
Review of Conjunctivitis Diagnosis and Treatment
Table 1. Selected Nonconjunctivitis Causes of Red Eyea
Differential Diagnosis
Symptoms
Penlight Examination Findings
Dry eye disease
Burning and foreign-body sensation. Symptoms are usually transient, worse with prolonged reading or watching
television because of decreased blinking. Symptoms are
worse in dry, cold, and windy environments because of
increased evaporation.
Bilateral redness
Blepharitis
Similar to dry eyes
Redness greater at the margins of eyelids
Uveitis
Photophobia, pain, blurred vision. Symptoms are usually
bilateral.
Decreased vision, poorly reacting pupils, constant eye
pain radiating to temple and brow. Redness,
severe photophobia, presence of inflammatory cells in
the anterior chamber.
Angle closure glaucoma
Headaches, nausea, vomiting, ocular pain, decreased
vision, light sensitivity, and seeing haloes around lights.
Symptoms are usually unilateral.
Firm eye on palpation, ocular redness with limbal injection. Appearance of a hazy/steamy cornea, moderately
dilated pupils that are unreactive to light.
Carotid cavernous fistula
Chronic red eye; may have a history of head trauma
Dilated tortuous vessels (corkscrew vessels), bruits on
auscultation with a stethoscope
Endophthalmitis
Severe pain, photophobia, may have a history of eye surgery or ocular trauma
Redness, pus in the anterior chamber, and
photophobia
Cellulitis
Pain, double vision, and fullness
Redness and swelling of lids, may have restriction of the
eye movements, may have a history of preceding sinusitis (usually ethmoiditis)
Anterior segment tumors
Variable
Abnormal growth inside or on the surface of the eye
Scleritis
Decreased vision, moderate to severe pain
Redness, bluish sclera hue
Subconjunctival hemorrhage
May have foreign-body sensation and tearing or be
asymptomatic
Blood under the conjunctival membrane
a
Data are from Cronau et al18 and Leibowitz.1 The examination can be done by shining a penlight in the patient’s affected eye(s).
13年10月24日木曜日
7. Table 2. Ophthalmic Therapies for Conjunctivitis
Category
Epidemiology
Acute bacterial
conjunctivitis
135 case per 10 000
population in US3
18.3%-57% of all acute
conjunctivitis7-9,12,13
Type of
Discharge
Mucopurulent
Cause
Treatment
S aureus,
S epidermidis, H influenzae,
S pneumoniae,
S viridans, Moraxella spp
Level of Evidence
for Treatment
Aminoglycosides
B20-22
Tobramycin ointment: 3 ×/d for 1 wk
A23-30
Besifloxacin: 1 drop 3 ×/d for 1 wk
•
Gentamicin
Ointment: 4 ×/d for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
A31-34
Ciprofloxacin ointment: 3 ×/d for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
A24,28,29
Adenovirusによる結膜炎は10-50%で感染播種する.
Fluoroquinolones
•
感染経路は浸出液が付いた手, 物, 医療機器, プール等.
Gatifloxacin: 3 ×/d for 1 week
Levofloxacin: 1-2 drops 4 ×/d for 1 wk
潜伏期間は5-12日間で, 排菌期間は10-14日間. 3 ×/d for 1 wk
Moxifloxacin:
Ofloxacin: 1-2 drops 4 ×/d for 1 wk
B35
B36-38
A34,39,40
A37,38,41,42
Macrolides
特異的な治療は無く, 冷やしたり, 人工涙を使用したり, 1 drop
Azithromycin: 2 ×/d for 2 d; then
A27,30,43,44
Erythromycin:
抗ヒスタミンを使用する等対症療法を行う. 4 ×/d for 1 wk
•
B45
daily for 5 d
Sulfonamides
•
7-10日で改善しない場合や,
Clinical Review & Education Review
B22
Sulfacetamide ointment: 4 ×/d and at
bedtime for 1 wk
Solution: 1-2 drops every 2-3 h for 1 wk
Review of Conjunctivitis Diagnosis and Treatment
Combination drops
合併症を生じた場合は眼科コンサルトの必要がある.
Trimethoprim/polymyxin B: 1 or 2 drops
4 ×/d for 1 wk
NA
Purulent
Hyperacute
Table 2. Ophthalmic Therapies for Conjunctivitis
bacterial
conjunctivitis
in adults
Category
Acute
Viral bacterial
conjunctivitis
conjunctivitis
Herpes zoster
virus
13年10月24日木曜日
Epidemiology
135 case per all 000
9%-80.3% of 10 acute
population in US3
conjunctivitis8-13
18.3%-57% of all acute
conjunctivitis7-9,12,13
NA
Type of
Discharge
Mucopurulent
Serous
Variable
Cause
S aureus, are due to
Up to 65%
S epidermidis, H influenzae,
adenovirus strains49
S pneumoniae,
S viridans, Moraxella spp
Herpes zoster virus
Ceftriaxone: 1 g IM once
C16,47
Lavage of the infected eye
Neisseria gonorrhoeae
A22,40,46
C16
Level of Evidence
for Treatment
C48
Treatment to cover chlamydia is indicated
Dual therapy
Aminoglycosides
Cold compress
Artificial tears
Gentamicin
Antihistamines
Ointment: 4 ×/d for 1 wk
Solution: 1-2 dropsmg: 5 ×/d 1 wk
Oral acyclovir 800 4 ×/d for for 7-10 d
Tobramycin ointment: 3 ×/d for 1 wk
C16,50
B20-22
C16
16
A23-30
8. Tobramycin ointment: 3 ×/d for 1 wk
•
A23-30
Fluoroquinolones
Herpes Conjunctivitis; ヘルペス結膜炎 Besifloxacin: 1 drop 3 ×/d for 1 wk
A31-34
Ciprofloxacin ointment: 3 ×/d for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
•
A24,28,29
Gatifloxacin: 3 ×/d for 1 week
B35
HSVは急性結膜炎の1.3-4.8%を占める原因.
Levofloxacin: 1-2 drops 4 ×/d for 1 wk
Moxifloxacin: 3 ×/d for 1 wk
B36-38
A34,39,40
通常片側で浸出液は水様で, 眼瞼結膜に小水疱性眼瞼炎を生じる.
Ofloxacin: 1-2 drops 4 ×/d for 1 wk
A
37,38,41,42
Macrolides
局所, 経口の抗ウイルス薬は病期を短縮し得る. for 2 d; then 1 drop
Azithromycin: 2 ×/d
daily for 5 d
Erythromycin: 4 ×/d for 1 wk
•
Sulfonamides
VZVも原因となる. V1,2を含む帯状疱疹の場合に生じ,
Sulfacetamide ointment: 4 ×/d and at
bedtime for 1 wk
Solution: 1-2 drops every 2-3 h for 1 wk
A27,30,43,44
B45
B22
眼瞼に生じることが多い(45.8%). 次いで結膜に生じる(41.1%)
Combination drops
角膜の障害を38.2%, ぶどう膜炎を19.1%で生じる. B: 1 or 2 drops
Trimethoprim/polymyxin
Clinical Review & Education Review
NA
Hyperacute
bacterial
conjunctivitis
in adults
Purulent
Neisseria gonorrhoeae
Lavage of the infected eye
Table 2. Ophthalmic Therapies for Conjunctivitis
9%-80.3% of all acute
conjunctivitis8-13
Epidemiology
Serous
Type of
Discharge
Up to 65% are due to
adenovirus strains49
Cause
Acute zoster
Herpes bacterial
conjunctivitis
virus
135
NA case per 10 000
population in US3
18.3%-57% of all acute
conjunctivitis7-9,12,13
Mucopurulent
Variable
S aureus,
Herpes zoster virus
S epidermidis, H influenzae,
S pneumoniae,
S viridans, Moraxella spp
1.3-4.8 of all acute
conjunctivitis9-12
Variable
Herpes simplex virus
C16
Dual therapy to cover chlamydia is indicated
Viral
conjunctivitis
Category
Herpes simplex
virus
A22,40,46
4 ×/d for 1 wk Review of Conjunctivitis Diagnosis and Treatment
Ceftriaxone: 1 g IM once
C16,47
C48
Cold compress
Artificial tears
Treatment
Antihistamines
Aminoglycosides mg: 5 ×/d for 7-10 d
Oral acyclovir 800
Level of Evidence
C16,50
for Treatment
C16
Gentamicin
Oral famciclovir 500 mg: 3 ×/d for 7-10 d
Ointment: 4 ×/d for 1 wk
Oral valacyclovir 1000 mg: 3 wk
Solution: 1-2 drops 4 ×/d for 1×/d for 7-10 d
20-22
BC16
Topical acyclovir: 1 drop 9 for
Tobramycin ointment: 3 ×/d×/d 1 wk
23-30
AC16
Fluoroquinolones mg: 7-10 d
Oral acyclovir 400
C16
C16
Besifloxacin: 1 drop 3 ×/d for×/d for 7-10 d
Oral valacyclovir 500 mg: 3 1 wk
13年10月24日木曜日1.8%-5.6% of all acute
Adult inclusion
Variable
Chlamydia trachomatis
31-34
AC16
Ciprofloxacin ointment: 3once for 1 wk
Azithromycin 1 g: orally ×/d
24,28,29
AB16,51
13. Fluoroquinolones
Table 2. Ophthalmic Therapies for Conjunctivitis
Category
Acute bacterial
conjunctivitis
Epidemiology
135 case per 10 000
population in US3
18.3%-57% of all acute
conjunctivitis7-9,12,13
Type of
Discharge
Mucopurulent
Cause
S aureus,
S epidermidis, H influenzae,
S pneumoniae,
S viridans, Moraxella spp
Hyperacute
bacterial
conjunctivitis
in adults
NA
Viral
conjunctivitis
9%-80.3% of all acute
conjunctivitis8-13
Serous
Up to 65% are due to
adenovirus strains49
Herpes zoster
virus
NA
Variable
Herpes zoster virus
Hyperacute
Herpes simplex
bacterial
virus
conjunctivitis
in adults
NA
1.3-4.8 of all acute
conjunctivitis9-12
Viral
Adult inclusion
conjunctivitis
9%-80.3% of all acute
1.8%-5.6%of all acute
8-13
conjunctivitis5,8-11
Serous
Variable
Up to 65% are due to
Chlamydia trachomatis
adenovirus strains49
Allergic
90% of all allergic
NA
15
Serous or
Variable
Pollens zoster virus
Herpes
Herpes zoster
13年10月24日木曜日
Purulent
Besifloxacin: 1 drop 3 ×/d for 1 wk
Neisseria gonorrhoeae
A31-34
Ciprofloxacin ointment: 3 ×/d for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
Treatment
Gatifloxacin: 3 ×/d for 1 week
Aminoglycosides
A24,28,29Evidence
Level of
for Treatment
B35
Levofloxacin: 1-2 drops 4 ×/d for 1 wk
Gentamicin
Ointment: 4 3 for 1 wk
Moxifloxacin:×/d×/d for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
Ofloxacin: 1-2 drops 4 ×/d for 1 wk
Tobramycin ointment: 3 ×/d for 1 wk
Macrolides
Fluoroquinolones
Azithromycin: 2 ×/d for 2 d; then 1 drop
Besifloxacin:
daily for 5 d 1 drop 3 ×/d for 1 wk
Ciprofloxacin 4 ×/d for 3 ×/d
Erythromycin:ointment: 1 wk for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
Sulfonamides
Gatifloxacin: 3 ×/d for 1 week
Sulfacetamide ointment: 4 ×/d and at
Levofloxacin: 1-2
bedtime for 1 wk drops 4 ×/d for 1 wk
Solution: 1-2 drops every wk h for 1 wk
Moxifloxacin: 3 ×/d for 1 2-3
Combination drops
Ofloxacin: 1-2 drops 4 ×/d for 1 wk
Trimethoprim/polymyxin B: 1 or 2 drops
Macrolides
4 ×/d for 1 wk
Azithromycin: 2 ×/d for
Ceftriaxone: 1 g IM once2 d; then 1 drop
daily for 5 d
Lavage of the infected eye
Erythromycin: 4 ×/d for 1 wk
Dual therapy to cover chlamydia is indicated
Sulfonamides
Cold compress
Sulfacetamide
Artificial tears ointment: 4 ×/d and at
bedtime for 1 wk
Antihistamines
Solution: 1-2 drops every 2-3 h for 1 wk
Oral acyclovir 800 mg: 5 ×/d for 7-10 d
Combination drops
Oral famciclovir 500 mg: 3 ×/d for 7-10 d
Trimethoprim/polymyxin B: 1 or 2 drops
Oral valacyclovir 1000 mg: 3 ×/d for 7-10 d
4 ×/d for 1 wk
B36-38
B20-22
A34,39,40
A37,38,41,42
A23-30
A27,30,43,44
A31-34
A24,28,29
B45
B35
B22
B36-38
A34,39,40
A37,38,41,42
A22,40,46
A27,30,43,44
C16,47
C16
B45
C48
B22
C16,50
C16
C16
A22,40,46
C16
C16,47
C16
C16
C16
Dual therapy to cover chlamydia is 7-10 d
Oral valacyclovir 500 mg: 3 ×/d forindicated
Neisseria gonorrhoeae
Herpes simplex virus
Ceftriaxone: 1 g IM once
Topical acyclovir: 1 drop 9 ×/d
Lavage of the 400 mg: 7-10
Oral acyclovir infected eye d
Purulent
Variable
C48
C16
Cold compress
Azithromycin 1 g: orally once
Artificial tears
Doxycycline 100 mg: orally 2 ×/d for 7 d
Antihistamines
Topical antihistamines 5 ×/d for 7-10 d
Oral acyclovir 800 mg:
B16,51
16,50
C16,51
B
C16
17. Herpes zoster
virus
NA
Variable
Herpes zoster virus
1.3-4.8 of all acute
conjunctivitis9-12
C16
Oral famciclovir 500 mg: 3 ×/d for 7-10 d
C16
Review of ×/d for 7-10 Diagnosis and Treatment
Oral valacyclovir 1000 mg: 3Conjunctivitis d
C16
Clinical Review & Education Review
Herpes simplex
virus
Oral acyclovir 800 mg: 5 ×/d for 7-10 d
Table 2. Ophthalmic Therapies for Conjunctivitis
Adult inclusion
conjunctivitis
Category
1.8%-5.6% of all acute
conjunctivitis5,8-11
Epidemiology
Variable
Type of
Discharge
Chlamydia trachomatis
Cause
Acute bacterial
Allergic
conjunctivitis
conjunctivitis
135 case per 10 000
90% of all allergic
population in 15 3
US
conjunctivitis ;
18.3%-57% of all acute
up to 40% of 7-9,12,13
conjunctivitis
population may be
affected15
Mucopurulent
Serous or
mucoid
S aureus,
Pollens
S epidermidis, H influenzae,
S pneumoniae,
S viridans, Moraxella spp
C16
C16
Oral valacyclovir 500 mg: 3 ×/d for 7-10 d
Herpes simplex virus
Topical acyclovir: 1 drop 9 ×/d
Oral acyclovir 400 mg: 7-10 d
Variable
C16
Azithromycin 1 g: orally once
Treatment
Doxycycline 100 mg: orally 2 ×/d for 7 d
B16,51of Evidence
Level
for Treatment
B16,51
Aminoglycosides
Topical antihistamines
Gentamicin
Azelastine 0.05%: 1 drop 2 ×/d
Ointment: 4 ×/d for 1 wk
Solution: 1-2 drops 4 ×/d 4 1 wk
Emedastine 0.05%: 1 dropfor×/d
Tobramycin cell inhibitors
Topical mastointment: 3 ×/d for 1 wk
20-22
B52
A
A52
A23-30
Fluoroquinolones
Cromolyn sodium 4%: 1-2 drops every 4-6 h
Besifloxacin: 1 drop 3 drops 1 wk
Lodoxamide 0.1%: 1-2×/d for4 ×/d
A52
A31-34
A52
Ciprofloxacin ointment: 3 2 ×/d
Nedocromil 2%: 1-2 drops ×/d for 1 wk
Solution: 1-2 drops 4 ×/d for 1 wk
NSAIDs
Gatifloxacin: 3 ×/d for 1 week
Ketorolac: 1 drop 4 ×/d
Levofloxacin: 1-2 drops 4 ×/d for 1 wk
Vasoconstrictor/antihistamine
Moxifloxacin: 3 ×/d for 1 wk
Naphazoline/pheniramine: 1-2 drops up to
Ofloxacin: 1-2 drops 4 ×/d for 1 wk
4 ×/d
Macrolides
Combination drops
A24,28,29
A52
Azithromycin: 2 ×/d drop d; then
Ketotifen 0.025%: 1 for 2 2-3 ×/d1 drop
daily for 5 d
Olopatadine 0.1%: 1 drop 2 ×/d
Erythromycin: 4 ×/d for 1 wk
Abbreviations: IM, intramuscularly; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs.
Sulfonamides
Sulfacetamide ointment: 4 ×/d and at
bedtime for 1 wk
Solution: 1-2 drops every 2-3 h for 1 wk
B35
B53,54
B36-38
A34,39,40
B55
A37,38,41,42
A27,30,43,44
A56,57
A58,59
B45
B22
Combination drops
Trimethoprim/polymyxin B: 1 or 2 drops
4 ×/d for 1 wk
JAMA October 23/30, 2013 Volume 310, Number 16
Hyperacute
bacterial
13年10月24日木曜日
NA
Purulent
Neisseria gonorrhoeae
A22,40,46
Ceftriaxone: 1 g IM once
C16,47
Lavage of the infected eye
C16
jama.com