List of Abbreviations
AC — allergic conjunctivitis
BC — bacterial conjunctivitis
IOP — intraocular pressure
VC — viral conjunctivitis
ICD-10 — International Classification of Diseases 10th Revision
NSAIDs — nonsteroidal anti-inflammatory drugs
DES — conjunctivitis in dry eye syndrome
DED – dry eye disease
CC — chlamydial conjunctivitis
** — this symbol indicates a medicinal product used for indications according to its instructions for use
# — this symbol indicates a medicinal product used for indications not included in the instructions for use of the medicinal product.
Terms and Definitions
Conjunctivitis is an inflammatory reaction of the conjunctiva to various stimuli, characterized by hyperemia and edema of the eyelids and ocular mucosa, specific discharge in the conjunctival cavity, and the formation of follicles and/or papillae.
Conjunctival injection is passive dilatation of conjunctival vessels
Follicles are yellowish-white, discrete, round elevations of the conjunctiva formed as a result of a lymphocytic reaction.
Papillae are formed as a result of a reactive, histamine-mediated vascular reaction due to edema and infiltration of the conjunctiva by polymorphonuclear granulocytes, lymphocytes, and plasma cells.
Conjunctival membranes represent a fibrinous exudate that has penetrated into the superficial layers of the conjunctival epithelium.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Conjunctivitis is an inflammatory reaction of the conjunctiva to various stimuli, characterized by hyperemia and edema of the eyelids and mucous membrane of the eye, characteristic discharge in the conjunctival sac, and the formation of follicles and/or papillae [1–3].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
By etiology, conjunctivitis is divided into the following groups:
Infectious conjunctivitis:
Bacterial
Viral meningitis
Chlamydial
Non-infectious conjunctivitis:
Allergic
Conjunctivitis associated with dry eye syndrome
Unspecified conjunctivitis
Other specified disorders of conjunctiva
Bacterial conjunctivitis (BC) is an inflammatory reaction of the conjunctiva developing as a result of the introduction of a bacterial agent. Cocci, primarily staphylococci, are the most frequent cause of infectious conjunctival involvement. The most dangerous pathogens are Neisseria gonorrhoeae and Pseudomonas aeruginosa , which cause severe acute conjunctivitis frequently involving the cornea [1–4].
Viral conjunctivitis (VC) is an inflammatory reaction of the conjunctiva developing as a result of the introduction of a viral agent, with the most common clinical form presenting as epidemic adenoviral conjunctivitis [1, 2, 3, 5].
Chlamydial conjunctivitis (parachlamydia) (CC) — an inflammatory reaction of the conjunctiva developing as a result of the effect of Chlamydia trachomatis on ocular tissues [1, 2, 3, 6].
Allergic conjunctivitis (AC) — an inflammatory reaction of the conjunctiva developing as a result of the effect of various allergens on ocular tissues [1, 2, 3, 7].
Conjunctivitis in dry eye syndrome (DES) — an inflammatory reaction of the conjunctiva developing as a result of altered tear film homeostasis and accompanied by ophthalmological symptoms, in the development of which tear film instability and hyperosmolarity, inflammation and damage to the ocular surface, as well as neurosensory abnormalities play an etiological role [1, 2, 3, 8].
Neonatal conjunctivitis — any conjunctivitis with discharge occurring within the first 28 days of life.
By clinical course type:
Acute conjunctivitis
Chronic conjunctivitis
Pathogenesis of acute conjunctivitis. An acute inflammatory reaction characterized by varying degrees of edema resulting from transudation and exudation of protein and plasma cells from conjunctival capillaries into the interstitial space of connective tissue, along with dilation of conjunctival vessels accompanied by injection of varying severity [1–9].
Pathogenesis of chronic conjunctivitis. Chronic conjunctivitis is characterized by pathological changes in the structure and morphology of epithelial cells, alteration in goblet cell numbers, development of epithelial hyperplasia and metaplasia, xerosis, and lymphocytic and plasmacytic infiltration. Subepithelial changes present as reactive lymphoid hyperplasia [1–9].
1.3 Epidemiology of the Disease or Condition
Conjunctivitis is among the most widespread eye diseases; according to ROSSTAT data in the Russian Federation in 2023, 926,459 cases of this disease were registered among the adult population and 404,112 cases among children.
1.4 Features of Coding the Disease or Condition
Conjunctivitis H10
H10.0 – Mucopurulent conjunctivitis
H10.1 – Acute atopic conjunctivitis
H10.2 – Other acute conjunctivitis
H10.3 – Acute conjunctivitis, unspecified
H10.4 – Chronic conjunctivitis
H10.5 – Blepharoconjunctivitis
H10.8 – Other conjunctivitis
H10.9 – Conjunctivitis, unspecified
H11.8 – Other specified disorders of conjunctiva
P39.1 – Neonatal conjunctivitis
1.5 Classification of the disease or condition
Conjunctivitis is classified according to etiology and clinical course [1–7].
1.6 Clinical presentation of the disease or condition
Clinical manifestations of conjunctivitis depend on the etiology of the disease [1–7].
Complaints: patients with conjunctivitis may complain of redness and swelling of the eyelids, eye redness, discharge of various character, lacrimation, itching, burning, and a gritty sensation in the eyes. In infectious conjunctivitis, the main complaints are discharge and lacrimation. In non-infectious conjunctivitis, complaints include itching, burning, and a gritty sensation in the eyes. Children with conjunctivitis often do not voice complaints; parents notice symptom manifestations through behavioral cues (rubbing eyes, lacrimation, frequent blinking, etc.).
Clinical signs of conjunctivitis:
General nonspecific clinical signs of conjunctivitis:
- eyelid edema and hyperemia
- conjunctival or mixed injection.
- conjunctival edema of varying severity.
- follicular conjunctival reaction.
- papillary conjunctival reaction.
- discharge of various character (serous, mucous, mucopurulent, purulent)
Specific clinical signs of conjunctivitis:
Infectious conjunctivitis:
Bacterial conjunctivitis (BC) — occurs upon primary infection of the conjunctiva by a bacterial pathogen. It may be accompanied by skin, nasopharyngeal, sinus, or ear infections, as well as occur against the background of chronic blepharitis, dry eye syndrome, or lacrimal drainage pathway disorders. A characteristic sign is purulent discharge [1–4].
Gonococcal conjunctivitis (gonoblenorrhea, blennorrheal conjunctivitis).
Conjunctivitis caused by gonococcus develops fulminantly, proceeds aggressively, with abundant purulent discharge resembling meat wash water, pronounced chemosis, and eyelid edema. There is a high risk of corneal involvement ranging from corneal ulcer to loss of the eye [1, 2, 3, 10].
Viral conjunctivitis (VC). Acute viral conjunctivitis occurs upon primary infection of the conjunctiva by viral agents. VC can be sporadic or occur in epidemic outbreaks.
Characteristic signs of VC include painful regional lymphadenopathy, follicular conjunctival reaction, membranes, and subconjunctival hemorrhages of varying size (from petechial to diffuse) [1, 2, 3, 5].
Non-infectious conjunctivitis:
Allergic and autoimmune conjunctivitis (AC) — an inflammatory reaction of the conjunctiva to allergens or immune complexes. It develops as a consequence of IgE-mediated allergy and can be seasonal or perennial.
The most frequent forms of AC:
- pollinotic conjunctivitis
- chronic perennial allergic conjunctivitis [1, 2, 3, 7].
Pollinotic conjunctivitis — causative agent: pollen of grasses, cereals, trees. Specific timing of exacerbation. Characteristic signs include itching, eyelid edema, conjunctival edema, and follicular reaction [2, 3, 7, 14].
Chronic perennial allergic conjunctivitis — chronic inflammation of the conjunctiva with minimal clinical manifestations but persistent complaints of burning, discharge, and eyelid itching. Main causes include house dust, household chemicals, pet dander and fur, feathers, fluff, and food products.
Drug-induced conjunctivitis — inflammation of the conjunctiva arising as a hypersensitivity reaction to medications upon topical, less frequently systemic, administration. It occurs in response to drugs, eye drop preservatives, or drug bases. It has an acute or chronic course. A characteristic sign is more pronounced conjunctival injection at the site of contact with the medicinal product [1, 2, 3, 12].
Conjunctivitis in dry eye syndrome — conjunctival involvement caused by the loss of tear film homeostasis and accompanied by symptoms in the development of which tear film instability and hyperosmolarity, inflammation and damage to the ocular surface, as well as neurosensory abnormalities play an etiological role. Characteristic complaints include grittiness, foreign body sensation, discomfort, rapid eye fatigue, and fluctuations in visual acuity (there is a discrepancy between patient complaints and the severity of the clinical picture).
Characteristic clinical picture — edema of the bulbar conjunctiva with the formation of horizontal conjunctival folds, mucous or mucofrequent discharge in the inferior conjunctival fornix [1, 2, 3, 8].
Giant papillary conjunctivitis arises against the background of prolonged contact with a foreign body (soft contact lenses, ocular prostheses, sutures, etc.). Characteristic clinical signs include large or giant papillae — 1 mm or more in diameter — on the tarsal conjunctiva of the upper eyelid. Itching, limbal involvement, and other allergic reactions are typically absent [1, 2, 3, 12].
Other specified disorders of conjunctiva — includes atrophy of conjunctiva, senile atrophy of conjunctiva, lymphoid hypertrophy of conjunctiva, conjunctival lymphangiectasia, and pseudopterygium [1, 2, 3, 8].
Complications of conjunctivitis.
The frequency of occurrence and structure of complications of conjunctivitis depend on the etiological form, duration and severity of the course, and adequacy of diagnosis and treatment.
Possible complications of conjunctivitis include:
- conjunctival scarring;
- keratitis;
- corneal ulcer;
- entropion, ectropion, trichiasis, symblepharon.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for diagnosing conjunctivitis include:
- analysis of complaints and medical history;
- ophthalmological examination data;
- results of laboratory diagnostic tests;
- results of instrumental diagnostic examinations;
2.1 Complaints and Anamnesis
It is recommended to take an anamnesis and evaluate complaints in all patients with conjunctivitis to establish or clarify the diagnosis [1, 2, 3].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments:
1. Complaints of eyelid redness and swelling, eye redness, various types of discharge, lacrimation, itching, burning, sensation of foreign body («grit» or «sand») in the eyes, etc. In infectious conjunctivitis, the main complaint is discharge and lacrimation. In non-infectious conjunctivitis, complaints include itching, burning, and a foreign body sensation in the eyes. Children with conjunctivitis often have no complaints; parents notice the symptoms based on behavioral patterns (rubbing the eyes, lacrimation, frequent blinking, etc.).
2. When taking the medical history, attention should be paid to the onset and development of the disease (acute or gradual), history of contact with patients suffering from acute conjunctivitis or a systemic viral illness, seasonality of the disease, worsening of symptoms in aggressive environments (air conditioning, airplane travel, bathhouse, sauna, etc.), and prolonged computer work.
3. History of ocular surgeries and trauma (presence/absence).
4. Allergic history. For children — and/or the allergic history of the parents.
5. The presence of general diseases diagnosed by specialists should be clarified.
2.2 Physical Examination
Physical examination is not indicated. Palpation of the preauricular and submandibular lymph nodes is recommended in patients with suspected infectious conjunctivitis.
It is recommended to refer patients with conjunctivitis and suspected or confirmed concomitant systemic and syndromic diseases to specialized physicians (rheumatologist, dermatologist, allergist, pulmonologist, general practitioner, pediatrician, hematologist, otorhinolaryngologist, urologist, gynecologist) to clarify the diagnosis and/or the activity of systemic and syndromic diseases, which is important for the patient's further management strategy [1–3].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the choice of a specialist profile is determined based on the patient's suspected or confirmed systemic or syndromic disease and the risk of systemic complications.
2.3 Laboratory Diagnostics
Additional laboratory diagnostic tests are prescribed to clarify the diagnosis and detect systemic and syndromic diseases associated with conjunctivitis, which is important for the patient's further management strategy. The decision on the selection and assignment of additional laboratory tests is made based on the results of the baseline examination by an ophthalmologist and/or specialists in other fields (rheumatologist, dermatologist, allergist, pulmonologist, general practitioner, pediatrician, hematologist, otorhinolaryngologist, urologist, gynecologist).
Comments: At the discretion of the ophthalmologist, additional laboratory tests may be prescribed:
1. Microbiological examination of a smear of the conjunctival sac contents.
2. Cytological examination of a conjunctival scraping.
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.4 Instrumental Diagnostics
At the diagnostic stage and during follow-up examinations:
It is recommended to perform visometry in all patients with conjunctivitis to detect decreased visual acuity and the possibility of its correction after recovery [1–3].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform an external eye examination in all patients with conjunctivitis to identify changes in the facial skin, eyelids, presence of edema, asymmetry associated with conjunctivitis [2–8, 10].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform biomicroscopy of the anterior segment of the eye in all patients with conjunctivitis to identify signs of inflammation, degenerative changes, and/or complications of conjunctivitis in the anterior segment [1–3].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform ophthalmotonometry in patients with conjunctivitis when intraocular pressure (IOP) abnormalities are suspected (hypotony, ocular hypertension) [1–3].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.5 Other Procedures
It is recommended to perform the Schirmer test to assess tear production.
Strength of recommendation — CEvidence level — 5Level of recommendation validity C (level of evidence reliability — 5) [2, 3, 8]
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
The goal of treatment is to eliminate the pathogen, relieve active inflammation through local and systemic drug administration, achieve clinical recovery and/or long-term, preferably non-pharmacological remission, and preserve visual functions.
The treatment strategy is determined by the etiology of the inflammatory process, the risk of complications and visual function loss, and the presence of associated systemic, syndromic, and concomitant diseases.
Treatment of conjunctivitis is carried out by an ophthalmologist; in the presence of an associated systemic or syndromic disease, it is conducted in close cooperation with relevant specialists (rheumatologist, dermatologist, allergist, gynecologist, urologist, etc.).
The ophthalmologist performs local therapy, determines the indications for prescribing and adjusting systemic treatment, and monitors the development of potential local and systemic complications of therapy in cases where there is no systemic disease.
General practitioners, in accordance with established etiological causes, conduct therapy in accordance with the Federal Clinical Guidelines for the treatment of the underlying disease, monitor the somatic status of patients and adverse events of systemic therapy.
Patients (or patients' parents) must be informed about the benefits and potential side effects of therapy.
It is recommended to prescribe S01A antimicrobial agents: S01AE fluoroquinolones (ofloxacin** is approved for children from 1 year of age according to the instructions, ciprofloxacin** is approved for children from 0 years of age, levofloxacin** is approved for children from 1 year of age, moxifloxacin** is approved for children from 1 year of age); S01AA antibiotics (netilmicin is approved for children from 3 years of age; tobramycin is approved for children from 2 months of age); S01AA Antibiotics (tetracycline is approved for children from 8 years of age); S01AA Antibiotics (erythromycin is approved for children from 0 years of age); chloramphenicol is approved for infants from 4 weeks of age; S01AA20 Antibiotic combinations (Colistimethate sodium + Rolitetracycline + Chloramphenicol is approved for children from 8 years of age) for patients with infectious conjunctivitis (bacterial, chlamydial) or for suspected/prophylactic prevention of secondary bacterial infection in conjunctivitis of other etiologies for antibacterial purposes [1–4, 13–25].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: local antibiotic therapy is recommended as etiotropic therapy for the treatment of infectious conjunctivitis (bacterial, chlamydial) or for suspected/prophylactic prevention of secondary bacterial infection in conjunctivitis of other etiologies for antibacterial purposes.
Information on the method of administration, dosage, and duration of treatment: ofloxacin** 1–2 drops every 4–6 hours, ciprofloxacin** 1–2 drops every 4 hours, levofloxacin** 1–2 drops every 2 hours up to 8 times a day, moxifloxacin** 1 drop 3 times a day. The course of treatment may last 5–10 days [5, 85].
Information on the method of administration, dosage, and duration of treatment: netilmicin 1–2 drops 3 times a day, tobramycin** 1–2 drops every 4 hours. The course of treatment may last 5–10 days [17].
Information on the method of administration dosage, and duration of treatment: tetracycline** eye ointment, 0.5–1 cm 3–4 times a day. The course of treatment may last 5–7 days [17].
Information on the method of administration erythromycin eye ointment, dosage, and duration of treatment: 0.5–1 cm a day, in chlamydial conjunctivitis — up to 5–7 times a day. The course of treatment may last 5–10 days [17].
Information on the method of administration, dosage, and duration of treatment of chloramphenicol: 1 drop every 3–4 times a day. The course of treatment may last 5–10 days [3, 4, 17].
Information on the method of administration of colistimethate sodium + tetracycline + chloramphenicol** eye ointment, dosage, and duration of treatment: 1–1.5 cm 3–4 times a day. The course of treatment may last from 7–8 to 14 days [3, 4, 17].
It is recommended to prescribe topical S01AX antimicrobials — other antimicrobials (picloxydine; benzyldimethyl-myristoylamino-propylammonium) for adult patients with infectious conjunctivitis (bacterial, chlamydial) or for suspected/prophylactic prevention of secondary bacterial infection in conjunctivitis of other etiologies for antibacterial purposes [28].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: local antiseptic therapy is recommended as etiotropic therapy for the treatment of infectious conjunctivitis (bacterial, chlamydial) or for suspected/prophylactic prevention of secondary bacterial infection in conjunctivitis of other etiologies for antiseptic purposes.
Information on the method of administration, dosage, and duration of treatment of picloxydine: 1 drop 2 to 6 times/day for adults and 1 drop 6 times/day for children. The course of treatment may last 10 days [3, 16, 27].
Information on the method of administration dosage, and duration of treatment of benzyldimethyl-myristoylamino-propylammonium: instillation of 1–2 drops 4–6 times/day. The course of treatment may last 5–14 days [3, 16, 26, 27].
It is recommended to prescribe antiviral drugs (S01AD antiviral drugs) (interferon alfa-2b + diphenhydramine) to patients with infectious conjunctivitis (viral) for antiviral purposes [3, 28, 29, 30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: local antiviral therapy is recommended as etiotropic therapy for the treatment of infectious conjunctivitis (viral) for antiviral purposes.
Information on the route of administration, dosage, and duration of treatment with the medicinal product interferon alfa-2b + diphenhydramine: 1–2 drops 6–8 times/day. As the inflammatory process subsides, the number of instillations is reduced to 2–3 times/day. The course of treatment lasts until the symptoms of the disease disappear [3, 28, 29].
It is recommended to prescribe antiviral drugs (S03D other ophthalmological and otological agents) (aminobenzoic acid) to patients with infectious conjunctivitis (viral) for antiviral purposes [3, 28, 29, 30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: local antiviral therapy is recommended as etiotropic therapy for the treatment of infectious conjunctivitis (viral) for antiviral purposes.
Information on the route of administration, dosage, and duration of treatment with the medicinal product aminobenzoic acid: 1–2 drops 6–8 times/day. The course of treatment lasts until the symptoms of the disease disappear. After clinical recovery, continue instillations of 2 drops 3 times/day. The course of treatment is 7 days [31].
It is recommended to prescribe local immunostimulants (L03AX other immunostimulants) (sodium deoxyribonucleate) to patients with infectious conjunctivitis (viral) for immunostimulatory purposes [31, 32]
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: local immunostimulatory therapy is recommended as etiotropic therapy for the treatment of infectious conjunctivitis (viral) to enhance antiviral immunity.
Information on the route of administration, dosage, and duration of treatment with the medicinal product sodium deoxyribonucleate: 1–2 drops 2–3 times/day. The course of treatment is 14–45 days [31, 32].
It is recommended to prescribe antiallergic agents (S01GX other antiallergic agents) (olopatadine 0.1%; 0.2%; epinastine, according to the instructions, is used in children from 12 years of age; cromoglicic acid, according to the instructions, is used in children from 2 years of age [with caution], and from 4 years of age) to patients with non-infectious conjunctivitis (allergic) or in case of suspected allergic reaction in conjunctivitis of another etiology for antiallergic purposes [35;37].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comments: Local antiallergic therapy is etiotropic treatment in patients with non-infectious conjunctivitis (allergic) or in case of suspected allergic reaction in conjunctivitis of another etiology for antiallergic purposes.
Information on the route of administration of the medicinal product olopatadine 0.1%; 0.2%, its dosage, and duration of treatment: 1 drop 2 times/day at an 8-hour interval. The course of treatment is 14–45 days [36, 37].
Information on the route of administration, dosage, and duration of treatment with the medicinal product epinastine: 1 drop 2 times/day. The course of treatment lasts until the clinical symptoms of conjunctivitis disappear, for a maximum of 8 weeks [38].
Information on the route of administration, dosage, and duration of treatment with the medicinal product cromoglicic acid: 1 drop 4 times/day. The course of treatment lasts until the clinical symptoms of conjunctivitis disappear [35–38].
It is recommended to prescribe decongestants and antiallergic agents used in ophthalmology (S01GA Sympathomimetics used as decongestants) (diphenhydramine + naphazoline, according to the instructions, is used in children from 2 years of age) to patients with non-infectious conjunctivitis (allergic) or in case of suspected allergic reaction in conjunctivitis of another etiology for antiallergic purposes [39].
LoR CGoE 3Level of Recommendation C (Level of Evidence – 3)
Comments: Local antiallergic therapy is etiotropic treatment in patients with non-infectious conjunctivitis (allergic) or in case of suspected allergic reaction in conjunctivitis of another etiology for antiallergic purposes. Information on the route of administration, dosage, and duration of treatment with the medicinal product diphenhydramine + naphazoline: in case of allergic conjunctivitis symptoms, 1–2 drops every 6–8 hours until clinical symptoms disappear. If symptoms persist for more than 72 hours, the use of the drug should be discontinued [39].
It is recommended to prescribe topical glucocorticosteroids (S01BA Corticosteroids) (dexamethasone 0.1%, hydrocortisone** 0.5%, 1%, 2.5% eye ointment, fluorometholone 0.1% eye drops, according to the instructions, are used in children from 2 years of age) to patients with non-infectious conjunctivitis (allergic) or with a pronounced inflammatory reaction in the subacute period of infectious conjunctivitis for antiallergic and anti-inflammatory purposes [2, 31, 40, 41]
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Local antiallergic and anti-inflammatory therapy is etiotropic treatment in patients with non-infectious conjunctivitis (allergic) or in case of suspected allergic reaction in conjunctivitis of another etiology for antiallergic purposes, as well as in pronounced inflammatory reactions in conjunctivitis of other etiologies.
Information on the route of administration, dosage, and duration of treatment with the medicinal product dexamethasone 0.1%: 1 drop 3–5 times/day until clinical symptoms disappear. The course of treatment is no more than 3 weeks [2, 31, 40, 41]
Information on the route of administration, dosage, and duration of treatment with the medicinal product hydrocortisone** 0.5%, 1%, 2.5% eye ointment: 1 cm is administered into the conjunctival sac 2–3 times a day. The course of treatment is no more than 3 weeks [2, 31, 40, 41].
Information on the route of administration of the medicinal product fluorometholone 0.1%, its dosage, and duration of treatment: 1–2 drops 2–4 times a day until clinical symptoms disappear. The course of treatment is no more than 3 weeks [2, 31, 40, 41].
When using topical glucocorticosteroids, intraocular pressure must be monitored to prevent its elevation, and the condition of the anterior segment of the eye must be monitored to avoid the development of complications [2, 31, 40, 41].
It is recommended to prescribe non-steroidal anti-inflammatory drugs as eye drops (S01BC NSAIDs) (diclofenac** 0.1%, bromfenac 0.09%, contraindicated in patients under 18 years of age) to adult patients with non-infectious conjunctivitis for anti-inflammatory purposes [2, 31, 42–45].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: local NSAID therapy is recommended as symptomatic therapy for the treatment of non-infectious conjunctivitis with pronounced inflammatory manifestations.
Information on the route of administration, dosage, and duration of treatment with the medicinal product diclofenac** 0.1%: 1 drop 3–4 times/day. The course of treatment may last from 1 to 2 weeks [2, 31, 42–45].
Information on the route of administration, dosage, and duration of treatment with the medicinal product bromfenac 0.09%: instillations of 1 drop 1–2 times a day for 1 to 2 weeks [2, 31, 42–45]
It is recommended to prescribe S01CA corticosteroids and anti-infectives in combinations (dexamethasone 0.1% + tobramycin 0.3%, according to the instructions, is used in children over 2 years of age; dexamethasone 1 mg/ml + levofloxacin 5 mg/ml; tobramycin 3 mg/ml + fluorometholone 1 mg/ml), to patients with non-infectious conjunctivitis for anti-inflammatory and antibacterial purposes [2, 31, 46].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Instillations of glucocorticosteroid-antibiotic combinations are prescribed as symptomatic therapy for non-infectious conjunctivitis accompanied by a pronounced inflammatory process and the addition or risk of addition of bacterial flora.
Information on the route of administration of the medicinal product dexamethasone 0.1% + tobramycin 0.3%, its dosage, and duration of treatment: instillations of 1–2 drops every 4–6 hours; dexamethasone 0.1% + neomycin 3500 IU; dexamethasone 0.1% + levofloxacin 0.5%, dosage and duration of treatment: instillations of 1–2 drops every 2 hours up to 8 times a day, then 1–2 drops 4 times a day; fluorometholone 0.1% + tobramycin 0.3%, dosage and duration of treatment: instillations of 1–2 drops every 4–6 hours. The course of treatment is from 5 days, not exceeding 2–3 weeks.
It is recommended to prescribe moderate-potency corticosteroids in combination with antibiotics (D07CB) (dexamethasone 0.3 mg + gentamicin 5 mg, eye ointment) to patients with non-infectious conjunctivitis for anti-inflammatory and antibacterial purposes. Used only in adult patients [2, 31, 46].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Instillations of dexamethasone in combination with antibiotics are prescribed as symptomatic therapy for non-infectious conjunctivitis accompanied by a pronounced inflammatory process and/or the addition or risk of addition of bacterial flora.
Information on the route of administration, dosage, and duration of treatment with the medicinal product dexamethasone 0.3 mg + gentamicin 5 mg: eye ointment – 1 cm 2–3 times/day. The course of treatment is from 5 days, not exceeding 2–3 weeks [2, 31, 46].
When topical glucocorticosteroids are used, monitoring of intraocular pressure is required to prevent its elevation, along with monitoring the condition of the anterior segment of the eye to avoid complications [2,31,46].
It is recommended to prescribe tear-substitute therapy for patients with non-infectious conjunctivitis and/or clinical manifestations of dry eye syndrome in order to relieve its symptoms [8].
Level of Evidence CGrade of Recommendation 5Level of Recommendation C (Grade of Evidence – 5)
It is recommended to prescribe S01XA – other ophthalmological immunosuppressants (cyclosporine) for patients with dry eye syndrome for anti-inflammatory purposes when tear-substitute therapy is ineffective [2,31].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: Cyclosporine instillation is prescribed as etiotropic therapy for non-infectious conjunctivitis (dry eye syndrome) when tear-substitute therapy is ineffective [2,8,31].
Information on the method of administration, dose, and duration of cyclosporine: eye drops – instillation of 1 drop 1–2 times/day. The course of treatment is at least 2 months [2,8].
Comments: All drugs are prescribed taking into account age restrictions according to the instructions.
Surgical treatment
Not applicable.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not required.
5. Prevention and Dispensary Observation
It is recommended to observe sanitary and hygienic standards for the prevention of conjunctivitis [3].
Level of Evidence CGrade of Recommendation 5Level of Recommendation C (Grade of Evidence – 5)
It is recommended to carry out the prevention of infectious eye diseases in newborns during initial newborn care by applying tetracycline** 1% eye ointment (a 0.5 to 1 cm strip) into the lower conjunctival sac once [48-53].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (Level of Confidence of Data – 5)Information on the method of administration of tetracycline** 1% eye ointment: applied to the lower conjunctival sac once a day [47-52].
Comments: primary prevention of infectious eye diseases in newborns, primarily gonoblenorrhea, is carried out in accordance with the Clinical Guidelines «Basic neonatal care in the delivery room and postnatal ward» [47-52].
6. Organization of Medical Care
Routine medical care is provided in an outpatient setting.
Stages of Medical Care Delivery
1. outpatient clinic
Medical indications for hospitalization in a medical organization
Not required.
Criteria for discharging the patient from a medical organization: not required.
7. Additional Information
The prognosis of conjunctivitis is favorable and largely determined by the etiopathogenetic form of the disease. Predictors of a good functional prognosis include a mild course of the inflammatory process in the eye, as well as the timely administration of local therapy.
Predictors of a poor functional prognosis include: severe course and development of conjunctivitis complications, resistance to ongoing therapy, and a prolonged course of the disease.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1. | Visometry was performed | Yes/No |
2. | Ocular biomicroscopy performed | Yes/No |
4. | Tonometry performed | Yes/No |
5. | Conservative treatment was prescribed | Yes/No |
6. | Clinical recovery and/or prolonged remission was achieved | Yes/No |
References
Show references
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Appendix A1. Working Group Composition
Arestova N.N. Doctor of Medical Sciences, Leading Researcher, Department of Pediatric Eye Pathology, National Medical Research Center for Eye Diseases named after Helmholtz of the Ministry of Health of the Russian Federation, member of the Association of Ophthalmologists, member of the Society of Ophthalmologists of Russia.
Brzheskiy V.V. Doctor of Medical Sciences, Professor, Head of the Department of Ophthalmology, Saint Petersburg State Pediatric Medical University, member of the Association of Ophthalmologists, member of the Society of Ophthalmologists of Russia.
Grishina E.E. Doctor of Medical Sciences, Professor, Professor of the Department of Ophthalmology and Optometry, Faculty of Advanced Training for Physicians, Moscow Regional Research Clinical Institute named after M.F. Vladimirsky, member of the Association of Ophthalmologists, member of the Society of Ophthalmologists of Russia.
Drozdova E.A., MD, PhD, Associate Professor, Professor at the Department of Eye Diseases, South Ural State Medical University of the Ministry of Health of Russia, Member of the Association of Ophthalmologists, Member of the Russian Ophthalmological Society.
Kasparova E.A. Candidate of Medical Sciences, Leading Researcher, Department of Pathology of Optical Media of the Eye, National Medical Research Center of Eye Diseases, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Lebedev O.I. Doctor of Medical Sciences, Professor, Head of the Department of Ophthalmology, Omsk State Medical Academy, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Maichuk D.Yu. Doctor of Medical Sciences, Head of the Department of Therapeutic Ophthalmology, S.N. Fyodorov Eye Microsurgery Federal State Institution
Markova E.Yu. Doctor of Medical Sciences, Head of the Department of Eye Microsurgery and Functional Rehabilitation in Children, S.N. Fyodorov Eye Microsurgery Federal State Institution, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Obrubov A.S. Candidate of Medical Sciences, Associate Professor of the Department of Ophthalmology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia; ophthalmologist at the inpatient department of the Moscow City Ophthalmological Center, Botkin City Clinical Hospital, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Panova I.E., MD, PhD, Professor, Deputy Director for Science, St. Petersburg Branch of the S.N. Fyodorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of the Russian Federation, Member of the Association of Ophthalmologists, Member of the Russian Ophthalmological Society.
Polovinkina G.V. Ophthalmologist, Ophthalmological Department, Diagnostic Center No. 7; expert in medical care quality control for patients of Department No. 1 (Pathology of the Anterior Segment of the Eye), member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Riks I.A. Candidate of Medical Sciences, Head of the Ophthalmology Department, "Nashe Zdorovie" Multidisciplinary Clinic, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Saidasheva E.I. Doctor of Medical Sciences, Professor of the Department of Ophthalmology, I.I. Mechnikov North-Western State Medical University of the Ministry of Health of Russia, Chief Pediatric Ophthalmologist of the Ministry of Health of Russia in the North-Western Federal District, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Safonova T.N. Candidate of Medical Sciences, Leading Researcher, M.M. Krasnov Research Institute of Eye Diseases, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Senchenko N.Ya. Candidate of Medical Sciences, "Honored Doctor of the Russian Federation", Chief Medical Officer of Dr. Belikova's Eye Clinics, Moscow, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Slonimsky A.Yu. Doctor of Medical Sciences, Professor, Moscow Eye Clinic, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Subbotina I.N. Doctor of Medical Sciences, Professor, Academician E.A. Vagner Perm State Medical University, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Trufanov S.V. Doctor of Medical Sciences, Deputy Director for Science, "Nashe Zdorovie" Multidisciplinary Clinic, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Chernakova G.M. Candidate of Medical Sciences, Associate Professor, Head of the Consultative Department, Moscow City Ophthalmological Center, Botkin City Clinical Hospital, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Chekhova T.A. Candidate of Medical Sciences, Head of the Therapeutic Department, Novosibirsk Branch of the S.N. Fyodorov Eye Microsurgery Federal State Institution, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Yani E.V. Candidate of Medical Sciences, Head of the Department of Infectious and Allergic Eye Diseases, National Medical Research Center of Eye Diseases of the Ministry of Health of the Russian Federation, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Yanchenko S.V. Doctor of Medical Sciences, Associate Professor, Professor of the Department of Ophthalmology, Bashkir State Medical Institute, highest-category physician, member of the Association of Ophthalmologists, member of the Ophthalmologists Society of Russia.
Conflict of interest: none
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Ophthalmologists;
General practitioners (family physicians)
Methods used for evidence collection/selection: searching electronic databases, analysis of current scientific developments on the problem of conjunctivitis in Russia and abroad; generalization of practical experience of Russian and foreign specialists; library resources. Description of methods used for evidence collection/selection: the evidence base for the guidelines includes publications included in the Cochrane Library, EMBASE and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on this topic. The search depth was 10 years. Methods used to assess the quality and strength of evidence: expert consensus, assessment of significance in accordance with the rating scheme.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic review of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials, using meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | There is only a justification of the mechanism of action or expert opinion |
Table 2. Scale for grading levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials using meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading the grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of evidence of proper quality; all considered efficacy criteria [outcomes] are unimportant, all studies have low methodological quality, and their conclusions regarding outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Current package leaflets for the drugs mentioned in these clinical guidelines can be found on the website http://grls.rosminzdrav.ru
International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). World Health Organization.
Nomenclature of Medical Services. Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services."
Federal Law No. 323-FZ "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" dated November 21, 2011.
Procedure for Providing Medical Care to the Adult Population for Diseases of the Eye, its Adnexa, and Orbit. Order of the Ministry of Health of the Russian Federation No. 902n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Adult Population for Diseases of the Eye, its Adnexa, and Orbit."
List of Vital and Essential Drugs for Medical Use for 2020. Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019 (as amended on April 26, 2020), "On Approval of the List of Vital and Essential Drugs for 2020, as well as Lists of Drugs for Medical Use and the Minimum Assortment of Drugs Required for the Provision of Medical Care."
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Conjunctivitis – inflammation of the mucous membrane of the eye – if not diagnosed and treated in a timely manner, can lead to corneal involvement and decreased visual acuity.
Conjunctivitis is a polymorphic group of diseases caused by bacteria, viruses, allergic agents, and other non-infectious processes.
A patient with diagnosed infectious (viral) conjunctivitis is a source of infection, poses a danger to others, and requires isolation.
The patient must be informed about the possible symptoms of conjunctivitis and its complications, and the need to seek urgent medical attention from an ophthalmologist if they appear. Urgent consultation with an ophthalmologist is necessary if any of the following symptoms occur: photophobia, pain, decreased and/or blurred vision, changes in iris color, pupil size, and shape.
Strict adherence to all prescriptions of the ophthalmologist and related specialists (rheumatologist, dermatologist, general practitioner, pediatrician, urologist, gynecologist, etc.) is required.
The patient must be aware of the potential side effects of therapy and the need to seek immediate medical attention from an ophthalmologist (or related specialists) if they develop.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Rating scales, questionnaires, and other patient status assessment tools are not used.