• Pharyngoconjunctival Fever (PCF)
• Epidemic Keratoconjunctivitis (EKC)
• Stages of Keratitis
• Management

	URL: http://www.opt.indiana.edu/ce/virker/part1.htm Revised: November 28, 2005
	IU Optometry home page: http://www.opt.indiana.edu/ Comments (content): Dr. Vic Malinovsky at malinovs@indiana.edu or Dr. Jane Ann Grogg at jgrogg@indiana.edu Comments: Web Administrator Page design and coding: Terri Greene Copyright © 2005, The Trustees of Indiana University

Pharyngoconjunctival Fever Pharyngoconjunctival fever (PCF) can be found in any age group, but is most common in children. Transmission modalities such as schools, swimming pools, and hot tubs have been implicated in the development of PCF epidemics. Fecal contamination of pools is often found to spread the infection. Pool chlorination does not always inhibit the virus; thus, PCF has been called "swimming pool conjunctivitis. Pharyngoconjunctival fever is usually caused by adenoviral types 3, 4 and 7. Clinical presentation of PCF Pharyngitis Follicular conjunctivitis; mild to moderate hyperemia Fever Headaches Bilateral or unilateral Rapid evolution of conjunctivitis with mild epithelial keratitis seen in about 30%; rarely progresses to anterior stromal infiltrates similar to epidemic kertatoconjunctivitis Only conjunctivitis with a distinct, predictable systemic association that precedes eye infection by 1 to 2 weeks Lymphadenopathy [Return to top]
Epidemic Keratoconjunctivitis Epidemic keratoconjunctivitis (EKC) is a hyperacute infection more common in adults than children. There is no seasonal pattern. It is a flu-like illness (pharyngitis, fever, malaise, nausea, vomiting, diarrhea) with rhinitis occurring in 50% of patients. Some say there are no systemic symptoms. Severe keratitis occurs in about 80% of cases. Presentation can be unilateral or bilateral. A typical evolution of epithelial and subepithelial keratitis occurs in 80%. EKC can be seen as epidemic (find a common source). It is usually caused by adenoviral types 8 & 19. Clinical presentation of EKC Severity of ocular disease cannot be predicted during early course; typical EKC usually evident by Days 4 to 6 Unilateral to bilateral follicular conjunctiva in 3 to 7 days (the first eye involved is worse) . . . earliest sign, more evident in inferior fornix Abrupt onset of photophobia, tearing, pain, and severe red eye Watery discharge Conjunctival hyperemia with significant chemosis; may involve the caruncle Edema and pain of the upper lid with slight ptosis; mistaken for periorbital cellulitis Hyperemia and chemosis may mask follicular formation; also a papillary response Subconjunctival and palpebral hemorrhages; range from minor petechial to diffuse subconjunctival hemorrhages Membrane and pseudomembrane formation occurs commonly; potential for conjunctival scarring Tender and swollen preauricular or submandibular adenopathy within the first few days Acute conjunctivitis (red eye) resolves by second to third week Corneal involvement Bilateral involvement, with second eye having significantly less symptoms and signs Early, nonspecific punctate staining Later a specific, orderly, symmetrical, and progressive epithelial and subepithelial keratitis Late stages--subepithelial infiltrates presumed to be antigen-antibody reaction	Acute EKC. Acute EKC with significant conjunctival chemosis. EKC: follicular conjunctivitis. EKC: pseudomembrane conjunctivitis. EKC: subepithelial infiltrates.
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Stages of Keratitis Stage 0:    Mild punctate epithelial erosions developing within the first 2 to 4 days; stain poorly with rose bengal and fluorescein. Stage 1:    Fine, diffuse punctate epithelial keratitis (PEK) persists for 2 to 5 days; either resolving or progressing to Stage 2. Stage 2:    Fine and coarse punctate epithelial keratitis (stains brilliantly with rose bengal; involves the deeper subepithelium); persists for 2 to 5 days (Day 4 through 8). Stage 3:    Coarse, granular infiltrates within deep epithelium; appearance of faint subepithelial infiltrates (scattered, fine and coarse punctate epithelial keratitis may remain); persists for 2 to 5 days (Days 6 through 12). Stage 4:    Classic subepithelial infiltrates: Punctate epithelial keratitis resolved; no staining; can occur as early as 2 weeks, may persist for weeks to months to even several years; loss of symmetry of distribution. Stage 5:    Punctate epithelial granularity (superficial and deep epithelium) developing late--weeks to months after onset occurs; continuous and separate from subepithelial opacities. May cause permanent scars. [Return to top]
Management of EKC Primarily supportive. Prevent transmission--highly contagious! Office Management Precautions Avoid instrument contact Set aside separate area or room for examination of suspected cases? Hand washing before and after each examination with use of paper towels Use gloves Adequate instrument cleaning and sterilization (immersion in 1% to 2% solution of sodium hypochlorite [household bleach] or 3% hydrogen peroxide) Infrequent follow-up visits of established cases? Patient instructions Inform patient of expected course of infection; may get worse before resolving in 2-4 weeks. Restriction of activity of eye care professionals and others with direct hand-to-patient contact for 2 weeks. Patient instructions regarding viral shedding for a period up to 12 days from onset. Warn patient of the contagious nature: Need to wash hands frequently, to use towels and soap separate from others, and to avoid direct contact with others. May be necessary to stay at home from work or school for up to 2 weeks or until there is no discharge. Ocular Management No topical ophthalmic anti-adenoviral drugs approved. Cold compresses, topical decongestants such as Naphcon-A qid, artifical tears q3-4h, cosmetic sun Rx, and topical NSAIDs plus cycloplegic drops. Remove symptomatic membranes with wet cotton swab or forceps; prescribe antibiotic/steroid ointment (e.g., Tobradex). Reserve topical steroids or antibiotic/steroids for severe conjunctivitis and keratitis only if Herpes simplex conjunctivitis has been ruled out (controversial?). Use if severe conjunctival membrane or . . . Macro ulceration Severe keratitis Severe discomfort or prolonged symptoms If patient is unable to work Late judicious use of topical corticosteroids only for symptomatic complications of subepithelial infiltrates (SEI). Topical steroids reduce the quantity and density of SEI--exacerbation of infiltrates upon discontinuation. Topical Steroids Soft steroids: Alrex, Lotemax qid x 1-3 weeks and taper as soon as symptoms improve; rarely need Pred Forte. Antibiotic steroid combination: Tobradex. Topical NSAIDs Topical Acular or Voltaren qid. May be a safer alternative than potent topical steroids (1% prednisolone acetate) to control the symptoms during the acute stage. Topical Ophthalmic Antiviral Agents No clinical proven benefit of idoxuridine, vidarabine, or viroptic Betadine (povidone-iodine) 5% Sterile Ophthalmic Prep Solution Off-label use for acute moderate to advanced EKC. Instill 1 gt of 0.5% proparacaine (Betadine stings), then instill 2-3 gtt of Betadine. Roll eyes around for 60-90 seconds, then swab lid margin with cotton swab moistened with Betadine. Irrigate eye thoroughly with sterile saline. May treat only the more involved eye. Then prescribe Lotemax or generic FML qid for 5-7 days, plus artificial tears and cold compresses. [Return to top]

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