• Oct 2014
    AAO Cornea/External Disease PPP Panel, Hoskins Center for Quality Eye Care
    Cornea/External Disease


    These are summary benchmarks for the Academy’s Preferred Practice Patterns®  (PPP) guidelines. The Preferred Practice Patterns series of guidelines has been written on the basis of three principles.

    • Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
    • Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
    • Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

    Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. They physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

    The Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

    For each major disease condition, recommendations for the process of care, including the history, physical exam and ancillary tests, are summarized, along with major recommendations for the care management, follow-up, and education of the patient. For each PPP, a detailed literature search of PubMed and the Cochrane Library for articles in the English language is conducted. The results are reviewed by an expert panel and used to prepare the recommendations, which they rated in two ways.

    The panel first rated each recommendation according to its importance to the care process. This “importance to the care process” rating represents care that the panel thought would improve the quality of the patient’s care in a meaningful way. The ratings of importance are divided into three levels.

    • Level A, defined as most important
    • Level B, defined as moderately important
    • Level C, defined as relevant but not critical

    The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The “ratings of strength of evidence” also are divided into three levels.

    • Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
    • Level II includes evidence obtained from the following:
      • Well-designed controlled trials without randomization
      • Well-designed cohort or case-control analytic studies, preferably from more than one center
      • Multiple-time series with or without the intervention
    • Level III includes evidence obtained from one of the following:
      • Descriptive studies
      • Case reports
      • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review) 

    PPPs are intended to serve as guides in patient care, with greatest emphasis on technical aspects. In applying this knowledge, it is essential to recognize that true medical excellence is achieved only when skills are applied in a such a manner that the patients’ needs are the foremost consideration. The AAO is available to assist members in resolving ethical dilemmas that arise in the course of practice. (AAO Code of Ethics)

    Initial Evaluation

    Initial Exam History

    • Ocular symptoms and signs (e.g., itching, discharge, irritation, pain, photophobia, blurred vision)
    • Duration of symptoms and time course
    • Exacerbating factors
    • Unilateral or bilateral presentation
    • Character of discharge
    • Recent exposure to an infected individual
    • Trauma (mechanical, chemical, ultraviolet)
    • Mucus fishing
    • Contact lens wear (lens type, hygiene and use regimen)
    • Symptoms and signs potentially related to systemic diseases (e.g., genitourinary discharge, dysuria, dysphagia, upper respiratory infection, skin and mucosal lesions)
    • Allergy, asthma, eczema
    • Use of topical and systemic medications
    • Ocular history (e.g., previous episodes of conjunctivitis and previous ophthalmic surgery)
    • Compromised immune status
    • Current and prior systemic diseases
    • Social history (e.g., smoking, occupation and hobbies, travel and sexual activity)

    Initial Physical Exam

    • Visual acuity
    • External examination
      • Regional lymphadenopathy (particularly preauricular)
      • Skin(signs of rosacea, eczema, seborrhea)
      • Abnormalities of the eyelids and adnexae(swelling, discoloration, malposition, laxity, ulceration, nodules, ecchymosis, neoplasia)
      • Conjunctiva(pattern of injection, subconjunctival hemorrhage, chemosis, cicatricial change, symblepharon, masses, discharge)
    • Slit-lamp biomicroscopy
      • Eyelid margins(inflammation, ulceration, discharge, nodules or vesicles, blood-tinged debris, keratinization)
      • Eyelashes(loss of lashes, crusting, scurf, nits, lice, trichiasis)
      • Lacrimal puncta and canaliculi(pouting, discharge)
      • Tarsal and forniceal conjunctiva
      • Bulbar conjunctiva/limbus(follicles, edema, nodules, chemosis, laxity, papillae, ulceration, scarring, phlyctenules, hemorrhages, foreign material, keratinization)
      • Cornea
      • Anterior chamber/iris(inflammation reaction, synechiae, transillumination defects)
      • Dye-staining pattern (conjunctiva and cornea)

    Diagnostic Tests

    • Cultures, smears for cytology and special stains are indicated in cases of suspected infectious neonatal conjunctivitis.
    • Smears for cytology and special stains are recommended in cases of suspected gonococcal conjunctivitis.
    • Confirm diagnosis of adult and neonate chlamydial conjunctivitis with immunodiagnostic test and/or culture.
    • Biopsy the bulbur conjunctiva and take a sample from an uninvolved area adjacent to the limbus in an eye with active inflammation when ocular mucous membrane pemphigoid is suspected.
    • A full-thickness lid biopsy is indicated in cases of suspected sebaceous carcinoma.
    • Confocal microscopy may be helpful to evaluate some forms of conjunctivitis (e.g., atopic, SLK).
    • Thyroid function tests are indicated for patients with SLK who do not have known thyroid disease.

    Management Recommendations

    Care Management

    • Avoid indiscriminate use of topical antibiotics or corticosteroids because antibiotics can induce toxicity and corticosteroids can potentially prolong adenoviral infections and worsen herpes simplex virus infections
    • Treat mild allergic conjunctivitis with an over-the-counter antihistamine/vasoconstrictor agent or second-generation topical histamine H1-receptor antagonists. If the condition is frequently recurrent or persistent, use mast-cell stabilizers.
    • For contact lens-related keratoconjunctivitis, discontinue contact lens wear for 2 or more weeks
    • If corticosteroids are indicated, prescribe the lowest potency and frequency based on patient response and tolerance
    • If corticosteroids are used, perform baseline and periodic measurement of intraocular pressure and pupillary dilation
    • Use systemic antibiotic treatment for conjunctivitis due to Neisseria gonorrhoeae or Chlamydia trachomatis
    • Treat sexual partners to minimize recurrence and spread of disease when conjunctivitis is associated with sexually transmitted diseases and refer patients and their sexual partners to an appropriate medical specialist
    • Refer patients with manifestation of a systemic disease to an appropriate medical specialist

    Follow-Up Evaluation

    • Follow-up visits should include
      • Interval history
      • Visual acuity
      • Slit-lamp biomicroscopy
    • If corticosteroids are used, perform periodic measurement of intraocular pressure and pupillary dilation to evaluate for cataract and glaucoma

    Patient Education

    • Counsel patients with contagious varieties to minimize or prevent spread of diseases in the community
    • Inform patients who may require repeat short-term therapy with topical corticosteroid of potential complications of corticosteroid use
    • Advise patients with allergic conjunctivitis that frequent clothes washing and bathing/showering before bedtime may be helpful