Summary
We welcomed the update to the existing ‘All Wales Common Ailments formulary’ published in February 2018, as the advice and recommendations align with our CMGs on conjunctivitis (bacterial) and dry eye. We have made suggestions to aid differential diagnosis and make it clear that wherever possible the patient should be referred to an optometrist for an eye examination in the first instance as both these conditions may be difficult to distinguish and may mimic more serious eye conditions or reveal underlying health conditions.
Is there anything you would like to see added to the All Wales Common Ailments Service formulary document?
For managing conjunctivitis (or any eye condition), patients should be referred in the first instance to attend for a free Eye Health Examination Wales (EHEW) with an accredited optometrist. They have the necessary training and equipment to differentially diagnose and offer advice and treatment – cases of viral and bacterial conjunctivitis are difficult to distinguish and inappropriate prescribing of topical antibiotics not only impacts resources/costs but contributes toward antibiotic resistance; while allergic conjunctivitis require different treatment paradigm (avoidance strategies; medication - antihistamines, mast cells stabilisers or combination drugs). We would recommend the following addition under section 7.1:
“When the condition of conjunctivitis is suspected, the person can also be referred to an Eye Health Examination Wales (EHEW) accredited optometrist to have a free eye health examination. Referral is recommended because symptoms are not specific and accurate differential diagnosis is important for subsequent treatment decisions.”
Differentiation of conjunctivitis (bacterial versus viral) would also include consideration of predisposing factors such as recent history of upper respiratory tract infection. Bacterial conjunctivitis typically affects both eyes, but history often reveals development in one eye initially, before affecting the fellow eye 1-2 days later. This information may aid in differential diagnosis under section 7.1.
The following text should also be included under section 7.3 as the following symptoms may mimic conjunctivitis:
“Refer immediately for same day assessment to eye casualty or A&E if acute glaucoma, keratitis/iritis or corneal ulcer is suspected. Symptoms include:
- moderate-to-severe eye pain and/or photophobia
- marked redness in one eye
- reduced visual acuity”
Dry eye symptoms are typically bilateral (but may be asymmetrical) so this should be added under section 10.1 as an aid to differential diagnosis.
We would also recommend adding under 10.6 (Advice for Patients) that where symptoms do not improve/get worse despite advice and treatment, patient should be referred to their optometrist in the first instance to access EHEW, not just their GP. There may be another ocular cause for the symptoms or underlying health conditions that requires specialist assessment; or a subtype of dry eye that would benefit from prescription medication (topical anti-inflammatories such as steroids or NSAIDs) or more invasive treatment such as punctum plugs.