Common Chronic (Infective) Conjunctivitis and Nasal Rinsing
by Kon Zagoritis
Many patients suffer form chronic eye infection or apparent inflammation
which cannot be attributed directly to pollen, or any other obvious
cause. The symptoms range from a fairly constant low grade irritation
without any overt signs of inflammation to semi-acute episodes of
foreign-body sensation, redness, watering, mild itch etc.
Not infrequently, the patient has a history of a recent cold or
has nasal symptoms. This is often associated with mucous secretion
in the mornings at the inner canthi ("sleep"). The patient
usually rubs the eye and as this usually exacerbates the condition,
he/she may make an appointment to be seen. Often the complaint is
made in passing to the health practitioner whilst attending for
Sometimes the symptoms may be related to causes such as blepharitis,
lagophthalmos etc. or a recent adenoviral infection due to working
in the garden etc. However, most often there are no obvious external
eye factors causing a direct infection or inflammation to the eye.
Even in cases of people working in a dusty environment, the inflammation
is often transient and resolves soon after the direct irritant ceases
to affect the eye.
The most common slit-lamp finding is a low-grade follicular
conjunctivitis and possibly fine papillary conjunctivitis.
When the papillae are so fine as to appear like a granular redness
over the entire superior palpebral conjunctiva, I have found this
most likely indicates spread of toxins from the sinuses.
Upon questioning the patient specifically regarding nasal symptoms,
there is often one of the following findings:
1. Generalised nasal congestion.
2. Alternating blockage of one nostril or the other.
3. A runny nose with or without mild mucopurulent exudate.
4. Post-nasal drip.
5. Simply a feeling that one needs to blow the nose to clear it
(especially in the mornings).
Sometimes there can be itching of the nose or bleeding, or the
secondary effects of nasal infection of the throat or ears may cause
the only symptoms. Patients who suffer concurrently from sinusitis
may also report the usual symptoms of pain in varying sites around
the orbit and may complain that the eyes feel as if they are swollen,
especially in the morning.
I have found that it is patients who have these (often subclinical)
nasal problems who also have "sensitive"
eyes that usually become more easily irritated by additional external
factors such as air pollution etc. This increased sensitivity would
be due to chronic infective conjunctivitis, (CIC) secondary
to infective agents spreading from the nasal passages. I have found
that this is by far the most common cause of CIC and eye irritation
It would be logical to then look at preventing the underlying nasal
problems if we are to alleviate chronic eye irritation. By doing
so, the added benefits are as extensive as nasal-related problems
can be. These most commonly include sinusitis,
ear infections and throat infections.
Sinusitis in particular has the potential to cause many serious
diseases by spread of infection e.g. orbital cellulitis, cavernous
sinus thrombosis, meningitis etc.
CIC due to nasal infection could pre-dispose to hypersensitivity
reactions triggered by bacterial toxins. These include
episcleritis, phlyctencular disease and marginal ulcers. CIC can
also pre-dispose individuals to blepharitis and
infected cysts involving the lids, meibomianitis,
chronic dacryocystitis etc.
The pre-disposing factors to nasal infection are
many and varied. This is obviously not my area of work. Very briefly
they can range from displaced septums, to adenoids, colds, allergies,
air-conditioning, and reactions to a whole range of air pollutants
such as cigarette smoke, household dust (from carpet, especially
when ducted heating is used without air filters), vehicle emission
pollution, dust or fumes at work etc.
The best solution would be to eliminate or avoid the cause
of the nasal inflammation if it can be detected. For example,
ducted heating units can be fitted with filters which need to be
regularly cleaned. A humidifier can be used to prevent drying of
the mucous membranes which is likely to occur in the presence of
ducted heating and which pre-disposes to nasal infection.
It should be noted that air pollution can also affect the
eyes directly, apart from indirect irritation
through nasal infection. However the latter appears to be more persistent
and can affect the eyes overnight when they are closed. "Sleep"
in the mornings appears to be brought on in this way. Thus this
indirect source of infection is more apt to produce chronic eye
irritation than the direct effect of irritants on the eye. Tears
most often immediately rinse these out. Modifying our environment
to reduce air pollution would have benefits in reducing both direct
and indirect eye irritation and should be attempted if at all possible.
However, there are many things one cannot change, such as outdoor
air pollution and even peoples' smoking habits. The next best option
is to find a way of removing pollutants, including infective
agents, from the nasal passages. As we are dealing with a mucous
membrane, rinsing with normal saline is probably
the best way. Certainly most of the patients to whom I recommend
nasal rinsing with normal saline, find it very useful.
I usually hand out an information sheet to patients
on nasal rinsing. This explains matters such as the benefits
of nasal rinsing, the effect of not using the right salt concentration,
the appropriate time that it should be carried out etc. I also try
to get contact lens wearers who suffer from chronic
infective conjunctivitis to practice this procedure.
I was first made aware of the ocular benefits of nasal rinsing
by patients who were advised of it by a Melbourne ophthalmologist,
although I am sure that nasal hygiene would have been practiced
for thousands of years. I have since come across many people who
have grown up with the habit of rinsing their nostrils with tap
water. To these people, this has been just another hygienic procedure,
just as we brush our teeth regularly.
I recommend nasal rinsing regularly to my patients if there are
any nasal symptoms. Health practitioners should try nasal rinsing
themselves and then recommend it to their family and patients, especially
where there is eye irritation that does not seem to resolve with
eye drops alone. With proper instruction, it is quite a safe procedure
that almost everybody can routinely practice. Infants and young
children can have their nostrils irrigated with saline using a dropper.
This is usually followed by sneezing which helps to empty out the
saline. Patients have reported positive feedback with this.
Some patients are put off by the idea of nasal rinsing, probably
because they see the nose as harboring "germs". However,
this is precisely the reason why nasal rinsing should be performed,
and preferably on a regular basis. Those people who can't find the
time to prepare the saline as above may wish to use ready-made normal
saline. Alternatively they could even use tap water to make the
saline, especially if it is filtered and they can simply rinse out
the nostrils alone. This would be preferable to no rinsing at all.
Boiling the water is recommended if deeper parts of the nasal passages
are to be rinsed.
The instructions that I give to patients are in Appendix 1 under
"GENERAL EYE ADVICE". One must emphasise to patients that
it is vitally important to follow the instructions carefully
in order to gain the most benefit and to prevent any unwanted effects.
Patients should be particularly advised to take the necessary measures
to ensure that saline does not remain in the sinuses and nasal
passages. One such measure is to stoop several times after
rinsing (over the following couple of hours) to empty any residual
saline from the nose. Another is to tilt the head back or lie in
the supine position for a short time to empty residual saline into
the pharynx. The saline can then be dislodged from the mouth. These
measures are especially important if one chooses to clean deep in
the nasal passages by emitting the saline from the mouth. Infection
may set up if saline is allowed to accumulate in the sinuses. As
it may take some time for the saline to drain out after rinsing,
patients should ensure that they do not
retire to bed immediately after nasal rinsing. This procedure
should be performed atleast 2-3 hours before sleeping as excess
saline may drip back into the throat and trachea.
Finally, it should be stressed that nasal rinsing should be seen
more as a way to maintain healthier nasal passages and
not as a quick method of overcoming acute nasal or eye infections.
In these cases of course, standard medical treatment should first
be instituted, followed by nasal rinsing for maintenance.
Home of Professional Section