EYE ADVICE: Professional Papers

Paper 2

Common Chronic (Infective) Conjunctivitis and Nasal Rinsing

by Kon Zagoritis BscOptom FVCO

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 other problems.

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 in general.

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.

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