July 19, 2023
By Lilian White, M.D.
The patient’s red eyes were the first thing I noticed. They were too red. “Yet another case of pink eye!” the nurse quipped before I knocked on the clinic door. It had been a rough season for conjunctivitis in our little urgent care, but these eyes were different — full of tears and pain. My clinical ears perked up to listen to her story.
Alejandra was 7 years old with beautiful, dark brown hair and even darker eyes. Her mother, who only spoke Spanish, and the patient’s slightly older brother accompanied her. Alejandra spoke some English, but she deferred most of the history to her mother due to pain and her age. Our conversation, which involved using a translator on the phone, felt repetitive and circuitous until finally a story began to form.
She had been an otherwise healthy child. About a week earlier, she had developed rhinorrhea and a mildly productive cough, which her mother attributed to cold. A few days into her symptoms, she developed some redness and a little bit of drainage from her eyes. Being concerned for a bacterial infection, they presented to the emergency room for care. After waiting for several hours there, she was examined and given ciprofloxacin drops for a diagnosis of bacterial conjunctivitis. Shortly after, her eyes became redder and painful, and she developed photophobia. She denied any fevers, periorbital edema or vision changes.
During my own exam of her eyes, I couldn’t detect drainage, but I winced with her as her eyes profusely watered against the light I shone to check her pupils. Her conjunctiva was injected diffusely. No hand or feet swelling. No rash, no mucositis. Her vision was 20/20.
I was concerned for her. Being only a few months into working at the urgent care during my third year of residency, I excused myself from the room to turn where I usually do in uncertain clinical situations — a more experienced physician and an American Family Physician article. Given the prevalence of conjunctivitis, I had reviewed the condition multiple times in the prior weeks, but somehow seeing the algorithm and evidence in front of me had a way of grounding my thoughts.
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I traced Alejandra’s story and the exam again in my mind: Her mild conjunctivitis in the setting of upper respiratory symptoms was consistent with what was likely viral conjunctivitis. Her photophobia and pain now were likely secondary to keratitis from a reaction from the eye drops given the timing. I ran my thoughts by my mentor to be on the safe side. I ultimately recommended she stop the drops and continue supportive care until an urgent ophthalmology appointment the following day.
That night, I reflected on this sweet girl and how easily it could have been for me as the clinician in the emergency room, writing the prescription for ciprofloxacin drops.
And while antibiotic drops for infectious conjunctivitis in children may still have benefits, being able to ground my assessment of viral conjunctivitis and feel comfortable and confident recommending she stop antibiotics by referencing the AFP article and my mentor was incredibly reassuring.
I felt a sense of gratitude for algorithms and evidence-based practice — in the context of clinical judgment — to best care for patients. It’s not possible to know it all. I have a responsibility as a physician to be knowledgeable, but when I don’t feel confident in my judgment, I must have the humility to admit it and seek out references and others who do. I’ve relied heavily on AFP articles primarily as a point-of-care reference. The Strength of Recommendations Tables guide how strongly (or not) I emphasize certain recommendations, and I’ve often found myself sighing in relief when I find just the right algorithm to guide my practice. The uniquely family medicine perspective of the journal also aligns with the patient-centered approach to care I strive for — which makes AFP stand out among references for me.
A few days after our visit, I pulled up Alejandra’s chart. The ophthalmologist determined she had a case of bilateral global scleritis from the ciprofloxacin drops. Alejandra quickly improved with steroid drops and without any impact on her vision. I breathed a sigh of relief. This is the power of evidence-based medicine.
Lilian White, M.D., is a recent graduate of the family medicine residency program at Cleveland Clinic and a former resident representative of the American Family Physician Editorial Board. She plans to start a direct primary care practice, Empowered Health, this fall in Cleveland.