conjyctivitis....................

1. ACUTE CONJUNCTIVITIS
DR.N.DEEPTHI

3. Inflammation of conjunctiva ,
characterized by cellular infiltration,
vascular dilation,
exudation

4. OCULAR DEFENSE MECHANISMS
• Bony orbital rim and eyelids
• Tears
– remove debris and microbes
– prevent desiccation of the corneal epithelium
• Tear film
Lactoferrin ,Beta-lysin,Lysozyme ,Secretory IgA
• Squamous epithelium of the conjunctiva and cornea
– Mechanical barrier
• Corneal epithelial cells and keratocytes
– Secrete cytokines
• Langerhans cells
– Activate T-cells when foreign antigens are processed
• Conjunctiva-associated lymphoid tissue (CALT)

5. • Normal bacterial flora
– At birth
• Staphylococcus epidermidis,
• Staphylococcus aureus,
• Streptococci
• Escherichia coli
– With increasing age
• More Gram-negative organisms are isolated
• S. epidermidis,S. aureus, and Corynebacterium species
remain predominant

6. CLASSIFICATION
• BASED ON ONSET
acute
subacute
chronic
• TYPE OF EXUDATE
serous(viral,allergic,toxic)
catarrhal(allergy)
purulent
mucopurulent
membranous
pseudomembranous

7. • BASED ON CONJ RESPONSE
follicular
papillary
granulomatous

8. ETIOLOGY
•INFECTIOUS
Bacterial : S.aureus,H.influenza,N.gonorrhoeae,Strep pyogenes
viral : HSV, adeno, molloscum
Chlamydial
Fungal
parasitic
•NON-INFECTIOUS
allergic
endogenous/autoimmune
dry eye
toxic
idiopathic

9. INFECTIOUS
• ACUTE – <4 weeks
• b/l
• Bacterial
• Viral
• chlamydial

10. BACTERIAL CONJUNCTIVITIS
• ACUTE PURULENT & MUCOPURULENT
Contagious
clinical presentation - virulence "and "pathogenicity of the organism
- the host's immune response
m/c- S.aureus
Haemophilus aegyptius and N.gonorrhoeae- widespread epidemics

12. Clinical features
• mucous membrane
• hyperaemia with mucus discharge,
• Sticky lids in the mornings
• more severe cases-fiery red -pink
• matting the lashes
• coloured halos
• 'pseudomembrane’ - pneumococcal conjunctivitis

13. Papillae and Follicles
• Commonly seen in bacterial conjunctivitis
• PAPILLA minute , hyperemic, opaque , polygonal mound with central vascular
core separated from each other by fibrils
• FOLLICLE is slightly larger ( 1- 2 mm) than
papillae and appears as smooth, translucent
elevation without central vascular core

14. HYPERACUTE

16. Complications
• Rare
• Corneal abrasions
• Superficial punctate epitheliopathy
• Marginal corneal ulceration
• Superficial keratitis
• Blepharitis
• Dacryocystitis

17. Treatment
• No bandage
• Fomites
• TOPICAL ANTIBIOTICS
CHLORAMPHENICOL 1%
GENTAMYCIN 0.3 %
CIPROFLOXACIN 0.3%
OFLOXACIN 0.3%
MOXIFLOXACIN
BESIFLOXACIN

18. Gonorrhoeal conjunctivitis
Rare
poor personal hygiene
Neisseria gonorrhoeae is a bun-shaped Gram-negative diplococcus
N. catarrhalis and N. meningitidis- gram neg
Clinical features:
Acute
adult males
marked tendency - involvement of the cornea
few hours to 3 days

19. • gonococcus is capable of invading intact epithelium
• Complications : Corneal Ulcer
Iritis and iridocyclitis
Gonorrhoeal arthritis
endocarditis
septicaemia

20. Treatment
• primary objective - prevent or limit corneal involvement, protect the other eye
• irrigate with warm saline
• 2-hourly intensive therapy
• antibiotic e/d (e.g. ofloxacin, ciprofloxacin, gentamicin or tobramycin)
• bacitracin ointment 6 hourly
• lgm ceftriaxone as im inj
• inj of 1 g ceftriaxone given i.v. every 12 to 24 hours
• allergic to penicillin or cephalosporins - TETRACYCLINE

21. Membranous and pseudomembranous
conjunctivitis
• C.diphtheriae, S. pneumoniae, H.aegyptius, N.gonorrhoeae, S.aureus, and E.coli
• Diphtheritic inf - children
• Clinical features
• mild cases - swelling of the lid mucopurulent or sanguinous discharge
• Memb- coagulation of exudates
• white membrane which peels off easily – pseudomembranous
• severe cases-necrosis- both the conjunctiva and cornea
• membrane -bleeding from the underlying surface-diphtheritic infection
• preauricular LN enlarged
• Symblepharon

24. Treatment
TOPICAL – PENCILLIN EYE DROPS
- ANTIDIPTHERIC SERUM
- BROAD SPECTRUM ANTIBIOTIC
SYSTEMIC- CRYSTALLINE PENCILLIN 5 LAC UNITS IM TWICE A DAY- 10 DAYS
ANTIDIPTHERIC SERUM 50,000 UNITS IM
PREVENTION OF SYMBLEPHARON

25. Angular conjunctivitis
• diplobacillarv conjunctivitis
• Moraxella lacunata
• large, thick rods, placed end to end
• Gram negative
• macerating the epithelium
• inner and outer canthi- excoriation of the skin at the inner and outer
palpebral angles
• Treatment: tetracycline ointment
• e/d containing zinc inhibit the proteolytic ferment

27. Viral conjunctivitis
• serous or clear watery discharge
• systemic viral illnesses such as influenza, mumps, measles and
chickenpox
• Treatment : systemic viral disease is treated as usual, supplemented
with artificial tears 4-8t/d

28. Follicular conjunctivitis
mc caused by viruses
follicles- lower conjunctiva
ACUTE - chlamydial inclusion conjunctivitis
epidemic KC
pharyngoconjunctival fever
Newcastle conjunctivitis
haemorrhagic conjunctivitis
primary herpetic conjunctivitis
recurrent herpes simplex conjunctivitis
SUBACUTE OR CHRONIC : drug-induced (pilocarpine)
secondary to local lid lesions(molluscum contagiosum)
trachoma

30. Epidemic Keratoconjunctivitis
• Adenovirus
• follicular conjunctivitis with marked inflammatory symptoms
• scanty exudate
• preauricular adenopathy
• punctate epithelial infiltrates discrete subepithelial opacities a/w photophobia
• markedly contagious
• widespread epidemics
• rising Ig titres in the blood
• Treatment
• non-specific - lubricant drops
• antibiotic drops - secondary bac infection

32. Haemorrhagic conjunctivitis
• Picorna viruses - coxsackie virus and enterovirus
• pandemic form - violent inflammatory conjunctivitis with lacrimation
and photophobia.
• Subconj haemorrhages and enlarged preauricular LN
• cornea – unaffected

34. Acute Herpetic conjunctivitis
• primary manifestation of herpes
• young children
• acute stomatitis- vesicular lesions on the face
• preauricular adenopathy
• dendritic figures
• Large follicles
• corneal sensation – dec
• atypical form - adults as acute follicular conjunctivitis without lesions of
the face, eyelid or cornea - resembles epidemic KC

35. Treatment
• topical lubricating drops - 4-6 t/d
• followup - 2-5 days
• corneal involvement : acyclovir 3%
• vidarabine 3% e/o
• trifluorothymidine 1% e/d
• five t/d

36. CHLAMYDIAL CONJUNCTIVITIS
• serotypes D-K
• inclusion bodies
• sexual transmission
• mild urethritis in the male and cervicitis in the female
• genitals by the fingers
• water in swimming pools(swimming-pool conjunctivitis)
• mother to the newborn

37. CLINICAL FEATURES
• acute onset,
• incubation period 10 days
• Follicular hypertrophy more prominent in LL>UL
• cornea – SPK with some pannus
• genital and oculogenital infections
• Assoc - non-gonococcal and post-gonococcal urethritis, cervicitis, salpingitis,
epididymitis and Reiter disease

38. INVESTIGATIONS
• direct immuno-fluorescent stain of smears using monoclonal anti-bodies
• ELISA
• Giemsa staining of conjunctival scrapings
• McCoy cell cultures

39. TREATMENT
• Benign course,
• Healing spontaneously if untreated in 3-12 months
• Broadspectrum antibiotics or systemic rx
• TETRACYCLINE -250 mg at 6-houriy intervals for 14 days or
• 100 mg doxycycline 12 hourly for 14 days or
• (oral tetracycline and doxycycline are C/I young children and lactating mothers.)
• Erythromycin 250 mg 12 hourly for 14 days.
• Azithromycin administered as a single oral dose of lg
• Ofloxacin 300 mg orally twice daily for 7 days

41. Ophthalmia neonatorum
• mucoid, mucopurulent, or purulent discharge
• first month
• preventable disease
• acquired at the time of birth
• poor hygiene
• limited access to proper health care
• Chlamydia oculogenitalis, Streptococcus pneumoniae or other organisms.
• watery secretion, from a baby's eyes during the first week should be viewed
with suspicion, since tears are not secreted so early in life.

43. • Causative agent - Incubation period
• Chemical - 4-6 hours
• Gonococcal - 2-4 days
• Other Bacterial - 4-5 days
• Neonatal Inclusion conjunctivitis - 5-14 days
• Herpes simplex - 5-7 days

44. DD
congenitally blocked nasolacrimal duct
acute dacryocystitis
congenital glaucoma
Infections -Neisseria gonorrhoeae
staphylococci
streptococci
Chlamydia trachomatis
HSV
chemical causes.

45. NEISSERIA GONORRHOEAE
manifests earliest,
typically within the first 48 hours of birth
mucopurulent and then purulent.
conjunctiva - intensely inflamed
bright red and swollen
thick yellow pus discharge.

46. • Marked chemosis
• dense infiltration of the bulbar conjunctiva
• lids are swollen and tense
• gonococcus – invading intact epithelium
• ulcers tend to extend rapidly, both superficially and in depth, resulting in
perforation

47. • Chlamydia trachomatis inclusion conjunctivitis
• Relatively late
• Usually over 1 week after birth
• Common cause of ophthalmia neonatorum
• Intracellular inclusion bodies
• venereal infection derived from the cervix or urethra of the mother
• Inflammation is less severe than in the gonococcal type
• Conjunctiva - swollen and oedematous while the discharge may be purulent.
• No follicles
• Superficial keratitis – occasionally in prolonged cases
• Corneal periphery may be invaded by a pannus

48. • OTHER BACTERIA manifest 48-72 hours after birth
• HSV - 5-7 days after birth
• CHEMICAL TOXICITY - within a few hours of prophylactic topical treatment with silver
nitrate solution in some cases

49. DIAGNOSIS
• Gram stained smear is a useful and sensitive test
• Giemsa stains
• Gram- intracellular diplococci with PMN leucocytes –
GONOCOCCAL
• PMN leucocytes and lymphocytes without bacteria -
CHLAMYDIA TRACHOMATIS
• Many bacteria and PMN leucocytes -BACTERIAL INFECTION
– S.Aureus, S. Pneumoniae or haemophilus

50. TREATMENT
• Preventable
• Prophylactic treatment
• newborn baby's closed lids should be thoroughly cleansed with
sterile cotton-wool soaked in sterile normal saline and dried
• If the mother is suspected to be infected with gonococci or
chlamydia 1% tetracycline or erythromycin e/o
• Penicillin and tetracycline topically and erythromycin given
orally
• Eyes are washed or irrigated with saline

51. • IF GONOCOCCAL INFECTION IS CONFIRMED on smear examination or suspected
clinically,
• if the CORNEA IS INVOLVED,
the baby should be HOSPITALIZED
GENTAMICIN DROPS
BACITRACIN OINTMENT
ATROPINE

52. PENICILLINASE-PRODUCING N. GONORRHOEAE
single im inj of ceftriaxone 125 mg/cefotaxime 50mg/kg i.v. or i.m. in three divided
doses, or kanamycin 25 mg/kg body weight.
Local - gentamicin 0.3% drops BE,
repeated in 15 minutes and then after every feed for 3 days along with bacitracin
e/o 2-4 hourly

53. • CHLAMYDIAL INFECTION
• ERYTHROMYCIN 50 mg/kg daily in four divided doses before feeds for
2-3 weeks
• or AZITHROMYCIN 10 mg/kg for 3 days.
• Local treatment - chlortetracycline 1% or erythromycin e/o after
feeds.
• Both parents - treatment for genital infection.

54. • BACTERIAL OPHTHALMIA OTHER THAN GONOCOCCAL OR
CHLAMYDIAL
• local with neomycin-bacitracin e/o after feeds, to both eyes.
• HSV INFECTION - vidarabine 3% or acyclovir 3% e/o is used 5 t/d for a
week and then 3 t/d till resolution.
• Systemic acyclovir is recommended for systemic involvement after
paediatric consultation.
• If CHEMICAL TOXICITY - no treatment
• All affected babies must be re-evaluated daily for the first 48-72
hours and repeat cultures taken if required