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Conjunctivitis
- 1. DEPT. OF SHALAKYATANTRA-NETRA ROGA B.V.D.U.C.O.A;PUNE-43 CONJUNCTIVITIS DR. AMANDEEP GUPTA M.S (SCHOLAR) NETRA ROGA
- 2. CONJUNCTIVITIS The conjunctivais a thin membrane that covers the inner surface of the eyelid and the white part of the eyeball(sclera). Inflammation of the conjunctiva is called conjunctivitis, which makes the white of the eye appear red.
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- 5. Prevalence Adult percent Pediatric percent Bacterial 40 80 Viral36 13 Allergic 24 2 No diagnosis 24 15 Note: In U.S.A Bacterial conjunctivitis (Chlamydia trachomatis or Neisseria gonorrhoeae ) has been estimated to account for between 377 and 875 U.S dollar million annually in health care cost . Bacteria Patients (%age) H. influenza 67.6 S. pneumonia 19.7 S. aureus 8.0 H. Parainfluenza e 2.5 Other bacteria 2.2 Causes of bacterial conjunctivitis in 238 culture positive patients Meltzer JA et al. Arch Pediatr Adolesc Med 2010; 164:263-267. Prevalence of etiologies of acute conjunctivitis By Age group ‘Data from weiss,A,Brinser,JH,Nazar-stewart, V j Pediatr 1993,
- 6. TYPES OF CONJUNCTIVITIS Infective Conjunctivitis Allergicconjunctivitis Cicatricial conjunctivitis Toxic conjunctivitis • Bacterial conjunctivitis •Chlamydial conjunctivitis •Viral conjunctivitis •Ophthalmia neonatorum •Granulomatous conjunctivitis ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` •Simplex conjunctivitis •Vernal conjunctivitis •Atopic conjunctivitis •Giant papillary conjunctivitis •Phlyctenular conjunctivitis •Contact dermoconjunctivitis •Ocular mucous membrane pemphigoid •Toxic epidermal necrolysis •Stevens Johnson syndrome •Secondary cicatricial conjunctivitis
- 7. Bacterial conjunctivitis Acute conjunctivitisHyperacute conjunctivitis Chronic bacterial conjunctivitisAngular bacterial conjunctiv
- 8. Bacterial Conjunctivitis Predisposing factors:Mode of Infection Causative organisms •Flies •Poor hygienic conditions •Hot dry climate •Poor sanitation •Dirty habits •Exogenous Infection •Local Spread •Endogenous Infection •Staphylococcus aureus-most common •Staphylococcus epidermidis •Streptococcus pneumoniae •Streptococcus pyogenes •Haemophilus influenzae •Moraxella lacunata •Pseudomonas pyocyanea •Neisseria gonorrhoeae •Neisseria meningitidis •Corynebacterium diptheriae
- 9. Acute bacterial conjunctivitis •Characterizedby marked conjunctival hyperaemia and mucopurulent discharge. •Most common Symptoms •Discomfort & F.B sensation •Mucopurulent discharge •Mild photophobia •Slight blurring of vision •Sticking of lid margins •Coloured halos Signs •Conjunctival congestion •Chemosis •Petechial haemorrhages •Flakes of mucopus •Matting of eyelashes
- 10. Clinical course •Peak in3-4 days •Cured in 10-15 days •Pass it to chronic catarrhal conjunctivitis Differential diagnosis •Other causes of red eye •Other type of conjunctivitis
- 11. Treatment •Topical antibiotics: chloramphenicol/ moxifloxacin / tobramycin eye drops •Ointment at night •Anti-inflammatory & analgesic drugs General measures: Irrigation of conjunctivial sac Dark goggles No bandage No steroids
- 12. Hyperacute bacterial conjunctivitis •Characterisedby a violent inflammatory response. •It occurs in two forms: 1) Adult purulent conjunctivitis 2) ophthalmia neonatorum in newborn Hyperacute conjunctivitis of adults Causative agents •Gonococcus, staph. aureus,pneumococuss
- 13. Symptoms •Pain •Purulent discharge •Swelling ofeyelids signs •Tenderness •Purulent, copius thick discharge •Bright red velvety chemosed conjunctiva •Pre-auricular LN enlarged •Tense and swollen lids
- 15. Treatment •Systemic therapy •Topical antibioticstherapy (moxifloxacin,ciprofloxacin or tobram •Bacitracin ointment QID •Add cycloplegics (if corneal involvement is there) General measures: Frequent irrigation of eyes Treatment of partner
- 16. Chronic bacterial conjunctivitis ETIOLOGY: •Predisposingfactors: Chronic exposure to smoke, dust, chemical irritants Local irritant as trichiasis, concretions, FB Eye-strain due to Ref error,convergence insufficiency Alcohol abuse Causative agents: •Staph aureus commonly, gram-ve entrobaccilli
- 17. Source & modeof infections: •As continuation of acute mucopurulent conjunctivitis •As chronic infection from chronic dacryocystitis or chronic URI •As a mild exogenous infection from direct contact or air-borne
- 18. SYMPTOMS: •Burning & grittinessof eyes, specially in evening •Mild chronic redness •Feeling of heat & dryness on lid margins •Difficulty in keeping eyes open •Mild mucoid disharge •On & off lacrimation •Feeling of sleeping & tiredness in the eyes SIGNS: •Congestion of posterior conjunctival vessels •Mild papillary hypertrophy •Surface of conjunctiva look sticky, congested lid margins
- 19. TREATMENT: •Topical antibiotics :chloramphenicol / gentamycin 3- 4 times for 2 weeks •Astringent eye drops : zinc boric acid for symptomatic relief
- 20. Angular bacterial conjunctivitis •Mildchronic conjunctivitis confined to the conjunctiva & lid margins near the angles Etiology: •Moraxella Axenfield Bacilli •Rarely staphylococci PATHOLOGY: •Production of proteolytic enzyme •Causes maceration of epithelium
- 21. SYMPTOMS: •Irritation discomfort •H/O collectionof dirty white foamy discharge at the angles •Redness in the angles of the eye SIGNS: •Hyperaemia of bulbar conjunctiva near the canthi •Hyperaemia of lid margins near the angles •Excoriation of skin around the angles •Presence of foamy mucopurulent discharge at the angles
- 22. TREATMENT: •Oxytetracycline 1 %eye ointment 2-3 times x 10-14 days •Zinc lotion at day time and zinc oxide ointment at bedtime General measures: •Good personal hygiene
- 23. Ophthalmia neonatorum •In childrenaged <30 days •Any discharge or watering, in the first week of life should arouse suspicion ETIOLOGY: •Before birth: infected amniotic fluid •During birth: infected birth canal •After birth: first bath, soiled clothes, unhygienic conditions
- 24. CAUSITIVE AGENTS •Chemical conjunctivitis:silver nitrate solution •Gonococcal infection: •Other bacterial infections: Staph aureus Strept hemolyticus Strept pneumoniae •Neonatal inclusion conjunctivitis: Chlamydia trachomatis serotype D to K •Herpes Simplex Ophthalmia Neonatorum
- 25. Incubation period •Chemical conjunctivitis:4-6 hours •Gonococcal infection: 2-4 days •Other bacterial infections: 4-5 days •Neonatal inclusion conjunctivitis: 5-14 days •Herpes Simplex Ophthalmia Neonatorum : 5-7 days
- 26. Clinical features •Pain andtender eyeball •Purulent conjunctival discharge (gonococcal) •Mucoid / mucopurulent (other bacterial infections) •Swollen lids •Corneal involvement rarely •Chemosed conjunctiva •Watering •Conjunctival congestion
- 27. Treatment •PROPHYLAXIS: Antenatal: Treatment of genitalinfections of mother Natal: Delivery under aseptic conditions Newborns eyelids should be well cleaned Postnatal: 1% tetracycline / 0.5% erythromycin ointment 1 % silver nitrate solution (Crede’s method) Single injection of Ceftriaxone 50mg/kg IM/IV
- 28. CURATIVE TREATMENT •Chemical conjunctivitis:self-limiting •Gonococcal: •Topical: Bacitracin ointment QID •Moxifloxin drops 5000-10000units per ml every min for 30 min, every 5 min for 30 min, and then every 30m in till infection controlled •Atropine ointment if corneal involvement •Systemic: Ceftriaxone 75-100mg/kg/day IV/IM Q.I.D. Cefotaxime 100-150mg/kg/day IV/IM B.D. If gonococcal: cryst benzyl Peni G 50000 units for full term babies (20000 to premature) IM BD x 3 days
- 29. Other bacterial infections •Broadspectrum antibiotic drops / ointment x 2weeks •Neonatal inclusion conjunctivitis: Topical tetracycline / erythromycin ointment QID x 3weeks Systemic erythromycin •Herpes Simples: Self limiting, topical antivirals control effectively
- 30. Chlamydial conjunctivitis Trachoma Adultinclusion conjunctivitis Neonatal chamydial conjunct •Lie midway between bacteria & viruses •Obligate intracellular & filterable •Contain both D.N.A & R.N.A Chlamydial conjunctivitis
- 31. Trachoma •Formerly called asEgyptian ophthalmia •Chronic keratoconjunctivitis •Affecting superficial epithelium of cornea and conjunctiva •One of the leading cause of preventable blindness •Characterized by mixed follicular & papillary reaction Etiology CAUSITIVE ORGANISM: •Chlamydia trachomatis (Psittacosis-lymphogranulomato •11 serotypes recognized
- 32. PREDISPOSING FACTORS: •Age: commonlyin infancy & childhood, but age no bar •Gender: more in females •Race: very common in Jews •Climate: dry & dusty weather favors •Socio-economic status: more in poor classes due to unhygienic conditions, overcrowding, unsanitary conditions, flies, lack of education etc •Environmental: exposure to dust, irritants, smoke, sunlight etc
- 33. SOURCE OF INFECTION: •Conjunctivaldischarge of affected person Superimposed bacterial infection speed up the process MODES OF INFECTION: •Direct spread by air-borne or water-borne modes Vector transmission by flies Maternal transfer through contaminated fingers, clothes, bedding etc
- 34. PREVALENCE: •Mostly in NorthAfrica, Middle East & South East Asia •Affecting 500 million people in world •Responsible for 15-20% of blindnessSymptoms: •No secondary bacterial infection: Mild FB sensation Occasional lacrimation Stickiness of lids Scanty mucoid discharge •With secondary bacterial infection: All typical symptoms of acute bacterial conjunctivitis
- 35. Conjunctival signs: •Congestion ofupper tarsal and forniceal conjunctiva •Conjunctival follicles •Papillary hyperplasia •Conjunctival scarring •Concretions Corneal signs: •Superficial keratitis •Herbert follicles •Pannus •Corneal ulcer •Herbert Pits •Corneal opacity
- 36. Differential Diagnosis •With follicular hypertrophy: Adenoviral conjunctivitis •Withpapillary hypertrophy Vernal Conjunctivitis
- 37. MANAGEMENT: Treatment of ActiveTrachoma •Topical therapy: 1% tetracycline / 1% erythromycin eye ointment 4 times daily for 6 weeks •Systemic therapy: Tetracycline / erythromycin 250mg QID orally for 4 weeks Or Doxycycline 100mg BD orally for 4 weeks Or single dose of Azithromycin orally •Combined therapy: Preferred when severe disease Or associated genital infection is present
- 38. Safe Strategy forTrachoma Blindness: •Surgery to correct eyelid deformity & prevent blindness •Antibiotics for acute infections & community control •Facial Hygiene •Environmental changes
- 39. ADULT INCLUSION CONJUNCTIVITIS •acutefollicular conjunctivitis associated with mucopurulent discharge ETIOLOGY: •Chlamydia trachomatis Serotype D to K •Primary source urethritis & cervicitis •Transmission through contact through fingers Or by contaminated water of swimming pool
- 40. Incubation Period: •4-12 days Symptoms: •Oculardiscomfort, foreign body sensation •Mild photophobia •Mucopurulent discharge from the eyes Signs: •Conjunctival hyperaemia, marked in fornices. •Acute follicular hypertrophy predominantly of lower palpebral conjunctiva •Superficial keratitis in upper half •Superior micropannus occasionally •Pre-auricular lymphadenopathy
- 41. Treatment: •Topical therapy: Tetracycline 1% eye ointment QID for 6 weeks •Systemic therapy: Tetracycline 250 mg four times a day for 3-4 weeks. Erythromycin 250 mg four times a day for 3-4 weeks Doxycycline 100 mg twice a day for 1-2 weeks 200 mg weekly for 3 weeks Azithromycin 1 gm as a single dose
- 42. Viral conjunctivitis •Most viralinfections are keratoconjunctivitis VIRAL INFECTIONS OF CONJUNCTIVA –Adenoviral conjunctivitis –Herpes Simplex kerato conjunctivitis –Herpes Zoster conjunctivitis –Pox virus conjunctivitis –Myxovirus conjunctivitis –Paramyxovirus conjunctivitis –ARBOR virus conjunctivitis
- 43. Clinical presentations: Two clinicalforms: 1. Acute haemorrhagic conjunctivitis 2. Acute follicular conjunctivitis Adenoviral conjunctivitis •Commonest cause of viral conjunctivitis •Non- enveloped, double-standard DNA viruses
- 44. Types of adenoviralconjunctivitis: •Epidemic keratoconjunctivitis(EKC) •Nonspecific acute follicular conjunctivitis •Pharyngoconjunctival fever (PCF) •Chronic relapsing adenoviral conjunctivitis
- 45. Epidemic keratoconjunctivitis: •Associated withsuperficial punctate keratitis (SPK) and occur in epidemics •Adenovirus type 8 and 19 •Markedly contagious and direct contact transfer •Incubation : 8 days Symptoms: •Redness associated with watering •Mild mucoid discharge •Ocular discomfort & f.b sensation •Photophobia
- 46. Signs: •Swollen eyelids •Conjunctival signs: Chemosisconjunctiva Follicles (small to moderate size) Petechial subconjunctival haemorrhages Pseudomembrane lining Corneal involvement: •superior punctate keratitis (typical feature of ekc) Pre-auricular lymphadenopathy : •Associated in all cases of ekc
- 48. Treatment : supportivetherapy: Cold compresses & sunglasses Decongestant & lubricant tear drops
- 49. Pharyngoconjunctival fever: •Adenovirus type3 and 7 Acute follicular conjunctivitis With pharyngitis, Fever & Pre auricular LN •Primarily in children and in epidemic forms •Corneal involvement in 30% cases •Treatment : supportive
- 50. Newcastle conjunctivitis: •Rare •Caused byNewcastle virus •Contact with diseased owls •Affects poultry workers •Similar to pharyngoconjunctival fever.
- 51. Acute herpetic conjunctivitis: •Alwaysaccompanies with primary herpetic infection •HSV type 1 commonly •Clinically: Usually unilateral, incubation within 3-10 days Typical Form: Follicular conjunctivitis with other herpetic lesions Atypical Form: Follicular conjunctivitis without other herpetic lesions Corneal involvement & preauricular lymphadenopathy Treatment: self limiting, antiviral drugs
- 52. ACUTE HEMORRHAGIC CONJUNCTIVITIS •Acute conjunctivitischaracterised by: Multiple conjunctival hemorrhages Hyperemia Mild follicular hyperplasia ETIOLOGY: •Picornavirus •Disease very contagious, direct hand-to-eye contact Clinical features: •Incubation period: 1-2 days
- 53. Symptoms: •Pain, redness, watering,mild photophobia •Transient blurring of vision, lid edema Signs: •conjunctival congestion & chemosis •multiple haemorrhages in bulbar conjunctiva •mild follicular hyperplasia, lid oedema •pre-auricular lymphadenopathy •Fine corneal keratitis
- 54. Treatment: •Prophylaxis very important •Nospecific treatment •Broad spectrum antibiotics •Self-limiting within 5-7 days •Supportive measures are same as EKC
- 55. ALLERGIC CONJUNCTIVITIS •Inflammation ofconjunctiva due to allergic or hypersensitivity reactions TYPES: 1)Simple allergic conjunctivitis •Hay fever conjunctivitis •Seasonal allergic conjunctivitis (SAC) •Perennial allergic conjunctivitis (PAC) 2)Vernal keratoconjunctivitis (VKC) 3)Atopic keratoconjunctivitis (AKC) 4)Giant papillary conjunctivitis (GPC) 5)Phlyctenular keratoconjunctivitis (PKC) 6)dermoconjunctivitis (CDC)
- 56. SIMPLE ALLERGIC CONJUNCTIVITIS •Mild,non-specific allergic conjunctivitis •Itching, hyperaemia and mild papillary response •Basically an urticarial reaction Etiology: •Hay fever : pollens, animal dandruff •Seasonal allergens (grass pollens) •Perenial allergens (house dust, mites)
- 57. Symptoms •Intense itching &burning •Watery discharge & mild photophobia Signs: •Hypreremia & chemosis •Mild papillary reaction •Lid edema may be present Diagnosis: •Typical signs & symptoms •Normal conjunctival flora •Abundant eosinophils in discharge
- 58. Treatment: •Elimination of allergenif possible •Local palliative measures for immediate relief: •Vasoconstrictors : naphazoline, adrenaline, ephedrine •Sodium cromoglycate eye drops •Steroids only for short course in acute cases •Systemic antihistaminics in acute cases •Desensitization – not much effective
- 59. VERNAL KERATOCONJUNCTIVITIS •Recurrent, bilateral,self-limiting, allergic inflammation of conjunctiva ETIOLOGY: •Hypersensitivity to some exogenous allergen •IgE mediated atopic mechanisms Predisposing factors: •4-20 years, common in males •More in summer •Prevalent in tropics, non-existent in cold climate
- 60. Symptoms: •Marked burning anditching, usually intoreble •Mild photophobia, lacrimation •“Ropy Discharge” •Heaviness of eyelids
- 61. Signs: Palpabrel form: •Upper tarsalconjunctiva •Presence of hard, flat topped, papillae arranged in 'cobble-stone' 'pavement stone', fashion •Giant papillae in severe cases •White ropy conjunctival discharge Bulbar form: •Dusky red triangular congestion of bulbar conjunctiva in palpebra •Gelatinous thickened accumulation of tissue around the limbus •Presence of discrete whitish raised dots along the limbus (Tranta Mixed: •Combined features of both forms
- 62. 5 types oflesions can be seen: 1)Punctate epithelial keratitis: •Involves upper cornea, mostly in palpabrel form •Lesions always stain with rose bengal 2)Ulcerative vernal keratitis: •Shallow transverse ulcer in upper part of cornea due to epithelial m 3)Vernal corneal plaques: 4)Due to coating of areas of epithelial macroerosions with coating o exudates •Subepithelial scarring: •In a form of a ring scar 5)Pseudogerontoxon: Classical cupid bow outline
- 63. Clinical course: •Disease isself-limiting •Usually goes off spontaneously in 5-10 years Differential diagnosis: •Trachoma with predominantly papillary hypertrophy Treatment: •Local therapy •Systemic therapy •Treatment of large papillae •General measures •Desensitization •Treatment of vernal keratopathy
- 64. Treatment: Local therapy •Topical steroids: Effectivein all forms Use should be minimal and for short-duration Frequent instillation to tapering within few days Flouromethalone, dexamethasone, loteprednol •Mast cell stabilizers: Sodium cromoglycate, azelastine, ketotifen •Topical antihistaminic eye drops •Acetyl cysteine (0.5%) eye drops •Topical cyclosporine eye drops
- 65. Treatment: Systemic therapy •Oral histaminics •Oralsteroids in severe cases for short duration Treatment of large papillae: •Supratarsal injection of long acting steroid •Cryo application •Surgical excision for extra-ordinary large papillae
- 66. Treatment: General measures: •Dark goggles •Coldcompress & ice packs •Change of environment (working environment also) Desensitization •Not much awarding results Treatment of vernal keratopathy: •PEK : steroid instillation should be increased •Large vernal plaque: surgical lamellar keratectomy •Severe shield ulcer: debridement, superficial keratectomy, amniotic membrane
- 67. ATOPIC KERATOCONJUNCTIVITIS •Adult equivalentof vernal keratoconjunctivitis •Often associated with atopic dermatitis •Mostly young male adults Symptoms: •Itching, soreness, dry sensation •Mucoid discharge •Photophobia or blurred vision
- 68. Signs: Lid margins: •chronically inflamed •roundedposterior borders Tarsal conjunctiva: •milky appearance •very fine papillae, hyperaemia and scarring with shrink Cornea: •punctate epithelial keratitis •more severe in lower half •corneal vascularization, thinning and plaque
- 69. Clinical course: •Protracted course •Tendsto become inactive by 5th decade Treatment: •Often frustrating •Treat lid disease effectively •Mast cell stabilizers, steroids, tear supplements may be
- 70. GIANT PAPILLARY CONJUNCTIVITIS •Conjunctivalinflammation with very large sized papillae Etiology: •Localized allergic response •Contact lens, prosthetic shell •Suture irritation Symptoms: •Itching, stringy discharge •Reduced wearing time of contact lens or prosthetic shel Signs: •Papillary hypertrophy upper tarsal conjunctiva with hype
- 71. Treatment: •The offending causeshould be removed. •Disodium cromoglycate is known to relieve the symptom enhance the rate of resolution. •Steroids are not of much use in this condition.
- 72. PHLYCTENULAR KERATOCONJUNCTIVITIS •Nodular affectionas a allergic response to endogenous allergens •World wide , more in developing countries Etiology: Delayed hypersensitivity •Causative allergens •Tuberculous, Staphylococcus •Proteins of Moraxella Axenfeld bacillius, Parasites Predisposing factors •Age. Peak age group is 3-15 years. •Gender. Incidence is higher in girls than boys. •Living conditions. Overcrowded and unhygienic. •Season. all climates (spring and summer seasons)
- 73. Symptoms: •Very few •Mild discomfort,discharge, irritation, reflex tearing Signs: Simple: •Most common •Typical pinkish-white nodule at limbus surrounded by h mostly solitary. Necrotizing: •Very large phlycten with necrosis & ulceration •Leads to severe pustular conjunctivitis Miliary: •Multiple phlyctens, may be arranged like a ring around
- 74. Phlyctenular Keratitis: Ulcerative: •Sacrofulous ulcer:shallow marginal ulcer •Fascicular ulcer: has prominent parallel leash of vessels •Miliary ulcer: multiple ulcers scattered all over Diffuse Infiltrative: •Central infiltration of cornea •Characteristic rich vascularization all around limbus •Usually self-limiting, disappears in 8-10 days D/D: •Episcleritis, scleritis, FB granuloma
- 75. Treatment: Local therapy: •Topical steroideye drops and ointment •Topical antibiotic eye drops & ointment •Atropine eye ointment when cornea involved Systemic therapy: •Diagnosis & management of TB •Septic foci like caries, folliculitis, tonsillitis, adenoiditis to adequately treated •Parasitic infestations to be ruled out & treated if present General measures: •Improve hygiene & supplement high-protein diet
- 76. S.N O Name of bookAuthor Publisher Edition 1. Comprehensive ophthalmology A.K Khurana Jaypee 6th 2. Kanski’s clinical ophthalmology Brad bowling Elsevier 8th Bibliography