Conjunctivitis

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Vaidya on Oct 28, 2012 Says :

VERY NICE PRESENTATION

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KABERA René,MD PGY III Resident Family and Community Medicine National University of Rwanda Conjunctivitis

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DESCRIPTION Inflammation of palpebral and/or bulbar conjunctiva. Pink eye refers to non-Neisseria bacterial conjunctivitis. Systems(s) affected: Nervous ,Skin/Exocrine Incidence/Prevalence in Rwanda: Unknown, but common Predominant age: Depends on cause Predominant sex: Male = Female

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Anatomy

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anatomy

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SIGNS AND SYMPTOMS • General ? Conjunctival hyperemia ? Burning ? Foreign body sensation ? Pruritus ? Lacrimation ? Exudation and matting ? Chemosis ? Pseudoptosis ? Preauricular adenopathy ? Tarsal plate papillary hypertrophy ? Tarsal plate lymphoid follicles ? Pseudomembranous and membranes ? Photosensitivity ? Decreased acuity if there is complicating ulcer or keratitis ? Granulomas (rare)

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Bacterial Minimal pruritus Moderate tearing Profuse exudate, particularly Neisseria species Usually unilateral (or initially unilateral) Small tarsal plate papillae Neisseria species may cause chemosis Gram and Giemsa stain: Polymorphonuclear neutrophils (PMN's) and bacteria (gram negative intracellular diplococci with Neisseria species)

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Ophthalmia neonatorum

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Viral Minimal pruritus ,Profuse tearing ,Minimal exudate ,Often bilateral Preauricular adenopathy common Subconjunctival hemorrhage (acute hemorrhagic conjunctivitis) Associated viral systemic symptom (fever, myalgia, etc.) Tarsal plate follicles

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Viral Pharyngeal follicles if associated pharyngitis Gram and Giemsa stain: Mononuclear cells (lymphocytes) Rare chemosis except with epidemic keratoconjunctivitis Subepithelial corneal opacities with epidemic keratoconjunctivitis Diffuse punctate corneal fluorescein uptake or dendrites with herpes simplex Typical zoster rash along ophthalmic branch of trigeminal nerve with varicella-zoster Blepharoconjunctivitis ,Typical measles rash, Koplik's spots, etc. with measles

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Viral conjunctivitis

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Chlamydial Known as inclusion blennorrhea is the most common infectious cause of neonatal conjunctivitis in many series. The incubation period varies from 5 to 15 days. Chlamydia trachomatis serotypes D through K are usually associated with genital infection and inclusion conjunctivitis

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Chlamydial Minimal pruritus Moderate to profuse tearing Profuse exudate (sometimes modest) Often bilateral Small tarsal plate papillae Tarsal plate follicles present

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Chlamydial Gram and Giemsa stain: PMN's, plasma cells, inclusion bodies, in trachoma large palely staining lymphoblastic cells Inclusion conjunctivitis commonly has preauricular adenopathy and large tarsal plate papillae and follicles. Occasionally associated genitourinary symptoms in young adults or history of bilateral conjunctivitis unresponsive to topical antibiotics. Lymphogranuloma venereum is rare and non-follicular (mostly granulomatous conjunctival) with large preauricular node (visible bubo)

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Allergic Severe pruritus Moderate tearing No exudate Bilateral Chemosis very common Tarsal papillae

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Allergic Gram and Giemsa's stain: Eosinophils and basophils Allergic rhinoconjunctivitis has associated sneezing, rhinitis Vernal conjunctivitis is recurrent in warm weather associated with large "cobblestone" papillae in those with history of atopic allergy Giant papillary conjunctivitis has similar appearance to vernal conjunctivitis with less pruritus and is seen in soft (and occasionally hard) contact lens use

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Chemical or irritative Tarsal follicles with conjunctivitis of topical medications Tearing and exudation depends on toxicity of chemical Chemosis common in post therapeutic irrigation Gram and Giemsa stain: PMN's if tissue necrosis

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CAUSES Bacterial Staphylococcus aureus Streptococcus pneumoniae Haemophilus influenzae Neisseria gonorrhoeae Neisseria meningitidis Rarely other Streptococcal sp., pseudomonas, Branhamella catarrhalis, Coliforms, Klebsiella, Proteus, Corynebacterium diphtheriae, Mycobacterium tuberculosis, Treponema pallidum

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Causes Viral Adenoviruses types 3, 4, 7 (pharyngitis with conjunctivitis) Adenoviruses types 8 and 19 (epidemic keratoconjunctivitis) Adenovirus 11, Coxsackie A24, enterovirus 70 (acute hemorrhagic conjunctivitis) Herpes simplex (primary and recurrent) Coxsackievirus type A28 Molluscum contagiosum Varicella ,Herpes zoster ,Measles virus

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Causes Chlamydial Chlamydia trachomatis (trachoma) Allergic Rhinoconjunctivitis (hay fever) - humoral Vernal conjunctivitis Giant papillary conjunctivitis Delayed (cellular) Autoimmune (Sjogren, pemphigoid, Wegener granulomatosis)

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Causes Chemical or irritative Topical medication Home/industrial chemicals Wind, Smoke ,Ultraviolet light Other Rickettsial, fungal, parasitic, tuberculosis, syphilis, Kawasaki disease Thyroid disease, gout, carcinoid, sarcoidosis, psoriasis, Stevens-Johnson syndrome, Ligneous conjunctivitis, Reiter syndrome

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RISK FACTORS Trauma from wind, Cold and heat, Chemicals Foreign body

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Risk factors: foreign body

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Risk factors: trauma

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DIAGNOSIS DIFFERENTIAL DIAGNOSIS Uveitis (iritis, iridocyclitis, choroiditis) Acute glaucoma Corneal disease or foreign body Canalicular obstruction (canaliculitis, dacryocystitis) Scleritis and episcleritis

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Diagnosis LABORATORY Culture from conjunctiva Gram and Giemsa stain of the discharge or scrapings DIAGNOSTIC PROCEDURES Culture of exudate Smear and stain of exudate

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TREATMENT APPROPRIATE HEALTH CARE Outpatient GENERAL MEASURES Record acuity, See Medications Fluorescein staining to detect ulcer, keratitis Culture No topical steroids, No patch

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General measures Ophthalmologic referral if ulcer, keratitis, suspected herpes or worsens after 24 hours of treatment • Compresses - warm if infective, cold if allergic or irritative • Remove purulent material and debris (may require frequent irrigation) • Giant papillary allergic conjunctivitis requires discontinuing use of contact lenses

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MEDICATIONS:DRUG(S) OF CHOICE Bacterial 0.3% tobramycin or gentamicin. As drops (1-2 gtts) instilled every 4 hours while awake for 5 days, as ointment qid. 10% sodium sulfacetamide. As drops (1-2 gtts) instilled every 4 hours while awake for 5 days, as ointment qid and hs (stings). Erythromycin ophthalmic ointment qid Systemic treatment for Neisseria species as other sites usually involved. Some authorities (with ophthalmology consult) add topical erythromycin.

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Medications: drugs of choice Viral Trifluridine 1% drops, 1 drop every 2 hours while awake, maximum 9 drops a day Acyclovir oral and topical for herpetic (wide range of doses, consult drug reference) Chlamydial Oral doxycycline 100 mg bid (3 weeks) for inclusion conjunctivitis

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Medications drugs of choice Allergic Topical vasoconstrictor and/or antihistamine combination such as naphazoline 0.05% or antazoline (Albalon-A, Vasocon-A) 0.5% Oral antihistamine Topical cromolyn (Opticrom) 4% qid starting 2 weeks before season.

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Medications Contraindications: • Tetracycline: not for use in pregnancy or children < 8 years. Precautions: • Tetracycline: may cause photosensitivity; sunscreen recommended. • Vasoconstrictors make the eye appear less severely affected • Avoid contamination of medication bottles by touching lids Significant possible interactions: • Tetracycline: avoid concurrent administration with antacids, dairy products, or iron

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Medications:ALTERNATIVE DRUGS Bacterial Polymyxin-gramicidin Neomycin-polymyxin B-bacitracin (Neosporin); 15% of people have hypersensitivity reaction to neomycin Chloramphenicol - warning, slight hematological risk Ciprofloxacin Framycetin Norfloxacin

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Medications: Alternative drugs Chlamydial Oral tetracycline or erythromycin (3 weeks) for inclusion conjunctivitis. Topical tetracycline or erythromycin in addition. Allergic Numerous topical vasoconstrictors and antihistamines. Numerous oral antihistamines.

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COMPLICATIONS Bacterial Chronic marginal blepharitis Conjunctival scar if membrane developed Corneal ulcer or perforation Hypopyon Rare portal of entry for meningococcus

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Complications Viral Corneal scars with herpes simplex Corneal scars, lid scars, entropion, misdirected lashes with Varicella-zoster Bacterial superinfection Allergic, chemical and others Bacterial superinfection

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Complications Chlamydial Trachoma (follicular conjunctivitis not with inclusion conjunctivitis) is the leading cause of infectious blindness in the world. Cycles of infection-reinfection with Chlamydia trachomatis serotypes A, B, and C are responsible for the clinical findings.

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Complication: trachoma

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PROGNOSIS Bacterial 10-14 days without treatment 2-4 days with treatment Viral 10 days for pharyngitis with conjunctivitis 3-4 weeks for epidemic keratoconjunctivitis 2-3 weeks for Herpes simplex Chlamydial 3-9 months for untreated inclusion conjunctivitis 3-5 weeks for trachoma with treatment

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Thank you The End

Allergic conjunctivitis

Neonatal conjunctivitis

Vernal conjunctivitis

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