CONJUNCTIVITIS
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causes-of-r
Acute bacterial conjunctivitis/ acute mucopurulent conjunctivitis: red eye+ mucopurulent
- Bilateral
- Conjunct. + exanthemata (rash)= organisms: [Link], [Link], [Link]
- CF.: discomfort, FB sensation, mild photophobia, redness, mucopurulent discharge
(d/t mucus: slight blurring, coloured halos, sticking of lid margins during sleep).
- Signs: lids- oedematous, eyelash(cilia)- matted together with yellow crusts, flakes,
conjunctiva- swelling (chemosis), congestion (red eye- less in circumcorneal zone).
Petechial haemorrhages in Pneumococcus.
- Complicate to superficial punctate epitheliopathy, marginal corneal ulceration,
superficial keratitis, blepharitis, dacryocystitis
- Tx: oral PCM/ibuprofen, topical AB.- broad spectrum- chloramphenicol,
gentamicin/tobramycin; no response -> quinolones
- Irrigation of conjuc. sac with saline (but no frequent eyewash)
- Dark goggles
- No eye bandage; if no -> good medium for bac. growth
- No steroids; if no -> to corneal ulcer
- Prevent: good hygiene- handwash, no sharing personal items
Hyperacute bacterial conjunctivitis; gonococcal – adult/newborn
ADULTS (GONOCOCCAL CONJUNCTIVITIS)
- M>F, associated with urethritis, arthritis
- CF: PAIN, purulent discharge (copious) [d/t mucus: lids sticking together, blurring],
eyelid swelling, photophobia
- Signs: lids- oedematous, tenderness, thick, copious discharge, conjunctiva- chemosis,
congestion, pseudomembranous (often), preauricular LN enlarged and tender.
- Complicate into: normal corneal involvement -> ulcer/perforation, iridocyclitis,
systemic- endocarditis, septicaemia, arthritis
- Tx: SYSTEMIC !!!!
o 3rd gen cephalosporins: IM ceftriaxone 1g qid x 5d / IV cefoxitin 1g / IV
cefotaxime 500mg qid
o Quinolones, spectinomycin
FOLLOWED BY: doxycycline 100mg bd or oral erythromycin 250-400mg
qid
o Topical AB
o Eye irrigation with saline
o Topical atropine 1% drop
o Sexual partners tx with systemic AB and checked for other STDs.
NEWBORNS (OPHTHALMIA NEONATORUM)
- Bilateral, in infant (<30d)
- Any discharge or watering from eye in the 1st week of life -> sus of ophthalmia
neonatorum bec tears are not formed by then
- Infection (mom -> child):
o Before birth- ruptured membrane -> infected liquor amnii
o During birth- vertical transmission—face presentation or with forceps
o After birth- during first bath from soiled clothes or infected fingers
- Causes:
- CF:
- Signs:
- Complicate into:
- Tx:
- Prophylaxis:
Chronic bacterial conjunctivitis
- [Link] common, other factors: chr exposure to dust, smoke/ eye strains/ alcohol
abuse -> insomnia, metabolic cond/ local cause- FB, trichiasis
- CF, Signs, Tx: same as acute,, broad spectrum AB
Angular bacterial conjunctivitis = inflammation confined to eye angle, maceration of skin
- By Moraxella Axenfield
- Tx: Oxytetracycline 1% 2-3x/day, for 9-14d, zinc lotion
Viral Conjunctivitis [keratoconj. = involves both cornea and conj.], preauricular LN+,
unilateral- sequential bilateral
Adenoviral conjunctivitis
- CF: redness, watery, photophobia
- Symptoms may be preceded by upper respiratory tract symptoms
- Signs: lid oedema, Conjunctiva: injection, chemosis, follicles, subconjunctival
haemorrhages, Punctate keratitis (use fluorescein), subepithelial infiltrates (1-2
weeks after onset)
- Severe cases: pseudomembrane/membrane, symblepharon formation [bulbar and
palpebral form adhesion]
- Ix: PCR if diagnosis in ques.
- Tx: cool compresses, lubricant eye drops, sun glasses
- Ab only if superadded bacterial infections, antiviral not much helpful, steroids not to
be used during active cases.
- Pseudomembrane/membrane formation: peel membrane using topical anaesthesia,
cotton bud or fine forceps. Lyse symblepharon using glass rod.
- Disinfect room/equipment immediately on discharge of patient.
Indications for topical steroids: IF ON STEROIDS MUST HAVE FOLLOW UP
Pseudomembrane/membrane formation
Subepithelial infitrates (SEI) decreasing vision (<6/12). Can be difficult to wean steroid with SEI as
they may recur with taper
Options: the following can be used 3-4 times a day with slow taper:
- Fluorometholone acetate (Flarex®) eye drops
- Fluorometholone (FML®) eye drops
- Consider Prednisolone acetate 1%, (Prednefrin Forte®) or Dexamethasone 0.1% (Maxidex®)
eye drops for moderately severe pseudomembranes
FOLLOW UP:
- Limit follow up appointments, if possible, to decrease spread of disease: patient
should return if symptoms worsen/do not resolve in 2-3 weeks
- Pseudomembrane/membrane formation: follow every 2-3 days until membrane
formation ceases, then time between follow up intervals can be increased. Monitor
IOP if steroids prescribed.
- Subepithelial infiltrates on topical steroids: 2-3 weekly intervals until improvement,
then time between follow up intervals can be increased
- If patient weaned off topical steroids too quickly, may have recurring symptoms/SEI
- Consider Chlamydia PCR for symptoms lasting >3 weeks
Discharge instructions:
- Instructions on symptomatic relief of symptoms: lubricant eye drops, cool
compresses
- Natural history of condition: self-limited, can worsen in first few days, usually
resolves in 2-3 weeks
- Highly contagious, spread by contact, strict hand-washing, no sharing of linen,
minimise contact with others. Usually contagious for 10-14 days after symptoms
begin or fellow eye involved. In general, patients remain infectious while their eyes
are symptomatic. Patients on topical steroids may be contagious for 2 weeks after
symptoms resolve and should take precautions not to spread the disease. Avoid
work/school while contagious, in particular for child care providers/teachers/health
care workers. Medical Certificate as required.
- Instruct patient to return if condition worsens or persists longer than 2-3 weeks.
- Contact lens wearer: discard previous lens and resume contact lens wear with a fresh
contact lens only once eye has been asymptomatic for 1 week
Acute herpetic conjunctivitis
- Got primary herpetic infection (HSV1~ kissing), common in adolescents, small
children
- Unilateral, IP- 5-14d
- 2 forms: typical- conj. + face and lids lesion, atypical- conj. – no face or lids lesion
- Corneal involvement, preauricular LN +
- Tx: self-limiting, topical antiviral drugs
Acute haemorrhagic conjunctivitis
- Multiple conj haemorrhages, hyperaemia, follicular hyperplasia
- Caused by picornavirus [IP- short 1-2d]
- CF: pain, redness, watery discharge, photophobia, blurring, lid swelling
- Signs: congestion, swelling, multiple hemorrhage in bulbar conj., lid edema,
preauricular LN enlargement, corneal involvement: epithelial keratitis
- Tx: broad spectrum antibiotics, general measures
Degenerative conditions
1. Pinguecula
o Yellow white, triangular patch on bulbar near limbus = looks like fat
o Common: exposed to strong sunlight, dust or wind
o Bilateral, apex of triangle is away from limbus, affects nasal side 1st
o If conj. congestion-> pinguecula appears avascular
o Tx: usually no tx. But if needed, excised. If inflamed, topical steroid
(1) (2)
2. Pterygium
o Wing shaped fold of conj growing towards the centre of eye.
o Common: old age, male, exposed to sunlight, dry heat, high wind
o Unilateral or bilateral, usually nasal side
o CF: early- no symptoms, later- FB sensation, irritation, defective vision if pupil
or cornea affected, diplopia
o Signs: triangular fold of conjunctiva
o Tx: (medical)- tear substitute, topical steroids, protection from sunlight (UV),
(surgical)- can reoccur after surgery (30-50%)
(MAIN DIFF.: visual disturbances in pterygium)