conjunctivitis-200105121616 (1).pptx
- 1. Conjunctivitis Viral, Bacterial & Allergic dr. Frenky R. de Jesus National Eye Centre Postgraduate diploma in Ophthalmology
- 2. Definition The conjunctiva is a thin membrane that covers the inner surface of the eyelid and sclera The conjunctivitis is an inflammation of the conjunctiva, which eye appear red with or without discharges. Infectious Non-Infectious
- 3. Classification of Conjunctivitis Infectious Viral Bacterial Toxin Allergic Neoplasm Foreign Body Trauma Non-Infectious • Hyperacute • Acute • Chronic • Angular • Epidemic keratoconjunctivitis • Non specific acute follicular Conj. • Pharingoconjunctival fever. • Chronic/relapsing adenoviral.
- 4. 1. Allergic Conjunctivitis 2. Viral Conjunctivitis 3. Bacterial Conjunctivitis
- 5. 1. Bacterial Conjunctivitis Predisposin g Factors Mode of Infection Causative Organism s • Flies • Poor hygienic conditions • Hot dry climate • Poor sanitation • Dirty habits • Exogenous infections: directly, vector transmission, material transfer. • Local spread: infected lacrimal sac, lids and nasopharynx. • Endogenous infections: blood. • Staphylococcus aureus- (most common) • Staphylococcus epidermidis • Streptococcus pneumoniae • Streptococcus pyogenes • Haemophilus influenzae • Moraxella lacunata • Pseudomonas pyocyanea • Neisseria gonorrhoeae • Neisseria meningitidis Corynebacterium diptheriae
- 6. Characterised by a violent inflammatory response. It occurs in two forms: • Adult purulent conjunctivitis (Gonococcus, staph.aureus, pneumococcus) • Ophthalmia neonatorum in newborn Symptoms • Pain • Purulent discharge • Swelling of eyelids Signs • Tenderness • Purulent, copius thick discharge • Bright red velvety chemosed conjunctiva • Pre-auricular LN enlarged • Tense and swollen lids a. Hyperacute bacterial conjunctivitis
- 7. Treatment • Systemic therapy • Topical antibiotics therapy (moxifloxacin, ciprofloxacin or tobramycin) • Bacitracin ointment • Cycloplegics General measures • Frequently irrigation.
- 8. Medical Therapy • Fluoroquinolones: • 2nd generation: Ciprofloxacin 0.3% drops or ointment, or Ofloxacin 0.3% drops • 3rd generation: Levofloxacin 0.5% drops • 4th generation: Moxifloxacin 0.5% drops, Gatifloxacin 0.5% drops, or Besifloxacin 0.6% drops • Aminoglycosides: • Tobramycin 0.3% drops • Gentamicin 0.3% drops • Macrolides: • Erythromycin 0.5% ointment • Azithromycin 1 % solution • Other • Bacitracin ointment • Bacitracin/Polymixin B ointment • Neomycin/Polymixin B/Bacitracin • Neomycin/Polymixin B/gramicidin • Polymixin B/Trimethoprim • Sulfacetamide • Chloramphenicol • Fusidic Acid (Common treatment in the UK; not used in the US)
- 9. • Characterized discharge. • Most common by marked conjunctival hyperaemia and mucopurulent b. Acute bacterial conjunctivitis Symptoms • Discomfort & F .B sensation • Mucopurulent discharge • Mild photophobia • Slight blurring of vision • Sticking of lid margins Signs • Conjunctival congestion • Chemosis • Petechial haemorrhages • Flakes of mucopus • Matting of eyelashes Clinical Course • Peak in 3-4 days • Cured in 10-15 days • Pass it to chronic catarrhal
- 10. 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
- 11. c. Chronic bacterial conjunctivitis Predisposin g Factors Mode of Infection Causative Organism s • Chronic exposure to smoke, dust, chemical irritants • As continuation of acute mucopurulent conjunctivitis • Staphylococcus aureus- (most common) • Gram - (Entrobacilli) • Local irritant as trichiasis, concretions, FB • Eye-strain due to Ref error, convergence insufficiency • Alcohol abuse • As chronic infection from chronic dacryocystitis or chronic URI • As a mild exogenous infection from direct contact or air-borne
- 12. Symptoms • Burning & grittiness of 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 Treatment • Topical antibiotics : chloramphenicol, moxifloxacin /tobramycin eye drops. • Astringent eye drops : zinc boric acid for symptomatic relief
- 13. • Characterized by Mild chronic conjunctivitis confined to the conjunctiva & lid margins near the angles. • Etiology: Moraxella Axenfield Bacilli, Rarely staphylococci. d. Angular bacterial conjunctivitis Symptoms • Irritation discomfort • H/O collection of 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 Treatment • Oxytetracycline 1 % eye ointment 2-3 times x 10-14 days
- 14. 2. Viral Conjunctivitis • Usually benign and self-limited, (longer course approximately 2-4 weeks) • Is highly contagious. • Avoid touching their eyes, shaking hands, and sharing towels, among other activities. • Transmission; accidental inoculation of viral particles from the patient's hands or by contact with infected upper respiratory droplets, fomites, or contaminated swimming pools. • Common External Ocular infection. • In 90% cases, Adenovirus is the causative agent. • May be Sporadic, or occur in epidemics.
- 15. Causative agents • Adenovirus conjunctivitis(>90% cases). • Herpes simplex keratoconjunctivitis. • Herpes zoster conjunctivitis. • Picorna viruses(Enterovirus and coxsackie virus). • Poxvirus conjunctivitis. • Myxovirus conjunctivitis. • Parammyxovirus conjunctivitis. • ARBOR virus conjunctivitis
- 16. Spread of infection Facilitated by • Virus can survive on dry surfaces for weeks. • Viral shedding may occur for many days before clinical features are apparent. Transmission by • Contact with Respiratory or ocular secretions. • Via Contaminated Fomites such as Towels. • Route of transmission is usually Eye-Hands-Eyes. • In Clinical setting,Eye-Instruments-Eye.
- 17. Presentation Epidemic Keratoconjunctivitis • Most severe presentation. • Caused by adenoviruses type 8,19 and 37. • Markedly contagious. • incubation period after infection (8 days) & virus shed from the inflamed eye for 2-3 weeks. • Keratitis occurs in 8 0 % cases. Non-specific acute follicular Conj. • Most common form of acute follicular conjunctivitis • Caused by adenovirus serotypes 1 to 11 & 19 • Milder form of acute follicular conjunctivitis. • Unilateral symptoms, Other eye involved 1-2 days later , but less severely. • Patient may have systemic symptoms such as sore throat or common cold.
- 18. Pharyngoconjunctival fever • Adenoviral infection commonly associated with subtypes 3,4 & 7. • Acute follicular conjunctivitis, associated with pharyngitis. • Fever & pre-auricular lymphadenopathy. • Cornea : superficial punctate keratitis. (30%) Chronic/relapsing adenoviral conj. • Rare • Gives a clinical picture of chronic non-specific • Follicles/papillas. • Can persist over years, but eventually self limiting.
- 19. Clinical features Symptoms • Watering • Redness • Irritation. • Itching. • Photophobia (When Cornea is involved). Signs • Eyelids Edema, Ranging from mild to Severe. • Lymphadenopathy Tender Pre-auricular nodes (common). • Conjunctiva Hyperemia, Follicles. May be Papillae (Particularly conjunctiva). • Severe Inflammation: may be associated with conjunctiva superior tarsal Hamorrhages, chemosis, membranes (Rare) and pseudomembranes. Sometimes conjunctiva Scarring. • Keratitis (Adenoviral): PEK Usually occur in 7-10 days of onset of symptoms. Resolving in 2 weeks. • Anterior Stromal infiltrates/SEI: may persist for months or years. • Anterior uveitis: Usually mild.
- 21. Herpes simplex Virus • Causes Follicular conjunctivitis particularly in primary disease. • Usually unilateral. • Often Associated skin lesions. • Micro dendrites may be mistaken for punctate epithelial keratitis, But Corneal sensation is reduced in HSV Acute hemorrhagic conjunctivitis • Usually occurs in tropical areas. • Caused by Enterovirus and coxsackie virus (Picornavirus family). • Rapid onset, resolves within 1-2 weeks.
- 22. Treatment Approach Considerations Treatment of adenoviral conjunctivitis is supportive. Symptomatic Treatment Cold compresses and lubricants, such as artificial tears, for comfort. Topical vasoconstrictors and antihistamines. Antibiotic and Topical Steroid Treatment
- 23. 3. Allergic Conjunctivitis Inflammation of conjunctiva due to allergic or hypersensitive reaction which may be immediate (humoral ) or delayed (cellular) to specific antigens
- 24. 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.Contact dermoconjunctivitis (CDC)
- 25. • Mild, non specific IgE mediated Type I hypersensitivity reaction. Etiology: • Hay fever conjunctivitis: associated with allergic rhinitis. • Allergens: pollens, grass, animal dandruffs. • SAC: common, grass pollens • PAC: not common, house dust and mites 1. Simple allergic conjunctivitis Symptoms • Itching • Redness • Burning sensation • Watery discharge • Mild photophobia Signs • Hyperemia and chemosis • Mild papillary reaction • Oedema of eyelids
- 26. Treatment • Elimination of allergens if possible • Cold compresses • Antihistamines oral/ topical (epinistine, fexofenadrine) • Mast cell stabilizers (sodium cromoglycate, lodaximide) • Combination( ketotifen, patalon, azelastine) • Topical corticosteroids • Immunosuppressant's (cyclosporin) for steroid resistant cases
- 27. • Recurrent, Bilateral, self limiting allergic inflammation of the conjunctiva affecting children and young adults • More common in males. • Allergic disorder in which IgE and cell mediated immune mechanism play an important role Symptoms • 9 8 % bilateral, can be asymmetric • Intense ocular itching, Lacrimation, Photophobia, blepharospasm, blurred vision, FB sensation, burning and difficulty opening eyes in the morning. • Thick mucous discharge, Pseudoptosis due to large papillae. • Giant papillae on the superior Palpebral conjunctiva are the clinical hallmark. 2. Vernal Keratoconjunctivitis (VKC)
- 28. VKC types
- 29. VKC types
- 30. VKC types
- 31. Treatment • Topical antihistamine • Mast cell stabilizers: sodium chromoglycate 2 % drops 4-5 times/day • Topical steroid: Every 4 hrs. for 2 days followed by 3-4 times a day for 2 weeks . MONITOR IOP TO PREVENT STEROID INDUCED GLAUCOMA • Acetyl cysteine (0.5%) • Systemic : I. Oral antihistamine : for itching II.Oral steroid : short course for very severe non responsive case • T reatment of large papilla supratarsal injection of long acting steroid or surgical removal • General measures: dark goggles, cold compress, change of place from hot to cold
- 32. 3. Atopic Keratoconjunctivitis (AKC)
- 33. Symptoms • Itching • Soreness • Dry sensation • Mucoid discharge • Photophobia Signs • Lid margins: inflamed with round posterior borders • Conjunctiva : inferiorly involve, watery discharge, milky appearance, very fine papilla, hyperaemia scarring with shrinkage • Limbal: limbal involvement similar to limbal VKC • Cornea; punctate epithelial keratitis in lower half, vascularization , plaque
- 35. Treatment • Topical antihistamine • Mast cell stabilizers: sodium chromoglycate 2 % drops 4-5 times/day • Topical steroiD • Supratarsal steriod injection in severe • Others: treat facial eczema and lid margin disease Immunosuppressive agents( cyclosporine, tacrolimus)
- 36. 4. Giant Papillary Conjunctivitis
- 37. SYMPTOMS AND SIGNS Thick mucous discharge, inflamed superior papillae and blurry vision, FB sensation, redness – GPC staging • Stage 1: itching and decreased lens tolerance • Stage 2: blurred vision, superior tarsal papillae ( >0.3mm) • Stage 3: excessive contact lens movement because tarsal papillae don’t allow smooth movement of lid . • Stage 4: similar appearance to mild VKC
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