Conjunctivitis

KABERA Ren,MDPGY III Resident Family and Community Medicine National University of Rwanda

Conjunctivitis 1DESCRIPTIONInflammation of palpebral and/or bulbar conjunctiva. Pink eye refers to non-Neisseria bacterial conjunctivitis.Systems(s) affected: Nervous ,Skin/ExocrineIncidence/Prevalence in Rwanda: Unknown, but commonPredominant age: Depends on causePredominant sex: Male = Female2Anatomy

3anatomy

4SIGNS 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)5Bacterial

Minimal pruritusModerate tearingProfuse exudate, particularly Neisseria speciesUsually unilateral (or initially unilateral)Small tarsal plate papillaeNeisseria species may cause chemosisGram and Giemsa stain: Polymorphonuclear neutrophils (PMN's) and bacteria (gram negative intracellular diplococci with Neisseria species)6Ophthalmia neonatorum

What is the age of this patient? What do you notice about the eyes?The baby is less than four weeks old and has a very severe purulent conjunctivitis - this is newborn conjunctivitis or ophthalmia neonatorum. This type of conjunctivitis starts soon after birth because the baby was infected by the mother during delivery. The mother already had an infection of the vagina due to the presence of a sexually transmitted disease, in this case gonorrhoea.On examination you can see that both eyes are red and there is a lot of purulent discharge. Be careful because the pus is infectious! Wash your hands carefully after your examination. You must clean the eyelids and eyes with water and swabs and then apply tetracycline 1% eye ointment every hour until there is improvement. Arrange for referral to the eye specialist.The child will need at least one antibiotic injection and possibly more than one, depending on the antibiotic used. If the cornea is not clear due to involvement in the infection then this is a very serious disease and you must immediately refer the baby for specialist opinion.Advise both parents to seek medical treatment for the sexually transmitted disease which probably affects the father as well as the mother.Ophthalmia neonatorum may be caused by a number of different organisms, but the most common are Chlamydia trachomatis and Neisseria gonorrhoeae.You can prevent this disease by immediately cleaning the eyelids of newborn babies with a clean cloth and water and applying tetracycline 1% eye ointment. Every newborn baby should be treated in this way by the midwife or nurse.

7Viral

Minimal pruritus ,Profuse tearing ,Minimal exudate ,Often bilateralPreauricular adenopathy commonSubconjunctival hemorrhage (acute hemorrhagic conjunctivitis)Associated viral systemic symptom (fever, myalgia, etc.)Tarsal plate follicles8Viral Pharyngeal follicles if associated pharyngitisGram and Giemsa stain: Mononuclear cells (lymphocytes)Rare chemosis except with epidemic keratoconjunctivitisSubepithelial corneal opacities with epidemic keratoconjunctivitisDiffuse punctate corneal fluorescein uptake or dendrites with herpes simplexTypical zoster rash along ophthalmic branch of trigeminal nerve with varicella-zosterBlepharoconjunctivitis ,Typical measles rash, Koplik's spots, etc. with measles

9Viral conjunctivitis

10Chlamydial

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

11Chlamydial Minimal pruritusModerate to profuse tearingProfuse exudate (sometimes modest)Often bilateralSmall tarsal plate papillaeTarsal plate follicles present

12Chlamydial Gram and Giemsa stain: PMN's, plasma cells, inclusion bodies, in trachoma large palely staining lymphoblastic cellsInclusion 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)13Allergic

Severe pruritusModerate tearingNo exudateBilateralChemosis very commonTarsal papillae14Allergic Gram and Giemsa's stain: Eosinophils and basophilsAllergic rhinoconjunctivitis has associated sneezing, rhinitis Vernal conjunctivitis is recurrent in warm weather associated with large "cobblestone" papillae in those with history of atopic allergyGiant papillary conjunctivitis has similar appearance to vernal conjunctivitis with less pruritus and is seen in soft (and occasionally hard) contact lens use

15Chemical or irritative

Tarsal follicles with conjunctivitis of topical medicationsTearing and exudation depends on toxicity of chemicalChemosis common in post therapeutic irrigationGram and Giemsa stain: PMN's if tissue necrosis16CAUSES

BacterialStaphylococcus aureusStreptococcus pneumoniaeHaemophilus influenzaeNeisseria gonorrhoeaeNeisseria meningitidisRarely other Streptococcal sp., pseudomonas, Branhamella catarrhalis, Coliforms, Klebsiella,Proteus, Corynebacterium diphtheriae, Mycobacterium tuberculosis, Treponema pallidum

17Causes ViralAdenoviruses 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 A28Molluscum contagiosumVaricella ,Herpes zoster ,Measles virus

18Causes ChlamydialChlamydia trachomatis (trachoma)AllergicRhinoconjunctivitis (hay fever) - humoralVernal conjunctivitisGiant papillary conjunctivitisDelayed (cellular)Autoimmune (Sjogren, pemphigoid, Wegener granulomatosis)19Causes Chemical or irritativeTopical medicationHome/industrial chemicalsWind, Smoke ,Ultraviolet lightOtherRickettsial, fungal, parasitic, tuberculosis, syphilis, Kawasaki diseaseThyroid disease, gout, carcinoid, sarcoidosis, psoriasis, Stevens-Johnson syndrome, Ligneous conjunctivitis, Reiter syndrome

20RISK FACTORS

Trauma from wind, Cold and heat, Chemicals Foreign body 21Risk factors: foreign body

22Risk factors: trauma

23DIAGNOSIS

DIFFERENTIAL DIAGNOSISUveitis (iritis, iridocyclitis, choroiditis)Acute glaucomaCorneal disease or foreign bodyCanalicular obstruction (canaliculitis, dacryocystitis)Scleritis and episcleritis

24Diagnosis LABORATORYCulture from conjunctivaGram and Giemsa stain of the discharge or scrapingsDIAGNOSTIC PROCEDURESCulture of exudateSmear and stain of exudate

25TREATMENT

APPROPRIATE HEALTH CAREOutpatientGENERAL MEASURESRecord acuity, See MedicationsFluorescein staining to detect ulcer, keratitisCultureNo topical steroids, No patch26General 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

27MEDICATIONS:DRUG(S) OF CHOICE

Bacterial0.3% 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 qidSystemic treatment for Neisseria species as other sites usually involved. Some authorities (with ophthalmology consult) add topical erythromycin.28Medications: drugs of choice ViralTrifluridine 1% drops, 1 drop every 2 hours while awake, maximum 9 drops a dayAcyclovir oral and topical for herpetic (wide range of doses, consult drug reference)ChlamydialOral doxycycline 100 mg bid (3 weeks) for inclusion conjunctivitis29Medications drugs of choice AllergicTopical vasoconstrictor and/or antihistamine combination such as naphazoline 0.05% or antazoline (Albalon-A, Vasocon-A) 0.5%Oral antihistamineTopical cromolyn (Opticrom) 4% qid starting 2 weeks before season.30Medications 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 lidsSignificant possible interactions: Tetracycline: avoid concurrent administration with antacids, dairy products, or iron

31Medications:ALTERNATIVE DRUGSBacterialPolymyxin-gramicidinNeomycin-polymyxin B-bacitracin (Neosporin); 15% of people have hypersensitivity reaction to neomycinChloramphenicol - warning, slight hematological riskCiprofloxacinFramycetinNorfloxacin32Medications: Alternative drugs ChlamydialOral tetracycline or erythromycin (3 weeks) for inclusion conjunctivitis. Topical tetracycline or erythromycin in addition.AllergicNumerous topical vasoconstrictors and antihistamines.Numerous oral antihistamines.

33COMPLICATIONS

BacterialChronic marginal blepharitisConjunctival scar if membrane developedCorneal ulcer or perforationHypopyonRare portal of entry for meningococcus

34Complications ViralCorneal scars with herpes simplexCorneal scars, lid scars, entropion, misdirected lashes with Varicella-zosterBacterial superinfectionAllergic, chemical and othersBacterial superinfection

35Complications ChlamydialTrachoma (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.36Complication: trachoma

37PROGNOSIS

Bacterial10-14 days without treatment2-4 days with treatmentViral10 days for pharyngitis with conjunctivitis3-4 weeks for epidemic keratoconjunctivitis2-3 weeks for Herpes simplexChlamydial3-9 months for untreated inclusion conjunctivitis3-5 weeks for trachoma with treatment38 Thank you

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