case of papillary conjunctival reaction

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  • 7/29/2019 case of papillary conjunctival reaction

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    Arlene Fernandez

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    The Case

    This is a case of 67/F whocame in due to Redness ofthe left eye

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    History of Present Illness

    4 days PTC:

    Noted her left eye was mildly

    swollen on the infraorbital area

    No associated eye pain, dryness,excessive lacrimation, itchinessand blurring of vision

    No medication taken, no consultdone

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    History of Present Illness

    3 days PTC:

    Persistence of the above

    symptoms

    Applied hypromellose e/s BIDwhich provided no relief

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    History of Present Illness

    1 day PTC:

    Symptoms still persisted with

    associated itchiness, redness,and increased in lacrimationof the left eye.

    Also noted the sensation offoreign body on the left eye

    Used hypromellose, no relief

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    History of Present Illness

    Few hours PTC

    Persistence of the above

    symptoms promptedconsultation

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    Past Medical History

    No hypertension, DiabetesMellitus, PTB, allergies, BA

    No previous hospitalizationand surgery

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    Previous Eye history

    Unremarkable

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    Family Medical History

    No hypertension, diabetesmellitus, allergies, PTB

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    Personal and social history

    Non-smoker and nonalcoholic beverage drinker

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    Review of Systems

    Constitutional: no weight loss, noloss of appetite

    Respiratory:no cough, no colds, nodifficulty of breathing, nohemoptysis

    GIT:no vomiting, no diarrhea, noconstipation, no abdominal pain

    GUT:no dysuria, no hematuria

    Hematology: no easy bruising, nobleeding of gums

    Neurology:no seizure, no tremors,no loss of consciousness

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    Physical Examination

    Visual Acuity:

    OD: 20/30 -1

    OS: 20/30

    External Eye Examination:

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    Physical Examination

    External Eye Examination

    Hyperemia

    Conjunctivalpapillae reaction

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    Physical Examination

    Extraocular muscles movement

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    Physical Examination

    Slit Lamp

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    Physical Examination

    Fundoscopy:

    OD: (+) ROR clear media, DDB,

    CDR: 0.3, AVR: 2:3, (-) H/E

    OS: (+) ROR, clear media, DDB,CDR: 0.3, AVR: 2:3, (-) H/E

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    Salient Features

    Subjective

    Redness, Itchiness, increase

    in lacrimation, OS

    Foreign body sensation, OS

    Objective

    Hyperemia of the upper

    palpebral and bulbarconjunctiva

    Conjunctival Papillae, OS

    Other eye PE were normal

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    Differential DiagnosisSubjective

    Redness, itchiness, increase in lacrimation

    Foreign body sensation

    Objective

    Hyperemia of the upper palpebral and bulbar conjunctiva

    Conjunctival Papillae, OSOther eye PE were normal

    AcuteConjunctivitis

    AllergicAtopic

    Viral

    Bacterial

    ForeignBody

    ForeignBody

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    Foreign Body SensationRule in:

    Foreign BodySensation

    Redness of the eye

    Increase inlacrimation

    Rule Out:

    On PE, there wereno FB findings

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    Differential DiagnosisSubjective

    Redness, itchiness, increase in lacrimation

    Foreign body sensation

    Objective

    Hyperemia of the upper palpebral and bulbar conjunctiva

    Conjunctival Papillae, OS

    Other eye PE were normal

    AcuteConjunctivitis

    AllergicAtopic

    Viral

    Bacterial

    ForeignBody

    AcuteConjunctivitis

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    Acute Conjunctivitis

    Rule in:Red Eye/ Redness

    of the eye

    Discharge(watery/purulent)

    Foreign BodySensation

    Rule Out:

    Cannot be ruled out

    is a conjunctival vascular dilation (hyperemia), sometimesaccompanied by conjunctival edema and discharge less than4-week duration of symptoms

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    Differential DiagnosisSubjective

    Redness, itchiness, increase in lacrimation

    Foreign body sensation

    Objective

    Hyperemia of the upper palpebral and bulbar conjunctiva

    Conjunctival Papillae, OS

    Other eye PE were normal

    AcuteConjunctivitis

    AllergicAtopic

    Viral

    Bacterial

    ForeignBody

    Allergic

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    Allergic ConjunctivitisRule in:

    Itchingwatery discharge,Hyperemia of the

    conjunctivaeconjunctival

    papillae

    Rule Out:

    history of allergiestypical

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    Differential DiagnosisSubjective

    Redness, itchiness, excessive lacrimation, OS

    Foreign body sensation

    Objective

    Hyperemia of the upper palpebral and bulbar conjunctiva

    Conjunctival Papillae, OS

    Other eye PE were normal

    AcuteConjunctivitis

    AllergicAtopic

    Viral

    Bacterial

    ForeignBody

    Atopic

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    Atopic ConjunctivitisRule in:

    ItchingRedness of the eye

    Rule Out:

    history of atopySeasonal

    recurrences

    Follicular papillae

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    Differential DiagnosisSubjective

    Redness, itchiness, increase in lacrimation

    Foreign body sensation

    Objective

    Hyperemia of the upper palpebral and bulbar conjunctiva

    Conjunctival Papillae, OS

    Other eye PE were normal

    AcuteConjunctivitis

    AllergicAtopic

    Viral

    Bacterial

    ForeignBody

    Viral

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    Viral ConjunctivitisRule in:

    ItchingRedness of the eyeForeign body

    sensation

    Rule Out:

    Cannot be ruled out

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    Differential DiagnosisSubjective

    Redness, itchiness, increase in lacrimation

    Foreign body sensation

    Objective

    Hyperemia of the upper palpebral and bulbar conjunctiva

    Conjunctival Papillae, OS

    Other eye PE were normal

    AcuteConjunctivitis

    Allergic Atopic

    Viral

    Bacterial

    ForeignBody

    Bacterial

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    Bacterial ConjunctivitisRule in:

    ItchingRedness of the eyeForeign body

    sensationConjunctival

    papillae

    Rule Out:

    No mucopurulentdischarge

    Cannot be totallyruled out

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    Assessment

    Papillary Conjunctivitisbacterial vs viral in origin

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    Discussion

    Acute Conjunctivitis is a conjunctivalvascular dilation (hyperemia),

    sometimes accompanied byconjunctival edema and dischargeless than 4-week duration ofsymptoms

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    Algorithm for Follicular and

    papillary conjunctival reaction

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    Viral Conjunctivitis

    Etiology:

    Most commonly adenovirus

    Pharyngoconjunctival fever:

    pharyngitis and fever; usuallyin children.

    Acute hemorrhagic conjunctivitis:

    large subconjunctivalhemorrhage,

    Caused by: coxsackie andenterovirus, 1 to 2 weeksduration. Tends to occur in

    tropical regions

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    Viral Conjunctivitis

    Work-Up

    No conjunctivalcultures/swabs areindicated unlessdischarge is excessive

    or the conditionbecomes chronic

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    Viral Conjunctivitis

    Treatment

    Supportive treatment

    Self-limited condition Worse for the first 4-7 days and

    may not resolve for 2-3 weeks orlonger

    Avoid touching the eyes (highly

    contagious) Frequent handwashing

    Preservative-free artificial tears

    Cool compress several times perday.

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    Viral Conjunctivitis

    Treatment

    Cool compress several times a

    day Antihistamine (e.g., epinastine

    0.05% b.i.d.) if itching is severe.

    Routine use of topical antibioticsor steroids for viral conjunctivitis

    is discouraged unless erosionsare present or in severe cases

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    Bacterial (Non-Gonococcal)ConjunctivitisEtiology

    Commonlly: S. aureus

    (associated with blepharitis,phlyctenules, and marginalsterile infiltrates)

    S. epidermidis, Streptococcuspneumoniae, and Haemophilus

    influenzae (especially inchildren)

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    Bacterial (Non-Gonococcal)Conjunctivitis Done only if severe,

    recurrent, or recalcitrant,

    conjunctival swab forroutine cultures andsensitivities (blood andchocolate agar) and

    immediate Gram stain toevaluate for gonococcus

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    Bacterial (Non-Gonococcal)ConjunctivitisTreatment

    Use topical antibiotic therapy

    [e.g., trimethoprim/polymyxin Bor fluoroquinolone drops q.i.d.]for 5 to 7 days

    H. influenzae conjunctivitisshould be treated with oral

    amoxicillin/clavulanate (20 to 40mg/kg/day in three divideddoses) because of occasionalextraocular involvement (e.g.,otitis media, pneumonia, andmeningitis).

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    Plan for the patient

    Strict hand washing

    Warm compress on the lefteye for 15 mins every 6hours

    Tobramycin E/S 1 drop every8 hours for 7 days.

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    Papillary ConjunctivalReaction

    A response w/c is nonspecific andcan be caused by many agents

    usually seen on the upper tarsalconjunctiva

    a fine mosaic pattern of dilated,telangiectatic blood vessels.

    Papillae vary in size from tiny reddots to polygonal elevations.

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    Papillary ConjunctivalReaction

    Pathophysiology:

    It can occur in any nonspecific

    conjunctival inflammation, includingmechanical irritation and allergic

    eye disease

    Each papilla has a centralfibrovascular core that gives rise to a

    vessel branching outward in a spokelike pattern

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    Papillary ConjunctivalReaction The connective tissue septa

    surrounding the papillae are

    anchored in the conjunctivalstroma, resulting inhyperemic areas surroundedby pale tissue when

    papillary hypertrophy occurs

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    Follicular ConjunctivalReaction The presence of a follicular

    conjunctival response ishelpful in differentiatingfrom papillary response.

    Pathophysiology:

    Follicles constitute lymphoidgerminal centers

    appear as smooth, roundednodules beneath the

    conjunctival epithelium

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    Follicular ConjunctivalReactionPathophysiology:

    nodules are avascular attheir apices and aresurrounded by fine vesselsat their bases

    regional lymphadenopathyoften coexists, representinga similar lymphoblasticproliferation.

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    Follicular ConjunctivalReaction Causes:

    adenoviral infection, primary

    herpes simplex viral infection,molluscum contagiosum infection,enteroviral infection, chlamydialinfection, and toxicity from certainmedications

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