case of papillary conjunctival reaction
TRANSCRIPT
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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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