Conjunctivitis

By: Lubna Altawil

Types
1) Bacterial 2) Viral 3) Allergic 4) Chemical

5) Neonatal

Bacterial Conjunctivitis

Background:
caused by staphylococci, streptococci, chlamydial organism, and gonocci mild conjunctivitis usually benign and selflimited and can be easily treated with antibiotics severe conjunctivitis (gonococci) can cause

blindness and can signify a severe underlying

systemic disease

Pathophysiology:
surface tissues of eye and ocular adnexa are colonized by normal flora such as streptococci, staphylococci, and Corynebacterium strains alterations in host defense or in species of bacteria can lead to clinical infection alteration in flora can occur by external contamination or spread from adjacent infectious sites primary defense against infection is epithelial layer covering the

conjunctiva
disruption of this barrier can lead to infection secondary defenses include hematologic immune mechanisms carried by

conjunctival vasculature; tear film immunoglobulins and lysozyme; and

rinsing action of lacrimation and blinking

Risk factors:
occurs in otherwise healthy individuals frequent exposure to infected individuals sinusitis immunodeficiency states

exposure to agents of STD at birth

Signs and Symptoms:

Conjunctival injection may be present segmentally or diffusely.

Using slit-lamp biomicroscopy and everting both the upper and lower eyelids, follicles or papillae can be identified on the inflamed conjunctiva. Follicules

have blood vessels that circumscribe the base of tiny elevated lesions.
Follicules are characteristic of a viral or chlamydial conjunctivitis. Papillae have vessels coming up the center of the tiny elevated lesion and are characteristic of bacterial or allergic conjunctivitis. Purulent discharge "mattering" of the lid margins and difficulty in prying the lids open following sleep. The mucopurulent discharge can appear white, yellow, or even greenish in color. In uncomplicated bacterial conjunctivitis, slit lamp examination reveals a quiet anterior chamber that is devoid of cells and flare. The vitreous is also unaffected.

 A preauricular lymph node is unusual in bacterial conjunctivitis but is found in severe conjunctivitis caused by N gonorrhoeae. Eyelid edema is often present, but it is mild in most cases of bacterial conjunctivitis. Severe lid edema in the presence of copious purulent discharge raises the suspicion N gonorrhoeae infection. Visual acuity is preserved in bacterial conjunctivitis as long as the cornea is intact, except for the expected mild blur secondary to the

discharge and debris in the tear film.

The pupil reacts normally in bacterial conjunctivitis

Complications:
membrane formation and subsequent scarring of the punctum corneal ulcer when the epithelium is not intact;

symblepharon from severe inflammation.

In eyes with previous intraocular surgery, particularly

with filtering blebs, endophthalmitis could result

Diagnosis:
Conjunctival scrapings and culture

Treatment:
Trimethoprim with polymixin B Gentamicin Tobramycin Neomycin Ciprofloxacin

Ofloxacin
Gatifloxacin Erythromycin

Topical antibiotics can be administered in the form of eye drops or

ointments. Eye drops have the advantage of not interfering with vision. Ointments have the advantage of prolonged contact with the ocular surface and an accompanying soothing effect.

Viral Conjunctivitis

Background:
Adenovirus most common cause, and herpes simplex virus (HSV) is

the most problematic

Less common causes include varicella-zoster virus (VZV), picornavirus, poxvirus, HIV usually benign and self-limited, tends to follow a longer course than acute bacterial conjunctivitis, lasting for approximately 2-4 weeks Viral infection is characterized commonly by an acute follicular conjunctival reaction and preauricular adenopathy.

Signs and Symptoms:

ocular itching foreign body sensation tearing, redness discharge, eyelids sticking (worse in the morning) photophobia (with corneal involvement, as in epidemic keratoconjunctivitis

 Acute hemorrhagic conjunctivitis has been

reported in epidemics in association with 2 major

picornaviruses: enterovirus 70 and

Coxsackievirus A24 mostly affects children and young adults in the lower socioeconomic classes Patients experience a rapid onset of watery discharge, foreign body sensation, burning, and photophobia within 24 hours of exposure

Diagnosis:
Specimens should be obtained for culture and smear if inflammation is severe, in chronic or recurrent infections, with atypical conjunctival reactions, and with failure to respond to treatment. Giemsa staining of conjunctival scrapings may aid in characterizing the inflammatory response. Polymorphonuclear

cells are prevalent in bacterial infections, whereas

mononuclear cells and lymphocytes are seen with viruses.

Treatment:
use cold compresses and lubricants, such as artificial tears, for comfort. Topical vasoconstrictors and antihistamines may

be used for severe itching but generally are not

indicated, because they are minimally helpful and

may cause rebounding of symptoms, as well as

local toxicity and hypersensitivity.

 For patients who may be susceptible, a topical

astringent or antibiotic may be used to prevent bacterial superinfection.

Topical steroids may be used for pseudomembranes or

when subepithelial infiltrates impair vision, although subepithelial infiltrates may recur after discontinuing the steroids. Extreme caution should be taken when using

corticosteroids, as they may worsen an underlying HSV

infection.

Neonatal Conjunctivitis

Background:
presents during the first month of life. It may be aseptic or septic. Aseptic neonatal conjunctivitis most often is a chemical conjunctivitis that is induced by silver nitrate solution, which is used for prophylaxis of infectious conjunctivitis. Chemical conjunctivitis is less common owing to the use of erythromycin ointment in place of silver nitrate solution for the prophylaxis of infectious conjunctivitis. Bacterial and viral infections are major causes of septic neonatal conjunctivitis, with Chlamydia being the most common infectious agent. Infants may acquire these infective agents as they pass through the birth

canal during the birth process

Pathology:
pathology of neonatal conjunctivitis is influenced by anatomy of conjunctival tissues in newborn inflammation of conjunctiva may cause blood vessel

dilation, chemosis, and excessive secretion.

This reaction tends to be more serious due to the lack of

immunity, absence of lymphoid tissue in conjunctiva,

and absence of tears at birth.

Etiology:
Silver nitrate solution
Crede's method of instilling a drop of 2% silver nitrate into a newborn's eyes was a major advance in preventing neonatal conjunctivitis.

Silver nitrate is a surface-active chemical, facilitating agglutinate gonococci

and inactivating them. Ironically, silver nitrate was later found to be toxic to the conjunctiva, potentially causing a sterile neonatal conjunctivitis.

Chlamydial conjunctivitis
Chlamydia trachomatis is an obligate intracellular parasite and has been identified as the most common infectious cause of neonatal conjunctivitis.

The reservoir of the organism is the maternal cervix or urethra. Infants who are
born to infected mothers are at high risk (approximately 25-50%) for developing an infection.

Neisserial conjunctivitis
Neisseria gonorrhoeae is a gram-negative diplococcus and is potentially the most dangerous and virulent infectious cause of neonatal conjunctivitis. Similar

to chlamydia, the reservoir of N gonorrhoeae is the mother of the infant and is

acquired during birth. Gonococci can penetrate intact epithelial cells and divide rapidly inside them

Herpes simplex
Herpes simplex virus (HSV) can cause neonatal keratoconjunctivitis, but it is rare (< 1% ) and can be associated with a generalized herpes simplex infection. Most infants acquire the disease during the birth process Caesarean delivery is considered when active genital disease is recognized at term since the risk of transmitting HSV to the neonate during vaginal delivery is 25-60%

Incubation period:
Chemical conjunctivitis secondary to silver nitrate solution application usually occurs in the first day of life, disappearing spontaneously within 2-

4 days.
Gonococcal conjunctivitis tends to occur 2-7 days after birth but can present later. Chlamydial conjunctivitis usually has a later onset than gonococcal conjunctivitis; the incubation period is 5-14 days. The incubation period for other, nongonococcal, nonchlamydial conjunctivitis is also 5-14 days. Herpetic conjunctivitis usually occurs within the first 2 weeks after birth

and has an incubation period of approximately 6-14 days.

Gonococcal conjunctivitis:
tends to be more severe than other causes of ophthalmia neonatorum; there is a classic presentation of bilateral purulent conjunctivitis. Corneal involvement, including diffuse epithelial edema and ulceration, may progress to perforation of the cornea and endophthalmitis. Patients also may have systemic manifestations (eg, rhinitis, stomatitis, arthritis, meningitis, anorectal infection, septicemia).

Chlamydial conjunctivitis:
presentation may range from mild hyperemia with scant mucoid discharge to eyelid swelling, chemosis, and pseudomembrane formation.

Blindness, although rare and much slower to develop than in gonococcal

conjunctivitis, is not due to corneal involvement as in gonococcal conjunctivitis; eyelid scarring and pannus (as in trachoma) cause it.

A follicular reaction does not occur, because newborns have no requisite

lymphoid tissue present in the conjunctiva. Like gonococcal conjunctivitis, chlamydial conjunctivitis also may be

associated with extraocular involvement, including pneumonitis, otitis, and

pharyngeal and rectal colonization.

Herpes simplex keratoconjunctivitis:

usually presents in infants with generalized herpes simplex with corneal epithelial involvement or vesicles on the skin (which surround the eye). Serious systemic complications, such as encephalitis, may occur in these neonates due to their poor immunologic response.

Diagnosis:
Bacterial cultures on blood and chocolate agar are indicated in every case of neonatal conjunctivitis and remain the criterion standard despite newer diagnostic methods. Since Chlamydia bacteria are obligate intracellular organisms, culture specimens need to contain epithelial cells and not only exudative material. gonorrhea is suspected, the agar should be inoculated immediately since N gonorrhoeae is very sensitive to moisture and temperature changes. A culture for HSV is indicated if a corneal epithelial defect is present, if vesicles are present on the eyelids or other parts of the body, and if the diagnosis cannot be made on ocular examination. Presence of HSV in tissue culture remains the criterion standard in the diagnosis of HSV, despite a high false-negative rate.

 Histologic findings for various forms of conjunctivitis are as

follows:
Chemical conjunctivitis - Neutrophils, occasional lymphocytes on

Gram stain
Bacterial conjunctivitis - Bacteria, neutrophils on Gram stain Gonococcal conjunctivitis - Neutrophils, Gram-negative intracellular

diplococci on Gram stain

Chlamydial conjunctivitis - Neutrophils, lymphocytes, plasma cells on Gram stain; basophilic intracytoplasmic inclusions in epithelial cells on

Giemsa stain
Herpetic conjunctivitis - Lymphocytes, plasma cells, multinucleate giant cells on Gram stain; eosinophilic intranuclear inclusions in

epithelial cells on Papanicolaou smear (low sensitivity)

Neonatal Chlamydial Conjunctivitis:

This infection is treated with oral erythromycin (50 mg/kg/d divided qid) for 14 days.

Topical treatment alone is ineffective. Topical erythromycin ointment may

be beneficial as an adjunctive therapy. Since the efficacy of systemic erythromycin therapy is approximately 80%,

a second course sometimes is required.

Systemic treatment is important in cases of chlamydial conjunctivitis since topical therapy is ineffective in eradicating the bacteria in the nasopharynx

of the infant, which could cause a life-threatening pneumonia if left

untreated

Neonatal Herpetic Conjunctivitis:

Neonates with a suspected herpetic simplex infection should be

treated with systemic acyclovir to reduce the chance of a systemic

infection. An effective dose is 60 mg/kg/day IV divided tid.

The recommended minimal duration is 14 days, but a course as long

as 21 days may be required. Infants with neonatal HSV keratitis should receive a topical

ophthalmic drug, most commonly 1% trifluridine drops or 3%

vidarabine ointment

Allergic Conjunctivits

Background:
inflammation of the conjunctiva due to allergy. Although allergensdiffer between patients, the most common cause is hay fever. Symptoms consist of redness (mainly due to vasodilation of the peripheral small blood vessels), oedema of the conjunctiva, itching and increased lacrimation (production

of tears). If this is combined with rhinitis, the condition is

termed allergic rhinoconjunctivitis.

Pathophysiology:
symptoms are due to release of histamine and other active substances by mast cells, which stimulate dilation of blood vessels, irritate nerve endings and increase secretion of tears

Etiology:
Pollen
Animal skin and secretions such as saliva Perfumes

Cosmetics
Skin medicines Air pollution

Smoke
Dust mites Eye drops

Classification:
SAC and PAC Both seasonal allergic conjunctivitis and perennial allergic conjunctivitis are two acute allergic conjunctival disorders. SAC is the most common ocular allergy. Symptoms include itching and pink to reddish eye(s). These two eye conditions are mediated by mast cells. Nonspecific measures to ameliorate symptoms include cold compresses, eyewashes with tear substitutes, and avoidance of allergens. Treatment consists of antihistamine, mast cell stabilizers, dual mechanism anti-allergen agents, or topical antihistamines. Corticosteroids are another option, but, considering the side-effects of cataracts and increased intraocular pressure. VKC and AKC Both vernal keratoconjunctivitis and atopic keratoconjunctivitis are chronic allergic diseases wherein eosinophils, conjunctival fibroblasts, epithelial cells, mast cells, and TH2 lymphocytes aggravate the biochemistry and histology of the conjunctiva. VKC is a disease of childhood and is prevalent in males living in warm climates. VKC and AKC

can be treated by medications used to combat allergic conjunctivitis or the use of

steroids.

 Giant papillary conjunctivitis

Giant papillary conjunctivitis is not a true ocular allergic reaction and is caused by repeated mechanical irritation of

the conjunctiva. Repeated contact with the conjunctival

surface caused by the use of contact lenses is associated with GPC.

Phlyctenular keratoconjunctivitis
PKC results from a hypersensitivity/inflammatory reaction to bacteria. Common pathogens include Staph. aureus, Mycobacterium tuberculosis, Chlamydia and Candida.