Case Presentation

AD E N OVIRAL K E RATOC ON JU N C TIVITIS

By:
Yumna
Asmaa
House officer
CMH Lahore
Supervised
by:
Brig. Abdul Majeed
Malik
HOD ophthalmology

Case History

Patient Particulars
Age- 36 years
Gender- Female
Resident of- Lahore
Occupation- Housewife
Marital status- married
Education - matriculate

Presenting Complaints
Watering
Redness
Irritation
Left > Right

04 days

History of presenting illness

Sudden in onset
Watering
Slight visual blurring
Redness
Stickiness- particularly in morning

Past History
Upper respiratory tract symptoms- 02 weeks ago
No eye surgery/ trauma/ contact lens usage
No significant medical & surgical history

Family History
2 children- flu
1 child- slightly red, sticky eyes

Examination

General physical examination

Vitals
Pulse
78 beats /min
Blood Pressure
130/80
mmHg
Temperature
98.6o F
Respiratory Rate
16 breaths /
min

Systemic Examination
Respiratory
system

Cardiovascular
system
NAD
Nervous system

Gastrointestinal
system

Ocular Examination

Visual Acuity
Righ
t

Left
6/9

6/24
6/18

Eyelids
Swollen & red
tears

Conjunctiva
Hyperemia
Follicles on inferior
tarsal conjunctiva
Petechial subconjunctival
hemorrhages
Chemosis

Conjunctiva
(contd.)

Right- hemorrhages

Left- pseudo
membrane

Cornea

Stellate white opacities

in anterior stroma

Fluorescein staining of
overlying epithelium

Ocular Examination (contd.)

Left

Right

No cells/ flare

Anterior chamber

No cells/ flare

Iris

Round, dilated,
reactive

Pupils

Round, dilated,
reactive

Normal

Intra-ocular
pressure

Normal

Relevant
Examination
Left pre-auricular
lymphadenopathy

Management

Differential Diagnosis
Adenoviral conjunctivitis
Bacterial conjunctivitis
Allergic conjunctivitis
Atopic conjunctivitis
Herpes-simplex conjunctivitis
Chlamydial infection

Final Diagnosis
ADENOVIRAL
KERATOCONJUNCTIVITIS

Treatment
Supportive treatment
Artificial tears
Cold compresses
Decongestantsi

Counselling to prevent contagious spread

Topical corticosteroids
Antibiotics

Case Discussion

Adenoviral keratoconjunctivitis
Viral conjunctivitis
Caused by adenoviruses
Three major presentations
Follicular conjunctivitis (serotypes 3, 4, 7a)
Epidemic keratoconjunctivitis (EKC, serotypes 8, 19, 37, 54)
Pharyngeal conjunctival fever (PCF, serotypes 3, 4, 7a, 11)

Seasonal- spring & winter

Etiology
Adenoviruses- more than 50 types
19 serotypes cause epidemic keratoconjunctivitis
Most common- adenovirus 8, 19, 37
Epidemics in closed institutions
Mode of transmission- direct contact
Incubation period- 2-14 days

Role of medical professionals

Many epidemics initiated in ophthalmology OPD
Mode of transmission- contaminated instruments
Reasons:
Viability- 5 weeks
Resistance to standard disinfectants
Infective period- 3 days before & 14 days after symptoms

Clinical Presentation

Symptoms
Irritation (foreign body sensation)
Soreness
Red eye noted by the patient
Photophobia
Swollen lids
Watering during the day
Crusting noted in the mornings
Noted in one eye first

Symptoms (contd.)
Ocular/ periorbital pain
Decreased visual acuity

History
May be preceded by flu-like symptoms
Recent history of eye examination
History of exposure within family

Signs (eyelids)
Swelling and erythema
Watery, mucoid discharge
Crusting

Signs
Conjunctival hyperemia
Chemosis

Signs
Follicular reaction
Papillary hypertrophy
Sub conjunctival &
petechial hemorrhages

Signs
Pseudomembranes
Conjunctival scarring
Symblepharon

Signs of corneal involvement

Usually mild & transient
3-4 days: Diffuse, fine epithelial keratitis
1 week: Focal epithelial keratitis
Central ulcerations and irregular borders with gray-white dots

Corneal
Involvement
2 weeks: Subepithelial infiltrates

Signs
Pre- auricular
lymphadenopathy

Management

Differential Diagnosis
Herpes simplex keratitis
Allergic conjunctivitis
Viral conjunctivitis
Bacterial conjunctivitis
Chlamydial infection
Contact lens complications
Corneal abrasion
Foreign body

Investigations
Rapid Pathogen Screening (RPS) Adeno Detector Plus
immunoassay
Simple, point-of-care test
10 minutes to return results
93% sensitivity
96% specificity

Treatment
Supportive
Medical
Surgical

Supportive Management
Artificial tears
Cold compresses
Decongestants
Cycloplegic agents for severe photophobia

Medical Management
Topical corticosteroids
Severe membranous conjunctivitis
Late sub epithelial opacities

Topical antivirals
Cidofovir

Antibiotics
No therapeutic effect
Precipitate allergic/ toxic contact inflammation

Surgical
Management
Pseudomembrane
removal

Every 2-3 days

Prevention
Patients
DO NOT touch others
DO NOT share tissues, towels, handkerchiefs
Wash hands frequently
Warn other family members about disease
Personnel who are infected should be removed from duty for 2
weeks

Prevention
Professionals
Wash hands immediately after examining any patient with red
eye
Anything that patient might have touched should be disinfected
red eye room

Take Home Message

Wash your hands before examining
any patient
Properly clean & sterilize ophthalmic instruments with
hypochlorite solution

Questions?

References
Parsons diseases of the eye
www.medscape.com
www.eyerounds.org

Thank You