Conjunctivitis

Conjunctiva The conjunctiva is a thin vascular mucous membrane that normally of shiny appearance. It forms the conjunctival sac together with the surface of the cornea. There are: 1. bulbar conjunctiva 2. palpebral conjunctiva 3. conjunctival fornix Function of the conjunctival sac: - Motility of the eyeball. - Articulating layer. - Protective function.

Conjunctivitis

Definition: Conjunctivitis is an inflammatory process involving the surface of the eye and characterized by vascular dilation, cellular infiltration, and exudation. Two forms of the disorder are distinguished:

Acute conjunctivitis. Onset is abrupt and initially unilateral with inflammation of the second eye within one week. Duration is less than four weeks.

Chronic conjunctivitis. Duration is longer than three to four weeks.

Conjunctivitis

Typical symptoms that permit an accurate diagnosis, include the type of exudation, conjunctival findings, or swollen preauricular lymph nodes.

Hyperemia.

Reddened eyes are a typical sign of conjunctivitis. The conjunctival injection is due to increased filling of the conjunctival blood vessels, which occurs most prominently in the conjunctival fornices. Hyperemia is present in all forms of conjunctivitis.

The following types of injection are distinguished.

Conjunctival injection (bright red, clearly visible distended vessels that move with the conjunctiva, decreasing toward the limbus)

The following types of injection are distinguished.

Pericorneal injection (superficial vessels, circular or circumscribed in the vicinity of the limbus).

The following types of injection are distinguished.

Ciliary injection (not clearly discernible, brightly colored nonmobile vessels in the episclera near the limbus).

The following types of injection are distinguished.

Mixed injection (frequent).

ConjunctivitisI. Bacterial Conjunctivitis 1. Acute bacterial conjunctivitis. 2. Haemophilus influenzae (H. aegyptius,

Koch-Weeks bacillus) 3. Pseudomembranous conjunctivitis. a) pneumococcus b) diphtheria 4. Neonatal ConjunctivitisII. Viral Conjunctivitis 1. Epidemic keratoconjunctivitis 2. Pharyngoconjunctival fever (PCF) 3. Acute epidemic hemorrhagic

conjunctivitisIII. Chlamydial ConjunctivitisIV. Trachoma

Bacterial Conjunctivitis

Symptoms: Typical symptoms include severe reddening, swelling of the con junctiva, and purulent discharge that leads to formation of yellowish crusts.

Treatment: Bacterial conjunctivitis usually

responds very well to antibiotic treatment. Substances include gentamicin, tobramycin, Aureomycin, chloramphenicol, neomycin, polymyxin В in combination with bacitracin and neomycin, Tetramycin, kanamycin, fusidic acid, ofloxacin, and acidamphenicol. The conjunctival cavity is irrigated with disinfectants (1:5000 Furacillin solution, 1:5000 potassium permanganate, strong tea).

Treatment: The following agents should be

frequently instilled into the eye (at 30 min. to 1 hour intervals): 30 % solution of Natrium sulfacyl, 10-20 % solution of natrium sulfapyridazil, 0,25 % solution of Levomycetin, 1 % solution of Erythromycin, 0,5 % Gentamycin solution, 0,5 solution of Neomycin-phosphate and other antibiotics. Thrice or four times a day an antibacterial ointment should be put under the lids: 1 % Tetracyclinic cream, 1% Erythromycin cream, 0.3 % Tombramycin cream, 0.3 % Floxal cream. Don’t cover the eye.

Haemophilus influenzae (H. aegyptius, Koch-Weeks bacillus)

Symptoms: It is a toxigenic organism and can be accompanied by patchy conjunctival hemorrhages during an acute infection. An untreated case can last for 9-12 days, occurring as a self-limited infection

Treatment: There is no specific treatment for this form of conjunctivitis. Good results are achieved by application of antibiotics and sulfanilamides (locally).

Pseudomembranous conjunctivitis

a) pneumococcus Symptoms: This

organism more commonly affects the conjunctiva of children and can run a self-limiting course of 9-10 days. Although an infrequent cause of conjunctivitis, the organism is invasive and toxigenic and thus is capable of producing a pseudomembranous conjunctivitis.

Pseudomembranous conjunctivitis

The pseudomembrane consists of a fibrinous layer entrapping inflammatory cells and is attached to the conjunctival surface. Removal of this pseudomembrane is possible with minimum bleeding of the underlying tissue.

Treatment is by frequent irrigation, local and general therapy with sulfanilamides and antibiotics, Penicillin and ointments (according to a causative agent’s susceptibility to them).

Pseudomembranous conjunctivitis.

b) diphtheria

It is often bilateral. The conjunctivitis can start as a routine mucopurulent conjunctivitis that rapidly evolves into a severe inflammation with copious exudate and marked chemosis and lid edema. Gray deposit appears in the conjunctiva, which is difficult to remove.

Pseudomembranous conjunctivitis.

The conjunctiva bleeds at the sites where deposit is removed. This clinical appearance demands laboratory confirmation, immediate therapy, and occasionally hospitalization

Treatment is by frequent irrigation, local and general therapy with sulfanilamides and antibiotics.

Neonatal Conjunctivitis

Symptoms: Depending on the pathogen, the inflammation will manifest itself between the second and fourteenth day of life. The spectrum ranges from mild conjunctival irritation to life-threatening infection (especially with gonococcal infection). Conjunctivitis as a result of Crede's method of prophylaxis appears with hours but only leads to mild conjunctival irritation.

Neonatal Conjunctivitis

Treatment: Topical administration of broad-spectrum antibiotics (gentamicin eye drops every hour) and systemic penicillin (penicillin G IV 2 mill. IU daily) or cephalosporin in the presence of penicillinase-producing strains.

Prophylaxis: application of 1 % silver nitrate solution

Viral ConjunctivitisEpidemic

keratoconjunctivitis Diagnostic

considerations: Characteristic findings include reddening and swelling of the plica semilunaris and lacrimal caruncle, follicles in the lower transitional fold and corneal lesion in the form of round gray subepithelial infiltrates 8-15 days after infection

Viral Conjunctivitis Treatment: Antiviral therapy is

possible. Treatment with artificial tears helps to relieve symptoms. Glucocorticosteroids should be avoided as they can compromise the immune system and prolong the clinical symptoms.

Pharyngoconjunctival fever (PCF)

Symptoms: After an incubation period of 5-12 days following droplet or fomite inoculation onto the conjunctival surface, symptoms of irritation and watery discharge are accompanied by hyperemia of the conjunctiva and follicle formation, often in association with preauricular adenopathy. PCF is characterized by pharyngitis, fever, and follicular conjunctivitis

Treatment is primarily by antiviral agents. Application of antibiotics is only necessary as prevention of secondary infection.

Acute epidemic hemorrhagic conjunctivitis C l i n i c a l f e a t u r e s. After

a short incubation period (from 12 to 24 hours) it has a sudden onset expressed in full-blown conjunctivitis, a foreign body sensation, lacrimation, mucous or muco-purulent discharge. On focal examination moderate palpebral edema, evident conjunctival infiltration when pulling the lids away, profuse massive hemorrhages on the bulbar conjunctiva as in trauma are seen. Hemorrhages, which are the major symptom, occur due to capillary toxicity of picornovirus.

Viral Conjunctivitis Treatment: These are 0.1 % solution of Florenal,

0.25 %, 0.5 % or 0.05 % Bonoffon ointment; 0.25 % Oxolin ointment; Virolex and Zavirax in the form of ointments, pills and i/v injections; Tebrofen ointment; 0.5 % solution of Poludan; 0.05 % solution of DNA-sis out of means of nonspecific immunotherapy; Interferon, Interloc- globulin with antiviral antibodies i/m and s/c at the dosage of 0.5 ml once during 3 days or 6 times a day in the form of drops. Interpheronogens have inhibitory action. For instance Prodegiozan, Poludan and Interferon prevent the virus from penetrating the cell as well as from multiplication. Pirogenal (antiviral agent), vitamins and antihistaminic agents are also appropriate for treatment. Combination of antiviral agents with corticosteroids is not advisable.

Chlamydial Conjunctivitis Symptoms: The eyes are

only moderately red and slightly sticky from viscous discharge.Tarsal follicles are observed typically on the upper and lower eyelids, and pannus will be seen to spread across the limbus of the cornea.

Treatment: In adults, the disorder is treated with tetracycline or erythromycin eyedrops or ointment over a period of four to six weeks.

TrachomaIn endemic regions (warm

climates, poor standard of living, and poor hygiene), it is among the most frequent causes of blindness for symptoms.

Left untreated, the disorder progresses through four stages:

Stage I: Hyperplasia of the lymph follicles on the upper tarsus.

Trachoma Stage II: Papillary

hypertrophy of the upper tarsus, subepithelial corneal infiltrates, pannus formation, follicles on the limbus.

Stages III and IV: Increasing scarring and symptoms of keratoconjunctivitis sicca. The progression is entropion, trichiasis, keratitis, superinfection, ulceration, perforation, and finally loss of the eye.