FOLLICULAR CONJUNCTIVITIS

Introduction

• Conjunctiva:

thin and delicate membrane that lines the eyelid and surrounds the

eyeball. It is one of the most sensitive parts of the body that gets

easily infected by environmental agents and microorganisms, leading

to conjunctivitis

• Inflammation of conjunctiva:-

the inflammation has 2 forms:

1-acute generalized hyperplasia

2-lymphocyte aggregation in adenoid layer (acute/chronic) due to toxic

or allergic response to drugs e.g:Atropine

• Definition of Follicular conjunctivitis:It is conjunctivitis associated with hypertrophic lymphoid tissue as pinkish round bodies in the conjunctival fornices ; can be acute or chronic.

• Histology of Follicular conjunctivitis:-regular follicles-plasma cells-pannus-pmnc-infeltration by lymphocyte-no true capsule

• Conditions induce follicles formations:

1.Acute follicular conjunctivitis

a.Inclusion conjunctivitisb.Adenovirus conjunctivitis: i.Epidemic keratoconjunctivitis ii.Pharyngoconjunctival fever

c.Acute herpetic conjunctivitisd.Newcastle conjunctivitise.Allergic conjunctivitisf.Acute trachoma in foreigners

2. Chronic follicular conjunctivitis3. Toxic follicular conjunctivitis: a. Molluscum contagiosum 4. Folliculosis

Acute follicular conjunctivitis

1-Acute Adenovirus Conjunctivitis

• Adenoviruses are known to produce acute follicular

conjunctivitis as seen in pharyngoconjunctival fever (PCF)

and epidemic keratoconjunctivitis (EKC).

**Pharyngoconjunctival Fever:Pharyngoconjunctival fever primarily affects children and appears in epidemic form. It is due to adenovirus serotypes 3, 4 and 7. The conjunctivitis is self-limiting and there is no specific treatment but topical antibiotics should be used to control secondary bacterial infection.

** Epidemic Keratoconjunctivitis:keratoconjunctivitis occurs in widespread epidemics that mostly spreads through infected ophthalmic instruments especially tonometers.Etiology:Epidemic keratoconjunctivitis is caused by adenovirus serotypes 3, 7, 8 and 19.

• C/P:

photophobia, acute follicular or membranous conjunctivitis,

subepithelial infiltrates in the cornea, scanty discharge and

preauricular lymphadenopathy.

Pseudomembrane on the palpebral conjunctiva develops

predominantly. Petechial hemorrhages on bulbar conjunctiva and

subconjunctival hemorrhages can occur.

Diffuse punctate epithelial keratitis is the earliest corneal lesion.

Stromal corneal infiltrates develop within two weeks’ time due to

immune response to the adenovirus.

• Treatment:

1-nonspecific and symptomatic.

2-Broad-spectrum antibiotics are often used to prevent secondary

infections.

3-Topical corcosteroids are recommended in patients with

conjunctival membrane or photophobia.

2-Herpes Simplex Virus Conjunctivitis• Acute follicular conjunctivitis may be caused by HSV type 1 .• Signs:

unilateral, blepharoconjunctivitis with vesicular lesions on the lids, intense papillary hypertrophy of The conjunctiva and classical dendritic lesion on the cornea. There occurs marked enlargement of the preauricular lymph glands.•Treatment:

self limited.

3-Newcastle Conjunctivitis• Newcastle conjunctivitis is a rare disorder occurring in small

epidemics among poultry workers and is caused by Newcastle virus.

4-Acute trachoma in foreigners• it occurs when a non immunized person is exposed to heavy dose of

infection by chlamydia trachomatis.

5-Contact allergic blephro-conjunctivitis• resulting from allergy to eye drops as brimonidine.

Chronic follicular conjunctivitis

trachoma

• Def:trachoma is a chronic infective disease which affects the conjunctiva

and cornea of humansIt means roughness in Greekcaused by Chlamydia trachomatis (serotypes A,B,C )it is endemic in Egypttransmitted by contact with conjunctival discharge

• Pathology:

trachomatous agent secretes toxins that diffuse to subepithelial tissue leading to

a chronic inflammatory reaction (follicle)

follicles increase in size forming papillae

healing occurs by fibrosis (cicatrisation)

hyaline degeneration then calcification,in secretions that are retained between

papillae

• Classification:

McAllen's classification:

Stage 1(incipient trachoma): Characterized by:--minimal papillary hyperplasia &immature follicles on the upper palpebral conjunctiva-may be associated with micropannus

Stage 2 (manifest trachoma): Characterized by:--Mature soft follicles on the superior tarsal conjunctiva-Papillary hypertrophy and gross pannus--limbal follicles or herbert's pits

Stage 3 (Healing trachoma):Characterized by:-

-Cicatrization or scarring develops around the ncrotizing trachomatous follicles

-Signs of stage 2 may be present

Stage 4 (Healed trachoma): Characterized by:-

-follicles and papillary hypertrophy disappear

-pannus resolves

-Herbert's pits may be seen or not at limbus-palpebral conjunctiva is completely cicatrized and smooth, the scar may be thin or thick

Who classification: Includes 5 stagesTF:

-trachomatous follicular inflammation-5 or more follicles in upper tarsal conjunctiva

TI:-Trachomatous inflammation-inflammatory thickening of the upper tarsal conjunctiva that includes several tarsal deep vessels

TS:-Trachomatous scarring-presence of scarring in tarsal conjunctiva

TT:-Trachomatous trichiasis-in which eyelashes are rubbing on the eyeball

CO:-Corneal opacity-easily visible corneal opacity that involves a part of the pupillary

margin

• C/P:

Incubation period: 5 to 12 days

Insidious: onset

Symptoms:

foreign body sensation, watering, itching, photophobia , redness and

scanty mucopurulent discharge

Signs:The conjunctiva:

A-The active stage : upper palpebral conjunctiva and fornix show:1-immature,non-expressible,yellowish ,not raised follicles2-mature,expressible,large follicles3-fine,pink,finger-like papillae. giving the surface velvety appearance

B-The healing stage: there is:1-irregular,white,fibrous patches (linear or star shaped)2-Arlet line :a white line of fibrosis in sulcus subtarsalis3-PTDs, and PTCs :numerous white spots

The cornea:1- Herbert’s rosettes:

- multibleyellow follicles in the upper cornea . caused by aggregation of inflammatory cells between epithelial cells and Bowman’s membrane

- on healing:they leave depressed pits (Herbert’s pits)2- trachomatous pannus:

- pannus means:vascularization and infiltration by chronic inflammatory cells in the superficial layers of cornea

- stages:progressive/regressive/healed3- trachomatous ulcers:

- typical:related to pannus on its surface or at its edges . linear,horizontaland superficial

- atypical: has any shape and size

• Complications:

1-corneal ulceration

2-Iritis

3-cicatrization….

4-Trachomatous ptosis

• Diagnosis: The clinical diagnosis of trachoma requires the presence of at least

two of the following signs:(i) follicles or Herbert’s pits(ii) epithelial or subepithelial keratitis(iii) pannus(iv) cicatrization

The diagnosis can be confirmed by direct demonstration of the inclusion bodies in conjunctival scrapings and staining with Giemsa or iodine stain

DNA amplification techniques that use the polymerase chain reaction (PCR) or the ligase chain reaction (LCR) are very sensitive for diagnosing trachoma. However, these tests are time consuming and expensive.

• Treatment:

(All cases of active trachoma must be treated)

Ciprofloxacin, erythromycin, tetracycline, ofloxacin and azithromycin

are quite effective against TRIC agent

Instillation of ciprofloxacin 0.3% or ofloxacin 0.3% eye drop 4 times a

day and application of 1% erythromycin or tetracycline ointment at

bed time for 6 weeks control the infection in most cases

250 mg erythromycin or tetracycline 4 times a day or doxycycline 100

mg twice a day) for 3 weeks provides dramatic results

It is claimed that a single dose of azithromycin 20 mg per kg body

weight for children and a single dose of 1-1.5 g for adults gives

superior cure rate of trachoma. Further, azithromycin has fewer side

effects than tetracycline and sulfonamides.

Chloramphenicol and penicillin are less effective.

Aqueous soluble sulfonamide (20-30%) topically and long-acting

sulfonamide orally may be used. However, sulfa drugs may cause

allergic reaction in some patients.

To combat trachomatous blindness, the WHO has developed the SAFE

strategy

It is an acronym for: S: Surgery for trichiasis A: Antibiotic treatment of

active infection F: Facial cleanliness E: Environmental improvement To

eliminate trachoma and its blindness

each component of the SAFE strategy must be implemented

A follow-up examination is necessary to assess the complete cure of the

disease

In Persistent trachoma follicles:

combination of local and systemic antibiotic therapy is preferred no matter

one has to continue the drug for a longer time.

• Control:

Trachoma is a specific communicable keratoconjunctivitis which is a

public health problem in the developing countries

The disease is closely associated with personal hygiene and

environmental sanitation

Trachoma often spreads by the transfer of infected conjunctival

secretions through fingers, common towel and flies

Therefore, mothers are instructed not to apply eye cosmetics (Kajal)

to all children of the family with the same finger.

Toxic follicular conjunctivitis

Molluscum contagiosum • Molluscum contagiosum is caused by a virus and it causes a low grade

follicular conjunctivitis• The conjunctival lesions and corneal vascularization occur due to the

release of viral proteins and other substances in the tear film. More than one molluscum nodules may be present on the lid margin • Molluscum nodules on the skin of the eyelids are small and smooth

with an umblicated core• Treatment:

excision or cryo application to the eyelid nodule

folliculosis

• a condition characterized by the development of a large number of

lymph follicles, which may or may not be associated with an infection

• In conjunctival folliculosis the large number of lymph follicles may

give the conjunctival sac a granular appearance

• affects children in association with enlarged tonsils and adenoids

• the follicles are present in the lower palpebral conjunctiva and are

arranged in parallel rows

Thank You