Viral Konjungtivitis

8/18/2019 Viral Konjungtivitis

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Bacterial konjungtivitis

Pathophysiology

The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as

streptococci, staphylococci, and Corynebacterium strains. Alterations in the host defense or in thespecies of bacteria can lead to clinical infection. Alteration in the flora can occur by external

contamination (eg, contact lens wear, swimming) or spread from adjacent infectious sites (eg, rubbing

of the eyes).

The primary defense against infection is the epithelial layer coering the conjunctia. !isruption of this

barrier can lead to infection. "econdary defenses include hematologic immune mechanisms carried

by the conjunctial asculature# tear film immunoglobulins and lysozyme# and the rinsing action of

lacrimation and blin$ing.

%tiology

&acterial conjunctiitis most often occurs in otherwise healthy indiiduals. 'is$ factors include

freuent exposure to infected indiiduals, contact lens wear, sinusitis, immunodeficiency states, and

exposure to agents of sexually transmitted disease at birth.

%pidemiology

&acterial conjunctiitis is common worldwide. ost benign cases are treated with topical antibiotics or

can resole spontaneously. *nternationally, isolated epidemics can be deastating in areas affected by

blinding infections of newborns, especially in areas heaily affected by Chlamydia trachomatis.+-

Racial and sexual differences in incidence

&acterial conjunctiitis occurs in persons of all races, although differences in freuencies may be

reflected by geographical ariations of pathogen prealence.

ales and females hae eual natural resistance to bacterial conjunctiitis. !ifferences in infection

rates may reflect enironmental and behaioral patterns, such as the exposure of female elementary

school teachers to children affected by the condition.

Age-related differences in incidence

Age is a releant factor in the significance of bacterial conjunctiitis. The practitioner must be igilant

in considering sexually transmitted diseases caused by Neisseria gonorrhoeae and Chlamydia in

sexually actie age groups and in newborns who may hae been exposed during birth. Tactful and

confidential history ta$ing are a necessary s$ill so as not to iolating *PPA regulations. *n an ethical

or medicolegal situation, obtaining adice from administration and/or colleagues is recommended.

Prognosis

The prognosis for complete recoery without seuelae is excellent in bacterial conjunctiitis, as long

as the cornea is not inoled. 0omplications are expected to deelop only in cases caused by

extremely pathogenic bacteria, such as Chlamydia trachomatis or N gonorrhoeae.


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ortality in the setting of bacterial conjunctiitis is related to the failure to recognize and treat the

underlying disease. "epsis and meningitis caused by N gonorrhoeae can be life threatening.+1- 0hlamydial infection in the newborn can lead to pneumonia and/or otitis media. +2-

"igns and symptoms of discomfort, mucopurulent ocular discharge, and conjunctial redness are

common in benign cases and often lead to absence from wor$ and school to minimize infection toothers. orbidity can be associated with misdiagnosis. "ince many eye diseases cause the eye to be

red, it is beneficial to hae a solid approach to diagnosis.

Physical %xamination

0onjunctial injection may be present segmentally or diffusely. The palpebral conjunctial pattern may

hold clues to the etiology.

3sing slit4lamp biomicroscopy and eerting both the upper and lower eyelids, follicles or papillae can

be identified on the inflamed conjunctia. 5ollicules hae blood essels that circumscribe the base of

tiny eleated lesions. 5ollicules are characteristic of a iral or chlamydial conjunctiitis. Papillae haeessels coming up the center of the tiny eleated lesion and are characteristic of bacterial or allergic

conjunctiitis.

The discharge in bacterial conjunctiitis is typically more purulent than the watery discharge of iral

conjunctiitis. Thus, there is more 6mattering6 of the lid margins and associated difficulty in prying the

lids open following sleep. The mucopurulent discharge can appear white, yellow, or een greenish in

color.

*n uncomplicated bacterial conjunctiitis, slit lamp examination reeals a uiet anterior chamber that is

deoid of cells and flare. The itreous is also unaffected.

A preauricular lymph node is unusual in bacterial conjunctiitis but is found in seere conjunctiitis

caused by N gonorrhoeae. *t is associated with iral ocular syndromes, typically herpes simplex

$eratitis and epidemic $eratoconjunctiitis.

%yelid edema is often present, but it is mild in most cases of bacterial conjunctiitis. "eere lid edema

in the presence of copious purulent discharge raises the suspicion N gonorrhoeae infection.

7isual acuity is presered in bacterial conjunctiitis 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 conjunctiitis. A fixed pupil in the setting of a red eye shouldraise the suspicion for angle4closure glaucoma or iritis with posterior synechiae.

!ilation and tortuosity of the major essel injection suggests a caernous sinus4carotid artery fistula

rather than conjunctiitis.

0omplications

&acterial conjunctiitis, as long as the cornea is not affected, seldom leads to complications.

8eneral concerns include membrane formation and subseuent scarring of the punctum# corneal

ulcer when the epithelium is not intact# and symblepharon from seere inflammation.

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*n eyes with preious intraocular surgery, particularly with filtering blebs, endophthalmitis could result.

Topical Antibiotic Therapy

Practice patterns for prescribing topical antibiotics ary. ost practitioners prescribe a broad4spectrum

agent on an empirical basis without culture for a routine, mild4to4moderate case of bacterialconjunctiitis. Always be aware of the differential diagnosis, and instruct patients to see$ follow4up

care if the expected improement does not occur or if ision becomes affected.

0ommonly used first4line topical agents include the following9

• Trimethoprim with polymixin &

• 8entamicin

• Tobramycin

• :eomycin

• 0iprofloxacin

•;floxacin

• 8atifloxacin

• %rythromycin

Topical antibiotics can be administered in the form of eye drops or ointments. %ye drops hae the

adantage of not interfering with ision. ;intments hae the adantage of prolonged contact with the

ocular surface and an accompanying soothing effect.

:eonatal 0hlamydial and 8onococcal *nfection

0hlamydial infection of the newborn reuires systemic treatment of the neonate, the mother, and at4

ris$ contacts. The neonate may be treated with erythromycin orally in liuid form == mg

orally twice daily for ? days.

N gonorrhoeae infection of the newborn also reuires systemic treatment of the neonate, the mother,

and at4ris$ contacts. The neonate may be treated with intraenous aueous penicillin 8 >== units/$g/d

in 2 diided doses for > wee$. The mother and at4ris$ contacts may be treated with a single dose of

intramuscular ceftriaxone >< mg followed by oral doxycycline >== mg twice daily for ? days.

Prophylaxis against ophthalmia neonatorum

Prophylaxis against ophthalmia neonatorum is a major force in the worldwide effort to preentblindness. +@ siler nitrate solution, >@ tetracycline

ointment, or =.


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A patient with bacterial conjunctiitis should wash hands often and aoid contaminating public

swimming pools. or$ers and students often are excused during the first seeral days of treatment to

decrease the possibility of spread.

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Viral Konjungtivitis