Conjunctiva 2

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  • 1. Infective Conjunctivitis

2. Classification of conjunctivitis

  • 1. Based on Onset
  • a. Acute b. Subacute c. Chronic
  • 2. Based on type of Exudate
  • Serous, Catarrhal (allergic), Purulent, Mucopurulent, Membranous, Pseudomembranous
  • 3.Based on conjunctival response
  • Follicular, Papillary, Granulomatous (fungal, Parinaud oculoglandular syndrome, parasitic, foreign body)
  • 4. Based on Aetiology
  • a. Infectious bacterial, viral, chlamydial, fungal, parasitic
  • b. Noninfectious allergic, irritants, autoimmune, dry eye, toxic.

3. Infective conjunctivitis

  • 1. Bacterial conjunctivitis
  • 2. Viral conjunctivitis
  • 3. Chlamydial conjunctivitis
  • 4. Fungal conjunctivitis
  • 5. Parasitic conjunctivitis

4. 5. Bacterial conjunctivitis: Acute purulent and mucopurulent conjunctivitis

  • Aetiology :
  • Staph. aureus and albus
  • Haemophilus influenzae and aegypticus
  • N. gonorrhoeae and meningitidis
  • Strept. Pyogenes and pneumoniae
  • Moraxella lacunata
  • Proteus
  • Klebsiella
  • E.coli
  • Diphtheroids

6. Acute purulent and mucopurulent conjunctivitis

  • Commonly seen in children and adults
  • Self-limiting condition
  • Spread of infection : direct contact with infected secretions
  • Clinical features depend on virulence and pathogenicity of the organism and the hosts immune response.

7. Acute purulent and mucopurulent conjunctivitis

  • Symptoms:
  • Acute redness, grittiness, burning, discharge, on waking eyelids stuck together and difficult to open
  • Both eyes are usually involved, although one may become affected before the other.

8. Acute purulent and mucopurulent conjunctivitis

  • Signs :
  • Eyelids : crusted, oedematous
  • Discharge : initially watery, later becomes mucopurulent
  • Injection : maximum at the fornices
  • Tarsal conjunctiva : velvety, beefy-red (Fiery-red) appearance, mild papillary changes
  • Superficial punctate epithelial erosions may be seen
  • Flakes of mucus passing across the cornea colored haloes owing to prismatic action.

9. Acute purulent and mucopurulent conjunctivitis

  • Presence of purulent or mucopurulent discharge is suggestive of bacterial infection. It is usually not possible to make a diagnosis of the organism clinically
  • However, certain features do indicate an increased likelihood of certain specific infections :
  • Pneumococcal conjunctivitis : chemosis, small ecchymoses, pseudomembrane
  • N. gonorrhoeae conjunctivitis(Hyperacute conjunctivitis/ acute blenorrhoea) : severe form of acute purulent conjunctivitis, moderate to severe pain, lid swelling, copious purulent discharge (discharge reaccumulates within seconds of cleaning), tender (sometimes suppurative) preauricular lymphadenopathy.

10. Acute purulent and mucopurulent conjunctivitis

  • Complications: rare
  • Mild and untreated or partially treated may become less intense, chronic condition
  • Abrasions of cornea may get infected causing ulcers
  • Superficial keratitis/ marginal ulcers

11. Acute purulent and mucopurulent conjunctivitis

  • Treatment:
  • Even without treatment simple conjunctivitis resolves within 10-14 days and laboratory tests are not routinely performed.
  • Eyes should not be bandaged (prevents drainage of discharge)
  • Dark goggles/sun shade should be worn to prevent discomfort in bright light.
  • Patient must keep his hands clean
  • No one else should be allowed to use patients towel, handkerchief, pillow or other fomites.

12. Acute purulent and mucopurulent conjunctivitis

  • Antibiotic drops(broad-spectrum) chloramphenicol, ciprofloxacin, ofloxacin, lomefloxacin, moxifloxacin, gentamicin, neomycin, tobramycin in a frequency of 4-6 times a day is prescribed empirically.
  • Antibiotic Ointment: applied into lower fornix and smeared along lids at bedtime prevents lids from sticking together by retained secretions , obviate pain on opening lids, provide higher concentrations for longer periods than drops (use during day causes blurred vision) chloramphenicol, gentamicin, tetracycline, ciprofloxacin, tobramycin
  • Topical steroids should NOT be used.

13. Gonococcal Keratoconjunctivitis

  • Gonorrhoea is a venereal genitourinary tract infection caused by Gram-negative diplococcus Neisseria gonorrhoeae capable of invading the intact corneal epithelium. Incubation period : hours to 3 days

14. Gonococcal Keratoconjunctivitis

  • Conjunctivitis:
  • Eyelids : oedematous and tender
  • Discharge : profuse, purulent
  • Intense conj. Hyperemia, chemosis, pseudomembrane formation
  • Lymphadenopathy- promiment, may suppurate in severe cases
  • Keratitis:
  • Marginal ulceration in the pus filled sulcus between chemosed conjunctiva and the cornea at the limbus
  • Coalescence to form a peripheral ring ulcer
  • Central ulceration may rapidly lead to perforation and endophthalmitis
  • Iritis and iridocyclitis: may be present

15. Gonococcal Keratoconjunctivitis

  • Diagnosis: aided by coincident urethritis.
  • Treatment:
  • patient hospitalized, cultures taken, discharge removed at frequent intervals by irrigation with warm saline
  • Systemic treatment: Single dose of Ceftriaxone 1 gm im / cefotaxime 1 gm iv bd x 3-5 days
  • Topical treatment: ciprofloxacin, ofloxacin, gentamicin , tobramycin drops hourly, bacitracin ointment 6 hourly, cycloplegics for corneal involvement. Patients allergic to penicillin/cephalosporins : tetracycline
  • Skin and VD consultation, treatment of patients sexual partner
  • No immunity is conferred by the attack.

16. Membranous and pseudomembranous conjunctivitis

  • Organisms : Corynebacterium diphtheriae, beta-hemolytic streptococci, Streptococcus pneumoniae, Haemophilus aegypticus, Neisseria gonorrhoeae, Staph. Aureus and E.coli.
  • Pseudomembranous :palpebral conj covered with white membrane which peels off easily without much bleeding, associated with mild cases of conjunctivitis with mucopurulent discharge.
  • Membranous :Diphtheritic + Strept. pyogenes infection, associated with severe cases , lid edema, palpebral conj covered with true membrane compressing the vessels, impairing mobility, which separates less readily, with bleeding from the underlying surface, prevents the formation of free discharge.

17. Membranous and pseudomembranous conjunctivitis

  • Membranous and pseudomembranous types cannot be distinguished clinically with certainty, hence it is best to use the term membranous conjunctivitis until a bacteriological diagnosis is done.
  • Membrane may be patchy or cover the entire palpebral conj, but not the bulbar conj.
  • Preauricular lymph node may be enlarged

18. Membranous and pseudomembranous conjunctivitis

  • Complications :corneal ulcer, symblepharon formation
  • Treatment :
  • After sending samples for cultures, treated as in purulent bacterial conjunctivitis.
  • Removal of membrane is not required. (if done may precipitate symblepharon formation)
  • Streptococcal membranous conjunctivitis : danger to cornea intense systemic + topical antibiotics required
  • In children not immunised, every case is treated as diphtherial unless cultures are negative intense topical + systemic penicillin along with injection of antidiphtheritic serum

19. Ophthalmia neonatorum

  • Neonatal conjunctivitis isdefinedas mucoid, mucopurulent or purulent discharge from one or both eyes in the first month of life.
  • Any discharge, even a watery secretion, from a babys eyes during the first week should be viewed with suspicion, since tears are not secreted so early in life.
  • It is a preventable disease occurring in newborn child due to maternal infection acquired at the time of birth, and used to be responsible for 50 % of blindness among children. Recently almost eliminated except in communities with poor hygiene and limited healthcare .

20. Ophthalmia neonatorum

  • Differential diagnosis:congenitally blocked nasolacrimal duct, acute dacryocystitis, congenital glaucoma
  • Bacteriological examinationshould be done in every case: Grams and Giemsa staining of conj. Smears, Chlamydial immunoflourescent antibody test on conj scrapings, viral,chlamydial and bacterial C/S.

21. Ophthalmia neonatorum: mode of presentation, differential diagnosis and treatment 22. Ophthalmia neonatorum

  • Neisseria gonorhoeae: within 48 hrs