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Infective Conjunctivitis
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.
Infective conjunctivitis
1. Bacterial conjunctivitis 2. Viral conjunctivitis 3. Chlamydial conjunctivitis 4. Fungal conjunctivitis 5. Parasitic conjunctivitis
Bacterial conjunctivitis: Acute purulent and mucopurulent conjunctivitisAetiology: Staph. aureus and albus Haemophilus influenzae and aegypticus N. gonorrhoeae and meningitidis Strept. Pyogenes and pneumoniae Moraxella lacunata Proteus Klebsiella E.coli Diphtheroids
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 host’s immune response.
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.
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.
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.
Acute purulent and mucopurulent conjunctivitisComplications : 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
Acute purulent and mucopurulent conjunctivitisTreatment: 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.
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.
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
Gonococcal KeratoconjunctivitisConjunctivitis : 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
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 patient’s sexual partner
No immunity is conferred by the attack.
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.
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
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
Ophthalmia neonatorum
Neonatal conjunctivitis is defined as mucoid, mucopurulent or purulent discharge from one or both eyes in the first month of life.
Any discharge, even a watery secretion, from a baby’s 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.
Ophthalmia neonatorum Differential diagnosis: congenitally blocked
nasolacrimal duct, acute dacryocystitis, congenital glaucoma
Bacteriological examination should be done in every case: Gram’s and Giemsa staining of conj. Smears, Chlamydial immunoflourescent antibody test on conj scrapings, viral,chlamydial and bacterial C/S.
Ophthalmia neonatorum: mode of presentation, differential diagnosis and treatment
Ophthalmia neonatorumNeisseria gonorhoeae : within 48 hrs Mucopurulent and later purulent discharge Marked chemosis and injection– retractors required to
examine baby’s eyes Tense and swollen lids False membrane may form Corneal ulceration may occur - perforation Complications –
Perforation : anterior synechiae, adherent leucoma, anterior staphyloma, anterior capsular cataract, panophthalmitis.
Dense corneal opacities : nystagmus
Ophthalmia neonatorum
Chlamydia trachomatis inclusion conjunctivitis: > 1 week after birth Less severe than gonococcal type No follicles (no adenoid layer in children) Superficial keratitis – pannus Complications : pneumonia, otitis
Ophthalmia neonatorum Treatment : As the disease is preventable, prophylactic treatment is of
prime importance. Any suspicious vaginal discharge during antenatal period should be
treated, and meticulous obstetric asepsis maintained at birth.
Newborn baby’s closed lids should be thoroughly cleansed with sterile cotton-wool soaked in sterile normal saline and dried.
If mother suspected to be infected with gonococci or chlamydia, then 1% tetracycline or erythromycin eye ointment should be applied.
Eyes should be carefully watched during the first week. If ophthalmia neonatorum is confirmed, then initial treatment is based on
the immediate results of Gram and Giemsa stains. Once the sensitivity is available antibiotic may be changed if required depending upon clinical response