Ophthalmia nodosaNodular conjunctivitis due to irritation

caused by caterpillar hairsSmall semitranslucent, reddish or yellowish-

grey nodules are formed on the conjunctiva, cornea and sometimes in the iris

Microscopic examination shows hairs surrounded by giant cells and lymphocytes

Treatment : excision of conj nodules containing the hairs, antibiotics, cyclopegics

Allergic catarrhal conjunctivitis

Most common form of ocular and nasal allergyCinical subtypes:1. Acute allergic conjunctivitis : immediate reaction to

allergens2. Seasonal allergic rhinoconjunctivitis : conjunctivitis part of hay

fever, during the summer – common allergens are pollens or certain flowers (primula, etc)– elevated IgE levels in plasma and tears.

3. Perennial allergic rhinoconjunctivitis : causes symptoms throughout the year with exacerbation in the autumn when exposure to dust mites and fungal allergens is greatest.

Other allergens: animals (horses, cats), chemicals, cosmetics, eyelash dyes , drugs (atropine, brimonidine allergy)

Acute allergic catarrhal conjunctivitisPresentation : transient, acute attacks of redness, watering and

itching associated with sneezing and nasal discharge. (hyperemia is less marked, watery secretion – not purulent, containing eosinophils, tendency for subacute recurrences on renewed contact with the allergen)

Signs : - lid edema - conj has milky or pinkish appearance due to edema and injection - small papillae may be present on upper tarsal conj. Treatment : - Removal of allergen from the environment - Desensitization by course of injections - topical mast cell stabilizers (nedocromil, Iodoxamide, ketotifen) - topical antihistamines ( levocabastine, azelastine, emedastine) - both antihistamine and mast cell stabilizer (Olopatadine 0.1% BD) - Topical steroids short course (Loteprednol etabonate 0.5% QID)

Acute allergic catarrhal conjunctivitis

Acute allergic catarrhal conjunctivitis

Vernal keratoconjunctivitis (spring catarrh)Recurrent, bilateral, external ocular inflammation,

primarily affecting boys and young adults living in warm,dry climates

Occurs with the onset of hot weather (summer), rather than a spring complaint

Family history of atopy is commonPatients may develop asthma and eczema in infancyType I hypersensitivity reaction to pollen and other

atmospheric exogenous allergens mediated by IgE (eosinophilia).

Onset is usually after the age of 5 years and condition resolves around puberty.

May occur on a seasonal basis/ may persist year round

Vernal keratoconjunctivitis (spring catarrh)Symptoms : intense ocular itching,

lacrimation, photophobia, foreign body sensation, burning, white ropy discharge

3 main clinical types :1. Palpebral VKC: 2. Limbal VKC3. Mixed VKC

Vernal keratoconjunctivitis (spring catarrh)1. Palpebral VKC:Difuse papillary hypertrophy, most marked on the superior

tarsusPapillae enlarge and have a flat-topped polygonal

appearance reminiscent of cobblestone (made of dense fibrous tissue with overlying thickened epithelium giving milky hue, infiltration with eosinophils, lymphocytes, plasma cells, macrophages, basophils)

Severe cases: connective tissue septa rupture, giving rise to giant papillae, coated by copious mucus

As inflammation settles, the papillae shrink, become more seperated but do not disappear

2. Limbal VKC:Mucoid nodules scattered around the limbus (gelatinous

thickening of limbus) with discrete white superficial spots (Horner - Tranta dots)composed predominantly of eosinophils and epithelial debris at the apices of the lesions.

3. Mixed VKC

Vernal keratoconjunctivitis (spring catarrh)

Vernal keratoconjunctivitis (spring catarrh)Keratopathy :1. Punctate epithelial erosions : superior cornea2. Shield ulceration : are sterile ulcers which occur in

superior cornea due to cobblestone papillae rubbing on cornea, look like a shield because inferior edge is pointed, may also result from chemical damage to the epithelial surface by mediators released from mast cells and eosinophils, are indolent and may take months to re-epitheliaze, may be complicated by bacterial keratitis, rarely perforation

3. Plaque formation: occurs when the base of the ulcer becomes coated with desiccated mucus – results in defective wetting by tears, prevents re-epithelialization, and predisposes to subepithelial scarring and vascularization

4. Pseudogerontoxon : resembles arcus senilis, “cupid’s bow” outline in a previously inflammed segment of the limbus.

Vernal keratoconjunctivitis (spring catarrh)

Vernal keratoconjunctivitis (spring catarrh)Treatment : Purely symptomatic

1.Topical : a. Steroids : mainly for keratopathy, severe discomfort

with only conj involvement, 4-6 hourly. - Flourometholone has weaker ocular hypertensive

effect than dexamethasone and prednisolone. - treat exacerbations vigorously with high doses, taper

to small dose as quickly as possible, discontinue between attacks

b. Mast cell stabilizers : Nedocromil 4% BD, Iodoxamide QID, can be used for prolonged periods, not effective in controlling acute exacerbations

c. Antihistamines : levocabastine, Olopatadine BD d. Acetylcysteine 0.5% - has mucolytic properties

(controls excess mucus), treatment for plaque formation

e. Cyclosporine 2% : useful in steroid – resistant cases

Vernal keratoconjunctivitis (spring catarrh)2. Supratarsal steroid injection : of betamethasone

or triamcinolone for severe disease not responsive to conventional therapy

3. Surgical Treatment : required for severe shield ulcers resistant to medical therapy – debridement, supericial keratectomy, excimer laser phototherapeutic keratectomy, amniotic membrane transplantation

4. Others : - Cold compresses : relieves irritation - Tinted glasses to provide comfort - Patient dissuaded from rubbing the eyes as this

induces mast cell degranulation with release of

histamine

Giant papillary conjunctivitisCauses : soft hydrophilic contact lens use, protruding

suture ends, ocular prosthesis, after several years of rigid contact lens use

Mechanism : types I and IV hypersensitivity reactionSymptoms : itching, watering, foreign body sensation,

blurring of visionSigns : conjunctival congestion predominantly in

upper palpebral region with large polygonal papillae on suprior tarsal conj.

Macropapillae : 0.3 – 1.0 mm in sizeGiant papillae : 1 – 2 mm in size

Giant papillary conjunctivitis

Giant papillary conjunctivitisTreatment : - discontinue contact lens use - remove offending sutures - cleaning and polishing ocular prosthesis/ replacing

one coated with biocoat (biocompatible material) - topical mast cell stabilizers ( cromolyn sodium 6

hourly / olopatadine 12 hourly) - topical antihistamines - decongestants - artificial tears - topical steroids for short terms if needed - subtarsal long -acting steroid injection in severe cases

Phlyctenular conjunctivitisAetiology : non specific delayed hypersensitivity

reaction to endogenous bacterial proteins (most commonly tuberculo-protein, staphylococcal, chlamydia) or rarely in mild, long-standing infections of tonsils/adenoids. Many patients also have associated blepharitis

Rare today perhaps due to improved hygiene and control of milk infected by bovine tuberculosis

Symptoms : discomfort, irritation, reflex lacrimation, pain and photophobia (reflex blepharospasm) if cornea is involved or mucopurulent complication.

Phlyctenular conjunctivitisSigns : one or more small (1 mm), round, grey or yellow nodules,

slightly raised above the surface, are seen on the bulbar conjunctiva, near the limbus, congestion of the vessels is limited to near the area around the phlyctens.

- In later stages : epithelium over the surface becomes necrotic and small ulcers are formed on conj – heals rapidly without scar

- can be complicated by mucopurulent conjunctivitis - becomes serious when cornea is involved : usually occur near

the corneal margin involving only epithelium and superficial layers

- corneal phlycten is a grey nodule, slightly raised above the surface, may form yellow ulcer if epithelium breaks down – becomes infected usually by staphylococci

- may become absorbed without destruction of superficial layers of stroma (no permanent opacity)

Phlyctenular conjunctivitis

Phlyctenular conjunctivitis

Investigations : for TBTreatment :Steroid drops or ointments have a dramatic

effect in non-tubeculosis patientsIf cornea is involved, antibiotics and

cycloplegicsLid scrubs for associated blepharitisDark glasses may be used

Steven-Johnson syndrome (Erythema multiforme major)

Acute, severe, muco-cutaneous blistering disease, primarily occuring in young healthy individuals (M>F)

Type II hypersensitivity reaction to drugs or systemic infections

Drugs : sulphonamides, NSAIDs , antibiotics, antimlarials, antiepileptics (barbiturates, phenytoin)

Infections : Mycoplasma pneumoniae, Herpes simplex virus, some fungi

Basic lesion is an acute vasculitis, which affects skin and mucous membranes in all patients and conjunctiva in 90%.

Disease can be fatal in some patients

Steven-Johnson syndrome (Erythema multiforme major)Presentation : fever, malaise, sore throat, cough,

arthralgiaSigns :

- crusty eyelids, transient papillary conjunctivitis

- severe membranous/ pseudomembranous conjunctivitis with fibrotic areas is less common

- general : skin rash, erythematous lesions followed by bullae and epidermal necrosis, ulcerative lesions of mucous membranes, esp of mouth.

Complications :

1.Lids : cicatricial entropion

2.Corneal vascularization and scarring

3.Symblepharon formation

4.Epiphora due to punctal occlusion

5.Dry eye due to obstruction of lacrimal gland ductules

6.Keratopathy : secondary to cicatricial entropion, trichiasis

symblepharonCauses : Steven Johnson syndrome, Cicatricial

pemphigoid, Atopic keratoconjunctivitis, Toxic epidermal necrolysis

Adhesions between palpebral and bulbar conjComplications : incomplete blink/lid closure,

exposure keratopathy, entropion, trichiasis, restricted ocular motility, dry eye

Prevention : sweeping the fornix with glass rod coated with antibiotics/paraffin, frequent lubrication with artificial drops/ointments, bandage/scleral contact lenses, systemic immunosuppression

Treatment : symblepharon lysis and fornix reconstruction, amniotic membrane grafting

Steven-Johnson syndrome (Erythema multiforme major)

Symblepharon

Steven-Johnson syndrome (Erythema multiforme major)Treatment :1. Lysis of adhesions forming between bulbar and palpebral

conjunctiva by passing a glass rod coated with antibiotic or plain paraffin ointment in the fornices

2. Systemic steroids : necessary3. Topical steroids : may prevent conj infarction4. Topical antibiotics to prevent secondary infections5. Acyclovir if herpes simplex is suspected6. Scleral ring consisting of a large haptic lens with the

central zone removed helps prevent symblepharon formation7. Other measures : Topical retinoic acid for keratinization,

tear supplements, therapeutic contact lenses, punctal occlusion, surgery to correct permanent lid deformitie, transplantation of conj or buccal mucous membrane, limbal stem cell/ amniotic membrane transplantation to restore integrity and to promote healing