Conjunctivitis

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  • Bacterial conjunctivitis
    • Staphylococcus aureus is the most common cause  (MCQ)
    • Haemophilus influenzae (aegyptius, Koch- Weeks bacillus).
      • classically causes epidemics of mucopurulent conjunctivitis, known as ‘red-eye’.
    • Moraxella lacunate (Moraxella Axenfeld bacillus) (MCQ)
      • most common cause of angular conjunctivitis and angular blepharoconjunctivitis.
    • Neisseria gonorrhoeae
      • typically produces
        • acute purulent conjunctivitis in adults
        • ophthalmia neonatorum in new born.
      • It is capable of invading intact corneal epithelium.(MCQ)
  • Angular conjunctivitis (MCQ)
    • It is a type of chronic conjunctivitis
    • characterised by mild grade inflammation confined to the conjunctiva and lid margins near the angles (hence the name) associated with maceration of the surrounding skin.
    • Etiology
      • Moraxella Axenfeld is the commonest causative organism.
      • MA bacilli are placed end to end, so the disease is also called ‘diplobacillary conjunctivitis’
    • Curative treatment consists of :
      • Oxytetracycline (1%) eye ointment
      • Zinc lotion
  • Viral conjunctivitis
    • Most of the viral infections tend to affect the epithelium, both of the conjunctiva and cornea,
    • typical viral lesion is a ‘keratoconjunctivitis’.
    • conjunctival involvement is more prominent (e.g., pharyngo-conjunctival fever)
    • corneal involvement is more prominent (e.g., herpes simplex).
  • Acute haemorrhagic conjunctivitis (mcq)
    • It is an acute inflammation of conjunctiva charac-terised by multiple conjunctival haemorrhages, conjunctival hyperaemia and mild follicular hyperplasia.
    • The disease is caused by picornaviruses (enterovirus type 70) which are RNA viruses of small (pico) size. (MCQ)
    • The disease is very contagious
    • transmitted by direct hand-to-eye contact.
    • The disease is also called
      • epidemic haemorrhagic conjunctivitis (EHC) (MCQ)
      • Apollo conjunctivitis
    • Incubation period of EHC is very short (1-2 days).
    • Usually the disease has a self-limiting course of 5-7 days.
  • Follicular conjunctivitis
    • Follicles are formed due to localised aggregation of lymphocytes in the adenoid layer of conjunctiva.
    • Their appearance resembles boiled sago- grains.
  • Epidemic Keratoconjunctivitis (EKC) (MCQ)
    • It is a type of acute follicular conjunctivitis
    • mostly associated with superficial punctate keratitis
      • a distinctive feature of EKC
    • usually occurs in epidemics, hence the name EKC.
    • EKC is mostly caused by adenoviruses type 8 and 19 (MCQ)
    • The condition is markedly contagious
    • spreads through contact with contaminated fingers, solutions and tonometers.
    • Incubation period after infection is about 8 days
    • virus is shed from the inflamed eye for 2-3 weeks.
    • Preauricular lymphadenopathy is associated in almost all cases (MCQ)
    • Treatment.
      • results are reported with adenine arabinoside (Ara-A).
      • Corticosteroids should not be used during active stage.
  • Vernal keratoconjunctivitis (vkc) or spring catarrh
    • It is a recurrent, bilateral, interstitial, self-limiting, allergic inflammation of the conjunctiva having a periodic seasonal incidence.
    • It is considered a hypersensitivity reaction to some exogenous allergen, such as grass pollens.
    • It is atopic allergic disorder in many cases
    • IgE-mediated mechanisms play an important role.
    • Such patients may give personal or family history of other atopic diseases such as hay fever, asthma, or eczema
    • peripheral blood shows eosinophilia and inceased serum IgE levels.
    • Predisposing factors
      • Age and sex.
        • 4-20 years
        • more common in boys than girls (MCQ)
      • Season.
        • More common in summer; hence the name spring catarrh looks a misnomer.
        • Recently it is being labelled as Warm weather conjunctivitis’.
      • Climate. More prevalent in tropics
    • Pathology
      • Conjunctival epithelium
        • undergoes hyperplasia
        • sends downward projections into the subepithelial tissue.
      • Adenoid layer
        • shows marked cellular infiltration by eosinophils, plasma cells, lymphocytes and histiocytes.
      • Fibrous layer
        • shows proliferation which later on undergoes hyaline changes.
      • Conjunctival vessels
      • show proliferation, increased permeability and vasodilation.
    • Clinical picture
      • Symptoms.
        • marked burning and itching sensation which is usually intolerable
          • accentuated when patient comes in a warm humid atmosphere.
        • Itching is more marked with palpebral form of disease.
        • Other associated symptoms include:
          • mild photophobia
          • lacrimation
          • stringy (ropy) discharge (MCQ)
          • heaviness of lids.
      • Signs
        • Palpebral form.
          • Usually upper tarsal conjunctiva of both eyes is involved. (MCQ)
          • cobble-stone’ apprearence (MCQ)
            • The typical lesion is characterized by the presence of hard, flat topped, papillae arranged in a cobble-stone’ or ‘pavement stone’, fashion
          • ‘giant papillae’
            • In severe cases, papillae may hypertrophy to produce cauliflower like excrescences of ‘giant papillae’.
          • Conjunctival changes are associated with white ropy discharge. (MCQ)
        • Bulbar form is characterised by
          • dusky red triangular congestion of bulbar conjunctiva in palpebral area;
          • gelatinous thickened accumulation of tissue around the limbus;
          • presence of discrete whitish raised dots along the limbus (Tranta’s spots) (MCQ)
        • Mixed form shows combined features of both palpebral and bulbar forms
        • Vernal keratopathy.
          • Corneal involvement in VKC shows 5 types of lesions:
          • Punctate epithelial keratitis
            • involves upper cornea
            • usually associated with palpebral form of disease.
            • The lesions always stain with rose bengaland invariably with fluorescein dye.
          • Ulcerative vernal keratitis (shield ulceration) (MCQ)
            • presents as a shallow transverse ulcer in upper part of cornea.
          • Vernal corneal plaques
          • Subepithelial scarring occurs in the form of a ring scar.
          • Pseudogerontoxon (MCQ)
            • characterised by a classical ‘cupid’s bow’ outline.
    • Clinical course of disease
      • often self-limiting
      • usually burns out spontaneously after 5-10 years.
    • Differential diagnosis.
      • Palpebral form of VKC needs to be differentiated from trachoma with pre-dominant papillary hypertrophy
    • Treatment
      • Local therapy
        • Topical steroids
          • Medrysone and fluorometholone are safest of all these.
        • Mast cell stabilizers such as sodium cromoglycate (2%) drops (MCQ)
        • Topical antihistaminics are also effective.
        • Acetyl cysteine (0.5%) used topically has mucolytic properties
        • Topical cyclosporine (1%) drops
      • Systemic therapy
        • Oral antihistaminics
        • Oral steroids
      • Treatment of large papillae.
        • Supratarsal injection of long acting steroid
        • Cryo application
        • Surgical excision
  • Phlyctenular keratoconjunctivitis (MCQ)
    • a characteristic nodular affection
    • occur as an allergic response of the conjunctival and corneal epithelium to some endogenous allergens to which they have become sensitized.
    • It is believed to be a delayed hypersensitivity (Type IV-cell mediated) response to endogenous microbial proteins.(MCQ)
    • Causative allergens
      • Tuberculous proteins
      • Staphylococcus proteins are now most common cause.(MCQ)
      • Other allergens may be
        • proteins of Moraxella Axenfeld bacillius
        • certain parasites (worm infestation).
    • Predisposing factors
      • Age. Peak age group is 3-15 years.
      • Sex. Incidence is higher in girls than boys.
      • Undernourishment. Disease is more common in undernourished children.
      • Living conditions. Overcrowded and unhygienic.
      • Season.
        • It occurs in all climates
        • incidence is high in spring and summer seasons.
    • Presence of one or more whitish raised nodules on the bulbar conjunctiva near the limbus, with hyperaemia usually of the surrounding conjunctiva, in a child living in bad hygienic conditions (most of the times) are the diagnostic features of the phlyctenular conjunctivitis.
    • Clinical course
      • usually self-limiting
      • phlycten disappears in 8-10 days leaving no trace.
      • However, recurrences are very common.
  • Management
    • Local therapy.
      • Topical steroids
      • Antibiotic drops and ointment
      • Atropine (1%) eye when cornea is involved.

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