Abstract

Aim : To describe the case profile and conjunctivitis management in dr. Saiful
Anwar Malang, during the period of January 2018 to December 2019.

Methods: This study used a retrospective analysis of the patients medical records
with conjunctivitis diagnosis at dr. Saiful Anwar Malang Hospital during the visit
period from January 2018 to December 2019. The recording included
demographic data such as age and gender, perceived complaints, involved eyes,
conjunctival ophthalmological examinations of papils and follicles, diagnosis and
given treatment.

Results: There were 321 patients diagnosed with conjunctivitis. Demographic

data based on gender obtained 205 women (63.86%) and 116 (36.14%) men. Most
conjunctivitis at the age of 13-25 years (40.50%). All patients (100%) complained
of red eye and the location of the eye involved was bilateral 219 patients
(68.25%). In conjunctival ophthalmology examination as many as 48 patients
(14.95%) had papillae and 60 patients (18.70%) had follicles. There were 208
patients (64.8%) diagnosed by conjunctivitis which was established based on the
onset of the disease and and based on etiology, there were 64 patients (19.94%)
had viral causes, 7 patients (2.18%) of bacterial causes, 33 patients (10, 28%) and
other causes as many as 9 patients (2.80%). The given treatment had some
varieties according to the suspected etiology of the disease. Patients who received
lubrication as many as 304 patients (94.70%), 212 patients (66.04%) received
corticosteroid and antibiotic combination therapy, 92 patients (28.66%) received
antibiotics alone, 2 patients (0.62) received corticosteroids alone and 16 patients
(4.98%) received anti-histamine. The administration of combination therapy with
corticosteroids and antibiotics can be considered to help reduce conjunctival
inflammation and shorten the duration of acute conjunctivitis.

Conclusion: Most cases of conjunctivitis occured in women and the age range
was 13-25 years. Most complaints were red eyes and involved both eyes. The
most common etiology was virus. The given treatment were lubricants and a
combination of corticoteroids and antibiotics.
PREFACE

The conjunctiva is a thin, transparent mucous membrane that lines the anterior
part of the eyeball and the interior of the palpebra. The conjunctiva functions as a
component of the eye's protection system from inflammation and infection.
Conjunctivitis is an inflammatory condition of the conjunctiva that can be caused
by various factors. 1,2

Conjunctivitis and other disorders of the conjunctiva belong to the top 10

outpatient diseases in hospitals in Indonesia, with a number of visits of 87,513.
The number of new cases was 68,026, consisting of 30,250 male patients and
37,776 female patients (Ministry of Health of the Republic of Indonesia, 2010) .3

Conjunctivitis can be classified based on etiology and disease onset. Infectious

conjunctivitis can be caused by viruses, bacteria, parasites and fungi, while non-
infectious conjunctivitis can be caused by allergies and toxins. Based on the onset
of the disease can be acute and chronic. 4,5

Estimates of the proportion of conjunctivitis by etiology vary by age and season.

About 80% of cases of infectious conjunctivitis are caused by viruses and most
(90%) are adenoviruses. Transmission through contact with eye secretions or
inhalation, fomites, contaminated swimming pools and populations who are living
together such as in schools or dormitories.

Other types of viruses that cause viral conjunctivitis are herpetic viruses, namely
herpes simplex virus (HSV) and varicella zoster virus (VZV). Herpetic viral
infection of the eye is the most common cause of blindness in the United States. 10
Primary infection can occur through direct contact with VZV skin lesions or via
airborne droplets. In addition, it can occur due to reactivation of the virus which
then affects the ophthalmic branch ganglion so that the symptoms of herpes zoster
are visible in the eye. Herpes zoster can affect any age but it is more common in
people over 50 years old. Herpes simplex infection can occur through direct
contact with infectious lesions, exposure to asymptomatic viruses or through the
birth canal.
Bacteria are the second most common cause of infectious conjunctivitis and are
responsible for the majority of cases in children (50-75%). Bacterial conjunctivitis
results from the growth and infiltration of bacteria on the epithelium surface of the
conjunctiva. Bacterial conjunctivitis can be caused by both gram-positive and
gram-negative bacteria, but gram-positive bacteria are more dominant.5 Bacterial
conjunctivitis can be transmitted by direct contact with an infected individual (eye
contact with hands) or colonization of the patient's own nasal or sinus mucosal
organisms. Although bacterial conjunctivitis can heal on its own, it can be vision
threatening if it is caused by highly virulent bacteria such as Staphylococcus
pyogenes and Neisseria gonorrhoeae. This conjunctivitis can affect anyone and is
common throughout the world, especially in hot climates.

Meanwhile, allergic conjunctivitis occurs in approximately 15%-40% of the

population in the United States. Allergic conjunctivitis is a non-infectious
inflammation of the conjunctiva due to an allergic reaction, can be a fast reaction
like a normal allergy and a slow reaction after several days of contact such as
reactions to drugs and toxins. In addition, allergic conjunctivitis is a reaction to
humoral antibodies against allergens, usually with a history of atopy.5,6,8

The classic symptoms of bacterial conjunctivists include red eye and foreign body
sensation, morning sticky lashes, purulent or mucopurulent discharge,
conjunctival papillae, and rare preauricular lymphadenopathy. Symptoms of viral
conjunctivitis are itching and watering, a history of recent upper respiratory tract
infections, watery discharge, inferior palpebral conjunctival follicles, and tender
preauricular lymphadenopathy. Allergic conjunctivitis includes symptoms of
itching or burning eyes, a history of allergy / atopy, watery secretions, edema of
the eyelids, conjunctival papillae and no preauricular lymphadenopathy.

Management of viral conjunctivitis is supportive, such as cold compresses and

artificial tears, diligently washing hands to break the chain of transmission. If the
cause is the herpes virus, then oral antivirals are useful for speeding up the
resolution of signs and symptoms. The management of allergic conjunctivitis is to
avoid allergens, administering artificial tears, antihistamines and mast cell
stabilizers.
The purpose of this study was to determine the disease profile and management
given to cases of conjunctivitis in dr. Saiful Anwar Malang Hospital during the
period January 2018 to December 2019.

METHODS

This study was conducted by collecting retrospective data by consecutive

sampling from the medical records of patients diagnosed with conjunctivitis at the
Eye Polyclinic, Infection and Immunology Division and the General Eye
Polyclinic of dr. Saiful Anwar Malang Hospital for 2 years, from January 2018 to
December 2019.

The research data taken from the patient's medical records included age, gender,
clinical signs found on the conjunctiva, kengkinan cause and management given.

STUDY RESULT

The sociodemographic characteristics obtained were age and gender. It was found
that from 321 patients diagnosed with conjunctivitis in dr. Saiful Anwar Malang
Hospital between January 2018 - December 2019 involved in this study as many
as 7 patients (2.18%) 0-13 years of age, 130 patients (40.50%) 14-27 years of age,
61 patients (19.00%) 28-41 years of age, 51 patients (15.89%) 42-55 years of age,
49 patients (15.26%) 56-69 years of age and 23 patients (7.16%) 70-83 years of
age. Characteristics based on age mostly at 14-27 years of age (40.50%). The
distribution of disease based on gender showed 205 patients were female
(63.86%) and 116 patients were male (36.14%) (Figure 1).

The distribution of conjunctivitis based on blurring eye symptoms was occurred in

87 patients (27.10%), red eye was occurred in 321 patients (100%), discharge was
occurred in 219 (68.22%), watery was occurred in 205 patients (63.86%), itching
was occurred in 180 patients (36.07 %), wedge was occurred in 134 patients
(41.74%), glare was occurred in 68 patients (21.18%), and painful for 72 patients
(22.43%). (Figure 2).

Conjunctival papillary examination was found in 48 patients (14.95%), there were

no papils in 181 patients (56.39%) and no data for 92 patients (28.66%). There
were 60 patients (18.69%) had follicles in the conjunctiva, 174 patients (54.21%)
had no follicles and no data for 87 patients (27.10%) (Figure 4).

The distribution of conjunctivitis cases based on the eye involved was mostly
bilateral with 219 patients (68.22%), whereas unilateral was 102 patients
(31.78%) (Graph. 5).

The distribution of conjunctivitis based on possible causes was divided into viral
causes as many as 64 patients (19.94%), 7 patients with bacteria (2.18%), 33
patients with allergies (10.28%) and other causes (SJS, drugs) as many as 9
patients (2.80%). Meanwhile, as many as 208 patients (64.8%) had conjunctivitis
based on acute disease onset (Figure 6).

Based on the management of the therapy given, they received lubricants from 304
patients (94.70%) combined with antibiotics and corticosteroids for 212 patients
(66.04%), antibiotics for 92 patients (28.66%), corticosteroid for 2 patients
(0.62%) and anti-histamine for 16 patients (4.98%) (graph 7).

DISCUSSION

In this study, it was found that the highest number of conjunctivitis patients was in
the age range of 14-27 years, namely 130 patients (40.50%) of a total of 321
patients. This study was done by taking medical record data of patients who
visited the Infection and Immunology division polyclinic and general eye
polyclinic, while cases in children were obtained based on the number of
consulants from the Pediatric Ophthalmology and Strabismus Division so that it
affected the number of cases.

Based on the sex, the most conjunctivitis was in women as many as 205 patients
(63.86%) from a total of 321 patients, in contrast to the results of the study at
Indera Hospital Denpasar, 2014, which found that the majority of conjunctivitis
was male. This is in accordance with the literature which states that conjunctivitis
can occur at all ages, sexes and social strata.

Based on the most affected eyes were bilateral as many as 219 patients (68.22%).
Conjunctivitis often affects the eyes bilaterally, but can also occur unilaterally.
Conjunctivitis affecting both eyes is usually due to allergic conjunctivitis. In
bacterial or virus infectious conjunctivitis usually starts in one eye and then within
a few days spreads to the other side. The increased risk of transmission to the
other side of the eye is influenced by the location of the two eyes being close
together. This condition is transmitted through eye contact with hands
contaminated with bacteria or germs. 2, 4, 6

Based on the symptoms experienced by patients in this study, the symptoms of

blurred eyes were 87 patients (27.10%), red eyes were in 321 patients (100%),
discharge were in 219 (68.22%), watery were 205 patients (63.86%), itching were
180 patients (36.07%), bumped 134 patients (41.74%), glare in 68 patients
(21.18%), painful 72 patients (22.43%). Conjunctivitis has clinical symptoms
similar to other eye diseases that threaten vision. A complete history and physical
examination are needed to establish the correct diagnosis and management
according to etiology. 6,7,8

Visual disturbances in conjunctivitis may be mild due to debris on the tear film. If
there is severe visual disturbance, it is necessary to suspect a corneal or other eye
disease. Conjunctival injection or pink eye is the predominant clinical sign of
conjunctivitis. The cause of this inflammation can be due to infectious pathogens
or non-infectious irritants. The result of this irritation or infection is injection or
dilation of the posterior conjunctival vessels, which differentiates it from ciliary
injections involving branches of the anterior ciliary artery and indicates
inflammation of the cornea, iris or ciliary body. It is important to differentiate
conjunctivitis pink eye from other pink eye diseases such as blepharitis, corneal
abrasion, foreign bodies, subconjunctival hemorrhage, keratitis, iritis, glaucoma,
chemical trauma and scleritis.

The type of eye secretions can provide clues to the cause of conjunctivitis.
Purulent or mucopurulent discharge is often caused by bacterial conjunctivitis.
Watery discharge is more likely to lead to viral conjunctivitis. Meanwhile, watery
discharge in allergic conjunctivitis is accompanied by prominent symptoms of
itching, chemosis and redness. 8,9,11
It is further necessary to differentiate between viral and bacterial conjunctivitis.
The presence of one eye followed by involvement of the other eye within 24-48
hours is an indication of bacterial infection, whereas if the other eye becomes
infected after 48 hours with enlarged periauricular lymph nodes, the viral etiology
should be considered.

Apart from the type of secretions, symptom onset and duration and laterality,
papillary conjunctival or pseudomembranous conjunctivitis and follicular
conjunctival reactions were used to determine the etiology.8 This study obtained
conjunctival examination data in the form of papils and follicles. Conjunctival
papillae were found in 45 patients (14.02%) and conjunctival follicles in 60
patients (18.69%). There are several medical records that do not list the presence
or absence of papils or follicles. Conjunctival papules are more common in
bacterial infections and are also associated with an immune response, such as
VKC, or a response to a foreign body such as contact lenses or ocular prostheses.

Conjunctival follicles can be found in inflammation due to viral infections and

chlamydial infections, toxins or including topical drugs. 1, 4, 5, 9 In this study,
208 patients (64.8%) were diagnosed with acute conjunctivitis. The diagnosis of
conjunctivitis due to viruses was 64 patients (19.94%), bacteria 7 patients
(2.18%). This is in accordance with the literature which stated that infectious
conjunctivitis is mostly caused by viral infections and the second is by bacteria.6
Most non-infectious conjunctivitis were caused by allergies, as many as 33
patients (10.28%) and other causes (immune-mediated, drugs) were 9 patients
(2.80%).

Viral conjunctivitis is mostly caused by adenovirus with clinical features of

pharyngoconjunctivitis fever and epidemic keratoconjunctivitis (EKC). The most
severe manifestation is EKC, which affects the conjunctiva and cornea, leaving
permanent and prolonged changes in the surface of the eye and visual
disturbances. Ocular manifestations of EKC include the presence of secretions,
follicular conjunctivitis, corneal subepithelial infiltrates, corneal scars,
conjunctival and pseudomembranous membranes, and symblepharone formation.
Other viral conjunctivitis can be caused by the herpes simplex virus and herpes
zoster. Viral conjunctivitis due to herpes simplex is unilateral with thin, watery
secretions and lesions on the vesicular lids. In conjunctivitis due to herpes zoster
there can be complications in the cornea (38.2% of cases) and uveitis (19.1% of
cases) .4,5,6,9

Bacterial conjunctivitis can occur because it is transmitted directly from an

infected individual or because of the abnormal proliferation of the conjunctival
flora. The most common pathogens for bacterial conjunctivitis in adults are the
staphylococcal species, followed by Streptococcus pneumoniae and Haemophilus
influenzae. In children, this disease is often caused by H influenzae, S
pneumoniae, and Moraxella catarrhalis. Other causative bacteria are Neisseria
gonorrhoeae, Chlamydia trachomatis, and Corynebacterium diphtheria. N.
gonorrhoeae. Most causes bacterial conjunctivitis in neonates. 8,9

Hyperacute bacterial conjunctivitis presents with excessive purulent discharge and

decreased vision. There is often swelling of the eyelids, eye pain on palpation and
preauricular adenopathy. It is often caused by Neisseria gonorrhoeae and is at high
risk for corneal involvement and corneal perforation.

Bacterial conjunctivitis due to chlamydia is estimated to occur in 1.8% to 5.6% of

cases of acute conjunctivitis. The majority of cases of chlamydial infection
coincide with genital infections and are characterized by conjunctival hyperemia,
mucopurulent secretions and lymphoid follicles. Spread through oculogenital or
intimate contact with an infected individual, in newborns the eye can become
infected after birth through the vagina of the infected mother. 7,8,9

Chronic bacterial conjunctivitis is used to describe any conjunctivitis lasting more

than 4 weeks, with the most common causes being Staphylococcus aureus,
Moraxellalacunata and enteric bacteria.

Conjunctival culture studies are impractical and rarely indicated in conjunctivitis.

Conjunctival culture and cytology can be performed in cases of recurrent
conjunctivitis, resistance to treatment, suspected gonococcal or chlamydial
infection, neonatal conjunctivitis and adults with severe purulent secretions. Rapid
antigen tests are performed to detect the causative virus and to prevent
unnecessary use of antibiotics because the accuracy of viral diagnosis without
laboratory testing is less than 50% and many are misdiagnosed as bacterial
conjunctivitis. However, laboratory tests are rarely performed because antigen
detection is not widely available. Meanwhile, culture of conjunctival secretions
took three days, delaying therapy. For allergic conjunctivitis, skin scraping tests or
intradermal allergen injection and tests to detect elevated levels of specific serum
IgE in vitro may be performed.

However, the clinical presentation is often nonspecific. The type of discharge and
symptoms do not always provide an accurate direction for the diagnosis. In
addition, there is a lack of scientific evidence linking the symptoms and signs of
conjunctivitis to the underlying cause. There are several challenges in diagnosing
acute conjunctivitis. The presence of clinical ambiguity between viral and
bacterial infections and forms of allergy can confuse the diagnosis 8,10,12

The management of therapy provided was lubricants by 304 patients (94.70%)

combined with antibiotics and corticosteroids for 212 patients (66.04%),
antibiotics for 92 patients (28.66%), corticosteroids for 2 patients (0.62%) and anti
histamine for 16 patients (4.98%). Management of conjunctivitis was given based
on possible underlying causes.

There is no effective treatment for conjunctivitis due to adenovirus but

administering artificial tears, topical anti-histamines or cold compresses can be
given to relieve symptoms. Steroid administration in viral conjunctivitis is
indicated if there is formation of sub-epithelial membrane and infiltrate.
6,10,11,12

Conjunctivitis due to herpes simplex can be given oral antivirals to shorten the
course of the disease. Antiviral options for herpes simplex are acyclovir 5x400mg
for 10 days, famciclovir 3x250mg for 10 days, valacyclovir 2x1000mg for 10
days, valgancyclovir 2x900mg induction phase for 21 days and 1x900mg
maintenance phase. Antivirus in herpes zoster is useful for reducing the amount of
virus in vesicle skin lesions, reducing systemic spread of the virus and reducing
the incidence and severity of ocular complications. Recommended therapy is
famciclovir 3x500mg, valacyclovir 3x1g or acyclovir 5x800mg for 7-10 days.

Bacterial conjunctivitis, can self-limiting in 2 to 7 days without medication.

Topical antibiotics are only used to reduce the duration of the disease. The
antibiotic suspension of choice for benign acute bacterial conjunctivitis is topical
polymyxin B / trimethoprim, ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin,
gatifloxacin or azithromycin, while bacitracin, erythromycin or ciprofloxacin in
the form of an ointment. Bacterial conjunctivitis due to wearing contact lenses is
given fluoroquinolones class antibiotics to provide empirical coverage for
Pseudomonas. 6,9,10

Treatment options for conjunctivitis due to N gonorrhoeae are Ceftriaxone 1 gram

intramuscular (IM) and topical with erythromycin, bacitracin and gentamicin
ointment. Treatment of chlamydial conjunctivitis with oral systemic antibiotics
such as single dose azithromycin 1000 mg, doxycycline 2x100 mg, tetracycline
4x250 mg or erythromycin 4x500 mg. Treatment of gonococcal conjunctivitis
infection along with chlamydial infection were 1 gram ceftriaxone IM dan 1 gram
azithromycin per oral. 3,7,12,15 The neonatal dose for gonococcal conjunctivitis
is 25 to 50 mg / kg ceftriaxone IV / IM with a maximum dose of 125 mg, with
azithromycin PO 20 mg / kg once daily for three days. 8,9,11

Allergic conjunctivitis treatment consists of avoiding allergens and administering

artificial tears which are useful for eliminating allergens. Antihistamines and mast
cell stabilizers serve to reduce the symptoms of conjunctivitis. Steroids in certain
cases must be used carefully and wisely because long-term use of steroids can
cause side effects in the form of increased intraocular pressure, glaucoma and
cataracts.8,9,10 Cyclosporine-A and tacrolimus are effective in treating severe eye
allergies. and chronic 8,9,11

The high percentage of antibiotic use in this study is in line with a study
conducted in the United States which found that 58% of acute conjunctivitis
patients received topical antibiotic therapy and a study conducted in the
Netherlands which found that 80% of acute conjunctivitis patients received a
topical antibiotic prescription.10,11

Several things that can affect the high percentage of antibiotic use, among others,
are the difficulty in distinguishing between viral, bacterial or allergic
conjunctivitis based on clinical symptoms and signs alone, whereas it is
impractical to wait for microbiological results before starting treatment. who feel
more satisfied if they get a prescription for antibiotics.10,11,12 However, the use
of antibiotics needs rational considerations so that antibiotic resistance does not
appear. However, antibiotics can be considered if conjunctivitis does not resolve
after 10 days and bacterial superinfection is suspected. 11,12,13

Meanwhile, the use of topical steroids in cases of acute conjunctivitis is still

controversial. R Pinto et al. [13] suggested topical use of 0.1% dexamethasone
helps reduce conjunctival inflammation and shortens the duration of acute
conjunctivitis.14 Other studies have also recommended the management of
various causes of acute conjunctivitis with broad spectrum therapy in the form of
corticosteroids and anti-infectious / antiseptic agents. Topical corticosteroids have
been shown to be efficacious and well tolerated when used for a short time in
combination with an anti-infective / antiseptic.

Although the presentations can often overlap, a systematic approach and a

thorough history and physical examination can safely rule out an acute vision-
threatening diagnosis and point to possible causes of conjunctivitis. 10,11,12

Complications of acute conjunctivitis are rare. Patients with HZV conjunctivitis

are at the highest risk of complications. Approximately 38.2% of patients with
HZV had corneal complications, and 19.1% developed uveitis; Patients with N.
gonorrhea are also at high risk for corneal involvement and secondary corneal
perforation and should therefore be treated appropriately. 7,8,9

Education in infectious conjunctivitis in order to avoid viral and bacterial

contamination is necessary to break the chain of transmission, whereas in allergic
conjunctivitis by avoiding allergens to prevent recurrence. Another important
thing is to provide understanding to patients, families and communities about the
risks and benefits of treatment options (even if there is no treatment at all) .
9,10,11

In adenovirus conjunctivitis it can be spread through contaminated fingers,

medical devices, contaminated swimming pools, or through sharing personal
items. Bacterial conjunctivitis can occur either from direct contact with an
infected individual or from abnormal proliferation of the normal conjunctival
flora, contaminated fingers, oculogenital spread. In addition, certain conditions
such as impaired tear production, disruption of natural epithelial barrier, adnexal
structural abnormalities, trauma, and immunosuppression status increase the
likelihood of contracting bacterial conjunctivitis.

The provided educations were diligently washing hands, minimizing contact,

delaying returning to work or school and separating personal items such as
handkerchiefs, towels, sheets and pillows from other family members.

This study was retrospective study where data was taken from medical records.
The limitation in this study was the unavailability of complete medical record
registration data in the eye clinic of dr. Saiful Anwar Malang Hospital. The
existing medical record data was made by more than 1 person so that a very wide
variety of data can be obtained. Patients who came only once so they could not
evaluate anything else. Writing incomplete status and loss of patient status are
also limitations of this study because they affect the number of samples analyzed
so that they can affect the results of this study.

Conclusion

The conclusion of the case profile study and the conjunctivitis management for
the period of January 2018 - December 2019 at Saiful Anwar Hospital Malang, it
was found that conjunctivitis was most commonly found in women 14-27 years of
age, located in both eyes, with the most symptoms and clinical signs in were red
eyes.

The most commonly used management of conjunctivitis were lubricants and

antibiotics with corticosteroids.
Suggestion

The limitations in this study were found at the time of collecting medical record
data.

It is hoped that there will be improvements in terms of systematic history taking,

complete ophthalmological examination and storage of medical record status so
that no medical record status is lost so that further research with a longer time
period, larger sample size and more complete of recording will provide more valid
results and provides a better description of the conjunctivitis cases profile in dr.
Saiful Anwar Malang Hospital.

Furthermore, it is necessary to do more selective analytic studies regarding the

effectiveness of antibiotics and steroids in acute conjunctivitis cases.