Conjunctivitis

Etiology Clinic-pathological features

A) Infective Symptoms
1. Bacterial { mucopurulent conjunctivitis} 1) Discomfort = burning - foreign body – sandy sensation
2. Chlamydial NB: itching is severe in spring catarah { vernal } .
 Chlamydia trachomatis serotypes A-C = trachoma 2) Discharge {not in phlycten }
 Chlamydia oculogenitalis { trachomatis serotypes D-K} = 3) Redness
acute inclusion conjunctivitis = swimming pool conjunctivitis
3. Viral Signs :
 Herpes simplex 1) Lid & conjunctival edema (chemosis)
 Molluscum contagiosum (pox virus) 2) Conjunctival injection or hyperemia maximal at fornices
 Adenoviral and fading towards the limbus
i) Serovars 3,4,7 = pharyngoconjunctival fever
ii) Serovars 8,19 = epidemic keratoconjunctivitis
B) Non-infective
1. Spring cataraah { vernal keratoconjunctivitis}
2. Phlycten

3) Discharge :
a) Watery (serous) = Viral
Ophthalmia neonatorum b) Mucoid : Ropy in spring catarrah { rich in eosinophils }
c) Mucopurulent = bacterial = causing sticking of the lids at
Any conjunctivitis occurring in the first month of life the morning and gluing or matting of the lashes

d) Purulent ( severe bacterial ) : eg . gonococcal

1) Infective : contact with contaminated maternal passages

a) Chlamydia oculogenitalis (mc)
b) Neiserria gonorrhea
c) Other bacteria eg . staph, strept
d) Viral : HSV II
2) Non-infective : drug induced

NB: the adenoid layer is absent before 3 months = no follicles 4) Follicles : focal collections of lymphocytes that appear as
gelatinous yellow elevations
Causes :
(i) Viral eg. adeno, herpes or molluscum
(ii) Chlamydial eg. active trachoma – inclusion conjunctivitis

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5) Papillae: Epithelial proliferation with a vascular CT core that are
seen as red bumps each with a central vascular core of vessels. Complications
Causes :
(1) Chlamydial eg. active trachoma – inclusion conjunctivitis a) Corneal ulcer { keratitis }
(2) Spring catarrh  Bacterial = Secondary corneal ulcers with vascularization
(3) Ophthalmia neonatorum and opacification
(4) Contact lens wear = giant papillary conjunctivitis {GPC}

6) Conjunctival nodule : phlycten

7) Pre-auricular lymphadenopathy = Viral

8) Lid :
 Vesicles = herpes { unilateral }

 Adenoviral = punctate +/- subepithelial infiltrates

 Herpes = dendritic {rare}
 Spring catarah = shield ulcer
 Phlycten = fasicular ulcer

NB : fluorescein stain in any conjunctivitis esp if presenting with

blepharospasm, lacrimation, photophobia, +/- pain
 Mollusca lesion = umblicated pearly nodule

NB: multiple mollusca may denote immunosuppression eg AIDS

NB: Spring catarrh = increased risk of keratoconus

b) Conjunctival scarring eg trachoma = causing trichiasis,

entropian, dryness {xerosis} and symblepharon
c) Systemic spread eg. chlamydia oculogenitalis in children
(pneumonia – otitis media)

9) Systemic features :
Management
 Fever – pharyngitis { sorethroat } = adenoviral
 urethritis - cervicitis = Chlamydia oculogenitalis  Bacterial
 urethritis – painless aphthus ulcers – uveitis = 1) Bathe (wash) the discharge
Reiters symdrome 2) Topical Antimicrobial broad spectrum eye drops during
daytime (frequency according to severity) & ointments at night
3) If corneal ulcer = add atropine
4) If severe or systemic features = add systemic

NB: NEVER bandage or patch if discharge is present

 Chlamydia : systemic azithromycin

 In opthalmia neonatorum :
1) Treatment of maternal cervicitis before birth
2) Prophylactic broad spectrum topical antibiotics
3) +/- systemic erythromycin
4) Examine and treat parents
 In viral :
o Adenoviral = symptomatic +/- topical steroid if severe keratitis
o Herpes = acyclovir
 Vernal & phlycten :
o Treat cause
o NSAIDs
o short course of topical steroids

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 Trachoma ( Egyptian ophthalmia )
Definition : chronic infectious kerato-conjunctivitis that heals by b) Stage T II : mature follicles: (> 1mm) + trachomatous papillae
cicatrization {fingerlike velvety}

Epidemiology :most common cause of preventable blindness

Endemic in Egypt

Causative agent : Chlamydia trachomatis A-C

 large ( > 200um) - obligate intracellular parasite

 that contains both DNA and RNA and has a cell wall
 Sensitive to antibiotics ( eryrthromycin , tetracycline, sulpha c) Stage T III : healing by fibrosis
and azithromycin) i. Arlet's line : dense white line at the sulcus subtarsalis
 Epitheliotrophic ( with production of soluble toxins ) ii. Post – trachomatous degenerations ( PTD's) :
 with no solid immunity (recurrences common) necrotic shed epithelium with dried mucous in the
 Produces intra-cytoplasmic basophilic inclusion bodies in pseudocrypts between the papillae.
epithelial cells ( by Giemsa stain) iii. Post – trachomatous concretions or calcifications
( PTC's) : sandy white calcified PTDs

d) Stage IV : healed trachoma { no inclusion bodies in

conjunctival scraping } .

Conjunctival features (Mac Callan's classification)

Corneal features
Affects mainly the upper limbus & usually together with the
Affects mainly the upper palpebral conjunctiva
conjunctival features
a) Stage T 1 : immature follicles (<1mm )
1. Limbal follicles ( Herbert's rosettes ) : subepithelial
lymphoid infiltration with surrounding capillaries.
2. Active Pannus : subepithelial infiltration by vessels and cells

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 Morphological Types of active pannus :
a) Pannus carnosus ( sarcomatosis ) = fleshy cellular Complications
b) Pannus vasculosis = vascular
c) Pannus teanius : thin 1. Corneal ulceration, vascularization and opacification dt
d) Pannus annulosis : annular {rare} projecting PTDs and complications eg. trichiasis
2. Eyelids: trichiasis , cicatricial entropian
3. Herbert's pits : healed rosettes giving a serrated appearance. 3. Conjunctiva :
 Dryness {Xerosis} : dt obstruction of the main gland
duct openings & destruction of goblet cells and
accessory lacrimal glands.
 posterior symblepharon leading to a shallow fornix
4. lacrimal : punctual occlusion {epiphora}

4. Healed pannus {Pannus siccus}

Treatment
NB: As there is no solid immunity, recurrent infection is common = a) Systemic Azithromycin ( zithromax ) could be repeated after
the patient may show different stages eg . active follicles or papillae one week . or Doxycycline 100mg/d for 10 days or
and signs of scarring eg. healed pannus eryrthromycin - tetracyclin 500 mg bid for 6 – 12 weeks

NB: Tetracycline is contra-indicated in pregnancy - lactation – children below 12 years

b) If corneal ulcer : add atropine & dark glasses

c) Surgical :
(1) Picking of projecting PTDs / PTCs only
(2) Treatment of complications eg lid surgery for entropian,
keratoplasty for corneal scarring

NB: " SAFE " strategy supported by the WHO { Surgical -

Antibiotic - Facial cleanliness - Environmental improvement }

WHO classification

TF : > 5 follicles {>0.5mm} on the upper tarsus

TI : inflammation obscuring > 50% of tarsal vessels
TS : trachomatous scarring
TT : trachomatous trichiasis { at least one lash}
CO : corneal opacity obscuring at least part of the pupil

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 b) Topical steroids { short course < 14 days)
Spring catarah = Vernal
Abuse of steroids for a long time may cause complicated
keratoconjunctivitis cataract and secondary glaucoma

Bilateral recurrent chronic seasonal allergic conjunctivitis ( type I c) Intra-lesional ( supratarsal) injection of steroids
allergy = atopy) due to allergy to an exogenous antigen eg. UV d) Topical cyclosporine in resistant cases
rays , pollen, dust, fumes.
2) Inbetween the attacks = Mast cell stabiliziers eg. Disodium
 Age : 5 -25 years cromoglycate - antihistaminics (topical & systemic)
 Sex : more common in boys
 Season : spring and summer
 Family history : positive
Phlyctenular conjunctivitis (phlycten)
Types
Acute allergic (type IV = delayed hypersensitivity) conjunctivitis due
1) Palpebral : Large flat topped { cobble stone } papillae to an endogenous antigen eg. staphylococcal blepharitis –
affecting the upper palpebral conjunctiva. May induce tuberculosis - streptococcal tonsillitis - intestinal parasites.
mechanical ptosis
Signs: mobile non-tender nodule surrounded with a zone of
hyperemia

Corneal features :
2) Bulbar ( or limbal) : Gelatinous masses +/- Tranta spots { white
concretions of necrotic epithelium + eosinophils +/- calcium } 1) Corneal phlycten and pannus

2) Corneal Fascicular ulcer : superficial serpiginous { with an

Corneal features :
undermined advancing and a healing vascularized edge) that
1) Pannus
creeps towards the center leaving a superficial
2) Punctate microerosions ( keratitis superficilais vernalis of Tobgy)
3) Macroerosions +/- corneal plaques = shield ulcer
Treatment :
1) Treat the cause eg staph blepharitis, TB
2) NSAIDS
3) Topical short course of steroids
4) Annular 360 pannus
4) If cornea : add Atropine

DD: nodular episcleritis

Episcleritis Phlycten
4. There is an increased risk for keratoconus
Middle aged female 5 – 15
+/- rheumatoid
Treatment: arthritis
Tenderness +
1) During the attack Conjunctiva fixed to sclera mobile with
a) Topical NSAIDS, antihistaminics & decongestants {conjunctiva moves conjunctiva
freely over it }

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 Pterygium Symblepharon
Fibrovascular triangular encroachment of the conjunctiva on the Adhesions between the palpebral {lid} and bulbar conjunctiva
cornea dt chronic irritation by the effect of ultraviolet rays and dust. {globe} dt conjunctival scarring eg. Chemical injuries - trachoma

Symptoms : Types :
 Disfigurement
 Drop of vision if pupillary affection +/- astigmatism a) Anterior : between lid margin and cornea or conjunctiva

Signs : Commonly nasal and bilateral.

b) Posterior : at the fornix ( shallow or obliterated fornix)

Treatment = If affecting pupil or disfiguring = Excision with

Limbal stem cell transplantation +/- mitomycin {to decrease
recurrence}

DD = pseudo-pterygium
c) Total :
True Pseudo

Cause  limbal scarring eg chemical injuries = limbal

stem cell deficiency
 After conjunctivoplasty { conjunctival flap
surgery} in resistant corneal ulcers

Site Nasal Any site

Laterality Bilateral
Hook test Negative Positive in flap surgery
Clinical picture :

a) Disfugerment
b) Binocular Diplopia and limitation of motility
c) Diminution of vision ( if cornea affected)

Complications : Exposure keratitis

Treatment :
 Glass rod coated with antibiotic - steriod ointment to be
passed between the lid and the globe +/- sclera shell

Pinguecula
An age related degeneration dt chronic ultraviolet exposure.
Yellow nasal non-vascular with its base towards the cornea.

 Definitive treatment : synechotomy - mucous membrane graft

Treatment : not indicated {unless large and disfiguring}