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Dr Sanjay Shrivastava
Classification I Based on onset a. Acute b. Sub-acute c. Chronic II Based on type of Exudates a. Serous (Viral, allergic, toxic)
3/8/2011 Dr Sanjay Shrivastava 2
Classification of Conjunctivitis
b. Catarrhal (allergic ± Ropy or thread like thick mucoid discharge) c. Mucopurulent d. Purulent c. Pseudo-membranous / Membranous
Dr Sanjay Shrivastava
Classification of Conjunctivitis
III Based on Conjunctival Reaction a. Follicular b. Papillary c. Granulomatous IV Based on Etiology a. Infectious (Bacterial, Viral, Chlamydial, Fungal and parasitic) b. Non-infectious (Allergic, Irritants
3/8/2011 Dr Sanjay Shrivastava 4
Classification of Conjunctivitis
Endogenous or autoimmune, Dry Eye, Toxic (chemical or drug induced, self inflicted) and Idiopathic.
Dr Sanjay Shrivastava
Risk Factors for the Development of Bacterial Conjunctivitis
Disruption of host defense mechanism caused by: 1. Dry Eye 2. Exposure due to lid retraction, exophthalmos, lagophthalmos, inadequate blinking 3. Nutritional deficiencies/ Avitaminosis A
3/8/2011 Dr Sanjay Shrivastava 6
. contd 4.Risk Factors for the Development of Bacterial Conjunctivitis . Local or Systemic Immune Deficiency: * after topical and systemic immunosupressive therapy * Nasolacrimal duct obstruction and infection * Radiation damage * Trauma * Surgery 3/8/2011 Dr Sanjay Shrivastava 7 .
Contd * Prior Conjunctival inflammation or infection * Systemic Infection * Exogenous inoculation 3/8/2011 Dr Sanjay Shrivastava 8 .Risk Factors for the Development of Bacterial Conjunctivitis..
Gonorrhoeal Conjunctivitis I. 3/8/2011 Dr Sanjay Shrivastava 9 . still seen in individuals and communities where Gonorrhoea is still a problem and hygienic standards are poor. Epidemiological Aspect Rare in developed countries.
Incubation period is few hours to three days.shaped Gramnegative intracellular diplococcus).Gonorrhoeal Conjunctivitis Etiology ± Caused by Neisseria Gonorrhoeae (a bun. Condition is found in cases suffering from Gonorrhoeal genital infection. Neisseria Catarrhalis may be seen/found in chronic forms. 3/8/2011 Dr Sanjay Shrivastava 10 .
Clinical Features Symptoms Swelling of eyelids. Pain. inability to open eye(s). grittiness. purulent discharge. Diminution of Vision 3/8/2011 Dr Sanjay Shrivastava 11 . redness.
occurring usually in adult males. Upper lids are tense. Often in RE to begin with. overhanging on lower lid. Matting of lashes and pus on lids margins. Lids are swollen.Clinical Features Signs Acute disease. 3/8/2011 Dr Sanjay Shrivastava 12 . Eversion is difficult. Deep red velvety conjunctiva sometimes with membrane After two to three weeks discharge diminishes but subacute form of conjunctivitis with presence of Gonococci persists for several weeks.
tenderness and suppuration 3/8/2011 Dr Sanjay Shrivastava 13 .Signs « Contd Pre-auricular lymphadenopathy.
Associated systemic signs ± Urethritis. 3/8/2011 Dr Sanjay Shrivastava 14 . rise of temperature and depression. all round. Marginal Ulcer . Progressing rapidly depth-wise leading to perforation and complications associated with it.Corneal involvement ± Gonococcus is capable of invading the normal cornea through intact cornea. Complications.Clinical Features No immunity is conferred by an attack. Location of Corneal Ulcer ± Central.
3/8/2011 Dr Sanjay Shrivastava 15 .Clinical Features Other complications of Gonorrhoeal Conjunctivitis ± Iritis . Endocarditis and Septicaemia. Iridocyclitis Non Ocular complications ± Arthritis.
Treatment Of Gonococcal Conjunctivitis is started on confirmation of intracellular Gram-negative diplococci in conjunctival scrapings in clinically suspected cases. Aim of therapy is to prevent or limit the corneal involvement and to eliminate systemic source. 3/8/2011 Dr Sanjay Shrivastava 16 .
single dose Local Treatment * Cleanliness * Ciprofloxacin / Ofloxacin/ Gentamicin/ Tobramycin Eye Drops 2 hrly. 3/8/2011 Dr Sanjay Shrivastava 17 .Treatment Systemic Treatment Ceftriaxone 1 Gm IM .
Treatment * Bacitracin Eye Ointment 6 hrly * Cycloplegic (Atropine) ± in cases of Corneal involvement * Tetracycline In cases where co-existing Chlamydial Trachomatis infection is suspected and cases with history of allergy to Penicillin / Cephalosporins 3/8/2011 Dr Sanjay Shrivastava 18 .
Angular Conjunctivitis Specific type of Conjunctival inflammation characterized by involvement of intermarginal Conjunctiva and neighboring bulbar conjunctiva. 3/8/2011 Dr Sanjay Shrivastava 19 . caused by Morax axenfield diplobacilli called Moraxella Lacunata.
Angular Conjunctivitis Etiology ± Caused by Staphylococci and more typically by Moraxella Lacunata. 3/8/2011 Dr Sanjay Shrivastava 20 .
The organisms are resistant to drying . 3/8/2011 Dr Sanjay Shrivastava 21 .thick rods placed end to end which stain well with basic stains. which acts by macerating epithelium.Pathogenesis Moraxella Lacunata is a gram-negative diplobacilli. It produces proteolytic ferment. pair of large . The incubation period is usually 4 days .
3/8/2011 Dr Sanjay Shrivastava 22 .Pathogenesis Moraxella is also found in nasal tract of healthy persons and often present in the nasal discharge of patients of angular conjunctivitis.
3/8/2011 Dr Sanjay Shrivastava 23 . frequent blinking.Symptoms Redness. sharp pricking pain and mucopurulent discharge. discomfort. Incubation period : Symptoms develop after 4 days of exposure.
corneal ulcer (marginal or central associated with hypopyon) Attack does not confer immunity. and relapses may occur.Chronic conjunctivitis. Excoriation of skin at inner and outer palpabral angles Complications.Signs Congestion limited to intermarginal strip at inner and outer canthi and neighboring bulbar conjunctiva. 3/8/2011 Dr Sanjay Shrivastava 24 . Blepheritis.
Treatment Tetracycline eye ointment Eye drops containing Zinc also beneficial. acts by inhibiting proteolytic ferment. 3/8/2011 Dr Sanjay Shrivastava 25 .
Acute inclusion Chlamydial Conjunctivitis Its acute conjunctival inflammation caused by Chlamydial infection (Serotype D-K) characterized by inclusion bodies. 3/8/2011 Dr Sanjay Shrivastava 26 .
3/8/2011 Dr Sanjay Shrivastava 27 .Acute inclusion Chlamydial Conjunctivitis Etiology ± Caused by Chlamydia Trachomatis (serotype D-K) Pathogenesis ± characterized by inclusion bodies identical with those occurring in Trachoma.
3/8/2011 Dr Sanjay Shrivastava 28 .Spread Spread by sexual transmission from genital reservoir (urethritis/ cervicitis). Common mode of infection is through swimming pool water (swimming pool conjunctivitis) May also be transmitted by mothers to newborn.
superficial punctate keratitis. intolerance to light . Follicles.10 days Symptoms. peripheral vascularization (pannus) 3/8/2011 Dr Sanjay Shrivastava 29 . redness.Usually 5. discharge Signs ± Conjunctival hyperaemia. papillary hyperplasia.Acute onset . more prominent in lower lid. foreign body sensation.Clinically Features Incubation period.
Clinical features Chlamydia Trachomatis is also responsible for genital and oculogenital infections. Associations have been reported with nongonococcal and post gonococcal urethirits. 3/8/2011 Dr Sanjay Shrivastava 30 . cervicitis and infections of genital tract. Arthiritis is also seen in these cases.
Giemsa staining of conjunctival scrapping and McCoy cell cultures. Other tests are immuno-sorbitant assay.Diagnosis Direct immuno-fluorescent stain of smear using monoclonal antibodies. 3/8/2011 Dr Sanjay Shrivastava 31 . Test has 100% sensitivity and 94% specificity. Urethral and cervical secretions should also be tested.
3/8/2011 Dr Sanjay Shrivastava 32 . Erythromycin 250 mg twice for two weeks. Doxycycline 100 mg twice for two weeks. Locally ± Tetracycline or Erythromycin eye ointment twice daily for two weeks. Systemic ± Tetracycline 250 mgm qid for 2 weeks.Treatment Heals spontaneously in 3 -12 months if left untreated. Azithromycin 1 Gm single dose and Ofloxacin 300 mg twice for 7 days.
mucopurulent or purulent discharge from one or both eyes during first month of life. It¶s a preventable disease in newborn babies caused by maternal infection. 3/8/2011 Dr Sanjay Shrivastava 33 . acquired at the time of birth.Ophthalmia Neonatorum Conjunctival inflammation associated with mucoid.
3/8/2011 Dr Sanjay Shrivastava 34 .Epidemiology Although its incidence has declined due decrease in incidence of Gonorrhoea and due effective prophylaxis and treatment . disease is still prevalent and remains a public health problem in communities with poor hygiene and limited access to proper health care.
Streptococcus Pneumoniae.Etiology Neisseria Gonorrhoeae. Chlamydial Trachomatis. Staphylococcus etc. Chalmydial Oculogenitalis Chemical Conjunctivitis due to Silver Nitrate 1or 2% (used as Crede¶s method) 3/8/2011 Dr Sanjay Shrivastava 35 .
3/8/2011 Dr Sanjay Shrivastava 36 . cornea is seen at bottom of a crater like pit. chemosis. thick yellow discharge. soon becomes purulent Both eyes are affected. one more severe than other. Conjunctiva is intensely inflamed with severe congestion.Neisseria Gonorrhoeae Manifest within 48Hrs of birth Discharge is Mucopurulent to begin with.
Corneal complications. conjunctiva is puckered and velvety. later becomes softer.Clinical Features « contd Lids are swollen. Discharge is pus. stasis of blood giving appearance of intense congestion.corneal ulcer with its complications is common 3/8/2011 Dr Sanjay Shrivastava 37 . serum and blood. tense. Pseudomembrane formation.
rarely oval marginal ulcer. panophthalmitis. prolapse of lens. anterior staphyloma. prolapse of vitreous. just below the centre of cornea. prolapse of uveal tissue. anterior capsular cataract. adherent leucoma. purulent uveitis.Complications Corneal Ulcer : Oval ulcer. 3/8/2011 Dr Sanjay Shrivastava 38 . Scarring of cornea. progressive ulcer resulting in ± perforation of corneal ulcer.
Complications« Contd Non development of fixation due to corneal opacity during first 3 weeks. Nystagmus due to non-development of macular fixation 3/8/2011 Dr Sanjay Shrivastava 39 .
Chlamydia Trachomatis Inclusion Conjunctivitis Develop usually over one week after birth Its venereal infection derived from cervix or urethra Less severe than Gonococcal infection 3/8/2011 Dr Sanjay Shrivastava 40 .
Other Bacterial Infections Manifest usually 48-72 hrs after birth Herpes Simplex Infection presents 5-7 days after birth 3/8/2011 Dr Sanjay Shrivastava 41 .
Chemical Toxicity Seen within few hours after prophylactic treatment with Silver Nitrate Solution 1 or 2% (Crede¶s Method) applied for prophylaxis of Gonococcal infection 3/8/2011 Dr Sanjay Shrivastava 42 .
Diagnosis Grams staining Giemsa staining of epithelial scraping Chlamydial Immunofluorescent antibody test Viral and Bacterial culture sensitivity test 3/8/2011 Dr Sanjay Shrivastava 43 .
3/8/2011 Dr Sanjay Shrivastava 44 .Differential Diagnosis Differential Diagnosis of discharge in child within the first month of life ± Congenital blockade of nasolacrimal duct Acute Dacryocystitis Congenital Glaucoma.
Treatment Prophylaxis In cases of any suspicious vaginal discharge in antenatal period should be treated meticulously New born babies closed lids should be cleaned properly Prophylactic used of 1% Tetracycline eye ointment in babies eyes 3/8/2011 Dr Sanjay Shrivastava 45 .
Prophylaxis . contd Close observation during first week Prophylactic use of Penicillin or other antibiotic drops 3/8/2011 Dr Sanjay Shrivastava 46 ..
3% and Bacitracin eye ointment. 3/8/2011 Dr Sanjay Shrivastava 47 .Treatment Is on lines of Gonorrheoeal Conjunctivitis Child is hospitalized and treated with Gentamicin eye drops 0. Atropine is added if corneal involvement is there.
Or Kanamycin 25 mgm /kg body weight. Gonorrhoeae is treated with single I. N. Contd.3% in both eyes repeated in 15 min and then after every feed (2hrly) for 3 days. 3/8/2011 Dr Sanjay Shrivastava 48 .M.Treatment «. Local treatment consists of Gentamicin eye drops 0. dose of Ceftriaxone 125 mgm or Cefotaxime 50 mgm /kg. IV or IM in three divided dosage.
Chlamydial Infection is treated with Erythromycin ethylsuccinate 50mgm /kg daily in 4 divided dosage before feed for 23 weeks or Azithromycin 10 mgm/kg body weight for 3 days Local treatment Chlortetracycline 1% or Erythromycin eye ointment after feeds. 3/8/2011 Dr Sanjay Shrivastava 49 . Contd. Parents should be treated for genital infection.Treatment «.
endemic in middle east during prehistoric period. Trachoma is still a leading cause of preventable blindness world wide. spread far and wide in Europe by French Army during Napoleonic wars.TRACHOMA At one time known as Egyptian Ophthalmia. 3/8/2011 Dr Sanjay Shrivastava 50 . third after Cataract and Glaucoma.
Approximately 1/5th population of world is affected by Trachoma, amounting to 150 million people across the 48 countries . It is estimated that 6 million people are blind in both eyes. It still remains a significant problem in areas of Africa, South East Asia, the Middle East and Australia.
Dr Sanjay Shrivastava
Trachoma is caused by Chlamydia Trachomatis immunotypes / serotypes A,B and C. Chlamydia organisms shares properties of both, bacteria and virus. It is an obligatory intracellular bacteria.
Dr Sanjay Shrivastava
Unhygienic and crowded surroundings Low socio-economic status Lack of water No race is exempted
Dr Sanjay Shrivastava
Transmission Direct transmission from eye to eye through discharge Through fomites. flies and eye cosmetics Disease is contagious in acute phase Incubation period is 5 -12 days 3/8/2011 Dr Sanjay Shrivastava 54 .
Clinical Features 3/8/2011 Dr Sanjay Shrivastava 55 .
Symptoms Pure Trachoma is usually asymptomatic condition or there may be minimum symptoms There may be redness. irritation. lacrimation and photophobia Systemic symptoms like Rhinitis. discharge. pre auricular lymphadenopathy and upper respiratory infection may be present 3/8/2011 Dr Sanjay Shrivastava 56 . foreign body sensation.
Symptoms « contd Onset is usually sub-acute. but may occur as acute when infection is massive as occurs in experimental or accidental or clinical infection 3/8/2011 Dr Sanjay Shrivastava 57 .
later may become uniformly thick like jelly. Plica. Caruncle.Signs Primary infection is Epithelial. Bulbar Conjunctiva near limbus) 3/8/2011 Dr Sanjay Shrivastava 58 . involving conjunctiva and cornea characterized by: Conjunctival congestion. upper tarsal Conjunctiva appears red and velvety. upper fornix. upper margin of Tarsus. Palpabral Conjunctiva. Follicles (in lower fornix.
3/8/2011 Dr Sanjay Shrivastava 59 .5 mm in diameter) but may measure upto 5 mm in diameter. Papillary enlargement.Signs « contd. Invasion of lacrimal passages may also be there. Follicles are small (0.
3/8/2011 Dr Sanjay Shrivastava 60 . tending to spread towards the centre . Vassels are superficial between epithelium and Bowman¶s membrane. extending deep into stroma Pannus and Lymphoid infiltration with vascularization seen in upper half.Corneal Signs Superficial Keratitis in upper part Epithelial erosion. Whole cornea may be covered with pannus .
. 3/8/2011 Dr Sanjay Shrivastava 61 . Chronic. occurs anywhere but commonest at the advancing edge of pannus.Corneal Signs. are shallow ulcer with little infiltration. Contd Stages of Pannus: Progressive (infiltration is beyond vascularization) Regressive (infiltration has receded and vessels are ahead of infiltration) * Corneal ulcer .
Pathology Chlamydia Trachomatis is seen in conjunctival scarping in the form of colonies in the epithelial cells as Halberstaedter Prowazek inclusion bodies. 3/8/2011 Dr Sanjay Shrivastava 62 . Inclusion bodies are composed of innumerable elementary bodies embedded in carbohydrate matrix.
in cells divide to form innumerable elementary bodies embedded in carbohydrate matrix. Numerous initial bodies.Pathology « Contd Elementary bodies. attacking epithelial cells. The nucleus of cell is displaced . to attack new cells. degenerates and cell burst to release elementary bodies. 3/8/2011 Dr Sanjay Shrivastava 63 . enlarge to become initial bodies in the cytoplasm of the cells.
Pathology « contd. Aggregation of lymphocyte without capsule forms follicles Follicles shows necrosis and contains large multinucleated Laber cells. Lymphocytic infiltration in Adenoid layer. An attack confers little immunity 3/8/2011 Dr Sanjay Shrivastava 64 . polymorphonuclear cell infiltration is noticed and later on lymphocytes are dominant. In TF and TI stages.
Trachomatous infiltration may spread deep into subepithelial tissues of the palpabral conjunctiva and even invade the tarsal plate Fibrosis around follicles giving rise to cicatricial bands (Arlt line in superior tarsus) 3/8/2011 Dr Sanjay Shrivastava 65 .Pathology «. Contd.
Diagnosis Culture of Chlamydia Trachomatis in irradiated McCoy cells Micro-Immunofluorescence (Micro-IF) test Monoclonal Direct Antibody test Demonstration of inclusion bodies in conjunctival epithelial scrapping 3/8/2011 Dr Sanjay Shrivastava 66 .
Follicles 2. Typical Trachomatous Scarring (Stellate or Linear Scarring of upper tarsus) Diagnosis is confirmed by demonstration of inclusion bodies 3/8/2011 Dr Sanjay Shrivastava 67 .Clinical Diagnosis Is based on identification of at least two of the following signs: 1. Epithelial Keratitis 3. Limbal Follicles/ Herbert Pits 5. Pannus 4.
pannus. superior corneal epithelial infiltrates Dr Sanjay Shrivastava 68 3/8/2011 .Trachoma Classification I. Limbal follicles. MacCallan¶s Classification Stage I ± Immature follicles on tarsus . SPK and Pannus Stage II ± Florid Superior Tarsal follicular reaction with mature follicles or marked papillary hyperplasia .
MacCallan Classification Stage ±III : Signs of stage II with Cicatrization Stage ± IV Cicatrization and its sequelae 3/8/2011 Dr Sanjay Shrivastava 69 .
Severe infection with high risk of complication. thickening of Conjunctiva obscuring >50% conjunctival blood vessels. 3/8/2011 Dr Sanjay Shrivastava 70 .5 mm in diameter. If treated properly. papillae. patient recovers with no or minimal scarring Stage -II Trachomatous Infiltartion ± Intense (TI) : Follicles.WHO Classification Stage ± I Trachomatous Infiltration ± Follicular (TF) 5 or more follicles of at least 0.
V : Corneal Opacity (CO) corneal opacity occupying pupillary area 3/8/2011 Dr Sanjay Shrivastava 71 .WHO Classification« Contd Stage ± III : Trachomatous scarring (TS) Stage ± IV : Trachomatous Trichiasis (TT) Stage .
Sequelae of Trachoma Distortion of lids Trachomatous Ptosis Entropion Trichiasis Tylosis 3/8/2011 Dr Sanjay Shrivastava 72 .
Late Complications Sever dry eye Keratitis Corneal scarring Fibrovascular pannus Corneal Bacterial Superinfection 3/8/2011 Dr Sanjay Shrivastava 73 .
Rifampicin and Sulphonamides are effective orally Topical Erythromycin and Tetracycline ointment 3/8/2011 Dr Sanjay Shrivastava 74 .Treatment Tetracycline. Erythromycin.
Treatment « contd Treatment of TF Stage ± Topical Erythromycin twice for 6 weeks Oral Azithromycin 1 Gm single dose Tetracycline 250 mgm qid for 2 weeks Doxycycline 100 mgm twice for 2 weeks 3/8/2011 Dr Sanjay Shrivastava 75 .
Or Cryotherapy 3/8/2011 Dr Sanjay Shrivastava 76 . tarsal rotation .Treatment « contd Treatment of TI Stage : same as TF stage Treatment of TS stage : Ocular lubricants Treatment of TT Stage : Epilation . Radiofrequency/ diathermy or electrolysis epilation .
depending on depth of corneal opacity 3/8/2011 Dr Sanjay Shrivastava 77 .Treatment « contd Treatment of CO Stage : After treatment of lid deformities LKP or PKP.
under which µSAFE¶ strategy has been adopted.WHO¶s GET 2020 WHO in 1997 started Global Elimination of Trachoma by 2020 programme called WHO GET 2020 programme. S : Surgery for entropion/ trichiasis A : Antibiotics for infectious trachoma F : Facial cleanliness to reduce transmission E : Environmental improvement 3/8/2011 Dr Sanjay Shrivastava 78 .
Trachoma Control Programme Tetracycline eye ointment 1% twice daily on 5 consecutive days every month for 12 months Mass treatment should be annually in endemic zones ( <35% children are affected) and Biannually in hyperendemic zones (>50% children are affected) 3/8/2011 Dr Sanjay Shrivastava 79 .
resembling tuberculosis.Ophthalmia Nodosa Nodular conjunctivitis. 3/8/2011 Dr Sanjay Shrivastava 80 . reddish or pale gray nodules formed in bulbar. due to irritation caused by caterpillar hairs. cornea and rarely in iris tissue. palpabral conjunctiva. Small semitranslucent pinkish.
Contd Hairs are surrounded by giant cells and lymphocytes. Treatment: Symptomatic. Local Steroids in selected cases. 3/8/2011 Dr Sanjay Shrivastava 81 ..Ophthalmia Nodosa . under supervision and excision of conjunctival nodules.
3/8/2011 Dr Sanjay Shrivastava 82 . characterized by chronic redness in one or both eyes with persistence of annoying symptoms.Chronic Non-specific Conjunctivitis Is a clinical condition resulting from continuation of acute conjunctivitis or due to variety of etiological factors.
seborrhoea . Dacryocystitis . misdirected eyelash(es). Unilateral Conjunctivitis foreign body retained in conjunctiva or Dacryocystitis 3/8/2011 Dr Sanjay Shrivastava 83 . poor quality air.Etiology 1. Hypersensitivity to allergen. alcohol abuse. Exposure to Chronic irritants like. dandruff etc 4. Chronic Rhinitis. dust. 2. sinusitis. late hours. 3. smoke. Concretions. blepharitis. heat.
* Increased secretions. burning. * Difficulty in keeping eyes open. lids may stick together in the morning on waking up.Symptoms * Discomfort. together 3/8/2011 Dr Sanjay Shrivastava 84 . grittyness. especially in the evening when eyes becomes red and eyelid margins feel hot and dry. mucoid or mucopurulent discharge.
Signs Hyperaemic lid margins Conjunctival Congestion particularly in lower fornix Papillary hyperplasia 3/8/2011 Dr Sanjay Shrivastava 85 .
3/8/2011 Dr Sanjay Shrivastava 86 .Treatment Elimination of cause Treatment of infection foci in nose and upper respiratory passage Treatment of conjunctival infection with appropriate antibiotic Treatment of meibomian gland abnormality by mechanical expression and warm compression.
Allergic Conjunctivitis Allergy or Hypersensitivity is a state which is commonly regarded as an unfortunate by product of the process of immunity whereby the tissues react by an abnormal and injurious response to foreign substance (allergens) 3/8/2011 Dr Sanjay Shrivastava 87 .
Delayed Hypersensitivity 3/8/2011 Dr Sanjay Shrivastava 88 .Allergy Two types of reactions: a. Immediate and b.
Characterized by circulating antibodies.Immediate Hypersensitivity Ten days after initial exposure to foreign protein. 3/8/2011 Dr Sanjay Shrivastava 89 . anaphylactic reaction follows after second exposure to same protein.
The sensitization is the property of the cells themselves. 3/8/2011 Dr Sanjay Shrivastava 90 .Delayed Hypersensitivity There are no circulating humoral antibodies of anykind. The hypersensitivity is caused by prior contact of the tissue with a protein and seems to be due to the development of sessile antibodies on or within the cells so that when they are re-exposed to the same antigen a reaction causing cellular damage develops which may even involve necrosis.
3/8/2011 Dr Sanjay Shrivastava 91 . Typical example is tuberculin reaction.Delayed Hypersensitivity This reaction does not occur immediately and reach its maximum only after 24 to 72 hours.
repeated contacts may result in hypersensitivity reaction eg Sulphonamide allergy and autosensitization induced by the haemolytic Streptococcus.Autosensitization In this case individual¶s own tissue protein are altered and thus rendered ³foreign´ by a pathogenic agent. either bacterial or a chemical acting as a haptene. 3/8/2011 Dr Sanjay Shrivastava 92 .
Some individuals are hypersensitive to light of a certain wave-band.cold. 3/8/2011 Dr Sanjay Shrivastava 93 .Physical Allergy Certain individuals react to physical agents such as heat. light or mechnical irritation by a typical hypersensitive response often of urticarial type.
3/8/2011 Dr Sanjay Shrivastava 94 .Physical Allergy The reaction is due to auto-antigen liberated in the tissues either due to alteration of their specificity or due to their capability of reacting with antibody only under the physical condition created by the stimulus.
Delayed Type (i) Contact Dermatoconjunctivitis due to local chemicals (ii) Microbial Allergic Conjunctivitis (iii) Keratoconjunctivitis Medicamentosa due to ingestion of drugs like arsenic and gold. 3/8/2011 Dr Sanjay Shrivastava 95 . Simple Allergic Conjunctivitis A. Immediate Anaphylactic (Hay fever) type mediated by circulating antibody B.Types of Allergic Conjunctivitis 1.
Interstitial Allergic Conjunctivitis A. B. Vernal Catarrh ± Allergic disease of immediate type ± an exogenous allergy.Types of Allergic Conjunctivitis 2. 3/8/2011 Dr Sanjay Shrivastava 96 .Endogenous microbial allergy. Phlyctenular Keratoconjunctivitis ± Delayed reaction.
Acute or Sub-acute Allergic Catarrhal Conjunctivitis Is an allergic condition characterized by hyperaemia which not as intense as found in bacterial conjunctivitis. chemicals. pollens. cosmetics. medications etc. and sometimes bacterial protein of endogenous nature. Itching is a prominent symptom. dye. flower. Etiology: Exogenous allergen (contact with animals. accompanied by watery secretion containing eosinophils. the most common being Staphylococcal infection. 3/8/2011 Dr Sanjay Shrivastava 97 .
presence of eosinophils and elevated IgE level. edema of lids may be there. watering. swelling of lids and there may symptoms of hay fever Signs: Conjunctival Congestion. redness. watery discharge. 3/8/2011 Dr Sanjay Shrivastava 98 . Symptoms: Itching.
Topical 2% sodium cromoglycate drops.Treatment 1. 3/8/2011 Dr Sanjay Shrivastava 99 . Short course corticosteroid drops 4. olopatadine. Removal of allergen from environment 2. Astringent lotion. ketotifen etc) 3. antihistaminic drops (chlorpheniramine). adrenalin 1:10000. mast cell stabilizers (sodium cromoglycate.
Vernal Keratoconjunctivitis (VKC) It is a chronic . self limiting disease/ condition usually due to exogenous allergens. interstitial inflammation of the conjunctiva of periodic seasonal incidence. 3/8/2011 Dr Sanjay Shrivastava 100 . bilateral conjunctival inflammatory condition found in individuals predisposed by their atopic background. It is recurrent.
associated with itching . and a distinctive type of keratitis . a gelatenous hypertrophy of the limbal conjunctiva. Characterized by flat topped papillae usually on the tarsal conjunctiva resembling cobble stones in appearance . either discrete or confluent. redness of the eyes lacrimation and mucinous or lardaceous discharge usually containing eosinophils 3/8/2011 Dr Sanjay Shrivastava 101 .
Epidemiology Sporadically occuring with a wide geographical incidence. It is essentially a disease of yoth occuring most frequently between ages of 6 and 20 years. 3/8/2011 Dr Sanjay Shrivastava 102 . Its more common in India and the tropics than in U.K. Colored races are particularly prone to limbal form of disease.
Family History of allergy is found in 40 ± 60 % cases. Sex incidence ± Very high percentage of cases are seen in males. 3/8/2011 Dr Sanjay Shrivastava 103 .
manifestation of an allergic condition. animal inhalants. ingestants etc) 3/8/2011 Dr Sanjay Shrivastava 104 .Etiology Three theories 1. Due to action of physical factors (as heat. humidity and light) 2. Most affected people show a marked hypersensitivity to a variety of antigens (pollen. Disorder of the endocrine glands associated with vagotonic state 3.
foreign body sensation. thick. blepharospasm. dirt white or cream colored. typical stringy discharge . thick mucous discharge. ptosis.Symptoms Severe itching and photophobia. ropy and lardaceous. burning. 3/8/2011 Dr Sanjay Shrivastava 105 . Discharge is scanty.
Types ± Palpabral form ± Limbal/ Bulbar form ± Mixed type 3/8/2011 Dr Sanjay Shrivastava 106 .Signs The signs are confined to conjunctiva and cornea. the skin of the lids are not involved.
Palpabral VKC Conjunctiva develops a papillary response in the upper tarsal conjunctiva and at the limbus. Tarsal papillae are discrete larger than 1 mm in diameter. flat tops . 3/8/2011 Dr Sanjay Shrivastava 107 . Conjunctiva is congested later on becomes milky. they are cobblestone in appearance.
broadening and opacification of the limbus which overrides the corneal periphery as a semitranslucent hood. This develop mostly at the upper margin of the cornea Limbal Papillae tend to be gelatinous and confluent 3/8/2011 Dr Sanjay Shrivastava 108 .Limbal / Bulbar Form In limbal or bulbar form the first change is usually a thickening.
In the raised mass. These changes may lead to superficial corneal vascularization. 3/8/2011 Dr Sanjay Shrivastava 109 . nasally and temporally. whitish Horner.Trantas¶s spots may occur at any stage. Limbal Nodules ± Their most common site is in the palpabral aperture. Horner Trantas dots are collection of epithelial cells and eosinophils.
3/8/2011 Dr Sanjay Shrivastava 110 .Corneal Findings Punctate Epithelial Keratitis Horizontally oval ulcer in upper part of cornea called Shield Ulcer Peripheral superficial gray white deposition termed Pseudogeronton.
Pathogenesis Biopsy of tarsal papilla in VKC reveals that epithelium contain large number of mast cells and eosinophils. IgE and IgG have been isolated from tears. also contains CD4 + T cells. Mast cells contains basic fibroblast growth factor Cytology shows more eosinophils and neutrophils. Substantia properia contains elevated number of mast cells. Histamins and trytase are elevated in tears Protein deposition diffusely in conjunctiva 3/8/2011 Dr Sanjay Shrivastava 111 .
3/8/2011 Dr Sanjay Shrivastava 112 . The flat-topped nodules are hard . not follicle. basophils and eosinophils may also be seen. macrophages. but the epithelium over them is thickened . giving rise to the milky hue. In addition . Eosinophils are present in them in great numbers. Histologically they are hypertrophied papillae. plasma cells . and consist chiefly of dense fibrous tissue . infiltration with lymphocytes.
Diagnosis History Clinical findings (young boys living in warm climates presenting with intense photophobia. ptosis and gaint papillae) 3/8/2011 Dr Sanjay Shrivastava 113 .
Steroids ± Patients with significant seasonal exacerbation . Dexamethasone 0. a short term high dose pulse regimen of topical steroid is necessary.TREATMENT 1. tapered rapidly. Local Treatment a.1% or Prednisolon Phosphate 1% . 8 times for one week brings excellent result. Avoidance of allergen 2. 3/8/2011 Dr Sanjay Shrivastava 114 .
3/8/2011 Dr Sanjay Shrivastava 115 .b. a mast cell stabilizer or a dualo acting drug such as Olopatidine. it decreases the release of interlukin2.05%) twice daily. Ketotifen or Azelastine (mast cell stabilization and antihistamine) c. Topical Cyclosporin-A (0. reduces expansion of T cell clones. Mast Cell stabilizer: Cromolyn sodium.
Treatment of Corneal Shield Ulcer: Antibiotic. If plaque forms ± superficial keratectomy Phototherapeutic Keratectomy and Keratectomy with amniotic membrane graft placement.steroid ointment and occlusion. 3/8/2011 Dr Sanjay Shrivastava 116 .
3/8/2011 Dr Sanjay Shrivastava 117 . Injection of short term or long term acting steroids into tarsal papilla has been shown effective in reducing their size.Surgical Treatment Cryablation of upper tarsal cobble stones ± but may lead to lid and tear film abnormalities.
3. Systemic Treatment: 1. Oral Aspirin (high dose of 2400 mgm daily) 4. Non sedating antihistaminic 2. Climatotherapy 3/8/2011 Dr Sanjay Shrivastava 118 .