CONJUNCTIVITIS

Dr Dilon Noronha
Objectives:-
• Anatomy of conjunctiva

• Conjunctivitis: Definition & classification

• Bacterial Conjunctivitis: Etiology, C/F and Management

• Allergic Conjunctivitis : Etiology, C/F and Management

Anatomy:
Parts:
• Palpebral:
Marginal
Tarsal
Orbital
• Bulbar conjunctiva
Limbal conjunctiva
• Conjunctival fornix
Structure of conjunctiva:
Glands of conjunctiva
 Mucin secretory glands: Goblet cells, Crypts of Henle, glands of Manz
 Accessory lacrimal glands: Glands of Krause, Glands of Wolfring
Blood supply:
 Marginal conjunctiva: marginal arterial arcade of the eyelid
 Forniceal conjunctiva: peripheral arterial arcade
 Post conjunctival artery : 4mm of the limbus
 Ant conjunctival artery: limbus
 Capillary arcades: extend 1mm into the cornea.
Lymphatics & Nerve supply:
 Medial 1/3 of the superior and 2/3 of inferior conjunctiva Submandibular LN
 Lateral 2/3 of sup & 1/3 of inferior conjunctiva Preauricular LN

NERVE SUPPLY:-
Conjunctival nerve
Classification of conjunctivitis:
1. Onset :
Acute
Subacute
Chronic
2. Type of exudate:-
Serous (viral, allergic, toxic)
Catarrhal (bacterial)
Purulent (bacterial)
Mucopurulent (bacterial, chlamydial)
Membranous
Pseudomembranous
3. Conjunctival response:-
Follicular
Papillary
Granulomatous

4. Aetiolgy:-
Infective : Bacterial, Viral, Chlamydial, Fungal
Non infective: Allergic, endogenous, Toxic, Idiopathic
 Predisposing Mode of Causative
factors infection organism
• Flies • Staph aureus
• Poor sanitation • Exogenous • Staph
• Hot dry • Local spread epidermidis
climate • endogenous • Strep
BACTERIAL • Unhygienic pneumoniae
CONJUNCTIVITIS conditions • Strep pyogenes
• H.influenzae
• Moraxella
Axenfeld
• N.Gonorrhoeae
• N.Meningitidis
• C.diphtheriae
• PATHOLOGY:-
CLINICAL TYPES:-
 Acute mucopurulent conjunctivitis
 Acute purulent conjunctivitis
 Acute membranous conjunctivitis
 Acute pseudomembranous conjunctivitis
 Chronic bacterial conjunctivitis
 Chronic angular conjunctivitis
 ACUTE BACTERIAL CONJUNCTIVITIS:-

• Or Acute mucopurulent conjunctivitis

Clinical features:-
• Symptoms:-
• Signs:-
 Conjunctival congestion
 Chemosis
 Petechial hemorrhages
 Flakes of mucopus
 Matting of eyelashes
 Slightly oedematous eyelids
CLINICAL COURSE: –
• Peak in 3-4days
• Cured in 10-15 days
• Chronic Catarrhal Conjunctivitis

COMPLICATIONS:
• Marginal corneal ulcer
• Superficial keratitis
• Blepharitis
• Dacryocystitis
Treatment:-
• Topical antibiotics:
Chloramphenicol(1%) / ciprofloxacin(0.3%) / ofloxacin(0.3%) e/d 3-4 hourly in day(ointment at night)
• Irrigation of conjunctival sac with NS/RL
• Dark goggles
• No bandaging
• No steroids
• Anti inflammatory & analgesic drugs orally
 ACUTE PURULENT CONJUNCTIVITIS:-

• Or Acute blenorrhoea or Hyperacute

Bacterial conjunctivitis
• 2 forms:-
• Adult purulent conjunctivitis
• Ophthalmia neonatarum(in newborn)

Etiology:-
• Affects predominantly males
• Spread: genitals to eye
Clinical Features:-
Stage of infiltration
Stage of Blenorrhea
Stage of slow healing
Complications:-
• Corneal involvement
• Iridocyclitis
• Systemic:
Arthritis
Endocarditis
Septicemia
Treatment:-
• Systemic therapy:
• Topical antibiotic therapy:
• Frequent irrigation of eyes
• General measures
• Cycloplegics (if corneal involvement is there): 1% atropine e/d
• Treatment of partner with systemic antibiotics
 ANGULAR CONJUNCTIVITIS

• Diplobacillary conjunctivitis
• Confined to conjunctiva & lid margins near the
angles
• Maceration of surrounding skin
Etiology:
• C.O:
 Moraxella Axenfeld
 Staphylococcus

• Source of infection: Nasal cavity

• Mode of infection: contaminated fingers or handkerchief

• Pathology:

MA produces a proteolytic enzyme

Enzyme collects at the angle by the action of tears

Macerarion of the conjunctival epithelium, lid margin & skin

Vascular & cellular response: mild grade chr inflammation

C/F:
• Symptoms:
 Burning, irritation, discomfort
 Collection of dirty white foamy discharge
 Redness in the angles of the eyes

• Signs:
 Hyperemia of the bulbar conj near the canthi
 Hyperemia of the lid margins near the angles
 Excoriation of skin around the angles
 Foamy mucopurulent discharge at the angles
Complications:-
• Blepharitis
• Marginal catarrhal corneal ulcer

Treatment:-
• Good personal hygiene
• Oxytetracycline 1% ointment, 2-3 times a day for 2weeks
• Zinc lotion daytime & Zinc oxide ointment bed time
 MEMBRANOUS CONJUNCTIVITIS:

• Conjunctival inflammation with formation of a true membrane

ETIOLOGY:
• Corynebacterium diphtheriae
• Occasionally streptococcus haemolyticus

PATHOLOGY:
• Deposition of fibrinous exudate on the surface & substance of conjunctiva usually in the palpebral
conjunctiva
CLINICAL FEATURES:-
Usually in children 2-8 years (not immunized)
 Stage of infiltration:
• Scanty discharge and severe pain
• Swollen and hard lids, red swollen conjunctiva covered with grey yellow membrane
• On removal, membrane bleeds

 Stage of suppuration:
• Pain decreases, membrane sloughs off
• Copious purulent discharge

 Stage of cicatrization:
• Raw surface covered with granulation tissue & epithelized
• Cicatrization occurs, trichiasis, conjunctival xerosis
COMPLICATIONS:
• Corneal ulceration
• Delayed: Symblepheron, trichiasis, entropion,
conjunctival xerosis
TREATMENT:
Topical:
• Penicillin eye drops 1:10000 unit/ml every 30 min
• Anti-diphtheric serum every 1 hour
• Atropine 1% ointment (if corneal involvement)
• Broad spectrum antibiotic ointment at bed time

Systemic:
• Cryst penicillin 5 lac units IM BD x 10 days
• Anti-diphtheric serum 50,000 units IM stat

Prevention:
• When surface raw: apply BCL or sweep glass rod with ointment
ACUTE PSEUDOMEMBRANOUS
CONJUNCTIVITIS:

Bacterial:
Staphylococcus
Streptococcus
H.Influenzae
N.Gonorrhoea

Viral Chemical
Herpes simples Acids, ammonia, lime,
adenovirus copper sulphate,
silver nitrate
CLINICAL FEATURES:
• Acute mucopurulent conjunctivitis
a/w pseudomembrane formation

TREATMENT:
Same as mucopurulent conjunctivitis
ALLERGIC CONJUNCTIVITIS:-
CLASSIFICATION:-
1. Simple allergic conjunctivitis
-hay fever conjunctivitis
-seasonal allergic conjunctivitis (SAC)
-perennial allergic conjunctivitis(PAC)

2. Vernal keratoconjunctivitis (VKC)

3. Atopic keratoconjunctivitis (AKC)
4. Giant papillary conjunctivitis (GPC)
5. Phlyctenular keratoconjunctivitis(PKC)
6. Contact Dermoconjunctivitis
Simple allergic
conjunctivitis:
• Mild ,non specific IgE mediated Type I
hypersensitivity reaction

Etiology :
Hay fever conjunctivitis : associated with
allergic rhinitis
Allergens : pollens , grass , animal
dandruffs
SAC: common , d/t: grass pollens
PAC: not common , d/t: house dust and
mites
Pathogenesis:-
Allergen enters tear film

Contact with conjunctival mast cells that bear

IgE antibodies

Degranulation of mast cells releases histamine

Histamine promotes vasodilatation & edema
C/F:-
Treatment:-
– Elimination of allergens if possible
– cold compresses
– antihistamines oral/ topical (epinistine,fexofenadrine)
– mast cell stabilizers (sodium cromoglycate,lodaximide) –
--Combination( ketotifen,patalon,azelastine)
– topical corticosteroids
– Immunosuppressant's (cyclosporin) for steroid resistant cases
VKC or Spring Catarrh
 recurrent, bilateral, interstitial, self-limiting
 periodic seasonal incidence.

Etiology
 Hypersensitivity reaction to some exogenous allergen.
 IgE mediated atopic mechanisms
 Raised IgE + eosinophilia
 personal or family h/o other atopic diseases ( hay fever, asthma, or eczema)
Predisposing factors:

 4-20 years, common in males

 More in summer -'Warm weather
conjunctivitis’
 Prevalent in tropics
Clinical features:-
Vernal Keratopathy
Treatment:
Local therapy
 Topical steroids: FML, dexamethasone, loteprednol
 Mast cell stabilizers: Sodium cromoglycate, azelastine, ketotifen
 Topical antihistaminic e/d: olopatidine, ketotifen
 Acetyl cysteine (0.5%) e/d - mucolytic property
 Topical cyclosporine 1% eye drops
 Tacrolimus e/ointment (0.03%) for refractory cases

Systemic therapy
 Oral histamine
 Oral steroids in severe cases for short duration
Treatment of large papillae:
 Supratarsal injection of long acting steroid
 Cryo application
 Surgical excision for extra-ordinary large papillae
General measures:
 Dark goggles
 Cold compress & ice packs
 Change of environment (working environment also) Desensitization
Treatment of vernal keratopathy:
 PEK : steroid instillation should be increased
 Large vernal plaque: surgical lamellar keratectomy
 Severe shield ulcer: debridement, superficial keratectomy, AMT
PKC:
 characteristic nodular affection
 allergic response of the conjunctival and corneal epithelium
 to some endogenous allergens to which they have become sensitized.

Etiology
Delayed hypersensitivity
Causative allergens
Tuberculous, Staphylococcus, Proteins of Moraxella Axenfeld bacillius, Parasites
Predisposing factors
 Age
 Sex
 Undernourishment
 Living conditions
 Season: all climates
Clinical features:-
Symptoms:
 Discomfort in the eye
 Irritation
 Reflex watering
 Mucopurulent conjunctivitis d/t sec bacterial infection
Signs:-
1.Simple phlyctenular C
2. Necrotizing phlyctenular C
3. Miliary phlyctenular C
Treatment:-
Local therapy:
 Topical steroid e/d and ointment
 Topical antibiotic e/d & ointment
 Atropine eye ointment(1%) when cornea involved

Systemic therapy:
 Diagnosis & management of TB
 Septic foci like caries, folliculitis, tonsillitis, adenoiditis to be adequately treated
 Parasitic infestations to be ruled out & treated if present

General measures:
 Improve hygiene & supplement high-protein diet