Conjunctivitis and other

ocular lesions
Dr Senata Tinaiseru
Advanced Eye and Ear care
Definition
• Conjunctivitis: inflammation of the
conjunctiva • Conjunctiva: thin, translucent,
elastic tissue layer with bulbar and palpebral
portions
• Bulbar: lines the outer surface of the globe to
the limbus (junction of sclera and cornea)
• Palpebral: covers the inside of the eyelids
• Two layers: epithelium, substantia propria
Eye Anatomy
Classification of Conjunctivitis

• Infectious Noninfectious
Viral  Allergic,
 Toxins/ Chemicals,

Bacterial  Foreign body,

 Trauma,
 Hyperacute  Neoplasm
 Acute
 Chronic
Viral Conjunctivitis

 Most common viral cause is adenovirus

(enterovirus, HSV)
 Occurs in community epidemics (schools,

workplaces, physicians’ offices)

 Usual modes of transmission: contaminated

fingers, medical instruments, swimming pool

water
Viral Conjunctivitis

 Presentation:  May be part of viral

unilateral or prodrome:
bilateral, acutely red adenopathy, fever,
eye, watery or pharyngitis, cough,
mucoserous rhinorrhea
discharge, chemosis,
tender preauricular
node, burning/
sanding/gritty
feeling in eye(s),
rarely photophobia
Acute Bacterial Conjunctivitis

 Common causes in neonates: Chlamydia

trachomatis, Neisseria gonorrhoeae
 In children: Haemophilus influenzae (80%),

Streptococcus pneumoniae (20%), and

Moraxella catarrhalis. Concurrent OM seen in
25%.
 In adults: Staphylococcus aureus
Acute Bacterial Conjunctivitis

 Presentation: Unilateral  Highly contagious:

or bilateral, red eye,
spread by direct
mucopurulent or
purulent discharge contact or by
continuously throughout contaminated
the day, burning, objects
irritation, mild chemosis
 Neonates: symptoms
appear 5-14d after birth
(inclusion conjunctivitis
of the newborn)
Hyperacute Bacterial Conjunctivitis
 Etiology: Neisseria species, most commonly N.
gonorrhoeae
 Presentation: profuse, purulent discharge with rapidly
progressive symptoms of marked conjunctival
injection, irritation, tenderness to palpation, chemosis,
lid swelling, and tender preauricular adenopathy
 Ophthalmia neonatorum: gonococcal ocular infection
with bilateral discharge 3-5d after birth from vaginal
transmission
 Sexually active teens: transmitted from genitalia to
hands to eyes, commonly see concurrent urethritis
 Sight-threatening
 Ohthalmia Neonatarum
Chronic Bacterial Conjunctivitis
 Most common etiology: Staphylococcus
species
 More common in adults and patients with

acne rosacea or facial seborrhea

 Presentation varies: redness, itching,

burning, foreign-body sensation, flaky

debris, blepharitis (common), eyelash loss
 Concurrently see styes and chalazia of the lid

margin from chronic inflammation of the

meibomian glands
Allergic Conjunctivitis

 Most commonly seasonal  Presentation:

allergic
rhinoconjunctivitis, also Bilateral pruritis,
called hay fever redness, watery
rhinoconjunctivitis discharge,
IgE mediated
rhinorrhea/congest


hypersensitivity reaction
precipitated by small ion
airborne allergens→ local  Patients often
mast cell degranulation →
release of chemical
have h/o atopy,
mediators (histamine, seasonal allergy or
eosinophil chemotactic specific allergy
factors, PAF, etc.)
Diagnosis of Conjunctivitis

• Clinical diagnosis of exclusion

• Morning crusting of eye unreliable for
determining etiology
• If focal pathology (hordeolum, cancerous
lesion or blepharitis), conjunctivitis is reactive
rather than primary
• If redness is localized rather than diffuse,
consider foreign body, pterygium or episcleritis
Cultures
• Not necessary for initial diagnosis and
therapy of acute conjunctivitis
• When to culture:
1. Neonates
2. Hyperacute purulent conjunctivitis
(immediate Gram staining)
3. Chronic or recurrent conjunctivitis
Treatment
• Viral, allergic, and nonspecific conjunctivitis
are self-limited
• Bacterial conjunctivitis is also likely to be
self-limited but abx treatment shortens the
course, reduces person-to-person spread, and
lowers the risk of sight-threatening
complications
Treatment of Viral Conjunctivitis

• Topical antibiotics not necessary because

secondary bacterial infection is uncommon
• Reassurance that the sxs may get worse for 3-
5d before getting better and persist for 2-3 weeks
• Some relief from cold compresses and topical
antihistamines/decongestants
• Do not use topical corticosteroids due to risk of
sight-threatening complications (scarring, corneal
melting, perforation), especially if etiology is
herpes simplex virus or bacterial keratitis
Treatment of Acute Bacterial
Conjunctivitis
 Topical broad-spectrum antibiotics: erythromycin
ointment, bacitracin-polymyxin B ointment (Polysporin),
trimethropim-polymyxin B (Polytrim), sulfa drops
 Most H. flu and S. pneumoniae resistant to macrolides
 Sulfa drops (Bleph-10): less effective and rare side
effect of Stevens-Johnson syndrome
 Rx: 1/2” ointment inside lower lid or 1-2 drops QID for
57 days (response seen typically within 1-2d)
 Inclusion Conjunctivitis of the Newborn: treat with 2
week course of erythromycin (50mg/kg/d po divided
QID) or sulfisoxazole (150mg/kg/d po divided QID),
topical unnecessary with systemic
Treatment of Hyperacute Bacterial
Conjunctivitis
• Immediate ophthalmic referral
• Systemic and topical antibiotics and saline irrigation
• Systemic antibiotic of choice due to penicillin-resistant N.
gonorrhoeae is single-dose Ceftriaxone (25-50mg/kg IV or
IM, not to exceed 125mg) or single-dose Cefotaxime
(100mg/kg IV or IM) in neonates
• If venereal disease present in teens, also treat with
singledose of azithromycin (1g) because over 30% of these
patients will have concurrent chlamydial disease
• AAP and CDC recommendations for prevention of
ophthalmia neonatorum: silver nitrate 1% aqueous solution
(side effect of chemical conjunctivitis), erythromycin 0.5%
ophthalmic ointment, tetracycline 1% ophthalmic ointment
Treatment of Allergic Conjunctivitis
• Self-limiting
• Allergen avoidance, cold compresses, topical
antihistamines/vasoconstrictors (do not use for
greater than 2 weeks), artificial tears, topical
NSAIDS (low efficacy)
• Prophylaxis: oral antihistamines (onset of
action=days), mast cell stabilizers (onset of
action=5-14d)
Treatment according to Etiology
When to Refer to Ophthalmology

• Neonates
• Hyperacute Purulent Conjunctivitis
• Chronic Conjunctivitis
• Sxs of pain, blurred vision, and photophobia
• Reactive conjunctivitis vs. primary
School/Daycare
 Bacterial and viral conjunctivitis are highly
contagious
 Red Book 2003: Except when viral or bacterial
conjunctivitis is accompanied by systemic signs of
illness, infected children should be allowed to
remain in school once any indicated therapy is
implemented, unless their behavior is such that
close contact with other students cannot be
avoided. Exclude from daycare if purulent d/c.
 Safest approach for a child with bacterial
conjunctivitis is to stay home until there is no
longer purulent discharge (12d after Rx started).
Other Eye Lesions

Episcleritis Scleritis
• Etiology: Idiopathic, • Etiology: systemic
rarely seen with disease (RA, IBD, SLE,
arthropathies HSP, sarcoidosis,
• Presentation: young Wegener’s)
woman, acute, unilateral, • Presentation: all ages,
intense erythema, large more common in women,
blood vessels, serous d/c painful, photophobia,
• Tx: self-limiting (2- perforation, vision
21d), no threat to vision, changes • Tx: systemic
topical lubricants NSAIDS, steroids, treat
underlying condition
Episcleritis/Scleritis
 Episcleritis  scleritis
Hordoleum (sty)
 Swelling of one or more sebaceous glands of
the eyelid from bacterial infxn, internal or
external
 Tx: warm compresses, I&D if no drainage

occurs, topical abx

Chalazion
Hard tumor formed by distention of a
meibomian gland with secretion
 Tx: warm compresses, mild topical Steroid

ointment
Pinguecula / Ptegyrium
Pinguecula
 Pinguecula are growths of fat, protein, or
calcium on the conjunctiva. They are caused
when the eye is exposed to sand, dust, and
ultraviolet rays.
Pingueculitis
 Tx – Artificial tears
 Vasoconstrictors,

Naphazoline, 1
drop BD
 Topical Steroids

drops may be
prescribed
 Sun/UV protection
Pterygium
 Triangular thickening of bulbar conjunctiva
extending from inner canthus to border of
cornea with the apex towards the pupil
 Caused by UV radiation and dust, trauma,

or post chemical injury

 Common symptoms include redness,

blurred vision, and eye irritation.

 Stockers line- Iron deposition line in the corneal
epithelium, located at the corneal leading edge of a
pterygium. Color may vary from yellow to golden
brown.
Grading of Pterygium
Management
Treatment depends on the  Conjunctival
size and nature of the autograft
pterygium, the symptoms
and whether vision is
 Amniotic sac graft
affected.  Keratoplasy
 Artificial tears
Lamellation
 Vasoconstrctors-

Naphazoline drops
 Steroids if inflamed,

otherwise not indicated

 Surgery from

Grade 2 , 3