Conjunctiva Flashcards
what is blepharoconjunctivitis?
secondary to lid disease = secondary bacterial conjunctivitis
if a non-pediatric or non-geriatric patient presents with true primary bacterial conjunctivitis in the absence of lid disease - what are some causes?
overstressed lifestyle, acquired immune dysfunction, acquired immune deficiency (HIV, AIDS) or an oddball unusual microbe
what are some symptoms of blepharoconjunctivitis?
burn, itch, red, watery/tearing, lids mattered shut in AM, scratchy, FB sensation and swollen
what are some signs of blepharoconjunctivitis?
red/edematous eyelids, interpalpebral injection, NaFl staining SPK near lid margins, papillae, chemosis, mucopurulent discharge, -PAN
what are some of the eye’s defenses to prevent bacterial invasion of conjunctiva from lid infections?
bacteriostatic lysozymes and immunoglobulins in tear film, blink force and immune system in general
what organism causes blepharoconjunctivitis and where do they colonize?
staphylococci lid margins, conjunctiva, and meibomian glands
what is the goal of blepharoconjunctivitis treatment?
complete eradication is impossible - need to control amount of staph but maintain its position in anterior segment’s normal flora **focus on lid disease**
what is the initial treatment for blepharoconjunctivitis?
aggressive initial therapy = lid hygiene at least daily, topical antibiotic (AzaSite) BID for several weeks then Besivance TID (Durasite) soaks/scrubs/massage/ATs
how do you alter the treatment for blepharoconjunctivitis after the lid disease is under control?
alternate antibiotic ointments to reduce the chance of resistance - Polysporin and erythromycin
what are some treatment options for blepharoconjunctivitis in resistant cases?
AzaSite and Doxycycline 50-100mg PO x 3 weeks or more, Dicloxacillin, erythromycin ethylsuccinate (EES if allergic to PCN)
when is Dicloxacillin contraindicated?
if patient is allergic to penicillin/cephalosporins or newborns (children are ok)
when is doxycycline contraindicated?
children under 8-12 years old, pregnant or lactating females
when is erythromycin ethylsuccinate (EES) contraindicated?
patient with impaired hepatic function - ok in children and pregnant/lactating females
how do you treat blepharoconjunctivitis when you suspect an oddball bacterial infection?
culture/sensitivity testing - strong antibiotic drop = Besifloxacin suspension
gentamicin, trimethoprim, vancomycin = MRSA
which two drugs are no longer the “big guns” and resistance has become a problem?
moxifloxacin (Vigamox) and gatifloxacin (Zymar)
what is the great antibiotic is too dangerous to legally prescribe?
chloramphenicol - a few premature infants have died from aplasitc enemia with topical use
what information should you provide another provider when referring a patient?
detailed documentation of your treatment and the lack of resolution of the patient’s symptoms and signs
who typically develops true primary bacterial conjunctivitis?
pediatric (immune system is still developing) and geriatric (immune system is in decline)
what organisms cause primary bacterial conjunctivitis?
staph aureus, staph epidermidis, strep pneumoniae, and haemophilus influenzae
what are the various topical antibiotics used to treat bacterial conjunctivitis?
*aminoglycosides are not first choice* fluoroquinolones, polymyxin B combinations, and others (AzaSite, Ilotycin, Bacitracin)
what does epidemic history, petechial hemorrhages with scant discharge suggest in bacterial conjunctivitis?
strep pneumoniae
if a patient has copious discharge in bacterial conjunctivitis - what organism might they have?
haemophilus influenzae
what type of treatment should you use in children with bacterial conjunctivitis?
amoxicillin/clavulanate (Augmentin) PO for H.flu and small children may respond better to ung than gtt - start with Polytrim gtt
what are some additional treatments for bacterial conjunctivitis besides antibiotic drops?
warm compresses, irrigation, lid hygiene, no school or work
what are some symptoms of viral conjunctivitis/epidemic keratoconjunctivitis (EKC)?
watery/tearing, scratchy, FB sensation, lids mattered shut in AM, itchy, red, swollen
what are some signs of viral conjunctivitis/EKC?
follicles, watery/mucus discharge, red/edematous eyelids, +PAN, pinpoint subconjunctival hemorrhages, pesudomembrane, +URI, subepithelial infiltrates
what is the pathophysiology for viral conjunctivitis/EKC?
adenovirus - search for memory B cells
what is the typical course for viral conjunctivitis?
Hx of recent URI/red eye - starts with one eye and moves to other within days - begins with hyperemic and congestive conjunctival reaction, within days - follicles, serous discharge, +PAN, +SEI, fibrinous pseudomembrane
what is the treatment for typical viral conjunctivitis?
cool compress and AT’s (PF), may need vasoconstrictor/antihistamine (Naphcon-A), low dose steroids (fluorometholone alcohol or prednisolone phosphate 0.125%) for pseudomembrane or SEI
what else could any follicular conjunctivitis or keratoconjunctivitis also be?
EKC or herpes simplex keratitis (HSK) - rule out punctate epithelial lesions and avoid steroids
why is EKC so contagious and how long is the patient contagious for?
the virus is shed in the tears and through nasopharynx - usually spreads during first week when patient is asymptomatic
contagious about 2 weeks - they are non-contagious when SEI’s appear
what is the treatment for EKC?
no antivirals - not effective use cool compress, lubricant’s, vasoconstrictors (Naphcon-A QID), NSAID (aspirin), antibiotic, and possibly a steroid
why would you prescribe an antibiotic for EKC and what would you give?
prophylaxis for bacterial conjunctivitis/keratitis Chlorofluoroquinolone, polytrim, fluoroquinolones QID or polysporin, ciloxan erythromycin ointment qhs
why are steroids controversial in EKC treatment? What kind would you give?
if you are unsure if there is HSK use low concentration 0.125% prednisolone phosphate or Lotemax sol/gel for pseudomembranes or SEIs
how do you treat secondary iritis that may occur with EKC?
cycloplegics - homatropine 2-5% BID or cyclopentolate 1% BID
what is the purpose/goal of using Betadine to treat EKC?
rapid decrease or elimination of live virus from ocular surface - decreased time for viral particles to migrate into anterior stromal tissues and incite an immune response (SEI)
what are some symptoms of allergic conjunctivitis?
itching, watering, tearing, redness, scratching, FB sensation, lids mattered shut in AM, swollen
what are some signs of allergic conjunctivitis?
thin watery discharge, redness, AM crusting, papillae, injection, chemosis, red/edematous eyelids, -PAN
what 2 responses does an allergen on the conjunctiva initiate?
release of pre-formed inflammatory mediators = histamine and bradykinin
production of arachidonic acid and its conversion to prostaglandins, thromboxanes, and leukotrienes
what is the regimen of treatment for allergic conjunctivitis in increasing order?
cool compresses, OTC topical vasoconstrictors or OTC topical vasoconstrictors/antihistamines (Naphcon-A, Vasocon-A) QID, topical antihistamines, topical dual mechanism (anti-H and MCS), topical steroids TID-QID, oral antihistamines or combo with decongestant, mast cell stabilizers QID
how do you reduce serous leakage in allergic conjunctivitis?
topical decongestants (can cause rebound hyperemia) = naphazoline (Naphcon, Vasocon, Albalon)
oral decongestants = pseudoephedrine 30, 60 mg/ 120, 240mg
oral anti-histamines + decongestant = loratadine 5mg + pseudoephedrine 120mg or chlorpheniramine 4mg + pseudoephedrine 60mg
why would you prescribe topical steroids for allergic conjunctivitis and what are some examples for hayfever conjunctivitis?
indicated for severe conditions with symptoms and signs loteprednol 0.2%, medrysone 1%, prednisolone phosphate 0.125%, FML 0.1%
what do you educate patients on for allergic conjunctivitis?
discover/prevent exposure to allergen
pre-treat seasonal allergies with mast cell stabilizers QID or OTC ketotifen (Zaditor) BID or Rx olopatadine (Patanol BID/Pataday QD)
should patients who suffer significantly from allergies suspend CL wear?
need to look at superior palpebral conjunctiva - look for hyperemia, edema or papillae - if they are present then yes and treat with corticosteroid QID and an allergy drop
which oral antihistamines are more sedating? which are less?
sedating = benadryl (diphenhydramine) and Chlor-Trimeton (chlorpheniramine)
non-sedating = claritin, clarinex, allergra, and zyrtec
what type of conjunctivitis is seen here?
True bacterial conjunctivitis
what type of conjunctivitis is seen here and what clinical sign do they have?
Viral conjunctivitis = ECK
pseudomembrane
what type of conjunctivitis is seen here?
blepharoconjunctivitis (secondary bacterial conjunctivitis)
what is seen is this photo?
Subepithelial infiltrates (EKC)
what type of conjunctivitis is seen here?
Allergic conjunctivitis
what type of conjunctivitis is seen here?
EKC
what type of conjunctivitis is seen here?
allergic conjunctivitis
