Conjunctiva: Conjunctivitis Flashcards
Describe acute conjunctivitis vs chronic conjunctivitis?
- Conjunctivitis:
o Acute or chronic
Acute: - Rapid onset of redness & irritation
- Sloughing of necrotic epithelium
- Increased inflammatory cell production
- Pseudomembrane (membrane would usually have a vascular blood supply, pseudomembrane just a lot of inflammatory material released in a large amount so has been compressed & forms layer over ocular surface – needs peeled away)
Chronic: - Slower onset
- Localised nodules (e.g. papillae or follicles) & surface infoldings
o Diffuse or localised
o Infectious or non-infectious - Ask yourself if the conjunctivitis is acute or chronic
Acute can turn into chronic if lasts for many months and sometimes years – can lead to scarring – fibrosis (scar tissue) – on tarsal conj – if this is roughened epithelium then every time px blinks, will cause significant inflammation & discomfort
Describe bacterial conjunctivitis?
- V common
- Redness
- Pain – FB sensation/grittiness
- <4week duration
- Less “itchy” than other types of conjunctivitis
- Signs:
o Purulent discharge - yellowy
o Sticky – worse in morning
o Papillae
o Chemosis – conj becomes oedematous and lifts off sclera - Conjunctival swab if severe – if going on for >4wks then REFER
Describe treatment for bacterial conjunctivitis?
o Most often eyelid hygiene and cold compresses is satisfactory
o Topical antibiotics (NOT ALWAYS NECESSARY – may only speed up recovery by day or 2)
Chloramphenicol 0.5% Eyedrops QDS 1 week
o Eyelid hygiene – if any infected material or bacteria gathering on eyelashes – need to be removed
o Cold compresses – symptomatic relief – ice water in a cup & clean towel – rest it on eyelids couple of times a day
o Usually managed in community, refer if atypical or uncertain of diagnosis
Describe Adenoviral Conjunctivitis?
- Pain – itchy/burning/FB sensation
- Recent upper respiratory tract infection – ask in H&S – adenovirus can tract up nasolacrimal duct
- Recent contact w/ infected person
- Both eyes involved within 1-2 days – occurs in one eye first
- Signs:
o Follicles
o Preauricular lymph nodes – just in front of pxs ear may be tender as lymph nodes are swollen – can also feel lymph nodes underneath mandible
o Watery/ mucus discharge – pseudomembrane
o Red & swollen eyelids
o Pinpoint subconjunctival haemorrhage
Describe the treatment for Adenoviral Conjunctivitis?
o Most will get better on own w/o tx – no tx for adenoviral conjunctivitis like there is no tx for common cold
o Artificial tears – 3 or 4 times a day – keep them in fridge to get cooling effect
o Antihistamine drops
o Cold compresses
o Peeling of pseudomembrane if present – acts as harbour of infection w/o removal
o Usually managed in community, refer if atypical or uncertain of diagnosis – REFER if there is cornel involvement w/ evidence of keratitis & effecting pxs vision
Would maybe give px mild steroid e.g. FML if the pxs vision is dropping – risk that px becomes dependent on steroid – steroid doesn’t treat the disease, it only dampens the disease process
Describe Herpes Simplex Conjunctivitis and its treatment?
- Hx of ocular HSV or cold sores
- Environmental stressors
o Fever, UV light exposure, stress - FB sensation
- Unilateral follicular conjunctivitis
- Herpetic skin lesions along lid or skin
- Preauricular lymph node
- Check for corneal involvement – chronic keratitis caused by HSV can cause severe visual impairment & can be v challenging – check corneal sensation & use NaFl to make sure no ulceration
- Tx:
o Topical antiviral therapy – aciclovir ganciclovir nowadays 5 times a day – use for up to 2 weeks (& no longer) as it can cause irritation to ocular surface
o Cold compresses
Describe Shingles - Herpes Zoster Ophthalmicus & its treatment?
- Can involve eye when there is involvement of trigeminal nerve, either in 1st or 2nd distribution – when it involves either of these then this is Herpes Zoster Ophthalmicus – there doesn’t need to be necessarily any eye involvement
- Skin rash & discomfort/pain
- Headache, fever, malaise
- Blurred vision, eye pain, red eye
- Vesicular skin rash – w/ time inflamed skin reaction will settle & progresses to scarring
- Unilateral, dermatome of 5th CN
- Hutchinson sign – rash appears on tip of nose (due to involvement of nasociliary nerve which is part of CN5 – nasociliary nerve passes through orbit – if see this then know that since the nerve passing through the orbit then eye is likely to be affected)
- Tx:
o Normally px will have presented to GP or A&E 1st – more w/ rash than w/ eye involvement will be given antiviral agent
o If px presents to you & still had rash – IP Optoms can prescribe oral antiviral agent in presence of skin lesion
Aciclovir – 800mg – 5 times a day for a week
o Topical aciclovir not effective – good penetration w/ oral agents
o Cold compresses
o Cleaning lids
o Lubrication
Describe Allergic Conjunctivitis: allergnes, symptoms & signs?
- Perennial or seasonal
- Hypersensitivity to airborne allergen that enters tear film & comes into contact w/ conjunctival mast cells
- Frequently associated w/ nasal symptoms
o Rhinoconjunctivitis - Allergens:
o Seasonal: pollens - “hay fever”
o Perennial: dust might, animal hairs - Perennial tends to be less severe
- Perennial pxs can have seasonal exacerbations especially summer as can have allergy to pollen on top of other allergies
- Often based off history alone to determine what it is
- Symptoms:
o Itchy/ red/ burning
o Watery or scant discharge
o Symptoms usually mild
o Remissions & exacerbations during session
o May be unilateral or bilateral
o Sneezing or nasal discharge - Signs:
o Conjunctiva – mild injection and oedema (chemosis)
Pinkish appearance
o Papillary hypertrophy possible – EVERT LIDS
o Eyelid – mild oedema may be present
o No corneal involvement – px’s vision should not be affected - Often there are no distinguishing signs and symptoms – other than just a mild red eye
- Diagnosis can be made by classic mild to moderate symptoms & almost normal appearing eye w/ no specific signs
Describe the differential diagnosis for allergic conjunctivitis?
o Blepharitis
o Contact allergy
o Infectious conjunctivitis
o Other forms of allergic conjunctivitis
o Trauma – mechanical or chemical
o Cellulitis – periorbital or orbital
Describe the management of allergic conjunctivitis?
o Non-pharmacological measures
Avoid inciting agent / advice – avoid pollens/grasses etc which are inducing the conjunctivitis
Cold compresses – for comfort to take heat out eyelids – ice water, clean towel, couple times day
o Artificial tears – soothes ocular surface – keep in fridge to get cooling effect
o Anti-allergy drops: antihistamine / mast cell stabiliser / combination drop – px should take for couple of weeks but more often than not they will just stop taking them when their eye feels better
o NSAIDs eye drops – for ongoing allergy to control inflammation
o Mild topical steroid – FML
o Oral antihistamine – px can buy these over counter
o REFER if tried various options and px’s symptoms not getting any better – this would be after number of weeks
Describe atopic keratoconjunctivitis?
- Px’s are atopic if they have eczema, dermatitis or asthma or allergic eye disease
- Most typically occurs in men presenting in late teens or 20s and last until 30s/40s
- History of atopy – asthma, hay fever, urticaria
- Positive family history for atopy - ASK
- Risk of reduced vision if corneal involvement e.g. can cause keratitis w/ ulceration and vascularisation
o Also reduction in vision from corneal vascularisation, pannus formation & scarring
What are the symptoms & signs of atopic keratoconjunctivitis?
- Symptoms:
o Extreme itch / burning – can be from recurrent eye rubbing – px’s w/ atopic eye disease also present w/ keratotonus in the longer term
o Photophobia
o Altered visual acuity
o Significant Redness – a lot more than seasonal/perennial conjunctivitis
o Evidence of scratching on face
o Mucus discharge ++ causing eyes to be stuck in morning - Signs:
o Bulbar conjunctiva is erythematous and chemotic
o Papillary hypertrophy – papillae usually more sever on eyelid eversion
o Conjunctival scarring – commonly upper palpebral region – as this is chronic conjunctivitis
o Gelatinous limbal infiltrates – inflammatory infiltrates around cornea
o Cornea:
Superficial punctate keratopathy
Persistent epithelial defects e.g. ulceration
Secondary infection and eventual scarring from chronic inflammation
o Red, thickened and swollen lids as a result of atopic dermatitis with superadded infection
What is the management of atopic keratoconjunctivitis?
- Management:
o Aims:
Maintain visual acuity
Avoid allergens
Relieve symptoms
o Non-pharmacological measures – avoid any exacerbating factors, cold compresses, lid hygiene
o Topical therapy
NSAIDs useful in controlling itching
Topical corticosteroids may be necessary at an earlier stage if severe with corneal involvement – before px develops a chronic epithelial defect - Should still be avoided long term
o Long term maintenance often required
Mast cell stabiliser, sodium cromoglycate
Oral antihistamine
o Blepharitis management:
Lid hygiene
Topical antibiotic – if build up of bacteria on lid margin
Follow-Up:
o Every few weeks
o Tapering of topical tx dependent on ocular response – for chronic conditions try & control symptoms on minimal amount of tx possible lots of tx and regularly is difficult for px to keep up with
o Monitoring of IOP for those requiring topical steroids
Describe Vernal Keratoconjunctivitis?
- Bilateral, severe, sight threatening allergic conjunctivitis – sight threatening due to ulcers that develop on cornea
- Commonly seen in young children & adolescent males, lasts up to 10 years
- Most symptomatic during spring and summer
- Some experience symptoms year-round requiring maintenance therapy
- Symptoms:
o Extreme itching
o Redness
o Photophobia
o Blepharospasm
o Altered acuity – if corneal involvement with ulceration
o Mucus discharge ++ (significant) - Signs:
o Giant papillae on upper tarsal plate >1mm in size
o Cobblestone appearance
o Pseudomembrane as a result of excess mucus production
o Limbal conjunctiva – gelatinous limbal infiltrates
Describe the corneal changes in vernal keratoconjunctivitis?
Corneal Changes:
o Superficial punctate erosions
o Trantas’ dots – inflammatory infiltrates round limbal area
o Macroerosions
o Shield ulcer – ulcer develops because of superficial punctate keratopathy, this then becomes a confluent mass, develop ulcer, have all this inflammatory material that has been released as part of conjunctivitis collecting within ulcer & can get plaque forming within epithelial defect which means it cannot heal
Shield ulcer w/ corneal plaque
o Corneal plaque
o Corneal vascularisation
