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
Describe the management for Vernal Keratoconjunctivitis?
o Although severe, is self-limiting – so long as look after eye as best as possible, it will settle & px’s vision will be preserved
o Resolves without scarring
o Non-pharmacological measures – cold compresses, lid hygiene
o Topical anti-allergy and systemic antihistamine
o If cornea compromised w/ epithelial defect:
Topical steroids, FML (or could use something stronger) – use FML to begin w/ for a week but if still not healed after this then use something stronger (e.g. topical prednisolone 0.5% or 1% or dexamethasone 0.1%))
Vernal keratoconjunctivitis is exception to rule of avoiding steroids due to impeding the epithelial healing it is the inflammatory process here which is preventing the epithelium healing, so steroids are required to treat this inflammation
* Need a balance too much steroid & epithelium won’t heal but if don’t treat inflammation w/ steroids epithelium won’t heal either
o Acute episodes – quickly tapered topical steroids usually necessary
o Admission in severe cases not responding to treatment may help with a change in the environment
Can admit px if significant sight threatening ulcer
o Treatment of chronic blepharitis:
Oral and topical antibiotics
Eyelid hygiene
o Occasional bandage contact lens when severe corneal complications are present – more for comfort, stops papillae causing ongoing abrasions
Bandage CL can be a good way for mucus & discharge to remain on ocular surface – increases risk of infection
Try to avoid bandage CL unless absolutely necessary
List the 3 types of chlamydial conjunctivitis?
- Acute Chlamydial Conjunctivitis
- Trachoma
- Neonatal Chlamydial Infection
Describe acute chlamydial conjunctivitis?
- Sexually transmitted disease
- Chlamydia trachomatis D to K
- Young pxs
- More common in West of Scotland
- Other concomitant infections – ask about in H&S
- 1 week incubation – before developing symptoms in eye
- Follicular conjunctivitis
- Similar to adenoviral but becomes chronic – see someone attending for many weeks w/ follicular conjunctivitis that hasn’t resolved w/ tx may be chlamydial conjunctivitis
Describe trachoma chlamydial conjunctivitis?
- Chronic infection
- Chlamydial trachomatis A, B, Ba, C
- Developing countries & poor sanitation
- Grading Scheme:
o TF – follicular conjunctivitis upper tarsus
o TI – thickening/obscuring tarsal vessels
o TS – cicatrisation (scaring of conjunctiva) w/ fibrous bands
o TT – trichiasis (when conjunctiva scars, it contracts & pulls eyelids and thus eyelashes inwards – eyelashes are facing inwards & rub against ocular surface causing inflammation & corneal scarring)
o CO – corneal opacity
What is the management for trachoma & chlamydial conjunctivitis?
- Oral antibiotics:
o Azithromycin
o Doxycycline
o Tetracycline - REFER to HES – refer to sexual health clinic for appropriate tracing & systemic tx
Describe neonatal chlamydial conjunctivitis?
- Notifiable disease – can be passed from mother to child at birth
- Most common cause neonatal conjunctivitis
- Presentation 1-3 weeks after birth (not straight away)
- Mucopurulent discharge
- Papillary conjunctivitis
o Infants unable to form follicles
Describe cicatricial pemphigoid?
- Can present as acute form of conjunctivitis that becomes chronic & cause scarring
- AKA ocular mucus membrane, pemphigoid, ocular cicatricial pemphigoid (OCP)
- Chronic autoimmune blistering disease – Type 2 Hypersensitivity
- Predominantly affects mucous membranes
o Can also affect mucous membranes in mouth, throat, oesophagus, conjunctiva
When occurs in mouth, throat & oesophagus – tissues inside mouth can contract so much so that pxs may need teeth removed can cause strictures in oesophagus which means they cannot swallow - Blistering formation, blisters rupture causing acute inflammation (conjunctivitis) & this can scar – when it scars it causes tissue contraction
o When becomes chronic, if there is scarring of conjunctiva, it can then contract & pull eyelid in the way, causing eyelashes to rub against eye
Autoimmune mediated inflammation
What may the patient present with in cicatricial pemphigoid?
o Red eye, tearing, dry eye, burning / foreign body sensation, pain
o Blepharospasm
o Decreased vision, photophobia – often corneal involvement
o Diplopia – scar tissue is contracting so much that it’s preventing ocular muscles from moving
o Symblepharon – may be subtle to begin with
Describe the treatment for cicatricial pemphigoid?
o Depends on severity of disease at presentation
o Step up approach – px presents with less severe presentation, start with more simple tax with less risks and build it up to control symptoms e.g. someone in 80s presenting w/ chronic condition (don’t need aggressive tx)
o Step down approach – someone presents acutely with sight threatening ulcer – treat these px’s w/ more aggressive tx to start with & then taper it down e.g. someone in 40s presenting v acutely
o REFER for further investigation into chronic conjunctivitis
o Artificial tears – to lubricate scarred surface
o Blepharitis treatment
o Goggles to provide moist environment – not provided on NHS
o Punctal occlusion – to try & preserve tears & increase tear reservoir – punctuated can become occluded anyway due to conjunctival scarring
o Topical / systemic steroids – Since systemic inflammation, often pxs need systemic txs e.g. topical steroids or systemic immunosuppression – can’t leave px’s on systemic steroids long term due to associated side effects
o Immunosuppressive agents
o Surgical correction of entropion – severe cases
o Mucus membrane grafts – cut & release scar tissue & transplant in mucous membranes tissue – helps to create additional space in the conjunctiva & preventing it turning inwards & lashes rubbing against eye
These are usually taken from inside mouth but since OCP involves all mucus membranes then there may not be any suitable for transplant
Try to avoid doing this & treat w/ topical & systemic txs
Describe Stevens Johnson Syndrome (SJS)?
- Can present as acute form of conjunctivitis that becomes chronic & cause scarring
- Severe immune mediated hypersensitivity reaction
- Mucocutaneous blistering disease
- Can be caused by:
o Drugs – tetracyclines, NSAIDs
o Viral infections
o Malignancies - Cell death causes separation of the epidermis from the dermis in skin – causes blistering – epithelium & conj lift of & it blisters which causes scarring - > can happen throughout body
- Membranous conjunctivitis
- Cicatricial conjunctivitis
- Px’s would not normally present to Optoms in 1st instance if severely unwell – may present if just have eye symptoms
What are the symptoms & treatment for treatment?
- Symptoms:
o Fever, rash, malaise, arthralgia
o Red, dry eyes
o Inflammation of eye may be severe
o Mucopurulent / pseudomembranous
o Episcleritis
o Iritis
Treatment:
o Tear deficiency
Artificial tears or lubricants
o Iritis
Topical steroid to
begin w/ but if v severe then systemic immunosuppression may be required
o Infection
Scrape, topical antibiotic
