wk9: AED - Conjunctival Infections 1 [DG] Flashcards by Alexander Bowden

Describe a non-infective reason why eyelids might be stuck together in the morning

Excess tearing from allergies can result in a crusty byproduct which will stick the lids together

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How does a non-infectious cause of eyelids sticking together in the morning differ from an infectious cause? (in terms of the reason they are sticking together) (1.5)

non-infectious: crusty byproduct sticking lids together

infectious: gooey byproduct sticking lids together

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What are the general symptoms of conjunctivitis? (5)

Discomfort
Discharge
Increased redness
Variable vision loss due to discharge, tear film disruption
Mild photophobia due to PEE/SPK (bit questionable)

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How can discomfort vary with conjunctivitis aetiology? (3)

Gritty/scratchy  = bacterial, viral (dry eye)
Itchy = allergic
Burning = bacterial, viral (dry eye)

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How can discharge vary with conjunctivitis? (3)

watery
mucoid
mucopurulent

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What is a good question to ask when a patient presents with variable vision? (1)

Does blinking clear up your vision? (i.e. b/c when you blink you create a new tear film layer, so this can help you see if tear film disruption is a problem, in which blinking should make it clearer for a bit)

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Does the “green-ness” of the discharge in conjunctivitis patients matter?

Not really

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What are general signs of conjunctivitis? (6)

Conjunctival reaction
Little or no corneal involvement
Slight lid oedema
Lymphadenopathy
Pseudomembranes/membranes
Discharge

(note patient won’t necessarily have all of these)

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What sorts of conjunctival reaction might you get in a patient with conjunctivitis? (3)

Injection/hyperaemia (redness)
Chemosis (oedema/swelling)
Follicular/papillary? (i.e. need to identify which one it is)

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How do you use conjunctivitis features to make a differential diagnosis? (5)

Type of discharge
Type of conjunctival reaction (papillary or follicular)
Pattern of hyperaemia
Presence of pseudomembranes/membranes 
Presence/Absence of lymphadenopathy

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What is the downside to patients physically pulling out mucoid ropey-like substance from their eye? (1)

This stimulates the eye to produce more mucoid. Problem not resolved

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Instead of pulling out mucoid physically, how is mucoid best removed from the eye? (1)

Wash it out with saline. This means you won’t produce any more mucoid

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What does the discharge from conjunctivitis consist of? (6)

Exudate from dilated conjunctival blood vessels
Mucus from goblet cells
Debris from dying or dead cells
Tear overproduction
WBCs (usually neutrophils) 
Microorganisms

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What are the diagnostic rules of thumb for conjunctivitis discharge? (4)

Watery = viral/allergic
Mucoid (ropy) = allergic
Purulent = acute bacterial
Mucopurulent (ropy purulent) = mild/chronic bacterial or chlamydial

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List the general aetiologies of conjunctivitis (7)

Viral
Bacterial
Allergic
Toxic
CL related
Trauma
Assoc. with lid and/or corneal pathology

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How does inflammation of the eye affect goblet cells? (1)

causes them to overproduce

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Name a condition where you can get follicles superiorly? (1)

Chlamydia

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Is it normal to have a few follicles in the palpebral conjunctiva?

yep

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When do follicles in the palpebral conjunctiva become apparent?

at 2 years old and older

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Where are follicles most common? (1)

Forniceal conjunctiva

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What do follicles near the lid margin or centre of tarsus suggest? (1)

suggests pathology

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How do follicles look in terms of blood vessels? (1)

Blood vessels at base or surrounding

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What causes follicles? Describe the mechanism (1)

Hyperplasia of lymphoid tissue in conjunctival stroma

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How can the size of follicles in a follicular conjunctival reaction vary?

0.2-2mm depending on severity and duration of inflammation

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Name the 3 main acute causes of follicular conjunctival reactions

viral infections chlamydial infections medication hypersensitivity

Which is more variable in appearance, follicular or papillary conjunctival reactions?

papillary

How would you describe a papillary reaction in the conjunctiva?

subepithelial fibrovascular core with surrounding oedema and cell infiltration

Where can a papillary conjunctival reaction occur? (2)

Palpebral conjunctiva | Bulbar conjunctiva at the limbus

What is a hallmark characteristic feature of papillae? (that can be used to distinguish them from follicles) (1)

characteristic central blood vessel (sometimes difficult to see in large papillae)

Describe the general appearance of a papillary reaction

Fine mosaic pattern of elevated polygonal hyperaemic areas often described as being like cobblestones

Can individual papillae vary in size? How?

Yes. Individual papillae can increase in size with more intense reactions

Name 4 common causes of a papillary conjunctival reaction

chronic blepharitis allergic disease bacteria-related infection contact lens related problems

How can you further classify conjunctivitis with follicles present? (2) [usefull table]

With swelling of pre-auricular lymph node | Without swelling of pre-auricular lymph node

Where are the pre-auricular lymph nodes?

located just in front of your ears

Where are the submandibular nodes?

Located under mandible, basically they are on the upper part of your neck close to centre. You can feel them pretty easily

How can you further classify conjunctivitis with follicles present and swollen pre-auricular nodes? (2) [useful table]

Herpetic signs present (e.g. dendrites, skin vesicles) | Herpetic signs not present

Assume you have a patient with conjunctivitis with follicles, pre-auricular node swelling and herpes signs present. What is the likely aetiology diagnosis? [useful table]

HSV

Assume you have a patient with conjunctivitis with follicles, pre-auricular node swelling and no signs of herpes. What is the aetiological diagnosis? (2) [useful table]

Adenoviral or Chlamydia

What is the diagnosis for a patient with conjunctivitis with follicles and no pre-auricular node swelling? (3) [useful table]

toxic conjunctivitis molluscum pediculosis

How can you classify papillary conjunctivitis? (3) [useful table]

Classify based on type and amount of discharge: Severe purulent Scant purulent Watery or Mucoid

What is the likely diagnosis for a papillary conjunctivitis with severe purulent discharge? (1) [useful table]

GPC

What is the likely diagnosis for a papillary conjunctivitis with scant purulent discharge? (1) [useful table]

Bacterial other than GC

What is the likely diagnosis for a papillary conjunctivitis with watery or mucoid discharge? (2) [useful table]

Allergic | Atopic

How common are membranes/pseudomembranes?

Relatively rare, may see one in clinic every 8 weeks or maybe only a few times a year

What is a pseudomembrane?

coagulated fibrinous exudate lightly adherent to inflamed conjunctiva

What happens to the conjunctival epithelium when you peel the pseudomembrane off?

Remains intact. (Pseudomembrane can be peeled without bleeding)

Name the 3 main causes of pseudomembranes

adenoviral infection gonococcal conjunctivitis alkali burns

Which is worse, acid burns or alkali burns. Why?

Alkali burns are worse, because while an acid burn is an "event", an alkali burn "keeps going for an extended time", so it lasts longe

What is a true membrane?

coagulated fibrous exudate anchored to the inflamed conjunctival epithelium (rare)

How does peeling of a true membrane compare to peeling of a pseudomembrane?

peeling of a true membrane is more difficult and rips the conjunctival epithelium, causing bleeding from conjunctival vessels

Name 4 common causes of true membrane formation

Beta-haemolytic streptococci Diphtheria (corynebacterium) Gonococcal Autoimmune conjunctivitis

Why do membranes and pseudomembranes have to be removed?

To stop scarring of underlying tissue

Are true membranes and pseudomembranes safe to remove?

Both are safe to remove

What MUST we do to confirm if somebody has adenovirus? (1)

Lymphadenopathy

What does lymphadenopathy involve?

Feeling the different lymph nodes to check for swelling/see if they are raised

What lymph nodes are we particularly interested in during lymphadenopathy? (2)

pre-auricular nodes | submandibular nodes

What 3 infections is lymphadenopathy commonly performed for?

Viral infection (adenovirus) Chlamydial infection Severe gonococcal infections

When performing lymphadenopathy as an optometrist, should you keep the patient's shirt on? ;)

Yes you should

Why is gonococcus dangerous?

Because it can get through intact cornea

In regards to non-gonococcal bacterial conjunctivitis, describe the following: A: How common? B: Acute or chronic? C: Do they persist or are they self-limiting?

A: very common B: acute C: usually self-limiting within 10-14 days

In regards to non-gonococcal bacterial conjunctivitis: D: Unilateral or bilateral? E: Symmetrical or Asymmetrical?

D: Bilateral E: Asymmetrical - with onset over a couple of days (usually starts in one eye then transfers)

Name 4 common pathogens that can cause non-gonococcal bacterial conjunctivitis

Staph aureus Staph epidermidis Strep pneumoniae Haemophillus influenzae (kids)

List the symptoms of non-gonococcal bacterial conjunctivitis (5)

Acute onset of: redness, gritty/burning, sticky discharge Eyelids frequently stuck together on waking May have mild photophobia due to SPK

Why would someone with bacterial conjunctivitis acquire SPK? (1)

Due to the endotoxins released from the bacterium damaging/breaking down the epithelium

Can Darryl Guest think of a bacterial infection that ISN'T an acute onset?

No he can't. So all bacterial infection = acute onset.

What 3 factors make the perfect environment for bacteria? (3)

Moist Dim Anaerobic

What is the most common cause of conjunctivitis presentation in eye clinics?

Viruses. By far

What are the signs of bacterial conjunctivitis? (5.5)

Conjunctival hyperaemia, especially in fornices Mild SPK Mild papillary reaction Mucopurulent discharge Crusting on lids, phlyctenules, corneal marginal infiltrates

What are phlyctenules?

A small vesicle or postule especially: one on the conjunctiva or cornea of the eye

What ddx exist for bacterial conjunctivitis? (3)

Viral conjunctivitis Allergic conjunctivitis Gonococcal conjunctivitis