Viral & Bacterial Conjunctivitis Sourov Roy 3rd Batch, B.Optom, ICO,CU

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

Viral• Infectious Hyperacute

Bacterial Acute

Chronic

• Noninfectious Allergic, Toxins/ Chemicals, Foreign body, Trauma, Neoplasm

Etiological classification

• 1. Infective conjunctivitis: bacterial, chlamydial, viral,fungal, rickettsial, spirochaetal, protozoal, parasitic etc.

• 2. Allergic conjunctivitis. • 3. Irritative conjunctivitis.• 4. Keratoconjunctivitis associated with diseases of skin and mucous membrane.• 5. Traumatic conjunctivitis.• 6. Keratoconjunctivitis of unknown etiology. eg: Trachoma..

Prevalence

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 infections of conjunctiva include:

• Adenovirus conjunctivitis• Herpes simplex keratoconjunctivitis• Herpes zoster conjunctivitis• Pox virus conjunctivitis• Myxovirus conjunctivitis• Paramyxovirus conjunctivitis• ARBOR virus (ARthropod-BOrne virus)

conjunctivitis

Clinical presentations.

• Acute viral conjunctivitis may present in three clinical forms:• 1. Acute serous conjunctivitis• 2. Acute haemorrhagic conjunctivitis• 3. Acute follicular conjunctivitis

Symptoms:

include:unilateral or bilateral• redness, • watering, • mild mucoid discharge, • mild photophobia • feeling of discomfort and foreign body sensation.

• May be part of viral prodrome:• tender preauricular node • adenopathy, • fever, • pharyngitis, • cough, • rhinorrhea

ACUTE SEROUS CONJUNCTIVITIS

• Etiology. It is typically caused by a mild grade viral infection which does not give rise to follicular response.

• Clinical features. Acute serous conjunctivitis is characterised by- a minimal degree of congestion, - watery discharge and - boggy swelling of the conjunctival mucosa.

• Treatment. Usually it is self-limiting and does not need any treatment. • But to avoid secondary bacterial infection, --broad spectrum antibiotic eye drops may be used three

times a day for about 7 days.

ACUTE HAEMORRHAGIC CONJUNCTIVITIS

• It is an acute inflammation of conjunctiva characterised by

• multiple conjunctival haemorrhages,• conjunctival hyperaemia and • mild follicular hyperplasia.

• Etiology. The disease is caused by picornaviruses

• Symptoms: include • pain,• redness, • watering,• mild photophobia• transient blurring of vision and • Lid swelling.

• Signs:• conjunctival congestion,• chemosis,• multiple haemorrhages in bulbar conjunctiva,• mild follicular hyperplasia, • lid oedema and• pre-auricular lymphadenopathy.

• Corneal involvement may occur in the form of-fine epithelial keratitis.

Treatment

• very infectious and poses major potential problems of cross-infection. Therefore,

• prophylactic measures are very important. • No specific effective curative treatment is known.

However,• broad spectrum antibiotic eye drops may be used to

prevent secondary bacterial infections.• Usually the disease has a self-limiting course of 5-7

days.

FOLLICULAR CONJUNCTIVITIS

• Types• 1. Acute follicular conjunctivitis.• 2. Chronic follicular conjunctivitis.• 3. Specific type of conjunctivitis with follicle formation

e.g., trachoma

ACUTE FOLLICULAR CONJUNCTIVITIS

It is an acute catarrhal conjunctivitis associated with--

• marked follicular hyperplasia-- especially of the lower fornix and lower palpebral conjunctiva.

Symptoms

--- similar to acute catarrhal conjunctivitis include:• Burning and grittiness in the eyes, especially

in the evening.• Feeling of heat and dryness on the lid

margins.• Difficulty in keeping the eyes open.• Feeling of sleepiness and tiredness in the eyes

• Mild chronic redness in the eyes.• Mild mucoid discharge especially in the

canthi. Off and on lacrimation.

Signs

• conjunctival hyperaemia, associated with- multiple follicles, more prominent in

lower lid than the upper lid

Treatment

• Primary herpetic infection is usually selflimiting.

• The topical antiviral drugs control the infection effectively and prevent recurrences

BACTERIAL CONJUNCTIVITIS

• Etiology:- Predisposing factors- Causative organisms- Acording to Mode of infection

Pathology

Vascular response

Cellular response

Conjunctival tissue repsonse

Conjunctival discharge

CLINICAL TYPES OF BACTERIALCONJUNCTIVITIS

• Acute catarrhal or mucopurulent conjunctivitis.

• Acute purulent conjunctivitis• Acute membranous conjunctivitis• Acute pseudomembranous conjunctivitis• Chronic bacterial conjunctivitis• Chronic angular conjunctivitis

ACUTE MUCOPURULENT CONJUNCTIVITIS

• Common causative bacteria are: Staphylococcus aureus,

Koch-Weeks bacillus, Pneumococcus and Streptococcus.

Symptoms

• Discomfort and foreign body• Mild photophobia.• Mucopurulent discharge from the eyes.• Sticking together of lid margins• Slight blurring of vision due to mucous flakes• may complain of coloured halos.

Signs

• Conjunctival congestion• Chemosis• Petechial haemorrhages• Flakes of mucopus• Cilia are usually matted• Yellow crust

Differentiate DiagnosisCLINICAL SIGNS Bacterial Viral

Congestion Marked Moderate

Chemosis ++ ±

Subconjunctival haemorrhages ± ±

Discharge Purulent or mucopurulent Watery

Papillae ± –

Follicles – +

Pseudomembrane ± ±

Pannus – –

Pre-auricular lymph nodes + ++

Complications

Occasionally the disease may be complicated by

• marginal corneal ulcer,• superficial keratitis,• blepharitis or dacryocystitis

Treatment

• Topical antibiotics- broad specturm antibiotics• Irrigation of conjunctival sac• Dark goggles• No steroids should be applied• No bandage• Anti-inflammatory and analgesic drugs

ACUTE PURULENT CONJUNCTIVITIS

Etiology:-causative organismClinical picture:1 Stage of infiltraton2 Stage of blenorrhoea3 Stage of slow healing

Stage of infiltraton

• Considerably painful and tender eyeball.• Bright red velvety chemosed conjunctiva.• Lids are tense and swollen.• Discharge is watery or sanguinous.• Pre-auricular lymph nodes are enlarged.

Stage of blenorrhoea

• Frankly purulent, copious, thick discharge trickling down the cheeks.

• Other symptoms are increased but tension in the lids is decreased

Complications

• 1. Corneal involvement• 2. Iridocyclitis• 3. Systemic complications— - gonorrhoea arthritis - endocarditis - septicaemia

Treatment

• Systemic therapy:• Norfloxacin 1.2 gm orally qid for 5 days• Cefoxitim 1.0 gm or cefotaxime 500 mg. IV qid• or ceftriaxone 1.0 gm IM qid, all for 5 days; or• Spectinomycin 2.0 gm IM for 3 days• Topical antibiotic therapy• ofloxacin, ciprofloxacin or tobramycin eye drops• bacitracin or• erythromycin eye ointment

• Irrigation of the eyes• Topical atropine 1 per cent

• Patient and the sexual partner should be referred for evaluation of other sexually transmitted diseases

OPHTHALMIA NEONATORUM

• Source and mode of infection:- Before birth infection is very rare through

infected liquor amnii in mothers with ruptured membrances

- During birth.- After birth

Causative agents

• Chemical conjunctivitis• Gonococcal infection• Other bacterial infections• Herpes simplex ophthalmia neonatorum

Symptoms and signs

• 1. Pain and tenderness in the eyeball.• 2. Conjunctival discharge. It is purulent in

gonococcal ophthalmia neonatorum and mucoid or mucopurulent in other bacterial cases and neonatal inclusion conjunctivitis.

• 3. Lids are usually swollen.• 4. Conjunctiva may show hyperaemia and

chemosis• 5. Corneal involvement, though rare.

Complications

• may develop corneal ulceration, • Which may perforate rapidly resulting in

corneal opacification or staphyloma formation.

Treatment

• A. Prophylaxis needs antenatal, natal and postnatal care.

• Curative treatment:• Chemical ophthalmia neonatorum is a self-

limiting condition, and does not require any treatment.

• Topical therapy - Saline lavage-Bacitracin eye ointment 4 times/day• However in cases with proved penicillin

susceptibility, penicillin drops 5000 to 10000 units per ml should be instilled every minute for half an hour, every five minutes for next half an hour and then half hourly till the infection is controlled.

• Systemic therapy:• Ceftriaxone 75-100 mg/kg/day IV or IM, QID.• Cefotaxime 100-150 mg/kg/day IV or IM, 12

hourly.• Ciprofloxacin 10-20 mg/kg/day or Norfloxacin

10 mg/kg/day.