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Acute Infective Conjunctivitis

 

 

A. ACUTE INFECTIVE CONJUNCTIVITIS

1. CATARRHAL CONJUNCTIVITIS

It is mild conjunctivitis characterized by catarrhal reaction.

Causes (acute or chronic conjunctival irritation):-

- Low virulence staph, strept and Koch-week’s bacillus.

- F.B. and rubbing lashes.

- Irritant fumes and smokes.

- Uncorrected errors of refraction.

Symptoms:- Mild gritty sensation, redness and scanty discharge.

Signs:- Typical conjunctival hyperemia.

Treatment:- Decongestant eye drops plus treatment of etiology.

 

 

2. MUCOPURULENT CONJUNCTIVITIS (MPC)

 

It is the acute infective conjunctival inflammation characterized by mucopurulent discharge.

Etiology:-

1. Koch - Week's bacillus (Hemophilus egypticus):

- It causes 80% of cases.

- It causes epidemics in months of breeding of flies (6, 7, 9 & 10).

2. Staph. and Streptococci (Staph. MPC after phlycten).

3. Pneumococcus: It is uncommon in Egypt. It is characterized by:

- More common in the winter.

- Marked conjunctival edema and subconjunctival hemorrhages.

Mode of infection: - By flies.

                              - By infected towels.

Clinical picture:-

I.P.: 12 - 24 hours.

Symptoms:

It is more common in children especially with bad hygiene.

1. Redness and mucopurulent discharge.

2. Burning and gritty sensation .

3. Lid swelling in severe cases.

4. Halos around the light when discharge moves in front of the cornea.

Signs:

1. Lids: Mild lid edema and the lashes are glued together, after removal of discharge the lid margin is seen to be free (differential diagnosis from ulcerative blepharitis).

2. conjunctiva: Conjunctival injection (bright red, more in the fornices due to dilatation of posterior conjunctival vessels. it moves with the movement of conjunctiva).

3. The discharge is yellowish and sticky.

NB. MPC heals by resolution (without scarring).

Complications:-

- Marginal corneal ulcers because discharge may accumulate in the gutter between the cornea and edematous conjunctiva.

- Central corneal ulcers (because the conjunctival edema will press on the perilimbic capillaries that supply the cornea causing corneal ischemia) ---> central scar ---> amblyopia and squint.

NB. If corneal ulcers develop, the patient will complain of photophobia.

Differential diagnosis:-

1. Differential diagnosis from other causes of red eye (see the red eye syndrome).

2. Glued lashes due to ulcerative blepharitis.

Treatment:-

A. Prophylactic treatment:

- Combat flies, raise the hygiene.

- The patient has to use separate towels to avoid infection of contacts.

B. Curative treatment:

1. Boric acid lotion 3 %.

2. Local antimicrobial drops every 1 - 2 hours during the day as:

a. Sulfacetamide eye drops 10 - 30 % for Koch - Week's bacillus.

b. Chloramphenicol 0.5 % eye drops for other bacteria.

NB. Sulfa is inactivated by pus, while antibiotics are not.

3. Local antibiotic ointment at bed time as tetracycline 1%. It has the following advantages:

- Prolonged duration of action.

- Prevents sticking of lids, so that it allows drainage of discharge.

4. Dark glasses (never patch the eye to allow drainage of discharge).

5. Hot fomentations 3 times every day to improve circulation.

6. Systemic antibiotics may be given in severe cases.

7. Atropine is added if there is corneal ulcer.

 

3. PURULENT CONJUNCTIVITIS

It is the acute conjunctival inflammation characterized by purulent discharge. There are marked symptoms and great tendency to affect the cornea.

Etiology:-

A. In adults:

* Gonococci in 80% of cases:

- Non venereal epidemics in summer by flies (more in children).

- From a genital infection (sporadic cases in adults).

* Staph and strept. in 20% of cases.

B. In neonates (ophthalmia neonatorum):

- Gonococci only in 20% of cases.

- Chlamydia oculogenitalis in 80% of cases.

Clinical picture:-

I.P.:  3 - 4 days for gonococci.

Symptoms:

- Red eye and lid swelling.

- Purulent discharge.

- Dull aching pain and headache.

- Fever.

Signs:

A. Stage of infiltration (3 - 5 days):

- Marked lid edema that closes the palpebral fissure.

- Marked conjunctival edema and injection with subconjunctival hemorrhages.

- Preauricular and submandibular lymphadenitis.

B. Stage of blanorrhea (2 - 3 weeks):

- There is purulent discharge.

- Decreased lid edema and improved general condition.

- The causative organism can be detected in the infectious discharge.

C. Stage of chronicity:-

It is a complication rather than a stage. It is characterized by:

- Scanty highly infectious discharge.

- Papillae in the palpebral conjunctiva. If occurs on top of trachoma, it is called stage T-IIc in trachoma classification.

Investigations:

1. Direct film stained by Gram stain shows the organism and PNL reaction.

2. Culture and sensitivity test.

Complications:-

1. Central and peripheral ulcers occur more often than in MPC because there is marked edema and toxins. Besides, gonococci can invade a cornea with intact epithelium.

NB. MPC and PC are the commonest causes of blindness in childhood.

2. Chronicity.

3. Gonococcal arthritis, endocarditis and septicemia may occur in the venereal type.

Treatment:-

A. Prophylactic treatment:

1. The adult type:

A. Combat the source of infection:-

  - Early treatment of genital infection and combat flies.

B. Avoid infection of contacts by using separate towels.

C. If one eye is infected the other eye should be protected by using antibiotic eye drops.

2. Prophylaxis against ophthalmia neonatorum:   see later.

B. curative treatment:

1. Boric acid lotion 3 % frequently to remove the discharge.

2. Local antibiotic drops every 1/2 or 1 hour as:-

    - Penicillin eye drops.

    - Chloramphenicol 0.5 %.

3. Antibiotic ointment at bed time as chloramphenicol (for gonococci) or tetracycline (for chlamydia).

4. Systemic penicillin.

5. Lateral canthotomy is done if there is severe lid edema to facilitate drainage of pus.

6. Atropine is added in cases of corneal ulcers.

 

4. MEMBRANOUS CONJUNCTIVITIS

It is severe conjunctivitis characterized by fibrinous membrane on the palpebral conjunctiva.

Types and causes:-

1. True membranous conjunctivitis (diphtheritic conjunctivitis):

- It is caused by diphtheria bacilli (Gram positive). It affects non immunized children aged 2 - 8 years, usually of low social class. It is accompanied by severe constitutional symptoms. It is rare.

- When the membrane is removed it leaves bleeding ulcers.

2. Pseudo-membranous conjunctivitis:

When membrane is removed it leaves intact conjunctival epithelium.

- Viral and fungal conjunctivitis.

- Pneumococcal conjunctivitis.

Clinical picture of diphtheritic conjunctivitis:-

I.P.: 1 - 3 days.

General condition:

- Fever with irrelevant tachycardia due to toxic myocarditis.

- Proteinurea due to toxic nephritis.

- Throat infection may be present.

Symptoms:

- Redness and lid swelling.

- Discharge that may be bloody.

- Dull aching pain and burning sensation.

Signs:

I. Stage of infiltration (5 - 10 days  before discharge):-

- Lids are markedly swollen and tender.

- The palpebral conjunctiva is covered by a greyish membrane that leaves bleeding ulcers when removed.

- Preauricular and submandibular lymphadenitis.

NB. The membrane is a paste of fibrin, organism, necrotic epithelium and RBCs.

II. Stage of discharge (2 - 3 weeks):-

- Profuse blood stained discharge.

- Lids become softer, degeneration of the membrane occurs leaving bleeding ulcers.

III. Stage of cicatrization:-

The membrane separates completely and healing occurs by cicatrization leading to the fibrotic complications.

Complications:-

A. Toxic complications:

- Toxic myocarditis and nephritis.

- Toxic neuritis (similar to diabetic neuritis.. See the chapter of retina).

B. Corneal ulcers:

Central and peripheral corneal ulcers can occur.

C. Fibrotic complications:

1. Conjunctival xerosis.

2. Trichiasis, cicatricial entropion and symblepharon.

3. Fibrosis of the ducts of lacrimal gland causing dryness.

Treatment:-

I. Prophylactic treatment:

1. Mass immunization.

2. Isolation of the patient and notification to health office.

3. Prophylactic antiserum 5000 IU for contacts.

4. If one eye is infected, prophylactic antibiotics should be given to the other eye.

II. Curative treatment:

1. Complete rest in bed to avoid hart failure.

2. Take a swab for culture and sensitivity test.

3. Antitoxic serum is given to neutralize diphtheria exotoxins:

a. I.M. 20'000 - 40'000 IU.

b. Locally as eye drops.

4. Penicillin is the antibiotic of choice because diphtheria is highly sensitive to it. It is given as:

a. One mega unit (1'200'000) I.M. every 4 - 6 hours.

b. Locally as eye drops every 5 - 30 min..

5. Guard against symblepharon:

a. A glass rod is passed in the fornices to cut any new adhesions.

b. Ointments are given to isolate the conjunctival row surfaces from each other.

NB. Canthotomy is never done to drain the discharge because it increases the surface for absorption of toxins.

5. OPHTHALMIA NEONATORUM

It is any form of conjunctivitis and discharge during the first month of life.

Etiology:-

I. Infective:

Usually it is purulent conjunctivitis because the resistance of the infant is poor. the commonest organisms & their I.P. are:

1. Chlamydia oculogenitalis (80%): Its I.P. is 1 - 2 weeks

2. Gonococci (20%): Its I.P is 2 - 3 days.

3. Other bacteria are less common as staph., strept., E. coli,... .

4. Viral infection as herpes genitalis. Its I.P. is 5 - 7 days.

 

The sources of infection are:

1. From infected birth canal of the mother.

2. From septic delivery or infection from personnels.

II. Non infective (Chemical conjunctivitis):

It is caused by silver nitrate painting that has been used as a prophylaxis of O.N.. It occurs few hours after birth as a mild catarrhal conjunctivitis and it rarely lasts for more than 1 day.

Clinical picture (BILATERAL):-

Symptoms (told by the mother):

- Redness and lid swelling.

- Discharge: - Serous in cases of chemical and viral conjunctivitis.

             - Purulent in cases of chlamydia and gonococcus.

N.B. Photophobia occurs if secondary corneal ulcer occurs.

Signs:

It may vary from mild catarrhal conjunctivitis to severe purulent conjunctivitis (mention the clinical picture of PC).

Differential diagnosis:

from other causes of watering and discharging eye in early childhood

1. Congenital dacryocystitis:

- Epiphora (viscid and scanty watering). Mucopurulent discharge is common due to secondary conjunctivitis.

- Swelling below the MPL with positive regurge test.

- Usually complicated by recurrent unilateral conjunctivitis.

2. Buphthalmos:

- Photophobia and lacrimation.

- Large hazy cornea with Haab's stria.

- High IOP and glaucomatous cupping of the disc.

Complications (Mainly the secondary corneal ulcers):-

1. Marginal corneal ulcers.

2. Central corneal ulcers that heal by scarring causing defective vision and amblyopia. If unilateral squint occurs. Nystagmus occurs if corneal scarring occurs bilaterally in early childhood.

3. Perforation of the secondary ulcer leading to endophthalmitis.

Treatment:-

I. Prophylactic treatment:

1. Proper antenatal care and treatment of any maternal infection.

2. Aseptic delivery.

3. Broad spectrum antibiotics 3 times daily for the first 3 days after delivery.

N.B: Crede method:  Silver nitrate eye drops after birth as a prophylactic chemotherapy (It is obsolete now).

II. active treatment:

1. For chlamydial infection we do:-

- Boric acid lotion 3%.

- Local tetracycline ointment 5 times daily.

- Systemic erythromycin 25 mg/Kg twice daily.

2. For gonococcal infection we do:-

- Boric acid lotion 3%.

- Local freshly prepared penicillin eye drops every hour.

- I.M. penicillin 25 mg/Kg twice daily.

Both parents should be examined for genital infection.

 

6. INCLUSION BLANORRHEA

It is acute chlamydial infection of the conjunctiva. It is caused by Chlamydia trachomatis serotypes D - K which is also the commonest cause of non specific urethritis (chlamydia oculogenitalis).

Modes of infection:-

1. Auto infection by the urethral discharge.

2. From swimming pools if a urethritis patient micturates in water.

Clinical picture:-

* The patient complains of conjunctival redness, MP discharge and gritty sensation.

* On examination follicles are found in the conjunctival sac.

N.B. It differs from trachoma in the following:

- It is acute disease.

- Follicles are present in both upper and lower parts of the conjunctival sac.

- No pannus.

- Heals by resolution not by scaring.

N.B. Chlamydia oculogenitalis infection of neonates (80% of cases of ophthalmia neonatorum) has no follicles because the adenoid layer of the conjunctiva is present only after the age of 3 months.

Treatment:-

Local and systemic sulfa drugs.

 

7. VIRAL CONJUNCTIVITIS

1. Adenovirus (serotypes 8 & 19):

It causes 2 syndromes: - Epidemic keratoconjunctivitis (EKC) and pharyngio- conjunctival fever (PCF).

Symptoms:

- Redness and lacrimation followed by photophobia 2 days later.

- Conjunctival redness and lid swelling.

- Fever and pharyngitis may be present especially in PCF especially in children.

Signs:

- Typical conjunctival hyperemia.

- Conjunctival follicles.

- Subepithelial corneal infiltrates are very characteristic especially in EKC.

- Pseudomembrane may be formed.

- Pre-auricular and submandibular lymphadenitis.

Investigations:

- Direct examination of discharge shows monocytes. If there is pseudomembrane PNL will be seen.

- The virus can be isolated on Hella cells.

Treatment:-

Local steroids and vasoconstrictor eye drops (antiviral drugs are not effective against adenovirus).

 

2. HSV:

 Clinical picture:-

As adenovirus plus herpetic skin eruptions. Corneal ulceration should be excluded by fluorescein staining.

Treatment:-

1. Antiviral drugs are essential.

2. Cold fomentations and antihistaminic eyedrops.

Steroids are contraindicated

 

3. HZV ophthalmicus.

See cornea.