dr.a.r.rajalakshmi, 02.2.17 intro, acute conj - i

DR. A.R.RAJALAKSHMIASSO. PROFESSOR

*ACUTE CONJUNCTIVITIS

*AIM

* The anatomy & functions of conjunctiva.* Enumerate the symptoms & signs of

conjunctival disorders.*Enumerate the causes of acute

conjunctivitis & its prevention & management .

*ANATOMY – CONJUNCTIVA

*CONJUNCTIVA

*ANATOMY

*Thin mucous membrane lining the surface of the eye & the eyelids.*Parts of conjunctiva : palpebral bulbar fornix

* CONJUNCTIVA - histology

THREE LAYERS *EPITHELIUM – non keratinised squamous

epithelium*ADENOID – loose connective tissue with

leucocytes (LYMPHOID LAYER)*FIBROUS

Conjunctiva – Functions

*Tear production ( goblets & accessory lacrimal glands)*Oxygen supply to cornea*Maintain a smooth ocular surface*Protection of the eye - intact epithelial

barrier, lacrimation, immunologic mechanism ( adenoid layer)

Conjunctiva – normal flora

*Non pathogenic commensal Staphylococcus albus, diphtheroids, Propionibacterium acnes, Neisseria catarrhalis , Corynebacterium xerosis

SYMPTOMS

*Redness*Watering *Discharge Stickiness *Irritation / foreign body sensation *Itching *Gritty sesnsation*Fleshy growth

IF PAIN OR DEFCECTIVE VISION IS THERE , THEN SUSPECT CORNEAL INVOLVEMENT / SOME OTHER DISORDER

SIGNS OF CONJUNCTIVAL

DISORDER

*CONGESTION /HYPEREMIA *DISCHARGE *FOLLICLE *PAPILLAE *CHEMOSIS

*RED EYE

Congestion

RED EYE

PALPEBRAL CONGESTION

CIRCUMCORNEALCONGESTION

SITE fornix Around the cornea

COLOUR Bright red Dull redArrangement Superficial DeepADRENALINE TEST

Immeditely blanch

Do not blanch

CAUSES Acute conjunctivitis

Keratitis , acute iridocyclitis

OCULAR DISCHARGE

OCULAR DISCHARGE

TYPE OF DISCHARGE CAUSATIVE FACTOR

Watery Viral conjunctivitis Foreign body

Mucoid / ROPY discharge Allergic conjunctivitis

Mucopurulent / purulent Bacterial conjunctivitis

PAPILLAE

*Reddish flat topped raised areas*Gives ‘VELVETTY ‘ apppearance to the

conjunctiva *Seen in ALLERGIC CONJUNCTIVITIS *Central core of dilated blood vessels

surrounded by lymphocytes & covered by hypertrophied epithelium

FOLLICLE

* ‘BOILED SAGO GRAIN ‘ APPEARANCE*Seen in upper palpebral conjunctiva –

TRACHOMA*subepithelial aggregation of lymphocytes,multinucleated giant cells with necrosis

CHEMOSIS

*ANATOMY

*Parts of conjunctiva *Layers of conjunctiva *Name two functions of conjunctiva*Causes of acute red eye *Difference between the two congestions* what is papillae *What is follicle *Diagnose this pic

CONJUNCTIVITIS

ACUTE CONJUNCTIVITIS

*Inflammation fo the conjunctiva < 4 weeks of duration .

22

* CLASSIFICATION

Based on onset –Acute , Sub-acute &Chronic.

Based on type of Exudates* Serous (Viral, allergic, toxic).* Catarrhal (allergic – Ropy or thread like thick

mucoid discharge).* Mucopurulent.* Purulent.* Pseudo-Membranous / Membranous.

23

*CLASSIFICATION (Continued)

Based on Conjunctival Reaction* Follicular.* Papillary. * Granulomatous.

Based on Etiology* Infectious (Bacterial, Viral, Chlamydial, Fungal and

parasitic).* Non-infectious (Allergic, Irritants).

*TOPICS

*Bacterial conjunctivitis – gonorrheal , angular, membraneous *Viral conjunctivitis *OPHTHALMIA NEONATORUM

*READING PATTERN of ANY

DISEASE

*Definition *Etiology – risk factors, cause*Pathogenesis *Clinical features – symptoms , signs *Investigations *Treatment – medical , surgical , complications *Prevention *Complications of the disease

26

* BACTERIAL CONJUNCTIVITIS Acute Purulent & Muco Purulent

Etiology* Staph.aureus – most common,

H.aegyptius , N.gonorrhoea* RISK FACTORS : highly Contagious , Transmitted by discharge

*BACTERIAL CONJUNCTIVITIS

Clinical FeaturesSymptoms * Mostly bilateral * Acute onset of redness associated

with * Purulent discharge* Stickiness of the lid* Haloes

*BACTERIAL CONJUNCTIVITIS

SIGNS :* purulent / muco prulent discharge *Matted eyelashes with yellow crusts * palpebral congestion *Cornea – clear

Treatment* Topical fluro quinolone – ciprofloxacin,

Ofloxacin, Moxifloxacin, Gatifloxacin.* Bacitracin or ciprofloxacin Ointment.

30

PREVENTION

*Frequent face wash & hand wash *No sharing of hankies, towels & pillows

*COMPLICATIONS

*Chronic conjunctivitis – if not treated *Corneal involvement – corneal ulcer *Iritis

32

GONORRHOEAL CONJUNCTIVITIS

Etiology* Caused by Neisseria Gonorrhoeae. * Transmitted from genitalia to eye through hands.

Clinical Features* Severe lid edema * Copious purulent discharge ( acute blenorrhea)* Pre-auricular lymphadenopathy, tenderness and

suppuration * Associated systemic signs – Urethritis, rise of

temperature and depression.

34

*BACTERIAL CONJUNCTIVITIS Gonococcal - ContinuedComplications

• Corneal involvement – Gonococcus is capable of invading the normal cornea through intact epithelium.

* Iritis , Iridocyclitis .

* Non Ocular complications – Arthritis, Endocarditis and Septicaemia.

35

*BACTERIAL CONJUNCTIVITIS Gonococcal - Continued

Invetigations:* conjunctival scraping - intracellular Gram-negative

diplococci .

36

*BACTERIAL CONJUNCTIVITIS Gonoccol - Continued

Treatment - Aim of therapy is to prevent or limit the corneal involvement and to eliminate systemic source. Systemic Treatment * Ceftriaxone - 1 gm IM , single dose.

Topical Treatment * Cleanliness * Ciprofloxacin / Ofloxacin/ Gentamicin/ Tobramycin Eye

Drops 2 hrly.* Bacitracin Eye Ointment 6 hrly.* Cycloplegic (Atropine) – in cases of Corneal involvement .

37

*BACTERIAL CONJUNCTIVITISMembranous & Pseudo Membranous

Etiology* Caused by C.diphtheriae, Streptococcus pneumonia* Occurs in children in assosiation with Measles , scarlet fever,

influenza & whooping cough.

Clinical Features* Swelling of lids* mucopurulant discharge * White Membrane on everting lid

40

* MEMBRANOUS CONJUNCTIVITIS

Treatment – ASK IMMUNISATION HISTORY* Systemic Treatment * 4,000 to 10,000 units of anti diphtheretic serum.* Penicillin

* Topical Treatment * Topical 10,000 units / ml drops made from injectable

preparations.

Complications:* corneal ulcerations * Increase risk of symblepharon

41

ANGULAR CONJUNCTIVITIS

Etiology* Moraxella Lacunata – diplobacillus.

CLINICAL FEATURESSymptoms - Redness, discomfortSigns * Congestion limited to intermarginal strip at inner and

outer canthi. * Excoriation of skin at inner and outer palpabral angles .

43

*BACTERIAL CONJUNCTIVITISAngular - Continued

Treatment* Topical Treatment * Tetracycline eye ointment .* Eye drops containing Zinc also beneficial, acts by

inhibiting proteolytic ferment.

44

*VIRAL CONJUNCTIVITISTYPES• Acute Follicular Conjunctivitis• Sub Acute or Chronic Follicular Conjunctivitis• Epidemic Keroto Conjunctivitis.• Pharyngo Conjuctival fever.• Heaymorrhagic Conjunctivitis• Acute Herpitic Conjunctivitis• Herps Simplex Conjunctivitis

46

*VIRAL CONJUNCTIVITIS(Continued)

Symptoms * Serous or watery discharge * Severe irritation with rednessSigns * Palpebral congestion * Conjunctival follicles * Sub Conjunival haemorrhage * Preauricular lymph node.* Decreased corneal sensation.

TreatmentTopical Treatment * Artificial Tears* Antibiotic eye drops to prevent

secondary infection* PREVENTION

48

*OPHTHALMIA NEONATORUMDefinition any discharge from the eye in the first month of life .* responsible for corneal blindness in children

Genitourinary tract of mother is infected

Normal delivery through the infected tract

Child gets infection

Causative factor

Time of onset after birth

Treatment

N. Gonorrhoea Within 24-48 hours

Ceftriaxone im injection, topical antibiotics

Chemical ( silver nitrate)

“ Wash eyes & observe

Other bacteria 48-72 hours Topical antibiotics

Herpes simplex 5-7 days Topical acyclovir eye ointment

Chlamydia trachomatis

> 1 week Erythromycin eye ointment

52

*OPHTHALMIA NEONATORUM (Continued)

Complications* Corneal Ulcer : progressive ulcer resulting in –

perforation of corneal ulcer, prolapse of uveal tissue, purulent uveitis, prolapse of lens, prolapse of vitreous.

* Scarring of cornea, adherent leucoma, anterior staphyloma, anterior capsular cataract, endophthalmitis.

PREVENTION:* ANTENATAL - treat the maternal

infection* INTRANATAL – aseptic precautions clean the closed closed eyelids ommediately after delivery erythromycin eye ointment – prophylactically

*INVESTIGATIONS

Conjunctival discharge *STAINING – Gram, Giemsa * CULTURE & SENSITIVITY – bacterial, viral,

chlamydia

55

* OPHTHALMIA NEONATORUM(Continued)

Treatment

* Systemic Treatment * Ceftriaxone – 25 to 50 mg/kg single dose.* Cefatoxime – 100 mg / kg single dose.

* Topical Treatment * Saline irrigation * Topical flouro quinolones.

ASSIGNMENT

* a 10 day old male baby is brought with the complaints of watering & discharge from both eyes since birth. It is also associated with inability to open the eyes.

1. Name four differential diagnosis ( 2 marks)

2. Define (1) Ophthalmia neonatorum . Describe the various causes(1), clinical features (2) , investigations(1) & management of the above condition(3).

*ANATOMY