Infective Conjunctivitis

Classification of conjunctivitis

1. Based on Onset a. Acute b. Subacute c. Chronic

2. Based on type of Exudate Serous, Catarrhal (allergic), Purulent, Mucopurulent,

Membranous, Pseudomembranous

3. Based on conjunctival response Follicular, Papillary, Granulomatous (fungal, Parinaud

oculoglandular syndrome, parasitic, foreign body)

4. Based on Aetiology a. Infectious – bacterial, viral, chlamydial, fungal, parasitic b. Noninfectious – allergic, irritants, autoimmune, dry eye, toxic.

Infective conjunctivitis

1. Bacterial conjunctivitis 2. Viral conjunctivitis 3. Chlamydial conjunctivitis 4. Fungal conjunctivitis 5. Parasitic conjunctivitis

Bacterial conjunctivitis: Acute purulent and mucopurulent conjunctivitisAetiology: Staph. aureus and albus Haemophilus influenzae and aegypticus N. gonorrhoeae and meningitidis Strept. Pyogenes and pneumoniae Moraxella lacunata Proteus Klebsiella E.coli Diphtheroids

Acute purulent and mucopurulent conjunctivitis Commonly seen in children and adults Self-limiting condition Spread of infection : direct contact with infected

secretions Clinical features depend on virulence and

pathogenicity of the organism and the host’s immune response.

Acute purulent and mucopurulent conjunctivitis

Symptoms : Acute redness, grittiness, burning, discharge, on

waking – eyelids stuck together and difficult to open

Both eyes are usually involved, although one may

become affected before the other.

Acute purulent and mucopurulent conjunctivitis

Signs: Eyelids : crusted, oedematous Discharge : initially watery, later becomes mucopurulent Injection : maximum at the fornices Tarsal conjunctiva : velvety, beefy-red (Fiery-red)

appearance, mild papillary changes Superficial punctate epithelial erosions may be seen Flakes of mucus passing across the cornea – colored haloes

– owing to prismatic action.

Acute purulent and mucopurulent conjunctivitis Presence of purulent or mucopurulent discharge is

suggestive of bacterial infection. It is usually not possible to make a diagnosis of the organism clinically

However, certain features do indicate an increased likelihood of certain specific infections :

Pneumococcal conjunctivitis: chemosis, small ecchymoses, pseudomembrane

N. gonorrhoeae conjunctivitis (Hyperacute conjunctivitis/ acute blenorrhoea) : severe form of acute purulent conjunctivitis, moderate to severe pain, lid swelling, copious purulent discharge (discharge reaccumulates within seconds of cleaning), tender (sometimes suppurative) preauricular lymphadenopathy.

Acute purulent and mucopurulent conjunctivitisComplications : rare Mild and untreated or partially treated may

become less intense, chronic condition Abrasions of cornea may get infected

causing ulcers Superficial keratitis/ marginal ulcers

Acute purulent and mucopurulent conjunctivitisTreatment: Even without treatment simple conjunctivitis resolves

within 10-14 days and laboratory tests are not routinely performed.

Eyes should not be bandaged (prevents drainage of discharge)

Dark goggles/sun shade should be worn to prevent discomfort in bright light.

Patient must keep his hands clean No one else should be allowed to use patients’ towel,

handkerchief, pillow or other fomites.

Acute purulent and mucopurulent conjunctivitis Antibiotic drops (broad-spectrum) – chloramphenicol, ciprofloxacin, ofloxacin, lomefloxacin, moxifloxacin, gentamicin, neomycin, tobramycin in a frequency of 4-6 times a day is prescribed empirically.

Antibiotic Ointment : applied into lower fornix and smeared along lids at bedtime – prevents lids from sticking together by retained secretions , obviate pain on opening lids, provide higher concentrations for longer periods than drops (use during day –causes blurred vision) – chloramphenicol, gentamicin, tetracycline, ciprofloxacin, tobramycin

Topical steroids should NOT be used.

Gonococcal Keratoconjunctivitis

Gonorrhoea is a venereal genitourinary tract infection caused by Gram-negative diplococcus Neisseria gonorrhoeae – capable of invading the intact corneal epithelium. Incubation period : hours to 3 days

Gonococcal KeratoconjunctivitisConjunctivitis : Eyelids : oedematous and tender Discharge : profuse, purulent Intense conj. Hyperemia, chemosis, pseudomembrane formation Lymphadenopathy- promiment, may suppurate in severe cases

Keratitis : Marginal ulceration in the pus filled sulcus between chemosed

conjunctiva and the cornea at the limbus Coalescence to form a peripheral ring ulcer Central ulceration – may rapidly lead to perforation and endophthalmitis

Iritis and iridocyclitis : may be present

Gonococcal Keratoconjunctivitis

Diagnosis : aided by coincident urethritis.

Treatment: patient hospitalized, cultures taken, discharge removed at

frequent intervals by irrigation with warm saline Systemic treatment: Single dose of Ceftriaxone 1 gm im /

cefotaxime 1 gm iv bd x 3-5 days Topical treatment: ciprofloxacin, ofloxacin, gentamicin ,

tobramycin drops hourly, bacitracin ointment 6 hourly, cycloplegics for corneal involvement. Patients allergic to penicillin/cephalosporins : tetracycline

Skin and VD consultation, treatment of patient’s sexual partner

No immunity is conferred by the attack.

Membranous and pseudomembranous conjunctivitis

Organisms : Corynebacterium diphtheriae, beta-hemolytic streptococci, Streptococcus pneumoniae, Haemophilus aegypticus, Neisseria gonorrhoeae, Staph. Aureus and E.coli.

Pseudomembranous : palpebral conj covered with white membrane which peels off easily without much bleeding, associated with mild cases of conjunctivitis with mucopurulent discharge.

Membranous : Diphtheritic + Strept. pyogenes infection, associated with severe cases , lid edema, palpebral conj covered with true membrane compressing the vessels, impairing mobility, which separates less readily, with bleeding from the underlying surface, prevents the formation of free discharge.

Membranous and pseudomembranous conjunctivitis Membranous and pseudomembranous types

cannot be distinguished clinically with certainty, hence it is best to use the term membranous conjunctivitis until a bacteriological diagnosis is done.

Membrane may be patchy or cover the entire palpebral conj, but not the bulbar conj.

Preauricular lymph node may be enlarged

Membranous and pseudomembranous conjunctivitis

Complications : corneal ulcer, symblepharon formation Treatment : After sending samples for cultures, treated as in

purulent bacterial conjunctivitis. Removal of membrane is not required. (if done – may

precipitate symblepharon formation) Streptococcal membranous conjunctivitis : danger to

cornea – intense systemic + topical antibiotics required In children not immunised, every case is treated as

diphtherial unless cultures are negative – intense topical + systemic penicillin along with injection of antidiphtheritic serum

Ophthalmia neonatorum

Neonatal conjunctivitis is defined as mucoid, mucopurulent or purulent discharge from one or both eyes in the first month of life.

Any discharge, even a watery secretion, from a baby’s eyes during the first week should be viewed with suspicion, since tears are not secreted so early in life.

It is a preventable disease occurring in newborn child due to maternal infection acquired at the time of birth, and used to be responsible for 50 % of blindness among children. Recently – almost eliminated except in communities with poor hygiene and limited healthcare.

Ophthalmia neonatorum Differential diagnosis: congenitally blocked

nasolacrimal duct, acute dacryocystitis, congenital glaucoma

Bacteriological examination should be done in every case: Gram’s and Giemsa staining of conj. Smears, Chlamydial immunoflourescent antibody test on conj scrapings, viral,chlamydial and bacterial C/S.

Ophthalmia neonatorum: mode of presentation, differential diagnosis and treatment

Ophthalmia neonatorumNeisseria gonorhoeae : within 48 hrs Mucopurulent and later purulent discharge Marked chemosis and injection– retractors required to

examine baby’s eyes Tense and swollen lids False membrane may form Corneal ulceration may occur - perforation Complications –

Perforation : anterior synechiae, adherent leucoma, anterior staphyloma, anterior capsular cataract, panophthalmitis.

Dense corneal opacities : nystagmus

Ophthalmia neonatorum

Chlamydia trachomatis inclusion conjunctivitis: > 1 week after birth Less severe than gonococcal type No follicles (no adenoid layer in children) Superficial keratitis – pannus Complications : pneumonia, otitis

Ophthalmia neonatorum Treatment : As the disease is preventable, prophylactic treatment is of

prime importance. Any suspicious vaginal discharge during antenatal period should be

treated, and meticulous obstetric asepsis maintained at birth.

Newborn baby’s closed lids should be thoroughly cleansed with sterile cotton-wool soaked in sterile normal saline and dried.

If mother suspected to be infected with gonococci or chlamydia, then 1% tetracycline or erythromycin eye ointment should be applied.

Eyes should be carefully watched during the first week. If ophthalmia neonatorum is confirmed, then initial treatment is based on

the immediate results of Gram and Giemsa stains. Once the sensitivity is available antibiotic may be changed if required depending upon clinical response