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OP14 Ophthalmology
Conjunctiva
Toronto Notes 2019
Types of Discharge
• Allergic: mucoid
• Viral: watery
• Bacterial: purulent
• Chlamydial: mucopurulent
• Follicles are usually seen in viral and chlamydial conjunctivitis
• Papillae are usually seen in allergic and bacterial conjunctivitis
Antibiotics vs. Placebo for Acute Bacterial Conjunctivitis
Cochrane DB Syst Rev 2012;9:CD001211 Purpose: To assess the benefits and harms of antibiotic therapy in the management of acute bacterial conjunctivitis.
Criteria: RCTs with any form of antibiotic treatment compared with placebo including topical, systemic or combined (e.g. antibiotics and steroids) antibiotic treatments.
Results: 11 RCTs, 3,673 participants. Topical antibiotics improve early (2-5 d) clinical and microbiological remission rates (RR 1.36, 95% CI 1.15-1.61; RR 1.55; 95% CI 1.37-1.76) and benefit clinical remission and microbiological cure rates at a late time point (6-10 d) (RR 1.21, 95% CI 1.10-1.33; RR 1.37, 95% CI 1.24-1.52). By 6-10 d 41% of cases had resolved in the placebo group. No serious outcomes were reported in any group.
Conclusion: The use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission in comparison to placebo. Antibiotic eye drops should therefore
be considered in order to speed the resolution of symptoms and infection although acute bacterial conjunctivitis is frequently self-limiting.
Conjunctival hyperemia
Ciliary flush
Figure 13. Conjunctival hyperemia vs. ciliary flush
• Enlarged lymph nodes suggest infectious etiology, especially viral or chlamydial conjunctivitis
• Temporal conjunctival lymphatics drain to preauricular nodes, and nasal to submandibular nodes
Conjunctivitis
Etiology
• infectious
■ bacterial, viral, chlamydial, gonococcal, fungal, and parasitic
• non-infectious
■ allergic, atopic, seasonal, giant papillary conjunctivitis (contact lens wearers)
■ toxic: irritants, dust, smoke, irradiation
■ secondarytoanotherdisorder:dacryocystitis,dacryoadenitis,cellulitis,andsystemicinflammatory
disease
Clinical Features
• redeye(conjunctivalinjectionoftenwithlimbalpallor),chemosis,andcornealsubepithelialinfiltrates • itching,foreignbodysensation,tearing,discharge,crustingoflashesinthemorning,andlidedema
• ± preauricular and/or submandibular nodes
• follicles: pale lymphoid elevations of the conjunctiva, overlain by vessels
• papillae: fibrovascular elevations of the conjunctiva with central network of finely branching vessels (cobblestone appearance)
Allergic Conjuctivitis
• associatedwithrhinitis,asthma,dermatitis,andhayfever
• ocular pruritus, small papillae, chemosis, redness, thickened and erythematous lids • seasonal (pollen, grasses, plant allergens)
Treatment
• allergenavoidance,coolcompresses,non-preservedartificialtears,topicalororalantihistamine,topical mast cell stabilizer (e.g. cromolyn, ketotifen, olopatadine), and topical corticosteroids
Atopic Conjuctivitis
• onsetlateadolescenceandearlyadulthoodwithpeakbetween30-50yrold
• intense ocular pruritus (perennially), tearing, burning, clear mucus discharge, redness, blurry vision,
photophobia, and foreign body sensation
• thickenedandintermittentswellingoftheeyelids,conjunctivalchemosis,conjunctivalhyperemia,and
tarsal papillary hypertrophy (Figure 13) Treatment
• calcineurininhibitorointment(e.g.tacrolimusandpimecrolimus),andtopicalcorticosteroid(clobetasone)
Giant Papillary Conjunctivitis
• immunereactiontomucusdebrisonlensesincontactlenswearers • largepapillaeformonsuperiorpalpebralconjunctiva
Treatment
• clean,changeordiscontinueuseofcontactlens,andtopicalcorticosteroids
Vernal Conjunctivitis
• largepapillae(cobblestones)formonsuperiorpalpebralconjunctivawithcornealulcersandkeratitis • seasonal(warmweather)
• occursinchildren,lastsfor5-10yrthenresolves
Treatment
• non-preservedartificialtears,considertopicalsteroid,topicalcyclosporine(byophthalmologist)
Viral Conjunctivitis (pink eye)
• presentswithitchiness,painandswelling
• serousdischarge,lidedema,follicles,andpseudomembranes
• subepithelialcornealinfiltrates
• preauricularnodeoftenpalpableandtender
• initiallyunilateral,oftenprogressestotheothereyewithinafewdays • mainlyduetoadenovirus–highlycontagiousforupto12d
Treatment
• coolcompresses,topicallubrication
• usuallyself-limiting(7-12d)
• properhygieneisimportanttopreventtransmission
Bacterial Conjunctivitis
• purulentdischarge,lidswelling,papillae,conjunctivalinjection,andchemosis
• commonagentsincludeS.aureus,S.pneumoniae,H.influenzaeandM.catarrhalis
• inneonatesorifsexuallyactivemustconsiderN.gonorrhoeae(invadescorneatocausekeratitis) • C.trachomatisisthemostcommoncauseinneonates
Treatment
• topical broad-spectrum antibiotic, systemic antibiotics if indicated (especially in neonates and children) • usually a self-limited course of 10-14 d if no treatment, 1-3 d with treatment
© Willa Bradshaw 2005