Conjuctivitis, glaucoma and fever of unkown origin. Abiola Akande Roll number : 703

Definition Conjunctivitis, also known as pinkeye. It is an 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

Types of conjunctivitis There are different types of conjuctivitis depending on the cause: Viral conjunctivitis Bacterial conjunctivitis Allergic conjunctivitis

Viral conjunctivitis Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold, and/or a sore throat. Viruses that can cause conjunctivitis include: adenovirus, enterovirus and coxsackie. It usually occurs in community epidemics (schools, workplace, physician’s office) It can be transmitted by contaminated fingers, medical instruments, swimming pool water.

Symptoms of viral conjunctivitis Unilateral or bilateral Redness(hyperaemia) Watering(epiphora), Itching, Mild mucoid discharge, Mild photophobia, Feeling of discomfort and foreign body sensation. The infection usually begins in one eye and involve the other within few days.

Treatment of Viral Conjunctivitis Topical antibiotics not necessary because secondary bacterial infection is uncommon Reassurance that the symptoms may get worse for 3-5d before getting better and persist for 2-3 weeks Some relief from cold compresses and topical antihistamines/decongestants Do not use topical corticosteroids due to risk of sight-threatening complications (scarring, corneal melting, perforation), especially if etiology is herpes simplex virus or bacterial keratitis

Bacterial conjunctivitis Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and mucopurulent discharge. Bacterial conjunctivitis due to common pyogenic (pus-producing) bacteria causes marked grittiness/irritation and a stringy, opaque, greyish or yellowish mucopurulent discharge that may cause the lids to stick together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may also occur Bacterial meningitis could be acute, hyperacute or chronic.  

Acute Bacterial Conjunctivitis Presentation: Unilateral or bilateral, red eye, mucopurulent or purulent discharge continuously throughout the day, burning, irritation, mild chemosis Neonates: symptoms appear 5-14d after birth (inclusion conjunctivitis of the newborn) Highly contagious: spread by direct contact or by contaminated objects

Hyperacute Bacterial Conjunctivitis Etiology: Neisseria species, most commonly N. gonorrhoeae Presentation: profuse, purulent discharge with rapidly progressive symptoms of marked conjunctival injection, irritation, tenderness to palpation, chemosis, lid swelling, and tender preauricular adenopathy Ophthalmia neonatorum: gonococcal ocular infection with bilateral discharge 3-5d after birth from vaginal transmission Sexually active teens: transmitted from genitalia to hands to eyes, commonly see concurrent urethritis Sight-threatening

Chronic Bacterial Conjunctivitis Most common etiology: Staphylococcus species More common in adults and patients with acne rosacea or facial seborrhea Presentation varies: redness, itching, burning, foreign-body sensation, flaky debris, blepharitis (common), eyelash loss Concurrently see styes and chalazia of the lid margin from chronic inflammation of the meibomian glands

Treatment of Acute Bacterial Conjunctivitis Topical broad-spectrum antibiotics: erythromycin ointment, bacitracin-polymyxin B ointment (Polysporin), trimethropim-polymyxin B (Polytrim), sulfa drops Most H. flu and S. pneumoniae resistant to macrolides Sulfa drops (Bleph-10): less effective and rare side effect of Stevens-Johnson syndrome Rx: 1/2” ointment inside lower lid or 1-2 drops QID for 5-7 days (response seen typically within 1-2d) Inclusion Conjunctivitis of the Newborn: treat with 2 week course of erythromycin (50mg/kg/d po divided QID) or sulfisoxazole (150mg/kg/d po divided QID), topical unnecessary with systemic

Treatment of Hyperacute Bacterial Conjunctivitis Immediate ophthalmic referral Systemic and topical antibiotics and saline irrigation Systemic antibiotic of choice due to penicillin-resistant N. gonorrhoeae is single-dose Ceftriaxone (25-50mg/kg IV or IM, not to exceed 125mg) or single-dose Cefotaxime (100mg/kg IV or IM) in neonates If venereal disease present in teens, also treat with single-dose of azithromycin (1g) because over 30% of these patients will have concurrent chlamydial disease AAP and CDC recommendations for prevention of ophthalmia neonatorum: silver nitrate 1% aqueous solution (side effect of chemical conjunctivitis), erythromycin 0.5% ophthalmic ointment, tetracycline 1% ophthalmic ointment

Allergic conjunctivitis Allergic conjunctivitis is inflammation of the conjunctiva (the membrane covering the white part of the eye) due to allergy. Allergens differ among patients. Symptoms consist of redness (mainly due to vasodilation of the peripheral small blood vessels), oedema (swelling) of the conjunctiva, itching, and increased lacrimation (production of tears). If this is combined with rhinitis, the condition is termed "allergic rhinoconjunctivitis". The symptoms are due to release of histamine and other active substances by mast cells, which stimulate dilation of blood vessels, irritate nerve endings, and increase secretion of tears.

Treatment of Allergic Conjunctivitis Self-limited Allergen avoidance, cold compresses, topical antihistamines/vasoconstrictors (do not use for greater than 2 weeks), artificial tears, topical NSAIDS (low efficacy) Prophylaxis: oral antihistamines (onset of action=days), mast cell stabilizers (onset of action=5-14d)

Glaucoma This is a disease of progressive optic neuropathy with loss of retinal neurons and their axons (nerve fiber layer) resulting in blindness if left untreated. It may have a classical sign –elevated intraocular pressure

Types There are two types Open angle glaucoma Closed angle glaucoma Congenital glaucoma

Congenital Glaucoma Onset: antenatally to 2 years old Signs Elevated IOP Buphthalmos Haab’s striae Corneal clouding Glaucomatous cupping Field loss Symptoms Irritability Photophobia Epiphora Poor vision Haab’s striae are found only in congenital glaucoma.

Buphthalmos and cloudy corneas Congenital Glaucoma Buphthalmos and cloudy corneas The right eye in each patient has congenital glaucoma.

Narrow Angle Glaucoma Onset: 50+ years of age Symptoms Severe eye/headache pain Blurred vision Red eye Nausea and vomiting Halos around lights Intermittent eye ache at night Signs Red, teary eye Corneal edema Closed angle Shallow AC Mid-dilated, fixed pupil “Glaucomflecken” Iris atrophy AC inflammation The classical signs and symptoms of narrow angle glaucoma.

Narrow Angle Glaucoma Mid-dilated, fixed pupil Mid-dilated, fixed pupils and cloudy corneas during an angle closure attack.

Open Angle Glaucoma Aka: chronic simple glaucoma (CSG) and primary open angle glaucoma (POAG) Risk Factors IOP Diabetes Age Myopia Race Gender Family history Cardiovascular Central corneal disease thickness Hormones

Open Angle Glaucoma Signs Elevated IOP Visual field loss Symptoms Onset: 50+ years of age Signs Elevated IOP Visual field loss Glaucomatous disk changes Symptoms Usually none May have loss of central and peripheral vision late Remember: most patients with open angle glaucoma have no symptoms. This is the best reason to have periodic eye examinations with pressure checks and optic nerve evaluations.

GLAUCOMA Medical Surgical Beta-blockers Carbonic anhydrase inhibitors Treatment Medical Surgical Miotics Beta-blockers Carbonic anhydrase inhibitors Prostaglandin analogues Alpha-2 agonists Argon laser trabeculoplasty Trabeculectomy Filtering procedure Cyclocryotherapy Cyclolaser ablation Iridotomy No treatment works all the time!

Fever of unkown origin(fuo)

PUO Definition Fever Persisting for more than 3 weeks. Documented Temp above 101 F Several Occasions. Uncertain diagnosis after extensive evaluation in hospital for . 1 week. PUO of 2 weeks no diagnosis could be made.

Pyrexia of Unknown Origin Causes: Infections. Neoplastic Diseases. Auto Immune Disease. Hentable Diseases. Granulamatous Disease. Drug Fever. Miscellaneous Causes.

Causes 1- Infections: Viral Syndrome 1. Cytomegalovirus. 2. Epstein-Barr Virus (Mononucleosis) 3. HIV Infection. Lyme Disease Pyelonephritis or Urinary Tract Infection Meningitis. Pneumonia Septicemia Acute Sinusitis Malaria

Osteomyelitis. Typhoid Fever or Enteric Fever Subacute Bacterial Endocarditis (SBE) Tuberculosis. Liver or Biliary infection. Abdominal or Pelvic abscess Dental Abscess Psittacosis Brucellosis

2- Neoplastic Disease: A. Leukemia B. Lymphoma C. Sarcoma D. Carcinomatosis E. Renal cell carcinoma F. Colon Cancer G. Pancreatic H. Hepatoma I. Metastic cancer

3- Autoimmune Disease: A. Juvenile Rheumatoid Arthritis (evanescent rash) B. Henoch-Schonlein Purpura C. Systemic Lupus Erythematosus D. Rheumatic Fever (Migratory Polyarthritis) E. Polymyalgia Rheumatica F. Temporal Arteritis G. Inflammatory Bowel Disease H. Reiter’s Syndrome

4- Heritable Disease Causes: A. Fabry’s Disease B. Familial Mediterranean fever C. Lamellar Ichthyosis D. Nephrogenic Diabetes Insipidus E. Anhydrotic ectodermal dysplasia F. Familial Dysautonomia

Drug-Induced Fever 1- Antibiotic Induced Fever: A. Erythromycin B. Isoniazid C. Penicillin D. Nitrofurantoin E. Procainamide F. Quinidine

3- Miscellaneous Medications Inducing Fever: A. Allopurinol B. Antihistamines C. Aspirin D. Cimetidine E. Heparin F. Meperidine G. Phenytoin

Investigations Hematology Urine examination Chest radiograph Other tests like liver function test, sputum culture etc