Copious overflowing discharge Ballooning of lids Swollen nodes

Hyperacute Bacterial Conjunctivitis Sexually active adults Neonates, 24-72 hours after birth Most common cause: Neisseria Gonorrhoeae Urgent condition, can penetrate cornea! Theyer Martin culture Tx: Ceftriaxone 1g IM, adults=5days kids=2days Also topical fluoroquinolone

Positive papillary response Beefy engorged vessels

Acute Bacterial Conjunctivitis Susceptible at any age Staph. Aureus is most common cause Steroids mask evolution of infection Tx: 4th gen fluoroquinilone Very contagious, stay home

Inferior Papillae Wax/wane

Chronic Bacterial Conjunctivitis Staph epi or Staph. Aureus Inferior papillae because it has had time to build up

Superior papillary response (-) lymphnode Edema > injection

Allergic Conjunctivitis Chemosis due to histamine breakdown Hyperemia gets worse due to rubbing Itching!!!! PAC: Mast cell stabilizer then combo drug SAC: Combo and sometimes mast cell stabilizer Steroids great when allergen challenge increases

Giant Papillae upper lid Trantas’ dots around limbus (not always)

Vernal Conjunctivitis Kids, 90% gone by age 16 1st attack is worst Males 2x more than females Caucasians: palpebral form AA/AI/Latinos: Limbal form Bilateral Sheild ulcer (uncommon) Itching!!! Mast cell stabilizer Steroid great for first attack

Nodule, pinkish-white Center of lesion necroses and turns gray

Phlyctenulosis 60% are women and young children Most likely Staph. Exotoxin from previous conjunctivitis Big in 1950s due to Tb Unilateral Pain, #1 symptom Inflammatory response, so steroids work Topical antibiotic to treat conjunctivitis Oral tetracyline if combo doesn’t work

“wimpy conjunctivitis”

Environmental Conjunctivitis Inflammatory response Multiple causes Disease of exclusion Can use mild steroid for a week to stop complaining, then artificial tear Attempt to optimize tear quality by management of blapharitis and meibomitis

Follicular response Vesicles Tender nodes

Primary Herpes Simplex Conjunctivitis Children 60% of population infected by age 5, 90% by 16 Unilateral, other eye follows in a week Doesn’t scar like zoster Foreign body sensation NO STEROIDS! Zirgan can be used instead of viroptic, doesn’t damage cornea as much Treat dendritic keratitis with viroptic/vidarabine ointment/ganciclovir gel HSV dendrites: Rose bengal stains edges

Herpes Zoster Conjunctivitis Older patients (55+) Hutchinson’s sign on nose Triggered by stress or fatigue May also cause keratitis and uveitis Anti-virals w/in 72 hours then less chance of post herpetic neuralgia Keratitis is Inflammatory, so treat with steroids (unlike HSV) Psuedodendrites: Rose bengal stains middle

Inferior follicles Subconjunctival or petechial hemorrhages (maybe) SEIs Pseudomembranes Tender nodes

Epidemic Keratoconjunctivitis Young adults Adenovirus 8 (can last days on surfaces) No systemic manifestations Unilateral, then other follows in a week or less R/O herpes, no vesicles or dermatomes Consider any keratoconjunctivitis to be HSV or EKC until proven otherwise Contagious Betadine ophthalmic prep solution

Fever Conjunctivitis Sore Throat Tender nodes Follicles Chemosis Possible SEIs

Pharyngoconjunctival Fever Kids between 5-15 Swimming pool conjunctivitis Adenovirus 3 Self limiting, 10-14 days Don’t use aspirin for fever because kid SEI interfere with vision, but not a big deal in kids so don’t treat with steroids

Fever Cough Coryza Conjunctivitis Koplik’s spots Inferior follicles

Rubeola Children under 10 Passed respiratory Highly contagious Paramyxovirus Supportive treatment, no antiviral (it will tear up cornea)

Unilateral follicular conjunctivitis Granulomas with follicles Node enlargement Chemosis Lid swelling

Oculoglandular Syndrome Cat scratch is most common cause

Lymph node enlargement Lesion at site of scratch

Cat Scratch Disease Young children about 10, girls>boys Bartonela Hensulae Bacillus Lesion at site of scratch appears 3 weeks later Self limiting May need oral tetracycline or macrolide

Fever Chills Malaise HA Nausea Conjunctivitis, necrotising granulomatous type

Tularemia “Rabbit Fever” Franciella tularensis Lesion at site of organism entry with adenopathy Treat with streptomycin

Primary site in lungs

Tuberculosis Central American, pacific rim Low income, inner city Mycobacterium Droplet spread Treatment: rifampin

Chancre Local adenopathy Uveitis Argyl-robinson

Syphilis Primary: Chancre Secondary: uveitis, skin rash, flu symptoms Tertiary: neurosyphilis, argyl-robinson Tx: penicillin or doxycycline

Conjunctiva shows red nodules that turn pink to purple to black and then necrose

Sporotrichosis “Rose Gardeners Disease” Sporothrix Fungus lives on vegetables or in soil Ulcerating nodules on extremeties and along lymph channels Tx: local=potassium iodide Systemic=ketoconazole

60% asymptomatic 40% fever, myalgia, hilar adenopathy May progress to chronic pneumonia

Coccidiodomycosis San Joaquin Valley and Southwest US - immigrant farm workers (25-55 years old) Airborne Fungus ‘94 breakout after big earthquake If accompanied by arthritis and erythema nodosa then called “valley fever syndrome: Tx: amphotericin B (very toxic) or ketoconazole

Fever, HA, malaise, sore throat, white patches on back of throat

Mononucleosis Young adults, uncommon in >25 Epstein-Barr Virus Acute episodes last from 1-3 weeks Self limiting Symptomatic relief Possible penicillin for related strep tonsillitis

Hamster face HA, myalgia, fever

Mumps Kids Myxovirus Supportive therapy Vaccination (MMR) at 15 months old

Hard lumps on face and neck Fever, chills, reduced lung function, chest tightness, cough, weezing

Actinomycosis Men 3x more than women Little bug goes in face Typically bad mouth hygiene HX of dental extraction, abdominal trauma, sinus infection, chronic pneumonia Tx: oral penicillin or erythromycin

Lungs = primary site Can involve liver, skin, eyes, parotid glands

Sarcoid Most common in female african americans in US Granulomatas disease of unknown etiology Mild cases don’t require therapy Remits spontaneously Oral steroids used in severe or chronic cases

Sometimes follicles, sometimes papillae

Toxic conjunctivitis Common = sulfacetamide Usually preservatives in meds (bilateral) Viral toxins (unilateral) Follicles not characteristic of all causative agents Epinephrine causes adrenochrome deposits (black spots on palpebral conj) TX: dicontinue all drops etc.

Chronic follicular conjunctivitis Upper tarsal involvement with follicles Conjunctival scarring Pannus Limbal follicles Herbert’s Pits

Trachoma Mainly children Leading cause of blindness in the world because is scars the cornea Eye is reservoir for C. Trachomatis Make more susceptible to H. flu and strep pneumoniae Advanced: basket weave of scarring on upper lid Herbert’s pit = scarred limbal follicles Tx: oral tetracyclines, macrolides for kids, triple sulfa is can’t take first two

Papillary response Follicles upper and lower Micropannus Tender pre-auricular nodes Chronic presentation

Inclusion Conjunctivitis Women 15-24 most susceptible Also neonatal conjunctivitis Causes majority of infertility and need a slit lamp to diagnose! Related to venereal disease Neotnates will only have papillae since lymph tissue is not mature enough to make follicles Tx: Erythromycin 500mg PO, QID Other Tx: oral Tetracycline, Azithromycin Neonates: tetracycline ointment, oral erythromycin

Prominent limbal arcades Nodules near limbus

Facial/Ocular Rosacea Women 4x more than men 20-40s have to rule out dermatitis Nodules not an acute response, takes a few months Tx: Doxycyclone, Tetracyclines up to 8 weeks, more anti-inflammatory than steroids with meibomian gland problems and rosacea Very mild steroid for anti-angiogenesis May need indefinite maintenance therapy

Bullous blistering Symblepharon Keratinization of conjunctiva

Benign Mucous Membrane Pemphigoid 75% more females, older Unusual condition: 1 in 20,000 Type IV inflammatory reaction No explaination Possible mucoud membrane involvement elsewhere Diagnosis of exclusion Tx: ocular lubricants on regular basis Immunosupressive therapy: Dapsone

Blistering Skin lesions, black lips Papular skin eruptions

Erythema Multiforme Uncommon blistering disorder of skin and mucous membranes Probably immune complex mediated Kick off most commonly by HSV and sulfa meds Most severe: Stevens-Johnson Syndrome Tx: Immunosuppressants, Antobiotic for secondary infections: fluoroquinilone Self limiting condition