1 CONJUNTIVA

2 RED EYE

CONJUNCTIVA 1.Conjunctivitis 2.Chronic conjunctivitis 3.Ophthalmia neonatorum 4.Adenoviral conjunctivitis 5.Trachoma 6.Allergic conjunctivitis 3 CONJUNCTIVA

4. CONJUNTIVA anatomy

Conjunctivitis Clasification acute acute hyperacute hyperacute chronic chronic 5

6 CONJUNCTIVAL SECRETION

7 Folliculles, papillae, chemosis

8 Bacterial conjunctivitis Clinic: quikly onset of unilateral conjunctival hyperemia quikly onset of unilateral conjunctival hyperemia lid edema lid edema mucopurulent discharge mucopurulent discharge second eye becomes involved 1-2 days later second eye becomes involved 1-2 days later

1.Bacterial conjunctivitis is characterized by: rapid onset of unilateral conjunctival hyperemia, lid edema and mucopurulent discharge; second eye becomes involved 1- 2 days later. Bacterial conjunctivitis (bc.) can be classified into three clinical types: acute, hyperacute and chronic. The most common conjunctival pathogens include Staphylococcus, Streptococcus, Haemophilus, Neisseria and Gram negative. 1.a. Acute bc. begins unilaterally with hyperemia, irritation, tearing and mucopurulent discharge; other common ocular manifestations include punctate epithelial keratitis, blepharitis, marginal ulcers. Treatment: topical antibiotic drops or ointment; the choice of antibiotic is based upon results of cultures; if the treatment is based upon clinical features, a broad- spectrum antibiotic such gentamicin, floroquinolone or trimethoprim-polimixin may be used for 7-10 days. 1.b. Hyperacute bc. The most common cause is Neisseria gonorrhea. This is an oculo-genital disease seen primarily in neonates, sexually active teenagers and young adults. The clinical course includes profuse, thick, yellow-green purulent discharge, painful hyperemia, and chemosis. Untreated cases may lead to peripheral corneal ulceration and eventual perforation with possible endophthalmitis. Treatment: conjunctival scraping and culture on blood and chocolate agar is suggested strongly. Gonococal conjunctivitis is treated with both topical and systemic antibiotics: ceftriaxone 1 g followed by 2-3 weeks course of oral tetracycline or erythromycin; topical antibiotics: bacitracine or erythromycin ointments every 2 hours. Frequent irrigation of the ocular surface is helpful.

Treatment: hygiene hots compresses, hots compresses, gentle shampoo applied gentle shampoo applied topical antibiotic drops or ointment (the choice of antibiotic is based upon results of cultures) if the treatment is based upon clinical features Aminoglicozid Aminoglicozid Floroquinolone Floroquinolonecorticosteroids 10

Ophthalmia neonatorum oral eritromycine syrup 50 mg/kg/day for 14 days; treatment of mother and sexual partners with tetracycline or eritromycine 7 days; prevention: treatment of chlamydial, gonococcal and herpetic infections during pregnancy treatment of chlamydial, gonococcal and herpetic infections during pregnancy Crede method Crede method 11

Ophthalmia neonatorum is defined as any conjunctivitis occurring within the first 4 weeks of life. It is caused by bacterial, viral, chlamydial infection or by toxic response to topically applied chemicals. a)chemical conjunctivitis results from the instillation of silver nitrate drops used for infection prophylaxis. b)Chlamydial infection is the most frequent cause of neonatal conjunctivitis in USA. Symptoms develops 5-14 days after delivery; initially infants develops a watery discharge and mucopurulent later. Signs include: lid edema, a papillary conjunctival response and pseudomembranes. The infection is mild and self-limited; however, severe cases may occur and have conjunctival scaring and peripheral corneal panus. Treatment:-oral eritromycine syrup 50 mg/kg/day for 14 days; -treatment of mother and sexual partners with tetracycline or eritromycine 7 days;-prevention: treatment of chlamydial, gonococcal and herpetic infections during pregnancy. c)Neisseria infection: hyperacute conjunctivitis with edema, chemosis and excessive purulent discharge, which begins hours after birth. The discharge is so copious that it reaccumulates after the eye has been clean. Gram stain is essential to prompt and effective treatment. Treatment:-systemic penicillin G 100,000ui/kg/day in 4 doses for 7 days or intravenous ceftriaxone mg/kg once a day for 7 days;-topical antibiotics. d) other bacterial infection bacteria are probably transmitted through the air to the infant. 12

Viral conjunctivitis (v.c.) is one of the most common causes of visits to the emergency room or doctor’s office. 2.a.Adenoviruses produce: -pharyngoconjunctival fever is a condition characterized by combination of pharyngitis, fever and conjunctivitis. The conjunctivitis is follicular with watery discharge, hyperemia and mild chemosis. The cornea may be involved with fine punctate epitheliopathy and preauricular limfonodes are enlarged in 90% of cases. Treatment is usually supportive with cold compresses, vasoconstrictive drops; the disease resolve spontaneously within 2 weeks. -epidemic keratoconjunctivitis is a more severe type and lasts for 7-21 days. Clinical signs:*hyperaemia, chemosis, watery discharge, a mixed papillary and follicular response and ipsilateral preauricular limphadenopathy, subconjunctival hemorrhages and conjunctival membranes;corneal involvement. Treatment:prevention – hand washing, relative isolation of infected individuals, disinfecting of ophthalmic instruments;curative :vasoconstrictive eye drops and for corneal involvement topical corticosteroids. 2.b. Acute hemorrhagic conj. are produced by picornaviruses. Signs: severe painful conjunctivitis with chemosis, tearing and subconjunctival hemorrhages; the disease resolves within 4-6 days but the hemorrhages clear later; the conjunctivitis tends to occur in epidemics with more than 50% of the local population affected. 2.c. Herpes simplex conj. is nonspecific; typical signs include: ocular irritation, watery discharge, follicular conjunctivitis and preauricular limphadenopathy, an epidermal vesicular eruption of the eyelid and lid margins. Conjunctivitis resolves spontaneously without treatment; if corneal involvement exist administration of topical antiviral is indicated. 2.d. Other causes rubella, rubella, varicela-zoster, Epstein-Barr viruses. 13

14 Viral conjunctivitis Adenoviruses pharyngoconjunctival fever pharyngoconjunctival fever epidemic keratoconjunctivitis epidemic keratoconjunctivitis Acute hemorrhagic Herpes simplex, varicela-zoster Rubella, Epstein-Barr viruses

15. Viral conjunctivitis.

16.chlamidial conjunctivitis Trachoma adult inclusion conjunctivitis neonatal conjunctivitis

McCallan classification I. early lymphoid hyperplasia with follicles formation on the superior tarsal conjunctiva; IIa. mature follicles on full superior tarsus; IIb. florid inflammation with increase in pretarsal and limbal follicular and papillary hypertrophy; III. resolution of the papillary hypertrophy and early conjunctival scaring; IV. no active inflammation, replacement of papillae and follicles with scars and resolution of panus. 17

Chlamidia trahomatis. Trachoma results from stereotypes A – C, is endemic in areas of close human contact and poor hygiene. Trachoma begins as a follicular conjunctivitis of the upper palpebral conjunctiva with associated limbal follicles. Other findings include conjunctival papillary hypertrophy, a superficial corneal panus and a fine epithelial keratitis. The inflammation leads to scaring of the cornea, conjunctiva and eyelids. McCallan classification: I. early lymphoid hyperplasia with follicles formation on the superior tarsal conjunctiva; IIa. mature follicles on full superior tarsus; IIb. florid inflammation with increase in pretarsal and limbal follicular and papillary hypertrophy; III. resolution of the papillary hypertrophy and early conjunctival scaring; IV. no active inflammation, replacement of papillae and follicles with scars and resolution of panus. Complications: conjunctival and eyelids deformities: trichiasis,distichiasis, entropion, ectropion; corneal involvement:scars, vascularization and ulcers (infection, perforation)  blindness. Treatment:-oral tetracycline (1 g/day) or doxicycline 100 mg/day 3-4 weeks; -topical tetracycline or eritromycine ointments twice a day for 5 days each month for 6 months;-oral azithromicine in endemic areas. 18

LECTURER DR. RUSU VALERIU19Trachoma.

Treatment oral tetracycline (1 g/day) or doxicycline 100 mg/day 3-4 weeks; topical tetracycline or eritromycine ointments twice a day for 5 days each month for 6 months; oral azithromicine in endemic areas has shown promise to eradicate the disease. 20

ALLERGIC CONJUNCTIVITIS 1.Acute atopic conjunctivitis is a Type 1 allergic response mediated by Ig E. The response is stimulated by airborne allergens such as: dust, pollen, spores and animal dander. Symptoms are itching, burning. Signs are hyperemia, lid edema, chemosis and watery discharge. Reaction may be limited to the eye or it may be part of a generalized allergic reaction with nasal and respiratory symptoms. Treatment: cold compresses, topical vasoconstrictors topical antihistamines (levocabastine); also corticosteroids for severe cases. 2.Chronic atopic conjunctivitis same symptoms as in acute condition except less evidence of the acute inflammation. Conjunctiva exhibits a pale edema with papillary hypertrophy. 3. Giant papillary conjunctivitis is a syndrome of inflammation of the upper palpebral conjunctiva associated with contact lens wear, ocular prosthesis. Patients complains of a mild itching after removal of the contact lenses; macropapillae and giant papillae cover superior tarsal conjunctiva. Treatment: stopping lenses wear until the inflammation subsides; the correct manipulation of the lens is essential; a short course of topical corticosteroids can lessen the symptoms in severe cases. 21

Alergic conjunctivitis Atopic conjunctivitis acute acute chronic chronic Allergic dermato-conjunctivitis Microbioallergic conjunctivitis Vernal conjunctivitis Giant papillary conjunctivitis 22

Symptoms itching itching burning burningSigns hyperemia hyperemia lid edema lid edema chemosis chemosis watery discharge watery discharge generalized allergic reaction nasal nasal respiratory symptoms. respiratory symptoms. 23

24 Treatment hygiene alergen eviction alergen eviction cold compresses cold compresses topical vasoconstrictors topical antihistamines (levocabastine) corticosteroids topical cyclosporine