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

2. 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

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

5. 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.

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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)

16. 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

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

18. 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.

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

20. 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.

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

23. 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

24. 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.

25. 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!

26. Fever of unkown origin(fuo)

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

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

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

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

33. 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

34. 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

35. 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

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

37. 3- Miscellaneous Medications Inducing Fever:
A. Allopurinol
B. Antihistamines
C. Aspirin
D. Cimetidine
E. Heparin
F. Meperidine
G. Phenytoin

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