conjunctiva I - infective conjunctivitis

define follicles and describe their appearance (4)

• accumulation of WBC’s

• Raised white/pinkish, round elevations

• Whitish-grey centres surrounded by small vessels

• Tarsal or forniceal conjunctiva (uncommonly on bulbar conjunctiva)

why do follicles form (2)

• response to viral or chlamydial infection

• also seen in toxic conjunctivitis

define papillae and describe their appearance (4)

• elevated areas of inflammation

• Raised swellings in the tarsal conjunctiva

• May be visible blood vessel in centre (vascular tuft)

• Classified by size - Small appear velvety - may be a normal finding // Large - ‘giant’ - cobblestone appearance

what are papillae indicative of 

• of an allergy or a bacterial infection 

what are the 3 categories/types of infective conjunctivitis

• viral

• bacterial

• chlamydial 

explain the aetiology of viral conjunctivitis (4:3:6)

can be caused by adenovirus: most common cause

• > 30 serotypes (types) capable of affecting eye

• commonest acute infective conjunctivitis (75%) - 3/4 cases are adenoviral

• presentation varies - mild-severe

can be acute haemorrhagic:

• rare epidemics

• enterovirus & coxsackievirus - conjunctiva primary site of infection

others: primary site not necessarily conjunctiva

• Molluscum contagiosum

• Papilloma

• SARS-CoV-2 coronavirus

• Herpes simplex (see cornea lecture)

• Mumps and measles

explain the symptoms of viral conjunctivitis (4:2)

Acute onset (3-7 days): 

•Redness

•Watery discharge

•Crustiness of eye lids

•Discomfort - burning or grittiness

Progression: 

•Unilateral becomes bilateral

•Blurred vision if cornea involved

what are the predisposing factors of viral conjunctivitis (4)

•Recent cold/upper respiratory tract infection

•Poor hygiene - failure washing hands

•Crowded conditions (school, camps, clinics) - can be passed on easily

•Eye clinic - passed on between px’s

describe the signs of viral conjunctivitis (7)

•Watery discharge

•Conjunctival hyperaemia (redness) 

•Follicles - upon lid eversion

•Pin-pick (petechial) subconjunctival haemorrhages (tiny dot-like red spots on conjunctiva when small blood vessels break) 

•Psuedomembranes (if severe) - layer of fibrin, inflammatory cells and exudates - coats surface of tarsal conjunctiva - white/yellow soft membrane sitting on conjunctiva 

•Lid oedema - swelling (variable extent)

•Watch for corneal involvement (keratitis) - check if clear - if not serious infection

describe the optometric management of viral conjunctivitis (8)

• Highly contagious - wash hands and clean equipment - reduce risk of cross infection

Patient advice: 

• Self-limiting condition (gets better on its own)

• Usually resolves in 1-2 weeks - 8-10 weeks to completely clear

• Highly contagious (family, friends, colleagues) - explain risk of passing it on - hand hygiene, not sharing towels etc. 

• Temporarily avoid contact lenses

Do not usually need to refer: however refer urgently if:

• pain

• Sight-compromising corneal involvement

• Psuedomembrane

what is the treatment for viral conjunctivitis (3)

•Cold compress - symptomatic relief

•Ocular lubricants

•Painkillers

what are the secondary care options for viral conjunctivitis (5)

•Antibiotics ineffective against viruses

•Generally no effective antiviral - however - viral culture - conjunctival swab - if effective against that then antiviral may be offered but not routinely

•Topical antihistamines - severe itching

•Weak topical steroid - used with care (membranous or risk of scarring) - suppress immune response BUT can make infection more likely + delay wound healing

•Adenovirus necessitates 2 weeks off work/school - reduce risk of contamination

describe the aetiology of bacterial infective conjunctivitis ()

• Very common

• Self-limiting infection (gets better on its own)

• caused by various bacteria: 

•Staphylococcus species

•Streptococcus pneumoniae

•Haemophilus influenzae

•Moraxella catarrhalis

what are the predisposing factors of bacterial infective conjunctivitis (7)

•Contamination of conjunctival surface

•Blepharitis

•Trauma

•Contact lens wearer - way in for bacteria - make infection more likely  

•Recent cold/upper respiratory tract infection or sinusitis (inflammation of the mucosa lining the paranasal sinuses)

•Immune compromise (including diabetes)

•Steroids (systemic or topical)

describe the symptoms of bacterial infective conjunctivitis (6)

• Acute onset (24-48 hours)

• Redness

• Discomfort - burning or grittiness (no pain - unless cornea is involved)

• Discharge - purulent or mucopurulent (sticky)

• Lids may be stuck together on waking

• Usually bilateral (can be asymmetrical - then may pass onto other eye)

what are the signs of bacterial infective conjunctivitis (5)

•Purulent or Mucopurulent discharge

•Conjunctival hyperaemia (redness) 

•Mild papillary conjunctivitis (tarsal conj)

•May be lid oedema

•+/- epithelial punctate staining due to tear film instability

describe the management of bacterial infective conjunctivitis (7)

• Self limiting condition - resolves spontaneously without treatment within 5-7 days - for MOST px’s 

• Highly contagious (e.g. through sharing towels) - advise px’s on this 

• Bathe/clean the eyes with sterile wipes, lint or damp cotton wool

• Cease contact lens wear until resolved - throw away potential contaminated lenses and contact lens case 

• May not need treatment, but… chloramphenicol drops or ointment (drops 2 hourly for first 48 hours then 4 hourly for 5 days)

• Contact lens wearers - risk of acanthamoeba - CHECK 

• Conjunctival swab if resistant to treatment or recurrent - referral if pain persists and if necessary 

explain the aetiology of chlamydial infective conjunctivitis (5)

• almost always sexually transmitted disease (rare eye to eye infection)

• Chlamydia trachomatis is an intracellular parasite (type of bacteria)

• Serotypes (strains) A-C:

•Trachoma

•a leading cause of worldwide blindness

• Serotypes (strains) D-K:

•Chlamydial (adult inclusion) conjunctivitis

•Ophthalmia neonatorum - STD

• Uncommon compared to bacterial and viral conjunctivitis

what are the predisposing factors of chlamydial infective conjunctivitis (2)

•Young adulthood (15-35 years) - sexually active years

•STD C. Trachomatis

symptoms of chlamydial infective conjunctivitis (5)

•History > 2 weeks (subacute)

•Gritty irritation

•Sticky discharge

•Often unilateral - can be bilateral

•Droopy lid(s) 

what are the signs of chlamydial infective conjunctivitis (6)

• Lid oedema & mechanical ptosis

• Mucopurulent discharge

• Conjunctival hyperaemia (redness) and chemosis (swelling) 

• Large follicles in upper and lower fornices

• +/- limbal and/or bulbar follicles

• Keratitis (superior “micropannus”)

describe the optometric management of chlamydial infective conjunctivitis (3)

•Advise against CL wear

•Ocular lubricants

•Liaise with GP/Ophthalmologist

what are the secondary care options for chlamydial infective conjunctivitis (3)

•Lab tests to confirm diagnosis (swab)

•Systemic antibiotics

•May need referral to Genitourinary clinic

describe what ophthalmia neonatorum is (3)

•Any conjunctivitis within first month of life - born with it/develops early on

•Infection of the maternal birth canal (STD)

•Since April 2010 is no longer a notifiable disease in the UK

what are the different types/causes of ophthalmia neonatorum (5)

•Chlamydial (5-14 days)

•Gonococcal (3-5 days)

•Staphylococcal

•Haemophilus spp

•Herpes simplex virus

symptoms and management of ophthalmia neonatorum (3)

•Bilateral redness, discharge, lid oedema

•At risk of corneal perforation (full-thickness hole in cornea - allowing contents of anterior chamber to leak out) 

Same day referral to ophthalmologist

what is chlamydial (trachoma) conjunctivitis (3)

•Second leading cause of blindness world wide (visual impairment in 1.8 million) - occurs in third world countries 

•Fomite transmission (flies & person-to-person)

-not a sexually transmitted disease 

what are the signs of chlamydial (trachoma) conjunctivitis (4)

• Conjunctival scarring

• trichiasis (misdirected eyelashes that turn inward and rub against cornea + conjunctiva)

• corneal ulcers

• Infiltrates, superior pannus, Herbert’s pits (scarred limbal follicles), 2° corneal infections

what are the risk factors of chlamydial (trachoma) conjunctivitis (3)

• Poverty

• crowded living conditions

• poor sanitation

treatment options for chlamydial (trachoma) conjunctivitis (4)

•Public health measures, hygiene

•Systemic & topical antibiotics

•Lubricants

•Consider lid surgery - correct scarring and placement of lids to prevent further corneal infections