bacterial conjunctivitis

conjunctival anatomy

1. thin and clear mucus membrane that covers posteirior portion of eyelid

2. lubricate

3. protect

4. provide nutrition

5. prevents friction btw eye and lids

brief blood supply review

anterior ciliary artery —> posterior conjunctival artery —>peripheral and marginal tarsal arcades

whats the venous drainge

inferior and posterior ophthalmic veins

where does lateral canthus drain

superficial parotid lymph nodes

where does medial canthus drain

submandibular lymph nodes

bacterial conjunctivitis risk factors

1. generally develop from exogenous contaminatino or from the bodys ocular surface flora

2. mostly seen as acute but can be present as hyperacute or chronic

whats this

mucopurulent discharge

whats pathoneumonic for bacterial conjunctivitis

mucopurulent discharge

what is mucopurulent discharge

A collection of tears and immune cells that are over expressed

whats the most common cause of acute bacterial conjunctivitis in ADULTS

-Staphylococcus Aureus-

what are signs of bacterial conjunctivitis

1. lid edema

2. sub conjunctival hyperemia

3. chemosis

4. foreign body sensation

5. mucopurulent discharge 2 most defining things

6. palpebral conjunctival papillae and hyperemia

classication of staph auereus

• gram + bacteria w spherical/cocci shape

• asymmetric onset but can become bilateral

• MOST COMMON IN ADULTS

diagnosis w staph aureus

1. blood agar plate or mannitol salt agar plate

streptococcus pyogenes conjunctivitis

1. • Mucopurulent discharge

2. • Conjunctival papillae

3. • Conjunctival hyperemia

4. • Chemosis

5. • Foreign body sensation

6. • Lid Edema •

7. Pseudo-membranes

whats a pseudomembrane

1. EASILY peeled off

2. NO bleeding

Corynebacterium Diphtheriae Conjunctivitis signs and symptoms

• Mucopurulent discharge

• Conjunctival papillae

• Conjunctival hyperemia •

Chemosis

• Foreign body sensation

• Lid Edema

• Membranes

Corynebacterium Diphtheriae

1. can penetrate cornea

2. Gram Positive (+) that is clubbed shaped

membrane

1. DIFFICULT to peel off

2. will cause conjunctival bleeding

why should we worry about membranes

1. palpebral conj can stick to bulbar —→ symblepharon

   1. can cause scarring

2. can possibly speed up healing if removed

3. can use cotton tip applicator/jewlers forceps

how do you treat acute bacterial conjunctivitis

4th generation Fluoroquinolone - 1 gtt TID for 5-7 days

• -Besifloxacin 0.6%

• -Gatifloxacin 0.5%

• -Moxifloxacin 0.5%

pregnancy category C

whats the MOA of 4th gen Fluoroquinolone-

MOA- inhibits DNA replication of bacteria by targeting enzymes DNA Gyrase and Topoisomerase IV

Good broad spectrum coverage

whats the contraindication for 4th gen Fluoroquinolone-

-Damage to growing cartilage in children

-Tendonitis and tendon rupture

what other than 4th gen fluorofquinolones can be used for acute bacterial conjunctivitis

Polymyxin B/Trimethoprim 1 gtt QID for 5-7 Days

Pregnancy Category C

MOA of Polymyxin B/Trimethoprim

Polymyxin B- binds to phospholipids in gram-NEGATIVE bacteria Trimethoprim- inhibits tetrahydropholic acid (THF) by binding to dihydrofolate reductase (DHFR) –effective with mostly grampositive bacteria and some gram NEGATIVE bacteria

if he gives an allergy give a back up

who is Polymyxin B/Trimethoprim for acute bacterial conjunctivitis good for

kids

whats the f/u for Acute Bacterial Conjunctivitis

• every 2-3 days initially

• then 5-7 days until resolved

  • once we see that it is working

hyperacute bacterial conjunctivitis cause

Neisseria Gonorrhea

CULTURE W CHOCOLATE AGAR

Neisseria Gonorrhea classification

1. gram - that is diplococcus/kidney bean shaped

2. acquired by sex

what does hyperacute mean

you wipe away the discharge and it comes back instantly

signs/symptoms of Hyperacute Bacterial ConjunctivitisNeisseria Gonorrhea

1. • Hyperacute mucopurulent discharge

   1. • ****When you remove, it reappears almost instantly**** •

2. Conjunctival papillae

3. • Pre-Auricular Adenopathy

4. • Severe conjunctival hyperemia

5. • Chemosis

6. • Corneal ulceration and possible perforation •

7. Foreign body sensation •

8. Severe Lid Edema

chemosis

swelling of conj

looks bubbly

how do you diagnose hyperacute bacterial conjunctivitis - neisseria gonorrhea

chocolage agar

thayer martin agar

what are the bacteria that can penetrate the cornea

1. Neisseria Gonorrhea

2. Neisseria Meningitidis

3. listeria species

4. Haemophilus influenza

5. corynebacterium diphtheriae

diagnosis of Gonococcal Conjunctivitis

• Confirmed by microbiology- Gram stains, PCR and culturing media including blood agar, chocolate agar and Thayer-Martin agar

how do you treat Gonococcal Conjunctivitis

1. • Would recommend consultation with infectious disease specialist

   1. • Treatment would include single dose 1g of cephtriaxone IM and azithromycin 1g P.O

   2. • If severe with corneal involvementtopical gtts include Fortified antibiotics(Tobramycin and cephazolin) and 4th generation FQ q1-2 hours

in reality we are probably not treating this - get them out adn report to department of public health

Follow Up Schedule for Gonococcal Conjunctivitis

1. wo/ corneal involvement —> every 2 days

2. serious corneal involvement —> every day

Hyperacute Conjunctivitis - Haemophilus Aegyptus

does the same thing just very aggressive

not as much as neiserria gonnorhea

hes not really focusin gon it = many types of bacterial cause many things

when does acute bacterial conjunctivitis go away

1-2 weeks

hyperacute too (about)

chornic bacterial conjunctivitis is characterized by

injection

discharge,

swelling

foreign body sensation

and papillae of the tarsal conjunctiva

persisting 2-3 weeks or longer

chlamidyal trachomatis

1. GRAM NEG

2. subtypes

   1. subtypes A-C = trachoma

   2. subtypes D-K = inclusion conjunctivitis

trachoma

1. superior palpebral conjunctivitis

2. vector is a fly

   1. seen more in regions w limited acess to water and sanitation

3. affects children more

signs of trachoma

1. chronic inflammation w large follicles/papillae on superior palpebral conj and scarring

   1. Arlt Line = horizontal scaring in conj ***************

   2. herberts pits = scarred limbal follicles **************

PATHONEUMONIC

inclusion conjunctivitis

1. oculo genital transmitted condition (HENCE subtypes D-K)

   1. more typically unilateral

   2. follicles/papillae on INFERIOR PALP CONJ

   3. can exhibit keratitis w SEI

2. can confirm w nucleic acid amplification test

how do you treat trachoma

1. doxycycline 100mg BID PO for 2 weeks,

2. or

3. Azithromycin 20mg/kg PO single dose

how do you treat inclusion conjuctivitis

Treat with doxycycline 100mg bid x 7-10 days

or

single dose of 1g azithromycin PO,

contraindications of doxycycline

1. Avoid in children, liver and kidney problems

2. teeth discoloration/enamel defect

3. – -Pregnancy Category D

4. -Side effects could include nausea/vomiting,

5. photosensitivity

pediatric bacterial conjunctivitis - MOST is caused by

H. influenza - bacteria

• similiar signs and symptoms as previous conjunctivitis

  • papillary

follicles vs papillae

1. follicles are big and mounded

   1. single feeder blood vessels

2. papillae are velvety

   1. bunch together

is pediatric bacterial conjunctivitis contagious

HIGHLY

how do you treat pediatric conjunctivitis

Polymyxin B/Trimethoprim 1 gtt 4-6 times per day (depending on severity) for 7-10 days

Great safety profile in children

Follow up every 2-3 days- must avoid interaction as it can be highly contagious

whats another pediatric bacterial conjunctivitis causer

streptococcus pneumoniae

category A

No evidence to fetus in 1st trimester or later

category X

Fetal abnormalities or toxicity in animal studies or human studies, and risk outweighs the benefits

what bacteria are acute, hyper acute, and chronic

acute = staph auerues (around eye)

hyperacute - gonnorrhea

chronic = chlamydia