2. Infectious Conjunctivitis

Conjunctivitis

Bacterial Conjunctivitis

  • Rapid onset (usually unilateral).

  • Tearing, irritation, grittiness, foreign body (FB) sensation.

  • Vascular engorgement: beefy red appearance that fades towards the limbus (not fully true - can be diffuse) .

  • Thick mucopurulent discharge, leading to crusted and oedematous lids.

  • Fellow eye involvement typically occurs within 2-3 days.

  • Possible mild corneal involvement, such as superficial punctate keratitis (SPK) or peripheral infiltrates.

  • Common Organisms:

    • Staph aureus

    • Staph epidermis

    • Other gram-positive cocci like Strep pneumoniae

    • Moraxella

    • Hemophilus influenzae

mucopurulent discharge
Management

  • Usually a self-limiting disease, resolving in 10-14 days with natural tears and mucous.

  • Topical broad-spectrum antibiotics can expedite resolution in 1-3 days.

  • Lid and eye cleaning are important.

  • Highly contagious, requiring simple hygiene precautions to prevent transmission.

    • Chloromycetin 0.5% (Chlorsig, chloramphenicol) (S3) - Bacteriostatic

      • Days 1 & 2: every 2 hours (q2h) - 1 drop

      • Review in 48 hours

      • Days 3-7: every 6 hours (q6h) - 1 drop, 4 times a day

      • Do not patch the eye

    • Alternative: Soframycin (Framycetin) 0.5%, 2 drops every 1-2 hours, then 2-3 drops every 8 hours (q8h).

Chronic Bacterial Conjunctivitis

  • Often associated with underlying lid disease.

  • Manage the underlying lid disease.

  • If non-responsive or with persistent recurrence, consider lid cultures.

Chlamydia

  • Caused by Chlamydia trachomatis (often called the "silent disease").

  • Sexually transmitted disease (STD) affecting the urethra in males and the cervix in females.

  • Manifestations in the conjunctiva:

    • Ophthalmia neonatorum (conjunctivitis in newborns)

    • Adult inclusion conjunctivitis

    • Trachoma

  • Notifiable disease due to its public health significance.

Ophthalmia Neonatorum

  • Conjunctivitis occurring in the first 4 weeks of life.

  • Typically secondary to chlamydia, gonococcus, or other bacteria acquired during birth; rarely due to Herpes simplex.

  • Prophylaxis involves erythromycin ointment.

  • Rare but serious emergency:

    • Gonococcus can lead to corneal perforation.

    • Chlamydia can lead to pneumonia.

    • Herpes can lead to encephalitis.

  • Characterized by the absence of follicles.

  • Variable postpartum onset:

    • Chlamydia: 5-14 days

    • Gonococcal: 1-2 days

    • Longer for HSV and other bacteria.

Neonatal Chlamydial Conjunctivitis Treatment

  • May be associated with otitis, rhinitis, and pneumonitis.

  • Presents between 5 and 19 days after birth.

  • Manifests as mucopurulent papillary conjunctivitis.

  • Treatment includes topical tetracycline and oral erythromycin + referral

Adult Inclusion Conjunctivitis

  • Sexually transmitted disease (STD).

  • Patients are generally young and sexually active.

  • Approximately 50% or more also have pelvic inflammatory disease (potentially asymptomatic).

  • Affects the cervix in females and the urethra in males.

  • About 1 in 300 individuals with genital chlamydia will develop conjunctivitis.

  • Symptoms:

    • Maybe unilateral or bilateral.

    • Red, irritated eye.

    • Watery to mucopurulent discharge.

    • Possible slight lid oedema.

    • Preauricular lymphadenopathy - tender swelling near earlobe

    • Palpebral conjunctiva initially shows a papillary reaction, followed by the development of large follicles, mostly in the inferior fornix but also possibly on the upper tarsal surface.

    • Keratitis is possible around week 2, with subepithelial infiltrates, marginal infiltrates, and superior limbal pannus.

    • Can become chronic, lasting for months.

Management

  • Referral to an STD clinic for investigations (as it is a notifiable disease).

  • Topical and systemic therapy:

    • Tetracycline ointment.

    • Oral azithromycin (1000mg single dose).

    • Doxycycline (100mg every 12 hours for 7-10 days).

    • Erythromycin (250-500mg every 6 hours for 3 weeks).

Case study - 23 yr old male

  • myope

  • good vision in each eye with rx

  • red irritable eyes

  • discharge evident on waking

  • duration three months

  • no pain or photophobia

    \Diagnosis: adult inclusion conjunctivitis

Trachoma

  • First presentation: mild, mucopurulent, self-limiting conjunctivitis.

  • caused by chlamydia

  • Chronic inflammation; leads to chronic follicular conjunctivitis, papillary hypertrophy (especially on the upper tarsal conjunctiva), pannus, and epithelial keratitis.

  • Repeated infections result in:

    • Scarring and cicatrization of the cornea, conjunctiva, and eyelids (entropion and trichiasis).

  • Linked to poor hygiene conditions, including sanitation issues, crowded living, and livestock proximity.

  • Flies serve as a major vector in the cycle of transmission.

  • Leading cause of preventable blindness worldwide.

  • WHO estimates: don’t need to memorise

    • 146 million with active disease

    • 10 million with trichiasis

    • 6 million blind

Treatment

  • Single oral dose of azithromycin.

  • Hygiene improvement (clean water, fly reduction).

  • Control of trichiasis.

SAFE Strategy (WHO)

  • Surgical management of trachomatous trichiasis.

  • Antibiotics.

  • Face washing to interrupt trachoma transmission.

  • Environment change (water, fly control, sanitation, managing cattle and crowding).

  • Prevalent in Africa, the Middle East, Latin America, Central and Southeast Asia.

  • Australia was the only developed country to still have endemic blinding trachoma.

Trachoma in Australia:

  • Primarily affects remote and very remote indigenous communities in the Northern Territory, South Australia, and Western Australia.

  • The National Trachoma Management Program was initiated in 2006 in Australia to enhance trachoma control, health promotion, and environmental improvement initiatives.

Viral Keratoconjunctivitis

  • Adenovirus

  • Molluscum contagiosum

Adenovirus

  • Ranges from mild to severe ocular involvement:

    • Follicular conjunctivitis

    • Pharyngoconjunctival fever

    • Epidemic keratoconjunctivitis (EKC)

  • Incubation period around 5-12 days

  • Clinical illness for about 5-15 days

  • practitioner hygiene to avoid spread - incredibly contagious. If someone in practice is suspected to have it - ensure proper cleaning of clinic (thorough).

  • Virus killed by alcohol

Follicular Conjunctivitis

  • Mildest form of adenovirus

  • Unilateral initially (spread to other 1-2 days)

    • Bilateral approx 60% cases

  • Watery discharge

  • Conjunctival hyperaemia

  • Mild to moderate burning sensation

  • Follicular response

  • Lymph node involvement

EKC: Epidemic Keratoconjunctivitis

  • Severe and highly contagious - disinfect slitlamps, tonometers, droppers etc.

  • Usually not associated with systemic symptoms, but may be low-grade fever with lymph involvement

  • Usually 7-21 day course

EKC Disease Course

  • First few days - hyperaemic palpebral conj with fine papillae

  • Develops into: ~ 1 week

    • Follicular conjunctivitis in the lower fornix in the first week, later may involve the tarsal surface

    • Watery discharge, hyperemia, chemosis

    • Preauricular lymphadenopathy

    • Subconj haemorrhage, lid oedema

    • Membranes (1/3 cases) - can cause conjunctival scarring and symblepharon

  • Corneal involvement:

    • Diffuse, fine, superficial keratitis (1st week)

    • Focal, elevated, staining epithelial lesions (FB sensation) (days 6-13)

    • Sub-epithelial opacities develop (day 14)

    • Epithelial changes may last 4-6 weeks

    • Subepithelial changes may last weeks - months - years

Pharyngoconjunctival Fever

  • Generally associated with adenovirus 3 and 7

  • Pharyngitis, follicular conjunctivitis and fever (URTI)

  • Preauricular adenopathy (90% cases)

  • Usually self-limiting over 5 - 14 days

  • Follicular conjunctivitis, scant watery discharge, conj hyperaemia.

  • often bilateral (systemic)

EKC and PCF Management

  • Treatment is primarily supportive

  • Usually resolves in 2 weeks

  • Cool compresses and lubricants

  • Antiviral drugs found ineffective

  • Topical antibiotics only reduce the risk of secondary infection - not necessary

  • Review in 5 days

  • No CL wear until 1 week after corneal signs disappear

  • Topical steroids WITH CAUTION (ophthalmologist?) - if vision is affected

  • Topical steroids inhibit or reduce the appearance of subepithelial infiltrates.

  • Infection control

EKC and PCF Management Infection Control: minimise outbreaks

  • Hand hygiene between patients; accessible to all staff in the practice.

  • Clean all equipment surfaces between cases with neutral detergent.

  • Staff instructed that patients with red eyes should not undergo preliminary examination procedures until the clinician has been consulted.

  • Single-dose vials of diagnostic drops to be used and discarded.

  • Tonometry - consider disposable tonometer prisms; disinfect reusable prisms with isopropyl alcohol swabs and air dry between patients; decontaminate at the end of a clinic session by soaking for 10 minutes in 0.05% sodium hypochlorite solution, then rinse and store dry (NSW Department of Health, June 2006).

Molluscum Contagiosum

  • Oncogenic virus (pox virus)

  • Characteristic nodule on lid margin:

    • Single or multiple

  • AIDS patients - multiple lesions

  • Characteristics

    • Small pale waxy umbilicated nodule - passes toxins into the conjunctiva

    • May be distant from lid margin

    • Mild mucoid discharge

    • Conjunctival follicular response on side of lesion

    • Epithelial keratitis and even pannus in long-standing cases

Molluscum Contagiosum Treatment

Refer for destruction of lid lesion:

  • excision

  • cryotherapy

  • cauterization

Benign Folliculosis

  • Common in children

  • Follicles in the inferior cul-de-sac without any other signs or symptoms of conjunctivitis

  • Disappear with age

  • can be bilateral

  • no treatment required