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MANAGEMENT OF THE DIFFERENT TYPES OF BACTERIAL AND VIRAL CONJUNCTIVITIS PRESENTED BY

MANAGEMENT OF THE DIFFERENT TYPES OF BACTERIAL AND VIRAL CONJUNCTIVITIS PRESENTED BY DR DURUEWURU KYRIAN. OUTLINE INTRODUCTION - Definition,Brief anatomy and Natural defence mechanism of the conjunctiva CLASSIFICATION -BACTERIAL CONJUNCTIVITIS; Clinical types and management

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MANAGEMENT OF THE DIFFERENT TYPES OF BACTERIAL AND VIRAL CONJUNCTIVITIS PRESENTED BY

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  1. MANAGEMENT OF THE DIFFERENT TYPES OF BACTERIAL AND VIRAL CONJUNCTIVITIS PRESENTED BY DR DURUEWURU KYRIAN

  2. OUTLINE INTRODUCTION-Definition,Brief anatomy and Natural defence mechanism of the conjunctiva CLASSIFICATION -BACTERIAL CONJUNCTIVITIS;Clinical types and management -VIRAL CONJUNCTIVITIS; Clinical types and management CONCLUSION

  3. INTRODUCTION DEFINITION; Conjunctivitis (pink eye) is the inflammation of the conjunctiva,usually associated with a discharge which may be watery, mucoidor purulent. ANATOMY; The conjunctiva is a transparent mucous membrane lining the inner surface of the eyelids and surface of the globe as far as the limbus.It is a richly vascular tissue,suppliedby the anterior ciliary and palpebralarteries(via the two palpebral arches in the eye lids)with venous drainage to the palpebral or ophthalmic veins,andlymphatics draining to the pre-auricular and submandibular lymph nodes. There are 3 parts viz; -palpebralconjunctiva -the fornices -bulbar conjunctiva(and limbus)

  4. The histological layers are;the epithelium(2-3 layers) and the substantiapropia(consisting of superficial adenoidal layer and deep fibrous layer,and contains goblet cells that secrete mucus for lubrication). NATURAL DEFENCE These protect the tissue from infections and other pathologies. 1.Low temperature due to exposure to air. 2.Physical protection by the lids 3.Flushing action of the tears. 4.Antibacterial activity of lysozymes. 5.Humoral protection by the immunoglobulins(IgA) in the tears. 6.Mechanical action of blinking, which occurs every 7 seconds.

  5. CLASSIFICATION Based on etiological factors ,can be classified as; -.Infective; which can be bacterial ,viral, chlamydialor fungal, -allergic -traumatic -associated with skin disease -associated with systemic disease -idiopathic

  6. BACTERIAL CONJUNCTIVITIS This is bacterial infection of the conjunctiva.Can occur sporadically, or as an epidemic.Constitutes about 15% of all conjunctivitis. PREDISPOSING FACTORS; -flies, -poor personal hygiene -hot dry climate -poor environmental hygiene These help the infection to establish as the disease is highly contagious. ETIOLOGICAL ORGANISMS; While some produce pus(pyogenic),others don’t(non-pyogenic).The pyogenic ones include; -Staphylococcus aureus(and epidermidis) -Streptococcus pneumonia (and pyogenes) -Haemophilius influenza , -Escherichia coli -Pseudomonas aeroginosa -Neisseriae gonorrhea (and meningitidis) Non-pyogenicones include; Corynebacteriumdiphteriae,mycobacteria tuberculosis and leprae,treponemapallidum,andmoraxella lacunae.

  7. MODE OF INFECTION Conjunctiva may get infected from 3 sources; 1.Exogenous infection; - directly from close contact as air-borne or water-borne -through vector transmission like flies -through material transfer like infected fingers,towels,handkerchief and tonometers. 2.Local spread; from surrounding structures like infected lacrimalsac,lids, nasopharynxand even the normal flora of the conjunctiva. 3.Endogenous infection; through blood,(though rare),as seen in meningococcal infections.

  8. PATHOLOGY 1.Vascularr response;congestion and increased vascular permeability with proliferation of capillaries. 2.Cellular response;exudation of neutrophils and other inflammatory cells into substantial propria of conjunctiva and its sac. 3.Conjuntival tissue response; These include edema,degeneration of superficial epithelial cells,and proliferation of mucin secreting goblet cells of the basal layer. 4.Conjunctival discharge;Consisting of tears,mucus,inflammatorycells,desquamated epithelial cells,fibrin,andbacteria.Ifsevere,there may even be diapedes of red blood cells,leading to blood-stained discharge.

  9. CLINICAL TYPES The hallmark of bacterial infection of the eye are rapid onset, redness ,discharge, soreness ,and usually with good visual acuity and likely secondary corneal involvement.It is usually bilateral.The clinical types include; A.Acutemucopurulent B.Acute purulent(including ophthalmianeonatorium) C.Acutemembraneous (and pseudomembraneous) D.Chronic conjunctivitis

  10. A.Acutemucopurulent(or catarrhal)conjunctivitis This is the most common.There is marked hyperaemia,withmucopurulent discharge from the eyes. Symptoms ; -eye discomfort and foreign body sensation due to engorged vessels -mild photophobia -mucopurulent discharge -lids stick together when asleep -slight visiual blurring(due to mucous flakes in front of cornea) -sometimes, coloured hallows due to the prismatic effect of the mucus in front of the cornea.

  11. Signs; This usually start in one eye and spread to the other. -conjunctival congestion which is usually more in the palpebral,forniceal and the peripheral part of bulbar conjunctiva, leading to “fiery red eye” appearance.Thus,less in the circumferential zone. -chemosis -petechialhaemorrhage in (pneumococcal infection). -mucous flakes in fornices,thecanthi and lid margins. -eye lashes usually matted together with yellow crusts.(due to the discharge) Prognosis; The condition usually peaks in 3-4 days,andusually self-limiting in 10-15 days.May eventually progress to chronic catarrhal conjunctivitis. Complications; May form superficial keratis,blepharitis,dacryocystitis or occasionally,marginal corneal ulcer.May become chronic.

  12. Lab investigations This is not always indicated except in cases of -severe purulent conjunctivitis, -follicular conjunctivitis -conjunctival inflammation in which the clinical picture is not distinctive enough to suggest an etiology -neonatal conjunctivitis. The relevant investigations include; -swab microscopy,culcure and sensitivity -cytology -inoculation -antigen detection(viral or chlamydial) -polymerase chain reaction(PCR)

  13. GRAM STAIN Gram stain is usually done to aid in classification of bacterial etiological agents, and in microscopy. The process involves -Collecting the swab sample -make a smear -fix the smear by heating -cover with crystal violet -wash off with water (do not blot) -cover with lugol’s iodine (both gram positive and negative ones are blue at this stage) -wash off with water -decolourise with alcohol (and acetone) for 10-30s.At this stage,the gram +ves remain blue,while the gram –ves are decoulorised -wash off with water -counter stain with 2.5% safranin (red colour) for 10-30s

  14. -wash with water -allow to air dry -then view with microscope (under oil immersion) The gram positive bacteria appear purple, while the gram negatives appear red. Thus,the etiological agents of bacterial conjunctivitis can be classified thus; Gram positive cocci; staphylococcus aureus,(and epidermidis) ,streptococcus pneumoniae (and pyogenes) Gram positive bacilli; clostridia and corynebacteria Gram negative cocci;moraxella and neisseria Gram negative bacilli;E.coli, and pseudomonas Gram negative cocobacilli; H.influenza Non-staining;treponema, mycobacteria spp.

  15. Treatment; -May need to take eye swab for microscopy,culture and sensitivity -Topical antibiotics like 1% Chloramphenicol,0.3% Gentamycin,0.3% Ciprofloxacin,0.3% Ofloxacin,andFramycetin.There eye drops are usually given every 3-4hourly,while the ointments are given noctae -Irrigate the conjunctival sac 1-2x everyday with sterile warm saline to remove deleterious materials.(However,frequent washing removes the lysozyme!) -Use of dark goggles is advocated to reduce photophobia -Avoid steroids because of immunosuppression -Avoid use of bandage (or padding)in other to keep the eye cool and allow the discharges to escape. -Use analgesics(usually oral or topical NSAIDS) to reduce pain and inflammation -However,the disease is self-limiting in 10-14days,but with treatment,can resolve in 3 days.

  16. B.Acute purulent(acute blenonorrhoea or hyperacute) conjunctivitis There are 2 forms of this variety of bacterial conjunctivitis;Adult variety and ophthalmic neonatorium. B1.Adult acute purulent conjunctivitis Mainly caused by gonococcus,(though staph.aureus and pseudomonas spp. can be involved too in rare occasions) Clinical features This has 3 clinical stages viz; 1.Stage of infiltration,usually the first 4-5 days.The eye ball becomes painfull and tender,conjunctivais bright red velvetlychemosed, eye lid tense and swollen,discharge watery or serosanguinous,with pre-auricular lymphadenopathy.

  17. 2.Stage of blenorrhoea which starts from the 5th day and lasts several days.There is frankly purulent,copious, thick discharge running down the cheeks.Other symptoms are increased but tension in the lids are reduced. 3.Stage of slow healing,characterized by slow subsiding of pain and lid swelling. Conjunctiva remains red and discharge diminishes slowly.Finally,resolution is completed. Complications; 1.Corneal involvement as gonnoccocus can easily invade an intact cornea.Thus,could be in the form of corneal edema,centralnecrosis,corneal ulceration or even perforation. 2.Iridocyclitis. 3.systemic involvement(rare) in the form of gonorrhea arthritis,endocarditis and septicaemia.

  18. Treatment -Systemic antibiotics indicated,such as I.V.Ceftriaxone 1g b.d. for 5days or Oral Norfloxacin 1.2g q.d for 5days, Then followed by Tab erythromycin 250-500mg q.d. -Other measures as in the acute mucopurulent variety. -If cornea is involved,Topical Atropine eye-drop is used b.d. -Patient and the sexual partner(s) should be reffered to the infectious disease unit of medical department for further evaluation.

  19. B2.Ophthalmia neonatorium This is the bilateral inflammation of the conjunctiva occurring in a neonate.Souces of infection can be -before birth -during the birth process -after birth It is a notifiable disease!! Etiological agents; These are gonococcus,staphylococcusaureus,streptococcushaemolyticus and pneumococcus. However,can also be caused by chemicals,chlamydia and herpes simplex virus Incubation period varies,depending on the agent.Gonococcal is 2-4 days,while other bacteria are usually 4-5 days.

  20. Clinical features; -Pain(excessive crying) and tender eyeball -discharge which is purulent(in gonococcal) or mucopurulent(others).Can actually spurt out when the eyelids are parted. -swollen lids -conjunctiva is hyperaemicand chemosed. Complications; This is mainly in the form of corneal ulceration, which may rapidly perforate,leading to corneal opacification or formation of staphyloma.Can cause blindness in neonates.

  21. Treatment; Prophylacticmeasures are; - Antenatal(maternal care and treatment of genital infections), -Natal(aseptic delivery technique,and thorough cleaning of the neonate’s closed eyelids) -Postnatal(Instill topical erythromycin into neonate”s eye just after birth,and if mother is infected,give systemic antibiotics) Curative treatment; -take swabs for culture -saline lavage hourly till discharge ceases -topical antibiotics every hourly for the first 24 hours ,then every 2 hours for day 2,thereafter,6 hourly for the next 10 days. -systemic antibiotics,especially if due to gonococcalinfection eg, IM Cefatixime 100mg/kg start.

  22. Acute membranous conjunctivitis It is an acute inflammation of the conjunctiva, characterized by formation of a true membrane on the conjunctiva. Now-a-days it is very rare because of markedly decreased incidence of diphtheria.This is due to the fact that immunization against diphtheria is very effective. Etiology The disease is typically caused by corynebacteriumdiptheriae and occasionally by virulent type of streptococcus haemolyticus. Pathology Corynebacteriumdiptheriae produces a violent inflammation of the conjunctiva,associated with deposition of fibrinous exudates on the surface as well as in the substance of the conjunctiva resulting in formation of a membrane .Usually membrane is formed in the palpebral conjunctiva. There is associated coagulative necrosis, resulting in sloughing of membrane. Ultimately, healing takes place by granulation tissue.

  23. Clinical features The disease usually affects children between 2-8 years of age who are not immunized against diphtheria.The disease may have a mild or very severe course.The child is toxic and febrile. The clinical picture can be divided into 3 stages; 1.stage of infiltration characterized by -scanty conjunctival discharge and severe pain -lids swollen and hard -conjunctiva red,swollen and covered by a thick yellow membrane(which bleeds on removal) -enlarged pre-auricular lymph node. 2.Stage of suppuration in which pain decreases and lid become soft.The membrane is sloughed off,leaving a raw surface.There is copius purulent discharge 3.stage of cicatrisation,in which the raw surface covered with granulation tissue re-epithelised.Healing occur by cicatrisation which may cause trichiasis and conjunctivalxerosis.

  24. Complications; Include corneal ulceration,symblepharon,trichiasis,entropion and conjunctivalxerosis. Treatment; -topical antibiotic eye drops (and ointment at bed time) -atropine ointment if corneal ulceration -systemic penicillin b.d. for 10 days. -antidiphteric serum given both topically and intramuscularly.

  25. Pseudomembranous conjunctivitis In this variety,there is formation of a pseudomembrane on the conjunctiva.This can easily be peeled off,leaving behind intact conjunctival epithelium with no bleeding(unlike that of membranous in which there is bleeding on peeling). Etiology; -corynebacterium diphtheria(low virulence) -staphylococcus aureus -streptococcal organisms -haemophilus influenza -neisseria gonorrhea Others are some viruses(herpes simplex and adenovirus) and some chemicals like acid.

  26. Pathology; These agents produce inflammation associated with pouring of fibrinous exudates on its surface,which coagulates and form a pseudomembrane. Clinical features; These are just as in acute mucopurulentconjunctivitis.However,thin yellowish-like ‘membranes’ are seen in the fornices and on the palpebral conjunctiva. Treatment; As in mucopurulent conjunctivitis

  27. Chronic bacterial conjunctivitis Predisposing factors include -chronic exposure to dust,smoke and chemical irritants -local irritants like trichiasis,foreignbody,etc -excessive straining of the eyes due to refractive errors,phoriasis,etc -alcoholic abuse,insomnia and metabolic disorders. Etiology; Mainly staphylococcus aureus.Rarely,E.coli and klebsiella spp.

  28. Mode of infection; -Poorly treated acute conjunctivitis -From associated chronic rhinitis,dacrocyctitis or upper respiratory tract infection -mild exogenous eye infection Symptoms; -burning and gritty sensation of eye -mild long-standing redness of eyes -heat and dry sensation on lid margin -mild mucoid discharge -sleepy sensation of the eye -difficulty in keeping eye open

  29. Signs; -grossly appears normal -careful examination might reveal conjunctival surface stickiness,congestion of posterior conjunctivalvessels,congested lid margins,and mild papillary hypertrophy of the palpebral conjunctiva. Treatment -treat\eliminate predisposing factors -topical antibiotics 3-4 times daily for about 2 weeks -symptomatic relief with astringent eye drops

  30. VIRAL CONJUNCTIVITIS Viral infections of the eye tend to affect both the conjunctiva and the cornea as well,thus the term viral keratoconjunctivitis. While the conjunctival lesion is more prominent in some viral infections(as in pharyngo-conjunctival fever),that of cornea is more prominent in cases like herpes simples.Its usually bilateral. Etiology; -Adenovirus -Herpes simplex(and zoster) -Pox virus -Myxovirus -Paramyxovirus -ARBOR virus

  31. TYPES Viral conjunctival infections usually present as acute infections.There are 3 clinical forms of acute viral conjunctivitis; -acute serous, -acute haemorrhagic, -acute follicular. Acute serous conjunctivitis This is a mild grade viral infection which does not give rise to follicular response. Clinical features; Minimal redness,watery discharge and swollen conjunctiva Treatment; Self-limiting. Prophylactic broad spectrum antibiotics used to prevent bacterial super-infection.

  32. Acute haemorrhagic (epidemic haemorrhagic) conjunctivitis This is popularly called APOLLO conjunctivitis because it’s first epidemic form was noticed in Ghana around the time when Apollo XI spacecraft returned from the moon( in 1969),thus raising the speculation that the spacecraft brought the etiologic agent from the moon. Etiology;Picornavirus (enterovirus type 70) which are RNA viruses. Incubation period is very short (1-2) days Symptoms; Sudden onset of pains, redness ,watery discharge, mild photophobia, transcient visual blurring and lid swelling. Signs;conjunctival congestion, chemosis,multiple bulbar haemorrhages, mild follicular hyperplasia, lid edema and pre-auricular lymphadenopathy. Complication;Corneal involvement as fine epithelial keratitis Treatment; The infection is highly contagious and therefore,prophylactic measures are very important.Its usually self-limiting in 5-7 days.No known cure,butbroadspectrum antibiotics are used to prevent secondary bacterial infection.

  33. Acute follicular Associated with marked follicular hyperplasia especially of the lower fornix and lower palpebral conjunctivitis. Symptoms;redness,watery,mucoiddischarge,mild photophobia and feeling of foreign body in the eye. Signs;conjunctivalhyperaemia,with multiple follicles (mainly in the lower lids). Clinical sub-types;Based on etiologic agents -Epidemic keratoconjunctivitis (EKC)by adenovirus type 8 and 19.(incubates for 8 days).Highly contagious,and presents as acute serous,laterfollicular,and then pseudomembraneousconjunctivitis.Corneal involvement is common and occur as “superficial punctuate keratitis”.

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