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Ocular diseases > CONJUNCTIVITIS > Flashcards

CONJUNCTIVITIS Flashcards

1
Q

CONJUNCTIVITIS

DEFINITIONS

  • Toxigenicity: ability to elaborate toxic substances
  • Pathogenicity: ability of an organism to cause disease
  • Virulence: ability to exhibit pathogenicity when present in small
    numbers
  • Invasiveness: ability to invade, multiply, and spread

LAB TECHNIQUES

  • Conjunctival cultures: helps to ID organism
    • chocolate agar: best for nisseria (g-)
    • sheep blood agar: best for staph (g+)
    • Also, perform drug sensitivity
  • Conjunctival smear: helps to ID WBC type associated with infection
    • Bacterial: mostly neutrophils
    • Viral: mostly lymphocytes
  • Conjunctival scraping: gets a better sample than a smear, use local anesthetic. Helps
    evaluate cytological response
A

CLINICAL CHARACTERISTICS

  • Hyperemia/hemorrhage
  • Chemosis (swelling)
  • Discharge
  • Papillae (bacterial/allergies)
  • Follicles (viral/toxicity)
  • Membrane/pseudo-membrane
    • Caused by xs fibrin in tears, coagulates
      and forms membrane in palpebral conj
  • Infiltrates/ulcers/flare
  • Posterior synechiae: iris can get stuck to lens due to uveitis
  • Pre-auricular adenopathy
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2
Q

ACUTE BACTERIAL CONCUNCTIVITIS

  • Staph aureus
  • Staph epidermidis
  • Streptococcus pneumonae
  • Haemophilus influenzae
  • Usually unilateral onset, bilateral in a few days
  • 2-3 days duration with signs increasing in intensity

SYMPTOMS

  • Mattered Lashes in AM
  • Mucopurulent discharge
  • Redness
  • No pain, non-specific irritation
A

SIGNS

    • PAN
  • Red meaty conj
  • Clear circumlimbal area
  • Hyperemia greatest at fornices
  • Papillae on palp conj
    • Polymorphoneutrophils
  • Corneal involvement: SPK superiorly/inferiorly

MANAGEMENT

  • Self-limiting (7-10 days)
    • Except persistent s. aureus – can cause chronic blepharitis
  • Warm compresses/lid scrubs BID/TID
  • Lavage: wash eye with saline BID
  • Disco makeup
  • Topical AB soln/ung
    • Ciloxan: Broad spectrum, but treats g-more than g+. gtts.
  • Non-resolving: after 48 hrs of tx, confirm compliance, cultures/sensitivity. Consider non-bacterial infection or 2nd site of infection
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3
Q

HYPERACUTE CONJUNCTIVITIS

  • AKA acute purulent
  • Intense inflammatory changes, overflowing purulent discharge
  • Neisseria Gonorrheae
  • Neisseria meningitis
  • Neisseria can perforate cornea in 24 hrs, pt can lose vision –
  • *emergency**!
  • Co-management with referral

SYMPTOMS

  • Similar to acute, but progresses much more quickly
  • Pain/tenderness
  • Copious discharge
  • Intermittent blurred vision
A

SIGNS

  • Adnexal edema
  • Decreased VA due to xs inflammation/discharge
  • +PAN
  • hyperemic lids, conj
  • excessive mucopurulent discharge

MANAGEMENT

  • Ocular emergency
  • Lab work-up mandated
  • Suspect N. gonorrheae unless proven otherwise (more dangerous strain)
  • Topical AND systemic ABs
  • Fluoroquinolone = “big guns” broad spec
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4
Q

CHRONIC CONJUNCTIVITIS

  • Very common, often overlooked
  • Usually accompanies chronic blepharitis
  • Lingers for several weeks
  • Symptoms highly variable

SYMPTOMS

  • Nonspcific irritation, burning, FBS
  • Lids stuck together in AM
  • Bilateral
  • -PAN
A

SIGNS

  • Lid involvement: madarosis, tyalosis, poliosis
  • Recurrent chalazion, hordeoli
  • Basal collarettes
  • Corneal involvement: SEI, SPK

MANAGEMENT

  • Warm compress/lid scrubs – tapered over time, at least 1x/wk baseline after
  • Topical ABs: polytrim 1 gtt TID, polysporin ung hs1 /4” strip on ll
  • Art tears: several x/day
  • Disco makeup
  • Steroids: tobradex
  • Oral ABs for repeat offenders – doxycycline
  • Pulse treatments (oral ABs)
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5
Q

VIRAL CONJUNCTIOVITIS

ADENOVIRUS

  • SUPER CONTAGIOUS –
    CLEAN ALL YOUR SHIT
  • Usually caused by adenovirus #1-4, 7-14
  • Self-limiting – 3 wks
  • Pharyngoconjunctival Fever

SYMPTOMS

  • Fever
  • Pharyngitis
  • FBS
  • watery discharge
  • redness
A

SIGNS

  • Superficial keratitis
    • ipsilateral PAN (lymphocytes)
  • diffuse hyperemia
  • usually bilateral
  • Follicles on inf palp conj
  • SEI, SPK

MANAGEMENT

  • Avoid contact with others, disinfect office/home
  • Tx is mostly supportive – cold compress for inflammation, art tears for SPK,
    topical decongestant
  • No collarettes, so no need for lid scrubs
  • ABs will make things worse
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6
Q

EPIDEMIC KERATOCONJUNCTIVITIS

  • DNA virus
  • SUPER CONTAGIOUS!!! Use bleach wipes – not alcohol,
    except use 1:9 dakin soln on tonometer tip (dip 20 mins,
    rinse, dry 20 mins)

SYMPTOMS

  • Malaise
  • Starts in one eye, moves to other
  • BFS
  • Copious discharge
A

SIGNS

    • PAN
  • copious discharge
  • conjunctival chemosis
  • pseudo-membrane formation
  • sub-conjunctival heorrhages
  • Acute follicular conjunctivitis
  • Follows rule of 7
    • Week 1: diffuse SPK
    • Week 2: elevated lesions w/ - fl staining
    • Week 3: finally not contagious, diffuse SEIs (-fl)

MANAGEMENT

  • Cold compress, art tears, lavage TID/QID
  • Remove pseudo membrane
  • Week 1: AB TID – prophylactic
  • Week 2: continue lavage/compress/art tears
  • Week 3: steroids for central SEI – long term, tapered
    • Prednisolone acetate: “pred forte” don’t use if high IOPs
    • Loteprednolol: has less effect on IOP, but $$$$
  • Betadine 5% soln: off label use!
    • Stings, use topical anesthetic b4
    • 4-5 gtts, rinse/lavage after 1 min omild SPK is 2ndary due to toxicity
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7
Q

HERPES ZOSTER

  • Adult chicken pox
  • AKA Shingles
  • Activation of latent varicella virus, harbored in DRG
  • Respects midlines, follows dermatomes
  • Can get CP from HZ person
  • Avg age of onset >45
  • Commonly involves thoracic nerve – v painful
  • HZ Ophthalmicus = CNV1
  • Can cause CNVII palsy

SYMPTOMS

  • Skin lesions
  • corneal desensitization
  • diffuse redness
A

SIGNS

  • Hutchinson’s sign: vesicular lesion on nose, has 40% chance
    of going into eye
  • Scleritis
  • Stromal keratitis
  • Uveitis
  • Trabeculitis
  • Episcleritis
  • Pseudo-dendrites
  • Palpebral follicles

MANAGEMENT

  • Oral antiviral – start within 72 hours of skin lesions (most effective, can still use
    after tho)
  • Acyclovir (Zovirax): 800mg 5x/day 7-10 days
  • Valacyclovir (Valtrex): 1000mg TID 7-10 days
  • Famvir (famciclovir): 500mg TID 7-10days
  • Supportive tx for pain (acupuncture,capsacin)
  • Preventative:
    • Zostavax vaccine: reduces risk 50%, need booster shot
    • Shingrix: 2 dosages a few wks apart
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8
Q

HERPES SIMPLEX

  • Type 1: above the waist
    • Transmitted by close contact
    • Lesions on mouth, eye, skin,pharynx mucous membs
  • Type 2: below the waist
    • Transmitted via sex
    • Genital/neonatal infections
    • Can also get into eye
  • DNA virus
  • Infects ectodermal tissue, nerves
  • Lays dormant in CNV, autonomic ganglia, brain stem
  • Primary cause of K blindness in US
  • w/in 2 yrs, 50% will be infected again

SYMPTOMS

  • Watery discharge
  • FBS
  • Redness
  • Unilateral
  • photophobia

SIGNS

  • Follicles
  • +PAN
  • hyperemia
  • random SPK
  • dendrites: end bulbs, tree branch
  • VA may or may not be affected depending on
    location/severity/complications
  • Decreased K sensitivity
A

MANAGEMENT

  • Debridement: remove viral particles from dendrite w/spatula
  • Topical antiviral:
    • Viroptic (triflururidine): ophth soln. 1gtt 9x/day 5-7 days, 1gtt QID 4 days.
      Effective, but toxic – causes SPK on top of dendrite. Give art tears for SPK.
      Must use full rx. Cheaper.
    • Vira A (idoxuridine): ung us, usually in combo w/ viroptic
    • Zirgan (ganciclovir): gel, 0.15%. 5x/day 3-7 days, no tapering. $$$$$$ but
      better compliance, no cytotoxic
    • Acyclovir: avail outside US, ung. can also use acyclovir oral with with
      viroptic gtts
  • DO NOT GIVE STEROIDS – will increase
    replication, prolong healing time

STROMAL INVOLVEMENT

  • Frequent, repeated occurrences
  • Viral particles in stroma cause immune response, cause edema
  • Give topical or oral antivirals
  • NOW you can add topical steroids – pred forte
  • Dendrites are literally fuckin huge – big blob
  • Give low dose oral acyclovir for ~1yr to stop repeated episodes
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9
Q

TRACHOMA INCLUSION CONJUNCTIVITIS

TYPE 1

  • Adult Inclusion Conjunctivitis (Chlamydia)
  • 18-35 yo
  • STD

SYMPTOMS

  • Photophobia
  • Redness
  • Mucopurulent discharge
  • Unilateral

OBJECTIVE FINDINGS

  • Acute follicular conjunctivitis -lower lid, LARGE
  • Bulbar hyperemia
  • SPK, SEI ʹ perip
    • PAN
  • Cytological smear: inclusion bodies
A

MANAGEMENT

  • Oral AB
    • Azithromycin, 1000mg QDA, 1 dose OR DQA/3 days
    • Doxycycline, 100 mg BID 1wk
    • Tetracycline, 250mg QID 3wks
  • Topical AB - recurrences
  • Involve PCP (systemic, partners)

OVERVIEW (Type 1 and 2)

  • Gram negative
  • Mimic both bacterial and viral infections
  • Chlamydia organisms
  • Cyclical stages: active to dormant
  • Common in dev. Countries
  • 3.6% global prevalence (decreasing)
    • Risk: Ethiopia (most affected), Malawi, Nigeria
  • Risk factors: poor sanitation, crowded living,poor hygeine, lack of
    water, dry dusty enviro (spread in villages bc human face fly)
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10
Q

TRACHOMA INCLUSION CONJUNCTIVITIS

TYPE 2 (Trachoma)

SYMPTOMS

  • Unilateral
  • Photophobia
  • Mucopurulent discharge

OBJECTIVE FINDINGS

  • Stage 1:
    • Follicular conjunctivitis- upper lid, cyclical, chronic
      • PAN
  • Stage 2:
    • chronic follicular conjunctivitis => scarring,hypertrophy; goblet cell destruction => dry eye; superior corneal neovasc => pannus, ghost vessles
  • Stage 3 & 4:
    • cicatrization of limbal follicles => ,Herbert’s pits(indented); upper lid scarring => Arlt’s line; entropion => trichasis; secondary corneal infections/ulceration; corneal scarring => blindness (can happen in other eye too)
A

MANAGEMENT

  • SAFE
    • Surgery - entropion
    • Antibiotics ʹ Azithromycin- 30mg/kg 1 dose/yr
    • Facial cleanliness
    • Environment improvement- Access to clean water,
      promo good hygeine

OVERVIEW (Type 1 and 2)

  • Gram negative
  • Mimic both bacterial and viral infections
  • Chlamydia organisms
  • Cyclical stages: active => dormant
  • Common in dev. Countries
  • 3.6% global prevalence (decreasing)
    • Risk: Ethiopia (most affected), Malawi,Nigeria
  • Risk factors: poor sanitation, crowded living, poor hygeine, lack of
    water, dry dusty enviro (spread in villages bc human face fly)
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11
Q

ALLERGIC CONJUNCTIVITIS

VERNAL

  • Type 1 hypersensitivity
  • Two forms: palpebral & limbal
  • Males 2x more affected
  • 3-40yos
  • Seasonal - stops after 10 yrs
  • Hot, dry climates

SYMPTOMS

  • Intense itching
  • Photophobia
  • Ropy, stringy white mucous discharge - constantly wiping
  • diffuse hyperemia

OBJECTIVE FINDINGS

  • Large papillae
    • Cobblestones, 7mm diameter, mid to lower palp conj
  • Ptosis (due to papillae weight)
  • Pannus
  • May have sup cornea neovasc
  • LIMBAL
    • Gelatinous precipitates - elevated
    • Trantas dot - white dot inside
A

MANAGEMENT

  • Vasoconstrictor
  • AH
  • Mast cell inhibitors
    • Takes 3-6 wks to work, stop mast cells from forming
    • OTC or RX
    • 1-2x/day
  • Topical Steroids
    • Pred forte, lotemax, fluoromethylone (FML, mild)
  • Combo drug: AH and Mast cell inhib

OVERVIEW

  • Hypersensitivity to agents that produce just a local irritation to ocular surface
  • Exogenous source: dust, pollen
  • Type 1:
    • anaphylactic/immediate hypersensitivity
  • Type 2: cell mediated rxns
  • Type 3: immune complex, rxns involved may be microbioallergic
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12
Q

ALLERGIC CONJUNCTIVITIS

Atopic
Keratoconjunctivitis

  • Heredity
  • Chronic AI prob
  • 20+ yo

SYMPTOMS

  • Itchy
  • Bilateral
  • Watery discharge
A

OBJECTIVE FINDINGS

  • Scaly, hard, leathery lids bilaterally
    • secondary to constant swelling and hyperemia over years
  • Papillae, not big but may scar
  • Secondary to staph infection
  • Many eosinophils

MANAGEMENT

  • Oral AH
  • Cold compress
  • Vasoconstrictors
  • steroids
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13
Q

Hay Fever (Atopic)
Conjunctivitis

  • exposure to airborne allergens, food, industrial chems
  • seasonal

SYMPTOMS

  • itching
  • burning
  • discharge
  • pronounced chemosis
  • runny nose

OBJECTIVE FINDINGS

  • bulbar conj elevated
  • blanched vessels
A

MANAGEMENT

  • lavage
  • cold compress for itch, BID, 10mins
  • AH for immediate relief
  • Mast cell stabilizer
  • Patanol - Rx
    • AH + Mast cell stab
    • BID, $$$
  • Pataday - Rx
    • AH + Mast cell stab
    • QDA, $$$
  • Zaditor ʹ OTC
    • AH + mast cell stab
    • BID
  • Vasocon-A - generic
    • Itchy/red relief, AH - short term
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14
Q

CL RELATED ALLERGIC CONJUNCTIVITIS

Giant Papillary
Conjunctivitis (GPC)

  • Tarsal conj rx to hard/soft CLs
  • Prosthetic eyes
  • Conj sutures

OBJECTIVE FINDINGS

  • Giant papillae lower lid (move to upper w time) secondary to rubbing => white scarring
  • Hyperemia - palp conj
  • Mucous discharge
  • Intermittently blurry VA
A

MANAGEMENT

  • Go to RGPCs => spectacles
  • Cold compressors
  • Topical AH
  • Mast cell stab.
  • Steroids
    • Pred forte or lotemax
    • QID/1wk Æ BID/1wk => QDA/1wk
  • 2 problems: lens, preservatives in lens cleaning soln
  • CL protein deposits (soft CLs prone)
  • Blink => palp conj rub => abrades lid epi
  • AB-AG rnx => allergic response
  • CL: material, age, reactivity, water content, cleaning regiment
  • Genetic predisposition
  • Seasonal allergy peaks
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15
Q

Drug Induced
Allergic Conjunctivitis

  • Secondary to preservatives - immediate rxn

SYMPTOMS

  • Redness
  • Stinging
  • Burning
  • hyperemia
A

OBJECTIVE FINDINGS

  • diffuse SPK

MANAGEMENT

  • avoid allergen
  • flush out with saline
  • ATs: gtts 6x/1wk; gel 4x/1wk
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16
Q
A

Ocular diseases (5 decks)

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