Disorders of conjunctiva

Question 1

RED FLAGS OF CONJUNCTIVITIS

Answer 1

RED FLAGS AND ASSESMENT SAME FOR ALL

Red flags which = urgent ophthalmological assessment:
- Reduced visual acuity
- Marked eye pain, headache or photophobia — sus systemic conditions (eg meningitis - photophobia).
- Red sticky eye in a neonate
- Hx of trauma (mechanical, chemical or UV) or possible foreign body.
- Copious rapidly progressive discharge can = gonococcal infection.
- Infection with a herpes virus.
- Soft contact lens use + corneal symptoms (eg photophobia, watering).

Question 2

Assessment/ Diagnosis for ALL

Answer 2

Eye examinations
History taking - SOCRATES

Question 3

Bacterial conjunctivitis

Answer 3

Signs and symptoms:
- an acute onset of redness,
- foreign body sensation,
- mucopurulent discharge
- eyelid crusting on waking.

Normally bilateral.

SELF LIMITING condition usually resolves in 10-14 days (BNF, nice says 5-7 days.

Treatment:
Severe: topical antibiotics – (symptoms >3 days):
For ALL, continue 48 hours after infection has gone

• Chloramphenicol 0.5% drops – 1 drop every 2 hrs for 2 days then reduce depending on severity 3-4 times/day usually enough.
• Chloramphenicol 1% ointment – TDS – QDS
• Fusidic acid 1% eye drops- 1 drop BD.

IN NEONATES need to be urgently referred (same day).

Question 4

Viral conjunctivitis

Answer 4

Highly infectious - SELF LIMITING
Signs and symptoms:
- acute onset
- with a watery mucous discharge,
- conjunctival hyperaemia and
- lid oedema.
- Mild/ moderate itching
Can be periauricular lymphadenopathy or subconjunctival haemorrhage (escape of blood from ruptured blood vessel)

Caused by: adenovirus (most common),

Treatment:
Self limiting resolves in 2-3 weeks (CKS - 7days)
- Advise on bathing/cleaning eye lids with cotton wool soaked in sterile saline/ boiled and cooled water to remove discharge,
- Cool compresses around area,
- lubricating agents or artificial tears.
AVOID ANTIBIOTICS.
Contagious - avoid close contact with others, separate towels, wash hands regularly.

Question 5

Allergic conjunctivitis

Answer 5

Type I hypersensitivity (IgE cross link - mast cell destabilise - histamine etc release) immune response is normally caused by allergens eg airborne pollen.

Signs and symptoms:
- Watery or mucoid discharge — ‘tearing’. Stringy or ropey discharge due to small amount of mucous.
- Conjunctival redness
- Conjunctival swelling
- Conjunctival papillary reaction.
- Eyelid oedema (swelling) — periorbital oedema can in severe.

Can happen with other atopic condition.
Types of severe - Vernal or Atopic - keratoconjunctivitis,

Treatment:
Non pharmacological 1st line-
- Avoid allergens, eye rubbing,
- do cold compresses,
- lubricants or artificial tears.
FAIL THEN – topical antihistamine + vasoconstrictor, mast cell stabilisers. Topical Ocular diclofenac

Review non pharm in 1 week time.

DRUGS:
Mast cell stabilisers - Sodium cromoglicate (QDS), Lodoxamide (>4yrs QDS)
Antihistamine- Antazoline (>12yrs BD-TDS MAX 7 days)
Mast cell + Antihistamine - Azelastine (>4 BD-QDS), Epinastine (>12 BD MAX 8 weeks), Ketotifen (>3 BD), Olopatadine (>3 BD MAX 1 month)

Topical Ocular diclofenac - Symptoms relief for seasonal type. 1 drop QDS PRN

Question 6

Adults’ chronic conjunctivitis

Answer 6

Chronic if its duration >4 weeks
Common causes: gonococcal or chlamydia infection

Treatment
Non pharmacological if no improvement THEN -
topical antihistamine or dual action (mast cell stabilisers + topical antihistamines)
(Mast cell stabilizer in recurrent/persistent symptoms)

Question 7

Neonatal conjunctivitis

Answer 7

Gonococcal version very rare. Chlamydia/Gram -ve rod version more likely

Treatment
Most cases self-limiting, Azithromycin, erythromycin
Chlamydia A- BD 3 days Review if no improvement. E - used as protection from other conditions <3months age - Oral

Need to be referred to prevent complications and find causative organism.

Question 8

Conjunctivitis - contact lens wearer

Answer 8

If topical fluorescein does not identify any corneal staining and dont need referral:
Advise STOP wearing lens.
Advise regular cleaning of eye with cotton wool soaked in sterile saline.
Treat infection -
Topical antibiotic effective vs gram -ve eg aminoglycoside (gentamicin) or quinolone (levofloxacin, moxifloxacin).

Question 9

Dry eye syndrome

Answer 9

Chronic condition
Types= Evaporative(>common), Aqueous deficient.
Characterized by a loss of homeostasis of the tear film with reduced tear production or tear film instability, with ocular discomfort and/or visual symptoms.

Tear film layers =
Innermost mucin - allows tears to adhere to the conjunctival surface
Middle aqueous - 90% of tear thickness
Outermost lipid - helps slow aqueous layer evaporation

Signs and symptoms:
Eye irritation, itching, or discomfort; eye dryness; transient blurry vision; and watery eyes. Eye redness or mucous discharge, GRITTY/sandy feeling

Risk factors:
>50yrs, Women, Contact lens use, diet low in VIT A

Treatment
Same for all ages. Depends on patient preference
MILD:
- HYPROMELLOSE - most used for tear deficiency (low viscosity)
ALT - Carbomers, PVA - these cling to eye surface and higher viscosity so less applications (QDS). Carbomer less tolerated than hypromellose BC impact vision.

MODERATE - SEVERE:
- sodium hyaluronate, hydroxypropyl guar, or carmellose sodium after TRIAL of mild options 6-8 weeks.

Ointments (contain paraffin) can be used in addition to lubricate eye surface. - can cause visual issues best use B4 sleep. DONT use during contact lens usage.

Follow up in 4-6 weeks.

Refer if: Red flags, uncertain diagnosis, sus underlying cause, abnormal lid anatomy, persistent symptoms dont respond to treatment after 1 to 3 months.