Definition. Acute inflammation of the conjunctiva due to either viral or bacterial infection

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2 Acute Conjuctivitis

3 Definition Acute inflammation of the conjunctiva due to either viral or bacterial infection

4 Viral causes Causes include adenovirus, Herpes simplex. Bacterial causes include Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae.. Ophthalmia neonatorum is conjunctivitis secondary to gonorrhoea or chlamydia within the first month of life.

5 Incidence Conjunctivitis is the most common cause of 'red eye'. Conjunctivitis accounts for around 44% of all eye problems presenting in general practice [Manners 1997]. 2-5% of all general practice consultations are eye related [Manners 1997]. Viral conjunctivitis is more common than bacterial conjunctivitis [Baum 1995].

6 Symptoms and Signs: I 'Red eye' (diffuse conjunctival injection). Eye discomfort/burning/gritty sensation (not painful). Minimal pruritus. Vision is usually normal - although 'smearing', particularly on waking, may be common. Photophobia mild or absent.

7 Symptoms and Signs: II May be unilateral or bilateral, although usually starts in one eye (not discriminatory of cause). Association with URTI, watery discharge, and preauricular lymphadenopathy are suggestive of viral cause. A purulent discharge suggests bacterial cause. History of contact with similarly affected person is common.

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10 Causes of Red Eye Acute Glaucoma Anterior Uveitis/Iritis Corneal Inflammation/ ulceration Corneal Trauma or infection Episcleritis/ Scleritis Dry eye Conjunctivitis Sub conjunctival haemorrhage Blepharitis Contact lens complications

11 Serious Red Eyes Acute Glaucoma Iritis/Uveitis Penetrating Trauma Microbial Keratitis Pain,reduced vision and unreactive pupil. Haloes around lights. Blurred vision, photophobia, deep boring pain. Reduced vision and history of trauma. Pain in excess of signs, reduced vision, photophobia.

12 Acute Glaucoma Symptoms of poor vision,pain,nausea and haloes around lights. Fixed pupil and redness with corneal haze.

13 Iritis/Uveitis Symptoms of boring pain, poor vision and photophobia. Peri-limbal congestion and A/C inflammation

14 Serious Trauma Pain may be minimal or intense, but vision reduced and history of acute onset following trauma.

15 Microbial Keratitis Considerable pain with reduced vision, photophobia and central corneal infiltrate. Usually history of recent contact lens wear.

16 Common Factors in Serious Red Eye Significant Pain Reduced Vision Photophobia

17 Scleritis/Episcleritis Episcleritis is benign and usually presents as a gritty or uncomfortable brick red eye.this is often misdiagnosed as bacterial conjunctivitis Scleritis can be very serious and patients present with often intense radiating pain and redness, which cannot be blanched with phenylepinephrine.

18 Episcleritis A focal nodular Episcleritis. Note brick red locally inflammed mobile vessels.self limiting in 2-3 weeks.

19 Scleritis Deep vessel inflammation and symptoms of deep chronic pain often associated with systemic diseases.

20 Types of Conjunctivitis INFECTIVE Can be bacterial,viral or chlamydial ALLERGIC Seasonal, perennial, vernal, atopic or Giant Papillary (associated with CL,s) INFLAMMATORY Reiters syndrome, oculocutaneous.

21 Is it pink, red or bloody red? Bloody red eyes are usually sub conjunctival haemorrhages.

22 Corneal or Conjunctival Infection? Conjunctivitis produces a generally pink eye but corneal involvement causes circumlimbal redness.

23 Is there any discharge? Acute bacterial conjunctivitis will always have a yellow or creamy mild purulent or mucopurulent discharge which tends to stick the eyelids together on waking and crusts. Serous or watery discharge usually indicates a viral or toxic aetiology Mucoid white or stringy discharge is associated with dry eye and allergic causes and early chlamydial conjunctivitis

24 Acute Bacterial Conjunctivitis Presents as an acute,red, MILDLY SORE sticky eye and is often unilateral or involves one eye more.

25 Viral Conjunctivitis Presents as a sore watery or slightly sticky eye and often with coexistent URT infection or similar history. Look for papillae or follicles, a serous or muco-serous discharge, scattered small sub conjunctival haemorrhages and preauricular lymphadenopathy. Possible corneal infiltrates.

26 Are there any visible follicles? Viral or chlamydial infections produce follicles and preauricular lymphadenopathy

27 Viral Conjunctival Follicles Translucent grains of rice appearance.

28 Are there any Papillae? Papillae are a poor diagnostic sign but it is essential to differentiate them from follicles

29 Papillae or Follicles? Papillae have a central vascular core

30 Viral Conjunctivitis

31 Corneal Infiltrates Take time to develop due to avascular structure of cornea. Aggregations of leukocytes enter cornea from limbal vessels.

32 Viral Conjunctivitis 2 types. Adenoviral or Herpes Virus Adenoviral conjunctivitis is highly contagious for two weeks from onset and produces mild pain, photophobia, follicles, chemosis and tender PAN. Pharyngoconjunctival Fever (3 F,s) Epidemic Keratoconjunctivitis ( beware of corneal infiltrates!)

33 Adenoviral Infections of the eye Epidemic Keratoconjunctivitis (EKC) Acute follicular conjunctivitis Pharyngoconjunctival fever

34 Pharyngoconjunctival fever Headache, fever, malaise Conjunctivitis and Pharyngitis Cervical adenopathy, rash and diarrhea also Main adenovirus types: 3, 4, 7, 14 Epidemics in summer months Contaminated water in swimming pools, fomites

35 Epidemic Keratoconjunctivitis Incidence in summer Conjunctivitis usually followed by keratitis Headache Pre-auricular lymphadenopathy Types 8, 19, 37 Nosocomial spread by fomites, hands, ophthalmologic equipment, medications

36 Epidemic Keratoconjunctivitis Begins as an obvious conjunctivitis, but then develops corneal infiltrates.

37 Adenoviral Infiltrates in Cornea.

38 Herpetic (HSV) Conjunctivitis Usually young children Unilateral Discomfort, photophobia,mucoid discharge,follicles and PAN Look for skin vesicles near eyelids. Self limiting in 3 weeks but must monitor for possible corneal involvement every few days.

39 Dendritic Ulcers in HSV

40 Allergic Conjunctivitis A type 1 hypersensitivity response of the conjunctival mast cells mediated by IgE. Seasonal, Vernal or Atopic in origin. SAC = hayfever,itching, mild chemosis and diffuse papillary reaction VKC= chronic recurrent inflammation usually in atopic young males, 5-20yrs. Large papillae and limbitis+ thick stringy discharge

41 Contact Lens Complications CL s can cause red eye by causing corneal erosions, inflammation or infection. Erosions are painful, creating a watery red eye. Inflammation causes perilimbal redness and often corneal infiltrates. Infection can lead to a permanent scar reducing vision for life.

42 CL Acute Red Eye Usually a reaction to bacterial exotoxins released from an infected contact lens.

43 Pseudomonas Infection

44 Acanthoemeba Infection Often mistaken for Adenoviral infection or CL associated red eye initially.

45 Three essential questions Has the eye been painful? Tenderness is ok but significant pain should be referred. Has your vision been affected? Any significant drop in vision or photophobia suggests corneal involvement. Have you worn contact lenses recently? All contact lens wearers should be checked by their own prescriber.

46 Management Issues General measures Conjunctivitis is contagious (particularly adenoviral). Advice should be given regarding sharing of towels, utensils etc with others, time off school/work if necessary, and minimal hand/eye contact. Doctors should also be aware of sterile techniques to avoid cross-contamination of instruments etc. [Donahue 1996] Contact lenses should not be worn if conjunctivitis is present or if topical treatments are being instilled.

47 Treatment of infection A topical antibacterial preparation is usually prescribed empirically for the following reasons In most cases it is clinically difficult to distinguish between viral and bacterial infection. Bacterial superinfection can occur in cases of viral conjunctivitis. To relieve symptoms and shorten the course of disease (spontaneous remission is likely to occur within several weeks [Baum 1995; Barza 1983]).

48 Treatment (cont.) Chloramphenicol remains the drug of choice for all superficial eye infections in the U.K. as it is effective, reliable, broad spectrum and cheap. Previous concerns over its association with aplastic anaemia have largely been discounted Fusidic Acid is an alternative that is more expensive but only twice daily

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