CONJUNCTIVITIS

Acute membranous conjunctivitis:

• It is an acute inflammation of the conjunctiva, characterized by formation of a true membrane on the conjunctiva. 
• The disease is typically caused by Corynebacterium diphtheriae. 
• This organism produces a violent inflammation of the conjunctiva, associated with deposition of fibrinous exudate on the surface as well as in the substance of the conjunctiva resulting in formation of a thick, grey-yellow membrane. 
• The membrane is tough and firmly adherent to the conjunctiva, which on removing bleeds and leaves behind a raw area. 

• Most of the viral infections tend to affect the epithelium, both of the conjunctiva and cornea, so, the typical viral lesion is a ‘keratoconjunctivitis’.
• Some viral infections, conjunctival involvement is more prominent (e.g., pharyngo-conjunctival fever), while in others cornea is more involved (e.g., herpes simplex).
• Viral infections usually cause a serous or clear watery discharge and are further characterized by the type of conjunctival inflammatory reaction they produce.
• The underlying systemic viral disease is treated, as usual, supplemented with artificial tears four to eight times a day for the eyes.

D. i.e. Papilloma virus

• Acute hemorrhagic conjunctivitis is a highly contagious illness usually caused by the picornaviruses, especially enterovirus 70 and coxsackievirus A24.
• Infection is characterized by the sudden onset of bilateral conjunctivitis associated with profuse watery discharge, lid edema, and fine, punctate epithelial keratitis.
• A prominent distinguishing feature is the presence of subconjunctival hemorrhage, which can be pinpoint or confluent. 
• However, other enteroviruses, including echoviruses coxsackieviruses B1 and B2, and several adenoviruses, can also cause acute hemorrhagic conjunctivitis.

VERNAL KERATOCONJUNCTIVITIS (VKC) OR SPRING CATARRH:

It is a recurrent, bilateral, interstitial, self-limiting, allergic inflammation of the conjunctiva having a periodic seasonal incidence.

Clinical picture Symptoms:

• Spring catarrh is characterised by marked burning and itching sensation which is usually intolerable and accentuated when the patient comes in a warm humid atmosphere. Itching is more marked with a palpebral form of the disease.
• Other associated symptoms include mild photophobia, lacrimation, stringy (ropy) discharge and heaviness of lids.

Signs of vernal keratoconjunctivitis can be described in the following three clinical forms:

1. Palpebral form: Usually upper tarsal conjunctiva of both eyes is involved. The typical lesion is characterized by the presence of hard, flat-topped, papillae arranged in a ‘cobble-stone’ or ‘pavement stone’, fashion.

2. Bulbar form: It is characterised by (i) dusky red triangular congestion of bulbar conjunctiva in the palpebral area; (ii) gelatinous thickened accumulation of tissue around the limbus; and (iii) presence of discrete whitish raised dots along the limbus (Tranta’s spots).

3.Mixed form: It shows combined features of both palpebral and bulbar forms.

Ans. Both of the above

Ans. Staphylococcus aureus

Ans., Chlamydia trachomatis

ADULT INCLUSION CONJUNCTIVITIS

• It is a type of acute follicular conjunctivitis associated with mucopurulent discharge.
•  It usually affects the sexually active young adults. Etiology Inclusion conjunctivitis is caused by serotypes D to K of Chlamydia trachomatis. 
• The primary source of infection is urethritis in males and cervicitis in females. 
• The transmission of infection may occur to eyes either through contaminated fingers or more commonly through contaminated water of swimming pools (hence the name swimming pool conjunctivitis). 

Clinical features

• Incubation period of the disease is 4-12 days. 

Symptoms are similar to acute mucopurulent conjunctivitis and include:

• Ocular discomfort, foreign body sensation, 
•  Mild photophobia, and Mucopurulent discharge from the eyes. 

Signs of inclusion conjunctivitis are: 

• Conjunctival hyperaemia, more marked in fornices. 
• Acute follicular hypertrophy predominantly of lower palpebral conjunctiva . 
•  Superficial keratitis in upper half of cornea. Sometimes, superior micropannus may also occur. 
• Pre-auricular lymphadenopathy is a usual finding. 

Clinical course.

• The disease runs a benign course and often evolves into the chronic follicular conjunctivitis. 
• Differential diagnosis must be made from other causes of acute follicular conjunctivitis.

Treatment

1. Topical therapy. It consists of tetracycline (1%) eye ointment 4 times a day for 6 weeks.

2. Systemic therapy is very important, since the condition is often associated with an asymptomatic venereal infection. 

Commonly employed antibiotics are:

• Tetracycline 250 mg four times a day for 3-4 weeks. 
• Erythromycin 250 mg four times a day for 3-4 weeks (only when the tetracycline is contraindicated e.g., in pregnant and lactating females). 
•  Doxycycline 100 mg twice a day for 1-2 weeks or 200 mg weekly for 3 weeks is an effective alternative to tetracycline. 
• Azithromycin 1 gm as a single dose is also effective.

Ans. Allergens are endogenous as well as exogenous

Ans. Adenovirus

Ans. Chlamydia

Ans. Membranous conjunctivitis

Ans. Foreign body retained is the fornix

Ans. Present only in infants

Ans. None

Ans. Aspergillus

• Neonatal conjunctivitis, also known as ophthalmia neonatorum, presents during the first month of life. It may be aseptic or septic.
• The etiology of neonatal conjunctivitis can be chemical or microbial. 
• Although several noninfectious and infectious agents can inflame the conjunctiva, the most common causes of neonatal conjunctivitis are silver nitrate solution and chlamydial, gonococcal, staphylococcal, and herpetic infections.

Ans. A: CMV

• Conjunctivitis can be classified as infectious or noninfectious.
• Infectious conjunctivitis (pinkeye) accounts for 70 percent of all cases and is caused by either a bacteria (usually staphylococci, pneumococci, streptococci, or chlamydia trachomatis) or a virus.
• Bacterial conjunctivitis occurs in 50 percent of all cases, and viral conjunctivitis occurs in 20 percent. Infectious conjunctivitis is very contagious.
• Noninfectious conjunctivitis (which accounts for the remaining 30 percent of all cases), can be caused by allergies (such as pollen or grass), chemicals (such as air pollutants, smoke or household cleaners), or underlying diseases (such as rheumatoid arthritis, lupus, Kawasaki’s disease, ulcerative colitis or Crohn’s disease).
• Additionally, conjunctivitis can be caused by hemorrhage from trauma or changes in pressure within the head (subconjunctival hemorrhage).

Viral causes of conjunctivitis:

• Herpes simplex
• Adenovirus
• Picornavirus (Coxsackie virus, enterovirus 70)
• Myxovirus (measles)
• Paramyxoviruses (mumps, Newcastle conjunctivitis)
• Molluscum contagiosum.

Ans. is ‘A’ i.e., Enterovirus 70

Acute hemorrhagic conjunctivitis (AHC) may be caused by adenoviruses, but two enteroviruses, enterovirus 70 and coxsackie A24 variant, are the major causes.

Ans. is ‘D’ 

Phlyctenular keratoconjunctivitis

• Phlyctenular conjunctivitis is an allergic response of the conjunctival and corneal epithelium to some endogenous allergens and characterized by formation of the phlyctens. 
• Phlyctens are grey, yellow or pinkish white nodules slightly raised above the surface, are seen on the bulbar conjunctiva, generally near the limbus. 
• Peak age group is 3-15 years with slight female preponderance.

Etiology

•  It is delayed hypersensitivity (Type IV cell-mediated) response to endogenous microbial proteins. 
•  Causative allergens are : – 
•  Staphylococcus proteins (most common)
•  Mycobacterium tuberculosis
•  Tuberculous proteins 

Symptoms 

• Phlyctens are pinkish white nodules at limbus. 
• Phlyctens are surrounded by hyperamia (congestion) and this congestion of vessels is limited to the area around phlyctens. Phlyctens ulcerate at apex.
• Corneal involvement may result in miliary ulcer, ring ulcer, 
• Fascicular ulcer – has a prominent parallel leash of blood vessels. It heals leaving a band-shaped opacity)
•  Sacrofulous ulcer –  shallow marginal ulcer due to the breakdown of limbal phlycten
• There may be diffuse infiltrative phlyctenular keratitis.

Treatment

• Topical steroids: Atropine if the cornea is involved.

Ans. is ‘A’ i.e., Corneal opacity

Vernal keratoconjunctivitis (spring catarrh)

• Spring catarrh is an allergic inflammation of the conjunctiva which is characterized by recurrent, bilateral, interstitial, self-limiting conjunctivitis that becomes aggravated during the spring and summer period.
• It is considered to be Type I hypersensitivity reaction (immediate-type) to exogenous allergens such as grass pollens.
• It is more common in boys and affects the age group 4-20 years.
• More common in summer, hence the name spring catarrh looks a misnomer.
• Recently it is being labelled as “Warm weather conjunctivitis”.

Clinical features of spring catarrh

• Spring catarrh is characterized by marked itching & burning, Stringy (ropy) discharge, lacrimation, photo-phobia and heaviness of lids.
• Clinically spring catarrh is divided into three types : ‑

1. Palpebral form: – It is the most common types. The upper palpebral conjunctiva shows papillae (papillary hypertrophy with their characteristic appearance: – i) Lage & flat toped, ii) Cobblestone appearance (Pavement stone appearance). These papillae heal without scarring.
2. Bulbar form: – It is characterized by (i) Dusky red triangular congestion of bulbar conjunctiva in the palpebral area; ii) Gelatinous thickened accumulation of tissue around the limbus; iii) Presence of discrete whitish raised dots along the limbus (Tranta’s spot).
3. Mixed form: – Both bulbar and palpebral manifestations occur together.

Corneal signs (Vernal keratopathy)

• Punctate epithelial keratitis
• Ulcerative vernal keratitis: shallow transverse ulcer (Shield ulcer)
• Vernal corneal plaques
• Subepithelial scarring
• Pseudogerontoxon: characterized by a classical “cupid’s bow” outline.

Ans C. Antibiotics are the mainstay of treatment

• The mainstay of treatment in viral conjunctivitis is only lubricants

Ans. is ‘a’ i.e., Moraxella 

Angular conjunctivitis

• It is a type of chronic conjunctivitis characterized by mild grade inflammation confined to conjunctiva and lid margins near the angles associated with maceration of the surrounding skin.
• Moraxella axenfeld (Moraxella lacunata), a diplobacillus, is the commonest causative organism. o Less commonly, staphylococcus aureus can also cause angular conjunctivitis.
• Angular conjunctivitis responds to tetracycline ointment.
• Eye drops containing zinc inhibit the proteolytic ferment and are of great value although less rapidly effective, and may be used in addition to tetracycline.

Ans. is ‘a’ i.e., Trachoma 

Adult inclusion conjunctivitis

• It is a type of follicular conjunctivitis caused by serotypes D to K of chlamydia trachomatis-in sexually active young adults.
• The primary source of infection is urethritis in males and cervicitis in females.
• Transmission may occur either through contaminated fingers or through contaminated water of swimming pools (Swimming pool granuloma).
• Presentation is similar to other acute follicular conjunctivitis with mucopurulent discharge. 
• The disease runs a benign course and often evolves into the chronic follicular conjunctivitis.

Ans. is ‘b’ i.e., Staphylococcus

Phlyctenular keratoconjunctivitis

• Phlyctenular conjunctivitis is an allergic response of the conjunctival and corneal epithelium to some endogenous allergens and characterized by formation of the phlyctens. Phlyctens are grey, yellow or pinkish white nodules slightly raised above the surface, are seen on the bulbar conjunctiva, generally near the limbus. Peak age group is 3-15 years with slight female preponderance.