CONJUNCTIVITIS
Signs of conjunctival inflammation
Conjunctival injection
The conjunctival vessels are most superficial and thin, and apart from the major arteries and veins, are virtually invisible to the naked eye.
Signs
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In conjunctivitis the injection is diffuse, beefy-red and is least at the limbus and maximal towards the fornices ( Fig. 3.1 ).
Fig. 3.1
Papillary reaction
Papillae are hyperaemic flat-topped elevations separated by pale outlines which occur on the palpebral tarsal conjunctiva and occasionally on the perilimbal conjunctiva. The clinical appearance of papillae varies greatly according to size and number, and can be arbitrarily graded 0–4.
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Grade 1 – micropapillae are tiny slightly elevated red dots that give rise to a smooth velvety appearance ( Fig. 3.2 ).
Fig. 3.2
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Grade 2 – macropapillae are less than 1 mm in diameter ( Fig. 3.3 ).
Fig. 3.3
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Grade 3 – giant papillae are more than 1 mm in diameter ( Fig. 3.4 ).
Fig. 3.4
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Grade 4 – enormous and protruding ( Fig. 3.5 ).
Fig. 3.5
Follicular reaction
Signs
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Discrete, yellowish, slightly elevated lesions most prominent in the fornices ( Fig. 3.6 ).
Fig. 3.6
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Blood vessels normally pass over the surface of a follicle and then as it enlarges the vessels are displaced peripherally.
Discharge
- a.
Watery occurs in acute viral and allergic disease.
- b.
Mucoid is typical of chronic allergic disease and dry eye.
- c.
Mucopurulent occurs in acute bacterial and chlamydial conjunctivitis.
- d.
Purulent is typical of gonococcal infection.
Membranes
Signs
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Coagulated exudate adherent to inflamed conjunctival epithelium ( Fig. 3.7 ).
Fig. 3.7
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Clinically, a true membrane causes bleeding on attempted removal and a pseudo-membrane does not, but this rule is not infallible.
Causes
The causes of true membranes and pseudo-membranes are essentially similar:
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Severe adenoviral conjunctivitis.
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Gonococcal conjunctivitis.
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Ligneous conjunctivitis.
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Acute Stevens–Johnson syndrome.
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Bacterial infection with Streptococcus spp. and Corynebacterium diphtheriae .
Haemorrhages
Causes
Adenoviral infection and occasionally bacterial infections caused by S. pneumoniae , H. influenzae and N. meningitis .
Preauricular lymphadenopathy ( Fig. 3.8 )
Causes
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Viral infection.
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Chlamydial infection.
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Gonococcal infection.
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Parinaud oculoglandular syndrome.
Acute papillary conjunctivitis
Simple bacterial
Signs
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Eyelids – crusty and covered by exudate ( Fig. 3.9 ).
Fig. 3.9
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Papillae – grade 1 (bilateral).
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Discharge – initially catarrhal and later mucopurulent ( Fig. 3.10 ).
Fig. 3.10
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Membranes – usually absent.
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Cornea – normal.
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Preauricular adenopathy – absent.
Gonococcal
Signs
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Eyelids – oedematous.
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Papillae – grade 1 (bilateral).
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Discharge – copious purulent.
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Membranes – present.
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Cornea – ulceration if treatment is delayed ( Fig. 3.11 ).
Fig. 3.11
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Preauricular adenopathy – present.
Look for
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In males – urethral discharge and dysuria.
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In females – vaginal discharge and less frequently dysuria.
Allergic rhinoconjunctivitis
Signs
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Eyelids – oedematous.
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Papillae – grade 1 (bilateral) and often associated with chemosis ( Fig. 3.12 ).
Fig. 3.12
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Discharge – watery.
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Membranes – absent.
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Cornea – normal.
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Preauricular adenopathy – absent.
Acute follicular conjunctivitis
Adenoviral
Signs
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Eyelids – oedematous.
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Follicles – (bilateral) most apparent in the inferior fornices.
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Discharge – watery.
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Membranes – if severe.
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Subconjunctival haemorrhages – if severe.
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Cornea – punctate epithelial keratitis is common. It may be followed by subepithelial opacities and anterior stromal infiltrates ( Fig. 3.13 ).
Fig. 3.13
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Preauricular adenopathy – may be present.
Herpes simplex
Signs
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Eyelids – vesicles.
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Follicles – (unilateral) most apparent in the inferior fornix.
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Discharge – watery.
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Membranes – absent.
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Subconjunctival haemorrhages – absent.
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Cornea – small dendritic ulcers are uncommon ( Fig. 3.14 ).
Fig. 3.14
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Preauricular adenopathy – present.
Other viral causes
- a.
Epstein–Barr .
- b.
Measles .
- c.
Mumps .
- d.
Newcastle disease .
- e.
Rubella .
- f.
Picornaviruses .
Chronic papillary conjunctivitis
Vernal keratoconjunctivitis
Definition
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A common recurrent bilateral condition which affects children and young adults.
Signs
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Eyelids – normal or may show eczema.
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Discharge – mucoid.
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Papillae – on superior tarsus grade 2–3, rarely 4.
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Limbitis – grade 3 papillae associated with small white (Trantas) dots ( Fig. 3.15 ).
Fig. 3.15
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Conjunctival scarring – absent.
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Cornea – superior corneal punctate epithelial erosions, epithelial macroerosions, shield ulcers and plaques ( Fig. 3.16 ), pseudogerontoxon and peripheral vascularisation.
Fig. 3.16
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Preauricular adenopathy – absent.
Atopic keratoconjunctivitis
Definition
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An uncommon, serious, bilateral condition which occurs in adults with atopic dermatitis.
Signs
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Eyelids – eczema (see Fig. 1.26 ), madarosis and staphylococcal blepharitis.
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Discharge – mucoid.
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Papillae – grade 1–2 most intense on the inferior palpebral conjunctiva.
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Limbitis – absent.
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Conjunctival scarring – featureless appearance of the superior tarsal conjunctiva ( Fig. 3.17 ).
Fig. 3.17
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Cornea – inferior punctate epithelial erosions, persistent epithelial defects ( Fig. 3.18 ) and peripheral vascularisation.
Fig. 3.18
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Preauricular adenopathy – absent.
| Vernal | Atopic | |
|---|---|---|
| Age | Younger | Older |
| Gender predilection | Males | Nil |
| Duration of disease | Self-limiting | Chronic |
| Time of year | Spring | Perennial |
| Conjunctival involvement | Superior tarsus | Inferior tarsus |
| Cicatrisation | Absent | Common |
| Cornea | Shield ulcer | Persistent epithelial defect |
| Corneal scarring | Mild | Severe |
| Corneal vascularisation | Rare | Common |
Giant papillary conjunctivitis
Definition
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A unilateral or bilateral condition, depending on the cause such as inappropriate contact lens wear, particularly soft, ocular prosthetics ( Fig. 3.19 ) and protruding sutures following surgery.
Fig. 3.19
Signs
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Eyelids – normal.
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Discharge – mucoid.
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Papillae – grade 2–3.
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Limbitis – absent.
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Cornea – normal.
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Preauricular adenopathy – absent.
Superior limbic keratoconjunctivitis
Definition
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An uncommon, usually bilateral condition which is frequently associated with thyroid dysfunction.
Signs
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Eyelids – normal or may show lid lag and retraction if associated with thyroid eye disease.
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Discharge – mucoid.
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Papillae – grade 1 on superior tarsal conjunctiva ( Fig. 3.20 ).
Fig. 3.20
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Superior conjunctiva – hyperaemic and thickened ( Fig. 3.21 ).
Fig. 3.21
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Limbitis – mild.
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Cornea – superior punctate erosions and filaments.
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Preauricular adenopathy – absent.
Chronic follicular conjunctivitis
Adult inclusion (TRIC)
Definition
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Usually a unilateral condition caused by C. trachomatis serotypes D–K.
Signs
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Eyelids – normal.
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Discharge – mucopurulent.
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Follicles – large in the inferior fornices and less prominent in the superior tarsal conjunctiva ( Fig. 3.22 ).
Fig. 3.22
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Limbitis – occasionally limbal follicles.
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Cornea – peripheral infiltrates (see Fig. 5.121 ).
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Preauricular adenopathy – present.
Look for
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In males – ‘non-specific urethritis’.
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In females – abacterial pyuria and cervicitis.
Trachoma
Definition
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A bilateral condition caused by C. trachomatis serotypes A, B, Ba and C that is associated with poverty and poor hygiene.
Signs
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Eyelids – scarring, trichiasis and cicatricial entropion in advanced disease.
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Discharge – mucopurulent.
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Follicles – initially mixed with papillae ( Fig. 3.23 ).
Fig. 3.23
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Limbitis – may give rise to a row of shallow depressions (Herbert pits) following resolution ( Fig. 3.24 ).
Fig. 3.24
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Cornea – scarring.
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Preauricular adenopathy – absent.
Molluscum contagiosum
Definition
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An uncommon unilateral condition caused by a poxvirus.
Signs
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Eyelids – umbilicated nodule on the lid margin ( Fig. 3.25 ).
Fig. 3.25
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Discharge – mild mucoid.
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Follicles – in inferior fornix and occasionally on the bulbar conjunctiva.
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Cornea – epithelial keratitis or micropannus in chronic cases.
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Preauricular adenopathy – absent.
Chronic toxic
Causes
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Topical eye medication.
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Eye make-up.
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Variety of environmental pollutants.
Signs
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Eyelids – may show signs of contact dermatitis ( Fig. 3.26 ).
Fig. 3.26
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Discharge – watery.
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Follicles – initially the reaction is papillary; follicles develop after several weeks and are most prominent in the inferior fornix and inferior palpebral conjunctiva.
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Cornea – inferior punctate erosions.
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Preauricular adenopathy – absent.
Parinaud oculoglandular syndrome
Definition
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A rare usually unilateral condition that has many diverse causes (see below).
Signs
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Eyelids – normal.
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Discharge – mucoid.
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Conjunctiva – ulceration or large follicles associated with granulomas ( Fig. 3.27 ).
Fig. 3.27
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Cornea – normal.
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Cervical and preauricular adenopathy – severe.
Causes
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Common – cat-scratch disease, tularaemia and sporotrichosis.
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Occasional – TB, syphilis and coccidioidomycosis.
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Rare – sarcoidosis, lymphogranuloma venereum and chancroid.
Neonatal conjunctivitis
Neonatal conjunctivitis is defined as conjunctival inflammation occurring during the first month of life.
Chemical
Presentation
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Within the first few days of life.
Cause
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Topical administration of silver nitrate at the time of birth.
Signs
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Mild diffuse conjunctival injection without discharge.
Gonococcal
Presentation
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Within 1–3 days of life.
Signs
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Copious purulent discharge ( Fig. 3.28 ) which may be associated with membrane formations.
