Conjunctival Infections and Inflammations

BLEPHARITIS AND MEIBOMITIS

Chronic blepharitis and meibomitis are very common, bilateral inflammations of the eyelid margins that may cause nonspecific ocular irritation, which is often worse in the morning. These conditions are often associated with dry eye disease and symptoms such as foreign body sensation. Conversely, some patients have severe blepharitis but minimal to no symptoms.

Etiology

• Staphylococcal infection, acne rosacea, seborrheic dermatitis

Signs

• Associated atopic and seborrheic dermatitis, and ocular rosacea

• Hyperemia, telangiectasias, crusting, scaling, formation of collarettes around bases of lashes (staphylococcal), sleeves along eyelashes (seborrheic), and pouting of meibomian gland orifices, which can be expressed to produce a thickened lipid secretion, sometimes of toothpaste-like consistency (Fig. 1-1)

• Frothy and foamy tear film, conjunctival injection, inferior superficial punctate keratopathy, phlyctenulosis, corneal infiltrates

Treatment

• Warm compresses 5 to 10 minutes b.i.d., eyelid margin scrubs with mild commercially available cleansers (e.g., Ocusoft Lid Scrub, Advanced Vision Research Sterilid, Novabay Avenova)

• Tear supplements while awake, topical azithromycin gel drops or erythromycin, bacitracin, or tetracycline ointment at bedtime

• Oral tetracycline 250 mg b.i.d. to q.i.d., doxycycline 100 mg q.d. to b.i.d., or minocycline 100 mg q.d. to b.i.d. in severe or recurrent cases. These medications can often be tapered to a much lower dose for long-term use (e.g., doxycycline and minocycline 20 mg b.i.d. or 50 mg q.d.). Oral erythromycin 250 mg b.i.d. to q.i.d. in adults or 30 to 50 mg/kg/day in four divided doses in children or azithromycin 250 to 500 mg daily in adults or 5 mg/kg/day
in children can also be used. These oral medications are usually continued for weeks to months and then often tapered and stopped.

• Judicious short-term use of topical corticosteroids for phlyctenulosis or infiltrates

FIGURE 1-1. A. Blepharitis. Significant crusting at the base of the eyelashes is seen. A few collarettes are present. B. Meibomitis. Severe pouting of the meibomian glands of the inferior eyelid can be seen. The eyelid margin is thickened and inflamed, with some conjunctival injection visible.

Prognosis

• Good for significant improvement in symptoms over weeks, but patients need to understand that the condition is chronic and can often be controlled rather than cured.

CHALAZION (INTERNAL HORDEOLUM, STYE)

A chalazion is a tender eyelid mass, often with surrounding erythema and swelling. It may be small or large and can cause significant eyelid inflammation when severe.

Etiology

• Blockage of meibomian gland orifices and stagnation of sebaceous secretions

• Associated with blepharitis/meibomitis and acne rosacea

Differential Diagnosis

• External hordeolum: an acute staphylococcal infection of a lash follicle and its associated gland of Zeis or Moll

• Pyogenic granuloma: a vascularized mass protruding from the conjunctiva

• Sebaceous carcinoma: suspect in recurrent chalazia, eyelid margin excoriation, or loss of lashes, especially if unilateral

Treatment

• Warm compresses, eyelid massage, and hygiene (see Blepharitis and Meibomitis earlier)

• Topical azithromycin gel drops or erythromycin, bacitracin, or tetracycline ointment for blepharitis/meibomitis

• Oral tetracycline 250 mg b.i.d. to q.i.d., doxycycline 100 mg q.d. to b.i.d., or minocycline 100 mg q.d. to b.i.d. in inflamed, severe, or recurrent cases, to prevent recurrent chalazia. Oral erythromycin 250 mg b.i.d. to q.i.d. in adults or 30 to 50 mg/kg/day in four divided doses in children or azithromycin 250 to 500 mg daily in adults or 5 mg/kg/day in children can also be used. These oral medications are usually continued for weeks to months and then often tapered and stopped.

• Corticosteroid injection can be considered to reduce scarring in recalcitrant cases.

• Incision and curettage if no improvement with medical treatment

Prognosis

• Very good with medical treatment

• If medical treatment is unsuccessful, surgical treatment is quite effective.

FIGURE 1-2. Chalazion. A. A large, inflamed chalazion of the upper eyelid. Severe blepharitis and crusting of the eyelid margin, predisposing factors for development of chalazia, are also present. B. Lower eyelid eversion reveals a large indurated mass consistent with a chalazion.

BACTERIAL CONJUNCTIVITIS (NONGONOCOCCAL)

Bacterial conjunctivitis is a relatively uncommon, often bilateral condition, characterized by a mucopurulent or purulent discharge.

Etiology

• Staphylococcus aureus, Staphylococcus epidermidis

• Streptococcus pneumoniae

• Haemophilus influenzae (especially in children), others

Diagnostic Evaluation

• Conjunctival swab for Gram stain, cultures, and sensitivities if severe or recurrent

Treatment

• Spontaneous resolution in days to 1 to 2 weeks is usual.

• Artificial tears to wash away discharge

• Empiric broad-spectrum topical antibiotic drops (e.g., polymyxin B/trimethoprim, fluoroquinolones, gentamicin, tobramycin, neomycin/gramicidin/bacitracin) q.i.d. for 1 week or azithromycin gel drops b.i.d. for 2 days, then q.d. for 5 days

• Antibiotic ointments (e.g., ciprofloxacin, tobramycin, gentamicin, tetracycline, bacitracin, polymyxin B/bacitracin) can be used q.i.d. for 1 week in patients in whom the drops wash out very quickly, such as crying children.

Prognosis

• Very good

• Severe infections can cause permanent conjunctival scarring.

FIGURE 1-3. Bacterial conjunctivitis. A. Diffuse conjunctival injection and a purulent discharge are present in this eye with bacterial conjunctivitis. B. A severe purulent discharge with crusting can be seen in this patient who has bacterial conjunctivitis. There is also moderate conjunctival injection.

GONOCOCCAL BACTERIAL CONJUNCTIVITIS

Gonococcal conjunctivitis is a rare, often bilateral condition, characterized by acute onset of a severe purulent discharge.

Etiology

• Primarily Neisseria gonorrhoeae

• Occasionally Neisseria meningitidis

• It is typically sexually transmitted.

Diagnostic Evaluation

• Conjunctival scraping for immediate Gram stain, cultures, and sensitivities. The diagnosis is confirmed if the Gram stain demonstrates gram-negative intracellular diplococci.

Treatment

• Systemic ceftriaxone 1 g intramuscularly (IM) in a single dose if there is no corneal involvement. If the patient is allergic to cephalosporins, then fluoroquinolones are the drugs of choice.

• If there is corneal involvement or corneal involvement cannot be excluded because of a limited slit-lamp examination, the patient should be treated with ceftriaxone 1 g IV q12h-q24h for 3 days.

• Topical fluoroquinolone (e.g., ciprofloxacin) drops q2h, or q1h if the cornea is involved.

• Ocular irrigation with saline q.i.d. to q2h to eliminate the discharge.

• Evaluate and treat for possible coinfection with Chlamydia (e.g., azithromycin 1 g PO once) or syphilis (e.g., benzathine penicillin G 2.4 million units IM).

• Sexual partners should be evaluated and treated for sexually transmitted infections.

Prognosis

• Very good if diagnosed and treated appropriately before corneal involvement occurs. If the cornea is involved, the prognosis is guarded.

FIGURE 1-4. Gonococcal conjunctivitis. A. Severe inflammation and chemosis are present throughout the conjunctiva in the right eye. Some purulent discharge is present on the eyelid and conjunctiva nasally. The cornea is not involved. B. A large corneal ulcer with significant tissue loss is found in the superior cornea; it is critical to examine the entire cornea in eyes with gonococcal conjunctivitis to determine whether there is corneal involvement.

VIRAL CONJUNCTIVITIS (TYPICALLY ADENOVIRUS)

Viral conjunctivitis is a common, highly contagious, usually bilateral condition, characterized by the rapid onset of redness, itchiness, and tearing, first in one eye and then in the other.

Etiology

• Adenovirus serotypes 8, 19, 37: epidemic keratoconjunctivitis

• Adenovirus serotypes 3, 7: pharyngoconjunctival fever, usually in children

• Others: herpes simplex virus, enteroviruses, Newcastle disease virus, Epstein-Barr virus

Signs

• Generalized conjunctival hyperemia, may have subconjunctival hemorrhages

• Watery discharge

• Eyelid edema (Fig. 1-5A), conjunctival follicles, which are frequently most apparent in the inferior fornices (Fig. 1-5B)

• Membranes or pseudomembranes in severe cases

• Conjunctival membranes consist of coagulated exudate adherent to inflamed conjunctival epithelium. Clinically, a true membrane causes bleeding on attempted removal and a pseudomembrane does not, but this rule is not universal. The causes of true membranes and pseudomembranes are similar.

• Central punctate epithelial keratitis, and occasionally an epithelial defect (Fig. 1-5C)

• Multiple small corneal infiltrates with overlying punctate staining may also be seen in the acute phase of severe infections (Fig. 1-5D).

• Preauricular lymphadenopathy is often present.

• Subepithelial infiltrates (SEIs) can occur weeks after the onset of the acute infection and may persist for months to years (Fig. 1-5E, eFig. 1-5A and B).

Diagnostic Evaluation

• A noninvasive, commercially available point of service test (Quidel Corporation, San Diego, CA) is available to rapidly detect adenoviral conjunctivitis in the office. It is often helpful to confirm the diagnosis.

Prognosis

• Very good. If clinically significant SEIs develop, the treatment course can be prolonged. Severe infections with membranes or pseudomembranes can cause permanent conjunctival scarring (Fig. 1-5F).

FIGURE 1-5. Viral conjunctivitis. A. Note the severe eyelid erythema and edema in this patient with Adeno-Plus-proven adenovirus conjunctivitis in the right eye. B. Diffuse conjunctival injection with a severe follicular reaction, greatest inferiorly, is present in this eye with viral conjunctivitis.

FIGURE 1-5. (continued) C. A central punctate epithelial keratitis as seen in this eye is often found early in the course of viral conjunctivitis, most commonly caused by adenovirus. D. In the acute phase, small superficial corneal infiltrates with overlying punctate staining can develop. Note the irregular light reflex.

FIGURE 1-5. (continued) E. Multiple subepithelial infiltrates (SEIs) of the cornea can be seen 2 months after resolution of adenoviral keratoconjunctivitis. These SEIs tend to resolve on their own. If they are severe, they can affect visual acuity and cause glare symptoms. SEIs generally respond to low-dose topical corticosteroid drops; however, if they are started, these drops need to be tapered very slowly, over months. F. Inferior conjunctival scarring is seen in this eye several months after adenoviral conjunctivitis.

CHLAMYDIAL CONJUNCTIVITIS (ADULT INCLUSION CONJUNCTIVITIS)

Adult chlamydial conjunctivitis is a relatively common, usually unilateral condition that is typically transmitted sexually and generally affects young adults.

Etiology

• Chlamydia trachomatis serotypes D through K

• Typically sexually transmitted

Signs

• Stringy, white mucopurulent discharge

• Large follicles in the inferior fornix (Fig. 1-6)

• Superior tarsal follicles, occasionally follicles at the limbus

• Superior limbal or peripheral nummular corneal infiltrates and pannus

• Mild preauricular lymphadenopathy may be present.

Prognosis

• Very good

FIGURE 1-6. Chlamydial conjunctivitis. A severe inferior conjunctival follicular reaction can be seen in this eye with chronic chlamydial conjunctivitis. There were similar conjunctival follicles superiorly. There is also diffuse bulbar conjunctival injection.

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