Conjunctival Infections and Inflammations



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





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




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



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.



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




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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Oct 13, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Conjunctival Infections and Inflammations
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