Conjunctiva/Sclera/Iris/External Disease

Conjunctiva/Sclera/Iris/External Disease

5.1 Acute Conjunctivitis


“Red eye” (conjunctival hyperemia), discharge, eyelids sticking or crusting (worse upon awakening from sleep), foreign body sensation, <4-week duration of symptoms (otherwise, SEE 5.2, CHRONIC CONJUNCTIVITIS) (see Figure 5.1.1).

Viral Conjunctivitis/Epidemic Keratoconjunctivitis


Itching, burning, tearing, gritty or foreign body sensation; history of recent upper respiratory tract infection or contact with someone with viral conjunctivitis. Often starts in one eye, and involves the fellow eye a few days later.


Critical. Inferior palpebral conjunctival follicles (see Figure 5.1.3), tender palpable preauricular lymph node.

Other. Watery discharge, red and edematous eyelids, pinpoint subconjunctival hemorrhages, punctate keratopathy (epithelial erosion in severe cases), membrane/pseudomembrane (see Figure 5.1.4). Fine intraepithelial microcysts are an early corneal finding which, if present, can be helpful in diagnosis. Subepithelial (anterior stromal) infiltrates (SEIs) can develop a few weeks after the onset of the conjunctivitis.

Figure 5.1.1 Algorithm for follicles and papillae.

Figure 5.1.2 Viral conjunctivitis.

Etiology and Variants of Viral Conjunctivitis

  • Most commonly adenovirus. Epidemic keratoconjunctivitis is most commonly caused by subgroup D of serotypes 8, 19, and 37. Pharyngoconjunctival fever is associated with pharyngitis and fever, usually in children, and is most commonly caused by serotypes 3 and 7.

  • Acute hemorrhagic conjunctivitis: Associated with prominent subconjunctival hemorrhages, usually 1 to 2 weeks in duration. Tends to occur in tropical regions. Caused by enterovirus 70 (rarely followed by polio-like paralysis), coxsackievirus A24, and adenovirus serotype 11.

NOTE: Many systemic viral syndromes (e.g., measles, mumps, influenza) can cause a nonspecific conjunctivitis. The underlying condition should be managed appropriately; the eyes are treated with artificial tears four to eight times per day. If tears are used greater than four times daily, preservative-free tears are recommended.

Figure 5.1.3 Follicles on the inferior palpebral conjunctiva.

Figure 5.1.4 Viral conjunctivitis with pseudomembranes.


No conjunctival cultures/swabs are indicated unless discharge is excessive or the condition becomes chronic (SEE 5.2, CHRONIC CONJUNCTIVITIS).


In 2 to 3 weeks, but sooner if the condition worsens significantly or if topical steroids are prescribed.

Herpes Simplex Virus Conjunctivitis

SEE 4.15, HERPES SIMPLEX VIRUS, for a detailed discussion. Patients may have a history of perioral cold sores. Manifests with a unilateral (sometimes recurrent) follicular conjunctival reaction, palpable preauricular node, and, occasionally, concurrent herpetic skin vesicles along the eyelid margin or periocular skin. Treat with antiviral therapy (e.g., trifluridine 1% drops eight times per day, ganciclovir 0.05% gel five times per day, or oral agents such as acyclovir 400 mg five times a day) and warm compresses. Steroids are contraindicated.

Figure 5.1.5 Allergic conjunctivitis.

Allergic Conjunctivitis


Itching, watery discharge, and a history of allergies are typical. Usually bilateral.


Chemosis, red and edematous eyelids, conjunctival papillae, periocular hyperpigmentation, no preauricular node (see Figure 5.1.5).


Two weeks. If topical steroids are used, tapering is required and patients should be monitored for side effects.

Vernal/Atopic Conjunctivitis


Usually bilateral but frequently asymmetric itching with thick, ropy discharge. More common in boys. Seasonal (spring/summer) recurrences in vernal conjunctivitis; history of atopy, dermatitis, and/or asthma without seasonal correlation in atopic conjunctivitis. Vernal conjunctivitis is usually seen in younger patients.


Critical. Large conjunctival papillae seen under the upper eyelid or along the limbus (limbal vernal) (see Figure 5.1.6).

Figure 5.1.6 Vernal/atopic conjunctivitis with large superior tarsal papillae.

Other. Superior corneal “shield” ulcer (a well-delineated, sterile, gray-white infiltrate with overlying epithelial defect), limbal raised white dots (Horner–Trantas dots) of degenerated eosinophils (see Figure 5.1.7), superficial punctate keratopathy (SPK).

Figure 5.1.7 Vernal/atopic conjunctivitis with raised white dots of eosinophils along limbus.


Every 1 to 3 days in the presence of a shield ulcer; otherwise, every few weeks. Topical medications are tapered slowly as improvement is noted. Antiallergy drops are maintained for the duration of the season and are often reinitiated a few weeks before the next spring. Patients on topical steroids should be monitored regularly with attention to IOP, even if used only on the skin.

Bacterial Conjunctivitis (Nongonococcal)


Redness, foreign body sensation, discharge; itching is much less prominent.


Critical. Purulent white-yellow discharge of mild-to-moderate degree.

Other. Conjunctival papillae, chemosis, preauricular node typically absent (unlike gonococcal in which a preauricular node is often palpable).


Commonly, Staphylococcus aureus (associated with blepharitis, phlyctenules, and marginal sterile infiltrates), Staphylococcus epidermidis, Haemophilus influenzae (especially in children and commonly associated with otitis media), Streptococcus pneumoniae, and Moraxella catarrhalis.

NOTE: Suspect gonococcal infection if onset is hyperacute with significant discharge, SEE IN THIS CHAPTER GONOCOCCAL CONJUNCTIVITIS.


If severe, recurrent, or recalcitrant, send conjunctival scrapings for immediate Gram stain (to evaluate for gonococcus) and for routine culture and sensitivities (e.g., blood and chocolate agar).


Every 2 to 3 days initially, then every 5 to 7 days when stable until resolved. Antibiotic therapy is adjusted according to culture and sensitivity results.

Gonococcal Conjunctivitis


Critical. Severe purulent discharge, hyperacute onset (classically within 12 to 24 hours).

Other. Conjunctival papillae, marked chemosis, preauricular adenopathy, eyelid swelling. SEE 8.9, OPHTHALMIA NEONATORUM (NEWBORN CONJUNCTIVITIS), for a detailed discussion of gonococcal conjunctivitis in the newborn.


  • Examine the entire cornea for peripheral ulcers (especially superiorly) because of the risk for rapid progression to perforation (see Figure 5.1.8).

  • Send conjunctival scrapings for immediate Gram stain and for culture and sensitivities (e.g., chocolate agar or Thayer–Martin agar).


Daily until consistent improvement is noted and then every 2 to 3 days until the condition resolves. The patient and sexual partners should be evaluated by their medical doctors for other sexually transmitted diseases.

Figure 5.1.8 Gonococcal conjunctivitis with corneal involvement.

Pediculosis (Lice, Crabs)

Typically develops from contact with pubic lice (usually sexually transmitted). Can be unilateral or bilateral.


Itching, mild conjunctival injection.


Critical. Adult lice, nits, and blood-tinged debris on the eyelids and eyelashes (see Figure 5.1.9).

Other. Follicular conjunctivitis.

Figure 5.1.9 Pediculosis.

5.2 Chronic Conjunctivitis


“Red eye” (conjunctival hyperemia), conjunctival discharge, eyelids sticking (worse on awakening from sleep), foreign body sensation, duration >4 weeks (otherwise SEE 5.1, ACUTE CONJUNCTIVITIS).

Differential Diagnosis

  • Parinaud oculoglandular conjunctivitis (SEE 5.3, PARINAUD OCULOGLANDULAR CONJUNCTIVITIS).


  • Contact lens-related (SEE 4.20, CONTACT LENS-RELATED PROBLEMS).

  • Conjunctival tumors (SEE 5.12, CONJUNCTIVAL TUMORS).

  • Autoimmune disease (e.g., reactive arthritis, sarcoidosis, discoid lupus, others).

Chlamydial Inclusion Conjunctivitis

Sexually transmitted, due to Chlamydia trachomatis serotypes D-K and typically found in young adults. A history of vaginitis, cervicitis, or urethritis may be present.


Inferior tarsal or bulbar conjunctival follicles, superior corneal pannus, palpable preauricular node, or peripheral SEIs. A stringy, mucous discharge may be present.


  • History: Determine the duration of red eye, any prior treatment, concomitant vaginitis, cervicitis, or urethritis. Sexually active?

  • Slit lamp examination.

  • In adults, direct chlamydial immunofluorescence test, DNA probe, chlamydial culture, or polymerase chain reaction of conjunctival sample.

    NOTE: Topical fluorescein can interfere with immunofluorescence test results.

  • Consider conjunctival scraping for Giemsa stain: Shows basophilic intracytoplasmic inclusion bodies in epithelial cells, polymorphonuclear leukocytes, and lymphocytes in newborns.


In 2 to 3 weeks, depending on the severity. The patient and sexual partners should be evaluated by their medical doctors for other sexually transmitted diseases. Occasionally a 6-week course of doxycycline may be required.


Principally occurs in developing countries in areas of poor sanitation and crowded conditions. Due to C. trachomatis serotypes A-C.


Figure 5.2.1 Trachoma showing Arlt line, or scarring, of the surgery tarsal conjunctiva.

MacCallan Classification

  • Stage 1: Superior tarsal follicles, mild superior SPK, and pannus, often preceded by purulent discharge and tender preauricular node.

  • Stage 2: Florid superior tarsal follicular reaction (2a) or papillary hypertrophy (2b) associated with superior corneal SEIs, pannus, and limbal follicles.

  • Stage 3: Follicles and scarring of superior tarsal conjunctiva.

  • Stage 4: No follicles, extensive conjunctival scarring.

  • Late complications: Severe dry eyes, trichiasis, entropion, keratitis, corneal scarring, superficial fibrovascular pannus, Herbert pits (scarred limbal follicles), corneal bacterial superinfection, and ulceration.

World Health Organization Classification

  • TF (trachomatous inflammation: follicular): More than five follicles on the upper tarsus.

  • TI (trachomatous inflammation: intense): Inflammation with thickening obscuring >50% of the tarsal vessels.

  • TS (trachomatous scarring): Cicatrization of tarsal conjunctiva with fibrous white bands.

  • TT (trachomatous trichiasis): Trichiasis of at least one eyelash.

  • CO (corneal opacity): Corneal opacity involving at least part of the pupillary margin.


  • History of exposure to endemic areas (e.g., North Africa, Middle East, India, Southeast Asia).

  • Examination and diagnostic studies as above (e.g., chlamydial inclusion conjunctivitis).


Every 2 to 3 weeks initially, then as needed. Although treatment is usually curative, reinfection is common if hygienic conditions do not improve.

NOTE: Currently, the World Health Organization is conducting a large-scale program to eradicate trachoma through intermittent widespread distribution of azithromycin as well as improving facial cleanliness and water sanitation in endemic areas. The aim is global elimination of trachoma by the year 2020 (GET 2020).

Molluscum Contagiosum


Critical. Dome-shaped, usually multiple, umbilicated shiny nodules on the eyelid or eyelid margin.

Other. Follicular conjunctival response from toxic viral products, corneal pannus, SPK. Immunocompromised patients may have larger (up to 5 mm) and more numerous lesions along with less conjunctival reaction. An increased incidence with pediatric atopic dermatitis has been observed.


Every 2 to 4 weeks until the conjunctivitis resolves, which often takes 4 to 6 weeks. If many lesions are present, consider human immunodeficiency virus (HIV) testing.

Microsporidial Keratoconjunctivitis


Diffuse, coarse, raised punctate keratitis and nonpurulent papillary or follicular conjunctivitis not responsive to conservative treatment. In immunocompromised patients, a corneal stromal keratitis resembling HSV or fungal keratitis can occur. Diagnosis is based on scrapings or biopsy of the conjunctiva or cornea; organisms can be identified with Gram stain, Giemsa stain, electron microscopy, and confocal microscopy in vivo.

Toxic Conjunctivitis/Medicamentosa


Inferior papillary reaction and/or inferior conjunctival staining with fluorescein from topical eye drops. Most notably from IOP-lowering medications, aminoglycosides, antivirals, and preserved drops (especially those containing benzalkonium chloride). With long-term use, usually more than 1 month, a follicular response can be seen with other medications including atropine, miotics, epinephrine agents, and nonaminoglycoside antibiotics. Inferior SPK and scant discharge may be noted.


In 1 to 4 weeks, as needed.


Seize MB, Ianhez M, Cestari Sda C. A study of the correlation between molluscum contagiosum and atopic dermatitis in children. An Bras Dermatol. 2011;86(4):663–668.

5.3 Parinaud Oculoglandular Conjunctivitis


Red eye, mucopurulent discharge, foreign body sensation.


Critical. Granulomatous nodule(s) on the palpebral and bulbar conjunctiva; visibly swollen ipsilateral preauricular or submandibular lymph nodes.

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Oct 20, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Conjunctiva/Sclera/Iris/External Disease

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