Conjunctivitis

By: Dr Israa Helali

Family Medicine Specialist & Trainer in the Egyptian
Fellowship Board
Objectives

Differentiate the causes of conjunctivitis

Diagnose different causes of conjunctivitis in a primary healthcare

setting

Manage cases safely

The Conjunctiva
Types of Conjunctivitis
Allergic : Simple
allergic, allergic Bacrterial: adults
keratoconjunctivitis, and neonates
vernal (ophthalmia
keratoconjunctivitis, neonatorum),
giant papillae trachoma
conjunctivitis

Viral: adenovirus, Chemical

herpes virus conjunctivitis
Allergic Conjunctivitis
An IgE hypersensitivity reaction

Usually associated with nasal symptoms

Classified into seasonal or perennial

Seasonal mainly caused by grass and weed pollens

Perennial mainly caused by indoor allergens as dust mites, animal dander and mold
Allergic Conjunctivitis

Symptoms & Signs

• Seasonal and recurrent
• Bilateral itching in the eyes with
temporary relief
• Edema of the eyelids and conjunctiva
• Bilateral conjunctival injection
• Chemosis
• Watery and mild mucous discharge
 Differential Diagnosis
Infectious conjunctivitis
Blepharitis
Dry Eyes Syndrome
Allergic Toxic conjunctivitis

Conjunctivitis Ocular rosacea

Keratitis
Episcleritis/scleritis
Angle Closure glaucoma
Phlyctenular conjunctivitis
Allergic Conjunctivitis
Management
• Basic eye care: cool compresses, artificial tears, avoid eye rubbing
• Minimize exposure to pollens and other allergens
• Eye drops include:
• Vasoconstrictor eye drops as naphazoline HCl 0.1% 1-2 drops every 3 – 4 hours in
children older than 13 years of age.
• Antihistamine eye drops are more expensive mut more effective as pheniramine eye
drops
• Combinations as Antihistamine/vasoconstrictor eye drops: e.g. naphazoline HCl/
pheniramine eye drops 1-2 drops 4 times daily are also available
• Systemic antihistaminic medications relieve systemic symptoms
• Mast cell stabilizers are third line and are only indicated in recurrent and persistent cases
Allergic Keratoconjunctivitis
• A chronic bilateral non-infectious inflammatory ocular surface disease
that may lead to vision loss
• Presents in patients with a history of atopic dermatitis
• Mixed type IV and I hypersensitivity reaction
• Decreased cornea sensitivity and conjunctival goblet cells
• Peaks between 30-50 years
 Risk Genetic predisposition
Factors
include History of atopy
Diet
Living in urban areas
Allergic
Keratoconjunctivits Smoking
Duration of breastfeeding in infancy
Obesity
Antibiotic use
 Symptoms

Patients typically suffer from atopic dermatitis and eczema

since childhood and develop ocular symptoms later in life

May be seasonal, but most often chronic and perennial

Allergic
Keratoconjunctivitis Presents as intense itching in the conjunctiva, eyelids and
periorbital skin

Copious mucoid rope-like discharge

Tearing, burning, photophobia and blurry vision are

common.
Allergic Keratoconjunctivitis
Signs
• The eyelids and periorbital skin show signs of
eczematous dermatitis
• The conjunctiva is hyperemic, edematous with
papillae on the tarsal conjunctiva that may lead to
scarring
• Horner-Trantas dots ( image on the bottom) may
be present
• Corneal involvement is common and may range
from punctate lesions to corneal perforation and
neovascularization
• Cataracts are common
Allergic Keratoconjunctivitis
• Diagnosis is based on clinical history and examination
• Serum IgE is raised
Differentials include:
• vernal keratoconjunctivitis
• seasonal allergic conjunctivitis
• giant papillary conjunctivitis
• toxic conjunctivitis
• trachoma
• ocular Rosacea
Complications include keratoconus, cataract, bilateral herpetic
disease, corneal neovascularization.
 Management
• Managed in collaboration with ophthalmologists,
dermatologists and allergists
• Limit environmental factors as pets, diet restrictions,
use of air-filtering devises and hypoallergenic bedding
• Enforce hand hygiene and cold compresses
Allergic
Initial treatment includes
Keratoconjunctivitis
• Topical mast cell stabilizers as: olopatadine 0.1% or
lodoxamine 0.1% once daily
• Topical antihistamines: azelastine 0.05% applied as one
drop twice daily
• Systemic antihistamines are necessary to prevent
keratoconus
Vernal
Keratoconjunctivitis
 Vernal Keratoconjunctivitis

Symptoms • Severe itching

are usually
• Photophobia
• Blepharospasm
• Blurry vision
bilateral and • Foreign body sensation
• Mucoid rope-like discharge
seasonal and • Buckley described these patients as having the "morning misery" as
these symptoms are usually exaggerated upon awakening making

include: them late for school.

Vernal Keratoconjunctivitis

Signs include:
• Conjunctival injection
• Giant papillae on the upper tarsal
conjunctiva that are discrete,
>1mm in size and have flat tops
• Horner-Trantas dots are present on
the limbus
• Punctate corneal erosions and
keratitis
 Vernal Keratoconjunctivitis

Complications include:
• Symblepharon and conjunctival fibrosis may occur
• Shield ulcers in the upper third of the cornea
• Pannus formation and corneal neovascularization
• Keratoconus
 Differential Diagnoses:
Vernal • Allergic Keratoconjunctivitis
Kertaoconjunctivitis • Simple allergic conjunctivitis
• Giant papillary conjunctivitis

Vernal Allergic
Kertaoconjunctivitis Keratoconjunctivitis
Age of onset Before 10 years of age 30 – 50 years
Tarsal conjunctiva involved Upper Lower

Course Seasonal Chronic

Prognosis Self-limiting Results in corneal scarring
 Vernal Keratoconjunctivitis

Management
• Avoid possible allergens
• Cool compresses
• Lid scrubs
• Topical mast cell stabilizers in addition to topical antihistamines is
recommended
• Referral to an ophthalmologist for steroid therapy and further treatment
options
Giant Papillary Conjunctivitis
• Usually develops in 1-5% of contact lens wearers
after 8 months of soft contact lens use and 8
years after hard contact lens use.
• Mixed type I and type IV hypersensitivity reaction
(similar to vernal keratoconjunctivitis)
• Symptoms range from mild itching and morning
mucous production on the nasal corner of the
eye to severe foriegn body sensation and sheets
of mucous that glue the eye shut.
• The most diagnostic sign is the presence of giant
papillae (>1 mm in diameter) on the upper tarsal
conjunctiva
 The goal is to allow the patient continue using their
contacts while feeling comfortable
Management includes conservative methods and
medications as:
• Cleaning the lens thoroughly and storing it in fresh
saline. The cold method, heat method or hydrogen
Giant Papillary peroxide method (needs special case) are used for
Conjunctivitis sterilization.
• Cleansing the lens weekly with a proteolytic enzyme
solution
• Irrigation of the eyes 2-3 times daily with fresh saline
• Cromolyn sodium drops
• Changing the type of contact lens
 Giant Papillary Conjunctivitis

The contact lenses should be withdrawn until 3-5 days after healing in the following
cases:
• The tops of the giant papillae stain with fluorescein
• Heavy mucous on the papillary conjunctiva
• Significant tarsal hyperemia
• Increased lens movement when the eye blinks
Bacterial Conjunctivitis

• Important to recognize because

morbidity is higher than other causes
of conjunctivitis Age Causative agents
Neonatal C.trachomatis, N.gonorrhea
• Causative agents differ by age group
Children H. influenza, M.catarrhalis,
• Transmitted from hand to S.pneumoniae, S.aureus

eye, fomite to eye or respiratory Adults S.aureus, MRSA

droplets Contact lens wearers Gram negative species

Immunocompromised P.aeruginosa
• Peaks from December to April
Bacterial Conjunctivitis
Clinical symptoms and signs
• Unilateral or bilateral redness
• Glued / sticky eyes in the morning and on examination
• Absence of itchiness
• No burning sensation
• Discharge – mostly purulent or mucopurulent
• Absence of watery discharge
• No previous history of conjunctivitis
• Visual acuity not affected
• Otitis media may be present concurrently in children
Bacterial Conjunctivitis
Differential diagnoses
• Other causes of conjunctivitis
• Other causes of the red eye
• Trauma
Prognosis
• Usually resolves within 1 week even without treatment
• May become complicated with corneal disease (especially on contact
lens wearers)
Bacterial Conjunctivitis
Cultures may be obtained in recurrent or persistent cases or suspected gonococcal or chlamydial infections

Complicated cases (immunocompromised, neonatal conjunctivitis or contact lens wearer) must be managed with
antibiotics
Clean eyes 4 times daily with boiled water to 0.9% sodium chloride

Proper hand washing before and after contact with eyes

Replace any contact lenses, cases, makeup and makeup brushes

Wash pillows, towels and eyeglasses

Topical polymyxinB/trimethoprim, fluoroquinolones (3 drops twice daily) or chloramphenicol ( 4 times daily) for 5-7
days are sufficient
Ophthalmia Neonatorum
• Conjunctival infection in the neonatal period
• 30 –50% caused by S. aureus, Streptococci, gram negatives and H.
influenzae
• Most significant organisms: Neisseria Gonorrhea and Chlamydia
Trachomatis
• Transmitted at the time of vaginal delivery
• Complications are severe and may result in corneal perforation
leading to blindness
Ophthalmia Neonatorum

Neisseria Gonorrhea Chlamydia Trachomatis

Onset of Symptoms 2 – 5 days after birth 5-14 days after birth

Symptoms Thick, purulent discharge, chemosis Copious then purulent discharge

and eyelid edema and eyelid edema
Image
Ophthalmia Neonatorum

Differential Diagnoses
• Chemical conjunctivitis: presents as erythema, chemosis and discharge within the
first 24 hours of birth
• Bacterial conjunctivitis (e.g S.aureus)
• Viral Conjunctivitis (E.g. adenovirus, herpes simplex virus)
• Dacrocystitis
• Congenital Glaucoma
• Keratitis
• Nasolacrimal duct obstruction
• Cellulitis
 Prevention
• Prophylaxis with erythromycin ointment 0.5%
applied once at birth
• Screening for other STIs especially HIV
Treatment

Ophthalmia • Frequent eye irrigation with isotonic saline

• Neisseria Gonorrhea: Ceftriaxone 25-50mg/kg once
Neonatorum (maximum 125 mg) or Cefotaxime 100 mg/kg as a
single dose

• Chlamydia Trachomatis: Erythromycin 50

mg/kg/day orally for 14 days +/- topical
erythromycin
Trachoma
• Bacterial infection of the eyes caused by Chlamydia Trachomatis
• One of the leading causes of blindness worldwide
• Treatable
• Transmitted from infected family members through personal contact
or by flies that have been in contact with eye or nose discharge of the
patients
• Recurrence of infection causes a chronic immune response probably
type IV hypersensitivity reaction
Trachoma
• Starts as an active inflammation (more common in pre-school
children) and presents as trachomatous conjunctivitis
• Infection becomes less frequent with increasing age
• The disease is endemic in many regions and reinfection elicits an
immune response and scarring
• Leads to trichiasis, foreign body sensation, constant pain and
photophobia
• If left untreated, corneal opacities occurs with resulting blindness at
30-40 years of age
Trachoma
• Risk Factors
• Women more than men (more contact with children that are the
main reservoir of infection)
• Inadequate hygiene
• Crowded households
• Inadequate access to clean water
• Low socio-economic standard
 Trachoma
• WHO Staging
• Trachomatous inflammation, follicular (TF)
• Trachomatous inflammation, intense (TI)
• Trachomatous scarring (TS)
• Trachomatous trichiasis (TT)
• Corneal opacity (CO)
Trachoma
• A reportable disease
• Quarantine for infected family members
• Face hygiene
• Environmental sanitation and improve water access
• Azithromycin 1 gm PO once is sufficient
• Surgery may be required to manage trichiasis and scarring
Viral Conjunctivitis
• Viral infections are responsible for the majority of the cases of
conjunctivitis
• Adenovirus is the most isolated organism
• Other causative agents include herpes simplex virus, herpes zoster
virus, picornavirus, COVID 19 and trachoma
• Infection is transmitted by airborne infection, direct contact and
through swimming pools
• Children are the most affected with viral infections
Adenoviral Conjunctivitis
Presents with
• Fever
• Follicular conjunctivitis
• Periauricular lymphadenopathy
• Pharyngitis
• Some serotypes may lead to corneal involvement
Adenoviral Conjunctivitis
Prognosis
• Remains contagious for 10-14 days
Management
• Strict hand hygiene
• Do not touch anything after touching your eyes
• Replace contact lenses and makeup
• Povidone iodine 2% is sufficient for resolution of symptoms
Herpes simplex conjunctivitis
• Caused by herpes simplex I and II
• Primary infection usually occurs in the neonatal period after
urogenital transmission or during childhood from orolabial
transmission
• The virus remains latent in the trigeminal ganglia
• Secondary infection may be severe and may lead to blindness
 Herpes Simplex
Conjunctivitis
• Presents with:
• Dendritic ulcer
• Decreased corneal sensitivity
• Epithelial Keratitis
• Marginal Keratitis
• Blepharoconjunctivitis
Herpes Simplex Conjunctivitis
• Management
• Must be referred to an ophthalmologist
• Topical and systemic antiviral agents are used according to the
disease severity
• Topical acyclovir 3% ointment to gancyclovir 3% gel are used 5
times/day
• Systemic acyclovir 400 mg 5 times / day or Valacyclovir 500 mg 3
times/day are used
Herpes Zoster
Conjunctivitis
A young child suffering from fever and sore throat began to
complain of lacrimation. On examination, follicles were found in
the lower palpebral conjunctiva with tender preauricular lymph
nodes. The most probable diagnosis is:
A. Trachoma
B. Staphylococcal Conjunctivitis
C. Adenoviral Conjunctivitis
D.Phlyctenular Conjunctivitis
Ten years old boy complains of itching. On examination,
there are mucoid nodules with smooth rounded surface
on the limbus, and mucous white ropy mucopurulent
conjunctival discharge. He most probably suffers from:
A. Trachoma
B. Mucopurulent Conjunctivitis
C. Bulbar spring catarrh
D.Purulent Conjunctivitis
A female patient 18 years old, who is contact lens wearer since
two years, is complaining of redness, lacrimation and foreign
body sensation of both eyes. On examination, visual acuity was
6/6 with negative fluorescein test. The expected diagnosis can
be:
A. Acute anterior uveitis
B. Giant Papillary conjunctivitis
C. Bacterial corneal ulcer
D.Acute congestive glaucoma
A recurrent bilateral conjunctivitis occurring with the onset of
hot weather in young boys with symptoms of burning, itching,
and lacrimation with large flat topped cobble stone papillae
raised areas in the palpebral conjunctiva is:
A. Trachoma
B. Phlyctenular conjunctivitis
C. Mucopurulent conjunctivitis
D.Vernal keratoconjunctivitis
A 30 years old male presents with a history of injury to the eye with a leaf 5
days ago and pain, photophobia and redness of the eye for 2 days. What
would be the most likely pathology?
A. Anterior Uveitis
B. Conjunctivitis
C. Fungal Corneal Ulcer
D. Corneal Laceration
References
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• Vernal keratoconjunctivitis EyeWiki. Available at: https://eyewiki.aao.org/Vernal_Keratoconjunctivitis (Accessed: 05 November 2023).
• Preventing pink eye (conjunctivitis) (2019) Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/conjunctivitis/about/prevention.html
(Accessed: 05 November 2023).
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• Kanukollu, V.M. and Patel, B.C. (2021). Herpes Simplex Ophthalmicus. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK559194/.
• Hutnik, Cindy, and Cheema. “Bacterial Conjunctivitis.” Clinical Ophthalmology, Dec. 2010, p. 1451, https://doi.org/10.2147/opth.s10162.
• World Health Organization: WHO. “Trachoma.” Who.int, World Health Organization: WHO, 27 June 2019, www.who.int/news-room/fact-sheets/detail/trachoma.
• Castro Ochoa, Kenny J., and Magda D. Mendez. “Ophthalmia Neonatorum.” PubMed, StatPearls Publishing, 2021, www.ncbi.nlm.nih.gov/books/NBK551572/.
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