CONJUNCTIVITIS

Supervisor :
dr. Muhammad Asroruddin, Sp. M

Anatria Amyrra Iqlima

I11112078
Anatomy
Conjunctiva is a thin mucous membrane that limits the inner
surface of the eyelids and folded back to wrap around the
front surface of the eyeball, except the clear portion in the
middle of the eye (cornea). This membrane contains many
blood vessels and turns red when there is inflammation.
Anatomy
Three parts of
conjunctiva:
Conjunctiva
palpebralis
Marginal conjunctiva
Tarsal conjunctiva
Orbital conjunctiva
Conjunctiva bulbaris
Cover part of the anterior
surface of the eyeball.
Separated from the
sclera anteriorly by
episclera tissue and
Tenon's capsule
Fornix
Histology
Conjunctival epithelial layer
Superficial epithelial cells
Basal epithelial cells
Conjunctival stroma
Adenoid layer
Fibrous layer
Conjunctiva has two glands :
Mucin secretory gland
Accessory lacrimal gland
Krause
Wolfring
Vascularization : a. siliaris anterior ; a. palpebralis
Innervation : first branch N.V
Definition
Conjunctivitis is inflammation of the
conjunctiva or inflammation of the
mucous membrane that cover eyelids and
eyeballs, in acute or chronic condition
Prevalence
Classification
Symptomps of Conjunctivitis in General

Discomfort and Foreign body

The pain that temporary
Itchy
Photophobia
Signs of Conjunctivitis in General
Hyperemia
Discharge (secretions)
Chemosis (conjunctiva edema)
Epistrophe (excess expenditure tear)
Pseudoptosis
Hypertrophy papillary blood vessels branching papillae cover
like the skeleton of an umbrella. Inflammatory exudate will
accumulate between the fibrils, forming conjunctival like a
mound
Hypertrophied follicles Local lymphoid hyperplasia
Membranes and pseudomembranous coagulation germs / toxic
materials
Fliktenula
Granuloma conjunctival stroma inflamed with red bulbous area and
there is a vascular injection
Swollen lymph nodes
Perbedaan Injeksi Konjungtiva
dan Injeksi Siliaris
Injeksi Konjungtiva Injeksi Siliaris
Kausa Iritasi, Konjungtivitis Keratitis,
Iridosiklitis,
Glaukoma Akut
Lokasi Forniks ke limbus Limbus ke forniks
makin kecil makin kecil
Warna Merah terang Merah padam
Pembuluh Bergerak dengan Tidak bergerak
darah konjungtiva
Adrenalin Menghilang Menetap
Sekret Sekret (+) Lakrimasi (+)
Intensitas Sedikit Nyeri
Nyeri
 Diagnosa banding
Glaukoma
Konjungtivitis Keratitis Uveitis Anterior
Kongestif Akut
Tergantung letak Menurun perlahan, Menurun
Visus Normal
infiltrat tergantung letak radang mendadak
Hiperemi konjungtiva perikornea siliar Mix injeksi
Epifora,
- + + -
fotofobia
Sekret Banyak - - -
Palpebra Normal Normal normal Edema
Edema, suram
Kornea Jernih Bercak infiltrat Gumpalan sel radang (tidak bening), halo
(+)
COA Cukup cukup Sel radang (+) dangkal
Sel radang (+), flare (+),
H. Aquous Normal normal Kental
tyndal efek (+)
Kripta menghilang
Iris Normal normal Kadang edema (bombans)
karena edema
Mid midriasis
Pupil Normal normal miosis
(d:5mm)

Lensa Normal normal Sel radang menempel Keruh

Klinik&Sitologi Viral Bakteri Chlamydia Alergika

Gatal Minim Minim Minim Hebat

Hiperemia Generalisata Generalisata Generalisata Generalisata

Eksudasi Minim Banyak Banyak Minimal

Menguncur
Adenopati Sering Jarang Hanya sering Tidak ada
preurikular pada
konjungtivitis
inklusi

Pewarnaan Monosit Bakteri, PMN PMN, Sel Eosinofil

kerokan & Plasma, badan
eksudat inklusi

Demam dan Sesekali Sesekali Tak Pernah Tak pernah

Sakit
tenggorokan
Lakrimasi ++ + + -
 Simple bacterial conjunctivitis
Signs

Crusted (Berkerak) eyelids and Subacute onset of mucopurulent

conjunctival injection discharge

Treatment - broad-spectrum topical antibiotics

- ceftriaxon 1 g single dose IM or ceftriaxon 1-2g / each
day for 5 days.
Etiology:
- Predisposing factors
- Causative organisms
- Acording to Mode of infection

BACTERIAL CONJUNCTIVITIS
 Vascular response

Cellular response

Conjunctival tissue repsonse

Conjunctival discharge

Pathology
1. Mucopurulent conjunctivitis.
2. Acute purulent conjunctivitis
3. Acute membranous conjunctivitis
4. Acute pseudomembranous
conjunctivitis
5. Chronic bacterial conjunctivitis
6. Chronic angular conjunctivitis

CLINICAL TYPES OF BACTERIAL

CONJUNCTIVITIS
Common causative bacteria are:,
Neonates: Chlamydia trachomatis,
Neisseria gonorrhoeae
Children: Haemophilus influenzae (80%),
Streptococcus pneumoniae (20%), and
Moraxella catarrhalis.
Adults : Staphylococcus aureus

1. MUCOPURULENT CONJUNCTIVITIS
Discomfort and foreign body
Mild photophobia.
Mucopurulent discharge from the eyes.
Sticking together of lid margins
Slight blurring of vision due to mucous
flakes
May complain of coloured halos.

Symptoms
Conjunctival congestion
Chemosis
Petechial haemorrhages
Flakes of mucopus
Cilia are usually matted
Yellow crust

Signs
Occasionally the disease may be
complicated by
marginal corneal ulcer,
superficial keratitis,
blepharitis or dacryocystitis

Complications
Etiology:
-causative organism
Clinical picture:
1 Stage of infiltraton
2 Stage of blenorrhoea
3 Stage of slow healing

2. PURULENT CONJUNCTIVITIS
Considerably painful and tender eyeball.
Bright red velvety chemosed conjunctiva.
Lids are tense and swollen.
Discharge is watery or sanguinous.
Pre-auricular lymph nodes are enlarged.

Stage of infiltraton
Frankly purulent, copious, thick discharge
trickling down the cheeks.
Other symptoms are increased but
tension in the lids is decreased

Stage of blenorrhoea
1. Corneal involvement
2. Iridocyclitis
3. Systemic complications
- gonorrhoea arthritis
- endocarditis
- septicaemia

Complications
Irrigation of the eyes
Topical atropine 1 percent

Patient and the sexual partner should be

referred for evaluation of other sexually
transmitted diseases

Treatment
Most common etiology: Staphylococcus
species
More common in adults and patients with acne
rosacea or facial seborrhea
Presentation varies: redness, itching, burning,
foreign-body sensation, flaky debris,
blepharitis (common), eyelash loss
Concurrently see styes and chalazia of the lid
margin from chronic inflammation of the
meibomian glands

3. Chronic Bacterial Conjunctivitis

3a. MEMBRANOSA CONJUNCTIVITIS
Etiology:
Corynebacterium diphteriae
Streptococcus haemolyticus
coagulation eksudat fibrinosa

3b. Pseudomembranosa conjungtivitis

Topical antibiotics- broad specturm
antibiotics
Irrigation of conjunctival sac
Anti-inflammatory and analgesic drugs

Treatment
 Gonococcal keratoconjunctivitis
Signs Complications

Acute, profuse, purulent discharge, Corneal ulceration, perforation

hyperaemia and chemosis and endophthalmitis if severe

Treatment
Topical gentamicin, bacitracin, ofloxaxin, levofloxacin
Intravenous cefoxitin, cefotaxime, ceftriaxone
Source and mode of infection:
- Before birth infection is very rare through
infected liquor amnii in mothers with
ruptured membrances
- During birth.
- After birth

OPHTHALMIA NEONATORUM
Chemical conjunctivitis
Gonococcal infection
Other bacterial infections
Herpes simplex ophthalmia neonatorum

Causative agents
1. Pain and tenderness in the eyeball.
2. Conjunctival discharge. It is purulent in
gonococcal ophthalmia neonatorum and
mucoid or mucopurulent in other bacterial
cases and neonatal inclusion
conjunctivitis.
3. Lids are usually swollen.
4. Conjunctiva may show hyperaemia and
chemosis
5. Corneal involvement, though rare.

Symptoms and signs

may develop corneal ulceration,
Which may perforate rapidly resulting in
corneal opacification or staphyloma
formation.

Complications
A. Prophylaxis needs antenatal, natal
and postnatal care.
Curative treatment:
Chemical ophthalmia neonatorum is a
self-limiting condition, and does not
require any treatment.

Treatment
Topical therapy
- Saline lavage
-Bacitracin eye ointment 4 times/day
However in cases with proved penicillin
susceptibility, penicillin drops 5000 to
10000 units per ml should be instilled
every minute for half an hour, every five
minutes for next half an hour and then
half hourly till the infection is controlled.
Systemic therapy:
Ceftriaxone 75-100 mg/kg/day IV or IM,
QID.
Cefotaxime 100-150 mg/kg/day IV or IM,
12 hourly.
Ciprofloxacin 10-20 mg/kg/day or
Norfloxacin 10 mg/kg/day.
Most common viral cause is adenovirus
(enterovirus, HSV)

Occurs in community epidemics (schools,

workplaces, physicians offices)

Usual modes of transmission:

contaminated fingers, medical
instruments, swimming pool water

Viral Conjunctivitis
 Presentation: May be part of viral
unilateral or bilateral, prodrome:
acutely red eye, adenopathy, fever,
watery or pharyngitis, cough,
mucoserous rhinorrhea
discharge, chemosis,
tender preauricular
node, burning/
sanding/gritty feeling
in eye(s), rarely
photophobia

Viral Conjunctivitis
Adenovirus conjunctivitis
Herpes simplex keratoconjunctivitis
Herpes zoster conjunctivitis
Pox virus conjunctivitis
Myxovirus conjunctivitis
Paramyxovirus conjunctivitis
ARBOR virus (ARthropod-BOrne virus)
conjunctivitis

Viral infections of conjunctiva

include:
Acute viral conjunctivitis may
present in three clinical forms:
1. Acute serous conjunctivitis
2. Acute haemorrhagic conjunctivitis
3. Acute follicular conjunctivitis

Clinical presentations.
May be part of viral prodrome:
tender preauricular node
adenopathy,
fever,
pharyngitis,
cough,
rhinorrhea
Etiology. It is typically caused by a mild
grade viral infection which does not give rise to
follicular response.

ACUTE SEROUS CONJUNCTIVITIS

Clinical features. Acute serous
conjunctivitis is
characterised by
- a minimal degree of congestion,
- watery discharge and
- boggy swelling of the conjunctival mucosa.
Treatment. Usually it is self-limiting and
does not
need any treatment.
But to avoid secondary bacterial infection,
--broad spectrum antibiotic eye drops may be
used three times a day for about 7 days.
 Adenoviral Keratoconjunctivitis
1. Pharyngoconjunctival fever
Adenovirus types 3 and 7
Typically affects children
Upper respiratory tract infection
Keratitis in 30% - usually mild

2. Epidemic keratoconjunctivitis
Adenovirus types 8 and 19
Very contageous
No systemic symptoms
Keratitis in 80% of cases - may be severe
 Signs of conjunctivitis

Usually bilateral, acute watery Subconjunctival haemorrhages and

discharge and follicles pseudomembranes if severe

Treatment - symptomatic 54
 Herpes simplex conjunctivitis
Signs

Unilateral eyelid vesicles Acute follicular conjunctivitis

Treatment - topical antivirals to prevent keratitis

55
ACUTE HAEMORRHAGIC CONJUNCTIVITIS
Itis an acute inflammation of conjunctiva
characterised by
multiple conjunctival haemorrhages,
conjunctival hyperaemia and
mild follicular hyperplasia.
Etiology.The disease is caused by
picornaviruses
Symptoms include :
pain,
redness,
watering,
mild photophobia
transient blurring of
vision and
Lid swelling.
Signs:
conjunctival congestion,
chemosis,
multiple haemorrhages in bulbar conjunctiva,
mild follicular hyperplasia,
lid oedema and
pre-auricular lymphadenopathy.
 Corneal involvement may occur in the form of
-fine epithelial keratitis.
 very infectious and poses major potential
problems of cross-infection. Therefore,
prophylactic measures are very important.
No specific effective curative treatment is
known. However,
broad spectrum antibiotic eye drops may be
used to prevent secondary bacterial infections.
Usually the disease has a self-limiting course of
5-7 days.

Treatment
Types
1. Acute follicular conjunctivitis.
2. Chronic follicular conjunctivitis.
3. Specific type of conjunctivitis with follicle
formation e.g., trachoma

FOLLICULAR CONJUNCTIVITIS
It is an acute catarrhal conjunctivitis
associated with--
marked follicular hyperplasia--
especially of the lower fornix and lower
palpebral conjunctiva.

ACUTE FOLLICULAR
CONJUNCTIVITIS
--- similar to acute catarrhal conjunctivitis
include:
Burning and grittiness in the eyes,
especially in the evening.
Feeling of heat and dryness on the lid
margins.
Difficulty in keeping the eyes open.
Feeling of sleepiness and tiredness in the
eyes

Symptoms
 Mild chronic redness in the eyes.
Mild mucoid discharge especially in the
canthi. Off and on lacrimation.
conjunctivalhyperaemia, associated with-
multiple follicles, more
prominent in lower lid than the upper lid

Signs
 Primary herpetic infection is usually
selflimiting.
The topical antiviral drugs control the
infection effectively and prevent
recurrences

Treatment
 Molluscum contagiosum conjunctivitis
Signs

Waxy, umbilicated eyelid nodule Ispilateral, chronic, mucoid

discharge
May be multiple Follicular conjuntivitis

Treatment - destruction of eyelid lesion

 Adult chlamydial keratoconjunctivitis
Infection with Chlamydia trachomatis serotypes D to K
Concomitant genital infection is common

Subacute, mucopurulent follicular Variable peripheral keratitis

conjunctivitis

Treatment - topical tetracycline and oral tetracycline

or erythromycin
Neonatal chlamydial conjunctivitis
Presents between 5 and 19 days after birth
May be associated with otitis, rhinitis and pneumonitis

Mucopurulent papillary conjunctivitis

Treatment - topical tetracycline and oral erythromycin

CLINICAL SIGNS Bacterial Viral

Congestion Marked Moderate

Chemosis ++

Subconjunctival
haemorrhages

Discharge Purulent or Watery

mucopurulent

Papillae

Follicles +

Pseudomembrane

Differentiate
Pannus Diagnosis

Pre-auricular lymph + ++
nodes
 Chlamydial conjunctivitis - Trachoma
Infection with serotypes A, B, Ba and C of Chlamydia trachomatis
Fly is major vector in infection-reinfection cycle

Progression

Acute follicular Conjunctival Herbert pits

conjunctivis scarring (Arlt line)

Pannus formation Trichiasis Cicatricial entropion

Treatment - systemic azithromycin

Trachoma
Trachoma - Mc Callan
Stadium Nama Gejala
Folikel imatur, hipertrofi
Stadium I Trakoma insipien
papilar minimal
Folikel matur pada dataran
Stadium II Trakoma
tarsal atas
Dengan Hipertrofi folikular
Stadium IIA Keratitis, Folikel limbal
yang menonjol
Aktivitas kuat dengan
Dengan Hipertrofi papilar folikel matur tertimbun
Stadium IIB
yang menonjol dibawah hipertrofi papilar
yang hebat
Parut pada konjungtiva
Stadium III Trakoma memarut (sikatrik) tarsal atas, permulaan
trikiasis, entropion
Tak aktif, tak ada hipertrofi
papilar atau folikular, parut
Stadium IV Trakoma sembuh
dalam bermacam derajat
variasi
Trachoma
Treatment
Tetrasiklin 1-1,5g each day - oral in four
dose for 3-4 weeks
Doksisiklin 100mg oral 2x1 in 3 weeks
Eritromisin 1g/day in four doses for 3-4
weeks
Azitromisin 1g - oral for childrens
Topical ointment or eye drops, like
sulfonamid, tetrasiklin, eritromisin, and
rifampisin, use it 4x1 in 6 weeks
Trachoma
Complication
Scars on conjunctiva reduce aqueosa
components on tear film precorneal
Cornea ulseration, cornea bacterial
infections, dan scars on cornea.
ALLERGIC CONJUNCTIVITIS

1. Allergic rhinoconjunctivitis

2. Vernal keratoconjunctivitis

3. Atopic keratoconjunctivitis
 Allergic rhinoconjunctivitis
Hypersensitivity reaction to specific airborn antigens
Frequently associated nasal symptoms
May be seasonal or perennial

Transient conjunctival oedema

Transient eyelid oedema
 Vernal keratoconjunctivitis
Frequently associated with atopy: asthma, hay fever and dermatitis
Recurrent, bilateral
Affects children and young
adults
More common in males
and in warm climates
Itching, mucoid discharge
and lacrimation
Types
Palpebral
Limbal
Mixed

Treatment
Topical mast cell stabilizers
Topical steroids
 Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus

80
Formation of cobblestone papillae Rupture of septae - giant papillae
Limbal vernal

Mucoid nodule Trantas dots

81
 Progression of vernal keratopathy

Punctate epitheliopathy Epithelial macroerosions

Plaque formation (shield ulcer) Subepithelial scarring

 Atopic keratoconjunctivitis

Typically affects young patients with Eyelids are red, thickened, macerated
atopic dermatitis and fissured

83
 Progression of atopic conjunctivitis
Infiltration of tarsal conjunctiva causing featureless appearance

Inferior forniceal papillae Mild symblepharon formation

84
 Progression of atopic keratopathy

Punctate epitheliopathy Persistent epithelial defects

Subepithelial scarring Peripheral vascularization

85
TERIMA KASIH