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•Copious overflowing discharge
•Ballooning of lids
•Swollen nodes
Hyperacute Bacterial
Conjunctivitis
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Sexually active adults
Neonates, 24-72 hours after birth
Most common cause: Neisseria Gonorrhoeae
Urgent condition, can penetrate cornea!
Theyer Martin culture
Tx: Ceftriaxone 1g IM, adults=5days
kids=2days
• Also topical fluoroquinolone
• Positive papillary
response
• Beefy engorged
vessels
Acute Bacterial Conjunctivitis
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Susceptible at any age
Staph. Aureus is most common cause
Steroids mask evolution of infection
Tx: 4th gen fluoroquinilone
Very contagious, stay home
• Inferior Papillae
• Wax/wane
Chronic Bacterial
Conjunctivitis
• Staph epi or Staph. Aureus
• Inferior papillae because it has had time
to build up
• Superior papillary
response
• (-) lymphnode
• Edema > injection
Allergic Conjunctivitis
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Chemosis due to histamine breakdown
Hyperemia gets worse due to rubbing
Itching!!!!
PAC: Mast cell stabilizer then combo drug
SAC: Combo and sometimes mast cell
stabilizer
• Steroids great when allergen challenge
increases
• Giant Papillae upper
lid
• Trantas’ dots around
limbus (not always)
Vernal Conjunctivitis
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Kids, 90% gone by age 16
1st attack is worst
Males 2x more than females
Caucasians: palpebral form
AA/AI/Latinos: Limbal form
Bilateral
Sheild ulcer (uncommon)
Itching!!!
Mast cell stabilizer
Steroid great for first attack
• Nodule, pinkishwhite
• Center of lesion
necroses and turns
gray
Phlyctenulosis
• 60% are women and young children
• Most likely Staph. Exotoxin from previous
conjunctivitis
• Big in 1950s due to Tb
• Unilateral
• Pain, #1 symptom
• Inflammatory response, so steroids work
• Topical antibiotic to treat conjunctivitis
• Oral tetracyline if combo doesn’t work
• “wimpy conjunctivitis”
Environmental Conjunctivitis
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Inflammatory response
Multiple causes
Disease of exclusion
Can use mild steroid for a week to stop
complaining, then artificial tear
• Attempt to optimize tear quality by
management of blapharitis and
meibomitis
• Follicular response
• Vesicles
• Tender nodes
Primary Herpes Simplex
Conjunctivitis
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Children
60% of population infected by age 5, 90% by 16
Unilateral, other eye follows in a week
Doesn’t scar like zoster
Foreign body sensation
NO STEROIDS!
Zirgan can be used instead of viroptic, doesn’t
damage cornea as much
• Treat dendritic keratitis with viroptic/vidarabine
ointment/ganciclovir gel
• HSV dendrites: Rose bengal stains edges
Herpes Zoster Conjunctivitis
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Older patients (55+)
Hutchinson’s sign on nose
Triggered by stress or fatigue
May also cause keratitis and uveitis
Anti-virals w/in 72 hours then less chance of
post herpetic neuralgia
• Keratitis is Inflammatory, so treat with steroids
(unlike HSV)
• Psuedodendrites: Rose bengal stains middle
• Inferior follicles
• Subconjunctival or
petechial
hemorrhages
(maybe)
• SEIs
• Pseudomembranes
• Tender nodes
Epidemic Keratoconjunctivitis
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Young adults
Adenovirus 8 (can last days on surfaces)
No systemic manifestations
Unilateral, then other follows in a week or
less
R/O herpes, no vesicles or dermatomes
Consider any keratoconjunctivitis to be HSV
or EKC until proven otherwise
Contagious
Betadine ophthalmic prep solution
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Fever
Conjunctivitis
Sore Throat
Tender nodes
Follicles
Chemosis
Possible SEIs
Pharyngoconjunctival Fever
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Kids between 5-15
Swimming pool conjunctivitis
Adenovirus 3
Self limiting, 10-14 days
Don’t use aspirin for fever because kid
SEI interfere with vision, but not a big
deal in kids so don’t treat with steroids
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Fever
Cough
Coryza
Conjunctivitis
Koplik’s spots
Inferior follicles
Rubeola
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Children under 10
Passed respiratory
Highly contagious
Paramyxovirus
Supportive treatment, no antiviral (it will
tear up cornea)
• Unilateral follicular
conjunctivitis
• Granulomas with
follicles
• Node enlargement
• Chemosis
• Lid swelling
Oculoglandular Syndrome
• Cat scratch is most common cause
• Lymph node enlargement
• Lesion at site of scratch
Cat Scratch Disease
• Young children about 10, girls>boys
• Bartonela Hensulae Bacillus
• Lesion at site of scratch appears 3
weeks later
• Self limiting
• May need oral tetracycline or macrolide
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Fever
Chills
Malaise
HA
Nausea
Conjunctivitis,
necrotising
granulomatous type
Tularemia
• “Rabbit Fever” Franciella tularensis
• Lesion at site of organism entry with
adenopathy
• Treat with streptomycin
• Primary site in lungs
Tuberculosis
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Central American, pacific rim
Low income, inner city
Mycobacterium
Droplet spread
Treatment: rifampin
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Chancre
Local adenopathy
Uveitis
Argyl-robinson
Syphilis
• Primary: Chancre
• Secondary: uveitis, skin rash, flu
symptoms
• Tertiary: neurosyphilis, argyl-robinson
• Tx: penicillin or doxycycline
• Conjunctiva shows
red nodules that turn
pink to purple to
black and then
necrose
Sporotrichosis
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“Rose Gardeners Disease”
Sporothrix
Fungus lives on vegetables or in soil
Ulcerating nodules on extremeties and
along lymph channels
• Tx: local=potassium iodide
Systemic=ketoconazole
• 60% asymptomatic
• 40% fever, myalgia,
hilar adenopathy
• May progress to
chronic pneumonia
Coccidiodomycosis
• San Joaquin Valley and Southwest US immigrant farm workers (25-55 years old)
• Airborne Fungus
• ‘94 breakout after big earthquake
• If accompanied by arthritis and erythema
nodosa then called “valley fever syndrome:
• Tx: amphotericin B (very toxic) or
ketoconazole
• Fever, HA, malaise,
sore throat, white
patches on back of
throat
Mononucleosis
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Young adults, uncommon in >25
Epstein-Barr Virus
Acute episodes last from 1-3 weeks
Self limiting
Symptomatic relief
Possible penicillin for related strep
tonsillitis
• Hamster face
• HA, myalgia, fever
Mumps
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Kids
Myxovirus
Supportive therapy
Vaccination (MMR) at 15 months old
• Hard lumps on face
and neck
• Fever, chills,
reduced lung
function, chest
tightness, cough,
weezing
Actinomycosis
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Men 3x more than women
Little bug goes in face
Typically bad mouth hygiene
HX of dental extraction, abdominal
trauma, sinus infection, chronic
pneumonia
• Tx: oral penicillin or erythromycin
• Lungs = primary site
• Can involve liver,
skin, eyes, parotid
glands
Sarcoid
• Most common in female african americans in
US
• Granulomatas disease of unknown etiology
• Mild cases don’t require therapy
• Remits spontaneously
• Oral steroids used in severe or chronic cases
• Sometimes follicles,
sometimes papillae
Toxic conjunctivitis
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Common = sulfacetamide
Usually preservatives in meds (bilateral)
Viral toxins (unilateral)
Follicles not characteristic of all causative
agents
• Epinephrine causes adrenochrome deposits
(black spots on palpebral conj)
• TX: dicontinue all drops etc.
• Chronic follicular
conjunctivitis
• Upper tarsal
involvement with
follicles
• Conjunctival scarring
• Pannus
• Limbal follicles
• Herbert’s Pits
Trachoma
• Mainly children
• Leading cause of blindness in the world
because is scars the cornea
• Eye is reservoir for C. Trachomatis
• Make more susceptible to H. flu and strep
pneumoniae
• Advanced: basket weave of scarring on upper
lid
• Herbert’s pit = scarred limbal follicles
• Tx: oral tetracyclines, macrolides for kids,
triple sulfa is can’t take first two
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Papillary response
Follicles upper and lower
Micropannus
Tender pre-auricular nodes
Chronic presentation
Inclusion Conjunctivitis
• Women 15-24 most susceptible
• Also neonatal conjunctivitis
• Causes majority of infertility and need a slit
lamp to diagnose!
• Related to venereal disease
• Neotnates will only have papillae since lymph
tissue is not mature enough to make follicles
• Tx: Erythromycin 500mg PO, QID
• Other Tx: oral Tetracycline, Azithromycin
• Neonates: tetracycline ointment, oral
erythromycin
• Prominent limbal
arcades
• Nodules near limbus
Facial/Ocular Rosacea
• Women 4x more than men
• 20-40s have to rule out dermatitis
• Nodules not an acute response, takes a few
months
• Tx: Doxycyclone, Tetracyclines up to 8
weeks, more anti-inflammatory than steroids
with meibomian gland problems and rosacea
• Very mild steroid for anti-angiogenesis
• May need indefinite maintenance therapy
• Bullous blistering
• Symblepharon
• Keratinization of
conjunctiva
Benign Mucous Membrane
Pemphigoid
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75% more females, older
Unusual condition: 1 in 20,000
Type IV inflammatory reaction
No explaination
Possible mucoud membrane involvement
elsewhere
• Diagnosis of exclusion
• Tx: ocular lubricants on regular basis
• Immunosupressive therapy: Dapsone
• Blistering
• Skin lesions, black
lips
• Papular skin
eruptions
Erythema Multiforme
• Uncommon blistering disorder of skin and
mucous membranes
• Probably immune complex mediated
• Kick off most commonly by HSV and sulfa
meds
• Most severe: Stevens-Johnson Syndrome
• Tx: Immunosuppressants, Antobiotic for
secondary infections: fluoroquinilone
• Self limiting condition