Dr. Amandeep Gupta Resident - Ophthalmology B.V.D.U Pune

1. DEPT. OF SHALAKYA TANTRA-NETRA ROGA
B.V.D.U.C.O.A;PUNE-43
CONJUNCTIVITIS
DR. AMANDEEP
GUPTA
M.S (SCHOLAR) NETRA
ROGA

2. CONJUNCTIVITIS
 The conjunctiva is a thin membrane that covers the inner
surface of the eyelid and the white part of the
eyeball(sclera).
 Inflammation of the conjunctiva is called conjunctivitis,
which makes the white of the eye appear red.

3. Parts of
Conjunctiva

4. Glands of conjunctiva

5. Prevalence
Adult
percent
Pediatric
percent
Bacterial 40 80
Viral 36 13
Allergic 24 2
No
diagnosis
24 15
Note: In U.S.A Bacterial conjunctivitis
(Chlamydia trachomatis or Neisseria
gonorrhoeae ) has been estimated to
account for between 377 and 875 U.S
dollar million annually in health care
cost .
Bacteria Patients (%age)
H. influenza 67.6
S. pneumonia 19.7
S. aureus 8.0
H.
Parainfluenza
e
2.5
Other bacteria 2.2
Causes of bacterial conjunctivitis in
238 culture positive patients
Meltzer JA et al. Arch Pediatr Adolesc
Med 2010; 164:263-267.
Prevalence of etiologies of acute
conjunctivitis By Age group
‘Data from weiss,A,Brinser,JH,Nazar-stewart,
V j Pediatr 1993,

6. TYPES OF CONJUNCTIVITIS
Infective
Conjunctivitis
Allergic conjunctivitis Cicatricial
conjunctivitis
Toxic conjunctivitis
• Bacterial
conjunctivitis
•Chlamydial
conjunctivitis
•Viral conjunctivitis
•Ophthalmia
neonatorum
•Granulomatous
conjunctivitis
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•Simplex conjunctivitis
•Vernal conjunctivitis
•Atopic conjunctivitis
•Giant papillary conjunctivitis
•Phlyctenular conjunctivitis
•Contact dermoconjunctivitis
•Ocular mucous membrane pemphigoid
•Toxic epidermal necrolysis
•Stevens Johnson syndrome
•Secondary cicatricial conjunctivitis

7. Bacterial conjunctivitis
Acute conjunctivitis Hyperacute conjunctivitis Chronic bacterial conjunctivitisAngular bacterial conjunctiv

8. Bacterial Conjunctivitis
Predisposing factors: Mode of Infection Causative organisms
•Flies
•Poor hygienic
conditions
•Hot dry climate
•Poor sanitation
•Dirty habits
•Exogenous Infection
•Local Spread
•Endogenous Infection
•Staphylococcus aureus-most
common
•Staphylococcus epidermidis
•Streptococcus pneumoniae
•Streptococcus pyogenes
•Haemophilus influenzae
•Moraxella lacunata
•Pseudomonas pyocyanea
•Neisseria gonorrhoeae
•Neisseria meningitidis
•Corynebacterium diptheriae

9. Acute bacterial conjunctivitis
•Characterized by marked conjunctival hyperaemia and
mucopurulent discharge.
•Most common
Symptoms
•Discomfort & F.B sensation
•Mucopurulent discharge
•Mild photophobia
•Slight blurring of vision
•Sticking of lid margins
•Coloured halos
Signs
•Conjunctival congestion
•Chemosis
•Petechial haemorrhages
•Flakes of mucopus
•Matting of eyelashes

10. Clinical course
•Peak in 3-4 days
•Cured in 10-15 days
•Pass it to chronic
catarrhal
conjunctivitis
Differential diagnosis
•Other causes of red eye
•Other type of conjunctivitis

11. Treatment
•Topical antibiotics: chloramphenicol / moxifloxacin /
tobramycin eye drops
•Ointment at night
•Anti-inflammatory & analgesic drugs
General measures:
Irrigation of conjunctivial sac
Dark goggles
No bandage
No steroids

12. Hyperacute bacterial conjunctivitis
•Characterised by a violent inflammatory
response.
•It occurs in two forms:
1) Adult purulent conjunctivitis
2) ophthalmia neonatorum in newborn
Hyperacute conjunctivitis of adults
Causative agents
•Gonococcus, staph.
aureus,pneumococuss

13. Symptoms
•Pain
•Purulent discharge
•Swelling of eyelids
signs
•Tenderness
•Purulent, copius thick discharge
•Bright red velvety chemosed conjunctiva
•Pre-auricular LN enlarged
•Tense and swollen lids

15. Treatment
•Systemic therapy
•Topical antibiotics therapy (moxifloxacin,ciprofloxacin or tobram
•Bacitracin ointment QID
•Add cycloplegics (if corneal involvement is there)
General measures:
 Frequent irrigation of eyes
Treatment of partner

16. Chronic bacterial conjunctivitis
ETIOLOGY:
•Predisposing factors:
Chronic exposure to smoke, dust, chemical
irritants
Local irritant as trichiasis, concretions, FB
Eye-strain due to Ref error,convergence
insufficiency
Alcohol abuse
Causative agents:
•Staph aureus commonly, gram-ve entrobaccilli

17. Source & mode of infections:
•As continuation of acute mucopurulent conjunctivitis
•As chronic infection from chronic dacryocystitis or
chronic URI
•As a mild exogenous infection from direct contact or
air-borne

18. SYMPTOMS:
•Burning & grittiness of eyes, specially in
evening
•Mild chronic redness
•Feeling of heat & dryness on lid margins
•Difficulty in keeping eyes open
•Mild mucoid disharge
•On & off lacrimation
•Feeling of sleeping & tiredness in the eyes
SIGNS:
•Congestion of posterior conjunctival vessels
•Mild papillary hypertrophy
•Surface of conjunctiva look sticky, congested
lid margins

19. TREATMENT:
•Topical antibiotics : chloramphenicol / gentamycin 3-
4 times for 2 weeks
•Astringent eye drops : zinc boric acid for
symptomatic relief

20. Angular bacterial conjunctivitis
•Mild chronic conjunctivitis confined to the
conjunctiva & lid margins near the angles
Etiology:
•Moraxella Axenfield Bacilli
•Rarely staphylococci
PATHOLOGY:
•Production of proteolytic enzyme
•Causes maceration of epithelium

21. SYMPTOMS:
•Irritation discomfort
•H/O collection of dirty white foamy discharge
at the angles
•Redness in the angles of the eye
SIGNS:
•Hyperaemia of bulbar conjunctiva near the
canthi
•Hyperaemia of lid margins near the angles
•Excoriation of skin around the angles
•Presence of foamy mucopurulent discharge at
the angles

22. TREATMENT:
•Oxytetracycline 1 % eye ointment 2-3 times x
10-14 days
•Zinc lotion at day time and zinc oxide ointment at
bedtime
General measures:
•Good personal hygiene

23. Ophthalmia neonatorum
•In children aged <30 days
•Any discharge or watering, in the first week of life
should arouse suspicion
ETIOLOGY:
•Before birth: infected amniotic fluid
•During birth: infected birth canal
•After birth: first bath, soiled clothes, unhygienic
conditions

24. CAUSITIVE AGENTS
•Chemical conjunctivitis: silver nitrate solution
•Gonococcal infection:
•Other bacterial infections:
Staph aureus
Strept hemolyticus
Strept pneumoniae
•Neonatal inclusion conjunctivitis:
Chlamydia trachomatis serotype D to K
•Herpes Simplex Ophthalmia Neonatorum

25. Incubation period
•Chemical conjunctivitis: 4-6 hours
•Gonococcal infection: 2-4 days
•Other bacterial infections: 4-5 days
•Neonatal inclusion conjunctivitis: 5-14 days
•Herpes Simplex Ophthalmia Neonatorum : 5-7
days

26. Clinical features
•Pain and tender eyeball
•Purulent conjunctival discharge (gonococcal)
•Mucoid / mucopurulent (other bacterial infections)
•Swollen lids
•Corneal involvement rarely
•Chemosed conjunctiva
•Watering
•Conjunctival congestion

27. Treatment
•PROPHYLAXIS:
Antenatal:
Treatment of genital infections of mother
Natal:
Delivery under aseptic conditions
Newborns eyelids should be well cleaned
Postnatal:
1% tetracycline / 0.5% erythromycin ointment
1 % silver nitrate solution (Crede’s method)
Single injection of Ceftriaxone 50mg/kg IM/IV

28. CURATIVE TREATMENT
•Chemical conjunctivitis: self-limiting
•Gonococcal:
•Topical:
Bacitracin ointment QID
•Moxifloxin drops 5000-10000units per ml every min for
30 min, every 5 min for 30 min, and then every 30m in till
infection controlled
•Atropine ointment if corneal involvement
•Systemic:
Ceftriaxone 75-100mg/kg/day IV/IM Q.I.D.
Cefotaxime 100-150mg/kg/day IV/IM B.D.
If gonococcal: cryst benzyl Peni G 50000 units for full
term babies (20000 to premature) IM BD x 3 days

29. Other bacterial infections
•Broad spectrum antibiotic drops / ointment x 2weeks
•Neonatal inclusion conjunctivitis:
Topical tetracycline / erythromycin ointment QID x
3weeks
Systemic erythromycin
•Herpes Simples:
Self limiting, topical antivirals control effectively

30. Chlamydial conjunctivitis
Trachoma Adult inclusion conjunctivitis Neonatal chamydial conjunct
•Lie midway between bacteria & viruses
•Obligate intracellular & filterable
•Contain both D.N.A & R.N.A
Chlamydial conjunctivitis

31. Trachoma
•Formerly called as Egyptian ophthalmia
•Chronic keratoconjunctivitis
•Affecting superficial epithelium of cornea and
conjunctiva
•One of the leading cause of preventable
blindness
•Characterized by mixed follicular & papillary
reaction
Etiology
CAUSITIVE ORGANISM:
•Chlamydia trachomatis (Psittacosis-lymphogranulomato
•11 serotypes recognized

32. PREDISPOSING FACTORS:
•Age: commonly in infancy & childhood, but age no bar
•Gender: more in females
•Race: very common in Jews
•Climate: dry & dusty weather favors
•Socio-economic status: more in poor classes due to
unhygienic conditions, overcrowding, unsanitary
conditions, flies, lack of education etc
•Environmental: exposure to dust, irritants, smoke,
sunlight etc

33. SOURCE OF INFECTION:
•Conjunctival discharge of affected person
Superimposed bacterial infection speed up the
process
MODES OF INFECTION:
•Direct spread by air-borne or water-borne modes
Vector transmission by flies Maternal transfer through
contaminated fingers, clothes, bedding etc

34. PREVALENCE:
•Mostly in North Africa, Middle East & South East
Asia
•Affecting 500 million people in world
•Responsible for 15-20% of blindnessSymptoms:
•No secondary bacterial infection:
Mild FB sensation
Occasional lacrimation
Stickiness of lids
Scanty mucoid discharge
•With secondary bacterial infection:
All typical symptoms of acute bacterial
conjunctivitis

35. Conjunctival signs:
•Congestion of upper tarsal and forniceal
conjunctiva
•Conjunctival follicles
•Papillary hyperplasia
•Conjunctival scarring
•Concretions
Corneal signs:
•Superficial keratitis
•Herbert follicles
•Pannus
•Corneal ulcer
•Herbert Pits
•Corneal opacity

36. Differential Diagnosis
•With follicular
hypertrophy:
Adenoviral
conjunctivitis
•With papillary
hypertrophy
Vernal Conjunctivitis

37. MANAGEMENT:
Treatment of Active Trachoma
•Topical therapy:
1% tetracycline / 1% erythromycin eye ointment 4 times
daily for 6 weeks
•Systemic therapy:
Tetracycline / erythromycin 250mg QID orally for 4 weeks
Or Doxycycline 100mg BD orally for 4 weeks
Or single dose of Azithromycin orally
•Combined therapy:
Preferred when severe disease
Or associated genital infection is present

38. Safe Strategy for Trachoma
Blindness:
•Surgery to correct eyelid deformity & prevent blindness
•Antibiotics for acute infections & community control
•Facial Hygiene
•Environmental changes

39. ADULT INCLUSION CONJUNCTIVITIS
•acute follicular conjunctivitis associated with
mucopurulent discharge
ETIOLOGY:
•Chlamydia trachomatis Serotype D to K
•Primary source urethritis & cervicitis
•Transmission through contact through fingers
Or by contaminated water of swimming pool

40. Incubation Period:
•4-12 days
Symptoms:
•Ocular discomfort, foreign body sensation
•Mild photophobia
•Mucopurulent discharge from the eyes
Signs:
•Conjunctival hyperaemia, marked in fornices.
•Acute follicular hypertrophy predominantly of lower
palpebral conjunctiva
•Superficial keratitis in upper half
•Superior micropannus occasionally
•Pre-auricular lymphadenopathy

41. Treatment:
•Topical therapy:
Tetracycline 1 % eye ointment QID for 6 weeks
•Systemic therapy:
Tetracycline 250 mg four times a day for 3-4
weeks.
Erythromycin 250 mg four times a day for 3-4
weeks
Doxycycline 100 mg twice a day for 1-2 weeks
200 mg weekly for 3 weeks
Azithromycin 1 gm as a single dose

42. Viral conjunctivitis
•Most viral infections are keratoconjunctivitis
VIRAL INFECTIONS OF CONJUNCTIVA
–Adenoviral conjunctivitis
–Herpes Simplex kerato conjunctivitis
–Herpes Zoster conjunctivitis
–Pox virus conjunctivitis
–Myxovirus conjunctivitis
–Paramyxovirus conjunctivitis
–ARBOR virus conjunctivitis

43. Clinical presentations:
Two clinical forms:
1. Acute haemorrhagic conjunctivitis
2. Acute follicular conjunctivitis
Adenoviral conjunctivitis
•Commonest cause of viral conjunctivitis
•Non- enveloped, double-standard DNA
viruses

44. Types of adenoviral conjunctivitis:
•Epidemic keratoconjunctivitis(EKC)
•Nonspecific acute follicular conjunctivitis
•Pharyngoconjunctival fever (PCF)
•Chronic relapsing adenoviral conjunctivitis

45. Epidemic keratoconjunctivitis:
•Associated with superficial punctate keratitis (SPK)
and occur in epidemics
•Adenovirus type 8 and 19
•Markedly contagious and direct contact transfer
•Incubation : 8 days
Symptoms:
•Redness associated with watering
•Mild mucoid discharge
•Ocular discomfort & f.b sensation
•Photophobia

46. Signs:
•Swollen eyelids
•Conjunctival signs:
Chemosis conjunctiva
Follicles (small to moderate size)
Petechial subconjunctival
haemorrhages
Pseudomembrane lining
Corneal involvement:
•superior punctate keratitis (typical feature of ekc)
Pre-auricular lymphadenopathy :
•Associated in all cases of ekc

48. Treatment :
 supportive therapy:
Cold compresses & sunglasses
Decongestant & lubricant tear drops

49. Pharyngoconjunctival fever:
•Adenovirus type 3 and 7
Acute follicular conjunctivitis
With pharyngitis, Fever & Pre auricular LN
•Primarily in children and in epidemic forms
•Corneal involvement in 30% cases
•Treatment : supportive

50. Newcastle conjunctivitis:
•Rare
•Caused by Newcastle virus
•Contact with diseased owls
•Affects poultry workers
•Similar to pharyngoconjunctival fever.

51. Acute herpetic conjunctivitis:
•Always accompanies with primary herpetic infection
•HSV type 1 commonly
•Clinically:
Usually unilateral, incubation within 3-10 days
Typical Form: Follicular conjunctivitis with other
herpetic lesions
Atypical Form: Follicular conjunctivitis without
other herpetic lesions
Corneal involvement & preauricular
lymphadenopathy
Treatment: self limiting, antiviral drugs

52. ACUTE HEMORRHAGIC
CONJUNCTIVITIS
•Acute conjunctivitis characterised by:
Multiple conjunctival hemorrhages
Hyperemia
Mild follicular hyperplasia
ETIOLOGY:
•Picornavirus
•Disease very contagious, direct hand-to-eye
contact
Clinical features:
•Incubation period: 1-2 days

53. Symptoms:
•Pain, redness, watering, mild photophobia
•Transient blurring of vision, lid edema
Signs:
•conjunctival congestion & chemosis
•multiple haemorrhages in bulbar conjunctiva
•mild follicular hyperplasia, lid oedema
•pre-auricular lymphadenopathy
•Fine corneal keratitis

54. Treatment:
•Prophylaxis very important
•No specific treatment
•Broad spectrum antibiotics
•Self-limiting within 5-7 days
•Supportive measures are same as
EKC

55. ALLERGIC CONJUNCTIVITIS
•Inflammation of conjunctiva due to allergic or
hypersensitivity reactions
TYPES:
1)Simple allergic conjunctivitis
•Hay fever conjunctivitis
•Seasonal allergic conjunctivitis (SAC)
•Perennial allergic conjunctivitis (PAC)
2)Vernal keratoconjunctivitis (VKC)
3)Atopic keratoconjunctivitis (AKC)
4)Giant papillary conjunctivitis (GPC)
5)Phlyctenular keratoconjunctivitis (PKC)
6)dermoconjunctivitis (CDC)

56. SIMPLE ALLERGIC CONJUNCTIVITIS
•Mild, non-specific allergic conjunctivitis
•Itching, hyperaemia and mild papillary
response
•Basically an urticarial reaction
Etiology:
•Hay fever : pollens, animal dandruff
•Seasonal allergens (grass pollens)
•Perenial allergens (house dust, mites)

57. Symptoms
•Intense itching & burning
•Watery discharge & mild photophobia
Signs:
•Hypreremia & chemosis
•Mild papillary reaction
•Lid edema may be present
Diagnosis:
•Typical signs & symptoms
•Normal conjunctival flora
•Abundant eosinophils in discharge

58. Treatment:
•Elimination of allergen if possible
•Local palliative measures for immediate relief:
•Vasoconstrictors : naphazoline, adrenaline, ephedrine
•Sodium cromoglycate eye drops
•Steroids only for short course in acute cases
•Systemic antihistaminics in acute cases
•Desensitization – not much effective

59. VERNAL KERATOCONJUNCTIVITIS
•Recurrent, bilateral, self-limiting, allergic inflammation of
conjunctiva
ETIOLOGY:
•Hypersensitivity to some exogenous allergen
•IgE mediated atopic mechanisms
Predisposing factors:
•4-20 years, common in males
•More in summer
•Prevalent in tropics, non-existent in cold climate

60. Symptoms:
•Marked burning and itching, usually intoreble
•Mild photophobia, lacrimation
•“Ropy Discharge”
•Heaviness of eyelids

61. Signs:
Palpabrel form:
•Upper tarsal conjunctiva
•Presence of hard, flat topped, papillae arranged in 'cobble-stone'
'pavement stone', fashion
•Giant papillae in severe cases
•White ropy conjunctival discharge
Bulbar form:
•Dusky red triangular congestion of bulbar conjunctiva in palpebra
•Gelatinous thickened accumulation of tissue around the limbus
•Presence of discrete whitish raised dots along the limbus (Tranta
Mixed:
•Combined features of both forms

62. 5 types of lesions can be seen:
1)Punctate epithelial keratitis:
•Involves upper cornea, mostly in palpabrel form
•Lesions always stain with rose bengal
2)Ulcerative vernal keratitis:
•Shallow transverse ulcer in upper part of cornea due to epithelial m
3)Vernal corneal plaques:
4)Due to coating of areas of epithelial macroerosions with coating o
exudates
•Subepithelial scarring:
•In a form of a ring scar
5)Pseudogerontoxon:
Classical cupid bow outline

63. Clinical course:
•Disease is self-limiting
•Usually goes off spontaneously in 5-10 years
Differential diagnosis:
•Trachoma with predominantly papillary hypertrophy
Treatment:
•Local therapy
•Systemic therapy
•Treatment of large papillae
•General measures
•Desensitization
•Treatment of vernal keratopathy

64. Treatment:
Local therapy
•Topical steroids:
Effective in all forms
Use should be minimal and for short-duration
Frequent instillation to tapering within few
days
Flouromethalone, dexamethasone,
loteprednol
•Mast cell stabilizers:
Sodium cromoglycate, azelastine, ketotifen
•Topical antihistaminic eye drops
•Acetyl cysteine (0.5%) eye drops
•Topical cyclosporine eye drops

65. Treatment:
Systemic therapy
•Oral histaminics
•Oral steroids in severe cases for short duration
Treatment of large papillae:
•Supratarsal injection of long acting steroid
•Cryo application
•Surgical excision for extra-ordinary large papillae

66. Treatment:
General measures:
•Dark goggles
•Cold compress & ice packs
•Change of environment (working environment also)
Desensitization
•Not much awarding results
Treatment of vernal keratopathy:
•PEK : steroid instillation should be increased
•Large vernal plaque: surgical lamellar keratectomy
•Severe shield ulcer: debridement, superficial keratectomy, amniotic membrane

67. ATOPIC KERATOCONJUNCTIVITIS
•Adult equivalent of vernal keratoconjunctivitis
•Often associated with atopic dermatitis
•Mostly young male adults
Symptoms:
•Itching, soreness, dry sensation
•Mucoid discharge
•Photophobia or blurred vision

68. Signs:
Lid margins:
•chronically inflamed
•rounded posterior borders
Tarsal conjunctiva:
•milky appearance
•very fine papillae, hyperaemia and scarring with shrink
Cornea:
•punctate epithelial keratitis
•more severe in lower half
•corneal vascularization, thinning and plaque

69. Clinical course:
•Protracted course
•Tends to become inactive by 5th decade
Treatment:
•Often frustrating
•Treat lid disease effectively
•Mast cell stabilizers, steroids, tear supplements may be

70. GIANT PAPILLARY CONJUNCTIVITIS
•Conjunctival inflammation with very large sized papillae
Etiology:
•Localized allergic response
•Contact lens, prosthetic shell
•Suture irritation
Symptoms:
•Itching, stringy discharge
•Reduced wearing time of contact lens or prosthetic shel
Signs:
•Papillary hypertrophy upper tarsal conjunctiva with hype

71. Treatment:
•The offending cause should be removed.
•Disodium cromoglycate is known to relieve the symptom
enhance the rate of resolution.
•Steroids are not of much use in this condition.

72. PHLYCTENULAR KERATOCONJUNCTIVITIS
•Nodular affection as a allergic response to
endogenous allergens
•World wide , more in developing countries
Etiology: Delayed hypersensitivity
•Causative allergens
•Tuberculous, Staphylococcus
•Proteins of Moraxella Axenfeld bacillius, Parasites
Predisposing factors
•Age. Peak age group is 3-15 years.
•Gender. Incidence is higher in girls than boys.
•Living conditions. Overcrowded and unhygienic.
•Season. all climates (spring and summer seasons)

73. Symptoms:
•Very few
•Mild discomfort, discharge, irritation, reflex tearing
Signs:
Simple:
•Most common
•Typical pinkish-white nodule at limbus surrounded by h
mostly solitary.
Necrotizing:
•Very large phlycten with necrosis & ulceration
•Leads to severe pustular conjunctivitis
Miliary:
•Multiple phlyctens, may be arranged like a ring around

74. Phlyctenular Keratitis:
Ulcerative:
•Sacrofulous ulcer: shallow marginal ulcer
•Fascicular ulcer: has prominent parallel
leash of vessels
•Miliary ulcer: multiple ulcers scattered all
over
Diffuse Infiltrative:
•Central infiltration of cornea
•Characteristic rich vascularization all around limbus
•Usually self-limiting, disappears in 8-10 days
D/D:
•Episcleritis, scleritis, FB granuloma

75. Treatment:
Local therapy:
•Topical steroid eye drops and ointment
•Topical antibiotic eye drops & ointment
•Atropine eye ointment when cornea involved
Systemic therapy:
•Diagnosis & management of TB
•Septic foci like caries, folliculitis, tonsillitis, adenoiditis to
adequately treated
•Parasitic infestations to be ruled out & treated if present
General measures:
•Improve hygiene & supplement high-protein diet

76. S.N
O
Name of book Author Publisher Edition
1. Comprehensive
ophthalmology
A.K
Khurana
Jaypee 6th
2. Kanski’s clinical
ophthalmology
Brad
bowling
Elsevier 8th
Bibliography