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An eye with conjunctivitis.
Conjunctivitis (also called pink eye or madras eye) is inflammation of the conjunctiva (the outermost layer of the eye and the inner surface of the eyelids). It is most commonly due to an infection (usually viral, but sometimes bacterial) or an allergic reaction.
Classification can be either by cause or by extent of the inflamed area.
- Allergic conjunctivitis
- Bacterial conjunctivitis
- Viral conjunctivitis
- Chemical conjunctivitis
- Neonatal conjunctivitis is often defined separately due to different organisms
By extent of involvement
Signs and symptoms
Red eye (hyperaemia), swelling of conjunctiva (chemosis) and watering (epiphora) of the eyes are symptoms common to all forms of conjunctivitis. However, the pupils should be normally reactive and the visual acuity normal.
Viral conjunctivitis is often associated with an infection of the upper respiratory tract, a common cold, and/or a sore throat. Its symptoms include excessive watering and itching. The infection usually begins with one eye, but may spread easily to the other.
Viral conjunctivitis, commonly known as pink eye, shows a fine, diffuse pinkness of the conjunctiva, which is easily mistaken for the ciliary injection of iritis, but there are usually corroborative signs on microscopy, particularly numerous lymphoid follicles on the tarsal conjunctiva, and sometimes a punctate keratitis.
Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and mucopurulent discharge. Typically, symptoms develop first in one eye, but may spread to the other eye within 2–5 days. Bacterial conjunctivitis due to common pyogenic (pus-producing) bacteria causes marked grittiness/irritation and a stringy, opaque, greyish or yellowish mucopurulent discharge that may cause the lids to stick together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may also occur, but, contrary to popular belief, discharge is not essential to the diagnosis. The gritty and/or scratchy feeling is sometimes localized enough for patients to insist they must have a foreign body in the eye. The more acute pyogenic infections can be painful.. Common bacteria responsible for non-acute bacterial conjunctivitis are Staphylococci and Streptococci.
Bacteria such as Chlamydia trachomatis or Moraxella can cause a non-exudative but persistent conjunctivitis without much redness. Bacterial conjunctivitis may cause the production of membranes or pseudomembranes that cover the conjunctiva. Pseudomembranes consist of a combination of inflammatory cells and exudates, and are loosely adherent to the conjunctiva, while true membranes are more tightly adherent and cannot be easily peeled away. Cases of bacterial conjunctivitis that involve the production of membranes or pseudomembranes are associated with Neisseria gonorrhoeae, β-hemolytic streptococci, and C. diphtheriae. Corynebacterium diphtheriae causes membrane formation in conjunctiva of non immunized children.
Chemical eye injury is due to either an acidic or alkali substance getting in the eye. Alkalis are typically worse than acidic burns. Mild burns will produce conjunctivitis while more severe burns may cause the cornea to turn white.Litmus paper is an easy way to rule out the diagnosis by verifying that the pH is within the normal range of 7.0—7.2. Large volumes of irrigation is the treatment of choice and should continue until the pH is 6—8.Local anaesthetic eye drops can be used to decrease the pain.
Irritant or toxic conjunctivitis show primarily marked redness. If due to splash injury, it is often present only in the lower conjunctival sac. With some chemicals, above all with caustic alkalis such as sodium hydroxide, there may be necrosis of the conjunctiva with a deceptively white eye due to vascular closure, followed by sloughing of the dead epithelium. This is likely to be associated with slit-lamp evidence of anterior uveitis.
Inclusion conjunctivitis of the newborn (ICN) is a conjunctivitis that may be caused by the bacteria Chlamydia trachomatis, and may lead to acute, purulent conjunctivitis. However, it is usually self-healing.
Conjunctivitis is identified by irritation and redness of the conjunctiva. Except in obvious pyogenic or toxic/chemical conjunctivitis, a slit lamp (biomicroscope) is needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva.
Conjunctivitis is most commonly caused by viral infection, but bacterial infections, allergies, other irritants and dryness are also common etiologies for its occurrence. Both bacterial and viral infections are contagious. Commonly, conjunctival infections are passed from person to person, but can also spread through contaminated objects or water.
The most common cause of viral conjunctivitis is adenoviruses.Herpetic keratoconjunctivitis (caused by herpes simplex viruses) can be serious and requires treatment with acyclovir. Acute hemorrhagic conjunctivitis is a highly contagious disease caused by one of two enteroviruses, Enterovirus 70 and Coxsackievirus A24. These were first identified in an outbreak in Ghana in 1969, and have spread worldwide since then, causing several epidemics.
The most common causes of acute bacterial conjunctivitis are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. Though very rare, hyperacute cases are usually caused by Neisseria gonorrhoeae or N. meningitidis. Chronic cases of bacterial conjunctivitis are those lasting longer than 3 weeks, and are typically caused by Staphylococcus aureus, Moraxella lacunata, or gram-negative enteric flora.
Cultures are done infrequently because most cases of conjunctivitis are treated empirically and (eventually) successfully, but often only after running the gamut of the common possibilities.
Swabs for bacterial culture are necessary if the history and signs suggest bacterial conjunctivitis, but there is no response to topical antibiotics. Viral culture may be appropriate in epidemic case clusters. Conjunctival scrapes for cytology can be useful in detecting chlamydial and fungal infections, allergy and dysplasia, but are rarely done because of the cost and the general lack of laboratory staff experienced in handling ocular specimens. Conjunctival incisional biopsy is occasionally done when granulomatous diseases (e.g., sarcoidosis) or dysplasia are suspected.
A purulent discharge (a whitish-yellow, yellow or yellow-brown substance, more commonly known as pus) suggests a bacterial infection. It can also be caused by bacteria from feces, pet hair, or by smoke or other fumes. Infection with Neisseria gonorrhoeae should be suspected if the discharge is particularly thick and copious.
A diffuse, less "injected" conjunctivitis (looking pink rather than red) suggests a viral cause, especially if numerous follicles are present on the lower tarsal conjunctiva on biomicroscopy.
Other symptoms, including pain, blurring of vision and photophobia, should not be prominent in conjunctivitis. Fluctuating blurring is common, due to tearing and mucoid discharge. Mild photophobia is common. However, if any of these symptoms are prominent, it is important to exclude other diseases such as glaucoma, uveitis, keratitis and even meningitis or caroticocavernous fistula.
Many people with conjunctivitis have trouble opening their eyes in the morning because of the dried mucus on their eyelids. There is often excess mucus over the eye after sleeping for an extended period.
The best effective prevention is hygiene and not rubbing the eyes by infected hands. Vaccination against adenovirus, haemophilus influenzae, pneumococcus, and neisseria meningitidis is also effective.
Conjunctivitis resolves in 65% of cases without treatment, within two to five days. The prescription of antibiotics is not necessary in most cases.
For the allergic type, cool water poured over the face with the head inclined downward constricts capillaries, and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, nonsteroidal anti-inflammatory medications and antihistamines may be prescribed. Persistent allergic conjunctivitis may also require topical steroid drops.
Bacterial conjunctivitis usually resolves without treatment. Antibiotics, eye drops, or ointment may only be needed if no improvement is observed after three days. In people receiving no antibiotics, recovery was in 4.8 days, with immediate antibiotics it was 3.3 days, and with delayed antibiotics 3.9 days. No serious effects were noted either with or without treatment. As they do speed healing in bacterial conjunctivitis, their use is also reasonable.
When appropriate, the choice of antibiotic varies, differing based on the cause (if known) or the likely cause of the conjunctivitis. For acute cases, 3rd or 4th generation fluoroquinolones, sodium sulfacetamide, or trimethoprim/polymyxin may be used, typically for 7–10 days. Cases of meningococcal conjunctivitis can be treated with systemic penicillin, as long as the strain is sensitive to penicillin.
The number of bacterial eye infections related to sexually transmitted disease is steadily rising. Chlamydial eye infections are the world's leading cause of blindness, and these cases will not resolve without antibiotics. If the conjunctivitis is known to be caused by gonorrhea, then it may be treated with a one-time injection of ceftriaxone, followed by 2–3 weeks of oral tetracycline or erythromycin.
In 2001, a stir was created when an ophthalmologist published anecdotal evidence that a brief povidone iodine eye wash in patients known to be suffering from viral conjunctivitis successfully helped to resolve the malady far faster than observation and supportive therapy alone. Since that time, investigators have been evaluating the agent to officially validate its use in this regard as well as potentially expand its role in the management of ocular disease. In the Review of Optometry 2002 Clinical Guide to Ophthalmic Drugs, Melton and Thomas present an "off-label" use of Betadine 5% solution to treat viral conjunctivitis.
However, in one study, though povidone iodine 1.25% ophthalmic solution was as effective as neomycin-polymyxin B-gramicidin for treating bacterial conjunctivitis and was somewhat more effective against Chlamydia, it was judged ineffective against viral conjunctivitis.
In 2011, Derek Cunningham, O.D., of Dell Laser Consultants Austin, noted that almost all published studies on povidone-iodine to that date have been from animal models or conjunctival isolates from normal eyes, and that there is a lack of well-controlled studies on the clinical effects of povidone-iodine mono-treatment on infected eyes.
The new treatment for viral eye infection involves a single treatment of Iodine solution (Betadine 2.5–5% concentration). After ocular anaesthetization, made necessary by the Iodine solution's irritating nature to the eye, a series of drops are instilled in the patient's eye.[unreliable medical source?] It is generally advisable to avoid touching the eyes or sharing towels and washcloths in the case of viral Conjunctivitis infection.
Because a topical anesthetic must be used, this should be an in-office procedure only, says Dr. Cunningham. Using Betadine as an at-home remedy could be dangerous for several reasons, especially because Betadine is a trade name for different solutions containing povidone-iodine, "Many commercially available [non-ophthalmic] preparations can contain detergents that are disruptive to tissue and can cause considerable cornea and conjunctiva damage," he says. "Time of exposure and possible adverse reactions need to be monitored [in office]."
Conjunctivitis due to chemicals is treated via irrigation with Ringer's lactate or saline solution. Chemical injuries (particularly alkali burns) are medical emergencies, as they can lead to severe scarring and intraocular damage. People with chemically induced conjunctivitis should not touch their eyes, regardless of whether or not their hands are clean, as they run the risk of spreading the condition to another eye.
A former superintendent of the Regional Institute of Ophthalmology in the city of Madras (the present day Chennai), India, Kirk Patrick, was the first to have found the adenovirus that caused conjunctivitis, leading to the name Madras eye for the disease.
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