Noninfectious Conjunctivitis

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Table 4.4 provides an overview of pathogens, symptoms, and treatments of noninfectious conjunctivitis.

Acute conjunctivitis is frequently attributable to a series of external irritants or to dry eyes (conjunctivitis sicca). The disorder is unpleasant but benign. Primary symptoms include foreign-body sensation, reddening of the eyes of varying severity, and epiphora. Therapy should focus on eliminating the primary irritant and treating the symptoms.

Acute conjunctivitis should be distinguished from the group of allergic forms of conjunctivitis, which can be due to seasonal influences and often affect the nasal mucosa. Examples include allergic conjunctivitis (hay fever; Fig.4.17) and vernal conjunctivitis. In giant papillary conjunctivitis, the inflammation is triggered by a foreign body (hard or soft contact lenses. There may also be an additional chronic microbial irritation such microbial contamination of contact lenses. Phlyctenular keratoconjunctivitis is a delayed allergic reaction to microbial proteins or toxins (staphylococcal inflammation). This disease occurs frequently in atopic individuals and is promoted by poor hygiene. The cardinal rule in allergic conjunctivitis is to avoid the causative agent. Desensitization should be performed as a prophylactic measure by a dermatologist or allergist. Long-term treatment includes cromoglycic acid eyedrops to prevent mast cell degranulation. Treatment of acute allergic con-

Seasonal allergic conjunctivitis.

Seasonal allergic conjunctivitis.

Conjunctival Chemosis
Fig. 4.17 Conjunctival swelling (chemosis) in a patient with hay fever.

junctivitis consists of administering cooling compresses, artificial tears with preservatives, astringent eyedrops (tetryzoline and naphazoline), and, if necessary, surface-acting cortisone eyedrops (fluorometholone).

Ocular-mucocutaneous syndromes such as Stevens-Johnson syndrome (erythema multiforme), Lyell's syndrome (toxic epidermal necrolysis), and ocular pemphigoid (progressive shrinkage of the conjunctiva) are clinical syndromes that involve multiple toxic and immunologic causative mechanisms. The clinical course of the disorder is severe, therapeutic options are limited, and the prognosis for eyesight is poor (Fig. 4.18).

— Stevens-Johnson syndrome (erythema multiforme).

— Stevens-Johnson syndrome (erythema multiforme).

Symblepharon Treatment
Fig. 4.18 After several years the conjunctival sac has fused completely (total symblepharon), effectively causing blindness.
Table 4.4 Overview of noninfectious conjunctivitis

Cause and form of

Clinical

Symptoms and

Other characteristic

Treatment

conjunctivitis

course

findings

features

Acute con- Acute to Foreign body sensation, junctivitis chronic conjunctival reddening, epiphora, blepharitis

Lack of tears(keratoconjunctivitis sicca)

External irritants: smoke, heat, cold, wind (car window or open convertible top), ultraviolet light (welding, high-alti-tude sunlight).

Positional anomalies of the eyelids or eyelashes

Uncorrected refractive error (usually hyperopia)

Dysfunction of binocular vision (uncompensated heterophoria)

Improperly centered eyeglasses or wrong correction

Overexertion, lack of sleep (burnout syndrome)

Artificial tears

Avoiding specific irritants

Correction of anomaly or eyelash epilation

Eyeglasses

Prism lenses

Center or replace eyeglass lenses

Rest

Specific elimination of underlying cause

Allergie con- Acute Severe tearing, chemo-junetivitis (hay (seasonal) sis (can be extremely fever) severe), watery dis charge, foreign body sensation, sneezing

Typically accompanied by rhinitis; seasonal allergy to pollen, grasses, and plant allergens.

Desensitization Astringent eyedrops (tetry-zoline, naphazoline), if necessary with surface-acting cortisone eyedrops (fluorometholone)

Vernal con- Acute * Tarsal and conjuncti-

junctivitis (seasonal) val form: "cobble stone" conjunctival projections on the palpebral conjunctiva of the upper eyelid, pseudoptosis, foreign body sensation, epiphora Limbic form: Swelling of the bulbar conjunctiva is the primary symptom, accompanied by a ring of nodules on the limbus of the cornea, foreign body sensation, and epiphora.

Corneal involvement: Widespread corneal erosion to which mucus adheres (plaques), defensive triad of pain, blepharospasm, and epiphora.

Occurs in boys and male adolescents during spring, either isolated in the eyes or in combination with generalized asthma; IgE-mediated reaction.

Brief treatment with cortisone eyedrops to control swelling

Acetylcysteine gel to liquify the mucus

Cromoglycic acid eyedrops as prophylaxis during the asymptomatic interval Levocabastine hydrochloride

Continued

Table 4.4 (Continued)

Cause and form of

Clinical

Symptoms and

Other characteristic

Treatment

conjunctivitis

course

findings

features

o

Giant papillary Chronic conjunctivitis

Conjunctival reddening and irritation with pronounced papillary hypertrophy, similar to the findings and symptoms in vernal conjunctivitis

Frequently due to overwearing contact lenses (especially soft lenses); microbial component is probable (smear should be obtained)

Use of contact lenses should be discontinued until the inflammation abates. Contact lenses should be replaced or refitted; if the disorder recurs, they should be discontinued.

Phlyctenular ker- Chronic atoconjunctivitis

Discrete nodular areas of inflammation of the cornea or conjunctiva (phlyctenules), photophobia, epiphora, itching, rarely foreign body sensation, no pain

Usually occurs in children and young adults living in poor hygienic conditions and in countries characterized by a high rate of tuberculosis. The disease is uncommon in western countries.

Topical broad-spectrum antibiotics combined with cortisone or cortisone eyedrops alone provide rapid relief of symptoms.

Ocular-muco-

cutaneous syndrome

Stevens-Johnson Chronic syndrome (erythema multiforme)

Allergic, membranous conjunctivitis with blistering and increasing symblepharon; often the skin is also involved.

Toxic immunologic disorder, usually generalized as a reaction to medications (generally an antibiotic); life-threatening

Bland ointment therapy (such as Bepanthen) Rarely cortisone eye ointment

* Clean conjunctiva of fibrin daily

Lysis of symblepharon

Toxic epidermal Hyper-necrolysis (Lyell's acute syndrome)

Generalized blistering and shedding or necrotic skin, mucous membrane, and conjunctivitis

Extremely acute, life-threatening disorder

Stevens-Johnson and Lyell's syndromes have a similar clinical course and similar treatment as well.

Ocular Chronic Chronic bilateral con pemphigoid junctivitis persisting for years; leads to increased scarring, Symblepharon, and increasingly shallow conjunctival fornix that may progress to total obliteration of the conjunctival sac between the bulbar conjunctiva and the palpebral conjunctiva.

Autoimmune process with chronic episodic course; eyedrops and preservatives used in them exacerbate the process.*

Symptomatic: Artificial tears without preservatives

- Topical broad-spectrum antibiotics in case of bacterial superinfection

- Topical steroid therapy relieves symptoms. Note: this increases intraocular pressure (risk of cataract)

- Systemic steroids in an acute episode

- Immunosuppressive agents: cyclosporin A

Conjunctival irritation symptoms can occur with Graves' orbitopathy, gout, rosacea, neurodermatitis, erythema multiforme, Sjogren's syndrome, and Reiter's syndrome (triad: conjunctivitis or iridocyclitis, urethritis, and polyarthritis). Parinaud's oculoglandular syndrome describes a clinical syndrome of widely varied etiology. Granulomatous conjunctivitis always occurs unilaterally and in conjunction with swollen preauricular and submandibular lymph nodes in the presence of tuberculosis, syphilis, viruses, bacteria, fungi, and parasites. The excisional biopsy of the conjunctival granuloma is itself part of the treatment of granulomatous conjunctivitis. The specific medications will depend on the underlying disorder.

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Responses

  • demsas
    Is a visual acuity needed for conjunctivitis?
    6 months ago

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