CONJUNCTIVITIS
The conjunctiva is the thin, transparent mucous membrane that lines the front part of the eyeball over the white sclera and the inner aspect of the eyelids, forming a continuous layer that physically prevents debris such as fallen eyelashes migrating to the back of the eye socket.
Conjunctivitis is an inflammation of that protective coat that is about 30 microns thick (roughly half the thickness of a human hair). Its supply of blood vessels dilates in response to inflammation and secretes mucus and tears, which contain immune cells to prevent infection. Chlorsig (OTC antibacterial) is commonly overused without prior examination.
Pain, sensitivity to light and visual disturbances are not the predominant features of conjunctivitis. The bulbar tissue stops at the junction between the sclera and cornea. The palpebral or tarsal conjunctiva covers the inner surface of both the upper and lower eyelids. When the small blood vessels in the conjunctiva are inflamed, they swell and become more visible, which causes the eyes to appear in a red eye or pink eye state.
Conjunctivitis needs to be differentiated from Corneal ulcer, Acute iritis, Acute glaucoma and then what form it is.
Treatments depend upon cause but to limit spreading
- Good hygiene is essential
- Keep your hands away from your eyes.
- Ensure towels, sheets, clothes, cosmetics etc., are fresh.
- Wash hands frequently.
- Handle and clean contact lenses properly.
Signs and symptoms:
- Redness
- Itchiness
- A gritty, uncomfortable feeling
- A discharge, which can form a crust during the night and make it difficult to open the eye in the morning, especially if bacterial
- Excessive tears especially if viral
- Swelling of the eyelid
- Sensitivity to light
Types of conjunctivitis
| Sign | Bacterial | Viral | Allergic |
|---|---|---|---|
| Bilaterality | Most cases | Normally one eye | Most cases |
| Discharge | Mucus/pussy | Watery | Little |
| Redness | Not so much in infants | Usually | Usually |
| Ear inflammation | 40% | 10% | No |
| Itchiness | No | No | No |
Viral conjunctivitis is the most common form of infectious conjunctivitis. A virus called adenovirus (which also causes respiratory infections and diarrhoea) is responsible for 65-90% of all cases of viral conjunctivitis. Other viruses, such as the herpes simplex virus (also responsible for cold sores) and varicella-zoster virus (also responsible for chickenpox), can also cause conjunctivitis.
The disease usually self-resolves in two to three weeks. No treatment may last for 2 or 3 weeks unless the herpes simplex virus can be treated with antiviral medications. Acyclovir oral tablet is available as both a generic and a brand-name drug Zovirax and an ointment and intravenous (IV) drug. Acyclovir is used to treat viral infections. These include varicella-zoster (shingles), genital herpes, and chickenpox.
Herpes simplex virus is the most common cause of the corneal ulcer.
The viral measles infection (that can be vaccinated against by the MMR- measles, mumps and rubella- vaccine) often presents as dry cough,running nose, rash, fever, and conjunctivitis that may not resolve quickly possible the bacterial form of conjunctivitis.
The staining pattern from fluorescein dye can help identify ulcer or damage causation (herpes). Wratten 12 and 15 are standard barrier filters in the slit lamp illumination that provide a deep yellow or orange colour to the dye. They work by eliminating all the reflected blue light. The filter can aid in the early diagnosis of ocular surface disease. It may help with staining related to contact lenses and solutions, RGP fluorescein patterns, and other corneal insults.
Bacterial conjunctivitis or post eye operation or foreign body removal chlorsig drops and ointment are used and not the high-dose oral form.
Bacterial conjunctivitis is less common than viral conjunctivitis and usually presents in both eyes, and tends to have a mucopurulent discharge. It is caused by bacteria such as Streptococcus pneumonia, Staphylococcus aureus, Moraxella catarrhalis and Haemophilus influenza.
Severe corneal ulcers can cause a hypopyon (a pool of WBC inferiorly in the anterior chamber). Hourly antibiotic drops or ointment is required
These bacteria are members of the typical colonies living on healthy eyes and usually do not cause disease. However, they can proliferate and cause conjunctivitis in certain conditions, such as dry eye, after damage to the eye, or in a weakened immune system. More commonly, though, these bacteria cause conjunctivitis when transmitted from an infected person to a non-infected person. Infective causes can be very contagious, e.g. coughing or sneezing in the viral form, which may last for up to two weeks. Children with bacterial pink eye may return to school or daycare 24 hours after starting eye drops or ointment. The conjunctivitis treatment depends upon the symptoms and cause.
Corneal abrasions and contact lens complications regarding the cornea can be vulnerable to severe Pseudomonas infection (bluish or green mucopurulent discharge.).Bacterial causes include staphylococcal infection, Pseudomonas Aeruginosa, Streptococcus pneumonia, and Moraxella. Pseudomonas Aeruginosa infections may have a bluish or green mucopurulent discharge.
Treatment with specific antibiotics for severe corneal infection is sometimes used. (e.g. ciprofloxacin, gentamicin, tobramycin).
Broad-spectrum antibiotic eye drops, such as chloramphenicol, are adequate but not in cases of STIs such as Neisseria gonorrhoeae (gonorrhoea) and Chlamydia trachomatis (chlamydia)
If contact lenses are involved, extra caution is required for correct diagnosis and treatment
Bacterial conjunctivitis is less common than viral conjunctivitis. It is caused by bacteria such as Streptococcus pneumonia, Staphylococcus aureus, Moraxella catarrhalis and Haemophilus influenza.
These bacteria are members of the normal colonies living on healthy eyes and usually do not cause disease. However, they can proliferate and cause conjunctivitis in certain conditions, such as dry eye, after damage to the eye, or in a weakened immune system. More commonly, though, these bacteria cause conjunctivitis when transmitted from an infected person to a non-infected person.
Broad-spectrum antibiotic eye drops, such as chloramphenicol, are adequate but not in cases of STIs such as Neisseria gonorrhoeae (gonorrhoea) and Chlamydia trachomatis (chlamydia)
Both viral and bacterial forms ( very contagious and be associated with sore throats and colds ) can cause a watery discharge, but the bacterial form usually has thicker yellow-green discharge.
Allergic causes include antihistamines and mast-cell stabilisers, anti-inflammatories and avoidance of allergens Allergic conjunctivitis is triggered by exposure to allergens. These include pollen, dust mites and animal dander (microscopic flecks of skin). Because micro-organisms do not cause it, this condition is not contagious and avoiding school or work is not required. Redness, itchiness and watering of both eyes are the prominent features. These may be accompanied by an itchy nose, itchy throat and sneezing.External irritant or allergen conditions can cause eczema, which affects the eye area. These occur more commonly in people with eczema elsewhere on the body – usually those with atopic eczema and related conditions (asthma and hay fever). Identifying and avoiding the offending allergen(s) is essential for treatment. This may require an allergy test. Symptom relief can be achieved through lubricating eye drops, cold compresses and antihistamine eye drops and tablets. These are available over the counter at pharmacies. However, eye drops containing the active ingredients antazoline and naphazoline (vasoconstrictors*, which reduce redness) should not be used for long periods. These may cause a rebound red eye when they are stopped. It is important to note that pain, sensitivity to light and visual disturbances are not features of conjunctivitis.
Sneezing, itchy mouth, sinus pressure, runny or blocked nose, headaches, red, sore and itchy eyes around springtime are classic hay fever and allergies. Inflammation can be moderated with antihistamine tablets, syrups, intranasal sprays and eye drops (non-sedating) Cold compresses help soothe red, inflamed eyes. Avoid eye rubbing ss it releases histamine increasing the inflammation. Allergic conjunctivitis is triggered by exposure to allergens such as pollen, dust mites and animal dander (microscopic flecks of skin). These may be accompanied by an itchy nose, itchy throat and sneezing. Associations with trachoma, allergic rhinitis, red eye, gonococcal causes, irritant causes, neonatal, giant papillary forms, degree of a sticky eye, discharge, eye redness all have to be considered to avoid recontamination.
Active substances that can cause allergic conjunctivitis include Animal fur,spores,Mould,Dust mites,Makeup,Eye drops. Pollen carried by the wind from plants and grass. Identifying and avoiding the offending allergen(s) is essential for treatment. This may require an allergy test.Symptom relief can be achieved through lubricating eye drops, cold compresses and OTC antihistamine eye drops and tablets.
However, eye drops containing the active ingredients antazoline and naphazoline (vasoconstrictors) should not be used for long periods as these may cause a rebound red eye when they are stopped. Allergies can affect both eyes and is often an IgE response inflammatory cascade, including histamine release. Artificial eyelashes or eyelash extensions sometimes can cause allergic or microbial reactions in the eye, so care is required.
Redness, itchiness and watering of both eyes are the prominent features.
In the newborn, certain infections can be invasive and can lead to rapid corneal perforation (gonorrhea) or conjunctivitis (chlamydia.) Newborn babies can pick up the condition as they pass through the birth canal. It can vary from severe, sight-threatening bacterial infection (e.g. from Chlamydia or Gonorrhoea) to less serious eye infections from more common bacteria or viruses resident in the birth canal or externally. In newborns, infectious causes can be severe and necessitating treatment.
In infants, babies and very young children, bacterial infection treatment may require swabbing and Paedetrician oversight and consider all structures rather than non-specialist OTC treatment.
A chemical injury or foreign object in the eye can result in red, watery eyes and a mucous discharge.
Often manifesting in some contact lens wearers as raised lumps diagnosed as Follicular or Papillary Conjunctivitis.
Management of GPC involves ceasing contact lens wear or monitor wearing times with daily lenses,if relevant. Often tear supplements are useds for flushing away of allergens and other debris. Topical mast cell stabilizers,and topical corticosteroids are needed under supervision.
Treatment of conjunctivitis and precautions with conjunctivitis
Causes of Eye Swelling on Both Sides.
- Oedema (serious). Edema is retained fluid within body tissues. Edema fluid first appears as swelling of the feet due to gravity. Edema fluid also occurs around both eyes after lying down. It’s caused by kidney, heart or liver failure.
- Anaphylaxis (severe). A severe life-threatening allergic reaction. Triggered by foods, drugs and bee stings. Serious symptoms such as trouble breathing or swallowing occur. Hives are almost always present.
Conjunctivitis can present in severe cases in later stages of the COVID 19 virus, rather than an initial presentation of the covid-19 infection.
Most forms are due to allergy, dryness or viral eye infections.
To avoid cross infection
- Keep your hands away from your eyes
- Wash hands frequently (and make sure children wash their hands properly)
- Handle and clean contact lenses properly
- Don’t share towels, tissues, handkerchiefs or cosmetics
Inflammation is normally from autoimmune causes, allergic reactions (sometimes requiring a diagnostic allergy test), dry eyes, mechanical irritation and not the bacterial form, especially in adults. Allergic dermatitis can be sudden and dramatic, after hours or days after contact with the allergen, e.g. medications such as atropine, neomycin drops, or preservatives in contact lens systems. Blepharitis refers to inflammation of the eyelid skin. It is a widespread problem found with seborrhoeic dermatitis that affects the face, scalp, ears and eyebrows, and eyelids. Small yellowish skin scales (dandruff scalp) collect around the eyelashes, making the eyes look tired, puffy and wrinkled.
How to get rid of conjunctivitis
Chlorsig OTC antibiotic drops and ointment
Iritis
The eye has two chambers separated by the lens that contains fluid that is normally homogenous and clear. The green lines indicate the anterior and posterior chamber showing microscopic particles that sometimes present there. Most commonly, vitreous floaters in the rear chamber are microscopic collagen fibres within the vitreous that tend to clump and cast shadows on the retina.
When the epithelial barrier between the blood vessel walls that supply the eye breaks down due to inflammation, proteins and white blood cells can enter the anterior and posterior chamber.
Uveitis is inflammation of one or all parts of the iris, the ciliary body, and the choroid. Iritis is uveitis but confined to the iris.
In iritis, the conjunctiva is most red at the border of the iris compared to conjunctivitis, which reddens the whites of the eyes.
Adhesions or synechiae between the iris can occur, which can be seen under the magnification of the slit lamp.
Also, floaters in the anterior chamber give rise to flare and circulate by convection currents and precipitate to the back of the cornea. There has been some concern over uveitis and Covid 19 regarding the suspected adverse drug reaction of AZD1222 vaccination.
Flare can be graded between nil to intense depending upon the number and density of cells seen under special magnification and illumination.
The “grainy” or Granulomatous form of inflammation may be due to infections like syphilis, tuberculosis, herpes infections or Lyme disease. Still, most commonly, it is associated with autoimmune disease or systemic illnesses.
Nongranulomatous inflammation is usually of unknown origin and more acute. It shows finer precipitates known as keratitis precipitates (KP’s).
Iritis requires instead an intense course of steroid eye drops (prednisolone acetate — Pred Forte) and a pupil dilation eye drop (e.g. atropine) to prevent the inflamed iris from sticking to the front of the eye’s natural lens. Anterior uveitis is an eye condition that has a strong association with other systemic inflammatory or autoimmune disorders.
Corneal foreign body
As an OTC product, precaution is still required as conjunctivitis can easily be misdiagnosed without slit-lamp examination.
In corneal foreign bodies, depth and size can be scanned by anterior OCT of the cornea.
Corneal foreign bodies, floaters, macula conditions can all be differentially diagnosed by slit lamp and Optical Coherence Tomography (OCT) examination.
READ MORE ABOUT CHLORSIG
- Chlorsig contains chloramphenicol, a synthetic antibiotic ( needs to be used judiciously, especially as is OTC ) as the active ingredient and is available as eye drops and eye ointment, for external use only.
Allergic reactions to Chlorsig may include irritation, pain and swelling in the eye. Skin rashes, blisters, and fever may also occur,
CHLORSIG EYE DROPS have Phenylmercuric acetate (0.002% w/v) as a preservative which can cause stinging.
CHLORSIG EYE OINTMENT contains no preservatives.
Chlorsig is overused, and caution applies in cases. It is used to treat a bacterial infection involving the mucous membrane of the eye’s surface and should ease after several days. Chlorsig eye drops are not associated with the rare Grey Baby Syndrome when injected chloramphenicol to the mother, cannot be metabolised sometimes by the baby.
Chlorsig is the generic name of an antibiotic drug used to treat eye infections. It was added to the PBS (pharmaceutical benefits scheme) in 2017 after being removed in 2016 with the restriction that it is only available to patients who identify as Aboriginal or Torres Strait Islander (ATSI).
Like trachoma (which leads to blindness), the rate of eye infections is three times higher for ATSI patients than for other Australians. The lower price for ATSI patients is extra funding under the government’s Closing the Gap PBS co-payment program.
The maximum cost to Aboriginal and Torres Strait Islanders: A$0-6.10
The maximum cost to other patients: A$20.11
Chlorsig eye drops dosage: For adults and children (2 years and over): For adults and children (2 years and over): Apply 1.5 cm of eye ointment every three hours for up to 5 days If ointment is used together with drops for day and night coverage, eye ointment should be applied before bedtime while using the drops during the day. If the condition does not get better after 2 days, seek advice. | Chlorsig eye drops: Active ingredient: Other ingredients: boric acid | Chlorsig eye ointment: Active ingredient: Other ingredients: paraffin – liquid |
PUNCTAL OCCLUSION TECHNIQUE TO REDUCE TEAR DUCT DRAINAGE
Punctal occlusion slows the drainage of the tears for better wetting times with poor tear volume. Punctal plugs are tiny biocompatible devices that are inserted into the lacrimal punctum.
This means penetration of any drops inserted into the eye and less systemic release and side effects. This involves pressing your finger near the inside drainage corner of your eye for 2 minutes after instilling the eye drop.The drop size of a commercial eyedropper bottle can be as large as 50-75 microlitres and the conjunctival sac is capable of holding only 25-30 microlitres so some are lost within 30 seconds but the total amount instilled disappearing within 10-20 min.
Allergic Conjunctvitis hayfever
Allergic rhinitis (commonly known as hay fever) affects around 18% of people (children and adults) in Australia.
A clinical immunology/allergy specialist referral may be required for further assessment, including allergy testing. e.g. particular season allergies to grass, weed or tree pollens, or year-round (usually house dust mites, moulds or animal hairs). Severe hay fever or chronic allergies can be treated with mast cell stabilisers or steroid eye drops.
• Intranasal corticosteroid nasal sprays (INCS)
• Decongestant sprays for no more than a few days.
• Decongestant tablets used with caution can have ‘stimulant’ side effects, e.g. tremors, anxiety or blood pressure issues.
Trachoma
The bacterial eye infection trachoma (known as ‘sandy blight’) has long been the leading infectious cause of blindness in the impoverished world. Repeated infections by contact with an infected person’s hands or clothing can, over the years, eventually lead to scarring that causes the margin of the eyelid to turn inwards, damaging the cornea, painfully scratching it and causing damage. Australia is the only developed country in the world where trachoma is endemic. Even very gentle eye rubbing can increase the pressure inside the eye and contribute to conditions such as keratoconus.
ECZEMA AND THE EYES
The itchy, red, dry, scaly seborrhoeic eczema of the eyelids affects just the eyelid margins and is seen more frequently in adults but occurs in all ages.
Emollients or topical steroids can treat eyelid eczema.
(0.5–1% hydrocortisone) Topical calcineurin inhibitors (TCI’s) are treatments that alter the immune system and have been developed for controlling eczema.
Tacrolimus ointment (Protopic) for moderate to severe eczema and Pimecrolimus cream (Elidel) for mild to moderate eczema.
A bland emollient to wash and moisturise can help. Contact dermatitis of the eyelids can occur as can be allergic or irritant in origins such as makeup, detergents, or solvents.