Conjuctivitis

Conjunctivitis is the most common inflammatory process affecting the conjunctiva. It is characterized by congestion, cellular infiltration and exudation. Typical symptoms are: swelling of the eyelids, which may progress to pseoudoptosis, secretion-glued eyelids in the morning, foreign body sensation and pressure in the affected eye, photophobia, increased tearing to blepharospasm, enlargement of the preauricular lymph nodes.

According to onset and duration, we can distinguish:

 * hyperacute conjunctivitis - within a few hours after contact
 * acute conjunctivitis - inflammation is unilateral, occurs within hours to days, affects the other eye during the week and does not last longer than 4 weeks
 * chronic conjunctivitis - longer than 4 weeks

According to the etiological point of view, we can distinguish:
Due to the etiology of the factors, there are a number of conjunctivitis, the clinical picture and symptoms of which may vary from individual to individual. The basis of the diagnosis is therefore a thorough examination. The general recommendation for conjunctivitis is not to use a bandage and to follow basic hygiene rules in an effort to minimize the damage to the other eye and infection of other members of the household. The clinical picture develops within hours. Conjunctival superficial injection and eyelid edema are other symptoms. Within 1-2 days, the other eye usually succumbs to inflammation. Bacterial conjunctivitis accounts for about 5% of all conjunctivitis.
 * infectious - bacterial, viral, parasitic, fungal
 * non-infectious - persistent irritation, allergic, toxic, in connection with other diseases

Hyperacute bacterial conjunctivitis
The infection is caused by Neisseria gonorrhoeae and Neisseria meningitidis. In the first case, it is mainly sexual transmission through direct contact (see neonatal conjunctivitis), or as an autoinfection of adults. The time window is only a few hours after the infection. Clinically, we describe painful to planar eyelid edema, chemosis, conjunctival injection and dense purulent secretion accompanied by swollen preauricular nodes. Untreated infection progresses to keratitis to corneal ulcer. Microscopic diagnosis confirms Gram-negative diplococcus stained according to Gram on swab and agar culture.

Therapy
Local and systemic antibiotics. Crystalline G penicillin i.m. 5-7 days at a dose of 100,000 IU / kg / day. Locally G penicillin 100,000 U / ml solid day after one hour, the next day after 2 hours and then 5 drops daily in both eyes 5 times a day. For beta-lactam allergy, we choose 2nd and 3rd generation cephalosporins.

Acute bacterial conjunctivitis
The most common pathogens are Streptococcus pneumoniae and Streptococcus pyogenes, Haemophilus influenzae, Staphylococcus aureus and Moraxella lacunata. Clinically, we describe conjunctival injection, tearing and slimy secretion, which glue the eyelids. The other eye is usually affected within 1-2 days. Streptococcus pneumoniae infection is accompanied by swelling of the eyelids, conjunctival hemorrhage, and the formation of membranes on the tarsal conjunctiva. Hemophilic infections, on the other hand, can lead to corneal complications (infiltrates, ulcers). In children, inflammation is usually accompanied by an alteration of the general condition. It disappears in 10-14 days.

Therapy
Iodidone rinsing (Betadine) with a dilution of 1:16, broad-spectrum anbiotics every 2–4 hours topically in drops or as an ointment with a duration of use of 7–10 days. Systemic antibiotic treatment is only necessary for chronic bacterial conjunctivitis.

Chronic bacterial conjunctivitis
Chronic bacterial conjunctivitis usually has a long, not dramatic course. The most common pathogens are S. aureus and Moraxella sp. Less often, they can typically be intestinal bacteria of the genus Proteus, E. coli, Klebsiella pneumoniae and others. The accompanying manifestation is inflammation of the eyelids.

A rare complication in the Czech Republic, however, is still the most common treatable cause of blindness in the world.

Viral conjunctivitis
Viral conjunctivitis is one of the most common conjunctivitis. Onset is usually very rapid, the patient complains of burning eyes (feeling of sand in the eyes), serous to serumucinous secretion, conjunctival injection, swelling of the eyelids, follicular reactions and swelling of the submandibular and preauricular nodes are visible. Virtually all viral agents (but most often adenoviruses) cause follicular conjunctivitis, sometimes with a transition to keratitis.

Adenovirus conjunctivitis
The disease is highly infectious, transmission is via secretions from the eyes or respiratory tract on daily necessities. Direct transmission by contact with an infected person is also possible. The duration of the disease is 3-6 weeks with the highest infectivity in the first week and a half. In clinical practice, we distinguish the course of infection as epidemic keratoconjunctivitis or as pharyngoconjunctival fever.

Epidemological conjunctivitis (KCE)
It is common in the adult population and is distinguished in three clinical stages. These first two stages result from the direct toxicity of the virus to the corneal epithelium. The infectivity of the infected is therefore the highest. At this stage, the infiltrates are already deposited subepithelially and in the surface layer of the corneal stroma. It can last for months to years.
 * I. stage - keratitis punctata in the first week of the disease
 * II. stage - keratitis epithelialis profunda in the second week of the disease
 * III.stage - keratitis subepithelialis nummularis in the third week

Therapy
We do not deal with KCE causally, we symptomatically apply eyelids, vasoconstrictors and short-term corticoids (maximum recommended time is one week) during a severe course affecting visual acuity.

Pharyngoconjunctival fever
It is typical of childhood, preceded by an upper respiratory tract infection accompanied by febrile illness. The onset is very rapid, follicular reactions of the eyelids, preauricular lymadenopathy and keratitis epithelialis punctata are typical manifestations. In severe cases, we also encounter pseudeomembranes and petechias. As with KCE, the therapy is purely symptomatic. As it affects children, cooperation with parents and sufficient erudition in the field of hygiene and the use of disposable daily necessities are essential.

Acute hemorrhagic conjunctivitis
It is a highly infectious disease caused by picornaviruses. As the name implies, subconjunctival hemorrhage and its swelling dominate in the clinical picture, as well as mucous secretion and lymphadenopathy of the preauricular nodes. An infected person feels tired when accompanied by inflammation of the upper respiratory tract. Therapy is symptomatic.

Conjunctivitis caused by HSV
Herpesviridae|Herpes simplex ]] viral conjunctivitis is very often unilateral, recurrent blepharoconjunctivitis with eyelid vesicles, conjunctival follicular response and preauricular node lymphadenopathy. The viruses behind inflammation are HSV 1 and 2. A dendritic epithelial lesion or keratitis punctata is typical. It is from the lesions that we can make a diagnosis, as well as by detecting the viral agent or culturing the virus. However, HSV conjunctivitis often occurs undiagnosed.

Keratitis dendritica-diagnosis seen by slit lamp examination. Fluorescein is used to elucidate the typical branched corneal patterns for herpes viruses.

Therapy
Antivirals locally in drops or ointments, in case of recurrent infections it is recommended to use them in general. Corticosteroids are strictly contraindicated.

Molluscum contagiosum
Rather, skin disease caused by poxvirus can occur at the edge of the eyelid, where it can cause chronic conjunctival irritation and inflammation. Treatment is surgical using excision or curettage.

Trachoma
It is one of the leading causes of blindness worldwide. It occurs in North Africa, the Middle East and India. The causative agent is Chlamydia trachomatis. Bilateral keratoconjunctivitis with mucous secretion resolves on its own. With repeated infections, follicle scarring occurs. Entropy, lagophthalmos, exposure keratitis and finally blindness develop. The diagnosis is confirmed by conjunctival cytology or, more recently, PCR.

Therapy
Represents the total administration of tetracycline 1-2 g daily p.o. for 3-6 weeks. We apply tetracycline ointment topically twice a day. We choose erythromycin for children and pregnant women.

Inclusive conjunctivitis
It is a sexually transmitted disease in adults. One week after contact, reddening of the eye occurs with mucous secretion and cutting. Large follicles are formed in the lower fornix, which can last untreated for many years.

Therapy
It is the same as trachoma. A single dose of 1 g of azithromycin orally is also sufficient. Sexual partners must always be treated.

Ocular cicatricidal
It is an autoimmune disease characterized by chronic scarring of the conjunctiva accompanied by extraordinary blisters and ulcers on the mucous membranes (oral cavity, nose, nasopharynx, larynx, trachea, urethra, vagina and anus), which subsequently also scarring. OCP appears after the 4th decade and most likely it is II. type of hypersensitivity to the production of antibodies against the epithelial basement membrane antigen. We distinguish the stage of the disease into 4 stages, which ends with keratinization of the cornea and conjunctiva, the formation of symblefaron and ankyblefaron.

Etiology
The infecting factors are usually eye infections and topical medications. The drug pseudopemphigoid is developmentally and pathognomically identical to OCP.

Therapy
Total immunosuppressants in monotherapy and in combination with corticoids. Topical therapy focuses on trichiasis, mucosal transplantation (oral cavity, nose) and the application of artificial tears. Corneal transplantation is unsuccessful, corneal defects can be healed by suturing the amniotic membrane, a temporary solution may be suturing a permanent keratoprosthesis.

References:

 * ROZSÍVAL, Pavel, et al. Ophthalmology. 1st edition. Prague: Galén, 2006. 373 pp.  ISBN 80-7262-404-0.


 * HYCL, Josef and Lucie VALEŠOVÁ. Atlas of ophthalmology. 1st edition. Prague: Triton, 2003.  ISBN 80-7254-382-2.