Dr.A.R.Rajalakshmi, 8.2.17 chronic conjunctivitis ii

1. CHRONIC
CONJUNCTIVITIS
DR.A.R.RAJALSKSHMI, M.S.

2.  Revision of previous class
 Submission of assignment

3. OUTLINE - CHRONIC
CONJUNCTIVITIS
 Definition
 Infective causes
 Allergic conjunctivitis
 Steven Johnson syndrome

4. DEFINE
 Duration of more than 4 weeks  chronic
conjunctivitis

5. OUTLINE
 TRACHOMA
 GRANULOMATOUS CONJUNCTIVITIS
 FUNGAL CONJUNCTIVITIS
 NON SPECIFIC CONJUNCTIVITIS

7. TRACHOMA
 The leading cause of preventable blindness in
the world
 15 – 20% world’s blindness
 Caused by chlamydia trachomatis A , B, Ba &
C
 Self limiting disease
 Repeated infections + secondary infection
blindness

8. CHLAMYDIA
CHLAMYDIA
TRACHOMA –
A,B,Ba,C
PARATRACHOMA
– D K
LGV –L1,L2,L3
C.PSITTACOSIS

9. Chlamydia trachomatis
 Bacterium – prokaryotic, obligatory
intracellular organism
 In Conjunctival epithelial cells as colonies –
HALBERSTEADTER – PROWAZEK
INCLUSION BODIES

10. LIFE CYCLE OF TRACHOMA

11. TRACHOMA
REPEATED
CONJUNCTIVITIS
• Does
not
cause
defectiv
e vision
CHRONIC
INFALMMATION
& SCARRING
• Complic
ations
Lid abnormalities
Corneal
complications
• Loss of
vision

12. Trachoma
 RISK FACTORS:
living in crowded & unhygienic
conditions
Transmitted by Fingers , Fomites &
FLIES

13. CLINICAL FEATURES
 ACTIVE STAGE
 CHRONIC STAGE
 COMPLICATIONS
ACTIVE
1st
decade
CHRONIC
2nd
decade
COMPLICATIONS
4th / 5th
decade

14. TRACHOMA
 CONJUNCTIVA
 Congestion, papillae & FOLLICLES
 UPPER TARSUS
 Follicles - > 5 mm in diameter
along the upper border of the upper
tarsus
NEVER ON THE BULBAR
CONJUNCTIVA
 MINUTE STELLATE SCARS
 HISTOPATH – aggregations of lymphocytes with
necrosis & leber cells - follicles

15. UPPER TARSAL FOLLICLES

16. FOLLICLES

17. TRACHOMA - CORNEA
CORNEA:
 Superficial keratitis – upper k – epithelial
erosions with infiltration
 TRACHOMATOUS PANNUS
 corneal ulcers
 LIMBUS – HERBERT FOLLICLES –
HERBERT PITS

18. TRACHOMATOUS PANNUS
 Defn: lymphoid infiltration with vascularisation
of the corneal margin – upper cornea
 2 types :
1. progressive pannus
2. regressive pannus

19. PANNUS
Progressive pannus regressive pannus

20. PANNUS

21. Corneal ulcer
 Usually occur at the advancing edge of the
pannus
 Shallow but more symptomatic

22. Chronic stage
 Cicatrization starts (SCARRING)
 Follicles - stellate scars
 Conjunctival scarring – Arlt line

23. COMPLICATIONS
 LIDS :
entropion, trichiasis, ptosis, tylosis,
madarosis & ankyloblepharon
 CONJUNCTIVA:
dry eyes, concretions, symblepharon
 CORNEA:
opacity, ectasia, xerosis, pannus
 Chronic dacryocystitis , chronic dacryoadenitis

25. video

26. investigations
 mcCoy cell cultures, monoclonal antibody test
& IgA-IPA light microscopy – best combination
 CLINICAL DIAGNOSIS:
any 2 of the signs
1.follicles on the upper tarsus
2.superficial keratitis – upper k
3.pannus – upper k
4.limbal follicles/ Herbert pits
5.stellate scars/Arlt’s line – upper tarsus

27. Maccallan classification
STAGES FEATURES
I IMMATURE FOLLICLES , SPK
IIA MATURE FOLLICLES
IIB PANNUS, LIMBAL FOLLICLES, SUPERFICIAL KERATITIS
III FOLLICLES + SCARRING
IV SCARRING

28. WHO CLASSIFICATION [
FISTO]
STAGES FEATURES TREATMENT
FOLLICLES ≥5 FOLLICLES, >0.5MM IN
UPPER TARSUS
NEEDS TREATMENT
NO SCARRING
INTENSE >50% PALPEBRAL BLOOD
VESSELS NOT SEEN
UREGENT
TREATMENT
COMPLICATIONS +
SCARRING TARSAL CONJ SCARRING WITH
WHITE FIBROUS BANDS
INACTIVE
TRICHIASIS ATLEAST ONE TRICHIATIC LASH CORRECTIVE
SURGERY
OPACITIES K OPACITY COVERING
PUPILLARY REGION

29. WHO CLASSIFICATION [
FISTO]
STAGES FEATURES TREATMENT
FOLLICLES ≥5 FOLLICLES, >0.5MM IN
UPPER TARSUS
NEEDS TREATMENT
NO SCARRING
INTENSE >50% PALPEBRAL BLOOD
VESSELS NOT SEEN
UREGENT
TREATMENT
COMPLICATIONS +
SCARRING TARSAL CONJ SCARRING WITH
WHITE FIBROUS BANDS
INACTIVE
TRICHIASIS ATLEAST ONE TRICHIATIC LASH CORRECTIVE
SURGERY
OPACITIES K OPACITY COVERING
PUPILLARY REGION

30. MANAGEMENT –
PREVENTION
How will you prevent this disease ?
 Manage the risk factors
 Frequent face wash & hand wash
 Prophylactic topical antibiotic therapy -
BLANKET THERAPY:
- In endemic areas
-1% tetracycline e/o 2 times / day –5 days a
month 6 months

31. TREATMENT – ACTIVE
STAGE
 TOPICAL:
 1% tetracycline / erythromycin
e/o
4 times /day 6 weeks
1% tetracycline e/o bed time6 weeks

32. TREATMENT
SYSTEMIC:
 Tetracycline / erythromycin 250mg q.i.d  3-4
wks
 Doxycycline 100 mg b.d  3-4 weeks
 Azithromycin 1 gm single dose

33. COMPLICATIONS
LID ABNORMALITIES
 lid surguries , EPILATION – trichiasis
CORNEAL OPACITY
 keratoplasty , optical iridectomy

34. TREATMENT- “nutshell”
 SAFE STRATEGY
S – surgery for trichiasis & entropion
A – antibiotic (erythromycin)
F – face washing
E – environmental hygiene

35. Management in a community
prevalence of
trachoma in
children 1-10 yrs
treatment Eye health
promotion
TF≥20%
TI≥5%
MASS TOPICAL
IF SEVERE- SYSTEMIC
SANITATION, FLIES
CONTROL, PERSONAL
HYGIENE,AB RX
DURING OUTBREAKS
TF 5-20% MASS TOPICAL
IF SEVERE -
SYSTEMIC
AS ABOVE
TF< 5% INDIVIDUAL TOPICAL
RX
CASE FINDING

36. IMPORTANT POINTS (must
know)
 By chlamydia trachomatis (HP bodies)
 3Fs – fomites , flies, fingers
 upper tarsal follicles  stellate scars, Arlt’s
line
 Trachomatous pannus  corneal opacity
 Lid trichiasis, entropion  corneal opacity
 FISTO
 SAFE STRATEGY

37. QUESTIONS
 TRACHOMA – essay
 Clinical features & complications of trachoma
 WHO classification of trachoma / FISTO
classification
 Management & prevention of trachoma
 SAFE strategy

38. GRANULOMATOUS
CONJUNCTIVITIS
 Rare, Unilateral , localised
conjunctival granuloma
 Associated with
LYMPHADENOPATHY
PARINAUD’S OCULOGLANDULAR
SYNDROME

39. GRANULOMATOUS
CONJUNCTIVITIS
 Pathogens causing systemic disease
 Enter through the conjunctiva
 Granulomatous conjunctivitis

40. CAUSES
 CAT SCRATCH DISEASE
 TULAREMIA
 TB
 SYPHILIS
 INFECTIOUS MONONUCLEOSIS
 FUNGAL
 LGV
 NON INFECTIOUS SARCOID,
LYMPHOMA, LEUKAEMIA

41. PARINAUD’S
OCULOGLANDULAR
SYNDROME

42. CLINICAL FEATURES
 SYSTEMIC: fever, malaise & skin rash
 LOCAL: redness, foreign body sensation
& mucopurulent discharge

43. OPHTHALMIA NODOSA
 Nodular conjunctivitis caused by caterpillar
hair
 Semitranslucent nodules on conjunctiva, k or
iris
 Hair surrounded by giant cells & lymphocytes
 Rx : excision

44. Ophthalmia nodosa

46. FUNGAL CONJUNCTIVITIS
 By aspergillus, candida, nocardia, leptothrix,
sporothrix
Modes of presentation:
 Follicular conjunctivitis with lymphadenopathy
 Ulcerative / pseudomembranous
 Granulomatous actinomycosis,
sporotrichosis, rhinosporidiosis
 Rx : topical miconazole or clotrimazole 1%

47. NON SPECIFIC
CONJUNCTIVITIS
 Continuation of simple conjunctivitis
 Chronic irritation: smoke, dust, heat, alcohol
abuse,etc
 Hypersensitivity to allergen
 Concretion, trichiasis, blepharitis,
dacryocystitis, chronic rhinitis
 Symptoms:
burning & grittiness ^^ in the evening

48. Non specific conjunctivitis
 Signs: lower lid congestion
sticky mucous membrane
Rx:
 Short course of antibiotics
 Eliminate the cause
 Lubricants

49. IMPORTANT QUESTIONS
 TRACHOMA
 TRACHOMA
 TRACHOMA
 Ophthalmia nodosa , Parinaud oculoglandular
syndrome.