Viral Conjunctivitis and it;s managment.pptx

Viral conjunctivitis, types and management

1. Dr Abeer Rehman Ophthalmology Resident Al- Shifa Trust Eye Hospital, Rawalpindi Viral C onjunctivitis

2. Case Scenario 22 year old college student visits your health centre with c/o redness , tearing and irritation in both eyes, scratchy feeling in her throat and low grade fever . O/E there is conjunctival hyperemia and some mild punctate keratitis . She denies any contact lens use or recent eye injuries.

3. Causative agents Adenoviral Keratoconjunctivitis Herpes Simplex Keratoconjunctivitis Herpes Zoster Conjunctivitis Picorna Viruses (Enterovirus and Coxsackie virus) Measles Mumps HIV

4. Herpes simplex virus Can cause follicular conjunctivitis particularly in primary infection Usually unilateral Associated skin vesicles Typical dendritic keratitis (Superficial punctate keratitis nay be detected in patients without dendritic lesions) Reduced corneal sensation Pseudomembranes /membranes and SEIs uncommon

5. Varicella zoster virus VZV gains access to sensory ganglia during primary infection (varicella) Reactivation of the latent virus in the trigeminal ganglia leads to involvement of V1 (ophthalmic nerve) dermatome and is referred to as herpes zoster ophthalmicus (Shingles)

6. Acute eye diseases in VZV Conjunctivitis (follicular/papillary) Episcleritis , scleritis Keratitis (Acute epithelial, nummular, stromal, disciform ) Anterior uveitis with sectoral iris ischaemia and atrophy Iop elevated Retinitis, choroiditis Neurological complications

7. Molluscum Contagiosum dsDNA poxvirus Peak incidence between the ages of 2-4 years Skin lesion shedding of viral particles  chronic follicular conjunctivitis

8. Acute Hemorrhagic Conjunctivitis Tropical areas Picorna virus family Enterovirus type 70 (EV70) and Coxsackievirus A type 24 variant (CA24v) Short incubation period, rapid disease course and less corneal Involvement Resolves within 1-2 weeks

9. Systemic viral infections Measles – High fever, cough, runny nose, generalised maculopapular rash, catarrhal conjunctivitis, superficial keratitis (severe in Vitamin A deficiency) and photophobia. Subconjunctival hemorrhages may be present. Mumps – Superficial punctate keratitis or stromal keratitis may be present. Secondary to HIV

10. Adenovirus Non-enveloped double stranded DNA virus 90% of all cases of viral conjunctivitis May be sporadic or occur in epidemics in environments such as workplaces (including hospitals), schools and swimming pools. Highly contagious Transmission is generally by contact with respiratory or ocular secretions, including via fomites such as contaminated towels.

11. Watering Redness Irritation Itching Photophobia (When cornea is involved) Symptoms

12. Types

13. Non specific acute follicular conjunctivitis Most common, milder form Caused by adenovirus serotypes 1-11 and 19 Initially unilateral symptoms. Other eye involved 1-2 days later but less severely Accompanying systemic symptoms such as a sore throat or common cold.

14. Epidemic keratoconjunctivitis (EKC) Most severe presentation and markedly contagious Caused by adenovirus serovars 8,19,37. Incubation period of 8 days and virus shed from inflamed eye for 2-3 weeks Keratitis ~ 80% Pseudomembranes Photophobia

15. Pharyngoconjunctival fever (PCF) Adenovirus Serovars 3, 4 and 7 Most commonly bilateral H/O upper respiratory tract infection Fever, pre-auricular lymphadenopathy Superficial punctate keratitis ~ 30% Hyperemia involves the entire conjunctiva but is more prominent in the inferior fornix

16. Chronic/relapsing adenoviral conjunctivitis Rare Gives a clinical picture of chronic non specific follicles/papillae Can persist over years, but eventually self limiting.

17. Signs Eyelid edema Tender preauricular lymphadenopathy Conjunctival hyperemia and follicles. Papillae may also be seen particularly Anterior uveitis is sometimes present but is mild.

18. Signs - Severe Conjunctival haemorrhage (usually petechial in adenoviral infection) Chemosis Membranes (rare) and pseudomembranes sometimes with conjunctival scarring after resolution and mild symblephara

19. Membranes can also rub against the cornea causing mechanical geographic ulcers mimicking Herpetic keratitis. Membranes/ Pseudomembranes

20. Stages of Adenoviral Keratitis Stage 1 Stage 2 Stage 3 Non staining epithelial microcysts develop within 1 st week. Punctate epithelial keratitis, developed within 7-10 days Resolves within 2 weeks Stage 4 Occurs after a further 24-48 hrs with focal white subepithelial/anterior stromal infiltrates Resolution of disease. The patient is left with non-staining subepithelial lesions

21. Generally unnecessary Giemsa stain Nucleic acid amplification techniques such as PCR Viral culture Immunochromatography Serology Investigation for other causes such as chlamydial infection may be indicated in non-resolving cases Investigations

22. Treatment Symptomatic treatment Artificial tears 4times/day preferably preservative free Topical antihistamines and vasoconstrictors Cold compresses Discontinuation of contact lens wear Removal of membranes/ pseudomembranes Topical antibiotics Povidone -iodine kills free adenoviruses

23. Topical steroids for severe membranous or pseudomembranous conjunctivitis and SEIs (May enhance viral replication and extend the period during which patient remains infectious) IOP should be monitored if treatment prolonged. Steroid sparing agents such as cyclosporine e/d to reduce the risk of scarring NSAIDs Treatment

24. Reduction of transmission risk Meticulous hand hygiene Washing pillowcases and towels often and avoid sharing them with others. Avoid eye rubbing Avoiding the use of swimming pools Disinfection of instruments and clinical surfaces after examining an infected person (Sodium hypochlorite, povidone -iodine) When necessary staying off school/work until symptoms have cleared ; this is generally when eyes are no longer red and irritated.

25. Surgery Late sequelae such as persisting scars, irregular shaping and irregular astigmatism after EKC may result in impairment of vision. In these cases a topography or wavefront-guided phototherapeutic keratectomy may restore vision.