Conjunctivitis – Allergic conjunctivitis (VKC)and Trachoma

Inflammation of conjunctiva due to allergic or hypersensitivity reactions which may be immediate (humoral) or delayed (cellular) to specific antigens
Types :
Simple allergic conjunctivitis
Hay fever conjunctivitis
Seasonal Conjunctivitis (SAC)
Perennial allergic conjunctivitis (PAC)
Vernal keratoconjunctivitis (VKS)
Atopic keratoconjunctivitis (AKC)
Giant papillary conjunctivitis (GPC)
Phlyctenular keratoconjunctivitis (PKC)
H1 antihistamine – vasoconstrictor : Antazoline phosphate 0.5% + Naphazoline hydrochloride 0.5%
Antihistamine with mast cell stabilization property: Olopatadine 0.1%, Epinastine, Azelastine, Ketotifin
H1 antihistamine : Levocabastine, emedastine
Mast cell stabilizer : Cromolyn sodium 4%, pemirolast potassium, Nedocromil, iodoxamide
Topical NSAIDS: Ketrorolac, Flurbiprofen
Topical Steroids : rarely necessary
Immunosuppressant’s (cyclosporin) for steroid resistant cases
Tear Substitute

1. Conjunctivitis – Allergic and Trachoma Dr Sambandha Dhoj Khati 2 nd year resident LEIRC 1

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3. Allergic conjunctivitis Inflammation of conjunctiva due to allergic or hypersensitivity reactions which may be immediate ( humoral ) or delayed (cellular) to specific antigens Types : Simple allergic conjunctivitis Hay fever conjunctivitis Seasonal Conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC) Vernal keratoconjunctivitis (VKS) Atopic keratoconjunctivitis (AKC) Giant papillary conjunctivitis (GPC) Phlyctenular keratoconjunctivitis (PKC) 3

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5. Simple allergic conjunctivitis Mild form of disease Type I Hypersensitivity reaction Two forms : Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC) 5

6. Etiology : Hay fever conjunctivitis : associated with allergic rhinitis Allergens : pollen , grass, animal dandruffs SAC : common and recurrent condition Caused by airborne allergen Worse during spring and summer PAC : from the allergens that exist year round : dust mites, animal dander or mold Less common and milder than SAC 6

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8. Symptoms : Itching (hallmark) Redness Tearing Burning sensation in eyes Sneezing and nasal discharge may be associated 8

9. Signs : Mild chemosis Conjunctival hyperemia Mild papillary reactions Eyelid edema Discharge : clear/ white discharge in acute Mucopurulent , thick , stringier discharge – chronic Allergic shiners Allergic salute 9

10. Investigation Generally not done Conjuctival scrapping : eosinophils Specific IgE level : increased in serum and tear Tear cytology : eosinophils , neutrophils Positive skin test : for specific allergens 10

11. Treatment Elimination of allergen if possible Preventive : limit time spent outdoor using air conditioner with filter avoiding animal dander Cold compression 11

12. H1 antihistamine – vasoconstrictor : Antazoline phosphate 0.5% + Naphazoline hydrochloride 0.5% Antihistamine with mast cell stabilization property : Olopatadine 0.1%, Epinastine , Azelastine , Ketotifin H1 antihistamine : Levocabastine , emedastine Mast cell stabilizer : Cromolyn sodium 4%, pemirolast potassium, Nedocromil , iodoxamide Topical NSAIDS: Ketrorolac , Flurbiprofen Topical Steroids : rarely necessary Immunosuppressant’s ( cyclosporin ) for steroid resistant cases Tear Substitute 12

13. Vernal Keratoconjunctivitis Derived from Greek word “vernal” meaning occurring in spring Rare but serious form of ocular allergy Recurrent bilateral disorders IgE and cell mediated immune mechanism plays role 13

14. Predisposing factors : 4-20 years, remission by late teen Common in males More in late spring and summer Prevalent in warm dry climates, middle east, north America , non-existent in cold climate Atopic condition – asthma, eczema present in 90% 2/3 rd have family history of atopy 14

15. Classification Palpebral VKC : primarily involves upper tarsal conjunctiva Limbal disease Mixed VKC 15

16. VKC pathology Conjunctival epithelium: hyperplasia and downward projection into the sub-epithelial tissue Adenoid layer : cellular infiltration by eosinophil’s, plasma cells, lymphocytes and histiocytes Fibrous layer: proliferation which later undergoes hyaline changes Conjunctival vessls : proliferation, increased permeability and vasodilation ALL THESE CHANGES LEADS TO MULTIPLE PAPILLAE FORMATION IN UPPER TARSAL CONJUNCTIVA 16

17. S ymptoms Intense itching Photophobia Lacrimation FB sensation Burning sensation Mucoid discharge – copious, tenacious, cord like 17

18. Signs Palpebral Disease : Early mild disease: conjunctival hyperemia, diffuse velvety papillary hypertrophy in upper tarsal plate Macro papillae (<1mm) : focal or diffuse, may progress to giant papillae (>1mm) over upper tarsal plate, Mucus deposition between giant papillae 18

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20. Limbal / bulbar form May start as a thickening and opacification of limbus Limbal nodules- mucoid nodules, which are gelatinous, elevated Horner – trantas dot – composed mainly of eosinophil's and epithelial debris ( limbal apices) 20

21. Limbal Vernal 21

22. Vernal keratopathy / corneal involvement Punctate epithelial erosion to macro erosions Sub epithelial scarring Pseudogerantoxon , Shield Ulcers – oval ulceration with thickened, opaque edges in upper part of cornea Superficial corneal vascularization keratoconus 22

23. Shield Ulceration pathophysiology 23

24. Hypothesis Mechanical hypothesis : Abrasion of cornea occurs by giant papillae on upper tarsal conjunctiva Hence there is superior location of shield ulcer Toxin hypothesis: Eosinophil granule contain major basic protein which are cytotoxic and inhibits epithelial healing Hence removal of inflammatory debris promotes epithelization 24

25. Grade I Transparent clear base Responds to medical management Minimal scarring, no vascularization Good outcome Grade II Inflammatory debris in ulcer base Responds poorly to medical management Surgical debridment of ulcer base required Re- epithelization in a week CAMERON’S GRADING OF SHIELD ULCER 25

26. Grade III Elevated plaque above surrounding epithelium Responds best to surgical treatment Promotes epithelization Antiscarring Antivascularization Anti inflammatory Acts as BCL 26

27. Progression of vernal keratopathy 27

28. Treatment Topical antihistamins Mast cell stablizers : Sodium chromoglycate 2% drops 4-5 times/day Topical steroid : every 4 hour for 2 days followed by 3-4 times a day for 2 weeks MONITOR IOP TO PREVENT STEROID INDUCED GLAUCOMA Acetylcysteine (10%) Topical cyclosporine (0.05%) : severe unresponsive case 28

29. Oral antihistamine : for itching Oral steroid : short course for very severe non responsive case Treatment of large papillae by supratarsal injection of long acting steroid or surgical removal General measures: dark goggles, cold compress, change of place from hot to cold 29

30. Supratarsal steriod injection TRICOT BEFORE AFTER 30

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32. The greater the papillary size, the more probable is the persistence or worsening of symptoms in the long term follow up period. Also indicated in poor prognosis for the persistence of the disease and its evolution into a chronic, perennial condition DOI:  10.1016/s0161-6420(00)00092-0 32

33. Other treatment modalities for giant papillae Surgical resection and autologous conjunctival graft in refractory cases Surgical resection and cryotherapy Superficial tarsectomy (compromises accessory lacrimal and meibomian gland function) Surgical resection and buccal mucous membrane graft 33

34. Differential diagnosis Bacterial/ viral conjunctivitis Rhinitis, dry eye Meibomian gland disease (resulting in tear film abnormality or insufficiency) Blepharitis Contact lens wear Topical and systemic medication use 34

35. Atopic keratoconjunctivitis Ocular manifestation of atopy Rare, billateral disease Peak incidence : 30-50 years of age No gender predilection Tends to be chronic and unremitting Both IgE and cell mediated immune response play role 35

36. Symptoms: Itching Soreness and dry sensation Mucoid discharge Photophobia Blurred of vision tearing 36

37. Signs Eyelids : Lid margin are chronically inflammed Maceration of inner and outer canthus Chornic blepharitis and madarosis may present Keratinization of lid margin may be present 37

38. Hertoghe sign Absense of the lateral portion of the eyebrow Dennie - morgan folds Lid skin folds caused by persistent rubbing 38

39. Conjunctiva Normally involves inferior palpebral conjunctiva Hyperemia, chemosis and watery discharge present Papillae are usually small Diffuse conjunctival infiltration, and scarring present 39

40. Cicatricial changes causes symblepharon formation and forniceal shortening Keratinization of caruncle Horner- trantas dots sometime present 40

41. Corneal Involvement : Punctate epithelial erosion over inferior third of cornea Peripheral vascularization and stromal scarring present Persistent epithelial defect may progress to cornea perforation and descematocele formation 41

42. Other: Anterior and posterior shield like cataract are common Retinal detachment and degenerative changes is common Risk of endophthalmitis are common after cataract surgery 42

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45. Investigation Serum and tear IgE : increased Conjunctival scrapping : eosinophil and mononuclear cells Tear assay : increased histamine, allergen specific IgE , tryptase 45

46. Treatment General measures: Allergen avoidance Cold compression Maintainance of eyelid hygiene Bandage contact lens 46

47. Local treatment Mast cell stabilizer: cromolyn sodium, neodocromil , iodoxamide Topical antihistamines: emendastine , epinastine , levocabastine , bepotastine Combined antihistamine and vasoconstriction: antazoline and oxymetazoline Combined antihistamine/ mast cell stabilizer : olopatadine , azelastine , ketotifen 47

48. NSAIDS Topical steroids along with topical antibiotics Mucolytic agents: N- acetylcysteine Immunomodulators : cyclosporin 0.05%, tacrolimus 0.03% ointment Supratarsal steroid injection : in severe palpebral disease and noncompliant 48

49. Systemic medication: Oral histamines, Oral antibiotics: to reduce blepharitis aggravated inflammtion . doxycyclin , azithromycin Immunosuppresive agent: steroids, cyclosporin , tacrolimus , azathioprine, mainly in AKC unresponsive to other treatment Other treatment: allergen desensitization, plasmapheresis in patient with high serum level of IgE 49

50. Surgery Superificial keratectomy: to remove plaque Surface maintenance/ restoration surgery : Amniotic membrane overlay graft or Lamellar keratoplasty Eyelid procedure – botulinum induced ptosis or lateral tarsorrhaphy – persistent ED or ulceration 50

51. Giant papillary conjunctivits Not a true allergic reaction Inflammatory reaction of upper tarsal conjunctiva associated with Contact lens use Surgical suture barbs Ocular prosthesis 51

52. Clinical features Symptoms Thick mucous discharge , I nflammed superior papillae B lurry vision FB sensation R edness Signs: Mild conjunctival hyperemia Papillary hypertrophy on upper tarsal conjunctiva Milky white discharge between the papillae 52

53. Treatment Offending cause should be removed Ensure effective cleaning of contact lens, prosthesis Topical medication : mast cell stabilizers, antihistaminics , NSAIDS can be used Steroids have limited role 53

54. Phlyctenular conjunctivitis Usually self limiting condition Delayed type hypersensitivity (type 4 ) reaction to tuberculous , staphylococcus antigens, moraxella axenfeld baccilus , parasites Common in developing countries Predisposing factors: Age: peak age group 3-15 years Gender : girls than boys Living condition : overcrowded and unhygenic 54

55. Pathology Stage of nodule formation : exudation and infiltration of lymphocytes Stage of ulceration : necrosis of apex of nodule leading to ulcer formation Stage of granulation Stage of healing 55

56. Symptoms Photophobia Lacrimation Mild discomfort blepharospasm 56

57. Signs: Simple : most common Typically pinkish-white nodule at limbus or conjunctiva surrounded by hyperemia, often solitary Necrotizing : very large phlycten with necrosis and ulceration Miliary : mulitple phlyctens , may be arranged like a ring around 57

58. Phlyctenular keratitis Ulcerative : Sacrofulous ulcer: shallow marginal ulcer Fascicular ulcer : has prominent parallel leash of vessels Miliary ulcer: multiple ulcers scattered all over Diffuse infiltrative: Central infiltration of cornea Characteristic rich vascularization all around limbus 58

59. Treatment Local therapy: Topical steroid eye drop and ointment Topical antibiotic eyedrop and ointment Atropine eye ointment when cornea involved Systemic therapy : Diagnosis and management of TB Septic foci like caries, folliculitis, tonsilitis , adenoiditis to be adequately treated Parasitic infestation to be ruled out and treated if present GENERAL MEASURES: improve hygiene and supplement high-protein diet 59

60. Contact dermoconjunctivitis Allergic reaction in the conjunctiva and eyelid skin to medications (or other toxic products like cosmetics) Etiology: delayed type hypersensitivity response to prolong contact with chemicals and ophthalmic medicines (atropine, neomycin, soframycin ) 60

61. Clinical feature Cutaneous involvement : Weeping eczema around the area involved with medication Conjunctival response : Lower fornix and lower palpebral conjunctiva 61

62. Treatment Discontinuing of causative chemical or medication Antihistamine NSAIDS Topical steroid eye drop Steroid ointment in involved surrounding area 62

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64. Comparison of VKC and AKC 64

65. TRACHOMA 65

66. Trachoma Formely called as egyptian ophthalmia Chronic keratoconjunctivitis Affecting superficial epithelium of cornea and conjunctiva Leading cause of preventable irreversible blindness Caused by Chlamydia trachomatis serovars A,B,Ba,C 66

67. Chlamydia trachomatis Three species: A, B, Ba and C trachoma (C is commenest ) D- K inclusion conjunctivitis L1, L2 and L3 lymphogranuloma venerum 67

68. Predisposing factors Age : infancy and childhood Gender : more in female Climate : dry and dusty weather Socio-economic status : poor, overcrowding, poor hygiene Environmental exposure to dust, irritant, smoke, sunlight 68

69. Source of infection : Conjunctival discharge of affected person Superimposed bacterial infection speed up process Mode of infection : Direct spread by airborne/water borne modes Vector transmission by flies ( Musca domestica ) Through contaminated fingers, clothing,bedding Incubation period : 5-21 days 69

70. Risk factors 6D’s Dry Dusty Dirty Dung Discharge Density (crowding) Transmission of Trachoma 5 F’s Fingers Flies Face Faeces Fomites 70

71. Development life cycle 71

72. Pathology C.trachomatis – prokaryotic, obligatory intracellular parasite Papillary hyperplasia Lymphoid infiltration Localized aggregation of lymphocytes form follicles Follicle is invaded by multinucleated macrophages Fibroblast grow from periphery and form scar Cicatricial conjunctiva undergo hyaline or amyloid degeneration 72

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75. Clinical features Symptoms Foreign body sensation Occasional lacrimation Stickiness of lids Scanty mucoid discharge Diminution of vision Photophobia 75

76. Signs: Divided into active trachoma and cicatricial trachoma Active trachoma Common in preschool children Mixed follicular and papillary reactions Mucopurulent discharge Superior epithelial keratitis Pannus formation 76

77. Pannus Progressive pannus : infiltration of cornea ahead of vessels Regressive pannus : vessels extend beyond the area of infiltration 77

78. Cicatricial trachoma : Prevalent in middle age Eyelid signs : trichiasis , distichiasis , cicatricial entropion Conjunctival signs : Linear or stellate conjunctival scars – mild cases Arlt’s line (broad confluent scar) – severe disease 78

79. Corneal signs Herbert pits Corneal vascularization Superificial punctate keratitis Corneal opacification 79

80. The WHO simplified system for the assessment of trachoma (1987) 80

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82. Mc callans classification Stage 1 – incipient trachoma / stage of infiltration Hypermia of palpebral conjunctiva and immature follicles Stage 2 – stage of florid infiltration Mature follicles, papillae, progressive pannus Stage 3- cicatrizaing trachoma/ stage of scarring Stage 4- healed trachoma / stage of sequale 82

83. Diagnosis Requires at least 2 of the following clinical features : Follicles on the upper tarsal conjunctiva Limbal follicles and their sequale ( herbert pits) Typical tarsal conjunctival scarring Vascular pannus most marked on the superior limbus 83

84. Sequelae Lids : trichiasis , entropion , tylosis , ptosis , madarosis Conjunctiva : concretion, pseudocyst , xerosis , symblepharon Cornea : opacity, ectasia , xerosis , total corneal pannus (blinding sequale ) Lacrimal apparatus : Punctal stenosis, fibrosis of canaliculi 84

85. Complication Corneal Ulcer Trichiasis Concretion (rubbing) Secondary bacterial infection Haemophilus aegypticus (commonest) 85

86. Differential diagnosis Folliculosis Toxic follicular conjunctivitis Molluscum contagiosum Topical drugs, cosmetics Bacterial conjunctivitis Axenfeld’s follicular conjunctivitis Chornic follicular conjunctivitis Perinaud’s oculoglandular sndrome Vernal conjunctivitis 86

87. Laboratory Diagnosis Detection of Halberstaedter - Prowazek bodies on smear done by conjunctival scrapping Lugol’s iodine Giemsa stain Immunofluorescent stain Cytology Isolation of chlamydia Yolk culture McCoy type II cells tritated with cyclohexamide Hela cell line 87

88. Serology Complement fixation test Immunodiffusion assay Radioisotope assay Micro- immunofluorescent antibody test ELSIA DNA probes and PCR 88

89. Management Treat the affected and the family members Topical therapy Oint . Tetracyclin 1% / Oint . Erythromycin 2-4times/day X 6 weeks Gtt. Azithromycn 1% BD X 2-3 days 89

90. Systemic antibiotics Tab . Azithromycin 20mg/kg single dose Tab. Tetracycline 250mg PO QID X 3-4 weeks Tab. Erythromycin 250mg PO QID X 3-4 weeks Tab Doxycyclin 100mg PO OD X 3-4 weeks 90

91. WHO recommendation for antibiotic treatment for trachoma Determine the district level prevalence of TF in 1-9 years old children: If prevalence is 10% or more, mass treatment with antibiotic throughout the district If prevalence is less than 10%, assessment at the community level in area of known disease 91

92. In assessment at the community level: In communities in which the prevalence of TF in 1-9 year-old children is 10% or more – mass treatment with antibiotic In communities in which the prevalence of TF in 1-9 years old children is 5% or more, but <10% - targeted treatment should be considered In communities in which the prevalence of TF in 1-9 year old children is <5% - antibiotic distribution is not recommended 92

93. Surgical management Concretion Removed with hypodermic needle Trichiasis Lash treatment Corrective lid surgery 93

94. 1 ) Lash treatment Epilation Lash follicle destructive procedure Cryotherapy Electrolysis Laser Radiotherapy Surgical excision of aberrant lash bearing follicles or tissue 94

95. 2) Corrective lid surgery Tarsal rotation procedure Tarsal advance procedure Posterior lamellar lengthening procedure Anterior lamellar and lid margin procedure Tarsectomy 95

96. Bilamellar Tarsal Rotation Bilamellar incision Horizontal matress sutures Postoperative lid eversion 96

97. Posterior Lamellar Tarsal Rotation Posterior lamellar incision Dividing posterior and anterior lamella Horizontal mattress sutures Postoperative lid eversion 97

98. Tarsal Advance and Rotation Posterior lamellar incision and division between posterior and anterior lamella Rotation and suturing of terminal tarsus, inferior advancement and suturing of posterior lamella 98

99. Prophylaxis Hygiene measure Health education Environment sanitation Good water supply Early treatment of conjunctivitis Blanket antibiotic therapy Intermittent treatment WHO recommendation – endemic areas Minimize intensity and severity of disease Regimen – 1% tetracyclin eye ointment BD X 5 days in a month for 6 months 99

100. Prevention of trachoma blindness Effective intervention (SAFE strategy) S urgery Correct lid deformity Prevent blindenss A ntibiotics Acute infection Community control F acial hygiene E nvironment changes Health education Sanitation Water supply 100

101. Achievement Nepal : first country in south- east Asia validated for eliminating trachoma (21 st MAY , 2018, 71 st General Assembly of WHO) https://www.who.int/news/item/21-05-2018-nepal-first-country-in-south-east-asia-validated-for-eliminating-trachoma 101