Abstract

Aim : To describe the case profile and conjunctivitis management in dr. Saiful Anwar
Malang, during the period of January 2018 to December 2019.

Methods: This study used a retrospective analysis of the patients medical records
with conjunctivitis diagnosis at dr. Saiful Anwar Malang Hospital during the visit
period from January 2018 to December 2019. The recording included demographic
data in the form of age and gender, perceived complaints, eyes involved, conjunctival
ophthalmological examinations in the form of papils and follicles, diagnosis and
treatment given.

Results: There were 321 patients diagnosed with conjunctivitis. Demographic data
based on gender obtained 205 women (63.86%) and 116 (36.14%) men. Most
conjunctivitis at the age of 13-25 years (40.50%). All patients (100%) complained of
red eye and the location of the eye involved was bilateral 219 patients (68.25%). In
conjunctival ophthalmology examination as many as 48 patients (14.95%) had
papillae and 60 patients (18.70%) had follicles. The diagnosis of conjunctivitis based
on the onset of the disease was 208 patients (64.8%) and based on etiology, 64
patients (19.94%) had viral causes, 7 patients (2.18%) of bacterial causes, 33 patients
(10, 28%) and other causes as many as 9 patients (2.80%). The treatment given varies
according to the suspected etiology of the disease. Patients who received as much
lubrication

304 patients (94.70%), 212 patients (66.04%) received corticosteroid and antibiotic
combination therapy, 92 patients (28.66%) received antibiotics alone, 2 patients
(0.62) received corticosteroids alone and 16 patients (4.98%) received anti-histamine.
The administration of combination therapy with corticosteroids and antibiotics can be
considered to help reduce conjunctival inflammation and shorten the duration of acute
conjunctivitis.
Conclusion: Most cases of conjunctivitis occur in women and the age range is 13-25
years. Most complaints are red eyes and involve both eyes. The most common
etiology is virus. The treatment obtained is in the form of lubricants and a
combination of corticoteroids and antibiotics.

PRELIMINARY

The conjunctiva is a thin, transparent mucous membrane that lines the anterior part of
the eyeball and the interior of the palpebra. The conjunctiva functions as a component
of the eye's protection system from inflammation and infection. Conjunctivitis is an
inflammatory condition of the conjunctiva that can be caused by various factors. 1,2

Conjunctivitis and other disorders of the conjunctiva are among the top 10 outpatient
diseases in hospitals in Indonesia, with a number of visits of 87,513. The number of
new cases was 68,026, consisting of 30,250 male patients and 37,776 female patients
(Ministry of Health of the Republic of Indonesia, 2010) .3

Conjunctivitis can be classified based on etiology and disease onset. Infectious

conjunctivitis can be caused by viruses, bacteria, parasites and fungi, while non-
infectious conjunctivitis can be caused by allergies and toxins. Based on the onset of
the disease can be acute and chronic. 4,5

Estimates of the proportion of conjunctivitis by etiology vary by age and season.

About 80% of cases of infectious conjunctivitis are caused by viruses and most (90%)
are adenoviruses. Transmission through contact with eye secretions or inhalation,
fomites, contaminated swimming pools and populations living together such as in
schools or dormitories.

Other types of viruses that cause viral conjunctivitis are herpetic viruses, namely
herpes simplex virus (HSV) and varicella zoster virus (VZV). Herpetic viral infection
of the eye is the most common cause of blindness in the United States.10 Primary
infection can occur through direct contact with VZV skin lesions or via airborne
droplets. In addition, it can occur due to reactivation of the virus which then affects
the ophthalmic branch ganglion so that the symptoms of herpes zoster are visible in
the eye. Shingles can affect any age but is more common in people over 50 years of
age. Herpes simplex infection can occur through direct contact with infectious
lesions, exposure to asymptomatic viruses or through the birth canal.

Bacteria are the second most common cause of infectious conjunctivitis and are
responsible for the majority of cases in children (50-75%). Bacterial conjunctivitis
results from the growth and infiltration of bacteria on the epithelium surface of the
conjunctiva. Bacterial conjunctivitis can be caused by both gram-positive and gram-
negative bacteria, but gram-positive bacteria are more dominant.5 Bacterial
conjunctivitis can be transmitted by direct contact with an infected individual (eye
contact with hands) or colonization of the patient's own nasal or sinus mucosal
organisms. Although bacterial conjunctivitis can heal on its own, it can be vision
threatening if it is caused by highly virulent bacteria such as Staphylococcus
pyogenes and Neisseria gonorrhoeae. This conjunctivitis can affect anyone and is
common throughout the world, especially in hot climates.

Meanwhile, allergic conjunctivitis occurs in approximately 15% -40% of the

population in the United States. Allergic conjunctivitis is a non-infectious
inflammation of the conjunctiva due to an allergic reaction, can be a fast reaction like
a normal allergy and a slow reaction after several days of contact such as reactions to
drugs and toxins. In addition, allergic conjunctivitis is a reaction to humoral
antibodies against allergens, usually with a history of atopy.5,6,8

The classic symptoms that can be seen with bacterial conjunctivists include red eye
and foreign body sensation, morning sticky lashes, purulent or mucopurulent
discharge, conjunctival papillae, rare preauricular lymphadenopathy. Symptoms of
viral conjunctivitis are itching and watering, a history of recent upper respiratory tract
infections, watery discharge, inferior palpebral conjunctival follicles, and tender
preauricular lymphadenopathy. Allergic conjunctivitis includes symptoms of itching
or burning eyes, a history of allergy / atopy, watery secretions, edema of the eyelids,
conjunctival papillae and no preauricular lymphadenopathy.

Management of viral conjunctivitis is supportive, such as cold compresses and

artificial tears, diligently washing hands to break the chain of transmission. If the
cause is the herpes virus, then oral antivirals are useful for speeding up the resolution
of signs and symptoms. The management of allergic conjunctivitis is to avoid
allergens, administering artificial tears, antihistamines and mast cell stabilizers.

The purpose of this study was to determine the disease profile and management given
to cases of conjunctivitis in dr. Saiful Anwar Malang Hospital during the period
January 2018 to December 2019.

METHODS

This study was conducted by collecting retrospective data by consecutive sampling

from the medical records of patients diagnosed with conjunctivitis at the Eye
Polyclinic, Infection and Immunology Division and the General Eye Polyclinic of dr.
Saiful Anwar Malang Hospital for 2 years, from January 2018 to December 2019.

The research data taken from the patient's medical records included age, gender,
clinical signs found on the conjunctiva, kengkinan cause and management given.

RESEARCH RESULT

The sociodemographic characteristics obtained were age and gender. It was found
that from 321 patients diagnosed with conjunctivitis in dr. Saiful Anwar Malang
Hospital between January 2018 - December 2019 involved in this study as many as 7
patients (2.18%) aged 0-13 years, 130 patients
(40.50%) aged 14-27 years, 61 patients (19.00%) aged 28-41 years, 51 patients
(15.89%) aged 42-55

years, 49 patients (15.26%) were aged 56-69 years and 23 patients (7.16%) were aged
70-83 years. Characteristics

based on age mostly at the age of 14-27 years (40.50%). The distribution of disease
based on gender was 205 patients (63.86%) and male as many as 116 patients
(36.14%) (Figure 1).

The distribution of conjunctivitis based on blurring eye symptoms in 87 patients

(27.10%), red eye 321 patients (100%), discharge 219 (68.22%), watery 205 patients
(63.86%), itching 180 patients (36.07 %), wedge 134

patients (41.74%), glare in 68 patients (21.18%), painful 72 patients (22.43%).

(Figure 2).

Conjunctival papillary examination was found in 48 patients (14.95%), there were no

papils as many as 181 patients (56.39%) and no data as many as 92 patients
(28.66%). There were 60 patients (18.69%) of follicles in the conjunctiva, 174
patients (54.21%) had no follicles and no data for 87 patients (27.10%) (Figure 4).

The distribution of conjunctivitis cases based on the eye involved was mostly
bilateral with 219 patients (68.22%), whereas unilateral was 102 patients (31.78%)
(Graph. 5).

The distribution of conjunctivitis based on possible causes was divided into viral
causes as many as 64 patients (19.94%), bacteria 7 patients (2.18%), allergies 33
patients (10.28%) and other causes (SJS,
drugs) as many as 9 patients (2.80%). Meanwhile, as many as 208 patients (64.8%)
had conjunctivitis based on acute disease onset (Figure 6).

Based on the management of the therapy given, they received lubricants from 304
patients (94.70%) combined with antibiotics and corticosteroids for 212 patients
(66.04%), antibiotics for 92 patients (28.66%),

corticosteroid 2 patients (0.62%) and anti-histamine 16 patients (4.98%) (graph 7).

DISCUSSION

In this study, it was found that the highest number of conjunctivitis patients was in
the age range of 14-27 years, namely 130 patients (40.50%) of a total of 321 patients.
This study took medical record data of patients who visited the Infection and
Immunology division polyclinic and general eye polyclinic, while cases in children
were obtained based on the number of consulants from the Pediatric Ophthalmology
and Strabismus Division so that it affected the number of cases.

Based on the sex, the most conjunctivitis was in women as many as 205 patients
(63.86%) from a total of 321 patients, in contrast to the results of the study at Indera
Hospital Denpasar, 2014, which found that the majority of conjunctivitis was male.
This is in accordance with the literature which states that conjunctivitis can occur at
all ages, sexes and social strata.

Based on the most affected eyes were bilateral as many as 219 patients (68.22%).
Conjunctivitis often affects the eyes bilaterally, but can also occur unilaterally.
Conjunctivitis affecting both eyes is usually due to allergic conjunctivitis. In bacterial
or infectious conjunctivitis
the virus usually starts in one eye and then within a few days spreads to the other
side. The increased risk of transmission to the other side of the eye is influenced by
the location of the two eyes being close together. This condition is transmitted
through eye contact with hands contaminated with bacteria or germs. 2, 4, 6

Based on the symptoms experienced by patients in this study, the symptoms of

blurred eyes were 87 patients (27.10%), red eyes 321 patients (100%), discharge 219
(68.22%), watery 205 patients (63.86%), itching 180

patients (36.07%), bumped 134 patients (41.74%), glare in 68 patients (21.18%),

painful 72 patients (22.43%). Conjunctivitis has clinical symptoms similar to other
eye diseases that threaten vision. A complete history and physical examination are
needed to establish the correct diagnosis and management according to etiology. 6,7,8

Visual disturbances in conjunctivitis may be mild due to debris on the tear film. If
there is severe visual disturbance, it is necessary to suspect a corneal or other eye
disease. Conjunctival injection or pink eye is the predominant clinical sign of
conjunctivitis. The cause of this inflammation can be due to infectious pathogens or
non-infectious irritants. The result of this irritation or infection is injection or dilation
of the posterior conjunctival vessels, which differentiates it from ciliary injections
involving branches of the anterior ciliary artery and indicates inflammation of the
cornea, iris or ciliary body. It is important to differentiate conjunctivitis pink eye from
other pink eye diseases such as blepharitis, corneal abrasion, foreign bodies,
subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical trauma and scleritis.

The type of eye secretions can provide clues to the cause of conjunctivitis. Purulent or
mucopurulent discharge is often caused by bacterial conjunctivitis. Watery discharge
is more likely to lead to viral conjunctivitis. Meanwhile, watery discharge in allergic
conjunctivitis is accompanied by prominent symptoms of itching, chemosis and
redness. 8,9,11
It is further necessary to differentiate between viral and bacterial conjunctivitis. The
presence of one eye followed by involvement of the other eye within 24-48 hours is
an indication of bacterial infection, whereas if the other eye becomes infected after 48
hours with enlarged periauricular lymph nodes, the viral etiology should be
considered.

Apart from the type of secretions, symptom onset and duration and laterality,
papillary conjunctival or pseudomembranous conjunctivitis and follicular
conjunctival reactions were used to determine the etiology.8 This study obtained
conjunctival examination data in the form of papils and follicles. Conjunctival
papillae were found in 45 patients (14.02%) and conjunctival follicles in 60 patients
(18.69%). There are several medical records that do not list the presence or absence
of papils or follicles. Conjunctival papules are more common in bacterial infections
and are also associated with an immune response, such as VKC, or a response to a
foreign body such as contact lenses or ocular prostheses.

Conjunctival follicles can be found in inflammation due to viral infections and

chlamydial infections, toxins or including topical drugs. 1, 4, 5, 9 In this study, 208
patients (64.8%) were diagnosed with acute conjunctivitis. The diagnosis of
conjunctivitis due to viruses was 64 patients (19.94%), bacteria 7 patients (2.18%).
This is in accordance with the literature which states that infectious conjunctivitis is
mostly caused by viral infections and the second is by bacteria.6 Most non-infectious
conjunctivitis is caused by allergies, namely 33 patients

(10.28%) and other causes (immune-mediated, drugs) 9 patients (2.80%).

Viral conjunctivitis is mostly caused by adenovirus with clinical features of

pharyngoconjunctivitis fever and epidemic keratoconjunctivitis (EKC). The most
severe manifestation is EKC, which affects the conjunctiva and cornea, leaving
permanent and prolonged changes in the surface of the eye and visual disturbances.
Ocular manifestations of EKC include the presence of secretions, follicular
conjunctivitis, corneal subepithelial infiltrates, corneal scars, conjunctival and
pseudomembranous membranes, and symblepharone formation. Other viral
conjunctivitis can be caused by the herpes simplex virus and herpes zoster. Viral
conjunctivitis due to herpes simplex is unilateral with thin, watery secretions and
lesions on the vesicular lids. In conjunctivitis due to herpes zoster there can be
complications in the cornea (38.2% of cases) and uveitis (19.1% of cases) .4,5,6,9

Bacterial conjunctivitis can occur because it is transmitted directly from an infected

individual or because of the abnormal proliferation of the conjunctival flora. The
most common pathogens for bacterial conjunctivitis in adults are the staphylococcal
species, followed by Streptococcus pneumoniae and Haemophilus influenzae. In
children, this disease is often caused by H influenzae, S pneumoniae, and Moraxella
catarrhalis. Other causative bacteria are Neisseria gonorrhoeae, Chlamydia
trachomatis, and Corynebacterium diphtheria. N. gonorrhoeae. Most causes bacterial
conjunctivitis in neonates. 8,9

Hyperacute bacterial conjunctivitis presents with excessive purulent discharge and

decreased vision. There is often swelling of the eyelids, eye pain on palpation and
preauricular adenopathy. It is often caused by Neisseria gonorrhoeae and is at high
risk for corneal involvement and corneal perforation.

Bacterial conjunctivitis due to chlamydia is estimated to occur in 1.8% to 5.6% of

cases of acute conjunctivitis. The majority of cases of chlamydial infection coincide
with genital infections and are characterized by conjunctival hyperemia,
mucopurulent secretions and lymphoid follicles. Spread through oculogenital or
intimate contact with an infected individual, in newborns the eye can become infected
after birth through the vagina of the infected mother. 7,8,9

Chronic bacterial conjunctivitis is used to describe any conjunctivitis lasting more

than 4 weeks, with the most common causes being Staphylococcus aureus,
Moraxellalacunata and enteric bacteria.
Conjunctival culture studies are impractical and are rarely indicated in conjunctivitis.
Conjunctival culture and cytology can be performed in cases of recurrent
conjunctivitis, resistance to treatment, suspected gonococcal or chlamydial infection,
neonatal conjunctivitis and adults with severe purulent secretions. Rapid antigen tests
are performed to detect the causative virus and to prevent unnecessary use of
antibiotics because the accuracy of viral diagnosis without laboratory testing is less
than 50% and many are misdiagnosed as bacterial conjunctivitis. However, laboratory
tests are rarely performed because antigen detection is not widely available.
Meanwhile, culture of conjunctival secretions took three days, delaying therapy. For
allergic conjunctivitis, skin scraping tests or intradermal allergen injection and tests to
detect elevated levels of specific serum IgE in vitro may be performed.

However, the clinical presentation is often nonspecific. The type of discharge and
symptoms do not always provide an accurate direction for the diagnosis. In addition,
there is a lack of scientific evidence linking the symptoms and signs of conjunctivitis
to the underlying cause. There are several challenges in diagnosing acute
conjunctivitis. The presence of clinical ambiguity between viral and bacterial
infections and forms of allergy can confuse the diagnosis 8,10,12

The management of therapy provided was lubricants by 304 patients (94.70%)

combined with antibiotics and corticosteroids for 212 patients (66.04%), antibiotics
for 92 patients (28.66%), corticosteroids in 2 patients (0.62%) and anti histamine in
16 patients (4.98%). Management of conjunctivitis is given based on possible
underlying causes.

There is no effective treatment for conjunctivitis due to adenovirus but administering

artificial tears, topical anti-histamines or cold compresses can be given to relieve
symptoms. Steroid administration in viral conjunctivitis is indicated if the sub-
epithelial membrane and infiltrate is formed.

6,10,11,12
Conjunctivitis due to herpes simplex can be given oral antivirals to shorten the course
of the disease. Antiviral options for herpes simplex are acyclovir 5x400mg for 10
days, famciclovir 3x250mg for 10 days, valacyclovir 2x1000mg for 10 days,
valgancyclovir 2x900mg induction phase for 21 days and 1x900mg maintenance
phase. Antivirus in herpes zoster is useful for reducing the amount of virus in vesicle
skin lesions, reducing systemic spread of the virus and reducing the incidence and
severity of ocular complications. Recommended therapy is famciclovir 3x500mg,
valacyclovir 3x1g or acyclovir 5x800mg for 7-10 days.

Bacterial conjunctivitis, can self-limiting in 2 to 7 days without medication. Topical

antibiotics are only used to reduce the duration of the disease. The antibiotic
suspension of choice for benign acute bacterial conjunctivitis is topical polymyxin B /
trimethoprim, ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin, gatifloxacin or
azithromycin, while bacitracin, erythromicin

or ciprofloxacin in the form of an ointment. Bacterial conjunctivitis due to wearing

contact lenses is given fluoroquinolones class antibiotics to provide empirical
coverage for Pseudomonas. 6,9,10

Treatment options for conjunctivitis due to N gonorrhoeae are Ceftriaxone 1 gram

intramuscular (IM) and topical with erythromycin, bacitracin and gentamicin
ointment. Treatment of chlamydial conjunctivitis with oral systemic antibiotics such
as single dose azithromycin 1000 mg, doxycycline 2x100 mg, tetracycline 4x250 mg
or erythromycin 4x500 mg .. Treatment of gonococcal conjunctivitis infection along
with chlamydial infection. 3,7,12,15 The neonatal dose for gonococcal conjunctivitis
is 25 to 50 mg / kg ceftriaxone IV / IM with a maximum dose of 125 mg, with
azithromycin PO 20 mg / kg once daily for three days. 8,9,11
Allergic conjunctivitis treatment consists of avoiding allergens and administering
artificial tears which are useful for eliminating allergens. Antihistamines and mast
cell stabilizers serve to reduce the symptoms of conjunctivitis. Steroids in certain
cases must be used carefully and wisely because long-term use of steroids can cause
side effects in the form of increased intraocular pressure, glaucoma and
cataracts.8,9,10 Cyclosporine-A and tacrolimus are effective in treating severe eye
allergies. and chronic 8,9,11

The high percentage of antibiotic use in this study is in line with a study conducted in
the United States which found that 58% of acute conjunctivitis patients received
topical antibiotic therapy and a study conducted in the Netherlands which found that
80% of acute conjunctivitis patients received a topical antibiotic prescription.10,11

Several things that can affect the high percentage of antibiotic use, among others, are
the difficulty in distinguishing between viral, bacterial or allergic conjunctivitis based
on clinical symptoms and signs alone, whereas it is impractical to wait for
microbiological results before starting treatment. who feel more satisfied if they get a
prescription for antibiotics.10,11,12 However, the use of antibiotics needs rational
considerations so that antibiotic resistance does not appear. However, antibiotics can
be considered if conjunctivitis does not resolve after 10 days and bacterial
superinfection is suspected. 11,12,13

Meanwhile, the use of topical steroids in cases of acute conjunctivitis is still

controversial. R Pinto et al. [13] suggested topical use of 0.1% dexamethasone helps
reduce conjunctival inflammation and shortens the duration of acute conjunctivitis.14
Other studies have also recommended the management of various causes of acute
conjunctivitis with broad spectrum therapy in the form of corticosteroids and anti-
infectious / antiseptic agents. Topical corticosteroids have been shown to be
efficacious and well tolerated when used for a short time in combination with an anti-
infective / antiseptic.
Although the presentations can often overlap, a systematic approach and a thorough
history and physical examination can safely rule out an acute vision-threatening
diagnosis and point to possible causes of conjunctivitis. 10,11,12

Complications of acute conjunctivitis are rare. Patients with HZV conjunctivitis are at
the highest risk of complications. Approximately 38.2% of patients with HZV had
corneal complications, and 19.1% developed uveitis; Patients with N. gonorrhea are
also at high risk for corneal involvement and secondary corneal perforation and
should therefore be treated appropriately. 7,8,9

Education in infectious conjunctivitis in order to avoid viral and bacterial

contamination is necessary to break the chain of transmission, whereas in allergic
conjunctivitis by avoiding allergens to prevent recurrence. Another important thing is
to provide understanding to patients, families and communities about the risks and
benefits of treatment options (even if there is no treatment at all) .9,10,11

In adenovirus conjunctivitis it can be spread through contaminated fingers, medical

devices, contaminated swimming pools, or through sharing personal items. Bacterial
conjunctivitis can occur either from direct contact with an infected individual or from
abnormal proliferation of the normal conjunctival flora, contaminated fingers,
oculogenital spread. In addition, certain conditions such as impaired tear production,
disruption of natural epithelial barrier, adnexal structural abnormalities, trauma, and
immunosuppression status increase the likelihood of contracting bacterial
conjunctivitis.

The education provided was in the form of diligently washing hands, minimizing
contact, delaying returning to work or school and separating personal items such as
handkerchiefs, towels, sheets and pillows from other family members.

This study is retrospective where data is taken from medical records. The limitation
in this study is the unavailability of complete medical record registration data in the
eye clinic of dr. Saiful Anwar Malang Hospital. The existing medical record data was
made by more than 1 person so that a very wide variety of data can be obtained.
Patients who came only once so they could not evaluate anything else. Writing
incomplete status and loss of patient status are also limitations of this study because
they affect the number of samples analyzed so that they can affect the results of this
study.

Conclusion

The conclusion of the case profile study and the management of conjunctivitis for the
period January 2018 - December 2019 at Saiful Anwar Hospital Malang, it was found
that conjunctivitis was most commonly found in women, aged 14-27 years, location
in both eyes, with the most symptoms and clinical signs in the form of red eyes.

The most commonly used management of conjunctivitis is lubricants and antibiotics

with corticosteroids.

Suggestion

Limitations in this study were found at the time of collecting medical record data.

It is hoped that there will be improvements in terms of systematic history taking,

complete ophthalmological examination and storage of medical record status so that
no medical record status is lost so that further research with a longer time period,
larger sample size and more complete recording will provide results. which is more
valid and provides a better picture of the profile of conjunctivitis cases in dr. Saiful
Anwar Malang Hospital.

Furthermore, it is necessary to do more selective analytic studies regarding the

effectiveness of antibiotics and steroids in acute conjunctivitis cases.