CONJUNCTIVAL INFECTIONS

1. Bacterial
• Simple bacterial conjunctivitis
• Gonococcal keratoconjunctivitis

2. Viral
• Adenoviral keratoconjunctivitis
• Molluscum contagiosum conjunctivitis
• Herpes simplex conjunctivitis
3. Chlamydial
• Adult chlamydial keratoconjunctivitis
• Neonatal chlamydial conjunctivitis
• Trachoma
 Anatomi Mata
• Palpebra
• Silia
• Konjungtiva
• Kornea
• Uvea
• Retina
• Sklera
• Air mata
 Anatomi Mata
Kornea COA

Limbus

Sklera
Clinical feature to the differential diagnosis
inflammation of conjunctival :

Symptoms:
a. Non specific: irritation, lacrimation
stinging, burning and photophobia
b. Pain and foreign body sensation
c. Itching is the hallmark of allergic
d. Disccharge can range from watery 
to grossly purulent
Discharge
a. A watery: serous exudate  acute viral &
acute allergic inflammations
b. A mucoid : Vernal conjunctivitis and
Keratoconjunctivitis sicca
c. A purulent: severe acute bacterial infection
d. A mucopurulent mild bacterial infection
( chlamydial infections)
Conjunctival reaction:
1. Conjunctival injection
2. Subconjunctival haemorrhage
3. Edema
4. Scarring
5. Follicular
6. Papillary
7. Membranes
8. Lymphadenopathy
Laboratory investigations
Indications:
1. Severe purulent conjunctivitis
2. Follicular conjunctivitis
3. Conjunctival inflammation
4. Neonatal conjunctivitis
Specific investigations:

Culture
1. Cytological investigations
2. Inoculation
3. Detection of viral or chlamydial antigens
4. Impression cytology
5. Polymerase chain reaction
Bacterial infection
Simple bacterial conjunctivitis:
• Common & self-limiting condition
• Most commonly affects children
• The most etiology staph. epidermidis, staph.
aureus, strep. pneumoniae & H. influenzae
• Spread of infection is direct contact
Clinical feature
Symptoms: acute redness. grittiness, burning and
discharge. On waking, the eyelids stuck together
and difficult to open, usually bilateral
Signs: the eyelids crusted, oedematous, discharge
watery, becomes mucopurulent, conjunctival
injection, the tarsal conjunctival has a velvety,
beefy-red appearance & mild papillary changes
Superficifial punctate epithelial erossions
Simple bacterial conjunctivitis

Crusted eyelids and conjunctival injection

Simple bacterial conjunctivitis

Subacute onset of mucopurulent discharge

Treatment
• Clean the eyelids and lashes of discharge
• Broad-spectrum antibiotics eye drops from
during waking hours and ointment at
bedtime until discharge has ceased
• Antibiotic drops: fusidic acid,
chloramphenicol, ciprofloxacin, ofloxacin,
lemefloxacin, gentamycin, neomycin,
framycin, tobramycin etc
Gonococal keratoconjunctivitis
E/ Diplococcus Neisseria gonorrhoeae
Conjunctivitis :
• Acute conjunctival discharge
• The eyelids oedematous and tender
• The discharge is profuse and purulent
• Intense conjunctival hyperaemia,
chemosis, pseudomembran
• Lymphadenopathy
Gonococcal conjunctivitis

Acute, profuse, purulent discharge,

hyperaemia and chemosis
 Gonococal keratoconjunctivitis

Keratitis may occur and progress:

1. Marginal ulceration
2. Coalescence to form a peripheral ring
ulcer
3. Central ulcerations
Gonococcal keratoconjunctivitis

Corneal ulceration, perforation and

endophthalmitis if severe
Treatment
1. Hospitalized, culture and discharge removed at
frequent intervals
2. Systemic cefotaxime 1 g iv b.d one day, if
corneal involved may necessitate treatment for
longer (100mg/kg), or ceftriaxone 25-50 mg/kg
IM
3. Topical gentamicin or bacitracin initially at very
frequent interval ( but in Sanglah hospital they
use 15000 IU solutions)
Viral conjuctivitis
Adenoviral eye infection from mild to full-
blown infection with significant morbidity
Transmission :
direct or indirect contamination
The incubation period : 4 – 10 days
The onset of conjunctivitis the virus : 12 days
To avoid transmission : washing of hands, not
contact with patients
Causative viruses
• Pharingoconjunctival fever (PCF):
E/ adenovirus type 3,4 & 7, occasionally 5
Transmitted : droplets, affects children, 
upper respiratory tract infection and 30 %
 keratitis.
• Epidemic keratoconjunctivitis (EKC):
E/ adenovirus type 8 & 19 transmitted by
direct or indirect contact and 80 % 
keratitis
Conjunctivitis due to viral
Symptoms: watering, redness, discomfort and
photophobia, involving both eyes
Signs : eyelid oedema, watery discharge,
conjunctival follicles, sub conjunctival
haemorrages, tender, chemosis and
pseuodomembranes, lympadenophaty
Treatment : symptomatc and supportive.
Topical steroid should be avoided.
Spontaneous resolution 2 weeks
 Conjunctivitis due to viral

Usually bilateral, acute waterydischarge and

follicles
 Conjunctivitis due to viral

Subconjunctival haemorrhages and pseudomembranes

if severe
Keratitis
Signs :
Stage I occurs 7 - 10 days, the onset a
punctate epithelial
keratitis which resoloves within 2
weeks
Stage II subepithelial opacities
Stage III anterior stromal opacities
Treatment: topical steroids
 Adenoviral Keratoconjunctivitis
1. Pharyngoconjunctival fever
• Adenovirus types 3 and 7
• Typically affects children
• Upper respiratory tract infection
• Keratitis in 30% - usually mild

2. Epidemic keratoconjunctivitis
• Adenovirus types 8 and 19
• Very contageous
• No systemic symptoms
• Keratitis in 80% of cases - may be severe
 Adenoviral Keratoconjunctivitis
Signs :
Stage I occurs 7 - 10 days, the onset a punctate
epithelial keratitis which resoloves within 2

weeks
Stage II subepithelial opacities
Stage III anterior stromal opacities
Treatment: topical steroids
 Signs of keratitis

• Focal, epithelial keratitis • Focal, subepithelial keratitis

• Transient • May persist for months

Treatment - topical steroids if visual acuity

diminished by subepithelial keratitis
 Molluscum contagiosum conjunctivitis
Signs

• Waxy, umbilicated eyelid nodule • Ispilateral, chronic, mucoid

discharge
• May be multiple • Follicular conjuntivitis

Treatment - destruction of eyelid lesion

 Herpes simplex conjunctivitis
Signs

Unilateral eyelid vesicles Acute follicular conjunctivitis

Treatment - topical antivirals to prevent keratitis

 Chlamydial infections
Adult chlamydial conjunctivitis
E/ sexually transmitted disease caused by
serotypes D to K Chlamydia trachomatis
I/ cervicitis in young women and urethritis
young men which may be asymptomatic
Transmission is by autoinoculation from
genital secretions although eye-to-eye
The incubation period about 1 week
 Clinical feature adult chlamydial
conjunctivitis
Symptoms:
subacute onset unilateral or bilateral
itching, tearing, redness
irritation, foreign body sesation
mucopurulent discharge
becomes chronic
persist for 3–12 month if untreated
 Clinical feature adult chlamydial
conjunctivitis
Signs:
mucopurulent discharge,
conjunctival injection,
large follicles in the inferior and superior
forniceal conjunctiva
peripheral corneal infiltrat (2-3 weeks)
tender lymphadenopthy
.
Adult chlamydial conjunctivitis

Subacute, mucopurulent follicular conjunctivitis

Adult chlamydial keratoconjunctivitis

Variable peripheral
keratitis
 Clinical feature adult chlamydial
conjunctivitis

Long-standing cases are characterized by

less prominent follicles
mild conjunctival scarring
superior pannus
 Laboratory investigations
Direct monoclonal fluorescent antibody
microscopy of conjuctival smear
1. Enzyme-link immunosorbent assay for
chlamydial antigens
2. Standard singel-passage McCoy cell
culture
3. Polymerase chain reaction
Treatment
1. Topical: tetracycline 1 % oitment q.i.d. for
6 week
2. Systemic: Azithromycin 1g single dose,
Doxycline 100mg b.d. for 1 – 2 weeks,
Erythromycine 500 mg q.i.d for 1 week
tetracycline 250 mg qid for 3 weeks
Neonatal chlamydial conjunctivitis
Associated with systemic chlamydial
infection: Otitis, rhinitis and pneumonitis.
Transmited from the mother during delivery.
Presentation is usually 5-19 days after birth.
Signs mucopurulent discharge, papillary
conjunctival reaction, membranes,
superior pannus, conjunctival scarring
intracytoplasmic inclusion.
Neonatal chlamydial conjunctivitis

Mucopurulent papillary
conjunctivitis
Neonatal chlamydial conjunctivitis

Treatment:
topical tetracycline , or sulfacetamide, or
erythromycin
erythromycin 12.5 mg/kg oral or
erythromycin 12.5 mg/kg IV qid for 14
days
Trachoma
E/ serotypes A, B, Ba and C of chlamydia
trachomatis
Underprivileged population with poor
condition of hygiene. The common fly is
the major vector in the infection-reinfection
cycle
Currently trachoma is the leading cause of
preventable blindness in the world.
Clinical feature
Symptoms:
mucopurulent discharge,
foreign body sesation
burning,
itching,
tearing
redness
Trachoma Clinical feature
Signs:
1. Mixed follicular/papillary conjunctivitis
2. Chronic conjunctival inflammation Arlt lines
3. Limbal follicles  Herbert pits
4. Keratitis  pannus
5. Progressive conjunctival scarring  entropion
6. End stage trachoma corneal ulceration
and opacification
Follicular in the superior tarsus

Acute follicular
conjunctivis
Neovascularization intraepithelial

Pannus formation
Conjunctival scarring

Conjunctival scarring (Arlt line

Herbert’s pits
Trichiasis
Entropion
World Health Organization grading of trachoma

TF = trachoma follicles
TI = trachomatous inflammation diffusely
TS = trachomatous conjunctival scarring
TT = trachomatous trichiasis touching the
cornea
CO = corneal opacity
 Adult chlamydial keratoconjunctivitis
• Infection with Chlamydia trachomatis serotypes D to K
• Concomitant genital infection is common

Subacute, mucopurulent follicular Variable peripheral keratitis

conjunctivitis

Treatment - topical tetracycline and oral tetracycline

or erythromycin
Neonatal chlamydial conjunctivitis
• Presents between 5 and 19 days after birth
• May be associated with otitis, rhinitis and pneumonitis

Mucopurulent papillary conjunctivitis

Treatment - topical tetracycline and oral erythromycin

 Trachoma
• Infection with serotypes A, B, Ba and C of Chlamydia
trachomatis
• Fly is major vector in infection-reinfection cycle
Progression

Acute follicular Conjunctival Herbert pits

conjunctivis scarring (Arlt line)

Pannus formation Trichiasis Cicatricial entropion

Treatment - systemic azithromycin