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Conjunctivitis - Ophthalmology Notes for MBBS

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1. Definition

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2. Classification

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3. Key Diagnostic Features: Papillae vs. Follicles

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4. Bacterial Conjunctivitis

4a. Acute Bacterial Conjunctivitis

• Staphylococcus aureus (most common in adults)
• Streptococcus pneumoniae
• Haemophilus influenzae (most common in children)
• Moraxella catarrhalis

• Acute onset redness, grittiness, burning, mucopurulent discharge
• Usually bilateral (second eye affected 1-2 days later)
• Eyelids stuck together on waking (lids glued = hallmark)
• Vision is usually normal
• Papillary reaction on tarsal conjunctiva
• Discharge: watery early → mucopurulent rapidly
• Lymphadenopathy usually absent (key distinguishing feature from viral)

• ~60% resolve within 5 days without treatment
• Topical antibiotics (4x/day for up to 1 week): chloramphenicol, gentamicin, tobramycin, ciprofloxacin, ofloxacin, azithromycin, erythromycin, fusidic acid
• Ointments/gels provide higher concentration but cause blurred vision - use at night
• Contact lens wear: discontinue until 48h after complete resolution

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4b. Hyperacute (Gonococcal) Conjunctivitis

• Profuse, copious purulent discharge - a medical emergency
• Marked eyelid edema and erythema
• Palpable preauricular lymphadenopathy
• Can rapidly invade intact corneal epithelium → perforation risk
• Usually sexually transmitted; bilateral involvement common
• Meningococcal conjunctivitis is a rare but serious alternative

• Gram stain: Gram-negative intracellular diplococci (kidney-shaped)
• Culture: Chocolate agar or Thayer-Martin medium

• Topical: Quinolone or gentamicin 1-2 hourly
• Systemic: Ceftriaxone (3rd generation cephalosporin) IM/IV; quinolones or macrolides as alternatives
• Seek genitourinary specialist input
• Profuse copious irrigation of the conjunctival sac

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4c. Chlamydial (Inclusion) Conjunctivitis

• Males: Non-gonococcal urethritis (most common cause), epididymitis, may trigger Reiter syndrome
• Females: Urethritis → pelvic inflammatory disease → risk of infertility; Fitz-Hugh-Curtis syndrome (perihepatitis, 5-10% of PID cases)

• Subacute onset; usually unilateral or bilateral redness, watering, discharge
• Large follicles in inferior fornix (most prominent)
• Tender preauricular lymphadenopathy
• Superficial punctate keratitis
• Perilimbal subepithelial corneal infiltrates (after 2-3 weeks)
• Mild conjunctival scarring + superior corneal pannus in chronic cases

• Tarsal conjunctival scrapings: Giemsa stain (basophilic intracytoplasmic inclusion bodies)
• PCR/NAAT - most sensitive
• Direct immunofluorescence: ~90% sensitivity/specificity
• Enzyme immunoassay for antigen detection

• Oral azithromycin 1g single dose (treatment of choice)
• Alternative: Doxycycline 100 mg BD x 7 days; erythromycin 500 mg QID x 7 days
• Treat sexual partners; refer to genitourinary clinic

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4d. Trachoma (Chlamydial)

• Surgery (for trichiasis)
• Antibiotics
• Facial cleanliness
• Environmental improvement

• TF: Trachomatous inflammation-Follicular (≥5 follicles on upper tarsus)
• TI: Trachomatous inflammation-Intense
• TS: Trachomatous Scarring
• TT: Trachomatous Trichiasis
• CO: Corneal Opacity

• Azithromycin 20 mg/kg (up to 1 g) single dose - treatment of choice
• Erythromycin 500 mg BD x 14 days or doxycycline 100 mg BD x 10 days
• Topical 1% tetracycline ointment (less effective than oral)
• Surgery for entropion/trichiasis: bilamellar tarsal rotation

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4e. Ophthalmia Neonatorum (Neonatal Conjunctivitis)

• N. gonorrhoeae: previously responsible for 25% of childhood blindness; profuse purulent discharge, risk of corneal perforation
• C. trachomatis: most common cause of moderate-severe neonatal conjunctivitis
• Systemic complications: HSV (encephalitis, skin vesicles), Chlamydia (pneumonitis, rhinitis, otitis), Gonococcal (disseminated gonococcal infection)
• Prophylaxis: Erythromycin 0.5% ointment or povidone-iodine 2.5% drops at birth

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5. Viral Conjunctivitis

5a. Adenoviral Conjunctivitis (Most Common - 90%)

• Inferior palpebral conjunctival follicles (hallmark)
• Tender palpable preauricular lymph node (key distinguishing sign)
• Watery (serous) discharge
• Red, edematous eyelids
• Pinpoint subconjunctival hemorrhages
• Pseudomembranes (in severe EKC)
• Subepithelial infiltrates (SEIs) appear 1-2 weeks after onset - can reduce vision

• Self-limiting (2-3 weeks); may last longer with corneal involvement
• Preservative-free artificial tears 4-8x/day
• Cool compresses several times/day
• Topical steroids ONLY if: membrane/pseudomembrane present, or SEIs reduce vision/cause photophobia
• Membrane/pseudomembrane: peel gently with cotton-tip or smooth forceps
• Contagious for 10-12 days from onset - strict hygiene, restrict school/work
• Antibiotics NOT routinely indicated (only if corneal erosions or mucopurulent discharge)

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5b. Herpes Simplex Virus (HSV) Conjunctivitis

• Usually primary infection; unilateral, often with history of perioral cold sores
• Follicular conjunctival reaction + palpable preauricular node
• Occasional herpetic skin vesicles on eyelid margin/periocular skin
• Treatment: Topical acyclovir 3% ointment 5x/day; oral acyclovir in severe cases

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5c. Molluscum Contagiosum-Associated Conjunctivitis

• Poxvirus (double-stranded DNA); peak incidence ages 2-4 years
• Chronic follicular conjunctivitis due to shedding of viral particles from eyelid lesion
• Always examine eyelash line in chronic follicular conjunctivitis - look for umbilicated nodule
• Treatment: Excision or cryotherapy of molluscum lesion resolves conjunctivitis

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6. Allergic Conjunctivitis

Comparison Table

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6a. Vernal Keratoconjunctivitis (VKC) - High Yield for MBBS

• Palpebral VKC: Upper tarsal conjunctiva involved; significant corneal disease due to close apposition
• Limbal VKC: Typically affects Black and Asian patients; gelatinous limbal papillae
• Mixed VKC: Features of both

• Giant papillae (>1 mm) - cobblestone appearance on upper tarsal conjunctiva
• Macropapillae (<1 mm) - flat-topped, polygonal
• Horner-Trantas dots - white cellular collections at limbus (eosinophil/epithelial cell aggregates)
• Limbal gelatinous papillae

• Superior punctate epithelial erosions
• Vernal (shield) ulcer - oval, sterile, upper cornea; due to toxic effect of eosinophil granule proteins
• Corneal plaque (calcified mucus deposits in shield ulcer)
• Superior subepithelial scarring

1. Avoid triggers; cold compresses
2. Topical mast cell stabilizers (sodium cromoglicate, lodoxamide, nedocromil)
3. Topical antihistamines / dual-action agents (olopatadine, ketotifen, azelastine)
4. Topical corticosteroids (short course for acute exacerbations)
5. Topical cyclosporine A (CsA) 0.05-2% - steroid-sparing; for moderate-severe cases
6. Systemic: oral antihistamines; CsA in recalcitrant cases
7. Shield ulcer: remove plaque under topical anaesthesia + bandage contact lens + topical steroid + antibiotic cover
8. Supratarsal steroid injection in resistant cases

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7. Differential Diagnosis of Red Eye (Key Distinctions)

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8. Summary of Discharge Types

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9. Important Exam High-Yield Points

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10. Management Summary Flowchart

Conjunctivitis (Red Eye + Discharge)
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    Duration?
   /         \
<4 weeks    >4 weeks → Chronic (trachoma, chlamydial, AKC)
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Discharge type?
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Watery → Viral / Allergic
   - Viral: follicles + preauricular node → supportive Rx
   - Allergic: itching + chemosis + papillae → antihistamines / mast cell stabilizers
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Mucopurulent → Bacterial
   - Topical antibiotics ± systemic
   - If copious purulent → Gonococcal EMERGENCY → systemic ceftriaxone + irrigation
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Ropy mucoid → VKC → mast cell stabilizers + steroids + CsA

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Surgery for MBBS - Important Topics & Exam Strategy

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PART 1: EXAM STRATEGY - HOW TO TOP IN SURGERY

Understanding the MBBS Surgery Exam Pattern

• Long answers (10-15 marks): Detailed clinical topics
• Short notes (5 marks): Specific pathologies, signs, investigations
• Spot questions: Identify instruments/specimens

• Long case: Full history, examination, diagnosis, management
• Short case: Focused clinical signs
• Viva: Rapid-fire factual recall
• OSCE stations

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The 4-Step Topping Strategy

1. Wound healing + complications
2. Hernia (inguinal/femoral)
3. Acute appendicitis
4. Burns management
5. Thyroid surgery
6. Breast disease
7. Peptic ulcer disease + complications
8. Intestinal obstruction
9. Deep vein thrombosis + pulmonary embolism
10. Varicose veins

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Time Allocation in Exam

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PART 2: HIGH-YIELD TOPIC NOTES

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TOPIC 1 - WOUND HEALING (Ultra-High Yield)

• Primary intention: Clean surgical wound, edges apposed
• Secondary intention: Open wound, heals by granulation
• Tertiary (delayed primary): Wound left open, closed after 4-5 days (contaminated wounds)

• Local: Infection, foreign body, ischaemia, radiation, tension, dead space
• Systemic: Malnutrition, vitamin C/zinc/A deficiency, diabetes, steroids, immunosuppressants, jaundice, uraemia, anaemia, old age

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TOPIC 2 - HERNIA (High Yield)

• Sac - peritoneal lining
• Sac contents - omentum, bowel, bladder, ovary
• Coverings - layers of abdominal wall

• Medial: Lateral border of rectus abdominis
• Lateral: Inferior epigastric artery
• Below: Inguinal ligament

• Passes through femoral canal (medial compartment of femoral sheath)
• More common in women (but inguinal still commoner overall even in women)
• Highest risk of strangulation of all groin hernias
• Boundaries of femoral canal: NAVY from lateral to medial - Nerve, Artery, Vein, Y-lymphatics (empty space = canal)

• Reducible - contents return to abdomen
• Irreducible/Incarcerated - cannot be reduced
• Obstructed - bowel lumen obstructed but vasculature intact
• Strangulated - blood supply cut off → ischemia → gangrene (emergency)
• Richter's hernia - only part of bowel wall caught in defect; no obstruction but strangulation risk
• Maydl's hernia - W-shaped loop; intervening loop is strangulated while both limbs are in abdomen

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TOPIC 3 - ACUTE APPENDICITIS (High Yield)

1. Periumbilical/central colicky pain (visceral, via T10)
2. Anorexia + nausea/vomiting
3. Pain shifts to Right Iliac Fossa (somatic, parietal peritoneum irritated)
4. Low-grade pyrexia (37.2-37.7°C), pulse 80-90 bpm

• Alvarado score (MANTRELS):
  • M - Migration of pain to RIF (1)
  • A - Anorexia (1)
  • N - Nausea/vomiting (1)
  • T - Tenderness in RIF (2)
  • R - Rebound tenderness (1)
  • E - Elevated temperature (1)
  • L - Leukocytosis (2)
  • S - Shift of WBC to left (1)
  • Score ≥7: Likely appendicitis; Score 5-6: Borderline; ≤4: Unlikely

• FBC: Leukocytosis (75% of cases)
• Urinalysis (exclude UTI)
• Pregnancy test (females, exclude ectopic pregnancy)
• USS: Thick-walled non-compressible appendix >6mm diameter
• CT abdomen: Most accurate (sensitivity 98%)
• CRP elevated

• Appendix mass (Phlegmon) - conservative initially (Ochsner-Sherren regimen), interval appendicectomy at 6 weeks
• Appendicular abscess - drainage + interval appendicectomy
• Perforation → peritonitis
• Portal pyaemia (rare)

• Female: Ectopic pregnancy, ovarian cyst torsion, PID (most important)
• Children: Mesenteric adenitis (fever >38.5°C with normal WBC)
• All ages: Crohn's disease, Meckel's diverticulitis, caecal carcinoma, ureteric colic

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TOPIC 4 - BURNS (High Yield)

• TBSA >10% in children/elderly, >15% in adults
• Full thickness burns
• Burns to face, hands, feet, genitalia, perineum, major joints
• Inhalation injury
• Circumferential burns
• Chemical/electrical burns

4 ml × body weight (kg) × % TBSA burned = Volume of Ringer's lactate in first 24 hours

• Give 50% in first 8 hours (from time of burn, not from time of admission)
• Give 50% in next 16 hours
• Only for burns >20% TBSA (some use >15%)

• Clean wounds, apply silver sulfadiazine cream (antimicrobial)
• Skin grafting for deep partial and full thickness burns (Split-thickness skin graft = STSG preferred)
• Donor site: Thigh, buttock

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TOPIC 5 - PEPTIC ULCER DISEASE (High Yield)

• H. pylori infection - most important cause
• NSAIDs - second most important
• Gastrinoma (Zollinger-Ellison syndrome) - excess gastrin → massive acid secretion
• Smoking, stress, alcohol (predisposing factors)

• Type I: Lesser curve, body (most common, low acid)
• Type II: Body + DU (high acid)
• Type III: Prepyloric (high acid, like DU)
• Type IV: Near gastroesophageal junction
• Type V: NSAIDs anywhere

1. Perforation - sudden severe generalised abdominal pain; board-like rigidity; Erect CXR: air under diaphragm; Treatment: Resuscitation + emergency laparotomy (Graham's patch repair)
2. Haemorrhage - Haematemesis/melaena; Rockall score (risk stratification); Treatment: OGD + endoscopic haemostasis; surgical if fails
3. Pyloric stenosis - Projectile vomiting; succussion splash; hypochloraemic hypokalaemic metabolic alkalosis; Treatment: Correction of electrolytes then surgery (Ramstedt's pyloromyotomy in infants/pyloplasty in adults)
4. Malignant transformation - Only gastric ulcer risk (DU does NOT turn malignant)

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TOPIC 6 - INTESTINAL OBSTRUCTION (High Yield)

• Mechanical - physical blockage
• Paralytic ileus - bowel stops functioning without physical obstruction

• ABCD: Abdominal pain (colicky), Bloating/distension, Constipation (absolute = no flatus OR stool), Distension, vomiting
• Vomiting early in small bowel obstruction
• Vomiting late (faeculent) in large bowel obstruction
• Bowel sounds: High-pitched tinkling (early) → absent (late peritonitis)

• Small bowel: Central, valvulae conniventes (cross entire bowel width), ladder pattern
• Large bowel: Peripheral, haustra (do not cross entire width), "picture frame" pattern
• Volvulus: Coffee bean sign (sigmoid), omega sign (sigmoid), bird-beak sign (caecal)

• Drip and suck (IV fluids + NG tube decompression)
• Urgent surgery if: Strangulation, closed-loop obstruction, no improvement in 24-48h
• Closed-loop obstruction = danger zone (both ends blocked; rapid ischaemia)

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TOPIC 7 - DEEP VEIN THROMBOSIS (DVT) & PULMONARY EMBOLISM (PE)

1. Stasis of blood
2. Hypercoagulability
3. Endothelial damage

• Score ≥2: DVT likely; <2: DVT unlikely

• Calf pain, swelling, redness, warmth
• Homans' sign: Pain on passive dorsiflexion of foot (non-specific, now discouraged)
• Pratt's sign: Calf tenderness on squeezing

• D-dimer (high sensitivity, low specificity; useful to rule out if negative)
• Compression duplex ultrasonography (investigation of choice)
• CT pulmonary angiography (CTPA) for PE - gold standard

• LMWH (initial rapid anticoagulation)
• NOACs (rivaroxaban, apixaban - factor Xa inhibitors; dabigatran - direct thrombin inhibitor) - at least 3 months
• IVC filter if anticoagulation contraindicated
• Thrombolysis/catheter-directed therapy for massive PE or iliofemoral DVT

• TED stockings (graduated compression stockings)
• LMWH (enoxaparin) subcutaneously
• Early mobilisation
• Intermittent pneumatic compression devices

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TOPIC 8 - VARICOSE VEINS

• Primary: Familial; defective vein wall/valves (most common)
• Secondary: DVT (post-thrombotic), pregnancy, pelvic tumour, AV fistula

• Originates at medial aspect of foot; joins femoral vein at saphenofemoral junction (SFJ) in groin
• Tributaries at SFJ: SCIPE - Superficial Circumflex Iliac, Superficial Epigastric, Pudendal veins (these must be ligated in surgery)

• Dilated, tortuous, prominent veins (long LSV distribution - medial thigh/calf)
• Aching, heaviness, itch, cramps, cosmetic concern
• Trendelenburg test (tourniquet test): identifies SFJ incompetence
• Tap test (Schwartz test): Impulse transmitted along vein

• Bleeding (can be severe, especially skin erosion)
• Thrombophlebitis
• Chronic venous insufficiency: Lipodermosclerosis (hard, fibrotic skin), Atrophie blanche (white scar)
• Venous ulcer - gaiter area (medial lower leg, above medial malleolus); flat edges, sloughy, shallow
• Eczema (varicose/stasis eczema)

• Conservative: Compression stockings, weight loss, elevation
• Foam sclerotherapy
• Endovenous thermal ablation (laser EVLA / radiofrequency RFA) - first-line surgical treatment
• Open surgery: Trendelenburg operation (flush ligation at SFJ) + stripping of LSV
• CEAP classification: Used to grade venous disease (C0-C6)

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TOPIC 9 - THYROID SURGERY (High Yield)

• Malignancy (confirmed or suspected)
• Toxic nodule/goitre not responding to medical treatment
• Compressive symptoms (dysphagia, stridor)
• Cosmetic
• Suspicion on FNAC

1. Clinical (history + examination)
2. FNAC (Fine needle aspiration cytology) - Bethesda classification
3. Imaging (USS ± CT ± RNI - radio-nuclide imaging)

1. Papillary (most common ~80%): Mixed/nuclear/Orphan Annie eye nuclei; psammoma bodies; spreads via lymphatics; excellent prognosis
2. Follicular (~10%): Capsular + vascular invasion; spreads haematogenously (lungs, bone); FNAC cannot distinguish from adenoma
3. Medullary (~5%): From C-cells (parafollicular); secretes calcitonin (tumour marker); associated with MEN 2A and 2B
4. Anaplastic (<5%): Most aggressive; rapid growth; poor prognosis; average survival <6 months

• Total thyroidectomy: For malignancy (bilateral disease)
• Hemithyroidectomy (lobectomy): For solitary nodule, unilateral disease
• Near-total thyroidectomy: Leaves <1g tissue

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TOPIC 10 - BREAST DISEASE (High Yield)

1. Clinical examination (history + palpation)
2. Imaging (mammography >35 years; USS <35 years)
3. Pathology (FNAC or core biopsy)

• Most common benign breast lump in young women (<35 years)
• Smooth, firm, mobile, non-tender - "breast mouse"
• Resolves in ~30% cases; surgical excision if >3 cm or anxiety

• Most common cancer in women worldwide
• Risk factors: Age, family history (BRCA1/2), OCP, HRT, nulliparity, early menarche/late menopause, obesity, alcohol, radiation

• T: Tumour size (T1 ≤2cm, T2 2-5cm, T3 >5cm, T4 skin/chest wall involvement)
• N: Lymph node involvement
• M: Metastasis

• Wide local excision (lumpectomy) + sentinel lymph node biopsy ± axillary clearance + radiotherapy
• Mastectomy: For large tumours, multifocal disease, patient preference
• Modified radical mastectomy (Patey's): Mastectomy + axillary clearance
• Reconstruction: Immediate or delayed

• Chemotherapy: Anthracycline + taxane regimens
• Hormonal: Tamoxifen (pre-menopausal ER+); Aromatase inhibitors (post-menopausal ER+)
• Targeted: Trastuzumab (Herceptin) for HER2-positive tumours
• Radiotherapy post-lumpectomy

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PART 3: SURGICAL SIGNS AND EPONYMS (Viva Gold)

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PART 4: IMPORTANT SHORT NOTES (Common 5-Markers)

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PART 5: INSTRUMENTS AND SPECIMENS (Spot Identification)

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PART 6: REVISION SCHEDULE TEMPLATE

1. Morning (2h): Read one full topic (Bailey and Love's / S Das)
2. Afternoon (1h): Write short notes from memory
3. Evening (1h): Clinical signs/eponyms + past paper MCQs
4. Night (30 min): Rapid revision of the day's topic

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