Diseases of the Conjunctiva - Conjunctivitis

Simple & Concise Notes | Based on A.K. Khurana's Comprehensive Ophthalmology + Kanski's Clinical Ophthalmology 10th Edition

ANATOMY OF THE CONJUNCTIVA (Brief Overview)

• Palpebral conjunctiva - attached to posterior tarsal plates
• Fornical conjunctiva - loose and redundant
• Bulbar conjunctiva - covers anterior sclera; fuses with Tenon's capsule at the limbus

PART 1: CAUSES AND CLINICAL FEATURES OF CONJUNCTIVITIS

Definition

CAUSES (Etiology)

GENERAL CLINICAL FEATURES OF CONJUNCTIVITIS

• Lacrimation, grittiness, stinging, burning
• Itching - hallmark of allergic disease
• Eyelid sticking on waking (especially bacterial)
• Visual acuity is usually not affected
• Significant pain or photophobia → suggests corneal involvement

• Watery - acute viral or acute allergic
• Mucoid - chronic allergic conjunctivitis or dry eye
• Mucopurulent - bacterial (most common)
• Purulent/Hyperacute - gonococcal or meningococcal

• Papillae - vascular cores with central vessel; seen in bacterial, chlamydial, allergic conjunctivitis; "cobblestone" in VKC
• Follicles - lymphoid aggregates without central vessel; seen in viral, chlamydial, molluscum
• Chemosis - conjunctival oedema; hallmark of acute allergic conjunctivitis
• Conjunctival injection - diffuse hyperaemia
• Membrane/Pseudomembrane - coagulated exudate on palpebral surface

• Preauricular lymphadenopathy (viral, gonococcal, chlamydial)
• Eyelid oedema in severe infection
• Subconjunctival haemorrhage (viral/toxic)

DIFFERENTIATING FEATURES (from A.K. Khurana's Table)

PART 2: DIAGNOSTIC AND THERAPEUTIC APPROACHES

A. BACTERIAL CONJUNCTIVITIS

• Common: Strep. pneumoniae, Staph. aureus, H. influenzae, Moraxella catarrhalis
• Severe/hyperacute: N. gonorrhoeae, N. meningitidis
• Neonatal: N. gonorrhoeae (day 2-4), Chlamydia (day 5-14)

• Acute onset redness, grittiness, burning
• Usually bilateral (one eye 1-2 days before other)
• Eyelids stuck together on waking
• Discharge: initially watery → rapidly becomes mucopurulent
• Hyperacute purulent discharge → gonococcal/meningococcal (emergency)
• Superficial corneal punctate epithelial erosions common
• Peripheral corneal ulceration/perforation risk in gonococcal

• Clinical in most cases - investigations not routinely needed
• Conjunctival swab for culture/sensitivity: indicated in
  • Neonates
  • Severe or hyperacute cases
  • Immunocompromised patients
  • Non-resolving conjunctivitis
• Gram stain: for gram-negative diplococci (gonococcal)
• Giemsa stain: for chlamydial intracytoplasmic inclusions

• Mostly self-limiting (resolves in 1-2 weeks without treatment)
• Topical antibiotics reduce duration and prevent spread:
  • Chloramphenicol 0.5% drops, 4x/day × 5-7 days (first choice)
  • Fusidic acid 1% gel (effective against Staphylococci)
  • Topical fluoroquinolones (ciprofloxacin, ofloxacin) - for resistant cases
• Regular eye cleaning with sterile saline to remove discharge
• Avoid contact lens wear until resolved

• Systemic antibiotics: ceftriaxone 1g IM single dose (or oral cefixime)
• Topical irrigation with saline (hourly in severe cases)
• Topical quinolone drops
• Sexual partner notification and treatment

• Oral azithromycin 1g single dose OR
• Doxycycline 100mg twice daily × 3 weeks
• Topical tetracycline ointment as adjunct
• Screen and treat sexual contacts

• Gonococcal: systemic ceftriaxone + topical irrigation
• Chlamydial: oral erythromycin × 2 weeks
• Prophylaxis: Credé's prophylaxis (1% silver nitrate) or tetracycline ointment at birth

B. VIRAL CONJUNCTIVITIS

• Adenovirus - most common (90%); serovars 3, 4, 7 (PCF); serovars 8, 19, 37 (EKC)
• HSV - primary infection, usually unilateral
• Enterovirus/Coxsackievirus - acute haemorrhagic conjunctivitis (tropical)
• Molluscum contagiosum - chronic follicular conjunctivitis
• Systemic viruses - varicella, measles, mumps

1. Non-specific acute follicular conjunctivitis - most common; mild; unilateral watering/redness/irritation, followed by other eye
2. Pharyngoconjunctival fever (PCF) - adenovirus 3,4,7; sore throat prominent; keratitis in 30%
3. Epidemic keratoconjunctivitis (EKC) - adenovirus 8,19,37; most severe; keratitis in 80%; significant photophobia
4. Acute haemorrhagic conjunctivitis - enterovirus; rapid onset; marked conjunctival haemorrhages; resolves in 1-2 weeks

• Follicular reaction (lower fornix predominant)
• Watery discharge
• Preauricular lymphadenopathy (usually present)
• Pseudomembrane may form in severe EKC
• Subepithelial corneal infiltrates (EKC - coin-shaped opacities)
• Lid vesicles (HSV)

• Mostly clinical
• PCR: sensitive and specific for viral DNA (adenovirus)
• Point-of-care immunochromatography test (10 min): for adenoviral antigen in tears - excellent sensitivity/specificity
• Viral culture: gold standard but slow and expensive
• Serology: rarely used

• Adenoviral - mostly self-limiting (resolves in 2-3 weeks); no specific antiviral against adenovirus
  • Artificial tears (4x/day) for symptom relief
  • Cold compresses for comfort
  • Topical antihistamines/vasoconstrictors for itching
  • Topical steroids (prednisolone 0.5% 4x/day): only for severe membranous/pseudomembranous disease or symptomatic keratitis (use cautiously - can extend infectious period, may enhance viral replication)
  • Prevention of transmission: meticulous hand hygiene, avoid eye rubbing and towel sharing, sodium hypochlorite or povidone-iodine disinfection of instruments
  • Discontinue contact lens wear
• HSV conjunctivitis - topical aciclovir ointment to limit corneal epithelial involvement
• Molluscum contagiosum - expression/excision of lid lesions to resolve secondary conjunctivitis

C. ALLERGIC CONJUNCTIVITIS

• Itching, watering, redness (bilateral)
• Associated sneezing, nasal discharge
• Conjunctival hyperaemia with mild papillary reaction
• Variable chemosis and lid oedema

• Dramatic chemosis (conjunctival oedema) - characteristic; alarming to parents
• Intense itching, watering
• Usually self-limiting within hours

• Bilateral, recurrent; predominantly boys; 5+ years; remission by late teens (95%)
• Common in warm climates (Mediterranean, sub-Saharan Africa, Middle East)
• Intense itching, lacrimation, photophobia, thick mucoid discharge
• Palpebral VKC: Giant/macro papillae on upper tarsal plate ("cobblestone" appearance), mucus deposition
• Limbal VKC: Gelatinous limbal papillae + Horner-Trantas dots (eosinophilic accumulations at limbus)
• Corneal complications: Shield ulcer, superficial punctate keratitis, corneal plaques

• Clinical; investigations usually not needed
• Conjunctival scraping: eosinophils in active disease
• Skin prick testing for specific allergens (rarely required)
• Serum IgE (in atopic cases)

1. Allergen avoidance (if possible)
2. Artificial tears - for mild symptoms, dilute allergens
3. Mast cell stabilizers: sodium cromoglicate, nedocromil sodium, lodoxamide - require days of use before maximal effect; suitable for long-term prophylaxis
4. Topical antihistamines: emedastine, epinastine, levocabastine, bepotastine - for symptomatic exacerbations
5. Dual-action (antihistamine + mast cell stabilizer): azelastine, ketotifen, olopatadine - rapid action, very effective for exacerbations
6. Oral antihistamines: for severe symptoms (loratadine - less sedating; diphenhydramine - sedating, aids sleep)
7. Topical NSAIDs: diclofenac - symptomatic relief, rarely used
8. Topical steroids: effective but use with caution (risk of glaucoma and cataract); short courses for acute severe flares
9. Immunotherapy (desensitization): subcutaneous or sublingual; for refractory cases with identified allergens

• Topical cyclosporine (CsA) 0.05-2% - very effective, steroid-sparing
• Tacrolimus 0.03-0.1% ointment - for refractory cases
• Supratarsal steroid injection
• Surgical removal of giant papillae in VKC if vision compromised

PART 3: HOMEOPATHIC MANAGEMENT OF DISEASES OF THE CONJUNCTIVA

KEY HOMEOPATHIC REMEDIES FOR CONJUNCTIVITIS

HOMEOPATHIC MANAGEMENT BY TYPE

• Argentum nitricum - purulent discharge, swollen inner canthi, corneal involvement
• Pulsatilla - thick bland yellow-green discharge, better cool air
• Belladonna - sudden onset, photophobia, burning sensation, dry eyes
• Euphrasia - acrid, burning discharge causing lid excoriation

• Aconite - first stage, acute onset, dry/burning, watery
• Allium cepa - watery acrid lacrimation + nasal symptoms (hay fever pattern)
• Rhus tox - spasmodic lid closure, gush of tears, photophobia

• Euphrasia - acrid burning tears
• Allium cepa - hay fever with eye symptoms, burning lacrimation
• Pulsatilla - bland discharge, itching, better cool air

• Acetic acid - dense adherent membrane
• Argentum nitricum - with severe discharge and corneal involvement

• Sulphur - chronic catarrhal, worse bathing
• Argentum nitricum - chronic lid thickening and ulceration
• Pulsatilla - chronic mild recurrent episodes

GENERAL HOMEOPATHIC PRINCIPLES IN CONJUNCTIVAL DISEASES

1. Totality of symptoms - remedy chosen based on the complete symptom picture (mental, physical, local)
2. Miasmatic background - acute cases may require acute remedies; chronic/recurrent cases need constitutional treatment
3. Repertorization - using Boericke's or Kent's Repertory under "EYES - Conjunctiva - inflammation (conjunctivitis)"
4. Common repertory rubrics:
   • Eyes: Conjunctiva, inflammation - acute catarrhal
   • Eyes: Conjunctiva, inflammation - purulent
   • Eyes: Discharge - purulent/acrid/bland
   • Eyes: Lacrimation - acrid/profuse
   • Eyes: Photophobia
5. Potency selection - Acute cases: 30C or 200C; Chronic: 200C or constitutional treatment
6. Homeopathic treatment addresses the individual patient constitution, aims to resolve current symptoms and prevent recurrence

QUICK SUMMARY TABLE - HOMEOPATHIC vs CONVENTIONAL

Sources: Kanski's Clinical Ophthalmology: A Systematic Approach, 10th Edition; A.K. Khurana, Comprehensive Ophthalmology (Chapter 4 - Diseases of the Conjunctiva); Homeopathic Materia Medica & Repertory (Boericke). Note: A.K. Khurana's latest comprehensive text (Jaypee series) is the primary reference for classification, differentiating features, and homeopathic remedy tables as cited in his Chapter on Diseases of the Conjunctiva.