DEFINITION

Conjunctivitis is an inflammation of the conjunctiva that is

characterized by vascular dilatation, cellular infiltration and exudation, or inflammation of the mucous membrane covering the back of the eyelid and eyeball.

1 ANATOMY
Conjunctiva is the outer layer of the eye consisting of a thin mucous membrane

that lines the eyelids In anatomy classification, the conjunctiva is divided into three parts, conjunctiva bulbaris, conjunctival palpebra, and conjunctiva fornix Conjunctival lymph vessels are arranged in layers and the superficial and profundus layer continuous with the lymph vessels to form a plexus of lymph palpebra a lot. Conjunctiva receive innervation from the first branch (ophthalmic) trigeminal nerve. These nerves are only have a relative few pain fibers

2 ANATOMY

1. Forniks superior & inferior 2. Konjungtiva tarsal sup & inf 3. Kripte henle 4. Gl.Krause 5. Gl.Wolfring 6. Gl.Lakrimal 7. Gl.Manz 8. Tarsus superior

3 ANATOMY
A. anterior ciliary (branch of a.ophtalmica) A. episclera, anastomosis with a. ciliaryis posterior longus forming a. circularis major (iris and ciliary body) A. episclera (sclera, intraocular) Pericorneal plexus (cornea)
A. posterior conjunctiva supplies the conjunctiva

ETIOLOGY
Infecion (viral,bacterial,or chlamydia) Allergic reactions to dust, pollen, animal dander Irritation by the wind, dust, smoke and other air

pollutants; ultraviolet rays from sunlight or electric welding.

Signs & Syptomps

Symptomps:
Red eyes Feeling of lump Dirty eyes Itchy Watery

.
Signs
Conjunctival injection Dicharge/secret There are patologic structure in conjunctiva Chemosis

CONJUNCTIVAL INJECTION
Congestion of conjuctival aa/vv

(posterior conjunctiva) Causes: mechanical, irritation, allergy, infection Signs: Mobile from its base Calibre increases to the periphery Fresh blood color, constricts with topical adrenalin

SILIAR INJECTION
Congestion of pericornea vessels (a. anterior ciliaris) Causes: - corneal inflammation (keratitis, corneal ulcer) - uveitis - acute glaucoma

- endophthalmitis - panophthalmitis
Signs: - does not follow movement of conjuctiva - fine, small vessels surrounding the cornea

- calibre decreases towards the fornices - dark red color, unchanged with topical adrenalin

Discharge
Various kind of discharge: Serous (clear liquid) Mucoid (clear liquid; elastic viscous) Purulent (cloudy yellow liquid)

Pathologic Structure

Classification
Causa Bacteri Virus Chlamydia Alergic Iritation Clinical pattern Conjungtivitis kataral Conjungtivitis purulent Conjungtivitis membran Conjungtivitis folikel Conjungtivitis flikten Conjungtivitis vernal Trachoma

Differential Of The Common types of conjunctivitis1

Differential Of The Common types of conjunctivitis2

Viral conjunctivitis
Viral conjunctivitis commonly is associated with upper respiratory tract infections and is usually caused by an adenovirus. This is the type of conjunctivitis that occurs in epidemics of pink eye. HistoryThe patient normally complains of both eyes being gritty and uncomfortable,

although symptoms may begin in one eye. There may be associated symptoms of a cold and a cough. The discharge is usually watery.
Viral conjunctivitis usually lasts longer than bacterial conjunctivitis and may go on for many weeks; patients need to be informed of this. Photophobia and discomfort may be severe if

the patient goes on to develop discrete corneal opacities.

Viral conjunctivitis
ExaminationBoth eyes are red with diffuse conjunctival injection

(engorged conjunctival vessels) and there may be a clear discharge. Small white lymphoid aggregations may be present on the conjunctiva (follicles). Small focal areas of corneal inflammation with erosions and associated opacities may give rise to pronounced symptoms, but these are difficult to see without high magnification. There may be associated head and neck lymphadenopathy with marked pre-auricular lymphadenopathy

Viral conjunctivitis
ManagementViral conjunctivitis is generally a self limiting condition, but antibiotic eye drops (for example, chloramphenicol) provide symptomatic relief and help prevent

secondary bacterial infection. Viral conjunctivitis is extremely contagious, and strict hygiene measures are important for both the patient and the doctor; for example, washing of hands and sterilising of instruments.

Viral conjunctivitis
Management - The period of infection is often longer than with bacterial pathogens and patients should be warned that symptoms may be present for several weeks. In some patients the infection may have a chronic, protracted course and steroid eye drops may be indicated if the corneal lesions and symptoms are persistent. Steroids must only be prescribed with ophthalmological supervision, because of the real danger of causing cataract or irreversible glaucomatous damage. Furthermore, if long term steroids are required, patients should remain under continuous ophthalmological supervision

A. Faringokonjungtival Fever
Infections caused by adenovirus virus 2.4, and 7. Sign & Symptomps Fever from 38.3 to 40 C, sore throat Follicular conjunctivitis in one or two eyes Red eyes and watery eyes are common, and sometimes a little turbidity subepithelial area Enlargement lymphadenopathy preaurikuler Treatment There is no specific treatment. Konjungtivitisnya recover on their own, generally within about 10 days. Treatment is usually symptomatic and antibiotics to prevent secondary infection

B. Epidemica Keratoconjunctivitis
Caused by adenovirus virus type 3,7,8, and 19 Signs and symptoms: Epidemika keratoconjunctivitis generally bilateral At first the patient feels there is an infection with pain and watery eyes, followed in 5-14 days by photophobia,epithelial keratitis, and subepithelial opacities round. Normal corneal sensation. Tender lymph preaurikuler which is typical. Palpebra edema, kemosis, and conjunctival hyperemia mark the acute phase. Follicles and conjunctival hemorrhage often appear within 48 hours. Pseudomembrane may form and may be followed by a flat scar or symblepharon formation

B. Keratokonjungtivitis epidemika1
Prevention Wash your hands regularly between the inspection and cleaning and sterilization tools tonometer touches the eye in particular is also a must. Aplanasi tonometer should be cleaned with alcohol or hypochlorite, then rinsed with sterile water and dried carefully Treatment: Currently there is no specific treatment, but a cold compress will reduce some symptoms despite having carefully as it will likely lead to the growth of bacteria or secondary infections. corticosteroids for acute conjunctivitis may prolong corneal involvement should be avoided. Antibacterial agent should be given in case of bacterial superinfection Complications can occur corneal opacities that persisted

C.Herpes simpleks conjunctivitis

Usually in children under the age of 2 years accompanied by ginggivostomatitis. Signs and symptoms: unilateral dilation of blood vessels, irritation, mucoid bertahi eyes, pain, and mild photophobia On corneal epithelial lesions appear generally separate fused to form a ulcer or ulcer-epithelial ulcers are highly branched (dendritic) Herpes vesicles sometimes appeared at the edge palpebra palpebra and, accompanied by severe edema palpebra. There is a node preaurikuler typical painful if pressed

C.Herpes simpleks conjunctivitis

Treatment

Local and systemic anti-virus should be given to prevent cornea involvemet For corneal ulcers may be required corneal debridement carefully by rubbing the ulcer with a sterile cotton swab sticks, dripping with antiviral drugs, and closed for 24 hours. Topical antiviral should be given 7-10 days: trifluridine every 2 hours while awake or rabine vida ointment five times a day, or idoxuridine 0.1%, 1 drop every hour while awake and 1 drop every 2 hours during the night. Herpes keratitis can also be treated with acyclovir ointment 3% five times daily for 10 days or with oral acyclovir, 400 mg five times daily for 7 days

D.Konjungtivitis Hemoragika Akut

Etiology are Picorna viral and enterovirus 70
Signs and symptoms: eye pain, photophobia, foreign

body sensation, a lot of tears, red, palpebra edema, and hemorrhage subkonjungtival. It sometimes happens kemosis conjunctiva. Treatment is usually symptomatic. The use of antibiotics can be used to prevent secondary infection.

Therapy:

Bacterial conjunctivitis
HistoryThe patient usually has discomfort and a purulent

discharge in one eye that characteristically spreads to the other eye. The eye may be difficult to open in the morningbecause the discharge sticks the lashes together. There may be a history of contact with a person with similar symptoms.

Bacterial conjunctivitis
Examination The vision should be normal after the discharge

has been blinked clear of the cornea. The discharge usually is mucopurulent and there is uniform engorgement of all the conjunctival blood vessels. When fluorescein drops are instilled in the eye there is no staining of the cornea.

Bacterial conjunctivitis
ManagementTopical antibiotic eye drops (for example,chloramphenicol)

should be instilled every two hours for the first 24 hours to hasten recovery, decreasing to four times a day for one week. Chloramphenicol ointment applied at night may also increase comfort and reduce the stickiness of the eyelids in the morning. Patients should be advised about general hygiene measures; for example, not sharing face towels

Chlamydial conjunctivitis
HistoryPatients usually are young with a history of a chronic bilateral conjunctivitis with a mucopurulent discharge. There may be associated symptoms of venereal disease. Patients generally do not volunteer genitourinary symptoms when presenting with conjunctivitis; these need to be elicited through questioning.

Chlamydial conjunctivitis
ExaminationThere is bilateral diffuse conjunctival injection with a mucopurulent discharge. There are many lymphoid aggregates in the conjunctiva (follicles). The cornea usually is involved (keratitis) and an infiltrate of the upper cornea (pannus) may be seen.

Chlamydial conjunctivitis
ManagementThe diagnosis is often difficult and special bacteriological tests may be necessary to confirm the clinical suspicions. Treatment with oral tetracycline or a derivative for at least one month can eradicate the problem, but poor compliance can lead to a recurrence of symptoms. Systemic tetracycline can affect developing teeth and bones and should not be used in children or pregnant women. Associated venereal disease should also be treated, and it is important to check the partner for symptoms or signs of venereal disease (affected females may be asymptomatic). It often is helpful to discuss cases with a genitourinary specialist before commencing treatment, so that all relevant microbiological tests can be performed at an early stage.

Various Chlamidya trachomatis serotypes that are obligate intracellular organism causes two eye infections are: a. Trachoma b. Inclusiuon Conjuctivitis

TRACHOMA
Tracoma is a form of chronic follicular conjunctivitis caused by Clamydia trachomatis. This disease can affect any age but more common on young people and children

Modes of transmission of this disease is through direct contact with

secretions or through a trachoma patients daily necessities such as towels, toilet articles and deodorized.
The average incubation period of 7 days (range 5 to 14 days)

TRACHOMA
According to the classification Mac Callan clinical picture of this disease is divided into several stages. Stage I; called insipien stadium Stage II; called established Stage III is called staging grated Stage IV; called the stage of healing

TRACHOMA
To ensure trachoma endemic in family or community, a number of children must show at least - least two signs of the following:
(1) Five or more follicles on the tarsal conjunctiva palpebra superior to the average eye. (2) Grate the tarsal conjunctiva conjunctiva at the superior characteristic. (3) follicles or sekuelenya limbus (Herbert wells). (4) The expansion of blood vessels onto the cornea, the clear upper limbus.

TRACHOMA
For control, the World Health Organization has

developed a simple way to check the disease. It includes a sign - a sign as follows

TRACHOMA
TF : five or more follicles on the upper tarsal

conjunctiva.

TRACHOMA
TI : Diffuse infiltrate and hypertrophy papil on the

conjuctiva tarsalis superior at least 50% of normal deep veins.

TRACHOMA
TS : Trachomatosa conjunctival scarring.

TRACHOMA
TT : Trikiasis or entropion(inverted eyelashes)

TRACHOMA
CO : Corneal blurred.

TRACHOMA
TF and Ti show an active infectious trachoma that

must be treated. TS is evidence of injury from this disease. TT is potentially blinding and indications for surgery kokreasi palpebra. CO is the final blinding lesion of trachoma.

TRACHOMA
Support investigation Inclusi body of chlamydia can be found in the conjunctival scrapings in sleeping with Giemsa, but not always exist. Outward appearance of fluorescein antibody and immuno - assay test of enzymes are commercially available and widely used in clinical laboratorium. This new test has replaced the outward appearance of Giemsa for preparation and isolation of the klamidial agents in cell cultures Differential diagnosis Follicularis conjunctivitis, vernal katarrh.

TRACHOMA
Complication a. Secondary infection b. Corneal opacities due to pannus covering the cornea c. Corneal xxerosis with keratitis Sika d. Enteropion and trikiasis e. Simblefaron Treatment Treatment of trachoma with tetracycline eye ointment 2-4 times a day, 3-4 weeks, a correction Surgery should be performed on the eyelashes turn inward to prevent scarring trachoma. For prevention by vaccination and eat a nutritious and hygienic good to prevent the spread.

Inclusion Conjunctivitis
The disease is transmitted sexually and can last for

chronic (up to 18 months) unless treated adequate

Inclusion Conjunctivitis1
Sign & Symptomps Patients often complain of red eyes, pseudo-ptosis, and especially in the morning belekandays. In neonates showed papillary conjunctivitis and a moderate amount of exudate,in cases of hyperacute, occasionally formed which can cause scarring pseudomembrane. Patients present with follicular conjunctivitis is mucopurulent and there mikropanusassociated with subepithelial scarring.

Inclusion Conjunctivitis2
Examination Support Rapid diagnostic test direct fluorescent antibody test, ELISA, and PCR was replace the outward appearance of Giemsa Differential diagnosis Active follicular trachoma

Treatment in infants Give erytromycin per oral suspension, 50 mg / kg / day in 4 divided doses sealam sekurangkurangnya 14 days. In adults Healing is achieved by doxycycline 100 mg orally twice daily for 7 days, or erythromycin 2 g / day for 7 days, or it could be azithromcin 1 g / dose.

Allergic conjunctivitis
HistoryThe main feature of allergic conjunctivitis is itching. Both eyes usually are affected and there may be a clear discharge. There may be a family history of atopy or recent contact with chemicals or eye drops. Similar symptoms may have occurred in the same season in previous years. It is important to differentiate between an acute allergic reaction and a more long term chronic allergic eye disease.

Allergic conjunctivitis
ExaminationThe conjunctivae are diffusely injected and may be oedematous (chemosis). The discharge is clear and stringy. Because of the fibrous septa that tether the eyelid (tarsal) conjunctivae, oedema results in round swellings (papillae). When these are large they are referred to as cobblestones.

Allergic conjunctivitis
ManagementTopical antihistamine and vasoconstrictor eye drops provide short term relief. Eye drops that prevent degranulation of mast cells also are useful, but they may need to be used for several weeks or months to achieve maximal effect. Oral antihistamines may also be used, particularly the newer compounds that cause less sedation. Topical steroids are effective but should not be used without regular ophthalmological supervision because of the risk of steroid induced cataracts and glaucoma

A. Atopic Conjunctivitis
Sign & Symptomps Burning sensation, Dirty eyes, Red eyes and photophobia. Palpebras edge eritemosa, and the conjunctiva was white as milk. There is a papilla refined, but not growing like a giant papilla on keratoconjunctivitis vernal, and more often found in the inferior tarsus.

A. Atopic Conjunctivitis1
Usually there is a history of allergies (hay fever, asthma, or eczema) in patients or her family. Most patients had suffered from atopic dermatitis since infancy. Grate in the folds of flexure folding elbow and wrist and knee often was found. As dermatitisnya, atopic keratoconjunctivitis lasts a prolongedand often experience exacerbations and remissions. such as keratoconjunctivitis vernal, the disease tends to be less active when the patient was aged 50 years.

laboratory Conjunctival scrapings revealed eosinophils, although not as much as that seen as much on vernal keratoconjunctivitis.

A. Atopic Conjunctivitis2
Treatment
Oral Antihistamine including terfenadine (60-120 mg 2x a day),

astemizole (10 mg four times daily), or hydroxyzine (50 mg bedtime, increased to 200 mg) proved to be beneficial. NSAID, such as ketorolac and iodoxamid, it can overcome the symptoms in these patients. In severe cases, plasmapheresis is an adjunctive therapy. In the case of advanced with severe corneal complications, corneal transplant may be necessary to restore the sharpness of his eyesight

B.Hay Fever Conjunctivitis

Signs and symptoms Inflammation of conjunctivitis non-specifics lightweight generally accompanies the hay fever(rhinitis Allergic). Usually there is a history of allergy to pollen, grass, feathers animals, and others. Patients complains about the itchy-itchy, watery , red eye,and often said that his eyes as if (sink into the surrounding tissue) Laboratory Hard to find eosinophils in conjunctival scrapings. Therapy Shed a vasoconstrictor local domain on stage of acute (epineprin, solution of 1:1000 given topically, will eliminate kemosis and symptoms in 30 minutes). Cold compresses help with the itching and antihistamine onlylittle benefit. Direct response to the treatment fairly well.

C. Vernal Conjunctivitis
An inflammation of the eyes of the outside of the seasonal and

considered to be an allergy.

Conjunctiva contains many cells of the immune system (mast

cells) the release of chemical compounds (mediators) in response to various stimuli (such as pollen or dust mites). mediators cause inflammation the eye, which may last a minute or longer. Approximately 20% of people have high levels of red eye allergy.

These

Diagnosis Found any signs of inflammation of the conjunctiva Found any giant papil the superior conjunctiva palpebra Found any tantras dot on the corneal limbus Sometimes accompanied by shield ulcer\ Recurrent Sign & Symptomps Red eyes (usually recurrent) Sometimes accompanied by intense itching A history of allergy The existence of diffuse papil hypertrophy especially of the conjunctiva tarsal superior Thickening of limbus with dot tantras Mucoid to mucopurulent discharge if there is secondary infection

Treatment
Mild cases: educational therapy (avoiding allergens, cold compresses, cool room, lubrication, eye ointment), giving antihistamines (topical levokabastin, emestadine), vasoconstrictor (phenileprine, tetrahidrolozine), mast cell stabilizer (4% sodium cromolin alomide) Moderate-severe cases:
mast cell stabilizer (sodium 4% alomide cromolin), topical steroid anti-inflammatory (ketorolac 0.5%), topical corticosteroids or agents modulator cyclosporine.

D.Flikten Conjunctivitis
Hypersensitivity reaction to microbial protein (such

as protein M.tbc, Stafilokok, Candida) Small lesions (1-3mm), hard, red, surrounded by prominent local hyperemia If the limbus -> triangular with the peak in the direction of the cornea -> recover form jar.parut.

Iatrogenic Conjunctivitis (Topical drug administration)

Follicular conjunctivitis Conjunctivitis toxic or non-specific infiltrate,which followed the formation of scar tissue, often caused by long using of dipivefrin, miotika, idoxuridine, neomycin, and other drugs are prepared in vehikel preservatives or toxic that cause irritation. Silver nitrate is dripped into the saccus conjingtiva at birth is often a causes a mild chemical conjunctivitis. If tear production is reduced due to continuous irritation, conjunctival injury because there would then exist dilution of the agents that damage when dropped into the saccus conjungtivae. Conjunctival scrapings often contain keratinized epithelial polymorphonuclear neutrophils, and occasional odd-shaped cells.

cells, a few

Conjunctivitis caused by Chemicals and irritants1

Acid, alkali, smoke, wind, and almost any irritant substance that makes the saccus conjungtiva can cause conjunctivitis. Some common irritants is fertilizer, soap, deodorant, hair spray, tobacco, ingredients make-up, and various acid and alkali. In certain areas, smog (a mixture of smoke and fog) The main cause of a mild chemical conjunctivitis. Specific irritant in smog can not be positively determined, and non-specific treatment. No a permanent effect

on the eye, but the affected eye is often red and disturbing is chronic.

Conjunctivitis caused by Chemicals and irritants

On the injury acid, it changes the nature and effect of protein networks directly. Alkali does not change the nature of the protein and tend to quickly infiltrate network and settled into the conjunctival tissue. Here they continued to damage sustained for hours or days old, depending on molar concentration of the alkali and the amount of intake. attachment between bulbi conjunctiva and cornea leokoma palpebra and more than likely occur if the cause is an

alkali agent. At any event, the main symptom chemical injury are pain, blood vessel dilation, photophobia, and blepharospasm. History of the trigger events can usually be disclosed.
.

Conjunctivitis caused by Chemicals and irritants

Immediate and thorough flushing with water or saccus conjungtivae salt solution is very important, and any solid material must be removed in mechanics. Do not use chemical antidotum. Symptomatic common action is a cold compress for 20 minutes every hour, 1% atropine drops twice day, and give systemic analgesics if necessary. Bacterial conjunctivitis can be treated with appropriate antibacterial agents. Scarring of the cornea may require corneal transplantation, and symblepharon may require plastic surgery of the conjunctiva. Severe burns and corneal kojungtiva prognosis poor despite surgery. However, if treatment is started soon enough, grated formed will be minimal and the prognosis is better

TERIMA KASIH