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Lecture notes, cheat sheets
Eye diseases. Diagnosis, clinical picture and treatment of conjunctival diseases (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 10. Diagnosis, clinic and treatment of diseases of the conjunctiva 1. General Provisions The most common pathology of the conjunctiva is its inflammation conjunctivitis. Detection in a patient of such signs as swelling and redness of the eyelids and conjunctiva, photophobia, tear or suppuration and blepharospasm, combined with an indication of gluing of the eyelids in the morning and after sleep, pain in the eyes, often help to diagnose conjunctivitis. For the purposes of the etiological and differential diagnosis of conjunctivitis, it is always necessary to pay attention to the intensity of hyperemia, the nature of the follicles or papillae, hemorrhages, films, the color, quantity and consistency of the discharge, changes in the regional lymph nodes (increase and soreness), the presence of headache, high temperature, general ailments, etc. Pronounced lacrimation with photophobia and blepharospasm may indicate involvement of the cornea. To make a diagnosis, it is important to find out how the disease began, how long it lasted, and what the previous treatment was. It is necessary to clarify the general condition of the patient’s body preceding this eye disease, contacts, the presence of the disease in areas adjacent to the eye (mumps, rhinitis, stomatitis, etc.). It must be remembered that the annual development of conjunctivitis during the flowering period of poplar and various flowers, as well as after eating certain berries, citrus fruits, pineapples and other fruits, may indicate the allergic nature of the inflammatory process. Only a clear understanding of the symptoms that are pathognomonic of certain types of conjunctivitis makes it possible to make a correct etiological diagnosis, and, therefore, to promptly resolve the issue of the place, method and duration of treatment, methods and means of prevention, etc. Thus, it is known that pronounced swelling and hyperemia of the eyelids occur with adenoviral conjunctivitis and gonoblenorrhea. Cyanosis and thickening of the eyelids are observed in the initial period of conjunctival diphtheria. The tear-stained appearance of a child in the first ten days of life often accompanies tear pneumococcal conjunctivitis. In young children with epidemic Koch-Wicks conjunctivitis (as a rule) and with adenoviral epidemic keratoconjunctivitis (in most cases), there is an increase in the preauricular and submandibular lymph nodes. Copious, watery, meat-slop-colored or purulent discharge of yellow-green color and creamy consistency, appearing two to three days after birth, is characteristic of the gonococcal process. For conjunctivitis caused by Koch-Wicks bacillus and pneumococcus, purulent discharge is specific in the area of the canthus and along the edge of the eyelids at the root of the eyelashes. Scanty mucous discharge occurs with adenoviral and allergic conjunctivitis. Any inflammatory process of the conjunctiva is primarily accompanied by dilation, tortuosity and hyperemia of the vessels of all its parts. Hyperemia of the conjunctiva of the eyeball is more pronounced at the fornix and decreases towards the limbus, has a bright pink color and moves with displacement of the conjunctiva. Hyperemia of the conjunctiva of the eyelids obscures the normal vascular pattern and characteristic striations, which are normally caused by the transillumination of the meibomian gland ducts. Films on the conjunctiva can be of different colors, thicknesses and sizes. Their formation is due to the ability of some pathogens (adenoviruses, diphtheria bacillus, some strains of pneumococcus) to coagulate tissue proteins. With pneumococcal and adenoviral conjunctivitis, the film is easily removed from the surface of the mucous membrane. If, after removing the film, a bleeding, ulcerated surface remains, this often indicates a diphtheria process. The appearance of follicles and papillae in the mucous membrane indicates the involvement of subconjunctival adenoid tissue in the process; follicles usually appear on the conjunctival cartilage at the corners of the palpebral fissure, as well as on the transitional folds. They may be small and pink in adenoviral keratoconjunctivitis, grayish-pink in pharyngoconjunctival fever. These conjunctivitis is characterized by the development of follicles on the unchanged mucous membrane. With trachoma, follicles develop on the infiltrated mucous membrane, have a grayish-pink color, and are randomly located. Large lumpy papillary growths located on the dull bluish conjunctiva, most often of the upper eyelid, resembling a cobblestone street in appearance, are characteristic of allergic spring conjunctivitis. Hemorrhages may be small and petechial in pneumococcal conjunctivitis caused by Koch-Wicks bacillus. In the study of the conjunctiva by the method of combined examination or in the light of a slit lamp, cicatricial changes are detected. More often they can be noted as radial stripes on the conjunctiva of the upper eyelid or as a linear scar running parallel to the sulcus subtarsalis. The presence of such changes, as a rule, indicates the postponed trachoma. In cases where, along with similar scars, the mucous membrane is infiltrated and there are follicles, there is every reason to diagnose trachoma of the second or third stage. Deep star-shaped scars remain after conjunctival diphtheria. To confirm the etiology of conjunctivitis, in addition to analyzing the corresponding clinical picture, bacteriological studies of discharge from the conjunctiva are carried out while simultaneously identifying the sensitivity of the pathogen to antibiotics and sulfonamides. This allows for etiotropic treatment. The presence of bluish-red areas on the conjunctiva that protrude above its surface, increasing when the child cries and tilts the head, is characteristic of a vascular hemangioma tumor. A small round formation with clear boundaries of a whitish-yellow color, found during a simple examination, most often located in the inferolateral quadrant, may be a dermoid of the conjunctiva. Sometimes on the conjunctiva of the eyeball, more often at three or nine o'clock at the limbus, there is a flat, somewhat raised formation of a yellowish color, in some cases with pigment inclusions. These are nevi, or birthmarks, of the mucous membrane. 2. Conjunctivitis Conjunctivitis is an inflammation of the mucous membrane that lines the back of the eyelids and the eyeball. Etiology. Due to the occurrence, bacterial conjunctivitis (staphylococcal, streptococcal, gonococcal, diphtheria, pneumococcal), viral conjunctivitis (herpetic, adenovirus, epidemic keratoconjunctivitis), chlamydial conjunctivitis (trachoma), allergic and autoimmune conjunctivitis (drug, hay fever, tuberculosis-allergic) are distinguished. According to the nature of the course, conjunctivitis is divided into acute and chronic. Clinical picture. General symptoms characteristic of all conjunctivitis include subjective complaints of the patient and objective signs. Subjective symptoms include a burning sensation and itching in the eye, a feeling of blockage, and photophobia. Objective symptoms include lacrimation, narrowing of the palpebral fissure, redness and swelling of the conjunctiva of the eyelids, due to which it loses its luster and becomes “velvety.” Redness of the eyeball with conjunctivitis is observed in the periphery. Acute infectious conjunctivitis (the most common of all bacterial conjunctivitis) is caused by staphylococci and streptococci. Both eyes are involved in the pathological process, but more often not simultaneously, but sequentially. In addition to the symptoms common to all conjunctivitis, this type is characterized by the presence of a purulent discharge that glues the eyelashes. The disease may be preceded by cooling or overheating, swimming in a polluted reservoir or staying in a dusty room, as well as acute respiratory illness. Objectively pronounced redness of the conjunctiva of the eyelids and eyes. Pneumococcal conjunctivitis develops most often in weakened individuals, the elderly and children. It is characterized by pinpoint hemorrhages in the conjunctiva, swelling of the eyelids and the formation of whitish-gray films. Acute epidemic Koch-Wicks conjunctivitis is highly contagious and is transmitted through contaminated hands, clothing and underwear. The disease begins suddenly with a sharp swelling of the eyelids, redness of the conjunctiva of the eyelids and the eyeball. Among other general symptoms, malaise, fever, runny nose and headaches are often observed. The discharge is initially scanty, then becomes profuse and purulent. The illness lasts five to six days. Sick people must be isolated. Gonococcal conjunctivitis (gonoblenorrhea) is caused by gonococcus and is clinically divided into gonoblennorrhea of newborns, children and adults. Newborns can become infected either by passing through the vaginal birth canal of a mother with gonorrhea or through baby care items. Clinically, gonoblennorrhea manifests itself on the second or third day after birth with pronounced swelling of the eyelids, sharp redness of the conjunctiva with profuse bloody discharge (the color of meat slop), which after three to four days, when the swelling of the eyelids has already decreased, becomes purulent in nature. A complication of gonoblenorrhea is ulceration of the cornea, which can lead to the formation of a thorn, and if the cornea is perforated, infection can penetrate into the deep parts of the eyeball and blindness. Currently, such serious complications are relatively rare. Gonoblenorrhea in adults occurs with severe general symptoms: fever, damage to the joints and the cardiovascular system. In adults, complications of gonococcal conjunctivitis are quite common. Diphtheria conjunctivitis is rare (if the anti-diphtheria vaccination regimen is not followed) and is accompanied by severe intoxication, high body temperature, enlarged lymph nodes and their soreness. Local distinctive signs of diphtheria conjunctivitis are gray filmy deposits on the conjunctiva of the eyelids and eyeball. Their removal is painful and accompanied by bleeding. After one to one and a half weeks, the discharge becomes purulent, the affected areas of the conjunctiva are rejected and heal with a scar within one and a half to two weeks. In this case, the formation of adhesions between the eyeball and the inner surface of the eyelids is possible. The causative agent of herpetic conjunctivitis is the herpes simplex virus. Most often, herpetic conjunctivitis is unilateral and has a long course. There are three forms: catarrhal, follicular and follicular-ulcerative. In the first case, the inflammation is mild, accompanied by the appearance of blisters on the edges of the eyelids and mucous or mucopurulent discharge; in the latter case, erosions and ulcers are formed. Adenovirus conjunctivitis is caused by adenoviruses and is accompanied by fever and pharyngitis. Allergic and autoimmune conjunctivitis develops with increased sensitivity of the body to a wide variety of substances. Drug conjunctivitis occurs with prolonged local treatment with antibiotics, anesthetics and is a special case of allergic conjunctivitis. Treatment. For acute infectious conjunctivitis, antimicrobial drugs are prescribed: 30% sodium sulfacyl solution, antibiotic solutions, furatsilin solution at a dilution of 1: 5000, 24% boric acid solution, 3% collargol solution. On the first day of illness, drops are instilled into the conjunctival sac every hour, in the next three to four days 56 times a day. In case of acute conjunctivitis, a sterile bandage should not be applied to the affected eye so as not to cause stagnation of purulent discharge. Prevention of acute conjunctivitis involves following the rules of personal hygiene. Treatment of gonococcal conjunctivitis includes the use of sulfanilamide drugs and broad-spectrum antibiotics orally and intramuscularly, frequent rinsing of the eyes with a weak solution of potassium permanganate with the instillation of albucid. At night, an ointment containing antibiotics or sulfonamides is applied over the eyelids. Treatment is carried out until complete recovery, which must be confirmed bacteriologically. The prognosis for timely and adequate treatment is favorable. In newborns, mandatory prevention of gonoblennorrhea is carried out: immediately after birth, a 30% solution of sulfacyl sodium is instilled into each eye three times within an hour. Treatment of diphtheria conjunctivitis is carried out in the infectious diseases department using anti-diphtheria serum and antibiotics or albucid and 1% tetracycline ointment locally. Treatment of viral conjunctivitis includes local use of antiviral drugs (0,11,2% oxolinum solution, 0,25% oxolinic ointment), specific antiviral immunotherapy (globulin) and the use of restoratives (vitamins). Treatment of allergic and medicinal conjunctivitis requires immediate discontinuation of the drugs that caused such a reaction, and the use of desensitizing and antihistamine drugs orally, as well as topical glucocorticosteroids (eye drops and ointments). Author: Shilnikov L.V. << Back: Diagnosis, clinic and treatment of orbital pathologies (Phlegmon of the orbit (Phlegmona orbitae). Sarcoma of the orbit. Lymphoma of the orbit) >> Forward: Clinical features and principles of treatment of some conjunctivitis and conjunctival tumors (Acute epidemic conjunctivitis (Koch-Wicks conjunctivitis). Pneumococcal conjunctivitis. Blenorrheal conjunctivitis. Diphtheria conjunctivitis. Treatment of bacterial conjunctivitis. Adenopharyngoconjunctival fever (AFCL). Epidemic follicular keratoconjunctivitis (EFK). Treatment adenoviral conjunctivitis. Tumors of the conjunctiva)
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