Viral Conjunctivitis

Learning Objectives

• Papillae vs follicles
• Membrane vs pseudo membrane
• Conjunctivitis vs keratoconjunctivitis
• Viral conjunctivitis identifiers
• Adenoviral conjunctivitis
• Acute herpetic conjunctivitis
• Acute haemorrhagic conjunctivitis

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�Papillae vs Follicles�

Papillae

• Hyperplastic conjunctival epithelium with a fibrovascular core and subepithelial stromal infiltrate
• Flat topped elevations , velvety appearance
• Palpebral conjunctiva, limbus
• Bacterial and allergic conjunctivitis
• Contact lens/ foreign body

Follicles

• Subepithelial localised area of lymphoid hyperplasia
• Multiple discrete slightly elevated lesions resembling sago grains
• Palpebral conjunctiva , Fornices
• Viral, trachoma, toxins

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�Papillae vs Follicles�

�Papillae vs Follicles�

Papillae

Follicles

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Papillae vs Follicles

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�Membrane vs Pseudo membrane�

Membrane

• Growth of true membrane into the conjunctival epithelial surface
• Significant bleeding upon peeling

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• Corynebacterium diphtheriae
• Beta hemolytic Streptococcus
• SJS, TEN
• Neisseria gonorrhea
• Adenovirus, HSV

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Pseudo membrane

• More superficial, no growth into the epithelium
• Can be removed with minimal bleeding

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• Pneumococci
• Adeno virus, HSV
• Staphylococcus aureus, Streptococci, Gonococci, low virulence diphtheriae, H.influenzae
• Ligneous conjunctivitis
• Chemical, GVHD

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Fibrinous sheet and inflammatory debris on epithelial surface of conjunctiva

Membrane vs Pseudo membrane

Membrane

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Pseudo membrane

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Membrane vs Pseudo membrane

Conjunctivitis vs Keratoconjunctivitis

• Inflammation of conjunctival epithelium alone

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• Inflammation of epithelium of both conjunctiva and cornea

Viral Conjunctivitis identifiers

Viral Conjunctivitis identifiers

Conjunctival signs

• Unilateral or bilateral diffuse conjunctival congestion
• Follicles – lower palpebral conjunctiva
• Chemosis
• Conjunctival hemorrhages - petechiae
• Membranes & pseudo membranes

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Viral Conjunctivitis identifiers

Corneal signs

• Epithelial microcysts
• Punctate epithelial keratitis
• Subepithelial infiltrates
• Pseudo dendritic epithelial formations

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Viral Conjunctivitis identifiers

Systemic signs

• Preauricular lymphadenopathy
• Prodrome : fever, diarrhea
• Upper respiratory tract infection /cold/ sore throat

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Viral Conjunctivitis

Viral Conjunctivitis

Viral Conjunctivitis

Viral Conjunctivitis

Viral Conjunctivitis

Adenovirus

• Most common cause of viral conjunctivitis
• 6 subgenus - A to F
• Most of the conjunctivitis are caused by subgenus D

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Adenoviral Conjunctivitis

Clinical presentation

• Epidemic keratoconjunctivitis
• Pharyngoconjunctival fever
• Nonspecific acute follicular conjunctivitis
• Chronic relapsing adenoviral conjunctivitis

�Epidemic Keratoconjunctivitis�

• Type of acute follicular conjunctivitis associated with superficial punctate keratitis
• Occurs in epidemics
• Adenoviruses type 8, 19, 37
• Incubation period 8 days
• Markedly contagious - Virus is shed for 2–3 weeks

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Epidemic Keratoconjunctivitis

Transmission

• Contaminated fingers or objects
• Swimming pool
• Instruments such as tonometer tips
• Hand contact

Epidemic Keratoconjunctivitis

Symptoms

• Redness of acute onset

• Watering - profuse, with mild mucoid discharge

• Foreign body sensation

• Photophobia

• Pain/ severe discomfort
• Visual acuity normal unless cornea involved

Epidemic Keratoconjunctivitis

Signs

• Lid edema
• Conjunctival hyperemia
• Chemosis
• Follicles
• Papillae
• Petechial subconjunctival hemorrhages

Epidemic Keratoconjunctivitis

Signs

• Pseudo membrane
• Epithelial microcystic changes
• Superficial punctate keratitis
• Subepithelial infiltrates
• Pre-auricular lymphadenopathy

Decreased visual acuity, photophobia, haloes

Epidemic Keratoconjunctivitis

Investigations

• Research purposes, non resolving cases
• Conjunctival cytology
• Polymerase chain reaction
• Point-of-care immunochromatography
• Viral culture

Epidemic Keratoconjunctivitis

Treatment

• Supportive treatment - Cold compresses, Sun glasses, Decongestant and lubricant tear drops
• Topical antibiotics help to prevent superadded bacterial infections

Epidemic Keratoconjunctivitis

Treatment

• Topical steroids should not be used during active inflammation - enhance viral replication and extend the period of infectivity
• Weak steroids such as Fluorometholone or Loteprednol are indicated in patients with subepithelial infiltrates and pseudo membrane formation

Epidemic Keratoconjunctivitis

Fate of EKC

• Complete healing
• Permanent corneal scarring
• Symblepharon formation
• Subconjunctival scarring
• Dry eye

Epidemic Keratoconjunctivitis

Preventive measures

• Frequent handwashing

• Relative isolation of infected individual

• Avoiding eye rubbing

• Avoid sharing of towel

• Disinfection of ophthalmic instruments and clinical surfaces after examination

�Pharyngoconjunctival Fever�

• Adenovirus subtypes 3,4 and 7
• Primarily affects children
• Occurs in small outbreaks
• Acute follicular conjunctivitis, Pharyngitis, Fever, Pre-auricular lymphadenopathy

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�Pharyngoconjunctival Fever�

• Sequential involvement
• Second eye is clinically less severe
• Abrupt onset of itching and irritation
• Abundant serous discharge, crusting of lashes

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�Pharyngoconjunctival Fever�

Transmission

• Personal contact, fomites, swimming pool
• Children’s summer camp

Communicability – high during first several days, lasts for 2 weeks

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�Pharyngoconjunctival Fever�

Signs

• Conjunctival congestion
• Mild punctate keratitis – occur 2 days to 1 week after onset of symptoms
• Persist for upto a week
• Supportive treatment

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�Nonspecific Acute Follicular Conjunctivitis�

• Adenovirus serotypes 1 to 11 and 19
• Milder form of acute follicular conjunctivitis with preauricular lymphadenopathy
• Corneal involvement commonly not present
• Resolution of signs and symptoms is more rapid than in EKC and PCF
• Patients are often cured by beginning of 3^rd week

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�Chronic Follicular Conjunctivitis�

• Least common form of adenoviral conjunctivitis
• Adenovirus serotypes 2, 3, 4 and 5
• Symptoms persist longer than expected
• Virus can be recovered many months or years after onset of symptoms
• Conjunctivitis has waxing and wanning course with superficial punctate epithelial keratitis and subepithelial infiltrates
• Spontaneous resolution

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�Acute Herpetic Conjunctivitis�

• Accompaniment of the primary herpetic infection
• HSV type 1 – common; spreads by kissing or other close personal contacts
• HSV type 2 – rare; children and adult
• Unilateral
• Incubation period - 3–10 days
• 2 clinical forms - typical and atypical

Acute Herpetic Conjunctivitis

• Typical form - follicular conjunctivitis associated vesicular lesions of face
• Atypical form - follicular conjunctivitis occurs without lesions of the face; resembles EKC
• Nonspecific hyperemia, follicular hyperplasia and pseudomembrane
• Corneal involvement - rare
• Fine or coarse epithelial keratitis or typical dendritic keratitis
• Preauricular lymphadenopathy

Acute Herpetic Conjunctivitis

Treatment

• Primary herpetic infection is usually self-limiting
• Topical antiviral drugs control the infection effectively and prevent recurrences
• Supportive measures are similar to EKC

Acute Hemorrhagic Conjunctivitis

• Acute inflammation of conjunctiva with multiple conjunctival hemorrhages, conjunctival hyperemia and mild follicular hyperplasia
• Etiology - Picornaviruses (enterovirus type 70, coxsackie A24)
• Incubation period 1–2 days
• Apollo conjunctivitis
• Pain, redness, watering, mild photophobia, transient blurring of vision and lid swelling

Acute Hemorrhagic Conjunctivitis

Acute Hemorrhagic Conjunctivitis

• Signs : Conjunctival congestion, chemosis, multiple haemorrhages in bulbar conjunctiva, mild follicular hyperplasia, lid oedema, fine epithelial keratitis and preauricular lymphadenopathy
• Usually self-limiting in course of 7 days
• Broad-spectrum antibiotic eyedrops - to prevent secondary bacterial infections
• Supportive measures are same as EKC

Take home

• Adenovirus – most common cause
• Highly contagious – isolation important
• Supportive treatment
• Topical steroids only when indicated – pseudo membrane, subepithelial infiltrate

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