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A. John Kanellopoulos, MD

A wide variety of disorders can overcome the natural defenses of the eye and ocular adnexa. Our challenge as ophthalmologists is to recognize and remedythe situations where the eye's defense systems have failed or overreacted.

Conjunctival Inflammation

The most common cause of red eye is conjunctival inflammation. Conjunctivitis represents a wide group of disorders that are characterized by cellular infiltration and exudation, in addition to vascular dilation of the conjunctiva. The conjunctiva is a thick translucent mucous membrane. Its palpebral portion lies over the posterior portion of the eyelids and is firmly attached to the tarsal plate, while the bulbar portion lies loosely over the anterior globe, with firm adherence at the limbus. The conjunctiva has an inferior layer of a submucosal substantia propria that consists of a superficial adenoid portion containing lymphoid tissue and a deeper fibrous portion containing mainly connective tissue.

Conjunctivitis is traditionally classified according to its duration as acute when under 3 weeks, duration, or chronic when it lasts more than 3 weeks.

Specific forms of responses of the conjunctiva, aside from the classic tetrad of ocular inflammation (pain, warmth, redness, swelling), can aid in the differential diagnosis of the insulting agent (bacteria, viruses, allergens). There are six responses of conjunctiva that will specifically be addressed.

Conjunctival Discharge

Conjunctival discharge can present as a serous or mucoid exudate or transudate arising from the inflamed superfi- cial vessels. In this case, conjunctival discharge is more representative of viral origin, toxicity to topically used ocular medications, or an acute response to an allergic stimulus. Purulent and thicker consistency discharge is more common with bacterial infections.

Papillae

Papillae represent edema of the substantia propria of the conjunctiva, that is densely adherent to the tarsal plate. Therefore, the portion of the substantia propria that lies between the fibrous attachments of the conjunctiva and the tarsal plate swells and forms an array of "bumps" to the palpebral conjunctival portion. Tarsal papillae are not specific signs of conjunctivitis, they can be mild when moderate conjunctiva inflammation is present, or they can be marked when severe or long-lasting conjunctival inflammation is present. Chronic conjunctivitis can cause the septae between individual papillae to break loose and resolve, it can also cause the papillary hypertrophy to become more confluent, generating larger papillae. Giant papillary conjunctivitis is usually a response to foreign bodies (contact lenses and suture materials), vernal conjunctivitis (a seasonal hypersensitivity reaction in young adults), and atrophy.

Follicles

Follicles represent whitish or yellow discrete round lesions of the conjunctiva produced by a specific response. Unlike papillae, the central portion of the follicle is avascular, with blood vessels sweeping up over the convexity from the base. They are most readily appreciated in the upper tarsal conjunctiva and the lower cul-de-sac. However, they can also be seen in the limbus. They represent normal findings when seen in the temporal tarsus in young adults. FoUicular conjunctivitis is usually diagnostically divided into acute foUicular conjunctivitis that can be caused by adenoviral conjunctivitis or viruses such as measles, vaccinia, coxsackieviruses, herpes, and enterovirus. Chronic follicular conjunctivitis is usually caused by chlamydial infections (inclusion conjunctivitis), toxic reactions, molluscum contagiosum, Moraxella, Lyme disease, toxic conjunctivitis, and foUiculosis

Pseudomembranes and True-Membranes

When inflammatory exudation intermixes with inflammatory cells and other infectious or allergic cellular debris, it may precipitate over the conjunctival surface as a uniform membra- nous sheet. This represents the membrane or pseudomembrane conjunctival formation. The difference between the two is purely the underlying hemorrhage when removal is present with true-membranes representing more serious, more adherent precipitation of inflammatory debris. Usual causes of membranous or pseudomembranous conjunctivitis are severe viral or bacterial conjunctivitis, such as epidemic keratoconjunctivitis or streptococcal infections, Stevens-Johnson syndrome, and chemical burns.

Cicatridal Changes and Granuloma

Cicatricial changes in the conjunctiva occur only when there is destruction ofstromal tissue. It follows the sequence of inflammation and linear fibrosis in the conjunctivia fornix, resulting in foreshortening of the fornix and possible symblepharon formation along with cicatricial entropion and trichiasis.

Enlarged Preauricular Lymph Node

The final clinical finding specifically related to conjunctival inflammation is the enlarged preauricular lymph node palpable to physical examination with or without tenderness. Usually the presence of a preauricular lymph node is indicative of viral, chlamydial, gonococcal, or allergic etiology.

Treatment

Obviously, the principal agents in the treatment of conjunctivitis are topical antimicrobials and anti-inflammatory agents. Antiviral therapy has evolved over the years and is currently available for herpes viruses. In the United States, three types of antivirals are currently available topically for herpetic conjunctivitis and keratitis - vidarabine, idoxurridine, and trifliridine. They are effective in managing herpetic keratoconjunctivitis, although they can cause significant toxic reactions, such as superficial punctate keratitis, corneal ulceration and chronic follicular conjunctivitis.

A medicine that has shown less topical toxicity and good antiviral efficacy is the topical formulation of acyclovir in 3% ointment. It is not commercially available in the United States. There has been promising development of an efficacious topical antiviral against adenoviruses and specifically the serotypes 8 and 19, which cause epidemic keratoconjunctivitis. The formulation is expected to be commercially available in the United States in the near future.

The antibacterial management agents effective against chlamydia are mainly sulfonamides and systemic medications (tetracycline, doxycycline, and minocycline). Erythromycin is used in the treatment of neonatal chlamydia eye disease. Agents used against gramnegative rods are topical aminoglycosides, such as gentamicin and tobramycin having good efficacy against such microbes. However, they can be responsible for some allergic and toxic reactions of the eye surface. Agents mainly effective against gram-positive cocci are bacitracin, cephalosporins and vancomycin. For purposes of wide spectrum activity against both gram-positive and gram-negative organisms, fluoroquinolones (ofloxacin and ciprofloxacin) can be used as monotherapy for the management of bacterial conjunctivitis especially when suspicion of corneal involvement is eminent.

In the management of allergic conjunctivitis, topical vasoconstructive agents along with topical antihistamines and mast cell stabilizers, and topical nonsteroidal anti-inflammatory agents are commonly employed. In severe allergic reactions, more potent anti-inflammatory agents such as corticosteroids can be used. Cyclosporine A, a potent T cell immunomodulator has been employed in special topical formulations in treating specific types of allergic conjunctivitis where helper T cell suppression and increased tear production are of benefit.

References

(Source: Therapeutic Update, 1999 Vol. 2 No 2)