Eye
Conjunctiva
Conjunctivitis
Conjunctivitis and variants
Author: Deepali Jain, M.D.
Last author update: 1 October 2014
Last staff update: 10 April 2024
Copyright: 2004-2024, PathologyOutlines.com, Inc.
PubMed Search: Conjunctivitis variants eye
Table of Contents
Allergic conjunctivitis | Chronic conjunctivitis | Giant papillary conjunctivitis | Infectious conjunctivitis | Papillary and follicular conjunctivitis (pending)Cite this page: Jain D. Conjunctivitis and variants. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/eyechronicconj.html. Accessed April 24th, 2024.
Allergic conjunctivitis
Epidemiology
Sites
Pathophysiology
Clinical features
Diagnosis
Treatment
Clinical images
Images hosted on other servers:
Microscopic (histologic) description
Cytology description
Differential diagnosis
- Prevalence of 15 - 40% (Curr Opin Allergy Clin Immunol 2011;11:471)
Sites
- Unilateral or bilateral; affects palpebral and bulbar conjunctiva
Pathophysiology
- Ocular surface inflammation (usually mast cell driven) is associated with type 1 hypersensitivity reactions (eMedicine: Allergic Conjunctivitis [Accessed 24 April 2018])
- May be part of systemic atopic reaction to a systemic allergen
- Most prevalent types (95%) are perennial and seasonal (hay fever eyes) (Curr Opin Allergy Clin Immunol 2013;13:543)
- Most frequent allergens are tree and grass pollens
- More severe forms
- Chronic vernal keratoconjunctivitis: more common in spring (vernal); conjunctival scarring, eyelid thickening, ptosis, corneal neovascularization, ulceration, thinning, infection, keratoconus, and vision loss
- Atopic keratoconjunctivitis: eyelid tightening, loss of eyelashes, cataracts
- Giant papillary conjunctivitis: eyelid inflammation and ptosis
Clinical features
- History of allergy, asthma, or eczema
- Itching (pruritus), chemosis, tearing and redness with or without sneezing and nasal discharge
- 2 - 3 times increased risk for herpetic infection (Curr Eye Res 2006;31:721)
Diagnosis
- Cobblestoning (vernal) or papillary hypertrophy (giant papillary) of upper tarsal conjunctiva in chronic forms
Treatment
- Allergy type medications; topical cyclosporine if severe (Cornea 2007;26:1035)
- Patient education, lifestyle modification and topical medications (antihistamines, mast cell stabilizers, corticosteroids, immunomodulators)
Clinical images
Images hosted on other servers:
Atopic kerato-conjunctivitis
Giant papillary conjunctivitis
Seasonal and perennial allergic conjunctivitis
Vernal conjunctivitis
Vernal
keratoconjunctivitis
Microscopic (histologic) description
- May have eosinophils in conjunctival scraping (Acta Ophthalmol (Copenh) 1988;66:381)
Cytology description
- Consistent with clinical diagnosis (Indian J Pathol Microbiol 1992;35:118)
Differential diagnosis
- Atopic keratoconjunctivitis
- Giant papillary keratoconjunctivitis:
- Lymphocyte and eosinophil predominant, versus predominance of mast cells and eosinophils in allergic cases
- Vernal keratoconjunctivitis
Chronic conjunctivitis
Pathophysiology
Etiology
Clinical features
Diagnosis
Case reports
Treatment
Clinical images
Images hosted on other servers:
Microscopic (histologic) description
Cytology description
Molecular / cytogenetics description
Differential diagnosis
Additional references
- Conjunctivitis that persists for 4+ weeks
Etiology
- Unilateral:
- Due to keratitis, nasolacrimal duct obstruction, occult foreign body, neoplasm, tuberculosis, phthiriasis palpebrarum (due to lice, Int Ophthalmol 2012;32:467)
- Bilateral:
- Due to bacteria, tuberculosis (Int Ophthalmol 2014;34:655), virus, trachoma, other microorganisms
- Also allergic or chemical causes, inflammation of meibomian glands of eyelid
- Tarsoconjunctival crypts containing bacteria (Am J Ophthalmol 2012;154:527)
- Giant fornix syndrome (Ophthal Plast Reconstr Surg 2012;28:4)
- Vitamin A deficiency
Clinical features
- Insidious onset; slow progression of ocular discomfort, conjunctival injection, discharge
Diagnosis
- Conjunctival scrapings and culture are useful for diagnosis (Eur J Ophthalmol 1997;7:19)
Case reports
- 50 year old woman with relapsing polychondritis and obliterative microangiopathy (Cornea 2006;25:621)
- Boy with X linked hypogammaglobulinemia and bilateral inflammation (J Paediatr Child Health 1996;32:463)
Treatment
- Antibiotics, artificial tears, topical medications
Clinical images
Images hosted on other servers:
Cause unspecified
Microscopic (histologic) description
- 2 basic patterns:
- Chronic follicular conjunctivitis (associated with cosmetics, infectious mononucleosis, molluscum contagiosum, moraxella, phthiriasis palpebrarum, psittacosis, topical medications, trachoma)
- Chronic papillary conjunctivitis (tarsal conjunctiva)
- Numerous goblet cells and papillary folds
- Chronic inflammatory cells (lymphoid follicles and plasma cells)
- Isolated islands of epithelium may form retention cysts that calcify
- Late changes are epithelial atrophy, keratinization and stromal scarring
- Note that lymphocytes are common within normal conjunctiva
Cytology description
- Scrapings may yield more specific findings than impression cytology in chronic conjunctivitis (Eur J Ophthalmol 1997;7:19)
Molecular / cytogenetics description
- PCR is gold standard for chlamydia related conjunctivitis (Semin Ophthalmol 2013;28:216)
Differential diagnosis
Additional references
Giant papillary conjunctivitis
Definition / general
Terminology
Epidemiology
Etiology
Clinical features
Diagnosis
Treatment
Clinical images
Images hosted on other servers:
Microscopic (histologic) description
Cytology description
Differential diagnosis
Additional references
- Noninfectious inflammatory disorder due to mechanical and immunologic processes (type I and type IV hypersensitivity)
Terminology
- Also known as contact lens induced papillary conjunctivitis
Epidemiology
- Young adults with history of atopy
- 1 - 5% of soft contact lens wearers
- Average onset after 10 - 20 months of contact lens use
Etiology
- Associated with soft, hydrogel contact lenses (Trans Am Ophthalmol Soc 1999;97:205)
- Also exposed sutures, prostheses, rigid lenses (incidence only 10% of soft lenses) (Clin Experiment Ophthalmol 2007;35:535, Cont Lens Anterior Eye 2008;31:41)
- Also ocular surgery, foreign body, cyanoacrylate glue
Clinical features
- Itching, burning, foreign body sensation, redness
- Mucus accumulating in inner canthus noticed in morning
- Blurred vision, contact lens coating
- Usually bilateral (10% unilateral)
Diagnosis
- Upper tarsal conjunctiva has inflammation and papules (usually > 0.3 mm)
Treatment
- Change contact lenses more frequently (Eye Contact Lens 2003;29:S37)
- Mast cell stabilizers
- Olopatadine and fluorometholone (Eye Contact Lens 2010;36:210)
Clinical images
Images hosted on other servers:
Giant papillary conjunctivitis
Microscopic (histologic) description
- Thickened and irregular epithelium
- Epithelial cells show polymorphism with greater number of conjunctival goblet cells
- Upper tarsal conjunctival biopsies show mast cells, eosinophils and basophils in epithelium and substantia propria
Cytology description
- Impression cytology: honeycomb pattern consistent with giant papillae, increased inflammation and mucous strands (Ophthal Plast Reconstr Surg 2005;21:39)
Differential diagnosis
- Allergic conjunctivitis
- Toxic conjunctivitis
Additional references
Infectious conjunctivitis
Definition / general
Epidemiology
Sites
Etiology
Clinical features
Case reports
Clinical images
Images hosted on other servers:
Microscopic (histologic) description
Additional references
- See also Granulomatous conjunctivitis, Trachoma, Infectious keratitis
- Often due to inadequate personnel hygiene
Epidemiology
- In children, bacterial conjunctivitis is more common than viral
- Viral conjunctivitis is highly contagious
Sites
- Bulbar and palpebral conjunctiva
Etiology
- Most bacterial conjunctivitis is acute; chronic bacterial conjunctivitis is often caused by Chlamydia, rarely by Moraxella
- Adenovirus conjunctivitis:
- Most common cause of viral conjunctivitis (Arch Soc Esp Oftalmol 2013;88:108)
- 60% of ER conjunctivitis patients in Florida
- Detected by PCR (Optometry 2007;78:236)
- Other viruses:
- Herpes simplex virus
- Varicella zoster virus
- Enterovirus 70
- Coxsackie A24
- Molluscum contagiosum
- Vaccinia
- Human immunodeficiency virus
- Alcaligenes xylosoxidans conjunctivitis:
- Rare; can cause chronic conjunctivitis (Cornea 2007;26:868)
- Conjunctivitis within first 4 weeks of life
- Usually S. aureus, S. epidermidis, S. pneumoniae, M. catarrhalis
- Also C. trachomatis, N. gonorrhoeae, herpes simplex virus (HSV)
- Mothers with untreated chlamydial infections have a 30 - 40% chance of transmission to newborns
- Unilateral or bilateral (Pediatr Rev 2010;31:196)
- Bacterial conjunctivitis in children:
- Should exclude infected children from school until asymptomatic (J Pediatr Ophthalmol Strabismus 2007;44:101)
- Local antibiotics may not be necessary (Prescrire Int 2007;16:120)
- Often due to H. influenzae and Streptococcus pneumoniae (Ophthalmology 2008;115:51)
- S. aureus is uncommon in children (Acad Emerg Med 2007;14:1)
- Bacterial conjunctivitis in adults:
- Often due to Staphylococcus aureus, may be methicillin resistant
- Streptococcus pneumoniae is associated with outbreaks (Pediatr Infect Dis J 2006;25:906)
- Delayed use of antibiotics may be appropriate (BMJ 2006;333:321)
- Hyperacute conjunctivitis:
- Rapid onset
- Due to Neisseria gonorrhoeae or N. meningitides (Pediatr Rev 2010;31:196)
- Other bacteria are Pneumococcus species, Pseudomonas (Infection 2012;40:579)
- Gonococcal conjunctivitis:
- Due to autoinoculation
- Rare in developed countries (J Fr Ophtalmol 2007;30:e18)
- May cause corneal perforation (Med J Malaysia 2006;61:366)
- Influenza A virus conjunctivitis:
- Outbreak from poultry (Proc Natl Acad Sci U S A 2004;101:1356)
Clinical features
- Bacterial: itching, tearing, redness, purulent discharge, matting of eyelids
- Viral: irritation, photophobia, watery discharge
Case reports
- Child with acute conjunctivitis caused by Ewingella americana (J Pediatr Ophthalmol Strabismus 2012;49)
- 23 year old woman with conjunctivitis due to Achromobacter xylosoxidans (Arq Bras Oftalmol 2009;72:261)
Clinical images
Images hosted on other servers:
Adenovirus: various images
Gonococcal
Molluscum contagiosum
Trachoma with follicles
Trachoma with intense inflammation
Microscopic (histologic) description
- Neutrophils on Gram stain if bacterial; lymphocytes in viral conjunctivitis
Additional references
Papillary and follicular conjunctivitis (pending)
Vernal
[Pending]
Atopic
[Pending]
Viral
[Pending]
Inclusion variants
[Pending]
[Pending]
Atopic
[Pending]
Viral
[Pending]
Inclusion variants
[Pending]
