CONJUNCTIVITIS (conjunctivitis) — the inflammation of a conjunctiva of preferential infectious etiology which is the most frequent disease of an eye with a favorable outcome.
Frequency of a disease To. is explained by the fact that the conjunctival sac by the anatomic situation is available to various external influences, and conjunctiva (see) has high reactivity, easily reacting to various influences of endogenous and exogenous character.
gained the Greatest distribution etiol, classification To., on a cut allocate:
1. Bacterial To. — acute bacterial, epidemic Koch — Uiksa K., blefarokonjyunktivit Moraks — Aksenfelda, blennoreya newborns and adults (see. Blennorey ), diphtheritic To.
2. Virus To. — adenoviral To., a Sander's disease, epidemic hemorrhagic To. at flu, a herpetic disease, at a disease of Newcastle.
3. To. with inclusions — a paratrachoma (see. Trachoma ).
4. Allergic, or toksiko-allergic, To. — fliktenulezny keratoconjunctivitis, atonic (senny), medicinal, alimentary, spring Qatar (see).
5. Fungal To. 6. To., developing at action various physical., chemical factors and beam energy.
On the nature of inflammatory process distinguish acute, subacute and hron. To., and on pathoanatomical features — catarral, purulent, filmy and follicular.
Among the reasons causing To., the causative agents of infections more often getting into an eye in exogenous and rather seldom endogenous way are on the first place. Usually it staphylococcus and pneumococci. At seasonal epid, flashes such activator, specific to an eye, as Koch's bacterium — Uiksa generally matters (see. Koch — Uiksa a bacterium ). Acute epid, Koch's conjunctivitis — Uiksa covers children's collectives, especially younger age more often (up to 2 years). Frequency To., Moraks called by diplobacillus — Aksenfelda (see. Moraksa — Aksenfelda a bacterium ), a streptococcus, an intestinal, diphtheritic stick, it is small. Gonorrheal To. (blennoreya newborns and adults), quite often leading to a blindness in pre-revolutionary Russia, thanks to active prevention in obstetrical institutions in sovr, practice meets extremely seldom.
Considerably specific weight increased To. virus etiology. Most often occur among them To., caused by adenoviruses of types 3, 7a, is more rare 6, 10, 11, 17, 21, 22 (adenoviral To., or adenofaringokonjyunktivalny fever — the old name) or type 8 (epid, a keratoconjunctivitis). Adenoviral To. are observed in various season in the form of numerous sporadic cases and epid, flashes among all age groups of the population. The activator K concerns to group of picornaviruses (entero-virus-70)., for the first time registered in Ghana in 1969 and received epidemic hemorrhagic K. V name of 1971 — 1973 it is a disease accepted character of the pandemic which captured the countries of Europe, Asia, Africa and the Middle East. In the USSR flashes epid, hemorrhagic were also noted To.
Increase in frequency allergic To. it is connected with continuous increase in the factors promoting change of reactivity of an organism (wide use of vaccines, serums, chemotherapeutic drugs, insecticides, objects of household chemicals, cosmetics etc.). Antibiotics, quinine, morphine, dionine, Eserinum, atropine and other medicines can be allergens.
A considerable role, especially in emergence hron. To., play various physical. and chemical factors at the enterprises of the chemical, textile, flour-grinding industry, at the sawing, brick, limy plants, and also light energy and ionizing radiation in the electroindustry, film production, at operation of X-ray equipments etc. Hron. To. develops also at various hron, diseases of an organism — inflammatory diseases of okolonosovy bosoms, a nasal part of a throat, went. - kish. a path, at a helminthic invasion etc. An etiology acute follicular To. generally infectious, whereas an etiology hron, follicular To. does not differ from an etiology hron, not follicular To. In some cases follicles are formed as a result of an age hyperplasia of an adenoid tissue at children — a folliculosis. Disturbances in activity can be the contributing moments for development of follicles went. - kish. a path, helminthic invasions, anemias, hypo - and avitaminosis, hron, intoxications, unsatisfactory a dignity. - a gigabyte. conditions.
The pathogeny and pathological anatomy
the Originality of an anatomic structure of a conjunctiva causes features morfol, a picture and a pathogeny To. The large role in their emergence is played by not only the activator, but also the reactivity of an organism defining character of a current To. various etiology.
By the available and well studied method morfol, researches at To. studying tsitol, pictures of scrapings of a conjunctiva is (see. Cytologic research ). At bacterial To. the tsitogramma of scraping is characterized by existence of a large number of neutrophils and lack of changes in epithelial cells. At To. a virus etiology dystrophic changes of cells of an epithelium, dominance in exudate of lymphomonocytic and histiocytic cells come to light. Exudate at allergic To. contains also eosinophils and basophiles.
At fungal To. in foamy separated the fungi which are quite often englobed by neutrophils and histiocytic cells are visible. Gistol, a research at To. in own fabric of a conjunctiva shows the hyperemia, hypostasis and exudation covering all conjunctiva or only a part it. Exudate at acute To. consists generally of the polinuklear forming accumulations around vessels and in a subepithelial layer of a conjunctiva. In the late periods infiltration is characterized by impurity of lymphocytes, eosinophils and plasmocytes. For allergic To. the local eosinophilia, and for hron is especially characteristic. To. lymphocytic and plazmotsitarny infiltration. In addition to infiltration, in the inflamed fabric of a conjunctiva proliferative changes in connective tissue elements are noted. At some To. in an adenoid tissue formation of focal accumulations of cellular elements in the form of follicles is observed; their presence and development defines special forms follicular To. At virus To. the greatest changes are found in epithelial cells of a conjunctiva as such viruses as adenovirus, possess an epiteliotropnost. There is a destruction of cells of an epithelium, vacuolation of cytoplasm and kernels, fragmentation of chromatin of kernels, accumulation of acid phosphatase.
A clinical picture
Despite variety etiol, factors in emergence To., the wedge, a picture is characterized by a number of the general signs — a hyperemia, a chemosis a century and transitional folds, existence separated.
Acute To. begins suddenly, without the prodromal phenomena, on one in the beginning, then on other eye. There are gripes or eye pain, a plentiful discharge and a hyperemia of a conjunctiva (tsvetn. fig. 8). The conjunctiva at the same time from light pink becomes bright red, hemorrhages quite often appear. The conjunctival injection of an eyeglobe which is most expressed at the arch and gradually decreasing to a cornea develops. The chemosis leads to its thickening, a smazannost of the drawing of glands of cartilages a century (meibomian glands). In hard cases owing to hypostasis the conjunctiva of an eyeglobe takes a peculiar form, rising in the form of a shaft around a cornea (hemoz conjunctivas). The discharge can be mucous, mucopurulent or purulent. Acute To. quite often is followed by a febricula, temperature increase and a headache. Duration acute To. fluctuates of 5 — 6 days to 2 — 3 weeks. At the severe complicated forms K. the current can drag on.
Children quite often have a filmy form K. It is characterized by moderate hypostasis a century, a bright hyperemia of a conjunctiva a century with existence of small hemorrhages and the slizistognoyny film which is easily removed a cotton plug or is spontaneous during the crying of the child. The most severe form filmy To. develops at diphtheritic To., meeting extremely seldom. Existence on a conjunctiva of the grayish films which are removed hardly and leaving the bleeding surface after removal is characteristic of it.
Unlike acute, chronic To. begins imperceptibly and it is characterized by a persistent and long current. Patients complain of unpleasant feelings in an eye, feeling of a contamination. The conjunctiva and transitional folds is slightly hyperemic, loosened a century, the surface has it an uneven, velvety appearance due to increase in height of nipples. Hron. To. can last for years or in a form, safe for an eye, catarral To., or to be followed by various complications from a cornea or a century that is characteristic, e.g., of trachoma.
To. can proceed with education on a conjunctiva of transitional folds of follicles — small, size about a pin head, translucent light pink educations. Most often follicular To. occurs at children that is explained by tendency of an adenoid tissue of a conjunctiva of children to growth. Unlike trachoma, follicular To. does not leave behind hems and does not give defeats of a cornea. At a folliculosis similar follicles on almonds, a mucous membrane of a back wall of a throat which disappear with age are found in children along with follicles on a conjunctiva, without leaving a mark.
Complications are rare, they can arise in connection with transition of inflammatory process to a cornea (see. Keratitis ). At trachoma there are cicatricial changes a century — ectropion of a century (see), torsion of a century (see), a trichiasis (see. Eyelids ).
The diagnosis usually comes easy. However for establishment of an etiology To. apply a row a lab. methods among which the greatest distribution was received by the following. 1. Bacterioscopy and bacterial. a research of smears and separated conjunctivas with the subsequent definition of pathogenicity of the allocated microorganisms and their sensitivity to antibiotics. 2. Tsitol, a research of scrapings of a conjunctiva for the purpose of differential diagnosis of a look To. 3. An immunofluorescent research of scrapings of a conjunctiva of the patient for detection of antigens of viruses (see. Immunofluorescence ). Carrying out these researches is especially important during the studying of an etiology of flashes To. in children's collectives to lay down. and other institutions. The technique allowing to conduct simultaneous examination of the patient concerning antigens of adenoviruses, influenza viruses, a parainfluenza, trachoma is developed To. with inclusions and rhinoviruses. 4. Immunol, and serol, methods. For diagnosis bacterial and allergic To. carrying out is shown serological researches (see) for the purpose of identification of antibodies to bacterial or medicinal allergens. At interpretation of flashes virus To. researches on definition of an antiserum capacity to adenovirus, flu, a parainfluenza in neutralization tests or braking of hemagglutination are important. 5. Intracutaneous and focal tests. Intracutaneous tests to Mant and the Tuberculine test with tuberculine (from 8th before the 3rd cultivation), tests with staphylococcal, streptococcal allergen (2 — 4 skin doses in 0,1 ml), pollen and other allergens are most often applied.
Treatment is carried out etiopatogenetichesky and symptomatic. At acute bacterial To. appoint antibiotics and sulfanamide drugs in the form of drops (20 — 30% solution of Sulfacylum-natrium, 0,25% solution of levomycetinum, 10% solution Norsulfazolum sodium). At plentiful separated a conjunctival cavity it is washed out by solution of potassium permanganate (1: 5000) or 2% solution boric to - you. Imposing of a bandage is not recommended. Due to the increased resistance of microorganisms to antibiotics and development of allergic complications at their use to use sulfanamide drugs of the prolonged action and the combined forms of antibiotics reasonablly more widely. For this purpose apply 10% solution Sulfapyridazinum sodium for 10% solution of polyvinyl alcohol and 1% diunguentum Tetracyclini on a polymeric basis once a day. The combined dosage form — tetracycline with Oleandomycinum — 1% oletetrinovy ointment is entered into a conjunctival sac 2 — 3 times a day at heavy To. and 1 time at easier forms. For decrease in side effect of antibiotics they are appointed in a combination with corticosteroids. At treatment hron. To., especially with allergic stratifications, complex drug on a polymeric basis — sulfadeks, Sulfapyridazinum sodium including 10% solution and 0,1% solution of dexamethasone is effective.
The method of treatment bacterial is developed To. by means of new type of eye medicinal films (see). They do not irritate tissues of an eye and promote prolongation of effect of medicines. As an effective agent Sulfapyridazinum sodium and an antibiotic Neomycinum is used.
At virus To. the most effective are the drugs of interferon having the expressed antiviral activity and a broad spectrum of activity and also tebrophenum, Florenalum and pyrogenal. Human leukocytic interferon is applied in the form of instillations of 6 — 8 times a day in an acute stage of a disease, tebrophenum and Florenalum — in the form of 0,25% of ointment 3 times a day. Corticosteroids (0,5% hydrocortisone ointment, 0,3% solution of Prednisolonum) appoint only in a stage of recovery. At epid, a keratoconjunctivitis injections of 5% of solution of oryzamin on 1 ml intramusculary once a day, are in addition recommended for a course of treatment of 15 injections, and in a stage of a rash of subepithelial infiltrates — 0,01% solution of citral, on 1 — 2 drops in a conjunctival sac. At the expressed general reaction of an organism appoint antibiotics or streptocides inside.
At allergic To. corticosteroids, and inside antihistaminic drugs — Dimedrol, Suprastinum, a gluconate of calcium on 1 tablet 1 — 3 times a day are shown locally.
The forecast and Prevention
the Forecast at easy forms K. favorable. At defeat of a cornea decrease in visual functions is possible.
Prevention includes carrying out a dignity. - a gigabyte. the actions providing observance of rules of personal hygiene, obligatory washing of hands before holding eye procedures, use of individual pipettes, sticks etc. The complex of actions in the child care, medical and other facilities directed to interruption of spread of an infection is necessary: wet cleaning of the room from 2% solution of chloroamine, disinfecting of air ultraviolet rays, long sterilization of pipettes, sticks, tools, control of disinfecting of water in public reservoirs, pools. The complex of preventive actions joins improvement of working conditions and observance of the accident prevention, especially at the enterprises with use of various harmful chemical substances. At epid, Koch's conjunctivitis — Uiksa is led to the autumn and summer period chemoprophylaxis — use of 1% of diunguentum Tetracyclini or eye medicinal films with Sulfapyridazinum within 6 days once a day. Chemoprophylaxis of a blennorea of newborns is performed in all obstetrical institutions on Matveev's way — Krede (see. Blennorey ). At adenoviral hemorrhagic To. the mortgaging of 0,1% of tebrofenovy ointment or instillation of interferon of 1 — 2 time a day are recommended to all persons contacting to the patient with this form To.
Separate forms of conjunctivitis
Separate forms of conjunctivitis are characterized by various features (tab).
Acute bacterial conjunctivitis. The most frequent activators are the pneumococcus, staphylococcus, less often the disease is caused by a streptococcus and colibacillus. To. develops sharply, the incubation interval lasts 1 — 2 day. The most characteristic signs are the sharp photophobia and dacryagogue. The conjunctiva a century and an eyeglobe of an infiltrirovan, is hyperemic, in it dot hemorrhages develop. On a conjunctiva a century often, especially at children, the grayish films which are easily removed wet cotton wool are formed. The cornea can be involved in process. In its surface layers on border with a limb there are small infiltrates which then are eroded, but do not leave behind permanent opacifications. Microbes in an acute stage find in separated and in cells of an epithelium. In child care facilities K. can carry epid, character.
Acute epidemic conjunctivitis of Koch — Uiksa is quite widespread disease of tropical countries. Meets in a look epid, flashes in children's collectives during the aestivo-autumnal period more often. Differs in high infectivity. An incubation interval short — of several hours to 1 — 2 days. Both eyes are surprised: in the beginning one, and then another. Typical manifestation To. sharply expressed hyperemia and a chemosis with is plentiful mucopurulent separated. To. quite often is followed by a febricula, temperature increase and a headache, 2 — 3 weeks on average last. At a heavy current complications from a cornea are possible.
Moraks's conjunctivitis — Aksenfelda has characteristic a wedge, a picture in the form of a so-called angular blefarokonjyunktivit with participation in process of edges a century, especially in corners of a palpebral fissure. At the same time the moderate hyperemia of a conjunctiva, a small mucous discharge and erubescence at outside and internal commissures is noted a century. To. can have subacute or the current is more often hron.
Adenoviral conjunctivitis. The incubation interval makes 4 — 8 days. Beginning of a disease acute. It is preceded or accompanied by damage of upper airways — rhinitis, pharyngitis, a nasopharyngitis. Dacryagogue, sometimes a photophobia, a hyperemia of a conjunctiva a century, the lacrimal meat and transitional folds is clinically noted. The conjunctiva is edematous, sometimes there are hemorrhages, deposits of films, especially at children. Discharge usually scanty, not purulent. Often find rashes small a follicle which are located on the lower transitional fold. To. the general displays of a disease in the form of temperature increase, a headache and increase in parotid lymph nodes can accompany. To. arises on one eye more often, and in 1 — 3 day also the second eye, and in easier form gets sick.
Adenoviral Sander's disease. It is characteristic, except To., frequent defeat of a cornea in the form of small subepithelial infiltrates on the periphery of a cornea. Large infiltrates of a monetovidny or discal form are less often observed. Fresh infiltrates usually appear during the first two days, and then regress, leaving opacification of a cornea for a long time.
Epidemic hemorrhagic conjunctivitis. Distinctiveness of this form virus To. existence on a conjunctiva a century and an eyeglobe of hemorrhages of various size — from small, dot, to extensive, occupying all surface of a conjunctiva is. Hemorrhages resolve in different terms depending on their size — dot usually in 3 — 6 days, extensive — in 2 — 3 weeks.
Allergic (or toksiko-allergic) conjunctivitis. Its wedge, picture it is quite diverse depending on the nature of an allergic factor. To infectious allergic To. the fliktenulezny keratoconjunctivitis most often observed at children up to 3 years belongs (tsvetn. fig. 9). Etiol, a factor is hl. obr. a sensitization to mycobacteria of tuberculosis. Toxins or decomposition products of mycobacteria from the center of primary tuberculosis extend and fixed on a conjunctiva where there is an antigenic contact with sensibilized lymphocytes. Along with a hyperemia and infiltration of a mucous membrane emergence in a limb of one or several yellowish-grayish, rounded shape of the small knots surrounded with expanded vessels is characteristic. Often the keratoconjunctivitis at children is followed by eczematic changes of skin at wings of a nose, in corners of a mouth. The cornea is quite often involved in process, the superficial keratitis develops in a cut.
The most characteristic representative atopic To. is To. at hay fever (see. Pollinosis ). Differs in seasonality, aggravations arise in the spring and in the summer in a blooming period of herbs and trees. Both eyes get sick at the same time, and the patient complains of burning sensation, dacryagogue and a photophobia. Sharp pain, an itch, a hyperemia of a conjunctiva with hypostasis and plentiful serous separated is noted. To. often is followed by rhinitis.
Medicinal conjunctivitis meets quite often. To. develops during 6 hours after use of medicine and it is characterized by quickly accruing hemozy conjunctivas, severe itch, burning and plentiful mucous separated. In certain cases after long topical administration of medicine (allergen) there can be a papillary hypertrophy of a conjunctiva by the form reminding spring Qatar. Follicular medicinal To. develops slowly, on average in 4 months, and gradually regresses after drug withdrawal, without leaving hems.
Allergic conjunctivitis is usually shown in 6 — 24 hours after reception of the sensibilizing product — a wild strawberry, a citrus, eggs, nuts etc. Family predisposition, existence in the childhood of allergic are characteristic dermatitis (see), the accompanying damages of skin. Quite often there is an allergic Quincke's edema (see. Quincke hypostasis ). Treats allergic conjunctivitis and spring Qatar (see).
Table. Clinicodiagnostic characteristic of the main forms of conjunctivitis
Bibliography: Age features of an organ of sight are normal also at pathology at children, under the editorship of E. I. Kowalewski, page 59, M., 1975; Zolotareva M. M. Acute epidemic conjunctivitis, M., 1955; Katsnelson A. B. Fliktenuleznoye (tubercular and allergic) inflammation of eyes, Chelyabinsk, 1948, bibliogr.; To m and a ft-ch to Yu. F. K to differential diagnosis of epidemic hemorrhagic conjunctivitis, Oftalm, zhurn., No. 6, page 419, 1974; The Multivolume guide to eye diseases, under the editorship of V. N. Arkhangelsky, t. 2, book 1, page 50, M., 1960, bibliogr.; X about r about sh and l about in and (Maslova) I. P. Morphogenesis and features of a pathogeny adenoviral and hlamidia of infections of a conjunctiva, Arkh. patol., t. 39, No. 2, page 23, 1977; Der Augenarzt, hrsg. v. To. Velhagen, Bd 3, S. 553, Lpz., 1975, Bibliogr.
A. I. Volokonenko, L. T. Arkhipov; authors of the tab. V. O. Andzhelov. E. B. Koneva, Yu. F. Maychuk.