Conjunctival Cytology: send us conjunctival specimens by mail!

For Professionals Only.



Indications: Detection and characterization of inflammatory/infectious processes of the conjunctiva.
Specimen Required: Direct smear of material collected from the conjunctival surface.
Results: by email
Stability: Indefinitely

Microscopic examination of direct ocular specimens may provide valuable information but depend on the quality of the sample. Smears are obtained from the conjunctiva.There are many types of stains used to examine direct specimens.The giemsa stain is used in our laboratory.The giemsa stain is used to determine cytology and is also excellent for detecting bacteria, fungus,chlamydia, and acanthamoeba. Many laboratories are uncomfortable with the giemsa stain because of limited experience.
Direct examination of conjunctival specimens can be valuable in diagnosing bacterial, viral, and chlamydia conjunctivitis. The presence of eosinophils can indicate allergy and abnormal epithelial cells from the tarsal conjunctiva can suggest the possibility of dry eye syndrome. Conjunctival specimens should NEVER be obtained with a soft-tipped applicator. Experience has determined that such collection results in poor specimens that are not diagnostic. Conjunctival smears are obtained by anesthetizing the conjunctiva with topical 0.5% proparacaine hydrochloride for about 5 minutes. Using a spatula, the bottom eyelid is lowered, the bulbar conjunctiva is firmly scraped for cells, and the specimen is placed on a glass microscope slide. In a similar manner, specimens can be obtained from the upper tarsal conjunctiva by inverting the upper eyelid. The slides must be air dried. We provide to staine, and examine them. Conjunctival specimens awaiting transport to the laboratory are quite stable so you can send us them by mail. This technique is not invasive. Superficial smears contain epithelial cells, inflammatory cells, and micro-organisms.


For more informations contact us by email (alfredo.digiovanni@fastwebnet.it).




Key Words:Commonly known as pinkeye, conjunctivitis is an inflammation of the conjunctiva, the clear membrane that covers the white part of the eye and lines the inner surface of the eyelids. It is a fairly common condition and usually causes no danger to the eye or your child's vision. The inflammation can have many causes, the most common of which are infectious, allergic, and irritant.Infectious conjunctivitis is usually caused by either bacteria or viruses. Many different bacteria can cause conjunctivitis but the most common are Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. The organisms that cause the sexually transmitted diseases gonorrhea and chlamydia can also infect the eyes and cause conjunctivitis. This type of eye infection can occur in sexually active people and in newborns who acquire the infection at birth from their mothers. Viral conjunctivitis is common with several viral infections most often with infections caused by adenoviruses or enteroviruses and can occur during a common cold or the flu. A less common but more serious viral conjunctivitis is herpes simplex infection. Parasites and fungal infections are rare causes of conjunctivitis. Allergic conjunctivitis occurs more frequently among children with allergic conditions such as hay fever. It is often seen only at certain times of the year, especially when caused by allergens such as grass or ragweed pollen. Other allergycausing substances like animal dander or dust mites can cause yearround symptoms of conjunctivitis. Although other forms of conjunctivitis often start in one eye, allergic conjunctivitis typically affects both eyes at the same time.Irritant conjunctivitis can be caused by chemicals such as those in chlorine and soaps or air pollutants such as smoke and fumes.When conjunctivitis occurs in babies younger than 4 weeks old, it is called neonatal conjunctivitis or ophthalmia neonatorum. This can be caused by a blocked tear duct, which can be treated by gentle massage between the eye and nasal area. Irritation from the antibiotic eyedrops regularly given to babies immediately after birth can cause a mild chemical conjunctivitis, which clears up on its own within a couple of days.Newborns are also susceptible to infectious conjunctivitis, which can be serious. The sexually transmitted bacteria Chlamydia trachomatis and Neisseria gonorrhoeae can pass from an infected mother's birth canal into her baby's eyes during delivery. These bacteria can cause symptoms of conjunctivitis in babies within the first 2 weeks of life, and both can lead to serious eye damage. Less commonly, the viruses that cause genital and oral herpes can similarly be passed to an infant at the time of delivery and may also damage the eyes.What Are the Signs and Symptoms?The different types of conjunctivitis can have different symptoms. In addition, symptoms may vary from child to child.One of the most common symptoms is discomfort or pain in the eye, which may feel like having sand in the eye. Many children have redness of the eye and inner eyelid as well; this redness led people to call conjunctivitis by its other common name, pinkeye. The child may also have swollen eyelids and be sensitive to bright light. Itchiness and tearing are common with allergic conjunctivitis.Discharge from the eyes may accompany the other symptoms. In bacterial conjunctivitis, the discharge will be somewhat thick and colored white, yellow, or green. Sometimes the discharge will cause the eyelids to stick together when the child awakens in the morning. In viral or allergic conjunctivitis, the discharge may be thinner and may be clear.Ear infections can occur in some children who are diagnosed with bacterial conjunctivitis because similar bacteria can cause both infections. A red, sore throat and runny nose often accompany conjunctivitis caused by viruses.Is It Contagious?All types of infectious conjunctivitis are contagious and can spread from one eye to the other by touching the eyes. A child can first become infected from direct contact with someone who has the infection or something that person has touched, such as a used tissue. The infectious organisms can also spread through coughing and sneezing. In addition, certain viruses spread in the summertime when children swim in contaminated water or share contaminated towels.Allergic and irritant conjunctivitis are not contagious. Allergic Conjunctivitis nearly always presents with a primary complaint of itching. red eyes, and other allergic symptoms such as rhinitis (stuffy, runny nose), "scratchy" throat, and dry, hacking cough are commonly present. Viral and bacterial forms of conjunctivitis are highly contagious, and can spread among children very rapidly, sometimes causing local epidemics.What are the causes of Conjunctivitis ? Bacterial conjunctivitis is often caused by bacteria such as staphylococcus and streptococcus.The viral type is often associated with an upper respiratory tract infection, cold, or sore throat.A history of close contact with a family member or any other individual with a "red eye" is also commonly elicited.Allergic conjunctivitis may be caused by intolerance to substances such as cosmetics, perfume, or drugs.Environmental irritants such as smoke or fumes may cause conjunctivitis.Any type of conjunctivitis is aggravated by dryness of the eyes.Conjunctivitis may be transmitted to the eye by contaminated hands, washcloths or towels, cosmetics (particularly eye makeup), false eyelashes or improper usage of contact lenses. Newborns can be infected by bacteria in the birth canal. This condition is called Ophthalmia Neonatorum and must be treated immediately to preserve sight.What are the symptoms of Conjunctivitis ? Mostly both eyes are affected, but often one starts before the other.Red, irritated eye. The lining of the eyelids also looks redder or pinker than usual.There may be a pus discharge and eye appears sticky.The eye is itchy or painful.The eye may become sensitive to sunlight. Swelling of the conjunctiva and eyelids.Watering of eyes is a common feature.Blurred vision and gritty feeling in the eyes are observed.How can we diagnose Conjunctivitis ? Conjunctivitis is diagnosed during a routine eye examination using a slit lamp microscope. In some cases, cultures are taken to determine the type of bacteria causing the infection. In some circumstances, fluorescent eye drops are used to examine the eye better.How can Conjunctivitis be treated ? Treatment varies depending on the cause. When treating allergic and chemical forms of conjunctivitis, the cause of the allergy or irritation must first be removed. For the allergic type, cool compresses and artificial tears sometimes relieve discomfort in mild cases. In more severe cases, nonsteroidal antiinflammatory medications and antihistamines may be prescribed. Some patients with persistent allergic conjunctivitis may also require topical steroid drops. Bacterial conjunctivitis is usually treated with antibiotic eye drops or ointments. Symptoms of viral conjunctivitis can be relieved with cool compresses and artificial tears. For the worst cases, topical steroid drops may be prescribed to reduce the discomfort from inflammation. Preventive measures.Although many kinds of conjunctivitis are hard to prevent, there are measures that can be taken to decrease your risk of reacquiring or spreading it to someone else.Avoid exposure to the irritants which may be causing the conjunctivitis.Wear protective goggles (i.e., for swimming or working) if you must be exposed to chemicals which are irritating. Do not use medication (eye drops, ointment, etc.) which has been prescribed for someone else.Do not share eye makeup or cosmetics of any kind with someone else.Avoid sharing washcloths, towels or pillowcases with anyone else, and wash these items after each use.Do not reuse handkerchiefs (using a tissue is best). Wash your hands frequently, and avoid touching or rubbing your eyes.Leftover prescription eye drops or ointments should not be used for treating "Red Eye".Frequently asked questions about Conjunctivitis... Which doctor should I go to if I have conjunctivitis?You can consult a general physician or an Opthalmologist.How is infectious Conjunctivitis treated? Infectious conjunctivitis, caused by bacteria, is usually treated with antibiotic eye drops and/or ointment. Other infectious forms, caused by viruses, can?t be treated with antibiotics.What is Conjunctivitis?Conjunctivitis is an inflammation of the conjunctiva, a thin, transparent layer covering the surface of the inner eyelid and the front of the eye. It affects people of all ages. What is Giant papillary Conjunctivitis (GPC) ?Giant papillary conjunctivitis (GPC) is a form of allergic conjunctivitis most often seen in soft contact lens wearers. People with asthma, hay fever or animal allergies may be at greater risk. The cause of GPC is probably an allergic reaction to collected debris on contact lenses.Allergic conjunctivitis is inflammation of the conjunctiva caused by an allergic reaction. The conjunctiva contains a large number of cells from the immune system (mast cells) that release chemical substances (mediators) in response to a variety of stimuli (such as pollens or dust mites). These mediators produce inflammation in the eyes, which may be brief or longlasting. About 20% of people have some degree of allergic conjunctivitis.Seasonal allergic conjunctivitis and perennial allergic conjunctivitis are the most common types of allergic reaction in the eyes. Seasonal allergic conjunctivitis is often caused by trees or grass pollens, leading to its typical appearance in the spring and early summer. Weed pollens are responsible for symptoms of allergic conjunctivitis in the summer and early fall. Perennial allergic conjunctivitis occurs yearround; it is most often caused by dust mites, animal dander, and feathers.Vernal conjunctivitis is a more serious form of allergic conjunctivitis in which the stimulant is not known. The condition is most common in boys, particularly those younger than 10 who also have eczema, asthma, or seasonal allergies. Vernal conjunctivitis typically reappears each spring and subsides in the fall and winter. Many children outgrow the condition by early adulthood.SymptomsPeople with all forms of allergic conjunctivitis develop intense itching and burning in both eyes. Although usually equal, occasionally, one eye may be more affected than the other. The conjunctiva becomes red, and sometimes the conjunctiva swells, giving the surface of the eyeball a puffy appearance that many people find disturbing. With seasonal and perennial conjunctivitis, there is a large amount of thin, watery discharge. Vision is seldom affected.With vernal conjunctivitis, the eye discharge is thick and mucuslike. Unlike other types of allergic conjunctivitis, vernal conjunctivitis often affects the cornea, and painful ulcers develop. These ulcers cause extreme sensitivity to bright light and sometimes lead to a permanent decrease in vision.Diagnosis and Treatment Doctors recognize allergic conjunctivitis by its typical appearance and symptoms. The condition is treated with allergy eye drops. Such drugs include cromolynSome Trade Names CROLOM INTAL NASALCROM lodoxamide, olopatadine Some Trade Names PATANOL and antihistamine eye drops, such as emedastineSome Trade Names EMADINE and levocabastine. KetorolacSome Trade Names TORADOLeye drops have antiinflammatory properties and help relieve symptoms. Corticosteroid eye drops have more potent antiinflammatory effects; however, they should not be used for more than a few weeks without close monitoring because they may produce increased pressure in the eyes (glaucoma), cataracts, and an increased risk of eye infections. Recently, eye drops that block both the release and the effects of the inflammatory mediators, such as azelastineSome Trade Names OPTIVAR nedocromilSome Trade Names TILADE and pemirolastSome Trade Names ALAMAST have been used successfully.Acute Conjunctivitis An acute conjunctival inflammation, occurring in populations with good hygiene, caused by viruses, bacteria, or allergy.Mixed or unidentifiable pathogens may be present. Conjunctivitis may also accompany the common cold and exanthems (especially measlessee Ch. 265). Conjunctivitis can also result from irritation due to wind, dust, smoke, other types of air pollution, and intense ultraviolet light of electric arcs, sunlamps, and reflection from snow. Retained corneal or conjunctival foreign bodies and corneal abrasion or ulcer may be ruled out by examining the eye under magnification with a good focal light and by staining the eye with fluorescein and then examining the eye with cobalt blue light (see Ch. 90).Prominent symptoms and signs found in acute conjunctivitis are shown in Table 952. The treatment of each type of acute conjunctivitis is described below.VIRAL CONJUNCTIVITIS An acute conjunctival inflammation caused by a virus.Adenoviruses can cause epidemic keratoconjunctivitis (usually serotypes Ad 8, 19, 37, and 5) and pharyngoconjunctival fever (usually serotypes Ad 3, 4, and 7see under Adenoviruses in Ch. 162). Outbreaks of acute hemorrhagic conjunctivitis, a rare conjunctivitis associated with infection by enterovirus type 70 (see under Enteroviral Diseases in Ch. 265), have occurred in Africa and Asia.Symptoms, Signs, and Diagnosis After an incubation period of about 5 to 12 days, symptoms include conjunctival hyperemia, watery discharge, ocular irritation, and eyelids that are stuck together on awakening. Symptoms are often bilateral and usually begin in one eye. Many patients have had contact with someone with conjunctivitis and/or a recent URI.The bulbar and tarsal conjunctivae are hyperemic. Conjunctival follicles are present on the palpebral conjunctiva. The preauricular lymph node is often enlarged and painful.In severe viral conjunctivitis, patients may complain of significant photophobia and foreignbody sensation. These patients may have pseudomembranes of fibrin and inflammatory cells on their conjunctival surfaces and/or focal corneal inflammation. Even after the conjunctivitis has resolved, residual corneal scarring (0.5 to 1.0 mm) may be visible by a slit lamp for up to 2 yr or longer. This corneal scarring will occasionally result in decreased vision and significant glare.Although cultures can be taken for viral conjunctivitis, special tissue culture facilities are necessary for growth of the virus. Secondary bacterial infection is very rare; if any element of the presentation is consistent with bacterial conjunctivitis, eg, purulent discharge, the eye should be cultured for bacteria. Smears can be examined microscopically and stained with Gram stain to identify bacteria and with Giemsa stain to determine the leukocytic response.Treatment Viral conjunctivitis is highly contagious and spreads by droplet, fomites, and handtoeye inoculation. To avoid transmitting infection, the physician must wash his hands thoroughly and sterilize instruments after examining the patient. The patient should be told to wash his hands thoroughly after touching his eyes or nasal secretions, to avoid touching the noninfected eye after touching the infected eye, and to avoid sharing towels or pillows. The eyes should be kept free of discharge and should not be patched. Viral conjunctivitis is selflimiting, lasting 1 wk in mild cases and up to 3 wk in severe cases. If the conjunctivitis is definitively due to a virus, no treatment is needed or available. If any clinical characteristics are consistent with bacterial conjunctivitis, the patient should be treated with topical antibiotics, eg, sulfacetamide sodium 10% drops or trimethoprim/polymyxin B qid for 7 to 10 days. Severe conjunctivitis associated with pseudomembranes, visionlimiting corneal inflammation, or scarring may need topical corticosteroids. However, topical corticosteroids can exacerbate ocular herpes simplex virus infections, possibly leading to corneal ulceration and perforation. Longterm corticosteroid use can lead to glaucoma and possibly cataracts. Their use should therefore be initiated and monitored by an ophthalmologist.NONGONOCOCCAL BACTERIAL CONJUNCTIVITIS An acute conjunctival inflammation caused by a nongonococcal bacterial infection.Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae are common causes of nongonococcal bacterial conjunctivitis.Symptoms, Signs, and Diagnosis Patients complain of conjunctival hyperemia, purulent discharge, ocular irritation, and eyelids that are stuck together on awakening. Symptoms are more often unilateral.The bulbar and tarsal conjunctivae are intensely hyperemic and edematous. Petechial subconjunctival hemorrhages, chemosis, and an enlarged preauricular lymph node are occasionally present.The discharge should be cultured, particularly if it is purulent. Smears should be examined microscopically and stained with Gram stain to identify bacteria and with Giemsa stain to determine the leukocytic response.Treatment The bacteria that cause bacterial conjunctivitis are contagious and spread by handtoeye and fomite inoculation. To avoid transmitting infection, the physician must wash his hands thoroughly and sterilize instruments after examining the patient. The patient should be told to wash his hands thoroughly after touching the eyes or nasal secretions, to avoid touching the noninfected eye after touching the infected eye, and to avoid sharing towels or pillows. The eyes should be kept free of discharge and should not be patched. Bacterial conjunctivitis is often selflimiting, lasting up to 3 wk without treatment and 1 to 2 days with treatment. If bacterial infection is suspected, sulfacetamide sodium 10% drops or trimethoprim/polymyxin B should be applied qid for 7 to 10 days. A poor clinical response after 2 or 3 days indicates that the cause is an insensitive bacterium, a virus, or an allergy. Antibiotic therapy may be modified depending on results of culture and sensitivity studies.ADULT GONOCOCCAL CONJUNCTIVITIS A rare, severe, purulent conjunctivitis in adults that is acquired from a gonorrheal contact or from selfinoculation during a gonorrheal genital infection.Usually only one eye is involved. Symptoms similar to those of neonatal gonococcal conjunctivitis (severe eyelid edema followed by chemosis and a profuse purulent exudate), but more severe, develop 12 to 48 h after exposure; rare complications include corneal ulceration, abscess, perforation, panophthalmitis, and blindness. Treatment involves a single dose of ceftriaxone 1 g IM or ciprofloxacin 500 mg bid po for 5 days. Bacitracin 500 U/g or gentamicin 0.3% ophthalmic ointment instilled into the affected eye q 2 h may be used in addition to systemic treatment. Sexual partners should also be treated. Since chlamydial genital infection is often present in patients with gonorrhea, all nonpregnant patients should also receive a single dose of azithromycin 1 g po or doxycycline 100 mg po bid for 7 days. (See also Neonatal Conjunctivitis under Neonatal Infections in Ch. 260.)INCLUSION CONJUNCTIVITIS(Adult Inclusion Conjunctivitis, Neonatal Inclusion Conjunctivitis, Inclusion Blennorrhea; Swimming Pool Conjunctivitis)An acute conjunctivitis, known as neonatal inclusion conjunctivitis in the newborn and as adult inclusion conjunctivitis in the adult, caused by Chlamydia trachomatis (serotypes D through K).C. trachomatis (see Trachoma, below) can persist asymptomatically in the cervix for prolonged periods. As a form of ophthalmia neonatorum, neonatal inclusion conjunctivitis results from passage through an infected birth canal and occurs in 20 to 40% of the newborns exposed to it. Most instances of acute adult inclusion conjunctivitis result from exposure to infected genital secretions. Usually, patients have acquired a new sexual partner in the preceding 2 mo.Symptoms, Signs, and Diagnosis Neonatal inclusion conjunctivitis usually appears 5 to 14 days after birth as a bilateral, intense papillary conjunctivitis, with lid swelling, chemosis, and mucopurulent discharge.The incubation period for adult inclusion conjunctivitis is 2 to 19 days. It is usually characterized by a unilateral mucopurulent discharge and a marked follicular conjunctivitis. Occasionally, superior corneal opacities and vascularization occur. Preauricular lymph nodes may be swollen on the side of the involved eye.C. trachomatis can be isolated in culture. Conjunctival epithelial cell basophilic cytoplasmic inclusion bodies are present in Giemsastained conjunctival scrapings. Immunofluorescent staining techniques can also detect C. trachomatis in conjunctival scrapings.Treatment Because at least 50% of infants with neonatal inclusion conjunctivitis also have a nasopharyngeal infection and 10% will develop chlamydial pneumonia, treatment is systemic with erythromycin 12.5 mg/kg po or IV qid for 14 days. The mother and her sexual partner also require treatment.In adult inclusion conjunctivitis, azithromycin 1 g po once, doxycycline 100 mg po bid for 1 wk, or erythromycin 500 mg po qid for 1 wk cures the conjunctivitis and concomitant genital infection. Sexual partners also require treatment (see Ch. 164).SEASONAL ALLERGIC CONJUNCTIVITIS(Hay Fever Conjunctivitis)An acute seasonal conjunctival inflammation caused by an allergy, generally to airborne pollens.This conjunctivitis is due to a type I anaphylactic hypersensitivity reaction to a specific antigen, usually an airborne pollen of trees, grasses, or weeds (see Ch. 148).Symptoms, Signs, and Diagnosis Patients complain of bilateral conjunctival hyperemia, watery discharge, and ocular itching. Most patients also complain of simultaneous rhinitis. Many patients have other atopic diseases such as eczema and asthma. Ocular itching often leads to eyelid rubbing and edema (see Ch. 94). The conjunctivitis is recurrent and seasonal, with symptoms peaking during the spring, late summer, and early fall. The bulbar and tarsal conjunctivae are hyperemic, but the predominant feature is edema. The bulbar conjunctiva appears translucent, bluish, and thickened. The papillae on the tarsal conjunctiva give it a velvety appearance. Chemosis is not uncommon.The diagnosis is usually made on clinical grounds. Eosinophils are present in conjunctival scrapings, which may be taken from the lower or upper tarsal conjunctiva.Treatment Avoidance can reduce symptoms and occasionally antigen desensitization is helpful. Topical OTC antihistamine/vasoconstrictors (eg, naphazoline HCl/pheniramine maleate) are useful for mild cases. Topical prescription antihistamines (eg, levocabastine), NSAIDs (eg, ketorolac), or topical mast cell inhibitors (eg, lodoxamide) can be used separately or in combination if OTC preparations do not provide sufficient relief. Topical corticosteroids (eg, fluorometholone 0.1% or prednisolone acetate 0.12 to 1.0% drops tid) can be useful in recalcitrant cases. Because topical corticosteroids can exacerbate ocular herpes simplex virus infections, possibly leading to corneal ulceration and perforation, or with longterm use lead to glaucoma and possibly cataracts, they should be initiated and monitored by an ophthalmologist. The incubation time for bacterial conjunctivitis is a few days. In viral cases, it can be up to a week. Can It Be Prevented?To prevent infectious conjunctivitis, teach your child to wash his or her hands often with warm water and soap. Children also should not share eyedrops, tissues, eye makeup, washcloths, towels, or pillowcases with other people. If your child already has conjunctivitis, ask your child to wash his or her hands after touching the eyes. Your child also should not touch the infected eye and then touch the other eye without first washing his or her hands. Be sure to wash your own hands thoroughly after touching your child's eyes, and throw away items like gauze or cotton balls after they have been used. Wash towels and other linens that your child has used in hot water separately from the rest of the family's laundry to avoid contamination. If you know your child is prone to allergic conjunctivitis, keep windows and doors closed on days when the pollen is heavy, and dust and vacuum frequently to limit allergy triggers in the home. Irritant conjunctivitis can only be prevented by avoiding the irritating causes. Many cases of neonatal conjunctivitis are prevented by screening and treating pregnant women for sexually transmitted diseases. The mothertobe may have bacteria in her birth canal even if she shows no symptoms, which is why prenatal screening is important. Other cases are prevented by treating all newborns with antibiotic ointment or eyedrops in the delivery room. This practice in certain countries, including the United States, has significantly decreased the rate of conjunctivitis due to gonorrhea in newborns and the blindness it can cause. To prevent conjunctivitis from herpes virus, a cesarean section is recommended when the mother has active genital herpes lesions at the time of delivery.You rub and rub your eyes, but they won't stop itching. When you look in the mirror, they are red and puffy. What's going on? Do you have a strange sickness? No you have a common problem called conjunctivitis. What Is Conjunctivitis?Conjunctivitis (say: conjunktihvitis) is the most common eye problem kids can have. It can cause redness, itching, inflammation (say: inflamayshun) or swelling, and a clear or white, yellow, or greenish gooey liquid to collect in the eyes. Many people know the more common name for conjunctivitis, which is pinkeye. It's called pinkeye because the white part of the eye and inside the eyelids become red or pink when you have it. Pinkeye may start in one eye, but many people get conjunctivitis in both eyes at the same time. Conjunctivitis usually doesn't hurt, but itching can be annoying. Sometimes it feels like you have an eyelash or a speck of sand in your eye and can't get it out.Adults, especially parents and teachers who spend a lot of time with kids, can get conjunctivitis, too. Conjunctivitis lasts a short time, usually about a week or less, and then goes away by itself or after treatment.How Do I Get Conjunctivitis?Kids get conjunctivitis for different reasons. Most kids get it from bacteria (say: bakteereeah) or viruses. This is called infectious (say: infeckshus) conjunctivitis. Bacteria can be seen only with a powerful microscope and viruses are even smaller than bacteria! Bacteria live on your skin or in your nose or mouth all the time and you never know it. Most don't ever bother you, but certain kinds of bacteria can cause infections like conjunctivitis. Sometimes kids get ear infections when they have conjunctivitis because the same bacteria can cause both problems. Viruses, like the kind that can give you a cold, can cause conjunctivitis, too. Conjunctivitis is easy to catch just through touching. You can get conjunctivitis by touching the hand of an infected friend who has touched his eyes. If you then touch your eyes, the infection can be spread to you. Washing your hands often with warm, soapy water is the best way to not get infected with conjunctivitis. Kids also get conjunctivitis because of allergies or because they get something irritating in their eyes, but these kinds of conjunctivitis are not contagious.What Should I Do if I Think I Have It?If your eyes are itchy, red, or more crusty than usual in the morning, you should tell your parent. Do not wait because conjunctivitis spreads easily. Your parent will probably call the doctor for an appointment. Acute conjunctivitis is redness and soreness (inflammation) of the clear covering (the conjunctiva) which coats the white of the eye and lines the inside of the eye lids. This comes on relatively quickly and lasts for a fairly short time. Acute conjunctivitis may clear on its own, but often needs treatment from your doctor. SymptomsMostly both eyes are affected, but often one starts before the other. The eye is red, with the blood vessels over the white of the eye more visible and swollen. The lining of the eyelids also looks redder or pinker than usual. The eye is sticky, with a discharge, which is worse when you wake up. The eye is itchy or painful. Sometimes people do not like to be in bright light (photophobia). CausesThe commonest cause is infection with bacteria. Virus infection may also occur. Allergic reactions, eg hayfever, may cause conjunctivitis, but do not usually cause a sticky discharge. DiagnosisYour doctor will want to rule out more serious problems, which might affect the vision, and may examine you with a special torch for looking into and at the eye (an ophthalmoscope). In some circumstances, if there is doubt about the diagnosis, your doctor might use special fluorescent eye drops to examine the eye better. Sometimes, especially if the treatment is slow to work, your doctor may take a specimen of the germs in the eye on a small swab (like a cotton bud) and send it to the laboratory for analysis. TreatmentIt helps to bathe the eyes with water or water with a pinch of salt in it. Beware, conjunctivitis is often very contagious. Wash your hands after touching your eyes (or your child's eyes, if you are nursing them), as it is very easy to infect others by spreading the germs on your fingers or on tissues etc. Over the counter eye cleansing solution can also soothe the eyes, but in the presence of a bacterial infection, you need to see the doctor as antibiotic eye drops or ointment are necessary. In some rare infections, antibiotics are also given by mouth. If the problem is a virus infection, then it will not respond to antibiotics, and your body will have to fight off the infection. If your doctor thinks that the problem is allergic, then you may be prescribed antihistamines, sodium cromoglycate eye drops, or nedocromil eye drops. There are proprietary eye washes and lotions which may soothe the eyes, and at least one eye treatment which is for mild infections, but in general these are merely a temporary measure. You should see your doctor for further advice. Your doctor may prescribe drops or ointment, or both. Drops stay in the eyes for a shorter time, but ointment tends to blur the vision. Sometimes your doctor may prescribe drops by day, with ointment at night. PreventionYou are more prone to conjunctivitis after a cold, but anyone can pick it up. Certainly it is important to avoid spreading the germs, and anyone with conjunctivitis, and those treating them, should be scrupulous about washing their hands after touching the eyes, and disposing of tissues straight into the bin. Conjunctivitis is an inflammation of the conjunctivae, which are the mucous membranes covering the white of the eyes and the inner side of the eyelids. It usually affects both eyes at the same time although it may start in one eye and spread to the other after a day or two. It may be asymmetrical, affecting one eye more than the other. There are many causes and the treatment will depend upon the cause. Conjunctivitis is a very common eye condition. It is not serious but can be very uncomfortable and irritating. What causes conjunctivitis? There are five different kinds of conjunctivitis, each with its own cause.Bacterial conjunctivitisBacterial conjunctivitis is an infection caused by bacteria such as staphylococci, streptococci or haemophilus. These organisms may come from the patient's own skin or upper respiratory tract or they may be caught from another person with conjunctivitis. Viral conjunctivitis Viral conjunctivitis is often associated with the common cold. This may be caused by a virus called 'adenovirus'. This type of conjunctivitis can spread rapidly between people and may cause an epidemic of conjunctivitis. Chlamydial conjunctivitis This type of conjunctivitis is caused by an organism called Chlamydia trachomatis. This organism may also affect other parts of the body and can cause the venereal disease chlamydia . Allergic conjunctivitis Allergic conjunctivitis is common in people who have other signs of allergic disease such as hay fever, asthma and eczema. The conjunctivitis is often caused by antigens like pollen, dust mites or cosmetics. Reactive conjunctivitis chemical or irritant conjunctivitisSome people are very susceptible to chemicals in swimming pools or to smoke or fumes and this can cause an irritation of the conjunctiva with discomfort, redness and watering. In such cases these irritants should be avoided. What are the symptoms of conjunctivitis? Bacterial conjunctivitis This is a condition that affects both eyelids. They usually feel gritty with a sticky discharge. Both eyes are red. The eyelids may be stuck together particularly in the mornings, and there may be discharge on the eyelashes. Viral conjunctivitisThe eyes are red and there may be a watery discharge. The eyes are uncomfortable and there may also be symptoms of a cold. Sometimes there are tender lymph nodes around the ear or the neck. This type of conjunctivitis may also spread to affect the cornea (keratitis) and it may persist for several weeks. Chlamydial conjunctivitisBoth eyes will be red with a sticky discharge. The cornea may also be involved in this condition. Allergic conjunctivitis Allergic conjunctivitis is usually associated with intense itching of the eyes. There may be a stringy discharge and the eyes are usually intermittently red. This may occur at particular times of the year, for instance during spring and summer when there is a lot of pollen in the air. Conjunctivitis in young children Small children may be susceptible to infective conjunctivitis and they may develop severe forms of the condition because of poor immune defences. This is particularly the case in babies and conjunctivitis in an infant aged less than one month old is a notifiable disease in the UK. This type of conjunctivitis (ophthalmia neonatorum) may be due to an infection that has been contracted during the passage through the birth canal and may include gonococcal or chlamydial infection. Small babies may develop conjunctivitis from other types of infection but swabs should always be taken in order that appropriate treatment can be given. Small babies often have poorly developed tear drainage passages (a condition known as nasolacrimal duct obstruction). These children are susceptible to watering eyes and they may intermittently become sticky, but this is usually not serious. How is conjunctivitis treated? Bacterial conjunctivitisThis is usually treated with broad spectrum antibiotic drops or ointment, (eg chloramphenicol or fusidic acid). The eyes should also be cleaned with cotton wool soaked in cooled boiled water to remove any crusts or stickiness. For bacterial conjunctivitis, research evidence shows that while 64 per cent of cases will clear on their own within five days, antibiotic eye medication does lead to increased cure rates and earlier remission. Viral conjunctivitis There is no effective treatment for viral conjunctivitis but the eyes may be made more comfortable by using a lubricant ointment such as LacriLube. Chloramphenicol ointment will also help to prevent secondary bacterial infection. As this is a highly contagious condition it is important to ensure that a strict code of hygiene is adhered to, such as hand and face washing and no sharing of face towels. This condition may go on for a prolonged time and in some instances corticosteroid drops have been advocated although these should only be given under the strict supervision of an eye specialist (ophthalmologist). Chlamydia conjunctivitisTreatment is with chlorotetracycline ointment and tetracycline tablets in order to ensure that infection elsewhere is controlled. Children cannot be treated with tetracycline and erythromycin is usually used for them. Because of the possible infection of other mucous membranes any associated venereal disease should be identified and both the patient and their partners must be treated. Conjunctivitis in infantsThis needs to be taken very seriously. Specimens are taken from the sticky discharge and such children must be seen by an ophthalmologist. Treatment is given depending on the underlying cause of the conjunctivitis. Allergic conjunctivitis This can be treated using topical antihistamine drops. Drops such as sodium cromoglicate can be used to prevent the allergic response and they need to be used for many weeks in order to give any result. Corticosteroid drops are occasionally used, but should only be used under the supervision of an ophthalmologist. The main treatment should be identifying what is triggering off the allergic response and removing this source of allergen. How does the doctor make the diagnosis? Conjunctivitis can usually be diagnosed and treated by your GP. The doctor will usually diagnose the condition based on examination of your eyes and the history that you give. Sometimes a swab has to be taken from the eye, especially if there is no improvement on standard treatment. In some cases that are severe or do not respond to treatment, you may need to see an eye specialist (ophthalmologist). What should I pay particular attention to? If there is any worsening of the symptoms despite treatment or if the vision deteriorates, then a further consultation with your doctor should be requested even if treatment is being carried out. What can be done to avoid conjunctivitis? Good hygiene of hands and face is important. There should be no sharing of face towels, especially if someone has conjunctivitis. Conjunctivitis can spread from one eye to the other, especially when you rub your eyes. Pus and crust should be removed by bathing the eye with lukewarm salt water which can also lessen the symptoms. Use disposable tissues when you dry the eyes and throw them away after use. This will limit the contamination. Dispose of any antibiotic eye drops after the treatment is over. People who suffer from conjunctivitis should have a special towel that only they use. How does conjunctivitis usually progress? Even if left untreated, most forms of conjunctivitis will gradually get better on their own in a few weeks. With appropriate treatment the eyes are usually more comfortable within a few days, although cases of adenoviral infection may cause problems for some weeksConjunctivitisINTRODUCTIONConjunctivitis, commonly known as "pink eye," is an inflammation of the membrane (conjunctiva) that covers the eye and lines the inner surface of the eyelid. There are four main causes of conjunctivitis.One cause involves the introduction of either bacterial or viral microorganisms into the eye. These may be transmitted to the eye by contaminated hands, washcloths or towels, cosmetics (particularly eye makeup), false eyelashes or extended wear contacts. Minor conjunctivitis can accompany a viral cold or flu. Although bacterial and some of the viral infections (particularly herpes) are not very common, they are potentially serious. Both types of infection are contagious.Irritants are another cause of conjunctivitis. Offenders of this type include air pollutants, smoke, soap, hairspray, makeup, chlorine, cleaning fluids, etc.Seasonal allergic response to grass and other pollens can cause some individuals to acquire conjunctivitis.Pink eye may be more serious if you: have a condition that decreases your ability to fight infection (impaired immune system), have vision in only one eye or you wear contact lenses.SYMPTOMSVarious combinations of the following symptoms may be present: itching, redness, sensitivity to light, feeling as if something is in the eye, swelling of the lids and/or discharge from the eyes. The consistency of possible discharge may range from watery to puslike, depending on the specific cause of the conjunctivitis.DURATIONIt usually takes from a few days to two weeks for most types of conjunctivitis to clear. Conjunctivitis due to an allergy may continue as long as the offending pollen is present. Under such conditions, symptoms are likely to recur each year.DIAGNOSISDiagnosis consists of physical examination of the eye by the clinician. If a discharge is present, a culture for bacteria may be warranted.TREATMENTTreatment varies depending on the cause. Medications in the form of ointments, drops or pills may be recommended to help kill the germ infecting the eye, relieve allergic symptoms and/or decrease discomfort. In the case of conjunctivitis due to a viral cold or flu, the practitioner may recommend that you be patient and let it run its course.OTHER MEASURES THAT SHOULD BE FOLLOWED:Apply cool compresses to the infected eye(s) three to four times per day for 1015 minutes using a clean washcloth each time. This should help reduce itching and swelling and provide some comfort. Wash your hands frequently and keep them away from your eyes in order to reduce or prevent recontamination. Avoid rubbing your eyes to decrease irritation of the area. Wear sunglasses if your eyes are sensitive to the light. Avoid exposure to the irritants that may be causing the conjunctivitis. Dispose of old eye makeup if the culture for bacteria is positive. Use a clean pillowcase each night. (Pillowcase can be changed every other day and turned over nightly). Avoid wearing contact lenses while you are using medications or if your eyes are uncomfortable. Cleanse contact lenses thoroughly. PREVENTIONAlthough many kinds of conjunctivitis are hard to prevent, there are measures that can be taken to decrease your risk of reacquiring or spreading it to someone else. These are listed below:Do not share eye makeup or cosmetics of any kind with anyone. Avoid sharing washcloths or towels. Wash hands frequently and keep away from the eyes. Wear protective goggles (i.e., for swimming or working) if you must be exposed to chemicals that are irritating. Do not use medication (eye drops, ointment, etc.) that has been prescribed for someone else. Avoid swimming in nonchlorinated pools or stagnant lakes or ponds. Do not save medication dispose of it when treatment is completed. CONCERNSIf any of the following problems should occur, notify your clinician:Visual changes Severe eye pain Pain when moving eyes Fever No improvement with medication within 4872 hours Drainage continues after you have completed full course of medication Roommates or other family members develop symptoms Eyes become very sensitive to light DIRECTIONS FOR USING EYE DROPS OR OINTMENTWash your hands before touching your eyes or your medications. Gently, pull your lower lid down with your finger. Look up toward the ceiling. To instill drops: Drop medicine inside center of your lower lid. Do not drop it on your eyeball. Close your eyes gently without squeezing the lids shut. Blink to distribute medication over the eye. To instill ointment: Starting in the corner of your eye closest to the nose, squeeze a thin ribbon of ointment along the inside of the lower lid. Close eyes gently without squeezing the lids shut. Roll eyes to distribute the medication over them. Remove excess solution or ointment outside your eye with a clean tissue, using a separate tissue for each eye. Wash hands after you have finished your medication, to avoid transmitting the infection to others. The patient complains of a red eye, a sensation of fullness, burning, itching, or scratching, and perhaps a gritty or foreign body sensat ion and tearing or purulent discharge and crusting or mattering. Examination discloses generalized injection of the conjunctiva, thinning out towards the cornea (localized inflammation suggests some other diagnosis such as a foreign body, episcleritis, or a viral or bacterial ulcer). Vision and pupillary reactions should be normal and the cornea and anterior chamber should be clear. Any discomfort should be temporarily relieved by instilling topical anesthetic solution. Deep pain, photophobia, decreased vision and injection more pronnounced around the limbus (ciliary flush) suggest more serious involvement of the cornea and iris.Different symptoms suggest different etiologies. Tearing, preauricular lymphadenopathy and upper respiratory symptoms suggest a viral conjunctivitis. Pain upon awakening with lid crusting and a copious purulent exudate suggests a bacterial conjunctivitis. Few symptoms upon awakening but discomfort worsening during the day suggests a dry eye. Little conjunctival injection with a seasonal recurrence of chemosis and itching, and cobblestone hypertrophy of the tarsal conjunctiva suggests allergic (vernal) conjunctivitis. Physical and chemical conjunctivitis, caused by particles, solutions, vapors, natural or occupational irritants that inflame the conjunctiva, should be evident from the history. What to do:Instill proparcaine anesthetic drops (Alcaine, Ophthaine) to allow for a more comfortable exam and to help determine if the patient's discomfort is limited to the conjunctiva and cornea or, if there is no pain relief, that the pain comes from deeper eye structures. Examine the eye, including visual acuity, inspection for foreign bodies, pupillary reaction fundoscopy, estimation of intraocular pressure by palpation of the globe above the tarsal plate, slit lamp examination (when available), and fluorescein and ultraviolet or cobalt blue light to assess the corneal epithelium. Ask about and look for any rash, arthritis, or mucous membrane involvement which could point to StevensJohnson syndrome, Kawasaki's, Reiter's, or some other syndrome that can present with conjunctivitis. For bacterial conjunctivitis, start the patient on warm compresses and seven days of topical antibiotics such as erythromycin, sulfacetamide, tobramycin or gentamycin ointment (which transiently blurs vision) every 4 hours, or solutions such as sulfacetamide 10%, tobramycin 0.3% or ciprofloxacin every 2 hours, with oral analgesics as needed. If it is unclear whether the problem is viral or bacterial, it is safest to treat it as bacterial. For viral and chemical conjunctivitis, use cold compresses and weak topical vasoconstrictors such as naphazoline 0.1% (Naphcon) every 34 hours, unless the patient has a shallow anterior chamber that would be prone to acute angle closure glaucoma with mydriatics. For allergic conjunctivitis, use cold compresses and topical decongestant antihistamine combinations such as drops of naphazoline with pheniramine (Naphcon A) or naphazoline with antazoline (Vasocon A) every 34 hours. Topical corticosteroid drops provide dramatic relief, but prolonged use increases the risk of opportunistic viral, fungal and bacterial corneal ulceration, cataract formation and glaucoma. If a severe contact dermatitis is suspected, then a short course of oral prednisone would be indicated. If the problem is dry eyes (keratoconjunctivitis sicca) use methylcellulose (Dacriose) artificial tear drops. Have the patient follow up with the ophthalmologist if the infection does not clearly resolve in 2 days. Obtain early consultation there is any involvement of cornea or iris.What not to do:Do not forget to wash your hands and equipment after examining the patient, or you may spread herpes simplex or epidemic keratoconjunctivitis to yourself and other patients. Also, do not forget to instruct the patient on the importance of hand washing and separation of towels and pillows for ten days after the onset of symptoms. Do not patch an affected eye, as this interferes with the cleansing function of tear flow. Do not give steroids without arranging for ophthalmologic consultation, and never give steroids if a herpes simplex infection is suspected.DiscussionWarm compresses are soothing for all types of conjunctivitis, but antibiotic drops and ointments should be reserved for when bacterial infection is likely. Neomycincontaining ointments and drops should probably be avoided, because allergic sensitization to this antibiotic is common. Any corneal ulceration requires ophthalmological consultation. Most viral and bacterial conjunctivitis will resolve spontaneously, with the possible exception of staphylococcus, meningiococcus, and gonococcus infections, which can produce destructive sequelae without treatment.Most bacterial conjunctivitis is caused by Streptococcus pneumoniae, Haemophilus aegyptus and Staphylococcus aureus. Routine conjunctival cultures are seldom of value, but you should Gram stain and culture a copious purulent exudate. Neisseria gonorrhoeae infection confirmed by Gramnegative intracellular diplococci on Gram stain requires immediate ophthalmologic consultation. Corneal ulceration, scarring and blindness can occur in a matter of hours. Chlamydial conjunctivitis will usually present with lid droop, mucopurulent discharge, photophobia and preauricular lymphadenopathy. Small white elevated conglomerations of lymphoid tissue can be seen on the upper and lower tarsal conjunctiva, and 90% of patients have concurrent genital infections. Doxycycline 100mg bid or erythromycin 400mg tid by mouth plus topical tetracycline (Achromycin Ophthalmic) for three weeks should control the infection (also treat any sexual partner).Epidemic keratoconjunctivitis is a bilateral, painful, highly contagious conjunctivitis usually caused by an adenovirus. The eyes are extremely erythematous, sometimes with subconjunctival hemorrhages. There is copious watery discharge and preauricular lymphadenopathy. Treat the symptoms with analgesics, cold compresses, and, if necessary, corticosteroids. Because the infection can last as long as three weeks and may result in permanent corneal scarring, provide ophthalmologic consultation and referral. Herpes simplex conjunctivitis is usually unilateral. Symptoms include a red eye, photophobia, eye pain and mucoid discharge. There may be periorbital vesicles, and a branching (dendritic) pattern of fluorescein staining makes the diagnosis. Treat with trifluridine 1% (Viroptic), analgesics and cold compresses. Cycloplegics such as homatropine may help control pain from iridocyclitis. Topical corticosteroids are contraindicated, because they can extend the infection, and ophthalmological consultation is required.Herpes zoster ophthalmicus is shingles of the opthalmic branch of the trigeminal nerve, which innervates the cornea and the tip of the nose. It begins with unilateral neuralgia, followed by a vesicular rash in the distribution of nerve. Ophthalmic consultation is again required, because of frequent ocular consultations, but topical corticosteroids may be used. Prescribe systemic acyclovir (Zovirax) 800mg q4h (five times a day) for ten days or famcyclovir (Famvir) 500mg tid for seven days.