Pathology of conjunctivitis

2021-02-02 12:00 AM

Bacterial conjunctivitis can sometimes be severe and affect vision if it is caused by highly toxic bacteria.


Conjunctivitis is a very common disease. Clinical manifestations include subjective symptoms such as itching, stinging, watery eyes ... and physical symptoms such as exudation, papillae, granulomas, pseudo and membranes, conjunctival ulcers, acne puffiness, ...

Subjective symptoms

In conjunctivitis is usually nonspecific. Signs of tearing, irritation, burning in the eyes or glare can be seen in all cases of conjunctivitis due to different causes. When there is damage to the cornea, there can be a pain, foreign bodies. Itching is a specific symptom of allergic conjunctivitis but can also appear in blepharitis, ...

Physical symptoms

Conjunctivitis: is caused by fluid seeping through the capillaries with the opening of the conjunctiva. Conjunctivitis is usually swollen, transparent (in severe cases it may be exposed to the eyelid).

Exudate (secretory): A fluid that oozes out through the conjunctival epithelium from dilated and erectile blood vessels. The characteristics of the secretions differ depending on the cause of inflammation (purulent secretions are typical of bacterial conjunctivitis, secretions containing fluid, mucus is of viral conjunctivitis, ...).

Conjunctivitis: Occurs in general conjunctivitis. Conjunctiva loses its normal glossiness, becomes thick and red, especially in the region of the map.

Papillary: Many causes acute or chronic conjunctivitis to the papillae response. The papillae appear only on the cartilage conjunctiva, the marginal conjunctiva where the epithelium is adjacent to the fibrous organization. The papillary structure includes the central vascular truck, surrounded by infiltrates of chronic inflammatory cells such as lymphocytes, cytoplasm and eosinophils. When the inflammatory process is prolonged, the papillae may merge to form giant papillae (in spring inflammation or in contact lenses). Papillae are common in allergic conjunctivitis, caused by bacteria, reaction when wearing contact lenses, blepharitis, ...

Granular: Typical in some conjunctivitis. The granule is an overproduction of the lymphoid organization in the conjunctival tissue. The size and location of the granule on the conjunctiva vary depending on the type of conjunctivitis and the degree of inflammation. The blood clot usually surrounds and invades the seed surface, not the inside of the seed.

Hypothesis and membrane: The fibrin infiltrates escape through the inflamed conjunctival blood vessels and the polymorphonuclear leukocytes and can coagulate on the surface of the epithelium. Hyphae and membranes appear in conjunctivitis depending on the cause. Hyphae are often easy to peel off, cause less bleeding. The membrane is often difficult to peel, when peeling will bleed a lot and when it does not leave scars under the epithelium.

Granuloma: A proliferation of granulomatous tissue in specific conjunctivitis such as tuberculosis, syphilis, sarcoidosis or by foreign bodies in the conjunctiva.

Conjunctivitis: Conjunctival ulcers are often below or above the eyeball conjunctiva, and may be obscured by conjunctival secretions or pseudomembranous. If the two ulcer conjunctival surfaces stick together, it can cause the eyelids to stick and dry together.

Pre-ear nodules: in some forms of conjunctivitis, the pre-ear lymph nodes are swollen, sometimes painful (viral conjunctivitis, chlamydia, ...).

Bacterial conjunctivitis

General features

Bacterial conjunctivitis can sometimes be severe and affect vision if it is caused by highly toxic bacteria. The cause of the disease is usually streptococci, staphylococci, pneumococcal, gonorrhea, Haemophilus influenza, bacillus Weeks, Moraxella Lacunata, ... The disease usually starts suddenly (if acute), initially in one eye, then spreads. another eye.

The subjective symptoms usually begin with sandiness in the eyes, burning and many secretions that make it difficult for the eyes to open in the morning when waking up. Objective symptoms: swelling of the eyelids, dry secretions. initially, a dilute form resembling viral conjunctivitis, later purulent, and erectile conjunctiva on the same map and lashes. False membranes may appear in the conjunctiva. The cornea is less likely to be infiltrated but may have superficial keratitis and marginal infiltrates. If the cause is staphylococci, it is often accompanied by a pimple on the skin. If the cause is streptococcus, there is usually an ulcer on the face of a crack in the fissure area. If the cause is Weeks, conjunctivitis with haemorrhage often develops. Diagnosis is usually based on clinical and subclinical symptoms: fresh microscopy test, direct examination of secretions, bacterial culture and antibiotic mapping). Treatment: wash the eyes with normal saline to get the maximum removal of hormones. Then, the patient has to apply antibiotics (water, fat) for 7-10 days. In mild cases, 0.4% Chloramphenicol can be used. In more severe cases: Tobramycin, Neomycin, ciprofloxacin can be used, ... Quinolone drugs can only be used in very severe cases but other drugs have no effect. The whole body can use antibiotics in the necessary cases. To prevent diseases, it is necessary to propagate about personal hygiene and environment, not contact with sick people. The whole body can use antibiotics in the necessary cases. To prevent disease, it is necessary to propagate about personal hygiene and environment, not contact with sick people. The whole body can use antibiotics in necessary cases. To prevent diseases, it is necessary to propagate about personal hygiene and environment, not contact with sick people.

Acute conjunctivitis due to pneumococcal

Usually occurs in children, often with inflammation of the upper respiratory tract fluid.


Swollen lashes, small haemorrhage in conjunctiva and sclera Often create a pseudo-membrane in the eyelash conjunctiva and the same bottom, grey-white, easy to peel off with cotton rolls. May include superficial corneal lesions in the periphery (small gonorrhoea, may develop into ulcers).


It is necessary to take the secretion for testing to confirm the causative agent before treatment. Need to peel the membrane daily or every other day, then wash the eyes with normal saline and apply antibiotics (Cebemycin, Bacitracin-polymyxin B, Ciprofloxacin, ..) 10-15 times/day.

Acute conjunctivitis due to gonorrhoea (Neisseria gonorrhoeae)

The disease progresses seriously, especially dangerous with the cornea. There are 3 clinical forms: Neonates, children and adults.

Acute conjunctivitis in a newborn

 The disease usually appears 2-3 days after birth, through the genital tract of a mother infected with gonorrhoea or even in the womb due to premature rupture of the amniotic fluid. The disease develops in 3 phases: Phase 1 (incubation) lasts for 3-4 days - red skin, strong oedema, hard lashes like wood make eyes difficult to open, conjunctival erectile and oedema, blood secretion; Stage 2 (pus discharge) lasts 5-7 days - softer lashes, more pus secretion (the more the wiping feature, the more difficult it is to examine the eyelashes (if examining the eyelid papillae is found); Stage 3 (papillary hyperplasia) lasts 6-8 days - hyperplasia thrives, the erectile conjunctiva looks like a granular structure, then the conjunctiva gradually returns to normal, leaving no trace (differs from adults: after recovery, it may cause scarring). The disease can progress very seriously, if not treated promptly, corneal ulcers, possibly corneal necrosis and perforation, Treatment is difficult and leaves scars. The disease is diagnosed based on clinical and laboratory conditions (direct examination of conjunctival secretions, Gram staining will clearly see coffee bean spheres).

Acute conjunctivitis due to gonorrhoea in children

 The disease usually develops in one eye, in the niece due to self-infection. Aggravates neonatal morphology, or causes corneal damage.

Acute conjunctivitis due to gonorrhoea in adults

Usually in 1 eye. Progression severe, with high fever, joint damage, muscle, heart. After the incubation period, two lashes were swollen, many dirty yellow secretions and thin foam came out when the rim of the eyelids appeared. Conjunctivitis with many tiny papillae. In severe cases, the cornea is injured in severe cases. At first, it is ulcerated at the edge of the edge, after the ulcer in the centre and can cause intraocular inflammation.

Treatment and prevention

Prevention: For newborns: apply Argyron 3% solution after giving birth (this method was first discovered by Russian doctor Matveevui, completed in the literature or called the Créde method - 1881). It is possible to apply an antibiotic, it is necessary to monitor and check the mother before giving birth to have measures to handle early. For the morphology of children and adults: it is necessary to keep the personal hygiene and the surrounding environment and to detect early and treat promptly if there is a systemic gonorrhoea infection.

Treatment: Wash eyes continuously with normal saline. Apply antibiotics sensitive to gonorrhoea. Penicillin was not used for treatment due to the increased incidence of penicillin-resistant gonorrhoea. Drugs used are quinolones, cephalosporin, bacitracin, gentamycin ... antibiotics are applied 10-15 times/day or in the form of a drop basket in the first days. Then 30 minutes-1 hours / 1 time. When the disease is nearly stable, reduce the dose 3-4 times/day. Body as a whole: with newborn babies should be very careful when indicated for the use of birth control; For adults: Cefoxitin 1g intramuscularly or Cefotaxime 0.5g t / mx 4 times/day, or Ceftriaxone 1g t / m injection or Spectinomycin 2g intramuscularly.

Acute conjunctivitis caused by diphtheria

 Diphtheria is an acute inflammation, characterized by membranes of bacterial entryways. The causative agent is the bacillus Lefflera (creating exotoxins). The disease usually spreads through the respiratory tract. The incubation period is 2-10 days. The disease usually develops in children 2-10 years old. If diphtheria and streptococci develop, the disease progresses very seriously. There are three clinical forms.

Diphtheria morphology

This is the most severe form. Basic injury: hard oedema, erection (especially the upper lids) that prevents the eyes from opening. Little mucus secretion. After 1-3 days, the lashes become softer, more secreted. Appears dirty grey film, adhering to the eyelash conjunctiva and the same map, the eyeball conjunctiva. It is difficult to peel the membrane, causing bleeding. The membrane will come off on its own after 7-10 days, leaving star scars in the conjunctiva. Pus secretion a lot. If not treated in time can develop corneal ulcers, inflammation of the entire eye.

Silk morphology

More often, the pellet progresses slightly more than the above pattern. The membrane only forms in the eyelash conjunctiva, softer, dirty grey, easier to peel off and less bleeding and scarring in the conjunctiva after shedding. The cornea is usually not damaged. Good prognosis.

Morphological form

Lightest progressive form, usually non-film forming. Lesions are mainly erectile and conjunctival oedema. No damage to the cornea.

Implementing the quadrants

Based on clinical lesions and subclinical tests (taking fluid and secretions from the conjunctiva for testing in the first 3 hours).

Differential diagnosis

The disease should be diagnosed differently from pneumococcal, streptococcal and adenovirus diphtheria conjunctivitis. For the first morphology: there is usually inflammation of the upper respiratory tract fluid or pneumonia, with pneumococcus or streptococcus in the specimen. The film is white, easy to peel and leaves no scars. For the following morphology: the course resembles diphtheria, but in these patients, there is inflammation of the upper respiratory tract fluid, the pre-ear lymph nodes and the jaw angle. The film is grey, soft, easy to peel and leaves no scars.


The first is to isolate the patient. Systemic: injected with anti-diphtheria serum (for mild form: 10,000 -15,000 AE / 1 time. Total dose is 30,000 - 40,000 AE. For severe form: increase dose of 1.5 to 2 times higher. Antibiotic with good effect belongs to the Tetracycline, Erythromycin line. In addition, it is necessary to give the patient an intravenous antidote, take vitamins. In the eyes: wash the eyes continuously with normal saline, take the membrane (if possible).), anti-sing tetracycline and Erythromycin strains. If there is damage to the cornea, it is necessary to coordinate treatment.

Viral conjunctivitis

Conjunctivitis caused by adenovirus

Adenoviruses can cause a variety of infections of the conjunctiva and cornea. Up to 10 out of 32 serotypes of adenoviruses can cause eye disease. The two most common forms are conjunctivitis with fever, pharyngoconjunctival fever (PCF) and conjunctivitis (Epidemic keratoconjunctivitis - EKC). Direct or indirect transmission (schools, swimming pools ...).

Conjunctivitis with fever, pharyngitis, lymphadenitis

This morphology is caused by serotype 3,4,7, often accompanied by inflammation of the upper respiratory tract. Patients with mild fever, sore throat, lymphadenopathy may appear in front of ears, and fatigue. In the eyes, the eyelashes are swollen and the lids are heavy, the feeling of sand is in the eyes, then the eyes swell quickly. The secretion is clear and sticky. Conjunctivitis, may be oedematous, appear as granules in the same map (large, pink, do not penetrate cartilage, do not leave scars). There may be conjunctival haemorrhage, conjunctival pseudomembrane (grey, soft, easy to peel). The cornea is not damaged.

Inflammation of the conjunctiva into fluid

Caused by serotype 8,11,19, usually without systemic symptoms. Conjunctivitis lesions are similar to the above morphology. Injury to the cornea progresses in 3 stages: stage 1 (progress within 7 days after the onset of disease) - On the cornea appears diffuse epithelial spots or may exfoliate as dots. usually clears after 2 weeks or goes to the later stage 2 (appears 7 to 10 days after onset) - Deep-dot epithelioid appears on the cornea. The disease can be completely cured after treatment. Stage 3 (appearing after day 8) - The disease is manifested by deep-dot epithelial inflammation, anterior parenchymal inflammation. Without proper treatment, these foci will persist for months or years and cause significant vision loss.

Prevention and treatment

Patient isolation and general hygiene should be kept. Since there is no specific anti-adenovirus, it is primarily symptomatic treatment and physical enhancement. The disease can go away on its own in 2 weeks if there are no special complications. Antibiotics should be used in the eye against superinfection. Caution should be taken when using corticoids: use low doses and do not stop suddenly to avoid causing prolonged and recurrent disease.

Conjunctivitis caused by Enterovirus

The causative agent is Enterovirus 70 (belonging to the Picornavirus group. This is a rare, highly contagious, rapidly progressive disease that can be cured after 1 week. the seed on the conjunctiva with sub-conjunctival haemorrhage, possibly with dot keratoconjunctivitis Treatment: no specific drugs, mainly general hygiene, good isolation, anti-superinfection.

Conjunctivitis caused by Molluscum contagiosum

The causative agent is Poxvirus AND. The disease is spread directly by contact with patients or through utensils. The disease usually develops in teenagers. Clinical manifestations are often manifested by granular conjunctivitis with eyelash lesions (pearl-seed nodules with sunken umbilical margin on the eyelids). May include macular sloughing of the cornea, damage to other parts of the body. Treatment: Surgical removal of nodules in the eyelids with frozen pressure, antibiotic treatment against superinfection.

Conjunctivitis caused by herpes virus

A viral disease that often recurs is always present in the body. It can develop in women as the menstrual cycle changes. Viruses often enter the body quietly, can cause strong reactions, high fever, blisters. At the eye develops acute granular conjunctivitis. Treatment: herpes antiviral and anti-superinfection drugs.

Acute conjunctivitis caused by Chlamydia

The disease is caused by the DK serotype of Chlamydia trachomatis, often develops in young people and children. Transmission: sexually or directly.

Clinical manifestations in the eye with inclusion conjunctivitis. Injury to the eye usually occurs one week after infection, combined with adenitis or nonspecific cervicitis. There are 2 clinical forms:

Chlamydia conjunctivitis in adults (buried conjunctivitis)

Subacute development, usually onset 1-2 weeks after infection, manifested by a granular reaction in the lower and lower eyelid conjunctiva, the eyeball conjunctiva and the semi-circular fold, do not form membranes, has fewer hormones purulent., may have pre-ear lymph nodes. In the cornea, there may be epithelial or sub-epithelial inflammation. The disease usually progresses with urethritis, cervix. Treatment: The disease can resolve on its own after 6-18 weeks, but very rare. At the eye, apply SMP10% solution and 1% Tetracycline fat; whole body take Tetracycline 0.25x4 tablets / day for 3 weeks, or Doxycycline 0.1x2 tablets / day for 3 weeks, or Erythromycin 0.25x4 tablets / day for 3 weeks, or Azithromycin 1g / day (single dose).

Chlamydia conjunctivitis in a newborn

Develops 5-14 days after birth. The first stage usually has no granules on the conjunctiva (the seed can appear only after 3 months of age), there may be membranes on the cartilage conjunctiva, many mucus secretions. The disease can be combined with damage to other organs in the body: pneumonia, otitis media. Need differential diagnosis with gonococcal conjunctivitis (need to take hormones and do gram or girly tests). Treatment: often respond well to the drug (SMP 10%, 1% tetracycline ointment or 1% Erythromycin ointment).

Chronic granular conjunctivitis

Unknow cause. The disease was first found by Axenfeld (German) and Morax (French). Therefore, it is called Morax granular conjunctivitis - Axenfeld. The disease begins with eye-catching, watery eyes. Congestive conjunctiva, granules develop in rows in the same map (equally large, not erectile), can last for a long time, but when it does not leave sequelae. There is no specific treatment, antibiotics and antiseptics are needed.

Allergic conjunctivitis

As a common disease, the allergen is usually exogenous.

Clinical morphology: susceptible conjunctivitis (atopia), contact conjunctivitis (dermatitis), microbial conjunctivitis, spring conjunctivitis.

Sensitive conjunctivitis

Progressive acute and chronic.

Acute (a rapid type of allergy): Patient has a burning sensation in the eyes, pain in fear of light, watery eyes. oedema, conjunctival erection, fluid discharge. Development of enlarged papillae on the cartilage conjunctiva. Occasionally appears dot keratitis.

Chronic: rich muscle symptoms (feeling like there is sand in the eyes, burning, watery eyes, ...). Physical symptoms are nonspecific (pale conjunctiva, erectile papillae, slightly thick bottom conjunctiva. Diagnosis is difficult, sometimes relying on self-monitoring of the patient.

Symptomatic treatment is mainly (antihistamine, anti-superinfection, anti-inflammatory steroid).

Conjunctivitis and contact dermatitis

The cause is usually exogenous allergens (drugs, chemicals, cosmetics, pollen, dust, food ...). The mechanism of the pathogenesis is similar to contact dermatitis and eczema. The disease progresses in a slow allergic pattern, usually after the second exposure to the allergen.

The clinical symptoms are quite typical: intense pain, burning, photophobia. Conjunctivitis and eyeball conjunctiva accumulation and oedema. Inflammatory papillae. Many purulent secretions (if taking this fluid for testing: there are many eosinophils, epithelial cells). Strong inflamed skin.

Conjunctivitis caused by microorganisms (bacteria, viruses, fungi, parasites)

The most common allergen is the staphylococcal exotoxin. Progresses in a slow allergic pattern.

Symptoms: conjunctival erectile, papillae and fusion on the conjunctiva, often accompanied by scaly blepharitis. Due to poor symptoms, additional skin tests are needed to make a definite diagnosis (especially testing with staphylococcal antigens).

Conjunctivitis with blisters

The cause is unknown, usually due to an allergy to the TB bacteria.

Symptoms: eye pain, watery eyes, photophobia, little or no loss of vision. On the conjunctiva or at the edge of the cornea appears pale yellow inflammatory nodules, with many blood vessels crawling in, conjunctiva around the erection.

Spring conjunctivitis

The disease develops mainly in teenage men. The disease progresses cyclically: paroxysmal in spring-summer, remission in winter (in some cases, the disease develops all year). The disease has a clear allergy mechanism, and what specific antigens are, is still being debated. Most authors believe that the disease is closely related to spring-summer, sunshine, hormonal changes and genetic factors.

Symptoms: the patient feels like an object in the eye, photophobia, watery eyes, decreased vision, especially itchy eyelids and eyes. Using the eyes sparingly, this is characterized by sticky, chewy and stretchable fibres. According to the physical injury, three forms can be classified: morphology, eyeball morphology and mixed morphology. The eyelid morphology is characterized by slight drooping, polygonal-shaped papillae that are typical of cartilage and pinkish-white in colour. The eyeball morphology is characterized by corneal fringe convergence, thickened marginal conjunctiva, pink-grey or greyish-yellow colour; In severe cases, on the base of thick marginal conjunctiva, white spots appear (Transat seeds). The mixed form is a combination of the two above

Symptomatic treatment is essential. When the disease is exacerbated, it is recommended to use antihistamines, mastocyte stabilizers, topical corticoid and systemic drink. If there are papillary lesions on the conjunctiva: can apply b- rays with a total dose of 4-5 minutes.

Principles of disease prevention

Many eye infections are preventable. Prevention is the duty of both physicians and patients, such as ensuring good hygiene and nutrition, using protective equipment to limit eye injuries, and using antiseptics. Specifically:

For health care workers: wash hands after each patient visit; avoid unnecessary contact with eye drops and other devices; disinfect all tools used after each visit, ...

For patients: personal hygiene, environmental sanitation, use of clean water, use protective equipment when necessary, ...