Purulent conjunctivitis

Inflammation of the mucous membrane of the eyes with the formation and release of purulent exudate is diagnosed by ophthalmologists as purulent conjunctivitis.

Epidemiology

Domestic statistics on the frequency of purulent conjunctivitis are not available (or are not kept). But according to foreign data, the prevalence of acute bacterial conjunctivitis, for example, in the United States is 13 cases per thousand population and accounts for 18-57% of all acute conjunctivitis, and almost half of them are associated with C. Trachomatis.

Neonatal conjunctivitis occurs in 0.8-1.6% of newborns in developed countries, and in the rest - in 10-12% of newborns. Thus, according to WHO, in some regions of Africa, the presence of purulent gonococcal conjunctivitis is observed in 30-40 newborns for every thousand live births (in North America - no more than three per 10 thousand).

Causes of the purulent conjunctivitis

The key causes of purulent inflammation conjunctiva are bacterial or viral infection. [1]

And depending on the etiology of the inflammatory process different types of this disease: purulent bacterial conjunctivitis [2] and causing purulent or mucopurulent discharge viral conjunctivitis. [3] In essence, this is catarrhal-purulent conjunctivitis, because catarrhal is inflammation affecting the mucosal epithelium.

By the nature of the course of inflammation distinguish acute purulent conjunctivitis and chronic.

In most cases, acute bacterial conjunctivitis is caused by staphylococci (Staphylococcus aureus, Staphylococcus epidermidis), streptococci (Streptococcus pneumonia, Streptococcus viridans), as well as by Pseudomonas aeruginosa, Moraxella lacunata, or Enterobacterales (Proteus mirabilis). All these microorganisms can enter the eye from the hands, dust particles or from colonies on neighboring mucous membranes (nose, sinuses or nasopharynx).

Both acute and chronic purulent conjunctivitis are often associated with staphylococcal blepharitis of the eyelids. [4] Damage to mucous membranes by Neisseria diplococcus Neisseria gonorrhoeae, which is sexually transmitted, is responsible for the development of gonococcal conjunctivitis - gonoblennorrhea. [5]

Chlamydia trachomatis chlamydial conjunctivitis is also a chronic form of bacterial inflammation of the conjunctiva. [6]

The development of chronic conjunctivitis may be caused by inflammation of the holocrine meibomian glands located at the eyelid margin - meibomitis. Unilateral chronic or recurrent bacterial conjunctivitis accompanied by mucopurulent discharge is observed in patients with nasolacrimal duct obstruction (dacryostenosis) and its chronic inflammation - dacryocystitis. [7]

As for the viral origin of conjunctivitis, ophthalmologists note the special contagiousness of their causative agents. First of all, these are most strains of adenoviruses - respiratory viruses, which affect the mucous membrane of the eyes, causing acute epidemic adenovirus conjunctivitis. [8] And the cause of epidemic hemorrhagic conjunctivitis is enterovirus infection - viruses of the genus Enterovirus.

No purulent conjunctivitis has been reported with SARS-CoV-2 coronavirus, but cases of follicular conjunctivitis have been observed in patients with Covid-19. [9] Eye redness and increased lacrimation in acute respiratory infections have been reported in the majority of patients infected with other strains of respiratory coronaviruses (Coronaviridae). [10]

Purulent conjunctivitis in children

According to experts, purulent conjunctivitis in children occurs more often than in adults. In addition to strepto and staphylococci, as well as adenoviruses, diphtheria bacillus (Corynebacterium diphtheriae) may be the causative agent of purulent inflammation of the conjunctiva in young children, for more information - Diphtheria conjunctivitis.

There may be mucopurulent conjunctivitis in varicella (chickenpox), which is caused by the HZV (Herpes zoster) virus. [11]

Read more in the publications:

• Conjunctivitis in varicella, measles, rubella
• Bacterial conjunctivitis and keratitis in children

Neonatal ophthalmia or neonatal conjunctivitis - purulent conjunctivitis in newborns - is a severe form of bacterial inflammation of the ocular mucosa occurring during the first four weeks of life due to infection with C. Trachomatis or N. Gonorrhea during labor: by contact with the birth canal of a mother with a sexually transmitted disease. Gonorrhea during childbirth: by contact with the birth canal of a mother with a sexually transmitted disease.

More details in the materials:

• Chlamydia conjunctivitis in a child
• Conjunctivitis in newborns

Risk factors

Factors that increase the risk of developing purulent inflammation of the conjunctiva include:

• Poor hygiene (touching the eye with dirty hands, using someone else's towel or eye makeup, poor contact lens hygiene);
• coughing or sneezing of a nearby person with an acute respiratory infection;
• the presence of an intrinsic upper respiratory tract infection, inflammation of the sinuses or nasopharynx;
• eye diseases (dry eyes, inflammation of the eyelid margin - blepharitis);
• weakened immune system.

Pathogenesis

In the development of infectious, in particular, bacterial inflammatory processes, pathogenesis is due to the activation of the complement system and mediated by inflammatory cytokines of phagocytes (macrophages and neutrophils) and T and B-lymphocytes enhanced response of cellular immunity to bacterial invasion.

First, by the action of their enzymes-cytolysins they break the integrity of cell membranes, then by adhesion they bind to the cell structures of various tissues of the body, and then invasion occurs. That is, the microbe destroys tissue cells, in this case, the conjunctiva, to maintain its existence with its exotoxins and enzymes (hyaluronidase, streptokinase, nucleases).

In addition, an enhanced inflammatory response aimed at lysis of bacteria leads to even greater tissue alteration, since the entire local pool of phagocyte cells is attracted to the site of bacterial invasion. The pus released is a mixture of dead mucosal tissue cells (detritus), dead leukocytic immune cells (macrophages, etc.) and the remains of bacteria destroyed by them. And hyperemia of the conjunctiva is the result of dilation of its vessels.

In the mechanism of development of viral infection, the main is considered the ability of virions of viruses to penetrate into cells and there begin replication of their RNA, which causes a protective, that is, inflammatory response. [12]

Symptoms of the purulent conjunctivitis

In bacterial infections, the first signs of purulent conjunctivitis are usually manifested by hyperemia (redness) of the eyes and epiphora - increased production of lacrimal fluid and its flow (lacrimation). As the inflammatory process develops, swelling of the eyelids and surrounding soft tissues increases, and there is a burning sensation in the eyes. At first, the discharge from the eyes is insignificant, mucous-purulent (in the case of gonococcal conjunctivitis - serous-bloody).

At the next stage, redness may be more intense (even the whites of the eyes appear pink or reddish); eyelids are even more swollen, their erythema is removed (in gonoblennorrhea, edema spreads to the mucous membrane of the sclera, and the skin of the eyelids acquire a bluish tint); there is a tearing in the eyes, and the discharge becomes more dense - yellowish-white or greenish-yellow, there is an accumulation of discharge in the corners of the eyes. During sleep, pus continues to flow out, drying on the eyelashes in the form of sticky crusts and by morning glues the lower and upper eyelid.

Viral infections can also cause moderate redness of the conjunctiva, swollen capillaries on the sclerae, pain in the eyes (as if sand got in), often intolerance to bright light (photophobia).

In epidemic hemorrhagic conjunctivitis on the conjunctiva appear small spots (white or pale yellow) - a sign of obturation of the lacrimal gland ducts, and in diphtheria on the conjunctiva formed gray films. [13]

Complications and consequences

In conjunctivitis caused by the HZV virus, the cornea or vasculature of the eye may become inflamed, resulting in impaired vision.

Complications and consequences of purulent conjunctivitis caused by gonococci (including in newborns) - the development of superficial inflammation of the cornea (keratitis), and subsequently its ulceration with possible perforation, resulting in corneal opacity.

Consequences of diphtheria suppurative conjunctivitis include corneal opacity, corneal ulceration with necrosis of the affected areas, and entropion (eyelid flap to the eyeball). In severe cases, there is a great threat of perforation of the cornea of the eyeball and its atrophy.

Diagnostics of the purulent conjunctivitis

Diagnosis of purulent conjunctivitis is most often clinical - based on physical examination and presenting symptoms.

An examination of the eye, and examination of the conjunctiva is performed.

The main tests for an accurate diagnosis are an eye swab and a bacterial examination of the discharge (to determine the pathogenic flora).

Instrumental diagnosis may be limited to biomicroscopy.

Differential diagnosis

Differential diagnosis should exclude keratitis, scleritis, episcleritis, blepharitis, corneal ulcer, chalazion, corneal foreign body. Chlamydial conjunctivitis and congenital nasolacrimal duct obstruction should be differentiated in newborns.

Allergic and purulent conjunctivitis are most easily differentiated, as allergic conjunctivitis is characterized by severely itchy eyes and watery discharge.

Treatment of the purulent conjunctivitis

In case of inflammation of the mucous membrane of the eyes with purulent discharge, patients have the first question: how to wash purulent conjunctivitis? The second question is: what drops should be used?

In this disease, ophthalmologists recommend using pharmacy saline solution (it can be prepared by dissolving a teaspoon of salt in 500 ml of cooled boiled water), as well as aqueous solution of furacilin for eye washings and removal of pus crusts. Read: Furacilin for eye wash: how to dissolve and dilute tablets

You can use antiseptic drops Ophthamyrin or Ocomistin.

But destroy the microbial infection, accelerating the disappearance of symptoms, only antibiotics for purulent conjunctivitis. Gentamicin and Erythromycin (in the form of ointments), Tebrofen ointment (with ofloxacin) are most often prescribed. For more information see:

• Ointments for conjunctivitis
• Eye ointments for inflammation

Eye drops for purulent conjunctivitis, for the most part, also contain antibiotics: Levomycetin, Okatsin (Lomecin, Lofox), Floxal (with ofloxacin), Vigamox (with moxifloxacin), Ciprofloxacin (Cipromed, C-flox). Of the sulfonamides, Sulfacil sodium drops (Albucid) are used. More complete and detailed information (with dosage, contraindications and possible side effects) in the materials:

• Eye drops for conjunctivitis
• Eye drops for newborns

Systemic therapy is carried out with antibacterial drugs such as, Azithromycin, Doxycycline, Ciprofloxacin, Cefazolin, Ceftriaxone, etc.

It should be borne in mind that in viral catarrhal-purulent conjunctivitis antibiotics do not help, but the symptoms can be alleviated with saline lavage, the use of drops Ophthalmoferon and Okoferon (with interferon). And if conjunctival inflammation is caused by herpesvirus (HSV), Virgan gel (based on ganciclovir) and Idoxuridine or Trifluridine eye drops should be used.

As an additional therapeutic method - in uncomplicated cases - herbal treatment is possible by rinsing the eyes with decoctions of pharmacy chamomile, eyebright, plantain, calendula, trifoliate succession. (consumption of dry raw materials per 200 ml of water - one tablespoon; the decoction is cooled and filtered).

In cases of nasolacrimal duct obstruction, surgical treatment is necessary to restore the normal outflow of lacrimal fluid by dacryocystorhinostomy.

Prevention

The primary prevention of any conjunctivitis is hand washing and observing the rules of hygiene. And in newborns, only treatment of chlamydia and gonorrhea in their future mothers can prevent purulent conjunctivitis.

Forecast

Since this disease is relatively easy to treat, the prognosis for the majority of patients with purulent conjunctivitis is favorable. However, given the real threat of complications of gonococcal and diphtheria inflammation of the conjunctiva, the negative consequences for the eyes and vision can be very serious.