Conjunctivitis pathophysiology: Difference between revisions
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* [[Anxiety disorder]] | * [[Anxiety disorder]] | ||
* [[Depression]] | * [[Depression]] | ||
Keratoconjunctivitis sicca associated [[Sjögren's syndrome]] may caused by focal | Keratoconjunctivitis sicca associated [[Sjögren's syndrome]] may caused by focal infiltration of the [[lacrimal gland]] and [[conjunctiva]] with [[CD4+ T cells]] and [[B cells]]. Focal infiltration can induce [[apoptosis]], and this results in dysfunction of the [[lacrimal gland]] with reduced [[tear]] production. | ||
Additionally, keratoconjunctivitis sicca associated [[Sjögren's syndrome]] can lead to chronic [[inflammatory state]] with production of [[autoantibodies]] such as:<ref name="pmid9820935">{{cite journal| author=Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC| title=The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. | journal=Cornea | year= 1998 | volume= 17 | issue= 6 | pages= 584-9 | pmid=9820935 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9820935 }} </ref> | Additionally, keratoconjunctivitis sicca associated [[Sjögren's syndrome]] can lead to chronic [[inflammatory state]] with production of [[autoantibodies]] such as:<ref name="pmid9820935">{{cite journal| author=Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC| title=The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. | journal=Cornea | year= 1998 | volume= 17 | issue= 6 | pages= 584-9 | pmid=9820935 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9820935 }} </ref> | ||
*[[Antinuclear antibody]] (ANA) | *[[Antinuclear antibody]] (ANA) | ||
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*[[Sjögren's syndrome]]-specific antibodies (anti-RO and anti-LA) | *[[Sjögren's syndrome]]-specific antibodies (anti-RO and anti-LA) | ||
====Superior Limbic Keratoconjunctivitis==== | ====Superior Limbic Keratoconjunctivitis==== | ||
[[Superior limbic keratoconjunctivitis|Superior limbic keratoconjunctivitis (SLK)]] is disease characterized by [[inflammation]] of the upper palpebral and superior [[bulbar conjunctiva]]. On microscopic [[histopathological]] analysis, it is charactrized by [[keratinization]] of the | [[Superior limbic keratoconjunctivitis|Superior limbic keratoconjunctivitis (SLK)]] is disease characterized by [[inflammation]] of the upper palpebral and superior [[bulbar conjunctiva]]. On microscopic [[histopathological]] analysis, it is charactrized by [[keratinization]] of the superior limbus, corneal filaments, and conjunctival filaments. | ||
The exact | The exact pathogenesis of superior limbic keratoconjunctivitis is not fully understood, a mechanical [[hypothesis]] seems most attractive. It is thought that mechanical trauma from tight upper lids or loose redundant conjunctiva could lead to the disruption of normal [[epithelium]]. Also association between [[thyroid]] abnormalities ([[Graves ophthalmopathy]]) and superior limbic keratoconjunctivitis has been reported.<ref name="pmid2695351">{{cite journal| author=Nelson JD| title=Superior limbic keratoconjunctivitis (SLK). | journal=Eye (Lond) | year= 1989 | volume= 3 ( Pt 2) | issue= | pages= 180-9 | pmid=2695351 | doi=10.1038/eye.1989.26 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2695351 }} </ref><ref name="pmid25792798">{{cite journal| author=Chelala E, El Rami H, Dirani A, Fakhoury H, Fadlallah A| title=Extensive superior limbic keratoconjunctivitis in Graves' disease: case report and mini-review of the literature. | journal=Clin Ophthalmol | year= 2015 | volume= 9 | issue= | pages= 467-8 | pmid=25792798 | doi=10.2147/OPTH.S79561 | pmc=4362972 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25792798 }} </ref><ref name=Superior_limbic_keratoconjunctivitis > American Academy of Ophthalmology (2015) http://eyewiki.aao.org/Superior_limbic_keratoconjunctivitis Accessed on June 27, 2016 </ref> | ||
===Gross Pathology=== | ===Gross Pathology=== | ||
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{{CMG}; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [5]
Overview
Conjunctivitis is defined as inflammation of bulbar and/or palpebral conjunctiva. Conjunctivitis has many etiologies, but the majority of cases can be caused by allergies, viruses, or bacteria. Viral conjunctivitis, typically caused by adenovirus, is a common, self-limiting condition. Bacterial conjunctivitis has many etiologies, such as Staphylococcus, Streptococcus, Corynebacterium, Haemophilus, Pseudomonas, and Moraxella. Allergic conjunctivitis may occur seasonally when pollen counts are high, and this type of conjunctivitis is a common occurrence in people who have other signs of allergic disease. Keratoconjunctivitis sicca (dry eye syndrome) is a multifactorial disease and associated with different medical conditions.[1][2]
Pathophysiology
Pathogenesis
Infective Conjunctivitis
Infective conjunctivitis is an infection of the conjunctiva either caused by viruses or bacteria . Both the palpebral and the bulbar ocular conjunctival surfaces are usually affected, and typically become red and inflamed. Infective conjunctivitis is spread by:[1][2]
- Direct contact with the infected person’s eye drainage or drainage from the person’s cough, sneeze, or runny nose
- Contact with the infected person’s fingers, hands or objects (eye makeup applicators, towels, shared eye medications)
- Adjacent infectious sites (rubbing of the eyes)
Any change in the host defense, or in the species of normal flora of the eye, such as Staphylococcus, Streptococcus, and Corynebacterium, can lead to clinical infection and conjunctivitis. Change in the normal flora can occurred by:[3]
- External contamination
- Contact lens wear
- Swimming
Viral conjunctivitis, typically caused by adenovirus, is a common, self-limiting condition. Viral conjunctivitis is highly contagious, and patients should avoid direct or indirect contact with other healthy individuals. Acute hemorrhagic conjunctivitis may be caused by picornaviruses that are clinically similar to adenovirus conjunctivitis, but are more severe and hemorrhagic. Acute hemorrhagic conjunctivitis also occurs in epidemics, and is characterized by sudden onset of painful, swollen red eyes, conjunctival hemorrhage, and excessive tearing.[4][5]
Neonatal Conjunctivitis
Neonatal conjunctivitis is occurring in a newborn during the first month of life, and often known as ophthalmia neonatorum. Neonatal conjunctivitis is mainly caused by sexually transmitted diseases agents such as Chlamydia trachomatis, Neisseria gonorrhoeae, and Herpes simplex virus (HSV). Chlamydia trachomatis is the most common cause of ophthalmia neonatorum in the developed countries because of higher prevalence of chlamydia as a sexually transmitted disease. The recognized routes of transmission of the organisms to the newborns include:[6]
- Infected birth canal during vaginal birth
- Transmembrane transmission of the infection
- Transplacental transmission of the infectio
On gross pathology, It is characterized by eyelids edema, erythema of the palpebral conjunctiva, and purulent eye discharge. On a gram stained of conjunctival smear, one or more polymorph nuclear per oil immersion field may be detected. Additionally, neonatal conjunctivitis may caused by irritation. it is generally secondary to the instillation of silver nitrate drops for ocular prophylaxis.[7]
Allergic Conjunctivitis
Airborne antigens may be involved in the pathogenesis of allergic conjunctivitis. Common airborne antigens include pollen, grass, and weeds.[8][9]
Allergic conjunctivitis is often associated with atopic diseases, such as allergic rhinitis (most common), eczema, and asthma. Development of allergic conjunctivitis is the result of type 1 hypersensitivity (immediate hypersensitivity) reactions involving the conjunctiva. Type I hypersensitivity is an allergic reaction provoked by reexposure to a specific type of antigen or allergens. IgE and mast cells play an important role in these allergic inflammations. IgE mediated release of histamine and other mediators from mast cells and basophils
Combination of type 1 and type 4 hypersensitivity reactions may be responsible for giant papillary conjunctivitis. Also, prolonged mechanical irritation to the superior tarsal conjunctiva of the upper lid from foreign bodies may also be a contributing factor in giant papillary conjunctivitis.[10][11]
Keratoconjunctivitis Sicca
Keratoconjunctivitis sicca (dry eye syndrome) is a multifactorial disease and associated with different medical conditions such as:[12][13]
- Sjögren's syndrome
- Ocular surface disease
- Ocular allergy
- Dysfunction of the lacrimal gland with reduced tear production and mucin deficiency
- Anxiety disorder
- Depression
Keratoconjunctivitis sicca associated Sjögren's syndrome may caused by focal infiltration of the lacrimal gland and conjunctiva with CD4+ T cells and B cells. Focal infiltration can induce apoptosis, and this results in dysfunction of the lacrimal gland with reduced tear production. Additionally, keratoconjunctivitis sicca associated Sjögren's syndrome can lead to chronic inflammatory state with production of autoantibodies such as:[14]
- Antinuclear antibody (ANA)
- Rheumatoid factor (RF)
- Fodrin (a cytoskeletal protein)
- Muscarinic M3 receptor
- Sjögren's syndrome-specific antibodies (anti-RO and anti-LA)
Superior Limbic Keratoconjunctivitis
Superior limbic keratoconjunctivitis (SLK) is disease characterized by inflammation of the upper palpebral and superior bulbar conjunctiva. On microscopic histopathological analysis, it is charactrized by keratinization of the superior limbus, corneal filaments, and conjunctival filaments. The exact pathogenesis of superior limbic keratoconjunctivitis is not fully understood, a mechanical hypothesis seems most attractive. It is thought that mechanical trauma from tight upper lids or loose redundant conjunctiva could lead to the disruption of normal epithelium. Also association between thyroid abnormalities (Graves ophthalmopathy) and superior limbic keratoconjunctivitis has been reported.[15][16][17]
Gross Pathology
On gross pathology, the following are characteristic findings of conjunctivitis:[18]
- Conjunctival injection
- Mucopurulent or non-purulent discharge
- Pseudomembrane formation
- Chemosis
- Eyelid swelling
- Conjunctival hemorrhage (specific for Acute hemorrhagic conjunctivitis)
Microscopic histopathological analysis
On microscopic histopathological analysis, the following are characteristic findings of conjunctivitis:[19]
- Mild spongiotic reaction pattern (low power view of the histology)
- Stromal infiltration by polymorphonuclear, leukocytes, plasma cells, mastocytes, and lymphocyte
- Eosinophils (allergic conjunctivitis)
- Numerous neutrophils (bacterial conjunctivitis)
- Hyperplastic with increase numbers of plasma cell (chronic conjunctivitis)
- epithelial cells Keratinization of the superior limbus (Superior limbic keratoconjunctivitis (SLK))
- Dyskeratosis (Superior limbic keratoconjunctivitis (SLK))
Images
The following are gross and microscopic images associated with conjunctivitis.
-
![Viral conjunctivitis[20]](/images/e/ee/An_eye_with_viral_conjunctivitis.jpg)
Viral conjunctivitis[20]
-
![Acute hemorrhagic conjunctivitis[21]](/images/7/7a/220px-Acute_hemorrhagic_conjunctivitis.jpg)
Acute hemorrhagic conjunctivitis[21]
-
Neonatal conjunctivitis<ref> Centers for Disease Control and Prevention's Public Health Image
-
![Chlamydial conjunctivitis (Day 5-14)[22]](/images/3/39/Chlamydial_conjunctivitis.jpg)
Chlamydial conjunctivitis (Day 5-14)[22]
![Viral conjunctivitis[20]](/index.php/File:An_eye_with_viral_conjunctivitis.jpg)
![Acute hemorrhagic conjunctivitis[21]](/index.php/File:220px-Acute_hemorrhagic_conjunctivitis.jpg){kind=small}
![Chlamydial conjunctivitis (Day 5-14)[22]](/index.php/File:Chlamydial_conjunctivitis.jpg)
References
- ↑ 1.0 1.1 Azari AA, Barney NP (2013). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMC 4049531. PMID 24150468.
- ↑ 2.0 2.1 Kyei S, Koffuor GA, Ramkissoon P, Abokyi S, Owusu-Afriyie O, Wiredu EA (2015). "Possible Mechanism of Action of the Antiallergic Effect of an Aqueous Extract of Heliotropium indicum L. in Ovalbumin-Induced Allergic Conjunctivitis". J Allergy (Cairo). 2015: 245370. doi:10.1155/2015/245370. PMC 4657065. PMID 26681960.
- ↑ Everitt H, Kumar S, Little P (2003). "A qualitative study of patients' perceptions of acute infective conjunctivitis". Br J Gen Pract. 53 (486): 36–41. PMC 1314490. PMID 12564275.
- ↑ Yin-Murphy M (1976). "Simple tests for the diagnosis of picornavirus epidemic conjunctivitis (acute hemorrhagic conjunctivitis)". Bull World Health Organ. 54 (6): 675–9. PMC 2366581. PMID 1088513.
- ↑ Centers for Disease Control and Prevention (2004) https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5328a2.htm Accessed on June 24, 2016
- ↑ Treadwell P (1994). "Sexually transmitted diseases in neonates and infants". Semin Dermatol. 13 (4): 256–61. PMID 7848819.
- ↑ Mallika P, Asok T, Faisal H, Aziz S, Tan A, Intan G (2008). "Neonatal conjunctivitis - a review". Malays Fam Physician. 3 (2): 77–81. PMC 4170304. PMID 25606121.
- ↑ Malling HJ, Montagut A, Melac M, Patriarca G, Panzner P, Seberova E; et al. (2009). "Efficacy and safety of 5-grass pollen sublingual immunotherapy tablets in patients with different clinical profiles of allergic rhinoconjunctivitis". Clin Exp Allergy. 39 (3): 387–93. doi:10.1111/j.1365-2222.2008.03152.x. PMC 4233960. PMID 19134019.
- ↑ Kämpe M, Stålenheim G, Janson C, Stolt I, Carlson M (2007). "Systemic and local eosinophil inflammation during the birch pollen season in allergic patients with predominant rhinitis or asthma". Clin Mol Allergy. 5: 4. doi:10.1186/1476-7961-5-4. PMC 2174506. PMID 17967188.
- ↑ Donshik PC (1994). "Giant papillary conjunctivitis". Trans Am Ophthalmol Soc. 92: 687–744. PMC 1298525. PMID 7886881.
- ↑ Donshik PC, Porazinski AD (1999). "Giant papillary conjunctivitis in frequent-replacement contact lens wearers: a retrospective study". Trans Am Ophthalmol Soc. 97: 205–16, discussion 216-20. PMC 1298261. PMID 10703125.
- ↑ Sivaraman KR, Jivrajka RV, Soin K, Bouchard CS, Movahedan A, Shorter E; et al. (2016). "Superior Limbic Keratoconjunctivitis-like Inflammation in Patients with Chronic Graft-Versus-Host Disease". Ocul Surf. doi:10.1016/j.jtos.2016.04.003. PMID 27179980.
- ↑ Messmer EM (2015). "The pathophysiology, diagnosis, and treatment of dry eye disease". Dtsch Arztebl Int. 112 (5): 71–81, quiz 82. doi:10.3238/arztebl.2015.0071. PMC 4335585. PMID 25686388.
- ↑ Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC (1998). "The pathology of dry eye: the interaction between the ocular surface and lacrimal glands". Cornea. 17 (6): 584–9. PMID 9820935.
- ↑ Nelson JD (1989). "Superior limbic keratoconjunctivitis (SLK)". Eye (Lond). 3 ( Pt 2): 180–9. doi:10.1038/eye.1989.26. PMID 2695351.
- ↑ Chelala E, El Rami H, Dirani A, Fakhoury H, Fadlallah A (2015). "Extensive superior limbic keratoconjunctivitis in Graves' disease: case report and mini-review of the literature". Clin Ophthalmol. 9: 467–8. doi:10.2147/OPTH.S79561. PMC 4362972. PMID 25792798.
- ↑ American Academy of Ophthalmology (2015) http://eyewiki.aao.org/Superior_limbic_keratoconjunctivitis Accessed on June 27, 2016
- ↑ National Eye Institute (2015) [1] Accessed on June 24, 2016
- ↑ DermNet NZ (2015)[2] Accessed on June 26, 2016
- ↑ Image Courtesy of Joyhil09 [3]
- ↑ Image Courtesy of James Heilman [4]
- ↑ http://picasaweb.google.com/mcmumbi/USMLEIIImages
![[3]](https://commons.wikimedia.org/wiki/File:An_eye_with_viral_conjunctivitis.jpg){kind=link}
![[4]](https://en.wikipedia.org/wiki/Acute_hemorrhagic_conjunctivitis#/media/File:Acute_hemorrhagic_conjunctivitis.jpg){kind=link}