|Conjunctivitis with Pseudomembrane
Signs and Symptoms
Pseudomembranes consist of coagulated exudate that is loosely adherent to the inflamed conjunctiva. They are typically not integrated with the conjunctival epithelium and can be removed by peeling, leaving the conjunctival epithelium intact. Their removal produces little if any bleeding. Epidemic keratoconjunctivitis (EKC), ligneous conjunctivitis (a rare idiopathic bilateral membranous/pseudomembranous conjunctivitis seen in children with thick, ropy, white discharge on the upper tarsal conjunctiva), allergic conjunctivitis, and bacterial infections are the primary causes.
Epidemic keratoconjunctivitis (EKC) often presents as a bilateral, inferior palpebral, follicular conjunctivitis, with epithelial and subepithelial keratitis and normal corneal sensation. It is extremely contagious. The subepithelial infiltrates (SEI) are typically concentrated in the central cornea. Mild EKC is regularly caused by adenovirus virus serotypes 1, 2, 3, 4. The more severe form of the disease is caused by virus serotypes 5, 8, 19 and 37.
Pharyngoconjunctival fever (PCF) is characterized by history of fever, sore throat, upper respiratory infection, and follicular conjunctivitis. It may be unilateral or bilateral. It is caused regularly by adenovirus 3 and 7. The cornea is rarely affected and infiltrates are uncommon. While the virus is shed from the conjunctiva in 14 days, it remains in fecal excretion for 30 days. This may explain why some epidemics center around swimming pools in summer. The disorder varies in severity and may persist for four days to two weeks.
If pseudo- or true membranes are present, debride them using a wet cotton-tipped applicator or forceps. Include supportive therapies such as cold compress and topical tear solutions, topical vasoconstrictors (Naphcon A), topical NSAID preparations (Acular, Voltaren), and topical steroids (Flarex, Pred Forte, Vexol) b.i.d. to q.i.d. Topical antibiotic/steroid combination therapy (Tobradex, Maxitrol) QID is indicated if the infection has a suspected bacterial source. Cycloplegia is only necessary in the most severe cases. When you suspect bacterial etiology, conjunctival scrapings may provide differential diagnostic information.
A new drug is on the horizon for treating entities causing pseudomembraneous conjunctivitis. Cidofovir, a topically applied DNA analog, has been proven clinically efficacious in the treatment of adenoviral conjunctivitis and epidemic keratoconjunctivitis and is currently awaiting approval for commercial use.
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