Keratoconjunctivitis is a combined inflammation of the cornea and conjunctiva of the eye. The disease occurs under the influence of infectious, allergic, traumatic or exogenous physical factors. The main symptoms of pathology include redness of the eye, photophobia, lacrimation, soreness and foreign body sensation. Diagnostics involves biomicroscopy, pachymetry, laboratory methods (bacteriological, virological, allergological examination). Treatment of the disease is based on the use of local remedies (drops, ointments, instillations), systemic drugs (antihistamines, anti-inflammatory, antimicrobial).
ICD 10
16.2 Keratoconjunctivitis
General information
Keratoconjunctivitis is a common eye pathology, which accounts for about 5% of all ophthalmic diseases. The greatest frequency of detection of the problem is observed in middle-aged and elderly patients, which is due to increased visual loads, the effect of occupational hazards, and the use of contact lenses. The disease is of great importance in practical ophthalmology, because it has a diverse etiology, requires a comprehensive examination and the appointment of differentiated therapy.
Causes
Many etiological factors play a role in the development of the disease: infectious pathogens, allergens, negative physical effects. The disease can begin as an isolated keratitis or conjunctivitis with the subsequent spread of the inflammatory process. The main causes of pathology include the following:
- Exposure to allergens. Spring keratoconjunctivitis is associated with sensitization of the body to plant allergens (pollen, fluff). The lesion can also be a component of a systemic allergic reaction of the body — it is noted in 20-40% of patients with atopic dermatitis.
- Infections. Of the bacterial agents, the development of the disease is most often provoked by Pseudomonas aeruginosa, gonococci. Specific epidemic keratoconjunctivitis is caused by adenoviruses of serotypes 8 and 19, severe damage to the conjunctiva and cornea is possible when infected with the herpes simplex virus. Rare variants include the acanthamoebic form of pathology.
- Eye injuries. Any mechanical damage to the eye shell, even microtrauma, can become a trigger factor in the formation of inflammation. The disease can be caused by chemical injuries, is a complication of intraoperative corneal damage.
- Radiation. The outer shell of the eyeball is affected by intense and prolonged exposure to light rays. Representatives of certain professions are most often ill: electric and gas welders, climbers, lighting workers in the theater.
- Reduced tear production. Corneal lesion with conjunctiva occurs with insufficient moistening with tear fluid. The condition develops with Sjogren’s syndrome, autoimmune diseases — systemic lupus erythematosus, rheumatoid arthritis.
Risk factors
Risk factors for the appearance of keratoconjunctivitis include work that requires constant strain of vision, especially at the computer, when the conjunctiva dries up due to rare blinking. A higher incidence rate is observed among people who live in windy areas, constantly stay in rooms with dry air. The risk of infectious damage to the organ of vision increases in patients who use lenses for vision correction. Women have a risk of developing pathology when using low-quality or expired cosmetics.
Pathogenesis
Hypersensitivity of the first type plays the main role in the mechanism of development of allergic forms of the disease. Immune inflammation of the ocular membranes is provoked by peptides eotaxin 1 and 2, accompanied by an increase in the level of interleukin-4. With the pathogenic influence of infectious agents, an acute inflammatory reaction occurs in the form of edema, dilation of conjunctival vessels, leukocyte or lymphocytic inflammatory cascade.
Pathomorphologically, with keratoconjunctivitis, there is swelling of the conjunctival tissue, roughness of its surface due to papillary hyperplasia, typically the appearance of lymphoid follicles — small grayish-yellow nodules. The presence of keratitis is indicated by infiltration of tissue by leukocytes, plasma cells, histiocytes. At the stage of recovery, neovascularization occurs — the germination of new vessels from the conjunctiva, the marginal loopy network.
Symptoms
Keratoconjunctivitis begins suddenly, affects both eyes, and often the process develops alternately. This is especially true for bacterial or viral forms of the disease, in which the infection is carried from the diseased eye to the healthy one with accidental touches. The disease that occurs with chronic blepharitis or dry eye syndrome may have a gradual onset.
Patients complain of pains and pains in the eye, a feeling of an alien body, photophobia. It is characterized by copious lacrimation, rapid fatigue of the visual apparatus, deterioration of visual acuity and fog in the eyes. With an allergic variant of pathology, severe itching often bothers. Taking into account the cause of the disease, an increase in body temperature, severe swelling of the eyelids, headaches, an increase in lymph nodes on the affected side is possible.
According to the etiology of the disease, pathognomonic symptoms occur. For adenovirus infection, small hemorrhages in the conjunctiva and superficial follicles are typical. The bacterial lesion is manifested by a yellowish-white infiltrate on the ocular surface. Spring keratoconjunctivitis is characterized by the formation of papillae of the “cobblestone pavement” type.
Upon examination, redness and swelling of the conjunctiva are determined, small vessels become clearly visible on all the surface of the eyeball and the inside of the eyelids. If a mucous or purulent discharge accumulates in the conjunctival cavity, this indicates the microbial nature of the disease. In patients with allergic keratoconjunctivitis, thin strips of mucus are visible. Films and opacities form on the surface of the cornea.
Complications
The disease is characterized by a severe course, in adverse cases, visual acuity is irreversibly reduced. In the absence of treatment, the inflammation turns into an ulcerative form: first, a small superficial turbidity appears on the cornea, which eventually builds up, transforms into a “hidden” ulcer. This condition is fraught with accumulation of purulent contents in the anterior chamber of the eye (hypopion), neovascularization of the cornea.
Inflammation of the outer membranes often spreads to deeper tissues with the development of scleritis, uveitis, chorioretinitis. In severe cases, purulent melting of the eyeball is possible — panophthalmitis, which requires enucleation of the organ. With keratoconjunctivitis, there is a risk of secondary cataracts, secondary glaucoma, corneal perforation.
With primary infectious keratoconjunctivitis or a secondary infection, there is a possibility of septic complications. The bacterial process spreads by contact, causing the phlegmon of the eye socket, can penetrate into the vascular bed and lead to thrombosis of the cavernous sinus, meningoencephalitis, abscess of the cerebellum or cerebral hemispheres.
Any cytopathogenetic agent that provokes inflammation of the outer ocular surface can cause “dry eye” syndrome. As a consequence, the stability of the tear film is disrupted due to the defeat of goblet cells, an increase in the rate of evaporation of moisture, a decrease in the production of tear fluid, mucins and lipids. The complication occurs on average in 2/3 of patients after the pathology.
Diagnostics
The examination is carried out by an ophthalmologist. During the initial diagnosis, the specialist needs to collect the patient’s complaints, find out in detail the anamnesis, including the epidemiological contacts of the patient. Then an external examination of the eyeball is performed to identify typical symptoms. To make a diagnosis, the following research methods are necessary:
- Biomicroscopy of the eye. A detailed examination of the tissues of the anterior part of the eyeball helps the doctor to detect inflammatory signs, confirm or exclude complications of keratoconjunctivitis. The study is carried out using a light lamp, has no contraindications, and is considered a basic diagnostic method.
- Diagnostic tests. To quickly detect corneal epithelial defects, a fluorescein test is shown: after instillation with a fluorescein solution, the affected areas are visible when examined in a blue slit lamp filter. The sensitivity of the cornea is also evaluated.
- Pachymetry. With the help of an ultrasound sensor, the thickness of the cornea is measured in different departments, which is necessary for the diagnosis of dystrophic processes, glaucoma. As a rule, corneal edema is determined in the central zone with an increase in the thickness of the shell of more than 500-600 nm. To study the curvature of the corneal surface, computer keratometry is indicative.
- Visometry. With the central localization of the infiltrate in the cornea, there is a decrease in visual acuity or temporary blindness to the affected eye, and in the case of peripheral location of inflammatory changes, visometry indicators remain within the normal range.
- Microbiological studies. If an infectious etiology of the disease is suspected, a cytological analysis of a smear-an imprint of the cornea or conjunctiva is performed. To clarify the diagnosis, bacteriological sowing of biomaterial, serological tests for specific blood antibodies are performed.
- Allergy tests. After the relief of acute manifestations of an allergic reaction, it is necessary to find out the individual provoking factors. For this purpose, application, scarification or intradermal tests are prescribed. Occasionally, a conjunctival provoking test is required.
Treatment
Conservative therapy
With keratoconjunctivitis, differentiated treatment is prescribed, taking into account the causes of the disease and the severity of symptoms. Treatment is mainly carried out on an outpatient basis. The therapeutic scheme is represented by local remedies (ointments, lotions, drops) in combination with systemic drugs for oral use. The main groups of medications that are being treated:
- Antihistamines. First-line medications for the treatment of spring or atopic keratoconjunctivitis, allowing you to quickly stop the symptoms, reduce the inflammatory process. To enhance the effectiveness, antihistamines are combined with nonsteroidal anti-inflammatory, mast cell membrane stabilizers.
- Corticosteroids. Hormonal preparations in the form of eye drops are used for severe forms of allergic inflammation of the conjunctiva, as well as as a comprehensive treatment of infectious variants. Occasionally, corticosteroids are prescribed in the format of systemic treatment.
- Antimicrobial agents. Treatment of bacterial forms of keratoconjunctivitis includes ointments or instillations with antibiotics, systemic antibacterial drugs. With viral infections, the laying of ointments with acyclovir, tebrofen is indicated. Immunomodulators are selected for the treatment of severe situations.
- Moisturizing drops. Most cases of pathology are accompanied by increased dryness of the eyes, therefore, drops of “artificial tear” are instilled to treat unpleasant symptoms. To ensure a prolonged moisturizing effect, ointments with retinol are laid at night.
- Mydriatics. Pupil dilation drops are prescribed in the treatment of various forms of keratoconjunctivitis to improve the outflow of intraocular fluid. Thus, it is possible to prevent the development of a secondary form of glaucoma.
- Regeneration stimulators. To accelerate the epithelization of defects of the outer ocular membrane, drops with taurine and other amino acids, vitamin supplements are used in the treatment regimen. The drugs are effective in the subacute and rehabilitation period of the disease.
To remove pathological exudate and cleanse the conjunctival cavity, treatment is prescribed by washing with solutions with antiseptics. Patients are explained the rules of personal hygiene to prevent the spread of infection: the use of disposable wipes for wiping the face, instilling each eye with a separate pipette, regular hand washing, avoiding touching the face.
Medical treatment is supplemented with physiotherapy techniques. Magnetotherapy, ultraphonophoresis with defibrosing enzymes, electrophoresis of antimicrobial drugs demonstrate high efficiency. In the recovery period, it is advisable to use low-intensity microwave therapy, darsonvalization.
Surgical treatment
If conservative treatment does not give the expected effect, and the patient’s visual function is progressively deteriorating, the help of ophthalmic surgeons is required. To restore the shape and light-conducting ability of the cornea, various keratoplasty techniques (anterior, posterior, through) are used. Microsurgical methods of treatment are widely used in modern ophthalmology: microdiathermocoagulation, excimer laser procedure.
Prognosis and prevention
The probability of a full recovery directly depends on timely access to a doctor who should prescribe comprehensive local and systemic treatment. If the recommendations of the specialist are followed, it is possible to stop the inflammation within 1-3 weeks, while starting regenerative reactions. An unfavorable outcome is observed when the process spreads to the remaining tissues of the eyeball with the risk of vision loss.
Prevention of keratoconjunctivitis includes compliance with the rules of personal hygiene, careful selection of decorative and care cosmetics, implementation of tips on wearing contact lenses. To avoid infectious lesions, it is necessary to use individual face towels (preferably disposable paper ones), get rid of the habit of rubbing your eyes. In the summer, it is necessary to wear high-quality sunglasses.
