Presented To:

Dr. Muhammad Fawad Rasool

Assistant Professor of Pharmacy Practice
Presented By:
Madiha Nasir(04-M-14)
Khilza Aiman(55-M-14)
Sana Kousar(60-M-14)
Asma Shoukat(63-M-14)
Ramsha Nasir(76-M-14)

Subject :
Clinical pharmacy
Faculty of Pharmacy,
Bahauddin Zakariya University, Multan.
 Pointstotobebe
Points discussed
discussed: :

Introduction • Defination of conjunctivitis

• Normal function of conjunctiva
• Causes of conjunctivitis

Diagnosis • Bacterial
• Viral
• Allergic

Types • Bacterial
• Viral
• Allergic
 The conjunctiva is the clear, thin membrane that
covers part of the front surface of the eye and the
inner surface of the eyelids

It has two segments:

 Bulbar conjunctiva: This portion of the conjunctiva covers the
anterior part of the sclera.
 Palpebral conjunctiva: This portion covers the inner surface of both
the upper and lower eyelids.
I. Keep the front surface of the eye moist and lubricated so they open
and close easily without friction or causing eye irritation.
II. Protect the eye from dust, debris and infection-causing
microorganisms.
III. The conjunctiva has many small blood vessels that provide nutrients
to the eye and lids
Figure # 1. The palpebral conjunctiva covers the inner lining of the eyelids and is continuous with the
bulbar conjunctiva that covers the white sclera of the eye.
 The American Optometric Association defines as
“Conjunctivitis is an inflammation or swelling of the conjunctiva.”

 Conjunctivitis is also commonly known as “Red Eye” .

 Conjunctivitis is a common eye disease, especially in children. It may
affect one or both eyes. Some forms of conjunctivitis are highly contagious.
I. Bacterial conjunctivitis
II. Viral conjunctivitis
III. Allergic conjunctivitis
 Bacterial Allergic
Viral conjunctivitis
conjunctivitis conjunctivitis

• Purulent •Watery discharge • Watery discharge may

discharge(pus may be present or may not present
milky, yellow or •No itching • Itching present
green) present •No pain & • No pain &
• No pain & photophobia photophobia
photophobia •Inflamed conjunctiva • Inflamed conjunctiva
• Inflamed conjunctiva
 symptoms:
Pain or photophobia?

Uveitis, acute narrow angle

No Yes glaucoma, keratitis or others.
Sign: Discharge?
Refer to ophthalmologist for
No Yes diagnosis.

Sign: purulent discharge?

Symptom: Itching? Diagnosis: Bacterial
No Yes conjunctivitus
No Yes

Watery discharge. Itching? Abrupt onset, copious

Dry eye, topical drug purulent discharge, rapid
toxicity, or others. Yes No progression?
Refer to
ophthalmologist for Yes
diagnosis. Diagnosis: viral Diagnosis:
Diagnosis: Allergic
conjunctivitus Hyperacute
conjunctivitus
Bacterial
Conjunctivitus.
 Allergic conjunctivitis is the inflammation of
conjunctiva due to allergic and hypersensitivity
reaction that may be immediate or delayed.
 Ocular allergy

Seasonal allergic conjunctivitis

(SAC)

perennial allergic conjunctivitis

(PAC)

Conjunctivitis medicamentosa

Hay fever conjunctivitis

Conjunctiva is first site of contact to allergens

Allergens bind with the IgE antibodies of mast cell

Degranulationof mast cell

Releaseof inflammatory mediators

Histamine Itching, redness, swelling

Increase mucous secretion and cellular

Leukotrienes& PG infiltration (chemosis), vasodilation
Non-pharmacological treatment

Pharmacological treatment
 Relief of current
allergic symptoms

No adverse Prevention of
effect from further allergic
treatment symptoms
 • Removal and avoidance of allergens
1

• Cold compress 3-4 times daily for redness, itching and to provide symptomatic
relief
2

• For conjunctivitis medicamentosa discontinue medication

3
 Pharmacological treatment
• Use artificial tear solution
Step- • Ointment
• Preservative free formulation
1

• Use topical anti-histamine

• Anti-histamine with decongestant
Step-2 • Mast cell stabilizer and Topical NSAIDs

• Short term topical corticosteroids

• immunotherapy
Step-3
 Drug Mechanism Notes

Available only in combination with naphazol

Pheniramine H1 receptor antagonist
Antazoline H1 receptor antagonist Available only in combination with naphazoli

Olopatadine Antihistamine,mast cell stabilizer

Cromolyn sodium Mast cell stabilizer May be used for up to 3 months

Ketorolac Prostaglandin inhibitor

Lodoxamide Mast cell stabilize May be used for upto 3 months

Loteprednol Corticosteroid Only 0.2% approved for seasonal

allergic conjunctivitis

`Table # 2 Mechanism of action of Ocular Allergy Drugs

 DRUG DOSING COMMON SIDE EFFECTS
PHENIRAMINE Varies by manufacturer and product Ocular stinging
Antazoline Varies by manufacturer and product Ocular stinging
Levocabastine 1-2 drops in affected eye four times Ocular stinging,headache
daily
Olopatadine 1-2 drops in affected eye two times Headache
daily at 6 to 8 hours interval

Emedastine 1 drop in affected eye upto 4 times Red eyes,headache

daily
Ketoifen 1 drop in affected eye twice daily Red eyes,headache
Azelastine 1 drop in affected eye twice daily Ocular stinging,bitter taste
Epinastine 1 drop in each eye twice daily Ocular stinging,cold symptoms
Nedocromil 1-2 drops in each eye twice daily Ocular stinging,bitter taste

Cromolyn sodium 1-2 drops in each eye 4-6 times daily Ocular stinging

Table # 3 Dosing & common side effects of Ocular Allergy Drugs

 Ensure an adequate Refer severe cases that
trial of the agent. If no do not respond to an
Monitor the patients
improvement is seen, ophthalmologist for
for relief of symptoms.
follow a stepped-care short-term topical
approach to treatment. corticosteroids.
 Etiology
 The most common cause of viral conjunctivitis is adenovirus.It is
often called “pink –eye.”Viral conjunctivitis infections are easily spread
through swimming pools,capms,contaminated fingers and medical
instruments.
 Patients often present with an upper respiratory tract infections or
recent exposureto viral conjuctivitis.
 The infection begins in one eye,it will spread to both eyes50% of the
time.
 It is usually self limiting,worsening after 4to 7 days but then
resolvingwithin 2 to 4 weeks
 5% of patients remain contagious 16 days after the appearance of
symptoms.
 Treatmemt
 Desired outcomes
 Complete resolution of the viral comjunctivitis
 Prevent adverse consequences of the infection
 Avoid spreading infection to other patients
 Non pharmacologic therapy
 Non pharmacologic measures are critical to prevent the spread of
viral comjunctivitis.
 Patients should not share towels or other contaminated
objects,should avoid close contact with other peopleand avoid
swimming for 2 weeks .
 The virus remani visible on dry surfaces for more than 2 weeks.Take
care in the medical setting to thoroughly decontaminate instruments
and wash hands.
 Patients may obtain symptomatic relief by using cold compresses and
artificial tears.If artificial tear solutions sting,recommend a
presrvative free formula.
 Pharmacologic Therapy
 Topical antivirals are not used to treat adenovirus conjunctivitis
 Topical antibiotics are often prescribed for it,ostensibly to prevent
bacterial superinfection.
 Avoid the use of antibiotic for viral infection.Eliminatimg superfloua
antibiotic use also helps prevent the development of antibiotic
resistance.
 If patient have a severe subepithelial infilteration,a topical steroid may
be required.However topical steroids may cause serious ocular
complications and may worsen hepatic conjunctivitis which has
symptoms similar to viral conjunctivitis.
 Additionally the period of virus shedding may be prolonged upto50% by
topical prednisolone.Only ophthalmologists should prescribe topical
steroids.
 Outcome Evaluation
 Refer patients that do not see improvement within 7 to 10
dayd to an ophthalmologist to rule out herpetic and other
infectious processes.
 If pain orphotophobia occurs,suspect corneal involvement and
refer the patient.This typically occurs 10 to 14 dayd after the
onset of conjunctivitis.
 Bacterial conjunctivitis is a common type of pink eye
caused by bacteria that infect the eye through various
sources of contamination
 Acute bacterial conjunctivitis is primary due to :

 Staphylococcus aureus
 Streptococcus pnuemoniae
 Hemophilus influenza
 Hyperacute conjunctivitis is due to:

 Neisseria gonorrhoea

 Chronic conjunctivitis is due to:

 Chlamydia trachomatis
 Poor hygiene
 Poor contact lens hygiene
 Contaminated cosmetics
 Ocular diseases including dry eye,blepharitis,and anatomic
abnormalities of the ocular surface and lids.
 Recent ocular surgery
 Chronic use of topical medications
 Immune compromise
 Acute mucopurulent conjunctivitis
 Acute purulent conjunctivitis
 Acute membranous conjunctivitis
 Acute pseudomembranous conjunctivitis
 Chronic bacterial conjunctivitis
 Chronic angular conjunctivitis
 Causative organisms are:

 Staphylococcus aurreus
 Stretococcus
 Pneumococcus
 Discomfort and mild photophobia
 Mucopurulent discharge from the eyes
 Sticking together of lid margins
 Slide blurring of vision due to mucous flakes
 May complain of coloured halos
 Conjunctival congestion
 Chemosis
 Petechial haemorrhages
 Flakes of mucopus
 Cilia are usually matted
 Yellow crust
 Marginal corneal ulcer
 Superficial keratitis
 Blepharitis or dacryocystitis
 Topical antibiotics—broad spectrum antibiotics
 Irrigation of conjunctival sac
 Dark goggles
 No steroids should be applied
 No bandages
 Anti_inflammatory and analgesic drugs
 Its clinical picture involve:

 1st one is stage of infiltration

 2nd one is stage of blenorrhoea
 3rd one is stage of slow healing
 Considerably painful and tender eyeball
 Bright red velvety chemosed conjunctiva
 Lids are tense and swollen
 Discharge is watery and sanguinous
 Pre auricular lymph nodes are enlarged
 Frankly purulent,copious,thick discharge trickling down the
cheeks.
 Other symptoms are increased but tension in the lids is
decreased
 Corneal involovement
 Iridocyclitis

 Systemic complications include:

 Gonorrhea
 Endocarditis
 septicaemia
 Systemic therapy:
 Norfloxacin 1.2gm orally qid for 5 days
 Cefoxitim 1.0 gm or cefotaxime 500mg IV qid
 Spectinomycin 2.00 gm IM for 3 days
 Topical antibiotic therapy
 Ofloxacin, ciprofloxacin or tobramycin eye drops
 Bacitracin or
 Erythromycin eye ointment
 Source and mode of infection
 Before birth infection is very rare through infected liquor amnii in mothers with
ruptured membrane
 During birth
 After birth
 Chemical conjunctivitis
 Gonococcal infection
 Other bacterial infections
 Herpes simplex ophthalmia neonatorum
 Pain and tenderness in the eyeball.
 Conjunctival discharge
 Lids are usually swollen.
 Conjunctiva may show hyperaemia and chemosis
 Corneal involvment,though rare.
 Prophylaxis needs antenal,natal and postnatal care
 Curativetreatment
 TOPICAL THERAPY

 Saline lavage
 Bacitracin eye ointment 4 times/day
 Systemic therapy:
 Ceftrixone 75-100mg/kg/day IV or IM ,QID
 Ciprofloxacin 10-20mg/kg/day or Norfloxacin
10mg/kg/day