Conjunctivitis

CLINICAL PROTOCOL FOR DIAGNOSIS AND TREATMENT

Classification: Clinical classification [1]

By course: acute; chronic.

By etiology: Allergic: seasonal/perennial allergic conjunctivitis; vernal conjunctivitis; atopic conjunctivitis. Mechanical/toxic: superior limbic keratoconjunctivitis; blepharoconjunctivitis; dry keratoconjunctivitis (SICCA); rosacea conjunctivitis; contact lens-associated keratoconjunctivitis; giant papillary conjunctivitis; keratoconjunctivitis caused by medications/preservatives. Immune-mediated: ocular mucous membrane pemphigoid; graft-versus-host disease/reaction (GVHD); Stevens-Johnson syndrome/toxic epidermal necrolysis; Graves' ophthalmopathy; vasculitis. Neoplastic: Viral: adenoviral conjunctivitis; conjunctivitis caused by varicella (herpes) zoster virus (VZV); molluscum contagiosum. Bacterial: bacterial conjunctivitis; gonococcal conjunctivitis/ophthalmia neonatorum; chlamydial conjunctivitis; conjunctivitis-otitis syndrome. Other: fibrous conjunctivitis (ligneous).

METHODS, APPROACHES AND DIAGNOSTIC PROCEDURES: 2.1 Diagnostic criteria: Complaints: eye redness of varying severity; discharge from the conjunctival cavity; foreign body sensation, tearing, mild photophobia; eyelid swelling and itching. History: symptoms and signs (e.g., eyelid sticking, itching, tearing, discharge,

irritation, pain, moderate photophobia); duration of symptoms and temporal course; aggravating factors; unilateral or bilateral manifestation; nature of discharge; poor hygiene; swimming pool or water body visits; cosmetic procedures on eyelids; recent contact with infected person; trauma: mechanical, chemical, physical (UV); recent surgical interventions, manipulations; mechanical irritation due to repetitive compulsive wiping of eyelids with conjunctival trauma, more common in elderly; contact lens wear: type of lenses, hygiene and usage regimen; symptoms and signs potentially associated with systemic;

diseases (urination disorders and genitourinary discharge, dysuria, dysphagia, upper respiratory tract infection, skin and mucous membrane lesions); allergic history, presence of bronchial asthma, eczema in history; use of topical and systemic medications; previous episodes of conjunctivitis; concomitant ocular surface diseases.

Laboratory examinations: Basic laboratory tests: none.

Additional laboratory tests: Performed for differential diagnosis when gonorrheal ophthalmia or chlamydial conjunctivitis is suspected.

Bacteriological examination of conjunctival cavity discharge for microflora with antibiotic sensitivity determination is not mandatory. Performed in chronic recurrent cases resistant to topical antibacterial therapy.

Bacterioscopy when gonococcal conjunctivitis is suspected. Bacterioscopy and special stains (Gram, Giemsa) are recommended when infectious neonatal conjunctivitis, chronic or recurrent conjunctivitis is suspected, as well as when gonococcal conjunctivitis is suspected in any age group [1].

Diagnostic tests for chlamydia. Blood ELISA, PCR of conjunctival scraping, cytological method with detection of cytoplasmic

inclusions in epithelial cells ("Prowazek-Halberstaedter bodies") [1].

Allergy tests and immunoglobulin E (IgE) determination are performed according to allergist recommendations as indicated [1].

Complete blood count. Elevated eosinophil levels in CBC in allergic conjunctivitis [1].

Instrumental examinations: Basic instrumental tests: Slit-lamp biomicroscopy should include examination of: Eyelid margins: ● inflammation; ● edema; ● hyperpigmentation; ● ulceration; ● discharge; ● presence of nodules or vesicles; ● bloody discharge; ● keratinization. Eyelashes: ● loss/abnormal growth/"moth-eaten" eyelashes; ● crust, scale formation; ● presence of mites (demodex), nits, lice. Lacrimal ducts and canaliculi:

presence of discharge;

presence of lacrimal canal patency. Tarsal conjunctiva and conjunctival fornices: ● presence and size of papillae and/or follicles; ● scarring, subepithelial fibrosis, conjunctival fornix shortening and symblepharon; ● pseudomembranes and true membranes; ● ulcer; ● hemorrhages; ● foreign body; ● mucus secretion; ● discharge; ● eyelid laxity. Bulbar conjunctiva/limbus: ● follicles; ● edema; ● nodules; ● chemosis;

● flaccidity; ● papillae; ● ulcerations; ● scars; ● phlyctenules; ● hemorrhages; ● foreign body; ● keratinization. Cornea: ● epithelial defects; ● punctate keratopathy; ● dendritic keratitis; ● subepithelial infiltrates; ● filaments; ● ulcer; ● infiltration, including subepithelial infiltrates and phlyctenules; ● vascularization; ● precipitates with or without corneal edema. Nature of staining: conjunctiva and cornea: anterior chamber/iris: inflammatory reaction, synechiae, Tyndall effect +.

Additional instrumental investigations: Radiological examinations chest X-ray, chest computed tomography and/or scintigraphy if sarcoidosis is suspected; ECG, echocardiogram in Kawasaki disease.

Indications for specialist consultations: Otorhinolaryngologist – in case of concomitant pathology of the ear, throat and nose organs; if conjunctivitis-otitis syndrome is suspected[2] Allergist – in allergic diseases; Endocrinologist – in the presence of diabetes mellitus, thyroid gland pathology, etc.; Urologist, gynecologist – in chlamydial, gonococcal etiology; Pediatrician – in ophthalmia neonatorum, when systemic antibacterial therapy is necessary; Rheumatologist – decision on systemic therapy in cicatricial pemphigoid of the conjunctiva.

More often unilateral process 2. As a rule, segmental nature of injection 3. Minimal subjective complaints Presence of edema, precipitates on corneal endothelium, miosis, ciliary pain

Presence of corneal pathology: edema, infiltrates; epithelial, stromal defects 1. On palpation the eye is "hard as stone" 2. Nature of pain: with irradiation to the corresponding half of the head, neck. 3. Significant sharp decrease in vision, corneal edema, mydriasis, shallow anterior chamber

TREATMENT TACTICS AT OUTPATIENT LEVEL: 3.1 Non-drug treatment: Regimen: general observance of eyelid hygiene; cessation of contact lens wear until complete recovery and resolution of all symptoms.

Seasonal/perennial allergic conjunctivitis [3-15] exclude allergen exposure; hypoallergenic diet.

Vernal/atopic conjunctivitis [16-18] exclude allergen exposure; use of cool compresses.

Floppy eyelid syndrome

Taping the patient's eyelids with adhesive tape or wearing a protective shield during sleep to avoid conjunctival trauma from spontaneous eyelid eversion [1]. In pronounced floppy eyelid – consultation with oculoplastic surgeon regarding surgical treatment decision.

Giant fornix syndrome [22] consultation with oculoplastic surgeon for surgical treatment.

Palpebral pediculosis: mechanical removal of adult lice and nits (eggs) from eyelids and eyelashes; epilation of damaged eyelashes.

Drug-induced keratoconjunctivitis: discontinuation of the drug that caused keratoconjunctivitis.

Conjunctivitis in GVHD "graft-versus-host disease" [23] ● use of scleral lenses, instillation of cyclosporine 0.1% as indicated.

Stevens-Johnson syndrome/toxic epidermal necrolysis [24] amniotic membrane transplantation in severe cases.

Sebaceous gland carcinoma [25] confirmed by biopsy, treatment jointly with oncologist.

Ocular surface neoplasia (conjunctiva, cornea) confirmed by biopsy, treatment jointly with oncologist.

Molluscum contagiosum [26-28] ● removal, curettage (aggressive enough to cause bleeding), simple excision, excision and cauterization, cryotherapy; ● symptomatic therapy.

Conjunctivitis in vasculitis: ● systemic therapy in coordination with rheumatologist.

Ligneous Conjunctivitis [29] ● intravenous administration of Lys-Plasminogen; ● instillation of plasminogen; ● surgical treatment - excision with immediate anticoagulant therapy and immunosuppression.

Treatment effectiveness indicators: Resolution of symptoms: redness and edema of eyelids, palpebral and bulbar conjunctiva, itching, burning, foreign body sensation, lacrimation, discharge from conjunctival cavity.

Clinical signs

Associated/predisposing factors History

Depending on medication use. Conjunctival injection, edema, follicles of lower conjunctival fornix and bulbar conjunctiva. 2. Distinctive features:

Glaucoma medications, topical NSAIDs, antibiotics, antiviral drugs, others; may be associated with presence of preservatives in any ocular medications. Most commonly

Gradual worsening with prolonged use Corneal epithelial erosion, persistent epithelial defect, corneal ulceration, pannus, corneal and conjunctival scarring contact dermatitis of eyelids with erythema, in some cases desquamation occurs with multiple ocular medications and/or exceeding instillation frequency Conjunctival chalasis Redundant conjunctiva 1.Previous eye surgery 2.DES 3.Redundant conjunctiva Redundant conjunctiva, chronic irritation, may be consequence of previous chemosis Chronic irritation, keratitis in DES Immune-mediated Cicatricial pemphigoid of the conjunctiva

Bilateral, often asymmetric. Bulbar conjunctival injection, papillary conjunctivitis, subepithelial fibrosis and keratinization of conjunctiva, conjunctival scarring beginning in papillary area, keratinization, progressive conjunctival contraction, symblepharon, entropion, trichiasis, corneal ulcers/perforation, neovascularization and scarring

1.Unknown (possibly genetic predisposition exists) 2.Topical medications may cause Pemphigoid-like disease with spectrum of severity from self-limiting to progressive disease indistinguishable from Pemphigoid. Associated with pilocarpine and timolol. Cicatrizing conjunctivitis externally similar to Pemphigoid may be associated with other diseases, including atopic

Onset, more often, at age over 50-60 years with loss of goblet cells and mucin deficiency. Progressive chronic course, sometimes with remissions and

exacerbations

Scarring and shrinkage of the conjunctiva with shortening of the conjunctival fornices; ankyloblepharon, symblepharon; trichiasis; corneal scarring, neovascularization, ulceration, perforation; keratinization of the ocular surface; bacterial conjunctivitis; cicatricial changes of the eyelids; xerosis; limbal stem cell deficiency; severe vision loss. Concomitant lesions of the mucosa

diseases and major neoplasms, for example, paraneoplastic pemphigus and lichen.

of the oral cavity, nasopharynx, larynx, esophagus, genitourinary tract and anus Graft-versus-host disease

1. Bilateral. Patients who have undergone allogeneic transplantation
2. Conjunctival injection, chemosis, pseudomembranous

Usually unilateral. Bulbar conjunctival injection, serous discharge, mild follicular reaction of the conjunctiva. Preauricular node may be palpable. May be bilateral in atypical or immunocompromised patients 2. Distinctive features: vesicular rash or ulcerations on the eyelids, pleomorphic or ulcerated

Usually unilateral or bilateral. Bulbar conjunctival injection, serous discharge, mild follicular reaction of the conjunctiva. Preauricular node may be palpable. Typically punctate keratitis in primary disease; punctate or dendritic keratitis in recurrent disease 2. Distinctive features: vesicular dermatomal rash or ulcerations on the eyelids, pleomorphic or pseudodendritic epithelial keratitis

Acute varicella, contact with a person with active chickenpox or herpes zoster (shingles)

Primary infection (chickenpox), as well as conjunctivitis before recurrent infection, usually resolves within a few days. Vesicles may form on the limbus, especially in primary infection

Ulcerations and scars from vesicles on the eyelid margins, conjunctiva, and in the corneal stroma in primary disease in children. Conjunctival scarring resulting from secondary infection may lead to cicatricial ectropion. In recurrent disease, epithelial or stromal keratitis with subsequent scarring and late corneal anesthesia or dry eye, retinitis

1. More often unilateral, but may be bilateral. Moderate or severe follicular reaction, punctate epithelial keratitis. There may be corneal pannus,

1. Predominantly older children and young adults. Immunocompromised state (e.g., HIV) may predispose to multiple and/or large

Conjunctivitis is associated with eyelid lesions, which may spontaneously resolve or persist from several months to several years

1. Distinctive features: single or multiple shiny, dome-shaped umbilicated skin lesions of the eyelids or their margin

molluscum lesions on the eyelids. 2. Associated with follicular conjunctivitis

Conjunctival scarring, epithelial keratitis, pannus; less commonly subepithelial infiltrates/haze/scars, follicular conjunctivitis, especially in prolonged course

Bacterial Non-gonococcal

1. Unilateral or bilateral. Bulbar conjunctival injection, purulent or mucopurulent discharge 2. See age-related features Associated/predisposing factors below

1. Infantile – nasolacrimal duct obstruction, concomitant bacterial

1. Mild: self-limiting in adults. May lead to

Approved by the Joint Commission on Quality of Medical Services of the Ministry of Health

of the Republic of Kazakhstan dated November 26, 2024

Protocol No. 219

CONJUNCTIVITIS

INTRODUCTORY PART 1.1 ICD-10 Code(s):

ICD-10

Code H 10.0 H 10.1 H 10.2 H 10.3 H 10.4 H 10.5 H 10.8 H 10.9 H 13.1

Name Mucopurulent conjunctivitis Acute atopic conjunctivitis Other acute conjunctivitis Acute conjunctivitis, unspecified Chronic conjunctivitis Blepharoconjunctivitis Other conjunctivitis Conjunctivitis, unspecified Acute conjunctivitis in diseases classified elsewhere: -diphtheritic (A36.8) -gonococcal (A54.3) -chlamydial conjunctivitis (A74.0) -acute hemorrhagic epidemic (B30.3) -adenoviral follicular (B 30.1) -herpesviral (B00.5)

Date of protocol development/revision: 2015 (revised 2019/2024).

Abbreviations used in the protocol: VKC vernal keratoconjunctivitis HSV herpes simplex virus HPV human papillomavirus GCS glucocorticosteroids MGD meibomian gland dysfunction STD sexually transmitted diseases ELISA enzyme-linked immunosorbent assay

CBC ARI NSAIDs PCR DES UVI

complete blood count acute respiratory viral infection nonsteroidal anti-inflammatory drugs polymerase chain reaction dry eye syndrome ultraviolet irradiation

Protocol users: ophthalmologists, general practitioners.

Patient category: adults, children.

Evidence level scale: A High-quality meta-analysis, systematic review of RCTs or large RCT with very low probability (++) of systematic error, the results of which can be applied to the relevant population. B High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of systematic error or RCT with low (+) risk of systematic error, the results of which can be applied to the relevant population. C Cohort or case-control study or controlled study without randomization with low risk of systematic error (+). Results that can be applied to the relevant population or RCT with very low or low risk of systematic error (++ or +), the results of which cannot be directly applied to the relevant population. D Case series description or uncontrolled study or expert opinion.

Diagnostic algorithm:

Complaints: - Eye redness of varying degrees

of severity - Discharge from the conjunctival

cavity - Eyelid swelling and itching

History: - Symptoms and signs - Duration of symptoms - Epidemiological history - Allergy history - Comorbidities - Eyelid hygiene violations

Additional laboratory examinations:

• Bacteriological examination of conjunctival cavity discharge
• Bacterioscopy when gonococcal conjunctivitis is suspected

- Diagnostic tests (allergy tests)

Objective signs: Nature of discharge Biomicroscopy

Differential diagnosis

Etiotropic (antibacterial, antiviral, antifungal, anti-inflammatory, antiallergic, symptomatic) therapy

Differential diagnosis and justification for additional

studies [1]: Diagnosis Justification for Examinations Exclusion criteria differential for diagnosis

diagnosis

Dry eye

1. Resistance to

Detailed history of 1. More often bilateral

syndrome ongoing treatment disease and lifestyle chronic nature or worsening of disease

Biomicroscopy of lesion, with

Diagnostic minimal

tests for DES

discharge

No discharge

Blood tests to exclude and lymphadenopathy

Episcleritis

Iritis

Keratitis Acute glaucoma attack

Resistance to ongoing treatment 2. Presence of long-standing unilateral localized injection

Pain syndrome of varying severity 2. Presence of long-standing unilateral injection 3. Resistance to ongoing treatment "corneal" syndrome

Severe pain syndrome 2. Resistance to ongoing treatment 3. Nausea, vomiting

systemic disease 1. Biomicroscopy 2. Blood tests to exclude systemic inflammatory disease, endogenous infections Biomicroscopy

Biomicroscopy, including dye test

Biomicroscopy 2. Tonometry (by palpation) 1.

Medical treatment: Seasonal/perennial allergic conjunctivitis [3-15] ● instillation of physiological saline; ● instillation of artificial tears; ● instillation of mast cell stabilizers 2 weeks before anticipated exacerbation; ● instillation of second-generation histamine H1-receptor antagonists; ● instillation of GCS in severe cases with corneal and IOP monitoring; ● systemic antihistamines; ● in severe cases – systemic corticosteroids, instillation of cyclosporine 0.1%.

Vernal/atopic conjunctivitis [16-18] ● instillation of physiological saline; ● instillation of artificial tears; ● instillation of mast cell stabilizers 2 weeks before anticipated exacerbation; ● instillation of second-generation histamine H1-receptor antagonists; ● instillation of GCS in severe cases with corneal and IOP monitoring; ● systemic antihistamines; ● in severe cases – systemic corticosteroids, instillations of cyclosporine 0.1%.

Superior limbic keratoconjunctivitis [19] ● instillation of physiological saline; ● instillation of artificial tears; ● instillation of mast cell stabilizers; ● instillation of histamine H1-receptor antagonists; ● instillation of glucocorticosteroids in severe cases with corneal and IOP monitoring; ● systemic antihistamines; ● in severe cases – systemic corticosteroids, instillations of cyclosporine 0.1%.

Rosacea conjunctivitis [20] ● instillation of glucocorticosteroids in severe cases with corneal and IOP monitoring; ● instillation of antibiotics in case of bacterial infection; ● instillation of artificial tears.

Contact lens-related keratoconjunctivitis

● instillation of glucocorticosteroids in severe cases with monitoring of the cornea and IOP;

● instillation of antibiotics in case of bacterial infection;

● instillation of tear preparations.

Giant papillary conjunctivitis [21]

● instillation of glucocorticosteroids, hydrocortisone eye ointment 0.5% externally on the eyelid skin;

● instillation of antibiotics in case of bacterial infection;

● instillation of tear preparations.

Floppy eyelid syndrome

● instillation of glucocorticosteroids in severe cases with monitoring of the cornea and IOP;

● instillation of anti-inflammatory drugs;

● instillation of tear preparations.

Giant fornix syndrome [22]

● instillation of antibiotics;

● instillation of tear preparations.

Drug-induced keratoconjunctivitis

● instillation of physiological saline;

● instillation of short-course GCS with corneal monitoring.

Cicatricial pemphigoid of the conjunctiva:

● instillation of tear preparations;

● instillation of glucocorticosteroids in severe cases with monitoring of the cornea and IOP;

● instillations of cyclosporine 0.1%.

Conjunctivitis in GVHD "graft-versus-host disease" [23]

● systemic immunosuppression;

● systemic GCS;

● instillation of glucocorticosteroids in severe cases with monitoring of the cornea and IOP;

● instillations of cyclosporine 0.1% as indicated.

Stevens-Johnson syndrome/toxic epidermal necrolysis [24]

● instillation of physiological saline;

● immunosuppressive and immunomodulating therapy;

● instillation of tear preparations;

● instillation of glucocorticosteroids in severe cases with monitoring of the cornea and IOP;

● instillations of cyclosporine 0.1% in the remote period.

Adenoviral conjunctivitis:

● instillation of physiological saline;

● instillation of antibiotics is permissible in the presence of signs of secondary infection (purulent discharge) or disruption of corneal epithelial integrity with risk of infection;

● instillation of glucocorticosteroids strictly as indicated, not earlier than the second week of disease, in complicated course with development of punctate epithelial keratitis under control of corneal epithelialization;

● hydrocortisone eye ointment 0.5% externally on the eyelid skin in complicated course with membrane formation, chemosis, depending on dynamics (2 times a day – 5 days, 1 time a day – 5 days);

● instillation of Povidone-iodine 1.0%.

Conjunctivitis caused by herpes simplex virus:

● instillation of physiological saline;

● 0.15% ganciclovir / acyclovir gel, used five times a day for no more than 2 weeks.

Conjunctivitis caused by varicella-zoster (herpes) virus:

● instillation of physiological saline;

● instillation of antibiotics in case of bacterial infection;

● oral antiviral drugs in consultation with general practitioner/pediatrician.

Bacterial conjunctivitis [1]

● Mild degree:

● instillation of physiological saline;

● instillation of broad-spectrum antibiotic in a short 5-7-day course;

● instillation of Povidone-iodine 1.0%.

● Moderate and severe degrees:

● irrigation with sterile physiological saline 0.9% 1-2 times a day and frequent instillations every 1-2 hours;

● instillation of broad-spectrum antibiotic;

● Systemic antibacterial therapy is permitted in cases of:

● chlamydial, gonococcal etiology;

● conjunctivitis-otitis syndrome in consultation with otolaryngologist/pediatrician [2]

Chlamydial conjunctivitis:

Antibacterial therapy: topical fluoroquinolones III / IV generation + systemic in consultation with gynecologist / urologist / pediatrician – in children.

Conjunctivitis-otitis syndrome in children

● systemic antibacterial therapy in consultation with otolaryngologist and pediatrician [2]

List of essential medicines (with 100% probability of use)

Pharmacotherapeutic group

INN

Route of administration

LE

Bacterial conjunctivitis Antimicrobial agent of the fluoroquinolone group Levofloxacin 0.5% Instillations of eye drops into the conjunctival sac B Antimicrobial agent of the fluoroquinolone group Ofloxacin Instillations of eye drops into the conjunctival sac B Antimicrobial agent of the fluoroquinolone group Moxifloxacin Instillations of eye drops into the conjunctival sac B Artificial tears and other indifferent preparations Sodium hyaluronate Instillations into the conjunctival sac B Viral conjunctivitis Antiseptic agent Povidone-iodine Instillations of ophthalmic solution 1.0% into the conjunctival sac C Artificial tears and other indifferent preparations Sodium hyaluronate Instillations into the conjunctival sac B Chlamydial conjunctivitis Antimicrobial agent of the fluoroquinolone group Levofloxacin 0.5% 5 ml Instillations of eye drops into the conjunctival sac B Antimicrobial agent of the fluoroquinolone group Ofloxacin Instillations of eye drops into the conjunctival sac B Antimicrobial agent of the macrolide group Erythromycin Instillations of eye ointment 1% into the conjunctival sac B Antimicrobial agent of the tetracycline group Tetracycline Instillations of eye ointment 1% into the conjunctival sac B Artificial tears and other indifferent preparations Sodium hyaluronate Instillations into the conjunctival sac B Fungal conjunctivitis Antifungal agent Fluconazole Instillations of solution 0.2% into the conjunctival sac B Allergic conjunctivitis Antiallergic drug Olopatadine Instillations of solution 0.1% into the conjunctival sac B Antiallergic drug Cromoglicic acid Instillations of solution 2% into the conjunctival sac C Glucocorticosteroids Dexamethasone Instillations of solution 0.1% into the conjunctival sac B Glucocorticosteroids Hydrocortisone Externally on the eyelid skin or into the conjunctival sac 0.5% eye ointment, depending on corneal condition B Artificial tears and other indifferent preparations* Sodium hyaluronate Instillations into the conjunctival sac B

Notes: The frequency and duration of instillations should be according to the instructions of the preparations, individually in each case.

Local therapy with corticosteroids and combinations of antibiotics with corticosteroids should be conducted under regular monitoring of the corneal condition.

Physiological solution for instillations – is not a medicinal product.

Artificial tears and other indifferent preparations* - after completion of the acute process for relief of transient dry eye syndrome, does not require diagnostic tests.

List of additional medicinal products (less than 100% probability of use)

INN of medicinal product

Method of administration

Antimicrobial preparation of the phenicol group Chloramphenicol Instillations of 0.25% eye drop solution into the conjunctival sac C Antimicrobial preparation of the fluoroquinolone group Ciprofloxacin Instillations of 0.3% eye drops into the conjunctival sac C Antimicrobial preparation of the aminoglycoside group *Gentamicin Instillations of 0.3% eye drop solution into the conjunctival sac C Antimicrobial preparation of the aminoglycoside group Tobramycin Instillations of 0.3% eye drop solution into the conjunctival sac B Combined preparations Dexamethasone in combination with antimicrobial and other preparations Application of eye ointment into the conjunctival sac or externally on the skin of the eyelids C Second-generation histamine H1-receptor antagonists Ketotifen Instillations into the conjunctival sac B Nonsteroidal anti-inflammatory drugs Ketorolac Instillations into the conjunctival sac B Local immunosuppressant Cyclosporine A Instillations into the conjunctival sac C

• NB! Gentamicin 0.3% solution eye drops is used for microflora sensitive to gentamicin.

Surgical intervention: none.

Further management: Patient management is conducted at the outpatient level. In most cases, the prognosis is favorable; however, chronic course with relapses is possible; complications are possible.

TREATMENT TACTICS AT THE INPATIENT LEVEL: none.

ORGANIZATIONAL ASPECTS OF THE PROTOCOL: 6.1 List of protocol developers with indication of qualification data: 1) Isergepova Botagoz Iskakovna – Candidate of Medical Sciences, ophthalmologist of the highest qualification category, Deputy General Director for Science of LLP "Kazakh Research Institute of Eye Diseases". 2) Sultanbaeva Zhansaya Temirbolatovna – ophthalmologist of the pediatric department of LLP "Kazakh Research Institute of Eye Diseases", Almaty city.

3) Mukazhanova Ainagul Serikovna – ophthalmologist of the consultative-rehabilitation department of the branch of LLP "Kazakh Research Institute of Eye Diseases", Astana city. 4) Arinova Gulnara Pasevnoevna, Candidate of Medical Sciences, Professor of the Department of Surgical Diseases of NAO "Karaganda Medical University". 5) Abilmazhinova Aliya Amangeldynovna – clinical pharmacologist of LLP "Kazakh Research Institute of Eye Diseases", Almaty city. 6) Eralieva Bibikhan Abdalieva – Doctor of Medical Sciences, Head of the Department of Clinical Pharmacology of NAO "S.D. Asfendiyarov Kazakh National Medical University", Chief freelance clinical pharmacologist of the Public Health Department of Almaty city.

6.2 Indication of absence of conflict of interest: none.

Reviewers: Utelbaeva Zauresh Tursunovna – Doctor of Medical Sciences, Professor of the Department of Ophthalmology of NAO "S.D. Asfendiyarov Kazakh National Medical University".

Indication of conditions for protocol revision: revision not less than once every 5 years and not more than once every 3 years in the presence of new diagnostic and treatment methods with level of evidence.

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Appendix 1 Etiological types of conjunctivitis that are most common or have specific treatment features [1] Type of conjunctivitis

Possible Complications

Allergic Seasonal/perennial Bilateral.

Allergens

Recurrent, Minimal, Eyelid edema, environmental (e.g., often local periorbital grasses, associated with hyperpigmentation pollen) allergic (allergic

Atmospheric

rhinitis, sheen), environmental dry eyes, conjunctival pollution: meibomian injection, chemosis, exhaust fumes, gland watery dust storms, dysfunction (MGD) discharge, mild industrial with mucin mucous waste, tobacco hyperproduction discharge smoke exposure 3.

Exposure to pet allergens (dogs, cats), including livestock Vernal Bilateral.

Hot, dry

Onset in

Giant climate Southern childhood;

papillary regions of Kazakhstan: chronic hypertrophy KZO, SKO, ZhO, AO, course with of upper tarsal regions of western and exacerbations conjunctiva, central in spring and bulbar Kazakhstan. summer.

May be

Gradual injection, associated with growth decrease in conjunctival hormone deficiency, activity by age scarring, globulin, 20 years.

watery and sex hormone-

Vernal

viscous mucoid binding, and keratoconjunctiviti discharge, dihydrotestosterone s (VKC) - more limbal Horner- or high estrogen commonly Trantas dots, levels. observed in limbal

Environmental young

"papillae", allergens during adults without corneal epithelial exacerbations history of erosions, 4. There is an childhood neovascularization association with allergic disease

Eyelid thickening; ptosis; conjunctival scarring (predominantly upper tarsal); secondary corneal changes: neovascularization, thinning, ulceration, infection, limbal stem cell deficiency; cataract and glaucoma caused by chronic

Atopic Upper and scarring more higher corneal, frequency vernal plaque / of shield ulcer keratoconus corticosteroid use; vision loss;

VKC in

adults with diffuse subepithelial thickening of tarsal plate without giant papillae, lower frequency of shield corneal ulcers (less common than in children) Bilateral.

1.Genetic Later Eyelid thickening Eczematoid predisposition to (than vernal) or induration, blepharitis;

atopy onset; loss of eyelid 2.Allergens chronic eyelashes; thickening, and course with conjunctival scarring;

environmental periods of scarring loss of eyelashes;

irritants during exacerbations (including papillary exacerbations

There is an lower lid); hypertrophy

association with secondary of upper and higher corneal lower tarsal frequency changes: conjunctiva;

of neovascularization, conjunctival keratoconus thinning, injection and ulceration, scarring;

infection, watery and limbal stringy mucoid stem cell discharge;

deficiency; corneal cataract neovascularization, and ulcers and glaucoma scarring;

caused by punctate chronic epithelial corticosteroid keratitis. Possible use; herpes- association associated with keratitis. keratoconus and/or subcapsular cataract Mechanical/toxic 1.Bilateral Often associated with Subacute onset Keratinization limbic dysthyroid of keratoconjunctiviti conditions, symptoms, s female gender usually bilateral.

May wax and wane over many years upper bulbar conjunctival injection, keratinization of upper conjunctiva, pannus, filamentary keratitis, chemosis Blepharoconjuncti Chronic with vitis exacerbations.

Involvement of eyelid skin, eyelash base and eyelash follicles in Dry anterior keratoconjunctiviti blepharitis.

s (sicca) Posterior blepharitis:

MGD,

tear film instability, concomitant

DES.

Bilateral, may be asymmetric

1.Anterior: staphylococcal, demodex, seborrheic 2.Posterior blepharitis: MGD 3.Angular: Staphylococcus aureus, Moraxella lacunata

Chronic blepharitis with exacerbation presenting as conjunctival injection. May have history of recurrent hordeolum, chalazion.

Chronic blepharitis, conjunctivitis, keratitis, corneal neovascularization, ulceration, thinning, scarring, perforation.

Rosacea conjunctivitis Bilateral Telangiectasias at Telangiectasias chronic lid margin, MGD, at lid margins, blepharitis, blepharitis, inspissation lid margin conjunctival of meibomian telangiectasias, hyperemia, glands with inspissation injection, pannus excessive of meibomian sebum glands with secretion, excessive conjunctival sebum hyperemia secretion, and conjunctival injection injection, evaporative type DES, chalazion, corneal neovascularization, stromal scars

Evaporative type DES, corneal neovascularization, stromal scarring. May be associated with acne rosacea with characteristic rash, facial erythema, telangiectasias, papules, pustules, hypersecretion of sebaceous glands, rhinophyma

Varies from mild to diffuse conjunctival injection; focal or diffuse, peripheral corneal neovascularization; focal or diffuse superficial punctate keratopathy. Papillary hypertrophy of tarsal conjunctiva. Possible development of limbal stem cell deficiency

Occurs in connection Subacute or with contact lens acute onset wear as a of symptoms.

reaction May to require mechanical several irritation, months to chronic resolve hypoxia the problem or with preservatives treatment and discontinuation of contact lenses

Corneal neovascularization; superior epitheliopathy and corneal scarring; limbal stem cell deficiency; may progress centrally to pupillary area

Giant papillary conjunctivitis 2.Conjunctival and corneal punctate/ punctate epitheliopathy, corneal filaments

More often associated with contact lens wear. Papillary hypertrophy of the upper tarsal conjunctiva, mucoid discharge. Papillae with white fibrous foci in patients with long-standing disease. In severe cases: eyelid edema, ptosis

1. Contact lens wear (risk factors include soft contact lenses, infrequent lens replacement, prolonged wear, poor lens hygiene, allergenic contact lens solutions, high water content or poor contact lens fit). 2. Also occurs with irritation from postoperative sutures and prostheses

Chronic gradual increase in symptoms and signs with contact lens wear, exposed corneal or scleral sutures, ocular prostheses.

Cicatricial changes of tarsal conjunctiva, ptosis Floppy eyelid syndrome

Edema of upper eyelid not always present; upper eyelid easily everts, sometimes by simple lifting or elevation of the lid;

Obesity, sleep apnea, laxity of upper eyelid, overhanging of upper eyelid over lower eyelid (lid imbrication).

Chronic eye irritation, risk of infection due to nocturnal eyelid ectropion caused by Punctate epithelial keratitis; corneal neovascularization, ulceration and

diffuse papillary reaction of upper tarsal conjunctiva; punctate epithelial keratopathy; pannus; mild discharge. Bilateral, often asymmetric

Increased risk of keratoconus contact of upper eyelid conjunctiva with bedding scarring Giant fornix syndrome Enlarged upper conjunctival fornix with mucopurulent discharge, ptosis Elderly women (80-90 years), upper eyelid ptosis with large upper fornix that retains mucopurulent discharge Chronic Ptosis, hyperemia mucopurulent of upper eyelid, conjunctivitis, chronic which conjunctivitis, improves with short upper fornix courses of topical

antibiotic therapy mucopurulent

discharge Palpebral pediculosis Unilateral or Usually bilateral transmitted sexually.

follicular May have conjunctivitis. concomitant In adults - lice at pubic lice or base of eyelashes, other nits (eggs) STDs.

adherent to eyelash shaft, bloody debris on eyelashes and eyelids Blepharitis and conjunctivitis persist until treatment Chronic blepharitis, conjunctivitis, less commonly - marginal keratitis Drug-induced keratoconjunctivitis

(GVHD)

conjunctivitis, keratoconjunctivitis sicca, superior limbic keratoconjunctivitis, cicatrizing eyelid disease, episcleritis, corneal epithelial sloughing, limbal insufficiency, calcific corneal degeneration

May affect multiple tissues including skin, liver, gastrointestinal tract, lungs and eyes. Graft-versus-host disease may develop acutely within the first 3 months after hematopoietic stem cell transplantation, but ocular disease is more common in the chronic phase

Conjunctivitis;

subconjunctival fibrosis;

symblepharon;

tearing, lacrimal gland involvement;

keratoconjunctivitis sicca;

cicatricial eyelid disease.

Less commonly seen are limbal stem cell deficiency, scarring or deep corneal involvement Stevens-Johnson syndrome/toxic epidermal necrolysis

1. Unilateral or bilateral. 2. Bulbar conjunctival injection, subepithelial fibrosis and keratinization of conjunctiva, conjunctival scarring, punctal stenosis and keratinization, progressive conjunctival shrinkage, symblepharon, entropion, trichiasis, ulcers/perforation,

1. Preceding infection (e.g., HSV, mumps, mycoplasma pneumonia) 2. Systemic medications (e.g., sulfonamides, barbiturates, phenytoin) cause inflammation and cicatricial changes of various mucous membranes of the body, including bulbar and palpebral conjunctiva

Severe mucocutaneous reaction with epidermal necrosis and may involve various mucous membranes including gastrointestinal tract, lungs and eyes following systemic use of sensitizing drugs or infectious agents

Conjunctival scarring and shrinkage with loss of goblet cells and mucin deficiency;

trichiasis;

scarring, neovascularization, corneal ulceration;

corneal neovascularization, 3. Genetic and corneal scarring predisposition

keratinization of ocular surface; bacterial conjunctivitis; cicatricial eyelid changes; acute tear deficiency/xerosis; complete vision loss

Graves' ophthalmopathy

Bilateral, but may be asymmetric. Edema and erythema of periorbital tissues and conjunctiva, upper eyelid retraction, keratopathy, enlargement of extraocular muscles, proptosis

1. Most patients have Graves' disease (hyperthyroidism); also associated with thyroid pathology (e.g., Hashimoto's thyroiditis) 2. Family history of thyroid disease is a risk factor 3. Cigarette smoking or tobacco smoke exposure, low blood selenium levels, increased stress levels may affect thyroid hormone levels

Associated with hyperthyroidism, most commonly occurs simultaneously or within 18 months of each other, although ophthalmopathy may precede or follow onset of hyperthyroidism by many years

Corneal ulceration, restrictive strabismus/diplopia, compressive optic neuropathy; globe subluxation Conjunctivitis in vasculitis

1. Unilateral or bilateral. 2. Conjunctivitis, conjunctival nodules or granulomas, symblepharon and/or scarring, proptosis, restrictive myopathy, episcleritis,

Sarcoidosis, granulomatosis with polyangiitis, Kawasaki disease, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), secondary vasculitis

Sarcoidosis (bimodal age, with highest incidence between ages 20 to 39 years), Wegener's syndrome, Kawasaki disease (mainly affects children),

1. Often involves multiple vessels, including lungs, lymph nodes, kidneys, skin, nervous system
2. Coronary artery aneurysm is

Sebaceous gland carcinoma necrotizing infections, scleritis, drug-induced peripheral ulcerative vasculitis keratitis, (methamphetamine, keratic intravenous precipitates, corneal immunoglobulins, ulcers, iris nodules, opioids, trabecular meshwork hydralazine, nodules, antifibrotics, peripheral anterior antibiotics, synechiae, leukotrienes), or uveitis, vasculitis associated choroidal with malignant granulomas, neoplasms vitreous opacities, optic disc edema linear IgA disease, mucous membrane pemphigoid

a fatal complication of Kawasaki disease

Neoplastic

1. Unilateral. Intense bulbar conjunctival infection, conjunctival scarring. May have mucopurulent discharge. Corneal epithelial ingrowth may occur
2. A firm nodular immobile mass may be observed on the eyelids, on the tarsal cartilage with a yellowish tint; may appear as a subconjunctival, cellular yellow mass, may resemble

Unknown Occurs more often Invasion into the (rarely after radiation in age over orbit,

therapy)

years with fairly regional or

rapid distant progression metastases, melanoma Squamous neoplasia of the ocular surface

Melanoma chalazion Conjunctival hyperemia, papillomatous or sessile nodules Associated with human papillomavirus (HPV); associated with significant ultraviolet light exposure

May have history of HPV, significant UV exposure, chronic inflammation; may be mistakenly considered as torpid blepharoconjunctivitis

Conjunctival hyperemia, carcinoma in situ or superficial squamous neoplasia, which may be locally invasive with regional metastases

Painless, flat or nodular, brown or white-pink lesion on bulbar or palpebral conjunctiva or caruncle. Enlargement of lesion, blood vessels or thickening.

Significant UV exposure, previous history of melanoma, previous primary acquired melanosis or nevus of Ota Tends to spread to other areas of the adnexal apparatus, and metastasize

Pigmented or non-pigmented lesion, regional metastases, history of previous melanoma, primary tumor may not be on conjunctiva

Viral Adenoviral

Sudden onset. Contact with

Unilateral or infected person bilateral (often (especially in school sequentially environment), bilateral). recent visit to Varies in severity. ophthalmologist, Bulbar conjunctival concurrent / injection, preceding watery discharge, URTI follicular reaction of lower tarsal

"self-limited disease" (disease capable of healing without treatment), with resolution of symptoms within 7-14 days in uncomplicated forms

In severe cases: conjunctival scarring, symblepharon, keratitis and multiple subepithelial round "coin- shaped" corneal opacities as an outcome of punctate epithelial keratitis,

conjunctiva, chemosis, eyelid edema and erythema

1. Distinctive features: preauricular lymphadenopathy, petechial and subconjunctival hemorrhages, corneal epithelial defects, multifocal epithelial punctate keratitis, progressing to anterior stromal keratitis, membrane/pseudomembrane formation

corneal opacity Herpes simplex virus

Previous HSV infection: trigger for reactivation may be stress, acute viral or febrile illnesses, URTI, UV exposure, surgery or trauma

1. Primary HSV infection: contact with infected person

Usually resolves Epithelial without treatment conjunctivitis within 4-7 days if and/or complications do blepharitis,

not occur

endotheliitis, keratitis, stromal keratitis, neovascularization, scarring, thinning, perforation, uveitis, trabeculitis, retinitis, corneal edema dendritic epithelial keratitis of cornea or conjunctiva Varicella (herpes) zoster virus

complications in

otitis media or children pharyngitis, contact 2. Severe: may with infected person persist without

1. Pediatric – treatment, rarely -

contact with subacute infected person;

concurrent bacterial otitis media, sinusitis or pharyngitis;

bacterial colonization of nasopharynx;

1. Adult -

Contact with infected person, Oculogenital spread, unsanitary living conditions, infection or abnormality of adnexal structure, incorrect eyelid position, acute tear deficiency / xerosis, immunosuppression, trauma

1. Rare, but

possible corneal infection

1. Corneal

infection; may be associated with pharyngitis, otitis media, meningitis Gonococcal

Chlamydial (inclusion)

1. Unilateral or bilateral. Marked eyelid edema, marked bulbar conjunctival injection, marked purulent discharge, preauricular lymphadenopathy
2. Important sign to detect: corneal infiltrate or ulcer, which can rapidly lead to corneal perforation

1. Neonatal: delivery from infected mother; inadequate prenatal care

1. In children and adults

• Entry of

gonococcal pathogens into conjunctival sac from outside or hematogenous route

• Oculogenital

spread: sexual abuse must be excluded

1. Neonatal: manifests within 1-7 days after birth; later - if topical antibiotic was used. Rapid evolution to severe form, purulent keratoconjunctivitis

Adult: rapid development of severe hyperpurulent conjunctivitis

1. Neonatal: corneal infection, corneal scarring, corneal perforation. Outcome - often corneal leukoma, blindness.

Septicemia with arthritis, meningitis

Adult: corneal infection, corneal scarring, corneal perforation, urethritis, pelvic inflammatory disease, septicemia, arthritis

1. Neonatal/infantile: unilateral or bilateral. Eyelid edema, bulbar conjunctival injection, discharge may be purulent or

Transmitted sexually, through contact-household routes

Caused by Chlamydia trachomatis serotypes D-K

1. Neonatal: manifests 5-19 days after birth, earlier if placental membranes ruptured before delivery. Untreated cases

1. Neonatal: corneal and conjunctival scarring; up to 50% have concomitant nasopharyngeal, genital, or pulmonary infection

Chlamydial (trachoma) mucopurulent, without follicles

Adult: unilateral or bilateral. Follicular conjunctivitis, chemosis, papillary hypertrophy, corneal pannus, Herbert's pits, conjunctival scarring, cicatricial entropion, trichiasis, limbal stem cell deficiency, corneal scarring/opacity

may persist for 3-12 months

Adult: follicular conjunctivitis, papillary hypertrophy, corneal pannus

Adult: Herbert's pits, conjunctival scars, cicatricial entropion, trichiasis, limbal stem cell deficiency, corneal scarring/opacity

1. Unilateral or bilateral. Bulbar conjunctival injection, follicular reaction of tarsal conjunctiva, mucoid discharge, corneal pannus, punctate epithelial keratitis, corneal opacity, entropion, trichiasis, preauricular lymphadenopathy
2. Distinctive feature: bulbar conjunctival follicles

Caused by Chlamydia trachomatis serotypes A, B, and C

1. In regions without adequate access to clean water and poor sanitation
2. May spread through direct or indirect contact with eye, nose, or throat secretions of an infected person

1. Conjunctivitis with mucopurulent discharge, preauricular lymphadenopathy

May persist/recur if not treated

Corneal infiltrates, pannus, cervicitis, urethritis, salpingitis, endometritis, perihepatitis Ligneous conjunctivitis Other

In 50% of cases bilateral, chronic, recurrent conjunctivitis with mucoid discharge, tearing, conjunctival injection, with subsequent pseudomembrane formation on palpebral conjunctiva involving upper/lower lid or bulbar conjunctiva

Genetic predisposition (may be inherited in autosomal recessive pattern)

Systemic plasminogen deficiency characterized by recurrent mucoid conjunctivitis with subsequent palpebral fibrinous pseudomembrane and mucosal thickening. 2. May include systemic pseudomembranous lesions and may be associated with fever, upper respiratory, ear, and/or genitourinary tract infection 3. Associated with congenital hydrocephalus and juvenile colloid.

Dense, firm/woody pseudomembranous structures on tarsal conjunctiva. 2. May cause chronic inflammation; corneal scarring, neovascularization, perforation, amblyopia, and vision loss. 3. May be life-threatening with airway involvement

INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF TYPE OF HOSPITALIZATION: none.