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Continuing Education & Training 

Roger J. Buckley MA, FRCS, FRCOphth, HonFCOptom 

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SPECIALISTS IN EYECARE 

Module 8 Part 5 

Therapeutics in 

clinical practice 

About the author 

Roger Buckley is Professor of 

Ocular Medicine, Department of 

Optometry and Visual Science, 

City University, and Honorary 

Consultant Ophthalmologist at 

Moorfields Eye Hospital, London. 

Therapeutics in practice 

Disorders of the conjunctiva – Part 1 

The conjunctiva is a mucous membrane, which in its normal state, 

is difficult to visualise as it is thin and transparent. 

Conjunctivitis is an inflammation of the conjunctivae, which 

usually affects both eyes at the same time – although it may start in 

one eye and spread to the other after a day or two. It may be 

asymmetrical, affecting one eye more than the other. 

There are many causes of conjunctivitis and 

the management will depend on the cause. 

The most frequent are bacterial or viral 

infection, and allergic or toxic reactions. 

However, it is important to note that there 

are many other causes (Table 1). 

Furthermore, it is important to distinguish 

secondary conjunctivitis (e.g. secondary to 

a disorder to the surrounding tissue, or 

other causes of red eye, Table 2) from 

primary conjunctivitis. The most frequent 

causes of red eye include subconjunctival 

haemorrhage, blepharitis, dry eye and 

minor ocular trauma. Appropriate 

history taking and clinical examination 

will enable the practitioner to differentiate 

between these and more serious disease and 

secondary conjunctivitis. 

1 CET point Infective Bacterial 

Viral (adenoviral & others, herpes simplex and herpes zoster) 

Chlamydial 

Allergic and toxic Seasonal (hayfever) and perennial 

allergic conjunctivitis 

Vernal keratoconjunctivitis 

Atopic keratoconjunctivitis 

Giant papillary conjunctivitis (CL related) 

Contact sensitivity and toxicity 

Inflammatory Reiter’s syndrome 

Oculocutaneous 

- Pemphigoid 

- Stevens-Johnson syndrome 

Parinaud’s oculoglandular syndrome 

Superior limbic keratoconjunctivitis 

Other 

Conjunctiva 

Cornea 

Eyelids 

Lacrimal 

Tear film 

Intraocular 

Sclera and episclera 

Orbital 

Artefacta (self-induced) 

Idiopathic (unknown cause) 

Subconjunctival haemorrhage 

Foreign body (e.g. subtarsal) 

Conjunctival neoplasm (cancer) 

Corneal foreign body 

Corneal abrasion 

Marginal keratitis 

Microbial keratitis 

Herpes simplex keratitis 

Table 1 

Causes and types of primary conjunctivitis 

Blepharitis 

Trichiasis (in-turning lashes) 

Entropion and ectropion 

Abnormal lid closure (exposure) e.g. lid paralysis 

Molluscum contagiosum (sheds irritant virus into tear film) 

Chronic infection of a blocked nasolacrimal system 

Dry eye 

Iritis, uveitis 

Acute glaucoma 

Scleritis 

Episcleritis 

Orbital cellulitis 

Dysthyroid eye disease 

Table 2 

Other causes of a red eye 

30 | May 6 | 2005 OT


Mechanisms of 

conjunctival inflammation 

Inflammation is the pathological process by 

which white blood cells and fluid 

accumulate within a tissue. It is 

characterised by pain, redness, swelling, 

heat and resulting loss of function. These 

features, which are regarded as classic and 

cardinal, are mediated by specific 

pathophysiological reactions, each of which 

is characterised by complex interactions 

between cellular effectors and chemical 

mediators. 

Pain is produced by the stimulation of 

nerve endings. Redness and heat result from 

dilatation of small blood vessels and 

accelerated metabolism. Swelling is caused 

by the accumulation of extracellular fluid, 

fibrin and inflammatory cells. All of these 

changes together impair the normal 

functions of the inflamed tissue. 

Three mechanisms that can initiate 

inflammation are infection, immune 

response and trauma. 

Infection 

Most infections, of the eye as well as of 

other tissues, cause inflammation. However, 

a few do not, for example, latent infection 

of the trigeminal ganglion by herpes 

simplex virus. In bacterial infection, cell 

wall components (endotoxins) of both 

gram-positive and gram-negative organisms 

trigger inflammatory reactions. A 

particularly powerful agent is bacterial 

lipopolysaccharide (LPS), a component of 

gram-negative bacterial cell walls. It activates 

the white blood cells, known as monocytes 

and polymorphonuclear leucocytes 

(‘polymorphs’) and causes them to 

degranulate with resulting tissue damage. 

LPS also upregulates the activity of cellstimulating 

chemical mediators, known as 

cytokines, activates the complement cascade 

(a group of proteins present in blood 

plasma and tissue fluid which combine with 

an antigen/antibody complex to bring about 

the lysis of foreign cells), and injures the 

endothelium of small blood vessels so that 

their contents leak into the tissues. 

In addition to the harmful effects of 

these endotoxins, bacteria can cause tissue 

damage via secretions known as exotoxins. 

Many of these are enzymes, which cause 

damage to cell membranes, thereby 

initiating inflammation. 

Immune response 

Reactions between antigens and antibodies 

are powerful triggers to inflammation. 

Antigen-antibody complexes can either be 

formed within the ocular tissues or 

deposited in them from the general 

circulation. These immune complexes 

initiate inflammation by a number of 

mechanisms. They activate the complement 

pathway, which causes tissue damage by 

attracting white cells (chemotaxis). They 

also cause degranulation of specific cells, 

such as mast cells and basophils, with the 

liberation of vasoactive substances which 

increase vascular permeability and obstruct 

blood flow by platelet aggregation. Some of 

these products of degranulation, for 

example, eosinophilic major basic protein, 

are toxic to the ocular surface and are 

probably involved in the corneal epithelial 

erosion that is typical of severe chronic 

allergic eye disease (vernal 

keratoconjunctivitis, VKC, and atopic 

keratoconjunctivitis, AKC). 

Another type of immune mechanism 

involves T-lymphocytes, which mediate 

delayed hypersensitivity reactions. Some 

T-lymphocytes are cytotoxic; one of these is 

the CD8 T-lymphocyte, which recognises 

infected host cells and destroys them with 

minimal associated tissue damage. Viral 

infections are controlled in this way. 

Another is the CD4 T-lymphocyte, which 

causes severe tissue damage in the course of 

eliminating the pathogen. 

Immediate hypersensitivity is another 

cause of inflammation. In a sensitised 

individual, this process begins when an 

allergen (such as plant pollen or animal 

dander) enters the eye through the tear film 

and conjunctiva and bridges 

immunoglobulin E (IgE) receptors on mast 

cells. This causes degranulation of the mast 

cells with the release of vasoactive 

substances, including histamine, tryptase, 

and platelet activating factor. These 

substances initiate complex cellular and 

humoral mechanisms, which together 

produce the symptoms and signs of allergic 

eye disease (for example, seasonal allergic 

conjunctivitis, SAC). 

Trauma 

Inflammation results from trauma of all 

kinds. Mechanical or chemical stimulation 

of sensory nerves produces vasodilatation 

and increased vascular permeability. Tissue 

damage, the introduction of infection and 

chemical injury all result in activation of 

cellular and humoral mechanisms, such as 

those already described. It should not be 

forgotten that surgery is a form of trauma 

and that the inflammation inevitably 

produced is potentially harmful, especially 

in the transparent ocular tissues where 

there is a threat to vision. Such 

inflammation can be controlled by the use 

of steroidal or non-steroidal 

anti-inflammatory drugs. 

In the very rare condition of sympathetic 

ophthalmitis, a perforating injury to one 

eye produces a granulomatous panuveitis 

in the fellow eye after a latent period. This 

is a predominantly T-lymphocyte 

modulated, delayed hypersensitivity 

reaction. 

Clinical signs of 

conjunctival inflammation 

The normal conjunctiva 

The conjunctiva is a mucous membrane. 

In its normal state, it is quite difficult to 

Figure 1 

Ciliary injection, that is, redness of the eye 

most marked around the limbus 

Figure 2 

Marked lid swelling, mild chemosis and a pink 

conjunctiva in seasonal allergic conjunctivitis 

(hayfever) 

visualise, being thin and transparent. Many 

of the blood vessels that are seen are, in 

fact, beneath it. 

Though the conjunctiva is a single 

continuous membrane, it is divided 

anatomically into three areas: 

• Bulbar (loosely covering the anterior 

part of the globe and fusing with the 

cornea and sclera at the limbus) 

• Tarsal (tightly adherent to the upper and 

lower tarsal plates) 

• Forniceal (loosely lining the upper, 

lower, temporal and nasal fornices) 

In order to examine the lower tarsal and 

forniceal conjunctiva, the lower lid is 

pulled down and the patient is asked to 

look up. The upper tarsal conjunctiva is to 

be seen when the upper lid is everted. 

Double eversion of the upper lid brings the 

upper forniceal conjunctiva into view. 

Hyperaemia 

Also called ‘injection’, this is redness of the 

conjunctiva caused by dilatation of its 

capillaries. It may be generalised (‘diffuse’), 

as in viral or bacterial infection, or 

confined to the para-limbal area. This 

‘ciliary injection’ is seen in corneal 

infection and intraocular inflammation 

(e.g. uveitis), rather than in superficial 

infection (Figure 1). Localised hyperaemia 

may be caused by a patch of episcleritis or 

by the presence of an embedded foreign 

body. 

Chemosis 

Chemosis is visible oedema, or waterlogging, 

of the conjunctiva, which produces 

31 | May 6 | 2005 OT


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5 

Figure 3 

Gelatinous follicles in the interior fornix 

a blistered or ballooned appearance. It is 

due to the escape of serum from inflamed 

blood vessels into the conjunctiva and 

underlying tissues. It is seen in viral and 

bacterial infection and in allergic disease, 

such as SAC (Figure 2). 

Infiltration 

The term infiltration (or ‘cellular 

infiltration’) implies that inflammatory 

cells have been liberated into the 

conjunctiva, and the result is loss of 

conjunctival transparency. In this situation, 

it is no longer possible to see the fine 

vessels underlying the tarsal conjunctival 

surfaces. Oedema, produced by the leakage 

of serum and protein, as well as 

inflammatory cells into the conjunctiva, 

contributes further to the opacification. 

Sub-conjunctival haemorrhage 

A cause of ‘red eye’, this is usually a less 

dramatic event than its appearance 

suggests. Sub-conjunctival haemorrhage is 

usually spontaneous or the result of minor 

trauma and can happen in the normal eye. 

Occasionally, it results from hypertension 

or a bleeding disorder, and small patches of 

haemorrhage known as ‘petechial 

haemorrhages’ may be seen in viral and 

bacterial infection. 

Discharge 

Discharge commonly accompanies 

conjunctivitis. The discharge in allergic 

conjunctivitis and in viral infection is thin 

and watery. In chronic, severe allergic eye 

disease, the discharge is thick and stringy. 

In bacterial conjunctivitis, a purulent 

(pus-containing) discharge is common, 

which may have a yellow or greenish 

colour. This may dry on the lid 

margins and lashes overnight and 

cause the lids to be gummed together on 

awaking. 

Follicles 

Follicles are typical of certain types of 

conjunctival inflammation. They are 

usually small, raised, whitish or pinkish 

lumps in the tarsal conjunctiva (Figure 3). 

There is normally no central blood vessel. 

Follicles consist of masses of lymphocytes, 

which have accumulated in response to an 

Figure 4 

Giant papillae, and a pale conjunctival 

scar under the upper lid in severe 

vernal keratoconjunctivitis 

immune reaction to viral or chlamydial 

infection. They are also seen in contact 

conjunctivitis and in staphylococcal 

blepharo-keratoconjunctivitis. 

Papillae 

Papillae are divisible into three types, 

according to their diameter (which can be 

measured using the length of the slit lamp 

beam): 

• 1mm: giant papillae (Figure 4) 

Micropapillae fall within the category of 

normality: a normal tarsal surface may be 

perfectly smooth or bear micropapillae. 

Macropapillae and giant papillae have 

similar histologies and pathogenesis and 

are the result of chronic inflammation, 

especially of allergic origin. 

Pseudomembrane 

Pseudomembrane is distinguished from 

true membrane (for example, that 

occurring in diphtherial infection) by the 

fact that it can be wiped away from the 

surface of the affected mucous membrane. 

Consisting of mucus, fibrin and 

inflammatory cells, it accumulates on the 

tarsal surfaces in severe conjunctival 

infections, such as that sometimes 

produced by the adenovirus. 

Scarring 

Scarring can occur as a result of any chronic 

conjunctivitis. In trachoma, there is 

cicatricial (shrinking) scarring which can 

produce entropion of the lid margins. In 

vernal keratoconjunctivitis, another disease 

caused by chronic conjunctival 

inflammation, this process is not seen. At 

the slit lamp, scar tissue is sometimes more 

easily seen if the red-free (green) filter is 

used. 

Keratinisation 

This dysplasia of the conjunctiva is seen in 

a number of chronic inflammations, such 

as Stevens-Johnson syndrome and ocular 

cicatricial pemphigoid. The normally nonkeratinising 

conjunctiva begins to produce 

keratin, especially just inside the lid 

margins, and this comparatively rough, 

32 | May 6 | 2005 OT

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Figure 5 

Multiple small star-like subepithelial corneal 

opacities in adenoviral infection 

Figure 6 

Molluscum contagiosum lesion on the lid margin 

skin-like, non-wetting surface can 

traumatise the ocular surface. Therapy with 

retinoic acid drops is sometimes prescribed 

for this condition. 

Bacterial infection 

Bacterial conjunctivitis is a common, 

usually self-limiting condition. The usual 

cause is a gram-positive infection 

(Staphylococcus epidermidis, Staphylococcus 

aureus, Streptococcus pneumoniae) but 

gram-negative infections (Haemophilus 

influenzae, Moraxella lacunata) are common 

also. Patients complain of a sudden onset 

of redness, watering and grittiness of the 

eye, which may be sticky on waking. The 

condition causes discomfort but is not 

painful. 

Clinical signs: 

• Hyperaemic conjunctiva 

• Epiphora 

• Mucopurulent discharge 

• Vision is usually normal as the cornea is 

unaffected, though it may be 

temporarily obscured by discharge 

Management: 

• Topical antibiotic drops, e.g. 

chloramphenicol 0.5%, applied every 

two hours for two days, then four times 

daily for another three or four days 

• Topical antibiotic ointment, e.g. 

chloramphenicol 1%, can also be used, 

though it temporarily causes smeary 

vision if too much is instilled. 

Bacteriostatic tear levels are achieved 

more readily with the ointment than 

with the drops 

• Other antibiotics that are commonly 

used include ofloxacin, gentamicin and 

fusidic acid 

Ophthalmia neonatorum can be contracted 

by the newborn during normal delivery 

when there is infection of the birth canal. 

The usual agents are Chlamydia trachomatis 

and Neisseria gonorrhoeae. These can 

produce severe infections involving the 

cornea as well as the conjunctiva, and 

require urgent management by an 

ophthalmologist. 

Viral infection 

Adenovirus 

Adenovirus infection is a common cause of 

acute epidemic keratoconjunctivitis, 

especially in the Summer months. It is 

highly contagious, being communicable for 

10 to 14 days with an incubation period of 

five to 12 days, and tends to proliferate in 

closed communities (e.g. schools, Summer 

camps, prisons) and in places where 

patients attend, such as eye out-patient 

departments and accident and emergency 

departments. Several strains of adenovirus 

may cause it; some are more virulent than 

others and some produce a keratitis also. 

Though the portal of entry is the 

conjunctiva, there is commonly an 

associated upper respiratory tract infection, 

which may precede the conjunctivitis by a 

few days. Because the disease is so easily 

picked up, there may be a history of others 

in the family, class or workplace having 

been affected. 


• Swelling of the lids 

• Follicular conjunctivitis, especially of 

lower fornix (easy to examine) and 

upper fornix (difficult to examine); 

usually one eye is earlier and more 

severely affected than the other 

• In severe cases, the tarsal 

surfaces may be covered by 

pseudomembrane 

• Swelling of pre-auricular and other 

local lymph nodes (lymphadenopathy) 

• Punctate epithelial and sub-epithelial 

keratopathy (requires slit lamp 

examination) (Figure 5) 

Management: 

• Specific anti-viral treatment 

is not yet available 

• Advise the patient that the 

condition is highly contagious 

• Non-severe cases are best managed 

outside eye departments because 

of the infective danger to other 

patients and to staff 

• A topical steroid can be used in severe 

cases (pseudomembrane, sight-involving 

keratitis). Treatment should be initiated 

and monitored by an ophthalmologist. 

This may be required for weeks or 

months and steroid-related adverse 

effects may result 

Herpes simplex virus 

It is a common clinical impression that 

cases of herpes simplex keratitis are 

becoming less frequent. The primary 

infection may be a mild and transitory 

unilateral or bilateral blepharoconjuctivitis. 

Recurrent disease (usually unilateral) is 

more serious, as it involves the cornea. The 

virus resides in the trigeminal ganglion, 

from which it cannot be eradicated. 


• Primary herpes: vesicles on lid margin, 

plus follicular conjunctivitis 

• Dendritic ulcer: a branching linear 

epithelial ulcer of the cornea, easily seen 

if fluorescein is instilled into the tear film 

and the eye is examined with a blue light 

• ‘Amoeboid’ or ‘geographical’ ulceration 

involves the corneal stroma and is more 

severe. It may result from incorrect use 

of topical steroid 

• Scarring, vascularisation of the cornea 

with reduction of vision if the central 

area is involved (disciform keratitis) 

Management: 

• Topical therapy with ophthalmic 

antivirals, such as aciclovir (Zovirax 

ophthalmic ointment) 

• Severe recurrent cases and bilateral cases 

may require systemic antivirals 

• If pseudomembrane is present, or if 

keratitis is severe or persistent, the 

ophthalmologist may prescribe a topical 

steroid in conjunction with a topical 

antiviral 

• A low-dose topical steroid is required on 

a long-term basis in some cases, without 

antiviral cover. The lowest possible dose 

is always prescribed. Very low dilutions 

of prednisolone in drop form are 

available from some hospital pharmacies 

Herpes zoster virus 

Herpes zoster infection of the ophthalmic 

division of the trigeminal nerve (herpes 

zoster ophthalmicus) may involve the 

anterior segment of the eye. Involvement of 

the nasociliary nerve, with skin lesions on 

the side or tip of the nose, makes this likely. 


• Maculopapular rash over forehead 

• Conjunctivitis 

• Episcleritis 

• Punctate epithelial keratitis 

• ‘Pseudodendrites’ of mucus (stain with 

rose bengal) 

• Nummular keratitis (cloudy stromal 

inflammation) 

• Disciform keratitis similar to herpes 

simplex keratitis 

• Associated with uveitis 

Management: 

• Systemic aciclovir 

• Systemic NSAID (e.g. flurbiprofen) 

for episcleritis 

• A topical steroid and antiviral (e.g. 

aciclovir ointment) 

33 | May 6 | 2005 OT


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Molluscum contagiosum 

The characteristic small umbilicated skin 

lesions of molluscum contagiosum may 

occur on the lids (Figure 6). Viral particles 

shed from the surface of the lesions may fall 

into the tear film, causing a unilateral or 

bilateral follicular conjunctivitis. 

Management is by removal (incision and 

curettage) of the lesions. There may be 

lesions elsewhere on the body and it is 

important that all of these be removed, 

otherwise the condition will recur. 

Chlamydial infection 

Inclusion conjunctivitis 

In the West, chlamydial keratoconjunctivitis 

is most often seen as a sexually transmitted 

condition and as a cause of ophthalmia 

neonatorum. It is known as inclusion 

conjunctivitis because of the appearance of 

characteristic basophilic cytoplasmic 

inclusion bodies on Giemsa staining of 

conjunctival smears. The causative agent is 

Chlamydia trachomatis sub-group A, 

serotypes D–K. 


• Follicular conjunctivitis 

• Punctate epithelial keratitis 

• Urethritis, cervicitis 

Management: 

• Topical tetracycline ointment (currently 

difficult to obtain) 

• Systemic tetracycline, doxycycline or 

erythromycin, when genital infection is 

also present 

• Referral to the genito-urinary clinic or 

sexually-transmitted disease clinic 

Trachoma 

Trachoma, caused by Chlamydia trachomatis 

(sub-group A, serotypes A–C) is one of the 

world’s most important causes of 

preventable blindness, and occurs in 

underprivileged populations, among whom 

it is spread by flies. 


• Chronic follicular conjunctivitis 

• Conjunctival scarring leading to tear 

deficiency and entropion 

• Corneal scarring and vascularisation 

secondary to lid disease and tear 

deficiency (Figure 7) 

Management: 

• Avoidance of infection by improved 

personal hygiene 

• Drug therapy as for inclusion 

conjunctivitis 

Recent experience in Tanzania has shown the 

value of mass treatment of a population. The 

prevalence of trachoma before the start of 

the study was 9.5%. Systemic azithromycin 

was given to the population, followed by 

tetracycline eye ointment in persistent cases. 

Two months later, the prevalence was 2.1% 

and this had fallen to 0.1% at two years. 

Ocular allergic disease 

Because of its exposed nature, the mucous 

membrane of the eye comes into contact 

with a huge number and a wide variety of 

airborne particles. Allergic diseases of the 

eye are responsible for a wide range of 

disorders, from the familiar and 

uncomfortable condition of SAC to rarer, 

life disrupting disorders, such as vernal 

keratoconjunctivitis. 

Six types of ocular allergic disease have 

been described: 

• Acute allergic conjunctivitis (AAC) 

• Seasonal allergic conjunctivitis (SAC) 

• Perennial allergic conjunctivitis (PAC) 

• Vernal keratoconjunctivitis (VKC) 

• Atopic keratoconjunctivitis (AKC) 

• Contact lens-associated papillary 

conjunctivitis (CLAPC) or giant 

papillary conjunctivitis (GPC) 

Table 3 shows the differences between the 

six basic conditions in terms of age of 

onset, need of topical steroid medication 

and morbidity. An interesting feature is the 

geographical variations between the 

conditions; in Europe, mild conditions are 

common while severe sight-threatening 

conditions are rare. 

Acute allergic conjunctivitis (AAC) 

This urticarial reaction presents as 

conjunctival and lid oedema of sudden 

onset and can affect both atopes and nonatopes. 

It results from the introduction of a 

significant amount of allergen (e.g. pollen, 

animal dander) into the eyes. The eyes itch 

and the lids may swell to the extent that 

they close. 


• Oedema of bulbar conjunctiva 

• Swelling of lids, ptosis 

• No corneal involvement 

Management: 

• Self-limiting, usually requiring no 

treatment 

• If recurrent, attempt to identify the 

allergen and counsel avoidance 

• If recurrent, consider treatment with 

topical mast cell stabilisers 

Seasonal allergic conjunctivitis (SAC) 

SAC is a common condition (also called 

hay fever conjunctivitis) affecting up to 

21% of the general population in the age 

group 10 to 40 years (peaking at 20 to 30 

years). It is the ocular component of hay 

Figure 7 

Progressive corneal scarring in AKC 

fever. The symptoms are itching, watering, 

stickiness and redness of the eyes, plus 

other symptoms of hay fever. It is 

important to ask the patient about his or 

her specific symptoms, as hay fever is 

variable in its manifestations. 

Clinical (ocular) signs: 

• Minimal conjunctival oedema and 

hyperaemia 

• Mild papillary hypertrophy of 

conjunctiva 

• No corneal involvement 

Management: 

• Allergen avoidance (which is difficult or 

impossible in the case of common 

allergens, such as grass pollen or house 

dust mite) 

• Topical mast cell stabilisers, 

e.g. sodium cromoglicate, lodoxamide, 

nedocromil sodium 

• Systemic anti-histamines, a number of 

which can be bought without 

prescription at pharmacies or even 

non-pharmaceutical retail outlets 

• Topical anti-histamines: guttae 

Otrivine-Antistin (a combination of 

vasoconstrictor and antihistamine) or 

modern H1-receptor antagonists, such 

as emedastine, azelastine, levocabastine 

and epinastine. Also mast cell 

stabiliser/antihistamine drugs such as 

olopatadine and ketotifen 

Perennial allergic conjunctivitis (PAC) 

PAC is less common than SAC; it occurs at 

any time of the year, with seasonal 

variation. In the UK, it is a response to the 

presence of house dust mite (HDM). The 

symptoms are the same as for SAC and 

again the signs are minimal. Drug 

management follows the same principles. 

Patients need advice on the reduction of 

Table 3 

Summary of allergic eye disease – age presentation, need of steroid and morbidity 

Condition Age at presentation Need of steroid Morbidity 

AAC All ages although highest prevalence in children Nil Low 

SAC Between the ages of 10 and 40 years Nil Medium 

PAC As above Low Medium 

VKC Usually less than 10 years of age Very likely High 

AKC Young adults Very likely High 

GPC Any age group although highest Very low, except in Medium 

prevalence in contact lens wearers prosthesis wearers 

34 | May 6 | 2005 OT

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Figure 8 

Epithelial macro-erosion in VKC 

Figure 9 

Corneal plaque in VKC 

HDM levels in their environments, 

especially the bedroom. This will involve 

high levels of domestic cleaning, removing 

carpets and curtains where possible and 

covering mattresses and pillows with 

mite-proof covers. Synthetic pillows 

that can be washed at 60˚C are to be 

preferred to pillows containing feather or 

down. 

Vernal keratoconjunctivitis (VKC) 

In the UK, this is a rare, serious disease of 

the young (incidence


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Module 8 Part 5 of Therapeutics in clinical practice – Disorders of the conjunctiva – Part 1 

Please note: There is only ONE correct answer 

1. Which one of the following 

statements is incorrect? 

Inflammation is: 

a. a process by which white blood cells 

and fluid accumulate within a tissue 

b. characterised by pain, redness, swelling, 

heat and resulting loss of function 

c. mediated by specific 

pathophysiological reactions 

d. initiated by infection only 


statements is incorrect regarding 

infection? 

a. Endotoxins trigger inflammatory 

reactions 

b. Lipopolysaccharide (LPS) is a 

component of gram-positive bacterial 

cell walls 

c. LPS activates white blood cells 

d. LPS upregulates the activity of 

cytokines 



the immune response? 

a. Immune complexes initiate 

inflammation by activating the 

complement pathway 

b. Immune complexes cause 

degranulation of mast cells and 

basophils 

c. T-lymphocytes mediate delayed 

hypersensitivity reactions 

d. Immediate hypersensitivity 

involves IgG receptors 



hyperaemia? 

a. It is caused by constriction of 

capillaries 

b. It may be diffuse in viral or bacterial 

infection 

c. Ciliary injection is associated with 

corneal infection and intraocular 

inflammation 

d. Localised hyperaemia may be caused by 

a patch of episcleritis or an embedded 

foreign body 

5. Which one of the following statements 

is incorrect regarding sub-conjunctival 

haemorrhage? 

a. Occurrences are usually spontaneous 

b. It may result from hypertension or a 

bleeding disorder 

c. Petechial haemorrhages may be seen in 

viral and bacterial infection 

d. It is usually caused by major trauma 


is incorrect? Conjunctival discharge in: 

a. allergic conjunctivitis is thin and watery 

b. viral infection is thin and watery 

c. chronic severe allergic eye disease is 

thick and stringy 

d. bacterial conjunctivitis is thin and 

watery 


is incorrect regarding follicles? 

a. They are usually small, raised, whitish 

or pinkish lumps in the tarsal 

conjunctiva 

b. Usually there is a central blood vessel 

c. Follicles consist of masses of 

lymphocytes 

d. They may be seen in staphylococcal 

blepharo-keratoconjuntivitis 


is incorrect regarding bacterial 

conjunctivitis? 

a. It is a common, usually self-limiting 

condition 

b. It is only caused by a gram-positive 

infection 

MCQs 

c. Patients complain of a sudden inset of 

redness, watering and grittiness of the 

eye 

d. Vision is usually normal (occasionally 

obscured by discharge) 


is incorrect regarding adenovirus? 

a. It is highly contagious for 10 to 14 days 

b. Some strains may produce a keratitis 

c. An upper respiratory tract infection may 

precede the conjunctivitis 

d. Papillary conjunctivitis is an associated 

feature 


is incorrect regarding herpes simplex 

virus? 

a. The primary infection may be mild 

b. Recurrent disease may involve the cornea 

c. The virus resides in the trigeminal 

ganglion 

d. The virus can be easily eradicated from 

the body 


is incorrect regarding acute allergic 

conjunctivitis? 

a. It presents as conjunctival and lid 

oedema of sudden onset 

b. The eyes are itchy 

c. The cornea is usually involved 

d. The condition is usually self-limiting 

12. Approximately what proportion of 

vernal keratoconjunctivitis sufferers 

have a history of atopic disease? 

a. 15% 

b. 55% 

c. 75% 

d. 95% 

An answer return form is included in this issue. It should be completed and returned to: 

CET initiatives (c-133), OT, Victoria House, 178-180 Fleet Road, 

Fleet, Hampshire, GU51 4DA by June 4, 2005. 

Under no circumstances will forms received after this date be marked 

– the answers to the module will have been published in our June 6, 2005 issue. 

36 | May 6 | 2005 OT

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