Conjunctivitis

Jimi Windmills

Introduction

Conjunctivitis is an inflammation of the conjunctiva, the connective tissue which lines the inside of the eyelid (palpebral conjunctiva) and folds back on itself to cover the sclera of the eye (bulbar conjunctiva). It is a common condition seen in emergency departments, roughly 30% of all ocular complaints are due to some form of conjunctivitis (Silverman et al. 2013).

The term conjunctivitis refers any inflammation of the conjunctiva. However, there are some aetiologies which are more common; Viral, bacterial, fungal, parasitic, toxic, chlamydial, chemical, and allergenic (Silverman et al. 2013). It is generally considered that viral aetiologies are most prevalent, however, a study by Fitch et al., found that viral conjunctivitis has a higher incidence in summer, while bacterial infections occur more frequently in winter and spring (1986: 1215-20). An article published in the American Journal of Ophthalmology by Fannin et al., found that store merchandise display hooks pose a risk of conjunctival laceration, which in turn could lead to irritation of the conjunctiva or a potential bacterial infection (1995: 397-9). However, one assumes this would constitute a very small percentage of cases.

Conjunctivitis is an interesting topic due to it having a diverse set of aetiologies, and relatively simple disease process. It is a condition that I have seen before, but as yet, have not had the opportunity to treat.

Western Medicine

Anatomy and Physiology.

The upper eyelid has five layers, from the most exterior skin layer, through the orbicularis muscle, the levator aponeurosis and muscle, the tarsal muscle, and the most interior layer, the conjuctiva. The lower eyelid has a similar build, but lacks clearly defined muscle and aponeurosis. The eyelids have cilia (eyelashes) which extend from follicles which are surrounded by nerve plexuses which exhibit a low threshold for tactile excitation. Each follicle has several sebaceous (Zeis) glands, which secrete sebum to the border of the eyelid, and base of the eyelashes (BenEzra 2006: 21).

In addition to the Zeis glands, there are also sebaceous glands in the tarsal plates, these Meibomian glands are arranged in a row, posterior to the lashes, and are visible through the conjunctiva as a thin white band. In addition to many sweat (Moll) glands, the eyelids also have primary lacrimal glands, as well as accessory lacrimal glands (glands of Krause and Wolfring), which produce the watery component of tears (BenEzra 2006: 21).

Tears in brief, form an antibacterial film covering the palpebral and bulbar conjunctiva, and the cornea. They lubricate the eye to enable blinking, and as well as removing cell debris and foreign material from the eye, provide the tissue of the ocular surface with oxygen and nutrients (BenEzra 2006: 22).

Clinical Pathology of Conjunctivitis

There are several systems that have been developed to grade the severity of conjunctivitis. The Ocular Surface Disease Index (OSDI), scores the length of time a symptom has been present; The Severity Index (SI), in which a patient subjectively scores the severity of a range of symptoms; The Subjective Function Ability Index (SFAI), subjectively measures the patients ability to perform their daily activities; Finally, the grading system developed by the International Ocular Inflammation Society (IOIS), the Grading of Symptoms and Signs (GOSAS), which is an extremely comprehensive grading system used to score the severity of ocular surface diseases, including conjunctivitis (BenEzra 2006: 41-2). See appendix 1.

Acute Conjunctivitis

The following signs and symptoms are usually apparent in acute conjunctivitis

• Edema – In conjunctivitis, referred to as inflammatory chemosis, involves the migration of fluids from the capillaries of the conjunctiva, into the subconjunctival tissue. This is a result of increased permeability of vessels due to the inflammatory response, and reduced flow of blood and lymph in the local area (BenEzra 2006: 50).
• Hyperemia – Responsible for the red appearance of the eyes, is due to vasodilation as an inflammatory response, leading to engorged blood vessels in the conjunctiva (BenEzra 2006: 50).
• Exudate - The discharge seen in conjunctivitis, may be useful in differential diagnosis. The discharge is composed of tears, mucus, plasma components, inflammatory cells, and epithelial debris. Different aetiologies will lead to different proportions of these components making up the discharge. Thus, the discharge may be watery, mucoid, serous, purulent or mucopurulent. While it is not definitive, a watery discharge may indicate the beginning of a viral infection, Serous and mucoid discharges are often found with allergic reactions, and purulent and mucopurulent discharge could indicate a bacterial infection (BenEzra 2006: 32).
• Ulcers – Result from a loss of surface epithelium. Usually deeper than abrasions, and often display some tissue necrosis (BenEzra 2006: 51).
• Membranes – There are two types, true membranes and psudomembranes. True membranes form from fibrin and cell exudate which permeates and binds the mucous membrane and the conjunctival epithelium. Attempts to remove a true membrane leaves behind torn tissue and a bleeding surface. Psudomembranes form a layer of fibrin and cell exudate which covers the conjunctival epithelium, but can be removes with little or no bleeding (BenEzra 2006: 51).
• Haemorrhage – When seen in conjunction with inflammation, usually occurs during viral conjunctivitis (BenEzra 2006: 51).

Chronic Conjunctivitis

Chronic conjunctivitis is distinguished from an acute attack by the presence of epithelial and subepithelial cell changes. The following cell changes are most common.

• Goblet Cells – Can increase in density, and can be found replacing large areas of normal conjunctival epithelium. This in turn may lead to increased mucus secretion (BenEzra 2006: 52).
• Epithelial Hyperplasia – A thickening, due to more rapid multiplication of the cells in the epithelium, as a result of chronic irritation (BenEzra 2006: 52).
• Metaplasia – A change in differentiated cells from one type to another. For eg. Squamous metaplasia, where superficial cells become desquamated and flat (BenEzra 2006: 52).
• Keratinization – Late stage squamous metaplasia of the conjunctival epithelium. Cells become flat and dry like that of the skin due to the production of keratin (BenEzra 2006: 52).

Diagnosis and Treatment

Treatment of conjunctivitis is dependant on its diagnosis. Viral conjunctivitis can generally be diagnosed by taking a patient history, and observing the signs. A recent history of common cold or respiratory tract infection, accompanied by watery discharge is usually sufficient to diagnose a viral cause. Lab tests may be done in more sever cases to rule out herpes simplex, or a varicella-zoster virus. Viral conjunctivitis is generally self limiting, lasting between 3-7 days, and 2-3 weeks in especially bad cases. Dryness and swelling can be relieved with artificial tears and a cool compress. For more serious viral infections, anti-viral medication may be prescribed (CDC 2013).

As with viral conjunctivitis, a bacterial cause can usually be determined by taking the patient history, and by signs and symptoms. If it is accompanied by an ear infection, and there is a thick exudate, it is likely a bacterial infection. In severe cases a sample of the discharge may be taken to assess which bacterium is involved. Bacterial infections are usually treated with antibiotics in the form of eye drops or ointments. Artificial tears and cold packs may help relieve the symptoms (CDC 2013).

Allergic conjunctivitis can also be diagnosed by symptoms, signs, and a patient history. If it typically occurs seasonally, or is accompanied by an intense itch, this may be enough to form a diagnosis. Other signs of allergenic type conjunctivitis may be a history of asthma, eczema, or allergic rhinitis. Allergic conjunctivitis resolves when the allergen is no longer present. Topical antihistamines in the form of eye drops, and allergy medication can also be of some help (CDC 2013).

Traditional Chinese Medicine

In Chinese medicine as in Western medicine, conjunctivitis is recognised as having acute and chronic presentations. The aetiology is generally considered to be an invasion of one of the six pathogenic influences, or from zangfu disturbance, which usually involves the Liver and Gallbladder.

There are six primary channels that travel to the head and either connect with or terminate at the eyes. These are the Large Intestine, Stomach, Small Intestine, Bladder, San Jiao and Gall Bladder channels. To these we can also add the extraordinary vessels Du and Ren, as well as the Chong which has an internal divergent branch which terminates below the eyes. Both the Yin Wei and Yang Wei Mai connect with the eyes, and the Yang Qiao Mai also passes through the area. A special note should be made for the Liver channel, which has an internal divergent branch which connects with the eyes on its way to the vertex of the head. It is through this connecting branch that the liver rules the eyes, and performs its role of nourishing and moistening them. It is easy to see then that there are potentially many factors that could be involved in eye disease, and that disharmony and one or more of these channel systems could either directly affect the eye, or leave the channels, or the eye itself vulnerable to invasion of an external pathogen. This idea is beautifully expressed by Masakazu, who says:

“The eyes are the outward expression of the liver and represent the flowering of the essence of the five Yin organs, the iris is liver wood, the inner and outer edges are the heart fire, the upper and lower lids are the spleen earth and the whites are the lung metal and the pupil is the essence of the kidney water” (2005: 260).

Patterns

There are many patterns in Chinese medicine for conjunctivitis. Some of these fall under the title 'conjunctivitis' while some fall under titles such as reddening of the eyes (Mu Chi) or swollen eyelids (Mu Bao Zhong Zhang). There are also unusual patterns, and patterns that are unique to particular authors. Such patterns as Yin Vacuity of the Liver and Kidneys, and Alcohol toxins brewing internally, fall into this category. With this in mind, I will discuss the two most common patterns, Wind-Heat invasion and Liver and Gallbladder Fire.

Wind-Heat Invasion

Sionneau tells us that people who are constitutionally more Yang will be prone to invasion of external wind-heat. When Wind-Heat invades and attacks the eyes, the bodies defensive Qi will enter a struggle with the pathogenic Qi, and cause stagnation of Qi and Blood in the vessels of the eyes, leading to redness. If the heat is predominant, it may force blood out of the vessels, and haemorrhaging may occur (2007: 61).

According to Mu, invasion of Wind-heat is the most prominent aetiological factor in conjunctivitis. Symptoms include redness, swelling, and pain in the eyes, lacrimation, fever, aversion to wind and a light, thin or yellow tongue coating with a rapid pulse (2000: 393). To these, Sionneau adds a rough sensation in the eyes, nasal congestion, headache and aversion to cold. He also tells us that there may be a thin white coat on the tongue and that the pulse may have a floating quality (2007: 63).

Cheng approaches Wind-Heat a little differently. He says that Wind-heat will invade either the Lung channel, or the Liver and Gallbladder channels. Each pattern has the Wind-Heat picture described by our other authors¹, but he differentiates between the two by the appearance of Liver type symptoms such as a bitter taste in the mouth, constipation, dizziness, irritable or angry, a red tongue with a yellow greasy coating, and a pulse which is wiry and slippery (2005: 389).

Treatment of Wind-Heat conjunctivitis should employ the following treatment principle; expel Wind-Heat, clearing the eyes, reduce swelling and alleviate pain.

• Mu's Points: Taiyang (EX-HN 5), BL2, GB1, Erjian (EX-HN 6), LI4, and LI11 (Mu 2000: 393).
• Cheng's Points: LI4, LR3, BL1, and Taiyang (EX-HN 5). Additional points for fever and aversion to cold: LU11 and DU23. For Wing-Heat in the Liver and Gallbladder channels: LR2 and GB43 (2005: 389).
• Sionneau's Points: GB20, DU23, Yuyao (EX-HN 8), Taiyang (EX-HN 9), LI4. Additionally, DU23, Taiyang, Yuyao and LI4 should be bled if heat is predominant. If there is constipation add ST44 (2007: 63).

Liver and Gallbladder Fire

The most common internal disharmony causing conjunctivitis is Liver and Gallbladder excess Fire (Mu 2000: 393). Sionneau elaborates further, saying that Liver and Gallbladder fire is typically generated by emotional disturbances like frustration, anger, or depression. Fire can also arise from externally contracted Damp-Heat, or from spleen insufficiency due to improper diet. We see here the connection of the liver and the eyes, where fire attacks along the channel, pushing blood out of the network vessels, reddening the eyes (2007: 62). This results in conjunctivitis with redness and swelling, pain in the eyes with sticky discharge, bitter taste in the mouth, irritability, dizziness, red tongue with yellow coat and a rapid pulse (Mu 2000: 393).

The treatment principle for conjunctivitis due to Liver and Gallbladder Fire is to clear and purge Liver and Gallbladder Fire, reduce swelling, and alleviate pain.

• Mu's Points: Taiyang (EX-HN 5), BL2, GB1, Erjian (EX-HN 6), LR2, and GB43 (Mu 2000: 393).
• Cheng's Points: LI4, ST36, Taiyang, BL1, BL2, SJ23 (2005: 390).

Wang takes a different approach. He views conjunctivitis as a shaoyang disorder, where counter flow of liver and gallbladder fire gives rise to wind-fire rising upward. Along with the presenting complaint of conjunctivitis, there may also be dryness or itchiness of the eyes, tinnitus, dizziness, and high blood pressure, headache, toothache, nasal congestion or vomiting. For this he prescribes SJ5 and GB41. Interestingly, this is an extraordinary point pair for the Dai Mai, and Yang Wei Mai, which clears heat from the head, and from the lower body as well (Wang and Robertson 2008: 555).

Conclusion

Conjunctivitis is a disease of many facets. In western medicine it has as many aetiologies as it does presenting features, and in Chinese medicine, it has as many patterns as there are authors who broach the subject. When it comes down it, in the end there is heat, and there may be a component of wind, or perhaps even damp. The beauty of Chinese medicine is that based on the presentation of the condition on the day you see it, and a description of the onset and course of the disease to date, a simple treatment principle to address to clinical features, and underlying elements, almost suggests itself. Based on this treatment principle it a logical and simple process to form a point prescription, and in all the authors prescriptions above, it is easy to identify their point rational and intentions. That said, I am a little dubious when it comes to needling a point like BL1 in a condition as temperamental as conjunctivitis. In the same way I would be dis-inclined to needle directly into a weeping ulcer on the leg of a diabetic. In a case where the course of the disease has been short, and so far only one eye has been affected, I may, with extreme care and attention to aseptic procedure, needle BL1 on the opposite eye as a contralateral point, but the risk of transfering the infection still seems to outway the benefit of the specific point, especially when there are a lot of other very effective treatment options.

References

Silverman, M, Bessman, E, Chiang, W, Brenner B 2013. Emergent Treatment of Acute Conjunctivitis, Viewed 16 April 2013 http://emedicine.medscape.com/article/797874-overview#a1

Fitch, C, Rapoza P, Owens, S, Murillo-Lopez, F, Johnson, R, Quinn, T, Pepose, J, Taylor, H 1989. 'Epidemiology and Diagnosis of Acute Conjunctivitis at an Inner-City Hospital', Ophthalmology, vol. 98 no. 8 pp. 1215-20.

Fannin, L, Fitch, C, Raymond, W, Flanagan, J, Mazzoli R 1995. 'Eye Injury from Merchandise Display Hooks', American Journal of Ophthalmology, vol. 120, no. 3, pp. 397-9.

BenEzra http://books.google.com.au/books?id=J3tqqfA6EC4C&printsec=frontcover&dq=conjunctivitis&hl=en&sa=X&ei=s5hsUcjrOePYigew6IDABg&redir_esc=y#v=onepage&q=conjunctivitis&f=false

Wang and Robertson 2008

Cheng http://books.google.com.au/books?id=snqNMaWpLCgC&pg=PA390&dq=acupuncture+conjunctivitis&hl=en&sa=X&ei=eNZsUaifA6e9iAfQ-4GwCw&redir_esc=y#v=onepage&q=acupuncture%20conjunctivitis&f=false

Sionneau, P, Gang, L 2007. The Treatment of Disease in TCM: Diseases of the Eyes, Ears, Nose, and Throat, Blue Poppy Press, Kalamazoo.

Mu, J 2000. Advanced TCM Series: Volume 6 Acupuncture and Moxibustion, Science Press, Beijing.

CDC http://www.cdc.gov/conjunctivitis/about/treatment.html

1Redness, swelling, pain, tearing, secretions of mucus, headache and fever with a red tongue and a floating rapid pulse.