**3. Conjunctivitis in the immunocompromised**

Conjunctivitis in the immunocompromised is something that is often overlooked by the gen‐ eral practioner. However, it is essential to properly investigate conjunctivitis in immunodefi‐ cient patients as they are more likely to suffer from long term complications such as dendritic ulcers and corneal damage.

#### **3.1. Epidemiology and conjunctival microvascular disease associated with HIV**

Up to 75% of HIV infected patients have suffered from conjunctivitis. Most will exhibit mi‐ crovascular changes of the conjunctiva, often the inferior perilimbal bulbar conjunctiva. These changes are often seen as capillary dilations, short irregular vessels and a granular ap‐ pearance of blood column within the vessels.

In some cases, there have been reports of direct infiltration of the vascular endothelial cells of the conjunctiva being infiltrated by the HIV virus, which causes a deposition of immune complexes within the conjunctiva, causing conjunctivitis.

#### **3.2. Infections causing conjunctivitis in the immunocompromised**

Most conjunctivitis reports in the immunocompromised, especially HIV, have shown *staphy‐ lococci* to be the main infective agent, with *coagulase negative staphylococci* (mostly *staphylococ‐ cal epidermidis* the majority) accounting for most of the cases. The major other normal flora organism which cause infection in immunocompromised patients include *cornybacterium pseudo/diphtherticum*(found in the nasopharynx) and certain members of the *Haemophilus* group. Isolated cases of *neisseriameningitidis*and the *measles* virus have also been found in im‐ munocompromised patients, although no study has yet shown a direct link between these two organisms and conjunctivitis in the immunocompromised.

Opportunistic infections may also cause conjunctivitis. Below are common pathogens that have been identified as opportunistic infections causing conjunctivitis:

**•** Microsporidial keratoconjunctivitis- Reports of microsporidial keratoconjunctivitis in AIDS patients have been noted. This infection is caused by an intracellular protozoan par‐ asite of the phylum *Microspora*. Patients affected with Microsporidial keratoconjunctivitis experience similar symptoms as with any other bacterial infection, but the symptoms of photophobia and extreme redness are also present. There may also be bilateral conjuncti‐ val hyperaemia with diffuse coarse white infiltrates, conjunctival hypertrophy and ero‐ sions of the corneal epithelium [30].

Microsporidial keratoconjunctivitis should not be overlooked in HIV patients because it rarely responds to conventional topical antivirals or antibacterials. In some cases, antiproto‐ zoal medication has also been reported as ineffective. A recent study found that Fumagillin (Fumidin B) is the treatment with most positive outcome in HIV patients with Microspori‐ dial keratoconjunctivitis [31].

**Figure 10.** Conjunctivitis in a patient suffering from AIDS

*2.2.5. Prognosis of viral conjunctivitis*

32 Common Eye Infections

how long the symptoms remain.

with viral conjunctivitis [29].

dendritic ulcers and corneal damage.

pearance of blood column within the vessels.

complexes within the conjunctiva, causing conjunctivitis.

**3.2. Infections causing conjunctivitis in the immunocompromised**

two organisms and conjunctivitis in the immunocompromised.

have been identified as opportunistic infections causing conjunctivitis:

**3. Conjunctivitis in the immunocompromised**

Viral conjunctivitis is extremely contagious and remains so for 14 days, which also is often

The prognosis is very good for viral conjunctivitis. It resolves completely within 2 weeks of the 'pink eye' onset and there are rarely any long term complications or problems associated

Conjunctivitis in the immunocompromised is something that is often overlooked by the gen‐ eral practioner. However, it is essential to properly investigate conjunctivitis in immunodefi‐ cient patients as they are more likely to suffer from long term complications such as

Up to 75% of HIV infected patients have suffered from conjunctivitis. Most will exhibit mi‐ crovascular changes of the conjunctiva, often the inferior perilimbal bulbar conjunctiva. These changes are often seen as capillary dilations, short irregular vessels and a granular ap‐

In some cases, there have been reports of direct infiltration of the vascular endothelial cells of the conjunctiva being infiltrated by the HIV virus, which causes a deposition of immune

Most conjunctivitis reports in the immunocompromised, especially HIV, have shown *staphy‐ lococci* to be the main infective agent, with *coagulase negative staphylococci* (mostly *staphylococ‐ cal epidermidis* the majority) accounting for most of the cases. The major other normal flora organism which cause infection in immunocompromised patients include *cornybacterium pseudo/diphtherticum*(found in the nasopharynx) and certain members of the *Haemophilus* group. Isolated cases of *neisseriameningitidis*and the *measles* virus have also been found in im‐ munocompromised patients, although no study has yet shown a direct link between these

Opportunistic infections may also cause conjunctivitis. Below are common pathogens that

**•** Microsporidial keratoconjunctivitis- Reports of microsporidial keratoconjunctivitis in AIDS patients have been noted. This infection is caused by an intracellular protozoan par‐ asite of the phylum *Microspora*. Patients affected with Microsporidial keratoconjunctivitis experience similar symptoms as with any other bacterial infection, but the symptoms of

**3.1. Epidemiology and conjunctival microvascular disease associated with HIV**

**•** Molluscum contagiosum-Although rarely affecting the conjunctiva even in immunocom‐ promised individuals, molluscum contagiosum has been noted to primarily affect the conjunctiva and also cause secondary conjunctival inflammation during infection. In one case report, a nodule of molluscum contagiosum was noted on the bulbar conjunctiva on a 34 year old man with AIDS [32]. However, in most cases of patients in an immunocom‐ promised state with molluscum contagiosum, the conjunctiva is secondarily affected, causing an associated follicular conjunctivitis [33].

Treatment of primarily conjuctival infection of molluscum contagiosum is via cryotherapy and/or surgery, although this has shown to provide only limited long term correction in HIV patients.

**•** Fungal infections- Fungal infections affecting the conjunctiva are rare. In immunocompro‐ mised patients, the cornea is often affected, causing a keratitis to develop. This can how‐ ever, cause a secondary conjunctivitis. Studies have shown that *Cryptococcus* and *Candida albicans* are the most common pathogens affecting the cornea and conjunctiva in immuno‐ compromised patients.

Fortunately, the treatment is very effective for fungal infections. Although hospital admis‐ sion is required in patients affected with keratitis, topical amphotericin B or natamycin, sub‐ conjunctival miconazole and oral ketoconazole are proven effective antifungals.
