Conjunctiva

Conjunctiva sac :
Bulbar conjunctiva fornix medial semilunar fold palpebral conjunctiva (tarsal conjunctiva)

Histology :
conjunctival epithelium :
stratified cuboidal (over tarsus) columnar (over fornix) squamous (over globe)

Substansia propia :
adenoid layer fibrous layer

Bacteriology :
Never free from microorganism Bacteria do not propagate (proliferate) easily, due to :
relatively low temperature (exposure) evaporation lacrimal fluid bacteriostatic lysozyme enzyme mechanic (washing)

Bacteriology :
Microorganism that could be found in normal conjunctival sac :
Staph. epidermis Staph. aureus Micrococcus sp Corynebacterium sp Propionibacterium acnes Streptococcus sp Haemophylus influenza

In children

Moraxella sp Enteric gram (-) bacilli Bacilus sp Anaerobic bacteria Yeast Filamentous fungi Demodex sp

 The establishment and severity of infection are influenced by the interplay between the following factors :
Virulence of the pathogen Size and route of the inoculums Presence or absence of risk factors that compromise host defenses Nature of the hosts immune and inflammatory response

Classification of conjunctival Disorder

Parsons
Inflammations
Infection Allergy

Degenerative changes Symptomatic condition Cyst and Tumors

 General Ophthalmology
Conjunctivitis
infection allergy autoimmune chemical / irritates unknown cause

Degenerative disease Miscellaneous disorders Tumors

 Ophthalmologic examination, usually by inspection :

magnifying devices (loupe) flashlight / penlight / slitlight do not forget to everse superior eye lid

 Clinical terms :
hyperemia = focal / diffuse dilatation of subepithelial plexus of conjunctival blood vessels chemosis = conjunctival edema tearing = excess tears from increased lacrimation or impaired lacrimal outflow discharge = exudates on the conjunctival surface: serous, mucoid, mucopurulent, purulent

 Papillla = dilated conjunctival blood vessel, surrounded by edema and inflammatory cells Follicle = focal lymphoid nodule with accessory vascularization Pseudomembrane = inflammatory coagulum on conjunctival surface that doesnt bleed during removal Membrane = inflammotory coagulum on the conjunctival surface that bleeds when stripes

 Granuloma = nodule of chronic inflammatory cells with fibrovascular proliferation Phlyctenule = a nodule of chronic inflammatory cells, often at near or the limbus Punctate epithelial erosion = loss of individual epithelial cells in a stippled pattern Epithelial defect = focal ara of epithelial loss

 inflammation of the conjunctiva :

origin :
infection allergy

hyperemia secret

Common Causes of conjunctival Inflammation

Papillary conjunctivitis: allergic, bacterial Follicular conjunctivitis: adenovirus, mollusucum contangiosum, chlamydial, HSV, drug-induced Conjunctival pseudomembrane or membrane: severe viral/bacterial, stevens-jhonson syndr, chemical burn Conjunctival granuloma: cat-scratch disease, sarcoidosis, foreign-body reaction Conjunctival erosion or ulceration: stevens-jhonson syndrome, cicatrical pemphigoid, graft-host disease,

 Secret :
serous : viral mucous, mucopurulent : bacteria purulent : beware of gonococcus

bacterial investigation by gram histological investigation by giemsa

Infection of the conjunctiva

Acute :
serous catarrhal mucopurulent purulent membranous

chronic : simple chronic conjunctivitis angular conjunctivitis follicular conjunctivitis

Acute Catarrhal or muco-purulent conjunctivitis

Hyperemia that associated with a mucous discharge ---> gums lid together (especially in the morning) The whole conjunctiva is a fiery red (pink eye) Reaches its height in 3 - 4 days Rare complication, but cornea abrasion may occur Etiology :
Staphylococci (most common) Haemophilus aegyptius Pneumococcal

Accompanies exanthema such as measles and scarlet fever

 Treatment :
bacteriostatic drop the eyes should not be bandaged dark google should be worn if photophobia is present care must be taken due to contagious disease

Prognosis :
Most of cases are good Neglected cases are treated as chronic conjunctivitis

Purulent conjunctivitis
Occurs in two forms :
Babies : ophthalmia neonatorum Adult : conjunctivitis

Main and most dangerous etiology: gonococcus, N. gonorrhea Direct infection from genital Clinical finding :
Swelling of the lids and conjunctiva Copious purulent discharge Constitutional disturbance

Ulcer may occur at any part of cornea

 Treatment :
appropriate systemic and topical antibiotic the eyes should be irrigated with warm saline and intensive solution of crystalline benzylpenicilin if any purulent discharge present should be directed first to protection of to other eye In Cicendo Eye Hospital :
cefotaxime I.m. gentamycine or sulfacetamide eye drops

Ophtalmia Neonatorum
found in newborn children due to maternal infection responsible for 50% of blindness in children

E/ :
Severe : N. gonorrhea Mild :Chlamydia oculogenitalis, Streptococcus pneumonia

 Clinical findings :
conjunctiva : inflamed, bright red, swollen, yellow pus at severe muco-purulent conjunctivitis : infiltration at bulbar conjunctiva & lids are swollen and tense corneal ulceration if untreated

 Prophylaxis:
The babys lids should be cleansed and dried If infection is suspected use :
Credes method : a drop of silver nitrate solution 1% into each eye

Treatment
for ophtalmia neonatorum : penicillin, tetracycline & eritromicyn by mouth for penicillinase-producing N. gonorrhoeae: cephalosporin & gentamicin 0,3% drop In BKEC :
cefotaxime I.m. gentamycine or sulfacetamide eye drops

Membranous conjunctivitis
Known also as diphtheritic conjunctivitis E/ : diphtheria bacillus, pneumococcus & streptococcus occur esp. at children who have not been immunized, after measles, scarlet fever w/ impetigo

 Clinical findings :
mild cases : swelling of the lids, muco-purulent or serous discharge severe cases : lids are more brawny, conjunctiva is permeated w/ semisolid exudates, tend to necrotize conjunctiva and cornea

Treatment :
treated as diphtherial : penicillin and antidiphtheritic serum (4-6-10.000 units repeated in 12 hours)

Simple chronic conjunctivitis

Continuation of simple acute conjunctivitis Etiology :
irritation : smoke, dust, alcohol, etc hypersensivity

Symptoms :
burning and grittiness (especially in the evening) difficult to keep eyes open posterior conjunctival vessels are seen to be congested

 Treatment :
This consist in eliminating the cause and restoring the conjunctiva to its normal condition. Swab should be taken short course of suitable antibiotic

Follicular conjunctivitis
Inclusion conjunctivitis
Relatively acute onset hypertrophy is always prominent in the lower lid E/ : chlamydial infection

relatively benign healing spontaneously in from 3 to 12 months topical broad spectrum antibiotics systemic Antibiotics (tetracycline 250 mg every 6 hours for 14 days)

 Epidemic kerato-konjunctivitis
characterized by a rapidly developing follicular conjunctiva associated with pre-auricular adenopathy may lead to corneal complication associated with adenovirus Treatment by adenine arabinoside (Ara-A) is promising

Herpes simplex conjunctivitis

detected by the fluorescent antibody (FA) usually seen in young children tiny ulcers on the intermarginal portion of eyelid ----> with flourescin test

Trachoma
E/ : Chlamydia trachomatis

Usually starts sub acutely primary infection is epithelial both conjunctiva and the cornea (keratoconjunctivitis) typical conjunctival sign :
diffuse inflammation ---> congestion papillary enlargement development of follicles

occuring in 4 stage trachomatous pannus may develops at a later stage

Stage of Trachoma Stage 1: earliest stage, before clinical diagnosis is

possible

Stage 2: periode between the appereance of typical

trachomatous lession & the development of scar tissue

Stage 3: scarring is obvious Stage 4: the desease become quiet, cicatrization

 WHO: TF: folicular conjunctival inflammation TI: diffuse conjunctival inflammation TS: tarsal conjunctival scarring TT: trichiasis or enteropion CO: corneal opacification

 Treatment :
the ideal has not been developed tetracycline, erythromycin, rifampicin and sulfonamides are efective pannus requires no special treatment corneal complication (ulcers) must be treated on general principles

Allergic type of Conjugtivitis

Acute or sub acute allergic catarrhal conjunctivitis
watery secretion (not purulent) allergen sometimes is a bacterial protein (staphylococcus is most common) treatment :
allergen removal astringent lotion antihistamine drop is more effective

 Eczematous conjunctivitis
characterized by one or more small grey or yellow nodules on the bulbar conjunctiva frequently complicated by muco-purulent conjunctivitis E/ : endogenous bacterial protein Symptoms : discomfort and irritation associated with reflex lacrimation Treatment : Steroid drop or ointment

 Vernal conjunctivitis
bilateral conjunctivitis occur in hot weather symptom :
burning, itching, photophobia and lacrimation white & ropy secretion

two types :
palpebral form bulbar form

 Treatment :

symptomatic steroid drops or ointment cryotherapy (for nodule) mast cell stabillizer Disodium cromoglycate 2% (adjuvant to topical steroid)

Degenerative Changes
Lithiasis
hard yellow spots in the palpebral conjunctiva common in elderly people removed with sharp needle

Pinguecula
triangular patch on conjunctiva looks like fat (yellow color) no treatment required

 Pterygium
proliferate subconjunctival tissue as vascularized granulation to invade the cornea frequently follow a pinguecula

 Pterygium morphology grading system:

Grade T1: athrophic pterygium Grade T2: intermediate pterygium Grade T3: fleshy pterygium

 Options for wound clossure after extirpation:

Bare sclera Simple clossure Sliding flap Rotational flap Conjungtival graft

Symptomatic condition
Subconjunctival ecchymosed
due to rupture of small vessels the blood becomes absorbed without treatment in 1 - 3 weeks

 Chemosis
edema of conjunctiva occur in :
acute inflammation obstruction to the circulation abnormal blood condition

 Xerophthalmia
dry condition of the conjunctiva due to deficiency of vitamin A accompanied by night blindness occurs in two groups :
as a sequel of a local ocular affection associated with general disease

Clinical findings :
bitots spots

 Classification by ocular sign :

Night blindness (XN) conjunctival xerosis (X1A) Bitots spot (X1B) Corneal xerosis (X2) Corneal ulceration/keratomalacia < 1/3 of corneal surface (X3A) Corneal ulceration/keratomalacia > 1/3 of corneal surface (X3B) Corneal Scar (XS) Xerophthalmic fundus (XF)

Cysts and Tumors

Cyst
lymphangiectasis lymphangiomata Subconjunctival cysticercus ---> rare hydatid cysts ---> rare Epithelial implantation cysts ---> rare, occur after injuries or strabismus operations

 Tumors
Congenital tumors
Dermoids

Dermo-lipomata

Large papillae papillomata simple granulomata eptheliomata Pigmented tumors

Naevi

 Precancerous melanosis

Malignant melanoma Rodent ulcer

References
Stephen J.H. Miller, Parsons Disease of The Eye D, Vaughan, General Ophthalmology American Academy of Ophthalmology, External Disease and Cornea