The conjunctiva

Baghdad University
College of Medicine
Department of Surgery
Ophthalmology Division
 Objectives
By the end of this lecture the students will be able to
 Outline the symptoms and signs of common

conjunctival disorders and recognize their possible

causes
 Describe clinical features and management, list the

causes and discriminate between different types of

conjunctivitis
 Describe the clinical features and management of
common conjunctival degenerations
 The conjunctiva
Applied anatomy:

Epithelium
Stroma (substantia propria)
a- Superficial adenoid layer:
b- Deep thicker fibrous tissue.
Mucin secretor cells:
Accessory lacrimal glands:
 Clinical Evaluation of
conjunctival inflammation:
 1- Symptoms:

Conjunctivitis: Has non-specific symptoms

Lacrimation
Irritation
Stinging
Burning
Photophobia
VA????????????? But if associated with
keratitis?????????
In allergic conditions, the hallmark is
itching
 Symptomatology
 Non-specific:
• Lacrimation
• Irritation
• Stinging
• Burning
• Photophobia
• Redness
 Specific:
• Pain and FB sensation in corneal involvement
• Itching in allergic, blephritis and dry eyes
 Clinical Evaluation of
conjunctival inflammation:
 2- Discharge:

a- Watery:
- Acute viral conjunctivitis.
- Allergic conjunctivitis.
b- Mucoid:
- Vernal conjunctivitis.
- Keratoconjunctivitis sicca.
 Clinical Evaluation of
conjunctival inflammation:
c- Purulent:
 - Severe acute bacterial conjunctivitis.
 Clinical Evaluation of
conjunctival inflammation:
d- Mucopurulent:
 - Mild bacterial conjunctivitis.

 - Chlamydial infections.
3- Conjunctival Appearance:

a- Conjunctival injection:
beefy-red
fish meat
 3- Conjunctival Appearance:
 b- Subconjunctival
haemorrhages:
 3- Conjunctival Appearance:

 c- Follicular reaction:
 hyperplasia of lymphoid tissue within
the stroma
 * The main causes of follicular
conjunctivitis
 - Viral infections.
 - Chlamydial infections.
 - Hyper sensitivity to topical
medications.
 3- Conjunctival Appearance:

 d-Papillary reaction:
hyperplasia of conjunctival epithelium
(surrounding a core of blood vessels)
 Main causes of papillary reaction:

 - Chronic blepharitis.
 - Allergic conjunctivitis.
 - Bacterial conjunctivitis.
 - Contact lens-related problems.
 3- Conjunctival Appearance:

 e- Oedema (chemosis):
 f- Scarring: its causes are:
 - Trachoma.
 - Autoimmune conjunctivitis.
 - Atopic conjunctivitis.
 - Prolonged use of
 topical medications.
 4- Conjunctival membranes:

a- True membranes:
- Beta-haemolytic Streptococci.
- Diphtheria.
 b- Pseudomembranes:
Coagulated exudates
 - Severe adenoviral infection.
 - Gonococcal conjunctivitis.
 - Steve-Johnson syndrom- .
 Clinical Evaluation of
conjunctival inflammation:
 5- Lymphadenpathy:

- Viral infections.
- Chlamydial infections.
- Severe Gonoccocal infections.
- Parinaud syndrome.
 Laboratory Investigations:
 Indications:

- Severe purulent conjunctivitis.

- Follicular conjunctivitis (viral, chlamydial).
- Atypical conjunctivitis.
- Neonatal conjunctivitis.
 Bacterial Conjunctivitis
1- Simple bacterial conjunctivitis:
 - Staphylococcus epidermidis.
 - Staphylococcus aureus.
 - Other like Strptococcus
 pneumoniae, H. influenzae.

Symptoms
Signs
treatment
 2- Neonatal bacterial
Keratoconjunctivitis:
 - Usually appears at 1-3 days of life.
 - Rare condition.
 2- Neonatal bacterial
Keratoconjunctivitis:
 Signs:
 - Hyperacute presentation.
 - Chemosis.
 - Pseudomembranes.
 - Corneal involvement.
 Treatment:
 Systemic and tropical.
 Viral Conjunctivitis
 1- Adenoviral keratoconjunctivitis:

 - It is a highly contagious virus.

 - Transmission is via respiratory

or ocular secretion.
 Signs:
 Conjunctivitis
 - Eyelids are oedematous.
 - Watery discharge.
 - Lymphadenopathy is tender.
- Follicular reaction
- Mild chemosis to moderate.
- Subconjunctival haemorrhages
Pseudomembranes.
Pseudomembranes.
 Keratitis:
 Corneal sub epithelial infiltration and
opacification.
 Treatment:
 Anti viral medications??????
 What is the treatment?????
2- Herpes simplex conjunctivitis:
 - Keratitis is uncommon.
 - No subconjunctival haemorrhage.
 - Keratitis is uncommon.
 treatment
 Chlamydial Conjunctivitis
 1- Adult chlamydial
keratoconjunctivitis:

 It is a sexually transmitted
disease caused by the obligate
intracellular bacterium
Chlamydia trachomatis.
 Signs:
 - Eyelids are lightly oedematous.
 - Mucopurulent discharge.
 - Large follicles are formed at the
inferior fornix.
 - Lymphadenopathy (not tender).
 - Keratitis is uncommon,
 Treatment
 Topical and systemic
 2- Neonatal chlamydial
conjunctivitis:
 - The most common cause of
neonatal conjunctivitis (ophthalmia
Neonatrum).

 What is the type of conjunctival

reaction?
 3- Trachoma:
 - It is an infection caused Chlamydia
trachomatis.
 Transmission:
 Common fly is the major vector,
currently trachoma is the leading
cause of preventable blindness in the
world.
 Presentation: is usually during
childhood.
 World Health Organization
(WHO) grading:
 TF:Trachoma follicles (5 or more follicles
in the superior tarsal conjunctiva).
 TI:Trachomatous intense inflammation
diffusely involving the tarsal conjunctiva.
 TS:Trachomatous conjunctival scarring.
 TT:Trachomatous trichiasis touching the
cornea.
 CO: Corneal opacity.
TS:Trachomatous conjunctival
scarring.
CO:Corneal opacity.
 Allergic conjunctivitis
 Vernal keratoconjunctivitis
(spring catarrh):

 - It is a recurrent, bilateral,
external, ocular inflammation
affecting children and young
adults.
 Vernal Keratoconjunctivitis
 - Vernal keratoconjunctivitis is an
allergic disorder in which IgE and
cell-mediated immune mechanisms
play an important role

 (hypersensitivity reactions type I &

IV).
 3 types of VKC
 a- Palpebral,
 b- Limbal and
 c- mixed.
Diffuse
papillary
hypertrophy
mostly on the
superior
tarsus (tarsal
conjunctiva).
 - Discrete white
superficial spots
(Trantas dots);
 Keratitis
 Punctate keratopathy
( micro erosions),
 Macro erosions
 Mucous Plaque
 Subepithelial scarring
 Pseudogerontoxon
 Treatment
 1- Topical steroids:
 2- Mast cell stabilizers
 3- Acetylcyseine 5% drops
 4- Topical cyclosporin A:
 5- Debridement
 6- Lamellar keratectomy:
 7- Supratarsal injection of steroids:
 Conjunctival Degenerations

1- Pinguecula:
2- Concretions:
ptyreguim