Ophthalmology Course no 4 .The lacrimal System.

Conjunctiva
I. THE DISEASES OF THE LACRIMAL SYSTEM
The lacrimal system is made up of a secretory system, which produces tears, and
an excretory system, which drains the tears.
The secretory system consists of the main lacrimal glands and the accessory
lacrimal glands The lacrimal glands, which secretes the tears, and its excretory
ducts, which convey the fluid to the surface of the human eye  are paired exocrine
glands, one for each eye that secrete the aqueous layer of the tear film. It provises
the reflex secretion stimulated by retinal illumination; disappears at night and in
extended darkness. The lacrimal glands are situated in the upper lateral region of
each orbit, in the lacrimal fossa of the orbit formed by the frontal bone. The
lacrimal gland produces tears which are secreted by the lacrimal ducts, and flow
over the ocular surface, and then into canals that connect to the lacrimal sac. From
that sac, the tears drain through the lacrimal duct into the nose.
The gland has two sections, a palpebral lobe and an orbital lobe. The palpebral lobe
lies close to the eye, along the inner surface of the eyelid; if the upper eyelid is
everted, the palpebral portion can be seen.
The orbital lobe of the gland, contains fine interlobular ducts that connect the
orbital lobe and the palpebral lobe. Tears secreted collect in the fornix conjunctiva
of the upper lid, and pass over the eye surface to the lacrimal puncta, small holes
found at the inner corner of the eyelids. These pass the tears through the lacrimal
canaliculi on to the lacrimal sac, in turn to the nasolacrimal duct.
Nerve supply
The lacrimal gland is innervated by the lacrimal nerve, which is the smallest branch
of the ophthalmic nerve, itself a branch of the trigeminal nerve (CN V). After the
lacrimal nerve branches from the ophthalmic nerve it receives a communicating
branch from the zygomatic nerve.
The parasympathetic innervation to the lacrimal gland increases the secretion of
lacrimal fluid from the lacrimal gland.
The accessory tear glands provide basal tear secretion, a permanent secretion.
tears spread to the conjunctiva and cornea by blinking.
Lacrimal fluid acts to the clean, nourish and lubricate the eyes. It forms tears when
produced in excess.

The excretory system

The lacrimal apparatus is the system responsible for the drainage of lacrimal fluid
from the orbit.
After secretion, lacrimal fluid circulates across the eye, and accumulates in the
lacrimal lake – located in the medial canthus of the eye. From here, it drains into
the lacrimal sac via the upper and lower lacrimal canaliculi.
The lacrimal sac is the dilated end of the nasolacrimal duct, and is located in a
groove formed by the lacrimal bone and frontal process of the maxilla. Lacrimal
fluid drains down the nasolacrimal duct and empties into the inferior meatus of the
nasal cavity.
Diseases of the secretory system
Dacryoadenitis refers to inflammation of the lacrimal gland and may be unilateral
or bilateral.
Lacrimal gland inflammation can be acute or chronic.
Acute dacryoadenitis are frequently infectious and are typically unilateral. Infection
most commonly ascends from the conjunctiva, but also may be from the skin,
penetrating trauma, or in bacteremia. The most common etiology for dacryoadenitis
is viral infection, with Epstein-Barr virus being the most common viral cause. Less
common viral causes include adenovirus, varicella zoster, herpes simplex,
rhinovirus, cytomegalovirus or mumps.
Bacterial forms tend to induce suppuration; the most common bacterial pathogen is
Staphylococcus aureus.
Chronic infectious dacryoadenitis is uncommon, with most cases attributed to
Mycobacterium tuberculosis.
Chronic inflammatory dacryoadenitis are non-specific orbital inflammation , IG
G4-related disease, Sjogren syndrome, sarcoidosis, Crohn disease, and
granulomatosis with polyangiitis, neoplastic causes, etc...
A large portion of inflammatory cases remains idiopathic
Diagnosis
Signs of dacryoadenitis include tenderness, edema, or erythema overlying the
superolateral orbit, conjunctivitis with or without chemosis, regional
lymphadenopathy, proptosis of the globe. Fever and malaise may be present.
Acute dacryoadenitis frequently presents with erythema and tenderness over the
superotemporal orbit, with enlargement of the gland causing the lateral portion of
the eyelid to fall, creating a characteristic S-shaped curve of the eyelid margin.
There can also be associated suppurative discharge from lacrimal ducts and pouting
of the lacrimal ductules. Inflammatory causes of dacryoadenitis may present
subacutely with typically painless swelling of the lacrimal glands and may be
bilateral.
Symptoms
Symptoms of dacryoadenitis include pain in the superolateral orbit, pain with eye
movements, ptosis or difficulty opening the affected eye, redness of the eye, and
possibly diplopia.
Diagnostic procedures
A contrast-enhanced computed tomography (CT) scan of the orbits will typically
demonstrate enlargement of the affected lacrimal gland with enhancement.
If sarcoidosis is suspected, a chest radiograph is a screening tool to evaluate for
lymphadenopathy or pulmonary disease.
Medical therapy
Depending on the severity of the presentation, therapy could range from warm
compresses to treatment of bacterial infection, with or without the addition of
systemic steroids.

Close follow up is made to detect optic nerve involvemen, if there are signs
including decreased visual acuity, pain with eye movements, relative afferent
pupillary defect, or abnormal color vision.
Acute viral dacryoadenitis is typically self-resolving within 4 to 6 weeks. The
benefit of oral antiviral medications is uncertain. Bacterial dacryoadenitis requires
systemic antibiotic therapy. When purulence is present, obtaining cultures of the
discharge can guide antibiotic therapy. Abscess formation may necessitate surgical
drainage.
Corticosteroids will induce decrease in volume of an enlarged lacrimal gland from
almost all sources of dacryoadenitis.
Refractory cases of inflammatory dacryoadenitis may benefit from orbital
radiotherapy, methotrexate, or rituximab.
In patients with dacryoadenitis who respond to treatment but the lacrimal mass does
not resolve by 3 months, a lacrimal gland biopsy after appropriate scanning is
necessary.
Differential Diagnosis
When focal swelling of the lacrimal gland is present, particularly in an older patient
with an indolent course, it is important to exclude malignancy.
Thyroid eye disease (TED) may sometimes resemble dacryoadenitis, presenting
with diplopia from restrictive inflammation of the extraocular muscles. Typically,
TED results in lid retraction rather than mild ptosis as is seen in dacryoadenitis.
Other infectious conditions that can cause periorbital swelling, erythema, and pain
must be considered, such as preseptal or orbital cellulitis. Focal swelling of the
upper eyelid may be due to chalazion or hordeolum, neither of which is associated
with true lacrimal gland enlargement.
Complications
Complications from infectious dacryoadenitis are rare; a lacrimal gland abscess
may develop, or the infection may lead to preseptal or orbital cellulitis.
Tumors of the lacrimal gland - see the chapter on the orbit
Dry eyes syndrome
The tear film is important for good vision.
The tear film is made of three layers:
An oily layer
A watery layer
A mucus layer
The oily layer is the outside of the tear film. It makes the tear surface smooth and
keeps tears from drying up too quickly. This layer is made in the eye’s meibomian
glands.
The watery layer is the middle of the tear film. It makes up most of the tears. This
layer cleans the eye, washing away particles that do not belong in the eye. This
layer comes from the lacrimal glands in the eyelids.
The mucus layer is the inner layer of the tear film. This helps spread the watery
layer over the eye’s surface, keeping it moist. Without mucus, tears would not stick
to the eye. Mucus is made in the conjunctiva. This is the clear tissue covering the
white of the eye and inside the eyelids.
Normally, the eyes constantly make tears to stay moist. If the eyes are irritated, or
while crying, the eyes make a lot of tears. Dry eye occurs when either the eye does
not produce enough tears or when the tears evaporate too quickly.
The dry eyes occurs also when something affects one or more layers of the tear
film.
Dry eye syndrome (DES), also known as keratoconjunctivitis sicca (KCS), is the
condition of having dry eyes.
Dry Eye Symptoms
Typical symptoms of dry eye syndrome are dryness, burning and a sandy-gritty eye
irritation that gets worse as the day goes on
Blurred vision, especially when reading
Symptoms are worsened by activities in which the rate of blinking is reduced due to
prolonged use of the eyes. These activities include prolonged reading, computer
usage, driving, or watching television. Symptoms increase in windy, dusty or
smoky areas, in dry environments high altitudes including airplanes, on days with
low humidity, and in areas where an air conditioner.
Symptoms reduce during cool, rainy, or foggy weather and in humid places.
There is a scratchy or gritty feeling like something is in the eye.
There are strings of mucus in or around the eyes.
It is painful to wear contact lenses.
In the onset phase, there may be excessive tearing.
Dry eye syndrome can occur at any age, and in people who are otherwise healthy. It
is more common with older age, when the individual produces fewer tears. It is also
more common in women than in men.
It is more common in malnutrition results in a vitamin A deficiency.
Dry eye occurs when either the eye does not produce enough tears or when the tears
evaporate too quickly. This can result from contact lens use, meibomian gland
dysfunction, pregnancy, Sjögren syndrome (an autoimmune disease that affects
lacrimal and salivary glands) , vitamin A deficiency, LASIK surgery, and certain
medications such as antihistamines, some blood pressure medication, hormone
replacement therapy, and antidepressants. Chronic conjunctivitis such as from
tobacco smoke exposure or infection may also lead to the condition.
Diagnosis is mostly based on the symptoms and Schirmer tests.
Treatment depends on the underlying cause. Artificial tears are the usual first line
treatment. Stopping or changing certain medications may help. The medication
ciclosporin or steroid eye drops may be used in severe cases( for exemple Sjögren
Syndrome). Another option is lacrimal plugs that prevent tears from draining from
the surface of the eye.
If the condition is left untreated or becomes severe, it can produce complications
that can cause eye damage, resulting in impaired vision by affecting the cornea.
Dacryocystitis is an infection or inflammation of the nasolacrimal sac, usually
accompanied by blockage of the nasolacrimal duct. Dacryocystitis can be acute or
chronic and congenital or acquired. When present, medial canthal swelling of
dacryocystitis is usually located below the medial canthal tendon.
Pain, swelling, redness over the lacrimal sac at medial canthus
Tearing, crusting, fever
Digital pressure over the lacrimal sac may extrude pus through the punctum
In chronic cases, tearing may be the only symptom
Initial treatment is with warm compresses and oral antibiotics for mild or severe
cases. The antibiotic is usually a 1st-generation cephalosporin or penicillinase-
resistant synthetic penicillin. If the infection does not respond as expected,
consideration should be given to methicillin-resistant Staphylococcus aureus
(MRSA), and antibiotics changed accordingly. The abscess can be drained and the
antibiotics can be changed based on culture results if the initial antibiotic proves
ineffective.
Patients with chronic dacryocystitis usually present with a mass under the medial
canthal tendon and chronic conjunctivitis. Definitive treatment for resolved acute
dacryocystitis or chronic conjunctivitis is usually surgery that creates a passage
between the lacrimal sac and the nasal cavity (dacryocystorhinostomy).
II. THE DISEASES OF CONJUNCTIVA
The conjunctiva is a fine, translucent mucous membrane that lines the inside of the
eyelids and covers the sclera.
It covers the posterior surface of the lids and reflects to cover the anterior part of
the sclera, then becomes continuous with the corneal epithelium. At the lidmargin
conjunctiva is continuous with the skin.
It is highly vascularized.
The conjunctiva can be divided into three regions: the palpebral or tarsal
conjunctiva, the bulbar or ocular conjunctiva, and the conjunctival fornices. The
The bulbar conjunctiva is divided into scleral and limbal parts.
The conjunctival fornices are divided into the superior, inferior, lateral, and medial
regions. The palpebral conjunctiva lines the eyelids. The conjunctiva has an
average thickness of 33 microns.
Conjunctiva of the Fornix: It is fold lining the cul-de-sac formed by conjunctiva
covering the posterior surface of the lids to the conjunctiva covering the anterior
surface of the globe. The conjunctiva here is comparatively thicker and loosely
attached in order to allow free movement of the globe.
The medial fornix is the shallowest and contains the caruncle and the plica
semilunaris.
The plica semilunaris is a small fold of bulbar conjunctiva on the medial canthus of
the eye. It functions during movement of the eye, to help maintain tear drainage.
The lacrimal caruncle, or caruncula lacrimalis, is the small, pink, globular nodule at
the inner corner (the medial canthus) of the eye. It is made of skin covering
sebaceous and sweat glands.
The plica semilunaris and lacrimal caruncle have a role of purifying stations
located upstream of the drainage of tears.

Inflammatory pathology
Conjunctivitis
Conjunctivitis can be divided into infectious and noninfectious causes.
Viruses and bacteria are the most common infectious causes.
Noninfectious conjunctivitis includes allergic, toxic, and cicatricial conjunctivitis,
as well as inflammation secondary to autoimmune diseases and neoplastic
processes.
The disease can also be classified into acute, hyperacute, and chronic according to
the mode of onset and the severity of the clinical response.

Subjective symptoms are: foreign body sensation, stinging or burning under the
eyelids.
Objective signs are common to inflammation of any mucosa: hyperemia,
conjunctival secretion, tearing, papillary hypertrophy, follicles, the presence of
membranes or pseudomembranes, chemosis.
Some conjunctivitis are accompanied by preauricular or submandibular adenopathy
Follicles and papillae are seen in palpebral part of conjunctiva. The palpebral
conjunctiva is an area where reactive pathology of the conjunctiva may be seen
clinically. There are two types of changes that can occur in this region: follicle
formation and papilla formation.
Follicles are thought to be identical to lymphoid follicles found elsewhere in the
body. Follicle formation is characteristic of viral and chlamydial infections as well
as toxic conjunctivitis due to the application of certain topical medications.
Papillae are composed of chronic inflammatory cells such as lymphocytes and
plasma cells and are distinguished from follicles by the presence of blood vessels at
their center. Giant papillae are found in certain allergic diseases (e.g., vernal
catarrh) and after long-term use of contact lenses, ocular prostheses, and cosmetic
shells.
Conjunctival hiperaemia
Conjunctival injection or hyperemia is a nonspecific response with enlargement of
conjunctival vessels induced by various diseases. Conjunctival injection is an
important diagnostic clue for infection or inflammation and can be utilized for the
monitoring of the disease progression and response to treatment.
Superficial hyperemia of conjunctival inflammatory cause predominates on the
palpebral conjunctiva and sac bottoms and attenuates as it approaches the bulbar
conjunctiva and the sclerocorneal limbus.
Deep or perikeratic hyperemia predominates in the immediate vicinity of the
sclerocorneal limbus. It may appear in isolation as a dark red perilimbic ring or may
be associated with superficial hyperemia.
Bacterial conjunctivitis
Acute conjunctivitis can be caused by numerous bacteria. Symptoms are
hyperemia, lacrimation, irritation, and discharge. Diagnosis is clinical.
Bacterial conjunctivitis is usually caused by Staphylococcus aureus, Streptococcus
pneumoniae, Haemophilus species, or, less commonly, Chlamydia trachomatis.
Neisseria gonorrhoeae causes gonococcal conjunctivitis, which usually results from
sexual contact with a person who has a genital infection.
Ophthalmia neonatorum (neonatal conjunctivitis) results from a maternal
gonococcal and/or chlamydial infection. Neonatal conjunctivitis occurs in neonates
delivered through an infected birth canal.
These organisms may be spread from hand to eye contact or through adjacent
mucosal tissues colonization such as nasal or sinus mucosa.
Risk Factors
Poor hygenic habits may increase the risk of infection
Poor contact lens hygiene
Contaminated cosmetics
Crowded living or social conditions such elementary schools
Ocular diseases including dry eye, blepharitis
Recent ocular surgery, or ocular foreign bodies
Chronic use of topical medications
Immune compromise
Symptoms are typically, red eye unilateral but frequently spread to the opposite eye
within a few days. Discharge is typically purulent.
Patients may complain of redness, discharge, crusting and sticking or gluing of the
eyelids upon waking, blurry vision, light sensitivity, irritation discomfort
intolerance to contact lens.
Almost all cases of acute bacterial conjunctivitis are self-limited and will clear
within 10 days without treatment.
Antibiotic treatment has been shown to decrease the duration of symptoms and
speed the eradication of microorganisms from the conjunctival surface.
If neither gonococcal nor chlamydial infection is suspected, moxifloxacin 0.5%
drops 3 times a day for 7 to 10 days or another fluoroquinolone are used.
A poor clinical response after 2 or 3 days indicates that the cause is resistant
bacteria, a virus, or an allergy.
Bacterial conjunctivitis are very contagious
Patients should be advised to
Use hand sanitizer and/or wash their hands thoroughly after touching their eyes or
nasal secretions
Avoid touching the noninfected eye after touching the infected eye
Avoid sharing towels or pillows
Avoid swimming in pools
To avoid transmitting infection, physicians must
-Use hand sanitizer or wash their hands properly (fully lather hands, scrub hands
for at least 20 seconds, rinse well, and turn off the water using a paper towel)
-Disinfect equipment after examining patients
Adult inclusion conjunctivitis is caused by sexually transmitted Chlamydia
trachomatis. Symptoms include chronic unilateral hyperemia and mucopurulent
discharge. Adult inclusion conjunctivitis is caused by Chlamydia trachomatis and,
in most instances, adult inclusion conjunctivitis results from sexual contact with a
person who has a genital infection.
The disease has an incubation period of 2 to 19 days. Most patients have a
unilateral mucopurulent discharge. The tarsal conjunctiva is often more hyperemic
than the bulbar conjunctiva. Characteristically, there is a marked tarsal follicular
response. Occasionally, superior corneal opacities and vascularization occur.
Preauricular lymph nodes may be swollen on the side of the involved eye. Often,
symptoms have been present for many weeks or months and have not responded to
topical antibiotics.
Diagnosis
Clinical evaluation
Laboratory testing
Chronicity (symptoms for > 3 weeks), mucopurulent discharge, marked tarsal
follicular response, and failure of topical antibiotics differentiate adult inclusion
conjunctivitis from other bacterial conjunctivitis.

Smears and conjunctival scrapings should be examined microscopically to identify

bacteria.
Treatment
Azithromycin 1 g orally once only or either doxycycline 100 mg orally twice a day
or erythromycin 500 mg orally 4 times a day for 1 week cures the conjunctivitis and
concomitant genital infection. Sex partners also require treatment.
Hyperacute bacterial conjunctivitis presents with a severe copious purulent
discharge and decreased vision . There is often accompanying eyelid swelling, eye
pain on palpation, and preauricular adenopathy. It is often caused by Neisseria
gonorrhoeae and carries a high risk for corneal involvement and subsequent corneal
perforation and blindness. Treatment for hyperacute conjunctivitis secondary to N
gonorrhoeae consists of intramuscular ceftriaxone.
Viral conjunctivitis
Viruses cause up to 80% of all cases of acute conjunctivitis. Many cases are
misdiagnosed as bacterial conjunctivitis. Between 65% and 90% of cases of viral
conjunctivitis are caused by adenoviruses, and they produce 2 of the common
clinical entities associated with viral conjunctivitis, pharyngoconjunctival fever and
epidemic keratoconjunctivitis.
Pharyngoconjunctival fever is characterized by abrupt onset of high fever,
pharyngitis, and bilateral conjunctivitis, and by periauricular lymph node
enlargement.
Epidemic keratoconjunctivitis is more severe and presents with watery discharge,
hyperemia, chemosis, and ipsilateral lymphadenopathy. Lymphadenopathy is more
prevalent in viral conjunctivitis compared with bacterial conjunctivitis.
Other viruses that can be responsible for conjunctival infection include herpes
simplex virus (HSV), varicella-zoster virus (VZV), picornavirus (enterovirus ,
Coxsackie), poxvirus (molluscum contagiosum, vaccinia), and human
immunodeficiency virus (HIV).
Viral conjunctivitis secondary to adenoviruses is highly contagious. The virus
spreads through direct contact via contaminated fingers, medical instruments,
swimming pool water.
Symptomatology
After an incubation period of about 5 to 12 days, conjunctival hyperemia, watery
discharge, and ocular irritation usually begin in one eye and spread rapidly to the
other. Follicles may be present on the palpebral conjunctiva. A preauricular lymph
node is often enlarged and painful. Many patients have had contact with someone
with conjunctivitis, a recent upper respiratory infection, or both.

In severe adenoviral conjunctivitis, patients may have photophobia and foreign

body sensation due to corneal involvement. Chemosis may be present.
Pseudomembranes of fibrin and inflammatory cells on the tarsal conjunctiva, focal
corneal inflammation, or both may blur vision. Even after conjunctivitis has
resolved, residual corneal subepithelial opacities (multiple, coin-shaped, 0.5 to 1.0
mm in diameter) may be visible with a slit lamp for up to 2 years. Corneal opacities
occasionally result in decreased vision and significant halos.
No effective treatment exists, artificial tears, topical antihistamines, or cold
compresses may be useful in alleviating some of the symptoms Available antiviral
medications are not useful and topical antibiotics are not indicated.
Allergic conjunctivitis
Allergic conjunctivitis is an inflammatory response of the conjunctiva to an
allergen. It is part of a larger systemic atopic reaction and is usually seasonal with
associated upper respiratory tract symptoms and complaints of redness and swelling
of the conjunctiva with severe itching and increased lacrimation. Presence of
rhinitis often terms this process as allergic rhinoconjunctivitis.
Classification
Vernal - of, or appropriate to spring
Atopic - denoting a form of allergy or hypersensitivity reaction
Perennial - chronic, year round
Allergic conjunctivitis
without involvement of the cornea:
- acute allergic conjunctivitis
- seasonal allergic conjunctivitis (SAC)
- perennial allergic conjunctivitis Symptoms occurring throughout all seasons
(PAC)
with involvement of the cornea:
Vernal keratoconjunctivitis (VKC)
Atopic keratoconjunctivitis (AKC)
Giant papillary conjunctivitis
This is not a true ocular allergy but rather an repetitive mechanical irritation, often
in due to contact lenses, that is aggravated by concomitant allergy.
Signs and Symptoms
Itching is the primary symptom where patients are constantly rubbing their eyes
with temporary relief. The eyelids and conjunctiva become edematous and diffusely
hyperemic. Presentation is most often bilateral, due to the systemic nature of the
disease

Seasonal/Perennial conjunctivitis
Bilateral conjunctival injection, chemosis, watery discharge, and mild mucous
discharge.
Recur seasonally with the changes in pollens and allergens present.
Minimal or local inflammation often resolves and remits.
Vernal keratoconjunctivitis (VKC)
Bilateral bulbar conjunctival injection with associated watery and mucoid
discharge. Patients develop a giant papillary hypertrophy of only the superior tarsal
conjunctiva, resembling “cobblestones”.
Corneal involvements: limbal dots that are small white-yellow chalky concretions
around the corneal limbus; corneal vernal plaques; or shield shaped ulcers of the
cornea. he onset of symptomatology begins in childhood and peaks at about 11-13
with acute exacerbations occurring more frequently during the spring and summer
months. Commonly the symptoms decreased ranging from 2-30 years of age.
Untreated VKC can lead to eyelid thickening that ultimately leads to ptosis. Severe
corneal involvement can cause corneal neovascularization, thinning, ulceration, and
infection. This can lead to vision loss. Conjunctival scarring can also occur.

Atopic keratoconjunctivits (AKC)

Bilateral conjunctival injection with associated eczematoid belpharitis,
watery/mucoid discharge, and boggy edema. Papillary hypertrophy of superior or
inferior tarsal conjunctival can occur with increased risk for eyelid thickening and
scarring. In more severe and untreated cases, patients can develop loss of eyelashes,
conjunctival scarring, corneal neovascularization, ulcers or scars, punctate
epithelial keratitis.
Similar to VKC, the onset of symptoms occurs during childhood but peaks during
young adult and continues into the fifth decade of life. The course remains chronic
with periodic acute exacerbations.
The sequelae are similar to VKC with eyelid thickening or tightening.
Conjunctival scarring can occur and involvement of the cornea can lead to scarring,
neovascularization, thinning, ulceration and infection. This can also develop into
keratoconus or cause vision loss. There can also be anterior or posterior subcapsular
cataracts.
Giant papillary conjunctivitis (GPC)
The laterality of symptoms is associated with contact lens, or prostheses wear
pattern. Most notably, patients will have papillary hypertrophy of the superior tarsal
conjunctiva. In long-standing, untreated disease, the papillae will develop white
fibrotic centers. In severe cases, patients will have lid swelling and ptosis.
This disease process is directly correlated with presence of risk factors.If left
untreated, GPC can cause acquired ptosis.
Treatment
Some additional measures can be used as adjunctive measures to improve symptom
management are as follows:
Artificial tears to dilute allergens
Cool compresses / ice packs
Avoid Allergens
Frequent clothes washing and bathing/showering before bedtime
Refer/consult allergy or dermatology for those who are not adequately controlled
with topical medications and oral antihistamines
Topical drops: antihistamines, Mast cell stabilizers, brief course of low-potency and
low-frequency topical corticosteroids
In VKC and AKC, another adjunctive therapy is addition of topical cyclosporin
2%. If the VKC or AKC is not responsive to topical therapy, supratarsal injection
of corticosteroid can be considered.

How to Differentiate Conjunctivitis of Different Origins

History and Physical Examination
Focused ocular examination and history are crucial for making appropriate
decisions about the treatment and management of any eye condition, including
conjunctivitis. Eye discharge type and ocular symptoms can be used to determine
the cause of the conjunctivitis. For example, a purulent or mucopurulent discharge
is often due to bacterial conjunctivitis , whereas a watery discharge is more
characteristic of viral conjunctivitis; itching is also associated with allergic
conjunctivitis.

Subconjunctival hemorrhage occurs when one or more blood spots appear on the
white of the eye. The eye’s conjunctiva contains a lot of tiny blood vessels that can
break. If they break, blood leaks between the conjunctiva and sclera. This bleeding .
These blood spots can look scary. But a subconjunctival hemorrhage is usually
harmless and often heals on its own.
Coughing, sneezing, straining, or other similar actions most commonly cause
subconjunctival hemorrhages. This is because they briefly raise blood pressure in
the veins. That quick pressure rise can cause capillaries to break.
Trauma to the eye can also cause subconjunctival hemorrhage. Even rubbing the
eyes too hard might cause capillaries to break.
Less common causes of subconjunctival hemorrhage include:
-diabetes
-high blood pressure
-medicines :aspirin, anticoagulant
Rarely, subconjunctival hemorrhage is caused by a blood clotting disorder or other
blood problem that affects the whole body.
Degenerative diseases of the conjunctiva
Pinguecula is a benign yellowish, raised growth on the conjunctiva. Is a common
type of conjunctival stromal degeneration in the eye. It appear in the bulbar
conjunctiva near to limbus . A pinguecula is a deposit of protein, fat, or calcium.
The exact etiology is unknown, but it may be associated with aging and excessive
exposure to UV light.
Pingueculae may enlarge slowly over time, but are a benign condition, usually
requiring no treatment. Artificial tears may help to relieve discomfort, if it occurs.
If cosmesis is a concern, or if there is discomfort in contact lens use, surgical
excision may be done. Laser photocoagulation may also be used to remove
pinguecula.

A pterygium is a triangular vascularized growth of bulbar conjunctiva that may

spread across and distort the cornea, induce astigmatism, and change the refractive
power of the eye. Symptoms may include decreased vision and foreign body
sensation. It is more common in sunny, hot, dry climates. To relieve symptoms
caused by a pterygium, artificial tears or a short period of treatment with
corticosteroid drops or ointments may be prescribed. Removal is often indicated for
documented growth, cosmesis, to reduce irritation, and to improve or preserve
vision. The technique with the best results to prevent recurrence is surgical removal
of the pterygium followed by conjunctival autograft and perhaps with cyclosporine
drops. Following surgery a pterygium may recur in around half of cases.
Tumors of the conjunctiva
Tumors that occur in the conjunctiva are generally recognized at a relatively early
stage. Because many of these tumors have typical clinical features, an accurate
diagnosis can often be made by external ocular examination and slit-lamp
biomicroscopy. A diagnostic biopsy is not usually necessary in cases of smaller
tumors that appear benign.
In cases of larger lesions it may be appropriate to remove a portion of the tumor
(incisional biopsy) to obtain a histopathologic diagnosis.
Most conjunctival tumors are epithelial or melanocytic in origin
Conjunctival cysts don’t always cause symptoms, especially when they’re very
small.
As they grow, a range of symptoms can occur, including:
-the feeling that something’s stuck in your eye
-swollen eyelid
-problems closing your eye
If the cyst makes it hard to close theeye, can occur: dryness tearing itchiness and
a burning sensation.
Treatment is surgical

Pigmented lesions of conjunctiva

Pigmented lesions that arise from the conjunctiva include nevus, complexion-
associated melanosis (CAM), primary acquired melanosis (PAM), and malignant
melanoma. All of these lesions arise from melanocytes.
-Nevi represent more than 50 percent of conjunctival lesions and are the most
benign of the pigmented lesions. Nevi usually appear in childhood. Conjunctival
nevi are very similar to those of the skin. Nevi should be monitored regularly.
-CAM, also known as racial melanosis, is a benign lesion found among darkly
pigmented individuals.
It is typically observed around the limbus. On examination, the pigmentation
appears flat and noncystic. It can cover the conjunctiva extensively and increase in
size with age; contrary to nevi and PAM, it is usually bilateral.
-PAM is almost always unilateral. is a diffuse intraepithelial disease, so it appears
as a thin dusting of pigment and is usually not well circumscribed.
Conjunctival malignant melanoma is an uncommon but potentially devastating
tumor that may invade the local tissues of the eye, spread systemically through
lymphatic drainage and hematogenous spread, and recur in spite of treatment.
Conjunctival melanoma commonly presents as a thickened, raised, pigmented
lesion with prominent feeder vessels and surrounding areas of melanosis.