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Ophthalmology
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Diseases of Conjunctiva

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Atul K Shankar

31

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ESSAYS

Discuss the etiology, clinical features, complications and treatment of

purulent conjunctivitis.
Etiology of Purulent Conjunctivitis

- The causative bacteria of purulent conjunctivitis

o Staphylococcus aureus
o Koch-Weeks Bacillus
o Pneumococcus
o Streptococcus

Clinical Features of Purulent Conjunctivitis

- Symptoms
o Discomfort, foreign body, grittiness, blurring and redness of sudden
onset
o Mild photophobia
o Mucopurulent discharge from the eyes
o Sticking together of lid margins with discharge during sleep
o Slight blurring of vision due to mucous flakes in front of cornea
o Coloured halos
- Signs
o flakes of mucopus seen in the fornices, canthi and lid margins is a critical
sign
o Conjunctival congestion, which is more marked in palpebral conjunctiva,
fornices and peripheral part of bulbar conjunctiva
 gives the appearance of fiery red eye
o Chemosis ie is swelling of conjunctiva
o Papillae of fine type may be seen
o Petechial haemorrhages are seen when causative organism is
Pneumococcus
o Cilia are usually matted together with yellow crusts
o Eyelids may be slightly oedematous

Complications of Purulent Conjunctivitis

- disease may be complicated by

o Superficial punctuate epitheliopathy
o Marginal Corneal Ulceration
o Superficial keratitis
o Blepharitis
o Dacryocystitis

Treatment of Purulent Conjunctivitis

- Topical Antibiotics
 o treatment may be started with
 Chloramphenicol
 Gentamicin
 Tobramycin
 Framycetin
- Irrigation of Conjunctival Sac
o washing conjunctival sac with sterile lukewarm saline once or twice a day
- Dark Goggles
o used to prevent photophobia
- Anti-inflammatory and analgesic drugs
o may be given orally for 2-3 days
o provides symptomatic relief from mild pain in sensitive patients
SHORT NOTES

Pterygium
- wing-shaped fold of the conjunctiva, encroaching upon the cornea from either
side within the interpalpebral fissure

Aetiology

- not definitely known

- most accepted known is response to prolonged effect of environmental factors

Pathology

- pterygium is a degenerative and hyperplastic conditions of conjunctiva

- subconjunctival tissue undergoes elastotic degeneration and proliferates as
vascularised granulation tissue under the epithelium
- this eventually encroaches the cornea
- the corneal epithelium, Bowman’s layer and superficial stroma are destroyed

Clinical Features

- Symptoms
o cosmetic intolerance may be the only issue in otherwise asymptomatic
conditions
o Foreign body sensation and irritation may be experienced
o Defective vision occurs upon encroachment of the papillary area
o Diplopia may occur occasionally due to limitation of ocular movements
- Signs
o Triangular fold of conjunctiva encroaching on the cornea in the area of
palpebral aperture
o Stocker line
 seen in corneal epithelium to the advancing head of pterygium

Complications of Pterygium

- Cystic degeneration and infection are infrequent

- Neoplastic change to epithelioma, fibrosarcoma or malignant melanoma, may
occur rarely

Treatment of Pterygium

- Medical Treatment of not much use

- Surgical excision is the only satisfactory treatment
o Cosmetic disfigurement
o Visual impairment due to significant regular or irregular astigmatism
o Continued progression threatening to encroach onto the papillary area
o Diplopia due to interference in ocular movements
 Difference between Pterygium & Pseudopterygium
PTERYGIUM PSEUDOPTERYGIUM
ETIOLOGY Degenerative process Inflammatory process
AGE Usually occurs in elder Can occur at any age
persons
SITE Always situated in the Can occur at any site
palpebral aperture
STAGES Either progressive, Always stationary
regressive or stationary
PROBE TEST Probe cannot be passed A probe can be passed
underneath under the neck

Ophthalmia neonatorum
- bilateral inflammation of the conjunctiva occurring in an infant less than 30
days old
- it is a preventable disease occurring as a result of carelessness at the time of
birth
- any discharge or even watering from the eyes in the 1 st week of life should
arouse suspicion of ophthalmia neonatorum, as tears are not formed till then
- ETIOLOGY
o Chemical Neonatal Conjunctivitis
o Gonococcal infection
o Staphylococcus, Haemophilus, Streptococcus infection
o Chlamydia trachomatis
o Herpes simplex
- Clinical Features
o Pain and tenderness of eyeball
o Conjunctival discharge
o Swollen eyelids
o Hyperaemic conjunctiva and chemosis
- Complications
o Corneal ulceration
 may perforate rapidly resulting in corneal opacification or
staphyloma formation
- Treatment
o Chemical ophthalmia neonatorum is self-limiting condition
o Gonococcal ophthalmia neonatorum
 Topical Therapy
 Saline lavage
 Bacitracin eye ointment
 Atropine sulphate, if cornea is involved
 Systemic Therapy
 Ceftriaxone, Cefotaxime, Ciprofloxacin
o Herpes simplex conjunctivity is self-limiting
 topical anti-viral drugs control the infection more effectively and may
prevent recurrence.
 Vernal Keratoconjunctivitis (Spring Catarrh)
- recurrent, bilateral, interstitial, self-limiting, allergic inflammation of the
conjunctiva having periodic seasonal incidence
- ETIOPATHOGENESIS
o found in individuals with predisposed atopic background
o has long been considered an atopic disorder
 mainly type 1 IgE-mediated hypersensitivity reaction to pollen
allergens
o it is now believed that pathogenesis of VKC is characterized by
 Th2 lymphocyte alteration
 exaggerated IgE response to common allergens is a secondary
event
- CLINICAL FEATURES
o Symptoms
 Marked burning and itching sensation
 usually intolerable and accentuated when patient comes in a
warm humid atmosphere
 itching is more marked with palpebral form of disease
 Other associated features includes
 Mild photophobia
 Lacrimation
 Stringy discharge
 Heaviness of lids
o Signs
 Palpebral form
 upper tarsal conjunctiva of both eyes is involved
 typical lesion is presence of hard, flat topped, papillae
arranged in a ‘cobble-stone’ or ‘pavement stone’ fashion
with conjunctival hyperaemia
 papillae may hypertrophy to produce cauliflower-like
excrescences of giant papillae
 Bulbar limbal form
 Dusky red triangular congestion of bulbar conjunctiva in
palpebral area
 Limbal papillae occur as gelatinous, thickened confluent
accumulation of tissue around the limbus
 Presence of discrete whitish raised dots along the limbus
 Mixed form
 shows combined features of palpebral and bulbar forms
- Treatment
o Topical anti-inflammatory therapy
 Topical steroids, Mast cell stabilizers, Dual action
antihistamines and mast cell stabilizers, NSAIDs eye drops,
Topical cyclosporine, Tacrolimus
o Topical lubricating and mucolytics – artificial tears, acetyl cysteine
o Systemic therapy – oral antihistamines, oral steroids
 Angular Conjunctivitis
- type of chronic conjunctivitis, characterised by
o Mild grade inflammation confined to the conjunctiva and lid margins near
the angles
o associated with maceration of the surrounding skin

- Etiology
o predisposing factors are same for simple chronic conjunctivitis
o Causative organisms are
 Moraxella axenfield
o source of infection is the nasal cavity
o Mode of infection is transmission from nasal cavity to the eyes by
contaminated fingers or handkerchief

- Pathology
o MA bacillus produces a proteolytic enzyme
 acts by macerating the epithelium of the conjunctiva, lid margin
and the skin, the surrounding angles of eye.
 maceration is followed by vascular and cellular responses in the
form of mild grade chronic inflammation
 Skin may show eczematous changes

- Clinical Features
o Symptoms
 Irritation, burning sensation and feeling of discomfort in eyes
 History of collection of dirty-white foamy discharge at the angles
 Redness in the angles of eyes
o Signs
 Hyperaemia of bulbar conjunctiva near the canthi
 Hyperaemia of lid margins near the angles
 Excoriation of the skin around the angles
 Foamy Mucopurulent discharge at the angles is usually present

- Complications
o Blepharitis
o Shallow marginal catarrhal corneal ulceration

- Treatment
o Prophylaxis
 treatment of associated nasal infection
 good personal hygiene
o Curative treatment
 Oxytetracycline eye ointment
 Zinc lotion in day time, and zinc oxide ointment at bed time
 inhibits the proteolytic ferment
 helps in reducing the maceration
 Phlyctenular Keratoconjunctivitis
- characteristic nodular affection occurring as an allergic response of the
conjunctival and corneal epithelium to some endogeneous allergens to which
they have become sensitized
- Phlyctenular conjunctivitis is of worldwide distribution

Etiology

- believed to be a delayed hypersensitivity response (TYPE IV-cell mediated)

response to endogenous microbial proteins so called as microbial allergic
conjunctivitis
- causative allergens
o Tuberculous proteins
o Staphylococcus proteins
o other allergens may be Moraxella axenfield bacillus

Pathology

- Stage of Nodule Formation

o occurs exudation and infiltration of leucocytes into the deeper layers of
conjunctiva leading to nodule formation
- Stage of Ulceration
o necrosis occurs at the apex of the nodule and an ulcer is formed
o Leucocytic infiltration increases with plasma cells and mast cells
- Stage of Granulation
o floor of the ulcer becomes covered in granulation tissue
- Stage of healing
o healing occurs usually with minimal scarring

Clinical Features

- Symptoms
o Mild discomfort in the eye
o Irritation and reflex watering
o associated Mucopurulent conjunctivitis due to secondary bacterial
infection
- Signs
o Presents in 3 forms
 Simple Phlyctenular conjunctivitis
 Necrotizing Phlyctenular conjunctivitis
 Miliary Phlyctenular conjunctivitis

Management

- Local Therapy
o Topical steroids, Antibiotic drops and ointment, Atropine eye ointment
- Specific therapy
o Anti-TB drugs, Systemic antibiotics, treatment for parasitic manifestation
 Pinguecula
- common degenerative condition of the conjunctiva
- characterized by
o formation of yellowish white patch on the bulbar conjunctiva near the
limbus

- ETIOLOGY
o not known exactly
o considered an age-change, occurring more commonly in persons exposed
to strong sunlight, dust and wind
o considered a precursor to Pterygium
 now suggested that it does not progress to Pterygium and that the
2 are distinct disorders

- PATHOLOGY
o there is an elastotic degeneration of collagen fibres of the substantia
propria of conjunctiva, coupled with deposition of amorphous hyaline
material in the substance of conjunctiva

- CLINICAL FEATURES
o Bilateral usually stationary condition
o presents as a yellowish-white triangular patch near the limbus
o apex of the triangle is away from the cornea
o affects the nasal side first and then the temporal side
o when conjunctiva is congested, it stands out as an avascular prominence

- COMPLICATIONS
o inflammation
o intraepithelial abscess formation
o rarely calcification
o doubtful progression to pterygium

- TREATMENT
o no treatment is required
o when cosmetically unaccepted and if so desired, it may be excised
o when inflamed it is treated with topical steroids
 Ecchymosis of Conjunctiva
- may vary in extent from small petechial haemorrhage to an extensive
haemorrhage spreading under the whole of the bulbar conjunctiva and thus
making the white sclera of the eye
- ETIOLOGY
o Trauma
 Local trauma to conjunctiva
 retrobulbar haemorrhage which almost
 retrobulbar injection
o Inflammations of the conjunctiva
 associated with acute haemorrhagic conjunctivitis caused by
 Picornaviruses
 Pneumococcal conjunctivitis
 Leptospirosis
 Icterohaemorrhagica conjunctivitis
o Sudden venous congestion of the head
 may occur owing to rupture of conjunctival capillaries due to
sudden rise in pressure
 common conditions are
 Whooping cough
 Epileptic fits
 Strangulation or compression of jugular veins
 Violent compression of thorax and abdomen
o Spontaneous rupture of the fragile capillaries
o Local vascular anomalies
o Blood dyscrasias
o Bleeding disorders
o Acute febrile systemic infections
o Vicarious bleeding
- CLINICAL FEATURES
o Symptoms
 symptomless
 red discolouration noted by patients as a serious symptom
 may be symptoms of associated causative disease
o Signs
 subconjunctival haemorrhage looks as a flat sheet of
homogeneous bright red colour with well defined limits

- TREATMENT
o treat the cause when discovered
o cold compresses to check bleeding in the initial stages
o hot compresses may help in absorption of blood in the late stages
o placebo therapy with astringent and lubricant eye drops
o psychotherapy and assurance to the patient is the MOST IMPORTANT
PART OF TREATMENT
 Viral Conjunctivitis
- tends to affect the epithelium
- both the conjunctiva and cornea
- typical viral lesion is a keratoconjunctivitis
- in some viral infections, conjunctival involvement is more prominent while in
others cornea is more involved

Viral infections of the conjunctiva include:

- Adenovirus conjunctivitis
- Herpes simplex keratoconjunctivitis
- Herpes Zoster conjunctivitis
- Molluscum contagiosum conjunctivitis
- Poxvirus conjunctivitis
- Myxovirus conjunctivitis
- ARBOR virus conjunctivitis

Clinical Presentation of acute viral conjunctivitis includes:

- Acute follicular conjunctivitis

- Acute haemorrhagic conjunctivitis