Diseases of Conjunctiva


Dr Sanjay Shrivastava


‡ Classification I Based on onset a. Acute b. Sub-acute c. Chronic II Based on type of Exudates a. Serous (Viral, allergic, toxic)
3/8/2011 Dr Sanjay Shrivastava 2

Classification of Conjunctivitis
b. Catarrhal (allergic ± Ropy or thread like thick mucoid discharge) c. Mucopurulent d. Purulent c. Pseudo-membranous / Membranous


Dr Sanjay Shrivastava


Classification of Conjunctivitis
III Based on Conjunctival Reaction a. Follicular b. Papillary c. Granulomatous IV Based on Etiology a. Infectious (Bacterial, Viral, Chlamydial, Fungal and parasitic) b. Non-infectious (Allergic, Irritants
3/8/2011 Dr Sanjay Shrivastava 4

Classification of Conjunctivitis
Endogenous or autoimmune, Dry Eye, Toxic (chemical or drug induced, self inflicted) and Idiopathic.


Dr Sanjay Shrivastava


Risk Factors for the Development of Bacterial Conjunctivitis
Disruption of host defense mechanism caused by: 1. Dry Eye 2. Exposure due to lid retraction, exophthalmos, lagophthalmos, inadequate blinking 3. Nutritional deficiencies/ Avitaminosis A
3/8/2011 Dr Sanjay Shrivastava 6

contd 4. Local or Systemic Immune Deficiency: * after topical and systemic immunosupressive therapy * Nasolacrimal duct obstruction and infection * Radiation damage * Trauma * Surgery 3/8/2011 Dr Sanjay Shrivastava 7 ..Risk Factors for the Development of Bacterial Conjunctivitis .

Contd * Prior Conjunctival inflammation or infection * Systemic Infection * Exogenous inoculation 3/8/2011 Dr Sanjay Shrivastava 8 .Risk Factors for the Development of Bacterial Conjunctivitis..

3/8/2011 Dr Sanjay Shrivastava 9 . still seen in individuals and communities where Gonorrhoea is still a problem and hygienic standards are poor.Gonorrhoeal Conjunctivitis I. Epidemiological Aspect Rare in developed countries.

shaped Gramnegative intracellular diplococcus). Condition is found in cases suffering from Gonorrhoeal genital infection. Neisseria Catarrhalis may be seen/found in chronic forms.Gonorrhoeal Conjunctivitis Etiology ± Caused by Neisseria Gonorrhoeae (a bun. Incubation period is few hours to three days. 3/8/2011 Dr Sanjay Shrivastava 10 .

grittiness.Clinical Features Symptoms Swelling of eyelids. Diminution of Vision 3/8/2011 Dr Sanjay Shrivastava 11 . purulent discharge. redness. Pain. inability to open eye(s).

Lids are swollen. overhanging on lower lid.Clinical Features Signs Acute disease. 3/8/2011 Dr Sanjay Shrivastava 12 . Often in RE to begin with. Deep red velvety conjunctiva sometimes with membrane After two to three weeks discharge diminishes but subacute form of conjunctivitis with presence of Gonococci persists for several weeks. Matting of lashes and pus on lids margins. Eversion is difficult. Upper lids are tense. occurring usually in adult males.

tenderness and suppuration 3/8/2011 Dr Sanjay Shrivastava 13 .Signs « Contd ‡ Pre-auricular lymphadenopathy.

Progressing rapidly depth-wise leading to perforation and complications associated with it. all round. Location of Corneal Ulcer ± Central. ‡ Associated systemic signs ± Urethritis. ‡ Complications. rise of temperature and depression. 3/8/2011 Dr Sanjay Shrivastava 14 . Marginal Ulcer .Corneal involvement ± Gonococcus is capable of invading the normal cornea through intact cornea.Clinical Features ‡ No immunity is conferred by an attack.

3/8/2011 Dr Sanjay Shrivastava 15 .Clinical Features ‡ Other complications of Gonorrhoeal Conjunctivitis ± Iritis . Endocarditis and Septicaemia. Iridocyclitis ‡ Non Ocular complications ± Arthritis.

Aim of therapy is to prevent or limit the corneal involvement and to eliminate systemic source. 3/8/2011 Dr Sanjay Shrivastava 16 .Treatment ‡ Of Gonococcal Conjunctivitis is started on confirmation of intracellular Gram-negative diplococci in conjunctival scrapings in clinically suspected cases.

Treatment ‡ Systemic Treatment Ceftriaxone 1 Gm IM . single dose Local Treatment * Cleanliness * Ciprofloxacin / Ofloxacin/ Gentamicin/ Tobramycin Eye Drops 2 hrly. 3/8/2011 Dr Sanjay Shrivastava 17 .

Treatment * Bacitracin Eye Ointment 6 hrly * Cycloplegic (Atropine) ± in cases of Corneal involvement * Tetracycline In cases where co-existing Chlamydial Trachomatis infection is suspected and cases with history of allergy to Penicillin / Cephalosporins 3/8/2011 Dr Sanjay Shrivastava 18 .

Angular Conjunctivitis Specific type of Conjunctival inflammation characterized by involvement of intermarginal Conjunctiva and neighboring bulbar conjunctiva. 3/8/2011 Dr Sanjay Shrivastava 19 . caused by Morax axenfield diplobacilli called Moraxella Lacunata.

3/8/2011 Dr Sanjay Shrivastava 20 .Angular Conjunctivitis Etiology ± Caused by Staphylococci and more typically by Moraxella Lacunata.

It produces proteolytic ferment.Pathogenesis Moraxella Lacunata is a gram-negative diplobacilli. which acts by macerating epithelium. pair of large .thick rods placed end to end which stain well with basic stains. 3/8/2011 Dr Sanjay Shrivastava 21 . The incubation period is usually 4 days . The organisms are resistant to drying .

3/8/2011 Dr Sanjay Shrivastava 22 .Pathogenesis Moraxella is also found in nasal tract of healthy persons and often present in the nasal discharge of patients of angular conjunctivitis.

discomfort. 3/8/2011 Dr Sanjay Shrivastava 23 . sharp pricking pain and mucopurulent discharge. Incubation period : Symptoms develop after 4 days of exposure. frequent blinking.Symptoms Redness.

Chronic conjunctivitis. 3/8/2011 Dr Sanjay Shrivastava 24 .Signs ‡ Congestion limited to intermarginal strip at inner and outer canthi and neighboring bulbar conjunctiva. and relapses may occur. Excoriation of skin at inner and outer palpabral angles ‡ Complications. Blepheritis. corneal ulcer (marginal or central associated with hypopyon) ‡ Attack does not confer immunity.

acts by inhibiting proteolytic ferment. 3/8/2011 Dr Sanjay Shrivastava 25 .Treatment Tetracycline eye ointment Eye drops containing Zinc also beneficial.

Acute inclusion Chlamydial Conjunctivitis Its acute conjunctival inflammation caused by Chlamydial infection (Serotype D-K) characterized by inclusion bodies. 3/8/2011 Dr Sanjay Shrivastava 26 .

Acute inclusion Chlamydial Conjunctivitis ‡ Etiology ± Caused by Chlamydia Trachomatis (serotype D-K) ‡ Pathogenesis ± characterized by inclusion bodies identical with those occurring in Trachoma. 3/8/2011 Dr Sanjay Shrivastava 27 .

3/8/2011 Dr Sanjay Shrivastava 28 . Common mode of infection is through swimming pool water (swimming pool conjunctivitis) May also be transmitted by mothers to newborn.Spread Spread by sexual transmission from genital reservoir (urethritis/ cervicitis).

superficial punctate keratitis. peripheral vascularization (pannus) 3/8/2011 Dr Sanjay Shrivastava 29 .Clinically Features ‡ Incubation period. papillary hyperplasia.10 days ‡ Symptoms. foreign body sensation. discharge ‡ Signs ± Conjunctival hyperaemia. redness. Follicles. more prominent in lower lid.Usually 5.Acute onset . intolerance to light .

Associations have been reported with nongonococcal and post gonococcal urethirits. 3/8/2011 Dr Sanjay Shrivastava 30 . Arthiritis is also seen in these cases. cervicitis and infections of genital tract.Clinical features Chlamydia Trachomatis is also responsible for genital and oculogenital infections.

Other tests are immuno-sorbitant assay. Urethral and cervical secretions should also be tested. Giemsa staining of conjunctival scrapping and McCoy cell cultures.Diagnosis Direct immuno-fluorescent stain of smear using monoclonal antibodies. Test has 100% sensitivity and 94% specificity. 3/8/2011 Dr Sanjay Shrivastava 31 .

Treatment Heals spontaneously in 3 -12 months if left untreated. Locally ± Tetracycline or Erythromycin eye ointment twice daily for two weeks. Azithromycin 1 Gm single dose and Ofloxacin 300 mg twice for 7 days. 3/8/2011 Dr Sanjay Shrivastava 32 . Erythromycin 250 mg twice for two weeks. Doxycycline 100 mg twice for two weeks. Systemic ± Tetracycline 250 mgm qid for 2 weeks.

mucopurulent or purulent discharge from one or both eyes during first month of life. 3/8/2011 Dr Sanjay Shrivastava 33 . acquired at the time of birth.Ophthalmia Neonatorum Conjunctival inflammation associated with mucoid. It¶s a preventable disease in newborn babies caused by maternal infection.

Epidemiology ‡ Although its incidence has declined due decrease in incidence of Gonorrhoea and due effective prophylaxis and treatment . 3/8/2011 Dr Sanjay Shrivastava 34 . disease is still prevalent and remains a public health problem in communities with poor hygiene and limited access to proper health care.

‡ Chlamydial Trachomatis. Streptococcus Pneumoniae. Chalmydial Oculogenitalis ‡ Chemical Conjunctivitis due to Silver Nitrate 1or 2% (used as Crede¶s method) 3/8/2011 Dr Sanjay Shrivastava 35 . Staphylococcus etc.Etiology ‡ Neisseria Gonorrhoeae.

one more severe than other. chemosis. 3/8/2011 Dr Sanjay Shrivastava 36 . soon becomes purulent ‡ Both eyes are affected. cornea is seen at bottom of a crater like pit. thick yellow discharge. ‡ Conjunctiva is intensely inflamed with severe congestion.Neisseria Gonorrhoeae ‡ Manifest within 48Hrs of birth ‡ Discharge is Mucopurulent to begin with.

conjunctiva is puckered and velvety.Clinical Features « contd ‡ Lids are swollen. stasis of blood giving appearance of intense congestion. ‡ Corneal complications. tense.corneal ulcer with its complications is common 3/8/2011 Dr Sanjay Shrivastava 37 . serum and blood. ‡ Discharge is pus. later becomes softer. Pseudomembrane formation.

3/8/2011 Dr Sanjay Shrivastava 38 . anterior staphyloma. rarely oval marginal ulcer. panophthalmitis. just below the centre of cornea. adherent leucoma. prolapse of vitreous. prolapse of uveal tissue. anterior capsular cataract. ‡ Scarring of cornea.Complications ‡ Corneal Ulcer : Oval ulcer. progressive ulcer resulting in ± perforation of corneal ulcer. purulent uveitis. prolapse of lens.

Complications« Contd ‡ Non development of fixation due to corneal opacity during first 3 weeks. ‡ Nystagmus due to non-development of macular fixation 3/8/2011 Dr Sanjay Shrivastava 39 .

Chlamydia Trachomatis Inclusion Conjunctivitis ‡ Develop usually over one week after birth ‡ Its venereal infection derived from cervix or urethra ‡ Less severe than Gonococcal infection 3/8/2011 Dr Sanjay Shrivastava 40 .

Other Bacterial Infections ‡ Manifest usually 48-72 hrs after birth Herpes Simplex Infection presents 5-7 days after birth 3/8/2011 Dr Sanjay Shrivastava 41 .

Chemical Toxicity ‡ Seen within few hours after prophylactic treatment with Silver Nitrate Solution 1 or 2% (Crede¶s Method) applied for prophylaxis of Gonococcal infection 3/8/2011 Dr Sanjay Shrivastava 42 .

Diagnosis ‡ Grams staining ‡ Giemsa staining of epithelial scraping ‡ Chlamydial Immunofluorescent antibody test ‡ Viral and Bacterial culture sensitivity test 3/8/2011 Dr Sanjay Shrivastava 43 .

Differential Diagnosis ‡ Differential Diagnosis of discharge in child within the first month of life ± Congenital blockade of nasolacrimal duct Acute Dacryocystitis Congenital Glaucoma. 3/8/2011 Dr Sanjay Shrivastava 44 .

Treatment Prophylaxis In cases of any suspicious vaginal discharge in antenatal period should be treated meticulously New born babies closed lids should be cleaned properly Prophylactic used of 1% Tetracycline eye ointment in babies eyes 3/8/2011 Dr Sanjay Shrivastava 45 .

contd ‡ Close observation during first week ‡ Prophylactic use of Penicillin or other antibiotic drops 3/8/2011 Dr Sanjay Shrivastava 46 ..Prophylaxis .

Atropine is added if corneal involvement is there.3% and Bacitracin eye ointment. 3/8/2011 Dr Sanjay Shrivastava 47 .Treatment Is on lines of Gonorrheoeal Conjunctivitis Child is hospitalized and treated with Gentamicin eye drops 0.

3/8/2011 Dr Sanjay Shrivastava 48 . IV or IM in three divided dosage. Or Kanamycin 25 mgm /kg body weight.Treatment «. dose of Ceftriaxone 125 mgm or Cefotaxime 50 mgm /kg. Contd. Gonorrhoeae is treated with single I.3% in both eyes repeated in 15 min and then after every feed (2hrly) for 3 days. ‡ N. ‡ Local treatment consists of Gentamicin eye drops 0.M.

Treatment «. ‡ Parents should be treated for genital infection. Contd. ‡ Chlamydial Infection is treated with Erythromycin ethylsuccinate 50mgm /kg daily in 4 divided dosage before feed for 23 weeks or Azithromycin 10 mgm/kg body weight for 3 days ‡ Local treatment Chlortetracycline 1% or Erythromycin eye ointment after feeds. 3/8/2011 Dr Sanjay Shrivastava 49 .

third after Cataract and Glaucoma. Trachoma is still a leading cause of preventable blindness world wide. 3/8/2011 Dr Sanjay Shrivastava 50 .TRACHOMA ‡ At one time known as Egyptian Ophthalmia. endemic in middle east during prehistoric period. spread far and wide in Europe by French Army during Napoleonic wars.

‡ Approximately 1/5th population of world is affected by Trachoma, amounting to 150 million people across the 48 countries . It is estimated that 6 million people are blind in both eyes. It still remains a significant problem in areas of Africa, South East Asia, the Middle East and Australia.


Dr Sanjay Shrivastava


‡ Trachoma is caused by Chlamydia Trachomatis immunotypes / serotypes A,B and C. Chlamydia organisms shares properties of both, bacteria and virus. It is an obligatory intracellular bacteria.


Dr Sanjay Shrivastava


Predisposing Factors
‡ ‡ ‡ ‡ Unhygienic and crowded surroundings Low socio-economic status Lack of water No race is exempted


Dr Sanjay Shrivastava


Transmission ‡ Direct transmission from eye to eye through discharge ‡ Through fomites. flies and eye cosmetics ‡ Disease is contagious in acute phase ‡ Incubation period is 5 -12 days 3/8/2011 Dr Sanjay Shrivastava 54 .

Clinical Features 3/8/2011 Dr Sanjay Shrivastava 55 .

discharge.Symptoms ‡ Pure Trachoma is usually asymptomatic condition or there may be minimum symptoms ‡ There may be redness. lacrimation and photophobia ‡ Systemic symptoms like Rhinitis. irritation. foreign body sensation. pre auricular lymphadenopathy and upper respiratory infection may be present 3/8/2011 Dr Sanjay Shrivastava 56 .

but may occur as acute when infection is massive as occurs in experimental or accidental or clinical infection 3/8/2011 Dr Sanjay Shrivastava 57 .Symptoms « contd ‡ Onset is usually sub-acute.

upper tarsal Conjunctiva appears red and velvety. upper margin of Tarsus.Signs ‡ Primary infection is Epithelial. later may become uniformly thick like jelly. Bulbar Conjunctiva near limbus) 3/8/2011 Dr Sanjay Shrivastava 58 . Caruncle. upper fornix. involving conjunctiva and cornea characterized by: Conjunctival congestion. Follicles (in lower fornix. Palpabral Conjunctiva. Plica.

‡ Follicles are small (0. ‡ Papillary enlargement.Signs « contd.5 mm in diameter) but may measure upto 5 mm in diameter. 3/8/2011 Dr Sanjay Shrivastava 59 . ‡ Invasion of lacrimal passages may also be there.

3/8/2011 Dr Sanjay Shrivastava 60 . extending deep into stroma ‡ Pannus and Lymphoid infiltration with vascularization seen in upper half. Whole cornea may be covered with pannus . Vassels are superficial between epithelium and Bowman¶s membrane. tending to spread towards the centre .Corneal Signs ‡ Superficial Keratitis in upper part ‡ Epithelial erosion.

Contd ‡ Stages of Pannus: Progressive (infiltration is beyond vascularization) Regressive (infiltration has receded and vessels are ahead of infiltration) * Corneal ulcer .Corneal Signs. occurs anywhere but commonest at the advancing edge of pannus. Chronic. are shallow ulcer with little infiltration. 3/8/2011 Dr Sanjay Shrivastava 61 ..

Pathology ‡ Chlamydia Trachomatis is seen in conjunctival scarping in the form of colonies in the epithelial cells as Halberstaedter Prowazek inclusion bodies. 3/8/2011 Dr Sanjay Shrivastava 62 . ‡ Inclusion bodies are composed of innumerable elementary bodies embedded in carbohydrate matrix.

3/8/2011 Dr Sanjay Shrivastava 63 . attacking epithelial cells. Numerous initial bodies. degenerates and cell burst to release elementary bodies. The nucleus of cell is displaced .Pathology « Contd Elementary bodies. in cells divide to form innumerable elementary bodies embedded in carbohydrate matrix. to attack new cells. enlarge to become initial bodies in the cytoplasm of the cells.

Pathology « contd. ‡ Lymphocytic infiltration in Adenoid layer. ‡ In TF and TI stages. polymorphonuclear cell infiltration is noticed and later on lymphocytes are dominant. ‡ Aggregation of lymphocyte without capsule forms follicles ‡ Follicles shows necrosis and contains large multinucleated Laber cells. ‡ An attack confers little immunity 3/8/2011 Dr Sanjay Shrivastava 64 .

Contd.Pathology «. ‡ Trachomatous infiltration may spread deep into subepithelial tissues of the palpabral conjunctiva and even invade the tarsal plate ‡ Fibrosis around follicles giving rise to cicatricial bands (Arlt line in superior tarsus) 3/8/2011 Dr Sanjay Shrivastava 65 .

Diagnosis ‡ Culture of Chlamydia Trachomatis in irradiated McCoy cells ‡ Micro-Immunofluorescence (Micro-IF) test ‡ Monoclonal Direct Antibody test ‡ Demonstration of inclusion bodies in conjunctival epithelial scrapping 3/8/2011 Dr Sanjay Shrivastava 66 .

Pannus 4. Typical Trachomatous Scarring (Stellate or Linear Scarring of upper tarsus) Diagnosis is confirmed by demonstration of inclusion bodies 3/8/2011 Dr Sanjay Shrivastava 67 . Limbal Follicles/ Herbert Pits 5. Epithelial Keratitis 3. Follicles 2.Clinical Diagnosis ‡ Is based on identification of at least two of the following signs: 1.

Limbal follicles. SPK and Pannus Stage II ± Florid Superior Tarsal follicular reaction with mature follicles or marked papillary hyperplasia . superior corneal epithelial infiltrates Dr Sanjay Shrivastava 68 3/8/2011 .Trachoma Classification I. MacCallan¶s Classification Stage I ± Immature follicles on tarsus . pannus.

MacCallan Classification Stage ±III : Signs of stage II with Cicatrization Stage ± IV Cicatrization and its sequelae 3/8/2011 Dr Sanjay Shrivastava 69 .

Severe infection with high risk of complication. thickening of Conjunctiva obscuring >50% conjunctival blood vessels. 3/8/2011 Dr Sanjay Shrivastava 70 .WHO Classification Stage ± I Trachomatous Infiltration ± Follicular (TF) 5 or more follicles of at least 0. If treated properly. papillae.5 mm in diameter. patient recovers with no or minimal scarring Stage -II Trachomatous Infiltartion ± Intense (TI) : Follicles.

V : Corneal Opacity (CO) corneal opacity occupying pupillary area 3/8/2011 Dr Sanjay Shrivastava 71 .WHO Classification« Contd Stage ± III : Trachomatous scarring (TS) Stage ± IV : Trachomatous Trichiasis (TT) Stage .

Sequelae of Trachoma ‡ ‡ ‡ ‡ ‡ Distortion of lids Trachomatous Ptosis Entropion Trichiasis Tylosis 3/8/2011 Dr Sanjay Shrivastava 72 .

Late Complications ‡ ‡ ‡ ‡ ‡ Sever dry eye Keratitis Corneal scarring Fibrovascular pannus Corneal Bacterial Superinfection 3/8/2011 Dr Sanjay Shrivastava 73 .

Erythromycin. Rifampicin and Sulphonamides are effective orally ‡ Topical Erythromycin and Tetracycline ointment 3/8/2011 Dr Sanjay Shrivastava 74 .Treatment ‡ Tetracycline.

Treatment « contd Treatment of TF Stage ± Topical Erythromycin twice for 6 weeks Oral Azithromycin 1 Gm single dose Tetracycline 250 mgm qid for 2 weeks Doxycycline 100 mgm twice for 2 weeks 3/8/2011 Dr Sanjay Shrivastava 75 .

tarsal rotation . Or Cryotherapy 3/8/2011 Dr Sanjay Shrivastava 76 .Treatment « contd Treatment of TI Stage : same as TF stage Treatment of TS stage : Ocular lubricants Treatment of TT Stage : Epilation . Radiofrequency/ diathermy or electrolysis epilation .

depending on depth of corneal opacity 3/8/2011 Dr Sanjay Shrivastava 77 .Treatment « contd ‡ Treatment of CO Stage : After treatment of lid deformities LKP or PKP.

‡ S : Surgery for entropion/ trichiasis ‡ A : Antibiotics for infectious trachoma ‡ F : Facial cleanliness to reduce transmission ‡ E : Environmental improvement 3/8/2011 Dr Sanjay Shrivastava 78 . under which µSAFE¶ strategy has been adopted.WHO¶s GET 2020 ‡ WHO in 1997 started Global Elimination of Trachoma by 2020 programme called WHO GET 2020 programme.

Trachoma Control Programme ‡ Tetracycline eye ointment 1% twice daily on 5 consecutive days every month for 12 months ‡ Mass treatment should be annually in endemic zones ( <35% children are affected) and Biannually in hyperendemic zones (>50% children are affected) 3/8/2011 Dr Sanjay Shrivastava 79 .

cornea and rarely in iris tissue. 3/8/2011 Dr Sanjay Shrivastava 80 .Ophthalmia Nodosa Nodular conjunctivitis. resembling tuberculosis. reddish or pale gray nodules formed in bulbar. due to irritation caused by caterpillar hairs. Small semitranslucent pinkish. palpabral conjunctiva.

Contd Hairs are surrounded by giant cells and lymphocytes.Ophthalmia Nodosa . Treatment: Symptomatic. 3/8/2011 Dr Sanjay Shrivastava 81 . Local Steroids in selected cases.. under supervision and excision of conjunctival nodules.

characterized by chronic redness in one or both eyes with persistence of annoying symptoms. 3/8/2011 Dr Sanjay Shrivastava 82 .Chronic Non-specific Conjunctivitis Is a clinical condition resulting from continuation of acute conjunctivitis or due to variety of etiological factors.

3. misdirected eyelash(es). 2. sinusitis. late hours. Concretions. dust. Exposure to Chronic irritants like. smoke. dandruff etc 4. Chronic Rhinitis.Etiology 1. poor quality air. Dacryocystitis . Unilateral Conjunctivitis foreign body retained in conjunctiva or Dacryocystitis 3/8/2011 Dr Sanjay Shrivastava 83 . blepharitis. heat. seborrhoea . alcohol abuse. Hypersensitivity to allergen.

grittyness. together 3/8/2011 Dr Sanjay Shrivastava 84 . * Difficulty in keeping eyes open. mucoid or mucopurulent discharge. lids may stick together in the morning on waking up. burning.Symptoms * Discomfort. * Increased secretions. especially in the evening when eyes becomes red and eyelid margins feel hot and dry.

Signs ‡ Hyperaemic lid margins ‡ Conjunctival Congestion particularly in lower fornix ‡ Papillary hyperplasia 3/8/2011 Dr Sanjay Shrivastava 85 .

3/8/2011 Dr Sanjay Shrivastava 86 .Treatment ‡ Elimination of cause ‡ Treatment of infection foci in nose and upper respiratory passage ‡ Treatment of conjunctival infection with appropriate antibiotic ‡ Treatment of meibomian gland abnormality by mechanical expression and warm compression.

Allergic Conjunctivitis ‡ Allergy or Hypersensitivity is a state which is commonly regarded as an unfortunate by product of the process of immunity whereby the tissues react by an abnormal and injurious response to foreign substance (allergens) 3/8/2011 Dr Sanjay Shrivastava 87 .

Delayed Hypersensitivity 3/8/2011 Dr Sanjay Shrivastava 88 . Immediate and b.Allergy ‡ Two types of reactions: a.

Immediate Hypersensitivity ‡ Ten days after initial exposure to foreign protein. anaphylactic reaction follows after second exposure to same protein. 3/8/2011 Dr Sanjay Shrivastava 89 . Characterized by circulating antibodies.

Delayed Hypersensitivity ‡ There are no circulating humoral antibodies of anykind. 3/8/2011 Dr Sanjay Shrivastava 90 . The sensitization is the property of the cells themselves. The hypersensitivity is caused by prior contact of the tissue with a protein and seems to be due to the development of sessile antibodies on or within the cells so that when they are re-exposed to the same antigen a reaction causing cellular damage develops which may even involve necrosis.

Delayed Hypersensitivity ‡ This reaction does not occur immediately and reach its maximum only after 24 to 72 hours. 3/8/2011 Dr Sanjay Shrivastava 91 . ‡ Typical example is tuberculin reaction.

Autosensitization ‡ In this case individual¶s own tissue protein are altered and thus rendered ³foreign´ by a pathogenic agent. repeated contacts may result in hypersensitivity reaction eg Sulphonamide allergy and autosensitization induced by the haemolytic Streptococcus. either bacterial or a chemical acting as a haptene. 3/8/2011 Dr Sanjay Shrivastava 92 .

cold. light or mechnical irritation by a typical hypersensitive response often of urticarial type. 3/8/2011 Dr Sanjay Shrivastava 93 . Some individuals are hypersensitive to light of a certain wave-band.Physical Allergy ‡ Certain individuals react to physical agents such as heat.

3/8/2011 Dr Sanjay Shrivastava 94 .Physical Allergy ‡ The reaction is due to auto-antigen liberated in the tissues either due to alteration of their specificity or due to their capability of reacting with antibody only under the physical condition created by the stimulus.

Delayed Type (i) Contact Dermatoconjunctivitis due to local chemicals (ii) Microbial Allergic Conjunctivitis (iii) Keratoconjunctivitis Medicamentosa due to ingestion of drugs like arsenic and gold. Immediate Anaphylactic (Hay fever) type mediated by circulating antibody B. 3/8/2011 Dr Sanjay Shrivastava 95 .Types of Allergic Conjunctivitis 1. Simple Allergic Conjunctivitis A.

Phlyctenular Keratoconjunctivitis ± Delayed reaction. 3/8/2011 Dr Sanjay Shrivastava 96 .Endogenous microbial allergy. Vernal Catarrh ± Allergic disease of immediate type ± an exogenous allergy. B.Types of Allergic Conjunctivitis 2. Interstitial Allergic Conjunctivitis A.

medications etc. 3/8/2011 Dr Sanjay Shrivastava 97 . and sometimes bacterial protein of endogenous nature. Itching is a prominent symptom.Acute or Sub-acute Allergic Catarrhal Conjunctivitis ‡ Is an allergic condition characterized by hyperaemia which not as intense as found in bacterial conjunctivitis. cosmetics. flower. accompanied by watery secretion containing eosinophils. dye. ‡ Etiology: Exogenous allergen (contact with animals. pollens. the most common being Staphylococcal infection. chemicals.

watering.‡ Symptoms: Itching. presence of eosinophils and elevated IgE level. watery discharge. swelling of lids and there may symptoms of hay fever ‡ Signs: Conjunctival Congestion. redness. 3/8/2011 Dr Sanjay Shrivastava 98 . edema of lids may be there.

adrenalin 1:10000. 3/8/2011 Dr Sanjay Shrivastava 99 . Removal of allergen from environment 2. Short course corticosteroid drops 4. olopatadine.Treatment 1. Astringent lotion. mast cell stabilizers (sodium cromoglycate. Topical 2% sodium cromoglycate drops. ketotifen etc) 3. antihistaminic drops (chlorpheniramine).

3/8/2011 Dr Sanjay Shrivastava 100 . interstitial inflammation of the conjunctiva of periodic seasonal incidence. It is recurrent. self limiting disease/ condition usually due to exogenous allergens.Vernal Keratoconjunctivitis (VKC) ‡ It is a chronic . bilateral conjunctival inflammatory condition found in individuals predisposed by their atopic background.

associated with itching . a gelatenous hypertrophy of the limbal conjunctiva. redness of the eyes lacrimation and mucinous or lardaceous discharge usually containing eosinophils 3/8/2011 Dr Sanjay Shrivastava 101 . and a distinctive type of keratitis .‡ Characterized by flat topped papillae usually on the tarsal conjunctiva resembling cobble stones in appearance . either discrete or confluent.

Colored races are particularly prone to limbal form of disease. 3/8/2011 Dr Sanjay Shrivastava 102 .K. ‡ It is essentially a disease of yoth occuring most frequently between ages of 6 and 20 years.Epidemiology ‡ Sporadically occuring with a wide geographical incidence. Its more common in India and the tropics than in U.

3/8/2011 Dr Sanjay Shrivastava 103 .‡ Sex incidence ± Very high percentage of cases are seen in males. ‡ Family History of allergy is found in 40 ± 60 % cases.

Etiology ‡ Three theories 1. animal inhalants. Due to action of physical factors (as heat. Most affected people show a marked hypersensitivity to a variety of antigens (pollen. ingestants etc) 3/8/2011 Dr Sanjay Shrivastava 104 . humidity and light) 2. manifestation of an allergic condition. Disorder of the endocrine glands associated with vagotonic state 3.

burning. ptosis. dirt white or cream colored. blepharospasm. 3/8/2011 Dr Sanjay Shrivastava 105 .Symptoms ‡ Severe itching and photophobia. ropy and lardaceous. thick mucous discharge. typical stringy discharge . foreign body sensation. thick. ‡ Discharge is scanty.

Signs ‡ The signs are confined to conjunctiva and cornea. ‡ Types ± Palpabral form ± Limbal/ Bulbar form ± Mixed type 3/8/2011 Dr Sanjay Shrivastava 106 . the skin of the lids are not involved.

Tarsal papillae are discrete larger than 1 mm in diameter.Palpabral VKC Conjunctiva develops a papillary response in the upper tarsal conjunctiva and at the limbus. flat tops . 3/8/2011 Dr Sanjay Shrivastava 107 . Conjunctiva is congested later on becomes milky. they are cobblestone in appearance.

This develop mostly at the upper margin of the cornea ‡ Limbal Papillae tend to be gelatinous and confluent 3/8/2011 Dr Sanjay Shrivastava 108 .Limbal / Bulbar Form ‡ In limbal or bulbar form the first change is usually a thickening. broadening and opacification of the limbus which overrides the corneal periphery as a semitranslucent hood.

In the raised mass. nasally and temporally. Horner Trantas dots are collection of epithelial cells and eosinophils. 3/8/2011 Dr Sanjay Shrivastava 109 . whitish Horner. ‡ These changes may lead to superficial corneal vascularization.‡ Limbal Nodules ± Their most common site is in the palpabral aperture.Trantas¶s spots may occur at any stage.

3/8/2011 Dr Sanjay Shrivastava 110 .Corneal Findings ‡ Punctate Epithelial Keratitis ‡ Horizontally oval ulcer in upper part of cornea called Shield Ulcer ‡ Peripheral superficial gray white deposition termed Pseudogeronton.

Pathogenesis ‡ Biopsy of tarsal papilla in VKC reveals that epithelium contain large number of mast cells and eosinophils. Mast cells contains basic fibroblast growth factor ‡ Cytology shows more eosinophils and neutrophils. Substantia properia contains elevated number of mast cells. also contains CD4 + T cells. Histamins and trytase are elevated in tears ‡ Protein deposition diffusely in conjunctiva 3/8/2011 Dr Sanjay Shrivastava 111 . IgE and IgG have been isolated from tears.

giving rise to the milky hue.‡ The flat-topped nodules are hard . In addition . plasma cells . infiltration with lymphocytes. but the epithelium over them is thickened . and consist chiefly of dense fibrous tissue . Histologically they are hypertrophied papillae. 3/8/2011 Dr Sanjay Shrivastava 112 . basophils and eosinophils may also be seen. Eosinophils are present in them in great numbers. macrophages. not follicle.

Diagnosis ‡ History ‡ Clinical findings (young boys living in warm climates presenting with intense photophobia. ptosis and gaint papillae) 3/8/2011 Dr Sanjay Shrivastava 113 .

TREATMENT 1. 3/8/2011 Dr Sanjay Shrivastava 114 . a short term high dose pulse regimen of topical steroid is necessary. Steroids ± Patients with significant seasonal exacerbation . Avoidance of allergen 2. Dexamethasone 0. Local Treatment a. tapered rapidly.1% or Prednisolon Phosphate 1% . 8 times for one week brings excellent result.

b. a mast cell stabilizer or a dualo acting drug such as Olopatidine. Topical Cyclosporin-A (0. Ketotifen or Azelastine (mast cell stabilization and antihistamine) c. reduces expansion of T cell clones. 3/8/2011 Dr Sanjay Shrivastava 115 . it decreases the release of interlukin2.05%) twice daily. Mast Cell stabilizer: Cromolyn sodium.

If plaque forms ± superficial keratectomy Phototherapeutic Keratectomy and Keratectomy with amniotic membrane graft placement. 3/8/2011 Dr Sanjay Shrivastava 116 .Treatment of Corneal Shield Ulcer: Antibiotic.steroid ointment and occlusion.

Injection of short term or long term acting steroids into tarsal papilla has been shown effective in reducing their size.Surgical Treatment Cryablation of upper tarsal cobble stones ± but may lead to lid and tear film abnormalities. 3/8/2011 Dr Sanjay Shrivastava 117 .

Climatotherapy 3/8/2011 Dr Sanjay Shrivastava 118 . Non sedating antihistaminic 2.3. Systemic Treatment: 1. Oral Aspirin (high dose of 2400 mgm daily) 4.

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