Bulbar conjunctiva – covers the anterior surface of the sclera – loosely attached to orbital...

• Bulbar conjunctiva

– covers the anterior surface of the sclera

– loosely attached to orbital septum in the fornices

– limbus : fusion of the tenon’s capsule and conjunctiva for about 3 mm around the cornea

• Palpebral conjunctiva

– covers the posterior surface of the lids

– firmly adherent to the tarsus

– posterior reflections: superior and inferior fornices

• Mucocutaneous junction– Part of the conjunctiva continuous with the skin at the lid

margin

• Semilunar fold

– in the inner canthus

– Caruncle: fleshy epidermoid structure

attached to the semilunar fold

– Contains cutaneous and mucous membranes

Tenon’s Capsule

• Also known as fascia bulbi

• Envelopes the globe from the limbus to the optic nerve

• In the limbus, there is fusion of conjunctiva, tenon’s capsule and episclera

• Tubular reflection in the extraocular muscle (EOM) become continuous in the fascia of the muscles

check ligaments 1. regulate direction of the EOM 2. act as functional mechanical origins

Check Ligaments

Anterior Ciliary Artery

• Lockwood’s ligament or suspensory ligament of the eyeball

– lower segment of the tenon’s capsule fused with 1. fascia of the inferior oblique and 2. fascia of the inferior rectus

– upon which the globe rests

Infantile Dacryocystitis

• Stenosis at the Valve of Hasner

• Failure of canalization in 4 to 7%

• Spontaneously open within the 1st month

• Probing after one year of age, effective in 75%

Dacryocystitis

- infection of the lacrimal sac due to obstruction of the nasolacrimal duct

- symptoms: tearing, discharge

Congenital NLD Obstruction

EPIPHORA, MATTING OF EYELASHES

ACUTE DACRYOCYSTITIS, infrequent

• Delayed canalization near the valve of Hasner

• Reflux of purulent material in the punctum on pressure

Non Surgical Management• Lacrimal sac massage

- Purpose:1. empties the sac2. applies hydrostatic

pressure to drainage obstruction- finger is placed above medial canthus, firmly press and slide down the nose

Treatment of congenital nasolacrimal duct obstruction

• Massage of nasolacrimal duct and antibiotic drops 4 times daily• Improvement by age 12 months in 95% of cases

• If no improvement - probe at 12-18 months• Results - 90% cure by first probing and 6% by second

Surgical Mx: PROBING

• There is a high spontaneous remission rate (60-90%) in the first year of life

• Surgical probing of lacrimal system is indicated if condition persists up to about age 12-15 months

• Acute Dacryocystitis children: Haemophilus influenza adults: Staph aureus

• Chronic Dacryocystitis Strep pnuemoniae

Dacryocystitis

Acute • Tearing

• Swelling + tenderness • Purulent discharge

• Systemic antibiotics, NLD massage

Chronic• Tearing

• Swelling

• Mucoid discharge

• Dacryocystorhinostomy

ACUTE DACROCYSTITIS

Acute Dacryocystitis

• Tender canthal swelling

• Mild Preseptal Cellulitis

• May develop into abscess

Chronic Dacryocystitis

• PAINLESS SWELLING AT THE INNER CANTHUS

• MUCOPURULENT MATERIAL EXPRESSED ON

PRESSURE

Dacryocystorhinostomy (DCR)

Canaliculitis

– Actinomyces israelli, Candida albicans, aspergillus

– Punctum pouts, discharge can be expressed

– Treatment: Curettage,Irrigation, Canaliculotomy, Tincture of Iodine

• EDEMA OF THE CANALICULUS

• POUTING OF THE PUNCTUM

• Expressed concretions consisting of sulphur granules

CANALICULITIS

ORBITAL CELLULITIS• Orbital Cellulitis/Abscess

- mostly caused by erosion of the lamina papyracea, paper-thin bone of the ethmoid

- most common cause of proptosis in children

• Presents as preseptal cellulitis: pain redness, edema and leukocytosis

• Orbital cellulitis: chemosis, proptosis, limitation of eye movement, and reduction of vision

• CT Scan, MRI

• Complications: Cavernous Sinus Thrombosis and brain abscess

ORBITAL CELLULITIS

• Intravenous antibiotics

• Culture and sensitivity of the blood, nasal and conjunctival secretions

(H. influenza, Staph, anaerobes)

• Nasal decongestants, vasoconstrictors, ENT consult

• Early surgical drainage of abscess

Periorbital Cellulitis

PAPILLAE

• Folds or projections of hypertrophic epithelium that contain a fibrovascular core. Blood vessel arborize on reaching the surface

PAPILLAE

• Folds or projections of hypertrophic epithelium that contain a fibrovascular core. Blood vessel arborize on reaching the surface

Vernal Keratoconjunctivitis

• Cobblestone

• Giant papilla in upper tarsal conjunctiva

Vernal Keratoconjunctivitis

• Males usually twice than female• Before age 10, two to 10 years long• Resolves before puberty• Kinds: seasonal (SAC) / flare-up perennial (PAC)/ all year round

Vernal Keratoconjunctivitis

• Allergic salute

• 75% history of asthma, eczema

Vernal Keratoconjunctivitis

• Severe itching, photophobia

• Pseudomembrane

• Mucous strands - conjunctival discharge

Vernal Keratoconjunctivitis

• Trantas’ dot

• Dead epithelial cells with eosinophils

• Superficial neovascularization in the limbus

Vernal Keratoconjunctivitis

• Shield ulcer

• Superiorly located oval ulcer with elevated margins

• Due to chemical damage to epithelium from mast cells and eosinophils

VKC

COBBLESTONE COBBLESTONE EOSINOPHILS

Vernal Keratoconjunctivitis

• Type I and IV reaction• Mast cells, eosinophils• Basophils, fibroblasts with newly secreted collagen• IgE, IgG

Atopic Keratoconjunctivitis

• Lid scaling, flaking, madarosis, symblepharon

• Redness, Itching, burning

• Mucoid discharge

Atopic Keratoconjunctivitis

• 25 to 42% allergic dermatitis, asthma

• Start in late teen years to 4th to 5th decade of life

• Peak: 30 – 50 years

Atopic Keratoconjunctivitis

• Papillary reaction in the tarsal conjunctiva

• Loss of goblet cells

• Associated cataract unrelated to steroid use

Giant Papillary Conjunctivitis

• nonuniform Papillary reaction, Signs and symptoms similar to VKC

• History of contact lens wear, exposed suture, prostheses

Giant Papillary Conjunctivitis

• Papilla due to an exposed suture

• IgE, mast cells, eosinophils, basophils

• Tx: suture removal, discontinue CL for 4 weeks, change of CL solution, replace CL,

mast cell stabilizer

STEROIDS ( Caution ! )

• Dexamethasone, Prednisolone acetate, Fluoromethalone acetate - cataract - glaucoma - herpes infection - fungal ulcer

• Follicular reaction

• Papillary reaction

FOLLICLES

• Yellowish-white, discrete , round elevations of the conjunctiva• A lymphocytic response• Central portion - avascular• Lymphoid germinal centers with fibroblasts in the center

FOLLICLES

• Yellowish-white, discrete , round elevations of the conjunctiva• Produced by a lymphocytic response• Central portion is avascular• Lymphoid germinal centers with fibroblasts in the center

FOLLICULAR CONJUNCTIVITIS

• Acute Follicular Conjunctivitis Adenovirus

Herpesvirus Paramyxovirus

Poxvirus Picornavirus Orthomyxoviruses Togavirus

Adenovirus - Epidemic Keratoconjunctivitis - Pharyngoconjunctival fever - Acute nonspecific follicular conjunctivitis

Adenovirus - EKC

• Serotypes 8 and 19• Watery discharge• Subconjunctival

hemorrhage• Preauricular /

submandubular node tenderness

• Cornea: subepithelial infiltrates

Adenovirus - PCF

• Serotypes 3 and 7• Follicular conjunctivitis• Pharyngitis• node

enlargement Preauricular, submandibular

Prevention: Adenovirus

• Frequent handwashing

• Asepsis of instruments

• Health personnel: no direct contact with patients up to 2 weeks

Human Diseases - Chlamydiae

C. trachomatis

A,B, Ba, C D,E,F,G, H,I,J,K L1 ,L2 ,L3

TrachomaHyperendemicBlinding form

Adult and NeonatalInclusion Conjunctivitis

ProctitisEpididymitis

CervicitisSalpingitis

Neonatal PneumonitisNongonoccocal urethritis

Reiter’s Syndrome

Lymphgranuloma venereum

Anorectal SyndromeParinaud’s Conjunctivitis

Uveitis

Chlamydia trachomatis

C. psittaciMultiple, unidentified

C. pneumoniaeTWAR

PsittacosisConjunctivitis

Respiratory DiseasePharyngitis

SinusitisOtitis

Chlamydia Obligate Intracellular Organism

• EB (elementary body)

• Extracellular

• Not metabolically active

• RB (reticulate body)

• Intracellular or initial body

• Metabolically active, capable of binary fission.

ATP, GTP

Trachoma• C. trachomatis, A to C• Transmission: Oculogenital, Fly, Hand to Eye, Eye to Eye

• TF : trachoma follicular conjunctivitis

Trachoma• TI: trachoma intense inflammation

• TS:

trachoma scarring

Alkali– Liquefaction necrosis– Hydrophilic and lipophylic properties– Hydroxyl ion causes saponification of cell

membranes, cell death and disruption of extracellular cell matrix

• Ammonium hydroxide – used in fertilizer production• Sodium hydroxide, caustic soda- cleaning drains and

pipes• Calcium hydroxide –found in cement and lime plants

Acid– Coagulation necrosis– Coagulated tissue act as chemical buffer and a

barrier to further penetration of acids

– Acids bind to collagen and causes fibril shrinkage

• Sulphuric acid – car batteries• Sulphurous acid – bleach• Hydrochloric acid – swimming pool cleaners

Specific TherapyWagener MD. Survey of Ophth41 JanFeb 1997

1. Copious irrigation

2. Debridement of Necrotic Epithelium• Remove nidus of continuing inflammation• Remove nidus of damaging proteolytic enzymes

3. Paracentesis of the anterior chamber – uncertain benefit

Early Repair, Grade 1(Corneal Epithelial Damage, No Limbal Ischemia, Good Prognosis)

• Topical corticosteroids – reduce the inflammation

• Prophylactic antibiotic to prevent infection

• Cycloplegics – reduce ciliary spasm

• Glaucoma medication as needed

Wagener MD. Survey of Ophth41 Jan Feb 1997

ALKALI BURN

CORNEAL EPITHELIAL STEM CELL TRANSPLANTATION

CORNEAL EPITHELIAL STEM CELL TRANSPLANTATION

CORNEAL EPITHELIAL STEM CELL TRANSPLANTATION

CORNEAL EPITHELIAL STEM CELL TRANSPLANTATION

Immunosuppression:

CYCLOSPORINE

Immunosuppression:

CYCLOSPORINE

Amniotic Membrane

• Acts as substrate to facilitate epithelialization

• Presence of – growth factors– cytokines – protease inhibitors in the stromal matrix

Evaluation of Amniotic Membrane Transplantation as an Adjunct to Medical Therapy as Compared with Medical Therapy Alone in Acute Ocular Burns

– In Grades II and III (Roper Classification): There is significant reduction in pain and faster

reepithelialization of the corneal surface.

– In Grade IV: There is no significant statistical difference in reepithelalization of the cornea between medical therapy alone and amniotic membrane transplantation with medical therapy.

Tamhane A, Vajpayee MS, Bisnas N, et al.

Ophthalmology Nov 2005;112:1963-1969

Penetrating keratoplasty

• Wait for at least one year

• Problems: neovascularization, unstable corneal surface , rejection, glaucoma

Chemical Injuires to the Eye

• 90% preventable