Conjunctiva and Diseases Juan S. Lopez, MD. Conjunctiva Thin transparent mucous membrane: Posterior...

Conjunctiva and Diseases

Juan S. Lopez, MD

Conjunctiva

Thin transparent mucous membrane: Posterior surface of the lids:

palpebral conjunctiva Anterior surface of the

sclera: bulbar conjunctiva Continuous with the skin at

the lid margin (mucocutaneous junction) and with the corneal epithelium at the limbus

Conjunctiva

Palpebral conjunctiva: firmly adherent to the tarsus Covers the episcleral tissue to become the bulbar

conjunctiva

Bulbar conjunctiva: Loosely attached to the orbital septum in the fornices Has many folds Allows the eye to move and enlarges the secretory

conjunctival surface Loosely attached to Tenon’s capsule and the underlying

sclera

Semi lunar fold- soft, movable, thickened fold of bulbar conjunctiva located at the inner canthus

Caruncle- small, fleshy, epidermoid structure attached superficially to the inner portion of the semilunar fold It is a transition zone

containing both cutaneous and mucous membrane elements.

Histology of conjunctiva: Conjunctival epithelium:

2-5 layers of stratified columnar epithelial cells Superficial cells- contains mucus-secreting goblet cells Basal cells- stains deeply and contains pigment

Conjunctival stroma Adenoid-contains lymphoid tissue; “follicle-like structures”; does

not develop until after 2 to 3 months Fibrous-composed of connective tissue that attaches to the tarsal

plate; loosely arranged over the globe Accessory lacrimal glands of Krause and Wolfring

Glands of Krause- upper fornix Glands of Wolfring- lies at the superior margin of the upper tarsus

Blood supply, lymphatics and nerve supply

Blood supply: Anterior ciliary and palpebral arteries

Lymphatics: arranged in superficial and deep layers

Nerve supply: ophthalmic division of fifth nerve Small number of pain fibers

Conjunctivitis

Inflammation of the conjunctiva

Most common eye disease worldwide

Mostly exogenous cause

Epithelial edema; chemosis, follicle formation; granuloma formation

Symptoms of conjunctivitis

Foreign body sensation Scratching or burning sensation Itching Photophobia

Signs of conjunctivitis Hyperemia- most conspicuous sign Tearing Exudation Chemosis Papillary hypertrophy- bacterial, vernal Follicles- viral Pseudomembrane and membrane Granulomas Phylectenules- represent delayed hypersensitivity to

microbes Preaurical lymphadenopathy*

Bacterial ConjunctivitisBacterial Conjunctivitis

• • Acute onset, unilateral or bilateralAcute onset, unilateral or bilateral

• • Redness, mucopurulent or purulent dischargeRedness, mucopurulent or purulent discharge

• • Lids swollen, stuck in the morning w/ dischargeLids swollen, stuck in the morning w/ discharge

• • Mild to severeMild to severe

Bacterial Conjunctivitis

Hyperacute bacterial conjunctivitis Usually caused by

Neisseria Profuse purulent exudate Warrants immediate

treatment If not treated can cause

corneal damage or loss of eye

Corneal melting

Gonococcal keratoconjunctivitis

Acute, profuse, purulent discharge, hyperaemia and chemosis

Corneal ulceration, perforation and endophthalmitis if severe

•

•

Signs Complications

Bacterial Conjunctivitis

• Acute mucopurulent- • Strep pneumoniae • Haemophilus

• Chronic- > 2 weeks• Corynebacterium• Strep pyogenes• Moraxella sp.

Bacterial Conjunctivitis

Course and prognosis:Untreated: 1 -14 daysWith proper treatment: 1-3 days

Treatment: Topical antibiotics Treat underlying cause (dacryocystitis, nasolacrimal

duct obstruction) For Neisseria: topical antibiotics + 1 gm Ceftriaxone

I

Chlamydial Conjunctivitis

Inclusion Conjunctivitis- serotypes D-K Trachoma- serotypes A, B, Ba, C

Adult chlamydial keratoconjunctivitis

Treatment

• Infection with Chlamydia trachomatis serotypes D to K• Concomitant genital infection is common•Scarring is not common

Subacute, mucopurulent follicular conjunctivitis

Variable peripheral keratitis

- topical tetracycline and oral tetracycline or erythromycin*(Systemic tetracycline should not be given to pregnantOr children < 7 years old)

Neonatal chlamydial conjunctivitis

Treatment

• May be associated with otitis, rhinitis and pneumonitis

• Presents between 5 and 19 days after birth

Mucopurulent PAPILLARY conjunctivitis

- topical tetracycline and oral erythromycin

Trachoma

Treatment - systemic tetracyclines, doxycycline, azithromycin

• Infection with serotypes A, B, Ba and C of Chlamydia trachomatis• Fly is major vector in infection-reinfection cycle

Acute follicular conjunctivis

Conjunctival scarring (Arlt line)

Herbert pits

Pannus formation Trichiasis Cicatricial entropion

Progression

Viral ConjunctivitisViral Conjunctivitis

• • Very commonVery common

• • Referred to by general public as “sore eyes” Referred to by general public as “sore eyes”

• • Easily spread, epidemic formEasily spread, epidemic form

• • Usually bilateralUsually bilateral

• • Mild to severeMild to severe

• • Redness, lid swelling, tearingRedness, lid swelling, tearing

• • Watery, mucoid or mucopurulent discharge Watery, mucoid or mucopurulent discharge

• • Associated w/ fever, sorethroatAssociated w/ fever, sorethroat

Viral Conjunctivitis

Adenoviruses-Adenoviruses- usual etiology usual etiology › › Most common cause of Membranous Most common cause of Membranous conjunctivitisconjunctivitis › › Pharyngoconjunctival Fever (PCF) - types 3,7Pharyngoconjunctival Fever (PCF) - types 3,7 › › Epidemic Keratoconjunctivitis ( EKC 25%) Epidemic Keratoconjunctivitis ( EKC 25%) - types 8, 19- types 8, 19• • Enterovirus 70, Coxsackievirus A24Enterovirus 70, Coxsackievirus A24 - rare epidemics- rare epidemics › › Acute Hemorrhagic Conjunctivitis (AHC)Acute Hemorrhagic Conjunctivitis (AHC)• Varicella ZosterVaricella Zoster• Herpes SimplexHerpes Simplex• MeaslesMeasles

Viral:Pharyngoconjunctival Fever

Characterized by fever, sore throat, non tender preauricular lymphadenopathy and follicular conjunctivitis in one or both eyes

Causative agent: Adenovirus 3,4,7

Conjunctival scrapings: mononuclear cells

Self limiting, usually lasts 10 days

Viral:Epidemic Keratoconjunctivitis

Usually bilateral involvement

Pain, injection, tearing, photophobia, chemosis, conjunctival hyperemia, pseudomemebranes

Causative agent: Adenovirus 8, 19, 29, 37

Viral:Epidemic Keratoconjunctivitis

No specific therapy Cold compresses Antibacterial agents in cases of bacterial

superinfection

Viral: Herpes Simplex Keratoconjunctivitis

Unilateral injection, irritation, mucoid discharge, photophobia

Usually associated with Herpes simplex keratitis

Cytology: mononuclear cells Usually self limited Treatment: Topical antivirals may be given to

prevent corneal involvement

Herpes simplex conjunctivitis

Unilateral eyelid vesicles Acute follicular conjunctivitis

Signs

Viral: Varicella-Zoster conjunctivitis

With typical vesicular eruption along the dermatomal distribution of V1

Scrapings may contain: giant cells and monocytes

Treatment: Oral acyclovir

Viral: Measles Conjunctivitis

Frequently precedes skin eruption Glassy appearance of conjunctivia (+) Koplik’s spots on the conjunctiva and

caruncle Treatment: mainly supportive; may give

topical antibacterial if superinfection occurs

Immunologic/Allergic Conjunctivitis

… is an immediate hypersensitivity reaction in which triggering antigens couple to reaginic antibodies (IgE) on the cell surface of mast cells & basophils, leading to release of histamine from secretory granules.

Immunologic/Allergic Conjunctivitis Itching: severe Hyperemia: generalized Preauricular adenopathy: none Stained scrapings & exudates:

eosinophils Tearing: moderate Exudation: minimal

Allergic Conjunctivitis

Hay fever conjunctivitis Commonly associated with allergic rhinitis (+) history of allergy (+) itching, tearing, redness Papillary reaction Treatment: topical antihistamines; mast-cell stabilizers

Allergic Conjunctivitis

Vernal “Spring catarrh”/

“Seasonal conjunctivitis” Begins in puberty and

lasts for 5-10 years boys> girls Common in warm

countries Presentation: milky

appearance of conj; stringy discharge

Cobble stone appearance of upper palpebral conjunctiva

Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus

Formation of cobblestone papillae

Rupture of septae - giant papillae

Allergic Conjunctivitis: Vernal

Treatment: Mast cell stabilizer Antihistamines Cold compresses, air-conditioned rooms Short course topical or systemic steroids

Allergic Conjunctivitis

Atopic conjunctivitis Usually presents with atopic dermatitis (Eczema)

Dermatologic signs: scarring of flexure creases of the wrists and knees

Scrapings: eosinophils

Treatment: chronic course of mast cell stabilizer, short course steroids; environmental control

Atopic keratoconjunctivitis

Typically affects young patients with atopic dermatitis

Eyelids are red, thickened, macerated and fissured

Summary of common types of conjunctivitis

Clinical findings and cytology

Viral Bacterial Chlamydial Allergic

Itching Minimal Minimal Minimal Sever

Hyperemia Generalized Generalized Generalized Generalized

Tearing Profuse Moderate Moderate Moderate

Exudation Minimal Profuse Profuse Minimal

Preaurical adenopathy

Common Uncommon Common in inclusion conj

None

Scrapings & exudates

Monocytes Bacteria, PMN’s

PMN, plasma cells inclusion bodies

Eosinophils

Sore throat & fever

Occasional Occasional Never Never

Chemical ConjunctivitisChemical Conjunctivitis• • True Ocular EmergencyTrue Ocular Emergency

• • Acids denature tissue protein immediately Acids denature tissue protein immediately - (Coagulative necrosis)- (Coagulative necrosis)

• • Alkalies penetrate tissues deeper & linger Alkalies penetrate tissues deeper & linger - (Liquefactive necrosis)- (Liquefactive necrosis)

- can cause symblepharon (palpebral & bulbar conj - can cause symblepharon (palpebral & bulbar conj adhesion) and corneal leukomaadhesion) and corneal leukoma

• • Pain, redness, photophobia, blepharospasmPain, redness, photophobia, blepharospasm• • Severe burns have poor prognosisSevere burns have poor prognosis

Chemical ConjunctivitisChemical Conjunctivitis

Localized conj. ischemia Diffuse conj. ischemiaLocalized conj. ischemia Diffuse conj. ischemia

Symblepharon, Corneal fibrovascular membraneSymblepharon, Corneal fibrovascular membrane

Chemical Burns

Treatment:Treatment:

› › Immediate Immediate profuse irrigationprofuse irrigation w/ water or saline solution w/ water or saline solution at least for 1 hour!!!at least for 1 hour!!!

No Chemical antidotes!!!No Chemical antidotes!!!

› › Remove any solid materialRemove any solid material

› › Cold compresses, analgesic, topical antibiotic, pupillary Cold compresses, analgesic, topical antibiotic, pupillary dilationdilation

› › Surgery for remediable cases Surgery for remediable cases

Degenerative Diseases of the Conjunctiva Pinguecula

- Yellow nodules on the sides of the cornea

- Commonly inflammed (pingueculitis)

- Usually no treatment, unless inflammed

Pterygium- Fleshy, triangular

encroachment on the cornea

- Risk factors: UV exposure, dry or windy envt

- Tx: excision of pterygium

Conjunctivitis due to Autoimmune Disease

Keratoconjunctivitis sicca - Associated with Sjogren’s syndrome- Triad of xerostomia, connective tissue

dysfunction, xerosis- More common in women- Lacrimal gland is infiltrated with lymphocytes and

plasma cells- Ocular presentation: conjunctival hyperemia,

mucoid discharge, diminished tear film- Treatment: tear film preservation, topical

cyclosporine

Conjunctivitis due to Autoimmune Disease Cicatricial pemphigoid

- Non specific chronic conjunctivitis that is resistant to therapy

- Eventually leads to progressive scarring, obliteration of the fornices, entropion and trichiasis

- Biopsy: eosinophils

Oral ulcers Skin ulcers

Ocular cicatricial pemphigoid

Diffuse hyperemia

Subepithelial fibrosis and shrinkage

Symblepharon

Pseudomembrane formation

Complications of OCP

Ankyloblepharon

Corneal keratinization

Metaplastic lashes Cicatricial entropion

Total obliteration of fornices

Secondary bacterial keratitis

Subconjunctival Hemorrhage Common disorder Sudden onset, bright red

appearance Caused by rupture of small

conjunctival vesells Forceful coughing,

sneezing, rubbing, straining, increased BP

Rule out blood dyscrasias if bilateral

Tx: reassurance; hemorrhage absorbs in 2-3 weeks

Conjunctival Tumors

Benign1. Nevus

2. Papilloma

3. Dermoid tumor

4. Lipodermoid/Dermolipoma Malignant

1. Carcinoma

2. Malignant Melanoma

Conjunctival Nevus

• 30% are almost non-pigmented

• Most frequently juxtalimbal• Sharply demarcated and slightly elevated

• Presents in first two decades

Conjunctival PapillomaPedunculated Sessile

• Presents in middle age• Not caused by infection• Single and unilateral

• Presents in childhood or early adulthood• Infection with papilloma virus • May be multiple and bilateral

• Presents in childhood• Smooth, soft mass, with hair follicles

• Removal indicated for cosmetic reasons• Occasionally Goldenhar syndrome

Conjunctival dermoid tumorSigns Association

Lipodermoid

• common congenital tumor• Soft, movable, subconjunctival mass• Most frequently at outer canthus

Intraepithelial neoplasia(carcinoma in situ)

• Juxtalimbal fleshy avascular mass

• May become vascular and extend onto cornea

• Presents in late adulthood•Resembles pterygium

• Tx: Excisional biopsy

Signs Progression

Malignant Melanoma

•Most arise from areas of primary acquired melanosis (PAM); some from conjunctival nevi• • Unilateral, irregular areas of flat,

brown pigmentation• May involve any part of conjunctiva

• Presents in late adulthood

Signs Types

Conjunctival melanoma

From PAM with atypia

• Sudden appearance of nodules

From nevus

• Sudden increase in size or pigmentation

Primary

• Solitary nodule• Frequently juxtalimbal but may be anywhere

• Very rare• Most common type

Localized tumor

• Excision

Treatment of conjunctival melanoma

Diffuse tumor

• Excision of nodules

Orbital recurrence

• Excision and radiotherapy

• Adjunctive cryotherapy or mitomycin C • Exenteration

• Adjunctive cryotherapy

Conjunctivitis associated with other diseases

Ocular rosacea-associated with acne rosacea

Psoriasis- 10% may involve the cornea

Steven Johnson’s syndrome- mucous membrane and skin involvement

Reiter’s syndrome- triad of nonspecific urethritis, arthritis, and conjunctivitis

Kawasaki disease- lips and oral cavity change, fever that fails to respond to antibiotics, erythema of palms and soles, exanthem of the trunk, swelling of cervical lymph nodes, conjunctivitis

Gouty conjunctivitis- associated with gouty attacks

Conjunctivitis in thyroid disease-