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• 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