Bulbar conjunctiva – covers the anterior surface of the sclera – loosely attached to orbital septum in the fornices – limbus : fusion of the tenon’s capsule

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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 tenons 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 junctionPart 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

  • Tenons CapsuleAlso known as fascia bulbi

    Envelopes the globe from the limbus to the optic nerve

    In the limbus, there is fusion of conjunctiva, tenons 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 LigamentsAnterior Ciliary Artery

  • Lockwoods ligament or suspensory ligament of the eyeball

    lower segment of the tenons capsule fused with 1. fascia of the inferior oblique and 2. fascia of the inferior rectus

    upon which the globe rests

  • Infantile DacryocystitisStenosis 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 ObstructionEPIPHORA, MATTING OF EYELASHESACUTE DACRYOCYSTITIS, infrequent Delayed canalization near the valve of Hasner Reflux of purulent material in the punctum on pressure

  • Non Surgical ManagementLacrimal 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: PROBINGThere is a high spontaneous remission rate (60-90%) in the first year of lifeSurgical 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 ChronicTearing


    Mucoid discharge



  • Acute Dacryocystitis

    Tender canthal swelling Mild Preseptal Cellulitis May develop into abscess



  • Dacryocystorhinostomy (DCR)Suturing of anterior

  • 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


  • ORBITAL CELLULITISOrbital 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


  • 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


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


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

  • Vernal Keratoconjunctivitis


    Giant papilla in upper tarsal conjunctiva

  • Vernal KeratoconjunctivitisMales usually twice than femaleBefore age 10, two to 10 years longResolves before pubertyKinds: seasonal (SAC) / flare-up perennial (PAC)/ all year round

  • Vernal Keratoconjunctivitis

    Allergic salute

    75% history of asthma, eczema

  • Vernal Keratoconjunctivitis

    Severe itching, photophobia


    Mucous strands - conjunctival discharge

  • Vernal KeratoconjunctivitisTrantas dot

    Dead epithelial cells with eosinophils

    Superficial neovascularization in the limbus

  • Vernal KeratoconjunctivitisShield ulcer

    Superiorly located oval ulcer with elevated margins

    Due to chemical damage to epithelium from mast cells and 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 ConjunctivitisPapilla 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 conjunctivaA lymphocytic responseCentral portion - avascularLymphoid germinal centers with fibroblasts in the center

  • FOLLICLES Yellowish-white, discrete , round elevations of the conjunctivaProduced by a lymphocytic responseCentral portion is avascularLymphoid germinal centers with fibroblasts in the center

  • FOLLICULAR CONJUNCTIVITISAcute Follicular Conjunctivitis Adenovirus Herpesvirus Paramyxovirus

    Poxvirus Picornavirus Orthomyxoviruses Togavirus

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

  • Adenovirus - EKCSerotypes 8 and 19Watery dischargeSubconjunctival hemorrhagePreauricular / submandubular node tendernessCornea: subepithelial infiltrates

  • Adenovirus - PCFSerotypes 3 and 7Follicular conjunctivitisPharyngitisnode enlargement Preauricular, submandibular

  • Prevention: Adenovirus

    Frequent handwashing

    Asepsis of instruments

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

  • Human Diseases - Chlamydiae

  • Chlamydia Obligate Intracellular OrganismEB (elementary body)


    Not metabolically activeRB (reticulate body)

    Intracellular or initial body

    Metabolically active, capable of binary fission. ATP, GTP

  • TrachomaC. trachomatis, A to CTransmission: Oculogenital, Fly, Hand to Eye, Eye to EyeTF : trachoma follicular conjunctivitis

  • TrachomaTI: trachoma intense inflammation

    TS: trachoma scarring

  • AlkaliLiquefaction necrosisHydrophilic and lipophylic propertiesHydroxyl ion causes saponification of cell membranes, cell death and disruption of extracellular cell matrixAmmonium hydroxide used in fertilizer productionSodium hydroxide, caustic soda- cleaning drains and pipesCalcium hydroxide found in cement and lime plants

  • AcidCoagulation necrosisCoagulated ti