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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-