Conjunctiva (conjoins the eyeball to the lids) Dr.Chandrakanth 1 ANATOMY Thin, transparent mucous membrane Continuous anteriorly - epithelium of the cornea cul de sac open in front at the palpebral fissure and only closed when the eyes are shut PARTS 1.Palpabral (Marginal/Tarsal/Orbital) 2.Bulbar (Bulbar proper/Limbal ) - 2 fornices 2 3 Palpebral conjunctiva - subdivided into marginal, tarsal, and orbital zones 4 5 6 7 The conjunctiva covering the lid margin and bulbar conjunctiva is a modified nonkeratinized, stratified squamous epithelium The tarsal and fornix conjunctiva is covered by stratified cuboidal to columnar epithelium of varying thickness. Goblet cells are abundant over the tarsus, fornix, and specialized areas such as the plica semilunaris. Goblet cells are scarce near the lid margin and adjacent to the cornea at the limbus. 8 Tarsal conjunctiva 9 stratified squamous epithelium tarsus 10 The puncta open on to the marginal portion of the conjunctiva, and through them the conjunctival sac becomes directly continuous with the inferior meatus of the nose via the lacrimal passages The conjunctiva contains specialized folds or bumps called the plica semilunaris and caruncle 11 12 CARUNCLE PLICA SEMILUNARIS Glands of conjunctiva Mucin secreting glands:- goblet cells (present in epithelium) crypts of Henle (present in tarsal conjunctiva) glands of Manz (present in limbal conjunctiva) Accesory lacrimal glands:- Glands of Krause (present in subconjunctival connective tissue of fornix, 42 in upper & 8 in lower) Glands of wolfring (present along the upper border of superior tarsus &along the lower border of inferior tarsus) 13 14 15 Blood supply Arteries peripheral arterial arcade of the eyelid Marginal arcade of the eyelid Anterior ciliary arteries Veins Veins that are more numerous than the arteries drain the conjunctiva into a perilimbal venous circle and then into radial episcleral collecting veins. Palpebral veins eventually drain into the superior ophthalmic vein or inferior ophthalmic vein 16 17 Lymphatics preauricular lymphnode Submandibular lymph node 18 Sensory Nerve Supply 19 Supra orbital Supra trochlear infratrochlear Infra orbital lacrimal Zygomatico facial FUNCTION OF THE CONJUNCTIVA Permits free movement of the eyeball in every direction of gaze Provides a smooth and glistening moist surface while moving the eye Protects the eye against pathogens Tear film Lymphoid follicles (mucosa-associated lymphoid tissue MALT) Conjunctival lymphatics are drained to the preauricular and submandibular lymph nodes 20 Tear film 21 conjunctivitis Conjunctivitis: inflammation of the conjunctiva Conjunctivitis is a common disease, especially in children. Although conjunctivitis can be highly contagious (known to spread rapidly in schools or daycare settings), it is rarely serious and will not damage your vision if detected and treated promptly 22 CLASSIFICATION ONSET ACUTESUBACUTECHRONIC 23 Conjunctivitis(infection) Acute conjunctivitis: resolves in < 4 weeks, usually bacterial, viral, chlamydial Subacute/chronic: resolves > 4 wks, usually angular conj. Follicular(trachoma) etc 24 TYPE OF EXUDATE SEROUSCATARRHALPURULENT MUCO PURULENT MEMBRANOUS PSEUDO MEMBRANOUS 25 CONJUNCTIVAL RESPONSE FOLLICULARPAPILLARYGRANULOMATOUS 26 AETIOLOGY 27 1.BACTERIAL 2.VIRAL 3.CHLAMYDIAL 4.FUNGAL 5.PARASITIC INFECTIOUS NON-INFECTIOUS 1.ALLERGIC 2.IRRITANTS 3.ENDOGENOUS 4.DRY EYE 5.TOXIC 6.IDIOPATHIC Pathophysiology: The eye has a series of defense mechanisms to prevent bacterial invasion. These include bacteriostatic factors within the tears, the shearing force of the blink, an intact immune system, and a population of normal colonizing non-pathogenic bacteria which competitively prevent invasion by abnormal organisms. When these defense mechanisms break down, infection by pathogenic bacteria can occur. 28 Invading bacteria, along with secreted exotoxins, represent foreign antigens which induce an antigen-antibody immune reaction and subsequent inflammation. In a normal, healthy eye, the bacteria will eventually be eradicated as the eye strives to return to homeostasis. However, the external load of organisms can potentially set the eye up for corneal infection or involvement of other adnexal structures. 29 Bacterial conjunctivitis pink eye, red eye Mucopurulent conjunctivitis is caused by bacterial organisms. Gram-positive for the following cocci - Staphylococcus epidermidis, Streptococcus pyogenes, and Streptococcus pneumoniae Gram-negative for the following cocci - Neisseria meningitidis and Moraxella lacunata Gram-negative for the following rods - genus Haemophilus and family Enterobacteriaceae 30 Newborns Chlamydial Conjunctivitis Chlamydial Conjunctivitis Gonorrheal Conjunctivitis Gonorrheal Conjunctivitis Children Streptococcus Pneumoniae Streptococcus Pneumoniae Haemophilus Influenzae Haemophilus Influenzae Staphylococcus species Staphylococcus Moraxella species Moraxella Adults Staphylococcus aureus Staphylococcus aureus Staphylococcus epidermidis Staphylococcus Streptococcus species Streptococcus Escherichia coli Escherichia coli Pseudomonas species Moraxella species Moraxella Gonorrheal Conjunctivitis (Neisseria Gonorrhea) Gonorrheal ConjunctivitisNeisseriaGonorrhea 31 Predisposing factors Flies Unhygienic conditions Hot dry climate Poor sanitation Dirty habits 32 Mode of infection EXOGENOUS INFECTIONS;- air borne infection close contact water borne LOCAL SPREAD:- infected lacrimal sac lids nasopharynx ENDOGENOUS INFECTIONS;- very rarely through blood e.g. gonococcal &meningococcal infections 33 PATHOLOGY VASCULAR RESPONSE:- *Characterized by congestion & inc. permeability of conj vessels associated with proliferation of capillaries. CELLULAR RESPONSE;- *Exudation of polymorphonuclear cells & other cells into the substantiapropria CONJUNCTIVAL TISSUE RESPONSE:- * Conj. Becomes edematous, *Degeneration & desquamation of the superficial epithelial cells *Proliferation of the basal layers of the conj. Epithelium *Increase in no. of mucin secreting goblet cells 34 CONJUNCTIVAL DISCHARGE:- consists of tears Mucous Inflammatory cells Desquamated epithelial cells Fibrin Bacteria Blood (due to diapedesis of the R.B.C, if the inflammation is very severe ) 35 36 CLINICAL TYPES Depending on the causative bacteria & severity of infection, the various types are ACUTE CATARRHAL OR MUCOPURULENT CONJUNCTIVITIS ACUTE PURULENT CONJUNCTIVITIS ACUTE MEMBRANOUS CONJUNCTIVITIS ACUTE PSEUDO MEMBRANOUS CONJUNCTIVITIS CHRONIC BACTERIAL CONJUNCTIVITIS CHRONIC ANGULAR CONJUNCTIVITIS 37 38 ACUTE MUCOPURULENT CONJUNCTIVITIS Most common type of acute bacterial conjunctivitis Causative organisms; staphylococcus aureus, koch-week bacillus, pneumococcus & streptococcus. Usually accompanies exanthemata such as measles and scarlet fever. 39 CLINICAL FEATURES SYMPTOMS Discomfort & foreign body sensation Mild photophobia Mucopurulent discharge Sticking of eye lids Slight blurring of vision Coloured halos 40 staphylococcus 41 42 43 Acute bacterial conjunctivitis caused by Streptococcus pneumoniae 44 Streptococcus Conjunctivitis 45 SIGNS Conjunctival congestion ; fiery red eye Chemosis Petechial haemorrages (pneumococcus) Flakes of mucopus Matting of eye lashes with yellow crusts 46 47 48 49 50 Clinical course:- reaches its peak in 3-4 days. It may get resolved in days in case of mild forms of disease or may may continue as chronic catarrhal conjunctivitis. Complications: marginal corneal ulcer superficial keratitis blepharitis Dacrocystitis. 51 Staphylococcal blepharitis 52 Staphylococcal conjunctivitis with a ring of marginal corneal ulcers 53 54 DIFFERENTIAL DIAGNOSIS OTHER CAUSES OF RED EYE OTHER TYPES OF CONJUNCTIVITIS. 55 56 Differential diagnosis of Conjunctivitis Bacteria l ChlamydialViralAllergic ItchingMildMildMildSevere RednessOverallOverallOverallOverall Epiphora Moderat e ModerateSevereModerate DischargMoreMoreLessLess Preauricular adenopathy RareFrequentFrequentNo Dischage finding Bacteria, neutrop hil Neutrophil, plasma cell, inclusion body Monocyte Eosinophi l 57 Lab Studies: Conjunctival scrapings and cultures most often are used in laboratory studies. Cultures can be completed for viral, chlamydial, and bacterial agents. Conjunctival scrapings can be performed with topical anesthetic and gentle use of a platinum spatula or similar blunt metallic object. 58 Gram stain is useful to identify bacterial characteristics. Giemsa stain is helpful to screen for intracellular inclusion bodies of Chlamydia. Additionally, the nature of the inflammatory reaction is reflected in the cellular response. Lymphocytes predominate in viral infections, neutrophils in bacterial infections, and eosinophils in allergic reactions. 59 Cocci are phagocytized by neutrophils (Giemsa) 60 Gram-stain of Staphylococcus epidermidis. 61 Gram stain of Staphylococcus aureus 62 Gram stain of Streptococcus pneumoniae 63 64 Diagnosis TIPS Predictors of bacterial infection Eyes glued shut in morning Especially if both eyes glued shut Predictors of viral infection ITCHING eyes Prior episodes of ConjunctivitisConjunctivitis Efficacy Eyes itch and not glued shut: 4% bacterial Glued shut, no itch, no prior history: 77% bacterial 65 Medical Care: The mainstay of medical treatment for bacterial conjunctivitis is topical antibiotic therapy. Practice patterns for prescribing topical antibiotics vary. Most practitioners prescribe a broad-spectrum agent on an empirical basis without culture, for a routine, mild-to-moderate case of bacterial conjunctivitis. gentamicin, tobramycin, ciprofloxacin, ofloxacin, gatifloxacin, and erythromycin are representatives of commonly used first-line agents. Eye drops have the advantage of not interfering with vision. Ointments have the advantage of prolonged contact with the ocular surface and an accompanying soothing effect. 66 67 Surgical Care: Surgical intervention is not required in the setting of bacterial conjunctivitis except when indicated for the treatment of causative conditions such as hordeolum, nasolacrimal duct obstruction, and sinusitis 68 Procedures : Certain procedures may address a known or suspected underlying cause for conjunctivitis or conditions that mimic it. Removal of offending lashes with epilation forceps or by electrolysis may be indicated for trichiasis. Nasolacrimal duct irrigation may be attempted to see if an obstruction that predisposes to infection is present. An obstruction should be suspected in chronic and intermittent purulent conjunctivitis. Eversion of the eyelid at the slit lamp is indicated when a foreign body is suspected. 69 precautions Activity precautions pertain to limiting the spread of the infection. It is customary to advise the infected individual to avoid sharing towels and linens. A patient with bacterial conjunctivitis should wash hands often and avoid contaminating public swimming pools. Workers and students often are excused during the first several days of treatment to decrease the possibility of spread No patching of the eye No steroids 70 ACUTE PURULENT CONJUNCTIVITIS ACUTE BLENORRHEA/HYPERACUTE CONJUNCTIVITIS characterised by violent inflammatory response. It occurs in two forms *adult purulent conjunctivitis *ophthalmia neonatorum in newborn. 71 ACUTE PURULENT CONJUNCTIVITIS OF ADULTS Usually affects adult males. Caused by gonococcus (commonest), rarely by staphylococcus aureus /pneumococcus. Gonococcal infection usually spreads directly from the genitals to the eye. 72 CLINICAL PICTURE STAGE OF INFILTRATION:- 4-5 DAYS Painful & tender eyeball Bright red velvetty chemosed conjunctiva Tense & swollen lids Watery/sanguinous discharge Enlarged preauricular lymph nodes. 73 74 75 76 77 STAGE OF BLENORRHOEA:- usually exteds from 5 th day & lasts for several days. Frankly purulent,copious, thick disharge trickling down the cheeks Tension in lids is decreased. 78 79 80 81 STAGE OF SLOW HEALING;- pain & swelling of eyelids decreased. Conjunctiva remains red thickened and velvety Discharge slowly decreases and resolves completely. 82 Complications corneal involvement: oedema central necrosis corneal ulceration perforation Iridocyclitis Systemic complications; endocarditis, urethritis, arthritis, septicemia 83 84 85 86 Gram stain of Neisseria gonorrhoeae 87 TREATMENT Systemic therapy; one of the following regimen can be used, norfloxacin 1.2 gm orally qid for 5 days/ ceftriaxone 1 gm IM qid for 5 days/ spectinomycin 2 gm IM for 3 days. The above regimens should be followed by either doxycycline 100 mg BD / erythromycin mg orally QID. 88 Topical antibiotics: * bacitracin/ erythromycin eye ointment every 2 hrs for the first 2-3 days & then 5 times daily for 7 days. * Irrigation of the eyes * Topical atropine 1 % eye drops 2 times per day * Pt. & partner should be referred for evaluation of other sexually transmitted diseases 89 Prevalence of etiologies of acute conjunctivitis by age group* Adult (%) Pediatric (%) Bacterial4080 Viral3613 others245 90 Conjunctivitis, Pneumocystis Carinii 91 Gram stain of Haemophilus influenzae 92 Gram stain of Pseudomonas aeruginosa. 93 bact 94 95 Gonococcal conjunctivitis 96 Gonococcal conjunctivitis of the newborn (ophthalmia neonatorum) 97 Chlamydial conjunctivitis showing the upper palpebral conjunctiva (top) and lower palpebral conjunctiva with follicles (bottom). 98 bact 99 bact 100 Discharge Associated with Conjunctivitis EtiologySerousMucoid Mucopur ulent Purulent Allergic++__ Viral+___ Chlamydi al _++_ Bacterial__++ Toxic+++_ 101 102 Gonorrhoeal conjunctivitis Caused by n.gonorrhoea(gm ve diplococci) Rare in developed countries Occur at unhygienic places Usually acute in onset 103 Clinical features Severe purulent conjunctivitis Involves the cornea Constitutional symptoms (temp& depression) Tensed and oedematous upper lid edged with pus Conj is deep red & velvetty Intense pain Tender & enlarged preauricular lymph nod 104 Associated with urethritis Prognostic factor:- involvement of the cornea. Gonococci are capable of invading the normal cornea through the intact epithelium, if untreated timely leads to blindness. 105 management Precautions:- 1)prevent corneal involvement 2)eliminate any systemic reservoir of infection Specific treatmnt:- *wash out the purulent discharge with warm saline *antibiotic drops hourly(ofloxacin,tobramycin) *bacitracin eye ointment 6 hrly If the cornea is involved inj. Of 1 gm ceftriaxone intravenous ever 12 24hrs. Cycloplegics should be used Sexual partners must also be treated 106 gon 107 108 109 Streptococcus, Pseudmembrane 110 111 Neonatal conjunctivitis 112 the most common bacterial cause is Streptoccus pneumonia followed by Staphyloccus aureus; Hemophilus influenzae is less frequent; other gram negative infections are even less common and are a result of poor hygiene in elderly diabetics or immunocompromized patients; Pseudomonas infection is associated with contact lens- induced infection or swimming pools 113 Conjunctivitis, Pneumocystis Carinii 114 Pneumocystis Carinii, Histology 115 Membraneous & pseudomembranous conjunctivitis 116 Giant papillary conjunctivitis 117