Conjunctival Diseases

Prof.Dr. Osman Ş. ARSLAN

1.The conjunctival epithelium is between two and five cell layersthick2.The stroma (substantia propria) consists of richly vascularizedconnective tissue which is separated from the epithelium bya basement membrane3.The mucin secretorsa)Goblet cells,b)Crypts of Henle, c)Glands of Manz, 4.Accessory lacrimal glands of Krause and Wolfring5.The three clinical parts of theconjunctiva are:

a)Palpebralb)Fornicealc)Bulbar

Applied Anatomy

The clinical features which should be considered in the differential diagnosis of conjunctival inflammation are:

a)symptoms,b)type of discharge,c)conjunctival appearance,d)presence of membranes, e)presence or absence of lymphadenopathy.

Clinical Evaluation of Conjunctival Inflammation

Many of the symptoms of conjunctivitis are non-specific, such as lacrimation, irritation, stinging, burning and photophobia.

Pain and a foreign body sensationmay be result of associated cornealinvolvement.

Symptoms

1.Watery discharge is composed of a serousexudate and a variable amount of reflexlysecreted tears. It is typical of acute viral andacute allergic inflammations.

2.Mucoid discharge is typical of vernalconjunctivitis and keratoconjunctivitis sicca.

3.Purulent discharge occurs in severe acutebacterial infections.

4.Mucopurulent discharge occurs in mildbacterial and chlamdyial infections.

Discharge

1.Conjunctival injection is non-specificfeature which is frequently maximal in thefornices.

2.Subconjunctival haemorrhages usuallyoccur with viral infections.

3.Follicular reaction has significant diagnosticimportance. Follicles consist of hyperplasia of lymphoid tissue within the stroma.

viral infections, chlamydial infections, parinaud oculoglandular syndrome, andhypersensitivity to topical medication

Conjunctival Appearance (1)

4.Papillary reaction is more non-specific andof less diagnostic value than a follicularresponse.

chronic blepharitis, allergic conjunctivitis, bacterial infections, contact lens-relatedproblems, superior limbic keratoconjunctivitis, floppy eyelid syndrome

5.Oedema (chemosis) occurs whenever theconjunctiva is severely inflamed. 6.Scarring may indicate trachoma, ocular cicatricial pemphigoid, atopic conjunctivitis, and the prolonged use of topical medications.

Conjunctival Appearance (2)

1.Pseudomembranes consist of coagulatedexudate adherent to the inflamed conjunctivalepithelium. Characteristically, they can be easilypeeled off leaving the epithelium intact.

a)severe adenoviral infection,b)ligneous conjunctivitis, c)gonococcal conjunctivitisd)Stevens-Johnson syndrome

2.True membranes form when the inflammatoryexudate permeates the superficial layers of theconjunctival epithelium. Attemps to remove themembrane may be accompained by tearing of theepithelium and bleeding. Beta-haemolyticstreptococcal and diphtheria infections.

Membranes

Lymphatic drainage of the conjunctiva is to the

preauricular and submandibular nodes which

corresponds to the drainage of the eyelids.

Lymphadenopathy is a feature of:

a)viral infections

b)chlamydial infections

c)severe gonococcal infection and

d)Parinaud syndrome

Lymphadenopathy

Simple bacterial conjunctivitis

Adult gonococcal keratoconjunctivitis

Neonatal gonococcal

keratoconjunctivitis

Bacterial Conjunctivitis

Clinical Features

1.Presentation is with an acute onset of redness, grittiness, burning and discharge

2.Signsa)The eyelids are crusted and may be slightlyoedematousb)The discharge in the early stages may be

wateryc)The conjunctiva shows a velvety, beefy-redappearance .In severe cases inflammatorymembranes may be presentd)Corneal involvement is uncommon althoughsome cases show punctate epitheliopathy and

peripheral corneal infiltrates.

Simple BacterialConjunctivitis

Even without treatment, simple conjunctivitisusually resolves within 10-14 days. Initialtreatment is broad spectrum antibiotics.

1.Antibiotic dropsa)Fusidic acid (Fucithalmic)b)Chloramphenicolc)Other antibiotics

2.Antibiotic ointments

Antibiotics available in ointment form are:

chloramphenicol, gentamicin, tetracycline,

and polytrim

Treatment

OCULAR FEATURES

1.Presentation is with a hyperacute, extremelyprofuse and thick creamy pus leaking from theeye.

2.Signsa)The eyelids are oedematous and tenderb)The discharge is profuse and purulentc)The conjunctiva shows intense hyperaemia, chemosis and frequently pseudomembraneformationd)Prominent preauricular lymphadenopathye)Keratitis may occur in severe cases

Adult gonococcalkeratoconjunctivitis

The patient should be hospitalized, cultures

taken and the eye irrigated at frequent

intervals with saline.

1.Systemic antibiotic therapy

a)Cefoxitin or cefotaxime

b)Spectinomycin

2.Topical antibiotic therapy is with gentamicin or

bacitracin

Treatment

Gonococcal infection is now a rare cause of neonatal conjunctivitis which is transmittedfrom the mother during delivery

1.Presentation is usually between 1 and 3 daysafter birth

2.Signs: hyperacute, purulent conjunctivitiswhich is associated with chemosis and sometimesmembrane or pseudo-membrane formation.

3.Treatment is with topical and systemicpenicillin.

Neonatal GonococcalKeratoconjunctivitis

Adenoviral keratoconjunctivitis

Herpes simplex conjunctivitis

Viral Conjunctivitis

Epidemic keratoconjunctivitis which is

most frequently caused by adenovirus

types 8 and 19.

Both conjunctiva and cornea may be

affected

Keratitis occurs in about 80% of cases

and may be severe

Adenoviral Keratoconjunctivitis(Epidemic Keratoconjunctivitis)

Conjunctivitis

1.Presentation is with acute onset of watering, redness, discomfort and photophobia. Both eyesare affected in about 60% of cases2.Signs

a)The eyelids are oedematousb)The discharge is wateryc)The conjunctiva shows mild to moderatechemosis and follicles.d)Lymphadenopathy is tender

3.Treatment is largely symptomatic andsupportive but spontaneous resolution occurswithin 2 weeks.

Keratitis1.Signs

a)Stage 1 occurs within 7 days of the onset of symptoms. It is characterized by a diffuseepithelial keratitis which resolves within 2

weeks.b)Stage 2 is characterized by a transient focal, epithelial keratitis which develops 1 week

after onsetc)Stage 3 is characterized by subepithelialinfiltrates which develop beneath fading

epithelial lesions. Untreated they may persist formonths or years

2.Treatment with topical steroids is indicatedonly if the eye uncomfortable or visual acutydiminished by stage 3 lesions

Herpes Simplex Conjunctivitis

Conjunctivitis may occur in patients with primaryherpes simplex infection1.Signs

a)The eyelids and periorbital skin showunilateral herpetic vesicles which may be associated with mild oedema

b)The discharge is wateryc)The conjunctiva shows an ipsilateral

follicular responsed)Lymphadenopathy is tendere)Keratitis is uncommon

2.Treatment is with antiviral agents for 21 daysto prevent keratitis

Trachoma

Trachoma is an infection caused by serotypes

A, B, Ba and C of Chlamydia trachomatis.

It is a disease of underprivileged populationswith poor conditions of hygiene.

The common fly is the major vector in theinfection-reinfection cycle.

Currently trachoma is the leading cause of preventable blindness in the world

Clinical Features (1)

1.Presentation is during childhood with thedevelopment of a follicular conjunctivitisassociated with diffuse papillary infiltration.

2.Chronic conjunctival inflammation results in scarring with fine linear or small stellate scars in milder cases, or broad confluent scars (Arlt lines)

3.Limbal follicles are a unique feature. On resulation they leave characteristic depression(Herbert pits)

Clinical Features (2)

4.Keratitis, during the inflammatory stage, rangesfrom superior epithelial keratitis to anteriorstromal infiltrates and pannus formation

5.Progressive conjunctival scarring, if severe, causes distortion of the eyelids, particularly of the upper tarsus, to produce trichiasis andentropion.

6.End-stage trachoma is characterized by severe visual impairement of blindness from cornealulceration and opacification

Treatment is with a single dose of azithromycin

The most important preventivemeasure is strict personal hygiene withinthe family, especially washing the face of young children

Treatment

Vernal keratoconjunctivitis

Allergic Conjunctivitis

Vernal keratoconjunctivitis (VKC)(spring catarrh) is an uncommonrecurrent, bilateral, external, ocular inflammation affecting children and youngadults.

VKC is an allergic disorder in which IgEand cell-mediated immune mechanismplay an important role.

Vernal keratoconjunctivitis

The main symptoms are intense ocular itching which may be associated withlacrimation, photophobia, foreign body sensation and burning.

Thick mucus discharge from the eyes andptosis also occur.

Clinical types:a)palpebral,b)limbal andc)mixed

Clinical Features (1)

1.Palpebral VKC in choronological order:a)Conjunctival hyperaemia followed by a diffuse papillary hypertrophy, most marked on the superior tarsusb)The papillae enlarge and have a flat-toppedpolygonal appearance reminiscent of cobblestonesc)In severe cases, the connective tissue septarupture, giving rise to gaint papillae whichmay be coated by copious mucusd)Active disease is characterized by redness, swelling and tightly packed papillae. As theinflammation settles the papillae becomemore seperated

Clinical Features (2)

2.Limbal VKC has a better prognosis

a)It is characterized by mucoid nodules that

have a smoth round surface

b)Discrete white superficial spots (Trantas dots)

composed predominantly of eosinophils are found

scattered around the limbus at the apices of the

lesions

3.Mixed VKC

Clinical Features (3)

1.Topical steroids

2.Mast cell stabilizers

3.Acetylcsteine

4.Topical cyclosporin

5.Debridement

6.Lamellar keratectomy

7.Supratarsal injection of steroid

Treatment of VKC

Pinguecula

A pinguecula is an extremely common lesionwhich consists of a yellow-white deposit on thebulbar conjunctiva adjacent to the nasal ortemporal aspect of the limbus.

Some pingueculae may enlarge very slowlybut surgical excision is seldom required.

Conjunctival Degenerations

Pterygium

A ptergium is a triangular sheet of fibrovascular tissue which invades the cornea.

Ptergia typically develop in patients who havebeen living in hot climates and may represent a response to chronic dryness and exposure to thesun.

Conjunctival Degenerations