49
DISEASES OF THE CONJUNCTIVA AYESHA S ABDULLAH 13.09.2014

DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Embed Size (px)

Citation preview

Page 1: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

DISEASES OF THE

CONJUNCTIVA AYESHA S ABDULLAH

13.09.2014

Page 2: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

LEARNING OUTCOMES

By the end of this lecture the students would be able to;

1. Classify diseases of the conjunctiva

2. Identify the common symptoms and signs of conjunctival diseases

3. Identify the common symptoms and signs of conjunctival diseases

4. Enlist the causes & risk factors of conjunctivitis.

5. Differentiate between bacterial, viral, chlamydial and allergic conjunctivitis on the basis of clinical presentation.

6. Describe the associated complications, treatment and prevention strategies for each type of conjunctivitis.

7. Identify Pterygium on photographs, describe its pathogenesis, complications and treatment.

Page 3: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Classification of conjunctival diseases

Inflammatory

infective & non-infective conditions like conjunctivitis

Degenerative disorders

Pinguecula, Pterygium, concretions and cysts

Neoplastic

Saquamous cell carcinoma, melanoma, lymphoma etc

Miscellaneous disorders

Dry eyes

Page 4: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Symptomatology

Red eye

Watering (lacrimation)

Irritation, stinging, burning and foreign body sensation

Itching

Blurring vision/ decreased vision, Photophobia and pain (danger alarm)

Growth or mass in the eye

Page 5: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

SIGNS Redness ; conjunctival redness

Discharge

Follicle & papillae

Phylectenule

Conjunctival oedema

Presence of membrane/

pseudomembrane

Subconjunctival haemorrhage

Lymphadenopathy

Keratinization

Scarring

Pigmentation

Mass

Page 6: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

REDNESS; CONJUNCTIVAL REDNESS

Superficial

Maximum at the fornices and fades

towards the limbus

Mild to severe

Page 7: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 8: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Conjunctival congestion Ciliary congestion

Page 9: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

DISCHARGE

What is discharge?

Reflex tearing and exudative response of the inflamed

conjunctiva mixed with mucus

Serous; watery exudate in acute viral and acute

allergic conjunctivitis.

Mucoid; mucus discharge in Vernal Kerato Conjunctivitis

(VKC) and dry eyes.

Purulent; puss in severe acute bacterial conjunctivitis.

Mucopurulent; puss plus mucus in mild bacterial

conjunctivitis and Chlamydial conjunctivitis.

Page 10: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 11: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Ophthalmia neonatorum

Bacterial conjunctivitis

Page 12: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 13: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Follicular reaction

Sub epithelial foci of hyperplastic lymphoid tissue

More prominent in fornices.

Multiple, discrete, slightly elevated,

Size from 0.5 to 5 mm.

Commonly seen in Viral conjunctivitis, Chlamydial

conjunctivitis & in cases of hypersensitivity to topical

medications.

Page 14: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 15: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

15

What are papillae?

Papillary reaction

Hyperplastic conjunctival epithelium with central core

vessel surrounded by infiltrate separated from each

other by fibrous septa- seen in allergic & bacterial

conjucntvitis

Page 16: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Papillary reaction

Can develop in palpebral conjunctiva and limbus- why?

Giant papilla (confluence)

make the conjunctiva look rough and velvety

Difficult to see the underlying conjunctival vessels

Seen in Allergic conjunctivitis, Bacterial conjunctivitis, Chronic blepharitis, Contact lens wearers

Page 17: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

17

Cobblestone papillae

Page 18: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Phylectenule

Page 19: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Conjunctival oedema- chemosis

it can happen in acute inflammation of the

conjunctiva as in acute infective/allergic

conjunctivits, orbital disorders (obstructing the

outflow of lymph and venous drainage) and certain

systemic conditions (acute nephritis, lymphoma)

Page 20: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Conjunctival oedema- chemosis

Page 21: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Membranes & Pseudomembrane

Coagulated exudate adherent to the inflamed epithelium.

Can be easily pealed off.

Causes; Severe adenoviral infection, Ligneous conjunctivitis, Gonococcal conjunctivitis, Stevens-Johnson syndrome

True conjunctival membrane infiltrates the superficial layers of conjunctival epithelium.

Conjunctiva bleeds if attempted to be removed.

Causes; infection with Diphtheria & Beta-hemolytic Streptococci and Neisseria Gonorrhoeae.

Page 22: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 23: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Subconjunctival Haemorrhage

Can happen in severe cases of viral or bacterial

conjunctivitis

Trauma

Haemotological disorders (bleeding disorders,

leukaemias)

Fracture base of the skull

Page 24: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Traumatic subconjunctival haemorrhage

Adenoviral conjunctivitis subconjunctival haemorrhage

Page 25: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 26: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Lymphadenopathy

Pre auricular and sub mandibular.

In ; Viral infection, Chlamydial infection

Page 27: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Systemic symptoms in conjunctivitis

Severe conjunctivitis with

Gonococcus,

Meningococcus,

Chlamydia

H.Influenzae

Page 28: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Diagnosis

Bacterial

Symptoms

Acute onset

Bilateral with one eye affected a day or two earlier

Discharge is purulent or mucopurulent

Glued eyelashes in the morning

Signs

Lid swelling in severe cases

Conjucntival redness

Punctate corneal epithalial erosion are common

Peripheral corneal ulceration may in gonococcal and meningococcal infection rapidly progressing to perforation.

Lymph adenopathy usually absent (except in gonococcal and meningococcal infection

Page 29: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion
Page 30: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Diagnosis

Viral

Symptoms

Acute onset watering, redness, discomfort & photophobia

Usually bilateral

Lid swelling

Signs

Conjunctiva:

Follicular conjunctivitis.

Mild-moderate chemosis.

Subconjunctival Haemorrhage.s

Pseudomembrane & membrane formation.

Tender pre-auricular lymphadenopathy.

Keratitis (80%)- 7 to 10 days later in the form of superficial punctate keratitis, subepithelial opacities and may remain for quite a long time.

Conjunctival scarring (rare)

Page 31: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Kanski 7th ed

Page 32: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Treatment of conjunctivitis

Bacterial conjunctivitis

Topical : Aminoglycosides, quinolones, polymxin B,

Fusidic Acid, chloroamphenicol, Bacitracin

Systemic in some cases?

Lid hygiene

Contact lens wear to be discontinued till the

antibiotic therapy is completed

Hand washing and avoid sharing towels

Page 33: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Treatment of conjunctivitis

Viral conjunctivitis

Spontaneous resolution within 2-3 weeks.

Symptomatic & supportive treatment with

Topical steroids to be avoided

Antivirals are ineffective

Reduce the risk of transmission

Hand hygiene

Avoid eye rubbing & towel sharing

Disinfection of eye instruments after examination

Page 34: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Ophthalmia neonatorum

Conjunctitivitis of the new born

Onset

Chemical…. First few days

Gonococcal…1st Week

Staphlococcal and other bacteria….End of 1st week

Herpes Simplex…..1-2 weeks

Chlamydia…..1-3 weeks

Treatment of conjunctivitis

Page 35: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Treatment

Mild –moderate cases topical antibiotic eye drops

and ointment

Systemic antibiotics and anitviral therapy

Gonococcal, Chlamydial and Herpes Simplex

Page 36: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Allergic conjunctivitis

Acute allergic conjunctivitis

Seasonal conjunctivitis

Vernal Keratoconjunctivitis

Atopic Keratoconjunctivitis

Giant Papillary conjunctivitis

Page 37: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

VKC

Recurrent & Bilateral

IgE & cell-mediated reaction

Common in males

Age-5 to late teens

Remission in late teens

Symptoms & Signs occur on seasonal basis.

Peak Incidence: April - August.

More common in warm, dry climates

Associated with other allergic disorders like?

Page 38: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Signs-Palpeberal type

Page 39: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Signs- Limbal type Tranta’s dots

Limbal papillae

Page 40: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Complications

Keratopathy

Side effects of steriods; Cataract & Glaucoma

Associations

Keratoconus

Herpes simplex keratitis

Page 41: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Corneal complications

Page 42: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Treatment

Allergen avoidance

Drugs

Mast cell stabilizers

Antihistamines

NSAIDs

Steroids

Decongestants

Lubricants

Page 43: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Other signs

Keratinization

Vitamin A deficiency

Systemic Immune disorders

Ocular pemphigoid

Stevens-Johnson Syndrome

KCS

Scarring

Chemical burns or mechanical trauma

Immune disorders

Chronic conjunctivitis (Trachoma)

Page 44: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Conjucntival Growth /mass

Benign ; cysts, pterygium, lipodermoid

Malignant ; melanoma, squamous cell carcinoma

and others

Page 45: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Benign Growths

Page 46: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Pterygium

A degenerative condition

Triangular, fibrovascular connective tissue overgrowth of bulbar conjunctiva onto the cornea usually on the nasal side

Can reduce vision through producing Astigmatism and corneal opacity

Many treatment modalities have been tried but so far the best option with least recurrence rate is excision of the pterygium with conjunctival autograft.

Page 47: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Laboratory Investigations

Indications

Severe purulent conjunctivitis

Follicular conjunctivitis: viral vs chlamydial

Conjunctival inflammation

Neonatal conjunctivitis

Page 48: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Laboratory Investigations

Cytological investigations

Cultures

Detection of viral and chlamydial antigens.

Impression cytology

Polymerase chain reaction for adenovirus, herpes simplex, chlamydia trachomatis.

Biopsy for tumours

Page 49: DISEASES OF THE CONJUNCTIVA - prime.edu.pk o… · Classify diseases of the conjunctiva 2. Identify the common symptoms and signs of conjunctival diseases 3. ... Conjunctival congestion

Homework

1. What is WHO Grading for Trachoma?

2. How is Trachoma spread?

3. What is SAFE strategy?

4. Why is Ophthalmia neonatorum an emergency?

5. What are the risk factors for corneal disease?

6. What is the most appropriate treatment for

pterygium?