Conjunctiva & Its disorders

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Conjunctiva & Its disorders

  1. 1. Dr. Mrinmayee Ghatak P.G., Dept. of Ophthalmology, K.I.M.S. Hospital, Bangalore Email: dr.mrin@gmail.com
  2. 2. <ul><li>Translucent mucous membrane </li></ul><ul><li>Lines the posterior surface of eyelids and anterior aspects of eyeball </li></ul><ul><li>Conjoin = “to join” </li></ul>
  3. 3. <ul><li>Parts of conjunctiva: </li></ul><ul><ul><li>Palpabrel </li></ul></ul><ul><ul><ul><li>Marginal </li></ul></ul></ul><ul><ul><ul><li>Tarsal </li></ul></ul></ul><ul><ul><ul><li>orbital </li></ul></ul></ul><ul><ul><li>Bulbar </li></ul></ul><ul><ul><li>Fornicial </li></ul></ul>
  4. 4. <ul><li>Histologically 3 layers: </li></ul><ul><ul><li>Epithelium : </li></ul></ul><ul><ul><ul><li>Marginal part : 5 layer stratified squamous </li></ul></ul></ul><ul><ul><ul><li>Tarsal part : 2 layer : </li></ul></ul></ul><ul><ul><ul><ul><li>Superficial is cylindrical cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Deeper is flat cells </li></ul></ul></ul></ul><ul><ul><ul><li>Fornicial & bulbar : 3 layer : </li></ul></ul></ul><ul><ul><ul><ul><li>Superficial cylindrical cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Middle layer if polyhedral cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Deep layer of cuboidal cells </li></ul></ul></ul></ul><ul><ul><ul><li>Limbal part: 5-6 layere squamous stratified </li></ul></ul></ul><ul><ul><li>Adenoid layer : Lymphoid layer </li></ul></ul><ul><ul><li>Fibrous layer : collagenous & elastic fibres </li></ul></ul>
  5. 5. <ul><li>Gland of conjunctiva: </li></ul><ul><ul><li>Mucin secretory glands </li></ul></ul><ul><ul><ul><li>Goblet cells </li></ul></ul></ul><ul><ul><ul><li>Crypts of Henle </li></ul></ul></ul><ul><ul><ul><li>Glands of Manz </li></ul></ul></ul><ul><ul><li>Asccessary lacrimal glands </li></ul></ul><ul><ul><ul><li>Glands of Krauze </li></ul></ul></ul><ul><ul><ul><li>Glands of Wolfring </li></ul></ul></ul><ul><li>Plica Semilunaris: </li></ul><ul><ul><ul><li>Pinkish cresenteric fold in medial canthus </li></ul></ul></ul><ul><ul><ul><li>Vestigeal structure – nictating membrane </li></ul></ul></ul><ul><li>Caruncle </li></ul><ul><ul><ul><li>Small, ovoid, pinkish mass in inner canthus </li></ul></ul></ul><ul><ul><ul><li>Piece of modified skin (all features of typical skin) </li></ul></ul></ul>
  6. 6. <ul><li>ARTERIES: </li></ul><ul><ul><li>Derived from 3 sources: </li></ul></ul><ul><ul><ul><li>Peripheral arterial arcade of eyelid </li></ul></ul></ul><ul><ul><ul><li>Marginal arterial arcade of eyelid </li></ul></ul></ul><ul><ul><ul><li>Anterior ciliary arteries </li></ul></ul></ul><ul><ul><li>Palpabrel & fornicial part: </li></ul></ul><ul><ul><ul><li>Arterial arcades (Peripheral & Marginal) of eyelid </li></ul></ul></ul><ul><ul><li>Bulbar part: </li></ul></ul><ul><ul><ul><li>Posterior conjunctival arteries (from arterial arcades of eyelids) </li></ul></ul></ul><ul><ul><ul><li>Anterior conjunctival arteries (from anterior ciliary arteries) </li></ul></ul></ul><ul><li>VEINS: </li></ul><ul><ul><li>Venous plexus of eyelids </li></ul></ul><ul><ul><li>Limbal part into anterior ciliary veins </li></ul></ul>
  7. 7. <ul><li>LYMPHATICS (divided into superficial & deep part) : </li></ul><ul><ul><li>From laterial side : preauricular LN </li></ul></ul><ul><ul><li>From medial side : submandibular LN </li></ul></ul><ul><li>NERVE SUPPLY: </li></ul><ul><ul><li>Circumcorneal zone: </li></ul></ul><ul><ul><ul><li>branches from long ciliary nerves </li></ul></ul></ul><ul><ul><li>Rest : by branches from: </li></ul></ul><ul><ul><ul><li>Lacrimal nerve </li></ul></ul></ul><ul><ul><ul><li>Infratrochlear nerve </li></ul></ul></ul><ul><ul><ul><li>Supratrochlear nerve </li></ul></ul></ul><ul><ul><ul><li>Supraorbital nerve </li></ul></ul></ul><ul><ul><ul><li>Frontal nerve </li></ul></ul></ul>
  8. 10. <ul><li>Infective: </li></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><li>Chlamydial </li></ul></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><li>Fungal </li></ul></ul><ul><ul><li>Rickettsial </li></ul></ul><ul><ul><li>Sporichaetal </li></ul></ul><ul><ul><li>Protozoal </li></ul></ul><ul><ul><li>Parasitic </li></ul></ul><ul><li>Allergic conjunctivitis </li></ul><ul><li>Irritative conjunctivitis </li></ul><ul><li>Keratoconjunctivitis with diseases of skin and mocous membrane </li></ul><ul><li>Traumatic conjunctivitis </li></ul><ul><li>Keratoconjunctivitis of unknown etiology </li></ul>
  9. 11. <ul><li>Acute catarrhal or mucopurulent conjunctivitis </li></ul><ul><li>Acute purulent conjunctivitis </li></ul><ul><li>Serous conjunctivitis </li></ul><ul><li>Chronic simple conjunctivitis </li></ul><ul><li>Angular conjunctivitis </li></ul><ul><li>Membranous conjunctivitis </li></ul><ul><li>Pseudomembranous conjunctivitis </li></ul><ul><li>Papillary conjunctivitis </li></ul><ul><li>Folliular conjunctivitis </li></ul><ul><li>Ophthalmia neonatorum </li></ul><ul><li>Granulomatous conjunctivitis </li></ul><ul><li>Ulcerative conjunctivitis </li></ul><ul><li>Cicatrizing conjunctivitis </li></ul>
  10. 13. <ul><li>Pathological changes: </li></ul><ul><ul><li>Vascular response: </li></ul></ul><ul><ul><ul><li>Congestion & increased permeability </li></ul></ul></ul><ul><ul><li>Cellular response </li></ul></ul><ul><ul><ul><li>PMN & other inflammatory cell exudation </li></ul></ul></ul><ul><ul><li>Conjunctival tissue response </li></ul></ul><ul><ul><ul><li>Edema, increase goblet cells </li></ul></ul></ul><ul><ul><li>Conjunctival discharge </li></ul></ul><ul><ul><ul><li>Tears, mucus, inflammatory cells, desquamated epithelial cells, fibrin, bacteria </li></ul></ul></ul>
  11. 14. <ul><li>CLINICAL TYPES: </li></ul><ul><ul><li>Acute mucopurulent conjunctivitis </li></ul></ul><ul><ul><li>Acute purulent conjunctivitis </li></ul></ul><ul><ul><li>Acute membranous conjunctivitis </li></ul></ul><ul><ul><li>Acute pseudomembranous conjunctivitis </li></ul></ul><ul><ul><li>Chronic bacterial conjunctivitis </li></ul></ul><ul><ul><li>Chronic angular conjunctivitis </li></ul></ul>
  12. 15. <ul><li>Most common </li></ul><ul><li>SYMPTOMS: </li></ul><ul><ul><li>Discomfort & FB sensation </li></ul></ul><ul><ul><li>Mild photophobia </li></ul></ul><ul><ul><li>Mucopurulent discharge </li></ul></ul><ul><ul><li>Sticking of lid margins </li></ul></ul><ul><ul><li>Slight blurring if vision </li></ul></ul><ul><ul><li>Sometimes coloured halos </li></ul></ul><ul><li>SIGNS: </li></ul><ul><ul><li>Conjunctival congestion </li></ul></ul><ul><ul><li>Chemosis </li></ul></ul><ul><ul><li>Petechial hemorrhages </li></ul></ul><ul><ul><li>Flakes of mucopus </li></ul></ul><ul><ul><li>Matting of eyelashes </li></ul></ul><ul><li>CLINICAL COURSE: </li></ul><ul><ul><li>Peak in 3-4days </li></ul></ul><ul><ul><li>Cured in 10-15 days </li></ul></ul><ul><ul><li>Pass into Chronic Catarrhal Conjunctivitis </li></ul></ul><ul><li>COMPLICATIONS: </li></ul><ul><ul><li>Marginal corneal ulcer </li></ul></ul><ul><ul><li>Superficial keratitis </li></ul></ul><ul><ul><li>Blepharitis </li></ul></ul><ul><ul><li>Dacryocystitis </li></ul></ul><ul><li>DIFFERENTIAL DIAGNOSIS: </li></ul><ul><ul><li>Other causes of red eye </li></ul></ul><ul><ul><li>Other types of conjunctivitis </li></ul></ul>
  13. 17. <ul><li>TREATMENT: </li></ul><ul><ul><li>Topical antibiotics: </li></ul></ul><ul><ul><ul><li>Chloramphenicol / ciprofloxacin / ofloxacin eye drops (ointment at night) </li></ul></ul></ul><ul><ul><li>Irrigation of conjunctival sac with NS/RL </li></ul></ul><ul><ul><li>Dark goggles </li></ul></ul><ul><ul><li>No bandage </li></ul></ul><ul><ul><li>No steroids </li></ul></ul><ul><ul><li>Anti-inflammatory & analgesics drugs </li></ul></ul>
  14. 18. <ul><li>ETIOLOGY: </li></ul><ul><ul><li>Predominantly males </li></ul></ul><ul><ul><li>Gonococcus, staph. aureus, pneumococuss </li></ul></ul><ul><li>CLINICAL FEATURES: </li></ul><ul><ul><li>Stage of infiltration: </li></ul></ul><ul><ul><ul><li>Painful, tender eye ball </li></ul></ul></ul><ul><ul><ul><li>Tense and swollen lids </li></ul></ul></ul><ul><ul><ul><li>Bright red velvety chemosed conjunctiva </li></ul></ul></ul><ul><ul><ul><li>Watery or sanguinous discharge </li></ul></ul></ul><ul><ul><ul><li>Pre-auricular LN enlarged </li></ul></ul></ul><ul><ul><li>Stage of blenorrhoea: </li></ul></ul><ul><ul><ul><li>Frankly purulent, copious thick discharge </li></ul></ul></ul><ul><ul><li>Stage of slow healing: </li></ul></ul><ul><ul><ul><li>Symptoms decreased </li></ul></ul></ul>
  15. 19. <ul><li>COMPLICATIONS: </li></ul><ul><ul><li>Corneal involvement </li></ul></ul><ul><ul><li>Iridocyclitis </li></ul></ul><ul><ul><li>Systemic: </li></ul></ul><ul><ul><ul><li>Arthritis </li></ul></ul></ul><ul><ul><ul><li>Endocarditis </li></ul></ul></ul><ul><ul><ul><li>Septecemia </li></ul></ul></ul>
  16. 21. <ul><li>TREATMENT: </li></ul><ul><ul><li>Systemic therapy: </li></ul></ul><ul><ul><li>Topical antibiotic therapy: </li></ul></ul><ul><ul><li>Frequent irrigation of eyes </li></ul></ul><ul><ul><li>General measures </li></ul></ul><ul><ul><li>Add cycloplegics (if corneal involvement is there) </li></ul></ul><ul><ul><li>Treatment of partner </li></ul></ul>
  17. 22. <ul><li>In children aged <30 days </li></ul><ul><li>Any discharge or watering, in the first week of life should arouse suspicion </li></ul><ul><li>ETIOLOGY: </li></ul><ul><ul><li>Before birth: infected amniotic fluid </li></ul></ul><ul><ul><li>During birth: infected birth canal </li></ul></ul><ul><ul><li>After birth: first bath, soiled clothes, unhygienic conditions </li></ul></ul>
  18. 23. <ul><li>CAUSITIVE AGENTS: </li></ul><ul><ul><li>Chemical conjunctivitis: silver nitrate solution </li></ul></ul><ul><ul><li>Gonococcal infection: </li></ul></ul><ul><ul><li>Other bacterial infections: </li></ul></ul><ul><ul><ul><li>Staph aureus </li></ul></ul></ul><ul><ul><ul><li>Strept hemolyticus </li></ul></ul></ul><ul><ul><ul><li>Strept pneumoniae </li></ul></ul></ul><ul><ul><li>Neonatal inclusion conjunctivitis: </li></ul></ul><ul><ul><ul><li>Chlamydia trachomatis serotype D to K </li></ul></ul></ul><ul><ul><li>Herpes Simplex Ophthalmia Neonatorum </li></ul></ul>
  19. 24. <ul><li>Incubation period: </li></ul><ul><ul><li>Chemical conjunctivitis: 4-6 hours </li></ul></ul><ul><ul><li>Gonococcal infection: 2-4 days </li></ul></ul><ul><ul><li>Other bacterial infections: 4-5 days </li></ul></ul><ul><ul><li>Neonatal inclusion conjunctivitis: 5-14 days </li></ul></ul><ul><ul><li>Herpes Simplex Ophthalmia Neonatorum : 5-7 days </li></ul></ul>
  20. 25. <ul><li>SYMPTOMS: </li></ul><ul><ul><li>Pain and tender eyeball </li></ul></ul><ul><ul><li>Purulent conjunctival discharge (gonococcal) </li></ul></ul><ul><ul><li>Mucoid / mucopurulent (other bacterial infections) </li></ul></ul><ul><ul><li>Swollen lids </li></ul></ul><ul><ul><li>Chemosed conjunctiva </li></ul></ul><ul><ul><li>Corneal involvement rarely </li></ul></ul><ul><li>COMPLICATIONS: </li></ul><ul><ul><li>Corneal ulceration with tendency to perforate </li></ul></ul>
  21. 26. <ul><li>PROPHYLAXIS: </li></ul><ul><ul><li>Antenatal: </li></ul></ul><ul><ul><ul><li>Treatment of genital infections of mother </li></ul></ul></ul><ul><ul><li>Natal: </li></ul></ul><ul><ul><ul><li>Delivery under aseptic conditions </li></ul></ul></ul><ul><ul><ul><li>Newborns eyelids should be well cleaned </li></ul></ul></ul><ul><ul><li>Postnatal: </li></ul></ul><ul><ul><ul><li>1% tetracycline / 0.5% erythromycin ointment </li></ul></ul></ul><ul><ul><ul><li>1 % silver nitrate solution (Crede’s method) </li></ul></ul></ul><ul><ul><ul><li>Single injection of Ceftriaxone 50mg/kg IM/IV </li></ul></ul></ul>
  22. 27. <ul><li>CURATIVE TREATMENT: </li></ul><ul><ul><li>Chemical conjunctivitis: self-limiting </li></ul></ul><ul><ul><li>Gonococcal: </li></ul></ul><ul><ul><ul><li>Topical: </li></ul></ul></ul><ul><ul><ul><ul><li>Bacitracin ointment QID </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Penicillin drops 5000-10000units per ml every min for 30 min, every 5 min for 30 min, and then every 30m in till infection controlled </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Atropine ointment if corneal involvement </li></ul></ul></ul></ul><ul><ul><ul><li>Systemic: </li></ul></ul></ul><ul><ul><ul><ul><li>Ceftriaxone 75-100mg/kg/day IV/IM Q.I.D. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cefotaxime 100-150mg/kg/day IV/IM B.D. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If gonococcal: cryst benzyl Peni G 50000 units for full term babies (20000 to premature) IM BD x 3 days </li></ul></ul></ul></ul>
  23. 28. <ul><li>CURATIVE TREATMENT: </li></ul><ul><ul><li>Other bacterial infections: </li></ul></ul><ul><ul><ul><li>Broad spectrum antibiotic drops / ointment x 2weeks </li></ul></ul></ul><ul><ul><li>Neonatal inculsion conjunctivitis: </li></ul></ul><ul><ul><ul><li>Topical tetracycline / erythromycin ointment QID x 3 weeks </li></ul></ul></ul><ul><ul><ul><li>Plus systemic erythromycin 125mg QID x 3 weeks </li></ul></ul></ul><ul><ul><li>Herpes Simples: </li></ul></ul><ul><ul><ul><li>Self limiting, topical antivirals control effectively </li></ul></ul></ul>
  24. 29. <ul><li>Conjunctival inflammation with formation of a true membran </li></ul><ul><li>ETIOLOGY: </li></ul><ul><ul><li>Corynebacterium diphtheriae </li></ul></ul><ul><ul><li>Occasionally strept hemolyticus </li></ul></ul><ul><li>PATHOLOGY: </li></ul><ul><ul><li>Deposition of fibrinous exdute on the surface & substance of conjunctiva </li></ul></ul><ul><ul><li>Usually in the palpabral conjunctiva </li></ul></ul>
  25. 30. <ul><li>CLINICAL FEATURES: </li></ul><ul><ul><li>Usually in children 2-8 years (not immunized) </li></ul></ul><ul><ul><li>Stage of infiltration: </li></ul></ul><ul><ul><ul><li>Scanty discharge and severe pain </li></ul></ul></ul><ul><ul><ul><li>Swollen and hard lids, red swollen conjunctiva covered with grey yellow membrane </li></ul></ul></ul><ul><ul><ul><li>On removal, membrane bleeds </li></ul></ul></ul><ul><ul><li>Stage of suppuration: </li></ul></ul><ul><ul><ul><li>Pain decreases, membrane sloughs off </li></ul></ul></ul><ul><ul><ul><li>Copious purulent discharge </li></ul></ul></ul><ul><ul><li>Stage of cicatrization: </li></ul></ul><ul><ul><ul><li>Raw surface covered with granulation tissue & epithelized </li></ul></ul></ul><ul><ul><ul><li>Cicatrization occurs, trichiasis, conjunctival xerosis </li></ul></ul></ul>
  26. 31. <ul><li>COMPLICATIONS: </li></ul><ul><ul><li>Corneal ulceration </li></ul></ul><ul><ul><li>Delayed: symblepheron, trichiasis, entropion, conjunctival xerosis </li></ul></ul><ul><li>DIAGNOSIS: </li></ul><ul><ul><li>By bacteriological examination </li></ul></ul>
  27. 32. <ul><li>TREATMENT: </li></ul><ul><ul><li>Topical: </li></ul></ul><ul><ul><ul><li>Penicillin eye drops 1:10000 unit/ml every 30 min </li></ul></ul></ul><ul><ul><ul><li>Anti-diphtheric serum every 1 hour </li></ul></ul></ul><ul><ul><ul><li>Atropine 1% ointment (if corneal involvement) </li></ul></ul></ul><ul><ul><ul><li>Broad spectrum antibiotic ointment at bedtime </li></ul></ul></ul><ul><ul><li>Systemic: </li></ul></ul><ul><ul><ul><li>Cryst penicillin 5 lac units IM BD x 10 days </li></ul></ul></ul><ul><ul><ul><li>Anti-diphtheric serum 50,000 units IM stat </li></ul></ul></ul><ul><ul><li>Prevention: </li></ul></ul><ul><ul><ul><li>When surface raw: apply BCL or sweep glass rod with ointment </li></ul></ul></ul>
  28. 33. <ul><li>ETIOLOGY: </li></ul><ul><ul><li>Bacterial: </li></ul></ul><ul><ul><ul><li>C. diphtheriae, Staphylococcus, Sterptococcus </li></ul></ul></ul><ul><ul><ul><li>H. influenzae, N. gonorrhoea </li></ul></ul></ul><ul><ul><li>Viral: </li></ul></ul><ul><ul><ul><li>Herpes simples & adenovirus </li></ul></ul></ul><ul><ul><li>Chemical: </li></ul></ul><ul><ul><ul><li>Acids, ammonia, lime, copper sulphate, silver nitrate </li></ul></ul></ul><ul><li>PATHOLOGY: </li></ul><ul><ul><li>Similar to membranous conjunctivitis </li></ul></ul>
  29. 34. <ul><li>CLINICAL FEATURES: </li></ul><ul><ul><li>Acute mucopurulent conjunctivitis a/w pseudomembrane formation </li></ul></ul><ul><li>TREATMENT: </li></ul><ul><ul><li>Same as mucopurulent conjunctivitis </li></ul></ul>
  30. 35. <ul><li>ETIOLOGY: </li></ul><ul><ul><li>Predisposing factors: </li></ul></ul><ul><ul><ul><li>Chronic exposure to smoke, dust, chemical irritants </li></ul></ul></ul><ul><ul><ul><li>Local irritant as trichiasis, concretions, FB </li></ul></ul></ul><ul><ul><ul><li>Eye-strain due to Ref error, phorias, convergence insufficiency </li></ul></ul></ul><ul><ul><ul><li>Alcohol abuse </li></ul></ul></ul><ul><ul><li>Causative agents: </li></ul></ul><ul><ul><ul><li>Staph aureus commonly, gram-ve entrobaccilli </li></ul></ul></ul>
  31. 36. <ul><ul><li>Source & mode of infections: </li></ul></ul><ul><ul><ul><li>As comtinuation of acute mucopurulent conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>As chronic infection from chronic dacryocystitis or chronic URI </li></ul></ul></ul><ul><ul><ul><li>As a mild exogenous infection from direct contact or air-borne </li></ul></ul></ul>
  32. 37. <ul><li>SYMPTOMS: </li></ul><ul><ul><li>Burning & grittiness of eyes, specially in evening </li></ul></ul><ul><ul><li>Mild chronic redness </li></ul></ul><ul><ul><li>Feeling of heat & dryness on lid margins </li></ul></ul><ul><ul><li>Difficulty in keeping eyes open </li></ul></ul><ul><ul><li>Mild mucoid disharge </li></ul></ul><ul><ul><li>On & off lacrimation </li></ul></ul><ul><ul><li>Feeling of sleeping & tiredness in the eyes </li></ul></ul><ul><li>SIGNS: </li></ul><ul><ul><li>Congestion of posterior conjunctival vessels </li></ul></ul><ul><ul><li>Mild papillary hypertrophy </li></ul></ul><ul><ul><li>Surface of conjunctiva look sticky, congested lid margins </li></ul></ul>
  33. 38. <ul><li>TREATMENT: </li></ul><ul><ul><li>Topical antibiotics : chloramphenicol / gentamycin 3-4 times for 2 weeks </li></ul></ul><ul><ul><li>Astringent eye drops : zinc boric acid for symptomatic relief </li></ul></ul>
  34. 39. <ul><li>Mild chronic conjunctivitis confined to the conjunctiva & lid margins near the angles </li></ul><ul><li>ETIOLOGY: </li></ul><ul><ul><li>Moraxella Axenfield Bacilli </li></ul></ul><ul><ul><li>Rarely staphylococci </li></ul></ul><ul><li>PATHOLOGY: </li></ul><ul><ul><li>Production of proteolytic enzyme </li></ul></ul><ul><ul><li>Causes maceration of epithelium </li></ul></ul>
  35. 40. <ul><li>SYMPTOMS: </li></ul><ul><ul><li>Irritation discomfort </li></ul></ul><ul><ul><li>H/O collection of dirty white foamy discharge at the angles </li></ul></ul><ul><ul><li>Redness in the angles of the eye </li></ul></ul><ul><li>SIGNS: </li></ul><ul><ul><li>Hyperaemia of bulbar conjunctiva near the canthi </li></ul></ul><ul><ul><li>Hyperaemia of lid margins near the angles </li></ul></ul><ul><ul><li>Excoriation of skin around the angles </li></ul></ul><ul><ul><li>Presence of foamy mucopurulent discharge at the angles </li></ul></ul>
  36. 41. <ul><li>COMPLICATIONS: </li></ul><ul><ul><li>Blepharitis </li></ul></ul><ul><ul><li>Marginal catarrhal corneal ulceration </li></ul></ul><ul><li>TREATMENT: </li></ul><ul><ul><li>Good personal hygiene </li></ul></ul><ul><ul><li>Oxytetracycline 1 % eye ointment 2-3 times x 10-14 days </li></ul></ul><ul><ul><li>Zinc lotion at day time and zinc oxide ointment at bedtime </li></ul></ul>
  37. 42. TYPES OF INFECTIONS BY CHLAMYDIA
  38. 43. JONES CLASSIFICATION
  39. 44. <ul><li>Formerly called as Egyptian ophthalmia </li></ul><ul><li>Chronic keratoconjunctivitis </li></ul><ul><li>Affecting superficial epithelium of cornea and conjunctiva </li></ul><ul><li>One of the leading cause of preventable blindness </li></ul><ul><li>Greek : Trachoma : “Rough” </li></ul><ul><li>Characterized by mixed follicular & papillary reaction </li></ul>
  40. 45. Etiology
  41. 47. <ul><li>Symptoms: </li></ul><ul><ul><li>No secondary bact infection: </li></ul></ul><ul><ul><ul><li>Minimal or asymtomatic </li></ul></ul></ul><ul><ul><ul><li>Mild FB sensation </li></ul></ul></ul><ul><ul><ul><li>Occasional lacrimation </li></ul></ul></ul><ul><ul><ul><li>Stickiness of lids </li></ul></ul></ul><ul><ul><ul><li>Scanty mucoid discharge </li></ul></ul></ul><ul><ul><li>With secondary bact infection: </li></ul></ul><ul><ul><ul><li>All typical symptoms of acute bacterial conjunctivitis </li></ul></ul></ul>
  42. 49. <ul><li>CONJUNCTIVAL FOLLICLES: </li></ul><ul><ul><li>Boiled sago-grains </li></ul></ul><ul><ul><li>Upper tarsal conjunctiva </li></ul></ul><ul><ul><li>Sometimes on bulbar conjunctiva also </li></ul></ul><ul><ul><li>Scattered aggregations of lymphocytes, </li></ul></ul><ul><ul><li>multinucleate giant cells (Leber cells), </li></ul></ul><ul><ul><li>mononuclear histiocytes etc </li></ul></ul><ul><ul><li>Signs of necrosis may be present </li></ul></ul>
  43. 50. <ul><li>CONJUNCTIVAL PAPILLAE: </li></ul><ul><ul><li>Reddish flat topped raised areas </li></ul></ul><ul><ul><li>Give red velvety appearance to tarsal conjunctiva </li></ul></ul><ul><ul><li>Central core of numerous dilated blood vessels surrounded by lymphocytes and covered by hypertrophic epithelium </li></ul></ul>
  44. 51. <ul><li>CONJUNCTIVAL SCARRING: </li></ul><ul><ul><li>May be irregular, star-shaped or linear </li></ul></ul><ul><ul><li>Arlt’s line in case of linear scar </li></ul></ul>
  45. 52. <ul><li>CONCRETIONS: </li></ul><ul><ul><li>Accumulation of dead epithelial cells and inspissated pus in depressions called glands of Henle </li></ul></ul>
  46. 53. <ul><li>HERBERT FOLLICLES: </li></ul><ul><ul><li>Similar to conjunctival follicles but present in limbal area </li></ul></ul><ul><li>HERBERT PITS: </li></ul><ul><ul><li>Oval or circular pitted scars left after healing of Herbert follicles in limbal area </li></ul></ul>
  47. 54. <ul><li>PANNUS: </li></ul><ul><ul><li>Infiltration of cornea associated with vascularization in the upper limbal area </li></ul></ul><ul><ul><li>Vessels lie between the epithelium & Bowman’s layer </li></ul></ul><ul><ul><li>Types: </li></ul></ul><ul><ul><ul><li>Progressive: infiltration ahead of vascularization </li></ul></ul></ul><ul><ul><ul><li>Regressive: vessels extend short distance beyond infiltration </li></ul></ul></ul>
  48. 55. McCallan’s Classification:
  49. 56. WHO Classification (FISTO):
  50. 57. <ul><li>SEQUELAE: </li></ul><ul><ul><li>In the lids: </li></ul></ul><ul><ul><ul><li>Trichiasis, entropion, tylosis, ptosis, madarosis </li></ul></ul></ul><ul><ul><li>In the conjunctiva: </li></ul></ul><ul><ul><ul><li>Concretions, pseudocysts, xerosis, symblepheron </li></ul></ul></ul><ul><ul><li>In the cornea: </li></ul></ul><ul><ul><ul><li>Corneal opacity, ectasia, xerosis, total corneal pannus </li></ul></ul></ul><ul><ul><li>Others: </li></ul></ul><ul><ul><ul><li>Chronic dacryosystitis, chronic dacryoadenitis </li></ul></ul></ul>
  51. 58. <ul><li>DIAGNOSIS: </li></ul><ul><ul><li>Clinical: </li></ul></ul><ul><ul><ul><li>Grading to be done as per WHO classification </li></ul></ul></ul><ul><ul><ul><li>At least 2 sets of signs should be present: </li></ul></ul></ul><ul><ul><ul><ul><li>Conjunctival follicles and papillae </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pannus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Epithelial keratitis near superior limbus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Signs & sequelae of cicatrization </li></ul></ul></ul></ul><ul><ul><li>Laboratory: </li></ul></ul><ul><ul><ul><li>Conjunctival cytology </li></ul></ul></ul><ul><ul><ul><li>Detection of inclusion bodies </li></ul></ul></ul><ul><ul><ul><li>ELISA for chlamydial antigens </li></ul></ul></ul><ul><ul><ul><li>PCR </li></ul></ul></ul><ul><ul><ul><li>Isolation & serotyping of organism </li></ul></ul></ul>
  52. 59. <ul><li>Differential Diagnosis: </li></ul><ul><ul><li>With follicular hypertrophy: </li></ul></ul><ul><ul><ul><li>Adenoviral conjunctivitis </li></ul></ul></ul><ul><ul><li>With papillary hypertrophy </li></ul></ul><ul><ul><ul><li>Vernal Conjunctivitis </li></ul></ul></ul>
  53. 60. <ul><li>MANAGEMENT: </li></ul><ul><ul><li>Treatment of Active Trachoma: </li></ul></ul><ul><ul><ul><li>Topical therapy: </li></ul></ul></ul><ul><ul><ul><ul><li>1% tetracycline / 1% erythromycin eye ointment 4 times daily for 6 weeks </li></ul></ul></ul></ul><ul><ul><ul><li>Systemic therapy: </li></ul></ul></ul><ul><ul><ul><ul><li>Tetracycline / erythromycin 250mg QID orally for 4 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Or Docycline 100mg BD orally for 4 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Or single dose of Azithromycin orally </li></ul></ul></ul></ul><ul><ul><ul><li>Combined therapy: </li></ul></ul></ul><ul><ul><ul><ul><li>Preferred when severe disease </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Or associated genital infection is present </li></ul></ul></ul></ul>
  54. 61. <ul><li>MANAGEMENT: </li></ul><ul><ul><li>Treatment of Sequelae: </li></ul></ul><ul><ul><ul><li>Removal of concretions </li></ul></ul></ul><ul><ul><ul><li>Epilation / electrolysis of trichasis </li></ul></ul></ul><ul><ul><ul><li>Surgical correction of entropion </li></ul></ul></ul><ul><ul><ul><li>Lubricating drops for xerosis </li></ul></ul></ul><ul><ul><li>Prophylaxis: </li></ul></ul><ul><ul><ul><li>Hygiene measures </li></ul></ul></ul><ul><ul><ul><li>Early treatment of conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>Blanket antibiotic therapy in endemic areas: </li></ul></ul></ul><ul><ul><ul><ul><li>1 % tetracycline ointment BD for 5 days in a month for 6 months </li></ul></ul></ul></ul>
  55. 62. <ul><li>MANAGEMENT: </li></ul><ul><ul><li>SAFE Strategy for Trachoma Blindness: </li></ul></ul><ul><ul><ul><li>S urgery to correct eyelid deformity & prevent blindness </li></ul></ul></ul><ul><ul><ul><li>A ntibiotics for acute infections & community control </li></ul></ul></ul><ul><ul><ul><li>F acial Hygiene </li></ul></ul></ul><ul><ul><ul><li>E nvironmental changes </li></ul></ul></ul>
  56. 63. <ul><li>acute follicular conjunctivitis associated with mucopurulent discharge </li></ul><ul><li>ETIOLOGY: </li></ul><ul><ul><li>Chlamydia trachomatis Serotype D to K </li></ul></ul><ul><ul><li>Primary source urethritis & cervicitis </li></ul></ul><ul><ul><li>Transmission through contact through fingers </li></ul></ul><ul><ul><li>Or by contaminated water of swimming pool </li></ul></ul><ul><ul><li>c/a Swimming Pool Conjunctivitis </li></ul></ul>
  57. 64. <ul><li>Incubation Period: </li></ul><ul><ul><li>4-12 days </li></ul></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Ocular discomfort, foreign body sensation </li></ul></ul><ul><ul><li>Mild photophobia </li></ul></ul><ul><ul><li>Mucopurulent discharge from the eyes </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Conjunctival hyperaemia, marked in fornices. </li></ul></ul><ul><ul><li>Acute follicular hypertrophy predominantly of lower palpebral conjunctiva </li></ul></ul><ul><ul><li>Superficial keratitis in upper half </li></ul></ul><ul><ul><li>Superior micropannus occasionally </li></ul></ul><ul><ul><li>Pre-auricular lymphadenopathy </li></ul></ul>
  58. 65. <ul><li>Treatment: </li></ul><ul><ul><li>Topical therapy: </li></ul></ul><ul><ul><ul><li>Tetracycline 1 % eye ointment QID for 6 weeks </li></ul></ul></ul><ul><ul><li>Systemic therapy: </li></ul></ul><ul><ul><ul><li>Very important </li></ul></ul></ul><ul><ul><ul><li>Tetracycline 250 mg four times a day for 3-4 weeks. </li></ul></ul></ul><ul><ul><ul><li>Erythromycin 250 mg four times a day for 3-4 weeks </li></ul></ul></ul><ul><ul><ul><li>Doxycycline 100 mg twice a day for 1-2 weeks 200 mg weekly for 3 weeks </li></ul></ul></ul><ul><ul><ul><li>Azithromycin 1 gm as a single dose </li></ul></ul></ul>
  59. 66. <ul><li>Most viral infections are keratoconjunctivitis </li></ul><ul><li>VIRAL INFECTIONS OF CONJUNCTIVA </li></ul><ul><li>(conjunctiva is predominantly affected): </li></ul><ul><ul><li>Adenoviral conjunctivitis </li></ul></ul><ul><ul><li>Herpes Simplex kerato conjunctivitis </li></ul></ul><ul><ul><li>Herpes Zoster conjunctivitis </li></ul></ul><ul><ul><li>Pox virus conjunctivitis </li></ul></ul><ul><ul><li>Myxovirus conjunctivitis </li></ul></ul><ul><ul><li>Paramyxovirus conjunctivitis </li></ul></ul><ul><ul><li>ARBOR virus conjunctivitis </li></ul></ul>
  60. 67. <ul><li>Clinical presentations: Three clinical forms: </li></ul><ul><li>1. Acute serous conjunctivitis </li></ul><ul><li>2. Acute haemorrhagic conjunctivitis </li></ul><ul><li>3. Acute follicular conjunctivitis </li></ul>
  61. 68. <ul><li>Mild grade viral infection </li></ul><ul><li>No follicular response </li></ul><ul><li>CLINICAL FEATURES: </li></ul><ul><ul><li>Minimal congestion </li></ul></ul><ul><ul><li>Watery discharge </li></ul></ul><ul><ul><li>Boggy swelling of conjunctival mucosa </li></ul></ul><ul><li>TREATMENT: </li></ul><ul><ul><li>Usually self limiting , no treatment </li></ul></ul><ul><ul><li>Broad spectrum antibiotic to prevent secondary bacterial infection for 7 days </li></ul></ul>
  62. 69. <ul><li>Acute conjunctivitis characterised by: </li></ul><ul><ul><li>Multiple conjunctival hemorrhages </li></ul></ul><ul><ul><li>Hyperemia </li></ul></ul><ul><ul><li>Mild follicular hyperplasia </li></ul></ul><ul><li>ETIOLOGY: </li></ul><ul><ul><li>Picornavirus </li></ul></ul><ul><ul><li>Disease very contagious, direct hand-to-eye contact </li></ul></ul>
  63. 70. <ul><li>Clinical features: </li></ul><ul><ul><li>Incubation period: 1-2 days </li></ul></ul><ul><ul><li>Symptoms: </li></ul></ul><ul><ul><ul><li>Pain, redness, watering, mild photophobia </li></ul></ul></ul><ul><ul><ul><li>Transient blurring of vision, lid edema </li></ul></ul></ul><ul><ul><li>Signs: </li></ul></ul><ul><ul><ul><li>conjunctival congestion & chemosis </li></ul></ul></ul><ul><ul><ul><li>multiple haemorrhages in bulbar conjunctiva </li></ul></ul></ul><ul><ul><ul><li>mild follicular hyperplasia, lid oedema </li></ul></ul></ul><ul><ul><ul><li>pre-auricular lymphadenopathy </li></ul></ul></ul><ul><ul><ul><li>Fine corneal keratitis </li></ul></ul></ul>
  64. 71. <ul><li>Treatment: </li></ul><ul><ul><li>Very infectious </li></ul></ul><ul><ul><li>Prophylaxis very important </li></ul></ul><ul><ul><li>No specific treatment </li></ul></ul><ul><ul><li>Broad spectrum antibiotics </li></ul></ul><ul><ul><li>Self-limiting within 5-7 days </li></ul></ul>
  65. 72. <ul><li>Acute conjunctivitis with formation of follicles, conjunctival hyperaemia and discharge from the eyes </li></ul><ul><li>TYPES: </li></ul><ul><ul><li>Acute follicular conjunctivitis (Non-Specific) </li></ul></ul><ul><ul><li>Chronic conjunctivitis </li></ul></ul><ul><ul><li>Specific type (trachoma, etc) </li></ul></ul>
  66. 73. <ul><li>Acute catarrhal conjunctivitis </li></ul><ul><li>Marked follicular hyperplasia especially of the lower fornix and lower palpebral conjunctiva </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Redness, watering, mild mucoid discharge </li></ul></ul><ul><ul><li>Mild photophobia and feeling of discomfort </li></ul></ul><ul><ul><li>Foreign body sensation </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>conjunctival hyperaemia </li></ul></ul><ul><ul><li>Multiple follicles, more prominent in lower lid than the upper lid </li></ul></ul>
  67. 75. <ul><li>ETIOLOGICAL TYPES: </li></ul><ul><ul><li>Adult inclusion conjunctivitis (non-viral) </li></ul></ul><ul><ul><li>Epidemic keratoconjunctivitis </li></ul></ul><ul><ul><li>Pharyngoconjunctival fever </li></ul></ul><ul><ul><li>Newcastle conjunctivitis </li></ul></ul><ul><ul><li>Acute herpetic conjunctivitis </li></ul></ul>
  68. 76. <ul><li>Epidemic keratoconjunctivitis : </li></ul><ul><ul><li>Associated with SPK and occur in epidemics </li></ul></ul><ul><ul><li>Adenovirus type 8 and 19 </li></ul></ul><ul><ul><li>Markedly contagious and direct contact transfer </li></ul></ul><ul><ul><li>Incubation : 8 days </li></ul></ul><ul><ul><ul><li>Phase 1 : acute serous conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>Phase 2 : acute follicular conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>Phase 3 : acute pseudomembranous conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>Corneal involvement : SPK </li></ul></ul></ul><ul><ul><ul><li>Pre-auricular lymphadenopathy in all cases </li></ul></ul></ul><ul><ul><li>Treatment : supportive therapy </li></ul></ul>
  69. 78. <ul><li>Pharyngoconjunctival fever: </li></ul><ul><ul><li>Adenovirus type 3 and 7 </li></ul></ul><ul><ul><ul><li>Acute follicular conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>With pharyngitis, Fever & Pre auricular LN </li></ul></ul></ul><ul><ul><li>Primarily in children and in epidemic forms </li></ul></ul><ul><ul><li>Corneal involvement in 30% cases </li></ul></ul><ul><ul><li>Treatment is supportive </li></ul></ul>
  70. 79. <ul><li>Newcastle conjunctivitis </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Caused by Newcastle virus </li></ul></ul><ul><ul><li>Contact with diseased owls </li></ul></ul><ul><ul><li>Affects poultry workers </li></ul></ul><ul><ul><li>Similar to pharyngoconjunctival fever. </li></ul></ul>
  71. 80. <ul><li>Acute herpetic conjunctivitis: </li></ul><ul><ul><li>Always accompanies with primary herpetic infection </li></ul></ul><ul><ul><li>HSV type 1 commonly </li></ul></ul><ul><ul><li>Clinically: </li></ul></ul><ul><ul><ul><li>Usually unilateral, incubation within 3-10 days </li></ul></ul></ul><ul><ul><ul><li>Typical Form: Follicular conjunctivitis with other herpetic lesions </li></ul></ul></ul><ul><ul><ul><li>Atypical Form: Follicular conjunctivitis without other herpetic lesions </li></ul></ul></ul><ul><ul><ul><li>Corneal involvement & preauricular lymphadenopathy </li></ul></ul></ul><ul><ul><li>Treatment: self limiting, antivirals ineffective </li></ul></ul>
  72. 81. <ul><li>Mild chronic catarrhal conjunctivitis with follicles predominantly in lower palpebral conjunctiva </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Infective: benign folliculosis (school folliculosis) </li></ul></ul><ul><ul><li>Toxic: due to cellular debris in molluscum contagiosum </li></ul></ul><ul><ul><li>Chemical: prolonged use of pilocarpine, IDU, adrenaline </li></ul></ul><ul><ul><li>Allergic: less commonly </li></ul></ul>
  73. 82. <ul><li>TYPES: </li></ul><ul><ul><li>Simple allergic conjunctivitis </li></ul></ul><ul><ul><ul><li>Hay fever conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>Seasonal allergic conjunctivitis (SAC) </li></ul></ul></ul><ul><ul><ul><li>Perennial allergic conjunctivitis (PAC) </li></ul></ul></ul><ul><ul><li>Vernal keratoconjunctivitis (VKC) </li></ul></ul><ul><ul><li>Atopic keratoconjunctivitis (AKC) </li></ul></ul><ul><ul><li>Giant papillary conjunctivitis (GPC) </li></ul></ul><ul><ul><li>Phlyctenular keratoconjunctivitis (PKC) </li></ul></ul><ul><ul><li>Contact dermoconjunctivitis (CDC) </li></ul></ul>
  74. 83. <ul><li>Mild, non-specific allergic conjunctivitis </li></ul><ul><ul><li>Itching, hyperaemia and mild papillary response </li></ul></ul><ul><li>Basically an urticarial reaction </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Hay fever : pollens, animal dandruff </li></ul></ul><ul><ul><li>Seasonal allergens (grass pollens) </li></ul></ul><ul><ul><li>Perenial allergens (house dust, mites) </li></ul></ul><ul><li>Pathology: </li></ul><ul><ul><li>Vascular + Cellular + Conjunctival Responses </li></ul></ul>
  75. 84. <ul><li>Symptoms: </li></ul><ul><ul><li>Intense itching & burning </li></ul></ul><ul><ul><li>Watery discharge & mild photophobia </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Hypreremia & chemosis </li></ul></ul><ul><ul><li>Mild papillary reaction </li></ul></ul><ul><ul><li>Lid edema may be present </li></ul></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Typical signs & symptoms </li></ul></ul><ul><ul><li>Normal conjunctival flora </li></ul></ul><ul><ul><li>Abundant eosinophils in discharge </li></ul></ul>
  76. 85. <ul><li>Treatment: </li></ul><ul><ul><li>Elimination of allergen if possible </li></ul></ul><ul><ul><li>Local palliative measures for immediate relief: </li></ul></ul><ul><ul><ul><li>Vasoconstrictors : naphazoline, adrenaline, ephedrine </li></ul></ul></ul><ul><ul><ul><li>Sodium cromoglycate eye drops </li></ul></ul></ul><ul><ul><ul><li>Steroids only for short course in acute cases </li></ul></ul></ul><ul><ul><li>Systemic antihistaminics in acute cases </li></ul></ul><ul><ul><li>Desensitization – not much effective </li></ul></ul>
  77. 86. <ul><li>C/a SPRING CATARRH </li></ul><ul><li>Recurrent, bilateral, interistitial, self-limiting, allergic inflammation of conjunctiva </li></ul><ul><li>ETIOLOGY: </li></ul><ul><ul><li>Hypersensitivity to some exogenous allergen </li></ul></ul><ul><ul><li>IgE mediated atopic mechanisms </li></ul></ul><ul><li>Predisposing factors: </li></ul><ul><ul><li>4-20 years, common in males </li></ul></ul><ul><ul><li>More in summer </li></ul></ul><ul><ul><li>Prevalent in tropics, non-existent in cold climate </li></ul></ul>
  78. 87. <ul><li>Pathology: </li></ul><ul><ul><li>Conjunctival epithelial hyperplasia </li></ul></ul><ul><ul><li>Marked infiltration in adenoid cell layer </li></ul></ul><ul><ul><li>Proliferation of fibrous layer </li></ul></ul><ul><ul><li>Conjunctival vascular changes seen </li></ul></ul><ul><ul><li>Formation of multiple papilllae in upper tarsal conjunctiva </li></ul></ul>
  79. 88. <ul><li>Symptoms: </li></ul><ul><ul><li>Marked burning and itching, usually intoreble </li></ul></ul><ul><ul><li>Mild photophobia, lacrimation </li></ul></ul><ul><ul><li>“ Ropy Discharge” </li></ul></ul><ul><ul><li>Heaviness of eyelids </li></ul></ul>
  80. 89. <ul><li>Signs: </li></ul><ul><ul><li>Palpabrel form: </li></ul></ul><ul><ul><ul><li>Upper tarsal conjunctiva </li></ul></ul></ul><ul><ul><ul><li>Presence of hard, flat topped, papillae arranged in 'cobble-stone' or 'pavement stone', fashion </li></ul></ul></ul><ul><ul><ul><li>Giant papillae in severe cases </li></ul></ul></ul><ul><ul><ul><li>White ropy conjunctival discharge </li></ul></ul></ul><ul><ul><li>Bulbar form: </li></ul></ul><ul><ul><ul><li>Dusky red triangular congestion of bulbar conjunctiva in palpebral area </li></ul></ul></ul><ul><ul><ul><li>Gelatinous thickened accumulation of tissue around the limbus </li></ul></ul></ul><ul><ul><ul><li>Presence of discrete whitish raised dots along the limbus (Tranta's spots) </li></ul></ul></ul><ul><ul><li>Mixed: </li></ul></ul><ul><ul><ul><li>Combined features of both forms </li></ul></ul></ul>
  81. 90. <ul><li>VERNAL KERATOPATHY: </li></ul><ul><ul><li>5 types of lesions can be seen: </li></ul></ul><ul><ul><ul><li>Punctate epithelial keratitis: </li></ul></ul></ul><ul><ul><ul><ul><li>Involves upper cornea, mostly in palpabrel form </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lesions always stain with rose bengal </li></ul></ul></ul></ul><ul><ul><ul><li>Ulcerative vernal keratitis: </li></ul></ul></ul><ul><ul><ul><ul><li>Shallow transverse ulcer in upper part of cornea due to epithelial macroerosions </li></ul></ul></ul></ul><ul><ul><ul><li>Vernal corneal plaques: </li></ul></ul></ul><ul><ul><ul><ul><li>Due to coating of areas of epithelial macroerosions with coating of altered exudates </li></ul></ul></ul></ul><ul><ul><ul><li>Subepithelial scarring: </li></ul></ul></ul><ul><ul><ul><ul><li>In a form of a ring scar </li></ul></ul></ul></ul><ul><ul><ul><li>Pseudogerontoxon: </li></ul></ul></ul><ul><ul><ul><ul><li>Classical cupid bow outline </li></ul></ul></ul></ul>
  82. 91. <ul><li>Clinical course: </li></ul><ul><ul><li>Disease is self-limiting </li></ul></ul><ul><ul><li>Usually goes off spontaneously in 5-10 years </li></ul></ul><ul><li>Differential diagnosis: </li></ul><ul><ul><li>Trachoma with predominantly papillary hypertrophy </li></ul></ul>
  83. 92. <ul><li>Treatment: </li></ul><ul><ul><li>Local therapy </li></ul></ul><ul><ul><li>Systemic therapy </li></ul></ul><ul><ul><li>Treatment of large papillae </li></ul></ul><ul><ul><li>General measures </li></ul></ul><ul><ul><li>Desensitization </li></ul></ul><ul><ul><li>Treatment of vernal keratopathy </li></ul></ul>
  84. 93. <ul><li>Treatment: </li></ul><ul><ul><li>Local therapy </li></ul></ul><ul><ul><ul><li>Topical steroids: </li></ul></ul></ul><ul><ul><ul><ul><li>Effective in all forms </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use should be minimal and for short-duration </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Frequent instillation to tapering within few days </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flouromethalone, dexamethasone, loteprednol </li></ul></ul></ul></ul><ul><ul><ul><li>Mast cell stabilizers: </li></ul></ul></ul><ul><ul><ul><ul><li>Sodium cromoglycate, azelastine, ketotifen </li></ul></ul></ul></ul><ul><ul><ul><li>Topical antihistaminic eye drops </li></ul></ul></ul><ul><ul><ul><li>Acetyl cysteine (0.5%) eye drops </li></ul></ul></ul><ul><ul><ul><li>Topical cyclosporine eye drops </li></ul></ul></ul>
  85. 94. <ul><li>Treatment: </li></ul><ul><ul><li>Systemic therapy </li></ul></ul><ul><ul><ul><li>Oral histaminics </li></ul></ul></ul><ul><ul><ul><li>Oral steroids in severe cases for short duration </li></ul></ul></ul><ul><ul><li>Treatment of large papillae: </li></ul></ul><ul><ul><ul><li>Supratarsal injection of long acting steroid </li></ul></ul></ul><ul><ul><ul><li>Cryo application </li></ul></ul></ul><ul><ul><ul><li>Surgical excision for extra-ordinary large papillae </li></ul></ul></ul>
  86. 95. <ul><li>Treatment: </li></ul><ul><ul><li>General measures: </li></ul></ul><ul><ul><ul><li>Dark goggles </li></ul></ul></ul><ul><ul><ul><li>Cold compress & ice packs </li></ul></ul></ul><ul><ul><ul><li>Change of environment (working environment also) </li></ul></ul></ul><ul><ul><li>Desensitization </li></ul></ul><ul><ul><ul><li>Not much awarding results </li></ul></ul></ul><ul><ul><li>Treatment of vernal keratopathy: </li></ul></ul><ul><ul><ul><li>PEK : steroid instillation should be increased </li></ul></ul></ul><ul><ul><ul><li>Large vernal plaque: surgical lamellar keratectomy </li></ul></ul></ul><ul><ul><ul><li>Severe shield ulcer: debridement, superficial keratectomy, amniotic membrane transplantation </li></ul></ul></ul>
  87. 96. <ul><li>Adult equivalent of vernal keratoconjunctivitis </li></ul><ul><li>Often associated with atopic dermatitis </li></ul><ul><li>Mostly young male adults </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Itching, soreness, dry sensation </li></ul></ul><ul><ul><li>Mucoid discharge </li></ul></ul><ul><ul><li>Photophobia or blurred vision </li></ul></ul>
  88. 97. <ul><li>Signs: </li></ul><ul><ul><li>Lid margins: </li></ul></ul><ul><ul><ul><li>chronically inflamed </li></ul></ul></ul><ul><ul><ul><li>rounded posterior borders </li></ul></ul></ul><ul><ul><li>Tarsal conjunctiva: </li></ul></ul><ul><ul><ul><li>milky appearance </li></ul></ul></ul><ul><ul><ul><li>very fine papillae, hyperaemia and scarring with shrinkage </li></ul></ul></ul><ul><ul><li>Cornea: </li></ul></ul><ul><ul><ul><li>punctate epithelial keratitis </li></ul></ul></ul><ul><ul><ul><li>more severe in lower half </li></ul></ul></ul><ul><ul><ul><li>corneal vascularization, thinning and plaques. </li></ul></ul></ul>
  89. 98. <ul><li>Clinical course: </li></ul><ul><ul><li>Protracted course </li></ul></ul><ul><ul><li>Tends to become inactive by 5 th decade </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Often frustrating </li></ul></ul><ul><ul><li>Treat lid disease effectively </li></ul></ul><ul><ul><li>Mast cell stabilizers, steroids, tear supplements may be beneficial </li></ul></ul>
  90. 99. <ul><li>Conjunctival inflammation with very large sized papillae </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Localized allergic response </li></ul></ul><ul><ul><li>Contant lens, prosthetic shell </li></ul></ul><ul><ul><li>Suture irritation </li></ul></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Itching, stringy discharge </li></ul></ul><ul><ul><li>Reduced wearing time of contact lens or prosthetic shell </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Papillary hypertrophy upper tarsal conjunctiva with hyperaemia </li></ul></ul>
  91. 100. <ul><li>Treatment: </li></ul><ul><ul><li>The offending cause should be removed. </li></ul></ul><ul><ul><li>Disodium cromoglycate is known to relieve the symptoms and enhance the rate of resolution. </li></ul></ul><ul><ul><li>Steroids are not of much use in this condition. </li></ul></ul>
  92. 101. <ul><li>Nodular affection as a allergic response to endogenous allergens </li></ul><ul><li>World wide , more in developing countries </li></ul><ul><li>Etiology: Delayed hypersensitivity </li></ul><ul><ul><li>Causative allergens </li></ul></ul><ul><ul><ul><li>Tuberculous, Staphylococcus </li></ul></ul></ul><ul><ul><ul><li>Proteins of Moraxella Axenfeld bacillius, Parasites </li></ul></ul></ul><ul><ul><li>Predisposing factors </li></ul></ul><ul><ul><ul><li>Age. Peak age group is 3-15 years. </li></ul></ul></ul><ul><ul><ul><li>Sex. Incidence is higher in girls than boys. </li></ul></ul></ul><ul><ul><ul><li>Undernourishment </li></ul></ul></ul><ul><ul><ul><li>Living conditions. Overcrowded and unhygienic. </li></ul></ul></ul><ul><ul><ul><li>Season. all climates (spring and summer seasons) </li></ul></ul></ul>
  93. 102. <ul><li>Pathology: </li></ul><ul><li>Stage of nodule formation: </li></ul><ul><ul><li>exudation and infiltration of leucocytes </li></ul></ul><ul><ul><li>neighbouring blood vessels dilate and their endothelium proliferates. </li></ul></ul><ul><li>Stage of ulceration: </li></ul><ul><ul><li>Necrosis apex of the nodule and an ulcer is formed </li></ul></ul><ul><li>Stage of granulation: </li></ul><ul><ul><li>Eventually floor of the ulcer becomes </li></ul></ul><ul><ul><li>covered by granulation tissue. </li></ul></ul><ul><li>Stage of healing </li></ul><ul><ul><li>Healing occurs usually with minimal </li></ul></ul><ul><ul><li>scarring . </li></ul></ul>
  94. 103. <ul><li>Symptoms: </li></ul><ul><ul><li>Very few </li></ul></ul><ul><ul><li>Mild discomfort, discharge, irritation, reflex tearing </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Simple: </li></ul></ul><ul><ul><ul><li>Most common </li></ul></ul></ul><ul><ul><ul><li>Typical pinkish-white nodule at limbus surrounded by hyperemia, mostly solitary. </li></ul></ul></ul><ul><ul><li>Necrotizing: </li></ul></ul><ul><ul><ul><li>Very large phlycten with necrosis & ulceration </li></ul></ul></ul><ul><ul><ul><li>Leads to severe pustular conjunctivitis </li></ul></ul></ul><ul><ul><li>Miliary: </li></ul></ul><ul><ul><ul><ul><li>Multiple phlyctens, may be arranged like a ring around limbus </li></ul></ul></ul></ul>
  95. 104. <ul><li>Phlyctenular Keratitis: </li></ul><ul><ul><li>Ulcerative: </li></ul></ul><ul><ul><ul><li>Sacrofulous ulcer: shallow marginal ulcer </li></ul></ul></ul><ul><ul><ul><li>Fascicular ulcer: has prominent parallel leash of vessels </li></ul></ul></ul><ul><ul><ul><li>Miliary ulcer: multiple ulcers scattered all over </li></ul></ul></ul><ul><ul><li>Diffuse Infiltrative: </li></ul></ul><ul><ul><ul><li>Central infiltration of cornea </li></ul></ul></ul><ul><ul><ul><li>Characteristic rich vascularization all around limbus </li></ul></ul></ul><ul><ul><li>Usually self-limiting, disappears in 8-10 days </li></ul></ul><ul><ul><li>D/D: </li></ul></ul><ul><ul><ul><li>Episcleritis, scleritis, FB granuloma </li></ul></ul></ul>
  96. 105. <ul><li>Treatment: </li></ul><ul><ul><li>Local therapy: </li></ul></ul><ul><ul><ul><li>Topical steroid eye drops and ointment </li></ul></ul></ul><ul><ul><ul><li>Topical antibiotic eye drops & ointment </li></ul></ul></ul><ul><ul><ul><li>Atropine eye ointment when cornea involved </li></ul></ul></ul><ul><ul><li>Systemic therapy: </li></ul></ul><ul><ul><ul><li>Diagnosis & management of TB </li></ul></ul></ul><ul><ul><ul><li>Septic foci like caries, folliculitis, tonsillitis, adenoiditis to be adequately treated </li></ul></ul></ul><ul><ul><ul><li>Parasitic infestations to be ruled out & treated if present </li></ul></ul></ul><ul><ul><li>General measures: </li></ul></ul><ul><ul><ul><li>Improve hygiene & supplement high-protein diet </li></ul></ul></ul>
  97. 106. <ul><li>Treatment: </li></ul><ul><ul><li>Local therapy: </li></ul></ul><ul><ul><ul><li>Topical steroid eye drops and ointment </li></ul></ul></ul><ul><ul><ul><li>Topical antibiotic eye drops & ointment </li></ul></ul></ul><ul><ul><ul><li>Atropine eye ointment when cornea involved </li></ul></ul></ul><ul><ul><li>Systemic therapy: </li></ul></ul><ul><ul><ul><li>Diagnosis & management of TB </li></ul></ul></ul><ul><ul><ul><li>Septic foci like caries, folliculitis, tonsillitis, adenoiditis to be adequately treated </li></ul></ul></ul><ul><ul><ul><li>Parasitic infestations to be ruled out & treated if present </li></ul></ul></ul><ul><ul><li>General measures: </li></ul></ul><ul><ul><ul><li>Improve hygiene & supplement high-protein diet </li></ul></ul></ul>
  98. 107. <ul><li>PINGUECULA </li></ul><ul><li>PTERYGIUM </li></ul><ul><li>CONCRETIONS </li></ul>
  99. 108. <ul><li>PINGUECULA: </li></ul><ul><ul><li>Extremely common </li></ul></ul><ul><ul><li>Yellowish white patch on </li></ul></ul><ul><ul><li>bulbar conjunctiva near the </li></ul></ul><ul><ul><li>limbus, nasal or temporal </li></ul></ul><ul><ul><li>Etiology: </li></ul></ul><ul><ul><ul><li>Age related change </li></ul></ul></ul><ul><ul><ul><li>Strong sunlight (UV) light exposure </li></ul></ul></ul><ul><ul><ul><li>Dusty, windy & smoky working environment </li></ul></ul></ul><ul><ul><ul><li>Considered as a precursor of pterygium </li></ul></ul></ul>
  100. 109. <ul><li>PINGUECULA: </li></ul><ul><ul><li>Pathology: </li></ul></ul><ul><ul><ul><li>Elastotic degeneration of collagen fibres of the substantia propria of conjunctiva </li></ul></ul></ul><ul><ul><ul><li>Deposition of amorphous hyaline material in the substance of conjunctiva </li></ul></ul></ul><ul><ul><li>Clinical features: </li></ul></ul><ul><ul><ul><li>Bilateral, usually stable, yellowish-white (may be triangular) patch near limbus, commonly nasal limbus </li></ul></ul></ul><ul><ul><ul><li>In congested conjunctiva, stands out as a avascular patch </li></ul></ul></ul>
  101. 110. <ul><li>PINGUECULA: </li></ul><ul><ul><li>Complications: </li></ul></ul><ul><ul><ul><li>Inflammations </li></ul></ul></ul><ul><ul><ul><li>Intraepithelial cysts </li></ul></ul></ul><ul><ul><ul><li>Intraepithelial abscess </li></ul></ul></ul><ul><ul><ul><li>Conversion into pterygium </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>No treatment </li></ul></ul></ul><ul><ul><ul><li>If required, excision can be done </li></ul></ul></ul><ul><ul><ul><li>Avoid exposure to sunlight, dust, smoke etc </li></ul></ul></ul>
  102. 111. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Pterygion = wing </li></ul></ul><ul><ul><li>Triangular wing-shaped fleshy fibrovascular mass or fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure </li></ul></ul><ul><ul><li>Etiology: </li></ul></ul><ul><ul><ul><li>Common in people living in hot climates </li></ul></ul></ul><ul><ul><ul><li>Rest same as of pinguecula </li></ul></ul></ul>
  103. 112. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Pathology: </li></ul></ul><ul><ul><li>Degenerative and hyperplastic condition of conjunctiva </li></ul></ul><ul><ul><li>Elastotic degeneration and proliferates as vascularised granulation tissue under the epithelium </li></ul></ul><ul><ul><li>Ultimately encroaches the cornea </li></ul></ul><ul><ul><li>Corneal epithelium, Bowman's layer </li></ul></ul><ul><ul><li>and superficial stroma are destroyed </li></ul></ul>
  104. 113. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Clinical features: </li></ul></ul><ul><ul><ul><li>FB sensation, watering, discomfort, visual disturbance </li></ul></ul></ul><ul><ul><ul><li>Cosmetic disfigurement </li></ul></ul></ul><ul><ul><ul><li>Common in outdoor working males </li></ul></ul></ul><ul><ul><ul><li>Unilateral or bilateral </li></ul></ul></ul><ul><ul><ul><li>Mostly on nasal side, temposal side not spared </li></ul></ul></ul><ul><ul><ul><li>Iron Deposition seen in corneal epithelium (stocker’s line) </li></ul></ul></ul>
  105. 114. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Parts of a fully developed pterygium: </li></ul></ul><ul><ul><ul><li>Head (apical part) </li></ul></ul></ul><ul><ul><ul><li>Neck (limbal part) </li></ul></ul></ul><ul><ul><ul><li>Body (scleral part) </li></ul></ul></ul>
  106. 115. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Types of Pterygium: </li></ul></ul><ul><ul><ul><li>Progressive: </li></ul></ul></ul><ul><ul><ul><ul><li>Thick, fleshy,vascular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Few infiltrates in the cornea, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>in front of the head of the pterygium </li></ul></ul></ul></ul><ul><ul><ul><li>Regressive: </li></ul></ul></ul><ul><ul><ul><ul><li>Thin, atrophic, attenuated, very little vascularity. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>There is no cap. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ultimately it becomes membranous but never disappears </li></ul></ul></ul></ul>
  107. 116. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Differential </li></ul></ul><ul><ul><li>Diagnosis: </li></ul></ul>
  108. 117. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Only satisfactory is SURGERY </li></ul></ul></ul><ul><ul><ul><li>Indications: </li></ul></ul></ul><ul><ul><ul><ul><li>Cosmetic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Continued progression </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diplopia due to interference of ocular movements </li></ul></ul></ul></ul>
  109. 118. <ul><li>PTERYGIUM: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Recurrence is very common </li></ul></ul></ul><ul><ul><ul><li>Can be reduced by following: </li></ul></ul></ul><ul><ul><ul><ul><li>Transplantation of pterygium in the lower fornix </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Postoperative beta irradiations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Postoperative / intraoperative use of antimitotic drugs (mitomycin-C or thiotepa) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgical excision with bare sclera </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgical excision with free conjunctival graft </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Excision with lamellar keratectomy and lamellar keratoplasty. </li></ul></ul></ul></ul>
  110. 119. <ul><li>PTERYGIUM: Treatment: Surgical steps: </li></ul>
  111. 120. <ul><li>PTERYGIUM: Treatment: Surgical steps: </li></ul>

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