The ConjunctivaThe ConjunctivaThe ConjunctivaThe Conjunctiva
the conjunctiva is divided into the following
•Palpebral which starts at the muco-
cutaneous junction at the eyelid margin and
is firmly adherent to the tarsal plates.
•Forniceal which is loose and redundant so
that it swells easily and is thrown into folds.
•Bulbar which lines the anterior sclera.
The conjunctival epithelium is between two and
five cell layers thick. With chronic exposure and
drying, the epithelium may become keratinized.
The stroma (substantia propria) consists of
richly vascularized connective tissue which is
separated from the epithelium by a basement
membrane. The accessory lacrimal glands are
located within the stroma. The mucin secretors
are of the following three types
•The goblet cells which are located within the
epithelium and are most dense inferonasally.
•The crypts of Henle which are located along the
upper third of the superior tarsal conjunctiva.
•The glands of Manz which encircle the limbus.
Clinical features of conjunctival diseases.
which should be considered in the differential
diagnosis of conjunctival inflammation are: (1)
type of discharge, (2) type of conjunctival
reaction, (3) presence of pseudomembranes or
true membranes and (4) presence or absence of
The following are the main types of discharge:
1-Watery discharge composed of a serous exudate
and a variable amount of refluxly secreted tears. It
is typical of viral and toxic inflammations.
2-Mucoid discharge is typical of vernal
conjunctivitis and keratoconjunctivitis sicca.
3-Prulent discharge occurs in severe acute
4-Mucoprulent discharge occurs in mild bacterial
as well as chlamydial infections.
Clinically, they appear as multiple, discrete, slightly
elevated lesions reminiscent of small grains of rice.
The THREE main causes of follicles are
(1) viral infections,
(2) Chlamydia infections,
(3) hypersensitivity to topical
PAPILLARY CONJUNCTIVAL REACTION
Papillae can develop only in the palpebral
conjunctiva and the bulbar conjunctiva at
the limbus. Papillae are most frequently
seen in the upper palpebral conjunctiva. A
papillary reaction is more non-specific and
of less diagnostic value than a follicular
response. The 4 main causes of papillae
are (1) chronic blepharitis, (2) vernal
disease, (3) bacterial infection, (4)
contact lens related problems .
they can be easily peeled off leaving
the epithelium intact). The four main
causes are (1) severe adenoviral
infection, (2) ligneous conjunctivitis,
(3) gonococcal conjunctivitis and (4)
Attempts to remove the membrane may be
accompanied by tearing of the epithelium and
bleeding. The main causes are infections
resulting from ß-haemolytic streptococci and
Lymphatic drainage of the conjunctiva is to the
preauricular and submandibular nodes.
Lymphadenopathy is a feature of
(1) viral infections,
(2) chlamydial infections and
(3) severe gonococcal
Disorders of the Conjunctiva
Bacterial conjunctivitis .
Simple bacterial conjunctivitis.
•a very common and usually self-limiting condition.
•The most common causative organisms are
Staphylococcus epidermidis and Staphylococcus
•other Gram-positive cocci, including Streptococcus
pneumoniae, are also frequent pathogens as are the
Gram-negative Haemophilus influenzae and
with an acute onset of redness, grittiness, burning and discharge.
Photophobia may be present if there is associated severe punctate
epitheliopathy or peripheral corneal infiltrates. On waking, the
eyelids are frequently stuck together and difficult to open as a result
of the accumulation of exudate during the night. Both eyes are
usually involved, although one may become affected before the other
by a day or so.
shows conjunctival hyperaemia which is maximal in the fornices a
mild papillary reaction, a mucopurulent discharge and lid crusting.
*Even without treatment, simple
conjunctivitis usually resolves within 10-14
days and laboratory tests are not routinely
*Before initiating treatment, it is important to
bathe all discharge away.
*Initial treatment is broad-spectrum
antibiotic drops during the day and ointment
at night until the discharge has ceased.
The spectrum of disease varies from mild and almost
inapparent, to full-blown cases characterized by two
(1)pharyngoconjunctival fever (PCF)
(2) epidemic keratoconjunctivitis (EKC)
both of which occur in epidemics and are highly
contagious for up to 2 weeks. Because the viruses
can be spread by finger-to-eye contact, it is important
for ophthalmologists to wash their hands after being
in contact with an acute red eye.
with acute onset of watering, redness, discomfort and photophobia. Both eyes
are affected in about 60% of cases.
shows lid oedema, a follicular response which is frequently associated with a
preauricular adenopathy. In severe cases, subconjunctival haemorrhages,
chemosis and pseudomembranes may develop.
unsatisfactory but spontaneous resolution within 2 weeks is the rule. Topical
steroids should be avoided unless the inflammation is very severe and the
possibility of herpes simplex infection has been excluded.
rarely a problem in PCF, but it may be severe in
patients with EKC.
with topical steroids is indicated only
1- if the eye is uncomfortable or
2-visual acuity diminished.
Steroids do not shorten the natural course of the
disease but merely suppress the corneal
inflammation so that the lesions tend to recur if
treatment is discontinued prematurely.
Adult inclusion conjunctivitis(TRIC)
1.(TRIC) typically affects young adults
during sexually active years.
2.The infection is almost invariably venereal
3.The eye lesions present about 1 week
following sexual exposure and
4.may be associated with a non-specific
urethritis or cervicitis.
CLINICAL FEATURES of TRIC.
is with a usually unilateral chronic muco-purulent discharge. If untreated, the
disease has a prolonged remittent course.
shows large opalescent follicles in the fornices upper tarsal involvement
predominates. As the disease progresses. Preauricular adenopathy is common.
Epithelial keratitis of the upper half of the cornea is the most frequent corneal
A/Topical treatment is with tetracycline ointment four times a day for 6 weeks.
B/Systemic treatment can be with one of the following oral antibiotics:
1.Doxycycline. (Contraindicated in childhood )
2.Tetracycline 250mg four times daily for 6 weeks(Contraindicated in
3.Erythromycin 250 mg four time daily for 6 weeks(to children and adults)
1-caused by Chlamydia trachomatis serotypes A,B,Ba
and C serotypes.
2-It is a disease of underprivileged populations with poor
conditions of hygiene.
3-the leading cause of preventable blindness in the
1-during childhood with the formation of bulbar and palpebral
Conjunctival follicles and
2-diffuse infiltration with papillae.
3-This is followed by chronic inflammation which eventually
4-causes Conjunctival scarring; this, in turn, may lead to
5-trichiasis and corneal complications in older children and adults.
World Health Organization grading :
•TF = trachomatous follicular inflammation of more than five
follicles larger than 0.5 mm on the upper tarsus .
•TI = trachomatous intense inflammation with thickening obscuring
over 50% of large, deep, tarsal vessels.
•TS = trachomatous (conjunctival) cicatrization with white lines,
bands or sheets of fibrosis in the tarsal conjunctiva.
•TT = trachomatous trichiasis of at least one inturning eyelash or
evidence of recent removal .
•CO = corneal opacity obscuring at least part of the pupil margin
and causing a visual acuity of less than 6/18.
a/of active disease is similar to adult inclusion conjunctivitis. The
most important preventive measure is strict personal hygiene
within the family, especially washing the faces of young children.
b/of chronic disease, treatment of complications…
Seasonal allergic conjunctivitis (hay fever) .
1- a very common allergic reaction
2-triggered by airborne antigens such as mould spores,
pollen, grass, hair, wool and feathers.
Presentation is with acute, transient attacks of
Examination …The conjunctiva shows
1-mild chemosis and
2-a diffuse papillary reaction. In severe cases,
3-the eyelids may be slightly oedematous but the cornea
Treatment of acute attack. Stage one.
Although topical steroids are also efficacious, their use must be
with great caution with appropriate antibiotic cover as short
courses with close follow up because of their potential for
Although systemic antihistamines are effective in suppressing
other symptoms of hay fever, they are of limited benefit in the eye.
As example chloropheneramine eye drops or more recently
selective antihistamine as levocabastin eye drops.
Prevention of acute attack. Stage two.
2-avoid allergen if known and possible…
3- a topical mast cell stabilizer instilled four to six times a day in
the form of 2% sodium cromoglycate drops 38
Acute allergic conjunctivitis
1- an urticarial reaction.
2- caused by a large amount of
allergen reaching the conjunctival sac.
the condition is characterized by a
a/sudden onset of severe chemosis
and swelling of the eyelids .
b/Most cases resolve spontaneously
within a few hours and, apart from
reassurance, require no specific
Vernal keratoconjunctivitis (VKC) (spring
is an uncommon recurrent, bilateral, external, ocular
inflammation affecting children and young adults.
The main symptoms are
1-intense ocular itching which may be associated with
2-lacrimation, photophobia, foreign body sensation and
3-Thick mucus discharge from the eyes and ptosis also
4-The symptoms may occur throughout the year, but are
characteristically worse during the spring and summer.
The three main clinical types are
(1) Palpebral. affect mainly palpebral
(2) Bulbar. affect mainly bulbar conjunctiva
and usually more severe.
(3) Mixed. affect both and usually the most
Patients with VKC have an increased incidence
•Topical steroids are usually effective but may not
achieve complete control of the disease in all cases. As
prolonged treatment is usually required, steroid- induced
complications are high and they must be used with great
•Avoid allergen…modify environment…
•Sodium cromoglycate 2% drops four times daily is
very useful in enabling patients to reduce or even
discontinue steroid medication. it is not, however, as
effective as steroids in controlling acute exacerbations
and only 20% of patients respond to cromoglycate
Chemical conjunctivitis .
A chemical burn is the only type of ocular injury that
requires immediate treatment without first taking a
history and performing a careful examination. It is top
1-are usually less serious than those caused by alkalis
because acids tend to precipitate tissue proteins which
coagulate and form a barrier preventing deep
2-The main damage is therefore restricted to the lids,
conjunctiva and cornea.
Alkaline burns .
1-are more serious because alkalis saponify lipids in the
corneal epithelium, and bind to the mucoproteins and
collagen in the corneal stroma.
2-They therefore disrupt the normal barriers of the
cornea and penetrate deep with rapidly increase the pH
of the anterior chamber, with resultant damage to the
lens and anterior uvea.
3-The late complications of alkali burns not only involve
the external ocular structures but can also give rise to
cataract, uveitis and secondary glaucoma.
4- In severe cases phthisis bulbi(blind degenerative eye)
is the tragic end result.
IMMEDIATE emergency/first aid!!!
1.Copious irrigation with bland sterile fluid and
even with tap water???
2.removal of all particulate matter.
As alkalis bind to the corneal stroma, they may
continue to injure ocular structures after initial
irrigation has removed all free alkali. For this
reason, prolonged irrigation is necessary in eyes
with alkali burns.
No rule in adding acids to equalize alkali as the
resultant heat from this reaction can create more
Subsequent treatment of alkali burns is aimed at preventing the
complications that occur 2-3 weeks after the initial insult (failure of
corneal re-epithelialization, melting and descemetocele
1.Topical steroids can be used safely during the first week to
combat uveitis without increasing the risk of corneal melting.
2.Vitamin C and citrate are beneficial in eyes with significant
burns but their exact mode of action is not fully understood:
3.Tear substitutes and, if necessary, punctal occlusion should be
used to prevent the effects of tear deficiency.
4.Contact lenses have a therapeutic role during recovery from a
chemical burn but will not prevent symblepharon formation.
5.Surgery for late complications of severe burns includes the
a-an extremely common lesion which
b-consists of a yellow-white deposit on the
bulbar conjunctiva adjacent to the nasal or
temporal aspect of the limbus.
c-Some pingueculae may enlarge very
slowly but surgical excision is seldom
a triangular sheet of fibro-vascular tissue which invades
the corneal epithelium.
pterygia typically develop in patients who have been
living in hot climates and may represent a response to
chronic dryness and exposure to the sun.
Treatment .by surgical excision is indicated either for
cosmetic reasons or in cases of progression towards the visual
axis. The most favoured method is excision of the conjunctival
component followed by grafting of free conjunctiva, usually from
the bulbar surface of the same eye
Conjunctival concretions are small yellow
white deposits commonly present in the
palpebral conjunctiva of the elderly.
They may also occur in patients with
chronic Conjunctival inflammatory
Concretions are usually discrete but
confluent concretions are not uncommon .
They can be easily removed with a needle.