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    Pathology of the conjunctiva baguio 2012 Pathology of the conjunctiva baguio 2012 Presentation Transcript

    • PATHOLOGY OF THE CONJUNCTIVA
    • CONJUNCTIVITIS• Inflammation of the Conjunctiva
    • Conjunctival sign of inflammation• Hyperemia• Injections• Papillae• Follicles• Chemosis• Membrane – true, pseudo• Keratinization• Scar• Symblepharon
    • HYPEREMIA• Increased redness of conjunctiva
    • Conjunctival INJECTIONS• Presence of dilated blood vessels at the periphery that fades towards the limbal area
    • FOLLICLES
    • PAPILLAE
    • 47- Palperal spring catarrh
    • 48- Palperal spring catarrh
    • 49- Palperal spring catarrh
    • 50- Palperal spring catarrh
    • CHEMOSIS
    • MEMBRANE
    • SCARRING
    • CLASSIFICATION• By Cause• By Type of Discharges• By age of onset• By Duration
    • By Cause• Bacterial• Viral• Chlamydial• Allergic
    • Bacterial conjunctivitis
    • Hyperacute conjunctivitis• Neisseria gonorrhoeae (GC) – Lid edema, conj injection, chemosis, purulent discharge, conjunctival memb, tender preauricular adenopathy – Keratitis 15-40% – Conjunctival swab – gram stain, C/S
    • • Neisseria gonorrhoeae (GC) – Treatment • copious irrigation • systemic ATB – ceftriaxone, cefixime, ciprofloxacin, ofloxacin • topical ATB – ciprofloxacin, erythromycin, gentamicin • concurrent chlamydial infection up to 33%  doxycycline, azithromycin
    • • Neisseria meningitidis – clinical almost identical to GC – younger, more bilateral – primary or secondary from septicemia, meningitis
    • • Neonatal GC conjunctivitis – 2-5 days after birth – Bilateral 75% – Serosanguinouspurulent discharge – No preauricular adenopathy – Rhinitis, proctitis, disseminated – Treatment-topical + systemic (cefotaxime, ceftriaxone)
    • Viral conjunctivitis– Benign, self limited, last longer than bacterial conjunctivitis– Almost all – acute follicular conjunctivitis, preauricular adenopathy
    • Epidemic keratoconjunctivitis(EKC)– Adenovirus serotype 8,11,19,37– Redness, FB sensation, tearing, photophobia– Bilateral > 50%– Lid swelling, conjunctival injection, watery discharge, follicles, preauricular adenopathy– Subconj hmg, membrane, pseudomembrane– Epithelial, subepithelial keratitis
    • EKC– Treatment • Prevent transmission • Supportive treatment – cold compress, topical artificial tear, topical vasoconstrictor – antihistamine,topical NSAID, topical steroid
    • Pharyngoconjunctival fever– Adenovirus serotype 3,4,7– Sign & symptom – same as EKC– Keratitis < EKC, mild– Pharyngitis, fever– Treatment – same as EKC
    • Acute hemorrhagic conjunctivitis – Picornavirus – enterovirus70, coxsackievirus A24 – Acute follicular conjunctivitis, subconjunctival hemorrhage – Keratitis < EKC, mild – Treatment – same as EKC
    • Chlamydial infection• Chlamydia trachomatis – obligate intracellular bacteria• Trachoma, adult inclusion conjunctivitis, neonatal inclusion conjunctivitis
    • • Trachoma – C.trachomatis serotype A-C – Poor hygiene – Repeated infection – Chronic follicular conjunctivitis  conjunctival and corneal scar – Preventable blindness
    • • MacCallan classification – Stage I incipient trachoma • Acute inflammation • Immature follicles – superior tarsal conj, fornices, limbus, semilunar fold • Minimal papillae • Epi-subepithelial keratitis, early pannus at superior cornea
    • – Stage II established trachoma IIa follicles predominant -mature follicles -keratitis and pannus more advanced IIb papillae predominant -florid inflammation -papillae at upper tarsal conj -keratitis and pannus more advanced -necrosis of follicles at limbus
    • – Stage III cicatrizing trachoma • Scar and cicatrization of conjunctiva and cornea • Limbal folliclesnecrosisscar (Herbert’s pit) • Upper tarsal conjunctivascar (Arlt’s line) • Cicatrization of lid and conjunctivatrichiasis, entropion, lid distortion, symblepharon • Pannus - grossly visible
    • – Stage IV healed trachoma • Inflammation subside • Lid complication and corneal opacity  visual impairment– Diagnosis • Conjunctival swab – Giemsa, Wright stain : intracytoplasmic inclusion body • Sign & symptom : at least 2 in 4 – Conjunctival follicles at UTC – Limbal follicles, Herbert’s pit – Typical conjunctival scar – Vascular pannus at superior cornea
    • – Treatment • Topical – tetracycline EO, erythromycin EO • Systemic – oral tetracycline, erythromycin • Surgery for lid complication
    • • Adult inclusion conjunctivitis – C.trachomatis serotype D-K – Oculogenital disease, sexual transmitted disease asso with urethritis, cervicitis – Direct, indirect contact with genital secretion, swimming pool, eye cosmetics – Subacute or acute follicular conjunctivitis – Scant mucopurulent discharge, follicles (lower>upper), preauricular adenopathy, keratitis, micropannus, no membrane, minimal scar – Treatment – topical +systemic ATB, sexual
    • • Neonatal inclusion conjunctivitis – C.trachomatis serotype D-K – 3-14 days after birth – Mucopurulent discharge, papillae, membrane, no preauricular adenopathy – Keratitis,pannus – Systemic infection- otitis media, rhinitis, vaginitis, pneumonia – Conjunctival scraping-Gram, Giemsa, Wright stain, C/S – Treatment- topical+systemic erythromycin, cotrimoxazole
    • Allergic conjunctivitis• Hay fever conjunctivitis – Type I hypersensitivity to airborne allergen, seasonal – Bilateral, itching, irritation, tearing – Lid edema, conjunctival injection, chemosis, papillae, mucoid discharge – Treatment – avoid allergen, cold compress, topical vasoconstrictor-antihistamine, topical NSAID, topical steroid, topical mast cell stabilizer, oral antihistamine
    • • Vernal keratoconjunctivitis – Type I and IV hypersensitivity – Male, children and young adult – Bilateral, 2 forms – Palpebral form – giant papillae at UTC, cobblestones – Limbal form – opalescent nodules at superior limbus – Horner-Trantas’ dots – degenerated Eo and epithelial cells – PEE, pannus, shield ulcer at superior cornea – Treatment – as hay fever, 2% cyclosporin ED, topical mucolytic, tear+CL in shield ulcer
    • • Atopic keratoconjunctivitis – Type I and IV hypersensitivity – Atopic dermatitis, infant and children – Blepharitis, smaller papillae at UTC and LTC, conjunctival scar at inferior fornix – PEE at inferior, marginal corneal ulcer, pannus, stromal opacity – Cataract – PSC, ASC – Treatment – same as VKC
    • • Contact lens induced conjunctivitis – Type IV hypersensitivity to CL, deposit on CL, repeated mechanical trauma from CL – Soft CL > RGP CL – Redness, itching, irritation, mucoid discharge, blurred vision – Papillae at UTC, limbal nodule, Trantas’ dot, keratitis, pannus, CL decentration – Treatment – resolve with off CL, improved lens hygiene, topical mast-cell stabilizer, topical steroid, refitting new CL(daily, disposable, RGP)
    • Adverse reaction to topical medication• Allergic reaction – Acute onset • Rare, type I • Within minutes  itching, lid erythema and swelling, chemosis, systemic anaphylaxis • Topical bacitracin, cephalosporin, penicillin, sulfacetamide, tetracycline, anesthetics • Treatment – withdraw medication, cold compress, lubricant, topical antihistamine or steroid
    • – Delayed onset • Type IV • Within 24-72 hrs • Contact blepharoconjunctivitis • Lid – acute eczema, erythema, scaling • Conjunctival injection, mucoid discharge, + papillae • Cornea – PEE at inferior • Topical atropine, homatropine, neomycin, penicillin, gentamicin, tobramycin, idoxuridine, trifluridine, natamycin, antazoline, epinephrine, thimerosal, EDTA • Treatment – withdraw medication, cold compress, topical antihistamine or steroid
    • • Toxic reaction (much more common than allergic reaction) – Toxic papillary conjunctivitis • Direct chemical irritation, long term use • Irritation, without itching • Conjunctival injection, papillae, mucopurulent discharge, PEE at inferior cornea • Topical aminoglycoside, antiviral, benzalkonium chloride • Treatment – withdraw medication, preservative free artificial tear
    • – Toxic follicular conjunctivitis • Long term use • Drug induced mitosis and lymphoblastic transformation of lymphocytes by nonimmunologic • Irritation without itching • Conjunctival injection, follicles at LTC, no discharge • PEE at inferior cornea • Topical atropine, homatropine, antiviral, glaucoma medication (epinephrine, dipivefrin, pilocarpine), sulfonamide • Treatment – withdraw medication, preservative free artificial tear
    • By Type of Discharges• Watery• Mucous• Purulent• Mucopurulent
    • By Age of onset• Neonatal Conjunctivitis• Adult Conjunctivitis
    • By Duration• Acute• Chronic
    • Acute conjunctivitis– Staph.aureus, H.aegyptius, H.influenzae, Strep.pneumoniae, Strep.pyogenes, P.aeruginosa, E.coli, C.piphtheriae– Duration< 3-4 wks– Conj injection, mucopurulent discharge, lid edema, FB sensation, tearing– Treatment- broad spectrum topical ATB
    • Chronic conjunctivitis– S.aureus, Branharnella catarrharis, E.coli, S.pyogenes, S.pneumoniae, Moraxella lacunata– >3-4 wks– Risk factor – lid malposition, dry eye, chronic dacryocystitis, poor hygiene, eye prosthesis, topical steroid– Mild and nonspecific symptom
    • conjunctivitis• Bacterial - most common in children• Viral - most common in adults• Allergic - bilateral, frequently c/o ‘itch’
    • bacterial conjunctivitis• Signs: – Discharge - purulent vs mucopurulent
    • Question• What type of neonatal conjunctivitis occurs on the first day?
    • Pitfalls: Adult Conjunctivitis• Adult Hyperacute Conjunctivitis – Gonococcus – Signs/symptoms of severe infection – Rapid onset• Chlamydial Conjunctivitis – Sexually active adolescents/adults – Unilateral, Follicular reaction – Chronic (>3 weeks) – Microtrak – Oral Tetracyclin
    • bacterial conjunctivitis• Usually self limited• Treatment necessary? – Limits spread – Shortens course – Patient comfort – Prevents recurrence – Prevents chronic staph conjunctivitis
    • bacterial conjunctivitis therapy• Choice of antibiotic depends on other factors: – Polysporin • no prescription required – Polytrim • Low cost • Well tolerated – Fucithalmic • BID dosing
    • Pitfalls in Treatment• Avoid – Gentamicin • Epithelial toxicity – Steroid containing solutions – Garasone – Tobradex – Blephamide • Increase IOP, Cataract • Geographic Herpes • Worsen Infection • Corneal Spread – Frequent switching of drops
    • Viral Conjunctivitis• History: Infectious Contacts, URTI, Drops/Drugs• Etiology: Adenovirus• Treatment: No specific therapy – Cool compresses, artificial tears, infectious precautions
    • Allergic Conjunctivitis• Symptoms: ITCHING• Signs: mild redness, conjunctival chemosis, watery discharge, papillary hypertrophy• Treatment: cold compress, antihistamines, non-steroidal drops, mast cell stabilizers, topical corticosteroids
    • Subconjunctival Hg• What is the appropriate management of a large subconjunctival hemorrhage – A) Stop any anticoagulation and observe for improvement – B) Observe. If no resolution in 1-2 weeks refer to ophthalmology – C) Observation only – D) If large, refer to ophthalmology
    • Subconjunctival Hemorrhage
    • 28-Typical conjunctival hyperemia
    • 29- Typical conjunctival hyperemia
    • Typical conjunctival hyperemia• C h a r a c t e r s :- 1- Vasodilatation of posterior Conjunctival vessels. 2- Bright red in color . 3- Maximum in fornices . 4- Move with movement of conjunctiva . 5- Usually associated with discharge (important)• E t io l o g y & Dif f e r e n t t y p e s o f c o n j u n c t iv it is : 1- MPC 2- PC 3- Ophtalmia neonatorum .
    • 30- Ophthalmia neonatorum
    • Ophthalmia neonatorum• C a u s a t iv e o r g a n is m : 1- Chlamydia oculogenitalis ( 80 % ) . 2- Gonococci ( 20 % ) . (1, 2 are most common & Acquired during passage in birth canal) 3- Other bacterial hospital infection e . staph , strept E.coli . 4- Viral infection ( Herpes genitalis ) . 5- Chemical kerato conjunctivitis e.g. silver nitrate .• S ig n s : 1- Marked lid edema . 2- Yellow profuse purulent discharge ( Blanorrhea ) . 3- Preauricular + submandibular lymphadenitis .• M o s t s e r io u s c o mp l ic a t io n : 1- Secondary corneal ulcer usually central with perforation . 2- Dense corneal opacity Defective macular development (amblyopia) Nystagmus  If unilateral Squint . 3- Anterior polar cataract . 4- Endophthalmitis & panophthalmitis .
    • Ophthalmia neonatorum• D.D: 1- Congenital NLD obstruction ( Congenital Dacrocystitis ). 2- ? May be Buphthalmos .• TTT: 1- prophylactic: 1- Proper antenatal care 2- Treatment of any maternal infection. 3- Anti - septic delivery . 4- Broad spectrum local eye lotion . 2- Active : 1- Hot fomentation , Boric eye lotion . 2- If Chlamydia  Local acid eye lotion  Erythromycin . 3- If gonococcal  Local penicillin  Examine parents . 4- Cycoplegic( Atropine ) If cornea is affected . 5- Systemic Broad spectrum antibiotic ( by pediatrician ) .• De f in e t h is c o n d it io n : It is any form of conjunctivitis occurring in first 10 days after birth , it is preventable & acquired during delivery .
    • 31- Mucopurulent conjunctivitis
    • Mucopurulent conjunctivitis• C a u s a t iv e o r g a n is m : 1- Koch - weeks bacilli ( Heamophillus egypticus ) . 2- Staph & Strept . 3- Pneomococci .• C / O : Redness + discharge + Burning sensation + lid swelling + Halos around light .• C o mp l ic a t io n : 1- Secondary corneal ulcer usually central with perforation . 2- Dense corneal opacity ( scar ) :defective macular development(Amblyopia) Nystagmus. If unilateral  squint . 3- Panophalmitis & Endophthalmitis . 4- Anterior polar cataract . 5- Chronicity .
    • Mucopurulent conjunctivitis• D.D: 1-Halos around light :1- Incipient stage of immature senile cortical cataract .2- ACG .3- Corneal edema . 2- Glued lashes  Ulcerative blepharitis . 3- Red eye  IC , CU , ACG , Scleritis , Episcleritis .• T T T :- 1- Boric acid lotion 2 - 4 % . 2- Hot fomentation & Dark glasses . 3- Local antibiotics : 1- Chlaramphenicol eye drops . 2- Tetracycline ointment at night . 3- Sulfonamide eye drops , if no pus . 4- Systemic antibiotics  severe cases . 5- Atropine ointment  if cornea is affected .
    • 32- Follicular conjunctivitis
    • Follicular conjunctivitis• D.D:1- Viral infectionAdenovirusEpidemic kerotoconjunctivitia- Pharyngeo - conjunctival fever Herpes simplex Herpetic conjunctivitis .2- Chlamydia oculogenitatis [ Inclusion blenorrhea[3- Acute trachoma in foreigners.4-Allergic , due to chronic medication [Drug induced e.g. + Atropine + eserine]5- Folliculosis.• C a u s a t iv e o r g a n is m:1- Adenovirus . 2-Herpes S. Virus.3- Chlamydia oculogenitatis. 4- Chronic use of drugs• TTT :1- Decongestant. 2- Removal of the cause.
    • 33- Acute trachomatous follicles & papillae
    • Acute trachomatous follicles & papillae• C a u s a t iv e o r g a n is m: 1- Chlamydia Trachomatous serotypes A.B.C.• C / O: Gritty sandy sensation, scanty MP discharge Redness + Heaviness of lids .• C o mp l ic a t io n s :Eye lid 1- Trichiasis [Multiple] 2- Ptosis. 3- Cicatricial entropion.Conj. 1- Xerosis. 2- Posterior symblepharon. 3- Corneal: Ulcers & opacities. 4- Lacrimal : Fibrosis of NLD  Dacrocystitis & Epiphora• TTT: 1- Boric acid lotion wash. 2- Local & systemic Sulfonamides[ sulphacetomide eye drops10-30%] . 3- Local & systemic Tetracycline [Ointment at night] 4- In sensitive cases  Chloromphenicot 0.4 % eye drops. 5- Atropine  If cornea affected .
    • 34- Acute trachomatous follicles & papillae + pannus
    • 35- Acute trachomatous follicles & papillae + pannus
    • 36- Acute trachomatous follicles & papillae + pannus
    • Acute trachomatous follicles & papillae + pannusSee previous comment (no. 33)
    • 37- Active trachomatous pannus
    • 38- Active trachomatous pannus
    • 39- Active trachomatous pannus
    • Active trachomatous pannus• De f in e : Sub epithelial infiltration with inflammatory cells + vasculariztion of corneal margin, usually limited to upper half of cornea .• D.D.: 1- Trachomatous. 2-Phlyctenutar. 3- Leprotic. 4- Degenerative [Atrophia bulbi & Absolute Glaucoma] 5- Mechanical [Rubbing lashes]• Fat e: 1- Complete resolution , If B.M. is intact. 2- C. opacity, if B,M. is destroyed. 3- Kertectasia [Bulging forwards of cornea]• TTT; S e e p r e v io u s s l id e
    • Active trachomatous pannus• C o a r s e o f t r a c h o ma t o u s pannus : 1- Progressive. 2- Regressive. 3- Healed• T y p e s o f t r a c h o mo t o u s pannus : 1- P. Tenius (Thin P) 2- P. Vasculosus (vascular P) 3- P. Annulosus (rounded P) 4- P. Carnosus (Fleshy P)
    • 41- Herbert’s pits (festooned cornea)
    • 42- Scarred palpebral conjunctivitis
    • Scarred palpebral conjunctivitis• M o s t c o mmo n c a u s e : Trachoma• Ca u s e s : 1- Trachoma. 2- Membranous conjunctivitis. 3- Chemical injures. 4- Steven - Johnsons syndrome.• T wo C o mp l ic a t io n s : 1- Cicatricial entropion Trichiasis. 2- Xerosis + Posterior symblepharon.
    • 43- Membranous conjunctivitis
    • Membranous conjunctivitis• C a u s a t iv e o r g . o r D.D.: 1- Diphtheria bacilli. [Diphtheria until proved other wise . 2- Viral [Severe Adenoviral infection]. 3- Chemical Burns & caustics . 4- Fungal conj. 5- Severe pneumococca! Conj.• S p e c if ic c o mp l ic a t io n : 1- General: 1- Toxic myocarditis , Nephropathy, Nephritis , Neuritis , Neuropathy. 2- Local: 1- Central & marginal C.Ulcer. 2- Xerosis . 3- Entropion Trichiasis 4- Symblepharon 5- Fibrosis of lacrimal duct 6- Optic neuritis + Squint d.t. cranial n. affection• S p e c if ic T T T : l- Anti- toxic serum . 2-Penicillin systemic & local .• I nvestigations: 1-Culture & sensitivity from membrane 2- Blood culture .
    • Membranous conjunctivitis• S p e c if ic l in e s o f T T T : 1- Prophylactic 1- Mass immunization . 2- Isolation of patient + Notify health office . 3- Prophylactic anti serum for contacts. 4- Prophylactic antibiotic in other eye. 2-Curative 1- Complete bed rest to avoid heart failure. 2- Antitoxin serum. 3- Local & systemic penicillin. 4- Guard against symblepharon (ointment).
    • 44- Posterior symblepharon
    • Posterior symblepharon• C / O: 1- Binocular diplopia [d.t. limitation of movement ] 2- Symptoms of lagophthalmos: Redness, burning sensation , dryness. 3- Cosmetic disfigurement.• Ca u s e s : 1- Healed Trachoma (post). 2- Chemical burns (ant). 3- Diphtheritic conj. {Membranous conj} (ant.) 4- Postoperative after ptregium surgery [after recurrent excision] (ant.).
    • Posterior symblepharon• C o mp l ic a t io n s :1- Binocular diplopia.2- Complications of lagophthalmos.3- Conj.: 1- Conj. Ulcers & keratinization . 2- Chronic conjunctivitis .4- Corneal: 1- C.U. & keratinization. 2- Exposure keratitis & Vasculariztion.• TTT: 1) Management of lagophthalmos. 2) Excision of fibrous tissue with gloss rod or artificial conjunctiva! Shell . 3) Mucous membrane graft . 4) TTT of the cause .
    • 45- Phlyctenular keratoconjunctivitis (limbal phlycten)
    • 46- Phlyctenular keratoconjunctivitis (V. important)
    • Phlyctenular keratoconjunctivitis• E t io l o g y : Type IV Hypersensitivity reaction [cell mediated I-R.] d.t. endogenous Toxins [Antigens]:- e.g. T.B. focus. Tonsillitis. Septic focus of Staph Intestinal parasites , Ulcerative Blepharitis• A s s o c ia t e d d is e a s e : T.B. ,Tonsillitis,.....etc• C o mp l ic a t io n s : 1- Recurrence, if the cause is not treated. 2- Limbal c.u. 3- Secondary infection by staph. MPC. 4- Phlyctenular pannus.
    • Phlyctenular keratoconjunctivitis• D .D 1- Conj. Phlycten:1- Pinguicuia .2- Episcleritis [Nodular] 2- Limbal Phlycten [in slide no. 45] 3- Limbal [bulbar] spring catarrh• TTT : l- Topical steroids. 2- TTT of septic focus [cause]. 3- Local Antibiotic, for secondary infection 4- (IN Slide no. 45) Cyctoplegic [Atropine]  if Keratoconjunctivitis .
    • 47- Palperal spring catarrh
    • 48- Palperal spring catarrh
    • 49- Palperal spring catarrh
    • 50- Palperal spring catarrh
    • Palperal spring catarrh• E t io l o g y : Atopy type I hypersensitivity reaction d.t. exogenous antigen (↑ IgE) .• Commonest presentation: Bilateral , recurrent , seasonal attacks of itching & ropy discharge + lacrimation .• Ot h e r c l in ic a l t y p e s y o u k n o w ; 1- Bulbar S.catarrh 2- Mixed type.• C o mp l ic a t io n s : 1-Corneal: 1- Keratitis superficialis vernalis of Tobgy. 2- Corneal plaques . 3- Arcus senilis like opacity (Cupids bow) . 4- Weakness of cornea  increase incidence of Keratoconus A keratectasia . 2- Comp. of prolonged use of steroids: 1- Sec. Glaucoma 2- Complicated cataract 3- Viral infection reactivation
    • Palperal spring catarrh• S a f e s t d r u g u s e d f o r l o n g t ime f o r t h is p a t ie n t : Local decongestant .• S a f e s t TTT: 1- Dark glasses & cold fomentations [ compresses] (Most effective). 2- Local decongestant & local Antihistaminics. 3- Local Disodium Cromoalycate . [DONT MENTTON STEROIDS]• T T T : 1,2,3, as before. + 4-Steroids in severe cases . 5- B-irradiation or cryo on papillae in resistant cases.• D.D. o f s p r in g c a t a r r h : 1-Trachomo. 2- MP & PC.• D.D. o f Gia n t p a p il l a r y c o n j u n c t iv it is : 1- Advanced Spring catarrh. 2- CL users. 3- Protruding stitches.
    • 51- Bulbar spring catarrh
    • Bulbar spring catarrh• See previous comment :
    • 52- Corneal plaque in spring catarrh
    • Corneal plaque in spring catarrh• Ca u s e : Corneal affection in spring catarrh .• Pat hol og y : Large micro erosions in corneal epithelium with deposition [covered with mucin]  Resistant Corneal ulcer .• TTT : As spring catarrh + Cycloplegic (Atropin) .
    • 53- Argyrosis (important)
    • Argyrosis (important)• E t io l o g y : 1- Prolonged repeated painting [using] Silver Nitrate  deposits in elastic tissue of conjunctiva [walls of B.V] 2- Occupational .
    • 54- Subconjunctival hemorrhage
    • Subconjunctival hemorrhage• M a n a g e me n t : Self limiting condition , needs no TTT [Reassurance of patient]• Ca u s e s : 1- Spontaneous. 2- Blunt trauma. 3- Excessive straining as whooping cough. 4- Hemorrhagic blood diseases. 5- Vascular diseases e.g. Diabetes A hypertension . 6- Conjunctivitis . [USUALLY THE Q IS MENTION 3 CAUSES]
    • 55- True pterygium (progressive)
    • True pterygium (progressive)• E t io l o g y : Degenerative disease of cornea & conjunctiva d.t. exposure to UV rays , heat , dust , irritative chemical fumes , dry sunny environment .• C / O : Cosmetic disfigurement Drop of vision  if irregular astigmatism .  if affecting central area of cornea.• C o mp l ic a t io n : 1- Recurrence , after excision (v. Common). 2- Repeated excisions: 1- Anterior symblepharon. 2- Cornea! thinning & opacity.• T T T : Surgical removal: 1- Excision e bare scleral technique. 2- Excision e lamellar KP. 3- Tucking. 4- Rotation island operation . Followed by Beta irradiation ( 3000-6000 rods over 3-5 days ) . 5- Conjunctival graft .
    • 56- Bitot spots in case of xerosis (important)
    • Bitot spots in case of xerosis• E t io l o g y : Abnormal activity of Meibomian gland [mucin deficiency] & gas formation by proliferation of Xerosis bacilli.• Ca u s e s : 1- Trachoma. 2- Chemical burns . 3- Repeated removal of pterygium. 4- Lagophthalmos. 5- Diphtheria.• S p e c if ic t e s t : Fluorescine break up time testTTT : 1- Scraping [removal of Bitot spots] . 2- Artificial tears [ Methyl cellulose eye drops 1% . 3- Vit A .
    • 57- Loss of corneal luster in cases of xerosis
    • Loss of corneal luster in cases of xerosis• C a u s e s : 1-Conjunctival scarring & fibrosis d.t.: 1- Healed Trachoma . 2- Chemical burns . 3- Diphtheria Membranous conj . 2- Lagophthalmos. 3- Vit A deficiency. 4- Sjorens syndrome . ( 1& 2 are common causes --- 3 is less common )• E t io l o a y : Mucin deficiency d.t. destruction of Goblet cells .• . C / 0 : Burning & gritty sensation + redness + Discharge• C o mp l ic a t io n s : l-Corneal ulcers, keratinization . 2- Conjunctival ulcers, kera+inizotion . Sp. Test: Fluorescine break up time test [ Normally l5-35sec, if less diagnostic ]• T T T o f c h o ic e : 1- Artificial tears [ Methyl cellulose eye drops 17o . 2- Therapeutic CL of high water content . 3- Ointment at night + Vit A .
    • NON-INFLAMMATORY• Pinguecula• Pterygium• Pseudopterygium• Nevus• Melanosis
    • PINGUECULA• It is a deposition of hyaline substance in the bulbar conjuctiva
    • Pinguecula• Elastotic degeneration of collagen at bulbar conjunctiva• Yellow-white conjunctival nodule at interpalpebral zone• Tearing, irritation, photophobia• Treatment –topical vasoconstrictor-antihistamine, topical steroid
    • Pterygium• Elastosis of collagen with subepithelial fibrovascular tissue at bulbar conjunctiva• Interpalpebral zone• Tearing, irritation, photophobia, blurred vision
    • Pterygium
    • Pterygium
    • Pterygium• Treatment – Medication – as pinguecula – Surgery – blurred vision, chronic inflammation, cosmetic
    • Molluscum contagiosum– DNA poxvirus– Elevated pearly umbilicated nodule near lid margin– Chronic follicular conjunctivitis– Treatment – curettage,complete excision, freezing (self limited-months, years)