8. PTERYGIUM
Pterygium derives it name from the latin word
Pterygion meaning a wing.
Pterygium is wing shaped fold of conjunctiva
encroaching upon the cornea from either side
within the inter palpebral fissure.
Etiology is not exactly known however it is usually seen in-
• People living in hot climates
• People working in sunny, dusty or sandy atmosphere
• Mostly in workers
Etiology
9. Parts:
It consists of three parts
Head (apical part): Present on the
cornea
Neck (limbal part): It is narrow
part near limbus.
Body (Scleral part): Extending
between limbus and the canthus.
10.
11. Type of pterygium
Depending upon the progression it may be of 2
types:
Progressive pterygium
• It is thick, fleshy and vascular with a few
infiltrates in the cornea, in front of the head
of the pterygium (called cap of pterygium).
Regressive pterygium
• It is thin, atrophic, attenuated with very little
vascularity. There is no cap. Ultimately it
becomes membranous but never disappears.
12. Corneal epithelium, Bowman's layer and superficial stroma are destroyed
Pathology
pterygium is a degenerative and hyperplastic condition of
conjunctiva
The subconjunctival tissue undergoes elastotic degeneration
and proliferates as vascularised granulation tissue under the
epithelium,
which ultimately encroaches the cornea
13. Symptoms
• It is usually symptomless.
• There is cosmetic disfigurement.
• Visual disturbances occur when it encroaches the pupillary area.
• Occasionally diplopia due to limitation of ocular movement.
• Triangular encroachment of the conjunctiva on the cornea.
Signs
14.
15. DIFFERENTIAL DIAGNOSIS
Characters Pterygium Pseudopterygium
Age More common
in older age
group
May be seen in any
group
Laterality Bilateral Mostly unilateral
Stages Either
progressive or
stationary
Always stationary
Limbal relation Adhered to
limbus
No adhered
16. TREATMENT
No treatment is required unless it is progressing towards the
pupillary area.
Surgical excision is the only satisfactory treatment, which may be
indicated for:
• Cosmetic reasons
• continued progression threatening to encroach onto the pupillary area
• diplopia due to interference in ocular movements.
17. Recurrence of the pterygium after surgical excision is the
main problem (30-50%).it can be reduced by any of the
following measures:
Transplantation of pterygium in the lower fornix
(McReynold's operation) is not performed now.
Postoperative beta irradiations (not used now).
Postoperative use of antimitotic drugs such as mitomycin-
C or thiotepa.
Surgical excision with bare sclera.
Surgical excision with free conjunctival graft taken from
the same eye or other eye is presently the preferred
technique.
In recurrent recalcitrant pterygium, surgical excision
should be coupled with lamellar keratectomy and lamellar
keratoplasty
19. Ecchymosis or subconjunctival haemorrhage is of very common
occurrence.
It may vary in extent from small petechial haemorrhage to an extensive
one spreading under the whole of the bulbar conjunctiva and thus
making the white sclera of the eye invisible.
The condition though draws the attention of the patients immediately
as an emergency but is most of the time trivial.
SUBCONJUNCTIVAL HAEMORRHAGE
Etiology. :
1. Trauma.
It is the most common cause of subconjunctival haemorrhage
(i) local trauma - surgery /subconjunctival injections,
(ii)retrobulbar haemorrhage which almost immediately spreads below the
bulbar conjunctiva. Mostly, it results from a retrobulbar injection and
trauma involving various walls of the orbit.
20. 2. Inflammations of the conjunctiva.
• Petechial subconjunctival haemorrhages are usually associated with acute
haemorrhagic conjunctivitis
4. Spontaneous rupture of fragile capillaries
occur in vascular diseases such as arteriosclerosis, hypertension and diabetes mellitus.
5. Local vascular anomalies
telengiectasia,varicosities, aneurysm or angiomatous tumour.
6. Blood dyscrasias
like anaemias, leukaemias
7. Bleeding disorders
haemophilia and scurvy.
3. Sudden venous congestion of head.
• rupture of conjunctival capillaries due to sudden rise in pressure.
• Common conditions are whooping cough, epileptic fits, strangulation
and violent compression of thorax and abdomen as seen in crush injuries.
21. Clinical features.
• Subconjunctival haemorrhage usually symptomless.
• symptoms of associated causative disease.
On examination
• looks as a flat sheet of homogeneous bright red colour with well defined limits
• In traumatic -posterior limit is visible when it is due to local trauma to eyeball, and
not visible when it is due to head injury or injury to the orbit.
Treatment.
• Most of the time it is absorbed completely within 7 to 21 days. During absorption
colour changes are noted from bright red to orange and then yellow.
Treat the cause when discovered.
Placebo therapy with astringent eye drops.
Psychotherapy and assurance to the patient is most important part of treatment.
(iv) Cold compresses
23. Pinguecula is an extremely common degenerative condition of the conjunctiva.
It is characterized by formation of a yellowish white patch on the bulbar
conjunctiva near the limbus.
This condition is termed pinguecula, because of its resemblance to fat, which
means pinguis.
Etiology
Not known exactly.
It has been considered as an age-change, occurring more commonly in persons
exposed to strong sunlight, dust and wind.
It is also considered a precursor of pterygium.
PINGUECULA
24. • bilateral, usually stationary condition, presenting as yellowish white triangular patch
near the limbus.
• Apex of the triangle is away from the cornea.
• It affects the nasal side first and then the temporal side.
Pathology.
• elastotic degeneration of collagen fibres of the substantia propria of
conjunctiva,
• deposition of amorphous hyaline material in the substance of
conjunctiva
Clinical features
Complications –
• inflammation, intraepithelial abscess ,pterygium
Treatment.
• In routine no treatment is required for pinguecula.
• excised
26. They term xerophthalmia is now reserved (by a joint WHO and USAID
Committee, 1976) to cover all the ocular manifestations of vitamin A deficiency,
including not only the structural changes affecting the conjunctiva, cornea and
occasionally retina, but also the biophysical disorders of retinal rods and cones
functions.
XEROPHTHALMIA
dietary deficiency of vitamin A
defective absorption of vitamin A from the gut.
protein-energy malnutrition (PEM) and infection
Etiology
27. WHO classification (1982)
XN Night blindness
X1A Conjunctival xerosis
X1B Bitot’s spots
X2 Corneal xerosis
X3A Corneal ulceration/keratomalacia affecting
less than one-third corneal surface
X3B Corneal ulceration/keratomalacia affecting
more than one-third corneal surface.
XS Corneal scar due to xerophthalmia
XF Xerophthalmic fundus.
28. 1. X N (night blindness).
• It is the earliest symptom of xerophthalmia in children.
• It has to be elicited by taking detailed history from the guardian or relative.
2. X1A (conjunctival xerosis).
• It consists of one or more patches of dry, lustreless, non wettable conjunctiva,
• described as ‘emerging like sand banks at receding tide’ when the child ceases to
cry.
• In more advanced cases, the entire bulbar conjunctiva may be affected.
• Typical xerosis may be associated with conjunctival thickening, wrinkling and
pigmentation.
Clinical features
29. 3. X1B (Bitot’s spots).
• It is an extension of the xerotic process seen in stage X1A.
• The Bitot’s spot is a raised, silvery white, foamy, triangular patch of keratinised
epithelium, situated on the bulbar conjunctiva.
• It is usually bilateral and temporal, and less frequently nasal.
4. X2 (corneal xerosis).
• The earliest change in the cornea is punctate keratopathy which begins in the lower
nasal quadrant, followed by haziness and/or granular pebbly dryness ,Involved
cornea lacks lustre
5. X3A and X3B (corneal ulceration/keratomalacia),
• Stromal defects occur in the late stage due to colliquative necrosis and take several
forms.
• Small ulcers (1-3 mm) occur peripherally and Large ulcers extend centrally or involve
the entire cornea.
• stromal defects involving less than one-third of corneal surface (X3A) usually heal,
• larger stromal defects (X3B) commonly result in blindness.
30. 6. XS (corneal scars).
• Healing of stromal defects results in corneal scars
of different densities and sizes
• which may or may not cover the pupillary area .
7. XFC (Xerophthalmic fundus).
• It is characterized by typical seed-like, raised,
whitish lesions scattered uniformly over the part
of the fundus at the level of optic disc .
31. 1. Local ocular therapy.
For conjunctival xerosis artificial tears instilled every 3-4 hours.
In the stage of keratomalacia, full-fledged treatment of bacterial corneal ulcer
should be instituted
Treatment
2. Vitamin A therapy.
• All patients above the age of 1 year (except women of reproductive age):
200,000 IU of vitamin A orally or 100,000 IU by intramuscular injection
• Children under the age of 1 year and children of any age who weigh less
than 8 kg should be treated with half the doses for patients of more than 1
year of age.
• Women of reproductive age, pregnant or not: treated with a daily dose of 10,000 IU of
vitamin A orally (1 sugar coated tablet) for 2 weeks.
3.Treatment of underlying conditions
such as PEM and other nutritional disorders, diarrhoea, dehydration and electrolyte
imbalance, infections and parasitic conditions should be considered
33. Scleritis refers to a chronic inflammation of the sclera proper.
It is a comparatively serious disease which may cause visual impairment
and even loss of the eye if treated inadequately.
its incidence is much less than that of episcleritis.
It usually occurs in elderly patients (40-70 years)
affected females more than the males.
SCLERITIS
Etiology
• It is found in association with multiple conditions
1. Autoimmune collagen disorders,
• Especially rheumatoid arthritis, is the most common association. Overall about
5% cases of scleritis are associated with some connective tissue disease
2. Metabolic disorders
• gout and thyrotoxicosis
34. 3. Some infections,
• particularly herpes zoster ophthalmicus, chronic staphylococcal and
streptococcal infection have also been known to cause scleritis.
4. Granulomatous diseases
• like tuberculosis, syphilis, sarcoidosis, leprosy can also cause scleritis.
5. Miscellaneous conditions
• like irradiation, chemical burns, Vogt-Koyanagi-Harada syndrome,
Behcet’s disease and rosacea
6. Surgically induced scleritis
• follows ocular surgery. It occurs within 6 month postoperatively.
Exact mechanism not known,
7. Idiopathic. In many cases cause of scleritis is unknown.
35. Classification
It can be classified as follows:
I. Anterior scleritis (98%)
Non-necrotizing scleritis (85%)
2. Necrotizing scleritis (13%)
II. Posterior scleritis (2%)
(a)Diffuse
(b) Nodular
(a)with inflammation
(b) without inflammation
(scleromalacia perforans)
36. Patients complain of moderate to severe pain which is deep and boring in
character
wakes the patient early in the morning .
Ocular pain radiates to the jaw and temple.
It is associated with localised or diffuse redness, mild to severe photophobia
and lacrimation. Occasionally there occurs diminution of vision.
Clinical features
Symptoms
Signs.
1. Non-necrotizing anterior diffuse scleritis.
It is the commonest variety, characterised by
widespread inflammation involving a quadrant or more
of the anterior sclera. The involved area is raised and
salmon pink to purple in colour
37. 2. Non-necrotizing anterior nodular scleritis.
It is characterised by one or two hard, purplish elevated
scleral nodules, usually situated near the limbus
Sometimes, the nodules are arranged in a ring around the
limbus (annular scleritis).
3. Anterior necrotizing scleritis with inflammation.
It is an acute severe form of scleritis characterised by
intense localised inflammation associated with areas of
infarction due to vasculitis.
The affected necrosed area is thinned out and sclera
becomes transparent and ectatic with uveal tissue
shining through it.
38. typically occurs in elderly females usually suffering
from long-standing rheumatoid arthritis.
It is characterized by development of yellowish patch of
melting sclera (due to obliteration of arterial supply)
which often together with the overlying episclera and
conjunctiva completely separates from the surrounding
normal sclera. This sequestrum of sclera becomes dead
white in colour, which eventually absorbs leaving
behind it a large punched out area of thin sclera through
which the uveal tissue shines.
Spontaneous perforation is extremely rar
4. Anterior necrotizing scleritis without inflammation (scleromalacia perforans)
39. 5. Posterior scleritis.
It is an inflammation involving the sclera behind the equator.
The condition is frequently misdiagnosed.
It is characterised by features of associated inflammation of adjacent structures,
which include: exudative retinal detachment, macular oedema, proptosis and
limitation of ocular movements.
TLC, DLC and ESR
Serum levels of complement (C3), immune complexes, rheumatoid factor,
antinuclear antibodies and L.E cells for an immunological survey.
FTA - ABS, VDRL for syphilis.
Serum uric acid for gout.
Urine analysis.
Mantoux test.
X-rays of chest, paranasal sinuses, sacroiliac joint and orbit to rule out foreign body
especially in patients with nodular scleritis.
Investigations
40. (A) Non-necrotising scleritis.
It is treated by topical steroid eyedrops and systemic indomethacin 100 mg daily
for a day and then 75 mg daily until inflammation resolves.
(B) Necrotising scleritis.
• It is treated by topical steroids and heavy doses of oral steroids tapered slowly.
• In non-responsive cases, immuno-suppressive agents like methotrexate or
cyclophos-phamide
• Subconjunctival steroids are contraindicated because they may lead to scleral
thinning and perforation.
Treatment
41. स्िान
दोष –
लक्षण
शुक्लस्िाैः ससतसपिकाैः ससरावृता यास्ता सवद्यादससत
सर्ीपजाैः ससराजाैः
सिसकत्सा
छे दन साध्य –
ससरासु सपिका जाता या न ससध्यक्ति भेषजैैः |
अर्मवन्ण्डलाग्रेण तासां छे दनसर्ष्यते
शंखािनजन
सशरापीसिका
42. Episcleritis is benign recurrent inflammation of the episclera, involving
the overlying Tenon’s capsule but not the underlying sclera.
It typically affects young adults, being twice as common in women than
men.
EPISCLERITIS
Exact etiology is not known.
It is found in association with gout, rosacea and psoriasis.
It has also been considered a hypersensitivity reaction to
endogenous tubercular or streptococcal toxins.
Etiology
43. Episcleritis is characterised by redness, mild ocular discomfort
described as gritty, burning or foreign body sensation.
Rarely, mild photophobia and lacrimation may occur.
Clinical picture
Symptoms.
On examination two clinical types of episcleritis, diffuse
(simple) and nodular.
Episclera is seen acutely inflamed in the involved area.
• In diffuse episcleritis,
although whole eye may be involved to some extent, the
maximum inflammation is confined to one or two quadrants
• In nodular episcleritis,
a pink or purple flat nodule surrounded by injection is seen,
usually situated 2-3 mm away from the limbus
Signs.
44. Differential diagnosis
• Occasionally episcleritis may be confused with inflamed pinguecula,
• swelling and congestion due to foreign body lodged in bulbar
conjunctiva and very rarely with scleritis.
1. Topical corticosteroid eyedrops
• instilled 2-3 hourly, render the eye more comfortable and resolve the
episcleritis within a few days.
2. Cold compresses
• applied to the closed lids may offer symptomatic relief from ocular
discomfort.
3. Systemic non-steroidal anti-inflammatory drugs
• flurbiprofen (300 mg OD),
• indomethacin (25 mg three times a day)
• oxyphenbutazone
Treatment
45. स्िान
दोष – कफज
लक्षण
कांस्याभो भवसत ससतेऽिुसबनदुतुल्यैः स ञेयोऽर्ृदुर
रुजो बलासकाख्यैः
सिसकत्सा
अशस्त्रक
ृ त – औषि् साध्य
संशोिन – वर्न सवरेिन से
क्षारानजन – नील यव क्षार
बलासग्रसित
46. CYSTS OF CONJUNCTIVA
The common cystic lesions of the conjunctiva are:
These are of rare occurrence and include congenital corneoscleral cyst
and cystic form of epibulbar dermoid.
Congenital cystic lesions
Lymphatic cysts of conjunctiva.
These are common and usually occur due to dilatation of lymph
spaces in the bulbar conjunctiva.
Lymphangiectasis is characterized by a row of small cysts.
Rarely, lymphangioma may occur as a single multilocular cyst.
47. It may develop following implantation of conjunctival epithelium in the
deeper layers, due to surgical or non-surgical injuries of conjunctiva
Retention cysts.
These occur occasionally due to blockage of ducts of accessory lacrimal
glands of Krause in chronic inflammatory conditions, viz., trachoma and
pemphigus.
Retention cysts are more common in upper fornix.
Epithelial implantation cyst (traumatic cyst).
48. subconjunctival cysticercus. hydatid cyst and
filarial
cyst are not infrequent in developing countries
Parasitic cysts
