This document discusses conjunctival disorders and conjunctivitis. It begins by defining the conjunctiva and its functions. Common symptoms of conjunctival problems include redness, irritation, tearing, itching and pain. Assessment of the conjunctiva involves visual examination of redness, discharge, papillae and follicles. Conjunctivitis is inflammation of the conjunctiva and can be caused by bacterial, viral, allergic or other inflammatory processes. Common types discussed are acute bacterial conjunctivitis, viral follicular conjunctivitis and pharyngio-conjunctival fever caused by adenovirus. Treatment depends on cause but may include antibiotics, cold compresses and artificial tears.

1. CONJUNCTIVAL DISORDERS
By DR EKI OGHRE
DEPARTMENT OF OPTOMETRY,
UNIVERSITY OF BENIN, BENIN CITY

2. CONJUNCTIVA
 A thin translucent membrane that attaches
the eyelid to the eyeball
 It lines the eyelid. It is reflected at the upper
and lower fornices onto the anterior surface
of the eyeball
 It fuses with the cornea along the
conjunctival limbus.
 The conjunctiva is a highly vascular
membrane

5. SYMPTOMS IN CONJUNCTIVAL PROBLEMS
 Redness
 Irritation
 Epiphora (tearing).
 Itching
 Pain - this is generally mild.
 Discharge.

6. ASSESSMENT OF THE CONJUNCTIVA
There are 3 components
1, Visual assessment
 Conjunctival reaction ( pattern and degree of redness)
 Mild/Severe
 Diffuse/ local
 Ingestion or haemorrhage
 Discharge.
 Watery/purulent
 Presence of follicles or papillae - distinguishing one from the
other can be tricky and both can occur together.
 Papillae - occur in allergic, bacterial and gonococcal conjunctivitis.
They are formed when the conjunctival inflammation is effectively
limited by fibrous septa, so giving rise to the appearance of vascular
bulges. Generally found on the upper tarsal conjunctiva, they can
coalesce to form giant (cobblestone) papillae.
 Follicles - are more often associated with viral conjunctivitis. They
are lymphoid collections and are raised gelatinous pale bumps
(resembling small grains of rice). They tend to occur on the lower
tarsal conjunctiva and along the upper tarsal border.

7.  Oedema (chemosis) - translucent swelling of
the conjunctiva
 Scarring this may occur as a result of
trachoma, ocular cicatricial pemphigoid,
atopic conjunctivitis or prolonged use of
topical medication.

8. OTHER ASSESSMENTS
2. Look for what you can not see.
 Evert the lids - foreign bodies and lesions
 Stain with fluorescein - a small conjunctival
laceration may well show up
 Swab - in the case of severe, purulent
conjunctivitis,

9. 3.Examine structures other than the
conjunctiva , ask about symptoms
 Assess visual acuities and cornea.
 Assess for associated blepharitis.
 Pain, photophobia, reduced visual acuity and
headache suggest uveitis.
 Check the preauricular and submandibular
nodes, as lymphadenopathy occurs in viral,
chlamydial and gonococcal infections.

10. CONJUNCTIVITIS
 Inflammation of the conjunctiva
 The most common eye disease. Conjunctivitis can
be generically described as swelling of the bulbar,
fornix or Palpebral conjuctival tissues.
 Characterised by
 Redness
 Foreign body sensation
 Discharge
 Follicles and/or papillae
 Mild to no pain
 Normal VA
 No photophobia

11. THE SIGNS AND SYMPTOMS
 These vary, depending on the cause,
 symptoms generally may include,
 itching,
 foreign body sensation,
 irritation and discomfort
 Signs may include
 hyperaemia,
 watery, stringy or mucopurulent discharge,
 follicles and papillae

12. TYPES OF CONJUNCTIVITIS
 INFECTIVE
 Bacterial
 Acute bacterial conjunctivitis,
 Viral
 (a) Folllicular conjunctivitis
 (b) Pharyngio-conjunctival fever
 (c) Epidemic keratoconjunctivitis
 (d) Acute haemorrahogic conjunctivitis
 Chlamydial
 (a) Trachoma
 (b) Inclusion conjunctivitis

13. TYPES OF CONJUNCTIVITIS CONTD.
 ALLERGIC
 Seasonal,
 perennial,
 vernal,
 atopic
 Giant Papillary (associated with CL,s)
 INFLAMMATORY
 Reiters syndrome , oculocutaneous.
 TOXIC

14. WORK-UP FOR CONJUNCTIVITIS
 Detailed ocular history, ie, Onset, duration,
quality, quantity.
 Detailed eye examination.(examine
unaffected eye first)
 Assess adjacent structures.
 Conjunctival scrapings and culture in severe
infections.

15. ACUTE BACTERIAL CONJUNCTIVITIS
 This is a common type of conjunctivitis, found in all age groups,
 History;
 Acute onset of redness, (2-3 days)
 often initially unilateral, becoming bilateral
 mucopurulent discharge;
 discomfort,
 foreign body sensation;
 eyelid erythema and oedema;
 vision minimally or unaffected; not itchy.
 Exam;
 injection of the bulbar conjunctival and episcleral vessels,
 Redness is more away from limbus
 mucoid or purulent discharge; (if severe consider gonococcal aetiology)
 clear cornea, no fluorescein stain;
 normal visual acuity and pupil response.
 Papillae may be present of absent
 Pseudomembranes may be present of absent

16. 16
ACUTE BACTERIAL CONJUNCTIVITIS:

17. 17
CHRONIC BACTERIAL CONJUNCTIVITIS

18. PATHOPHYSIOLOGY
 The eye has a series of defence mechanisms to
prevent bacterial invasion. These include
 bacteriostatic factors within the tears,
 a relatively nutrient poor environment unsupportive of
bacterial growth,
 the shearing force of the blink,
 an intact immune system, and
 a population of normal non-pathogenic bacteria which
competitively prevent invasion by abnormal organisms.
 When these defences break down or they are
overwhelmed by a pathogen not sensitive to these
defence mechanisms, an infection can occur

19. COMMONLY ENCOUNTERED ORGANISMS
 Staphylococcus aureus,
 Streptococcus pneumoniae ,
 Neisseria gonococci,
 Haemophilus influenzae, and
 Pseudomonas aeruginosa.
 Occasionally, there will be more than one
organism in an acute bacterial conjunctivitis.
 Otitis media may present concurrently with
acute bacterial conjunctivitis, especially in
children. This syndrome is highly indicative of H.
influenzae infection.

20. ASSESSMENT
 Microbiologic study with culturing and sensitivity
testing is the optimum means to reach a
conclusive diagnosis and treatment plan.
However, due to the expense of microbiologic
studies and relatively benign, self-limiting nature
of the condition, most clinicians advocate the
use of broad-spectrum, topical antibacterial
therapy, reserving culturing for hyperacute
conditions or those that fail to respond to initial
therapy.
 Assessment
 Gram’s stain and conjunctival culture

21. BACTERIAL CONJUNCTIVITIS
MANAGEMENT
 In majority of cases, acute bacterial conjunctivitis is a self-
limiting disease. Despite the benign, self-resolving nature,
bacterial conjunctivitis should be treated with topical
antimicrobial therapy in order to shorten the disease course
and improve the rate of clinical and microbiologic remission
 Treatment
 Warm or cold compresses, artificial tears, broad-spectrum antibiotics
4-6x/day
 Initial broad spectrum topical antibiotics
 Fluoroqionolone (Ciprofloxacin 0.3%, Ofloxacin 0.3%, Levofloxacin 0.5%)
 Polymyxin/trimethoprim (Polytrim)
 Gentamicin or tobramycin
 Adjust treatment on arrival of lab results
 Ophthalmology referral if hyperpurulent and hyperacute (GC
can rapidly invade and perforate cornea)

22. VIRAL CONJUNCTIVITIS
 Viral conjunctivitis can be caused by a number of different
viruses. but mainly Adenovirus
 Adenovirus is the most common ocular viral infection worldwide
 Adenoviral conjunctivitis is known to be the most common cause
of red eye in the world. Specific adenovirus serotypes are
associated with various types of ocular infection. There are three
major presentations:
 Follicular conjunctivitis (simple adenoviral conjunctivitis, serotypes 3,
4, 7a);
 epidemic keratoconjunctivitis (EKC, serotypes 8, 19, 37, 54); and
 pharyngoconjunctival fever (PCF, serotypes 3, 4, 7a, 11)
 .
 Most produce mild, self limiting disease

23. VIRAL CONJUNCTIVITIS
 May result from systemic viral infections, i.e. measles, mumps, chicken
pox, rubella, influenza, etc,
 Symptoms;
 Discomfort,
 foreign body sensation;
 photophobia
 often with coexistent URT infection or similar history
 watery discharge, often profuse; usually initially unilateral becoming bilateral in
3-7 days, recent contact history of someone with red eye; vision minimally or
unaffected.
 Signs;
 Diffusely injected conjunctiva;
 tarsal conjunctival follicles;
 clear cornea initially, possible small patches of subepithelial infiltrates developing
2 to 3 weeks after onset;
 occasionally palpable preauricular lymph nodes;
 no corneal fluorescein stain;
 normal visual acuity and pupil response.

24. VIRAL CONJUNCTIVAL FOLLICLES
Translucent “grains of rice” appearance.
Translucent “grains of rice” appearance.

25. VIRAL CONJUNCTIVITIS
 Treatment
 Self-limiting disease
 Cold compresses
 Artificial tears
 +/- Topical vasoconstrictor/antihistamine
 Infection control

26. SPECIFIC TYPES OF VIRAL CONJUNCTIVITIS
Follicular conjunctivitis (simple adenoviral
conjunctivitis)
 It is seasonal, occurring most frequently in the summer
and winter,
 spreads rapidly in crowded environments such as day
care centres, schools and military barracks.
 Adenoviral conjunctivitis and keratoconjunctivitis are
common and highly contagious. These conditions usually
affect both eyes.
 Patients may have painful conjunctival membranes and
palpable preauricular adenotherapy.
 Adenovirus is non-enveloped, resilient to disinfection and
long lasting on formites. However they are self-limiting.

27. PHARYNGIO-CONJUNCTIVAL FEVER
 PCF is characterized by a fever, sore throat and follicular
conjunctivitis.
 history of recent exposure to an individual with red eye
 may have a history of recent symptoms of an upper respiratory
tract infection
 Associated systemic manifestations such as sudden or gradual
onset of fever lasting up to several days. Myalgia, malaise, and
gastrointestinal disturbances
 More common in children,
 Caused by adenovirus types 3 -7.
 Conjunctivitis is preceded by pharyngitis
 Follicles may be present on the pharyngeal mucosa.
 Injection which begins at the inner canthal area and slowly spreads
laterally.
 Transient superficial keratitis,
 Non- tender preauricular lymphadenopathy

28. SYMPTOMS
 May range from
 slight itching and burning to marked irritation and tearing,
 little photophobia.
 Swelling of the lids may occur within 48 hours.
 Signs include
 Conjunctival hyperemia
 watery discharge,
 epiphora sometimes leading to a lateral canthal fissure
(splitting of the skin at the lateral juncture of the upper and
lower eyelids) and
 eyelid oedema.
 Follicular conjunctival reaction
The virus can be eradicated from the conjunctiva in as soon as 14 days,

29. MANAGEMENT
 Because PCF usually is a self-limited disease, treatment is mainly
symptomatic, as follows:
 Cold compresses several times per day for 1-2 weeks
 Artificial tears 4-8 times per day for 1-3 weeks
 The following drugs may be used but rarely are indicated:
 A topical vasoconstrictor/antihistamine may be instilled 4 times per
day for severe itching only, because it may cause a rebounding of
symptoms and it has a high incidence of local toxicity and
hypersensitivity.
 A topical antibiotic may be instilled 4 times per day to prevent
bacterial superinfection.
 Topical steroids dramatically suppress conjunctival inflammatory
signs, relieve symptoms, and are associated with resolution of the
corneal subepithelial infiltrates. However, due to their adverse
effects, topical steroids should only be used for pseudomembranes
or when subepithelial infiltrates severely reduce vision.

30. EPIDEMIC KERATOCONJUNCTIVITIS
 Epidemic keratoconjunctivitis (EKC) is caused by the
adenovirus serotypes 8, 19 and 37.
 Marked inflammatory reaction with symptoms of viral
infection, as well as blurred vision and photophobia
 a more critical form of adenoviral keratoconjunctivitis
because of the possible adverse consequences on visual
acuity.
 incubation period is 2-14 days before the clinical symptoms
present
 the person may remain infectious for 10-14 days after
symptoms develop.

31. EKC CONTD.
 EKC epidemics tend to occur in closed
institutions (eg, schools, hospitals, camps,
nursing homes, workplaces). Direct contact with
eye secretions is the major mode of
transmission.
 Infected medical equipment play an important
role in spreading the disease. Many epidemics
have been initiated in ophthalmology outpatient
clinics by direct contact with contaminated
diagnostic instruments

32. EKC CONTD.
 Begins as an obvious conjunctivitis, but then
develops corneal infiltrates.
 This acute phase of EKC is marked by a
severe conjunctivitis and lasts from two to
four weeks.
 the inflammatory reaction of the conjunctiva
can become so intense that it results in a
pseudomembrane and potentially permanent
symblepharon formation or punctual
occlusion

33. EKC CONTD.
 Usually bilateral but often starts with one eye,
 Symptoms are same as other viral conjunctivitis.
however, it is distinguished from other adenoviral
infections when the cornea becomes affected by the
development of multifocal subepithelial infiltrates.
 These infiltrates are typically observed within seven
to ten days after the onset of the initial signs of
infection.
 In 20-50% of cases, corneal opacities can persist for
a few weeks to months, and their presence can also
cause reduced visual acuity.


34. MANAGEMENT
 EKC is a self-limiting disease.
 Treatment is mostly symptomatic
 (cold compresses and artificial tears).
 mild topical corticosteroids can be used..

35.  If pseudo- or true membranes are present, they
should be removed using a forceps or a moistened
cotton-tipped applicator soaked in a combination of
antibiotic solution and anesthetic.
 Topical antibiotic steroidal combination (Tobradex,
Maxitrol, Zylet) therapy QID can be employed
following the removal of the inflammatory membrane.
Currently, no specific topical antiviral medication is
recognized as an effective treatment for viral
conjunctivitis.
 Most practitioners reserve topical steroidal therapy
for the severely symptomatic (SEI on the visual axis
decreasing acuity) or recalcitrant cases.

36. CLINICAL PEARLS
 Office equipment, instruments and areas should be
meticulously maintained so they do not become a
flashpoint for outbreak.
 EKC infiltrates typically resolve without scarring the
cornea. Patients should be told to expect worsening
over the first seven to 10 days and improvement over
three to six weeks.
 Most practitioners reserve topical steroidal therapy for
the severely symptomatic (SEI on the visual axis
decreasing acuity) or recalcitrant cases.
 Steroids should be tapered slowly as the condition
remits.

37. ACUTE HEMORRHAGIC CONJUNCTIVITIS
(APOLLO)
 Acute hemorrhagic conjunctivitis (AHC) is an epidemic
form of highly contagious conjunctivitis, characterized by
subconjunctival haemorrhages
 it is a variant of EKC produced by adenovirus types 19
and 37 .
 AHC is known to be directly transmitted by close person-
to-person contact or indirectly through soiled
ophthalmological materials or swimming pools.
 AHC has been noted throughout the tropical regions of
the world without regard to sex, race or ethnic
background.
 Occurs in epidemic proportions

38. AHC CONTD.
 AHC begins with an initial period of catarrhal inflammation
(profuse discharge of mucus and epithelial debris).
 Symptoms include
 painful red eyes,
 swelling of the conjunctival tissue,
 frequent mucus discharge from the eyes accompanied by
excessive tearing and subconjuntival haemorrhage. This
haemorrhaging is caused by the rupture of blood vessels
beneath the conjunctiva giving the eyes a bright red
appearance.
 These are associated with a painful, rapidly progressive
follicular conjunctivitis. The lids often become swollen and
indurated. The infection resolves within 5-7 days, during which
the symptoms of pain and irritation are present.

39. MANAGEMENT
 Management consists of symptomatic treatment while
waiting for the disease to run its 5 to 7day course.
 AHC almost always resolves without sequela, having a
good visual prognosis.
 Management
 Patients should stay home from work or school until
contagious discharge is eliminated, and should be warned
not to share common utensils, glasses, linens or
washcloths.
 Medical management may range from supportive cold
compress and artificial tears to topical vasoconstrictors
BD to QID.
 Office equipment, instruments and areas should be
meticulously maintained so they do not become a
flashpoint for outbreak.

40. CHLAMYDIAL CONJUNCTIVITIS(TRACHOMA)
 Trachoma is the leading infectious cause of
blindness world wide.
 It is caused by serovars A, B, Ba and C of
Chlamydia trachomatis. It is found primarily in
areas of poverty and over crowding.
 It is estimated that about 500 million people are
infected world wide with over 1million being
blind as a consequence.
 It is endemic in parts of Africa, Middle east,
India, and Southeast Asia..

41.  Chronic keratoconjunctivitis caused by
Chlamydia trachomatis
 Chlamydia are small obligate intracellular
pathogens and were once considered to be
viruses. However they contain DNA, RNA, and
ribosomes and make their own proteins and
nucleic acids so are now considered to be true
gram negative bacteria
 The infection occurs more often in children.
Transmission is by contact with contaminated
fingers, clothings, objects and flies.

42. CHLAMYDIAL CONJUNCTIVITIS(TRACHOMA)
 Endemic in underdeveloped countries, where
standard of living is low, poor personal hygiene
 Symptoms;
 Discomfort,
 foreign body sensation;
 mucus discharge, often profuse;
 usually initially unilateral, becoming bilateral;
 chronic symptoms despite topical antibiotics;
 vision minimally or unaffected; minimally or not itchy.
 Signs
 diffusely injected conjunctiva; large tarsal and limbal follicles,
superior keratitis, panus, normal visual acuity and pupil
response, linear and stellate cicatrization, entropion, trichiasis

43. TRACHOMA CONTND,
 The incubation period is about 5-14 days.
 The spread is associated with epidemics of bacterial conjunctivitis
and dry seasons in tropical and semitropical regions.
 Direct transmission usually between children and carers
 At onset, chronic and insidious and resolves with no
complications
 In adults, the onset is acute to subacute and complications may
occur.
 At onset, trachoma resembles acute bacterial conjunctivitis with
tearing, pain, hyperaemia, exudation, and sometimes
photophobia. As it progresses, there is lid oedema, chemosis of
the conjunctiva, papillary hypertrophy, tarsal and limbal follicles,
superior keratitis, pannus formation, preauricular node swelling.

44. TRACHOMA CONTND,
 Repeated episodes of reinfection within the
family causes chronic follicular or intense
conjunctival inflammation (active trachoma),
which leads to tarsal conjunctival scarring.
 The scarring distorts the upper tarsal plate and
in some individuals, leads to entropion and
trichiasis (cicatricial trachoma).
 The end result includes corneal abrasions;
corneal scarring and opacification; and,
ultimately, blindness. The acute form of the
disease is more infectious than the cicatrical
form.

45.  Two phases of the disease process exist: the active
phase and the cicatricial phase.
 The active trachoma phase resembles many other
diseases in which follicular conjunctivitis is a feature.
Without laboratory facilities, the diagnosis is solely
based on the clinical appearance of active trachoma
in someone living in a community where trachoma is
endemic or suspected to be endemic. However some
patients with active trachoma are relatively
asymptomatic.
 The cicatricial phase has unique clinical features,
which lead to definitive diagnosis in most cases.

46. ACTIVE PHASE
 characterized by a mucopurulent
keratoconjunctivitis.
 The conjunctival surface of the upper eyelid
shows a follicular and inflammatory response.
 The cornea may have limbal follicles, superior
neovascularization (pannus), and punctate
keratitis.
 Infection with C trachomatis concurrently occurs
in other extraocular mucous membranes,
commonly the nasopharynx, leading to a nasal
discharge.

47. CICATRICAL PHASE
 Conjunctival scarring: alone tends to be
asymptomatic, though the associated disturbance of
the architecture of the tear film often leads to dry
eye.
 Trichiasis causes an intensely irritating foreign body
sensation, as well as blepharospasm. Ultimately, it
leads to corneal scarring.
 Many patients self-epilate before their presentation.
 Corneal opacities or scars that cover any part of the
pupil impair the patient's vision.

48. COMPLICATIONS OF TRACHOMA
 Entropion
 Trachiasis,
 Ptosis,
 lacrimal and acessory lacrimal duct obstruction
from conjunctival scarring ,
 Dry eye,
 Corneal ulceration
 Corneal scaring,
 Bacterial infections,
 blindness

49. WHO SIMPLIFIED TRACHOMA GRADING SYSTEM
 The WHO grades trachoma into
 TF Trachomatous Inflammation – Follicular The
presence of five or more follicles in the upper tarsal
conjunctiva
 TI Trachomatous Inflammation – Intense Pronounced
inflammatory thickening of the tarsal conjunctiva that
obscures more than half of the normal deep tarsal vessels
 TS Trachomatous Scarring The presence of scarring in
the tarsal conjunctiva
 TT Trachomatous Trichiasis At least one eyelash rubs
on the eyeball or evidence of recent removal of inturned
eyelashes
 CO Corneal Opacity Easily visible corneal opacity over
the pupil.

50. 50
22 TRACHOMA

51. TRACHOMATOUS SCARRING

52. CHLAMYDIAL CONJUNCTIVITIS
 Treatment
 Oral doxycycline 100mg po bid x 3 weeks ( or erythromycin) vs
Azithromycin 1g po x 3/7
 Topical erythromycin or tetracycline ointment 2 - 4 x/day
 Treat family members
 The WHO recommends 2 antibiotics for trachoma control:
oral Azithromycin and tetracycline eye ointment.
Azithromycin eye drops have also been shown to be very
effective, but it is more expensive. National trachoma
control programs in a number of countries are fortunate to
be beneficiaries of a philanthropic donation of
azithromycin. Azithromycin is the drug of choice because
it is easy to administer as a single oral dose. Therefore,
compliance is higher than with tetracycline and can
actually be measured

53. PREVENTION AND CONTROL
 For trachoma, treatment coupled with
improved sanitation to prevent reinfection is
the best way to control the disease. The
WHO has developed the SAFE strategy for
trachoma control.
 S Surgery
 A Antibiotics
 F Facial washing
 E Environmental change

54. ADULT INCLUSION CONJUNCTIVITIS
 Also caused by Chlamydis trachomatis
 Infection is venerally transmitted instead
of from eye to eye
 Most common in young sexually active
adult with a history of GU infection
probably ongoing with Chlamydia
trachomatis.
 Presents as chronic conjunctivitis with
large follicles and mucopurulent
discharge and PAN

55. ADULT INCLUSION CONJUNCTIVITIS
Note the very enlarged follicles

56.  Management is same as for trachoma.

57. ALLERGIC CONJUNCTIVITIS
 Most common form of ocular allergic disease.
 Acute allergic conjunctivitis describes the abrupt and immediate
response seen in sensitized individuals after exposure to a
particular allergen or sensitizing agent.
 A type 1 hypersensitivity response of the conjunctival mast cells
mediated by IgE.
 Types
 seasonal allergic conjunctivitis (SAC), which coincides with pollen
blooms such as ragweed, occurs mainly in the spring, or harmatan
 perennial allergic conjunctivitis (PAC),in which exposure may occur
at any time throughout the year (e.g., allergies to cat dander or dust
mites).
 Vernal keratoconjunctivitis (VKC)
 Atopic keratoconjunctivitis (AKC)
 Giant papillart conjunctivitis (GPC)

58. ALLERGIC CONJUNCTIVITIS
 History;
 History of atopic disease, airborne allergens with type-I hypersensitivity
reaction
 Intense itching,
 Possible history of allergen exposure,
 watery, stringy discharge.
 Signs;
 Normal visual acuity;
 thick stringy discharge
 diffusely injected conjunctiva;
 chemosis (bulging of the clear/injected conjunctival layer with fluid
underneath,
 fine velvety papillae on tarsal conjunctiva, may develop giant cobblestone
appearance (vernal);
 clear cornea,
 no fluorescein stain;
 erythema and oedema to lids;
 normal pupil response;
 no preauricular lymph nodes palpable

59. 59
ALLERGIC CONJUNCTIVITIS:

60. DIFFUSE PAPILLARY REACTION
Small papillae often look like
grainy redness of the upper lid

61. SIGNS AND SYMPTOMS
 Ocular itching remains the hallmark symptom
 tearing is also an exceedingly common
complaint, particularly after rubbing the eyes in
response to itching.
 Others are ocular burning, foreign-body
sensation or photophobia, though these are
relatively rare.
 personal or family history of allergies.
Concurrent symptoms of allergic rhinitis, post-
nasal drip, or sinus congestion may be present,
especially in SAC.

62. EXAMINATION
 variable conjunctival hyperemia
 chemosis.
 Ocular discharge is watery, though mucus may
accumulate in the fornices or collect on the lash
margin in the form of "crusts
 Eversion of the eyelids may reveal a fine papillary
response, particularly along the upper tarsal plate.
 Externally, the eyelids may be red, swollen and
edematous, with a pseudoptosis in pronounced
cases.
 A palpable preauricular lymph node is noticeably
absent

63. PATHOPHYSIOLOGY
 Allergic response is an over-reaction of the body's immune system to
foreign substances (allergens).
 The key component to the ocular allergic response is the mast cell.
When mast cells interact with specific allergens, the cell degranulates,
causing discharge of chemical mediators into the surrounding tissues.
 The primary chemical mediator released is histamine, which is
responsible for increased vascular permeability, vasodilation, bronchial
contraction and increased secretion of mucus. Other substances i.e.
heparin, chymase, tryptase are also released from mast cells.
 In severe or prolonged allergic reactions, a "late- phase" response may
occur in which cell membranes begin to break down into arachidonic
acid, which is further degraded to form prostaglandins, leukotrienes and
thromboxane (powerful mediators of inflammation).
 This late phase is far more common in disorders such as atopic and
vernal keratoconjunctivitis,

64. MANAGEMENT
 Primarily aimed at reducing symptoms and quelling any significant inflammation.
 The most effective treatment is elimination or avoidance of the potentially offending allergen, if
possible or practical.
 Artificial tear solutions serve to soothe, lubricate and flush or dilute the antigens
 Cold compresses and topical decongestants
 Decongestant solutions (containing one of the following: naphazoline, antazoline,
tetrahydrozaline or phenylephrine) are available as over-the-counter preparations, either alone
or in combination with a mild topical antihistamine
 Antihistamines, e.g. Livostin (0.05% levocabastine hydrochloride, and Emadine (0.05%
emedastine dif umarate);
 Mast cell stabilizers, e.g. Opticrom (4% cromolyn sodium), Alomide (0.1% lodoxamide
tromethamine), Alocril (2% nedocromil sodium), and Alamast (0.1% pemirolast postassium);
 Antihistamine/mast cell stabilizer combinations, e.g. Patanol (olopatadine hydrochloride), Zaditor
(ketotifen fumarate), and Optivar (0.05% azelastine hydrochloride)
 Corticosteroids, e.g. Alrex (0.2% loteprednol etabonat), Vexol (1% rimexolone) and Pred Forte
(1% prednisolone acetate)
 Non-steroidal anti-inflammatory agents (NSAIDs), e.g. Acular (0.5% ketorolac).

65. SAC -SEASONAL ALLERGIC CONJUNCTIVITIS
 Most common form of ocular allergy
 Associated with seasonal rhinitis (hay fever)
and sensitization/exposure to airborne
allergens such as ragweed and grass pollen.
 Occurs often in spring and fall seasons,
when levels of pollens are at their peak.
 It accounts for half of ocular allergies,
affecting 10 to 30% world population

66.  Symptoms include
 redness,
 itching,
 burning and watery eyes,
 dryness and irritation,
 mucoid discharge.
 Signs are
 bulbar conjunctival hyperaemia,
 Oedema of eyelid
 Chemosis
 mild watery discharge,
 papillary hypertrophy of upper palpebral conjunctiva (redness
& roughness),

67. TREATMENT
 Avoid allergens
 Cool compresses
 Artificial tears
 Systemic and/or topical antihistamines
 Topical mast cell stabilizer (Patanol, Alomide,
Cromolyn)
 Topical NSAID (Acular, Voltaren
 Oral antihistamines should be used when
patient has significant nasal problems eg.
Cetirizine(Zyrtec), Loratadine(Claritin).

68. PAC -PERENNIAL ALLERGIC CONJUNCTIVITIS
 Although less intense, is more of a chronic
condition.
 usually involves sensitization to antigens that
are present year round, such as dust mites,
animal dander, mould, and air pollutants.
 affects about 1% of allergy sufferers and
causes year round disease due to dust,
animal skin and hair, mould, fungus et

69.  Signs and symptoms are very similar to SAC
although chronic and less severe.
 It continues throughout year with seasonal
exacerbation. Seasonal peaks are due to
heat and humidity.
 Management; Same as SAC

70. VKC –VERNAL KERATOCONJUNCTIVITIS
 VKC is a chronic, bilateral inflammation of the
superior and limbal palpebral conjunctiva.
 Onset typically occurs in children between
ages 3 and 25.
 Males typically are affected more than
females. (gender ratio 2/1),
 occurs more in warmer climates such as
Africa, India, and some parts of Asia.
 often, but not always, resolves upon entrance
into puberty.

71. SIGNS AND SYMPTOMS
 severe itching with thick, ropy mucoid discharge.
 tearing, burning, photophobia, chemosis, intense bilateral pruritus of the
eyelids, periorbital area, and conjunctiva
 history of allergies or infantile eczema.
 Lots of papillae in conjunctiva as well as limbus
 large conjunctival papillae on the back of the superior tarsus; raised
Horner-Trantas dots (gelatinous, white clumps of degenerated
eosinophils usually located at the superior limbus);
 areas of superficial punctate keratitis (SPK)
 in severe cases, well-demarcated, sterile corneal shield ulcers, located
superiorly.
 No specific allergen has been identified at the origin of VKC.
 Children who have VKC have a higher incidence of keratoconus than
the general population Y
 You can differentiate VKC from atopic keratoconjunctivitis (AKC) based
on age, location, dermatitis and lack of seasonal variability.

72. VERNAL CONJUNCTIVITIS
Papillae can become very large and flatten in
chronic vernal inflammation

73. 73
21 VERNAL CONJUNCTIVITIS

74. LIMBAL PAPILLAE
These are degenerated
eosinophils at corneal scleral
margin.

75. Atopic conjunctivitis
 Severe bilateral allergic inflammation of the conjunctiva, eyelids, and
cornea,
 This condition is chronic, sight threatening, and has no geographical
prevalence.
 Resembles VKC but occurs predominantly in adults between 20 and 50
years old.
 Symptoms of AKC usually become more severe in the winter season
 Rarer and more serious than VKC.
 Associated with a history of atopic dermatitis of face, neck and flexure
folds
 Often a history and/or family history of asthma, rhinitis or hay fever.
 Looks like VKC but with more corneal involvement, leading to scarring,
shield ulcers and vascularisation

76. ALLERGIC CONJUNCTIVITIS
 Treatment
 Avoid allergens
 Cool compresses
 Artificial tears
 Systemic and/or topical antihistamines
 Topical mast cell stabilizer (Patanol, Alomide,
Cromolyn)
 Topical NSAID (Acular, Voltaren)
 Vernal and Atopic occur rarely in people with FH of
allergy. Vernal affects young males 5-20 in spring
summer and improves in adulthood wheras atopic
tends to be chronic needing long term Mast cell
inhibitors and steroids.

77. Major Differentiating Factors Between VKC and AKC
Characteristics VKC AKC
Age at onset Generally presents at a younger age
than AKC. I.E. 3-20 years
Usually adults, over 20 years
Sex Males are affected preferentially. No sex predilection
Seasonal variation Typically occurs during spring months Generally perennial
Discharge Thick mucoid discharge Watery and clear discharge
Conjunctival scarring - Higher incidence of conjunctival
scarring
Horner-Trantas dots Horner-Trantas dots and shield ulcers
are commonly seen.
Presence of Horner-Trantas dots is
rare.
Corneal Not present Deep corneal neovascularization

78. GIANT PAPILLARY CONJUNCTIVITIS
 Often seen in CL wearers.
 10x more common with soft lenses than with
hard.
 May also occur with protruding sutures post
operatively or in prosthetic eyes.
 Bilateral, mild to moderate conjunctival
hyperemia,greater superiorly,
 small to giant papillae on the palpebral
conjunctiva, esp upper lid.
 Symptoms from none to moderate none specific
irritation and itching

79. GIANT PAPILLAE
 Papillae can merge together to form giant papillae of 2-3mm
diameter in chronic conditions ( especially in CL wearers
and chronic allergic disease ie. Vernal conjunctivitis or
superior limbic keratoconjunctivitis

80. MANAGEMENT
 Cleanse lens surface,
 Increase use of enzymatic cleaners,
 Replace old or poor quality lenses,
 Oral and topical antihistamines QDS
x4weeks
 In severe cases, oral antiinflammatory.
 If recurrence continues, discontinue lens use.

81. SUPERIOR LIMBAL KERATITIIS
 Associated with thyroid dysfunction in middle
aged women most commonly.

82. IS THERE ANY DISCHARGE?
 Acute bacterial conjunctivitis will always have
a yellow or creamy mild purulent or
mucopurulent discharge which tends to stick
the eyelids together on waking and crusts.
 Serous or watery discharge usually indicates
a viral or toxic aetiology
 Mucoid white or stringy discharge is
associated with dry eye and allergic causes
and early chlamydial conjunctivitis

83. INFLAMMATORY CONJUNCTIVITIS
 Reiters is usually in men who develop
arthritis and conjunctivitis following an attack
of Urethritis or Dysentry
 Oculocutaneous patients develop a severe
conjunctivitis which scars mucous glands
creating a severe dry eye
 And lid adhesions and corneal scarring..

84. TOXIC CONJUNCTIVITIS
 History
 exposure to toxic foreign substances. Ie. New
topical drugs , chronic use of topical drugs,
cosmetis, etc.
 Conjunctival injection, chemosis, itching,
burning,tearing, follicular conjunctivitis, more on
lower lid.
 Diagnosis is based primarily on history.

85. MANAGEMENT
 Stop offending agent
 Cold compress QID
 Topical mast cell stabilizers
 antihistamines

86. SUBCONJUNCTIVAL HEMORRHAGE
 A deep red colour, obscuring the underlying sclera.
 History;
 Spontaneous; trauma;
 occasionally history of Valsalva maneuver, coughing or sneezing;
 usually asymptomatic;
 occasional mild discomfort, or popping sensation at onset;
 possible association with systemic HTN or anticoagulant medication.
 Exam
 Diffuse or localised area of blood under conjunctiva, often sectorial;
 cornea clear, no fluorescein stain;
 normal visual acuity and pupil response;
 possible systemic HTN; BP should be measured in all cases and managed.
 Treatment
 Reassurance
 Cold compresses
 Artificial tears
 Resolves in 10-14 days

87. SUBCONJUNCTIVAL HEMORRHAGE

88. EPISCLERITIS
 75% idiopathic; young adults
 Others: collagen vascular disease, rosacea, gout, HZV,
thyroid disease, atopy, syphilis
 History
 Sectoral redness
 Painless or acute onset of dull ache
 Normal visual acuity or mild blurring
 Recurrent episodes
 Exam
 Sectoral or diffuse redness of one or both eyes
 Engorged episcleral vessels
 Nodule may be seen over redness
 No discharge or corneal involvement

89. EPISCLERITIS

90. EPISCLERITIS
 Assessment
 Phenylephrine (2.5%) test: blanching of episcleral
vessels
 Treatment
 Usually self-limited in 2-3weeks
 Cool compress
 Artificial tears
 Topical NSAID, vasoconstrictor
 Oral NSAID
 Topical steroids

91. SCLERITIS
 50% idiopathic
 50% with systemic disease (RA, SLE, polyarteritis nodosa,
Wegener’s, relapsing polychondritis, ankylosing spondylitis, GCA,
gout, TB, HZV, syphilis)
 History;
 Severe ocular pain and redness (prominent feature)
 Tearing,photophobia
 reduced visual acuity may be present;
 past medical history should be reviewed for any known systemic
associations such as connective tissue disorders including rheumatoid
arthritis, Wegener's granulomatosis, SLE etc
 Exam;
 deep scleral vessel engorgement,
 pain on ocular palpation;
 Sectoral or diffuse scleral erythema, thinning with bluish hue, edema,
possible nodules or necrosis
 Possible corneal and intraocular inflammation

92. SCLERITIS

93. SCLERITIS
 Assessment
 2.5% phenylephrine test: deep episcleral and scleral
vessels do not blanch
 Scleral vessels cannot be moved with a cotton swab
 Treatment
 Systemic evaluation by physician or rheumatologist
 Ophthalmology referral
 Oral NSAID or corticosteroid
 Topicals usually not effective
 Possible cytotoxic

94. CONJUNCTIVAL DEGENERATION
PINGUECULAR
 a common type of conjunctival degeneration
 Yellowish, slightly raised nodule on both
sides of bulber conjunctiva, adjacent to the
cornea.
 More common on nasal side.
 Rarely increases in size, but may get
inflammed from time to time.
 No treatment required, mild decongestant
may be used if hyperemic.

95.  Pingueculae are thought to arise as a result of the
effects of environmental irritants such as wind and
dust and are associated with UV-light exposure and
aging.
 It is bilateral and generally free of blood vessels.
 The nodule consist of hyaline and yellow elastic
tissue
 . Risk Factors include UV-light exposure, wind, dust,
outdoor lifestyle and proximity to the equator. age,
smoking, working outdoors, diabetes mellitus.
 Most pingueculae are asymptomatic but may cause
ocular surface irritation including foreign body
sensation, tearing, burning or itching.
 Some may find these lesions cosmetically
unacceptable.

97. PTERYGIUM
 Thick fleshy triangular mass growing from
conjunctiva unto the cornea.
 Benign Fibrovascular growth on the conjunctiva,
usually nasal and bilateral.
 Apex is usually towards cornea,
 Richly vascularized and hyperemic
 May press on cornea and cause irregular
astigmatism
 May grow in pupillary region and obstruct visual
axis.

98. PTERYGIUM
 The leading edge of this tissue often displays
a fine, reddish-brown iron deposition line
(Stocker’s line).
 More than 90% of pterygia occur nasally
 More common in warm dry climate
 UV light plays a major role

100. MANAGEMENT
 Management for asymptomatic or mildly irritative
pterygia involves UV-blocking spectacles and liberal
ocular lubrication.
 Patients should be advised to avoid smoky or dusty
 More inflamed or irritated pterygia may be treated
with topical corticosteroids (e.g., 1% prednisolone
acetate or 0.5% loteprednol etabonate q.i.d. for
several days).
 Surgical excision of pterygia is indicated for
unacceptable cosmesis, significant induced
astigmatism, threats to peripheral corneal hydration
and significant ingrowth to the visual axis.

101. CONCRETIONS
 Very commonly occurring chalky white/yellow
deposits which are usually found on the inferior
tarsal conjunctiva. They are more common in
the elderly and in those with meibomian gland
disease
 usually asymptomatic (unless very large when a
foreign body sensation is experienced), well-
defined deposits.
 Management: they are left alone unless
symptomatic when they can be removed under
topical anaesthetic, with a needle.

102. RETENTION CYST
 Very common, benign lesion.
 Asymptomatic (unless very large) clear fluid-
filled lesion occurring anywhere in the
conjunctiva.
 Management: they are left alone unless
symptomatic when they can be removed,
under topical anaesthetic, with a needle.

103. CICATRICIAL PEMPHIGOID
 An idiopathic subepidermal blistering and scarring autoimmune
condition occurring in the mucocutaneous parts of the body. It
always occurs bilaterally (not necessarily symmetrically) but
isolated conjunctival involvement is not common.
 : typically this occurs in the middle-aged patient, and is more
common in females. Nonspecific viral conjunctivitis-type
symptoms occur initially with progressive appearance of papillae,
bullae and eventually fibrosis. Diffuse hyperaemia and oedema
persist during the latent phases of the condition.
 Management: topical steroids, subconjunctival mitomycin C and
silicone contact lenses are used initially. Most patients will also
benefit from systemic steroids, dapsone ± cytotoxic agents.
Surgery is reserved for those with complications such as
cicatricial entropion or serious corneal complications

104. STEVENS-JOHNSON SYNDROME
 An acute, severe blistering disease of unknown exact aetiology
(hypersensitivity to drugs and viral infections appear to be
precipitating factors).
 A vasculitis affects the skin and mucous membranes (90% of
patients have conjunctival involvement).
 occurs in young, previously healthy individuals (more often
males) who present with fever, malaise, sore throat (± a cough)
and arthralgia. A mild conjunctivitis is noted in all but a handful of
patients who experience a severe membranous or
pseudomembranous conjunctivitis.
 Management: topical and systemic steroids (± antivirals if herpes
is suspected to have triggered it), lubricants and possibly surgical
intervention where the vasculitis and complications such as
severe scarring have occurred