this document is designed and serving to successfully help students, teachers or ophthalmic clinicians to deliver a sustained and effective management of conjuctiva disorders

1. Diseases of Conjunctiva
By
Dr. Okyere Bright Vandyke (Bsc.,OD)

2. Presentation Outline
• Introduction
• Symptoms and signs of conjunctivitis
• Blepharitis
• Bacterial conjunctivitis
• Neonatal conjunctivitis
• Viral conjunctivitis
• Allergic conjunctivitis
• Chemical conjunctivitis
• Keratoconjunctivitis Sicca
• Conjunctival degenerations
• Tumours of conjunctiva

3. Introduction
• Conjunctivitis is inflammation or infection of conjunctiva
• Conjunctiva is divided into tarsal, bulbar and fornicial
portions
• Tarsal conjunctiva is firmly attached to the tarsal plate
• Bulbar and fornicial are loosely attached to the
underlying tissues (except limbal area)
• Conjunctiva contains many lymphoid tissues and goblet
cells which secrete mucus – numerous in the fornix
• Conjunctiva has few sensory nerve endings
• It is the most exposed mucous membrane in the body as
eyes are normally open
• It is prone to infection and inflammation

4. Symptoms of Conjunctivitis
• Sensation of irritation, itching or discomfort
in the eye
• Slight pain and photophobia (when cornea
epithelium is affected in viral conjunctivitis)
• Vision is generally normal – However excess
secretions may form a film across cornea and
blur vision (vision improves when film is
blinked away)
Note:
Viral conjunctivitis can affect corneal epithelium, which
may cause slight blurring of vision

5. Signs of Conjunctivitis
• Red eye – vasodilatation of superficial vessels due to
inflammatory response. Either spread all over or
more towards the fornices
• Increased secretions
 Purulent in acute bacteial conjunctivitis
 Mucopurulent in mild bacterial conjunctivitis
 Watery (serous) in viral
 Thick sticky muous in allergic
• Chemosis (oedema of conjuctiva)
• Follicles (nodules of limphoid tissue beneath surface
of conjunctiva) – numerous in fornices and on upper
tarsal

6. Signs of Conjunctivitis (cont.)
• Papillae - raised area on surface of epithelium
(consist of blood vessels and inflammatory cells).
Conjunctival surface becomes rough and velvety.
Underlying blood vessels become obscured
• Pseudomembranes – coagulated exudate adhering to
inflamed conjuctival epithelium. Can be easily peeled
off leaving epithelium intact. Seen in gonococcal
conj., and severe adenoviral infection
• True membranes – inflammatory exudate enter
superficial layers of conj. epithelium. Removal
causes bleeding and tearing of epithelium. Found in
diphtheria and β-haemolytic streptococcal infections

7. Signs of Conjunctivitis (cont.)
• Keratinization – hard protein produced by skin cells
to resist wetting e.g. in Vit. A deficiency
• Scarring (fibrosis) – common in trachoma
• Increased pigmentation – it is a result of chronic
conjunctivitis in dark-skinned person esp. in children
(esp. in Vit. A deficiency and vernal conjunctivitis)
• Lymphadenopathy - enlargement of preauricular
and submandibular nodes. Found in Chlamydial,
viral and severe gonococcal conjunctivitis

8. Generalised injection of
conjuctiva Chemosis

9. Blepharitis
• Inflammation of the eyelid margins
• Exact cause unknown but attributed to
staphylococcal infection and saborrhoea
• Types
Anterior
Staphylococcal - Caused by chronic infection of bases of
eyelashes forming tiny intrafollicular abscess. More common
in females. Tend to affect younger people. Anterior lid
margins are hyperemic and have scales and lashes may be
matted down by yellow crust. Long standing may cause
madarosis, trichiasis, bacterial conjunctivitis and internal
hordeolum. Treatment – lid hygiene, topical antibiotics and
artificial tears
Seborrhoeic – disorder of glands of Zeis and moll. Has oily
and dry (dandruff) types. Eyelids have shiny-waxy
appearance with mild hyperaemia, dandruff (soft, yellow,
greasy scales) and lashes are also greasy and stuck together.
Treatment – lid hygiene and artificial tears

10. Blepharitis (cont.)
• Posterior blepharitis
Caused by dysfunction of meibomian glands
Characterized by
 Dilated meibomian glands (easily expressed to release
copious amount of lipid)
Frothy discharge at the inner canthi (meibomian foam)
Complications – papillary conjunctivitis, inferior
punctate keratopathy and tear film instability
Treatment – systemic antibiotics, eyelid hygiene,
topical steroids and artificial tears

11. Anterior blepharitis

12. Posterior blepharitis
Crust and eyelid swelling
Enlargement of mebomian gland
orifices

13. Bacterial Conjunctivitis
• It is usually bilateral. It may start in one eye and later
spread to the other
• Common organisms are Staphylococcus aureus and
Haemophilus influenzae
• Signs are:
Purulent or mucopurulent discharge
Hyperemia of conjunctiva, maximal in fornices
Chemosis
In severe cases there is oedema of eyelids
• Treatment - Topical antibiotics, cleaning of discharge and
dry secretions of eyelids with moist cotton wool swabs
• Note that eye should not be padded. Padding
encourages multiplication of micro-organism

15. Neonatal Conjunctivitis
(Ophthalmia Neonatorum)
• Conjunctivitis in a newborn child (0 - 28 days)
• Causes
Chlamydia is most common cause. Produce more mild
form within the first 2 weeks of birth. Has a later onset
than gonococcal
Gonococcus not common as chlamydia but most serious.
Produces acute form within few days (1 – 3 days after
birth) and cause cornea ulceration, sometimes
pseudomembrane, scarring and eventually blindness.
Herpes simplex and bacteria, like Staphylococcus – mild
cases
• Signs and symptoms – Swollen eyelids, purulent
discharge, child not able to open the eyes, fever may be
present in severe cases

16. Neonatal conjunctivitis
Mid form Severe form

17. Management of Neonatal Conjunctivitis
• Urgent and vigorous treatment required to prevent
permanent corneal damage
• If laboratory services available take conjunctival swab for
Gram stain (Gram-negative cocci)
• Culture is helpful but treatment should start immediately
• Where no lab. services, treat as if it were gonococcal
• Antibiotic be given both locally and systemically
• If cefotaxine 100mg/kg body weight (single IM). If
chlamydia, erythromycin 50mg/kg body weight per day by
mouth for 14 days. Tetracycline ointment for the eyes
• Mother and partner have to be treated for genital
infections
• Regular eyelid toileting
• Prevention: cleaning of eyelids with saline swab as soon as
the head is born and routine application of tetracycline
ointment

18. Viral Conjunctivitis
• The most common are:
Epidemic Keratoconjunctivitis (Adenovirus)
Epidemic haemorrhagic conjunctivitis
• Symptoms and Signs
Foreign body sensation
Slight photophobia (as cornea is frequently involved)
Watery discharge
Conjuctival injections
Follicles in the fornices and sometimes on upper tarsal
conjunctiva
• Self-limiting and may last for about 2-3 weeks

19. Epidemic Keratoconjunctivitis
(Adenovirus Conjunctivitis)
• Most common viral infection of conjunctiva
• Caused mainly by Type 8 adenovirus strain
• Transmitted from eye to eye by droplets or direct contact
• Usually bilateral
• Common where people live close together in unhygienic
conditions
• Usually occurs in epidemic
• There are ‘superficial punctate keratitis’
• In severe cases there may be fibrin “pseudomembrane “ on
upper tarsal conjuctival epithelium near the fornix
• Self-limiting and may last for about 2-3 weeks
• Treatment – No specific treatment needed. Topical
antibiotics to prevent secondary infections. Cold
compresses will help the discomfort

20. e
Follicles in viral conjunctivitis Epidemic keratoconjunctivitis

21. Epidemic Haemorrhagic Conjunctivitis
• First reported in West Africa in the 1960s ‘Apollo
disease’
• Caused by enterovirus 70
• Highly contageous
• Has a very short incubation period 1-2 days
• Small subconjunctival haemorrhages and multiple
petechial haemorrhages all over surface of
conjunctiva
• Disease is acute, but short-lived so patients
usually recover rapidly and completely
• Treatment - As for Epidemic Keratoconjunctivitis

22. Epidemic Haemorrhagic conjunctivitis

23. Allergic Conjunctivitis
• Most common eye diseases seen at the OPD
(esp. among children)
• Geographical, genetic and environmental
factors are influential in this disease
• Occur in the following forms:
Vernal conjunctivitis (the most important)
Hay fever conjunctivitis
Phlyctenular conjunctivitis
Allergies to drugs and cosmetics

24. Vernal Conjunctivitis
• Chronic allergic conjunctivitis
• Most common in children between 3 and 16
years old
• More common in boys than girls
• They are bilateral
• Onset isusually after age 5 years and eventually
resolves at 17 years old. Rarely can persist
beyond age 25 years
• Specific allergen not identified. May be due to
some material in the atmosphere e.g pollen

25. Symptoms and Signs of Vernal
Conjunctivitis
• Severe and persistent itching and irritation in both eyes
• Sticky white discharge (mucous)
• Thickening of conjunctiva with paplilae inside of upper
eyelid or at limbus
Papillary hypertrophy on inside of upper eyelid. Papillae
may become giant papillae and fit together to become
cobble-stones
At limbus, conjunctiva appears thick and swollen. Small
pin-point white spots appear (“Trantas’ spots”)
• Treatment –
 Topical steroids and antihistamines and eyelid toileting
Giant papillae that that don’t respond to medical
treatment and causing corneal scarring are destroyed by
cryotherapy or cautery

26. Verna conjunctivitis
Giant papillae (cobble-stones) Trantas’ spots

27. Phlyctenular Conjunctivitis
• Phlycten is a Greek word for blister
• Disease is caused by localized hypersensitivity reaction to
bacterial proteins in bloodstream (usually tubercular)
• Hence every patient with phlycten is a tuberculosis suspect
• Children and young adults more affected
• Commonly situated at or near limbus but can be anywhere
on bulbar conjunctiva
• Appears as a raised pinkish nodule surrounded by and area
of hyperaemia. Later develops necrotic grey surrounded by
reactive inflammation. Finally necrotic centre sloughs out
and heals with little or no scarring
• Might migrate towards centre of cornea, ulcerates and
heals with vascularization an scarring
• Treatment - Topical steroid. If due to tuberculosis treat
accordingly

28. Phlycten
Early stage Advancing to the cornea

29. Hay fever conjunctivitis
• An acute allergic reaction to pollen in air
• Usually associated with acute rhinitis
• Has no conjunctival structural changes like in
vernal conjunctivitis
• Symptoms subside with short course of
antihistamine drops

30. Traumatic Conjunctivitis
• Due to physical and chemical irritants
• Corneal foreign bodies are common and easy
to miss
• Snake venom conjunctivitis is common esp.
spitting cobra
• Symptoms and signs are as already discussed
• Treatment is specific

31. Keratoconjunctivitis Sicca (KCS)
• Refers to dry eye primarily resulting from aqueous tear deficiency
• Lacrimal gland and accessory conjunctival glands produce fewer
tears
• Causes: - Atrophy and fibrosis of lacrimal tissue
– In pure KCS, which the lacrimal glands are alone involved
– Sjogren’s syndrome, which autoimmune disease characterised by
rheumatoid arthritis, xerostoma (dry mouth),
hypergammaglobulinaemia and other mucous membrane problems
• Exposed conjunctival and corneal epithelial cells become
degenerated and dehydrated and result in superficial punctate
keratoconjunctivitis
• Quite common in old people
• Symptoms – Eyes feel dry, sore and gritty, and burning sensation
• Treatment
– Tear substitutes e.g methyl cellulose drops
– Topical antibiotic to prevent secondary infection
– In severe cases lacrimal puncta is closed with cautery

32. Summary of conjunctivitis
Type Symptoms and Signs Management Prevention
Bacterial
conjunctivitis
Red eye
Discharge of pus
Pain/Photophobia (especially
if secondary corneal
involvement)
Topical antibiotics
Intensive instillation
for first day or until
symptoms and signs
reduce
Personal hygiene:
hand washing
Correct cleaning and
disinfection of
instruments between
examinations
Viral
Conjunctivitis
Red eye
Watery discharge
Irritation
Subconjunctival
haemorrhages
Pain/Photophobia (especially
if secondary corneal
involvement)
Cold compresses to
relieve discomfort
Topical antibiotics to
prevent secondary
infections
Personal hygiene:
hand washing
Correct cleaning and
disinfection of
instruments between
examinations
Allergic
Conjunctivitis
Conjunctival
hyperpigmentation/Red eye
Itch/Irritation
Trantas spots
Cobblestones
Reassurance
Antihistamines (eye
drops or orally)
Steroid eye drops
Eye lid toileting
Avoid allergens

33. Conjunctival Degenerations
• Types
Pinguecula
Pterygium
• Pinguecula - Latin word "pinguis" for fat or grease.
It is a fatty degenerative (yellow-white) deposit on bulbar
conjunctiva adjacent to the limbus
Found on conjunctival epithelium in the exposed intrapalpebral
fissure
No significant symptoms but because if it is raised can become
inflamed
Most prevalent in tropical climates and is in direct correlation
with UV exposure
Most common in people over 40 yrs, but can be found in 20 and
30 years old adults who spend significant time in the sun
• Treatment – No treatment needed. If inflamed (i.e.
pingueculitis), topical steroid is used

34. Pinguecula

35. • Pterygium (means wing)
Triangular sheet of fibrovascular conjunctival tissue
Grows from limbus towards centre of cornea in a shape of
wedge
Usually starts nasally but occasionally temporally (3 o’clock or 9
o’clock)
Main part near the limbus is more vascular than surrounding
conjunctiva
At the tip is degeneration and opacification of superficial
cornea
Factors for growth is excessive exposure to sunlight, dry, hot and
dusty conditions
Pterygium is more active, vascular and fleshy in young people.
Becomes thin and atrophic in old people
It is twice as likely to occur in men than women
Symptoms are irritation to eye, blurred of vision due to
astigmatism and if reaches the pupil
Treatment – if small and inflamed vasoconstrictor or steroids are
used. Excision is done if it covers part of pupil.

36. Pterygium
Covered part of pupil Reached the centre of pupil

37. Tumours
• Melanocytic conjunctival lesions
Melanosis
Naevus
Melanoma
• Non-pigmented conjunctival tumours
Papilloma
Conjunctival interepithelial neoplasia
Invasive sqamous cell carcinoma
• Choristoma
Dermoids
Lipidermoids

38. Melanosis
• Increased pigmentation caused by hyperplasia or
hypertrophy of melanocytes
• Types of Melanosis
– Epithelial Melanosis
• Frequently seen in blacks and people with dark complexion
• Develops in first few years of life becomes static by early
adulthood
• Usually bilateral but intensity and distribution may be
asymmetrical
• Conjunctiva has areas of flat, patchy, brownish pigmentation
scattered all over
• Prominent in the interpalpebral fissure and fades in
intensity towards fornices
• Pigmentation may particularly marked at limbus
• It is within the epithelium and conjunctiva moves freely over
sclera
• No treatment as it does not become malignant

39. Conjunctival Epithelial Melanosis

40. Melanosis (cont.)
Oculodermal Melanosis (Naevus of Ota, Congenital ocular
melanocytosis)
Hyperpigmentation facial skin an mucous membranes in
the distribution of ophthalmia, maxillary and sometime
mandibular division of trigeminal nerve
Dermal – only the skin involved (1/3 of cases)
Ocular - Only episclera is involved. Rare. Does not move over
globe because of its deep location
 Oculodermal- Both skin and eye affected (2/3 of patients)
Other ocular findings include glaucoma*, melancytosis of
cornea and lens, uveitis, cataract and hyperpigmentation
of optic nerve head
Has malignant transformation
Melanosis frequently affects ipsilateral uvea, orbit and may
extend to the meninges and brain
No treatment but should be followed for malignancy and
glaucoma

41. Ocular Melanosis

42. Naevus
• Benign tumour composed of naevus cells or melanocytes
and can produce melanin
• Usually found during puberty or early adult life
• It is a solitary, sharply demarcated, flat or slightly
elevated lesion
• May be focal or diffuse but never multifocal
• Vast majority do not become malignant
• Rare on the palpebral and fornices. Hence pigmented
lesion there should be to rule out melanoma
• As it doesn’t extend to peripheral cornea, pigmented
lesion extended to cornea should be considerd as
malignant melanoma
• Treatment – Excision for cosmetic reasons. Other with
enlargement in adulthood should also be excised

43. Naevus
Deeply pigmented Lightly pigmented

44. Melanoma
• Accounts for only 2% of all ocular melanomas
• Typical during the early fifties
• Rare in blacks and during first decades of life
• Solitary, pigmented or non-pigmented nodule
• Non-pigmented has smooth, vascularized or fish-flesh
appearance
• Common site is the limbal area but can appear in other
sites
• Overall mortality rate is 25%
• Treatment – local excision. Exentration for bulky
tumours. Chemotherapy for metastatic disease

45. Melanoma
Limbal melanoma Tarsal melanoma

46. Non-pigmented Conjunctival Tumours
• Papilloma – can be pedunculated or sessile
Pedunculated papillomas
Affect children and young adults
Caused by infection with papillovirus
Treatment is by excision or cryotherapy
Sessile (neoplastic) papillomas
Affect older adults
Not infectious
Usually single and located on bulbar conjunctiva or
limbus
Treatment is surgical

47. Pedunculated papilloma

48. Sessile Papillomas

49. Squamous Cell Carcinoma
• Characterized by deep invasion of the stroma
with fixation to underlying tissues
• If untreated it may penetrate to reach inside of
eye and spread rapidly
• It is a white, roughened, raised lesion at limbus in
the interpalpebral fissure
• It is rare and may be misdiagnosed as pterygium
• Treatment – Excision, for advanced cases
enucleation or exenteration is done

50. Squamous Cell Carcinoma

51. Choristoma
• Congenital overgrowth of normal tissue in
abnormal locations
• Types
Dermoids
Consist of collagenous tissue covered by epidermoid
epethelium
Solid white mass mostly at the limbus
Lipodermoids
Consist of adipose tissue covered by surrounding tissue
Soft, yellow, movable, subconjunctiva mass
Mostly located at limbus or outer canthus
• Treatment - Excision

52. Dermoid in a Baby

53. Lipodermoid

54. THANK YOU!!