Anatomy of Conjunctiva with the applied Anatomy

1. DEPARTMENTAL SEMINAR
on
Anatomy of Conjunctiva
By,
Dr Anushruth T Bhandare
1st Year PG Scholar
SJGAMC
DATE : 12-07-2022
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2. Contents
Introduction
Parts of conjunctiva
Conjunctival glands
Blood supply and Lymphatic drainage
Nerve supply
Functions of conjunctiva
Tearfilm
Applied Anatomy of Conjunctiva
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3. INTRODUCTION
Conjunctiva is a transparent mucous
membrane that lines the posterior
surface of the eyelids and the anterior
surface of the eye ball, terminating at
the corneoscleral limbus.
It joins the eyeball to the eyelids
 it stretches from the lid margin to the
limbus and encloses a complex space
called conjunctival sac
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4. Parts of conjunctiva
Conjunctiva can be divided into
3 parts
A. Palpebral Conjunctiva
B. Bulbar Conjunctiva
C. Conjunctival Fornix
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PARTS OF CONJUNCTIVA
A. Palpebral
Conjunctiva
C. Conjunctival
Fornixes
B. Bulbar
Conjunctiva
1. Marginal
3. Orbital part
2. tarsal 2. Limbal
1. Scleral 1. Superior
2. Inferior
4. Medial
3. Lateral

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7. A. Palpebral conjunctiva
Highly vascular
Extremely thin
Can be subdivided into 3 part
1. Marginal Conjunctiva
2. Tarsal Conjunctiva
3. Orbital Conjunctiva
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8. 1. Marginal conjunctiva
 Extends from lid margin to about 2mm on the back of the
lid up to the sulcus sabtarsalis
Consist of 5 layers 5 layered non keratinized stratified
squamous epithelium
Superficial layer- squamous cells
Middle 3 layers- Polyhedral cells
Deepest layers- Cylindrical cells`
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9. 2. Tarsal conjunctiva
Tarsal conjunctiva is thin, transparent and highly vascular
In the upper lid it is Firmly adhered to tarsal plate
In lower lid it is adherent only to half width of the tarsus
Tarsal glands can be seen through this layer as a yellow
streak
Consist of 2 layers of stratified cuboidal epithelium
Superficial layer- cylindrical cells
Deepest layer- cuboidal cells 12-07-2022
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11. 3. Orbital conjunctiva
Lies loose between tarsal plate and fornix
Orbital conjunctiva of upper lid is loose and lies over the
muller’s muscle so folds readily
Shallow grooves and elevations are called stieda’s
plateaux and grooves
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12. b. Bulbar conjunctiva
Lies in contact with eyeball
Thin translucent and loosely attached by connective tissue
to sclera and fascia bulbi
Consist of 3 layers of stratified squamous epithelium
1. Superficial layer – Cylindrical cells
2. Middle layer – polyhedral cells
3. Deepest layer – cuboidal cells
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13. 1. Scleral conjunctiva
Covers the anterior sclera and is continuous with the
corneal epithelium at the limbus
It is transparent and lies loose over the underlying
structures and thus can be moved easily
Its separated from the anterior sclera by episcleral tissue
and tenon’ capsule
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14. 2. Limbal conjunctiva
Limbal conjunctiva is a 3 mm ridge of bulbar conjunctiva
around the cornea
In this area tenon’s capsule and episcleral tissue are fused
into a dense tissue which is strongly adherent to the
underlying corneoscleral junction
At the limbus the epithelium of conjunctiva becomes
continuous with that of cornea
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15. 12-07-2022
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16. c. Conjunctival fornix
It joins bulbar conjunctiva with
palpebral conjunctiva
Subdivided into
1. Superior fornix 10 mm from
limbus, ducts of lacrimal gland
open into the lateral part of
superior fornix
2. Inferior fornix 8 mm from
limbus
3. Lateral fornix 14 mm from
limbus
4. Medial fornix 7 mm from
limbus
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17. Conjunctival sac
The conjunctiva while lining the structures like the
posterior part of the lids and anterior part of the globe
forms a sac that opens at the palpebral fissure. The
conjunctival sac contains about 7µl of tear fluid but has
the capacity to accommodate fluid up to 30 µl.
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18. Histological structures of conjunctiva
Layers of conjunctiva
1. Epithelium
2. Adenoid layer
3. Fibrous layer
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19. 1. Cells present in epithelium
The conjunctival epithelium is a non-keratinized, stratified
columnar epithelium that lines the inside of the eyelids
and covers the sclera.
The conjunctiva contains Goblet Cells that secrete mucin,
which generates the moisture that covers the surface of the
eye and allows the eyelids to open and close easily
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20. 2. Adenoid layer
Also called as lymphoid layer
Consists of fine connective tissue reticulum in the meshes
of which lie lymphocytes
Most developed at fornixes
Not present at birth, develops after 3-4 months of life.
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21. 3. Fibrous layer
Consist of meshwork of collagenous and elastic fibres
This layer is thicker than the adenoid layer, except in the
region of tarsal conjunctiva
Blends with the underlying tenon’s capsule in the region
of bulbar conjunctiva
Contains blood vessels and nerves suppling conjunctiva
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CONJUNCTIVAL GLAND
1. Mucin
Secretory Gland
a. Goblet Cells
b. Henle’s Glands
c. Glands of
Manz
2. Accessory
Lacrimal
Glands
a. Glands of
Krause
b. Glands of
Wolfring

23. A. Goblet cells
Unicellular, round and oval cells present abundantly in
conjunctival of all regions except marginal and limbal
conjunctiva
Formed in the deepest layers of epithelium and then are
pushed upwards
They are destroyed after discharging their content, the
mucin
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24. a. Goblet cells
Numerous of cells present on the
nasal side, particularly in bulbar
conjunctiva and inferior fornix
Density of cells is high in children
and young adults
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25. b. Henle’s glands
Tubular structures with lumina of 15-30µm which
contains a few goblet cells
Present in the folds of mucous membrane present in the
palpebral conjunctiva between tarsal plate and fornixes
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26. c. Glands of manz
Found in limbal conjunctiva
Arranged in ring, near the cornea
Secrete mucus essential for wetting the cornea and
conjunctiva
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27. Functions of mucin
Provide a hydrophilic layer that allows for even
distribution of the tear film
Provide lubrication and protects the epithelial cells of
cornea and conjunctiva
Ensures tearfilm stability by reducing the surface tension
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28. a. Glands of Krause
Lie in deep sub-conjunctival tissue of the upper and lower
fornixes
Upper fornix- 42 in number
Lower fornix- 6-8 in number
In the upper fornix they lie between the palpebral part of
the lacrimal gland and tarsal plate
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29. b. Glands of wolfring
Also called as glands of ciaccio, larger than Glands of
Krause
Situated in the upper border of the tarsus midway between
the end of the tarsal glands
Upper lid- 2-5 in number
Lower lid- 1-3 in numbers
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31. The plica semilunaris
Pinkish crescentic fold of the conjunctiva, present in the
medial canthus
Lateral free border is concave which becomes less
prominent on abduction but forms a cul-de-sac about 2mm
in depth when eyeball is adducted
Vestigial in humans
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32. The plica semilunaris
Epithelium of this part of conjunctiva consist of 8-10
layers of cells with many goblet cells
Substantia propria is composed of oose connective tissue
containing numerous blood vessels, lobule of fat, a few
non striated muscle fibres and melaphores
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34. The caruncle
It is small (5mm×3mm), soft, ovoid, pinkish mass situated
in inner canthus, just medial to plica semilunaris
It is a piece of modified skin and so is covered with
stratified squamous epithelium and contains sweat glands,
sebaceous glands and hair follicles
Blood supply through superior medial palpebral artery
Nerve supply is from inferior trochlear nerve
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36. Blood supply and lymph drainage
Artery supply by
Peripheral arterial arcade
Marginal arterial arcade
Venous drainage
Venous plexus of eyelids
Pericorneal plexus
Lymphatic drainage
Lateral side- preauricular lymph nodes
Medial side- submandibular lymph nodes 12-07-2022
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37. Nerve supply
Circumcorneal zone- branches from long ciliary nerves
which supply the cornea
Rest of the conjunctiva- branches from lacrimal,
infratrochlear, supratrochlear, supraorbital and frontal
nerves
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38. Functions of conjunctiva
Production of tears (mucin by the goblet cells and aqueous
by the accessory lacrimal glands)
Supply of oxygen directly to the cornea when the eyes are
open
Wash off debris
Maintain a smooth ocular surface
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39. Functions of conjunctiva
Protection of the eye by defence mechanism which include
Non-Specific measures
i. presence of an intact epithelial barrier
ii. Lacrimation
iii. Provision f rich blood supply and mucin clumping
Specific immunological mechanisms
i. Outpouring of mast cells
ii. Leucocytes
iii. Presence of an active mucosal-associated lymphoid tissue
iv. Secretory IgA 12-07-2022
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40. Tear film
Conjunctival surface is lubricated by the tear film
It is triple-layered
1. Innermost mucinous layer- lines conjunctival cells and
corneal epithelium, secreted by the goblet cells,
crypts of Henle, and by glands of Manz.
2. Middle aqueous layer- secreted by glands of Krause and
glands of wolfring
3. Outermost superficial lipid layer- secreted by meibomian
glands , this layer limits the evaporation of tears
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41. Applied anatomy of conjunctiva
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42. Applied anatomy of conjunctiva
1. Inflammatory conditions of Conjunctiva
2. Degenerative conditions of Conjunctiva
3. Symptomatic conditions of Conjunctiva
4. Cysts and Tumors of Conjunctiva
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43. 1. Inflammatory conditions of Conjunctiva
Infective conjunctivitis
i. Bacterial conjunctivitis
ii. Chlamydial conjunctivitis
iii. Viral conjunctivitis
iv. Granulomatous
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44. 1. Inflammatory conditions of Conjunctiva
Allergic conjunctivitis-
inflammation due to allergic
or hypersensitivity reactions
may be immediate (humoral)
or delayed (cellular)
Simple Allergic conjunctivitis
Vernal keratoconjunctivitis
Atopic keratoconjunctivitis
Giant papillary conjunctivitis
Phlyctenular
keratoconjunctivitis (PKC)
Dermatoconjunctivitis (ADC)
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45. Simple Allergic conjunctivitis
It is a mild, nonspecific
allergic conjunctivitis
characterized by itching,
hyperaemia and mild papillary
response. Basically, it is an
acute or subacute urticarial
reaction.
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46. Vernal keratoconjunctivitis
VKC is a recurrent, bilateral,
interstitial, self-limiting, allergic
inflammation of the conjunctiva
having a periodic seasonal
incidence.
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47. Atopic keratoconjunctivitis
It can be thought of as an adult
equivalent of vernal
keratoconjunctivitis and is often
associated with topic dermatitis.
Most of the patients are young
adults, with male predominance
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48. Giant papillary conjunctivitis
GPC is the inflammation of
conjunctiva with formation of
very large sized papillae.
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49. PHLYCTENULARKERATOCONJUNCTIVITIS
Phlyctenular
keratoconjunctivitis is a
characteristic nodular
affection occurring as an
allergic response of the
conjunctival and corneal
epithelium to some
endogenous allergens to
which they have become
sensitized 12-07-2022
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50. CONTACTDERMATOCONJUNCTIVITIS
It is an allergic disorder,
involving conjunctiva and
skin of lids along with
surrounding area of face
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51. 1. Inflammation conditions of Conjunctiva
Cicatricial conjunctivitis-
its is a chronic
conjunctivitis with
conjunctival fibrosis
Toxic conjunctivitis- it is a
type of chronic follicular
conjunctivitis that occurs as
a response to toxic cellular
debris desquamated into the
conjunctival sac
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52. 2. Degenerative conditions
Pinguecula
Pterygium
Concretions
Amyloid degenerations
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53. Pinguecula
It is an extremely common
degenerative condition of
conjunctiva. characterized by
formation of a yellowish
white patch on the bulbar
conjunctiva near the limbus
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54. Pterygium
It is a wing shaped folds of
conjunctiva encroaching
upon the cornea from
either ide within the
interpalpebral fissure
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55. Concretions
These are formed due to
accumulation of inspissated
mucus and dead epithelial
cell debris into the
conjunctival depressions
called loops of Henle
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56. Amyloid degeneration of conjunctiva
The deposition of yellowish,
well-demarcated, irregular
amyloid material in the
conjunctiva with superior
fornix and tarsal conjunctiva
being more commonly
involved areas.
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57. Symptomatic conditions of Conjunctiva
A. Hyperaemia
B. Haemorrhages/Ecchymosis
C. Chemosis
D. Xerosis
E. Conjunctival discharge
F. Follicles
G. Papillae
H. Pseudomembranous
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58. a. Hyperaemia
Hyperaemia of conjunctiva means
congestion of the conjunctival vessels
Conjunctival hyperemia is caused by a
pathological vasodilatory response of the
microvasculature in response to
inflammation due to a myriad of
infectious and non-infectious etiologies
May be transitory, acute, recurrent or
chronic
Transitory Hyperaemia- due to
temporary irritation such as by small F/B
in conjunctival sac 12-07-2022
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59. a. Hyperaemia
Acute/Recurrent Hyperaemia-
concretions in palpebral conjunctiva
inspissated calcareous secretions in
meibomian glands
In-growing eye lashes
Chronic Hyperaemia- caused by
condition such as
Dusty
Ill-ventilated rooms
Exposure to heat or dryness
Allergic conditions such as hay fever
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60. b. Haemorrhages
A bright red patch appearing in
the white of the eye beneath
the clear lining of the eye
(conjunctiva)
May occur in
viral conjunctivitis- when
they are often multiple, small
and discrete such as
“Petechial bleeding”
Severe bacterial conjunctivitis
when they are lager and
diffuse 12-07-2022
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61. c. Chemosis (conjunctival oedema)
Chemosis of conjunctiva is due
to exudation from abnormal
permeable capillaries retained
within the mucous membrane
which becomes swollen and
gelatinous
Translucent swelling of
conjunctiva when severe may
protrude through the eyelids
Acute chemosis-
Hypersensitive response to
allergens' such as pollen
grains
Severe infective conjunctivitis
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62. c. Chemosis (conjunctival oedema)
Subacute/Chronic chemosis-
Local- thyroid eye disease,
chronic allergic conjunctivitis
trauma
Increased systemic vascular
permeability- vasculitis, allergic
conditions
Increased venous pressure-
superior venacava syndrome,
right-sided heart failure
Decreased plasma oncotic
pressure- nephrotic syndrome
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63. d. Xerosis
Refers to symptomatic
condition in which
conjunctiva becomes dry
and lusterless.
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64. e. Conjunctival discharge
Refers to the production of
excessive secretion in
conjunctival disorders
Depending upon nature of the
disease various types of
discharge can be seen
Watery/Mucoid discharge-
viral and allergic conjunctivitis
Mucopurulent discharge-
bacterial conjunctivitis
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65. f. Follicles
Appears as yellowish-white round
elevations more prominent in the
fornixes
1-2mm in diameter
Occurs due to localized aggregations
of lymphocytes in subepithelial
adenoid layer
Unless an acute inflammation is
present , the conjunctiva over them
remains normal
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66. g. papillae
Papillae are a hyperplasia of
normal vascular system with
glomerulus-like bunches of
capillaries growing into the
epithelium in inflammatory
conditions
Papillae can develop only in the
palpebral conjunctiva and in the
limbal bulbar conjunctiva where
it is attached to deeper fibrous
layers
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67. h. Pseudomembranous
A pseudomembrane is formed
when inflammatory exudate
rich in fibrin coagulates on
the conjunctiva
Pseudomembranous consist of
coagulated exudate adherent
to the inflamed conjunctival
epithelium.
They can be peeled away
leaving the underlying
epithelium intact. 12-07-2022
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68. 4. Cysts and tumours
Cysts of conjunctiva-common cystic lesions are
Congenital cystic lesions
lymphatic cysts
Retention cyst
Epithelial cyst
Aqueous cyst etc.
Tumors of conjunctiva- classified into 2 types
Non-pigmented tumours- congenital, benign, premalignant,
malignant
Pigmented tumours- benign, precancerous melanosis,
malignant 12-07-2022
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69. Common Symptoms of conjunctival disorders
Redness
Stickiness
Foreign body
sensation/ Grittiness
Lacrimation
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70. Common Symptoms of conjunctival disorders
Photophobia
Burning sensation
Dryness of eyes
Blurring of vision which
may be due to excessive
formation of tear film
over cornea
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71. Conclusion
Let us have a glans
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