The conjunctiva is a mucous membrane divided into palpebral, fornicial, and bulbar sections, characterized by a histology that includes various cells. Conjunctivitis is an inflammation with two main forms: acute and chronic, presenting symptoms like red sticky eyes, and can be caused by multiple factors including bacterial, viral, and allergic agents. Clinical evaluation involves assessing symptoms, discharge types, and potential underlying systemic diseases, with management strategies differing based on causative agents.

2. Introduction
• The conjunctiva is a thin vascularised mucous
membrane consisting of a non keratinising,
stratified, columno-squamous epithelium and
a substantia propria.
• It leaves the posterior surface of the eyelids
from which it is reflected forwards at the
fornices, to cover the anterior sclera.

3. Subdivisions
• 1. palpebral.
it is firmly adherent to
the tarsal plate.
• 2. fornicial.
loose, redundant and
swells easily.
• 3. bulbar.
covers ant sclera.
loosely attached to
underlying Tenon
except at limbus.

4. Histology
• 1. conjunctival epithelium
2-5 cells layer
- epithelial basal wing and
superficial polyhedral cells
- others :
• - melanocytes (in the basal
layer)
• - Langerhans antigen
presenting cells also (in the
basal layer)
• - goblet cells more numerous
in the fornices and plica (infro
nasaly)
• 2. the stroma ( substantia
propria)
- richly vascularized connective
tissue.
Note:-
Adenoid superfacial layer
doesn’t develop until age
of 3 months.

5. Conjunctivitis
• Conjunctivitis is an inflammatory process involving the
surface of the eye and characterized by vascular dilation,
cellular infiltration, and exudation.
• Two forms of the disorder are distinguished:
• 1. Acute conjunctivitis. Onset is abrupt and initially
unilateral with inflammation of the second eye within one
week. Duration is less than four weeks.
• 2. Chronic conjunctivitis. Duration is longer than three to
four weeks.

6. Conjunctivitis
• The most common ophthalmic
symptom is one of "red sticky
eyes" secondary to
conjunctivitis.
• Types of conjunctivitis
-Bacterial
-Chlamydial
-Viral
-Allergic/Hypersensitivity
-Toxic
-Other
Others:
• Blepharo-conjunctivitis.
• Rosacea kerato-
conjunctivitis
• Dry eye syndromes.
• Fungal conjunctivitis.
• Parasitic conjunctivitis.
• Ligneous conjunctivitis.
• Granulomatous
conjunctivitis.
• Systemic disease.
Conjunctivitis may be a feature
of a number of systemic
disorders including rheumatoid
arthritis, Wegener's
granulomatosis, Stevens-
Johnson syndrome, Lyell's
syndrome (toxic epidermal
necrolysis), scleroderma and
linear IgA disease.

7. Clinical evaluation
• Differential diagnosis determined from:
a. symptoms (eg. pain, Itching).
b. discharge.
c. conjunctival reaction.
d. membranes
e. lymphadenopathy.

8. Discharge
• It is exudate with epith debris, mucus and tears.
1. Watery (serous exudate+tears):
acute viral, allergic.
2. Mucoid :
vernal conj & keratoconj sicca.
3. purulent: severe acute bacterial.
4. mucopurulent:
mild bacterial, chlamydial.

10. Conjunctival reaction
• 1. Injection: more in fornices.

12. • 2. subconjunctival
hemorrhage
usually viral (mainly
picorna) highly
infectious but self-
limiting.
also strep. Pnemonia &
H. aegypticus do.

13. • 3. Oedema (chemosis)
In severely inflamed conj due to protien rich fluid

14. • 4. Scarring
trachoma, ocular cicatricial pemphygoid, atopic
conjunctivitis & prolonged use of topical medications.

16. 6. Papillary reaction
• Non specific.
• Hyperplastic conjunctival epithelium with central
vessels & diffuse infiltrate of chronic inflamatory
cells.
• Can develop only in palpebral conj & bulbar at
limbus.
• Mostly seen in upper palpebral conj as fine mosaic-
like elevated polygonal hyperemic areas separated
by palor channels.
• Causes: chronic blepharitis, allergic & bact
conjunctivitis, contact lenses and superior
limbic keratoconjunctivitis.

18. • Note: the appearance of normal sup edge of tarsal plate( inf
when inverted) may mimic papillae & follicles so should not
be used as a clinical sign.

19. Membranes
• 1. pseudo
membranes:
coagulated exudate
adherent w inflamed
conj, easily peeled of
leaving intact
epithelium.
Causes: adenoviral,
gonococcal, ligneous
conj & Steven Johnson
syndrome.

20. • 2. true
membrane:
infiltrate
superfecial
layer of epith
conj.
if removed
bleeding occurs.
causes: strep
pypgenes and
diphtheria.

21. Lymphadenopathy
• Lymph drainage of the conj is to the
preauricular and sub mandibular regions
corresponding to the drainage of eye lids.
• Causes: viral, chlamydial, gonococcal and
perinaud oculoglandular syndrome.

22. Lab investigations
• Indications:
- sever purulent conjunctivitis.
- follicular conjunctivitis.
to R/O chlamydial.
- conjunctival inflammations
that are insufficient ti achieve diagnosis.
- neonatal conjunctivitis.

23. • Cultures. These are usually made on
blood (aerobic bacteria, fungi) and
chocolate agar (neisseria, haemophilus),
thioglycolate and meat broths
(anaerobes) or on other special media
when necessary. Sabouraud's agar and
brain-heart broth may be used to grow
fungi.
• Others: cytologic investigations, detection
of viral or chlamydial antigens, impression
cytology and PCR.

26. Simple bacterial conjunctivitis
• The commonest causative bacteria are
Staphylococcus aureus (in children and adults),
Streptococcus pneumonia and Haemophilus
influenzas (especially in children) and others
include Streptococcus viridans and pyogenes.
• It is a common self limiting condition mostly
affecting children.
• Spread by direct contact with infected secretions.

27. -Usually the onset is relatively acute.
-The patient usually has discomfort and a purulent
discharge in one eye that characteristically spreads to
the other eye. The eye may be difficult to open in the
morning because the discharge sticks the lashes
together. There may be a history of contact with a
person with similar symptoms.
- Discharge initially watery
mimiking viral.
History:

28. • —The vision should be normal after the discharge has been blinked clear
of the cornea. The discharge usually is mucopurulent and there is uniform
engorgement of all the conjunctival blood vessels. When fluorescein
drops are instilled in the eye there is no staining of the cornea.
• Injection maximal at fornices and less at limbus.
- Valvety, beefy red tarsal conjunctiva.
- Superfacial punctate epithelial erosions.
Examination

29. Management
• even without treatment, simple types resolves
within 10-14 days .
• Topical antibiotic eye drops (for example,
chloramphenicol) should be instilled every two hours
for the first 24 hours to hasten recovery, decreasing
to four times a day for one week. Chloramphenicol
ointment applied at night may also increase comfort
and reduce the stickiness of the eyelids in the
morning. Patients should be advised about general
hygiene measures; for example, not sharing face
towels.

30. Gonococcal keratoconjunctivitis
• Caused by gram –ve diplococcus
Neisseria gonorrhoeae.
• It is capable of invading intact
corneal epith.
• Gonococcal conjunctivitis:-
- acute profuse purulent
discharge.
- edematous tender eye
lids, hyperemia, chemosis
and pseudo membranes.
- lymphadenopathy.

31. • Gonococcal keratitis:
- if conjunctivitis not
treated well, keratitis
occurs as follows:
1- marginal ulceration.
2 - coalescence to form a
pereferal ring ulcer.
3 - central ulceration
that may rapidly
lead to perforation and
endopthalmitis.

32. • Treatment:
1. admit, take cultures and remove discharge.
2. systemic
cefotaxime 1gm I.V b.d
( only 1 day if only conj involved).
3. topical gentamycin or bacitracin at very
frequent intervals.
Note: recognize and treat any associated chlamydial
infection.

34. Ophthalmia neonatorum
• is conjunctivitis occuring within the first three weeks of
life.
• The most serious cause is infection with Neisseria
gonorrhoeae,but in the UK it is caused more commonly
by Chlamydia trachomatis (neonatal inclusion
conjunctivitis - NIC) and by staphylococci or
pneumococci. Herpes simplex type 2 virus is a relatively
rare cause.
• Follicles and lymphadenopathy do not occur
• has an early onset from between 1 and 3 days post
partum.

37. Management
• Specimens should be obtained from the child, the
mother and her sexual partners).
• frequent irrigation.
• systemic and local antibiotics is appropriate for
bacterial conditions and aciclovir is used in
herpetic infection.
• Inclusion conjunctivitis is treated with systemic
and topical erythromycin.
• In all cases, the mother and her sexual partner
require appropriate treatment.

39. Adenoviral conjunctivitis
• varies from very mild to very severe.
• It is an occupational hazard of
opthalmologists.
• It is highly contagious and transmitted via
respiratory or ocular secretions &
dissimination by towels and equipments
as tonometer.
• Incubation period 4-10 days.

40. Adenoviral conjunctivitis.
• Adenoviral conjunctivitis can be classified into 3 types:
• -pharyngoconjunctival fever (PCF),
type 3, 4or 7 & may be 5
fever and general malaise
usually bilateral,
• -epidemic keratoconjunctivitis (EKC).
adenovirus type 8 or 19
absence of major systemic symptoms.
usually unilateral
• -non-specific follicular conjunctivitis (NFC).
mild adenoviral conjunctivitis, which is usually self-limiting
and requires no treatment.
Diagnosis is clinical, but can be aided by serology, or ELISA.

41. • Viral keratitis
• Stage 1:
- within 7-10 days
- punctate epith keratitis.
• Stage 2:
- focal white sub epithelial opacity, represents
immune response.
• Stage 3:
- anterior stromal infiltrates fades over months to
years.

43. • Clinical presentation
• acute watering, redness,
discomfort & photophobia.
Both eyes.
• usually lasts longer than
bacterial conjunctivitis and
may go on for many weeks;
patients need to be
informed of this.
• Photophobia and
discomfort may be severe if
the patient goes on to
develop discrete corneal
opacities.
• Examination
• bilateral diffuse
conjunctival injection.
• clear discharge.
• Small white lymphoid
aggregations may be
present on the conjunctiva
(follicles).
• Subconjunctival
hemorrhage.
• pre-auricular or
submandibular
lymphadenopathy

45. Management
• Viral conjunctivitis is generally a self limiting condition,
So only symptomatic, they mostly resolves spontaneously
within 2 weeks.
• but antibiotic eye drops (for example, chloramphenicol)
provide symptomatic relief and help prevent secondary
bacterial infection. Viral conjunctivitis is extremely contagious,
and strict hygiene measures are important for both the
patient and the doctor; for example, washing of hands and
sterilizing of instruments. The period of infection is often
longer than with bacterial pathogens and patients should be
warned that symptoms may be present for several weeks. In
some patients the infection may have a chronic, protracted
course and steroid eye drops may be indicated if the corneal
lesions and symptoms are persistent.