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Conjunctiva
This document provides information on diseases of the conjunctiva. It discusses the various types of conjunctivitis including bacterial, viral, allergic, and trachoma. It describes the clinical features, causes, treatment, and complications of acute bacterial conjunctivitis, gonococcal conjunctivitis, ophthalmia neonatorum, chronic bacterial conjunctivitis, angular bacterial conjunctivitis, vernal keratoconjunctivitis, pinguecula, and pterygium. The document is an extensive overview of conjunctival diseases and their management.
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Conjunctiva
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- 2. Glands of conjunctiva •Mucous secreting glands Goblet cells Crypts of henle Glands of manz • Accessory lacrimal glands Glands of Krause Glands of wolfring
- 3. INFECTIVE CONJUNCTIVITIS • BACTERIALCONJUNCTIVITIS: ETIOLOGY : 1. Predisposing factors: unhygienic conditions, flies, hot dry climate, dirty habits, poor sanitation 2. Causative organisms: Staphylococcus aureus/epidermidis, Streptococcus pyogenes/pneumoniae, Pseudomonas, Moraxella lacunata, Neisseria gonorrhea, Meningococcus, Hemophilus influenza 3. Mode of infection: exogenous, local spread, endogenous
- 4. PATHOLOGY : 1. Vascularresponse: congestion, permeabilility of conjunctival vessels, proliferation of capillaries. 2. Cellular response: exudation of PMN cells into subconjunctival propria. 3. Conjunctival tissue response: edematous, superficial epithelial cells degenerate and desquamate. Proliferation of basal layer of epithelium and inc. in goblet cells. 4. Conjunctival discharge: consists of tears, mucous, inflammatory cells, desquamated cells, fibrin and bacteria.
- 5. Clinical types • Acutebacterial conjunctivitis • Hyper acute bacterial conjunctivitis • Chronic bacterial conjunctivitis • Angular bacterial conjunctivitis
- 6. ACUTE BACTERIAL CONJUNCTIVITIS • M/c •A.k.a acute muco-purulent conjunctivitis • Marked conjunctival hyperemia and mucopurulent discharge. • Common causative organisms: staph. Strep. pneumococcus
- 7. Clinical features: Symptoms: • Redness •Mild photophobia • Discomfort, foreign body, grittiness • Muco-purulent discharge • Stickiness of lids during sleep • Colored halos • Slight blurring Signs : • Flakes of mucopus in fornices canthi and lid margins • Congestion – fiery red eye • Chemosis • Papillae • Petechial hemorrhage- pneumococcus • Odematous eyelids • Cilia matted with yellow crusts
- 8. Complications: • Marginal cornealulceration • Dacrocystitis • Superficial keratitis • Blepharitis Course: • One eye affected 1-2 days before other eye • Untreated mild case- 10-15 days • Or becomes chronic catarrhal conjunctivitis .
- 9. Differential Diagnosis: Differentiate fromother causes of red eye: • Conjunctivitis • Acute iridocyclitis • Acute congestive glaucoma Differentiate from other causes of conjunctivitis: • Bacterial • Viral • Allergic
- 10. Treatment: • Topical antibiotics-main treatment Start with Chloramphenicol, Gentamicin, Tobramycin eye drops in day and ointment at night. (stickiness+ Ab. effect) If not responding – Ciprofloxacin, Ofloxacin, Gatifloxacin, Moxifloxacin. • Dark goggles • Irrigation- with sterile luke warm saline 1-2/day • No bandage & no steroids • Anti inflammatory/ analgesic drugs Preventive measures: • Frequent hand washing • Avoid sharing towels, applicators, pillows
- 11. HYPERACUTE BACTERIAL CONJUNCTIVITIS • A.k.aacute purulent conjunctivitis • Violent inflammatory response • 2 types: gonococcal conjunctivitis & ophthalmia neonatorum
- 12. GONOCOCCAL CONJUNCTIVITISEtiology: • spread fromgenitals to eye, m/c in males Symptoms: • Pain • Discharge- purulent/ sanguineous(bloody) • Mild photophobia • Swelling of eyelids • Sticking of lid margins • Slight blurring - mucous flakes Signs: • Eyelids- tense and swollen • Tenderness marked • Copious discharge trickling onto cheeks • Enlarged pre-auricular lymph nodes • Conjunctive- Chemosis, papillae, congestion, pseudo-membrane
- 13. Association: • Urethritis • Arthritis Complications: •Corneal involvement- haze, ulceration, perforation, central necrosis ( gonococcus can invade intact epithelium ) • Iridocyclitis • Systemic complications- arthritis, endocarditis, septicemia.
- 14. TREATMENT : • Systemictherapy- 3rd gen. cephalosporin followed by a week of doxycycline or erythromycin. • Topical antibiotic therapy- ofloxacin/ ciprofloxacin/ Tobramycin • Irrigation- sterile saline • General measures- goggles, avoid sharing, maintain hygiene. • Topical atropine- if cornea involved. N.B – both sexual partners given systemic therapy and evaluated for other STD’s
- 15. OPHTHALMIA NEONATORUM • A.k.aneonatal conjunctivitis • Hyperacute conjunctivitis in neonates(<30 days old ) • bilateral inflammation Etiology: • Before birth- infected liquor amnii>>PROM • During birth- face presentation in infected birth canal • After birth- soiled clothes or fingers
- 16. CAUSATIVE AGENTS: • Chemical- (6hrs) Crede’s method (AgNO3) • Gonococcal- (2-5days) • Other bacteria- (5-8 days) • Neonatal inclusion- (5-14days) Chlamydia (D-K) • Herpes simplex- viral cause(6-15days)
- 17. SYMPTOMS & SIGNS: •Swollen eyelid- infective cause • Discharge- purulent/ mucopurulent • Congestion and Chemosis • Pain and tenderness • Corneal involvement Complications: • Corneal involvement >> ulceration >> opacification and staphyloma formation
- 18. TREATMENT • Chemical: selflimiting • Gonococcal: topical + systemic • Other bacteria: broad spec Ab. Neomycin/ bacitracin/ Tobramycin • Neonatal inclusion: topical tetracycline/ erythromycin + systemic erythromycin for URTI. Saline lavage Penicillin drops/ bacitracin ointment Atropine sulphate 3rd gen cephalosporin- •Cefotaxime •ceftriaxone Ciprofloxacin
- 19. CHRONIC BACTERIAL CONJUNCTIVITIS• A.k.achronic catarrhal conjunctivitis Etiology: Predisposing factors: • Exposure to dust, smoke, irritants • Local irritation- trichiasis, foreign body • Eye strain • Alcohol abuse, insomnia Causative organism: • Staph aureus, proteus, Klebsiella, E.coli, moraxella lacunata Source/ mode of infection: • Continuation of ac. Conj. • Chronic inf. from Dacrocystitis, chronic rhinitis. • Exogenously from contact, airborne, material transfer
- 20. Clinical features: Symptoms: • Mildredness • Discharge- mucoid at canthi • On and off watering • Burning, grittiness • Difficult to keep eyes open Signs: • Congestion of posterior conjunctival vessels • Lid congestion • Sticky look of conjunctiva • Papillary hypertrophy
- 21. TREATMENT: • Eliminate pre-disposing factors • Topical antibiotics- chloramphenicol, tobramycin, gentamicin • Astringent eye drops- zinc-boric drops
- 22. ANGULAR BACTERIAL CONJUNCTIVITIS Mild inflammationconfined to conjunctiva and lid margins @ canthi Etiology: • Pre-disposing factors similar to chronic conj. • Moraxella Lacunata/ Axenfeld • Source- nasal cavity • Mode of spread- from nasal cavity to eyes by contaminated fingers/ handkerchief Pathology: • Proteolytic enzyme from organism >>> accumulates at canthi >>> maceration of epithelium of conjunctiva, lid margin, skin surrounding angle of eye >>> vascular/cellular responses
- 23. Clinical features Symptoms: • Irritation/discomfort/ burning sensation • Redness at angles • Dirty white foamy discharge at angles Signs: • Hyperemia of bulbar conjunctiva at canthi • Hyperemia of lid margins at angles • Excoriation of skin around angles • Foamy mucopurulent discharge at angles
- 24. TREATMENT • PROPHYLAXIS: goodpersonal hygiene, treat ass. Nasal infection. • CURATIVE: oxytetracycline eye ointment , zinc lotion in day time and zinc oxide ointment at bed time.
- 25. TRACHOMA (EGYPTIAN OPHTHALMIA) DEFINITION : “Chronickeratoconjunctivitis primarily affecting superficial epithelium of conjunctiva and cornea simultaneously. Characterized by mixed follicular and papillary response of conjunctival tissue, pannus formation, and in late stages cicatrization giving it a rough appearance.”
- 26. Etiology : • Causativeorganisms: Chlamydia trachomatis Serotypes A, B, Ba, C- blinding trachoma (EYE TO EYE) Serotypes D-K – oculogenital chlamydial disease (GENITALS TO EYE) • Predisposing factors: a) Age- childhood and infancy b) Sex- females c) Socioeconomic status- poor classes d) Climate- dry dusty weather e) Environmental factors- dust, smoke, irritants
- 27. Source of infection: •Conjunctival discharge from affected persons Mode of infection: • Direct spread • Material transfer • Vector transmission through flies Phases of trachoma: I. Phase of active trachoma II. Phase of cicatricial trachoma
- 28. 1. Phase ofactive trachoma (Occurs in childhood) • Symptoms: (in absence of secondary infection) Mild foreign body sensation Occasional lacrimation Slight stickiness Mucoid discharge • Signs: Conjunctival – Follicles- boiled sago grain congestion papillary hyperplasia Corneal- ulcer superficial keratitis Herbert follicles progressive pannus
- 29. 2. Phase ofcicatricial trachoma • Type 4 delayed hypersensitivity reaction Conjunctival signs: • Scarring- ARLT’s LINE • Concretions • Pseudocyst • Xerosis • symblepharon Corneal signs: • Regressive pannus • Corneal opacity
- 30. WHO classification: • F– stage of inflammation- follicular • I – stage of intense inflammation • S – stage of scarring • T – stage of trichiasis • O – stage of corneal opacity
- 31. TREATMENT Of active trachoma: (TF &TI stages) • Topical: a) Tetracycline/ erythromycin (1%) b) Sulfacetamide(20%) • Systemic: a) Doxycycline, tetracycline/erythromycin b) Azithromycin-DOC(single oral dose)- not in pregnancy and <6yrs. • Both: in severe ocular inf. + genital inf. a) Tetracycline/ erythromycin b) Azithromycin
- 32. Of cicatricial (inactive)trachoma: (TS, TT &CO stages) TS stage: scarring • Concretions removed with hypodermic needle • Conjunctival Xerosis treated with artificial lubricating drops TT stage: trichiasis • Permanent removal of lash by electrolysis, cryolysis or radiofrequency epilation. • Bilamellar tarsal resection CO stage: corneal opacity • PK- penetrating keratoplasty • KP- keratoprosthesis
- 33. PROPHYLAXIS SAFE strategy: • S-surgery (tertiary prevention) • A- antibiotics (secondary prevention) • F- facial hygiene (primary prevention) • E- environmental hygiene (primordial prevention)
- 34. ALLERGIC CONJUNCTIVITIS • Inflammationin response to hypersensitivity • Humoral/ cellular Types: Simple allergic- seasonal, perennial Vernal keratoconjunctivitis Atopic keratoconjunctivitis Phlyctenular conjunctivitis Giant papillary conjunctivitis Dermatoconjunctivitis
- 35. VERNAL KERATO CONJUNCTIVITIS(VKC) SPRING CATARRH •Recurrent, bilateral, self-limiting allergic inflammation with seasonal incidence • Etiopathogenesis: IgE mediated hypersensitivity reaction • Predisposing factors: more common in boys of 4-20 yrs, family h/o atopy, summer, eczema/asthma • Pathology: various proliferative and infiltrative changes in conjunctival epithelium/ vessels, adenoid and fibrous layers leads to formation of multiple papillae . • Symptoms: intolerable burning/ itching sensation, mild photophobia, lacrimation, ropy discharge, heaviness of lids.
- 36. Signs: • Palpebral form:cobble stone/ pavement appearance. Severe- cauliflower like excrescences. • Bulbar form: gelatinous membrane around limbus, Horner - Tranta’s dots • Mixed form: combined features of both
- 37. • Vernal keratopathy: involvementof cornea in VKC due to extension of limbal lesions m/c due to palpebral form. a. Punctate epithelial keratitis b. Frank epithelial erosions c. Vernal corneal plaques d. Shield ulcerations e. Sub-epithelial scarring f. Pseudogerontoxon Differential Diagnosis: VKC should be differentiated from atopic keratoconjunctivitis (AKC) and papillary hypertrophy.
- 38. TREATMENT Topical anti-inflammatory therapy: •Steroids- fluorometholone, medrysone, beta/ dexamethasone • Mast cell stabilizer- sodium cromoglycate (2%) • Dual action antihistamine and mast cell stabilizer- olopatidine, ketotifen • NSAID eye drops- diclofenac, ketorolac • Tacrolimus • Topical cyclosporine
- 39. Topical lubricating andmucolytics • Artificial tears • Acetyl cysteine Systemic therapy: • Oral antihistamines • Oral steroids Rx of large papillae: • Surgical excision Supportive measures: • Dark goggles • Maintain air conditioned • Ice compress/ packs Rx of vernal keratopathy: • Large vernal plaque- surgical excision • Shield ulcers- debridement, superficial keratectomy
- 40. PINGUECULA • Common degenerativecondition “Elastotic degeneration of collagen fibers of substantia propria of conjunctiva associated with deposition of amorphous hyaline material in conjunctiva.” • B/L yellowish white triangular patch near limbus, nasal side first. • Complications- calcification, intraepithelial abscess, doubtful conversion into pterygium. • Treatment- c/o inflammation- topical steroids & c/o cosmetic defect- surgical excision.
- 41. PTERYGIUM • Degenerative &hyperplastic condn. of conjunctiva • U/L or B/L wing shaped fold of conjunctiva encroaching upon cornea from either side. • Etiology- hot dry climate, prolonged exposure to UV rays, high wind and abundance of dust. • Pathology- elastotic degeneration and proliferation of subconjunctival tissue as vascularised granulation tissue which encroaches onto cornea. • Symptoms- Cosmetic Foreign body sensation/ irritation Diplopia Dec. vision- if grown onto cornea
- 42. • Signs- • Triangularfold of conjunctiva • Stocker’s line- deposition of iron • Differential diagnosis- pseudo-pterygium • Treatment: Medical- tear substitutes/ topical steroids, protection from UV rays Surgical excision- best method Recurrence- CLAU( surgical excision with free conjunctival limbal autograft)/ surgical excision with amniotic membrane and mitomycin C application.