Conjunctiva

 The conjunctiva is a connection (conjunction) between
the eyelids, sclera and cornea.
 It is the mucous membrane that lines the posterior
surface of the eyelids (palpebral conjunctiva) and the
anterior aspect of the globe (bulbar conjunctiva).
 The potential space, lined by conjunctiva, between the
lids and the globe, is termed the conjunctival sac.
 The reflections of the conjunctiva from the lids to the
globe are known as fornices. The lacrimal glands open
into the superior fornix.
11/11/2017 2Dr. Mohammed Najmussadiq Khan M. S. (Ophth)

 The palpebral conjunctiva contains the openings of
the lacrimal canaliculi, thereby allowing tears within
the conjunctival sac to drain into the nasal cavity. The
palpebral conjunctiva is red and vascular and is
examined when anaemia is suspected.
 The palpebral conjunctiva is subdivided into marginal,
tarsal, and orbital zones. The marginal zone
transitions between skin and conjunctiva and shows
minimal keratinization. The tarsal conjunctiva is a
fairly flat layer. The orbital zone shows more
numerous Goblet cells.

 The bulbar conjunctiva is translucent, thereby
allowing the sclera to show through as the
"white of the eye". It is colourless, except
when its vessels are dilated as a result of
inflammation (conjunctivitis)
 The Goblet cells produce gel forming mucins
called MUC5AC that may be critical to
providing lubrication to the ocular surface.
11/11/2017 Dr. Mohammed Najmussadiq Khan M. S. (Ophth) 4

 The conjunctiva is supplied by branches of
the ophthalmic nerve.
 The vessels of the bulbar conjunctiva are
visible. They arise from (1) a peripheral
palpebral arcade and (2) the anterior ciliary
arteries

 The conjunctiva is the thin transparent
mucosa membrane that covers the posterior
surface of the lids (palpebral conjunctiva) and
the anterior surface of the sclera (bulbar
conjunctiva) separated by potential space
(conjunctiva sac) is closed up by superior
fornix and below by inferior fornix.

 The palpebral conjunctiva is lines the
posterior surface of lids and is firmly adherent
to the tarsus, its reflected posteriorly at the
superior and inferior to become the bulbar
conjunctiva .
 The bulbar conjunctiva is loosely attached to
the orbital septum in the fornices .

 Semilunar fold is soft, movable , thick fold of
bulbar conjunctiva located at inner canthus.
 Conjunctival epithelium is 2-5 layers of
stratified columnar cells ( superficial to basal
cells).
 Conjunctival stroma is divided into adenoid
and fibrous layers. Accessory Lacrimal glands
are located in the stroma.

A sagittal or vertical section of both
eyelids and the eye.
The cornea (1) and lens (2) provide
orientation.
The fornix (3) has more redundant
conjunctiva.
The marginal conjunctiva (4) and
tarsal conjunctiva (6) are indicated.
The palpebral portion of the lacrimal
gland (5) is also shown

The conjunctiva contains specialized folds or bumps
called the plica semilunaris (arrow 10 in the clinical
figure) and caruncle 11. The plica semilunaris lining
contains Goblet cells while the caruncle may have
hair, sebaceous glands emanating from the surface.

 The palpebral conjunctiva is subdivided into
marginal, tarsal, and orbital zones.
 The marginal zone transitions between skin
and conjunctiva and shows minimal
keratinization.
 The tarsal conjunctiva is a fairly flat layer.
 The orbital zone shows more numerous
Goblet cells.

The limbus (1) is the junction of the conjunctiva and cornea. The bulbar
conjunctiva (2) covers the eyeball and extends into the recess created by
forniceal conjunctiva (3). The tarsal conjunctiva (4) covers the tarsus.
The marginal conjunctiva (6) is at the eyelid margin where the epithelium
will begin to be keratinized. The punctum (5) is also shown.

 Symptoms of conjunctival disorders are
ocular discomfort, burning, exudation,
itching. Severe pain suggests corneal
involvement rather than conjunctival
diseases.
 Signs of conjunctival diseases are mainly
related to abnormalities of appearance,
vascular changes and edema.

Injection of conjunctival blood vessels :-
 Conjunctival injection is characterized by superficial
bright red blood vessels which are most clear in the
fornices and decrease towards the limbus .
 Conjunctiva and ciliary vascular beds are injected in
inflammation of anterior segment of the eye .
 To distinguish conjunctival diseases from deeper diseases
of the eye the examiner must be attention to cornea, iris
(s/s of anterior uveitis), pupillary reaction to light , visual
acuity (s/s of glaucoma) .

Dilatation of conjunctival blood vessels without
exudation or cellular infiltration .
Causes of conjunctival hyperaemia:-
 Irritation by smoke, chemical, fomites ….
 Exposure to sun and wind .
 Uncorrected refractive errors .
 Acne rosacea, characinoid .
 Blepharitis
 Prolonged use of vasoconstrictors .
 Inadequate ocular protector from U.V light .

 Foreign body sensation, conjunctival redness
 Temporary blanching with 1:1000 adrenaline
Treatment:-removal of the cause and
temporary relief by cold compresses or local
weak solution of a vasoconstrictor
.(phenylephrine , epinephrine ).

 Caused by rupture of a conjunctival blood
vessels. Looks as a bright red area
surrounded by normal conjunctiva. The
haemorrhage is located beneath the bulbar
conjunctiva and gradually disappear in two
weeks .

Sub conjunctival
haemorrhage

 Localized (trauma)-in direct trauma to the
eye the posterior limit is visible but in
head/orbital injury the subconjuctival
haemorrhage develops 12-24 hrs after
trauma and posterior limit is not visible.
 Hypertension, arteriosclerosis
 Blood dyscrasias like leukaemia, purpura,
haemophilia
 Rupture of posterior sclera

 Adenovirus conjunctivitis sometime is
associated with sever subconjuctival
haemorrhage .
 Usually cause is unknown .
 Infective-pneumococcus, koch-weeks
bacillus, adeno virus, picorna virus
 Mechanical-bronchitis, whooping cough,
compression of neck and chest

 No treatment or cold compress to constrict
the blood vessels
 In severe cases the subconjunctival space
may be puncture to drain the blood
 Ultimately it is absorbed within 2-3 weeks

 Sickle cell disease
 D.M ( venous congestion and dilatation and
micro aneurysms ).
 Cryoglobulinemia (blood stasis ).
 Fabry disease.

 A dull greyish conjunctiva may occur after
repeated instillation of silver and mercury
salts .
 Prolonged instillation of adrenaline may
cause deep black subconjunctival deposits of
adrenochrme (oxidized adrenaline ).

 Yellow conjunctiva may results from
excessive eating of carrots (must be
differentiated from jaundice).
 conjunctival pigmentation also occurs in
Addison disease and Ochronosis
(pigmentation of cartilages and other
tissues).

 The inflammation of conjunctiva with cellular
infiltration and exudation .
Signs of conjunctivitis

1- Hyperaemia
Sign of acute
conjunctivitis
and its marked
in the fornix
and diminishes
towards the
limbus

 2-Tearing is results from burring, foreign
body sensation and itching .
 If tear secretion is decrease--- granulomatus
conjunctivitis or keratoconjunctivitis sicca.
 3-Exudation is in all types of conjunctivitis
and a mild gumming of the lids on waking
occur in all types also .

4- Chemosis
Edema of
bulbar
conjunctiva
(stroma) this
strongly
suggests acute
hay fever
conjunctivitis
but may occur
in other types .

 5- Pseudoptosis is drooping of the upper lid
due to its increased weight from cellular
infiltration.

6- Papillary
hypertrophy
Non specific
conjunctival
reaction and its
large papillae on
upper tarsus means
vernal
keratoconjunctivitis,
if on lower tarsus is
atopic
keratoconjunctivitis.
Its invaded by
inflammatory cells .

Follicles
Minute lymph
follicle with
accessory
vascularisation. It
appear as a vascular
round white or gray
structure in the
fornix or on the tarsi
# follicle = lymphoid
hyperplasia in
conjunctiva .

Follicles

 A coagulum on the surface of the epithelium
when removed this membrane, the
epithelium remains intact e.g gonococcal
conjunctivitis. True membrane is a coagulum
involving the entire epithelium when
removed a raw bleeding surface remains.
 They occur in some types of conjunctivitis as
streptococci, epidemic keratoconjunctivitis,
diphtheria, primary herpes simplex virus
conjunctivitis .

9-
Granulomas
Occur in cases of
cat scratch disease
(lymphogranuloma
conjunctivitis),
sarcoid, syphilis,
rarely
coccidioidomycosis
, parinaud s
occuloglandular
syndrome .

 10-Phlyctenules is small red nodule with
ulcerated apex due to microbial allergy.
 11-Preauricular lymphadenopathy is occur
in primary herpes simplex conjunctivitis,
epidemic keratoconjunctivitis, trachoma,
acute hemorrhagic conjunctivitis,
gonorrhoea, Chlamydia infection. No
preauricular adenopathy in bacterial
conjunctivitis.

 Foreign body sensation, burring sensation,
sensation of fullness around eyes, itching,
photophobia (when cornea are also affected).
Types of discharges
 1- A watery is serous exudates + tears (viral and
toxic inflammation).
 2- A mucus is typically of vernal conjunctivitis +
keratoconjunctivitis sicca.
 3- A purulent is sever acute bacterial infection.
 4- A mucopurulent is mild bacteria like Chlamydia.

 1- history and clinical examination :- the infectious
disease is often bilateral and may involve other
family members.
 much exudates suggests bacterial inflammation and
stringy few exudates is allergy or viral or
preauricular adenopathy, severity of conjunctival
injection involvement of eyelid margins and
presences of follicles or papillary hypertrophy must
be noted.
 2- gram of conjunctival scrapings
 3- culture of conjunctival scrapings

 I- bacterial conjunctivitis :acute or chronic
bacterial conjunctivitis are the commonest
types of conjunctivitis.

Acute
mucopurulent
conjunctivitis
cause is gram +ve cocci (
staph and strepto) and N.
meningitides, hemophilus,
klebsiella, proteus,
pneumococcus, adeno
virus.
Aetiology—any age, poor
personal hygiene, other
family membrane also
affected, associated with
measles or exanthematous
fever
Clinical features--onset is
acute bilateral
mucopurulent exudates,
eyelids agglutinated on
waking.

 Redness
 Mucopurulent discharge
 Grittiness
 Lids stickiness
 Coloured halos
 Photophobia

 One eye is more affected than other, lid edema,
eyelashes matted, conj. congestion, chemosis,
mucopurulent discharge, subconj. haemorrhage
Composition of discharge—
 Tears, mucous
 Epithelial cells, bacteria,
 Leucocytes, fibrin, rarely RBC
Complications—
 Chronic conjunctivitis, corneal ulcers
 Marginal corneal ulcer with pseudopterygium
formation
 Chronic dacryocystitis

 Frequent wash with luke warm saline & dark
goggles
 Broad spectrum antibiotic qid to1 hourly
 Antibiotic eye oint. At night
 Other family members also treated
 Keep hands clean and separate personal
belongings

Purulent
conjunctivitis :
cause is Neisseria
gonorrhoea and
meningitides. It
may be adult or
newborn type
(ophthalmia
neonatorum).
Adult purulent
conjuctivitis—
more in males and
right eye

 Massive lid swelling with purulent discharge
 Conjunctival chemosis with or without membrane
formation
 Anterior polar cataract due to compression by
chemosis
 Thickening and hypertrophy of palpebral conjunctivitis
 Corneal ulcer leading to perforation
 Preauricular lymphadenopathy with increased body
temperature and mental depression
 Diagnosed by coincidence of uretheritis and
conjunctival scraping show gram –ve intracellular
organism

 Corneal edema, ulcer, perforation, opacity
 Adherent leucoma
 Iridocyclitis with or without hypopyon
 Blindness

 Patient kept in isolation
 Frequent irrigation of eyes with warm normal
saline
 Penicillin/ciprofloxacin/norfloxacin e.d. every
minute for half an hour then every 5 min for 1hr
then hourly for 3-5 days
 Tetracycline eye oint. At night
 Systemic antibiotics for 5 days
 1% atropine if corneal involvement

 Acute sever form of conjunctivitis and it occurs in
newborn infants who get infected during passage
through birth canal and in older people by
contamination from acute gonorrhoeal uretheritis.
 Exudates is first serous then purulent ----
inflammation of central cornea is common and
perforation may occur .
 Infants with purulent conjunctivitis should be
hospitalized with treatment by I.V penicillin G with
topical tetracycline or saline to eyes

 It’s a conjunctivitis of newborn and it occurs
within the 1st month of life.
 Cause include gonococci, inclusion bodies
Chlamydia ( blennorrhoea paratrachomes),
herpes simplex II
 Conjunctival infection follows contamination
of body’s eyes during its passage through
mother’s genital tract .

 If the cause is bacteria like gonococci, staph,
strep. pneumonae the time of onset is 2-5
days but inclusion blennorrhoea and viral
cause takes around 10 days. (5-14)
 Now a days gonococcal infection is rare but
Chlamydia oculo-genitalis is common.
 Sometime there may be chemical
conjunctivitis due to silver nitrate use

Diagnosis
By smear with
gram stain and
culture of
exudates.
Credes
prophylaxis is 1%
silver nitrate for
prevention of
gonorrhoeal
ophthalmia.

 The body shows tense swollen lids, bright red
conjunctiva, mucopurulent discharge with
pseudomembrane formation become purulent.
 In case of gonococcal presents between 1-3 days
after birth with a hyper acute purulent
conjunctivitis. In other cases it is catarrhal or
mucopurulent conjunctivitis.
 In chlamydial infection the conjunctival reaction is
papillary only , without any follicular response.

 Corneal ulceration then perforation especially
in gonococcal type

 Staining of smear & culture
 Freshly prepared penicillin / ciprofloxacin /
norfloxacin e.d. every min for half hr then every 5
min for 1 hr then hourly for 5 days
 Systemic penicillin 50,000 IU/kg i/m x 7 days
 For chlamydia-10%sulphacetamide qid/1%
tetracycline oint bd/systemic erythromycin 50
mg/kg in 4 divided doses for 3 weeks.
 1% atropine if cornea involved

Prophylaxis—
 Proper antenatal care and asepsis during
delivery
 Sulphacetamide 10% or framycetin or
gentamicin e.d. qid x 7-10 days
 Tetracycline 1% oint bd for a few days
 Credes method-1% silver nitrate e.d. after
birth

 Acute bacterial conjunctivitis is usually self limited if
treated its lasts 1-3 days if untreated more then 10 -14
days.
Exceptions are :-
 Staphylococcal may progress to blepharoconjuntivitis
and enter a chronic phase .
 Gonococcal if untreated can cause corneal perforation
and endophthalmitis .
 Meningitides meningococci to blood --- meningitis
and septicaemia.
 chronic bacterial conjunctivitis may not be self limited
and may cause therapeutic problems .

 Persistent organism----perform conjunctival
culture + change culture sensitivity tests
according to result of C.STEST
 Obstruction or infection of Lacrimal gland,
system dacryocystitis + Canaliculitis ).
 Chronic blepharitis
 Rosacea keratoconjunctivitis may be miss.
 Self infected mucus fishing syndrome.
 Dropping eyelids syndrome.
 Chlamydia infect.

 It is a type of acute conjuctivitis associated
with membrane formation on the inflamed
conjunctiva.
The causes are-
 Corynebacterium diphtheriae
 Sometimes pneumococcus, streptococcus
 Chemicals like alkali

 Mild to severe lid edema, red ,hot, tense eye,
 Pain and tenderness
 Purulent discharge
 Conjunctival membrane which is white and can
be peeled off easily without bleeding in case of
pseudo membrane while in case of true
membranous conjunctivitis it is difficult to
remove membrane and it bleeds on removal
 Preauricular lymphadenopathy and
symblepharon formation

Complications—
Corneal ulcer
Symblepharon
Trichiasis
Entropion
Xerosis of conjunctiva

 Isolation of patient and i/m crystalline
penicillin 50,000 IU/kg bd x 7 days
 i/v anti diphtheria serum
 penicillin e,d. And erythromycin eye oint at
night
 1% atropine if corneal involvement

 Chlamydia trachomatis which causes
oculourogenital disease like trachoma,
inclusion conjunctivitis, lymphogranuloma,
uretheritis.
 Chlamydia psittaci which causes non-ocular
disorders in birds and mammals like
psittacosis.

 A chronic contagious keratitis and conjunctivitis
caused by Chlamydia trachomatis serotypes [A, B,
C] and is the main cause of blindness especially in
developing countries and also k/a Egyptian
ophthalmia. Spread is by direct contact or fomites
or flies.
Aetiology—
 Any age, poor unhygienic condition
 Dry, dirty and sandy weather
 Eye seeking flies, surma

 Average incubation period 10 days.
 In children the onset is insidious and disease
is resolved with no complications.
 In adults onset is acute or sub-acute and
complications may develops .

Stage I (incipient trachoma) (early lymphoid
hyperplasia)
 Papillary hypertrophy and immature small follicles on
the upper tarsus---irritation to conjunctiva---vascular
proliferation of Limbal vessels---superficial
trachomatous pannus
Stage II (Established trachoma)
 II a- (follicular predominant) follicular hypertrophy
with mature (large) follicles on upper tarsus .
 II b- (papillary predominant) papillary hypertrophy
predominant and masking the follicles on upper tarsus
and is infected stage.

In the stage II there may be :-
 Superior epithelial keratitis
 Sub-epithelial keratitis
 Pannus
 Superior Limbal follicles ( stage III )
 Herbert s peripheral pits which are the cicatricial
remains of follicles .
 Follicles are semi-opaque, dome shape elevated
surrounded by the pannus.
 Pits are small depression in connective tissue of
limbo corneal junction11/11/2017 Dr. Mohammed Najmussadiq Khan M. S. (Ophth) 78

Stage III (cicatricial trachoma )
 Early conjunctival scarring in the form of white fine
lines(Artles line) in sub-epithelial conjunctiva
associated with persistent follicles and papillary
hypertrophy of upper tarsus.
Stage IV (Healed trachoma )
 Linear scar without inflammation on upper tarsus
no ( follicles, papillary).

Herberts pits

Conjunctival
scarring

 Tr-O trachoma free
 Tr-D trachoma dubium
 Tr-I trachoma onset with immature follicles on
upper tarsal conjunctiva with early corneal
changes
 Tr-II established trachoma with mature
follicles, papillary hypertrophy, pannus, follicles,
Herbert pits at limbus
 Tr-III cicatrizing trachoma with conjunctival
scarring
 Tr-IV healed trachoma with no inflammation

 Tearing
 Pain
 Edema of eyelids
 Chemosis of bulbar conjunctiva
 Tarsal and Limbal follicles
 Tender preauricular node
 Photophobia
 Exudation (mucopurulent)
 Hyperaemia
 Pannus (corneal)
 Papillary hypertrophy
 Superior keratitis

 Membrane of granulation (fibroblast, B.V rarely
formed) tissue covering the upper half or entire
cornea caused by toxic substance of organism and it
has 3 forms
Pannus sicuss is dry surface
Pannus crassus is thick (dense opacity)
Pannus tenuis is thin (slight opacity)
 pannus is cellular infiltration + vascularisation of
cornea. In progressive pannus the cellular infiltration
extends beyond the terminal ends of
neovascularisation and in regressive pannus the
vessels extend a short distance beyond the area of
cellular infiltration.

Clinically :-
 Follicles on upper tarsus.
 Limbal follicles scar Herbert s pits (unique
finding).
 Epithelial or sub-epithelial keratitis.
 Pannus in upper cornea.
 Conjunctival scarring in sub tarsal groove.
 Lab :-Giemsa stained conjunctival scarring.
culture in yolk sac. Exam of exudates.

 Viral conjunctivitis all types except molluscum
contagiosum are less then 3 weeks duration and all
are associated with mononuclear inflammatory
reaction unless there a pseudomembrane.
 Follicular conjunctivitis following antiviral
treatment; the follicular reaction subsides when
drugs is withdrawn.
 Long standing dacryocystitis or chronic
canaliculitis may be complicated by chronic
follicular conjunctivitis but no corneal changes there
no scar with cure.

 Folliculosis (increase lymph follicles) adenoid type and
there is no corneal changes and no papillary hypertrophy
and conjunctiva between follicles is normal.
 Inclusion conjunctivitis psittacosis there is no scaring
except in neonatal inclusion conjunctivitis---if a
pseudomembrane is formed.
 Parinaud s occuloglandular syndrome is characterized by
visible preauricular node.
 Vernal keratoconjunctivitis the conjunctiva has a milky
appearance, papillary are polygonal with flat top and
giant.

On lids :-
 Trichiasis is misdirection of eyelashes due to
hyperaemia and mal-arranged lashes.
 Entropion is inversion of eyelid--- Entropion of upper
lid due to cicatrisation of the lid after passage then
absorption of inflammation exudates causing
shrinkage and shortening of conjunctiva. Entropion of
lower lid due to decrease size of angle of lower fornix
by fibrous tissue.
 Ptosis, tylosis, scaphoid or boat shaped lid
 Madrosis, chalazion

On conjunctiva:-
 Xerosis is dryness of conjunctiva due to
cicatrisation of conjunctiva with atrophy of goblet
cells leads to deficiency of glandular tissue .
 Symblepharon is adhesion between one or two
lids to the eyeball .
 Hyaline degeneration of tarsus and conjunctiva.
 Pseudo-pterygium
 Epithelial plaque on either side of cornea.
 Loss of fornices, pigmentation

On cornea:-
 Diffuse corneal nebulae (fag like opacity) causing
irregular astigmatism. Leucoma due to cicatrisation
of corneal ulcer.
 Corneal ectasia (dilatation) due to weakness of
corneal stroma.
 Xerosis of cornea is opaque cornea .
 Epithelial plaque (corneal scarring ).
 Bacterial corneal infections .
 Ulceration of cornea .
 Herberts pits
 Trachomatous nodular keratopathy
 Loss of sensation

On Lacrimal gland :-
 Trachomatous infiltration of Lacrimal gland.
 Obstruction of ductules of accessory Lacrimal
gland leads to dacryocystitis.
 Obstruction of nasolacrimal ducts .
Others :-
 Phthisis bulbi shrinking of eyeball (in last
stage early).
 Glaucoma due to leukaemia.

 20% of cases heal spontaneously. With
treatment the prognosis is excellent
prognosis.
 Untreated cases with bad conditions have
major visual loss.

 Systemic one is tetracycline or erythromycin same
dose 250 mg qid for 3-4 days. Don’t give systemic
tetracycline to children under 7 years and pregnant
women or oral sulphonamide.
 Local one is ointments or drops like Sulphacetamide
(10-20%) or tetracycline or erythromycin in 4 times
daily for 6 weeks. 1% atropine if cornea is affected.
This is followed by intermittent treatment with
tetracycline oint bd x 5 days of each month for 6
months or once daily x 10 days of each month for 6
months. This is especially important in epidemic or
hyper-endemic areas

 By personal hygiene, avoid surma
 Avoid close person to person contact,
 Periodically treatment with 20%
sulphacetamide / 1% tetracycline eye oint as
intermittent therapy.

 Excision of fornix, tarsectomy
 Surgery for trichiasis and entropion
 Pannus treated by cryoapplication and peritomy
 Corneal ulcer treatment
 Mechanical expression of the follicles by Roller
forceps
 Silver nitrate painting
 Diathermy

 Common bilateral conjunctivitis.
 Cause is Chlamydia trachomatis which
serotypes is (D, K ).
 Infects male urethra and female cervix so
transmission usually from genitourinary tract.
 Typical affect young adult in their sexual
activity.

 Bilateral mucopurulent discharge especially
in morning (watering + sticky eyes ).
 Redness of eyes
 Pseudoptosis.
 Conjunctiva of tarsi with papillae and follicles
(no follicles in newborn because of absence of
adenoid tissue in stroma of conjunctiva but
follicles appear if the conjunctivitis persists
for 2-3 months.

 In newborn the papillary conjunctivitis,
moderate amounts of exudates,
pseudomembrane may be formed in hyper-
acute cases---scarring also pharyngitis and
otitis media.
 In adult papillary and follicular conjunctivitis
no pseudomembrane---no scarring there is
superficial keratitis and sometimes small
superior micropannus.

 Lab findings conjunctival scrapings do Giemsa stain
tissue culture.
Differential diagnosis :-Inclusion conjunctivitis to be
differentiated from trachoma by :
 I .C transmitted sexually or from mother.
 Conjunctival scarring is common in trachoma but
occur only in newborn in I.C. and only after formation
of a pseudomembrane.
 I .C may cause micropannus but never the gross
pannus of trachoma.
 Corneal scarring and Herbert s pits in trachoma only.

 Infant: 1% tetracycline, erythromycin
ointment.
 Adult: oral (tetracycline and erythromycin)
250 mg qid with treatment of sexual partner

 Cause :- Chlamydia trachomatis serotypes
L1, L2, L3. Granulomatus non-follicular
conjunctivitis reaction visible preauricular
node (bubo). Diffuse scarring of conjunctiva
and cornea.
 Treatment sulphonamide systemically for 3-4
weeks.

 Common diseases caused by many viruses
may be acute or chronic.

 Pharyngoconjunctivitis fever (Adeno virus 3
& 7)
 Epidemic keratoconjunctivitis (Adeno virus
8 & 19)
 Herpes simplex conjunctivitis
 Coxsackie virus conjunctivitis
 Acute hemorrhagic conjunctivitis

Chronic viral
conjunctivitis :-
1. Molluscum
contagiosum
blepharoconjunti
vitis,
2.Varcella zoster
blepharoconjunti
vitis,
3. Measles
keratoconjunctivitis .

 Adenovirus type 3, 8 rarely types 4, 7.
Follicular conjunctivitis in one or both eyes–
bilateral injection and tearing.
 Superficial epithelial keratitis
 Enlarged, non tender preauricular
lymphadenopathy.
 Follicles on both conjunctiva and pharyngeal
mucosa.
 Fever, sore throat (common in children)
 Its self limiting disease in about 10 days

 Adenovirus types 8, 19 highly contagious.
 Usually bilateral injection, pain tearing, sub-epithelial
opacity , large tender preauricular node, Chemosis
conjunctival hyperaemia with follicles & pseudo-membranes
, subconjunctival haemorrhage.
 In children there are systemic symptoms also fever, sore
throat, diarrhoea (not in adult).
 The only serious eye disease transmitted by :-
 Tonometry
 Physician s fingers .
▪ Contaminated eye solutions.
▪ Improperly sterilized ophthalmic instruments.
 Treatment :-cold compresses with antibiotics antiviral agent
acyclovir .

 Usually type I herpes virus but type II is a rare cause
in newborn and adult.
 Unilateral injection mucoid discharge mild
photophobia follicular conjunctivitis often associated
with keratitis.
 Herpetic vesicle on eyelids with severe edema of
eyelids .
 Large or small tender preauricular node.
 Self limited disease (therapy not necessary) and
Acyclovir ointment for herpetic keratitis.
 Steroids are contraindicated in herpes simplex
conjunctivitis because they aggravate the disease.

Herpes
simplex

 BY Enterovirus (picorna) and first recognized in
Africa in 1969 at time of Apollo XI moon trip so
disease called ( Apollo XI conjunctivitis ).
 It is highly contagious disease
 Self limited disease 5-7 days.
 Pain, photophobia, foreign body sensation,
increase tearing, redness, led edema, sub-
conjunctival haemorrhages, preauricular node,
conjunctival follicles, epithelial keratitis
 In some case anterior uveitis, fever and malaise.

 Cause : Onchocerciasis (river blindness ), Loa
Loa, ascaris (Butcher s conjunctivitis---
Butcher cutting tissues containing ascaris
which bit the eyes ), trichinella spiralis, ocular
myiasis,Tania solium.

 Immediate (humeral) hypersensitivity as (hay
fever, spring catarrh, atopic, giant papillary)
conj.
 Delayed (cellular) hypersensitivity as (contact
, phlyctenulosis).
 Autoimmune diseases as (k.c.s, Sjogren
syndrome , cicatricle pemphigoid).

 A mild non-specific conjunctivitis associated with hay
fever (allergic rhinitis).
 History of allergic: itching, eye redness, mild injection,
severe chemosis during acute attach so patient says
that his eyes seem to be sinking into surrounding
tissue. No conjunctival papillae or follicles
Treatment ;-
 Local vasoconstrictor, adrenaline 1: 1000 topically in
acute attach.
 Cold compresses, oral antihistaminic.
 Response is good but recurrences are common.
 Frequency and severity of attach decrease with
decrease in the age

 Chronic bilateral non-contagious allergic
conjunctivitis which tends to recur during
warm seasons (spring and summer ) and fall
in winter ; males more affected usually during
childhood if lasts 5-10 yrs.
 Cause hypersensitivity reaction to unknown
allergic mediated by IgE and heat , ultraviolet
light and humidity are contributing factors.
Family history.

 Itching [severe persistent].
▪Photophobia
▪White ropy discharge (abnormal mucus )
▪Fibrinous pseudomembranous (Maxwell
– Lyons sign )
▪Lacrimation.

 Palpebral: upper palpebral conjunctiva shows
thickening and the characteristic papillae which are flat
topped large due to hyaline degeneration cobble stone
appearance .Papillae are bluish white with capillary tufts
 Limbal (Bulbar): gelatinous nodules at the limbus.
There are mucus visible White spots of necrotic
epithelium sometime seen at the limbus called Horner-
tranta s dots or spots also named as vernal limbitis.
 Mixed: both bulbar and palpebral types.
 Prognosis-- good although recurrences persist for years
the disease eventually subside.

VERNAL
CONUNCTIVITIS (
SPRING CATARRH)
Cobble stone
appearance

VERNAL
CONUNCTIVITIS (
SPRING CATARRH)
Tranta s dots

ChronicVernal
Conjunctivitis

▪Corneal ulcer (superficial) + scarring .
▪Epithelial keratitis ( confluent punctate
epithelial keratitis ).
▪Subepithelial scarring
▪Pseudogerontoxon (with appearance of
cupids bow)
▪Higher incidence of keratoconus

▪ Local vasoconstrictor (adrenaline) .
▪ Local cortisone .
▪ Cold compression .
▪ Local cromolyn sodium(prophylactic agent
▪ Working and sleeping in cool climate if possible .
▪ Non steroidal anti inflammatory drugs like ketorolac,
flurbiprofen, diclofenac e. d.
▪ 10-20% acetyl cysteine to dissolve mucus
▪ For giant papillae—cryoapplication / β-irradiation /
excision

Papillae of spring catarrh Papillae of trachoma
 Main symptoms Heavy lids
itching
 Season Any time
summer , spring
 Size fine Large
 Age children Adults
 Top round flat
 Discharge No eosinophils
ropy with eosinophils
 Fornix involved
always free

 Burring sensation, mucoid discharge,
redness, photophobia, lacrimation, fine
papillae on the lower tarsus (unlike vernal
conjunctivitis that on upper tarsus).
 Usually there’s a history of allergy in patient
or patient s family.
 In late stage---corneal inflammation and
vascularisation.
 Treatment: topical steroids and local
vasoconstrictor

 Same sign and symptoms of vernal
conjunctivitis develop rarely in persons
wearing contact lenses.
 It’s a hypersensitivity reaction possibly lens
components and its associated with
protuberant suture ends at the upper limbus
following cataract extraction.
 Treatment: Use of glasses instead of contact
lens

GIANT PAPILLARY
CONJUNCTIVITIS

 It’s a mononuclear localized cell mediated conjunctival
hypersensitivity response to endogenous proteins of
tubercle bacilli, staphylococci, Candida albicans, intestinal
parasites.
 A conjunctival Phlyctenules begins as a small lesion
(nodule 1-3 mm diameter) red elevated surrounded by zone
of hyperaemia.
 Its greyish or yellowish frequently complicated by staph
mucopurulent conjunctivitis
 In children of 4-14 years
 Histologically-- the Phlyctenules contains (mononuclear
cells lymphocytes with ulcerated epithelium usually in
limbus and less common in bulbar conjunctiva (no scar) .

 Redness with bleb formation
 Irritation and lacrimation
 Pain and photophobia if cornea is involved

 One or more small round nodule at limbus
 Localised bulbar congestion but no discharge
 If secondary infection then mucopurulent
discharge
 May be associated with tonsillitis and
adenoids
 Corneal involvement ---- ulcerative keratitis .
 Phlyctenular pannus (vascularisation and
infiltration of cornea ).
 Scars are there .

PHLYCTENULAR
KERATOCONJUNCTI
VITIS

 Active blepharitis .
 Acute bacteria conjunctivitis .
 Corneal complication like Phlyctenular
keratitis, fascicular ulcer, superficial
phlyctenular pannus, ring ulcer
Investigations—
 TLC, DLC, ESR, Monteux test, X-ray chest
 ENT check-up
 Stool examination
 Conjunctival swab if corneal involvement

 Local antibiotic if 2ry infection exists .
 Atropine if cornea involved .
 Antituberculous drugs if cause isT.B.
D/D_
 pinguceula
 Episcleritis
 Limbal spring catarrh
 Limbal herpes simplex .

 Atropine, antibiotics, Pilocarpine….There
will be mild conjunctivitis, some irritation,
mild discharge hyperaemia. Conjunctivitis
discharge when the drugs is stopped.
 Others cause;-- cosmetic preparation,
contact lens solution, topical medication
(drops, ointments). Its cell mediated
hypersensitivity .

 Keratoconjunctivitis sicca associated with
Sjogren s syndrome
 Sjogren s syndrome---keratoconjunctivitis,
Xerostomia, Arthritis
 Cicatricial pemphigoid

PTERYGIUM (wing):-a wing shape fibro vascular
connective tissue overgrowth encroaching from
conjunctiva to cornea .It has
 Apex or head
 Neck-the constriction at limbus
 Body-bulky part
 Cap-a cellular semilunar infiltration in front of apex
 Cause :- unknown but is related to irritation by
dust, sunlight (ultraviolet rays), wind, hot and
sandy weather, Pinguiculla may act as precursor.

 Elastic degeneration of sub epithelial collagen
replaced by abnormal material .Replacement of
Bowman s layer by elastic and hyaline tissue .It
may be
 Progressive- thick, flashy with prominent
vascularisation, increasing in size, cap is present
and iron deposition as a line in corneal epithelium
in front of apex k/a Stockers line
 Atrophic(stationary)-thin, attenuated with poor
vascularity and stationary

 A mass usually nasal side of cornea (bilateral).
 Shape triangular and usually symptom less .
 Dimness of vision due to astigmatism
 Rarely diplopia due to symblepharon

Signs—
Decreased visual
acuity
Triangular
conjunctival mass
encroaching upon
the cornea
Usually bilateral and
nasal side
In a few cases limited
ocular movements

 If it reaches part of cornea---opacity and
astigmatism .
 Limitation of ocular movements with diplopia
(stationary or progressive).

 If small and stationary --- no surgery .
 Best operation ---- excision with bare sclera technique
 McRenolds transposition operation
 Surgery in case of : progressive pterygium encroaches
pupillary area and cosmetically distributing .
Surgery for recurrent pterygium--
 After bare sclera excision treated with beta
irradiation, thioTEPA solution, mitomycin –c (.02%)
 Amniotic membrane /Conjunctival grafting
 Lamellar keratoplasty for corneal opacity

D/D_
Pseudopterygium:-
An inflammatory
adhesion of conjunctiva
to damaged cornea
after trauma or
inflammation .
Occur anywhere around
the limbus .
Always stationary .
It is fixed to cornea only
at the apex so a probe
can be passed beneath
the neck of it. (PROBE
TEST)

Pinguceula :-
Benign degenerative
tumour of conjunctiva .
Appears as yellowish
nodule on both sides of
cornea, oval
usually bilateral and nasal
Path :- degeneration of
collagen fibers in
substantia propria with
deposition of hyaline
material .
Treatment :- no required ,
simple excision as
cosmetic .

 Dilated lymph vessels in conjunctiva. No
treatment unless they are irritating or fore
cosmetic appearance (by excision).

Dryness of conjunctiva caused by---
 Vitamin A deficiency seen more in children
also caused by trachoma, burns, pemphigus,
diphtheria, prolong use of beta blocker
 By eye exposure after proptosis, ectropion,
lagophthalmos
 Goblet cells stop secretion of mucus so water
fail to moisten the corneal epithelium

 Clinically:- night blindness, dry conjunctiva, Bitot s
spots (dirty yellowish on cornea due to
keratinization of conjunctiva which is not wetted
by tears), dry hazy cornea, keratomalacia (dryness
with ulcer and perforation).
Treatment :-
 Vitamin-A if other cause treat it.
 Dark glasses, artificial tears e. d.
 Correction of nutritional status

 Degeneration of conjunctival epithelium and
inspissated mucus in the depression called Henles
glands causing minute yellow deposits in the
palpebral conjunctiva .
 Never become calcareous so the name is misnomer
and generally asymptomatic.
 Treated by evacuation by a sharp needle under
local anaesthesia.

Concretions

Cicatricial adhesion between eyelids (palpebral
conjunctiva) and eyeball. May be :-
 Anterior:- adhesion of the lid and eyeball not
involving the fornix.
 Posterior:- adhesion involving the fornix.
Causes :
 Chemical burns
 Trachoma
 Steven Johnson syndrome

Complications: limitation of eye movement,
exposure keratitis, xerosis.
 Treatment & prevention (in conjunctiva
scaring)
▪Cut at small adhesion (glass rod such as
thermometer with ointment).
▪Graft from other conjunctiva or contact
lens or mucous membrane of mouth (if
large lesion).

Symblepharon

 Lymphangiectasis (lymphatic cysts)–They
are vary common
 Retention cysts—due to obstruction of the
ducts of accessory lacrimal gland of Krause in
the upper fornix
 Implantation cysts—due to conjunctival
epithelial cell implantation after surgery
 Parasitic cysts—due to sub conjunctival
cysticercosis/ hydatid cyst

Conjunctival
cysts—

Dermoid—
They appear as solid
white masses
frequently at the
limbus.
They consists of skin
with sebaceous
glands and hair
Treated by surgical
excision with a
lamellar sclero-
corneal patch graft

Lipodermoid

Lipoma

 It appears as reddish grey fleshy mass with broad
base and characterised by deep invasion into
stroma with fixation to underlying structure
 Mainly found at limbus and arises from a papilloma
or carcinoma in situ
 Distant metastasis occurs rapidly
Treated by–
 Radical excision
 Enucleation
 Exantration of the orbit

Congenital
subepithelial
melanosis

Conjunctiva

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