It involves Anatomy and physiology of Conjunctiva Disorders in detail with Optometrist management

1. Conjunctiva
SIMRAN PAHUJA
B.OPTOM 4TH YEAR

2. Introduction:
 It is a Translucent mucous membrane which
lines the posterior surface of the eyelids and
anterior aspect of the eyeball
 It stretches from the lid margin to the limbus

3. Parts of Conjunctiva
 Palpebral Conjunctiva
1. Marginal
2. Tarsal
3. Orbital
 Bulbar conjunctiva
1. Scleral
2. Limbal
 Conjunctival fornix
1. Superior
2. Inferior
3. Lateral
4. Medial

4. Palpebral Conjunctival
 Marginal conjunctiva
• It extends from the lid margin to about 2mm on the
back of the lid upto a shallow groove – Subtarsal
sulcus .
• The sulcus is the commonest site for lodgement of a
conjunctival foreign body .

5.  Tarsal Conjunctiva
• Thin, transparent, highly vascular
• It is firmly adherent to the whole tarsal
plate in the upper lid and in lower lid only
half width of the tarsus.
 Orbital part
• It lies loose between the tarsal plate and
fornix

6. Bulbar Conjunctiva
 Limbal
• A 3mm ridge of the bulbar conjunctiva around he
cornea is called as limbal conjunctiva
 Scleral
• Covers the eyeball above the anterior sclera
• Thin , transparent and loosely attached to the
underlying sclera

7. Conjunctival Fornix
 It joins the bulbar conjunctiva with the palpebral conjunctiva
 It is broken only at the medial side by the caruncle and plica
semilunaris

8.  Plica Semilunaris
 Pinkish crescentic fold of conjunctiva , present in the medial
canthus
 Its lateral free border is concave
 Caruncle
 Small, ovoid, pinkish mass, situated in the inner canthus ,
just medial to the plica semilunaris
 Piece of modified skin and consists of sweat glands ,
sebaceous glands and hair follicles

9. Structure Of Conjunctiva
 Conjunctiva consists of 3 layers
1. Epithelium
2. Adenoid layer
3. Fibrous layer

10. Epithelium
 Marginal part : 5 layers of stratified squamous
- superficial layer –squamous cell
-intermediate 3 layers – polyhedral cells
-deepest layer –goblet cells
 Tarsal part : 2 layers
- superficial is cylindrical cells
- deeper is flat cells
• Lower tarsal conjunctiva is made up of 3-4 layers of cells like the cubical,
polygonal , elongated ,wedge shaped and cone shaped cells

11.  Fornix and bulbar : 3 layers
- superficial layer -cylindrical cells
- middle layer - polyhedral cells
- deep layer -cuboidal cells
 Limbal conjunctiva : 8-10 layer of stratified squamous epithelium
-Most superficial 1-2 layers – squamous cells
-Intermediate several layers – polygonal cells
-Basal layer – cylindrical or cubical cells

12. Adenoid layer
 Lymphoid layer
 It is not present since birth but develops after 3-4 months of life .
 For this reason, conjunctival inflammation in an infant does not produce
follicular reactions.

13. Fibrous layer
 Meshwork of collagenous and elastic fibers
 Thicker than adenoid layer except in the Tarsal conjunctiva
 Consists of nerves and vessels of conjunctiva

14. Conjunctival glands
It consists of two types of glands :
 Mucin secretory glands :
1. Goblet cells
2. Crypts of Henle
3. Glands of Manz
 Accessory lacrimal glands :
1. Glands of Krause
2. Glands of Wolfring

15. Blood Supply
 Arteries :
- Derived from 3 sources
1. Peripheral arterial arcade of eyelids
2. Marginal arterial arcade of eyelids
3. Anterior ciliary arteries
 Palpebral and fornix part : Peripheral and Marginal arterial arcade of
eyelid
 Bulbar part : Anterior and posterior conjunctival arteries

16. Nerve Supply
 Circumcorneal zone : Branches from long ciliary nerves
 Rest : by branches from
1. Lacrimal nerve
2. Infratrochlear nerve
3. Supratrochlear nerve
4. Supraorbital nerve
5. Frontal nerve

17. Lymphatic Drainage
 Lymphatics of conjunctiva are arranged in 2 layers
- superficial
- deep
 Lymphatics from the lateral side drain into preauricular lymph nodes
 Lymphatics from the medial side drain into the submandibular lymph
nodes.

18. Diseases Of Conjunctiva
1. Degenerative conditions
2. Inflammatory conditions
3. Symptomatic conditions
4. Cysts and Tumours

19. 1.Degenerative conditions
1. Pinguecula
2. Pterygium
3. Concretions
4. Amyloid degenerations

20. Pinguecula
 Extremely common degenerative change
 Yellowish white path on bulbar conjunctiva near the limbus ,
nasal or temporal .

21. Etiology
 Age related change
 Strong sunlight exposure
 Dusty , windy and smoky working environment
 ?Considered as a precursor of pterygium

22. Symptoms :
 Usually asymptomatic
 Possible mild foreign body sensation and redness when inflamed
 Occasional cosmetic concern

23. Signs :
 Area of conjunctival thickening adjoining the limbus
 In the palpebral aperture, usually at 3 & 9 o’clock positions
 More common nasally
 Usually bilateral
 Elevated and less transparent than normal conjunctiva
 White to yellow colour, fat like appearance
 May become inflamed causing mild ocular irritation
 Decreased TBUT

24. Management by Optometrist
 Non pharmacological
• Reassure patient about benign nature of the lesion (no threat to health or
sight)
• Advise on UV protection to minimise risk of inflammation
-brimmed hat, sunglasses in wrap-around style for side protection
• Cold compresses when inflamed
 Pharmacological
• Ocular lubricants for symptomatic relief

25. Pterygium
 Pterygium is a wing shaped fold of conjunctiva encroaching upon the
cornea from either side within the interpalpebral fissure.
 Etiology ;
1. More common in people living in hot climates .
2. Exposure to sun
3. Dry heat
4. High wind
5. Abundance of dust

26. Signs
 Usually bilateral; often asymmetrical.
 More common nasally
 Starts with scarring, thickening and distortion of the bulbar conjunctiva
 Slow insidious growth on to cornea (or may become stable)
 Destroys Bowman’s membrane and superficial stroma lamellae
 Epithelial iron deposit (Stocker’s line) ahead of advancing pterygium
 Relatively rich surface vascularisation
 Flattening of cornea in horizontal meridian

27. Symptoms
 Mild irritation (redness, dryness, foreign body sensation)
 May be exacerbated by incidents of acute inflammation
 Cosmetic concern

28. Types of pterygium
1. Progressive
Thick , fleshy , vascular
Few infiltrates in the cornea , in front of the head of the pterygium
(Fuch’s spot)
1. Regressive
Thin , atrophic , attenuated , very little vascularity
Sometimes deposition of iron may be present

29. Treatment
Surgical excision is the only satisfactory treatment .
 Indications :
1. Cosmetic disfigurement
2. Visual impairment
3. Continued progression
4. Diplopia due to interference in ocular movement

30. Management by Optometrist
 Non pharmacological
• Advise on UV protection:
-brimmed hat, tinted lenses, wrap-around style for side protection
-reduces risk of progression and of becoming inflamed and irritated
• Measure and draw diagram (photo document if possible)
• Cold compress when inflamed
 Pharmacological
Ocular lubricants for symptomatic relief

31. Concretions
Concretions are formed due to accumulation of inspisated
mucus and dead epithelial cell debris into the conjunctival
depressions called loops of henle .

32.  Symptoms :
1. Usually none
2. May erode through the epithelium
3. foreign body sensation
 Signs :
1. Small white/yellow-white bodies with distinct edges in tarsal conjunctiva
2. Single or multiple Usually <1mm dia, sometimes up to 3mm
3. Usually low profile but may be raised if large.

33. Management by optometrist
 Non pharmacological
• Treatment rarely required
• Artificial tears and lubricating ointments
• Eroded concretions leading to irritation can be removed at the slit lamp
-topical anaesthetic
- with sterile hypodermic needle
 Pharmacological
• No specific drug treatment available

34. Amyloid Degeneration Of Conjunctiva
 Rare
 Occurs in 2 forms :
1. Primary conjunctival amyloid
2. Secondary conjunctival amyloid

35.  Clinical Features :
1. Deposition of yellowish , well demarcated, irregular amyloid
material in the conjunctiva
2. Subconjunctival haemorrhage may be associated with amyloid
deposition in blood vessels
 Treatment :
1. Lubricating drops for mild symptoms .
2. Excision can be performed with marked irritation due to raised
lesions .

36. Symptomology
• Non-Specific
 Lacrimation
 Irritation
 Stinging
 Photophobia
 Burning
 Redness
• Specific
 Pain and FB sensation in Corneal Involvement
 Itching in allergic, Blepharitis and dry eyes

37. Conjunctival Signs
 Type of Discharge
 Type of conjunctival reaction
 Presence of membrane/ Pseudo-membrane
 Lymphadenopathy
 Pigmentations

38. Discharge :
It is exudation from abnormally dilated blood vessels filtered
through conjunctival epithelium .
Types of discharge :
1. Watery Discharge – Viral infection
2. Mucinous Discharge – keratoconjunctivitis sicca
3. Purulent Discharge – severe bacterial infection
4. Mucopurulent Discharge – mild bacterial infection

39. Conjunctival Reactions :
1. Hyperaemia
2. Papillae
3. Follicles
4. Concretions
5. Chemosis / Conjunctival Oedema

40. Papillae
 It is response of conjunctiva to inflammation
 It consists of small capillary network surrounded by fibrous
network
 hyperplasia of epithelium
 usually more discrete and more red than follicles
 side walls of papillae appear perpendicular to tarsal plate

41. Follicles
 Follicles appear as multiple discrete slightly elevated lesions
 They may be 0.5 to 5 mm in size depending upon severity and duration
 Follicles present lymphocytic response
 Commonly seen in lower palpebral conjunctiva
 Acute Follicular Response- <4 weeks
 Chronic Follicular Response- >4 weeks
 hyperplasia of lymphoid tissue
 generally seen in viral conditions
 smooth, pale, pink-to-yellow, elevated lesions
 surrounded by displaced vessels

42. Chemosis
 It is seen when conjunctiva is inflamed and hyperemic due to transdation
of fibrin and protein rich fluid through damaged blood vessels .
 Due to laxity of bulbar conjunctiva the fluid commonly gets collected there
 Ballooning of conjunctiva occurs when fluid is in large quantity it is labelled
as chemosis

43. Pseudomembranous
 Lid swelling
 mucopurulent bloody discharge
 white membrane
 easily peel off without bleeding

44. Membranous
 Acute inflammation of the conjunctiva
 Lids are hardened
 semisolid exudates: result in necrosis of conjunctiva and cornea
 difficult to peel off
 associated with bleeding from the under surface

45. Lymphadenopathy-Swelling of Lymph
nodes
 Pre auricular and sub mandibular.
1. Viral infection.
2. Chlamydial infection.
3. Severe bacterial infections. (Gonococcal)
4. Parinaud oculo-glandular syndrome.

46. Bacterial Conjunctivitis
• Predisposing factors
 contamination of the conjunctival surface
 superficial trauma
 contact lens wear
 secondary to viral conjunctivitis
 recent cold, upper respiratory tract infection or sinusitis
 Diabetes
 Steroids
 Blepharitis

47. Symptoms
Acute onset of:
• redness
• discomfort, usually described as burning
• discharge
• Usually bilateral – one eye may be affected before the other (by one or two
days)

48. Signs
 Lid crusting
 Purulent or mucopurulent discharge
 Conjunctival hyperaemia – maximal in fornices
 Tarsal conjunctiva may show mild papillary reaction

49. Management by optometrist
• Non pharmacological
 Often resolves in 5-7 days without treatment
 Bathe/clean the eyelids with lint or cotton wool dipped in sterile saline or
boiled (cooled) water to remove crusting
 Advise patient that condition is contagious (do not share towels, etc.)
• Pharmacological
 Treatment with topical antibiotic may improve short-term outcome and
render patient less infectious to others

50. CL-associated Papillary Conjunctivitis (CLAPC),
Giant Papillary Conjunctivitis (GPC)
• Predisposing factors
 Common in soft compared to rigid lenses
 reported in silicone hydrogel, as well as hydrogel, lens wearers
 Lens deposits
 Thick or poorly designed or manufactured lens edges
 Meibomian gland dysfunction

51. Symptoms
 Itching and non-specific irritation
 may increase after lens removal Mucus discharge
 Increased lens movement
 Loss of lens tolerance
 Decreasing comfort
 Blurred vision

52. Signs
 Almost always bilateral
 Upper tarsal conjunctiva (lower usually not affected)
 papillae
 macro papillae (diameter between 0.3 and 1 mm) or giant papillae
(diameter > 1 mm)
 hyperaemia
 stringy mucus in tear film and on conjunctival surfaces
 conjunctival oedema

53. Management by optometrist
• Non pharmacological
 Removal of lens deposits
 Reduce exposure time
 Optimize lens fit, material and wearing regime
o change soft lens material to one with improved deposit resistance
o change to daily disposable soft lenses

54. Acute Allergic Conjunctivitis
• Aetiology
 A self-limiting reaction to an allergen (often unidentified) that comes into
contact with the conjunctiva provoking an immediate response
 Common in children
 Allergens include: grass pollen, animal dander , dust
• Predisposing factors
 History of allergic disease; can also occur without such history

55. • Symptoms
 Eyelid swelling
 Itching
 May be unilateral (if a direct contact response)
• Signs
 Lid oedema
 Conjunctival chemosis
 Mild watery or mucoid discharge

56. Management by optometrist
• Non pharmacological
 Most cases resolve spontaneously within a few hours
 Advise against eye rubbing (causes mechanical mast cell degranulation)
 Cool compresses may give relief
 If possible identify allergen and advise future avoidance
 Advise patient to return/seek further help if symptoms persist
• Pharmacological
 Not normally required (although ocular lubricant drops and/or topical anti-
histamines may provide symptomatic relief)

57. Seasonal Allergic Conjunctivitis
• Predisposing factors
 Atopic disposition
 Personal history of allergic disease (hay fever, asthma, eczema, food or
drug allergy)
 Family history of allergic disease
 Exposure to allergens

58. Symptoms
 Itching
 Watering of eye
 May be associated with sneezing and watery nasal discharge
 symptoms seasonal with climatic variations

59. Signs
Mild to moderate lid oedema
Bulbar and tarsal conjunctiva: chemosis , hyperaemia and diffuse papillary
reaction

60. Management by optometrist
 Identify allergens
 Advise avoidance of allergens
 Cool compresses for symptomatic relief
 Advise against eye rubbing

61. Viral Conjunctivitis
• Predisposing factors
 Recent cold or other upper respiratory tract infection
 Low standards of hygiene
 Crowded conditions (schools, camps, clinics)
 Eye clinics (transmission by clinicians’ fingers, tonometer , etc.)

62. Symptoms
Acute onset of :
 redness
 Discomfort
 watering
 Eyelids may be stuck together in the morning
 Often unilateral at first, becoming bilateral
 Blurred vision if central cornea involved

63. Signs
 Watery discharge
 Hyperemia
 Follicles
 Subconjunctival haemorrhages
 Pseudo membranes
 Pre-auricular lymphadenopathy which may be tender (not present in every
case)
 Corneal involvement in some cases

64. Management by optometrist
• Non pharmacological
 Wash hands carefully before and after examination and clean equipment
before next patient
 Do not applanate with a re-usable tonometer
• Advise patient:
 condition is normally self-limiting, resolving within one to two weeks
 condition is highly contagious (do not share towels, etc)
 cold compresses may give symptomatic relief
 discontinue contact lens wear in acute phase

65. Thank You !