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Conjunctiva and its Disorders
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- 2. Introduction: It isa 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 Marginalconjunctiva • 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 Itjoins 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 andbulbar : 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 Lymphoidlayer 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 Meshworkof collagenous and elastic fibers Thicker than adenoid layer except in the Tarsal conjunctiva Consists of nerves and vessels of conjunctiva
- 14. Conjunctival glands It consistsof 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 Circumcornealzone : 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 Lymphaticsof 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 commondegenerative change Yellowish white path on bulbar conjunctiva near the limbus , nasal or temporal .
- 21. Etiology Age relatedchange Strong sunlight exposure Dusty , windy and smoky working environment ?Considered as a precursor of pterygium
- 22. Symptoms : Usuallyasymptomatic Possible mild foreign body sensation and redness when inflamed Occasional cosmetic concern
- 23. Signs : Areaof 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 isa 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 isthe 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 formeddue 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 OfConjunctiva 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 Typeof Discharge Type of conjunctival reaction Presence of membrane/ Pseudo-membrane Lymphadenopathy Pigmentations
- 38. Discharge : It isexudation 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 isresponse 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 appearas 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 isseen 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 inflammationof 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 • Predisposingfactors 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 andnon-specific irritation may increase after lens removal Mucus discharge Increased lens movement Loss of lens tolerance Decreasing comfort Blurred vision
- 52. Signs Almost alwaysbilateral 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 Eyelidswelling 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 Wateringof eye May be associated with sneezing and watery nasal discharge symptoms seasonal with climatic variations
- 59. Signs Mild to moderatelid 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 • Predisposingfactors 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
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