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New real conjunctiva ,episclera ,sclera

The document provides a comprehensive overview of the conjunctiva, episclera, and sclera, covering their embryology, anatomy, vascular supply, and nerve supply, as well as clinical correlations and conditions affecting these structures. It details the development and specific parts of the conjunctiva, various associated glands, and common disorders such as pinguecula and pterygium. Additionally, it discusses symptoms of conjunctivitis and distinguishes between various conjunctival conditions based on their clinical signs.

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Conjunctiva ,Episclera ,Sclera :- Anatomy , Nerve supply, Vascular supply & Clinical correlations Moderator:- Presenters :- Mr. Sanjeeb Kumar Mishra Bipin koirala Jenisha bhattarai MMC , IOM
 Presentation layout:- 1. Embryology  Conjunctiva  sclera 2. Anatomy 3. Vascular supply 4. Nerve supply 5. Applied anatomy. 6. Summary 7. References
 Embryology Conjunctiva:-  Develops from the ectoderm lining the lids and covering the globe.  Conjunctival glands develop as a growth of the basal cells of upper conjunctival fornix. Fewer glands develop from the lower fornix.
 Embryology Sclera:-  Sclera is developed from the mesenchymal cells surrounding the optic cup.  The developmental process starts at limbal equatorial region around seventh week of gestation and is completed by fifth months.  Deposition of elastin and GAGs are added to extracellular matrix at a later date.
 Conjunctiva:- Translucent mucous membrane lining the posterior surface of eyelids and anterior surface of eye. Stretches from lid margin to limbus with conjunctival sac in between.
Conjunctiva Palpebral Marginal Tarsal Orbital Bulbar Limbal Scleral Conjunctival Fornix Superior Inferior Lateral Medial  Parts of conjunctiva:-
 Palpebral Conjunctiva:-  Extends from lid margin to 2 mm on the back of the lid upto a shallow groove called sulcus subtarsalis.  Common site for lodgment of conjunctival foreign body.  It is actually a transitional zone between skin and the conjunctiva proper. 1. Marginal conjunctiva:-
2. Tarsal conjunctiva:- Thin , transparent & highly vascular. Upper tarsal firmly adherent to whole tarsal plate. Lower tarsal adherent only to half width of tarsus. Tarsal conjunctiva is commonest site of follicular and papillary rxn.
3.Orbital conjunctiva:- Lies between tarsal conjunctiva and fornix. Orbital conjunctiva of upper lid lies over Muller's muscle.
 Seperated from anterior sclera by Episcleral tissue and tenon’s capsule.  Separated from anterior sclera by Episcleral tissue and Tenon’s capsule  Only tissue in body where vessels are visible  It has two parts:- 1.Scleral conjunctiva  Bulbar conjunctiva:- 2.Limbal conjunctiva  3 mm ridge of bulbar conjunctiva around cornea  The conjunctiva, tenon’s capsule and the Episcleral tissue are fused
 Conjunctival fornix:- Continuous circular cul-de sac broken only on medial side by caruncle and plica semilunaris. Joins bulbar conjunctiva with palpebral conjunctiva. Broken on its medial site by caruncle and the plica semilunaris. Can be subdivided into Superior , Inferior , Medial & Lateral fornixes.
 Extends from upper border of the tarsal plate to 10mm above the upper limbus, reaches superior orbital margin.  Superiorly attached to the fascial sheath of the Levator muscle and superior rectus muscles.  Foreign body in superior fornix-double eversion. 1. Superior fornix
 Extension - lower border of the lower tarsal plate to 8mm from the lower limbus.  located near the inferior orbital margin.  Attached to extension of fascial sheath of the inferior rectus and the inferior oblique muscle. 2.Inferior fornix
 Extends behind the equator of the eyeball.  14 mm from the lateral limbus.  5mm from the lateral canthus. 3. Lateral fornix 4. Medial fornix  Shallow cul-de-sac  Caruncle and plica semilunaris lies here in the pool of tears called lacus lacrimalis.
 Figure showing dimension of various parts in conjunctiva
 Crescentic fold of conjunctiva present in medial canthus.  Vestigial structure.  Represents nictitating membrane of lower animals.  Plica semilunaris
 Small, pinkish mass in inner canthus medial to Plica semilunaris  Piece of modified skin & has sweat glands, sebaceous glands & hair follicles Caruncle
Degenerative conditions of conjunctiva.  Pinguecula. 1. Yellowish-white patch on the bulbar conjunctiva. 2. Age related change. 3. Commonly seen in individual exposed to UV light, dust &wind. 4. Elastotic degeneration in substantia propria a/w deposition of hyaline materials.
Continue.. 5. Bilateral and stationery condition with triangular patch near limbus. 6. Apex lies away from cornea. 7. Complications like abscess formation inflammation and conversion into pterygium is also seen. Pingueculitis
 Pterygium 1. Wing shaped fold seen to be encroaching cornea. 2. Seen in individual with prolonged exposure to UV dry heat, dust and wind. 3. Degenerative and hyperplastic condition of conjunctiva. 4. Elastotic degeneration destroying corneal epithelia bowman’s layers & superficial stroma. 5. Apex lies towards cornea and frequently seen in nasal side .
Continue… 6. Pterygium can be divided into 4 parts :- a. Head b. Neck c. Body d. Cap 7. Depending upon progression 2 types. a. Progressive b. Regressive How to differentiate true with pseudo pterygium??? What is double pterygium??
Concretions. 1. Formed due accumulation of inspissated mucus & epithelial debris . 2. Degenerative condition seen in elderly individual. 3. Seen in palpebral conjunctiva ( Upper>>Lower). 4. Yellowish- white & Hard looking . 5. Can cause FB sensation and excess lacrimation .
 Conjunctivochalasis  Seen as fold of redundant conjunctiva b/w globe & lower lid protruding over lid margin.  Normal ageing change but exacerbated by stress , inflamn, dry eye.  Produces excess lacrimation due to blockage to L. Punctum and interference to lower tear meniscus.
Histology of conjunctiva:- It consists of 3 layers as follows:- 1. Epithelium 2. Adenoid layer 3. Fibrous layer
 Epithelium Epithelium varies from region to region. 1.Marginal conjunctiva:- Five layered non keratinized stratified squamous epithelium.  Superficial:- Squamous cells  Intermediate:- Polyhedral cells  Deepest:- Cylindrical cells
2. Tarsal conjunctiva:- Two layered epithelium. Upper eyelid:-  Superficial layer:- Cylindrical cells  Deep layer:- Cuboidal cells Lower eyelid:- 3 to 4 layers of cells from deep to superficial.  Cubical cells  Polygonal cells  Elongated wedge shaped cells  Cone shaped cells
3. Fornix and bulbar conjunctiva:-  3 layered epithelium.  Superficial layer: cylindrical cells  Middle layer: Polyhedral cells  Deep layers: cuboidal cells 4. Limbal conjunctiva:-  8 to 10 stratified squamous epithelium.  Contains palisades of vogt.  Epithelium of palisade zone provide germinative zone for the corneal epithelium.
2. Adenoid Layer:-  Fine connective tissue reticulum containing lymphocytes.  Most developed in fornixes.  Develops at 2 to 3 months of life. Conjunctival inflammation in an infant doesn’t produces follicular rxn.
3. Fibrous layer:-  Network of collagenous and elastic fibers.  Contains nerves and blood vessels.  Thicker than adenoid layer.  Thin at tarsal conjunctiva.
 Conjunctival glands On the basis of types of secretion, conjunctival glands can be divided into:- Glands associated with conjunctiva Mucin Glands Goblet Cells Henle’s Gland Glands of Manz Accessory Glands Gland of Krause Gland of Wolfring
Mucin glands a) Goblet cells:-  Unicellular mucous glands.  Present in conjunctiva except marginal mucocutaneous junction and limbal conjunctiva.  Formed from basal layer of conjunctiva and migrate towards the surface.  Cells destroyed after discharging their content.  Density high in children than in young adults.
b) Henle’s glands:-  Not true glands.  Tubular structures containing few goblet cells.  Present in palpebral conjunctiva. c) Glands of manz:-  Found in limbal conjunctiva.  Its presence is controversial in human.
 Functions of mucin:-  Mucin lubricate and protects the epithelial cells.  Maintains tear film stability by lowering surface tension. Clinical importance:-  Destruction of goblet cells occurs in Epithelium xerosis.  No. of goblet cells is increased in inflammatory conditions.
 Accessory glands:- A. Glands of Krause:-  Lies deep in sub conjunctival tissue.  Upper fornix- 42  Lower fornix - 6 to 8 B. Glands of wolfring:-  Upperboarder of superior tarsus - 2 to 5  Lower boarder of inferior tarsus - 2
 Blood supply of conjunctiva:-  Blood supply of conjunctiva is facilitated by:- 1. Marginal Arcade of eyelid 2. Peripheral Arcade of eyelid 3. Anterior Cilliary arteries
Perforating branches from peripheral arterial arcade Pierce the Levator palpebral muscle Ascending Branch Continue as posterior conjunctival arteries Reach conjunctiva & divides Descending Branches Marginal Branches Tarsal Branches Reach conjunctiva & divides Pierce the tarsus at the sulcus subtarsalis Perforating branches from marginal arterial arcade Anastomosis
Pass upwards & bend round the superior fornix to ascend under the bulbar conjunctiva Posterior conjunctival arteries Ascending Branch of peripheral tarsal arcade Travel along the tendon of the superior fornix to ascend under the bulbar conjunctiva Anterior conjunctival arteries Anterior ciliary arteries Send branches to the pericorneal plexus
Venous drainage Veins from conjunctiva Venous plexus of eyelid Superior/inferior ophthalmic veins A circumcorneal zone of veins 5-6mm from the limbus Anterior ciliary veins  Venous drainage:
 Lymphatic drainage:- From medial side From lateral side Submandibular lymph node Preauricular lymphnode
 Nerve supply to conjunctiva:- 1. Bulbous conjunctiva Anterior two third of circum corneal limbus is supplied by long cilliary nerves. 2. Superior palpebral conjunctiva, superior fornix, superior peripheral one third of bulbous conjunctiva is supplied by trochlear, supra orbital, lacrimal and frontal nerve.
3. Inferior lateral fornix, inferior lateral conjunctiva and inferior lateral one third of bulbous conjunctiva is supplied by lacrimal nerve. 4. Inferior medial fornix, inferior medial conjunctiva, inferior medial one third of bulbous conjunctiva is supplied by Infra orbital nerve.
Symptomatic conditions of conjunctiva  Hyperemia of conjunctiva.  Chemosis of conjunctiva.  Ecchymosis of conjunctiva.  Xerosis of conjunctiva.  Discoloration of conjunctiva
 Hyperaemia of conjunctiva  It is due to congestion of conjunctival blood vessels.  Etiologically two types:- Acute hyperaemia Chronic hyperaemia Caused by temporary irritants. Like FB, concretions, dust, smoke, fumes, rubbing with hands , extreme hot or cold. Chronic alcoholics , smokers, residents of dusty area and ill ventilated rooms , pts suffering from rosacea , insomnia.
Contd…..  Pts complains discomfort, grittiness, tiredness etc.  Can be treated by removal of causes.  Decongestants can be used for symptomatic relief
 Chemosis of conjunctiva  A.K.A edema of conjunctiva.  Causes of Chemosis can be grouped as:- Local inflammatory conditions Local blood / lymph flow obstructions Systemic causes 1.Conjunctivitis, 2.Corneal ulcers, 3.Uveitis 4.Acute meibomitis, 5.Orbital cellulitis, 6.Dacryoadenitis, 7.Dacryocystitis 1. Acute congestive glaucoma 2. Orbital lymphatics blockage 3. Cavernous sinus thrombosis 4. Orbital tumors & pseudo tumors. 1. Anaemia 2. Hypoproteinemia 3. Congestive heart failure etc..
 Ecchymosis of conjunctiva  A.K.A Subconjunctival hemorrhage.  Etiology a. Trauma or during surgery b. Acute hemorrhagic conjunctivitis. c. Whooping cough , violent compression of thorax. d. HTN & DM e. Bleeding disorders
 Xerosis of conjunctiva  Condition in which conjunctiva becomes dry & lusterless.  2 types (Etiologically) Parenchymatous Xerosis Epithelial Xerosis  Occurs due to cicatrical disorganization of conjunctiva.  Seen in trachoma, SJS, thermal & chemical burns  Conditions causing conjunctival exposure like ectropion, proptosis, lagophthalmos.  Occurs due to hypovitamintosis A.  Typically seen in children's  Conjunctiva is seen wrinkled, thickened and pigmented.
 Discoloration of conjunctiva.  Normal conjunctiva is transparent and looks pinkish too.  Conjunctiva discoloration is seen in various systemic conditions. Red Yellow Blue Greyish Brown  Sub conjunctival Hemorrhage  Jaundice  Malaria  Yellow fever  Conjunctival fat in elderly  A/w blue sclera  Scleromalacia perforans  Application of kajal  Non melanocytic pigmentation  Melanocytic pigmentation
Conjunctivitis:-  Inflammation of conjunctiva.  Symptoms of conjunctivitis.  lacrimation  Burning sensation  Itching  Pain (mild)  Photophobia  FB sensation & Grittiness
Be careful!!!! Some symptoms seen during conjunctivitis might also be seen in other ocular pathologies like as anterior uveitis , acute congestive glaucoma So conjunctivitis must be differentiated from anterior uveitis and acute congestive glaucoma before starting treatment
Tabular comparison b/w Acute conjunctivitis, Acute congestive glaucoma & Acute iridocyclitis Features Acute conjunctivitis Acute iridocyclitis Acute congestive glaucoma Onset Gradual Usually gradual Sudden Pain Mild Moderate Severe Discharge Mucopurulent Watery Watery Colored haloes May be present Absent Present Vision Normal slightly impaired Markedly impaired Congestion Superficial Deep ciliary Deep ciliary Pupil Normal Small, irregular Large ,oval Media Clear Hazy Hazy Ant. chamber Normal May be deep shallow Iris Normal Muddy Oedematous IOP Normal Normal Usually raised
Clinical signs in conjunctivitis. Congestion/ Hyperemia :- Dilation of superficial blood vessels.
 Clinical pictures in different types of congestion. Conjunctival congestion Circum ciliary congestion Mixed congestion
Discharge Consists of exudates filtered from the conjunctival epithelium through dilated blood vessels. Types of discharges Nature of discharge Associated conjunctivitis Watery Allergic & Acute viral Mucoid Chronic allergic Mucopurulent Chlamydial & Acute bacterial Mod purulent Acute bacterial Severe purulent Gonococcal conjunctivitis
 Follicles Translucent boiled grain like raised structure.  Upper tarsal conjunctiva & at fornixes.  Histology :- 1. Formed by scattered aggregation of lymphocytes in adenoid layer. 2. Central part composed immature lymphocytes & peripherally matured lymphocytes. 3. Blood vessels are present around and across the lesions. In case of trachoma follicles are seen in bulbar conjunctiva Herbert follicles
 Papillae  Hyperplasia of conjunctival epithelium is seen.  Seen in palpebral conjunctiva and at limbus.  Histology:- 1. Composed of stromal infiltration with inflammatory cells. 2. Central core is composed of dilated blood vessels.  Based on size:- 1. Micro papillae 2. Macro papillae (<1mm) 3. Giant papillae (>1mm)
Difference between Papillae & Follicles. Features Papillae Follicles Commonly seen Bacterial & Allergic conjunctivitis Viral and chlamydial conjunctivitis Appearance Reddish and velvety Translucent & boiled grain. Blood vessels Dilated blood vessels form center core of papillae Passes around & across the follicle Composition Hyperplastic epithelium Hyperplastic lymphoid tissue Where are they found?? Palpebral conjunctiva and limbal areas Fornixes and palpebral conjunctiva
 Membranes:- True membrane Pseudo membrane Involves inflammatory exudates interdigitated with superficial layer inflamed conjunctival epithelium. Involves coagulated exudates adherent to inflamed epithelium Removal leads to tearing and bleeding. Can be peeled away easily leaving underlying epithelium intact without bleeding. Neisseria gonorrhea, Corynebacterium diphtheria , SJS EKC, ALLERGIC conjunctivitis, Severe bacterial conjunctivitis
Clinical figures of True VS Pseudo membranes TRUE MEMBRANE PSEUDO MEMBRANE
 Conjunctival scarring:-  Whitish irregular, linear or stellate shaped opaque patches seen on tarsal conjunctiva.  Scarring is A/w loss of goblet cells and accessory lacrimal glands.  Seen in Trachoma, atopic conjunctivitis. Cicatricial pemphigoid etc. What is Arlt’s line??
 Conjunctival infiltration:-  It represents cellular recruitment to the site of chronic inflammation.  Typically accompanies papillary response.  Details of normal tarsal conjunctival blood vessels is lost.
 Chemosis:-  A.k.A conjunctival oedema.  Translucent swelling of conjunctiva.  Chemosis is seen in chronic allergic conjunctivitis.  Also seen in severe infective conjunctivitis.
 Haemorrhage:-  Seen in both viral as well as bacterial conjunctivitis  In Viral haemorrhages are multiple, small & discrete.  Picorna virus commonly cause haemorrhagic conjunctivitis.  In Bacterial conjunctivitis haemorrhages are large and diffused.  Pneumococcus bacteria commonly causes SCH.
 lymphadenopathy  A.K.A lymphadenitis ( Enlargement of lymph nodes.)  Commonly seen conjunctivitis A/W viral infections.  Also seen in chlamydial & severe bacterial conjunctivitis.  Common in Gonococcal conjunctivitis.  Preauricular lymph node is commonest to be affected.
Classification of conjunctivitis..
 Based on Etiology (a) Infective conjunctivitis Bacterial conjunctivitis Viral conjunctivitis Chlamydial conjunctivitis Ophthalmia neonatrum Granulomatous conjunctivitis
(b) Allergic conjunctivitis Simplex allergic conjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis Giant papillary conjunctivitis Phlyctenular conjunctivitis Contact dermoconjunctivitis
(c) Cicatricial conjunctivitis Ocular mucous membrane pemphigoid Stevens Johnson syndrome Toxic epidermal necrolysis Secondary cicatricial conjunctivitis (d) Toxic conjunctivitis
Secondary conjunctivitis:-  Conjunctivitis associated with disorders of lacrimal apparatus , eyelid deformities is called secondary conjunctivitis.  Some of the associated conditions are :- Dacryocystitis Trichiasis Entropion Ectropion Facial palsy
Differentiating conjunctivitis based on clinical features:- Clinical features Bacterial Viral Allergic Chlamydial Congestion Marked Moderate Mild to mod. Moderate Chemosis ++ + ++ +/- SCH +/- +/- - - Discharge Purulent or Mucopurulent Watery Ropy/watery Mucopurulent Papillae +/- - ++ +/- Follicles - + - ++ Pseudo membrane +/- +/- - - Pannus - - -(except VKC) + Lymphadenopathy + ++ - +/-
 Cysts of conjunctiva Congenital cystic lesion Lymphatic cysts Retention cyst Traumatic cyst Epithelial down growth cyst Aqueous cyst Pigmented epithelial cyst Parasitic cyst
 Conjunctival tumors  They can be both pigmented as well as non pigmented.  On the basis of nature and tissue of origin their types are:- Tissue of origin Benign Malignant Epithelial Papilloma Squamosal cell carcinoma Glandular Adenoma Adenocarcinoma Connective tissue Fibroma Sarcoma Vascular Hemangioma Angiosarcoma Reticular system Lymphoid hyperplasia Lymphosarcoam Pigment cells Naevus Melanoma
 Dermoid  Congenital tumors  Occurring at limbus as solid white mass.  Has sebaceous gland , hair , collagenous connective tissue.  Lined by epidermoid.
 Lipodermoid  Congenital tumor.  Found at limbus or outer canthus.  Appears soft, white , moveable, sub conjunctival mass. Orbital fat prolapse
 Naevi  A.k.A congenital moles of conjunctiva.  Greyish, blackish or brownish coloration.  Found as a flat or slightly raised nodule in bulbar conjunctiva.  May show increase size during puberty & pregnancy.  Pigmentary change seen during inflammation.
Anatomy of sclera:-  Dense connective tissue composed of collagen bundles of varying diameter.  Whole outer surface is covered by Tenon’s capsule.  Anterior part is covered by bulbar conjunctiva.
Sclera contd.. Inner surface of sclera lies in contact with choroid with a potential supra choroidal space between. Sclera forms the posterior 5/6th part of globe. Opaque appearance: less uniform orientation of collagen fibres.
Thickness of sclera.  Differs from individual to individual also based upon age.  Thinner in children than adult & female than male.  Sclera is thickest posteriorly and gradually gets thin anteriorly.  Posterior thickness is (1mm)  Thinnest at insertion of EOMS (0.3mm)  At equator (0.4-0.8mm)  At limbus (0.8 mm)
 Special regions of sclera:- 1. Scleral sulcus  It is a furrow on inner surface of ant most point of sclera.  It houses schlemn’s canal. 2. Scleral spur  Circular rim in ant most part of sclera lying deep to schlemn’s canal.  Meridonial fibers of ciliary body are attached to it.
Special region contd.. 3. Lamina cribrosa  Sieve like sclera  Optic nerve passes through it.  During glaucoma in which IOP will rise lamina cribrosa will gradually increase in posterior curvature.
Microscopic structures:- Histologically sclera consists of following layers:- 1. Episcleral tissue 2. Sclera proper 3. Lamina fusca
1. Episcleral tissue  It is thin, dense vascularized layer of connective tissue which covers sclera proper.  Fine fibroblasts, macrophages and lymphocytes are also present in this layer. 2. Sclera proper  It is an avascular structure which consists of dense bundles of collagen fibers.  The band of collagen tissue cross each other in all direction. 3. Lamina fusca  It is the innermost part of sclera which blends with supra choroidal and supracilliary lamina of the uveal tract.  It is brownish in color due to presence of pigmented cells.
 Vascular Supply:-  It is relatively avascular structure.  Anterior cilliary artery form a dense Episcleral plexus anterior to the insertion of rectus muscle.  Long and short posterior cillary artery supplies the posterior part.
 Nerve Supply:- Sclera is supplied by branches from the long cilliary nerves which pierce it 2 to 4 mm from limbus to form a plexus. Anterior region is supplied by long ciliary nerve Posterior region is also supplied by short ciliary nerve.
 Apertures piercing sclera:- Sclera is pierced by three sets of apertures:- 1. Posterior apertures :-  These are situated around the optic nerve and transmit long and short cilliary nerves and vessels. 2. Middle apertures:-  These are four in numbers.  Are situated slightly posterior to equator through which the four vortex veins(venae verticosae passes)
Apertures contd... 3. Anterior Apertures:-  Are situated 3 to 4mm away from the limbus.  Anterior cilliary vessels passes through the apertures.
 Inflammation of sclera.  Can be classified into Episcleritis & Scleritis. Episcleritis Normal sclera Scleritis
 Episcleritis Benign and recurrent inflammation of Episclera & Tenon's capsule. Causes of episcleritis:- 1. Idiopathic 2. Gout & connective tissue disorders 3. H/S Rxn like staphylococcal toxins 4. Herpes zoster , syphillis , TB Symptoms:- 1. Redness 2. Mild ocular discomfort 3. Burning ,FB sensation 4. Rarely photophobia and watering.
Episcleritis contd.. Clinically two types :- Simple Episcleritis Nodular episcleritis Characterized by sectoral ( occasionally diffused) inflamn of episclera. Characterized by pink flat nodule surrounded by blood vessels injection.
 Scleritis  Chronic inflammation of scleral proper.  Serious than episcleritis as it can severely affect vision. Causes :- 1. Idiopathic 2. RA, PAN, SLE. 3. Gout, Thyrotoxicosis. 4. HZO , Staphylococcal & streptococcal infection. 5. Syphilis, leprosy Symptoms:- 1. Pain 2. Redness 3. Photophobia 4. Diminution of vision
Scleritis contd.. 85% 13% 2% Scleritis classification Non necrotising scleritis Necrotising scleritis posterior scleritis
 Differentiating Scleritis from Episcleritis.  It is very important to differentiate Episcleritis from Scleritis.  In gross appearance both may look similar.  But their proper differentiation is necessary during clinical practice because scleritis may be vision threatening.
 Blanching:-  Helps to differentiate Scleritis from Episcleritis.  Vasoconstrictors are used for this process.  Phenylephrine (0.125%) are commonly used.  A drop is instilled in red eye and observed for 10-15 minutes.  If redness disappears then Episcleritis but if redness still persist then Scleritis.
 Slit lamp examination. 1. Using optical section ( slit beam). 2. Using red free filter ( green filter).  Will give more contrast to subtle red blood vessels.  Making easier in viewing dominant area of vascular congestion and zone of avascularity. Episcleritis Scleritis  Anterior slit beam is bowed forward due Episcleral edema.  Posterior beam is flat against normal sclera.  In scleritis posterior beam also bows forward due to underlying Scleral edema.
 Blue sclera  Marked generalized bluish discoloration of sclera.  Due to scleral thinning.  Seen in conditions like as:- Osteogenesis imperfecta Marfan’s syndrome Bupthalmos High myopia
What is the scleral color of newly born baby?? Bluish tint is seen in sclera of newly born. In newly born sclera is translucent and bluish tint is due to underlying uveal tissue coloration.
 Sclerocornea  Congenital anomaly  Sclera blends with cornea  No clear cut boundary b/w sclera & cornea.  Opacity ranges from peripheral to total.
 Staphyloma:-  Localized outward bulging of weak & thin outer tunic eyeball( sclera and cornea).  Lined by uveal tissue and shines through fibrous coat.  Anatomically can be divided into followings:- Staphyloma Anterior staphyloma Intercalary staphyloma Ciliary staphyloma Equatorial staphyloma Posterior staphyloma
 Clinical pictures in different types of staphylomas. Anterior staphyloma Intercalary staphyloma Ciliary staphyloma Equatorial staphyloma Posterior staphyloma
 Scleromalacia. Degenerative thinning of sclera.  Commonly seen in anterior necrotizing scleritis (scleromalacia perforans).  Patients with Rheumatoid arthritis commonly present with this condition.
 Summary:-  Conjunctiva, Tenon’s capsule, episclera and sclera are respectively present ongoing from outer layer to inner layer forming protective coating.  Conjunctivitis must be differentiated from anterior uveitis and acute congestive glaucoma before starting treatment.  It is very important to differentiate Episcleritis from Scleritis. Proper differentiation is necessary during clinical practice because scleritis may be vision threatening.
 References:-
New real conjunctiva ,episclera ,sclera

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New real conjunctiva ,episclera ,sclera

  • 2.
    Conjunctiva ,Episclera ,Sclera:- Anatomy , Nerve supply, Vascular supply & Clinical correlations Moderator:- Presenters :- Mr. Sanjeeb Kumar Mishra Bipin koirala Jenisha bhattarai MMC , IOM
  • 3.
     Presentation layout:- 1.Embryology  Conjunctiva  sclera 2. Anatomy 3. Vascular supply 4. Nerve supply 5. Applied anatomy. 6. Summary 7. References
  • 4.
     Embryology Conjunctiva:-  Developsfrom the ectoderm lining the lids and covering the globe.  Conjunctival glands develop as a growth of the basal cells of upper conjunctival fornix. Fewer glands develop from the lower fornix.
  • 5.
     Embryology Sclera:-  Sclerais developed from the mesenchymal cells surrounding the optic cup.  The developmental process starts at limbal equatorial region around seventh week of gestation and is completed by fifth months.  Deposition of elastin and GAGs are added to extracellular matrix at a later date.
  • 6.
     Conjunctiva:- Translucent mucousmembrane lining the posterior surface of eyelids and anterior surface of eye. Stretches from lid margin to limbus with conjunctival sac in between.
  • 7.
  • 8.
     Palpebral Conjunctiva:- Extends from lid margin to 2 mm on the back of the lid upto a shallow groove called sulcus subtarsalis.  Common site for lodgment of conjunctival foreign body.  It is actually a transitional zone between skin and the conjunctiva proper. 1. Marginal conjunctiva:-
  • 9.
    2. Tarsal conjunctiva:- Thin, transparent & highly vascular. Upper tarsal firmly adherent to whole tarsal plate. Lower tarsal adherent only to half width of tarsus. Tarsal conjunctiva is commonest site of follicular and papillary rxn.
  • 10.
    3.Orbital conjunctiva:- Lies betweentarsal conjunctiva and fornix. Orbital conjunctiva of upper lid lies over Muller's muscle.
  • 11.
     Seperated fromanterior sclera by Episcleral tissue and tenon’s capsule.  Separated from anterior sclera by Episcleral tissue and Tenon’s capsule  Only tissue in body where vessels are visible  It has two parts:- 1.Scleral conjunctiva  Bulbar conjunctiva:- 2.Limbal conjunctiva  3 mm ridge of bulbar conjunctiva around cornea  The conjunctiva, tenon’s capsule and the Episcleral tissue are fused
  • 12.
     Conjunctival fornix:- Continuouscircular cul-de sac broken only on medial side by caruncle and plica semilunaris. Joins bulbar conjunctiva with palpebral conjunctiva. Broken on its medial site by caruncle and the plica semilunaris. Can be subdivided into Superior , Inferior , Medial & Lateral fornixes.
  • 13.
     Extends fromupper border of the tarsal plate to 10mm above the upper limbus, reaches superior orbital margin.  Superiorly attached to the fascial sheath of the Levator muscle and superior rectus muscles.  Foreign body in superior fornix-double eversion. 1. Superior fornix
  • 14.
     Extension -lower border of the lower tarsal plate to 8mm from the lower limbus.  located near the inferior orbital margin.  Attached to extension of fascial sheath of the inferior rectus and the inferior oblique muscle. 2.Inferior fornix
  • 15.
     Extends behindthe equator of the eyeball.  14 mm from the lateral limbus.  5mm from the lateral canthus. 3. Lateral fornix 4. Medial fornix  Shallow cul-de-sac  Caruncle and plica semilunaris lies here in the pool of tears called lacus lacrimalis.
  • 16.
     Figure showingdimension of various parts in conjunctiva
  • 17.
     Crescentic foldof conjunctiva present in medial canthus.  Vestigial structure.  Represents nictitating membrane of lower animals.  Plica semilunaris
  • 18.
     Small, pinkishmass in inner canthus medial to Plica semilunaris  Piece of modified skin & has sweat glands, sebaceous glands & hair follicles Caruncle
  • 19.
    Degenerative conditions ofconjunctiva.  Pinguecula. 1. Yellowish-white patch on the bulbar conjunctiva. 2. Age related change. 3. Commonly seen in individual exposed to UV light, dust &wind. 4. Elastotic degeneration in substantia propria a/w deposition of hyaline materials.
  • 20.
    Continue.. 5. Bilateral andstationery condition with triangular patch near limbus. 6. Apex lies away from cornea. 7. Complications like abscess formation inflammation and conversion into pterygium is also seen. Pingueculitis
  • 21.
     Pterygium 1. Wingshaped fold seen to be encroaching cornea. 2. Seen in individual with prolonged exposure to UV dry heat, dust and wind. 3. Degenerative and hyperplastic condition of conjunctiva. 4. Elastotic degeneration destroying corneal epithelia bowman’s layers & superficial stroma. 5. Apex lies towards cornea and frequently seen in nasal side .
  • 22.
    Continue… 6. Pterygium canbe divided into 4 parts :- a. Head b. Neck c. Body d. Cap 7. Depending upon progression 2 types. a. Progressive b. Regressive How to differentiate true with pseudo pterygium??? What is double pterygium??
  • 23.
    Concretions. 1. Formed dueaccumulation of inspissated mucus & epithelial debris . 2. Degenerative condition seen in elderly individual. 3. Seen in palpebral conjunctiva ( Upper>>Lower). 4. Yellowish- white & Hard looking . 5. Can cause FB sensation and excess lacrimation .
  • 24.
     Conjunctivochalasis  Seenas fold of redundant conjunctiva b/w globe & lower lid protruding over lid margin.  Normal ageing change but exacerbated by stress , inflamn, dry eye.  Produces excess lacrimation due to blockage to L. Punctum and interference to lower tear meniscus.
  • 25.
    Histology of conjunctiva:- Itconsists of 3 layers as follows:- 1. Epithelium 2. Adenoid layer 3. Fibrous layer
  • 26.
     Epithelium Epithelium variesfrom region to region. 1.Marginal conjunctiva:- Five layered non keratinized stratified squamous epithelium.  Superficial:- Squamous cells  Intermediate:- Polyhedral cells  Deepest:- Cylindrical cells
  • 27.
    2. Tarsal conjunctiva:- Twolayered epithelium. Upper eyelid:-  Superficial layer:- Cylindrical cells  Deep layer:- Cuboidal cells Lower eyelid:- 3 to 4 layers of cells from deep to superficial.  Cubical cells  Polygonal cells  Elongated wedge shaped cells  Cone shaped cells
  • 28.
    3. Fornix andbulbar conjunctiva:-  3 layered epithelium.  Superficial layer: cylindrical cells  Middle layer: Polyhedral cells  Deep layers: cuboidal cells 4. Limbal conjunctiva:-  8 to 10 stratified squamous epithelium.  Contains palisades of vogt.  Epithelium of palisade zone provide germinative zone for the corneal epithelium.
  • 29.
    2. Adenoid Layer:- Fine connective tissue reticulum containing lymphocytes.  Most developed in fornixes.  Develops at 2 to 3 months of life. Conjunctival inflammation in an infant doesn’t produces follicular rxn.
  • 30.
    3. Fibrous layer:- Network of collagenous and elastic fibers.  Contains nerves and blood vessels.  Thicker than adenoid layer.  Thin at tarsal conjunctiva.
  • 31.
     Conjunctival glands Onthe basis of types of secretion, conjunctival glands can be divided into:- Glands associated with conjunctiva Mucin Glands Goblet Cells Henle’s Gland Glands of Manz Accessory Glands Gland of Krause Gland of Wolfring
  • 32.
    Mucin glands a) Gobletcells:-  Unicellular mucous glands.  Present in conjunctiva except marginal mucocutaneous junction and limbal conjunctiva.  Formed from basal layer of conjunctiva and migrate towards the surface.  Cells destroyed after discharging their content.  Density high in children than in young adults.
  • 33.
    b) Henle’s glands:- Not true glands.  Tubular structures containing few goblet cells.  Present in palpebral conjunctiva. c) Glands of manz:-  Found in limbal conjunctiva.  Its presence is controversial in human.
  • 34.
     Functions ofmucin:-  Mucin lubricate and protects the epithelial cells.  Maintains tear film stability by lowering surface tension. Clinical importance:-  Destruction of goblet cells occurs in Epithelium xerosis.  No. of goblet cells is increased in inflammatory conditions.
  • 35.
     Accessory glands:- A.Glands of Krause:-  Lies deep in sub conjunctival tissue.  Upper fornix- 42  Lower fornix - 6 to 8 B. Glands of wolfring:-  Upperboarder of superior tarsus - 2 to 5  Lower boarder of inferior tarsus - 2
  • 36.
     Blood supplyof conjunctiva:-  Blood supply of conjunctiva is facilitated by:- 1. Marginal Arcade of eyelid 2. Peripheral Arcade of eyelid 3. Anterior Cilliary arteries
  • 37.
    Perforating branches fromperipheral arterial arcade Pierce the Levator palpebral muscle Ascending Branch Continue as posterior conjunctival arteries Reach conjunctiva & divides Descending Branches Marginal Branches Tarsal Branches Reach conjunctiva & divides Pierce the tarsus at the sulcus subtarsalis Perforating branches from marginal arterial arcade Anastomosis
  • 38.
    Pass upwards &bend round the superior fornix to ascend under the bulbar conjunctiva Posterior conjunctival arteries Ascending Branch of peripheral tarsal arcade Travel along the tendon of the superior fornix to ascend under the bulbar conjunctiva Anterior conjunctival arteries Anterior ciliary arteries Send branches to the pericorneal plexus
  • 39.
    Venous drainage Veins from conjunctiva Venousplexus of eyelid Superior/inferior ophthalmic veins A circumcorneal zone of veins 5-6mm from the limbus Anterior ciliary veins  Venous drainage:
  • 40.
     Lymphatic drainage:- From medialside From lateral side Submandibular lymph node Preauricular lymphnode
  • 41.
     Nerve supplyto conjunctiva:- 1. Bulbous conjunctiva Anterior two third of circum corneal limbus is supplied by long cilliary nerves. 2. Superior palpebral conjunctiva, superior fornix, superior peripheral one third of bulbous conjunctiva is supplied by trochlear, supra orbital, lacrimal and frontal nerve.
  • 42.
    3. Inferior lateralfornix, inferior lateral conjunctiva and inferior lateral one third of bulbous conjunctiva is supplied by lacrimal nerve. 4. Inferior medial fornix, inferior medial conjunctiva, inferior medial one third of bulbous conjunctiva is supplied by Infra orbital nerve.
  • 43.
    Symptomatic conditions ofconjunctiva  Hyperemia of conjunctiva.  Chemosis of conjunctiva.  Ecchymosis of conjunctiva.  Xerosis of conjunctiva.  Discoloration of conjunctiva
  • 44.
     Hyperaemia ofconjunctiva  It is due to congestion of conjunctival blood vessels.  Etiologically two types:- Acute hyperaemia Chronic hyperaemia Caused by temporary irritants. Like FB, concretions, dust, smoke, fumes, rubbing with hands , extreme hot or cold. Chronic alcoholics , smokers, residents of dusty area and ill ventilated rooms , pts suffering from rosacea , insomnia.
  • 45.
    Contd…..  Pts complainsdiscomfort, grittiness, tiredness etc.  Can be treated by removal of causes.  Decongestants can be used for symptomatic relief
  • 46.
     Chemosis ofconjunctiva  A.K.A edema of conjunctiva.  Causes of Chemosis can be grouped as:- Local inflammatory conditions Local blood / lymph flow obstructions Systemic causes 1.Conjunctivitis, 2.Corneal ulcers, 3.Uveitis 4.Acute meibomitis, 5.Orbital cellulitis, 6.Dacryoadenitis, 7.Dacryocystitis 1. Acute congestive glaucoma 2. Orbital lymphatics blockage 3. Cavernous sinus thrombosis 4. Orbital tumors & pseudo tumors. 1. Anaemia 2. Hypoproteinemia 3. Congestive heart failure etc..
  • 47.
     Ecchymosis ofconjunctiva  A.K.A Subconjunctival hemorrhage.  Etiology a. Trauma or during surgery b. Acute hemorrhagic conjunctivitis. c. Whooping cough , violent compression of thorax. d. HTN & DM e. Bleeding disorders
  • 48.
     Xerosis ofconjunctiva  Condition in which conjunctiva becomes dry & lusterless.  2 types (Etiologically) Parenchymatous Xerosis Epithelial Xerosis  Occurs due to cicatrical disorganization of conjunctiva.  Seen in trachoma, SJS, thermal & chemical burns  Conditions causing conjunctival exposure like ectropion, proptosis, lagophthalmos.  Occurs due to hypovitamintosis A.  Typically seen in children's  Conjunctiva is seen wrinkled, thickened and pigmented.
  • 49.
     Discoloration ofconjunctiva.  Normal conjunctiva is transparent and looks pinkish too.  Conjunctiva discoloration is seen in various systemic conditions. Red Yellow Blue Greyish Brown  Sub conjunctival Hemorrhage  Jaundice  Malaria  Yellow fever  Conjunctival fat in elderly  A/w blue sclera  Scleromalacia perforans  Application of kajal  Non melanocytic pigmentation  Melanocytic pigmentation
  • 50.
    Conjunctivitis:-  Inflammation ofconjunctiva.  Symptoms of conjunctivitis.  lacrimation  Burning sensation  Itching  Pain (mild)  Photophobia  FB sensation & Grittiness
  • 51.
    Be careful!!!! Some symptomsseen during conjunctivitis might also be seen in other ocular pathologies like as anterior uveitis , acute congestive glaucoma So conjunctivitis must be differentiated from anterior uveitis and acute congestive glaucoma before starting treatment
  • 52.
    Tabular comparison b/wAcute conjunctivitis, Acute congestive glaucoma & Acute iridocyclitis Features Acute conjunctivitis Acute iridocyclitis Acute congestive glaucoma Onset Gradual Usually gradual Sudden Pain Mild Moderate Severe Discharge Mucopurulent Watery Watery Colored haloes May be present Absent Present Vision Normal slightly impaired Markedly impaired Congestion Superficial Deep ciliary Deep ciliary Pupil Normal Small, irregular Large ,oval Media Clear Hazy Hazy Ant. chamber Normal May be deep shallow Iris Normal Muddy Oedematous IOP Normal Normal Usually raised
  • 53.
    Clinical signs inconjunctivitis. Congestion/ Hyperemia :- Dilation of superficial blood vessels.
  • 54.
     Clinical picturesin different types of congestion. Conjunctival congestion Circum ciliary congestion Mixed congestion
  • 55.
    Discharge Consists of exudatesfiltered from the conjunctival epithelium through dilated blood vessels. Types of discharges Nature of discharge Associated conjunctivitis Watery Allergic & Acute viral Mucoid Chronic allergic Mucopurulent Chlamydial & Acute bacterial Mod purulent Acute bacterial Severe purulent Gonococcal conjunctivitis
  • 56.
     Follicles Translucent boiledgrain like raised structure.  Upper tarsal conjunctiva & at fornixes.  Histology :- 1. Formed by scattered aggregation of lymphocytes in adenoid layer. 2. Central part composed immature lymphocytes & peripherally matured lymphocytes. 3. Blood vessels are present around and across the lesions. In case of trachoma follicles are seen in bulbar conjunctiva Herbert follicles
  • 57.
     Papillae  Hyperplasiaof conjunctival epithelium is seen.  Seen in palpebral conjunctiva and at limbus.  Histology:- 1. Composed of stromal infiltration with inflammatory cells. 2. Central core is composed of dilated blood vessels.  Based on size:- 1. Micro papillae 2. Macro papillae (<1mm) 3. Giant papillae (>1mm)
  • 58.
    Difference between Papillae& Follicles. Features Papillae Follicles Commonly seen Bacterial & Allergic conjunctivitis Viral and chlamydial conjunctivitis Appearance Reddish and velvety Translucent & boiled grain. Blood vessels Dilated blood vessels form center core of papillae Passes around & across the follicle Composition Hyperplastic epithelium Hyperplastic lymphoid tissue Where are they found?? Palpebral conjunctiva and limbal areas Fornixes and palpebral conjunctiva
  • 59.
     Membranes:- True membranePseudo membrane Involves inflammatory exudates interdigitated with superficial layer inflamed conjunctival epithelium. Involves coagulated exudates adherent to inflamed epithelium Removal leads to tearing and bleeding. Can be peeled away easily leaving underlying epithelium intact without bleeding. Neisseria gonorrhea, Corynebacterium diphtheria , SJS EKC, ALLERGIC conjunctivitis, Severe bacterial conjunctivitis
  • 60.
    Clinical figures ofTrue VS Pseudo membranes TRUE MEMBRANE PSEUDO MEMBRANE
  • 61.
     Conjunctival scarring:- Whitish irregular, linear or stellate shaped opaque patches seen on tarsal conjunctiva.  Scarring is A/w loss of goblet cells and accessory lacrimal glands.  Seen in Trachoma, atopic conjunctivitis. Cicatricial pemphigoid etc. What is Arlt’s line??
  • 62.
     Conjunctival infiltration:- It represents cellular recruitment to the site of chronic inflammation.  Typically accompanies papillary response.  Details of normal tarsal conjunctival blood vessels is lost.
  • 63.
     Chemosis:-  A.k.Aconjunctival oedema.  Translucent swelling of conjunctiva.  Chemosis is seen in chronic allergic conjunctivitis.  Also seen in severe infective conjunctivitis.
  • 64.
     Haemorrhage:-  Seenin both viral as well as bacterial conjunctivitis  In Viral haemorrhages are multiple, small & discrete.  Picorna virus commonly cause haemorrhagic conjunctivitis.  In Bacterial conjunctivitis haemorrhages are large and diffused.  Pneumococcus bacteria commonly causes SCH.
  • 65.
     lymphadenopathy  A.K.Alymphadenitis ( Enlargement of lymph nodes.)  Commonly seen conjunctivitis A/W viral infections.  Also seen in chlamydial & severe bacterial conjunctivitis.  Common in Gonococcal conjunctivitis.  Preauricular lymph node is commonest to be affected.
  • 66.
  • 67.
     Based onEtiology (a) Infective conjunctivitis Bacterial conjunctivitis Viral conjunctivitis Chlamydial conjunctivitis Ophthalmia neonatrum Granulomatous conjunctivitis
  • 68.
    (b) Allergic conjunctivitis Simplex allergicconjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis Giant papillary conjunctivitis Phlyctenular conjunctivitis Contact dermoconjunctivitis
  • 69.
    (c) Cicatricial conjunctivitis Ocular mucousmembrane pemphigoid Stevens Johnson syndrome Toxic epidermal necrolysis Secondary cicatricial conjunctivitis (d) Toxic conjunctivitis
  • 70.
    Secondary conjunctivitis:-  Conjunctivitisassociated with disorders of lacrimal apparatus , eyelid deformities is called secondary conjunctivitis.  Some of the associated conditions are :- Dacryocystitis Trichiasis Entropion Ectropion Facial palsy
  • 71.
    Differentiating conjunctivitis basedon clinical features:- Clinical features Bacterial Viral Allergic Chlamydial Congestion Marked Moderate Mild to mod. Moderate Chemosis ++ + ++ +/- SCH +/- +/- - - Discharge Purulent or Mucopurulent Watery Ropy/watery Mucopurulent Papillae +/- - ++ +/- Follicles - + - ++ Pseudo membrane +/- +/- - - Pannus - - -(except VKC) + Lymphadenopathy + ++ - +/-
  • 72.
     Cysts ofconjunctiva Congenital cystic lesion Lymphatic cysts Retention cyst Traumatic cyst Epithelial down growth cyst Aqueous cyst Pigmented epithelial cyst Parasitic cyst
  • 73.
     Conjunctival tumors They can be both pigmented as well as non pigmented.  On the basis of nature and tissue of origin their types are:- Tissue of origin Benign Malignant Epithelial Papilloma Squamosal cell carcinoma Glandular Adenoma Adenocarcinoma Connective tissue Fibroma Sarcoma Vascular Hemangioma Angiosarcoma Reticular system Lymphoid hyperplasia Lymphosarcoam Pigment cells Naevus Melanoma
  • 74.
     Dermoid  Congenitaltumors  Occurring at limbus as solid white mass.  Has sebaceous gland , hair , collagenous connective tissue.  Lined by epidermoid.
  • 75.
     Lipodermoid  Congenitaltumor.  Found at limbus or outer canthus.  Appears soft, white , moveable, sub conjunctival mass. Orbital fat prolapse
  • 76.
     Naevi  A.k.Acongenital moles of conjunctiva.  Greyish, blackish or brownish coloration.  Found as a flat or slightly raised nodule in bulbar conjunctiva.  May show increase size during puberty & pregnancy.  Pigmentary change seen during inflammation.
  • 77.
    Anatomy of sclera:- Dense connective tissue composed of collagen bundles of varying diameter.  Whole outer surface is covered by Tenon’s capsule.  Anterior part is covered by bulbar conjunctiva.
  • 78.
    Sclera contd.. Inner surfaceof sclera lies in contact with choroid with a potential supra choroidal space between. Sclera forms the posterior 5/6th part of globe. Opaque appearance: less uniform orientation of collagen fibres.
  • 79.
    Thickness of sclera. Differs from individual to individual also based upon age.  Thinner in children than adult & female than male.  Sclera is thickest posteriorly and gradually gets thin anteriorly.  Posterior thickness is (1mm)  Thinnest at insertion of EOMS (0.3mm)  At equator (0.4-0.8mm)  At limbus (0.8 mm)
  • 80.
     Special regionsof sclera:- 1. Scleral sulcus  It is a furrow on inner surface of ant most point of sclera.  It houses schlemn’s canal. 2. Scleral spur  Circular rim in ant most part of sclera lying deep to schlemn’s canal.  Meridonial fibers of ciliary body are attached to it.
  • 81.
    Special region contd.. 3.Lamina cribrosa  Sieve like sclera  Optic nerve passes through it.  During glaucoma in which IOP will rise lamina cribrosa will gradually increase in posterior curvature.
  • 82.
    Microscopic structures:- Histologically scleraconsists of following layers:- 1. Episcleral tissue 2. Sclera proper 3. Lamina fusca
  • 83.
    1. Episcleral tissue It is thin, dense vascularized layer of connective tissue which covers sclera proper.  Fine fibroblasts, macrophages and lymphocytes are also present in this layer. 2. Sclera proper  It is an avascular structure which consists of dense bundles of collagen fibers.  The band of collagen tissue cross each other in all direction. 3. Lamina fusca  It is the innermost part of sclera which blends with supra choroidal and supracilliary lamina of the uveal tract.  It is brownish in color due to presence of pigmented cells.
  • 84.
     Vascular Supply:- It is relatively avascular structure.  Anterior cilliary artery form a dense Episcleral plexus anterior to the insertion of rectus muscle.  Long and short posterior cillary artery supplies the posterior part.
  • 85.
     Nerve Supply:- Sclerais supplied by branches from the long cilliary nerves which pierce it 2 to 4 mm from limbus to form a plexus. Anterior region is supplied by long ciliary nerve Posterior region is also supplied by short ciliary nerve.
  • 86.
     Apertures piercingsclera:- Sclera is pierced by three sets of apertures:- 1. Posterior apertures :-  These are situated around the optic nerve and transmit long and short cilliary nerves and vessels. 2. Middle apertures:-  These are four in numbers.  Are situated slightly posterior to equator through which the four vortex veins(venae verticosae passes)
  • 87.
    Apertures contd... 3. AnteriorApertures:-  Are situated 3 to 4mm away from the limbus.  Anterior cilliary vessels passes through the apertures.
  • 88.
     Inflammation ofsclera.  Can be classified into Episcleritis & Scleritis. Episcleritis Normal sclera Scleritis
  • 89.
     Episcleritis Benign andrecurrent inflammation of Episclera & Tenon's capsule. Causes of episcleritis:- 1. Idiopathic 2. Gout & connective tissue disorders 3. H/S Rxn like staphylococcal toxins 4. Herpes zoster , syphillis , TB Symptoms:- 1. Redness 2. Mild ocular discomfort 3. Burning ,FB sensation 4. Rarely photophobia and watering.
  • 90.
    Episcleritis contd.. Clinically twotypes :- Simple Episcleritis Nodular episcleritis Characterized by sectoral ( occasionally diffused) inflamn of episclera. Characterized by pink flat nodule surrounded by blood vessels injection.
  • 91.
     Scleritis  Chronicinflammation of scleral proper.  Serious than episcleritis as it can severely affect vision. Causes :- 1. Idiopathic 2. RA, PAN, SLE. 3. Gout, Thyrotoxicosis. 4. HZO , Staphylococcal & streptococcal infection. 5. Syphilis, leprosy Symptoms:- 1. Pain 2. Redness 3. Photophobia 4. Diminution of vision
  • 92.
    Scleritis contd.. 85% 13% 2% Scleritisclassification Non necrotising scleritis Necrotising scleritis posterior scleritis
  • 93.
     Differentiating Scleritisfrom Episcleritis.  It is very important to differentiate Episcleritis from Scleritis.  In gross appearance both may look similar.  But their proper differentiation is necessary during clinical practice because scleritis may be vision threatening.
  • 94.
     Blanching:-  Helpsto differentiate Scleritis from Episcleritis.  Vasoconstrictors are used for this process.  Phenylephrine (0.125%) are commonly used.  A drop is instilled in red eye and observed for 10-15 minutes.  If redness disappears then Episcleritis but if redness still persist then Scleritis.
  • 95.
     Slit lampexamination. 1. Using optical section ( slit beam). 2. Using red free filter ( green filter).  Will give more contrast to subtle red blood vessels.  Making easier in viewing dominant area of vascular congestion and zone of avascularity. Episcleritis Scleritis  Anterior slit beam is bowed forward due Episcleral edema.  Posterior beam is flat against normal sclera.  In scleritis posterior beam also bows forward due to underlying Scleral edema.
  • 96.
     Blue sclera Marked generalized bluish discoloration of sclera.  Due to scleral thinning.  Seen in conditions like as:- Osteogenesis imperfecta Marfan’s syndrome Bupthalmos High myopia
  • 97.
    What is thescleral color of newly born baby?? Bluish tint is seen in sclera of newly born. In newly born sclera is translucent and bluish tint is due to underlying uveal tissue coloration.
  • 98.
     Sclerocornea  Congenitalanomaly  Sclera blends with cornea  No clear cut boundary b/w sclera & cornea.  Opacity ranges from peripheral to total.
  • 99.
     Staphyloma:-  Localizedoutward bulging of weak & thin outer tunic eyeball( sclera and cornea).  Lined by uveal tissue and shines through fibrous coat.  Anatomically can be divided into followings:- Staphyloma Anterior staphyloma Intercalary staphyloma Ciliary staphyloma Equatorial staphyloma Posterior staphyloma
  • 100.
     Clinical picturesin different types of staphylomas. Anterior staphyloma Intercalary staphyloma Ciliary staphyloma Equatorial staphyloma Posterior staphyloma
  • 101.
     Scleromalacia. Degenerative thinningof sclera.  Commonly seen in anterior necrotizing scleritis (scleromalacia perforans).  Patients with Rheumatoid arthritis commonly present with this condition.
  • 102.
     Summary:-  Conjunctiva,Tenon’s capsule, episclera and sclera are respectively present ongoing from outer layer to inner layer forming protective coating.  Conjunctivitis must be differentiated from anterior uveitis and acute congestive glaucoma before starting treatment.  It is very important to differentiate Episcleritis from Scleritis. Proper differentiation is necessary during clinical practice because scleritis may be vision threatening.
  • 103.

Editor's Notes

  • #9 sulcus subtarsalis: perforating blood vessels pass through tarsus to supply conjunctiva Puncta opens in marginal zone-conjunctival infection may spread to nose and vice versa
  • #12 \
  • #17 Line a shows orbital margin. Line b shows: limit of superior fornix, limit of inferior fornix…dotted line shows boarder of upper and lower tarsus. Superior fornix extends slighty above boarder of upper tarsus from upperlimbus to orbital margin. inferior fornix extends slighty below boarder of lower tarsus from lower limbus to orbital margin
  • #20 Resembels fat hence name derived from the term pinguis.. Pinguecula Is called as precursor of pterygium..
  • #21 Usually nasal side is affected and earlier than temoral.. Inflamed pingecula
  • #22 Name derived from latin word pterygion..
  • #23 Probe test is done to differentiate pseudopterygium from true pterygium. If probe doesnot pass underneath then it is true pterygium. But if probe passes under the neck region then it is pseudopterygium.
  • #24 Also seen in pts at scarring stage of trachoma… Can be removed by hypodermic needle under local anesthesia…
  • #26 Adenoid and fibrous layer are combinely called substantia propria.
  • #37 Marginal arcade of eyelid: anastomosis of medial palpebral artery and lateral palpebral artery. Peripheral arcade of eyelid: anastomosis of Superior branch of medial palpebral artery, superificial temporal artery, transverse facial artery and infra orbital artery. Anterior cilliary artery: formed by seven branches from muscle(2 from SR, LR, SO) and 1 from LPS.
  • #45 Eg… 1:10000 adrenalin or napazoline …..
  • #47 Allergic conjunctivitis Chemosis is seen……
  • #48 Acute hemmorhagic conojunctivites is caused by picorna virus and also seen in pneumococcal conjunctivitis and ictero hemmoragic conjunctivitis. Dm ra htn ma arteriosclerotic changes will makr capillaries fragile leading to easy rupture during high pressure blood flow. Bleeding disorders are purpura,, haemophilia
  • #50 Pink is due to under lying fibrovascular tissue…
  • #51 Itching is typically hallmartk of allergic conjunctivitis.. Similarly pain photophobia is encountered in corneal involvement…
  • #54 Often the terms congestion and hyperemia are used as alternative of one another for deseribing same process but actually they are two different things. Hyperemia is active process……whereas congestionis passive process.
  • #56 Consists od mucus mixed with tears desqumated cells ,fibrins,and bacterias.. Pus greenish or yellowish white filled with pyogenic bacterias and epitheloid debris Mucus whitis and secretion of goblet cells only.
  • #57 Also seen in lower conkunctiva and carauncle plica semilunaris …..follicles in lower conjunctiva are commonly seen during viral conjunctiviutes.. Trachoma follicle can be differentiated from other follicle s from presence of leber cells and signs of necrosis…
  • #60 Streptococcus haemolyticus will produce pseudo membranous conjunctivitis…..
  • #65 Picorna virus is rna virus and causes epidemic haemorragic conjunctivitis. Also called appolo conjunctivitis,,,,
  • #68 Granulomatous means a/w tb sarciodosoiis, leprosy syphilis, ophthalmia nodosa. Ophthalmia neo ……child less than 30 days bilateral involvement , streptococcus staph, pneumococcus, HSV,
  • #76 Orbital fat prolapse looks similar like as lipodermoid I n gross appearrence. It associated with trauma and can occur at any location …occurs due to subconjunctival hernation of intraconal fat.
  • #81 Scleral spur has wedge shaped appperence.
  • #82 Border tissue of elsching b/w sclera and optic nerve. Lamina cribrosa gets blood from circle of zinn.
  • #91 Nodule is frim tendered and can be moved freely and separately from sclera.. simple episc;leritis df diagnosed from conjunctivitis And nodular from inflamed pingeucula.
  • #92 Spill of infection …. RA haru auto immune diseases…. Gout are metabolic disorders Syphillis are granulomatoius disorders… Deep boring pain trasfering to jaw and cheek . Pain during eye movement and and at night.
  • #93 Divided into anterior and posterior based on position of eom insertions … Necrotisiing scleritis can cause the scleral thinning ultimately leading to the scleral perforation called scleromalacia perforans.
  • #95 Other vasoconstrictors except phenylephrine…..
  • #97 Elhers danlos syndrome and also pseudo xanthoma elasticum Myopia scleral remodeling continuously occurs ..existing collagen degrades ,,new collagen is not formed and matrix gags are lost.
  • #99 Total sclerocornea is called sclerocornea totalis. Autosomal reccesive pattern inherited and concurrent with cornea plana.. Isolated peripheral sclera cornea…lower one is total sclerocornes.