ophthalmology:conjuctival infections and degeneration

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Conjunctival Disorders

• Tsedeke Asaminew. M.D

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Applied Anatomy

• Conjunctival subdivisions
• Palpebral (tarsal) conjunctiva
• Starts at the mucocutaneous junctions of lid
  margins
• Firmly adherent to tarsal plate
• Forniceal conjunctiva
• Loose and redundant
• Bulbar conjunctiva
• Covers anterior sclera
• Its stroma is attached to underlying Tenon
  capsule

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Histology

• Epithelium
• Non-keratinizing epithelium, 2-5 layers thick
• With chronic exposure and drying, it may become
  keratinized
• Stroma
• Richly vascularized connective tissue
• The lymphoid tissue doesnt develop until 3mths
  after birthgtgt follicular reaction is absent in
  newborns
• Glands
• Goblet cells
• Within epithelium, dense inferonasally
• Secrete mucin
• Accessory lacrimal glands of Kraus and Wolfring
  deep within stroma

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Clinical Evaluation

• Type of discharge
• Type of conjunctival reaction
• Pseudomembrane/ membrane
• Lymphadenopathy (preauricular, submandibular)
• Discharge
• Watery----viral, allergic
• Mucoid----vernal
• Purulent----severe bacterial
• Mucopurulent----mild bacterial, chlamydial

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Clinical Evaluation, (contd.)

• Reaction
• Follicular--viral, chlamydial, hypersensitivity
  to topical medications
• Folliclesgtgtsubepithelial foci of hyperplastic
  lymphoid in stroma
• Papillarychronic blepharitis, vernal, bacterial
• Papillaegtgthyperplastic epithelium thrown into
  folds and projections.
• Papillae are less specific than follicles

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Clinical Evaluation, contd.

• Pseudomembrane
• Coagulated exudates adherent to inflamed
  epithelium. MembraneIntact epithelium seen upon
  peeling
• Severe adenoviral, gonococcal
• True membrane infiltrates the superificial
  epithelium. Peeling results in bleeding
• Strept pyogens, diptheria

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Clinical Evaluation. contd

• Lymphadenopathy
• Viral, chlamydial, severe gonococcal
• Preauricular and submandibular lymph nodes

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Bacterial conjuctivitis

• Simple bacterial conjunctivitis
• Very common
• Mostly in children
• Self limiting
• Causes Staphlococcus epidermidis, Staph. Aureus,
  Strept. Pneumoniae, H. influenza
• Usually bilateral
• Redness, grittiness, burning, mucopurulent
  discharge, matted cilia (morning stickiness)

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Bacterial conjuctivitis

• Crusted eyelids
• Discharge on eyelash
• Injected conjunctiva
• Rx
• Lid hygienewash off discharge
• Chloramphenicol
• Gentamycin, tobramycin, Erythromycin, bacitracin

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Gonococcal keratoconjunctivitis

• Nesseria gonorrhea
• Acute profuse milky, purulent conjunctival
  discharge in sexually active individual
• Unilateral/bilateral
• Edematous eyelids
• Severe injection and chemosis
• The Conjunctivitis progresses to KERATITIS unless
  treated early

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Gonococcal keratoconjunctivitis

• Take Specimen for Gram stain, culture and
  sensitivity
• Gram staingtgt presumptive diagnosis(gram negative
  intra cellular diplococci in polymorphs)
• Rx
• Ceftriaxone 1gm IM stat
• Irrigate the eye with saline 4x a day until the
  discharge is gone
• Topical antibiotics(gentamycin,ciprofloxacin) 2
  hrly
• Admit severe cases, non compliant patients
• Treat associated chlamydial conjunctivitis
• Screen sexual partners

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Chlamydial conjunctivitis

• Chlamydia trachomatis serotypes D-K
• STD, concomitant genital infection is common
• Unilateral/bilateral
• Subacute mucopurulent discharge
• Follicular reaction(mainly inferior tarsal conj.)
• Rx
• Topical Tetracycline ointment for 6 weeks
• Systemic
• Azithromycin 1gm once PO
• Doxycycline 100mg BID for 3 weeks
• Erythromycin 500mg QID for 1 week (for TTC
  allergic)
• STD screening for sexual partners

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Ophthalmia Neonatorum

• Inflammation of the conjunctiva within one month
  of life
• Purulent/mucoid discharge one or both eyes
• Cause
• Chemical(silver nitrate)
• Chlamydia trachomatics
• Neisseria gonorrhea
• Staph aureus, Staph. Epidermidis, Strept.
  Pneumoniae/viridans, gram negatives
• Herpes simplex

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Ophthalmia Neonatorum

• Chlamydial trachomatis (developed countries)
• Neisseria gonorrhea (developing countries)?
• Rx
• Choice of antibiotic same as adults except
  systemic Tetracyclines are contraindicated in
  neonates
• Prophylaxis
• 1 Tetracycline
• 0.5 Erythromycin

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Viral conjunctivitis

• Most CommongtgtAdenovirus
• Clinical features
• Watery discharge, Redness, Photophobia
• Bilateral usually
• Usually Upper respiratory infection associated
  with it
• Highly contagious
• Follicular reaction, mainly inferior tarsal
  conjunctiva
• Preauricular lymphadenopathy
• Rx
• Cool compress
• Lubricating drops

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Allergic conjunctivitis

• Seasonal(hay fever) allergic rhinoconjunctivitis
• The commonest and mildest
• Allergens pollen, house mites, fungus
• Type I hypersensitivity
• Itching, watering, redness
• Sneezing, nasal discharge
• Bilateral injection, chemosis, papillary reaction
• Rx
• Allergen avoidance
• Cool compress, topical lubricants
• Topical antihistamines(e.g. lovocabastin)
• Topical NSAIDs (e.g. Ketorolac) for more severe
  cases
• Topical Steroids for severe cases only

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Vernal Keratoconjunctivitis

• Common in boys, young adults
• Onset after 5 years of age resolves around
  puberty
• Very recurrent
• Personal or family history of atopy
• Type I hypersensitivity as well as
  cell-mediated(type IV hypersensitivity
• C/F
• Intense itching, burning, lacrimation,
  photophobia, foreign body sensation
• Symptoms may occur throughout the year
• Thick mucus discharge

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Vernal Keratoconjunctivitis

• C/F contd
• Conjunctival hyperemia and chemosis
• Papillary reaction mostly on Upper conjunctiva
• Giant Papillae
• Flattened big papillae gtgt Cobblestone appearance
• Cornea involvement is frequent
• Rx
• Same as seasonal rhinoconjunctivitis
• Topical steroids are usually needed for acute
  flare up
• Topical mast cell stabilizers useful

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Conjunctival Degenerations

• Pinguecula
• Extremely common, bilateral asymptomatic
• Yellow-white deposits on the bulbar conjunctiva
• Adjacent to the nasal or temporal limbus
• Rx
• Usually not necessary
• If acutely inflamed (pingueculitis) it may
  require short course weak steroid (e.g
  terracortil eye susp)

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Conjunctival Degenerations contd

• Pterygium
• Triangular fibrovascular subepithelial
  degenerative growth on the bulbar conjunctiva
• Chronic sun exposure
• Rx
• Usually unnecessary
• Short course Weak topical steroid when inflamed
• Surgical Excision and conjunctival autograft if
  advanced
• High recurrence rate
• Juxta limbal squamous cell carcinoma (SCC) may
  masquerade as pterygium
• SCC has fleshy papillomatous growth with feeder
  vessels

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Concretions

• Extremely common
• Common in elderly
• Small, multiple, yellow- white deposits on tarsal
  conjunctiva
• Rx
• Removal of concretions with needle when
  symptomatic

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Thank you !!