Conjunctiva

1
Conjunctiva

• Applied anatomy
• Evaluation of conjunctival inflammation
• Infective conjunctivitis
• Acute catarrhal conjunctivitis
• Purulent conjunctivitis

2
Applied Anatomy

• Thin layer of mucous membrane that lines the
  posterior surface of the lid and is reflected to
  cover the anterior part of the sclera
• 3 parts
• palpebral attached to the eyelid
• bulbar attached to the limbus
• fornix cul-de- sac

3
Applied Anatomy

• Structure
• 1. Epithelium
• 2 to 5 layers thick
• mucus secreting goblet cells esp. in the bulbar
  and fornices
• 2. Adenoid layer
• Lymphoid layer - lymphocytes
• Most developed in fornix
• Develops 3-4 months after birth
• 3. Fibrous layer
• Collagenous elastic fibres
• Contains vessels nerves

4

• Glands of conjunctiva
• Mucin secretory glands
• - goblet cells ( epithelium)
• - crypts of henle (tarsal conj.)
• - glands of manz (limbus)
• 2. Accessory lacrimal glands
• - Glands of Krausse ( fornix )
• - Glands of wolfring (tarsal margins)

5
Applied Anatomy

• Blood supply per. marginal arcade of lids
  ant.ciliary arteries
• Nerve supply Ophthalmic division of 5th nerve
• Functions free movement of the eyeball
• protective
  mechanism against micro-
• organisms
• smooth surface
  as the lid blinks

6
Evaluation of conjunctival inflammation1.
Symptoms

• Most common lacrimation, irritation, burning,
  photophobia
• Pain and FB sensation --- corneal involvement
• Itching --- allergic nature BUT it can also
  occur in blepharitis and KCS

7
Evaluation of conjunctival inflammation 2.
Discharge

• Watery in acute allergic or viral inflammation
• Mucoid in in Vernal and KCS
• Purulent in acute bacterial infections
• Mucopurulent in chlamydial or mild bacterial
  infections

8
(No Transcript)
9
(No Transcript)
10
Discharge associated with conjunctiva
Etiology Serous Mucoid Mucopurulent Purulent
Viral Bacterial Chlamydia Allergy Toxic - - - - - - - - - -
11
Evaluation of conjunctival inflammation- 3.
Conjunctival appearance

• Conjunctival injection or congestion max. in
  the fornices
• Subconjunctival haemorrhage in viral and
  bacterial infections
• Membranes
• Follicular reaction
• Papillary reaction
• Oedema chemosis
• Scarring

12
(No Transcript)
13
Subconjuntival haemmorhage in viral, also in
bacterial
Conjunctival congestion in the fornices
14
Membranes

• Pseudomembranes
• - coagulated exudate adherent to
• the inflammed conjunctiva
• - it can be peeled off
• - eg. Gonoccocal , adenoviral
• conjunctivitis
• True membranes
• -Inflammatory exudate permeates
  sup. conjunctival layers
• -Tear the epithelium to peel it off.
• - Bleeding
• - Eg. ß- haem.streptococci,diphtheria

15
Evaluation of conjunctival inflammation- 3.
Conjunctival appearance

• Follicular reaction
• Defn hyperplasia of lymphoid tissue
• Prominent in the fornix
• Multiple discrete elevated lesions encircled by
  a tiny blood vessel
• Size about 0.5 to 5mm
• Causes viral,
• chlamydia,
• parinaudglandular syndrome,
• hypersensitivity to topical
  medication

16
(No Transcript)
17
Evaluation of conjunctival inflammation- 3.
Conjunctival appearance

• Papillary reaction
• Hyperplastic conjunctival epithelium
• Contains a central core of blood vessels
  surrounded by chronic inflammatory cells
  lymphocytes,plasma cells, eosinophils
• Mosaic like pattern consists of polygonal
  hyperaemic area separated by paler channels.
• Causes chronic blepharitis, allergic
  conjunctivitis , contact- lens related problems

18
Chemosis- oedema
19
(No Transcript)
20

• Scarring eg. in trachoma, ocular pemphigoid
  
  

21
Lymphadenopathy

• Drainage
• corresponds to eyelids to the preauricular
  and submandibular nodes
• Found in
• - Viral infection
• - Chlamydial
• - Severe gonoccocal
• infections

22
Conjunctivitis

• Defn inflammation of conjunctiva characterised
  by redness of the eye and conjunctival discharge.
• Classification Aetiological
• Clinical

23
Aetiological Classification

• 1. Infective bacterial , viral,
  fungal and chlamydial group
• 2. Non infective allergic, chemical,
  traumatic ,
• keratoconjunctivitis associated with
  skin and mucus membrane disorders
  and miscellaneous

24
Infective conjunctivitis

• Bacterial
• - gram eg. Staph. Epidermidis and aureus ,
  Strept. Pneumoniae
• - gram ve eg. are H. Influenzae , N.
  Gonococcus, Moraxella
• lacunata
• Viral
• Adenovirus, herpes simplex , zoster,
  measles, chickenpox etc.
• Fungal candida albicans
• Chlamydia group of organisms not a true virus
• eg. trachoma , inclusion conjunctivitis

25
Non - Infective conjunctivitis

• Allergic vernal, phlyctenular conjunctivitis
• Chemical acid and alkali
• Miscellaneous def. of lacrimal secretion KCS
  
• uncorrected
  refractive errors
• ocular pemphigus

26
Clinical classification

• Acute mucopurulent
• Acute purulent
• Serous
• Chronic simple
• Angular
• Membranous
• Pseudomembranous
• Papillary
• Follicular
• Ophthalmia neonatorum
• Granulomatous
• Ulcerative
• Cicatrising

27
Acute mucopurulent conjunctivitis
28
Acute mucopurulent conjunctivitis

• Acute simple , acute bacterial or acute catarrhal
  conjunctivitis
• Causes eg. Staph. Aureus., Strept. Viridans ,
  H. influenza
• Source of infection nose assoc. with hay fever
  or measles
• Affects all age groups and all times during the
  year
• Spread through droplet infection, contact
  fingers, towels
• Symptoms photophobia
• burning sensation
• sticky eyelids
• blurring of vision
  mucus lying on the cornea
• usually involves both
  eyes

29
Acute mucopurulent conjunctivitis

• Signs
• Conjunctiva bulbar and fornix are beefy red and
  swollen ---whole conj. is red.
• Secretion Watery mucoid mucopurulent
• Lashes matted by yellow crusts
• Cornea seldom involved punctate epithelial
  defects

30
Acute mucopurulent conjunctivitis

• Management
• -- Conjunctival swab for C/S and Gram stain
• -- Prophylaxis avoid sharing articles
• Treatment
• -- Clean the sac with normal saline
• -- Instill antibiotic eye drops
• Eg. Gutt. Chloromycetin 4h or 2h and
  Occ. CMC on.

31
Purulent conjunctivitis

• Adult gonococcal keratoconjunctivitis
• Caused by Neisseria G. gram ve diplococcus
• Systemic features
• In men you get a purulent urethral discharge
• In women asymptomatic or dysuria or vaginal
  discharge
• Ocular features
• Symptoms Acute profuse, thick pus ocular
  discharge .

32
Purulent conjunctivitis

• Ocular features
• Signs Discharge
• Eyelids tender
  and oedematous
• Conjunctiva hyperemia
  , chemosis ,
• 
  pseudomembrane form.
• Keratitis marginal
  ulcers ring ulcer
• 
  central corneal ulcer - perforation

33
Purulent conjunctivitis

• Management
• Investigations C/S of the discharge
• Treatment Admission to hospital
• topical
  antibioticfrequently ½ h or H
• Penicillin,Gentamici
  n
• Cefotaxime 1 gram
  6h x 10 14 days

34
Ophthalmia neonatorum
35
Ophthalmia neonatorum

• Neonatal conjunctivitis transmitted from the
  mother during delivery
• WHY is it severe at birth absence of tears
  lymphoid tissue at birth
• Causes N. gonorrhoeae 60 in developing
  countries
• Chlamydia 15
  30-
• Staph. Aureus
• Strept. Viridans,
  Haemolyticus
• Pneumococcus
• Infection during, or after birth
• before birth if there
  is premature rupture of membranes
  

36
Ophthalmia neonatorum

• Signs
• Can present within a few hours after birth or
  within the 1st month. There are 3 stages
• 1st stage Infiltration
• Eye is tender to touch
• Lids are swollen ,red and
  tense difficult to open them
• Palpebral conjunctiva -
  swollen, velvety and red
• 
  - chemosis
• 
  - pseudomembrane
• Secretion serous blood
  little pus
• Fever , preauricular
  lymphadenopathy

37
Ophthalmia neonatorum

• Signs
• 2nd stage Blenorrhoea which can last for 2 to
  3 weeks
• Eye is less tender to
  touch
• Lids are less swollen
• Palpebral conjunctiva -
  swollen, velvety and red
• 
  - chemosis is LESS
• 
  - pseudomembrane
• Secretion profuse thick
  yellow pus
• 3rd stage Healing
• pain and swelling subsides
  but the whole conjunctiva
• will appear RED ,
  velvety or granular

38
Ophthalmia neonatorum

• Management
• 1. Prophylaxis
• Antenatal period
  mother should be treated for any
• suspicious vaginal
  discharge
• Credes method (1
  silver nitrate )is not used
• 2. Investigation eye discharge for gram
  stain and C/S
• 3. Treatment irrigation of the eye with
  normal saline and
• removal of the
  eye discharge
• Topical
  penicillin 5,000 to 25,000units per ml.
• every ½ h or H
  for 1 or 2 days and then to taper
• Other
  alternatives
• In gonococcal
  infections
• - investigate
  both the parents and treat them.
• - For the infant
  IM benzyl pencillin 5,000units/kg
• in 2 divided
  doses.

39
Ophthalmia neonatorum

• Chlamydial Infections
• Topical tetracycline 1 qds.
• Oral erythromycin 50mgms /kg/day in divided doses
  for 3 weeks

40
Complications in Ophthalmia Neonatorum

• Corneal perforation
• Corneal opacities
• Adherent leucoma
• Anterior polar cataract
• Anterior staphyloma
• Panophthalmitis

41
(No Transcript)
42
(No Transcript)