Ophthalmia nodosa Nodular conjunctivitis due to irritation caused by caterpillar hairs Small semitranslucent, reddish or yellowish-grey nodules are formed on the conjunctiva, cornea and sometimes in the iris Microscopic examination shows hairs surrounded by giant cells and lymphocytes Treatment : excision of conj nodules containing the hairs, antibiotics, cyclopegics
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Ophthalmia nodosaNodular conjunctivitis due to irritation
caused by caterpillar hairsSmall semitranslucent, reddish or yellowish-
grey nodules are formed on the conjunctiva, cornea and sometimes in the iris
Microscopic examination shows hairs surrounded by giant cells and lymphocytes
Treatment : excision of conj nodules containing the hairs, antibiotics, cyclopegics
Allergic catarrhal conjunctivitis
Most common form of ocular and nasal allergyCinical subtypes:1. Acute allergic conjunctivitis : immediate reaction to
allergens2. Seasonal allergic rhinoconjunctivitis : conjunctivitis part of hay
fever, during the summer – common allergens are pollens or certain flowers (primula, etc)– elevated IgE levels in plasma and tears.
3. Perennial allergic rhinoconjunctivitis : causes symptoms throughout the year with exacerbation in the autumn when exposure to dust mites and fungal allergens is greatest.
Acute allergic catarrhal conjunctivitisPresentation : transient, acute attacks of redness, watering and
itching associated with sneezing and nasal discharge. (hyperemia is less marked, watery secretion – not purulent, containing eosinophils, tendency for subacute recurrences on renewed contact with the allergen)
Signs : - lid edema - conj has milky or pinkish appearance due to edema and injection - small papillae may be present on upper tarsal conj. Treatment : - Removal of allergen from the environment - Desensitization by course of injections - topical mast cell stabilizers (nedocromil, Iodoxamide, ketotifen) - topical antihistamines ( levocabastine, azelastine, emedastine) - both antihistamine and mast cell stabilizer (Olopatadine 0.1% BD) - Topical steroids short course (Loteprednol etabonate 0.5% QID)
Vernal keratoconjunctivitis (spring catarrh)1. Palpebral VKC:Difuse papillary hypertrophy, most marked on the superior
tarsusPapillae enlarge and have a flat-topped polygonal
appearance reminiscent of cobblestone (made of dense fibrous tissue with overlying thickened epithelium giving milky hue, infiltration with eosinophils, lymphocytes, plasma cells, macrophages, basophils)
Severe cases: connective tissue septa rupture, giving rise to giant papillae, coated by copious mucus
As inflammation settles, the papillae shrink, become more seperated but do not disappear
2. Limbal VKC:Mucoid nodules scattered around the limbus (gelatinous
thickening of limbus) with discrete white superficial spots (Horner - Tranta dots)composed predominantly of eosinophils and epithelial debris at the apices of the lesions.
3. Mixed VKC
Vernal keratoconjunctivitis (spring catarrh)
Vernal keratoconjunctivitis (spring catarrh)Keratopathy :1. Punctate epithelial erosions : superior cornea2. Shield ulceration : are sterile ulcers which occur in
superior cornea due to cobblestone papillae rubbing on cornea, look like a shield because inferior edge is pointed, may also result from chemical damage to the epithelial surface by mediators released from mast cells and eosinophils, are indolent and may take months to re-epitheliaze, may be complicated by bacterial keratitis, rarely perforation
3. Plaque formation: occurs when the base of the ulcer becomes coated with desiccated mucus – results in defective wetting by tears, prevents re-epithelialization, and predisposes to subepithelial scarring and vascularization
4. Pseudogerontoxon : resembles arcus senilis, “cupid’s bow” outline in a previously inflammed segment of the limbus.
suture ends, ocular prosthesis, after several years of rigid contact lens use
Mechanism : types I and IV hypersensitivity reactionSymptoms : itching, watering, foreign body sensation,
blurring of visionSigns : conjunctival congestion predominantly in
upper palpebral region with large polygonal papillae on suprior tarsal conj.
Macropapillae : 0.3 – 1.0 mm in sizeGiant papillae : 1 – 2 mm in size
Giant papillary conjunctivitis
Giant papillary conjunctivitisTreatment : - discontinue contact lens use - remove offending sutures - cleaning and polishing ocular prosthesis/ replacing
one coated with biocoat (biocompatible material) - topical mast cell stabilizers ( cromolyn sodium 6
hourly / olopatadine 12 hourly) - topical antihistamines - decongestants - artificial tears - topical steroids for short terms if needed - subtarsal long -acting steroid injection in severe cases
Phlyctenular conjunctivitisAetiology : non specific delayed hypersensitivity
reaction to endogenous bacterial proteins (most commonly tuberculo-protein, staphylococcal, chlamydia) or rarely in mild, long-standing infections of tonsils/adenoids. Many patients also have associated blepharitis
Rare today perhaps due to improved hygiene and control of milk infected by bovine tuberculosis
Symptoms : discomfort, irritation, reflex lacrimation, pain and photophobia (reflex blepharospasm) if cornea is involved or mucopurulent complication.
Phlyctenular conjunctivitisSigns : one or more small (1 mm), round, grey or yellow nodules,
slightly raised above the surface, are seen on the bulbar conjunctiva, near the limbus, congestion of the vessels is limited to near the area around the phlyctens.
- In later stages : epithelium over the surface becomes necrotic and small ulcers are formed on conj – heals rapidly without scar
- can be complicated by mucopurulent conjunctivitis - becomes serious when cornea is involved : usually occur near
the corneal margin involving only epithelium and superficial layers
- corneal phlycten is a grey nodule, slightly raised above the surface, may form yellow ulcer if epithelium breaks down – becomes infected usually by staphylococci
- may become absorbed without destruction of superficial layers of stroma (no permanent opacity)
Phlyctenular conjunctivitis
Phlyctenular conjunctivitis
Investigations : for TBTreatment :Steroid drops or ointments have a dramatic
effect in non-tubeculosis patientsIf cornea is involved, antibiotics and
cycloplegicsLid scrubs for associated blepharitisDark glasses may be used
Prevention : sweeping the fornix with glass rod coated with antibiotics/paraffin, frequent lubrication with artificial drops/ointments, bandage/scleral contact lenses, systemic immunosuppression
Treatment : symblepharon lysis and fornix reconstruction, amniotic membrane grafting
Steven-Johnson syndrome (Erythema multiforme major)Treatment :1. Lysis of adhesions forming between bulbar and palpebral
conjunctiva by passing a glass rod coated with antibiotic or plain paraffin ointment in the fornices
2. Systemic steroids : necessary3. Topical steroids : may prevent conj infarction4. Topical antibiotics to prevent secondary infections5. Acyclovir if herpes simplex is suspected6. Scleral ring consisting of a large haptic lens with the
central zone removed helps prevent symblepharon formation7. Other measures : Topical retinoic acid for keratinization,
tear supplements, therapeutic contact lenses, punctal occlusion, surgery to correct permanent lid deformitie, transplantation of conj or buccal mucous membrane, limbal stem cell/ amniotic membrane transplantation to restore integrity and to promote healing