Conjunctiva Applied anatomy Evaluation of conjunctival inflammation Infective conjunctivitis Acute catarrhal conjunctivitis Purulent conjunctivitis.

Conjunctiva

• Applied anatomy

• Evaluation of conjunctival inflammation

• Infective conjunctivitis

• Acute catarrhal conjunctivitis

• Purulent conjunctivitis

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

Structure1. 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

Applied Anatomy

Glands of conjunctiva:

1. 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)

• 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

Applied Anatomy

• Most common : lacrimation, irritation, burning, photophobia

• Pain and FB sensation --- corneal involvement

• Itching --- allergic nature BUT it can also occur in blepharitis and KCS

Evaluation of conjunctival inflammation1. Symptoms

- 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

Discharge associated with conjunctiva

Etiology Serous Mucoid Mucopurulent Purulent

Viral

Bacterial

Chlamydia

Allergy

Toxic

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• Conjunctival injection or congestion : max. in

the fornices• Subconjunctival haemorrhage in viral and

bacterial infections• Membranes• Follicular reaction • Papillary reaction• Oedema [ chemosis ]• Scarring

Evaluation of conjunctival inflammation- 3. Conjunctival appearance

Subconjuntival haemmorhage in viral, also in bacterial

Conjunctival congestion in the fornices

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. β-

haem.streptococci,diphtheria

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

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

Evaluation of conjunctival inflammation- 3. Conjunctival appearance

Chemosis- oedema

Scarring [ eg. in trachoma, ocular pemphigoid ]

Lymphadenopathy

• Drainage : corresponds to eyelids to the preauricular and

submandibular nodes

• Found in:

- Viral infection

- Chlamydial

- Severe gonoccocal

infections

Conjunctivitis

• Defn : inflammation of conjunctiva characterised by redness of the eye and conjunctival discharge.

• Classification : Aetiological

: Clinical

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

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

Non - Infective conjunctivitis

• Allergic : vernal, phlyctenular conjunctivitis

• Chemical : acid and alkali

• Miscellaneous : def. of lacrimal secretion [ KCS ]

: uncorrected refractive errors

: ocular pemphigus

Clinical classification

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

Acute mucopurulent conjunctivitis

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

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

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.

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 .

Purulent conjunctivitis

• Ocular features:

Signs : Discharge

Eyelids : tender and oedematous

Conjunctiva : hyperemia , chemosis ,

pseudomembrane form.

Keratitis : marginal ulcers – ring ulcer

central corneal ulcer - perforation

Purulent conjunctivitis

Management: • Investigations : C/S of the discharge• Treatment : Admission to hospital

: topical antibiotic[frequently ½ h or H ]

Penicillin,Gentamicin

: Cefotaxime 1 gram 6h x 10 – 14 days

Ophthalmia neonatorum

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

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

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

Ophthalmia neonatorum

• Management: 1. Prophylaxis : Antenatal period : mother should be treated for any suspicious vaginal discharge Crede’s 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.

Ophthalmia neonatorum

Chlamydial Infections

• Topical tetracycline 1% qds.

• Oral erythromycin 50mgms /kg/day in divided doses for 3 weeks

Complications in Ophthalmia Neonatorum

• Corneal perforation

• Corneal opacities

• Adherent leucoma

• Anterior polar cataract

• Anterior staphyloma

• Panophthalmitis