Download conjunctiva anatomy and physiology

CONJUCTIVITIS
THE 2017 FAMILY MEDICINE JOINT WOR
KSHOP
BY
DR F A OLANIYAN
MBBS Ib., MSc Ib.( Med Stat.& Epid), FWACP, FMCG
P, CaRT Fellow
Learning objectives
At the end of the session your should be able to:
• Correlate the structure with functions and com
mon clinical presentations.
• Identification of important anatomical landmar
ks of conjunctiva.
• Classify conjunctivitis.
• Identify the common symptoms and signs of c
onjunctival disease, differentiate various conju
ntivitidies and manage.
ANATOMY
It is the mucous membrane covering the under
surface of the lids and anterior part of the ey
eball up to the cornea.
Parts of conjunctiva
• Palpebral; covering the
lids—firmly adherent.
• Forniceal; covering the
fornices—loose—thro
wn into folds.
• Bulbar; covering the e
yeball—loosely attach
ed except at limbus.
Conjunctival fornices
• Transitional region between palp
ebral and bulbar conjunctivae.
• Superior fornix 10 mm from limb
us.
• Inferior fornix 8 mm from limbus
.
• Lateral fornix 14mm from limbus
.
• Medially absent.
• Ducts of lacrimal glands open int
o lateral part of superior fornix.
Lymphatic drainage
• Lymph vessels are arrang
ed as a superficial and a d
eep plexus in sub mucosa.
• Ultimately as in the lids t
o the pre auricular and su
b-mandibular lymph glan
ds.
Incidence
• Conjunctivitis is the most common cause of
'red eye'.
• Conjunctivitis accounts for around 44% of al
l eye problems presenting in general practic
e [Manners 1997].
• 2-5% of all general practice consultations ar
e eye related [Manners 1997].
• Viral conjunctivitis is more common than ba
cterial conjunctivitis [Baum 1995].
Conjunctivitis
The most common extraocular disorder
Etiology:
infection of microorganism
physical injuries
chemical injuries
allergic disorder
immunological disorder
nutritional deficiency
Symptomatology
Non-Specific;
• Lacrimation.
• Irritation.
• Stinging.
• Burning.
• Photophobia.
• Redness.
Specific;
• Pain and FB sensation in corneal involvement.
• Itching in allergic, blephritis and dry eyes.
SIGNS
• Type of discharge.
• Type of conjunctival reaction.
• Presence of membrane/ pseudomembrane.
• Lymphadenopathy.
DISCHARGE
Exudate plus debris plus mucus plus tears.
• Serous; watery exudate in acute viral and acute all
ergic conjunctivitis.
• Mucoid; mucus discharge in VKC and KCS (dry
eyes).
• Purulent; pus in severe acute bacterial conjunctivit
is.
• Mucopurulent; pus plus mucus in mild bacterial c
onjunctivitis and Chlamydial conjunctivitis.
Lymphadenopathy
• Pre auricular and sub mandibular.
1. Viral infection.
2. Chlamydial infection.
3. Severe bacterial infections. (Gonococcal).
Laboratory Investigations
Indications:
•
•
•
•
Sever purulent conjunctivitis.
Follicular conjunctivitis: viral vs chlamydial.
Conjunctival inflammation.
Neonatal conjunctivitis.
Laboratory Investigations—cont…
•
•
•
•
•
Cultures.
Cytological investigations.
Inoculation.
Detection of viral and chlamydial antigens.
Impression cytology for dry eyes, ocular cicatricia
l pemphigoid, infection.
• Polymerase chain reaction: small quantity of DNA
for adenovirus, herpes simplex, chlamydia tracho
matis.
CLASSIFICATION OF CONJUNCTIVIS
Morphological
•
•
•
•
Papillary
Follicular
Pseudomembranous
Membranous
Discharge
•
•
•
•
Serous
Mucous
Purulant
Mucopurulant
Etiological
• Infective
• Non-Infective:
Allergic
Autoimmune
Toxic
Chemical
Degenerations
Clinical
•
•
•
•
Acute
Sub-acute
Chronic
Recurrent
Age
• Neonatal
• Childhood
• Adult
Neonatal
•
•
•
•
•
Chlamydial
Gonococcal
Other bacteria
Viral
Chemical
Common Bacterial
• Mucopurulant
• Purulant
• Membraneous
CHLAMYDIAL OCULAR INFECTION
S
• Adult inclusion conjunctivitis.
• Neonatal chlamydial conjunctivitis.
• Trachoma.
Viral
•
•
•
•
•
Adenoviral
Picarna viral
Herpes simplex
Measles
Chicken pox
Allergic
•
•
•
•
Acute allergic conjunctivitis
Vernal keratoconjunctivitis
Atopic keratoconjunctivitis
Phlactenular keratoconjunctivitis
Autoimmune
• Phempegoid (Essential shrinkage of conjun
ctiva)
• Steven Johnson syndrome
Chemical
• Acid burns
• Alkali burns
• Others
Management
• Treat the cause:
Anti-inflammatory agents
Antibacterial
• Antiallergic
• Supportive
• Specific
Acute Bacterial Conjunctivitis
Mucopurulant conjunctivitis
• Caused by:
Staph epidermidis and Staph aureus –usually.
Strep pneumonae, H influensae and Morexella
lucanatae occasionally
Acute Bacterial Conjunctivitis
• Symptoms:
*Acute onset of redness, grittiness, burning and discharge.
*Photophobia may be present (corneal involvement)
*Stickiness of the eyelids
*Usually bilateral disease
• Signs:
*Conjunctival hyperaema
*Mild papillary reaction
*Mucopurulant discharge
*Lid crusting
*No lymphadenopathy.
*Normal VA
Acute Bacterial Conjunctivitis
Purulant cojunctivitis (Adult gonococcal)
• Symptoms:
*Hyperacute condition
*Extremely profuse, thick, creamy pus from the eye or eyes
• Signs:
*Severe conjunctival chemosis
*May be membrane formation
*Periocular edema
*Ocular tenderness
*Gaze restriction
*Lamphadenopathy
*Corneal involvement
• Treatment
Systemic and topical antiboitics
Chronic bacterial conjunctivitis
• Causes:
*Acute becoming chronic
*Refractive errors
*Secondary
Misplaced lashes, CDC, chronic blephritis
• Symptoms:
• Burning and photophobia
• Signs:
*Congestion, and sticky discharge
Treat:
remove the cause
antibiotics
COMMON TOPICAL ANTIBIOTICS
•
•
•
•
•
•
•
•
•
•
Trimethoprim + polymyxin B
Azithromycin
Genticin
chloramphenicol
Tobramycin
Neomycin
Ciprofloxacin
Ofloxacin
Levofloxacin
gatifloxacin
CHLAMYDIAL OCULAR INFE
CTIONS
CHLAMYDIAL OCULAR INFECTION
S
• Adult inclusion conjunctivitis.
• Neonatal chlamydial conjunctivitis.
• Trachoma.
TRACHOMA
• Etiology: Serotypes A, B, Ba & C of Chlamydia trach
omatis.
• Transmission: Common fly (major Vector), fomites, fi
ngers.
• Epidemiology:
–
–
–
–
Endemic in Africa, Asia, Middle East & Australia.
Leading cause of preventable blindness.
Worldwide 360 million people affected.
Six million people are blind from trachoma.
TRACHOMA
• Risk factors:
– Poverty & deprived members of community.
– Poor personal & community hygiene.
– Infectious pool: Preschool children of both sexes & their c
are providers.
• Age:
– Children: Follicular & inflammatory trachoma.
– Young adults: Trachomatous scarring.
– Middle-aged: Trichiasis & corneal opacity.
• Sex: Trichiasis & blindness 2-4 times more common in wo
men than men.
PRESENTATION
• During childhood.
• Symptoms:
– FB sensation.
– Redness.
– Lacrimation.
– Scanty mucoid discharge.
– Mucopurulent discharge if secondary infection.
STAGES
• I) Incipient: Characterized by:
– Minute immature follicles in upper tarsal conjunctiva.
– Cytoplasmic inclusions in conjunctival epithelium.
– Stromal hyperemia & oedema.
• IIa): Follicular hypertrophy:
– Large soft expressible follicles in upper tarsus, fornix
& limbus.
– Punctate keratitis.
– Follicular necrosis---Herbert’s pits.
– Stromal infilteration by plasma cells & macrophages.
STAGES
• IIb): Papillary hypertrophy:
– Trachoma of intense activity or chronic trachoma with
superimposed bacterial infections.
– Obscuration of follicles by papillary hypertrophy.
• III): Cicatrizing trachoma:
– Conjunctival Scarring.
– Pannus formation.
– Lacrimal gland obstruction.
– Trichiasis.
– Entropion.
STAGES
• IV): Healed stage:
– Resolution of inflammation.
– Replacement of follicles & papillae by scar tissue.
DIAGNOSIS
Clinical diagnosis of trachoma requires the presence of
at least two of the following features:
–
–
–
–
Conjunctival follicles on upper tarsal conjunctiva.
Limbal follicles and their sequelae.
Tarsal conjunctival scarring.
Fibrovascular pannus.
COMPLICATIONS
•
•
•
•
•
•
•
•
Upper lid entropion
Trichiasis.
Xerosis – obliteration of lacrimal ducts or glands.
Chlazion.
Symblepharon – obliteration of lower fornix.
Corneal ulceration.
Corneal opacity.
Pseudoptosis.
MANAGEMENT
• SAFE strategy developed by WHO:
• Surgery:
– To prevent blindness & limits progression of corne
al scarring.
– Can improve vision.
• Antibiotics:
– Azithromycin—1 G single dose (adults).
– Children: 20mg/kg single dose
MANAGEMENT
• Erythromycin 250 mg QID for 4 weeks. (childr
en 125mg/kg).
• Tetracycline 250 mg QID for 4 weeks.
• Topical tetracycline 1% 0.5 inch ribbon BD for
6 weeks.
MANAGEMENT
• Facial cleanliness:
– Reduces risk & severity of trachoma.
• Environmental change:
– Improved water supply & household sanitation.
– Personal & community hygiene.
– Adequate housing & water & sewage system.
VIRAL CONJUNCTIVITIS
•
•
•
•
•
Inflammation with follicle formation—may be associate
d with enlargement of regional lymph glands.
Severe conjunctival inflammation, minimal discharge, l
acrimation, Sub-conjunctival hemorrhage.
Mild hyperemia.
Conjunctival ulcers or membrane formation.
Corneal involvement;
1.Superficial punctate keratitis.
2.Superficial erosions.
3.Stromal infiltrates.
4.Necrotic stromal ulcer.
EPIDEMIC KERATOCONJUNCTIV
ITIS
•
•
•
•
Adeno virus serotypes 8 & 19.
Transmission: Direct or Indirect contact.
Epidemics: Schools, work places & physicians.
Mode of Spread: Contaminated fingers, medica
l instruments (tonometer), swimming pool or se
xual contact.
• Self limiting.
• Highly infectious.
EPIDEMIC KERATOCONJUNCTIV
ITIS
• Conjunctivitis:
Acute onset watering, redness, discomfort & p
hotophobia, both eyes (60%).
• Signs:
– Eyelids (oedematous).
– Scanty discharge (watery).
EPIDEMIC KERATOCONJUNCTIV
ITIS
• Conjunctiva:
– Follicular conjunctivitis.
– Mild-moderate chemosis.
– Haemorrhage.
– Pseudomembrane formation.
• Tender pre-auricular lymphadenopathy.
• Keratitis (80%)- 7 to 10 days later in the form of sup
erficial punctate keratitis, subepithelial opacities and
may remain for quite a long time.
EPIDEMIC KERATOCONJUNCTIV
ITIS
• Treatment: Symptomatic & supportive.
• Spontaneous resolution within 2 weeks.
• Topical steroids to be avoided.
• Antivirals ineffective.
• Cold compresses, topical vasoconstrictors.
ACUTE HAEMORRHAGIC CONJU
NCTIVITIS
•
•
•
•
•
•
•
•
Enterovirus 70 & Coxsackie virus A 24.
Sudden onset.
Short duration.
Bilateral, profuse watering and discharge.
Palpebral follicles.
Sub-conjunctival haemorrages.
Lymphadenopathy.
Mild transient epithelial keratitis.
Allergic Conjunctivitides
Definitions
Allergy is an altered or exaggerated susceptibility t
o various foreign substances or physical agents w
hich are harmless to the great majority of individu
als. It is due to an antigen antibody reaction.
Allergens is an agent capable of producing a state
or manifestation of allergy.
TYPES OF ALLERGIC CONJUNCTIVIT
IS
1: ALLERGIC RHINOCONJUNCTIVITIS.
2: ACUTE ALLERGIC CONJUNCTIVITIS.
3:VERNAL KERATOCONJUNCTIVITIS.
4: ATOPIC KERATOCONJUNCTIVITIS.
5: GIANT PAPILLARY KERATOCONJUNCTI
VITIS.
6: CONTACT OCULAR ALLERGY.
7: PHLACTENULAR CONJUNCTIVITIS.
Allergic Rhinoconjunctivitis
• Hypersensitivity reacti
on to specific airborn a
ntigens.
• Frequently associated
nasal symptoms.
• May be seasonal or per
ennial.
Transient conjunctival oedema
VERNAL KERATOCONJUNCTIVITIS
• Common, recurrent, bilateral, external, ocular infl
ammation affecting children & young adults.
• 6 – 20 years.
• Males > Females.
• VKC IgE & cell mediated immune mechanism pl
ay an important role.
• 3/4 patients have associated Atopy.
• 2/3 have close family hx. of Atopy.
VERNAL KERATOCONJUNCTIV
ITIS
• Atopic pts. have Asthma & Eczema in infancy.
• Peripheral blood shows esinophilia & increase ser
um IgE levels.
• Onset: After 5 years.
• Resolves: around puberty.
• Sign/Symptoms: occur on seasonal basis.
• Peak Incidence: April - August.
• More common in warm, dry climates e.g., Medite
rranean basin, Africa & East Asia.
Clinical Features
Symptoms:
Itching, lacrimation, photophobia, FB sensation, burning.
 Signs:
Giant papilla, ptosis, hyperemia, mucus, trantas dots, punctate keratopathy, corneal u
lcer.
Clinical Types
1: Palpebral VKC:
• Conjunctival hyperemia followed by a diffuse pa
pillary hypertrophy (marked on superior tarsus).
• Papilla enlarge & have flat topped polygonal appe
arance of cobble stones.
• In severe cases C.T. septa rupture giving giant pa
pillae which is coated by copious mucus.
• Active discharge by redness, swelling & tightly p
acked papilla.
2: Limbal VKC:
characterized by mucoi
d nodules having smoot
h round surface
discrete white superfici
al spots. trantas dots c
omposed predominantl
y esinophils, fibroblasts
& necrotic epithelium,
scattered around limbus
& the apices of the lesi
ons.
Limbal vernal
Mucoid nodule
Trantas dots
Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus
Formation of cobblestone papillae
Rupture of septae - giant papillae
Progression of vernal keratopathy
Punctate epitheliopathy
Plaque formation (shield ulcer)
Epithelial macroerosions
Subepithelial scarring
Treatment
1.Topical Steroid:
Fluorometholone, Dexamethason, Prednisolone.
2. Mast cell stabilizers:
Nedocromil 0.1%, Lodoxamide, Sodium Cromo
glycate.
3. Acetyl-cysteine 5%.
4. Topical Cyclosporin 2%.
5. Debridement of early mucous plaque.
Treatment
6. Lamellar keratectomy of densely adherent pla
ques.
7. Excimer laser phototherapeutic keratectomy.
8. Amniotic membrane transplantation.
9. Supratarsal inj. of steroid: Betamethasone or tr
iamcinolone.
10. Desensitizing immunotherapy.
ATOPIC KERATOCONJUNCTIVIT
IS
 Rare, potentially serious co
ndition affects young (18-5
0 yrs) patients with atopic
dermititis.
 Involved skin areas and lat
eral neck folds; antecubital
and popliteal fossae.
 Pts have Asthma, hay fever
, urticaria, Migraine, Rhinit
is.
 Chronic conjuntivitis.
 Serum IgE raised.
Atopic keratoconjunctivitis
Typically affects young patients with
atopic dermatitis.
Eyelids are red, thickened, macerated
and fissured.
TOXIC KERATOCONJUNCTIVITIS
Contact blepharoconjunctivitis due to drugs
1. Anaesthetics.
2. Atropine.
3. Gentamycin.
4. Neomycin.
5. Tobramycin.
6. Antivirals.
7. Epinephrine.
8. Pilocarpine.
9. Timolol.
10. Preservatives:
Benzalkonium chloride
Chlorobutanol
Chlorhexidine
EDTA
Thimerosal
11. Cosmetics.
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