Download Conjunctival Diseases

Conjunctival Diseases
Prof.Dr. Osman Ş. ARSLAN
Applied Anatomy
1.The conjunctival epithelium is
between two and five cell layers
thick
2.The stroma (substantia propria)
consists of richly vascularized
connective tissue which is
separated from the epithelium by
a basement membrane
3.The mucin secretors
a)Goblet cells,b)Crypts of Henle,
c)Glands of Manz,
4.Accessory lacrimal glands of
Krause and Wolfring
5.The three clinical parts of the
conjunctiva are:
a)Palpebral
b)Forniceal
c)Bulbar
Clinical Evaluation of
Conjunctival Inflammation
The clinical features which should be
considered in the differential diagnosis of
conjunctival inflammation are:
a)symptoms,
b)type of discharge,
c)conjunctival appearance,
d)presence of membranes,
e)presence or absence of lymphadenopathy.
Symptoms
Many of the symptoms of
conjunctivitis are non-specific, such as
lacrimation, irritation, stinging,
burning and photophobia.
Pain and a foreign body sensation
may be result of associated corneal
involvement.
Discharge
1.Watery discharge is composed of a serous
exudate and a variable amount of reflexly
secreted tears. It is typical of acute viral and
acute allergic inflammations.
2.Mucoid discharge is typical of vernal
conjunctivitis and keratoconjunctivitis sicca.
3.Purulent discharge occurs in severe acute
bacterial infections.
4.Mucopurulent discharge occurs in mild
bacterial and chlamdyial infections.
Conjunctival Appearance
(1)
1.Conjunctival injection is non-specific
feature which is frequently maximal in the
fornices.
2.Subconjunctival haemorrhages usually
occur with viral infections.
3.Follicular reaction has significant diagnostic
importance. Follicles consist of hyperplasia of
lymphoid tissue within the stroma.
viral infections, chlamydial infections,
parinaud oculoglandular syndrome, and
hypersensitivity to topical medication
Conjunctival Appearance
(2)
4.Papillary reaction is more non-specific and
of less diagnostic value than a follicular
response.
chronic blepharitis, allergic conjunctivitis,
bacterial infections, contact lens-related
problems, superior limbic keratoconjunctivitis,
floppy eyelid syndrome
5.Oedema (chemosis) occurs whenever the
conjunctiva is severely inflamed.
6.Scarring may indicate trachoma, ocular
cicatricial pemphigoid, atopic conjunctivitis,
and the prolonged use of topical medications.
Membranes
1.Pseudomembranes consist of coagulated
exudate adherent to the inflamed conjunctival
epithelium. Characteristically, they can be easily
peeled off leaving the epithelium intact.
a)severe adenoviral infection,
b)ligneous conjunctivitis,
c)gonococcal conjunctivitis
d)Stevens-Johnson syndrome
2.True membranes form when the inflammatory
exudate permeates the superficial layers of the
conjunctival epithelium. Attemps to remove the
membrane may be accompained by tearing of the
epithelium and bleeding. Beta-haemolytic
streptococcal and diphtheria infections.
Lymphadenopathy
Lymphatic drainage of the conjunctiva is to the
preauricular and submandibular nodes which
corresponds to the drainage of the eyelids.
Lymphadenopathy is a feature of:
a)viral infections
b)chlamydial infections
c)severe gonococcal infection and
d)Parinaud syndrome
Bacterial Conjunctivitis
‹
Simple bacterial conjunctivitis
‹
Adult gonococcal keratoconjunctivitis
‹
Neonatal gonococcal
keratoconjunctivitis
Simple Bacterial
Conjunctivitis
Clinical Features
1.Presentation is with an acute onset of redness,
grittiness, burning and discharge
2.Signs
a)The eyelids are crusted and may be slightly
oedematous
b)The discharge in the early stages may be
watery
c)The conjunctiva shows a velvety, beefy-red
appearance .In severe cases inflammatory
membranes may be present
d)Corneal involvement is uncommon although
some cases show punctate epitheliopathy and
peripheral corneal infiltrates.
Treatment
Even without treatment, simple conjunctivitis
usually resolves within 10-14 days. Initial
treatment is broad spectrum antibiotics.
1.Antibiotic drops
a)Fusidic acid (Fucithalmic)
b)Chloramphenicol
c)Other antibiotics
2.Antibiotic ointments
Antibiotics available in ointment form are:
chloramphenicol, gentamicin, tetracycline,
and polytrim
Adult gonococcal
keratoconjunctivitis
OCULAR FEATURES
1.Presentation is with a hyperacute, extremely
profuse and thick creamy pus leaking from the
eye.
2.Signs
a)The eyelids are oedematous and tender
b)The discharge is profuse and purulent
c)The conjunctiva shows intense hyperaemia,
chemosis and frequently pseudomembrane
formation
d)Prominent preauricular lymphadenopathy
e)Keratitis may occur in severe cases
Treatment
The patient should be hospitalized, cultures
taken and the eye irrigated at frequent
intervals with saline.
1.Systemic antibiotic therapy
a)Cefoxitin or cefotaxime
b)Spectinomycin
2.Topical antibiotic therapy is with gentamicin or
bacitracin
Neonatal Gonococcal
Keratoconjunctivitis
Gonococcal infection is now a rare cause of
neonatal conjunctivitis which is transmitted
from the mother during delivery
1.Presentation is usually between 1 and 3 days
after birth
2.Signs: hyperacute, purulent conjunctivitis
which is associated with chemosis and sometimes
membrane or pseudo-membrane formation.
3.Treatment is with topical and systemic
penicillin.
Viral Conjunctivitis
‹
Adenoviral keratoconjunctivitis
‹
Herpes simplex conjunctivitis
Adenoviral Keratoconjunctivitis
(Epidemic Keratoconjunctivitis)
Epidemic keratoconjunctivitis which is
most frequently caused by adenovirus
types 8 and 19.
Both conjunctiva and cornea may be
affected
Keratitis occurs in about 80% of cases
and may be severe
Conjunctivitis
1.Presentation is with acute onset of watering,
redness, discomfort and photophobia. Both eyes
are affected in about 60% of cases
2.Signs
a)The eyelids are oedematous
b)The discharge is watery
c)The conjunctiva shows mild to moderate
chemosis and follicles.
d)Lymphadenopathy is tender
3.Treatment is largely symptomatic and
supportive but spontaneous resolution occurs
within 2 weeks.
Keratitis
1.Signs
a)Stage 1 occurs within 7 days of the onset of
symptoms. It is characterized by a diffuse
epithelial keratitis which resolves within 2
weeks.
b)Stage 2 is characterized by a transient focal,
epithelial keratitis which develops 1 week
after onset
c)Stage 3 is characterized by subepithelial
infiltrates which develop beneath fading
epithelial lesions. Untreated they may persist for
months or years
2.Treatment with topical steroids is indicated
only if the eye uncomfortable or visual acuty
diminished by stage 3 lesions
Herpes Simplex Conjunctivitis
Conjunctivitis may occur in patients with primary
herpes simplex infection
1.Signs
a)The eyelids and periorbital skin show
unilateral herpetic vesicles which may be
associated with mild oedema
b)The discharge is watery
c)The conjunctiva shows an ipsilateral
follicular response
d)Lymphadenopathy is tender
e)Keratitis is uncommon
2.Treatment is with antiviral agents for 21 days
to prevent keratitis
Trachoma
Trachoma is an infection caused by serotypes
A, B, Ba and C of Chlamydia trachomatis.
It is a disease of underprivileged populations
with poor conditions of hygiene.
The common fly is the major vector in the
infection-reinfection cycle.
Currently trachoma is the leading cause of
preventable blindness in the world
Clinical Features
(1)
1.Presentation is during childhood with the
development of a follicular conjunctivitis
associated with diffuse papillary infiltration.
2.Chronic conjunctival inflammation results in
scarring with fine linear or small stellate scars in
milder cases, or broad confluent scars (Arlt lines)
3.Limbal follicles are a unique feature. On
resulation they leave characteristic depression
(Herbert pits)
Clinical Features
(2)
4.Keratitis, during the inflammatory stage, ranges
from superior epithelial keratitis to anterior
stromal infiltrates and pannus formation
5.Progressive conjunctival scarring, if severe,
causes distortion of the eyelids, particularly of
the upper tarsus, to produce trichiasis and
entropion.
6.End-stage trachoma is characterized by severe
visual impairement of blindness from corneal
ulceration and opacification
Treatment
Treatment is with a single dose of
azithromycin
The most important preventive
measure is strict personal hygiene within
the family, especially washing the face of
young children
Allergic Conjunctivitis
‹
Vernal keratoconjunctivitis
Vernal keratoconjunctivitis
Vernal keratoconjunctivitis (VKC)
(spring catarrh) is an uncommon
recurrent, bilateral, external, ocular
inflammation affecting children and young
adults.
VKC is an allergic disorder in which IgE
and cell-mediated immune mechanism
play an important role.
Clinical Features
(1)
The main symptoms are intense ocular
itching which may be associated with
lacrimation, photophobia, foreign body
sensation and burning.
Thick mucus discharge from the eyes and
ptosis also occur.
Clinical types:
a)palpebral,
b)limbal and
c)mixed
Clinical Features
(2)
1.Palpebral VKC in choronological order:
a)Conjunctival hyperaemia followed by a
diffuse papillary hypertrophy, most marked on
the superior tarsus
b)The papillae enlarge and have a flat-topped
polygonal appearance reminiscent of
cobblestones
c)In severe cases, the connective tissue septa
rupture, giving rise to gaint papillae which
may be coated by copious mucus
d)Active disease is characterized by redness,
swelling and tightly packed papillae. As the
inflammation settles the papillae become
more seperated
Clinical Features
(3)
2.Limbal VKC has a better prognosis
a)It is characterized by mucoid nodules that
have a smoth round surface
b)Discrete white superficial spots (Trantas dots)
composed predominantly of eosinophils are found
scattered around the limbus at the apices of the
lesions
3.Mixed VKC
Treatment of VKC
1.Topical steroids
2.Mast cell stabilizers
3.Acetylcsteine
4.Topical cyclosporin
5.Debridement
6.Lamellar keratectomy
7.Supratarsal injection of steroid
Conjunctival Degenerations
Pinguecula
A pinguecula is an extremely common lesion
which consists of a yellow-white deposit on the
bulbar conjunctiva adjacent to the nasal or
temporal aspect of the limbus.
Some pingueculae may enlarge very slowly
but surgical excision is seldom required.
Conjunctival Degenerations
Pterygium
A ptergium is a triangular sheet of
fibrovascular tissue which invades the cornea.
Ptergia typically develop in patients who have
been living in hot climates and may represent a
response to chronic dryness and exposure to the
sun.