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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.