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Conjunctiva
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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
Applied Anatomy
Structure
1. 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
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)
Applied Anatomy
• 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 microorganisms
: smooth surface as the lid blinks
Evaluation of conjunctival inflammation
1. Symptoms
• 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 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
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Bacterial
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Chlamydia
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Allergy
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Toxic
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Evaluation of conjunctival inflammation3. Conjunctival appearance
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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
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. βhaem.streptococci,diphtheria
Evaluation of conjunctival inflammation3. Conjunctival appearance
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 inflammation3. 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
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
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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
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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
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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