Conjunctiva

Conjunctiva sac :
Bulbar conjunctiva
fornix
medial semilunar fold
palpebral conjunctiva
(tarsal conjunctiva)

Histology :
conjunctival epithelium :

stratified cuboidal (over tarsus)

columnar (over fornix)
squamous (over globe)

Substansia propia :
adenoid layer
fibrous layer

Bacteriology :
Never free from microorganism
Bacteria do not propagate
(proliferate) easily, due to :

relatively low temperature (exposure)

evaporation lacrimal fluid
bacteriostatic
lysozyme enzyme
mechanic (washing)

Bacteriology :
Microorganism that could be found in
normal conjunctival sac :

Staph. epidermis
Staph. aureus
Micrococcus sp
Corynebacterium sp
Propionibacterium acnes
Streptococcus sp
Haemophylus influenza

In children

Moraxella sp
Enteric gram (-) bacilli
Bacilus sp
Anaerobic bacteria
Yeast
Filamentous fungi
Demodex sp

 The establishment and severity of

infection are influenced by the
interplay between the following factors :
Virulence of the pathogen
Size and route of the inoculums
Presence or absence of risk factors that
compromise host defenses
Nature of the hosts immune and
inflammatory response

Classification of
conjunctival Disorder
Parsons
Inflammations
Infection
Allergy

Degenerative changes
Symptomatic condition
Cyst and Tumors

 General Ophthalmology
Conjunctivitis
infection
allergy
autoimmune
chemical / irritates
unknown cause

Degenerative disease
Miscellaneous disorders
Tumors

 Ophthalmologic examination, usually

by inspection :

magnifying devices (loupe)

flashlight / penlight / slitlight
do not forget to everse superior eye lid

 Clinical terms :
hyperemia = focal / diffuse dilatation of
subepithelial plexus of conjunctival
blood vessels
chemosis = conjunctival edema
tearing = excess tears from increased
lacrimation or impaired lacrimal outflow
discharge = exudates on the
conjunctival surface: serous, mucoid,
mucopurulent, purulent

 Papillla = dilated conjunctival blood

vessel, surrounded by edema and
inflammatory cells
Follicle = focal lymphoid nodule with
accessory vascularization
Pseudomembrane = inflammatory
coagulum on conjunctival surface that
doesnt bleed during removal
Membrane = inflammotory coagulum on
the conjunctival surface that bleeds when
stripes

 Granuloma = nodule of chronic

inflammatory cells with fibrovascular
proliferation
Phlyctenule = a nodule of chronic
inflammatory cells, often at near or the
limbus
Punctate epithelial erosion = loss of
individual epithelial cells in a stippled
pattern
Epithelial defect = focal ara of epithelial
loss

 inflammation of the conjunctiva :

origin :
infection
allergy

hyperemia
secret

Common Causes of conjunctival

Inflammation
Papillary conjunctivitis:
allergic, bacterial
Follicular conjunctivitis: adenovirus, mollusucum
contangiosum, chlamydial, HSV, drug-induced
Conjunctival pseudomembrane or membrane:
severe viral/bacterial, stevens-jhonson syndr,
chemical burn
Conjunctival granuloma: cat-scratch disease,
sarcoidosis, foreign-body reaction
Conjunctival erosion or ulceration: stevensjhonson syndrome, cicatrical pemphigoid, grafthost disease,

 Secret :

serous : viral
mucous, mucopurulent : bacteria
purulent : beware of gonococcus

bacterial investigation by gram

histological investigation by giemsa

Infection of the
conjunctiva
Acute :

serous
catarrhal
mucopurulent
purulent
membranous

chronic :
simple chronic conjunctivitis
angular conjunctivitis
follicular conjunctivitis

Acute Catarrhal or
muco-purulent
Hyperemia
that associated with a mucous discharge
conjunctivitis
---> gums lid together (especially in the morning)

The whole conjunctiva is a fiery red (pink eye)

Reaches its height in 3 - 4 days
Rare complication, but cornea abrasion may occur
Etiology :

Staphylococci (most common)

Haemophilus aegyptius
Pneumococcal

Accompanies exanthema such as measles and

scarlet fever

 Treatment :
bacteriostatic drop
the eyes should not be bandaged
dark google should be worn if photophobia is
present
care must be taken due to contagious disease

Prognosis :
Most of cases are good
Neglected cases are treated as chronic
conjunctivitis

Purulent conjunctivitis
Occurs in two forms :
Babies : ophthalmia neonatorum
Adult : conjunctivitis

Main and most dangerous etiology: gonococcus, N.

gonorrhea
Direct infection from genital
Clinical finding :
Swelling of the lids and conjunctiva
Copious purulent discharge
Constitutional disturbance

Ulcer may occur at any part of cornea

 Treatment :
appropriate systemic and topical antibiotic
the eyes should be irrigated with warm
saline and intensive solution of crystalline
benzylpenicilin if any purulent discharge
present
should be directed first to protection of to
other eye
In Cicendo Eye Hospital :
cefotaxime I.m.
gentamycine or sulfacetamide eye drops

Ophtalmia Neonatorum
found in newborn children due to
maternal infection
responsible for 50% of blindness in
children
E/ :
Severe : N. gonorrhea
Mild :Chlamydia oculogenitalis,
Streptococcus pneumonia

 Clinical findings :
conjunctiva : inflamed, bright red, swollen, yellow
pus
at severe muco-purulent conjunctivitis : infiltration
at bulbar conjunctiva & lids are swollen and tense
corneal ulceration if untreated

 Prophylaxis:

The babys lids should be cleansed and dried

If infection is suspected use :

Credes method : a drop of silver nitrate solution 1%

into each eye

Treatment

for ophtalmia neonatorum : penicillin,

tetracycline & eritromicyn by mouth
for penicillinase-producing N. gonorrhoeae:
cephalosporin & gentamicin 0,3% drop
In BKEC :
cefotaxime I.m.
gentamycine or sulfacetamide eye drops

Membranous
conjunctivitis

Known also as diphtheritic

conjunctivitis
E/ : diphtheria bacillus,
pneumococcus & streptococcus
occur esp. at children who have not
been immunized, after measles,
scarlet fever w/ impetigo

 Clinical findings :
mild cases : swelling of the lids, muco-purulent
or serous discharge
severe cases : lids are more brawny, conjunctiva
is permeated w/ semisolid exudates, tend to
necrotize conjunctiva and cornea

Treatment :
treated as diphtherial : penicillin and
antidiphtheritic serum (4-6-10.000 units
repeated in 12 hours)

Simple chronic
conjunctivitis
Continuation of simple
acute conjunctivitis
Etiology :

irritation : smoke, dust,

alcohol, etc
hypersensivity

Symptoms :
burning and grittiness
(especially in the evening)
difficult to keep eyes open
posterior conjunctival
vessels are seen to be
congested

 Treatment :
This consist in eliminating the cause
and restoring the conjunctiva to its
normal condition.
Swab should be taken
short course of suitable antibiotic

Follicular conjunctivitis
Inclusion conjunctivitis
Relatively acute onset
hypertrophy is always prominent in
the lower lid
E/ : chlamydial infection

 relatively benign
healing spontaneously in from 3 to 12
months
topical broad spectrum antibiotics
systemic Antibiotics (tetracycline 250
mg every 6 hours for 14 days)

 Epidemic kerato-konjunctivitis
characterized by a rapidly developing follicular
conjunctiva
associated with pre-auricular adenopathy
may lead to corneal complication
associated with adenovirus
Treatment by adenine arabinoside (Ara-A) is promising

Herpes simplex conjunctivitis

detected by the fluorescent antibody (FA)
usually seen in young children
tiny ulcers on the intermarginal portion of eyelid ---->
with flourescin test

Trachoma
E/ : Chlamydia trachomatis

Usually starts sub acutely

primary infection is epithelial
both conjunctiva and the
cornea (keratoconjunctivitis)
typical conjunctival sign :
diffuse inflammation --->
congestion
papillary enlargement
development of follicles

occuring in 4 stage
trachomatous pannus may
develops at a later stage

Stage of Trachoma
Stage 1: earliest stage, before clinical
diagnosis is possible

Stage 2: periode between the

appereance of typical trachomatous

lession & the development of scar
tissue

Stage 3: scarring is obvious

Stage 4: the desease become quiet,
cicatrization

 WHO:
TF: folicular conjunctival inflammation
TI: diffuse conjunctival inflammation
TS: tarsal conjunctival scarring
TT: trichiasis or enteropion
CO: corneal opacification

 Treatment :
the ideal has not been developed
tetracycline, erythromycin,
rifampicin and sulfonamides are
efective
pannus requires no special treatment
corneal complication (ulcers) must be
treated on general principles

Allergic type of
Conjugtivitis

Acute or sub acute allergic catarrhal

conjunctivitis
watery secretion (not purulent)
allergen sometimes is a bacterial protein
(staphylococcus is most common)
treatment :
allergen removal
astringent lotion
antihistamine drop is more effective

 Eczematous conjunctivitis
characterized by one or more small grey or
yellow nodules on the bulbar conjunctiva
frequently complicated by muco-purulent
conjunctivitis
E/ : endogenous bacterial protein
Symptoms : discomfort and irritation
associated with reflex lacrimation
Treatment : Steroid drop or ointment

 Vernal conjunctivitis

bilateral conjunctivitis occur in hot

weather
symptom :
burning, itching, photophobia and
lacrimation
white & ropy secretion

two types :

palpebral form
bulbar form

 Treatment :

symptomatic
steroid drops or ointment
cryotherapy (for nodule)
mast cell stabillizer
Disodium cromoglycate 2%
(adjuvant to topical steroid)

Degenerative Changes
Lithiasis
hard yellow spots in the palpebral
conjunctiva
common in elderly people
removed with sharp needle

Pinguecula
triangular patch on conjunctiva
looks like fat (yellow color)
no treatment required

 Pterygium
proliferate subconjunctival
tissue as vascularized
granulation to invade the
cornea
frequently follow a pinguecula

 Pterygium morphology grading

system:

Grade T1: athrophic pterygium

Grade T2: intermediate pterygium
Grade T3: fleshy pterygium

 Options for wound clossure after

extirpation:

Bare sclera
Simple clossure
Sliding flap
Rotational flap
Conjungtival graft

Symptomatic condition
Subconjunctival ecchymosed
due to rupture of small vessels
the blood becomes absorbed without
treatment in 1 - 3 weeks

 Chemosis
edema of conjunctiva
occur in :
acute inflammation
obstruction to the circulation
abnormal blood condition

 Xerophthalmia

dry condition of the conjunctiva

due to deficiency of vitamin A
accompanied by night blindness
occurs in two groups :
as a sequel of a local ocular affection
associated with general disease

Clinical findings :
bitots spots

 Classification by ocular sign :

Night blindness (XN)
conjunctival xerosis (X1A)
Bitots spot (X1B)
Corneal xerosis (X2)
Corneal ulceration/keratomalacia < 1/3 of corneal
surface (X3A)
Corneal ulceration/keratomalacia > 1/3 of corneal
surface (X3B)
Corneal Scar (XS)
Xerophthalmic fundus (XF)

Cysts and Tumors

Cyst

lymphangiectasis
lymphangiomata
Subconjunctival cysticercus ---> rare
hydatid cysts ---> rare
Epithelial implantation cysts ---> rare,
occur after injuries or strabismus
operations

 Tumors
Congenital tumors
Dermoids

Dermo-lipomata

Large papillae
papillomata
simple granulomata
eptheliomata
Pigmented tumors
Naevi

 Precancerous melanosis

Malignant melanoma
Rodent ulcer

References
Stephen J.H. Miller, Parsons Disease
of The Eye
D, Vaughan, General Ophthalmology
American Academy of
Ophthalmology, External Disease
and Cornea