conjunctiva anatomy and physiology - …prime.edu.pk/4th_year_eye_lectures/conjunctiva...
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CONJUNCTIVA: ANATOMY , PHYSIOLOGY AND
SYMPTOMATOLOGY
Dr. Faizur Rahman
Associate Professor
Peshawar Medical College.
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ANATOMY
It is the mucous membrane covering the
under surface of the lids and anterior part
of the eyeball upto the cornea.
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Parts of conjunctiva
• Palpebral; covering the lids—firmly adherent.
• Forniceal; covering the fornices—loose—thrown into folds.
• Bulbar; covering the eyeball—loosely attached except at limbus.
• Also marginal and limbal parts and plica semilunaris.
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Palpebral conjunctiva
• Subtarsal sulcus 2mm from posterior edge of
the lid margin.
• Richly vascular.
• Extremely thin.
• Strongly bound to the tarsal plate.
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Conjunctival fornices
• Transitional region between palpebral and bulbar conjunctivae.
• Superior fornix 10 mm from limbus.
• Inferior fornix 8 mm from limbus.
• Lateral fornix 14mm from limbus.
• Medially absent.
• Ducts of lacrimal glands open into lateral part of superior fornix.
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Bulbar conjunctiva
• Lies in contact with eyeball.
• Thin, translucent and loosely attached by
connective tissue to sclera and fascia bulbi.
• Conjunctival limbus 1 mm anterior to corneal
limbus.
• Bulbar limbus 1.5 mm behind corneal limbus.
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Epithelium
• Stratified columnar epithelium 2 – 5 cells.
• At limbus change into stratified squamous non keratinized epithelium.
• At lid margin non keratinized stratified squamous epithelium changes into keratinized stratified squamous epithelium.
• Goblet cell – mucus.
• Accessory lacrimal glands.
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Sub mucosa
• Fine delicate connective tissue.
• Lymphocytes.
• Denser fibrous tissue, blood vessels, nerves,
smooth muscles and accessory lacrimal glands.
• Papillae.
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Nerve supply - Sensory
• Bulbar conjunctiva – long ciliary nerves – nasociliary N. – Ophthalmic division of trigeminal N.
• Superior palpebral and forniceal conjunctiva – frontal and lacrimal branches of Ophthalmic division of trigeminal N.
• Inferior palpebral and forniceal conjunctiva – laterally from lacrimal branches of Ophthalmic division of trigeminal N. and medially infraorbital N. – Maxillary division of trigeminal N.
Sympathetic;
• Superior cervical sympathetics to blood vessels.
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Blood supply
Arterial supply;
• Posterior conjunctival arteries derived from arterial arcade of lids which is formed by palpebral branches of nasal and lacrimal arteries of the lids.
• Anterior conjunctival arteries derived from the anterior ciliary arteries – muscular br. of ophthalmic artery to rectus muscles.
Venous drainage;
• Palpebral and Ophthalmic veins.
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Lymphatic drainage
• Lymph vessels are
arranged as a superficial
and a deep plexus in sub
mucosa.
• Ultimately as in the lids
to the pre auricular and
sub-mandibular lymph
glands.
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Lacrimal caruncle
• Small, pinkish ovoid body in lacus lacrimalis at medial canthus of eye.
• Medial to plica semilunaris.
• Modified skin, colorless hair, sebaceous, sweat glands and accessory lacrimal glands.
• Non keratinized stratified squamous epithelium.
• Superior medial palpebral artery.
• Submandibular lymph node.
• Infratrochlear br. of nasociliary N.
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Plica semilunaris
• Halfmoon shaped fold of
conjunctiva lateral to and party
under the caruncle.
• Lateral margin is free and
concave.
• Goblet cells, adipose tissue,
smooth muscle fibers and highly
vascular.
• Nictitating membrane.
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PHYSIOLOGY
• Smooth surface.
• Secretes mucin and aqueous component of tear film.
• Highly vascular: supplies nutrition to the peripheral cornea.
• Aqueous veins drains from anterior chamber maintenance of IOP.
• Lymphoid tissue helps in combating infections.
• Basic secretion—reflex secretion.
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Symptomatology
Non-Specific;
• Lacrimation.
• Irritation.
• Stinging.
• Burning.
• Photophobia.
• Redness.
Specific;
• Pain and FB sensation in corneal involvement.
• Itching in allergic, blephritis and dry eyes.
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SIGNS
• Type of discharge.
• Type of conjunctival reaction.
• Presence of membrane/ pseudomembrane.
• Lymphadenopathy.
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DISCHARGE
Exudate plus debris plus mucus plus tears.
• Serous; watery exudate in acute viral and acute allergic conjunctivitis.
• Mucoid; mucus discharge in VKC and KCS (dry eyes).
• Purulent; puss in severe acute bacterial conjunctivitis.
• Mucopurulent; puss plus mucus in mild bacterial conjunctivitis and Chlamydial conjunctivitis.
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TYPE OF CONJUNCTIVAL REACTION
• Hyperaemia: (Conjunctival injection) Bacterial.
• Sub-conjunctival Haemorrhage: Viral.
• Bleeding:
• Chemosis: (Oedema)
• Scarring: Trachoma, cicatricial pemphigoid, atopic conjunctivitis and prolong use of topical drops.
• Follicular reaction.
• Papillary reaction.
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Follicular reaction
• Sub epithelial foci of hyperplastic of lymphoid tissue with in stroma.
• More prominent in fornices.
• Multiple, discrete, slightly elevated, lesions encircled by a tiny blood vessel—small grains of rice.
• Size from 0.5 to 5 mm.
1. Viral.
2. Chlamydial.
3. Parinaud oculoglandular syndrome.
4. Hypersensitivity to topical medications.
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Follicular reaction
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Papillary reaction• Hyperplastic conjunctival epithelium.
• Can develop in palpebral conjunctiva (firmly attached) and limbus.
• Papilla may mask follicles.
• Giant papilla (confluence)
• Non-specific; (less diagnostic)
1. Chronic blephritis.
2. Allergic conjunctivitis.
3. Bacterial conjunctivitis.
4. Contact lens wears.
5. Superior limbic keratoconjunctivitis.
6. Floppy eyelid syndrome.
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Pseudomembrane
• Outside epithelium.
• Coagulated exudate adherent to the inflammed epithelium.
• Can be easily pealed off.
• Causes;
1. Severe adenoviral infection.
2. Ligneous conjunctivitis.
3. Gonococcal conjunctivitis.
4. Stevens-Johnson syndrome.
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Membrane
• Includes epithelium.
• Infiltrate the superficial layers of conjunctival epithelium.
• Epithelium is injured if removal attempted.
• Causes;
1. Diphtheria.
2. Beta-hemolytic steptococci.
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Lymphadenopathy
• Pre auricular and sub mandibular.
1. Viral infection.
2. Chlamydial infection.
3. Severe bacterial infections. (Gonococcal)
4. Parinaud oculoglandular syndrome.
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Laboratory Investigations
Indications:
• Sever purulent conjunctivitis.
• Follicular conjunctivitis: viral vs chlamydial.
• Conjunctival inflammation.
• Neonatal conjunctivitis.
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Laboratory Investigations—cont…
• Cultures.
• Cytological investigations.
• Inoculation.
• Detection of viral and chlamydial antigens.
• Impression cytology for ocular surface neoplasia, dry eyes, ocular cicatricial pemphigoid, limbal stem cells failure, infection.
• Polymerase chain reaction: small quantity of DNA for adenovirus, herpes simplex, chlamydia trachomatis.
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Differential diagnosis of red eye
• Conjunctival– Blepharoconjunctivitis– Bacterial conjunctivitis– Viral conjunctivitis– Chlamydial conjunctivitis– Allergic conjunctivitis– Toxic/chemical reaction– Dry eye– Pinguecula/pteyrgium
• Lid diseases– Clalazion– Sty– Abnormal lid function
• Corneal disease– Abrasion– Ulcer
• Foreign body
• Dacryoadenitis• Dacryocystitis• Masquerade syndrome• Carotid and dural fistula• Acute angle glaucoma• Anterior uveitis• Episcleritis/scleritis• Subconjunctival hemorrhage• Factitious
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THANK YOU