ConjungtivaConjungtiva

Binto AkturusianoBinto Akturusiano, dr, SpM, dr, SpM

Conjungtival sac :Conjungtival sac :

Bulbar conjungtivaBulbar conjungtiva fornixfornix medial semilunar foldmedial semilunar fold palpebral conjungtiva palpebral conjungtiva

(tarsal conjungtiva)(tarsal conjungtiva)

Histology :Histology :

Conjungtival epithelium :Conjungtival epithelium :– stratified cuboidal (over tarsus)stratified cuboidal (over tarsus)– columnar (over fornix)columnar (over fornix)– squamous (over globe)squamous (over globe)

Substansia propia :Substansia propia :– adenoid layeradenoid layer– fibrous layerfibrous layer

Bacteriology :Bacteriology :

Never free from microorganismNever free from microorganism Bacteria do not propagate Bacteria do not propagate

(proliferate) easily, due to :(proliferate) easily, due to :– relatively low temperature (exposure) relatively low temperature (exposure)

evaporation lacrimal fluidevaporation lacrimal fluid– bacteriostaticbacteriostatic– lysozyme enzymelysozyme enzyme– mechanic (washing)mechanic (washing)

Bacteriology :Bacteriology : Microorganism that could be found in Microorganism that could be found in

normal conjungtival sac :normal conjungtival sac :– Staph. EpidermisStaph. Epidermis– Staph. AreusStaph. Areus– Micrococcus sppMicrococcus spp– Corynebacterium sppCorynebacterium spp– Propionibacterium acnesPropionibacterium acnes– Streptococcus sppStreptococcus spp– Haemophylus influensaHaemophylus influensa In children

– Moraxella sppMoraxella spp– Enteric gram (-) bacilliEnteric gram (-) bacilli– Bacilus sppBacilus spp– Anaerobic bacteriaAnaerobic bacteria– yeastyeast– Filamentous fungiFilamentous fungi– Demodex sppDemodex spp

The establishment and severity of The establishment and severity of infection are influenced by the infection are influenced by the interplay between the following factors :interplay between the following factors :– Virulence of the pathogenVirulence of the pathogen– Size and route of the inoculumSize and route of the inoculum– Presence or absence of risk factors that Presence or absence of risk factors that

compromise host defencecompromise host defence– Nature of the host’s immune and Nature of the host’s immune and

inflammatory responseinflammatory response

Classification of Classification of Conjungtival DisorderConjungtival Disorder

Parson’sParson’s– InflamationInflamation

InfectionInfection AllergyAllergy

– Degenerative changesDegenerative changes– Symptomatic conditionSymptomatic condition– Cyst and TumoursCyst and Tumours

General OphthalmologyGeneral Ophthalmology– ConjungtivitisConjungtivitis

infectioninfection allergyallergy aoutoimmuneaoutoimmune chemical / irritativechemical / irritative unknown causeunknown cause

– Degenerative diseaseDegenerative disease– Miscellaneous disordersMiscellaneous disorders– TumoursTumours

Ophthalmological examination, Ophthalmological examination, usually by inspection :usually by inspection :– magnifying devices (loupe)magnifying devices (loupe)– flashligt / penlight / simlightflashligt / penlight / simlight– do not forget to everse superior eye do not forget to everse superior eye

lidlid

Clinical terms :Clinical terms :– hyperemia (conjungtival injection) = hyperemia (conjungtival injection) =

focal / diffuse dilalation of conjugntival focal / diffuse dilalation of conjugntival blood vesselsblood vessels

– chemosis = conjungtival edemachemosis = conjungtival edema– lacrimation = tearinglacrimation = tearing– secret = exudate on the conjungtival secret = exudate on the conjungtival

surface, serous / catarrh, mucoid, surface, serous / catarrh, mucoid, mucopurulent, murulentmucopurulent, murulent

– Papil = a nodule of blood vessel Papil = a nodule of blood vessel sorounded by edema and inflamatory sorounded by edema and inflamatory cellscells

– Follicle = lymphoid nodule with Follicle = lymphoid nodule with vascularizationvascularization

– Pseudomembrane = inflamatory Pseudomembrane = inflamatory coagulantcoagulant

– Granuloma = nodule consisted of Granuloma = nodule consisted of chronic inflamatory cells with chronic inflamatory cells with fibrovascular proliferationfibrovascular proliferation

– Phlycten = a nodule of chronic Phlycten = a nodule of chronic inflamatory cells near or at the limbusinflamatory cells near or at the limbus

Inflamation of the conjungtiva :Inflamation of the conjungtiva :– origin :origin :

infectioninfection allergyallergy

– hyperemiahyperemia– secretsecret

Secret :Secret :– serous : viralserous : viral– mucous, mucopurulent : bacteriamucous, mucopurulent : bacteria– purulent : beware of gonococcuspurulent : beware of gonococcus

bacterial investigation by grambacterial investigation by gram

histological investigation by giemsahistological investigation by giemsa

Infection of the Infection of the conjungtivaconjungtiva

Acute :Acute :– serousserous– catarrhalcatarrhal– mucopurulentmucopurulent– purulentpurulent– membranousmembranous

chronic :chronic :– simple chronic conjungtivitissimple chronic conjungtivitis– angular conjungtivitisangular conjungtivitis– follicular conjungtivitisfollicular conjungtivitis

Acute Catarrhal or Acute Catarrhal or muco-purulent muco-purulent Conjungtivitis Conjungtivitis

Hyperemia that associated with a mucous discharge Hyperemia that associated with a mucous discharge ---> gums lid together (especially in the morning) ---> gums lid together (especially in the morning)

The whole conjungtiva is a fiery red (‘pink eye’)The whole conjungtiva is a fiery red (‘pink eye’) Reaches its height in 3 - 4 daysReaches its height in 3 - 4 days Rare complication, but cornea abrasion may occurRare complication, but cornea abrasion may occur Etiology :Etiology :

– Staphylococci (most common)Staphylococci (most common)– Haemophilus aegyptiusHaemophilus aegyptius– PneumococcalPneumococcal

Accompanies exanthema such as measles and Accompanies exanthema such as measles and scarlet feverscarlet fever

Treatment :Treatment :– bacteriostatic dropbacteriostatic drop– the eyes should not be bandagedthe eyes should not be bandaged– dark google should be worn if photophobia is dark google should be worn if photophobia is

presentpresent– care must be taken due to contagious disease care must be taken due to contagious disease

Prognosis :Prognosis :– Most of cases are goodMost of cases are good– Neglected cases are treated as chronic Neglected cases are treated as chronic

conjugtivitisconjugtivitis

Purulent conjungtivitisPurulent conjungtivitis Occurs in two forms :Occurs in two forms :

– Babies : ophthalmia neonatorumBabies : ophthalmia neonatorum– Adult : conjungtivitisAdult : conjungtivitis

Main and most dangerous etiology: gonococcus, N. Main and most dangerous etiology: gonococcus, N. gonnorhoegonnorhoe

Direct infection from genitalDirect infection from genital Clinical finding :Clinical finding :

– Swelling of the lids and conjungtivaSwelling of the lids and conjungtiva– Copius purulent dischargeCopius purulent discharge– Constitutional disturbanceConstitutional disturbance

Ulcer may occur at any part of corneaUlcer may occur at any part of cornea

Treatment :Treatment :– apropriate systemic and topical antibiotic apropriate systemic and topical antibiotic – the eyes should be irrigated with warm the eyes should be irrigated with warm

saline and intensive solution of crystaline saline and intensive solution of crystaline benzylpenicilin if any purulent discharge benzylpenicilin if any purulent discharge presentpresent

– sholud be directed first to protection of to sholud be directed first to protection of to other eye other eye

– In Cicendo Eye Hospital :In Cicendo Eye Hospital : cefotaxime I.m.cefotaxime I.m. gentamycine or sulfacetamide eye dropsgentamycine or sulfacetamide eye drops

Ophtalmia NeonatorumOphtalmia Neonatorum

found in newborn children due to found in newborn children due to

maternal infectionmaternal infection

responsible for 50% of blindness in responsible for 50% of blindness in

childrenchildren

E/ : E/ : – Severe : N. gonorrhoeSevere : N. gonorrhoe

– Mild :Chlamydia oculogenitalis, Mild :Chlamydia oculogenitalis,

Streptococcus pneumoniaeStreptococcus pneumoniae

Clinical findings :Clinical findings :– conjunctiva : inflamed, bright red, swollen, yellow conjunctiva : inflamed, bright red, swollen, yellow

puspus– at severe muco-purulent conjunctivitis : infiltration at severe muco-purulent conjunctivitis : infiltration

at bulbar conjunctiva & lids are swollen and tenseat bulbar conjunctiva & lids are swollen and tense– corneal ulceration if untreatedcorneal ulceration if untreated

Prophylaxis:Prophylaxis:– The baby’s lids should be cleansed and driedThe baby’s lids should be cleansed and dried– If infection is suspected use : If infection is suspected use :

Crede’s method : a drop of silver nitrate solution 1% Crede’s method : a drop of silver nitrate solution 1% into each eyeinto each eye

TreatmentTreatment– for ophtalmia neonatorum : penicillin, for ophtalmia neonatorum : penicillin,

tetracycline & eritromicyn by mouthtetracycline & eritromicyn by mouth– for penicillinase-producing for penicillinase-producing N. gonorrhoeae:N. gonorrhoeae:

cephalosporin & gentamicin 0,3% dropcephalosporin & gentamicin 0,3% drop– In Cicendo Eye Hospital :In Cicendo Eye Hospital :

cefotaxime I.m.cefotaxime I.m. gentamycine or sulfacetamide eye dropsgentamycine or sulfacetamide eye drops

Membranous conjunctivitisMembranous conjunctivitis

Known also as diphtheritic Known also as diphtheritic conjunctivitisconjunctivitis

E/ : diphtheria bacillus, E/ : diphtheria bacillus, pneumococcus & streptococcuspneumococcus & streptococcus

occur esp. at children who have occur esp. at children who have not been immunized, after not been immunized, after measles, scarlet fever w/ impetigomeasles, scarlet fever w/ impetigo

Clinical findings :Clinical findings :– mild cases : swelling of the lids, muco-purulent mild cases : swelling of the lids, muco-purulent

or serous dischargeor serous discharge– severe cases : lids are more brawny, conjunctiva severe cases : lids are more brawny, conjunctiva

is permeated w/ semisolid exudates, tend to is permeated w/ semisolid exudates, tend to necrotize conjunctiva and corneanecrotize conjunctiva and cornea

Treatment :Treatment :– treated as diphtherial : penicillin and treated as diphtherial : penicillin and

antidiphtheritic serum (4-6-10.000 units antidiphtheritic serum (4-6-10.000 units repeated in 12 hours)repeated in 12 hours)

Simple chronic Simple chronic conjungtivitisconjungtivitis

Continuation of simple Continuation of simple acute conjungtivitisacute conjungtivitis

Etiologi :Etiologi :– irritation : smoke, dust, irritation : smoke, dust,

alcohol, etcalcohol, etc– hypersensivityhypersensivity

Symptoms :Symptoms :– burning and grittiness burning and grittiness

(especially in the evening)(especially in the evening)– difficult to keep eyes opendifficult to keep eyes open– posterior conjungtival posterior conjungtival

vessels are seen to be vessels are seen to be congestedcongested

Treatment :Treatment :– This consist in eliminating the cause This consist in eliminating the cause

and restoring the conjungtiva to its and restoring the conjungtiva to its normal condition. normal condition.

– Swab should be takenSwab should be taken– short course of suitable antibioticshort course of suitable antibiotic

Follicular ConjungtivitisFollicular Conjungtivitis

Inclusion ConjungtivitisInclusion Conjungtivitis– Relatively acute onsetRelatively acute onset– hypertrophy is always prominent in hypertrophy is always prominent in

the lower lidthe lower lid– E/ : chlamydial infectionE/ : chlamydial infection

– relatively benignrelatively benign– healing spontanously in from 3 to 12 healing spontanously in from 3 to 12

monthsmonths– topical broad spectrum antibioticstopical broad spectrum antibiotics– systemic Antibiotics (tetracycline 250 systemic Antibiotics (tetracycline 250

mg every 6 hours for 14 days)mg every 6 hours for 14 days)

Epidemic kerato-konjungtivitisEpidemic kerato-konjungtivitis– characterized by a rapidly developing folicular characterized by a rapidly developing folicular

conjungtivaconjungtiva– associated with pre-aulicular adenopathyassociated with pre-aulicular adenopathy– may lead to corneal complicationmay lead to corneal complication– associated with adenovirusassociated with adenovirus– Treatment by adenine arabinoside (Ara-A) is promisingTreatment by adenine arabinoside (Ara-A) is promising

Herpes simplex conjungtivitisHerpes simplex conjungtivitis– detected by the flourescent antibody (FA)detected by the flourescent antibody (FA)– usually seen in young childrenusually seen in young children– tiny ulcers on the intermarginal portion of eyelid ----> tiny ulcers on the intermarginal portion of eyelid ---->

with flourescin testwith flourescin test

TrachomaTrachoma EE/ : Chlamydia trachomatis/ : Chlamydia trachomatis Usually starts subacutelyUsually starts subacutely primary infection is epithelial primary infection is epithelial

both conjungtiva and the both conjungtiva and the corneacornea

typical conjungtival sign :typical conjungtival sign :– diffuse inflamation ---> diffuse inflamation --->

congestioncongestion– papillary enlargementpapillary enlargement– development of folliclesdevelopment of follicles

occuring in 4 stageoccuring in 4 stage trachomatous pannus may trachomatous pannus may

develops at a later stagedevelops at a later stage

Treatment :Treatment :– the ideal has not been developedthe ideal has not been developed– tetracycline, erythromycin, rifampicin tetracycline, erythromycin, rifampicin

and sulfonamides are efectiveand sulfonamides are efective– pannus requires no special treatmentpannus requires no special treatment– corneal complication (ulcers) must be corneal complication (ulcers) must be

treated on general principlestreated on general principles

Allergic type of Allergic type of ConjugtivitisConjugtivitis

Acute or subacute allergic catarrhal Acute or subacute allergic catarrhal conjungtivitisconjungtivitis– watery secretion (not purulent)watery secretion (not purulent)– allergen sometimes is a bacterial protein allergen sometimes is a bacterial protein

(staphylococcus is most comon)(staphylococcus is most comon)– treatment :treatment :

allergen removalallergen removal astringen lotionastringen lotion antihistamine drop is more effective antihistamine drop is more effective

Eczematous conjungtivitisEczematous conjungtivitis– characterized by one or more small grey or characterized by one or more small grey or

yellow nodules on the bulbar conjungtivayellow nodules on the bulbar conjungtiva– frequently complicated by muco-purulent frequently complicated by muco-purulent

conjungtivitisconjungtivitis– E/ : endogenous bacterial proteinE/ : endogenous bacterial protein– Symptoms : discomfort and iritation Symptoms : discomfort and iritation

associated with reflex lacrimationassociated with reflex lacrimation– Treatment : Steroid drop or ointmentTreatment : Steroid drop or ointment

Vernal conjungtivitisVernal conjungtivitis– bilateral conjungtivitis ocurr in hot bilateral conjungtivitis ocurr in hot

weatherweather– symptom :symptom :

burning, itching, photophobia and burning, itching, photophobia and lacrimationlacrimation

white & ropy secretionwhite & ropy secretion– two types :two types :

palpebral formpalpebral form bulbar formbulbar form

Treatment :Treatment :– symptomaticsymptomatic– steroid drops or ointmentsteroid drops or ointment– cryotherapy (for nodule)cryotherapy (for nodule)– Disodium cromoglycate 2% Disodium cromoglycate 2%

(adjuvant to topical steroid)(adjuvant to topical steroid)

Degenerative ChangesDegenerative Changes

LithiasisLithiasis– hard yellow spots in the palpebral hard yellow spots in the palpebral

conjungtivaconjungtiva– common in elderly peoplecommon in elderly people– removed with sharp needleremoved with sharp needle

PingueculaPinguecula– triangular patch on conjungtivatriangular patch on conjungtiva– looks like fat (yellow colour)looks like fat (yellow colour)– no treatment requiredno treatment required

PterygiumPterygium– proliferate subconjungtival proliferate subconjungtival

tissue as vascularized tissue as vascularized granulation to invade the granulation to invade the corneacornea

– frequently follow a pingueculafrequently follow a pinguecula

Symtomatic conditionSymtomatic condition Subconjungtival echymosisSubconjungtival echymosis

– due to rupture of small vesselsdue to rupture of small vessels– the blood becomes absorbed without the blood becomes absorbed without

treatment in 1 - 3 weekstreatment in 1 - 3 weeks

ChemosisChemosis– edema of conjungtivaedema of conjungtiva– occur in :occur in :

acute inflamationacute inflamation obstruction to the circulationobstruction to the circulation abnoral blood conditionabnoral blood condition

XerophthalmiaXerophthalmia– dry condition of the conjungtivadry condition of the conjungtiva– due to deficiency of vitamin Adue to deficiency of vitamin A– accompanied by night blindnessaccompanied by night blindness– occurs in two groups :occurs in two groups :

as a sequel of a local ocular affectionas a sequel of a local ocular affection associated with general diseaseassociated with general disease

– Clinical findings :Clinical findings : bitot’s spotsbitot’s spots

Clasification by ocular sign :Clasification by ocular sign :– Night blindness (XN)Night blindness (XN)– Conjungtival xerosis (X1A)Conjungtival xerosis (X1A)– Bitot’s spot (X1B)Bitot’s spot (X1B)– Corneal xerosis (X2)Corneal xerosis (X2)– Corneal ulceration/keratomalacia < 1/3 of corneal Corneal ulceration/keratomalacia < 1/3 of corneal

surface (X3A)surface (X3A)– Corneal ulceration/keratomalacia Corneal ulceration/keratomalacia >> 1/3 of corneal 1/3 of corneal

surface (X3B)surface (X3B)– Corneal Scar (XS)Corneal Scar (XS)– Xerophthalmic fundus (XF)Xerophthalmic fundus (XF)

Cyst and TumourCyst and Tumour

CystCyst– lymphangiectasislymphangiectasis– lymphangiomatalymphangiomata– Subconjungtival cysticercus ---> rareSubconjungtival cysticercus ---> rare– hydatid cysts ---> rarehydatid cysts ---> rare– Epithelial implantation cysts ---> rare, Epithelial implantation cysts ---> rare,

occur after injuries or strabismus occur after injuries or strabismus operationsoperations

TumoursTumours– Congenital tumoursCongenital tumours

DermoidsDermoids

Dermo-lipomataDermo-lipomata

– Large papilaeLarge papilae– papillomatapapillomata– simple granulomatasimple granulomata– eptheliomataeptheliomata– Pigmented tumoursPigmented tumours

NaeviNaevi

Precancerous melanosisPrecancerous melanosis

Malignant melanomaMalignant melanoma Rodent ulcerRodent ulcer

ReferencesReferences

Stephen J.H. Miller, Stephen J.H. Miller, Parson’s Parson’s Disease of The EyeDisease of The Eye

D, Vaughan, D, Vaughan, General General OphthalmologyOphthalmology

American Academy of American Academy of Ophthalmology, Ophthalmology, External Disease External Disease and Corneaand Cornea