The Conjunctiva

The
Conjunctiva
lecture one
dr.ali.a.taqi.
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Applied anatomy
the conjunctiva is divided into the following
three parts.
Palpebral which starts at the mucocutaneous junction at the eyelid margin and
is firmly adherent to the tarsal plates.
Forniceal which is loose and redundant so
that it swells easily and is thrown into folds.
Bulbar which lines the anterior sclera.
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Microscopic anatomy.
The conjunctival epithelium is between
two and five cell layers thick. With chronic
exposure and drying, the epithelium may
become keratinized.
The stroma (substantia propria) consists
of richly vascularized connective tissue
which is separated from the epithelium by
a basement membrane. The accessory
lacrimal glands are located within the
stroma. The mucin secretors are of the
following three types
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The goblet cells which are located within the

epithelium and are most dense inferonasally.
The crypts of Henle which are located along the
upper third of the superior tarsal conjunctiva.
The glands of Manz which encircle the limbus.
Clinical features of conjunctival
diseases.
which should be considered in the
differential diagnosis of conjunctival
inflammation are: (1) type of discharge,
(2) type of conjunctival reaction, (3)
presence of pseudomembranes or
true membranes and (4) presence or
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DISCHARGE types.
The following are the main types of
discharge:
1-Watery discharge composed of a serous
exudate and a variable amount of refluxly
secreted tears. It is typical of viral and toxic
inflammations.
2-Mucoid discharge is typical of vernal
conjunctivitis and keratoconjunctivitis
sicca.
3-Prulent discharge occurs in severe
acute bacterial infections.
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FOLLICULAR CONJUNCTIVAL
REACTION
Clinically, they appear as multiple, discrete,
slightly elevated lesions reminiscent of
small grains of rice. The THREE main
causes of follicles are

(1) viral infections,

(2) Chlamydia infections,
(3) hypersensitivity to topical
medication.
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PAPILLARY CONJUNCTIVAL REACTION

Papillae can develop only in the palpebral
conjunctiva and the bulbar conjunctiva at
the limbus. Papillae are most frequently
seen in the upper palpebral conjunctiva. A
papillary reaction is more non-specific and
of less diagnostic value than a follicular
response. The 4 main causes of papillae
are (1) chronic blepharitis, (2) vernal
disease, (3) bacterial infection, (4)
contact lens related problems .
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PSEUDOMEMBRANES AND
MEMBRANES.
Pseudomembranes Characteristically,
they can be easily peeled off leaving
the epithelium intact). The four main
causes are (1) severe adenoviral
infection, (2) ligneous conjunctivitis,
(3) gonococcal conjunctivitis and (4)
autoimmune conjunctivitis.
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True membranes
Attempts to remove the membrane may be
accompanied by tearing of the epithelium and
bleeding. The main causes are infections
resulting from -haemolytic streptococci and
diphtheria.

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LYMPHADENOPATHY
Lymphatic drainage of the conjunctiva is to the
preauricular and submandibular nodes.
Lymphadenopathy is a feature of

(1) viral infections,

(2) chlamydial infections and
(3) severe gonococcal
conjunctivitis.
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Disorders of the Conjunctiva

Bacterial conjunctivitis .
Simple bacterial conjunctivitis.
a very common and usually self-limiting
condition.
The most common causative organisms
are Staphylococcus epidermidis and
Staphylococcus aureus but
other Gram-positive cocci, including
Streptococcus pneumoniae, are also
frequent pathogens as are the Gramnegative Haemophilus influenzae and

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CLINICAL FEATURES.
Presentation.
with an acute onset of redness, grittiness, burning and
discharge. Photophobia may be present if there is
associated severe punctate epitheliopathy or peripheral
corneal infiltrates. On waking, the eyelids are frequently
stuck together and difficult to open as a result of the
accumulation of exudate during the night. Both eyes are
usually involved, although one may become affected
before the other by a day or so.

Examination.
shows conjunctival hyperaemia which is maximal in the
fornices a mild papillary reaction, a mucopurulent
discharge and lid crusting.
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TREATMENT.
*Even without treatment, simple
conjunctivitis usually resolves within
10-14 days and laboratory tests are
not routinely performed.
*Before initiating treatment, it is
important to bathe all discharge away.
*Initial treatment is broad-spectrum
antibiotic drops during the day and
ointment at night until the discharge
has ceased.
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Viral conjunctivitis
Adenoviral keratoconjunctivitis.
The spectrum of disease varies from mild and almost
inapparent, to full-blown cases characterized by two
syndromes :

(1)pharyngoconjunctival fever (PCF)

(2) epidemic keratoconjunctivitis (EKC)
both of which occur in epidemics and are highly
contagious for up to 2 weeks. Because the viruses
can be spread by finger-to-eye contact, it is important
for ophthalmologists to wash their hands after being
in contact with an acute red eye.
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CLINICAL FEATURES.
A-Conjunctivitis
Presentation.
with acute onset of watering, redness, discomfort and photophobia. Both eyes
are affected in about 60% of cases.

Examination .
shows lid oedema, a follicular response which is frequently associated with a
preauricular adenopathy. In severe cases, subconjunctival haemorrhages,
chemosis and pseudomembranes may develop.

Treatment .
unsatisfactory but spontaneous resolution within 2 weeks is the rule. Topical
steroids should be avoided unless the inflammation is very severe and the
possibility of herpes simplex infection has been excluded.

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B-Keratitis.
rarely a problem in PCF, but it may be severe in
patients with EKC.

Treatment .
with topical steroids is indicated only
1- if the eye is uncomfortable or
2-visual acuity diminished.
Steroids do not shorten the natural course of the
disease but merely suppress the corneal
inflammation so that the lesions tend to recur if
treatment is discontinued prematurely.

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Red eye differential diagnosis

Quiz 1

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Quiz 2

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Quiz 3

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Today wise word.

When you immersed in somethingyou can not
feel it.

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THE CONJUNCTIVA
Lecture two
Dr.Ali.A.Taqi.

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Chlamydia conjunctivitis.
Adult inclusion conjunctivitis(TRIC)
1.(TRIC) typically affects young adults
during sexually active years.
2.The infection is almost invariably venereal
in nature
3.The eye lesions present about 1 week
following sexual exposure and
4.may be associated with a non-specific
urethritis or cervicitis.
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CLINICAL FEATURES of TRIC.

Presentation
is with a usually unilateral chronic muco-purulent discharge. If untreated, the
disease has a prolonged remittent course.
Examination
shows large opalescent follicles in the fornices upper tarsal involvement
predominates. As the disease progresses. Preauricular adenopathy is common.
Epithelial keratitis of the upper half of the cornea is the most frequent corneal
finding.
TREATMENT
A/Topical treatment is with tetracycline ointment four times a day for 6 weeks.
B/Systemic treatment can be with one of the following oral antibiotics:
1.Doxycycline. (Contraindicated in childhood )
2.Tetracycline 250mg four times daily for 6 weeks(Contraindicated in
childhood).
3.Erythromycin 250 mg four time daily for 6 weeks(to children and adults)

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.Trachoma
1-caused by Chlamydia trachomatis serotypes A,B,Ba
and C serotypes.
2-It is a disease of underprivileged populations with poor
conditions of hygiene.
3-the leading cause of preventable blindness in the
developing world.
Presentation .
1-during childhood with the formation of bulbar and palpebral
Conjunctival follicles and
2-diffuse infiltration with papillae.
3-This is followed by chronic inflammation which eventually
4-causes Conjunctival scarring; this, in turn, may lead to
5-trichiasis and corneal complications in older children and adults.
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: World Health Organization grading

TF = trachomatous follicular inflammation of more than five
follicles larger than 0.5 mm on the upper tarsus .
TI = trachomatous intense inflammation with thickening obscuring
over 50% of large, deep, tarsal vessels.
TS = trachomatous (conjunctival) cicatrization with white lines,
bands or sheets of fibrosis in the tarsal conjunctiva.
TT = trachomatous trichiasis of at least one inturning eyelash or
evidence of recent removal .
CO = corneal opacity obscuring at least part of the pupil margin
and causing a visual acuity of less than 6/18.
Treatment .
a/of active disease is similar to adult inclusion conjunctivitis. The
most important preventive measure is strict personal hygiene
within the family, especially washing the faces of young children.
b/of chronic disease, treatment of complications
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Allergic conjunctivitis
Seasonal allergic conjunctivitis (hay fever) .
1- a very common allergic reaction
2-triggered by airborne antigens such as mould spores,
pollen, grass, hair, wool and feathers.
Presentation is with acute, transient attacks of
a/itching.
b/lacrimation.
c/redness.
Examination The conjunctiva shows
1-mild chemosis and
2-a diffuse papillary reaction. In severe cases,
3-the eyelids may be slightly oedematous but the cornea
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Treatment of acute attack. Stage one.

Although topical steroids are also efficacious, their use must be
with great caution with appropriate antibiotic cover as short
courses with close follow up because of their potential for
unwanted side.
Although systemic antihistamines are effective in suppressing
other symptoms of hay fever, they are of limited benefit in the eye.
As example chloropheneramine eye drops or more recently
selective antihistamine as levocabastin eye drops.
Prevention of acute attack. Stage two.
1-Modify environment.
2-avoid allergen if known and possible
3- a topical mast cell stabilizer instilled four to six times a day in
the form of 2% sodium cromoglycate drops
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Acute allergic conjunctivitis

1- an urticarial reaction.
2- caused by a large amount of
allergen reaching the conjunctival sac.
Clinically.
the condition is characterized by a
a/sudden onset of severe chemosis
and swelling of the eyelids .
b/Most cases resolve spontaneously
within a few hours and, apart from
reassurance, require no specific
treatment.
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Vernal keratoconjunctivitis (VKC) (spring

.catarrh)
is an uncommon recurrent, bilateral, external, ocular
inflammation affecting children and young adults.
CLINICAL FEATURES.
The main symptoms are
1-intense ocular itching which may be associated with
2-lacrimation, photophobia, foreign body sensation and
burning.
3-Thick mucus discharge from the eyes and ptosis also
occurs.
4-The symptoms may occur throughout the year, but are
characteristically worse during the spring and summer.
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Vernal keratoconjunctivitis (VKC) (spring catarrh) .

The three main clinical types are

(1) Palpebral. affect mainly palpebral
conjunctiva.
(2) Bulbar. affect mainly bulbar conjunctiva
and usually more severe.
(3) Mixed. affect both and usually the most
severe.
Patients with VKC have an increased incidence
of keratoconus.
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TREATMENT
Acute attack
Topical steroids are usually effective but may not
achieve complete control of the disease in all cases. As
prolonged treatment is usually required, steroid- induced
complications are high and they must be used with great
caution.
Prevention.
Avoid allergenmodify environment
Sodium cromoglycate 2% drops four times daily is
very useful in enabling patients to reduce or even
discontinue steroid medication. it is not, however, as
effective as steroids in controlling acute exacerbations
and only 20% of patients respond to cromoglycate
alone.
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Chemical conjunctivitis .
A chemical burn is the only type of ocular injury that
requires immediate treatment without first taking a
history and performing a careful examination. It is top
ocular emergency

Acid burns.
1-are usually less serious than those caused by alkalis
because acids tend to precipitate tissue proteins which
coagulate and form a barrier preventing deep
penetration.
2-The main damage is therefore restricted to the lids,
conjunctiva and cornea.
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Alkaline burns .
1-are more serious because alkalis saponify lipids in the
corneal epithelium, and bind to the mucoproteins and
collagen in the corneal stroma.
2-They therefore disrupt the normal barriers of the
cornea and penetrate deep with rapidly increase the pH
of the anterior chamber, with resultant damage to the
lens and anterior uvea.
3-The late complications of alkali burns not only involve
the external ocular structures but can also give rise to
cataract, uveitis and secondary glaucoma.
4- In severe cases phthisis bulbi(blind degenerative eye)
is the tragic end result.
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IMMEDIATE emergency/first aid!!!

1.Copious irrigation with bland sterile fluid and
even with tap water???
2.removal of all particulate matter.
As alkalis bind to the corneal stroma, they may
continue to injure ocular structures after initial
irrigation has removed all free alkali. For this
reason, prolonged irrigation is necessary in eyes
with alkali burns.
No rule in adding acids to equalize alkali as the
resultant heat from this reaction can create more
damage!!!
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SUBSEQUENT TREATMENT.
Subsequent treatment of alkali burns is aimed at preventing the
complications that occur 2-3 weeks after the initial insult (failure of
corneal re-epithelialization, melting and descemetocele
formation):
1.Topical steroids can be used safely during the first week to
combat uveitis without increasing the risk of corneal melting.
2.Vitamin C and citrate are beneficial in eyes with significant
burns but their exact mode of action is not fully understood:
3.Tear substitutes and, if necessary, punctal occlusion should be
used to prevent the effects of tear deficiency.
4.Contact lenses have a therapeutic role during recovery from a
chemical burn but will not prevent symblepharon formation.
5.Surgery for late complications of severe burns includes the
following:
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Conjunctival degenerations
1-Pinguecula.

a-an extremely common lesion which

b-consists of a yellow-white deposit on the
bulbar conjunctiva adjacent to the nasal or
temporal aspect of the limbus.
c-Some pingueculae may enlarge very
slowly but surgical excision is seldom
required.

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2-Pterygium.
Definition.
a triangular sheet of fibro-vascular tissue which invades
the corneal epithelium.
pterygia typically develop in patients who have been
living in hot climates and may represent a response to
chronic dryness and exposure to the sun.

Treatment .by surgical excision is indicated either for

cosmetic reasons or in cases of progression towards the visual
axis. The most favoured method is excision of the conjunctival
component followed by grafting of free conjunctiva, usually from
the bulbar surface of the same eye

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3-Concretions
Conjunctival concretions are small yellow
white deposits commonly present in the
palpebral conjunctiva of the elderly.
They may also occur in patients with
chronic Conjunctival inflammatory
conditions.
Concretions are usually discrete but
confluent concretions are not uncommon .
They can be easily removed with a needle.
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Pinguiculum and
ptyregium

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Today wise word

not everything shinningis gold or diamond it can be almost
nothinglike iceor much morelike nice glisining eyes!!!

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References
1-Parsons diseases of the
eye 2003
2-Clinical ophthalmology
Kanski J 2007
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