DISORDERS OF THE CONJUNCTIVA AND CORNEA Dr. VİLDAN ÖZTÜRK

Aims To learn the diagnostic criteria and treatment of conjunctival diseases To learn the diagnostic criteria and treatment of corneal infections, dystrophies and ectatic diseases To learn the steps of biomicroscopic conjunctival and corneal examination and biomicroscopic findings in diseases. To apprehend the importance of superior tarsal conjunctival examination and that patients have pain in case of corneal epithelial loss.  

Objectives To be able to completely list the diagnostic criteria and treatment of conjunctival infections, degenerations and tumors, corneal infections, dystrophies and ectatic diseases. To be able to perform conjunctival and corneal examination at the biomicroscope and identify biomicroscopic findings. To be able to perform superior tarsal conjunctival examination by inverting the upper lid. To be able to perform eye patching to cease pain speed the healing process in case of corneal epithelial loss. To be able to completely and correctly list the indications of corneal surgical techniques according to the pathology. To be able to completely and accurately list the indications of surgical techniques according to corneal pathologies.

ANATOMY

EXAMINATION: Inspection Eye lid eversing Staining Hyperemia, discharge, chemosis, epiphora, follicles, papillae, membranes

DISORDERS OF THE CONJUNCTIVA Conjunctivitis Conjunctival Degenerations Conjunctival Hemorrhage Pigmented Lesions and Tumours

Bacterial Conjunctivitis Viral Conjuntivitis Chlamydial Conjunctivitis Allergic Conjunctivitis Conjunctivitis in Mucocutaneous Diseases

SIMPLE BACTERIAL CONJUNCTIVITIS Signs Subacute onset of mucopurulent discharge Crusted eyelids and conjunctival injection Treatment - broad-spectrum topical antibiotics

SIMPLE BACTERIAL CONJUNCTIVITIS Staph.aureus Staph.epidermidis Gram + cocci (Strep.pneumonia) Gram – cocci (H.influenza, Moraxella lacunata) Treatment: Antibiotic drops: fusidic acid, gentamicin,tobramycin, fluroquinolons Antibiotic ointments: tetracycline, gentamicin, chlroamphenicol,bacitracin

GONOCOCCAL KERATOCONJUNCTIVITIS Signs (N. Gonorrhoeae) Complications Acute, profuse, purulent discharge, hyperaemia and chemosis Corneal ulceration, perforation and endophthalmitis if severe Treatment Topical gentamicin and bacitracin Intravenous cefoxitin or cefotaxime

Adenoviral keratoconjunctivitis Molluscum contagiosum conjunctivitis VIRAL CONJUNCTIVITIS Adenoviral keratoconjunctivitis Molluscum contagiosum conjunctivitis Herpes simplex conjunctivitis

ADENOVIRAL KERATOCONJUNCTIVITIS 1. Pharyngoconjunctival fever Adenovirus types 3 and 7 Typically affects children Upper respiratory tract infection Keratitis in 30% - usually mild 2. Epidemic keratoconjunctivitis Adenovirus types 8 and 19 Very contageous No systemic symptoms Keratitis in 80% of cases - may be severe

SIGNS OF ADENOVIRAL CONJUNCTIVITIS Usually bilateral, acute watery discharge and follicles Subconjunctival haemorrhages and pseudomembranes if severe Treatment - symptomatic

SIGNS OF KERATITIS Transient Treatment Focal, subepithelial keratitis Focal, epithelial keratitis Transient May persist for months Treatment - topical steroids if visual acuity diminished by subepithelial keratitis

MOLLUSCUM CONTAGIOSUM CONJUNCTIVITIS Signs: Waxy, umbilicated eyelid nodule Ipsilateral, chronic, mucoid discharge May be multiple Follicular conjuntivitis Treatment - destruction of eyelid lesion

HERPES SIMPLEX CONJUNCTIVITIS Signs: Unilateral eyelid vesicles Acute follicular conjunctivitis Treatment - topical antivirals to prevent keratitis

CHLAMYDIAL CONJUNCTIVITIS 1. Adult Chlamydial Conjuctivitis C.trachomatis serotypes D to K Mucopurulant discharge Tetracycline oint., systemic tetracycline/erythromycin-6 weeks 2. Neonatal Chlamydial Conjunctivitis 5-19 days after birth Otitis, rhinitis ,pneumonitis. Topical and oral tetracycline and erythromycin (14 days) 3. Trachoma (cont.)

ADULT CHLAMYDIAL KERATOCOJUNCTIVITIS Infection with Chlamydia trachomatis serotypes D to K Concomitant genital infection is common Subacute, mucopurulent follicular conjunctivitis Variable peripheral keratitis Treatment - topical tetracycline and oral tetracycline or erythromycin

NEONATAL CHLAMYDIAL KERATOCOJUNCTIVITIS Presents between 5 and 19 days after birth May be associated with otitis, rhinitis and pneumonitis Mucopurulent papillary conjunctivitis Treatment - topical tetracycline and oral erythromycin

TRACHOMA C. Trachomatis A, B, Ba, C, Leading cause of preventable blindness, Major vector common fly, presentation during childhood, Chr. Konjunctivitis  keratitis pannus  conj. scarring  trichiasis  ulceration opacification  blindness Azithromycin (single dose)

Trachoma Pannus formation Trichiasis Cicatricial entropion Infection with serotypes A, B, Ba and C of Chlamydia trachomatis Fly is major vector in infection-reinfection cycle Progression Acute follicular conjunctivis Conjunctival scarring (Arlt line) Herbert pits Pannus formation Trichiasis Cicatricial entropion Treatment - systemic azithromycin

ALLERGIC CONJUNCTIVITIS 1. Allergic rhinoconjunctivitis 2. Vernal keratoconjunctivitis 3. Atopic keratoconjunctivitis 4. Giant papillary conjunctivitis

ALLERGIC RHINOCONJUNCTIVITIS Hypersensitivity reaction to specific airborn antigens Frequently associated nasal symptoms May be seasonal or perennial Transient eyelid oedema Transient conjunctival oedema

VERNAL KERATOCONJUNCTIVITIS Frequently associated with atopy: asthma, hay fever and dermatitis Recurrent, bilateral Affects children and young adults More common in males and in warm climates Itching, mucoid discharge and lacrimation Types Palpebral Limbal Mixed Treatment Topical mast cell stabilizers Topical steroids

Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus Rupture of septae - giant papillae Formation of cobblestone papillae

Atopic keratoconjunctivitis Atopy affects 5-20% of the general population 20-40% of individuals with atopic dermatitis, 95% prevalence of concomitant eczema 87% prevalence of asthma. more prevalent in men than in women, the peak age of incidence is in persons aged 30-50 years

Giant papillary conjunctivitis Frequently seen in soft contact lens patients patients with exposed suture knots patients with prostheses Patients with asthma, hay fever or animal allergies may be at greater risk. The etiology may be immunological, where contact lens deposits act as allergens.

IMMUNOBULLOUS DISEASES Cicatricial pemphigoid a rare chronic autoimmune subepithelial blistering disease characterized by erosive skin lesions of the mucous membranes and skin that results in scarring of at least some sites of involvement 2. Stevens-Johnson syndrome 3. Toxic epidermal necrolysis (Lyell disease) 4. Epidermolysis bullosa 5. Pemphigus vulgaris 6. Linear IgA bullous dermatosis

Complications of ocular cicatricial pemphigoid Ankyloblepharon Metaplastic lashes Cicatricial entropion Corneal keratinization Total obliteration of fornices Secondary bacterial keratitis

STEVENS-JOHNSON SYNDROME Acute, and self-limiting Hypersensitivity to drugs or infection Typically affects young men Lesions of oral mucosa and lips Maculopapules which may develop into target lesions Vesciculobullous haemorrhagic and necrotic lesions

OCULAR COMPLICATIONS OF STEVENS-JOHNSON SYNDROME Transient conjunctivitis and lid crusting without sequelae Severe membranous or pseudomembranous conjunctivitis Focal fibrotic patches and occasionally symblepharon Metaplastic lashes

Toxic epidermal necrolysis Other immunobullous diseases (1) Toxic epidermal necrolysis (Lyell disease) Epidermolysis bullosa ‘Scalded’ skin lesions Skin bullae and necrosis induced by minor trauma Conjunctivitis - common and similar to Stevens-Johnson syndrome Conjunctivitis - common and may result in scarring

Pingeucula, pterygium

Pingeucula, pterygium Benign, reactive, proliferative lesion of the conjunctiva Yellow-white thickening with increased vascularity Sunlight and other environmental exposure are predisposing elements Pingeucula limited to the area of the conjunctiva and pterygium encroaching on the cornea Histologically, these lesions are characterized by degeneration of collagen in the substantia propria of bulbar conjunctiva (elastoid and basophilic degeneration Epithelium is alternately thinned (atrophy) or thickened (proliferative) and shows no atypia

Conjunctival Tumours / Non-pigmented tumours Conjunctival papilloma 1) Pedunculated papilloma -Human papilloma virus types 6 and 11 -In childhood or early adult life -Signs: may be multiple, ocassionally bilateral, mostly palpebral conj., fornix and caruncle -Treatment: -High rate of spontaneous resolution of small lesions -Large lesions→ cryotherapy, excision

Conjunctival Tumours / Non-pigmented tumours Conjunctival papilloma 2) Sessile papilloma -Nonviral -In midlle age -Signs: single, unilateral, mostly bulbar conj., or juxtalimbal -Treatment: -Complete excision, may need supplementary cryotherapy (malignant potential )

Conjunctival Tumours / Non-pigmented tumours Conjunctival intraepithelial hyperplasia -Treatment: complete exicisional biopsy, cryotherapy or application of mytomycin C -Synonyms: Carcinoma in situ, conjunctival dysplasia, intraepithelial epithelioma -Late adult life, rare, unilateral -Limbus → fornices and cornea -May evolve into invasive squamous cell carsinoma -Signs: slightly elevated, fleshy mass with blood vessels or gelatinous leukoplakic avascular lesion

Late adult life, from pre-existing intraepithelial hyperplasia Conjunctival Tumours / Non-pigmented tumours Conjunctival squamous cell carcinoma Rare, slowly growing, may invade the slera, cornea even penetrate the globe, rarely metastizes Late adult life, from pre-existing intraepithelial hyperplasia Signs: gelatinous mass with feeder vessels, located at the limbus, may involve cornea Treatment: -mytomycin C for early cases -exicion and cryotherapy for large tumors -enucleation for advanced cases

Conjunctival Tumours / Non-pigmented tumours Epibulber choristoma 1) Dermoids: -the most common epider mal tumors of childhood -frequency with Goldenhar syndrome -soft, white, usually located at inferotemporale quadrant of the limbus, mostly unilateral

Conjunctival Tumours / Non-pigmented tumours Epibulber choristoma 2) Lİpodermoids (dermolipomas) -congenital benign tm, bulbar conj., mostly temporal -yellow-white, solid tm, -surgical removal avoided because of frequent extension into the orbit

Vascular, slow growing, low malignancy In patients with AIDS Conjunctival Tumours / Non-pigmented tumours Conjunctival Kaposi Sarcoma Vascular, slow growing, low malignancy In patients with AIDS Bright red mass, mostly inferior fornix Focal radiotherapy is very effective, for small lesions not required

Conjunctival Tumours / Non-pigmented tumours Conjunctival lymphoma Great variety of benign and malignant lymphoid lesions Salmon–coloured, subconjunctival infiltrate Diagnostic histologically Treatment by exicional biopsy, radiotherapy Refer to an internist for systemic evaluation Systemic lymphoma may not develop

Congenital, episcleral, unilateral, blue-gray Conjunctival Tumours / Pigmented tumours Congenital ocular melanocytosis Congenital, episcleral, unilateral, blue-gray Ocular, dermal or oculodermal ( Naevus of Ota, most common) Associated with; ipsilateral iris hyperchromia, melanomas, glaucoma, iris mamillations

PAM without atypia: benign proliferation of melanocytes Conjunctival Tumours / Pigmented tumours Primary acquired melanosis (PAM) Hystologically; PAM without atypia: benign proliferation of melanocytes PAM with atypia: %5 risk of malignancy in 5 years Diagnostic by biopsy Treatment: no treatment for PAM without atypia, excisional biopsy with cryotherapy, radiotherapy or mitomycin C for PAM with atypia

Conjunctival Tumours / Pigmented tumours Conjunctival naevus Benign, unilateral First decades of life Solitary, sharply demarcated, flat or slightly elevated, %30 non-pigmented At puberty, may enlarge Mostly juxtalimbal, plical and at caruncle Treatment by surgical excision, bare sclera technique

Conjunctival Tumours / Pigmented tumours Conjunctival melanoma (1) Usually in 6th decade Usually limbal, solitary, black or gray nodule, may be non-pigmented, fixed to sclera %2 of all eye malignancies % 50-75 arises from PAM with atypia %20 arises from naevus Least common is novo

Conjunctival Tumours / Pigmented tumours Conjunctival melanoma (2) Differential diagnosis: -large naevus at puberty -ciliary body melanoma with extraocular extension -melanocytoma; congenital, black, can not be moved over the globe -pyogenic granuloma

Conjunctival Tumours / Pigmented tumours Conjunctival melanoma (3) Treatment: -Exicional biopsy often with supplemental cryotherapy unless intraocular or orbital involvement is present -Exenteration for extensive and aggressive disease, does not improve the survival

CORNEAL DİSEASES Corneal Infections (KERATITIS) Ectatic Corneal Diseases Dystrophies and Degenerations Corneal Surgery

-Epithelial CORNEAL INFECTIONS 1. Bacterial keratitis 2. Fungal keratitis 3. Acanthamoeba keratitis 4. Infectious crystalline keratitis Herpes simplex keratitis -Epithelial -Disciform 6. Herpes zoster keratitis

BACTERIAL KERATITIS Predisposing factors Contact lens wear Chronic ocular surface disease Corneal hypoaesthesia Expanding oval, yellow-white, dense stromal infiltrate Stromal suppuration and hypopyon Treatment - topical ciprofloxacin 0.3% or ofloxacin 0.3%

FUNGAL KERATITIS Frequently preceded by ocular trauma with organic matter Greyish-white ulcer which may be surrounded by feathery infiltrates Slow progression and occasionally hypopyon Treatment Topical antifungal agents Systemic therapy if severe Penetrating keratoplasty if unresponsive

ACANTHAMOEBA KERATITIS Contact lens wearers at particular risk Symptoms worse than signs Small, patchy anterior stromal infiltrates Perineural infiltrates (radial keratoneuritis) Ulceration, ring abscess & small, satellite lesions Stromal opacification Treatment - chlorhexidine or polyhexamethylenebiguanide

HERPES SIMPLEX EPITHELIAL KERATITIS Dendritic ulcer with terminal bulbs May enlarge to become geographic Stains with fluorescein Treatment Aciclovir 3% ointment x 5 daily Trifluorothymidine 1% drops 2-hourly Debridement if non-compliant

HERPES ZOSTER KERATITIS Acute epithelial keratitis Nummular keratitis Develops in about 50% within 2 days of rash Develops in about 30% within 10 days of rash Small, fine, dendritic or stellate epithelial lesions Multiple, fine, granular deposits just beneath Bowman membrane Tapered ends without bulbs Halo of stromal haze Resolves within a few days May become chronic Treatment - topical steroids, if appropriate

CORNEAL ECTASIAS 1. Keratoconus 2. Keratoglobus 3. Pellucid marginal degeneration

Morphological classification of keratoconus Nipple cone Oval cone Globus cone Small and steep curvature Larger and ellipsoidal Largest

Signs of keratoconus Bilateral in 85% but asymmetrical Oil droplet reflex Vogt striae Prominent corneal nerves Bulging of lower lids on downgaze Fleischer ring & scarring Munson sign Acute hydrops

CORNEAL DYSTROPHIES 1. Anterior 2. Stromal 3. Posterior Cogan microcystic Reis-Bucklers .. Meesmann Schnyder 2. Stromal Lattice I, II, III Granular I, II, III (Avellino) Macular 3. Posterior Fuchs endothelial Posterior polymorphous

Cogan microcystic dystrophy Most common of all dystrophies Neither familial nor progressive Recurrent corneal erosions in about 10% of cases Dots Cysts Fingerprints Maps

Lattice dystrophy Progression Fine, spidery, branching lines within stroma Later general haze may submerge lesions Treatment - penetrating keratoplasty if severe

Granular dystrophy Onset - first decade with recurrent corneal erosions Progression Initial superficial and central crumb-like opacities Later deeper and peripheral spread but limbus spared Eventual confluence Treatment - penetrating keratoplasty if severe

Macular dystrophy Onset - second decade with painless visual loss Progression Initial dense, poorly delineated opacities Later generalized opacification Thinning Treatment - penetrating keratoplasty

Fuchs endothelial dystrophy Inheritance - occasionally autosomal dominant Onset - old age Progression Gradual increase in cornea guttata with peripheral spread Later central stromal oedema Eventually bullous keratopathy Treatment - penetrating keratoplasty if advanced

CORNEAL DEGENERATIONS&DEPOSITS Age-related Arcus senilis 2. Lipid keratopathy Band keratopathy Spheroidal degeneration Salzmann nodular degeneration Cornea verticillata Kayser-Fleischer Ring

Arcus senilis Innocuous and extremely common in elderly Occasionally associated with hyperlipoproteinaemia Bilateral, circumferential bands of lipid deposits Peripheral border separated from limbus by clear zone Diffuse central and sharp peripheral border Clear zone may be thinned ( senile furrow)

Lipid keratopathy Primary Secondary Common, secondary to previous result of cholesterol or fatty acid extravasation Common, secondary to previous disciform keratitis Rare, occurs spontaneously in avascular cornea Usually unilateral stromal deposits without vascularization Unilateral stromal deposits with vascularization Treatment - coagulation of feeder vessels and/or keratoplasty Treatment: keratoplasty, if severe

Band keratopathy Central spread of calcification Common, unilateral or bilateral depending on cause Subepithelial calcification Ttrauma, surgery, some eye drops especially Pilocarpine, hipercalsemia with renal failure, sarcoidosis and certain malignancies Interpalpebral limbal opacification Central spread of calcification Separated by clear zone Small holes within calcified area

Cornea verticillata Fabry's disease -alpha-galactosidase A deficiency Variety of drugs amiodarone, chloroquine, meperidine, indomethacin, chlorpromazine tamoxifen

Kayser-Fleischer Ring -Copper at descemet Wilson disease: abnormalities basal ganglia of the brain, liver cirrhosis, splenomegaly, involuntary movements, muscle rigidity, psychiatric disturbances, dystonia and dysphagia

CORNEAL SURGERY 1. Keratoplasty (Penetrating , lamellar) 2. Keratoprosthesis 3. Refractive surgery Radial keratotomy (RK) Photorefractive keratectomy (PRK) Laser assisted subepithelial keratectomy(LASEK) Epithelial Laser in-situ keratomileusis (EpiLASIK) Laser in-situ keratomileusis (LASIK) Conductive keratoplasty (light-touch) (CK) Intracorneal ring segments (ICR)

Penetrating Keratoplasty 1. Indications Optical (e.g. bullous keratopathy, dystrophies) Tectonic (e.g. severe stromal thinning, descemetocele) Therapeutic (e.g. severe keratitis) Cosmetic 2. Adverse prognostic factors Severe stromal vascularization Absence of corneal sensation Progressive conjunctival inflammation (e.g. pemphigoid) Tear film dysfunction Glaucoma

Technique of penetrating keratoplasty a, b - Excision of host tissue Excision of donor tissue c - Fixation of donor tissue

Keratoprosthesis Indications Technique Main complications Bilateral blindness from ocular pemphigoid, chemical burns or repeated graft failure Insertion of artificial lenticule into corneal stroma Main complications Retrolenticular membrane formation Glaucoma

Radial keratotomy Decreases myopia by flattening cornea Deep incisions from edge of optical zone to limbus Main indications Main complications Stable myopia of up to 8D Accidental perforation Otherwise normal cornea Intrastromal epithelial cysts

Photorefractive keratectomy ( PRK ) Indications Stable myopia up to 6D with astigmatism no more than 3D Hypermetropia up to 2.5D Technique Main complication Subepithelial haze which usually resolves after 1-6 months Reshaping of cornea by excimer laser ablation of Bowman layer and anterior stroma

Laser in-situ keratomileusis (LASIK) Indications - similar to PRK but corrects higher degrees of myopia Technique Complications Wrinkles in flap Thin flap of cornea fashioned Cellular interface proliferation Bed treated with excimer laser Flap repositioned

Non-contact laser thermal keratoplasty Indications Patients over 40 years with hypermetropia up to 2D Following overcorrection of myopia Corneal curvature is steepened by application of laser heat to stroma Holmium laser spots applied to mid-cornea