1. DISORDERS OF THE CONJUNCTIVA AND CORNEA
Dr. VİLDAN ÖZTÜRK

2. 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.

3. 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.

4. ANATOMY

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

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

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

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

9. 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

10. 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

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

12. 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

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

14. 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

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

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

17. 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.)

18. 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

19. 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

20. 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)

21. 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

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

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

24. 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

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

26. 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 years

27. 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.

28. 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

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

30. 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

31. 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

32. 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

34. Pingeucula, pterygium

35. 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

36. 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

37. 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 )

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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
% arises from PAM with atypia
%20 arises from naevus
Least common is novo

48. 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

49. 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

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

51. -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

52. 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%

53. 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

54. 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

55. 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

56. 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

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

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

59. 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

60. 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

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

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

63. 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

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

65. 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

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

67. 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)

68. 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

69. 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

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

71. 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

72. 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)

73. 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

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

75. 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

76. 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

77. 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

78. 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

79. 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