1. conjunctiva
Dr. saif alshamarti

2. Conjunctiva

3. Anatomy
Microscopic: 1.Epiyhelium (non keratinized,includes goblet cell). 2.Epithelial basment membrane. 3.Stroma : a.Superfascial (adenoid layer).contain lymphoid tissue. b.Deep (fibrous layer). Macroscopic : 1.Palpepral 2.Forniceal 3.Bulbar

4. Lymphatics drain in sub mandibular and preauricular lymph node.
Conjunctiva has comparatively few pain fiber
From the trigeminal nerve (ophthalmic division)
So pain is poorly localized….

5. Conjunctival signs and symptoms
Key symptoms include:
1.Redness
2.Surface irritation.
3.Itching .
4.Discharge .
5.Watering .
6.Conjunctival swelling.

6. Examination Hyperaemia .(localized or diffuse).
Chemosis: edematous conjunctiva.
Sub conjunctival haemorrhage .
Discharge …..if mucoserous or watery (viral or toxic)
…..if mucopurulent (bacterial ).
…….watery (allergic).
Follicle :focal lymphoid aggregates in substantia p.
Papillae: vascular response(central tuft of vessels)…
Either small or giant papillae.

7. Conjunctivitis

8. Definition
Conjunctivitis: inflammation of mucous membrane that lines the inner surface of the lids and the globe up to the limbus (junction of the sclera and the cornea)

9. Diagnosis Can usually be diagnosed by history and physical exam
Cultures are usually unnecessary
Exception: hyperacute cases, in which gram stain/Giemsa stain for N. gonorrhoeae would be useful
-adenoviral test could be useful to r/o bacterial infection and thereby decrease antibiotic use etc

10. “Red Eye” Inflammation of conjunctiva leads to pink or red appearance,
Other etiologies of red eye:
Acute angle closure glaucoma
Hyphema
Iritis
keratitis
Stye
Blepharitis
Corneal abrasion
Dry Eye syndrome
Episcleritis& scleritis
-need to r/o other causes by looking for focal pathology in the lids like a stye, mound, ulceration, or blepharitis (in these cases, conjunctival hyperemia is reactive and not primary)
-conjunctival redness should be diffuse (if localized, consider pterygium or episcleritis)
-should include the tarsal conjunctiva (conditions like keratitis, iritis and glaucoma will often only involve the bulbar conjunctiva, with ciliary flush, but spare tarsal area)
-infectious keratitis: MUST be ruled out, can be severe. Note that it would cause foreign body sensation, and patient is usually unable to open the eye/keep it open, often there is a corneal opacity visible with a penlight
-Other serious signs/symptoms: reduction of visual acuity, photophobea, fixed pupil, severe headache with nausea

11. Etiology Infectious Noninfectious Bacterial Viral Allergic
Non-Allergic

12. Bacterial Conjunctivitis
Symptoms: redness and mucopurulent discharge in the eye, affected eye often is “stuck shut”
Common organisms: S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis
Hyperacute bacterial conjunctivitis: N. gonorrhoeae (seen with concurrent urethritis)
There is often profuse purulent discharge, chemosis, lid swelling, tender preauricular adenopathy
Treatment: antibiotics can shorten duration of disease if given before day 6
Erythromycin ointment or polymyxin/trimethoprin drops are most often used
-Antibiotics are given 4x daily for 5-7 days
-Ointment is peferred over drops for children, those with poor compliance, or those who have difficulty putting drops in the eyes
-Can also use bacitracin, sulfacetamide, polymixin-bacitracin, FQ drops or azithro. DO NOT USE Aminoglycosides beause they are toxic to corneal epithelium and can cause reactive keratoconjunctivitis
-For corneal ulcers, use FQs (active against pseudomonas) and can also use this for conjunctivitis in contact lens wearers after keratitis hasb een ruled out

13. Bacterial Conjunctivitis

14. Viral

15. Viral Conjunctivitis
Symptoms: injection, watery/mucoserous discharge, “burning”/sandy/gritty feeling in on eye, scant mucus, often bilateral
Common organisms: adenovirus
On Exam: profuse tearing/mucoid discharge, enlarged/tender preauricular node.
Can lead to keratitis (inflammation of the cornea), with symptoms of a foreign body sensation and multiple corneal infiltrates
Treatment: symptomatic relief with topical antihistamine/decongestants, warm/cool compresses
-Remember that both bacterial and viral conjunctivitis is highly contagious and often, 24 hours of treatment is required by schools before returning, although if there is still discharge or spreading of germs by contact, patient is still highly contagious

16. Adult Inclusion Conjunctivitis
Chronic form of conjunctivitis caused by certain serotypes of Chlamydia trachomitis
Often presents with concurrent asymptomatic urogenital infection
Symptoms: unilateral follicular conjunctivitis that does not respond to topical antibiotic therapy
Diagnosis: Giemsa staining of conjunctival smears or by culture/PCR of swabbed organisms
Treatment: systemic therapy with doxycycline, tetracycline, erythromycin or azithromycin
Note that Chlamydial infections can also cause trachoma, a roughening of the inner eyelid surface leading to discharge, turning in of eyelids and scarring of eyeball, often leading to corneal ulcer
-Often seen in underdeveoped countries, not as common in the USA

17. Chlamydial Conjunctivitis

18. Allergic Conjunctivitis
Symptoms: bilateral redness, watery discharge, itching, marked chemosis (may be bullous)
Patients often have a hx of atopy, seasonal allergy or specific allergy

19. Allergic Conjuctivitis

20. Noninfectious, Nonallergic Conjunctivitis
Often due to mechanical or chemical insult, transient, resolves in 24 hours without treatment
Symptoms: mucoid discharge
Treatment: topical lubricants
Note that Glucocorticoids have NO role in tx of conjunctivitis, and can cause corneal scarring, meling and perforation

21. Resolution of Symptoms
Bacterial conjunctivitis should improve within 1-2 days
All other forms should improve within 1-2 weeks

22. Neonatal Conjunctivitis

23. Neo natal conjunctivitis
Neonatal conjunctivitis includes bacterial, viral, and chemical causes
Time of disease onset is a clue to etiology
Gram stain and culture of discharge
Treatment based on etiology
Early treatment is necessary to prevent further permanent eye damage

24. Chemical Conjunctivitis
Silver nitrate solution used as prophylaxis for bacterial conjunctivitis
Occurs within the first 5 days of life
Spontaneous resolution
Decreasing incidence due to use of erythromycin.

25. Bacterial Conjunctivitis
Neisseria gonorrhoeae
Chlamydia trachomatis
Gram positive cocci (30-50% cases)
Some gram negatives
Prophylaxis includes topical erythromycin and silver nitrate at birth

26. Gonococcal Conjunctivitis
Occurs 2-7 days after birth
More severe than other forms
Bilateral purulent discharge
May progress to corneal involvement with perforation or endophthalmitis
Possible systemic manifestations
Treatment includes topical erythromycin, IV or IM 3rd generation cephalosporin, and Penicillin G (for penicillin susceptible organisms)

27. Chlamydial Conjunctivitis
Occurs 5-14 days after birth
Watery discharge, involvement of eyelids, pannus, possible corneal scarring with eyelashes
Treatment involves oral erythromycin for 2 weeks
Colonization of the nasopharynx causes atypical pneumonia

28. Chlamydia

29. Viral Conjunctivitis HSV keratoconjunctivitis
Occurs within the first 2 weeks of life
Corneal epithelium involvement, skin lesions around eyes, risk of encephalitis
C-section if mother has active lesions
Treated with IV acyclovir for 2-3 weeks

30. Pinguecula &ptrygium. Pinguecula
Triangular fibrovascular band .
Uv light ,dry climate.
Usually arises Nasal limbus .
Grows slowly across cornea and destruction of bowman layer.
Same histology .
Surgary if encroach visual axis,astigmatism,F.Bsensation
Cosmetic .
Extremly common ,yellow-whit patch of interpalpebral bulbar conjunctiva nasal or temporal to limbus.
Elastotic degeneration of collagen.
Re assurance +lubrication

31. Discussion
What are some questions you should ask the patient who presents with red eye?
What are specific things you can do to advise the patient in preventing future cases of conjunctivitis?

32. Thank you