1. The Disease of Conjunctiva (結膜) /Sclera (鞏膜)
眼科 黃奕勛 醫師

2. Palpebral, bulbar conjunctiva, fornix

3. Slit Lamp (裂隙燈、細隙燈)

4. Pinguecula (結膜黃斑) & Pterygium (眼翳)
Pinguecula: elevated yellow nodule near limbus in palpebral fissure
Pterygium: triangular fold of bulbar conjunctiva loosely attached to cornea except at the apex
elastoid degeneration
Sun (uv light), wind,---
usually nasal side, surgery excision for corneal astigmatism, visual axis involvement and cosmetic

5. Miscellaneous conjunctival disorders
Conjunctival concretions (眼結石) :
epithelial inclusion cysts filled with epithelial and keratin debris, elderly or chronic conjunctivitis, remove when irritation
Subconjunctival hemorrhage (結膜下出血 )
spontaneous, trauma, acute viral or bacterial conjunctivitis, Valsalva maneuver --
single eye, no treatment, 1-2 wks subside
recurrent and both eyes: suspect blood dyscrasis

6. Symptoms of conjunctivitis
Non-specific symptoms: lacrimation, irritation, stinging, burning, photophobia, ---
If pain or FB sensation --> associated corneal involvement
Itching, hallmark of allergic conjunctivitis

7. Discharge Watery - acute viral and allergic inflammations
Mucoid - VKC, dry eye
Purulent - acute bacteria infection
Mucopurulent – mild bacterial and chlamydia infection

8. Etiologic classification of conjunctivitis
Bacterial
Chlamydial
Viral
Allergic
Chemical/toxic or irritative
Associated with systemic disease, etiology unknown
Rickettsial, fungal, parasitic

9. Bacterial conjunctivitis
Common, usually self-limited, mostly children
Direct contact or from nasal and sinus mucosa
Conjunctival inflammation and purulent discharge
Organisms: Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae, --
Hyperacute (onset<24hrs): Neisseria gonorrhoeae, N. meningitidis

10. Gonococal conjunctivitis
G (-) diplococcus Neisseria gonorrhoeae
Adult: self contamination, acute onset with marked purulence, may progression to severe keratitis
Ophthalmia neonatorum: 3-5 days after parturition, profuse purulent discharge with swollen lids
Treatment: topical gentamicin
Parenteral penicillin, 3rd cephalosporin, ---

11. Chlamydial conjunctivitis—Trachoma (砂眼)
Chalmydia trachoma serotype A-C
Chronic follicular conjunctivitis, pannus formation, limbal follicles and Herberts pits, later scaring of conjunctiva (Arlt’s line), upper tarsal>lower
Late complication: tear deficiency, dacryostenosis, entropion, trichiasis, corneal scarring, salzman’s nodules
Giemsa stain: basophilic intracytoplsmic epithelial inclusions
Immunofluorescent testing, EIA(Enzyme immunoassay), PCR, McCoy cell culture, ---
Treat with topical and oral tetracycline or erythromycin
Leading cause of preventable blindness in the world

12. Trachoma – Early (tarsal follicles and Herbert’s pits)

13. Trachoma - Late

14. Viral conjunctivitis Via respiratory or ocular secretions
Epidemic keratoconjunctivitis (EKC)
Adenovirus 8, 11, 19, 37
Epidemic hemorrhage keratoconjunctivitis (EHKC)
Picornavirus (Enterovirus 70), coxaschievirus A24
subconjunctival hemmorrhage
Pharyngoconjunctival fever (PCF)
Adenovirus 3, 4, 7
fever, URI, conjunctivitis, transmitted by droplets , children

15. Adenoviral keratoconjunctivitis—Epidemic keratoconjunctivitis (EKC)
Incubation:4-10 days
Duration:14 days
Acute onset red eye, watery discharge, photophobia, foreign body sensation, preauricular lymph node, second eye mild involvement
Both eyes affected 60% cases

16. Treatment for EKC nature course is self limited; supportive treatment
topical steroid when membrane formation, the eye is uncomfortable due to very severe inflammation or visual acuity diminished by keratitis
Steroids do not shorten natural course of the disease but merely suppress the inflammation

17. Allergic rhinoconjunctivitis
Itching, foreign body sensation, tearing, lid swelling, red conjunctiva, ---
Tx: self limited, remove allergen, cool compress, Mast cell stabilizers, antihistamin, topical steroid, NSAID

18. 隱形眼鏡配戴不適症候群
視力模糊、視力不穩、頭痛、眼睛轉動不舒服、彩色光圈、畏光、癢、流淚、異物感、燒灼感、疼痛 ---

19. 原因 體質：乾眼症、過敏 環境：空調不佳、過度除濕 長時間配戴 驗配之問題：弧度太鬆或太緊 清潔不當 角膜炎：感染性或非感染性
結膜炎：化學毒性或過敏性

20. CL related allergy and toxicity
CL intrinsically inert
Solution chemicals and lens deposits
Allergy termed a hypersensitivity reaction
Toxicity direct effect of chemicals
Increased risk of extended wear SCL

21. Giant papillary conjunctivitis (GPC, 巨大乳頭狀結膜炎 )
Soft CL>Hard CL; exposure sutures; ocular prosthesis
Redness, itching, mucoid discharge, CL intolerance, lens decentration
Abnormal large papillae (>0.3 mm) on super tarsal conjunctiva
Mechanical trauma, hypersensitivity to CL or adherent material

22. Treatment of GPC Discontinue CL wear Improving lens hygiene
Discarding or refitting, daily wear, disposable CL or RGP
Topical steroid, mast-cell stabilizer

23. Episcleritis and Scleritis

24. Sclera posterior 5/6 of the globe
dense connective tissue composed of collagen bundles of varying diameters (primary type1)
opaque appearance: less uniform orientation of collagen fibers

25. Normal, episcleritis, scleritis

26. Episcleritis
simple %
nodular %

27. Disease Entities - Inflammation
A: Episcleritis
inflammation of episcleral tissue between recti m. insertion & limbus, episcleral edema without scleral edema
sudden onset with localized injection and swelling in interpalpebral region
unilateral in 2/3 cases
cause unknown, maybe hypersensitivity reaction
20-50 y/o
transient attack, <10 days,
60 % recurrent in either eye, minor associated disease

28. Episcleritis
course and management: transient, self-limit, ocular redness with mild irritation, blanch with topical phenylephrine
topical vasoconstrictors, NSAIDs, corticosteroid
oral NSAIDs

29. Scleritis
intense dull radiating pain of insidious onset, bilateral, recurrent
other ocular findings:
keratitis: 50% with scleritis
iridocyclitis: 50% with scleritis
vitritis, secondary glaucoma, cataract, macular edema, choroidal detachment, --
Mechanism: immune-mediated (typically immune-complex) vasculitis lead to destruction of sclera
one third (diffuse or nodular scleritis) to two thirds (necrotizing scleritis) pts associated with systemic diseases, the most common rheumatoid arthritis
women are more commonly affected

31. Treatment Medical underlying disease
almost never responds to topical tx alone
systemic corticosteroid, NSAID, immunosuppressive agents

33. 重點複習

34. Adenoviral keratoconjunctivitis—Epidemic keratoconjunctivitis (EKC)
Incubation:4-10 days
Duration:14 days
Acute onset red eye, watery discharge, photophobia, foreign body sensation, preauricular lymph node, second eye mild involvement
Both eyes affected 60% cases

35. Giant papillary conjunctivitis (GPC, 巨大乳頭狀結膜炎 )
Soft CL>Hard CL; exposure sutures; ocular prosthesis
Redness, itching, mucoid discharge, CL intolerance, lens decentration
Abnormal large papillae (>0.3 mm) on super tarsal conjunctiva
Mechanical trauma, hypersensitivity to CL or adherent material