1. Diseases of the conjunctiva Ayesha s Abdullah 21.09.2013

2. LEARNING OUTCOMES
By the end of this lecture the students would be able to;
Classify diseases of the conjunctiva
Identify the common symptoms and signs of conjunctival diseases
Enlist the causes & risk factors of conjunctivitis.
Differentiate between bacterial, viral, chlamydial and allergic conjunctivitis on the basis of clinical presentation.
Describe the associated complications, treatment and prevention strategies for each type of conjunctivitis.
Identify Pterygium on photographs, describe its pathogenesis, complications and treatment.

3. Classification of conjunctival diseases
Inflammatory
infective & non-infective conditions like conjunctivitis
Degenerative disorders
Pinguecula, Pterygium, concretions and cysts
Neoplastic
Saquamous cell carcinoma, melanoma, lymphoma etc
Miscellaneous disorders
Dry eyes

4. Symptomatology Red eye Watering (lacrimation)
Irritation, stinging, burning and foreign body sensation
Itching
Blurring vision/ decreased vision, Photophobia and pain (danger alarm)
Growth or mass in the eye

5. SIGNS Redness ; conjunctival redness Discharge Keratinization
Follicle & papillae
Phylectenule
Conjunctival oedema
Presence of membrane/ pseudomembrane
Subconjunctival haemorrhage
Lymphadenopathy
Keratinization
Scarring
Pigmentation
Mass

6. REDNESS; CONJUNCTIVAL REDNESS
Superficial
Maximum at the fornices and fades towards the limbus
Mild to severe

8. Conjunctival congestion
Ciliary congestion

9. DISCHARGE What is discharge?
Reflex tearing and exudative response of the inflamed conjunctiva mixed with mucus
Serous; watery exudate in acute viral and acute allergic conjunctivitis.
Mucoid; mucus discharge in Vernal Kerato Conjunctivitis (VKC) and dry eyes.
Purulent; puss in severe acute bacterial conjunctivitis.
Mucopurulent; puss plus mucus in mild bacterial conjunctivitis and Chlamydial conjunctivitis.

11. Ophthalmia neonatorum
Bacterial conjunctivitis

13. Follicular reaction
Sub epithelial foci of hyperplastic lymphoid tissue
More prominent in fornices.
Multiple, discrete, slightly elevated,
Size from 0.5 to 5 mm.
Commonly seen in Viral conjunctivitis, Chlamydial conjunctivitis & in cases of hypersensitivity to topical medications.

15. Papillary reaction What are papillae?
Hyperplastic conjunctival epithelium with central core vessel surrounded by infiltrate separated from each other by fibrous septa- seen in allergic & bacterial conjucntvitis

16. Papillary reaction
Can develop in palpebral conjunctiva and limbus- why?
Giant papilla (confluence)
make the conjunctiva look rough and velvety
Difficult to see the underlying conjunctival vessels
Seen in Allergic conjunctivitis, Bacterial conjunctivitis, Chronic blepharitis, Contact lens wearers

17. Cobblestone papillae

18. Phylectenule

19. Conjunctival oedema- chemosis
it can happen in acute inflammation of the conjunctiva as in acute infective/allergic conjunctivits, orbital disorders (obstructing the outflow of lymph and venous drainage) and certain systemic conditions (acute nephritis, lymphoma)

20. Conjunctival oedema- chemosis

21. Membranes & Pseudomembrane
Coagulated exudate adherent to the inflamed epithelium.
Can be easily pealed off.
Causes; Severe adenoviral infection, Ligneous conjunctivitis, Gonococcal conjunctivitis, Stevens- Johnson syndrome
True conjunctival membrane infiltrates the superficial layers of conjunctival epithelium.
Conjunctiva bleeds if attempted to be removed.
Causes; infection with Diphtheria & Beta-hemolytic Streptococci and Neisseria Gonorrhoeae.

23. Subconjunctival Haemorrhage
Can happen in severe cases of viral or bacterial conjunctivitis
Trauma
Haemotological disorders (bleeding disorders, leukaemias)
Fracture base of the skull

24. Traumatic subconjunctival haemorrhage
Adenoviral conjunctivitis subconjunctival haemorrhage

26. Lymphadenopathy Pre auricular and sub mandibular.
In ; Viral infection, Chlamydial infection, Severe bacterial infections, Parinaud oculoglandular syndrome.

27. Systemic symptoms in conjunctivitis
Severe conjunctivitis with
Gonococcus,
Meningococcus,
Chlamydia
H.Influenzae

28. Treatment of conjunctivitis
Bacterial conjunctivitis
Topical : Aminoglycosides, quinolones, polymxin B, Fusidic Acid, chloroamphenicol, Bacitracin
Systemic in some cases?
Lid hygiene
Contact lens wear to be discontinued till the antibiotic therapy is completed
Hand washing and avoid sharing towels

29. Treatment of conjunctivitis
Ophthalmia neonatorum
Conjunctitivitis of the new born
Onset
Chemical…. First few days
Gonococcal…1st Week
Staphlococcal and other bactersia….End of 1st week
Herpes Simplex…..1-2 weeks
Chlamydia…..1-3 weeks

30. Mild –moderate cases topical antibiotic eye drops and ointment
Treatment
Mild –moderate cases topical antibiotic eye drops and ointment
Systemic antibiotics and anitviral therapy ?
Gonococcal, Chlamydial and Herpes Simplex

31. Viral conjunctivitis Commonest – adenoviral conjunctivitis
Spontaneous resolution in 2-3 weeks
Topical antibiotic eye drops to prevent secondary infection
Antiviral ointment – Herpetic infection with corneal involvement

32. Allergic conjunctivitis
Acute allergic conjunctivitis
Seasonal conjunctivitis
Vernal Keratoconjunctivitis
Atopic Keratoconjunctivitis
Giant Papillary conjunctivitis

33. VKC recurrent Bilateral IgE & cell-mediated reaction Common in males
Age-5 to late teens
Remission in late teens
Associated with other allergic disorders like?

34. Signs

35. Signs

36. Complications Keratopathy
Side effects of steriods. Cataract & Glaucoma
Associations
Keratoconus
Herpes simplex keratitis

37. Corneal complications
Corneal complications; macroerosions & shield ulcer, plaque, pseudogerontoxon

38. Treatment Allergen avoidance Drugs Mast cell stabilizers
Antihistamines
NSAIDs
Steroids
Decongestants
Lubricants

39. Other signs Keratinization Scarring Vitamin A deficiency
Systemic Immune disorders
Ocular pemphigoid
Stevens-Johnson Syndrome
KCS
Scarring
Chemical burns or mechanical trauma
Immune disorders
Chronic conjunctivitis (Trachoma)

40. Keratinization

41. Scarring

42. Conjucntival Growth /mass
Benign ; cysts, pterygium, lipodermoid
Malignant ; melanoma, squamous cell carcinoma and others

48. Benign Growths

49. ? Pterygium A degenerative condition
Triangular, fibrovascular connective tissue overgrowth of bulbar conjunctiva onto the cornea usually on the nasal side
Can reduce vision through producing Astigmatism and corneal opacity
Many treatment modalities have been tried but so far the best option with least recurrence rate is ?
pterygium (from the Greek, pterygos, “little wing”) is a wing-shaped, vascular, fleshy growth that originates on the conjunctiva and that can spread to the corneal limbus and beyond

50. Laboratory Investigations
Indications
Severe purulent conjunctivitis
Follicular conjunctivitis: viral vs chlamydial
Conjunctival inflammation
Neonatal conjunctivitis

51. Laboratory Investigations
Cytological investigations
Cultures
Detection of viral and chlamydial antigens.
Impression cytology
Polymerase chain reaction for adenovirus, herpes simplex, chlamydia trachomatis.
Biopsy for tumours
Cytological investigations. Gram staining,Geimsa staining and special stains
Cultures
Detection of viral and chlamydial antigens.
Impression cytology for ocular surface neoplasia, dry eyes, ocular cicatricial pemphigoid, limbal stem cells failure, infection.
Polymerase chain reaction: small quantity of DNA for adenovirus, herpes simplex, chlamydia trachomatis.
Biopsy for tumours

52. Homework What is WHO classification for Trachoma What is SAFE strategy
Why is Ophthalmia neonatorum an emergency
What are the causative agents of ophthalmia neonatorum
List the risk factors for corneal disease
Most appropriate treatment for pterygium

53. Homework-Ans
What is WHO classification for Trachoma
1. Trachomatous Follicles (TF): Presence of five or more follicles in the upper tarsal conjunctiva.
2. Trachomatous Inflammation (TI): Inflammatory thickening of the tarsal conjunctiva that obscures more than half of the normal deep tarsal vessels.
3. Trachomatous conjunctival Scarring (TS).
4. Trachomatous Trichiasis (TT): At least one eyelash touching the cornea.
5. Corneal opacity (CO).

54. What is SAFE strategy Surgery: Antibiotics:
To prevent blindness & limits progression of corneal scarring.
Can improve vision.
Antibiotics:
Azithromycin—1 G single dose (adults).
Children: 20mg/kg single dose
Erythromycin 250 mg QID for 4 weeks. (children 125mg/kg).
Tetracycline 250 mg QID for 4 weeks.
Topical tetracycline 1% 0.5 inch ribbon BD for 6 weeks.
Facial cleanliness:
Reduces risk & severity of trachoma.
Environmental change:
Improved water supply & household sanitation.
Personal & community hygiene.
Adequate housing & water & sewage system

55. Why is Ophthalmia neonatorum an emergency
It is considered as an ophthalmic emergency because with the immature immune system and ocular surface of the newborn the infection can result in corneal ulceration, perforation and systemic consequences. The complications that the baby can develop are;
Corneal ulceration & scarringBlindness
infections like
Otitis
Rhinitis
Pneumonitis
Death
If untreated, corneal ulceration may occur in N gonorrhoeae infection and rapidly progress to corneal perforation.
When not immediately treated, Pseudomonas infection may lead to endophthalmitis and subsequent death.
Pneumonia, rhinitis and otitis has been reported with chlamydial conjunctivitis.
HSV keratoconjunctivitis can cause corneal scarring and ulceration. Additionally, disseminated HSV infection often includes central nervous system involvement

56. What are the causative agents of ophthalmia neonatorum
Staphylococcus Pneumoniae
S. Aureus
Chlamydia Trachomatis
Neisseiria Gonorrhoea
H.influenzae
Enterobacteriaceae
Herpes Simplex
Chemical like silver nitrate/disinfectants used at birth

57. List the risk factors for corneal disease
Ocular surface diseases like lid problems (trichiasis, entropion , ectropion), lacrimal diseases ( CDC, dry eyes)
Systemic problems like Immunocompromised states & malnutrition (VAD)
Most appropriate Treatment for pterygium
Excision with conjunctival autograft