Conjunctiva

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Conjunctival degeneration
Pterygium
Definition is a triangular fibrovascular subepithelial ingrowth of degenerative bulbar
conjunctival tissue over the limbus onto the cornea.

usually on the Nasal side , Bilateral and in Elderly

Etiology Unknown
Risk factor:- old age, Exposure to sun (UV), drying, wind and dust

Pathology Head =Overlying Cornea

Neck =Overlying Limbus
Body =Overlying Sclera

pterygium is elastotic degeneration, which invades corneal epithelium,

Bowman's layer and superficial stroma.
Types 1- Progressive: Vascular, thick & fleshy.
2- Stationary: less vascular, thin & membranous.

Symptoms 1-Decrease vision due to

A-Head of pterygium cover center of the cornea lead to diminution of vision.
B-Astigmatism

2- may infected
3- Dry eye
4- very rare may lead to binocular diplopia

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Treatment 1-No TTT :- if small & stationary
2- Surgical excision :- if
1- Reach pupillary area
2- Progressive type
3- Cosmetically

Disadvantage of Surgical excision is high rate of recurrent.(around 80%) that

may be more aggressive than the initial lesion.

To prevent recurrence the following is done

1-Cover the bare area either Conjunctival autograft or amniotic membrane
2- Expose the bare area to Beta-irradiation or mitomycin C

Pingueculum
Definition Triangular grayish yellow thickening of bulbar conjunctiva.
usually on the Nasal side, usually Bilateral and in Elderly
More common than Pterygium((elastotic’ degeneration))

Etiology Unknown
Risk factor:- old age, Exposure to sun (UV), drying,wind and dust

Symptoms Asymptomatic
Treatment No treatment is necessary

Pseudopterygium
Is fold of conjunctiva attached to base of healed peripheral corneal ulcer
True Pterygium Pseudo Pterygium
Hook((IMP)) Cannot pass under the neck Can pass

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 Conjunctivitis

1- Bacterial conjunctivitis

Trachoma

Chronic infective bacterial conjunctivitis, usually bilateral

Caused by Chlamydia trachomatis serotype (A, B, Ba, C)

It is spread by direct contact, usually from other family members

Insect vectors especially flies play a role in transmission.

Trachoma is the leading cause of preventable blindness in the world.

Symptoms Foreign body sensation, pain.

Signs Conjunctival hyperemia

Conjunctival follicles & Papillary hypertrophy
Pannus (fibrovascular membrane arising from the limbus)
Tender preauricular node.

**Herbert's pits (Pathognomonic) small white depressions in at the limbo

corneal junction.

Linear or stellate conjunctival scars in mild cases or broad scars Arlt’s lines in
severe disease
**All of the signs of trachoma are more severe in the upper than in the
lower conjunctiva and cornea.

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 Classification TF: Five or more follicles on the upper palpepral conjunctiva.

WHO TI: Diffuse infiltration & papillary hypertrophy of upper palpepral Conj.
TS: Trachomatous conjunctival scarring.
TT: Trichiasis or entropion.
CO: Corneal opacity.

TF and TI indicate active infectious trachoma and a need for treatment.

TS is evidence of damage from the disease.
TT is potentially blinding and is an indication for corrective lid surgery.
CO is the final blinding lesion of trachoma.

Complications A- EYE LID

1- Trichiasis (Pure) 2- Cicatricial entropion
3- Ptosis 4- Inflammation: - Blepharitis, Meibomianitis

B- Conjunctiva
1- Dry eye 2- Symblepharon

C- Cornea
1- Corneal ulceration 2- Corneal opacity 3- corneal vascularization

D- Lacrimal system
1- Punctum obstruction 2- Canaliculitis 3- NLD obstruction
4- Dacryocystitis 5- Dacryoadenitis

Treatment 1- Topical ointments or drops, including tetracycline, erythromycin

2- Systemic tetracycline or erythromycin.

The most preventive measure is strict personal hygiene.

Systemic tetracycline should not be given to a child under 7 years or to pregnant woman,
since lead to congenital discoloration of the permanent teeth and skeletal abnormalities.

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 2- Viral conjunctivitis

A- Adenoviral keratoconjunctivitis

Characterized by 2 syndromes: (1) pharyngo-conjunctival fever (PCF) and

(2) Epidemic kerato-conjunctivitis (EKC) both epidemics & highly contagious.

PCF is caused by adenovirus types 3, 4 and 7. It typically causes an upper

respiratory tract infection. Keratitis develops in 30% of cases.

EKC is caused by adenovirus types 8, 19 and 37, and is not usually associated
with systemic symptoms. Keratitis occurs in about 80% of cases.

CLINICAL FEATURES

 Conjunctivitis

1-Presentationwatering, redness, and photophobia.

2-Signs
Lid edema, preauricular adenopathy, Subconjunctival hemorrhages

Treatment spontaneous resolution within 2 weeks. topical steroid may help

 Keratitis

Keratitis is rare in PCF, but it may be severe in patients with EKC.

Examination shows the following three stages:

Stage 1 characterized by a diffuse punctate epithelial keratitis
Stage 2 is characterized by focal white subepithelial opacities
Stage 3 is characterized by anterior stromal infiltrates.

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 B- Acute Hemorrhagic Conjunctivitis

Hemorrhagic conjunctivitisEpidemics
It is caused by enterovirustype70 and coxsackievirus A24.
It typically affects individuals of low socioeconomic status
The disease is highly contagious but self-limiting
it is characterized by subconjunctival hemorrhages.
Most patients have preauricular lymphadenopathy
There is no effective treatment. (SELF-LIMITING)

3- Allergy conjunctivitis

1-Vernal Keratoconjunctivitis (VKC)

This disease, also known as "spring catarrh"

bilateralallergic disease

usually beginsgenerally from about the age of 5 years.

It occurs much more often in boys than in girl.

The disease is less common in temperate than in warm climates

VKC is IgE-mediated mechanism.

About three-quarters of patients have associated atopy and two-thirds have a

close familyhistoryofatopy.

Patients with VKC have an increased incidence of keratoconus.

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Symptoms Itching with lacrimation, photophobia, foreignbodysensation, discharge

papillary hypertrophyin upper palpebral conjunctiva. The papillae then

&
become larger and have a flat-topped polygonal appearancecobble-stone.

Signs Trantas' dots are whitish dots seen at the limbus. Composed of eosinophils

Micropannus, Superficial Punctate Keratitis

Recurrences are the rule; butleaving no scars.

Treatment 1- Newer mast cell stabilizer (Sodium cromoglycate) -antihistamine

Self-limited combinations are useful prophylactic and therapeutic agents

disease
2- Topical steroids are usually effective (not used for long time)(sever cases)

3- Cold compresses. (Relief symptoms)

2- Giant papillary conjunctivitis

GPC is a foreign body-associated conjunctivitis associated with the following:

(1) contact lenses, (2) artificial eyes and (3) protruding sutures

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 Ophthalmia neonatorum
(Neonatal conjunctivitis)

It's Conjunctival inflammation that occurs during the first month of life.
It is the most common infection of any kind in neonates
The three main causes are (1) Chlamydial (2) Gonococcal (3) Miscellaneous.

 Chlamydial conjunctivitis
Chlamydial infection is the most common cause of neonatal conjunctivitis.
Presentation7& 14 days after birth with mucopurulent conjunctivitis
Systemic complications such as otitis, rhinitis and pneumonia may develop.
Treatment is with topical tetracycline and oral erythromycin for 14 days.

 Gonococcal conjunctivitis
Presentation is between 7days after birth, purulent conjunctivitis.
Treatment with topical and systemic penicillin.
1% silver nitrate prophylaxis for the prevention of gonorrheal Ophthalmia.

 Miscellaneous conjunctivitis
1- Chemical conjunctivitis may be caused by silver nitrate
2- Bacterial conjunctivitis caused by staphylococcus aureus, Streptococci, H.
influenzae
3- Herpes simplex caused by herpes simplex type 2

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 Clinical features of conjunctival inflammation

 Red eye (Conjunctival injection)

 SUBCONJUNCTIVAL HEMORRHAGE
Causes
(1) Idiopathic (2) Trauma (3) Surgery
(4) Hypertension (5) Blood disease(Leukemia)
(6) Conjunctivitis (special viral conjunctivitis) (7) Severe coughing or sneezing

Sign: - ((bright-redhomogenous appearance))

The hemorrhage usually absorbs in 2–3 weeks, NO treatment.

 Chemosis
Edema of conjunctiva
Causes :- conjunctivitis(mainly allergic & viral), trauma, endophthalmitis, Carotid - Cavernous
fistula

 CONJUNCTIVAL DISCHARGE
Watery discharg is typical of viral inflammations.
Mucoid discharge is typical of vernal conjunctivitis
Prulent discharge occurs in severe acute bacterial infections.
Mucoprulent discharge occurs in mild bacterial as well as chlamydial infections.

 FOLLICULAR CONJUNCTIVAL REACTION

Follicles consist of hyperplasia of lymphoid tissue within the stroma.
Causes (1) viral infections, (2) chlamydial infections (3) topical medication.

 PAPILLARY CONJUNCTIVAL REACTION

Papillae are composed of hyperplastic conjunctival epithelium
Causes
(1) blepharitis, (2) Allergy (3) bacterial infection (4) superior limbic keratoconjunctivitis.

 PRE-AURICULAR LYMPHADENOPATHY
1) viral infections(MCC) (2) chlamydial infections (3) severe gonococcal infections.

 PSEUDOMEMBRANES AND MEMBRANES

Pseudomembranes
consist of coagulated exudate adherent to the inflamed conjunctival epithelium.
Characteristically, they can be easily peeled off leaving the epithelium intact.
Causes (1) adenoviral infection, (2) Bacterial conjunctivitis

True membranes
consist of coagulated exudate invades conjunctival epithelium. Characteristically, peeled off
membrane may be accompanied by tearing of the epithelium and bleeding.
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Causes ß-haemolytic streptococci and diphtheria.
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