Conjunctiva

Dr. Mita Saha

 Anatomy
 Thin mucous membrane covering the surface
of anterior part of eyeball (bulbar) and
eyelids (palpebral)
Palpebral conjunctiva - firmly adherent to lid
Bulbar conjunctiva - loose over the sclera,
except near the limbus (junction of cornea
and conjunctiva)
Parts of conjunctiva
from superficial to
deep:
Epithelium – thicker
near the limbus,
mostly stratified
squamous
Adenoid layer –
loose connective
tissue containing
leucocytes
Fibrous layer
Blood supply : richly supplied by vessels -
A. Anterior conjunctival artery, branch of
anterior ciliary artery
B. Posterior conjunctival artery, branch of
peripheral arcade of lid
Lymphatic drainage:
-- pre-auricular and submandibular nodes
Nerve supply:
Branches from ophthalmic and maxillary
division of
V cranial nerve
Clinical features of conjunctival
disorders
Hyperemia -
 more towards the
palpebral part, fornix and
peripheral part of bulbar
conjunctiva, fades
towards the limbus
In contrast with the true
ciliary congestion
 Acute - by some irritants
like F.B, fume or infection
Chronic – by chronic
infection or irritation,
 Symptoms
Irritation:
Pain is rare, unless the lid is severely
inflamed
More of a F.B sensation or grittiness or
‘tightness’
Discharge:
-Serous or watery: Viral infection, irritant
-Mucoid , sometimes stringy or ropy – allergic
-Mucopurulent or purulent – bacterial
infection
 Signs
Inflammatory
reactions
 Follicles – yellowish white
round elevation, 1-2 mm in
diameter, localized
aggregations of
lymphocytes in sub-
epithelial adenoid layer e.g
in trachoma, viral infection

 Papillae - hyperplasia of
normal vascular system
with glomerulus like
 Sub conjunctival hemorrhage
Rupture of small vessels
Usually benign
Margin clear cut, no symptoms
like irritation, discharge etc
Spontaneous in elderly people,
hypertension
Traumatic- local or base of the
skull #
Strain like chest trauma,
chronic cough
Rarely leukemia or other blood
dyscrasia
 Treatment
Observation and reassurance
Usually takes time to clear, about 2-3 wks
Placebo eyedrops like lubricant or tear
substitute
If recurrent – search and treat cause
 Conjunctival chemosis
Acute inflammation –
gonococcal conjunctivitis,
insect bite, orbital
cellulitis
Obstruction to circulation
– orbital tumour
impending venous or
lymphatic drainage
Systemic conditions like
nephritis, anemia,
urticaria, angioneurotic
edema, lymphoma
 Conjunctivitis
Infection
Allergy
 Infective conjunctivitis
Acute : Resolving in less than 4 weeks
Chronic : More than 4 wks duration

Etiology:
Bacterial
Viral – Adenovirus, herpes virus,
picornavirus etc
Fungal –rarely, aspergillus, candida
 Bacterial conjunctivitis
Acute onset
Redness, irritation,
mucopurulent dischage
Stickiness of eyes,
especially getting up
from sleep
Gram +ve and Gram –
ve,
rare causes like
C. diphtheriae,
gonococcus, hemophilus
 Pneumococcal conjunctivitis:
more chemosis,
small ecchymoses
and a membranous
film over palpebral
conjunctiva
 Pseudomembranous or membranous
conjunctivitis
Pseudomembrane: True membrane:
greyish white Peels off with much
membrane covering difficulty, if at all,
the palpebral leaves a raw area of
conjunctiva bleeding
peels off easily Classically described
without much in diphtheritic
bleeding conjunctivitis but
Classically in actually found in
Pneumo, Strepto, severe cases of any
Staphylo, E coli but infection
actually found in any
 Management of bacterial
conjunctivitis
Usually no microbiological investigation
needed, unless non-responding
Broad spectrum antibiotic drop like a
fluoroquinolone, chloramphenicol or
tobramycin given, frequency depends on
severity, usually 4-8 times a day
A broad spectrum antibiotic ointment at night
to prevent sticking together of the eyelids
 No Steroid in infective conjunctivitis
 Systemic antibiotic usually not needed,
except in some special cases
 Gonococcal conjunctivitis
Rare
S.T.D
Hyperacute
features
Huge chemosis
Frank purulent
discharge
Very early corneal
involvement
Perforation
 Gonococcal conjunctivitis -
Management
Hospitalisation
Systemic therapy : Inj. Ceftriaxone I.M 1 gm
single dose, in corneal involvement I.V
ceftriaxone 1 gm b.i.d for 3 days
Topically fluoroquinolones
Saline irrigation to remove the discharge
 Membranous conjunctivitis
In children who are not immunized, should be
treated as diphtheria
Topical penicillin freshly made from
injectable preparation
Systemic penicillin
Inj of anti diphtheritic serum
Removal of membrane discouraged
 Ophthalmia Neonatorum
Mucoid, mucopurulent or purulent discharge
from one or both eyes within first month of
life
Time of onset etiology Treatment

With in 48 hrs Chemical Wash, erythromycin oint,

usually improves by itself
Gonococcus Ceftriaxone 25-50mg/kg single
I.M, max 125mg
Topical fluoroquinolone
48-72 hrs Other bacteriae Erythromycin eye ointment,
fluoroquinolone drops

5-7 days HSV II Acyclovir 3% ointment

> 1 wk Chlamydia trachomatis Erythromycin ointment,

systemic erythromycin

Prevention: application of povidone iodine 2.5% eyedrops just after birth

 Viral conjunctivitis
Adenovirus
Epidemic keratoconjunctivitis
Pharyngo-conjunctival fever
Herpes virus
Picornavirus
Molluscum contagiosum
 Epidemic keratoconjunctivitis
Epidemic
Rapidly developing
follicular conjunctivitis,
often bilateral
Serous discharge
Lid oedema,
Pre-auricular
lymphadenopathy
Occasionally sub conj hge,
membranous conjunctivitis
Sometimes, usually
after 7-10 days --
corneal involvement-
superficial punctate
keratitis,

subepithelial
infiltrates
 Treatment
Antiviral drugs don’t work
Some broad-spectrum topical antibiotic to
prevent secondary infection
Lubricating drops
Steroid eye drops in severe membranous
conjunctivitis to prevent symblepharon or
sometimes in subepithelial infiltrates
involving the visual axis
 Herpes virus infection
Often the primary
manifestation of herpes
Usually in young children
Vesicles in lid margins
Acute follicular
conjunctivitis
Preauricular
lymphadenopathy
Corneal involevent
sometimes
Reduced corneal sensation
Antibiotic and lubricating
 Angular conjunctivitis
Typically due to Moraxella lacunata, but may
be due to staphylococci
Discomform, mild mucopurulent discharge
Congestion typically at the intermarginal
strip , especially near the inner and outer
canthi
Congestion of adjacent bulbar conjunctiva
Mild excoriation of the skin like scruffiness at
the inner and outer palpebral angles
May be chronic if left untreated
 Treatment
Eyedrops or
ointment containing
zinc, which inhibits
proteolytic ferments
Tetracycline
ointment - 3 times
daily
 Chronic conjunctivitis
Unilateral chronic conjunctivitis
1. Chronic dacryocystitis
2. Concealed foreign body, especially in
upper fornix
3. Malingering
 Chronic conjunctivitis
Trachoma
Granulomatous conjunctivitis
Tuberculosis, leprosy
Cat-scratch disease
Parinaud’s oculoglandular syndrome
Lymphogranuloma venereum
Ophthalmia nodosa – caterpillar hairs
 Trachoma
Once a significant blinding disease in India
Endemic in dry, unhygienic , crowded
surroundings
More often in children
Contagious by flies, fingers, fomites
Both conjunctival and corneal epithelium
involved
Diffuse conjunctivitis
with both papillae
and follicles
Large follicles,
especially >5mm
diam almost
diagnostic
Scarring of the
tarsal plates cause
trichiasis and
entropion
 Corneal involvement
Initially superficial
keratitis, especially
at upper part
Trachomatous
pannus-
vascularization from
the margin with
lymphoid infiltration
--- progressive
--- regressive
 Trachomatous scarring
Trachomatous
Conjunctival scarring
trichiasis
WHO grading of trachoma
Treatment
 Antibiotic therapy
Oral doxycycline 100 mg twice daily for 3-6
wks
Or
Single dose of Azithromycin (1 gm)

Topical therapy - Erythromycin or

tetracycline ointment three times daily for 5
consecutive days in a month for a period of
12 months
 Allergic conjunctivitis
Acue or subacute allergic catarrhal
conjunctivitis
Vernal conjunctivitis
Phlyctenular conjunctivitis
 Acute or subacute catarrhal
allergic conjunctivitis
Hyperemia usually less marked than infective
No mucopurulent secretion
Secretion contains eosinophils
Tendency to recur or chronic
Sometimes allergy to bacterial endotoxin
Contacts with animals, pollens, flowers
Chemicals and cosmetics
Drugs like atropine , brimonidine or
neomycin
 Vernal keratoconjunctivitis
(spring catarrh)
Recurrent bilateral conjunctivitis
Seasonal, usually starts in spring or rather,
summer, subsides in cooler months
Young boys commonly involved
Family history or history of atopy common
Type I hypersensitivity reaction, IgE
mediated, accompanied by eosinophilia
Hypersensitivity to pollens or other
atmospheric allegens
 Symptoms
Severe itching - hallmark
Mucoid or ‘ropy’ discharge
Some photophobia and lacrimation
Usually self-limiting as the child grows, but
sometimes persistent
 signs
Two typical forms:
1. palpebral
2. Bulbar or limbal
may be mixed
 Palpebral type
Everting the upper
eyelid – hypertrophied
papillae, mapped out
like polygonal raised
area, sometimes like
cobblestone,
sometimes with milky
hue
May be in lower
palpebral conjuctiva
even
Eosinophils in
conjunctival secretion
 Bulbar or limbal
Gelatinous or
nodular thickening
of the limbus
White dots
containing
eosinophils and
epithelial debri
called Horner-
Trantus dots at the
limbus
Yellowish or dirty
discolouration of
 Corneal involvement
A fine diffuse
superficial punctate
keratitis
In severe case – a
‘Shield’ ulcer
 Treatment
Symptomatic – cold compress
 antihistamine eye drops like
chlorpheniramine, azelastine in milder forms
Steroid eye drops like prednisolone,
fluorometholone or loteprednol , frequency
acc to severity -4-6 times/day –to be used for
short term only
Mast cell stabiliser for prophylaxis- e.g
cromolyn sodium or olopatadine eye drops
Subtarsal injection of triamcinolone in severe
cases
Tear substitue
Mucolytic like acetyle-cystein
Corneal lesions – steroid eye drops, tear
substitute or amniotic membrane transplant
in severe cases
 Phlyctenular conjunctivitis
Allergy to endogenous toxins – classically of
tubercular bacilli, more commonly to staphylo
,strepto or others
Discomfort, Irritation, redness or discharge
as frequently associated with mucopurulent
conjunctivitis
Small nodule at or
near the limbus,
surrounded by
congestion, may be
multiple
May be necrotic
and ulcerate later on
Adjacent cornea may
be involved with
infiltration and
vascularisation
 Treatment
Local – steroid eye drop- 4-6 timesa day
Antibiotic drops if associated with
mucopurulent conjunctivitis
Systemic examination to exclude TB or other
infections
Corneal involvement- cycloplegics are added
 Conjunctival degenerations
Concretions
Pinguecula
Pterygium
 Concretions
Minute hard yellow
spots in palpebral
conjunctiva
Accumulation of
epithelial cells and
inspissated mucus in
depressions called
‘crypts of Henle’
If projected above the
surface, may cause F.B
sensation
If symptomatic –
removed with a needle
 Pinguecula
Triangular patch on
conjunctiva beside limbus
In people exposed to
sunlight, dust, wind
Hyaline infiltration and
elastotic degeneration of
submucous tissue
No treatment necessary,
unless inflammed – topical
NSAID or weak steroid for
short term
May be a precursor of
 Pterygium
Degenerative condition of subconjunctival
tissue
Proliferates as a triangular vascular band
from the inner or outer or rarely both canthi
into the cornea
Interpalpebral region
Three parts – head, neck and body
Numerous punctate opacities present in front
of the head or apex
Loosely adherent to the underlying sclera for
the whole length
Two stages:
1. Progressive – thick
fleshy mass
2. Stationary or
atrophic – thin, little
vascular, membranous
If not treated,
sometimes moves into
the corneal destroying
the Bowman’s and supf
stroma covering the
pupil
 Symptoms
Cosmetic blemish
Visual disturbance if encroaches the pupil
Astigmatism if the fibrotic band pulls on the
corneal distorting the surface
Diplopia, if the thin fibrotic band restricts eye
movement
 Treatment
Early – Observation
If progresses or about
22 mm corneal
involvement -surgery
Excision of pterygium
with a limbal
conjunctival autograft
– minimal recurrence
Previously excision
with a bare sclera
technique- no longer
recommended for high
recurrence
 Recurrence
 Most common post-op complication
Re-excision with per or post op local
application of mitomycin C or thio-tepa
Beta irradiation
 Conjunctival Cysts
Lymphatic cysts
Implantation cysts
Parasitic cysts
 Conjunctival tumours
Benign – Naevus
Dermoid
Dermolipoma
Papilloma
Pyogenic Granuloma
Malignant-
Squamous cell CA
Malignant melanoma
Lymphoma
Caposi sarcoma
Thank you