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Conjungtival sac :
Bulbar conjungtiva fornix medial semilunar fold palpebral conjungtiva (tarsal conjungtiva)
Histology :
Conjungtival epithelium :
stratified cuboidal (over tarsus) columnar (over fornix) squamous (over globe)
Substansia propia :
adenoid layer fibrous layer
Bacteriology :
Never free from microorganism Bacteria do not propagate (proliferate) easily, due to :
relatively low temperature (exposure) evaporation lacrimal fluid bacteriostatic lysozyme enzyme mechanic (washing)
Bacteriology :
Microorganism that could be found in normal conjungtival sac :
Staph. Epidermis Staph. Areus Micrococcus spp Corynebacterium spp Propionibacterium acnes Streptococcus spp Haemophylus influensa
In children
Moraxella spp Enteric gram (-) bacilli Bacilus spp Anaerobic bacteria yeast Filamentous fungi Demodex spp
The establishment and severity of infection are influenced by the interplay between the following factors :
Virulence of the pathogen Size and route of the inoculum Presence or absence of risk factors that compromise host defence Nature of the hosts immune and inflammatory response
Parsons
Inflamation
Infection Allergy
General Ophthalmology
Conjungtivitis
Clinical terms :
hyperemia (conjungtival injection) = focal / diffuse dilalation of conjugntival blood vessels chemosis = conjungtival edema lacrimation = tearing secret = exudate on the conjungtival surface, serous / catarrh, mucoid, mucopurulent, murulent
Papil = a nodule of blood vessel sorounded by edema and inflamatory cells Follicle = lymphoid nodule with vascularization Pseudomembrane = inflamatory coagulant
Granuloma = nodule consisted of chronic inflamatory cells with fibrovascular proliferation Phlycten = a nodule of chronic inflamatory cells near or at the limbus
infection allergy
hyperemia secret
Secret :
serous : viral mucous, mucopurulent : bacteria purulent : beware of gonococcus
Acute :
serous catarrhal mucopurulent purulent membranous
Hyperemia that associated with a mucous discharge ---> gums lid together (especially in the morning) The whole conjungtiva is a fiery red (pink eye) Reaches its height in 3 - 4 days Rare complication, but cornea abrasion may occur Etiology :
Staphylococci (most common) Haemophilus aegyptius Pneumococcal
Treatment :
bacteriostatic drop the eyes should not be bandaged dark google should be worn if photophobia is present care must be taken due to contagious disease
Prognosis :
Most of cases are good Neglected cases are treated as chronic conjugtivitis
Purulent conjungtivitis
Main and most dangerous etiology: gonococcus, N. gonnorhoe Direct infection from genital Clinical finding :
Swelling of the lids and conjungtiva Copius purulent discharge Constitutional disturbance
Treatment :
apropriate systemic and topical antibiotic the eyes should be irrigated with warm saline and intensive solution of crystaline benzylpenicilin if any purulent discharge present sholud be directed first to protection of to other eye In Cicendo Eye Hospital :
Ophtalmia Neonatorum
found in newborn children due to maternal infection responsible for 50% of blindness in children
E/ :
Severe : N. gonorrhoe Mild :Chlamydia oculogenitalis, Streptococcus pneumoniae
Clinical findings :
conjunctiva : inflamed, bright red, swollen, yellow pus at severe muco-purulent conjunctivitis : infiltration at bulbar conjunctiva & lids are swollen and tense corneal ulceration if untreated
Prophylaxis:
The babys lids should be cleansed and dried If infection is suspected use :
Treatment
for ophtalmia neonatorum : penicillin, tetracycline & eritromicyn by mouth for penicillinase-producing N. gonorrhoeae: cephalosporin & gentamicin 0,3% drop In Cicendo Eye Hospital :
Membranous conjunctivitis
Known also as diphtheritic conjunctivitis E/ : diphtheria bacillus, pneumococcus & streptococcus occur esp. at children who have not been immunized, after measles, scarlet fever w/ impetigo
Clinical findings :
mild cases : swelling of the lids, mucopurulent or serous discharge severe cases : lids are more brawny, conjunctiva is permeated w/ semisolid exudates, tend to necrotize conjunctiva and cornea
Treatment :
treated as diphtherial : penicillin and antidiphtheritic serum (4-6-10.000 units repeated in 12 hours)
Symptoms :
burning and grittiness (especially in the evening) difficult to keep eyes open posterior conjungtival vessels are seen to be congested
Treatment :
This consist in eliminating the cause and restoring the conjungtiva to its normal condition. Swab should be taken short course of suitable antibiotic
Follicular Conjungtivitis
Inclusion Conjungtivitis
Relatively acute onset hypertrophy is always prominent in the lower lid E/ : chlamydial infection
relatively benign healing spontanously in from 3 to 12 months topical broad spectrum antibiotics systemic Antibiotics (tetracycline 250 mg every 6 hours for 14 days)
Epidemic kerato-konjungtivitis
characterized by a rapidly developing folicular conjungtiva associated with pre-aulicular adenopathy may lead to corneal complication associated with adenovirus Treatment by adenine arabinoside (Ara-A) is promising
Trachoma
E/ : Chlamydia trachomatis
Usually starts subacutely primary infection is epithelial both conjungtiva and the cornea typical conjungtival sign :
diffuse inflamation ---> congestion papillary enlargement development of follicles
Treatment :
the ideal has not been developed tetracycline, erythromycin, rifampicin and sulfonamides are efective pannus requires no special treatment corneal complication (ulcers) must be treated on general principles
Eczematous conjungtivitis
characterized by one or more small grey or yellow nodules on the bulbar conjungtiva frequently complicated by muco-purulent conjungtivitis E/ : endogenous bacterial protein Symptoms : discomfort and iritation associated with reflex lacrimation Treatment : Steroid drop or ointment
Vernal conjungtivitis
two types :
burning, itching, photophobia and lacrimation white & ropy secretion palpebral form bulbar form
Treatment
symptomatic steroid drops or ointment cryotherapy (for nodule) Disodium cromoglycate 2% (adjuvant to topical steroid)
Degenerative Changes
Lithiasis
hard yellow spots in the palpebral conjungtiva common in elderly people removed with sharp needle
Pinguecula
triangular patch on conjungtiva looks like fat (yellow colour) no treatment required
Pterygium
proliferate subconjungtival tissue as vascularized granulation to invade the cornea frequently follow a pinguecula
Symtomatic condition
Subconjungtival echymosis
due to rupture of small vessels the blood becomes absorbed without treatment in 1 - 3 weeks
Chemosis
edema of conjungtiva occur in :
Xerophthalmia
dry condition of the conjungtiva due to deficiency of vitamin A accompanied by night blindness occurs in two groups :
as a sequel of a local ocular affection associated with general disease bitots spots
Clinical findings :
Cyst
lymphangiectasis lymphangiomata Subconjungtival cysticercus ---> rare hydatid cysts ---> rare Epithelial implantation cysts ---> rare, occur after injuries or strabismus operations
Tumours
Congenital tumours
Dermoids
Dermo-lipomata
Naevi
Precancerous melanosis
References
The Eye