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Conjungtiva

Binto Akturusiano, dr, SpM

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

Classification of Conjungtival Disorder

Parsons
Inflamation

Infection Allergy

Degenerative changes Symptomatic condition Cyst and Tumours

General Ophthalmology
Conjungtivitis

infection allergy aoutoimmune chemical / irritative unknown cause

Degenerative disease Miscellaneous disorders Tumours

Ophthalmological examination, usually by inspection :


magnifying devices (loupe) flashligt / penlight / simlight do not forget to everse superior eye lid

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

Inflamation of the conjungtiva :


origin :

infection allergy

hyperemia secret

Secret :
serous : viral mucous, mucopurulent : bacteria purulent : beware of gonococcus

bacterial investigation by gram histological investigation by giemsa

Infection of the conjungtiva

Acute :
serous catarrhal mucopurulent purulent membranous

chronic : simple chronic conjungtivitis angular conjungtivitis follicular conjungtivitis

Acute Catarrhal or muco-purulent Conjungtivitis

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

Accompanies exanthema such as measles and scarlet fever

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

Occurs in two forms :


Babies : ophthalmia neonatorum Adult : 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

Ulcer may occur at any part of cornea

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 :

cefotaxime I.m. gentamycine or sulfacetamide eye drops

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

Credes method : a drop of silver nitrate solution 1% into each eye

for ophtalmia neonatorum : penicillin, tetracycline & eritromicyn by mouth for penicillinase-producing N. gonorrhoeae: cephalosporin & gentamicin 0,3% drop In Cicendo Eye Hospital :

cefotaxime I.m. gentamycine or sulfacetamide eye drops

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)

Simple chronic conjungtivitis


Continuation of simple acute conjungtivitis Etiologi :


irritation : smoke, dust, alcohol, etc hypersensivity

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

Herpes simplex conjungtivitis


detected by the flourescent antibody (FA) usually seen in young children tiny ulcers on the intermarginal portion of eyelid ----> with flourescin test

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

occuring in 4 stage trachomatous pannus may develops at a later stage

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

Allergic type of Conjugtivitis

Acute or subacute allergic catarrhal conjungtivitis


watery secretion (not purulent) allergen sometimes is a bacterial protein (staphylococcus is most comon) treatment :

allergen removal astringen lotion antihistamine drop is more effective

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

bilateral conjungtivitis ocurr in hot weather symptom :

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 :

acute inflamation obstruction to the circulation abnoral blood condition

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 :

Clasification by ocular sign :


Night blindness (XN) Conjungtival xerosis (X1A) Bitots spot (X1B) Corneal xerosis (X2) Corneal ulceration/keratomalacia < 1/3 of corneal surface (X3A) Corneal ulceration/keratomalacia > 1/3 of corneal surface (X3B) Corneal Scar (XS) Xerophthalmic fundus (XF)

Cyst and Tumour

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

Large papilae papillomata simple granulomata eptheliomata Pigmented tumours

Naevi

Precancerous melanosis

Malignant melanoma Rodent ulcer

References

Stephen J.H. Miller, Parsons Disease of

The Eye

D, Vaughan, General Ophthalmology American Academy of Ophthalmology,

External Disease and Cornea

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