conjuctival inflammation and degenration

conjuctivitis and infection affecting conjuctiva

1. Conjunctiva

2. The conjunctiva is a thin transparent mucous membrane lining the inner surface of the eyelid and covering the anterior sclera.

3. MINUTE ANATOMY The conjunctiva is formed of two layers: an anterior stratified columnar epithelium and the substantia propria : 1. The epithelium: It is 2 to 7 layers thick and contains numerous unicellular mucous glands (goblet cells) that secrete the inner mucoid layer of the tear film. 2. The substantia propria : It is formed of a superficial adenoid and a deep fibrous layer: a. The adenoid layer is formed of fine connective tissue rich in lymphocytes . The fibrous layer is a thick meshwork of connective tissue housing the nerves and vessels of the conjunctiva.

4. BLOOD SUPPLY AND LYMPH DRAINAGE: 1. The conjunctiva receives its arterial supply from: . Posterior conjunctival arteries, which arise from the palpebral arteries to supply most of the conjunctiva except near the limbus . Anterior conjunctival arteries, which arise from the anterior ciliary arteries and supply the conjunctiva around the limbus . 2. Venous drainage: to the palpebral and ophthalmic veins. 3. Lymphatic drainage: parallels that of the lid, the lateral 2/3 drains into the pre-auricular lymph nodes. The medial 1/3, the caruncle and plica semilunaris drain into the submandibular lymph nodes NERVE SUPPLY: The conjunctiva is supplied by branches of the trigeminal nerve.

5. INFLAMMATIONS OF THE CONJUNCTIVA CONJUNCTIVITIS Classification: 1. Infective Conjunctivitis: A- Acute - Bacterial 1- mucopurulent 2- purulent 3- membranous -viral B- Chronic 1-spesific : Trachoma 2-Non-spesific : staph,strept 2. Non-infective Conjunctivitis: A- allergic : vernal conjunctivitis , phylectenular conjunctivitis B- Irritative

6. ACUTE INFECTIVE CONJUNCTIVITIS Mucopurulent Conjunctivitis (MPC): Causative Agents: The commonest organisms are: 1. Haemophilus Egypticus (Koch-Week's bacillus). 2. Staphylococci, streptococci and pneumococci. 3. Acute fevers: measles, scarlet fever.

7. Clinical Picture: 1- Non specific symptoms :,red eye, burning sensation, lacrimation 2-Lid edema. 3-Mucopurulent discharge . 4- Conjunctival edema. 5. Petechial hemorrhage in severe cases.

8. Management: Prevention: Combat flies and good personal hygiene. Protect the fellow eye in unilateral cases. Patients must use separate towels that should be boiled. Treatment: 1. Frequent washing with sterile water or boric acid lotion 4% to remove discharge. 2. Hot foments. 3. Local antibiotic eye drops used frequently: Broad spectrum antibiotics. 4. Antibiotic ointment at night: • Long acting effect due to slow release of the antibiotic. • Prevents gluing of lashes. 5. Systemic antibiotics in severe cases. 6. Dark glasses for cases with photophobia.

9. Purulent Conjunctivitis: Causative Agents: 1. Gonococci: 60-80% of cases. 2. Staphylococci, streptococci and mixed infections. Clinical Forms: adult and neonatal. I- ADULT TYPE: The organism may reach the eyes through flies, dust, and contaminated towels or through the genitals. Clinical Picture and Stages: 1. Incubation period : few hours to 3 days . 2. Stage of infiltration: a. Lid edema and tenderness. Marked conjunctival edema. Marked hyperemia: may show sub- conjunctival hemorrhage Mucoid discharge. Enlarged tender pre-auricular lymph nodes may be detected 3. Stage of discharge: a. Decreased lid edema, the lids are tense and may be painful b. Decreased edema with hyperemia and papillae formation at the palpebral conjunctiva (velvet-like). c. Profuse purulent discharge.

10. Fate and complications: 1. Purulent conjunctivitis disappears spontaneously within 2 weeks or after treatment. 2. Chronicity: slight swelling of lids with residual redness of lids, palpebral and bulbar conjunctiva. 3. Corneal ulcers: The most important complication. May be central, marginal or may form ring ulcers. dense corneal scars or anterior staphyloma . May perforate causing endophthalmitis , 4. Iridocyclitis .

11. Management: A. Prevention: 1-Combat flies, personal hygiene, and healthy sex-habits. 2- Protect the fellow eye in unilateral cases, use prophylactic antibiotic eye drops. 3. Patients should use separate towels and bed sheets that should be changed and frequently boiled. 4. Careful disinfection of infected fingers. B. Treatment: 1. Frequent washing and removal of discharge with sterile lotions warm water. 2. Local antibiotic eye drops -broad spectrum antibiotics 3. Antibiotic ointment at night. 4. Systemic antibiotics: . 5. Dark glasses for cases with photophobia. 6. Local atropine in cases with corneal involvement or iritis .

12. II- OPHTHALMIA NEONATORUM: Definition: It is any form of conjunctivitis occurring in the first month of life. Any discharge from the eye of a newborn infant is suspicious since tears are not secreted at this early date. The condition should be differentiated from congenital dacryocystitis , which is unilateral and pressure on the lacrimal sac yields regurge of pus. Etiology: 1. Infectious: ocular contact with contaminated maternal passages or towels. • Bacterial: gonococci, staphylococci, streptococci,pneumococci . Viral: herpes simplex and adenoviruses. Chlamydia.

13. 2. Chemical: prolonged postpartum instillation of drops or ointment for prophylaxis against infection. Management: Prevention: Treatment of the mother before labor especially herpetic cervicitis. Washing of the body of the baby from above downward. Broad spectrum antibiotic eye drops are instilled in the eyes after birth for 1 week. Prolonged use of topical antibiotics should be avoided as it could result in chemical conjunctivitis. Treatment: Once suspected, treatment should start immediately: 1. Local antibiotic eye drops used frequently (broad spectrum antibiotics). 2. Frequent removal of discharge. 3. Antibiotic ointment at night or as frequently as required. 4. Systemic antibiotics in severe cases. 5. Local atropine ointment in cases with corneal involvement or iritis .

14. Membranous (Diphtheritic) Conjunctivitis: Causative Agent : Corynebacterium Diphtheriae . It is a rare condition since children are now effectively immunized against diphtheria. Membranous conjunctivitis affects non-immunized children.

15. Clinical Picture and Stages: Incubation period: 12 hours to 3 days. 1- Systemic manifestations: Infection of the throat or nasopharynx . Constitutional symptoms, fever and malaise. II- Ocular manifestations: a. Stage of infiltration: (5-10 days): I. Lid edema, redness, tenderness and induration. ii. Conjunctival edema covered with yellowish exudation. iii. Scanty mucopurulent discharge. iv. There is a true membrane, grayish yellow in color, which may be patchy, or covers the whole palpebral conjunctiva. b. Stage of discharge: Marked hyperemia of the conjunctiva. Purulent blood stained discharge containing pieces of the sloughed membrane. iii. When the membrane separates it leaves a septic granulation tissue that exudes thick yellow pus.

16. Fate and complications: a. Local complications: Cicatrization : the raw conjunctival surfaces heal together by fibrosis resulting in Lids : Trichiasis , entropion , and symblepharon . Lacrimal system : closure of ducts and fibrosis of the accessory lacrimal glands leading to xerosis . Conjunctiva : xerosis , symblepharon and pseudopterygium . Cornea : ulcers, xerosis , and vascularization. b. General complications: Complications are mostly due to the diphtheritic exotoxin: Toxic myocarditis and heart failure. Respiratory failure. Toxic nephritis with albuminuria.

17. Neuropathy and paralytic manifestations: paralysis of accommodation, paralytic squint, and other neurologic manifestations. Prevention: Immunization against diphtheria. Isolation of the patients and notification of the health authorities. Treatment: Complete bed rest. Anti-diphtheritic serum 40,000-60,000 U; can be repeated every 12 hours to neutralize the circulating toxin. 3. Systemic IM penicillin injections. 4. Local antibiotic eye drops. 5. Local anti-diphtheritic serum. 6. Antibiotic ointment applied between the palpebral and bulbar conjunctiva using a glass rod to avoid symblepharon . 7. Local atropine ointment in cases with corneal involvement or iritis .

18. Viral Conjunctivitis: Causative Agents: 1. Adenovirus : causes epidemic keratoconjunctivitis (EKC).It takes an epidemic form with many cases occurring over a short period of time. It spreads by droplet infection and may be accompanied bysore throat. 2. Herpes simplex, Enterovirus 3. Acute viral fevers : measles, influenza, and mumps may be associated with conjunctivitis. Clinical Picture: Hyperemia of the conjunctiva. Discharge is usually watery. Photophobia. Conjunctival edema. Sudden onset of subconjunctival hemorrhage is characteristic of acute hemorrhagic conjunctivitis, 6. Follicular conjunctivitis. 7. Preauricular lymph nodes are enlarged and tender. 8. Punctate epithelial keratitis in EKC. 9. Lid vesicles in herpetic cases.

19. Fate: Self-limited, resolving in 7-14 days. Affection of the fellow eye a few days after the first eye. Prevention: 1. Protect the fellow eye in unilateral cases. Patient should use separate towels and bed sheets that should be boiled. Treatment: Supportive treatment with cool compresses and artificial lubricants. acyclovir and oral acyclovir can be used in herpes. 3. Local atropine in cases with corneal involvement.

20. chronic Conjunctivitis: Trachoma It is a chronic contagious inflammation characterized by: Subepithelial cellular infiltration, . The formation of follicles and papillae . The formation of pannus and Healing by cicatrization . It is the greatest single cause of preventable blindness in the world. It affects 400 million people worldwide. Trachoma is endemic in Egypt

21. Etiology: Causative agent is Chlamydia trachomatis. Large-sized obligate intracellular organism. Contains both DNA and RNA. Has a cell wall. Susceptible to tetracycline, erythromycin and sulphonamides . Produces intracellular basophilic inclusion bodies in epithelial cells. No solid immunity so recurrences are common. Mode of infection: • Through conjunctival discharge carried by fingers, towels and flies. • Common in low socioeconomic areas and occurs at childhood in endemic areas. Pathology: The organism is epitheliotropic . The elementary body is composed of a core of DNA surrounded by a protein cover which enters the cell by endocytosis. Division inside the cell occurs. The inclusion body is formed of many elementary bodies. The cell ruptures discharging its content of elementary bodies to infect new cells. This cycle takes about 24 hours.

22. WHO Classification (FISTO)

23. (1) Conj. Manifestations: According to Mac Callen's Classification , there are "4 "stages that affect upper palpebral conj & upper fornix.   (1) Stage 1 (T1) Early follicle: . Small < 1 mm, surrounded by dilated capillaries • Not raised, not expressible (not rupture with pressure). Yellowish

24. (2) Stage 2 (T2): T2a: Typical follicle: - Large (1-3 mm), surrounded by dilated capillaries. - Raised, expressible (if squeezed – gelatinous material = central necrotic tissue). - Yellowish.

25. T2 b: Papillary trachoma: The conjunctiva shows fine, pink, finger like & rounded toped projections. - It gives velvety appearances of surface - Increase the wight of the upper lid → mechanical ptosis.

26. Stage 3 (T3): Healing trachoma (stage of complications) 1-White patches of fibrosis. 2- Von - Arlet's line: white line of fibrosis at sucicus subtarasalis (highly vascularized). 3- PTDs & PTCs 4- Abnormal vascular pattern

27. Stage 4 (T4) "Cured = healed trachoma" - Patient not infective. - C/P as T3 but conjunctival Scarping shows No inclusion bodies (the marker of the virus)

28. Corneal Manifestations of Trachoma: a. Superficial keratitis: Numerous epithelial erosions involving the upper part of the cornea which shows positive staining with fluorescein. b. Corneal follicles: Small rounded grayish areas in the upper cornea. Subepithelial lymphoid infiltrations (Herbert's rosettes). On healing they leave depressed pits (Herbert's pits) giving a serrated appearance to the lower edge of the pannus .

29. c. Trachomatous pannus : Superficial vascularization and lymphoid infiltration of the upper cornea. The vessels run sub- epithelially between the limbal follicles. The patient may complain of pain, lacrimation, photophobia and blepharospasm .

30. Course: Progressive pannus : vessels are parallel and directed vertically downward extending to a level forming a horizontal line. Infiltration precedes vascularization. Regressive pannus : infiltration regresses and vessels narrow. Healed : a superficial scar is formed with fine obliterated vessels. Fate: • Complete resolution leaving a clear cornea if the basement membrane is not destroyed. A permanent opacity if BM is destroyed ( pannus siccus ).

31. d. Corneal ulcers: Typical trachomatous ulcer: superficial, linear, horizontal ulcers at the lower edge of the pannus . They are chronic, spread slowly . They heal by facet formation. Marginal or central ulcers unrelated to the pannus . Ulcers due to trachoma complications as Trichiasis and PTDs.

32. E. Xerosis : due to Atrophy of goblet cells. Obstruction of the lacrimal ducts. Fibrosis of lacrimal glands. F. Keratectasia : Bulging forwards of the cornea weakened by trachoma.

33. Sequelae and Complications of Trachoma: 1. Lid: -Ptosis: either mechanical (heaviness due to cellular infiltration) or due to fibrosis and weakness of Muller's muscle. - Trichiasis : due to local scarring around the lid margin. - Cicatricial entropion : due to conjunctival shrinkage. Chronic meibomianitis .

34. 2. Conjunctiva: • Posterior symblepharon : adhesions in the fornices . Xerosis . • Hyaline and amyloid degeneration of upper tarsus and conjunctiva. Pigmentation. 3. Lacrimal system: Obstruction of puncti by fibrosis. Chronic canaliculitis with epiphora . Chronic dacryocystitis . Chronic dacryoadenitis . 4 . Corneal complications: according to the stage

35. Diagnosis of Trachoma: 1- Clinical signs: expressible follicles, pannus with Herbert's pits Arlt's line, and PTDs 2- Intracytoplasmic basophilic inclusion bodies in congunctival scaraping stained with Giemsa stain 3- Immunologic tests.

36. Prevention: 1. Combat flies. 2. The patient should use separate towels that must be boiled. 3. Careful disinfection of infected fingers. 4. Early diagnosis and treatment.

37. Treatment: 1. Medical: Local sulfonamide or broad-spectrum antibiotic eye drops and ointment (tetracycline, erythromycin, chloramphenicol) used frequently for 6-12 weeks. Atropine if the cornea is involved. General erythromycin, tetracycline or broad-spectrum antibiotics. 2. Surgical : must be used with medical treatment. Expression of follicles. Scraping of papillae. Picking of PTDs.

38. CHRONIC NON-INFECTIVE CONJUNCTIVITIS Phlyctenular conjunctivitis: Etiology: Hypersensitivity to an endogenous antigen: a. Tuberculo -protein b. Intestinal parasites. c. Septic focus. d. Staphylococcal blepharoconjunctivitis . Clinical picture: Symptoms: • Irritation: Discomfort, burning and foreign body sensation. • Watery or mucoid discharge. Photophobia and blepharospasm in cases with corneal affection. Signs: a. Phlycten : Rounded raised nodule 1-3 mm in size. Grayish or yellowish. Common at the limbus and bulbar conjunctiva. Formed of lymphocytic aggregation covered with intact epithelium, which ulcerates later with secondary infection. Surrounded by a small area of congestion.

39. b. Corneal manifestations: A corneal phlycten may occur superficial or deep to Bowman's membrane Phlyctenular ulcers: Limbal : single or multiple, may fuse to form a ring ulcer. Fascicular: superficial ulcer that creeps in a serpiginous manner towards the center and is supplied by a leash of blood vessels. On healing its track leaves an opacity maximum where it stops. Phlyctenular pannus : Affects any part of the limbus . a. Thin and vascular with marked irritation. b. Straight vessels deep to BM. c. Infiltration and vascularization with a rounded edge. d. Eczema of the lids and face, fissures at the outer canthus may occur.

40. Treatment: Treat the cause of allergy if possible. Dark glasses. Topical steroids. Lotions and local antibiotics in cases complicated with mucopurulent conjunctivitis. Local atropine in cases with corneal involvement. Fascicular ulcer needs cautery with carbolic acid and actual cautery for blood vessels at the limbus .

41. Vernal conjunctivitis (Spring Catarrh): It is a chronic allergic condition of the conjunctiva, affecting mainly children and young adults characterized by seasonal variation and may be associated with keratoconus . It is due to hypersensitivity to airborne allergens. It is common in patients with asthma, hay fever or atopy

42. Clinical picture: Symptoms: 1. Itching and lacrimation. 2. Scanty whitish ropy mucoid discharge. 3. Hyperemia 4. Photophobia and blepharospasm . 5. Symptoms increase in spring and summer (seasonal variation) Signs: It may present as palpebral, bulbar, or mixed types: a. Palpebral Type: 1. Large flat-topped papillae giving a cobblestone appearance on the tarsus and absent from the fornix affecting mainly the upper tarsus 2. The papillae are bluish-white or red, formed of a central core of fibrous tissue rich in eosinophils covered by thick epithelium. The center and the edges of the papillae show tiny twigs of blood vessels. 3. If the papillae are exposed by lid eversion, they are covered by a sticky milky white film of discharge rich in eosinophils .

43. b. Bulbar Type: more severe: It manifests as gelatinous limbal masses formed of hypertrophied epithelium with connective tissue core and hyaline degeneration. It usually starts at the upper limbus , then later all round. White spot concretions of eosinophils and necrotic epithelium may be seen ( Tranta Spots). c. Mixed type: The mixed type is a mixture of the palpebral and bulbar types Other manifestations include: 1. Fine punctate epithelial keratitis, 2. 360-degree corneal pannus may occur. 3. Rarely vernal corneal ulcers.

44. Treatment: Symptomatic treatment: • Dark glasses and cold compresses. • Vasoconstrictor and anti-histaminic drops • Systemic antihistaminics may help. • Avoid exposure to allergens if known Mast cell stabilizers: which prevents mast cell degranulation preventing histamine release. Topical steroids: • Only in severe non-responsive cases. • Prolonged use may cause cataract and secondary glaucoma.

45. Degenerations of conjunctiva Pterygium • Definition: It is the encroachment of conjunctiva over the cornea. AE : Unknown, may be: 1- Chronic irritation by Ultraviolet rays, heat, dust. 2- it may follow pingueclua 3- Limbal stem cell deficiency Pathology : 1) Conj. epithelium & fibro-vascular tissue proliferation & encroachment over the cornea. 2) Bowman's membrane & superficial layers of stroma are destroyed.

46.  C/P: Symptoms: 1- Discomfort + irritation. 2- Disfigurement. 3- Diminution of vision (if cross pupil) & compression on the cornea cause irregular astigmatism Sings: a triangular fold, commonly nasal • It consist of 1- Apex over cornea (a pigmented iron line "Stocker line"may be seen in the corneal epithelium anterior to the head - 2- Neck At limbus 3. Body: over sclera (loosely adherent)

47. Types: 1-Stationary: Thin, membranous& less vascular 2-Progressive active: Thick (fleshy) more vascular + infiltration cap (hazy line) 3-Recurrent: After surgical removal (usually associated with ant. Symblepharon

48. D.D

49.  Treatment (1) Follow up: If Pterygium is small & stationary as recurrence is common after op. (2) Operative treatment: Indications: 1. Cosmetically bad. 2. Progressive type. 3.Encroachment on the pupil 4.Recurrent

50. choice of operation 1-lamellar keratectomy excision with bare sclera operation: To prevent recurrence we use : -Beta Irradiation - Mitomicin C or 5FU (antimitotic) 2-Excision with graft - conjunctival or amniotic membrane graft

51. 3-Excision with stem cell transplantation 4-Excision with lamllar keratoplasty 5-Retrograde excision

52. (2) Pinguecula Definition Degenerative condition of conj. In old age with yellow, raised, triangular (base towards the cornea), non vascularized nodule, nasal to limbus . & it's bilateral Etiology : Unknown (heat & UV rays). Pathology : Area of hyaline degeneration(cholesterol), with deposition of elastic tissue. Treatment No ttt ., Excision: if cosmetically annoying the pt.