Conjunctiva & Its disorders
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Dr. Mrinmayee GhatakP.G., Dept. of Ophthalmology,K.I.M.S. Hospital, Bangalore
Email: [email protected]
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Translucent mucous membrane Lines the posterior surface of eyelids
and anterior aspects of eyeball Conjoin = “to join”
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Parts of conjunctiva: Palpabrel
Marginal Tarsal orbital
Bulbar Fornicial
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• Histologically 3 layers:– Epithelium :
• Marginal part : 5 layer stratified squamous• Tarsal part : 2 layer :
– Superficial is cylindrical cells– Deeper is flat cells
• Fornicial & bulbar : 3 layer :– Superficial cylindrical cells– Middle layer if polyhedral cells– Deep layer of cuboidal cells
• Limbal part: 5-6 layere squamous stratified– Adenoid layer : Lymphoid layer– Fibrous layer : collagenous & elastic fibres
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• Gland of conjunctiva:– Mucin secretory glands
• Goblet cells• Crypts of Henle• Glands of Manz
– Asccessary lacrimal glands• Glands of Krauze• Glands of Wolfring
• Plica Semilunaris:• Pinkish cresenteric fold in medial canthus• Vestigeal structure – nictating membrane
• Caruncle• Small, ovoid, pinkish mass in inner canthus• Piece of modified skin (all features of typical skin)
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• ARTERIES:– Derived from 3 sources:
1. Peripheral arterial arcade of eyelid2. Marginal arterial arcade of eyelid3. Anterior ciliary arteries
– Palpabrel & fornicial part:• Arterial arcades (Peripheral & Marginal) of eyelid
– Bulbar part:• Posterior conjunctival arteries (from arterial arcades of
eyelids)• Anterior conjunctival arteries (from anterior ciliary arteries)
• VEINS:– Venous plexus of eyelids– Limbal part into anterior ciliary veins
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• LYMPHATICS (divided into superficial & deep part):– From laterial side : preauricular LN– From medial side : submandibular LN
• NERVE SUPPLY:– Circumcorneal zone:
• branches from long ciliary nerves– Rest : by branches from:
• Lacrimal nerve• Infratrochlear nerve• Supratrochlear nerve• Supraorbital nerve• Frontal nerve
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• Infective:– Bacterial– Chlamydial– Viral– Fungal– Rickettsial– Sporichaetal– Protozoal– Parasitic
• Allergic conjunctivitis• Irritative conjunctivitis• Keratoconjunctivitis with diseases of skin and mocous
membrane• Traumatic conjunctivitis• Keratoconjunctivitis of unknown etiology
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• Acute catarrhal or mucopurulent conjunctivitis• Acute purulent conjunctivitis• Serous conjunctivitis• Chronic simple conjunctivitis• Angular conjunctivitis• Membranous conjunctivitis• Pseudomembranous conjunctivitis• Papillary conjunctivitis• Folliular conjunctivitis• Ophthalmia neonatorum• Granulomatous conjunctivitis• Ulcerative conjunctivitis• Cicatrizing conjunctivitis
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Pathological changes: Vascular response:
Congestion & increased permeability Cellular response
PMN & other inflammatory cell exudation Conjunctival tissue response
Edema, increase goblet cells Conjunctival discharge
Tears, mucus, inflammatory cells, desquamated epithelial cells, fibrin, bacteria
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CLINICAL TYPES: Acute mucopurulent conjunctivitis Acute purulent conjunctivitis Acute membranous conjunctivitis Acute pseudomembranous conjunctivitis Chronic bacterial conjunctivitis Chronic angular conjunctivitis
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Most common SYMPTOMS:
Discomfort & FB sensation Mild photophobia Mucopurulent discharge Sticking of lid margins Slight blurring if vision Sometimes coloured halos
SIGNS: Conjunctival congestion Chemosis Petechial hemorrhages Flakes of mucopus Matting of eyelashes
• CLINICAL COURSE:– Peak in 3-4days– Cured in 10-15 days– Pass into Chronic Catarrhal
Conjunctivitis
• COMPLICATIONS:– Marginal corneal ulcer– Superficial keratitis– Blepharitis– Dacryocystitis
• DIFFERENTIAL DIAGNOSIS:– Other causes of red eye– Other types of conjunctivitis
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TREATMENT: Topical antibiotics:
Chloramphenicol / ciprofloxacin / ofloxacin eye drops (ointment at night)
Irrigation of conjunctival sac with NS/RL Dark goggles No bandage No steroids Anti-inflammatory & analgesics drugs
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ETIOLOGY: Predominantly males Gonococcus, staph. aureus, pneumococuss
CLINICAL FEATURES: Stage of infiltration:
Painful, tender eye ball Tense and swollen lids Bright red velvety chemosed conjunctiva Watery or sanguinous discharge Pre-auricular LN enlarged
Stage of blenorrhoea: Frankly purulent, copious thick discharge
Stage of slow healing: Symptoms decreased
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COMPLICATIONS: Corneal involvement Iridocyclitis Systemic:
Arthritis Endocarditis Septecemia
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TREATMENT: Systemic therapy: Topical antibiotic therapy: Frequent irrigation of eyes General measures Add cycloplegics (if corneal
involvement is there) Treatment of partner
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In children aged <30 days Any discharge or watering, in the first
week of life should arouse suspicion ETIOLOGY:
Before birth: infected amniotic fluid During birth: infected birth canal After birth: first bath, soiled clothes,
unhygienic conditions
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CAUSITIVE AGENTS: Chemical conjunctivitis: silver nitrate
solution Gonococcal infection: Other bacterial infections:
Staph aureus Strept hemolyticus Strept pneumoniae
Neonatal inclusion conjunctivitis: Chlamydia trachomatis serotype D to K
Herpes Simplex Ophthalmia Neonatorum
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Incubation period: Chemical conjunctivitis: 4-6 hours Gonococcal infection: 2-4 days Other bacterial infections: 4-5 days Neonatal inclusion conjunctivitis: 5-14 days Herpes Simplex Ophthalmia Neonatorum :
5-7 days
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SYMPTOMS: Pain and tender eyeball Purulent conjunctival discharge (gonococcal) Mucoid / mucopurulent (other bacterial infections) Swollen lids Chemosed conjunctiva Corneal involvement rarely
COMPLICATIONS: Corneal ulceration with tendency to perforate
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PROPHYLAXIS: Antenatal:
Treatment of genital infections of mother Natal:
Delivery under aseptic conditions Newborns eyelids should be well cleaned
Postnatal: 1% tetracycline / 0.5% erythromycin ointment 1 % silver nitrate solution (Crede’s method) Single injection of Ceftriaxone 50mg/kg IM/IV
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CURATIVE TREATMENT: Chemical conjunctivitis: self-limiting Gonococcal:
Topical: Bacitracin ointment QID Penicillin drops 5000-10000units per ml every min for 30
min, every 5 min for 30 min, and then every 30m in till infection controlled
Atropine ointment if corneal involvement Systemic:
Ceftriaxone 75-100mg/kg/day IV/IM Q.I.D. Cefotaxime 100-150mg/kg/day IV/IM B.D. If gonococcal: cryst benzyl Peni G 50000 units for full term
babies (20000 to premature) IM BD x 3 days
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CURATIVE TREATMENT: Other bacterial infections:
Broad spectrum antibiotic drops / ointment x 2weeks
Neonatal inculsion conjunctivitis: Topical tetracycline / erythromycin ointment QID
x 3 weeks Plus systemic erythromycin 125mg QID x 3 weeks
Herpes Simples: Self limiting, topical antivirals control effectively
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Conjunctival inflammation with formation of a true membran
ETIOLOGY: Corynebacterium diphtheriae Occasionally strept hemolyticus
PATHOLOGY: Deposition of fibrinous exdute on the
surface & substance of conjunctiva Usually in the palpabral conjunctiva
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CLINICAL FEATURES: Usually in children 2-8 years (not immunized) Stage of infiltration:
Scanty discharge and severe pain Swollen and hard lids, red swollen conjunctiva covered
with grey yellow membrane On removal, membrane bleeds
Stage of suppuration: Pain decreases, membrane sloughs off Copious purulent discharge
Stage of cicatrization: Raw surface covered with granulation tissue & epithelized Cicatrization occurs, trichiasis, conjunctival xerosis
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COMPLICATIONS: Corneal ulceration Delayed: symblepheron, trichiasis,
entropion, conjunctival xerosis DIAGNOSIS:
By bacteriological examination
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TREATMENT: Topical:
Penicillin eye drops 1:10000 unit/ml every 30 min Anti-diphtheric serum every 1 hour Atropine 1% ointment (if corneal involvement) Broad spectrum antibiotic ointment at bedtime
Systemic: Cryst penicillin 5 lac units IM BD x 10 days Anti-diphtheric serum 50,000 units IM stat
Prevention: When surface raw: apply BCL or sweep glass rod with
ointment
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ETIOLOGY: Bacterial:
C. diphtheriae, Staphylococcus, Sterptococcus H. influenzae, N. gonorrhoea
Viral: Herpes simples & adenovirus
Chemical: Acids, ammonia, lime, copper sulphate, silver
nitrate PATHOLOGY:
Similar to membranous conjunctivitis
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CLINICAL FEATURES: Acute mucopurulent conjunctivitis a/w
pseudomembrane formation
TREATMENT: Same as mucopurulent conjunctivitis
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ETIOLOGY: Predisposing factors:
Chronic exposure to smoke, dust, chemical irritants
Local irritant as trichiasis, concretions, FB Eye-strain due to Ref error, phorias,
convergence insufficiency Alcohol abuse
Causative agents: Staph aureus commonly, gram-ve entrobaccilli
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Source & mode of infections: As comtinuation of acute mucopurulent
conjunctivitis As chronic infection from chronic dacryocystitis
or chronic URI As a mild exogenous infection from direct
contact or air-borne
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SYMPTOMS: Burning & grittiness of eyes, specially in evening Mild chronic redness Feeling of heat & dryness on lid margins Difficulty in keeping eyes open Mild mucoid disharge On & off lacrimation Feeling of sleeping & tiredness in the eyes
SIGNS: Congestion of posterior conjunctival vessels Mild papillary hypertrophy Surface of conjunctiva look sticky, congested lid margins
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TREATMENT: Topical antibiotics : chloramphenicol / gentamycin
3-4 times for 2 weeks Astringent eye drops : zinc boric acid for
symptomatic relief
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Mild chronic conjunctivitis confined to the conjunctiva & lid margins near the angles
ETIOLOGY: Moraxella Axenfield Bacilli Rarely staphylococci
PATHOLOGY: Production of proteolytic enzyme Causes maceration of epithelium
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SYMPTOMS: Irritation discomfort H/O collection of dirty white foamy discharge at the
angles Redness in the angles of the eye
SIGNS: Hyperaemia of bulbar conjunctiva near the canthi Hyperaemia of lid margins near the angles Excoriation of skin around the angles Presence of foamy mucopurulent discharge at the
angles
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COMPLICATIONS: Blepharitis Marginal catarrhal corneal ulceration
TREATMENT: Good personal hygiene Oxytetracycline 1 % eye ointment 2-3
times x 10-14 days Zinc lotion at day time and zinc oxide
ointment at bedtime
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TYPES OF INFECTIONS BY CHLAMYDIA
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JONES CLASSIFICATION
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Formerly called as Egyptian ophthalmia Chronic keratoconjunctivitis Affecting superficial epithelium of cornea
and conjunctiva One of the leading cause of preventable
blindness Greek : Trachoma : “Rough” Characterized by mixed follicular &
papillary reaction
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Etiology
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Symptoms: No secondary bact infection:
Minimal or asymtomatic Mild FB sensation Occasional lacrimation Stickiness of lids Scanty mucoid discharge
With secondary bact infection: All typical symptoms of acute bacterial
conjunctivitis
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CONJUNCTIVAL FOLLICLES: Boiled sago-grains Upper tarsal conjunctiva Sometimes on bulbar conjunctiva also Scattered aggregations of lymphocytes,multinucleate giant cells (Leber cells),mononuclear histiocytes etc Signs of necrosis may be present
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CONJUNCTIVAL PAPILLAE: Reddish flat topped raised areas Give red velvety appearance to tarsal conjunctiva Central core of numerous dilated blood vessels surrounded
by lymphocytes and covered by hypertrophic epithelium
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CONJUNCTIVAL SCARRING: May be irregular, star-shaped or linear Arlt’s line in case of linear scar
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CONCRETIONS: Accumulation of dead epithelial cells and inspissated
pus in depressions called glands of Henle
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HERBERT FOLLICLES: Similar to conjunctival follicles but present in limbal
area HERBERT PITS:
Oval or circular pitted scars left after healing of Herbert follicles in limbal area
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PANNUS: Infiltration of cornea associated with vascularization in
the upper limbal area Vessels lie between the epithelium & Bowman’s layer Types:
Progressive: infiltration ahead of vascularization Regressive: vessels extend short distance beyond infiltration
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McCallan’s Classification:
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WHO Classification (FISTO):
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SEQUELAE: In the lids:
Trichiasis, entropion, tylosis, ptosis, madarosis In the conjunctiva:
Concretions, pseudocysts, xerosis, symblepheron In the cornea:
Corneal opacity, ectasia, xerosis, total corneal pannus Others:
Chronic dacryosystitis, chronic dacryoadenitis
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DIAGNOSIS: Clinical:
Grading to be done as per WHO classification At least 2 sets of signs should be present:
Conjunctival follicles and papillae Pannus Epithelial keratitis near superior limbus Signs & sequelae of cicatrization
Laboratory: Conjunctival cytology Detection of inclusion bodies ELISA for chlamydial antigens PCR Isolation & serotyping of organism
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Differential Diagnosis: With follicular hypertrophy:
Adenoviral conjunctivitis With papillary hypertrophy
Vernal Conjunctivitis
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MANAGEMENT: Treatment of Active Trachoma:
Topical therapy: 1% tetracycline / 1% erythromycin eye ointment 4 times daily for
6 weeks Systemic therapy:
Tetracycline / erythromycin 250mg QID orally for 4 weeks Or Docycline 100mg BD orally for 4 weeks Or single dose of Azithromycin orally
Combined therapy: Preferred when severe disease Or associated genital infection is present
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MANAGEMENT: Treatment of Sequelae:
Removal of concretions Epilation / electrolysis of trichasis Surgical correction of entropion Lubricating drops for xerosis
Prophylaxis: Hygiene measures Early treatment of conjunctivitis Blanket antibiotic therapy in endemic areas:
1 % tetracycline ointment BD for 5 days in a month for 6 months
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MANAGEMENT: SAFE Strategy for Trachoma Blindness:
Surgery to correct eyelid deformity & prevent blindness
Antibiotics for acute infections & community control
Facial Hygiene Environmental changes
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acute follicular conjunctivitis associated with mucopurulent discharge
ETIOLOGY: Chlamydia trachomatis Serotype D to K Primary source urethritis & cervicitis Transmission through contact through fingers Or by contaminated water of swimming pool c/a Swimming Pool Conjunctivitis
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Incubation Period: 4-12 days
Symptoms: Ocular discomfort, foreign body sensation Mild photophobia Mucopurulent discharge from the eyes
Signs: Conjunctival hyperaemia, marked in fornices. Acute follicular hypertrophy predominantly of lower palpebral conjunctiva Superficial keratitis in upper half Superior micropannus occasionally Pre-auricular lymphadenopathy
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Treatment: Topical therapy:
Tetracycline 1 % eye ointment QID for 6 weeks
Systemic therapy: Very important Tetracycline 250 mg four times a day for 3-4 weeks. Erythromycin 250 mg four times a day for 3-4 weeks Doxycycline 100 mg twice a day for 1-2 weeks 200 mg weekly for 3 weeks Azithromycin 1 gm as a single dose
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• Most viral infections are keratoconjunctivitis
VIRAL INFECTIONS OF CONJUNCTIVA(conjunctiva is predominantly affected):
– Adenoviral conjunctivitis– Herpes Simplex kerato conjunctivitis– Herpes Zoster conjunctivitis– Pox virus conjunctivitis– Myxovirus conjunctivitis– Paramyxovirus conjunctivitis– ARBOR virus conjunctivitis
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Clinical presentations: Three clinical forms:
1. Acute serous conjunctivitis 2. Acute haemorrhagic conjunctivitis 3. Acute follicular conjunctivitis
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Mild grade viral infection No follicular response CLINICAL FEATURES:
Minimal congestion Watery discharge Boggy swelling of conjunctival mucosa
TREATMENT: Usually self limiting , no treatment Broad spectrum antibiotic to prevent secondary bacterial infection for
7 days
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Acute conjunctivitis characterised by: Multiple conjunctival hemorrhages Hyperemia Mild follicular hyperplasia
ETIOLOGY: Picornavirus Disease very contagious, direct hand-to-eye contact
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Clinical features: Incubation period: 1-2 days Symptoms:
Pain, redness, watering, mild photophobia Transient blurring of vision, lid edema
Signs: conjunctival congestion & chemosis multiple haemorrhages in bulbar conjunctiva mild follicular hyperplasia, lid oedema pre-auricular lymphadenopathy Fine corneal keratitis
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Treatment: Very infectious Prophylaxis very important No specific treatment Broad spectrum antibiotics Self-limiting within 5-7 days
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Acute conjunctivitis with formation of follicles, conjunctival hyperaemia and discharge from the eyes
TYPES: Acute follicular conjunctivitis (Non-Specific) Chronic conjunctivitis Specific type (trachoma, etc)
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Acute catarrhal conjunctivitis Marked follicular hyperplasia especially of the lower fornix and
lower palpebral conjunctiva Symptoms:
Redness, watering, mild mucoid discharge Mild photophobia and feeling of discomfort Foreign body sensation
Signs: conjunctival hyperaemia Multiple follicles, more prominent in lower lid than the upper
lid
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ETIOLOGICAL TYPES: Adult inclusion conjunctivitis (non-viral) Epidemic keratoconjunctivitis Pharyngoconjunctival fever Newcastle conjunctivitis Acute herpetic conjunctivitis
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Epidemic keratoconjunctivitis: Associated with SPK and occur in epidemics Adenovirus type 8 and 19 Markedly contagious and direct contact transfer Incubation : 8 days
Phase 1 : acute serous conjunctivitis Phase 2 : acute follicular conjunctivitis Phase 3 : acute pseudomembranous conjunctivitis Corneal involvement : SPK Pre-auricular lymphadenopathy in all cases
Treatment : supportive therapy
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Pharyngoconjunctival fever: Adenovirus type 3 and 7
Acute follicular conjunctivitis With pharyngitis, Fever & Pre auricular LN
Primarily in children and in epidemic forms Corneal involvement in 30% cases Treatment is supportive
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Newcastle conjunctivitis Rare Caused by Newcastle virus Contact with diseased owls Affects poultry workers Similar to pharyngoconjunctival fever.
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Acute herpetic conjunctivitis: Always accompanies with primary herpetic infection HSV type 1 commonly Clinically:
Usually unilateral, incubation within 3-10 days Typical Form: Follicular conjunctivitis with other herpetic
lesions Atypical Form: Follicular conjunctivitis without other
herpetic lesions Corneal involvement & preauricular lymphadenopathy
Treatment: self limiting, antivirals ineffective
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Mild chronic catarrhal conjunctivitis with follicles predominantly in lower palpebral conjunctiva
Etiology: Infective: benign folliculosis (school folliculosis) Toxic: due to cellular debris in molluscum contagiosum Chemical: prolonged use of pilocarpine, IDU, adrenaline Allergic: less commonly
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TYPES:1. Simple allergic conjunctivitis
Hay fever conjunctivitis Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC)
2. Vernal keratoconjunctivitis (VKC)3. Atopic keratoconjunctivitis (AKC)4. Giant papillary conjunctivitis (GPC)5. Phlyctenular keratoconjunctivitis (PKC)6. Contact dermoconjunctivitis (CDC)
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Mild, non-specific allergic conjunctivitis Itching, hyperaemia and mild papillary response
Basically an urticarial reaction Etiology:
Hay fever : pollens, animal dandruff Seasonal allergens (grass pollens) Perenial allergens (house dust, mites)
Pathology: Vascular + Cellular + Conjunctival Responses
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Symptoms: Intense itching & burning Watery discharge & mild photophobia
Signs: Hypreremia & chemosis Mild papillary reaction Lid edema may be present
Diagnosis: Typical signs & symptoms Normal conjunctival flora Abundant eosinophils in discharge
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Treatment: Elimination of allergen if possible Local palliative measures for immediate relief:
Vasoconstrictors : naphazoline, adrenaline, ephedrine Sodium cromoglycate eye drops Steroids only for short course in acute cases
Systemic antihistaminics in acute cases Desensitization – not much effective
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C/a SPRING CATARRH Recurrent, bilateral, interistitial, self-limiting, allergic inflammation of
conjunctiva ETIOLOGY:
Hypersensitivity to some exogenous allergen IgE mediated atopic mechanisms
Predisposing factors: 4-20 years, common in males More in summer Prevalent in tropics, non-existent in cold climate
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Pathology: Conjunctival epithelial hyperplasia Marked infiltration in adenoid cell layer Proliferation of fibrous layer Conjunctival vascular changes seen Formation of multiple papilllae in upper tarsal conjunctiva
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Symptoms: Marked burning and itching, usually intoreble Mild photophobia, lacrimation “Ropy Discharge” Heaviness of eyelids
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Signs: Palpabrel form:
Upper tarsal conjunctiva Presence of hard, flat topped, papillae arranged in 'cobble-stone' or
'pavement stone', fashion Giant papillae in severe cases White ropy conjunctival discharge
Bulbar form: Dusky red triangular congestion of bulbar conjunctiva in palpebral area Gelatinous thickened accumulation of tissue around the limbus Presence of discrete whitish raised dots along the limbus (Tranta's spots)
Mixed: Combined features of both forms
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VERNAL KERATOPATHY: 5 types of lesions can be seen:
Punctate epithelial keratitis: Involves upper cornea, mostly in palpabrel form Lesions always stain with rose bengal
Ulcerative vernal keratitis: Shallow transverse ulcer in upper part of cornea due to epithelial
macroerosions Vernal corneal plaques:
Due to coating of areas of epithelial macroerosions with coating of altered exudates
Subepithelial scarring: In a form of a ring scar
Pseudogerontoxon: Classical cupid bow outline
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Clinical course: Disease is self-limiting Usually goes off spontaneously in 5-10 years
Differential diagnosis: Trachoma with predominantly papillary hypertrophy
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Treatment: Local therapy Systemic therapy Treatment of large papillae General measures Desensitization Treatment of vernal keratopathy
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Treatment: Local therapy
Topical steroids: Effective in all forms Use should be minimal and for short-duration Frequent instillation to tapering within few days Flouromethalone, dexamethasone, loteprednol
Mast cell stabilizers: Sodium cromoglycate, azelastine, ketotifen
Topical antihistaminic eye drops Acetyl cysteine (0.5%) eye drops Topical cyclosporine eye drops
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Treatment: Systemic therapy
Oral histaminics Oral steroids in severe cases for short duration
Treatment of large papillae: Supratarsal injection of long acting steroid Cryo application Surgical excision for extra-ordinary large papillae
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Treatment: General measures:
Dark goggles Cold compress & ice packs Change of environment (working environment also)
Desensitization Not much awarding results
Treatment of vernal keratopathy: PEK : steroid instillation should be increased Large vernal plaque: surgical lamellar keratectomy Severe shield ulcer: debridement, superficial keratectomy,
amniotic membrane transplantation
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Adult equivalent of vernal keratoconjunctivitis Often associated with atopic dermatitis Mostly young male adults Symptoms:
Itching, soreness, dry sensation Mucoid discharge Photophobia or blurred vision
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Signs: Lid margins:
chronically inflamed rounded posterior borders
Tarsal conjunctiva: milky appearance very fine papillae, hyperaemia and scarring with shrinkage
Cornea: punctate epithelial keratitis more severe in lower half corneal vascularization, thinning and plaques.
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Clinical course: Protracted course Tends to become inactive by 5th decade
Treatment: Often frustrating Treat lid disease effectively Mast cell stabilizers, steroids, tear supplements may
be beneficial
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Conjunctival inflammation with very large sized papillae Etiology:
Localized allergic response Contant lens, prosthetic shell Suture irritation
Symptoms: Itching, stringy discharge Reduced wearing time of contact lens or prosthetic shell
Signs: Papillary hypertrophy upper tarsal conjunctiva with hyperaemia
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Treatment: The offending cause should be removed. Disodium cromoglycate is known to relieve the symptoms
and enhance the rate of resolution. Steroids are not of much use in this condition.
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Nodular affection as a allergic response to endogenous allergens World wide , more in developing countries Etiology: Delayed hypersensitivity
Causative allergens Tuberculous, Staphylococcus Proteins of Moraxella Axenfeld bacillius, Parasites
Predisposing factors Age. Peak age group is 3-15 years. Sex. Incidence is higher in girls than boys. Undernourishment Living conditions. Overcrowded and unhygienic. Season. all climates (spring and summer seasons)
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Pathology: Stage of nodule formation:
exudation and infiltration of leucocytes neighbouring blood vessels dilate and their endothelium proliferates.
Stage of ulceration: Necrosis apex of the nodule and an ulcer is formed
Stage of granulation: Eventually floor of the ulcer becomes
covered by granulation tissue. Stage of healing
Healing occurs usually with minimalscarring.
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Symptoms: Very few Mild discomfort, discharge, irritation, reflex tearing
Signs: Simple:
Most common Typical pinkish-white nodule at limbus surrounded by hyperemia,
mostly solitary. Necrotizing:
Very large phlycten with necrosis & ulceration Leads to severe pustular conjunctivitis
Miliary: Multiple phlyctens, may be arranged like a ring around limbus
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Phlyctenular Keratitis: Ulcerative:
Sacrofulous ulcer: shallow marginal ulcer Fascicular ulcer: has prominent parallel leash of vessels Miliary ulcer: multiple ulcers scattered all over
Diffuse Infiltrative: Central infiltration of cornea Characteristic rich vascularization all around limbus
Usually self-limiting, disappears in 8-10 days D/D:
Episcleritis, scleritis, FB granuloma
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Treatment: Local therapy:
Topical steroid eye drops and ointment Topical antibiotic eye drops & ointment Atropine eye ointment when cornea involved
Systemic therapy: Diagnosis & management of TB Septic foci like caries, folliculitis, tonsillitis, adenoiditis to
be adequately treated Parasitic infestations to be ruled out & treated if present
General measures: Improve hygiene & supplement high-protein diet
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Treatment: Local therapy:
Topical steroid eye drops and ointment Topical antibiotic eye drops & ointment Atropine eye ointment when cornea involved
Systemic therapy: Diagnosis & management of TB Septic foci like caries, folliculitis, tonsillitis, adenoiditis to
be adequately treated Parasitic infestations to be ruled out & treated if present
General measures: Improve hygiene & supplement high-protein diet
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PINGUECULA PTERYGIUM CONCRETIONS
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PINGUECULA: Extremely common Yellowish white patch on
bulbar conjunctiva near thelimbus, nasal or temporal
Etiology: Age related change Strong sunlight (UV) light exposure Dusty, windy & smoky working environment Considered as a precursor of pterygium
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PINGUECULA: Pathology:
Elastotic degeneration of collagen fibres of the substantia propria of conjunctiva
Deposition of amorphous hyaline material in the substance of conjunctiva
Clinical features: Bilateral, usually stable, yellowish-white (may be
triangular) patch near limbus, commonly nasal limbus In congested conjunctiva, stands out as a avascular patch
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PINGUECULA: Complications:
Inflammations Intraepithelial cysts Intraepithelial abscess Conversion into pterygium
Treatment: No treatment If required, excision can be done Avoid exposure to sunlight, dust, smoke etc
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PTERYGIUM: Pterygion = wing Triangular wing-shaped fleshy fibrovascular mass or
fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure
Etiology: Common in people living in hot climates Rest same as of pinguecula
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PTERYGIUM: Pathology: Degenerative and hyperplastic condition of
conjunctiva Elastotic degeneration and proliferates as
vascularised granulation tissue under the epithelium Ultimately encroaches the cornea Corneal epithelium, Bowman's layer
and superficial stroma are destroyed
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PTERYGIUM: Clinical features:
FB sensation, watering, discomfort, visual disturbance Cosmetic disfigurement Common in outdoor working males Unilateral or bilateral Mostly on nasal side, temposal side not spared Iron Deposition seen in corneal epithelium (stocker’s line)
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PTERYGIUM: Parts of a fully developed pterygium:
Head (apical part) Neck (limbal part) Body (scleral part)
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PTERYGIUM: Types of Pterygium:
Progressive: Thick, fleshy,vascular Few infiltrates in the cornea,
in front of the head of the pterygium Regressive:
Thin, atrophic, attenuated, very little vascularity. There is no cap. Ultimately it becomes membranous but never disappears
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PTERYGIUM: Differential
Diagnosis:
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PTERYGIUM: Treatment:
Only satisfactory is SURGERY Indications:
Cosmetic Continued progression Diplopia due to interference of ocular movements
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PTERYGIUM: Treatment:
Recurrence is very common Can be reduced by following:
Transplantation of pterygium in the lower fornix Postoperative beta irradiations Postoperative / intraoperative use of antimitotic drugs (mitomycin-C
or thiotepa) Surgical excision with bare sclera Surgical excision with free conjunctival graft Excision with lamellar keratectomy and lamellar keratoplasty.
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PTERYGIUM: Treatment: Surgical steps:
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PTERYGIUM: Treatment: Surgical steps:
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