Conjunctiva & Its disorders

Dr. Mrinmayee GhatakP.G., Dept. of Ophthalmology,K.I.M.S. Hospital, Bangalore

Email: dr.mrin@gmail.com

Translucent mucous membrane Lines the posterior surface of eyelids

and anterior aspects of eyeball Conjoin = “to join”

Parts of conjunctiva: Palpabrel

Marginal Tarsal orbital

Bulbar Fornicial

• 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

• 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)

• 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

• 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

• 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

• 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

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

CLINICAL TYPES: Acute mucopurulent conjunctivitis Acute purulent conjunctivitis Acute membranous conjunctivitis Acute pseudomembranous conjunctivitis Chronic bacterial conjunctivitis Chronic angular conjunctivitis

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

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

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

COMPLICATIONS: Corneal involvement Iridocyclitis Systemic:

Arthritis Endocarditis Septecemia

TREATMENT: Systemic therapy: Topical antibiotic therapy: Frequent irrigation of eyes General measures Add cycloplegics (if corneal

involvement is there) Treatment of partner

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

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

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

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

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

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

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

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

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

COMPLICATIONS: Corneal ulceration Delayed: symblepheron, trichiasis,

entropion, conjunctival xerosis DIAGNOSIS:

By bacteriological examination

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

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

CLINICAL FEATURES: Acute mucopurulent conjunctivitis a/w

pseudomembrane formation

TREATMENT: Same as mucopurulent conjunctivitis

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

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

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

TREATMENT: Topical antibiotics : chloramphenicol / gentamycin

3-4 times for 2 weeks Astringent eye drops : zinc boric acid for

symptomatic relief

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

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

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

TYPES OF INFECTIONS BY CHLAMYDIA

JONES CLASSIFICATION

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

Etiology

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

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

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

CONJUNCTIVAL SCARRING: May be irregular, star-shaped or linear Arlt’s line in case of linear scar

CONCRETIONS: Accumulation of dead epithelial cells and inspissated

pus in depressions called glands of Henle

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

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

McCallan’s Classification:

WHO Classification (FISTO):

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

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

Differential Diagnosis: With follicular hypertrophy:

Adenoviral conjunctivitis With papillary hypertrophy

Vernal Conjunctivitis

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

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

MANAGEMENT: SAFE Strategy for Trachoma Blindness:

Surgery to correct eyelid deformity & prevent blindness

Antibiotics for acute infections & community control

Facial Hygiene Environmental changes

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

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

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

• 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

Clinical presentations: Three clinical forms:

1. Acute serous conjunctivitis 2. Acute haemorrhagic conjunctivitis 3. Acute follicular conjunctivitis

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

Acute conjunctivitis characterised by: Multiple conjunctival hemorrhages Hyperemia Mild follicular hyperplasia

ETIOLOGY: Picornavirus Disease very contagious, direct hand-to-eye contact

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

Treatment: Very infectious Prophylaxis very important No specific treatment Broad spectrum antibiotics Self-limiting within 5-7 days

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)

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

ETIOLOGICAL TYPES: Adult inclusion conjunctivitis (non-viral) Epidemic keratoconjunctivitis Pharyngoconjunctival fever Newcastle conjunctivitis Acute herpetic conjunctivitis

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

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

Newcastle conjunctivitis Rare Caused by Newcastle virus Contact with diseased owls Affects poultry workers Similar to pharyngoconjunctival fever.

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

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

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)

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

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

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

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

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

Symptoms: Marked burning and itching, usually intoreble Mild photophobia, lacrimation “Ropy Discharge” Heaviness of eyelids

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

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

Clinical course: Disease is self-limiting Usually goes off spontaneously in 5-10 years

Differential diagnosis: Trachoma with predominantly papillary hypertrophy

Treatment: Local therapy Systemic therapy Treatment of large papillae General measures Desensitization Treatment of vernal keratopathy

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

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

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

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

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.

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

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

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.

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)

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.

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

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

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

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

PINGUECULA PTERYGIUM CONCRETIONS

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

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

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

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

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

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)

PTERYGIUM: Parts of a fully developed pterygium:

Head (apical part) Neck (limbal part) Body (scleral part)

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

PTERYGIUM: Differential

Diagnosis:

PTERYGIUM: Treatment:

Only satisfactory is SURGERY Indications:

Cosmetic Continued progression Diplopia due to interference of ocular movements

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.

PTERYGIUM: Treatment: Surgical steps:

PTERYGIUM: Treatment: Surgical steps: