conjunctiva Dr. saif alshamarti

Conjunctiva

Anatomy Microscopic: 1.Epiyhelium (non keratinized,includes goblet cell). 2.Epithelial basment membrane. 3.Stroma : a.Superfascial (adenoid layer).contain lymphoid tissue. b.Deep (fibrous layer). Macroscopic : 1.Palpepral 2.Forniceal 3.Bulbar

Lymphatics drain in sub mandibular and preauricular lymph node. Conjunctiva has comparatively few pain fiber From the trigeminal nerve (ophthalmic division) So pain is poorly localized….

Conjunctival signs and symptoms Key symptoms include: 1.Redness 2.Surface irritation. 3.Itching . 4.Discharge . 5.Watering . 6.Conjunctival swelling.

Examination Hyperaemia .(localized or diffuse). Chemosis: edematous conjunctiva. Sub conjunctival haemorrhage . Discharge …..if mucoserous or watery (viral or toxic) …..if mucopurulent (bacterial ). …….watery (allergic). Follicle :focal lymphoid aggregates in substantia p. Papillae: vascular response(central tuft of vessels)… Either small or giant papillae.

Conjunctivitis

Definition Conjunctivitis: inflammation of mucous membrane that lines the inner surface of the lids and the globe up to the limbus (junction of the sclera and the cornea)

Diagnosis Can usually be diagnosed by history and physical exam Cultures are usually unnecessary Exception: hyperacute cases, in which gram stain/Giemsa stain for N. gonorrhoeae would be useful -adenoviral test could be useful to r/o bacterial infection and thereby decrease antibiotic use etc

“Red Eye” Inflammation of conjunctiva leads to pink or red appearance, Other etiologies of red eye: Acute angle closure glaucoma Hyphema Iritis keratitis Stye Blepharitis Corneal abrasion Dry Eye syndrome Episcleritis& scleritis -need to r/o other causes by looking for focal pathology in the lids like a stye, mound, ulceration, or blepharitis (in these cases, conjunctival hyperemia is reactive and not primary) -conjunctival redness should be diffuse (if localized, consider pterygium or episcleritis) -should include the tarsal conjunctiva (conditions like keratitis, iritis and glaucoma will often only involve the bulbar conjunctiva, with ciliary flush, but spare tarsal area) -infectious keratitis: MUST be ruled out, can be severe. Note that it would cause foreign body sensation, and patient is usually unable to open the eye/keep it open, often there is a corneal opacity visible with a penlight -Other serious signs/symptoms: reduction of visual acuity, photophobea, fixed pupil, severe headache with nausea

Etiology Infectious Noninfectious Bacterial Viral Allergic Non-Allergic

Bacterial Conjunctivitis Symptoms: redness and mucopurulent discharge in the eye, affected eye often is “stuck shut” Common organisms: S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis Hyperacute bacterial conjunctivitis: N. gonorrhoeae (seen with concurrent urethritis) There is often profuse purulent discharge, chemosis, lid swelling, tender preauricular adenopathy Treatment: antibiotics can shorten duration of disease if given before day 6 Erythromycin ointment or polymyxin/trimethoprin drops are most often used -Antibiotics are given 4x daily for 5-7 days -Ointment is peferred over drops for children, those with poor compliance, or those who have difficulty putting drops in the eyes -Can also use bacitracin, sulfacetamide, polymixin-bacitracin, FQ drops or azithro. DO NOT USE Aminoglycosides beause they are toxic to corneal epithelium and can cause reactive keratoconjunctivitis -For corneal ulcers, use FQs (active against pseudomonas) and can also use this for conjunctivitis in contact lens wearers after keratitis hasb een ruled out

Bacterial Conjunctivitis

Viral

Viral Conjunctivitis Symptoms: injection, watery/mucoserous discharge, “burning”/sandy/gritty feeling in on eye, scant mucus, often bilateral Common organisms: adenovirus On Exam: profuse tearing/mucoid discharge, enlarged/tender preauricular node. Can lead to keratitis (inflammation of the cornea), with symptoms of a foreign body sensation and multiple corneal infiltrates Treatment: symptomatic relief with topical antihistamine/decongestants, warm/cool compresses -Remember that both bacterial and viral conjunctivitis is highly contagious and often, 24 hours of treatment is required by schools before returning, although if there is still discharge or spreading of germs by contact, patient is still highly contagious

Adult Inclusion Conjunctivitis Chronic form of conjunctivitis caused by certain serotypes of Chlamydia trachomitis Often presents with concurrent asymptomatic urogenital infection Symptoms: unilateral follicular conjunctivitis that does not respond to topical antibiotic therapy Diagnosis: Giemsa staining of conjunctival smears or by culture/PCR of swabbed organisms Treatment: systemic therapy with doxycycline, tetracycline, erythromycin or azithromycin Note that Chlamydial infections can also cause trachoma, a roughening of the inner eyelid surface leading to discharge, turning in of eyelids and scarring of eyeball, often leading to corneal ulcer -Often seen in underdeveoped countries, not as common in the USA

Chlamydial Conjunctivitis

Allergic Conjunctivitis Symptoms: bilateral redness, watery discharge, itching, marked chemosis (may be bullous) Patients often have a hx of atopy, seasonal allergy or specific allergy

Allergic Conjuctivitis

Noninfectious, Nonallergic Conjunctivitis Often due to mechanical or chemical insult, transient, resolves in 24 hours without treatment Symptoms: mucoid discharge Treatment: topical lubricants Note that Glucocorticoids have NO role in tx of conjunctivitis, and can cause corneal scarring, meling and perforation

Resolution of Symptoms Bacterial conjunctivitis should improve within 1-2 days All other forms should improve within 1-2 weeks

Neonatal Conjunctivitis

Neo natal conjunctivitis Neonatal conjunctivitis includes bacterial, viral, and chemical causes Time of disease onset is a clue to etiology Gram stain and culture of discharge Treatment based on etiology Early treatment is necessary to prevent further permanent eye damage

Chemical Conjunctivitis Silver nitrate solution used as prophylaxis for bacterial conjunctivitis Occurs within the first 5 days of life Spontaneous resolution Decreasing incidence due to use of erythromycin.

Bacterial Conjunctivitis Neisseria gonorrhoeae Chlamydia trachomatis Gram positive cocci (30-50% cases) Some gram negatives Prophylaxis includes topical erythromycin and silver nitrate at birth

Gonococcal Conjunctivitis Occurs 2-7 days after birth More severe than other forms Bilateral purulent discharge May progress to corneal involvement with perforation or endophthalmitis Possible systemic manifestations Treatment includes topical erythromycin, IV or IM 3rd generation cephalosporin, and Penicillin G (for penicillin susceptible organisms)

Chlamydial Conjunctivitis Occurs 5-14 days after birth Watery discharge, involvement of eyelids, pannus, possible corneal scarring with eyelashes Treatment involves oral erythromycin for 2 weeks Colonization of the nasopharynx causes atypical pneumonia

Chlamydia

Viral Conjunctivitis HSV keratoconjunctivitis Occurs within the first 2 weeks of life Corneal epithelium involvement, skin lesions around eyes, risk of encephalitis C-section if mother has active lesions Treated with IV acyclovir for 2-3 weeks

Pinguecula &ptrygium. Pinguecula Triangular fibrovascular band . Uv light ,dry climate. Usually arises Nasal limbus . Grows slowly across cornea and destruction of bowman layer. Same histology . Surgary if encroach visual axis,astigmatism,F.Bsensation Cosmetic . Extremly common ,yellow-whit patch of interpalpebral bulbar conjunctiva nasal or temporal to limbus. Elastotic degeneration of collagen. Re assurance +lubrication

Discussion What are some questions you should ask the patient who presents with red eye? What are specific things you can do to advise the patient in preventing future cases of conjunctivitis?

Thank you