Disease of the conjunctiva

General description of conjunctivitis Conjunctivitis:the most common extraocular disorder Etiology: infection of microorganism physical injuries chemical injuries allergic disorder immunological disorder nutritional deficiency

General description of conjunctivitis Classification According to the cause: bacterial, chlamydial, viral, fungal, allergic conjunctivitis According to the course: acute, subacute and chronic

General description of conjunctivitis Clinical manifestation Symptoms:foreign body sensation, burning sensation, itching and tearing, pain and photophobia when cornea is involved Physical sign: 1)conjunctival hyperemia and edema: situation, movable, adrenalin test 2)increase of secretion: bacterial:serous,mucous and purulent viral: watery or serous allergic one or xerophthalmia: ropy filamentous

General description of conjunctivitis Clinical manifestation Physical sign 3)subconjunctival hemorrhage 4)papillary hyperplasia: palpebral conjunctival epithelium; follicular formation: accumulation of lymphocyte beneath the conjunctival epithelium, seen in chlamydial and drug-induced conjunctivitis

General description of conjunctivitis Clinical manifestation Physical sign: 5)pseudomembrane or membrane of the palpebral conjunctiva: the exudation rich in fibrin from palpebral conjunctiva . Pseudomembrane: in baby and children, adenoviral, neonatal inclusion, streptococcal conj. True membrane: diphtheritic conj. 6)preauricular lymphadenectasis with tenderness: viral conj.

General description of conjunctivitis Examination and diagnosis Clinical examination Cytologic examination smear of conjunctival and scaling smear of conjunctiva Bacteriological examination bacterial culture and drug sensitive test Virus isolation and its antigenic detection

General description of conjunctivitis Principle treatment Remove pathogenic cause, take local phamacotherapy as major, systemic treatment as supplement if necessary 1)instillation of eyedrops 2)instillation of ointment 3)washing of conjunctival sac 4)systemic treatment Prevention

Bacterial conjunctivitis Acute catarrhal conjunctivitis “pink eye”, in spring and autumn, sporadic or epidemic Clinical finding: acute onset(1-3days), both eye tearing, foreign body and burning sensation conjunctival hyperemia, purulent secretion, palpebral swelling, spots of subconjunctival hemorrhage Ill process: 2 weeks Treatment Prevention

Bacterial conjunctivitis Chronic catarrhal conjunctivitis Etiology 1)bacterial infection: acute-chronic or infection of bacterial with weak toxicity 2)non-infectious: environment factors: dust, chemical smoke or gas and irritating eye drugs 3)complicated from other disorders:

Bacterial conjunctivitis Chronic catarrhal conjunctivitis Clinical finding: 1)chronic onset, both eye 2)itching, foreign body and asthenopia or no symptoms 3)conjunctival hyperemia mucous secretion papillary and follicle hyperplasia Treatment: give management according to different causes

Bacterial conjunctivitis Gonococcal conjunctivitis Hyperacute purulent conjunctivitis with the strongest infectivity and large destructibility Etiology: diplococcus gonorrhoeae adult: auto infection children: touch infection newborn: direct infection

Bacterial conjunctivitis Gonococcal conjunctivitis Clinical findings 1)incubation period: 10h-2, 3d, acute onset 2)opthalmalgia, photophobia, tearing 3)swelling of the eyelids palpebral and bulbar hyperemia and chemosis secretion: serous-bloody-purulent-nong lou yan inflammatory pseudomembrane preauricular lymphadenectasis corneal ulcer and perforation

Bacterial conjunctivitis Gonococcal conjunctivitis Diagnosis: clinical findings lab examination(Gram’ stain, G- diplococcus) Treatment: topical and systemic one is the same important Prevention be isolated to avoid infection and epidemic

Chlamydial conjunctivitis Chlamydia is microorganism between bacterium and virus Chlamydin psittaci: Chlamydia trachomatis: antigen:ABCBa DEFGHIJK trachoma genitourinary system inclusion conjunctivitis Chlamydia is sensitive to tetracyclin or erythromycin

Chlamydial conjunctivitis Trachoma A chronic, infectious keratoconjunctivits Named from rough, uneven appearance on the surface of palpebral conjunctiva that looks like sand Our country: before 1950s: the first cause of blindness 1955: separated the pathogen after 1970s: decreased greatly now: remote districts Developing countries of the Asian-African area

Chlamydial conjunctivitis Trachoma(clinical findings) Commonly occurred in children and juvenile, with bilateral acute or subacute onset Incubation time: 5-14d(children), 7d(average) Acute or subacute stage(1-2mon): photophobia, tearing, foreign body sensation 1)palpebral and bulbar conjunctival hyperemia 2)ropy secretion 3)papillary hyperplasia, follicles formation 4)corneal epithelitis be cured without scar left

Chlamydial conjunctivitis Trachoma(clinical findings) Chronic stage: superinfections or concomitant bacterial infections 1)Conjunctival hyperemia 2)ropy secretion 3)papillary hyperplasia, follicles in upper fornix and palpebral conjunctiva conjunctival thickening scar white luster like tenden 4)corneal epithelitis trachomatous pannus

Chlamydial conjunctivitis Trachoma(classification) Our country Mac Callan’s I Early stage of infiltration hyperemia and thickening early follicle and corneal panus I progressive stage papillae and follicles, upper fornix is blurred, corneal panus II active stage II regressive stage scar,a little active lesion III precicatricial stage III complete cicatricial stage scar, no active lesion and infectivity IV cicatricial stage

Chlamydial conjunctivitis Trachoma(sequela and complication) Entropion and trichiasis Blepharopatosis Symblepharon (lower fornix) Parenchymatous xerosis of conjunctiva Chronic dacryocystitis Corneal opacity

Chlamydial conjunctivitis Trachoma(diagnosis) 1)the vessels of upper fornix and palpebral conjunctiva are blurred, congested, papillary hyperplasia or follicle formation or both 2)corneal pannus 3)scar 4)trachomatous inclusion Diagnosis on the basis of the first plus one of other three antigenic test

Chlamydial conjunctivitis Trachoma(differential diagnosis) Chronic follicular conjunctivitis 1)follicles in lower palpebral /fornix conjunctiva, no fusion tendency, translucent, conjunctiva is not thickened 2)no scar and corneal pannus. Spring catarrh 1)papillae are large and flat, no lesion on upper fornix 2)no cornea pannus 3)eosinophil cells in secretion smear Inclusion conjunctivitis 1)follicles in lower palpebral and fornix conjunctiva 2)no corneal pannus and scar.

Chlamydial conjunctivitis Trachoma(treatment) Topical tetracyclin, erythromycin Systemic sulfadiazine, rifampin Operative: sequelae and complication

Viral conjunctivitis Acute follicullar viral conjunctivitis: epidemic keratoconjunctivitis herpes simplex conjunctivitis epidemic hemorrhagic conjunctivitis Relative subacute or chronic conjunctivitis: besides conjunctivitis, complicated with palpebral, cornea, as well as systemic clinical findings

Viral conjunctivitis Epidemic keratoconjunctivitis Acute onset, strong infectivity, may be sporadic or epidemic Etiology: adenovirus, type 8, 19, 29 and 37.

Viral conjunctivitis Epidemic keratoconjunctivitis Clinical findings: 1)incubation period: 5-7d. 2)foreign body sensation, itching, pain, photophopia and tearing 3)palpebral edema, conjunctival hyperemia and chemosis, less and watery secretion, follicles in palpebral and fornix conjunctiva, preauricular lymphadeectasis and tenderness 4)be cured after one week exacerbate: superfial punctate keratitis

Viral conjunctivitis Epidemic keratoconjunctivitis Diagnosis: Acute folliclar cinjunctivitis superfial punctate keratitis preauricular lymphadenectasis neutrophial Treatment: no specific drug 1)antiviral:topical(mainly) and systemic-acyclic 2)antibiotic

Viral conjunctivitis Epidemic hemorrhagic conjunctivitis Fulminant epidemic ocular infections Etiology: entero-virus type 70, picornavirus Coxsackie virus type A 24 Clinical findings: 1)incubation period: 24hr 2)ill course: self-limited, 10d or shorter

Viral conjunctivitis Epidemic hemorrhagic conjunctivitis Clinical findings: 3)ophthalmagia, foreign body sensation, photophopia and tears 4)eyelid and conjunctiva red and swollen, watery secretion, follicular hyperplasis of palpebral conjunctiva, patchy hemorrhage on bulbar conjunctiva, preauricular lymphadenectasis 5) Transient fine punctate epithelial keratitis

Allergic conjunctivitis Vernal conjunctivitis(spring catarrh) A seasonal disease, also named spring catarrh, with recurrence in warm spring, summer, commonly seen in youth (male) with age under 20 years, bilateral, relapses every year. Etiology: unclear, immunologic disorder (type I of allergic reaction) sensitinogen: plant pollen, dust, animal furfurous, feather, sun light temperature, antigenic components of microorganisms

Allergic conjunctivitis Vernal conjunctivitis (Clinical findings) Symptom:extreme itching Sign 1)palpebral type: papillary hyperplasia in the upper palpebral conjunctiva that like oval flat cobblestone, eosinophillia in secretion 2)corneal limbal type: collid tubercles at the corneal limbus 3)mixed type:

Allergic conjunctivitis Vernal conjunctivitis Treatment: 1)self-limited, no vision affected 2)general treatment: keep away proble sensitinogen 3)medical treatment: natrii cromoglycas corticosteroid

Allergic conjunctivitis Immediated allergic antigen: pollen, contact lens, etc. Delayed one: various drug Clinical findings: immediate type: dermatitis of palpebral skin, blepharitis, mild infiltrative conjunctivitis

Allergic conjunctivitis Lab examination: degenerative epithelial cell, few polynuclear cells and mononuclear cells in secretion Treatment: 1)find out and get rid of sensitinogen 2)corticosteroid 3)3% boric solution 4)anti-allergic agents

Allergic conjunctivitis phlyctenular keratoconjunctivitis Etiology: delayed reaction to protein of microorganism, mostly to mycobecterium tuberculosis and staphylococcus aureus Clinical findings: herpetic tubercle may appear on the bulbar conjunctiva or limbus.

Tears,tears film and xerosis Tears Mainly produced by the lacrimal gland and conjunctival goblet cells. Volume: 5-9ul Major organic component: protein albumin, globulin, lysozyme immunoglobulin (IgA,IgG,IgE) Main ions: K+Na+Cl- A little Lipin, glucose, urea PH: 5.20-8.35(7.35) isotonic

Tears,tears film and xerosis Tears film Tear film: tears form a thin layer (about 7-10um thick), composed three layers: lipid, watery, mucous layer. Functions: 1)cover and fill in corneal surface, to make the cornea be a smooth optic interface 2)moisten and protect corneal and conjunctival epithelium 3)inhibit the growth of microorganism through mechanical and antimicrobic effect 4)supply necessary nutrient to the cornea

Tears,tears film and xerosis primary tear dysfunction any abnormality of involved component in tear film, deficiency of tear secretion or its abnormal distribution or maintenance Rubbing and foreign body sensation, drying and burning sensation Conjunctival hyperemia, mucous filamentous secretion, papillary hyperplasia, filamentous keratitis Schirmer test, rupture time of the tear film, fluorescein staining of corneal epithelium

Tears,tears film and xerosis Xerosis of conjunctiva Epithelial xerosis dificency of vitamin A, when complicated with corneal epithelial xerosis called xerophthalmia Xerosis of conjunctivae Parenchymatosa caused by topical ocular disorder 1)cicatricial xerosis of conjunctiva 2)exposure keratoconjunctival xerosis Keratoconjunctivitis sicca an autoimmune disorder, Sjogren syndrome

Tears,tears film and xerosis Xerosis of conjunctiva Treatment: 1)etiological treatment 2)treatment against deficiency of tear secretion

Other common conjunctival disorders Pterygium Etiology: unclear, outdoor work Clinical findings: 1)hypertrophic bular conjunctiva and its subconjunctival tissue invade onto the cornea with the shape of tiangle 2)composed of head, neck, body. 3)progressive, stationary 4)differentiated with pseudopterygium Treatment: operation

Other common conjunctival disorders Pinquecula A degenerative lesion of the bulbar conjunctiva caused by the effect of ultraviolet rays Clinical findings: a kind of white–yellow amorphous subepithelial deposition near to the limbus Treatment: no needed

Other common conjunctival disorders Subconjunctival hemorrhage Caused by vascular rupture beneath the bulbar conjunctiva or by osmotic increase of vascular wall Causes: injury, severe cough, conjunctival inflammation, hypertension, arteriosclerosis, nephritis, hemotopathy, infectious diseases Treatment: 1)find out the cause 2)good explanation

Other common conjunctival disorders Conjunctival concretion Concrement on the palpebral conjunctiva Old or those with chronic conjunctivitis White-yellow deposit Treatment: no need be rejected