The Disease of Conjunctiva (結膜) /Sclera (鞏膜) 眼科 黃奕勛 醫師

Palpebral, bulbar conjunctiva, fornix

Slit Lamp (裂隙燈、細隙燈)

Pinguecula (結膜黃斑) & Pterygium (眼翳) Pinguecula: elevated yellow nodule near limbus in palpebral fissure Pterygium: triangular fold of bulbar conjunctiva loosely attached to cornea except at the apex elastoid degeneration Sun (uv light), wind,--- usually nasal side, surgery excision for corneal astigmatism, visual axis involvement and cosmetic

Miscellaneous conjunctival disorders Conjunctival concretions (眼結石) : epithelial inclusion cysts filled with epithelial and keratin debris, elderly or chronic conjunctivitis, remove when irritation Subconjunctival hemorrhage (結膜下出血 ) spontaneous, trauma, acute viral or bacterial conjunctivitis, Valsalva maneuver -- single eye, no treatment, 1-2 wks subside recurrent and both eyes: suspect blood dyscrasis

Symptoms of conjunctivitis Non-specific symptoms: lacrimation, irritation, stinging, burning, photophobia, --- If pain or FB sensation --> associated corneal involvement Itching, hallmark of allergic conjunctivitis

Discharge Watery - acute viral and allergic inflammations Mucoid - VKC, dry eye Purulent - acute bacteria infection Mucopurulent – mild bacterial and chlamydia infection

Etiologic classification of conjunctivitis Bacterial Chlamydial Viral Allergic Chemical/toxic or irritative Associated with systemic disease, etiology unknown Rickettsial, fungal, parasitic

Bacterial conjunctivitis Common, usually self-limited, mostly children Direct contact or from nasal and sinus mucosa Conjunctival inflammation and purulent discharge Organisms: Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae, -- Hyperacute (onset<24hrs): Neisseria gonorrhoeae, N. meningitidis

Gonococal conjunctivitis G (-) diplococcus Neisseria gonorrhoeae Adult: self contamination, acute onset with marked purulence, may progression to severe keratitis Ophthalmia neonatorum: 3-5 days after parturition, profuse purulent discharge with swollen lids Treatment: topical gentamicin Parenteral penicillin, 3rd cephalosporin, ---

Chlamydial conjunctivitis—Trachoma (砂眼) Chalmydia trachoma serotype A-C Chronic follicular conjunctivitis, pannus formation, limbal follicles and Herberts pits, later scaring of conjunctiva (Arlt’s line), upper tarsal>lower Late complication: tear deficiency, dacryostenosis, entropion, trichiasis, corneal scarring, salzman’s nodules Giemsa stain: basophilic intracytoplsmic epithelial inclusions Immunofluorescent testing, EIA(Enzyme immunoassay), PCR, McCoy cell culture, --- Treat with topical and oral tetracycline or erythromycin Leading cause of preventable blindness in the world

Trachoma – Early (tarsal follicles and Herbert’s pits)

Trachoma - Late

Viral conjunctivitis Via respiratory or ocular secretions Epidemic keratoconjunctivitis (EKC) Adenovirus 8, 11, 19, 37 Epidemic hemorrhage keratoconjunctivitis (EHKC) Picornavirus (Enterovirus 70), coxaschievirus A24 subconjunctival hemmorrhage Pharyngoconjunctival fever (PCF) Adenovirus 3, 4, 7 fever, URI, conjunctivitis, transmitted by droplets , children

Adenoviral keratoconjunctivitis—Epidemic keratoconjunctivitis (EKC) Incubation:4-10 days Duration:14 days Acute onset red eye, watery discharge, photophobia, foreign body sensation, preauricular lymph node, second eye mild involvement Both eyes affected 60% cases

Treatment for EKC nature course is self limited; supportive treatment topical steroid when membrane formation, the eye is uncomfortable due to very severe inflammation or visual acuity diminished by keratitis Steroids do not shorten natural course of the disease but merely suppress the inflammation

Allergic rhinoconjunctivitis Itching, foreign body sensation, tearing, lid swelling, red conjunctiva, --- Tx: self limited, remove allergen, cool compress, Mast cell stabilizers, antihistamin, topical steroid, NSAID

隱形眼鏡配戴不適症候群 視力模糊、視力不穩、頭痛、眼睛轉動不舒服、彩色光圈、畏光、癢、流淚、異物感、燒灼感、疼痛 ---

原因 體質：乾眼症、過敏 環境：空調不佳、過度除濕 長時間配戴 驗配之問題：弧度太鬆或太緊 清潔不當 角膜炎：感染性或非感染性 結膜炎：化學毒性或過敏性

CL related allergy and toxicity CL intrinsically inert Solution chemicals and lens deposits Allergy termed a hypersensitivity reaction Toxicity direct effect of chemicals Increased risk of extended wear SCL

Giant papillary conjunctivitis (GPC, 巨大乳頭狀結膜炎 ) Soft CL>Hard CL; exposure sutures; ocular prosthesis Redness, itching, mucoid discharge, CL intolerance, lens decentration Abnormal large papillae (>0.3 mm) on super tarsal conjunctiva Mechanical trauma, hypersensitivity to CL or adherent material

Treatment of GPC Discontinue CL wear Improving lens hygiene Discarding or refitting, daily wear, disposable CL or RGP Topical steroid, mast-cell stabilizer

Episcleritis and Scleritis

Sclera posterior 5/6 of the globe dense connective tissue composed of collagen bundles of varying diameters (primary type1) opaque appearance: less uniform orientation of collagen fibers

Normal, episcleritis, scleritis

Episcleritis simple 78.3% nodular 21.7%

Disease Entities - Inflammation A: Episcleritis inflammation of episcleral tissue between recti m. insertion & limbus, episcleral edema without scleral edema sudden onset with localized injection and swelling in interpalpebral region unilateral in 2/3 cases cause unknown, maybe hypersensitivity reaction 20-50 y/o transient attack, <10 days, 60 % recurrent in either eye, minor associated disease

Episcleritis course and management: transient, self-limit, ocular redness with mild irritation, blanch with topical phenylephrine topical vasoconstrictors, NSAIDs, corticosteroid oral NSAIDs

Scleritis intense dull radiating pain of insidious onset, bilateral, recurrent other ocular findings: keratitis: 50% with scleritis iridocyclitis: 50% with scleritis vitritis, secondary glaucoma, cataract, macular edema, choroidal detachment, -- Mechanism: immune-mediated (typically immune-complex) vasculitis lead to destruction of sclera one third (diffuse or nodular scleritis) to two thirds (necrotizing scleritis) pts associated with systemic diseases, the most common rheumatoid arthritis women are more commonly affected

Treatment Medical underlying disease almost never responds to topical tx alone systemic corticosteroid, NSAID, immunosuppressive agents

重點複習

Adenoviral keratoconjunctivitis—Epidemic keratoconjunctivitis (EKC) Incubation:4-10 days Duration:14 days Acute onset red eye, watery discharge, photophobia, foreign body sensation, preauricular lymph node, second eye mild involvement Both eyes affected 60% cases

Giant papillary conjunctivitis (GPC, 巨大乳頭狀結膜炎 ) Soft CL>Hard CL; exposure sutures; ocular prosthesis Redness, itching, mucoid discharge, CL intolerance, lens decentration Abnormal large papillae (>0.3 mm) on super tarsal conjunctiva Mechanical trauma, hypersensitivity to CL or adherent material