CONJUNCTIVA: ANATOMY, PHYSIOLOGY, SYMPTOMATOLOGY AND CLASSIFICATION Dr. Faizur Rahman Professor of Ophthalmology Peshawar Medical College.

Learning objectives At the end of the session the students would be able to: Correlate the structure of the conjunctiva with its functions and clinical presentations in common clinical disorders. Identify important anatomical landmarks of conjunctiva. Classify diseases of the conjunctiva. Identify the common symptoms and signs of conjunctival disease, differentiate various conjuntivitidies and manage.

ANATOMY It is the mucous membrane covering the under surface of the lids and anterior part of the eyeball upto the cornea.

Parts of conjunctiva Palpebral; covering the lids—firmly adherent. Forniceal; covering the fornices—loose—thrown into folds. Bulbar; covering the eyeball—loosely attached except at limbus. Also marginal and limbal parts and plica semilunaris.

Palpebral conjunctiva Subtarsal sulcus 2mm from posterior edge of the lid margin. Richly vascular. Extremely thin. Strongly bound to the tarsal plate.

Conjunctival fornices Transitional region between palpebral and bulbar conjunctivae. Superior fornix 10 mm from limbus. Inferior fornix 8 mm from limbus. Lateral fornix 14mm from limbus. Medially absent. Ducts of lacrimal glands open into lateral part of superior fornix.

Bulbar conjunctiva Lies in contact with eyeball. Thin, translucent and loosely attached by connective tissue to sclera and fascia bulbi. Conjunctival limbus 1 mm anterior to corneal limbus. Bulbar limbus 1.5 mm behind corneal limbus.

Epithelium Stratified columnar epithelium 2 – 5 cells. At limbus change into stratified squamous non keratinized epithelium. At lid margin non keratinized stratified squamous epithelium changes into keratinized stratified squamous epithelium. Goblet cell – mucus. Accessory lacrimal glands.

Sub mucosa Fine delicate connective tissue. Lymphocytes. Denser fibrous tissue, blood vessels, nerves, smooth muscles and accessory lacrimal glands. Papillae.

Nerve supply - Sensory Bulbar conjunctiva – long ciliary nerves – nasociliary N. – Ophthalmic division of trigeminal N. Superior palpebral and forniceal conjunctiva – frontal and lacrimal branches of Ophthalmic division of trigeminal N. Inferior palpebral and forniceal conjunctiva – laterally from lacrimal branches of Ophthalmic division of trigeminal N. and medially infraorbital N. – Maxillary division of trigeminal N. Sympathetic; Superior cervical sympathetics to blood vessels.

Blood supply Arterial supply; Posterior conjunctival arteries derived from arterial arcade of lids which is formed by palpebral branches of nasal and lacrimal arteries of the lids. Anterior conjunctival arteries derived from the anterior ciliary arteries – muscular br. of ophthalmic artery to rectus muscles. Venous drainage; Palpebral and Ophthalmic veins.

Lymphatic drainage Lymph vessels are arranged as a superficial and a deep plexus in sub mucosa. Ultimately as in the lids to the pre auricular and sub-mandibular lymph glands.

PHYSIOLOGY Smooth surface. Secretes mucin and aqueous component of tear film. Highly vascular: supplies nutrition to the peripheral cornea. Aqueous veins drains from anterior chamber maintenance of IOP. Lymphoid tissue helps in combating infections. Basic secretion—reflex secretion.

Symptomatology Non-Specific; Lacrimation. Irritation. Stinging. Burning. Photophobia. Redness. Specific; Pain and FB sensation in corneal involvement. Itching in allergic, blephritis and dry eyes.

SIGNS Type of discharge. Type of conjunctival reaction. Presence of membrane/ pseudomembrane. Lymphadenopathy.

DISCHARGE Exudate plus debris plus mucus plus tears. Serous; watery exudate in acute viral and acute allergic conjunctivitis. Mucoid; mucus discharge in VKC and KCS (dry eyes). Purulent; puss in severe acute bacterial conjunctivitis. Mucopurulent; puss plus mucus in mild bacterial conjunctivitis and Chlamydial conjunctivitis.

TYPE OF CONJUNCTIVAL REACTION Hyperaemia: (Conjunctival injection) Bacterial. Sub-conjunctival Haemorrhage: Viral. Bleeding: Chemosis: (Oedema) Scarring: Trachoma, cicatricial pemphigoid, atopic conjunctivitis and prolong use of topical drops. Follicular reaction. Papillary reaction.

Follicular reaction Sub epithelial foci of hyperplastic of lymphoid tissue with in stroma. More prominent in fornices. Multiple, discrete, slightly elevated, lesions encircled by a tiny blood vessel—small grains of rice. Size from 0.5 to 5 mm. 1. Viral. 2. Chlamydial. 3. Parinaud oculoglandular syndrome. 4. Hypersensitivity to topical medications.

Follicular reaction

Papillary reaction Hyperplastic conjunctival epithelium. Can develop in palpebral conjunctiva (firmly attached) and limbus. Papilla may mask follicles. Giant papilla (confluence) Non-specific; (less diagnostic) 1. Chronic blephritis. 2. Allergic conjunctivitis. 3. Bacterial conjunctivitis. 4. Contact lens wears. 5. Superior limbic keratoconjunctivitis. 6. Floppy eyelid syndrome.

Pseudomembrane Outside epithelium. Coagulated exudate adherent to the inflammed epithelium. Can be easily pealed off. Causes; 1. Severe adenoviral infection. 2. Ligneous conjunctivitis. 3. Gonococcal conjunctivitis. 4. Stevens-Johnson syndrome.

Membrane Includes epithelium. Infiltrate the superficial layers of conjunctival epithelium. Epithelium is injured if removal attempted. Causes; 1. Diphtheria. 2. Beta-hemolytic steptococci.

Lymphadenopathy Pre auricular and sub mandibular. 1. Viral infection. 2. Chlamydial infection. 3. Severe bacterial infections. (Gonococcal) 4. Parinaud oculoglandular syndrome.

Laboratory Investigations Indications: Sever purulent conjunctivitis. Follicular conjunctivitis: viral vs chlamydial. Conjunctival inflammation. Neonatal conjunctivitis.

Laboratory Investigations— cont… Cultures. Cytological investigations. Inoculation. Detection of viral and chlamydial antigens. Impression cytology for ocular surface neoplasia, dry eyes, ocular cicatricial pemphigoid, limbal stem cells failure, infection. Polymerase chain reaction: small quantity of DNA for adenovirus, herpes simplex, chlamydia trachomatis.

CLASSIFICATION OF THE DISEASES OF CONJUNCTIVA

Morphological Papillary Follicular Pseudomembranous Membranous

Discharge Serous Mucous Purulant Mucopurulant

Etiological Infective Non-Infective: Allergic Autoimmune Toxic Chemical Degenerations

Clinical Acute Sub-acute Chronic Recurrent

Age Neonatal Childhood Adult

Neonatal Chlamydial Gonococcal Other bacteria Viral Chemical

Common Bacterial Mucopurulant Purulant Membraneous

CHLAMYDIAL OCULAR INFECTIONS Adult inclusion conjunctivitis. Neonatal chlamydial conjunctivitis. Trachoma.

Viral Adenoviral Picarna viral Herpes simplex Measles Chicken pox

Allergic Acute allergic conjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis Phlactenular keratoconjunctivitis

Autoimmune Phempegoid (Essential shrinkage of conjunctiva) Steven Johnson syndrome

Chemical Acid burns Alkali burns Others

Management Treat the cause: Anti-inflammatory agents Antibacterial Antiallergic Supportive Specific

Acute Bacterial Conjunctivitis Mucopurulant conjunctivitis Caused by: Staph epidermidis and Staph aureus – usually. Strep pneumonae, H influensae and Morexella lucanatae occasionally

Acute Bacterial Conjunctivitis Symptoms: *Acute onset of redness, grittiness, burning and discharge. *Photophobia may be present (corneal involvement) *Stickiness of the eyelids *Usually bilateral disease Signs: *Conjunctival hyperaema *Mild papillary reaction *Mucopurulant discharge *Lid crusting *No lymphadenopathy. *Normal VA

Acute Bacterial Conjunctivitis Purulant cojunctivitis (Adult gonococcal) Symptoms: *Hyperacute condition *Extremely profuse, thick, creamy puss from the eye or eyes

Acute Bacterial Conjunctivitis Signs: *Severe conjunctival chemosis *May be membrane formation *Periocular edema *Ocular tenderness *Gaze restriction *Lamphadenopathy *Corneal involvement Treatment Systemic and topical antiboitics

Chronic bacterial conjunctivitis Causes: *Acute becoming chronic *Refractive errors *Secondary Misplaced lashes, CDC, chronic blephritis Symptoms: Burning and photophobia Signs: *Congestion, and sticky discharge Treat: remove the cause antibiotics

Membraneous conjunctivitis Causes *Children with ill health *Low immunity after diseases *Corynbact diphtharae and virulant strains of beta hemolytic streptococci Symptoms: highly toxic and ill patient pyrexial membrane Signs: high temprature lid edema membrane

Angular conjunctivitis Adult infection More common in sprig and summers Hemophilis lacunatis involved Bilateral and contageous

Angular conjunctivitis Symptoms: Irritation Itching Smarting sensation in the eyes Signs: Hyperama Excoriation of conj epithelium Cong at medial and lat canthus Scanty mucopurulant discharge prolonge course corneal involvement

CHLAMYDIAL OCULAR INFECTIONS

Adult inclusion conjunctivitis. Neonatal chlamydial conjunctivitis. Trachoma.

TRACHOMA Etiology: Serotypes A, B, Ba & C of Chlamydia trachomatis. Transmission: Common fly (major Vector), fomites, fingers. Epidemiology: –Endemic in Africa, Asia, Middle East & Australia. –Leading cause of preventable blindness. –Worldwide 360 million people affected. –Six million people are blind from trachoma.

TRACHOMA Risk factors: –Poverty & deprived members of community. –Poor personal & community hygiene. –Infectious pool: Preschool children of both sexes & their care providers.

TRACHOMA Age: –Children: Follicular & inflammatory trachoma. –Young adults: Trachomatous scarring. –Middle-aged: Trichiasis & corneal opacity. Sex: Trichiasis & blindness 2-4 times more common in women than men.

PRESENTATION During childhood. Symptoms: –FB sensation. –Redness. –Lacrimation. –Scanty mucoid discharge. –Mucopurulent discharge if secondary infection.

STAGES I) Incipient: Characterized by: –Minute immature follicles in upper tarsal conjunctiva. –Cytoplasmic inclusions in conjunctival epithelium. –Stromal hyperemia & oedema.

STAGES IIa): Follicular hypertrophy: –Large soft expressible follicles in upper tarsus, fornix & limbus. –Punctate keratitis. –Follicular necrosis---Herbert’s pits. –Stromal infilteration by plasma cells & macrophages.

STAGES IIb): Papillary hypertrophy: –Trachoma of intense activity or chronic trachoma with superimposed bacterial infections. –Obscuration of follicles by papillary hypertrophy.

STAGES III): Cicatrizing trachoma: –Conjunctival Scarring---Arlt lines. –Pannus formation. –Lacrimal gland obstruction. –Trichiasis. –Entropion. –Symblepharon.

STAGES IV): Healed stage: –Resolution of inflammation. –Replacement of follicles & papillae by scar tissue.

DIAGNOSIS Clinical diagnosis of trachoma requires the presence of at least two of the following features: –Conjunctival follicles on upper tarsal conjunctiva. –Limbal follicles and their sequelae (Herbert’s pits). –Tarsal conjunctival scarring. –Fibrovascular pannus.

WHO GRADING 1. Trachomatous Follicles (TF): Presence of five or more follicles in the upper tarsal conjunctiva. 2. Trachomatous Inflammation (TI): Inflammatory thickening of the tarsal conjunctiva that obscures more than half of the normal deep tarsal vessels. 3. Trachomatous conjunctival Scarring (TS). 4. Trachomatous Trichiasis (TT): At least one eyelash touching the cornea. 5. Corneal opacity (CO).

COMPLICATIONS Upper lid entropion Trichiasis. Xerosis – obliteration of lacrimal ducts or glands. Chlazion. Symblepharon – obliteration of lower fornix. Corneal ulceration. Corneal opacity. Pseudoptosis.

MANAGEMENT SAFE strategy developed by WHO: Surgery: –To prevent blindness & limits progression of corneal scarring. –Can improve vision. Antibiotics: –Azithromycin—1 G single dose (adults). –Children: 20mg/kg single dose

MANAGEMENT Erythromycin 250 mg QID for 4 weeks. (children 125mg/kg). Tetracycline 250 mg QID for 4 weeks. Topical tetracycline 1% 0.5 inch ribbon BD for 6 weeks.

MANAGEMENT Facial cleanliness: –Reduces risk & severity of trachoma. Environmental change: –Improved water supply & household sanitation. –Personal & community hygiene. –Adequate housing & water & sewage system.

VIRUSES DNA /RNA particles covered by protein. Viruses are not cells, they are not capable of independent replication. Can synthesize neither their own energy nor their own proteins. They are too small to be seen by light microscope. Internal core of DNA/RNA + protective coat (lepoprotein envelope). Replication is different from animal. Obligatory intra-cellular pathogens. Several types of viruses can cause conjunctivitis.

VIRAL CONJUNCTIVITIS Inflammation with follicle formation—may be associated with enlargement of regional lymph glands. Severe conjunctival inflammation, minimal discharge, lacrimation, Sub-conjunctival hemorrhage. Mild hyperemia. Conjunctival ulcers or membrane formation. Corneal involvement; 1.Superficial punctate keratitis. 2.Superficial erosions. 3.Stromal infiltrates. 4.Necrotic stromal ulcer.

ACUTE FOLLICULAR CONJUNCTIVITIS Follicle formations with signs of acute cattharal inflammation may be produced by different viruses. 1. Acute herpetic conjunctivitis. 2. Epidemic Keratoconjunctivitis. 3. Pharyngo-conjunctival fever. 4. New castle conjunctivitis. 5. Acute hemorrhagic conjunctivitis. 6. Molluscum contagiosum conjunctivitis.

EPIDEMIC KERATOCONJUNCTIVITIS Adeno virus serotypes 8 & 19. Transmission: Direct or Indirect contact. Epidemics: Schools, work places & physicians. Mode of Spread: Contaminated fingers, medical instruments (tonometer), swimming pool or sexual contact. Self limiting. Highly infectious.

EPIDEMIC KERATOCONJUNCTIVITIS Conjunctivitis: Acute onset watering, redness, discomfort & photophobia, both eyes (60%). Signs: –Eyelids (oedematous). –Scanty discharge (watery).

EPIDEMIC KERATOCONJUNCTIVITIS Conjunctiva: –Follicular conjunctivitis. –Mild-moderate chemosis. –Haemorrhage. –Pseudomembrane formation. Tender pre-auricular lymphadenopathy. Keratitis (80%)- 7 to 10 days later in the form of superficial punctate keratitis, subepithelial opacities and may remain for quite a long time.

EPIDEMIC KERATOCONJUNCTIVITIS Treatment: Symptomatic & supportive. Spontaneous resolution within 2 weeks. Topical steroids to be avoided. Antivirals ineffective. Cold compresses, topical vasoconstrictors.

ACUTE HAEMORRHAGIC CONJUNCTIVITIS Enterovirus 70 & Coxsackie virus A 24. Sudden onset. Short duration. Bilateral, profuse watering and discharge. Palpebral follicles. Sub-conjunctival haemorrages. Lymphadenopathy. Mild transient epithelial keratitis.

Allergic Conjunctivitides

Definitions Allergy is an altered or exaggerated susceptibility to various foreign substances or physical agents which are harmless to the great majority of individuals. It is due to an antigen antibody reaction. Allergens is an agent capable of producing a state or manifestation of allergy.

TYPES OF ALLERGIC CONJUNCTIVITIS 1: ALLERGIC RHINOCONJUNCTIVITIS. 2: ACUTE ALLERGIC CONJUNCTIVITIS. 3:VERNAL KERATOCONJUNCTIVITIS. 4: ATOPIC KERATOCONJUNCTIVITIS. 5: GIANT PAPILLARY KERATOCONJUNCTIVITIS. 6: CONTACT OCULAR ALLERGY. 7: PHLACTENULAR CONJUNCTIVITIS.

Allergic Rhinoconjunctivitis Hypersensitivity reaction to specific airborn antigens. Frequently associated nasal symptoms. May be seasonal or perennial. Transient conjunctival oedema

VERNAL KERATOCONJUNCTIVITIS Common, recurrent, bilateral, external, ocular inflammation affecting children & young adults. 6 – 20 years. Males > Females. VKC IgE & cell mediated immune mechanism play an important role. 3/4 patients have associated Atopy. 2/3 have close family hx. of Atopy.

VERNAL KERATOCONJUNCTIVITIS Atopic pts. have Asthma & Eczema in infancy. Peripheral blood shows esinophilia & increase serum IgE levels. Onset: After 5 years. Resolves: around puberty. Sign/Symptoms: occur on seasonal basis. Peak Incidence: April - August. More common in warm, dry climates e.g., Mediterranean basin, Africa & East Asia.

Clinical Features Symptoms: Itching, lacrimation, photophobia, FB sensation, burning. Signs: Giant papilla, ptosis, hyperemia, mucus, trantas dots, punctate keratopathy, corneal ulcer.

Clinical Types 1: Palpebral VKC: Conjunctival hyperemia followed by a diffuse papillary hypertrophy (marked on superior tarsus). Papilla enlarge & have flat topped polygonal appearance of cobble stones. In severe cases C.T. septa rupture giving giant papillae which is coated by copious mucus. Active discharge by redness, swelling & tightly packed papilla.

2: Limbal VKC: characterized by mucoid nodules having smooth round surface discrete white superficial spots. trantas dots composed predominantly esinophils, fibroblasts & necrotic epithelium, scattered around limbus & the apices of the lesions.

Limbal vernal Trantas dots Mucoid nodule

3: Mixed: Signs of both palpebral & limbal VKC. Keratopathy: a) Punctate epitheliopathy. b) Macroerosions due to continuous epithelial loss. c) Plaque due to epithelial macroerosions in which the bare area becomes coated with layers of dessicated mucus cannot be wetted by tears resist re-epithelialization. d) Sub-epithelial scarring is a sign of previous severe corneal involvement. e) Pseudogeranotoxon (cupid’s bow). f) Keratoconus.

Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus Formation of cobblestone papillae Rupture of septae - giant papillae

Progression of vernal keratopathy Punctate epitheliopathyEpithelial macroerosions Plaque formation (shield ulcer)Subepithelial scarring

Treatment 1.Topical Steroid: Fluorometholone, Dexamethason, Prednisolone. 2. Mast cell stabilizers: Nedocromil 0.1%, Lodoxamide, Sodium Cromoglycate. 3. Acetyl-cysteine 5%. 4. Topical Cyclosporin 2%. 5. Debridement of early mucous plaque.

Treatment 6. Lamellar keratectomy of densely adherent plaques. 7. Excimer laser phototherapeutic keratectomy. 8. Amniotic membrane transplantation. 9. Supratarsal inj. of steroid: Betamethasone or triamcinolone. 10. Desensitizing immunotherapy.

ATOPIC KERATOCONJUNCTIVITIS Rare, potentially serious condition affects young (18-50 yrs) patients with atopic dermititis. Involved skin areas and lateral neck folds; antecubital and popliteal fossae. Pts have Asthma, hay fever, urticaria, Migraine, Rhinitis. Chronic conjuntivitis. Serem IgE raised.

Atopic keratoconjunctivitis Typically affects young patients with atopic dermatitis. Eyelids are red, thickened, macerated and fissured.

TOXIC KERATOCONJUNCTIVITIS Contact blepharoconjunctivitis due to drugs 1. Anaesthetics. 2. Atropine. 3. Gentamycin. 4. Neomycin. 5. Tobramycin. 6. Antivirals. 7. Epinephrine. 8. Pilocarpine. 9. Timolol. 10. Preservatives: Benzalkonium chloride Chlorobutanol Chlorhexidine EDTA Thimerosal 11. Cosmetics.

Differential diagnosis of red eye Conjunctival –Blepharoconjunctivitis –Bacterial conjunctivitis –Viral conjunctivitis –Chlamydial conjunctivitis –Allergic conjunctivitis –Toxic/chemical reaction –Dry eye –Pinguecula/pteyrgium Lid diseases –Clalazion –Sty –Abnormal lid function Corneal disease –Abrasion –Ulcer Foreign body Dacryoadenitis Dacryocystitis Masquerade syndrome Carotid and dural fistula Acute angle glaucoma Anterior uveitis Episcleritis/scleritis Subconjunctival hemorrhage Factitious

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