Conjunctiva and Diseases Juan S. Lopez, MD

Conjunctiva Thin transparent mucous membrane: Posterior surface of the lids: palpebral conjunctiva Anterior surface of the sclera: bulbar conjunctiva Continuous with the skin at the lid margin (mucocutaneous junction) and with the corneal epithelium at the limbus

Conjunctiva Palpebral conjunctiva: firmly adherent to the tarsus Covers the episcleral tissue to become the bulbar conjunctiva Bulbar conjunctiva: Loosely attached to the orbital septum in the fornices Has many folds Allows the eye to move and enlarges the secretory conjunctival surface Loosely attached to Tenon’s capsule and the underlying sclera

Semi lunar fold- soft, movable, thickened fold of bulbar conjunctiva located at the inner canthus Caruncle- small, fleshy, epidermoid structure attached superficially to the inner portion of the semilunar fold It is a transition zone containing both cutaneous and mucous membrane elements.

Histology of conjunctiva: Conjunctival epithelium: 2-5 layers of stratified columnar epithelial cells Superficial cells- contains mucus-secreting goblet cells Basal cells- stains deeply and contains pigment Conjunctival stroma Adenoid-contains lymphoid tissue; “follicle-like structures”; does not develop until after 2 to 3 months Fibrous-composed of connective tissue that attaches to the tarsal plate; loosely arranged over the globe Accessory lacrimal glands of Krause and Wolfring Glands of Krause- upper fornix Glands of Wolfring- lies at the superior margin of the upper tarsus

Blood supply, lymphatics and nerve supply  Blood supply:  Anterior ciliary and palpebral arteries  Lymphatics:  arranged in superficial and deep layers  Nerve supply:  ophthalmic division of fifth nerve  Small number of pain fibers

Conjunctivitis Inflammation of the conjunctiva Most common eye disease worldwide Mostly exogenous cause Epithelial edema; chemosis, follicle formation; granuloma formation

Symptoms of conjunctivitis Foreign body sensation Scratching or burning sensation Itching Photophobia

Signs of conjunctivitis Hyperemia- most conspicuous sign Tearing Exudation Chemosis Papillary hypertrophy- bacterial, vernal Follicles- viral Pseudomembrane and membrane Granulomas Phylectenules- represent delayed hypersensitivity to microbes Preaurical lymphadenopathy*

Bacterial Conjunctivitis Bacterial Conjunctivitis Acute onset, unilateral or bilateral Acute onset, unilateral or bilateral Redness, mucopurulent or purulent discharge Redness, mucopurulent or purulent discharge Lids swollen, stuck in the morning w/ discharge Lids swollen, stuck in the morning w/ discharge Mild to severe Mild to severe

Bacterial Conjunctivitis Hyperacute bacterial conjunctivitis Usually caused by Neisseria Profuse purulent exudate Warrants immediate treatment If not treated can cause corneal damage or loss of eye Corneal melting

Gonococcal keratoconjunctivitis Acute, profuse, purulent discharge, hyperaemia and chemosis Corneal ulceration, perforation and endophthalmitis if severe SignsComplications

Bacterial Conjunctivitis Acute mucopurulent- Strep pneumoniae Haemophilus Chronic- > 2 weeks Corynebacterium Strep pyogenes Moraxella sp.

Bacterial Conjunctivitis Course and prognosis: Untreated: days With proper treatment: 1-3 days Treatment: Topical antibiotics Treat underlying cause (dacryocystitis, nasolacrimal duct obstruction) For Neisseria: topical antibiotics + 1 gm Ceftriaxone I

Chlamydial Conjunctivitis Inclusion Conjunctivitis- serotypes D-K Trachoma- serotypes A, B, Ba, C

Adult chlamydial keratoconjunctivitis Treatment Infection with Chlamydia trachomatis serotypes D to K Concomitant genital infection is common Scarring is not common Subacute, mucopurulent follicular conjunctivitis Variable peripheral keratitis - topical tetracycline and oral tetracycline or erythromycin *(Systemic tetracycline should not be given to pregnant Or children < 7 years old)

Neonatal chlamydial conjunctivitis Treatment May be associated with otitis, rhinitis and pneumonitis Presents between 5 and 19 days after birth Mucopurulent PAPILLARY conjunctivitis - topical tetracycline and oral erythromycin

Trachoma Treatment - systemic tetracyclines, doxycycline, azithromycin Infection with serotypes A, B, Ba and C of Chlamydia trachomatis Fly is major vector in infection-reinfection cycle Acute follicular conjunctivis Conjunctival scarring (Arlt line) Herbert pits Pannus formation Trichiasis Cicatricial entropion Progression

Viral Conjunctivitis Viral Conjunctivitis Very common Very common Referred to by general public as “sore eyes” Referred to by general public as “sore eyes” Easily spread, epidemic form Easily spread, epidemic form Usually bilateral Usually bilateral Mild to severe Mild to severe Redness, lid swelling, tearing Redness, lid swelling, tearing Watery, mucoid or mucopurulent discharge Watery, mucoid or mucopurulent discharge Associated w/ fever, sorethroat Associated w/ fever, sorethroat

Viral Conjunctivitis Adenoviruses- usual etiology › Most common cause of Membranous › Most common cause of Membranous conjunctivitis conjunctivitis › Pharyngoconjunctival Fever (PCF) - types 3,7 › Pharyngoconjunctival Fever (PCF) - types 3,7 › Epidemic Keratoconjunctivitis ( EKC 25%) › Epidemic Keratoconjunctivitis ( EKC 25%) - types 8, 19 - types 8, 19 Enterovirus 70, Coxsackievirus A24 Enterovirus 70, Coxsackievirus A24 - rare epidemics - rare epidemics › Acute Hemorrhagic Conjunctivitis (AHC) › Acute Hemorrhagic Conjunctivitis (AHC) Varicella Zoster Varicella Zoster Herpes Simplex Herpes Simplex Measles Measles

Viral: Pharyngoconjunctival Fever Characterized by fever, sore throat, non tender preauricular lymphadenopathy and follicular conjunctivitis in one or both eyes Causative agent: Adenovirus 3,4,7 Conjunctival scrapings: mononuclear cells Self limiting, usually lasts 10 days

Viral: Epidemic Keratoconjunctivitis Usually bilateral involvement Pain, injection, tearing, photophobia, chemosis, conjunctival hyperemia, pseudomemebranes Causative agent: Adenovirus 8, 19, 29, 37

Viral: Epidemic Keratoconjunctivitis No specific therapy Cold compresses Antibacterial agents in cases of bacterial superinfection

Viral: Herpes Simplex Keratoconjunctivitis Unilateral injection, irritation, mucoid discharge, photophobia Usually associated with Herpes simplex keratitis Cytology: mononuclear cells Usually self limited Treatment: Topical antivirals may be given to prevent corneal involvement

Herpes simplex conjunctivitis Unilateral eyelid vesicles Acute follicular conjunctivitis Signs

Viral: Varicella-Zoster conjunctivitis With typical vesicular eruption along the dermatomal distribution of V1 Scrapings may contain: giant cells and monocytes Treatment: Oral acyclovir

Viral: Measles Conjunctivitis Frequently precedes skin eruption Glassy appearance of conjunctivia (+) Koplik’s spots on the conjunctiva and caruncle Treatment: mainly supportive; may give topical antibacterial if superinfection occurs

Immunologic/Allergic Conjunctivitis … is an immediate hypersensitivity reaction in which triggering antigens couple to reaginic antibodies (IgE) on the cell surface of mast cells & basophils, leading to release of histamine from secretory granules.

Immunologic/Allergic Conjunctivitis Itching: severe Hyperemia: generalized Preauricular adenopathy: none Stained scrapings & exudates: eosinophils Tearing: moderate Exudation: minimal

Allergic Conjunctivitis Hay fever conjunctivitis Commonly associated with allergic rhinitis (+) history of allergy (+) itching, tearing, redness Papillary reaction Treatment: topical antihistamines; mast-cell stabilizers transient conjunctival edematransient eyelid edema

Allergic Conjunctivitis Vernal “Spring catarrh”/ “Seasonal conjunctivitis” Begins in puberty and lasts for 5-10 years boys> girls Common in warm countries Presentation: milky appearance of conj; stringy discharge Cobble stone appearance of upper palpebral conjunctiva

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

Allergic Conjunctivitis: Vernal Treatment: Mast cell stabilizer Antihistamines Cold compresses, air-conditioned rooms Short course topical or systemic steroids

Allergic Conjunctivitis Atopic conjunctivitis Usually presents with atopic dermatitis (Eczema) Dermatologic signs: scarring of flexure creases of the wrists and knees Scrapings: eosinophils Treatment: chronic course of mast cell stabilizer, short course steroids; environmental control

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

Summary of common types of conjunctivitis Clinical findings and cytology ViralBacterialChlamydialAllergic ItchingMinimal Sever HyperemiaGeneralized TearingProfuseModerate ExudationMinimalProfuse Minimal Preaurical adenopathy CommonUncommonCommon in inclusion conj None Scrapings & exudates MonocytesBacteria, PMN’s PMN, plasma cells inclusion bodies Eosinophils Sore throat & fever Occasional Never

Chemical Conjunctivitis Chemical Conjunctivitis True Ocular Emergency True Ocular Emergency Acids denature tissue protein immediately Acids denature tissue protein immediately - (Coagulative necrosis) Alkalies penetrate tissues deeper & linger Alkalies penetrate tissues deeper & linger - (Liquefactive necrosis) - (Liquefactive necrosis) - can cause symblepharon (palpebral & bulbar conj adhesion) and corneal leukoma Pain, redness, photophobia, blepharospasm Pain, redness, photophobia, blepharospasm Severe burns have poor prognosis Severe burns have poor prognosis

Chemical Conjunctivitis Chemical Conjunctivitis Localized conj. ischemia Diffuse conj. ischemia Symblepharon, Corneal fibrovascular membrane Symblepharon, Corneal fibrovascular membrane

Chemical Burns Treatment: › Immediate profuse irrigation w/ water or saline solution at least for 1 hour!!! › Immediate profuse irrigation w/ water or saline solution at least for 1 hour!!!  No Chemical antidotes!!! › Remove any solid material › Remove any solid material › Cold compresses, analgesic, topical antibiotic, pupillary dilation › Cold compresses, analgesic, topical antibiotic, pupillary dilation › Surgery for remediable cases › Surgery for remediable cases

Degenerative Diseases of the Conjunctiva Pinguecula - Yellow nodules on the sides of the cornea - Commonly inflammed (pingueculitis) - Usually no treatment, unless inflammed Pterygium - Fleshy, triangular encroachment on the cornea - Risk factors: UV exposure, dry or windy envt - Tx: excision of pterygium

Conjunctivitis due to Autoimmune Disease Keratoconjunctivitis sicca - Associated with Sjogren’s syndrome - Triad of xerostomia, connective tissue dysfunction, xerosis - More common in women - Lacrimal gland is infiltrated with lymphocytes and plasma cells - Ocular presentation: conjunctival hyperemia, mucoid discharge, diminished tear film - Treatment: tear film preservation, topical cyclosporine

Conjunctivitis due to Autoimmune Disease Cicatricial pemphigoid - Non specific chronic conjunctivitis that is resistant to therapy - Eventually leads to progressive scarring, obliteration of the fornices, entropion and trichiasis - Biopsy: eosinophils Oral ulcersSkin ulcers

Ocular cicatricial pemphigoid Diffuse hyperemia Subepithelial fibrosis and shrinkage Symblepharon Pseudomembrane formation

Complications of OCP Ankyloblepharon Corneal keratinization Metaplastic lashes Cicatricial entropion Total obliteration of fornices Secondary bacterial keratitis

Subconjunctival Hemorrhage Common disorder Sudden onset, bright red appearance Caused by rupture of small conjunctival vesells Forceful coughing, sneezing, rubbing, straining, increased BP Rule out blood dyscrasias if bilateral Tx: reassurance; hemorrhage absorbs in 2-3 weeks

Conjunctival Tumors Benign 1. Nevus 2. Papilloma 3. Dermoid tumor 4. Lipodermoid/Dermolipoma Malignant 1. Carcinoma 2. Malignant Melanoma

Conjunctival Nevus 30% are almost non-pigmented Most frequently juxtalimbal Sharply demarcated and slightly elevated Presents in first two decades

Conjunctival Papilloma PedunculatedSessile Presents in middle age Not caused by infection Single and unilateral Presents in childhood or early adulthood Infection with papilloma virus May be multiple and bilateral

Presents in childhood Smooth, soft mass, with hair follicles Removal indicated for cosmetic reasons Occasionally Goldenhar syndrome Conjunctival dermoid tumor Signs Association

Lipodermoid common congenital tumor Soft, movable, subconjunctival mass Most frequently at outer canthus

Intraepithelial neoplasia (carcinoma in situ) Juxtalimbal fleshy avascular mass May become vascular and extend onto cornea Presents in late adulthood Resembles pterygium Tx: Excisional biopsy SignsProgression

Malignant Melanoma Most arise from areas of primary acquired melanosis (PAM); some from conjunctival nevi Unilateral, irregular areas of flat, brown pigmentation May involve any part of conjunctiva Presents in late adulthood SignsTypes

Conjunctival melanoma From PAM with atypia Sudden appearance of nodules From nevus Sudden increase in size or pigmentation Primary Solitary nodule Frequently juxtalimbal but may be anywhere Very rare Most common type

Localized tumor Excision Treatment of conjunctival melanoma Diffuse tumor Excision of nodules Orbital recurrence Excision and radiotherapy Adjunctive cryotherapy or mitomycin C Exenteration Adjunctive cryotherapy

Conjunctivitis associated with other diseases Ocular rosacea-associated with acne rosacea Psoriasis- 10% may involve the cornea Steven Johnson’s syndrome- mucous membrane and skin involvement Reiter’s syndrome- triad of nonspecific urethritis, arthritis, and conjunctivitis Kawasaki disease- lips and oral cavity change, fever that fails to respond to antibiotics, erythema of palms and soles, exanthem of the trunk, swelling of cervical lymph nodes, conjunctivitis Gouty conjunctivitis- associated with gouty attacks Conjunctivitis in thyroid disease-