1. Conjunctiva Applied anatomy Evaluation of conjunctival inflammation
Infective conjunctivitis
Acute catarrhal conjunctivitis
Purulent conjunctivitis

2. Applied Anatomy
Thin layer of mucous membrane that lines the posterior surface of the lid and is reflected to cover the anterior part of the sclera
3 parts
palpebral: attached to the eyelid
bulbar : attached to the limbus
fornix : cul-de- sac

3. Applied Anatomy Structure 1. Epithelium 2. Adenoid layer
2 to 5 layers thick
mucus secreting goblet cells esp. in the bulbar and fornices
2. Adenoid layer
Lymphoid layer - lymphocytes
Most developed in fornix
Develops 3-4 months after birth
3. Fibrous layer
Collagenous & elastic fibres
Contains vessels & nerves

4. Glands of conjunctiva:
Mucin secretory glands
- goblet cells ( epithelium)
- crypts of henle (tarsal conj.)
- glands of manz (limbus)
2. Accessory lacrimal glands
- Glands of Krausse ( fornix )
- Glands of wolfring (tarsal margins)

5. Applied Anatomy
Blood supply : per. & marginal arcade of lids & ant.ciliary arteries
Nerve supply : Ophthalmic division of 5th nerve
Functions : free movement of the eyeball
: protective mechanism against micro-
organisms
: smooth surface as the lid blinks

6. Evaluation of conjunctival inflammation 1. Symptoms
Most common : lacrimation, irritation, burning, photophobia
Pain and FB sensation --- corneal involvement
Itching --- allergic nature BUT it can also occur in blepharitis and KCS

7. Evaluation of conjunctival inflammation 2. Discharge
Watery in acute allergic or viral inflammation
Mucoid in in Vernal and KCS
Purulent in acute bacterial infections
Mucopurulent in chlamydial or mild bacterial infections

10. Discharge associated with conjunctiva
Etiology
Serous
Mucoid
Mucopurulent
Purulent
Viral
Bacterial
Chlamydia
Allergy
Toxic + -

11. Evaluation of conjunctival inflammation- 3. Conjunctival appearance
Conjunctival injection or congestion : max. in the fornices
Subconjunctival haemorrhage in viral and bacterial infections
Membranes
Follicular reaction
Papillary reaction
Oedema [ chemosis ]
Scarring

13. Subconjuntival haemmorhage in viral, also in bacterial
Conjunctival congestion in
the fornices

14. Membranes Pseudomembranes - coagulated exudate adherent to
the inflammed conjunctiva
- it can be peeled off
- eg. Gonoccocal , adenoviral
conjunctivitis
True membranes
-Inflammatory exudate permeates sup. conjunctival layers
-Tear the epithelium to peel it off.
- Bleeding
- Eg. β- haem.streptococci,diphtheria

15. Evaluation of conjunctival inflammation- 3. Conjunctival appearance
Follicular reaction
Defn : hyperplasia of lymphoid tissue
Prominent in the fornix
Multiple discrete elevated lesions encircled by a tiny blood vessel
Size about 0.5 to 5mm
Causes : viral,
: chlamydia,
: parinaudglandular syndrome,
: hypersensitivity to topical medication

17. Evaluation of conjunctival inflammation- 3. Conjunctival appearance
Papillary reaction
Hyperplastic conjunctival epithelium
Contains a central core of blood vessels surrounded by chronic inflammatory cells [ lymphocytes,plasma cells, eosinophils ]
Mosaic like pattern consists of polygonal hyperaemic area separated by paler channels.
Causes : chronic blepharitis, allergic conjunctivitis , contact- lens related problems

18. Chemosis- oedema

20. Scarring [ eg. in trachoma, ocular pemphigoid ]

21. Lymphadenopathy Drainage : Found in: - Viral infection
corresponds to eyelids to the preauricular and submandibular nodes
Found in:
- Viral infection
- Chlamydial
- Severe gonoccocal
infections

22. Conjunctivitis
Defn : inflammation of conjunctiva characterised by redness of the eye and conjunctival discharge.
Classification : Aetiological
: Clinical

23. Aetiological Classification
1. Infective : bacterial , viral, fungal and chlamydial group
2. Non – infective : allergic, chemical, traumatic ,
keratoconjunctivitis associated with skin and mucus membrane disorders and miscellaneous

24. Infective conjunctivitis
Bacterial
- gram + eg. Staph. Epidermidis and aureus , Strept. Pneumoniae
- gram –ve eg. are H. Influenzae , N. Gonococcus, Moraxella
lacunata
Viral :
Adenovirus, herpes simplex , zoster, measles, chickenpox etc.
Fungal: candida albicans
Chlamydia group of organisms [ not a true virus]
eg. trachoma , inclusion conjunctivitis

25. Non - Infective conjunctivitis
Allergic : vernal, phlyctenular conjunctivitis
Chemical : acid and alkali
Miscellaneous : def. of lacrimal secretion [ KCS ]
: uncorrected refractive errors
: ocular pemphigus

26. Clinical classification
Acute mucopurulent
Acute purulent
Serous
Chronic simple
Angular
Membranous
Pseudomembranous
Papillary
Follicular
Ophthalmia neonatorum
Granulomatous
Ulcerative
Cicatrising

27. Acute mucopurulent conjunctivitis

28. Acute mucopurulent conjunctivitis
Acute simple , acute bacterial or acute catarrhal conjunctivitis
Causes : eg. Staph. Aureus., Strept. Viridans , H. influenza
Source of infection : nose assoc. with hay fever or measles
Affects all age groups and all times during the year
Spread through droplet infection, contact [ fingers, towels ]
Symptoms : photophobia
: burning sensation
: sticky eyelids
: blurring of vision – mucus lying on the cornea
: usually involves both eyes

29. Acute mucopurulent conjunctivitis
Signs :
Conjunctiva : bulbar and fornix are beefy red and swollen ---whole conj. is red.
Secretion : Watery – mucoid –mucopurulent
Lashes matted by yellow crusts
Cornea seldom involved : punctate epithelial defects

30. Acute mucopurulent conjunctivitis
Management
-- Conjunctival swab for C/S and Gram stain
-- Prophylaxis : avoid sharing articles
Treatment :
-- Clean the sac with normal saline
-- Instill antibiotic eye drops
Eg. Gutt. Chloromycetin 4h or 2h and Occ. CMC on.

31. Purulent conjunctivitis
Adult gonococcal keratoconjunctivitis
Caused by Neisseria G. [ gram –ve diplococcus ]
Systemic features
In men you get a purulent urethral discharge
In women : asymptomatic or dysuria or vaginal discharge
Ocular features:
Symptoms : Acute profuse, thick pus ocular discharge .

32. Purulent conjunctivitis
Ocular features:
Signs : Discharge
Eyelids : tender and oedematous
Conjunctiva : hyperemia , chemosis ,
pseudomembrane form.
Keratitis : marginal ulcers – ring ulcer
central corneal ulcer perforation

33. Purulent conjunctivitis
Management:
Investigations : C/S of the discharge
Treatment : Admission to hospital
: topical antibiotic[frequently ½ h or H ]
Penicillin,Gentamicin
: Cefotaxime 1 gram 6h x 10 – 14 days

34. Ophthalmia neonatorum

35. Ophthalmia neonatorum
Neonatal conjunctivitis transmitted from the mother during delivery
WHY is it severe at birth : absence of tears + lymphoid tissue at birth
Causes : N. gonorrhoeae [ 60% in developing countries ]
: Chlamydia [15 – 30-% ]
: Staph. Aureus
: Strept. Viridans, Haemolyticus
: Pneumococcus
Infection : during, or after birth
before birth if there is premature rupture of membranes

36. Ophthalmia neonatorum
Signs :
Can present within a few hours after birth or within the 1st month. There are 3 stages :
1st stage : Infiltration
Eye is tender to touch
Lids are swollen ,red and tense [ difficult to open them ]
Palpebral conjunctiva - swollen, velvety and red
- chemosis
- pseudomembrane
Secretion : serous + blood + little pus
Fever , preauricular lymphadenopathy

37. Ophthalmia neonatorum
Signs :
2nd stage : Blenorrhoea which can last for 2 to 3 weeks
Eye is less tender to touch
Lids are less swollen
Palpebral conjunctiva - swollen, velvety and red
- chemosis is LESS
- pseudomembrane
Secretion : profuse thick yellow pus
3rd stage : Healing
pain and swelling subsides but the whole conjunctiva
will appear RED , velvety or granular

38. Ophthalmia neonatorum
Management:
1. Prophylaxis :
Antenatal period : mother should be treated for any
suspicious vaginal discharge
Crede’s method (1% silver nitrate )is not used
2. Investigation : eye discharge for gram stain and C/S
3. Treatment : irrigation of the eye with normal saline and
: removal of the eye discharge
: Topical penicillin 5,000 to 25,000units per ml.
every ½ h or H for 1 or 2 days and then to taper
: Other alternatives :
: In gonococcal infections
- investigate both the parents and treat them.
- For the infant IM benzyl pencillin 5,000units/kg
in 2 divided doses.

39. Ophthalmia neonatorum
Chlamydial Infections
Topical tetracycline 1% qds.
Oral erythromycin 50mgms /kg/day in divided doses for 3 weeks

40. Complications in Ophthalmia Neonatorum
Corneal perforation
Corneal opacities
Adherent leucoma
Anterior polar cataract
Anterior staphyloma
Panophthalmitis