Transcript Conjunctiva and Diseases

Conjunctiva and
Diseases
Juan S. Lopez, MD
Conjunctiva
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Thin transparent mucous
membrane:
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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
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Palpebral conjunctiva:
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firmly adherent to the tarsus
Covers the episcleral tissue to become the bulbar
conjunctiva
Bulbar conjunctiva:
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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
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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
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It is a transition zone
containing both cutaneous
and mucous membrane
elements.
Histology of conjunctiva:
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Conjunctival epithelium:
 2-5 layers of stratified columnar epithelial cells
 Superficial cells- contains mucus-secreting goblet cells
 Basal cells- stains deeply and contains pigment
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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
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Glands of Krause- upper fornix
Glands of Wolfring- lies at the superior margin of the upper tarsus
Blood supply, lymphatics and
nerve supply
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Blood supply:
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Lymphatics:
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Anterior ciliary and palpebral arteries
arranged in superficial and deep layers
Nerve supply:
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ophthalmic division of fifth nerve
Small number of pain fibers
Conjunctivitis
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Inflammation of the
conjunctiva
Most common eye
disease worldwide
Mostly exogenous
cause
Epithelial edema;
chemosis, follicle
formation; granuloma
formation
Symptoms of conjunctivitis
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Foreign body sensation
Scratching or burning sensation
Itching
Photophobia
Signs of conjunctivitis
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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
• Acute onset, unilateral or bilateral
• Redness, mucopurulent or purulent discharge
• Lids swollen, stuck in the morning w/ discharge
• Mild to severe
Bacterial Conjunctivitis
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Hyperacute bacterial
conjunctivitis
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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
Signs
Acute, profuse, purulent discharge,
hyperaemia and chemosis
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Complications
Corneal ulceration, perforation
and endophthalmitis if severe
Bacterial Conjunctivitis
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Acute mucopurulent•
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Strep pneumoniae
Haemophilus
Chronic- > 2 weeks
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Corynebacterium
Strep pyogenes
Moraxella sp.
Bacterial Conjunctivitis
Course and prognosis:
Untreated: 1 -14 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
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Inclusion Conjunctivitis- serotypes D-K
Trachoma- serotypes A, B, Ba, C
Adult chlamydial keratoconjunctivitis
• Infection with Chlamydia trachomatis serotypes D to K
• Concomitant genital infection is common
•Scarring is not common
Subacute, mucopurulent follicular
conjunctivitis
Variable peripheral keratitis
Treatment - topical tetracycline and oral tetracycline
or erythromycin
*(Systemic tetracycline should not be given to pregnant
Or children < 7 years old)
Neonatal chlamydial conjunctivitis
• Presents between 5 and 19 days after birth
• May be associated with otitis, rhinitis and pneumonitis
Mucopurulent PAPILLARY conjunctivitis
Treatment - topical tetracycline and oral erythromycin
Trachoma
• Infection with serotypes A, B, Ba and C of Chlamydia
trachomatis
• Fly is major vector in infection-reinfection cycle
Progression
Acute follicular
conjunctivis
Pannus formation
Conjunctival
scarring (Arlt line)
Trichiasis
Herbert pits
Cicatricial entropion
Treatment - systemic tetracyclines, doxycycline, azithromycin
Viral Conjunctivitis
• Very common
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Referred to by general public as “sore eyes”
Easily spread, epidemic form
Usually bilateral
Mild to severe
Redness, lid swelling, tearing
Watery, mucoid or mucopurulent discharge
Associated w/ fever, sorethroat
Viral Conjunctivitis
Adenoviruses- usual etiology
› Most common cause of Membranous
conjunctivitis
› Pharyngoconjunctival Fever (PCF) - types 3,7
› Epidemic Keratoconjunctivitis ( EKC 25%)
- types 8, 19
• Enterovirus 70, Coxsackievirus A24
- rare epidemics
› Acute Hemorrhagic Conjunctivitis (AHC)
• Varicella Zoster
• Herpes Simplex
• Measles
Viral:
Pharyngoconjunctival Fever
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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
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Usually bilateral
involvement
Pain, injection, tearing,
photophobia, chemosis,
conjunctival hyperemia,
pseudomemebranes
Causative agent:
Adenovirus 8, 19, 29,
37
Viral:
Epidemic Keratoconjunctivitis
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No specific therapy
Cold compresses
Antibacterial agents in cases of bacterial
superinfection
Viral: Herpes Simplex
Keratoconjunctivitis
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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
Signs
Unilateral eyelid vesicles
Acute follicular conjunctivitis
Viral: Varicella-Zoster
conjunctivitis
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With typical vesicular eruption along the
dermatomal distribution of V1
Scrapings may contain: giant cells and
monocytes
Treatment: Oral acyclovir
Viral: Measles Conjunctivitis
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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
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Itching: severe
Hyperemia: generalized
Preauricular adenopathy: none
Stained scrapings & exudates:
eosinophils
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Tearing: moderate
Exudation: minimal
Allergic Conjunctivitis
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Hay fever conjunctivitis
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Commonly associated with allergic rhinitis
(+) history of allergy
(+) itching, tearing, redness
Papillary reaction
Treatment: topical antihistamines; mast-cell stabilizers
Allergic Conjunctivitis
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Vernal
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“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
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Treatment:
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Mast cell stabilizer
Antihistamines
Cold compresses, air-conditioned rooms
Short course topical or systemic steroids
Allergic Conjunctivitis
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Atopic conjunctivitis
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Usually presents with atopic dermatitis (Eczema)
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Dermatologic signs: scarring of flexure creases of
the wrists and knees
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Scrapings: eosinophils
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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
Viral
Bacterial
Chlamydial
Allergic
Itching
Minimal
Minimal
Minimal
Sever
Hyperemia
Generalized
Generalized
Generalized
Generalized
Tearing
Profuse
Moderate
Moderate
Moderate
Exudation
Minimal
Profuse
Profuse
Minimal
Preaurical
adenopathy
Common
Uncommon
Common in
inclusion conj
None
Scrapings &
exudates
Monocytes
Bacteria,
PMN’s
PMN, plasma
cells inclusion
bodies
Eosinophils
Sore throat &
fever
Occasional
Occasional
Never
Never
Chemical Conjunctivitis
• True Ocular Emergency
• Acids denature tissue protein immediately
- (Coagulative necrosis)
• Alkalies penetrate tissues deeper & linger
- (Liquefactive necrosis)
- can cause symblepharon (palpebral & bulbar conj
adhesion) and corneal leukoma
• Pain, redness, photophobia, blepharospasm
• Severe burns have poor prognosis
Chemical Conjunctivitis
Localized conj. ischemia
Diffuse conj. ischemia
Symblepharon, Corneal fibrovascular membrane
Chemical Burns
Treatment:
› Immediate profuse irrigation w/ water or saline solution
at least for 1 hour!!!
 No Chemical antidotes!!!
› Remove any solid material
› Cold compresses, analgesic, topical antibiotic, pupillary
dilation
› Surgery for remediable cases
Degenerative Diseases of the
Conjunctiva
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Pinguecula
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Yellow nodules on the sides
of the cornea
Commonly inflammed
(pingueculitis)
Usually no treatment,
unless inflammed
Pterygium
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Fleshy, triangular
encroachment on the
cornea
Risk factors: UV exposure,
dry or windy envt
Tx: excision of pterygium
Conjunctivitis due to
Autoimmune Disease
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Keratoconjunctivitis sicca
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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
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Cicatricial pemphigoid
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Non specific chronic conjunctivitis that is resistant to therapy
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Eventually leads to progressive scarring, obliteration of the
fornices, entropion and trichiasis
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Biopsy: eosinophils
Oral ulcers
Skin ulcers
Ocular cicatricial pemphigoid
Diffuse hyperemia
Subepithelial fibrosis and
shrinkage
Pseudomembrane formation
Symblepharon
Complications of OCP
Ankyloblepharon
Metaplastic lashes
Corneal keratinization Total obliteration of
fornices
Cicatricial entropion
Secondary bacterial
keratitis
Subconjunctival Hemorrhage
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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
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Nevus
Papilloma
Dermoid tumor
Lipodermoid/Dermolipoma
Malignant
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Carcinoma
Malignant Melanoma
Conjunctival Nevus
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Presents in first two decades
Sharply demarcated and slightly
elevated
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Most frequently juxtalimbal
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30% are almost non-pigmented
Conjunctival Papilloma
Pedunculated
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Presents in childhood or early
adulthood
Infection with papilloma virus
May be multiple and bilateral
Sessile
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Presents in middle age
Not caused by infection
Single and unilateral
Conjunctival dermoid tumor
Signs
Presents in childhood
• Smooth, soft mass, with hair follicles
Removal indicated for cosmetic reasons
Association
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Occasionally Goldenhar
syndrome
Lipodermoid
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common congenital tumor
Soft, movable, subconjunctival mass
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Most frequently at outer canthus
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Intraepithelial neoplasia
(carcinoma in situ)
Signs
Presents in late adulthood
•Resembles pterygium
• Juxtalimbal fleshy avascular mass
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Progression
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May become vascular and extend onto
cornea
Tx: Excisional biopsy
Malignant Melanoma
Signs
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Presents in late adulthood
Unilateral, irregular areas of flat,
brown pigmentation
May involve any part of conjunctiva
Types
Most arise from areas of primary
•acquired melanosis (PAM); some from
conjunctival nevi
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Conjunctival melanoma
From PAM with atypia
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Most common type
Sudden appearance of
nodules
From nevus
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Primary
• Solitary nodule
Very rare
Sudden increase in size • Frequently juxtalimbal
but may be anywhere
or pigmentation
Treatment of conjunctival melanoma
Localized tumor
Diffuse tumor
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Excision
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Adjunctive cryotherapy
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Excision of nodules
Adjunctive cryotherapy or
mitomycin C
Orbital recurrence
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Excision and
radiotherapy
Exenteration
Conjunctivitis associated with
other diseases
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Ocular rosacea-associated with acne rosacea
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Psoriasis- 10% may involve the cornea
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Steven Johnson’s syndrome- mucous membrane and skin involvement
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Reiter’s syndrome- triad of nonspecific urethritis, arthritis, and conjunctivitis
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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
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Gouty conjunctivitis- associated with gouty attacks
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Conjunctivitis in thyroid disease-