The Disease of Conjunctiva () /Sclera ()

Palpebral, bulbar conjunctiva, fornix

Slit Lamp ()

Pinguecula () & Pterygium () Pinguecula: elevated yellow nodule near limbus in palpebral fissurePterygium: triangular fold of bulbar conjunctiva loosely attached to cornea except at the apexelastoid degenerationSun (uv light), wind,---usually nasal side, surgery excision for corneal astigmatism, visual axis involvement and cosmetic

Miscellaneous conjunctival disordersConjunctival concretions () :epithelial inclusion cysts filled with epithelial and keratin debris, elderly or chronic conjunctivitis, remove when irritationSubconjunctival hemorrhage ( )spontaneous, trauma, acute viral or bacterial conjunctivitis, Valsalva maneuver --single eye, no treatment, 1-2 wks subsiderecurrent and both eyes: suspect blood dyscrasis

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

DischargeWatery - acute viral and allergic inflammationsMucoid - VKC, dry eyePurulent - acute bacteria infectionMucopurulent mild bacterial and chlamydia infection

Etiologic classification of conjunctivitisBacterialChlamydialViralAllergicChemical/toxic or irritativeAssociated with systemic disease, etiology unknownRickettsial, fungal, parasitic

Bacterial conjunctivitisCommon, usually self-limited, mostly childrenDirect contact or from nasal and sinus mucosaConjunctival inflammation and purulent dischargeOrganisms: Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae, --Hyperacute (onset

Gonococal conjunctivitisG (-) diplococcus Neisseria gonorrhoeaeAdult: self contamination, acute onset with marked purulence, may progression to severe keratitisOphthalmia neonatorum: 3-5 days after parturition, profuse purulent discharge with swollen lidsTreatment: topical gentamicinParenteral penicillin, 3rd cephalosporin, ---

Chlamydial conjunctivitisTrachoma ()Chalmydia trachoma serotype A-CChronic follicular conjunctivitis, pannus formation, limbal follicles and Herberts pits, later scaring of conjunctiva (Arlts line), upper tarsal>lowerLate complication: tear deficiency, dacryostenosis, entropion, trichiasis, corneal scarring, salzmans nodulesGiemsa stain: basophilic intracytoplsmic epithelial inclusionsImmunofluorescent testing, EIA(Enzyme immunoassay), PCR, McCoy cell culture, ---Treat with topical and oral tetracycline or erythromycinLeading cause of preventable blindness in the world

Trachoma Early (tarsal follicles and Herberts pits)

Trachoma - Late

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

Adenoviral keratoconjunctivitisEpidemic keratoconjunctivitis (EKC)Incubation:4-10 daysDuration:14 daysAcute onset red eye, watery discharge, photophobia, foreign body sensation, preauricular lymph node, second eye mild involvementBoth 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 keratitisSteroids do not shorten natural course of the disease but merely suppress the inflammation

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

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CL related allergy and toxicityCL intrinsically inertSolution chemicals and lens depositsAllergy termed a hypersensitivity reactionToxicity direct effect of chemicalsIncreased risk of extended wear SCL

Giant papillary conjunctivitis (GPC, )Soft CL>Hard CL; exposure sutures; ocular prosthesisRedness, itching, mucoid discharge, CL intolerance, lens decentrationAbnormal large papillae (>0.3 mm) on super tarsal conjunctivaMechanical trauma, hypersensitivity to CL or adherent material

Treatment of GPCDiscontinue CL wearImproving lens hygieneDiscarding or refitting, daily wear, disposable CL or RGPTopical steroid, mast-cell stabilizer

Episcleritis and Scleritis

Scleraposterior 5/6 of the globedense connective tissue composed of collagen bundles of varying diameters (primary type1)opaque appearance: less uniform orientation of collagen fibers

Normal, episcleritis, scleritis

Episcleritissimple 78.3% nodular 21.7%

Disease Entities - InflammationA: Episcleritisinflammation of episcleral tissue between recti m. insertion & limbus, episcleral edema without scleral edemasudden onset with localized injection and swelling in interpalpebral regionunilateral in 2/3 casescause unknown, maybe hypersensitivity reaction20-50 y/otransient attack,

Episcleritis

course and management: transient, self-limit, ocular redness with mild irritation, blanch with topical phenylephrinetopical vasoconstrictors, NSAIDs, corticosteroidoral NSAIDs

Scleritisintense dull radiating pain of insidious onset, bilateral, recurrentother 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 scleraone third (diffuse or nodular scleritis) to two thirds (necrotizing scleritis) pts associated with systemic diseases, the most common rheumatoid arthritiswomen are more commonly affected

TreatmentMedicalunderlying diseasealmost never responds to topical tx alonesystemic corticosteroid, NSAID, immunosuppressive agents

Adenoviral keratoconjunctivitisEpidemic keratoconjunctivitis (EKC)Incubation:4-10 daysDuration:14 daysAcute onset red eye, watery discharge, photophobia, foreign body sensation, preauricular lymph node, second eye mild involvementBoth eyes affected 60% cases

Giant papillary conjunctivitis (GPC, )Soft CL>Hard CL; exposure sutures; ocular prosthesisRedness, itching, mucoid discharge, CL intolerance, lens decentrationAbnormal large papillae (>0.3 mm) on super tarsal conjunctivaMechanical trauma, hypersensitivity to CL or adherent material