Diseases of Conjunctiva

1
Diseases of Conjunctiva
2
Conjunctivitis

• Classification
• I Based on onset
• a. Acute
• b. Sub-acute
• c. Chronic
• II Based on type of Exudates
• a. Serous (Viral, allergic, toxic)

3
Classification of Conjunctivitis

• b. Catarrhal (allergic Ropy or thread like
  thick mucoid discharge)
• c. Mucopurulent
• d. Purulent
• c. Pseudo-membranous / Membranous

4
Classification of Conjunctivitis

• III Based on Conjunctival Reaction
• a. Follicular
• b. Papillary
• c. Granulomatous
• IV Based on Etiology
• a. Infectious (Bacterial, Viral,
  Chlamydial, Fungal and parasitic)
• b. Non-infectious (Allergic, Irritants

5
Classification of Conjunctivitis

• Endogenous or autoimmune, Dry Eye, Toxic
  (chemical or drug induced, self inflicted) and
  Idiopathic.

6
Risk Factors for the Development of Bacterial
Conjunctivitis

• Disruption of host defense mechanism caused by
• 1. Dry Eye
• 2. Exposure due to lid retraction, exophthalmos,
  lagophthalmos, inadequate blinking
• 3. Nutritional deficiencies/ Avitaminosis A

7
Risk Factors for the Development of Bacterial
Conjunctivitis .. contd

• 4. Local or Systemic Immune Deficiency
• after topical and systemic immunosupressive
  therapy
• Nasolacrimal duct obstruction and infection
• Radiation damage
• Trauma
• Surgery

8
Risk Factors for the Development of Bacterial
Conjunctivitis.. Contd

• Prior Conjunctival inflammation or infection
• Systemic Infection
• Exogenous inoculation

9
Gonorrhoeal Conjunctivitis

• I. Epidemiological Aspect
• Rare in developed countries, still seen in
  individuals and communities where Gonorrhoea is
  still a problem and hygienic standards are poor.

10
Gonorrhoeal Conjunctivitis

• Etiology Caused by Neisseria Gonorrhoeae (a
  bun- shaped Gram-negative intracellular
  diplococcus). Neisseria Catarrhalis may be
  seen/found in chronic forms. Condition is found
  in cases suffering from Gonorrhoeal genital
  infection.
• Incubation period is few hours to three days.

11
Clinical Features

• Symptoms
• Swelling of eyelids, Pain, redness, inability
  to open eye(s), purulent discharge, grittiness,
  Diminution of Vision

12
Clinical Features

• Signs
• Acute disease, occurring usually in adult males.
  Often in RE to begin with. Lids are swollen.
  Upper lids are tense, overhanging on lower lid.
  Matting of lashes and pus on lids margins.
  Eversion is difficult. Deep red velvety
  conjunctiva sometimes with membrane
• After two to three weeks discharge diminishes
  but subacute form of conjunctivitis with presence
  of Gonococci persists for several weeks.

13
Signs Contd

• Pre-auricular lymphadenopathy, tenderness and
  suppuration

14
Clinical Features

• No immunity is conferred by an attack.
• Associated systemic signs Urethritis, rise of
  temperature and depression.
• Complications- Corneal involvement Gonococcus
  is capable of invading the normal cornea through
  intact cornea.
• Location of Corneal Ulcer Central, Marginal
  Ulcer , all round. Progressing rapidly depth-wise
  leading to perforation and complications
  associated with it.

15
Clinical Features

• Other complications of Gonorrhoeal Conjunctivitis
  Iritis , Iridocyclitis
• Non Ocular complications Arthritis,
  Endocarditis and Septicaemia.

16
Treatment

• Of Gonococcal Conjunctivitis is started on
  confirmation of intracellular Gram-negative
  diplococci in conjunctival scrapings in
  clinically suspected cases.
• Aim of therapy is to prevent or limit the
  corneal involvement and to eliminate systemic
  source.

17
Treatment

• Systemic Treatment
• Ceftriaxone 1 Gm IM , single dose
• Local Treatment
• Cleanliness
• Ciprofloxacin / Ofloxacin/ Gentamicin/
  Tobramycin Eye Drops 2 hrly.

18
Treatment

• Bacitracin Eye Ointment 6 hrly
• Cycloplegic (Atropine) in cases of Corneal
  involvement
• Tetracycline In cases where co-existing
  Chlamydial Trachomatis infection is suspected and
  cases with history of allergy to Penicillin /
  Cephalosporins

19
Angular Conjunctivitis

• Specific type of Conjunctival inflammation
  characterized by involvement of inter-marginal
  Conjunctiva and neighboring bulbar conjunctiva,
  caused by Morax axenfield diplobacilli called
  Moraxella Lacunata.

20
Angular Conjunctivitis

• Etiology Caused by Staphylococci and more
  typically by Moraxella Lacunata.

21
Pathogenesis

• Moraxella Lacunata is a gram-negative
  diplobacilli, pair of large ,thick rods placed
  end to end which stain well with basic stains.
• It produces proteolytic ferment, which acts by
  macerating epithelium. The incubation period is
  usually 4 days . The organisms are resistant to
  drying .

22
Pathogenesis

• Moraxella is also found in nasal tract of healthy
  persons and often present in the nasal discharge
  of patients of angular conjunctivitis.

23
Symptoms

• Redness, discomfort, frequent blinking, sharp
  pricking pain and mucopurulent discharge.
• Incubation period Symptoms develop after 4 days
  of exposure.

24
Signs

• Congestion limited to intermarginal strip at
  inner and outer canthi and neighboring bulbar
  conjunctiva. Excoriation of skin at inner and
  outer palpabral angles
• Complications- Chronic conjunctivitis,
  Blepheritis, corneal ulcer (marginal or central
  associated with hypopyon)
• Attack does not confer immunity, and relapses may
  occur.

25
Treatment

• Tetracycline eye ointment
• Eye drops containing Zinc also beneficial, acts
  by inhibiting proteolytic ferment.

26
Acute inclusion Chlamydial Conjunctivitis

• Its acute conjunctival inflammation caused by
  Chlamydial infection (Serotype D-K) characterized
  by inclusion bodies.

27
Acute inclusion Chlamydial Conjunctivitis

• Etiology Caused by Chlamydia Trachomatis
  (serotype D-K)
• Pathogenesis characterized by inclusion bodies
  identical with those occurring in Trachoma.

28
Spread

• Spread by sexual transmission from genital
  reservoir (urethritis/ cervicitis). Common mode
  of infection is through swimming pool water
  (swimming pool conjunctivitis)
• May also be transmitted by mothers to newborn.

29
Clinically Features

• Incubation period- Usually 5- 10 days
• Symptoms- Acute onset , redness, foreign body
  sensation, intolerance to light , discharge
• Signs Conjunctival hyperaemia, Follicles, more
  prominent in lower lid, papillary hyperplasia,
  superficial punctate keratitis, peripheral
  vascularization (pannus)

30
Clinical features

• Chlamydia Trachomatis is also responsible for
  genital and oculogenital infections. Associations
  have been reported with non-gonococcal and post
  gonococcal urethirits, cervicitis and infections
  of genital tract.
• Arthiritis is also seen in these cases.

31
Diagnosis

• Direct immuno-fluorescent stain of smear using
  monoclonal antibodies. Test has 100 sensitivity
  and 94 specificity. Urethral and cervical
  secretions should also be tested.
• Other tests are immuno-sorbitant assay, Giemsa
  staining of conjunctival scrapping and McCoy cell
  cultures.

32
Treatment

• Heals spontaneously in 3 -12 months if left
  untreated.
• Systemic Tetracycline 250 mgm qid for 2 weeks,
  Doxycycline 100 mg twice for two weeks,
  Erythromycin 250 mg twice for two weeks,
  Azithromycin 1 Gm single dose and Ofloxacin 300
  mg twice for 7 days.
• Locally Tetracycline or Erythromycin eye
  ointment twice daily for two weeks.

33
Ophthalmia Neonatorum

• Conjunctival inflammation associated with mucoid,
  mucopurulent or purulent discharge from one or
  both eyes during first month of life.
• Its a preventable disease in newborn babies
  caused by maternal infection, acquired at the
  time of birth.

34
Epidemiology

• Although its incidence has declined due decrease
  in incidence of Gonorrhoea and due effective
  prophylaxis and treatment , disease is still
  prevalent and remains a public health problem in
  communities with poor hygiene and limited access
  to proper health care.

35
Etiology

• Neisseria Gonorrhoeae, Streptococcus Pneumoniae,
  Staphylococcus etc.
• Chlamydial Trachomatis, Chalmydial Oculogenitalis
• Chemical Conjunctivitis due to Silver Nitrate 1or
  2 (used as Credes method)

36
Neisseria Gonorrhoeae

• Manifest within 48Hrs of birth
• Discharge is Mucopurulent to begin with, soon
  becomes purulent
• Both eyes are affected, one more severe than
  other.
• Conjunctiva is intensely inflamed with severe
  congestion, chemosis, thick yellow discharge,
  cornea is seen at bottom of a crater like pit.

37
Clinical Features contd

• Lids are swollen, tense, later becomes softer,
  conjunctiva is puckered and velvety, stasis of
  blood giving appearance of intense congestion.
  Pseudomembrane formation.
• Discharge is pus, serum and blood.
• Corneal complications- corneal ulcer with its
  complications is common

38
Complications

• Corneal Ulcer Oval ulcer, just below the centre
  of cornea, rarely oval marginal ulcer,
  progressive ulcer resulting in perforation of
  corneal ulcer, prolapse of uveal tissue, purulent
  uveitis, prolapse of lens, prolapse of vitreous.
• Scarring of cornea, adherent leucoma, anterior
  staphyloma, anterior capsular cataract,
  panophthalmitis.

39
Complications Contd

• Non development of fixation due to corneal
  opacity during first 3 weeks.
• Nystagmus due to non-development of macular
  fixation

40
Chlamydia Trachomatis Inclusion Conjunctivitis

• Develop usually over one week after birth
• Its venereal infection derived from cervix or
  urethra
• Less severe than Gonococcal infection

41
Other Bacterial Infections

• Manifest usually 48-72 hrs after birth
• Herpes Simplex Infection
• presents 5-7 days after birth

42
Chemical Toxicity

• Seen within few hours after prophylactic
  treatment with Silver Nitrate Solution 1 or 2
  (Credes Method) applied for prophylaxis of
  Gonococcal infection

43
Diagnosis

• Grams staining
• Giemsa staining of epithelial scraping
• Chlamydial Immunofluorescent antibody test
• Viral and Bacterial culture sensitivity test

44
Differential Diagnosis

• Differential Diagnosis of discharge in child
  within the first month of life
• Congenital blockade of nasolacrimal duct
• Acute Dacryocystitis
• Congenital Glaucoma.

45
Treatment

• Prophylaxis
• In cases of any suspicious vaginal discharge in
  antenatal period should be treated meticulously
• New born babies closed lids should be cleaned
  properly
• Prophylactic used of 1 Tetracycline eye
  ointment in babies eyes

46
Prophylaxis .. contd

• Close observation during first week
• Prophylactic use of Penicillin or other
  antibiotic drops

47
Treatment

• Is on lines of Gonorrheoeal Conjunctivitis
• Child is hospitalized and treated with Gentamicin
  eye drops 0.3 and Bacitracin eye ointment.
  Atropine is added if corneal involvement is
  there.

48
Treatment . Contd.

• N. Gonorrhoeae is treated with single I.M. dose
  of Ceftriaxone 125 mgm or Cefotaxime 50 mgm /kg,
  IV or IM in three divided dosage. Or Kanamycin 25
  mgm /kg body weight.
• Local treatment consists of Gentamicin eye drops
  0.3 in both eyes repeated in 15 min and then
  after every feed (2hrly) for 3 days.

49
Treatment . Contd.

• Chlamydial Infection is treated with Erythromycin
  ethylsuccinate 50mgm /kg daily in 4 divided
  dosage before feed for 2-3 weeks or Azithromycin
  10 mgm/kg body weight for 3 days
• Local treatment Chlortetracycline 1 or
  Erythromycin eye ointment after feeds.
• Parents should be treated for genital infection.

50
TRACHOMA

• At one time known as Egyptian Ophthalmia, endemic
  in middle east during prehistoric period, spread
  far and wide in Europe by French Army during
  Napoleonic wars. Trachoma is still a leading
  cause of preventable blindness world wide, third
  after Cataract and Glaucoma.

51

• Approximately 1/5th population of world is
  affected by Trachoma, amounting to 150 million
  people across the 48 countries . It is estimated
  that 6 million people are blind in both eyes. It
  still remains a significant problem in areas of
  Africa, South East Asia, the Middle East and
  Australia.

52

• Trachoma is caused by Chlamydia Trachomatis
  immunotypes / serotypes A,B and C. Chlamydia
  organisms shares properties of both, bacteria and
  virus. It is an obligatory intracellular
  bacteria.

53
Predisposing Factors

• Unhygienic and crowded surroundings
• Low socio-economic status
• Lack of water
• No race is exempted

54
Transmission

• Direct transmission from eye to eye through
  discharge
• Through fomites, flies and eye cosmetics
• Disease is contagious in acute phase
• Incubation period is 5 -12 days

55
Clinical Features
56
Symptoms

• Pure Trachoma is usually asymptomatic condition
  or there may be minimum symptoms
• There may be redness, irritation, discharge,
  foreign body sensation, lacrimation and
  photophobia
• Systemic symptoms like Rhinitis, pre auricular
  lymphadenopathy and upper respiratory infection
  may be present

57
Symptoms contd

• Onset is usually sub-acute, but may occur as
  acute when infection is massive as occurs in
  experimental or accidental or clinical infection

58
Signs

• Primary infection is Epithelial, involving
  conjunctiva and cornea characterized by
• Conjunctival congestion, upper tarsal
  Conjunctiva appears red and velvety, later may
  become uniformly thick like jelly.
• Follicles (in lower fornix, upper fornix, upper
  margin of Tarsus, Caruncle, Plica, Palpabral
  Conjunctiva, Bulbar Conjunctiva near limbus)

59
Signs contd.

• Follicles are small (0.5 mm in diameter) but may
  measure upto 5 mm in diameter.
• Invasion of lacrimal passages may also be there.
• Papillary enlargement.

60
Corneal Signs

• Superficial Keratitis in upper part
• Epithelial erosion, extending deep into stroma
• Pannus and Lymphoid infiltration with
  vascularization seen in upper half, tending to
  spread towards the centre . Whole cornea may be
  covered with pannus . Vassels are superficial
  between epithelium and Bowmans membrane.

61
Corneal Signs.. Contd

• Stages of Pannus
• Progressive (infiltration is beyond
  vascularization)
• Regressive (infiltration has receded and vessels
  are ahead of infiltration)
• Corneal ulcer , Chronic, occurs anywhere but
  commonest at the advancing edge of pannus, are
  shallow ulcer with little infiltration.

62
Pathology

• Chlamydia Trachomatis is seen in conjunctival
  scarping in the form of colonies in the
  epithelial cells as Halberstaedter Prowazek
  inclusion bodies.
• Inclusion bodies are composed of innumerable
  elementary bodies embedded in carbohydrate matrix.

63
Pathology Contd

• Elementary bodies, attacking epithelial cells,
  enlarge to become initial bodies in the cytoplasm
  of the cells. Numerous initial bodies, in cells
  divide to form innumerable elementary bodies
  embedded in carbohydrate matrix. The nucleus of
  cell is displaced , degenerates and cell burst to
  release elementary bodies, to attack new cells.

64
Pathology contd.

• In TF and TI stages, polymorphonuclear cell
  infiltration is noticed and later on lymphocytes
  are dominant.
• Lymphocytic infiltration in Adenoid layer.
• Aggregation of lymphocyte without capsule forms
  follicles
• Follicles shows necrosis and contains large
  multinucleated Laber cells.
• An attack confers little immunity

65
Pathology . Contd.

• Trachomatous infiltration may spread deep into
  subepithelial tissues of the palpabral
  conjunctiva and even invade the tarsal plate
• Fibrosis around follicles giving rise to
  cicatricial bands (Arlt line in superior tarsus)

66
Diagnosis

• Culture of Chlamydia Trachomatis in irradiated
  McCoy cells
• Micro-Immunofluorescence (Micro-IF) test
• Monoclonal Direct Antibody test
• Demonstration of inclusion bodies in conjunctival
  epithelial scrapping

67
Clinical Diagnosis

• Is based on identification of at least two of the
  following signs
• 1. Follicles
• 2. Epithelial Keratitis
• 3. Pannus
• 4. Limbal Follicles/ Herbert Pits
• 5. Typical Trachomatous Scarring (Stellate or
  Linear Scarring of upper tarsus)
• Diagnosis is confirmed by demonstration of
  inclusion bodies

68
Trachoma Classification

• MacCallans Classification
• Stage I Immature follicles on tarsus , SPK and
  Pannus
• Stage II Florid Superior Tarsal follicular
  reaction with mature follicles or marked
  papillary hyperplasia , pannus, Limbal follicles,
  superior corneal epithelial infiltrates

69
MacCallan Classification

• Stage III Signs of stage II with
  Cicatrization
• Stage IV Cicatrization and its sequelae

70
WHO Classification

• Stage I Trachomatous Infiltration Follicular
  (TF) 5 or more follicles of at least 0.5 mm in
  diameter. If treated properly, patient recovers
  with no or minimal scarring
• Stage -II Trachomatous Infiltartion Intense
  (TI) Follicles, papillae, thickening of
  Conjunctiva obscuring gt50 conjunctival blood
  vessels. Severe infection with high risk of
  complication.

71
WHO Classification Contd

• Stage III Trachomatous scarring (TS)
• Stage IV Trachomatous Trichiasis (TT)
• Stage - V Corneal Opacity (CO) corneal opacity
  occupying pupillary area

72
Sequelae of Trachoma

• Distortion of lids
• Trachomatous Ptosis
• Entropion
• Trichiasis
• Tylosis

73
Late Complications

• Sever dry eye
• Keratitis
• Corneal scarring
• Fibrovascular pannus
• Corneal Bacterial Superinfection

74
Treatment

• Tetracycline, Erythromycin, Rifampicin and
  Sulphonamides are effective orally
• Topical Erythromycin and Tetracycline ointment

75
Treatment contd

• Treatment of TF Stage Topical Erythromycin
  twice for 6 weeks
• Oral Azithromycin 1 Gm single dose
• Tetracycline 250 mgm qid for 2 weeks
• Doxycycline 100 mgm twice for 2 weeks

76
Treatment contd

• Treatment of TI Stage same as TF stage
• Treatment of TS stage Ocular lubricants
• Treatment of TT Stage Epilation , tarsal
  rotation , Radiofrequency/ diathermy or
  electrolysis epilation . Or Cryotherapy

77
Treatment contd

• Treatment of CO Stage After treatment of lid
  deformities LKP or PKP, depending on depth of
  corneal opacity

78
WHOs GET 2020

• WHO in 1997 started Global Elimination of
  Trachoma by 2020 programme called WHO GET 2020
  programme, under which SAFE strategy has been
  adopted.
• S Surgery for entropion/ trichiasis
• A Antibiotics for infectious trachoma
• F Facial cleanliness to reduce transmission
• E Environmental improvement

79
Trachoma Control Programme

• Tetracycline eye ointment 1 twice daily on 5
  consecutive days every month for 12 months
• Mass treatment should be annually in endemic
  zones ( lt35 children are affected) and
  Biannually in hyperendemic zones (gt50 children
  are affected)

80
Ophthalmia Nodosa

• Nodular conjunctivitis, resembling tuberculosis,
  due to irritation caused by caterpillar hairs.
• Small semitranslucent pinkish, reddish or pale
  gray nodules formed in bulbar, palpabral
  conjunctiva, cornea and rarely in iris tissue.

81
Ophthalmia Nodosa .. Contd

• Hairs are surrounded by giant cells and
  lymphocytes.
• Treatment Symptomatic, Local Steroids in
  selected cases, under supervision and excision of
  conjunctival nodules.

82
Chronic Non-specific Conjunctivitis

• Is a clinical condition resulting from
  continuation of acute conjunctivitis or due to
  variety of etiological factors, characterized by
  chronic redness in one or both eyes with
  persistence of annoying symptoms.

83
Etiology

• 1. Exposure to Chronic irritants like, smoke,
  dust, heat, poor quality air, late hours, alcohol
  abuse.
• 2. Hypersensitivity to allergen.
• 3. Concretions, misdirected eyelash(es),
  Dacryocystitis , Chronic Rhinitis, sinusitis,
  blepharitis, seborrhoea , dandruff etc
• 4. Unilateral Conjunctivitis foreign body
  retained in conjunctiva or Dacryocystitis

84
Symptoms

• Discomfort, burning, grittyness, especially in
  the evening when eyes becomes red and eyelid
  margins feel hot and dry.
• Difficulty in keeping eyes open.
• Increased secretions, mucoid or mucopurulent
  discharge, lids may stick together in the morning
  on waking up. together

85
Signs

• Hyperaemic lid margins
• Conjunctival Congestion particularly in lower
  fornix
• Papillary hyperplasia

86
Treatment

• Elimination of cause
• Treatment of infection foci in nose and upper
  respiratory passage
• Treatment of conjunctival infection with
  appropriate antibiotic
• Treatment of meibomian gland abnormality by
  mechanical expression and warm compression.

87
Allergic Conjunctivitis

• Allergy or Hypersensitivity is a state which is
  commonly regarded as an unfortunate by product of
  the process of immunity whereby the tissues react
  by an abnormal and injurious response to foreign
  substance (allergens)

88
Allergy

• Two types of reactions
• a. Immediate and
• b. Delayed Hypersensitivity

89
Immediate Hypersensitivity

• Ten days after initial exposure to foreign
  protein, anaphylactic reaction follows after
  second exposure to same protein. Characterized by
  circulating antibodies.

90
Delayed Hypersensitivity

• There are no circulating humoral antibodies of
  anykind. The sensitization is the property of the
  cells themselves. The hypersensitivity is caused
  by prior contact of the tissue with a protein and
  seems to be due to the development of sessile
  antibodies on or within the cells so that when
  they are re-exposed to the same antigen a
  reaction causing cellular damage develops which
  may even involve necrosis.

91
Delayed Hypersensitivity

• This reaction does not occur immediately and
  reach its maximum only after 24 to 72 hours.
• Typical example is tuberculin reaction.

92
Autosensitization

• In this case individuals own tissue protein are
  altered and thus rendered foreign by a
  pathogenic agent, either bacterial or a chemical
  acting as a haptene, repeated contacts may result
  in hypersensitivity reaction eg Sulphonamide
  allergy and autosensitization induced by the
  haemolytic Streptococcus.

93
Physical Allergy

• Certain individuals react to physical agents such
  as heat,cold, light or mechnical irritation by a
  typical hypersensitive response often of
  urticarial type. Some individuals are
  hypersensitive to light of a certain wave-band.

94
Physical Allergy

• The reaction is due to auto-antigen liberated in
  the tissues either due to alteration of their
  specificity or due to their capability of
  reacting with antibody only under the physical
  condition created by the stimulus.

95
Types of Allergic Conjunctivitis

• Simple Allergic Conjunctivitis
• A. Immediate Anaphylactic (Hay fever) type
  mediated by circulating antibody
• B. Delayed Type
• (i) Contact Dermatoconjunctivitis due to local
  chemicals
• (ii) Microbial Allergic Conjunctivitis
• (iii) Keratoconjunctivitis Medicamentosa due to
  ingestion of drugs like arsenic and gold.

96
Types of Allergic Conjunctivitis

• 2. Interstitial Allergic Conjunctivitis
• A. Phlyctenular Keratoconjunctivitis Delayed
  reaction- Endogenous microbial allergy.
• B. Vernal Catarrh Allergic disease of
  immediate type an exogenous allergy.

97
Acute or Sub-acute Allergic Catarrhal
Conjunctivitis

• Is an allergic condition characterized by
  hyperaemia which not as intense as found in
  bacterial conjunctivitis, accompanied by watery
  secretion containing eosinophils. Itching is a
  prominent symptom.
• Etiology Exogenous allergen (contact with
  animals, pollens, flower, chemicals, cosmetics,
  dye, medications etc. and sometimes bacterial
  protein of endogenous nature, the most common
  being Staphylococcal infection.

98

• Symptoms Itching, watering, redness, swelling of
  lids and there may symptoms of hay fever
• Signs Conjunctival Congestion, edema of lids may
  be there, watery discharge, presence of
  eosinophils and elevated IgE level.

99
Treatment

• Removal of allergen from environment
• Astringent lotion, adrenalin 110000,
  antihistaminic drops (chlorpheniramine), mast
  cell stabilizers (sodium cromoglycate,
  olopatadine, ketotifen etc)
• Short course corticosteroid drops
• Topical 2 sodium cromoglycate drops.

100
Vernal Keratoconjunctivitis (VKC)

• It is a chronic , bilateral conjunctival
  inflammatory condition found in individuals
  predisposed by their atopic background. It is
  recurrent, interstitial inflammation of the
  conjunctiva of periodic seasonal incidence, self
  limiting disease/ condition usually due to
  exogenous allergens.

101

• Characterized by flat topped papillae usually on
  the tarsal conjunctiva resembling cobble stones
  in appearance , a gelatenous hypertrophy of the
  limbal conjunctiva, either discrete or confluent,
  and a distinctive type of keratitis , associated
  with itching , redness of the eyes lacrimation
  and mucinous or lardaceous discharge usually
  containing eosinophils

102
Epidemiology

• Sporadically occuring with a wide geographical
  incidence. Its more common in India and the
  tropics than in U.K. Colored races are
  particularly prone to limbal form of disease.
• It is essentially a disease of yoth occuring most
  frequently between ages of 6 and 20 years.

103

• Sex incidence Very high percentage of cases are
  seen in males.
• Family History of allergy is found in 40 60
  cases.

104
Etiology

• Three theories
• 1. Due to action of physical factors (as heat,
  humidity and light)
• 2. Disorder of the endocrine glands associated
  with vagotonic state
• 3. manifestation of an allergic condition. Most
  affected people show a marked hypersensitivity to
  a variety of antigens (pollen, animal inhalants,
  ingestants etc)

105
Symptoms

• Severe itching and photophobia, foreign body
  sensation, ptosis, thick mucous discharge,
  blepharospasm, burning, typical stringy discharge
  .
• Discharge is scanty, thick, ropy and lardaceous,
  dirt white or cream colored.

106
Signs

• The signs are confined to conjunctiva and cornea
  the skin of the lids are not involved.
• Types
• Palpabral form
• Limbal/ Bulbar form
• Mixed type

107

• Palpabral VKC
• Conjunctiva develops a papillary response in the
  upper tarsal conjunctiva and at the limbus.
  Conjunctiva is congested later on becomes milky.
• Tarsal papillae are discrete larger than 1 mm in
  diameter, flat tops , they are cobblestone in
  appearance.

108
Limbal / Bulbar Form

• In limbal or bulbar form the first change is
  usually a thickening, broadening and
  opacification of the limbus which overrides the
  corneal periphery as a semitranslucent hood. This
  develop mostly at the upper margin of the cornea
• Limbal Papillae tend to be gelatinous and
  confluent

109

• Limbal Nodules Their most common site is in the
  palpabral aperture, nasally and temporally. In
  the raised mass, whitish Horner- Trantass spots
  may occur at any stage. Horner Trantas dots are
  collection of epithelial cells and eosinophils.
• These changes may lead to superficial corneal
  vascularization.

110
Corneal Findings

• Punctate Epithelial Keratitis
• Horizontally oval ulcer in upper part of cornea
  called Shield Ulcer
• Peripheral superficial gray white deposition
  termed Pseudogeronton.

111
Pathogenesis

• Biopsy of tarsal papilla in VKC reveals that
  epithelium contain large number of mast cells and
  eosinophils. Substantia properia contains
  elevated number of mast cells, also contains CD4
  T cells. Mast cells contains basic fibroblast
  growth factor
• Cytology shows more eosinophils and neutrophils,
  IgE and IgG have been isolated from tears.
  Histamins and trytase are elevated in tears
• Protein deposition diffusely in conjunctiva

112

• The flat-topped nodules are hard , and consist
  chiefly of dense fibrous tissue , but the
  epithelium over them is thickened , giving rise
  to the milky hue. Histologically they are
  hypertrophied papillae, not follicle. Eosinophils
  are present in them in great numbers. In addition
  , infiltration with lymphocytes, plasma cells ,
  macrophages, basophils and eosinophils may also
  be seen.

113
Diagnosis

• History
• Clinical findings (young boys living in warm
  climates presenting with intense photophobia,
  ptosis and gaint papillae)

114
TREATMENT

• Avoidance of allergen
• Local Treatment
• a. Steroids Patients with significant seasonal
  exacerbation , a short term high dose pulse
  regimen of topical steroid is necessary.
  Dexamethasone 0.1 or Prednisolon Phosphate 1 ,
  8 times for one week brings excellent result,
  tapered rapidly.

115

• b. Mast Cell stabilizer Cromolyn sodium, a
  mast cell stabilizer or a dualo acting drug such
  as Olopatidine, Ketotifen or Azelastine (mast
  cell stabilization and antihistamine)
• c. Topical Cyclosporin-A (0.05) twice daily,
  it decreases the release of interlukin-2, reduces
  expansion of T cell clones.

116

• Treatment of Corneal Shield Ulcer
• Antibiotic- steroid ointment and occlusion. If
  plaque forms superficial keratectomy
• Phototherapeutic Keratectomy and Keratectomy with
  amniotic membrane graft placement.

117

• Surgical Treatment
• Cryablation of upper tarsal cobble stones but
  may lead to lid and tear film abnormalities.
• Injection of short term or long term acting
  steroids into tarsal papilla has been shown
  effective in reducing their size.

118

• 3. Systemic Treatment
• 1. Non sedating antihistaminic
• 2. Oral Aspirin (high dose of 2400 mgm daily)
• 4. Climatotherapy