The Disease of Conjunctiva (??) /Sclera (??)

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The Disease of Conjunctiva (??) /Sclera (??)

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Palpebral, bulbar conjunctiva, fornix
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Slit Lamp (???????)
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Pinguecula (????) Pterygium (??)

• Pinguecula elevated yellow nodule near limbus in
  palpebral fissure
• Pterygium triangular fold of bulbar conjunctiva
  loosely attached to cornea except at the apex
• elastoid degeneration
• Sun (uv light), wind,---
• usually nasal side, surgery excision for corneal
  astigmatism, visual axis involvement and cosmetic

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Miscellaneous conjunctival disorders

• Conjunctival concretions (???)
• epithelial inclusion cysts filled with
  epithelial and keratin debris, elderly or chronic
  conjunctivitis, remove when irritation
• Subconjunctival hemorrhage (????? )
• spontaneous, trauma, acute viral or bacterial
  conjunctivitis, Valsalva maneuver --
• single eye, no treatment, 1-2 wks subside
• recurrent and both eyes suspect blood dyscrasis

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Symptoms of conjunctivitis

• Non-specific symptoms lacrimation, irritation,
  stinging, burning, photophobia, ---
• If pain or FB sensation --gt associated corneal
  involvement
• Itching, hallmark of allergic conjunctivitis

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Discharge

• Watery - acute viral and allergic inflammations
• Mucoid - VKC, dry eye
• Purulent - acute bacteria infection
• Mucopurulent mild bacterial and chlamydia
  infection

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Etiologic classification of conjunctivitis

• Bacterial
• Chlamydial
• Viral
• Allergic
• Chemical/toxic or irritative
• Associated with systemic disease, etiology
  unknown
• Rickettsial, fungal, parasitic

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Bacterial conjunctivitis

• Common, usually self-limited, mostly children
• Direct contact or from nasal and sinus mucosa
• Conjunctival inflammation and purulent discharge
• Organisms Staphylococcus aureus, Streptococcus
  pneumonia, Haemophilus influenzae, --
• Hyperacute (onsetlt24hrs) Neisseria gonorrhoeae,
  N. meningitidis

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Gonococal conjunctivitis

• G (-) diplococcus Neisseria gonorrhoeae
• Adult self contamination, acute onset with
  marked purulence, may progression to severe
  keratitis
• Ophthalmia neonatorum 3-5 days after
  parturition, profuse purulent discharge with
  swollen lids
• Treatment topical gentamicin
• Parenteral penicillin, 3rd cephalosporin, ---

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Chlamydial conjunctivitisTrachoma (??)

• Chalmydia trachoma serotype A-C
• Chronic follicular conjunctivitis, pannus
  formation, limbal follicles and Herberts pits,
  later scaring of conjunctiva (Arlts line), upper
  tarsalgtlower
• Late complication tear deficiency,
  dacryostenosis, entropion, trichiasis, corneal
  scarring, salzmans nodules
• Giemsa stain basophilic intracytoplsmic
  epithelial inclusions
• Immunofluorescent testing, EIA(Enzyme
  immunoassay), PCR, McCoy cell culture, ---
• Treat with topical and oral tetracycline or
  erythromycin
• Leading cause of preventable blindness in the
  world

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Trachoma Early (tarsal follicles and Herberts
pits)
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Trachoma - Late
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Viral conjunctivitis

• Via respiratory or ocular secretions
• Epidemic keratoconjunctivitis (EKC)
• Adenovirus 8, 11, 19, 37
• Epidemic hemorrhage keratoconjunctivitis (EHKC)
• Picornavirus (Enterovirus 70),
  coxaschievirus A24
• subconjunctival hemmorrhage
• Pharyngoconjunctival fever (PCF)
• Adenovirus 3, 4, 7
• fever, URI, conjunctivitis, transmitted by
  droplets , children

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Adenoviral keratoconjunctivitisEpidemic
keratoconjunctivitis (EKC)

• Incubation4-10 days
• Duration14 days
• Acute onset red eye, watery discharge,
  photophobia, foreign body sensation, preauricular
  lymph node, second eye mild involvement
• Both eyes affected 60 cases

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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 keratitis
• Steroids do not shorten natural course of the
  disease but merely suppress the inflammation

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Allergic rhinoconjunctivitis

• Itching, 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 toxicity

• CL intrinsically inert
• Solution chemicals and lens deposits
• Allergy termed a hypersensitivity reaction
• Toxicity direct effect of chemicals
• Increased risk of extended wear SCL

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Giant papillary conjunctivitis (GPC, ???????? )

• Soft CLgtHard CL exposure sutures ocular
  prosthesis
• Redness, itching, mucoid discharge, CL
  intolerance, lens decentration
• Abnormal large papillae (gt0.3 mm) on super tarsal
  conjunctiva
• Mechanical trauma, hypersensitivity to CL or
  adherent material

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Treatment of GPC

• Discontinue CL wear
• Improving lens hygiene
• Discarding or refitting, daily wear, disposable
  CL or RGP
• Topical steroid, mast-cell stabilizer

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Episcleritis and Scleritis
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Sclera

• posterior 5/6 of the globe
• dense connective tissue composed of collagen
  bundles of varying diameters (primary type1)
• opaque appearance less uniform orientation of
  collagen fibers

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Normal, episcleritis, scleritis
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Episcleritis

• simple 78.3
• nodular 21.7

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Disease Entities - Inflammation

• A Episcleritis
• inflammation of episcleral tissue between recti
  m. insertion limbus, episcleral edema without
  scleral edema
• sudden onset with localized injection and
  swelling in interpalpebral region
• unilateral in 2/3 cases
• cause unknown, maybe hypersensitivity reaction
• 20-50 y/o
• transient attack, lt10 days,
• 60 recurrent in either eye, minor associated
  disease

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Episcleritis

• course and management
  transient, self-limit, ocular redness with mild
  irritation, blanch with topical phenylephrine
• topical vasoconstrictors, NSAIDs, corticosteroid
• oral NSAIDs

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Scleritis

• intense dull radiating pain of insidious onset,
  bilateral, recurrent
• other 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
  sclera
• one third (diffuse or nodular scleritis) to two
  thirds (necrotizing scleritis) pts associated
  with systemic diseases, the most common
  rheumatoid arthritis
• women are more commonly affected

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Treatment

• Medical
• underlying disease
• almost never responds to topical tx alone
• systemic corticosteroid, NSAID, immunosuppressive
  agents

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Adenoviral keratoconjunctivitisEpidemic
keratoconjunctivitis (EKC)

• Incubation4-10 days
• Duration14 days
• Acute onset red eye, watery discharge,
  photophobia, foreign body sensation, preauricular
  lymph node, second eye mild involvement
• Both eyes affected 60 cases

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Giant papillary conjunctivitis (GPC, ???????? )

• Soft CLgtHard CL exposure sutures ocular
  prosthesis
• Redness, itching, mucoid discharge, CL
  intolerance, lens decentration
• Abnormal large papillae (gt0.3 mm) on super tarsal
  conjunctiva
• Mechanical trauma, hypersensitivity to CL or
  adherent material