By
Staff Members
Ophthalmology Department
Zagazig University
2020
ANATOMY
Gross Anatomy :
1. It is a thin transparent mucous membrane,
lining inner surface of upper and lower
eyelids, and then reflected at the fornices
and covers anterior aspect of the eye ball
as far as the corneoscleral junction
(Limbus).
2. It forms a sac, (Conjunctival sac), which
opens in front at the palpebral fissure and
only closed when the eyelids are shut.
It consists of 5 parts :
(1) Palpebral conjunctiva :
• Starts at gray line.
• Lines posterior surface of eyelids.
• Firmly adherent to tarsus.
• Meibomian glands can be seen through
the conjunctiva because the conjunctiva is
transparent.
• Shows a groove 2 mm form the lid margin
called sulcus subtarsalis.
Parts of the conjunctiva
(2) Fornix :
• Site of reflection of the bulbar conjunctiva to
line the eyelids.
• Divided into upper, lower, medial, and lateral
fornices.
• Upper fornix is deep and receives a strip of
insertion of levator muscle and lacrimal
ducts open in it.
(3) Bulbar conjunctiva :
• Covers the anterior part of the sclera.
(4) Plica semilunaris :
• Crescentic fold of the conjunctiva at the
inner canthus.
• Represents third eyelid of lower animals.
(5) Caruncle :
• Vascular fleshy elevation in the medial
canthus.
• Modified
skin
containing
sebaceous glands.
hairs
and
Histology :
1. Epithelium : Stratified squamous nonkeratinized epithelium and contains goblet
cells.
2. Substantia propria : Consists of 2 layers.
a) Superficial adenoid layer :
• Consists of
lymphocytes.
loose
C.T.
and
contains
• Formed 3 months after birth, so the follicles
never formed before this age, this explains
that newborn conjunctivitis is papillary in
nature rather than follicular.
b) Deep fibrous layer :
• Contains main blood vessels and nerves of
the conjunctiva.
Glands of the conjunctiva :
a) Goblet cells → Mucous glands in the
epithelium → secrete mucus.
b) Accessory lacrimal glands; (Krause and
Wolfring glands) which are located in
the stroma of the conjunctiva.
Blood supply :
1. Arteries :
a) Anterior conjunctival arteries :
• Branches of the anterior ciliary arteries
before they pierce the sclera.
• Supply only an area about 4 mm around the
limbus.
b) Posterior conjunctival arteries:
• Branches from the palpebral arcades and
anastomose freely with the anterior
conjunctival arteries.
2- Veins : They follow the arteries.
a- Anterior conjunctival veins: They drain to
anterior ciliary veins to ophthalmic veins.
b- Posterior Conjunctival veins: They drain
to palpebral veins to ophthalmic veins.
Nerve supply :
Ophthalmic division of 5th
cranial nerve.
Lymph drainage : As eyelids.
Function of the conjunctiva :
a)
Contains abundant
Defense mechanism.
lymphoid
elements
→
b) Supplies precorneal tear film with the aqueous
layer (Accessory lacrimal glands), and mucin
layer (Goblet cells).
c) Contains normal conjunctiva flora :
• Staph. Albus. and Diphtheroids (Xerosis bacilli), which
inhibit the action of some pathogenic strains of bacteria
attacking the conjunctiva.
• Saprophytic fungi.
N.B : Conjunctiva is named because it conjoins the eyeball to
the eyelids.
Conjuntivitis
Definition :
It is an inflammation of the conjunctiva which is
characterized by dilatation of the conjunctival
vessels (conjunctival injection) resulting in
hyperemia and edema of the conjunctiva associated
with discharge.
Clinical signs of conjunctiva :
a- Redness of the conjunctiva (hyperaemia) :
 More obvious in the fornices and moves with
movement of conjunctiva. (≈ conjunctival
injection, D.D ciliary injection).
 Due to dilatation of the posterior conjunctival
vessels.
b- Discharge :
 Watery (Serous) discharge, in cases of viral and
toxic conjunctivitis.
 Mucopurulent discharge, in cases of mild
bacterial (MPC) and chlamydial infections.
 Purulent discharge, in cases of purulent
conjunctivitis (PC).
 Sanguineous
discharge,
in
cases
of
membranous conjunctivitis, and eye injuries.
 Ropy (Thready) discharge, in cases of spring
catarrh.
Classification (Etiology) of conjunctiva :
1- Infective conjunctivitis :
i. Acute :
Bacterial :
a) Mucopurulent.
b) Purulent.
c) Membranous.
Chlamydia : Inclusion conjunctivitis.
Viral conjunctivitis :
a) Adenovirus,
b) Herpes simplex virus (HSV).
c) Herpes zoster virus (HZV).
ii. Chronic :
a- Trachoma.
b- Angular.
c- Specific infection (Tuberculosis or Syphilis).
2- Non-infective conjunctivitis :
i. Allergic :
a- Allergic simple conjunctivitis.
b- Spring catarrh (Vernal keratoconjunctivitis).
c- Phlyctenular kerato-conjunctivitis.
ii- Toxic : Chemical or drug induced (irritative
conjunctivitis)
Mucopurulent Conjunctivitis
(MPC)
Definition :
It is an acute conjunctivitis characterized by
hyperemia and edema of the conjunctiva and
mucopurulent discharge.
Causative organisms :
• Koch-week’s bacillus (Haemophillus Aegyptius) :
Gram -ve bacillus (80% of cases).
• Staph.,
Strept.
Peumococci
and
rarely
Hemophillus influenza bacillus.
Clinical picture (Usually bilateral) :
Symptoms :
• Acute onset of redness,
• Gritty and burning sensation
• Discharge : Sticky eyelid
margins in the morning.
• Haloes around light may
occur
when
discharge
crosses the pupil.
Signs :
1- Eyelids :
• Edema.
• Lashes are glued together by the discharge.
2- Conjunctiva :
• Mucopurulent discharge.
• Conjunctival injection
marked in the fornices
which
is
most
• Edema of the conjunctiva (Chemosis).
• Peticheal
hemorrhage
pneumococcal cases.
especially
Fate :
• Disappears in 2 weeks or,
• Becomes chronic (Chronic catarrhal).
in
Complications :
• Secondary corneal ulcer: uncommon, superficial,
and often marginal.
Treatment :
a- Prophylactic :
- Eradication of flies.
- Using separate towels.
b- Curative :
1- Control of infection by :
- Frequent broad spectrim antibiotic eye
drops during day.
- Antibiotic eye ointment in the conjunctival
sac before sleep →
•
Prevents stickiness of lids during sleep →
Allow free exit of discharge.
•
Prolongs duration of action of antibiotic
into the eye.
2- Hot fomentation :
Produces vasodilatation → increase blood
flow and bring more antibodies &
leucocytes to affected area.
3- Dark glasses :
To avoid photophobia : (Bandage is
contraindicated to allow free exit of the
discharge).
Purulent conjunctivitis (PC)
Definition :
It is an acute infective conjunctivitis which
is characterized by :
•
•
•
•
•
Copious purulent discharge.
Tendency to corneal involvement.
Enlargement of lymph nodes (L.N).
General manifestation (Fever).
Two Types occur :
1- Purulent conjunctivitis in adult.
2- Ophthalmia neonatorum.
1- Purulent conjunctivitis in adult :
Etiology :
 Gonococci, in 80% of cases.
 Staph. strept. & b. coli are rare.
Transmission of infection :
 From eye to eye.
 Rarely comes from genital gonorrhea.
Clinical picture :
Symptoms :
 Discharge : Purulent and extensive.
 Red eye.
 Fever, anorexia, headache and malaise.
Signs :
1) Stage of infiltration : 2-3 days.
 Lids : Marked edema closing the palpebral
fissure.
 Conjunctiva : Marked edema (Chemosis)
and hyperemia (But no discharge).
 Cornea : may show ulceration.
 General : Mild fever + Preauricular
lymphadenopathy (Enlarged and tender).
2) Stage of discharge : 2-3 weeks.
 Lids : Marked edema.
 Conjunctiva :
- Intense conjunctival injection & chemosis.
- Profuse purulent discharge.
- Pseudo membrane.
 General : Mild
improvement
of
general condition.
3) Chronic stage :
 Lids : Edema subsides.
 Conjunctiva :
- Discharge becomes less, full of
gonococci and the patient becomes a
carrier who initiates epidemic.
- Edema subsides.
- Injection is present only in the fornices.
- Palpebral conjunctiva shows papillae.
Complications :
Secondary corneal ulcers : may by :
 Marginal ulcer (Most common).
 Ring ulcer: Very serious and may lead to
corneal necrosis.
 Central and para central ulcers : May
perforate.
Common because :
 Gonococci can invade intact epithelium.
 Gonococci can invade intact epithelium.
 Conjunctival edema press on limbal
capillaries, thus corneal nutrition is
impaired.
 Gutter formed around the cornea by
chemotic conjunctiva gives a chance
for accumulation of organisms and
toxins.
Treatment :
a- Prophylactic :
 Avoid infection from other eye by antibiotic
eye drops in both eyes.
 Avoid infection of other persons by good
personal hygiene.
b- Curative :
1. Frequent removal of discharge by
irrigating solution (saline or boric acid
4%).
1. Control of infection by:
• Frequent antibiotic eye drops during day.
• Antibiotic eye ointment before sleep.
• Systemic antibiotic e.g. Ciprofloxacin
tablets 500 mg. every 12 hours for 5 days.
3- Atropine eye ointment : In cases of corneal
ulceration.
4- Cold compresses : in purulent conjunctivitis
eyelids and conjunctival edema is marked
and hot fomentation may increase it.
2- Ophthalmia Neonatorum :
Definition :
It is an acute conjunctivitis occurring in newly
born infant in the first 4 weeks of life.
Etiology :
a- Infection from maternal passages :
 Gonococci (Dangerous but less common)
 Inclusion
conjunctivitis
trachomatis).
(Chlamydia
 Herpes simplex virus (HSV), Type 2.
b) Infection from contaminated towels or
instruments:




Gonococci.
Streptococcus viridans.
Staphylococcus aureus.
E coli.
Clinical picture :
a- Gonococcal conjunctivitis :
 Occurs 3 : 5 days after birth.
 Copious
purulent
or
sero-sanguinous
discharge.
 Complications: Corneal ulcers, perforation and
endophthalmitis.
b- Chlamydial conjunctivitis :
 Occurs 6 : 12 days after birth.
 Mucopurulent discharge.
Etiology
Chemical
Gonococci
Chlamydia
HSV
Incubation period
1 day
2 – 5 day
6 – 14 day
6 – 14 day
Differential diagnosis :
From congenital dacryocystitis by :
 - ve regurge test.
 Any discharge in the first 3 weeks of life must
be suspected (As lacrimal gland starts to
secrete tears after one months from birth).
Laboratory diagnosis :
Conjunctival scrapings, then Gram and Giemsa
stains to identify causative agents:
1- Chlamydia.
3- Other bacteria.
2- Gonococci.
Treatment :
a- Prophylactic :
 Proper treatment of mother before labor.
 Wash the infant with head up.
 Antibiotic eye drops after birth (Tobramycin
or fluoroquinolone).
b- Curative :
 As purulent conjunctivitis.
 Systemic antibiotic (Ceftriaxone 25 mg/Kg
BW) IM or IV injection for gonococcal
conjunctivitis.
 Erythromycin 12.5 mg/Kg BW oral every 6
hours for 14 days.
Membranous Conjunctivitis
Definition :
It is a severe form of acute conjunctivitis
characterized by :
• Usually affects children between 2-8 years of age
who are not immunized against diphtheria.
• Hyperemia.
• Sanguineous purulent discharge.
• Formation of a true membrane on the conjunctiva.
• General manifestations (Fever and enlarged pre
auricular lymph nodes).
Differential diagnosis :
Complications :
1. Corneal
ulceration
is
a
frequent
complication in acute stage. The bacteria
may even involve intact corneal epithelium.
2. Delayed complications due to cicaterization
include symblepharon, trichiasis, entropion
and conjunctival xerosis.
Treatment :
a- Prophylactic :
 Immunization (D.P.T vaccine)
b- Curative :
1- General :
• The patient is isolated.
• Notification of health authorities.
• A smear is taken and 20,000-40,000 units
of Anti-diphtheria serum are given I.M.
and if the smear is + Ve, a similar dose is
given.
• Crystalline Penicillin, 1 million units
intramuscularly twice a day for 10 days.
• Vitamins & tonics.
2- Local :
• Anti-diphtheria serum drops every one hour.
• Penicillin eye drops (1:10000 units per ml)
every half hour.
• Broad spectrum antibiotic ointment at bed
time.
• Atropine eye ointment for corneal ulcer.
• Passing a glass rod with ointment in the
fornices to prevent symblepharon.
• Avoid canthotomy as this increases the
surface which absorbs the toxins.
Viral Conjunctivitis
Symptoms of viral conjunctivitis :
• Watery discharge, foreign body sensation,
pain, diffuse conjunctival injection.
1- Adenoviral Kerato-conjunctivitis :
a- Simple follicular conjunctivitis :
• Follicular conjunctivitis.
• Not
associated
with
manifestations.
systemic
b- Pharyngo-Conjunctival Fever (PCF) :
•
•
•
•
Fever, Anorexia, headache and malaise.
Pharyngitis.
Follicular conjunctivitis.
Pre-auricular lymphadenitis.
c- Epidemic keratoconjunctivitis (E.K.C)
•
•
•
•
•
Fever, headache, malaise & pharyngitis.
Superficial punctate keratitis (SPK).
Sub epithelial corneal infiltrates.
Conjunctival follicles.
Pre auricular and sub mandibular
lymphadenitis.
2- Acute hemorrhagic conjunctivitis :
•
•
•
•
•
Subconjunctival hemorrhage.
Intense conjunctival hyperemia.
Superficial punctate keratitis.
Preauricular lymphadenopathy.
Self limiting,disappears after two weeks.
Treatment :
• Topical corticosteroids drops and ointment are
used under supervision..
• Topical antibiotic drops to guard against
secondary infection.
• Artificial tears eye drops.
• Cold fomentation.
Trachoma
Definition :
Trachoma
is
a
chronic
infective
keratoconjunctivitis caused by Chlamydia
trachomatis and characterized by formation
of :
1) Follicles.
2) Papillae.
3) Pannus.
4) Heals by cicatrisation.
Epidemiology :
• Trachoma is endemic in Egypt, affecting 8090% of population.
• Endemic in Middle East, central Africa,
Central & East of Asia and East of Europe.
• More common in poor community.
Mode of infection :
• Through Conjunctival discharge, transmitted
by fingers, towels and flies.
Pathology :
• Trachoma is an epitheliotropic organism that
multiplies within cytoplasm of the epithelial
cells of conjunctiva, cornea and lacrimal
apparatus
forming
intracytoplasmic
basophilic inclusion bodies.
• It secretes toxins that diffuse to the sub
epithelial
tissues
producing
chronic
inflammatory reaction which may be:
a. Localized leading to formation of follicles,
which are at first small and then increase in
size and their centers show necrosis, Or
b.
Diffuse and excessive,
epithelium forming papillae.
raising
the
• Trachoma heal by fibrosis → Complications.
Clinical picture :
Incubation period : 6-12 days.
Mode of onset : Insidious, in foreigners it
may be acute.
Age of onset : 6 months to 2 years.
Symptoms :
•
•
•
•
F.B. sensation, lacrimation & itching.
Scanty Mucopurulent discharge.
Photophobia due to corneal involvement.
Heaviness of eyelids.
Signs :
I- Conjunctival manifestation of trachoma in
upper palpebral conjunctiva & fornix:
1. Trachomatous follicles :
a) Early follicles :
• Minute up to 1 mm.
• Yellowish.
• Not raised, not expressible.
• Surrounded by dilated capillaries.
• Scraping of epithelium shows inclusion
bodies.
b) Typical trachomatous follicles :
• Large 1-3 mm.
• Yellowish.
• Raised
and
expressible
gelatinous material.
necrotic
2. Trachomatous papillae :
• Fine, pink finger like projections which
give the conjunctival surface velvety
appearance (Highly vascular).
• Increases weight of the eyelid leading to
mechanical ptosis.
3.
Conjunctival
cicatrization
(Stage
of
complications): Palpebral conjunctiva shows:
• White fibrosis (Linear or star shaped).
• Arlet’s line; White line of fibrosis in sulcus
subtarsalis (Pathognomonic of trachoma).
• PTDs (Post-trachomatous degeneration) :
- Yellowish in color.
- Due to hyaline degeneration in a closed
crypt (Between papillae).
• Post - trachomatous concretion (PTCs):
- White in color.
- Due to calcification of PTDs.
4. Healed trachoma :
• Patient is cured and not infective (Scraping of
the conjunctiva shows no inclusion bodies).
2- Corneal manifestation of trachoma :
1- Corneal follicles :
• Appears in upper part of the cornea.
• Yellowish in color.
• Caused by aggregation of inflammatory
cells between epithelial cells and Bowman’s
layer at end of blood vessels giving a
rosette shaped appearance (Herbert’s
rosettes.).
• When these follicles heal, they leave
depressed pits (Herbert’s pits), which give
the central edge of the pannus a serrated
appearance.
2- Trachomatous pannus :
• Means, vascularization and infiltration of
superficial layers of the cornea by chronic
inflammatory cells.
• Stages of pannus :
1. Progressive pannus : Infiltration precede
vascularization.
2. Regressive pannus : Infiltration regress, but
vessels never regress.
3. Healed pannus (Dry pannus of pannus siccus) :
• Superficial scar is seen in upper part of the
cornea, which shows obliterated blood vessels.
• Herbert’s pits give it a serrated edge.
3- Trachomatous ulcers :
a- Typical ulcers :
• Site : Related to the pannus.
• Shape : Linear and horizontal.
• Superficial.
• Secondary infection is common.
• Heal by corneal facet (Corneal surface
is depressed at site of healing due to
less fibrous tissue).
b- Atypical ulcers :
• Site : Any site.
• Shape : Any shape.
• Produced mechanically by PTDs or
rubbing lashes.
Classification of trachomatous lesions :
WHO classification of trachoma
includes five signs (F.I.S.T.O.).
:
It
1. Trachomatous follicular (TF): Presence of
five or more follicles in upper tarsal
conjunctiva.
2. Trachomatous intense (TI): Intense diffuse
inflammatory thickening of the upper
tarsal conjunctiva, obscuring 50% or more
of the normal deep tarsal vessels; papillae
are present
3. Trachomatous scarring (TS): Scaring
in tarsal conjunctiva and Arlet’s line.
4. Trachomatous trichiasis (TT): Eyelash
rubs on the cornea.
5. Corneal opacity (CO): Corneal opacity
development affecting vision.
Diagnosis of trachoma :
1. Pathognomonic signs are : PTDs,
PTCs, Arlet’s line, and pannus
siccus.
2. Conjunctival scraping and Geimsa
stain
show
:
Intracytoplasmic
basophilic inclusion bodies.
Difference
between
chlamydial
conjunctivitis in neonates and adult :
Chlamydial conjunctivitis in neonates is
characterized by :
1. No follicular response.
2. Amount of mucopurulent discharge is
greater.
3. Membranes on the tarsal conjunctiva can
develop.
4. Infection is more likely to respond to
topical medications.
Complications of trachoma :
Eyelids:
•
•
•
Rubbing lashes and trichiasis.
Cicatricial entropion.
Ptosis, due to :
-
•
Heaviness of eyelid (Mechanical ptosis).
Weakness of levator and Muller’s ms. due
to fibrosis.
Chalazion, due to obstruction of Meibomian
glands ducts by fibrosis.
Conjunctiva :
• Posterior symblepharon.
• Xerosis, due to fibrosis causing atrophy of
goblet cells or obstruction of lacrimal ducts.
Cornea :
•
•
•
•
•
Ulceration.
Pannus.
Opacity.
Keratectasia.
Xerosis.
Larcimal :
• Dacryoadenitis and dacryocystitis.
• Epiphora due to obstruction of lacrimal
passage.
Differential diagnosis :
• Follicular
Trachoma
conjunctivitis.
• Papillary
Trachoma
conjunctivitis.
:
From
follicular
:
From
papillary
• Trachomatous pannus : From other types of
pannus (Phylectenular, degenerative, leprotic).
Treatment of trachoma :
A- Prophylactic :
•
•
•
Health education.
Raising the standard of living.
Combat flies.
B- Curative :
1- Medical treatment :
Systemic :
•
•
Azithromycin 1 gm single oral dose.
Doxycycline 100mg capsule (Vibramycin),
twice daily for 3 weeks.
Topical :
• Azithromycin 1% eye drops four times
daily for 2 weeks
• Terramycin eye ointment for at least 1
month.
• Atropine eye ointment, If the cornea is
ulcerated.
2- Surgical treatment :
•
Picking of PTDs.
Follicular Conjunctivitis
• It is a conjunctival reaction most commonly
caused by viruses.
• Follicles can be seen in the superior or
inferior tarsal conjunctiva.
Acute follicular conjunctivitis :
• Viral conjunctivitis :
• Adenovirus.
• Herpes simplex.
• Herpes zoster
Chronic follicular conjunctivitis :
• Drug induced : Atropine or pilocarpine eye
drops.
• Trachoma.
Angular Conjunctivitis
Definition :
It is a chronic inflammation of angles of eyelids
and adjacent conjunctiva.
Aetiology :
Morax Axenfield diplobacillus :
• Gram - ve organism
• Killed by lysozyme in tear film, which is deficient
at the angles of the eye, so its effect is tense at
the canthi.
• Secretes a proteolytic enzyme, which macerates
the epithelium.
Symptoms :
• Itching and discomfort.
• Scanty mucopurulent discharge.
• Redness of angles of the eye.
Signs :
Inner and outer canthi show :
• Angular skin excoriation (Angular dermatitis).
• Angular redness of eyelid margins (Angular
blepharitis).
• Angular redness of conjunctiva (Angular
conjunctivitis).
Complications :
Corneal ulcer may be :
• Marginal and shallow.
• Hypopyon ulcer (Atypical).
Treatment :
• Zinc sulphate (It inactivate proteolytic
enzymes) eye drops T.D.S.
• Terramycin eye ointment (Organism is
sensitive to Terramycin).
• Macerated skin → Paint with Gentian
violet skin paint 1%.
Allergic Conjunctivitis
1- Seasonal allergic conjunctivitis.
2- Phlyctenular conjunctivitis.
3- Spring catarrh.
1- Seasonal allergic conjunctivitis. :
• Type 1 Hypersensitivity → Itching,
lacrimation, redness, and lid edema.
• Treatment :
- Mast cells stabilizers eye drops, e.g : Na
chromoglycate drops 2%.
- Topical vasoconstrictors and antihistaminics.
2- Phlyctenular conjunctivitis :
Definition :
nodule inflammation of the conjunctiva
or cornea induced by allergic reaction to
endogenous antigen.
Aetiology :
Delayed hypersensitivity reaction to endogenous
antigen as:
• Microbial proteins e.g.
- Staphylococcus aureus in tonsilitis
- Tuberculo-protein.
• Intestinal parasites.
Clinical picture : Mostly affects children.
Symptoms :
• Discomfort and watering of the eye.
• If cornea is involved → Photophobia and
blepharospasm.
Signs :
Characteristic lesion is phlycten :
• Rounded nodule.
• 1-3 mm in size.
• Grayish in color.
• Elevated above surface of the conjunctiva
and cornea.
• Marked injection of the surrounding by
conjunctival blood vessels.
Conjunctival manifestations :
• Phlycten frequently occurs at the limbal
region but may affect any part of the
conjunctiva.
• Epithelium is first intact but later it may
ulcerate.
Corneal manifestations :
a. Corneal phlycten:
- May occur deep or superficial to Bowman’s
layer
- May ulcerate causing phlyctenular ulcer or
vascularized causing phlyctenular pannus.
b. Phlyctenular ulcers:
• Limbal ulcer or multiple limbal ulcers
(May fuse to form a ring ulcer).
•Fascicular ulcer :
 Superficial ulcer, which creeps over the
cornea towards the centre and is
supplied by a leash (Bundle) of parallel
vessels.
 When it heals, its track leaves opacity.
c. Phlyctenular pannus :
•It is vascularization and infiltration.
Differential diagnosis :
• Pinguecula.
• Limbal spring catarrh.
• Nodular episcleritis.
• Phlyctenular pannus must be differentiated
from trachomatous pannus.
Treatment :
• Steroid eye drops.
• if the cornea is involved ,Cycloplegic eye
drops are added.
• If corneal ulceration occurs , antibiotic
eye drops are added.
• Treatment of the underlying cause if
recognized .
3- Spring catarrh (Vernal kerato-conjunctivitis)
Definition :
It
is
chronic
bilateral
seasonal
conjunctivitis recurring in the warm
seasons and characterized by Itching,
photophobia,
discharge.
lacrimation
and
ropy
Etiology :
• Allergy of the conjunctiva to an unknown
exogenous factor.
• Ultra-violet rays in the sun, heat, pollen and
dust are contributing factors.
Pathology :
• Cellular
infiltration
(Eosinophils
and
lymphocytes).
• Proliferation of epithelium over the papillae.
Incidence :
• Age : Children.
• Sex : Boys more.
• Season : Summer.
Symptoms : Most marked in summer
•
•
•
•
Itching.
Photophobia.
Watering of the eye.
Ropy discharge (White thready). The
discharge is formed of mucus, eosinophils
and epithelial debris so that it is scanty, white
and elastic.
Signs : It has three types :
1- Palpebral type (70%) :
Upper
tarsal
conjunctiva
shows
characteristic papillae :
• Large, flat-topped papillae.
• Polygonal appearance (Cobblestones).
If the papillae are left exposed for 1-2
minutes, a milky white film forms on
them. This film is sticky and is rich in
eosinophils.
• Fornix always free.
2- Bulbar type (10%) :
Upper limbus shows :
• Gelatinous masses (Due to thickened
epithelium and hyaline degeneration)
occur on the limbus.
• White spots (Tranta spots) may be
seen within these masses due to
aggregation of eosinophils+ epithelial
debris + calcium deposits.
3- Mixed type (20%) :
• Palpebral and bulbar types are present.
Corneal manifestations :
a- Superficial punctate epithelial erosion .
b- Epithelial plaque formation.
c- Weakness of the cornea with increase
incidence of Keratoconus & other forms of
corneal ectasia
Differential diagnosis :
• Palpebral type must be differentiated from
papillary trachoma.
• Bulbar type must be differentiated from
phlyctens.
Treatment :
Local treatment :
a- Cortisone eye drops : to control inflammation
• Weak steroids as fluorometholone is used
rather
than
dexamethasone
or
prednisolone → Less elevation of IOP.
• Withdraw cortisone gradually.
b. Combined antihistamine and vasoconstrictors
eye drops.
c. Mast cells stabilizers eyedrops : e.g Disodium
cromoglycate eye drops.
Dark glasses, for photophobia.
Cold compresses, for sensation of heat.
Resistant cases are treated by :
1. Immuno-suppressant agents (e.g.
Cyclosporine A 2% eye drops).
2. Supratarsal injection of steroids.
3. Debridement, for mucous plaque.
4. Cryotherapy on the papillae.
Degeneration of the Conjunctiva
1- Pinguecula.
2- Pterygium.
PINGUECULA
Definition :
It is a degenerative condition occurring in old
people, characterized by a yellow nodule on
the nasal side of the limbus.
Symptoms :
- Asymptomatic
- Disfigurement.
Signs : Triangular nodule :
• Base towards the cornea.
• On nasal side of the conjunctiva, rarley temporal.
• Yellow in color.
Pathology :
Hyaline degeneration of the conjunctiva with
deposition of elastic tissue (yellow).
Differential diagnosis : Phlycten.
Treatment : No treatment. If cosmetically bad
it can be excised.
PTERYGIUM
Definition :
It is a triangular encroachment of the conjunctiva
onto the cornea.
Etiology : Unknown but it may be related to :
• Ultra violet rays in the sun.
• Chronic irritation by dust, wind, and fumes.
• Recently, it may be due to limbal stem cell
deficiency.
Clinical picture :
Symptoms :
• Disfigurement.
• Symptoms of irritation.
• If it reaches central part of the cornea, vision is
affected.
Signs :
- Site : Nasal side, less commonly temporal.
- Shape : Triangular and consists of :
• Apex, lies over the cornea and may grow to
reach the pupillary area.
• Body. lies over the sclera.
• Neck, overlies the limbus.
- Usually bilateral.
Course :
1- Progressive: Characterized by thick, fleshy,
vascular and preceded by white dots.
2-
Stationary:
Characterized
membranous and less vascular.
by
thin,
N.B :
• Pterygium never disappears alone.
• It is not known if it is a primary degeneration of
the conjunctiva or cornea.
• It is not known if pinguecula is the precursor of
pterygium or not.
Differential diagnosis :
Pseudo-pterygium : It is a fold of the bulbar
conjunctiva attached to the cornea. Formed
due to the adherence of inflamed conjunctiva
to the base a marginal corneal ulcer.
Treatment :
• If the pterygium is small and stationary, it is
best left alone because operation may be
followed by recurrence.
• Indications for operation are :
1. Progressive pterygium.
2. Encroachment on pupillary area.
3. Cosmetically annoying the patient.
• Operations used for pterygium are :
1. Excision of pterygium with leaving bare
sclera allows corneal epithelium to cover
the cornea before conjunctival epithelium
reaches the limbus.
2. Excision of pterygium with application of
conjunctival or amniotic membrane graft
to bare area of sclera.
3. To prevent recurrence, the following is
tried:
a- Beta irradiation to the bare area of sclera
(it produces endarteritis obliterans so
prevents growth of new vessels which
are the causes of recurrence).
b- Intraoperative application of Mitomycin C
to the bare area of sclera inhibition of
proliferation.
c- Excision & lamellar keratoplasty.
d- Stem cell transplantation.
Symblepharom
Definition :
It is a partial or complete adhesion between the
palpebral conjunctiva and the bulbar conjunctiva.
Etiology :
• Formation of two raw surfaces opposite to each
other allowing adhesions, cicatrization and
fibrosis
• It is seen in the following conditions :
1. Injuries, burns and caustics.
2. Trachoma (Posterior symblepharon).
3. Diphtheria.
Types :
• Anterior
:
Adhesion between palpebral
conjunctiva adjacent to lid margin and eye ball.
• Posterior: Adhesion obliterating the fornix.
• Total : Posterior surface of the eyelid is totally
adherent to the globe.
Symptoms :
• Diplopia due
movement.
to
limitation
of
ocular
• Disfigurement.
• Diminution of vision if the cornea is
involved.
Treatment :
Prophylactic :
• If two raw surfaces occur in the bulbar and
palpebral conjunctiva, we should :
1- Pass a glass rod smeared with antibiotic
ointment in the fornix several times daily.
2- Use a contact shell.
Curative :
• Surgical release of the adhesions and
mucous or amniotic membrane grafting.
Thank You