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