The Disease of Conjunctiva
(結膜) /Sclera (鞏膜)
眼科 黃奕勛 醫師
Palpebral, bulbar conjunctiva,
fornix
Slit Lamp (裂隙燈、細隙燈)
Pinguecula (結膜黃斑) &
Pterygium (眼翳)
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Pinguecula: elevated yellow
nodule near limbus in
palpebral fissure
Pterygium: triangular fold of
bulbar conjunctiva loosely
attached to cornea except at
the apex
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elastoid degeneration
Sun (uv light), wind,--usually nasal side, surgery
excision for corneal
astigmatism, visual axis
involvement and cosmetic
Miscellaneous conjunctival
disorders
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Conjunctival concretions (眼
結石) :
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epithelial inclusion cysts filled
with epithelial and keratin
debris, elderly or chronic
conjunctivitis, remove when
irritation
Subconjunctival hemorrhage
(結膜下出血 )
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spontaneous, trauma, acute
viral or bacterial conjunctivitis,
Valsalva maneuver -single eye, no treatment, 1-2
wks subside
recurrent and both eyes:
suspect blood dyscrasis
Symptoms of conjunctivitis
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Non-specific symptoms: lacrimation, irritation,
stinging, burning, photophobia, --If pain or FB sensation --> associated corneal
involvement
Itching, hallmark of allergic conjunctivitis
Discharge
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Watery - acute viral and allergic
inflammations
Mucoid - VKC, dry eye
Purulent - acute bacteria infection
Mucopurulent – mild bacterial and chlamydia
infection
Etiologic classification of
conjunctivitis
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Bacterial
Chlamydial
Viral
Allergic
Chemical/toxic or irritative
Associated with systemic disease, etiology unknown
Rickettsial, fungal, parasitic
Bacterial conjunctivitis
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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 (onset<24hrs): Neisseria gonorrhoeae, N.
meningitidis
Gonococal conjunctivitis
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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, ---
Chlamydial conjunctivitis—
Trachoma (砂眼)
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Chalmydia trachoma serotype A-C
Chronic follicular conjunctivitis, pannus formation, limbal
follicles and Herberts pits, later scaring of conjunctiva (Arlt’s
line), upper tarsal>lower
Late complication: tear deficiency, dacryostenosis, entropion,
trichiasis, corneal scarring, salzman’s 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
Trachoma – Early (tarsal follicles
and Herbert’s pits)
Trachoma - Late
Viral conjunctivitis
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Via respiratory or ocular
secretions
Epidemic
keratoconjunctivitis (EKC)
Adenovirus 8, 11, 19, 37
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Epidemic hemorrhage
keratoconjunctivitis (EHKC)
Picornavirus (Enterovirus 70), coxaschievirus
A24
subconjunctival hemmorrhage
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Pharyngoconjunctival fever
(PCF)
Adenovirus 3, 4, 7
fever, URI, conjunctivitis, transmitted by
droplets , children
Adenoviral keratoconjunctivitis—
Epidemic keratoconjunctivitis (EKC)
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Incubation:4-10 days
Duration:14 days
Acute onset red eye, watery
discharge, photophobia,
foreign body sensation,
preauricular lymph node,
second eye mild involvement
Both eyes affected 60% cases
Treatment for EKC
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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
Allergic rhinoconjunctivitis
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Itching, foreign body
sensation, tearing, lid
swelling, red conjunctiva,
--Tx: self limited, remove
allergen, cool compress,
Mast cell stabilizers,
antihistamin, topical
steroid, NSAID
隱形眼鏡配戴不適症候群
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視力模糊、視力不穩、頭痛、眼睛轉動不
舒服、彩色光圈、畏光、癢、流淚、異物
感、燒灼感、疼痛 ---
原因
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體質：乾眼症、過敏
環境：空調不佳、過度除濕
長時間配戴
驗配之問題：弧度太鬆或太緊
清潔不當
角膜炎：感染性或非感染性
結膜炎：化學毒性或過敏性
CL related allergy and toxicity
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CL intrinsically inert
Solution chemicals and lens deposits
Allergy termed a hypersensitivity reaction
Toxicity direct effect of chemicals
Increased risk of extended wear SCL
Giant papillary conjunctivitis
(GPC, 巨大乳頭狀結膜炎 )
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Soft CL>Hard CL; exposure
sutures; ocular prosthesis
Redness, itching, mucoid
discharge, CL intolerance,
lens decentration
Abnormal large papillae
(>0.3 mm) on super tarsal
conjunctiva
Mechanical trauma,
hypersensitivity to CL or
adherent material
Treatment of GPC
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Discontinue CL wear
Improving lens hygiene
Discarding or refitting, daily wear, disposable CL
or RGP
Topical steroid, mast-cell stabilizer
Episcleritis and
Scleritis
Sclera
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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
Normal, episcleritis, scleritis
Episcleritis
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simple
78.3%
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nodular
21.7%
Disease Entities - Inflammation
A: Episcleritis
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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, <10 days,
60 % recurrent in either eye, minor associated disease
Episcleritis
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course and management:
transient, self-limit, ocular redness with mild
irritation, blanch with topical phenylephrine
topical vasoconstrictors, NSAIDs, corticosteroid
oral NSAIDs
Scleritis
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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
Treatment
Medical
 underlying disease
 almost never responds to topical tx alone
 systemic corticosteroid, NSAID, immunosuppressive
agents
重點複習
Adenoviral keratoconjunctivitis—
Epidemic keratoconjunctivitis (EKC)
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Incubation:4-10 days
Duration:14 days
Acute onset red eye, watery
discharge, photophobia,
foreign body sensation,
preauricular lymph node,
second eye mild involvement
Both eyes affected 60% cases
Giant papillary conjunctivitis
(GPC, 巨大乳頭狀結膜炎 )
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Soft CL>Hard CL; exposure
sutures; ocular prosthesis
Redness, itching, mucoid
discharge, CL intolerance,
lens decentration
Abnormal large papillae
(>0.3 mm) on super tarsal
conjunctiva
Mechanical trauma,
hypersensitivity to CL or
adherent material