CONJUNCTIVA:
ANATOMY , PHYSIOLOGY,
SYMPTOMATOLOGY AND
CLASSIFICATION
Dr. Faizur Rahman
Professor of Ophthalmology
Peshawar Medical College.
Learning objectives
At the end of the session the students would
be able to:
• Correlate the structure of the conjunctiva with its
functions and clinical presentations in common
clinical disorders.
• Identify important anatomical landmarks of
conjunctiva.
• Classify diseases of the conjunctiva.
• Identify the common symptoms and signs of
conjunctival disease, differentiate various
conjuntivitidies and manage.
ANATOMY
It is the mucous membrane covering the under
surface of the lids and anterior part of the
eyeball upto the cornea.
Parts of conjunctiva
• Palpebral; covering the
lids—firmly adherent.
• Forniceal; covering the
fornices—loose—thrown
into folds.
• Bulbar; covering the
eyeball—loosely attached
except at limbus.
• Also marginal and limbal
parts and plica
semilunaris.
Palpebral conjunctiva
• Subtarsal sulcus 2mm from posterior edge of the
lid margin.
• Richly vascular.
• Extremely thin.
• Strongly bound to the tarsal plate.
Conjunctival fornices
• Transitional region between
palpebral and bulbar
conjunctivae.
• Superior fornix 10 mm from
limbus.
• Inferior fornix 8 mm from
limbus.
• Lateral fornix 14mm from
limbus.
• Medially absent.
• Ducts of lacrimal glands open
into lateral part of superior
fornix.
Bulbar conjunctiva
• Lies in contact with eyeball.
• Thin, translucent and loosely attached by
connective tissue to sclera and fascia bulbi.
• Conjunctival limbus 1 mm anterior to corneal
limbus.
• Bulbar limbus 1.5 mm behind corneal limbus.
Epithelium
• Stratified columnar epithelium 2 – 5 cells.
• At limbus change into stratified squamous non
keratinized epithelium.
• At lid margin non keratinized stratified
squamous epithelium changes into keratinized
stratified squamous epithelium.
• Goblet cell – mucus.
• Accessory lacrimal glands.
Sub mucosa
• Fine delicate connective tissue.
• Lymphocytes.
• Denser fibrous tissue, blood vessels, nerves,
smooth muscles and accessory lacrimal glands.
• Papillae.
Nerve supply - Sensory
• Bulbar conjunctiva – long ciliary nerves – nasociliary
N. – Ophthalmic division of trigeminal N.
• Superior palpebral and forniceal conjunctiva – frontal
and lacrimal branches of Ophthalmic division of
trigeminal N.
• Inferior palpebral and forniceal conjunctiva – laterally
from lacrimal branches of Ophthalmic division of
trigeminal N. and medially infraorbital N. – Maxillary
division of trigeminal N.
Sympathetic;
• Superior cervical sympathetics to blood vessels.
Blood supply
Arterial supply;
• Posterior conjunctival arteries derived from
arterial arcade of lids which is formed by
palpebral branches of nasal and lacrimal arteries
of the lids.
• Anterior conjunctival arteries derived from the
anterior ciliary arteries – muscular br. of
ophthalmic artery to rectus muscles.
Venous drainage;
• Palpebral and Ophthalmic veins.
Lymphatic drainage
• Lymph vessels are
arranged as a superficial
and a deep plexus in sub
mucosa.
• Ultimately as in the lids
to the pre auricular and
sub-mandibular lymph
glands.
PHYSIOLOGY
• Smooth surface.
• Secretes mucin and aqueous component of tear
film.
• Highly vascular: supplies nutrition to the
peripheral cornea.
• Aqueous veins drains from anterior chamber
maintenance of IOP.
• Lymphoid tissue helps in combating infections.
• Basic secretion—reflex secretion.
Symptomatology
Non-Specific;
• Lacrimation.
• Irritation.
• Stinging.
• Burning.
• Photophobia.
• Redness.
Specific;
• Pain and FB sensation in corneal involvement.
• Itching in allergic, blephritis and dry eyes.
SIGNS
• Type of discharge.
• Type of conjunctival reaction.
• Presence of membrane/ pseudomembrane.
• Lymphadenopathy.
DISCHARGE
Exudate plus debris plus mucus plus tears.
• Serous; watery exudate in acute viral and acute
allergic conjunctivitis.
• Mucoid; mucus discharge in VKC and KCS (dry
eyes).
• Purulent; puss in severe acute bacterial
conjunctivitis.
• Mucopurulent; puss plus mucus in mild bacterial
conjunctivitis and Chlamydial conjunctivitis.
TYPE OF CONJUNCTIVAL
REACTION
• Hyperaemia: (Conjunctival injection)
Bacterial.
• Sub-conjunctival Haemorrhage: Viral.
• Bleeding:
• Chemosis: (Oedema)
• Scarring: Trachoma, cicatricial
pemphigoid, atopic conjunctivitis and
prolong use of topical drops.
• Follicular reaction.
• Papillary reaction.
Follicular reaction
• Sub epithelial foci of hyperplastic of
lymphoid tissue with in stroma.
• More prominent in fornices.
• Multiple, discrete, slightly elevated,
lesions encircled by a tiny blood
vessel—small grains of rice.
• Size from 0.5 to 5 mm.
1. Viral.
2. Chlamydial.
3. Parinaud oculoglandular syndrome.
4. Hypersensitivity to topical
medications.
Follicular reaction
Papillary reaction
• Hyperplastic conjunctival epithelium.
• Can develop in palpebral conjunctiva (firmly attached)
and limbus.
• Papilla may mask follicles.
• Giant papilla (confluence)
• Non-specific; (less diagnostic)
1. Chronic blephritis.
2. Allergic conjunctivitis.
3. Bacterial conjunctivitis.
4. Contact lens wears.
5. Superior limbic keratoconjunctivitis.
6. Floppy eyelid syndrome.
Pseudomembrane
• Outside epithelium.
• Coagulated exudate adherent to the inflammed
epithelium.
• Can be easily pealed off.
• Causes;
1. Severe adenoviral infection.
2. Ligneous conjunctivitis.
3. Gonococcal conjunctivitis.
4. Stevens-Johnson syndrome.
Membrane
• Includes epithelium.
• Infiltrate the superficial layers of conjunctival
epithelium.
• Epithelium is injured if removal attempted.
• Causes;
1. Diphtheria.
2. Beta-hemolytic steptococci.
Lymphadenopathy
• Pre auricular and sub mandibular.
1. Viral infection.
2. Chlamydial infection.
3. Severe bacterial infections. (Gonococcal)
4. Parinaud oculoglandular syndrome.
Laboratory Investigations
Indications:
•
•
•
•
Sever purulent conjunctivitis.
Follicular conjunctivitis: viral vs chlamydial.
Conjunctival inflammation.
Neonatal conjunctivitis.
Laboratory Investigations—
cont…
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•
•
•
•
Cultures.
Cytological investigations.
Inoculation.
Detection of viral and chlamydial antigens.
Impression cytology for ocular surface neoplasia,
dry eyes, ocular cicatricial pemphigoid, limbal
stem cells failure, infection.
• Polymerase chain reaction: small quantity of
DNA for adenovirus, herpes simplex, chlamydia
trachomatis.
CLASSIFICATION OF THE DISEASES OF CONJUNCTIVA
Morphological
•
•
•
•
Papillary
Follicular
Pseudomembranous
Membranous
Discharge
•
•
•
•
Serous
Mucous
Purulant
Mucopurulant
Etiological
• Infective
• Non-Infective:
Allergic
Autoimmune
Toxic
Chemical
Degenerations
Clinical
•
•
•
•
Acute
Sub-acute
Chronic
Recurrent
Age
• Neonatal
• Childhood
• Adult
Neonatal
•
•
•
•
•
Chlamydial
Gonococcal
Other bacteria
Viral
Chemical
Common Bacterial
• Mucopurulant
• Purulant
• Membraneous
CHLAMYDIAL OCULAR
INFECTIONS
• Adult inclusion conjunctivitis.
• Neonatal chlamydial conjunctivitis.
• Trachoma.
Viral
•
•
•
•
•
Adenoviral
Picarna viral
Herpes simplex
Measles
Chicken pox
Allergic
•
•
•
•
Acute allergic conjunctivitis
Vernal keratoconjunctivitis
Atopic keratoconjunctivitis
Phlactenular keratoconjunctivitis
Autoimmune
• Phempegoid (Essential shrinkage of
conjunctiva)
• Steven Johnson syndrome
Chemical
• Acid burns
• Alkali burns
• Others
Management
• Treat the cause:
Anti-inflammatory agents
Antibacterial
• Antiallergic
• Supportive
• Specific
Acute Bacterial Conjunctivitis
Mucopurulant conjunctivitis
• Caused by:
Staph epidermidis and Staph aureus –
usually. Strep pneumonae, H influensae and
Morexella lucanatae occasionally
Acute Bacterial Conjunctivitis
• Symptoms:
*Acute onset of redness, grittiness, burning and discharge.
*Photophobia may be present (corneal involvement)
*Stickiness of the eyelids
*Usually bilateral disease
• Signs:
*Conjunctival hyperaema
*Mild papillary reaction
*Mucopurulant discharge
*Lid crusting
*No lymphadenopathy.
*Normal VA
Acute Bacterial Conjunctivitis
Purulant cojunctivitis (Adult gonococcal)
• Symptoms:
*Hyperacute condition
*Extremely profuse, thick, creamy puss
from the eye or eyes
Acute Bacterial Conjunctivitis
• Signs:
*Severe conjunctival chemosis
*May be membrane formation
*Periocular edema
*Ocular tenderness
*Gaze restriction
*Lamphadenopathy
*Corneal involvement
• Treatment
Systemic and topical antiboitics
Chronic bacterial conjunctivitis
• Causes:
*Acute becoming chronic
*Refractive errors
*Secondary
Misplaced lashes, CDC, chronic blephritis
• Symptoms:
• Burning and photophobia
• Signs:
*Congestion, and sticky discharge
Treat:
remove the cause
antibiotics
Membraneous conjunctivitis
• Causes
*Children with ill health
*Low immunity after diseases
*Corynbact diphtharae and virulant strains of beta
hemolytic streptococci
Symptoms:
highly toxic and ill patient
pyrexial
membrane
Signs:
high temprature
lid edema
membrane
Angular conjunctivitis
•
•
•
•
Adult infection
More common in sprig and summers
Hemophilis lacunatis involved
Bilateral and contageous
Angular conjunctivitis
• Symptoms:
Irritation
Itching
Smarting sensation in the eyes
• Signs:
Hyperama
Excoriation of conj epithelium
Cong at medial and lat canthus
Scanty mucopurulant discharge
prolonge course
corneal involvement
CHLAMYDIAL OCULAR
INFECTIONS
CHLAMYDIAL OCULAR
INFECTIONS
• Adult inclusion conjunctivitis.
• Neonatal chlamydial conjunctivitis.
• Trachoma.
TRACHOMA
• Etiology: Serotypes A, B, Ba & C of Chlamydia
trachomatis.
• Transmission: Common fly (major Vector),
fomites, fingers.
• Epidemiology:
–
–
–
–
Endemic in Africa, Asia, Middle East & Australia.
Leading cause of preventable blindness.
Worldwide 360 million people affected.
Six million people are blind from trachoma.
TRACHOMA
• Risk factors:
– Poverty & deprived members of community.
– Poor personal & community hygiene.
– Infectious pool: Preschool children of both
sexes & their care providers.
TRACHOMA
• Age:
– Children: Follicular & inflammatory trachoma.
– Young adults: Trachomatous scarring.
– Middle-aged: Trichiasis & corneal opacity.
• Sex: Trichiasis & blindness 2-4 times more
common in women than men.
PRESENTATION
• During childhood.
• Symptoms:
–
–
–
–
–
FB sensation.
Redness.
Lacrimation.
Scanty mucoid discharge.
Mucopurulent discharge if secondary infection.
STAGES
• I) Incipient: Characterized by:
– Minute immature follicles in upper tarsal
conjunctiva.
– Cytoplasmic inclusions in conjunctival
epithelium.
– Stromal hyperemia & oedema.
STAGES
• IIa): Follicular hypertrophy:
– Large soft expressible follicles in upper tarsus,
fornix & limbus.
– Punctate keratitis.
– Follicular necrosis---Herbert’s pits.
– Stromal infilteration by plasma cells &
macrophages.
STAGES
• IIb): Papillary hypertrophy:
– Trachoma of intense activity or chronic
trachoma with superimposed bacterial
infections.
– Obscuration of follicles by papillary
hypertrophy.
STAGES
• III): Cicatrizing trachoma:
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–
–
–
–
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Conjunctival Scarring---Arlt lines.
Pannus formation.
Lacrimal gland obstruction.
Trichiasis.
Entropion.
Symblepharon.
STAGES
• IV): Healed stage:
– Resolution of inflammation.
– Replacement of follicles & papillae by scar
tissue.
DIAGNOSIS
Clinical diagnosis of trachoma requires the presence
of at least two of the following features:
–
–
–
–
Conjunctival follicles on upper tarsal conjunctiva.
Limbal follicles and their sequelae (Herbert’s pits).
Tarsal conjunctival scarring.
Fibrovascular pannus.
WHO GRADING
1. Trachomatous Follicles (TF): Presence of five or
more follicles in the upper tarsal conjunctiva.
2. Trachomatous Inflammation (TI): Inflammatory
thickening of the tarsal conjunctiva that obscures
more than half of the normal deep tarsal vessels.
3. Trachomatous conjunctival Scarring (TS).
4. Trachomatous Trichiasis (TT): At least one
eyelash touching the cornea.
5. Corneal opacity (CO).
COMPLICATIONS
•
•
•
•
•
•
•
•
Upper lid entropion
Trichiasis.
Xerosis – obliteration of lacrimal ducts or glands.
Chlazion.
Symblepharon – obliteration of lower fornix.
Corneal ulceration.
Corneal opacity.
Pseudoptosis.
MANAGEMENT
• SAFE strategy developed by WHO:
• Surgery:
– To prevent blindness & limits progression of
corneal scarring.
– Can improve vision.
• Antibiotics:
– Azithromycin—1 G single dose (adults).
– Children: 20mg/kg single dose
MANAGEMENT
• Erythromycin 250 mg QID for 4 weeks.
(children 125mg/kg).
• Tetracycline 250 mg QID for 4 weeks.
• Topical tetracycline 1% 0.5 inch ribbon BD
for 6 weeks.
MANAGEMENT
• Facial cleanliness:
– Reduces risk & severity of trachoma.
• Environmental change:
– Improved water supply & household sanitation.
– Personal & community hygiene.
– Adequate housing & water & sewage system.
VIRUSES
• DNA /RNA particles covered by protein.
• Viruses are not cells, they are not capable of
independent replication.
• Can synthesize neither their own energy nor their
own proteins.
• They are too small to be seen by light microscope.
• Internal core of DNA/RNA + protective coat
(lepoprotein envelope).
• Replication is different from animal.
• Obligatory intra-cellular pathogens.
• Several types of viruses can cause conjunctivitis.
VIRAL CONJUNCTIVITIS
•
•
•
•
•
Inflammation with follicle formation—may be
associated with enlargement of regional lymph glands.
Severe conjunctival inflammation, minimal discharge,
lacrimation, Sub-conjunctival hemorrhage.
Mild hyperemia.
Conjunctival ulcers or membrane formation.
Corneal involvement;
1.Superficial punctate keratitis.
2.Superficial erosions.
3.Stromal infiltrates.
4.Necrotic stromal ulcer.
ACUTE FOLLICULAR
CONJUNCTIVITIS
• Follicle formations with signs of acute
cattharal inflammation may be produced by
different viruses.
1. Acute herpetic conjunctivitis.
2. Epidemic Keratoconjunctivitis.
3. Pharyngo-conjunctival fever.
4. New castle conjunctivitis.
5. Acute hemorrhagic conjunctivitis.
6. Molluscum contagiosum conjunctivitis.
EPIDEMIC
KERATOCONJUNCTIVITIS
•
•
•
•
Adeno virus serotypes 8 & 19.
Transmission: Direct or Indirect contact.
Epidemics: Schools, work places & physicians.
Mode of Spread: Contaminated fingers,
medical instruments (tonometer), swimming
pool or sexual contact.
• Self limiting.
• Highly infectious.
EPIDEMIC
KERATOCONJUNCTIVITIS
• Conjunctivitis:
Acute onset watering, redness, discomfort &
photophobia, both eyes (60%).
• Signs:
– Eyelids (oedematous).
– Scanty discharge (watery).
EPIDEMIC
KERATOCONJUNCTIVITIS
• Conjunctiva:
– Follicular conjunctivitis.
– Mild-moderate chemosis.
– Haemorrhage.
– Pseudomembrane formation.
• Tender pre-auricular lymphadenopathy.
• Keratitis (80%)- 7 to 10 days later in the form of
superficial punctate keratitis, subepithelial opacities
and may remain for quite a long time.
EPIDEMIC
KERATOCONJUNCTIVITIS
• Treatment: Symptomatic & supportive.
• Spontaneous resolution within 2 weeks.
• Topical steroids to be avoided.
• Antivirals ineffective.
• Cold compresses, topical vasoconstrictors.
ACUTE HAEMORRHAGIC
CONJUNCTIVITIS
•
•
•
•
•
•
•
•
Enterovirus 70 & Coxsackie virus A 24.
Sudden onset.
Short duration.
Bilateral, profuse watering and discharge.
Palpebral follicles.
Sub-conjunctival haemorrages.
Lymphadenopathy.
Mild transient epithelial keratitis.
Allergic Conjunctivitides
Definitions
Allergy is an altered or exaggerated susceptibility
to various foreign substances or physical agents
which are harmless to the great majority of
individuals. It is due to an antigen antibody
reaction.
Allergens is an agent capable of producing a state
or manifestation of allergy.
TYPES OF ALLERGIC
CONJUNCTIVITIS
1: ALLERGIC RHINOCONJUNCTIVITIS.
2: ACUTE ALLERGIC CONJUNCTIVITIS.
3:VERNAL KERATOCONJUNCTIVITIS.
4: ATOPIC KERATOCONJUNCTIVITIS.
5: GIANT PAPILLARY
KERATOCONJUNCTIVITIS.
6: CONTACT OCULAR ALLERGY.
7: PHLACTENULAR CONJUNCTIVITIS.
Allergic Rhinoconjunctivitis
• Hypersensitivity
reaction to specific
airborn antigens.
• Frequently associated
nasal symptoms.
• May be seasonal or
perennial.
Transient conjunctival oedema
VERNAL
KERATOCONJUNCTIVITIS
• Common, recurrent, bilateral, external, ocular
inflammation affecting children & young adults.
• 6 – 20 years.
• Males > Females.
• VKC IgE & cell mediated immune mechanism
play an important role.
• 3/4 patients have associated Atopy.
• 2/3 have close family hx. of Atopy.
VERNAL
KERATOCONJUNCTIVITIS
• Atopic pts. have Asthma & Eczema in infancy.
• Peripheral blood shows esinophilia & increase
serum IgE levels.
• Onset: After 5 years.
• Resolves: around puberty.
• Sign/Symptoms: occur on seasonal basis.
• Peak Incidence: April - August.
• More common in warm, dry climates e.g.,
Mediterranean basin, Africa & East Asia.
Clinical Features
Symptoms:
Itching, lacrimation, photophobia, FB sensation, burning.
 Signs:
Giant papilla, ptosis, hyperemia, mucus, trantas dots, punctate keratopathy, corneal
ulcer.
Clinical Types
1: Palpebral VKC:
• Conjunctival hyperemia followed by a diffuse
papillary hypertrophy (marked on superior
tarsus).
• Papilla enlarge & have flat topped polygonal
appearance of cobble stones.
• In severe cases C.T. septa rupture giving giant
papillae which is coated by copious mucus.
• Active discharge by redness, swelling & tightly
packed papilla.
2: Limbal VKC:
characterized by
mucoid nodules having
smooth round surface
discrete white
superficial spots.
trantas dots composed
predominantly
esinophils, fibroblasts
& necrotic epithelium,
scattered around limbus
& the apices of the
lesions.
Limbal vernal
Mucoid nodule
Trantas dots
3: Mixed: Signs of both palpebral & limbal VKC.
Keratopathy:
a) Punctate epitheliopathy.
b) Macroerosions due to continuous epithelial loss.
c) Plaque due to epithelial macroerosions in which
the bare area becomes coated with layers of
dessicated mucus cannot be wetted by tears resist
re-epithelialization.
d) Sub-epithelial scarring is a sign of previous
severe corneal involvement.
e) Pseudogeranotoxon (cupid’s bow).
f) Keratoconus.
Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus
Formation of cobblestone papillae
Rupture of septae - giant papillae
Progression of vernal keratopathy
Punctate epitheliopathy
Plaque formation (shield ulcer)
Epithelial macroerosions
Subepithelial scarring
Treatment
1.Topical Steroid:
Fluorometholone, Dexamethason, Prednisolone.
2. Mast cell stabilizers:
Nedocromil 0.1%, Lodoxamide, Sodium
Cromoglycate.
3. Acetyl-cysteine 5%.
4. Topical Cyclosporin 2%.
5. Debridement of early mucous plaque.
Treatment
6. Lamellar keratectomy of densely adherent
plaques.
7. Excimer laser phototherapeutic keratectomy.
8. Amniotic membrane transplantation.
9. Supratarsal inj. of steroid: Betamethasone or
triamcinolone.
10. Desensitizing immunotherapy.
ATOPIC
KERATOCONJUNCTIVITIS
 Rare, potentially serious
condition affects young
(18-50 yrs) patients with
atopic dermititis.
 Involved skin areas and
lateral neck folds;
antecubital and popliteal
fossae.
 Pts have Asthma, hay
fever, urticaria, Migraine,
Rhinitis.
 Chronic conjuntivitis.
 Serem IgE raised.
Atopic keratoconjunctivitis
Typically affects young patients with
atopic dermatitis.
Eyelids are red, thickened, macerated
and fissured.
TOXIC KERATOCONJUNCTIVITIS
Contact blepharoconjunctivitis due to drugs
1. Anaesthetics.
2. Atropine.
3. Gentamycin.
4. Neomycin.
5. Tobramycin.
6. Antivirals.
7. Epinephrine.
8. Pilocarpine.
9. Timolol.
10. Preservatives:
Benzalkonium chloride
Chlorobutanol
Chlorhexidine
EDTA
Thimerosal
11. Cosmetics.
Differential diagnosis of red eye
•
Conjunctival
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•
Lid diseases
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Clalazion
Sty
Abnormal lid function
Corneal disease
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•
Blepharoconjunctivitis
Bacterial conjunctivitis
Viral conjunctivitis
Chlamydial conjunctivitis
Allergic conjunctivitis
Toxic/chemical reaction
Dry eye
Pinguecula/pteyrgium
Abrasion
Ulcer
Foreign body
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•
•
•
•
•
•
•
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Dacryoadenitis
Dacryocystitis
Masquerade syndrome
Carotid and dural fistula
Acute angle glaucoma
Anterior uveitis
Episcleritis/scleritis
Subconjunctival hemorrhage
Factitious
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