Lec:4
د. عامر يحيى رجب6/11/2013
العدد ( 8)
THE CONJUNCTIVA I
THE CONJUNCTIVA
The conjunctiva is a transparent mucous membrane lining the inner surface of the eyelid and covering the anterior sclera.
Gross anatomy
Palpebral conjunctiva
The conjunctival fornix
Bulbar conjunctiva
Plica Semilunaris
Caruncle
Blood supply and lymph drainage:
I. Arterial supply1.Posterior conjunctival arteries 2.Anterior conjunctival arteries
II. Venous drainage
1.Palpebral vein 2.Ophthalmic vein
III. Lymphatic drainage
1.Preauricular lymph node 2.Sub mandibular lymph node
IV. Nerve supply ( Trigeminal nerve)
Minute anatomy
The epithelium.
The substantia propria
A. Adenoid Layer
B. Fibruos Layer
Pathological manifestation of conjunctival inflammation
discharges.
Chemosis.
Hypereamia.
Follicles.
Papillae.
Giant papillae.
Membranes.
Pseudomembrane.
Disease of the Conjunctiva
Inflammations.Degenerations.
Dry eye.
Pigmentations.
Conjunctival tumors.
Conjunctivitis
Classifications:
Infective conjunctivitis;
A. acute:( serous, catarrhal, muco-purulent, purulent, viral and membranous).
B. Sub acute:( catarrhal, angular and follicular).
C. Chronic:( follicular and granulomatous).
Non-infective conjunctivitis
A. acute:( mechanical injuries, allergic, photophthalmia and burns)
B. chronic :( simple catarrhal, keratoconjuncvtivitis sicca, vernal, phlyctenular and ocular pemphigoid.
ACUTE INFECTIVE CONJUNCTIVITIS
Mucopurulent Conjunctivitis
Causative agents: The commonest organisms are
Haemophilus aegypticus (Koch-Week’s bacillus): causes epidemics in April, May & September, and October. This is related to the fly breeding season
Staphylococci, streptococci and peneumococci
Acute fevers
Clinical features
It’s an acute infective type of conjunctivitis characterized by hyperaemia of the bulbar conjunctiva and papillary hypertrophy of the palpebral conjunctiva associated with muco-purulent discharge.
It may manifest itself either in severe or mild form.
Treatment
Based on two principles :
1- Frequent irrigation of the conjunctival cul-de-sac to remove the discharge.
2- Control of the infection.
OPHTHALMIA NEONATORUM
In children aged <30 days
Any discharge or watering, in the first week of life should arouse suspicion
ETIOLOGY:
Before birth: infected amniotic fluid
During birth: infected birth canal
After birth: first bath, soiled clothes, unhygienic conditions
CAUSITIVE AGENTS:
Chemical conjunctivitis: silver nitrate solution
Gonococcal infection:
Other bacterial infections:
Staph aureus
Strept hemolyticus
Strept pneumoniae
Neonatal inclusion conjunctivitis:
Chlamydia trachomatis serotype D to K
Herpes Simplex Ophthalmia Neonatorum
Incubation period:
Chemical conjunctivitis: 4-6 hours
Gonococcal infection: 2-4 days
Other bacterial infections: 4-5 days
Neonatal inclusion conjunctivitis: 5-14 days
Herpes Simplex Ophthalmia Neonatorum : 5-7 days
SYMPTOMS:
Pain and tender eyeball
Purulent conjunctival discharge (gonococcal)
Mucoid / mucopurulent (other bacterial
infections)
Swollen lids
Chemosed conjunctiva
Corneal involvement rarely
COMPLICATIONS:
Corneal ulceration with tendency to perforate
PROPHYLAXIS:
Antenatal:
Treatment of genital infections of mother
Natal:
Delivery under aseptic conditions
Newborns eyelids should be well cleaned
Postnatal:
1% tetracycline / 0.5% erythromycin ointment
1 % silver nitrate solution (Crede’s method)
Single injection of Ceftriaxone 50mg/kg IM/IV
ACUTE FOLLICULAR CONJUNCTIVITIS
Epidemic keratoconjunctivitis:
Associated with SPK and occur in epidemics
Adenovirus type 8 and 19
Markedly contagious and direct contact transfer
Incubation : 8 days
Phase 1 : acute serous conjunctivitis
Phase 2 : acute follicular conjunctivitis
Phase 3 : acute pseudomembranous conjunctivitis
Corneal involvement : SPK
Pre-auricular lymphadenopathy in all cases
Treatment : supportive therapy
Pharyngoconjunctival fever:
Adenovirus type 3 and 7Acute follicular conjunctivitis
With pharyngitis, Fever & Pre auricular LN
Primarily in children and in epidemic forms
Corneal involvement in 30% cases
Treatment is supportive
ACUTE NON-INFECTIVE CONJUNCTIVITIS
Mechanical injury
Photophthalmia
Acute allergic conjunctivitis
ANGULAR CONJUNCTIVITIS
Mild chronic conjunctivitis confined to the conjunctiva & lid margins near the angles
ETIOLOGY:
Moraxella Axenfield Bacilli
Rarely staphylococci
PATHOLOGY:
Production of proteolytic enzyme
Causes maceration of epithelium
SYMPTOMS:
Irritation discomfort
Collection of dirty white foamy discharge at the angles
Redness in the angles of the eye
SIGNS:
Hyperaemia of bulbar conjunctiva near the canthi
Hyperaemia of lid margins near the angles
Excoriation of skin around the angles
Presence of foamy mucopurulent discharge at the angles
COMPLICATIONS:
Blepharitis
Marginal catarrhal corneal ulceration
TREATMENT:
Good personal hygiene
Oxytetracycline 1 % eye ointment 2-3 times x 10-14 days
Zinc lotion at day time and zinc oxide ointment at bedtime
CHRONIC NON-INFECTIVE CONJUNCTIVITIS
PHLYCTENULAR CONJUNCTIVITIS
It is an allergic reaction of the conjunctiva caused by endogenous bacterial toxins and characterized by bleb or nodule formation near the limbus.
Aetiology :
- Tuberculo-protein- Toxins from staphylococcus or streptococcus- Toxins from intestinal parasitesClinical Types :
- Phyctenular conjunctivitis- Phyctenular Kerato-conjunctivitis- Phyctenular Keratitis
Vernal kerato-conjunctivitis (spring Catarrh):
It is a chronic allergic condition of the conjunctiva, affecting mainly children and young adults characterized by seasonal variation and may be associated with Keratoconus. It is due to hypersensitivity to airborne allergens. It is common in patients with asthma, hay fever or atopy.
Clinical picture:
Itching and lacrimationScanty whitish ropy mucoid discharge.
Hyperemia.
Photophobia and belpharospasm.
Symptoms increase in spring and summer ( seasonal variation)
Signs
Palpebral Type
Bulbar Type: more severe
Mixed type
Giant papillary conjunctivitis
Etiology:Associated with contact lens wear especially extended-wear contact lenses least with hard lenses.
May result from irritation with ocular prosthesis or by exposed corneal sutures.
