Conjunctiva1

Conjunctiva is a thin translucent vascular membrane which cover the under surface of the lids and reflected over anterior surface of the sclera up to the limbus. It consists of two layers, the outer one is the epithelium and inner one is the stroma. The stromal layer consists of blood vessels, connective tissues, glands such as Krauses, Wolfring and Goblet cells. The conjunctiva is supplied by sensory nerve via branches of ophthalmic and maxillary division of 5th cranial nerve. Sympathetic nerves are derived from sympathetic plexus.

Bacteriology: Non-pathogenic bacteria–Diplococci, Corynebacterium xerosis, Staphylococcus albus, etc.

Pathogenic Bacteria – Streptococcus, E.coli, B.proteus, gonococci, H. aegyptius, Moraxella, etc.

Virus- Adenovirus, herpes.

Inflammation (conjunctivitis): Classification

It is often associated with measles and scarlet fever. It occur as epidemic and usually bilateral. It is contagious and spreads by flies, fingers and fomites. It is self limiting.

There is readness of the conjunctiva with the foreign body sensation.

Conjunctival-congestion with red eye. Chemosis of conjunctiva may be associated with subconjunctival haemorrhage.

Superficial-keratitis and marginal corneal ulcer.

Staphylococci, Haemophilus aegypticus, pneumococci.

It is contagious, due to the gonococci, staphylococci and Corynebacterium diphtheriae.

Common in adults as well in children. In adult the infection comes from genitals. Swelling of the lids + conjunctival congestion with chemosis +ve. Copious purulent discharge +ve. Cornea is diffuse and hazy with gray or yellow spot on the centre. Ulcer may be formed at any part of the cornea due to necrosis of epithelium. Marginal ulcer may extent completely due to collection of pus and bacteria at gutter. Ulcer may be perforated. Iridocyclitis, endocarditis even septicaemia may also form as its complications.

It occur in the new baby due to maternal infection. This is virulent conococci infection cause 50% blindness in children. It is usually bilateral.

Discharge purulent +ve with the oedematous eyelids. Conjunctiva intensively inflamed, bright red, with marked chemosis. Later on purulent discharge changes into the mixture of pus, serum and blood.

Cornea hazy due to the marginal and central ulceration, it may lead the perforation of the cornea—Iris prolapse, lens may be extruded and ultimately form panophthalmitis. Metastatic stomatitis and arthritis of big joints 3-4 weeks of the disease.

Swelling of the lids +ve with serous or mucopurulent discharge.

Palpebral conjunctiva is covered by white membrane.

Cause the bleeding if membrane is peeled of from conjunctiva. In severe cases lids are browny and membrane firmly attached with conjunctiva by semisolid exudates. Show the changes of necrosis in conjunctiva and cornea.

Every case should be treated as diphtheria unless good negative evidence is offorded. This consists of the intensive local and general administration of penicillin together with the prompt injection of antidiphtheritic serum (4-6-10,000 units repeated in 12 hours). Antitoxin given early and in adequate amounts both locally and systemically is curative, but it should be combined with the antibiotic.

It is the continuation of simple acute conjunctivitis. It is frequent when a cause of irritation is continuous as smoke, dust, heat, bad air, permanent irritation from concretion in the palpebral conjunctiva, misplaced lashes, dacryocystitis, chronic rhinitis, etc.

Burning and grittiness. Difficulty in keeping eye open.

Conjunctival congetion of palpebral + bulbar conjunctiva +ve

Treatment for the cause.

Intermarginal strip of the bulbar conjunctiva is conjested at the inner and outer canthi. Excoriation of the skin at the inner and outer palpebral angles. Complaints are frequent Blinking + Mucopurulent discharge.

1) Blepharitis, 2) Marginal, central or hypopyon corneal ulcer.

Associated with the development of follicles that is the aggregation of lymphocyte cells. In children the follicles develop after the age of 3 months.

It was the major cause for blindness as 1/5 of world population is affected by trachoma. It is commonly seen in crowded unhygienic dusty and dirty environment. It is not racial disease. Chlamydia trachomatis is the cause of this disease, spread by sexual transmission. Contagious disease in its acute stage being spread by the transference of conjunctival secretion by such means fingers, towel, or by flies. Primary infection is epithelium and involves both conjunctiva and cornea.

Varities of Pannus (Fig. 1.2)—Two types of pannus:

Progressive pannus: Lymphocytes infiltration is beyond the growing end of blood vessels indicate the acute stage of the disease.

Regressive pannus: Lymphocytes infiltration is behind the growing end of blood vessels.7

Pathology: Chlamydia trachomatis is seen inconjunctival scraping in the colony form in the epithelial cells as Halberstadter-Prowazek inclusive body. Inclusive body burst and liberate the large number of elimentary bodies.

Corneal ulcer is the only complication of trachoma.

Sequelae are:

Histological examination of the inclusive body.8

It is acute reaction to allergen.

Itching with watery secretion and marked redness of the conjunctiva. Secretion contains the large number of eosinophilia.

Removal of allergan, anti-histaminic drugs, corticosteroid drops useful in severe cases.

It is characterized having phlycten or Bleb at the limbus, is supposed to be due to the tuberculous protein. In some cases it is associated with the infection of tonsil and adenoid. It is common in children in between the ages of 5 to 15 years.9

Corticosteroid in the form drops and ointment is very effective. Treatment should be given for the cause, e.g. tuberculosis, tonsil and adenoid, etc.

It is caused by the exogenous allergen such as pollen and dust. It is common in young boys 5 to 15 years. It is bilateral, usually occurs at the onset of hot weather. Patients main complains are: 1) Itching. 2) Thick white ropy mucous discharge. 3) Burning and foreign body sensation. 4) Photophobi, and 5) Lacrimation.

This is the accumulation of epithelial cells and inspissated mucus in Henle's gland. Occur as minute, hard, yellow spot in the palpebral conjunctiva project from the surface. It scratches the cornea and gives the sensation of foreign body, commonly in the elderly people.

Should be removed with the sharp needle under the topical anaesthesia.

Trangular patch on the conjunctiva. Common in the elderly people, those exposed to the strong sun light, dust. wind and so on. Yellow in colour and look like a fat (fat = pinquis). It is situated near the limbus in the palpebral aperture. The base of the pinguecula is always toward rhe limbus and apex away from the cornea. This is due to the hyaline infiltration and elastotic degeneration of the submucous tissue.

No treatment as it is symptomless condition.

Degenerative condition of the conjunctiva which encroaches over the cornea in the form of vascular granulation sheath. It is the subepithelial hyaline type degeneration, commonly in the sunny climate. Ultraviolet light is probably an aetiological factor. It is bilateral commonly present on nasal side, males are affected more. In some cases it presents on the nasal side as well as temporal side in the unilateral eye. It is triangular in shape consists of head, neck and body. Pterygium invades the cornea by 11head and involve the Bowman's membrane and the superficial layer of stroma. It is loosely attached to the sclera by its whole length. The area of its adhesion being always smaller than its breadth. So that there are folds at the upper and lower border of the pterygium. It frequently follows the pinguecula.

Pterygium is supposed to be the minor ocular disorder but major ophthalmic problem because of it's high rate of recurrence. Surgery is the only choice of treatment. Encroachment of the pterygium's head over the pupillary area not less than 1 mm by which the vision of the patient is affected may be considered for the surgery.

Surgeries are:

The common conjunctival cysts are due to: 1) Lymphangiomata: This is due to the dilation of lymph spaces (Lymphangiectasis). 2) Larger retention cyst of Krause's accessory lacrimal gland in the upper fornix. 3) Cysticercus and Hydatid cyst: These represent in the form of subconjunctival cyst. 4) Epithelial implantation cyst: Cysts are present at the site of injury or at the site of operation for strabismus.

Excision or cauterization by thermal or laser.

It is a dry lusterless condition of the conjunctiva. This is due to the unstable tear film, exposing the conjunctival epithelium to evaporation. Tear film consists of three layers (Figs 1.7A to C): 1) Outer one is lipid layer – secreted by meibomian gland and zeis gland. 2) Aqueous layer – It is secreted by lacrimal and accessory gland. It consists of inorganic salts, lysozyme, lactoferrin and immunoglobulin. 3) Mucin layer – Secreted by goblet cells. Normal rate of tear production is 1 to 2 microlitre/minute.

Foregin body sensation or dry sensation