DISORDERS OF THE CONJUNCTIVA AND CORNEA

1. DISORDERS OF THE CONJUNCTIVA AND CORNEA • Yrd.Doç. Dr. VİLDAN ÖZTÜRK

2. ANATOMY

3. EXAMINATION: • Inspection • Eye lid eversing • Staining • Hyperemia, discharge, chemosis, epiphora, follicles, papillae, membranes

4. DISORDERS OF THE CONJUNCTIVA • Conjunctivitis • Conjunctival Degenerations • Conjunctival Hemorrhage • Pigmented Lesions and Tumours

5. CONJUNCTIVITIS • Bacterial Conjunctivitis • Viral Conjuntivitis • Chlamydial Conjunctivitis • Allergic Conjunctivitis • Conjunctivitis in Mucocutaneous Diseases

6. SIMPLE BACTERIAL CONJUNCTIVITIS Signs Subacute onset of mucopurulent discharge Crusted eyelids and conjunctival injection Treatment - broad-spectrum topical antibiotics

7. SIMPLE BACTERIAL CONJUNCTIVITIS • Staph.aureus • Staph.epidermidis • Gram + cocci (Strep.pneumonia) • Gram – cocci (H.influenza, Moraxella lacunata) • Treatment: • Antibiotic drops: fusidic acid, gentamicin,tobramycin, fluroquinolons • Antibiotic ointments: tetracycline, gentamicin, chlroamphenicol,bacitracin

8. GONOCOCCAL KERATOCONJUNCTIVITIS Signs Complications Acute, profuse, purulent discharge, hyperaemia and chemosis Corneal ulceration, perforation and endophthalmitis if severe Treatment • Topical gentamicin and bacitracin • Intravenous cefoxitin or cefotaxime

9. VIRAL CONJUNCTIVITIS • Adenoviral keratoconjunctivitis • Molluscum contagiosum conjunctivitis • Herpes simplex conjunctivitis

10. ADENOVIRAL KERATOCONJUNCTIVITIS 1. Pharyngoconjunctival fever • Adenovirus types 3 and 7 • Typically affects children • Upper respiratory tract infection • Keratitis in 30% - usually mild 2. Epidemic keratoconjunctivitis • Adenovirus types 8 and 19 • Very contageous • No systemic symptoms • Keratitis in 80% of cases - may be severe

11. SIGNS OF ADENOVIRAL CONJUNCTIVITIS Usually bilateral, acute watery discharge and follicles Subconjunctival haemorrhages and pseudomembranes if severe Treatment - symptomatic

12. SIGNS OF KERATITIS • Focal, subepithelial keratitis • Focal, epithelial keratitis • Transient • May persist for months Treatment - topical steroids if visual acuity diminished by subepithelial keratitis

13. MOLLUSCUM CONTAGIOSUM CONJUNCTIVITIS Signs: • Waxy, umbilicated eyelid nodule • Ipsilateral, chronic, mucoid • discharge • May be multiple • Follicular conjuntivitis Treatment - destruction of eyelid lesion

14. HERPES SIMPLEX CONJUNCTIVITIS Signs: Unilateral eyelid vesicles Acute follicular conjunctivitis - topical antivirals to prevent keratitis Treatment

15. CHLAMYDIAL CONJUNCTIVITIS 1. Adult Chlamydial Conjuctivitis C.trachomatis serotypes D to K Mucopurulant discharge Tetracycline oint., systemic tetracycline/erythromycin-6 weeks 2. Neonatal Chlamydial Conjunctivitis 5-19 days after birth Otitis, rhinitis ,pneumonitis. Mucopurulant discharge Topical and oral tetracycline and erythromycin (14 days) 3. Trachoma (cont.)

16. ADULT CHLAMYDIAL KERATOCOJUNCTIVITIS • Infection with Chlamydia trachomatis serotypes D to K • Concomitant genital infection is common Subacute, mucopurulent follicular conjunctivitis Variable peripheral keratitis Treatment - topical tetracycline and oral tetracycline or erythromycin

17. NEONATAL CHLAMYDIAL KERATOCOJUNCTIVITIS • Presents between 5 and 19 days after birth • May be associated with otitis, rhinitis and pneumonitis Mucopurulent papillary conjunctivitis - topical tetracycline and oral erythromycin Treatment

18. TRACHOMA • C. Trachomatis A, B, Ba, C, • Leading cause of preventable blindness, • Major vector common fly, presentation during childhood, • Chr. Konjunctivitis  keratitis pannus conj. scarring  trichiasis  ulceration opacification  blindness Azithromycin (single dose)

19. Trachoma • Infection with serotypes A, B, Ba and C of Chlamydia • trachomatis • Fly is major vector in infection-reinfection cycle Progression Conjunctival scarring (Arlt line) Acute follicular conjunctivis Herbert pits Pannus formation Trichiasis Cicatricial entropion Treatment - systemic azithromycin

20. ALLERGIC CONJUNCTIVITIS 1. Allergic rhinoconjunctivitis 2. Vernal keratoconjunctivitis 3. Atopic keratoconjunctivitis 4. Giant papillary conjunctivitis

21. ALLERGIC RHINOCONJUNCTIVITIS • Hypersensitivity reaction to specific airborn antigens • Frequently associated nasal symptoms • May be seasonal or perennial Transient eyelid oedema Transient conjunctival oedema

22. VERNAL KERATOCONJUNCTIVITIS Frequently associated with atopy: asthma, hay fever and dermatitis • Recurrent, bilateral • Affects children and young • adults • More common in males • and in warm climates • Itching, mucoid discharge • and lacrimation Types • Palpebral • Limbal • Mixed Treatment • Topical mast cell stabilizers • Topicalsteroids

23. Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus Rupture of septae - giant papillae Formation of cobblestone papillae

24. Atopic keratoconjunctivitis • Atopy affects 5-20% of the general population • 20-40% of individuals with atopic dermatitis, • 95% prevalence of concomitant eczema • 87% prevalence of asthma. • more prevalent in men than in women, • the peak age of incidence is in persons aged 30-50 years

25. Giant papillary conjunctivitis • Frequently seen in • soft contact lens patients • patients with exposed suture knots • patients with prostheses • Patients with asthma, hay fever or animal allergies may be at greater risk. • The etiology may be immunological, where contact lens deposits act as allergens.

26. IMMUNOBULLOUS DISEASES • Cicatricial pemphigoid • a rare chronic autoimmune subepithelial blistering disease • characterized by erosive skin lesions of the mucous membranes and skin that results in scarring of at least some sites of involvement • 2. Stevens-Johnson syndrome • 3. Toxic epidermal necrolysis (Lyell disease) • 4. Epidermolysis bullosa • 5. Pemphigus vulgaris • 6. Linear IgA bullous dermatosis

27. Complications of ocular cicatricial pemphigoid Ankyloblepharon Cicatricial entropion Metaplastic lashes Corneal keratinization Total obliteration of fornices Secondary bacterial keratitis

28. STEVENS-JOHNSON SYNDROME • Acute, and self-limiting • Hypersensitivity to drugs or infection • Typically affects young men Lesions of oral mucosa and lips Vesciculobullous haemorrhagic and necrotic lesions Maculopapules which may develop into target lesions

29. OCULAR COMPLICATIONS OF STEVENS-JOHNSON SYNDROME Transient conjunctivitis and lid crusting without sequelae Severe membranous or pseudomembranous conjunctivitis Focal fibrotic patches and occasionally symblepharon Metaplastic lashes

30. Other immunobullous diseases (1) Toxic epidermal necrolysis (Lyell disease) Epidermolysis bullosa • Skin bullae and necrosis induced by • minor trauma • ‘Scalded’ skin lesions • Conjunctivitis - common and similar to • Stevens-Johnson syndrome • Conjunctivitis - common and may result • in scarring

31. Pingeucula, pterygium

32. Pingeucula, pterygium • benign, reactive, proliferative lesion of the conjunctiva • yellow-white thickening with increased vascularity • sunlight and other environmental exposure are predisposing elements • Pingeucula limited to the area of the conjunctiva and pterygium encroaching on the cornea • histologically, these lesions are characterized by degeneration of collagen in the substantia propria of bulbar conjunctiva (elastoid and basophilic degeneration • epithelium is alternately thinned (atrophy) or thickened (proliferative) and shows no atypia

33. 1) Pedunculated papilloma -Human papilloma virus types 6 and 11 -In childhood or early adult life -Signs: may be multiple, ocassionally bilateral, mostly palpebral conj., fornix and caruncle -Treatment: -High rate of spontaneous resolution of small lesions -Large lesions→ cryotherapy, excision Conjunctival Tumours / Non-pigmented tumoursConjunctival papilloma

34. 2) Sessile papilloma -Nonviral -In midlle age -Signs: single, unilateral, mostly bulbar conj., or juxtalimbal -Treatment: -Complete excision, may need supplementary cryotherapy (malignant potential ) Conjunctival Tumours / Non-pigmented tumoursConjunctival papilloma

35. -Synonyms: Carcinoma in situ, conjunctival dysplasia, intraepithelial epithelioma -Late adult life, rare, unilateral -Limbus → fornices and cornea -May evolve into invasive squamous cell carsinoma -Signs: slightly elevated, fleshy mass with blood vessels or gelatinous leukoplakic avascular lesion -Treatment: complete exicisional biopsy, cryotherapy or application of mytomycin C Conjunctival Tumours / Non-pigmented tumours Conjunctival intraepithelial hyperplasia

36. Rare, slowly growing, may invade the slera, cornea even penetrate the globe, rarely metastizes Late adult life, from pre-existing intraepithelial hyperplasia Signs: gelatinous mass with feeder vessels, located at the limbus, may involve cornea Treatment: -mytomycin C for early cases -exicion and cryotherapy for large tumors -enucleation for advanced cases Conjunctival Tumours / Non-pigmented tumours Conjunctival squamous cell carcinoma

37. 1) Dermoids: -the most common epider mal tumors of childhood -frequency with Goldenhar syndrome -soft, white, usually located at inferotemporale quadrant of the limbus, mostly unilateral Conjunctival Tumours / Non-pigmented tumours Epibulber choristoma

38. 1) Lİpodermoids (dermolipomas) -congenital benign tm, bulbar conj., mostly temporal -yellow-white, solid tm, -surgical removal avoided because of frequent extension into the orbit Conjunctival Tumours / Non-pigmented tumours Epibulber choristoma

39. Vascular, slow growing, low malignancy In patients with AIDS Bright red mass, mostly inferior fornix Focal radiotherapy is very effective, for small lesions not required Conjunctival Tumours / Non-pigmented tumoursConjunctival Kaposi Sarcoma

40. Great variety of benign and malignant lymphoid lesions Salmon–coloured, subconjunctival infiltrate Diagnostic histologically Treatment by exicional biopsy, radiotherapy Refer to an internist for systemic evaluation Systemic lymphoma may not develop Conjunctival Tumours / Non-pigmented tumours Conjunctival lymphoma

41. Congenital, episcleral, unilateral, blue-gray Ocular, dermal or oculodermal ( Naevus of Ota, most common) Associated with; ipsilateral iris hyperchromia, melanomas, glaucoma, iris mamillations Conjunctival Tumours / Pigmented tumours Congenital ocular melanocytosis

42. Hystologically; PAM without atypia: benign proliferation of melanocytes PAM with atypia: %5 risk of malignancy in 5 years Diagnostic by biopsy Treatment: no treatment for PAM without atypia, excisional biopsy with cryotherapy, radiotherapy or mitomycin C for PAM with atypia Conjunctival Tumours / Pigmented tumours Primary acquired melanosis (PAM)

43. Benign, unilateral First decades of life Solitary, sharply demarcated, flat or slightly elevated, %30 non-pigmented At puberty, may enlarge Mostly juxtalimbal, plical and at caruncle Treatment by surgical excision, bare sclera technique Conjunctival Tumours / Pigmented tumours Conjunctival naevus

44. %2 of all eye malignancies % 50-75 arises from PAM with atypia %20 arises from naevus Least common is novo Usually in 6th decade Usually limbal, solitary, black or gray nodule, may be non-pigmented, fixed to sclera Conjunctival Tumours / Pigmented tumours Conjunctival melanoma (1)

45. Conjunctival Tumours / Pigmented tumours Conjunctival melanoma (2) • Differential diagnosis: -large naevus at puberty -ciliary body melanoma with extraocular extension -melanocytoma; congenital, black, can not be moved over the globe -pyogenic granuloma

46. Conjunctival Tumours / Pigmented tumours Conjunctival melanoma (3) • Treatment: -Exicional biopsy often with supplemental cryotherapy unless intraocular or orbital involvement is present -Exenteration for extensive and aggressive disease, does not improve the survival

47. CORNEAL DİSEASES • Corneal Infections (KERATITIS) • Ectatic Corneal Diseases • Dystrophies and Degenerations • Corneal Surgery

48. CORNEAL INFECTIONS 1. Bacterial keratitis 2. Fungal keratitis 3. Acanthamoeba keratitis 4. Infectious crystalline keratitis • Herpes simplex keratitis • -Epithelial • -Disciform 6. Herpes zoster keratitis

49. Treatment - topical ciprofloxacin 0.3% or ofloxacin 0.3% BACTERIAL KERATITIS Predisposing factors • Contact lens wear • Chronic ocular surface disease • Corneal hypoaesthesia Expanding oval, yellow-white, dense stromal infiltrate Stromal suppuration and hypopyon

50. FUNGAL KERATITIS Frequently preceded by ocular trauma with organic matter Greyish-white ulcer which may be surrounded by feathery infiltrates Slow progression and occasionally hypopyon Treatment • Topical antifungal agents • Systemic therapy if severe • Penetrating keratoplasty if unresponsive