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CONJUNCTIVA: ANATOMY , PHYSIOLOGY, SYMPTOMATOLOGY AND CLASSIFICATION

CONJUNCTIVA: ANATOMY , PHYSIOLOGY, SYMPTOMATOLOGY AND CLASSIFICATION. Dr. Faizur Rahman Professor of Ophthalmology Peshawar Medical College. L earning objectives. At the end of the session the students would be able to:

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CONJUNCTIVA: ANATOMY , PHYSIOLOGY, SYMPTOMATOLOGY AND CLASSIFICATION

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  1. CONJUNCTIVA: ANATOMY , PHYSIOLOGY, SYMPTOMATOLOGY AND CLASSIFICATION Dr. Faizur Rahman Professor of Ophthalmology Peshawar Medical College.

  2. 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.

  3. ANATOMY It is the mucous membrane covering the under surface of the lids and anterior part of the eyeball upto the cornea.

  4. 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.

  5. Palpebral conjunctiva • Subtarsal sulcus 2mm from posterior edge of the lid margin. • Richly vascular. • Extremely thin. • Strongly bound to the tarsal plate.

  6. 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.

  7. 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.

  8. 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.

  9. Sub mucosa • Fine delicate connective tissue. • Lymphocytes. • Denser fibrous tissue, blood vessels, nerves, smooth muscles and accessory lacrimal glands. • Papillae.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. Symptomatology Non-Specific; • Lacrimation. • Irritation. • Stinging. • Burning. • Photophobia. • Redness. Specific; • Pain and FB sensation in corneal involvement. • Itching in allergic, blephritis and dry eyes.

  15. SIGNS • Type of discharge. • Type of conjunctival reaction. • Presence of membrane/ pseudomembrane. • Lymphadenopathy.

  16. 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.

  17. 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.

  18. 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.

  19. Follicular reaction

  20. 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.

  21. 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.

  22. Membrane • Includes epithelium. • Infiltrate the superficial layers of conjunctival epithelium. • Epithelium is injured if removal attempted. • Causes; 1. Diphtheria. 2. Beta-hemolytic steptococci.

  23. Lymphadenopathy • Pre auricular and sub mandibular. 1. Viral infection. 2. Chlamydial infection. 3. Severe bacterial infections. (Gonococcal) 4. Parinaud oculoglandular syndrome.

  24. Laboratory Investigations Indications: • Sever purulent conjunctivitis. • Follicular conjunctivitis: viral vs chlamydial. • Conjunctival inflammation. • Neonatal conjunctivitis.

  25. Laboratory Investigations—cont… • 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.

  26. CLASSIFICATION OF THE DISEASES OF CONJUNCTIVA

  27. Morphological • Papillary • Follicular • Pseudomembranous • Membranous

  28. Discharge • Serous • Mucous • Purulant • Mucopurulant

  29. Etiological • Infective • Non-Infective: Allergic Autoimmune Toxic Chemical Degenerations

  30. Clinical Acute Sub-acute Chronic Recurrent

  31. Age Neonatal Childhood Adult

  32. Neonatal • Chlamydial • Gonococcal • Other bacteria • Viral • Chemical

  33. Common Bacterial • Mucopurulant • Purulant • Membraneous

  34. CHLAMYDIAL OCULAR INFECTIONS • Adult inclusion conjunctivitis. • Neonatal chlamydial conjunctivitis. • Trachoma.

  35. Viral • Adenoviral • Picarna viral • Herpes simplex • Measles • Chicken pox

  36. Allergic • Acute allergic conjunctivitis • Vernal keratoconjunctivitis • Atopic keratoconjunctivitis • Phlactenular keratoconjunctivitis

  37. Autoimmune • Phempegoid (Essential shrinkage of conjunctiva) • Steven Johnson syndrome

  38. Chemical • Acid burns • Alkali burns • Others

  39. Management • Treat the cause: Anti-inflammatory agents Antibacterial • Antiallergic • Supportive • Specific

  40. Acute Bacterial Conjunctivitis Mucopurulant conjunctivitis • Caused by: Staph epidermidis and Staph aureus –usually. Strep pneumonae, H influensae and Morexella lucanatae occasionally

  41. 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

  42. Acute Bacterial Conjunctivitis Purulant cojunctivitis (Adult gonococcal) • Symptoms: *Hyperacute condition *Extremely profuse, thick, creamy puss from the eye or eyes

  43. 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

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