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Conjunctiva

Conjunctiva. Applied anatomy Evaluation of conjunctival inflammation Infective conjunctivitis Acute catarrhal conjunctivitis Purulent conjunctivitis. Applied Anatomy.

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Conjunctiva

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  1. Conjunctiva • Applied anatomy • Evaluation of conjunctival inflammation • Infective conjunctivitis • Acute catarrhal conjunctivitis • Purulent conjunctivitis

  2. Applied Anatomy • Thin layer of mucous membrane that lines the posterior surface of the lid and is reflected to cover the anterior part of the sclera • 3 parts palpebral: attached to the eyelid bulbar : attached to the limbus fornix : cul-de- sac

  3. Applied Anatomy Structure 1. Epithelium • 2 to 5 layers thick • mucus secreting goblet cells esp. in the bulbar and fornices 2. Adenoid layer • Lymphoid layer - lymphocytes • Most developed in fornix • Develops 3-4 months after birth 3. Fibrous layer • Collagenous & elastic fibres • Contains vessels & nerves

  4. Glands of conjunctiva: • Mucin secretory glands - goblet cells ( epithelium) - crypts of henle (tarsal conj.) - glands of manz (limbus) 2. Accessory lacrimal glands - Glands of Krausse ( fornix ) - Glands of wolfring (tarsal margins)

  5. Applied Anatomy • Blood supply : per. & marginal arcade of lids &ant.ciliary arteries • Nerve supply :Ophthalmic division of 5th nerve • Functions : free movement of the eyeball : protective mechanism against micro- organisms : smooth surface as the lid blinks

  6. Evaluation of conjunctival inflammation1. Symptoms • Most common : lacrimation, irritation, burning, photophobia • Pain and FB sensation --- corneal involvement • Itching --- allergic nature BUT it can also occur in blepharitis and KCS

  7. Evaluation of conjunctival inflammation 2. Discharge • Watery in acute allergic or viral inflammation • Mucoid in in Vernal and KCS • Purulent in acute bacterial infections • Mucopurulent in chlamydial or mild bacterial infections

  8. Discharge associated with conjunctiva

  9. Evaluation of conjunctival inflammation- 3. Conjunctival appearance • Conjunctival injection or congestion : max. in the fornices • Subconjunctival haemorrhage in viral and bacterial infections • Membranes • Follicular reaction • Papillary reaction • Oedema [ chemosis ] • Scarring

  10. Subconjuntival haemmorhage in viral, also in bacterial Conjunctival congestion in the fornices

  11. Membranes • Pseudomembranes - coagulated exudate adherent to the inflammed conjunctiva - it can be peeled off - eg. Gonoccocal , adenoviral conjunctivitis • True membranes -Inflammatory exudate permeates sup. conjunctival layers -Tear the epithelium to peel it off. - Bleeding - Eg. β- haem.streptococci,diphtheria

  12. Evaluation of conjunctival inflammation- 3. Conjunctival appearance Follicular reaction • Defn : hyperplasia of lymphoid tissue • Prominent in the fornix • Multiple discrete elevated lesions encircled by a tiny blood vessel • Size about 0.5 to 5mm • Causes : viral, : chlamydia, : parinaudglandular syndrome, : hypersensitivity to topical medication

  13. Evaluation of conjunctival inflammation- 3. Conjunctival appearance Papillary reaction • Hyperplastic conjunctival epithelium • Contains a central core of blood vessels surrounded by chronic inflammatory cells [ lymphocytes,plasma cells, eosinophils ] • Mosaic like pattern consists of polygonal hyperaemic area separated by paler channels. • Causes : chronic blepharitis, allergic conjunctivitis , contact- lens related problems

  14. Chemosis- oedema

  15. Scarring [ eg. in trachoma, ocular pemphigoid ]

  16. Lymphadenopathy • Drainage : corresponds to eyelids to the preauricular and submandibular nodes • Found in: - Viral infection - Chlamydial - Severe gonoccocal infections

  17. Conjunctivitis • Defn : inflammation of conjunctiva characterised by redness of the eye and conjunctival discharge. • Classification : Aetiological : Clinical

  18. Aetiological Classification 1. Infective : bacterial , viral, fungal and chlamydial group 2. Non – infective : allergic, chemical, traumatic , keratoconjunctivitis associated with skin and mucus membrane disorders and miscellaneous

  19. Infective conjunctivitis • Bacterial - gram + eg. Staph. Epidermidis and aureus , Strept. Pneumoniae - gram –ve eg. are H. Influenzae , N. Gonococcus, Moraxella lacunata • Viral : Adenovirus, herpes simplex , zoster, measles, chickenpox etc. • Fungal: candida albicans • Chlamydia group of organisms [ not a true virus] eg. trachoma , inclusion conjunctivitis

  20. Allergic : vernal, phlyctenular conjunctivitis Chemical : acid and alkali Miscellaneous : def. of lacrimal secretion [ KCS ] : uncorrected refractive errors : ocular pemphigus Non - Infective conjunctivitis

  21. Clinical classification • Acute mucopurulent • Acute purulent • Serous • Chronic simple • Angular • Membranous • Pseudomembranous • Papillary • Follicular • Ophthalmia neonatorum • Granulomatous • Ulcerative • Cicatrising

  22. Acute mucopurulent conjunctivitis

  23. Acute mucopurulent conjunctivitis • Acute simple , acute bacterial or acute catarrhal conjunctivitis • Causes : eg. Staph. Aureus., Strept. Viridans , H. influenza • Source of infection : nose assoc. with hay fever or measles • Affects all age groups and all times during the year • Spread through droplet infection, contact [ fingers, towels ] • Symptoms : photophobia : burning sensation : sticky eyelids : blurring of vision – mucus lying on the cornea : usually involves both eyes

  24. Acute mucopurulent conjunctivitis Signs : • Conjunctiva : bulbar and fornix are beefy red and swollen ---whole conj. is red. • Secretion : Watery – mucoid –mucopurulent • Lashes matted by yellow crusts • Cornea seldom involved : punctate epithelial defects

  25. Acute mucopurulent conjunctivitis • Management -- Conjunctival swab for C/S and Gram stain -- Prophylaxis : avoid sharing articles • Treatment : -- Clean the sac with normal saline -- Instill antibiotic eye drops Eg. Gutt. Chloromycetin 4h or 2h and Occ. CMC on.

  26. Purulent conjunctivitis • Adult gonococcal keratoconjunctivitis • Caused by Neisseria G. [ gram –ve diplococcus ] Systemic features • In men you get a purulent urethral discharge • In women : asymptomatic or dysuria or vaginal discharge • Ocular features: Symptoms : Acute profuse, thick pus ocular discharge .

  27. Purulent conjunctivitis • Ocular features: Signs : Discharge Eyelids : tender and oedematous Conjunctiva : hyperemia , chemosis , pseudomembrane form. Keratitis : marginal ulcers – ring ulcer central corneal ulcer - perforation

  28. Purulent conjunctivitis Management: • Investigations : C/S of the discharge • Treatment : Admission to hospital : topical antibiotic[frequently ½ h or H ] Penicillin,Gentamicin : Cefotaxime 1 gram 6h x 10 – 14 days

  29. Ophthalmia neonatorum

  30. Ophthalmia neonatorum • Neonatal conjunctivitis transmitted from the mother during delivery • WHY is it severe at birth : absence of tears + lymphoid tissue at birth • Causes : N. gonorrhoeae[ 60% in developing countries ] :Chlamydia [15 – 30-% ] : Staph. Aureus : Strept. Viridans, Haemolyticus : Pneumococcus • Infection : during, or after birth before birth if there is premature rupture of membranes

  31. Ophthalmia neonatorum • Signs : Can present within a few hours after birth or within the 1st month. There are 3 stages : • 1st stage : Infiltration Eye is tender to touch Lids are swollen ,red and tense [ difficult to open them ] Palpebral conjunctiva - swollen, velvety and red - chemosis - pseudomembrane Secretion : serous + blood + little pus Fever , preauricular lymphadenopathy

  32. Ophthalmia neonatorum • Signs : • 2nd stage : Blenorrhoea which can last for 2 to 3 weeks Eye is less tender to touch Lids are less swollen Palpebral conjunctiva - swollen, velvety and red - chemosis is LESS - pseudomembrane Secretion : profuse thick yellow pus • 3rd stage : Healing pain and swelling subsides but the whole conjunctiva will appear RED , velvety or granular

  33. Ophthalmia neonatorum • Management: 1. Prophylaxis : Antenatal period : mother should be treated for any suspicious vaginal discharge Crede’s method (1% silver nitrate )is not used 2. Investigation : eye discharge for gram stain and C/S 3. Treatment : irrigation of the eye with normal saline and : removal of the eye discharge : Topical penicillin 5,000 to 25,000units per ml. every ½ h or H for 1 or 2 days and then to taper : Other alternatives : : In gonococcal infections - investigate both the parents and treat them. - For the infant IM benzyl pencillin 5,000units/kg in 2 divided doses.

  34. Ophthalmia neonatorum Chlamydial Infections • Topical tetracycline 1% qds. • Oral erythromycin 50mgms /kg/day in divided doses for 3 weeks

  35. Complications in Ophthalmia Neonatorum • Corneal perforation • Corneal opacities • Adherent leucoma • Anterior polar cataract • Anterior staphyloma • Panophthalmitis

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