结 膜 疾 病 Disease of the conjunctiva

1. 结 膜 疾 病Disease of the conjunctiva

2. 目的与要求 • 了解结膜的解剖 • 熟悉各种充血的特点及其临床意义 • 掌握细菌及病毒引起的急性结膜炎，并了解春季结膜炎 • 认识沙眼的危害及其传播途径，掌握沙眼的诊断和鉴别诊断、并发症及防治办法 • 了解结膜干燥症、翼状胬肉的分类及处理原则

3. 结膜的解剖 结膜炎总论 细菌性结膜炎 急性卡他性结膜炎 慢性卡他性结膜炎 淋菌性结膜炎 衣原体性结膜炎 变态反应性结膜炎 泡性眼炎 春季卡他性结膜炎 病毒性结膜炎 流行性角结膜炎 流行性出血性结膜炎 结膜干燥症 结膜变性及其他结膜病 内容

4. 结膜的解剖 • 半透明粘膜组织 • 分三部分 • 睑结膜 • 球结膜 • 穹隆结膜 • 血管 • 眼睑动脉弓→结膜后动脉 • 眼动脉肌支→睫状前动脉→角膜缘血管网 结膜上穹窿 结膜囊 结膜下穹窿

5. 结膜充血和睫状充血的鉴别

6. The Red Eye 结膜充血 睫状充血 混合充血

7. General description of conjunctivitis • The most common ocular disorder • Etiology • Infection of microorganism • Physical injuries • Chemical injuries • Allergic disorder • Immunological disorder • Nutritional deficiency

8. General description of conjunctivitis classification • According to the cause • Bacterial, chlamydial, viral, fungal, allergic conjunctivitis • According to the course • Acute, subacute and chronic

9. General description of conjunctivitisClinical manifestation • Symptoms • Foreign body sensation, burning sensation, itching • Tearing, pain and photophobia when cornea is involved • Physical sign • Conjunctival hyperemia and edema • Increase of secretion • Bacterial: serous,mucous and purulent • Viral: watery or serous • Allergic one or xerophthalmia: ropy filamentous

10. General description of conjunctivitisClinical manifestation • Symptoms • foreign body sensation,burning sensation,itching • tearing,pain and photophobia when cornea is involved • Physical sign • conjunctival hyperemia and edema • increase of secretion • Bacterial: serous,mucous and purulent • viral: watery or serous • allergic one or xerophthalmia: ropy filamentous

11. General description of conjunctivitisClinical manifestation • Physical sign • subconjunctival hemorrhage • papillary hyperplasia • palpebral conjunctival epithelium • follicular formation • accumulation of lymphocyte beneath the conjunctival epithelium, seen in chlamydial and drug-induced conjunctivitis

12. General description of conjunctivitisClinical manifestation • Physical sign • Pseudomembrane or membrane of the palpebral conjunctiva • The exudation rich in fibrin from palpebral conjunctiva • Pseudomembrane: in baby and children, adenoviral, neonatal inclusion, streptococcal conjunctivitis • True membrane: diphtheritic conjunctivitis • Preauricular lymphadenectasis with tenderness • viral conjunctivitis

13. General description of conjunctivitisExamination and diagnosis • Clinical examination • Cytologic examination • Smear of conjunctiva and scaling smear of conjunctiva • Bacteriological examination • Bacterial culture and drug sensitive test • Virus isolation and its antigenic detection

14. General description of conjunctivitisPrinciple treatment • General principles • Remove pathogenic cause • Take local phamacotherapy as major • Systemic treatment as supplement if necessary • Instillation of eyedrops • Instillation of ointment • Washing of conjunctival sac • Systemic treatment • Prevention

15. Bacterial conjunctivitis • Acute catarrhal conjunctivitis • Chronic catarrhal conjunctivitis • Hyperacute bacterial conjunctivitis

16. Acute catarrhal conjunctivitis • “pink eye”, in spring and autumn, sporadic or epidemic • Clinical finding • Acute onset(1-3days) • Both eye • Tearing, foreign body and burning sensation • Conjunctival hyperemia, purulent secretion, palpebral swelling, spots of subconjunctival hemorrhage • Ill process: 2 weeks • Treatment • Prevention

17. Chronic catarrhal conjunctivitis • Etiology • Bacterial infection • Acute-chronic or infection of bacterial with weak toxicity • Non-infectious • Environment factors • Dust • Chemical smoke or gas • Irritating eye drugs • Complicated from other disorders

18. Chronic catarrhal conjunctivitis • Clinical finding • Chronic onset, both eye • Itching, foreign body and asthenopia or no symptoms • Conjunctival hyperemia • Mucous secretion • Papillary and follicle hyperplasia • Treatment • Give management according to different causes

19. Gonococcal conjunctivitis • Hyperacute purulent conjunctivitis with the strongest infectivity and large destructibility • Etiology: Diplococcus gonorrhoeae • Adult: auto infection • Children: touch infection • Newborn: direct infection

20. Gonococcal conjunctivitis • Clinical findings • Incubation period: 10h-2, 3d, acute onset • Opthalmalgia, photophobia, tearing • Swelling of the eyelids • Palpebral and bulbar hyperemia and chemosis • Secretion: serous-bloody-purulent 浓漏眼 • Inflammatory pseudomembrane • Preauricular lymphadenectasis • Corneal ulcer and perforation

21. Gonococcal conjunctivitis • Diagnosis • Clinical findings • Lab examination(Gram’ stain, G- diplococcus) • Treatment • topical and systemic one is the same important • Prevention • Be isolated to avoid infection and epidemic

22. Chlamydial conjunctivitis——Trachoma • Chlamydia is microorganism between bacterium and virus • Chlamydia trachomatis: antigen: ABCBa DEFGHIJK trachoma genitourinary system inclusion conjunctivitis • Chlamydia is sensitive to tetracyclin or erythromycin

23. Trachoma • A chronic, infectious keratoconjunctivits • Named from rough, uneven appearance on the surface of palpebral conjunctiva that looks like sand • Our country: before 1950s: the first cause of blindness 1955: separated the pathogen after 1970s: decreased greatly now: remote districts • Developing countries of the Asian-African area

24. Trachoma(clinical findings) • Commonly occurred in children and juvenile, with bilateral acute or subacute onset • Incubation time: 5-14d(children), 7d(average) • Acute or subacute stage(1-2mon): photophobia, tearing, foreign body sensation • Palpebral and bulbar conjunctival hyperemia • Ropy secretion • Papillary hyperplasia, follicles formation • Corneal epithelitis • Be cured without scar left

25. Trachoma(clinical findings) • Chronic stage: superinfections or concomitant bacterial infections • Conjunctival hyperemia • Ropy secretion • Papillary hyperplasia, follicles in upper fornix and palpebral conjunctiva conjunctival thickening scar white luster like tenden • Corneal epithelitis • Trachomatous pannus

26. Trachoma (classification) • I Stage progressive stage papillae and follicles, upper fornix is blurred, corneal panus • II Stage regressive stage scar,a little active lesion • III Stage complete scar, no active cicatricial stage lesion and infectivity

27. Chlamydial conjunctivitisTrachoma(sequela and complication) • Entropion and trichiasis • Blepharoptosis • Symblepharon (lower fornix) • Parenchymatous xerosis of conjunctiva • Chronic dacryocystisis • Corneal opacity

28. Chlamydial conjunctivitisTrachoma(diagnosis) • 1)the vessels of upper fornix and palpebral conjunctiva are blurred, congested, papillary hyperplasia or follicle formation or both 2)corneal pannus 3)scar 4)trachomatous inclusion • Diagnosis on the basis of the first plus one of other three antigenic test

29. Trachoma (differential diagnosis) • Chronic follicular conjunctivitis 1)follicles in lower palpebral /fornix conjunctiva, no fusion tendency, translucent, conjunctiva is not thickened 2)no scar and corneal pannus. • Spring catarrh 1)papillae are large and flat, no lesion on upper fornix 2)no cornea pannus 3)eosinophil cells in secretion smear • Inclusion conjunctivitis 1)follicles in lower palpebral and fornix conjunctiva 2)no corneal pannus and scar.

30. Trachoma (treatment) • Topical tetracyclin, erythromycin • Systemic sulfadiazine, rifampin • Operative: sequelae and complication • SAFE • Surgery • Antibiotic • Facial cleanliness • Environmental improvement

31. Allergic conjunctivitisVernal conjunctivitis(spring catarrh) • A seasonal disease, also named spring catarrh, with recurrence in warm spring, summer, commonly seen in youth (male) with age under 20 years, bilateral, relapses every year. • Etiology: unclear, immunologic disorder (type I of allergic reaction) sensitinogen: plant pollen, dust, animal furfurous, feather, sun light temperature, antigenic components of microorganisms

32. Allergic conjunctivitisVernal conjunctivitis(Clinical findings) • Symptom:extreme itching • Sign 1)palpebral type: papillary hyperplasia in the upper palpebral conjunctiva that like oval flat cobblestone, eosinophillia in secretion 2)corneal limbal type: collid tubercles at the corneal limbus 3)mixed type:

33. Allergic conjunctivitisVernal conjunctivitis • Treatment: 1)self-limited, no vision affected 2)general treatment: keep away proble sensitinogen 3)medical treatment: natrii cromoglycas corticosteroid

34. Allergic conjunctivitis • Immediated allergic antigen: pollen, contact lens, etc. Delayed one: various drug • Clinical findings: immediate type: dermatitis of palpebral skin, blepharitis, mild infiltrative conjunctivitis

35. Allergic conjunctivitis • Lab examination: degenerative epithelial cell, few polynuclear cells and mononuclear cells in secretion • Treatment: 1)find out and get rid of sensitinogen 2)corticosteroid 3)3% boric solution 4)anti-allergic agents

36. Allergic conjunctivitisphlyctenular keratoconjunctivitis • Etiology • Delayed reaction to protein of microorganism • Mostly to mycobecterium tuberculosis and staphylococcus aureus • Clinical findings • Herpetic tubercle may appear on the bulbar conjunctiva or limbus • Treatment • Topical steroid drops

37. Viral conjunctivitisEpidemic keratoconjunctivitis • Acute onset, strong infectivity, may be sporadic or epidemic • Etiology: adenovirus, type 8, 19, 29 and 37.

38. Viral conjunctivitisEpidemic keratoconjunctivitis(EKC) • Clinical findings • Incubation period: 5-7d • Foreign body sensation, itching, pain, photophopia and tearing • Palpebral edema, conjunctival hyperemia and chemosis, less and watery secretion, follicles in palpebral and fornix conjunctiva, preauricular lymphadeectasis and tenderness • Be cured after one week exacerbate: superfial punctate keratitis

39. Viral conjunctivitisEpidemic keratoconjunctivitis • Diagnosis: Acute folliclar cinjunctivitis superfial punctate keratitis preauricular lymphadenectasis neutrophial • Treatment: no specific drug • Antiviral:topical(mainly) and systemic-acyclic • Antibiotic

40. Viral conjunctivitisEpidemic hemorrhagic conjunctivitis • Fulminant epidemic ocular infections • Etiology • Entero-virus type 70, picornavirus • Coxsackie virus type A 24

41. Viral conjunctivitisEpidemic hemorrhagic conjunctivitis • Clinical findings • Incubation period: 24hr • Ill course: self-limited, 10d or shorter • Ophthalmagia, foreign body sensation, photophopia and tears • Eyelid and conjunctiva red and swollen, watery secretion, follicular hyperplasis of palpebral conjunctiva, patchy hemorrhage on bulbar conjunctiva, preauricular lymphadenectasis • Transient fine punctate epithelial keratitis

42. Tears,tears film and xerosisTears • Mainly produced by the lacrimal gland and conjunctival goblet cells. • Volume: 5-9ul • Major organic component: protein albumin, globulin, lysozyme immunoglobulin (IgA,IgG,IgE) • Main ions: K+Na+Cl- • A little Lipin, glucose, urea • PH: 5.20-8.35(7.35) • isotonic

43. Tears,tears film and xerosisTears film • Tear film • Tears form a thin layer (about 7-10um thick), composed three layers: lipid, watery, mucous layer. • Functions • Cover and fill in corneal surface, to make the cornea be a smooth optic interface • Moisten and protect corneal and conjunctival epithelium • Inhibit the growth of microorganism through mechanical and antimicrobic effect • Supply necessary nutrient to the cornea

44. Tears,tears film and xerosisprimary tear dysfunction • any abnormality of involved component in tear film, deficiency of tear secretion or its abnormal distribution or maintenance • Rubbing and foreign body sensation, drying and burning sensation • Conjunctival hyperemia, mucous filamentous secretion, papillary hyperplasia, filamentous keratitis • Schirmer test, rupture time of the tear film, fluorescein staining of corneal epithelium

45. Tears,tears film and xerosisXerosis of conjunctiva • Epithelial xerosis dificency of vitamin A, when complicated with corneal epithelial xerosis called xerophthalmia • Xerosis of conjunctivae Parenchymatosa caused by topical ocular disorder 1)cicatricial xerosis of conjunctiva 2)exposure keratoconjunctival xerosis • Keratoconjunctivitis sicca an autoimmune disorder, Sjogren syndrome

46. Tears,tears film and xerosisXerosis of conjunctiva • Treatment: 1)etiological treatment 2)treatment against deficiency of tear secretion

47. Other common conjunctival disordersPterygium • Etiology: unclear, outdoor work • Clinical findings: 1)hypertrophic bular conjunctiva and its subconjunctival tissue invade onto the cornea with the shape of tiangle 2)composed of head, neck, body. 3)progressive, stationary 4)differentiated with pseudopterygium • Treatment: operation

48. Other common conjunctival disordersPinguecula • A degenerative lesion of the bulbar conjunctiva caused by the effect of ultraviolet rays • Clinical findings: a kind of white–yellow amorphous subepithelial deposition near to the limbus • Treatment: no needed

49. Other common conjunctival disordersSubconjunctival hemorrhage • Caused by vascular rupture beneath the bulbar conjunctiva or by osmotic increase of vascular wall • Causes: injury, severe cough, conjunctival inflammation, hypertension, arteriosclerosis, nephritis, hemotopathy, infectious diseases • Treatment: 1)find out the cause 2)good explanation

50. Other common conjunctival disordersConjunctival concretion • Concrement on the palpebral conjunctiva • Old or those with chronic conjunctivitis • White-yellow deposit • Treatment: no need be rejected