congectiva finish

The Conjunctivitis

Is a thin mucous membrane that lines the inside of the eyelids and covers the front of the sclera.

Histology of the Conjunctiva

1.The conjunctiva epithelium
2.The stroma
a.lympoid layer
b.fibrous layer

Evaluation Clinical

The clinical features that should be considered in the differential diagnosis of the conjunctival disorders include the following:

1.the symptoms;

many are non specific such as;lacrimation,irritation ,stinging, burning and photophobia.

2.the discharge

a. watery discharge, viral infection, acute allergy.
b.mucoid discharge; vernal disease, dry eye.
c.purulent discharge; acute bacterial infection.
d.muopurulent;trachoma.


3.Appearance
a.conjunctival injection
b.sub-conjunctival hemorrhage
c.follicular reaction.
d.papillary reaction.
e.edema.
f.scarring.

4.Membrane;

a. pseudo-membrane;
severe adeno-viral infection,GC conjunctivitis.
b.true-membrane;diphtheria.

5.lymphadenopathy;

-viral infection.
-Chlamydia.
Severe GC infection.
Follicles

a
Signs. Multiple, discrete, slightly elevated lesions resembling translucent grains of rice, most prominent in the fornices (Fig. 5.3A). Blood vessels run around or across rather than within the lesions.


b
Histology shows a subepithelial lymphoid germinal centre with central immature lymphocytes and mature cells peripherally (Fig. 5.3B).

c
Causes include viral and chlamydial conjunctivitis, Parinaudoculoglandular syndrome and hypersensitivity to topical medications. Small follicles are a normal finding in childhood (folliculosis), as are follicles in the fornices and at the margin of the upper tarsal plate in adults.

Papillae

can develop only in the palpebral conjunctiva and in the limbal bulbar conjunctiva where it is attached to the deeper fibrous layer.

a
Signs

•
In contrast to follicles, a vascular core is present.

•
Micropapillae form a mosaic-like pattern of elevated red dots as a result of the central vascular channel (see Fig. 5.12A).

•
Macropapillae (<1 mm – Fig. 5.3C) and giant papillae (>1 mm) develop with prolonged inflammation.


•
Apical staining with fluorescein or the presence of mucus between giant papillae (see Fig. 5.12C) indicates active disease.

•
Limbal papillae have a gelatinous appearance (seeFig. 5.13).

b
Histology shows folds of hyperplastic conjunctival epithelium with a fibrovascular core and subepithelial stromal infiltration with inflammatory cells (Fig. 5.3D). Late changes include superficial stromal hyalinization, scarring, and the formation of crypts containing goblet cells.

c
Causes include bacterial conjunctivitis, allergic conjunctivitis, chronic marginal blepharitis, contact lens wear, superior limbic keratoconjunctivitis and floppy eyelid syndrome.

Bacterial Conjunctivitis

1-Acute simple bacterial conjunctivitis,
most common organisms;
-Staph.epidermidis.
-Staph.aureus .

Clinical Features:

-----Presentation Acute onset of redness,burning,grittiness.
---- Signs -eyelids –crusted and slightly edematous.
-discharge is purulent
-the conjunctiva is red
The treatment
Topical antibiotics; drop and ointment


Adult GonococcalKeratoconjunctivitis
The presentation is with hyper acute extremely profuse and thick creamy pus leaking from the eye.

The Signs
- Lids edematous
- The conjunctiva-hyperemia , chemosis and frequently pseudo membrane formation.
-Keratitis
- Marginal
- Central.

The Treatment:

-----Systemic treatment;

Cefotaxime 500mg IV x4
If there is involvement of the conjunctiva only the treatment is for one day only.
If there is involvement of the cornea the treatment is for 3-5 days.

-----Topical Treatment
With gentamycin or bacitracin.


Viral Conjunctivitis
Adenoviral conjunctivitis is of 2 types;
1.PCF caused by serotypes 3,7,11;causesURT infection,keratitis occurs in 30% of cases.
2.EKC caused by serotypes 8,19,37. not usually associated with systemic symptoms,keratitis occurs in 80% and may be severe.
The presentation ; Acute onset of watering,redness,discomfort and photophobia.
------The Signs --eyelids _________ edematous
---discharge ________ watery
----the conjunctiva is with mild to moderate chemosis,follicles,sub-conjunctival hemorrhage and pseudo membrane formation.
----The Cornea is involved in severe cases with sub-epithelial infiltrates.
----The Treatment .
Is symptomatic with cold compresses and systemic anti-histamine.
Indications for topical corticosteroid therapy:
a.pseudomembrane formation.
b.subconjunctival hemorrhage .
c.severe impairment of vision.

Allergic Disorders

Allergic Rhino conjunctivitis

Itching, red ,watery eye and nasal discharge and sneezing.

Seasonal or perennial
The treatment
Antihistamine topical and systemic.


Vernal Keratoconjunctivitis
Conjunctival hyperemia and papillary reaction
Cobble-stone, Giant papillae.

Limbal nodules-------Trantas dots---white dots.

Keratopathy—erosion ------ulceration.

Th e treatment ------topical steroid, oral antihistamine, mast cell stabilizers.

Atopic keratoconjunctivitis

relatively rare .
eye manifestations +skin manifestations
eyelids—thiclened,macerated,fissured.
The conjunctiva is pale and featureless .And it is hyperemic with chemosis and papillary hypertrophy during exacerbation.
Kratopathy ---erosion and ulceration.
The treatment ----topical steroid. mast cell stabilizers. systemic antibiotics.

Adult Chlamydial Conjunctivitis

STD caused by Chlamydia trachomatis serotypes D--------K
Clinical feature
Presentation with sub acute onset of unilateral or bilateral mucopurulent discharge.
--the signs
Edematous eyelids,mucopurulent discharge, papillary hypertrophy and large follicles.
Non-tender lymphadenopathy.Corneal involvement with epithelial keratitis,sub-epithelial opacities marginal infiltrates.
The treatment
Topical therapy with tetracycline eye ointment. Systemic therapy with doxycycline 100mg daily for 1-2 weeks.


Neonatal Chlamydial conjunctivitis
Presentation usually between 5 and 19 days after birth with papillary conjunctivitis and mucopurulent discharge; also may cause pneumonitis,otitis media, rhinitis.
The treatment is with topical tetracycline and systemic erythromycin ethyl succinate 25mg/kg b.d. for 14 days.
Chlamydial Conjunctivitis

Trachoma

Chronic conjunctivitis
Caused by Chlamydia trachomatis serotypes A,B,Bc,C.
Common fly is the major vector.
Clinical Features:
The presentation is during childhood with follicular conjunctivitis associated with diffuse papillary infiltration.
In children under 2 years of age the papillary reaction may be the predominant feature.
Chronic conjunctival inflammation results in scarring.
Keratitis during the inflammatory stage ranges from superior epithelial keratitis to anterior stromal infiltrates and pannus formation.
Progressive conjunctival scarring causes distortion of the eyelids and produces trichiasis.
End stage trachoma is characterized by corneal ulceration and opacification which will cause blindness.

WHO grading of trachoma;

TF Trachoma Follicles
TI Trachoma Inflammation
TS Trachoma conjunctival Scarring
TT Trachoma Trichiasis
CO Corneal Opacity
The Treatment
is with single dose of azithromycin


ConjunctivalDegenrations

1.Pingueculum
Yellow-white deposits on bulbar conjunctiva . The treatment is by observation only.

2.Pterygium
Triangular sheet of fibro vascular growth onto the cornea.
The treatment is by excision.
3.Concretions
Small yellow-white deposits due to chronic inflammation.
The treatment is by removal with a needl under topical anaesthesia.

4.Retention cyst
Cyst containing clear fluid.
The treatment is by simple puncture with a needle under topical anaesthesia.

The Red Eye

Red eye is a non-specific term to describe an eye that appears red .
Red eye is a cardinal sign of ocular inflammation, which can be caused by several conditions,which range from simple ones such as conjunctivitis to serious conditions such as acute congestive glaucoma or iridocyclitis.


Causes of Red Eye
1.conjunctivitis 2.episcleritis 3.scleritis 4.sub-conjunctival hemorrhage 5acute.antrior uveitis
6.dry eye 7.acute congestive glaucoma 8.blepharitis 9.corneal disease 10.trauma(injury).

The treatment

Is accordingly

Causes of unilateral red eye:(usually but not always)

Episcleritis,subconjuntivalhemorrhage,acute anterior uveitis,acute congestive glaucoma,cornealdisease,trauma.

Causes of bilateral red eye::(usually but not always)

Conjuctivitis,scleritis,dryeye,blephritis.
Painless red eye:
Conjuctivitis,episcleritis,subconjuctivalhemorrhage,dryeye,blepharitis.
Painfull red eye:
Scleritis,acute anterior uveitis,acue congestive glaucoma,cornealdisease.trauma.

Written byomarabidALsamerrea

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