DR ABDUL HALEEM

Assistant professor
GMMMC
At end of this chapter 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.


It is the mucous membrane covering the under
surface of the lids and anterior part of the
eyeball upto the cornea.
 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.
 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.
 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.
Non-Specific;
 Lacrimation.

 Irritation.

 Stinging.

 Burning.

 Photophobia.

 Redness.

Specific;
 Pain and FB sensation in corneal involvement.

 Itching in allergic, blephritis and dry eyes.

 Type of discharge.
 Type of conjunctival reaction.
 Presence of membrane/ pseudomembrane.
 Lymphadenopathy.
Exudate + debris + mucus + 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.

 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.
 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.
 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.
 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.
 Includes epithelium.
 Infiltrate the superficial layers of conjunctival
epithelium.
 Epithelium is injured
if removal attempted.
 Causes;
1. Diphtheria.
2. Beta-hemolytic steptococci.
 Pre auricular and sub mandibular.

1. Viral infection.

2. Chlamydial infection.

3. Severe bacterial infections. (Gonococcal)

4. Parinaud oculoglandular syndrome.

 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.
CLASSIFICATION OF THE DISEASES OF CONJUNCTIVA
 Papillary
 Follicular
 Pseudomembranous
 Membranous
 Serous
 Mucous
 Purulant
 Mucopurulant
 Infective
 Non-Infective:
Allergic
Autoimmune
Toxic
Chemical
Degenerations
 Acute
 Sub-acute
 Chronic
 Recurrent
 Neonatal
 Childhood
 Adult
 Chlamydial
 Gonococcal
 Other bacteria
 Viral
 Chemical
 Mucopurulant
 Purulant
 Membraneous
 Adult inclusion conjunctivitis.
 Neonatal chlamydial conjunctivitis.
 Trachoma.
 Adenoviral
 Picarna viral
 Herpes simplex
 Measles
 Chicken pox
 Acute allergic conjunctivitis
 Vernal keratoconjunctivitis
 Atopic keratoconjunctivitis
 Phlactenular keratoconjunctivitis
 Phempegoid (Essential shrinkage of
conjunctiva)
 Steven Johnson syndrome
 Acid burns
 Alkali burns
 Others
 Treat the cause:
Anti-inflammatory agents
Antibacterial
 Antiallergic
 Supportive
 Specific
Mucopurulant conjunctivitis
 Caused by:
 usually

Staph epidermidis and Staph aureus

 Occasionally

Strep pneumonae, H influensae and Morexella

lucanatae
 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
Purulant cojunctivitis (Adult gonococcal)
 Symptoms:

*Hyperacute condition
*Extremely profuse, thick, creamy puss
from the eye or eyes
 Signs:
*Severe conjunctival chemosis
*May be membrane formation
*Periocular edema
*Ocular tenderness
*Gaze restriction
*Lamphadenopathy
*Corneal involvement
Systemic and topical antiboitics
 Causes:
*Acute becoming chronic
*Refractive errors
*Secondary
Misplaced lashes, CDC, chronic blephritis
 Symptoms:
 Burning and photophobia
 Signs:

*Congestion, and sticky discharge

Treat:
remove the cause
antibiotics
 Causes
*Children with ill health
*Low immunity after diseases
*Corynbact diphtharae and virulant strains of beta hemolytic
streptococci
Symptoms:
highly toxic and ill patient
pyrexial
membrane
Signs:
high temprature
lid edema
membrane
 Adult infection
 More common in sprig and summers
 Hemophilis lacunatis involved
 Bilateral and contageous
 Symptoms:
Irritation
Itching
Smarting sensation in the eyes
 Signs:
Hyperama
Excoriation of conj epithelium
Cong at medial and lat canthus
Scanty mucopurulant discharge
prolonge course
corneal involvement
 Adult inclusion conjunctivitis.
 Neonatal chlamydial conjunctivitis.
 Trachoma.
 Etiology: Serotypes A, B, Ba & C of Chlamydia
trachomatis.
 Transmission: Common fly (major Vector),
fomites, fingers.
 Epidemiology:
 Endemic in Africa, Asia, Middle East & Australia.
 Leading cause of preventable blindness.
 Worldwide 360 million people affected.
 Six million people are blind from trachoma.
 Risk factors:
 Poverty & deprived members of community.
 Poor personal & community hygiene.
 Infectious pool: Preschool children of both sexes &
their care providers.
 Age:
 Children: Follicular & inflammatory trachoma.
 Young adults: Trachomatous scarring.
 Middle-aged: Trichiasis & corneal opacity.
 Sex: Trichiasis & blindness 2-4 times more
common in women than men.
 During childhood.
 Symptoms:
 FB sensation.
 Redness.
 Lacrimation.
 Scanty mucoid discharge.
 Mucopurulent discharge if secondary infection.
 I) Incipient: Characterized by:
 Minute immature follicles in upper tarsal
conjunctiva.
 Cytoplasmic inclusions in conjunctival epithelium.
 Stromal hyperemia & oedema.
 IIa): Follicular hypertrophy:
 Large soft expressible follicles in upper tarsus, fornix
& limbus.
 Punctate keratitis.
 Follicular necrosis---Herbert’s pits.
 Stromal infilteration by plasma cells & macrophages.
 IIb): Papillary hypertrophy:
 Trachoma of intense activity or chronic trachoma
with superimposed bacterial infections.
 Obscuration of follicles by papillary hypertrophy.
 III): Cicatrizing trachoma:
 Conjunctival Scarring---Arlt lines.
 Pannus formation.
 Lacrimal gland obstruction.
 Trichiasis.
 Entropion.
 Symblepharon.
 IV): Healed stage:
 Resolution of inflammation.
 Replacement of follicles & papillae by scar tissue.
Clinical diagnosis of trachoma requires the
presence of at least two of the following
features:

 Conjunctival follicles on upper tarsal conjunctiva.

 Limbal follicles and their sequelae (Herbert’s pits).
 Tarsal conjunctival scarring.
 Fibrovascular pannus.
1. Trachomatous Follicles (TF): Presence of five or
more follicles in the upper tarsal conjunctiva.
2. Trachomatous Inflammation (TI): Inflammatory
thickening of the tarsal conjunctiva that
obscures more than half of the normal deep
tarsal vessels.
3. Trachomatous conjunctival Scarring (TS).
4. Trachomatous Trichiasis (TT): At least one
eyelash touching the cornea.
5. Corneal opacity (CO).
 Upper lid entropion
 Trichiasis.
 Xerosis – obliteration of lacrimal ducts or
glands.
 Chlazion.
 Symblepharon – obliteration of lower fornix.
 Corneal ulceration.
 Corneal opacity.
 Pseudoptosis.
 SAFE strategy developed by WHO:
 Surgery:
 To prevent blindness & limits progression of corneal
scarring.
 Can improve vision.
 Antibiotics:
 Azithromycin—1 G single dose (adults).
 Children: 20mg/kg single dose
 Erythromycin 250 mg QID for 4 weeks.
(children 125mg/kg).
 Tetracycline 250 mg QID for 4 weeks.
 Topical tetracycline 1% 0.5 inch ribbon BD for 6
weeks.
 Facial cleanliness:
 Reduces risk & severity of trachoma.
 Environmental change:
 Improved water supply & household sanitation.
 Personal & community hygiene.
 Adequate housing & water & sewage system.
 DNA /RNA particles covered by protein.
 Viruses are not cells, they are not capable of
independent replication.
 Can synthesize neither their own energy nor
their own proteins.
 They are too small to be seen by light
microscope.
 Internal core of DNA/RNA + protective coat
(lepoprotein envelope).
 Replication is different from animal.
 Obligatory intra-cellular pathogens.
 Several types of viruses can cause conjunctivitis.
 Inflammation with follicle formation—may be
associated with enlargement of regional lymph
glands.
 Severe conjunctival inflammation, minimal discharge,
lacrimation, Sub-conjunctival hemorrhage.
 Mild hyperemia.
 Conjunctival ulcers or membrane formation.
 Corneal involvement;
1.Superficial punctate keratitis.
2.Superficial erosions.
3.Stromal infiltrates.
4.Necrotic stromal ulcer.
 Follicle formations with signs of acute cattharal
inflammation may be produced by different
viruses.
1. Acute herpetic conjunctivitis.
2. Epidemic Keratoconjunctivitis.
3. Pharyngo-conjunctival fever.
4. New castle conjunctivitis.
5. Acute hemorrhagic conjunctivitis.
6. Molluscum contagiosum conjunctivitis.
 Adeno virus serotypes 8 & 19.
 Transmission: Direct or Indirect contact.
 Epidemics: Schools, work places & physicians.
 Mode of Spread: Contaminated fingers, medical
instruments (tonometer), swimming pool or
sexual contact.
 Self limiting.
 Highly infectious.
 Conjunctivitis:
Acute onset watering, redness, discomfort &
photophobia, both eyes (60%).

 Signs:
 Eyelids (oedematous).
 Scanty discharge (watery).
 Conjunctiva:
 Follicular conjunctivitis.
 Mild-moderate chemosis.
 Haemorrhage.
 Pseudomembrane formation.
 Tender pre-auricular lymphadenopathy.
 Keratitis (80%)- 7 to 10 days later in the form of
superficial punctate keratitis, subepithelial
opacities and may remain for quite a long
time.
 Treatment: Symptomatic & supportive.
 Spontaneous resolution within 2 weeks.
 Topical steroids to be avoided.
 Antivirals ineffective.
 Cold compresses, topical vasoconstrictors.
 
 Enterovirus 70 & Coxsackie virus A 24.
 Sudden onset.
 Short duration.
 Bilateral, profuse watering and discharge.
 Palpebral follicles.
 Sub-conjunctival haemorrages.
 Lymphadenopathy.
 Mild transient epithelial keratitis.
Allergy is an altered or exaggerated susceptibility to
various foreign substances or physical agents
which are harmless to the great majority of
individuals. It is due to an antigen antibody
reaction.

Allergens is an agent capable of producing a state

or manifestation of allergy.
1: ALLERGIC RHINOCONJUNCTIVITIS.
2: ACUTE ALLERGIC CONJUNCTIVITIS.
3:VERNAL KERATOCONJUNCTIVITIS.
4: ATOPIC KERATOCONJUNCTIVITIS.
5: GIANT PAPILLARY
KERATOCONJUNCTIVITIS.
6: CONTACT OCULAR ALLERGY.
7: PHLACTENULAR CONJUNCTIVITIS.
 Hypersensitivity
reaction to specific
airborn antigens.
 Frequently associated
nasal symptoms.
 May be seasonal or
perennial.

Transient conjunctival oedema

 Common, recurrent, bilateral, external, ocular
inflammation affecting children & young adults.
 6 – 20 years.
 Males > Females.
 VKC IgE & cell mediated immune mechanism
play an important role.
 3/4 patients have associated Atopy.
 2/3 have close family hx. of Atopy.
 Atopic pts. have Asthma & Eczema in infancy.
 Peripheral blood shows esinophilia & increase
serum IgE levels.
 Onset: After 5 years.
 Resolves: around puberty.
 Sign/Symptoms: occur on seasonal basis.
 Peak Incidence: April - August.
 More common in warm, dry climates e.g.,
Mediterranean basin, Africa & East Asia.
Symptoms:
Itching, lacrimation, photophobia, FB sensation, burning.
 Signs:

Giant papilla, ptosis, hyperemia, mucus, trantas dots, punctate keratopathy, corneal ulcer.
1: Palpebral VKC:
 Conjunctival hyperemia followed by a diffuse
papillary hypertrophy (marked on superior
tarsus).
 Papilla enlarge & have flat topped polygonal
appearance of cobble stones.
 In severe cases C.T. septa rupture giving giant
papillae which is coated by copious mucus.
 Active discharge by redness, swelling & tightly
packed papilla.
 2: Limbal VKC:
characterized by
mucoid nodules
having smooth round
surface
discrete white
superficial spots.
trantas dots composed
predominantly
esinophils, fibroblasts
& necrotic epithelium,
scattered around limbus
& the apices of the
lesions.
Limbal vernal

Mucoid nodule Trantas dots

3: Mixed: Signs of both palpebral & limbal VKC.
Keratopathy:
a) Punctate epitheliopathy.
b) Macroerosions due to continuous epithelial loss.
c) Plaque due to epithelial macroerosions in which the
bare area becomes coated with layers of dessicated
mucus cannot be wetted by tears resist re-
epithelialization.
d) Sub-epithelial scarring is a sign of previous severe
corneal involvement.
e) Pseudogeranotoxon (cupid’s bow).
f) Keratoconus.
 Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsus

Formation of cobblestone papillae Rupture of septae - giant papillae

 Progression of vernal keratopathy

Punctate epitheliopathy Epithelial macroerosions

Plaque formation (shield ulcer) Subepithelial scarring

1.Topical Steroid:
Fluorometholone, Dexamethason, Prednisolone.
2. Mast cell stabilizers:
Nedocromil 0.1%, Lodoxamide, Sodium
Cromoglycate.
3. Acetyl-cysteine 5%.
4. Topical Cyclosporin 2%.
5. Debridement of early mucous plaque.
6. Lamellar keratectomy of densely adherent
plaques.
7. Excimer laser phototherapeutic keratectomy.
8. Amniotic membrane transplantation.
9. Supratarsal inj. of steroid: Betamethasone or
triamcinolone.
10. Desensitizing immunotherapy.
 Rare, potentially serious
condition affects young (18-
50 yrs) patients with atopic
dermititis.
 Involved skin areas and
lateral neck folds;
antecubital and popliteal
fossae.
 Pts have Asthma, hay fever,
urticaria, Migraine, Rhinitis.
 Chronic conjuntivitis.
 Serem IgE raised.
 Atopic keratoconjunctivitis

Typically affects young patients with Eyelids are red, thickened, macerated
atopic dermatitis. and fissured.
 8. Pilocarpine.
1. Anaesthetics. 9. Timolol.
2. Atropine. 10. Preservatives:
3. Gentamycin. Benzalkonium chloride
4. Neomycin. Chlorobutanol
5. Tobramycin. Chlorhexidine
6. Antivirals. EDTA
7. Epinephrine. Thimerosal
11. Cosmetics.
 Conjunctival  Dacryoadenitis
 Blepharoconjunctivitis  Dacryocystitis
 Bacterial conjunctivitis  Masquerade syndrome
 Viral conjunctivitis  Carotid and dural fistula
 Chlamydial conjunctivitis  Acute angle glaucoma
 Allergic conjunctivitis
 Toxic/chemical reaction
 Anterior uveitis
 Dry eye  Episcleritis/scleritis
 Pinguecula/pteyrgium  Subconjunctival hemorrhage
 Lid diseases  Factitious
 Clalazion
 Sty
 Abnormal lid function
 Corneal disease
 Abrasion
 Ulcer
 Foreign body