Conjunctiva

Question 1

Anatomy: Layers of the conjunctiva

Answer 1

The conjunctiva is a mucous membrane which consists of two layers:

1. Epithelium: 2-5 layers of nonkeratinising cells.
2. Stroma: richly vascularised connective tissue under the epithelium.

Question 2

Anatomy: Lymphatic drainage of the conjunctiva

Answer 2

To the preauricular and submandibular lymph nodes.

Question 3

Anatomy: Clinical subdivisions of the conjunctiva

Answer 3

3 Parts:

1. Palpebral conjunctiva: Extends from mucocutaneous jx –>on lid margin –>fornix. Lines the ocular surface of the eyelid.
2. Forniceal conjunctiva/fornix: The fold where the conjunctiva is reflected from the eyelid onto the eyeball.
3. Bulbar conjunctiva: from fornices–> corneal limbus. Covers the anterior part of the sclera.

Question 4

Conjunctival disease:

Answer 4

1. Bacterial Conjunctivitis
   - Acute bacterial conjunctivitis
   - Gonococcal conjunctivitis
   - Chlamydial conjunctivitis
   - Chronic blepharoconjunctivitis (2° to chronic blepharitis and covered in Eyelids)
2. Viral Conjunctivitis
   - Adenoviral conjunctivitis
   (a) Pharyngoconjunctival fever
   (b) Epidemic keratoconjunctivitis
   - Acute haemorrhagic conjunctivitis
   - Herpes simplex keratoconjunctivitis (Covered in Cornea)
   - Molluscum contagiosum keratoconjunctivitis (Covered in Eyelids)
3. Allergic Conjunctivitis
   - Hayfever conjunctivitis
   - Acute allergic blepharoconjunctivitis
   - Vernal conjunctivitis
   - Giant papillary conjunctivitis
   - Stevens-Johnson syndrome
4. Opthalmia Neonatorum
5. Conjunctival degeneration
   - Pinguecula
   - Pterigium
6. Conjunctival tumours
   - Naevus
   - Melanoma
   - Squamous Carcinoma
   - Koposi’s Sarcoma

Question 5

General conjunctivitis

Answer 5

DISCHARGE

1. Watery: viral and most allergic conjunctivitides.
2. Mucoid: vernal conjunctivitis and keratoconjunctivitis sicca.
3. Purulent: bacterial infections–> eyelids sticking together on waking in the morning.

APPEARANCE
1. Hyperemia: > Redness fornices and < red limbus–> generalised conjunctival injection.
2. Oedema: accumulation clear fluid in conjunctiva visible–> chemosis.
3. Small lymphoid follicles in inferior fornix: slightly raised, discrete, greyish nodules of 0.5 mm to 3.0 mm in diameter–> Follicular conjunctivitis: intracellular organisms such as viruses and chlamydia.
4. Conjunctival papillae/ giant papillae (chronic)–> tarsal conjunctiva a cobblestone appearance (vernal conjunctivitis and giant papillary conjunctivitis)
5. Subconjunctival haemorrahages:
Causes:
a) Spontaneous
b) Valsalva manoeuvre
c) Trauma
d) Conjunctivitis
e) Systemic vasculitis
f)Coagulation defects
g) unexplained haemorrhages–> screening for systemic inflammatory conditions and coagulation defects.

LYMPHADENOPATHY
preauricular and/or submandibular Lymphadenopathy
(viral and chlamydial)

Question 6

ACUTE BACTERIAL CONJUNCTIVITIS
Cause
Presentation
Treatment

Answer 6

CAUSE:

1. Staph. epidermidis
2. Staph. aureus
3. Haemophilus
4. Streptococcus species.

SYMPTOMS
1. Redness
2. Scratching sensation
3. Purulent discharge–> eyelids stick together on waking in the morning.
SIGNS
1. Generalised conjunctival injection.
2. Purulent discharge often forming crusts on the eyelid margins and eyelashes.

TREATMENT
Even without treatment, the condition usually resolves within 10 to 14 days.
1. AB drops will clear condition within a few days: hourly on first day followed by 2–6 hourly for at least 5 days or until 3 days after symptoms have disappeared.
2. Not responsive: conjunctival swabs and scrapings should be taken
3. referred to an ophthalmologist.

Question 7

GONOCOCCAL CONJUNCTIVITIS

Presentation
Treatment

Answer 7

Present:

1. hyperacute purulent conjunctivitis.
2. conjunctiva is extremely hyperaemic and chemotic
3. eyelid oedema is present
4. copious purulent discharge.
5. Membranes and pseudomembranes may form and prominent preauricular lymphadenopathy occurs.
6. Peripheral corneal involvement may occur–> ulceration and rapid corneal perforation.

Treatment:
1. local and systemic antibiotics: 3rd generation cephalosporin such as ceftriaxone.

Question 8

CHLAMYDIAL CONJUNCTIVITIS
Inclusion conjunctivitis and trachoma:

Epidemiology
Presentation
Treatment

Answer 8

INCLUSION CONJUNCTIVITIS
EPIDEMIOLOGY
1. venereal–> young, sexually active adults.

PRESENTATION:

1. Symptoms start about 1w after contact and may be accompanied by a nonspecific urethritis or cervicitis.
2. Bilateral, acute, mucopurulent conjunctivitis with large follicles.
3. Preauricular lymphadenopathy is frequently present.
4. The condition becomes chronic if not treated.

TREATMENT
Topical tetracycline or erythromycin ointment 4 times daily for 6 weeks Orally one of the following:
• Tetracycline HCl 250 mg 4 times a day for 6 weeks
• Erythromycin 250 mg 4 times a day for 6weeks
• Doxycycline 100 mg per day for 10 days
• Azithromycin 1g stat and repeated after 1 week is the drug of choice in many centres.

TRACHOMA
EPIDEMIOLOGY
1. poor personal hygiene, and although direct transmission does occur
2. vector is probably the housefly.

CLINICAL FEATURES
The disease starts with an episode of acute inflammation, usually in the first decade.
• Follicular conjunctivitis
• Keratitisofthesuperiorpartofthecornea. The disease gradually becomes less active, but the chronic, low-grade inflammation produces scarring.
• White lines appear in the palpebral conjunctiva.
• Fibrovascular pannus develops in the superior cornea–> Later follicles and other signs of active inflammation disappear, but advanced conjunctival scarring causes distortion of the eyelid margins to form entropion and trichiasis and their sequelae.

TREATMENT
1. Topical tetracycline or erythromycin ointment 4 times daily for 6 weeks
2. Orally one of the following:
• Tetracycline HCl 250 mg 4 times a day for 6 weeks
• Erythromycin 250 mg 4 times a day for 6weeks
• Doxycycline 100 mg per day for 10 days
• Azithromycin 1g stat and repeated after 1 week is the drug of choice in many centres.

Question 9

ADENOVIRAL CONJUNCTIVITIS

Types
Presentation
Treatment

Answer 9

A variety of adenoviral serotypes cause conjunctivitis:

1. Pharyngoconjunctival fever: concurrent conjunctivitis and upper respiratory tract infection. Keratitis develops in 30% of cases. It typically affects children.
2. Epidemic keratoconjunctivitis: isolated conjunctivitis with no systemic effects. Keratitis develops in 80% of cases. It typically affects both adults and children.
3. Non-spesific infection

Presentation:

1. Redness,
2. tearing
3. scratching.
4. bilateral in 60% of cases.
5. Follicles in inferior conjunctival fornix
6. preauricular lymphadenopathy
7. Photophobia –> mild keratitis.
8. severe
   - chemosis
   - subconjunctival haemorrhage
   - pseudomembranes

COMPLICATION:
Punctate superficial stromal corneal infiltrates may occur. They may or may not affect vision, and resolve spontaneously in months to years.

TREATMENT
Resolves without any complications within about two weeks.
1. Prophylactic antibiotic drops to prevent secondary bacterial infection should be given, and a vasoconstrictor drop sometimes makes the eye more comfortable.
2. Steroids only if corneal infiltrates affecting vision are present–> Not in acute stage unless the inflammation is severe and Herpes simplex infection has been excluded.

Question 10

ACUTE HAEMORRHAGIC CONJUNCTIVITIS

Presentation
Treatment

Answer 10

CLINICAL FEATURES

1. bilateral
2. eyes are extremely red with prominent subconjunctival haemorrhages.
3. Marked tearing, eyelid oedema and palpebral follicles are present.

TREATMENT
It resolves spontaneously after 7 days.
1. Prophylactic antibiotic drops to prevent secondary bacterial infection should be given
2. vasoconstrictor drops may provide some symptomatic relief.

Question 11

ACUTE ALLERGIC BLEPHAROCONJUNCTIVITIS

Pathophysiology
Presentation
Treatment

Answer 11

PATHOPHYSIOLOGY
This condition manifests when large quantities of antigen reach the conjunctiva.
It is seen mainly in children who come into contact with grass or especially pets to which they are allergic.

CLINICAL FEATURES

1. severe chemosis
2. lid swelling.

TREATMENT
The condition will settle on its own within hours.
No specific treatment is indicated.
Ice-packs relieve the symptoms appreciably.

Question 12

VERNAL CONJUNCTIVITIS

Pathophysiology
Presentation
Clinical types
Treatment

Answer 12

EPIDEMIOLOGY

• drier parts of South Africa
• children and teenagers and tends to worsen seasonally.

CLINICAL FEATURES
1. intense itch
2. tear
3. scratchy
4. mild photophobia
5. secondary eyelid skin changes: swelling, thickening and pigmentation.
If severe: corneal erosions and dry white plaques may occur.

Clinical types:
1. Palpebral: Massive and diffuse papillary hypertrophy on the superior tarsal conjunctiva forms giant papillae known as cobblestones, with thick mucoid secretions.
2. Limbal: A limbitis produces mucoid limbal follicles filled with eosinophils. These follicles
eventually atrophy and calcify to form white punctate deposits known as Tranta’s dots.

TREATMENT

1. MIld: antihistamine drops containing a vasoconstrictor may be prescribed–> Sodium chromoglycate (Opticrom) 2 weeks
2. Topical steroids are very effective, but should be avoided because side effects are a major problem.

Question 13

GIANT PAPILLARY CONJUNCTIVITIS

Epidemiology
Presentation
Treatment

Answer 13

EPIDEMIOLOGY
Occurs in contact lens users.

CLINICAL FEATURES

1. months or years of contact lens use.
2. eyes itch, feel irritated
3. photophobic.
4. mucoid discharge
5. Either cannot keep their lenses in for very long, or that they cannot wear them at all.
6. When the upper lids are everted, giant papillae can be seen.

TREATMENT

1. No contact lens wear for a minimum of 3 months.
2. Topical mast cell stabilisers and steroids are used.
3. Contact lens cleaning agents that contain preservatives must be discarded and replaced with another cleaning regime, such as a heat process.

Question 14

STEVENS-JOHNSON SYNDROME

Epidemiology
Presentation
Complications
Treatment

Answer 14

EPIDEMIOLOGY
Mucocutaneous vesiculobullous disease that is caused by hypersensitivity to sulphonamides (Diamox is one!), antibiotics, bacteria and viruses.

CLINICAL FEATURES
Systemic:
1. Fever
2. malaise
3. sore throat
4. arthralgia.
5. vesicobullous eruption may develop on any body surface.
Ocular: mucopurulent conjunctivitis occurs
1. red areas of haemorrhagic conjunctival infarction, over which white membranes develop.
2. The membranes slough to leave fibrotic areas behind.

COMPLICATIONS

1. conjunctival destruction with symblepharon formation.
2. Destruction of goblet cells and the ducts of the lacrimal gland causes dry eyes.
3. Cicatrization of the conjunctiva causes entropion and trichiasis.
4. Secondary corneal ulceration, vascularisation and perforation may ensue.

TREATMENT

1. Topical steroids
2. cyclosporin
3. referred to an ophthalmologist within the first week.

Question 15

OPHTHALMIA NEONATORUM

Definition
Classification
Prophylaxis
Presentation
Treatment

Answer 15

Definition:Conjunctivitis within the first month of life. It is a notifiable condition.

Classification: 
1. Chemical: Present 1st or 2nd day
2. Bacterial: 
 Gonococcus: Early in the 1st week
 Staphylococcus and others: Late in the 1st week
 Chlamydia:   1-3 weeks
3. Viral:
 HSV: 1-2 weeks

Prophylaxis:
Routine
1. Povidone iodine 2.5%
2. Silver nitrate 1% is still used in areas where the prevalence of gonococcus is high.
3. Antibiotic ointments like chloramphenicol, erythromycin or tetracycline.

CHEMICAL OPHTHALMIA NEONATORUM
Cause: 1% silver nitrate drops or antibiotic drops that are used prophylactically against gonococcal infection.
Presentation: It usually presents within the first few hours after delivery and seldom lasts longer than 24 hours, mild, transient hyperemia.

BACTERIAL OPHTHALMIA NEONATORUM
1. GONOCOCCUS
Presentation: 2nd to the 4th day of life with a hyperacute purulent conjunctivitis, swelling of the eyelids, chemosis, eyelids stuck together, copious amounts of pus in the conjunctival sac.
Complication: Gonococci penetrate cornea cause ulceration and even perforation.
Treatment:
1. Topical penicillin and systemic penicillin/ cephalosporin is critical
Topical 1:100 penicillin G eye drops are administered as follows:
• Every minute for 15 minutes
• Then every 5 minutes for 30 minutes • Then every 15 minutes for 4 hours
• Then hourly until a total of 48 hours of treatment have elapsed
• Then 4 hourly until a total of 5 days of treatment have elapsed
2. During treatment the eyes must be kept free of pus by irrigating the conjunctival sac and gently swabbing the eyelids with normal saline.
3. Additionally one of the following must be given concurrently IM:
• Benzyl penicillin 50,000 units/kg/day in two divided doses for 7 days
• Cefotaxime 100mg/kg as a single dose stat
4. Remember to examine both parents for signs of genital infection.
2. CHLAMYDIA
Presentation: acute mucopurulent conjunctivitis after an incubation period of 5-14 days.
DDX: Exclude other neonatal chlamydial infections such as otitis, rhinitis and pneumonitis. Treatment: Oral erythromycin syrup, Silver nitrate not effective against chlamydia.

VIRAL OPHTHALMIA NEONATORUM
Cause: Herpes simplex
Presentiation: It usually presents on the 5th to 7th day of life with a blepharoconjunctivitis, but the cornea may also be affected.
Treatment: IV and topical acyclovir.

Question 16

PINGUECULA

Presentation
Treatement

Answer 16

Presentation:

1. slightly raised yellowish nodule
2. on the bulbar conjunctiva adjacent to the limbus temporally or nasally.
3. It never grows over the cornea.
4. It may slowly enlarge and occasionally becomes inflamed

Treatment:
excision is rarely indicated.

Question 17

PTERYGIUM

Definition
Presentation
Treatment

Answer 17

Definition:
growth of fibrovascular conjunctival tissue over the limbus and onto the cornea.

Presentation

1. nasal; lateral pterygia are much less frequent.
2. more active in younger patients
3. gradually enlarging, becoming more raised and growing over the cornea towards the pupil. 4. irregular ocular surface which results in breaking up of the tear film and patches of dryness.
4. Recurrent attacks of red irritated eyes occur secondary to combinations of dryness, inflammation and superficial ulceration.
5. become less active and may regress in older patients.

treatment is medical:
1. Artificial tears for symptoms of dryness.
2. Antihistamine drops for itch.
3. Vasoconstrictor drops for redness and irritation. Beware of overuse and rebound vasodilation.
4. Antibiotic drops for secondary infection.
5. Steroid drops under supervision of an ophthalmologist for recurrent episodes of noninfective inflammation.
6. Sx removal: recurrence after surgery–> not be removed without good reason.
Indications for surgery:
1. Discomfort not adequately relieved by medical treatment.
2. Visual:
(a) Increasing astigmatism.
(b) Growth over the visual axis.
3. To enable contact lens wear.
4. Cosmesis.
5. Risk of malignancy if the appearance or behaviour is atypical.

Question 18

NÆVUS

Presentation
Treatemtn

Answer 18

Presentation

1. They arise in childhood as isolated
2. well-circumscribed
3. flat or slightly raised
4. areas of pigmentation
5. located on the caruncle or near the limbus.

Treatment
These lesions should be observed, although the incidence of malignant change is low.

Question 19

MELANOMA

Presentation

Answer 19

Presentation:

growth, especially elevation, and distortion of surrounding tissues.

Question 20

SQUAMOUS CARCINOMA

Population
Presentation

Answer 20

Population:

1. immunocompetent individuals: AIDS
2. elderly.

Presentation:

1. white, raised mass near the limbus.
2. Atypical “pterygia” should be referred early so that this diagnosis can be excluded, especially in patients with AIDS.

Question 21

KAPOSI’S SARCOMA

Population

Answer 21

Population: Conjunctival Kaposi’s sarcoma occurs in patients with AIDS.

Question 22

HAYFEVER CONJUNCTIVITIS

Answer 22

CLINICAL FEATURES
1. red
2. itching 
3. tearing eyes. 
In severe cases:  lids may also be swollen, but the cornea is not affected.

TREATMENT

1. Systemic antihistamines, which help for many of the symptoms of hayfever, are frequently ineffective for relieving the ocular symptoms.
2. Antihistamine drops containing a vasoconstrictor, sometimes give relief.