Dr Zainab N Hamoodi Lecturer ophthalmologist MBChB FICMS Ophth ICO Learning Objectives To identify the clinical application of conjunctival anatomy amp histology ID: 998558
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1. The ConjunctivaPart 1Dr. Zainab N. HamoodiLecturer ophthalmologistM.B.Ch.B. , F.I.C.M.S.(Ophth), ICO
2. Learning ObjectivesTo identify the clinical application of conjunctival anatomy & histology.To recognize the physical signs seen in conjunctival pathology.To recognize common types of microbial conjunctivitis (bacterial/viral/chlamydial) in terms of clinical course & management.
3. Contents : Anatomy Conjunctival inflammation Microbial conjunctivitis :Bacterial conjunctivitisViral conjunctivitis Chlamydial conjunctivitis
4. Anatomy :The conjunctiva is a thin transparent mucous membrane lining the inner surface of the eyelids & surface of the globe as far as the Limbus .It can be divided into 3 parts :The Palpebral / Tarsal conjunctiva =lines the inner surface of the lids & firmly attached to it .The Forniceal conjunctiva = loose & redundant, may be thrown into folds , located at the fornix .3. The Bulbar conjunctiva = covers the anterior sclera up to the limbus (covering the globe) .
5. Anatomical divisions
6. Anatomical divisions
7. Histology :Epithelium = Non keratinized stratified columnar/cuboidal epithelium about 2 - 5 cell layer in thickness.It contains goblet cells (unicellular mucin secreting glands ) → mucin is a component of the tear film .
8. 2. Stroma (substancia propria)consists of richly-vascularized loose connective tissue, can be subdivided into: Superficial adenoid layer → contains lymphoid tissue, it develops at 3 months after birth, hence inability of the neonates to develop follicular conjunctival reaction.Deep fibrous layer → it contains accessory lacrimal glands.Inflammatory diseases → damage the conjunctiva → destruction of goblet cells/accessory lacrimal glands → dry eye.
9. ConjunctivitisIt is inflammation of the conjunctiva , which is either :Microbial OR Allergic Symptoms :❶ Foreign body sensation, itching or burning sensation .❷ Redness❸Discharge
10. Signs :Hyperemia = dilatation of conjunctival blood vessels, non specific →seen in microbial/allergic inflammation .Chemosis = swelling of bulbar & fornix conjunctiva , due to transudation of fluid from damaged blood vessels into subconjunctiva , non specific sign . Sub-conjunctival hemorrhage =→ ocular trauma, viral conjunctivitis, or spontaneously .
11. Conjunctival hyperemia
12. Conjunctival chemosis
13. Sub-conjunctival hemorrhage
14. PapillaeMultiple translucent hyperemic up growth of inflamed conjunctiva, non specific sign= hyperplasia of epithelium + edema of stroma with central core of blood vessel .
15. Papillae (conjunctival papillary reaction)
16. FolliclesMultiple solid nodular up growth pushing blood vessel aside = aggregation of inflammatory cells, lymphocytes & monocytesMore specific →Viral infectionsChlamydial infectionsdrug hypersensitivityInfants less than 3 months old → NO follicles
17. Conjunctival follicles
18. Follicles (conjunctival follicular reaction)
19. Membrane= coagulated exudates adherent to inflamed conjunctiva, seen in conjunctivitis + profuse secretion .True membrane = firmly adherent to inflamed conjunctiva , as in DiphtheriaPseudo membrane = loosely adherent to inflamed conjunctiva, as in gonococcal conjunctivitis
20. Membranes
21. Type of discharge Watery → viral/allergicPurulent →severe bacterial conjunctivitisMucopurulent → mild bacterial conjunctivitisMucinous → severe allergic conjunctivitis
22. Regional LymphadenopathyInvolving the preauricular + submandibular L.N.→ viral, Chlamydia, gonococcal conjunctivitisLab Ix :Smears → Gram stain, Giemsa stainIndicated →Severe, chronic, follicularOphthalmia neonatorum conjunctivitis
23. Microbial conjunctivitis1. Bacterial conjunctivitisCommon, acute self limiting infection, mainly caused by Strept. pneumoniae , Staph. aureus , Staph. epidermidis .Symptoms → Acute onset of redness, grittiness, discharge, discomfort, irritation, F.B sensation .Frequently the eyelids are stuck together upon waking up in the morning, unilateral then becomes bilateral .Signs →❶ Crusted eyelids ❷ Mucopurulent discharge ❸Conjunctival congestion in the form of papillary reaction .
24. TreatmentLocal antibiotic eye drops &/or ointment →Ciprofloxacin, Fucithalmic, Gentamicin ointment
25. Gonococcal conjunctivitisIs caused by G-ve diplococci Neisseria gonorrhoea →newborn (Ophthalmia neonatorum), young adultsSymptoms :hyperacute , profuse purulent ocular discharge .Signs①eyelid edema, erythema , conjunctival Chemosis②In severe cases → pseudo-membrane ③ Tender pre-auricular lymphadenopathy .④ Keratitis = preipheral corneal ulceration, may rapidly progress to perforation within 48 hr = EMERGENCY
26. Gonococcal conjunctivitis
27. Gonococcal conjunctivitis
28. Management :❶ Hospital admission❷ Topical antibioticsinitially topical antibiotics should be given frequently → every 5 minutes → gradually reducing the frequency of instillation❸ Systemic antibiotics third generation cephalosprin (Cefotaxime)
29. Viral ConjunctivitisAdenovirus is the most commonSymptoms : F.B. sensation, redness, lacrimationSigns :Hyperemic conjunctiva, chemosis, watery secretion,sub conjunctival hemorrhage, follicular up-growth,regional lymphadenopathy.Sometimes may affect the cornea →punctate epithelial keratitis = multiple intraepithelial gray granular dots
30. Adenoviral keratoconjunctivitisClinically 2 ocular syndromes caused by adenovirus :❶ Pharyngoconjunctival fever→ sero type 3 & 7children with URTI❷ Epidemic keratoconjunctivitis→ sero type 8 & 9keratitis > common , NO systemic symptoms
31. Adenoviral keratoconjunctivitis
32. ManagementSelf limiting disease, ↑↑ contagious infectionTransmission → respiratory droplets/ ocular secretions/ contaminated towels or objects .Precautions → washing hands + disinfecting ophthalmic instruments .
33. COVID-19 conjunctivitisCausative agent is SARS-CoV-2 (Severs Acute Respiratory Syndrome Corona Virus 2), well-known as COVID-19.Viral RNA recovered in tears of infected patients (including asymptomatic ones) → so ocular surfaces serve as portal of entry & source for viral transmission.Conjunctivitis could be the first feature of the disease.Mechanism of infection → exposure to aerosolized droplets or contaminated hand-eye contact.
34. Symptoms :Unilateral or bilateral red eye, lid swelling, watery eyes.Signs:Eyelid edema, conjunctival hyperemia, chemosis, watery discharge, follicular reaction, pre-auricular lymphadenopathy.
35. COVID-19 CONJUNCTIVITIS
36. Diagnosis:Conjunctival swab analyzed for PCR → negative results will not exclude the infection.Treatment: No therapeutic strategy against COVID-19 have been proved to be safe & effective to date.Precautions should be taken during examination of patients with features suggestive of viral conjunctivitis.Mandatory to inquire about respiratory symptoms/systemic review suggestive of potential COVID-19 infection.
37. Treatment:Inquire about contact with COVID-19 patients.Educating patients for meticulous eye-hand hygiene to avoid viral transmission.Symptomatic treatment for viral conjunctivitis & topical antibiotics for secondary bacterial conjunctivitis.
38. Chlamydia infection of the eye❶ Trachoma❷ Adult inclusion conjunctivitis❸ Ophthalmia Neonatorum
39. TrachomaCausative agent → Chlamydia trachomatis serotype A,B,CVector → common flyLeading cause of preventable blindness → affects ˃ 500 million peopleCommon in communities with poor hygieneEndemic in the middle east region
40. Clinical FeaturesPresentation : In 1st decade of life →Bilateral redness, F.B. sensation, mucupurulent dischargeFollicles :mostly at upper palpebral conjunctiva + upper limbusIntense inflammatory reaction Kratitis = inflammation of the cornea →Initially punctate epithelial erosions (PEE) in upper corneaPannus = sub epithelial fibro vascular ingrowth invading the cornea from above → center
41. ScarringFollicles in upper palpebral conjuctiva disappear with scar as a stellate/horizontal line = Arlet’s linesFollicles in the upper limbus replaced by concave depressions = Herbert’s pits Complications① Lid scarring →Trichiasis = posterior misdirection of eyelashesEntropion = inward inversion of the lid margin② Conjunctival scarring → destruction of accessory lacrimal glands/goblet cells → Dry eye Cicatricial trachoma → predisposes to microbial keratitis
42. TRACHOMA Follicles
43. Trachoma conjunctival scarring
44. Corneal pannus Trichiasis Entropion
45. Stages of trachoma = WHO classificationTF = Follicles in the upper palpebral conjunctivaTI = intense inflammatory reactionTS = ScarringTT = TrichiasisTCO = Corneal opacification
46. WHO staging of trachoma
47. Management :→→SAFE strategy (WHO)S = Surgery for trichiasisA = Antibiotics for active diseaseF = Facial hygieneE = Environmental improvement❶ Topical antibiotics → Tetracycline eye ointment, twice daily for 6 weeks❷ Systemic antibiotics → Tetracycline/DoxycyclineYoung children → systemic erythromycin OR Azithromycin 20 mg/kg →→ single oral dose
48. Adult inclusion conjunctivitisCausative agent → Chlamydia trachomatis serotype D to K STD → typically affects young adultsPresented →Acute bilateral mucopurulent follicular conjuctivitis + regional LAPKeratitis; superior pannus may also occur.Treatment :① Topical antibiotics →Tetracyclin eye ointment twice daily for 6 weeks ② Systemic antibiotics → tetracyclin/doxycyclinePregnant women → systemic erythromycineOR Azithromycin → 20 mg/kg single oral dose
49. Adult chlamydia inclusion conjunctivitis
50. References :Kanski Clinical Ophthalmology Oxford handbook of clinical ophthalmology American Academy of Ophthalmology
51. Thank You