conjunctiva applied anatomy evaluation of conjunctival inflammation infective conjunctivitis acute...
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Conjunctiva
• Applied anatomy
• Evaluation of conjunctival inflammation
• Infective conjunctivitis
• Acute catarrhal conjunctivitis
• Purulent conjunctivitis
Applied Anatomy
• Thin layer of mucous membrane that lines the posterior surface of the lid and is reflected to cover the anterior part of the sclera
• 3 parts
palpebral: attached to the eyelid
bulbar : attached to the limbus
fornix : cul-de- sac
Structure1. Epithelium • 2 to 5 layers thick
• mucus secreting goblet cells esp. in the bulbar and fornices
2. Adenoid layer• Lymphoid layer - lymphocytes
• Most developed in fornix
• Develops 3-4 months after birth
3. Fibrous layer• Collagenous & elastic fibres
• Contains vessels & nerves
Applied Anatomy
Glands of conjunctiva:
1. Mucin secretory glands
- goblet cells ( epithelium)
- crypts of henle (tarsal conj.)
- glands of manz (limbus)
2. Accessory lacrimal glands
- Glands of Krausse ( fornix )
- Glands of wolfring (tarsal margins)
• Blood supply : per. & marginal arcade of lids & ant.ciliary arteries
• Nerve supply : Ophthalmic division of 5th nerve
• Functions : free movement of the eyeball
: protective mechanism against micro-
organisms
: smooth surface as the lid blinks
Applied Anatomy
• Most common : lacrimation, irritation, burning, photophobia
• Pain and FB sensation --- corneal involvement
• Itching --- allergic nature BUT it can also occur in blepharitis and KCS
Evaluation of conjunctival inflammation1. Symptoms
- Evaluation of conjunctival inflammation
2. Discharge
• Watery in acute allergic or viral inflammation
• Mucoid in in Vernal and KCS
• Purulent in acute bacterial infections
• Mucopurulent in chlamydial or mild bacterial infections
Discharge associated with conjunctiva
Etiology Serous Mucoid Mucopurulent Purulent
Viral
Bacterial
Chlamydia
Allergy
Toxic
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• Conjunctival injection or congestion : max. in
the fornices• Subconjunctival haemorrhage in viral and
bacterial infections• Membranes• Follicular reaction • Papillary reaction• Oedema [ chemosis ]• Scarring
Evaluation of conjunctival inflammation- 3. Conjunctival appearance
Membranes
• Pseudomembranes - coagulated exudate adherent to
the inflammed conjunctiva - it can be peeled off - eg. Gonoccocal , adenoviral conjunctivitis
• True membranes -Inflammatory exudate
permeates sup. conjunctival layers
-Tear the epithelium to peel it off. - Bleeding - Eg. β-
haem.streptococci,diphtheria
Follicular reaction• Defn : hyperplasia of lymphoid tissue• Prominent in the fornix• Multiple discrete elevated lesions encircled by a tiny
blood vessel• Size about 0.5 to 5mm• Causes : viral, : chlamydia, : parinaudglandular syndrome, : hypersensitivity to topical medication
Evaluation of conjunctival inflammation- 3. Conjunctival appearance
Papillary reaction• Hyperplastic conjunctival epithelium
• Contains a central core of blood vessels surrounded by chronic inflammatory cells [ lymphocytes,plasma cells, eosinophils ]
• Mosaic like pattern consists of polygonal hyperaemic area separated by paler channels.
• Causes : chronic blepharitis, allergic conjunctivitis , contact- lens related problems
Evaluation of conjunctival inflammation- 3. Conjunctival appearance
Lymphadenopathy
• Drainage : corresponds to eyelids to the preauricular and
submandibular nodes
• Found in:
- Viral infection
- Chlamydial
- Severe gonoccocal
infections
Conjunctivitis
• Defn : inflammation of conjunctiva characterised by redness of the eye and conjunctival discharge.
• Classification : Aetiological
: Clinical
Aetiological Classification
1. Infective : bacterial , viral, fungal and chlamydial group
2. Non – infective : allergic, chemical, traumatic ,
keratoconjunctivitis associated with skin and mucus membrane
disorders and miscellaneous
Infective conjunctivitis
• Bacterial
- gram + eg. Staph. Epidermidis and aureus , Strept. Pneumoniae
- gram –ve eg. are H. Influenzae , N. Gonococcus, Moraxella
lacunata
• Viral :
Adenovirus, herpes simplex , zoster, measles, chickenpox etc.
• Fungal: candida albicans
• Chlamydia group of organisms [ not a true virus]
eg. trachoma , inclusion conjunctivitis
Non - Infective conjunctivitis
• Allergic : vernal, phlyctenular conjunctivitis
• Chemical : acid and alkali
• Miscellaneous : def. of lacrimal secretion [ KCS ]
: uncorrected refractive errors
: ocular pemphigus
Clinical classification
• Acute mucopurulent• Acute purulent• Serous• Chronic simple• Angular• Membranous• Pseudomembranous• Papillary• Follicular• Ophthalmia neonatorum• Granulomatous • Ulcerative• Cicatrising
Acute mucopurulent conjunctivitis
• Acute simple , acute bacterial or acute catarrhal conjunctivitis
• Causes : eg. Staph. Aureus., Strept. Viridans , H. influenza
• Source of infection : nose assoc. with hay fever or measles• Affects all age groups and all times during the year• Spread through droplet infection, contact [ fingers, towels ]• Symptoms : photophobia
: burning sensation
: sticky eyelids
: blurring of vision – mucus lying on the cornea
: usually involves both eyes
Acute mucopurulent conjunctivitis
Signs :
• Conjunctiva : bulbar and fornix are beefy red and swollen ---whole conj. is red.
• Secretion : Watery – mucoid –mucopurulent
• Lashes matted by yellow crusts
• Cornea seldom involved : punctate epithelial defects
Acute mucopurulent conjunctivitis
• Management -- Conjunctival swab for C/S and Gram stain -- Prophylaxis : avoid sharing articles
• Treatment : -- Clean the sac with normal saline -- Instill antibiotic eye drops Eg. Gutt. Chloromycetin 4h or 2h and Occ. CMC
on.
Purulent conjunctivitis
• Adult gonococcal keratoconjunctivitis
• Caused by Neisseria G. [ gram –ve diplococcus ]
Systemic features
• In men you get a purulent urethral discharge
• In women : asymptomatic or dysuria or vaginal discharge
• Ocular features:
Symptoms : Acute profuse, thick pus ocular discharge .
Purulent conjunctivitis
• Ocular features:
Signs : Discharge
Eyelids : tender and oedematous
Conjunctiva : hyperemia , chemosis ,
pseudomembrane form.
Keratitis : marginal ulcers – ring ulcer
central corneal ulcer - perforation
Purulent conjunctivitis
Management: • Investigations : C/S of the discharge• Treatment : Admission to hospital
: topical antibiotic[frequently ½ h or H ]
Penicillin,Gentamicin
: Cefotaxime 1 gram 6h x 10 – 14 days
Ophthalmia neonatorum
• Neonatal conjunctivitis transmitted from the mother during delivery
• WHY is it severe at birth : absence of tears + lymphoid tissue at birth
• Causes : N. gonorrhoeae [ 60% in developing countries ]
: Chlamydia [15 – 30-% ]
: Staph. Aureus
: Strept. Viridans, Haemolyticus
: Pneumococcus
• Infection : during, or after birth
before birth if there is premature rupture of membranes
Ophthalmia neonatorum
• Signs : Can present within a few hours after birth or within the 1st month.
There are 3 stages :
• 1st stage : Infiltration Eye is tender to touch Lids are swollen ,red and tense [ difficult to open them ] Palpebral conjunctiva - swollen, velvety and red - chemosis - pseudomembrane Secretion : serous + blood + little pus Fever , preauricular lymphadenopathy
Ophthalmia neonatorum
• Signs :• 2nd stage : Blenorrhoea which can last for 2 to 3 weeks Eye is less tender to touch Lids are less swollen Palpebral conjunctiva - swollen, velvety and red - chemosis is LESS - pseudomembrane Secretion : profuse thick yellow pus• 3rd stage : Healing pain and swelling subsides but the whole conjunctiva will appear RED , velvety or granular
Ophthalmia neonatorum
• Management: 1. Prophylaxis : Antenatal period : mother should be treated for any suspicious vaginal discharge Crede’s method (1% silver nitrate )is not used 2. Investigation : eye discharge for gram stain and C/S 3. Treatment : irrigation of the eye with normal saline and : removal of the eye discharge : Topical penicillin 5,000 to 25,000units per ml. every ½ h or H for 1 or 2 days and then to taper : Other alternatives : : In gonococcal infections - investigate both the parents and treat them. - For the infant IM benzyl pencillin 5,000units/kg in 2 divided doses.
Ophthalmia neonatorum
Chlamydial Infections
• Topical tetracycline 1% qds.
• Oral erythromycin 50mgms /kg/day in divided doses for 3 weeks
Complications in Ophthalmia Neonatorum
• Corneal perforation
• Corneal opacities
• Adherent leucoma
• Anterior polar cataract
• Anterior staphyloma
• Panophthalmitis