THE CONJUNGTIVATHE CONJUNGTIVA

SRI FULINASRI FULINA

ANATOMYANATOMY Conjungtiva is a thin,translucent,vascular Conjungtiva is a thin,translucent,vascular

mucous membran which covers the under mucous membran which covers the under of the eyelid and is reflected over the of the eyelid and is reflected over the anterior part of the eyeball up to the anterior part of the eyeball up to the limbus .limbus .

Parts consist:Parts consist:1.Palpebral :it covers the under surface of 1.Palpebral :it covers the under surface of

both upper and lower lids.both upper and lower lids.2.Bulbar :it covers the anterior part of the 2.Bulbar :it covers the anterior part of the

eyeball.eyeball.

3.Fornices :these are folds of the conjunctiva 3.Fornices :these are folds of the conjunctiva formed by the reflection of the mucous formed by the reflection of the mucous membrane from the lids to the eyeball.membrane from the lids to the eyeball.

4.Pilca semilunaris:it’s a crescentic fold of 4.Pilca semilunaris:it’s a crescentic fold of the conjunctiva situated at the inner the conjunctiva situated at the inner canthus.canthus.

Structure consists of two layers :Structure consists of two layers :- The epithelium: there are 2-5 layers of- The epithelium: there are 2-5 layers of epithelial cells.epithelial cells.- The stroma :it consists of blood vessels,- The stroma :it consists of blood vessels, connective tissue,gld of Krause,Wolfringconnective tissue,gld of Krause,Wolfring and goblet cells.and goblet cells.

Blood Supply :Blood Supply : - A/V.conjunctival anterior and posterior.- A/V.conjunctival anterior and posterior.

Lymhatic Drainage :Lymhatic Drainage : - Lymphonode preauricular- Lymphonode preauricular - Lymphonode submandibular- Lymphonode submandibular Nerve Supply :Nerve Supply : -Sensory nerves:a.Ophthalmica,a.Maxillary-Sensory nerves:a.Ophthalmica,a.Maxillary -Sympathetic nerves :plexus Sympathetic.-Sympathetic nerves :plexus Sympathetic.

Bacteriology :Bacteriology : - Non pathgenic bacteria: Diplococcus, - Non pathgenic bacteria: Diplococcus, Corynebacterium xerosis, Corynebacterium xerosis,

StaphylococcusStaphylococcus albus etc.albus etc. - Pathogenic bacteria : Stphylococcus,- Pathogenic bacteria : Stphylococcus,

Streptococcus,Pneumococcus,Ps.PyociaStreptococcus,Pneumococcus,Ps.Pyocianeanea

E.coli,B.proteus etc.E.coli,B.proteus etc.

The bacterial growth is inhibited by :The bacterial growth is inhibited by : 1. Mechanical washing away action of1. Mechanical washing away action of tears.tears. 2. The tears contains lysozyme,IgA,IgG 2. The tears contains lysozyme,IgA,IgG wich are bacteriostatic.wich are bacteriostatic. 3. Low temperature due to 3. Low temperature due to

evaporation of evaporation of tear,exposure and moderate blood tear,exposure and moderate blood supply.supply.

Red eyes all look Red eyes all look similar!similar!

DISEASES OF THE CONJUNGTIVADISEASES OF THE CONJUNGTIVA I.INFLAMATION=CONJUNGTIVITIS.I.INFLAMATION=CONJUNGTIVITIS. 1.Infective types :1.Infective types : - Acut : Sereous Mucoprulent- Acut : Sereous Mucoprulent Catarrhal PurulentCatarrhal Purulent - Subacut or chronic :- Subacut or chronic : Simple chronicSimple chronic Angular Angular FollicularFollicular Trachoma,TBC,syphilis.Trachoma,TBC,syphilis.

2. Allergic types :2. Allergic types : - Acute / subacute catarrhal- Acute / subacute catarrhal - Phlyctenular- Phlyctenular - Spring catarrhal / vernal - Spring catarrhal / vernal

conjungtivitis.conjungtivitis.II.DEGENERATIVE CONDITIONII.DEGENERATIVE CONDITION 1. Lithiasis1. Lithiasis 2. Pinguecula2. Pinguecula 3. Pterygium3. Pterygium

III.SYMPTOMATIC CONDITIONIII.SYMPTOMATIC CONDITION 1. Subconjungtival haemorrhage1. Subconjungtival haemorrhage 2. Chemosis2. Chemosis 3. Xerosis3. Xerosis

CONJUNGTIVITISCONJUNGTIVITISI.EVALUATION:I.EVALUATION: 1.The type of discharge1.The type of discharge 2.The charasterics of conjungtival 2.The charasterics of conjungtival

reactions .reactions . 3. The presence of lymphadenopathy.3. The presence of lymphadenopathy.1.Discharge it consists of :1.Discharge it consists of : - Watery :it present in acute allergic - Watery :it present in acute allergic

andand viral cunjungtivitis. viral cunjungtivitis.

- Mucin :it seen in spring catarrh and - Mucin :it seen in spring catarrh and keratoconjuntivitis sicca.keratoconjuntivitis sicca. - Mucopurulent :it present in mild - Mucopurulent :it present in mild

bacterialbacterial infection and chlamydial infection.infection and chlamydial infection. - Purulent :it seen in severe acute - Purulent :it seen in severe acute

bacterialbacterial infection.infection.2.Conjungtival Reaction :2.Conjungtival Reaction : - Hyperaemia - Hyperaemia - Oedema and chemosis- Oedema and chemosis - Follicle and papila - Follicle and papila

3. Lymphadenopathy :3. Lymphadenopathy : The preauricular nodes are in ,The preauricular nodes are in , Viral and Chlamydial infection.Viral and Chlamydial infection.II.DIAGNOSIS :II.DIAGNOSIS : 1. Bacteriological examination for the1. Bacteriological examination for the presence of bacteria & inclusion bodies.presence of bacteria & inclusion bodies. 2. Histological examination of the 2. Histological examination of the

secretionsecretion and scrapings of the epithelium.and scrapings of the epithelium. 3. Conjungtival culture it taken from lid 3. Conjungtival culture it taken from lid margin conjungtival sac.with steril margin conjungtival sac.with steril

cotton.cotton.

TREATMENT:TREATMENT: Antibiotic drops / ointment.Antibiotic drops / ointment.

ACUTE CONJUNGTIVITISACUTE CONJUNGTIVITIS1.Acute Mucopurulent Conjungtivitis .1.Acute Mucopurulent Conjungtivitis .Etiology :Etiology : Staph,Strept,Pneumoc,Adenovirus etc.Staph,Strept,Pneumoc,Adenovirus etc.Incidens :Incidens : - It occurs in epidemics and is bilateral - It occurs in epidemics and is bilateral

usuusu ally.ally.

- It is contagious and spreads by flies- It is contagious and spreads by flies fingers and fomites.fingers and fomites. - It is often self limiting.- It is often self limiting.Symptoms :Symptoms : 1.There is redness and grittiness,,feeling of 1.There is redness and grittiness,,feeling of foreign body sensation.foreign body sensation. 2.Mucopurulent discharge and crusting is2.Mucopurulent discharge and crusting is present in the fornices and margins of lidspresent in the fornices and margins of lids 3.Tere is sticking together of lids specially3.Tere is sticking together of lids specially in the morning because of accumulationin the morning because of accumulation of mucous discharge during the night.of mucous discharge during the night.

Acute Bacterial Acute Bacterial ConjunctivitisConjunctivitis

Presents as an acute,red, MILDLY Presents as an acute,red, MILDLY SORE sticky eye and is often SORE sticky eye and is often unilateral or involves one eye more. unilateral or involves one eye more.

Corneal or Conjunctival Corneal or Conjunctival Infection?Infection?

Conjunctivitis produces a generally Conjunctivitis produces a generally “pink eye” but corneal involvement “pink eye” but corneal involvement causes circumlimbal redness.causes circumlimbal redness.

Signs :Signs : 1. Conjungtival congestion is always1. Conjungtival congestion is always present,pink eye or red eye.present,pink eye or red eye. 2. Chemosis and subconjungtival 2. Chemosis and subconjungtival

haemorrhhaemorrh may be present.may be present.Complication :Complication : There are rare but superficial keratitis,There are rare but superficial keratitis, marginal corneal ulcer,chronic marginal corneal ulcer,chronic

conjungtivitis may occur.conjungtivitis may occur.

Treatment :Treatment : 1. Cleanliness,frequent washing of the 1. Cleanliness,frequent washing of the eyes with warm saline or clean water.eyes with warm saline or clean water. 2.Control of infection,2.Control of infection, - Antibiotic eye drops /ointment.- Antibiotic eye drops /ointment. - Not be bandaged- Not be bandaged - Dark glasses in case of photophobia.- Dark glasses in case of photophobia.Prophylaxis :Prophylaxis : 1.Isolation1.Isolation 2.Patient must keep his hands clean by 2.Patient must keep his hands clean by washing them often. washing them often.

2.Purulent Conjungtivitis .2.Purulent Conjungtivitis . Types :Types : - In adults :Acute purulent conjungtivitis- In adults :Acute purulent conjungtivitis - In babies:Ophthalmia neonatorum- In babies:Ophthalmia neonatorumAcute Purulent ConjungtivitisAcute Purulent ConjungtivitisEtiology :Etiology : Most cases by Gonococcus.Most cases by Gonococcus.Incidence :Incidence : - It occurs in males commonly affecting - It occurs in males commonly affecting

thethe right eye first.right eye first.

- The incubation period is from a few - The incubation period is from a few

hourshours to 3 days.to 3 days.Symptoms :Symptoms : - There is acute onset with much - There is acute onset with much

swellingswelling of the lids and conjungtiva.of the lids and conjungtiva. - Purulent discharge is present at lid- Purulent discharge is present at lid borders ,canthi and fornices.borders ,canthi and fornices.

Signs:Signs: -Conjungtival congestion is seen-Conjungtival congestion is seen -Palpebral conjungtiva is red -Palpebral conjungtiva is red -Severe chemosis and pus discharge-Severe chemosis and pus discharge -Lids are swollen,red,tense and tender-Lids are swollen,red,tense and tender -Preauricular lymphadenopathy may be-Preauricular lymphadenopathy may be present.present.

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Complication :Complication : 1. Subacute conjungtivitis1. Subacute conjungtivitis 2. Corneal ulcers(marginal) are common2. Corneal ulcers(marginal) are common 3. Iritis and iridocyclitis3. Iritis and iridocyclitis 4. Perforation of cornea leads to 4. Perforation of cornea leads to

blindnessblindnessPrognosis :Prognosis : It depends on the condition of the other It depends on the condition of the other

eyeeye Its bad in untreated cases.Its bad in untreated cases.

Treatment :Treatment :1.Frequent washing of the conjungtival 1.Frequent washing of the conjungtival

sac sac with warm salinewith warm saline2.Instillation of antibiotic drop/ointment.2.Instillation of antibiotic drop/ointment.Prophylaxis :Prophylaxis :1.1. Protect the other eye by topical antibProtect the other eye by topical antib2.2. Isolation of the patient should be Isolation of the patient should be

done. done.

Ophthalmia NeonatoriumOphthalmia NeonatoriumEtiology:Etiology: Virulent gonococcus infection used to be Virulent gonococcus infection used to be responsible for 50% blindness in children.responsible for 50% blindness in children. Chlamydia oculogenitalis,Strep.pneumoniaChlamydia oculogenitalis,Strep.pneumonia or other organism cause mild infection.or other organism cause mild infection.Incidens :Incidens : - Its bilateral usually- Its bilateral usually - Its commonly occurs in the newborns due- Its commonly occurs in the newborns due to maternal infection.to maternal infection.

Symptoms :Symptoms :1.Secreted only 3-4 weeks after birth.1.Secreted only 3-4 weeks after birth.2.The conjungtiva is bright red and 2.The conjungtiva is bright red and

swollenswollen with yellow pus.with yellow pus.3.Thick pus accumulates at the lid border,3.Thick pus accumulates at the lid border, lashes and canthi.lashes and canthi.Signs :Signs :1.Lids are swollen and tense do to dense1.Lids are swollen and tense do to dense infiltration of the bulbar conjungtiva,infiltration of the bulbar conjungtiva,

2.Conjungtiva is markedly congested 2.Conjungtiva is markedly congested andand

chemosed.chemosed.3.Pseudomembran may be present3.Pseudomembran may be present

Complication:Complication:These are common in untreated case .These are common in untreated case .1.Corneal ulcer and opacity1.Corneal ulcer and opacity2.Perforated corneal ulcer with 2.Perforated corneal ulcer with

prolapse of iris. prolapse of iris.

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Treatment:Treatment: - Topical antibiotic or parenteral penicillin- Topical antibiotic or parenteral penicillin (cephalosporin) for 3-5days.(cephalosporin) for 3-5days.Prophylaxis :Prophylaxis : -A septic delivery using gloves &steril -A septic delivery using gloves &steril

techniqtechniq -Proper antenatal care and treatment of any-Proper antenatal care and treatment of any vaginal discharge prior to delivery.vaginal discharge prior to delivery. -Instill penicillin or broad spectrum AB eye-Instill penicillin or broad spectrum AB eye drop immediately after birth. drop immediately after birth.

CHRONIC CONJUNGTIVITISCHRONIC CONJUNGTIVITIS

1.Simple chronic 1.Simple chronic ConjungtivitisConjungtivitis

Etiology :Etiology : -Irritation by -Irritation by

smoke,dust,heat,allergensmoke,dust,heat,allergen -misplaced eye lashes,dacryocystitis-misplaced eye lashes,dacryocystitis chronic rhinitis.chronic rhinitis. -retained foreign body in the fornix -retained foreign body in the fornix

Symptoms .Symptoms .1.There is burning discomfort and grittiness1.There is burning discomfort and grittiness specially in the evening.specially in the evening.2.The edges of the lids feel hot and dry2.The edges of the lids feel hot and dry3.There is difficulty in keeping the lids open3.There is difficulty in keeping the lids open4.Mild serous discharge may be present.4.Mild serous discharge may be present.Signs.Signs.1.The surface of the conjungtiva looks 1.The surface of the conjungtiva looks

stickysticky2.Congestion of fornices and palpebral2.Congestion of fornices and palpebral

Treatment .Treatment .1.Local antibiotic drop/ointment.1.Local antibiotic drop/ointment.2.Protective glasses 2.Protective glasses 3.Bacteriological exam is done3.Bacteriological exam is done

2 .Angular Conjungtivitis2 .Angular ConjungtivitisEtiology.Etiology. By Morax-Axenfield diplobacillus.By Morax-Axenfield diplobacillus.Symptoms.Symptoms. -Red eye is the most common feature-Red eye is the most common feature -There is discomfort&frequent blinking.-There is discomfort&frequent blinking. -Mild mucopurulent discharge may be -Mild mucopurulent discharge may be

present.present.Signs.Signs. - Redening the bulbar conj .- Redening the bulbar conj . - Excoriation of skin at the outer &inner - Excoriation of skin at the outer &inner

canthicanthi

Complication :Complication :- Blepharitis occurs in chronic - Blepharitis occurs in chronic

untreateduntreated cases.cases.- Marginal,central or hypopyon corneal Marginal,central or hypopyon corneal

ulcerulcer may occur.may occur.- Recurrences are common.Recurrences are common.Treatment:Treatment:- Oxytetracycline oitment is the DOC.Oxytetracycline oitment is the DOC.

3.Follicular Conjungtivitis3.Follicular Conjungtivitis..Etyology:Etyology:- It may be due to exposure to certainIt may be due to exposure to certain chemical and toxins chemical and toxins

eg.pilocarpin,esserin.eg.pilocarpin,esserin.- Its commonly caused by viruses e.gIts commonly caused by viruses e.g herpes and adenovirus.herpes and adenovirus.- Any conj of long duration may cause Any conj of long duration may cause

thisthis condition.condition.

Symptoms:Symptoms:- There is slihgt irritation and There is slihgt irritation and

discomfortdiscomfort- Foreign body sensation is often Foreign body sensation is often

presentpresentSigns:Signs: Multiple follicles are mainly present Multiple follicles are mainly present

in the lower fornix.There is no in the lower fornix.There is no scarring which differentiates it from scarring which differentiates it from trachoma.trachoma.

Types :Types :1.Inclusions conj: caused by chlamydial 1.Inclusions conj: caused by chlamydial

infection&produce inclusion bodies.infection&produce inclusion bodies.2.Epidemic keratoconj :its associated with2.Epidemic keratoconj :its associated with several types(3,7,8,19) of adenovirus.several types(3,7,8,19) of adenovirus.3.Pharyngoconjungtival fever.3.Pharyngoconjungtival fever.4.Acute herpetic conj4.Acute herpetic conj5.New castle conj: caused by new castle 5.New castle conj: caused by new castle

virus from infected fowls.virus from infected fowls.

Complication:Complication: Follicles may persist for several years Follicles may persist for several years

but but always resolve without scarring.always resolve without scarring.Treatment :Treatment : - Astringet eyedrop are applied - Astringet eyedrop are applied

frequentlyfrequently - Improve general health & nutrition .- Improve general health & nutrition .

4.Trachoma4.TrachomaEtyology:Etyology: -Chlamydia trachomatosis-Chlamydia trachomatosis -It lies between bacteria and virus.-It lies between bacteria and virus. -They stay inside the cells-They stay inside the cells -It is seen in the conj scrapings of the-It is seen in the conj scrapings of the epithelial cells as the epithelial cells as the HalberstaedterHalberstaedter Prowazek inclusion bodies.Prowazek inclusion bodies.

Incidence:Incidence:1.Its estimed that 1/5 of world population 1.Its estimed that 1/5 of world population

is affected by trachoma.is affected by trachoma.2.Its prevalent in Europe,Asia,Africa and 2.Its prevalent in Europe,Asia,Africa and South America,Australia.South America,Australia.3.In India it is common and endemic.3.In India it is common and endemic.4.Its commonly seen in 4.Its commonly seen in

unhygienic,crowdedunhygienic,crowded dusty and dirty enviroment.dusty and dirty enviroment.5.Its contagious in the acute stages,its 5.Its contagious in the acute stages,its

spread by finger,flies,towels &fomites spread by finger,flies,towels &fomites

Symptoms :Symptoms :-Mild irritation and foreign body sensation-Mild irritation and foreign body sensation-Mild itching is a common complaint-Mild itching is a common complaint-In chronic stage cornea is involved -In chronic stage cornea is involved

causingcausing pain,lacrimation and photophobia.pain,lacrimation and photophobia.

Signs:Signs: The primary infection is epithelial & The primary infection is epithelial &

involvesinvolves the epithelium of both the conj & the the epithelium of both the conj & the

corneacornea

1.Conjungtival:1.Conjungtival: - Congestion,there is red,velvety,jelly-- Congestion,there is red,velvety,jelly-

likelike thickening of the palpebral conj.thickening of the palpebral conj. - Papillae- Papillae - Follicles,are seen in yhe upper &lower- Follicles,are seen in yhe upper &lower fornix,palpebral conj,plica,bulbar conjfornix,palpebral conj,plica,bulbar conj (pathognomonic),size 1-5 mm. (pathognomonic),size 1-5 mm.

-Star-shape scarring seen in the centre-Star-shape scarring seen in the centre of the follicles in late stages.of the follicles in late stages. - Arts line, a line of palp.conj scarring is - Arts line, a line of palp.conj scarring is seen 2 mm from the upper lid margin.seen 2 mm from the upper lid margin.

2.Corneal :2.Corneal : - Superficial keratitis may be present in - Superficial keratitis may be present in upper part.upper part. - - HerbetHerbet‘spits,‘spits,there is follicle like there is follicle like

infiltrationinfiltration near the limbus in the upper part.near the limbus in the upper part. - - Pannus,Pannus,there is lymphoid infiltration there is lymphoid infiltration

withwith vascularitation seen in the upper part vascularitation seen in the upper part

ofof cornea.cornea.

1.Mac Callan Classification1.Mac Callan Classification There is four clinical stages :There is four clinical stages :1.Trachoma I (subclinical Stage)1.Trachoma I (subclinical Stage) It’s the earliest stage before clinical diagIt’s the earliest stage before clinical diag nosis is possible.nosis is possible.2.Trachoma II (Typical trachomatous 2.Trachoma II (Typical trachomatous

lesions)lesions) - follicle papillae- follicle papillae - epithelial keratitis- epithelial keratitis - pannus- pannus

3.Trachoma III ( stages of scarring )3.Trachoma III ( stages of scarring )4.Trachoma IV (stage of sequelaen and4.Trachoma IV (stage of sequelaen and complcation ),the deseases is quiet complcation ),the deseases is quiet

and and cured but cicatrization gives rise to cured but cicatrization gives rise to symptoms.symptoms.

II.World Health Organization(WHO) II.World Health Organization(WHO) Classification.Classification.

1.TF ( Trachomatous inflammation follicular)1.TF ( Trachomatous inflammation follicular) a. Atleast 5 or more follicles in the uppera. Atleast 5 or more follicles in the upper tarsal conj.tarsal conj. b. The deep tarsal vessels should beb. The deep tarsal vessels should be visible through the follicles.visible through the follicles.2. TI ( Trachomatous inflammation intens )2. TI ( Trachomatous inflammation intens ) a. There is marked inflammatory a. There is marked inflammatory

thickeningthickening of the upper tarsal conj wich appearsof the upper tarsal conj wich appears red,rough,thickened with follicles.red,rough,thickened with follicles.

3.TS (Trachomatous scarring )3.TS (Trachomatous scarring ) Which is seen as white fibrous Which is seen as white fibrous

lines ,lines , bands or sheets.bands or sheets.4.TT (Trachomatous trichiasis )4.TT (Trachomatous trichiasis ) - Atleast one or more misdirected- Atleast one or more misdirected eyelashes rub against the eyeball.eyelashes rub against the eyeball.5. CO ( Corneal opacity ). 5. CO ( Corneal opacity ).

Diagnosis .Diagnosis .1.Clinical :1.Clinical : - Follicles or papillae- Follicles or papillae - Epithelial keratitis- Epithelial keratitis - Pannus- Pannus -Typical star-shaped scarring of the -Typical star-shaped scarring of the

conjconj2.Laboratory :2.Laboratory : - Histological ,inclusion bodies- Histological ,inclusion bodies - Culture in irradiated McCoy cells- Culture in irradiated McCoy cells

- Microimmunofluorescence test- Microimmunofluorescence test - IgA-IPA light microscopy test- IgA-IPA light microscopy test - Monoclonal antibody direct test- Monoclonal antibody direct testSequelae and complications :Sequelae and complications : The only complication of trachoma is The only complication of trachoma is corneal ulcer.corneal ulcer.Sequelae of trachoma ;Sequelae of trachoma ; - Trichiasis- Trichiasis - Entropion- Entropion - Corneal ulcer, corneal opacity- Corneal ulcer, corneal opacity

- Xerosis ,scarring of conj result of detruction - Xerosis ,scarring of conj result of detruction of goblet cells. of goblet cells.

- Ptosis,It occurs due to large follicles - Ptosis,It occurs due to large follicles formation.formation.

- Blindness,perforation of corneal ulcer.- Blindness,perforation of corneal ulcer.Treatment :Treatment :1.Medical.1.Medical. Trachoma organisms are sensitive to Trachoma organisms are sensitive to tetracycline,sulphonamides,erythromycin,tetracycline,sulphonamides,erythromycin, rifampycin,floxacin etc.rifampycin,floxacin etc.

a.Topical treatment:a.Topical treatment: - Sulphacetamide 20-30% ed 4x1/6 weeks- Sulphacetamide 20-30% ed 4x1/6 weeks - Addition atrificial tears .- Addition atrificial tears . - Topical treatment (antibiotic) ,Its applied- Topical treatment (antibiotic) ,Its applied 3-6 weeks. 3-6 weeks. b. Systemic treatment :b. Systemic treatment : - Doxycyclin100 mg 2x1 for 3-4 weeks.- Doxycyclin100 mg 2x1 for 3-4 weeks. c. Combined topical and systemic treatment.c. Combined topical and systemic treatment. - Its preferred when the ocular infection is - Its preferred when the ocular infection is severe.severe.

2. Surgical treatment.2. Surgical treatment. Its not necessary usually with the Its not necessary usually with the

adventadvent of antibiotics.of antibiotics. - Exicision fornix , if the follicles of the- Exicision fornix , if the follicles of the upper fornix are very large and closelyupper fornix are very large and closely packed,exicision can be done.packed,exicision can be done. - Tarsectomy,if the tarsal plate is much - Tarsectomy,if the tarsal plate is much

diseased and distorted.diseased and distorted. - Tratment of various sequelae such as - Tratment of various sequelae such as trichiasis,entropion,dry eye should betrichiasis,entropion,dry eye should be done. done.

Prophylaxis .Prophylaxis . 1.Personal hygiene and enviromental1.Personal hygiene and enviromental sanitation is improved.sanitation is improved. 2.A good water supply improves washing2.A good water supply improves washing habbits.habbits. 3.Blanket antibiotic treatment may be 3.Blanket antibiotic treatment may be

givengiven in endemic area.apply 1% tetracycline in endemic area.apply 1% tetracycline

eoeo 2x1 for 5 days/month. This is done for 62x1 for 5 days/month. This is done for 6 months regularly. months regularly.

ALLERGIC CONJUNCTIVITISALLERGIC CONJUNCTIVITIS1.Acut or subacut Catarrhal conj.1.Acut or subacut Catarrhal conj.Etiology :Etiology :- Bacterial protein of endogenous Bacterial protein of endogenous

nature,egnature,eg Staphylococcus in nose or upper Staphylococcus in nose or upper

respiratory tract.respiratory tract.- Exogenous protein as in hay Exogenous protein as in hay

fever,contact with animals,pollens or fever,contact with animals,pollens or flowers.flowers.

- Chemicals,cosmetics,drugs ets.Chemicals,cosmetics,drugs ets.

Symptoms .Symptoms .- Itching is the most prominent Itching is the most prominent

feature .feature .- Watery secretionWatery secretion- Marked redness of the conj .Marked redness of the conj .Signs.Signs.- Congestion of the conj with multiple Congestion of the conj with multiple

follicles.follicles.- Watery mucoid discharge is present.Watery mucoid discharge is present.- Skin of the lid is red and swollen.Skin of the lid is red and swollen.

Differential diagnosis.Differential diagnosis. It can be differentiated from acute It can be differentiated from acute

bacterial infection by the following bacterial infection by the following features:features:

- In allergic conj hiperaemia with itching.- In allergic conj hiperaemia with itching. - Watery secretion contains large - Watery secretion contains large

number ofnumber of eosinophils.eosinophils.- There is chronic course with subacute - There is chronic course with subacute

remissions.remissions.

Treatment.Treatment.1.Removal of the allergen is absolutely 1.Removal of the allergen is absolutely

necessary.necessary.2.Astringet lotions are applied frequently.2.Astringet lotions are applied frequently.3.Vasoconstrictor reduces the congestion.3.Vasoconstrictor reduces the congestion.4.Antihistamin drugs.4.Antihistamin drugs.5.Disodium cromoglycate 2% is a mast 5.Disodium cromoglycate 2% is a mast

cellscells stabilizer ,preventing the release of stabilizer ,preventing the release of

histamine.histamine.6.Corticosteroid drops (severe cases). 6.Corticosteroid drops (severe cases).

2.Phlyctenular Conjungtivitis.2.Phlyctenular Conjungtivitis. Its an allergic reaction to endogenousIts an allergic reaction to endogenous protein charasteristised by formation ofprotein charasteristised by formation of bleb or nodule near the bleb or nodule near the

limbus(phlycten).limbus(phlycten). Etiology.Etiology. Allergic reaction to endogenous bact,tbcAllergic reaction to endogenous bact,tbc

Incidence:Incidence:- Age, its common in children 4-14 years.Age, its common in children 4-14 years.- Unhygienic living condition and Unhygienic living condition and

malnutrition are important predisposing malnutrition are important predisposing factors.factors.

Symptoms:Symptoms: - Discomfort,irritation,itching,reflex - Discomfort,irritation,itching,reflex

lacrimation are commont complaints.lacrimation are commont complaints.Signs:Signs:- One or small,round,grey-yellow nodules One or small,round,grey-yellow nodules 1-3 mm is seen on the bulbar conj.1-3 mm is seen on the bulbar conj.- Congestion is seen around the nodule.Congestion is seen around the nodule.

Clinical Types.Clinical Types.1.Phlyctenular conj.1.Phlyctenular conj.2.Phlyctenular kerato-conj2.Phlyctenular kerato-conj3.Phlyctenular keratitis3.Phlyctenular keratitisComplications.Complications.1.Keratoconjunctivitis1.Keratoconjunctivitis2.Fascicular corneal ulcer2.Fascicular corneal ulcer3.Corneal opacity3.Corneal opacity

Tratment.Tratment.1.Local:1.Local: - corticosteroid drops and ointment- corticosteroid drops and ointment - antibiotic drops and ointment- antibiotic drops and ointment - atropine ed is applied is associated- atropine ed is applied is associated corneal ulcer.corneal ulcer. - Dark glasses .- Dark glasses .2.General;2.General; - improvement of general health & - improvement of general health &

nutritionnutrition - treatment of the cause.eg tbc,adenoid - treatment of the cause.eg tbc,adenoid

etc.etc.

3.Spring Catarrhalis ( Vernal 3.Spring Catarrhalis ( Vernal cony )cony )

Etiology :Etiology : - it is caused by exogenous allergen,such- it is caused by exogenous allergen,such as pollens and dust.as pollens and dust. - it is mediated by IgE as shown by the - it is mediated by IgE as shown by the accompanying eosinophilia.accompanying eosinophilia.Incidens :Incidens : - it affects young boys usually 5-10 years.- it affects young boys usually 5-10 years. - it is a bilateral and recurrent condition.- it is a bilateral and recurrent condition. - It usually occurs at the spring season.- It usually occurs at the spring season. - It is sporadic and non contagious in nature.- It is sporadic and non contagious in nature.

Symptoms :Symptoms : 1. itching is the most common 1. itching is the most common

complaint.complaint. 2. thick,white,ropy mucous discharge is 2. thick,white,ropy mucous discharge is charasterisic.charasterisic. 3. burning and foreign body sensation 3. burning and foreign body sensation

may may be present.be present. 4. photophobia is present in cases of4. photophobia is present in cases of corneal involvement.corneal involvement. 5. lacrimation or watering 5. lacrimation or watering

Types : two types forms are seen :Types : two types forms are seen :1.Palpebral form :1.Palpebral form : - there is conj hyperaemia and chemosis- there is conj hyperaemia and chemosis -on everting the upper lid,palppebral conj-on everting the upper lid,palppebral conj shows multiple polygonal-shape raisedshows multiple polygonal-shape raised areas like cobble stones due to diffuseareas like cobble stones due to diffuse paplillary hypertrophy.paplillary hypertrophy. -the colour is milky white due to -the colour is milky white due to

thickenedthickened epithelium of the conyungtiva.epithelium of the conyungtiva. -hypertropied papillae-hypertropied papillae

2.Bulbar form :2.Bulbar form : - multiple nodules in the upper part - multiple nodules in the upper part

of theof the limbus its diagnostic of spring limbus its diagnostic of spring

catarrhcatarrh - Horner-tranta- Horner-tranta‘s dots.‘s dots.Course:Course: it may persist for several years.it may persist for several years.

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Complcations :Complcations : mainly due to corneal involvement.mainly due to corneal involvement. serious compl are never seen and the serious compl are never seen and the

ultimate prognosis is good.ultimate prognosis is good.Treatment :Treatment :Symptomatic :Symptomatic : - topical corticosteroid- topical corticosteroid - disodium cromoglycate 2%- disodium cromoglycate 2% - non-steroidal anti-inflamatory- non-steroidal anti-inflamatory

III.DegenerationIII.Degeneration1 Lithiasis .1 Lithiasis . Incidence :- eldery personIncidence :- eldery person there is accumulation of epithelial there is accumulation of epithelial

cellscells and mucus in Henleand mucus in Henle''s gland.s gland. Symptoms :Symptoms : foreign body sensation & irritationforeign body sensation & irritation Signs :Signs : Yellow spot in the palpebral cony .Yellow spot in the palpebral cony . Treatment : Removed with needleTreatment : Removed with needle

22 .Pinguecula ..Pinguecula . Triangular yellow patch on cony nearTriangular yellow patch on cony near the limbus.the limbus. Etiology :Etiology : occurs in elderly person exposed tooccurs in elderly person exposed to strong sunlight,dust ,wind etc.strong sunlight,dust ,wind etc. Treatment :Treatment : no treatment. no treatment.

3. Pterygium :3. Pterygium : Def: Pterygium is a triangular Def: Pterygium is a triangular

sheetsheet of fibrovascular tissue wichof fibrovascular tissue wich invades the cornea.invades the cornea. It consits three parts :It consits three parts : - apex , neck ,body.- apex , neck ,body. Etiology :Etiology : - dry sunny ( uv )- dry sunny ( uv )

Incidence : nasal side Incidence : nasal side Symptoms : its usually symptomlessSymptoms : its usually symptomless ,there is cosmetic disfigurement,there is cosmetic disfigurement ,vision is impaired due to astigmat,vision is impaired due to astigmat or if pupilllary area is covered.or if pupilllary area is covered. Signs :There is a triangular Signs :There is a triangular

enroachment enroachment of the conyungt on the cornea of the conyungt on the cornea

fromfrom the inner canthus.the inner canthus.

Pathology :Pathology : - it’s a degenerative condition of the - it’s a degenerative condition of the

subconyungtiva tissue wich proliferates subconyungtiva tissue wich proliferates as a vascularized granulation tissue.as a vascularized granulation tissue.

Differential Diagnosis :Differential Diagnosis : - Pseudopterygium- Pseudopterygium its formed due to adhesion of bulbarits formed due to adhesion of bulbar cony. to a marginal corneal ulcus in cony. to a marginal corneal ulcus in chemical burn.chemical burn. Probe test:can be passed easily beneath Probe test:can be passed easily beneath the neck of pseudopterygium.the neck of pseudopterygium.

Complication :Complication : - astigmatism- astigmatism - visual impairment - visual impairment - occasionally may be diplopia due to- occasionally may be diplopia due to limitation of movement of the limitation of movement of the

eyeball.eyeball. Treatment :Treatment : Indications for surgery include;Indications for surgery include; - visual impairment , astigmat ,- visual impairment , astigmat , - cosmetic , limitation of ocular- cosmetic , limitation of ocular movement and dipolopiamovement and dipolopia Simple excision.Simple excision.

III.Symptomatic ConditionsIII.Symptomatic Conditions1.Subconyungtival haemorrhage1.Subconyungtival haemorrhage (Echymosis) :Ruptureof conyungtival (Echymosis) :Ruptureof conyungtival

bloodblood vessels causes a bright red.vessels causes a bright red.Etiology:Etiology: - Minor injury to the eyeball and orbit- Minor injury to the eyeball and orbit - Spontaneous/haemorrhage- Spontaneous/haemorrhage - Severe conyungtivitis- Severe conyungtivitis - Mechanical straining,eg vomiting cough- Mechanical straining,eg vomiting cough - Head injury- Head injury

Subconjunctival HemorrhageSubconjunctival Hemorrhage

Symptom :Symptom : Red eye is the most predominant feature.Red eye is the most predominant feature. Sign :Sign : Fresh bright red blood is visible under the Fresh bright red blood is visible under the conyungtiva.conyungtiva. Treatment:Treatment: - no treatment is required as blood gets- no treatment is required as blood gets absorbed in 1-3 weeks.absorbed in 1-3 weeks. - vitamin C may help in healing process- vitamin C may help in healing process - cold fomentation is given to stop - cold fomentation is given to stop

bleedingbleeding

2. Xerosis ( Dry Eye ).2. Xerosis ( Dry Eye ). Etiology :Etiology : a. Deficiency of tearsa. Deficiency of tears - Syogren- Syogren‘ syndrome‘ syndrome ( keratoconyungtivitis sicca )( keratoconyungtivitis sicca ) - Senile or idiopathic atrophy of the - Senile or idiopathic atrophy of the lacrimal gland.lacrimal gland. b. Deficiency of conyungtival mucusb. Deficiency of conyungtival mucus - Trachoma- Trachoma - Vit.A deficiency- Vit.A deficiency

- Burns ;chemical,termal,radiation- Burns ;chemical,termal,radiation - Stevens Jhonson syndrom- Stevens Jhonson syndrom c.Insufficient resurfacing of the c.Insufficient resurfacing of the

corneacornea - facial nerve palsy- facial nerve palsy - proptosis- proptosis d. Visual display terminal d. Visual display terminal

syndrome(VDTS)syndrome(VDTS) is seen in contact lens & computer is seen in contact lens & computer

usersusers

Keratoconyuntivitis siccaKeratoconyuntivitis sicca - - It is autoimmune diseasesIt is autoimmune diseases - It is occurs in woman after menopause- It is occurs in woman after menopause - It is often associated with rheumatoid- It is often associated with rheumatoid arthritis.arthritis.Visual display terminal syndromeVisual display terminal syndrome Computers ; this because the Computers ; this because the

palpebralpalpebral fissure is widened and blink rate is fissure is widened and blink rate is decrease while using computer.,decrease while using computer.,

Contact lens : also contribute toContact lens : also contribute to development of dry eyes due todevelopment of dry eyes due to - rigid lenses disrupt the lipid layer,- rigid lenses disrupt the lipid layer, enhansing evaporation of the tear enhansing evaporation of the tear

filmfilm - cl also decrease the corneal - cl also decrease the corneal

sensationsensation Symptoms :Symptoms : - burning and irritation- burning and irritation - photophobia and lacrimation- photophobia and lacrimation - impaired vision in case corneal opacity- impaired vision in case corneal opacity - night blindness in cases of vit.A def- night blindness in cases of vit.A def

Xeropthalmia(vitamin A Xeropthalmia(vitamin A deficiencydeficiency

WHO Classification :WHO Classification :1.1. Primary sign :Primary sign : - X IA : Conyungtival xerosis- X IA : Conyungtival xerosis - X IB : Bitot- X IB : Bitot‘s spots with cony.xerosis‘s spots with cony.xerosis < 1/3 corneal surface.< 1/3 corneal surface. - X 2 : Corneal xerosis- X 2 : Corneal xerosis - X 3A: Corneal ulceration with xerosis- X 3A: Corneal ulceration with xerosis 1/3 corneal surface1/3 corneal surface - X 3B: Keratomalacia 1/3 corneal- X 3B: Keratomalacia 1/3 corneal surface.surface.

Secondary sign :Secondary sign : - XN : Night blindness- XN : Night blindness - XF : Xerophthalmia fundus- XF : Xerophthalmia fundus ( pale yellow spots )( pale yellow spots ) - XS : Xerophthalmia scars ( in - XS : Xerophthalmia scars ( in

cornea)cornea)Investigation :Investigation : - Slit –lamp exam- Slit –lamp exam - Fluorescein staining- Fluorescein staining - Schirmer test - Schirmer test

Treatment :Treatment : - tears substitutes eye drop- tears substitutes eye drop - vit.A is given high doses of cases - vit.A is given high doses of cases

vit.Avit.A def. 200,000 IU(tretinoin) to def. 200,000 IU(tretinoin) to

childrenchildren between 1-6 years age.between 1-6 years age. - supplementthe diet with foodsrich - supplementthe diet with foodsrich

in vit.in vit. A,eg fish,liver,egg,milk,carrot etc.A,eg fish,liver,egg,milk,carrot etc.

3. Chemosis :3. Chemosis : oedema of the cony. Due to oedema of the cony. Due to

vascularvascular statis.statis. Etiology :Etiology : - acut inflammation - acut inflammation - obstruction to the venous - obstruction to the venous

circulationcirculation - abnormal bloos conditions ,anemia ,- abnormal bloos conditions ,anemia , urticaria.urticaria.

Pterigium adalah kelainan pada Pterigium adalah kelainan pada konjungtiva bulbi, berbentuk konjungtiva bulbi, berbentuk segitiga ,berada di fisura palpebra segitiga ,berada di fisura palpebra dan mengarah ke korneadan mengarah ke kornea

Bagian-bagian pterigium :Bagian-bagian pterigium :1. Kaput1. Kaput2. Apeks2. Apeks3. Kollum3. Kollum4. Korpus 4. Korpus

ETIOLOGIETIOLOGI- Belum diketahui pasti- Belum diketahui pasti- Teori yang dikemukakan :- Teori yang dikemukakan :

1. Paparan sinar matahari (UV)1. Paparan sinar matahari (UV)2. Iritasi kronik dari lingkungan 2. Iritasi kronik dari lingkungan

( udara, angin, debu )( udara, angin, debu )

PATOLOGIPATOLOGI- Proses degeneratif (hiperplasia) jar. - Proses degeneratif (hiperplasia) jar. subkonjungtivasubkonjungtiva- Perubahan kornea ( apeks pterigium ) - Perubahan kornea ( apeks pterigium ) →→ membran konjungtiva rusak dan lamel membran konjungtiva rusak dan lamel superficial kornea diinvasi jar. superficial kornea diinvasi jar. granulasigranulasi

KLASIFIKASIKLASIFIKASIA. Berdasarkan luas A. Berdasarkan luas

perkembangannya :perkembangannya : Stadium IStadium I : pterigium belum : pterigium belum mencapai mencapai limbus limbus Stadium IIStadium II : sudah mencapai atau : sudah mencapai atau melewati limbus tapi belum melewati limbus tapi belum mencapai daerah pupilmencapai daerah pupil Stadium IIIStadium III : sudah mencapai daerah : sudah mencapai daerah pupil pupil

B. Berdasarkan progresifitas B. Berdasarkan progresifitas tumbuhnya :tumbuhnya :Stasioner : relatif tidak berkembang Stasioner : relatif tidak berkembang

lagi ( tipis, pucat, atrofi )lagi ( tipis, pucat, atrofi )Progresif : berkembang lebih besar Progresif : berkembang lebih besar dalam waktu singkatdalam waktu singkat

C. Berdasarkan tipenya :C. Berdasarkan tipenya : Membran/fibrosa : tipis & pucat, Membran/fibrosa : tipis & pucat,

p.drh 5< p.drh 5< Vaskuler : hiperemi , p. drh >5Vaskuler : hiperemi , p. drh >5

GAMBARAN KLINIKGAMBARAN KLINIK ● ●Lesi biasanya terdapat di sisi nasal Lesi biasanya terdapat di sisi nasal konjungtiva bulbi.konjungtiva bulbi. ● ●Bisa dijumpai di sisi nasal dan temporal Bisa dijumpai di sisi nasal dan temporal pada satu mata ( Pterigium dupleks )pada satu mata ( Pterigium dupleks ) atau pada kedua mata ( Pterigium bilateral )atau pada kedua mata ( Pterigium bilateral )

Gejala subyektif :Gejala subyektif : Rasa perih, terganjal, sensasi benda asing, silau, Rasa perih, terganjal, sensasi benda asing, silau, berair, gangguan visus, masalah kosmetik.berair, gangguan visus, masalah kosmetik.

Gejala Obyektif :Gejala Obyektif : ● ● Konjungtiva bulbi ( fissura palp ) Konjungtiva bulbi ( fissura palp ) jar. Fibrovaskuler berbentuk segitiga jar. Fibrovaskuler berbentuk segitiga (apeks menuju kornea atau di kornea)(apeks menuju kornea atau di kornea) ● ● Di depan apeks kdg dijumpai :Di depan apeks kdg dijumpai :

– – Yellow brown line = PigmentedYellow brown line = Pigmented iron line = Stocker’s lineiron line = Stocker’s line

– – Grey cap ( Grey zone )Grey cap ( Grey zone )

● ● Pada pterigium yang besar, Pada pterigium yang besar, gerakan gerakan bola mata terbatas ke bola mata terbatas ke arah yang ber-arah yang ber-

lawanan dgn lesi.lawanan dgn lesi. ● ● Gangguan visus Gangguan visus stad III stad III ok : menutupi zona optik korneaok : menutupi zona optik kornea kurvatur kornea terganggu kurvatur kornea terganggu

astigmatastigmat ● ● Diplopia timbul bila pterigium Diplopia timbul bila pterigium

besar besar

DIAGNOSISDIAGNOSISDitegakkan berdasarkan gejala klinik Ditegakkan berdasarkan gejala klinik

DIAGNOSIS BANDINGDIAGNOSIS BANDING1. Pinguekula (pterigium std. I)1. Pinguekula (pterigium std. I)2. Pseudopterigium (pterigium stad. II 2. Pseudopterigium (pterigium stad. II

& III) & III)

PTERIGIUMPTERIGIUM PSEUDOPTERIGIUMPSEUDOPTERIGIUM1.Lokasi1.Lokasi Selalu di Selalu di

fissura fissura palpebrapalpebra

Sembarang lokasiSembarang lokasi

2.Progresi2.Progresififi tas tas

Bisa Bisa progresif progresif atau atau stasionerstasioner

Selalu stasionerSelalu stasioner

3.Riwayat3.Riwayat peny.peny.

Ulkus Ulkus kornea(-) kornea(-)

Ulkus kornea (+)Ulkus kornea (+)

4.Tes 4.Tes sondase sondase

NegatifNegatif positifpositif

PENGOBATANPENGOBATAN 1. Non bedah1. Non bedah

Mengurangi keluhan subjektif, mis :Mengurangi keluhan subjektif, mis : gatalgatalantihistaminantihistamin

merahmerahvasokonstriksi topikalvasokonstriksi topikal 2. Operasi2. Operasi Bare scleraBare sclera Simple closureSimple closure Sliding flapSliding flap Rotational flapRotational flap Conjungtival graftConjungtival graft

INDIKASI OPERASIINDIKASI OPERASI1. Menurut Ziegler1. Menurut Ziegler Mengganggu visusMengganggu visus Mengganggu pergerakan bolamataMengganggu pergerakan bolamata Berkembang progressif Berkembang progressif Mendahului suatu operasi intraokulwerMendahului suatu operasi intraokulwer KosmetikKosmetik2. Menurut Guilermo Pico2. Menurut Guilermo Pico ProgressifProgressif Mengganggu visusMengganggu visus Mengganggu pergerakan bola mataMengganggu pergerakan bola mata

Masalah kosmetikMasalah kosmetik Di depan apeks pterigium terdapat grey Di depan apeks pterigium terdapat grey

zonezone Pada pterigium dan kornea sekitarnya ada Pada pterigium dan kornea sekitarnya ada

nodul pungtatnodul pungtat Terjadi kongesti (klinis) secara periodikTerjadi kongesti (klinis) secara periodikKOMPLIKASIKOMPLIKASIA. Selama operasi A. Selama operasi Perforasi kornea atau skleraPerforasi kornea atau sklera Trauma pada m. rektus medialis atau Trauma pada m. rektus medialis atau laterallateral

2. Sesudah operasi2. Sesudah operasi - Infeksi- Infeksi - Granuloma- Granuloma - Fuch’s dellen- Fuch’s dellen - Neovaskularisasi- Neovaskularisasi - Sikatriks kornea- Sikatriks kornea - Astigmat kornea- Astigmat kornea

PTERIGIUM REKURENPTERIGIUM REKURENDisebut juga pterigium sekunder = Disebut juga pterigium sekunder =

pt.residifpt.residif* Disebut rekuren bila timbul kembali dlm * Disebut rekuren bila timbul kembali dlm

waktu 7 hari- 6 bulan post opwaktu 7 hari- 6 bulan post op* Bukan merupakan suatu pterigium yg * Bukan merupakan suatu pterigium yg

benar-benar rekuren, lebih tepat disebut benar-benar rekuren, lebih tepat disebut pterigium sekunderpterigium sekunder

* Insidens : 30 – 50 %* Insidens : 30 – 50 %* Faktor yg mempengaruhi :* Faktor yg mempengaruhi :

- Usia- Usia - progresifitas- progresifitas - Tipe pterigium- Tipe pterigium - Tehnik / metode operasi- Tehnik / metode operasi - Iritasi- Iritasi* Upaya mengurangi rekuren :* Upaya mengurangi rekuren : 1. Tunda op sampai usia dekade 41. Tunda op sampai usia dekade 4 2. Gunakan sitostatika topikal, mis 2. Gunakan sitostatika topikal, mis mitomicin C (Pt progresif)mitomicin C (Pt progresif)

3. Gunakan radiasi sinar beta (tipe 3. Gunakan radiasi sinar beta (tipe vaskuler) vaskuler) 4. Pilih metode operasi yg baik4. Pilih metode operasi yg baik 5. Kurangi iritasi 5. Kurangi iritasi

PINGUEKULAPINGUEKULA Pinguekula : suatu kelainan berwarna Pinguekula : suatu kelainan berwarna kekuning-kekuningan, berbtk segitiga yg kekuning-kekuningan, berbtk segitiga yg terdpt dikonj.bulbiterdpt dikonj.bulbiLokalisasi:Lokalisasi:- Fissura palpebra, seringkali dibag nasal, - Fissura palpebra, seringkali dibag nasal,

bbrp milimeter dari limbus korneabbrp milimeter dari limbus korneaEtiologi:Etiologi:-Proses degenerasi hyalin jar. Ikat disertai -Proses degenerasi hyalin jar. Ikat disertai

proliferasi serat elastik kuning disubstansi proliferasi serat elastik kuning disubstansi propria konjungtivapropria konjungtiva

Gambaran klinis:Gambaran klinis: - lesi kekuningan menyerupai lemak, - lesi kekuningan menyerupai lemak,

dg perkembangan yg stasioner dg perkembangan yg stasioner berbtk segitiga difissura palpebralis berbtk segitiga difissura palpebralis dg basis mengarah ke korneadg basis mengarah ke kornea

Pengobatan:Pengobatan: - Tidak perlu pengobatan- Tidak perlu pengobatan - Biasanya diangkat dg operasi krn - Biasanya diangkat dg operasi krn

alasan kosmetik (pinguekula yg alasan kosmetik (pinguekula yg besar) besar)

Thank You For Your Thank You For Your AttentionAttention