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Disease of the Conjunctiva

ANATOMY The palpebral conjunctiva is divided into


marginal, tarsal and orbital zones. The marginal
The conjunctiva is a translucent membrane conjunctiva forms a transitional zone between
which covers the posterior surface of the lids the skin of the lid and the conjunctiva proper. It
and then reflected onto the anterior part of the is continuous for about 2 mm on the back of the
eyeball upto the margin of the cornea (limbus). lid forming the subtarsal fold. The tarsal
It has 3 parts: the palpebral conjunctiva lining conjunctiva is firmly adherent to the tarsus of
the eyelid, the bulbar conjunctiva covering a part the upper lid, while in the lower lid it is only
of the eyeball and the fornix which unites the adherent to the breadth of the tarsus. It is
two (Fig. 1). highly vascular. The tarsal glands shine
through it as yellow streaks. The orbital part of
the conjunctiva lies loosely between the upper
border of the tarsal plate and the fornix.
The bulbar conjunctiva covers the anterior
part of the sclera. It is freely movable over the
sclera excepting a zone of 3 mm width
around the cornea (limbal conjunctiva) and at the
insertions of the rectus muscle tendons. The
limbus is a circular transitional zone between the
cornea on one hand and the conjunctiva and the
sclera on the other. The epithelium here is
several layers thick and irregularly arranged.
It shows papilliform digitations and contains
blood vessels, lymphatics and melanin
pigments.
The forniceal conjunctiva is a continuous cul-
de-sac which is interrupted on the medial side
by the caruncle and plica. It may be divided
Fig. 1: Parts of conjunctiva into a superior, an inferior and a lateral fornix.
Diseases of the Conjunctiva 1
Diseases of the Conjunctiva 2

Histologicall goblet cells are Bl a


y, the present in the oo r
conjunctiva epithelium of d t
consists of bulbar Su e
conjunctiva and pp r
3 layers:
fornix. They are ly i
epithelial,
of
adenoid and true unicellular e
th
fibrous. There mucous glands s
e
are which moisten Co .
two layers of the conjunctiva nj The
epithelium over and the cornea un palpebral
the palpebral by discharging cti conjunctiva
conjunctiva. mucin. va is supplied
The layers by the
Plica semilunaris The
gradually post-tarsal
is a vestigeal conjunctiva
increase in plexus of the
structure in derives its
number from the upper and
human beings. It blood supply
fornix to the lower lids.
represents the from:
limbus. The The perforating
third eyelid or 1. Palpebral
adenoid branches from
the nictitating branches
layer consists of the peripheral
membrane of of nasal
loose connective palpebral
lower and
tissue containing arcade supply
vertebrates. It is lacrimal
lymphocytes, the fornix, their
a crescent- arteries of
mast cells and des- cending
shaped fold of the lids
histiocytes. The branches
conjunctiva and
adenoid layer anastomose
found at the 2. Anterior
does not with the
inner canthus conjunctival
develop until marginal
with its arteries, the
after the first
concavity branches
2 or 3 months of
towards the o
life, hence,
cornea. f
follicles do not
appear in early Caruncle is a
infancy. The small fleshy a
fibrous layer is ovoid body n
a thick measuring 5 t
meshwork of mm 3 mm e
collagen and situated in the r
elastic fibres lacus lacrimalis i
which blends to the medial o
with Tenons side of plica r
capsule. semilunaris. It is
Goblet cells, covered by c
serous glands stratified i
and accessory squamous l
serous glands epithelium and i
are found in the contains hair a
conjunctiva. follicles and r
Numerous sebaceous and y
mucus secreting sweat glands.
Diseases of the Conjunctiva 3

arcade and h d a of
ascending a e the
branches l s Con
continue in the m . junc
bulbar i tiva
conjunctiva as c Ne The conjunctiva
the posterior rve is practically
conjunctival v Su never free from
artery and e ppl
organisms. The
supply the i
y
eyes of infants
whole of the of
n harbor a
the
bulbar . number of
Co
conjunctiva Lymphatics of bacterial
nju
excepting a zone conjunctiva lie nct species
4 mm wide superficially as iva including S.
around the well as deep aureus , S.
limbus. The The sensory
and form an epidermidis,
terminal nerve supply of
irregular Streptococci and
branches of the the conjunctiva
network. E. coli. With
posterior is derived from
Lymphatics of increasing age,
conjunctival the trigeminal
the palpebral gram-negative
artery nervefrom the
conjunctiva join bacteria invade
anastomose infratrochlear
the the conjunctiva.
freely with the branch of
lymphatics of Propionibacteriu
anterior nasociliary
lids. The lymph m acnes and
conjunctival nerve,
vessels from the Coryne-
artery forming a supratrochlear
lateral side bacterium xerosis
pericorneal and supraorbital
drain into the can be isolated
plexus. branches from
preauricular from the healthy
The conjunctival veins the frontal
lymph conjunctiva.
drain either in the post- nerve, the
nodes and A relatively
tarsal venous lacrimal nerve
those from the low temperature
plexus of the lid and the
medial side into infraorbital of the conjunc-
or in the the nerve. The tiva due to
superior s ciliary nerves constant
o u supply the evaporation of
r b limbal tears, mecha-
m conjunctiva. The
i a
n sympathetic
n nerves come
f d from the
e i sympathetic
r b plexus along the
i u branches of the
o l ophthalmic
r a artery.
r
o
Bac
p n teria
h o l
t Flor
Diseases of the Conjunctiva 4
Diseases of the Conjunctiva 5

nical action of following heads: include irritant


the lids, 1. hyperemia, provides prompt
pumping action Symptomatic chemosis, relief.
on the tear conditions of ecchymosis, Adverse
drainage the xerosis and atmospheric
system, constant conjunctiva pigmentation of conditions,
epithelial 2. the conjunctiva. especially dry
exfolia- tion and Inflammatio dusty climate,
a moderate n of the H refractive
blood supply conjunctiva y errors,
make the (conjuncti- p metabolic
conjunctiva vitis) e disorders such
unsuitable for r as gout and
3.
e
the propagation Deg diabetes,
m
of organisms. ener allergic
i
Further, tears atio a
contain ns
lysozymes, of o
betalysins, IgA the f
and IgG, all of conj
which inhibit unct t
bacterial growth. iva h
Nevertheless, 4. e
the conjunctiva Cysts
is quite and C
frequently tumors o
implicated in of the n
diseases because conjunc j
it is exposed to tiva.
u
all types of n
exogenous c
Sym
irritants and t
pto
i
infections. mati
v
Moreover, it is c
a
prone to Con
allergic ditio Hyperemia or
reactions and ns congestion of
often gets of the conjunctival
involved in the vessels may be
metabolic C transient or
disorders. o chronic.
n
j Etiology The
DISEAS
u transient
ES OF
n hyperemia is
THE
c due to irritation
CONJUN t
CTIVA by a foreign
i body (eyelash,
v coal particle,
The diseases of
a
the conjunctiva concretion,
may be Symptomatic etc.). The
described under conditions removal of the
Diseases of the Conjunctiva 6

predispositions, h may also be


over-indulgence e associated with
in smoking and m orbital tumors
alcohol, o and thyroid
insomnia and s
exophthalmos
exposure to i
owing to venous
strong light, s
stasis.
may cause
recurrent or o Systemic
chronic f diseases such as
hyperemia of nephritis,
the conjunctiva. t congestive heart
h
Clinical features failure,
e
The patient hypoproteinem
complains of ia and allergic
C
dis- comfort in o reactions (drug
the eye often n allergy,
associated with j urticaria,
grittiness, u angioneurotic
heaviness and n edema)
tiredness. The c frequently
eye appears t produce
i chemosis of the
normal except
v
for mild to conjunctiva.
a
moderate Clinical features
congestion Chemosis or
The conjunctiva
towards the edema of the
becomes swollen
fornices. conjunctiva is
and appears
quite common.
Treatment gelatinous
Symptomatic Etiology because of
relief may be Chemosis exudation from
obtained by occurs due to the capillaries.
instillation of laxity of the The collection of
an astringent tissue and seen exudate is most
lotion like zinc in ocular and prominent in
sulphate (0.25%) systemic bulbar and
or a diseases. forniceal
decongestant conjunctiva.
The local causes
eye drop like of chemosis of
levocabastine conjunctiva
and include acute
naphazoline, but conjunctivitis,
for lasting cure keratitis,
the primary corneal ulcer,
factor causing iridocyclitis,
hyperemia orbital cellulitis,
should be panophthal-
removed. mitis and acute
congestive
C glaucoma. It
Diseases of the Conjunctiva 7

Treatment The management of chemosis Treatment Generally, the subconjunctival


includes treatment of the underlying cause. hemor- rhage gets absorbed by itself within two
to three weeks. Cold compresses check the
Ecchymosis of the Conjunctiva bleeding in the initial stages. Most cases do not
Ecchymosis or subconjunctival hemorrhage is require any treatment except reassurance.
often seen in children and aged people.
Etiology Ecchymosis is found in acute conjunc- Xerosis
tivitis, especially in acute hemorrhagic
conjuncti- vitis and conjunctivitis caused by Xerosis is defined as a dry lusterless condition
Streptococcus pneumoniae and Haemophilus of the conjunctiva which manifests in two
aegyptius (Koch- Weeks bacillus). Trivial forms:
trauma causes rupture of the conjunctival 1. Parenchymatous xerosis: A sequel to local
capillaries leading to small subconjunctival disease of the conjunctiva involving all its
hemorrhage, while fracture of the base of skull layers, and
or a violent whooping cough gives rise to large 2. Epithelial xerosis: Associated with vitamin
subconjunctival hemorrhage. In fracture of the A deficiency.
base of skull, the blood seeps along the floor of
the orbit and appears under the conjunctiva Parenchymatous xerosis Parenchymatous xerosis
within 12 to 24 hours after the injury. is a cicatricial degeneration of the
Hemorrhages are also seen after crush conjunctiva following widespread
injuries due to pressure on thorax and
destructive interstitial conjunctivitis as seen in
abdomen. Blood dyscrasias, scurvy, diabetes,
arteriosclerosis and hypertension are the other trachoma, membranous conjunctivitis,
important causes of ecchymosis. pemphigus or pemphigoid conjunc- tivitis and
physical/chemical burns. Severe degree of
Clinical features Most cases of subconjunctival
hemorrhage are symptomless. However, xerosis is seen in long-standing proptosis, ectro-
ecchymo- sis due to conjunctivitis or trauma pion and lagophthalmos following exposure.
gives annoying symptoms. The hemorrhage
Epithelial xerosis (Xerophthalmia) Xerophthalmia
may be petechial or an extensive one covering
the bulbar conjunctiva (Fig. 2). The latter gives is a term applied to all ocular manifestations of
an alarming picture. impaired vitamin A metabolism from night-
blindness to more or less complete corneal
destruction. It is responsible for nearly 100000
new cases of blindness worldwide each year.

Etiology Xerophthalmia results either from an


inadequate supply of vitamin A or a defective
absorption from the gut due to gastrointestinal
disorders. Epithelial xerosis is predominantly a
disease of children under 5 years of age coming
from lower socio-economic strata. They are
usually ill-nourished, ill-looking and
marasmic. Con- current infections with
measles, microbial agents and herpes simplex
Fig. 2: Subconjunctival hemorrhage may predispose the child to keratomalacia.
Diseases of the Conjunctiva 8
Diseases of the Conjunctiva 9

Main Bitots spots l spot is a


pathological X2 i white, foamy
changes are Corneal n lusterless
found in the xerosis i triangular
epithelium X3A (base at the
c
which assumes Corneal limbus and
a
epidermoid ulceration/k apex
l towards the
character like eratomalaci
skin a outer
(epidermidalizat affect f canthus)
ion of the ing e plaque
conjunctival less a invariably
epithelium) than t situated on
with granular one- u the bulbar
and horny third r conjunctiva
layers. Owing to corne e (Figs 3 and
the destruction al 4). It is
s
of goblet cells, s superficial
:
the mucus is not u and raised
secreted and r XNNight- above the
dry, dull or f blindness is surface of
pigmented spots a the earliest the
appear in the c symptom of conjunctiva.
conjunctiva. e xerophthalm It is usually
Vicarious X3B ia. bilateral and
secretion from Corneal temporal,
X1A
the meibomian ulceration/k and less
Conjunctival
eratomalaci frequently
glands is xerosis is
a nasal.
deposited on characterize
these spots, so affect d by lack of
the tear film ing luster of the
fails to moisten more conjunctiva
them. than associated
Corynebacteriu one- with its
m xerosis grows third wrinkling
abundantly in corne owing to the
xerotic al loss of
conjunctiva. s elasticity.
u The
Classification
r wrinkling of
For diagnostic
f the
and therapeutic
a conjunctiva
purposes, the
c can be seen
following WHO
e on lateral
classification of
XS movements
xerophthalmia
Corneal scar of the eye as
is used:
due to the
XN
xerophthalm conjunctiva
Night-
ia forms
blindness
XF crescents
X1A
Xerophthal along the
Conjunctival
mic fundus. limbus.
xerosis
X1B C X1BBitots
Diseases of the Conjunctiva 10

The cornea
X2Corneal appears
xerosis cloudy and
soft. The
manifests
sloughing of
into two
the necrotic
forms:
stroma
precorneal
leaves a
xerosis
large ulcer
wherein
which may
there occurs perforate
loss of (Fig. 5).
corneal
F luster and
i decreased
g
. corneal
sensiti- vity
3 and true
: corneal
xerosis in
B
i
which
t cornea lacks
o luster and its
t
surface
s becomes
pebbly.
s Sometimes
p
o keratinized
t plaques may
be formed on
the cornea.
X3A, X3B
Corneal
ulceration/ker
atomalacia is
a late
manifestation
of
xerophthalmi
a in which
less than one-
third of the
Fi corneal
g.
4: stroma melts
Bi away due to
tot colliquative
s
sp necrosis
ot (X3A). In
wi Keratomalaci
th
ke a (X3B) more
ra than one-
tin third of the
iz
ati cornea is
on involved.
Diseases of the Conjunctiva 11
Diseases of the Conjunctiva 12

ocular chemical burns. The tear substitutes and


mucous grafting are often needed.
The epithelial xerosis in infants can be
preven- ted by administering prophylactic
vitamin A in mothers during pregnancy.
Breastfeeding should be encouraged. Proper
treatment of gastro- intestinal disturbance,
particularly worm infesta- tions, is necessary.
Methyl cellulose or lubricating eye drops are
used locally. If secondary infection is feared,
topical antibiotic is added. X3A and X3B cases
need treatment on the lines of corneal ulcer.
Generally, the daily requirement of vitamin A
Fig. 5: Keratomalacia (Courtesy: Prof Manoj Shukla and for a child is 3000 to 4000 IU. It should be
Dr Prashant Shukla, AMUIO, Aligarh)
supple- mented with protein-rich diet to correct
protein- energy-malnutrition (PEM) and to
facilitate the absorption of vitamin A. In mild to
XSCorneal scars are of different densities
and are left after healing of ulcers. If they moderate degree of xerophthalmia, dietetic
cover the pupillary area, visual acuity is correction with the inclusion of vitamin A rich
grossly impaired. green vegetables, carrot, butter, egg, fish, cod-
liver or halibut-liver oil, gives satisfactory
XFXerophthalmic fundus lesions appear as results.The WHO recommen- ded a dose of
small, discrete, yellow dots in the peripheral 200000 IU of vitamin A in 3 doses for the
fundus. Perhaps, they represent a focal management of clinical xerophthalmia (Table
depigmentation of the retinal pigment 1).
epithe- lium.
Conjunctival Pigmentation
Treatment
The conjunctiva may show discoloration in
The parenchymatous xerosis is a preventable following systemic and local conditions:
condition. Prompt treatment of trachoma or 1. It becomes yellow in jaundice due to
membranous conjunctivitis should be carried presence of bile pigments.
out. Adequate precautions should be taken to 2. Brown to slaty discoloration of
avoid conjunctiva is found in Addisons disease
or chronic adrenal insufficiency.

Table 1: WHO recommended vitamin A therapy for xerophthalmia

Patients Age Dose Schedule

Children < 12 months 100000 IU 1st day, 2nd day and repeat 2-4 weeks later
Children 12 months or older 200000 IU 1st day, 2nd day and repeat 2-4 weeks later
Women with Child-bearing age 10000 IU Daily for 2 weeks or
NB or Bitots spot 25000 IU Weekly for 4 weeks
Women with 200000 IU 1st day, 2nd day and repeat 2-4 weaks later
corneal lesions

NB: Night-blindness
3. A pigmentati formation conjunctiva.
characteris on. Local of
tic application black
symmetric of soot spots in
al (Kajal) or the
semilunar mascara conjunctiv
accumulati (often used a owing to
on of by females) oxidation
brown or leads to of
gray black adrenaline
pigments pigmentati to melanin.
in the on of
conjunctiv INFLAM
sclera MATION
a.
and/or OF THE
6. Iatrogenic
bulbar CONJUN
brownish
conjunctiv CTIVA
staining of
a is found (CONJUN
the
in CTIVITIS)
conjunc-
ochronosis tiva is Conjunctivitis is
wherein an known as the most
incomplete argyrosis. It common eye
metabolis was disease
m of common worldwide. It is
tyrosine due to usually of two
(alkaptonu prolonged types:
ria) and application 1. Infectious
phenylalan of silver and
ine occurs. salts 2.
4. The for the Noninfectious.
conjunctiva manageme The
becomes nt of noninfectiou
red in trachoma s
subconjunc in the past conjunctiviti
- tival and s may
hemorrhag resulted in further
e and later impregnati be subdivided
leaves a on of into:
brown reduced a. Allergic
pigmentar metallic b. Toxic
y spot. silver in c. Traumatic
5. Benign the elastic d. Secondary,
melanoma tissue of and
of the the
e. Idiopathic.
conjunctiv conjunctiv
a and a. Infectious
precancero 7. Long-term Conjunctivitis
us topical
melanosis A wide variety
use of
of the adrenaline of etiological
conjunctiv in agents, bacteria,
a impart glaucoma virus and fungi,
brown- patients can cause
black may cause infection in the
There is no be associated c such as measles
uniform with rickettsial t and scarlet
criterion for the or viral i fever.
classification of conjunctivitis. v
i Clinical features
infective To facilitate
t Acute
conjunctivitis. description, acute i mucopurulent
Depending on conjunctivitis s conjunc- tivitis
the onset it may may further be
Acute catarrhal may manifest
be divided into classified as
conjunctivitis is either in a mild
two broad acute catarrhal
an acute infec- or a severe form.
clinical or muco-
tive type of The former
categories: acute purulent,
conjunctivitis gives minimum
and chronic. purulent,
characterized symptoms, but
The etiology of membranous
by hyperemia of the presence of
infective conjunctivitis and hemorrhagic.
the bulbar hyperemia of
has
conjunctiva and conjunctiva and
shown a A
c papi- llary tags of mucus at
remarkable
u hypertrophy of the canthi help
change in the
t the palpebral in the diagnosis.
recent past.
e conjunctiva Quite
During
associated with erroneously, it is
preantibiotic C mucopurulent called cold in the
era, bacterial a discharge. The eyes.
conjunctivitis t condition is
dominated. But a
commonly seen
after the middle r
r in children.
of the twentieth
h However, it may
century, 75%
a affect any age
cases of
l group. It has a
conjunctivitis
short
were found to
o incubation
be nonbacterial r period (24-48
in origin in a M hours).
survey u
conducted in c Etiology The
London. Viruses o disease is
were p caused by
responsible for u Staphylococcus
35% of r aureus
u (coagulase-
conjunctivitis. In
l positive), Koch-
the East,
e Weeks bacillus,
outbreaks of n
bacterial Pneumococcus
t
conjunctivitis and
still occur C Streptococcus. It
during each o may also occur
premonsoon n in association
period which j with acute
may or may not u infective
n eruptive fevers
The severe may cause Ideally, the
form reaches its superficial selection of an
peak in 3 to 4 corneal erosions, antibiotic or
days. Heaviness while pneumo- chemotherapeuti
or discomfort in coccal c agent for the
the eye, glueing conjunctivitis control of
of the eyelashes shows petechial infection should
of the upper and hemor- rhages be done after
lower lids, on the bulbar sensitivity test.
particularly after
conjunctiva. However, it is
the night sleep,
Treatment The not possible in
photophobia
treatment of practice.
and colored Fig. 6:
mucopurulent Therefore, one of
halos are the Acute
con- junctivitis
mucopurule the broad-
common nt
symptoms. The is essentially conjunctivitis spectrum
conjunctiva based on two antibiotics like
becomes fiery principles: ciprofloxacin
red with marked frequent 0.3%, ofloxacin
papillary hyper- irrigation of the 0.3%,
trophy of the conjunctival cul- gatifloxacin
palpebral de-sac to remove 0.3%,
conjunctiva (Fig. the discharge moxifloxacin
6) and and control of 0.5% or
congestion of the infection. chloramphenico
vessels towards The infected eye l 0.5% is
the fornices. The commonly used.
is washed 4 to 5
lids are slightly An antibiotic
times a day with
edematous. The ointment
normal saline
mucopurulent (ciprofloxacin,
warmed at room
discharge is gatifloxacin,
temperature.
found in the tetracycline or
The irrigation
fornices and on oxytetracycline)
the margin of not only
removes the is applied at bed
the lids matting
mucus but time to prevent
the lashes. The
dilutes the the lids from
accumulation of
toxins and sticking together.
mucus over the
increases the Dark glasses
cornea results in
flow of may be worn to
colored halos
due to the antibodies. minimize
prismatic effect. photophobia, but
the eye should
Complications
never be
The condition
bandaged as this
is benign but if
promotes the
untreated
growth of
passes into a
organisms and
chronic phase.
enhances the
Staphylococcal
accumulation of
mucopurulent
discharge.
conjunctivitis
Considering the the 20th century ( Staphylococcus
contagious nature of and caused O aureus,
the untold miseries p Streptococcus
disease, by its blinding h pneumoniae,
t Staphylococcus
prophylactic sequelae. It
h
measures must occurs in two
a
be taken to forms: l
check its spread 1. Purulent m
in the family conjunctivitis of i
and community. newborn a
(ophthal-
A m N
c i e
u a o
t n
e n a
e t
P o o
u r
n
r u
a
u m
t )
l
o
e Ophthalmia
r
n neonatorum is a
t u
m bilateral
) conjunc- tivitis
C
, of newborn,
o
characterized
n
j a by copious
u n purulent
n d discharge,
c 2. marked
t Pur chemosis of the
i ule conjunctiva and
v nt swelling of the
i lids.
con
t
jun Etiology The
i
s ctiv disease is
itis contacted
Acute purulent of during birth
conjunctivitis is ad from the
also known as ult. mothers
acute blenorrhea infected
and is marked Purul genitourinary
by a profuse ent tract or from
purulent Conj infected linen
discharge. The uncti and fingers. A
vitis
disease was number of orga-
of
rampant in the nisms, viz.
New
Middle East in born Neisseria
the early part of gonorrhoeae,
hemolyticus and E.coli are established causative
pathogens. Gonococcal ophthalmia
neonatorum is a serious and violent condition,
while Chlamydia and adenoviruses cause mild
purulent conjunc- tivitis.
Causes of neonatal conjunctivitis can be
separated on the basis of duration of onset of
disease. The chemical conjunctivitis starts within
a few hours after the application of silver nitrate
drops (used for prophylaxis of ophthalmia
neonatorum), gonococcal and meningococcal
con- junctivitis 3 days after exposure and
neonatal inclusion conjunctivitis and herpes
Fig. 7: Acute purulent conjunctivitis
simplex conjunctivitis 5 or more days after
exposure (Table 2).
crater-like pit. The lids are swollen and brawny.
Clinical features Ophthalmia neonatorum
The flakes of thick purulent discharge are seen
usually manifests in the first week after birth.
over the conjunctiva and the lid margin. Both
Initially, a watery secretion is noticed from the
gram and Giemsa stains of the conjunctival
babys eye (normally tears are not secreted in
scrapings help to identify N. gonorrhea, C.
the first six weeks of life, therefore, any secretion
trachomatis and other causative organisms.
from the eye should be considered abnormal). It
The disease has a short incubation period (1-3
soon becomes mucopurulent and ultimately
days). If untreated, the acute phase lasts for 10-
purulent. Both eyes are almost always involved.
15 days and then the discharge diminishes
The infant is irritable and his conjunctiva
and swelling gradually subsides.
intensely inflamed, chemotic and red (Fig. 7).
The chemosis is so marked that the bulbar Complications In gonococcal ophthalmia neo-
conjunctiva bulges through the lids and cornea natorum, the corneal complication is a rule. The
appears to be situated at the bottom of a

Table 2: Diagnostic features of neonatal conjunctivitis


Causes Onset Discharge Smear and culture

Silver nitrate (Credes prophylaxis) Within few hours Slight watery or mucus Negative culture
Gonococcal conjunctivitis 2-4 days Copious purulent discharge Intracellular gram-negative
diplococci, culture positive
on blood agar
Nongonococcal bacterial 4-5 days Mucopurulent Gram-positive or gram-
(S. aureus, Streptococcus negative organisms in smear
pneumoniae) and positive culture
Chlamydia (TR-IC infection) 5-14 days Mucopurulent, Cytoplasmic
occasionally purulent inclusion bodies, negative
culture
Herpes simplex infection 5-7 days Watery Multinucleated giant cells,
cytoplasmic inclusion bodies
and negative culture
organism is thoroughly intensive infection can be
capable of cleaned with a antibiotic controlled by
invading the piece of sterile therapy. Earlier topical erythro-
intact corneal gauze. the standard mycin or
epithelium; the Prophylactic regimen was tetracycline.
corneal medication instillation of Systemic
ulceration either by penicillin drops, erythromycin
develops over adopting Credes in a 12.5 mg per/kg
an area just method or other concentration of oral or IV for 14
below the center regimen should 5000 to 10000 days is
of the pupil be carried out. unit/ ml, every recommended to
corres- ponding In Credes minute for half control mixed
to the lower lid method a drop an hour, every infection. Great
margin. The of 1% silver five minutes for care is needed to
nitrate is another half an examine and
ulcer is prone to
instilled in each hour and then treat the eye if
perforation. A
eye of the infant half- hourly the cornea is
mild to severe
soon after birth. instillations till involved.
degree of
The procedure the infection is Topical atropine
iridocyclitis
may cause a controlled. eye ointment
accompanies the
mild chemical Owing to must be used
ulcer. The
conjunc- tivitis increasing but the eye must
perforation of
which is self- prevalence of not be
ulcer gives
limiting. Topical resistance to bandaged.
many blinding penicillin,
sequelae, such instillation of a
combination of topical therapy Acute
as, leukoma with Purulent
adherence, bacitracin and
tetracycline, Conjunc
partial or total polymyxin B
gentamicin, tivitis of
anterior may also be
bacitracin and Adults
staphyloma, used. Povidone-
fluoroquinolone Acute purulent
nystagmus and iodine 5% is
is conjunctivitis of
phthisis bulbi. commonly used
recommended. adults is often
as a prophylactic
Treatment Topical unilateral and
eye drop that
Ophthalmia ciprofloxacin associated with
does not cause
neonatorum is a 0.3% drops urethritis and
any toxic
preven- table hourly and arthritis.
reaction.
disease. The cephtriaxone 25
The infants Etiology The
prenatal to 50 mg/kg IV
with disease is
diagnosis and or IM single
ophthalmia venereal in
treatment of dose or
neonatorum origin and the
cephotaxime 25
birth canal require prompt infection is
mg/kg IM or IV
infection should treatment. The transmitted
12 hourly are
be carried out eye must be from genitals to
found to be very
adequately. irrigated with the eye. Males
effective.
Aseptic warm saline at are
Chlamydial
measures must least four times predominantly
be taken at the a day. Neisseria affected. The
time of delivery. gonorrhoeae disease has a
Soon after birth, infection is short incubation
the lids of the usually period. It is
infant be controlled by commonly due
to N. gonorrhoeae perforation of
but other the corneal
organisms ulcer. The
responsible for patient is febrile
ophthalmia and has
neonatorum can enlarged and
also cause the painful
disease. preauricular
Clinical features lymph nodes.
Gritty sensation, In gonococcal
photophobia, conjunctivitis,
blurring of urethritis is
vision, pain in almost an
the eye and mild invariable
consti- tutional accompaniment
disturbances are . Arthritis,
common endocarditis
symptoms of the and septicemia
disease. The may also be
patient is found.
generally in Treatment The
agony and does basic principle
not allow ocular of treatment of
examination acute purulent
easily. There conjunctivitis of
occurs brawny adults is to
edema of the
protect the
upper lid. The
unaffected eye
eyelashes are
and a prompt
matted with
control of
organized thick
discharge. The
conjunctiva is
markedly
edema- tous and
velvety in
appearance.
Complications
The cornea
becomes hazy
with central
gray area of
necrosis.
Marginal ulcers
usually develop
due to retention
of pus in the
ballooned
conjunctiva.
Iridocyclitis may
ensue even
before
infection in the eral s
affected one. sym
The other eye pto w
can be protected ms. e
by using an eye The l
shield. treatment of l
However, the gonococcal
most effective conjunctiviti a
method is to s s
institute without
prophylactic septicemia in e
treatment in the adults is a c
healthy eye. single dose of o F
Repeated i
ceftriaxone 1g n g
irrigation IM. However, o .
and patients with m
intensive keratoconjuncti i 8
:
therapy vitis or c
with disseminated a M
ciprofloxacin gonococcal l e
(0.3%) eye drop infection should . m
b
2 hourly and be treated with r
erythromycin Acu a
ceftriaxone 1 g
1% eye te n
IV o
ointment often Me
or IM 12 hourly u
bring mbr s
for at least 3 ano
improvement in days. Patients us c
the clinical allergic Con o
picture. to penicillin junc n
j
Gonococcus should be tiviti u
may be present treated with s n
in the spectinomycin c
Acute t
conjunctiva for a 2 g IM as a one i
inflammation of
long period, time dose or 12 v
the conjunctiva i
hence, the hourly in associated with t
therapy should divided i
the formation of
be continued for doses. Oral s
a membrane or
two to ciprofloxacin pseudo-
three weeks. and norfloxacin membrane on
Atropine is are also the palpebral
applied if the e conjunctiva (Fig.
cornea and f 8) characterizes
the uvea are f acute
involved. e membranous
Analgesics are c conjunctivitis.
helpful in t
ame i
lior v
atin e
g
the a
gen
Etiology The deposited on the diagnosis can
membranous surface of the be 3
conjunctivitis is epithelium, made only after
more or less while in a true the s
synonymous membrane the bacteriological t
with epithelial layers examination. a
diphtheritic undergo g
Clinical features
conjunc- tivitis coagulative e
Mucopurulent
since necrosis. The s
discharge, mild
Corynebacterium removal of a .
degree of
diphtheriae pseudo-
swelling of the Stage of
causes membrane
conjunctiva and infiltration: The
membrane leaves an intact
lids, a white conjunctiva is
formation. epithelium,
pseudomembr markedly
However, while a raw
ane on the chemosed and
Streptococcus bleeding surface
palpebral infiltrated with
hemo- is left behind
conjunctiva and semisolid
lyticus, following the
regional exudates
Streptococcus removal of a
lymphadenopat
pneumoniae, true membrane.
hy may be seen
Neisseria Membranous
in the mild
gonorrhoeae, conjunctivitis usually
variety of
Staphylococcus occurs in
conjunctivitis.
aureus, H. children
In severe
aegyptius, E. coli, between 2 and 8
cases, the patient
adenoviruses years of age,
is toxic and
and herpes who are
acutely ill. Pain
simplex virus not immunized.
is often severe.
can also The disease may
The lids are
produce appear either in
swollen, red and
membranous a mild or a
tense making
conjunctivitis. severe form.
their eversion
Ery- Membranous
difficult.
thema conjunc-
The course of
multiforme and tivitis of
membranous
alkali burn may diphtheritic
conjunctivitis can
also lead to origin is often
b
membrane severe. It is,
e
formation. however,
The membrane may be sometimes seen
d
false (pseudo) or true, that mild cases
i
it appears as a of
v
result of membranous
i
coagulative conjunctivitis
d
response to may be
e
infectious or diphtheritic
d
toxic agents. In and severe
pseudomembra nondiphtheritic,
i
ne a coagulum especially
n
consisting of strepto-
t
fibrin, mucus coccal.Therefore
o
and pus is , a confirmed
which impair The 12 hourly. Herpe
ocular motility cicatrization of Diphtheritic s
and threaten the conjunctiva may antitoxins given Simpl
corneal lead to xerosis locally ex
transparency. An and systemically Virus
and entropion.
extensive true are effective Conju
membrane is Treatment when nctivit
found to cover Proper administered is
the entire immunization w Acute
palpebral in infancy and i conjunctivitis
conjunctiva; it is quick isolation t may also be
seldom found of the infected h caused by herpes
on the bulbar patient are the simplex virus
conjunctiva. The usual preventive a (HSV) type 1
regional lymph measures. To n and 2. Herpes
nodes are start with, every t simplex virus
usually enlarged case of i type 1 causes an
and may membranous b acute unilateral
undergo conjunctivitis i blepharo-
suppuration. The must be treated o conjunctivitis
membrane may as diphtherial t with vesicular
also be seen unless proved i lesions on the
covering the otherwise by lids, intense
c
throat or nasal bacterio- logical papillary
.
mucosa in examination. hypertrophy of
Use of
diphtheritic Immediate local
contact shell the conjunctiva
conjunctivitis. and general
may prevent and classical
treatment with dendritic lesion
Stage of symble-
penicillin is on the cornea.
suppuration: The pharon
instituted. Anti-
acute phase formation. Some There occurs
diphtheritic
lasts for 6 to cases may need marked
serum (ADS) enlargement of
10 days during plastic
and penicillin
which cornea surgery with the preauricular
drops (10000 lymph glands.
may ulcerate. amniotic
unit per ml) are The virus can
Gradually, the membrane
instilled hourly also produce a
transplantation.
necrosed into the
For the follicular
conjunctiva conjunctival sac.
management conjunctivitis.
sloughs out and Atropine
of Herpes
appears red and sulphate (1%)
nondiphtheri simplex virus
succulent. should be type 2
tic con-
applied if conjunctivitis is
Stage of junctivitis,
cornea is
cicatrization: treatment with essentially a
involved.
Adhesions topical and venereal
Intramuscular infection
(symblepharon) systemic
injections of acquired by
usually develop antibiotic
antidiphtheritic direct
between the raw (depending on
serum (10000
areas on the the sensitivity of contamination
unit) and
the organism) is of eye from birth
palpebral and crystalline
energetically canal. Primary
the bulbar penicillin (5 lacs HSV
instituted.
conjunctiva. unit) are given
conjunctivitis is j
a self-limiting u E
disease. Topical n p
antiviral therapy c i
with acyclovir t d
3% eye ointment i e
v m
controls the
a i
infection.
l c
A
F K
c
e e
ut
v r
e
e a
A
r t
d
o
e Pharyngoconju c
n nctival fever o
o primarily n
vi affects children j
ru
and appears in u
s
epidemic form. n
C
It is due to c
o
adenovirus t
nj
serotypes 3, 4 i
u
and 7. Acute v
n
follicular i
cti
t
vit conjunctivitis,
i
is pharyngitis,
s
fever and
Adenoviruses
preauricular As is evident by
are known to
lymphadenopat the name, the
produce acute
hy are the keratoconjunctivi
follicular
characteristic tis occurs in
conjunctivitis as
signs. Systemic widespread
seen in
signs mimic epidemics that
pharyngo-
influenza. mostly spreads
conjunctival
Punctate through infected
fever (PCF) and
keratitis may be ophthalmic
epidemic kerato-
the only corneal instruments
conjunctivitis
sign of the especially
(EKC).
disease. tonometers.
The conjunctivitis is self-
P
h limiting and there is
a no specific
r treatment but
y topical
n antibiotics
g should be used
o to control
c secondary
o bacterial
n infection.
Etiology develop within u
n
Epidemic two weeks time c
keratoconjunctiv due to immune t
itis is caused by response to the i
v
adenovirus adenovirus. i
serotypes 3, 7, 8 Later, discrete t
anterior i
and 19. The
s
definitive stromal
diagnosis is infiltrates
made after covering the
recovering the pupillary area
virus from eye (Fig. 9) may
and growing it appear which F
in cell culture. may persist for i
months or g
Clinical features .
years causing
EKC is
visual
characterized by 9
disturbances. :
photo- phobia,
acute follicular Prophylaxis In C
or membranous order to o
conjunc- tivitis, prevent the r
n
subepithelial spread of e
infiltrates in the epidemic, a
cornea, scanty cleaning and l
discharge and sterilization of
all instruments i
preauricular
n
lymphadeno- that touch the f
pathy. patients eye i
must be done. l
Pseudomembr t
ane on the r
Treatment The
palpebral a
treatment of t
conjunctiva
EKC is e
develops s
nonspecific and
predominantly.
symptomatic.
Petechial i
Broad-spectrum n
hemorrhages on
antibiotics are
bulbar
often used to e
conjunctiva and p
prevent
sub- i
secondary
conjunctival d
hemorrhages infections. e
m
can occur. Topical corti- i
Diffuse c
punctate
k
epithelial e
keratitis is r
the a
t
earliest corneal o
lesion. Stromal c
corneal o
n
infiltrates j
costeroids are gic tarsal
recommended Con conjunctiva
in patients with junc and
conjunctival tiviti preauricular
s
membrane or
photophobia. An epidemic of
acute
N hemorrhagic
e conjunctivitis
w occurred at the
c time when
a Apollo
s spacecraft was
t launched,
l hence, it is also
e known as
Apollo
C conjunctivitis.
o Fig. 10: Acute
n Etiology The hemorr
j etiological hagic
conjunc
u agents of tivitis
n acute showin
c hemorrhagic g
hemorr
t conjunctivitis hages
i are identified as in the
v coxsackie virus bulbar
conjunc
i and enterovirus tiva
t 70 belonging to
i picornavirus
s group. The
Newcastle disease affects
conjunctivitis all age groups
is a rare but is mostly
disorder seen in young
occurring in patients. It is
small epidemics contagious and
among poultry its transmission
workers and is appears to be by
caused by hand-to-eye
Newcastle virus. contact.
The Clinical features
conjunctivitis is A sudden onset
indistinguishable of mixed papil-
from pharyngo- lary and
conjunctival follicular
fever. hyperplasia,
petechial and
Acu coalesced
te hemorrhages in
He the bulbar (Fig.
mor 10) and the
rha
lymphadenopath n Simple chronic patients.
y are the c conjunctivitis
Clinical features
hallmarks of the t is marked by
i The patient
disease. Edema congestion of the
v often complains
of the eyelids posterior
i of burning and
and chemosis of conjunctival
t heaviness of the
the conjunc- tiva vessels and
i eyes and feels
are marked. The papillary
s difficulty in
disease may hypertrophy of
cause transient keeping the eyes
Chronic the palpebral
blurring of open. The
conjunctivitis conjunctiva
vision. symptoms are
may occur as a associated with
usually
Complications legacy from an burning or
exaggerated
Ocular inadequately grittiness in the
during evening
complications treated acute eye.
hours. Presence
except punctate conjunctivitis or
Etiology The of concretion,
keratopathy are as simple
condition results trichiasis,
seldom seen. chronic
from foreign body or
Neurological conjunctivitis or
continuation of
sequel specific granulo-
an acute
(radiculomyelitis matous
conjunctivitis
) is noticed in a conjunctivitis.
in absence of
few cases.
an adequate
S
Treatment Acute treatment.
i
hemorrhagic m Errors of
conjunctivitis p refraction, nasal
has no curative l or upper
treatment, it has e respiratory tract
a self-limiting catarrh,
course. Broad- C pollution from
spectrum h smoke and dust,
antibiotics r abuse of alcohol,
should be used o insomnia and
to prevent n metabolic
secondary i disorders more
bacterial c often than not
infection and predis- pose to
cross- infection. C simple chronic
o conjunctivitis.
C n
Occasio- nally,
h j
chronic
r u
n dacryocystitis,
o
c rhinitis or
n
t blepharitis may
i
i be associated
c
v with it.
C i Staphylococcus
o t aureus is usually
n i cultured from
j s conjunctival cul-
u de-sac of these
dacryocystitis i canthi
The
causes unilateral s associated with
inflammatory
chronic conjunc- blepharitis.
Intense itching, reaction of the
tivitis. White Shallow
conjunctival conjunctiva to
scanty discharge marginal corneal
congestion noxious agents
is deposited on ulcers may
towards the usually
the canthi due to occasionally be
inner and outer manifests in two
vicarious found.
canthi, forms an
activity of the
excoriation of Treatment The acute
meibomian
the skin of lid diplobacillary generalized
glands.
margins at the conjunctivitis papillary
Treatment The angle and scanty responds quickly hyperplasia
treatment of mucopurulent to the (vascularization
chronic discharge application of with epithelial
conjunctivitis characterize tetracycline or hyperplasia) and
includes angular oxytetracycline
elimination of conjunctivitis. ointment (1%) 2
predisposing to 3 times a day.
Etiology The
and cau- sative Topical eye
condition is
factors. A drops
caused by
course of containing zinc
Morax- Axenfeld
topical (0.125-
gram-negative
antibiotics 0.25%) are also
diplobacilli
usually controls effective as they
(Moraxella
the infection but inhibit the
lacunata),
symptoms may proteolytic
arranged end-
persist. ferment.
to-end in pairs.
Astringent
The organism F
drops provide
liberates a o
symptomatic
proteolytic l
relief.
enzyme which l
macerates the i
A
epithelium of c
n
the lid margin. u
g
Staphylococci can l
u
also cause such a
l
a condition. r
a
r Clinical features C
Itching, o
C burning, n
o discomfort, j
n
frequent blinking u
j
and slight n
u
mucopurulent c
n
discharge are t
c
common i
t
symptoms. There v
i
occurs redness of i
v
t
i the conjunctiva
i
t towards the
s
a localized follicles, mental factors u
aggregation of papillary favoring the e
lymphocytes hypertrophy of transmission.
(follicles) in the the palpebral In t
subepithelial conjunctiva, trachoma o
adenoid layer. neovascularizati endemic zones,
It is not on and it is almost g
infrequent to infiltration of always r
observe both the the cornea contacted in o
reactions (pannus) and, infancy; eye-to- s
occurring in late stages, eye transmission s
concurrently in conjunctival can
the diseased cicatrization. It be considered as c
conjunctiva. The is one of the a rule. In i
follicles in the oldest and most sporadic cases, c
conjunctiva may widespread genitals a
be found in diseases may be the t
acute affecting more source of r
conjunctivitis, than one-fifth of infection. i
chronic the population Overcrowding, c
conjunctivitis, as of the world. It abundant fly i
a result of is still an population, a
allergic or toxic important insanitary l
response to the cause of visual conditions,
drugs such as impairment paucity of s
topical atropine and blindness. water and poor e
and pilocarpine, The distribution personal q
and in benign of the disease in hygiene u
folliculosis of the world is contribute to e
unknown heterogeneous. the l
etiology. It is highly dissemination a
prevalent in and persistence
e
T North Africa, of the infection.
.
r Middle-East and Trachoma
a certain regions seldom occurs
c of South-East in pure
h Asia. No race is form in endemic
o immune to this zones where
m disease. secondary
a It is bacterial
increasingly or viral
The word
realised that infections
trachoma is
trachoma in superimpose.
derived from a
its The latter helps
Greek word
natural course in transmission
meaning rough.
has a low by increasing
Trachoma is a
contagiousness the conjunctival
specific type of
but secretion and
contagious
becomes adds to the
keratoconjunct
endemic only severity of the
ivitis of chronic
when there disease
evolution
exists environ- d
characterized by
Etiology forms colonies the epithelium
Trachoma is in the and lymphoid
caused by a conjunctival
large-sized epithelial cells
atypical virus called
belonging to the Halberstaedter-
psittacosis- Prowazek
lympho- inclusion bodies
granuloma- (Fig. 11). A few
trachoma (PLT) healthy
group epithelial cells
Chlamydia are attacked by
trachomatis. small elementary
Microimmunoflu bodies which F
i
orescence test is take g
the serologic intracellular .
standard for extranuclear
Chlamydia. As 1
position. They 1
many as 14 swell to form ill- :
serotypes of defined initial
Chlamydia are bodies. On
T
r
recognized and staining, the a
designated by initial bodies c
h
the letters A, B, take violet stain. o
Ba, C, D, Da, E, They rapidly m
a
F, G, H, I, Ia, J divide into
and K. The small, multiple i
agents isolated elementary n
from the bodies
c
l
patients of embedded in a u
trachoma and carbohydrate
s
i
inclusion matrix to form o
conjunctivitis are n
the inclusion
indistinguishable
body, and b
, hence, two are
displace the o
jointly known as d
nucleus of the
TRIC agent (TR i
cell. The cell e
for trachoma and
swells up and s
IC for inclusion
ultimately bursts
conjunctivitis).
to set free the
The life cycle of
elementary
the agent can be
bodies which
studied in the
may attack other
scrapings from
cells.
the conjunctiva.
Pathology The
Life cycle of
TRIC agent
chlamydia
induces
trachomatis
papillary
Chlamydia hyperplasia of
trachomatis
Fig. 12: Histopathology of trachomatous follicles Fig. 13: Papillary hyperplasia of conjunctiva:
Trachoma stage 1
infiltration in the symptomless Papillary cicatrization.
adenoid layer of disease which hyperplasia of The follicles of
the conjunctiva. undergoes conjunctiva
Localized spontaneous involves
aggregations of regression in mainly the
lymphocytes persons with upper palpebral
form follicles good personal conjunctiva that
which undergo hygiene. appears
necrotizing Acute or congested, red
change. The subacute onset and thickened.
follicle (Fig. 12) of trachoma is
Follicle is the
is invaded by seen in adults
characteristic
multinucleated which resembles
lesion of
macrophages bacterial
(Lebers cells) conjunctivitis in trachoma Fig. 14: Trachoma follicles:

which engulf the signs and preferentially Trachoma stage 2

cyto- plasmic symptoms. The appears on the


and nuclear symptoms of upper palpebral
debris. At this trachoma conjunctiva. The
stage, fibro- include foreign follicles appear
blasts grow body on the lower
from the sensation, palpebral
periphery and watering, conjunctiva as
result in itching, well and,
scarring. The photophobia occasionally, on
cicatrized and redness. the bulbar
conjunctiva may The infection conjunctiva. The
undergo hyaline involves both latter is patho-
or amyloid the conjunctiva gnomonic of the
degeneration. and the cornea disease. The
The necrotic and at about the trachoma
cicatricial same time in follicles are
changes in majority of
bigger in size
trachoma cases.
and variable in
follicles distin- The
consistency (soft
guish them from conjunctival
in the center
non- signs
and firm in the
trachomatous include
periphery) as
follicles as none congestion,
of these changes diffuse compared to the
develop in the papillary follicles of
latter. hyperplasia follicular
(Fig. 13) and conjunc- tivitis.
Clinical features They are
appearance of
In most of the
follicles on the irregularly
cases trachoma
mid upper arranged on
has an insidious
tarsal both the upper
onset after an
conjunctiva. (Fig. 14) and
incubation
lower palpebral
period of 5 to 15
conjunc- tivae
days. In pure
form it is a and undergo
Fig. 15: Follicular conjunctivitis Fig. 16: Trachomatous pannus
follicular epithelial ration lies
conjunctivitis erosions over beyond the
are the upper half of terminal ends of
predominantly the cornea can nonanas-
seen on the be demon- tomozing
lower palpebral strated by parallel vessels.
conjunctiva fl uorescein But in regressive
stain. pannus, the
(Fig. 15),
Subepithelial vessels extend a
regularly
infiltration may short distance
arranged in
develop later. beyond the area
rows and never
Typical follicles of cellular
undergo infiltration. An
F
(Herberts i
cicatrization. extensive
follicles) may g
pannus, .
The develop on the
trachomatous limbus. invading the
1
cicatrization may pupillary area, 7
A superficial causes visual :
be localized or
avascular impairment.
diffuse. A fine
keratitis and a Follicles H
linear scar
thin pannus leave oval or
e
appears in the r
(lymphoid circular pits b
sulcus infiltration with e
subtarsalis (Herberts r
vasculariza- tion peripheral pits) t
Arlts line. of the upper at the limbus
Multiple star- limbus) may be s
shaped scars are (Fig. 17). The
evident on slit- pits are highly
seen in lamp
p
trachoma of pathognomonic i
biomicroscopy of trachoma as t
moderate in the initial
severity and none of the
stages of other ocular
white thick trachoma.
dense scarring of diseases is
However, the known to
upper tarsal pannus becomes produce them.
conjunc- tiva is obvious with the Superficial irregular
commonly extension of indolent ulcers may
found in severe blood vessels develop at the
recurring from the advancing edge
trachoma. The vascular loops of the pannus as
latter may cause towards the
a
trichiasis and center of the
result of
entropion. cornea
breakdown of
The cornea associated
pustules. They
is almost with dense
cause
always cellular
irritation,
involved in infi ltration
lacrimation and
trachoma more (Fig. 16). In
photophobia.
or less progressive
Later, a
simultaneously pannus, the
with the cellular infilt-
conjunctiva.
Small punctate
dense corneal 1 T hypertrophy,
scar appears. In r gross pannus
the beginning, ( . and limbal
the pannus lies I follicles or
between the n I Herberts pits
epithelium and c I characterize this
Bowmans i stage of
membrane. p trachoma.
T
Slowly, it erodes i
r
Bowmans e T
a
membrane and n r
t c
invades the .
h
substantia
T o
propria. In such I
r m
cases, resolution I
of pannus leaves a a
I
corneal haze. c

However, early h S
o T
pannus may t
m r
resolve a
a a
completely g
) c
without any e
Incipient
h
corneal haze.
trachoma o
Classification The 2
represents the m
course of earliest stage of a
trachoma is (
the disease with
arbitrarily M
minimal S
divided into a
papillary t
four stages by hyperplasia and n
a
MacCallan. immature i
g
follicles on the f
T e
upper palpebral e
r
conjunctiva s
. 3
associated with t
micropannus.
I (
Some- times, T
H
clinical signs r
T e
are a
r a
nonconclusive c
a
and laboratory l
c h
investigations i
h o
o like n
m
m demonstration g
a
a of inclusion
)
bodies and T
isolation of Mature soft r
S
Chlamydia sagograin-like a
t
a trachomatis are follicles in the c
g required to superior tarsal h
e confirm the conjunctiva, o
diagnosis. papillary m
the
a cicatrization. nor
) Trachomatous mal
d
Cicatrization or ptosis develops e
scarring following dense e
p
develops usually infiltration and
around the cicatrization of t
a
necrotizing the tarsal plate r
trachoma of the upper lid. s
a
follicles (Fig. The contraction l
18). Besides of the scar tissue
v
scarring, some at the lid margin e
or all the signs Fig. 18: s
s
of stage 2 may Healing Table
trachoma: e
be present. Trachoma
3:
l
WHO s
stage 3 classif TS
Tr. IV ication Trachomatous
Trachoma of scarring The
The WHO tracho
Stage 4 presence of
has revised the ma scarring in
(Healed the
classification of Stages
Trachoma) Sign
tars
tra- choma in al
Definitio
The follicles 1987 mainly conj
n unc
and papillary with the tiva
TF
hypertrophy purpose of pre- Trachomato
TT
Trachomatous
dis- appear, and venting the us trichiasis At least
The
the palpebral trachomatous one eyelash rubbing
presence of o
conjunctiva is blindness. It 5 or more n
com- pletely inflammati
includes on: t
cicatrized and 5 stages (Table follicular h
smooth. The 3). This
follicles in e
the upper
scar may be thin classification is tarsal e
or dense. helpful for
c y
o e
Pannus resolves
paramedical n b
and the j a
field workers to u
presence of l
diagnose and n l
incomplete or c CO Corneal
manage the
complete t opacity
disease. i Easily visible
Herberts pits v corneal opacity
may be seen at Complications a inv
TI olvi
the limbus. and sequelae ng
Trachomatous
Corneal Pronounced at
ulceration and inflammatory leas
inflammation: intense ta
occasional iritis thickening of the upper tarsal part
are the conj of
unc p
complications of tiva u
trachoma. that p
obs i
In endemic cure l
zones, the s l
mor a
disease often e r
causes sequelae tha y
n
owing to half m
a
r
g
i
n
specific antibodies by microimmunofluorescence
technique. DNA amplification techniques that
use the polymerase chain reaction (PCR) or the
ligase chain reaction (LCR) are very sensitive
for diagnosing trachoma. However, these tests
are time consuming and expensive.
Diff erential diagnosis Trachoma should be
differentiated from non- trachomatous
follicular conjunctivitis. Following conditions
can induce follicle formation in the conjunctiva.
1. Acute follicular
Fig. 19: Pannus crassus conjunctivitis:
a. Inclusion conjunctivitis
b. Adenovirus conjunctivitis:
may lead to trichiasis and entropion. Thickening
i. Epidemic keratoconjunctivitis
of the lid margin (tylosis) is not uncommon.
ii. Pharyngoconjunctival fever
Xerosis and symblepharon may develop in the
c. Acute herpetic conjunctivitis
conjunctiva. Corneal scar and pannus crassus (Fig.
d. Newcastle conjunctivitis
19) or total pannus may cause marked visual
2. Chronic follicular conjunctivitis
impairment and more or less total blindness.
3. Toxic follicular conjunctivitis:
Trachomatous dacryocystitis and secondary
a. Miotic drugs
glaucoma may occur in some patients.
b. Molluscum contagiosum
Diagnosis The clinical diagnosis of trachoma c. Other irritants
requires the presence of at least two of the 4. Folliculosis.
following signs: (i) follicles or Herberts pits, (ii) Trachoma follicle can be differentiated from
epithelial or subepithelial keratitis, (iii) pannus, nontrachomatous follicle (Table 4). The non-
and (iv) cicatrization. The diagnosis can be trachomatous follicles preferentially develop on
confirmed by direct demonstration of the the
inclusion bodies in conjunctival scrapings and lower palpebral conjunctiva and lower fornix.
staining with Giemsa or iodine stain, They are firm in consistency and never resolve by
isolation of TRIC agent and fibrosis. Out of all follicular conjunctivitis, only
trachoma develops characteristic pannus.

Table 4: Difference between trachoma follicle and nontrachomatous follicle


Trachoma follicle Nontrachomatous follicle

Common site Upper palpebral conjunctiva Lower palpebral


and upper fornix conjunctiva and lower fornix
Characteristics Follicles have varying Follicles are firm in
consistency often soft consistency
due to low grade necrosis
Resolution Follicles resolve by cicatrization Follicles resolve without cicatrization
Herberts pits Follicles develop at limbus Follicles do not develop at
and resolve by leaving limbus and hence no pits
characteristic Herberts pits
I females. The controlling the cryo application
n transmission infection. to the eyelid
c may occur Systemic nodule.
l either by erythromycin
Treatment of
u fingers or 500 mg 4 times a
day or trachoma All
s through the
doxycycline 100 cases of active
i water of the
o mg twice a day trachoma must
pool.
n for 2 weeks may be treated.
Clinical features also be used. Ciprofloxacin,
Inclusion erythromycin,
C conjunctivitis has Molluscu
o an acute onset. m
n Acute follicular Contagio
j hypertrophy of sum
u
the lower Conjuncti
n
palpebral vitis
c
conjunctiva, Molluscum
t
mild superficial contagiosum is
i
punctate keratitis caused by a
v
or, occasional, virus and it
i
micropannus causes a low
t
and preauri- grade follicular
i
cular conjunctivitis.
s
lymphadenopath The conjunctival
Etiology y are the clinical lesions and
Inclusion features of the corneal
conjunctivitis is disease. vascularization
caused by
Treatment The occur due to the
serotype D-K of
disease runs a release of viral
Chlamydia
benign course. proteins and
trachomatis. It
Improvement other
manifests in two in the personal substances in
forms: (i) acute hygiene and the tear film.
papillary chlorination of More than one
conjunctivitis of swimming pool molluscum
newborn, and check the local nodules may be
(ii) acute epidemics. present on the
follicular Topical lid margin (Fig.
conjunctivitis of erythromycin 20). Molluscum
children or 0.5% or tetra- nodules on the
adults. The cycline 1% skin of the
latter is also ointment eyelids are small
known as applied 4 times and smooth
swimming-bath or a day for 3 with an
swimming-pool weeks provides umblicated core.
conjunctivitis. relief. The
The primary Azithromycin 1 treatment of
source of g in a single oral toxic
infection dose or conjunctivitis
appears to be a ofloxacin 300 due to
mild urethritis in mg twice a day molluscum
males and for 1 week is contagiosum is
cervicitis in effective in by excision or
reaction in f
some patients. o
Instillation of r
ciprofloxacin :
0.3% or S: Surgery for trichiasis
ofloxacin 0.3% A: Antibiotic treatment
eye drop 4 times of active infection
a day and appli- F: Facial cleanliness
cation of 1% E: Environmental
erythromycin or improvement
tetracycline To eliminate trachoma
F ointment at bed and its blindness each
i time for 6 weeks component of
g
control the the SAFE
.
infection in strategy must be
2 most cases. In imple-
0 addition to m
: topical e
antibiotic n
M
o therapy, t
l administration e
l of oral antibiotic d
u
s (250 mg .
c erythromycin or A six-week treatment
u tetracycline 4 eliminates the infection
m
times a day or from the
c doxycycline 100 conjunctival sac
o mg twice a day) though the
n for 3 weeks follicle may
t
a provides
g dramatic results.
i It is claimed that
o
s a single dose of
u azithromycin 20
m mg per kg body
weight for
tetracycline, children and a
ofloxacin and single dose of 1-
azithromycin are 1.5 g for adults
quite effective gives superior
against TRIC cure rate of
agent. trachoma.
Chloramphenico Further,
l and penicillin azithromycin
are less effective. has fewer side
Aqueous soluble effects than
sulfonamide (20- tetracycline and
30%) topically sulfonamides.
and long-acting To combat trachomatous
sulfonamide blindness, the WHO
orally may be has developed
used. However, the SAFE
sulfa drugs may strategy. It is an
cause allergic acronym
not resolve. A problem in the the trachoma the standard of
follow-up developing endemic zones. living of
examination is countries. The A community trachoma
necessary to disease is closely having more affected
assess the associated with than population.
complete cure personal 50% prevalence
of the disease. hygiene and of trachoma is Gra
Persistent environmental covered by a nul
trachoma sanitation. blanket om
follicles were Trachoma often antibiotic ato
dealt with, in us
spreads by the therapy (WHO
the past, by Co
transfer of intermittent
mechanical nju
infected con- schedule of ncti
expression by junctival treatment). The viti
roller forceps or secretions antibiotic s
by painting with through fingers, ointment is
copper sulphate Granulomatous
common towel applied to the
or silver nitrate infections such
and flies. entire as tuberculosis,
solution. Such
Therefore, population syphilis and
drastic
mothers are twice daily for 3 leprosy produce
procedures
instructed not to to 5 days in a specific
resulted in
apply eye month for 3 to 6 reactions in the
heavy
cosmetics (Kajal) months. As conjunctiva.
cicatrization,
to all children of trachoma
therefore, dis-
the family with infection does T
carded. ub
the same finger. not give any
Presently, a er
Free mixing of lasting
combination of cu
local and acute cases of immunity,
lo
systemic trachoma in immunization of si
antibiotic school or other the population is s
therapy is public places futile. Although of
preferred no should be the trachoma th
matter one has checked strictly. control e
to continue the Breeding of flies programs are C
be minimized being in on
drug for a longer
by adopting operation in ju
time. The
proper sanitary
nc
management of many countries,
tiv
trichiasis and measures. the ultimate
a
entropion Health solution of the
requires surgical education on problem lies in Etiology
intervention. trachoma should the overall Tuberculosis of
be given to the improvement in the conjunctiva
Trachoma is uncommon,
general public.
control and occurs in
Adoptation of
Trachoma is a young people. It
adequate health may or may not
specifi c
measures has be associated
communicable
minimized the with systemic
keratoconjuncti
intensity and tuber- culosis.
vitis which is a
severity of the The infection is
public health
disease even in usually
exogenous in at t
origin. the i
limb s
Clinical features
us. Syphilitic lesions
The conjunctiva
may rarely get Pathology of the
infected by Histopathology conjunctiva are
Mycobacterium of the lesion uncommon.
tuberculosis. presents a Conjunctiva
The infection is typical tubercle may be affected
invariably formation with in all the three
exogenous in Langerhans stages of the
origin. The giant cells. The disease.
preauricular conjunctival
lymph glands scrapings may
are often show acid-fast
involved and tubercular
tend to bacilli.
suppurate.
Treatment The
Types of lesions primary affection
The tubercular of the
lesions of the conjunctiva
conjunctiva may requires excision
manifest in and
following forms: cauterization.
1. Small However, a
multiple complete course
miliary of systemic
ulcers on the antitubercular
palpebral drugs should be
conjunctiva administered.
2. Granular
or follicular S
type of y
conjunctivitis p
3. Gelatinous h
cocks comb-like i
excrescences in l
the fornices i
4. t
Polyp
i
c
oid
pedun
culate
C
o
d
n
outgro
j
wth
u
5. n
Tub c
ercu t
lar i
nod v
ule i
A primary systemic Oculo Treatment
chancre may antisyphilitic glandu Currently no
rarely develop drugs and lar definitive
in the Syndr treatment is
topical
conjunctiva. It ome available.
tetracycline
may resemble a should be Parinaud Azithromycin,
chalazion if adminis- tered. oculoglandular ciprofloxacin,
present on the erythro- mycin
syndrome
palpebral L or doxycycline
(POS) is
conjunctiva. e may be tried
characterized by
A catarrhal p systemically
follicular
conjunctivitis r along with
conjunctivitis
may occur in o NSAIDs.
t with regional
the secondary
i lymphadenopath F
stage of syphilis.
c y and symptoms u
A gumma or
of fever, n
gummatous
C headache and g
ulceration of the
o anorexia. Rarely, a
conjunctiva n the disease may l
associated with j cause optic
enlarged u C
neuritis,
preauri- cular n
encephalitis and o
lymph glands c n
hepatitis.
may be found in t j
the tertiary i Etiology The u
syphilis. v disease is n
i mainly caused c
Besides
t t
syphilis and by Bartonella
i i
tuberculosis, henselae (cat-
s v
conjunc- tival scratch disease);
i
ulceration may Ocular other causes t
occur due to involvement in include i
trachoma and leprosy is not tularemia, s
foreign body. infrequent. tuberculosis,
Nonspecific Candida
syphilis,
Diagnosis The conjunctivitis albicans,
sarcoidosis and
demonstration may develop. Nocardia,
fungal
of spirochetes in There may be Aspergillus and
infections.
the scraping nodules on the Sporothrix can
from the lesion lids, limbus or cause chronic
and positive cornea. conjunctivitis.
fluorescent Exposure Candida in
treponemal keratitis debilitated
antibody consequent to persons may
absorption Bells palsy produce a
(FTA-ABS) test occurs in late pseudo-
confirm the cases of leprosy. membranous or
diagnosis. ulcerative
Treatment A full Parina conjunctivitis.
course of ud Leptothrix and
other fungi may
cause follicular
conjunctivitis
associated with
preauricular
lymphadenopath
y. Topical
fl uconazole or
miconazole 1%
and natamycin
are used in the
treatment of
Fig.
fungal 21:
conjunctivitis. Rhin
ospo
ridio
Rhino sis
of
sporid conj
iosis uncti
of the va
Conju (Courtesy: Dr TP
Itteyrah, Little
nctiva Flower Hospital,
Angamally)
Rhinosporidiosis
of the
conjunctiva is
not a rare fungal
affection of the
conjunctiva. It is
caused by
Rhinosporidium
seeberi. The
characteristic
conjunc- tival
lesions are
pedunculated or
sessile fleshy
growths with
irregular surface
dotted with
white spots (Fig.
21). The
effective
treatment is
complete
surgical removal
of the growth.
O u rare and also However,
p t included in the artificial tears
h a oculocutaneous and
t n syndrome. grafting of
h e Numerous amniotic
a o vesicles membrane and
l u appear on stem cells
m s the transplantation
i conjunctival by means of
a S conjunctival
surface, they
y auto- grating
rupture and
N n may be helpful.
undergo
o d
d r progressive
A
o o cicatrization
l
s m causing
l
a e essential e
s shrinkage of the r
Ophthalmia conjunctiva often
Inflammation
g
nodosa is a associated with i
foreign body of conjunctiva, corneal compli- c
nodular inflammatory c
conjunctivitis involvement of a C
caused by the mucous t o
retained hair of membranes of i n
caterpillars. The mouth, nose, o j
condition is urethra and u
n
common in vulva, eruptive n
s
summer months lesions of the c
and the lesion skin, and t
a
consists of varying degree i
n
yellowish-gray of v
d i
translucent constitutional
raised nodule on symptoms are t
x i
the bulbar found in a
e s
conjunctiva. number of
r
The nodule is clinical entities Allergic or
o hypersensitivit
formed as a (Stevens-
p y reactions of
result of Johnson
syndrome, h the conjunctiva
lymphocytic
Reiters t are not
and giant cells
syndrome and h uncommon.
infiltration
Behets a They may be
around the
hair. Excision of syndrome) l immediate
the nodule gives described under m (humoral) as
relief. erythema i seen in hay
multiforme or a fever, acute or
O oculocutaneous . subacute
c syndrome. Treatment of conjunctivitis
u Pemphigus or oculocutane and vernal
l pemphigoid ous conjunc- tivitis,
o reaction in the syndrome is or delayed
c conjunctiva is unsatisfactory. (cellular) as
found in Acute or conjunctiva and itching may be
phlycte- nular Subacute severe chemosis obtained by
conjunctivitis. Allergic are found. giving systemic
Conjunctivi Scrapings from antihistaminics.
tis the conjunctiva
Acute or show some V
eosinophils. e
subacute
Remissions are r
catarrhal
common.
n
inflammation of a
conjunctiva is Treatment The l
often associated disease can be
with allergic prevented by K
rhinitis. the elimination e
of allergens r
Etiology The
from the a
condition is t
caused by surroundings or
o
exogenous the patient may
c
allergens such as be moved to a
o
pollen, grass, pollen-free area. n
animal dander, Desensitization j
etc. against specific u
Occasionally, allergen may be n
helpful but is a c
cosmetics,
cumbersome t
chemicals and
process. i
drugs applied
Symptomatic v
topically can i
relief is quickly
induce a violent t
obtained by cold
follicular or i
compresses and
nonfollicular s
instillation of
reaction in the
corticosteroid Vernal
conjunctiva. The
drops. keratoconjunctivit
conjunctivitis
Astringent is (VKC), a
is often seen in
lotions and recurrent bilate-
the Western
antihistaminic ral seasonal
countries as a
drops bring conjunctivitis, is
part of typical
temporary relief. characterized by
hay fever, hence,
Cromolyn intense itching,
known as hay
sodium 2-4% photophobia,
fever
drops 4 times a white ropy
conjunctivitis.
day and discharge and
Clinical features olopatadine appearance of
Itching, hydrochloride well-defined
watering and 0.1% drops 2 polygonal raised
redness of the times a day are areas of
eye are common effective in papillary
complaints of controlling the hypertrophy on
the patient. Mild seasonal the palpebral
to moderate exacerbations. conjunctiva and
injection of the Relief from a wall of
gelatinous
thickening at the
limbus.
Etiology Vernal with change of degene- ration
keratoconjunctiv weather. imparts bluish-
itis is caused by However, it is a white or milky
an immediate self-limiting color to the
hypersensitivity disease and the papilla. The
reaction to some frequency of papillae may
exogenous attacks and also appear in
allergens. The severity of the the lower
immunopathoge symptoms palpebral
nesis involves eventually conjunctiva. A
both type I and subside as the stringy
type IV patient ages. conjunctival
hypersensitivity The disease discharge or a Fig. 22:
reactions. VKC is usually fibrinous Palpebral
is found mostly seen in two pseudomembr form of
vernal
in families with clinical ane (Maxwell- conjunctiviti
a history of forms, the Lyons sign) may s:
atopy and palpebral and the sometimes be Moderate
papillae
asthma. There is limbal, both may found.
an increased IgE co- exist in a The limbal or
and eosinophils patient. bulbar form is
in the blood. The palpebral less
The disease has form is characteristic
the onset in relatively and frequently
summer more seen in black
months, hence, common, races. The
it is also known the upper striking lesion is
as spring catarrh, palpebral at the limbus
which is a conjunctiva is where a wall of
misnomer may hypertrophic gelatinous
be seen round and shows the thickening
the year in presence of appears (Fig. Fig. 23:
tropical climate. small to giant 23). It may be Bulbar
form of
The disease is papillae (Fig. associated with vernal
less common in 22). Each papilla micropannus conjunct
temperate zones is polygonal (Fig. 11.24). As ivitis

and almost non- with a flat the disease


existent in cold top and contains progresses, the
climate. tufts of thickening
capillaries and becomes
Clinical features
dense fibrous irregular and a
Vernal
tissue. The few discrete,
conjunctivitis
polygonal white,
frequently
raised areas of superficial
affects children
palpebral
between 4 and
conjunctival
15 years, often
hypertrophy
boys more than
are seen
girls. The
mimicking
disease shows
cobblestones. Fig. 24:
exacerbations
The hyaline Vernal
and remissions conjunctiviti
s:
Micropannu
s and
corneal
infiltrates
dots or nodules, eosinophils, (0.1% solution 4 supratarsal
Horner-Trantas plasma cells, times daily) conjunctiva.
spots, appear at lymphocytes acts faster than
the limbus that and monocytes cromolyn
are mainly in the adenoid sodium and
composed of layer, and (iii) relieves
dege- nerated spectacular symptoms by
eosinophils. increase in the reducing mast
The corneal fibrous layer cell
lesions of which later on degranulation
vernal undergoes and inhibiting
hyaline eosinophil
conjunctivitis
degeneration. chemotaxis.
(vernal
Photophobia in
keratopathy) T
VKC can be
include r prevented by
superficial e wearing dark
punctate a glasses.
keratitis, t
epithelial m Severe VKC:
erosions, Severe cases or
e
noninfectious patients with
n
oval ulcer seasonal
t
(shield ulcer), exacerbation
subepithelial Mild to need topical
scarring and moderate VKC: corticosteroids.
Topical The instillation
pseudogerontox
cromolyn of
on with a
sodium and corticosteroids
classical cupid-
ketorolac should be
bow outline. An
tromethamine tapered
association
offer relief in gradually. To
between VKC
patients with avoid
and kerato-
year-round corticosteroid-
conus has been disease. related compli-
reported. Diclofenac cations,
Pathology sodium or intermittent
Smears of ketorolac (pulse) therapy
conjunctiva tromethamine is indicated.
show the 0.5% drops are Soluble
presence of considered safe corticosteroid
eosinophilic and may be drops are used
granules in used on a long- 2-4 hourly for 5-
great numbers. term basis. In 7 days and then
Histopathology mild to rapidly tapered.
of vernal moderate An alter- native
conjunctivitis symptom-free to topical
reveals: (i) cases only steroid therapy
excessive cromolyn is an injection of
epithelial sodium is triamcinolone
hyperplasia, (ii) needed. acetonide (40
extensive Lodoxamide mg per ml)
infiltration by tromethamine injected in the
Refractory t are effective conjunctivitis is
VKC: Refractory i measures to a delayed
cases of VKC s manage the hypersensitivity
usually do not papillae. (type IV, cell-
A giant
respond to mediated)
papillary
routine therapy. P response to
reaction in the
An immuno- h endogenous
conjunctiva
suppressive l microbial
occurs in
agent, y proteins which
contact lens
cyclosporin A,
c in most of the
(hydrophilic
t cases are
that inhibits lenses) e tubercular or
chemotaxis, can wearers, n staphylococcal.
be used as 1-2% patients with u Phlyctenulosis
drops in these ocular l may occur
cases. prosthesis and a secondary to
Giant patients in r staphy- lococcal
papillae are whom corneal
blepharitis. The
treated either by sutures, C disease is
application of - particularly of o common in
radiation (600- keratoplasty, are n malnourished
1500 rad) or by not removed. j
and debilitated
cryo application. The papillae are u
children
Persistent giant polygonal and n
between
nodules need resemble c
5 and 12 years of
excision. cobblestones as t
age. These
in vernal i
children suffer
G conjunctivitis. v
i from enlarged
i They are
composed of t tonsils and
a cervical
n eosinophils, i
basophils and s lymphadenopat
t
mast cells. hy.
Phlyctenular
P Local conjunctivitis is
a corticosteroid an endogenous
p drops or allergic
i cromolyn conjunctivitis
l sodium drops marked by
l may relieve the photophobia,
a symptoms of mucopurulent
r foreign body discharge and
y sensation, presence of a
itching and single or
C photophobia multiple gray-
o transiently. white raised
n Cleaning of nodules at the
j the deposits on limbus
u the contact lens, surrounded by
n discontinuation an area of
c of lens or
t conjunctival
prosthesis wear congestion.
i
and removal of
v Etiology
corneal sutures
i Phlyctenular
Clinical features rarity. The size phlycten
Phlyctenular of the phlycten resolves by
conjunctivitis is may vary from cicatrization, in
usually 0.5 to 4 mm. The cornea the scar
unilateral, but bigger phlycten undergoes
the other eye appears as a nodular
may get pustule (Fig. dystrophy.
involved in a 25B) and
Pathology The
few months. The overlying
epithelium histopathology
disease in a pure
undergoes of a phlycten
form does not
ulceration. Both shows a
give many
vascular and characteristic
symptoms F
cellular i subepithelial
except mild
reactions occur
g mononuclear
discomfort and .
around the infiltration in a
irritation with 2
phlycten. 5 triangular area,
reflex A
The cornea is the apex of the
lacrimation. :
infiltrated or P triangle being
However, as the
may be
h towards the
disease is l
invaded by deeper layers of
usually y
a corneal c the cornea.
complicated by t
phlycten. When secondary
mucopurulent e
Corneal n infection
conjunctivitis, u
phlycten often supervenes,
photophobia l
and causes a additional
mucopurulent pain and r polymorphonuc
c
discharge photophobia. A o lear cells appear
become pannus is seen n and the
j
prominent around u
overlying
symptoms. a raised gray n epithelium
The phlycten. The c undergoes
ti
characteristic phlycten v necrosis.
lesion of the ulcerates it
i Differential
conjunctivitis and forms a s diagnosis
is a phlycten or triangular
Besides
phlyctens (blebs). fascicular ulcer
phlycten, a
Single or with
nodule at the
multiple, prominent
limbus may be
small, round vascularization.
seen in
white or gray Multiple
phlyctens episcleritis,
nodules raised inflamed
above the may surround
the cornea and pinguecula,
surface are
their filtering bleb
found at or near
subsequent following
the limbus (Fig.
necrosis leads to glaucoma
25A). The
the formation of surgery, suture
presence of
a ring ulcer. The cyst, dermoid
phlycten on the
and foreign
palpebral
body
conjunctiva is a
granuloma.
The
distinguishing
features of
phlyctenular
conjunctivitis,
inflamed
pinguecula and
episcleritis are
listed in Table 5.
Treatment The
treatment of
phlyctenular Fig. 25B: A big
conjunc- tivitis is phlycten appearing
as pustule
aimed to
(Courtesy:
improve the Prof. Manoj Shukla
general health of and Dr Prashant
Shukla, AMUIO,
the child and Aligarh)
management of
local condition.
Infected tonsils
and adenoids
should be
properly treated
and attempts
should be made
to desensitize
the patient
against
tubercular or
Staphylococcal
allergens. A
calorie-rich diet
supplemented
with vitamins A,
C and D and
calcium should
be given.
Concurrent
infections need
systemic
antibiotic
therapy.
Table 5: Distinguishing features of phlyctenular conjunctivitis, inflamed pinguecula and episcleritis
Features Phlyctenular Inflamed Episcleritis
conjunctivitis pinguecula

1 . Age Below 15 years Above 50 years 16-40 years


(Children) (Elderly) (Young)
2 . Sex Both sexes Male Female
3 . Site Usually at Away from Away from
limbus limbus and limbus and usually
usually nasally temporally
4 . Shape Small raised round Flat and Relatively bigger flat
nodule triangular round nodule
5. Color White Dull-pink, fleshy Dull purple
6. Discharge Mucopurulent No discharge Watery
7. Ulceration Common Does not occur Does not occur
8. Tenderness Seldom May be present Usually present
9. Regional lymph glands Enlarged Not enlarged Enlarged
10. Complications Keratitis and May lead to Rarely scleritis
nodular pterygium
degeneration formation
Hot s papillary S IN
compresses and hypertrophy or THE
irrigation with Etiology Toxic a chronic CO
saline reduce conjunctivits follicular NJU
mucopurulent may occur conjunctivitis. NCT
discharge. following the Follicles are IVA
Instillation of use of most
antibiotic and ophthalmic The common
predominantly
corticosteroid medications. degenerative
seen on the
eye drop several Benzalkonium conditions of
inferior tarsal
times in a day chloride and the conjunctiva
conjunctiva and
has a dramatic thiomersal are include
fornix.
effect on the often used as concretions,
Occasionally, a
secondary pinguecula and
preservatives in progressive
infection as well pterygium.
ophthalmic conjunctival
as on the
preparations scarring can lead
phlycten. The C
which may to contraction of
latter o
cause toxic fornices
disappears n
reaction. (pseudopem-
within a week. c
Atropine, phigoid
When cornea is r
involved miotics, reaction). The e
cycloplegic antiviral agents, corneal toxicity t
should be aminoglycosides manifests as i
applied. , epinephrine punctate o
Recurrences are and epithelial n
frequent if apraclonidine erosion of s
general have been inferior cornea
associated with Concretions or
condition is not or a whorl-
dealt with. follicular lithiasis are
pattern
Tinted glasses conjunctivitis. small, hard,
keratopathy.
protect against Prostaglandin elevated yellow
Rarely, stromal
glare and analogue and deposits in the
opacities and
photophobia. brimonidine palpebral
neovascularizati
may also cause conjunctiva.
on may occur.
T toxic conjunc- They never
o tivitis. Treatment The undergo
x drug should be calcareous
i Clinical features
immediately degeneration,
c The
discontinued. therefore, the
characteristic
Use of term is a
C toxic reaction in preservative-free
o the conjunctiva drugs misnomer.
and
n occurs either in topical lubricant Concretions are
j the form of a caused by
drops may
u
n provide relief.
c
DEG
t
i
ENE
v RAT
i IVE
t CHA
i NGE
accumulation of towards the derived from the wind blown
inspissated canthus. It Latin word areas of
mucus and appears on the meaning wing. Australia,
degene- rated nasal side first It is Middle-East,
epithelial cells in and then the characterized by South-Africa
the loops of temporal side is a triangular and Texas, and
Henle. They are affected. The encroachment of represents a
commonly condition is the conjunctiva response to
found in elderly onto the cornea chronic dryness
found in elderly
people, usually on the and UV
persons suffering
especially in nasal side. exposure.
from trachoma
those living in Pathologic changes in
or chronic Etiology
dusty and the conjunctiva are
conjunctivitis. Etiology of
windy climate. basically the
Foreign body pterygium is
The name same as those in
sensation is the disputed. A
pinguecula is the pinguecula,
main symptom number of
derived from but
and occasionally theories such as
pinguis meaning proliferative
a corneal primary
fat. However, it inflammatory
degeneration of
abrasion may is really a reaction is quite
the conjunctiva
develop. hyaline prominent. The
and the cornea
Removal of infiltration and vascularized
(Fuchs),
concre- tions elastotic granulation
inflammatory
with a sharp degeneration of tissue invades
response of the
needle after the submucosa Bowmans
conjunctiva
topical of the membrane and
(Kamel) and
anesthesia conjunctiva with superficial
irritative
eliminates the little or no l
reaction to
symptoms. vascularization. a
ultraviolet (UV)
It is usually y
light have been
P stationary and e
propagated.
i does not need r
Currently,
n treatment. If s
pterygium is
g pinguecula
believed to be a
u causes cosmetic o
growth disorder
e disfigurement it f
c characterized by
has to be
u conjunctivalizati
surgically t
l on of the cornea
removed. h
a due to localized
UV rays induced e
Pinguecula is a P
damage to the
degeneration of t c
limbal stem
the bulbar e o
r cells. Pterygium
conjunctiva r
y is common in
characterized by n
g sunny, dusty,
the presence of a e
i sandy or
yellowish a
u
triangular spot l
m
near the limbus,
the apex of the The term s
triangle being pterygium is
t
r When
o pterygium stops
m growing,
a infiltration and
. vascu- larization
disappear, and it
Clinical features
becomes pale
Pterygium
and thin (Fig.
seldom gives
27).
any symptom
but its
progression
may cause
astigmatism and
its extension in
the pupillary
area of the
cornea may
cause serious
visual
impairment.
Classically, a
pterygium has
four parts: (i) a
F
blunt apex, head, i
(ii) a few g
infiltrates in .
front of the apex,
2
cap, (iii) a limbal 6
part, neck, and :
(iv) a bulbar
portion P
r
extending o
between the g
r
limbus and the e
canthus, body. s
A progressive pterygium is s
i
thick and vascular v
(Fig. 26) and e
encroaches onto
p
the cornea with t
prominent e
infiltrates. r
y
Stockers line g
represents i
u
deposition of m
iron in the
corneal
epithelium
anterior to the
head of the
pterygium.
Fig. 27: Stationary pterygium Fig. 28: Pseudopterygium
Treatment y Table 6: CTIV
Differentiating
Pterygium g A
features between
requires surgical i pterygium and
removal, u pseudopterygium C
m Features y
especially if it
Pterygium s
threatens to A pterygium- Pseudopterygi t
encroach onto like condition um s
the pupillary (Fig. 11.28) may
area. Excision of e Usually
develop due to seen o
pterygium is adhesion of the Usually f
generally chemotic bulbar seen in
adults
recommended. conjunctiva to a in children t
However, marginal 2 . Etiology h
recurrence of the corneal ulcer Unknown e
ptery- gium Postinflammato
following acute
ry C
after surgery is conjunctivitis or
e Palpebral
not rare. An o
chemical burn of Palpebral
autoconjunc- aperture n
the eye. It can be j
aperture
tival graft or differentiated cum fornix u
amniotic from a true 4. n
membrane pterygium by Co
c
nfi
transplantation the passage of a gu t
(See video) probe between - i
often prevents H v
it and the bulbar ori
the recurrence conjunctiva. zo
a
of pterygium. An early age nt
The conjunctiva
al
-radiation of onset, O is a common site
and topical use obliquity of bli
for development
of mitomycin-C qu
the axis and e of cysts.
(MMC) are also stationary course rat Conjunctival
helpful in are other io
cysts may occur
n
preventing the differentiating due to dilatation
s Progressive
recurrence. features (Table Almost of lymph spaces,
Topical MMC always
6 . Neckor Adherent Free
6). The stationary lymphangiectasis,
to limbus
may cause late pseudopterygiu stationary ofCan the bulbar
7 . Probe Cannot be be passed
aseptic scleral m should be passed conjunctiva.
necrosis and excised. underneath
Sometimes, a
sclerokeratitis in solitary multi-
some patients. locular cyst,
lymphangioma,
P CYS (Fig. 29) may be
s TS found.
e AND Occasionally,
u TUM obstruction of
d
ORS the duct of
o
p
OF
t THE
e CON
r JUN
Fig require careful Fig. e
. 31:
29: surgical Cysti r
Ly removal. cercu m
mp s o
ha cyst
ngi C of
l
om o conju i
a
n
nctiv p
of a
con g o
jun e m
ctiv
n a
a
it
Dermolipoma is
a
a yellowish-
l
E white, fibro-
p fatty congenital
i tumor
b commonly
u found at the
l outer canthus.
b
a
r
D
e Fig.
r 32:
Hist
m opa
Fig. 30: Retention o thol
cyst of upper i ogy
palpebral of
conjunctiva
d cyst
icer
Congenital cus
epibulbar
Krauses dermoid of the
accessory conjunctiva is a
covering partly
lacrimal gland white or yellow
the conjunctiva
results in a large oval mass at
and partly the
retention cyst the limbus
cornea.
(Fig. 30). Conjunctival
Implantation dermoid (Figs
cysts may 33 and
develop 34) grows
following slowly and
strabismus consists of
surgery or epidermoid
injury. epithelium and
Subconjunctival fibrous tissue
cysticercus (Figs containing hair
31 and 32) and follicles and
hydatid cysts are sebaceous
not rare in the glands.
developing
D
countries. They
Fig. 33: Dermoid of conjunctiva
Fig. 35: Nevus of conjunctiva

Fig. 34: Histopathology of dermoid of conjunctiva


Fig. 36: Papilloma of conjunctiva

Tumors of the Conjunctiva Papilloma


Both benign and malignant tumors may Papilloma is a benign polypoid tumor of the
involve the conjunctiva.
conjunctiva occurring in the fornix or at the
canthus (Fig. 36). It may resemble the cocks
Benign Tumors
comb type of tuberculosis of the conjunctiva. As
Nevus it has a tendency to become malignant, it
Nevus or congenital mole is frequent on the should be removed.
bulbar conjunctiva (Fig. 35). It is congenital and
tends to grow at puberty. It appears as brownish Fibroma
or black flat lesion. Histologically, it is
composed of nests of typical pigmented nevus Fibroma is a rare firm or hard polypoid growth
cells. The nevus does not require excision lest often seen in the lower fornix needing surgical
malignant changes develop. removal.
Angiomas
Conjunctival angiomas are congenital and may
be hemangioma or lymphangioma.
Hemangiomas manifest as capillary nevi or
encapsulated hemangioma. The latter is more
common.

Granuloma
Granuloma of the conjunctiva may develop
either on the palpebral or on the bulbar
conjunctiva (Fig. 37) The granuloma may
Fig. 37: Granuloma of bulbar conjunctiva
develop following strabismus surgery, retained
foreign body and extrusion of chalazion
through the conjunctiva. It may appear as a
cauliflower-like (Fig. 38) or fungating mass of
granulation tissue. Granuloma often needs
surgical removal.

Malignant Tumors
Squamous Cell Carcinoma
Squamous cell carcinoma or epithelioma
(Fig. 39) is a fleshy vascular gelatinous mass
with feeder vessels usually seen at the limbus
or at the lid margins. Treatment includes
surgical excision with adjunctive cryotherapy
or topical MMC. Intraocular spread of tumor Fig. 38: Granuloma of palpebral conjunctiva

warrants enucleation of the eyeball.

Intraepithelial Epithelioma
Intraepithelial epithelioma or Bowens
carcinoma is a rare epibulbar tumor with low
malignant potential. Epithelioma can involve
an extensive conjunctival area and may rarely
cause perforation of the globe. Treatment
consists of free excision of conjunctiva with
adjunctive cryotherapy or topical MMC or 5-
fluorouracil to avoid recurrence.

Basal Cell Carcinoma


Fig.39: Squamous cell carcinoma of conjunctiva
Basal cell carcinoma is a common tumor which (Courtesy: Dr SG Honavar, LVPEI, Hyderabad)
usually involves the plica semilunaris and
medial part of the lower lid. Surgical excision
and radiotherapy are common modes of
treatment.
Precancerous Melanosis

Precancerous melanosis of the conjunctiva is a


diffuse pigmentation of the conjunctiva and
periorbital skin (Fig. 40) in elderly persons. It is
prone for malignancy.

Malignant Melanoma

Malignant melanoma may arise from a pre-


existing nevus or de novo in the normal
conjunctiva. It is mostly seen at the limbus and Fig. 41: Melanoma of conjunctiva
may involve other parts of the (Courtesy: Dr SG Honavar, LVPEI, Hyderabad)

conjunctiva as well (Fig. 41). Metastases occur


elsewhere in the body, commonly in liver.
Excision of the globe or exenteration of the orbit
may be required.

BIBLIOGRAPHY
1 . Basic and Clinical Science Course sec 8: External
Diseases and Cornea. American Academy of
Ophthalmology, 2004.
2 . Feign RD, Cherry JD (Eds). Textbook of Pediatric
Infectous Diseases. 4th ed. Philadelphia, Saunders,
1998.
3 . Lang GK. Ophthalmology. Stuttgart, Thieme, 2000.
4 . Remington JS, Klein JO (Eds). Infectous Diseases of
Fetus and Newborn Infants. 5th ed. Philadelphia,
Saunders, 2001.
5 . Wilson LA. External Diseases of the Eye. London,
Fig. 40: Oculodermal melanosis Harper and Row, 1979.