CONJUNCTIVA

Fourth year
Omar Al-mukhtar Univercity
2019-2020
 Definition:
• the conjunctiva is a transparent mucous membrane lining
the inner surface of the eye lid and covering the anterior
sclera. When the lids are closed it forms the conjunctival
sac.
Gross Anatomy:
It divided into 3 parts:
1)palpebral: lines the
posterior surface of the lid
and it’s formed of
a- marginal part(pars
marginalis): from the
mucocutanous junction
(behind the grey line)of the lid
margin to the sulcus
subtarsalis(2mm from the
posterior lid margin).
b-tarsal part(pars tarsalis): very
vascular and firmly adherent to
the underlying tissue.
c-pars orbitalis(orbital part)
2)fornix: it’s the reflected part between lids and the globe.
It’s formed of the superior, inferior, lateral and medial
fornices.
The superior fornices is the deepest and receives the

i-opening of the ducts of the lacrimal gland(lateraly)

ii- insertion of the levator palpebrae superioris(suspensory ligament of the conjunctiva)

3)Bulbar: cover the anterior part of the sclera and the

limbus.It’s loosely attached to the underlying sclera except 4mm
around the limbus(allows accumulation of fluid,pus and blood easily).

4)plica semilunaris: delicat vertical crescent shaped fold at

the medial canthus.

5)caruncle : small wart like red structure at the medial

canthus ;which contain skin structures eg fine hair and
sebaceous glands.
• Minute anatomy:

1) Epithelium: stratified columnar 2-7 layers according to site”

a) Marginal part and at the limbus: stratified squamous nonkeratinized epith. With goblet cells.
b) Tarsal: 2 layers of columnar epithelium with goblet cells.
c) Fornix: a third layer is added.
2) Substantia propria: formed of
a) Superficial adenoid layer: fine connective tissue rich in lymphocytes , but no true lymphoid
follicles.
b) Deep fibrous layer: thick connective tissue housing the nerves and vessels of the conjunctiva
adherent to the tarsus.

• Glands of the conjunctiva:

a) Accessory lacrimal glands of Krause and wolfring.

b) Goblet cells: unicellular – secreting mucous.
• Blood supply:

1) Arterial:
a) Posterior conjunctival vessels: from the palpebral arteries →supplies
most of the conjunctiva except near the limbus.
b) Anterior conjunctival arteries from the anterior ciliary arteries and
supply the conjunctiva around the limbus.

2) Venous drainage: palpebral veins and ophthalmic veins.

• Lymphatics: as lids
a) Lateral 2/3 :pre-auricular
b) Medial 1/3&caruncle, plica→submandibular

• Nere supply: trigeminal nerve(as lid)

• *Normal conjunctival flora: staph albus ,and xerosis bacilli *
 `

Infective → chlamydial Bacterial Viral

 I)Chlamydia conjunctivitis
Adult inclusion
conjunctivitis:
Causative organism:
chlamydia trachomatis(D-
K);chlamydia
oculogenitalis.

Types:
1. Neonatal
2. Adult.

Spread:
1-water eg swimming
pools

2-contaminated finger
from genitalia.
Symptoms: DDR(discomfort, discharge, redness)
Signs:
▪ Mild lid conj edema.
▪ Conj injection
▪ Mucopurulent scanty discharge
▪ Pre-auricular lymphadenopathy
▪ Lower lid forniceal follicles(+/- upper tarsal)

General signs:
• males: urethritis(urethral discharge)
• female: cervicitis(vaginal discharge)

Fate/complications:
• Spontaneous resolution within 3-12 months.
• Punctate epithelial keratitis.
Treatment:
1. Azithromycin 1g repeated after 1 week(2nd and 3rd dose usually required in
30%)
2. Reduce transmission by abstinence of sexual contact for 1 wk after
azithromycin.
3. Doxycycline 100mg bid for 10 days
4. Topical and systemic tetra/erythro for 6-12 wks.
 II)Ophthalmia Neonatorum
Definition: any conjunctivitis occurring in the first month of life.
“ any discharge from newborn is suspicious since tears are not
secreted at this early date”

Etiology:
•Infective: ocular contact with contaminated
maternal passage of towels.
•Chlamydia oculogenitals(MC)
•Neiserria gonorrhea
•Other bacteria eg staph, strept
•Viral: HSV II
•Non-infective: chemical(drug induced); dt prolonged postpartum
AB prophylaxis.

Symptoms: DR(discharge ,redness)

Signs:
• lid and conj edema.
•Conj injection
•Discharge acc. To cause
•Pre-auricular lymphadenopathy ++
•Papillary reaction.
Investigations:
•Conj scraping(basophilic cytoplasmic inclusion bodies in chlamydia,
lipschotz bodies in herpes)
•Immunofluroscent test for chlamydia
•Herpes culture
Complications:
a)corneal ulcer up to perforation.
b)systemic spread
prevention:
•Treatment of infected mother befor labour
•Washing baby body from above downwards.
•Broad spectrum AB drops for 1wk after birth
Treatment:
[once suspected, treat immediately esp in gonoccoal cases]
1. Frequent topical antibiotic eye drops.
2. AB ointment at night or as required
3. Frequent removal of discharge
4. Systemic erythromycin in sever cases.
5. Add atropine ointment if ulcer or iritis
6. Examin and treat the parents.
DD:
‘’ watering neonate’’
•Buphthalmos
•Congenital dacryocystitis(unilateral +ve regurge)
 Chlamydia gonorrhea viral Chemical
Incubation 1-3 wks 1st wk 1-2 Few days
period wks
History Parentral symptoms drug
Discharge MP P watery watery
Lid
vesicles
Keratitis + +
Systemic + + +
treatment Erythro Systemic Topical -Stop
oral and cephalo acyclovi drug -
oint r +/- artifitial
systemic tears

Genito-urinary specialist
 III)Trachoma
Definition: chronic infectious kerato-conjunctivitis characterized By;
– Subepithelial cellular infiltration.
– Formation of follicles and papillae.
– Formation of pannus.
– That’s heals by cicatrization.

Epidemiology:
-the most common cause of preventable blindnees in the world.
-400 million world wide.
-endimic in eygpt(80% of population)

Causative agent:
Chlamydia Trachomatis (A-C)

Mode of infection:
Through conj. Discharge carried by finger, towels and flies esp. in low
socioeconomic area.
 Clinical picture:
Symptoms:
• Mild irritation and itchiness of eyelids
• Pain in the eyes
• Light sensitivity (photophobia)
• Swelling of the eyelids
• Mucoid or mucopurulent discharge from the eyes
Signs:
– Mild lid and conj edema.
– Conjunctival injection.
– Mucopurulant discharge:scanty
– Keratoconjuntivitis.

• (Mac Callan’s classification):

❖ Conjunctival features:
Affect mainly the upper palpebral conj.
Stage TI: Incipient trachoma; hyperemia of the palpebral conjunctiva(<1mm)immature
follicles).
Stage TII:
TII a: pinkish expressile large raised(>1mm)mature follicle.
TII b: Trachomatous papillae(soft vascular, pink projectile fingerlike velvety
Stage T III: palpebral follicles(healing by cicatrization)in the form of lines-
patches.
• Arlet’s line:dense whit line at the sulcus subtarsalis
• Post-trachomatous degenrations(PTD’s):necrotic shed epithelium with dried
mucous in the pseudocrypts betw papillae.
• Post-trachomatous concretions or calcifecations(PTC’s):sandy white
calcified PTDs.
[as there is no solid immunity and recurrent infection is common, the conj. May show different
stages of the disease”active follicle or papillae and signs of scarring]

Stage T IV: healed Trachoma chrct, by complete cicatrization and absence of

follicles, papillae and no inclusion body in conj. scraping.

❖ Corneal features:
Affect mainly the upper limbus and usually together with the conjunctival
features.
➢ Superficial keratitis: multiple epithelial erosions involving upper part of
cornea stained with fluorescein.
➢ Corneal follicle(Herbert’s rosettes): greyish round subepithelial lymphoid
infiltration resembling limbal follicles at the upper limbus with surrounding
capillaries on healing they leave depressed pits(Herbert’s pits)giving a
serrated appearance at the lower edge of the pannus.
➢ Active trachomatous pannus: superficial vascularization and lymphoid
infiltration of the upper cornea. The vs run subepithelially betwwen the
limbal follicles..the pt may c/o photophobia and pain
Course:
• Progressive: vessels are parallel and directed vertically downward
extending to a level forming a horizontal line. Infiltration precedes
vascularization.
• Regressive: infiltration regresses and vs narrow.
• Healed: superficial scaring with fine obliterated vessels.

Fate:
1. Complete resolution with clear cornea.
2. Pannus siccus(healed pannus)
3. Corneal ulcers:
-Typical trachomatous ulcers: superficial linear horizontal ulcers at the
lower edge of pannus
-Marginal or central ulcers unrelated to the pannus.
Ulcers due to trachoma complications "as trichasis or projected PTD’s”
4. Xerosis: due to – distruction of goblet cells -obstruction of lacrimal
gland duct opening - lacrimal gland fibrosis.
5. Keratoectasia: due to bulging of a week scarred cornea.
Diagnosis of Trachoma:
a)Clinically:
Active: -follicls/papillae
-active pannus
-Herbert’s rossetes
Inactive: -Herbert’s pits
-Arlet’s line
-PTDs/PTCs
- pannus siccus

b) investigations:
-conj scraping for intra-cytoplasmic
basophilic inclusion bodies
(Giemsa stain)
-immunological test and PCR.
Complications:
Eyelids:
i. Trichiasis due to local scarring along lid margin.
ii. Cicatricial entropian due to conj. Shrinkage.
iii. Ptosis(mechanical dt cellular infiltration or Muller’s ms fibrosis and weakness).
iv. Chronic meibomitis.
Conjunctiva:
i. Dry eye dt →xerosis(destruction of goblet cells) →keratoconjunctivitis
sicca:(destruction of accessory LG , destruction of main ducts of LG) .
ii. Posterior symblepharon(shallow fornix or occlusion)
iii. Hyaline/amyloid degeration
iv. Pigmentation.
Lacrimal:
i. Chronic dacryoadenitis.
ii. Punctual occlusion.
iii. Chronic canaliculitis with epiphora
iv. Dacryocystitis.
Cornea:
i. corneal ulcers
ii. Corneal vascularization & opacification.
iii. Xerosis
iv. Corneal scarring & keratoectasia.
Treatment:
1. Systemic Azithromycin 1g
2. Doxycycline 100mg /d for 10days or Erythromycin 500mg/bid 6-12 wks
3. Topical AB : Tetracyclin(C/I in pegnant,lacating &children<12yr)
4. If corneal ulcer: Atropin &dark glasses
5. Surgical:
i. picking only projecting PTD’s & PTC’s
ii. Ttt complications.
iii. expression of follicles
iv. scraping of papillae

Prevention:
Facial cleanliness- Environmental improvement.

*SAFE” strategy supported by WHO (Surgical- Antibiotic-

Facial cleanliness- Environmental improvement).
 Bacterial conjunctivitis
I) Mucopurulent (simple bacterial) = MPC
• Causative agent:
a) Haemophilus aegypticus(Koch’s weeks bacillus).
b) Staph, strept, pneumococcus.

• Symptoms: DDR
– Discharge
– Discomfort
– Redness.

• Signs:
a) Mild lid and conj. Edema.
b) Conj. Injection.
c) Mucopurulent discharge with gluing of eyelashes esp on awakening.
d) +/- petechial hge in severe cases.
 • Fate:
i. -Resolution within 2 wks or with treatment.
ii. -Secondary marginal corneal ulcer.

• Management:

1) Topical broad spectrum→ eye drops during daytime , and eye

ointment during night.
2) Wash the discharge by baby shampoo or water
3) If corneal ulcer: add atropine and dark glasses.
4) If severe add systemic antibiotic.
5) Decrease transmission of infection:→ hand washing- avoid sharing of
towels- protect fellow eye by antibiotic.
*never bandage or patch the eye in the presence of discharge*
 II) Purulent conjunctivitis (PC)
• Causative agent:
1-Neiserria gonorrhoea(80%). 2-other bacteria(20%)mixed.
• Types:
1-adult: flies, dust, towels or genitals.
2-Neonatal
• *Clinical picture &stages:
→incubation period: few hours to 3 days.
→stage of infiltration:
➢ Symptoms: sever DDR
➢ Signs:
1. Sever lid edema and tenderness.
2. Marked conj edema and hyperemia ,+/-subconj hge.
3. Pre-auricular lymphadenopathy and fever.
4. +/- watery or mucoid discharge.
• →Stage of discharge:
1. Decrease lid and conj edema and hyperemia.
2. Papillary formation in palpebral conj.(velvety appearance)
3. Profuse purulent creamy discharge.
4. +/-pseudomembrane.
 • complication:
‘’Neisseria can invade an intact epithelium’’
1)Secondary corneal ulcer
-marginal -central -ring
-may perforate and cause endophthalmitis.
2)systemic spread eg septicaemia, arthritis, endocarditis.

• Treatment:
1. Hospitalization.
2. Conjunctival swab or scraping.
3. Topical broad spectrum antibiotics
→drops : every 5 min for an hour then every hour for 2 days then 4
times for 10 dayes
→ointment at night.
4. Systemic cephalosporins(single ceftriaxone injection)for gonococcal
cases.
5. Bath the discharge and never bandage.
6. If ulcer: add atropine and dark glasses.
7. Reduce transmission.
 III) Membranous conjunctivitis(diphteritic)
• Causative agent:
-Coryne bacterium diphtheriae(rarely affect non-immunized children).

• Clinical pictures and stages:

➢ Incubation period :12hr – 3 days
➢ Systemic manifestation:
fever +pharyngitis throat or naso-pharyngeal infection.
➢ Ocular manifestations:
1. Stage of infiltration.
Symptoms: DDR
Signs:
1. Sever lid edema, tenderness and ‘’woody like infiltration’’
2. Sever conjunctival edema &hyperemia.
3. True membrane grayish yellow-patchy or cover the whole conjunctiva.
4. Pre-auricular lymphadenopathy.
5. +/- scanty mucopurulent discharge.
2. Stage of discharge:
1. Marked conj. Hyperemia.
2. Purulent blood stained discharge containing sloughed membrane,That when
separates leave septic granulation tissue that exudes thick yellow pus.
• Fate and complications:
1. Cornea: secondary corneal ulcers & vascularization, xerosis
[diphtheriae can invade intact epithelium]
2. Conjunctival scarring:
a) Trichiasis- entropian- symblepharon- pseudopterygium.
b) Dry eye.
3. xerosis: destruction of goblet cells.
4. Keratoconjunctivitis sicca: due to closure of the ducts and fibrosis of the
accessory lacrimal gland.
5. Systemic complication(exotoxins)
a. Myocarditis.
b. Respiratory failure.
c. Nephritis &albuminuria
d. Neuritis
a. Optic neuropathy.
i) Paralytic squint
ii) Paralysis of accommodation.
• Prevention: immunization

• Treatment:
1) bed rest
2) notification of health authorities and isolation of sporadic cases.
3) Topical anti-diphteritic antitoxic serum and broad spectrum
antibiotics drops and ointments.
4) Systemic antidiphtertitic serum(40000-60000units IM repeated after
12 hrs)and penicillin.
5) Antibiotic ointment using a glass rod between the palpebral and
bulbar conjunctiva to avoid symblepharon.
6) If corneal ulcer:add atropine and dark glasses.
 Viral conjunctivitis
• Causative agents:
1) Adenoviral :
a) Pharyngo-conjunctival fever: serovars 3,4,7 / corneal affection 30% / fever pharyngitis(sore
throat)
b) Epidemic-kerato-conjunctivitis: serovars 8, 19 /corneal affection 80% /Epidemic.
2) Herpes simplex
3) Molluscum contagiosum(pox virus)
4) Viral fevers eg measles, mumps.
• Symptoms: redness, lacrimation, lid swollen, discomfort,+/-photophobia
• Signs:
1) Lid edema and conjunctival chemosis
2) Conj injection
3) Watery discharge
4) Conj lower follicles
5) Pre-auricular lymphadenopathy
6) Pseudomembrane and petechiae in sever cases
7) In adenoviral: punctate epithelial keratits
8) In herpitic: unilateral / lid vesicles on lid margin
9) In molluscum: umblicated pearly nodule on lid margin.
10) In enteroviral and coxackie: subconj hge
 • Fate and complications:
1. Adenoviral: self limiting in 2wks but highly contagious.
2. Herpes: usually self limiting / rarely dentritic keratitis or systemic spread eg
encephalitis’’

• Treatment:
1) Herpes: antiviral acyclovir ointment for 3 wks +/- systemic if needed.
2) Adenoviral: topical steroid only if sever keratitis.
3) Cold compressors and artificial lubricant.
4) If cornea→ Atropin
5) Preventive measures: separet boiled towels and bed sheets.
 Non- Infective conjunctivitis
I)Spring catarrh(vernal keratoconjunctivitis)
Bilateral recurrent chronic seasonal allergic conjunctivitis(type I
allergy=Atopy)dt allergy to exogenous antigen eg. UV rays, pollen, dust,
fumes)

Demography:
▪ Age: 5-25yrs
▪ Sex: more in boys.
▪ Season: spring and summer
▪ Family history : +ve
▪ ** associated with an increase
risk of Kratoconus and common in pt with atopic disease eg. Asthma, hay
fever**
Symptoms:
1. DDR +BLP(thread ropy white sticky discharge),
(discomfort, discharge, redness,
+ burning, lacrimation, photophobia)
2. Sever itching.
3. Mechanical ptosis.(from papillae)
Signs(types):
1. Palpebral : cobble stone papillae
➢ Large red flat topped.
➢ Affecting upper palpebral conj, fornix is free.
➢ On eversion of lid for one min it will be covered by sticky discharge full
of eosinophils.
2. Bulbar(or limal):more sever, commoner in dark races. Gelatinous mass
around the limbus,usually start upper
with white spot concretions of necrotic epithelium with eosinophils+/-
calcium (Tranta spots)
3. mixed type
4. corneal (complications)
➢ risk of keratoconus
➢ punctate microerosion
➢ macroerosions
➢ annular 360 panuss
➢ corneal plaque: macroerosions with dried mucous= vernal or shield ulcer)
Treatment:

• During the attak:

1. NSAID
2. Antihistamin eye drops eg. Livostin
3. Topical decongestants
4. In sever cases: steroids →Topical →short course(<2wks)
5. Intralesional (supratarsal) injection of steroids
6. Topical cyclosporine in resistant cases
7. Symptomatic ttt: -Dark glasses -cold foments.

• Inbetween attacks:
A) Mast cell sabilizers eg.disodium cromoglycate(opticrom),
lodoxamide(epichrome)
b) Antihistaminics(topical and systemic)
c) Change surroundin automsphere and avoid antigen exposure.
 II)Giant papillary conjunctivitis

Etiology:
1. Contact lens wear.
2. Ocular prosthesis.
3. Exposed corneal stitches.

Symptoms:
1. CL intolerance.
2. DDR + pain ,photophobia
3. Blurred vision(mucous coating of CL)
Signs:
1. Hyperemia.
2. Mucoid discharge.
3. Large flat topped papillae affecting the superior tarsal conj covered
with mucous.

Treatment:
a. Treat the cause
b. Topical ttt as spring catarrh.
 III)Phlyctenular conjunctivitis

➢ Acute allergic(type IV = delayed hypersensitivity)conjunctivitis dt an

endogenous antigen eg;
o Staphylococcal blepharitis.
o Tuberculoprotein eg. Chest TB
o Streptococcal tonsillitis
o Intestinal parasites

Symptoms:
•DR(discomfort, redness)
•Discharge if secondary infection or ulceration.
•pain and photophobia if cornea affected.

Signs(types):
❖ Nodule
•Greyisg white or yellow nodule
•1-3mm in size
•Single or multipule, uni or bilateral.
•Surrounded with a zone of hyperemia.
•It might ulcerate +/- 2ry infecton.
Pathologically:
Consists of lymphocyte aggregation covered by intact epithelium.
➢ Site(clinical type):
•Bulbar
•Limbal
•Corneal
❖ Corneal complication:
•Corneal phlycten(superficial or deep to bowman’s mm)
•Phlyctenular panuss: at any part of limbus, thin&vascular with straight vs.
•Ulcers: -limbal(single or multipul fuse to form a ring ulcer)
-Fascicular ulcer(acute serpiginous ulcer)
Complications:
1. Recurrence.
2. Corneal: ulcers and opacification.
3. 2ry infection MPC.
Treatment:
1. Treat the cause.
2. NSAID.
3. Topical short course of steroids
4. If cornea; add atropine, dark glasses
5. AB topical if 2ry infection.MPC
6. Ttt of Fascicular: 1-Topical steroid 2-Cautery for the leash of bl vs
3-Carbolic cauterization for the ulcer
D.D: conjunctival nodule..

episcleritis Phlycten
tenderness Tender not
Age- sex Middle age 5-15yrs
femal
color purpule Yellow
level deep Superficial
Conj Move freely Move with it
over it ,fixed to
sclera

Topical Not blanching Blanches

vasoconstrictor

Ulceration and Absent +/-

suppuration
 Conjunctival degenerations

1. Ptrygium
2. pingecula
PTERYGIUM
 PTERYGIUM
• Def: Fibroavascular triangular encroachment of the conjunctiva
• Etiology:
a. Chronic irritation by the effect of ultraviolet rays and dust.
b. Aquired limbal stem cell dificincy.
• Pathology:
Elastotic degeneration of stromal collagen with a single layer of thick conj
epithelium and distruction of Bowman’s mm.
• Symptoms:
1. Disfigurement.
2. Drop of vision due to: →papillary affection
→astigmatism
• Signs:
‘’Commonly nasal and bilateral’’
It consist of :
•Apex or head or cap (over the cornea)+/- pigmentation at it’s
end(stocker’s line)
•Neck: overlying the limbus
•Body :loosly adherent to slera.
• Types:
•Progressive: vascular fleshy creeping towards corneal center.
•Stationary or regressive: fibrous or membranous(thin less vascular)
• DD:
❖ Pseudo ptrygium

• Treatment:
a) Follow up: if small and no symptoms.
b) Surgical excision.
•Indication: → cosmotic
→affecting pupil
•Technique :excision with
i. Bare sclera technique…high recurrence rate.
ii. To decrease recurrence:
✓ Beta-irradiation with strontium 90(might lead to scleral
necrosis)
✓ Mitomycin C
✓ Conjunctival graft
✓ Limbal stem cell transplantation
iii. Lamellar keratoplasty if indicated.
 Pinguecula
Elastotic hyaline degeneration of the subepithelial conj tissue due to the
effect of U/V rays in old age.

• Signs:

➢ Bilateral yellow triangular yellow raised non-vascular nodule in the nasal

side of the conj. With base towards the cornea

• DD.: conj nodules

• Complication : pingueculitis

• Treatment: no unless large and disfiguring.

 Symblepharon
• Defenition: Adhesion between palpebral and bulbar conj or adhesion
between the lid and the globe.

• Cause= conj scarring

1. Chemical injury and burns

2. Post-inflamatory eg. Trachoma,
diphtheria.
3. Ocular cicatricial pemphigoid.
4. Post op: multiple ptrygium surgeries.

• Types:
❑ Anterior: adhesion between lid and cornea or bulbar conj.
❑ Posterior: adhesion at the fornix(shallow or obliterated fornix) eg Trachoma.
❑ Total: adhesion between lid and the globe
 • Clinical picture:
1. Disfugerment
2. Binocular diplopia and limitation of motility.
3. Diminution of vision(of cornea affected)

• Complications:
1. Exposure keratitis.
2. +/- ankyloplepharon

• Treatment:
Prophylactic
1. Lubrication by steroid(if no infection) – antibiotic ointment
2. Glass rod coated with antibiotic ointment to be passed between the lid and
the globe.
3. Contact scleral shell.
Definitive ttt:
1. Synechtomy
2. Mucous mm graft
3. keratoplasty
D.D of conjunctival signs

❖ Papillae:
1. spring or vernal(flat topped)
2. trachomatous(finger like or round topped)
3. giant papillary conjunctivitis

❖ Follicles:
1. active trachoma(T1-T2)..upper
2. viral
3. adult inclusion conjunctivitis.
4. Drugs
5. Folliculosis
❖
Pannus:
1. Trachomatous
2. Leprotic
3. Phlyctenular
4. Degenerative
5. Spring catarrah

❖ Nodule:→