conjunctiva
DESCRIPTION
Lecture on conjunctival diseases from RCSITRANSCRIPT
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THE CONJUNCTIVA
Ms. A. Bobart Hone
RCSI- 2009
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Anatomy• Loose transparent tissue overlying the sclera, lining the
inside of the eyelids and terminating at the cornea
• Clinically it has 3 components :– Palpebral- adherent to tarsal plates on inner aspect of the eyelids– Forniceal– Bulbar-covering the anterior sclera
• Composed of – Epithelium,– Stroma- vascularised connective tissue
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The conjunctiva:red eye or conjunctival injection secondary to conjunctivitis
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Conjunctival disease
• Infective
• Inflammatory/Allergic
• Neoplastic
• Degenerative
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INFECTIVE • Bacterial : red or injected eye associated with a sticky discharge
– Diagnosis– do swab if does not resolve with first line treatment– Treat with antibiotic firstline
• Viral eg Herpes Simplex, Adenovirus
– Herpes conjunctivitis treated with topical 3% Aciclovir ointment 5 times a day– Follicular conjunctivitis typical of Adenovirus- supportive treatment with cool
compresses and lubricants, rarely steroids if severe corneal involvement
• Other organisms • Chlamydia
– Follicles (Lymphoid hyperplasia under the lids) + mucopurulent discharge – Rx with Topical and oral Tetracycline/ Erythromycin in adults
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Bacterial Conjunctivitis
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Herpes Simplex conjunctivitis and corneal dendritic ulcer
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ALLERGIC • Type 1, IGE mediated reactions most common type
– Watery, itchy, photophobic, red eyes associated with papillae– raised lesions/ papillae on conjunctiva, usually under the lids or rarely at the
limbus (called Trantas dots at limbus) are typical of allergic conjunctivitis. – Giant cobblestone papillae are seen in Vernal and Giant Papillary conjunctivitis
associated with mucoid discharge and shield ulcers of the cornea in severe disease.
• Types:– Hay fever conjunctivitis (seasonal)– Atopic conjunctivitis – Vernal conjunctivitis ( usually seasonal)– Giant papillary conjunctivitis – remove the cause eg suture, contact lens etc
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Normal vs Giant cobblestone papillae
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Treatment
• Topical mast cell stabilisers long term
• Lubrication with preservative free drops to soothe
• Systemic Antihistamines
• In Vernal or adult keratoconjunctivitis if severe add topical or subtarsal steroid injections
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NEOPLASMS OF THE CONJUNCTIVA
• Benign – Papillomas, dermoids, dermolipoma
– Treatment: excision ( and for papillomas also apply cautery to destroy virus) • Malignant:
– Melanoma– Squamous cell carcinoma– Lymphoma– Kaposi’s sarcoma.
– Treatment: Dependent on severity and extent – Surgical excision to more ‘radical ‘treatment such with topical mitomycin or
radiotherapy
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Amelanotic malignancy encroaching onto corneal surface
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Degenerative • Pingueculum
– Yellowish white plaques- close to lateral or medial limbus in interpalpebral area
– No treatment warranted but can excise
• Pterygium – A fibrovascular over growth of conjunctiva onto cornea usually
in nasal interpalpebral area, predominantly seen in arid / hot climates
– Treatment: Topical anti-inflammatories if injected and lubricants
– If grows onto cornea and inducing problem on visual axis or astigmatism consider excision with conjunctival auto graft sewn or glued with surgical glue over denuded area to decrease recurrence
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Pterygium
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Miscellaneous
• Stevens Johnson Syndrome– In spite of the other systemic complications resolving after the acute
episode, the eye continues to have the following problems
• Dry eyes• Trichiasis• Entropion or Ectropion• Corneal epitheliopathy, melt or ulcers• Symblepharon- adhesion between bulbar and tarsal (inner lid) conjunctiva
– Treatment
• Avoid inciting medication or precipitant if the cause• Preservative free drops- lubricants, sometimes ongoing steroids• Removal of lashes permanently as can cause ulcers- may need to further
immunosuppress eyes prior to any ocular surgery
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Stevens Johnson SyndromeN.B. symblepharon
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Subconjunctival haemorrhage
• Secondary to – Trauma– Hypertension– Positive valsalva manouvers eg coughing, straining
etc– Anti coagulants or ‘blood thinners’ eg warfarin,
aspirin, persantin, heparin, ginko biloba– Clotting diathesesNo treatment but avoid any inciting cause
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Subconjunctival haemorrhage
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Subconjunctival haemorrhage post cataract surgery
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Superior limbic keratoconjunctivitismay be associated with thyroid eye
disease