The lymphatic drainage is to the^submandibular nodes)which drain the medial one-third of the superior conjunctivaand the medial two-thirds of the inferior conjunctiva;and the preauricular nodes which drain the lateral twothirdsof the superior conjunctiva and lateral one-third ofthe inferior conjunctiva.The conjunctival nerve supply consists of branches ofthe ophthalmic division and branches of the maxillarydivision of the fifth cranial nerve.

The functions of the conjunctiva include tear production(mucin by the goblet cells and aqueous by theaccessory lacrimal glands),tear film mucinous layer lining the conjunctivalcells and corneal epithelium secreted by the goblet cells,

aqueous layer secreted by the lacrimal and accessoryconjunctival glands, and a superficial

lipid layer which issecreted by the meibomian glands and limits the evaporationof tears. This triple-layered sandwich maintains asmooth ocular surface and the oxygen dissolved in it fromthe atmosphere nourishes the corneal epithelium.

CLINICAL FEATURES OF CONJUNCTIVALDISORDERSredness, stickiness, foreign body sensation or grittiness,lacrimation and sometimes photophobia. Vision is generallynormal but a slight blurring may occur if excesssecretions form a film over the cornea.burning sensationand dryness of the eyes.Hyperaemia of the conjunctivaConjunctival discharge1- watery or mucoid discharge occurs in viral and allergic2-mucopurulent, or franklyPurulent discharge is seen in bacterial conjunctivitis.3-Itching with a 'ropy! or 'stringy' mucoid dischargeis characteristic of allergic conjunctivitis.

Foreivn body sensation or grittiness may be a manifestationof dry eye, eye strain, trachoma, contact lens inducedpapillary conjunctivitis, trichiasis Follicles - Appear asyellowish-white, round elevations, 1-2 mm in diameter, andare due to localized aggregations of lymphocytes in the subepithelialadenoid layer Papillae - are a hyperplasia of the normal vascular systemwith glomerulus-like bunches of capillaries growing intothe epithelium in inflammatory conditionsSubconjunctival haemorrhage

CONJUNCTIVITISInflammation of the conjunctiva manifests usually of aninfective or allergic origin. Hyperaemia and increasedsecretion always accompany it. The hyperaemia variesin degree and in distribution, and the secretion varies innature and amount. The nature of the secretion is of diagnosticimportance. Acute conjunctivitis(resolving in less than 4 weeks) further classified type of discharge, conjunctival reaction or aetiology.Neonatal conjunctivitis includes a limited spectrum ofacute conjunctivitis . Subacute / chronic conjunctivitis (of more than 4 weeks' duration)i non-specific conjunctivitis, angular conjunctivitis,some types of follicular conjunctivitis including trachoma,and granulomatous conjunctivitis.

Epidemic Keratoconjunctivitis: This disease is usuallyCaused by adeno virus of serotypes 8 and 19, but also 3 and7 and is characterized by a rapidly developing follicularconjunctivitis with marked inflammatory symptoms andscanty exudate, associated with a preauricular adenopathy.

pharyngoconjunctival fever; caused by adenovirus serotypes3;_4,and^7 and is characterized by an acute follicnlarconjunctivitis in association with pharyngitis, feverand occasionally preauricular adenopathy, seen chieflyin children in the epidemic form. Corneal involvementas a superficial, fine, punctate keratitis manifesting asepitheliopathy can occur but is rare

Newcastle conjunctivitis is clinically indistinguishable fromthe conjunctivitis of pharyngoconjunctival fever; the Newcastlevirus is derived from contact with diseased jfowDD

Haemorrhagic conjunctivitis is due to picornavi ruses,namely, coxsackie virus and emerovirus . It is also known asApcfflgronjunctivitis and occurs in a pandemicform producing a violent inflammatory conjunctivitiswith lacrimation and photophobia. Subconjunctivalhaemorrhages and enlarged preauricular lymph nodesare common. The cornea is usually unaffected

Chlamydial conjunctivitisAcute inclusion conjunctivitis The disease is caused by chlamydial infection (serotypesD-K) and produces inclusion bodies morphologicallvidentical with those occurring in trachoma.QChlamydia inclusion conjunctivitis is generally spread bysexual transmission from a genital reservoir of infection. Theprimary source of infection is a benign subclinical venerealdisease producing a mild urethritis in the male and cervicitisin the female. In adults the organism may be transferredfrom the genitals by the fingers, but a common mode ofinfection is through the water in swimming pools; thus thedisease may occur in local epidemics (sivimmim-pool conjunctivitis.).It is also commonly transmitted from the motherto the newborn.

Ophthalmia neonatorumNeonatal conjunctivitis is defined as a mucoid, mucopurulent,or purulent discharge from one or both eyes in thefirst month of life. It is a preventable disease occurringin a newborn child due to maternal infection acquired atthe time of birth, and used to be responsible for 50% ofblindness among children. The recent decline in the incidenceof gonorrhoea as well as effective methods of prophylaxisand treatment have almost eliminated its occurrenceand the seriousness of its sequelae. However, thedisease is still prevalent and is a public health problemin communities with poor hygiene and limited access toproper health care. It may be due to Chlamydia oculogenitalis,Streptococcus pneumoniae or other organisms.

Acute conjunctivitisThis is usually bacterial, viral or due to Chlamydia trachomatisserotypes D-K. Bacterial conjunctivitis - 1Acute purulent and mucopurulent conjunctivitis 1 -1Aetiology: Mucopurulent and purulent conjunctivitis maybe caused by a number of bacteria and iscontagious, being transmitted directly by the discharge.

Table 14.1 Classification of conjunctivitisI Based on onset• Acute• Subacute• ChronicII Based on type of exudate• Serous* (viral, allergic, toxic)• Catarrhal* (allergic)• Purulent (bacterial)• Mucopurulent (bacterial, chlamydial)• Membranous (bacterial)• Pseudomembranous (bacterial)III Based on conjunctival response• Follicular (viral, chlamydial)• Papillary (allergic)• granulomatous (fungal, Parinaud oculoqlandular syndrome, tuberculosis, syphilis, sarcoidosis, tularaemia, actinomycosis, sporotrichosis,parasitic, mviasis. foreign body)

Non-infectious- Allergic- Irritants (physical, foreign bodies, contact lens use, radiation)- Endogenous or autoimmune- Dry eye- Toxic (chemical or drug-induced)- Factitious or self-inflicted,-Idiopathic

severe form of acute purulent conjunctivitis'pseudomembrane' in pneumococcal conjunctivitis. Iritis is a rare except in pneumococcal conjunctivitis

Neisseria gononhoeaepresents as ophthalmia neonatorum in newborn babiesand as severe purulent conjunctivitis in adults. It is associated with moderate to severe pain and lid swelling with copious purulentdischarge and tender, sometimes suppurative, preauricularlymphadenopathy.

Membranous and pseudomembranous conjunctivitisCorynebacterium diphtheriae, beta-haemolyticstreptococci, Streptococcus pneumoniae, HaemopMus aegyptius,Neisseiia gononhoeae, Staphylococcus aureus, and EscheiichiaColipalpebral conjunctiva is seen to be covered with a white membrane which peels off easily without much bleeding this form is often referred to as pseudomembranous.

severe cases the conjunctivais permeated with semisolid exudates, which tend to necrotize both the conjunctiva and cornea. In these cases the membraneseparates less readily, with bleeding from the underlyingsurface, which is often described as membranous and ismore common with diphtheritic infectiondanger of adhesions forming between the palpebral andbulbar parts of the conjunctiva symblepharon

Angular conjunctivitis (diplobacillarv conjunctivitis)

Aetiology: Such a condition may be caused by staphylococcibut is typically due to Moraxella lacunata, a diplobacillusconsisting of pairs of large, thick rods, placed endto end which stain well with basic stains, are Gram negativejmdeasily recognized in films. They produce a proteolyticferment, which acts by macerating the epithelium.

Viral conjunctivitisViral infections usually cause a serous)or clear waterydischarge and are further characterized byThe type ofconjunctival inflammatory reaction they produce. Inaddition, many systemic viral illnesses such as influenza,mumps, measles and chickenpox can be accompaniedby a non-specific conjunctivitis.

Follicular conjunctivitisThis conjunctival reaction is most commonly caused byvirusesIsolated follicles, however, may occur particularly in thelower conjunctiva in any conjunctivitis of long standingand with the prolonged topical use of some medications.Follicular conjunctivitis can be (i) acute, or (ii) subacuteand chronic. Acute follicular conjunctivitis is due to differentcauses, namely, chlamydial inclusion conjunctivitis, epidemickeratoconjunctivitis, pharvngoconjunctival fever,Newcastle conjunctivitis, haemorrhagic conjunctivitis, primaryherpetic conjunctivitis and recurrent hejpes simplexconjunctivitis.