CONJUNCTIVITIES BY DNYANESHWAR BHAGWAN POTFODE

1. conjunctivitis
DNYANESHWAR B. POTFODE
OPHTHALMIC OFFICER

2. Anatomy of conjunctiva
• The conjunctiva is a translucent mucous
membrane which lines the posterior
surface of the eyelids and anterior aspect
of eyeball.
• It stretches from the lid margin to the
limbus, and encloses a complex space
called conjunctival sac.

3. Parts of conjunctiva
• 1. Palpebral conjunctiva
• i. Marginal conjunctiva
• ii. Tarsal conjunctiva
• iii. Orbital part
• 2. Bulbar conjunctiva
• 3. Conjunctival fornix.

4. Parts of conjunctiva and conjunctival glands.

5. INFLAMMATIONS OF CONJUNCTIVA
• Inflammation of the conjunctiva
(conjunctivitis) is classically defined
as conjunctival hyperemia associated
with a discharge which may be
watery, mucoid, mucopurulent or
purulent.

6. conjunctivitis

7. conjunctivitis

8. Etiological classification
1. Infective conjunctivitis: bacterial, chlamydial,
viral, fungal, rickettsial, spirochaetal, protozoal,
parasitic etc.
2. Allergic conjunctivitis.
3. Irritative conjunctivitis.
4. Keratoconjunctivitis associated with diseases of
skin and mucous membrane.
5. Traumatic conjunctivitis.
6. Keratoconjunctivitis of unknown etiology

9. Clinical classification
• 1. Acute catarrhal or mucopurulent conjunctivitis.
• 2. Acute purulent conjunctivitis
• 3. Serous conjunctivitis
• 4. Chronic simple conjunctivitis
• 5. Angular conjunctivitis
• 6. Membranous conjunctivitis
• 7. Pseudomembranous conjunctivitis
• 8. Papillary conjunctivitis
• 9. Follicular conjunctivitis
• 10. Ophthalmia neonatorum
• 11. Granulomatous conjunctivitis
• 12. Ulcerative conjunctivitis
• 13. Cicatrising conjunctivitis

10. INFECTIVE CONJUNCTIVITIS
• Infective conjunctivitis, i.e., inflammation of the
conjunctiva caused by microorganisms is the
commonest variety
• Low temperature due to exposure to air,
• Physical protection by lids,
• Flushing action of tears,
• Antibacterial activity of lysozymes
• Humoral protection by the tear immunoglobulins

11. BACTERIAL CONJUNCTIVITIS
• There has occurred a relative decrease in the
incidence of bacterial conjunctivitis in general
and those caused by gonococcus and
corynebacterium diphtheriae in particular.

13. Etiology
• A. Predisposing factors
• B. Causative organisms
• C. Mode of infection

14. Predisposing factors
• Bacterial conjunctivitis, especially
epidemic forms, are flies, poor
hygienic conditions, hot dry climate,
poor sanitation and dirty habits.
These factors help the infection to
establish, as the disease is highly
contagious

15. Causative organisms
• It may be caused by a wide range of organisms
• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Haemophilus influenzae
• Moraxella lacunate
• Pseudomonas pyocyanea
• Neisseria gonorrhoeae
• Neisseria meningitidis

16. Mode of infection
• 1. Exogenous infections
• 2. Local spread
• 3. Endogenous infections

17. 1. Exogenous infections
(i) Directly through close contact, as air-borne
infections or as water-borne infections;
(ii) Through vector transmission (e.g., flies); or
(iii) Through material transfer such as infected
fingers of doctors, nurses, common towels,
handkerchiefs, and infected tonometers

18. 2. Local spread
• It occur from neighbouring structures
such as infected lacrimal sac, lids, and
nasopharynx.
• In addition to these, a change in the
character of relatively innocuous
organisms present in the conjunctival
sac itself may cause infections.

19. 3. Endogenous infections
• It occur very rarely through blood e.g.,
gonococcal and meningococcal
infections.

20. Pathology
• Pathological changes of bacterial conjunctivitis
consist of :
• 1. Vascular response
• 2. Cellular response
• 3. Conjunctival tissue repsonse
• 4. Conjunctival discharge.

21. 1. Vascular response
• It is characterised by congestion and
increased permeability of the
conjunctival vessels associated with
proliferation of capillaries.

22. 2. Cellular response
• It is in the form of exudation of
polymorphonuclear cells and other
inflammatory cells into the substantia
propria of conjunctiva as well as in the
conjunctival sac.

23. 3. Conjunctival tissue repsonse
• Conjunctiva becomes oedematous. The
superficial epithelial cells degenerate,
become loose and even desquamate.
• There occurs proliferation of basal layers
of conjunctival epithelium and increase
in the number of mucin secreting goblet
cells.

24. 4. Conjunctival discharge.
• It consists of tears, mucus, inflammatory cells,
desquamated epithelial cells, fibrin and
bacteria.
• If the inflammation is very severe, diapedesis
of red blood cells may occur and discharge
may become blood stained
• The changes are thus more marked in
purulent conjunctivitis than mucopurulent
conjunctivitis.

25. Acute mucopurulent conjunctivitis.

26. Symptoms
• Discomfort and foreign body sensation due to engorgement of
vessels.
• Mild photophobia, i.e., difficulty to tolerate light.
• Mucopurulent discharge from the eyes.
• Sticking together of lid margins with discharge during sleep.
• Slight blurring of vision due to mucous flakes in front of
cornea.
• Sometimes patient may complain of coloured halos due to
prismatic effect of mucus present on cornea.
• Flakes of mucopus are seen in the fornices, canthi and lid
margins.
• Cilia are usually matted together with yellow crusts

27. Acute mucopurulent conjunctivitis

28. Complications.
• Occasionally the disease may be
complicated by marginal corneal ulcer,
superficial keratitis, blepharitis or
dacryocystitis

30. Treatment
• 1. Topical antibiotics
• 2. Irrigation of conjunctival sac
• 3. Dark goggle
• 4. No bandage
• 5. No steroids
• 6. Anti-inflammatory and analgesic drugs

31. ACUTE PURULENT CONJUNCTIVITIS
• Acute purulent conjunctivitis also known as
acute blenorrhea or hyperacute conjunctivitis
is characterised by a violent inflammatory
response. It occurs in two forms:
• (1) Adult purulent conjunctivitis.
• (2) Ophthalmia neonatorum in newborn.

32. OPHTHALMIA NEONATORUM
• Ophthalmia neonatorum is the name given
to bilateral inflammation of the conjunctiva
occurring in infant, less than 30 days old.
• It is preventable disease usually occurring
as result of carelessness at the time of birth.
• any discharge or even watering from eyes
in first week of life should suspicion of
ophthalmia neonatorum, as tears are not
formed till then.

33. Etiology
• Source and mode of infection
• Causative agents

34. OPHTHALMIA NEONATORUM

35. Source and mode of infection
• 1. Before birth infection is very rare through
infected liquor amnii in mothers with
ruptured membrances.
• 2. During birth. It is the most common mode
of infection from the infected birth canal
especially when the child is born with face
presentation or with forceps.
• 3. After birth. Infection may occur during first
bath of newborn or from soiled clothes or
fingers.

36. Causative agents
• 1. Chemical conjunctivitis
• 2. Gonococcal infection
• 3. Other bacterial infections
• 4. Neonatal inclusion conjunctivitis
• 5. Herpes simplex ophthalmia neonatorum

37. Symptoms and signs
• 1. Pain and tenderness
• 2. Conjunctival discharge.
• 3. Lids are usually swollen.
• 4. Conjunctiva may show hyperaemia and
chemosis
• 5. Corneal involvement, though rare, may
occur in the form of superficial punctate
keratitis especially in herpes simplex
ophthalmia neonatorum

38. Complications
• Untreated cases, especially of gonococcal
ophthalmia neonatorum, may develop
corneal ulceration, which may perforate
rapidly resulting in corneal opacification
or staphyloma formation.

39. Treatment
1. Antenatal measures include thorough care of
mother and treatment of genital infections when
suspected.
2. Natal measures are of utmost importance, as mostly
infection occurs during childbirth.
• Deliveries should be conducted under hygienic
conditions taking all aseptic measures.
3. Postnatal measures include : Use 1 percent
tetracycline ointment or 0.5 percent erythromycin
ointment or 1 percent silver nitrate solution into the
eyes of the babies immediately after birth.

40. B. Curative treatment.
• 1. Chemical ophthalmia neonatorum
• 2. Gonococcal ophthalmia neonatorum
• i. Topical therapy
• ii. Systemic therapy

41. ACUTE MEMBRANOUS
CONJUNCTIVITIS
• It is an acute inflammation of the conjunctiva,
characterized by formation of a true
membrane on the conjunctiva.
• Now-a-days it is of very-very rare occurrence,
because of markedly decreased incidence of
diphtheria. It is because of the fact that
immunization against diptheria is very
effective.

42. PSEUDOMEMBRANOUS
CONJUNCTIVITIS
• It is a type of acute conjunctivitis,
characterised by formation of a
pseudomembrane (which can be easily
peeled off leaving behind intact
conjunctival epithelium) on the
conjunctiva.

43. CHRONIC CATARRHAL CONJUNCTIVITIS
• ‘Chronic catarrhal conjunctivitis’ also
known as ‘simple chronic conjunctivitis’
is characterized by mild catarrhal
inflammation of the conjunctiva

44. ANGULAR CONJUNCTIVITIS
• It is a type of chronic conjunctivitis
characterised by mild grade
inflammation confined to the
conjunctiva and lid margins near the
angles (hence the name) associated with
maceration of the surrounding skin.

45. Angular conjunctivitis.

46. CHLAMYDIAL CONJUNCTIVITIS
• Chlamydia lie midway between
bacteria and viruses, sharing some of
the properties of both.

47. FOLLICULAR CONJUNCTIVITIS
• It is the inflammation of conjunctiva,
characterised by formation of follicles,
conjunctival hyperaemia and discharge from
the eyes.
• Follicles are formed due to localised
aggregation of lymphocytes in the adenoid
layer of conjunctiva.
• Follicles appear as tiny, greyish white
translucent, rounded swellings, 1-2 mm in
diameter.

48. ACUTE HAEMORRHAGIC
CONJUNCTIVITIS
• It is an acute inflammation of
conjunctiva characterised by multiple
conjunctival haemorrhages, conjunctival
hyperaemia and mild follicular
hyperplasia.

49. ALLERGIC CONJUNCTIVITIS
• It is the inflammation of conjunctiva due
to allergic or hypersensitivity reactions
which may be immediate (humoral) or
delayed (cellular). The conjunctiva is ten
times more sensitive than the skin to
allergens.

50. ALLERGIC CONJUNCTIVITIS

51. Types
• 1. Simple allergic conjunctivitis
• Hay fever conjunctivitis
• Seasonal allergic conjunctivitis (SAC)
• Perennial allergic conjunctivitis (PAC)
• 2. Vernal keratoconjunctivitis (VKC)
• 3. Atopic keratoconjunctivitis (AKC)
• 4. Giant papillary conjunctivitis (GPC)
• 5. Phlyctenular keratoconjunctivitis (PKC)
• 6. Contact dermoconjunctivitis (CDC)

52. SIMPLE ALLERGIC CONJUNCTIVITIS
• It is a mild, non-specific allergic
conjunctivitis characterized by
itching, hyperaemia and mild
papillary response. Basically, it is an
acute or subacute urticarial reaction.

53. Clinical picture
Symptoms- include intense itching and burning
sensation in the eyes associated with watery
discharge and mild photophobia.
Signs.
(a) Hyperaemia and chemosis which give a
swollen juicy appearance to the conjunctiva.
(b) Conjunctiva may also show mild papillary
reaction.
(c) Oedema of lids.

54. Treatment
1. Elimination of allergens if possible.
2. Local palliative measures which provide
• i. Vasoconstrictors like adrenaline, ephedrine, and
naphazoline.
• ii. Sodium cromoglycate drops are very effective in
preventing recurrent atopic cases.
• iii. Steroid eye drops should be avoided. However,
these may be prescribed for short duration in severe
and non-responsive patients.
3. Systemic antihistaminic drugs are useful in acute
cases with marked itching.

55. GIANT PAPILLARY CONJUNCTIVITIS
(GPC)
• It is the inflammation of conjunctiva
with formation of very large sized
papillae

56. GIANT PAPILLARY CONJUNCTIVITIS
(GPC)

57. Subconjunctival haemorrhage