By DR EKI OGHRE

DEPARTMENT OF OPTOMETRY,
UNIVERSITY OF BENIN, BENIN CITY

CONJUNCTIVAL DISORDERS
CONJUNCTIVA
 A thin translucent membrane that attaches the
eyelid to the eyeball
 It lines the eyelid. It is reflected at the upper and
lower fornices onto the anterior surface of the
eyeball
 It fuses with the cornea along the conjunctival
limbus.
 The conjunctiva is a highly vascular membrane
SYMPTOMS IN CONJUNCTIVAL PROBLEMS

 Redness
 Irritation
 Epiphora (tearing).
 Itching
 Pain - this is generally mild.
 Discharge.
ASSESSMENT OF THE CONJUNCTIVA

There are 3 components

1, Visual assessment
 Conjunctival reaction ( pattern and degree of redness)
 Mild/Severe
 Diffuse/ local
 Ingestion or haemorrhage
 Discharge.
 Watery/purulent
 Presence of follicles or papillae - distinguishing one from the other can be
tricky and both can occur together.
 Papillae - occur in allergic, bacterial and gonococcal conjunctivitis. They are
formed when the conjunctival inflammation is effectively limited by fibrous
septa, so giving rise to the appearance of vascular bulges. Generally found on the
upper tarsal conjunctiva, they can coalesce to form giant (cobblestone) papillae.
 Follicles - are more often associated with viral conjunctivitis. They are lymphoid
collections and are raised gelatinous pale bumps (resembling small grains of rice).
They tend to occur on the lower tarsal conjunctiva and along the upper tarsal
 Oedema (chemosis) - translucent swelling of the
conjunctiva
 Scarring this may occur as a result of trachoma,
ocular cicatricial pemphigoid, atopic
conjunctivitis or prolonged use of topical
medication.
OTHER ASSESSMENTS

2. Look for what you can not see.

 Evert the lids - foreign bodies and lesions
 Stain with fluorescein - a small conjunctival
laceration may well show up
 Swab - in the case of severe, purulent
conjunctivitis,
3.Examine structures other than the
conjunctiva , ask about symptoms
 Assess visual acuities and cornea.
 Assess for associated blepharitis.
 Pain, photophobia, reduced visual acuity and
headache suggest uveitis.
 Check the preauricular and submandibular nodes, as
lymphadenopathy occurs in viral, chlamydial and
gonococcal infections.
CONJUNCTIVITIS
 Inflammation of the conjunctiva
 The most common eye disease. Conjunctivitis can be generically
described as swelling of the bulbar, fornix or Palpebral
conjuctival tissues.
 Characterised by
 Redness
 Foreign body sensation
 Discharge
 Follicles and/or papillae
 Mild to no pain
 Normal VA
 No photophobia
THE SIGNS AND SYMPTOMS
 These vary, depending on the cause,
 symptoms generally may include,
 itching,
 foreign body sensation,
 irritation and discomfort
 Signs may include
 hyperaemia,
 watery, stringy or mucopurulent discharge,
 follicles and papillae
TYPES OF CONJUNCTIVITIS
 INFECTIVE
 Bacterial
 Acute bacterial conjunctivitis,
 Viral
 (a) Folllicular conjunctivitis
 (b) Pharyngio-conjunctival fever
 (c) Epidemic keratoconjunctivitis
 (d) Acute haemorrahogic conjunctivitis
 Chlamydial
 (a) Trachoma
 (b) Inclusion conjunctivitis
TYPES OF CONJUNCTIVITIS CONTD.
 ALLERGIC
 Seasonal,
 perennial,
 vernal,
 atopic
 Giant Papillary (associated with CL,s)
 INFLAMMATORY
 Reiters syndrome , oculocutaneous.
 TOXIC
WORK-UP FOR CONJUNCTIVITIS
 Detailed ocular history, ie, Onset, duration,
quality, quantity.
 Detailed eye examination.(examine unaffected
eye first)
 Assess adjacent structures.
 Conjunctival scrapings and culture in severe
infections.
ACUTE BACTERIAL CONJUNCTIVITIS
 This is a common type of conjunctivitis, found in all age groups,
 History;
 Acute onset of redness, (2-3 days)
 often initially unilateral, becoming bilateral
 mucopurulent discharge;
 discomfort,
 foreign body sensation;
 eyelid erythema and oedema;
 vision minimally or unaffected; not itchy.
 Exam;
 injection of the bulbar conjunctival and episcleral vessels,
 Redness is more away from limbus
 mucoid or purulent discharge; (if severe consider gonococcal aetiology)
 clear cornea, no fluorescein stain;
 normal visual acuity and pupil response.
 Papillae may be present of absent
 Pseudomembranes may be present of absent
ACUTE BACTERIAL CONJUNCTIVITIS:

16
CHRONIC BACTERIAL CONJUNCTIVITIS

17
PATHOPHYSIOLOGY
 The eye has a series of defence mechanisms to prevent bacterial
invasion. These include
 bacteriostatic factors within the tears,
 a relatively nutrient poor environment unsupportive of bacterial
growth,
 the shearing force of the blink,
 an intact immune system, and
 a population of normal non-pathogenic bacteria which competitively
prevent invasion by abnormal organisms.
 When these defences break down or they are overwhelmed by a
pathogen not sensitive to these defence mechanisms, an
infection can occur
COMMONLY ENCOUNTERED ORGANISMS
 Staphylococcus aureus,
 Streptococcus pneumoniae ,
 Neisseria gonococci,
 Haemophilus influenzae, and
 Pseudomonas aeruginosa.
 Occasionally, there will be more than one organism in
an acute bacterial conjunctivitis.
 Otitis media may present concurrently with acute
bacterial conjunctivitis, especially in children. This
syndrome is highly indicative of H. influenzae infection.
ASSESSMENT
 Microbiologic study with culturing and sensitivity
testing is the optimum means to reach a conclusive
diagnosis and treatment plan. However, due to the
expense of microbiologic studies and relatively benign,
self-limiting nature of the condition, most clinicians
advocate the use of broad-spectrum, topical antibacterial
therapy, reserving culturing for hyperacute conditions or
those that fail to respond to initial therapy.
 Assessment
 Gram’s stain and conjunctival culture
BACTERIAL CONJUNCTIVITIS
MANAGEMENT
 In majority of cases, acute bacterial conjunctivitis is a self-limiting
disease. Despite the benign, self-resolving nature, bacterial
conjunctivitis should be treated with topical antimicrobial therapy in
order to shorten the disease course and improve the rate of clinical
and microbiologic remission
 Treatment
 Warm or cold compresses, artificial tears, broad-spectrum antibiotics
4-6x/day
 Initial broad spectrum topical antibiotics
 Fluoroqionolone (Ciprofloxacin 0.3%, Ofloxacin 0.3%, Levofloxacin 0.5%)
 Polymyxin/trimethoprim (Polytrim)
 Gentamicin or tobramycin
 Adjust treatment on arrival of lab results
 Ophthalmology referral if hyperpurulent and hyperacute (GC can
rapidly invade and perforate cornea)
VIRAL CONJUNCTIVITIS
 Viral conjunctivitis can be caused by a number of different viruses. but
mainly Adenovirus
 Adenovirus is the most common ocular viral infection worldwide
 Adenoviral conjunctivitis is known to be the most common cause of
red eye in the world. Specific adenovirus serotypes are associated with
various types of ocular infection. There are three major presentations:
 Follicular conjunctivitis (simple adenoviral conjunctivitis, serotypes 3, 4,
7a);
 epidemic keratoconjunctivitis (EKC, serotypes 8, 19, 37, 54); and
 pharyngoconjunctival fever (PCF, serotypes 3, 4, 7a, 11)
 .
 Most produce mild, self limiting disease
VIRAL CONJUNCTIVITIS

 May result from systemic viral infections, i.e. measles, mumps, chicken pox,
rubella, influenza, etc,
 Symptoms;
 Discomfort,
 foreign body sensation;
 photophobia
 often with coexistent URT infection or similar history
 watery discharge, often profuse; usually initially unilateral becoming bilateral in 3-7 days,
recent contact history of someone with red eye; vision minimally or unaffected.
 Signs;
 Diffusely injected conjunctiva;
 tarsal conjunctival follicles;
 clear cornea initially, possible small patches of subepithelial infiltrates developing 2 to 3
weeks after onset;
 occasionally palpable preauricular lymph nodes;
 no corneal fluorescein stain;
 normal visual acuity and pupil response.
VIRAL CONJUNCTIVAL FOLLICLES
Translucent “grains of rice” appearance.

Translucent “grains of rice” appearance.

VIRAL CONJUNCTIVITIS
 Treatment
 Self-limiting disease
 Cold compresses
 Artificial tears
 +/- Topical vasoconstrictor/antihistamine
 Infection control
 SPECIFIC TYPES OF VIRAL CONJUNCTIVITIS

Follicular conjunctivitis (simple adenoviral conjunctivitis)

 It is seasonal, occurring most frequently in the summer and winter,
 spreads rapidly in crowded environments such as day care centres,
schools and military barracks.
 Adenoviral conjunctivitis and keratoconjunctivitis are common and
highly contagious. These conditions usually affect both eyes.
 Patients may have painful conjunctival membranes and palpable
preauricular adenotherapy.
 Adenovirus is non-enveloped, resilient to disinfection and long
lasting on formites. However they are self-limiting.
 PHARYNGIO-CONJUNCTIVAL FEVER

 PCF is characterized by a fever, sore throat and follicular conjunctivitis.

 history of recent exposure to an individual with red eye
 may have a history of recent symptoms of an upper respiratory tract
infection
 Associated systemic manifestations such as sudden or gradual onset of
fever lasting up to several days. Myalgia, malaise, and gastrointestinal
disturbances
 More common in children,
 Caused by adenovirus types 3 -7.
 Conjunctivitis is preceded by pharyngitis
 Follicles may be present on the pharyngeal mucosa.
 Injection which begins at the inner canthal area and slowly spreads laterally.
 Transient superficial keratitis,
 Non- tender preauricular lymphadenopathy
SYMPTOMS
 May range from
 slight itching and burning to marked irritation and tearing,

 little photophobia.

 Swelling of the lids may occur within 48 hours.

 Signs include
 Conjunctival hyperemia

 watery discharge,

 epiphora sometimes leading to a lateral canthal fissure (splitting of

the skin at the lateral juncture of the upper and lower eyelids) and
 eyelid oedema.

 Follicular conjunctival reaction

The virus can be eradicated from the conjunctiva in as soon as 14 days,

MANAGEMENT
 Because PCF usually is a self-limited disease, treatment is mainly
symptomatic, as follows:
 Cold compresses several times per day for 1-2 weeks
 Artificial tears 4-8 times per day for 1-3 weeks
 The following drugs may be used but rarely are indicated:
 A topical vasoconstrictor/antihistamine may be instilled 4 times per day for severe
itching only, because it may cause a rebounding of symptoms and it has a high
incidence of local toxicity and hypersensitivity.
 A topical antibiotic may be instilled 4 times per day to prevent bacterial
superinfection.
 Topical steroids dramatically suppress conjunctival inflammatory signs, relieve
symptoms, and are associated with resolution of the corneal subepithelial
infiltrates. However, due to their adverse effects, topical steroids should only be
used for pseudomembranes or when subepithelial infiltrates severely reduce vision.
EPIDEMIC KERATOCONJUNCTIVITIS
 Epidemic keratoconjunctivitis (EKC) is caused by the adenovirus
serotypes 8, 19 and 37.
 Marked inflammatory reaction with symptoms of viral infection,
as well as blurred vision and photophobia
 a more critical form of adenoviral keratoconjunctivitis because of
the possible adverse consequences on visual acuity.
 incubation period is 2-14 days before the clinical symptoms
present
 the person may remain infectious for 10-14 days after symptoms
develop.
EKC CONTD.
 EKC epidemics tend to occur in closed
institutions (eg, schools, hospitals, camps,
nursing homes, workplaces). Direct contact with
eye secretions is the major mode of transmission.
 Infected medical equipment play an important
role in spreading the disease. Many epidemics
have been initiated in ophthalmology outpatient
clinics by direct contact with contaminated
diagnostic instruments
EKC CONTD.
 Begins as an obvious conjunctivitis, but then
develops corneal infiltrates.
 This acute phase of EKC is marked by a severe
conjunctivitis and lasts from two to four weeks.
 the inflammatory reaction of the conjunctiva can
become so intense that it results in a
pseudomembrane and potentially permanent
symblepharon formation or punctual occlusion
EKC CONTD.
 Usually bilateral but often starts with one eye,
 Symptoms are same as other viral conjunctivitis. however, it is
distinguished from other adenoviral infections when the
cornea becomes affected by the development of multifocal
subepithelial infiltrates.
 These infiltrates are typically observed within seven to ten
days after the onset of the initial signs of infection.
 In 20-50% of cases, corneal opacities can persist for a few
weeks to months, and their presence can also cause reduced
visual acuity.

MANAGEMENT
 EKC is a self-limiting disease.
 Treatment is mostly symptomatic
 (cold compresses and artificial tears).
 mild topical corticosteroids can be used..
 If pseudo- or true membranes are present, they should be
removed using a forceps or a moistened cotton-tipped applicator
soaked in a combination of antibiotic solution and anesthetic.
 Topical antibiotic steroidal combination (Tobradex, Maxitrol,
Zylet) therapy QID can be employed following the removal of
the inflammatory membrane. Currently, no specific topical
antiviral medication is recognized as an effective treatment for
viral conjunctivitis.
 Most practitioners reserve topical steroidal therapy for the
severely symptomatic (SEI on the visual axis decreasing acuity)
or recalcitrant cases.
CLINICAL PEARLS

 Office equipment, instruments and areas should be

meticulously maintained so they do not become a flashpoint
for outbreak.
 EKC infiltrates typically resolve without scarring the cornea.
Patients should be told to expect worsening over the first
seven to 10 days and improvement over three to six weeks.
 Most practitioners reserve topical steroidal therapy for the
severely symptomatic (SEI on the visual axis decreasing
acuity) or recalcitrant cases.
 Steroids should be tapered slowly as the condition remits.
ACUTE HEMORRHAGIC CONJUNCTIVITIS (APOLLO)

 Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of

highly contagious conjunctivitis, characterized by
subconjunctival haemorrhages
 it is a variant of EKC produced by adenovirus types 19 and 37 .
 AHC is known to be directly transmitted by close person-to-
person contact or indirectly through soiled ophthalmological
materials or swimming pools.
 AHC has been noted throughout the tropical regions of the
world without regard to sex, race or ethnic background.

 Occurs in epidemic proportions

AHC CONTD.
 AHC begins with an initial period of catarrhal inflammation
(profuse discharge of mucus and epithelial debris).
 Symptoms include
 painful red eyes,
 swelling of the conjunctival tissue,
 frequent mucus discharge from the eyes accompanied by excessive
tearing and subconjuntival haemorrhage. This haemorrhaging is caused
by the rupture of blood vessels beneath the conjunctiva giving the eyes a
bright red appearance.
 These are associated with a painful, rapidly progressive follicular
conjunctivitis. The lids often become swollen and indurated. The
infection resolves within 5-7 days, during which the symptoms of pain
and irritation are present.
MANAGEMENT
 Management consists of symptomatic treatment while waiting for
the disease to run its 5 to 7day course.
 AHC almost always resolves without sequela, having a good
visual prognosis.
 Management
 Patients should stay home from work or school until contagious
discharge is eliminated, and should be warned not to share
common utensils, glasses, linens or washcloths.
 Medical management may range from supportive cold compress
and artificial tears to topical vasoconstrictors BD to QID.
 Office equipment, instruments and areas should be meticulously
maintained so they do not become a flashpoint for outbreak.
CHLAMYDIAL CONJUNCTIVITIS(TRACHOMA)
 Trachoma is the leading infectious cause of blindness
world wide.
 It is caused by serovars A, B, Ba and C of Chlamydia
trachomatis. It is found primarily in areas of poverty
and over crowding.
 It is estimated that about 500 million people are
infected world wide with over 1million being blind as a
consequence.
 It is endemic in parts of Africa, Middle east, India, and
Southeast Asia..
 Chronic keratoconjunctivitis caused by Chlamydia
trachomatis
 Chlamydia are small obligate intracellular pathogens
and were once considered to be viruses. However they
contain DNA, RNA, and ribosomes and make their
own proteins and nucleic acids so are now considered
to be true gram negative bacteria
 The infection occurs more often in children.
Transmission is by contact with contaminated fingers,
clothings, objects and flies.
CHLAMYDIAL CONJUNCTIVITIS(TRACHOMA)
 Endemic in underdeveloped countries, where standard of living is
low, poor personal hygiene
 Symptoms;
 Discomfort,
 foreign body sensation;
 mucus discharge, often profuse;
 usually initially unilateral, becoming bilateral;
 chronic symptoms despite topical antibiotics;
 vision minimally or unaffected; minimally or not itchy.
 Signs
 diffusely injected conjunctiva; large tarsal and limbal follicles, superior
keratitis, panus, normal visual acuity and pupil response, linear and stellate
cicatrization, entropion, trichiasis
TRACHOMA CONTND,
 The incubation period is about 5-14 days.
 The spread is associated with epidemics of bacterial conjunctivitis
and dry seasons in tropical and semitropical regions.
 Direct transmission usually between children and carers
 At onset, chronic and insidious and resolves with no complications
 In adults, the onset is acute to subacute and complications may
occur.
 At onset, trachoma resembles acute bacterial conjunctivitis with
tearing, pain, hyperaemia, exudation, and sometimes photophobia.
As it progresses, there is lid oedema, chemosis of the conjunctiva,
papillary hypertrophy, tarsal and limbal follicles, superior keratitis,
pannus formation, preauricular node swelling.
TRACHOMA CONTND,
 Repeated episodes of reinfection within the family causes
chronic follicular or intense conjunctival inflammation
(active trachoma), which leads to tarsal conjunctival
scarring.
 The scarring distorts the upper tarsal plate and in some
individuals, leads to entropion and trichiasis (cicatricial
trachoma).
 The end result includes corneal abrasions; corneal scarring
and opacification; and, ultimately, blindness. The acute form
of the disease is more infectious than the cicatrical form.
 Two phases of the disease process exist: the active phase
and the cicatricial phase.
 The active trachoma phase resembles many other diseases in
which follicular conjunctivitis is a feature. Without
laboratory facilities, the diagnosis is solely based on the
clinical appearance of active trachoma in someone living in
a community where trachoma is endemic or suspected to be
endemic. However some patients with active trachoma are
relatively asymptomatic.
 The cicatricial phase has unique clinical features, which lead
to definitive diagnosis in most cases.
ACTIVE PHASE
 characterized by a mucopurulent keratoconjunctivitis.
 The conjunctival surface of the upper eyelid shows a
follicular and inflammatory response.
 The cornea may have limbal follicles, superior
neovascularization (pannus), and punctate keratitis.
 Infection with C trachomatis concurrently occurs in
other extraocular mucous membranes, commonly the
nasopharynx, leading to a nasal discharge.
 CICATRICAL PHASE

 Conjunctival scarring: alone tends to be asymptomatic,

though the associated disturbance of the architecture of
the tear film often leads to dry eye.
 Trichiasis causes an intensely irritating foreign body
sensation, as well as blepharospasm. Ultimately, it leads
to corneal scarring.
 Many patients self-epilate before their presentation.
 Corneal opacities or scars that cover any part of the pupil
impair the patient's vision.
COMPLICATIONS OF TRACHOMA
 Entropion
 Trachiasis,
 Ptosis,
 lacrimal and acessory lacrimal duct obstruction from
conjunctival scarring ,
 Dry eye,
 Corneal ulceration
 Corneal scaring,
 Bacterial infections,
 blindness
WHO SIMPLIFIED TRACHOMA GRADING SYSTEM

 The WHO grades trachoma into

 TF Trachomatous Inflammation – Follicular The presence of five
or more follicles in the upper tarsal conjunctiva
 TI Trachomatous Inflammation – Intense Pronounced
inflammatory thickening of the tarsal conjunctiva that obscures
more than half of the normal deep tarsal vessels
 TS Trachomatous Scarring The presence of scarring in the tarsal
conjunctiva
 TT Trachomatous Trichiasis At least one eyelash rubs on the
eyeball or evidence of recent removal of inturned eyelashes
 CO Corneal Opacity Easily visible corneal opacity over the pupil.
22 TRACHOMA

50
TRACHOMATOUS SCARRING
CHLAMYDIAL CONJUNCTIVITIS
 Treatment
 Oral doxycycline 100mg po bid x 3 weeks ( or erythromycin) vs Azithromycin 1g po x
3/7
 Topical erythromycin or tetracycline ointment 2 - 4 x/day
 Treat family members
 The WHO recommends 2 antibiotics for trachoma control: oral
Azithromycin and tetracycline eye ointment. Azithromycin eye drops
have also been shown to be very effective, but it is more expensive.
National trachoma control programs in a number of countries are
fortunate to be beneficiaries of a philanthropic donation of
azithromycin. Azithromycin is the drug of choice because it is easy
to administer as a single oral dose. Therefore, compliance is higher
than with tetracycline and can actually be measured
PREVENTION AND CONTROL
 For trachoma, treatment coupled with improved
sanitation to prevent reinfection is the best way to
control the disease. The WHO has developed the
SAFE strategy for trachoma control.
 S Surgery
 A Antibiotics
 F Facial washing
 E Environmental change
ADULT INCLUSION CONJUNCTIVITIS
 Also caused by Chlamydis trachomatis
 Infection is venerally transmitted instead of
from eye to eye
 Most common in young sexually active adult
with a history of GU infection probably
ongoing with Chlamydia trachomatis.
 Presents as chronic conjunctivitis with large
follicles and mucopurulent discharge and PAN
ADULT INCLUSION CONJUNCTIVITIS
Note the very enlarged follicles
 Management is same as for trachoma.
ALLERGIC CONJUNCTIVITIS
 Most common form of ocular allergic disease.
 Acute allergic conjunctivitis describes the abrupt and immediate response seen in
sensitized individuals after exposure to a particular allergen or sensitizing agent.
 A type 1 hypersensitivity response of the conjunctival mast cells mediated by
IgE.
 Types
 seasonal allergic conjunctivitis (SAC), which coincides with pollen blooms such as
ragweed, occurs mainly in the spring, or harmatan
 perennial allergic conjunctivitis (PAC),in which exposure may occur at any time
throughout the year (e.g., allergies to cat dander or dust mites).
 Vernal keratoconjunctivitis (VKC)
 Atopic keratoconjunctivitis (AKC)
 Giant papillart conjunctivitis (GPC)
ALLERGIC CONJUNCTIVITIS
 History;
 History of atopic disease, airborne allergens with type-I hypersensitivity reaction
 Intense itching,
 Possible history of allergen exposure,
 watery, stringy discharge.
 Signs;
 Normal visual acuity;
 thick stringy discharge
 diffusely injected conjunctiva;
 chemosis (bulging of the clear/injected conjunctival layer with fluid underneath,
 fine velvety papillae on tarsal conjunctiva, may develop giant cobblestone appearance
(vernal);
 clear cornea,
 no fluorescein stain;
 erythema and oedema to lids;
 normal pupil response;
 no preauricular lymph nodes palpable
ALLERGIC CONJUNCTIVITIS:

59
DIFFUSE PAPILLARY REACTION

Small papillae often look like grainy

redness of the upper lid
SIGNS AND SYMPTOMS
 Ocular itching remains the hallmark symptom
 tearing is also an exceedingly common complaint,
particularly after rubbing the eyes in response to
itching.
 Others are ocular burning, foreign-body sensation
or photophobia, though these are relatively rare.
 personal or family history of allergies. Concurrent
symptoms of allergic rhinitis, post-nasal drip, or
sinus congestion may be present, especially in SAC.
EXAMINATION
 variable conjunctival hyperemia
 chemosis.
 Ocular discharge is watery, though mucus may accumulate
in the fornices or collect on the lash margin in the form of
"crusts
 Eversion of the eyelids may reveal a fine papillary
response, particularly along the upper tarsal plate.
 Externally, the eyelids may be red, swollen and edematous,
with a pseudoptosis in pronounced cases.
 A palpable preauricular lymph node is noticeably absent
PATHOPHYSIOLOGY
 Allergic response is an over-reaction of the body's immune system to foreign
substances (allergens).
 The key component to the ocular allergic response is the mast cell. When mast cells
interact with specific allergens, the cell degranulates, causing discharge of chemical
mediators into the surrounding tissues.
 The primary chemical mediator released is histamine, which is responsible for
increased vascular permeability, vasodilation, bronchial contraction and increased
secretion of mucus. Other substances i.e. heparin, chymase, tryptase are also
released from mast cells.
 In severe or prolonged allergic reactions, a "late- phase" response may occur in
which cell membranes begin to break down into arachidonic acid, which is further
degraded to form prostaglandins, leukotrienes and thromboxane (powerful
mediators of inflammation).
 This late phase is far more common in disorders such as atopic and vernal
keratoconjunctivitis,
MANAGEMENT
 Primarily aimed at reducing symptoms and quelling any significant inflammation.
 The most effective treatment is elimination or avoidance of the potentially offending allergen, if
possible or practical.
 Artificial tear solutions serve to soothe, lubricate and flush or dilute the antigens
 Cold compresses and topical decongestants
 Decongestant solutions (containing one of the following: naphazoline, antazoline,
tetrahydrozaline or phenylephrine) are available as over-the-counter preparations, either alone or
in combination with a mild topical antihistamine
 Antihistamines, e.g. Livostin (0.05% levocabastine hydrochloride, and Emadine (0.05%
emedastine dif umarate);
 Mast cell stabilizers, e.g. Opticrom (4% cromolyn sodium), Alomide (0.1% lodoxamide
tromethamine), Alocril (2% nedocromil sodium), and Alamast (0.1% pemirolast postassium);
 Antihistamine/mast cell stabilizer combinations, e.g. Patanol (olopatadine hydrochloride), Zaditor
(ketotifen fumarate), and Optivar (0.05% azelastine hydrochloride)
 Corticosteroids, e.g. Alrex (0.2% loteprednol etabonat), Vexol (1% rimexolone) and Pred Forte
(1% prednisolone acetate)
 Non-steroidal anti-inflammatory agents (NSAIDs), e.g. Acular (0.5% ketorolac).
SAC -SEASONAL ALLERGIC CONJUNCTIVITIS

 Most common form of ocular allergy

 Associated with seasonal rhinitis (hay fever) and
sensitization/exposure to airborne allergens such
as ragweed and grass pollen.
 Occurs often in spring and fall seasons, when
levels of pollens are at their peak.
 It accounts for half of ocular allergies, affecting
10 to 30% world population
 Symptoms include
 redness,
 itching,
 burning and watery eyes,
 dryness and irritation,
 mucoid discharge.
 Signs are
 bulbar conjunctival hyperaemia,
 Oedema of eyelid
 Chemosis
 mild watery discharge,
 papillary hypertrophy of upper palpebral conjunctiva (redness & roughness),
TREATMENT
 Avoid allergens
 Cool compresses
 Artificial tears
 Systemic and/or topical antihistamines
 Topical mast cell stabilizer (Patanol, Alomide, Cromolyn)
 Topical NSAID (Acular, Voltaren
 Oral antihistamines should be used when patient has
significant nasal problems eg. Cetirizine(Zyrtec),
Loratadine(Claritin).
PAC -PERENNIAL ALLERGIC CONJUNCTIVITIS

 Although less intense, is more of a chronic

condition.
 usually involves sensitization to antigens that are
present year round, such as dust mites, animal
dander, mould, and air pollutants.
 affects about 1% of allergy sufferers and causes
year round disease due to dust, animal skin and
hair, mould, fungus et
 Signs and symptoms are very similar to SAC
although chronic and less severe.
 It continues throughout year with seasonal
exacerbation. Seasonal peaks are due to heat and
humidity.
 Management; Same as SAC
VKC –VERNAL KERATOCONJUNCTIVITIS

 VKC is a chronic, bilateral inflammation of the superior

and limbal palpebral conjunctiva.
 Onset typically occurs in children between ages 3 and
25.
 Males typically are affected more than females. (gender
ratio 2/1),
 occurs more in warmer climates such as Africa, India,
and some parts of Asia.
 often, but not always, resolves upon entrance into
puberty.
SIGNS AND SYMPTOMS
 severe itching with thick, ropy mucoid discharge.
 tearing, burning, photophobia, chemosis, intense bilateral pruritus of the eyelids,
periorbital area, and conjunctiva
 history of allergies or infantile eczema.
 Lots of papillae in conjunctiva as well as limbus
 large conjunctival papillae on the back of the superior tarsus; raised Horner-Trantas
dots (gelatinous, white clumps of degenerated eosinophils usually located at the
superior limbus);
 areas of superficial punctate keratitis (SPK)
 in severe cases, well-demarcated, sterile corneal shield ulcers, located superiorly.
 No specific allergen has been identified at the origin of VKC.
 Children who have VKC have a higher incidence of keratoconus than the general
population Y
 You can differentiate VKC from atopic keratoconjunctivitis (AKC) based on age,
location, dermatitis and lack of seasonal variability.
VERNAL CONJUNCTIVITIS
Papillae can become very large and flatten in chronic
vernal inflammation
21 VERNAL CONJUNCTIVITIS

73
LIMBAL PAPILLAE
These are degenerated eosinophils at
corneal scleral margin.
 Atopic conjunctivitis

 Severe bilateral allergic inflammation of the conjunctiva, eyelids, and cornea,

 This condition is chronic, sight threatening, and has no geographical prevalence.
 Resembles VKC but occurs predominantly in adults between 20 and 50 years
old.
 Symptoms of AKC usually become more severe in the winter season
 Rarer and more serious than VKC.
 Associated with a history of atopic dermatitis of face, neck and flexure folds
 Often a history and/or family history of asthma, rhinitis or hay fever.
 Looks like VKC but with more corneal involvement, leading to scarring, shield
ulcers and vascularisation
ALLERGIC CONJUNCTIVITIS
 Treatment
 Avoid allergens
 Cool compresses
 Artificial tears
 Systemic and/or topical antihistamines
 Topical mast cell stabilizer (Patanol, Alomide, Cromolyn)
 Topical NSAID (Acular, Voltaren)
 Vernal and Atopic occur rarely in people with FH of allergy.
Vernal affects young males 5-20 in spring summer and
improves in adulthood wheras atopic tends to be chronic
needing long term Mast cell inhibitors and steroids.
 Major Differentiating Factors Between VKC and AKC

Characteristics VKC AKC

Age at onset Generally presents at a younger age than Usually adults, over 20 years

AKC. I.E. 3-20 years

Sex Males are affected preferentially. No sex predilection

Seasonal variation Typically occurs during spring months Generally perennial

Discharge Thick mucoid discharge Watery and clear discharge

Conjunctival scarring - Higher incidence of conjunctival

scarring

Horner-Trantas dots Horner-Trantas dots and shield ulcers are Presence of Horner-Trantas dots is rare.

commonly seen.

Corneal Not present Deep corneal neovascularization tends to

neovascularization develop
GIANT PAPILLARY CONJUNCTIVITIS
 Often seen in CL wearers.
 10x more common with soft lenses than with hard.
 May also occur with protruding sutures post operatively
or in prosthetic eyes.
 Bilateral, mild to moderate conjunctival
hyperemia,greater superiorly,
 small to giant papillae on the palpebral conjunctiva, esp
upper lid.
 Symptoms from none to moderate none specific irritation
and itching
GIANT PAPILLAE
 Papillae can merge together to form giant papillae of 2-3mm
diameter in chronic conditions ( especially in CL wearers and
chronic allergic disease ie. Vernal conjunctivitis or superior
limbic keratoconjunctivitis
MANAGEMENT
 Cleanse lens surface,
 Increase use of enzymatic cleaners,
 Replace old or poor quality lenses,
 Oral and topical antihistamines QDS x4weeks
 In severe cases, oral antiinflammatory.
 If recurrence continues, discontinue lens use.
SUPERIOR LIMBAL KERATITIIS
 Associated with thyroid dysfunction in middle
aged women most commonly.
IS THERE ANY DISCHARGE?
 Acute bacterial conjunctivitis will always have a
yellow or creamy mild purulent or mucopurulent
discharge which tends to stick the eyelids
together on waking and crusts.
 Serous or watery discharge usually indicates a
viral or toxic aetiology
 Mucoid white or stringy discharge is associated
with dry eye and allergic causes and early
chlamydial conjunctivitis
INFLAMMATORY CONJUNCTIVITIS
 Reiters is usually in men who develop arthritis
and conjunctivitis following an attack of
Urethritis or Dysentry
 Oculocutaneous patients develop a severe
conjunctivitis which scars mucous glands
creating a severe dry eye
 And lid adhesions and corneal scarring..
TOXIC CONJUNCTIVITIS
 History
 exposure to toxic foreign substances. Ie. New topical
drugs , chronic use of topical drugs, cosmetis, etc.
 Conjunctival injection, chemosis, itching,
burning,tearing, follicular conjunctivitis, more on
lower lid.
 Diagnosis is based primarily on history.
MANAGEMENT
 Stop offending agent
 Cold compress QID
 Topical mast cell stabilizers
 antihistamines
SUBCONJUNCTIVAL HEMORRHAGE
 A deep red colour, obscuring the underlying sclera.
 History;
 Spontaneous; trauma;
 occasionally history of Valsalva maneuver, coughing or sneezing;
 usually asymptomatic;
 occasional mild discomfort, or popping sensation at onset;
 possible association with systemic HTN or anticoagulant medication.
 Exam
 Diffuse or localised area of blood under conjunctiva, often sectorial;
 cornea clear, no fluorescein stain;
 normal visual acuity and pupil response;
 possible systemic HTN; BP should be measured in all cases and managed.
 Treatment
 Reassurance
 Cold compresses
 Artificial tears
 Resolves in 10-14 days
SUBCONJUNCTIVAL HEMORRHAGE
EPISCLERITIS
 75% idiopathic; young adults
 Others: collagen vascular disease, rosacea, gout, HZV, thyroid
disease, atopy, syphilis
 History
 Sectoral redness
 Painless or acute onset of dull ache
 Normal visual acuity or mild blurring
 Recurrent episodes
 Exam
 Sectoral or diffuse redness of one or both eyes
 Engorged episcleral vessels
 Nodule may be seen over redness
 No discharge or corneal involvement
EPISCLERITIS
EPISCLERITIS
 Assessment
 Phenylephrine (2.5%) test: blanching of episcleral vessels
 Treatment
 Usually self-limited in 2-3weeks
 Cool compress
 Artificial tears
 Topical NSAID, vasoconstrictor
 Oral NSAID
 Topical steroids
SCLERITIS
 50% idiopathic
 50% with systemic disease (RA, SLE, polyarteritis nodosa, Wegener’s,
relapsing polychondritis, ankylosing spondylitis, GCA, gout, TB, HZV,
syphilis)
 History;
 Severe ocular pain and redness (prominent feature)
 Tearing,photophobia
 reduced visual acuity may be present;
 past medical history should be reviewed for any known systemic associations such as
connective tissue disorders including rheumatoid arthritis, Wegener's granulomatosis,
SLE etc
 Exam;
 deep scleral vessel engorgement,
 pain on ocular palpation;
 Sectoral or diffuse scleral erythema, thinning with bluish hue, edema, possible nodules
or necrosis
 Possible corneal and intraocular inflammation
SCLERITIS
SCLERITIS
 Assessment
 2.5% phenylephrine test: deep episcleral and scleral vessels do
not blanch
 Scleral vessels cannot be moved with a cotton swab
 Treatment
 Systemic evaluation by physician or rheumatologist
 Ophthalmology referral
 Oral NSAID or corticosteroid
 Topicals usually not effective
 Possible cytotoxic
CONJUNCTIVAL DEGENERATION
PINGUECULAR

 a common type of conjunctival degeneration

 Yellowish, slightly raised nodule on both sides of
bulber conjunctiva, adjacent to the cornea.
 More common on nasal side.
 Rarely increases in size, but may get inflammed
from time to time.
 No treatment required, mild decongestant may be
used if hyperemic.
 Pingueculae are thought to arise as a result of the effects
of environmental irritants such as wind and dust and are
associated with UV-light exposure and aging.
 It is bilateral and generally free of blood vessels.
 The nodule consist of hyaline and yellow elastic tissue
 . Risk Factors include UV-light exposure, wind, dust,
outdoor lifestyle and proximity to the equator. age,
smoking, working outdoors, diabetes mellitus.
 Most pingueculae are asymptomatic but may cause
ocular surface irritation including foreign body sensation,
tearing, burning or itching.
 Some may find these lesions cosmetically unacceptable.
PTERYGIUM
 Thick fleshy triangular mass growing from
conjunctiva unto the cornea.
 Benign Fibrovascular growth on the conjunctiva,
usually nasal and bilateral.
 Apex is usually towards cornea,
 Richly vascularized and hyperemic
 May press on cornea and cause irregular astigmatism
 May grow in pupillary region and obstruct visual axis.
PTERYGIUM

 The leading edge of this tissue often displays a

fine, reddish-brown iron deposition line
(Stocker’s line).
 More than 90% of pterygia occur nasally

 More common in warm dry climate

 UV light plays a major role

MANAGEMENT
 Management for asymptomatic or mildly irritative pterygia
involves UV-blocking spectacles and liberal ocular
lubrication.
 Patients should be advised to avoid smoky or dusty
 More inflamed or irritated pterygia may be treated with
topical corticosteroids (e.g., 1% prednisolone acetate or 0.5%
loteprednol etabonate q.i.d. for several days).
 Surgical excision of pterygia is indicated for unacceptable
cosmesis, significant induced astigmatism, threats to
peripheral corneal hydration and significant ingrowth to the
visual axis.
CONCRETIONS

 Very commonly occurring chalky white/yellow deposits

which are usually found on the inferior tarsal
conjunctiva. They are more common in the elderly and in
those with meibomian gland disease
 usually asymptomatic (unless very large when a foreign
body sensation is experienced), well-defined deposits.
 Management: they are left alone unless symptomatic
when they can be removed under topical anaesthetic,
with a needle.
RETENTION CYST

 Very common, benign lesion.

 Asymptomatic (unless very large) clear fluid-
filled lesion occurring anywhere in the
conjunctiva.
 Management: they are left alone unless
symptomatic when they can be removed, under
topical anaesthetic, with a needle.
CICATRICIAL PEMPHIGOID

 An idiopathic subepidermal blistering and scarring autoimmune condition

occurring in the mucocutaneous parts of the body. It always occurs
bilaterally (not necessarily symmetrically) but isolated conjunctival
involvement is not common.
 : typically this occurs in the middle-aged patient, and is more common in
females. Nonspecific viral conjunctivitis-type symptoms occur initially with
progressive appearance of papillae, bullae and eventually fibrosis. Diffuse
hyperaemia and oedema persist during the latent phases of the condition.
 Management: topical steroids, subconjunctival mitomycin C and silicone
contact lenses are used initially. Most patients will also benefit from
systemic steroids, dapsone ± cytotoxic agents. Surgery is reserved for those
with complications such as cicatricial entropion or serious corneal
complications
STEVENS-JOHNSON SYNDROME

 An acute, severe blistering disease of unknown exact aetiology

(hypersensitivity to drugs and viral infections appear to be precipitating
factors).
 A vasculitis affects the skin and mucous membranes (90% of patients
have conjunctival involvement).
 occurs in young, previously healthy individuals (more often males) who
present with fever, malaise, sore throat (± a cough) and arthralgia. A mild
conjunctivitis is noted in all but a handful of patients who experience a
severe membranous or pseudomembranous conjunctivitis.
 Management: topical and systemic steroids (± antivirals if herpes is
suspected to have triggered it), lubricants and possibly surgical
intervention where the vasculitis and complications such as severe
scarring have occurred