DISEASES OF THE CONJUNCTIVA

AND CORNEA
DR OGO L.I
Ophthalmology Department, BSUTH
ANATOMY OF THE CONJUNCTIVA
• A transparent mucous membrane that lines
the inner surface of the eyelids and the
anterior surface of the globe, terminating at
the corneoscleral limbus.
• Richly vascular
• Supplied by the anterior ciliary and palpebral
arteries.
ANATOMY OF THE CONJUNCTIVA
• Anatomically divided into:
Palbebral conjunctiva
Forniceal conjunctiva
Bulbar conjunctiva
• Has a dense lymphatic network with drainage
to the preauricular and submandibular nodes
corresponding to that of the eyelids.
 ANATOMY OF THE CONJUNCTIVA
HISTOLOGY
• Epithelium is non keratinizing and around five
cell layers deep
• Stroma (substantia propia) which consists of
richly vascularized loose connective tissue.
• Conjunctiva Associated Lymphoid Tissue
(CALT) is critical in the initiation and regulation
of ocular surface immune responses.
 BACTERIAL CONJUNCTIVITIS
Acute bacterial conjunctivitis
Common and usually self limiting
Caused by direct contact with infected
secretions
Most common isolates are Streptococcus
pneumoniae, Staphylococcus aureus,
Haemophilus influenza and Moraxella
catarrhalis.
• ACUTE BACTERIAL CONJUNCTIVITIS
• Neisseria gonorrhoeae,
• Neisseria meningitidis ( rare and affects
children)
 ACUTE BACTERIAL CIONJUNCTIVITIS
CLINICAL FEATURES
 Symptoms- acute onset of redness, grittiness,
burning and discharge.
• Involvement is usually bilateral although one
eye may become affected 1-2 days before the
other.
• Sticking of the eyelids on waking
ACUTE BACTERIAL CONJUNCTIVITIS
• Systemic symptoms may occur in patients with
severe conjunctivitis associated with
gonococcus, meningococcus, Chlamydia and
H. influenzae.
• Progression to systemic involvement should
always be borne in mind in affected children.
ACUTE BACTERIAL CONJUNCTIVITIS
 Signs- variable and depend on severity of
infection
• Eyelid edema and erythema
• Conjunctival hyperemia
• Discharge- may be initially watery, mimicking
viral conjunctivitis, but rapidly becomes
mucopurulent
• Hyper acute purulent discharge- gonnococcal or
meningococcal conjunctivitis.
ACUTE BACTERIAL CONJUNCTIVITIS
• Superficial punctate epithelial erosions are
common
• Peripheral corneal ulceration rapidly
progressing to corneal perforation –
gonococcal and meningococcal infection.
• Lymphadenopathy usually absent except in
severe gonoccocal and meningoccocal
infection.
ACUTE BACTERIAL CONJUNCTIVITIS
ACUTE BACTERIAL CONJUNCTIVITIS
INVESTIGATIONS
• Not performed routinely but may be indicated
in the following situations:
• Binocular conjunctival swabs and scrapings-
done in severe cases to exclude gonnococcal
and menningococcal infection.
• Culture for N. gonorrhoea- enriched media
used eg Chocolate agar or Thayer-Martin
ACUTE BACTERIAL CONJUNCTIVITIS
INVESTIGATIONS
• Polymerase Chain Reaction (PCR) may be
required for less severe cases that fail to
respond to treatment, particularly to rule out
the possibility of chlamydial and viral
infection.
ACUTE BACTERIAL CONJUNCTIVITIS
TREATMENT
• About 60% resolve within 5 days without
treatment.
• Topical antibiotics are frequently administered
to speed up recovery and prevent re-infection
and transmission.
• Eg Chloramphenicol, aminoglycosides
(gentamicin, neomycin, tobramycin)
ACUTE BACTERIAL CONJUNCTIVITIS
 TREATMENT
• Quinolones – Ciprofloxacin, Ofloxacin
levofloxacin, lomefloxacin, gatifloxacin,
moxifloxacin, besifloxacin
• Macrolides- Erythromycin, azithromycin
• Polymyxin B
• Fusidic acid
• Bacitracin
ACUTE BACTERIAL CONJUNCTIVITIS
• Gonoccocal and meningococcal conjunctivitis
should be treated with a quinolone,
gentimicin, chloramphenicol or bacitracin as
well as systemic therapy.
• Systemic antibiotics eg Ceftriazone,
quinolones, macrolides, amoxicillin+ clavulanic
acid, intramuscular benzylpenicillin.
ACUTE BACTERIAL CONJUNCTIVITIS
OTHER CARE
• Irrigation to remove excessive discharge
• Contact lens wear should be discontinued
while on topical antibiotics and also until at
least 48 hours after complete resolution of
symptoms.
• Hand washing and avoidance of towel sharing
to reduce the risk of transmission.
 ADULT CHLAMYDIAL CONJUNCTIVITIS
• An oculogenital infection
• Caused by Serovariants D-K of Chlamydia
trachomatis
• Affects 5-20% of sexually active young adults in
Western countries.
• Transmission is by autoinoculation from genital
secretions.
• Eye to eye spread probably accounts for about
10%
 ADULT CHLAMYDIAL CONJUNCTIVITIS
• Most common cause of non gonoccocal
urethritis in males
• Infection may progress from urethritis to PID
in females.
• Incubation period is about a week
 ADULT CHLAMYDIAL CONJUNCTIVITIS
Clinical features
• Symptoms: subacute onset of unilateral or
bilateral redness, watering and discharge.
• Signs: Watery or mucopurulent discharge
• Tender preauricular lymphadenopathy
• Large follicles in the inferior fornix. May
involve the upper tarsal conjunctiva
ADULT CHLAMYDIAL CONJUNCTIVITIS
• Superficial punctate keratitis
• Perilimbal subepithelial corneal infiltrates may
appear after 2-3 weeks
• Chronic cases have less prominent follicles and
commonly develop papillae
• Conjunctival scarring and superior corneal
pannus are common
ADULT CHLAMYDIAL CONJUNCTIVITIS
 ADULT CHLAMYDIAL CONJUNCTIVITIS
INVESTIGATIONS
• Swabs for bacterial culture and serology in
some cases
• Giemsa staining for basophilic intracytoplasmic
bodies.
• PCR (Investigation of choice)
• Direct immunofluorescence –detects free
elementary bodies with about 90% sensitivity
and specificity
 ADULT CHLAMYDIAL CONJUNCTIVITIS
• Enzyme Immunoassay for direct antigen
detection
• McCoy cell culture is highly specific
 ADULT CHLAMYDIAL CONJUNCTIVITIS
TREATMENT
• Empirical treatment given if the clinical picture
is convincing pending investigation results or if
investigations are negative.
• Refer to genitourinary specialist
• Topical antibiotics eg erythromycin or
tetracycline ointment for rapid relief of ocular
symptoms. But are insufficient alone.
 ADULT CHLAMYDIAL CONJUNCTIVITIS
• Systemic Rx: Azithromycin(Rx of choice)
Doxycyline (relatively contraindicated in
pregnancy/breastfeeding and children below
12 years of age)
Alternatives: Erythromycin, amoxicillin and
ciprofloxacin.
 ADULT CHLAMYDIAL CONJUNCTIVITIS
OTHER MEASURES
 Abstinence from sexual contact until completion
of treatment
 Apply other precautions for infective
conjunctivitis
• NB: Symptoms commonly take weeks to settle.
• Corneal infiltrates and follicles can take months
to settle due to prolonged hypersensitivity
response to chlamydial antigen
 NEONATAL CONJUNCTIVITIS
• Also called ophthalmia neonatorum.
• Defined as conjunctival inflammation
developing within the first month of life.
• Most common infection of any kind in
neonate, occurring in up to 10%.
• Results from infection transmitted from
mother to infant during delivery
NEONATAL CONJUNCTIVITIS
CAUSES
• Organisms acquired during vaginal delivery:
Chlamydia trachomatis (most common cause), N.
gonorrhoeae, herpes simplex virus (typically HSV-2)
• Staphyloccoci, streptococci, H. influenzae and
various gram negative organisms
• Topical preparations used as prophylaxis against
infection
• Congenital nasolacrimal duct obstruction
 NEONATAL CONJUNCTIVITIS
DIAGNOSIS
• Timing of Onset is important
• Chemical irritation: first few days
• Gonococcal: first week
• Staphylococci and other bacteria: end of the
first week
• HSV: 1-2 weeks
• Chlamydia: 1-3 weeks
 NEONATAL CONJUNCTIVITIS
HISTORY
• Instillation of a prophylactic chemical
preparation
• Parental symptoms of STI
• Recent conjunctivitis in close contacts
• Features of systemic illness in the child:
pneumonitis, rhinitis and otitis in chlamydial
infection, skin vesicles and features of
encephalitis in HSV
 NEONATAL CONJUNCTIVITIS
• Prior persistent watering without inflammation
may indicate an uncanalized nasolacrimal duct.
• Signs: Mildly sticky eye in staphylococcal infection
or with delayed nasolacrimal duct canalization.
• Discharge: watery in chemical and HSV infection,
mucopurulent in chlamydial infection, purulent in
bacterial infection and hyperpurulent in
gonococcal conjunctivitis.
 NEONATAL CONJUNCTIVITIS
• Severe eyelid edema
• Eyelid and periocular vesicles in HSV infection.
• Corneal examination is mandatory especially if
gonococcal infection is suspected, as
ulceration with rapid progression is common.
NEONATAL CONJUNCTIVITIS
 NEONATAL CONJUNCTIVITIS
 INVESTIGATIONS
• Depend on the clinical picture
• Results of any parental prenatal testing for STI
should be obtained
• Conjunctival scrapings for PCR (C. trachomatis
and HSV)
• Conjunctival swabs for bacterial culture
 NEONATAL CONJUNCTIVITIS
TREATMENT
• Prophylaxis: A single instillation of povidone
iodine 2.5% solution is effective against
common pathogens.
• Erythromycin 0.5% or tetracycline 1% ointment
• Silver nitrate 1% solution in conjunction with a
single intramuscular dose of benzylpenicillin
when maternal infection is present.
 NEONATAL CONJUNCTIVITIS
• Mild conjunctivitis: investigation is often
unnecessary. Rx with broad spectrum topical
antibiotics eg chloramphenicol, erythromycin,
fusidic acid ointment.
• Moderate to severe cases: oral erythromycin,
broad spectrum topical antibiotic eg
chloramphenicol, erythromycin or bacitracin for
gram positive organisms, neomycin, ofloxacin or
gentimicin for gram negative organisms.
 NEONATAL CONJUNCTIVITIS
• Severe conjunctivitis requires hospital admission.
Empirical topical treatment eg erythromycin to
minimise ocular risk from gonococcal infection.
• Parenteral ceftriazone is also given in severe cases.
• Chlamydial infection: Oral erythromycin
• Gonnococcal conjunctivitis: saline irrigation to
remove excessive discharge; administer a systemic
third generation cephalosporin and topical
treatment.
NEONATAL CONJUNCTIVITIS
• HSV: High dose aciclovir
• Paediatric specialist involvement is mandatory
when systemic disease may be present.
• Genitourinary referral for the mother and her
sexual contacts.
• The neonate should be screened for other STIs
 VIRAL CONJUNCTIVITIS
• Most frequent causative agent is the
adenovirus (90% of cases)
• Transmission is by contact with respiratory or
ocular secretions, including formites such as
contaminated towels.
VIRAL CONJUNCTIVITIS
SIGNS
• Eyelid edema
• Lymphadenopathy ( tender pre- auricular)
• Conjunctival hyperemia, papillae and follicles
• Keratitis
• Anterior uveitis
• Molluscum contagiosum: pale waxy umbilicated
nodule on the lid margin associated with follicular
conjunctivitis and mild watery and mucoid discharge.
VIRAL CONJUNCTIVITIS
INVESTIGATIONS
• Generally unnecessary but should be
considered if diagnosis is in doubt or there is
failure of resolution.
• Giemsa stain: shows predominantly
mononuclear cells
• PCR
• Viral culture
• Serology(rarely used)
VIRAL CONJUNCTIVITIS
TREATMENT
• No antiviral agent with clinically useful activity
against adenovirus has yet been produced.
• Symptoms may resolve spontaneously with 2-3
weeks of infection
• Topical antibiotics if secondary bacterial infection is
suspected.
• Topical steroids are used with caution as they
suppress inflammation and may enhance viral
replication.
VIRAL CONJUNCTIVITIS
• Other measures
• Good hand hygiene and cleaning of
instruments and clinical surfaces after
examination of an infected patient (Sodium
hyopochlorite, povidone iodine)
• Discontinuation of contact lens wear until
resolution of symptoms.
VIRAL CONJUNCTIVITIS
• Topical antihistamines and vasoconstrictors for
symptomatic relief
• Artificial tears for symptomatic relief.
 ALLERGIC CONJUNCTIVITIS
• A Type I hypersensitivity reaction
• Subtypes include:
• Acute allergic conjunctivitis
• Seasonal and perennial allergic conjunctivitis
• Vernal keratoconjunctivitis
• Atopic keratoconjunctivitis
 VERNAL KERATOCONJUNCTIVITIS(VKC)
• A recurrent bilateral disorder
• Relative common in warm climates
• Primarily affects boys and onset is generally
from the age of 5 years onwards.
• Remission occurs in the late teens in 95% of
cases although the remainder develop AKC.
VERNAL KERATOCONJUNCTIVITIS (VKC)
• SYMPTOMS
• Intense itching associated with lacrimation,
photophobia, foreign body sensation, burning
and thick mucoid discharge, increased
blinking.
• Eyelid disease is usually mild.
 ATOPIC KERATOCONJUNCTIVITIS(AKC)
• A rare bilateral disease
• Typically develops in adulthood ( peak
incidence 30-50 years) following a long history
of atopic dermatitis (eczema)
• Asthma is extremely common
 ATOPIC KERATOCONJUNCTIVITIS (AKC)
• Symptoms are similar to those of VKC but
more severe and unremitting
• Eyelids: erythema, dryness, scaliness and
thickening, excoriation
• TREATMENT OF VKC AND AKC
General measures
• Avoidance of allergen
• Cool compress
• Lid hygiene
• Bandage contact lens wear to aid healing of
persistent epithelial defects.
 TREATMENT OF VKC AND AKC
LOCAL TREATMENT
• Mast cell stabilisers eg Na cromoglycate,
nedocromil sodium, lodoxamide
• Topical antihistamines eg epinastine,
emedastine
• Combined antihistamine and vasoconstrictor
eg antazoline + xylometazoline
 TREATMENT OF VKC AND AKC
• NSAIDS
• Topical steroids
• Antibiotics
Systemic treatment
• Oral antihistamines eg loratadine
• Antibiotics eg Doxycycline
• Immunosuppressive agents eg steroids
Surgery
DEGENERATIONS OF THE CONJUNCTIVA
 PINGUECULA
• A common asymptomatic elastotic degeneration of the
conjunctival stroma
• A yellow-white mound or aggregation of smaller mounds
is seen on the bulbar conjunctiva adjacent to the limbus.
• Limbal barrier to extension is intact, though
transformation can occur
• Common in hot climates
• Caused by actinic damage as a response to UV exposure
PINGUECULUM

Pingueculum
PINGUECULUM
PINGUECULUM RX
• Topical lubrication for irritation
• Short course topical steroids for pingueculitis
• Excision- for cosmetic reasons or for
significant irritation
• Thermal laser ablation
 PTERYGIUM
• A triangular fibrovascular subepithelial
ingrowth of degenerative bulbar conjunctival
tissue over the limbus onto the cornea.
• Develops in patients living in hot climates
• May represent a response to UV exposure and
to other factors eg chronic surface dryness.
• Histologically similar to a pingueculum
PTERYGIUM
• Shows elastotic degenerative changes in
vascularised subepithelial stromal collagen.
• In contrast to pingueculae, pterygia encroach
unto the cornea, invading the bowmans layer.
PTERYGIUM
SYMPTOMS
• Growth
• Grittiness
• Intermittent inflammation
• Reduced vision
SIGNS
• A triangular growth consisting of a cap, a head
and a body.
PTERYGIUM
PTERYGIUM
TREATMENT
• Sunglasses to reduce UV exposure in order to
decrease the growth stimulus
• Surgery:
o Pterygium excision with conjunctival autografting
o Bare sclera technique (associated with a high rate of
recurrence)
o The risk of recurrence can be reduced by using either
a conjunctival autograft or by applying mitomycin C to
the operation site.
 DISEASES OF THE CORNEA

ANATOMY
• The cornea is a transparent avascular structure
which is responsible for two thirds of the
refractive power of the eye.
• Highly innervated
• Consists of 5 layers: epithelium, bowman layer,
corneal stroma, descemet membrane,
endothelium
 SIGNS OF CORNEAL DISEASE
• Punctate epithelial erosions
• Punctate epithelial keratitis
• Subepithelial infiltrates
• Superficial puctate keratitis
• Epithelial edema
• Ulceration
• Melting
• Vascularisation
KERATITIS
• Inflammation of the cornea
• Examples
• Bacterial keratitis caused by Staph aureus, Staph
epidermidis etc
• Fungal keratitis caused by candida, fusarium,
aspergillus
• Viral keratitis eg Herpes zoster ophthalmicus (shingles)
caused by VZV; herpes simplex keratitis
• Protozoan keratitis eg acanthamoeba keratitis
(frequently associated with contact lens wear)
Loss of lustre in mild corneal edema
Punctate epithelial erosions stained with
fluorescein dye
Herpes Zoster Ophthalmicus (shingles)
HZO dendritic ulcer with tapered ends
HSV keratitis- dendritic ulcer with terminal
buds
CORNEAL ULCER
• Refers to tissue excavation associated with an
epithelial defect, usually with infiltration and
necrosis
• Ulcers start as keratitis (inflammation of the
cornea) after a break in the corneal epithelium
permits organisms to enter it.
CORNEAL ULCER
CLINICAL FEATURES
• Depends on the cause
• Pain
• Photophobia
• Lacrimation
• Conjunctival hyperemia
• Varying degree of visual loss
• Epithelial defect which stains with fluorescein dye.
CORNEAL ULCER
• CAUSES
• Infective causes eg bacteria (Staph aureus,
Staph epidermidis etc) , fungi(aspergillu,
fusarium etc), viruses(HSV, VZV)
protozoa(acanthamoeba esp in contact lens
wearers)
• Trauma
• Autoimmune diseases
Corneal ulcer

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CORNEAL ULCER
INVESTIGATIONS
• Corneal scrapings for m/c/s
• Gram staining
TREATMENT
• Hospital admission for patients who are not likely
to comply or self administer medications. Also
considered for aggressive diseases.
• Discontinue contact lens wear
• Eye shield
• Topical and systemic antibiotics/ antivirals if
viruses are involved
• Subconjunctival antibiotics/ antifungals
• mydriatrics
CORNEAL ULCER
COMPLICATIONS
• Visual deterioration and loss
• Endophthalmitis
• Meningitis
• Corneal perforation
• Corneal opacity
Corneal perforation
Corneal opacity
Conclusion
• Prompt diagnosis and appropriate treatment
of conjunctival and corneal diseases is key.
• This would prevent worsening of symptoms,
visual loss and other complications.
• THANK YOU