*Bulbar conjunctiva

*fornix

*medial semilunar fold

*palpebral conjunctiva (tarsal conjunctiva)

*conjunctival epithelium :

*stratified cuboidal (over tarsus)

*columnar (over fornix)

*squamous (over globe)

*Substansia propia :

*adenoid layer

*fibrous layer

*Never free from microorganism

*Bacteria do not propagate (proliferate) easily, due to :

*relatively low temperature (exposure)

*evaporation lacrimal fluid

*bacteriostatic

*lysozyme enzyme

*mechanic (washing)

Microorganism that could be found in normal conjunctival sac :

*Staph. epidermis

*Staph. aureus

*Micrococcus sp

*Corynebacterium sp

*Propionibacterium acnes

*Streptococcus sp

*Haemophylus influenza In children

*Moraxella sp

*Enteric gram (-) bacilli

*Bacilus sp

*Anaerobic bacteria

*Yeast

*Filamentous fungi

*Demodex sp

*The establishment and severity of infection are influenced by the interplay between the following factors :

*Virulence of the pathogen

*Size and route of the inoculums

*Presence or absence of risk factors that compromise host defenses

*Nature of the host’s immune and inflammatory response

*Parson’s

*Inflammations

*Infection

*Allergy

*Degenerative changes

*Symptomatic condition

*Cyst and Tumors

*General Ophthalmology

*Conjunctivitis

*infection

*allergy

*autoimmune

*chemical / irritates

*unknown cause

*Degenerative disease

*Miscellaneous disorders

*Tumors

*Ophthalmologic examination, usually by inspection :

*magnifying devices (loupe)

*flashlight / penlight / slitlight

*do not forget to everse superior eye lid

*Clinical terms :

*hyperemia = focal / diffuse dilatation of subepithelial plexus of conjunctival blood vessels

*chemosis = conjunctival edema

*tearing = excess tears from increased lacrimation or impaired lacrimal outflow

*discharge = exudates on the conjunctival surface: serous, mucoid, mucopurulent, purulent

*Papillla = dilated conjunctival blood vessel, surrounded by edema and inflammatory cells

*Follicle = focal lymphoid nodule with accessory vascularization

*Pseudomembrane = inflammatory coagulum on conjunctival surface that doesn’t bleed during removal

*Membrane = inflammotory coagulum on the conjunctival surface that bleeds when stripes

*Granuloma = nodule of chronic inflammatory cells with fibrovascular proliferation

*Phlyctenule = a nodule of chronic inflammatory cells, often at near or the limbus

*Punctate epithelial erosion = loss of individual epithelial cells in a stippled pattern

*Epithelial defect = focal ara of epithelial loss

*inflammation of the conjunctiva :

*origin :

*infection

*allergy

*hyperemia

*secret

*Papillary conjunctivitis: allergic, bacterial

*Follicular conjunctivitis: adenovirus, mollusucum contangiosum, chlamydial, HSV, drug-induced

*Conjunctival pseudomembrane or membrane: severe viral/bacterial, stevens-jhonson syndr, chemical burn

*Conjunctival granuloma: cat-scratch disease, sarcoidosis, foreign-body reaction

*Conjunctival erosion or ulceration: stevens-jhonson syndrome, cicatrical pemphigoid, graft-host disease,

*Secret :

*serous : viral

*mucous, mucopurulent : bacteria

*purulent : beware of gonococcus

bacterial investigation by gram

histological investigation by giemsa

*Acute :*serous

*catarrhal

*mucopurulent

*purulent

*membranous

*chronic :*simple chronic conjunctivitis

*angular conjunctivitis

* follicular conjunctivitis

*Hyperemia that associated with a mucous discharge ---> gums lid together (especially in the morning)*The whole conjunctiva is a fiery red (‘pink eye’)*Reaches its height in 3 - 4 days*Rare complication, but cornea abrasion may occur*Etiology :*Staphylococci (most common)*Haemophilus aegyptius*Pneumococcal

*Accompanies exanthema such as measles and scarlet fever

*Treatment :*bacteriostatic drop

*the eyes should not be bandaged

*dark google should be worn if photophobia is present

*care must be taken due to contagious disease

*Prognosis :*Most of cases are good

*Neglected cases are treated as chronic conjunctivitis

*Occurs in two forms :*Babies : ophthalmia neonatorum*Adult : conjunctivitis

*Main and most dangerous etiology: gonococcus, N. gonorrhea*Direct infection from genital*Clinical finding :*Swelling of the lids and conjunctiva*Copious purulent discharge*Constitutional disturbance

*Ulcer may occur at any part of cornea

*Treatment :*appropriate systemic and topical antibiotic

*the eyes should be irrigated with warm saline and intensive solution of crystalline benzylpenicilin if any purulent discharge present

*should be directed first to protection of to other eye

*In Cicendo Eye Hospital :*cefotaxime I.m.

*gentamycine or sulfacetamide eye drops

*found in newborn children due to maternal infection

*responsible for 50% of blindness in children

*E/ :

*Severe : N. gonorrhea

*Mild :Chlamydia oculogenitalis, Streptococcus pneumonia

*Clinical findings :*conjunctiva : inflamed, bright red, swollen, yellow pus

*at severe muco-purulent conjunctivitis : infiltration at bulbar conjunctiva & lids are swollen and tense

*corneal ulceration if untreated

*Prophylaxis:*The baby’s lids should be cleansed and dried*If infection is suspected use : *Crede’s method : a drop of silver nitrate solution 1% into each eye

*Treatment*for ophtalmia neonatorum : penicillin, tetracycline & eritromicyn by mouth*for penicillinase-producing N. gonorrhoeae: cephalosporin & gentamicin 0,3% drop*In BKEC :*cefotaxime I.m.*gentamycine or sulfacetamide eye drops

*Continuation of simple acute conjunctivitis

*Etiology :

*irritation : smoke, dust, alcohol, etc

*hypersensivity

*Symptoms :

*burning and grittiness (especially in the evening)

*difficult to keep eyes open

*posterior conjunctival vessels are seen to be congested

*Treatment :

*This consist in eliminating the cause and restoring the conjunctiva to its normal condition.

*Swab should be taken

*short course of suitable antibiotic

*E/ : Chlamydia trachomatis

*Usually starts sub acutely

*primary infection is epithelial both conjunctiva and the cornea (keratoconjunctivitis)

*typical conjunctival sign :

*diffuse inflammation ---> congestion

*papillary enlargement

*development of follicles

*occuring in 4 stage

*trachomatous pannus may develops at a later stage

*Stage 1: earliest stage, before clinical diagnosis is possible

*Stage 2: periode between the appereance of typical trachomatous lession & the development of scar tissue

*Stage 3: scarring is obvious

*Stage 4: the desease become quiet, cicatrization

*WHO:

*TF: folicular conjunctival inflammation

*TI: diffuse conjunctival inflammation

*TS: tarsal conjunctival scarring

*TT: trichiasis or enteropion

*CO: corneal opacification

*Treatment :

*the ideal has not been developed

*tetracycline, erythromycin, rifampicin and sulfonamides are efective

*pannus requires no special treatment

*corneal complication (ulcers) must be treated on general principles

*Acute or sub acute allergic catarrhal conjunctivitis

*watery secretion (not purulent)

*allergen sometimes is a bacterial protein (staphylococcus is most common)

*treatment :

*allergen removal

*astringent lotion

*antihistamine drop is more effective

*Vernal conjunctivitis*bilateral conjunctivitis occur in hot weather*symptom :*burning, itching, photophobia and lacrimation*white & ropy secretion

*two types :*palpebral form*bulbar form

*Treatment :*symptomatic*steroid drops or ointment*cryotherapy (for nodule)*mast cell stabillizer *Disodium cromoglycate 2% (adjuvant to topical steroid)

*Lithiasis

*hard yellow spots in the palpebral conjunctiva

*common in elderly people

*removed with sharp needle

*Pinguecula

*triangular patch on conjunctiva

*looks like fat (yellow color)

*no treatment required

*Pterygium

*proliferate subconjunctival tissue as vascularized granulation to invade the cornea

*frequently follow a pinguecula

*Pterygium morphology grading system:

*Grade T1: athrophic pterygium

*Grade T2: intermediate pterygium

*Grade T3: fleshy pterygium

*Options for wound clossure after extirpation:

*Bare sclera

*Simple clossure

*Sliding flap

*Rotational flap

*Conjungtival graft

*Subconjunctival ecchymosed

*due to rupture of small vessels

*the blood becomes absorbed without treatment in 1 - 3 weeks

*Chemosis

*edema of conjunctiva

*occur in :

*acute inflammation

*obstruction to the circulation

*abnormal blood condition

*Xerophthalmia

*dry condition of the conjunctiva

*due to deficiency of vitamin A

*accompanied by night blindness

*occurs in two groups :

*as a sequel of a local ocular affection

*associated with general disease

*Clinical findings :

*bitot’s spots

*Classification by ocular sign :

*Night blindness (XN)

*conjunctival xerosis (X1A)

*Bitot’s spot (X1B)

*Corneal xerosis (X2)

*Corneal ulceration/keratomalacia < 1/3 of corneal surface (X3A)

*Corneal ulceration/keratomalacia > 1/3 of corneal surface (X3B)

*Corneal Scar (XS)

*Xerophthalmic fundus (XF)

*Stephen J.H. Miller, Parson’s Disease of The Eye

*D, Vaughan, General Ophthalmology

*American Academy of Ophthalmology, External Disease and Cornea