CONJUNCTIVA 😊

CONJUNCTIVA

Anatomy of Conjunctiva

• Types:

Type	Location / Function
Bulbar	Lines the sclera
Palpebral	Lines the eyelids
Forniceal	Connects bulbar and palpebral conjunctiva

• Histology:
• Goblet cells:
• Present in conjunctival epithelium.
• Secretes mucin
• Forms innermost layer of tear film.

• Lymphatic drainage:

Region	Drains Into	Mnemonic
Medial	Submandibular lymph nodes	Standing → Tears run down
Lateral	Preauricular lymph nodes	Lying down → Tears run to ear

Conjunctivitis/Eye Flu

Clinical Features:

• Redness, watering, stickiness.

• Irritation, foreign body sensation.

• No loss of vision, no pain.

Signs:

• Discharge:
• Eyelids sticking in morning.
• May cause colored halos.
• Types:
• Watery (Allergies, Viral);
• Mucopurulent (Bacterial, Chlamydial).

• Follicle → Grey → Covid 19

• Papillae → Pink

• Hyperemia/congestion (Redness).

• Subconjunctival hemorrhage.

• Chemosis (Edema of bulbar conjunctiva).

Bacterial Conjunctivitis Types:

Chlamydia trachomatis serotypes:

Serotypes	Causes
A, B, Ba, C	• TraChoma
D, E, F, G, H, I, K (no J)	• Non-Gonococcal Urethritis (NGU) • Fitz-Hugh-Curtis syndrome • Inclusion conjunctivitis • Ophthalmia neonatorum
L1, L2, L3	• LGV
Chlamydia pneumoniae	• TWAR strain • Pneumono
Chlamydia psittaci	• Causes Psittacosis. • Has several serotypes

Inclusion Bodies:

• Halberstadter-Prowazeki bodies (HP) are seen in trachoma.

• Levinthal cole lillie body is seen in C. Psittaci.

Trachoma/Egyptian Ophthalmia:

• Agent: Chlamydia Trachomatis (immune type A, B, C)

• IP (Incubation Period): 5-12 days

• Age: 0-10 years (average: 2-5 years)

• Most common cause of preventive blindness in adults.

• DOC (Drug of Choice): Azithromycin 20mg/kg oral single dose.

Stages of Trachoma

• Stage 1: Incipient
• Immature follicles, asymptomatic

• Stage 2: Established
• Typical lesions, no scarring

• Stage 3: Cicatrising
• Scarring + active infection

• Stage 4: Healed
• Only scarring, disease quiet

• Eliminated in 2024, Not eradicated

• Spread: Finger, fly, fomites.

• Signs:
• Sago grain follicles + papillae.
• Arlt’s line:
• Line of cicatrization from concurrent inflammation & healing.
• Herbert’s pits:
• At limbus
• Pannus:
• Vascularization of cornea.

• Mnemonic: Trachoma → Trackil odan Horse power venam (Halb Prow). Odikondirunnapo oru Panni (Pannus) Pit (Herberts Pits) undakki Grains (Sago grains) ittu vachu. But safe (SAFE) ayi line (Arlts) cross cheyth

• Diagnosis: 
• Halberstaedter–Prowazek bodies (cytoplasmic inclusion bodies).

• Treatment (SAFE strategy):
• Surgery → for trichiasis → leading cause of blindness in trachoma
• Antibiotics: Azithromycin 1 gm single dose (Stat).
• Facial cleanliness.
• Environment changes.

• GET strategy

• Complication → Blindness:
• Infections → Inflammation → Scarring of eyelids → Trichiasis → Irritation of cornea by eyelashes → Corneal opacity.

Viral Conjunctivitis

Viral Conjunctivitis:	ㅤ
Adenoviral	ㅤ
ㅤ	Epidemic keratoconjunctivitis (EKC) ↳ serotype 8, 19, 37
ㅤ	Pharyngoconjunctival fever (PCF) / Swimming pool conjunctivitis: ↳ serotype 3, 7, 14 • 3rd day → floating • 7th day → basic • 14th day → advanced
Acute hemorrhagic/ Apollo conjunctivitis	PACE Mnemonic
ㅤ	Picornavirus
ㅤ	Adenovirus
ㅤ	Coxsackie A24
ㅤ	Enterovirus type 70
Others	ㅤ
ㅤ	Angular conjunctivitis: Moraxella
ㅤ	HSV conjunctivitis.
ㅤ	Molluscum contagiosum conjunctivitis.

Condition	Coxsackie	Enterovirus
HFMD	A16	71
Acute hemorrhagic Conjunctivitis	A24	70

Allergic Conjunctivitis:

• Seasonal.
• Types:
• Vernal keratoconjunctivitis (VKC)/Spring catarrh.
• Atopic keratoconjunctivitis (like VKC in adults).
• Giant papillary conjunctivitis
  (due to mechanical irritation)
• contact lens,
• protruding sutures,
• ill-fitting prosthesis
• Phlyctenular conjunctivitis.

Phlyctenular Keratoconjunctivitis

Type of Reaction

• It is not an allergic reaction → but delayed hypersensitivity to TB antigens

• Type IV hypersensitivity reaction

• Due to endogenous allergen

Etiology

• Most common cause in India: TB (Tuberculosis)

• Most common cause in Western countries: Staphylococcus aureus

Phlycten:

• Nodule near the limbus

• Grows toward cornea

• Ulcerates with progression

• Types of ulcers formed:
• Sacrofulous ulcer
• Fascicular ulcer
• Miliary ulcer

Treatment

• Topical steroids

VKC/Spring catarrh:

• M/c in boys of 5–15 yrs.

• Hypersensitivity: Type 1 > 2.

• Signs:
• Cobblestone papilla.
• Eosinophilic deposits at limbus (Horner-Trantas dots).
• Pseudogerontoxon (white ring around the limbus).
• Ropy discharge
• Maxwell-Lyon sign.

• Treatment:
• Olopatadine (DOC):
• Antihistamine + Mast cell stabilizer.
• Topical steroids for immediate relief/acute exacerbations.

• Mnemonic: Springil (spring catarah) 15 year old (5-15 yr) children kulikkan poi → cobble stones (cobblestone) indarnnu → Rope climb (ropy discharge → Maxwell Lyon) cheyth → Horn (Horner Traunt dots) ulla Lion (Maxwell Lyon) with dots ne kandu (maxwell lion)

Gerontoxon / Arcus Lipoides / Arcus senilis

• Most common peripheral corneal opacity

• Age-related lipid degeneration of peripheral cornea

• Appears as light grey / bluish ring

• Bilateral

• Benign

• Common in elderly

• If unilateral ⇒ contralateral carotid artery stenosis

• Interval of Vogt
• Clear corneal zone
• Located between arcus and limbus
• Always spared

Arcus Juvenilis

• Arcus seen < 50 years

• Suggests underlying lipid disorder

• Associated with increased cardiovascular risk

• Lipid profile screening required

Pterygium

• Description: Triangular fibrovascular growth of subconjunctiva over cornea.
• normally covers only sclera
• Nasal > Lateral

• Marker: ABCG2, CD34

• Causes:
• A/w P53 gene
• Limbal stem cell deficiency
• Activation of matrix metalloproteinase.
• Due to ↓↓ activity of tissue inhibitors of metalloproteinases
• UV, dust, heat.
• Elastotic degeneration and hyalinization

• Destroys Bowman's layer § superficial stroma.

• Progression & Impact:
• Over pupil → Obstruction of visual axis → Loss of vision
• Not over pupil → Visual defect due to astigmatism.
• Growth with apex towards cornea → Deposition of Iron infront of Apex
• Called Stockers line

• Treatment of choice
• Excision with conjunctival autograft
• PERFECT Sx
• Pterygium extended margin f/b extended conjunctival transplant

• Prevention of recurrence:
• Mitomycin C
• Autograft
• Both reduce rate of recurrence to 5%

Pinguecula

• Whitish yellow lesion surrounded by erythema

• Degenerative conjunctival lesion

• Yellowish-white patch

• On bulbar conjunctiva near limbus

• Site
• Starts on nasal side
• Then temporal side

• Common in elderly

• Pathology
• Elastotic degeneration of collagen fibers
• In substantia propria
• Amorphous hyaline material deposition

• Treatment
• No treatment if asymptomatic
• If inflamed:
• Topical steroid