THE CONJUNCTIVA

Ms. A. Bobart Hone

RCSI- 2009

Anatomy• Loose transparent tissue overlying the sclera, lining the

inside of the eyelids and terminating at the cornea

• Clinically it has 3 components :– Palpebral- adherent to tarsal plates on inner aspect of the eyelids– Forniceal– Bulbar-covering the anterior sclera

• Composed of – Epithelium,– Stroma- vascularised connective tissue

The conjunctiva:red eye or conjunctival injection secondary to conjunctivitis

Conjunctival disease

• Infective

• Inflammatory/Allergic

• Neoplastic

• Degenerative

INFECTIVE • Bacterial : red or injected eye associated with a sticky discharge

– Diagnosis– do swab if does not resolve with first line treatment– Treat with antibiotic firstline

• Viral eg Herpes Simplex, Adenovirus

– Herpes conjunctivitis treated with topical 3% Aciclovir ointment 5 times a day– Follicular conjunctivitis typical of Adenovirus- supportive treatment with cool

compresses and lubricants, rarely steroids if severe corneal involvement

• Other organisms • Chlamydia

– Follicles (Lymphoid hyperplasia under the lids) + mucopurulent discharge – Rx with Topical and oral Tetracycline/ Erythromycin in adults

Bacterial Conjunctivitis

Herpes Simplex conjunctivitis and corneal dendritic ulcer

ALLERGIC • Type 1, IGE mediated reactions most common type

– Watery, itchy, photophobic, red eyes associated with papillae– raised lesions/ papillae on conjunctiva, usually under the lids or rarely at the

limbus (called Trantas dots at limbus) are typical of allergic conjunctivitis. – Giant cobblestone papillae are seen in Vernal and Giant Papillary conjunctivitis

associated with mucoid discharge and shield ulcers of the cornea in severe disease.

• Types:– Hay fever conjunctivitis (seasonal)– Atopic conjunctivitis – Vernal conjunctivitis ( usually seasonal)– Giant papillary conjunctivitis – remove the cause eg suture, contact lens etc

Normal vs Giant cobblestone papillae

Treatment

• Topical mast cell stabilisers long term

• Lubrication with preservative free drops to soothe

• Systemic Antihistamines

• In Vernal or adult keratoconjunctivitis if severe add topical or subtarsal steroid injections

NEOPLASMS OF THE CONJUNCTIVA

• Benign – Papillomas, dermoids, dermolipoma

– Treatment: excision ( and for papillomas also apply cautery to destroy virus) • Malignant:

– Melanoma– Squamous cell carcinoma– Lymphoma– Kaposi’s sarcoma.

– Treatment: Dependent on severity and extent – Surgical excision to more ‘radical ‘treatment such with topical mitomycin or

radiotherapy

Amelanotic malignancy encroaching onto corneal surface

Degenerative • Pingueculum

– Yellowish white plaques- close to lateral or medial limbus in interpalpebral area

– No treatment warranted but can excise

• Pterygium – A fibrovascular over growth of conjunctiva onto cornea usually

in nasal interpalpebral area, predominantly seen in arid / hot climates

– Treatment: Topical anti-inflammatories if injected and lubricants

– If grows onto cornea and inducing problem on visual axis or astigmatism consider excision with conjunctival auto graft sewn or glued with surgical glue over denuded area to decrease recurrence

Pterygium

Miscellaneous

• Stevens Johnson Syndrome– In spite of the other systemic complications resolving after the acute

episode, the eye continues to have the following problems

• Dry eyes• Trichiasis• Entropion or Ectropion• Corneal epitheliopathy, melt or ulcers• Symblepharon- adhesion between bulbar and tarsal (inner lid) conjunctiva

– Treatment

• Avoid inciting medication or precipitant if the cause• Preservative free drops- lubricants, sometimes ongoing steroids• Removal of lashes permanently as can cause ulcers- may need to further

immunosuppress eyes prior to any ocular surgery

Stevens Johnson SyndromeN.B. symblepharon

Subconjunctival haemorrhage

• Secondary to – Trauma– Hypertension– Positive valsalva manouvers eg coughing, straining

etc– Anti coagulants or ‘blood thinners’ eg warfarin,

aspirin, persantin, heparin, ginko biloba– Clotting diathesesNo treatment but avoid any inciting cause

Subconjunctival haemorrhage

Subconjunctival haemorrhage post cataract surgery

Superior limbic keratoconjunctivitismay be associated with thyroid eye

disease