Chapter 6 195

Conjunctiva

Anatomy and physiology  196

Conjunctival signs  198
Conjunctival diagrams  200
Bacterial conjunctivitis (1)  202
Bacterial conjunctivitis (2)  204
Viral conjunctivitis  206
Chlamydial conjunctivitxis  208
Allergic conjunctivitis (1)  210
Allergic conjunctivitis (2)  212
Cicatricial conjunctivitis (1)  213
Cicatricial conjunctivitis (2)  214
Cicatricial conjunctivitis (3)  216
Cicatricial conjunctivitis (4)  218
Dry eyes: clinical features (1)  220
Dry eyes: clinical features (2)  222
Dry eyes: clinical features (3)  224
Dry eyes: treatment (1)  226
Dry eyes: treatment (2)  228
Ocular neuropathic pain  230
Miscellaneous conjunctivitis and conjunctival degenerations  232
Pigmented conjunctival lesions  234
Non-​pigmented conjunctival lesions (1)  236
Non-​pigmented conjunctival lesions (2)  238

S For additional images relevant to this chapter, please see the online
image bank at oxfordmedicine.com/ophthalmologyc6.
196

196 Chapter 6   Conjunctiva

Anatomy and physiology

The conjunctiva is a mucous membrane that is essential for a healthy eye.
At the histological level, it comprises the epithelium, BM, and stroma. At
the macroscopic clinical level, it is divided into palpebral, forniceal, and
bulbar parts.
Microscopic
Epithelium
This is a 2-​to 5-​layered, non-​keratinized epithelium that may be stratified
squamous (palpebral and limbal) or stratified columnar (bulbar conjunctiva).
The microvilli on the apical surface harbour glycoproteins that form a
hydrophilic glycocalyx layer that helps stabilize the tear film. The epithelial
layer also contains goblet cells (constituting about 10% of epithelial cells).
Epithelial BM
The BM consists mainly of type IV collagen, anchoring fibrils, and hemides-
mosomes linking to the conjunctival epithelial cells.
Stroma
This consists of a superficial lymphoid layer and a deeper fibrous layer.
The superficial layer is attached to the epithelium via the BM and contains
lymphoid tissue. The deeper fibrous layer is attached to the episclera/​
Tenon’s layer and comprises collagenous elastic tissue interspersed with
neurovascular tissue.
Macroscopic
Palpebral
This is firmly adherent to the posterior lamella of the lid; it contains the
crypts of Henle and goblet cells (both secrete mucin).
Forniceal
This is loose and relatively mobile. It contains accessory lacrimal glands of
Krause and Wolfring (secrete aqueous component of tears) and goblet cells.
Bulbar
This is loosely attached to the Tenon’s layer but firmly attached at the lim-
bus. It contains glands of Manz (secrete mucin) and goblet cells.
The tear film
Although conventionally described as a defined trilaminar structure, it is
more complex with an underlying muco-​aqueous gradient, rather than two
discrete layers and an overlying lipid layer (see Fig. 6.1).
Mucin
Mucin is secreted primarily by the goblet cells. Membrane-​bound mucins
abuts the surface epithelium and provides a smooth hydrophilic surface that
stabilizes the aqueous against the otherwise hydrophobic epithelium, and
soluble mucins are found within the aqueous layer.
 

Anatomy and physiology 197

Tear flim components and their origins

Lipid Meibomian glands
Glands of Zeis
Aqueous Lacrimal gland
Muco-aqueous component Glands of Krause
Gradient Glands of Wolfring
Mucin Goblet cells
component Glands of Manz
Crypts of Henle
Epithelium

Fig. 6.1 Tear film components and their origins.

Aqueous layer
The aqueous component (secreted by the lacrimal gland and the accessory
glands) consists primarily of water, but also nutritional elements such as
epidermal growth factor, vitamins, glucose, lactoferrin, lysozyme, immuno-
globulins, and cytokines.
Phospholipid layer
The aqueous layer is supported by a phospholipid layer (secreted primarily
by the MGs) that resists evaporative loss of aqueous and stabilizes the tear
film by increasing surface tension. For further details, see E Blepharitis and
meibomian gland dysfunction (MGD) (1), p. 158.