Conjunctiva and Tears

TINATIN JIKURASHVILI PHD

ASSOCIATED PROFESSOR

OPTHALMOLOGIST

LASER SURGEON
Conjunctivitis

► Inflammation of conjunctiva, that is characterized by eye redness , itching,

different types of discharge, papillary or follicular infiltration .
► Visual acuity is rarely affected
► Frequently – self limited
► Generally highly contagious
Symptoms

► Pain and irritation – irritation and foreign body sensation is frequent

pain- rare, mainly in cases of corneal involvement
► Redness – entire conjunctiva is red ( including tarsal plates).
If redness is localized only around limb other pathologies
should be considered
► Discharge – purulent suggest bacterial conjunctivitis
Watery – Viral conjunctivitis
► Visual loss which is not cleared by blinking- other pathologies
Papillary conjunctival reaction

► Non-specific response caused by many agent

► Usually seen on the upper tarsal conjunctiva
► Fine mosaic pattern of dilated teleangiectatic
blood vessels
► Each has a central fibrovascular core that gives
rise to a vessel branching out in a spike like pattern
► Conjunctival septae surrounding the papillae are
anchored by pale tissue when papillary hypertrophy
occurs
Clinical signs
Follicles
► Follicles = lymphoid collection
with germinal centers
► Smooth nodules which are
avascular at the apices surrounded
by fine vessels at their bases
► Can be a normal variant if found
in the lower conjunctiva without
infection
Follicular conjunctival reaction

► Etiology
- Adenoviral conjcuntivitis
- Infection from primary herpes simplex virus
- Molluscum contagiosum
- Enterovirus
- Chlamidia
- Toxicity from medications
Subconjunctival hemorrhage
Classification of Conjunctivitis Hyoperacute ( purulent)

bacterial Acute ( mucopuulent

Subacute
Chronia Trachoma‘
Inclusion conjunctivitis
chlamidyal Lymphogranuloma
Acute viral follicular veneerium
Chronic viral follicular

Viral Viral
blepharoconjunctivitis Nonmurulent
conjunctivitis with
hyperemia and minimal
infiltration, ofthen a
fature of ricketsial
Rickettsial Ulcerative
disease
granulomatous
Granulomatous

Fungal
conjunctivitis

Chronic conjunctivitis
and
blepharoconjuntiviitis

Parasitic
Immediate hypersensitivity
Hey fever , vernal, Atopic,
Giant cell
Delayed hypersensitivity
Phlyctenulosis
Immunologic Secondary to contact blepharitis
(allergic) Iatrpgenic
Occupational

Chemical or Folliculosis
irritative Ocular rosacea
Psoriases etc

Unknown Thyroid disease

etiology Gouty conjuntiviti

Carcinoid conjunctivitis
Sarcoidoisi
tuberculosis

Associated w/systemic
diseases
Symptoms of conjunctivitis
Clinical Viral Bacterial Chlamidyal Allergic
findings
Itching minimal minimal minimal Severe
Hyperemia Generalized Generalized Generalized Generalized
Tearing Profuse Moderate Moderate Moderate
Exudation minimal Profuse profuse minimal
Preauricular common uncommon Only in none
adenopathy inclusion
conjunctivitis
In stained Monocytes PMN, Bacteria PMC, plasma Eosinophils
scarpings and cells, Inclusion
exudates bodies
Associated Occasionally Occasionally Never Never
sore throat ad
fever
 Bacterial conjunctivitis
► Acute form self limited and lasts app 14 days
► Commonest organisms- Staphylococcus ,
Streptococcus , Pneumococcus and Haemophilus
► Hyperacute ( caused by N gonorrhea and N
Meningitidis) leads to serous complications if not
treated promptly.
► Chronic – mainly in patients with nasolacrimal duct
obstruction
► Treatment- antibiotic eye drops
in the case of Neisseria species- topical and systemic
antibiotics should be started
Angular conjunctivitis
► Angular conjunctivitis/Morax-Axenfeld
conjunctivitis/diplobacillary conjunctivitis: a
subacute bilateral conjunctival inflammation
caused by the Morax-Axenfeld diplobacillus,
marked by redness of the lateral canthi and scanty,
stringy discharge that adheres to the lashes.

► Treatment – erythromycin or bacitracin ophthalmic

ointment
Ophthalmia Neonatorum

Definition

Ophthalmia Neonatorum (ON) (conjunctivitis of the newborn) occurs within the first month of
life. It is a bacterial, chlamydial or viral infection acquired during passage through an infected
birth canal. 
Causes
► The commonest agent was Neisseria gonorrhoeae (also known as ‘gonococcus’, and
a cause of sexually-transmitted disease). The use of silver nitrate drops as prophylaxis
was introduced in the C19.
► Nowadays a more usual agent, also sexually acquired by the mother, is Chlamydia
trachomatis. Babies born to women with untreated chlamydial infection at delivery
have a 30-50% chance of developing ON
► Third important agent is herpes Simplex Virus
► The incubation period is usually as follows:
► C. trachomatis: 5-14 days
► N. gonorrhoeae: 3-5 days
► HSV : 2-3 days
 Signs and complications

► Purulent bilateral
conjunctival discharge ▪ Corneal ulcer/perforation
► Hyper acute blenorrhea ▪ Uveitis/ panopthalmitis
► Swelling of lids
▪ Corneal scarring
► Mucopurulent discharge
▪ bindness

▪ etc
Treatment
► Systemic treatment
- Ceftriaxone – 125 mg as single IM dose ( gonococcal infection)
- Erythromycin oral suspension 50mg/kg/d in four divided doses for 2 weeks
(chlamydial infection)
- Acyclovir 30 mg/kg/d in three divided doses for 14 days (HSV infection)
► Topical Treatment
► - saline irrigation
► - topical fluoroquinolones
► - topical cycloplegia
Chlamydial Conjunctivitis
Inclusion Conjunctivitis
► Bilateral acute or subacute conjunctivitis
► Sexually transmitted or indirectly transmitted in inadequately chlorinated pools
► In newborns during birth by direct contamination of conjunctiva with cervical lsecretion

Symptoms – redness, pseudoptosis, discharge ( especially In the morning), papillary and follicular
reaction, pseudomembranes, micropannus

Diagnosis - by detection of chlamydial antigens, using immunofluorescence,

or
by identification of typical inclusion bodies by Giemsa staining in
conjunctival swab or scrape specimens.
or ELISA and PCR
Treatment- doxycycline 100mg orally twice a day fir 7 days
erythromicyn – 2g/d for 7 days
azythromicyn – 1mg in a single dose
Trachoma

► Leading cause of preventable blindness worldwide

► Endemic in areas of poor hygiene, poverty, overcrowding, lack of clean water.
► Blinding trachoma occurs in many parts of Africa, in some parts of Asia, among
Australian aborigens, and in northern Brazil

► Is bilateral, spread by flies.

► Hallmark of disease- subconjunctival fibrosis due to frequent re- infections
associated with unhygienic conditions
Trachoma

► Incubation period- 5-14 days

► Acute or subacute onset
► Signs and symptoms- like bacterial conjunctivitis- tearing , photophobia,
exudation, edema, chemosis,hyperemia, tarsal and limbal folliculles
► Superior keratitis, pannus, cicatricial remnants of follicules ( Herbert’s pits) –
are pathognomic of trachomatous conjunctivitis.
► Compications- scarring, corneal, ulceration, corneal scarring,
treatment

► Tetracycline 1-1.5 g/d orally in four divided doses for 3-4 weeks;
► Doxycycline 100 mg orally twice daily for 3 – 4 weeks
► Azitromicine 1 g dose is the drug of choice due to less side effects
► Topical oniments- Sulfonamides, tetracycline, erythromicine- 4 timed daily for 6
weeks
► Surgical correction of trichiasis
Acute viral conjunctivitis
Pharyngoconjunctival fever
Cause- adenovirus type3 and types 4 and 7.
Symptoms – fever, sore throat, bilateral
( usually) , conjunctival hyperemia, tearing,
transient superficial keratitis..
Treatment- generally self limiting in 10 days.
Only supportive treatment with lubricants.
Epidemic keratoconjunctivitis
► Caused by adenovirus types 8,19,29 and 37
► Acute onset , commonly unilateral, or asymmetric
► Not associated fever and sore throat
► Symptoms- tearing, pain, redness, conjunctival edema,
chemosis, sub conjunctival hemorrhages
► pseudo membranes , corneal subepithelial opacities
► Conjunctivitis resolves in 3-4 weeks, subepithelial opacities
heal within several months.
► Treatment- cold compresses, lubricants. Corticosteroids are
used carefully. If bacterial superinfection - antibiotic drops
should be used.
Epidemic keratoconjunctivitis
Subepithelial corneal infiltrates

The infiltrates are a product of the immune

response to the keratitis and are smaller, more
numerous, denser, produce greater photophobia
and last longer (up to a year) than PCF infiltrates.

In addition, EKC may lead to persistent dry eye or

conjunctival scarring
Allergic conjunctivitis

Immediate humoral Delayed Hypersensivity

hypersensivity reactions reactions

► Hay Fever or seasonal Conjunctivitis ► Phlyctenulosis

► Vernal conjunctivitis ► Mild conjunctivitis secondary to contact
blepharitis
► Atopic keraticonjunctivitis
► Giant papillary Conjunctivitis
 Hay Fever conjunctivitis
( allergic rhinitis)

► bilateral
► Allergy to pollens , grasses, animal dander etc itching,
redness, tearing
► During acute attacks – chemosis
► Treatment – topical antihistamins
vasoconstrictors
cold compresses
 Vernal keratoconjunctivitis
“spring catarrh”
► Occurs in prepubertal years and last for 5-10 years.
► Bilateral, mainly in warm weather
► Itching, milky appearance
► Giant papillae on upper conjunctiva (cobblestones)
► Perilimbal gelatinous swelling and Tranta’s dots
► Corneal “shielded “ulcer
Treatment- generally self-limited
cold climate, cold compresses
topical antihistamins, vasoconstrictors and
steroid drops
Atopic conjunctivitis

► Associated with atopic dermatitis

► Ocular itching, photophobia, and watery or
mucoid discharge
► Small to medium sized papillae both upper&
lower conjunctiva, milky bulbar conjunctiva or
corneal vascularization & opacification
► Conjunctival carring and can lead to
symblepharon formation
► Develop posterior subcapsular or shield shape
anterior subcapsular lens opacities
Giant papillary conjunctivitis

► Chronic inflammation of the conjunctiva

with prominent papillary hypertrophy of the
superior tarsus
► Associated with soft contact lens material,
protein debris accumulating on the lens surface,
or chemicals involved in lens cleaning
► Also seen in ocular prosthesis, loose nylon
sutures, filtering blebs
Conjunctival/corneal phlyctenes

► Focal translucent lymphocytic nodules located at the

limbus
► Neutrophils enter the nodule a few days after inset a
necrosis develops
► Results from delayed cell-mediated hypersensitivity
reaction to staphylococcal antigens or tubercle bacilli
► May result in fibrosis and vascularization of the
peripheral cornea
► May wander across the cornea producing vascularization
& scarring
► Treatment with topical steroids and antibiotic in
conjunction with treatment of underlying disease
Pinguicula

► These elevated, fleshy conjunctival masses are

located in the interpalpebral region, most
commonly on nasal side’
► Yellow or light brown
► Associated with chronic actinic exposure,
repeated trauma and dry, windy conditions
► Elastic degeneration, but the tissue is not actually
composed of elastin
Pterygium
► Benign proliferation of fibrovascular tissue, covered by
conjunctival like epithelium extending onto the
peripheral cornea
► Risk factors: UV light, wind & dust
► Can occur above and within bowman’s layer
► Corneal iron line ( stokcer’s line) can be seen in advance
of the head of a pterygium on the cornea
► Treatment: removal
Tear Film
 Dry eye syndrome

Dry eye is a condition of the ocular surface due to a deficiency of tear quantity or
composition or excessive evaporation, characterized by hyperosmolarity and leading
to ocular surface damage, inflammation and symptoms of discomfort and visual loss.
An alternative term is keratoconjunctivitis sicca ( KCS ).

https://www.youtube.com/watch?v=7Nu7wWhsRQU
Dry eye syndrome

► Aqueous- deficient dry eye - Deficient tear production

Caused by aging or diseases such as Sjogren syndrome

► Evaporative dry eye – inadequate Meibomian fat delivary or lid malposition

caused by Meibomian gland obstruction
ectropion, lagophthalmos, proptosis
► Cicatricial dry eye ( due to goblet cell loss)- cicatricial conjunctival lesions
vitamin A deficiency ( xeropthalmia)
Symptoms

► A stinging, burning or scratchy sensation in your eyes.

► Stringy mucus in or around your eyes.
► Sensitivity to light.
► Eye redness.
► Foreign body sensation
► Difficulty wearing contact lenses.
► Difficulty with nighttime driving.
► Watery eyes, which is the body's response to the irritation of dry eyes.
Diagnostic methods

► Symptoms
► Schirmer’s test
► Fluorescein
► Tear film stability(TBUT)
► Tear film composition ( osmolarity)
► Lissamine green and rose Bengal ( for conjunctiva)
► Serology ( for Sjogren)
Schirmer test

For assessment of tear production

A negative (more than 10 mm of moisture on the

filter paper in 5 minutes) test result is normal.
Tear film break up time

Tear breakup time (TBUT) Tear breakup time (TBUT) is a clinical test used to

assess for evaporative dry eye disease. TBUT within 10 seconds is abnormal
Fruorescein staining
Lissamine green and Rose Bengal
Tear film Osmolarity
Treatment