ophthalmology .........................................................................................................ppt .......................................................................................

1. DISEASES OF CONJUNCTIVA

2. ANATOMY & PHYSIOLOGY
• THIN TRANSPARENT MUCUS MEMBRANE
• LINES POSTERIOR SURFACE OF EYE BALL AND ANTERIOR ASPECT OF
EYE BALL
• EXTENDS FROM LID MARGIN TO LIMBUS
• ENCLOSES “CONJUNCTIVAL SAC “ OPEN IN FRONT THROUGH
PALPEBRAL FISSURE

3. PARTS OF COJUCTIVA

4. PARTS OF CONJUCTIVA
CONJUNCTIVA
PALPEBRAL
MARGINAL
TARSAL
ORBITAL
BULBAR

5. PALPEBRAL CONJUNCTIVA
• LINES THE LIDS
PALPEBRAL
MARGINAL
TARSAL
ORBITAL

6. MARGINAL CONJUNCTIVA
• EXTENDS FROM LID MARGIN TO SULCUS SUBTERMINALIS(2mm
ABOVE &PARALLEL TO LID MARGIN)
• TRANSITIONAL ZONE B/W SKIN &CONJUNCTIVA

7. TRANSITIONAL CONJUNCTIVA
• THIN TRANSPARENT AND HIGHLY VASCULAR
• IN THE UPPER EYE LIDFIRMLY ADHERENT TO WHOLE OF TARSAL PLATE
• IN THE LOWER EYE LID ADHERENT ONLY TO HALF

8. ORBITAL CONJUNCTIVA
• LOOSE B/W TARSAL PLATE &FORNIX

9. BULBAR CONJUNCTIVA
• THIN TRANSPARENT LIES LOOSE OVER UNDERLYING STRUCTURES
AND CAN BE MOVED EASILY
• SEPARATED FROM ANTERIOR SCLERA BY EPISCLERAL TISSUE AND
TENONS CAPSULE
• LIMBAL CONJUNCTIVA: 3mmRIDGE OF BULBAR CONJUNCTIVA
AROUND CORNEA ,TENONS CAPSULE AND EPISCLERAL TIISUE ARE
FUSED TO FORM A DENSE TISSUE

10. CONJUNCTIVAL FORNIX
• Cul-de-sac
• SUPERIOR,INFERIOR,LATERAL AND MEDIAL FORNIX
• BROKEN ON MEDIAL SIDE BY CARUNCLE AND PLICA SEMILUNARIS

11. STRUCTURE OF CONJUNCTIVA
CONJUNCTIVA
EPITHELIUM
ADENOID LAYER
FIBROUS LAYER

12. EPITHELIUM
• MARGINAL: 5 LAYERED STRATIFIED SQUAMOUS EPITHELIUM
• TARSAL:2 LAYERED
SUPERFICIAL CYLINDRICAL
DEEP FLATTENED
• FORNIX AND BULBAR: 3 LAYERED
SUPERFICIAL CYLINDRICAL
MIDDLE POLYHEDRAL
DEEP CUBOIDAL
• LIMBAL:5 LAYERED STRATIFIED SQUAMOUS EPITHELIUM

13. LYMPHOID LAYER(ADENOID LAYER
• FINE MESHES OF RETICULUM IN WHICH LIE LYMPHOCYTES
• MOST DEVELOPED IN FORNICES
• NOT PRESENT AT BIRTH DEVELOPS 3-4 MONTHS AFTER BIRTH
CONJUNCTIVITIS IN AN INFANT DOES NOT INVOLVE FOLLICULAR REACTION

14. FIBROUS LAYER
• MESHWORK OF COLLAGENOUS AND ELASTIC CONNECTIVE TISSUE
• CONTAIN VESSELS AND NERVES
• THIN AT TARSAL CONJUNCTIVA

15. GLANDS OF CONJUNCTIVA

16. MUCIN SECRETORY GLANDS
• GOBLET CELLS: UNICELLULAR GLANDS LOCATED WITHIN THE
EPITHELIUM
• CRYPTS OF HENLE:IN TARSAL CONJUNCTIVA
• GLAND OF MANZ: LIMBAL CONJUNCTIVA

17. ACCESSORY LACRIMALGLANDS
• GLANDS OF KRAUSE : SUBCONJUNCTIVAL CONNECTIVE TISSUE
42 IN UPPER FORNIX
8 IN LOWER FORNIX
• GLANDS OF WOLFRING:ALONG ‘SUPERIOR’ BORDER OF ‘SUPERIOR’
TARSAL PLATE
ALONG ‘INFERIOR’ BORDER OF ‘INFERIOR’
TARSAL PLATE

18. PLICA SEMILUNARIS
• VESTIGEAL ORGAN (NICTATING MEMBRANE OF LOWER ANIMALS)
• IN MEDIAL CANTHUS,CRESCENTIC FOLD OF MUCOSA,PIMK

19. CARUNCLE
• SMALL OVOID PINKISH MASS IN INNER CANTHUS, MEDIAL TO PLICA
• MODIFIED SKIN WITH SWEAT ,SEBACEOUS GLAND & HAIR FOLLICLES

20. BLOOD SUPPLY
PERIPHERAL ARTERIAL ARCADE
MARGINAL ARTERIAL ARCADE
• 3 SOURCES ANTERIOR CILIARY ARTERIES
PALPEBRAL CONJUNCTIVA PERIPHERAL ARTERIAL ARCADE
FORNIX

21. • BULBAR CONJUNCTIVA POST CONJUCTIVAL ARTERY(4M ARTERIAL
ARCADE)
ANT CONJUNCTIVAL ARTERY(4M ANTERIOR
CILIARY ARTERY)

22. VENOUS DRAINAGE

23. NERVE SUPPLY

24. LYMPHATIC DRAINAGE
• IN BULBAR CONJUNCTIVA
IN PALPEBRAL , AS IN EYE LID

25. CONJUNCTIVITIS
• BASED ON ONSET
CONJUNCTIVITIS
ACUTE
SUBACUTE
CHRONIC
RESOLVING IN LESS
THAN 4 WEEKS
OF MORE THAN 4
WEEKS DURATION

26. CONJUNCTIVITIS
• BASED ON TYPE OF EXUDATE
CONJUNCTIVITIS
SEROUS
CATARRHAL
PURULENT
MUCOPURULENT
MEMBRANOUS
PSEUDOMEMBRANOUS

27. • SEROUS DISCHARGE: clear fluid like serum viral , allergic, toxic
• CATARRHAL: thick or viscid secretion like mucus allergic
• PURULENT: bacterial
• MUCOPURULENT: bacterial, chlamydial
• MEMBRANOUS:bacterial
• PSEUDOMEMBRANOUS :bacterial

28. BASED ON CONJUNCTIVAL RESPONSE
• FOLLICULAR (viral & chlamydial)
• PAPILLARY(allergic)
• GRANULOMATOUS(fungal,
TB,syphilis,sarcoidosis,tularemia,actinomycosis……)
conjunctivitis
follicular
papillary
granulomatous

29. FOLLICULAR
CONJUNCTIVITIS
FOLLICLES(ROUND TO OVAL ELEVATIONS,0.5-
1.5MM IN DIAMETER,MORE OFTEN IN
SUPERIOR &INFERIOR TARSAL CONJUNCTIVA)
ACUTE
VIRAL(EBV,IMN,HERPEZ)
CHLAMYDIAL
CHRONIC
CHRONIC CHLAMYDIAL

30. FOLLICULAR CONJUNCTIVITIS
• FOLLICLES :-LYMPHOID GERMINAL CENTRES
AVASCULAR AT THEIR APICES,SURROUNDED BY FINE
VESSELS AT THEIR BASES
WITH REGIONAL LYMPHADENOPATHY
LYMPHOBLASTIC PROLIFERATION

31. PAPILLARY
CONJUNCTIVITIS
NONSPECIFIC RESPONSE DUE TO MANY
AGENTS
UPPER TARSAL CONJUNCTIVA
FINE MOSAIC PATTERN OF DILATED
TELENGIECTATIC VESSELS
CENTRAL FIBROVASCULAR CORE THAT GIVES
VESSELS IN SPOKE LIKE PATTERN

32. GRANULOMATOUS CONJUNCTIVITIS
• GRANULOMATOUS CONJUNCTIVITIS
• characterised by proliferative lesions which usually tend to remain localized to
one eye and
• are mostly associated with regional lymphadenitis.
• Common granulomatous conjunctival inflammations are:
 Tuberculosis of conjunctiva
 Sarcoidosis of conjunctiva
 Syphilitic conjunctivitis
 Leprotic conjunctivitis
 Conjunctivitis in tularaemia
 Ophthalmia nodosa

33. BASED ON ETIOLOGY
CONJUNCTIVITIS
INFECTIOUS
NON
INFECTIOUS

34. INFECTIOUS CAUSES
• BACTERIAL (Staphylococcus aureus and albus,Haemophilus
aegypticus, H. influenza, N.gonorrhea, N.meningitides, E.coli,
Proteus, streptococcus pyogenes, streptococcus pneumonia,
 VIRAL (herpes simplex, adenovirus, picorna virus(coxsackie & enterovirus, myxovirus,
paramyxovirus
CHLAMYDIAL trachoma (A,B &C)
inclusion conjunctivitis(D-K)
Lymphogranuloma venerum (L1,L2 &L3)
FUNGAL (candida,aspergillus,nocardia,sporithrix,leptothrix)
PARASITIC

35. NON INFECTIOUS CAUSES
ALLERGIC
IRRITANTS
ENDOGENOUS OR AUTO IMMUNE
DRY EYE
TOXIC (chemical/drug induced)
SELF INFLICTED.FACTITIOUS
IDIOPATHIC

36. INFECTIOUS COJUNCTIVITIS
• COMMONEST
• PROTECTIVE MECHANISM
LOW TEMP( DUE TO EXPOSURE TO AIR)
LIDS(PHYSICAL PROTECTION)
LYSOZYMES
FLUSHING ACTION BY TEARS
SECRETORY IMMUNOGLOBULINS

37. BACTERIAL CONJUNCTIVITS
• ETIOLOGY
PREDISPOSING FACTORS
FLIES
DIRTY HABITS
HOT DRY CLIMATE
POOR SANITATION
POOR HYGIENE

38. CAUSATIVE ORGANISM
 STAPHYLOCOCCUS AUREUS(most common cause of bacterial conjunctivitis & blepharoconjunctivitis )
 STAPHYLOCOCCUS EPIDERMIDIS(innocuous flora of conjunctiva)
 STREPTOCOCCUS PNEUMONIAE(a/c conjunctivitis with petechial subconjunctival hge)
 STREPTOCOCCUS PYOGENES (pseudo membranous)
 HAEMOPHILUS AEGYPTICUS(mucopurulent,RED EYE)
 MORAXELLA LACUNATE (angular conjunctivitis)
 PSEUDOMONAS PYOCYANEA(invades cornea)
 CORYNEBACTERIUM DIPTHERIA (membranous conjunctivitis)
 NEISSERIA GONORRHEA------ OPHTHALMIA NEONATORUM in new born
-------a/c Purulent conjunctivitis in adults
 NEISSERIA MENINGITIDIS (mucopurulent)

39. MODE OF SPREAD
EXOGENOUS
DIRECT CONTACT
VECTOR (FLIES)
FOMITES
LOCAL
SURROUNDINGS
INFECTED LACRIMAL
SAC
INFECTED
NASOPHARYNX
INFECTED LID
ENDOGENOUS
THROUGH BLOOD
(M.COCCI &G.COCCI)

40. PATHOLOGICAL CHANGES
• VASCULAR RESPONSE congestion
capillary proliferation
increased vascular permeability
• CELLULAR CHANGES exudation of PMNL in to substantia propria of
conjunctiva and conjunctival sac
• CONJUNCTIVAL TISSUE RESPONSE
conjunctiva becomes edematous,desqumation
of superficial epithelial cells, proliferation of basal
cells
• CONJUNCTIVAL DISCHARGE
Tear+fibrin+bacteria+infl.cells+desq.epithelial cells++
diapedesis of RBC---blood stained---in severe cases

41. BACTERIAL CONJUNCTIVITIS
A/CCATARRHAL(MUCOPURULENT)
A/C PURULENT
A/C MEMBRANOUS
A/C PSEUDOMEMBRANOUS
C/C BACTERIAL
C/C ANGULAR

42. ACUTE MUCOPURULENT CONJUNCTIVITIS
• MOST COMMON
• MARKED CONJUCTIVAL HYPERAEMIA
• MUCOPURULENT DISCHARGE FROM EYE
• CAUSATIVE ORGANISMS
STAPH AUREUS
H.AEGYPTICUS
PNEUMOCOCCUS
STREPTOCOCCUS
EXANTHEMATA IN MEASLES &SCARLET FEVER

43. SYMPTOMS
• DUE TO ENGORGED VESSELS =>DISCOMFORT & FOREIGN BODY
SENSATIONS
• MUCOPURULENT DISCHARGE FROM EYES
• STICKING OF MARGINS OF LIDS AFTER SLEEP
• MILD PHOTOPHOBIA
• DUE TO MUCUS FLAKES -----BLURRING OF VISION
-----COLOURED HALOS (due to prismatic
effect of mucus flakes)

44. SIGNS
• FLAKES OF MUCOPUS IN FORNICES,CANTHI &LID MARGINS
• MATTED TOGETHER CILIA WITH YELLOW CRUSTS
• COJUNCTIVAL CONGESTION
• CHEMOSIS
• PETECHIAL HAEMORRHAGES(in pneumococcus)

45. CLINICAL COURSE
• PEAK IN 3-5 DAYS
• RESOLVES IN MILD CASES
• OR MAY BECOME LESS INTENSE C/C CATARRHAL CONJUNCTIVITIS

46. COMPLICATIONS
• MARGINAL CORNEAL ULCER
• SUPERFICIAL KERATITIS
• BLEPHARITIS
• DACROCYSTITIS

47. DIFFERENTIAL DIAGNOSIS
• A/C RED EYE
• OTHER TYPES OF CONJUNCTIVITS

48. TREATMENT
1. TOPICAL ANTIBIOTICS: chloramphenicol(1%), gentamycin(0.3%)
framycetin 3-4 hrly in a day and ointment at
night
if ineffective
ciprofloxacin (0.3%) ofloxacin (0.3%)
gatifloxacin (0.3%)

49. • IRRIGATION OF CONJUNCTIVAL SAC: with sterile warm saline once or
twice a day
frequent eye wash is
contraindicated (it will wash of
lysozymes and protective
proteins)

50. • DARK GOGGLES to prevent photophobia
• NO BANDAGE ( exposure to air temperature helps in
growth of bacteria)
• ANTI INFLAMMATORY & ANTI ANALGESIC DRUGS
• NO STEROIDS----aggravate infn----corneal ulcers

51. ACUTE PURULENT CONJUNCTIVITIS
• A/C BLENORRHEA, HYPER A/C CONJUNCTIVITIS
• 2 FORMS----------ADULT PURULENT CONJUNCTIVITIS
-----------OPHTALMA NEONATORUM

52. ADULT PURULENT CONJUNCTIVITIS
• ADULTS (mainly males)
• Direct spread from genitals
• CAUSATIVE ORGANISM: N.Gonorrhea, staph aureus (rare)
pneumococcus(rare)

53. CLINICAL PICTURE
• STAGE OF INFILTRATION: lasts for 4-5 days
painful & tender eyeball
bright red chemosed conjunctiva
water /sanguinous discharge
pre auricular Ln+

54. • STAGE OF BLENORRHEA: 5TH DAY-SEVERAL DAYS
PURULENT DISCHARGE DOWN CHEEKS
OTHER SYMPTOMS BUT TENSION IN LID

55. • STAGE OF SLOW HEALING:
PAIN ,TENSION IN LID
DISCHARGE SLOWLY
CONJUNCTIVA REMAINS RED VELVETY
THICKENED

56. ASSOCIATIONS
• URETHRITIS,ARTHRITIS

57. COMPLICATIONS
• CORNEAL INVOLVEMENT: due to ability to invade normal cornea
DIFFUSE HAZINESS with grey or yellow spots near the Centre , EDEMA
,CENTRAL NECROSIS due to direct invasion by organisms,
ULCERATION/PERFORATION due to necrosis
• IRITIS & IRIDOCYCLITIS
• SYSTEMIC COMPLICATIONS: SEPTICEMIA, ENDOCARDITIS,ARTHRITIS

58. TREATMENT
• SYSTEMIC THERAPY
Norfloxacin 1.2mg orally qid*5 days
Cefoxitim 1.o gm iv *5 days ,cefotaxime 500mg iv*5days,ceftriaxone 1.2
gm im qid*5 days
Spectinomycin 2gm im *3 days
Any of the above regime+1 wk course of erythromycin 250-500mg qid
Doxycycline 100 mg orally

59. • TOPICAL ANTIBIOTICS
• Ciprofloxacin,ofloxacin,tobramycin eye drops
• Bacitracin or erythromycin eye ointment every 2 hrs for initial
2-3 days, 5 times
daily for 7 days

60. • IRRIGATION using sterile saline---removes infected debris
• Tropical atropine 1% 2 times daily if corneal involvement
• Pt & sexual partner for STD
• SAME AS a/c mucopurulent

61. ACUTE MEMBRANOUS CONJUNCTIVITIS
• TRUE MEMB FORMATION BLEEDS ON PEELING
• CAUSATIVE ORGANISM: corynebacterium diphtheria
b hemolutic streptococci
N.gonorrhe
H.aegypticus
s.aureus
E.coli
viral infn
thermal & chemical burns

62. pathology
Corynebacterium diphtheriae produces a violent inflammation of the conjunctiva
with deposition of fibrinous exudate on the surface as well as in the substance of the
conjunctiva
resulting information of a membrane in palpebral conjunctiva.
associated coagulative necrosis sloughing of membrane.
healing takes place by granulation tissue.

63. CLINICAL FEATURES:
 Usually in children 2-8 years (not immunized) toxic & febrile
 Stage of infiltration:
 Scanty discharge and severe pain
 Swollen and hard lids, red swollen conjunctiva covered with grey yellow membrane
 On removal, membrane bleeds
 pre auricular LN +
 Stage of suppuration:
 Pain decreases, membrane sloughs off lids are soft
 Copious purulent discharge
 Stage of cicatrization:
 Raw surface covered with granulation tissue & epithelized
  trichiasis, conjunctival xerosis

64. complications
• Corneal ulcer
• Delayed complications cicatrization  symblepharon, trichiasis,
entropion & conjunctival xerosis.
• DIAGNOSIS:
• By bacteriological examination

65. TREATMENT:
 Topical:
 Penicillin eye drops 1:10000 unit/ml every 30 min
 Anti-diphtheric serum every 1 hour
 Atropine 1% ointment (if corneal involvement)
 Broad spectrum antibiotic ointment at bedtime
 Systemic:
 Cryst penicillin 5 lac units IM BD x 10 days
 Anti-diphtheric serum 50,000 units IM stat
 Prevention of symblepharon:
 When surface raw: apply contact shell or sweep glass rod with ointment

66. Prophylaxis
• 1. Isolation of patient
• 2. Proper immunization against diphtheria

67. ACUTE PSEUDOMEMBRANOUS
CONJUNCTIVITIS
• ETIOLOGY:
• Bacterial:
• C. diphtheria(low virulence), Staphylococcus, Sterptococcus
• H. influenzae, N. gonorrhoea
• Viral:
• Herpes simples & adenovirus
• Chemical:
• Acids, ammonia, lime, copper sulphate, silver nitrate
• PATHOLOGY:
• Similar to membranous conjunctivitis

68. • CLINICAL FEATURES:
• Acute mucopurulent conjunctivitis a/w pseudomembrane formation
• TREATMENT:
• Same as mucopurulent conjunctivitis

69. Chronic catarrhal conjunctivitis
• ETIOLOGY:
• Predisposing factors:
• Chronic exposure to smoke, dust, chemical irritants
• Local irritant as trichiasis, concretions, FB
• Eye-strain due to Ref error, phorias, convergence insufficiency
• Alcohol abuse,insomnia metabolic disorders
• Causative agents:
• Staph aureus commonly,
• G –ve bacilli Proteus mirabilis,Klebsiella pneumoniae, Escherichia coli and Moraxella
lacunata

70. • Source & mode of infections:
• As continuation of acute mucopurulent conjunctivitis (untreated)
• As chronic infection from chronic dacryocystitis ,c/c RHINITIS, c/c URI
• As a mild exogenous infection from direct contact / air-borne

71. SYMPTOMS:
• SYMPTOMS:
• Burning & grittiness of eyes, specially in evening
• Mild chronic redness
• Feeling of heat & dryness on lid margins
• Difficulty in keeping eyes open
• Mild mucoid disharge
• On & off lacrimation
• Feeling of sleeping & tiredness in the eyes
• SIGNS:
• Congestion of posterior conjunctival vessels
• Mild papillary hypertrophy
• Surface of conjunctiva look sticky, congested lid margins

72. • TREATMENT:
• Elimination of predisposing cause
• Topical antibiotics : chloramphenicol / gentamycin 3-4 times for 2 weeks
• Astringent eye drops : zinc boric acid for symptomatic relief

73. Angular conjunctivitis (diplobacillary
conjunctivitis)
• chronic conjunctivitis confined to the conjunctiva & lid margins near
the angles
• associated with maceration of the surrounding skin.

74. • Etiology
1. Predisposing factors  'simple chronic conjunctivitis'.
2. Causative organisms. Moraxella Axenfeld (commonest). MA bacilli are
placed end to end 'diplobacillary conjunctivitis'.
staphylococci (Rare)
3. Source of infection nasal cavity.
4. Mode of infection.
nasal cavity to the eyescontaminated fingers or handkerchief.

75. pathology
MA produces a proteolytic enzyme
This enzyme collects at the angle by the action of tears
It causes maceration of epithelium of the conjunctiva, lid margin and the skin
vascular and cellular responses mild grade chronic inflammation.

76. • SYMPTOMS:
• Irritation discomfort
• H/O collection of dirty white foamy discharge at the angles
• Redness in the angles of the eye
• SIGNS:
• Hyperaemia of bulbar conjunctiva near the canthi
• Hyperaemia of lid margins near the angles
• Excoriation of skin around the angles
• Presence of foamy mucopurulent discharge at the angles

77. • COMPLICATIONS:
• Blepharitis
• Marginal catarrhal corneal ulceration
• TREATMENT:
• Good personal hygiene + treatment of nasal infections
• Oxytetracycline 1 % eye ointment 2-3 times x 10-14 days
• Zinc lotion at day time and zinc oxide ointment at bedtime

78. CHLAMYDIAL CONJUNCTIVITIS
TYPES OF INFECTIONS BY CHLAMYDIA

79. CHLAMYDIAL CONJUNCTIVITIS
Class 1: Blinding
Trachoma:
• Hyperendemic
trachoma
• Serotypes A,B,
Ba, C of C.
trachomatis
• Associated with
secondary
bacterial infection
• Eye to eye by
ocular discharge
Class 2: Non-blinding
Trachoma
• Serotypes A, B
Ba, C of C.
trachomatic
• Usually not
associated with
bacterial
infections
• Mild disease
Class 3:
Paratrachoma:
• Serotypes D to K
• From genitals to
eye
• Adult inclusion
conjunctivitis /
ophthalmic
neonatorum
JONES CLASSIFICATION

80. trachoma
• c/c keratoconjunctivitis,
• primarily affecting the superficial epithelium of conjunctiva & cornea
simultaneously.
• mixed follicular & papillary response of conjunctival tissue.
• one of the leading causes of preventable blindness in the world.

81. Etiology
CAUSITIVE ORGANISM:
• Chlamydia trrachomatis (Psittacosis-lymphogranulomatous
group)
• 11 serotypes (A to K)
PREDISPOSING FACTORS:
• Age: commonly in infancy & childhood, but age
no bar
• Sex: more in females
• Race: very common in Jews
• Climate: dry & dusty weather favors
• Socio-economic status: more in poor classes
• Environmental: exposure to dust, irritants,
smoke, sunlight etc
SOURCE OF INFECTION:
• Conjunctival discharge of affected person
• Superimposed bacterial infection increased
secretions more spread
MODES OF INFECTION:
• Direct spread by air-borne or water-borne
modes
• Vector transmission by flies
• Maternal transfer through contaminated
fingers, clothes, bedding etc

82. CLINICAL PROFILE:
• Incubation period:
• 5-21 days, mostly incidious onset
• Clinical course:
• Pure trachoma is mild & symptomless, often neglected
• If superimposed with bacterial infection, presents with typical bacterial conjunctivitis
• Natural History:
• Development of acute disease in 1st decade of life
• Continues with slow progression
• Becomes inactive in 2nd decade
• Sequelae occurs after 20 years of disease
• Peak incidence of blindness in 4th or 5th decade

83. • Symptoms:
• No secondary bact infection:
• Minimal or asymtomatic
• Mild FB sensation
• Occasional lacrimation
• Stickiness of lids
• Scanty mucoid discharge
• With secondary bact infection:
• All typical symptoms of acute bacterial conjunctivitis

84. Conjunctival signs:
• Congestion of upper tarsal and
fornicial conjunctiva
• Conjunctival follicles
• Papillary hyperplasia
• Conjunctival scarring
• Concretions
Corneal signs:
• Superficial keratitis
• Herbert follicles
• Pannus
• Corneal ulcer
• Herbert Pits
• Corneal opacity

86. • CONJUNCTIVAL FOLLICLES:
• Boiled sago-grains like appearance
• Upper tarsal conjunctiva
• also on bulbar conjunctiva also (pathognomonic of trachoma )
• Central part  mononuclear histiocytes,+ few
lymphocytes and large multinucleated cells ( Leber
cells).
• The cortical part a zoneof lymphocytes showing
active proliferation.
• Bloodvessels are present in the most peripheral part
• Signs of necrosis +

87. Presence of Leber cells &
signs of necrosis differentiate
trachoma follicles from follicles of other
forms of follicular conjunctivitis

88. CONJUNCTIVAL PAPILLAE:
• Reddish flat topped raised areas
• Give red velvety appearance to tarsal conjunctiva
• Central core of numerous dilated blood vessels surrounded by lymphocytes and
covered by hypertrophic epithelium

89. Conjunctival scarring
• which may be irregular, star-shaped or linear.
• Linear scar present in the sulcus subtarsalis } Arlt's line.

91. Concretions
due to accumulation of dead epithelial cells & inspissated mucus in the
depressions called glands of Henle.

92. CORNEAL SIGNS
• Superficial keratitis in the upper part.
.

93. Pannus formation
pannus
aggressive
regressive
infiltration of cornea is
ahead of vascularization.
vessels
extend a short distance beyond the area of
infiltration.
Infiltration of cornea + vascularization

94. Corneal ulcer
• develop at the advancing edge of pannus.

95. Corneal opacity
• Corneal opacity
• in the upper part.
• extend down and involve the pupillary area.

96. Herberts follicles
typical follicles present
in the limbal area.

97. Herberts pits
oval or circular brown pitted
scars, left after healing of Herbert follicles in
the
limbal area

98. McCallan’s Classification:
STAGE 1: Incipient Trachoma / stage of infiltration
• Hyperemia of conjunctiva & immature follicles
STAGE 2: Established Trachoma / stage of florid infiltration
• Mature follicles, papillae, progressive pannus
STAGE 3: Cicatrising Trachoma / stage of scarring
• Obvious scarring of palpebral conjunctiva
STAGE 4: Healed Trachoma / stage of sequelae
• Disease is cured
• Sequelae results in symptoms

100. WHO classification FISTO
• Active disease, predominantly follicles
• At least 5 or more follicles in upper palpebral conjunctiva
TF (Trachomatous Inflammation
– Follicular)
• Pronounced inflammatory thickening of upper palpebral
conjunctiva obscures > half of normal deep tarsal vessels
TI (Trachomatous Inflammation –
Intense)
• Presence of scarring in tarsal cunjunctiva
• Seen as white bands or sheets of fibrosis
TS (Trachomatous Scarring)
• When at least 1 eyelash rubs the ocular surface
• Evidence of recently removed trichiatic eyelashes
TT (Trachomatous Trichiasis)
• Easily visible corneal opacity present in pupillary area
• Causes significant visual impairment
Corneal Opacity

101. WHO classification FISTO

102. Sequelae of trachoma
lids:
• Trichiasis, entropion, tylosis, ptosis,
madarosis
conjunctiva:
• Concretions, pseudocysts, xerosis,
symblepheron
cornea:
• Corneal opacity, ectasia, xerosis, total corneal
pannus
Others:
• Chronic dacryosystitis, chronic
dacryoadenitis

103. DIAGNOSIS
• Clinical:
• Grading to be done as per WHO classification
• At least 2 sets of signs should be present:
• Conjunctival follicles and papillae
• Pannus
• Epithelial keratitis near superior limbus
• Signs & sequelae of cicatrization

104. Laboratory:
• Conjunctival cytologypolymorphonuclear reaction with presence
of plasma cells and Leber cells in Geimsa
• Detection of inclusion bodiesGiemsa stain, iodine stain or
IF staining
• ELISA for chlamydial antigens
• PCR
• Isolation & serotyping of organism

105. Differential diagnosis
Trachoma with follicular hypertrophy
• follicles in trachoma upper palpebral
conjunctiva and fornix
• papillae and pannus+
• Laboratory diagnosis of trachoma
helps in differentiation.
acute adenoviral follicular
conjunctivitis (epidemic keratoconjunctivitis)
• follicles in EKC Lower palpebral
conjunctiva and fornix

106. Trachoma with predominant papillary
hypertrophy
• pH of tears in trachoma it is acidic,
• follicles and pannus+
• Conjunctival cytology and other laboratory tests
for trachoma usually help in diagnosis.
palpebral
form of spring catarrh
• Papillae are large in size
• typical cobble-stone arrangement in spring
catarrh.
• pH of tears is usually alkaline in spring catarrh
• Discharge is ropy in spring catarrh.

107. • MANAGEMENT:
• Treatment of Active Trachoma:
• Topical therapy:
• 1% tetracycline / 1% erythromycin eye ointment 4 times daily for 6 weeks
• Systemic therapy:
• Tetracycline / erythromycin 250mg QID orally for 4 weeks
• Or Docycline 100mg BD orally for 4 weeks
• Or single dose of Azithromycin orally
• Combined therapy:
• Preferred when severe disease
• Or associated genital infection is pr

108. • MANAGEMENT:
• Treatment of Sequelae:
• Removal of concretions
• Epilation / electrolysis of trichasis
• Surgical correction of entropion
• Lubricating drops for xerosis
• Prophylaxis:
• Hygiene measures
• Early treatment of conjunctivitis
• Blanket antibiotic therapy in endemic areas:
• 1 % tetracycline ointment BD for 5 days in a month for 6 months

109. • MANAGEMENT:
• SAFE Strategy for Trachoma Blindness:
• Surgery to correct eyelid deformity & prevent blindness
• Antibiotics for acute infections & community control
• Facial Hygiene
• Environmental changes

110. ADULT INCLUSION CONJUNCTIVITIS
acute follicular conjunctivitis associated with mucopurulent discharge.
sexually active young adults.
• Etiology
• Caused by D to K of Chlamydia trachomatis.
• source of infection urethritis in males and cervicitis in females.
• The transmission contaminated fingers or more
contaminated water of swimming
pools(swimming pool
conjunctivitis)

111. • Incubation Period:
• 4-12 days
• Symptoms:
• Ocular discomfort, foreign body sensation
• Mild photophobia
• Mucopurulent discharge from the eyes
• Signs:
• Conjunctival hyperaemia, marked in fornices.
• Acute follicular hypertrophy predominantly of lower palpebral conjunctiva
• Superficial keratitis in upper half
• Superior micropannus occasionally
• Pre-auricular lymphadenopathy

112. • Treatment:
• Topical therapy:
• Tetracycline 1 % eye ointment QID for 6 weeks
• Systemic therapy:
• Very important
• Tetracycline 250 mg four times a day for 3-4 weeks.
• Erythromycin 250 mg four times a day for 3-4 weeks
• Doxycycline 100 mg twice a day for 1-2 weeks 200 mg weekly for 3 weeks
• Azithromycin 1 gm as a single dose

113. Viral conjunctivitis

114. Viral conjunctivitis
• corea+conjunctival involvement  keratoconjunctivitis
• Viral infections of conjunctiva include
• Adenovirus conjunctivitis
• Herpes simplex keratoconjunctivitis
• Herpes zoster conjunctivitis
• Pox virus conjunctivitis
• Myxovirus conjunctivitis
• Paramyxovirus conjunctivitis
• ARBOR virus conjunctivitis

115. Clinical presentation of viral conjunctivitis
• 1. Acute serous conjunctivitis
• 2. Acute haemorrhagic conjunctivitis
• 3. Acute follicular conjunctivitis

116. ACUTE SEROUS CONJUNCTIVITIS
• Etiology.
mild grade viral infection which does not give rise to follicular
response.
• Clinical features.
minimal degree of congestion,+
watery discharge +
boggy swelling of the conjunctival mucosa.
• Treatment.
self-limiting no treatment.
broad spectrum antibiotic eye drops 3 times a day for about 7 days(to
avoid secondary bacterial infection),

117. ACUTE HAEMORRHAGIC CONJUNCTIVITIS
Apollo conjunctivitis
multiple conjunctival haemorrhages,Conjunctival hyperaemia &
mild follicular hyperplasia.
• Etiology.
Picornaviruses (enterovirus type 70)
transmitted by direct hand-to-eye contact.

118. Clinical picture.
Incubation period
1-2 days.
Symptoms
pain,
redness, watering,
mild photophobia,
transient blurring of vision and
lid swelling.

119. Signs of EHC
conjunctival congestion,
chemosis,
multiple haemorrhages in bulbar conjunctiva,
mild follicular hyperplasia,
lid oedema and
pre-auricular lymphadenopathy.
Corneal involvementfine epithelial keratitis

120. treatment
• self-limiting course of 5-7 days.
• No specific effective curative treatment is known.
• broad spectrum antibiotic eye drops prevent secondary bacterial
infections.

121. Follicular conjunctivitis

122. Follicular conjunctivitis
formation of follicles+ conjunctival hyperaemia + discharge from the
eyes.
Follicles……….(resembles boiled sagograins) ……….tiny white
translucent, rounded swellings……….., 1-2 mm in diameter..
• localised aggregation of lymphocytes in the adenoid layer of
conjunctiva.

123. Types of follicular conjunctivitis
• Acute follicular conjunctivitis.
• Chronic follicular conjunctivitis.
• Specific type of conjunctivitis with follicle formation e.g., trachoma

124. Acute follicular conjunctivitis
• an acute catarrhal conjunctivitis
• associated with marked follicular hyperplasia especially of the lower
fornix & lower palpebral conjunctiva.

125. • Symptoms:
• Redness, watering, mild mucoid discharge
• Mild photophobia and feeling of discomfort
• Foreign body sensation
• Signs:
• conjunctival hyperaemia
• Multiple follicles, more prominent in lower lid than the upper lid

126. Etiological types of follicular conjunctivitis
• Adult inclusion conjunctivitis .
• Epidemic keratoconjunctivitis
• Pharyngoconjunctival fever
• Newcastle conjunctivitis
• Acute herpetic conjunctivitis.

127. Epidemic Keratoconjunctivitis (EKC)
• acute follicular conjunctivitis + superficial punctate keratitis
• as epidemics, EKC.
• Etiology.
• adenoviruses type 8 and 19
• spreads through contact with contaminated fingers, solutions and
tonometers.

128. Clinical picture
• Incubation period
• 8 days and virus is shed for 2-3 weeks

129. Clinical stages
acute serous
conjunctivitis
• non-specific
• conjunctival hyperaemia, mild
chemosis and
• lacrimation
acute follicular
conjunctivitis,
• formation of follicles which are
more marked inlower lid.
acute
pseudomembranous
conjunctivitis
• formation of a
pseudomembrane on the
conjunctival surface
SPK
• Corneal involvement
Pre-auricular lymphadenopathy in all cases

130. treatment
• supportive

131. Pharyngoconjunctival fever (PCF)
• Etiology.
• Adenovirus subtypes 3 and 7.
• Clinical picture
• acute follicular conjunctivitis,+
• pharyngitis, +
• fever & preauricular lymphadenopathy.
• children and appears in epidemic form.
• superficial punctate keratitis 30 %
• Treatment is usually supportive.

132. Newcastle conjunctivitis
• Rare
• Caused by Newcastle virus
• Contact with diseased owls
• Affects poultry workers
• Similar to pharyngoconjunctival fever

133. Acute herpetic conjunctivitis
• Associated with 'primary herpetic infection',
• mainly in small children and in adolescents.
Etiology
• HSV type 1 ,spreads by kissing or other close personal contacts.
• HSV type 2,( rarely.)

134. Acute herpetic conjunctivitis
• usually unilateral
• Incubation period of 3-10 days.
• Can be either typical/atypical
typical form
It is usually associated with other
lesions of primary
infection such as vesicular lesions of
face and
lids
• Corneal involvement+
• Preauricular LN+
atypical form, it
occurs without lesions of the face,
eyelid and the
condition then resembles epidemic
keratoconjunctivitis.

135. CHRONIC FOLLICULAR CONJUNCTIVITIS
• Mild chronic catarrhal conjunctivitis with follicles
predominantly in lower palpebral conjunctiva
• Etiology:
• Infective: benign folliculosis (school folliculosis)
• Toxic: due to cellular debris in molluscum contagiosum
• Chemical: prolonged use of pilocarpine, IDU, adrenaline
• Allergic: less commonly

136. Ophthalmia neonatorum
• Bilateral inflammn of the conjunctiva occurring in an infant,
(<30 days old).
• any discharge or even watering from the
eyes in the first week of life
ophthalmia neonatorum,
as tears are not formed till then

137. Source and mode of infection
• Before birth  infected liquor amnii in ruptured memb
• During birth infected birth canal (face prstn, forceps delivery)
• After birth  during first bath of newborn / 4m soiled clothes
fingers with infected lochia

138. Causative organism
• Chemical conjunctivitisAgNO3
• Gonococcal
• Other bacterialStaphylococcus aureus, Streptococcus
haemolyticus, and Streptococcus pneumoniae.
• Neonatal inclusion conjunctivitis
serotypes D to K of Chlamydia trachomatis
• Herpes simplex ophthalmia neonatorum
HSV2

139. • Incubation period:
• Chemical conjunctivitis: 4-6 hours
• Gonococcal infection: 2-4 days
• Other bacterial infections: 4-5 days
• Neonatal inclusion conjunctivitis: 5-14 days
• Herpes Simplex Ophthalmia Neonatorum : 5-7 days

140. • SYMPTOMS:
• Pain and tender eyeball
• Purulent conjunctival discharge (gonococcal)
• Mucoid / mucopurulent (other bacterial infections)
• Swollen lids
• Chemosed conjunctiva
• Corneal involvement rarely
• COMPLICATIONS:
• Corneal ulceration with tendency to perforate

141. prophylaxis
 Antenatal:
 Treatment of genital infections of mother
 Natal:
 Delivery under aseptic conditions
 Newborns eyelids should be well cleaned
 Postnatal:
 1% tetracycline / 0.5% erythromycin ointment
 1 % silver nitrate solution (Crede’s method)
 Single injection of Ceftriaxone 50mg/kg IM/IV

142. treatment
 CURATIVE TREATMENT:
 Chemical conjunctivitis: self-limiting
 Gonococcal:
 Topical:
 Saline lavge
 Bacitracin ointment QID
 Penicillin drops 5000-10000units per ml every min for 30 min, every 5 min for 30 min, and then
every 30m in till infection controlled
 Atropine ointment if corneal involvement
 Systemic:
 Ceftriaxone 75-100mg/kg/day IV/IM Q.I.D.
 Cefotaxime 100-150mg/kg/day IV/IM B.D.
 If gonococcal: cryst benzyl Peni G 50000 units for full term babies (20000 to premature) IM BD x 3
days

143. • CURATIVE TREATMENT:
• Other bacterial infections:
• Broad spectrum antibiotic drops / ointment x 2weeks
• Neonatal inculsion conjunctivitis:
• Topical tetracycline / erythromycin ointment QID x 3 weeks
• Plus systemic erythromycin 125mg QID x 3 weeks
• Herpes Simples:
• Self limiting, topical antivirals control effectively

144. Allergic conjunctivitis

145. • inflammation of conjunctiva
• due to allergic or hypersensitivity reactions
• which may be immediate (humoral) or delayed (cellular).

146. • 1. Simple allergic conjunctivitis
• Hay fever conjunctivitis
• Seasonal allergic conjunctivitis (SAC)
• Perennial allergic conjunctivitis (PAC)
• 2. Vernal keratoconjunctivitis (VKC)
• 3. Atopic keratoconjunctivitis (AKC)
• 4. Giant papillary conjunctivitis (GPC)
• 5. Phlyctenular keratoconjunctivitis (PKC)
• 6. Contact dermoconjunctivitis (CDC)

147. SIMPLE ALLERGIC CONJUNCTIVITIS
• mild, non-specific allergic conjunctivitis
• characterized by itching, hyperaemia and mild papillary response.

148. etiology
Seasonal allergic conjunctivitis (SAC).
• response to seasonal allergens such as grass pollens.
• common. hay fever conjunctivitis (ass. With hay fever)
Perennial allergic conjunctivitis (PAC)
• response to perennial allergens such as house dust and mite animal
fur.
• rare

149. PATHOLOGY
• .
• .
• Conjunctival response is in the form of boggyswelling of conjunctiva
followed by increased connective tissue formation and mild papillary
hyperplasia.

150. Vascular response
sudden and extreme
vasodilation
increased
permeability of vessels
leading to exudation
Cellular response
conjunctival
infiltration & exudation in the
discharge of
eosinophils, plasma cells and
mast cells producing
histamine and histamine-like
substances
Conjunctival response
boggy swelling of
conjunctiva increased
connective tissue formation
and mild papillary
hyperplasia.

151. • Symptoms
• intense itching and burning sensation in the eyes
• watery discharge
• mild photophobia.
• Signs.
• (a) Hyperaemia and chemosis swollen juicy appearance
• (b)Conjunctiva may also show mild papillary reaction.
• (c) Oedema of lids.

152. diagnosis
• Diagnosis is made from :
• (1) typical symptoms and signs;
• (2) normal conjunctival flora;
• (3) abundant eosinophils in the discharge+

153. treatment
• Elimination of allergens if possible.
• Local palliative :
• i. Vasoconstrictors adrenaline, ephedrine,and naphazoline.
• ii. Sodium cromoglycate in preventing recurrent atopic cases.
• iii. Steroid eye drops short duration in severe and non-responsive
patients.
• 3. Systemic antihistaminic acute cases with marked itching.
• 4. Desensitization

154. VERNAL KERATOCONJUNCTIVITIS (VKC)
SPRING CATARRH
• recurrent, bilateral, interstitial, self-limiting,
• periodic seasonal incidence.
Etiology
• hypersensitivity reaction to some exogenous allergen(grass pollens.
• IgE mediated atopic mechanisms
• Raised IgE + eosinophilia
• personal or family h/o other atopic diseases ( hay fever, asthma, or
eczema)

155. Predisposing factors:
• 4-20 years, common in males
• More in summer  'Warm weather conjunctivitis’
• Prevalent in tropics, non-existent in cold climate

156. pathology
• Conjunctival epithelial hyperplasia
• Marked infiltration in adenoid cell layer
• Proliferation of fibrous layer
• Conjunctival vascular proliferation
vasodilation & permeability
Formation of multiple
papilllae in upper tarsal
conjunctiva

157. • Marked burning and itching, more in warm climate
• Mild photophobia, lacrimation
• “Ropy(stingy) Discharge”
• Heaviness of eyelids

158. signs
• Palpabrel form:
• Upper tarsal conjunctiva
• Presence of hard, flat topped, papillae arranged in 'cobble-stone' or
'pavement stone', fashion
• Giant papillae in severe cases
• White ropy conjunctival discharge

159. • Bulbar form:
• Dusky red triangular congestion of bulbar conjunctiva in palpebral area
• Gelatinous thickened accumulation of tissue around the limbus
• Presence of discrete whitish raised dots along the limbus (Tranta's spots)
• Mixed:
• Combined features of both forms

160. Corneal involvement inVKC
• Punctate epithelial keratitis:
• Involves upper cornea, mostly in palpebral form
• Lesions always stain with rose bengal
• Ulcerative vernal keratitis:
• (shield ulceration)
• Shallow transverse ulcer in upper part of cornea due to epithelial
macroerosions
• Vernal corneal plaques:
• Due to coating of areas of epithelial macroerosions with coating of altered
exudates

161. • Subepithelial scarring:
• In a form of a ring scar
• Pseudogerontoxon
a lesion that resembles a small segment of arcus senilis( gerontoxon)
and is seen in many individuals with limbal vernal or atopic
keratoconjunctivitis. It is an important clinical finding because
pseudogerontoxon is often times the only clinical evidence of previous
allergic eye disease.

162. • Clinical course:
• Disease is self-limiting
• Usually goes off spontaneously in 5-10 years
• Differential diagnosis:
• Trachoma with predominantly papillary hypertrophy

163. treatment
• Local therapy
• Topical steroids:Flouromethalone, dexamethasone, loteprednol
Use should be minimal and for short-duration
Frequent instillation (4 hourly for 2 days) maintenance therapy for 3-4
times a day* 2 weeks.
• Mast cell stabilizers:Sodium cromoglycate, azelastine, ketotifen
• Topical antihistaminic eye drops
• Acetyl cysteine (0.5%) eye drops mucolytic property
• Topical cyclosporine 1% eye drops

164. Systemic therapy
• Oral histaminics
• Oral steroids in severe cases for short duration
Treatment of large papillae:
• Supratarsal injection of long acting steroid
• Cryo application
• Surgical excision for extra-ordinary large papillae

165. General measures:
• Dark goggles
• Cold compress & ice packs
• Change of environment (working environment also)
Desensitization
• Not much awarding results
Treatment of vernal keratopathy:
• PEK : steroid instillation should be increased
• Large vernal plaque: surgical lamellar keratectomy
• Severe shield ulcer: debridement, superficial keratectomy, amniotic membrane
transplantation

166. Atopic keratoconjunctivitis (AKC)
• Adult equivalent of vernal keratoconjunctivitis
• associated with atopic dermatitis
• Mostly young male adults
Symptoms:
• Itching, soreness, dry sensation
• Mucoid discharge
• Photophobia or blurred vision

167. Signs:
• Lid margins:
• chronically inflamed
• rounded posterior borders
• Tarsal conjunctiva:
• milky appearance
• very fine papillae, hyperaemia and scarring with shrinkage
• Cornea:
• punctate epithelial keratitis
• more severe in lower half
• corneal vascularization, thinning and plaques.

168. • Clinical course:
• Protracted course
• Tends to become inactive by 5th decade
• Treatment:
• Often frustrating
• Treat lid disease effectively
• Mast cell stabilizers, steroids, tear supplements may be beneficial

169. Giant papillary conjunctivitis
• very large sized papillae.
• Etiology.
• It is a localised allergic response to a
physically rough or deposited surface (contact lens,
prosthesis, left out nylon sutures).

170. • Symptoms.
• Itching,
• stringy discharge and
• Reduced wearing time of contact lens or prosthetic shell.
• Signs.
• Papillary hypertrophy (1 mm in diameter) in the upper tarsal
conjunctiva

171. treatment
• Treatment
• 1. The offending cause should be removed.
• 2. Disodium cromoglycate.
• 3. Steroids are not of much use in this condition.
spontaneous
resolution

172. PHLYCTENULAR KERATOCONJUNCTIVITIS
• characteristic nodular affection
• occurring as an allergic response of the conjunctival and corneal
epithelium
• to some endogenous allergens to which they have become
sensitized.

173. Etiology
• : Delayed hypersensitivity
• Causative allergens
• Tuberculous, Staphylococcus
• Proteins of Moraxella Axenfeld bacillius, Parasites
• Predisposing factors
• Age. Peak age group is 3-15 years.
• Sex.f>m.
• Undernourishment
• Living conditions. Overcrowded and unhygienic.
• Season. all climates (spring and summer seasons

174. pathology
• Stage of nodule formation:
• exudation and infiltration of leucocytes
• neighbouring blood vessels dilate and their endothelium proliferates.
• Stage of ulceration:
• Necrosis apex of the nodule and an ulcer is formed
• Stage of granulation:
• Eventually floor of the ulcer becomes
covered by granulation tissue.
• Stage of healing
• Healing occurs usually with minimal
scarring.

175. Symptoms
• Very few
• Mild discomfort, discharge, irritation, reflex tearing

176. signs
• Occur in 3 forms
• 1. Simple phylctenular conjunctivitis. (Commonest)
• pinkish white nodule surrounded by hyperaemia, near the
limbusulceratedepithelised. Rest of the conjunctiva is normal.
• 2.Necrotizing phlyctenular conjunctivitis
• very large phlycten with necrosis and ulceration a severe pustular
conjunctivitis
• 3.Miliary phlyctenular conjunctivitis
• multiple phlyctens
• arranged haphazardly or in the form of a ring around the limbus a ring
ulcer.

177. Phlyctenular keratitis.
1’ly affectedrare
2’ly affectedextended 4m conjunctival phlycten
• in two forms: the 'ulcerative phlyctenular keratitis' or 'diffuse
infiltrative keratitis'.
Phlyctenular
keratitis
Ulcerative
sacrofulous
fascicular
miliary
diffuse

178. Ulcerative phlyctenular keratitis
• three forms:
Sacrofulous
Fascicular
miliary

179. • 1. Sacrofulous ulcer shallow marginal ulcer formed due to breakdown
of small limbal phlycten.
• It differs from the catarrhal ulcer in that there is no clear space
between the ulcer and the limbus and its long axis is frequently
perpendicular to limbus.
• Such an ulcer usually clears up without leaving any opacity

181. • 3. Miliary ulcer. multiple small ulcers are scattered over a portion of
or whole of the cornea.

182. Diffuse infiltrative phlyctenular keratitis
• appear in the form of central infiltration of cornea
• with characteristic rich vascularization from the periphery, all around
the limbus.
• It may be superficial or deep.

183. • Treatment:
• Local therapy:
• Topical steroid eye drops and ointment
• Topical antibiotic eye drops & ointment
• Atropine eye ointment when cornea involved
• Systemic therapy:
• Diagnosis & management of TB
• Septic foci like caries, folliculitis, tonsillitis, adenoiditis to be adequately treated
• Parasitic infestations to be ruled out & treated if present
• General measures:
• Improve hygiene & supplement high-protein diet

184. CONTACT DERMOCONJUNCTIVITIS
• It is an allergic disorder, involving conjunctiva and
• skin of lids along with surrounding area of face.
• Etiology
• delayed hypersensitivity (type IV)response to prolonged contact with
chemicals and drugs (atropine, penicillin, neomycin, soframycin and
Gentamycin)

185. Clinical picture
• 1. Cutaneous involvement
• Weeping eczematous reaction
• 2. Conjunctival response
• hyperaemia
• generalised papillary response affecting the lower fornix and lower
palpebral conjunctiva more than the upper.

186. Diagnosis :
• Typical clinical picture.
• Conjunctival cytology shows a lymphocytic response with masses of
eosinophils.
• Skin test to the causative allergen is positive in most of the cases.

187. Treatment:
• 1. Discontinuation of the causative medication,
• 2. Topical steroid eye drops to relieve symptoms,
• 3. Application of steroid ointment on the involved skin.

188. Parinaud's oculoglandular syndrome
• 1. Unilateral granulomatous conjunctivitis (nodular elevations
surrounded by follicles),
• 2. Preauricular lymphadenopathy, and
• 3. Fever.
• causes  tularaemia, cat-scratch disease, tuberculosis, syphilis and
lymphogranuloma venereum

189. Ophthalmia nodosa (Caterpillar hair conjunctivitis)
• granulomatous inflammation of the conjunctiva
• formation of a nodule on the bulbar conjunctiva in response to
irritation caused by the retained hair of caterpillar.
Histopathological examination
• Hair surrounded by giant cells and lymphocytes.
Treatment
• excision biopsy of the nodule

190. DEGENERATIVE CONDITIONS

191. PINGUECULA
• YELLOWISH WHITE
• TRIANGULAR PATCH WITH APEX AWAY FROM CORNEA
• ON BULBAR CONJUNCTIVA NEAR LIMBUS
• B/L
• AFFECTS NASAL SIDE INITIALLYTEMPORAL

192. ETIOLOGY OF PINGUECULA
• AGE CHANGE
• EXPOSURE TO STRONG SUNLIGHT
• PRECURSOR OF PTERYGIUM

193. PATHOLOGY
• ELASTOTIC DEGENERATION OF COLLAGE FIBRES OF SUBSTANTIA
PROPRIA OF CONJUNCTIVA
+
• DEPOSITION OF AMORPHOUS HYALINE MATERIAL

194. COMPLICATIONS
• INFECTIONS
• PTERYGIUM
• INTRAEPITHELIAL ABSCESS FORMN

195. TREATMENT
• NO ROUTINE
• IF NEEDED EXCISION

197. PTERYGIUM
• TRIANGULAR FOLD OF CONJUNCTIVA
• ENCROACHING CORNEA FROM EITHER SIDE
• WITH IN INTERPALPEBRAL FISSURE
• USUALLY ON NASAL SIDE

198. Parts of pterygium
parts
BODY (ON SCLERA)
NECK (ON LIMBUS)
HEAD (ON CORNEA)

199. Types of pterygium
pterygium
progressive
regressive
Thick fleshy vascular
Cap of pterygium (few
infiltrate infront of head)
Thin atrophic
No cap

200. etiology
• Exposure to uv
• Sunlight
• Heat
• Dust
• wind

201. PATHOLOGY
• DEGENERATION OF SUBCONJUNCTIVAL TISSUE
• PROLIFERATION OF VASCULAR GRANULATION TISSUE

202. symptoms
• Asymptomatic early
• Cosmetic
• Visual disturbance on reaching cornea
• Diplopia (limitation of ocular movements)

203. complications
• Cystic degeneration
• Infection
• Neoplastic changeepithelioma ,fibrosarcoma , malig. Melanoma
• Corneal astigmatism

204. DD
• PSEUDOPTERYGIUM bulbar conjunctiva adheres to cornea at site of
burns
• Probe test probe can be passed underneath pseudopterygium

206. treatment
• Surgical excision
• Indications
1. Cosmetic
2. Diplopia
3. Encroaching pupillary area (if once it crosses one margin wait till it
crosses other margin)

207. technique
Topical anaesthesia Cleansing of eye draped & exposed using universal speculum
Lift the head & dissect off from cornea
Separate from superficial conjunctiva & underlying sclera
Excise without damaging MR muscle
Hemostasis through cauterization

209. Limbal conjunctival autograft transplantation
(LLAT) to
cover the defet after
pterygium
excision is the latest and most
effective
technique in the management of
pterygium.
In bare sclera technique, some part
of
conjunctiva is excised and its edges
are
sutured to the underlying episcleral
tissue
leaving some bare part of sclera near
the
limbus (Fig. 4.29D).
Free conjunctival membrane graft may
be
used to cover the bare sclera (Fig.
4.29E).
This procedure is more effective in
reducing
recurrence. Free conjunctiva from the
same
or opposite eye may be used as a graft.

210. Autograft technique

211. Bare sclera technique

212. Decrease recurrence
• Surgical excision with bare sclera.
• Surgical excision with free conjunctival graft taken =preferred
technique.
• B irradiation
• Antimitotis = mitomycin & thiotepa
• Transplantation of pterygium in the lower fornix (McReynold's
operation)

213. Concretions/lithiasis
• In elderly
• Accumalation of mucus & dead epithelial cell debris in conjunctival
depressions ( henles loop)
• In palpebral conjunctiva (upper>lower)
• Yellowish white raised  fb sensation , lacrimationcorneal
abrasion
• Hypodermic needle under topical anaesthesia