ConjunctivaDr. Ernita Tantawi Sp.M

Conjunctiva sac :1.marginal2.tarsal3.orbital4.Fornix 5.Bulbar6.limbal

Histology :Lapisan epitelSuperfisial,mengandung sel GobletmusinBasal,menangkap zat warna lebih dalam daripada sel2 spf,dekat limbus bisa berisi pigmen

Lapisan stromaLapisan adenoid,tdd jar.limfoidLapisan fibrosa,tdd jar.ikat.melekat pd tarsus secara hexagonal

Bacteriology :Tidak pernah bebas dari mikroorganismeBakteri tidak mudah berkembang biak krn:Reflex mengedip dan air mata: membersihkanSilia:filter debu yg mungkin mgd bakteriTemperatur relatif rendah o.k terpapar kedunia luar,suplai darah sedangLisozim : bakteriostatik

Bacteriology : Mikroorganisme yang dapat dijumpai pd sakus konjungtiva (flora normal mata)

Terbanyak : stafilokok dan difteroidIn children

Terjadinya dan beratnya infeksi dipengaruhiVirulensi dari kumanCara masuknyaAdanya faktor resikoDaya tahan tubuh

KLASIFIKASI : radang : pembagian menurut gb klinis dan penyebab perubahan degenerativeKista and Tumors

General OphthalmologyConjunctivitisinfectionallergyautoimmunechemical / irritatesunknown causeDegenerative diseaseMiscellaneous disordersTumors

Pemeriksaan mata ( inspeksi ) :Kaca pembesar (loupe)flashlight / senterKelopak mata atas harus dieversi

Gambaran klinik :hyperemia = focal / diffuse dilatation of subepithelial plexus of conjunctival blood vesselschemosis = conjunctival edematearing = excess tears from increased lacrimation or impaired lacrimal outflowdischarge = exudates on the conjunctival surface: serous, mucoid, mucopurulent, purulent

Papillla = dilated conjunctival blood vessel, surrounded by edema and inflammatory cellsFollicle = focal lymphoid nodule with accessory vascularizationPseudomembrane = inflammatory coagulum on conjunctival surface that doesnt bleed during removalMembrane = inflammotory coagulum on the conjunctival surface that bleeds when stripes

Granuloma = nodule of chronic inflammatory cells with fibrovascular proliferationPhlyctenule = a nodule of chronic inflammatory cells, often at near or the limbusPunctate epithelial erosion = loss of individual epithelial cells in a stippled patternEpithelial defect = focal ara of epithelial loss

inflammation of the conjunctiva :origin :infectionallergyhyperemiasecret

Common Causes of conjunctival InflammationPapillary conjunctivitis: allergic, bacterialFollicular conjunctivitis: adenovirus, mollusucum contangiosum, chlamydial, HSV, drug-inducedConjunctival pseudomembrane or membrane: severe viral/bacterial, stevens-jhonson syndr, chemical burnConjunctival granuloma: cat-scratch disease, sarcoidosis, foreign-body reactionConjunctival erosion or ulceration: stevens-jhonson syndrome, cicatrical pemphigoid, graft-host disease,

Secret :serous : viralmucous, mucopurulent : bacteriapurulent : beware of gonococcusbacterial investigation by gramhistological investigation by giemsa

Infection of the conjunctivaAcute :serouscatarrhalmucopurulentpurulentmembranouschronic :simple chronic conjunctivitisangular conjunctivitisfollicular conjunctivitis

Acute Catarrhal or muco-purulent conjunctivitis Hyperemia that associated with a mucous discharge ---> gums lid together (especially in the morning)The whole conjunctiva is a fiery red (pink eye)Reaches its height in 3 - 4 daysRare complication, but cornea abrasion may occurEtiology :Staphylococci (most common)Haemophilus aegyptiusPneumococcalAccompanies exanthema such as measles and scarlet fever

Treatment :bacteriostatic dropthe eyes should not be bandageddark google should be worn if photophobia is presentcare must be taken due to contagious disease Prognosis :Most of cases are goodNeglected cases are treated as chronic conjunctivitis

Purulent conjunctivitisOccurs in two forms :Babies : ophthalmia neonatorumAdult : conjunctivitisMain and most dangerous etiology: gonococcus, N. gonorrheaDirect infection from genitalClinical finding :Swelling of the lids and conjunctivaCopious purulent dischargeConstitutional disturbanceUlcer may occur at any part of cornea

Treatment :appropriate systemic and topical antibiotic the eyes should be irrigated with warm saline and intensive solution of crystalline benzylpenicilin if any purulent discharge presentshould be directed first to protection of to other eye In Cicendo Eye Hospital :cefotaxime I.m.gentamycine or sulfacetamide eye drops

Ophtalmia Neonatorumfound in newborn children due to maternal infectionresponsible for 50% of blindness in childrenE/ : Severe : N. gonorrheaMild :Chlamydia oculogenitalis, Streptococcus pneumonia

Clinical findings :conjunctiva : inflamed, bright red, swollen, yellow pusat severe muco-purulent conjunctivitis : infiltration at bulbar conjunctiva & lids are swollen and tensecorneal ulceration if untreated

Prophylaxis:The babys lids should be cleansed and driedIf infection is suspected use : Credes method : a drop of silver nitrate solution 1% into each eyeTreatmentfor ophtalmia neonatorum : penicillin, tetracycline & eritromicyn by mouthfor penicillinase-producing N. gonorrhoeae: cephalosporin & gentamicin 0,3% dropIn Cicendo Eye Hospital :cefotaxime I.m.gentamycine or sulfacetamide eye drops

Membranous conjunctivitisKnown also as diphtheritic conjunctivitisE/ : diphtheria bacillus, pneumococcus & streptococcusoccur esp. at children who have not been immunized, after measles, scarlet fever w/ impetigo

Clinical findings :mild cases : swelling of the lids, muco-purulent or serous dischargesevere cases : lids are more brawny, conjunctiva is permeated w/ semisolid exudates, tend to necrotize conjunctiva and corneaTreatment :treated as diphtherial : penicillin and antidiphtheritic serum (4-6-10.000 units repeated in 12 hours)

Simple chronic conjunctivitisContinuation of simple acute conjunctivitisEtiology :irritation : smoke, dust, alcohol, etchypersensivitySymptoms :burning and grittiness (especially in the evening)difficult to keep eyes openposterior conjunctival vessels are seen to be congested

Treatment :This consist in eliminating the cause and restoring the conjunctiva to its normal condition. Swab should be takenshort course of suitable antibiotic

Follicular conjunctivitisInclusion conjunctivitisRelatively acute onsethypertrophy is always prominent in the lower lidE/ : chlamydial infection

relatively benignhealing spontaneously in from 3 to 12 monthstopical broad spectrum antibioticssystemic Antibiotics (tetracycline 250 mg every 6 hours for 14 days)

Epidemic kerato-konjunctivitischaracterized by a rapidly developing follicular conjunctivaassociated with pre-auricular adenopathymay lead to corneal complicationassociated with adenovirusTreatment by adenine arabinoside (Ara-A) is promisingHerpes simplex conjunctivitisdetected by the fluorescent antibody (FA)usually seen in young childrentiny ulcers on the intermarginal portion of eyelid ----> with flourescin test

TrachomaE/ : Chlamydia trachomatisUsually starts sub acutelyprimary infection is epithelial both conjunctiva and the corneatypical conjunctival sign :diffuse inflammation ---> congestionpapillary enlargementdevelopment of folliclesoccuring in 4 stagetrachomatous pannus may develops at a later stage

Stage of Trachoma Stage 1: earliest stage, before clinical diagnosis is possibleStage 2: periode between the appereance of typical trachomatous lession & the development of scar tissue Stage 3: scarring is obviousStage 4: the desease become quiet, cicatrization

WHO: TF: folicular conjunctival inflammation TI: diffuse conjunctival inflammationTS: tarsal conjunctival scarringTT: trichiasis or enteropionCO: corneal opacification

Treatment :the ideal has not been developedtetracycline, erythromycin, rifampicin and sulfonamides are efectivepannus requires no special treatmentcorneal complication (ulcers) must be treated on general principles

Allergic type of ConjugtivitisAcute or sub acute allergic catarrhal conjunctivitiswatery secretion (not purulent)allergen sometimes is a bacterial protein (staphylococcus is most common)treatment :allergen removalastringent lotionantihistamine drop is more effective

Eczematous conjunctivitischaracterized by one or more small grey or yellow nodules on the bulbar conjunctivafrequently complicated by muco-purulent conjunctivitisE/ : endogenous bacterial proteinSymptoms : discomfort and irritation associated with reflex lacrimationTreatment : Steroid drop or ointment

Vernal conjunctivitisbilateral conjunctivitis occur in hot weathersymptom :burning, itching, photophobia and lacrimationwhite & ropy secretiontwo types :palpebral formbulbar form

Treatment :symptomaticsteroid drops or ointmentcryotherapy (for nodule)mast cell stabillizer Disodium cromoglycate 2% (adjuvant to topical steroid)

Degenerative ChangesLithiasishard yellow spots in the palpebral conjunctivacommon in elderly peopleremoved with sharp needlePingueculatriangular patch on conjunctivalooks like fat (yellow color)no treatment required

Pterygiumproliferate subconjunctival tissue as vascularized granulation to invade the corneafrequently follow a pinguecula

Pterygium morphology grading system:Grade T1: athrophic pterygiumGrade T2: intermediate pterygiumGrade T3: fleshy pterygium

Options for wound clossure after extirpation:Bare scleraSimple clossureSliding flapRotational flapConjungtival graft

Symptomatic conditionSubconjunctival ecchymoseddue to rupture of small vesselsthe blood becomes absorbed without treatment in 1 - 3 weeks

Chemosisedema of conjunctivaoccur in :acute inflammationobstruction to the circulationabnormal blood condition

Xerophthalmiadry condition of the conjunctivadue to deficiency of vitamin Aaccompanied by night blindnessoccurs in two groups :as a sequel of a local ocular affectionassociated with general diseaseClinical findings :bitots spots

Classification by ocular sign :Night blindness (XN)conjunctival xerosis (X1A)Bitots spot (X1B)Corneal xerosis (X2)Corneal ulceration/keratomalacia < 1/3 of corneal surface (X3A)Corneal ulceration/keratomalacia > 1/3 of corneal surface (X3B)Corneal Scar (XS)Xerophthalmic fundus (XF)

Cysts and TumorsCystlymphangiectasislymphangiomataSubconjunctival cysticercus ---> rarehydatid cysts ---> rareEpithelial implantation cysts ---> rare, occur after injuries or strabismus operations

TumorsCongenital tumorsDermoids

Dermo-lipomata

Large papillaepapillomatasimple granulomataeptheliomataPigmented tumorsNaevi

Precancerous melanosis

Malignant melanomaRodent ulcer

ReferencesStephen J.H. Miller, Parsons Disease of The EyeD, Vaughan, General OphthalmologyAmerican Academy of Ophthalmology, External Disease and Cornea