Lecture 4, Conjunctiva PDF

 Thin, translucent, vascular mucous membrane which covers the under surface of the lids and is reflected over the anterior part of the eyeball up to limbus.  It is considered as the wrapping membrane of the eye.  It covers the under surface of both upper and lower lids....

 Thin, translucent, vascular mucous membrane which covers the under surface of the lids and is reflected over the anterior part of the eyeball up to limbus.  It is considered as the wrapping membrane of the eye.  It covers the under surface of both upper and lower lids.  Palpebral conjunctiva is adherent to tarsus and cannot be easily dissected.  It is very thin. ① The marginal conjunctiva starts at the grey line of the lid margin and ① PALPEBRAL merges into the sub-tarsal groove. ② The tarsal conjunctiva is thin, transparent and very vascular. It is closely adherent to the tarsal plate. ③ The orbital conjunctiva lies between the proximal border of the tarsal plate and the fornix.  It covers the anterior part of the eyeball. ② BULBAR  It is loosely attached to the underlyingtissue but it is firmly adherent to the Tenon’s capsule 3 mm around the limbus.   Conjunctival fold (cul-de-sac) formed by the reflection of the palpebral conjunctiva on to the anterior portion of the eyeball. It is a loose (eyeball ③ FORNICES moves freely) but thick membrane.  The conjunctiva of the fornix is richly supplied with blood vessels and contains the accessory lacrimal glands of Krause. ④ PLICA  Crescentic fold of the conjunctiva situated at the inner canthus. SEMILUNARIS ⑤ CARUNCLE  The fleshy mass situated on the plica semilunaris.  Stratified squamous non keratinized epithelium. ① EPITHELIUM  It contains goblet cells that secrete mucous.  It is the connective tissue underlying the surface epithelium.  The stroma comprises the following layers: ① Superficial adenoid layer:  made up of extremely fine fibrous network, profusely infiltrated ② SUBSTANTIA with lymphocytes among which few mast cells and histiocytes PROPRIA may be found.  Glands such as glands of Krause, glands of Wolfring. ② Deep fibrous layer: Thick meshwork of collagenous and elastic fibers.  This layer is absent over the tarsal region.  The anterior and posterior conjunctival arteries and veins. The preauricularand submandibular lymph nodes.  Micro-organisms are mechanically washed out by the flow of tears. ① SECRETORY Lysozyme, being a normal constituent of the lacrimal fluid, inhibits the multiplication of most conjunctival micro-organisms. ② EPITHELIAL  The desquamation of the conjunctival epithelium and its rapid BARRIER reformation is a barrier against bacteria. ③ LYMPHATIC  There is a lot of lymphoid tissue in the conjunctiva. BARRIER ① IRRITATION  Discomfort, itching, burning and foreign body sensation.  Depending on etiology and severity of inflammation, discharge may be: ① Serous (watery). ② DISCHARGE ② Mucoid. ③ Mucopurulent. ④ Purulent. ③ CHEMOSIS  Edema of subepithelial connective tissue.  Conjunctival injection due to dilatation of the posterior conjunctival vessels sweeping forwards from the fornices. ④ HYPEREMIA  Focal collections of lymphocytes in substantia propria of the conjunctiva.  They are most prominent in inferior fornix as gelatinous elevations.  They are commonly caused by: ① Viral infections: As adenovirus, herpes or molluscum contagiosum. ② Chlamydia: Trachoma and adult inclusion conjunctivitis. ③ Drug reaction: Atropine, Epinephrine, and glaucoma medications. ⑤ FOLLICLES   Non-specific response to chronic irritation leading to epithelial proliferation with a vascular core.  They are seen on the superior tarsal conjunctiva as multiple red bumps each with a central core of vessels.  They are commonly caused by: ① Chronic infections. ② Allergy. ⑥ PAPILLAE  The size of the papillae is usually restricted by the fibrous septa attaching the conjunctiva to the underlying tarsus. With severe and chronic inflammation, these septa rupture and the papillae coalesce to form giant papillae.  They are commonly caused by: ① Prolonged contact lenses wear (giant papillary conjunctivitis). ② Vernal keratoconjunctivitis (spring catarrh). ⑦ GIANT PAPILLAE   Damage of the conjunctival vessels and epithelial surface by severe inflammation can cause exudation of fibrin, inflammatory cells, necrotic cells and serous fluid, forming a dirty grayish membrane on the surface. Removal of a membrane produces a raw bleeding surface; they usually lead to adhesions between different parts of the conjunctiva or between ⑧ MEMBRANE the conjunctiva and the cornea.  These adhesions are called symblepharon.  The most common causes are: ① Diphthericconjunctivitis. ② Alkali or acid burns. ③ Severe viral infections.  Formed by condensation of discharge and exudates over the conjunctival surface.  They are easily removed leaving an intact, epithelial surface. ⑨ PSEUDO- MEMBRANES FOLLICLES PAPILLAE White-grey nodules (WBC Inflamed areas of elevated APPEARANCE accumulation) conjunctiva BV Avascular Central blood vessel CONJUNCTIVITIS Chlamydia, toxic, viral Non-specific, allergic, bacterial ACRONYM "CTV" "pABillae"  CONJUNCTIVAL INJECTION CILIARY INJECTION Bright red in color Pink Fine, straight & radiate from the Tortuous and dilated vessels Cornea Superficial Deep Moves freely with moving BLOOD VESSELS Cannot move with conjunctiva Conjunctiva More marked at the fornix More marked at the limbus Vessels are seen (not blurred) Vessels are blurred Vessels are constricted by Adrenaline Not constricted by adrenaline Form posterior Conjunctival vessels Form anterior ciliary vessels. Keratitis CAUSES Conjunctivitis Corneal ulcer Iridocyclitis   Bacterial: According to the type of discharge it is subdivided into: ① Mucopurulent conjunctivitis. ② Purulent conjunctivitis:  Gonococcal conjunctivitis occurring in adults  Ophthalmia neonatorum conjunctivitis in newly born infants. ① ACUTE INFECTIVE ③ Membranous conjunctivitis: This may be pseudo or true CONJUNCTIVITIS membranous conjunctivitis.  Viral: Usually shows follicular conjunctivitis. It includes: ① Adenoviral conjunctivitis. ② Acute haemorrhagic conjunctivitis (Apollo virus) ③ Acute herpetic conjunctivitis ⑥ Chronic infective ① Angular conjunctivitis. Conjunctivitis ② Trachoma (caused by Chlamydia) 1 Hypersensitivity to exogenous allergen: ① Vernal kerato-conjunctivitis (spring catarrh). ② Atopic kerato-conjunctivitis ⑦ Non-infective Conjunctivitis ③ Giant papillary conjunctivitis. 2 Hypersensitivity to endogenous allergen:  Phlyctenular conjunctivitis  ① Koch-Week's bacillus: Causes epidemics in April, May, September, and CAUSATIVE October. AGENTS ② Staphylococcus aureus & epidermidis ③ Pneumococci. ① Discomfort and redness. ② Discharge: Mucopurulent (Composed of mucus and pus). SYMPTOMS ③ Haloes around the light: if the discharge crosses the cornea. ④ Heat sensation (burning). ① Lid edema. ② Hyperemia of the conjunctiva (conjunctival injection). ③ Mucopurulentdischarge formed of a mixture of mucus, tears, leucocytes and serum. ④ Gluing of lashes by the discharge especially in the morning on waking up. ⑤ Conjunctival edema (chemosis). ⑥ Petechial hemorrhage in severe cases. SIGNS  The disease reaches its height in a few days.  The disease may disappear in two weeks if untreated (self-limiting) or COURSE & become chronic. COMPLICATIONS  Corneal ulcer may occur only if the cornea gets abraded during infection (usually superficial, crescent shaped, & marginal).   Combat of flies is essential.  Towels and bed clothes of infected patients must be used privately & PROPHYLAXIS boiled.  Care must be taken to protect the other eye. ① Frequent washing:  with sterile water or boric acid lotion 4% to remove discharge. ② Hot fomentations (heat→ VD→ ↑ blood supply carrying Abs). ③ Local antibiotic eye drops used frequently e.g. Choloramphenicol, Gentamycin, Tobramycin, Quinolones & Fucidic acid. ACTIVE ④ Antibiotic ointment as Terramycin or Tobramycin at night: TREATMENT  Long acting effect due to slow release of the antibiotic.  Prevents gluing of lashes. ⑤ Systemic antibiotics in severe cases. ⑥ Dark glasses for cases with photophobia. ⑦ No bandage as it accumulates discharge and allows more multiplication of the organism. PURULENT CONJUNCTIVITIS   Acute suppurative inflammation characterized by copious formation of DEFINITION pus with enlargement of the draining LNs.  Gonococci are the most common causative organisms (80%). CAUSATIVE  Gram-negative diplococcic. AGENTS  Rarely: Streptococci, Staphylococci  Epidemic type: most common type occurring during summer. CLINICAL TYPES  Genital type: adult males suffer more. It occurs by auto-infection by hand OF GONOCOCCAL from genital gonorrhoea. CONJUNCTIVITIS  Ophthalmia neonatorum: In babies from there mothers during birth.  Incubation period: Few hours to 3 days.  Stage of infiltration: ① Lid edema and tenderness. ② Marked conjunctival edema. ③ Marked hyperemia: Conjunctival injection, subconjunctival hemorrhage. CLINICAL PICTURE AND ④ Watery or mucoid discharge. STAGES ⑤ Enlarged tender pre-auricular lymph nodes may be detected.  Stage of discharge: ① Decreased lid edema, the lids are tense and may be painful. ② Decreased edema with hyperemia and papillae formation at the palpebral conjunctiva (velvet-like). ③ Profuse purulent discharge.  Purulent conjunctivitis disappears spontaneously within 2 weeks or after treatment. COURSE &  Chronicity→ papillary thickening of conjunctiva for several weeks COMPLICATIONS  Gonococci are capable of invading the corneal epithelium producing severe corneal ulcers which are liable to perforate.   Same treatment of MPC including frequent lotions and antibiotic drops. A ACTIVE smear is done to know the causal organism. TREATMENT  Local treatment: Gentamycin or Bacitracin drops & ointment.  Single injection of Cefotriaxone for gonococcal cases. PURULENT CONJUNCTIVITIS   Conjunctival inflammation during the first month of life, usually caused by DEFINITION contamination from maternal passages during delivery. ① Gonococci: cause purulent conjunctivitis. CAUSATIVE ② Chlamydia (serotypes D, E, and F) AGENTS ③ Other bacterial infections e.g. staph, Strept, Pneumococci... ④ Herpes Simplex (genital herpes): type 2 Herpes simplex.  Treatment of the mother before labor especially herpetic cervicitis.  Washing of the body of the baby from above downward. PREVENTION  Penicillin or broad spectrum antibiotic eye drops are instilled after birth for 1 Week. ① Local antibiotic eye drops (Penicillin or broad spectrum antibiotics). ② Frequent removal of discharge. TREATMENT ③ Antibiotic ointment at night or as frequently as required ④ Systemic antibiotics in severe cases. ⑤ Local Atropine ointment in cases with corneal involvement or iritis. Any discharge even watery secretion from baby's eyes during first week of life should be viewed with suspicion (because tear secretion does not start at this early time). OPHTHALMIA NEONATORUM   Rare condition since children are now effectively immunized against DEFINITION diphtheria. Membranous conjunctivitis affects non-immunized children. CAUSATIVE  Corynebacterium diphtheriae. AGENTS (INCUBATION PERIOD: 12 HOURS TO 3 DAYS).  Systemic manifestations:  Infection of throat or nasopharynx  Constitutional symptoms: Fever and malaise.  Ocular manifestations:  Stage of infiltration: (5-10 days) ① Lid edema, redness, tenderness. ② Conjunctival edema covered with yellowish exudation. ③ Scanty mucopurulent discharge. ④ There is a true membrane, grayish yellow in color, which may be patchy, or covers the whole palpebral conjunctiva. CLINICAL  Stage of discharge: PICTURE & ① Marked hyperemia of the conjunctiva. STAGES ② Purulent blood stained discharge containing pieces of the sloughed membrane. ③ When the membrane separates it leaves a septic granulation tissue that exudes thick yellow pus.   Local complications:  Results from cicatrization→ The raw conjunctival surfaces heal together by fibrosis resulting in the following: ① Lids: Trichiasis, entropion. ② Lacrimal system: Closure of ducts and fibrosis of the accessory lacrimal glands leading to xerosis. ③ Conjunctiva: Xerosis, symblepharon and pseudopterygium. FATE & ④ Cornea: Ulcers, xerosis, and vascularization. COMPLICATIONS  General complications:  Complications are mostly due to the diphtheritic exotoxin ① Toxic myocarditis and heart failure. ② Respiratory failure. ③ Toxic nephritis with albuminuria. ④ Neuropathy and paralytic manifestations: Paralysis of accommodation, paralytic squint, and other neurologic manifestations.  Immunization against diphtheria (DDT). PREVENTION  Isolation of the patients and notification of the health authorities. ① Isolation & Complete bed rest. ② Anti- diphtheritic serum:  40,000-60,000 U  Can be repeated every 12 hours to neutralize the circulating toxin. ③ Systemic IM Penicillin injections. TREATMENT ④ Local antibiotic eye drops (Penicillin 10000 ug/ml). ⑤ Local anti- diphtheritic serum eye drops. ⑥ Antibiotic ointment applied between the palpebral and bulbar conjunctiva to avoid symblepharon. ⑦ Local Atropine ointment in cases with corneal ulcers or iritis. 1 Adenoviral conjunctivitis. 2 Acute haemorrhagic conjunctivitis. 3 Acute herpetic conjunctivitis. All those types of viral conjunctivitis show formation of conjunctival follicles. - So, they are all considered acute follicular conjunctivitis. - Anti-virals are used in case of corneal affection. ADENOVIRAL CONJUNCTIVITIS  Takes epidemic form with many cases occurring over short period of time. DEFINITION  It spreads by droplet infection and may be accompanied by sore throat. ① Acute red eye with conjunctival follicles more evident in the lower palpebral conjunctiva and lower fornix. ② Preauricular lymphadenopathy. ③ Subconjunctival hemorrhages in severe cases. ④ Photophobia and watery discharge. CLINICALLY  No specific treatment.  The condition is self-limited.  We can prescribe artificial tears to ↓ pain and discomfort. TREATMENT  Antibiotics can guard against secondary bacterial infection.  Anti-virals available are not effective against adenovirus  Topical povidone iodine 5% drops → giving good results   Chronic infection of conjunctiva and cornea.  Caused by Chlamydia trachomatis and characterized by: ① Formation of follicles and papillae in upper tarsal conjunctiva ② Formation of pannus in upper part of the cornea. ③ Healing occurs by cicatrisation  Based on June 2022 data by WHO:  125 million people live in trachoma endemic areas & are at risk of trachoma blindness  1.9 million people are affected either by blindness or visual impairment.  Before availability of suitable antibiotics trachoma was the greatest single cause of preventable blindness in the world & was endemic in Egypt affecting ˃ 80% of population.  in endemic areas, children are affected between 6 months and 2 years of AGE age. PREVALENCE &  related to environmental & behavioral factors→ poor communities with SEVERITY unavailable safe water are more affected CAUSATIVE  Chlamydia trachomatis (Chlamydia serotypes A, B, C). ORGANISMS  Direct and indirect contact with infected material (eye conjunctival MODE OF discharge of patients) by hands, by clothes, towels,... etc. TRANSMISSION  Flies play a main role in transmission of the organism.  (THE DISEASE AFFECTS MAINLY THE UPPER PALPEBRAL CONJUNCTIVA)  Occurs around the invading organism → formation of sub-epithelial small ① CELLULAR pin point grayish follicles. INFILTRATION  These follicles are not raised above the surface, non expressible and are called immature follicles (T. I).  enlarge and become pinkish, raised above the surface and are ② FOLLICLES expressible (T. IIa). ③ PAPILLAE  Formed (T. IIb) where they are soft, vascular and pinkish in color.  occurs by cicatrization (T. III), which may take the form of lines, patches, or a dense white line at the sulcus subtarsalis called Arlt's line.  Post-trachomatous degenerations (PTDs) may occur in the conjunctival ④ HEALING crypts between adjacent papillae.  Calcification may occur in these degenerate areas leading to sandy white calcified spots called post trachomatous concretions (PTCs). ⑤ COMPLETE  the end point where cicatrization is complete with no follicles or papillae HEALING & absence of inclusion bodies in conjunctival scraping. ① SUPERFICIAL  Numerous epithelial erosions involving the upper part of the cornea KERATITIS  which shows positive staining with fluorescein. ① Small rounded grayish areas in the upper cornea. ② Sub-epithelial lymphoid infiltrations (Herbert's rosettes). ③ On healing they leave depressed pits (Herbert's pits) giving a serrated appearance to the lower edge of the pannus. ② CORNEAL FOLLICLES ① Superficial vascularization and lymphoid infiltration of the upper cornea. ③ TRACHOMATOUS ② The vessels run subepithelially between the limbal follicles. PANNUS ③ The patient may complain of pain, lacrimation, photophobia and blepharospasm.  Atrophy of goblet cells. ④ XEROSIS  Obstruction of the lacrimal ducts.  Fibrosis of lacrimal glands.  ① Typical trachomatous ulcer:  Superficial, linear, horizontal ulcers at the lower edge of the pannus.  They are chronic, spread slowly and secondary infection is not ⑤ CORNEAL common. ULCERS  They heal by facet formation. ② Marginal or central ulcers: Unrelated to the pannus. ③ Ulcers due to trachoma complications: As trichiasis and PTDs. ⑥ KERATECTASIA  Bulging forwards of the cornea weakened by trachoma COURSE OF TRACHOMATOUS PANNUS PROGRESSIVE  Vessels are parallel and directed vertically downward extending to a PANNUS level forming a horizontal line. Infiltration precedes vascularization. REGRESSIVE PANNUS  Infiltration regresses and vessels narrow. ① Complete resolution leaving a clear cornea if the basement membrane HEALED PANNUS is not destroyed. ② Permanent opacity if BM is destroyed (pannus siccus).  ① Ptosis: either mechanical (heaviness due to cellular infiltration) or due to fibrosis and weakness of Muller's muscle. ① LID ② Trichiasis: Due to local scarring around the lid margin. ③ Cicatricial entropion: Due to conjunctival shrinkage. ④ Chronic Meibomianitis. ① Posterior symblepharon: adhesions in the fornices. ② CONJUNCTIVA ② Xerosis. ③ Hyaline and amyloid degeneration of upper tarsus and conjunctiva. ① Obstruction of puncti by fibrosis. ③ LACRIMAL ② Chronic canaliculitis with epiphora. SYSTEM ③ Chronic dacryocystitis. ④ Chronic dacryoadenitis. ④ CORNEAL  According to the stage (SEE CORNEAL MANIFESTATIONS). ① Clinical sure signs:  Expressible follicles  Pannus with Herbert's pits  Arlt's line  Post trachomatous degenerations (PTDs). ② Intracytoplasmic basophilic inclusion bodies:  In conjunctival scrapings stained with Giemsa stain. ③ Immunologic tests. ① FOLLICULAR  From other causes of follicular conjunctivitis. TRACHOMA ② PAPILLARY  From other causes of papillae mainly spring catarrh. TRACHOMA ③ TRACHOMATOUS  From other causes of pannus. PANNUS ① Combat flies. ② The patient should use separate towels that must be boiled. ③ Careful disinfection of infected fingers. ④ Early diagnosis and treatment. a) Azythromycin:  Indications: new or recent-onset of active disease  Route of administration: ① Oral azithromycin→ single dose ① MEDICAL ② Topical azithromycin→ twice daily for 3 days b) Broad-spectrum antibiotic eye drops & ointment (Tetracycline, Erythromycin, Quinolones) used for 6-12 weeks. c) Atropine if the cornea is involved.  May be needed with medical treatment a) Expression of follicles. ② SURGICAL b) Scraping of papillae. c) Picking of PTDs.   Hypersensitivity to airborne plant or animal allergen especially ETIOLOGY patients with asthma, hay fever or atopy. (minutes after exposure)  Itching and eyelid swelling. CLINICAL PICTURE  Watery or mucoid discharge.  Hyperemia.  Edema of lids and conjunctiva. ① Remove the cause. ② Astringent and vasoconstrictor drops (Zinc sulfate). ③ Cold compresses. TREATMENT OF ACUTE NON-INFECTIVE ④ Artificial lubricants (Methyl cellulose). CONJUNCTIVITIS ⑤ Non-steroidal anti-inflammatory drugs (Diclofenac, Ketorolac). ⑥ Antiallergic eye dros. ⑦ Topical steroids (Prednisolone, Dexamethasone). ACUTE ALLERGIC CONJUNCTIVITIS  1  Hypersensitivity to an endogenous antigen: ① Tuberculo-protein ETIOLOGY ② Intestinal parasites. ③ Septic focus as tonsillitis. ④ Staphylococcal blepharoconjunctivitis. ① Irritation: Discomfort, burning and foreign body sensation. SYMPTOMS ② Watery or mucoid discharge. ③ Photophobia and blepharospasm in cases with corneal affection. 1 Phlycten: ① Rounded raised nodule 1-3 mm in size. ② Grayish or yellowish. ③ Common at the limbus and bulbar conjunctiva. ④ Formed of lymphocytic aggregation covered with intact epithelium, which ulcerates later with secondary infection. ⑤ Surrounded by a small area of congestion. SIGNS  2 Corneal manifestations: ① Corneal phlycten may occur superficial or deep to Bowman's membrane. ② Phlyctenular ulcers: a. Limbal: Single or multiple, may fuse to form a ring ulcer. b. Fascicular: Superficial ulcer that creeps in a serpiginous manner towards the center and is supplied by a leash of blood vessels. On healing its track leaves an opacity maximum where it stops. ③ Phlyctenular pannus: Affects any part of the limbus. a. Thin and vascular with marked irritation. b. Straight vessels deep to BM. c. Infiltration and vascularization with a rounded edge d. Eczema of the lids and face, fissures at the outer canthus may occur. ① Investigate & treat → cause of allergy if possible. ② Dark glasses. ③ Topical steroids. ④ Lotions and local antibiotics in cases complicated with mucopurulent TREATMENT conjunctivitis. ⑤ Local Atropine in cases with corneal involvement. ⑥ Fascicular ulcer needs cautery with carbolic acid and actual cautery for blood vessels at the limbus.  2  Chronic recurrent bilateral allergic inflammation of conjunctiva. DEFINITION  Usually affecting children & young adults (5-25 y) and showing exacerbation during spring and summer.  It is allergic IgE mediated disorder. ETIOLOGY  The allergy is to unknown exogenous factors e.g. dust, pollen grains. ① Itching ④ Hyperemia. SYMPTOMS ② Lacrimation. ⑤ Photophobia ③ Scanty whitish ropy mucoid discharge. ⑥ Blepharospasm. 1 Palpebral Type:  Large flat-topped papillae giving a cobblestone appearance on tarsi (specially upper) & absent from fornix.  Papillae are bluish-white or red, formed of a central core of fibrous tissue rich in eosinophils covered by thick epithelium.  The center & edges of papillae show tiny twigs of blood vessels.  If the papillae are exposed by lid eversion, they are covered by a sticky milky white film of discharge rich in eosinophils. SIGNS  2 Bulbar Type: (More severe)  Manifests as gelatinous limbal masses formed of hypertrophied epithelium with CT core and hyaline degeneration.  It usually starts at upper limbus, then later all round.  White spot concretions of eosinophils and necrotic epithelium may be seen (Tranta’s spots). 3 Mixed type: mixture of the palpebral and bulbar types. 4 Other corneal manifestations:  Fine punctate epithelial keratitis (Keratitis Superficialis Vernalis of Tobgy).  Rarely vernal corneal ulcers (shield ulcers). ① Palpebral type should be differentiated from papillary trachoma. ② Bulbar type should be differentiated from limbal phlycten. ③ Giant papillary conjunctivitis: caused by presence of foreign body irritating the conjunctiva as in: DIFFERENTIAL DIAGNOSIS  Contact lens wearers  Patients with artificial shell  Irritating exposed ends of monofilament nylon sutures after intraocular surgery.  ① Symptomatic:  Dark glasses and cold compresses.  Vasoconstrictor and  Oral anti-histaminics may be given only if there is evident lid oedema or chemosis.  Avoid exposure to allergens if known. ② Anti-histaminic drops:  ketotifen or olopatadine ③ Mast cell stabilizers: TREATMENT  Prevents mast cell degranulation preventing histamine release  Disodium chromoglycate.  Lodoxamide. ④ Topical steroids:  Only in severe non-responsive cases.  Prolonged use may cause cataract and secondary glaucoma.  Tapered gradually ⑤ Resistant cases:  Topical immunomodulators like cyclosporin (0.05 to 2%) and tacrolimus (0.1%)  1  Degenerative condition occurring in elderly due to: ① Effects of UV rays. DEFINITION ② Chronic irritation.  Hyaline degeneration of subepithelial conjunctival tissue with elastoid tissue deposition.  Triangular in shape (base towards the cornea) raised yellow nodule.  Usually on nasal side of limbus and it is avascular. CLINICAL PICTURE  No treatment is required as it is a symptomless condition. TREATMENT  Surgical excision is done for cosmotic reasons. 2  Degenerative condition of the subconjunctival tissues which proliferate DEFINITION as a vascularised granulation tissue to invade the cornea.  Unknown. ① UV rays may be the most important factor because the condition is ETIOLOGY common in dry sunny climates. ② Chronic irritation by dust and fumes. ③ Also, pinguecula may be a precursor of pterygium  The complaints include: SYMPTOMS  Most commonly → disfigurement (COMPLAINT)  Less commonly → visual deterioration caused by astigmatism and later on by encroachment of the pterygium on pupillary area to cover pupil.  Triangular encroachment of conjunctiva upon cornea formed of: ① Head: Lies over the cornea and may grow to cover the pupil. ② Neck: Overlying the limbus. ③ Body: Over the sclera being loosely adherent to it. SIGNS PROGRESSIVE TYPE REGRESSIVE TYPE  Thick, vascular and fleshy.  Thin, less vascular and TYPES  It creeps towards the center of membranous. the cornea affecting vision.  Pterygium should be differentiated from pseudo-pterygium. PTERYGIUM PSEUDO-PTERYGIUM A fold of conj. attached to NATURE Degenerative condition the base of a healed D.D. corneal Ulcer SITE Bilateral on nasal side Unilateral – anywhere ATTACHMENT TO Hook Cannot be passed Can be passed under the CONJUNCTIVA under the neck Neck COURSE Progressive or stationary Always stationary  ONLY SURGICAL.  INDICATIONS:  Small asymptomatic stationary pterygium → better not to operate.  Symptomatic or progressive pterygium → Surgical excession.  OPERATIONS: ① Simple excision with closure of the conjunctiva (recurrence is common). ② Excision with bare scleral technique ③ Excision with grafting (conjunctival auto-graft, limbal stem cell graft, amniotic membrane). ④ If the cornea is affected, lamellar keratoplasty may be indicated. ⑤ Beta irradiation (direct post-operative) or mitomycin-C use (intra- operative) helps prevent recurrence. TREATMENT ① Cobblestone appearance of the conjunctiva is seen in a. Spring catarrh b. angular conjunctivitis c. eczematous conjunctivitis d. trachoma ② Follicles are not seen in which of the following a. spring catarrh b. trachoma c. adenovirus conjunctivitis d. streptococcal conjunctivitis ③ Angular conjunctivitis is caused by a. Staphylococcus b. pneumococcus c. virus d. Morax-Axenfeld bacillus ④ Eyes should not be bandaged in a. corneal ulcer b. purulent conjunctivitis c. glaucoma d. retinal detachment ⑤ The following is not a sequelae of trachoma a. pseudoptosis b. cicatricial entropion c. trichiasis d. pinguacula ⑥ Herbert’s pits are seen on the a. lid margin b. palpebral conjunctiva c. Arlt’s line d. limbus ⑦ As a complication of acute mucopurulent conjunctivitis, the corneal ulcers that develop are a. marginal b. central c. anywhere on cornea d. no where ⑧ True membranous conjunctivitis is caused by a. trachoma b. Morax-Axenfeld bacillus c. virus d. diphtheria ⑨ Phlyctenular conjunctivitis is due to a. pneumococcus b. Pseudomonas pyocyanea c. allergy to endogenous protein d. allergy to exogenous protein ⑩ Pinguecula is due to the infiltration of a. hyaline b. lipid c. calcium d. fatty acids ⑪ The association of keratoconjunctivitis sicca with rheumatoid arthritis is a. Reiter’s syndrome b. Sjögren’s syndrome c. Stevens-Johnson syndrome d. Mikulicz’s syndrome ⑫ The treatment of angular conjunctivitis is a. oxytetracycline ointment b. zinc oxide c. both d. none ⑬ Herbert’s pits are seen in a. trachoma b. herpetic conjunctivitis c. ophthalmia neonatorum d. spring catarrh