Conjunctiva 1.pdf

Anatomy: Transparent mucous-like connective tissue Owes it name b/c it connects the eyelids to the eyeball by the conjoining of the palpebral, forniceal, bulbar ○ Palpebral conjunctiva Marginal conjunctiva extends from the lid margin to ~2 mm on the back...

Anatomy: Transparent mucous-like connective tissue Owes it name b/c it connects the eyelids to the eyeball by the conjoining of the palpebral, forniceal, bulbar ○ Palpebral conjunctiva Marginal conjunctiva extends from the lid margin to ~2 mm on the back of lid up to a shallow groove, the sulcus subtarsalis Tarsal conjunctiva is firmly adherent to the whole tarsal plate in the upper lid. In the lower lid, it is adherent only to half width of the tarsus Orbital part of palpebral conjunctiva lies loose between the tarsal plate and fornix ○ Forniceal conjunctiva Joins the bulbar conjunctiva with the palpebral conjunctiva Superior, inferior, medial, and lateral fornices Caruncle Small (5x3 mm) fleshy nodular prominence in nasal portion of interpalpebral fissure between skin and conjunctiva Modified cutaneous tissue Lined by conjunctival epithelium and nonkeratinized squamous epithelium  Contains cutaneous adnexal structures, accessory lacrimal gland tissue (Glands of Wolfring and Krause) ○ Bulbar conjunctiva Lies loose over the underlying structures Separated from the anterior sclera by Tenon’s capsule and episcleral tissue Ridge of bulbar conjunctiva around the cornea is called limbal conjunctiva In the area of limbus (point of adhesion b/w cornea and sclera) The conjunctiva, Tenon’s capsule and the episcleral tissue are fused into a dense tissue which is strongly adherent to the underlying corneoscleral junction The epithelium of conjunctiva becomes continuous with that of cornea Histology 1a) Epithelium: protective barrier 1b) Adenoid layer: secretory portion 1c) Fibrous layer: works as adhesive, fibrous attachment Blood supply to the conjunctiva Ophthalmic artery: anterior ciliary and palpebral arteries* Nerve supply Sensory innervation of the superior palpebral conjunctiva is provided by the frontal and lacrimal branches of the ophthalmic nerve (V1) Innervation of the inferior palpebral conjunctiva is provided by the lacrimal nerve and the infraorbital branch of the maxillary nerve (V2) Papillae (Bacterial, Allergic) Epithelium that grows, vascular core surrounded by vessels / edema / fluid Inflamed/epithelial hyperplasia conjunctiva Central vascular core, surrounded edema and inflammatory cells Less than 1 mm in size to very large Fibrous septa- hard to see Non-specific and less diagnostic, but commonly in allergic (upper) and bacterial (lower) conjunctivitis Follicles (Viral, toxic) Avascular, white-gray nodules, raised, gelatinous, oval lesions ~1 mm in diameter Found usually in the lower tarsal conjunctiva and upper tarsal border, and occasionally at the limbus Each follicle represents a lymphoid collection with its own germinal centre Located tarsal and fornix, collection of lymphoid (lower lid and limbus area) The causes of follicles are more specific (e.g. viral and chlamydial infections) ○ Remember that chlamydial infections are intracellular bacteria– behaves like a virus but it is not Acute Bacterial Conjunctivitis Most common: S. aureus (gram + bacteria)*** ○ Strep. Pneumoniae (in children) ○ H. influenza (in children) Less common: Pseudomonas, Moraxella, Enterobacteria (Serratia marcescens, Salmonell) Risk factors: warmth and humidity, poor hygiene, crowded environments (nurseries, schools) Signs (no patient should report pain w/ acute bacterial conjunctivitis– if they do, think viral) ○ Mucopurulent discharge (yellowish, mild-mod.) ○ No lymphadenopathy ○ Conjunctival hyperemia > inferiorly ○ Papillary reaction in the upper tarsus ○ SPK inferiorly mainly ○ Inferior marginal infiltrates/ ulcers (sterile) Inferior marginal infiltrates are typically seen as cloudy areas at the corneal margin with inflammation, while sterile ulcers are more about corneal surface defects or erosion around limbal area  Marginal infiltrates ○ Streptococcus pneumoniae conjunctivitis May be associated to otitis media/URT inf. Petechiae (bulbar/fornix): pinpoint hemorrhaging Membranes 1 does not stick to bulbar conj. And other one does???? ○ H. Influenza May be associated with sinusitis Petachiae (tarsus) Membranes Symptoms ○ Acute onset of redness ○ Discharge (>AM), AM “eyes stuck”, unilateral at first ○ NO pain Treatment ○ Mild Self-limiting in 7-19 days, suspect Staph. but can also be Haemophilus Polytrim QID x 1 wk. (good pediatric) TOC***** Polymyxin B + Trimethoprim ○ Remember the Poly. works on the cell membrane of bacteria by “washing it out” ○ Trimethoprim disrupts the folic acid pathways by bacteria requiring folic acid for its nitrogenous base to replicate 2nd option– AzaSite QID x 1 wk (B category; good pediatric) Azithromycin [Macrolide]-- inhibits protein synthesis at 50s protein subunit 3rd option– Tobramycin/Gentamycin QID for 3-5 days risk of toxicity after that  Very potent/toxic to the cornea unless it is used for short treatment (3-5 days) Inhibits protein synthesis @ 30s subunit F/U 1 wk. ○ Moderate-severe Suspect Staph– Quixin, Zymar or Vigamox q 3-4 h x 1 wk. Suspect Heamophilus– any fluoroquinolones q 3-4 h x 1 wk. Lidscrubs; Polysporin ung hs F/U 5 days If is getting worse, tx with fluoroquinolones ○ Marked inflammation, marginal infiltrate/ulcer (sterile) Tobradex or Zylet ophth. susp. q 4-6 h x 1 wk. 2nd option– Maxitrol q 4-6 h. x 1 wk. (beware of allergy) F/U 3-5 days ○ Suspected bacterial ulcer Zymar or Vigamox q 1 hr. and 4% fortified Tobramycin “Out the door”-- immediate referral* ○ Important treatment considerations A lot of purulency- do not even consider a sulfa*** ^ pus deactivates the activity of folic acid pathway and acts as a barrier, so sulfa will not work Kids w/ hx of sinusitis, very puffy lids (preseptal?) - think about Haemophilus, rx oral antibiotic (Augmentin), and consult pediatrician Chronic Bacterial Conjunctivitis Cause: organisms of normal flora proliferate, S. aureus most common Signs ○ Hyperemia ○ Some mucous discharge/mattering AM ○ Eyelid margin disease ○ Hordeola ○ Marginal corneal infiltrates Symptoms ○ Non-specific to burning ○ Constant redness ○ Symptoms intermittent and longstanding Treatment ○ Treat as blepharoconjunctivitis ○ Bacitracin ung BID-QID and Polytrim QID ○ Attack the lids Hot compresses/Lid scrubs QID; If MGD/Meibomianitis add Alodox 20 mg BID x 1 month then QD Doxy. is a anti-microbial  ○ Marginal infiltrate- Tobradex or Zylet instead of Polytrim ○ Culture if resistant and consult w/ specialist Hyperacute Bacterial Conjunctivitis Etiology ○ Neisseria gonorrhea Neonate (infected through birth canal) Sexually active adolescents and young adults Starts unilateral ○ Neisseria meningitides In children (concerning b/c do not want meningococcal infection) Associated with systemic with meningococcal infections *vaccine toxoid (tx ASAP) Bilateral, do not see often Signs ○ Heavy purulency ○ Severe hyperemia ○ Chemosis ○ Eyelid swelling ○ Pseudomembrane/membrane formation True membrane: pull out Pseudomembrane: Stuck and will bleed ○ Lymphadenopathy (severity of infection) Symptoms ○ Pain and discomfort Complications ○ Preseptal cellulitis ○ Keratitis, ulceration/ perforation Management ○ Culture Chocolate and Thayer-Martin agar Gram/Giesma stain ○ Treatment Ceftriaxone (3rd gen. cephalosporin) Adults: (>12)-- 1-2 grams in a single adm. or div. in BID Pediatric: (4 y/o) or Lodoxamide (Alomide) 1% QID (>2 y/o) Other alternatives ○ Nedocromil (Alocril) BID - HA’s 40% of patients (> 3 y/o) ○ Pemirolast (Alamast) BID-QID - best for pre-treating ragweek (>3 y/o) ○ Adjunctive systemic therapy for severe atopic patients Antihistamines 1) Diphenhydramine (Benadryl), chlorpheniramine maleate (chlor-trimeton) – older gen. 2) Fexofenadine (Allegra), Loratadine (Claritin), Citirizine (Zyrtec)  3) caution – may cause angle closure in hyper-reactive patients with narrow angles 4) F/U 5-7 days, warn patient about dryness of eyes, c/l wear, etc Steroidal nasal spray Fluticasone propionate (Flonase), Budesonide (Rhinocort), etc. F/U 5-7 days Chronic Allergic Conjunctivitis ○ Longstanding with variable acute signs and symptoms ○ Treatment Maintenance therapy Artificial tears, cold compresses Mast cell stabilizer Oral antihistamine PRN Acute treatment during period of exacerbation Giant Papillary Conjunctivitis Hypersensitivity/inflammatory disease ○ Cl wearers primarily ○ Prostesis ○ Sutures (PK) Cause: Hypersensitivity Type I and IV ○ Primarily due to cl deposits &/or cl induced sensitivity (loose fit) to superior tarsus ○ Increased eosinophils and mast cells but < VKC Signs: ○ Early stage Itch after CL wear removal Hyperemia Papillary reaction (small) Mucous discharge ○ Late stage Cl intolerance Coated lens (more mucous) Giant papillae Pseudoptosis  Treatment ○ Mild to moderate D/C cl wear; replace cl, consider daily disposable Hydrogen peroxide systems Cold compresses Topical antihistamine 5 min. and after removal Refresh tears QID ○ Severe (topical steroid is a MUST) Suspend cl wear and refit when symptoms clear (1-4 mo.) Lotemax (Loteprednol 0.5%), FML 0.1% QID and taper ○ Maintenance treatment after resolution- mast cell stabilizer BID before (5 min) and after removal Vernal Keratoconjunctivitis Vernal means “spring”, uncommon to see this but will appear in late March/early April to August Disease of the young in warm weather Boys more affected, 80% younger than 14 Typically subsides after 4-10 years Type I and IV Hypersensitivity Associated factors: atopia, asthma, sinusitis, allergies Signs ○ Palpebral Cobblestone papillae (more superior) Hyperemia Corneal keratitis (Togby)  Shield ulcer (non-sterile) ○ Limbal Limbal papillae Horner Trantas Dots ○ Scrapping reveals excessive # of eosinophils and mast cells in conj. epith. 10x more than normal person Symptoms ○ Severe itching ○ Photophobia ○ Burning ○ Thick, ropy discharge Treatment ○ Mild Cold compresses Topical antihistamines, in combo w/ mast cell inhibitors (olopatadine, ketotifen, azelastine qd/ bid ) Environmental control (keep it cool, air conditioning) F/U q 1week - maintenance therapy after resolution (mast cell stabilizer) 1) lodoxamine or cromolyn sodium qid x 3 months (takes to 2-3 wks)  Alomide has been found to be superior to cromolyn in improving papillae, limbal involvement (trantas) and alleviating symptoms ○ Moderate to severe Use steroids to treat papillae- Lotemax 0.5%, FML 0.1% or Prednisolone 1% q 1-2 hr. for 4-7 days, the QID for 4-7 days and taper Acetylcysteine (Mucomyst 5-10% in artificial tears) QID F/U q 3 days, check IOPs after 1 week ○ Severe- very severe or resistant add Cyclosporine A 0.05% (Restasis) BID Oral steroids (Prednisone) F/U q 3 days, check IOP * vekacia ○ Refractory cases (papillary hypertrophy) consider surgical excision, cryotherapy, Triamcinolone supratarsal injection ○ If patient has shield ulcer Topical antibiotic (e.g., Erythromycin ung QID) Cycloplegic agent: Cyclopentolate 2% or Homatropine 5% TID Lubrication F/U 1 daily