‫فهد شارع‬

‫بالتعاون مع الدفع السابقه‬

 ‫اليدر ‪ /‬معاذ ال مشدود‬
‫منسق ا=قرر ‪ /‬مسفر الوادعي‬

‫التسويف يفسد الراحة كما يفسد العمل‬

‫‪Ophthalmology‬‬

‫ا‪#‬سم ‪/‬‬

‫‪ocular physiology‬‬ ‫ا*حاضرة ‪/‬‬

 ‫‪ENT‬‬

‫‪Abdulrahman Al-amri‬‬
‫______________‪Dr :‬‬

‫‪Conjunctival diseases‬‬
‫______________‪Lecture title :‬‬

‫‪NOTES :‬‬
‫اللون‪.‬‬ ‫ـ التفريغ بهذا‬
‫حاتم الشهري‬
‫______________‪Note by : :‬‬
‫‪+‬‬
‫ـ محاضرة بسيطة ومختصرة‪.‬‬
‫الدفعات السابقة‬ ‫ـ بعض النقاط ا‪J‬همة اللي ركز‬
‫عليها الدكتور عندها‬
 Preview
Anatomy
Physiology
Pathology
Conjunctivitis
Infectious
Bacterial
Viral
Allergic
Seasonal Allergic Conj (SAC)
‫ الرمد الربيعي‬Vernal Keratoconjunctivitis (VKC)
Neoplastic
o Benign
Papilloma-Pterygium-Nevus
o Malignant
eview
 ‫من قوقل‬

Conjunctival Anatomy
Mucous membrane

1. Palpebral Covers eyelid from inside

2. Forniceal*most abundant goblet cells Between palpebral and bulbar
3. Bulbar Covers eyeball
 Histology
Epithelium
Goblet cells: secrete mucin layer of tear film
Dry eye = Tears evaporate faster
Stroma
Lymphoid tissue
Lymphoid in viral disease—> follicles.
will appear as follicles
 Physiology
Mucin layer of tear film secreted by goblet (Innermost layer)
Even spreading of the tear film

‫فترض الصبغه تتوزع بشكل متساوي‬8‫ا‬

Dryness duo to deficiency

Dryness ofDry
mucin
spot layer
 Symptoms
Redness Foreign body sensation

Discharge

Chemosis (conjunctival edema)

Ballooning of conjunctiva
Signs

Discharge:
Watery (Viral, allergic)
Mucoid (Vernal Keratoconjunctivitis: VKC)
Purulent (Gonococcal)
 Follicles in fornix
(Lymphoid
Hyperplasia)
Surrounded by blood
vessels

Germinal center
Germinal centerdifference between follicles
(There’s no blood and papillae: Follicles have an
(There’s no blood vessels
vessels in the center)
in pallor)
empty center (Central
the center)
Central pallor
-Fornix full of follicles, so ask the patient look up It is lymphoid tissue
and pull the lower lid gently to see it. Found in stromal layer
(Central pallor)
G60
-what are the causes of
follicular conjunctivitis?
-drug induced.
-adenovirus.
-chlamydia.
-Herpes.
Papillae (In the center there is blood vessels). follicle 9‫الفرق مهم بينها وب‬

vessles surrounded by stromal edema and epith

Follicles (Lymphoid
hyperplasia Fingers like projections
Like projections Hyperplasia) germinal
Center(pallor)
What are the causes of papillary
conjunctivitis? ‫ بس الدكتور ذكرها‬papillae ‫كمان البكتيريا تسبب‬
Papillae (epith hyperplasia)
G60 -Allergic ‫يد‬7‫تحت مو في هذا الس‬
Bleed vessels in the Center
-Vernal keratoconjunctivitis(VKC)
-Bacterial infection
Pathology
 1
Scenario:
Redness
FB sensation
Swelling
Discharges
Tearing
DDx :
conjunctivitis
Keratitis
 ‫حدة ا@بصار‬
Visual acuity VA Normal
Hyperemia Redness
Disharges &crusts Dry discharge
Chemosis Ballooning of conjunctiva
(conjunctival edema)
Papillae
See it by slit lamp
Diagnosis
Bacterial conjunctivitis

Treatment
Topical broad-spectrum antibiotic As eye drops
Bacteriology

Staphylococcus aureus (adults)

Streptococcus pneumonia Most common
Haemophilus influenza (children)
 Sexually transmitted disease

Neisseria gonorrhoeae

Gonococcal Keratoconjunctivitis
 Same senario above but more sever

2
Signs Complications

Gonorrhea Keratitis
How we know
Inflammation of
there’s perforation?
the cornea
We can see the iris.

High amount Purulent discharge Corneal ulceration + PerforationPerforation

G60
Hyperaemia Iris prolapse
Chemosis G60
Membranes*
Follicles unusual
Management Diplococci

Take scraping:
Gram staining
Neutrophils-Bacterial
Lymphocytes-Viral
Eosinophil-Allergic

C&S. Culture & sensitivity

-Give the patient topical and systemic to
Rx?
cover gram -ve:

Topical
Gentamycin

Systemic G60
Ceftriaxone IV
 3
Redness
FB sensation
Discharges
Tearing
 Signs
Periocular
Lymphadenopathy
Lid edema
Subconjunctivial
SCH Subconjunctival hemorrhage G60 hemorrhage

Follicles,
Pseudomembrane
+-Keratopathy
Corneal problems.

Case: Patient complaining off redness,

discharge, tearing and FB sensation with
subconjunctival haemorrhage,
pseudomembrane and periocular
lymphadenopathy What’s your diagnosi?? G60 Pseudomembrane
Viral conjunctivitis

Adenovirus
Rx ?
Acyclovir
Strict hygiene:
Sharing of towels
Hand washing G60
Touching the eye
Shaking hands*
contagious for 14 days
Cold compresses
Lubricants
Vasocostrictor
(Naphcon A) Naphazoline/pheniramine-antihistamine
 4
Symptoms
Signs:
Lid edema + redness
G60
Lid vesicles
Whenever you see Lid vesicles
Follicles
these follicles, directly
+-Keratopathy diagnose herpes
Lymph

Steroids is contraindicated in
herpes and fungal

Lid edema + lid vesicles +

follicles = Directly herpes
simplex conjunctivitis Follicles
Herpes simplex
conjunctivitis
 Rx

Antiviral
Acyclovir oint
Gancyclovir gel
 Nothing special about it,
Homework 5 But instead of Follicles
there is Papillae Because
Neonatal chlamydial conjunctivitis the immune system still
premature In such cases
Mucopurulent Discharges
Papillary conjunctivitis*
Systemic
Otitis (Media)
Peumonia
Dx
Giemsa stain
IF

Treatment - topical and oral antibiotics

 6

Chronic disease

Infection with serotypes A, B,

G60

and C of Chlamydia trachomatis

Common fly..poor hygiene

Not sexually transmitted

While subtypes D-K are

sexually transmitted
Common in old pt
 Follicle marks (Everts the upper eyelid)
Central pallor

G60
Conjunctival scar due to untreated trachoma Leads to inward deviation of lashes (Trichiasis)
+ dryness
-also untreated trachoma cause: conjunctival shrinks, corneal scar that
cause blindness and destroy goblet cell that cause dryness .
Corneal scar
+
Corneal ulcer
+
Blindness

All are Complication of

Chlamydia trachomatis
 It’s follicles healed with fibrosis Herbert's pits at limbus corneoscleral junction
and give these small depression. Pathognomonic of trachoma (Landmark for cataract surgery )
Untreated follicles
G60
Trichiasis: eyelashes grow the wrong
way, toward your eye rather than Fibrosis
away from it.

Entropion: eyelid turns inward so

that your eyelashes and skin rub Herbert's pits
against the eye surface.
measure basal tear secretion using
Schirmer s test with anesthesia

Lastly the
Dry spots patient end
with Corneal
transplantation
L G60
G60
G60

(Dryness) Destruction of goblet cells.(Trichiasis) and eyelashes touch cornea causing (Corneal scar)—> blindness
Eyelashes misdirected
 If the Trichiasis sever
Couse entropion

DDx

Trachoma inclusion conjunctivitis [TRIC]

Chlamydia trachomatis sero D to K
Chronic, follicular conjunctivitis
TRIC is a STD
Tender enlarged preauricular lymph node is common.
Findings: bulbar follicles, subepithelial infiltrates, no
membranes
 Rx
Acute Uncommon

Topical:
Tetracycline ointment
Systemic Antibiotics
*Doxycycline
**Erythromycin
**Azithromycin Best because it is just a single dose
Mgm
Chronic Common
Medical: Artificial Tears
Surgical (Lid, Cornea) For Trichiasis or entropion
In case of Corneal scar (Corneal
transplantation)
 ! ‫ فيها‬-‫الجرعات مو مطالب‬
Skip
3-6 weeks is recommended
Oral tetracycline (500 mg qid)
Oral doxycycline (100 mg bid)
Oral erythromycin stearate (500 mg qid).
Azithromycin can be given as a single dose
of 1 g
Tetracyclines are avoided in children
younger than 7 years and in women who are
pregnant or breastfeeding.
Topical antibiotics..relatively ineffective
 7
Molluscum contagiosum
Poxviridae family
Chronic follicular conjunctivitis
associated with elevated umbilicated
(central depression) lid lesions
Due to release of toxic viral products
Treatment: excision of lesions or
cryosurgery
‫بالتبريد‬

Causes chronic conjunctivitis

 8
G60 Allergic conjunctivitis
Common
Type I Hypersensitivity reaction
Symptoms
Itching
Signs G60

Papillae
 Rx

Precipitating factors
Cold compresses
Topical antihistamine
Mast cell stabilizer: if chronic
Steroid: if severe
Bc it may couse glaucoma and cataracts and fungal infection
 9
Vernal keratoconjunctivitis VKC
‫حساسية مفرطة‬ Severe
Type I
G60
+
Cell-mediated So, it's chronic

History G60
Itching
Discharge Mucoid
..

• Presentations : G60

Same above but chronic & sever + cobblestone

Cobblestones
 G60

Cobblestone Edematous papilla Edema + papillae

Ruptured
In the septum in between the papillae
epithelial cells Of the septum
G60 Papillae If the edema sever it’s raptured—> finger like
projection(giant papillae) Giant
Herbert's pits: Fibrosed follicles as a Complication papillae
of Chlamydia trachomatis(dark spots).

Horner-Trantas dots: eosinophils seen in Vernal

keratoconjunctivitis VKC (white spots).

G60 Horner-Trantas dots Full of eosinophils

-In limbus White spots
 Complications ‫ما شرحها‬

Ocular surface disease

Dry eyes
Cornea
(Irreversible) Keratoconus Due to itching ‫قرنيه مخروطية‬
Neovascularization
Shield Ulcer Healed with
Scar
Cataract
Due to long course of steroids
Glaucoma
-So try to give steroid sparing agent because
the disease is chronic.
 ‫ما شرحها‬

Treatment

oMast cell stabilizer + antihistamines

oSteroid Short course
oImmuno-suppresive medications (Cyclosporine)
 10
Conjunctival lesions
Pigmented
Benign
Nevus
Malignant
melanoma
Non-pigm
Benign
Papilloma
Pterygium
Malig:
SCC
 Conjunctival lesions
Pigmented :
Benign G60 -flat
Nevus -not dark
melanocytes -blood vessels not dilated
-not attached to underline
Malignant structure ‫تتحرك معك‬
melanoma
Non-pigm
Benign
papilloma
Malig:
SCC
Brown not black like malignant
 Conjunctival lesions
Pigmented :
Benign
Nevus
Malignant -jet black ‫نفس لون العبايه‬
-swelled(nodule)
melanoma -attached to underlying
structure
Non-pigm -dilated blood vessels
Benign
papilloma
Malig:
SCC
• Black
• attached to underlying structure
• Dilated blood vessels around it
Conjunctival lesions
Pigmented :
Benign
Nevus
Malignant
Melanoma
Non-pigm
Benign
Papilloma
Malig: At limbus so we call it limbal mass
Squamous cell carcinoma-SCC Jelly-like
Jelly-likelimbual mass
Confirmation by histopathology
Treatment: Excision with Dilated blood vessels
histopathology confirmation
 Pterygium
G60

Interpalpebral, wing-
shaped, fibrovascular
‫لحمية‬
tissue From the Conjunctiva
‫يهاجم القرنية‬
invade the cornea

Pathology
elastoid degeneration
Conservative Mx unless
surgery is needed
It will Cause stigmatism and it will affect
Pterygium
Etiology: unknown but may bcz of ultralights exposure like sun light ☀ the vision when it’s near the visual axis.
 Review
Anatomy
Physiology
Pathology
Conjunctivitis
Infectious
Bacterial Papillae
Viral Follicles
Allergic
Seasonal Allergic Conj (SAC) -Horner-Trantas dots ‫بيضاء‬
Vernal Keratoconjunctivitis (VKC) -cobblestone Upper eyelid
Neoplastic -giant papillae
o Benign
Papilloma-Pterygium-Nevus
o Malignant
Melanoma-SCC
 Conjunctival disorders
1 what are the contents of conjunctival mucous membrane ?
i - palpebral = covering the lids from inside .
ii forniceal .
iii bulbar = covering the globe .

2 what are the types of conj. Histology ?

i epithelium = contains goblet cells .
ii stroma = contains lymphoid tissues .

3 what does goblet cells secrete ?

Mucin layer of tear film

4 what will happen if goblet cells destructed ? give example .

Destruction will lead to eye dryness , eg : trachoma .

5 hyperplasia of lymphoid tissues will lead to ?

Follicles formation

6 mention some symptoms that patient may presents with (regarding conj. disorders) .
Itching redness FB sensation discharge

7 - mention some signs that patient may presents with ( regarding conj. Disorders ) .
Hyperemia discharge follicles papillae pseudomembrane

8 mention the different types of eye discharges & give example for each of them .
A = watery ( viral , allergic inf. _
B = mucoid ( VKC )
C = purulent ( gonococcal inf. )
D = mucopurulent ( bact. Inf. )
9 what are the causes of follicles formation ?
Viral inf. + chlamydial inf. + drug induced

10 what is the mechanism of papillae formation ?

Stromal edema & epithelial hyperplasia will lead to papillae formation

11 how to differentiate b/w follicles & papillae clinically ?

Follicles = have central pallor bcz it originates from germinal center .
Papillae = have central redness .

12 what is the mechanism of pseudomembrane formation ?

Fibrin exudation due to hyperpermiabelity of blood vessels .

13 what is MC .. gram +ve or gram ve bacterial infection ?

Gram +ve

14 mention some symptoms of bact. Inf. & which one is the main ? what about vision ?
Redness FB sensation discharge ( the main symptom ) , vision is normal .

15 in examination of eye with bact. Inf. , how will be the visual acuity ( VA ) ?
Normal

16 mention some signs of bact. Inf.

Hyperemia discharge crusts chemosis papillae formation

17 what does ( chemosis ) mean ?

Ballooning of conj.

18 mention infections that present chemosis .

Bact. Inf. & gonococcal inf.

19 how can we ttt eye bact. Inf. ?

By topical antibiotics
20 what is the most dangerous eye inf. ?
Gonococcal inf.

21 mention some signs of eye Gonococcal inf.

Purulent discharge hyperemia chemosis

22 what is the complication of gonococcal inf. ?

Blindness due to corneal perforation

23 how to dx gonococcal inf. ?

i - GM staining
ii C&S ( culture & staining )

24 how to ttt gonococcal inf. ?

Topical + systemic antibiotics

25 mention some symptoms of viral inf.

Discharge ( watery ) redness FB sensation lid swelling blurred vision ( if cornea is
involved )

26 - mention some signs of viral inf. & what is the main sign ?
Lymphadenopathy lid edema subconj. Hemorrhage follicles formation keratopathy
LAP is the main symptom ( pre orecular + submandibular groups )

27 how can we ttt viral inf. ?

By hygiene .

28 what is the main symptom in herpes simplex conjunctivitis ?

Vesicles & follicles formation

29 how can we ttt herpes simplex conjunctivitis ?

By antiviral drugs ( acyclovir = zovirax )
30 mention some signs of neonatal chlamydial conj.
Mucopurulent discharge papillary conj. !!

31 why there formation of papillae in neonatal chlamydial conj. Although it is bact. Inf.
?
bcz the immune system of neonates is immature .

32 what is the causative of trachoma ?

Serotypes A , B & C of chlamydia trachomatis .

33 what is WHO grading of trachoma ?

follicles inflammation scarring ( of palpebral conj. ) trichiasis ( misdirection of
eye lashes inwards ) corneal opacity ( blindness ) .

34 define Herbert`s spots .

Small depressions on limbus , it indicates old trachoma .

35 how to dx trachoma ?
Clinically

36 how to ttt trachoma ?

i topically = antibiotics ( tetracycline ointment )
ii systemic antibiotics
iii artificial tearing ( bcz trachoma causes eye dryness )
iv surgery ( if needed )

37 how to differentiate b/w active & old trachoma ?

Follicles active dz
Herbert`s spots old

38 what type of allergy associated with allergic conj. ?

Type 1

39 what is the hallmark of allergic conj. ?

Itching
40 how can we ttt allergic conj. ?
Cold compresses topical antihistamine mast cell stabilizer if chronic ( sodium
chromoglycate ) steroids if severe- .

41 - what type of allergy associated with vernal keratoconjunctivitis ( VKC ) ?

Type 1 + cell mediated

42 what is the type of discharge associated with VKC ?

Mucoid

43 mention some signs of VKC .

Papillae H Trantas dots

44 - define H Trantas dots . & what do they contain ?

White spots at the limbus , easily to be seen and diagnosed . they contain eosinophils .

45 - how can we ttt VKC ?

Like allergic conj. ( mast cell stabilizer + antihistamine + steroids if severe - )

46 benign pigmented lesion in the eye , it is movable ????

Nevus

47 47 y/o pt came in your clinic complaining of rapid progressive mass in his eye , in
examination you found elevated & pigmented ( black ) lesion , what is your Dx ?
Melanoma

48 define pterygium of eye .

It is fibrovascular membrane ( part of conj. ) that invading cornea , so vision could be
affected .