Diseases of Conjunctiva

10/15/08 Dr Sanjay Shrivastava 1

 Conjunctivitis
• Classification
I Based on onset
a. Acute
b. Sub-acute
c. Chronic
II Based on type of Exudates
a. Serous (Viral, allergic, toxic)

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 Classification of Conjunctivitis
b. Catarrhal (allergic – Ropy or thread
like thick mucoid discharge)
c. Mucopurulent
d. Purulent
c. Pseudo-membranous / Membranous

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 Classification of Conjunctivitis
III Based on Conjunctival Reaction
a. Follicular
b. Papillary
c. Granulomatous
IV Based on Etiology
a. Infectious (Bacterial, Viral,
Chlamydial, Fungal and parasitic)
b. Non-infectious (Allergic, Irritants
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 Classification of Conjunctivitis
Endogenous or autoimmune, Dry
Eye, Toxic (chemical or drug
induced, self inflicted) and
Idiopathic.

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 Risk Factors for the Development
of Bacterial Conjunctivitis
Disruption of host defense mechanism
caused by:
1. Dry Eye
2. Exposure due to lid retraction,
exophthalmos, lagophthalmos, inadequate
blinking
3. Nutritional deficiencies/ Avitaminosis A

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 Risk Factors for the Development
of Bacterial Conjunctivitis .. contd
4. Local or Systemic Immune Deficiency:
* after topical and systemic
immunosupressive therapy
* Nasolacrimal duct obstruction and
infection
* Radiation damage
* Trauma
* Surgery
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 Risk Factors for the Development
of Bacterial Conjunctivitis.. Contd
* Prior Conjunctival inflammation or
infection
* Systemic Infection
* Exogenous inoculation

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 Gonorrhoeal Conjunctivitis
I. Epidemiological Aspect
Rare in developed countries, still seen
in individuals and communities where
Gonorrhoea is still a problem and hygienic
standards are poor.

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 Gonorrhoeal Conjunctivitis
Etiology – Caused by Neisseria
Gonorrhoeae (a bun- shaped Gram-
negative intracellular diplococcus).
Neisseria Catarrhalis may be seen/found
in chronic forms. Condition is found in
cases suffering from Gonorrhoeal genital
infection.
Incubation period is few hours to three
days.

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 Clinical Features
Symptoms
Swelling of eyelids, Pain, redness,
inability to open eye(s), purulent
discharge, grittiness, Diminution of Vision

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 Clinical Features
Signs
Acute disease, occurring usually in adult males.
Often in RE to begin with. Lids are swollen.
Upper lids are tense, overhanging on lower lid.
Matting of lashes and pus on lids margins.
Eversion is difficult. Deep red velvety conjunctiva
sometimes with membrane
After two to three weeks discharge diminishes
but subacute form of conjunctivitis with presence
of Gonococci persists for several weeks.

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 Signs … Contd
• Pre-auricular lymphadenopathy,
tenderness and suppuration

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 Clinical Features
• No immunity is conferred by an attack.
• Associated systemic signs – Urethritis, rise of
temperature and depression.
• Complications- Corneal involvement –
Gonococcus is capable of invading the normal
cornea through intact cornea.
Location of Corneal Ulcer – Central, Marginal
Ulcer , all round. Progressing rapidly depth-wise
leading to perforation and complications
associated with it.

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 Clinical Features
• Other complications of Gonorrhoeal
Conjunctivitis – Iritis , Iridocyclitis
• Non Ocular complications – Arthritis,
Endocarditis and Septicaemia.

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 Treatment
• Of Gonnococcal Conjunctivitis is started
on confirmation of intracellular Gram-
negative diplococci in conjunctival
scrapings in clinically suspected cases.
Aim of therapy is to prevent or limit the
corneal involvement and to eliminate
systemic source.

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 Treatment
• Systemic Treatment
Ceftriaxone 1 Gm IM , single dose
Local Treatment
* Cleanliness
* Ciprofloxacin / Ofloxacin/ Gentamicin/
Tobramycin Eye Drops 2 hrly.

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 Treatment
* Bacitracin Eye Ointment 6 hrly
* Cycloplegic (Atropine) – in cases of
Corneal involvement
* Tetracycline In cases where co-existing
Chlamydial Trachomatis infection is
suspected and cases with history of
allergy to Penicillin / Cephalosporins

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 Angular Conjunctivitis
Specific type of Conjunctival inflammation
characterized by involvement of inter-
marginal Conjunctiva and neighboring
bulbar conjunctiva, caused by Morax
axenfield diplobacilli called Moraxella
Lacunata.

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 Angular Conjunctivitis
Etiology – Caused by Staphylococci and
more typically by Moraxella Lacunata.

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 Pathogenesis
Moraxella Lacunata is a gram-negative
diplobacilli, pair of large ,thick rods placed
end to end which stain well with basic
stains.
It produces proteolytic ferment, which acts
by macerating epithelium. The incubation
period is usually 4 days . The organisms
are resistant to drying .

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 Pathogenesis
Moraxella is also found in nasal tract of
healthy persons and often present in the
nasal discharge of patients of angular
conjunctivitis.

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 Symptoms

Redness, discomfort, frequent blinking, sharp

pricking pain and mucopurulent discharge.

Incubation period : Symptoms develop after 4 days

of exposure.

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 Signs
• Congestion limited to intermarginal strip at
inner and outer canthi and neighboring
bulbar conjunctiva. Excoriation of skin at
inner and outer palpabral angles
• Complications- Chronic conjunctivitis,
Blepheritis, corneal ulcer (marginal or
central associated with hypopyon)
• Attack does not confer immunity, and
relapses may occur.
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 Treatment
Tetracycline eye ointment
Eye drops containing Zinc also beneficial,
acts by inhibiting proteolytic ferment.

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 Acute inclusion Chlamydial
Conjunctivitis

Its acute conjunctival inflammation caused

by Chlamydial infection (Serotype D-K)
characterized by inclusion bodies.

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 Acute inclusion Chlamydial
Conjunctivitis
• Etiology – Caused by Chlamydia
Trachomatis (serotype D-K)
• Pathogenesis – characterized by inclusion
bodies identical with those occurring in
Trachoma.

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 Spread
Spread by sexual transmission from genital
reservoir (urethritis/ cervicitis). Common
mode of infection is through swimming
pool water (swimming pool conjunctivitis)
May also be transmitted by mothers to
newborn.

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 Clinically Features
• Incubation period- Usually 5- 10 days
• Symptoms- Acute onset , redness, foreign
body sensation, intolerance to light ,
discharge
• Signs – Conjunctival hyperaemia,
Follicles, more prominent in lower lid,
papillary hyperplasia, superficial punctate
keratitis, peripheral vascularization
(pannus)
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 Clinical features
Chlamydia Trachomatis is also responsible
for genital and oculogenital infections.
Associations have been reported with non-
gonococcal and post gonococcal
urethirits, cervicitis and infections of
genital tract.
Arthiritis is also seen in these cases.

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 Diagnosis
Direct immuno-fluorescent stain of smear
using monoclonal antibodies. Test has
100% sensitivity and 94% specificity.
Urethral and cervical secretions should
also be tested.
Other tests are immuno-sorbitant assay,
Giemsa staining of conjunctival scrapping
and McCoy cell cultures.

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 Treatment
Heals spontaneously in 3 -12 months if left
untreated.
Systemic – Tetracycline 250 mgm qid for 2
weeks, Doxycycline 100 mg twice for two
weeks, Erythromycin 250 mg twice for two
weeks, Azithromycin 1 Gm single dose
and Ofloxacin 300 mg twice for 7 days.
Locally – Tetracycline or Erythromycin eye
ointment twice daily for two weeks.
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 Ophthalmia Neonatorum
Conjunctival inflammation associated with
mucoid, mucopurulent or purulent
discharge from one or both eyes during
first month of life.

It’s a preventable disease in newborn babies

caused by maternal infection, acquired at
the time of birth.
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 Epidemiology
• Although its incidence has declined due
decrease in incidence of Gonorrhoea and
due effective prophylaxis and treatment ,
disease is still prevalent and remains a
public health problem in communities with
poor hygiene and limited access to proper
health care.

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 Etiology
• Neisseria Gonorrhoeae, Streptococcus
Pneumoniae, Staphylococcus etc.
• Chlamydial Trachomatis, Chalmydial
Oculogenitalis
• Chemical Conjunctivitis due to Silver
Nitrate 1or 2% (used as Crede’s method)

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 Neisseria Gonorrhoeae
• Manifest within 48Hrs of birth
• Discharge is Mucopurulent to begin with,
soon becomes purulent
• Both eyes are affected, one more severe
than other.
• Conjunctiva is intensely inflamed with
severe congestion, chemosis, thick yellow
discharge, cornea is seen at bottom of a
crater like pit.
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 Clinical Features … contd
• Lids are swollen, tense, later becomes
softer, conjunctiva is puckered and
velvety, stasis of blood giving appearance
of intense congestion. Pseudomembrane
formation.
• Discharge is pus, serum and blood.
• Corneal complications- corneal ulcer with
its complications is common
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 Complications
• Corneal Ulcer : Oval ulcer, just below the
centre of cornea, rarely oval marginal
ulcer, progressive ulcer resulting in –
perforation of corneal ulcer, prolapse of
uveal tissue, purulent uveitis, prolapse of
lens, prolapse of vitreous.
• Scarring of cornea, adherent leucoma,
anterior staphyloma, anterior capsular
cataract, panophthalmitis.

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 Complications… Contd
• Non development of fixation due to
corneal opacity during first 3 weeks.
• Nystagmus due to non-development of
macular fixation

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 Chlamydia Trachomatis Inclusion
Conjunctivitis
• Develop usually over one week after birth
• Its venereal infection derived from cervix
or urethra
• Less severe than Gonococcal infection

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 Other Bacterial Infections
• Manifest usually 48-72 hrs after birth

Herpes Simplex Infection

presents 5-7 days after birth

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 Chemical Toxicity
• Seen within few hours after prophylactic
treatment with Silver Nitrate Solution 1 or
2% (Crede’s Method) applied for
prophylaxis of Gonococcal infection

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 Diagnosis
• Grams staining
• Giemsa staining of epithelial scraping
• Chlamydial Immunofluorescent antibody
test
• Viral and Bacterial culture sensitivity test

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 Differential Diagnosis
• Differential Diagnosis of discharge in child
within the first month of life –
Congenital blockade of nasolacrimal duct
Acute Dacryocystitis
Congenital Glaucoma.

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 Treatment
Prophylaxis
In cases of any suspicious vaginal
discharge in antenatal period should be
treated meticulously
New born babies closed lids should be
cleaned properly
Prophylactic used of 1% Tetracycline eye
ointment in babies eyes
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 Prophylaxis .. contd
• Close observation during first week
• Prophylactic use of Penicillin or other
antibiotic drops

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 Treatment
Is on lines of Gonorrheoeal Conjunctivitis
Child is hospitalized and treated with
Gentamicin eye drops 0.3% and Bacitracin
eye ointment. Atropine is added if corneal
involvement is there.

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 Treatment …. Contd.
• N. Gonorrhoeae is treated with single I.M.
dose of Ceftriaxone 125 mgm or
Cefotaxime 50 mgm /kg, IV or IM in three
divided dosage. Or Kanamycin 25 mgm
/kg body weight.
• Local treatment consists of Gentamicin
eye drops 0.3% in both eyes repeated in
15 min and then after every feed (2hrly)
for 3 days.

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 Treatment …. Contd.
• Chlamydial Infection is treated with
Erythromycin ethylsuccinate 50mgm /kg
daily in 4 divided dosage before feed for 2-
3 weeks or Azithromycin 10 mgm/kg body
weight for 3 days
• Local treatment Chlortetracycline 1% or
Erythromycin eye ointment after feeds.
• Parents should be treated for genital
infection.
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 TRACHOMA
• At one time known as Egyptian
Ophthalmia, endemic in middle east
during prehistoric period, spread far and
wide in Europe by French Army during
Napoleonic wars. Trachoma is still a
leading cause of preventable blindness
world wide, third after Cataract and
Glaucoma.

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• Approximately 1/5th population of world is
affected by Trachoma, amounting to 150
million people across the 48 countries . It
is estimated that 6 million people are blind
in both eyes. It still remains a significant
problem in areas of Africa, South East
Asia, the Middle East and Australia.

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• Trachoma is caused by Chlamydia
Trachomatis immunotypes / serotypes A,B
and C. Chlamydia organisms shares
properties of both, bacteria and virus. It is
an obligatory intracellular bacteria.

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 Predisposing Factors
• Unhygienic and crowded surroundings
• Low socio-economic status
• Lack of water
• No race is exempted

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 Transmission

• Direct transmission from eye to eye

through discharge
• Through fomites, flies and eye cosmetics
• Disease is contagious in acute phase
• Incubation period is 5 -12 days

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 Clinical Features

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 Symptoms
• Pure Trachoma is usually asymptomatic
condition or there may be minimum
symptoms
• There may be redness, irritation,
discharge, foreign body sensation,
lacrimation and photophobia
• Systemic symptoms like Rhinitis, pre
auricular lymphadenopathy and upper
respiratory infection may be present
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 Symptoms … contd
• Onset is usually sub-acute, but may occur
as acute when infection is massive as
occurs in experimental or accidental or
clinical infection

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 Signs
• Primary infection is Epithelial, involving
conjunctiva and cornea characterized by:
Conjunctival congestion, upper tarsal
Conjunctiva appears red and velvety, later
may become uniformly thick like jelly.
Follicles (in lower fornix, upper fornix,
upper margin of Tarsus, Caruncle, Plica,
Palpabral Conjunctiva, Bulbar Conjunctiva
near limbus)
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 Signs … contd.

• Follicles are small (0.5 mm in diameter)

but may measure upto 5 mm in diameter.
• Invasion of lacrimal passages may also be
there.
• Papillary enlargement.

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 Corneal Signs
• Superficial Keratitis in upper part
• Epithelial erosion, extending deep into
stroma
• Pannus and Lymphoid infiltration with
vascularization seen in upper half, tending
to spread towards the centre . Whole
cornea may be covered with pannus .
Vassels are superficial between epithelium
and Bowman’s membrane.
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 Corneal Signs.. Contd
• Stages of Pannus:
Progressive (infiltration is beyond
vascularization)
Regressive (infiltration has receded and
vessels are ahead of infiltration)
* Corneal ulcer , Chronic, occurs anywhere
but commonest at the advancing edge of
pannus, are shallow ulcer with little
infiltration.
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 Pathology
• Chlamydia Trachomatis is seen in
conjunctival scarping in the form of
colonies in the epithelial cells as
Halberstaedter Prowazek inclusion bodies.
• Inclusion bodies are composed of
innumerable elementary bodies
embedded in carbohydrate matrix.

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 Pathology … Contd
Elementary bodies, attacking epithelial cells,
enlarge to become initial bodies in the
cytoplasm of the cells. Numerous initial
bodies, in cells divide to form innumerable
elementary bodies embedded in
carbohydrate matrix. The nucleus of cell is
displaced , degenerates and cell burst to
release elementary bodies, to attack new
cells.
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 Pathology … contd.
• In TF and TI stages, polymorphonuclear
cell infiltration is noticed and later on
lymphocytes are dominant.
• Lymphocytic infiltration in Adenoid layer.
• Aggregation of lymphocyte without
capsule forms follicles
• Follicles shows necrosis and contains
large multinucleated Laber cells.
• An attack confers little immunity
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 Pathology …. Contd.
• Trachomatous infiltration may spread
deep into subepithelial tissues of the
palpabral conjunctiva and even invade the
tarsal plate
• Fibrosis around follicles giving rise to
cicatricial bands (Arlt line in superior
tarsus)

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 Diagnosis
• Culture of Chlamydia Trachomatis in
irradiated McCoy cells
• Micro-Immunofluorescence (Micro-IF) test
• Monoclonal Direct Antibody test
• Demonstration of inclusion bodies in
conjunctival epithelial scrapping

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 Clinical Diagnosis
• Is based on identification of at least two of the
following signs:
1. Follicles
2. Epithelial Keratitis
3. Pannus
4. Limbal Follicles/ Herbert Pits
5. Typical Trachomatous Scarring (Stellate or
Linear Scarring of upper tarsus)
Diagnosis is confirmed by demonstration of
inclusion bodies
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 Trachoma Classification
I. MacCallan’s Classification
Stage I – Immature follicles on tarsus ,
SPK and Pannus
Stage II – Florid Superior Tarsal
follicular reaction with mature follicles or
marked papillary hyperplasia , pannus,
Limbal follicles, superior corneal
epithelial infiltrates
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 MacCallan Classification
Stage –III : Signs of stage II with
Cicatrization
Stage – IV Cicatrization and its sequelae

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 WHO Classification
Stage – I Trachomatous Infiltration – Follicular
(TF) 5 or more follicles of at least 0.5 mm in
diameter. If treated properly, patient recovers
with no or minimal scarring
Stage -II Trachomatous Infiltartion – Intense (TI)
: Follicles, papillae, thickening of Conjunctiva
obscuring >50% conjunctival blood vessels.
Severe infection with high risk of complication.

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 WHO Classification… Contd
Stage – III : Trachomatous scarring (TS)
Stage – IV : Trachomatous Trichiasis (TT)
Stage - V : Corneal Opacity (CO) corneal
opacity occupying pupillary area

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 Sequelae of Trachoma
• Distortion of lids
• Trachomatous Ptosis
• Entropion
• Trichiasis
• Tylosis

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 Late Complications
• Sever dry eye
• Keratitis
• Corneal scarring
• Fibrovascular pannus
• Corneal Bacterial Superinfection

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 Treatment
• Tetracycline, Erythromycin, Rifampicin
and Sulphonamides are effective orally
• Topical Erythromycin and Tetracycline
ointment

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 Treatment … contd
Treatment of TF Stage – Topical
Erythromycin twice for 6 weeks
Oral Azithromycin 1 Gm single dose
Tetracycline 250 mgm qid for 2 weeks
Doxycycline 100 mgm twice for 2 weeks

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 Treatment … contd
Treatment of TI Stage : same as TF stage

Treatment of TS stage : Ocular lubricants

Treatment of TT Stage : Epilation , tarsal

rotation , Radiofrequency/ diathermy or
electrolysis epilation . Or Cryotherapy

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 Treatment … contd
• Treatment of CO Stage : After treatment of
lid deformities LKP or PKP, depending on
depth of corneal opacity

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 WHO’s GET 2020
• WHO in 1997 started Global Elimination of
Trachoma by 2020 programme called
WHO GET 2020 programme, under which
‘SAFE’ strategy has been adopted.
• S : Surgery for entropion/ trichiasis
• A : Antibiotics for infectious trachoma
• F : Facial cleanliness to reduce
transmission
• E : Environmental improvement
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 Trachoma Control Programme
• Tetracycline eye ointment 1% twice daily
on 5 consecutive days every month for 12
months
• Mass treatment should be annually in
endemic zones ( <35% children are
affected) and Biannually in hyperendemic
zones (>50% children are affected)

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 Ophthalmia Nodosa
Nodular conjunctivitis, resembling
tuberculosis, due to irritation caused by
caterpillar hairs.

Small semitranslucent pinkish, reddish or

pale gray nodules formed in bulbar,
palpabral conjunctiva, cornea and rarely in
iris tissue.
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 Ophthalmia Nodosa .. Contd
Hairs are surrounded by giant cells and
lymphocytes.

Treatment: Symptomatic, Local Steroids in

selected cases, under supervision and
excision of conjunctival nodules.

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 Chronic Non-specific Conjunctivitis
Is a clinical condition resulting from
continuation of acute conjunctivitis or due
to variety of etiological factors,
characterized by chronic redness in one or
both eyes with persistence of annoying
symptoms.

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 Etiology
1. Exposure to Chronic irritants like,
smoke, dust, heat, poor quality air, late
hours, alcohol abuse.
2. Hypersensitivity to allergen.
3. Concretions, misdirected eyelash(es),
Dacryocystitis , Chronic Rhinitis, sinusitis,
blepharitis, seborrhoea , dandruff etc
4. Unilateral Conjunctivitis foreign body
retained in conjunctiva or Dacryocystitis
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 Symptoms
* Discomfort, burning, grittyness,
especially in the evening when eyes
becomes red and eyelid margins feel hot
and dry.
* Difficulty in keeping eyes open.
* Increased secretions, mucoid or
mucopurulent discharge, lids may stick
together in the morning on waking up.
together
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 Signs
• Hyperaemic lid margins
• Conjunctival Congestion particularly in
lower fornix
• Papillary hyperplasia

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 Treatment
• Elimination of cause
• Treatment of infection foci in nose and
upper respiratory passage
• Treatment of conjunctival infection with
appropriate antibiotic
• Treatment of meibomian gland
abnormality by mechanical expression and
warm compression.
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