SCLERA & CONJUNCTIVA NOTES

                        SCLERA & CONJUNCTIVA

                            EPISCLERITIS

DEF-

Benign inflamn of subconj connective tiss & superficial scleral lamella.

• Young adults
• Females
• H/O RA

TYPES- Simple

          -Nodular

C/F-

Symptoms-UL

                -Acute redness

                -discomfort

                -tenderness

                 -watering

Signs-

1.SIMPLE EPISCLERITIS-

  a]  Sectoral  OR

  B] Diffuse

*  D/T engorgement of large episcleral Vs running in a radial dir beneath the conj

*   Never ulcerate

*   Cor & uvea NOT inv

*   May resolve or leave a slate coloured scar to which conj is adherent

2.NODULAR  EPISCLERITIS-

*  Localized, raised , congested nodule

*  Ant scleral surf is not raised

*  Traversed by deeper episcleral Vs.So look purple & not red.

T/T-1.  Lubricants

      2.Topical steroids

      3. NSAIDs- T. Flurbiprofen 100mg tds

                        - OR t. Aspirin

                        - T. Indomethacin

                          SCLERITIS [j-01, d-02, j-04]

DEF-

Edema & cellular infiltration of entire scleral thickness.

CAUSES-

1.Systemic-

*  RA

*  Wegener’s granulomatosis

*   Relapsing polychondritis

*   PAN

2.Surgery-

* Cataract surg

* RD surg

* Filtration surg

* pterygium excision + beta rad + MMC

3.Infections-

* Corneal ulcer

*Trauma

* Org- Pseudo aeruginosa, strep pneum, staph aureus, varicella zoster

CLASS-

1. Anterior scleritis-

1. Non-necrotizing-Diffuse or nodular
2. Necrotizing- With or without inflamn

2.Posterior scleritis

ANTERIOR NON-NECROTIZING SCLERITIS-

1 ]Diffuse scleritis-

*   Inv a sector or entire anterior sclera

*   Distorts the nml radial vascular pattern

2] Nodular scleritis-

*   Scleral nodule cannot be moved over the underlying tiss

*   Dark red or bluish, later purple

T/T-

1.Oral NSAIDs

2.Oral steroids

3. Steroids + NSAIDs

4.S/C Triamcinolone acetonide 40mg/ml

ANTERIOR NECROTIZING SCLERITIS-

WITH INFLAMN-

• Localized redness
• Pain-radiates to temple,brow or jaw
• Congestion of deep vascular plexus.
• Vascular distortion & occlusion → avascular patches
• Scleral necrosis with overlying conj ulceration
• Resolution → scleral thinning→uvea visible as bluish tinge
• COMPLICATIONS-Staphyloma

                                    -Cataract

                                    -Keratitis

                                    -Keratolysis

                                    -Sec glaucoma

                                    -Macular edema

T/T-

1.Oral steroids

2.Immunosuppressives-

Cyclophosphamide-1-2 mg/kg/day

Azathioprine-1-3mg/kg/day

Cyclosporin-2-5 mg/kg/day

3.Combined therapy-

Pulsed IV methylprednisone 1gm + cyclophosphamide 500mg

ANTERIOR NECROTIZING SCLERITIS

WITHOUT INFLAMN-

Also k/as –SCLEROMALACIA PERFORANS

• Asymptomatic yellow ,necrotic,scleral patches in uninflamed sclera
• Scleral thinning→  exposes uvea
• Staphyloma
• T/T- ineffective

POSTERIOR SCLERITIS-

C/F-

• Pain
• Visual impairment
• Lid edema
• Proptosis
• O’plegia
• Asstd ant scleritis
• Fundus-Disc edema, mac edema,choroidal folds,exud RD,Ring choroidal det& subretinal lipid exud
• INV-

2. USG-“ T” sign-Thickening in post sclera & fld in tenon’s   space.Stem of T is formed by optic N & cross-bar by fld in subtenon’s space

3. CT SCAN-  Posterior scleral thickening

T/T- same

                         STAPHYLOMA-case

DEF-

Ectasia of outer coats of the eye with an incarceration of uveal tissue

Underlying cause is inflammation / degeneration

CLASS-

1. Anterior
2. Intercalary
3. Ciliary
4. Equatorial
5. Posterior

1. ANTERIOR STAPHYLOMA-

• Partial- Part of cornea inv
• Total-Whole of cornea inv
• MCC- Sloughing corneal ulcer→ perforates → Heals & forms pseudocor by exudative organization & laying down of fibrous tissue
• Lined internally by iris & externally by epith
• AC-flat
• Sec glaucoma dev later
• Gradually weak ant surf of eye protrudes out→ Ant staphyloma

2. INTERCALARY STAPHYLOMA-

• Located at the limbus
• Lined by iris root & ant part of CB
• Seen externally from the limbus upto 2mm behind the limbus
• Causes-

1. Perforating inj of peripheral cor
2. Marginal cor ulcer
3. Ant scleritis
4. Scleromalacia perforans
5. Complicated cataract surg with poor wound apposition
6. Sec glauc

3.CILIARY STAPHYLOMA-

*   Affects the ciliary zone [8mm behind the limbus]

* CB is incarcerated in scleral ectasia

* Bluish & lobulated

Causes-

1.Dev glauc

2.End stage glauc

3.Scleritis

4.Trauma to ciliary region

4.EQUATORIAL STAPHYLOMA-

*  Occurs at the equatorial reg with incarceration of choroid [14mm behind the limbus]

* Equator is Weak d/t passage of venae vorticosae

Causes-

1. Scleritis
2. deg myopia
3. Chr uncontrolled glauc

POSTERIOR STAPHYLOMA-

• Posterior pole of eye
• Lined by choroid
• MCC- deg high axial myopia
• Ectatic portion detected externally
• Fundus-Crescentic shadow in macular region

               -Retinal Vs change dir dipping into the region

*Staphylomatous area- pale d/t deg in ret, RPE &

Choroid

T/T-

1. T/T of underlying cause
2. Local excision & repair with corneal & scleral patch graft
3. Unsightly & blind eye-Staphylectomy & KP

                                      OR Enucleation + implant

PARTS OF CONJUNCTIVA-

1. Palpebral-

1. Marginal
2. Tarsal
3. Orbital

2.Fornix

3.Bulbar

4.Limbal

MICROSCOPIC-

1. EPITHELIUM

• Palpebral conj- 2 layers of epith
• Intermarginal strip-Transitional stratified squamous epith
• From fornix to limbus-4-6 layers
• Limbus- stratified epith

2. SUB-EPITHELIAL / ADENOID LAYER-

Loose connective tiss + leucocytes

C . FIBROUS LAYER

XEROPHTHALMIA-WHO CLASS-

XN-   Nightblindness

XIA- Conjunctival xerosis

XIB-  Bitot’s spots

X2-    Corneal xerosis

X3A-  Corneal ulceration/keratomalacia <1/3rd cor surf

X3B-   Corneal ulceration / keratomalacia > 1/3rd cor surf

XS-   Corneal scar

XF-   Xerophthalmic fundus [UYEMURA’S FUNDUS]

Night blindness is also k/as –Chicken eyes [since chickens lack rods & are nightblind]

CONJUNCTIVAL CONGESTION	CILIARY CONGESTION
Bright red	Dull red
Near the fornix	Around the limbus
Branch dichotomously	Branch radially
Arise from post conj Vs	Arise from anterior ciliary Vs
Phenylepherine→ blanch	Do not blanch
Vs fill up from the fornix	Vs fill up from the limbus
Superficial inv-c’vitis, simple hyperaemia	Deep inv-iritis, scleritis

TRUE PTERYGIUM	PSEUDOPTERYGIUM
Degenerative	Inflammatory
Usually progressive	Stationary
Probe cannot be passed underneath the head of pterygium	Probe can be passed.

FOLLICLES-

Localised aggregation of lymphocytes in the subepithelial adenoid layer.

CAUSES-

1. HSV conjunctivitis
2. molluscum contagiosum c’vitis
3. chlamydial inf
4. Parinaud’s oculoglandular syn

Q Diff bet trachomatous folliclec & follicles in follicular conjunctivitis?

A- Trachomatous follicles- 5mm dia

                                         -Commence in lower fornix

                                         -Form a row along upper tarsal margin

                                         -Undergo cicatrisation & form minute

                                           Stellate scars.

PAPILLAE-

Hyperplasia of central Vs surrounded by diffuse infiltrates of lymphocytes,plasma cells & eosinophils

CAUSES-

1. Chr blepharitis
2. Vernal catarrh
3. Giant papillary c’vitis
4. contact lens induced
5. Superior limbic keratoconjunctivitis

FOLLICULAR CONJUNCTIVITIS [d-04]

1.Acute

2.Subacute / chronic

ACUTE FOLLICULAR CVITIS-

• Chlamydial inclusion conjunctivitis
• Epidemic keratoconjunctivitis
• Pharyngoconj fever
• Newcastle cvitis
• H’hic cvitis
• Primary herpetic cvitis
• Recurrent herpes simplex cvitis

SUBACUTE /CHRONIC

• Drug induced [pilocaropine]
• Sec to lid lesions-moll contagiosum,pediculosis
• Trachoma

1) CHLAMYDIAL INCLUSION CVITIS-

• Agent-Chlamydia trachomatis[D-K]
• Spread-genitals,eye-eye,swimming pool
• C/F- UL/BL mucopurulent discharge
• SIGNS-large follicles in lower fornix→2-3wks→SPK + pannus
• T/T-

1. Topical tetracycline e/o qid for 6wks
2. Tab doxy 100mg 12hrly for 2wks
3. Tab erythro 250mg 12 hrly for 2wks
4. Tab. Azithro 1gm OD

  2)  EPIDEMIC KERATOCONJUNCTIVITIS-

• Agent- Adenovirus 8 & 19
• Spread- contaminated fingers,sol,tonometer
• C/F –Foll cvitis

          -Preauricular LNpathy

         -Punctate epith infiltrates

         -discrete subepith opacities

*  T/T- Decongestive & lubricating drops

         -Antibiotic e/d

3) PHARYNGOCONJUNCTIVAL FEVER-

• Agent-adenovirus3,4&7
• C/F-
• Foll cv
• Pharyngitis
• Fever
• Preaur LNpathy
• SPK

4) NEWCASTLE CV

• contact with diseased fowls
• indistinguishible from others

5) H’GHIC CV

• picorna v , coxsackie v & entero v
• C/F-VIOLENT INFLAM CV
• LACRIMATION
• Photophobia
• Subconj h’age
• Preaur LNpathy

6) ACUTE HERPETIC CV

• Prim herpes
• preaur LNpathy
• corneal vesicles→ merge→ dendritic figures
• large follicles
• reduced cor sensation

7) RECURRENT HERPES SIMPLEX CV

• Acute foll cv without lesions of face,lids or cor
• Microdendrites
• Reduced cor sensation
• T/T-

1. Artificial tears
2. acyclovir e/o  3%  5 /day
3. Vidarabine e/o 3%  5/d
4. Trifluorothymidine 1 % e/d 5/d

               VERNAL    CATARRH [j-04, d-02]

• Also k/as vernal c’vitis or spring catarrh
• EPIDEMIO- Recurrent

                       -Sporadic

                       -non-contagious

                      -BL

                      -Hot weather

                      -Young boys

                     -F/H of atopy

                     -Type –I hypersensitivity-Ig E mediated

                                                             -eosinophilia

*  C/F-

-Burning

-Itching

-Photophobia

-Lacrimation

-White ropy discharge [b/o fibrin]

2 forms-1] Palpebral

             2] Limbal / Bulbar

PALPEBRAL-

• Palp conj is hypertrophied [papillae]& mapped out into polygonal raised areas like cobblestones
• Bluish –white like milk
• Flat topped nodules are hard & consist of dense fibrous tiss.The overlying epith is thickened,therefore milky hue.

BULBAR-

• Wall of gelatinous thickening at the limbus
• HORNER TRANTAS DOTS-white dots consisting of eosinophils & epith debris

COMPLICATIONS-

1. SPK
2. Dry eyes
3. Corneal [ shield] ulcer
4. Scarring

T/T-

1. Cold compression  & tinted glasses
2. Antihistaminic e/d
3. Topical steroid e/d  4-6 hrly
4. Disodium chromoglycate e/d 2% 8 hrly or 4% 12 hrly
5. Olopatadine e/d BD- new mast cell stabilizer
6. Subtarsal inj of triamcinolone
7. Acetyl cysteine 10 % or 20 % drops-for excess mucus
8. Cryotherapy of nodules

           ANTI-ALLERGIC  DRUGS [j-07]

1. H1- RECEPTOR ANTAGONIST [ANTIHISTAMINICS]

Competetively inhibit histamine at the receptor sites

     IND-

1. VKC
2. GPC
3. Allergic cvitis

     TOPICAL-

• Emedastine  qid
• Levocabastine
• Azelastine OD or BD
• Antazoline qid
• Chlorpheniramine qid

    SYSTEMIC-

• Loratidine
• Cetrizine
• Astemizole
• Fexofenadine

2. MAST CELL STABILIZERS-

Stabilize the membrane of mast cells→ prevent release of histamine

1. Cromolyn sodium-

-2-4 %  E/D  6 hrly

-  2 %  oint  HS

-  Ind- VKC

       -GPC

         - onset of action- 3-4 weeks

2. Ketotifen –
• TDS
• Quicker onset of action

3. Lodoxamide-

- 0.1 %   TDS

4. Olopatadine-
• 0.1 %  12 hourly
• Antihistaminic +  mast cell stabilizer

5. Others- pemirolast  , nedocromil sodium

3]  ANTIHISTAMINES + MAST CELL STABILIZERS-

*  Olopatadine

*   Ketotifen [ anti-inflam]

*  Azelastine  [      “         ]

4]  NSAIDs

     - Ketorolac- Reduces itching

                       - but stinging

5] VASOCONSTRICTORS-

   -Naphazoline / pheniramine

   - Naphazoline /  Antazoline

6] STEROIDS-topical

  - Loteprednol

  - Flurometholone

  - Rimexolone