MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES

XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA,
ALPHE

Class 2010 SUBJECT: Ophthalmology DATE:

July 3, 2008
TOPIC: Conjunctiva, Cornea, Sclera
LECTURER: Lola Ophtha
TRANSGROUP: Eis, Cands, Jas, Say
AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

lymphoid tissues with peripheral

CONJUNCTIVA vascularization
• mucosal lining of the inner part of the
lids and anterior portion of the eyeballs Bacteriology
• Divided into palpebral and bulbar parts • Conjunctiva harbors bacteria at birth.
 separated by fornix • Growth of these organisms is hampered
• Palpebral portion – has three sections by the low temperature in the
o Marginal – groove near the lid conjunctival sac, the anti-bacterial
margin to which it is adherent action of the lysozyme in tears, the
o Tarsal – vascular portion attached mechanical effect of blinking, the
to the tarsus flushing action of the tear flow and the
o Orbital – loosely connected to the production of antibiotics by some of the
bacteria present in the conjunctiva
palpebral muscle
• Debilitated persons with serious illness
• Bulbar portion – thin layer that overlies
– gram-negative rods increase (esp. P.
the Tenon’s capsule but becomes fixed
aeruginosa and enterobacter species)
to it near the limbus
o Presence of mucus glands (goblet • Bacterial flora of the normal conjunctiva
cells) found in the epithelium of can be a potential source of infection
bulbar and tarsal portions under these conditions:
o Serous glands located in upper o Decrease in the general physical
fornix condition of the individual
o Secretions from both glands form o Disturbance in the immunologic
part of the pre-corneal tear film set-up
o Application of local steroids
• Conjunctiva is the only superficial tissue
o Increase in the bacterial count in
of the body
the face, hands, and upper
Pathology respiratory tract
• Foreign body sensation is the single • Airborne infection and endogenous
clue signifying pathology metastatic bacteremia – minor roles in
conjunctival infection
• Objectively: conjunctival injection,
lacrimation or discharge, formation of
INFLAMMATORY CONDITIONS
papilla or follicle, hemorrhage,
• Conjunctivitis – inflammation of the
ulceration or growth
conjunctiva
• Conjunctival injection or dilatation –
• Appearance of other clinical signs
dilatation of superficial blood vessels
which denotes pathology; widespread in depends on the etiologic factor
location, blanches on pressure or on o Infective agents: bacteria,
application of epinephrine viruses, Chlamydia
o Infection is by direct contact with
• Ciliary injection – (+) corneal or
intraocular disorder located near the contaminated hands or materials,
limbus, unaffected by pressure or occasionally by air-borne or
epinephrine endogenous means
o Non-infective conditions: allergic
• Papilla – vascular reaction characterized
conjunctivitis is common
by neoformation of blood vessels at the
center (red dot) surrounded by
Bacterial Conjunctivitis

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• Can cause either a diffused
conjunctivitis (produces mucoid,
mucopurulent or purulent discharge) or
a localized granuloma (produces a
localized area of conjunctival injection
within it is a nodule or an ulcer)
• Mucoid discharge – produced by the
Moraxella-Axenfeld diplobacillus;
discharge accumulates at the lid
margins and canthi
o Lateral canthus – often called
angular conjunctivitis
o The organism can be destroyed
by Polymixin, neomycin,
chloramphenicol, and sulfa
solutions or ointments
• Purulent discharge – Neiserria
gonorrhea and beta Streptococcus
o One of the most frequent causes
of ophthalmia neonatorum
• Muco-purulent discharge produced by:
o Hemophilus aegyptius (Koch-
Weeks)
o Hemophilus influenza
o Staphylococcus aureus
o Pseudomonas aeruginosa
o Escherichia coli
o Proteus miranilis
o Treatment: C & S Test (results are
after 1 week), than proper
antibiotics
Viral Conjunctivitis
Three types:
1. Epidemic kerato-conjunctivitis -
produces a pseudo-membrane in the
lower and upper palpebral conjunctiva
2. Pharyngo-conjunctiva fever -
accompanied by marked febrile
symptoms
3. Acute hemorrhagic conjunctivitis – has
subconjunctival hemorrhages in the
upper bulbar conjunctiva
All three produce:
• Intense congestion
• Chemosis
• Lower palpebral folliculosis
• Lacrimation
• Epithelial and subepithelial keratitis
• Pre-auricular adenopathy
No specific therapy, only palliative measures:
cold compresses, anti-histaminics, and
sunglasses
• Oral methisoprinol (Isoprinosine) –
reduces the intensity of the symptoms
and the duration of the condition by
enhancing the immune response
Other known viruses that may produce
conjunctivitis:
• Exenthematous viruses (small pox,
chicken pox, measles, German measles)
• Herpes viruses (herpes simplex, herpes
zoster)
• Myxoviruses (mumps, influenza, New
castle disease)
“Care of cornea is more important than
the conjunctiva”
Chlamydia Conjunctivitis
• Chlamydia – organisms that can be
classified in between the bacteria and
the viruses
Trachoma
• Caused by Chlamydia trachomatis
• Condition assumes a gradual chronic
course lasting for months or years
• Stage I – formation of follicles in the
upper palpebral conjunctiva with
beginning limbal vascularization and
cellular infiltration (pannus)
• Stage II – presence of papillary
hypertrophy and the transformation of
the follicles into “sago-grain” structures
• Stage III – beginning of scarring
• Stage IV – period of cicatricization when
all inflammatory activities end
• Treatment: important to recognize the
condition early (esp the first 2 stages)
o When scarring appears, the
changes become permanent and
irreversible
o Regimen: systemic use of
sulfonamides and topical
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application of tetracycline and
erythromycin for 14 days
Inclusion blenorrhea
• Caused by Chlamydia oculogenitalis –
also causes urethritis in man and
cervicitis in women
• One of the three causes of ophthalmia
neonatorum where the purulent
discharge is prominent
• Secretion is concentrated in the lower
palpebral conjunctiva
• Tx: Sulfanilamides
Allergic Conjunctivitis
• Most produces marked chemosis;
itching is very annoying
• Eosinophils are found in the discharge
Phlyctenular conjunctivitis
• Generally a kerato-conjunctivitis but
can affect only the bulbar conjunctiva
• Localized whitish nodule with a necrotic
excavated center (phlyctenule)
surrounded by conjunctival injection
• Commonly found among malnourished
children and those suffering from PTB
• Recurrent condition, can disappear
spontaneously
• Associated with tooth decay
• Tx: local steroids
Vernal conjunctivitis
• Recurrent condition affecting the upper
palpebral conjunctiva of both eyes
during summer months
• Thick syrupy discharge and much
itchiness
• Palpebral conjunctiva shows big papillae
arranged in a cobble-stone appearance
• Tx: topical steroids and cold
compresses
o Big papillae can be excised to
lessen discomfort
o Moving to colder places has
helped prevent recurrences
Atopic conjunctivitis
• Marked chemosis and watery discharge
due to exposure to certain grasses
(talahib), plants (roses), and trees (pine
trees)
• Secretion contains many eosinophils
• Tx: local and systemic antihistaminics
Contact conjunctivitis
• Due to contact with certain drugs
(those used for cosmetics, hair
dressings, and ophthalmic medications)
• Intense itching, chemosis, and thick
syrupy discharge; plenty of eosinophils
in secretion; follicles in lower formnix
• Withdrawal of the offensive drugs for
improvement
• Tx: cold compresses, local and systemic
antihistaminics, steroids
NON-INFLAMMATORY CONDITIONS
DEGENERATIONS:
Pinguecula
• Triangular elevated yellowish mass at
the bulbar conjunctiva with the base
towards the limbus
• Appears with senility, aggravated by
exposures to wind, dust, sun
• Becomes congested; produces a foreign
body sensation if irritated
• Needs no treatment unless unsightly 
either excised or cauterized
• Topical steroids can reduce congestion
Pterygium
• Fleshy mass in the bulbar conjunctiva
that invades the cornea at the
horizontal meridian
• Common in areas where there is too
much sunlight, wind, dust
• Can produce astigmatic errors and
obstruct normal vision if it encroaches
the papillary area
• Tx: excision of the mass; additional
topical instillation of thiotepa solution
(1:2,000) for 3 months minimizes
further recurrences
NEOPLASMS
Nevi
• Pigmented elevated tumors at the
bulbar conjunctiva
Melanosis
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• Flat diffused conjunctival pigmentation
occurring after the age of 40 y/o
• Exenteration of the orbit is necessary if
frank evidences of malignancy are
present
CORNEA
• A clear and transparent ocular medium;
anterior portion of the external coat of
the eye, has both protective and optical
functions
• Nearly circular but the transverse
diameter (12 mm) is larger than vertical
diameter (11 mm)
• Has five layers:
o Epithelium
o Bowman’s membrane
o Stroma or substantia propia
o Descemet’s membrane
o Endothelium – monolayer of
mesodermal cells, important in
corneal hydration
• Has a rich sensory nerve supply, part of
the protective mechanism of the eye;
pain is most common symptom
• Avascular, entirely dependent on air
and tears anterirorly and aqueaous
humor posteriorly for its nutrition
• Normally in a relative stage of
dehydration, has tremendous swelling
property
• Endothelium greatly influences corneal
dehydration by providing a barrier to
the easy access of the aqueous humor
into the corneal stroma and by the
metabolic acitvitiy of the corneal
stroma that is made to lose fluid
INFLAMMATORY CONDITIONS
• Signs of active corneal inflammation:
o Cellular infiltration of the stroma
o Edema
o Neovascularization (superficial or
deep)
o Necrosis
• Central stromal keratitis: inflammation
occurs within the central 2/3 of the
cornea and may result in visual loss
• Peripheral inflammatory disease:
peripheral 1/3 of cornea and limbus
Corneal Ulcer
• Commonly exogenous
• Painful initially, with lacrimation,
photophobia, blepharospasm, ciliary
injection, and an area of cloudy cornea
due to loss of epithelium with edema at
the site of ulceration
• Microbiology is influenced by the factors
of geography, climate, and social and
economic status of the individuatl
• Widespread use of antibiotics and of
corticosteroids – emergence of fungal
corneal infection
Bacterial Corneal Ulcer
• Pneumococcus is the most common
cause, followed by Moraxella and
Pseudomonas aeruginosa
• Stages:
1. Heal without scarring
2. Penetrate into the stroma
3. Penetrate deeply to expose the
Descemet’s membrane
4. Perforate giving rise to adherent
leukoma
5. Panophthalmitis
• Broad spectrum antibiotics are availed
of initially until results are secured
• Atropine 1% is given topically  dilates
pupil
Viral keratitis
• Most common form due to Herpes
simplex – inhabits the mucous
membrane of the nose and throat
• Gives rise to a superficial ulcer forming
branch-like extensions when stained
with flourescein
• Lacrimation and photophobia with less
amount of ciliary injection and very
little pain; cornea becomes anesthetic
with the progression of the ulcer
• Virus becomes lodged in the corneal
epithelium due to primary infection
• Duration of untreated: 21 days
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• Tx for epithelial type of involvement:
0.1% solution of 5-iodo-2-desoxyuridine
(IDU) topically
• Corticosteroid is contraindicated when
with active viral replication, but may be
used with caution in stromal and deep
keratitis
Fungal keratitis
• Has a history of trauma often with
vegetable matter
• Most common etiologic agents:
Fusarium, Aspergillus, Mycelia sterile
• Lesion may mimic bacterial and
herpetic infections or even co-exist with
them
• Fungal corneal ulcer may appear as
white or gray white elevated hard ulcer
with dot-like satellite opacities around;
hypopyon and minimal vascularization
may appear
• Superficial keratomycosis: curettage or
anterior keratectomy is an effective
adjunct
• Antifungal drugs: amphotericin B,
nystatin, pimaricin
• Mechanical removal of the infected and
necrotic tissues hastens control of
infection; minimizes the destructive
effects of inflammation on the remaning
normal corneal tissue
Phlyctenular keratoconjunctivitis
• Allergic reaction to an exogenous
tuberculo-protein
• Common in childhood (poor and
malnourished)
• 1 mm in diameter, raised and yellowish
in color; may occur on the bulbar
conjunctiva or limbus; ulceration may
occur
• Ocular discomfort, itchiness, redness,
photophobia
• Tx: topical steroid-antibiotic preparation
and improvement of general nutritional
state of the patient
Padi Keratitis
• Coin-like corneal opacities found among
farmers and agricultural workers
• S/sx: white spot in the eye, foreign body
sensation, photophobia, blurry vision,
ciliary infection
• Tx: topical steroid – relives redness,
tearing, pain
Idiopathic disciform keratitis
• Characterized by a central disciform
opacity with epithelial and stromal
edema, slight to moderate degree of
stromal infiltration, folding of the
Descemet’s membrane, and presence
of fine to medium sized endothelial
precipitates
• Symptoms: foreign body sensation, mild
photophobia, blurred vision
• Inflammatory reaction: most prominent
sign during the first 4-5 months
• Tx: topical steroids; regimen continued
until the corneal stroma clears up or
only residual scarring or edema remains
Bullous keratopathy
• Presence of vesicles or blebs,
accompanied by foreign body sensation
and pain
• Hypertonic solutions or ointments give
temporary relief
INFLAMMATORY SEQUELAE
Opacities of the Cornea
• Corneal opacity – lack of corneal
transparency resulting from severe
inflammation such as ulceration or
injury
• Classification of scar according to
density:
o Nebula – faint, cloud-like seen
with oblique illumination
o Macula – large enough to be seen
as a gray spot
o Leukoma – dense and white scar
• Adherent leukoma – iris becomes
attached to the scar tissue
• These opacities cause visual
disturbance because of the resulting
diffusion of light and irregular refraction
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of light especially when located within
the optical center of cornea
• Corneal staphyloma – bulging cicatrix of
the cornea as a result of perforation; iris
becomes adherent to the back surface
of the cornea; no recoverable vision
• Superficial corneal opacitiy – superficial
keratectomy can improve vision
• Full thickness corneal opacity – corneal
transplantation or keratoplasty
• Corneal staphyloma – enucleation is
advised
Corneal Opacity Associated with Measles
• Extensive scarring has been observed
after
• Due to secondary bacterial infections
• Cornea is thickened and vascularized;
final outcome in severe inflammation is
blindness
NON-INFLAMMATORY CONDITIONS
Developmental Anomalies of the Cornea
• Involve aberration in shape, size,
curvature, and clarity of the cornea
• Microcornea – small cornea, measuring
less than 10 mm, without visual
disturbance
• Megalocornea – bilateral enlargement of
the cornea, more than 13.5 mm;
anterior chamber is deep with some iris
atrophy
Corneal Degeneration
• Arcus senilis – opaque ring within the
corneoscleral junction
• Characterized by lipid deposit, no
definite association with serum lipid
abnormalities
• Band keratopathy – calcific
degeneration of the Bowman’s
membrane; extends across the cornea
o Sequel of uveitis, keratitis, or
long standing glaucoma
o Associated with other systemic
diseases such as sarcoidosis,
hyperparhtyroidisim, and vit. D
toxicitiy
• Hassel Henle bodies – small
excresences in the periphery of
Descemet’s membrane, which stains
similarly as normal Descemet’s
membrane; seen after age 20
• Mooren’s ulcer – progressive disease
starting at the periphery and progresses
centrally; often ends in perforation
requiring surgical intervention
• Senile marginal degeneration (Terrien
ulcer, gutter degeneration) – marginal
opacification with some superficial
peripheral vascularization follwed by
loss of corneal substance
Corneal dystrophies
Endothelial (Fuch’s dystrophy)
• Usually bilateral, begins as endothelial
degeneration followed by stromal and
epithelial edema and appearance of
bulbae
• Accompanied by pain, blurring of vision
and photophobia
• Chronic condition
• Tx: hypertonic solution, use of soft
contact lens
Familial dystrophies
• Hereditary bilateral corneal lesion
showing hyaline-like deposits in the
stroma either as granular, macular, or
lattice
Keratoconus
• Non-inflammatory protrusion of the
center of the cornea due to gradual
thinning of the apex
• Common in females; bilateral condition
• Lower lid bulges when the patient looks
down  Munson’s sign
Nutritional Lesions of the Cornea
Keratomalacia
• Softening of the cornea; starts as
conjunctival necrosis with or without
Bitot’s spot, followed by corneal xerosis
which ulcerats and perforates
• Supportive measures such as
improvement of the nutrition of the
child and local antibiotic and vitamin A
treatment
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Vitamin B-complex keratitis ciliary region; usually located at the

temporal side
KERATOPLASTY • Similar to a severe case of plyctenular
• Replacement of a partial of full conjunctivitis
thickness of diseased host cornea with
donor tissue Scleritis
• Indications: improvement of visual • Inflammation of the deeper portion of
function of opaque or diseased cornea, the sclera
the correction of severe altered • Makes the affected are bluish red in
structure, the replacement of active color
diseased cornea, and the improvement
of the cosmetic appearance of the eye
• Failure of the graft to take will be
aggravated if the new formed blood
vessels involve a wider area and the
deeper layers of the cornea
• Donor eye should be removed ASAP
after death (w/in 10 hours)
• Young donor material is preferred –
denser endothelial population and
greater potential for cell proliferation

SCLERA
• Tunic coat which forms the external
fibrous layer of the eyeball
• Opaque and inelastic
• Function: mainly protective
• Composed of CT with some elastic
fibers; continuous with the cornea
anteriorly
• Pierced by the optic nerve 2.5 mm
nasal to the posterior pole of the eye
• Covered by the Tenon’s capsule and the
conjunctiva, to which it is joined by the
episclera

INFLAMMATORY CONDITIONS
• Usually manifestations of a collagen
disease or may be associated with
keratitis or uveitis

Episcleritis
• Superficial inflammation of the sclera
• Symptoms: pain, lacrimation, ocular
discomfort, photophobia
• Lesion appears as a flat or raised hard
immovable nodule surrounded by dark
red or purple colored congestion in the

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