GRANULOMATOUS CONJUNCTIVITIS

Granulomatous conjunctivitis "granulomatous conjunctivitis contacts" is the term used to
describe certain specific chronic inflammations of the
conjunctiva, characterised by proliferative lesions
which usually tend to remain localized to one eye and
are mostly associated with regional lymphadenitis.

Common granulomatous conjunctival inflammations
are:

• Tuberculosis of conjunctiva
• Sarcoidosis of conjunctiva
• Syphilitic conjunctivitis
• Leprotic conjunctivitis
• Conjunctivitis in tularaemia
• Ophthalmia nodosa

Parinaud's oculoglandular syndrome
It is the name given to

CONTACT DERMOCONJUNCTIVITIS

Contact dermoconjunctivitis is an allergic disorder, involving conjunctiva and
skin of lids along with surrounding area of face.

Etiology
It is in fact a delayed hypersensitivity (type IV)
response to prolonged contact with chemicals and
drugs. A few common topical ophthalmic medications

known to produce contact

Phlyctenular keratitis.

Corneal involvement may occur secondarily from extension of conjunctival
phlycten; or rarely as a primary disease. It may present in two forms: the 'ulcerative phlyctenular keratitis' or 'diffuse infiltrative keratitis'.

A. Ulcerative phlyctenular keratitis may occur in the following three forms:
1. Sacrofulous ulcer is a shallow marginal ulcer formed due to breakdown of small limbal phlycten. It differs from the catarrhal ulcer in that there is no clear space between the ulcer and the limbus and its

PHLYCTENULAR KERATOCONJUNCTIVITIS

Phlyctenular keratoconjunctivitis is a characteristic nodular affection occurring as an allergic response of the conjunctival and corneal epithelium to some endogenous allergens to which they have become sensitized. Phlyctenular conjunctivitis is of worldwide distribution. However, its incidence is higher in developing countries.
Etiology
It is believed to be a delayed hypersensitivity (Type IV-cell mediated) response to endogenous microbial proteins.
I. Causative allergens
1. Tuberculous proteins were considered, previously, as the most common cause.
2. Staphylococcus proteins are

GIANT PAPILLARY CONJUNCTIVITIS (GPC)

Giant papillary conjunctivitis is the inflammation of conjunctiva with formation of very large sized papillae.

Etiology. It is a localised allergic response to a physically rough or deposited surface (contact lens, prosthesis, left out nylon sutures). Probably it is

Atopic keratoconjunctivitis (AKC)

Atopic  keratoconjunctivitis (AKC) can be thought of as an adult equivalent of vernal keratoconjunctivitis and is often associated with atopic dermatitis. Most of the patients are young atopic adults, with male predominance.

Symptoms include:

• Itching, soreness, dry sensation.
• Mucoid discharge.
• Photophobia or blurred vision.

Signs

• Lid margins are chronically inflamed with

vernal keratoconjunctivitis Treatment

A. Local therapy
1. Topical steroids. These are effective in all forms
of spring catarrh. However, their use should be
minimised, as they frequently cause steroid
induced glaucoma. Therefore, monitoring of
intraocular pressure is very important during
steroid therapy. Frequent instillation (4 hourly) to
start with (2 days) should be followed by

VERNAL KERATOCONJUNCTIVITIS

vernal keratoconjunctivitis (vkc) or spring catarrh
It is a recurrent, bilateral, interstitial, self-limiting, allergic inflammation of the conjunctiva having a periodic seasonal incidence.

Etiology
It is considered a hypersensitivity reaction to some exogenous allergen, such as grass pollens. VKC is thought to be an atopic allergic disorder in many
cases, in which IgE-mediated mechanisms play an important role. Such patients may give personal or family history of

SIMPLE ALLERGIC CONJUNCTIVITIS

Simple allergic conjunctivitis is a mild, non-specific allergic conjunctivitis
characterized by itching, hyperaemia and mild papillary response. Basically, it is an acute or sub acute urticarial reaction.

Etiology
It is seen in following forms:
1. Hay fever conjunctivitis. It is commonly associated with hay fever (allergic rhinitis). The common allergens are pollens, grass and

OPHTHALMIA NEONATORUM

Ophthalmia neonatorum is the name given to bilateral inflammation of the conjunctiva occurring in an infant, less than 30 days old. It is a preventable disease usually occurring as a result of carelessness at the time of birth. As a matter of fact any discharge or even watering from the eyes in the first week of life should arouse suspicion of ophthalmia neonatorum, as tears are not formed till then.
Etiology
Source and mode of infection
Infection may occur in three ways: before birth, during birth or after birth.

1. Before birth infection is very rare through infected liquor amnii in mothers with ruptured membrances.

2. During birth. It is the most common mode of infection from the

CHRONIC FOLLICULAR CONJUNCTIVITIS

Chronic follicular conjunctivitis is a mild type of chronic catarrhal conjunctivitis associated with follicular hyperplasia, predominantly
involving the lower lid.

Etiological types
1. Infective chronic follicular conjunctivitis is essentially a condition of 'benign folliculosis' with a superadded mild infection.
Benign folliculosis, also called 'School folliculosis', mainly affects school children. This condition usually occurs as a part of generalized
lymphoid

ACUTE FOLLICULAR CONJUNCTIVITIS

Acute follicular conjunctivitis is an acute catarrhal conjunctivitis"OR KNOWN AS ACUTE MUCOPURULENT CONJUNCTIVITIS" associated with marked follicular hyperplasia especially of the lower fornix and lower palpebral conjunctiva.

General clinical features
Symptoms are similar to acute catarrhal conjunctivitis and include: redness, watering, mild mucoid discharge, mild photophobia and feeling of

VIRAL CONJUNCTIVITIS

Most of the viral infections tend to affect the epithelium, both of the conjunctiva and cornea, so, the typical viral lesion is a 'keratoconjunctivitis'. In some viral infections, conjunctival involvement is more prominent (e.g., pharyngo-conjunctival fever), while in others cornea is more involved (e.g., herpes simplex).

Viral infections of conjunctiva include:

• Adenovirus conjunctivitis
• Herpes simplex keratoconjunctivitis
• Herpes zoster conjunctivitis
• Pox virus conjunctivitis
• Myxovirus conjunctivitis
• Paramyxovirus conjunctivitis
• ARBOR virus conjunctivitis

Clinical presentations. Acute viral conjunctivitis may
present in

ADULT INCLUSION CONJUNCTIVITIS

Adult Inclusion conjunctivitis is a type of acute follicular conjunctivitis associated with mucopurulent discharge. It usually affects the
sexually active young adults.

Etiology
Inclusion conjunctivitis is caused by serotypes D to
K of Chlamydia trachomatis. The primary source of
infection is urethritis in males and cervicitis in

Trachoma Management

Management of trachoma should involve curative as
well as control measures.

A. Treatment of active trachoma
Antibiotics for treatment of active trachoma may be
given locally or systemically, but topical treatment is
preferred because:

• It is cheaper,
• There is no risk of systemic side-effects, and

TRACHOMA Complications & Diagnosis

Complications
The only complication of trachoma is corneal ulcer
which may occur due to rubbing by concretions, or
trichiasis with superimposed bacterial infection.

Diagnosis
A. The clinical diagnosis of trachoma is made from
its typical signs; at least two sets of signs should be
present out of the following:

Grading of trachoma

McCallan's classification
McCallan in 1908, divided the clinical course of the
trachoma into following four stages:

• Stage I (Incipient trachoma or stage of infiltration). It is characterized by hyperaemia of palpebral conjunctiva and immature follicles.
• Stage II (Established trachoma or stage of florid infiltration). It is characterized by appearance of mature

TRACHOMA Symptoms & Signs

Symptoms

• In the absence of secondary infection, symptoms are minimal and include mild foreign body sensation in the eyes, occasional lacrimation, slight stickiness of the lids and scanty mucoid discharge.
• In the presence of secondary infection, typical symptoms of acute mucopurulent conjunctivitis develop.

Signs
A. Conjunctival signs
1. Congestion of upper tarsal and forniceal conjunctiva.

2. Conjunctival follicles. Follicles (Fig. 1 and Fig.2) look like boiled

what is trachoma ?

Trachoma (previously known as Egyptian ophthalmia) is a chronic keratoconjunctivitis, primarily affecting the superficial epithelium of
conjunctiva and cornea simultaneously. It is characterised by a mixed follicular and papillary response of conjunctival tissue. It is still one of the
leading causes of 

CHLAMYDIAL CONJUNCTIVITIS

Chlamydia lie midway between bacteria and viruses,
sharing some of the properties of both. Like viruses,
they are obligate intracellular and filterable, whereas
like bacteria they contain both

ANGULAR CONJUNCTIVITIS

ANGULAR CONJUNCTIVITIS is a type of chronic conjunctivitis characterised by mild grade inflammation confined to the conjunctiva and lid margins near the angles (hence the name) associated with maceration of the surrounding skin.

Etiology
1. Predisposing factors are same as for 'simple chronic conjunctivitis'.
2. Causative organisms. Moraxella Axenfeld is the commonest causative organism. MA bacilli are placed end to end, so the disease is also called

CHRONIC CATARRHAL CONJUNCTIVITIS

Chronic catarrhal conjunctivitis’ also known as
‘simple chronic conjunctivitis’ is characterised by
mild catarrhal inflammation of the conjunctiva.

Etiology
A. Predisposing factors
1. Chronic exposure to dust, smoke, and chemical
irritants.
2. Local cause of irritation such as trichiasis,
concretions, foreign body and seborrhoeic scales.
3. Eye strain due to 

PSEUDOMEMBRANOUS CONJUNCTIVITIS

It is a type of acute conjunctivitis, characterised by
formation of a pseudomembrane (which can be easily
peeled off leaving behind intact conjunctival
epithelium) on the conjunctiva.

Etiology
It may be caused by following varied factors:
1. Bacterial infection. Common causative organisms
are Corynebacterium diphtheriae of low virulence,
staphylococci, streptococci, H. influenzae and N.
gonorrhoea.
2. Viral infections such as

ACUTE MEMBRANOUS CONJUNCTIVITIS

It is an acute inflammation of the conjunctiva,
characterized by formation of a true membrane on the
conjunctiva. Now-a-days it is of very-very rare
occurrence, because of markedly decreased
incidence of diphtheria. It is because of the fact that
immunization against diptheria is very effective.

Etiology
The disease is typically caused by Corynebacterium
diphtheriae and occasionally by virulent type of

ACUTE MUCOPURULENT CONJUNCTIVITIS AND OTHER TYPES OF CONJUNCTIVITIS

CLINICAL TYPES OF BACTERIAL
CONJUNCTIVITIS

Depending upon the causative bacteria and the
severity of infection, bacterial conjunctivitis may
present in following clinical forms:

•  Acute catarrhal or mucopurulent conjunctivitis. (DISCUSSED BELOW)
•  Acute purulent conjunctivitis (visit link)
•  Acute membranous conjunctivitis (visit link)
•  Acute pseudomembranous conjunctivitis (visit link)
•  Chronic bacterial conjunctivitis (visit link)
•  Chronic angular conjunctivitis (DISCUSSED IN COMING POSTS)

ACUTE MUCOPURULENT CONJUNCTIVITIS
Acute mucopurulent conjunctivitis is the most
common type of 

INFECTIVE & BACTERIALCONJUNCTIVITIS

Infective conjunctivitis, i.e., inflammation of the
conjunctiva caused by microorganisms is the
commonest variety. This is in spite of the fact that
the conjunctiva has been provided with natural
protective mechanisms in the form of :

•  Low temperature due to exposure to air,
•  Physical protection by lids,
•  Flushing action of tears,
•  Antibacterial activity of lysozymes and
•  Humoral protection by the tear immunoglobulins.

 BACTERIAL CONJUNCTIVITIS
There has occurred a relative decrease in the
incidence of bacterial conjunctivitis in general and
those caused by gonococcus and corynebacterium
diphtheriae in particular. However, in developing
countries it still continues to be the commonest type
of conjunctivitis. It can occur as sporadic cases and
as epidemics. Outbreaks of bacterial conjunctivitis
epidemics are quite frequent during monsoon season.

Etiology
A. Predisposing factors for bacterial conjunctivitis,
especially epidemic forms, are flies, poor hygienic
conditions, hot dry climate, poor sanitation and dirty
habits. These factors help the

INFLAMMATIONS OF CONJUNCTIVA

Inflammation of the conjunctiva (conjunctivitis) is
classically defined as conjunctival hyperaemia
associated with a discharge which may be watery,
mucoid, mucopurulent or purulent.

Etiological classification
1. Infective conjunctivitis: bacterial, chlamydial, viral, fungal, rickettsial, spirochaetal, protozoal, parasitic etc.
2. Allergic conjunctivitis.

3. Irritative conjunctivitis.
4. Keratoconjunctivitis associated with

Blood supply of conjunctiva

Arteries supplying the conjunctiva are derived from
three sources (Fig. 1):

(1) peripheral arterial arcade of the eyelid;
(2) marginal arcade of the eyelid; and
(3) anterior ciliary arteries.

• Palpebral conjunctiva and fornices are supplied by branches from the peripheral and marginal arterial arcades of the eyelids.
• Bulbar conjunctiva is supplied by two sets of vessels: the posterior conjunctival arteries which are branches from the

Glands of conjunctiva

The conjunctiva contains two types of glands
(Fig. 1):


1. Mucin secretory glands. These are goblet cells
(the unicellular glands located within the epithelium),
crypts of
Henle (present in the tarsal conjunctiva)
and glands of Manz (found in limbal conjunctiva).
These glands secrete mucus which is  
essential for wetting the

Structure of conjunctiva

Histologically, conjunctiva consists of three layers
namely, (1) epithelium, (2) adenoid layer, and (3)
fibrous layer (Fig. 1 below ).


1. Epithelium. The layer of epithelial cells in
conjunctiva varies from region to region and in its
different parts as
follows:

• Marginal conjunctiva has 5-layered stratified squamous type of epithelium.
• Tarsal conjunctiva has

ANATOMY of Conjunctiva

The conjunctiva is a translucent mucous membrane
which lines the posterior surface of the eyelids and
anterior aspect of eyeball. The name conjunctiva
(conjoin: to join) has been given to this mucous
membrane owing to the fact that it joins the eyeball
to the lids. It stretches from the lid margin to the
limbus, and encloses a complex space called
conjunctival sac which is open in front at the
palpebral fissure.

Parts of conjunctiva
Conjunctiva can be divided into three parts (Fig. 1):
1. Palpebral conjunctiva. It lines the lids and can be
subdivided into marginal, tarsal and orbital
conjunctiva.
i. Marginal conjunctiva extends from the

Refractive surgery for presbyopia

Refractive surgery for presbyopia, still under trial,
includes :

• Monovision LASIK, i.e., one eye is corrected for distance and other is made slightly near sighted.
• Monovision conductive keratoplasty (CK) is being considered increasingly to correct presbyopia in one eye. Principle is same as for correction of hypermetropia.
• Scleral expansion procedures are being tried, but results are controversial.
• LASIK-PARM i.e., LASIK by Presbyopia Avalos Rozakis Method is a technique undertrial in which the shape of the

Refractive surgery for astigmatism

Refractive surgical techniques employed for myopia
can be adapted to correct astigmatism alone or
simultaneously with myopia as follows:
1. Astigmatic keratotomy (AK) refers to making
transverse cuts in the mid periphery of the steep
corneal meridian (Fig. 1).

Fig. 1. Astigmatic keratotomy. (A) showing flat and deep meridians of cornea; (B) paired transverse incisions to flattern
the steep meridian; (C) showing correction of astigmatism after astigmatic keratotomy.

AK can be performed
alone (for astigmatism only) or along with RK (for
associated myopia).
2. Photo-astigmatic refractive keratotomy (PARK)
is performed using 

Refractive surgery for hyperopia

In general, refractive surgery for hyperopia is not as
effective or reliable as for myopia. However, following
procedures are used:

1. Holmium laser thermoplasty has been used for
low degree of hyperopia. In this technique, laser spots
are applied in a ring at the periphery to produce central
steepening. Regression effect and induced
astigmatism are the main problems.

2. Hyperopic PRK using excimer laser has also been
tried. Regression effect and prolonged epithelial
healing are the  

Refractive surgery of myopia

Surgery to correct refractive errors has become very
popular. It should be performed after the error has
stabilized; preferably after 20 years of age.

Refractive surgery of myopia
1. Radial keratotomy (RK) refers to making deep (90 percent of corneal thickness) radial incisions in the peripheral part of cornea leaving the central 4 mm optical zone (Fig 1).

Fig. 1. Radial keratotomy. (A) configuration of radial
incisions; (B) depth of incision.

These incisions on healing; flatten the central cornea thereby reducing its
refractive power. This procedure gives very good correction in low to moderate myopia (2 to 6 D).

Disadvantages. Note: Because of its disadvantages
RK is not recommended presently. (i) Cornea is
weakened, so chances of globe rupture following
trauma are