2-12-2012, 16:49

Description

The structure and functions of the conjunctiva

The connective membrane of the eye, or conjunctiva, - This is the mucous membrane that lines the eyelids from the back and goes on eyeball down to the cornea and thus connects the eyelid with the eyeball. With a closed palpebral fissure, the connective membrane forms a closed cavity - conjunctival sac, which is a narrow slit-like space between the eyelids and the eyeball.

The mucous membrane covering the posterior surface of the eyelids is called conjunctival eyelidand covering the sclera - conjunctival eyeball or sclera. The part of the conjunctiva of the eyelids, which, forming arches, passes to the sclera, is called the conjunctiva of transitional folds or the arch. Accordingly, the upper and lower conjunctival arches are distinguished. At the inner corner of the eye, in the region of the rudiment of the third century, the conjunctiva forms a vertical lunate fold and a lacrimal meat.

In the conjunctiva there are two layers - epithelial and subepithelial. The conjunctiva of the eyelids is tightly fused with the cartilaginous plate. The conjunctival epithelium is multilayered, cylindrical with a large number of goblet cells. The conjunctiva of the eyelids is smooth, brilliant, pale pink, through which yellowish columns of meibomian glands passing through the thickness of the cartilage shine through. Even with the normal condition of the mucous membrane at the outer and inner corners of the eyelids, the conjunctiva that covers them looks slightly hyperemic and velvety due to the presence of small papillae.

The conjunctiva of transitional folds is loosely connected to the underlying tissue and forms folds that allow the eyeball to move freely. The conjunctiva of the arches is covered with stratified squamous epithelium with a small number of goblet cells. Subepithelial layer represented by loose connective tissue with inclusions of adenoid elements and accumulations of lymphoid cells in the form of follicles. In the conjunctiva there are a large number of additional lacrimal glands of Krause.

The conjunctiva of the sclera is tender, loosely connected to the episcleral tissue. The stratified squamous conjunctiva squamous epithelium smoothly passes to the cornea.

The conjunctiva borders on the skin of the edges of the eyelids, and on the other hand, with the corneal epithelium. Diseases of the skin and cornea can spread to the conjunctiva, and diseases of the conjunctiva to the skin of the eyelids (blepharoconjunctivitis) and the cornea (keratoconjunctivitis). Through the lacrimal opening and the lacrimal tubule of the conjunctiva is also connected with the mucous membrane of the lacrimal sac and nose.

Conjunctiva abundantly supplied with blood from the arterial branches of the eyelids, as well as from the anterior ciliary vessels. Any inflammation and irritation of the mucous membrane is accompanied by a bright hyperemia of the vessels of the conjunctiva of the eyelids and arches, the intensity of which decreases towards the limb.

Due to the dense network of nerve endings of the first and second branches of the trigeminal nerve, the conjunctiva acts as a integumentary sensory epithelium.

The main physiological function of the conjunctiva - eye protection: when a foreign body enters, eye irritation appears, tear fluid secretion increases, blinking movements become more frequent, as a result of which the foreign body is mechanically removed from the conjunctival cavity. The secret of the conjunctival sac constantly moistens the surface of the eyeball, reduces friction during its movements, and helps maintain the transparency of the moistened cornea. This secret is rich in protective elements: immunoglobulins, lysozyme, lactoferrin. The protective role of the conjunctiva is also provided due to the abundance of lymphocytes, plasma cells, neutrophils, mast cells and the presence of immunoglobulins in all five classes.

Conjunctival disease

Among the diseases of the conjunctiva, inflammatory diseases occupy the main place. Conjunctivitis- This is an inflammatory reaction of the conjunctiva to various effects, characterized by hyperemia and swelling of the mucous membrane; swelling and itching of the eyelids, separated from the conjunctiva, the formation of follicles or papillae on it; sometimes accompanied by damage to the cornea with visual impairment.

Conjunctival hyperemia - an alarm signal common to many eye diseases (acute iritis, an attack of glaucoma, an ulcer or trauma to the cornea, scleritis, episiscleritis), therefore, when establishing a diagnosis of conjunctivitis, it is necessary to exclude other diseases accompanied by redness of the eye.

The following three groups of conjunctival diseases have fundamental differences:

• infectious conjunctivitis (bacterial, viral, chlamydial);
• allergic conjunctivitis (pollinosis, spring catarrh, drug allergy, chronic allergic conjunctivitis, large-capillary conjunctivitis);
• degenerative diseases of the conjunctiva (dry keratoconjunctivitis, pingvecula, pterygium).

Infectious conjunctivitis

Bacterial conjunctivitis

Any of the widespread pathogens of purulent infection can cause inflammation of the conjunctiva. Cocci, primarily staphylococci, are the most common cause of conjunctival infection, but it proceeds more favorably. The most dangerous pathogens are pseudomonas aeruginosa and gonococcuscausing severe acute conjunctivitis, in which the cornea is often affected (Fig. 9.1).

Fig. 9.1. Acute bacterial conjunctivitis.

Acute and chronic conjunctivitis caused by staphylococcus . Acute conjunctivitis more often occurs in children, less often in older people, even less often in middle-aged people. Usually the pathogen enters the eye from the hands. First, one eye is affected, after 2-3 days - the other. The clinical manifestations of acute conjunctivitis are as follows. In the morning, the patient hardly opens his eyes, as the eyelids stick together. With conjunctival irritation, the amount of mucus increases. The nature of the discharge can quickly change from mucous to mucopurulent and purulent. Detachable flows over the edge of the century, dries on the eyelashes. An external examination reveals hyperemia of the conjunctiva of the eyelids, transitional folds and sclera. The mucous membrane swells, loses transparency, the pattern of meibomian glands is erased. The severity of superficial conjunctival vascular infection decreases towards the cornea. The patient is disturbed by eyelids, itching, burning and photophobia.

Chronic conjunctivitis develops slowly, proceeds with periods of improvement. Patients are disturbed photophobia, mild irritation and rapid eye fatigue. The conjunctiva is moderately hyperemic, loosened, along the edge of the eyelids, dried discharge (crusts). Conjunctivitis may be associated with a disease of the nasopharynx, otitis media, sinusitis. In adults, conjunctivitis often occurs with chronic blepharitis, dry eye syndrome, and lesions of the lacrimal passages.

To detect a bacterial infection in conjunctivitis of newborns and acute conjunctivitis, a microscopic examination of smears and cultures of the conjunctiva is used. The isolated microflora is examined for pathogenicity and sensitivity to antibiotics.

The main place in treatment is local antibiotic therapy: instill sulfacyl sodium, vitabact, fucitalmic, 3-4 times a day or ocular ointment: tetracycline, erythromycin, "..." a, 2-3 times a day. In acute cases, eye drops of tobrex, ocacin, "..." are prescribed up to 4-6 times a day. With edema and severe irritation of the conjunctiva, instillations of anti-allergic or anti-inflammatory drops (alomide, lecrolin or naklof) are added 2 times a day.

In acute conjunctivitis, it is impossible to tie and glue the eye, since under the bandage favorable conditions for the multiplication of bacteria, the risk of developing corneal inflammation increases.

Acute conjunctivitis caused by Pseudomonas aeruginosa . The disease begins acutely: a large or moderate amount of purulent discharge and swelling of the eyelids are noted, the conjunctiva of the eyelids is sharply hyperemic, bright red, swollen, loosened. Without treatment, a conjunctival infection can easily spread to the cornea and cause the formation of a rapidly progressing ulcer.

Treatment: instillation of antibacterial eye drops (tobrex, niacin, "..." or gentamicin) in the first 2 days, 6-8 times a day, then up to 3-4. The most effective combination of two antibiotics, for example, Tobrex + Ocacin or Gentamicin + Polymyxin. When the infection spreads to the cornea, tobramycin, gentamicin or ceftazidime is administered parabulbarly and tavanic tablets or gentamicin, tobramycin are injected systemically. With severe edema of the eyelids and conjunctiva, they additionally install anti-allergic and anti-inflammatory drops (spersallerg, allergophthal or naklof) 2 times a day. With corneal damage, funds are needed metabolic therapy - drops (taufon, vitasic, carnosine) or gels (cornegel, solcoseryl).

Acute conjunctivitis caused by gonococcus . Venereal disease. sexually transmitted (direct genital-ocular contact or transmission of the genitals - hand - eye). Hyperactive purulent conjunctivitis is characterized by rapid progression. The eyelids are swollen, the discharge is plentiful, purulent, the conjunctiva is sharply hyperemic, bright red, irritated, gathers in protruding folds, swelling of the sclera conjunctiva (chemosis) is often noted. Keratitis develops in 15-40% of cases, at first superficial, then a corneal ulcer is formed, which can lead to perforation in 1-2 days.

In acute conjunctivitis, presumably caused by Pseudomonas aeruginosa or gonococcus, treatment is started immediately, without waiting for laboratory confirmation, since a delay of 1-2 days can lead to the development of corneal ulcers and eye death.

Treatment: in case of gonococcal conjunctivitis confirmed by laboratory tests or suspected on the basis of clinical manifestations and medical history, antibiotic therapy is first carried out: rinsing the eyes with boric acid solution, instillation of eye drops (ocacin, "..." or penicillin) 6-8 times a day. Conduct systemic treatment: quinolone antibiotic 1 tablet 2 times a day or penicillin intramuscularly. In addition, instillations of anti-allergic or anti-inflammatory drugs (spersallerg, allergophthal or naklof) are prescribed 2 times a day. With the phenomena of keratitis, Vitasic, carnosine or taufon is also instilled 2 times a day.

Of particular danger gonococcal conjunctivitis in newborns (gonoblenorrhea). Infection occurs during the passage of the fetus through the birth canal of a mother suffering from gonorrhea. Conjunctivitis usually develops on the 2nd-5th day after birth. Edematous dense cyanotic-crimson eyelids are almost impossible to open for eye examination. With pressure, a blood-purulent discharge is poured from the palpebral fissure. The conjunctiva is sharply hyperemic, loosened, bleeds easily. The exclusive danger of gonoblenrhea is to damage the cornea until the death of the eye. Local treatment the same as in adults, and systemic - the introduction of antibacterial drugs in doses corresponding to age.

Diphtheria conjunctivitis . Conjunctival diphtheria caused by diphtheria bacillus is characterized by the appearance of grayish films that are difficult to remove on the conjunctiva of the eyelids. The eyelids are dense, swollen. A cloudy liquid with cereal is released from the palpebral fissure. The films are tightly soldered to the underlying fabric. Their separation is accompanied by bleeding, and after necrotization of the affected areas, scars form. The patient is isolated in the infectious ward and treated according to the diphtheria therapy regimen.

Viral conjunctivitis

Viral conjunctivitis is common and occurs in the form of epidemic outbreaks and episodic diseases.

Epidemic keratoconjunctivitis . Adenoviruses (more than 50 of their serotypes are already known) cause two clinical forms eye lesions: epidemic keratoconjunctivitis, which is more severe and accompanied by damage to the cornea, and adenovirus conjunctivitis, or pharyngoconjunctival fever.

Epidemic keratoconjunctivitis is hospital infectionmore than 70% of patients become infected in medical facilities. The source of infection is a patient with keratoconjunctivitis. The infection spreads by contact, less often - by airborne droplets. The transmission factors of the pathogen are infected hands of medical staff, reusable eye drops, tools, devices, eye prostheses, contact lenses.

The duration of the incubation period of the disease is 3-14, usually 4-7 days. The duration of the infectious period is 14 days.

The onset of the disease is acute, usually both eyes are affected: first one, after 1-5 days the second. Patients complain of pain, a foreign body sensation in the eye, and lacrimation. The eyelids are swollen, the conjunctiva of the eyelids is moderately or significantly hyperemic, the lower transitional fold is infiltrated, folded, in most cases small follicles and pinpoint hemorrhages are detected.

After 5-9 days from the onset of the disease, stage II disease develops, accompanied by the appearance of characteristic point infiltrates under the corneal epithelium. With the formation of a large number of infiltrates in the central zone of the cornea, vision decreases.

Regional adenopathy - an increase and pain in the parotid lymph nodes - appears on the 1-2 day of the disease in almost all patients. Damage to the respiratory tract is observed in 5-25% of patients. The duration of epidemic keratoconjunctivitis is up to 3-4 weeks. As studies conducted in recent years have shown, the severe consequence of adenovirus infection is the development of dry eye syndrome in connection with a violation of the production of tear fluid.

Laboratory diagnosis of acute viral conjunctivitis (adenovirus, herpesvirus) includes a method for determining fluorescent antibodies in conjunctival scrapings, a polymerase chain reaction, and, less commonly, a virus isolation method.

Treatmentfraught with difficulties since there is no medicines selective effects on adenoviruses. They use drugs of broad antiviral effect: interferons (Lockeron, ophthalmoferon, etc.) or interferon inducers, instill 6-8 times a day, and at the 2nd week reduce their number to 3-4 times a day. In the acute period, an anti-allergic drug allergophthal or spersallerg is additionally instilled 2-3 times a day and antihistamines are taken orally for 5-10 days. In cases of subacute course apply drops of alomid or lecrolin 2 times a day. With a tendency to the formation of films and during the period of corneal rashes, corticosteroids (dexapos, maxidex or optan-dexamethasone) are prescribed 2 times a day. With corneal lesions, taufon, carnosine, vitasic or root corn are used 2 times a day. In cases of a lack of tear fluid for a long period of time, tear replacement preparations are used: a natural tear 3-4 times a day, ophthalmol or vidisic gel 2 times a day.

Prevention of nosocomial adenovirus infection includes the necessary anti-epidemic measures and measures of the sanitary-hygienic regime:

• examination of the eyes of each patient on the day of hospitalization to prevent the introduction of infection into the hospital;
• early detection of cases of development of diseases in a hospital;
• isolation of patients with isolated cases of the onset of the disease and quarantine during outbreaks, anti-epidemic measures;
• health education.

Adenoviral conjunctivitis . The disease is easier than epidemic keratoconjunctivitis, and rarely causes outbreaks of hospital infection. The disease usually occurs in children's groups. The transmission of the pathogen occurs by airborne droplets, less often - by contact. The duration of the incubation period is 3-10 days.

Symptoms of the disease are similar to the initial clinical manifestations epidemic keratoconjunctivitis, but their intensity is much lower: scanty discharge, conjunctiva hyperemic and moderately infiltrated, few follicles, they are small, sometimes point hemorrhages are noted. In 1/2 patients, regional adenopathy of the parotid lymph nodes is detected. Pointed epithelial infiltrates may appear on the cornea, but they disappear without a trace, without affecting visual acuity.

For adenoviral conjunctivitis common symptoms: respiratory tract lesions with fever and headache. Systemic damage may precede eye disease. The duration of adenoviral conjunctivitis is 2 weeks.

Treatmentincludes instillations of interferons and anti-allergic eye drops, and in case of insufficiency of tear fluid - an artificial tear or oftagel.

Preventionthe nosocomial spread of the infection is the same as with epidemic keratoconjunctivitis.

Epidemic Hemorrhagic Conjunctivitis (EGC) . EHC, or acute hemorrhagic conjunctivitis, has been described relatively recently. The first EGC pandemic began in West Africa in 1969, and then spread to countries in North Africa, the Middle East and Asia. The first outbreak of EHC in Moscow was observed in 1971. Epidemic outbreaks in the world arose in 1981-1984 and 1991 - 1992. The disease requires close attention, since EGC outbreaks in the world are repeated with a certain frequency.

The causative agent of EGC is enterovirus-70. EHC is characterized by a short incubation period unusual for a viral disease - 12-48 hours. The main route of infection is through contact. EGC is highly contagious, the epidemic is “explosive”. In eye hospitals, in the absence of anti-epidemic measures, 80-90% of patients can be affected.

Clinical and epidemiological features of EGC so characteristic that, on their basis, the disease can be easily distinguished from other ophthalmic infections. The onset is acute, first one eye is affected, after 8-24 hours - the second. Due to severe pain and photophobia, the patient seeks help on the first day. The mucous or mucopurulent discharge from the conjunctiva, the conjunctiva is sharply hyperemic, subconjunctival hemorrhages are especially characteristic: from point petechiae to extensive hemorrhages, which capture almost the entire conjunctiva of the sclera (Fig. 9.2).

Fig. 9.2. Epidemic hemorrhagic conjunctivitis.

Changes in the cornea are minor - point epithelial infiltrates, disappearing without a trace.

Treatmentconsists in the use of antiviral eye drops (interferon, interferon inducers) in combination with anti-inflammatory drugs (first anti-allergic, and corticosteroids from the 2nd week). The duration of treatment is 9-14 days. Recovery is usually without consequences.

Herpes virus conjunctivitis.

Although herpetic lesions of the eye are among the most common diseases, and herpetic keratitis is recognized as the most common corneal lesion in the world, herpesvirus conjunctivitis is most often a component of primary infection of the herpes virus in early childhood.

Primary herpetic conjunctivitis more often has a follicular nature, as a result of which it is difficult to distinguish from adenovirus. The following symptoms are characteristic of herpetic conjunctivitis: one eye is affected, the edges of the eyelids, skin and cornea are often involved in the pathological process.

Herpes relapse can occur as follicular or vesicular-ulcerative conjunctivitis, but usually develops as superficial or deep keratitis (stromal, ulcerative, keratouveitis).

Antiviral treatment. Preference should be given to selective antiherpetic agents. Zovirax eye ointment is prescribed, which is laid 5 times in the first days and 3-4 times in the following or drops of interferon or an interferon inducer (instillation 6-8 times a day). Inside, take Valtrex 1 tablet 2 times a day for 5 days or Zovirax 1 tablet 5 times a day for 5 days. Additional therapy: for moderate allergies, anti-allergic drops of alomide or lecrolin (2 times a day), for severe allergies, allergophthal or spersallerg (2 times a day). In case of damage to the cornea, Vitasik, carnosine, taufon or cornegel drops are additionally installed 2 times a day, in case of a relapsing course, immunotherapy is performed: lycopide 1 tablet 2 times a day for 10 days. Immunotherapy with lycopid improves the specific treatment of various forms of ophthalmic herpes and significantly reduces the frequency of relapses.

Chlamydial eye disease

Chlamydia(Chlamydia trachomatis) - an independent species of microorganisms; they are intracellular bacteria with a unique development cycle, exhibiting the properties of viruses and bacteria. Different serotypes of chlamydia cause three different conjunctival diseases: trachoma (serotypes A-C), chlamydial conjunctivitis in adults and newborns (serotypes D-K) and venereal lymphogranulomatosis (serotypes L1, L2, L3).

Trachoma . Trachoma is a chronic infectious keratoconjunctivitis characterized by the appearance of follicles with their subsequent scarring and papillae on the conjunctiva, inflammation of the cornea (pannus), and in the later stages, eyelid deformity. The emergence and spread of trachoma is associated with a low level of sanitary culture and hygiene. In economically developed countries, trachoma practically does not occur. Huge work on the development and implementation of scientific, organizational and therapeutic measures has led to the elimination of trachoma in our country. However, according to WHO, trachoma remains the main cause of blindness in the world. It is believed that up to 150 million people are affected by active trachoma, mainly in Africa, the Middle East, and Asia. Trachoma infection of Europeans visiting these regions is possible today.

Trachoma occurs as a result of the introduction of pathogens into the conjunctiva of the eye. The incubation period is 7-14 days. The lesion is usually bilateral.

IN clinical course trachomas distinguish 4 stages.

In severe form and prolonged course of trachoma may occur corneal pannus - Infiltration extending to the upper segment of the cornea with vessels growing into it (Fig. 9.5).

Fig. 9.5. Trachomatous pannus.

Pannus is a characteristic sign of trachoma and is important in differential diagnosis. During scarring at the site of the pannus, intense clouding of the cornea occurs in the upper half with a decrease in vision.

With trachoma, various complications can occur from the side of the eye and adnexa. The addition of bacterial pathogens aggravates inflammatory process and makes diagnosis difficult. A serious complication is inflammation of the lacrimal gland, lacrimal tubules and lacrimal sac. The resulting purulent ulcers during trachoma caused by a concomitant infection are difficult to heal and can lead to perforation of the cornea with the development of inflammation in the eye cavity, and therefore there is a risk of eye death.

In the process of scarring, severe consequences of trachoma: shortening of the conjunctival arches, the formation of fusion of the eyelid with the eyeball (simblepharon), the degeneration of the lacrimal and meibomian glands, causing corneal xerosis. Scarring causes distortion of the cartilage, inversion of the eyelids, incorrect position of the eyelashes (trichiasis). In this case, the eyelashes touch the cornea, which leads to damage to its surface and contributes to the development of corneal ulcers. Narrowing of the tear ducts and inflammation of the lacrimal sac (dacryocystitis) may be accompanied by persistent lacrimation.

Laboratory diagnostics includes a cytological examination of conjunctival scrapings in order to detect intracellular inclusions, isolation of pathogens, determination of antibodies in blood serum.

The main place in treatment is taken by antibiotics. (tetracycline or erythromycin ointment), which are used according to two main schemes: 1–2 times a day for mass treatment or 4 times a day for individual therapy, respectively, for several months to several weeks. Expression of follicles with special forceps to increase the effectiveness of therapy is currently practically not used. Trichiasis and inversion of the eyelids eliminate surgically. The prognosis for timely treatment is favorable. Relapses are possible, therefore, after completing the course of treatment, the patient should be monitored for a long period of time.

Chlamydial conjunctivitis . There are chlamydial conjunctivitis (paratrachoma) in adults and newborns. Significantly less often observed epidemic chlamydial conjunctivitis in children, chlamydial uveitis, chlamydial conjunctivitis with Reiter's syndrome.

Chlamydial conjunctivitis in adults - infectious subacute or chronic infectious conjunctivitis caused by C. trachomatis and sexually transmitted. The prevalence of chlamydial conjunctivitis in developed countries is slowly but steadily increasing; they make up 10-30% of identified conjunctivitis. Infection usually occurs between the ages of 20-30. Women get sick 2-3 times more often. Conjunctivitis is mainly associated with urogenital chlamydial infection, which may be asymptomatic.

The disease is characterized by an inflammatory reaction of the conjunctiva with the formation of numerous follicles that are not prone to scarring. More often one eye is affected, a bilateral process is observed in about 1/3 of patients. The incubation period is 5-14 days. Conjunctivitis more often (in 65% of patients) occurs in acute formless often (in 35%) - in chronic.

Clinical picture: severe edema of the eyelids and narrowing of the palpebral fissure, severe hyperemia, edema and infiltration of the conjunctiva of the eyelids and transitional folds. Especially characteristic are large loose follicles located in the lower transitional fold and subsequently merging in the form of 2-3 ridges. First mucopurulent discharge, in a small amount, with the development of the disease, it becomes purulent and plentiful. More than half of patients with a slit lamp study can detect lesions of the upper limb in the form of swelling, infiltration and vascularization. Often, especially in the acute period, the cornea is affected in the form of superficial small-dot infiltrates that are not stained with fluorescein. From the 3-5th day of the disease on the side of the lesion, a regional pre-adenopathy arises, usually painless. Often, on the same side, the phenomena of eustachitis are noted: noise and pain in the ear, hearing loss.

Treatment: ocacin eye drops 6 times a day or tetracycline eye ointment, erythromycin, "..." 5 times a day, from the 2nd week drops 4 times, ointment 3 times, inside - tavanic antibiotic 1 tablet per day for 5-10 days. Additional therapy includes instillation of anti-allergic drops: in the acute period - allergophthal or spersallerg 2 times a day, in the chronic - alomide or lecrolin 2 times a day, inside - antihistamines for 5 days. From the 2nd week, dexapos or maxsidex eye drops are prescribed once a day.

Epidemic Chlamydia Conjunctivitis . The disease is more benign than paratrachoma, and occurs in the form of outbreaks in visitors to baths, pools and children 3-5 years old in organized groups (orphanages and orphanages). The disease can begin acutely, subacute or proceed as a chronic process.

Usually one eye is affected: hyperemia, edema, conjunctival infiltration, papillary hypertrophy, follicles in the lower arch are detected. The cornea is rarely involved in the pathological process; point erosion, subepithelial point infiltrates are detected. Often they find a small precancerous adenopathy.

All conjunctival phenomena and without treatment can undergo a reverse development after 3-4 weeks. Local treatment: tetracycline, erythromycin or "..." ointment 4 times a day or ocacin eye drops or "..." 6 times a day.

Chlamydial conjunctivitis (paratrachoma) of the newborn . The disease is associated with urogenital chlamydial infection: it is detected in 20-50% of children born to mothers infected with chlamydia. The frequency of chlamydial conjunctivitis reaches 40% of all conjunctivitis of newborns.

Of great importance preventive eye treatment in newborns, which, however, is difficult due to the lack of highly effective, reliable means, since the traditionally used silver nitrate solution does not prevent the development of chlamydial conjunctivitis. Moreover, its instillations often cause irritation of the conjunctiva, i.e., contribute to the occurrence of toxic conjunctivitis.

Clinically, chlamydial conjunctivitis of newborns proceeds as acute papillary and subacute infiltrative conjunctivitis.

The disease begins acutely on the 5-10th day after the birth with the appearance of an abundant liquid purulent discharge, which due to the impurity of the blood may have a brown tint. Edema of the eyelids is pronounced, the conjunctiva is hyperemic, edematous, with papillary hyperplasia, pseudomembranes can form. Inflammation is reduced after 1-2 weeks. If active inflammation lasts more than 4 weeks, follicles appear, mainly on the lower eyelids. In approximately 70% of newborns, the disease develops in one eye. Conjunctivitis can be accompanied by pre-adenopathy, otitis media, nasopharyngitis and even chlamydial pneumonia.

Treatment: tetracycline or erythromycin ointment 4 times a day.

WHO (1986) gives the following eye treatment guidelines for the prevention of conjunctivitis in newborns: in areas of increased risk of infection with gonococcal infection (most developing countries), instillations of a 1% solution of silver nitrate are prescribed, you can also put 1% tetracycline ointment over the eyelid. In areas of low risk of infection of gonococcal infection, but a high prevalence of chlamydia (most industrialized countries), 1% tetracycline or 0.5% erythromycin ointment is practiced.

In the prevention of conjunctivitis of the newborn, the central place is the timely treatment of urogenital infection in pregnant women.

Allergic conjunctivitis

Allergic conjunctivitis - This is an inflammatory reaction of the conjunctiva to the action of allergens, characterized by hyperemia and swelling of the mucous membrane of the eyelids, swelling and itching of the eyelids, the formation of follicles or papillae on the conjunctiva; sometimes accompanied by damage to the cornea with visual impairment.

Allergic conjunctivitis occupies an important place in the group of diseases united under the general name “red eye syndrome”: they affect about 15% of the population.

Due to the anatomical location of the eyes, they are often exposed to various allergens. Hypersensitivity often manifests itself in the inflammatory response of the conjunctiva (allergic conjunctivitis), but any part of the eye can be affected, and then allergic dermatitis and swelling of the eyelids, allergic blepharitis, conjunctivitis, keratitis, iritis, iridocyclitis, retinitis, optic neuritis can develop.

Eyes can be the site of an allergic reaction in many systemic immunological disorders, and eye damage is often the most dramatic manifestation of the disease. An allergic reaction plays an important role in the clinical picture. infectious diseases eye.

Allergic conjunctivitis often combined with such systemic allergic diseases, as bronchial asthma, allergic rhinitis, atopic dermatitis.

Hypersensitivity reactions (a synonym for allergies) are classified as immediate (develop within 30 minutes of exposure to an allergen) and delayed (develop after 24-48 hours or later after exposure). This separation of allergic reactions is of practical importance in the construction of pharmacotherapy. Immediate reactions cause a "friendly" release into the tissue at a specific site (local process) of biologically active mediators from mast cell granules of the mucous membranes and blood basophils, which is called activation or degranulation of mast cells and basophils.

In some cases, a typical picture of the disease or its clear connection with the effects of an external allergenic factor leaves no doubt about the diagnosis. In most cases, the diagnosis of allergic eye diseases is associated with great difficulties and requires the use of specific allergological research methods.

Allergic history - the most important diagnostic factor. It should reflect data on hereditary allergic burden, the characteristics of the course of the disease, the totality of effects that can cause allergic reaction, the frequency and seasonality of exacerbations, the presence of allergic reactions, in addition to ocular. Naturally occurring or specially conducted elimination and exposure tests are of important diagnostic value. The first is to "turn off" the alleged allergen, the second is to re-exposure it after the clinical phenomena subside. A carefully collected medical history suggests a "guilty" allergenic agent in more than 70% of patients.

Allergic skin testsused in ophthalmic practice (application, prik-test, scarification, scarification and application), are less traumatic and at the same time quite reliable.

Provocative allergy tests (conjunctival, nasal and sublingual) are used only in exceptional cases and with great care.

Laboratory Allergy Diagnostics highly specific and possible in the acute period of the disease without fear of harming the patient.

The identification of eosinophils in the co-bracket from the conjunctiva is of important diagnostic value.

The basic principles of therapy:

• elimination, that is, the exclusion of the “guilty” allergen, if possible, is the most effective and safe method for the prevention and treatment of allergic conjunctivitis;
• symptomatic drug therapy: local, with the use of ophthalmic drugs, and general - antihistamines inside with severe lesions occupies a central place in the treatment of allergic conjunctivitis;
• specific immunotherapy is carried out in medical institutions with insufficient effectiveness of drug therapy and the inability to exclude the "guilty" allergen.

For anti-allergic therapy, two groups of eye drops are used: the first - inhibiting mast cell degranulation: Cromones - 2% lecrolin solution, 2% lecrolin solution without preservative, 4% cousicrom solution and 0.1% lodoxamide solution (alomide), the second is antihistamines: antazolin + tetrizolin (spersallerg) and antazolin + naphazoline (allergophthal). Additionally, corticosteroid drugs are used: 0.1% dexamethasone solution (dexapos, maxidex, optan-dexamethasone) and 1% or 2.5% hydrocortisone-POS solution, as well as non-steroidal anti-inflammatory drugs - 1% diclofenac solution (naklof).

The most common clinical forms of allergic conjunctivitis are characterized by their own characteristics in the choice of treatment:

• hay fever conjunctivitis,
• spring keratoconjunctivitis,
• drug allergy
• chronic allergic conjunctivitis,
• large-papillary conjunctivitis.

Pollinous conjunctivitis . These are seasonal allergic eye diseases caused by pollen during the flowering of herbs, cereals, trees. The time of exacerbation is closely related to the calendar of pollination of plants in each climatic region. Pollinous conjunctivitis can begin acutely: intolerable itching of the eyelids, burning under the eyelids, photophobia, lacrimation, edema and hyperemia of the conjunctiva. Conjunctival edema can be so pronounced that the cornea "drowns" in the surrounding chemotic conjunctiva. In such cases, marginal infiltrates appear in the cornea, the bowl in the region of the palpebral fissure. Translucent focal surface infiltrates located along the limb can merge and ulcerate, forming superficial corneal erosion. More often, pollinous conjunctivitis occurs chronically with moderate burning under the eyelids, slight detachable, occasionally itchy eyelids, mild hyperemia of the conjunctiva, small follicles or papillae on the mucous membrane can be detected.

Chronic treatment: alomide or lecrolin 2 times a day for 2-3 weeks, in the acute course - allergophthal or spersallerg 2-3 times a day. Supplementary therapy for severe cases: antihistamines inside for 10 days. When blepharitis impose ointment hydrocortisone-PIC on the eyelids. In case of persistent recurrent course, specific immunotherapy is carried out under the supervision of an allergist.

Spring keratoconjunctivitis (spring catarrh) . The disease usually occurs in children aged 3-7 years, more often in boys, has a predominantly chronic stubborn debilitating course. The clinical manifestations and prevalence of spring catarrh vary in different territories. The most characteristic clinical sign is papillary growths on the conjunctiva of the cartilage of the upper eyelid (conjunctival form), usually small, flattened, but can be large, deforming the eyelid (Fig. 9.6).

Fig. 9.6. Spring keratoconjunctivitis.

Less commonly, papillary growths are located along the limbus (limbal form). Sometimes there is a mixed form. The cornea is often affected: epithelialopathy, erosion or corneal ulcer, keratitis, hyperkeratosis.

Treatment: in mild cases, instillation of alomide or lecrolin 3 times a day for 3-4 weeks. In severe cases, use spersallerg or allergoftal 2 times a day. In the treatment of spring catarrh, a combination of anti-allergic drops with corticosteroids is necessary: \u200b\u200binstillation of eye drops of dexapos, maxxidex or oftan-dexamethasone 2-3 times a day for 3-4 weeks. Additionally, antihistamines (diazolin, suprastin or clarithin) are prescribed orally for 10 days. In case of corneal ulcer, reparative agents are used (eye drops Vitasic taufon or solcoseryl gels, cornegel) 2 times a day until the cornea improves5. With a prolonged, stubborn course of spring catarrh, a course of treatment with histoglobulin is carried out (4-10 injections).

Allergic conjunctivitis . The disease can occur acutely after the first use of any drug, but usually develops chronically with prolonged treatment with the drug, and an allergic reaction to both the main drug and preservative eye drops is possible. An acute reaction occurs within 1 h after administration of the drug (acute drug conjunctivitis, anaphylactic shock, acute urticaria, Quincke's edema, systemic capillarotoxicosis, etc.). Subacute reaction develops during the day (Fig. 9.7).

Fig. 9.7. Medicinal blepharoconjunctivitis (subacute).

A prolonged reaction manifests itself over several days and weeks, usually with prolonged local application medicines. Eye reactions of the latter type are most common (in patients 90%) and are chronic in nature. Almost any drug can cause an allergic reaction of the eye. The same drug in different patients can cause uneven manifestations. However, various drugs can cause a similar clinical picture of drug allergies.

The characteristic signs of acute allergic inflammation is hyperemia, swelling of the eyelids and conjunctiva, lacrimation, sometimes hemorrhage; chronic inflammation is characterized by itching of the eyelids, hyperemia of the mucous membrane, moderate discharge, formation of follicles. With drug allergies, the conjunctiva, cornea, skin of the eyelids are most often affected, much less often - the choroid, retina, optic nerve.

The main attraction of drug allergy is cancellation of the "guilty" drug or switching to the same drug without a preservative.

After canceling the “guilty” drug in acute cases, eye drops of allergophthal or spersallerg are used 2-3 times a day, in chronic cases, alomide, lecrolin or lecrolin without preservative 2 times a day. In severe and protracted course, there may be a need for taking antihistamines inside.

Chronic Allergic Conjunctivitis . Allergic conjunctivitis more often occurs chronically: moderate burning of the eyes, slight discharge, periodically occurring itching of the eyelids. It should be borne in mind that often numerous complaints of discomfort are combined with minor clinical manifestations, which complicates the diagnosis.

Among the causes of persistent flow may be hypersensitivity to pollen, industrial hazards, food products, household chemicals, house dust, dandruff and animal hair, dry fish food, drugs, cosmetics, contact lenses.

The most important treatment is the exclusion of risk factors for allergies, if it is possible to establish them. Local treatment includes instillation of eye drops of lecrolin or alomide 2 times a day for 3-4 weeks. With blepharitis, an ointment of hydrocortisone-PIC is prescribed 2 times a day for ever and an instillation of an artificial tear (natural tear) 2 times a day.

Allergic conjunctivitis when wearing contact lenses . It is believed that most patients wearing contact lenses will someday have an allergic conjunctival reaction: eye irritation, photophobia, lacrimation, burning under the eyelids, itching, discomfort when inserting a lens. On examination, you can find small follicles, small or large papillae on the conjunctiva of the upper eyelids, hyperemia of the mucous membrane, edema and pinpoint erosion of the cornea.

Treatment: It is necessary to refuse to wear contact lenses. Assign instillation of eye drops of lecrolin or alomide 2 times a day. In an acute reaction, allergophthal or spersallerg is used 2 times a day.

Large Papillary Conjunctivitis (CPC) . The disease is an inflammatory reaction of the conjunctiva of the upper eyelid, for a long period in contact with a foreign body. The occurrence of CPC is possible under the following conditions: wearing contact lenses (hard and soft), the use of eye prostheses, the presence of sutures after cataract or keratoplasty extraction, tightening scleral fillings.

Patients complain of itching and mucous discharge. In severe cases, ptosis may occur. Large (giant - with a diameter of 1 mm or more) papillae are grouped along the entire surface of the conjunctiva of the upper eyelids.

Although the clinical picture of CPC is very similar to the manifestations of the conjunctival form of spring catarrh, there are significant differences between them. First of all, PDA develops at any age. and always in the presence of remaining seams or wearing contact lenses. Complaints of itching and discharge during CPC are less pronounced, the limb and cornea are usually not involved in the process. Finally, all symptoms of CPC quickly disappear after removal of a foreign body. Patients with CPC do not necessarily have a history of allergic diseases and seasonal exacerbations are not noted.

In treatment, the main value is foreign body removal. Until the symptoms completely disappear, alomide or lecrolin is instilled 2 times a day. Wearing new contact lenses is possible only after the complete disappearance of inflammatory phenomena. For the prevention of CPC, systematic care for contact lenses and prostheses is necessary.

Prevention of Allergic Conjunctivitis. In order to prevent the disease, certain measures must be taken.

• Elimination of causative factors. It is important to reduce, and if possible, eliminate contact with allergy risk factors such as house dust, cockroaches, pets, dry fish food, household chemicals, cosmetics. It should be remembered that in patients with allergies, eye drops and ointments (especially antibiotics and antiviral agents) can cause not only allergic conjunctivitis, but also a general reaction in the form of urticaria and dermatitis.
• In the event that it is assumed that a person will fall into such conditions when it is impossible to exclude contact with factors causing allergies to which he is sensitive, he should start instilling lecrolin or alomide one drop 1-2 times a day 2 weeks before contact.
• If the patient has already fallen into such conditions, they instill an allergophthal or a spersallerg, which give an immediate effect that lasts for 12 hours.
• With frequent relapses, specific immunotherapy is carried out during the period of conjunctivitis remission.

Dystrophic conjunctival disease

This group of conjunctival lesions includes several diseases of various origins:

• dry keratoconjunctivitis,
• pingvekula
• pterygoid hymen.

Dry eye syndrome (dry keratoconjunctivitis) - This is a lesion of the conjunctiva and cornea that occurs in connection with a marked decrease in the production of tear fluid and a violation of the stability of the tear film.

The tear film consists of three layers. The surface, lipid layer produced by the meibomian glands prevents the evaporation of the liquid, thereby maintaining the stability of the tear meniscus. The middle, water layer, which makes up 90% of the thickness of the tear film, is formed due to the main and additional lacrimal glands. The third layer, directly covering the corneal epithelium, is a thin mucinous film produced by the goblet cells of the conjunctiva. Each layer of the tear film can be affected by various diseases, hormonal disorders, drug effects, which leads to the development of dry keratoconjunctivitis.

Dry eye syndrome is one of the most common diseases, especially often occurs in people over 70 years old.

Patients complain of sensation of a foreign body under the eyelids, burning, pain, dryness in the eye, note photophobia, poor tolerance of wind, smoke. All phenomena worsen in the evening. Eye irritation is caused by instillation of any eye drops. The enlarged vessels of the conjunctiva of the sclera are objectively observed, the tendency to the formation of folds of the mucous membrane, flocculent inclusions in the lacrimal fluid, the surface of the cornea fades. The following clinical forms of corneal lesions are distinguished, corresponding to the severity of the disease: epithelialopathy (barely noticeable or pinpoint defects of the corneal epithelium, detected by staining with fluorescein or Bengal pink), corneal erosion (more extensive defects of the epithelium), filamentous keratitis (epithelial flaps, twisted in the form of one end fixed to the cornea), corneal ulcer.

When diagnosing dry eye syndrome, the patient's characteristic complaints, the results of a biomicroscopic examination of the edges of the eyelids, conjunctiva and cornea, as well as special tests.

1. A sample for assessing the stability of a tear film (Norn test). When looking down when drawn upper eyelid instill a 0.1-0.2% solution of fluorescein in the limb area for 12 hours. After turning on the slit lamp, the patient should not blink. Watching the painted surface of the tear film, determine the time of tearing of the film (black spot). The tear film rupture time of less than 10 s is of diagnostic value.
2. Schirmer test with a standard strip of filter paper, one end inserted in the lower eyelid. After 5 minutes the strip is removed and the length of the wetted part is measured: its value less than 10 mm indicates a slight decrease in the production of tear fluid, and less than 5 mm indicates a significant.
3. A test with a 1% solution of Bengal pink is especially informative, since it allows you to identify dead (stained) epithelial cells covering the cornea and conjunctiva.

Diagnosis of dry eye syndrome is fraught with great difficulties and is based only on the results of a comprehensive assessment of patient complaints and clinical picture, as well as the results of functional tests.

Treatmentremains a difficult task and involves a gradual individual selection of medicines. Eye drops containing a preservative are worse for patients and can cause an allergic reaction, so eye drops without a preservative should be preferred. The main place is taken by tear replacement therapy. Drops of natural tears are used 3-8 times a day, and gel formulations oftagel or vidisic-gel - 2-4 times a day. In cases of allergic conjunctival irritation, add alomide, lecrolin or lecrolin without a preservative (2 times a day for 2-3 weeks). In case of damage to the cornea, vitasic drops, carnosine, taufon or solcoseryl gel or cornegel are used.

Pingvekula (Wen) - this is an irregularly shaped elastic formation slightly rising above the conjunctiva, located a few millimeters from the limb within the palpebral fissure from the nose or temporal side. Usually occurs in the elderly symmetrically in both eyes. Pingvekula does not cause pain, although it attracts the attention of the patient. No treatment is required, except in rare cases when Pingvekula becomes inflamed. In this case, anti-inflammatory eye drops (dexapos, maxidex, optan-dexamethasone or hydrocortisone-PIC) are used, and complex preparations (dexagentamycin or maxitrol) are used when pingvecules are combined with a mild secondary bacterial infection.

Pterygoid hymen (pterygium) - a flat surface vascularized fold of a conjunctiva of a triangular shape, growing on the cornea. Irritation factors, wind, dust, temperature changes can stimulate the growth of pterygium, which leads to visual impairment. Pterygium slowly advances toward the center of the cornea, is tightly connected with the bowman shell and the surface layers of the stroma. Anti-inflammatory and anti-allergic agents (drops of alomide, lecrolin, dexapos, maxidex, optan-dexamethasone, hydrocortisone-POS or naklof) are used to delay the growth of pterygium and prevent relapse. Surgery should be carried out at a time when the film has not yet covered the central part of the cornea. When excising recurrent pterygium produce edge layered keratoplasty.

Article from the book:.

The connective membrane of the eye, or conjunctiva (tunica conjunctiva), is a mucous membrane of a pale pink color that lines the eyelids from the back and passes to the eyeball up to the cornea and, thus, connects the eyelid with the eyeball. With a closed palpebral fissure, the connective membrane forms a closed cavity - the conjunctival sac, which is a narrow slit-like space between the eyelids and the eyeball.

The mucous membrane covering the posterior surface of the eyelids is called the conjunctiva (tunica conjunctiva palpebrarum), and the sclera covering the conjunctiva of the eyeball (tunica conjunctiva bulbaris) or sclera. The part of the conjunctiva of the eyelids, which, forming arches, passes to the sclera, is called the conjunctiva of transitional folds or the arch. Accordingly, the upper and lower conjunctival arches (fornix conjunctiva superior et inferior) are distinguished. At the inner corner of the eye, in the rudiment of the third century, the conjunctiva forms a vertical lunate fold and a lacrimal meat.

The entire space lying in front of the eyeball, limited by the conjunctiva, is called the conjunctival sac (saccus conjunctivalis), which closes when the eyelids are closed. The lateral angle of the eye (angulus oculi lateralis) is sharper, the medial (angulus oculi medialis) is rounded and on the medial side it limits the deepening - the lacrimal lake (lacus lacrimalis). Here, at the medial corner of the eye, there is a slight elevation - the lacrimal meat (caruncula lacrimalis), and to the lateral from it - the lunate fold of the conjunctiva (plica semilunaris conjunctivae) - the remainder of the migratory (third) century of the lower vertebrates. On the free edge of the upper and lower eyelids, near the medial corner of the eye, outside of the tear lake, there is a noticeable elevation - the lacrimal papilla (papilla lacrimalis). At the top of the papilla there is a hole - the lacrimal opening (punctum lacrimale), which is the beginning of the lacrimal tubule.

Two layers are distinguished in the conjunctiva - epithelial and subepithelial. The conjunctiva of the eyelids is tightly fused with the cartilaginous plate. The conjunctival epithelium is multilayered, cylindrical with a large number of goblet cells. The conjunctiva of the eyelids is smooth, brilliant, pale pink, through which yellowish columns of meibomian glands passing through the thickness of the cartilage shine through. Even with the normal condition of the mucous membrane at the outer and inner corners of the eyelids, the conjunctiva that covers them looks slightly hyperemic and velvety due to the presence of small papillae.

Allocate:

• The conjunctival epithelium has a thickness of 2 to 5 layers of cells. Basal cubic cells pass into flat multifaceted cells reaching the surface. With chronic exposure and drying, the epithelium can keratinize.
• The stroma (substantia propria) consists of richly vascularized connective tissue, separated from the epithelium by the main membrane. The adenoid surface layer does not develop until about 3 months after birth. This is associated with the absence of a follicular conjunctival reaction in the newborn. A deeper, thicker fibrous layer is connected with the tarsal plates and represents the subconjunctival tissue, and not the conjunctiva proper.

Conjunctival glands

Mucin Secreting Cells

• goblet cells are located within the epithelium, with the highest density in the lower nasal section;
• henle crypts are located in the upper third of the upper and lower third of the lower tarsal conjunctiva;
• manz glands surround the limb.

NB: Destructive processes in the conjunctiva (for example, scarring pemphigoid) usually cause mucin secretion, while chronic inflammation is associated with an increase in the number of goblet cells.

The extra lacrimal glands Krause and Wolfring are located deep within the lamina propria.

The conjunctiva of transitional folds is loosely connected to the underlying tissue and forms folds that allow the eyeball to move freely. The conjunctiva of the arches is covered with stratified squamous epithelium with a small number of goblet cells. The subepithelial layer is represented by loose connective tissue with inclusions of adenoid elements and accumulations of lymphoid cells in the form of follicles. In the conjunctiva there are a large number of additional lacrimal glands of Krause.

The conjunctiva of the sclera is tender, loosely connected to the episcleral tissue. The stratified squamous conjunctiva squamous epithelium smoothly passes to the cornea.

The conjunctiva borders on the skin of the edges of the eyelids, and on the other hand, with the corneal epithelium. Diseases of the skin and cornea can spread to the conjunctiva, and diseases of the conjunctiva to the skin of the eyelids (blepharoconjunctivitis) and the cornea (keratoconjunctivitis). Through the lacrimal opening and the lacrimal tubule of the conjunctiva is also connected with the mucous membrane of the lacrimal sac and nose.

The conjunctiva is abundantly supplied with blood from the arterial branches of the eyelids, as well as from the anterior ciliary vessels. Any inflammation and irritation of the mucous membrane is accompanied by a bright hyperemia of the vessels of the conjunctiva of the eyelids and arches, the intensity of which decreases towards the limb.

Due to the dense network of nerve endings of the first and second branches of the trigeminal nerve, the conjunctiva acts as a integumentary sensory epithelium.

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Functions

The main physiological function of the conjunctiva is eye protection: when a foreign body enters, eye irritation appears, tear fluid secretion intensifies, blinking movements become more frequent, as a result of which the foreign body is mechanically removed from the conjunctival cavity. The secret of the conjunctival sac constantly moistens the surface of the eyeball, reduces friction during its movements, and helps maintain the transparency of the moistened cornea. This secret is rich in protective elements: immunoglobulins, lysozyme, lactoferrin. The protective role of the conjunctiva is also provided due to the abundance of lymphocytes, plasma cells, neutrophils, mast cells and the presence of immunoglobulins in all five classes.

Clinical features characteristic of the diagnosis of conjunctival diseases are: complaints, discharge, conjunctival reaction, films, lymphadenopathy.

Symptoms of conjunctival disease

Nonspecific symptoms: lacrimation, irritation, pain, burning sensation and photophobia.

1. Pain and a foreign body sensation suggest involvement in the cornea process.
2. Itching is a sign of allergic conjunctivitis, although it can be with blepharitis and dry keratoconjunctivitis.

Detachable

It consists of exudate, which is filtered through the conjunctival epithelium from dilated blood vessels. On the surface of the conjunctiva, decay products of epithelial cells, mucus and tears are found. The discharge can vary from watery, mucopurulent to severe purulent.

1. The watery discharge consists of serous exudate and an excess of reflexively secreted tears. It is typical for acute viral and allergic inflammations.
2. Mucous discharge is typical of spring conjunctivitis and dry keratoconjunctivitis.
3. Purulent discharge occurs in severe acute bacterial infections.
4. Mucopurulent discharge occurs both in case of mild bacterial and chlamydial infections.

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Conjunctival reaction

• Conjunctival injection is most pronounced in the vaults. The velvety, bright red conjunctiva indicates a bacterial etiology.
• Subconjunctival hemorrhages usually occur in viral infections, although they can also be in bacterial infections caused by Strep. pneumoniae and N. aegypticus.
• Edema (chemosis) occurs with acute inflammation conjunctiva. Translucent swelling occurs due to the exudation of protein-rich fluid through the walls of inflamed blood vessels. Large excessive folds can form in the arch and in severe cases, the edematous conjunctiva can go beyond the closed eyelids.
• Scarring can occur with trachoma, ocular form of scarring pemphigus, atopic conjunctivitis, or with prolonged use of local medications.

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Conjunctival follicular reaction

Composition

• Follicles - subepithelial foci of hyperplastic lymphoid tissue within the stroma with additional vascularization;

Symptoms

• Numerous, separate, slightly rising formations resembling small grains of rice, the most prominent in the arches.
• Each follicle is surrounded by a tiny blood vessel. The size of each formation can be from 0.5 to 5 mm, which indicates the severity and duration of inflammation.
• Follicles increase in size, so the vessel accompanying them moves to the periphery, as a result, a vascular capsule forms, which forms the basis of the follicle.

The reasons

• The reasons may be viral and chlamydial infectionsParinaud syndrome and hypersensitivity to local treatment.

Papillary conjunctival reaction

The papillary conjunctival reaction is nonspecific and therefore is of less diagnostic value than the follicular reaction.

• Hyperplastic conjunctival epithelium, located in numerous folds or protrusions with the central vessel, diffuse inflammatory cell infiltrate, including lymphocytes, plasma cells and eosinophils.
• Papillae can form only in the palpebral and bulbar conjunctiva in the limb region, where the conjunctival epithelium is connected by fibrous septa to the underlying structures.

Symptoms

• Papillae are the most common find on the conjunctiva of the upper eyelid in the form of an elegant mosaic-like structure with towering polygonal hypersmired areas separated by paler grooves.
• The central fibrovascular nucleus of the papilla secretes secret on its surface.
• At prolonged inflammation fibrous septa that attach the papillae to the underlying tissues can rupture and cause them to fuse and increase in size.
• Recent changes include superficial stromal hyalinization and the formation of crypts containing goblet cells between the papillae;

With a normal upper edge of the tarsal plate (when the lower one is inverted), the papillae can imitate follicles, which cannot be considered a clinical sign.

The reasons

Chronic blepharitis, allergic and bacterial conjunctivitis, wearing contact lenses, upper limbal keratoconjunctivitis and "sleeping" eyelid syndrome.

Film

1. Pseudomembranes consist of coagulated exudate attached to an inflamed conjunctival epithelium. They are easily removed, leaving the epithelium intact (characteristic). The causes may be severe adenovirus and gonococcal infections, fibrous conjunctivitis, and Stevens-Johnson syndrome.
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Pterygium is formed from conjunctival tissue that has undergone degenerative changes, and grows from the limb towards the middle of the cornea. Pterygium can have different sizes - from a couple of millimeters to large formations that cover the cornea and significantly reduce the patient's quality of life.

What is pterygium?

Pterygium, or pterygoid hymen is an abnormal formation located on the inner corner of the eye, having a triangular shape.

The development of pathology can be rapid, characterized by rapid growth, or slow.

Prevalence

Epidemiology is directly related to the person’s place of residence. For example, in the United States, in geographic areas that are above 40 degrees latitude, pathology does not exceed 2% of 100% of the population.

In settlements located at a latitude of 28-36 degrees, the incidence increases to 10%.

According to experts, this is due to an increase in the amount of solar radiation received by man.


In women, the pathology develops less often than in men, which is due to the more frequent presence of men under the scorching rays of the sun in connection with the type of work. The first signs of pterygium are usually observed in young and adulthood (25-40 years). Until the age of 20, the disease is rarely recorded.

Causes of the disease

The reasons for the development of the disease are: the high frequency and duration of the influence of ultraviolet radiation on the eye area, which is inherent in residents of regions with a hot climate, work in the open, neglect of methods and means of protecting the eyes. The hereditary disposition to the appearance of signs of pterygium is also proved.

Symptoms of Ptergium

In the early stages of the disease, any symptoms may be completely absent. Later signs of eye irritation, conjunctival redness, a feeling of the presence of sand, "fog" in the eyes, swelling of the eyelids, and a slight decrease in visual function develop.

Diagnostic Methods

Examination by an ophthalmologist includes visual acuity and a visual examination using a special lamp. If there are phenomena of myopia, astigmatism, keratotopography is prescribed. Dynamic tracking of ongoing processes allows you to calculate the rate of development of the disease.

Consequences and Complications

Among the unpleasant symptoms that can join as the pterygium progresses are:

• incomplete vision of objects, distortion of their outlines;
• significant drop in vision;
• eye pain, severe irritation, inflammation of the conjunctiva due to rubbing, combing;
• the appearance of adhesions, scars on the cornea, eyelids, etc .;
• fusion of pterygium tissues with other parts of the organ of vision, decreased mobility of extraocular muscles, as a result of which the eyeball may lose mobility;
• double objects ().

The phenomena of diplopia most often develop due to partial paralysis of the external muscle. If the patient suffered surgical intervention regarding pterygium, such unpleasant consequences can be observed as a result of separation of the muscle tendon from the area of \u200b\u200bits attachment.

A rare complication of pterygium is the degeneration of the cornea with its pronounced thinning, which is observed against the background of regular contact of the cornea with the bulging part of the formation.

The most dangerous, but the rarest consequence of a disease can be its degeneration into a malignant tumor.

Ptergium Treatment

To reduce the speed of the disease, drops of the “artificial tear” type are used, moisturizing gels and ointments. Patients are advised to constantly wear glasses with UV filters when outdoors. To eliminate the symptoms of pterygium, eye ointments and drops with glucocorticosteroids are used.

Surgical treatment

A radical way to eliminate the formation in the inner corner of the eye is surgery. It is carried out to return the aesthetic attractiveness of the face, as well as for therapeutic purposes (to normalize visual acuity, eliminate discomfort, irritation and other symptoms).

Surgical removal of pterygium can be performed according to various methods, but all of them are aimed at excising abnormally overgrown tissues.

It is noted that the removal of pterygium without subsequent drug treatment leads to its reappearance in half or more cases.

To prevent this from happening, immediately after the operation, they are treated with immunosuppressants (cytostatics), β-radiation therapy courses are carried out, the affected area is treated with cryocoagulants, etc.

If postoperative therapy has been carried out in full, the likelihood of recurrence of pterygium is not more than 10%.

If the pterygium is large, transplantation (gluing or suturing) of the conjunctival autograft or special artificial membranes may be necessary to conceal the resulting cosmetic defect.

The operation is not complicated and is often performed under local anesthesia. In parallel with anti-relapse treatment, antibiotic therapy is prescribed, drops to prevent inflammation.

In some cases, the operation leads to the development of complications. Such can be: infection of the eye, transplant rejection, inflammation of the tissues in the suture area, visual dysfunctions (for example, doubling of objects), the appearance of scars on the cornea of \u200b\u200bthe eye.

The most rare, but still occurring complications are perforation of the eyeball, penetration of blood into the vitreous body. Against the background of treatment with cytostatics and radiation therapy, the cornea may become thinner, sometimes sclera ectasia occurs.

Conjunctiva

Conjunctiva - This is a thin transparent fabric that covers the eye from the outside. It starts with limba, the outer edge of the cornea, covers the visible part of the sclera, as well as the inner surface of the eyelids.

Content

• Conjunctiva structure
• Conjunctival function

Conjunctiva structure

With closed eyelids, the entire conjunctiva of the eyelids and sclera forms, as it were, a bag with a capacity of 2 drops of liquid. The conjunctiva consists of the epithelium and connective tissue base. The surface of the conjunctiva of the cartilage is lined with a multilayer cylindrical epithelium, under which lies a thin layer of loose connective tissue, which has the character of an adenoid. The conjunctiva is tightly soldered with cartilage, has a pink color, is well vascularized, smooth, and transparent. The meibomian glands are visible through the transparent conjunctiva of the cartilage. At the corners of the eyelids of the conjunctiva, it is somewhat rough due to the presence of papillae here, which can be detected with a simple eye, while the papillae of the entire surface of the conjunctiva are smoothed out and not visible to the naked eye. The conjunctiva of the arch or transitional fold is loosely connected to the underlying tissue due to the presence of subconjunctival tissue rich in elastic fibers underneath. Here it forms folds that provide free movement of the eyeball.

The surface of the transitional fold is smooth, does not have papillae, and the epithelium here has a transitional form from a multilayer cylindrical to a multilayer flat. The adenoid layer in this section of the conjunctiva is most pronounced and it always has follicles (accumulations of lymphoid cells). In early childhood subconjunctival tissue is very insignificant, it does not have follicles and papillae. There are also goblet cells and complex tubular glands - additional lacrimal glands of Krause.

Due to the presence of goblet cells and lacrimal glands, the conjunctiva maintains constant moisture, which is essential for the normal state of the cornea. In the temporal part of the upper arch, the excretory ducts of the lacrimal gland open.

The mucous membrane of the eyeball is very delicate, characterized by smoothness, transparency, through which the white color of the sclera is visible. At the limb, it is tightly soldered to the underlying tissues, and on the rest it is loose. Therefore, here the mucous membrane is freely displaced and easily swells in inflammatory processes.

The conjunctiva of the eyeball, open in the region of the palpebral fissure, performs a protective function. It is lined with stratified squamous epithelium, which in the normal state does not keratinize. The adenoid layer of the conjunctiva of the eyeball is less pronounced than in the transitional fold. It ends at the edge of the cornea.

In the inner corner of the eye, the conjunctiva of the eyeball forms a duplicature, the so-called lunate fold - an analog of the third century animals. It, as well as the conjunctiva of the eyeball, is covered with a multilayer polymorphic epithelium. Inside the lunate fold, at the bottom of the tear lake there is a lacrimal meat, which is a modified skin covered with a multilayer, but not keratinizing epithelium, contains rudimentary hair, sebaceous glands, modified sweat and modified lacrimal glands of the alveolar-tubular structure. The conjunctiva is abundantly supplied with blood vessels from two systems of eyelid arteries and anterior ciliary.

Twigs from the medial and lateral vessels of the eyelids and from the cartilaginous arch form the posterior conjunctival vessels that feed the conjunctiva of the cartilage, transitional fold and conjunctiva of the eyeball, with the exception of the perilimbal zone. The latter is supplied with anterior conjunctival vessels, which are formed from the anterior ciliary vessels, which are a continuation of the vessels of the four rectus muscles of the eye (from the orbital artery system).

The anterior ciliary arteries are directed towards the limbus and divide without reaching 2-3 mm, giving part of the branches into the eye, part to the limb of the cornea, part to the episclera and part to the perilimbal zone of the conjunctiva of the eyeball. Perilimbal vessels are called anterior conjunctival vessels. The anterior and posterior conjunctival vessels are connected by anastomoses. At inflammatory diseases conjunctiva, anterior and posterior conjunctival vessels dilate, and the eyeball becomes bright red. This is a superficial conjunctival injection, which is most pronounced closer to the transitional folds, and further to the cornea it decreases. It must be distinguished from pericorneal injection, which has a dark purple color and surrounds the cornea in the form of a corolla. By the arches of the conjunctiva, it becomes smaller. This is an injection of deep, episcleral vessels that form the marginal loop network. Pericorneal injection is a sign of corneal disease, iris, or deeper parts of the eyeball. Mixed injection is characteristic for simultaneous damage to the mucous membrane and the anterior part of the eye.

Conjunctival veins accompany arteries, but their branches are more numerous. The outflow of venous blood from the conjunctiva is mainly through the skin, palpebral system of blood vessels, into the system of facial veins. A very small part of the venous blood from the conjunctiva of the eye along the anterior conjunctival veins flowing into the anterior ciliary veins goes into the system of the orbit's veins.

Lymphatic vessels are well developed and are present in all parts of the conjunctiva. Their expansion gives a peculiar picture of lymphectasias. From the temporal half of the conjunctiva, the lymph enters the anterior the lymph nodes, and from the nasal - to the submandibular. The sensory nerves of the conjunctiva receives from the first and second branches of the trigeminal nerve.

The lacrimal nerve (n. Lacrimalis) from the first branch of the trigeminal nerve supplies the temporal part of the conjunctiva of the upper and partly lower eyelid, the supraorbital nerve (n. Supraorbitalis) and supratrochlear (n. Supratrochlearis) supply the nasal part of the conjunctiva of the upper eyelid. From the second branch of the trigeminal nerve, the zygomatic nerve departs, supplying the temporal lobe, and the lower orbit nerve - the nasal half of the lower eyelid conjunctiva.

The sensitivity of the conjunctiva determines its reflex reaction to irritations: the ingress of foreign bodies, dust, touch. The conjunctival sac contains lysozyme, acting lytically on bacteria, especially active on saprophytes. The number of bacteria in the conjunctival sac is less than anywhere else on the surface of the body. But the conjunctiva can serve as an entrance gate for vulgar microorganisms, however, it is more resistant to some viruses.

The connective membrane at an early age is less wet, it is thin and tender, the mucous and lacrimal glands are not sufficiently developed and small in it, the subconjunctival tissue is poorly expressed, it does not have papillae and follicles, and sensitivity is reduced.

Conjunctival function

The main function of the conjunctiva is to secretion of the mucous and fluid parts of the lacrimal fluid which wets and lubricates the eye.

The conjunctiva also performs the following functions:

protective - when it enters the conjunctival cavity of foreign bodies or with inflammation;

mechanical - manifested by abundant secretion of tears and mucus to flush foreign agents (dust, germs, etc.),

moisturizing - which contributes to the insensitive mobility of the eyeball and eyelids;

barrier - due to the richness of the lymphoid elements of the submucous adenoid tissue.

Many of the cellular elements of the conjunctiva are involved in phagocytosis; in reactions that promote the removal of allergens, they are involved in providing immunological memory. In the conjunctiva, mainly in the subepithelial tissue, immunoglobulins of all five classes were found.
The conjunctiva also performs a nutritional function, because from its vessels and from the tear fluid partially penetrate through the cornea into the eye nutrients.

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After examining the lacrimal organs, the mucosa (conjunctiva) of the eyelids, transitional folds and the eyeball are examined. In the open palpebral fissure, only a small area of \u200b\u200bthe tender translucent conjunctiva is visible. This is the mucosa covering the sclera. To examine the rest of its departments, you should turn out the eyelids.

The eversion of the eyelids is carried out as follows. To examine the conjunctiva of the lower eyelid, the patient must look up. With the thumb, located in the middle of the lower eyelid 1 cm below the ciliary edge, the lower eyelid is slightly pulled down and somewhat away from the eye. It is a mistake to put a finger too far on the skin of the eyelid, then the examination of the conjunctiva is difficult. If the eversion of the lower eyelid is correct, then it is exposed first bottom part conjunctiva of the eyeball, then the conjunctiva of the transitional fold and conjunctiva of the eyelid.

Inversion of the upper eyelid requires a certain skill. To exclude the action of muscle lifting upper eyelid, and displacements of the sensitive cornea, the patient is asked to look down. The index and thumb of one hand take the ciliary edge of the eyelid and slightly pull it forward and down. Then, the index finger of the other hand is placed in the middle of the eyelid drawn down, namely, on the upper edge of the cartilage, pressing on the tissue in this place, and then the eyelid edge of the eyelid is quickly raised upward, while the index finger serves as a fulcrum. The upper eyelid can be turned out using a glass stick or an eyelift instead of the index finger. On the upper eyelid sulcus subtarsalis is located - a thin groove parallel to the edge of the eyelid, passing 3 mm from its edge. It is especially easy to get stuck in. foreign bodies. For pain, local anesthetics may partially help in the study. To restore the situation of the turned eyelid, the doctor asks the patient to look up and at the same time gently pulls the eyelashes down.

Normally, the conjunctiva of the eyelids is pale pink, smooth, transparent, moist. The vasculature is clearly visible, the meibomian glands lying in the thickness of the cartilage are visible. They have the appearance of yellowish-gray stripes located vertically in the tarsal plate perpendicular to the edge of the eyelid. Above and below the tarsal plate there are many narrow folds, small follicles are found, or lymphoid tissue is visible. Appearance palpebral conjunctiva varies with age.

Follicles are normally absent in adolescents, expressed in children and less noticeable in adults. The conjunctiva above the cartilaginous plates is tightly fused with them and normally has no follicles.

The conjunctiva boulevard, or the eyeball conjunctiva, is examined with easy dilution of the eyelids. The patient is asked to look in all directions of the gaze - up, down, right and left. A healthy bulbar conjunctiva is a thin membrane that is almost completely transparent and looks like a white-pink tissue, although some patients may have a normal red (red) eye due to the expansion of many thin conjunctival vessels passing through the mucous membrane. An ophthalmologist should be able to observe the white sclera through a transparent bulbar conjunctiva. The deeper conjunctiva are the episcleral vessels that extend radially from the cornea. Inflammation in these vessels indicates an eyeball disease.

The normal surface of the conjunctiva is so smooth that analogies arise with a convex reflective surface. Any minimal surface disturbance will be apparent, especially when viewed under magnification, by a change in the reflection of the light reflex. Conjunctival ulceration or erosion is easily determined by instilling a fluorescein or applying a paper strip with fluorescein to the conjunctival cavity. When illuminated with white light, the affected area looks like yellow-green, cobalt blue light - like bright green.

On each side of the limb horizontally, a slightly raised yellowish section of the mucous membrane (pingvekula) can be seen, with age, its yellowness usually increases due to benign degeneration of elastic tissue. Benign flat pigmented nevi may occur.

According to the indications, the flora of the conjunctival cavity and its sensitivity to antibiotics are determined. A smear is taken from the conjunctiva before the installation of antibacterial drugs. For this purpose, a special loop of thin wire is used. The loop is preliminarily calcined on an alcohol burner, and then it is cooled and after that it is carried out along the conjunctiva in the lower arch, trying to capture a piece of the discharge. A smear is applied in a thin layer on a sterile glass slide and dried. The taken contents of the conjunctival cavity is placed in a test tube with a nutrient medium - produce inoculation. A smear and culture are sent to the laboratory for research. The accompanying note indicates the date of the analysis, the name of the patient, which eye was examined and the alleged diagnosis. With severe edema of the eyelids, as well as in young children, the conjunctiva can be examined only with the help of an eyelid lifter. The mother or nurse places the child on her lap with her back to the doctor, and then puts him on the lap of the doctor who is sitting opposite. If necessary, he can hold the child’s head with his knees. A mother holds her elbows on her knees, and with her hands holds his hands. Thus, both hands of the doctor are free and he can carry out any manipulations. Before the examination, anesthesia of the eye with 0.5% dicaine solution is performed. The eyelid is taken in the right hand, the upper eyelid is pulled down and forward by the fingers of the left hand, the eyelid is brought under it and with its help the eyelid is lifted up. Then the second eyelid is opened behind the lower eyelid and is taken down.

In diseases of the conjunctiva and eyeball, there is hyperemia (redness) of the eye of varying intensity and localization: superficial (conjunctival) and deep (ciliary, pericorneal) injections. It is necessary to learn to distinguish between them, since a superficial injection is a sign of inflammation of the conjunctiva, and a deep one is a symptom of a serious pathology in the cornea, iris or ciliary body. The signs of conjunctival injection are as follows: the conjunctiva has a bright red color, the intensity of hyperemia is greatest in the region of transitional folds, it decreases as it approaches the cornea. Separate blood-filled vessels located in the conjunctiva are clearly visible. They move together with the mucosa, if, touching the edge of the eyelid with a finger, slightly move the conjunctiva. And, finally, installations in the conjunctival sac of drops containing adrenaline lead to a pronounced short-term decrease in superficial hyperemia.

With pericorneal injection, the anterior ciliary vessels and their episcleral branches expand, which form around the cornea a marginal loop of the vessels. The signs of ciliary injection are as follows: it has the appearance of a purple-pink corolla around the cornea. Towards the vaults, the injection decreases. Separate vessels in it are not visible, as they are hidden by episcleral tissue. When the conjunctiva is displaced, the injected area does not move. Adrenaline installations do not cause a decrease in ciliary hyperemia.

T. Birich, L. Marchenko, A. Chekina

"Inspection of the mucous membrane of the eyelids in the diagnosis of diseases" - article from the section