3. SIMPLE ALLERGIC CONJUNCTIVITIS
Mild ,non specific IgE mediated Type I hypersensitivity reaction
Etiology :
Hay fever conjunctivitis : associated with allergic rhinitis
Allergens : pollens , grass , animal dandruffs
SAC: common , d/t: grass pollens
PAC: not common , d/t: house dust and mites
4. SAC PATHOLOGY:
Vascular response: vasodilation increased vessel permeability exudation
Cellular response: Conjunctival infiltration (eosinophil , plasma cells and mast cells )
and exudation
producing histamine and histamine like substance
Conjunctival response: boggy swelling , increase connective tissue formation and
mild papillary hyperplasia
5. Symptoms: itching
burning sensation in the eye
watery discharge and
mild photophobia
Signs : hyperemia and chemosis
mild papillary reaction
oedema of eyelids
SAC
6. MANAGEMENT :
• Exposure to allergens should be reduced as far as possible
• Cold compresses
• Topical tear substitutes to flush out allergens
medications:
• vasoconstrictors
• Mast cell stabilizer: sodium chromoglycate 2% [QID]
• severe and non-responsive: steroids
• Systemic antihistamines : Cetirizine 10 mg OD(acute with marked
itching)
7. VERNAL KERATOCONJUNCTIVITIS
Recurrent , bilateral , interstitial ,self limiting,
Age : 4- 20 yrs , sex: boys> girls
Season: Summer hence the name SPRING CATARRH
Etiology : IgE mediated hypersensitivity reaction
Personal family history of hay fever, eczema , asthma
Peripheral blood shows : eosinophilia increased IgE
8. VKC PATHOLOGY:
Conjunctival epithelium : hyperplasia and downward projections into the sub
epithelial tissue
Adenoid layer : cellular infiltration by eosinophil's , plasma cells ,
lymphocytes and histiocytes .
Fibrous layer : proliferation which later undergoes hyaline changes
Conjunctival vessels: proliferation , increased permeability and vasodilation
ALL THESE LEADS TO MULTIPLE PAPILLA
FORMATION IN UPPER TARSAL CONJUNCTIVA
10. PALPEBRAL FORM
Diffuse papillary hypertrophy, >
on superior tarsus
Papillae have a flat-topped
polygonal appearance
resembling
COBBLESTONES
Severe cases- Giant papillae,
which may be coated with
mucus
11. LIMBAL / BULBAR FORM
May start as a thickening &
opacification of limbus
Limbal nodules - Mucoid nodules,
which are gelatinous, elevated
Horner-Trantas dots – composed
mainly of eosinophils and
epithelial debris (limbal apices)
12. VERNAL KERATOPATHY / CORNEAL
INVOLVEMENT
Punctate epithelial erosions
to macroerosions
Shield ulcers – Oval
ulceration with thickened,
opaque edges
13. Plaque formation – Occur when ulcer base
becomes coated with desiccated mucus
Results in –
Subepithelial ring scarring
Pseudogerontoxon – Arc like whitish peripheral
corneal deposition ‘cupid’s bow’ outline
in a inflamed segment of the limbus
Clinical course : self limiting burns out spontaneously after 5 – 10 yrs
14. TREATMENT
Local:
• Topical steroid : Every 4 hrs. for 2 days followed by 3-4 times a day
for 2 weeks .
MONITOR IOP TO PREVENT STEROID INDUCED GLAUCOMA
• Mast cell stabilizers : sodium chromoglycate 2 % drops 4-5 times/day
• Topical antihistamine
• Acetyl cysteine (0.5%)
• Topical cyclosporine (1%): severe unresponsive case
15. SYSTEMIC :
I. Oral antihistamine : for itching
II. Oral steroid : short course for very severe non responsive case
Treatment of large papilla supratarsal injection of long acting steroid
or cryo application or surgical removal
General measures: dark goggles , cold compress , change
of place from hot to cold
16. ATOPIC KERATOCONJUNCTIVITIS
Adult equivalent of VKC Young atopic adults with male predominance
May be associated with atopic dermatitis
Symptoms ;itching , soreness , dry sensation , mucoid discharge , phtophobia or
blurred vision
Signs :
lid margins: inflamed with round posterior borders
tarsal : milky appearance , very fine papilla , hyperaemia scarring with shrinkage
cornea-punctate epithelial keratitis in lower half, vascularization , plaque
17. Treatment :
• treat facial eczema and lid margin disease
• sodium chromoglycate
• steroids and
• tear drops
18. GIANT PAPILLARY CONJUNCTIVITIS
Conjunctivitis with very large sized papilla
Cause :allergic response to rough or deposited surface (contact lens ,
prosthesis, left out nylon suture )
Symptoms: itching , STRINGY DISCHARGE, reduced wearing time of
contact lens or prosthetic shell
Signs : papillary hypertrophy(1mm in diameter) of upper tarsus
Treatment :
• Removal of cause
• disodium chromoglycate
• Steroids not much use
19. PHLYCTENULAR CONJUNCTIVITIS
Characteristic nodular affection (an allergic response) Conjunctival and corneal
epithelium to some endogenous allergens to which they have become
sensitized.
Etiology:
Delayed type hypersensitivity in response to endogenous microbial protein.
Previously tuberculus protein ,now staphylococcus
other allergens :Moraxella axenfield and certain parasites.
Predisposing factors: age – ( 3 to 15 yrs. ) , sex : F>M , undernourished
20. PATHOLOGY:
1. Stage of nodule formation: Conjunctival infiltration and exudation
peripherally lymphocyte and central PMN
cells
nodule formation (phylcten)
necrosis of apex of nodule
2. Stage of ulceration: ulceration
3.Satge of granulation: floor of ulcer covered with granulation
tissue
4 .Stage of healing : healing with minimal scar formation
21. SYMPTOMS :
Discomfort in eye
MUCOPURULENT conjunctivitis d/t secondary infection
Reflex watering
Sign: 3 forms
Simple Phlyctenular conjunctivitis: pinkish white nodule surrounded by hyperaemia
on bulbar conjunctiva
Necrotizing Phlyctenular conjunctivitis: large phlycten with necrosis & ulceration leading
to severe pustular conjunctivitis.
Miliary Phlyctenular conjunctivitis: multiple phlycten arranged haphazardly or ring form
22. PHLYCTENULAR KERATITIS
Secondary extension of Conjunctival phlycten to cornea. Two forms :
A. Ulcerative :
• Sacrofulous: shallow marginal ulcer(phlycten break down),no space
between limbus and ulcer heals without leaving opacity.
• Fasicular: superficial, leaves parallel bundles of BV, band shaped
superficial opacity
• Miliary: multiple ulceration scattered over
B. Diffuse infiltrative :
central infiltration of cornea with rich peripheral vascularization
around limbus
23. MANAGEMENT OF PHLYCTENULAR CONJUNCTIVITIS
A. Local
• Topical steroid
• Antibiotic drops
• Atropine 1% eye ointment
B. Specific
• Tuberculous infection ruled out
• Septic focus treated
• Parasitic infestation eradicated
C. General
Protein rich diet, vitamin A and vitamin D
24. CONTACT DERMOCONJUNCTIVITIS
Allergic d/o, involvement of conjunctiva & skin lid along with some facial area
Etiology: delayed type hyper sensitivity response to prolong contact with chemicals and
ophthalmic medicines( atropine, neomycin, soframycin)
C/F:
Cutaneous involvement: weeping eczema around the area involved with medication
Conjunctival response: lower fornix and lower palpebral conjunctiva
Treatment: hyperaemia, papillary response
• Discontinuing of causative chemical or medications
• Topical steroid eye drops
• Steroid ointment in involved surrounding area
25. CLINICAL INVESTIGATIONS:
• Skin prick test / positive result
• Different cell types infiltrate the conjunctiva
SAC, PAC
T cells
Eosinophils
Mast Cells
Neutrophils
GPC, VKC, AKC
Mast cells
Eosinophils
Neutrophils
