Diseases of Conjunctiva

Conjunctivitis

► Classification
I Based on onset
a. Acute
b. Sub-acute
c. Chronic

II Based on type of Exudates
a. Serous (Viral, allergic, toxic)
b. Catarrhal (allergic – Ropy or thread like thick mucoid discharge)
c. Mucopurulent
d. Purulent
c. Pseudo-membranous / Membranous

III Based on Conjunctival Reaction
a. Follicular
b. Papillary
c. Granulomatous
IV Based on Etiology
a. Infectious (Bacterial, Viral, Chlamydial, Fungal and parasitic)
b. Non-infectious (Allergic, Irritants

Endogenous or autoimmune, Dry Eye, Toxic (chemical or drug induced, self inflicted) and Idiopathic.

Risk Factors for the Development of Bacterial Conjunctivitis

Disruption of host defense mechanism caused by:
1. Dry Eye
2. Exposure due to lid retraction, exophthalmos, lagophthalmos, inadequate blinking
3. Nutritional deficiencies/ Avitaminosis A


4. Local or Systemic Immune Deficiency:
* after topical and systemic immunosupressive therapy
* Nasolacrimal duct obstruction and infection
* Radiation damage
* Trauma
* Surgery
* Prior Conjunctival inflammation or infection
* Systemic Infection
* Exogenous inoculation

Gonorrhoeal Conjunctivitis

I. Epidemiological Aspect
Rare in developed countries, still seen in individuals and communities where Gonorrhoea is still a problem and hygienic standards are poor.



Etiology – Caused by Neisseria Gonorrhoeae (a bun- shaped Gram-negative intracellular diplococcus). Neisseria Catarrhalis may be seen/found in chronic forms. Condition is found in cases suffering from Gonorrhoeal genital infection.
Incubation period is few hours to three days.

Clinical Features
Symptoms
Swelling of eyelids, Pain, redness, inability to open eye(s), purulent discharge, grittiness, Diminution of Vision
Signs
Acute disease, occurring usually in adult males. Often in RE to begin with. Lids are swollen. Upper lids are tense, overhanging on lower lid. Matting of lashes and pus on lids margins. Eversion is difficult. Deep red velvety conjunctiva sometimes with membrane
After two to three weeks discharge diminishes but subacute form of conjunctivitis with presence of Gonococci persists for several weeks.
► Pre-auricular lymphadenopathy, tenderness and suppuration

► No immunity is conferred by an attack.
► Associated systemic signs – Urethritis, rise of temperature and depression.
► Complications- Corneal involvement – Gonococcus is capable of invading the normal cornea through intact cornea.
Location of Corneal Ulcer – Central, Marginal Ulcer , all round. Progressing rapidly depth-wise leading to perforation and complications associated with it.
► Other complications of Gonorrhoeal Conjunctivitis – Iritis , Iridocyclitis
► Non Ocular complications – Arthritis, Endocarditis and Septicaemia.
Treatment
► Of Gonococcal Conjunctivitis is started on confirmation of intracellular Gram-negative diplococci in conjunctival scrapings in clinically suspected cases.
Aim of therapy is to prevent or limit the corneal involvement and to eliminate systemic source.
► Systemic Treatment
Ceftriaxone 1 Gm IM , single dose
Local Treatment
* Cleanliness
* Ciprofloxacin / Ofloxacin/ Gentamicin/ Tobramycin Eye Drops 2 hrly.

* Bacitracin Eye Ointment 6 hrly
* Cycloplegic (Atropine) – in cases of Corneal involvement
* Tetracycline In cases where co-existing Chlamydial Trachomatis infection is suspected and cases with history of allergy to Penicillin / Cephalosporins

Angular Conjunctivitis

Specific type of Conjunctival inflammation characterized by involvement of inter-marginal Conjunctiva and neighboring bulbar conjunctiva, caused by Morax axenfield diplobacilli called Moraxella Lacunata.


Etiology – Caused by Staphylococci and more typically by Moraxella Lacunata.
Pathogenesis
Moraxella Lacunata is a gram-negative diplobacilli, pair of large ,thick rods placed end to end which stain well with basic stains.
It produces proteolytic ferment, which acts by macerating epithelium. The incubation period is usually 4 days . The organisms are resistant to drying .

Pathogenesis
Moraxella is also found in nasal tract of healthy persons and often present in the nasal discharge of patients of angular conjunctivitis.
Symptoms
Redness, discomfort, frequent blinking, sharp pricking pain and mucopurulent discharge.

Incubation period : Symptoms develop after 4 days of exposure.
Signs
► Congestion limited to intermarginal strip at inner and outer canthi and neighboring bulbar conjunctiva. Excoriation of skin at inner and outer palpabral angles
► Complications- Chronic conjunctivitis, Blepheritis, corneal ulcer (marginal or central associated with hypopyon)
► Attack does not confer immunity, and relapses may occur.
Treatment
Tetracycline eye ointment
Eye drops containing Zinc also beneficial, acts by inhibiting proteolytic ferment.

Acute inclusion Chlamydial Conjunctivitis

Its acute conjunctival inflammation caused by Chlamydial infection (Serotype D-K) characterized by inclusion bodies.


► Etiology – Caused by Chlamydia Trachomatis (serotype D-K)
► Pathogenesis – characterized by inclusion bodies identical with those occurring in Trachoma.
Spread
Spread by sexual transmission from genital reservoir (urethritis/ cervicitis). Common mode of infection is through swimming pool water (swimming pool conjunctivitis)
May also be transmitted by mothers to newborn.
Clinically Features
► Incubation period- Usually 5- 10 days
► Symptoms- Acute onset , redness, foreign body sensation, intolerance to light , discharge
► Signs – Conjunctival hyperaemia, Follicles, more prominent in lower lid, papillary hyperplasia, superficial punctate keratitis, peripheral vascularization (pannus)

Chlamydia Trachomatis is also responsible for genital and oculogenital infections. Associations have been reported with non-gonococcal and post gonococcal urethirits, cervicitis and infections of genital tract.
Arthiritis is also seen in these cases.
Diagnosis
Direct immuno-fluorescent stain of smear using monoclonal antibodies. Test has 100% sensitivity and 94% specificity. Urethral and cervical secretions should also be tested.
Other tests are immuno-sorbitant assay, Giemsa staining of conjunctival scrapping and McCoy cell cultures.
Treatment
Heals spontaneously in 3 -12 months if left untreated.
Systemic – Tetracycline 250 mgm qid for 2 weeks, Doxycycline 100 mg twice for two weeks, Erythromycin 250 mg twice for two weeks, Azithromycin 1 Gm single dose and Ofloxacin 300 mg twice for 7 days.
Locally – Tetracycline or Erythromycin eye ointment twice daily for two weeks.

Ophthalmia Neonatorum

Conjunctival inflammation associated with mucoid, mucopurulent or purulent discharge from one or both eyes during first month of life.

It’s a preventable disease in newborn babies caused by maternal infection, acquired at the time of birth.
Epidemiology
► Although its incidence has declined due decrease in incidence of Gonorrhoea and due effective prophylaxis and treatment , disease is still prevalent and remains a public health problem in communities with poor hygiene and limited access to proper health care.
Etiology
► Neisseria Gonorrhoeae, Streptococcus Pneumoniae, Staphylococcus etc.
► Chlamydial Trachomatis, Chalmydial Oculogenitalis
► Chemical Conjunctivitis due to Silver Nitrate 1or 2% (used as Crede’s method)

Neisseria Gonorrhoeae
► Manifest within 48Hrs of birth
► Discharge is Mucopurulent to begin with, soon becomes purulent
► Both eyes are affected, one more severe than other.
► Conjunctiva is intensely inflamed with severe congestion, chemosis, thick yellow discharge, cornea is seen at bottom of a crater like pit.
Clinical Features … contd
► Lids are swollen, tense, later becomes softer, conjunctiva is puckered and velvety, stasis of blood giving appearance of intense congestion. Pseudomembrane formation.
► Discharge is pus, serum and blood.
► Corneal complications- corneal ulcer with its complications is common


Complications
► Corneal Ulcer : Oval ulcer, just below the centre of cornea, rarely oval marginal ulcer, progressive ulcer resulting in – perforation of corneal ulcer, prolapse of uveal tissue, purulent uveitis, prolapse of lens, prolapse of vitreous.
► Scarring of cornea, adherent leucoma, anterior staphyloma, anterior capsular cataract, panophthalmitis.
Complications… Contd
► Non development of fixation due to corneal opacity during first 3 weeks.
► Nystagmus due to non-development of macular fixation



Chlamydia Trachomatis Inclusion Conjunctivitis
► Develop usually over one week after birth
► Its venereal infection derived from cervix or urethra
► Less severe than Gonococcal infection
Other Bacterial Infections
► Manifest usually 48-72 hrs after birth

Herpes Simplex Infection

presents 5-7 days after birth
Chemical Toxicity
► Seen within few hours after prophylactic treatment with Silver Nitrate Solution 1 or 2% (Crede’s Method) applied for prophylaxis of Gonococcal infection
Diagnosis
► Grams staining
► Giemsa staining of epithelial scraping
► Chlamydial Immunofluorescent antibody test
► Viral and Bacterial culture sensitivity test
Differential Diagnosis
► Differential Diagnosis of discharge in child within the first month of life –
Congenital blockade of nasolacrimal duct
Acute Dacryocystitis
Congenital Glaucoma.


Treatment
Prophylaxis
In cases of any suspicious vaginal discharge in antenatal period should be treated meticulously
New born babies closed lids should be cleaned properly
Prophylactic used of 1% Tetracycline eye ointment in babies eyes
► Close observation during first week
► Prophylactic use of Penicillin or other antibiotic drops
Is on lines of Gonorrheoeal Conjunctivitis
Child is hospitalized and treated with Gentamicin eye drops 0.3% and Bacitracin eye ointment. Atropine is added if corneal involvement is there.
► N. Gonorrhoeae is treated with single I.M. dose of Ceftriaxone 125 mgm or Cefotaxime 50 mgm /kg, IV or IM in three divided dosage. Or Kanamycin 25 mgm /kg body weight.
► Local treatment consists of Gentamicin eye drops 0.3% in both eyes repeated in 15 min and then after every feed (2hrly) for 3 days.
Treatment …. Contd.
► Chlamydial Infection is treated with Erythromycin ethylsuccinate 50mgm /kg daily in 4 divided dosage before feed for 2-3 weeks or Azithromycin 10 mgm/kg body weight for 3 days
► Local treatment Chlortetracycline 1% or Erythromycin eye ointment after feeds.
► Parents should be treated for genital infection.

TRACHOMA

► At one time known as Egyptian Ophthalmia, endemic in middle east during prehistoric period, spread far and wide in Europe by French Army during Napoleonic wars. Trachoma is still a leading cause of preventable blindness world wide, third after Cataract and Glaucoma.

► Approximately 1/5th population of world is affected by Trachoma, amounting to 150 million people across the 48 countries . It is estimated that 6 million people are blind in both eyes. It still remains a significant problem in areas of Africa, South East Asia, the Middle East and Australia.


► Trachoma is caused by Chlamydia Trachomatis immunotypes / serotypes A,B and C. Chlamydia organisms shares properties of both, bacteria and virus. It is an obligatory intracellular bacteria.
Predisposing Factors
► Unhygienic and crowded surroundings
► Low socio-economic status
► Lack of water
► No race is exempted

Transmission

► Direct transmission from eye to eye through discharge
► Through fomites, flies and eye cosmetics
► Disease is contagious in acute phase
► Incubation period is 5 -12 days

Clinical Features

Symptoms
► Pure Trachoma is usually asymptomatic condition or there may be minimum symptoms
► There may be redness, irritation, discharge, foreign body sensation, lacrimation and photophobia
► Systemic symptoms like Rhinitis, pre auricular lymphadenopathy and upper respiratory infection may be present

► Onset is usually sub-acute, but may occur as acute when infection is massive as occurs in experimental or accidental or clinical infection


Signs
► Primary infection is Epithelial, involving conjunctiva and cornea characterized by:
Conjunctival congestion, upper tarsal Conjunctiva appears red and velvety, later may become uniformly thick like jelly.
Follicles (in lower fornix, upper fornix, upper margin of Tarsus, Caruncle, Plica, Palpabral Conjunctiva, Bulbar Conjunctiva near limbus)



► Follicles are small (0.5 mm in diameter) but may measure upto 5 mm in diameter.
► Invasion of lacrimal passages may also be there.
► Papillary enlargement.


Corneal Signs
► Superficial Keratitis in upper part
► Epithelial erosion, extending deep into stroma
► Pannus and Lymphoid infiltration with vascularization seen in upper half, tending to spread towards the centre . Whole cornea may be covered with pannus . Vassels are superficial between epithelium and Bowman’s membrane.
Corneal Signs.. Contd


► Stages of Pannus:
Progressive (infiltration is beyond vascularization)
Regressive (infiltration has receded and vessels are ahead of infiltration)
* Corneal ulcer , Chronic, occurs anywhere but commonest at the advancing edge of pannus, are shallow ulcer with little infiltration.


Pathology
► Chlamydia Trachomatis is seen in conjunctival scarping in the form of colonies in the epithelial cells as Halberstaedter Prowazek inclusion bodies.
► Inclusion bodies are composed of innumerable elementary bodies embedded in carbohydrate matrix.

Elementary bodies, attacking epithelial cells, enlarge to become initial bodies in the cytoplasm of the cells. Numerous initial bodies, in cells divide to form innumerable elementary bodies embedded in carbohydrate matrix. The nucleus of cell is displaced , degenerates and cell burst to release elementary bodies, to attack new cells.

► In TF and TI stages, polymorphonuclear cell infiltration is noticed and later on lymphocytes are dominant.
► Lymphocytic infiltration in Adenoid layer.
► Aggregation of lymphocyte without capsule forms follicles
► Follicles shows necrosis and contains large multinucleated Laber cells.
► An attack confers little immunity

► Trachomatous infiltration may spread deep into subepithelial tissues of the palpabral conjunctiva and even invade the tarsal plate
► Fibrosis around follicles giving rise to cicatricial bands (Arlt line in superior tarsus)

Diagnosis
► Culture of Chlamydia Trachomatis in irradiated McCoy cells
► Micro-Immunofluorescence (Micro-IF) test
► Monoclonal Direct Antibody test
► Demonstration of inclusion bodies in conjunctival epithelial scrapping


Clinical Diagnosis
► Is based on identification of at least two of the following signs:
1. Follicles
2. Epithelial Keratitis
3. Pannus
4. Limbal Follicles/ Herbert Pits
5. Typical Trachomatous Scarring (Stellate or Linear Scarring of upper tarsus)
Diagnosis is confirmed by demonstration of inclusion bodies
Trachoma Classification
• MacCallan’s Classification
Stage I – Immature follicles on tarsus , SPK and Pannus
Stage II – Florid Superior Tarsal follicular reaction with mature follicles or marked papillary hyperplasia , pannus, Limbal follicles, superior corneal epithelial infiltrates
MacCallan Classification
Stage –III : Signs of stage II with Cicatrization
Stage – IV Cicatrization and its sequelae
WHO Classification
Stage – I Trachomatous Infiltration – Follicular (TF) 5 or more follicles of at least 0.5 mm in diameter. If treated properly, patient recovers with no or minimal scarring
Stage -II Trachomatous Infiltartion – Intense (TI) : Follicles, papillae, thickening of Conjunctiva obscuring >50% conjunctival blood vessels. Severe infection with high risk of complication.
WHO Classification… Contd
Stage – III : Trachomatous scarring (TS)
Stage – IV : Trachomatous Trichiasis (TT)
Stage - V : Corneal Opacity (CO) corneal opacity occupying pupillary area
Sequelae of Trachoma
► Distortion of lids
► Trachomatous Ptosis
► Entropion
► Trichiasis
► Tylosis

Late Complications
► Sever dry eye
► Keratitis
► Corneal scarring
► Fibrovascular pannus
► Corneal Bacterial Superinfection

Treatment
► Tetracycline, Erythromycin, Rifampicin and Sulphonamides are effective orally
► Topical Erythromycin and Tetracycline ointment
Treatment … contd
Treatment of TF Stage – Topical Erythromycin twice for 6 weeks
Oral Azithromycin 1 Gm single dose
Tetracycline 250 mgm qid for 2 weeks
Doxycycline 100 mgm twice for 2 weeks


Treatment of TI Stage : same as TF stage

Treatment of TS stage : Ocular lubricants

Treatment of TT Stage : Epilation , tarsal rotation , Radiofrequency/ diathermy or electrolysis epilation . Or Cryotherapy

► Treatment of CO Stage : After treatment of lid deformities LKP or PKP, depending on depth of corneal opacity

WHO’s GET 2020
► WHO in 1997 started Global Elimination of Trachoma by 2020 programme called WHO GET 2020 programme, under which ‘SAFE’ strategy has been adopted.
► S : Surgery for entropion/ trichiasis
► A : Antibiotics for infectious trachoma
► F : Facial cleanliness to reduce transmission
► E : Environmental improvement
Trachoma Control Programme
► Tetracycline eye ointment 1% twice daily on 5 consecutive days every month for 12 months
► Mass treatment should be annually in endemic zones ( <35% children are affected) and Biannually in hyperendemic zones (>50% children are affected)

Ophthalmia Nodosa

Nodular conjunctivitis, resembling tuberculosis, due to irritation caused by caterpillar hairs.

Small semitranslucent pinkish, reddish or pale gray nodules formed in bulbar, palpabral conjunctiva, cornea and rarely in iris tissue.

Hairs are surrounded by giant cells and lymphocytes.

Treatment: Symptomatic, Local Steroids in selected cases, under supervision and excision of conjunctival nodules.

Chronic Non-specific Conjunctivitis

Is a clinical condition resulting from continuation of acute conjunctivitis or due to variety of etiological factors, characterized by chronic redness in one or both eyes with persistence of annoying symptoms.
Etiology
1. Exposure to Chronic irritants like, smoke, dust, heat, poor quality air, late hours, alcohol abuse.
2. Hypersensitivity to allergen.
3. Concretions, misdirected eyelash(es), Dacryocystitis , Chronic Rhinitis, sinusitis, blepharitis, seborrhoea , dandruff etc
4. Unilateral Conjunctivitis foreign body retained in conjunctiva or Dacryocystitis
Symptoms
* Discomfort, burning, grittyness, especially in the evening when eyes becomes red and eyelid margins feel hot and dry.
* Difficulty in keeping eyes open.
* Increased secretions, mucoid or mucopurulent discharge, lids may stick together in the morning on waking up. together

Signs
► Hyperaemic lid margins
► Conjunctival Congestion particularly in lower fornix
► Papillary hyperplasia

Treatment
► Elimination of cause
► Treatment of infection foci in nose and upper respiratory passage
► Treatment of conjunctival infection with appropriate antibiotic
► Treatment of meibomian gland abnormality by mechanical expression and warm compression.
Allergic Conjunctivitis
► Allergy or Hypersensitivity is a state which is commonly regarded as an unfortunate by product of the process of immunity whereby the tissues react by an abnormal and injurious response to foreign substance (allergens)
Allergy
► Two types of reactions:
a. Immediate and
b. Delayed Hypersensitivity

Immediate Hypersensitivity
► Ten days after initial exposure to foreign protein, anaphylactic reaction follows after second exposure to same protein. Characterized by circulating antibodies.
Delayed Hypersensitivity
► There are no circulating humoral antibodies of anykind. The sensitization is the property of the cells themselves. The hypersensitivity is caused by prior contact of the tissue with a protein and seems to be due to the development of sessile antibodies on or within the cells so that when they are re-exposed to the same antigen a reaction causing cellular damage develops which may even involve necrosis.
Delayed Hypersensitivity
► This reaction does not occur immediately and reach its maximum only after 24 to 72 hours.
► Typical example is tuberculin reaction.
Autosensitization
► In this case individual’s own tissue protein are altered and thus rendered “foreign” by a pathogenic agent, either bacterial or a chemical acting as a haptene, repeated contacts may result in hypersensitivity reaction eg Sulphonamide allergy and autosensitization induced by the haemolytic Streptococcus.
Physical Allergy
► Certain individuals react to physical agents such as heat,cold, light or mechnical irritation by a typical hypersensitive response often of urticarial type. Some individuals are hypersensitive to light of a certain wave-band.
Physical Allergy
► The reaction is due to auto-antigen liberated in the tissues either due to alteration of their specificity or due to their capability of reacting with antibody only under the physical condition created by the stimulus.
Types of Allergic Conjunctivitis

• Simple Allergic Conjunctivitis

A. Immediate Anaphylactic (Hay fever) type mediated by circulating antibody
B. Delayed Type
(i) Contact Dermatoconjunctivitis due to local chemicals
(ii) Microbial Allergic Conjunctivitis
(iii) Keratoconjunctivitis Medicamentosa due to ingestion of drugs like arsenic and gold.
Types of Allergic Conjunctivitis
2. Interstitial Allergic Conjunctivitis
A. Phlyctenular Keratoconjunctivitis – Delayed reaction- Endogenous microbial allergy.
B. Vernal Catarrh – Allergic disease of immediate type – an exogenous allergy.
Acute or Sub-acute Allergic Catarrhal Conjunctivitis
► Is an allergic condition characterized by hyperaemia which not as intense as found in bacterial conjunctivitis, accompanied by watery secretion containing eosinophils. Itching is a prominent symptom.
► Etiology: Exogenous allergen (contact with animals, pollens, flower, chemicals, cosmetics, dye, medications etc. and sometimes bacterial protein of endogenous nature, the most common being Staphylococcal infection.

► Symptoms: Itching, watering, redness, swelling of lids and there may symptoms of hay fever
► Signs: Conjunctival Congestion, edema of lids may be there, watery discharge, presence of eosinophils and elevated IgE level.
Treatment
• Removal of allergen from environment
• Astringent lotion, adrenalin 1:10000, antihistaminic drops (chlorpheniramine), mast cell stabilizers (sodium cromoglycate, olopatadine, ketotifen etc)
• Short course corticosteroid drops
• Topical 2% sodium cromoglycate drops.
Vernal Keratoconjunctivitis (VKC)
► It is a chronic , bilateral conjunctival inflammatory condition found in individuals predisposed by their atopic background. It is recurrent, interstitial inflammation of the conjunctiva of periodic seasonal incidence, self limiting disease/ condition usually due to exogenous allergens.

► Characterized by flat topped papillae usually on the tarsal conjunctiva resembling cobble stones in appearance , a gelatenous hypertrophy of the limbal conjunctiva, either discrete or confluent, and a distinctive type of keratitis , associated with itching , redness of the eyes lacrimation and mucinous or lardaceous discharge usually containing eosinophils

Epidemiology
► Sporadically occuring with a wide geographical incidence. Its more common in India and the tropics than in U.K. Colored races are particularly prone to limbal form of disease.
► It is essentially a disease of yoth occuring most frequently between ages of 6 and 20 years.

► Sex incidence – Very high percentage of cases are seen in males.
► Family History of allergy is found in 40 – 60 % cases.
Etiology
► Three theories
1. Due to action of physical factors (as heat, humidity and light)
2. Disorder of the endocrine glands associated with vagotonic state
3. manifestation of an allergic condition. Most affected people show a marked hypersensitivity to a variety of antigens (pollen, animal inhalants, ingestants etc)
Symptoms
► Severe itching and photophobia, foreign body sensation, ptosis, thick mucous discharge, blepharospasm, burning, typical stringy discharge .
► Discharge is scanty, thick, ropy and lardaceous, dirt white or cream colored.
Signs
► The signs are confined to conjunctiva and cornea; the skin of the lids are not involved.
► Types
 Palpabral form
 Limbal/ Bulbar form
 Mixed type

Palpabral VKC

Conjunctiva develops a papillary response in the upper tarsal conjunctiva and at the limbus. Conjunctiva is congested later on becomes milky.
Tarsal papillae are discrete larger than 1 mm in diameter, flat tops , they are cobblestone in appearance.
Limbal / Bulbar Form
► In limbal or bulbar form the first change is usually a thickening, broadening and opacification of the limbus which overrides the corneal periphery as a semitranslucent hood. This develop mostly at the upper margin of the cornea
► Limbal Papillae tend to be gelatinous and confluent

► Limbal Nodules – Their most common site is in the palpabral aperture, nasally and temporally. In the raised mass, whitish Horner- Trantas’s spots may occur at any stage. Horner Trantas dots are collection of epithelial cells and eosinophils.
► These changes may lead to superficial corneal vascularization.
Corneal Findings
► Punctate Epithelial Keratitis
► Horizontally oval ulcer in upper part of cornea called Shield Ulcer
► Peripheral superficial gray white deposition termed Pseudogeronton.
Pathogenesis
► Biopsy of tarsal papilla in VKC reveals that epithelium contain large number of mast cells and eosinophils. Substantia properia contains elevated number of mast cells, also contains CD4 + T cells. Mast cells contains basic fibroblast growth factor
► Cytology shows more eosinophils and neutrophils, IgE and IgG have been isolated from tears. Histamins and trytase are elevated in tears
► Protein deposition diffusely in conjunctiva

► The flat-topped nodules are hard , and consist chiefly of dense fibrous tissue , but the epithelium over them is thickened , giving rise to the milky hue. Histologically they are hypertrophied papillae, not follicle. Eosinophils are present in them in great numbers. In addition , infiltration with lymphocytes, plasma cells , macrophages, basophils and eosinophils may also be seen.

Diagnosis
► History
► Clinical findings (young boys living in warm climates presenting with intense photophobia, ptosis and gaint papillae)


TREATMENT
• Avoidance of allergen
• Local Treatment
a. Steroids – Patients with significant seasonal exacerbation , a short term high dose pulse regimen of topical steroid is necessary. Dexamethasone 0.1% or Prednisolon Phosphate 1% , 8 times for one week brings excellent result, tapered rapidly.

b. Mast Cell stabilizer: Cromolyn sodium, a mast cell stabilizer or a dualo acting drug such as Olopatidine, Ketotifen or Azelastine (mast cell stabilization and antihistamine)
c. Topical Cyclosporin-A (0.05%) twice daily, it decreases the release of interlukin-2, reduces expansion of T cell clones.

Treatment of Corneal Shield Ulcer:
Antibiotic- steroid ointment and occlusion. If plaque forms – superficial keratectomy

Phototherapeutic Keratectomy and Keratectomy with amniotic membrane graft placement.

Surgical Treatment
Cryablation of upper tarsal cobble stones – but may lead to lid and tear film abnormalities.

Injection of short term or long term acting steroids into tarsal papilla has been shown effective in reducing their size.

3. Systemic Treatment:
1. Non sedating antihistaminic
2. Oral Aspirin (high dose of 2400 mgm daily)

4. Climatotherapy