Problems of Conjunctiva

Conjunctiva is best examined with a torch. Note the color. Look for any edema (chemosis), hemorrhages, pigmentation. It may also occur in scurvy, thrombocytopenia, injury or even in malaria.

Chemosis. Edema of conjunctiva may be due to orbital cellulitis, nephritis, urticaria, angioneurotic edema or cavernous sinus thrombosis.

Pigmentation. Vitamin A deficiency causes conjunctival xerosis (manifesting as dryness and wrinkling) and triangular white dry patches on the outer and inner sides of the cornea (Bitot’s spots). Wedge shaped brownish lesions are seen in chronic non-neuronopathic form of Gaucher’s disease while Pingueculae (whitish yellow elevated lesion on bulbar conjunctiva) are characteristic of the adult type of the disease.

Deposits. Deposits of cystine crystals in the conjunctiva are seen in the infantile variety of cystinosis. Surface nodules over conjunctiva may be seen in tuberculosis, leprosy and syphilis. Conjunctival neurofibromas are found in neurofibromatosis.

Inflammation (conjunctivitis)

Conjunctivitis may be observed as a part of generalized viral (measles, adenovirus) or bacterial (membranous conjunctivitis of diphtheria) infections. It may at times be an allergic manifestation such as (i) endogenous i.e., phlyctenular conjunctivitis of tuberculosis and streptococcal infection and (ii) exogenous i.e., vernal (allergic) conjunctivitis associated with eosinophilia. Conjunctivitis may be a component of Reiter’s disease (arthritis, urethritis, conjunctivitis). Pseudomembranous conjunctivitis occurs characteristically in Steven-Johnson syndrome.

Problems of Cornea

Cornea should be examined with a focussed light and not a diffuse one (such as a pen torch). Measure the size. Cornea has a diameter of 10 mm at birth and achieves the adult size of 12 mm by the end of second year of life. Corneal diameter of more than 13 mm is known as megalocornea. It is observed in Marfan’s syndrome and osteogenesis imperfecta.

Note down any corneal haze, opacities, pigmentations, scarring or ulceration. Kayser Fleischer rings, colored gray green or golden brown are located round the periphery of cornea in Wilson’s disease.

Conical cornea (keratoconus) in which cornea is thin near the center and progressively bulges forwards is a feature ©f Down’s syndrome, Marfan’s syndrome and osteogenesis imperfecta.

Opacities and pigmentation

Haze. Corneal haze at birth or early infancy may be due to congenital anomalies, birth injury or metabolic disorders including mucopolysaccharidosis, glycogen storage disease and lipidosis. Full fledged opacities are observed in mucopolysaccharidosis and glycogen storage disease.

This type of keratitis may also develop in Riley-Day syndrome.

Phlyctenular keratitis. Corneal phlycten may be a manifestation of an allergic reaction to tubercular protein. In phlycten, a leash of capillaries is seen leading from the scleral conjunctiva towards the limbus or over the cornea.

Interstitial keratitis. Congenital syphilis causes inflammation of corneal stroma producing interstitial keratitis. Corneal opacities develop and generally remain as permanent stigmata of the disease. Interstitial keratitis may also follow lesions due to tuberculosis or leprosy.

Problems of Scleria

Color
Sclera becomes yellow in jaundice. Blue sclera is observed in Marfan’s syndrome, osteogenesis imperfecta and cutis hyperelastica. Blackish discoloration of sclera is due to accumulation of homogentisic acid in alcaptonuria (ochronosis).
Look for any infection. Superficial infection (episcleritis) presents as raised congested nodules at the sclera around the cornea while deep infection (scleritis) is characterized by dusky ciliary congestion and opacification of cornea at the periphery.
Episcleritis occurs as an allergic reaction to tuberculosis or streptococcal infection. Scleritis is associated with connective tissue disorders such as polyarteritis nodosa, SLE and rheumatoid arthritis.