This course is designed for optometry bachelor entrance students

1. Anatomy of conjunctiva: blood supply
& nerve supply
anatomy of sclera & episclera: blood
supply & nerve supply

2. PRESENTATION LAYOUT
1. Embryology
2. Anatomy of conjunctiva
➢Parts of conjunctiva
➢Histology of conjunctiva
➢Conjunctival glands
3. Blood supply and nerve supply
4. Clinical correlation
5. Anatomy of sclera and episclera
6. Inflammation of sclera and episclera
7. refrences

3. embryology

4. Sclera is developed from the fibrous layer of
mesenchyme surrounding the optic cup
(corresponding to dura of CNS)

5. ➢ Conjunctiva develops from
the ectoderm lining the
lids and covering the
globe.
➢ Conjunctival glands
develop as growth of the
basal cells of upper
conjunctival fornix.
➢ Fewer glands develop from
the lower fornix.

6. ANATOMY OF conjunctiva
❖ Translucent mucous membrane lining the posterior
surface of eyelids and anterior surface of eye
❖Joins the eyeball to the eyelids
❖Stretches from lid margin to limbus with conjuctival
sac in between

7. PARTS OF CONJUCTIVA
Conjunctiva
Palpebral
Marginal
Tarsal
Orbital
Bulbular
Limbal
Scleral
Conjunctival Fornix
Superior
Inferior
Lateral
Medial

9. PALPEBRAL CONJUCTIVA
❑ Extends from lid margin to 2 mm on the back of the
lid upto a shallow groove called sulcus subtarsalis
❑ Common site for lodgement of conjuctival foreign
body
❑ It is actually a transitional zone between skin and
the conjunctiva proper

10. Upper tarsal Lower Tarsal
➢ Firmly adherent to whole
tarsal plate
➢ Adherent only to half
width of tarsus

11. ❑ Lies between tarsal conjunctiva and fornix

12. BULBAR CONJUCTIVA
❖ Thin
➢ Seperated from anterior sclera by episcleral tissue and
tenon’s capsule
❖ Transparent
❖ Mobile
❖ separated from anterior sclera by episcleral tissue
and tenon’s capsule

13. ❑ 3 mm ridge of bulbar conjuctiva
around cornea
❑ the conjunctiva, tenon’s capsule
and the episcleral tissue are
fused

14. Conjuctival fornix
➢Continuous circular cul-de sac broken
only on medial side by caruncle and plica
semilunaris
➢Joins bulbar conjuctiva with palpebral
conjuctiva
➢ Broken on its medial site by caruncle
and the plica semilunaris

15. ➢ extends from upper border of the tarsal plate to
10mm above the upper limbus, reaches superior
orbital margin
➢ Superiorly attached to the fascial sheath of
the levator and superior rectus muscles
➢ Foreign body in superior fornix-double eversion

16. ➢ Extension - lower border of the lower tarsal
plate to 8mm from the lower limbus
➢ located near the inferior orbital margin
➢ Attached to extension of fascial sheath of the
inferior rectus and the inferior oblique muscle

17. ➢ Extends behind the equator of the eyeball
➢ 14 mm from the lateral limbus
➢ 5mm from the lateral canthus

18. ➢ Shallow cul-de-sac
➢ caruncle and plica semilunaris lies here in
the pool of tears called lacus lacrimalis

19. ➢ Crescentic fold of conjunctiva present in
medial canthus
➢ Vestigial structure
➢ Represents nictitating membrane of lower
animals

20. ➢ Small, pinkish mass in inner canthus medial to
plica semilunaris
➢ Piece of modified skin & has sweat glands,
sebaceous glands & hair follicles

23. HISTOLOGY OF CONJUCTIVA
❖3 histological layers
a. Epithelium
b. Adenoid layer
c. Fibrous layer

25. ❖ Epithelium
➢ Vary from region to region
➢ 5 layered non keratinised stratified squamous
epithelium
▪ Superficial : squamous cells
▪ Intermediate layers : polyhederal cells
▪ Deepest : cylindrical cells

26. ➢ 2 layered epithelium
❑ Upper eyelid :
o superficial layer cylindrical
cells
o deep layer cubical cells
❑ Lower eyelids:
3-4 layers of cells, from deep to superficial
o cubical cells
o polygonal cells
o elongated wedge-shaped cells
o cone shaped cells

27. 3- layered epithelium
➢superficial layer- cylindrical cells
➢middle layer - polyhedral cells
➢deep layer- cuboidal cells
➢ 8-10, stratified squamous epithelium
contains papillae : palisades of Vogt
• epithelium of palisade zone provides
germinative zone for the corneal epithelium

28. ❖ADENOID LAYER
❑ Fine connective tissue reticulum containing
lymphocytes
❑ Most developed in fornices
❑ Develops at 2-3 months of life
❑ Conjuctival inflammation in an infant does not
produce follicular reaction

29. FIBROUS LAYER
➢ Network of collagenous and elastic fibres
➢ Contains nerves and blood vessels
➢ Thicker than adenoid layer
➢ Thin at tarsal conjunctiva

30. CONJUCTIVAL GLANDS
❖On basis of types of secretion,
A. Mucin secreting glands
B. Accessory lacrimal glands

31. ➢ Unicellular mucous glands
➢ Present in conjunctiva except marginal
mucocutaneous junction and limbal conjunctiva
➢ Formed from basal layer of conjunctiva and
migrate towards the surface
➢ Cells destroyed after discharging their contents
➢ Density high in children and young adults

32. ➢ Not true glands
➢ Tubular structure containing few goblet cells
➢ Present in palpebral conjuctiva
➢ Found in limbal conjuctiva
➢ Presence controversial in humans

33. Function of mucin:
➢ Mucin lubricate and protects the epithelial cells
➢ Maintains tear film stability by lowering surface
tension
Importance
❑ Destruction of goblet cells occur in epithelium
xerosis (hypovitaminosis A)
❑ Number of goblet cells is increased in the
inflammatory condition.

34. o Lies in deep subconjunctival tissue
o Upper fornix:42
o Lower fornix:6-8
o Upper border of superior Tarsus: 2-5
o Lower border of inferior Tarsus:2

36. BLOOD SUPPLY OF CONJUCTIVA
❖ Peripheral arterial arcade of the eyelid
❖ Marginal arcade of the eyelid
❖ Anterior ciliary arteries

38. Palpebral conjunctiva & fornices –
❖ Branches from peripheral & marginal arterial
arcades of eyelids
Bulbar conjunctiva –
❖ Posterior conjunctival arteries
❖ Anterior conjunctival arteries- Branches of anterior
ciliary arteries
❖ Terminal branches of posterior conjuctival arteries
anastomose with anterior conjuctival arteries to
form pericorneal plexusus

39. ➢Into venous plexus of the eyelids
➢A circumconeal zone of veins drain into the
anterior ciliary veins
➢Ultimately into superior and inferior ophthalmic
veins

41. ➢Lateral side:
into preauricular lymph nodes
➢ Medial side:
into submandibular lymph nodes

43. ❖From ophthalmic division of TRIGEMINAL NERVE
o Long ciliary nerves-to circumcorneal zone
o Lacrimal nerves
o Infratrochlear nerves
o Supratrochlear nerves
o Frontal nerves-to the rest parts.

45. Clinical correlation
❖Inflammation of conjuctiva
❖Degenerative conditions of conjuctiva
❖Conjuctival tumors

46. ➢ Termed as ‘conjunctivitis’ -most common cause
of red eye

47. symptoms
➢ Redness
➢ Stickiness
➢ Foreign body sensation or grittiness
➢ Watering
➢ Burning sensation
➢ Dryness
➢ Itching

48. Rarely a growth BUT
❖ PAIN,PHOTOPHOBIA and BLURRED VISION
should get extra attention
o Are not typical features of a primary conjuctival
inflammatory response
o suggest underlying ocular or orbital disease process
including keratitis,uveitis,acute glaucoma and orbital
cellulitis

50. ➢ Dilatation of superficial conjuctival vessels

51. Conjunctival congestion Ciliary congestion
Mixed congestion Sub-conjunctival Haemorrhage.

53. ❖ Consists of tears , mucus , inflammatory
cells , desquamated epithelial cells ,
fibrin and bacteria
❖Composed of exudates that has filtered
from the conjunctival epithelium from
the dilated blood vessels

54. ❖ Due to hyperplasia of normal vascular system,
appear as elevated polygonal hyperemic areas

55. ❖ Due to localized aggregation of lymphocytes in
the subeithelial adenoid layer
❖ Not seen in babies before 2-3 months of age ????

57. True Membrane Pseudo membrane
➢ Involve superficial
layers of conj.
epithelium
➢ Coagulated exudates
adherent to inflamed
conj. epithelium
➢ Attempt to remove-
Bleeding & tearing of
epithelium
➢ Can be easily peeled
off
➢ Diphtheria &
➢ Strep. pyogenes
➢ Infection
➢ Severe conjunctival
infections
Causes

58. ➢ white opaque
lines/patches under
tarsal conjuctiva
➢ conjunctiva becomes hard,
opaque and unwettable as
in Vit.A deficiency

59. ➢ edema of conjuctiva
due to exudation
from abnormally
permeable
capillaries
➢ blood collects under
conjuctiva due to
rupture of small
blood vessels

60. Feature Bacterial Viral Allergic Chlamydial
Congestion Marked Moderate Mild to
moderate
moderate
Chemosis ++ +- ++ +-
SH +- +- - -
Discharge Purulent/mu
copurulent
watery Ropy/watery mucopurulen
t
Papillae +- - ++ +-
Follicles - + - ++
Pseudomem
brane
+- +- - -
Preauricular
lymphnodes
+ ++ - +-

61. DEGENERATVE CONDITIONS
➢ Physiologic decomposition of tissue
elements and deterioration of tissue
functions
➢ A common condition
➢ Has little effect on vision and ocular
functions

62. ComMon ocular
degenerative conditions
A. PINGUECULA
B. PTERYGIUM
C. CONCRETIONS

63. ➢Yellowish white patch on bulbar conjuctiva near
limbus
➢Degeneration of substantia propria of conjuctiva
➢Predisposing factors: aging,exposure to strong
sunlight,wind and dust

64. ➢ Affects nasal side first
➢ Apex is always away from cornea
➢ Precursor of pterygium

65. ❖Wing-shaped fold of
conjunctiva encroaching
upon cornea
❖Destroys corneal epithelium,
bowman’s layer and
superficial stroma
❖Symptoms: FB sensation,
defective vision and diplopia

67. ❑ Small, yellow white deposits
in the palpebral conjuctiva
❑ Epithelial inclusion cysts
filled with epithelial and
keratin debris
❑ Usually asymptomatic or
c/o FB sensation

68. Conjuctival tumors
Tisssue of origin Benign Malignant
Epithelial surface papilloma Squamous cell carcinoma
glandular adenoma adenocarcinoma
Connective tissue fibroma sarcoma
vascular hemangioma angiosarcoma
Reticular system Lymphoid hyperplasia lymphosarcoma
Pigment cells naevus melanoma

69. papilloma
❑Pedunculated
➢ Presents in childhood
➢ Infection with HPV
➢ Multiple or bilateral
❑ Sessile
➢ Presents in middle age
➢ Not by infection
➢ Single or unilateral

70. Squamous cell carcinoma
➢Arises from intraepithelial
neoplasia or de novo
➢ rarely metastasizes
Progression
Signs
➢ Presents in late adulthood
➢ Frequently juxtalimbal
➢ Slow-growing
➢ May spread extensively

71. nevus
➢ Present in 1st two
decades
➢ Sharply demarcated and
slightly elevated
➢ 30% are almost non
pigmented

72. Conjunctival melanoma
From naevus
❖ Very rare
❖ Sudden increase in size
or pigmentation
Primary
❖ Solitary nodule
❖ Frequently juxtalimbal
but may be anywhere

73. Kaposi’s sarcoma
➢Affects persons with AIDS
➢Vascular,slow-growing tumor
of low maliganancy
➢Very sensitive to radiotherapy
➢Most frequently in inferior
fornix

74. Epibulbar dermoid
➢ Signs
o Congenital
o Smooth, firmly fixed to cornea
o Usually at limbus
➢ Association
o Occasionally
Goldenhar
syndrome

75. lipodermoid
❖Congenital
❖Soft, movable
subconjuctival mass
❖Mostly present at outer
canthus

76. Anatomy of sclera
➢ Dense connective tissue composed of collagen
bundles of varying bundles of varying diameter
➢ Sclera forms the posterior 5/6th part of globe
➢ Opaque appearance: less uniform orientation
of collagen fibers

77. ➢ Whole outer surface is covered by Tenon's
capsule.
➢Anterior part is covered by bulbar
conjunctiva
➢ Inner surface lies in contact with choroid
with a potential suprachoroidal space in
between.
➢Thickness of sclera varies considerably in
different individuals and with the age of
the person.

78. Special regions of sclera
1. Scleral sulcus:
➢It is furrow on the inner surface of the anterior most
point of the sclera near limbus
➢It houses schlemm’s canal
2. Scleral spur:
➢Lies deep to schlemm’s canal
➢Appear wedge shaped
➢Corneoscleral part of trabecular meshwork extends
from the scleral spur to schwalbe’s line
➢Meriodinal fibres of ciliary muscle are attached to
scleral spur

79. 3. Lamina cribrosa:
➢It is a sieve-like sclera from which the fibres of
the optic nerve pass.
➢When IOP is increased for a prolonged period
of time, such as in POAG, the lamina cribrosa
gradually increases in posterior curvature

80. Apertures:
Sclera is pierced by three sets of apertures
1. Posterior apertures are situated around the
optic nerve and transmit long and short ciliary
nerves and vessels
2. Middle apertures (four in number) are situated
slightly posterior to the equator; through these
pass the four vortex veins (vena verticosae).
3. Anterior apertures are situated 3 to 4 mm
away from the limbus. Anterior ciliary vessels
pass through these apertures.

82. Microscopic structure:
Histologically, sclera consists of following three
layers:
❑Episcleral tissue
➢It is a thin, dense vascularised layer of
connective tissue which covers the sclera
proper.
➢Fine fibroblasts, macrophages and
lymphocytes are also present in this layer.

83. ❑ Sclera proper
➢ It is an avascular structure which consists
of dense bundles of collagen fibres.
➢ The bands of collagen tissue cross each
other in all directions.

84. ❑ Lamina fusca:
➢ It is the innermost part of sclera which
blends with suprachoroidal and
supraciliary laminae of the uveal tract.
➢ It is brownish in colour owing to the
presence of pigmented cells.

85. ❖Nerve supply:
➢Sclera is supplied by branches from the
long ciliary nerves which pierce it 2-4 mm
from the limbus to form a plexus.

86. Blood Supply:

87. Inflammation of sclera and
episclera
Normal Episcleritis Scleritis
➢ Radial superficial
episcleral vessels
➢ Deep vascular
plexus adjacent to
sclera
➢ Maximal
congestion of
episcleral vessels
➢ Maximal
congestion of deep
vascular plexus
➢ Slight congestion
of episcleral
vessels

91. a

92. References