THE CONJUNCTIVA AND ITS DISEASES

A five-year action plan to manage the growing number of deer has been published by the Welsh Government. The plan calls for a joint approach by public and private land owners and managers to control the impacts of wild deer on agriculture, forestry and vulnerable habitats.

It follows the development of a Strategy for Wild Deer Management in Wales by Forestry Commission Wales in partnership with the Welsh Government, Countryside Council for Wales (CCW) and the Deer Initiative.

The actions include:

• raising awareness of wild deer and their impacts (both positive and negative)

• developing effective methods for monitoring the presence of wild deer

• developing a more collaborative approach to managing wild deer

• promoting best practice for population management to ensure the welfare of the deer

• encouraging the reporting of road collisions involving deer.

The plan recognises that groups will need to work together if the Welsh Government is to achieve its vision that Wales benefits from its wild deer population in balance with the natural, social and economic environment.

John Griffiths, Minister for Environment and Sustainable Development, said, “The action plan stresses the importance of a co-ordinated approach to the management of wild deer involving private landowners, public bodies and non-governmental organisations.

“Only by working in partnership can many of the actions be delivered and I am pleased to see this reflected in the involvement – through the Deer Initiative Partnership in Wales – of a wide range of groups and organisations in the production of this plan.”

Although wild deer are not as numerous or widespread in Wales as in other parts of the UK, their numbers and spread are increasing along with their impact.

Deer are very adept at moving through the countryside and woodland expansion, coupled with management of other habitats, has encouraged their spread, increasing the need to control populations in order to maintain the balance of nature.

Deer can damage native flora, agricultural crops and trees, cause road traffic incidents and could potentially transmit TB.

Data collected by the CCW indicates that deer damage has been recorded in 22 Special Areas of Conservation, mainly in the Wye, Elwy and Elan Valleys.

Jane Rabagliati, chairman of the Deer Initiative, welcomed publication of the action plan.

She said, “Deer management must be undertaken at a landscape scale if it is to be effective, and this requires co-ordinated action. We look forward to supporting the next stage, which will be the building of a strong partnership to deliver it.”

The actions will be monitored annually and a progress report published. The plan will be reviewed and updated after five years in 2016.

NOTES

A total of 14.3 per cent of Wales is covered by woodlands. Of this, 38% (126,000 hectares/311,000 acres) is owned by the Welsh Government.

Forestry Commission Wales is the Welsh Government’s department of forestry and manages these woodlands on its behalf.

THE CONJUNCTIVA AND ITS DISEASES

Anatomy of the Conjunctiva

The conjunctiva covers all posterior surface of the eyelids, passes to the anterior surface of the eyeball and does not end near the edge of the cornea, and covers it in a little changed kind.

The fissure cavity between the posterior surface of the eyelids and anterior segment of the eyeball is called a conjunctival sac.

Three parts are distinguished in the conjunctiva: the first ond covers the back surface of the eyelids — the conjunctiva of carta lage (conjunctiva tarsi): the second one covers the front surface of the eyeball — the conjunctiva of the eyeball (conjunctiva butt hi); the third one unites all these parts — the conjunctiva of fori nix (conjunctiva fornicis), or a transitional fold.

Near the internal corner of the eye conjunctiva forms a verti-1 cal fold (plica semilunaris), that is the phylogenetic remnant of the third eyelid. Outside lacrimal caruncle is located.

The conjunctiva of cartilage and fornix is covered by a stratij fied cylinder epithelium, the conjunctiva of eyeball — stratified flat epithelium.

Glands of the conjunctiva. There are glass-shaped cells of cylin­der epithelium in a tarsal part of the conjunctiva, and also tubular deepenings of epithelium (hanov's glands), which product liquid.

Additional lacrimal glands, the ramified tubular glands, which are similar to lacrimal glands by their structure, take place, main­ly, near the upper edge of cartilage (Waldeier's glands), as well as fornix of the conjunctiva (Krause's glands).

Vessels of the conjunctiva. The conjunctiva of eyelids, transi­tional folds and, partly, the eyeball are supplied by the branches of aa. palpebralis mediales et laterales and arcus tarseus — poste­rior conjunctival arteries. The conjunctiva, that adjoins the limbus of the cornea, is supplied by anterior conjunctival vessels from the system of anterior ciliar arteries. Anterior and posterior conjunc­tival vessels anastomose with each other.

While examining the conjunctiva it is needed to pay attention at its color, transparency, smoothness, presence of excretions and scars. A normal conjunctiva is transparent, moistened, has a smooth surface. In a tarsal part meibomian glands are visible through it.

Diseases of the Conjunctiva

The diseases of the conjunctiva can be divided into the follow­ing groups:

1. Inflammatory diseases of the conjunctiva:

— inflammatory diseases of the conjunctiva of exogenous ori­gin: infectious conjunctivitis; conjunctivitis caused by physical and chemical factors; allergic conjunctivitis;

— inflammatory diseases of endogenous origiri; conjunctivitis in general diseases, autoallergic conjunctivitises.

— Degeneration of the conjunctiva.

— Tumours.

Inflammatory Diseases of the Conjunctiva (Conjunctivitis)

Conjunctivitis can have both acute and chronic clinical course. Acute conjunctivitis is characterised by sharp hyperemia of conjunc­tiva. In case of inflammation mucous membrane swells up, loses transparency and gets red because of vasodilatation. We should dis­tinguish a superficial, or the conjunctival injection, from a deep one, or pericorneal injection, that has an important practical value. The first one is caused by the disease of the conjunctiva, the second one

by the disease of the cornea, iris or ciliar body, that is those parts

of the eyeball, which are supplied by branches of anterior ciliar ves­sels. At inflammation of the conjunctiva the superficial vessels are dilatated. All the vessels net is easily removed together with the con­junctiva while replacing by a glass stick. The conjunctiva of the eye­ball has a bright red colour. The injection is mostly revealed in the parts which lie farther from the cornea, in the area of the fornix and eyelids, and as far as it approaches to the limbus it diminishes.

A transitional fold is swollen, in drawing of the lower eyelid or ectropion of the upper one it comes forward as a roller. The sur­face of conjunctiva can remain smooth, but sometimes it becomes rough, follicles appear.

At inflammation of mucous membrane there are always mucose-rous, mucopurulent or purulent discharge, which dries up on eye­lids and glues together their edges.

Subjectively a patient feels the presence of a foreign body, pres­sure and causalgia in the eye. A certain eyes sensitiveness to light is marked.

Acute epidemic conjunctivitis. This form of conjunctivitis is caused by the Koch — Weeks' bacillus. The disease has an epi­demic character and quite often envolves the whole families or or­ganized groups of people. The disease, as a rule, affects both eyes, thus the second eye falls ill in 1-2 days after the first one (a peri­od of incubation). Multiple small haemorrhages in a mucous mem­brane and hemosis of transitional folds especially of the inferior one are characteristic for this form of conjunctivitis. Acute epidemic conjunctivitis is often accompanied by the temperature reaction, headaches, insomnia.

Pneumococcal conjunctivitis. Acute conjunctivitis, more often is met in children, the causative agent is Frenkel — Weikselbaum's

pneumococc. Pellides which are easily taken off by moist cotton wool appear on the mucous membrane of eyelids. It is a so called pellicle conjunctivitis (conjunctivitis membranacea). Pneumococ­cal conjunctivitis can be mixed up with gonoblennorrhea or diph­theria of the eye, therefore bacteriological analysis is necessary.

Treatment of sharp conjunctivitis. First of all secretion should be carefully deleted, washing eyes once or twice a day by 1% so­lution of boric acid, by furacillinum solution or kalii permanganas 1:5000. Sulfonamides give good results, especially in conjunctivi­tis, caused be Koch — Wicks' bacillus: sulfacylum solubile is used each 2 hours as powder or 30% solution. In severe forms of the disease sulfonamides act quickly and effectively at internal use.

At the acute conjunctivitises, caused by the Koch — Wicks' ba­cillus, pneumococcus, stafilococcus, there are widely used appli­cation of 1% gentamycin solution as drops (each 2-3 hours), 0.25% laevomycetin solution 6-8 times a day, normax, tobrex — 4-5 times a day. Overnight in a conjunctival sac it is put 1%) tetracyclini or erythromycini ointment. Medical films with sulfonamides are ap­plied.

Angular conjunctivitis is caused by Morax — Axenfeld's diplo-bacillus, always bilateral, has an acute, even chronic clinical course. The characteristic reddening of lids edges of near external and in­ternal angles joins the catarrhal phenomena. Due to this sign the conjunctivitis got its name. Discharge are mostly insignificant, mu­cous and foamy. The strong itch is subjectively felt. Quite often there is the lesion of the cornea (regional keratitis).

Treatment. Zincum oxydum which as 0,5-1% solution is brought into a conjunctival sac 4-5 times per a day is a specific mean. The edges of eyelids are oiled by 1% zinc ointment. Treatment needs to be continued a few weeks more after all sickly phenomena dis­appeared, otherwise the relapse comes easily.

Gonoblennorrhea is inflammation of the conjunctiva, caused by the Neisser's gonococci, belongs to very serious diseases of eyes. As well as at gonorrheal urethritis, gonococci can spread outside a conjunctiva and cause generalisation of infection with all its own distinctive phenomena and complications. Therefore in gonoblen­norrhea gonitis, myositis, endocarditis, general indispositions and increase of temperature are possible.

The incubation period lasts for 1-2 days. First signs of the dis­ease: eyelids swell up strongly, become firm so that it is impossi­ble to open them. Discharge are serous bloody, like "meat slops" (the first stage is infiltration). On the 4th-5th day eyelids become softer, the amount of discharge increases, they become purulent. Yellow-green pus flows out from the eye in great amounts (the 2nd stage — suppuration). The conjunctiva is hyperemic, friable, swol­len, has a rough surface. On the 7th—10th day the oedema of con­junctiva diminishes gradually, wrinkles and pappilae appear on it (the third stage is pappilar hypertrophy). In 4-6 weeks conjuncti­va goes back to the normal condition.

The danger of gonoblennorrhea is predetermined by the damage of the cornea. The oedema of the conjunctiva of eyeball, squeezing the regional vascular net of the cornea, violates its supply. Epitheli­um of the cornea is covered by erosions, an ulcer can develop easi­ly. Limited infiltrate of grey color which soon becomes yellow ap­pears in the cornea, disintegrating, grows into an ulcer. Clinical course of ulcer is different. It can clear up and, replaced by connect­ing tissue, heals over, leaving after itself dimness of the cornea (mac­ula or leucoma). Spreading of ulcer into the deep can lead to perfo­ration of the cornea, that results in leukoma, adherent with an iris (leucoma cornea adhaerens). An ulcer, that takes all the cornea, ends with a complete leukoma (leucoma totale), and sometimes sta­phyloma formation (a stretched leukoma, that protrudes ahead). At distribution of infection inward the eye panophthalmia (pyoinflam-mation of all membranes of eyeball) can develop, which results in shrinkage of the eyeball — subatrophy of the eye.

Treatment of gonoblennorrheal conjunctivitis. At considerable purulent discharge frequent eyes washing is needed, solution of po­tassium is preferable. Sulfonamides (30% solution of silfacylum-natrium), penicillin, gentamicin each 2-3 hours are administered. A bandage on a sick eye is contraindicated. General treatment is conducted by a specialist in skin and veneral diseases.

Prophylaxis of gonoblennorrhea! conjunctivitis of newborns: the child after birth is wiped eyelids by the cotton wool moistened with 1% solution of boric acid, then instill 1-2 drops of 30% solution of silfacylum-natrium in each eye three times an hour.

Diphtherial inflammation of the conjunctiva is caused by cori-nobacteria of Lefler's diphtheria. It occurs mainly in children.

The disease begins with acute oedema of the eyelids, their skin is tense, red; eyelids are firm, as a board; discharge are serous bloody. In intercostal space, as well as on the conjunctiva dirty-gray films are visible, often with numerous haemorrhages. After the removal of films conjunctiva bleeds very much.

Further the injured parts of the conjunctiva necrotize and in 7-10 days fall off, leaving granulation. Afterwards a scar appears at the place of granulation tissue. Commissures may form between palpebral mucus and sclera — symblepharon. Since the first days the process involves the cornea which in the case of severe disease form quite often fully destroyed.

Diphtheria of the conjunctiva is rarely taking as an isolated disease. More often it is combined with diphtheria of nose, fauces, larynx.

Prognosis at diphtheria is always serious both for the eye and life of the patient.

Treatment. When suspecting diphtheria, without waiting for the results of bacteriological analysis, a patient should be isolated and injected with antidiphtheric serum (6,000-10,000 AO).

Locally there are prescribed sulfacil-natrium, penicillin, nor­floxacin, gentamicin in drops, 1% tetracyclini ointment.

Trachoma (trachoma, conjunctivitis trachomatosa) is infectious chronic inflammation of the conjunctiva. It is characterized by dif­fuse infiltration of mucus and follicles development with following necrosis and scarring. Trachoma is widespread in the countries of Asia, Africa and Latin America. According to WOAP data, there are about 400 million patients with trachoma in the whole world. This disease often results in blindness.

Etiology. Trachoma is the infectious disease, that is transmissed from a sick man to a healthy one by transference of discharge from a sick eye. The causative agent of trachoma belongs to the group of so called Chlamidia. In tissue of the conjunctiva it forms extra- and intracellular includings which are revealed at cytologic analysis of conjunctiva.

Clinical course. In trachoma the conjunctiva becomes thickened, swelled, uneven — hence the name "trachoma" (from Greek, trahus — uneven, rough). Roughness is given by pappilae and follicles lo­cated in the layer of diffusely infiltrated tissue of the conjunctiva.

Trachoma is revealed by hyperemia and swelling up of transi­tional folds of connecting membrane, where follicles appear espe­cially noticeable in the transitional fold of the upper eyelid. At the ectropion of eyelids a transitional fold protrudes as a cushion. It is studded with corns which resemble frog caviar.

The conjunctiva of cartilage swells up a little, thickens: follicles appear on it. A cartilage is infiltrated, thickened. Therefore an eye­lid becomes heavy and goes down — ptosis appear (ptosis trachom­atosa). Insignificant paresis of the muscle that lifts an upper eyelid favours to ptosis. Follicles appear in a half-moon fold. In the con iunctiva of sclera follicles happen rarely. Scars appear, as a rule, near the protuberant edge of cartilage on the verge of it and transi­tional fold, and also at the area of sulcus near the free edge of carti­lage- Ribs which have the appearance of linear silvery strips appear also in cartilage mucus. The amount of follicles decreases gradual­ly the amount of scars increase, scarring begins to prevail. Along the edge of the eyelid, in accordance with a sulcus (sulcus sublar-salis), a wide white scar spreads, all conjunctiva of cartilage is white.

Classification. The clinical forms of trachoma are so various, that it is difficult to represent them schematically. However, for the proper organization of fight against this illness, with the pur­pose of the count and registration trachoma is divided into 4 stag­es according to its clinical course. Suspicion on trachoma and pre-trachoma are also considered.

Suspicion on trachoma (trachoma dibium — TrD). A diagno­sis is made usually at mass prophylactic examinations in those cas­es, when there are no clear clinical and laboratory data.

Pretrachoma (PrTr). Slight hyperemia and insignificant infil­tration of conjunctiva, follicles are not present.

First stage (Trl). Infiltration of conjunctiva with development of follicles in transitional folds and cartilages.

Second stage (Tr2). Against a background infiltration of the conjunctiva and development of follicles there is necrosis which is accompanied by scarring.

Third stage (Tr3). Widespread scarring of the conjunctiva with infiltration and follicles in it.

Fourth stage (Tr4). Complete scarring of the conjunctiva with­out infiltration (a noncontagious form, curable).

Introduction of the fourth stage enables to select in a separate group a fully curable, noncontagious trachoma and, the same, take into account efficiency of measures against trachoma. Damage of the cornea as a so-called trachomatous pannus (pannus trachom-alosus, or keratitis superficialis diffusa vasculosa). which is spe­cific superficial diffuse vascular keratitis, is characteristic for tra­choma. Pannus appears always near the upper edge of the cornea. Infiltration in the superficial layers of the cornea has the appear­ance of turbid diffuse shroud, that goes down from the upper lim-bus on the cornea, like a curtain. This shroud is pierced by conjunc­tival vessels. Thin, vascular and fleshy pannus are distinguished.

The differential diagnosis of trachoma is conducted with a fol­licular conjunctivitis (Table. 1).

Table 1. Differential diagnosis of trachoma and follicular conjunctivitis

Follicular conjunctivitis

Mostly lower transitional fold is in­jured

Infiltration of conjunctiva is insignif­icant

The follicles are rose, stood out above a surface, locate as regular rows in the area of the inferior transitional fold

The scarry changes of conjunctiva are absent

The cornea is not involved into the process

Complication of trachoma. ThE ulcers of the cornea, which ap­pear on the edge of pannus as a groove, that separates pannus from the healthy cornea.

Complications from the side of the conjunctiva can appear as acute conjunctivitis which complicates the disease course very much and often presents considerable problems for diagnosis of tra­choma. The presence of purulent discharge favours the spreading of trachoma.

At trachoma lacrimal ducts are affected (inflammation of lac­rimal sac, dacryocystitis).

Consequences of trachoma. A transitional fold shortens as a re­sult of cicatritial regeneration of the conjunctiva, a fornix becomes less deep. When drawing the eyelid, especially a lower one, the conjunctiva between it and the eyeball becomes taut as separate vertical folds, forming back accretion — posterior symblepharon (symblepharon posterior). This type of accretion differs from an­terior symblepharon (symblepharon anterior), that is adhesion be­tween the eyelid and eyeball, under which it is sometimes possible to conduct a probe.

As a result of the shrinkage of cartilage tissue and mucous mem­brane, that covers it, a cartilage curves and gets a wash-tab-like form with a bulge reversed ahead.

That leads to one of severe consequences of trachoma — entro­pion. Blepharospasm assists to development of ectropion, arising in complications from the side of the cornea.

Eyelashes change the growth direction, begin to grow towards the eyeball. Such wrong growth of eyelashes is called trichiasis.

The process of scarring can cause devastation of the glands placed in a conjunctiva and excretory duct of the lacrimal gland. There stops their secretion, necessary for the normal moistening ₀f mucus and cornea membranes which gradually begin to dry out (xeropthalmia). The detached dry plaques of mat-white color ap­pear on the surface of the cicatrically changed conjunctiva. The cornea becomes dull and opaque, an ulcer and its perforation can develop.

Treatment. At trachoma sulfonamides and antibiotics of tetra-cyclin row are used, which are applied locally, in a conjunctival sac, and also intramuscular or per os during a few months accor­ding to the regimen. In the active disease forms it is conducted ex­pression (squeezing out) of the follicle after the V. P. Filatov's me­thod.

Treatment of trachoma consequences is surgical: plasty of eye­lids, removal of symblepharon, transplantation of mucous mem­brane from a lip or cheek, keratoplasty, transplantation of excre­tory duct of the parotid salivary gland in a conjunctival sac.

Prognosis is always serious. When there are pannus and xero­sis, prognosis is considerably worse, blindness is possible.

Date: 2014-12-21; view: 1343