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Overview of Conjunctival and Scleral Disorders

By Melvin I. Roat, MD, FACS, Clinical Associate Professor of Ophthalmology; Cornea Service, Sidney Kimmel Medical College at Thomas Jefferson University; Wills Eye Hospital

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The conjunctiva lines the back of the eyelids (palpebral or tarsal conjunctiva), crosses the space between the lid and the globe (forniceal conjunctiva), then folds back on itself as it spreads over the sclera to the cornea (bulbar conjunctiva). The conjunctiva helps maintain the tear film and protect the eye from foreign objects and infection.

The sclera is the thick white sphere of dense connective tissue that encloses the eye and maintains its shape. Anteriorly, the sclera fuses with the cornea at the limbus, and posteriorly it blends with the meninges where the optic nerve penetrates the globe.

The episclera is a thin vascular membrane between the conjunctiva and the sclera.

The most common disorders are inflammatory (eg, conjunctivitis, episcleritis, scleritis). Conjunctivitis can be acute or chronic and is infectious, allergic, or irritant in origin. Episcleritis and scleritis usually result from immune-mediated disease. Episcleritis usually does not threaten vision, but scleritis can destroy vision and the eye. Major symptoms of conjunctivitides (eg, conjunctival hyperemia) are similar. Early, accurate diagnosis is important.

Select eye findings in conjunctival disorders

Edema of the bulbar conjunctiva results in a diffusely translucent, bluish, thickened conjunctiva. Gross edema with ballooning of the conjunctiva, often leading to prolapse of conjunctiva, is known as chemosis.

Edema of the tarsal conjunctiva (typical of allergic conjunctivitis) results in fine, minute projections (papillae), giving the conjunctiva a velvety appearance.

Hyperplasia of lymphoid follicles in the conjunctiva can occur in viral conjunctivitis or chlamydial conjunctivitis. It appears as small bumps with pale centers, resembling cobblestones. It occurs most commonly in the inferior tarsal conjunctiva.

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