Conjunctiva

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Conjunctiva
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The upper half of a sagittal section through the front of the eyeball (label for 'Conjunctiva' visible at center-left)
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Horizontal section of the eyeball (conjunctiva labeled at upper left)
Details
Part of Eye
Artery Lacrimal artery, anterior ciliary arteries
Nerve Supratrochlear nerve
Identifiers
Latin tunica conjunctiva
MeSH D003228
TA98 A15.2.07.047
TA2 6836
FMA 59011
Anatomical terminology
Image of a human eye showing the blood vessels of the bulbar conjunctiva Beccas Oga.JPG
Image of a human eye showing the blood vessels of the bulbar conjunctiva
Hyperaemia of the superficial bulbar conjunctiva blood vessels Hyperemia conjunctiva.jpg
Hyperaemia of the superficial bulbar conjunctiva blood vessels

In the anatomy of the eye, the conjunctiva (pl.: conjunctivae) is a thin mucous membrane that lines the inside of the eyelids and covers the sclera (the white of the eye). [1] It is composed of non-keratinized, stratified squamous epithelium with goblet cells, stratified columnar epithelium and stratified cuboidal epithelium (depending on the zone). The conjunctiva is highly vascularised, with many microvessels easily accessible for imaging studies.

Contents

Structure

The conjunctiva is typically divided into three parts:

PartArea
Palpebral or tarsal conjunctivaLines the eyelids
Bulbar or ocular conjunctivaCovers the eyeball, over the anterior sclera: This region of the conjunctiva is tightly bound to the underlying sclera by Tenon's capsule and moves with the eyeball movements. The average thickness of the bulbar conjunctival membrane is 33 microns. [2]
Fornix conjunctivaForms the junction between the bulbar and palpebral conjunctivas: It is loose and flexible, allowing the free movement of the lids and eyeball. [3]

Blood supply

Blood to the bulbar conjunctiva is primarily derived from the ophthalmic artery. The blood supply to the palpebral conjunctiva (the eyelid) is derived from the external carotid artery. However, the circulations of the bulbar conjunctiva and palpebral conjunctiva are linked, so both bulbar conjunctival and palpebral conjunctival vessels are supplied by both the ophthalmic artery and the external carotid artery, to varying extents. [4]

Nerve supply

Sensory innervation of the conjunctiva is divided into four parts: [5]

AreaNerve
Superior
Inferior Infraorbital nerve
Lateral Lacrimal nerve (with contribution from zygomaticofacial nerve)
Circumcorneal Long ciliary nerves

Microanatomy

The conjunctiva consists of unkeratinized, both stratified squamous and stratified columnar epithelium, with interspersed goblet cells. [6] The epithelial layer contains blood vessels, fibrous tissue, and lymphatic channels. [6] Accessory lacrimal glands in the conjunctiva constantly produce the aqueous portion of tears. [6] Additional cells present in the conjunctival epithelium include melanocytes, T and B cell lymphocytes. [6]

Function

The conjunctiva helps lubricate the eye by producing mucus and tears, although a smaller volume of tears than the lacrimal gland. [7] It also contributes to immune surveillance and helps to prevent the entrance of microbes into the eye.

Clinical significance

Disorders of the conjunctiva and cornea are common sources of eye complaints, in particular because the surface of the eye is exposed to various external influences and is especially susceptible to trauma, infections, chemical irritation, allergic reactions, and dryness.

Bulbar conjunctival microvasculature

Vessel morphology

The bulbar conjunctival microvasculature contains arterioles, meta-arterioles, venules, capillaries, and communicating vessels. Vessel morphology varies greatly between subjects and even between regions of the individual eyes. In some subjects, arterioles and venules can be seen to run parallel with each other. Paired arterioles are generally smaller than corresponding venules. [22] The average bulbar conjunctival vessel has been reported to be 15.1 microns, which reflects the high number of small capillaries, which are typically <10 microns in diameter. [23]

Blood oxygen dynamics

The bulbar conjunctival microvasculature is in close proximity to ambient air, thus oxygen diffusion from ambient air strongly influences their blood oxygen saturation. Because of oxygen diffusion, hypoxic bulbar conjunctival vessels will rapidly reoxygenate (in under 10 seconds) when exposed to ambient air (i.e. when the eyelid is open). Closing the eyelid stops this oxygen diffusion by placing a barrier between the bulbar conjunctival microvessels and ambient air. [24]

Blood vessel imaging methods

The bulbar conjunctival microvessels are typically imaged with a high-magnification slit lamp with green filters. [25] [26] [27] With such high-magnification imaging systems, it is possible to see groups of individual red blood cells flowing in vivo. [25] Fundus cameras may also be used for low-magnification wide field-of-view imaging of the bulbar conjunctival microvasculature. Modified fundus cameras have been used to measure conjunctival blood flow [28] and to measure blood oxygen saturation. [24] Fluorescein angiography has been used to study the blood flow of the bulbar conjunctiva and to differentiate the bulbar conjunctival and episcleral microcirculation. [29] [30] [31]

Vasodilation

The bulbar conjunctival microvasculature is known to dilate in response to several stimuli and external conditions, including allergens (e.g. pollen), [32] temperature, [33] time-of-day, [33] contact-lens wear, [13] and acute mild hypoxia. [24] Bulbar conjunctival vasodilation has also been shown to correlate changes in emotional state. [34]

Type 2 diabetes is associated with an increase in average bulbar conjunctival vessel diameter and capillary loss. [11] [12] Sickle-cell anemia is associated with altered average vessel diameter. [14]

See also

Additional images

Related Research Articles

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<span class="mw-page-title-main">Blood vessel</span> Tubular structure of circulatory system

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<span class="mw-page-title-main">Capillary</span> Smallest type of blood vessel

A capillary is a small blood vessel, from 5 to 10 micrometres in diameter, and is part of the microcirculation system. Capillaries are microvessels and the smallest blood vessels in the body. They are composed of only the tunica intima, consisting of a thin wall of simple squamous endothelial cells. They are the site of the exchange of many substances from the surrounding interstitial fluid, and they convey blood from the smallest branches of the arteries (arterioles) to those of the veins (venules). Other substances which cross capillaries include water, oxygen, carbon dioxide, urea, glucose, uric acid, lactic acid and creatinine. Lymph capillaries connect with larger lymph vessels to drain lymphatic fluid collected in microcirculation.

<span class="mw-page-title-main">Diabetic retinopathy</span> Diabetes-induced damage to the retina of the eye

Diabetic retinopathy, is a medical condition in which damage occurs to the retina due to diabetes. It is a leading cause of blindness in developed countries.

<span class="mw-page-title-main">Microangiopathy</span> Medical condition

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<span class="mw-page-title-main">Arteriole</span> Small arteries in the microcirculation

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<span class="mw-page-title-main">Superior limbic keratoconjunctivitis</span> Medical condition

Superior limbic keratoconjunctivitis is a disease of the eye characterized by episodes of recurrent inflammation of the superior cornea and limbus, as well as of the superior tarsal and bulbar conjunctiva. It was first described by F. H. Théodore in 1963.

<span class="mw-page-title-main">Vernal keratoconjunctivitis</span> Medical condition

Vernal keratoconjunctivitis is a recurrent, bilateral, and self-limiting type of conjunctivitis having a periodic seasonal incidence.

<span class="mw-page-title-main">Corneal ulcer</span> Medical condition of the eye

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<span class="mw-page-title-main">Cotton wool spots</span> Medical condition of the eye

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<span class="mw-page-title-main">Symblepharon</span> Medical condition

A symblepharon is a partial or complete adhesion of the palpebral conjunctiva of the eyelid to the bulbar conjunctiva of the eyeball. It results either from disease or trauma. Cicatricial pemphigoid and, in severe cases, rosacea may cause symblepharon. It is rarely congenital. Its treatment is symblepharectomy.

<span class="mw-page-title-main">Accessory visual structures</span> External parts of the eye including eyebrow, eyelid, and lacrimal apparatus

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Conjunctival squamous cell carcinoma and corneal intraepithelial neoplasia comprise ocular surface squamous neoplasia (OSSN). SCC is the most common malignancy of the conjunctiva in the US, with a yearly incidence of 1–2.8 per 100,000. Risk factors for the disease are exposure to sun, exposure to UVB, and light-colored skin. Other risk factors include radiation, smoking, HPV, arsenic, and exposure to polycyclic hydrocarbons.

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Sickle cell retinopathy can be defined as retinal changes due to blood vessel damage in the eye of a person with a background of sickle cell disease. It can likely progress to loss of vision in late stages due to vitreous hemorrhage or retinal detachment. Sickle cell disease is a structural red blood cell disorder leading to consequences in multiple systems. It is characterized by chronic red blood cell destruction, vascular injury, and tissue ischemia causing damage to the brain, eyes, heart, lungs, kidneys, spleen, and musculoskeletal system.

References

  1. ↑ "Conjunctiva". www.sciencedirect.com. Retrieved 4 August 2022.
  2. ↑ Efron N, Al-Dossari M, Pritchard N (May 2009). "In vivo confocal microscopy of the bulbar conjunctiva". Clinical & Experimental Ophthalmology. 37 (4): 335–44. doi:10.1111/j.1442-9071.2009.02065.x. PMID   19594558. S2CID   35398240.
  3. ↑ Eye, human Encyclopædia Britannica
  4. 1 2 Pavlou AT, Wolff HG (July 1959). "The bulbar conjunctival vessels in occlusion of the internal carotid artery". A.M.A. Archives of Internal Medicine. 104 (1): 53–60. doi:10.1001/archinte.1959.00270070055007. PMID   13660526.
  5. ↑ "Table 1: Summary of sensory nerve supply". Archived from the original on February 14, 2013. Retrieved July 31, 2016.
  6. 1 2 3 4 Goldman L (2012). Goldman's Cecil Medicine (24th ed.). Philadelphia: Elsevier Saunders. p.  2426. ISBN   978-1437727883.
  7. ↑ London Place Eye Center (2003). Conjunctivitis Archived 2004-08-08 at the Wayback Machine . Retrieved July 25, 2004.
  8. ↑ Khansari MM, Wanek J, Tan M, Joslin CE, Kresovich JK, Camardo N, et al. (April 2017). "Assessment of Conjunctival Microvascular Hemodynamics in Stages of Diabetic Microvasculopathy". Scientific Reports. 7: 45916. Bibcode:2017NatSR...745916K. doi:10.1038/srep45916. PMC   5384077 . PMID   28387229.
  9. ↑ Khansari MM, O'Neill W, Penn R, Chau F, Blair NP, Shahidi M (July 2016). "Automated fine structure image analysis method for discrimination of diabetic retinopathy stage using conjunctival microvasculature images". Biomedical Optics Express. 7 (7): 2597–606. doi:10.1364/BOE.7.002597. PMC   4948616 . PMID   27446692.
  10. ↑ Isenberg SJ, McRee WE, Jedrzynski MS (October 1986). "Conjunctival hypoxia in diabetes mellitus". Investigative Ophthalmology & Visual Science. 27 (10): 1512–5. PMID   3759367.
  11. 1 2 Fenton BM, Zweifach BW, Worthen DM (September 1979). "Quantitative morphometry of conjunctival microcirculation in diabetes mellitus". Microvascular Research. 18 (2): 153–66. doi:10.1016/0026-2862(79)90025-6. PMID   491983.
  12. 1 2 Ditzel J (1967-01-12). "The in vivo reactions of the small blood vessels to diabetes mellitus". Acta Medica Scandinavica. Supplementum. 476 (S476): 123–34. doi:10.1111/j.0954-6820.1967.tb12691.x. PMID   5236035.
  13. 1 2 Cheung AT, Ramanujam S, Greer DA, Kumagai LF, Aoki TT (2001-10-01). "Microvascular abnormalities in the bulbar conjunctiva of patients with type 2 diabetes mellitus". Endocrine Practice. 7 (5): 358–63. doi:10.4158/EP.7.5.358. PMID   11585371.
  14. 1 2 Fink AI (1968-01-01). "Vascular changes in the bulbar conjunctiva associated with sickle-cell disease: some observations on fine structure". Transactions of the American Ophthalmological Society. 66: 788–826. PMC   1310317 . PMID   5720854.
  15. ↑ Isenberg SJ, McRee WE, Jedrzynski MS, Gange SN, Gange SL (January 1987). "Effects of sickle cell anemia on conjunctival oxygen tension and temperature". Archives of Internal Medicine. 147 (1): 67–9. doi:10.1001/archinte.147.1.67. PMID   3800533.
  16. ↑ Wanek J, Gaynes B, Lim JI, Molokie R, Shahidi M (August 2013). "Human bulbar conjunctival hemodynamics in hemoglobin SS and SC disease". American Journal of Hematology. 88 (8): 661–4. doi:10.1002/ajh.23475. PMC   4040222 . PMID   23657867.
  17. ↑ Harper RN, Moore MA, Marr MC, Watts LE, Hutchins PM (November 1978). "Arteriolar rarefaction in the conjunctiva of human essential hypertensives". Microvascular Research. 16 (3): 369–72. doi:10.1016/0026-2862(78)90070-5. PMID   748720.
  18. ↑ Lee RE (August 1955). "Anatomical and physiological aspects of the capillary bed in the bulbar conjunctiva of man in health and disease". Angiology. 6 (4): 369–82. doi:10.1177/000331975500600408. PMID   13275744. S2CID   11589129.
  19. ↑ "Conjunctivochalasis - Medical Definition". Medilexicon.com. Archived from the original on 2016-03-03. Retrieved 2012-11-13.
  20. ↑ Hughes WL (January 1942). "Conjunctivochalasis". American Journal of Ophthalmology. 25 (1): 48–51. doi:10.1016/S0002-9394(42)93297-5.
  21. ↑ Varde MA, Biswas J (January 2009). "Ocular surface tumors". Oman Journal of Ophthalmology. 2 (1): 1–2. doi: 10.4103/0974-620X.48414 . PMC   3018098 . PMID   21234216.
  22. ↑ Meighan SS (September 1956). "Blood vessels of the bulbar conjunctiva in man". The British Journal of Ophthalmology. 40 (9): 513–26. doi:10.1136/bjo.40.9.513. PMC   1324675 . PMID   13364178.
  23. ↑ Shahidi M, Wanek J, Gaynes B, Wu T (March 2010). "Quantitative assessment of conjunctival microvascular circulation of the human eye". Microvascular Research. 79 (2): 109–13. doi:10.1016/j.mvr.2009.12.003. PMC   3253734 . PMID   20053367.
  24. 1 2 3 MacKenzie LE, Choudhary TR, McNaught AI, Harvey AR (August 2016). "In vivo oximetry of human bulbar conjunctival and episcleral microvasculature using snapshot multispectral imaging" (PDF). Experimental Eye Research. 149: 48–58. doi:10.1016/j.exer.2016.06.008. PMID   27317046. S2CID   25038785.
  25. 1 2 van Zijderveld R, Ince C, Schlingemann RO (May 2014). "Orthogonal polarization spectral imaging of conjunctival microcirculation". Graefe's Archive for Clinical and Experimental Ophthalmology. 252 (5): 773–9. doi:10.1007/s00417-014-2603-9. PMID   24627137. S2CID   1595902.
  26. ↑ Khansari MM, O'Neill W, Penn R, Chau F, Blair NP, Shahidi M (July 2016). "Automated fine structure image analysis method for discrimination of diabetic retinopathy stage using conjunctival microvasculature images". Biomedical Optics Express. 7 (7): 2597–606. doi:10.1364/BOE.7.002597. PMC   4948616 . PMID   27446692.
  27. ↑ Khansari MM, Wanek J, Felder AE, Camardo N, Shahidi M (February 2016). "Automated Assessment of Hemodynamics in the Conjunctival Microvasculature Network". IEEE Transactions on Medical Imaging. 35 (2): 605–11. doi:10.1109/TMI.2015.2486619. PMC   4821773 . PMID   26452274.
  28. ↑ Jiang H, Ye Y, DeBuc DC, Lam BL, Rundek T, Tao A, et al. (January 2013). "Human conjunctival microvasculature assessed with a retinal function imager (RFI)". Microvascular Research. 85: 134–7. doi:10.1016/j.mvr.2012.10.003. PMC   3534915 . PMID   23084966.
  29. ↑ Meyer PA (1988-01-01). "Patterns of blood flow in episcleral vessels studied by low-dose fluorescein videoangiography". Eye. 2 ( Pt 5) (5): 533–46. doi: 10.1038/eye.1988.104 . PMID   3256492.
  30. ↑ Ormerod LD, Fariza E, Webb RH (1995-01-01). "Dynamics of external ocular blood flow studied by scanning angiographic microscopy". Eye. 9 ( Pt 5) (5): 605–14. doi: 10.1038/eye.1995.148 . PMID   8543081.
  31. ↑ Meyer PA, Watson PG (January 1987). "Low dose fluorescein angiography of the conjunctiva and episclera". The British Journal of Ophthalmology. 71 (1): 2–10. doi:10.1136/bjo.71.1.2. PMC   1041073 . PMID   3814565.
  32. ↑ Horak F, Berger U, Menapace R, Schuster N (September 1996). "Quantification of conjunctival vascular reaction by digital imaging". The Journal of Allergy and Clinical Immunology. 98 (3): 495–500. doi:10.1016/S0091-6749(96)70081-7. PMID   8828525.
  33. 1 2 Duench S, Simpson T, Jones LW, Flanagan JG, Fonn D (June 2007). "Assessment of variation in bulbar conjunctival redness, temperature, and blood flow". Optometry and Vision Science. 84 (6): 511–6. doi:10.1097/OPX.0b013e318073c304. PMID   17568321. S2CID   943038.
  34. ↑ Provine RR, Nave-Blodgett J, Cabrera MO (2013-11-01). "The Emotional Eye: Red Sclera as a Uniquely Human Cue of Emotion". Ethology. 119 (11): 993–998. Bibcode:2013Ethol.119..993P. doi:10.1111/eth.12144. ISSN   1439-0310.
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