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Anatomia da Conjuntiva
Conjuntiva é uma membrana mucosa fina e translúcida que une e cobre a superfície anterior do globo ocular e do lado
posterior das pálpebras.Ele cobre a superfície posterior das pálpebras e reflete para cobrir a parte anterior da esclera, em
seguida, torna-se contínua com o epitélio da córnea . Na margem da tampa, a conjuntiva é contínua com a pele.
Etimologia:
Partes da conjuntiva:
Etimologia:
Folículos e papilas são vistos na parte palpebral da conjuntiva. A conjuntiva palpebral é uma área onde a patologia reativa
da conjuntiva pode ser vista clinicamente. Existem dois tipos de alterações que podem ocorrer nesta região: formação de
folículos e formação de papilas. Acredita-se que os folículos sejam idênticos aos folículos
do folículo linfoide encontrados em outras partes do
corpo. A formação de folículos é característica de
infecções virais e por clamídia, bem como de
conjuntivite tóxica devido à aplicação de certos
medicamentos tópicos. PapilasSão compostos de
células inflamatórias crônicas, como linfócitos e
plasmócitos, e distinguem-se dos folículos pela
presença de vasos sangüíneos no centro. As
papilas gigantes são encontradas em certas
doenças alérgicas (por exemplo, catarro vernal) e
após o uso prolongado de lentes de contato,
ceratopróteses, próteses de pós-nucleação ocular e
conchas cosméticas.
Conjuntiva do Fornix: É a dobra do revestimento do fundo-de-saco formado pela conjuntiva cobrindo a superfície posterior
das pálpebras à conjuntiva cobrindo a superfície anterior do globo. A conjuntiva aqui é comparativamente mais espessa e
frouxamente fixada para permitir a livre movimentação do globo. Está dividido em 4 regiões
Fórix superior fica entre a pálpebra superior e o globo. Estende 8 a 10 mm da borda superior do limbo.
Fórix inferior fica entre a pálpebra inferior e o globo. Estende-se até uma distância de 8 mm abaixo da parte inferior do
limbo.
Fórix lateral fica entre o canto lateral e o globo. Estende-se por uma distância de 15 mm da parte lateral do limbo.
O fórnice medial é o mais superficial e contém carúnculo e plica semilunar.
No limbo, a conjuntiva, a cápsula de tenon e a esclera se fundem. Como a conjuntiva nesta região é menos móvel, uma retenção mais firme do
globo pode ser obtida com a ajuda de fórceps no momento da cirurgia.
Microscopicamente conjuntiva consiste em três camadas - epitélio, camada adenóide e camada fibrosa.
1. Epitélio Conjuntival:
Nas junções da pele das pálpebras e conjuntiva marginal (junção mucocutânea), o epitélio escamoso queratinizado da
epiderme se transforma em epitélio escamoso não queratinizado da conjuntiva. A morfologia do epitélio conjuntival varia de
região para região. As diferentes regiões da conjuntiva e seus epitélios são descritas abaixo.
Camada mais
profunda: Células
cilíndricas
Camada mais
profunda: células
cubiodais
Camada
intermediária:
células
poliédricas
Camada mais
profunda: células
cuboidais
Camada
intermediária:
células poligonais
Basal-cúbico
As margens da pálpebra são cobertas anteriormente por epitélio seco e queratinizado, que se funde ao epitélio úmido e não-queratinizado,
cobrindo posteriormente o tarso. Em muitos distúrbios da superfície ocular, o epitélio normal é modificado e se torna não secretor e
queratinizado. Essa transição patológica é denominada metaplasia escamosa.
Goblet cells: Goblet cells are seen throughout the conjunctiva lying in between the cells of conjunctival epithelium. These
cells are actually unicellular glands which secret mucin. They are believed to arise from basal layer of epithelium. They
gradually enlarge, become larger as they reach the surface of the conjunctiva. On reaching the surface they discharge their
mucin content and finally shed away. These cells are round and oval in shape and 10-20 µm in size.
These cells are called goblet cells because of their goblet-like shape. Goblet is footed cup intended to hold a drink. It is intended for
drinking during a ceremony. In ultramicroscopic examination, apical portion of the cell is shaped like a cup, as it is distended by large
number of mucin granules whereas its basal portion is shaped like a stem for lack of these granules
Goblet cells may produce up to 2.2 mL of mucus daily. Mucus is essential for ocular surface integrity as it
lubricates and protects the epithelial cells. Mucin reduces the surface tension of the tear film to ensure its
stability.
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Melanocytes:Melanocytes are primarily seen in limbus, fornix, plica semilunaris, caruncle and at the sites of perforation of
the anterior cilliary vessels. Sometimes they give the conjunctiva a brownish tinge.
Langerhans cells:Langerhans cells are actually dendritic cells, immune cells that form part of the immune system. Their
main function is to process antigen material and present it on the surface to other cells of the immune system. Thus they
function as antigen-presenting cells. The highest density of Langerhans cells has been found in tarsal conjunctiva followed
by fornix and bulbar conjunctiva. The number of the cells decreases with age.These cells contain rod shaped or "tennis-
racket" shaped cytoplasmic organelles known as Birbeck granule, which stains positively for ATPase.
Historical Perspectives:
The Langerhans cell is named after Paul Langerhans, a physician and anatomist from Germany, who discovered the cells at the age
of 21 when he was a medical student.
It consists of superficial lymphoid layer and deeper fibrous layer. The conjunctival epithelium rests on a connective tissue
layer called the substantia propria. This tissue has enormous anti-infectious potential. Numerous mast cells (6000/mm3),
lymphocytes, plasma cells, and neutrophils are normally present in this layer
Lymphoid layer:
Lymphoid layer consists of many lymphocytes which are scattered to form this fine connective tissue reticulum. This layer is
thickest in fornices and terminates near sulcus subtarsalis. So the marginal conjunctiva is devoid of this layer.
Important point:
Lymphoid layer is absent in newborn. This layer first appears in fornices at 3 to 4 months of age.
Lymphocytes, primarily T lymphocytes are found abundantly in conjunctiva. They are present in substantia propria
and epithelium in a ratio of 2:3.Lymphoid aggregations similar to mucosal associated lymphoid tissue (MALT) found in gut
and bronchi, are also seen in conjunctiva. These lymphoid aggregations which consist of T & B lymphocytes are known as
conjunctiva associated lymphoid tissue (CALT).
Mast cells:
Mast cells are granulocytic cell-like basophils. The conjunctiva contains high number of mast cells in substantia propria. The
total number of mast cells in the conjunctiva and adnexal tissue will be around 50 million. Allergic conjunctivitis is a typical
mast cell mediated hypersensitivity reaction. In patients with allergic conjunctivitis the mast cells have been found in
conjunctival epithelium also.
The surface of the mast cell is coated with IgE antibody. There are about 10000 to 50000 IgE receptors in one mast cell of which 16% are
occupied. Exposure of appropriately sensitized IgE coated mast cell to airborne allergen is the initiating stimulus for the drama of allergy. The
allergen binds to two separate IgE molecules creating a dimer that initiate a chain of reactions in the mast cell plasma membrane, and the
mast cell membrane ruptures leading to extrusion of the contents of the cell to the surrounding tissue. The contents of the mast cell act like
mediators of the allergic reactions. These mediators are histamine, prostaglandin, eosinophilic granule major basic protein, eosinophil
chemotactic factor, platelet activating factor.
These mediators and many other cell mediators stimulate the proliferation of fibroblasts and recruitment of many cell types in the conjunctiva. These
events play an active role in development of papillae in patients with VKC.
3. Fibrous layer:
This layer contains the vessels and nerves of conjunctiva and glands of Krause. Except for the tarsal part of conjunctiva,
where it is very thin and blends with the tarsal plates, the fibrous layer is thicker than the lymphoid layer.
Glands of Krause: The glands of Krause lie in deep subconjunctival tissue of the
upper and lower fornices. They are about 42 in number in upper fornix and 6 to 8
in lower fornix. In upper fornix they lie between the palpebral part of the lacrimal
gland and tarsal plate.Microscopically structures of these glands are similar to
main lacrimal glands. Their ducts unite to forma long duct which opens into the
fornix.
Historical perspectives:
Glands of
Wolfring or Ciaccio: Glands
of Wolfring are larger than the
glands of Krause. There are 2
to 5 in the upper lid and 1-3 in the lower lid.
Bulbar conjunctiva is the only tissue in body, where constituent blood vessels are
visible
Palpebral arcades: There are two palpebral arcades which are the major
source of the blood supply of conjunctiva. These are marginal tarsal
arcade & peripheral tarsal arcade. Marginal tarsal arcades are larger than
peripheral tarsal arcade. The medial and lateral palpebral branches of the
nasal and lacrimal arteries of the lid supply the eyelid. (Lateral palpebral
arteries are the branches of Lacrimal arteries and medial palpebral arteries derive separately or together from main
ophthalmic artery or dorsal nasal arteries). The superior and inferior branches from these arteries enter the eyelid by piercing
orbital septum. Each branch of medial palpebral artery then anastomoses with corresponding lateral palpebral artery and this
is how they form the marginal arcade.
Marginal Arcade: Marginal tarsal arcade lies in the sub muscular plane in front of
the tarsal plate, 2mm away from the margin of the eyelids. Perforating branches of
the marginal tarsal arcade pierce the tarsal plate at the region of sulcus subtarsalis
and enter the conjunctiva to supply the palpebral part of the conjunctiva.
Point to note:
Marginal arcade lies in close proximity to the lid margin & peripheral tarsal arcade lies near
the peripheral marginal arcade
The nerve supply to the conjunctiva is derived from the first division of the
trigeminal nerve. The nerves to the lid supply most of the conjunctiva. These
nerves comprise the infratrochlear branch of the nasociliary nerve, the
lacrimal nerve, the supratrochlear and supraorbital branches of the frontal
nerve, and the infraorbital nerve from the maxillary division of the trigeminal
nerve. The limbal area is supplied by branches from the ciliary nerves. All
nerves form a network in the conjunctiva and terminate either peripherally in
various forms of specialized endings or on blood vessels and epithelial cells.
The majority of nerve endings in the conjunctiva are free, unmyelinated
nerve endings. They form a sub-epithelial plexus in the superficial part of the
substantia propria. Many of these fibers end on blood vessels, and others
form an intraepithelial plexus around the base of epithelial cells and send
free nerve endings between cells.
Lymphatics
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