THE CONJUNGTIVA

SRI FULINA

ANATOMY

Conjungtiva is a thin,translucent,vascular mucous membran which covers the under of the eyelid and is reflected over the anterior part of the eyeball up to the limbus .

Parts consist: 1.Palpebral :it covers the under surface of both upper and lower lids. 2.Bulbar :it covers the anterior part of the eyeball.

3.Fornices :these are folds of the conjunctiva formed by the reflection of the mucous membrane from the lids to the eyeball. 4.Pilca semilunaris:its a crescentic fold of the conjunctiva situated at the inner canthus. Structure consists of two layers : - The epithelium: there are 2-5 layers of epithelial cells. - The stroma :it consists of blood vessels, connective tissue,gld of Krause,Wolfring and goblet cells.

Blood Supply : - A/V.conjunctival anterior and posterior.

Lymhatic Drainage : - Lymphonode preauricular - Lymphonode submandibular Nerve Supply : -Sensory nerves:a.Ophthalmica,a.Maxillary -Sympathetic nerves :plexus Sympathetic.

Bacteriology : - Non pathgenic bacteria: Diplococcus, Corynebacterium xerosis, Staphylococcus albus etc. - Pathogenic bacteria : Stphylococcus, Streptococcus,Pneumococcus,Ps.Pyocianea E.coli,B.proteus etc.

The bacterial growth is inhibited by : 1. Mechanical washing away action of tears. 2. The tears contains lysozyme,IgA,IgG wich are bacteriostatic. 3. Low temperature due to evaporation of tear,exposure and moderate blood supply.

Red eyes all look similar!

DISEASES OF THE CONJUNGTIVA

I.INFLAMATION=CONJUNGTIVITIS. 1.Infective types : - Acut : Sereous Mucoprulent Catarrhal Purulent - Subacut or chronic : Simple chronic Angular Follicular Trachoma,TBC,syphilis.

2. Allergic types : - Acute / subacute catarrhal - Phlyctenular - Spring catarrhal / vernal conjungtivitis. II.DEGENERATIVE CONDITION 1. Lithiasis 2. Pinguecula 3. Pterygium

III.SYMPTOMATIC CONDITION 1. Subconjungtival haemorrhage 2. Chemosis 3. Xerosis

CONJUNGTIVITIS
I.EVALUATION: 1.The type of discharge 2.The charasterics of conjungtival reactions . 3. The presence of lymphadenopathy. 1.Discharge it consists of : - Watery :it present in acute allergic and viral cunjungtivitis.

- Mucin :it seen in spring catarrh and keratoconjuntivitis sicca. - Mucopurulent :it present in mild bacterial infection and chlamydial infection. - Purulent :it seen in severe acute bacterial infection. 2.Conjungtival Reaction : - Hyperaemia - Oedema and chemosis - Follicle and papila

3. Lymphadenopathy : The preauricular nodes are in , Viral and Chlamydial infection. II.DIAGNOSIS : 1. Bacteriological examination for the presence of bacteria & inclusion bodies. 2. Histological examination of the secretion and scrapings of the epithelium. 3. Conjungtival culture it taken from lid margin conjungtival sac.with steril cotton.

TREATMENT: Antibiotic drops / ointment. ACUTE CONJUNGTIVITIS 1.Acute Mucopurulent Conjungtivitis . Etiology : Staph,Strept,Pneumoc,Adenovirus etc. Incidens : - It occurs in epidemics and is bilateral usu ally.

- It is contagious and spreads by flies fingers and fomites. - It is often self limiting. Symptoms : 1.There is redness and grittiness,,feeling of foreign body sensation. 2.Mucopurulent discharge and crusting is present in the fornices and margins of lids 3.Tere is sticking together of lids specially in the morning because of accumulation of mucous discharge during the night.

Acute Bacterial Conjunctivitis

Presents as an acute,red, MILDLY SORE sticky eye and is often unilateral or involves one eye more.

Corneal or Conjunctival Infection?

Conjunctivitis produces a generally pink eye but corneal involvement causes circumlimbal redness.

Signs : 1. Conjungtival congestion is always present,pink eye or red eye. 2. Chemosis and subconjungtival haemorrh may be present. Complication : There are rare but superficial keratitis, marginal corneal ulcer,chronic conjungtivitis may occur.

Treatment : 1. Cleanliness,frequent washing of the eyes with warm saline or clean water. 2.Control of infection, - Antibiotic eye drops /ointment. - Not be bandaged - Dark glasses in case of photophobia. Prophylaxis : 1.Isolation 2.Patient must keep his hands clean by washing them often.

2.Purulent Conjungtivitis . Types : - In adults :Acute purulent conjungtivitis - In babies:Ophthalmia neonatorum Acute Purulent Conjungtivitis Etiology : Most cases by Gonococcus. Incidence : - It occurs in males commonly affecting the right eye first.

- The incubation period is from a few hours to 3 days. Symptoms : - There is acute onset with much swelling of the lids and conjungtiva. - Purulent discharge is present at lid borders ,canthi and fornices.

Signs: -Conjungtival congestion is seen -Palpebral conjungtiva is red -Severe chemosis and pus discharge -Lids are swollen,red,tense and tender -Preauricular lymphadenopathy may be present.

Complication : 1. Subacute conjungtivitis 2. Corneal ulcers(marginal) are common 3. Iritis and iridocyclitis 4. Perforation of cornea leads to blindness Prognosis : It depends on the condition of the other eye Its bad in untreated cases.

Treatment : 1.Frequent washing of the conjungtival sac with warm saline 2.Instillation of antibiotic drop/ointment. Prophylaxis : 1. Protect the other eye by topical antib 2. Isolation of the patient should be done.

Ophthalmia Neonatorium Etiology: Virulent gonococcus infection used to be responsible for 50% blindness in children. Chlamydia oculogenitalis,Strep.pneumonia or other organism cause mild infection. Incidens : - Its bilateral usually - Its commonly occurs in the newborns due to maternal infection.

Symptoms : 1.Secreted only 3-4 weeks after birth. 2.The conjungtiva is bright red and swollen with yellow pus. 3.Thick pus accumulates at the lid border, lashes and canthi. Signs : 1.Lids are swollen and tense do to dense infiltration of the bulbar conjungtiva,

2.Conjungtiva is markedly congested and chemosed. 3.Pseudomembran may be present

Complication: These are common in untreated case . 1.Corneal ulcer and opacity 2.Perforated corneal ulcer with prolapse of iris.

Treatment: - Topical antibiotic or parenteral penicillin (cephalosporin) for 3-5days. Prophylaxis : -A septic delivery using gloves &steril techniq -Proper antenatal care and treatment of any vaginal discharge prior to delivery. -Instill penicillin or broad spectrum AB eye drop immediately after birth.

CHRONIC CONJUNGTIVITIS

1.Simple chronic Conjungtivitis

Etiology : -Irritation by smoke,dust,heat,allergen -misplaced eye lashes,dacryocystitis chronic rhinitis. -retained foreign body in the fornix

Symptoms . 1.There is burning discomfort and grittiness specially in the evening. 2.The edges of the lids feel hot and dry 3.There is difficulty in keeping the lids open 4.Mild serous discharge may be present. Signs. 1.The surface of the conjungtiva looks sticky 2.Congestion of fornices and palpebral

Treatment . 1.Local antibiotic drop/ointment. 2.Protective glasses 3.Bacteriological exam is done

2 .Angular Conjungtivitis
Etiology. By Morax-Axenfield diplobacillus. Symptoms. -Red eye is the most common feature -There is discomfort&frequent blinking. -Mild mucopurulent discharge may be present. Signs. - Redening the bulbar conj . - Excoriation of skin at the outer &inner canthi

Complication : - Blepharitis occurs in chronic untreated cases. - Marginal,central or hypopyon corneal ulcer may occur. - Recurrences are common. Treatment: - Oxytetracycline oitment is the DOC.

3.Follicular Conjungtivitis.
Etyology: - It may be due to exposure to certain chemical and toxins eg.pilocarpin,esserin. - Its commonly caused by viruses e.g herpes and adenovirus. - Any conj of long duration may cause this condition.

Symptoms: - There is slihgt irritation and discomfort - Foreign body sensation is often present Signs: Multiple follicles are mainly present in the lower fornix.There is no scarring which differentiates it from trachoma.

Types : 1.Inclusions conj: caused by chlamydial infection&produce inclusion bodies. 2.Epidemic keratoconj :its associated with several types(3,7,8,19) of adenovirus. 3.Pharyngoconjungtival fever. 4.Acute herpetic conj 5.New castle conj: caused by new castle virus from infected fowls.

Complication: Follicles may persist for several years but always resolve without scarring. Treatment : - Astringet eyedrop are applied frequently - Improve general health & nutrition .

4.Trachoma
Etyology: -Chlamydia trachomatosis -It lies between bacteria and virus. -They stay inside the cells -It is seen in the conj scrapings of the epithelial cells as the Halberstaedter

Prowazek inclusion bodies.

Incidence: 1.Its estimed that 1/5 of world population is affected by trachoma. 2.Its prevalent in Europe,Asia,Africa and South America,Australia. 3.In India it is common and endemic. 4.Its commonly seen in unhygienic,crowded dusty and dirty enviroment. 5.Its contagious in the acute stages,its spread by finger,flies,towels &fomites

Symptoms : -Mild irritation and foreign body sensation -Mild itching is a common complaint -In chronic stage cornea is involved causing pain,lacrimation and photophobia.
Signs: The primary infection is epithelial & involves the epithelium of both the conj & the cornea

1.Conjungtival: - Congestion,there is red,velvety,jelly-like thickening of the palpebral conj. - Papillae - Follicles,are seen in yhe upper &lower fornix,palpebral conj,plica,bulbar conj (pathognomonic),size 1-5 mm. -Star-shape scarring seen in the centre of the follicles in late stages. - Arts line, a line of palp.conj scarring is seen 2 mm from the upper lid margin.

2.Corneal : - Superficial keratitis may be present in upper part. - Herbetspits,there is follicle like infiltration near the limbus in the upper part. - Pannus,there is lymphoid infiltration with vascularitation seen in the upper part of cornea.

1.Mac Callan Classification

There is four clinical stages : 1.Trachoma I (subclinical Stage) Its the earliest stage before clinical diag nosis is possible. 2.Trachoma II (Typical trachomatous lesions) - follicle papillae - epithelial keratitis - pannus

3.Trachoma III ( stages of scarring ) 4.Trachoma IV (stage of sequelaen and complcation ),the deseases is quiet and cured but cicatrization gives rise to symptoms.

II.World Health Organization(WHO) Classification. 1.TF ( Trachomatous inflammation follicular) a. Atleast 5 or more follicles in the upper tarsal conj. b. The deep tarsal vessels should be visible through the follicles. 2. TI ( Trachomatous inflammation intens ) a. There is marked inflammatory thickening of the upper tarsal conj wich appears red,rough,thickened with follicles.

3.TS (Trachomatous scarring ) Which is seen as white fibrous lines , bands or sheets. 4.TT (Trachomatous trichiasis ) - Atleast one or more misdirected eyelashes rub against the eyeball. 5. CO ( Corneal opacity ).

Diagnosis . 1.Clinical : - Follicles or papillae - Epithelial keratitis - Pannus -Typical star-shaped scarring of the conj 2.Laboratory : - Histological ,inclusion bodies - Culture in irradiated McCoy cells

- Microimmunofluorescence test - IgA-IPA light microscopy test - Monoclonal antibody direct test Sequelae and complications : The only complication of trachoma is corneal ulcer. Sequelae of trachoma ; - Trichiasis - Entropion - Corneal ulcer, corneal opacity

- Xerosis ,scarring of conj result of detruction of goblet cells. - Ptosis,It occurs due to large follicles formation. - Blindness,perforation of corneal ulcer. Treatment : 1.Medical. Trachoma organisms are sensitive to tetracycline,sulphonamides,erythromycin, rifampycin,floxacin etc.

a.Topical treatment: - Sulphacetamide 20-30% ed 4x1/6 weeks - Addition atrificial tears . - Topical treatment (antibiotic) ,Its applied 3-6 weeks. b. Systemic treatment : - Doxycyclin100 mg 2x1 for 3-4 weeks. c. Combined topical and systemic treatment. - Its preferred when the ocular infection is severe.

2. Surgical treatment. Its not necessary usually with the advent of antibiotics. - Exicision fornix , if the follicles of the upper fornix are very large and closely packed,exicision can be done. - Tarsectomy,if the tarsal plate is much diseased and distorted. - Tratment of various sequelae such as trichiasis,entropion,dry eye should be done.

Prophylaxis . 1.Personal hygiene and enviromental sanitation is improved. 2.A good water supply improves washing habbits. 3.Blanket antibiotic treatment may be given in endemic area.apply 1% tetracycline eo 2x1 for 5 days/month. This is done for 6 months regularly.

ALLERGIC CONJUNCTIVITIS
1.Acut or subacut Catarrhal conj. Etiology : - Bacterial protein of endogenous nature,eg Staphylococcus in nose or upper respiratory tract. - Exogenous protein as in hay fever,contact with animals,pollens or flowers. - Chemicals,cosmetics,drugs ets.

Symptoms . - Itching is the most prominent feature . - Watery secretion - Marked redness of the conj . Signs. - Congestion of the conj with multiple follicles. - Watery mucoid discharge is present. - Skin of the lid is red and swollen.

Differential diagnosis. It can be differentiated from acute bacterial infection by the following features: - In allergic conj hiperaemia with itching. - Watery secretion contains large number of eosinophils. - There is chronic course with subacute remissions.

Treatment. 1.Removal of the allergen is absolutely necessary. 2.Astringet lotions are applied frequently. 3.Vasoconstrictor reduces the congestion. 4.Antihistamin drugs. 5.Disodium cromoglycate 2% is a mast cells stabilizer ,preventing the release of histamine. 6.Corticosteroid drops (severe cases).

2.Phlyctenular Conjungtivitis. Its an allergic reaction to endogenous protein charasteristised by formation of bleb or nodule near the limbus(phlycten). Etiology. Allergic reaction to endogenous bact,tbc

Incidence: - Age, its common in children 4-14 years. - Unhygienic living condition and malnutrition are important predisposing factors. Symptoms: - Discomfort,irritation,itching,reflex lacrimation are commont complaints. Signs: - One or small,round,grey-yellow nodules 1-3 mm is seen on the bulbar conj. - Congestion is seen around the nodule.

Clinical Types. 1.Phlyctenular conj. 2.Phlyctenular kerato-conj 3.Phlyctenular keratitis Complications. 1.Keratoconjunctivitis 2.Fascicular corneal ulcer 3.Corneal opacity

Tratment. 1.Local: - corticosteroid drops and ointment - antibiotic drops and ointment - atropine ed is applied is associated corneal ulcer. - Dark glasses . 2.General; - improvement of general health & nutrition - treatment of the cause.eg tbc,adenoid etc.

3.Spring Catarrhalis ( Vernal cony )

Etiology : - it is caused by exogenous allergen,such as pollens and dust. - it is mediated by IgE as shown by the accompanying eosinophilia. Incidens : - it affects young boys usually 5-10 years. - it is a bilateral and recurrent condition. - It usually occurs at the spring season. - It is sporadic and non contagious in nature.

Symptoms : 1. itching is the most common complaint. 2. thick,white,ropy mucous discharge is charasterisic. 3. burning and foreign body sensation may be present. 4. photophobia is present in cases of corneal involvement. 5. lacrimation or watering

Types : two types forms are seen : 1.Palpebral form : - there is conj hyperaemia and chemosis -on everting the upper lid,palppebral conj shows multiple polygonal-shape raised areas like cobble stones due to diffuse paplillary hypertrophy. -the colour is milky white due to thickened epithelium of the conyungtiva. -hypertropied papillae

2.Bulbar form : - multiple nodules in the upper part of the limbus its diagnostic of spring catarrh - Horner-trantas dots. Course: it may persist for several years.

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Complcations : mainly due to corneal involvement. serious compl are never seen and the ultimate prognosis is good. Treatment : Symptomatic : - topical corticosteroid - disodium cromoglycate 2% - non-steroidal anti-inflamatory

III.Degeneration
1 Lithiasis . Incidence :- eldery person there is accumulation of epithelial cells and mucus in Henle's gland. Symptoms : foreign body sensation & irritation Signs : Yellow spot in the palpebral cony . Treatment : Removed with needle

2 .Pinguecula . Triangular yellow patch on cony near the limbus. Etiology : occurs in elderly person exposed to strong sunlight,dust ,wind etc. Treatment : no treatment.

3. Pterygium : Def: Pterygium is a triangular sheet of fibrovascular tissue wich invades the cornea. It consits three parts : - apex , neck ,body. Etiology : - dry sunny ( uv )

Incidence : nasal side Symptoms : its usually symptomless ,there is cosmetic disfigurement ,vision is impaired due to astigmat or if pupilllary area is covered. Signs :There is a triangular enroachment of the conyungt on the cornea from the inner canthus.

Pathology : - its a degenerative condition of the subconyungtiva tissue wich proliferates as a vascularized granulation tissue. Differential Diagnosis : - Pseudopterygium its formed due to adhesion of bulbar cony. to a marginal corneal ulcus in chemical burn. Probe test:can be passed easily beneath the neck of pseudopterygium.

Complication : - astigmatism - visual impairment - occasionally may be diplopia due to limitation of movement of the eyeball. Treatment : Indications for surgery include; - visual impairment , astigmat , - cosmetic , limitation of ocular movement and dipolopia Simple excision.

III.Symptomatic Conditions
1.Subconyungtival haemorrhage (Echymosis) :Ruptureof conyungtival blood vessels causes a bright red. Etiology: - Minor injury to the eyeball and orbit - Spontaneous/haemorrhage - Severe conyungtivitis - Mechanical straining,eg vomiting cough - Head injury

Subconjunctival Hemorrhage

Symptom : Red eye is the most predominant feature. Sign : Fresh bright red blood is visible under the conyungtiva. Treatment: - no treatment is required as blood gets absorbed in 1-3 weeks. - vitamin C may help in healing process - cold fomentation is given to stop bleeding

2. Xerosis ( Dry Eye ). Etiology : a. Deficiency of tears - Syogren syndrome ( keratoconyungtivitis sicca ) - Senile or idiopathic atrophy of the lacrimal gland. b. Deficiency of conyungtival mucus - Trachoma - Vit.A deficiency

- Burns ;chemical,termal,radiation - Stevens Jhonson syndrom c.Insufficient resurfacing of the cornea - facial nerve palsy - proptosis d. Visual display terminal syndrome(VDTS) is seen in contact lens & computer users

Keratoconyuntivitis sicca

It is autoimmune diseases

- It is occurs in woman after menopause - It is often associated with rheumatoid arthritis.

Visual display terminal syndrome Computers ; this because the palpebral fissure is widened and blink rate is decrease while using computer.,

Contact lens : also contribute to development of dry eyes due to - rigid lenses disrupt the lipid layer, enhansing evaporation of the tear film - cl also decrease the corneal sensation Symptoms : - burning and irritation - photophobia and lacrimation - impaired vision in case corneal opacity - night blindness in cases of vit.A def

Xeropthalmia(vitamin A deficiency
WHO Classification : 1. Primary sign : - X IA : Conyungtival xerosis - X IB : Bitots spots with cony.xerosis < 1/3 corneal surface. - X 2 : Corneal xerosis - X 3A: Corneal ulceration with xerosis 1/3 corneal surface - X 3B: Keratomalacia 1/3 corneal surface.

Secondary sign : - XN : Night blindness - XF : Xerophthalmia fundus ( pale yellow spots ) - XS : Xerophthalmia scars ( in cornea) Investigation : - Slit lamp exam - Fluorescein staining - Schirmer test

Treatment : - tears substitutes eye drop - vit.A is given high doses of cases vit.A def. 200,000 IU(tretinoin) to children between 1-6 years age. - supplementthe diet with foodsrich in vit. A,eg fish,liver,egg,milk,carrot etc.

3. Chemosis : oedema of the cony. Due to vascular statis. Etiology : - acut inflammation - obstruction to the venous circulation - abnormal bloos conditions ,anemia , urticaria.

Pterigium adalah kelainan pada konjungtiva bulbi, berbentuk segitiga ,berada di fisura palpebra dan mengarah ke kornea Bagian-bagian pterigium : 1. Kaput 2. Apeks 3. Kollum 4. Korpus

ETIOLOGI - Belum diketahui pasti - Teori yang dikemukakan : 1. Paparan sinar matahari (UV) 2. Iritasi kronik dari lingkungan ( udara, angin, debu )

PATOLOGI - Proses degeneratif (hiperplasia) jar. subkonjungtiva - Perubahan kornea ( apeks pterigium ) membran konjungtiva rusak dan lamel superficial kornea diinvasi jar. granulasi

KLASIFIKASI A. Berdasarkan luas perkembangannya : Stadium I : pterigium belum mencapai limbus Stadium II : sudah mencapai atau melewati limbus tapi belum mencapai daerah pupil Stadium III : sudah mencapai daerah pupil

B. Berdasarkan progresifitas tumbuhnya : Stasioner : relatif tidak berkembang lagi ( tipis, pucat, atrofi ) Progresif : berkembang lebih besar dalam waktu singkat C. Berdasarkan tipenya : Membran/fibrosa : tipis & pucat, p.drh 5< Vaskuler : hiperemi , p. drh >5

GAMBARAN KLINIK Lesi biasanya terdapat di sisi nasal konjungtiva bulbi. Bisa dijumpai di sisi nasal dan temporal pada satu mata ( Pterigium dupleks ) atau pada kedua mata ( Pterigium bilateral ) Gejala subyektif : Rasa perih, terganjal, sensasi benda asing, silau, berair, gangguan visus, masalah kosmetik.

Gejala Obyektif : Konjungtiva bulbi ( fissura palp ) jar. Fibrovaskuler berbentuk segitiga (apeks menuju kornea atau di kornea) Di depan apeks kdg dijumpai : Yellow brown line = Pigmented iron line = Stockers line Grey cap ( Grey zone )

 Pada pterigium yang besar, gerakan bola mata terbatas ke arah yang berlawanan dgn lesi. Gangguan visus stad III ok : menutupi zona optik kornea kurvatur kornea terganggu astigmat Diplopia timbul bila pterigium besar

DIAGNOSIS Ditegakkan berdasarkan gejala klinik

DIAGNOSIS BANDING 1. Pinguekula (pterigium std. I) 2. Pseudopterigium (pterigium stad. II & III)

PTERIGIUM

PSEUDOPTERIGIUM

1.Lokasi

Selalu di fissura palpebra

Sembarang lokasi

2.Progresifi Bisa progresif Selalu stasioner atau stasioner tas 3.Riwayat peny. 4.Tes sondase Ulkus kornea(-) Negatif Ulkus kornea (+) positif

PENGOBATAN 1. Non bedah Mengurangi keluhan subjektif, mis : gatalantihistamin merahvasokonstriksi topikal 2. Operasi Bare sclera Simple closure Sliding flap Rotational flap Conjungtival graft

INDIKASI OPERASI 1. Menurut Ziegler Mengganggu visus Mengganggu pergerakan bolamata Berkembang progressif Mendahului suatu operasi intraokulwer Kosmetik 2. Menurut Guilermo Pico Progressif Mengganggu visus Mengganggu pergerakan bola mata

Masalah kosmetik Di depan apeks pterigium terdapat grey zone Pada pterigium dan kornea sekitarnya ada nodul pungtat Terjadi kongesti (klinis) secara periodik KOMPLIKASI A. Selama operasi Perforasi kornea atau sklera Trauma pada m. rektus medialis atau lateral

2. Sesudah operasi - Infeksi - Granuloma - Fuchs dellen - Neovaskularisasi - Sikatriks kornea - Astigmat kornea

PTERIGIUM REKUREN
Disebut juga pterigium sekunder = pt.residif * Disebut rekuren bila timbul kembali dlm waktu 7 hari- 6 bulan post op * Bukan merupakan suatu pterigium yg benar-benar rekuren, lebih tepat disebut pterigium sekunder * Insidens : 30 50 % * Faktor yg mempengaruhi :

- Usia - progresifitas - Tipe pterigium - Tehnik / metode operasi - Iritasi * Upaya mengurangi rekuren : 1. Tunda op sampai usia dekade 4 2. Gunakan sitostatika topikal, mis mitomicin C (Pt progresif)

3. Gunakan radiasi sinar beta (tipe vaskuler) 4. Pilih metode operasi yg baik 5. Kurangi iritasi

PINGUEKULA
Pinguekula : suatu kelainan berwarna kekuning-kekuningan, berbtk segitiga yg terdpt dikonj.bulbi Lokalisasi: - Fissura palpebra, seringkali dibag nasal, bbrp milimeter dari limbus kornea Etiologi: -Proses degenerasi hyalin jar. Ikat disertai proliferasi serat elastik kuning disubstansi propria konjungtiva

Gambaran klinis: - lesi kekuningan menyerupai lemak, dg perkembangan yg stasioner berbtk segitiga difissura palpebralis dg basis mengarah ke kornea Pengobatan: - Tidak perlu pengobatan - Biasanya diangkat dg operasi krn alasan kosmetik (pinguekula yg besar)

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