Year : 1968 | Volume
: 16 | Issue : 3 | Page : 148--151
Ligneous conjunctivitis- Recurrent membranous conjunctivitis
Department of Ophthalmology, Jawaharlal Institute of Post-graduate Medical Education and Research, Pondicherry-6, India
N N Sood
Department of Ophthalmology, Jawaharlal Institute of Post-graduate Medical Education and Research, Pondicherry-6
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Sood N N. Ligneous conjunctivitis- Recurrent membranous conjunctivitis.Indian J Ophthalmol 1968;16:148-151
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Sood N N. Ligneous conjunctivitis- Recurrent membranous conjunctivitis. Indian J Ophthalmol [serial online] 1968 [cited 2021 Jun 17 ];16:148-151
Available from: https://www.ijo.in/text.asp?1968/16/3/148/37540
Membranous type of inflammation of conjunctiva is an uncommon type of conjunctivitis. This condition is associated with the formation of fibrinous exudates on the surface and into the substance of the epithelium of conjunctiva. It may be caused by a variety of noxious influences, the most common types being due to organisms (like diphtheria, streptococci) or chemical irritants like acids or alkalies. Rarely, membrane formation on the conjunctiva may be associated with bullous mucocutaneous lesions like erythema multiforme, benign mucous membrane pemphigus. The condition of ligneous conjunctivitis, is very rarely encountered, only 50 cases having been reported till 1965 (DUKE ELDER. 
During the last two years at the General Hospital and JIPMER Hospital, Pondicherry there were eight patients with membrane formation on the conjunctiva, as shown in [Table 1].
Since the cause of membranous conjunctivitis other than ligneous conjunctivitis are well known, only the latter condition will be discussed.
The condition of ligneous conjunctivitis is characterised by the formation of a membrane on the conjunctiva in children, persisting for months and years and later leading to the formation of granuloma of hyaline connective tissue. Because of the woodlike firmness of the resulting granuloma, the term ligneous conjunctivitis was suggested by BOREL  . Other names by which this condition has been designated are chronic membranous conjunctivitis, recurrent membranous conjunctivitis.
Case No. 1:
G - an eight year old boy presented with irritation of the left eye of a few weeks duration. Previous history revealed sore eyes at the age of two months which was followed by shrinkage of the right eye.
Examination revealed a phthisis bulbi of the right eye. The left eye showed congestion of fornix and on everting the upper lid, there was a whitish membrane on the tarsal conjunctiva measuring 10 mm horizontally and 4 mm vertically [Figure 1]. The membrane was adherent to the tarsal conjunctiva and removal resulted in bleeding. The cornea, and bulbar conjunctiva were normal. His visual acuity was 6/6 and the fundus was normal. Similar lesions were present in the upper tarsal conjunctiva of the right eye. Examination of nose and throat was normal. The child was suspected to be having diphtheritic conjunctivitis and 20,000 units of antidiphtheritic serum was given. Along with local instillation of penicillin drops, injections of penicillin were given intramuscularly. Two days later the lesions appeared slightly smaller but did not disappear.
The smears examined by direct staining and cultures failed to reveal any organism. General examination (including dermatological examination) showed nothing abnormal. Two months later, when the child was seen again, the lesion had assumed its original dimensions. A small portion of the membrane was removed and subjected to bacteriological and histological examinations. No organisms could be cultured and histology revealed a fibrinous exudation with lymphocytes and polymorphs [Figure 2].
All this time the child had minimal eye symptoms. Twelve months later when seen again, in the middle of the membrane a polypoidal mass could be seen [Figure 3]. This was excised and when subjected for histological examination showed hyalinised areas in the submucous region with scanty cellular reaction [Figure 4].
During all this time the vision in this eye has stayed normal.
Case No. 2:
M- a three year old female child was brought to the General Hospital with the complaints of redness, irritation and mild discharge. Examination revealed a well built but poorly nourished child. Ocular examination revealed a congested superior fornix of the right eye. On everting the lid a membrane was seen on the palpebral conjunctiva 5 mm X3 mm, firmly adherent to the underlying tarsal plate. Attempts at separation resulted in bleeding. A part of the membrane was subjected to smear and cultural examination. 20,000 units of antidiphtheritic serum was given intramuscularly along with penicillin drops. There was no regression of the membrane with the treatment. No organisms could be demonstrated in the smear and cultures. The child was attending the hospital regularly for nearly ten months and during this time there was neither any change in the size nor appearance of the lesion. The patient has failed to return for further follow up.
This condition of ligneous conjunctivitis has a predilection for children (2-6 years) and is more common in females (DUKE ELDER  ).
The condition is usually bilateral affecting often both upper lids, but sometimes all four lids. It frequently has an acute onset and may be associated with nasopharyngitis.
The membrane is chronic and recurs following attempts at surgical removal. Eventually the membrane is replaced by a granuloma formation.
The pathogenesis of the condition is uncertain.
Bacteriological examination is negative, occasionally secondary bacterial invaders may be present. VERHOEFF  postulated that the primary infectious agent in ligneous conjunctivitis may be a virus.
GOLDMAN AND HOF  consider that the disease may be familial. Their patient belonged to a family which in two generations had five cases. They therefore, concluded that a familial hereditary lowering of resistance played an important role in the disease. WINTER AND MICHLER  reported the cases of two brothers affected with the disease at an interval of about one year. It was noted by these authors that a membrane could be induced to form in a previously uninvolved area by traumatizing the conjunctiva with forceps. Traumatizing the conjunctiva with carbondioxide snow (dry ice) also induces the formation of a membrane. It is possible that ligneous conjunctivitis depends not only upon hereditary susceptibility to the original infection, but also upon an hereditary peculiarity of the palpebral tissue in its response to injury.
The treatment in the absence of a aetiological factors is unsatisfactory. In the acute phase, use of antibiotics may protect the cornea by preventing secondary infection. But the antibiotics and corticosteroids have not been found to decrease the severity or shorten the course of the disease.
Surgical treatment of granulomas is not advisable, due to recurrences. PAUFIQUE AND MOREAU  by repeatedly treating the denuded area by beta rays, prevented recurrences of the granulomas. As these cases are otherwise symptom free, and the disease does not affect the vision, it is advisable to leave them alone. In VERHOEF'S  case the granulomas persisted for 36 years without affecting the vision.
The essential features of ligneus conjunctivitis are summarized below.
Predilection for children:Chronic course. Yellowish white membrane on the tarsal conjunctiva [Figure 1] leading to a palpebral granuloma- [Figure 3].Histological examination: essentially fibrinous exudates [Figure 2] with development of hyalinization of submucous region [Figure 4] in the granuloma stage.Rapid reformation of membrane on the conjunctiva following attempts at removal.Hereditary peculiarity of palpebral tissue to trauma (WINTERS).Treatment is unsatisfactory. It may be left alone.Vision is usually not affected (except when the initiation of the disease is as an acute process (Case No. 1).
One histologically proven case of Ligneous conjunctivitis starting as an acute process is presented. A second case where the membrane formation on the conjunctiva is persisting for nearly ten months is also showing some of the features of this type of conjunctivitis. However, no granuloma could be seen during the period of her follow up. The condition has two distinct clinical phases - membranous or pseudomembranous stage -followed by a chronic course leading to the palpebral granuloma stage. The first case showed both the stages while the second case showed only the membranous stage lasting ten months, - the period of follow up.
|1||BOREL, M. G.: A new palpebral syndrome (In French) Bull. et mem. Soc. Franc. Ophth. 46, 168: 1933.|
|2||DUKE ELDER, S.: System of Ophthalmology. Diseases of outer eye. Vol. VIII. Henry Kimpton. London. 1965. P. 95.|
|3||GOLDMANN, H., and HOF, W.: Familial Pseudomembranous Conjunctivitis (In German) Schweitz. med. Voch. 84: 73, 1954.|
|4||PAUFIQUE AND MOREAU (1953)Bull. Soc. Ophthal. France. 120. Cited by DUKE ELDER, in 2.|
|5||VERHOEFF, F. H.: A. Case of Ligneous conjunctivitis now 36 years in duration. Amer. J. Ophthal. 54(2): 246, 1958.|
|6||WINTER, F. C., and MICHLER, R. R.: Chronic Membranous conjunctivitis Arch. Ophthal. (Chicago) 99: 161, 1953.|