Conjunctival Follicles versus Papillae – How to differentiate Follicles and Papillae on Slit Lamp Exam?

Papillae : Flat-topped elevations in the tarsal conjuctiva containig blood vessels and having a smooth, velvety appearance, present in some forms of allergic conjuctivitis.

Papillae are flat-topped polygonal elevations in the conjunctiva that are separated from each
other by a narrow gap . A papilla consists of a tuft of vessels covered by epithelium and surrounded
by fibrous septa.

There are two types of papillae:
Simple papillae: 1-2 mm in size, seen in the
upper tarsal conjunctiva. They are seen in
spring catarrh and atopic conjunctivitis.
Giant papillae: These are larger than 2 mm
in diameter. They are seen in contact lens
users, eyes using ocular prosthesis or where
round nylon sutures are left following
various surgeries. Rarely giant papillae are
seen in spring catarrh and atopic keratoconjunctivitis.

More on Conjunctival Papillae here.

On the other hand, follicle formation in conjunctiva is a lymphoid
reaction to insult of the conjunctiva, eg, bacterial, viral, irritant and drugs.
Follicles are small hemispherical
raised spots; there is no vessel in the
follicle. It mostly comprises lymphoid tissue,
with vessels either surround the follicles or
develop underneath them.

Follicle: localised area of lymphoid herplasia, appearing white or grey elevations in the upper or lower tarsal conjunctiva, which may be accompned by inflammation(folliculosis) accompanrd by viral, allergic or bacterial conjuctivitis.

More on Conjunctival Follicles here.

It is important to differentiate conjunctival follicles from papillae, as they can often look similar clinically on slit lamp examination.

discrete rounded elevated lesionelevated polygonal hyperemic areas separated by paler areas
0.5 – 5 mm diameter0.3- 2.0 mm , giant if > 1.0 mm
Usually located in the inferior palpebral conj although they can be seen superiorly ; may be present at the limbusAnywhere on the conjunctiva, limbus , giant papillae over superior tarsus
Vascular network around the follicle; vessels disappear towards the center of the follicleCentral fibrovascular core in each papilla which on reaching the surface forms arborised vascular figure
Represents new formation of lymphoid tissue composed of lymphocytes , macrophages, plasma cells – may form lymphoid folliclesComposed of PMN leucocytes and other acute inflammatory cells; epithelial hypertrophy
No histologic difference in the follicles due to different causes- irritants, infections or in folliculosisConnective tissue septae are anchored into deeper tissues, resulting in polygonal outline; giant papillae occur when these septae rupture
Follicles versus Papillae
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