26. Conjunctivitis II & Eyelid Disorders

Question 1

What are the 7 viruses that can cause viral conjunctivitis?

Answer 1

• Adenovirus
• Herpes simplex virus
• Variola
• Molluscum
• Rubella
• Epstein-Barr
• COVID-19

Question 2

What are the prevalence of viral conjunctivitis?

Answer 2

80% of all acute conjunctivitis are viral

65-90% of viral conjunctivitis are adenovirus

Question 3

What are the 2 viral conjunctivitis that adenovirus commonly cause?

Answer 3

• Pharyngoconjunctival fever (PCF)
• Epidemic keratoconjunctivitis (EKC)

Question 4

PCF stands for .... It is caused by ... serotypes ... and .... This is more common in .... It causes a characteristic trifactor of conditions: ..., ... and .... PCF is ... but .... Symptoms include: watery, ... eyes and .... Often arise ... and then become ... in ... days. Can be associated with ... and ....

Answer 4

PCF stands for pharyngoconjunctivtial fever. It is caused by adenovirus serotypes 3 and 7. This is more common in children. It causes a characteristic trifactor of conditions: pink eye, low grade fever and upper respiratory tract infection. PCF is self-limiting but highly contagious. Symptoms include: watery, gritty eyes and FB sensation. Often arise unilateral and then become bilateral in 3-7 days. Can be associated with pharyngitis and fever.

Question 5

Signs of PCF:
*... conjunctivitis
* Eyelid ...
* Often ... in presentation
* Positive ... = ... usually ... days after onset
* May have ... → should be removed
* May have ... in up to ...% of cases, involve `` or rarely ....

Answer 5

Signs of PCF:
*Follicular conjunctivitis
* Eyelid oedema
* Often bilateral in presentation
* Positive PAN → preauricular adenopathy usually 3-4 days after onset
* May have psuedomemebrane → should be removed
* May have keratitis in up to 30% of cases, involve diffuse SPK or rarely subepithelial infiltrates.

Question 6

Treatment of PCF is relatively simple due to PCF being .... Px should be ... in order to prevent spread of ..., infected individuals tend to be infectious for ... (...). Symptoms may persist .... There are no ... proven effective against adenovirus. Some practitioners may use ... (... ...%) off label or combine ... with ... QID for 5 days. General treatment is mostly for .../ ..., which includes ..., ..., ` relief of … and … and use of … for severe inflammation e.g. … (dosing regimen) with …. PCF should resolve within … to … days and Optoms should … and … for any …`.

Answer 6

Treatment of PCF is relatively simple due to PCF being self limiting. Px should be educated in order to prevent spread of adenovirus, infected individuals tend to be infectious for 2 weeks (2/52). Symptoms may persist after px is not contagious anymore. There are no antiviral agent proven effective against adenovirus. Some practitioners may use Betadine (povidone-iodine 2%) off label or combine betadine with dexamethosome QID for 5 days. General treatment is mostly for symptom relieve/ supportive therapy, which includes cold compresses, artificial tears, relief of pharyngitis and fever and use of steroids for severe inflammation e.g. Flarex BID or QID with slow taper. PCF should resolve within 7-14 days and Optoms should review and monitor for any corneal involvement.

Question 7

What are the 4 differential diagnosis for pharyngoconjunctival fever?

Answer 7

• Epidemic keratoconjunctivitis
• Molluscum contagiosum conjunctivitis
• Allergic conjunctivitis
• Topical drug hypersensitivity

Question 8

EKC stands for .... It is caused by ... serotypes ..., ..., .... It has a characteristic ... onset of ..., ... with .... This may become ... later on. It can be associated with ..., ..., or ... conjunctivitis. Unlike, PCF, there is no .... Px may present with ..., ... eyes. Conjunctivitis will persist for ... weeks and may also involve .... Px tend to be highly contagious for ...-... days.

Answer 8

EKC stands for Epidemic Keratoconjunctivitis. It is caused by adenovirus serotypes 8, 19, 37. It has a characteristic acute onset of unilateral, follicular conjunctivitis with ipsilateral node. This may become bilateral later on. It can be associated with haemorrhagic, pseudomembranous, or membranous conjunctivitis. Unlike, PCF, there is no respiratory involvement. Px may present with watery, uncomfortable eyes. Conjunctivitis will persist for 1-2 weeks and may also have corneal involvement. Px tend to be highly contagious for 21-28 days.

Question 9

What are the corneal involvement overtime with EKC? (At infection → 1 week → 2 weeks → 1 month)

Answer 9

• At infection → fine SPK
• Week 1 → focal epithelial opacities
• Week 2 → subepithelial infiltrates develop under opacities (49-80% incidence in EKC; No virus isolation after 14 days)
• 1 month → epithelium healed but subepithelial infiltrate persist for months up to 1 year

Question 10

Treatment of EKC:
* There are no .... Px should be prescribed ..., which involves ... and ` …. * Some practitioners may use …-… 2% ` (…) off label
* Topical ... may be required to control inflammation, such as ... ... to ... with slow .... This may be continued ... period, which is useful in reducing ..., therefore can ....

Answer 10

Treatment of EKC:
There are no antivirals proven to be effective against Adenovirus. Px should be prescribed supportive treatments, which involves vasoconstrictors and cold compress.
* Some practitioners may use Povidone-Iodine 2% (Betadine) off label
* Topical steroids may be required to control inflammation, such as Flarex BID to QID with slow taper. This may be continued post-infectious period, which is useful in reducing subepithelial infiltrates, therefore can improve visual acuity.

Question 11

What are the main prevention methods of EKC?

Answer 11

• Px education → frequent hand washing, avoid eye rubbing; stay home during infectious period
• Office outbreaks are common
∴ should disinfect equipment; beware of contaminated eye drops bottle tops; use hydrogen peroxide; use glove; frequent hand washing

Question 12

Herpes conjunctivitis can be caused by two different viruses: ... or ....
* ... presents as a .... It makes up of ...% of acute conjunctivitis. Common characteristics involve ... discharge, ` … lesions on eyelid skin, and postive …. Antivirals are commonly used to treat this, which includes …, …, … and trifluridine. * … involves conjunctivitis, …, …, … and …`.

Answer 12

Herpes conjunctivitis can be caused by two different viruses: Herpes Simplex virus or Herpes Zoster Virus.
* Herpes Simplex virus presents as a unilateral follicular conjunctivitis. It makes up of 1.3-4.8% of acute conjunctivitis. Common characteristics involve water discharge, vesicular lesions on eyelid skin, and postive preauricular lymphadenopathy.
Antivirals are commonly used to treat this, which includes ganciclovir, idoxurdine, vidarabine and trifluridine.
* Herpes Zoster virus involves conjunctivitis, eyelid lesions, uveitis, subepithelial infiltrates and pseudodendrites.

Question 13

Link the viral infections to the conditions that they cause:

Herpes virus
* Varicella zoster - chickenpox
* Herpes zoster ophthalmicus - recurrent chickenpox

Paramyxoviruses
* Mumps virus - follicular conjunctivitis, SPK, disciform keratitis
* Measles virus - follicular conjunctivitis, SPK, interstitial keratitis, corneal ulcers
* Newcastle disease - follicular conjunctivitis, SPK, SEI Papovaviruses
* Human papilloma virus - warts, papillae, SPK

Answer 13

Link the viral infections to the conditions that they cause:

Herpes virus
* Varicella zoster - chickenpox
* Herpes zoster ophthalmicus - recurrent chickenpox

Paramyxoviruses
* Mumps virus - follicular conjunctivitis, SPK, disciform keratitis
* Measles virus - follicular conjunctivitis, SPK, interstitial keratitis, corneal ulcers
* Newcastle disease - follicular conjunctivitis, SPK, SEI Papovaviruses
* Human papilloma virus - warts, papillae, SPK

Question 14

Link the viral infections to the conditions that they cause:
Picornavirus
* Entero (coxsackie) virus - ..., ..., ..., ....
Poxvirus
* Variola (smallpox) - ..., ...
* ...- follicular conjunctivitis, SPK, pannus lesion
Togavirus
* ... - follicular conjunctivitis, SPK

Answer 14

Link the viral infections to the conditions that they cause:
Picornavirus
* Entero (coxsackie) virus - acute haemorrhagic conjunctivitis, follicular conjunctivitis, subconjunctivital haemorrhages, watery discharge.
Poxvirus
* Variola (smallpox) - follicular conjunctivitis, corneal pocks/ interstitial/ disciform keratitis
* Molluscum contagiosum- follicular conjunctivitis, SPK, pannus lesion
Togavirus
* Rubella - follicular conjunctivitis, SPK

Question 15

Link the viral infections to the conditions that they cause:
Epstein-Barr virus
* Infectious mononucleosis - ..., ..., ...
Ebola viruses
* ..., ...
Cornoaviruses
* Possible ...

Answer 15

Link the viral infections to the conditions that they cause:
Epstein-Barr virus
* Infectious mononucleosis - follicular conjunctivitis, focal epithelial keratitis, lamellar corneal infiltrates
Ebola viruses
* Acute haemorrhagic conjunctivitis, subconjunctivital haemorrhages
Cornoaviruses
* Possible conjunctivitis

Question 16

Molluscum contagiosum is common in ... and in ... patients. They are spread through ... or ....
There are characteristic signs including ..., ..., and pannus. Px may also present with multiple ... with a pearly, waxy, ... that are commonly found on the ... etc. These lesions are ....

Answer 16

Molluscum contagiosum is common in kids and in immunocompromised patients. They are spread through skin-to-skin or sexual intercourse.
There are characteristic signs including follicular conjunctivitis, SPK, and pannus. Px may also present with multiple umbilicated lesions/ papules with a pearly, waxy, dome-shaped/ creamcake lesion that are commonly found on the eyelids, face, arms, legs, abdomen etc. These lesions are self-limiting.

Question 17

Ebola virus disesase is previously known as .... It is rare, severe and has ... fatality rate. It is spread through .... Ocular signs of infection includes ... and .... Early signs of infection includes fever, ... and sore throat. Later on, px may have vomitting, ..., rash, ..., and impaired kidney and liver function.

Answer 17

Ebola virus disesase is previously known as Ebola haemorrhagic fever. It is rare, severe and has 50% fatality rate. It is spread through bodily fluids, blood and fruit bats. Ocular signs of infection includes conjunctival injection and subconjunctival haemorrhage. Early signs of infection includes fever, muscle pain and sore throat. Later on, px may have vomitting, diarrhoea, rash, internal and external bleeding, and impaired kidney and liver function.

Question 18

... related conjunctivitis is rare and present as .... Symptoms usually include ..., ... in palpebral conjunctiva, ..., ..., watery discharge, eyelid edema and positive .... It is theorised that the ocular suface may be the .... Vaccines that utilises ... have been associated with ....

Answer 18

COVID-19 related conjunctivitis is rare and present as unilateral. Symptoms usually include mild hyperaemia, follicles in palpebral conjunctiva, chemosis, epiphora, watery discharge, eyelid edema and positive PAN. It is theorised that the ocular suface may be the transmission site. Vaccines that utilises viral vectors have been associated with follicular conjunctivitis.

Question 19

Toxic Follicular conjunctivitis is also known as .... This can be caused by the exposure to ...; long term use of ... containing ...; or direct cytotoxicity from ..., ..., ... or scarring. This has to be differentially diagnosed from ..., ..., toxic epidermal necrolysis or ....

Answer 19

Toxic Follicular conjunctivitis is also known as keratoconjunctivitis medicamentosa. This can be caused by the exposure to noxious foreign substances; long term use of topical eye medications containing benzalkonium chloride (BAK); or direct cytotoxicity from chronic inflammation, ocular surface changes, fibrosis or scarring. This has to be differentially diagnosed from inclusion conjunctivitis (chlamydia), allergic conjunctivitis, toxic epidermal necrolysis or Stevens-Johnson syndrome.

Question 20

What is epiblepharon? How is this treated?

Answer 20

Epiblepharon is a congenital condition where the lower eyelids turn inwards, sometimes the lashes may also turn in and cause kertopathy. This is common in Asian children and is usually bilateral. This condition is self resolving and may require epilation of the lashes of eyelid surgery.

Question 21

What are epicanthal folds?

Answer 21

Epicanthal folds are when the medial fold of the superior eyelid, causing the nasal canthus to be covered. This is common in Asians and may also be associated with medical conditions such as FAS, Downs syndrome or Blepharophimosis. No treatment is required. This may give psuedostrabismus, which is the false appearance of esotropia.

Question 22

Eyelid coloboma is a rare, ..., facial cleft. It can present as .... Usually ... are unvolved. It can range from having a small notch to .... This is also associated with other ocular abnormalities: ..., lipodermoid, ..., coloboma of the ..., and .... It may also be associated with syndromes: ..., Treacher Collins, CHARGE, Goldenhar etc. Treatment include ..., amblyopia management or surgery.

Answer 22

Eyelid coloboma is a rare, congenital, facial cleft. It can present as unilateral or bilateral. Usually 1 to 4 eyelids are unvolved. It can range from having a small notch to full thickness eyelid defect. This is also associated with other ocular abnormalities: dermoid, lipodermoid, keratoconus, coloboma of the iris, and microophthalmia. It may also be associated with syndromes: Fraser Syndrome, Treacher Collins, CHARGE, Goldenhar etc. Treatment include corneal protection, amblyopia management or surgery.

Question 23

Ptosis is also called ... which is when the .... This is because of the .... This can be ... such that it can be related to amblyopia or ..., or it can be ... due to paralysis of the .... This can be due to midbrain infraction (...), head injury, ..., diabetes, or ....
Pharmacological treatment tend to only be effective with ..., where ... 0.1% is used. Sugerical treatments includes ....

Answer 23

Ptosis is also called blepharoptosis which is when the upper eyelid droops. This is because of the dehiscence or stretching of the levator aponeurosis from the tarsal plate. This can be congenital such that it can be related to amblyopia or Marcus Gunn phenomenon, or it can be acquired due to paralysis of the motor and sensory nerve fibres. This can be due to midbrain infraction (CN3 palsy), head injury, muscular dystrophy, diabetes, or brain tumour.
Pharmacological treatment tend to only be effective with acquired adult ptosis, where oxymetazoline 0.1% is used. Sugerical treatments includes Levator resection surgery.

Question 24

BPES stands for .... This is a rare, ... and ... condition that encompasses 4 different eyelid abnormalities: ..., ..., ... and .... There are two different surgeries for this condition: ... and ptosis surgery.

Answer 24

BPES stands for Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome. This is a rare, hereditary and congenital condition that encompasses 4 different eyelid abnormalities: blepharophimosis, ptosis, epicanthus inversus and telecanthus. There are two different surgeries for this condition: epicanthus-telecanthus surgery and ptosis surgery.

Question 25

What is lagophthalmos? What are the consequences and treatments for this condition?

Answer 25

Lagopthalmos is the incomplete eyelid closure, causing the cornea (inferior) to be exposed and evaporation of tear film. It will result in inferior horizontal band of SPK.
Treatment includes lubrication and eyelid taping.

Question 26

What is blepharospasm? What are the consequences and treatment for this condition?

Answer 26

Blepharospasm is the involuntary eyelid twitching and forceful closure. Px will struggle with instilling eye drops and contact lenses. There is no confirmed cause for this condition, but it is speculated that it is due to overactivity of CN7.
Treatment options include injection of Botulism toxin A (Botox), however one of the most common side effect of this treatment is ptosis.

Question 27

Dermatochalasis is the ... due to reduced ..., age, gravity, and loss of .... The upper eyelid tend to have ... compared to the lower eyelid, which can lead to .... This can be associated with ..., xanthelasma and ....
Treatment includes ....

Answer 27

Dermatochalasis is the drooping of the upper eyelid skin due to reduced skin redundancy, laxity, age, gravity, and loss of connective tissues. The upper eyelid tend to have more drooping compared to the lower eyelid, which can lead to superior visual field loss and driving complications. This can be associated with Ehler-Danlos syndrome, xanthelasma and cutis laxa.
Treatment includes blepharoplasty.

Question 28

What are the 5 abbreviations for spotting malignant eyelid lesions?

Answer 28

• HABCD
• loss of Hair
• Asymmetrical, Abnormal blood vessel
• Border, pigmented
• Change in colour/ size
• Diameter larger than 5 mm

Question 29

Basal cell carcinoma makes up of ...% of all skin carcinomas. 80% are found on the ... or ..., whereas 20% are found on .... This tend to emerge around the age of ...yo. BCC have a low ..... rate and ... is rare. However, there is a a high tendency to .... Lid ... is often necessary following the excision of BCC, due to ... defects.
Signs of BCC includes ... edges, ... colour, ... and .... Not all BCC are visible and palpebal mass is only seen in ...% of cases. ... is often required along with a ... scan to confirm diagnosis and check if there is any ....

Answer 29

Basal cell carcinoma makes up of 70-80% of all skin carcinomas. 80% are found on the head or neck, whereas 20% are found on eyelids. This tend to emerge around the age of 60-80yo. BCC have a low mortality rate and metastasis is rare. However, there is a a high tendency to invade neighbouring tissues. Lid reconstruction is often necessary following the excision of BCC, due to post-excisional defects. Signs of BCC includes pearly edges, pinkish colour, ulceration and bleeding. Not all BCC are visible and palpebal mass is only seen in 37% of cases. Biopsy is often required along with a CT scan to confirm diagnosis and check if there is any orbital invasion.

Question 30

Squamous cell carcinoma is rare but ..., with ...% chance of metastasis. This is often found as .... They develop ... or from other lesions, such as ..., actinic keratosis, ....
There are various presentations of SCC, including ..., irregular rolled edges, ..., central ..., flat pale ... lesion. SCC needs to be ....

Answer 30

Squamous cell carcinoma is rare but potentially fatal, with 20% chance of metastasis. This is often found as epithelial lower eyelid tumours. They develop spontaneously or from other lesions, such as keratocanthomas, actinic keratosis, radiation dermatosis.
There are various presentations of SCC, including nodular, irregular rolled edges, telangiectasis, central ulceration, flat pale reddish flaky lesion. SCC needs to be surgerically excised.

Question 31

Sebaceous cell carcinoma is rare but .... There is a mortality rate of ...%. SCC is more common in ... ethnicities. It is often found .../ along .... SCC can arise from the ... and associate with the tarsal region and hair follicles.
SCC can present as a ... or .... It often has a similar appearance to ..., therefore must be carefully differential diagnosed. This is managed (in order) by: ... → ... → save vision → ... → cosmetic appearance.

Answer 31

Sebaceous cell carcinoma is rare but aggressive. There is a mortality rate of 30%. SCC is more common in Asian ethnicities. It is often found periorbital/ along eyelids. SCC can arise from the meibomian glands and associate with the tarsal region and hair follicles.
SCC can present as a solitary nodule or diffuse eyelid thickening. It often has a similar appearance to chalazion, therefore must be carefully differential diagnosed. This is managed (in order) by: tumour control → save globe → save vision → patient comfort → cosmetic appearance.