2: Conjunctiva Flashcards
1
Q
viral conjunctivitis
A
viral infection of the conjunctiva
2
Q
viral conjunctivitis etiology
A
- adenovirus in 90% of cases: transmission is through contact with respiratory or ocular secretions and fomites (e.g., towels, pool equipment, toys)
- rarely, mumps, measles, enterovirus, coxsackievirus, herpes simplex virus, varicella zoster virus, poxvirus
3
Q
viral conjunctivitis demographics
A
no predilection
4
Q
viral conjunctivitis laterality
A
- often starts in one eye and involves the fellow eye within a few days
- exception: herpes simplex and varicella zoster viruses typically cause a unilateral infection
5
Q
viral conjunctivitis symptoms
A
- red eye(s)
- watery mucous discharge
- ocular irritation (e.g., burning, FBS)
- Hx of recent upper respiratory infection (URI) or contact with someone with viral conjunctivitis
6
Q
viral conjunctivitis signs
A
- conjunctival injection and chemosis
- palpebral follicles*
- tender and/or swollen preauricular lymph nodes
- watery mucous discharge
- eyelid edema
- keratitis: epithelial microcysts in early stages, superficial punctate keratitis (SPK), focal white subepithelial infiltrates (SEIs) which may persist for months
- membrane/pseudomembrane with severe inflammation
7
Q
viral conjunctivitis management
A
- self-limiting within 2-3 weeks- cold compresses and topical lubricant for palliative treatment
- 5% ophthalmic betadine (povidone-iodine) wash in office- kills the adenovirus and reduces risk of transmission
- topical steroid- highly recommend if SEIs are present; slow taper as SEIs can last for months; may extend the period during which the patient remains infectious
- if a membrane or pseudomembrane is present, peel it with a cotton-tip applicator or smooth forceps; Rx topical steroid to reduce scarring
- discuss hand-washing, avoidance of eye rubbing and towel sharing, and restrict work or school to reduce risk of transmission
8
Q
viral conjunctivitis pearls:
- viral conjunctivitis is highly contagious as long as ____
- adenovirus particles can survive on dry surfaces for _____
- adenoplus can be used to ____
- spectrum of viral conjunctivitis- most common is _____
- a similar follicular conjunctivitis can occur due to ____
A
there is tearing/discharge or if the eyes are red (assuming the pt is not using a steroid), typically 10-12 days;
up to 7 weeks;
detect adenovirus and confirm the diagnosis- 90% sensitivity and 96% specificity;
non-specific acute follicular conjunctivitis (mild form);
a toxic reaction to a wide variety of ocular meds (known as toxic conjunctivitis or conjunctivitis medicamentosa)
9
Q
viral conjunctivitis pearls:
-epidemic keratoconjunctivitis (EKC)
A
- caused by adenovirus serotypes 8, 19, 37
- occurs in epidemics in workplaces (including hospitals), schools, and swimming pools
- severe form of viral conjunctivitis with corneal involvement in 80% of cases
10
Q
viral conjunctivitis pearls:
-pharyngoconjunctival fever (PCF)
A
- caused by adenovirus serotypes 3, 4, 7
- pharyngitis (sore throat) and a low grade fever are present
11
Q
viral conjunctivitis pearls:
-acute hemorrhagic conjunctivitis
A
- caused by enterovirus and coxsackie virus
- more common in tropical areas
- marked subconjunctival hemorrhage is present
12
Q
acute bacterial conjunctivitis
A
bacterial infection of the conjunctiva
13
Q
acute bacterial conjunctivitis etiology
A
- most commonly Staph aureus, Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis- transmission is through direct contact with ocular secretions
- minority of cases due to Neisseria gonorrhoeae- transmission is through direct contact with genital secretions
14
Q
acute bacterial conjunctivitis demographics
A
- more common in children and the elderly
- gonococcal infection occurs in sexually active adults
15
Q
acute bacterial conjunctivitis laterality
A
unilateral or bilateral
16
Q
acute bacterial conjunctivitis symptoms
A
- red eye(s)
- mucous discharge with eyelids stuck together on waking
- ocular irritation (e.g., burning, FBS)
- systemic symptoms may occur in patients with infection from Haemophilus influenzae (otitis media) and Neisseria gonorrhoeae (pain/burning while urinating, more frequent urinating, vaginal discharge)
17
Q
acute bacterial conjunctivitis signs
A
- conjunctival injection and chemosis
- palpebral papillae
- mucopurulent/purulent discharge*
- eyelid edema
- superficial punctate keratitis (SPK)
- if gonococcal, tender and/or swollen lymph nodes
18
Q
acute bacterial conjunctivitis management
A
- self-limiting within 1-2 weeks- broad spectrum topical antibiotic to speed recovery and prevent re-infection and transmission
- remove discharge with saline and/or cotton-tip applicator
- discuss hand-washing and avoidance of towel sharing to reduce risk of transmission
- in severe cases or if no resolution, culture to determine causative organism
- Haemophilus influenzae and Neisseria gonorrhoeae require systemic treatment in addition to a topical antibiotic- H. influenzae can be treated with Augmentin; N. gonorrhoeae should be referred out for 250 mg of IM ceftriaxone and 1 g of oral azithromycin
19
Q
acute bacterial conjunctivitis pearls:
- suspect gonococcal infection if _____
- if infection occurs in newborns (most commonly N. gonorrhoeae, C. trachomatis, HSV-2), called _____
A
onset is hyperacute (classically within 12-24 hours) with significant discharge;
ophthalmia neonatorum or neonatal conjunctivitis- prophylaxis is routinely performed with 2.5% ophthalmic betadine or eryhtromycin 0.5% ung
20
Q
(very) general rule:
- if an adult presents with a red eye, think _____
- when a child or elderly patient presents with a red eye, think _____
- if unsure if your diagnosis, you could _____
- if patient is a CL wearer, think ____
A
viral first (but could be bacterial);
bacterial first (but could be viral);
Rx a combo (ex: tobradex, zylet, maxitrol);
bacterial
21
Q
inclusion conjunctivitis
A
(adult chlamydial conjunctivitis)
chlamydial infection of the conjunctiva
22
Q
inclusion conjunctivitis etiology
A
- chlamydia trachomatis serotypes D-K: transmission is through direct contact with genital secretions
- is also a version that can be spread to humans from exotic birds
23
Q
inclusion conjunctivitis demographics
A
sexually active adults
24
Q
inclusion conjunctivitis laterality
A
often starts in one eye and involves the fellow eye within a few days
25
inclusion conjunctivitis symptoms
- red eye(s)
- mucous discharge
- ocular irritation (e.g., burning, FBS)
- systemic symptoms include pain/burning while urinating, more frequent urinating, vaginal discharge
26
inclusion conjunctivitis signs
- conjunctival injection
- palpebral papillae and follicles inferior > superior
- tender and/or swollen preauricular lymph nodes
- mucopurulent discharge
- eyelid edema
- keratitis: SPK, SEIs, pannus (vascular fibrous tissue on the corneal surface)
27
inclusion conjunctivitis management
- azithromycin 1 g in a single dose or doxycycline 100 mg bid PO x 1 week and concomitant topical erythromycin ung x 2-3 weeks
- confirmation of chlamydia through culturing of conjunctival sample or through urinalysis or genital swab
- refer to genitourinary specialist to exclude other STIs and trace sexual partners
28
inclusion conjunctivitis pearls:
- inclusion conjunctivitis can last ____
- symptoms commonly take ______ and follicles and SEIs can take _____
- chlamydia trachomatis can be a trigger for ____
for months (if a pt has a chronic conjunctivitis that does not resolve with topical antibiotics or steroids, consider chlamydial infection);
weeks to settle after treatment;
months to resolve;
reactive arthritis
29
trachoma
chlamydial infection of the conjunctiva
30
trachoma etiology
- chlamydia trachomatis serotypes A-C
- transmission is through direct contact with ocular or nasal secretions
- flies are also a vector
31
trachoma demographics
children and adults in areas of poor sanitation and crowded conditions
32
trachoma laterality
bilateral
33
trachoma symptoms
- red eye(s)
- mucous discharge
- ocular irritation (e.g., burning, FBS, pain)
- blurred vision
34
trachoma signs
- conjunctival injection
- palpebral papillae and follicles superior > inferior
- limbal follicles superior > inferior
- tender and/or swollen preauricular lymph nodes
- mucopurulent discharge
- eyelid edema
- keratitis superior: SPK, SEIs, pannus
- scarring of the conjunctiva: Herbert's pits (scarring of limbal follicles), Arlt's line (scarring of superior tarsal conjunctiva)
35
trachoma complications
- symblepharon
- cicatricial entropion
- trichiasis
- corneal ulceration
- corneal opacification (scarring)- secondary to cicatricial entropion with trichiasis
36
symblepharon
adhesion of palpebral conj to bulbar conj
37
cicatricial entropion
in-turning of the eyelid due to scarring of the tarsal conjunctiva
38
trichiasis
in-turning of the eyelashes due to entropion
39
corneal ulceration
stromal thinning with overlying epithelial epithelial defect
40
trachoma management
- SAFE strategy by WHO: surgery for trichiasis due to entropion, antibiotic for active disease, facial hygiene, environmental protection
- if non-healing epithelial defect or ulceration, consider bandage contact lens or amniotic membrane to relieve symptoms and facilitate healing
- if corneal opacification affects vision, refer for keratoplasty
41
trachoma pearls:
- leading cause of _____
- overcrowding and poor hygiene lead to _____
preventable, irreversible blindness worldwide;
cycles of re-infection which leads to more severe signs of conjunctival scarring, cicatricial entropion, trichiasis, corneal ulceration and opacification
42
allergic conjunctivitis
inflammation of the conjunctiva due to an allergen
43
allergic conjunctivitis etiology/associations
- seasonal allergic conjunctivitis (SAC)
- perennial allergic conjunctivitis (PAC)
- contact allergic blepharoconjunctivitis
44
seasonal allergic conjunctivitis (SAC)
type I hypersensitivity reaction typically caused by tree and grass pollens
45
perennial allergic conjunctivitis (PAC)
type I hypersensitivity reaction typically caused by dust mites, animal dander, fungal allergens
46
contact allergic blepharoconjunctivitis
type IV hypersensitivity reaction typically caused by contact with a substance; most commonly ophthalmic medications cosmetic products
47
allergic conjunctivitis demographics
no predilection
48
allergic conjunctivitis laterality
- bilateral for SAC, PAC
| - unilateral or bilateral for contact allergic blepharoconjunctivitis
49
allergic conjunctivitis symptoms
- red eye(s)
- ocular itching- esp at nasal canthus; if contact blepharoconjunctivitis, eyelid itching too
- watery or ropy mucous discharge
- sneezing and nasal discharge if SAC or PAC
50
allergic conjunctivitis signs
- conjunctival injection and chemosis
- palpebral papillae
- watery or ropy mucous discharge
- eyelid edema
- if contact blepharoconjunctivitis, vesicular rash with scaling/crusting of eyelid skin- if chronic, lichenification (leathery patches of skin) may be present
51
allergic conjunctivitis management
- identify allergens (consider allergy testing) and avoid them
- palliative therapy (cool compress, topical lubricant, dual action mast cell stabilizer/antihistamine)
- topical steroid in moderate to severe conjunctivitis in addition to above therapy
- if eyelid involvement, steroid ung or cream
- if systemic symptoms, consider recommending OTC systemic medication or referring to PCP
52
allergic conjunctivitis pearls:
- SAC is typically worse _____
- PAC is ____ and is ____ common and ____ than SAC
- if contact blepharoconjunctivitis only involves the skin, called _____
- patients can exarcebate a conjunctivitis (typically allergic conjunctivitis) by _____; called ____
during spring and summer;
throughout the year (worse in fall); less; milder;
contact dermatitis;
removing mucous from the eye;
mucus fishing syndrome- creates a cycle of inflammation and mucous production
53
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC)
severe allergic conjunctivitis that also involves the cornea
54
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) etiology/associations
- type I and IV hypersensitivity reaction induced by nonspecific stimuli (e.g., wind, dust, sunlight)
- commonly associated with other atopic conditions (e.g., allergic rhinitis, asthma, eczema)
55
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) demographics
- VKC: children, men > women
| - AKC: late teenage to 50s
56
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) laterality
bilateral
57
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) symptoms
- red eyes
- intense ocular itching
- watery or ropy mucous discharge
- ocular irritation (e.g., burning, FBS, pain)
58
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) signs
-conjunctival injection and chemosis
-palpebral papillae:
-VKC: giant, cobblestone appearance, superior >
inferior
-AKC: smaller, inferior > superior
-limbal papillae in VKC- may be associated with Horner-Trantas dots (collection of eosinophils)
-discharge:
-VKC: ropy, mucous discharge with deposition
between papillae
-AKC: watery mucous discharge
-eyelid edema
-keratitis: SPK, pannus, shield ulcer (more common in VKC vs AKC)
-atopic dermatitis (eczema) of the eyelid and elsewhere is common in AKC (erythema, scaling/crusting, lichenification)
-conjunctival and eyelid scarring occurs in severe cases of AKC
59
complications of AKC
- symblepharon
- ciciatricial ectropion
- cicatricial entropion
- trichiasis
- keratoconus due to intense, chronic eye rubbing
- anterior/posterior subcapsular cataract
60
cicatricial ectropion
out-turning of the eyelid due to scarring of the eyelid skin
61
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) management
- identify allergens (consider allergy testing) and remove them
- palliative treatment (cool compress, topical lubricant, dual action mast cell stabilizer/antihistamine- start 2-3 weeks before spring starts in VKC)
- topical steroid in moderate to severe conjunctivitis in addition to above therapy
- if shield ulcer, topical antibiotic for prophylaxis of bacterial infection and topical steroid (shield ulcers may need to be scraped to remove superficial plaque-like material before re-epithelialization will occur, may also consider a BCL or amniotic membrane to relieve symptoms and facilitate healing)
- if eyelid involvement, steroid ung or cream or tacrolimus ung
- if entropion, ectropion, or symblepharon, refer for surgery
62
vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) pearls:
- symptoms of VKC and AKC are similar, though those associated with ____ are more severe and unremitting
- VKC Is worse in _____; typically resolves by ____; ~___% develop AKC later in life
- AKC tends to be _____ and worse in ____; low expectation of _____
```
AKC;
late spring and summer;
late teens;
5;
year-round;
in the winter;
resolution
```
63
giant papillary conjunctivitis (GPC)
allergic conjunctivitis due to mechanical irritation of the tarsal conjunctiva from a foreign body
64
giant papillary conjunctivitis (GPC) etiology/associations
- contact lenses in 95% of cases (CLPC)- mainly due to build-up of proteinaceous deposits and cellular debris on the CL surface
- other causes include ocular prosthesis and exposed suture
65
giant papillary conjunctivitis (GPC) demographics
no predilection
66
giant papillary conjunctivitis (GPC) laterality
unilateral or bilateral
67
giant papillary conjunctivitis (GPC) symptoms
- red eye(s)
- ocular irritation (e.g., burning, FBS)
- ocular itching
- watery mucous discharge
- if contact lens related, CL intolerance due to excessive movement and FBS upon removal of CL
68
giant papillary conjunctivitis (GPC) signs
- conjunctival injection and chemosis
- giant palpebral papillae superior
- watery mucous discharge
- if contact lens related, deposits on CLs and excessive CL mobility due to UL capture
69
giant papillary conjunctivitis (GPC) management
- remove the stimulus if possible (CL wear should be d/c for several weeks)
- palliative therapy (cool compress, topical lubricant, dual action mast cell stabilizer/antihistamine)
- topical steroid in moderate to severe conjunctivitis
- refit in daily disposables (if pt declines, discuss CL hygiene and reduced wearing time)
70
giant papillary conjunctivitis (GPC) pearls:
| -_____ on all CL patients
evert the UL
71
superior limbic keratoconjunctivitis (SLK)
inflammation of the superior limbus, cornea, bulbar and tarsal conjunctiva
72
superior limbic keratoconjunctivitis (SLK) etiology/associations
- idiopathic (may be due to friction between superior tarsal and superior bulbar conj)
- associated with thyroid disease (50% of cases, typically hyperthyroid), dry eye, and CL wear
73
superior limbic keratoconjunctivitis (SLK) demographics
- typically occurs between the ages of 45-65 years
| - women > men
74
superior limbic keratoconjunctivitis (SLK) laterality
bilateral > unilateral
75
superior limbic keratoconjunctivitis (SLK) symptoms
- red eye(s) superior
- ocular irritation (e.g., burning, FBS, pain)
- ocular itching
- symptoms worse than signs
76
superior limbic keratoconjunctivitis (SLK) signs
- conjunctival injection and chemosis superior
- conjunctivochalasis superior
- palpebral papillae superior
- keratitis superior: SPK, SEIs, mild pannus
- mucous filaments superior
77
superior limbic keratoconjunctivitis (SLK) management
- aggressive topical lubrication (drop 4-8x/day and ung qhs)- reduce friction between tarsal and bulbar conj
- in moderate to severe cases, options include: topical steroid, autologous serum drop, tacrolimus ung, silver nitrate 0.5% soln applied to superior conj x10-20 secs
- BCL can relieve symptoms and facilitate healing
- acetylcysteine for dissolving mucous filaments
- if no resolution, refer for surgery (conj thermocautery, conj resection)
- if etiology is suggestive of thyroid disease and pt has not been diagnosed, order thyroid function tests (T3, T4, TSH)
78
superior limbic keratoconjunctivitis (SLK) pearls:
| -SLK is a chronic disease with _____
exacerbations and remissions that tend to diminish in frequency as age increases
79
ocular mucous membrane pemphigoid (ocular cicatricial pemphigoid- OCP)
systemic disorder characterized by blistering lesions that primarily affect mucous membranes (e.g., mouth, nose, throat, genitalia, anus); in some cases, blistering lesions may also develop on the skin especially the head and neck
80
ocular mucous membrane pemphigoid etiology/associations
autoimmune disease
81
ocular mucous membrane pemphigoid demographics
- typically affects patients 55 years and older
| - women > men
82
ocular mucous membrane pemphigoid laterality
bilateral
83
ocular mucous membrane pemphigoid symptoms
- red eyes
- discharge
- ocular irritation (e.g., burning, FBS, pain)
- blurred vision
- blistering of mouth, nose, throat
84
ocular mucous membrane pemphigoid signs
- conjunctival injection
- mucous discharge
- keratitis (SPK, pannus)
- membrane/pseudomembrane
- conjunctival scarring
- blistering of other mucous membranes (e.g., mouth, nose, throat)
85
ocular mucous membrane pemphigoid complications
- symblepharon
- cicatricial entropion
- trichiasis
- corneal ulceration
- corneal opacification (scarring- secondary to cicatricial entropion with trichiasis)
86
ocular mucous membrane pemphigoid management
- if diagnosis is in question, refer for conjunctival biopsy to detect the presence of the specific antibodies
- palliative therapy: topical lubricant, Restasis, punctal occlusion, moisture goggles
- topical steroid to suppress inflammation
- if corneal epithelial defect or ulceration present, topical antibiotic for prophylaxis of bacterial infection
- if non-healing epithelial defect or ulceration, consider BCL or amniotic membrane to relieve symptoms and facilitate healing
- if complications occur, consider referral for surgery (e.g., entropion surgery, keratoprosthesis)
- refer to PCP for systemic treatment (immunosuppressant, oral steroid, Dapsone)
87
ocular mucous membrane pemphigoid pearls:
- OCP is a chronic disease with ____
- most commonly affects _____
exacerbations and remissions;
| the eyes and mouth
88
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
systemic disorder of the skin and mucous membranes
89
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) etiology/associations
type IV hypersensitivity reaction induced by drugs (e.g., antibiotics, sulfa drugs, anti-epileptics, allopurinol, NSAIDs, acetaminophen) and infections (e.g., Mycoplasma pneumoniae, HSV, and adenovirus) most commonly
90
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) demographics
no predilection
91
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) laterality
bilateral
92
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) symptoms
- red eyes
- discharge
- ocular irritation (e.g., burning, FBS, pain)
- blurred vision
- blistering of nose, throat, genitalia
- red or purplish rash on the body followed by blistering and peeling of the skin
- fever and flu-like symptoms
93
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) signs
- conjunctival injection
- mucous discharge
- keratitis (SPK, pannus)
- membrane/pseudomembrane
- conjunctival scarring
- blistering of other mucous membranes (e.g., nose, throat)
- red or purplish rash on the body followed by blistering and peeling of the skin
- fever
94
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) complications
- symblepharon
- cicatricial entropion
- trichiasis
- corneal ulceration
- corneal opacification (scarring- secondary to cicatricial entropion with trichiasis)
95
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) management
-refer to ED: medical emergency, similar ocular treatment as ocular pemphigoid
96
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) pearls:
- ____ is the more mild form; _____ is the severe form
- SJS involves _____ body surface area
- TEN involves _____ body surface area
- can take _____ to recover, depending on severity
- mortality rate is ____ in SJS, up to _____ in TEN (due to _____)
```
SJS;
TEN;
<10%;
>30%;
weeks to months;
10%;
50%;
infection (through open skin sores)
```
97
pinguecula
- a benign, yellowish raised growth on the conjunctiva
- composed of an increased amount of distorted elastin fibers (with a degeneration of collagen fibers) in the conj stroma
98
pinguecula etiology/associations
- environment (e.g., sun, wind, dust, sand)
| - chronic ocular surface irritation
99
pinguecula demographics
- patients with increased exposure to sun, wind, dust, sand (e.g., construction workers, surfers)
- patients with chronic ocular surface irritation (e.g., allergies, dry eye)
100
pinguecula laterality
bilateral > unilateral
101
pinguecula symptoms
- asymptomatic
- may notice yellow discoloration
- ocular irritation (e.g., burning, FBS)
- ocular itching
102
pinguecula signs
- yellow-white, often triangular, slightly elevated conjunctival lesion adjacent to the nasal or temporal side of the limbus
- nasal > temporal
- may be vascularized
- dellen
103
dellen
thinning of the adjacent cornea secondary to drying
104
pinguecula complications
- pingueculitis (inflammation of the pinguecula)
| - pterygium
105
pterygium
- extension of fibrovascular tissue onto the corneal epithelium
- typically extends from a pinguecula
- can induce irregular astigmatism
- may extend into the visual axis
106
pinguecula management
- UV protection
- topical lubrication
- if pingueculitis, topical steroid
- if pterygium is affecting vision, refer for surgical excision (may recur after surgery)
107
pinguecula pearls:
| -_____ may be seen in the cornea at the leading edge of a pterygium
stocker line (an iron line)
108
conjunctivochalasis (redundant conjunctiva)
fold of redundant bulbar conjunctiva caused by the breakdown of collagen and elastin
109
conjunctivochalasis (redundant conjunctiva) etiology/associations
- age
- chronic conjunctivitis
- SLK
110
conjunctivochalasis (redundant conjunctiva) demographics
depends on etiology
111
conjunctivochalasis (redundant conjunctiva) laterality
unilateral or bilateral
112
conjunctivochalasis (redundant conjunctiva) symptoms
- asymptomatic
| - tearing
113
conjunctivochalasis (redundant conjunctiva) signs
- sagging bulbar conjunctiva
- typically inferior
- may extend over the lid margin
114
conjunctivochalasis (redundant conjunctiva) complications
epiphora (excess tearing due to blockage of inferior punctum)
115
conjunctivochalasis (redundant conjunctiva) management
- no treatment necessary if asymptomatic
| - if epiphora, refer for surgical conjunctival resection
116
concretion
- yellow-white deposit embedded in the palpebral and forniceal conjuntiva
- composed of protein and degenerated conjunctival epithelial cells that often undergo calcification
117
concretion etiology/associations
- age
| - chronic conjunctivitis
118
concretion demographics
depends on etiology
119
concretion laterality
unilateral or bilateral
120
concretion symptoms
- asymptomatic
| - FBS
121
concretion signs
- small, yellow-white deposits in the palpebral and forniceal conj
- inferior > superior
- typically embedded in the stroma but may erode through the epithelium
122
concretion management
- no treatment necessary if asymptomatic
| - if symptomatic, remove with a small gauge needle under topical anesthesia
123
conjunctival retention cyst (inclusion cyst)
thin-walled, fluid-filled cyst of the conjunctiva
124
conjunctival retention cyst (inclusion cyst) etiology/associations
- typically occurs as a result of trauma (e.g., surgery, eye rubbing) or chronic ocular inflammation (e.g., dry eye, allergies)
- conjunctival cells become reorganized forming pockets in which extracellular fluid can collect
125
conjunctival retention cyst (inclusion cyst) demographics
depends on etiology
126
conjunctival retention cyst (inclusion cyst) laterality
unilateral or bilateral
127
conjunctival retention cyst (inclusion cyst) symptoms
- asymptomatic
| - FBS
128
conjunctival retention cyst (inclusion cyst) signs
- translucent fluid-filled cyst
| - typically in the inferior fornix
129
conjunctival retention cyst (inclusion cyst) management
- no treatment necessary if asymptomatic
- if symptomatic, drain cyst with simple puncture with small gauge needle under topical anesthesia; may recur if cystic wall remains intact; for larger cysts or cysts that recur, surgical excision
130
conjunctival retention cyst (inclusion cyst) pearls:
| -similar finding is _____
lymphangiectasia:
- obstruction of bulbar conjunctiva lymphatic vessels
- appears as a cluster of small cysts like "string of pearls"
- often resolve spontaneously; if no resolution and symptomatic, similar treatment as retention cyst
131
pyogenic granuloma (lobular capillary hemangioma)
vascular lesion composed of endothelial cells of budding capillaries and inflammatory cells (polymorphonuclear lymphocytes and fibroblasts)
132
pyogenic granuloma (lobular capillary hemangioma) etiology/associations
-thought to occur as an abnormal reaction to wound healing- occurs in areas of prior trauma, chalazion, hordeolum
133
pyogenic granuloma (lobular capillary hemangioma) demographics
no predilection
134
pyogenic granuloma (lobular capillary hemangioma) laterality
unilateral
135
pyogenic granuloma (lobular capillary hemangioma) symptoms
- asymptomatic
- rapidly growing, red growth on eye
- ocular irritation (e.g., FBS, dryness)
136
pyogenic granuloma (lobular capillary hemangioma) signs
vascularized, pedunculated lesion that bleeds easily
137
pyogenic granuloma (lobular capillary hemangioma) management
- topical steroid qid x1-2 weeks
| - if no response to steroids, surgical excision; may recur after surgery
138
pyogenic granuloma (lobular capillary hemangioma) pearls:
- name of lesion is a ______
- can also occur _____
misnomer- it is not pyogenic (relating to pus), it is not a granuloma (mass of chronically inflamed tissue);
on the skin
139
conjunctival papilloma
benign tumor of the conjunctival epithelium
140
conjunctival papilloma etiology/associations
- proliferation of epithelial cells overlying a vascular core
- may be a response to viral infection (most commonly HPV)
141
conjunctival papilloma demographics
- if associated with HPV, children and young adults are most commonly affected
- if non-viral, most commonly occurs in the elderly
142
conjunctival papilloma laterality
unilateral
143
conjunctival papilloma symptoms
- asymptomatic
- growth on eye
- FBS
144
conjunctival papilloma signs
- sessile or pedunculated lesion with a fibrovascular core
| - often pink and spongy looking
145
conjunctival papilloma management
- may resolve spontaneously (more common with viral etiology)
- if symptomatic or suspicion for malignancy, refer out: surgical excision often with cryotherapy, adjunctive topical interferon alpha-2b or topical mitomyucin C or 5-fluorouracil to reduce recurrence
146
conjunctival papilloma pearls:
| -if it occurs in the elderly, consider _____
squamous cell carcinoma
147
limbal dermoid
benign tumor at the limbus
148
limbal dermoid etiology
- choristoma (normal tissue in an abnormal location) consisting of skin elements (stratified squamous epithelium, dense connective tissue, pilosebaceous units)
- congenital
- may be associated with Goldenhar syndrome (very rare developmental problem that affects half the face)
149
limbal dermoid laterality
unilateral or bilateral
150
limbal dermoid symptoms
- asymptomatic
- growth on eye
- FBS
151
limbal dermoid signs
- smooth, white, solid lesion at the limbus (typically IT limbus)
- irregular astigmatism
- egg type appearance
152
limbal dermoid complications
- refractive amblyopia
| - dellen
153
limbal dermoid management
- topical lubricant
- periodic removal of cilia
- correct the refractive error
- if symptomatic, refer out for surgical excision
154
limbal dermoid pearls:
| -may enlarge, especially during _____
puberty
155
conjunctival epithelial melanosis (racial melanosis)
excess pigmentation within the conjunctival epithelium
156
conjunctival epithelial melanosis (racial melanosis) etiology/associations
excess melanin related to race
157
conjunctival epithelial melanosis (racial melanosis) demographics
- apparent during 1st few years of life; may become more pronounced during puberty
- more common in dark-skinned individuals
158
conjunctival epithelial melanosis (racial melanosis) laterality
bilateral > unilateral
159
conjunctival epithelial melanosis (racial melanosis) symptoms
- asymptomatic
| - visible discoloration of the conjunctiva
160
conjunctival epithelial melanosis (racial melanosis) sigsn
- brown, flat, patchy, pigmentation scattered diffusely over the conj
- often concentrated around the limbus and Axenfeld loops
161
conjunctival epithelial melanosis (racial melanosis) management
none
162
conjunctival epithelial melanosis (racial melanosis) pearls:
| -similar finding is _____
primary acquired melanosis (PAM):
- typically occurs between 45-65 yoa
- flat brown patches of pigmentation w/o cysts
- more common in Caucasians
- unilateral
- may extend onto cornea
- ~10-30% develop into melanoma; suspect malignant transformation with elevation, increase in vascularity, size of > 2 clock hours
163
conjunctival nevus
benign tumor of the conjunctival epithelium
164
conjunctival nevus etiology/associations
proliferation of melanocytes
165
conjunctival nevus demographics
- often appear during puberty
| - more common in Caucasians
166
conjunctival nevus laterality
unilateral or bilateral
167
conjunctival nevus symptoms
- asymptomatic
| - visible discoloration of the conjunctiva
168
conjunctival nevus signs
- yellow to brown, flat or slightly elevated, circumscribed lesion; may be amelanotic
- typically in the interpalpebral region near the limbus
- often contains small cysts within the lesion
169
conjunctival nevus complications
malignant potential:
- most important sign is documented growth (however, may increase in size during puberty)
- risk is <1%
170
conjunctival nevus management
- monitor for melanoma: SL exam, ASeg photos
| - if change occurs, refer out
171
conjunctival melanoma
malignant tumor of the conjunctiva
172
conjunctival melanoma etiology
- proliferation of atypical melanocytes
| - arise from PAM (70%), nevus (20%), de novo (10%)
173
conjunctival melanoma demographics
- typically occurs between the ages of 45-65
| - more common in Caucasians
174
conjunctival melanoma laterality
unilateral
175
conjunctival melanoma symptoms
- asymptomatic
| - visible spot or discoloration of the conjunctiva or enlargement of a preexisting conjunctival lesion
176
conjunctival melanoma signs
- yellow to brown, elevated lesion with indistinct margins and irregular pigmentation; may be amelanotic
- well vascularized
- may extend onto the cornea
177
conjunctival melanoma complications
- intraocular and orbital invasion
| - metastasis; risk is 25%; mortality rate is 12% at 5 years and 25% at 10 years
178
conjunctival melanoma management
-refer out: surgical excision often with cryotherapy
179
ocular surface squamous neoplasia (OSSN)
- conjunctival-corneal intraepithelial neoplasia (CIN): pre-malignant tumor of the conjunctival and/or corneal epithelium
- carcinoma in situ: pre-malignant tumor of the conjunctival and/or corneal epithelium
- squamous cell carcinoma (SCC): malignant tumor of the conjunctiva and/or cornea
180
ocular surface squamous neoplasia (OSSN) etiology/associations
- proliferation of atypical epithelial cells of the conjunctiva and/or cornea
- CIN: confined to basal epithelial layers
- carcinoma in situ: involving the entire epithelial layer
- SCC: involving the entire epithelial layer and extending into stroma
181
ocular surface squamous neoplasia (OSSN) demographics
- typically occurs between ages of 50-70; suspect immunosuppression in patients <50
- more common in Caucasians
- men > women
182
ocular surface squamous neoplasia (OSSN) laterality
unilateral
183
ocular surface squamous neoplasia (OSSN) symptoms
- asymptomatic
- growth on eye
- ocular irritation (e.g., FBS, dryness)
184
ocular surface squamous neoplasia (OSSN) signs
- elevated lesion that appears gelatinous, leukoplakic, or papillomatous
- varies in color from pearly gray to reddish brown
- typically begins at the limbus in the interpalpebral region
- may extend onto the cornea; appears waxy and scalloped
- well vascularized
185
ocular surface squamous neoplasia (OSSN) complications
- CIN and carcinoma in situ: malignant potential
| - SCC: intraocular and orbital invasion; metastasis (risk is <1%)
186
ocular surface squamous neoplasia (OSSN) management
-refer out: surgical excision often with cryotherapy; adjunctive topical interferon alpha-2b or topical mitomycin C or 5-fluorouracil to reduce recurrence
187
ocular surface squamous neoplasia (OSSN) pearls:
| -_____ is the most common conjunctival malignancy
SCC
