25. Conjunctival Abnormalities Flashcards
(41 cards)
Conjunctiva is consist of an ... and ....
Conjunctival ... is ... cell layers thick and it consists of 3 different mucin secretors:
* ... cells
* Crypts of ...
* Glands of ...
Conjunctival ... is a ... connective tissue. It consists of 2 different accessory lacrimal glands:
* Glands of ...
* Glands of ...
Conjunctiva is consist of an epithelium and stroma.
Conjunctival epithelium is 2-10 cell layers thick and it consists of 3 different mucin secretors:
* Goblet cells
* Crypts of Henle
* Glands of Manz
Conjunctival stroma is a vascular connective tissue. It consists of 2 different accessory lacrimal glands:
* Glands of Krause
* Glands of Wolfring
-
...conjunctiva covers the inner surface of the eyelids -
...conjunctiva covers the junction between the two other parts -
...conjunctiva covers the sclera
”* Palpebral conjunctiva covers the inner surface of the eyelids
* Forniceal conjunctiva covers the junction between the two other parts
* Bulbar conjunctiva covers the sclera”
What are the risk factors of pinguecula?
- Ultraviolet light
- Trauma
*Wind, dust, sand - Working outdoors for a long duration
- Advancing age
- CLs wear
Pinguecula are ... deposition in the conjunctiva adjacent to the ..., mostly in the nasal position at either ... and ... o’clock positions. They can present as white, ..., ... and may have ... present. They are usually not excessively vascularised. This is caused by degeneration of the collagen fibres of the conjunctiva and thickening of the conjunctival stroma. Px can be asymptomatic mostly, but they can become inflamed, causing pingueculitis.
Pinguecula are gelatinous deposition in the conjunctiva adjacent to the limbus, mostly in the nasal position at either 3 and 9 o’clock positions. They can present as white, yellow, transparent and may have calcifications present. They are usually not excessively vascularised. This is caused by degeneration of the collagen fibres of the conjunctiva and thickening of the conjunctival stroma. Px can be asymptomatic mostly, but they can become inflamed, causing pingueculitis.
Dellen is the .... This present as ... at the limbus. They are the result of destruction that the ... cause to the tear film.
Dellen is the thinning portions next to pinguecula. This present as saucer-like excavations at the limbus. They are the result of destruction that the pinguecula cause to the tear film.
What are the treatments for pinguecula?
- Mildly symptomatic: Ocular lubricants e.g. Hylofresh QID, Systane TID; Cold compresses if FB sensation
- Severe inflammation: topcial steriods e.g. FML or Flarex QID - followup according to treatment schedule
- Refer for cosmetic surgery if required or if dellen persists
- Educate px on UV exposure, use of sunglasses
What are the differential diagnosis of pinguecula?
- Pterygium
- Conjunctival intraepithelial neoplasia (CIN)
- Other tumours e.g. papilloma, amelanotic conjunctival melanoma
- Limbal dermoid
- Conjunctival retention cyst
Pterygium is a vascular, ... mass of tissue that usually have a base towards the ... and slowly advancing tip towards the .... This generally arises at the .... This is often ... and can also have two one the same eye, such that they can be .... There is an opaque ... that overlies the defect in front of the .... Pterygium can cause increase in ... and px may experience ... and ....
Pterygium is a vascular, triangular mass of tissue that usually have a base towards the conjunctiva and slowly advancing tip towards the central cornea. This generally arises at the nasal conjunctiva. This is often bilateral and can also have two one the same eye, such that they can be medial and temporal together. There is an opaque epithelium that overlies the defect in front of the leading edge. Pterygium can cause increase in astigmatism and px may experience ocular surface irritation and foreign body sensation.
What is Stocker’s line?
Stocker’s line is a corneal epithelial iron line that can occur near the leading edge of a pterygium.
What techniques are used to assess a pterygium?
- Slit lamp, Keratometry/ Topography -> to monitor any astigmatism induced and if it has gotten worse
- Fluorescein staining
- Tear workup if indicated
- Document: photo or measurement, grading scales
Pterygium is managed via:
* Educating px on ... and the use of ...
* ... e.g. Hylofresh/ forte QID
* if acute inflammation -> topical ... e.g. FML or ... QID with ...
* Refer if any features ...
* Indications for surgery: ..., ...., recurrent ..., approaching ...
* advise px ... may occur within ...
Differential diagnosis: pinguecula, ..., ...
Pterygium is managed via:
* Educating px on UV protection and the use of sunglasses
* Ocular surface lubricants e.g. Hylofresh/ forte QID
* if acute inflammation -> topical corticosteroids e.g. FML or Flarex QID with tapering
* Refer if any features suggestive of malignancy
* Indications for surgery: progressive growth, progressive astigmatism, recurrent inflammation, approaching visual axis *advise px recurrence may occur within a year
Differential diagnosis: pinguecula, pannus, Conjunctival Intraepithelial Neoplasm (CIN)
How can Pterygium and Conjunctival Intraepithelial Neoplasm (CIN) be differentiated?
Pterygium:
* Nasal limbus
* Straight blood vessels
* No leukoplakia
* Fuch’s flecks (white flecks inside pterygium)
CIN
* Anywhere
* Telangiectatic vessels
* Common with leukoplakia
* No flecks
Concretions are small .... seen in the ... and ... conjunctiva. They are commonly seen in ... or people who had .... Px are mostly asymptomatic, but some may experience .... The most common aetiology is ... and may also be caused by .... This is commonly differentiated from abrasion and ....
Concretions are usually managed with ... if px are symptomatic. They can also be removed under ... at the slit lamp with a ... if leading to ocular surface irritation.
Concretions are small white to yellow crystalline deposits seen in the tarsal and forniceal conjunctiva. They are commonly seen in elderly or people who had conjunctivitis. Px are mostly asymptomatic, but some may experience foreign body sensation. The most common aetiology is idiopathic and may also be caused by chronic low grade inflammation. This is commonly differentiated from abrasion and conjunctival retention cysts.
Concretions are usually managed with tear supplements if px are symptomatic. They can also be removed under topical anaesthetics at the slit lamp with a 25-gauge needed if leading to ocular surface irritation.
Subconjunctival haemorrhage is also known as ..., which is .... There is a classic sign of ... as well as being able to locate the .... This is usually ... and may spread and look worse on the .... Similar to a bruise, they will turn ... and disappear within .... Px should be reasurred that the haemorrhage .... They do not associate with ..., ... or .... Subconjunctival haemorrhage is common in ... px, especially those with underlying ... disorders e.g. ..., .... Younger px tend to have more ... or ... causes. Px should be assessed of any ..., ..., intraocular pressure, ... and ....
Subconjunctival haemorrhage is also known as ecchymosis, which is bleeding underneath the conjunctiva. There is a classic sign of clear ring around the limbus as well as being able to locate the posterior limit to the haemorrhage. This is usually unilateral and may spread and look worse on the second day. Similar to a bruise, they will turn green or yellow and disappear within 3 weeks. Px should be reasurred that the haemorrhage may look worse before it looks better. They do not associate with discharge, ocular pain or vision disturbance. Subconjunctival haemorrhage is common in eldery px, especially those with underlying vascular disorders e.g. diabetes, hypertension. Younger px tend to have more spontaneous or traumatic causes. Px should be assessed of any trauma, conjunctival lesions, intraocular pressure, pupil reaction and ocular motility.
What are the causes of subconjunctival haemorrhage?
- Spontaneous/ unknown cause
- Physical trauma to eye
- Violent coughing, sneezing or vomiting
- High blood pressure
- Medications e.g. aspirin and warfarin that thin the blood and therefore increase the risk of bleeding
What should be done if there are more than 2 occurrence of subconjunctival haemorrhages in a year?
Refer for further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects.
What are the differential diagnosis of subconjunctival haemorrhage?
- Conjunctival Kaposi’s sarcoma
- Haemorrhagic conjunctivitis
- Breakthrough bleed from behind globe
- Other ocular neoplasia with secondary haemorrhage
Bitot’s spot is a dirty white, ..., foamy, ... in shape patches see in the conjunctiva due to ... of the .... It is usually ... in the ... side of the ... conjunctiva. This occurs in ... deficiencies in most developing countries. They can also occur in people in developed countries secondary to ..., ..., or self-imposed .... The whole conjunctiva can become .... Vitamin A deficiency can also lead to .... This is commonly differentially diagnosed from ..., ... and ....
Bitot’s spot is a dirty white, silver grey, foamy, triangular in shape patches see in the conjunctiva due to kertinisation of the conjunctival epithelium. It is usually bilateral in the temporal side of the bulbar conjunctiva. This occurs in vitamin A deficiencies in most developing countries. They can also occur in people in developed countries secondary to chronic liver disease, gut malabsorption syndromes, or self-imposed dietary restrictions. The whole conjunctiva can become lusterless. Vitamin A deficiency can also lead to xerophthalmia. This is commonly differentially diagnosed from pinguecula, amyloidosis and CIN.
How is Bitot’s spot managed?
- Refer to GP for blood test to confirm Vitamin A deficiency
- Usually disappears with high dose vitamin A therapy, unless longstanding and have permanent epithelial metaplasia
- Manage any dry eye symptoms as appropriate e.g. Hylofresh/ forte QID.
- Follow up over period of vitamin A therapy or if change in size or symptoms.
Floppy Eyelid Syndrome (FES) is characterised by ... and ... of the ... conjuncitva. Px may also experience slight ..., ..., sore eyes, ... vision, increased .... Px’s upper eyelids may ..., therefore may require ..., this therefore causes corneal exposure, including .... FES is rare but is associated with ... and ....
Px’s history of ... and loud snoring are indicative of FES. Px should be slit lamp examinated with ... and should observe ... and examine ....
Floppy Eyelid Syndrome (FES) is characterised by loose upper eyelids and papillary conjunctivitis of the tarsal conjuncitva. Px may also experience slight mucous discharge, gritty, sore eyes, blurred vision, increased lacrimation. Px’s upper eyelids may evert during sleep, therefore may require un-eversion upon waking, this therefore causes corneal exposure, including SPK. FES is rare but is associated with obesity and sleep apnoea.
Px’s history of excessive daytime sleepiness and loud snoring are indicative of FES. Px should be slit lamp examinated with fluorescein and should observe lash position and examine lid laxity.
What are the treatments for FES?
- Refer for investigation of obstructive sleep apnoea
- Mx of apnoea will improve condition
- Weight loss program
- Ocular lubricant before sleep e.g. Vita-Pos ointment
- Taping lid shut during sleep or wearing a firm sleep mask to prevent lid eversion
- Surgical horizontal tightening of the upper eyelids
What are the differential diagnosis of FES?
- Dry Eye Syndrome
- Superior limbic keratoconjunctivitis
- Rosacea keratitis
- Range of chronic keratitis/ conjunctivitis/ canaliculitis.
... is the excess folds of conjunctival tissue. This occurs more frequently with .... This is more common in the ... conjunctiva compared to .... Many of the symptoms are similar to complaints in ..., including eye pain, ..., ..., dryness and presence of .... If these symptoms worsen in ... gaze, it is more likely that they are ....
Conjunctivochalasis is the excess folds of conjunctival tissue. This occurs more frequently with age. This is more common in the inferotermpral bulbar conjunctiva compared to inferonasal. Many of the symptoms are similar to complaints in dry eye disease, including eye pain, blurred vision, epiphora, dryness and presence of subconjunctival haemorrhage. If these symptoms worsen in down gaze, it is more likely that they are conjunctivochalasis.
How is conjunctivochalasis managed?
If asymptomatic, no treatment is needed
If mildly symptomatic, start therapy with lubrication and topical corticosteroids e.g. FML or Flarex
If continue to be in discomfort, refer for surgical opinion e.g. excision of bulbar conjunctiva/ suture fixation or electro coagulation of excessive conjunctiva.
