Conjunctiva

Question 1

watery (serous exudate) discharge occurs in:

Answer 1

acute viral conjunctivitis

acute allergic conjunctivitis

Question 2

mucoid discharge (stringy/ropy filaments) highly indicative of:

Answer 2

chronic allergic conjunctivitis

dry eye (bc of less aqueous in aq:mucus tear ratio)

Question 3

mucopurulent discharge is seen in:

Answer 3

chlamydia

acute bacterial conjunctivitis

Question 4

purulent discharge is seen in:

Answer 4

moderate cases often acute bacterial conjuncitivitis

severe in gonoccocal infections

Question 5

which arteries give rise to the conjunctival vessels?

Answer 5

anterior ciliary and palpebral aa.

Question 6

conjunctival injection

Answer 6

superficial bright red blood vessels, worse near fornices, move as the conj is manipulated, and are blanched by topical phenylephrine

Question 7

conjunctival hyperemia

Answer 7

secondary to dilation of the conjunctival blood vessels, can be caused by environmental factors, or prolonged vasoconstrictor use

Question 8

subconjunctival hemorrhage

Answer 8

may be flat or elevated, well-defined, visible, coalesced blood between the bulbar conj and episclera

can be caused by injury, HTN (check bp!), DM, blood disorders, conjunctivitis, or Valsalva maneuver

Question 9

chemosis (edema)

Answer 9

an accumulation of fluid within or beneath the conj, severe inflammation, translucent swelling, acute non-traumatic hypersensitivity or chronic orbital outflow restrictions

Question 10

where do papillae form?

Answer 10

only form where conj is attached to underlying tissue by anchoring septae (tarsus, or bulbar limbus) flat-topped at tarsus, dome-shaped at limbus

Question 11

signs of papillae

Answer 11

red velvety appearance, central elevated tuft of vessels surrounded by a pale base. papillae are a nonspecific sign of conj inflammation, edema, PMN cell infiltration

giant papillary conj. can appear whitened due to fibrosis

Question 12

papillae can be due to:

Answer 12

bacterial or allergic conjunctivitis, chlamydia, chronic marginal blepharitis, superior limbic keratoconjunctivitis, floppy eyelid syndrome, CL wear

Question 13

follicles presentation:

Answer 13

yellowish-white, discrete, round elevations of conj. produced by a lymphocytic response. difference from papillae is that the center is avascular and the vessels appear on top of the bumps

Question 14

follicles can be due to:

Answer 14

viral conjunctivitis, chlamydia, parinaud oculoglandular syndrome, medicamentosa

common with adenovirus or herpes viral infections

Question 15

membranes/pseudomembranes

Answer 15

fibrin attached to the epithelial conj surface, true membranes cause bleeding when peeled off and reflect a higher degree of inflammatory response

Question 16

most common causes for membranous/pseudomembranous conjunctivitis:

Answer 16

severe adenoviral conjunctivitis (most common), bacterial infections, gonococcal, stevens johnson syndrome

Question 17

what happens to the conjunctiva as a person ages?

Answer 17

conjunctiva becomes thinner, more fragile, less transparent, epithelial layer thickens and subepithelial tissue atrophies, gradual hyaline degeneration and fatty infiltration, loss of elastic fibers, presence of conjunctival chalasis in some pts

Question 18

conjunctivochalasis

Answer 18

common, bilateral, characterized by redundant, loose, nonedematous conjunctiva (extra tissue) associated with aging. important to look for in pts with ocular irritation and epiphora, as extra tissue can block punctum

Question 19

pinguecula

Answer 19

common, elastotic degeneration of collagen fibers of the conjunctival stroma, due to UV exposure, hot, dusty environments, etc.

looks like a yellowish-white mound on bulbar conj., often bilateral and nasal interpalpebral zone

Question 20

pingueculitis

Answer 20

inflammation of a pinguecula, can be treated if symptomatic, with lubricants, corticosteroids, or topical NSAIDs, or sx

Question 21

pterygium

Answer 21

common, triangular, winglike mass of fibrovascular tissue extending from the conj to the cornea at the 3 and 9 o’clock locations. highly vascular as opposed to pinguecula

Question 22

concretions

Answer 22

common, bilateral, white/yellow spots found on palpebral conj, may become calcified, easily removed if needed

Question 23

conjunctival retention cyst (epithelial inclusion cyst)

Answer 23

common, thin-walled fluid-filled cyst on palpebral or bulbar conj.

Question 24

lymphangiectasia

Answer 24

irregular, dilated, sausage-shaped channels of lymphatic channels anastomosis 1 mm from limbus. occasionally may be filled with blood

Question 25

conjunctival capillary hemiangioma

Answer 25

rapidly developing lesions of the conj., without pre-existing trauma, red and protuberant, may be excised or use cryo

Question 26

scleral hyaline plaque

Answer 26

bilateral, oval, dark grey areas located close to insertion of the horizontal rectus muscles

Question 27

conjunctival squamous papilloma

Answer 27

uni or bilateral lesions anywhere on conj that are benign and very small risk of conversion. can be associated with HPV when there are lots of lesions present. can be large lesions, pedunculated or sessile, may encroach on cornea or interfere with lid closure

Question 28

squamous papilloma definition

Answer 28

presence of central vascular core surrounded by squamous epithelium

Question 29

treating conjunctival squamous papilloma:

Answer 29

small lesions may resolve spontaneously, large lesion can be excised or use cryo, for recurrence use mitomycin C, alpha interferon, cimetidine, or CO2 laser biopsy to make sure benign

Question 30

Ocular Surface Squamous Neoplasia (OSSN)

Answer 30

includes non-invasive: CIN (conjunctival intraepithelial neoplasia) and invasive: squamous cell carcinoma

Question 31

conjunctival intraepithelial neoplasia (CIN)

Answer 31

non-invasive OSSN/carcinoma in situ/conjunctival dyskeratosis - involving any area of conj or cornea although 95% at limbus, assoc. w/UV exposure, HPV, AIDS, xeroderma pigmentosum, stem cell therapy

Question 32

different CIN presentations

Answer 32

- gelatinous limbal thickening, leukoplakia, mild conj injection around - elevated, translucent conj lesion beneath a leukoplakic nodular lesion - sessile, papillary appearance - assoc. w/HPV - dysplastic squamous lesions can have fine vascular patterns with a hairpin configuration

Question 33

squamous cell carcinoma (invasive OSSN)

Answer 33

CIN is often a precursor, becomes invasive when dysplastic epithelial cells penetrate the basement membrane. pink, papillomatous lesion, feeder vessels, diffuse growth, metastasis rare

Question 34

conjunctival nevus

Answer 34

common, 1% chance of malignant transformation, usually solitary unilateral discrete mildly elevated intraepithelial lesion with variable pigmentation, may have cystic spaces

Question 35

conjunctival melanosis

Answer 35

does not elevate the surface like nevi can, retention of pigment/excessive melanin production

Question 36

Secondary acquired melanosis

Answer 36

increased pigmentation is attributed to racially associated genetic, metabolic, or toxic factors. common, usually bilateral but asymmetric, and no malignant potential

Question 37

Primary acquired melanosis (PAM)

Answer 37

rare, unilateral, fair-skinned pts \>45yrs, flat, usually near limbus, sudden onset of nodules(melanocytic cellular atypia)=strong suspicion of melanoma, 50% chance within 5yrs. w/o atypia = benign, no risk of malignancy biopsy to make sure!

Question 38

Malignant melanoma of conj

Answer 38

conjunctival melanoma can be pigmented or not, arise from \*PAM (74%), a nevus (7%), or de novo. usually \>6o yrs old pt, appear as black/grey vascularized nodule anywhere on conj, can also be pink, smooth "fish flesh" appearance with intense vascularity

Question 39

prognosis for conjunctival melanoma

Answer 39

mortality of 12% at 5 yrs, 25% at 10 years main sites of metastasis: lymph nodes, lung, brain, liver indications of poorer prognosis: multifocal tumors, extralimbal tumors involving fornices or caruncle, tumor thickness \>2mm, recurrence, lymphatic or orbital spread

Question 40

what infections can present with preauricular lymphadenopathy?

Answer 40

viral conjunctivitis (EKC), chlamydial conjunctivitis, gonococcal conjunctivitis, dacryoadenitis Parinaud's oculoglandular syndrome presents with both preauricular and submandibular lymphadenopathy simple bacterial conjunctivitis does NOT present with preauricular lymphadenopathy

Question 41

scleromalacia perforans

Answer 41

necrotizing scleritis without inflammation most commonly occurring in RA (15% of all cases of scleritis are caused by RA)