Conjunctiva Flashcards

Question

WHO grading of Trachoma?

Answer 1

TF = trachomatous inflammation (follicular): five or more follicles (>0.5 mm) on the superior tarsal plate TI = trachomatous inflammation (intense): diffuse involvement of the tarsal conjunctiva, obscuring 50% or more of the normal deep tarsal vessels; papillae are present TS = trachomatous conjunctival scarring: easily visible fibrous white tarsal bands TT = trachomatous trichiasis: at least one lash touching the globe CO = corneal opacity sufficient to blur details of at least part of the pupillary margin

Answer 2

○Mixed follicular/papillary conjunctivitis associated with a mucopurulent discharge. In children under the age of 2 years the papillary component may predominate. ○Superior epithelial keratitis and pannus formation

Answer 3

○Linear or stellateconjunctival scars in mild cases, or broad confluent scars (Arlt line) in severe disease. ○Although the entire conjunctiva is involved, the effects are most prominent on the upper tarsal plate. ○Superior limbal follicles may resolve to leave a row of shallow depressions (Herbert pits) ○Trichiasis, distichiasis, corneal vascularization and cicatricial entropion ○Severe corneal opacification. ○Dry eye caused by destruction of goblet cells and the ductules of the lacrimal gland.

Answer 4

Surgery for trichiasis, Antibiotics for active disease, Facial hygiene Environmental improvement.

Answer 5

Tooth staining

Answer 6

as conjunctival inflammation developing within the first month of life. It is the most common infection of any kind in neonates, occurring in up to 10%.

Answer 7

*Organisms acquired during vaginal delivery: C. trachomatis, N. gonorrhoeae *Staphylococci are usually responsible for mild conjunctivitis. *Topical preparations used as prophylaxis *Congenital nasolacrimal obstruction. Despite poor neonatal tear production

Answer 8

○Chemical irritation: first few days. ○Gonococcal: first week. ○Staphylococci and other bacteria: end of the first week. ○Herpes simplex virus (HSV): 1–2 weeks. ○Chlamydia: 1–3 weeks.

Answer 9

○A mildly sticky eye may occur in staphylococcal infection, or with delayed nasolacrimal duct canalization (mucopurulent reflux on pressure over the lacrimal sac). ○Discharge is characteristically watery in chemical and HSV infection, mucopurulent in chlamydial infection, purulent in bacterial infection and hyperpurulent in gonococcal conjunctivitis. ○Pseudomembranes are not uncommon in chlamydial conjunctivitis.

Answer 10

Prophylaxis with 2.5% poviodine Chemical conjunctivitis with artificial tears Mild conjunctivitis broad spectrum topical abx like CPL. Moderate-severe cases Ix with microscopy and treatment with broad spectrum abx liek CPL/Erythromycin Severe conjunctivitis with systemic illness take samples and treat with broad spectrum abx like erythromycin. Cover for chlamydia Chlamydial infection treated with PO erythromycin for 2/52 Gonococcal conjunctivitis treated systemically with 3rd gen Cephalosporin HSV with high dose intravenous aciclovir under paediatrics

Answer 11

Viral conjunctivitis is a common external ocular infection, adenovirus (a non-enveloped double-stranded DNA virus) being the most frequent (90%) causative agent.

Answer 12

Non specific acute follicular conjunctivitis Pharyngoconjunctival fever (PCF) Epidemic Keratoconjunctivitis (EKC) Acute haemorrhagic conjunctivitis Chronic/relapsing adenoviral conjunctivitis HSV Systemic viral infections Molluscum contagiosum

Answer 13

most common clinical form of viral conjunctivitis and is typically due to adenoviral infection by a range of serological variants. Unilateral watering, redness, irritation and/or itching and mild photophobia occur, the contralateral eye generally being affected 1–2 days later, often less severely.

Answer 14

caused mainly by adenovirus serovars 3, 4 and 7. It is spread by droplets within families with upper respiratory tract infection. Keratitis develops in about 30% of cases but is seldom severe. Symptoms are essentially as above, though sore throat is typically prominent.

Answer 15

caused mainly by adenovirus serovars 8, 19 and 37 and is the most severe ocular adenoviral infection. Keratitis, which may be marked, develops in about 80%. Photophobia may be correspondingly prominent.

Answer 16

occurs in tropical areas. It is typically caused by enterovirus and coxsackievirus, though other microorganisms may present similarly. It has a rapid onset and resolves within 1–2 weeks. Conjunctival haemorrhage is generally marked

Answer 17

*Eyelid oedema *Lymphadenopathy: tender preauricular *Conjunctival hyperaemia and follicles Keratitis (adenoviral). Epithelial microcysts, PEE's, focal white subepithelial/anterior stromal infiltrates, small pseudodendritic epithelial formations *Anterior uveitis- mild *Molluscum contagiosum- pale waxy umbilicated nodule on lid margin

Answer 18

*Giemsa stain- mononuclear cells in adenoviral conjunctivitis and multinucleated giant cells in herpetic infection. * NAAT eg. PCR are sensitive and specific for viral DNA. *Viral culture with isolation is the reference standard but is expensive and fairly slow. Sensitivity is variable but specificity is around 100%. *A immunochromatography test takes 10 minutes to detect adenoviral antigen in tears; sensitivity and specificity are excellent. * Serology for IgM or rising IgG antibody titres to adenovirus has limitations and is rarely used. *Investigation for other causes such as chlamydial infection may be indicated in non-resolving cases.

Answer 19

*Spontaneous resolution of adenoviral infection 2-3 weeks *Reduction of transmission risk with hand hygiene *Molluscum- lesions self limiting but remove in immunocompromised *Topical steroids- Pred 0.5% QDS for severe membranous conjunctivitis. Use with caution suppress inflammation and corneal infiltrates recur after stopping. *Discontinue lens wear *Cold or warm compress *Artificial tears

Answer 20

‘hay fever eyes’), worse during the spring and summer, is the more common. The most frequent allergens are tree and grass pollens, although the specific allergen varies with geographic location.

Answer 21

Causes symptoms throughout the year, generally worse in the autumn when exposure to house dust mites, animal dander and fungal allergens is greatest. It is less common and tends to be milder than the seasonal form.

Answer 22

*Symptoms. Transient acute or subacute attacks of redness, watering and itching, associated with sneezing and nasal discharge. *Signs. Normal vision. Conjunctival hyperaemia with a relatively mild papillary reaction, variable chemosis and lid oedema.

Answer 23

Artificial tears Mast cell stabilisers (sodium cromoglicate) PO antihistamines Dual action antihistamines and mast cell stabilizers eg olopatidine, ketotifen act rapidly NSAID- rarely used Topical steroids effective

Answer 24

(VKC) is a recurrent bilateral disorder in which both IgE- and cell-mediated immune mechanisms play important roles. It primarily affects boys and onset is generally from about the age of 5 years onwards. There is remission by the late teens in 95% of cases, although many of the remainder develop atopic keratoconjunctivitis.

Answer 25

Palpebral VKC- involves upper tarsal conjunctiva associated with significant corneal disease Limbal disease affects black and Asian patients Mixed VKC- featrures of both palpebral and limbal disease

Answer 26

intense itching, which may be associated with lacrimation, photophobia, a foreign body sensation, burning and thick mucoid discharge. Increased blinking is common.

Answer 27

Early disease- papillary hypertrophy on superior tarsal plate Macropapilla (<1mm). Progression to giant papillae (>1mm) can occur. Mucous deposition between giant papillae Keratopathy SPEE's with mucous on the cornea.

Answer 28

Gelatinous limbal conjunctival papillae associated with white cellular collections (Horner Trantas Dots)

Answer 29

a rare bilateral disease that typically develops in adulthood (peak incidence 30–50 years) following a long history of atopic dermatitis (eczema). Asthma is also extremely common in these patients. About 5% have suffered from childhood VKC

Answer 30

*Fewer eosinophils on conjucntival scrapings in AKC *Symptoms unremitting in AKC *Skin changes more in AKC (Eczematoid changes/ dryness/scaling) *Madarosis common *Hertoghe sign- absence of lateral eyebrows *Dennie Morgan folds -lid skin folds caused by persistent rubbing *Conjunctival involvement usually inferior in AKC with cicatricial changes seen in AKC over VKC. *Horner trantas dots seen in both. *PEE's over inferior 1/3 of cornea *Peripheral vascularization and scarring more in AKC *Presenile shield like subcapsular cataracts common in AKC *RD commoner in AKC after cataract surgery

Answer 31

*Allergen avoidance *Cool compress *Lid hygiene *BCL *Mast cell stabilizers *Topical antihistamines *Combined antihistamine/vasconstrictor *Combined antihistamine/mast cell stabilizer *NSAID *Topical steroids *Steroid ointment *Antibiotics *NAC *Ciclosporin if steroids ineffective *Calcineurin inhibitors eg Tacrolimus *Systemic oral antihistamine/abx/immunosuppresive *agents *Surgery with superficial keratectomy. *Surface maintenance/restoration surgery

Answer 32

NAEC seen in middle aged women with concurrent dry eyes. Similar pathogenesis to allergic eosinophilic rhinitis. Conjunctival eosinophilia present without significant IgE levels in serum/tear film. Treatment with 1-2 week course of topical steroid for exacerbations and maintenance with topical mast cell stabilizers/NSAIDS/antihistamines

Answer 33

Occurs secondary to mechanical stimuli of tarsal conjunctiva eg contact lens wear CLPC. Risk increased by build up of proteinaceous debris on CL surface. Ocular prosthesis, exposed sutures and scleral buckles.

Answer 34

in a variety of underlying anterior segment disorders, patients develop or exacerbate a chronic papillary reaction due to repetitive manual removal of mucus. Giant papillae can also be seen in other conditions such as VKC and AKC.

Answer 35

*FB sensation, redness, itching, increased mucus production, blurring and loss of CL tolerance. Symptoms may be worse after lens removal. Patients should be questioned about CL cleaning and maintenance. Signs *Variable mucous discharge *CL protein deposits *Excessive CL mobility *Ptosis due to irritative spasm and tissue laxity secondary to chronic inflammation

Answer 36

*Removal of stimulus eg CL wear/exposed sutures/scleral buckle *Assessment of fit/status of ocular prosthesis *Filtering bleb excision/revision *Change CL solution if preservatives *Switch to monthly then daily lenses *Cessation of CL wear *Prosthesis polishing/cleaning/coating *Topical mast cell stabilizers PF. *Antihistamines/NSAIDS *Topical steroids

Answer 37

also known as ocular cicatricial pemphigoid (OCP), comprises a group of chronic autoimmune mucocutaneous blistering diseases. An unknown trigger leads to a Type II (cytotoxic) hypersensitivity response resulting in antibodies binding at the basement membrane zone (BMZ), the activation of complement and the recruitment of inflammatory cells, with localized separation of the epidermis from the dermis at the BMZ and subsequent progression to scarring. Studies of HLA typing have found an increased susceptibility to the disease in patients with HLA-DR4. The HLA-DQB1 allele in particular shows a strong association with OCP and other forms of pemphigoid disease.

Answer 38

The disease typically presents in old age and affects females more commonly than males by a 2: 1 ratio.

Answer 39

Diagnosis is principally clinical, but biopsy of involved mucous membrane often shows supportive changes (linear antibody and complement BMZ deposition). ○Stage I: early stage associated with chronic conjunctivitis, tear dysfunction and subepithelial fibrosis. ○Stage II: forniceal shortening, particularly inferiorly. ○Stage III: symblepharon formation. ○Stage IV: surface keratinization and cicatricial ankyloblepharon.

Answer 40

Conjunctiva- Papillary conjunctivitis/diffuse hyperaemia. Fine lines of subconjunctival fibrosis and shortening of inferior fornix. Symblepharon Flattening of plica/keratinization of caruncle Dry eye Eyelids- trichiasis/chronic blepharitis/keratinization of lid margin Ankyloblepharon Cornea- epithelial defects with drying and exposure Infiltration and peripheral vascularization Keratinization and conjunctivalization of corneal surface End stage disease characterized by symblepharon/corneal opacification

Answer 41

Symblepharon (plural: symblephara) formation refers to adhesion between the bulbar and palpebral conjunctiva

Answer 42

An adhesion at the outer canthus between the upper and lower lids

Answer 43

Dapsone- 1st line treatment mild-mod disease. Contraindicated in G6PD deficiency. Sulfasalazine better tolerated sometimes. Antimetabolites (azathioprine/methotrexate/mycophenolate) mild-mod disease if dapsone contraindicated/poor tolerated. Steroids rapid disease control side effects limit long term use. IOP monitoring needed Rituximab/immunoglobulins

Answer 44

Artificial tears Topical steroids/ciclosporin/tacrolimus Retinoic acid reduce keratinization Antibiotics when indicated Lid hygiene low dose tetracycline for blepharitis Subconjunctival mitomycin C can be used temporarily. CL with caution to prevent corneal damage from trichiasis/dehydration

Answer 45

*Aberrant eyelashes *Punctal occlusion to aid tear retention. *Lateral tarsorrhaphy or botulinum toxin-induced ptosis may be used to promote healing of corneal epithelial defects. *Entropion repair: conjunctival incision is avoided if possible. *Cataract surgery is commonly required. *Mucous membrane autograft/amniotic membrane transplant *Limbal stem cell transfer for corneal re-epithelialization *Keratoprosthesis in end stage disease

Answer 46

a cell-mediated delayed hypersensitivity reaction, usually related to drug exposure. A wide range of medications have been incriminated, including antibiotics (especially sulfonamides and trimethoprim), analgesics including paracetamol (acetaminophen), nevirapine (widely prescribed as a part of combination therapy for HIV infection), cold remedies and anticonvulsants. Infections due to microorganisms such as Mycoplasma pneumoniae and HSV and some cancers have also been implicated. Because symptoms often take weeks to develop, in many cases the precipitant cannot be identified. Mortality overall is around 5% in SJS (death is commonly due to infection), but is considerably higher in TEN.

Answer 47

Symptoms- redness/mild-severe grittiness, photophobia, watering and blurry vision. Acute signs-haemorrhagic crusting of lid margins, papillary conjunctivitis, conjunctival (pseudo)membranes, keratopathy with PEE's. Late signs- conjunctival cicatrization with forniceal shortening and symblepharon formation, cicatricial entropion, keratopathy eg scarring/vascularization, watery eyes due to fibrosis

Answer 48

Skin biopsy to make the diagnosis Symptoms- Flu like symptoms can be severe may last upto 2 weeks before lesions occur. Signs- blistering mucosal lesions, haemorrhagic lid crusting, purpuric vesicular skin lesions on extremities, face and trunk.

Answer 49

*Removal of the precipitant eg discontinuation of drugs and treatment of suspected infection. *General supportive measures such as maintenance of adequate hydration, electrolyte balance and nutrition (especially protein replacement) are critical. *Systemic steroids remain controversial. *Other immunosuppressants including ciclosporin, azathioprine, cyclophosphamide and intravenous immunoglobulin may be considered in selected cases, but are controversial *Systemic antibiotics may be given as prophylaxis against skin or other systemic infection, avoiding those known to be at higher risk of precipitating SJS/TEN.

Answer 50

*Daily review cornea and check symblepharon formation *Topical lubricants *Prevent corneal exposure *Topical steroids for irits/conjunctival inflammation *Topical cycloplegia for comfort *Lysis of developing symblephara with sterile glass rod/cotton bud *Scleral ring may prevent symblephara formation *Treat bacterial keratitis if developing *IOP monitoring

Answer 51

Lubrication Topical transretinoic acid may reverse keratinization Treatment of aberrant lashes BCL (gas permeable scleral lenses) Mucous membrane grafting for forniceal reconstruction Corneal rehab with superficial keratectomy for keratinization, lamella corneal grafting for superficial scarring. LSCT, keratoprosthesis

Answer 52

Ocular graft-versus-host disease (GVHD) occurs in patients who have undergone allogenic haematological stem cell transplantation, an operation that is undertaken on an estimated 25,000 individuals annually worldwide Clinically it manifests in a similar fashion to SJS

Answer 53

Keratoconjunctivitis sicca Conj hyperaemia with (pseudo)membrane formation Chronic inflammation leading to cicatricial changes Corneal SPEE's, marginal keratitis, filamentary keratitis, corneal erosion, thinning, ulceration, perforation

Answer 54

Artificial tears Topical cyclosporine Systemic treatment (oral steroids)

Answer 55

a relatively uncommon chronic disease of the superior limbus and the superior bulbar and tarsal conjunctiva. It affects one or both eyes of middle-aged women, approximately 50% of whom have abnormal thyroid function (usually hyperthyroidism).

Answer 56

the result of blink-related trauma between the upper lid and the superior bulbar conjunctiva, precipitated in many cases by tear film insufficiency and an excess of lax conjunctival tissue.

Answer 57

FB sensation, burning, mild photophobia, mucoid discharge, frequent blinking. Conjunctiva- hyperaemia, limbal papillary hypertrophy, petechial haemorrhages, keratinization on biopsy or impression cytology Cornea- SPEE's separated from the limbus by normal epithelium. Filamentary keratitis in 1/3 cases. Mild superior pannus. Keratoconjunctivitis sicca in 50%

Answer 58

Thyroid function testing Biopsy or impression cytology may show keratinization of superior bulbar conjunctiva.

Answer 59

*Topical- lubricants, NAC, mast cell stabilizers and steroids, topical rebamipide, ciclosporin, retinoic acid for keratinization, autologous serum drops *Soft CL *Supratarsal steroid injections *Temporary superior+/- inferior punctal occlusion *Resection of superior limbic conjunctiva *Conjunctival ablation to affected area *Treatment of thyroid dysfunction

Answer 60

rare potentially sight- and even life-threatening disorder characterized by recurrent, often bilateral fibrin-rich pseudomembranous lesions of wood-like consistency that develop mainly on the tarsal conjunctiva.

Answer 61

amorphous subepithelial deposits of eosinophilic material consisting predominantly of fibrin

Answer 62

*conjunctivitis, usually in childhood (median age 5 years), although onset may be at any age. A conjunctival lesion is commonly noted by parents. *Enlarging red-white lobular conjunctival masses which may be covered by thick yellow-white mucoid discharge *Corneal scarring, vascularization, infection or melting.

Answer 63

*Discontinue antifibrinolytic drugs Surgical removal with diathermy from the base of the lesion. Preop topical plasminogen to soften pseudomembranes *After membrane removal, hourly heparin and steroids commenced until wound re-epithelialized *Recurrence retarded with long term use of ciclosporin and steroids *IV or topical plasminogen *Amniotic membrane transplant *Prophylactic heparin

Answer 64

a rare condition consisting of chronic low-grade fever, unilateral granulomatous conjunctivitis with surrounding follicles and ipsilateral regional (preauricular) lymphadenopathy.

Answer 65

synonymous with cat scratch disease (caused by Bartonella henselae), although several other causes have been implicated, including tularaemia, insect hairs (ophthalmia nodosum), Treponema pallidum, sporotrichosis, tuberculosis and acute C. trachomatis infection.

Answer 66

Self-injury (factitious keratoconjunctivitis) is most often intentional, but can also occur inadvertently, as in mucus fishing syndrome and removal of contact lenses. Damage may be the result of either mechanical trauma or of the instillation of irritant but readily accessible household substances, such as soap. Occasionally over-instillation of prescribed ocular medication is responsible.

Answer 67

Symptoms disproportionate to signs. Inferior conj injection and staining with Rose Bengal with quiet superior bulbar conjunctiva Linear corneal abrasions/persistent ED/focal corneal perforations Secondary infection with Candida Sterile ring infiltrate and hypopyon Corneal scarring

Answer 68

*Exclude other diagnoses. *Close observation may be required. *Confrontation often leads to failure to return for review. *A psychiatric opinion may be appropriate.

Answer 69

an innocuous but extremely common asymptomatic elastotic degeneration of the conjunctival stroma. A yellow–white mound or aggregation of smaller mounds is seen on the bulbar conjunctiva adjacent to the limbus Calcification sometimes present

Answer 70

Nasally>temporal limbus.

Answer 71

pinguecula resembles pterygium histologically. The distinction is that the limbal barrier to extension has remained intact with a pinguecula, though transformation can occur. In contrast to pingueculae, pterygia encroach onto the cornea, invading the Bowman layer

Answer 72

*Usually unneccessary to treate *Irritation with lubrication *Pingueculitis with lubrication/short course topical steroid *Excision for cosmetic reasons. Low recurrence compared to pterygium. *Thermal laser ablation can be effective

Answer 73

a triangular fibrovascular subepithelial ingrowth of degenerative bulbar conjunctival tissue over the limbus onto the cornea. Develops in patients who have been living in sunny countries and, as with pinguecula, may represent a response to ultraviolet exposure and to other factors such as chronic surface dryness.

Answer 74

shows elastotic degenerative changes in vascularized subepithelial stromal collagen

Answer 75

○Most small lesions are asymptomatic. ○Irritation and grittiness are caused by a dellen – localized drying – effect at the advancing edge due to interference with the precorneal tear film ○Intermittent inflammation/ pingueculitis ○Linear epithelial iron deposition (Stocker line) may be seen in the corneal epithelium anterior to the head of the pterygium ○Fuchs islets are small discrete whitish flecks consisting of clusters of pterygial epithelial cells often present at the advancing edge.

Answer 76

a ‘cap’ (an avascular halo-like zone at the advancing edge), a head a body

Answer 77

Medical- sunglasses reduce UV exposure Surgery- Simple excision with bare sclera technique

Answer 78

○pterygium is excised from the cornea and conjunctiva leaving bare sclera ○Conjunctival autografting. The donor conjunctival patch is usually harvested from the superior or upper-temporal para-limbal region. The graft is sutured into position using 10-0 nylon sutures. The site heals rapidly. Conjunctival grafts can be secured with tissue glue (for example: TISSEEL fibrin glue) rather than sutures, thus shortening operating time and reducing postoperative irritation. ○Adjunctive treatment with mitomycin C or beta-irradiation can be used in place of patching techniques. ○ Peripheral lamellar keratoplasty may be required for deep lesions.

Answer 79

extremely common and are usually associated with ageing, although they can also form in patients with chronic conjunctival inflammation such as trachoma. appear as multiple tiny cysts containing yellowish–white deposits of epithelial debris including keratin, commonly located subepithelially in the inferior tarsal and forniceal conjunctiva. Become calcified and erode through overlying epithelium causing irritation

Answer 80

appears as a fold of redundant conjunctiva interposed between the globe and lower eyelid, protruding over the lid margin. It is probably a normal ageing change that may be exacerbated by inflammation and mechanical stress related to dry eye and lid margin disease.

Answer 81

topical lubricants and treatment of any blepharitis. A short course of topical steroids or another anti-inflammatory agent may be helpful. Conjunctival resection can be performed in severe cases

Answer 82

thin-walled lesions on the bulbar conjunctiva containing clear or occasionally turbid fluid.

Answer 83

a fluid-filled internal cavity lined by a double epithelial layer.

Answer 84

by simple puncture with a needle under topical anaesthesia, but recurrence is common. Bleeding should be encouraged within the ruptured cyst as it may promote adhesion of the walls and reduce the chance of recurrence. Cyst wall excision under topical anaesthesia can be carried out for recurrent cyst formation.

Answer 85

common phenomenon that is often idiopathic and apparently spontaneous, occurring particularly in older individuals. It may result from surgery, conjunctivitis and trauma. The haemorrhage is usually asymptomatic but a momentary sharp pain or a snapping or popping sensation is sometimes felt.