25. Conjunctival Abnormalities Flashcards
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.
Conjunctival cysts are also known as .... They are typically small clear ... within the ..., ... or ... conjunctiva (...mm). They can also present as ...e swelling of the ... lymphatic, which is more ... than cysts. These cysts are ... to touch and with blink and is usually .... Px are typically ... or have .... This should be assessed with ... and documented. This is commonly differentially diagnosed from ..., ..., ....
Conjunctival cysts are also known as lymphangiectasia. They are typically small clear cysts within the bulbar, forniceal or palpebral conjunctiva (2-5mm). They can also present as tube-like swelling of the bulbar lymphatic, which is more transparent than cysts. These cysts are mobile to touch and with blink and is usually unilateral. Px are typically asymptomatic or have foreign body sensation. This should be assessed with slit lamp examination and documented. This is commonly differentially diagnosed from CIN, conjunctivochalasis/ chemosis, phlyctenule.
How are conjunctival cysts treated?
- Usually monitor if asymptomatic
- Lance cysts (25G needle + anaesthesia), massage closed lid to drain, but will usually re-occur
- May require prophylactic antibiotics
Amyloidosis is an uncommon ... on the conjunctiva, which is usually an accumulation of a variety of .... They present as ..., ..., ... deposits within the ... or ... conjunctiva and can be associated with .... Amyloidosis is usually ... and can be primary or secondary to diseases e.g. .... This may be a localised or a .... Px are usually ... in the eye deposits, not tender unless .... They is commonly differentially diagnosed from ..., conjunctival ..., or other conjunctival ....
Amyloidosis is an uncommon amyloid deposit on the conjunctiva, which is usually an accumulation of a variety of proteins of differing origins. They present as yellowish, avascular, waxy deposits within the bulbar or forniceal conjunctiva and can be associated with recurrent bleeding. Amyloidosis is usually unilateral and can be primary or secondary to diseases e.g. tuberculosis. This may be a localised or a systemic disorder. Px are usually asympatomatic in the eye deposits, not tender unless large enough to affect lid function or give FB sensation. They is commonly differentially diagnosed from pinguecula, conjunctival papilloma, or other conjunctival tumours`.
How are Amyloidosis treated?
- Check if amyloid is present elsewhere in the eye - eyelids, anterior chamber, optic nerve, cornea, iris, lacrimal gland
- Removal required if FB sensation or for cosmesis
- Refer for biopsy, removal or to rule out systemic Amyloidosis
Superior Limbic Keratoconjunctivitis is a ... inflammatory condition that is associated with ..., ... and middle aged women. This is speculated to be caused by the rubbing of ... and ... conjunctivitis against palpebral conjunctivitis. It involves ... of the superior tarsus, hyperaemia of ..., ... of superior cornea and possibly .... Px who wear CLs and have ..., ... and solution response may also experience this. Px will experience burning, ..., slightly ..., photophobia and .... This is commonly differentiated from ..., trachoma, and ....
Superior Limbic Keratoconjunctivitis is a bilateral inflammatory condition that is associated with thyroid dysfunction, dry eye and middle aged women. This is speculated to be caused by the rubbing of bulbar and Limbal conjunctivitis against palpebral conjunctivitis. It involves papillary hypertrophy/ papillae of the superior tarsus, hyperaemia of superior bulbar conjunctiva, SPK of superior cornea and possibly corneal filaments. Px who wear CLs and have tight lids, hypoxia and solution response may also experience this. Px will experience burning, FB sensation, slightly blurred vision, photophobia and lacrimation/ mucoid discharge. This is commonly differentiated from Terrien's marginal degeneration, trachoma, and adult inclusion conjunctivitis.
What are the treatment for Superior Limbic Keratoconjunctivitis?
- Refer for evaluation of thyroid function
- Evaluate CL fit, material, hygiene and wear if appropriate
- Treatment to manage inflammation, reduce friction, reduce interaction of upper lid with limbus and reducing subconjunctival space
- Topical steroids e.g. Flarex/ Predforte QID + taper
- Topical vasoconstrictors
- Ocular lubrication/ Punctal plug
- Soft bandage CLs
- Sx - cauterisation of bulbar conj, fusing of conj and episclera
Conjunctival Squamous Papilloma is caused by infections with ... serotypes ... and ... and is transmitted through ... .There are two types of conjunctival squamous papilloma: ... and .... Px are often ... and may occasionally experience ... from direct involvement of the ... or through secondary .... These papilloma have a ... appearance with ....
This is commonly differentially diagnosed from ..., ... and ....
Conjunctival Squamous Papilloma is caused by infections with HPV serotypes 6 and 11 and is transmitted through direct contact .There are two types of conjunctival squamous papilloma: pedunculated and sessile. Px are often asymptomatic and may occasionally experience epiphora from direct involvement of the punctum or through secondary occlusion. These papilloma have a flat with broad base appearance with corkscrew vessels.
This is commonly differentially diagnosed from OSS, SCC and amelanotic melanoma.
What is the most common tumour of the ocular surface?
Conjunctival intraepithelial neoplasia
Conjunctival intraepithelial neoplasia is a tumour forming at the .... This is common in px with a history of ... and other UV changes e.g. ..., .... These tumours are ... growing and can spread .... Px may report ... and ... if it extends to the pupil.
They are commonly differentially diagnosed from ..., ..., naevus, ..., ..., ... and episcleritis.
Conjunctival intraepithelial neoplasia is a tumour forming at the interpalpebral limbus/ conjunctiva. This is common in px with a history of sun exposure and other UV changes e.g. pterygium, pingueculae. These tumours are slow growing and can spread locally. Px may report irritation and blurred vision if it extends to the pupil.
They are commonly differentially diagnosed from pterygium, melanoma, naevus, Limbal stem cell deficiency, conjunctival lymphoma, epibulbar choristoma and episcleritis.
There are 3 morphological types of conjunctival intraepithelial neoplasia:
En ...
* Most common appearance
* ..., ..., stuck on appearance with tufts of ...
Papillomatous
* .. with raised discrete lesion with surface ... blood vessels ...
* Least common
* Tumour ... involves an area of ...
* May resemble an area of ...
There are 3 morphological types of conjunctival intraepithelial neoplasia:
En plaque
* Most common appearance
* Gelatinous, raised, stuck on appearance with tufts of superficial blood vessels
Papillomatous
* Wart like with raised discrete lesion with surface corkscrew like blood vessels Diffuse
* Least common
* Tumour diffusely involves an area of thickened conjunctiva or limbus
* May resemble an area of chronic conjunctivitis
How is conjunctival intraepithelial neoplasia managed?
- Refer
- Sx for excision & surrounding affected tissue = 1st choice
- Adjunctive treatments e.g. diathermy or cryotherapy (but more tissue damage)
- Recurrences are increasingly treated with topical agents e.g. mitomycin C
Conjunctival melanoma causes a ..., ..., ... leison with prominent ... and surrounding areas of .... ... can also occur therefore pigment cannot be the definitive indication. Most px will complain of noticing ... without any ... or .... Conjunctival melanoma common occur on the ....
Conjunctival melanoma causes a thickened, raised, pigmented leison with prominent feeder vessels and surrounding areas of melanosis. Amelanotic conjunctival melanoma can also occur therefore pigment cannot be the definitive indication. Most px will complain of noticing pigmented spot without any ocular pain or irritation. Conjunctival melanoma common occur on the bulbar conjuncitiva.
Conjunctival melanoma should be assessed with a thorough history, including ..., ..., ... ..., ..., and ....
On slit lamp, inspect the ocular surface carefully for ..., ..., and ..., remembering to examine intertriginous areas e.g. ... and ... conjuncitva by .... The presence of ... particularly on the ... conjunctival should heighten suspicion for CMM. Px should also be ... to exclude a ... that has eroded through the sclera.
Conjunctival melanoma should be assessed with a thorough history, including age, symptoms, sun exposure, evolution of lesion, previous cancers, and review of old photograph.
On slit lamp, inspect the ocular surface carefully for pigment, nodularity, and feeder vessels, remembering to examine intertriginous areas e.g. fornix and tarsal conjuncitva by everting both the lower and upper eyelids. The presence of pigment particularly on the tarsal conjunctival should heighten suspicion for CMM. Px should also be dilated to exclude a ciliary body melanoma that has eroded through the sclera.
How is conjunctival melanoma managed?
- Refer for confirmation of diagnosis & biopsies
- Sx adjunct topical chemotherapy, radiation and/ or cryotherapy
- 6/12 review with annual systemic investigation is indicated for the rest of px’s life
What are the differential diagnosis of conjunctival melanoma?
*PAM & conjunctival nevi
* Amelanotic melanoma → progenie granulomas lymphomas, squamous lesions
* Staphyloma, subconjunctival hepatomas, mascara, foreign bodies, hepatic cysts
Conjunctival lymphoma are mostly ... but some px may experience ..., ptosis and .... It is characterised by a ..., which classically take on a ..., ... appearance when deep to the .... This is a rare tumour and can be ... (20%). The average delay between clincal onset and diagnosis is ...months secondary to lack of .... This is commonly differentially diagnosed from ... and .... For management, px should be .... If confirmed, ... is needed.
Conjunctival lymphoma are mostly asymptomatic but some px may experience foreign body sensation, ptosis and epiphora. It is characterised by a painless enlarging mass, which classically take on a salmon-pink, flesh-coloured appearance when deep to the conjuncitva. This is a rare tumour and can be unilateral and bilateral (20%). The average delay between clincal onset and diagnosis is 6-8 months secondary to lack of significant symptoms. This is commonly differentially diagnosed from benign lymphoid hyperplasia and non-pigmented conjunctival naevus. For management, px should be referred for biopsy. If confirmed, local radiation is needed.
What are the 5 suspicious features for most ocular surface tumours?
- Non-bulbar location
- Raised
- Wide indistinct edges
- Feeder vessels
- Leukoplakia
