5 - Conjunctiva Flashcards
Conj cyst
aka inclusion cyst aka retention cyst
Common, benign, fluid-filled (clear) sac on conj
Conj concretions
aka ocular lithiasis
= mucus + epi OR ca2+
Superficial white-yellow deposits on palpebral conj
Usually asymptomatic; mild FBS sensation
Conj nevus
Rare benign proliferation of melanoCYTES
Presents around PUBERTY - not uncommon for size/darkness to incr during this time
Unil, solitary, flat, freely mobile, occasionally non-pigmented (30%)
-usually juxtalimbal, plica, or cauncle
INCLUSION CYSTS WITHIN THE LESION ARE DIAGNOSTIC FOR A CONJUNCTIVAL NEVUS
Primary acquired melanosis
Unilateral acquired pigmentation with INDISTINCT margins
More common in elderly, white pts
Can be located anywhere on conj, usually flat
PREMALIGNANT 30% progress to MALIGNANT MELANOMA (or conj melanoma)
-esp nodular lesions with incr vascularity and/or incr growth
Conj melanomas
Secondary to uncontrolled proliferation of melanoCYTES
ALMOST EXCLUSIVELY CAUCASIANS, esp around age 50
Pigmented or non-pigemented
Most commonly arise from PAM (50-75%)
-others: pre-existing nevus (33%), de novo (rare)
Most important prognositc is THICKNESS of lesion
Most common site of metastasis is LIVER
Conjunctival intraepithelial neoplasia
- who
- progression
CIN, aka Bowen’s disease aka conjunctival squamous dysplasia
Rare - most common conj neoplasia in usa
UVB exposure, smoking, fair skin, xeroderma pigmentosa, HIV/HPV
Premalignant -> SCC
Conjunctival intraepithelial neoplasia
- presentation
- diagnostics
Elevated, gelatinous mass with neovascularization
10% exhibit leukophakia (keratinization)
95% are found at the limbus within the interpalpebral fissure
Can progress onto cornea
Toluidine blue 0.05% staining (PPV only 41%, NPV 88%)
-doesn’t distinguish b/w malignant and pre
Conj squamous cell carcinoma
Rare, slow-growing, malignant tumor
Elderly, Caucasian (90%), males (81%)
Usually derived from CIN, assoc with UV/HPV
Usually found at limbus, may involve adjacent cornea
Commonly contains feeder vessel
Pyogenic granuloma
Pedunculated, benign, red, vascular lesion of palpebral conj
From trauma, surgery, chalazion, etc
Conj granuloma
Inflamed area within conj stromal tissue
From retained FBs, surgery, trauma, infxn, systemic (sarcoid)
Asymptomatic; ocular irritation, FBS
Simple bacterial conjunctivitis
- who
- pathophys
Children (rare in adults)
H FLU (gram neg) in kids S epi/aureus in adults
Simple bacterial conjunctivitis
-signs/symp
Signs: mod-severe mucopurulent discharge
-corneal signs and lymphadenopathy are rare (if present think gonococcal, EKC, adult inclusion)
Symp: acute onset (within hour) of redness, usually unil -> bilateral
- FBS, eyelids stuck together when awakening
- typically subside in 10-14 days, even without treatment
Gonococcal conjunctivitis
- who
- pathophys
Young adults with hx of multiple partners
Transmitted vaginally to infants
Sexually transmitted
N gonorrhea is most common: G(-) diplococci, Thayer-Martin/chocolate agar
All pts should also be tested for co-existing Chlamydial systemic infxn (common co-infxn)
Gonococcal conjunctivitis
-signs/symp
Signs: severe purulent discharge, chemosis + PSEUDOMEMBRANES, severe papillary rxn, PREAURICULAR LYMPHADENOPATHY, tender/swollen lids
- CNHL: can invade intact corneal epi = peripheral ulceration
- ONLY bacterial conj-itis with pseudomemb + preauricular (usually assoc with viral)
Symp: hyperacute (minute it began) severe purulent discharge, unil -> bilateral
-redness, FBS, eyelids stuck together upon waking
Systemic:
-men: purulent discharge, 3-5 incubation
-women: discharge less common, 50% asymptomatic
Adenoviral conjunctivitis
- who
- pathophys
- 3 types
- mnemonic it’s a part of
Adults (kids think bacterial, not viral)
Most result from UPPER RESPIRATORY TRACT or nasal mucosal infxn
Transmission via direct contact
-highly contagious 12-14 days
Acute non-specific follicular
Pharyngoconjunctival fever
Epidemic keratoconjunctivitis
CHAT (follicles)
Acute non-specific follicular conjunctivitis
- serotypes
- presentation
1-11, 19
Most common
DIFFUSE red eye, conj FOLLICLES in INFERIOR FORNICES, tearing, mild discomfort
-corneal involvement is rare
Pharyngoconjunctival fever
- serotypes
- presentation
3-5, 7
aka “swimming pool conjunctivitis”
Usually children, highly contagious
Triad: acute FOLLICULAR conj-itis, mild low-grade fever, pharyngitis (mild sore throat) (“Fever Follicles Faryngitis”)
-corneal involvement uncommon
Epidemic keratoconjunctivitis
- serotypes
- presentation
8 (also 19, 37)
PAIN, CORNEAL INVOLVEMENT (80%)
8’s: Serotype 8, Symp in 8 days, SEI 8 days later
-SEIs indicate no longer contagious
PREAURICULAR LYMPHADENOPATHY is almost always present
May also have pseudomembranes
Major diff: EKC vs acute non-specific
EKC = preauricular lymphadenopathy
Epidemic keratoconjunctivitis
-signs/symp
Signs: acute follicular conj-itis (esp inf fornix), marked conj injection, PSEUDOMEMBRANE formation, PREAURICULAR LYMPHADENOPATHY, diffuse keratitis
Symp: rapid onset redness, tearing, mild discomfort, preauricular lymphadenopthy
-unil -> bilateral
Molluscum contagiosum
- who
- pathophys
Rare; children/YA, poor hygiene
DNA POX VIRUS spread via direct contact
-if multiple present, test for HIV
Molluscum contagiosum
-signs/symp
Dome-shaped, umbilicated, waxy nodules on lid/margin
Usually asymptomatic; mild mucus discharge
Rupture -> chronic follicular conj-itis (CHAToxic) + superficial pannus
Allergic conjunctivitis
- who
- seasonal vs perennial
- signs/symp
Common, all ages
S: T1 HS rxn, triggered by airborne allergens (e.g. pollen)
P: T1 HS rxn, triggered by household allergens (e.g. dust mites, animal dander)
Conj chemosis, PAPILLAE, itching (esp medial canthus), tearing, watery discharge
Vernal keratoconjunctivitis
-who
Very rare (<1% of allergic conj-itis cases)
Young males (under 10)
Hot, dry climates
Occurs for 2-10 years before resolving around puberty
Pts predisposed with atopic systemic condns (rhinitis, ASTHMA)
-eczema/asthma 40-75%
-family hx atopy 40-60%
Vernal keratoconjunctivitis
- pathophys
- signs/symp
- main concerns
Seasonal outbreaks during warm months, possibly year round
Signs: bilateral prominent papillae - either on limbus (TRANTAS DOTS) or SUPERIOR palpebral conj (COBBLESTONE PAPILLAE)
- can have corneal involvement: begins with punctate epi keratitis -> coalesces into large erosions -> plaque formation -> SHIELD ULCER
- outer eyelids relatively unaffected compared to AKC
Symp: INTENSE ITCHING, PHOTOPHOBIA, ptosis, thick mucus discharge, initial outbreak is most severe
Concerns: shield ulcer + keratoconus (eye rubbing, more so AKC)
Atopic keratoconjunctivitis
- who
- pathophys
Rare (3% allergic conj-itis cases)
Young to mid-age (20yo)
Hx of atopic dermatitis (a type of chronic eczema, 25-42% have ocular involvement, severe leads to cataracts b/w ages 15-30)
NOT SEASONAL
T1 AND T4 HS mechanisms
Atopic keratoconjunctivitis
-signs/symp
Signs: PROMINENT OUTER EYELID (scaly, thickened, swollen), periorbital involvement (DENNIE’S LINES - extra crease under lower lid due to periorbital edema), atopy “SHINERS” (bags under eyes from rubbing), INFERIOR papillae, corneal neovascularization, early ct, keratoconus (more common than VKC), SYMBLEPHARON in inferior fornices
Symp: bilateral itching, watery discharge, redness, photophobia, pain
Premature cataracts
Mr Wilson is MAD about early cts Wilsons Myotonic dystrophy AKC Diabetes
Papillae vs follicles (super basic)
P: red, central vessel, very small (<1mm) to very large (GPC/VKC)
F: white-gray (immature lymphocyte), avascular, at tarsal/fornix conj
Giant papillary conjunctivitis
-causes (6)
1 = SILICON HYDROGEL CLS* (95%)
-risk factors: extended wear, high water-ionic lenses, higher modulus of elasticity, poor replacement compliance
-can occur as early as 3 weeks; avg length of time before development is 8mo
Exposed SUTURES
Glaucoma filtering BLEBS
Scleral BUCKLES
Ocular prosthetics
#2 = Environmental factors (severe allergies)
*can occur with any type of contact lens, most commonly assoc with EXTENDED-WEAR SOFT CLS
Giant papillary conjunctivitis
-pathophys
Non-infectious inflammatory disorder assoc with FRICTION and an IMMUNE RESPONSE to contact lens surface deposits (esp PROTEIN)
Giant papillary conjunctivitis
-signs/symp
Signs: mild-severe papillae* (friction = non-specific) of UPPER tarsal conj/eyelid, ptosis, mucus
- GPC is charac by papillae >0.3mm diameter
- giant papillae defined as >1.0mm form when neighboring papillae break down septae + coalesce
Symp: itching, scant (early) -> ropy (late) mucus discharge, decr lens wearing time, photophobia
-often MORE SEVERE AFTER REMOVING LENSES
Additional CLS-related disorders -solution hypersensitivity —type of reaction —solutions containing \_\_ are often most severe —signs
Toxicity -> follicles (inferior due to gravity)
Chlorhexidine, thimerosal
Follicular conj-itis, DIFFUSE injection, DIFFUSE SPK (3+ corneal rxn)
Additional CLS-related disorders
-corneal neovascularization
—results from
—amount that’s abnormal/concerning
Chronic hypoxia
> 1.5mm
Additional CLS-related disorders
-corneal warpage
—type of lenses classically seen with
—signs
Long-term PMMA wearers, GP wearers with pooly fitting lenses
Initially: vision is clear in cls, not glasses; ghost images, diplopia Irregular astigmatism (can mimic keratoconus) -high riding classically causes inferior steepening over time
Additional CLS-related disorders
-superior limbic keratoconjunctivitis
—causes (3)
—signs
FRICTION: contacts lenses, TED, dry eye
-cls hypersensitivity rxn (esp THIMEROSAL, poor lens fit)
SUPERIOR BULBAR/UPPER TARSAL INJECTION
-papillary rxn/corneal filaments uncommon (vs slk in ted)
Thickened, red, SUPERIOR bulbar conj + adjacent spk and FILAMENTARY KERATITIS
Additional CLS-related disorders
-contact lens deposits
—when you see issues with
—deposits on GP vs soft
Only if on back surface
GP: plaques
Soft: jelly bumps
Additional CLS-related disorders
-tight-lens syndrome
—more common with whom
—signs/symp
High myopes (>8)
Signs: INJECTION/INDENTATION AROUND LIMBUS, distorted keratometry mires that clear with blinking
- severe: corneal edema/blebs, ant chamber reaction
- may have corneal abrasion from lens removal
Symp: redness that WORSENS AFTER LENS IS REMOVED, hazy vision, halos, dryness
Additional CLS-related disorders
-3 and 9 o’clock staining
—who/cause
—signs/symp
Most common complication assoc with GP lens wear
Classically due to low-riding GP that doesn’t adequately cover cornea -> poor spreading of tears
Signs: may lead to DELLEN formation, pseudopterygia, corneal vascularization
Symp: asymptomatic; horizontal redness
Classic CLS complications
- lenses that ride too high
- too low
High = corneal warpage
Low = 3/9 o’clock staining
Additional CLS-related disorders -superior epithelial arcuate lesion (SEAL) —cause —app —symp
Tight extended-wear hydrogel lenses
Arcuate shape superior corneal staining within 1mm of limbus
30% asymptomatic
FBS, irritation, corneal SEI (40%)
Additional CLS-related disorders
-dimple veiling
—cause
—app
Small gas bubbles becomming trapped under lens, esp GP
Small depression in cornea that pool fluoro
Adult inclusion conjunctivitis
-who/cause/pathophys
Rare - most commonly in sexually active young adults
Chlamydia = #1 STD in the usa (and #1 cause ophth neonatorum), ask about painful urination
-54% men, 74% women will have active genital infection
Serotypes D-K (dick)
Usually spread via direct inocculation
-esp common in right eye due to right-handedness
-reported cases of contaminated pool water, shared cosmetics
-ocular manifestation begins 5-14days after innoculation
Adult inclusion conjunctivitis
-signs/symp
Signs: HUGE FOLLICLES (chat) + little papillae concentrated in INFERIOR palpebral conj/fornices, PREAURICULAR LYMPHADENOPATHY, scant mucopurulent discharge
-corneal involvement 30-85%, incl punctate keratitis, superior pannus, SEIs
Symp: acute follicular + papillary conj-itis that becomes CHRONIC (3-12mo if not tx), unil -> bilateral
Trachoma conjunctivitis
-who/cause/pathophys
Most prevalent: ages 1-5, 3rd-world, poor hygiene
LEADING CAUSE PREVENTABLE BLINDNESS WORLDWIDE
Spread directly: eye-eye, fomites/flies/shared cosmetics
Chlamydia serotypes A-C (“trA-Choma”)
Trachoma conjunctivitis
-signs/symp
Early: FOLLICULAR conj-itis, esp SUPERIOR tarsal conj, mucopurulent discharge, lymphadenopathy, mild superior pannus
Late: ARLT’S LINES (white scarring of SUPERIOR tarsal conj), HERBERT’S PITS (depression on limbal conj AFTER follicle resolution), progressive scarring -> distortion of eyelids -> CORNEAL ULCERATION FROM TRICHIASIS -> blindness
Condns to assoc with preauricular adenopathy (5)
Chlamydia (tachoma, adult inclusion) EKC Gonococcal conj-itis Parinauds oculoglandular syndrome Phthiriasis palpebrarum
Phlyctenular keratoconjunctivitis
- who
- pathophys
Teenage females, possible hx of TB (3rd world)
T4 HS rxn to STAPH (esp blepharitis), tb, acne rosacea
Phlyctenular keratoconjunctivitis
-signs/symp
Signs:
- conj phlyc = limbus, pink/fleshy nodules, injection
- corneal = limbus, small, white nodule (lymphocytes), adjacent injection
Symp: tearing, fbs, itch, significant photophobia with corneal
Ligneous conjunctivitis
-associated deficiency
Plasminogen
Parinauds oculoglandular syndrome
- who
- pathophys
1 cause: CAT-SCRATCH fever (bartonella henselae) (“parinoyed about cats”)
Rare, exposure to cats, dogs, rabbits, squirrels, ticks
Tularemia (rabbits, squirrels, ticks)
Tuberculosis, syphilis
Parinauds oculoglandular syndrome
-signs/symp
Signs: UNILATERAL GRANULOMATOUS (rare combo), follicular, palpebral conj-itis, PREAURICULAR LYMPHADENOPATHY, fever, rash
Symp: red eye, fbs, mucopurulent discharge
Phthiriasis palpebarum
- pathophys
- signs/symp
aka pediculosis ciliaris
From phthirus pubis (crab louse) -> infects lashes, brows, etc.
Signs: transparent lice, white nits, blood-tinged debris, chronic follicular conj-itis, preauricular lymphadenopathy
-note: no sleeving of lash bases like demodex
Symp: ranges from mild itching to marked inflammation
Subconj hemorrhage
- common causes
- tests to order for idiopathic cases
Valsavla, meds (aspirin, warfarin), HTN, blood clotting disorder
CBC
PT/PTT
Sickledex (sickle screening)
*these tests are esp important in African/Mediterranean pops
Pterygium + Pingueculum
-who/pathophys
Assoc with environmental + UV exposure (work outdoors)
#1 cause = UV exposure
Other causes incl chronic dryness
—> lead to degeneration of collagen fibrils within conj stroma
Pterygium + Pingueculum
-signs/symp
Signs: both typically at 3/9 O’CLOCK
- pteryg: TRIANGULAR fibrovascular growth of bulbar conj, extends ONTO CORNEA, destroying BOWMAN’S -> WTR astig, STOCKER’S line (iron deposits at ant/leading edge)
- ping: YELLOW-WHITE, typically raised, adjacent to limbus - NOT on cornea
Symp: asymptomatic; irritation, redness, decr vision (location-dependent)
