AED - Conjunctival Degeneration - Week 4 Flashcards
Describe the SOAP mnemonic.
Subjective (symptoms
Objective (signs)
Assessment (DDx)
Plan (Mx)
Where are goblet cells located?
Just inferior to the forniceal conjunctiva on the bulbar conjunctiva
List three structures that secrete mucin.
Goblet cells
Crypts of henle
Glands of menz
List two basal lacrimal secretors.
Glands of krause
Glands of wolfring
Where are glands of krause located?
At the forniceal conjunctiva
Where are glands of manz located?
Inferior to goblet cells on the bulbar conjunctiva
Where are crpyts of henle found?
Inferior to the glands of wolfring, on the palpebral conjunctiva close to the tarsal plate
What is a sign of pingueculum? What does it look like?
A triangle with the base at the limbus, yellowish mass. Looks like a gelatinous deposit
Are pingueculae raised or flat?
Slightly raised
Are pingueculae common or rare? Are they uni- or bilateral?
Very common and generally bilateral
List 3 symptoms of pingueculae.
Usually asymptomatic
Foreign body sensation if inflammed
Cosmetically unappealing
List the three components for a pingueculum workup.
Slit lamp
Fluorescein staining
Tear workup if symptomatic
Do pingueculae affect visiond?
No
Are pingueculae vascularised? Explain (2).
Not vascular but can be hyperaemic if inflammed.
Which of the following are thought to be a possible cause of pingueculae?
Family history
Sun exposure
Age
Racial background
Family history only
The rest are not significant
What is the histopathology of pingueculae (4)?
Elastotic degeneration of collagen
Hyalinisation of the conjunctival stroma
Collection of elastotic fibres
Granular deposits
List 4 differential diagnoses for pingueculae.
Pterygium
Conjunctival intraepithelial neoplasia
Other tumours (papilloma)
Limbal dermoid
List 3 treatment options for pingueculae (no severe inflammation).
Vasoconstrictors to reduce redness [note: “vasoconstrictors useless in chronic patients” - Darryl
Ocular lubricants and cold compresses if foreign body sensation is felt
List two treatment options for pingueculae with severe inflammation.
NSAIDs or topical steroids
What should be done if dellen persists in pingueculae?
Refer for cosmetic surgery
What are two ways pingueculae can be removed?
Excision surgery - excision with the conjunctiva
Argon laser - photocoagulation
List1 3 signs of pterygium.
A vascular triangular mass ith the base to the conjunctiva
Slowly advancing to the central cornea
Increasing astigmatism
Are pterygia vascular?
Yesd
Are pterygia uni- or bilateral?
Often bilateral
Are pterygia generally nasal or temporal?
Generally nasal
What is Stocker’s line? What is it caused by?
An orange-brown line at the leading edge of pterygia caused by iron deposits
Aside from Stocker’s line, what can be seen at the leading edge of pterygia?
An opaque epithelium
List three symptoms of pterygia.
Foreign body sensation
Dryness
Reduction in vision if encroaching on the visual axes/increasing cyl
What can pterygia rarely cause?
Diplopia
List 4 differential diagnoses for pterygia.
Pingueculum
Pannus
Conjunctival intraepithelial neoplasm
Other tumours
List the 5 components for pterygia assessment.
Slit lamp
Keratometry/topography
Fluorescein staining
Tear workup if indicated
Grading scale (efron)
List 3 treatment options for pterygium (no severe inflammation).
Vasoconstrictors to reduce redness? (not if chronic)
Ocular lubricants for ocular irritation and corneal signs
List two treatment options for pterygium with severe inflammation.
NSAIDs or topical steroids
In what 5 cases would pterygia be referred for surgery?
Rapid advancement
Chronic irritation
Diplopia
Marked effect on vision
Cosmesis concern
What is the histopathology of pterygia (3)?
Activated fibroblasts in the leading edge invade and fragment bowman’s layer as well as a variable amount of the superficial corneal stroma
What does pterygium development resemble histologically?
Actinic degeneration of the skin
What does the follow-up of pterygium depend on (3)?
Rate of progression
If stable, review in 1-2 years
If progressive or new patient, review in 3-6 months
What should be advised for patients with pterygium?
UV protection
Can pterygium recur following surgical removal?
Yesd
What is the standard surgical removal for pterygia?
Bare scleral resection
What is the recurrence rate for standard surgical removal of pterygia? What about adjunctive treatments?
Bare scleral resection - up to 80%
Adjuncts - <10%
What colour are concretions?
Yellow-white
How big are concretions?
<1mm but up to 4mm
What are concretions?
Deposits in the palpebral conjunctival epithelium
In which age group are concretions common in?
The elderly
What are concretions composed of (3)?
Mucin
Necrotic cells
Eosinophilic proteins
What may concretions be associated with (2)?
Chronic conjunctivitis
Contact lens wear
What additional cyst may be seen with concretions?
A clear cyst
List 2 symptoms of concretions.
Generally asymptomatic
May have a gritty foreign body sensation
List the to components for a concretion assessment.
Slit lamp
Fluorescein staining for erosion
List 3 differential diagnoses for concretions.
Other foreign bodies
Conjunctival cysts
Conjunctival trauma
What is the treatment for concretions if asymptomatic?
Monitor
What are 3 general treatment options for concretions?
Review contact lens care
Ocular lubricants
Remove using topical anaesthesia and a needle
Prophylactic antibiotic after removal
How should concretions be followed up (if removed and not removed)?
If removed - 3-5 days after removal
If not removed - follow-up at patient’s request
What colour is an amyloidosis?
Yellowish
Is an amyloidosis vascular or avascular?
Avascular
What is an amyloidosis and where can it be found?
A waxy deposit within the bulbar or forniceal conjunctiva
What can an amyloidosis be associated with?
Recurrent bleeding
What are amyloidoses composed of?
Amyloid
Are amyloidoses usually uni- or bilateral?
Unilateral
Are amyloidoses localised or a systemic disorder?
Can be either
List 3 symptoms of amyloidoses.
Usually asymptomatic
Not tender unless large enough to affect lid function or give a foreign body sensation
List three differential diagnoses for amyloidoses.
Pingueculae
Conjunctival papilloma
Other conjunctival tumours
What are the to components to an amyloidosis assessment?
Slit lamp
Fluorescein staining
hat is the treatment option for amyloidosis (3)?
Check if amyloid is present elsewhere in the eye
Removal required if foreign body sensation is felt or for cosmesis
Refer for biopsy to rule out systemic amyloidosis
How should amyloidosis be followed up (3)?
Early if doubt over diagnosis, change in size, or symptoms
What is lymphaniectasia?
Conjunctival cysts
Are lymphangiectasia opaque or clear?
Small clear cysts like a bubble
Where can lymphangiectasia be found?
Bulbar or forniceal or palpebral conjunctiva
Are lymphangiectasia always bubble shaped or can they be other shapes? Explain.
Can also be a tube-like swelling, which is more transparent than a cyst (this occurs in the bulbar region)
Are lymphangiectasia mobile to touch/blinking?
Yesd
Are lymphangiectasia typically uni- or bilateral?
Unilateral
List two symptoms of lymphangiectasia.
Typically asymptomatic
May have a foreign body sensation
List 4 differential diagnoses for lymphangiectasia.
Conjunctival intraepithelial neoplasm
Conjunctivochalasis
Chemosis
Phlyctenule
What is the treatment option for lymphangiectasia if asymptomatic?
Usually monitor
What is the general treatment option for lymphangiectasia if removal is required (2)?
Lance the cyst under local anaesthesia, massage closed lids to drain
Prophylactic antibiotic required
Refer for surgical removal from base if required
Do lymphangiectasia that have been lanced and drained typically re-occur?
Yes
How should lymphangiectasia be followed up (2)?
Monitor if lanced
At patient’s request
What is ecchymosis?
Sub-conjunctival blood anywhere under the bulbar conjunctiva
What is notable in ecchymosis?
A distinct white border at the limbus and conjunctival fornix
Are echhymosis common or rare?
Very common
Are ecchymosis uni- or bilateral?
Unilateral
What are ecchymosis also known as?
Sub-conjunctival haemorrhage
Are ecchymosis painful? Does it affect vision?
Painless and has no effect on vision
List the six components for an assessment of ecchymosis.
History for any precipitating event
Slit lamp
Pupils
Eye movements
IOP
Blood pressure
List 4 differential diagnoses for ecchymosis.
Conjunctival Kaposi’s sarcoma
Haemorrphagic conjunctivitis
Breakthrough bleed from behind the globe
Other ocular neoplasia with secondary haemorrhage
What is the treatment option foe ecchymosis?
Reassure the patient
Cold packs to stop bleeding for 1-2 days followed by hot packs to assist haemolysis
How long may ecchymosis take to resolve?
1-3 weeks
How should ecchymosis be followed up? What about if there are more than 2 recurrences in a year?
Review after one week if concerned or no other resolution
If more than 2 recurrences - refer to determine if its systematic or for cauteristation
What are bitot’s spot? How do they look? Are they raised or flat? Where on the eye can they be found?
Foamy, slightly raised patches on the bulbar conjunctiva
What is bitot’s spot due to (2)?
Metaplastic keratinisation of the conjunctival epithelium and loss of goblet cells
Are bitot’s spots usually temporal or nasal?
Usually temporal, less frequently nasal
Bitot’s spot is associated with the colonisation of what bacteria? What aspect of bitot’s spot exactly?
Hyperkeratinisation of the local area is associated with colonisation by crynebacterium
What is bitots spot characteristic of?
Late stage vitamin A deficiency
List 3 symptoms of bitot’s spot.
Ocular surface irritation
Reduced vision
Nightblindness
List two components for the assessment of bitot’s spot.
Slit lamp
Dry eye workup
List three differential diagnoses for bitot’s spot.
Pingueculum
Amyloidosis
Conjunctival intraepithelial neoplasm
What is the treatment option for bitot’s spot (3)?
Refer to GP for a vitamin A deficiency
Will normally disappear with high dose vitamin A theraphy
Manage dry eye symptoms as appropriate
What may happen if bitot’s spot is longstanding?
May have permanent epithelial metaplasia
How should bitot’s spots be followed up (2)?
Over the period of vitamin A therapy
If there is a change in size or symptoms
List 3 signs of superior limbic keratoconjunctivitis.
Papillary hypertrophy of the superior tarsus (papillae)
Hyperaemia of the superior bulbar conjunctiva
SPK of the superior cornea
Is superior limbic keratoconjunctivitis usually uni- or bilateral?
Bilateral
In what percentage of superior limbic keratoconjunctivitis cases can corneal filaments be found?
30%
In what age population and gender does superior limbic keratoconjunctivitis usually occur?
Middle-aged women
In what percentage of superior limbic keratoconjunctivitis cases is there associated dry eye? What about thyroid dysfunction?
25% for dry eye
50% for thyroid dysfunction
What happens with superior limbic keratoconjunctivitis over time?
It is recurrent, but usually disappears with time
What kind of other response is similar to superior limbic keratoconjunctivitis?
Contact lens wearers develop an identical condition
List 5 symptoms of superior limbic keratoconjunctivitis.
Burning
Foreign body sensation
Slightly blurred vision
Photophobia
Lacrimation/mucoid discharge
List 3 components for the assessment of superior limbic keratoconjunctivitis.
History
Slit lamp with lid eversion
Dry eye workup
List 3 differential diagnoses for superior limbic keratoconjunctivitis.
Terriens marginal degeneration
Trachoma
Adult inclusion conjunctivitis
Should superior limbic keratoconjunctivitis be referred? Explain.
Yes, for evaluation of thyroid function
List 6 possible treatment options for superior limbic keratoconjunctivitis.
Evaluate contact lens fit and material
Topical steroids
Topical vasoconstrictors
Ocular lubrication
Soft contact lens bandage
Surgery
What is the treatment of superior limbic keratoconjunctivitis aimed at (4)?
Managing inflammation
Reducing friction
Reducing interaction of the upper eyelid with the limbus
Reducing subconjunctival space
How should superior limbic keratoconjunctivitis be followed up?
Every 1-2 weeks during the attack, more if management requires it
What is floppy eyelid syndrome?
Loose upper eyelids
What kind of conjunctivitis occurs with floppy eyelid syndrome and why?
Papillary conjunctivitis of the tarsal conjunctiva - the upper eyelid everts during sleep resulting in exposure
What kind of discharge occurs in floppy eyelid syndrome?
Slight mucous discharge
Is the cornea exposed in floppy eyelid syndrome?
Yes (SPK, SLK etc)
Is floppy eyelid syndrome common or rare? Which population is it found in (gender too)?
Rare, found in obese men
What is floppy eye syndrome associated with?
Sleep apnoea
List 4 symptoms of floppy eye syndrome.
Gritty sore eyes
Blurred vision
Increased lacrimation
Lids require uneversion on waking
List four components for the assessment of floppy eyelid syndrome.
History of bad snoring
Slit lamp
Observe lash position
Feel for lid laxity
List four differential diagnoses for floppy eyelid syndrome.
Dry eye syndrome
Superior limbic keratoconjunctivitis
Rosacea keratitis
Range of chronic keratitis/conjunctivitis/canaliculitis
What are 5 treatment options for floppy eyelid syndrome?
Refer for sleep apnoea investigation - management of sleep apnoea will improve condition
Weight loss program
Ocular lubricant before sleep
Taping lids shut during sleep
Surgical horizontal tightening of the upper lid
How should floppy eyelid syndrome be followed?
Up to weekly as appropriate until resolved
