AED - Conjunctival Degeneration - Week 4 Flashcards by Davud Akgun

Describe the SOAP mnemonic.

Subjective (symptoms
Objective (signs)
Assessment (DDx)
Plan (Mx)

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Where are goblet cells located?

Just inferior to the forniceal conjunctiva on the bulbar conjunctiva

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List three structures that secrete mucin.

Goblet cells
Crypts of henle
Glands of menz

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List two basal lacrimal secretors.

Glands of krause

Glands of wolfring

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Where are glands of krause located?

At the forniceal conjunctiva

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Where are glands of manz located?

Inferior to goblet cells on the bulbar conjunctiva

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Where are crpyts of henle found?

Inferior to the glands of wolfring, on the palpebral conjunctiva close to the tarsal plate

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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

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Are pingueculae raised or flat?

Slightly raised

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Are pingueculae common or rare? Are they uni- or bilateral?

Very common and generally bilateral

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List 3 symptoms of pingueculae.

Usually asymptomatic
Foreign body sensation if inflammed
Cosmetically unappealing

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List the three components for a pingueculum workup.

Slit lamp
Fluorescein staining
Tear workup if symptomatic

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Do pingueculae affect visiond?

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Are pingueculae vascularised? Explain (2).

Not vascular but can be hyperaemic if inflammed.

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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

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What is the histopathology of pingueculae (4)?

Elastotic degeneration of collagen
Hyalinisation of the conjunctival stroma
Collection of elastotic fibres
Granular deposits

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List 4 differential diagnoses for pingueculae.

Pterygium
Conjunctival intraepithelial neoplasia
Other tumours (papilloma)
Limbal dermoid

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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

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List two treatment options for pingueculae with severe inflammation.

NSAIDs or topical steroids

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What should be done if dellen persists in pingueculae?

Refer for cosmetic surgery

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What are two ways pingueculae can be removed?

Excision surgery - excision with the conjunctiva

Argon laser - photocoagulation

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List1 3 signs of pterygium.

A vascular triangular mass ith the base to the conjunctiva
Slowly advancing to the central cornea
Increasing astigmatism

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Are pterygia vascular?

Yesd

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Are pterygia uni- or bilateral?

Often bilateral

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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