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(2) Tri A Clinical opthalmology > Anterior Eye 1 - Conjunctiva > Flashcards

Anterior Eye 1 - Conjunctiva Flashcards

1
Q

Conjunctival Tumours (4 normal, 6 “..omas”)

A

• Epibulbar Dermoid
• Melanosis Oculi
• Conjunctival Cyst
• Naevus

• Papilloma
• Conjunctival Squamous Carcinoma
• Dermolipoma
• Malignant Melanoma
• Lymphoma
• Kaposi Sarcoma

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2
Q

Degenerative Changes

A

• Pinguecula
• Pterygium
• Concretions
• Conjunctivochalasis
• Retention Cyst

• Trauma

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3
Q

Conjunctivitis types:-

A

• Bacterial Conjunctivitis
• Viral Conjunctivitis
• Allergic Conjunctivitis
• Cicatrizing Conjunctivitis
• Other Conjunctivitis

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4
Q

What is the Conjunctiva and its different sections?

A

• Mucus membrane lining posterior surface of eyelids and anterior globe as far as the limbus
• Divided into different sections
- Palpebral
- Forniceal
- Bulbar

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5
Q

Zones of conjunctiva

A

• Marginal
• Tarsal
• Orbit
• Fornix
• Bulbar
• Limbal

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6
Q

Conjunctival cell types?

A

• Stratified
• Non-keratinizing
• Squamous

• Contains mucus secreting goblet cells
- Most numerous in fornix, absent in epibulbar area
• Palpebral - thickened and covers lymphocytes, vessels and lymphoid tissue

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7
Q

Histology 2

A

• Overlying epithelium
• Stroma includes collagen fibres, vessels, nerves, resident lymphocytes, plasma cells, mast cells
• Medial conjunctiva forms fold - plica semilunaris
• Medial to this - caruncle
- Non-keratinizing stratified squamous epithelium

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8
Q

Different causes of lesions of conjunctiva:-

A

• Congenital Anomaly
• Inflammation
• Degeneration
• Dystrophy; inherited
• Neoplasia

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9
Q

Congenital conjunctival types:

A

• Abnormality in size, location, organization or amount of tissue

• Choristoma
- Normal, mature tissue at abnormal location
- Dermoid

• Hamartoma
- Exaggerated hypertrophy and hyperplasia of mature tissue at a normal location
- Haemangioma

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10
Q

What is a Neoplasia?

A

• New growth of particular tissue
• Benign or malignant
• Pigmented / Non-pigmented

• Epithelial (including glandular)
- Squamous papilloma

• Subepithelial
- Malignant lymphoma

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11
Q

What types of Neoplasia are there?

A

• Adenoma (benign) and adenocarcinoma (malignant) in glandular epithelium
- Oma - benign. Sarcoma - malignant in soft tissue
• Hyperplasia - benign. Leukaemia/lymphoma - malignant in haemogopoietic tissue

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12
Q

What is Conjunctival Neoplasia?

A

• Often affects cornea
• Similar classification to tumours affecting the eyelid

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13
Q

What is the epithelial inclusion cyst?

A

• Common finding in lower fornix. Benign
• Form in apposition of conjunctival folds
• Large cysts following burying of epithelium following trauma / surgery / inflammation

• Clear with normal epithelium
• Differential diagnosis - lymphangiectasia
• Complete excision to prevent recurrence

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14
Q

What are the three stages of Epithelial tumours, and its progression name through the stages?

A

• Benign
- Papilloma
• Pre-invasive
- Intraepithelial Neoplasia
• Malignant
- Squamous cell carcinoma

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15
Q

What is conjunctival Papilloma and the different types of growth?

A

Caused by:
• Human papillomavirus (HPV) 6 or 11 initiates neoplastic growth
• Vascular proliferation
2 types:
• Pedunculated growth
- Fleshy, exophytic growth from stalk, multilobulated, clear epithelium
- Underlying tortous blood vessels

• Sessile growth
- Flat, glistening appearance with numerous red spots
- May spread onto cornea
- Rarely represents a carcinomatous lesion - HPV 16 & 18

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16
Q

How to manage Conjunctival Papilloma?

A

• Spontaneous regression
- Months to years
• Observe small pedunculated lesions
• Excision
- Risk of recurrence
- Incomplete excision: worse appearance
- Excision with cryotherapy ‡ adjunctive therapy
• Mitomycin C or Interferon a

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17
Q

What is Preinvasive epithelial neoplasia and its cause?

A

• Conjunctival intraepithelial neoplasia
• Epithelial basement membrane is not compromised
• Mild / moderate / severe
• Carcinoma in situ when neoplasia throughout epithelium

• Caused by ? HPV virus or sunlight
• HIV in young adults
• Most commonly occur on exposed areas near limbus

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18
Q

How can the appearance of Conjunctival intraepithelial neoplasia described?

A

• Appearance
- Papilliform
- Gelatinous
- Leukoplakic
• Mild inflammation and abnormal vascularisation
• Large feeder vessels
• Slow growing

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19
Q

How is conjunctival intraepithelial neoplasia treated?

A

• Adjunctive therapy
- Mitomycin C
- Interferon
• Excision with clear margins
• Cryotherapy to surrounding area
• Risk if limbal stem cell failure

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20
Q

How do we treat squamous cell carcinoma?

A

• Excision with clear borders - 4mm
• Cryotherapy
• Rate of recurrence dependent on clearance of margins
• Risk of intraocular then systemic spread
• Exenteration

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21
Q

What are the categories if pigmented lesions, and the definition of Melanosis?

A

• Melanosis - excessive pigmentation without an elevated mass
- Can be acquired or congenital
• categories by Cell type
- Epithelial melanocytes
- Subepithelial melanocytes
- Nevus cells
• Benign
• Pre-invasive/malignant

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22
Q

What type of lesions is a freckle?

A

• Benign pigmented lesions
- congenital epithelial melanosis
• Flat brown patch near limbus
• Present from early stage
• More common in dark skinned

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23
Q

How is a Benign acquired melanosis described?

A

• Increasing diffuse pigmentation with age in dark skinned individuals
• Most apparent interpalpebral bulbar conjunctiva and perilimbal area
• Possibly related to UV exposure

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24
Q

How is ocular Melanocytosis described?

A

• 1 in 2500, more common in dark skinned
• Congenital melanosis of the episclera
• Focal proliferation of subepithelial melanocytes
• Slate grey, non mobile, unilateral lesions
• May have ipsilateral naevus of Ota (deraml melanocytosis)
• Together called oculodermal melanocytosis

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25
What is a Conjunctival Naevus?
• Conjunctival hamartoma • Junctional, compound or subepithelial • Flat near limbus • Elevated elsewhere • Variable pigmentation • Small inclusion cysts may be present leading to enlargement • Rapid enlargement can occur at puberty
26
What to do when you find Conjunctival Naevus in practise?
• High junctional activity but rarely become malignant • Observe • Excision if suspicious • Rare on palpebral conjunctiva - excise lesions in fornix or over tarsus
27
What are preinvasive pigment lesions and their description?
• Primary acquired melanosis - Similar to lentigo maligna on skin - Abnormal melanocyte proliferation of unclear aetiology - Unilateral, flat, brown lesions • More common in Caucasian population • Usually benign but may progress to melanoma - suspect with nodularity, enlargement or increased vascularity
28
How do you investigate if it really is primary acquired melanosis?
• Small areas may be observed • Suspicion and biopsy palpebral or forniceal conjunctiva, plica or caruncle • Excision biopsy in large progressive lesions • Clear margins • Topical Mitomycin C or Interferon a
29
Describe Malignant pigmented lesions melanoma
• Rare - 1 per 2 000 000 in Europeans • Can metastasize but better prognosis than cutaneous melanoma • Arise from acquired naevi / PAM / normal conjunctiva • Direct spread from ciliary body or metastasisze to conjunctiva • Most common in bulbar conjunctiva or limbus
30
what is the appearance of melanoma and how is it treated?
• Variable pigmentation • Vascularised - can bleed easily (feeder vessels) • Nodular appearance • Invade globe or orbit or metastasize to regional lymph nodes, brain and other sites • Excisional biopsy with 4mm borders and amniotic membrane graft • Cryotherapy and Mitomycin C
31
What is the Freckle onset, area, location and Malignant potential?
Onset - Youth Area - small Location - Conjunctiva Malignant Potential - No
32
What is the Benign Acquired Melanosis onset, area, location and Malignant potential?
Onset - Adult hood Area - Patchy or diffuse Location - Conjunctiva Malignant potential - No
33
What is the Naevus onset, area, location and Malignant potential?
Onset - Youth Area - Small cystic Location - Conjunctiva Malignant Potential - Low
34
What is the Ocular Melanocytosis onset, area, location and Malignant potential?
Onset - Congenital Area - Patchy or diffuse Location - Episclera Malignant Potential - Yes
35
What is the Primary Acquired Melanosis onset, area, location and Malignant potential?
Onset - Middle age Area - Patchy or diffuse Location - Conjunctiva Malignant potential - Yes
36
What are Lymphoid lesions and their occurrence?
• Occurs in young to middle age adults • Range from benign reactive hyperplasia to lymphoma • Similar clinical appearances • Light pink, salmon coloured lesion • Relatively flat, smooth and soft - Bulbar conjunctiva - oval - Fornix conjunctiva - horizontal
37
What is a Kaposi Sarcoma and how is it treated?
• Slow growing malignant tumour associated with AIDS • Painless or discomfort • Vascular - red or purple • Inferior fornix • Treatment - Investigation for HIV status - Radiotherapy - Excision ‡ cryotherapy
38
What are Limbal Dermoids?
• Congenital Abnormalities • Choriostomas • Limbal Dermoids - Benign - Usually located at the limbus, encroaching cornea - Firm, dome shaped, white, elevations - Few mm to 1cm - Occur in isolation or as part of congenital syndrome if bilateral - Goldenhar • Surgical incision if amblyopia
39
What is a dermolipoma?
• Benign tumour • Temporal bulbar conjunctiva • Yellow-white solid tumour • Softer than dermoid due to adipose • Extend posteriorly into orbit • May be associated with Goldenhar svndrome • Avoid treatment due to globe extension
40
What are Degenerations?
• Deleterious tissue changes with time • Loss of tissue mass or acellular material • Wide variety of disease processes -Vascular - Normal aging - Trauma • Dystrophies - Bilateral symmetrical inherited conditions that have no environmental relationship
41
What are the common types of Degenerations?
• Pinguecula • Pterygium • Concretions • Conjunctivochalasis
42
What are pingeucula?
• Small, yellowish / grey nodule nasal or temporal to limbus • Vascularised or injected • Degeneration of collagen • Prolonged sun exposure and increasing age • No treatment necessary
43
What is a Ptergium?
• Similar location, history, histological changes • Encroaches onto cornea in "wing-like" fashion • Can become inflamed • Encroach visual axis - Astigmatism - Corneal scarring • Invade Bowman's layer
44
How is Ptergium managed?
• Lubrication - Artificial tears • Mild topical steroid • Surgical Excision • Risk of recurrence • Conjunctival Autograft • Fibrin Glue
45
What are conjunctivochalasis?
• Age related degenerative change • Excess folds of conjunctiva • Noted inferior fornix • May be asymptomatic • May complain of - Irritation - Epiphora - Dry eye • Symptomatic treatement
46
What are concretions?
• Sign of chronic meibomian gland dysfunction • Symptoms of blepharitis • Multiple small yellow deposits on inferior tarsal conjunctiva • No treatment necessary
47
What are the different categories of inflammations of the conjunctiva?
• Coniunctivitis • Acute or chronic / Diffuse or localised • Infectious / Non-infectious • Acute - Rapid onset of redness and irritation - Sloughing of necrotic epithelium Increased inflammatory cell production - pseudomembrane • Chronic - Slower onset - Localised nodules and surface infoldings
48
What are acute conjunctivitis signs/symptoms?
• "Red eye" - hyperaemia • Discharge - type dependent on underlying cause • Sticky in morning • Foreign body sensation but rarely pain • Usually short duration (less than 4 weeks) • Follicles • Papillae
49
Where are Papillae most commonly seen?
• Allergic - atopic, vernal, seasonal, perennial • Topical preperations • Chronic irritation - giant papillary conjunctivitis, superior limbic conjunctivitis
50
Where are follicles most commonly seen?
• Virus Infection - adenovirus, herpes simplex, molluscum contagiosum • Chlamydial • Drug Induced • Lymphoid disease - benign hyperplasia and lymphoma
51
What is bacterial conjunctivitis and its signs?
• Redness • Pain - Foreign body sensation / grittiness • Less than 4 week duration • Less "itchy" than other types of conjunctivitis • Signs • Purulent discharge • Sticky - worse in morning • Papillae • Chemosis
52
How is Bacterial conjunctivitis treated?
• Conjunctival swab if severe • Topical antibiotics - Chloramphenicol QDS 1 week • Eyelid hygiene • Cold compresses • Usually managed in community, refer if atypical or uncertain of diagnosis
53
What is Viral conjunctivitis- adenoviral, and how does it present?
• Pain - itchy / burning / FB sensation • Recent upper respiratory tract infection • Recent contact with infected person • Both eyes involved within 1-2 days • Follicles • Preauricular lymph nodes • Watery / mucus discharge - pseudomembrane • Red and swollen eyelids • Pinpoint subconjunctival haemorrhage
54
How is Viral conjunctivitis treated?
• Treatment: symptomatic relief - Artificial tears - Antihistamine drops - Cold compresses - Peeling of pseudomembrane if present • self limiting, usually managed in community, refer if atypical
55
What are the other types of Viral conjunctivitis?
• Herpes simplex • Varicella Zoster • Molluscum contagiosum
56
What is Herpes simplex conjunctivitis?
• History of ocular HSV or cold sores • Environmental stressors - Fever, UV light exposure, stress • Foreign body sensation • Unilateral follicular conjunctivitis • Herpetic skin lesions along lid or skin • Preauricular lymph node
57
What is Herpes simplex keratitis differentiated from conjunctivitis?
• Check for corneal involvement • Topical antiviral therapy - aciclovir • Cold compresses
58
How is Herpes Zoster - shingles described?
• Skin rash and discomfort • Headache, fever, malaise • Blurred vision, eye pain, red eye • Vesicluar skin rash, progresses to scarring • Unilateral, dermatome of fifth cranial nerve • Hutchison sign
59
How is herpes zoster - shingles, treated?
• Oral antiviral agent in presence of skin lesion • Topical aciclovir not effective - good penetration with oral agents • Cold compresses • Lubrication
60
What is Molluscum contagiosum?
• Oncogenic virus • Characteristic lesions of skin and mucus membranes - Domes shaped, umbilicated shiney nodules • Associated follicular conjunctivitis • Can be associated with HIV • Excision of lesion to treat conjunctivitis
61
What is allergic conjunctivitis and their symptoms?
• Perennial or seasonal - Hypersensitivity to airborne, allergen that enters tear film and comes into contact with conjunctival mast cells • Frequently associated with nasal symptoms - Rhinoconjunctivitis • Allergens - Seasonal: Pollens, "hay fever" - Perennial: dust might, animal hairs • Perennial tends to be less severe • Perennial patients can have seasonal exacerbations
62
Symptoms of allergic conjunctivitis?
• Symptoms - Itchy / red / burning - Watery or scant discharge - Symptoms usually mild - Remissions and exacerbations during season - May be unilateral or bilateral - Sneezing or nasal discharge
63
What are Allergic conjunctivitis signs and symptoms?
• Signs - Conjunctiva - mild injection and oedema ~ Pinkish appearance - Papillary hypertrophy possible - Eyelid - mild oedema may be present - No corneal involvement • Often there are no distinguishing signs and symptoms • Diagnosis can be made by classic mild to moderate symptoms and almost normal appearing eye with no specific signs
64
What are the differential diagnosis for allergic conjunctivitis?
• Differential Diagnosis - Blepharitis - Contact allergy - Infectious conjunctivitis - Other forms of allergic conjunctivitis - Trauma - mechanical or chemical - Cellulitis - periorbital or orbital
65
What is management of allergic conjunctivitis?
• Non-pharmacological measures • Avoid inciting agent / advice • Cold compresses • Artificial tears • Anti-allergy drops: antihistamine / mast cell stabiliser / combination drop • NSAIDs • Mild topical steroid - FML • Oral anti-histamines
66
What is Atopic keraconjunctivitis?
• Most typically occurs in men presenting in late teens or 20s and last until 30s/40s • History of atopy - asthma, hay fever, urticaria • Positive family history for atopy • Risk of reduced vision from corneal vascularisation, pannus formation and scarring
67
What are Atopic keraconjunctivitis symptoms?
- Extreme itch / burning - Photophobia - Altered acuity - Redness ++ - Evidence of scratching on face - Mucus discharge ++ causing eyes to be stuck in morning
68
What are Atopic keraconjunctivitis signs?
• Signs - Bulbar conjunctiva is erythematous and chemotic - Papillary hypertrophy - Conjunctival scarring - commonly upper palpebral region - Gelatinous limbal infiltrates - Cornea ~ Superficial punctate keratopathy ~ Persistent epithelial defects ~ Secondary infection and eventual scarring from chronic inflammation - Red, thickened and swollen lids as a result of atopic dermatitis with superadded infection
69
How is Atopic keraconjunctivitis managed?
• Long term maintenance often required - Mast cell stabiliser, sodium cromoglycate - Oral antihistamine • Blepharitis management - Lid hygiene - Topical antibiotic • Follow up every few weeks • Tapering of topical treatment dependent on ocular response • Monitoring of IOP for those requiring topical steroids
70
What is Vernal Keratoconjuncticitis?
• Bilateral, severe, sight threatening allergic coniunctivitis • Commonly seen in young children and adolescent males, lasts up to 10 years • Most symptomatic during spring and •summer • Some experience symptoms year round requiring maintenance therapy
71
What are the symptoms Vernal Keratoconjunctivitis?
• Symptoms - Extreme itching - Redness - Photophobia -Blepharospasm - Altered acuity - Mucus discharge ++
72
What are the signs of Vernal Keratoconjunctivitis?
• Signs - Giant papillae on upper tarsal plate >1mm in size - Cobblestone appearance - Pseudomembrane as a result of excess mucus production - Limbal conjunctiva - gelatinous limbal infiltrates • Corneal changes - Superficial punctate erosions - Trantas' dots - Macroerosions - Shield ulcer - Corneal plaque - Corneal vascularisation
73
How is Vernal Keratoconjunctivitis managed?
• Although severe, is self limiting • Resolves without scarring • Non-pharmacoogical measures • Topical anti-allergy and systemic antihistamine • Corneal compromise - Topical steroids, FML • Acute episodes - quickly tapered topical steroids usually necessary
74
When is Vernal Keratoconjunctivitis referred?
• Admission in severe cases not responding to treatment may help with a change in the environment • Treatment of chronic blepharitis - Oral and topical antibiotics - Eyelid hygiene • Occasional bandage contact lens when severe corneal complications are present
75
What are the different types of Chlamydial Conjunctivitis?
• Acute Chlamydial Conjunctivitis • Trachoma • Neonatal Chlamydial infection
76
What is Acute Chlamydial Conjunctivitis?
• Sexually transmitted disease • Chlamydia trachomatis D to K •Young • Other concomitant infections • 1 week incubation • Follicular conjunctivitis • Similar to adenoviral but becomes chronic
77
What is Trachoma?
• Chlamydia trachomatis A, B, Ba, C • Developing countries and poor sanitation • TF : Follicular conjunctivitis upper tarsus • TI : Thickening / obscuring tarsal vessels • TS : Cicatrization with fibrous bands • TT : Trichiasis • CO : Corneal opacity
78
How is Trachoma and Chlamydial Conjunctivitis treated?
• Oral antibiotics • Azithromycin • Doxycycline • Tetracycline
79
What is Neonatal Chlamydial Conjunctivitis?
• Notifiable disease • Most common cause neonatal conjunctivitis • Presentation 1-3 weeks after birth • Mucopurulent discharge • Papillary conjunctivitis - Infants unable to form follicles
80
What are the two types of Cicatrising Conjunctivitis?
• Cicatricial Pemphigoid • Stevens Johnson Syndrome
81
What is Cicatricial Pemphigold?
• Chronic autoimmune blistering disease • Predominantly affects mucous membranes - Mouth, throat, oesophagus, conjunctiva • Patients may present with: - Red eye, tearing, dry eye, burning / foreign body sensation -Blepharospasm - Decreased vision, photophobia - Diplopia
82
How is Ocular Cicatricial Pemphigold managed?
• Step up/down approach depending on severity • Artificial tears • Blepharitis treatment • Goggles to provide moist environment • Punctal occlusion • Topical / systemic steroids • Immunosuppressive agents • Surgical correction of entropion • Mucus membrane grafts
83
What is Stevens Johnson syndrome?
• Severe immune mediated hypersensitivity reaction • Mucocutaneous blistering disease • Can be caused by: - Drugs - tetracyclines, NSAIDs - Viral infections - Malignancies • Cell death causes separation of the epidermis from the dermis in skin
84
What are ocular symptoms of steven johnsons syndrome?
• Fever, rash, malaise, arthralgia • Red, dry eyes • Mucopurulent / pseudomembranous • Episcleritis • Iritis
85
How is steven johnsons syndrome treated?
• Tear deficiency - Artificial teats • Iritis - Topical steroid • Infection - Scrape, topical antibiotic
86
What are the types of trauma relevant to this unit?
• Conjunctival foreign body • Conjunctival laceration • Subconjunctival haemorrhage • Chemical injury
87
What is a Conjunctival foreign body?
• History • Irritation, tearing • Visible foreign body • Subtarsal foreign body - Pain when blinking - Evert eyelid in suspect cases - Linear abrasion on cornea • Usually removed with soaked cotton bud
88
What us Conjunctival Laceration?
• History of trauma • Mild pain, red eye • Fluorescein staining • Associated with adjacent subconjunctival haemorrhage • Requires close inspection to exclude scleral injury - beware chemosis • Usually resolves with lubrication
89
What is a subconjunctival haemorrhage?
• Asymptomatic or Mild irritation • Blood underneath conjunctiva - Valsalva - Traumatic - Hypertension - Bleeding disorder - Ideopathic
90
What presents with a chemical injury?
• Chemosis • Conjunctival blanching • Associated corneal epithelial defects • Immediate irrigation • Search fornices

(2) Tri A Clinical opthalmology (19 decks)

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