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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
Q

What is a Conjunctival Naevus?

A

• 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

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26
Q

What to do when you find Conjunctival Naevus in practise?

A

• High junctional activity but rarely become malignant
• Observe
• Excision if suspicious
• Rare on palpebral conjunctiva - excise lesions in fornix or over tarsus

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27
Q

What are preinvasive pigment lesions and their description?

A

• 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

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28
Q

How do you investigate if it really is primary acquired melanosis?

A

• 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

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29
Q

Describe Malignant pigmented lesions melanoma

A

• 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

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30
Q

what is the appearance of melanoma and how is it treated?

A

• 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

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31
Q

What is the Freckle onset, area, location and Malignant potential?

A

Onset - Youth
Area - small
Location - Conjunctiva
Malignant Potential - No

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32
Q

What is the Benign Acquired Melanosis onset, area, location and Malignant potential?

A

Onset - Adult hood
Area - Patchy or diffuse
Location - Conjunctiva
Malignant potential - No

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33
Q

What is the Naevus onset, area, location and Malignant potential?

A

Onset - Youth
Area - Small cystic
Location - Conjunctiva
Malignant Potential - Low

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34
Q

What is the Ocular Melanocytosis onset, area, location and Malignant potential?

A

Onset - Congenital
Area - Patchy or diffuse
Location - Episclera
Malignant Potential - Yes

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35
Q

What is the Primary Acquired Melanosis onset, area, location and Malignant potential?

A

Onset - Middle age
Area - Patchy or diffuse
Location - Conjunctiva
Malignant potential - Yes

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36
Q

What are Lymphoid lesions and their occurrence?

A

• 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

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37
Q

What is a Kaposi Sarcoma and how is it treated?

A

• 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
Q

What are Limbal Dermoids?

A

• 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
Q

What is a dermolipoma?

A

• 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
Q

What are Degenerations?

A

• 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
Q

What are the common types of Degenerations?

A

• Pinguecula
• Pterygium
• Concretions
• Conjunctivochalasis

42
Q

What are pingeucula?

A

• 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
Q

What is a Ptergium?

A

• 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
Q

How is Ptergium managed?

A

• Lubrication
- Artificial tears
• Mild topical steroid

• Surgical Excision
• Risk of recurrence
• Conjunctival Autograft
• Fibrin Glue

45
Q

What are conjunctivochalasis?

A

• Age related degenerative change
• Excess folds of conjunctiva
• Noted inferior fornix
• May be asymptomatic
• May complain of
- Irritation
- Epiphora
- Dry eye
• Symptomatic treatement

46
Q

What are concretions?

A

• Sign of chronic meibomian gland dysfunction
• Symptoms of blepharitis
• Multiple small yellow deposits on inferior tarsal conjunctiva
• No treatment necessary

47
Q

What are the different categories of inflammations of the conjunctiva?

A

• 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
Q

What are acute conjunctivitis signs/symptoms?

A

• “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
Q

Where are Papillae most commonly seen?

A

• Allergic - atopic, vernal, seasonal, perennial
• Topical preperations
• Chronic irritation - giant papillary conjunctivitis, superior limbic conjunctivitis

50
Q

Where are follicles most commonly seen?

A

• Virus Infection - adenovirus, herpes simplex, molluscum contagiosum
• Chlamydial
• Drug Induced
• Lymphoid disease - benign hyperplasia and lymphoma

51
Q

What is bacterial conjunctivitis and its signs?

A

• 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
Q

How is Bacterial conjunctivitis treated?

A

• 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
Q

What is Viral conjunctivitis- adenoviral, and how does it present?

A

• 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
Q

How is Viral conjunctivitis treated?

A

• Treatment: symptomatic relief
- Artificial tears
- Antihistamine drops
- Cold compresses
- Peeling of pseudomembrane if present
• self limiting, usually managed in community, refer if atypical

55
Q

What are the other types of Viral conjunctivitis?

A

• Herpes simplex
• Varicella Zoster
• Molluscum contagiosum

56
Q

What is Herpes simplex conjunctivitis?

A

• 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
Q

What is Herpes simplex keratitis differentiated from conjunctivitis?

A

• Check for corneal involvement
• Topical antiviral therapy - aciclovir

• Cold compresses

58
Q

How is Herpes Zoster - shingles described?

A

• 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
Q

How is herpes zoster - shingles, treated?

A

• Oral antiviral agent in presence of skin lesion
• Topical aciclovir not effective - good penetration with oral agents

• Cold compresses
• Lubrication

60
Q

What is Molluscum contagiosum?

A

• 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
Q

What is allergic conjunctivitis and their symptoms?

A

• 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
Q

Symptoms of allergic conjunctivitis?

A

• 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
Q

What are Allergic conjunctivitis signs and symptoms?

A

• 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
Q

What are the differential diagnosis for allergic conjunctivitis?

A

• Differential Diagnosis
- Blepharitis
- Contact allergy
- Infectious conjunctivitis
- Other forms of allergic conjunctivitis
- Trauma - mechanical or chemical
- Cellulitis - periorbital or orbital

65
Q

What is management of allergic conjunctivitis?

A

• 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
Q

What is Atopic keraconjunctivitis?

A

• 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
Q

What are Atopic keraconjunctivitis symptoms?

A
  • Extreme itch / burning
  • Photophobia
  • Altered acuity
  • Redness ++
  • Evidence of scratching on face
  • Mucus discharge ++ causing eyes to be stuck in morning
68
Q

What are Atopic keraconjunctivitis signs?

A

• 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
Q

How is Atopic keraconjunctivitis managed?

A

• 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
Q

What is Vernal Keratoconjuncticitis?

A

• 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
Q

What are the symptoms Vernal Keratoconjunctivitis?

A

• Symptoms
- Extreme itching
- Redness
- Photophobia
-Blepharospasm
- Altered acuity
- Mucus discharge ++

72
Q

What are the signs of Vernal Keratoconjunctivitis?

A

• 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
Q

How is Vernal Keratoconjunctivitis managed?

A

• 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
Q

When is Vernal Keratoconjunctivitis referred?

A

• 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
Q

What are the different types of Chlamydial Conjunctivitis?

A

• Acute Chlamydial Conjunctivitis
• Trachoma
• Neonatal Chlamydial infection

76
Q

What is Acute Chlamydial Conjunctivitis?

A

• Sexually transmitted disease
• Chlamydia trachomatis D to K
•Young
• Other concomitant infections
• 1 week incubation

• Follicular conjunctivitis
• Similar to adenoviral but becomes chronic

77
Q

What is Trachoma?

A

• 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
Q

How is Trachoma and Chlamydial Conjunctivitis treated?

A

• Oral antibiotics

• Azithromycin
• Doxycycline
• Tetracycline

79
Q

What is Neonatal Chlamydial Conjunctivitis?

A

• Notifiable disease
• Most common cause neonatal conjunctivitis
• Presentation 1-3 weeks after birth
• Mucopurulent discharge
• Papillary conjunctivitis
- Infants unable to form follicles

80
Q

What are the two types of Cicatrising Conjunctivitis?

A

• Cicatricial Pemphigoid

• Stevens Johnson Syndrome

81
Q

What is Cicatricial Pemphigold?

A

• 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
Q

How is Ocular Cicatricial Pemphigold managed?

A

• 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
Q

What is Stevens Johnson syndrome?

A

• 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
Q

What are ocular symptoms of steven johnsons syndrome?

A

• Fever, rash, malaise, arthralgia
• Red, dry eyes
• Mucopurulent / pseudomembranous
• Episcleritis
• Iritis

85
Q

How is steven johnsons syndrome treated?

A

• Tear deficiency
- Artificial teats
• Iritis
- Topical steroid
• Infection
- Scrape, topical antibiotic

86
Q

What are the types of trauma relevant to this unit?

A

• Conjunctival foreign body
• Conjunctival laceration
• Subconjunctival haemorrhage
• Chemical injury

87
Q

What is a Conjunctival foreign body?

A

• 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
Q

What us Conjunctival Laceration?

A

• 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
Q

What is a subconjunctival haemorrhage?

A

• Asymptomatic or Mild irritation
• Blood underneath conjunctiva
- Valsalva
- Traumatic
- Hypertension
- Bleeding disorder
- Ideopathic

90
Q

What presents with a chemical injury?

A

• Chemosis
• Conjunctival blanching
• Associated corneal epithelial defects

• Immediate irrigation
• Search fornices

(2) Tri A Clinical opthalmology (19 decks)

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