Competency 6.1.4 & 6.1.7 Flashcards
1
Q
What is a Limbal Dermoid?
A
- Presents as a whitish or yellowish lesion at the corneal limbus
- limbus-sparing dermoids and dermoids involving the entire cornea have been reported
- Patients with corneal dermoids usually present early in life, as the condition is congenital
- associated with Goldenhar Syndrome.
2
Q
Limbal Dermoid Symptoms
A
- Irritation
- Dry eye symptoms
3
Q
Limbal Dermoid Signs
A
- Young patient age
- Most are located at the inferior temporal limbus, though can affect only the cornea iself in some cases
- In terms of appearance:
o Usually has a dome shape
o Visible hair follicles
o Often vascularised - May also have coloboma of eyelids, duanes retraction syndrome and microphthalamos
- May suffer from recurrent conjunctivitis
4
Q
Limbal Dermoid Non-Surgical Management
A
- Main concern is visual development and preventing amblyopia
- Close monitoring of lesion size
- Close monitoring of VA, stereopsis and refraction
- If amblyopia proven then treated with patching therapy
5
Q
When is Surgery indicated for Limbal Dermoid?
A
o Chronic eye rubbing due to irritation and recurrent conjunctivitis
o Amblyopia unresponsive to medical management
o Progressive dellen with corneal surface decompensation
o Growth and encroachment into pupillary area or optical zone
o Aesthetic considerations
o Inadequate lid closure
6
Q
What is a Conjunctival Inclusion Cyst?
A
- a benign cyst filled with clear serous fluid containing shed cells or mucoid material
- constitute 80% of all cystic lesions of the conjunctiva
7
Q
Conjunctival Inclusion Cyst Risk Factors
A
- Inflammatory conditions of the conjunctiva
- Overactive immune system
- Trauma
- Surgery
- Sub-Tenon anesthesia
8
Q
Conjunctival Inclusion Cyst Symptoms
A
- If small
o Generally asymptomatic
o FB sensation - If large
o Pain
o Motility disturbances
o VF defect
o Induced refractive error
9
Q
Conjunctival Inclusion Cyst Management
A
- Generally these cysts disappear spontaneously
- If persistant:
o Surgical excision
o Empyting of cyst using needle
o YAG laser
10
Q
What is Conjunctival Papilloma?
A
- can be benign or malignant and can be found in numerous anatomical locations (eg, skin, conjunctiva, cervix, breast duct)
- conjunctival papillomas are benign squamous epithelial tumors with minimal propensity toward malignancy
- A strong association exists between Human Papilloma Virus (HPV) types 6 and 11
- usually seen in younger patients (HPV related)
- a slight association exists between UV radiation and limbal conjunctival papilloma so these may be seen in older patients
11
Q
Limbal Papilloma Signs
A
- Seen in older patients
- History of UV exposure
- Possible decrease in VA
- Recurrance is not common
- Almost always single and unilaterial
- Slowly increase in size
12
Q
Infectious Papilloma Signs
A
- Benign and self limiting
- Commonly seen in children and young adults
- Most asymptomatic without connjuctvitis
- No decrease in VA
- Commonly located in inferior fornix
- May be bilaterial and mulitiple
- Appears as a grayish red, fleshy, soft, pedunculated mass with an irregular surface (cauliflowerlike)
13
Q
What is a Pyogenic Granuloma
A
- is a common, non-cancerous growth of blood vessels which do not produce pus or involve the chronic inflammation typical of granulomas
- appear as smooth, red-purple bumps, either flat or on a stalk
- can recur after removal.
- PG can appear anywhere on the body, most frequently on the skin, affecting men and women equally
- ## they are twice as common in the mucous membranes of women, such as the conjunctiva, and are associated with pregnancy
14
Q
Pyogenic Granuloma Risk factors
A
- Pregnancy
- More common in women when conjunctival
- Linked to inflammation after strabismus surgery
- Herdeolum/chalazion
- Young age
15
Q
Pyogenic Granuloma Symptoms
A
- Discomfort (depending on location)
- Lesion will bleed with very little trauma
16
Q
Pyogenic Granuloma Management
A
- Topical steroids
- Cryotherapy
- Steroid injection
- Excision
17
Q
Conjunctival Papillae Characteristics (vs Follicles)
A
- Can be larger
- Cobblestone arrangement
- Flattened top
- Central vascular cores
- Commonly caused by allergic immune response or FB/contact lens
- Structure: Lymphocytes, plasma cells and mast cells in stroma surrounding a central vascular channel
- Appears more red at surface and pale at the base
18
Q
Conjunctival Follicles Characteristics (vs Papillae)
A
- Smaller
- Dome-shaped
- May have overlying vessels but lack the prominent central vessel
- Typically caused by inflammation due to pathogens (e.g. viruses, bacteria and toxins)
- Structure: Centre of immature proliferating lymphocytes with surrounding corona of more mature lymphocytes and plasma cells.
- Appears more red at base and paler at surface
19
Q
Causes of Follicular Reaction
A
- Toxins (e.g apraclonidine)
- Viruses (e.g. adenovirus)
- Chlamydia
20
Q
Causes of Papillary Reaction
A
- Allergy (AKC or VKC)
- Foreign body
- Superior limbic keratoconjucntivitis
21
Q
What are Conjunctival Membranes?
A
- True membrane formation occurs when the fibrinous deposit secreted by the invading microorganisms or ocular tissues adheres to the conjunctiva’s epithelial surface due to capillaries’ growth into the membrane
- Peeling membranes in membranous conjunctivitis causes bleeding and leaves behind a raw surface, representing more intense inflammation.
22
Q
Conjunctival Membranes Causes
A
Causes of Membranous conjunctivitis include:
- Bacterial infections can cause true membrane formation. Bacterial infections include Chlamydia.
- Viral causes include adenovirus (most common) and potential for fibrosis. Herpes simplex virus (HSV) and Epstein-Barr virus (EBV) may also be implicated.
- Drug reactions including hypersensitivity spectrum reactions, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), often in response to adverse drug reactions.
- Autoimmune diseases
- Eye-limited inflammatory etiologies include ocular cicatricial pemphigoid and chemical or thermal injury.
23
Q
What are Conjunctival Pseudomembranes?
A
- Pseudomembranous conjunctivitis membranes are more superficial, with no growth into the conjunctival epithelium, and can be removed with minimal bleeding.
- bleeding may still be observed in pseudomembranous conjunctivitis due to severe inflammation and friability of the underlying conjunctiva
24
Q
Conjunctival Pseudomembranes Causes
A
- Bacterial causes include Chlamydia
- Viral causes include adenovirus but COVID-19 has also been implicated
- Inflammatory etiologies include hypersensitivity reactions, such as SJS,
25
Q
What is a Subconjunctival Haemorrhage?
A
Subconjunctival haemorrhage (S-CH) results from rupture of conjunctival or episcleral blood vessels causing bleeding into the subconjunctival space
- Two main causes:
- spontaneous (higher incidence in adults over 50 years)
- Traumatic (higher incidence in younger adults)
26
Q
Subconjunctival Haemorrhage Spontaneous Causes
A
- idiopathic (most common)
- Valsalva manoeuvre (e.g. coughing, lifting, straining, vomiting) producing increase in central venous pressure
- systemic vascular disease (e.g. hypertension, diabetes)
- medication (anticoagulants, NSAIDs)
27
Q
Subconjunctival Haemorrhage Traumatic Causes
A
- injury
- eye rubbing
- ocular surgery/procedure (cataract surgery, refractive surgery, anaesthesia technique such as sub-Tenon’s anaesthetic or peribulbar block and intravitreal injection)
- contact lens handling injury
28
Q
Subconjunctival Haemorrhage Risk Factors
A
- Older age (highest incidence at 60-80 years)
- Trauma (including contact lens-related injury)
- Anticoagulant medication (e.g. aspirin, warfarin, clopidogrel, rivaroxaban, apixaban)
- Hypertension, diabetes and other systemic vascular disorders
- Bleeding abnormality (leukaemia, clotting disorders)
- Long-term topical steroid treatment
- Conjunctival vascular lesion
29
Q
Subconjunctival Haemorrhage Symptoms
A
- Mild ache or irritation (if extensive haemorrhage, otherwise painless)
- May be asymptomatic
30
Q
Subconjunctival Haemorrhage Signs
A
- Red area on eye, location usually temporal or inferior, caused by blood beneath the conjunctiva of which the posterior border can be seen
- Haemorrhage-localised or diffuse
- Usually unilateral
- No discharge
31
Q
Subconjunctival Haemorrhage Management
A
- Reassure patient
- Condition usually clears within 5-10 days
- Tear supplement / ocular lubricant if mild ocular irritation is present
- Cold compresses for any discomfort
- Consider ocular/orbital involvement in patients on anticoagulation
o Retinal haemorrhage
o Diplopia
o Proptosis
32
Q
What is a Pingecula?
A
- Elastotic degeneration of the conjunctiva
- appears as a yellow white raised lesion in the interpalpebral bulbar conjunctiva
- Pinguecula does not progress to become pterygium; they are two distinct conditions
33
Q
Pingecula Predisposing Factors
A
- Increasing age (seen in most eyes by age 70)
- Long term exposure to UV radiation
- Sunlight (residence at or near the equator, outdoor work, especially on reflective surfaces e.g. sand, concrete, water, snow)
- Welding and other occupational exposure
- Male gender (likely to be related to occupational exposure)
- Chronic irritation from wind or dust
- Contact lens wear
34
Q
Pingecula Symptoms
A
- Usually asymptomatic
- Possible mild foreign body sensation and redness when inflamed (pingueculitis)
- Occasional cosmetic concern
35
Q
Pingecula Signs
A
- Area of conjunctival thickening
- Located in the palpebral aperture, usually situated horizontally at the limbus and more common nasally
- usually bilateral
- Elevated and less transparent than normal conjunctiva
- White to yellow colour, fat like appearance, calcification sometimes present
- Sometimes slightly more hyperaemic than surrounding conjunctiva
- May lead to Dellen in adjacent cornea
- Decreased tear break-up time (TBUT)
36
Q
Pingecula Management
A
- Advice
o Reassure patient about benign nature of the lesion
o Advise on UV protection to minimise risk of inflammation
o Brimmed hat
o Sunglasses in wrap-around style for side protection - Treatment
o Cold compresses when inflamed
o Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime)
o PoM Pingueculitis usually responds to a brief course of a ‘non-penetrating’ topical steroid
- Fluorometholone 0.1% eye drops 4x daily (reduce by 1 drop a week to zero)
37
Q
What is a Pterygium?
A
- A winged-shaped fibrovascular growth progressing from the bulbar conjunctiva to involve the cornea
38
Q
Pterygium Predisposing Factors
A
- Older age
- Male gender (probably related to occupational exposure)
- Long term exposure to ultraviolet radiation
- Sunlight (residence at or near the equator, outdoor work, especially on reflective surfaces e.g. sand, concrete, water, snow)
- Dry, arid climate
- Inflammatory and allergic ocular surface disease
39
Q
Pterygium Symptoms
A
- Mild irritation, redness, dryness, foreign body sensation which may be exacerbated by episodes of acute inflammation
- Effect on vision
o result of astigmatism (with the rule)
o in severe cases, pterygium may extend over visual axis - Cosmetic concern
40
Q
Pterygium Signs
A
- Typically bilateral; most common nasally; often asymmetrical.
- Starts with scarring, thickening and distortion of the bulbar conjunctiva
- Small grey corneal opacities appear near the limbus later conjunctiva overgrows these opacities
- Slow insidious growth on to cornea (or may become stable)
- Destroys Bowman’s membrane and superficial stroma lamellae
- Epithelial iron deposit (Stocker’s line) ahead of advancing pterygium
- Relatively rich surface vascularisation
- Flattening of cornea in horizontal meridian
- Tear film instability
41
Q
Pterygium Management
A
- Advice
o Advise on UV protection to minimise risk of inflammation
- Brimmed hat
- Sunglasses in wrap-around style for side protection - If inflamed
o Cold compress when inflamed
o Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime)
o PoM Acute inflammation of a pterygium usually responds to a brief course of a ‘non-penetrating’ topical steroid
- Fluorometholone 0.1% eye drops 4x daily (reduce by 1 drop a week to zero) - Normally no referral unless
o Threatens visual axis
o Induces irregular astigmatism
o Associated with chronic inflammation
o Cosmetically unacceptable - Possible management by Ophthalmologist
o Topical steroids if inflamed
o Excision
42
Q
What is Acute Bacterial Conjunctivitis?
A
- Most cases are acute, self-limited, and not a major cause of morbidity
- because of its high prevalance, it has a large societal impact in terms of missed days of school or work
43
Q
Organisms which Cause Acute Bacterial Conjunctivitis
A
- Staphylococcus aureus
- Streptococcus pneumoniae
- Haemophilus influenzae.
44
Q
Acute Bacterial Conjunctivitis Predisposing Factors
A
- Children and the elderly have an increased risk of infective conjunctivitis
(NB Bacterial conjunctivitis in the first month of life is a serious condition that must be referred urgently to the ophthalmologist. - contamination of the conjunctival surface
- superficial trauma
- contact lens wear (particularly poor lens hygiene) (NB infection may be Gram –ve)
- secondary to viral conjunctivitis
- diabetes (or other disease compromising the immune system)
- steroids (systemic or topical, compromising ocular resistance to infection)
- blepharitis (or other chronic ocular inflammation)
45
Q
Acute Bacterial Conjunctivitis Symptoms
A
- Acute onset of:
o Redness
o discomfort, usually described as burning or grittiness
o discharge (may cause temporary blurring of vision)
o crusting of lids (often stuck together after sleep and may have to be bathed open) - Usually bilateral – one eye may be affected before the other (by one or two days)
46
Q
Acute Bacterial Conjunctivitis Signs
A
- lid crusting
- purulent or mucopurulent discharge
- conjunctival hyperaemia – maximal in fornices
- tarsal conjunctiva may show mild papillary reaction
- cornea: usually no involvement
- pre-auricular lymphadenopathy is usually absent
47
Q
Acute Bacterial Conjunctivitis Management
A
- Advice
o Bathe/clean the eyelids with proprietary sterile wipes, lint or cotton wool dipped in sterile saline or boiled (cooled) water to remove crusting.
o Advise patient that condition is contagious (do not share towels, etc.)
o Public health guidance in all UK Nations states that school or nursery exclusion is not required for children with this condition
o Contact lenses should not be worn during the treatment period. Beware corneal involvement in contact lens wearers - Pharmacological Treatment
o Treatment with topical antibiotic for one week may improve short-term outcome and render patient less infectious to others
- Ask if allergic to Chloramphenicol
- If not, supply Chloramphenicol 1% eye ointment 3 times daily for a week
- If allergic to Chloramphenicol, or pregnant, supply Fusidic acid 1% liquid gel twice a day for a week - Refer if:
o Condition fails to resolve
o There is corneal involvement - Possible management by Ophthalmologist
o Conjunctival swabs taken for analysis
o Treatment with other antibiotics, based on culture results
48
Q
What is Chlamydial Conjunctivitis?
A
- Chronic follicular conjunctivitis caused by the sexually transmitted microorganism Chlamydia trachomatis
- Spread by direct contact or fomites
- Chlamydial infection ranges in severity from mild to severe.
49
Q
Chlamydial Conjunctivitis Predisposing Factors
A
- Most common in young adulthood (15-35 years)
- Sexual activity leading to genital infection (up to 70% of cases of chlamydial conjunctivitis have a concurrent genital infection):
50
Q
Chlamydial Conjunctivitis Symptoms
A
- History usually more than two weeks
- Ocular gritty sensation and sticky discharge
- Drooping upper lid(s) (often unilateral but may involve both eyes)
51
Q
Chlamydial Conjunctivitis Signs
A
- Lid and other features
o oedema +/- ptosis (‘mechanical’)
o non-tender pre-auricular lymph node swelling (may or may not be present) - Conjunctival features
o hyperaemia and chemosis
o mucopurulent conjunctivitis
o large follicles in upper and lower fornices (double eversion of lid needed to view upper fornix)
o limbal and/or bulbar follicles may also be present - Corneal features
o epithelial keratitis, usually superior
o subepithelial infiltrates, similar to those seen in adenovirus KC
o marginal infiltrates
o superior pannus
52
Q
Chlamydial Conjunctivitis Management
A
- Advice
o Advise against contact lens wear
o Advise patient that genitourinary infection commonly associated (70% of cases) - Non-Pharmacological Treatment
o Symptomatic relief with ocular lubricants - Referral Urgency
o Urgent referral to ophthalmologist and GP - Ophthalmologist Management
o Conjunctival swabs and genital swabs for chlamydia
o Liaison with Sexual Health Clinic
o Treatment with systemic Azithromycin
o Topical Azithromycin
53
Q
Signs on Ophthalmic Exam Which Suggest Viral over Acute Bacterial
A
- Follicular reaction
- Pre-auricular lymphadenopathy
- Watery discharge
- Itchy eyes
- Concurrent pharyngitis, fever, and upper respiratory infection
- A history of prior conjunctivitis
54
Q
What is Adenoviral Conjunctivitis?
A
- is the most common form of acute infective conjunctivitis
- Adenoviruses are highly contagious pathogens (over 50 serotypes)
- the spectrum of disease varies from mild to severe
55
Q
Adenoviral Conjunctivitis Risk Factors
A
- Infection may be preceded by ‘flu-like symptoms
- Low standards of hygiene
- Outbreaks can occur in the general population, especially in crowded conditions (schools, camps), in hospital environments (especially ophthalmological units, and neonatal intensive care units) and in nursing homes
- Eye clinics (transmission by clinicians’ fingers, tonometer prisms, etc.)
56
Q
Adenoviral Conjunctivitis Symptoms
A
- Acute onset
- Redness
- discomfort, usually described as burning or grittiness
- watering
- Symptoms of EKC usually appear within 14 days of exposure and typically last 7 to 21 days
- Often unilateral at first, becoming bilateral, first eye usually more affected
- Blurred vision if central cornea involved
- Systemic malaise
57
Q
Adenoviral Conjunctivitis Signs
A
- Watery discharge
- Conjunctival hyperaemia (may be intense) and chemosis
- Follicles on palpebral conjunctiva, especially upper and lower fornix (if abundant, follicles can produce folds)
- Petechial (pin-point) subconjunctival haemorrhages
- Pseudomembranes on tarsal conjunctival surfaces (severe cases only)
- Pre-auricular lymphadenopathy which may be tender (not present in every case)
- Corneal involvement in some cases:
o punctate epithelial lesions within first two weeks
o later replaced by sub-epithelial infiltrates which may persist for months
58
Q
Adenoviral Conjunctivitis
A
- Advice
o condition is normally self-limiting, resolving within one to two weeks
o condition is highly contagious for family, friends and work colleagues (do not share towels, etc)
o remain infectious for 2 weeks after symptom onset
o Time off work or school not recommended
o cold compresses may give symptomatic relief
o discontinue contact lens wear in acute phase - Pharmacological Treatment
o Current topical and systemic anti-viral agents also ineffective in adenovirus infection
o Artificial tears and lubricating ointments (drops for use during the day, unmedicated ointment for use at bedtime) may relieve symptoms
o Topical antihistamines may be used for severe itching - Management Category
o Normally no referral
o Emergency referral IF:
- Visual loss
- Severe pain
- Significant keratitis
- Pseudomembrane - Possible management by Ophthalmologist
o Conjunctival swabs for virus isolation and strain identification
o Topical low dose steroids may be prescribed where sub-epithelial opacities affect vision
o Topical steroid may also be indicated for conjunctival pseudomembrane formation
59
Q
The Two Syndromes of Adenoviral Infection
A
- epidemic conjunctivitis and keratoconjunctivitis (EKC)
o most cases affect adults aged 20 to 40 years - pharyngoconjunctival fever
o systemic symptoms predominate, with pharyngitis, tender pre-auricular lymphadenopathy, fever and an acute follicular conjunctivitis
60
Q
What is Molluscum Contagiosum?
A
- Is a localised skin infection caused by a poxvirus which is mildly contagious and spreads through skin-to-skin contact
- is particularly common in immunocompromised individuals
- Lesions on the lid margins may shed viral toxins into the conjunctival sac, causing:
- follicular conjunctivitis
- uncommonly, corneal involvement
61
Q
Molluscum Contagiosum Risk Factors
A
- attendance at swimming pools
- eczema
- Strong association with Human Immunodeficiency Virus (HIV) infection
62
Q
Molluscum Contagiosum Symptoms
A
- Presence of skin lesion(s)
- Ocular symptoms (all mild)
o Redness
o Watering
o Photophobia
o blurring of vision
63
Q
Molluscum Contagiosum Signs
A
- Skin lesion
o Skin nodule(s) (typically 2-3 mm diameter), often with a central depression (‘umbilicated’)
o No visible inflammation
o Central core has cheese-like or waxy material which may discharge spontaneously
o May be single or multiple on the lid(s) and/or elsewhere on the body - Ocular signs (usually unilateral):
o hyperaemic conjunctiva
o conjunctival follicles
o corneal involvement including:
- punctate keratopathy
- subepithelial opacities
- pannus
o watery discharge
o No lymphadenopathy
