Conjunctiva Flashcards
watery (serous exudate) discharge occurs in:
acute viral conjunctivitis
acute allergic conjunctivitis
mucoid discharge (stringy/ropy filaments) highly indicative of:
chronic allergic conjunctivitis
dry eye (bc of less aqueous in aq:mucus tear ratio)
mucopurulent discharge is seen in:
chlamydia
acute bacterial conjunctivitis
purulent discharge is seen in:
moderate cases often acute bacterial conjuncitivitis
severe in gonoccocal infections
which arteries give rise to the conjunctival vessels?
anterior ciliary and palpebral aa.
conjunctival injection
superficial bright red blood vessels, worse near fornices, move as the conj is manipulated, and are blanched by topical phenylephrine
conjunctival hyperemia
secondary to dilation of the conjunctival blood vessels, can be caused by environmental factors, or prolonged vasoconstrictor use
subconjunctival hemorrhage
may be flat or elevated, well-defined, visible, coalesced blood between the bulbar conj and episclera
can be caused by injury, HTN (check bp!), DM, blood disorders, conjunctivitis, or Valsalva maneuver
chemosis (edema)
an accumulation of fluid within or beneath the conj, severe inflammation, translucent swelling, acute non-traumatic hypersensitivity or chronic orbital outflow restrictions
where do papillae form?
only form where conj is attached to underlying tissue by anchoring septae (tarsus, or bulbar limbus) flat-topped at tarsus, dome-shaped at limbus
signs of papillae
red velvety appearance, central elevated tuft of vessels surrounded by a pale base. papillae are a nonspecific sign of conj inflammation, edema, PMN cell infiltration
giant papillary conj. can appear whitened due to fibrosis
papillae can be due to:
bacterial or allergic conjunctivitis, chlamydia, chronic marginal blepharitis, superior limbic keratoconjunctivitis, floppy eyelid syndrome, CL wear
follicles presentation:
yellowish-white, discrete, round elevations of conj. produced by a lymphocytic response. difference from papillae is that the center is avascular and the vessels appear on top of the bumps
follicles can be due to:
viral conjunctivitis, chlamydia, parinaud oculoglandular syndrome, medicamentosa
common with adenovirus or herpes viral infections
membranes/pseudomembranes
fibrin attached to the epithelial conj surface, true membranes cause bleeding when peeled off and reflect a higher degree of inflammatory response
most common causes for membranous/pseudomembranous conjunctivitis:
severe adenoviral conjunctivitis (most common), bacterial infections, gonococcal, stevens johnson syndrome
what happens to the conjunctiva as a person ages?
conjunctiva becomes thinner, more fragile, less transparent, epithelial layer thickens and subepithelial tissue atrophies, gradual hyaline degeneration and fatty infiltration, loss of elastic fibers, presence of conjunctival chalasis in some pts
conjunctivochalasis
common, bilateral, characterized by redundant, loose, nonedematous conjunctiva (extra tissue) associated with aging. important to look for in pts with ocular irritation and epiphora, as extra tissue can block punctum
pinguecula
common, elastotic degeneration of collagen fibers of the conjunctival stroma, due to UV exposure, hot, dusty environments, etc.
looks like a yellowish-white mound on bulbar conj., often bilateral and nasal interpalpebral zone
pingueculitis
inflammation of a pinguecula, can be treated if symptomatic, with lubricants, corticosteroids, or topical NSAIDs, or sx
pterygium
common, triangular, winglike mass of fibrovascular tissue extending from the conj to the cornea at the 3 and 9 o’clock locations. highly vascular as opposed to pinguecula
concretions
common, bilateral, white/yellow spots found on palpebral conj, may become calcified, easily removed if needed
conjunctival retention cyst (epithelial inclusion cyst)
common, thin-walled fluid-filled cyst on palpebral or bulbar conj.
lymphangiectasia
irregular, dilated, sausage-shaped channels of lymphatic channels anastomosis 1 mm from limbus. occasionally may be filled with blood
conjunctival capillary hemiangioma
rapidly developing lesions of the conj., without pre-existing trauma, red and protuberant, may be excised or use cryo
scleral hyaline plaque
bilateral, oval, dark grey areas located close to insertion of the horizontal rectus muscles
conjunctival squamous papilloma
uni or bilateral lesions anywhere on conj that are benign and very small risk of conversion. can be associated with HPV when there are lots of lesions present. can be large lesions, pedunculated or sessile, may encroach on cornea or interfere with lid closure
squamous papilloma definition
presence of central vascular core surrounded by squamous epithelium
treating conjunctival squamous papilloma:
small lesions may resolve spontaneously, large lesion can be excised or use cryo, for recurrence use mitomycin C, alpha interferon, cimetidine, or CO2 laser
biopsy to make sure benign
Ocular Surface Squamous Neoplasia (OSSN)
includes non-invasive: CIN (conjunctival intraepithelial neoplasia) and invasive: squamous cell carcinoma
conjunctival intraepithelial neoplasia (CIN)
non-invasive OSSN/carcinoma in situ/conjunctival dyskeratosis - involving any area of conj or cornea although 95% at limbus, assoc. w/UV exposure, HPV, AIDS, xeroderma pigmentosum, stem cell therapy
different CIN presentations
- gelatinous limbal thickening, leukoplakia, mild conj injection around
- elevated, translucent conj lesion beneath a leukoplakic nodular lesion
- sessile, papillary appearance - assoc. w/HPV
- dysplastic squamous lesions can have fine vascular patterns with a hairpin configuration
squamous cell carcinoma (invasive OSSN)
CIN is often a precursor, becomes invasive when dysplastic epithelial cells penetrate the basement membrane. pink, papillomatous lesion, feeder vessels, diffuse growth, metastasis rare
conjunctival nevus
common, 1% chance of malignant transformation, usually solitary unilateral discrete mildly elevated intraepithelial lesion with variable pigmentation, may have cystic spaces
conjunctival melanosis
does not elevate the surface like nevi can, retention of pigment/excessive melanin production
Secondary acquired melanosis
increased pigmentation is attributed to racially associated genetic, metabolic, or toxic factors. common, usually bilateral but asymmetric, and no malignant potential
Primary acquired melanosis (PAM)
rare, unilateral, fair-skinned pts >45yrs, flat, usually near limbus, sudden onset of nodules(melanocytic cellular atypia)=strong suspicion of melanoma, 50% chance within 5yrs.
w/o atypia = benign, no risk of malignancy
biopsy to make sure!
Malignant melanoma of conj
conjunctival melanoma can be pigmented or not, arise from *PAM (74%), a nevus (7%), or de novo. usually >6o yrs old pt, appear as black/grey vascularized nodule anywhere on conj, can also be pink, smooth “fish flesh” appearance with intense vascularity
prognosis for conjunctival melanoma
mortality of 12% at 5 yrs, 25% at 10 years
main sites of metastasis: lymph nodes, lung, brain, liver
indications of poorer prognosis: multifocal tumors, extralimbal tumors involving fornices or caruncle, tumor thickness >2mm, recurrence, lymphatic or orbital spread
what infections can present with preauricular lymphadenopathy?
viral conjunctivitis (EKC), chlamydial conjunctivitis, gonococcal conjunctivitis, dacryoadenitis
Parinaud’s oculoglandular syndrome presents with both preauricular and submandibular lymphadenopathy
simple bacterial conjunctivitis does NOT present with preauricular lymphadenopathy
scleromalacia perforans
necrotizing scleritis without inflammation most commonly occurring in RA
(15% of all cases of scleritis are caused by RA)
