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Duke Elder > Conjunctiva > Flashcards

Conjunctiva Flashcards

1
Q
A
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2
Q

Conjunctival Segments (3)

A

Palpebral conjunctiva - lines the posterior surface of the eyelids

Bulbar conjunctiva - lines the anterior surface of the sclera

Forniceal conjunctiva - a folded layer between the palpebral and bulbar conjunctiva. It allows movement of the eyelids.

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3
Q

Where does the conjunctiva fuse with the sclera?

A

At the limbus

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4
Q

Innervation to conjunctiva

A

Main - CNV1 (ophthalmic division of the trigeminal nerve)

Inferior conjunctiva - infraorbital nerve

Limbus - long ciliary nerve (branch of the nasociliary nerve)

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5
Q

Lymphatics of the conjunctiva

A

Medial conjunctiva - submandibular nodes
Lateral conjunctiva - preauricular nodes

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6
Q

List 4 signs of conjunctival disease?

A
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7
Q

What is Hyperaemia (conjunctival injection)

A

Enlargement of conjunctival vessels

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8
Q

What is Chemosis (conjunctival oedema)

A

Transparent swelling of the conjunctiva

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9
Q

What are conjunctival membranes

A

Exudative adherences of the conjunctiva

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10
Q

What is Cicatrization?

A

Scarring of the conjunctiva

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11
Q

What are Follicles?

A

Discrete lesions which appear like transparent grains of rice. No vessels inside the lesion

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12
Q

What are Papillae?

A

Lesions confined to the palpebral conjunctiva with a vascular center.

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13
Q

What are the 2 distinct clinical appearances of conjunctivitis

A

Follicles vs papillae
(help you differentiate the potential causes)

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14
Q

Compare follicles vs papillae conjunctivitis

A

Papillae
* Papillae have a red (blood vessel) center and fat top
* More common on the upper lid
* Associated with: viral, chlamydial & toxic conjunctivitis

Follicles
* Dome-shaped discrete transparent lesions
* More common on the lower lid
* Associated with: bacterial & allergic conjunctivitis

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15
Q

Compare broad presentations of microbial conjunctivitis

A
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16
Q

Investigations for conjunctivitis

A
  • Diagnosis is clinical
  • Conjunctival swabs for microbiology are only required in unresolving cases or severe infections.

Any involvement of the cornea (keratitis) can be sight-threatening and warrants admission for further workup

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17
Q

When to suspect bacterial conjunctivits

A

Bacterial infection of the conjunctiva is common, often self-limiting, and frequently encountered in primary care.

It should be suspected in patients with red gritty sticky eyes and purulent discharge.

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18
Q

Pathology of Bacterial Conjunctivitis

A

Cool climates → Streptococcus Pneumoniae and Haemophilus influenzae

Warm climates → Haemophilus aegyptius

Children → Haemophilus influenzae

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19
Q

Chronic and relapsing conjunctivitis

A

Typically indicates the presence of a nearby reservoir colony.

This should be suspected in the case of chronic dacryocystitis, staph blepharitis and giant fornix syndrome

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20
Q

What is Giant fornix syndrome?

A

Giant fornix syndrome is characterised by the sequestration of bacteria in the upper fornix of the conjunctiva and is typically seen in the elderly.

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21
Q

Presentation of bacterial conjunctivits

A
  • Acute/hyperacute red sticky eyes with purulent discharge
  • Typically bilateral but often starts unilaterally
  • Patients complain of their eyes being stuck together in the morning
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22
Q
A

A patient with bacterial conjunctivitis. The eye is red and there is a purulent green discharge.

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23
Q

Management of bacterial conjunctivitis

A

Initial
* Practice good hand and eye hygiene
* Advise the patient to return if the infection doesn’t self-resolve within a week or gets worse
* Switch to spectacles from contact lenses during the episode

Medications
* Topical chloramphenicol drops
* Systemic antibiotics are reserved for gonococcal conjunctivitis in adults or H.influenzae/Meningococcal conjunctivitis in children
* H.influenzae → PO Co-amoxiclav

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24
Q

Important side effect of Chloramphenicol

A

Aplastic anaemia

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25
Q

What are the two types of conjunctivitis caused by Chlamydia trachomatis

A
  1. Trachoma
  2. Adult Inclusion Body Chlamydial Conjunctivitis
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26
Q

Pathology of Adult Inclusion Body Chlamydial Conjunctivitis

A

Caused by Chlamydia trachomatis, a gram-negative intracellular obligate organism

Associated with serotypes D-K of Chlamydia trachomatis

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27
Q

What Immunotypes of Chlamydia cause Lymphogranuloma Venereum

A

L1, L2, L3

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28
Q

Presentation of adult inclusion body Chlamydia

A
  • Subacute (2-3wks) unilateral conjunctivitis in young people
  • Associated with STI symptoms such as urethritis
  • Inferior follicular conjunctivitis with persisting mucopurulent discharge and lymphadenopathy
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29
Q

Investigations for adult inclusion body chlamydia

A

Conjunctival swab for PCR provides prompt diagnosis

Giemsa stain shows basophilic intracytoplasmic inclusion bodies

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30
Q

Management of Adult Inclusion Body Chlamydial Conjunctivitis

A

1g oral azithromycin STAT or 100mg doxycycline BD for 14 days

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31
Q
A

A patient with Chlamydial conjunctivitis. Note the inferior follicular conjunctivitis.

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32
Q

What is the leading cause of preventable blindness worldwide.

A

Trachoma

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33
Q

Pathology of Trachoma

A
  • Caused by Chlamydia trachomatis serotypes A-C
  • Acute conjunctivitis is caused by the pore-like infectious particle (elementary body) of chlamydia
  • A type 4 hypersensitivity reaction occurs after initial infection → scarring → trichiasis and entropion → corneal damage → blindness
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34
Q

How does Trachoma cause entropion?

A

The conjunctival scarring leads to entropion, where the lids roll inwards. This causes the lashes to rub against the cornea when blinking.

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35
Q

Presentation of Trachoma

A
  • Seen in poverty and crowded places
  • Chronic superior follicular conjunctivitis
  • Herbert pits (depressions of superior limbus)
  • Arlt’s line (a thick band of scar tissue in the conjunctiva)
  • Trichiasis and entropion
36
Q

Management of Trachoma
“WHO SAFE strategy”

A

Surgery for trichiasis (bilamellar rotation)
Azithromycin 1g PO
Facial hygiene
Environmental improvement

37
Q

Pathology of adult gonococcal conjunctivitis

A

Caused by infection with Neisseria gonorrhoeae, a gram -ve diplococcus.
These patients can be severely unwell.

38
Q

Presentation of adult gonococcal conjunctivitis

A

Hyperacute and with severe pain, tearing and red-eye.
Conjunctival membranes and preauricular lymphadenopathy

39
Q

Investigations for adult gonococcal conjunctivitis

A

Conjunctival swab for microbiology and referral to GUM clinic for sexual health follow up

40
Q

Management of adult gonococcal conjunctivitis

A
  • Treat all with topical ofloxacin drops
  • Ceftriaxone IM 1g STAT to treat gonorrhoea
  • If keratitis → admit for IV ceftriaxone
41
Q

What is Ophthalmia Neonatorum?

A

Conjunctivitis within the first 30 days of life

42
Q

Compare the causes and treatment of Ophthalmia Neonatorum

A
43
Q
A

Gonococcal ophthalmia neonatorum

44
Q

What is the most common microbial cause of conjunctivitis

A

Adenovirus
highly contagious

44
Q

How to diagnosis Viral Conjunctivitis

A

PCR

45
Q

Management of viral conjunctivitis

A

Conservative with cold compress and artificial tears.

46
Q

What are the 3 clinical syndromes of viral conjunctivitis

A
47
Q
A

A patient with epidemic keratoconjunctivitis. Note the clear discharge and follicular conjunctivitis.

48
Q

Pathology of allergic conjunctivitis

A

Allergic conjunctivitis is a Type 1 (immediate IgE) reaction involving mast cell degranulation. It is characterised by bilateral itchy papillary conjunctivitis.

49
Q
A

A patient with allergic conjunctivitis.

50
Q

4 types of allergic conjunctivitis

A

Perennial and seasonal are common subacute conditions mediated by a type 1 hypersensitivity reaction with mast cell degranulation.

Vernal Keratoconjunctivitis (VKC) and Atopic Keratoconjunctivitis (AKC) are clinically serious with a chronic/recurrent component mediated by a type 4 hypersensitivity component in addition to the acute type 1 reaction.

51
Q

Management of allergic conjunctivitis

A
  1. Artificial tears to dilute allergen and restore surface integrity
  2. Mast cell stabilizers and/or antihistamines
  3. Topical steroids
  4. Systemic immunosuppression with steroids or steroid-sparing agents such as cyclosporine
  5. Surgical debridement and/or keratectomy to address corneal ulcers in vision-threatening disease
52
Q

What must we be aware of when using When using immunosuppressive medications

A

HSV reactivation - patients should receive antiviral therapy.

53
Q

What is Seasonal Conjunctivitis?

A

A common subacute conjunctivitis seen in hay fever.

54
Q

Pathology of seasonal conjunctivitis

A

Type 1 hypersensitivity reaction with mast cell degranulation
Typically triggered by pollen in the summer period

55
Q

Presentation of seasonal conjunctivitis

A

Subacute bilateral itchy conjunctivitis
Characteristic seasonal pattern of onset and prior episodes

56
Q

Management of Seasonal Conjunctivitis

A

Often benign and self-limiting. Treatment options include:
* Artificial tears to dilute allergen and restore surface integrity
* Mast cell stabilizers and/or antihistamines

57
Q

What is Perennial Conjunctivitis

A

A similar disease to seasonal conjunctivitis, except it can occur at any point and does not necessarily follow a seasonal pattern.

58
Q

Pathology of Perennial Conjunctivitis

A

Type 1 hypersensitivity reaction with mast cell degranulation.
Thought to be caused by allergy to moulds and dust mites

59
Q

Presentation of Perennial Conjunctivitis

A

Subacute bilateral itchy conjunctivitis
No specific seasonal variation

60
Q

Management of Perennial Conjunctivitis

A

Often benign and self-limiting. Treatment options include:
Artificial tears to dilute allergen and restore surface integrity
Mast cell stabilizers and/or antihistamines

61
Q

What is Vernal Keratoconjunctivitis

A

A recurrent conjunctivitis that characteristically effects teenage boys

62
Q

Pathology of VKC

A

An acute type 1 hypersensitivity reaction with mast cell degranulation followed by a chronic type 4 hypersensitivity mediated by T cells.

The additional type 4 component makes this disease chronic
Subtypes are categorised based on which part of the conjunctiva is affected: palpebral, limbal or mixed

63
Q

Presentation of VKC

A

Manifests in adolescent boys in dry climates
Initial onset is often in the summer
Also involves the cornea
Effects the upper conjunctiva with characteristic cobblestone appearance

64
Q

Management of VKC

A

Clinically serious and likely to require steroids during acute attacks and steroid-sparing agents long term to reduce attack frequency

  1. Artificial tears to dilute allergen and restore surface integrity
  2. Mast cell stabilizers AND/OR Antihistamines
  3. Topical steroids
  4. Systemic immunosuppression with steroids or steroid-sparing agents such as cyclosporine
  5. Surgical debridement AND/OR keratectomy to address corneal ulcers in vision-threatening disease
65
Q

What is Atopic Keratoconjunctivitis

A

This is the most severe disease of the group and is characteristically associated with other atopic conditions.

66
Q

Pathology of AKC

A

An acute type 1 hypersensitivity reaction with mast cell degranulation followed by a chronic/recurrent type 4 hypersensitivity mediated by T cells.

The additional type 4 component makes this disease chronic

67
Q

Presentation of AKC

A

Affects the lower conjunctiva
More associated with lid diseases such as: blepharitis and eczema

68
Q

Management of AKC

A

Clinically serious and likely to require steroids during acute attacks and steroid-sparing agents long term to reduce attack frequency

  1. Artificial tears to dilute allergen and restore surface integrity
  2. Mast cell stabilizers AND/OR Antihistamines
  3. Topical steroids
  4. Systemic immunosuppression with steroids or steroid-sparing agents such as cyclosporine
  5. Surgical debridement AND/OR keratectomy to address corneal ulcers in vision-threatening disease
69
Q

What medicication is highly effective in exacerbations of AKC

A

Calcineurin inhibitors

70
Q

What is Cicatricial conjunctivitis?

A

Refers to inflammation of the conjunctiva which has led to scarring.

It can be used to describe a wide number of conditions from chemical burns to infections such as trachoma, and systemic diseases such as sarcoidosis and Stevens-Johnson syndrome.

The presence of a cicatrix (conjunctival scar) should be suspected in trichiasis, entropion, symblepharon and keratinisation.

71
Q

Pathology of Cicatricial Conjunctivitis

A

These diseases are typically bilateral and progressive.

The essential pathology is inflammation which leads to loss of goblet cells → failure of ocular surface integrity → limbitis and limbal stem cell failure → keratopathy and scarring

72
Q
A

Symblepharon of the lower conjunctiva

73
Q

What is Ocular Mucous Membrane Pemphigoid?

A

A chronic blistering type 2 hypersensitivity reaction of the mucosal surfaces. Suspect in severe bilateral cases of papillary conjunctivitis with evidence of cicatrisation and systemic cutaneous involvement.

74
Q

Pathology of Ocular Mucous Membrane Pemphigoid

A

Linear deposits of IgA, IgG and complement in the basement membranes of mucosal surfaces. This can be seen on conjunctival autofluorescence.

The antibodies target hemidesmosomes and components of the basement membranes.

75
Q

Management of Ocular Mucous Membrane Pemphigoid

A

In general, topical steroids and doxycycline are administered. Disease-modifying treatment is stepwise:

Mild → dapsone
Moderate → mycophenolate, methotrexate or azathioprine
Severe → IV methylprednisolone and/or cyclophosphamide or rituximab long term (se. pulmonary toxicity)

76
Q

What are Erythema Multiforme, SJS and TEN

A

These conditions can be thought of as a spectrum of diseases where TEN is the most severe.

77
Q

Pathology of Erythema Multiforme, SJS and TEN

A

Inflammation of the vessels of the mucous membranes and skin, driven by type 4 hypersensitivity to a variety of triggers.
Triggers include: drugs (sulfonamides, allopurinol and AEDs) and infections such as HSV

78
Q

Presentation of Erythema Multiforme, SJS and TEN

A

Acutely unwell with target lesions, bullae and mucous membrane inflammation.

Nikolsky sign - sloughing sheets of skin

79
Q

Management of Erythema Multiforme, SJS and TEN

A

Management in the acute phase is with steroids and expert help with a burns unit should be sought, particularly in cases of TEN.
In the chronic phase, management is stepwise and follows the same structure as for ocular mucous membrane pemphigoid (above).

80
Q

What are Pterygium and Pinguecula

A
  • Both are conjunctival surface degenerations.
  • They start nasally and invade laterally.
  • UV light and age are important risk factors.
  • The key difference is that pterygium invades into the cornea, pinguecula does not.
  • Surgery is only needed in cases of pterygium where vision is obscured.
81
Q
A

A patient with Pterygium. Note how the lesion invades the cornea.

82
Q
A

A patient with pinguecula. Note how the lesion does not invade the cornea

83
Q

Superior Limbic Keratoconjunctivitis

A

A chronic disease of the superior limbus and conjunctiva.
It is believed to be secondary to superior bulbar conjunctival laxity which can be induced by thyroid eye disease.

84
Q

Ligneous Conjunctivitis

A

An idiopathic chronic conjunctivitis of children, with associated systemic disease. It is characterised by recurrent ‘wood’ like pseudomembranes of the conjunctiva and other mucous membranes.

85
Q

Parinaud Oculoglandular syndrome

A

It is a triad of:
* Unilateral granulomatous conjunctivitis
* Ipsilateral preauricular lymphadenopathy
* Fever

It is caused by infection with Bartonella henselae

Duke Elder (12 decks)

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