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Duke Elder > Conjunctiva > Flashcards

Conjunctiva Flashcards

1
Q

How many sections can the conjunctiva be anatomically divided into.

A

3 sections.

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1
Q

What is the conjunctiva?

A

Thin, transparent membrane that lines the surface of the sclera and the underside of the eyelid.

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2
Q

What are the 3 sections of the conjunctiva?

A
  • Palpebral.
  • Bulbar.
  • Forniceal.
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3
Q

What is the palpebral conjunctiva?

A

Lines the posterior surface of the eyelid.

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4
Q

What is the bulbar conjunctiva?

A

Lines the anterior surface of the sclera.

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5
Q

What is the forniceal conjunctiva?

A

A folded layer between the palpebral and bulbar conjunctiva.

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6
Q

What is the role of the forniceal conjunctiva?

A

Allows movement of the eyelids.

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7
Q

Where does the conjunctiva fuse?

A

Fuses with the sclera at the limbus.

N.B., does not cover the cornea.

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8
Q

Which nerve mainly innervates the cornea?

A

CNV1 (ophthalmic branch of the trigeminal nerve).

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9
Q

Which nerve innervates the inferior conjunctiva?

A

Infraorbital nerve.

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10
Q

Which nerve innervates the limbus?

A

Long ciliary nerve (branch of the nasociliary nerve).

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11
Q

Which lymph node does the medial conjunctiva drain into?

A

Submandibular nodes.

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12
Q

Which lymph node does the lateral conjunctiva drain into?

A

Pre-auricular nodes.

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13
Q

What is hyperaemia? (signs of conjunctival disease)

A

Conjunctival injection - enlargement of conjunctival vessels.

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14
Q

What is chemosis? (signs of conjunctival disease)

A

Conjunctival oedema - transparents swelling of the conjunctiva.

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15
Q

What are conjunctival membranes? (signs of conjunctival disease)

A

Exudative adherences of the conjunctiva.

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16
Q

What is cicatrization? (signs of conjunctival disease)

A

Scarring of the conjunctiva.

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17
Q

What are follicles? (signs of conjunctival disease)

A

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

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18
Q

What are papillae? (signs of conjunctival disease)

A

Lesions confined to the palpebral conjunctiva with a vascular centre.

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19
Q

What are the two distinct clinical appearances of conjunctivitis?

A
  • Papillae.
  • Follicles.
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20
Q

What do papillae look like in conjunctivitis?

A

Red (blood vessel) centre and flat top.

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21
Q

Where are papillae more commonly found in conjunctivitis?

A

Upper lid.

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22
Q

Which types of conjunctivitis are papillae associated with?

A
  • Viral.
  • Chlamydia.
  • Toxic.
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23
Q

What do follicles look like in conjunctivitis?

A

Dome-shaped discrete transparent lesions.

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24
Q

Where are follicles more commonly found in conjunctivitis?

A

Lower lid.

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25
Q

Which types of conjunctivitis are follicles associated with?

A
  • Bacterial.
  • Allergic.
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26
Q

Describe the presentation of bacterial conjunctivitis.

A
  • Acute/hyperacute.
  • Red, sticky eyes.
  • Purulent discharge.
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27
Q

Describe the presentation of viral conjunctivitis.

A
  • Acute.
  • Red, watery eyes.
  • Lymphadenopathy.
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28
Q

Describe the presentation of chlamydial conjunctivitis.

A
  • Subacute.
  • Unilateral, red eye.
  • Persisting mucopurulent discharge.
  • Lymphadenopathy.
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29
Q

Describe the presentation of gonococcal conjunctivitis.

A
  • Hyperacute (<24 hours).
  • Red eyes.
  • Keratitis.
  • Severe, purulent discharge.
  • STI risk factors.
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30
Q

Describe the presentation of allergic conjunctivitis.

A
  • Acute/recurrent.
  • Red, itchy eyes.
  • Watery discharge.
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31
Q

When are conjunctival swabs indicated?

A

Reserved for severe/atypical cases and not routinely indicated in simple acute bacterial/viral conjunctivitis.

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32
Q

What are the common causes of bacterial conjunctivitis in cool climates?

A
  • Streptococcus pneumoniae.
  • Haemophilus influenzae.
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33
Q

What are the common causes of bacterial conjunctivitis in warm climates?

A

Haemophilus aegyptius.

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34
Q

What are the common causes of bacterial conjunctivitis in children?

A

Haemophilus influenzae.

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35
Q

What does chronic and relapsing conjunctivitis indicate?

A

The presence of a nearby reservoir colony.

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36
Q

When should chronic/relapsing conjunctivitis be suspected?

A
  • Chronic dacryocystitis.
  • Staphylococcus blepharitis.
  • Giant fornix syndrome.
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37
Q

What is giant fornix syndrome characterised by?

A

Sequestration of bacteria in the upper fornix of the conjunctiva. Typically seen in the elderly.

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38
Q

Describe the presentation of bacterial conjunctivitis.

A
  • Acute/hyperacute, red, sticky eyes with purulent discharge.
  • Starts unilateral, becomes bilateral.
  • Eyes stuck together in the morning.
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39
Q

What investigations are done for bacterial conjunctivitis? When are swabs required?

A
  • Clinical diagnosis.
  • Swabs only required in unresolving cases or severe infections.
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40
Q

When can bacterial conjunctivitis become dangerous?

A

Involvement of the cornea (keratitis).

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41
Q

What is the initial management of bacterial conjunctivitis?

A
  • Good hand and eye hygiene.
  • Advise to return if unresolved in a week.
  • Stop contact lenses temporarily.
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42
Q

Which medications are prescribed for bacterial conjunctivitis?

A

Topical chloramphenicol drops.

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43
Q

When are systemic antibiotics prescribed for bacterial conjunctivitis?

A
  • Gonococcal disease in adults.
  • H. influenzae/meningococcal disease in children.
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44
Q

Which antibiotic is preferred in appropriate cases of bacterial conjunctivitis?

A

PO co-amoxiclav.

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45
Q

Which organism causes adult inclusion body chlamydial conjunctivitis?

A

Chlamydia trachomatis.

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46
Q

Which serotype of Chlamydia trachomatis causes adult inclusion body chlamydial conjunctivitis?

A

Serotypes D-K.

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47
Q

Which immunotypes of Chlamydia trachomatis cause lymphogranuloma venereum?

A

L1, L2 and L3.

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48
Q

Describe the presentation of adult inclusion body chlamydial conjunctivitis.

A
  • Subacute (2-3 weeks).
  • Unilateral conjunctivitis in young people.
  • Associated with STI symptoms such as urethritis.
  • Inferior follicular conjunctivitis with persisting mucopurulent discharge and lymphadenopathy.
49
Q

Which investigations are used to diagnose adult inclusion body chlamydial conjunctivitis? What do they show?

A

Swab > PCR > prompt diagnosis.

Giemsa stain shows basophilic intracystoplasmic inclusion bodies.

50
Q

Describe the management of adult inclusion body chlamydial conjunctivitis.

A

1g PO azithromycin STAT

OR

100mg doxycycline BD for 14 days.

51
Q

What is trachoma?

A

Highly infectious epidemic conjunctivitis in developing countries.

52
Q

What is the leading cause of preventable blindness worldwide?

A

Trachoma.

53
Q

Which organism causes trachoma?

A

Chlamydia trachomatis.

54
Q

Which serotypes of chlamydia trachomatis cause trachoma?

A

Serotypes A-C.

55
Q

Describe the pathology of trachoma.

A
  • Acute conjunctivitis caused by pore-like infectious particle (elementary body) of chlamydia.
  • Type 4 hypersensitivity reaction after initial infection > scarring > trichiasis and entropion > corneal damage > blindness.
56
Q

Describe the presentation of trachoma.

A
  • Seen in poverty and crowded places.
  • Chronic superior follicular conjunctivitis.
  • Herbert pits (depressions of the superior limbus).
  • Arlt’s line (a thick band of scar tissue in the conjunctiva).
  • Trichiasis and entropion.
57
Q

What is a Herbert pit (trachoma)?

A

Depressions of the superior limbus.

58
Q

What is Arlt’s line (trachoma)?

A

A thick band of scar tissue in the conjunctiva.

59
Q

Describe the management for trachoma. (mnemonic: SAFE)

A
  • Surgery for trichiasis (bilamellar rotation).
  • Azithromycin 1mg PO.
  • Facial hygiene.
  • Environmental improvement.
60
Q

Which organism causes adult gonococcocal conjunctivitis?

A

Neisseria gonorrhoea, gram negative diplococcus.

61
Q

Describe the presentation of adult gonococcal conjunctivitis.

A
  • Severely unwell patients.
  • Hyperacute and severe pain, tearing and red eye.
  • Conjunctival membranes and pre-auricular lymphadenopathy.
62
Q

Which investigations are used to diagnose adult gonococcal conjunctivitis?

A
  • Treat all with ofloxacin drops.
  • Ceftriaxone IM 1g STAT to treat gonorrhoea.
  • If keratitis > admit for IV ceftriaxone.
63
Q

What is ophthalmia neonatorum?

A

Conjunctivitis within the first 30 days of life.

64
Q

Which are the 4 organisms that can cause ophthalmia neonatorum? Which is most common?

A
  • Chlamydia (most common).
  • Gonococcus.
  • HSV.
  • Staphylococcus.
65
Q

Describe the treatment for chlamydial ophthalmia neonatorum.

A

PO erythromcycin.

66
Q

What can chlamydial ophthalmia neonatorum progress into?

A

Chlamydial pneumonitis.

67
Q

Describe the treatment for gonococcal ophthalmia neonatorum.

A

IM ceftriaxone + IV penicillin.

68
Q

When does gonococcal ophthalmia neonatorum typically present?

A

Within 3 days of birth.

69
Q

Describe the treatment for HSV ophthalmia neonatorum.

A

IV aciclovir.

70
Q

Describe the presentation of HSV ophthalmia neonatorum.

A
  • Watery discharge.
  • Vesicular rash.
71
Q

Which is the most common cause of viral conjunctivitis?

A

Adenovirus.

72
Q

How is definitive diagnosis achieved for viral conjunctivitis?

A

PCR.

73
Q

Describe the management for viral conjunctivitis.

A

Cold compress + artificial tears.

74
Q

What are 3 clinical syndromes of viral conjunctivitis?

A
  • Acute non-specific follicular conjunctivitis (ANFC).
  • Pharyngoconjunctival fever.
  • Epidemic keratoconjunctivitis.
75
Q

Describe the presentation of acute non-specific follicular conjunctivitis (ANFC).

A
  • Unilateral, red, itchy, watery eye.
  • Progressive involvement of the fellow eye.
  • Lymphadenopathy.
76
Q

Describe the presentation of pharyngoconjunctival fever.

A
  • Unilateral, red, itchy, watery eye.
  • Progressive involvement of the fellow eye.
  • Lymphadenopathy.
  • Pharyngitis/URTI.
  • Fever.
77
Q

Which serotype of adenovirus causes pharyngoconjunctival fever?

A

3, 4 and 7.

78
Q

Describe the presentation of epidemic keratoconjunctivitis.

A
  • Follicular conjunctivitis as ANFC.
  • Unilateral, red, itchy, watery eye.
  • Progressive involvement of the fellow eye.
  • Lymphadenopathy.
  • Keratitis characterised by microcysts and punctate epithelial lesions.
79
Q

Which serotype of adenovirus causes epidemic keratoconjunctivitis?

A

8, 19 and 37.

80
Q

What is the pathology of allergic conjunctivitis?

A

Type 1 (immediate IgE) reaction involving mast cell degranulation.

81
Q

What are the 4 types of allergic conjunctivitis?

A

Common:
- Seasonal.
- Perennial.

Clinically serious:
- Vernal keratoconjunctivitis (VKC).
- Atopic keratoconjunctivitis (AKC).

82
Q

What in the pathology differentiates seasonal and perennial conjunctivitis from VKC and AKC?

A

VKC and AKC have a chronic/recurrent component mediated by type 4 sensitivity in addition to the acute type 1 reaction.

83
Q

Describe the basic course of treatment for allergic conjunctivitis.

A

Treatment ladder:
1. Artificial tears to dilute allergen and restore surface integrity.
2. Mast cell stabilisers and/or anti-histamines.
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.

84
Q

What is seasonal conjunctivitis?

A
  • Subacute, seen in hayfever.
  • Triggered by pollen in Summer.
  • Type 1 hypersensitivity with mast cell degranulation.
85
Q

Describe the presentation of seasonal conjunctivitis.

A
  • Subacute, bilateral, itchy conjunctivitis.
  • Characteristic seasonal pattern of onset and prior episodes.
86
Q

Describe the management of seasonal conjunctivitis.

A

Benign and self-limiting:
- Artificial tears to dilute the allergen and restore surface integrity.
- Mast cell stabilisers and/or antihistamines.

87
Q

What is perennial conjunctivitis?

A
  • Like hayfever but can occur at any point and does not follow a seasonal pattern.
  • Triggered by moults and dust mites.
  • Type 1 hypersensitivity with mast cell degranulation.
88
Q

What is vernal keratoconjunctivitis (VKC)?

A
  • Recurrent conjunctivitis.
  • Acute type 1 hypersensitivity reaction with mast cell degranulation follows by chronic type 4 hypersensitivity mediated by T cells.
89
Q

Which demographic does VKC typically affect?

A

Teenage boys.

90
Q

What are the subtypes of VKC? What are they based on?

A
  1. Palpebral.
  2. Limbal.
  3. Mixed.
91
Q

Describe the presentation of VKC.

A
  • Adolescent boys in dry climates.
  • Initial onset in Summer.
  • Also involves cornea.
  • Affects upper conjunctiva with characteristic cobblestone appearance.
92
Q

Describe the management of VKC.

A
  1. Artificial tears to dilute allergen and restore surface integrity.
  2. Mast cell stabilisers 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.
93
Q

What is atopic keratoconjunctivitis (AKC)?

A
  • Recurrent conjunctivitis.
  • Acute type 1 hypersensitivity reaction with mast cell degranulation follows by chronic type 4 hypersensitivity mediated by T cells.
94
Q

Describe the presentation of AKC.

A
  • Affects the lower conjunctiva.
  • More associated with lid diseases such as blepharitis and eczema.
95
Q

Describe the management of AKC.

A
  1. Artificial tears to dilute allergen and restore surface integrity.
  2. Mast cell stabilisers 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.

N.B., Calcineurin inhibitors are highly effective in exacerbations of AKC.

96
Q

What is cicatricial conjunctivitis?

A

Inflammation of the conjunctiva > scarring > formation of cicatrix.

97
Q

Describe the pathology of cicatricial conjunctivitis.

A

Inflammation > loss of goblet cells > failure of ocular surface integrity > limbitis and limbal stem cell failure > keratopathy + scarring.

98
Q

What is ocular mucous membrane pemphigoid?

A

Chronic blistering type 2 hypersensitivity reaction of the mucosal surfaces.

99
Q

When should we suspect ocular mucous membrane pemphigoid?

A

Severe, bilateral cases of papillary conjunctivitis with evidence of cicatrisation and systemic cutaneous involvement.

100
Q

Describe the 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.
  • Antibodies target hemidesmosomes and components of the basement membranes.
101
Q

Describe the management of mild ocular mucous membrane pemphigoid.

A

Dapsone.

102
Q

Describe the management of moderate ocular mucous membrane pemphigoid.

A

Mycophenolate, methotrexate or azathioprine.

103
Q

Describe the management of severe ocular mucous membrane pemphigoid.

A

IV methylprednisolone and/or cyclophosphamide or rituximab long term.

104
Q

What is an important side effect of rituximab?

A

Pulmonary toxicity.

105
Q

What are erythema multiforme, SJS and TEN?

A
  • Spectrum of diseases where TEN is the most severe.
  • Inflammation of the vessels of the mucous membranes and skin, driven by type 4 hypersensitivity to a variety of triggers.
106
Q

What are common triggers of erythema multiforme, SJS and TEN?

A
  • HSV.
  • Drugs (sulphonamides, allopurinol, AEDs).
107
Q

Describe the presentation of SJS and TEN.

A
  • Acutely unwell with target lesions, bullae and mucous membrane inflammation.
  • Nikolsky sign.
108
Q

What is Nikolsky sign?

A

Sloughing sheets of skin.

109
Q

Describe the management of acute SJS and TEN.

A

Steroids and burns unit.

110
Q

Describe the management of acute SJS and TEN.

A

Same as for ocular mucous membrane pemphigoid.

  • Mild → dapsone.
  • Moderate → mycophenolate, methotrexate or azathioprine.
  • Severe → IV methylprednisolone and/or cyclophosphamide or rituximab long term (side effect: pulmonary toxicity)).
111
Q

What are pterygium and pinguecula?

A

Conjunctival surface degenerations.

112
Q

How do pterygium and pinguecula invade?

A

Start nasally and invade laterally.

113
Q

What are the risk factors for pterygium and pinguecula?

A

UV light and age.

114
Q

When is surgery required for pterygium and pinguecula?

A

Only required in pterygium if vision is obscured.

115
Q

What is the key difference between pterygium and pinguecula?

A
  • Pterygium invades into the cornea.
  • Pinguecula does not.
116
Q

What is superior limbic keratoconjunctivitis?

A

A chronic disease of the superior limbus and conjunctiva.

117
Q

What is superior limbic keratoconjunctivitis secondary to?

A

Superior bulbar conjunctival laxity.

118
Q

What is ligneous conjunctivitis?

A

An idiopathic chronic conjunctivitis of children, associated with systemic disease.

119
Q

What is characteristic about ligneous conjunctivitis?

A

Recurrent ‘wood’ like pseudomembranes of the conjunctiva and other mucous membranes.

120
Q

What is the symptom triad for parinaud oculoglandular syndrome?

A
  • Unilateral granulomatous conjunctivitis.
  • Ipsilateral pre-auricaular lymphadenopathy.
  • Fever.
121
Q

Which organism causes parinaud oculoglandular syndrome?

A

Bartonella henselae.

Duke Elder (11 decks)

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