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Conjunctiva Flashcards

1
Q

Conjunctiva Anatomy

A
  • Transparent mucous membrane
  • Vascular & lymphatic network - Passive & active immunity
  • Palpebral conjunctiva lines the inner lid
  • Forniceal conjunctiva
  • Bulbar Conjunctiva
    • ​Overlies the anterior sclera
    • Continuous with corneal epithelium at the limbus
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2
Q

List the Conjunctival Reaction

A
  • Hyperemia
  • Hemorrhages
  • Chemosis
  • Membranes
  • Infiltration
  • Subconjunctival Scarring
  • Follicles
  • Papillae
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3
Q

Hyperemia Injection

A
  • Engorgement of blood vessels
    • Without accompanying exudation or infiltration
    • Anterior ciliary & palpebral arteries
  • Causes
    • Trauma/Irritation
      • Mechanical manipulation
      • Dryness
    • Infection
    • Environmental
      • smoke/smog/chemical fumes
      • Wind
      • UV radiation
      • Prolonged topical instillation vasoconstrictors
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4
Q

Hemorrhages

A
  • Escape of blood from vessels
  • Causes
    • Trauma
    • Infection
      • Viral
      • Bacterial - infrequent
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5
Q

Petechial hemorrhages

A
  • Pinpoint hemorrhaging from capillaries (allergies & rubbing)
  • Causes
    • Prolonged straining
    • Medical conditions
    • Medications
    • Trauma
  • Can be result of asphyxiation
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6
Q

Chemosis

A
  • Conjunctival swelling
    • Frequently with accumulation of fluid within or beneath
  • May protrude through closed lids if severe (can have trouble closing lids)
  • Causes
    • Hypersensitivity reaction
    • Manipulation
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7
Q

Define true membrane and pseudomembrane

A
  • True membrane (Palpebral conj)
    • ​involves superficial conjunctival layers
    • Cannot be peeled - results in tearing of conjunctival epithelium
    • Associated with Stevens Johnson Syndrome
    • Adenoviral infection
    • HSV conjunctivitis
  • Pseudomembrane
    • ​Coagulated exudate adherent to inflamed tissues
    • Can be peeled off leaving underlying epithelium intact
    • Adenoviral infection
    • HSV conjunctivitis
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8
Q

Infiltration

A
  • Cellular recruitment to the site of chronic inflammation
  • Frequently accompanies papillary reaction
  • loss of detail of normal tarsal conjunctival vessels
  • More pronounced UL
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9
Q

Cicatrization Subconjunctival Scarring

A
  • Destruction of stromal tissue
    • Associated with loss of goblet cells & accessory lacrimal glands
  • Complications
    • Cicatrizing entropion
    • DES
    • Trichiasis
    • Foreshortening of fornix
    • Keratinization
    • Ankyloblepharon
  • Cause
    • ​Trachoma
    • Cicatrizing conjunctivitis
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10
Q

Follicles

A
  • Multiple, discreet, slightly elevated lesions
    • collections of lymphocytes
    • Resemble grains of rice
  • Small, dome-shaped nodules without a vascular core
  • Causes
    • Viral, chlamydial
    • Parinaud oculoglandular syndrome
    • Medication hypersensitivity
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11
Q

Papillae

A
  • Occur on palpebral conjunctiva & limbal bulbar conjunctiva
  • Nodule with fibrovascular core
  • Appearance depends on location
    • Tarsal - flattented
    • Limbal - dome-shaped
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12
Q

List the conjunctival degenerations

A
  • Pinguecula
  • Pterygium
  • Concretions
  • Conjunctivochalasis
  • Retention cyst (epithelial inclusion cyst)
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13
Q

Conjunctival degeneration

A
  • Decomposition & deterioration of the tissue elements & functions
  • Age-related
  • Disease-specific
  • Chronic environmental exposures
  • Unilateral or bilateral
  • Asymmetric
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14
Q

Pinguecula

A
  • Extremely common
  • Elastotic degeneration of the collagen fibers of conjunctival stroma
  • Actinic degeneration
  • Often bilateral, asymmetric
  • Cause
    • UV exposure
    • Conjunctival injury
  • Signs
    • ​yellow/white elevation on bulbar conjunctiva
      • Adjacent to limbus, DOES NOT extend onto the cornea
    • Within palpebral fissure
    • Nasal > temporal
    • May develop calcification or pigmentation
  • Symptoms ​
    • Cosmesis
    • FBS
    • Tearing
    • DES
  • Treatment
    • ​None
    • Lubrication - ATs, gels
    • UV protection
    • Surgical excision
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15
Q

Pingueculitis

A
  • Acute inflammation of pinguecula
  • May lead to dellen (area of extreme dryness next to area of elevation)
  • Treatment
    • None if asymptomatic
    • Lubrication
    • Short course of weak topic steroid
      • FML, Loteprednol
    • Excision if repeatedly inflamed or large causing irritation, cosmesis
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16
Q

Pterygium

A
  • Triangular, fibrovascular subepithelial ingrowth
  • Invades superficial corneal layers
  • Common in warm climates
    • Pt often long h/o of UV exposure or chronic surface dryness
  • M>F
  • Forms in interpalpebral zone
    • Nasal > Temporal
    • May be double (nasal & temporal)
  • 20-30 yo onset
  • Symptoms
    • ​Small lesions asymptomatic
    • Irritation & grittiness
      • Dellen formation at advancing edge
    • CL intolerance
    • Decreased vision
      • Induced irregular astigmatism
      • Interference with visual axis
    • Intermittent inflammation
    • Cosmesis
  • Pseudopterygium
    • ​Band of conjunctiva adhering to comprised cornea
    • Reponse to acute inflammation or inciting event
  • Treatment
    • ​None, most are asymptomatic
    • UV protection
    • Medical
      • Tear substitutes
      • Topical steroids
    • Surgical
      • Excision - 50% recurrence rate
        • Autograft
        • Mitomycin C
        • Amniotic graft
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17
Q

Concretions

A
  • Extremely common
  • Age-related
  • Chronic conjunctival inflammation
    • Multiple, tiny cysts with yellow/white deposits (epithelial debris)
    • May become calcified
      • if large, can erode overlying epithelium
    • Most common inferiorly
  • Sx
    • None
    • FBS
  • Treatment: none
    • Excision with needle at slit-lamp with topical anesthesia
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18
Q

Conjunctivochalsis

A
  • Normal aging process exacerbated by posterior lid margin disease
  • Interferes with normal tear flow
  • Symptoms
    • ​Asymptomatic
    • Watering
      • obstruction of puncta & interference with tear meniscus
    • FBS on downgaze
  • Signs
    • Redundant conjunctival tissue
    • Inferior conjunctival & corneal staining with bengal
  • Evaluation
    • observation of blink
    • Physically move conjunctiva with lid
    • NaFL to observe conjunctival folds
    • Rose bengal staining
  • Treatment
    • ​Topical lubrication
    • Treatment of blepharitis
    • Short course of topical steroids
    • Surgical resection if severe
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19
Q

Retention/Epithelial Inclusion Cyst

A
  • Fluid-filled cyst
    • fluid clear to turbid
  • No discomfort
  • Treatment
    • ​None if asymptomatic
    • Puncture with needle to drain if pt bothered
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20
Q

List the vascular disorders of the eye

A
  • Subconjunctival hemorrhage
  • Conjunctival hemangioma
  • Pyogenic granuloma
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21
Q

Subconjunctival hemorrhage

A
  • Bleeding between conjunctiva & sclera
  • Often in one sector of eye - may spread
  • Sx
    • ​Asymptomatic
    • Cosmesis
    • FBS
  • Causes
    • ​Valsava maneuvers
    • Anticoagulation medications
    • Infection
    • Trauma/Surgery
    • Systemic vascular disease
    • Bleeding disorder
  • Treatment
    • ​Spontaneous resolution 1-3 weeks
    • Education & reassurance
    • Assessment for ocular trauma
      • Rule out penetrating injury
    • ATs
    • Consideration of blood work
    • Avoidance of anticoagulants (ASA, NSAIDs)
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22
Q

Conjunctival hemangioma

A
  • Vascular tumor
  • Sx
    • ​Asymptomatic
    • Mild ocular irritation
    • Spontaneous bleeding or bloody tears
  • Signs
    • ​Benign, slowly progressive, bright red patches
    • Round, nodular, lobulated, polypoid
    • Growth possible
  • Treatment
    • ​Observation
    • Surgical excision
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23
Q

Pyogenic Granuloma

A
  • Vascular tumor of skin or mucous membranes
    • Rapid development
  • Fibrovascular proliferative response to conjunctival injury
  • Any age - children & young adults most common
  • Causes
    • ​Trauma
      • Mechanical
      • Surgical
    • Infection
    • Hormonal influences
    • Idiopathic
  • Treatment
    • ​Steroids
    • Excision
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24
Q

List the Non-malignant tumors

A
  • Conjunctival nevus
  • Racial melanosis
  • Choriostoma
    • Dermolipoma
    • Osseous choristoma
  • Papilloma
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25
Q

Conjunctival nevus

A
  • Most common melanocytic tumor
  • 1% risk malignancy
  • 1st - 2nd decade
  • often unilateral
  • Presentation
    • ​Discrete, slightly elevated, pigmented lesion on bulbar conjunctiva
      • Juxtalimbal
      • Plica semilunaris
      • Caruncle
    • Cystic spaces within nevus common
    • May exhibit growth due to hormonal changes or local inflammation
  • Types
    • Junctional
    • Subepithelial
    • Compound/combined
    • Blue
    • Congenital melanocytosis
  • Tx
    • ​None - periodic observation or photo documentation
    • Excision for cosmesis
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26
Q

Racial Melanosis

A
  • Flat conjunctival pigmentation in darkly pigmented individuals
  • Patchy pigmentation scattered throughout conjunctiva
    • Most dense at limbus - may extend onto the cornea
    • Palpebral or foniceal conjunctiva possible
  • Bilateral - asymmetric
  • Generally present at young age
  • Management - periodic observation or photo documentation
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27
Q

Choristoma

A
  • Benign, congenital proliferations of normal tissue that is not typically found at the site of mass
  • Types
    • Limbal dermoid
    • Dermolipoma (pale yellow dermoid containing adipose tissue)
    • Ectopic lacrimal glands
    • Osseous choristomas
      • Solid nodules
      • Composed of mature, compact bone, pilosubaceous units & hair follicles
      • Rarest form of choristoma
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28
Q

Papilloma

A
  • Benign sqamous epithelial tumors
  • Classification
    • ​Pedunculated
      • ​infectious
      • squamous cell
    • Sessile - limbal
    • Mucoepidermoid - inverted
  • Sqamous cell papilloma
    • ​Usually seen in yonger pts
    • History of maternal HPV infection at the time of birth
    • A past history of tumor excision with recurrence
    • Refractive to past medical & surgical treatments
    • No decrease or loss of VA
    • A hx of a sibling w/ same condition
    • A hx of cutaneous warts outside the eye
  • Limbal papilloma
    • ​Seen in older adults
    • History of UV exposure
    • Possible decrease or loss of visual acuity
    • Recurrence after excision, not common
    • History of chronic conjunctivitis refractive to medications
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29
Q

List the malignant tumors

A
  • Squamous carcinoma
  • Lymphoma
  • Kaposi sarcoma
  • Primary acquired melanosis
  • Melanoma
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30
Q

Squamous cell carcinoma

A
  • MOST COMMON TYPE OF CONJUNCTIVAL TUMOR***
  • Older age
  • Male > female
  • Chronic UV exposure
    • HIV infection in younger pts
  • Risk Factors
    • ​Fair skin
    • Tendency to sunburn
    • outdoor occupation
    • living close to the equator
    • History of actinic skin lesions
    • Xeroderma Pigmentosum (Genetic disorder w/ decreased ability to repair DNA caused by UV)
    • Immunosuppression
    • Male gener
    • Older age
  • Sx
    • ​Chronic conjunctivitis
    • Ocular irritation
  • Presentation
    • ​White, flesh-colored or red patch
    • Round, elevated growth
    • Gel-like appearance
    • Ofen originate at/near the limbus
    • Supsect SCC in any pt with conjunctivitis lasting >3months
  • Treatment
    • ​Excision & Biopsy
    • Radiation &/or chemotherapy
    • Extenteration if orbital extension
  • Prognosis
    • ​Mortality rate = 4-8%
    • Better prognosis if no orbital extension or metastasis to lymph nodes
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31
Q

Lymphoma

A
  • Salmon colored patches on the eye
    • Firm
    • smooth, mobile
  • May represent underlying systemic lymphoma
    • Primarily non-Hodgkin lymphoma
  • Unilateral
  • Sx
    • Conjunctival - pinkish mass
    • Orbital - pain, exophthalmos, diplopia
  • Tx
    • ​Excision & biopsy
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32
Q

Kaposi Sarcoma

A
  • Highly vascularized, red, gelatinous lesion
  • Resembles subconjunctival hemorrhage
  • Associated with squamous cell carcinoma & HIV infection
  • M>F
  • Older age
    • Younger onset with HIV infection/immunosuppression
  • 7-18% are conjunctival
  • Presentation
    • ​Inferior conjunctiva & fornix
    • Recurrent subconjunctival hemorrhages
    • Injection
    • Chemosis
  • work-up
    • ​Blood work
    • Biopsy
    • Evaluate for immunosuppression in younger pts
  • Treatment
    • ​Monitor if no discomfort
    • Alleviate ocular irritation
    • Prevent disfigurement
    • Regain immunocompetent state
    • Excision
    • F/u frequency depends on severity of ocular involvement
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33
Q

Primary Acquired Melanosis (PAM)

A
  • Unilateral - rarely bilateral
  • Fair-skinned individuals
  • Middle aged or older >45 yo
  • Intraepithelial disease
    • Appears as fine dusting of pigmentation
  • Presentation
    • Irregular, flat pigmented patches
      • Generally interpalpebral or juxtalimbal
    • Size changes frequent
    • Intensity of pigmentation changes
    • Risk of malignant conversion
  • Treatment
    • ​Small lesions (1-2 clock hours)
      • yearly monitoring
      • excision if nodularity, thickening, vascularity
    • Moderate lesions (2-5 clock hours)
      • Excisional biopsy
      • Cryotherapy at edges
    • Large lesions (>5 clock hours)
      • Incisional map biopsy of all quadrants to determine malignancy
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34
Q

Melanoma

A
  • Nodular or diffuse mass often with feeder vessels
  • 2% of ocular malignancy
    • PAM - 75%
    • Pre-existing nevus - 20%
    • Primary melanoma (de novo) - 5%
  • 6th decade
  • No sex predilection
  • More common in lighter pigmented individuals
  • Locations
    • Limbal - best prognosis
    • Caruncle
    • Tarsus
    • Fornix
  • Presentation
    • ​Nodular or diffuse
      • with feeder vessels
      • Multinodular lesions possible
    • Grey to black vascularized nodule
    • Amelanotic lesions possible
      • pink, flesh colored lesions
    • May spread to adjacent tissues (lids, nasolacrimal drainage system)
    • Metastasis to regional lymph nodes
  • Management
    • ​biopsy & excision
    • Radiotherapy
  • Poor Prognostic factors
    • ​Non-limbal location
    • De novo development
    • Older age
    • Male
    • Non-white race
    • Nodularity or ulceration of tumor
  • Mortality
    • ​5 years = 12%
  • Metastases
    • ​regional lymph nodes
    • Lung
    • Brain
    • Liver
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35
Q

Comparison of pigmented conjunctival lesions

A
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36
Q

Questions to consider in pts with pigmented conjunctival lesions

A
  • laterality
  • when did you first notice?
  • Has it changed in size or color?
  • Does it cause discomfort?
  • Has it ever bled?
  • Med hx
  • Occupation
37
Q

Conjunctivitis

A
  • Conjunctival inflammation
  • Sx often non-specific
    • Watering
    • Grittiness
    • Stinging
    • Burning
    • Itching (hallmark of allergic disease)
    • Pain, photophobia & marked FBS suggest corneal involvment
38
Q

Discharge

A
  • Watery
    • ​Serous exudate & tears
    • Acute viral, acute allergic
  • Mucoid
    • ​Mucus
    • Chronic allergic, DES
  • Mucopurulent
    • ​Mucus & pus
    • Chlamydial, acute bacterial
  • Purulent
    • ​Pus
    • Moderately purulent - acute bacterial
    • Severe purulent - Gonococcal
39
Q

List Allergic conjunctivitis

A
  • inflammatory response of the conjunctiva to an allergen
  • often occurring with systemic disease
  • May be only manifestation
  • Clinical variants
    • Acute allergic conjunctivitis
    • Seasonal allergic conjunctivitis
    • Perennial allergic conjunctivitis
    • Vernal keratoconjunctivitis
    • Atopic keratoconjunctivitis
    • Contact dermatitis
    • Phlyctenular keratoconjunctivitis
    • Giant papillary conjunctivitis
    • Mucus-Fishing syndrome
40
Q

Allergic response

A
  • Hypersensitive immune reaction to a substance that would not normally elicit the response in all persons
  • Atopy: genetic predisposition to hypersensitivity reactions upon exposure to environmental antigens
  • Type I hypersensitivity
    • ​Anaphylactic response
    • Immediate hypersensitivity response
    • Humoral response
      • Exposure to soluble allergen causing sensitization of plasma cells
      • Production of IgE specific for that antigen
      • IgE binds in great number to mast cells
      • Re-exposure to allergen causes degranulation of mast cells & relesae of allergic mediators
  • Chemical mediators - Chemotactic mediators
    • ​Stimulate migration of cellular components of immune system
      • Eosinophilic chemotactic factor of anaphylaxis
        • Major component
    • High molecular weight neutrophil chemotactic factors
    • Leukotriene B
    • Prostaglandins
  • Eosinophils
    • ​Terminally differentiated granulocytic effector cells
    • Produce
      • ​cytotoxic proteins
      • lipid mediators
      • chemotactic peptides
      • cytokines
    • players in innate & adaptive immunity
  • Chemical mediators: Vasoactive mediators
    • ​Activate smooth muscles, small blood vessels, mucus glands & sensory nerve endings
      • Histamine - major component
      • Leukotrienes C,D,E
      • Platelet activating factors
      • Serotonin
      • Prostaglandins
      • Heparin
  • Histamines
    • ​Spasmogenic to smooth muscle
    • Increased heart rate
    • Diastolic hypotension
    • Flushing (vasodilation)
    • HA
    • Increased vascular permeability
    • Stimulating of peripheral nerve ending
    • Exocrine secretion
    • Gastric secretion
41
Q

Allergic response (Early phase & Late Phase)

A
  • Release of chemical mediators results in the development of the early & late signs & sx of an allergic response
  • Early phase
    • ​Due to mast cell degranulation & release of chemical mediators including histamine, prostaglandins, heparin, cytokines & PAF
    • Produce sx of itching, redness & chemosis
  • Late phase
    • ​Begins hours after allergen exposure & may last for hours
    • Due to infiltration of activated inflammatory cells including eosinophils, basophils, neutrophils & macrophages recruited by mediators released in early phase
    • Cells release additional mediators responsible for perpetuating the signs & sx of the early phase
    • May also casue new sx
      • Tearing
      • Irritation
      • Stinging/Burning
      • Photophobia
42
Q

Type I hypersensitivity

A
  • Common 10-20%
  • Variable
    • Mild presentation to anaphylactic shock
  • Rapid
    • Signs as early as 5 minutes
    • Sx in 30 mins
  • Young males > young females
  • Increased IgE in serum & tears
  • Eosinophil accumulation at site
  • Conditions
    • Acute allergic conjunctivitis
    • Seasonal allergic conjunctivitis
    • Perennial allergic conjunctivitis
    • Vernal keratoconjunctivitis
    • Atopic keratoconjunctivitis
43
Q

Type II hypersensitivity

A
  • Cytotoxic
  • Autoimmune response
    • Inability to distinguish self from non-self
    • Production of auto antibodies
    • Etiology unknown
44
Q

Type III hypersensitivity

A
  • Immune complex
    • soluble antigen/antibody complex which stimulates neutrophils & complementary system
    • Results in overwhelming destruction of surrounding tissues
  • Examples
    • Drug rxn
    • Erythema multiforme
    • Steven-Johnson syndrome
45
Q

Type IV hypersensitivity

A
  • Delayed hypersensitivity reaction
  • Mediated by T-lymphocytes
  • Less common than type I
  • Slower response
    • Occurs 24-72 after re-exposure
      • Contact dermatitis
      • Thimerosol sensitivity
      • PPD
  • Localized response
  • No increase IgE serum or tears
  • Examples
    • Contact dermatitis
    • Phlyctenular conjunctivitis
    • Giant papillary conjunctivitis
      • Combination of Type I & Type IV
46
Q

Comparison of Hypersensitivity Reactions

47
Q

Maagement of ocular allergic disease

A
  • Supportive Antihistamines
  • Mast cell stabilizers
  • combo agents
  • Steroids
  • NSAIDs (Decrease inflammation)
  • Decongestants (nasal sprays, vasoconstrictors)
  • Isolation & removal of the allergen**
48
Q

Acute Allergic Conjunctivitis

A
  • Acute conjunctival reaction to an environmental antigen
  • Young children, after playing outdoors esp in spring & summers
  • Presentation
    • Acute itching
    • Watering
    • Severe chemosis
  • Treatment
    • ​None often resolves in hours of removal of allergen
    • Cool compresses
    • Topical adrenaline 0.1% - decrease chemosis
49
Q

Seasonal & Perennial allergic conjunctivitis

(Which age group affected, Association with which disease, Presentation, Tx?)

A
  • Estimated to affect 20% of population annually
  • Young adults more common
    • Age of presentation 20yo
    • sx tend to decreased with age
    • Possible to develop as an older adult
  • High association with other allergic disease
    • Allergic rhinitis
    • Asthma
    • Atopic dermatitis
  • Presentation
    • ​Hyperemia
    • Tearing
    • Watery, ropy discharge
    • Burning****
    • Itching****
    • Chemosis (1+ trace)
    • Eyelid edema
    • Papillary reaction
      • Rarely follicular (chronic presentations)
    • Petechial hemorrhaging
    • Sneezing
    • Nasal discharge
    • Often complete resolution between attacks
  • Treatment
    • ​Artificial tears
    • Mast cell stabilizers
    • Antihistamines
    • Dual action agents
    • Topical steroids
    • Oral antihistamines
50
Q

Seasonal allergic conjunctivitis

A
  • Sub-acute condition
  • Common
  • Hay-fever
  • High association with rhinitis
  • Attributable to outdoor pollens
  • Develops over days to weeks in response to specific pollen
  • Causes
    • Spring - tree pollens
    • Summer - grass pollen
    • Late summer, early fall - weed pollen
    • Variation based on geographic location
    • Tree & grass pollens most common
51
Q

Perennial allergic conjunctivitis

A
  • Sx throughout the year
  • Mild, chronic, waxing & waning conjunctivitis
  • Autumn
  • Indoor allergens
    • Dust mites, animal dander, mold/fungal
  • More mild presentation than seasonal
52
Q

Vernal Keratoconjunctivitis

A
  • Recurrent, bilateral
  • IgE & cell-mediated immune response
  • Boys age 5+
    • 95% remit by late teens
    • Remainder often develop atopic keratoconjunctivitis
  • Mostly in warm, dry, subtropical climates
  • 90% with other atopic conditions
    • asthma eczema
  • Seasonal exacerbations
    • Late spring to summer
    • Mild perennial sx
  • Uncommon
  • Symptoms
    • ​Intense itching
    • Lacrimation
    • Photophobia
    • FBS
    • Burning
    • Thick mucoid discharge
    • Increased blinking
  • Signs
    • ​Palpebral
      • upper tarsal conjunctiva
      • Early mild - conjunctival hyperemia, diffuse papillary hypertrophy on superior tarsus
    • Macropapillae - flat topped polygonal appearance
    • Giant papillae - smaller lesions amalgamate
      • Mucus deposition between papillae
      • Characteristics polygonal “cobblestones”
    • Limbal
      • ​May occur alone or in associate with palpebral
      • Thickening & opacification at the limbus
        • nodules may become confluent
      • Homer-Trantas’ dots
      • More severe in tropical regions
    • Keratopathy
      • ​More freqeuent in the presence of palpebral disease
      • Superior punctate epithelial erosions (PEE)
      • Pannus
      • Plaques & shield ulcers
      • Subepithelial scars
      • Pseudogerontoxon
      • Mild eyelid disease
53
Q

Atopic Keratoconjunctivitis (AKC)

A
  • Rare - prevalence unknown
  • Bilateral
  • Develops in adulthood following long h/o eczema
    • Peak 30-50
    • 5% chronic VKC in childhood
  • M=F
  • Perennial, worse in winter
  • Less responsive to tx
  • Type I & IV reactions contribute
  • Sx
    • Similar to VKC
    • more severe
    • Unremitting
    • Intense itching
    • Lacrimation
    • Photophobia
    • FBS
    • Burning
    • Thick mucoid discharge
    • Increased blinking
    • Eyelid changes
      • intermittent swelling
  • Signs
    • ​Eyelid
      • Skin changes - erythema, dryness, scaling & thickening
      • Chronic staphylococcal blepharitis
      • Madarosis
      • Keratinization of lid margin
      • Induration
      • Tightening of facial skin
        • Ectropion
        • Epiphora
    • Conjunctiva
      • ​Inferior, palpebral > superior
      • Discharge - watery to stringy mucoid
      • Smaller papillae initially
      • Diffuse infiltration
      • Scarring
      • Cicatricial changes
        • Moderate symblepharon
        • Forniceal shortening
        • Keratinization of caruncle
      • Horner-Trants dots
    • Keratopathy
      • ​Inferior PEK
      • Persistent epithelial defects
      • Plaque formation
      • Peripheral vascularization
      • Predisposition to 2^ bacterial & fungal infection
      • Agressive HSK (herpect disease)
      • Keartoconus - due to chronic rubbing, thinning of cornea
    • Cataract
      • ​Presenile shield-like anterior or posterior subcapsular
      • Worsen with long-term steroid use
    • Retina
      • ​Retinal detachment
54
Q

Treatment for VKC & AKC

A
  • Allergen avoidance
  • Cool compress
  • Lid hygiene
  • Topical treatment
    • Mast cell stabilizers - decrease frequency
    • Antihistamines - acute
    • Dual action
    • NSAIDs
    • Steroids - severe
    • Immune modulators - restasis
  • Systemic tx
    • Antihistamines
    • Antibiotics
    • Immunosuppressive agents
    • ASA- avoid in children du eot reye’s risk
  • Surgical tx
    • BCL
    • Superficial keratectomy
    • Surface maintenance
      • Amniotic graft
      • Lamellar keratoplasty
      • BOTOX
      • Lateral tarsorrhaphy
55
Q

Contact Dermatitis

A
  • More common in pt with atopy
  • F > M
  • Often associated with topical ocular agents
    • Antibiotics
    • Dilation agents
    • Preservatives
  • Presentation
    • ​Marked crusting, scaling & thickening of lids
    • Moderate to severe lid edema
    • Conjunctival injection
    • Chemosis
    • PEK
  • Treatment
    • ​Identification & avoidance of irritant
    • Treatment of inflammation
56
Q

Phlyctentular Keratoconjunctivitis

A
  • Local conjunctival/corneal immune response to some previously sensitized antigen
    • Historical association with TB
    • Staph antigens most frequent agent now
  • More common in children
  • Initial episode always affects limbus
    • Subsequent episodes involve cornea & bulbar conjunctiva
  • Subepithelial inflammatory nodules made of WBC & blood vessels
    • Macrophages
    • Lymphocytes
    • Plasma cells
    • PMNs
  • Sx
    • Conjunctiva - injection, tearing, FBS
    • Corneal - extreme photophobia, pain, blepharospasm
  • Signs
    • ​Limbal - first attack - single or multiple pinkish-white nodules adjacent to area of conjunctival hyperemia
      • Great variation in size
      • Becomes grayish in color, ulcerates, then resolves
    • Corneal ​
      • White mound bordered by radial pattern of dilated vessles of conjunctiva
      • Progresses toward central cornea as a wedge-shaped gray, necrotic, superficial ulcer leaving a white anterior stromal infiltrate
      • No clear zone between limbus****
      • Perpendicular to limbus
  • Management
    • ​Determination of cause (Check for staph & TB)
    • PPD, chest x-ray
    • Lid margin &/or conjunctival cultures
  • Treatment (NEED BOTH b/c it is an immune response against a previously sensitized antigen)
    • ​Anti-inflammatory
    • Anti-infective
57
Q

Giant Papillary conjunctivitis

A
  • Mechanically-induced papillary conjunctivitis
    • CLs- any type
    • Prosthesis
    • Suture
    • Corneal scars
  • Combination type I & IV rxn
  • Directed at mucin coating & recurrent trauma
  • Both sexes, any age possible
  • Etiology
    • Mechanical irritation & or antigenic stimulus on the upper tarsal conj
    • Histologic changes - mast cell degranulation & secondary allergic cascade
    • Conjunctivitis, tissue changes & inflammatory marker in tears
  • Symptoms
    • ​FBS
    • Redness
    • Itching
    • Increased mucus
    • Blurred vision
    • CL/prosthesis intolerance
  • Signs
    • ​Giant papillae
    • Mechanical ptosis
    • Stringy mucous discharge
    • Increased discharge on CLs or prosthesis
    • Conjunctival injection
  • Treatment
    • ​Avoidance of mechanical stimulation
    • Mast cell stabilizer
    • Antihistamines
      • Not as effective
    • NSAIDs
    • Topical steroids
      • Caution - may lead to secondary infection
  • Prognosis
    • ​80% able to return to comfortable CL wear
    • Remissions & exacerbations common
    • Ptosis may resolve
    • May have scarring or permanent giant papillae
58
Q

Mucus-Fishing Syndrome

A
  • Chronic papillary conjunctivitis
  • Pts exacerbate conjunctival irritation by mechanically removing excess mucus from globe or inferior fornix
  • Associations
    • DES
    • Blepharitis
    • Allergic conjunctivitis
    • GPC
    • Floppy eyelid syndrome
  • Symptoms
    • ​FBS
    • Excess mucus
    • Lacrimation
    • Intolerance of CL/prosthetic
  • Examination
    • ​Thorough history
      • ask about discharge
      • Have pt show you how they remove from eye
    • Staining - look for staining on inferior cornea & conjunctiva in area that pt removes mucus
  • Treatment
    • ​Avoidance
    • treat underlying condition
    • Mucolytic agent - N-acetylcysteine 10%
    • Antihistamine- mast cell stabilizers
      • epinastine (elestat)
      • Ketotifen (alaway, zaditor)
      • Olopatadine (patanol, etc)
    • Therapy
59
Q

Stevens-Johnson Syndrome

A
  • Type III hypersensitivity
  • Rare, potentially fatal condition
  • Cell-mediated delayed hypersensitivity reaction
    • Drugs
    • Epithelial cell antigens modified by drug exposure
  • Risk
    • Viral infection
    • Weakened immune system
    • H/O Stevens-Johnson syndrome
      • ​Previous reaction
      • Immediate family member
    • HLA-B1502
  • Presentation
    • ​Flu-like sx up to 14 days prior to mucotaneous lesions
    • Early
      • ​Hemorrhagic crusting of lid margins
      • Papillary conjunctivitis
        • Severe hyperemia
        • Membrane/pseudomembranes
        • Blisters
        • Patchy infarction
      • Keratopathy
    • Late
      • ​Keratinized of conjunctiva & lid margin
      • Forniceal shortening & symblepharon
      • Cicatricial complications of lids
  • Systemic Tx
    • ​Hospitalization
      • Often placed in burn units
    • Removal of precipitant
    • Supportive measures
    • Others
      • Systemic steroids
      • Immunosuppressants
      • Systemic antibiotics
  • Ocular tx
    • ​Supportive therapy
    • pseudomembrane peeling
    • Scleral ring
    • Mucous membrane grafting
    • Amniotic membrane
    • Keratoprosthesis (Boston K-pro)
60
Q

Superior Limbic Keratoconjunctivitis

A
  • Rare, chronic recurrent disease affecting the superior limbus, superior bulbar & tarsal conjunctiva
  • W > M
  • Presentation around 6th decade
  • years of exacerbations & remissions
  • Pathogenesis
    • ​Unknown etiology
    • ​Traumatic
      • mechanical irritation from friction between tarsal & bulbar conj
      • Conjunctivochalasis******
    • Other
      • infectious
      • Immunologic
      • allergic
  • Associations
    • ​Hyperthyroid - 50% ****
    • KCS - up to 50% (Dry eye, Keratoconjunctivitis sicca)
    • Hyperparathyroidism***
    • CL wear
    • UL trauma/surgery
  • Symptoms
    • ​FBS
    • Photophobia
    • Increased blinking
    • Burning
    • Pain
    • Itching
    • Ocular dryness
  • Presentation
    • ​Conjunctiva
      • Papillary hypertrophy
      • Sectoral hyperemia of superior bulbar & limbal conjunctiva
      • Petechial hemorrhages
      • Redundancy & thickening of superior conjunctiva
    • Cornea
      • SPK common
      • Superior filamentary keratitis
      • Superior pannus (blood vessel growth)
      • KCS in about 50% cases (Dry eye)
  • Examination
    • ​Careful examination of upper tarsal & bulbar conjunctiva
      • look for redundancy, folds, hyperemia, filaments
    • Staining technique
    • Cotton swab manual manipulation of conjunctiva
    • Schirmer testing
    • Lab testing
      • Thyroid function
      • Autoimmune serologic tests
  • Treatment
    • ​Thyroid function testing in pts without documented thyroid dysfunctions ***
      • refer to rheumatologist or endocrinologist
    • Mild
      • Lubrication
      • Punctal occlusion
      • restasis
      • Cromolyn sodium drops (Mast cell stabilizers)
    • Moderate to severe
      • Silver nitrate solution applied with cotton swab (Shrink conjunctivochalasis)
      • Bandage CL
      • Acetylecysteine if mucous or filaments present
      • BOTOX injection (make lid more floppy to reduce tension of UL)
61
Q

List the bacterial conjunctivitis

A
  • Acute bacterial conjunctivitis
    • S. aureus
    • S. pneumoniae
    • H. influenzae
  • Hyperacute bacterial conjunctivitis
    • N. gonorrhoeae
    • N. meningitidis
  • Chronic bacterial conjunctivitis
    • Adult chlamydial conjunctivitis
    • Trachoma
  • Neonatal conjunctivitis
62
Q

Barriers to infection

A
  • Ocular defense mechanisms
    • Intact epithelium
    • Normal lid/tear film function
    • Low conjunctival & corneal temperature
    • Mucus
    • Conjunctival lymphoid elements (MALT - mucosa associated lymphatic tissues)
  • Normal microbial flora
    • Staphylococcus peidermidis
    • Aerobic & anaerobic diphtheroids
    • Transient pathogens
63
Q

Pathogens (Gram + & Gram -)

A
  • Gram + organisms
    • ​Staphylococcus aureus
      • Gram + cocci
      • MOST COMMON cause of conjunctivitis
    • Streptococcus pneumoniae
      • ​Gram + diplococci
    • Cornebacterium diphtheria*
      • ​Gram + bacillus
      • Uncommon highly invasive & toxigenic
  • Gram - organism
    • ​Haemophilus influenza*
      • Gram - coccobacillus
      • Affects young children (esp <5yo)
    • Moraxella lacunata
      • Gram - diplobacillus
      • Affects elderly & debilitated
    • Neisseria gonorrhoeae*
      • Gram - diplococcus
      • Highly pathogenic, virulent & invasive
      • Associated with venereal disease
    • Neisseria meningitides*
      • Gram - diplococci
      • uncommon
      • Associated with meningitis in children
64
Q

Response to infection (Pathogenesis & Histopathology)

A
  • Role of microorganism
    • Adherence
    • Invasion
    • Multiplication & spread
    • Introduction of host inflammatory response by PMNs
    • Tissue damage
  • Response of host tissue
    • ​Conjunctival
      • ​Vascular engorgement
      • Increased vascular permeability
      • Cellular exudate
      • Papillary & follicular hypertrophy
    • Corneal
      • ​Infiltration by PMNs (conj vessels -> tears -> cornea)
      • Release of proteolytic enzymes
65
Q

Acute bacterial conjunctivitis

A
  • Rapid onset conjunctivitis
  • Less severe
  • Begins unilateral & may spread to fellow eye
  • Sx generally last 10-14 days, but may become chronic
  • Causative agents
    • ​S. aureus - all ages, regions, seasons
    • S. pnuemonia - children>adults, northern US, colder months
    • H. influenza - young children, southeastern US, warmer months, more severe presentation
    • Moraxella Catarrhalis
  • Sx
    • ​Unilateral
    • Acute onset redness, grittiness, burning, discharge
    • Eyelids stuck shut on awakening
    • Systemic sx rare
  • Signs
    • ​Conjunctival injection - palpebral & bulbar
    • Mild discharge - mucopurulent
    • Diffuse PEK
    • Peripheral corneal ulcerations
    • Lymphadenopathy absent (Preauricular node)
  • Lab work up
    • ​Rarely necessary
      • organisms typically responds to broad spectrum antibiotics
      • Self-limiting infection - resolves in 1-2 wks without tx
        • 60% resolution in 5 days without tx
    • Giemsa stain
    • Gram stain
  • Supportive therapy
    • ​lavage (Irrigate)
    • Cool compresses
    • Topical antibiotics - QID x 1 week
    • Oral antibitoics - depends on causative agent
    • Topic steroids - to reduce scarring, membrane formation
      • Caution - slow healing time
  • Treatment
    • ​Discontinuation of CL wear & change all solutions/cases/accessories
    • Hygiene - hand washing, changing towels/bedding
    • Avoidance while contagious - stay home from work/school
    • Notification of public health authorities - depends on causative agent
66
Q

Hyperacute bacterial conjunctivitis

A
  • Rare
  • More severe presentation
  • Rapidly progressive
  • Symptoms
    • ​Unilateral tearing & irritation
    • Eye ache
    • Lid tenderness
    • Lids stuck closed
    • Systemic sx common
  • Signs
    • ​Marked bulbar & palpebral conjunctival hyperemia
    • Severe conjunctival chemosis
    • Copious purulent discharge
    • Severe lid edema
    • Prominent preauricular lymphadenopathy
    • Corneal ulceration possible
  • Causative agents
    • ​N.gonorrhoeae
      • ​more common
        • 2 mill annually cases of genital infection
        • ~3000 develop ocular involvement per year
      • Neonatal & adult forms
        • 3-19 day incubation period for GU infection
        • Precedes ocular infection by 1+ weeks
    • N. meningitidis
      • ​Uncommon
        • associated with meningitis
        • may be bilateral onset
      • Younger pts
      • Ocular signs
        • Purulent signs
        • EOM palsies
        • Increased intracranial pressure -> papilledema
        • Nystagmus
      • ** Kids with systemic sx need to go to PCP immediately **
  • Gonococcal conjunctivitis
    • ​Markedly inflamed conjunctiva
    • Intense dilation of conjunctival vessels
    • Petechial hemes
    • Purulent discharge
    • Decreased vision
  • Lab workup
    • ​MANDATORY
    • Giemsa stain
      • Overwheling PMN response
    • Gram stain
    • Culture & sensitivity testing
      • Chocolate agar
      • Thayer-Martin medium
    • Consider tests for syphilis, chlamydia & HIV **
  • Treatment
    • ​Supportive therapy
      • saline lavage
      • cool compresses
    • Ocular therapy
      • topical antibiotics - q1-2hrs initially, then taper to q2-4hrs, then QID
      • Follow closley - q24hrs for first few days
    • Systemic therapy
      • Oral antibiotics
67
Q

List the chronic bacterial conjunctivitis

A
  • Chlamydial conjunctivitis
  • Trachoma conjunctivitis
68
Q

Chlamydial conjunctivitis

A
  • Oculogenital infection - autoinoculation from genital secretions
  • 10% eye to eye spread
  • Affects 5-20% sexually active adults in western countries
  • Incubation period 1 week
  • Causative agent: chlamydia trachomitis
    • Serotypes D-K
  • No gender predilection
  • 15-35yo most common presentation
  • Unilateral or bilateral
  • Conjunctivitis chronic - may last many months
  • Women - concomitant vaginal discharge secondary to chronic vaginitis or cervicitis
  • Men - symptomatic or asymptomatic urethritis
  • Inquire about duration of sx, prior tx, sexual exposure
  • Sx
    • ​Subacute onset unilateral or bilateral redness, watering & discharge
    • Tender PAN common
    • Keratitis may develop in 2nd week
    • Untreated conjunctivitis becomes chronic
    • Ask about sexual exposure if suspected
  • Signs
    • ​Watery or mucopurulent discharge
    • Large follicles - esp. bulbar or plica semilunaris
    • PEK
    • Peripheral subepithelial corneal infiltrates
      • 2-3wks after onset conjunctivitis
    • Tender PAN
    • Conjunctival injection
    • Chemosis
    • Superior micropannus
  • Workup
    • ​Referal to GU specialist mandatory
    • Lab testing
      • Giemsa staining
      • Chlamydial cultures of conjunctiva
      • ELISA
      • Serum immunoglobulin G titers
    • Complete STD workup of pts & partners
  • Treatment
    • ​Systemic antibiotics
      • Azythromycin 1000mg single does
        • 30% require subsequent doses
      • Doxycycline 100mg BID x 7-10 days
      • Tetracycline 100mg QID x 7-10 days
        • Tetracyclines contraindicated in pregnancy/nursing, under 12yo
      • Erythromycin 500mg QID x 7-10 days
    • Topical antibiotics - speed resolution of ocular involvement
    • Reduction of transmission risk
      • Avoidance of sexual contact until completion of therapy
69
Q

Trachoma conjunctivitis

A
  • Leading cause of preventable, irreversible blindness in the world
    • vision impairment in 1.8 million (WHO.org)
    • Irreversible blindness in 0.5 million
      • 1.4% global total of blind individuals
  • Chronic infection leads to cell-mediated hypersensitivity response (type IV)
  • Spread through personal contact & infected flies
  • Causative agent: chlamydia trachomatis
    • Serotypes A, B, Ba, & C
  • Stages
    • ​Active trachoma
    • Cicatricial trachoma
      • Trachomatous scarring
      • Trachomatous trichiasis
      • Corneal opacity
  • Active trachoma
    • ​Mixed follicular/papillary conjunctivitis
    • Mucopurulent discharge
    • Superior epithelial keratitis & pannus formation
    • 60-90% infection in endemic regions
  • Cicatricial trachoma
    • ​30-40 yo
    • Women 2-3x more than men
    • Conjunctival scarring
      • Mild: linear or stellate
      • Severe: Arlt’s line, broad, confluent
    • Herbert pits
    • Trichiasis, distichiasis
    • Corneal vascularization
    • Cicactrical entropion
    • Severe corneal opacification
    • Destruction of goblet cells & ductules of lacrimal glands = DES
  • Treatment
    • ​SAFE strategy - managed & supported by WHO
      • S - Surgery: entropion & trichiases repair
      • A - Antibiotics: pt & family members
        • Azythromycin 20mg/kg to 1000mg single dose
        • Erythromycin 500mg BID x 14 days
        • Topical 1% tetracycline ung. QID x 6 weeks
      • F - Facial cleanliness: preventative
      • E - Environmental improvements: access to clean water & sanitation, control of flies
70
Q

Neonatal conjunctivitis

A
  • Infection transmitted mother to infant during delivery within 1st month of life
  • Most common infection of neonates
  • Causes
    • C. trachomatis
    • N. gonorrhoeae
    • HSV
    • H. influenzae
    • Strep species
  • Presentation
    • ​Depends on causative agent
    • Discharge
    • Lid edema
    • Lid/periocular vesicles
    • Keratitis
  • Treatment
    • ​Variable from supportive for mild cases to oral antibiotics or antiviral therapy for more severe infections
    • Consultation with microbiologist or pediatrician for severe infection
    • Referal to genitourinary specialist for mother & sexual partners depending on causative agent.
71
Q

List the viral Conjunctivitis

A
  • Non-specific viral conjunctivitis
  • Adenoviral conjunctivitis
    • epidemic keratoconjunctivitis
    • Pharyngoconjunctival fever
  • Acute hemorrhagic conjunctivitis
72
Q

Viral Conjunctivitis

A
  • General characteristics of viruses
    • smallest infectious organisms
    • Obligate intracellular parasite
    • Depend on hosts metabolic processes for multiplication
  • Ocular infection
    • ​Acute conjunctivitis, keratitis, blepharitis
    • Chorioretinitis, uveitis
    • Optic neuritis, papillitis, oculomotor paresis
    • Induction of tumors (esp.. Epstein - Barr)
73
Q

Adenoviral conjunctivitis

A
  • Infection by adenovirus
    • DNA virus
    • 50+ serotypes - 1/3rd with ocular mvmt
      • Severity depends on serotype
  • Most common cause of viral conjunctivitis 75% cases
  • Any age, gender, race
  • Virus remains infections in desiccated (dry) state for weeks at room temp
  • Clinical course
    • 7-6 day (avg.10) incubation period
    • 7-28 day symptomatic
    • Different serotypes with different duration
  • Prior URI
  • Presentation
    • ​Lid edema
    • Serous discharge
    • Crusting on lashes
    • Pseudomembranes
    • PAN
    • Subepithelial infiltrates possible 15-35%
74
Q

Non-specific Viral Conjunctivitis

A
  • Pink eye
  • More mild presentation
  • Most common ocular manifestation
    • 65-90% caused by adenovirus
  • Self-limited
    • Sx last 1-3 wks
  • Transmission via upper respiratory droplets
  • Symptoms
    • ​FBS
    • Burning
    • Redness
    • Mild - Photophobia
  • Signs
    • ​Serous discharge
    • Moderate follicular response
    • Diffuse bulbar injection (pink)
    • Mild chemosis
    • Discrete lid edema
    • No corneal involvement
    • No/mild preauricular lymphadenopathy
    • Starts Unilateral, moves bilateral
  • Treatment
    • ​Supportive thearpy - lubrication, ocular decongestants, cool compress
    • Hygiene - hand washing, change pillowcases/towels/sheets daily
    • F/u - 1wk - may cancel if pt resolves
75
Q

Epidemic Keratoconjunctivitis

A
  • Acute, highly infectious infection
    • Outbreaks common in clinics
  • Common in developed countries
  • More common in adults (20-40)
  • Adenovirus serotypes 8,19, & 37
  • Transmission
    • Direct contact with ocular secretions
    • Contact with instruments in eye clinics
    • Work-place, eye care facilities, close personal contact, neonatal units, nursing homes
  • 3-4 week duration, occasionally longer
  • Incubation period 4-24 days
  • Biphasic infection
    • Infective phase
    • Inflammatory phase: begins 7-10 days after initial infection
    • Pt remain infectious for 10-14 days
  • Starts unilateral, becomes bilateral in 70% cases
  • Symptoms
    • ​FBS
    • Photophobia
    • Conjunctival hyperemia
    • Sero-fibrinous discharge
  • Severe cases
    • ​Decreased VA
    • Orbital or periorbital pain
  • Often have recent h/o of eye exam
  • May be preceded by flu-like sx
    • Fever, malaise, myalgia, respiratory sx, nausea, vomiting, diarrhea
  • 2 Phases
    • ​Acute phase
    • Sequelae phase
  • Acute phase
    • ​Begins unilateral, moves to fellow eye but less severe
    • Follows 7-16 day course
    • Sudden onset of profuse serous discharge
    • Periorbital pain
      • Esp. when bend forward
    • Severe follicular conjunctivitis with petechial hemes on palpebrum
    • Moderate to severe eyelid edema
    • Chemosis
    • Preauricular lymphadenopathy
    • Potential pseudomembrane formation
    • Subconjunctival hemorrhaging
    • Chemosis
    • Corneal involvement
      • PEK
      • Early in 2nd week
      • Virus-infected cells
      • May form focal keratitis
  • Sequelae phase
    • ​Variable course
    • Subepithelial infiltrates
      • Early in 3rd week
      • Variable number, location & density
      • Variable effect on VA
      • Delayed hypersensitivity reaction to viral antigen in overlying epithelium
  • Treatment
    • ​Hygiene
    • Discared CL & accessories
    • Supportive therapy
      • ice packs
    • Analgesics
    • Peeling of pseudomembranes
    • Topical corticosteroids
      • Decreased inflammation
      • Soften membranes/pseudomembranes
    • Cycloplegics
    • Antivirals
    • Betadine
  • What you should do when pt sees you
    • DO NOT see pts if you have EKC
    • Wear gloves
    • Disinfect instrumetns well
      • anyting pt touched
    • Careful about tonometry
      • Can live in fluress for up to 1 month
    • If have more than 1 exam lane, confine pts to same room
76
Q

Pharyngoconjunctival fever

A
  • Sx
    • ​Ocular
      • ​Redness, watering, itching, burning
    • systemic
      • ​Pharyngitis
      • Fever - gradual onset - 100-104 deg
      • Other associations - diarrhea, rhinitis
  • Signs
    • ​Follicular conjunctivitis - often bilateral
      • starts unilateral & spreads to 2nd eye in 1-3 days
      • Copious serious discharge
    • Lid edema
    • Hyperemia
    • Chemosis
  • Tx
    • ​Non-self-limiting
    • Supportive therapy
      • Artificial tears
      • Cool compresses
    • Analgesics/antihistamines
77
Q

Viral conjunctivitis: Diagnosis

A
  • Clinical examination
    • Most often used method
    • Poor accuracy reported
  • Cell culturing
    • Giemsa staining
  • PCR
    • High accuracy of diagnosis
  • Antigen detection
    • AdenoPlus
      • Fast, completed in-office in ~10 mins
      • High accuracy
      • Point of care testing to detect unkown serotypes of adenovirus
        • 90% sensitivity
        • 96% specificity
      • Fast - results in about 10 mins
      • Reads like pregnancy test
        • Red & blue line = positive
        • Blue line = negative
        • No line = invalid test
78
Q

Adenoviral conjunctivitis tx

A
  • Tx
    • ​topical lubrication
    • Hygiene
    • D/C CL wear & discared/replace all accessories
    • Topical steroids for membranes or severe corneal involvement
    • Cool compresses
    • Off-lable tx
      • Topical antiviral
        • Canciclovir (Zirgan) in trial currently
    • Opthalmic betadine
      • In office single tx
        • instill topical anesthetic & topical NSAID then lavage the eye with betadine
        • Have pt close eyes & swab lids with betadine
        • Rinse with sterile saline & instill topical NSAIDS
      • Clinical evidence shows increased rate of healing with decreased sequelae
      • No well-controlled studies on efficacy
      • Risk for conjunctival & corneal irritation
79
Q

Acute Hemorrhagic conjunctivitis

A
  • Picorna virus
    • ​Enterovirus 70
    • Coxsackie virus A-24
  • Coastal & tropical cities with high humidity & population density
  • Short incubation period giving rapid spread
  • Any age group, gender
  • sx
    • ​Tearing
    • FBS
    • Itching
    • Redness
    • Discharge
  • Signs
    • ​Seromucous discharge
    • Follicles
    • Pronounced lid edema
    • Petechial hemorrhages on bulbar conjunctiva which spread & become confluent to total subconj heme
    • Preauricular lymphadenopathy
    • Minimal corneal involvement
      • Minimal PEK
    • Secondary bacterial infections common
      • Mucopurulent conjunctivitis
      • N. gonorrhoeae
    • Neurological sequelae
      • Polio-like paralysis
      • 1/10,000 - 1/20,000 affected
    • Onset 1-8 weeks after conjunctivitis
    • Begins with fever, malaise & pain along a nerve-root with eventual paralysis
      • Usually limbs or cranial nerves
    • Great variability in severity
    • 1/3 remain permanently handicapped
    • Respiratory paralysis = death
  • Tx
    • ​Usually self-limiting in 3-5 days
    • Prophylactic antibiotics
    • Avoid corticosteroids
      • worsen condition
      • Promote secondary infection
      • Prolonged recovery
    • Supportive therapy
    • Hygiene
80
Q

List trauma

A
  • Conjunctival foreign body
  • Abrasions & lacerations
  • Chemical burns
    • Acid
    • Alkali
    • Glue
  • Thermal burns
81
Q

Conjunctival foreign body

A
  • Object in conjunctiva
    • May be bulbar, palpebral or forniceal conjunctiva
    • Superficial or deep
  • Sx
    • ​Redness
    • Pain, irritation
    • FBS
    • Photophobia possible
    • Watering
  • Signs
    • ​Visible foreign body
    • Corneal or conjunctival tracking
    • Subconjunctival hemorrhage
    • Abrasion
    • Seidel sign
    • Dilate pt to r/o intraocular foreign body
  • Tx
    • ​Superficial
      • Removal at slit lamp
        • anesthetize eye
        • Remove with cotton swab, golf spud, needle
      • Prophylactic antiboiotic
      • Lubrication
      • analgesic (pain reliever)
      • BCL
    • Deep
      • Refer for surgical removal
82
Q

Abrasions & Lacerations

A
  • Abrasion = irregularity of the epithelial surface of the conjunctiva
    • frequent association with corneal abrasions
  • Laceration = full thickness defect conjunctiva
    • Associations
      • Chemosis
      • Subconjunctival hemorrhage
      • Open globe
      • Hyphema (blood to front of eye)
  • Risks
    • ​M>F
    • Generally occur at work/home
    • Failure to wear protective eyewear
    • Substance abuse
  • Cause
    • ​Blunt objects - fist, rocks, baseball
    • Sharp objects - scissors, knives, screwdrivers, nails
  • Sx
    • ​Pain
    • FBS
    • Photophobia
    • Decreased vision
    • Watering
  • Signs
    • ​staining with NaFL
    • Chemosis
    • Subconjunctival hemorrhage
    • Normal to decreased vision
  • Evaluation
    • ​Thorough history
      • when & how injury occurred
      • what material they think got in the eye
      • General health of pt
    • External exam
    • Pupil testing
    • Evaluate for seidel sign
    • Dilate to r/o penetrating injury
    • Consider B-scan or imaging studies if suspect intraocular foreign body
  • Signs of open globe
    • ​Seidel sign
    • Prolapsed uveal tissue
    • Low IOP
    • Decreased vision
    • Shallow or flat anterior chamber
    • Hyphema
    • Iris deformities
    • Dislocated lens
    • Retinal detachment
  • Small wound/closed globe
    • ​prophylactic antibiotics
    • Lubrication
  • Large wound/open globe
    • ​Fox shield
    • Refer for surgery
83
Q

List chemical injury

A
  • Acid
  • Alkali
  • Glue
84
Q

Chemical injury - Acid burns

A
  • Low pH
  • Dissociate into hydrogen ions & anions
  • Cause coagulation of proteins
    • Coagulative necrosis
    • Clouding of conjunctival/corneal tissue
    • Prevents further penetration into structures
  • Increased concentration or exposure leads to greater damage
  • Hydrofluoric acid can penetrate ocular surface
85
Q

Chemical injury - alkali burns

A
  • High pH
  • Readily dissociate into hydroxyl ions & cations
    • Hydroxyl ions
      • saponification & breaks down fatty acids in cell membranes
      • Liquefactive necrosis
    • Cations
      • Interaction with collagen & glycosaminoglycans of the stroma
      • Fogging of stroma
    • Deeper penetration & infilatration of the anterior segment
      • Increased IOP/Secondary glaucoma
      • Iritis
      • Decreased VA
86
Q

Common caustic agents & source of alkali & acid injury

87
Q

Chemical Injury

A
  • Sx
    • ​Acute onset pain/burning
    • FBS
    • Excessive tearing
    • Blurred vision possible
    • Swollen lids
    • Photophobia
      • Red/white eyes possible
    • Blepharospasm
  • Initial evaluation
    • ​Type & form of chemical injury
    • Quantity
    • Concentration
    • Duration of exposure
    • How injury occurred
    • Determine if irrigation has occured
    • Determine pH of tears in cul-de-sac
    • Irrigate until neutral pH obtained
  • Examination
    • ​May need anesthetic to improve pt cooperation
    • VA - not unusual for pt to be HM/LP
    • Pupil testing
    • EOMs
    • Feel for crepitus
    • Slit lamp
      • ever lids to look for retained particles - esp in cases of explosions
      • look for vascular ischemia
    • NaFL staining
    • applanation tonometry
    • Dilated exam
    • Evaluate both eyes
  • Signs
    • ​Blurred vision
    • Chemosis
    • Blanching of vessels
    • Lacrimation
  • Complications​
    • ​Eyelids scarring - entropion, ectropion
    • Conjunctival scarring - symblepharon, ankyloblepharon
    • dry eyes
    • Corneal opacification/thinning/ulceration/perforation
    • Secondary glaucoma
      • 15-55% of severe chemical burns
    • Cataract
    • Pthisis bulbi
  • Treatment
    • ​Antibiotics - ointment or drop
    • Cycloplegic
    • Steroid
    • Lubrication
    • IOP management
    • Symblepharon ring
    • Other - alkali burns
      • ​Vit C / ascorbic acid drops or po
      • Doxycycline
      • Citrate drops
  • Examination
    • ​Ensure neutrality of ocular surface
      • Irrigate until obtain neutrality
    • Check VA
      • Likely to be reduced
      • May need anesthetic at this stage
    • Pupils/CVF/EOMs
    • Slit lamp exam
      • including staining
    • IOP
      • Goldman, tonopen, icare
    • Dilation
  • Surgical Tx
    • ​Epithelial debridement of necrotic tissue
    • Amniotic membrane transplant
    • Limbal stem cell transplant
    • Corneal transplant
    • Boston k-pro
    • Surgical correction of cicatricial changes
88
Q

Chemicaly injury - glue

A
  • glue
    • superglue
    • Nail glue
  • Injury occurs form dried particles of glue
  • Accidental from mistake for eye drops
  • Abuse
  • Sx
    • ​Inability to open lids
    • Watering
    • FBS
    • Often unilateral
  • Signs
    • ​Glue tarsorrhaphy
    • Conjunctival or corneal abrasion
  • Treatment
    • ​Rinse thoroughly before dries
    • Trim lashes
    • Acetone
    • Bland ointment
    • Removal w/ forceps
    • Treat ocular injury with lubrication, prophylactic antibiotics, NSAIDs/steroids, cycloplegic
89
Q

Thermal Burns

A
  • Rarely affect conjunctiva due to reflexive closure of the eye upon exposure
  • Causes
    • Fireworks explosions
    • Steam
    • Boiling water
    • Molten metals or plastics
    • Curling irons
  • Symptoms
    • ​Pain
    • Watering
    • Decreased VA
  • Signs
    • ​Conjunctival injection
    • Corneal abrasion/edema
    • Burns to skin of lids & adnexa
    • Cicatrical changes common
  • Treatment
    • ​As with other thermal injuries for external burns
    • Supportive
      • lubrication
      • Cool compresses
    • Analgesics
      • Oral NSAIDs
      • Cycloplegia
    • Prophylactic antibiotic therapy
      • Secondary infection common
    • Symblepharon prevention
    • Avoid rubbing

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