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
2
Q
List the Conjunctival Reaction
A
- Hyperemia
- Hemorrhages
- Chemosis
- Membranes
- Infiltration
- Subconjunctival Scarring
- Follicles
- Papillae
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
-
Trauma/Irritation
4
Q
Hemorrhages
A
- Escape of blood from vessels
- Causes
- Trauma
- Infection
- Viral
- Bacterial - infrequent
5
Q
Petechial hemorrhages
A
- Pinpoint hemorrhaging from capillaries (allergies & rubbing)
- Causes
- Prolonged straining
- Medical conditions
- Medications
- Trauma
- Can be result of asphyxiation
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
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
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
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
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
11
Q
Papillae
A
- Occur on palpebral conjunctiva & limbal bulbar conjunctiva
- Nodule with fibrovascular core
- Appearance depends on location
- Tarsal - flattented
- Limbal - dome-shaped
12
Q
List the conjunctival degenerations
A
- Pinguecula
- Pterygium
- Concretions
- Conjunctivochalasis
- Retention cyst (epithelial inclusion cyst)
13
Q
Conjunctival degeneration
A
- Decomposition & deterioration of the tissue elements & functions
- Age-related
- Disease-specific
- Chronic environmental exposures
- Unilateral or bilateral
- Asymmetric
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
-
yellow/white elevation on bulbar conjunctiva
-
Symptoms
- Cosmesis
- FBS
- Tearing
- DES
-
Treatment
- None
- Lubrication - ATs, gels
- UV protection
- Surgical excision
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
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
- Excision - 50% recurrence rate
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
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
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
20
Q
List the vascular disorders of the eye
A
- Subconjunctival hemorrhage
- Conjunctival hemangioma
- Pyogenic granuloma
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)
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
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
-
Trauma
-
Treatment
- Steroids
- Excision
24
Q
List the Non-malignant tumors
A
- Conjunctival nevus
- Racial melanosis
- Choriostoma
- Dermolipoma
- Osseous choristoma
- Papilloma
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
-
Discrete, slightly elevated, pigmented lesion on bulbar conjunctiva
-
Types
- Junctional
- Subepithelial
- Compound/combined
- Blue
- Congenital melanocytosis
-
Tx
- None - periodic observation or photo documentation
- Excision for cosmesis
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
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
28
Q
Papilloma
A
- Benign sqamous epithelial tumors
-
Classification
-
Pedunculated
- infectious
- squamous cell
- Sessile - limbal
- Mucoepidermoid - inverted
-
Pedunculated
-
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
29
Q
List the malignant tumors
A
- Squamous carcinoma
- Lymphoma
- Kaposi sarcoma
- Primary acquired melanosis
- Melanoma
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
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
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
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
- Irregular, flat pigmented patches
-
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
-
Small lesions (1-2 clock hours)
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
-
Nodular or diffuse
-
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
35
Q
Comparison of pigmented conjunctival lesions
A
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
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
- Occurs 24-72 after re-exposure
- 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
A
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
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
-
Palpebral
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
-
Eyelid
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
-
Limbal - first attack - single or multiple pinkish-white nodules adjacent to area of conjunctival hyperemia
-
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
-
Thorough history
-
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
-
Hospitalization
-
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)
-
Conjunctiva
-
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
-
Careful examination of upper tarsal & bulbar conjunctiva
-
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)
-
Thyroid function testing in pts without documented thyroid dysfunctions ***
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
-
Rarely necessary
-
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
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
-
Ocular
-
Signs
-
Follicular conjunctivitis - often bilateral
- starts unilateral & spreads to 2nd eye in 1-3 days
- Copious serious discharge
- Lid edema
- Hyperemia
- Chemosis
-
Follicular conjunctivitis - often bilateral
-
Tx
- Non-self-limiting
- Supportive therapy
- Artificial tears
- Cool compresses
- Analgesics/antihistamines
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
86
Q
Common caustic agents & source of alkali & acid injury
A
