Conjunctiva: Degenerations

Question 1

Describe what a conjunctival degeneration is and the 4 types?

Answer 1

• Deleterious tissue changes w/ time
  o As normal tissue ages, there is a breakdown of material & loss of overall mass of tissue
• Loss of tissue mass or acellular material
• Wide variety of disease processes
  o Vascular
  o Normal aging
  o Trauma (chronic, low grade)
• Dystrophies
  o Bilateral symmetrical inherited conditions that have no environmental relationship
• Pinguecula
• Pterygium
• Conjunctivochalasis
• Concretions

Question 2

Describe pinguecula?

Answer 2

• Small, yellowish/grey nodule
• Nasal or temporal to limbus
• Vascularised or injected
• Degeneration of collagen within stroma of conjunctiva
• As a result of prolonged sun exposure & increasing age
• No tx necessary
• Document that px has it but no referral necessary

Question 3

Describe pterygium?

Answer 3

• Similar to pinguecula, similar process – breakdown of the collagen within stroma of conj, occur in similar location, similar history (UV exposure), similar histological appearance
• Encroaches onto cornea in “wing-like” fashion
• Can become inflamed & irritated
• Can encroach visual axis:
  o Corneal astigmatism
  o Corneal scarring
• Invade Bowman’s layer

Question 4

Describe treatment for pterygium?

Answer 4

o Vast majority don’t need anything done – if incidental finding then do not refer
o Only consider referral if you feel they need surgical excision
o Lubrication
 Artificial tears for mild dry eye
o Mild topical steroid – if it is intermittently inflamed
o Surgical excision – if documented that it is increasing in size & encroaching onto visual axis & as a result is affecting px’s vision or if it’s known to be inducing significant astigmatism (which is also affecting px’s vision)
o Pterygium can induce scarring in underlying stroma – so don’t want to wait until pterygium has encroached over visual axis because if were then to remove it, will be left with scarring underneath which could affect eyesight
o If it is recurrently inflamed & causing px pain – consider surgical excision
o Risk of recurrence – if pterygium regrows even 5-10 yrs later, surgical removal for 2nd time is more difficult, can be more inflamed & carries risk
 Would only want to do surgical removal if it was only absolutely necessary
o Conjunctival Autograft – small amount of conj from bulbar conj (underneath eyelid) in same eye, once removed pterygium – then fill gap with conjunctival graft  reduces amount of inflammation & reduces risk of recurrence
 Either suture it down or use Fibrin Glue
 Heals well

Question 5

Describe conjunctivochalasis?

Answer 5

• Age related degenerative change
• Excess folds of conj
• V common
• Seen in older pxs
• Can cause problems if not diagnosed
• Occurs in inferior fornix
  o Conjunctiva from tarsal & bulbar conj have been rubbing against each other entire life & as collagen breaks down can get excessive folds
• May not cause any problems but if the excessive folds then start to ride up over lid margin – can cause tear film disruption & can cause discomfort
• May be asymptomatic
• Px symptoms can be a lot worse than clinical appearance may suggest
• May complain of:
  o Irritation
  o Epiphora
  o Dry eye
• Symptomatic treatment: lubricants for dry eye, if excessive & isn’t resolved can surgically excise the excess conjunctiva
  o Can cause quite lot of bleeding, inflammation

Question 6

Describe Concretions?

Answer 6

• Sign of chronic meibomian gland dysfunction
• Symptoms of blepharitis
• Multiple small yellow deposits on inferior tarsal conjunctiva
• No tx necessary – don’t refer px