conjunctiva ocular disease Flashcards
What are concretions made of?
mucous, epithelial cells + calcium
do concretions cause symptoms? if so how do you resolve them?
usually asymptomatic
if bothersome or if stain remove
what is a conj nevus? What is diagnostic for a conj lesion?
benign proliferation of melanocytes
inclusion cysts within lesion are diagnostic
What is primary acquired melanosis? What does it look like?
precursor to malignant melanoma.
unilateral acquired pigmentation with indistinct margins
Why do conjunctival melanomas occur?
due to uncontrolled proliferation of melanocytes
From what do malignant conjunctival melanomas arise from?
primary acquired melanosis
What is the most common site of metastasis of conjunctival melanomas ?
liver
What is a conjunctival intraepithelial Neoplasia (CIN)?
unilateral premalignant condition that can progress to squamous cell carcinoma.
What is the most common conjunctival neoplasia? Risk?
conjunctival intraepithelial neoplasia
risk is low because basement membrane usually is intact
what are other names for CIN?
Bowen’s disease
conjunctival squamous dysplasia
What does conjunctival intraepithelial Neoplasia (CIN) look like?
elevated gelatinous mass with neovascularization
What does conjunctival intraepithelial Neoplasia (CIN) look like?
elevated gelatinous mass with neovascularization
toluidine Blue 0.05% stain usage
diagnostic tool to differentiate a benign lesion vs malignant/pre-malignant lesion
does not differentiate between pre-malignant and malignant conjunctival lesions
what does a pyogenic granuloma look like?
benign pedunculated (has a stalk) red vascular lesion
why do pyogenic granulomas occur?
trauma, sx, chalazion, or other forms of chronic irritation
what are conjunctival squamous cell carcinoma typically associated with?
UV light
HPV
From what is conjunctival squamous cell carcinoma derived from?
CIN
from what is conjunctival melanoma derived from?
PAM
from what is conjunctival melanoma derived from?
PAM
What is a conjunctival granuloma?
white/yellow/clear/brown lesion in the conjunctival stromal tissue.
what is a conjunctival granuloma caused by?
retrained foreign body (eyelash), surgery, trauma
how do you treat a conjunctival granuloma?
steroids
When do you see papillae ?
allergies
bacterial conjuntivitis
friction
How do you differentiate staph from other bacterias?
A + +
ie. catalase (+) and coagulase (+)
Who gets simple bacterial conjunctivitis?
kids>adults
what causes simple bacterial conjunctivitis?
Kids:
Haemophilus influenzae
adults:
S. Epidermidis
S aureus
What is the gram stain of Haemophilus influenzae
gram (-)
what are the symptoms of simple bacterial conjunctivitis?
sudden onset within the hour of redness that becomes bilateral.
FBS
eyelids stuck together when wake up
discharge (mod-severe)
- initially is serous then becomes mucopurulent
How do you treat simple bacterial conjunctivitis?
typically symptoms go away in 10-14 days without treatment
it is contagious so want to rx polytrim
What organism is the most frequent cause of bacterial conjunctivitis world wide in all ages?
S aureus
When do you use chocolate agar and what is their gram stains?
think nestle and Hershey
N. gonorrhea -> gram (-) diplococci
H. influenzae -> gram (-)
What are the most dangerous bugs for your epithelium ie. what bugs don’t need an epithelial defect to enter?
CANADIAN NATIONAL HOCKEY LEAGUE
1. corneum bacterium
2. N. gonorrhea
3. H. influenzae
4. listeria
what is another name for chocolate agar?
thayer- Martin agar
how is gonococcal conjunctivitis transmitted?
STD
or via vaginal birth canal during birth
What are symptoms of gonococcal conjunctivitis ?
minute is began (hyper acute) severe purulent discharge
- think “ gonorrhea -> diarrhea -> peeing pus (wipe and back again)
swollen conj, nodes, eyelids
can have a pseudomembrane
papillae
How do you treat gonococcal conjunctivitis ?
gram (-)
- ceftriaxone (3rd generation more gram (-) than cephalexin which is 1st gen)
What else do you need to test for if a patient has gonorrhea?
chlamdiyan systemic infection
What is the only bacteria that causes findings associated with viral conjunctivitis ie. PAL + pseudomembrane?
gonorrhea
What causes EKC?
serotype B adenovirus
What are the symptoms/ signs of EKC. How long do these last and what do they indicate?
pain! due to corneal involvement! ( only form of adenovirus that has corneal involvement)
PAL
diffuse red eye + follicle+ pseudomembrane ( not always have to be there)
Cornea: diffuse superficial keratitis initially (decreased vision) -> Infiltrates - once seen indicate that condition is no longer contagious
caused by serotype 8, Symptoms start 8 days after initial exposure and after 8 more days get SEI
ie. meat you are contagious for upto 16 days
Do you see follicles or papillae in viral conjunctivitis?
follicles
How many serotypes does adenovirus have? What are the different conditions caused by adenovirus ? What is special about each form?
15 different serotypes and can manifest as 3 different conditions.
1. acute non-specific (more common classic form)
2. EKC (NODES swollen)
3. PCF ( think 3 F’s)
What are the conditions where you see follicles?
CHAT
c- chlamydial (inclusion cyst and trachoma)
h - herpes (simplex and zoster)
a - Adeno ( EKC, PCF, acute non-spec)
T - toxic (molluscum , eye drops/cls solution causing allergic conjunctivits that has follicles )
Who is the classic adenoviral conjunctivitis patient ?
40 year old + diffuse pink eye + follicles
what causes adenoviral conjunctivitis?
upper respiratory tract/ nasal mucosal infections.
ie. patient is usually sick prior to ocular involvement
What are all 3 adenoviral syndromes associated with?
sick prior
follicles
pseudomembrane ( may not always be there)
diffuse conj redness
acute non-specific symptoms/ signs
sick prior + follicles + diffuse redness
tearing NOT muscus
mild discomfort (feels hot)
What is PCF? who does it affect?
“swimming pool conjunctivitis”
VERY CONTAGIOUS
affects mostly kids, but it is rare.
What are the symptoms/signs of PCF?
3 F’s
F-fever - low grade
F-follicles
pharyngitis -> sore throat
viral and bacterial conjunctivitis stats in adults and kids
kids - usually see bacterial conjunctivitis, rarely viral
adults - usually see viral conjunctivitis, rarely bacterial
what form of adenovirus will always have PAL?
EKC
What is a pseudomembrane?
located in the inferior conj and contains active virus
this is why we need to peel it.
follicles vs papillae
papillae - allergy, follicles, non-specific (ie. friction)
- fiction -> GPC, floppy eyelid
- have a central vessel
follicles - avascular
Who is the classic molluscum contagiousum patient?
this is rare condition that occurs in communities with poor hygiene Ie. kids and young adults
what causes molluscum contagiousum and how is it transmitted?
DNA pox virus
and is spread through direct contact
What does it mean if you see multiple lesions of molluscum contagiousum? What testing should you do?
check for HIV or other immune deficiency
- ie. CD4 < 200 aids, 50 cmv
- do an Eliza/ western blot
what are the sings/symptoms of molluscum contagiousum?
dome shaped waxy nodule located on lid/lid margin
possible watery discharge
Why should you worry if the molluscum contagiousum lesion ruptures?
if ruptures can enter fornix, palpebral conj and cause follicles
- this is the Toxic in CHAT
What are conditions that cause unilateral follicular conjunctivitis with watery discharge ?
molluscum contagiousum
herpes simplex
What are the different allergic disorders of the conj?
- allergic conjunctivitis - type 1 hypersensitivity
- vernal keratoconjunctivits ( VKC)
- atopic keratoconjunctivits ( AKC) - type 1 and 4
- giant papillary conjunctivitis (GPC)
Who is the classic VKC patient ?
8 year old boy who has asthma with itchy eyes every spring
What is VKC?
seasonal outbreaks during warm months in patients with atopic systemic conditions ( ie. asthma, rhinitis, eczema)
What are signs/symptoms of VKC?
bilateral
huge cobblestone papillae superiorly
trantas dots
corneal involvement
itchy eyes, photophobia, mucous discharge
Symptoms decrease over time.
what are trantas dots?
papillae at the limbus
What are you worried about in patients with VKC?
shield ulcer formation caused by PEK -> large erosion -> shield ulcer
What is unique about VKC vs AKC?
VKS signs are predominantly in the conj and cornea. Eyelid skin and margins are not affected
Who is the Classic AKC patient ?
20-40 year old with atopic dermatitis
NOTE: no asthma nor seasonal allergies
What are AKC and VKC patients at risk for?
keratoconus due to eye rubbing
What are the signs/symptoms of AKC?
Com-location-has?
microscopic papillae inferiorly
CONSTANT eye rubbing -> leads to patients loosing normal oil -> fissures in outer lids-> Dennie’s line
—-> keratoconus / cataracts
can be associated with pain + allergy symptoms
swollen/scaly outer eyelid
periorbital edema
Dennie’s line
atopy shiners
may see symblepharon
What is AKC?
a skin infection that gets into patient’s eyes
what is atopic dermatitis?
chronic eczema since birth
what is pruritis ?
itching
What is Dennie’s line?
extra crease under the lower lid due to periorbital edema
What is atopy shiners?
bags under eyes due to constant rubbing
What causes GPC?
friction of lens rubbing
- ie. silicone hydrogel cls - more rigid than normal cls
- extended wear cls
immune response to protein on cls
sutures
blebs
buckles
ocular prosthetics
cls risk factors for GPC?
switch to silicone hydrogel cls
high water-ionic lenses
extended wear
higher modulus of elasticity
poor replacement
signs / symptoms of GPC
allergy symptoms +
mucous discharge
- early it is little than later becomes ropy
- symptoms are worse after removing cls
-mild to severe papillae superiorly (giant papillae = coalesce after prolonged inflammation)
What medication causes SPK?
tobra - gen 30
Why does corneal Neo occur in cls? What should you look for? When is Neo really concerning ?
chronic hypoxia -> neo
look for superior pannus( NOTE : if corneal Neo> 1.5 mm = abnormal/concerning)
Why does corneal warpage occur with cls? What do patients complain of?
due to the alteration on corneal shape as a result of long term PMMA wearers/ GP lenses that ride too high!, poorly fitting contacts
patients say that vision is clearer in cls than glasses. ghost image/diplopia
what does SLK occur?
friction
1. cls
2. TED
3. dry eyes ie. KCS - due to dryness b.w bulbar conj and upper eyelid (natural turnover cycle of cells does not occur)
what are signs and symptoms of SLK ? What clinical technique should you do if you suspect SLK? what is unique about SLK caused by cls?
symptoms usually worse than the signs
superior injection, FBS -> blink a lot, no discharge
usually bilateral thick red superior bulbar conj, SPK and filamentary keratitis (stains) all superior, papillae superiorly
Have patient load down and lift lid to see
use lissamine green dye to check for staining
what do deposits on GP lenses vs soft cls look like?
GP lenses - plaques
soft cls - jelly bumps
what does it mean if deposits are only seen on the back surface of cls lens?
the patient is digitally cleaning incorrectly
should use finger and palm
what is tight lens syndrome? who is it seen in ? what are the symptoms?
when a lens is too tight and so get poor movement with blink
- more commonly seen in high myopes (> -8.00 D) , cls are too steep
redness that worsens after cls removal , indentation or redness around limbus
distorted keratometry miers that clears with blinking
why do we see 3 and 9’o clock staining? what complication can occur as result of this?
complication of GP cls that ride too low
dellen formation can occur (see image)
What is SEAL (superior epithelial Arcuate Lesion) and why does it occur?
This superior corneal staining in the shape of an arcuate,
mostly cccurs due to tight extended wear hydrogel cls.
what is dimple veiling and why does it occur?
depressions in the cornea that pool NaFl
caused by small gas bubbles that get trapped under a cls - usually GP
what is keratoconjunctivitis?
simultaneous inflammation of the cornea and conjunctiva
What is the most common sexually transmitted disease?
Chlamydia
What are the 2 presentations of an ocular chlamydial infection?
trachoma
adult inclusion conjunctivitis
Who gets adult inclusion conjunctivitis?
25 year old
what serotypes cause adult inclusion conjunctivitis?
D -> K
what are the symptoms of adult inclusion conjunctivitis?
chronic unilateral red eye >3months ( usually OD because most patient’s are right handed)
huge follicles inferiorly + a little papillae inferiorly= mixed rxn
PAL
sub epithelial infiltrates around the cornea peripherally
pain during urination
what are the symptoms of trachoma?
bilateral
superior follicles leading to art’s line and Herbert’s pits (follicles at the limbus)
arlt’s line and Herbert’s pits are scars from follicles
mild superior pane
mucopuulent discharge
PAL
who gets trachoma?
3rd world countries, can be spread by house flies/ directly from eye to eye/ fomites
what serotypes cause trachoma?
serotype A-C
how is adult inclusion conjunctivitis transmitted?
direct touching eye
treatment for adult inclusion conjunctivitis?
azithromycin
doxy
What is ophthalmia neonatorum? what is it caused by?
acute conjunctivitis in newborns
most commonly caused by chlamydia
what is arlt’s lines ?
white scarring on the superior conj - can have multiple
what are Herbert’s pits?
depression on the gimbal conj after resolution
What conditions is PAL associated with?
P C PEG
P- parinaud’s oculoglandular syndrome
C- chlamydia
P-phthiriasis palprebrarum
E- EKC
G - gonorrhea
What are the causes of parinaud’s oculoglandular syndrome?
- cat scratch fever - most common “think paranoid of cats” —-> cat scratches one eye/ cat flea bites
- tularemia –> via ticks, rabbits, squirrels
- TB and syphilius
How do you treat trachoma?
doxy and azithro
Who gets phlyctenular keratoconjunctivits? What are the symptoms and signs?
16 year old F
FBS and itching + phylectenules on conj/cornea, photophobia
What causes phlyctenular keratoconjunctivits?
type 4 hypersensitivity to STAPH ie. blepaharits! number one cause
in 3rd world countries, number 1 cause is TB
can also be caused ny acne rosacea
what are phlyctenules?
White lymphocytes that can be located on the conj or cornea
- always close to the limbus
how do you treat phlyctenular keratoconjunctivits?
cornea and lids need to be treated with azisite, bacitracin
What is a PPD test?
This is a skin test for TB. Needed to be read within 48-72 hours.
What is ligneous Conjunctivitis?
eye manifestation of a systemic disorder ie. systemic plasminogen deficiency resulting in a “woody” plaque of the superior tarsal plate.
specifically affects the mucous membranes or the body
What is plasminogen?
catalyzes the breakdown of fibrin (makes the mesh that holds the platelet plug) which results in stopping an unwanted clot from forming in healthy vessels
what are signs of Parinaud’s oculoglandular syndrome?
unilateral granulomatous conjunctivitis + follicles + PAL
what causes phthiriasis palpebrarum? what are the signs? what are symptoms? How is it transmismitted?
occurs from phthirus pubis (crab from hair follicles in gentian region.
you see transparent lice and eggs attached to lashes. + blood tinged debri on lids and lashes + follicles + PAL
symptoms- burning itching tearing etc.
transmitted via direct contact of infected people or clothing
What conditions make the T in CHAT?
- phthiriasis palpebrarum
- Parinaud’s oculoglandular syndrome
- molluscum
- eye drops/cls solution causing allergic conjunctivits that has follicles
What causes a pterygium and pingueculum?
UV light
what is a pinguecula?
raised deposit next to the limbs. Does not go onto the cornea
what is a pterygium? What are its implications?
growth of bulbar conj onto the cornea causing the destruction of Bowman’s membrane. Leads to WTF astigmatism due to flattening of the horizontal meridian.
what is stocker’s line?
this is iron deposit that may be present ant the leading edge of a pterygium.
What conditions affect Bowmans?
keratoconus
Band K
Reis Buckler
Pterygium
