Conjunctiva Pathologies Flashcards
Pinguecula: Aetiology (5)
Benign degenerative lesion on the conjunctiva
Horizontally situated at the limbus
Degeneration of collagen fibres in the stroma of the conjunctiva
Overlying epithelium thins
Can occasionally calcify
Pinguecula: Predisposing Factors (4)
Age - especially 70+
Long term UV exposure (surfers eye, outdoor work & occupational exposure)
Male
Chronic irritation from wind and dust
Pinguecula: Signs (7)
Off-white raised area of conjunctival thickening
Adjacent to limbus
Limited to palpebral aperture at 3&9 o’clock positions
Usually bilateral
Can become inflamed - surrounding conjunctiva can be more hyperaemic
Lid vaulting can cause dellen at adjacent corneal margin
Reduced TBUT
Pinguecula: Symptoms (4)
Asymptomatic
Cosmetically concerning
Foreign body sensation
CL intolerance
Pinguecula: Grading (3)
Grade 0 = no pinguecula
Grade 1 = mild/moderate - yellow/white flat or slightly raised and no bigger than 5mm
Grade 2 = severe - highly vascularised & elevated or larger than 5mm
Pinguecula: Differential diagnosis (3)
Pterygium
Squamous neoplasia
Epithelial inclusion cyst
Pinguecula: Management (3)
UV protection - close fit sunnies & wide brim hat
Reassurance
Cold compress if inflamed (IP optoms can prescribe topical steroids to reduce this short term)
Pinguecula: Referral (2)
Routine
Removal rarely required - mostly cosmetic reasons
Pinguecula: Contact Lens Implications (2)
Ensure CL edge does not aggravate lesion (consider smaller or larger diameter)
Consider ocular lubricants
Pterygia: Aetiology (2)
Thick fibrovascular growth from bulbar conjunctiva
Likely from chronic irritation
Pterygia: Predisposing factors (4)
Advancing age
Male
Prolonged UV exposure
Dry environment
Pterygia: Signs (8)
Bilateral
Usually located nasally
Slow growth onto cornea (can cease progression)
Disruption of Bowman’s and stromal layers
Neovascularisation overlying
Corneal flattening along horizontal meridian
May intrude visual axis and cover pupil
In advance cases, iron deposits can be seen
Pterygia: Symptoms (6)
Asymptomatic
Cosmetically concerning
Mild irritation
With the rule astigmatism changes
Visual blur as it encroaches visual axis
Contact lens intolerance
Pterygia: Grading (3)
Measure lesion encroaching cornea in mm
Always note changes
Use Efron grading 0-4 to show any inflammation
Pterygia: Differential diagnosis (2)
Squamous neoplasia
Pannus - flat focal opacification caused by superficial vascular invasion of the cornea
Pterygia: Management (4)
UV protection; Close fitting sunglasses & wide brim hat
UV protection cL may offer some protection
Cold compress if inflamed (IP can offer topical steroids to reduce inflammation short term)
Ocular lubricants (day drops & night gel)
Pterygia: Referral (5)
Routine
If threatens visual axis
Induced irregular astigmatism (not 90 to one another)
Regular incidence of inflammation
Cosmetically concerning
Pterygia: Contact Lens Implications (2)
Comsider smaller or larger diameter to ensure edge does not aggravate
Ocular lubricants to support wear
Sub Conjunctival Haemorrhage: Aetiology (3)
Usually spontaneous
Valsalva manoeuvre causing sudden increase in blood pressure. Eg sneezing, straining and child birth
Following eye surgery or trauma
Sub Conjunctival Haemorrhage: Predisposing Factors (7)
Hypertension
Advance age
Medication such as blood thinners or topical steroids
Excessive eye rubbing
Recent trauma
Blood clotting issues
Previous history of subconj haems
Sub Conjunctival Haemorrhage: Signs (5)
Bright red eye
Usually sectoral and inferior
Blood beneath conjunctiva
Limited to fornix border (able to see white around fornix if patient looks up/down and lid is moved) IF NOT consider retrobulbar haemorrhage
Usually unilateral
Sub Conjunctival Haemorrhage: Symptoms (3)
Asymptomatic
Cosmetically concerning
Can experience bruised sensation but no pain
Sub Conjunctival Haemorrhage: Grading (4)
Record position and extent (diagram is good)
Specifically note is white posterior border at fornix can be seen
Record timeline of incident and previous occurrences
Any verbal advise given MUST be noted
Sub Conjunctival Haemorrhage: Differential Diagnosis (3)
Retrobulbar/intra cranial haemorrhage
Conjunctival squamous neoplasms
Trauma
Sub Conjunctival Haemorrhage: Management (3)
Reassurance - usually clears in a week like a bruise
Cold compress
Patient to return is reoccurs or does not resolve
Sub Conjunctival Haemorrhage: Referral (3)
Routine
GP to measure blood pressure if reoccurs
GP to review medication if on blood thinners
Sub Conjunctival Haemorrhage: Contact Lens Implications (2)
None
Poor removal technique could cause haemorrhage
Allergic Seasonal Conjunctiva: Aetiology (3)
Allergens cause hypersensitivity
- mast cells release histamines causing inflammatory reaction
Conjunctival injection
Oedema caused by increased permeability of blood vessels
Allergic Seasonal Conjunctiva: Predisposing Factors (5)
Allergy to seasonal allergens (grass pollen, trees and flowers) - more severe
Allergy to perennial allergens (house dust, mites and animal hair) - less severe
1/3 of population have atopic disposition
Family history of allergy
Known exposure to allergens
Allergic Seasonal Conjunctiva: Signs (8)
Bilateral red injected eyes
Papillae in palpebral conjunctiva with lid eversion
Watery
Mild to moderate oedema of lids
Oedema of bulbar conjunctiva
Sneezing and watery eyes may present
Time course will suggest if seasonal, perennial or acute
No corneal involvement
Allergic Seasonal Conjunctiva: Symptoms (3)
Itchy
Gritty
Strand-like watery discharge
Allergic Seasonal Conjunctiva: Grading (1)
Use Efron grading scale for redness and papillary conjunctivitis
Allergic Seasonal Conjunctiva: Differential Diagnosis (2)
Acute allergic reactions
Contact lens associated papillary conjunctivitis (CLAPC)
Allergic Seasonal Conjunctiva: Management (3)
Advice on allergens and avoidance
Cold compress for comfort
Do not rub eyes as more histamine releases
Allergic Seasonal Conjunctiva: Referral (3)
Routine
Pharmacist can advise on systemic antihistamines
Written prescription for topical mast cell stabilisers (sodium cromoglicate)
Bacterial Conjunctiva: Aetiology (1)
Bacterial infection of conjunctiva
- self limiting (resolves in 5-7 days without treatment)
Bacterial Conjunctiva: Common Pathogens (4)
Straphylococcus
Streptococcus
Haemophilus influenza
Moraxella catarrhalis
Bacterial Conjunctiva: Predisposing Factors (6)
Poor hygiene & close contact environments
Contact lens wear
Diabetics
Steroid use
Blepharitis
Contamination of eye products
Bacterial Conjunctiva: Signs (5)
Mucopurulent discharge - if absent look in fornix under slit lamp
Crusted lids especially on waking
Conjunctiva hyperaemia
Mild papillary response on palpebral conjunctiva
Unlikely to involve cornea
Bacterial Conjunctiva: Symptoms (3)
Gritty sensation
Sometimes burning feeling but not painful
Discharge can blur vision
Bacterial Conjunctiva: Grading (4)
Use Efron to grade conjunctival injection
Note type and quantity of discharge
Note onset and duration
Note corneal clarity
Bacterial Conjunctiva: Differential Diagnosis (2)
Exclude other forms of conjunctivitis
- No follicles (viral)
- No corneal involvement (viral)
- Not particularly itchy (allergic)
- Excessive discharge and very acute onset (gonococcal)
Exclude other red eye challenges:
- Not photophobia (uveitis)
- No pain (keratitis)
- Normal IOPs (angle closure glaucoma)
Bacterial Conjunctiva: Management (4)
Clean cotton pads to clean lids (separate wipes each eye, dispose of carefully and wash hands)
Advise contagious, no sharing towels but kids can attend school
Advise usually resolves in 5-7 days
Cease contact lens wear
Bacterial Conjunctiva: Referral (2)
Reviewed in 1 weeks, if not improved then refer for topical antibiotics
Infants under 1 month should be an emergency referral
Bacterial Conjunctiva: Contact Lens Implications (4)
Cease contact lens wear
Dispose of lenses, storage cases and any cosmetics
Wait until resolves before wearing lenses
Return at 1 week if not better, should be reviewed at 1 week
Viral Conjunctivitis: Aetiology (4)
Viral infection of conjunctiva
Self limiting
Often resolves between 7-21 days without treatment
Adenovirus is the most common pathogen
Viral Conjunctivitis: Predisposing Factors (3)
Preceding flu-like/respiratory symptoms
Hygiene
Crowded. close contact environments
Viral Conjunctivitis: Signs (6)
Serous discharge
Conjunctival injection and hyperaemia
Dot subconjunctival haemorrhages
Follicles on palpebral conjunctiva
Sometimes corneal involvement:
- diffuse punctate lesions
- sub-epithelial infiltrative lesions
Dendritic ulcer if herpetic - urgent referral for anti-viral (usually unilateral)
Viral Conjunctivitis: Symptoms (3)
Discomfort - burning or grittiness
Watery eyes
Photophobia if corneal involvement
Viral Conjunctivitis: Grading (4)
Grade conjunctival injection using Efron
Type and quantity of discharge
Note onset and duration
Note corneal clarity
- painful lesions should be observed again 24hrs later
Viral Conjunctivitis: Differential Diagnosis (5)
Exclude other forms of conjunctivitis
- No follicles (viral)
- No corneal involvement (viral)
- Not particularly itchy (allergic)
- Excessive discharge and very acute onset (gonococcal)
Exclude other red eye challenges:
- Not photophobia (uveitis)
- No pain (keratitis)
- Normal IOPs (angle closure glaucoma)
Main exclusion is corneal involvement and dendritic ulcer
Viral Conjunctivitis: Management (6)
Thorough hygiene before and after appointment
Self limiting over 1-2 weeks
High contagious - do not share towels
Cold compress for comfort
Discontinue contact lens wear
Review again soon if corneal involvement, pain and photophobia
Viral Conjunctivitis: Referral (3)
Very little can be done
antibiotics and antivirals ineffective
Steroids can be offered in special cases
Viral Conjunctivitis: Contact Lens Implications (4)
Cease contact lens wear
Dispose of contact lenses, storage and eye products
Wait until resolves before continuing contact lens wear
Return if no improvement in 1 week
Fungal Conjunctivitis: Aetiology (4)
Aggressive infection
Slow onset
Unlikely to self resolve
Commonly affects cornea
Fungal Conjunctivitis: Common Pathogens (3)
Candida (yeast)
Fusarium (rapid onset)
Aspergillus
Fungal Conjunctivitis: Predisposing Factors (6)
Contact lens wear
Ineffective solutions
Poor hygiene
Trauma involving organic material (gardeners/grounds keepers)
Immunocompromised patients
Complications with ocular surface
Fungal Conjunctivitis: Signs (5)
Mucus discharge
Epiphora
Intense conjunctival injection and hyperaemia
Corneal lesions
Anterior chamber involvement, flare and in severe cases hypopyon
Fungal Conjunctivitis: Symptoms (4)
Pain - moderate to severe
Intense photophobia
Unilateral
Blurred vision
Fungal Conjunctivitis: Grading (4)
Use Efron to grade conjunctival injection
Note type and quantity of discharge
Note onset and duration
Note any trauma prior
Fungal Conjunctivitis: Differential Diagnosis (2)
Any history of organic matter - treat as fungal
Corneal involvement more likely to be fungal than bacterial
Fungal Conjunctivitis: Referral (4)
Emergency - same day
Call HES ahead to inform
Take contact lenses and case with to hospital (not wearing)
Emphasis importance of attending appointment (sight threatening)
Fungal Conjunctivitis: Contact Lens Implications (2)
Cease contact lens wear
Return for contact lens reassessment after hospital treatment complete
CL Associated Papillary Conjunctivitis (CLAPC): Aetiology (5)
Papillary inflammation response from contact lenses
Multifactorial aetiology:
- proteins on lens
- exotoxins of bacteria on lens
- Aggravation and release of histamine
CL Associated Papillary Conjunctivitis (CLAPC): Predisposing Factors (6)
Soft contact lenses (esp silicon hydrogel)
Lens deposits
Poor lens edge design
High modulus
Atopic history
MGD
CL Associated Papillary Conjunctivitis (CLAPC): Signs (8)
Papillae on tarsal conjunctiva (location where lens would be)
Giant papillae GPC .1mm
String like mucus
Poor lens position
Discharge on lens causing blurred vision
Superior limbic keratoconjunctivitis SLK may be present
Superior epithelial arcuate lesion SEAL may be present
Diffuse bulbar conjunctival hyperaemia
CL Associated Papillary Conjunctivitis (CLAPC): Symptoms (5)
Itching and irritation
Lens intolerance
Decreased comfort and wear time
Symptoms can worsen on kens removal (acts like a bandage)
Visual blur
CL Associated Papillary Conjunctivitis (CLAPC): Grading (3)
Grade conjunctival redness and papillary conjunctivitis using Efron
Neovascularisation
Staining, especially superior corneo-limbal
CL Associated Papillary Conjunctivitis (CLAPC): Differential Diagnosis (3)
Contact lens induced allergy responses (removal/break from lenses will cause improvement)
Other allergic conjunctivitis
Likely to occur following a change to lens or solution
CL Associated Papillary Conjunctivitis (CLAPC): Management (5)
Consider ceasing contact lens wear and reviewing in 1 week
Discomfort will get worse initially and then improve - reassure
Refit to a new lens
- lower modulus
- More frequent replacement
- Rub and rinse solutions
- Review lens hygiene
Lubricants
Sodium cromoglicate (mast cell stabiliser) can be recommended to reduce response
CL Associated Papillary Conjunctivitis (CLAPC): Referral (1)
Routine referral for cases that do not resolve for steroid treatment
CL Associated Papillary Conjunctivitis (CLAPC): Contact Lens Implications (1)
Refit and management is necessary due to the lenses being the cause
Conjunctival Lithiasis (concretions): Aetiology (3)
Build up of keratin type debris
Associated with conjunctival inclusion cysts
May push through epithelium leading to foreign body sensation
Conjunctival Lithiasis (concretions): Predisposing Factors. (4)
Age - especially 60+
Prevalence is about 40%
Reoccurring or long standing conjunctivitis
Historical chalazion causing lipid accumulation
Conjunctival Lithiasis (concretions): Signs (3)
Off white/yellow granular deposits with defined edges in palpebral/tarsal conjunctiva
Can be one single deposit (small or large in size)
Can be several less than 1mm in size
Conjunctival Lithiasis (concretions): Symptoms (3)
Usually asymptomatic
Cosmetically noticed
In severe cases. foreign body sensation
Conjunctival Lithiasis (concretions): Differential Diagnosis (1)
Follicles
Conjunctival Lithiasis (concretions): Referral (1)
Refer only for removal
Conjunctival Lithiasis (concretions): Contact Lens Implications (1)
None
predisposing factor is longstanding conjunctivitis - implications there
Conjunctival Pigmented Lesion: Aetiology (5)
Can be malignant or benign
Hypermelanosis (benign) is common in those with darker skin
Naevi (benign) usually congenital but can be acquired
Melanoma
- feeder vessels
- raised
- uneven borders
- necrosis
Conjunctival Pigmented Lesion: Predisposing Factors (4)
Darker skin ethnicity
Caucasian and older age (acquired melanosis)
Melanoma most likely with fair skin and blue eyes
Melanoma presents 50+
Conjunctival Pigmented Lesion (Ethnic Hypermelanosis): Signs (5)
Flat
Moves over sclera freely
Patchy brown
Commonly near limbus
Likely bilateral but asymmetric
Conjunctival Pigmented Lesion (Naevus): Signs (6)
Single lesion with well marked borders
Can be raised
Moves freely over sclera
Close to limbus but never over cornea
Not vascularised or inflamed
Brown to pink in colour (can be faint)
Conjunctival Pigmented Lesion (Melanoma): Signs (5)
Any raised pigment lesion should be considered melanoma
Vascularised mass with feeder vessels
Fixed to sclera and unmoving
About 20% of cases can be unpigmented
Grows in size
Conjunctival Pigmented Lesion: Symptoms (2)
Asymptomatic
Cosmetic concern
Conjunctival Pigmented Lesion: Management (2)
Reassure if confident in diagnosis
Monitor
- take photos
- review in 3-6 months if unsure
Conjunctival Pigmented Lesion: Referral (1)
Urgent if meets criteria of melanoma (within 1-2 weeks)
Conjunctival Pigmented Lesion: Contact Lens Implications (1)
None
Papillae (7)
Allergy response
Inflammatory cells under epithelium
Almost always bilateral
Central vascular tufts see at centre of swellings
Found in tarsal area
Flat top elevations
Variable in size depending on severity
Follicles (5)
Due to viral response
Lymphocytes and plasma cells are present
Commonly unilateral at first
Swellings 0.5-2mm encircled with vessels
Common in fornices and palpebral areas
