conjunctival disorder - waldron

Question 1

what are pinguecula and pterygium

Answer 1

benign growths of the conjunctiva that can result from chronic actinic irritation
both typically appear adjacent to cornea at 3, 9 oclock or both

Question 2

what is Pinguecula

Answer 2

raised yellowish white mass within the bulbar conjunctiva, adjacent to the cornea
dose not tend to grow onto cornea
may cause irritation or cosmetic blemish
treatment rarely necessary - can easily be removed

Question 3

what is a Pterygium

Answer 3

fleshy triangular growth of bulbar conjunctiva that may spread across and distort the cornea, induce astigmatism, change refractive power of eye
symptoms: decreased vision and foreign body sensation
more common in sunny, hot, dry climates

Question 4

what is the treatment of Pterygium

Answer 4

symptomatic relief: artificial tears or short period of treatment with corticosteroid drops/ointments
removal indicated for documented growth, cosmetic concerns, to reduce irritation to improve or preserve vision- surgical removal

Question 5

what is conjunctivitis

Answer 5

inflammation or infection of conjunctiva
usually self limiting and rarely resulting in vision loss
essential to rule out other sight-threatening cause of red-eye

Question 6

what is the conjunctiva composed of

Answer 6

bulbar conjuntiva - covers globe
tarsal (or palpebral) conjunctiva - which lines eyelid’s inner surface

Question 7

what are the types of conjunctivitis

Answer 7

viral (80% of acute cases), allergic and bacterial

Question 8

what are the most common cause of conjunctivitis
viral
allergic
bacterial

Answer 8

viral: Adenovirus, herpes simplex, herpes zoster, enterovirus
allergic: allergens, toxin, local irritants (m/c)
bacterial: adults: s. aureus, s. pneumonia, h. influenzae
kids: H. influenza, s. pneumoniae
neonates: N. gonorrhoeae

Question 9

when are conjunctivitis common to present

Answer 9

kids: march/may
allergic: spring/summer
bacterial: december to april

Question 10

what is viral conjunctivitis

Answer 10

children most susceptible
direct contact with virus or airborne transmission
most cases highly contageous for 10-14 days
washing hands and avoidance of eye contract key to preventing transmission

Question 11

what is Picornaviruses

Answer 11

acute hemorrhagic conjunctivitis; highly infectious
RARE

Question 12

what is HIV conjunctivitis

Answer 12

protracted course marked by irritation, redness and tearing

Question 13

what is the clinical presention of viral conjunctivitis

Answer 13

presents with FB sensation, red eyes, itching, light sensitivity, burning, watery discharge
usu. hx of recent URI or sick contact
visual acuity usu. at or near their baseline
cornea can have subepithelial infiltrates; causes photophobia, diminished vision, glare

Question 14

what is seen with viral conjunctivitis with HSV

Answer 14

vesicles may appear on face or eyelids and vision may be affected; corneal involvement possible

Question 15

what is seen with viral conjunctivitis with Zoster

Answer 15

vesicular dermatomal pattern; conjunctiva usually red with mucopurulent discharge

Question 16

how do you diagnose/work up viral conjunctivitis

Answer 16

lab testing not indicated unless: no resolving (>4wks, chlamydial infection concern, significant immunocompromised, excessive discharge, gonorrhea co-infection suspected)
ophthalmologist usually diagnose clinically

Question 17

what is the treatment of viral conjunctivitis

Answer 17

symptomatic relief: artificial tears, cool compresses
resolution can take up to 3 weeks’ most resolve in 14 days
preventing spread
membrane peeled off with topical anesthetic, topical steroids, topical antivirals for HSV and Zoster

Question 18

what is bacterial conjunctivitis

Answer 18

spread usually hand to eye or person to person via respiratory droplets
m/c causative in kids is H. influenza, adults is s. aureus
contact lens wearers: more susceptible to gram-negative

Question 19

what is the clinical presentation of bacterial conjunctivitis

Answer 19

redness, tearing, discharge from one/both eyes (glued eyes)
duration divided into hyperacute, acute (3-4wks), chronic (>4wks)
conjunctival erythema, purulent discharge; may have mattering of eyelids upon waking
complete ocular examination

Question 20

what should be assessed in kids with bacterial conjunctivitis

Answer 20

inquire about otic symptoms - children may have concurrent otitis media; otoscopic examination warranted

Question 21

what is the work up for bacterial conjunctivitis

Answer 21

labratory/radiographs not required
cultures

Question 22

what is the treatment of bacterial conjunctivitis

Answer 22

untreated will resolve within one week
if treat:
uncomplicated: topical abx or manage expectantly
complicated: topical abx
duration of treatment: generally 5-7 days

Question 23

what are the abx of choice for bacterial conjunctivitis

Answer 23

aminoglycosides
polymyxin B combinations (polymyxin B/trimethoprim)
macrolides
fluoroquinolone

topical erythromycin

Question 24

what are the topical exceptions for bacterial conjunctivitis

Answer 24

gonococcal or chlamydial infections require systemic treatment
- if gonorrhea: admit, single dose IV/IM ceftriaxone, eye irrigation until resolution
- if chlamydia: PO or IV erythromycin plus topical erythromycin for 14 days

oral abx indicated if concurrent acute otitis media

Question 25

what can severe bacterial conjunctivitis result in

Answer 25

keratitis, corneal ulceration and perforation and blindness

Question 26

what is keratoconjuncitivits

Answer 26

inflammatory process involving both conjunctiva and superficial cornea (keratitis)
usually occur in association with viral, bacterial, autoimmune, toxin, allergic etiologies
list of cases are extensive
unilat or bilat

Question 27

what can cause keratoconjunctivitis

Answer 27

viral&raquo_space; bacterial
epidemic keratoconjunctivitis (EKC) - adenovirus
non-infectious: allergic, toxic, immune-mediated
vernal keratoconjuncitivits (VKC) - sever allergic
superior limbic keratoconjunctivitis (SLK) - chronic inflammatory

Question 28

what is keratoconjunctivitis siccca

Answer 28

dry eye syndrome (DES), various etiologies including several (primarily autoimmune), systemic conditions

Question 29

what is the presentation of keratoconjunctivitis

Answer 29

eye discomfort, pruritis, light sensitivity, minor blurring, epiphora
conjunctival injection, conjunctival chemosis, eye discharge

Question 30

what is the presentation of viral (epidemic)keratoconjunctivitis

Answer 30

initially unilat with spread to contralateral, usually. asymmetric findings
present with ocular discomfort/itching, light sensitivity
conjuncival injection and chemosis
follicular reaction, petechial hemorrhages, pseudo-membrane
lymphadenopathy and/or antecedent URI
may last 7-21 days, may remain infections for 10-14 days

Question 31

what is the presentation of keratoconjuncitivitis sicca

Answer 31

chronic, usually intermittent, bilateraly (usu. asymmetric) burning, stinging, FB sensation, photophobia
eye fatigue, sense of heavy eyelids, pruritis, epiphora, watery discharge, blurred vision
blurring worse with reading, computer use, TV, or other electronics

Question 32

what is found on exam with keratoconjunctivitis sicca

Answer 32

conjunctiva injection
eyelid margin telangiectasias
erythema
decreased tear lake
reduced tear production

Question 33

what is the presentation of superior limbic keratoconjunctivitis

Answer 33

bilateral burning, irritation, FB sensation
usually chronic with gradual clearing - may have periods of remission
asymmetric involvement
watery discharge and epiphora, superior palpebral and bulbar conjunctival injection, chemosis
punctate epithelial erosions in upper third of cornea often present

Question 34

how do you diagnose/work up keratoconjunctivitis

Answer 34

acuity, visual fields, pupillary reactions, motility
IOP
eyelid examination including eversion
fluorescein staining with wood’s lamp or slit lamp

refer to definitive diagnosis and mgmt

Question 35

what is the treatment of epidemic keratoconjunctivitis

Answer 35

extremely contageous, prevent spread to others
incubation 5-12 days, contageous 10-14 days
no effective treatment exists
symptomatic tx: artificial tears, cool compresses, topical antihistamines

Question 36

what is the treatment for keratoconjunctivitis sicca

Answer 36

initial: artificial tears, warm compresses, lid scrubs, oral flaxeed oil/fish oil supplement.
meds: typical cyclosporine A, tacrolimus, lifitegrast; steroid-sparing dampening agents
topical steroids
PO doxycycline (low dose)
procedural tx: punctal plus to prevent lacrimal drainage of tears

Question 37

what is the treatment of superior limbic keratoconjunctivitis

Answer 37

first line: preservative-free artificial tears, gels, ointment
second line: topicals i.e. mast-cell stabilizers, ati histamines, vit A, NSAIDs
chemocautery with silver nitrate results in symptomatic relief 1-2 months
surgical conjunctival resection of affected/redundant conjunctiva

Question 38

what is allergic conjunctiviits

Answer 38

common, benign process
rarely vision-threatening; can significantly decrease QOL
acute, seasonal and perennial wtih 4 primary fomrs

Question 39

what is simple allergic conjunctivitis

Answer 39

secondary to simple allergen exposure

Question 40

what is vernal keratoconjunctivitis

Answer 40

some combination of climate and allergen

Question 41

what is atopic keratoocnjunctivitis

Answer 41

combination of allergen exposure, atopic dermatitis, and/or genetic predisposition

Question 42

what is giant papillary conunctiviitis

Answer 42

allergen exposure and response secondary to ocular foreign body

Question 43

What is the clinical presentation of allergic conjunctivitis

Answer 43

frequently accompanies seasonal allergy symptoms
itchiness and diffuse conjunctival injection are the most common symptoms and present in all subtypes

Question 44

what is the workup for allergic conjunctivitis

Answer 44

based on torough history and classic PE findings
if concern, fluoroscein straining of cornea can ensure no corneal abrasion