wk4: AED - Conjunctival Degeneration Flashcards
What does the SOAP mnemonic stand for?
S - Subjective (symptoms)
O - Objective (signs)
A - Assessment (DDx/DEx + tests for Dx)
P - Plan (Mx)
What 3 parts of the conjunctiva are responsible for secreting mucin?
Goblet Cells
Crypts of Henle
Glands of Manz
What are crypts of henle?
microscopic pockets (that secrete mucin) found in scattered sections of the conjunctiva
What are glands of manz?
an anatomical structure (that secretes mucin) in the conjunctiva arranged in a ring around the cornea, near the scleral junction
What are goblet cells?
a column-shaped cell that secretes mucin
What is mucin? What does it do for the eye?
a proteinous substances that makes up the inner layer of tears. It coats the cornea to provide a hydrophilic layer that allows for even distribution of the tear film
What happens to the tear film if mucin producing components malfunction?
unstable tear film
How thick is the conjunctival epithelium?
2-10 cell layers thick
What do the glands of kraus and glands of wolfring do?
They are accessory lacrimal glands. The function of both is to produce tears which are secreted onto the surface of the conjunctiva. They are known as basal lacrimal secretors (i.e. basal tears)
Where in the conjunctiva are the accessory lacrimal glands found?
stroma
Describe the structure of the conjunctival stroma
vascular connective tissue
How many glands of krause are located in the superior and inferior conjunctival fornix (own study)?
Superior: 20
Inferior: about 10
What happens to the tear film if superior and inferior fornix is inflamed?
Unstable tear film - because glands of krause are affected since some of them are located there
Define Pingueculum
a benign, non-cancerous, yellowish deposit on the conjunctiva
Name 3 signs that a patient has pingueculum
- triangular (base toward limbus) yellowish, slightly elevated mass on nasal or temporal sclera - sometimes like discrete gelatinous deposits
- very common + generally bilateral (3 o’clock and 9 o’clock)
- not vascular, but can be hyperaemic if inflamed
What is hyperaemia?
excess of blood in a body part (as from an increased flow of blood due to vasodilation)
Describe the symptoms of pingueculum (4)
usually asymptomatic - but can cause dry eye
cosmetically unappealing
foreign body sensation if inflamed
no affect on vision
Is pingueculum a growth?
It’s not a growth, per-say, it’s a deposit
In what orientation does the triangular appearance of a pingueculum present on the conjunctiva?
The base of the triangle is at the limbus
How can we assess pingueculum? (4)
Slit Lamp
Fluoroscein stain (?dellen)
Tear workup (if symptoms)
Document
How can pingueculum cause dry eye?
As the mass is raised above the tear film, the tissue next to it dries, which can result in a dellen (sterile ulcer as the tissue dissolves away)
What is the main cause of pingueculum?
Genetic
(note: age is not significant)
Describe the histopathology of pingueculum (4)
Elastotic (elastin tissue breakdown) degeneration of the collagen
Hyalinization of the conjunctival stroma
Collection of elastotic fibres
Granular deposits
What conditions should pingueculum be differentially diagnosed from? [4]
pterygium
conj. intraepithelial neoplasia (CIN)
other tumours (e.g. papilloma)
limbal dermoid
How might we treat pingueculum? [5]
Leave it - in vast majority of patients
Vasoconstrictors - to reduce redness; useless in chronic (repeat after me: useless)
Ocular lubricants, cold compresses: if FB sensation
NSAIDs or topical steroids - if severe inflammation
Cosmetic surgery = last resort
If you choose not to treat a patient with pingueculum, what advice can you give a patient to help manage it?
Glasses/sunglasses when outside to protect against wind. Wind dries out eyes and will dry out the raised mass/surroundings even more. Wraparound glasses are particularly good protection here
Is UV exposure a risk for pingueculum?
NO it is not!
When do we schedule a follow up for a patient with pingueculum?
At a normal review time, unless patient requests earlier if diagnosis uncertain
What side effect might the use of NSAIDs in treating chronic pingueculum lead to?
stomach ulcers
How can you differentially diagnose the following conditions from pingueculum?
Dermoid, Papilloma, CIN
Dermoid: internal blood vessel structure, variation of own tissue
Papilloma: more spongey, blood vessel structure within them
CIN: sits on top of everything and continues to grow
Why might we not be inclined to remove pingueculum?
Surgical removal is very painful! Conjunctival healing is uncomfortable and hard to anaesthesize!
Describe the process of surgical removal of pingueculum [4]
- excision including overlying conjunctiva
- wound closure with suture
- amniotic membrane for larger wound
- prophylactic topical antibiotic + anti steroid (pred forte)
How does an argon laser work for pingueculum removal?
photocoagulation of pingueculum, followed by prophylactic topical antibiotic + anti steroid (pred forte)
What is Pterygium? [4]
a pinkish, triangular tissue growth on the cornea of the eye., similar to pingueculum
List 6 signs that a patient has pterygium
- vascular triangular mass of tissue (base to conj.), generally on nasal conj + cornea
- may be slowly growing/advancing toward central cornea
- often bilateral, can be medial + temporal together
- may have orange-brown (iron deposits) line at leading edge (stocker’s line)
- opaque epithelium, overlying defect in front of leading edge
- increasing astigmatism
Name 4 symptoms of pterygium
cosmetically unappealing
FB sensation, dryness
reduction in vision if encroaching on visual axis or increasing cyl
rarely diplopia (monocular)
How can we assess pterygium? [4]
Slit lamp, keratometry/topography
Fluoroscein staining
Tear workup if indicated
Document (photo or measurment, grading scales)
How do we treat pterygium? [3]
vasoconstrictors to reduce redness?
ocular lubricants - for ocular irritation + corneal signs
topical steroid or NSAID - for severe irritation
Under what scenarios should we refer pterygium for surgical removal? [5]
if:
advancing rapidly
chronic irritation
diplopia
marked effect on vision
cosmesis concern
Describe the pathophysiology of pterygium [3]
Activated fibroblasts in leading edge of pterygium invade + fragment bowman’s layer + a variable amount of superficial corneal stroma
Describe the histology of pterygium development [1]
resembles actinic degeneration of the skin
When do we schedule a follow up for a pterygium patient?
Depends on rate of progression:
If stable: review in 1-2 years
If progressive or new patient: review in 3-6 months
Is UV exposure a risk for pterygium?
YES
Can pterygium regrow after surgery?
yes
How does the timing of pterygium removal affect the likelihood of a successful outcome?
earlier the removal, better the result
What are the 2 main aims of pterygium surgery?
Remove pterygium
Prevent recurrence
Why is a wide excision necessary in pterygium surgery?
to reduce recurrence
What is the standard surgical removal technique for pterygium?
bare scleral resection
How can an autograph/primary closure surgery be useful for pterygium?
Useful as an adjunct treatment alongside bare scleral resection. Helps prevent recurrence.
Name 3 adjunct treatments that can be used to minimise recurrence of pterygium
autogroph/primary closure surgery
mitomycin C
beta irradiation
Describe the conjunctival autograph surgery. How does it work?
tissue transplant from upper eyelid fills the gap in the conjunctiva where the pterygium was removed
What is the recurrence rates of pterygium for the following removal treatments:
Base Sclera
Beta irradiation
Mitmycin C
Autoconjunctival graph
Base sclera: up to 80%
Beta irradiation: less than 10%
Mitomycin C: less than 10%
Autoconjunctival graph: 7%
In what type of patients do concretions most typically occur?
people with systemic or topical chronic inflammation
What is a concretion?
a hard solid mass formed by the local accumulation of matter, especially within the body or within a mass of sediment.
List 4 signs of concretions
- yellow-white, usually <1mm (but up to 4mm) deposits in palpebral conjunctival epithelium + epithelium of inferior fornix
- common in elderly - ?mucin and necrotic cells/eosinophilic proteins, etc.
- may be assoc. with chronic conjunctivitis, CL wear
- may see associated clear cyst
Describe the symptoms of concretions [2]
generally asymptomatic
may have ‘gritty’ FB sensation
How can we assess concretions? [2]
Slit lamp
Fluorescein stain for erosion
Name 3 conditions that need to be differentially diagnosed from concretions
other FBs
conjunctival cysts
conjunctival trauma
How can we treat concretions? [5]
monitor if asymptomatic (tx if symptoms)
review CL care + assoc env factors
ocular lubricants
removal: using anaesthesia + needle (e.g. 25G)
prophylactic antibiotic after removal
When should we schedule a follow up for a concretions patient?
If not removed: schedule at px request
if removed: 3-5 days after
What is Amyloidosis?
deposition of amyloid in the body.
List 4 signs of amyloidosis in the eye
- yellowish, avascular, waxy deposits within the bulbar or forniceal conjunctival - can be assoc. with recurrent bleeding
- material is amyloid (an accumulation of a variety of proteins of differing origins)
- usually unilateral - may be primarily (usually in conjunctiva) or secondary (e.g. to TB)
- may be a localised (usually for conj) or systemic disorder
What might we ask in patient history about systemic issues if we suspect amyloidosis?
ask about lung complaints, because can be secondary to tuberculosis
Describe the symptoms of amyloidosis [3]
usually asymptomatic in the eye deposits, not tender unless large enough to affect lid function or give FB sensation
How can we treat amyloidosis? [3]
Check if amyloid present elsewhere in eye (e.g. lids, ant. chamber, optic nerve, cornea, iris, lacrimal gland)
Removal required if FB sensation or for cosmesis
Refer for biopsy (if diagnosis uncertain), removal, or to rule out systemic amyloidosis
When should we schedule a follow up in amyloidosis patient?
early if doubt over diagnosis, change in size or symptoms
List 4 signs of conjunctival cysts
- typically small clear cyst (bubble) within bulbar, forniceal, or palpebral conjunctiva (2-5mm)
- or tube-like swelling of bulbar lymphatic (may be multiple) which is more transparent than cyst
- mobile to touch and with blink
- usually unilateral
List 2 symptoms of conjunctival cysts
typically asymptomatic, may have FB sensation
patient frequently cosmetically concerned
How can we assess conjunctival cysts? [2]
Slit lamp
Document
What is conjunctivochalasis?
excess redundant tissue in conjunctiva (is a DDx for conjunctival cysts, and some other stuff)
How can we treat conjunctival cysts? [4]
usually monitor if asymptomatic
lance cyst (25G needle + anaethesia), massage closed lid to drain, but will usually re-occur
prophylactic antibiotic required
refer for surgical removal from base if required
When do we schedule follow up in conjunctival cyst patients?
to monitor if lanced and antibiotic prescribed
at patient request
List 4 signs of ecchymosis
- sub-conjunctival blood anywhere under the bulbar conjunctiva
- distinct white border at limbus and conjunctival fornix (posterior limit)
- very common, usually unilateral, (aka sub-conj haemorrhage)
- most idiopathic but must exclude precipitating event
Name 2 symptoms of ecchymosis
painless and no affect on vision (by itself)
if associated with trauma: other assoc. symptoms likely present
How do we assess ecchymosis? [3]
Hx for any precipitating event (e.g. trauma, hypertension)
Slit lamp (AC and internal exam depending on hx)
Pupils, eye movements, IOP (depending on hx), blood pressure
What 4 conditions should we DDx with ecchymosis?
conjunctival kaposi’s sarcoma
haemorrhagic (or other) conjunctivitis
breakthrough bleed from behind globe
other ocular neoplasia with secondary haemorrhage
How can we treat ecchymosis? [4]
if traumatic, manage as appropriate
reassure patient
cold packs: to stop bleed in first 1-2 days, followed by hot packs assisting haemolysis
may take 1-3 weeks to resolve
When should we schedule a follow up in ecchymosis patient? [2]
1 week: if concerned or no resolution
Also schedule if: more than 2 recurrences in 1 year - to determine if systemic cause determination or cauterisation
What are bitot’s spots?
Bitot’s spots are buildup of keratin located superficially in the conjunctiva of human´s eyes.
List 6 signs of bitot’s spots
- ‘foamy’ slightly raised patches on temporal bulbar conjunctiva
- due to metaplastic keratinisation of conjunctival epithelium and loss of goblet cells
- usually temporal, less frequently nasal
- hyperkeratinisation of local area assoc. with colonisation by corynebacterium
- assoc with Vitamin A deficiency
- uncommon in aus
Name 3 symptoms of bitot’s spots
ocular surface irritation
reduced vision
nightblindness assoc.
How do we assess bitot’s spots? [3]
Slit lamp
dry eye workup
document
How can we treat bitot spot?
Refer to GP for blood test to confirm vit A deficiency
High dose Vit A therapy - can normally make it disappear
May regress within weeks, if longstanding, may have permanent epithelial metaplasia and so will remain
Manage dry eye symptoms as appropriate
Is there any way the patient can manage early bitot spot?
a change in diet may be sufficient
When do we schedule follow up in bitot spot patient? [2]
over period of vitamin A therapy
if change in size or symptoms
Still have a few more slides to go
how annoying
