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OD2 S2 > wk4: AED - Conjunctival Degeneration > Flashcards

wk4: AED - Conjunctival Degeneration Flashcards

1
Q

What does the SOAP mnemonic stand for?

A

S - Subjective (symptoms)
O - Objective (signs)
A - Assessment (DDx/DEx + tests for Dx)
P - Plan (Mx)

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2
Q

What 3 parts of the conjunctiva are responsible for secreting mucin?

A

Goblet Cells
Crypts of Henle
Glands of Manz

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3
Q

What are crypts of henle?

A

microscopic pockets (that secrete mucin) found in scattered sections of the conjunctiva

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4
Q

What are glands of manz?

A

an anatomical structure (that secretes mucin) in the conjunctiva arranged in a ring around the cornea, near the scleral junction

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5
Q

What are goblet cells?

A

a column-shaped cell that secretes mucin

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6
Q

What is mucin? What does it do for the eye?

A

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

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7
Q

What happens to the tear film if mucin producing components malfunction?

A

unstable tear film

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8
Q

How thick is the conjunctival epithelium?

A

2-10 cell layers thick

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9
Q

What do the glands of kraus and glands of wolfring do?

A

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)

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10
Q

Where in the conjunctiva are the accessory lacrimal glands found?

A

stroma

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11
Q

Describe the structure of the conjunctival stroma

A

vascular connective tissue

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12
Q

How many glands of krause are located in the superior and inferior conjunctival fornix (own study)?

A

Superior: 20
Inferior: about 10

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13
Q

What happens to the tear film if superior and inferior fornix is inflamed?

A

Unstable tear film - because glands of krause are affected since some of them are located there

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14
Q

Define Pingueculum

A

a benign, non-cancerous, yellowish deposit on the conjunctiva

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15
Q

Name 3 signs that a patient has pingueculum

A
  1. triangular (base toward limbus) yellowish, slightly elevated mass on nasal or temporal sclera - sometimes like discrete gelatinous deposits
  2. very common + generally bilateral (3 o’clock and 9 o’clock)
  3. not vascular, but can be hyperaemic if inflamed
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16
Q

What is hyperaemia?

A

excess of blood in a body part (as from an increased flow of blood due to vasodilation)

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17
Q

Describe the symptoms of pingueculum (4)

A

usually asymptomatic - but can cause dry eye
cosmetically unappealing
foreign body sensation if inflamed
no affect on vision

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18
Q

Is pingueculum a growth?

A

It’s not a growth, per-say, it’s a deposit

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19
Q

In what orientation does the triangular appearance of a pingueculum present on the conjunctiva?

A

The base of the triangle is at the limbus

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20
Q

How can we assess pingueculum? (4)

A

Slit Lamp
Fluoroscein stain (?dellen)
Tear workup (if symptoms)
Document

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21
Q

How can pingueculum cause dry eye?

A

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)

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22
Q

What is the main cause of pingueculum?

A

Genetic

(note: age is not significant)

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23
Q

Describe the histopathology of pingueculum (4)

A

Elastotic (elastin tissue breakdown) degeneration of the collagen
Hyalinization of the conjunctival stroma
Collection of elastotic fibres
Granular deposits

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24
Q

What conditions should pingueculum be differentially diagnosed from? [4]

A

pterygium
conj. intraepithelial neoplasia (CIN)
other tumours (e.g. papilloma)
limbal dermoid

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25
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
26
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
27
Is UV exposure a risk for pingueculum?
NO it is not!
28
When do we schedule a follow up for a patient with pingueculum?
At a normal review time, unless patient requests earlier if diagnosis uncertain
29
What side effect might the use of NSAIDs in treating chronic pingueculum lead to?
stomach ulcers
30
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
31
Why might we not be inclined to remove pingueculum?
Surgical removal is very painful! Conjunctival healing is uncomfortable and hard to anaesthesize!
32
Describe the process of surgical removal of pingueculum [4]
1. excision including overlying conjunctiva 2. wound closure with suture 3. amniotic membrane for larger wound 4. prophylactic topical antibiotic + anti steroid (pred forte)
33
How does an argon laser work for pingueculum removal?
photocoagulation of pingueculum, followed by prophylactic topical antibiotic + anti steroid (pred forte)
34
What is Pterygium? [4]
a pinkish, triangular tissue growth on the cornea of the eye., similar to pingueculum
35
List 6 signs that a patient has pterygium
1. vascular triangular mass of tissue (base to conj.), generally on nasal conj + cornea 2. may be slowly growing/advancing toward central cornea 3. often bilateral, can be medial + temporal together 4. may have orange-brown (iron deposits) line at leading edge (stocker's line) 5. opaque epithelium, overlying defect in front of leading edge 6. increasing astigmatism
36
Name 4 symptoms of pterygium
cosmetically unappealing FB sensation, dryness reduction in vision if encroaching on visual axis or increasing cyl rarely diplopia (monocular)
37
How can we assess pterygium? [4]
Slit lamp, keratometry/topography Fluoroscein staining Tear workup if indicated Document (photo or measurment, grading scales)
38
How do we treat pterygium? [3]
vasoconstrictors to reduce redness? ocular lubricants - for ocular irritation + corneal signs topical steroid or NSAID - for severe irritation
39
Under what scenarios should we refer pterygium for surgical removal? [5]
if: advancing rapidly chronic irritation diplopia marked effect on vision cosmesis concern
40
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
41
Describe the histology of pterygium development [1]
resembles actinic degeneration of the skin
42
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
43
Is UV exposure a risk for pterygium?
YES
44
Can pterygium regrow after surgery?
yes
45
How does the timing of pterygium removal affect the likelihood of a successful outcome?
earlier the removal, better the result
46
What are the 2 main aims of pterygium surgery?
Remove pterygium Prevent recurrence
47
Why is a wide excision necessary in pterygium surgery?
to reduce recurrence
48
What is the standard surgical removal technique for pterygium?
bare scleral resection
49
How can an autograph/primary closure surgery be useful for pterygium?
Useful as an adjunct treatment alongside bare scleral resection. Helps prevent recurrence.
50
Name 3 adjunct treatments that can be used to minimise recurrence of pterygium
autogroph/primary closure surgery mitomycin C beta irradiation
51
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
52
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%
53
In what type of patients do concretions most typically occur?
people with systemic or topical chronic inflammation
54
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.
55
List 4 signs of concretions
1. yellow-white, usually <1mm (but up to 4mm) deposits in palpebral conjunctival epithelium + epithelium of inferior fornix 2. common in elderly - ?mucin and necrotic cells/eosinophilic proteins, etc. 3. may be assoc. with chronic conjunctivitis, CL wear 4. may see associated clear cyst
56
Describe the symptoms of concretions [2]
generally asymptomatic may have 'gritty' FB sensation
57
How can we assess concretions? [2]
Slit lamp Fluorescein stain for erosion
58
Name 3 conditions that need to be differentially diagnosed from concretions
other FBs conjunctival cysts conjunctival trauma
59
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
60
When should we schedule a follow up for a concretions patient?
If not removed: schedule at px request if removed: 3-5 days after
61
What is Amyloidosis?
deposition of amyloid in the body.
62
List 4 signs of amyloidosis in the eye
1. yellowish, avascular, waxy deposits within the bulbar or forniceal conjunctival - can be assoc. with recurrent bleeding 2. material is amyloid (an accumulation of a variety of proteins of differing origins) 3. usually unilateral - may be primarily (usually in conjunctiva) or secondary (e.g. to TB) 4. may be a localised (usually for conj) or systemic disorder
63
What might we ask in patient history about systemic issues if we suspect amyloidosis?
ask about lung complaints, because can be secondary to tuberculosis
64
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
65
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
66
When should we schedule a follow up in amyloidosis patient?
early if doubt over diagnosis, change in size or symptoms
67
List 4 signs of conjunctival cysts
1. typically small clear cyst (bubble) within bulbar, forniceal, or palpebral conjunctiva (2-5mm) 2. or tube-like swelling of bulbar lymphatic (may be multiple) which is more transparent than cyst 3. mobile to touch and with blink 4. usually unilateral
68
List 2 symptoms of conjunctival cysts
typically asymptomatic, may have FB sensation patient frequently cosmetically concerned
69
How can we assess conjunctival cysts? [2]
Slit lamp Document
70
What is conjunctivochalasis?
excess redundant tissue in conjunctiva (is a DDx for conjunctival cysts, and some other stuff)
71
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
72
When do we schedule follow up in conjunctival cyst patients?
to monitor if lanced and antibiotic prescribed at patient request
73
List 4 signs of ecchymosis
1. sub-conjunctival blood anywhere under the bulbar conjunctiva 2. distinct white border at limbus and conjunctival fornix (posterior limit) 3. very common, usually unilateral, (aka sub-conj haemorrhage) 4. most idiopathic but must exclude precipitating event
74
Name 2 symptoms of ecchymosis
painless and no affect on vision (by itself) if associated with trauma: other assoc. symptoms likely present
75
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
76
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
77
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
78
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
79
What are bitot's spots?
Bitot's spots are buildup of keratin located superficially in the conjunctiva of human´s eyes.
80
List 6 signs of bitot's spots
1. 'foamy' slightly raised patches on temporal bulbar conjunctiva 2. due to metaplastic keratinisation of conjunctival epithelium and loss of goblet cells 3. usually temporal, less frequently nasal 4. hyperkeratinisation of local area assoc. with colonisation by corynebacterium 5. assoc with Vitamin A deficiency 6. uncommon in aus
81
Name 3 symptoms of bitot's spots
ocular surface irritation reduced vision nightblindness assoc.
82
How do we assess bitot's spots? [3]
Slit lamp dry eye workup document
83
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
84
Is there any way the patient can manage early bitot spot?
a change in diet may be sufficient
85
When do we schedule follow up in bitot spot patient? [2]
over period of vitamin A therapy if change in size or symptoms
86
Still have a few more slides to go
how annoying

OD2 S2 (63 decks)

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