Conjunctiva Disorders

follicles

• lymphoid tissue

• reactive hyperplasia w/in stroma

• conjunctival lymphoma

• appearance: multiple, elevated, lumpy/grain of rice appearance

• large ones can be common in children w/ no clinical significance

papilla

• non-specific finding

• inflammatory cells

• appearance:

  • vascular core that branches out over the surface

  • velvety

chemosis

• severe inflammation of the conjunctiva

• transudation of fibrin & protein fluid through the walls of leaky blood vessels

• usually associated with an immediate allergic rxn

• appearance:

  • translucent swelling

  • can protrude through closed lids & impact lid closure

  • jelly-like appearance

conjunctivochalasis

• etiology:

  • aging (most common)

  • allergies

  • post-op

  • venous congestion

  • angioneurotic edema

  • myxedema

• appearance:

  • presence of excess folds in conjunctiva

  • slack/sagging of the conjunctiva, bunched up appearance

• tx: surgical resection

pseudomembrane

• etiology:

  • severe adenoviral infections (EKC, SJS, gonococcal herpes, allergic & bacterial conjunctivitis)

• combo of fibrin & proteinaceous coagulated exudates

• loosely attached to the inflamed conjunctival epithelium

• appearance:

  • wet scab

  • can be seen on upper or lower lid

  • removal may cause bleeding & scaring but not usually

• very uncomfortable & can cause corneal issues

• tx: usually can be easily peeled off w/ a wet swab

true membrane

• etiology:

  • severe infections (strep)

  • SJS

  • chemical burns

• forms when inflammatory exudate secreted by invading microorganisms or ocular tissues permeates the superficial layers of the conjunctival epithelium & vascularity

• appearance:

  • bleed when removal is attempted

  • firmly attached

  • will scar

subconjunctival hemorrhage

• etiology:

  • valsalva maneuver

  • trauma

  • surgical

  • HTN

  • bleeding disorders

  • blood thinners

  • post-op

  • severe infections

  • idiopathic

• appearance:

  • blood underneath the conjunctiva

  • often sectoral

  • can obstruct the entire view of the episclera & sclera

• tx:

  • may take 2wks to resolve

  • no tx needed, like a bruise

  • AT PRN

  • monitor BP & NSAID usage

concretions

• etiology:

  • idiopathic

  • chronic conjunctival infections

  • just trapped cellular debris that calcifies

• appearance:

  • small, hard, yellow-white, crystal-like deposits w/in palpebral conjunctiva

  • usually 1-2mm in size

• sx:

  • usually asymptomatic

  • FB sensation

  • FB tracking if superior

• associations:

  • inclusion cysts

• tx:

  • none if asymptomatic

  • can remove if symptomatic (cotton swab, needle, forceps)

inclusion (lymphatic) retension cysts

• etiology: blockage of ducts of glands of Krause

• appearance:

  • clear, fluid filled cysts on palpebral, bulbar, or canthal areas

  • conjunctival blood vessels pass over

• tx:

  • none usually

  • if large, can be excised or punctured w/ needle

symblepharon

• etiology:

  • EKC

  • post-op

  • trauma

  • burns

  • long-standing inflammation

  • atopic

  • ocular cicatricial pemphigoid

  • SJS

  • radiation

  • congenital

• fusion of the palpebral conjunctiva w/ the bulbar conjunctiva

conjunctival degenerations

• usually seen in people over 30

• etiology:

  • exposure to noxious environmental stimuli & UV light

  • age-related or environmental

  • chronic exposure to wind/dust/sun

  • altered collagen & elastic tissues

• appearance

  • usually in interpalpebral (exposed) conjunctival area

• rarely produces any serious effects on ocular functioning

pinguecula

• extremely common

• usually seen in pt over 30yo

• etiology: elastic degeneration of the collagen tissue of conjunctival stroma (age related or environmental)

• appearance:

  • yellow-white elevation on bulbar conjunctiva adjacent to nasal or temporal aspect of the limbus

  • can be highly vascularized & injected

  • usually in 3/9 oclock positions

• signs/sx:

  • irritation

  • redness

  • asymptomatic

• associations:

  • can become inflammed

  • SPK

  • dellen

  • CL

  • can progress to a pterygium

• tx:

  • cosmetic concern

  • protection from UV light

  • surgical excision is rarely necessary

  • important to R/O other pathologies

pingueculitis

• inflammation of a pinguecula

• sx:

  • irritation

  • redness

  • tearing

  • can be asymptomatic

• tx:

  • may not require

  • mild soft steroids

pterygium

• etiology:

  • age-related

  • environmental

  • increased incidence in hot, dusty regions

  • chronic inflammation

• seen in those over 20

• more common in males

• damages limbal stem cells

• appearance:

  • raised, triangular, white, fibrovascular overgrowth of bulbar conjunctiva onto the cornea

  • early on: small, gray opacities near limbus

  • bilateral

  • nasal > temporal

  • interpaplebral area

  • Stocker’s line

• signs/sx:

  • blurry vision if overgrows visual axis or K’s get distorted

  • red, scratchy, inflamed eye

  • dry eye complaints

  • cosmetic concern

• tx:

  • AT

  • soft steroids

  • surgery (excision)

  • protection from UV

Stocker’s line

• iron deposition line at the leading edge of pterygium

• yellow, golden/reddish brown, brown

pseudopterygium

adhesion of a fold of conjunctiva to a peripheral ulcer, fixed only at the apex

ex: ocular cicatricial pemphigoid

ocular cicatricial pemphigoid

• rare

• etiology: chronic autoimmune sub-epithelial blistering

• affects basement membrane

• appearance:

  • erosive skin lesions of mucous membranes

  • scars

• affects all mucous membranes of the body

dermoid cyst

• etiology:

  • congenital choristoma

• appearance:

  • mass of collagen tissue containing hair, follicles, & glands covered by keratinized epithelium

choristoma

congenital overgrowth of normal tissue in an abnormal location, composed of tissue not normally found in the region

limbal dermoid cyst

• etiology:

  • congenital

• appearance:

  • smooth, soft, yellowish-white, solid, oval, conjunctival mass at the limbus

  • usually at lower temporal limbus & involves cornea, conjunctiva & sclera

  • can enlarge (puberty)

• signs/sx:

  • DES

  • irritation

  • lagophthalmos

• associations:

  • eyelid colobomas

  • preauricular accessory skin tags

  • vertebral abnormalities

  • mal-development of the jaw

  • hearing loss (Goldenhar’s syndrome)

  • systemic abnormalities

  • amblyopia

  • astigmatism

• tx:

  • removal for cosmetic & visual reasons near school age

  • sclerokeratectomy w/ excisional biopsy

    • leaves a scar & underlying tissue can be very thin

Goldenhar’s syndrome

includes accessory auricles, limbal & ocular dermoids, & sometimes jaw malformation

dermatolipoma

• etiology:

  • congenital

  • can be part of Goldenhar’s syndrome or separate

• appearance:

  • firm, elevated, movable, yellowish, subconjunctival mass

  • outer canthal angle of eye

  • usually obscured in primary gaze (pt must look in a different gaze to be able to see it)

  • usually a smooth surface but can contain hair follicles, glands, or fatty tissue

• tx:

  • none unless cosmetic concern

lymphangiectasia

• etiology:

  • blockage of lymphatic channels

• more common in pt w/ chronic irritation

• appearance:

  • clear, yellowish, serous cyst w/ dilated, tortuous clear or yellowish tubules

  • 2-10mm

  • round or linear

  • can fill with blood

• typically resolve on their own

conjunctival lymphoma

• etiology:

  • Hodgkin disease

  • variety of benign & malignant lymphoid lesions

• affects young to middle aged adults

• appearance:

  • salmon colored, subconjunctival lesion

  • fleshy

  • may grow rapidly

  • often arise from the fornix & extend to the cornea

• tx:

  • radiotherapy

  • systemic chemotherapy

pyogenic granuloma

• etiology: overgrowth of tissue due to irritation or physical trauma/infection/inflammation

• appearance:

  • vascular lesion

  • red/pink or purple & smooth or lobulated

  • can grow & bleed

papilloma

• etiology:

  • HPV

  • viral infection

• appearance:

  • soft, pink, strawberry red, elevated lesion w/ a slightly irregular surface

  • multiple cores of corkscrew blood vessels

  • may grow rapidly

  • most commonly at the caruncle, fornices, lid margin, & limbus

  • pedunculated or sessile

• signs/sx:

  • asymptomatic

  • FB sensation

  • itching

  • tearing

  • improper lid closure

• tx:

  • if viral, often left untreated due to frequent recurrence

  • if non-viral (sessile), usually excisional biopsy

Kaposi sarcoma

• etiology: occurs in pt w/ AIDS

• appearance:

  • bright red, purplish, vascular, nodular, subconjunctival mass

  • usually in inferior cul-de-sac

  • often combined with subconjunctival heme

  • may also involve skin of the lid, lid margins, & orbit

conjunctival intraepithelial neoplasia (CIN)

• etiology:

  • UV

  • HPV

  • AIDS

• usually occurs in late adulthood, in fair-skinned people

• rare

• appearance:

  • begins near limbus

  • can spread over the cornea

  • leukoplakic (gray-white), elevated, gelatinous or highly vascularized, ameboid shaped, fleshy lesion

  • RB or LG staining

  • movable

• can metastasize

• can evolve to SCC

• tx:

  • local excision

  • biopsy

squamous cell carcinoma

• rare

• typically seen in white pt 50+ that have had significant UV exposure

• appearance:

  • starts as small, elevated, fleshy, pink, gray nodule

  • becomes almond shaped as it extends around the limbus

  • large feeder vessels

  • flaky placoid white area over the surface

hemangioma

• etiology:

  • usually present at birth but can appear up to 10y

• appearance:

  • can enlarge w/ time

  • mass of fine, tortuous blood vessels

  • slowly progressive

  • bright red patch

  • rounded, nodular, lobulated

  • capillary (mass of fine vessels) or cavernous (broad base)

• associations:

  • Sturge Weber

racial/congenital melanosis

• etiology:

  • congenital

  • can increase w/ age

  • greater in darkly pigmented races

• no/little malignancy

• appearance:

  • flat, pigmented brown patches

  • usually near the limbus or around perforating vessels

  • bilateral

  • can extend into the cornea

acquired melanosis

• can be benign, precancerous, or cancerous

• more common in those 30-40+

• almost always in Caucasians

• higher risk of developing into melanoma

• unilateral

primary acquired melanosis (PAM)

• appearance:

  • development of irregular, diffuse, flat, grayish-black, brown, or tan bulbar pigmentation

  • may extend into palpebral conjunctiva

  • w/o cysts

  • suspect malignancy when elevation, nodules, or increase in vascularity occurs

• tx:

  • monitor very closely

  • DFE

PAM w/o atypia

benign proliferation of normal melanocytes confined to the basal layers of the conjunctiva

PAM w/ atypia

• pre-malignant condition w/ a 50% chance of malignant transformation w/in 5y

• characterized by melanocytes involving all layers of the conjunctiva

nevus

• benign

• etiology:

  • usually appear during 1st 2 decades of life

  • increase in pigment during puberty or pregnancy

• appearance:

  • usually unilateral

  • most commonly juxtalimbal, at plica or caruncle

  • 70% are pigmented

  • amelanotic/pink

  • multiple cysts w/in on histology

• associations:

  • 25% of conjunctival melanomas arise from this

• tx:

  • monitor

  • cosmetic concern or suspicious - excisional biopsy

malignant melanoma

• most common b/t 40-60y in Caucasians

• etiology:

  • can arise spontaneously from nevus or acquired melanosis

• 2% of all eye malignancies

• appearance:

  • commonly at limbus

    • higher concern if at upper tarsal plate or lower fornix

  • nodular brown or solitary black or gray nodule

  • fixed to episclera

  • can be pink

  • smooth, fish-flesh appearance

  • dilated feeder vessels

• signs/sx:

  • ABCDEs

  • bleeding/ulceration

• tx:

  • prognosis is generally good, small risk of metastasis if caught early

  • excision

conjunctival laceration

• etiology: trauma

• appearance:

  • red eye w/ subconj heme, torn edges retracted, revealing underlying sclera

  • NaFl staining & pooling

• signs/sx:

  • less symptomatic than corneal abrasion

  • mild pain/scratchy/FBS

• tx:

  • broad spectrum antibiotic sol or ointment

  • if larger than 2cm, suture

acid (sulphuric, acetic, solvents, detergents, irritants)

_______ chemical burns cause rapid denaturation & coagulation of tissue proteins, may produce a physical barrier than prevents further penetration, more often confined to superficial tissues

alkali (lye, ammonia, lime, NaOH, cements, plastics)

______ chemical burns cause dissolving of tissue proteins & allow for deep & rapid penetration through tissues

mild to moderate burn

• signs:

  • corneal epithelial defects

  • mild stromal haze

  • no significant area of perilimbal ischemia

  • focal areas of conjunctival chemosis/hypermeia/hemorrhages

  • mild eyelid edema

  • mild AC rxn

  • 1st/2nd degree burns of periocular skin

severe burns

• signs:

  • pronounced chemosis & conjunctival blanching

  • limbal ischemia

  • corneal edema

  • dense stromal haze & opacification

  • poor/no view of AC, iris, lens

  • moderate to severe AC rxn

  • increased IOP

  • 2nd/3rd degree burns of periocular skin n

1. necrosis of conjunctiva/cornea

2. loss of limbal stem cells

3. sterile corneal ulcers

4. neovascularization

5. OSD

6. symblepharon

7. entropion

8. severe stromal opacification

9. iris/lens damage

10. hypotony

11. phthisis bulbi

what are some ocular complications of burns? (11)

follicles

papilla

edema

chemosis

conjunctivochalasis

conjunctivochalasis

pseudomembrane

pseudomembrane

symblepharon

true membrane

scarring

subconjunctival hemorrhage

subconjunctival hemorrhage

subconjunctival hemorrhage

subconjunctival hemorrhage

concretions

concretions

concretions

concretions

conjunctival cyst

inclusion retention (lymphatic) cysts

inclusion retention (lymphatic) cysts

conjunctivochalasis

symblepharon

pinguecula

pinguecula

pinguecula

pinguecula

pingueculitis

pterygium

pterygium

pterygium

pterygium

Stocker’s line

pterygium

pterygium

pterygium

pterygium

pterygium

pseudopterygium

choristoma

dermoid

limbal dermoid cyst

limbal dermoid cyst

dermoid

Goldenhar’s syndrome

Goldenhar’s syndrome

limbal dermoid cyst

limbal dermoid cyst

limbal dermoid cyst

dermatolipoma

dermatolipoma

dermatolipoma

dermatolipoma

lymphangiectasia

lymphangiectasia

lymphangiectasia