TMOD (Conjunctiva)

Pterygium

Fibrovascular growth destroying the Bowman’s layer

Related to chronic exposure to UV and ocular irritation (dry eye)

Induced WTR astigmatism

Pterygium Treatment/Management

Monitor

AT for comfort (PF if used >QID)

Educate to wear sunglasses

Surgical removal if enroaches across visual axis/reduces vision

If inflammation, tx with topical NSAID or steroid depending on severity

Pinguecula/Pingueculitis

Abnormal mounds of collagen on conj (never cornea)

Related to chronic UV exposure and ocular irritation (dry eye)

May be responsible for CL intolerence

Pinguecula/Pingueculitis Treatment/Management

Pinguecula

• monitor

• AT for comfort (PF if used >QID)

• educate to wear sunglasses

• surgical removal if AT doesn’t help

Pingueculitis

• topical NSAID or mild steroid depending on severity

Cicatricial Pemphigoid

Usually in women >60yo

Autoimmune disease of the mucous membranes (ocular, oral, respiratory, genital tissues)

Type II hypersensitivity (drug-induced timolol, epinephrine, pilocarpine)

Inferior symblepharon, ankyloblepharon (connection of inferior and superior lid),discharge, hyperemia, keratitis, entropion, trichiasis, keratinization

Cicatricial Pemphigoid stages

Stage 1: chronic conjunctivitis with mild corneal involvement

Stage 2: cicatrization with conj shrinkage and foreshortening fornices

Stage 3: symblepharon, subepi scarring leading to distortion of lashes

Stage 4: ankyblepharon, severe corneal involvement (stromal ulcers, scarring, neo, diffuse keratinization)

Cicatricial Pemphigoid Treatment/Management

Systemic steroids or immunosuppressive agents

AT and punctal plugs

If present, tx corneal defects with antibiotics

Surgery may be needed for symblepharon, ankyloblepharon, entropion, trichiasis

Cicatricial Pemphigoid prognosis

Poor, chronic progressive disease and surgery often initiates exacerbations

Erythema Multiforme (Steven-Johnson Syndrome)

Caused by infection or poor rxn to medication (sulfonamides are most common)

Type III & IV hypersenitivity rxn

Target skin lesions/eruptions, symblepharon, ankyloblepharon, discharge, hyperemia, keratitis, entropion, trichiasis, keratinization

Early systemic signs

• fever, malaise, HA, nausea/vomitting

Erythema Multiforme (Steven-Johnson Syndrome) Treatment/Management

AT and punctal plugs

If corneal defect, tx with antibiotics

If inflammation, tx with topical or oral steroids depending on severity

Surgery may be needed for symblepharon, ankyloblepharon, entropion, trichiasis

Amniotic membrane used in severe cases

Early systemic signs

• fever, malaise, HA, nausea/vomitting

Erythema Multiforme (Steven-Johnson Syndrome) prognosis

Mortality in up to 30% of cases

Subconjunctival Hemorrhage

Bleeding under conj

Causee include increase intraorbital pressure: sneezing, coughing, straining, difficult bowel movement, or even HTN, aspirin/anticoagulant use or bleeding disorder (anemia or sickle cell)

Subconjunctival Hemorrhage Treatment/Management

No tx it will resolve in 2-3 weeks

Discontinue aspirin

If recurrent, refer to PCP to rule out bleeding disorder

Superior Limbic Keratoconjunctivitis (SLK)

When superior lid chafes the superior bulbar conj

• friction caused by thyroid disease, dry eye, excessive CL wear

FB sensation, pain, burning (complaints outweigh signs)

Presents with inflammation and hyperemia and will stain with NaFl and filaments may also be present

Superior Limbic Keratoconjunctivitis (SLK) Treatment/Management

Tx underlying condition

1st line of tx is excessive use of AT and punctal plugs

If severe, silver nitrate can be applied for 10-20 seconds and then rinsed with saline then 1 week of antibiotic ointment

If filaments, tx with topical acetylcysteine

SLK due to CL responds well to steroids (but not SLK due to TED)

FU 2-4 weeks

Allergic Conjunctivitis

Type I hypersensitivity rxn

Complaint of itchy, watery eyes

Presents with papillae and possible chemosis

2 Types of Allergic Conjunctivitis

1.Seasonal Allergic Conjunctivitis

• most common type

• pollen and hay fever

2.Perennial Allergic Conjunctivitis

• year round

• dust and dander

Allergic Conjunctivitis Treatment/Management

Topical antihistamines and or steroids depending on severity

Coll compresses several times per day

For severe cases, FML for 2 days then QID for 1 week then taper then can switch to antihistamines and follow up in 2 weeks if steroids are used

Atopic Conjunctivitis

Associated with atopic dermatitis/eczema, allergic rhinitis, asthma - hereditary predilection for allergic disease

Complaint of itchy, watery eyes, photobia, pain

Presents with papillae and possible chemosis, symblepharon, neo, keratoconus, cataract

Concurrently seen with Atopic Dermatitis - Dennies lid

Atopic Conjunctivitis Treatment/Management

Topical antihistamines and or steroids depending on severity

Coll compresses several times per day

For severe cases, FML for 2 days then QID for 1 week then taper then can switch to antihistamines and follow up in 2 weeks if steroids are used

Vernal Conjunctivitis

Rare anomaly seen in boys under 10yo in hot climates and predilection for atopy

Outbreaks decrease in severity over time and resolve during puberty

Complaint of itchy, watery eyes, photobia, pain

Presents with papillae and possible chemosis, thick ropy discharge, Horner-Trantas dots (eosinophils), shield ulcer (sterile, superiorly located, well-delineated, grey infiltrate), large cobblestones in superior palpebral conj

Vernal Conjunctivitis Treatment/Management

Topical antihistamines and or steroids depending on severity

Coll compresses several times per day

For severe cases, FML for 2 days then QID for 1 week then taper then can switch to antihistamines and follow up in 2 weeks if steroids are used

Shield ulcer, tx with antibiotics and cyclo (if severe, oral antibiotics and steroid (after infection has cleared)

• FU daily

Bacterial Conjunctivitis (non-gonococcal)

Most commonly caused by G+ bacteria (Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis)

Most common cause of conj in children <3yo

Knows when it occurred but not exact time

History of recent cold

Mucopurulent discharge, hyperemia, papillae, chemosis, papillae, lid swelling, NO corneal involvement and NO lymphadenopathy

Bacterial Conjunctivitis (non-gonococcal) Treatment/Management

Topical antibiotic

• adults - fluoroquinalone, polytrim, tobramycin

• children - polytrim or polysporin

Gonococcal Conjunctivitis

STI

Caused by Neisseria gonorrhoeae (which can attack intact corneal epithelium; along with Canadian-Corynebacterium Hockey-Haemophilus League-Listeria)

HYPERACUTE - knows the exact second it occurs

Presents with severe mucopurulent discharge, hyperemia, chemosis, papillae, lid swelling, pseudomembrane, +lymphadenopathy, may also have corneal ulcers typically superior (bacteria is attacking corneal epi and causing infectious keratitis)

Unilateral then bilateral

Gonococcal Conjunctivitis Treatment/Management

IM ceftriaxone (if cornea is not involved

IV ceftriaxone (if cornea is involved) and hospitalized

Fluoroquinolones (if PCN or cephalosporin allergy) and refer to infectious specialist

Evaluate for chlamydia also

Can send conj scrapings for immediate gram stain and culture (chocolate agar or thayer-martin agar)

• G- diplococci

FU daily until improvement is noted then every 2-3 days until condition is resolved

Tx sexual partners with oral antibiotics

Ophthalmia Neonatorum (Newborn Conjunctivitis)

Develops within 4 days after birth (Neisseria gonorrhoeae is most common)

HYPERACUTE - knows the exact second it occurs

Presents with severe mucopurulent discharge, hyperemia, chemosis, papillae, lid swelling, pseudomembrane, +lymphadenopathy, may also have corneal ulcers typically superior (bacteria is attacking corneal epi and causing infectious keratitis)

Ophthalmia Neonatorum (Newborn Conjunctivitis) Treatment/Management

Erythromycin ointment prophylactically

If infection develops, give IM or IV ceftriaxone

Adult Inclusion Conjunctivitis (Chlamydial Conjunctivitis)

Chronic conjunctivitis, can last up to 12 months without treatment

Serotypes D-K

Large follicles inferior palpebral conj (even though bacterial infection), papillae, stringy mucous discharge, tender, +PAN palpable preauricular nodes

Adult Inclusion Conjunctivitis (Chlamydial Conjunctivitis) Treatment/Management

Single does of oral Azithromycin then oral doxycycline, erythromycin, or tetracycline for 1-2 weeks

FU every 2-3 weeks until resolution

Tx sexual partners with oral antibiotics

Trachoma (Chlamydial Conjunctivitis)

Chronic, can last up to 12 months without treatment

Serotypes A-C

Leading cause of preventable blindnessin the world

Follicles in superior palpebral conj (even though bacterial infection), papillae, stringy mucous discharge, tender, +PAN palpable preauricular nodes, Herpert’s pits (indentation from follicles), Arlt lines

Trachoma (Chlamydial Conjunctivitis) Treatment/Management

Single does of oral Azithromycin then oral doxycycline, erythromycin, or tetracycline for 1-2 weeks

FU every 2-3 weeks until resolution

Tx sexual partners with oral antibiotics

Adenoviral Conjunctivitis (Viral Conjunctivitis)

Most common cause of “pink eye” or viral conjunctivitis

Highly contagious for 14 days (via contact)

History of recent cold

FB sensation, Itching, burning, gritty feeling, follicles, +lymphadenopathy, serous discharge, hyperemia, lid edema

3 Types of Adenoviral Conjunctivitis (Viral Conjunctivitis)

1.Nonspecific

• most common

2.Epidemic Keratoconjunctivitis

• SEIs (2-3 wks after onset = no longer contagious)

• severe pain

• remember rule of 8 (serotype 8, symptoms after 8 days, SEI 8 days after symptoms)

3.Pharyngoconjunctival fever

• swimming poool conjunctivitis

• fever + sore throat + follicular conj

Adenoviral Conjunctivitis (Viral Conjunctivitis) Treatment/Mangement

FU 2-3 wks

Educate on contagious nature and avoid contact with others, also to clean bedsheets and towels

Mild/mod: Self resolves, can rec cool compresses & PF ATs

Severe: lotemax with taper

Molluscum Contagiosum

DNA pox virus spread via direct contact

Domes shaped umbilicated shiny nodules and lid margin (if multiple, HIV may be underlying etiology) & ruptured nodules lead to pannus and chronic conjuctivitis

Molluscum Contagiosum Treatment/Management

Excision, curettage, cryotherapy

Refer for HIV testing (Western Blot & ELISA)

Conjunctival Intraepithelial Neoplasia (CIN) → Squamous Cell Carcinoma

CIN is a precursor to SCC (most common conj malignancy in the US)

Usually in elderly caucasian males with heavy smokers, UV radiation, HPV

If <50yo, suspect HIV

Ocular irritation, FB sensation, dry eye

CIN appears as white, gelatinous dysplasia

SCC is a peripapillary, gelatinous lesion with abnormal loops of vessels

Conjunctival Intraepithelial Neoplasia (CIN) → Squamous Cell Carcinoma Treatment/Management

Refer for medical work up and MRI ot rule out invasion

Excision with biopsy, exenteration (remove globe and all contents of the eye socket), radiation

If recurrent, topical interferon alpha-2beta, mitomycin C (DNA synthesis inhibitor), or 5-fluorouracil can be consider

Conjunctival Intraepithelial Neoplasia (CIN) → Squamous Cell Carcinoma prognosis

Metastasis and orbital invasion is rare for SCC but mortality is 8%

Primary Acquired Melanosis (PAM) → Malignant Melanoma

70% of Malignant Melanoma comes from PAM

Unilateral and mostly middle-aged caucasians

1st area of metastasis of malignant melanoma is the parotid and/or submandibular lymph nodes

Primary Acquired Melanosis (PAM) → Malignant Melanoma Treatment/Management

PAM - monitor with photos

Malignant Melanoma - excisional biopsy, cryotherapy, corneal epitheliectomy, exenteration (depending on severity)

• If recurrent, tx with topical mitomycin C

Primary Acquired Melanosis (PAM) → Malignant Melanoma prognosis

Malignant Melanoma has a 45% mortality rate