conjunctiva III - lumps and bumps

what are the 3 categories of conjunctival abnormalities

• degenerations

• pigmented lesions

• non-pigmented lesions 

state the different degenerations (4)

• sub-conjunctival haemorrhage 

• pinguecula 

• concretions 

• pterygium 

what is a Sub-conjunctival haemorrhage (3)

•Blood under conjunctiva- between sclera and conjunctiva 

•Asymptomatic - VA normal, no pain, no discharge - occasionally a dull ache or mild discomfort - usually an incidental finding

•Usually unilateral

aeitology of sub-conjunctival haemorrhage (3)

•Idiopathic

•Valsalva manoeuvre - coughing, straining, vomiting

•Trauma (surgery)

pre-disposing factors of a sub-conjunctival haemorrhage (3)

•Older age (60-80 years)

•Systemic hypertension, diabetes, vascular disorders

•px who are on anticoagulants (warfarin, aspirin)

signs of sub-conjunctival haemorrhage (3)

•Blood in sub-conjunctival space

•Visible clear space between the cornea and conjunctiva - around the limbus

-Trauma ? intracranial hemorrhage if posterior border cannot be seen (rare) - bleeds into sub-conjunctival space

management of a sub-conjunctival haemorrhage (2)

•Reassure patient - Usually resolves 1-3 weeks

•Refer to GP if recurrent (BP check) or history of bleeding/blood clotting abnormalities

explain what pinguecula is (5)

•Yellow-white deposits - slightly raised on conjunctiva at 3/9 oclock 

•Exposed peri-limbal bulbar conjunctiva, nasal and/or temporal - usually bilateral 

Degeneration of collagen fibres of the conjunctival stroma - Degenerative condition (benign)

•Common, especially in elderly - Seen in most eyes > 70 years

•May be associated with chronic UV exposure

treatment/management of pinguecula

•No treatment needed although if unsightly/very protuding may be removed through surgery

explain what concretions are (4) (conjunctival lithiasis)

•Small soft or hard yellowish-white deposits in tarsal conjunctiva - Usually < 1mm diam, up to 3mm - Usually low profile

•Epithelial inclusion cysts (keratin/calcification)

•Common in older people (>50 yrs)

•Usually asymptomatic - can cause foreign body sensation

treatment/management of concretions

•Treatment rarely required

•Can be teased out with hypodermic needle after anaesthetising the surface

describe what a pterygium is (3)

•Fibrovascular growth from bulbar conjunctiva across to involve the cornea - often a triangular shape

•?Tissue response to irritants

•Attributed to chronic UV exposure, dust and wind

risk factors of pterygium (3)

•Sunlight - living near equator, working out of doors, occupational exposure to UV

•Arid climate - dry climate - little rainfall - dust and wind

•Older age

symptoms of pterygium

mild irritation, may be periodic acute exacerbations

signs of pterygium (3)

•Usually bilateral (asymmetrical)

•Starts with thickening/distortion of bulbar conjunctiva, small grey opacities near the limbus, conjunctiva overgrows the opacities

•Stocker’s line - epithelial iron deposit ahead of advancing pterygium

optometric management of pterygium (4)

•Monitor development

•Photographic evidence

•Lifestyle advice - the conditions that might deterioate (UV/wind)

Refraction (astigmatism)

secondary care options for pterygium (2)

•May need surgical excision if: cosmesis important or visual axis threatened

•Tends to recur following surgery

summarize the 3 categories of pigmented lesions (2:3:1)

describe conjunctival epithelial melanosis and its features (6)

•also called Racial/ethnic melanosis - associated with dark skin

•Flat, Patchy and Brown pigmentation

•Bilateral - Asymmetrical

•Intra-epithelial - moves freely over sclera - between conjunctiva and sclera

•Develops in early years

•Unlikely to progress to melanoma

explain what Secondary acquired melanosis is (3)

•Adrenochrome deposits - pigment spots on the conjunctiva - can be due to:

•Oxidation of epinephrine drops

•Addison's disease

describe the features of (pre-malignant) naevus (5)

•Common (52% of ocular pigmented lesions)

•Congenital or acquired

•May change at puberty or during pregnancy

•Asymptomatic

-Malignant transformation rare - does occasionally happen so monitor

describe the signs of naevus (4)

•Solitary, well demarcated, flat or slightly elevated

•Brown/black (30% amelanotic no colour/pigment)

•Often cystic spaces - reassuring sign that it is a naevus

•Intraepithelial - moves freely over sclera

what is the management for naevus (3)

•Advise px to report any changes (increase in size, elevation, colour)

•Review after 6/12, then annually

•Photograph if possible

(unlikely to be malignant) 

what is primary acquired melanosis (PAM) (4)

• or also known as conjunctival melanocytic intraepithelial neoplasia (C-MIN)

•New conjunctival pigmentation

•Potential for malignancy (20%) - refer (biopsy)

•Elevation is suspicious for malignancy

describe the clinical features of PAM (6)

•Middle-aged to elderly white patients

•Unilateral

•Flat, intraepithelial, single or multiple

•Light to dark brown, indistinct areas

•No cystic spaces (naevus), no nodules (melanoma)

•Can change - enlarge, shrink, darken or lighten - refer promptly for investigation

describe what melanoma is (4)

•Rare (3-5% of ocular malignancies)

•May arise from nowhere OR , from a naevus or PAM

•Mainly affects white adults

•Metastasise (lymph)

what are the signs of a melanoma (5)

•Diffuse, nodular or mixed

•Unifocal or multifocal

•Melanotic or amelanotic - pigmented/non-pigmented 

•+/- Dilated feeder vessel

•Fixed to underlying sclera

optometric management of melanoma

• urgent referral !!! 

summarize the 3 categories of non-pigmented lesions (2:1:2)

explain what papilloma is (its 2 types) (4:4)

viral (HPV):

• often pedunculated (attached by a stalk) 

• multiple and bilateral

• in children & young adults

• May spontaneously resolve

Non viral:

• single, sessile (flatter/no stalk) lesion

• in older patients

• Appears similar to squamous cell carcinoma

• treatment: Excision and cryotherapy (freezing)

explain what Epibulbar choristoma is and its management (4)

•Dermoid - soft yellow limbal mass and Lipodermoid - soft white mass

• normal tissue growing on the surface of the eye where it doesn’t belong.

• monitor if vision isn’t affected

• surgical excision: cosmesis, significant astigmatism, affects eyelid closure/ocular movement

explain what intraepithelial dysplasia is (4)

•Raised, reddish lesion - crosses the limbus 

•Seen more in older age group (>50)

•Slow growing

•May transform to squamous cell carcinoma - refer for second opinion

describe squamous cell carcinoma (3)

•Similar in appearance to intra-epithelial dysplasia

•Requires excision Good prognosis (may re-occur)

•Local invasion

describe lymphoma (4)

•Salmon pink subconjunctival mass

•Most often located in the fornices

•Usually older pts 60-70 years

•Very rare - life threatening - refer urgently

what i need to know 

Must knows

•Subconjunctival Haem

•Pinguecula

•Concretions

•Key features of malignant lesions

Should know

•Pterygium

•Pigmented lesions

Good to know

•Papilloma

•Squamous cell carcinoma

•Lymphoma