Diseases of the Conjunctiva

Anatomy Review

• Conjunctiva Definition: A transparent mucous membrane that lines the inner surface of the eyelids and the surface of the globe up to the limbus.

• Vascularization: Highly vascularized, supplied by the anterior ciliary arteries and the palpebral arteries.

• Lymphatic System: Features a lymphatic system that drains to the preauricular and submandibular lymph nodes.

• Three Divisions:

  • Palpebral: Starts at the mucocutaneous junction of the lid margin and attaches to the posterior tarsal plate.

  • Forniceal: Loose and redundant conjunctiva that folds on itself.

  • Bulbar: Covers the anterior sclera and is continuous with the corneal epithelium at the limbus.

• Attachment: Loosely attached to Tenon's capsule, except at the limbus.

• Included Structures: Includes the plica semilunaris and caruncle.

• Histological Overview (Three Layers):

  • Epithelium: Non-keratinized, five layers thick.

  • Stroma: Vascularized loose connective tissue, contains lacrimal glands of Krause and Wolfring as well as goblet cells (both important for tear production).

  • Conjunctiva-Associated Lymphoid Tissue (CALT): Responsible for immune response.

Diseases of the Conjunctiva: Foundation Information

Discharge Observed with Conjunctival Infection/Inflammation

• Watery: Composed of serous exudate and tears, seen with viral or allergic conjunctivitis.

• Mucoid: Stringy or ropy, seen with chronic allergic conjunctivitis or dry eye.

• Purulent: Associated with eyes stuck shut in the morning.

  • Mucopurulent: Chlamydial or acute bacterial conjunctivitis.

  • Moderately Purulent: Acute bacterial conjunctivitis.

  • Severe Purulent: Gonococcal conjunctivitis.

Conjunctival Reactions

• Hyperemia (aka Injection): Redness of the conjunctiva.

• Hemorrhage: Area of bleeding.

  • Seen with viral and occasionally bacterial conjunctivitis.

• Chemosis: Area of conjunctival swelling.

  • Acute chemosis represents hypersensitivity.

  • Chronic chemosis is associated with orbital outflow constriction.

• Membranes:

  • Pseudomembrane: Coagulated exudate that adheres to the inflamed conjunctival epithelium. Can be peeled away without bleeding.

  • Membrane (True): Coagulated exudate that adheres to the inflamed conjunctival epithelium, contains more fibrin and blood vessels. Bleeding occurs when trying to pull the membrane away due to tearing of conjunctival tissue.

• Infiltration: Associated with chronic inflammation and a papillary response.

  • Characterized by loss of conjunctival details.

  • Common on the superior tarsal plate.

• Subconjunctival Scarring: Common in trachoma.

  • Severe scarring leads to the loss of goblet cells and accessory lacrimal glands, potentially causing entropion.

• Follicles:

  • Seen with: Viral infections, chlamydial infections, Parinaud oculoglandular syndrome, hypersensitivity to topical medications.

  • Histology: Composed of lymphocytes.

  • Presentation: Translucent, elevated lesion appearing as a "grain of rice." Blood vessels run around the lesion. Common in the fornices.

• Papillae:

  • Seen with: Bacterial infections, allergic reactions, chronic marginal blepharitis, contact lens wear, superior limbal keratoconjunctivitis, floppy eyelid syndrome.

  • Histology: Hyperplastic conjunctival epithelium with a fibrovascular core and inflammatory cell infiltration.

  • Presentation: May be present on the palpebral or bulbar conjunctiva. Will have a vascular core.

    • Micropapillae: Mosaic pattern of red dots.

    • Macropapillae: <1mm, develop with chronic inflammation.

    • Giant Papillae: >1mm, develop with chronic inflammation.

    • Limbal Papillae: Gelatinous appearance.

• Lymphadenopathy:

  • Commonly associated with: Viral infections, chlamydial infections, severe bacterial infections, Parinaud oculoglandular syndrome.

  • Affected Site: Preauricular site is commonly affected, as the lateral 1/3 of the eye drains to the preauricular lymph node.

Bacterial Conjunctival Disease

Acute Bacterial Conjunctivitis

• Causative Agents: S. pneumonia, S. aureus, H. influenza, Moraxella catarrhalis, Neisseria gonorrhea, Neisseria meningitidis.

• Nature: Self-limiting condition.

• Symptoms: Redness, grittiness, burning, and discharge.

• Presentation: Typically begins unilaterally and becomes bilateral within 1-2 days.

  • Lid edema and redness.

  • Conjunctival hyperemia.

  • Mucopurulent discharge.

  • Punctate epithelial erosions.

  • No lymphadenopathy.

• Treatment:

  • Culture as needed to identify the causative agent and customize treatment.

  • Topical antibiotics.

  • Systemic antibiotics are used for Gonococcal, H. influenza, and Meningococcal infections.

Adult Chlamydial Conjunctivitis

• Causative Agent: Chlamydia trachomatis (serological variants D-K).

• Transmission: Sexually transmitted infection.

  • Affects 5-20\% of sexually active adults.

  • In 2018, there were 1.8 million cases in the US.

  • 10\% of infections result from eye-to-eye contact.

  • Males may have urethritis (most are asymptomatic).

  • Females may have urethritis, causing painful urination, and can progress to pelvic inflammatory disease and infertility.

• Presentation:

  • Watery or mucopurulent discharge.

  • Large follicles prominent in the inferior fornix or superior tarsal plate.

  • Punctate epithelial erosions.

  • Peripheral subepithelial corneal infiltrates (may have a 2-3 week delay of onset).

  • Tender preauricular lymphadenopathy.

  • Conjunctival scarring and corneal pannus are seen with chronic infections.

• Treatment:

  • Culture.

  • Referral to a genitourinary specialist.

  • Systemic antibiotics.

  • Topical antibiotics.

Trachoma

• Significance: Leading cause of preventable irreversible blindness in the world.

• Association: Related to poverty, overcrowding, and poor hygiene.

• Caused by: Chlamydia trachomatis (serological variants A, B, Ba, C).

• Two Stages:

  • Active Trachoma:

    • Common in pre-school children.

    • Mixed papillary and follicular reaction (follicular reaction absent in children under 2).

    • Mucopurulent discharge.

    • Superior epithelial keratitis and pannus formation.

  • Cicatricial Trachoma:

    • More common in middle-aged individuals.

    • Conjunctival scarring:

      • Mild infection: linear or stellate scarring.

      • Severe infection: broad confluent scars (Arlt lines).

      • Superior tarsus affected more than other areas.

    • Superior limbal follicles: once resolved, shallow pits (Herbert pits) occur.

    • Corneal opacification with vascularization.

    • Trichiasis and distichiasis.

    • Dry eye due to goblet cell destruction.

• Grading of Trachoma by WHO:

  • TF (Trachomatous Inflammation-Follicular): Five or more follicles (>0.5mm) on the superior tarsus.

  • TI (Trachomatous Inflammation-Intense): Diffuse involvement of the tarsal conjunctiva, 50\% of tarsal blood vessels obscured, papillae present.

  • TS (Trachomatous Scarring): Scarring of the conjunctiva.

  • TT (Trachomatous Trichiasis): At least one eyelash touching the globe.

  • CO (Corneal Opacification): Opacification of the cornea, half of the pupil margin obscured.

• Treatment (SAFE Strategy): Dependent on disease classification.

  • S - Surgery: Aims to repair entropion and trichiasis, allows for complete lid closure. Used for Trachomatous Trichiasis (TT).

  • A - Antibiotics: Topical and systemic. Used for Trachomatous Inflammation-Follicular (TF, topical only) and Trachomatous Inflammation-Intense (TI, topical and systemic).

  • F - Facial Cleanliness: Used for all stages.

  • E - Environmental Improvement: Access to clean water and sanitation.

Adult Gonococcal Conjunctivitis

• Cause: Neisseria gonorrhea.

• Transmission: Sexually transmitted disease.

  • In 2018, there were 583,405 cases in the US.

  • Both males and females tend to be asymptomatic systemically.

• Symptoms: Rapid onset (12-24 hours).

  • Severe mucopurulent discharge that quickly returns once wiped away.

• Presentation:

  • Lid edema.

  • Chemosis.

  • Papillary conjunctival reaction.

  • Corneal involvement: infiltrate, ulceration, perforation (N. gonorrhea can invade an intact corneal epithelium).

• Treatment:

  • Culture.

  • Intramuscular antibiotics.

  • If the cornea is involved, hospitalization with IV antibiotics is required.

  • Topical antibiotics.

  • Management with primary care physicians.

Neonatal Conjunctivitis (aka Ophthalmia Neonatorum)

• Definition: Conjunctivitis seen in the first month of life.

• Causes and Onset:

  • Chlamydia trachomatis: Symptoms present 1-3 weeks after birth.

  • Neisseria gonorrhea: Symptoms present the first week of life.

  • Herpes Simplex (HSV-2): Symptoms present 1-2 weeks after birth.

  • Staph and strep species: Symptoms occur at the end of the first week of life.

  • Chemical: Due to the use of silver nitrate after birth.

• Presentation:

  • Discharge: Varies depending on causative agent (e.g., mucopurulent for chlamydial, purulent for gonococcal).

  • Eyelid edema: Severe and associated with gonococcal infection.

  • Eyelid and periorbital vesicles: Associated with herpes.

  • Conjunctival hyperemia.

  • Keratitis: Associated with gonococcal or herpes infection, presents as epithelial edema and ulceration, which may lead to corneal perforation.

• Treatment:

  • Culture to determine causative agent.

  • Antibiotics: Topical for mild conjunctivitis, oral for moderate to severe conjunctivitis.

  • IV antiviral for herpes.

Viral Conjunctival Disease

Adenoviral Conjunctivitis

• Contagion: Highly contagious through respiratory or ocular secretions. Viral shedding can occur for days prior to symptom onset.

• Four Types:

  • Non-specific Acute Follicular Conjunctivitis:

    • Most common form.

    • Associated sore throat or cold.

    • Ocular symptoms are mild: irritation, foreign body sensation.

    • Presentation: Follicular conjunctival reaction, conjunctival hyperemia, punctate epithelial erosions, preauricular lymphadenopathy.

    • Treatment: Palliative care.

  • Pharyngoconjunctival Fever:

    • Commonly seen in children.

    • Associated pharyngitis (sore throat) and fever.

    • Presentation: Follicular conjunctival reaction, conjunctival hyperemia, rhinitis, preauricular lymphadenopathy.

    • Treatment: Palliative care.

  • Epidemic Keratoconjunctivitis (EKC):

    • Caused by: Adenovirus serotypes 8, 19, 37.

    • Symptoms: Ocular irritation/foreign body sensation, photophobia, epiphora (excessive tearing), blurred vision.

    • Presentation: Clear or yellow discharge, eyelid swelling, bulbar and palpebral conjunctival hyperemia, conjunctival chemosis with follicular reaction.

    • Keratitis: Epithelial microcysts (early stage), punctate epithelial erosions (day 7-10), infiltrates (day 14, may last months to years, due to immune response).

    • Membrane or pseudomembrane formation.

    • Preauricular lymphadenopathy.

    • Treatment:

      • Palliative treatment: cold compresses, artificial tears.

      • Topical steroids: commonly prescribed when corneal involvement is seen.

      • Povidone-iodine (off-label use): May decrease duration of symptoms and signs.

  • Chronic/Relapsing Adenoviral Conjunctivitis: (Mentioned as a type, but no further details provided in transcript).

Molluscum Contagiosum Conjunctivitis

• Cause: Poxvirus (from Molluscum contagiosum lid lesion).

• Incidence: Typically between 2-4 years of age.

• Lid Lesion: Molluscum lesion typically seen along the eyelid margin.

• Symptoms: Chronic unilateral ocular irritation.

• Presentation: Pale, waxy, umbilicated nodule on the lid margin.

  • Follicular conjunctival reaction.

  • Bulbar conjunctival nodule (seen with immunocompromised patients).

  • Epithelial keratitis and pannus can be seen in longstanding untreated cases.

• Treatment: Excision of the lid lesion, incision and drainage of the lid lesion, or cryosurgery of the lid lesion.

Herpes Simplex Conjunctivitis

• Cause: Herpes Simplex Virus 1 (HSV-1).

• Virus Latency: Virus lays dormant in the trigeminal ganglion and reactivates along any branch of the trigeminal nerve.

• Activation Triggers: Stress, fever, trauma, ultraviolet light.

• Nature: Conjunctivitis is considered a primary HSV infection and typically goes undiagnosed.

• Symptoms: Redness, pain, photophobia.

• Presentation: Unilateral follicular conjunctival reaction, conjunctival hyperemia.

• Treatment: Oral antiviral.

COVID-19 Conjunctivitis

• Cause: SARS-CoV-2 (an upper respiratory disease transmitted by respiratory secretions).

• Virus in Tears: Reports of the virus being present in the tears.

• Ocular Manifestation: Ocular manifestations have been reported as a first sign of the disease, and also in individuals with severe manifestations.

• Symptoms: Discharge, epiphora, photophobia.

• Presentation: Follicular conjunctival reaction, conjunctival hyperemia, chemosis.

• Treatment: Palliative care: artificial tears and lid hygiene.

Allergic Conjunctival Disease

Allergic Conjunctivitis (Acute, Seasonal, Perennial)

• Three Variants: Acute, seasonal, and perennial.

  • Acute is more common in children.

  • Seasonal and perennial can affect all individuals.

• Commonality: Common condition caused by environmental allergens.

• Seasonal Allergic Conjunctivitis: Symptoms worse in spring and summer, pollen is the causative agent (more common).

• Perennial Allergic Conjunctivitis: Symptoms throughout the year, causative agents are house dust mites, animal dander, and fungal allergens (less common and tends to be milder).

• Symptoms: Itching and watering.

• Presentation: Papillary reaction, conjunctival hyperemia, conjunctival chemosis.

• Treatment: Topical or oral antihistamines, topical mast cell stabilizers, topical steroids, cold compresses.

Vernal Keratoconjunctivitis (VKC)

• Immune Response: IgE and cell-mediated immune response.

• Demographics: Affects males more than females. Onset of symptoms at 5 years of age; symptoms improve with age.

• Climate/Season: More common in hot, dry climates. Peak incidence in spring and summer.

• Symptoms: Itching, foreign body sensation, thick mucoid discharge.

• Presentation (Divided into Conjunctival, Limbal, and Corneal Disease):

  • Conjunctival:

    • Macropapillae of the superior tarsal plate (tend to be <1mm and have flattened tops).

    • Giant papillae of the superior tarsal plate (tend to be >1.0mm and have flattened tops; mucus seen between them).

    • Conjunctival hyperemia.

  • Limbal:

    • Limbal papillae: gelatinous-appearing papillae at the limbus.

    • Horner-Trantas dots: focal white dots at the limbus, made up of degenerated epithelial cells and eosinophils.

  • Corneal (commonly seen with conjunctival disease):

    • Superior punctate epithelial erosions: associated with sheets of mucus.

    • Epithelial macroerosions: due to coalesced punctate epithelial erosions, inflammatory mediators, and mechanical injury from superior tarsal papillae.

    • Plaques and shield ulcers: Plaques composed of fibrin and mucus, collect on macroerosions and form shield ulcers.

    • Subepithelial scars: appearing grey and oval, may affect vision.

    • Pseudogerontoxon: seen with recurrent limbal disease, a white-grey band in the anterior stroma of scarring, adjacent to the area of previous limbal inflammation.

    • Corneal neovascularization: tends to be superior.

• Treatment:

  • Allergen avoidance.

  • Palliative care: cold compresses and lid hygiene.

  • Topical antihistamines (mild cases).

  • Topical antihistamine and mast cell stabilizer combination (moderate cases).

  • Topical steroids (most effective).

  • Topical cyclosporine.

  • Systemic steroids (only with sight-threatening conditions).

  • Surgical: amniotic membrane and keratectomy for severe corneal disease.

Atopic Keratoconjunctivitis (AKC)

• Immune Reaction: Combination of type I and type IV reactions.

• Onset: Develops in adulthood, age of onset 30-50 years.

• Demographics: Males = Females.

• Associated Conditions: Individuals typically also diagnosed with eczema, asthma, allergies. 5\% of individuals previously diagnosed with VKC.

• Nature: Tends to be perennial, worse in the winter.

• Symptoms: More severe than VKC. Itching, tearing, photophobia, mucoid discharge.

• Presentation (Affects Eyelids, Conjunctiva, Cornea, and Lens):

  • Eyelids:

    • Eczematous dermatitis: red, thickened, dry skin with blistered patches.

    • Blepharitis.

    • Madarosis and/or trichiasis.

    • Ectropion: due to tightening of the lower lid, can result in epiphora.

  • Conjunctiva (worse inferior):

    • Papillary conjunctival reaction.

    • Conjunctival hyperemia.

    • Horner-Trantas dots.

    • Conjunctival scarring and symblepharon formation, leading to a shortened fornix and keratinization of the caruncle.

  • Cornea:

    • Punctate epithelial erosions: inferior one-third of the cornea.

    • Persistent epithelial defects: may have associated corneal thinning.

    • Plaques.

    • Peripheral vascularization with stromal scarring: more common with AKC than VKC.

  • Lens:

    • Cataract: Shield-like anterior or posterior subcapsular cataract.

• Treatment:

  • Remove antigen.

  • Palliative care: lid hygiene, cold compresses, artificial tears.

  • Topical mast cell stabilizer, antihistamine, or combination.

  • Topical steroid and cyclosporine.

  • Oral antihistamine or steroid.

  • Bandage contact lens for persistent corneal defects.

  • Surgical: amniotic membrane, keratoplasty for persistent corneal defects.

Giant Papillary Conjunctivitis (GPC)

• Cause: Mechanical irritation.

  • Contact lenses (protein buildup).

  • Ocular prosthetic.

  • Exposed suture (e.g., corneal transplant).

  • Scleral buckle (retinal detachment repair).

  • Filtering bleb from trabeculectomy (glaucoma surgery).

  • Mucus fishing syndrome.

• Symptoms: Foreign body sensation, redness, itching, mucus discharge, contact lens intolerance (worsens after contact lens removal).

• Presentation:

  • Conjunctival hyperemia of the superior tarsal plate.

  • Medium sized papillae (>0.3mm) on the superior tarsal plate (may ulcerate in advanced cases).

  • Contact lens intolerance: excessive movement of the contact lens, protein deposits on the contact lens.

• Treatment:

  • If caused by contact lenses: discontinue wear until resolution, stress proper wear schedule and cleaning regimen.

  • If caused by ocular prosthetic: stress proper cleaning regimen.

  • Topical mast cell stabilizers, antihistamines, and combinations.

  • Topical steroids.

Mucocutaneous Disease with Conjunctivitis

Cicatricial Pemphigoid (aka Mucus Membrane Pemphigoid)

• Definition: Group of chronic autoimmune mucocutaneous blistering diseases.

• Affected Areas: Conjunctiva, nasopharynx, upper airways, gastrointestinal system.

• Demographics: Typically affects elderly individuals. Females are affected more than males (2:1).

• Cause: Type II hypersensitivity, where antibodies bind with complement at the basement membrane and recruit inflammatory cells.

• Presentation: Insidious onset, bilateral but asymmetric condition.

• Affected Ocular Structures: Conjunctiva, cornea, eyelids.

• Conjunctival Findings: Papillary reaction, diffuse hyperemia and chemosis, flattening of the plica and keratinization of the caruncle, conjunctival fibrosis and shortening of the inferior fornix, symblepharon (adhesions between bulbar and palpebral conjunctiva), destruction of goblet cells and accessory lacrimal glands (resulting in dry eye), necrosis in severe cases.

• Corneal Findings: Punctate epithelial erosions, vascularization, infiltrates, keratinization of the cornea due to limbal stem cell failure.

• Eyelid Findings: Aberrant lashes, blepharitis, keratinization of the lid margin, ankyloblepharon (connection of the upper and lower lid at the lateral canthus).

• Treatment:

  • Systemic Treatment: Oral antibiotics/anti-inflammatories, antimetabolites (chemotherapy drugs), oral steroids.

  • Ocular Treatment: Artificial tears, topical steroids, blepharitis treatment (lid hygiene and tetracyclines), subconjunctival injections (mitomycin-C or steroid).

• Treatment of Complications:

  • Laser removal of aberrant eyelashes.

  • Punctal occlusion for severe dry eye.

  • Tarsorrhaphy when persistent epithelial defects are present.

  • Amniotic membrane for keratinization of the conjunctiva.

  • Entropion repair.

  • Keratoplasty or keratoprosthetic.

Stevens-Johnson Syndrome

• Rarity: Rare condition (less than 5000 individuals in US diagnosed).

• Demographics: Can affect children and adults.

• Causes: Viral infections in children; medications (antibiotics, anti-inflammatory pain killers, epilepsy medications) in adults.

• Cause: Cell-mediated delayed hypersensitivity.

• Mortality: Can be fatal with a mortality rate of 5\%.

• Presentation: Individuals present with systemic and ocular manifestations.

• Symptoms: Prodromal phase (fever, malaise, muscle and joint pain).

• Systemic Presentation: Skin rash develops on the trunk and face; eventually the skin becomes necrotic and sloughs off.

• Ocular Presentation: Bilateral conjunctival hyperemia with purulent discharge.

  • Other Ocular Findings: Subconjunctival hemorrhage, conjunctival membranes, punctate epithelial erosions with epithelial defects.

• Complications: Symblepharon, lid margin keratinization, meibomian gland disease/dry eye, corneal opacification, distichiasis.

• Treatment:

  • Systemic: Removal of the causative agent.

  • Ocular: Artificial tears and ointments, topical antibiotics, removal of conjunctival membranes, treatment of complications.

Miscellaneous Conjunctival Disease

Superior Limbic Keratoconjunctivitis (SLK)

• Nature: Bilateral condition with episodes of exacerbation and remission.

• Association: Associated with Thyroid Eye Disease (50\% of individuals with TED have SLK).

• Symptoms: Foreign body sensation, photophobia, pain.

• Presentation: Radial injection of the superior bulbar conjunctiva starting at the limbus, papillary reaction of the superior palpebral conjunctiva, punctate staining of the superior cornea (filaments may also be present).

• Treatment: Similar to dry eye treatment (artificial tears, concurrent lid disease management, topical anti-inflammatory medication like topical cyclosporine), bandage contact lens.

Subconjunctival Hemorrhage

• Causes: Valsalva (coughing, sneezing, constipation), systemic conditions (hypertension, bleeding disorders), medication-induced (antiplatelet or anticoagulant medication), traumatic, idiopathic.

• Symptoms: Typically none, may have irritation if hemorrhage is large.

• Presentation: Collection of blood beneath the conjunctiva. Tends to be sectoral but can be diffuse. Details of the sclera will be blocked by the blood.

• Treatment:

  • Palliative care: artificial tears for irritation.

  • Check blood pressure.

  • Communicate with primary care physician if taking antiplatelet or anticoagulant medication.

  • Lab work for recurrent subconjunctival hemorrhages: prothrombin time, partial thromboplastin time, complete blood work with platelet count.

Ligneous Conjunctivitis

• Rarity: Rare condition that is potentially sight and life-threatening.

• Demographics: Typically presents in childhood. Females > Males.

• Cause: Plasminogen deficiency, which leads to diminished wound healing. When the eye undergoes trauma, the body produces a fibrin-rich matrix. Plasmin is responsible for removing this matrix. When there is a plasminogen deficiency, the matrix is not removed. Associated with trauma or surgery.

• Symptoms: Mucus discharge, conjunctival hyperemia, systemic symptoms (fever, upper respiratory infection).

• Presentation: Pseudomembrane that thickens and gives a wood-like appearance. Enlarged red-white lobular conjunctival masses. Corneal involvement: scarring and vascularization.

• Treatment: Surgical excision. Topical steroids and topical cyclosporine may help with recurrence.

Parinaud Oculoglandular Syndrome

• Cause: Cat-scratch disease (Bartonella henselae), tuberculosis, and acute Chlamydia trachomatis.

• Presentation: Unilateral granulomatous conjunctivitis, follicular reaction, low-grade fever, ipsilateral pre-auricular lymphadenopathy.

• Treatment: Palliative care as the condition is self-limiting. Oral antibiotics in severe cases to prevent secondary infection.

Factitious Conjunctivitis

• Cause: Self-injury (intentional or unintentional).

• Presentation: Inferior conjunctival injection with quiet superior conjunctiva.

  • Corneal findings: Persistent punctate epithelial erosions, abrasion, ring infiltrate with hypopyon (collection of inflammatory cells in the anterior chamber), perforation, scarring.

• Treatment: Diagnosis of exclusion. Consider psychiatric evaluation.

Mucus Fishing Syndrome

• Characterization: Continuous extraction of mucus from the eye.

• Cause: Excessive production of mucus due to ocular irritation.

  • Common irritants: Dry eye, blepharitis, ocular allergies.

  • The individual attempts to remove the mucus by "fishing" it out.

• Presentation: Mechanical abrasion of the conjunctiva or cornea.

• Treatment: Eliminate ocular irritation. Counsel the individual against touching the ocular surface.

Conjunctival Degeneration

Pinguecula

• Commonality: Common condition.

• Definition: Degeneration of the conjunctival stromal fibers.

• Symptoms: None, unless it becomes inflamed.

• Presentation: Yellow-white dome on the bulbar conjunctiva. Typically located near the temporal or nasal limbus.

• Treatment: None. If inflamed, topical steroids can be prescribed. Excision can be performed if large and irritating.

Pterygium

• Definition: Triangular fibrovascular subepithelial ingrowth of degenerative bulbar conjunctival tissue that grows from the conjunctiva to the limbus and spreads across the cornea.

• Prevalence: More prevalent in hot climates, with chronic UV exposure, and chronic dryness.

• Symptoms: Wide range, many individuals are asymptomatic. May experience irritation or grittiness. Blurred vision due to induced astigmatism.

• Presentation: Triangle-shaped conjunctival tissue that starts interpalpebral (nasal) and migrates over the limbus to the center of the cornea.

  • Composed of three parts:

    • Cap: Avascular zone at the leading edge.

    • Head: Apex of the pterygium, usually raised and vascularized.

    • Body: Fleshy portion containing tortuous blood vessels.

  • Corneal irregularities (punctate epithelial erosions or thinning) may be seen at the leading edge.

  • Iron deposition (Stocker line) may be present at the leading edge.

• Treatment: Observation. Surgical excision (use caution as pterygium can recur and be more aggressive).

Concretion

• Commonality: Common condition seen with aging. May also be seen with chronic conjunctivitis.

• Presentation: Small yellow-whitish cysts. Cysts made up of keratin and may become calcified. May become large and erode through the conjunctiva, causing irritation.

• Treatment: Observation. If causing irritation, excision.

Conjunctivochalasis

• Commonality: Seen with aging.

• Association: Associated with posterior blepharitis.

• Symptoms: Watering and foreign body sensation in downgaze.

• Presentation: Redundant conjunctiva (inferior) that folds and protrudes over the lid margin.

• Treatment: Artificial tears, topical steroids, treatment of posterior blepharitis, surgical resection.

Retention Cyst (Epithelial Inclusion Cyst)

• Symptoms: None to mild discomfort.

• Presentation: Fluid-filled cyst; benign.

• Treatment: Observation or artificial tears for irritation.

Benign Tumors of the Conjunctiva

Conjunctival Nevus

• Most Common Tumor: Involving conjunctival melanocytes.

• Risk for Melanoma: 1\% risk of developing into melanoma.

  • Melanoma development occurs when: Nevus location is unusual (fornix or palpebral conjunctiva), prominent feeder vessels, increase in size or pigmentation, presents after the second decade.

• Presentation: Presents in the 1^{st} or 2^{nd} decade. Unilateral, pigmented, elevated conjunctival lesion.

  • Frequently found juxtalimbal (near the limbus), plica, and caruncle.

  • Cysts may be present within the nevus.

• Treatment: Observation. Surgical excision for cosmetic reasons.

Conjunctival Papilloma

• Histology: Irregular non-keratinized stratified squamous epithelium with a fibrovascular core.

• Two Types of Lesions:

  • Sessile: More common in children and young adults, commonly caused by human papillomavirus.

  • Pedunculated: More common in older adults, commonly caused by UV exposure.

• Symptoms: Ocular irritation or impediment of lid closure (larger lesions).

• Presentation: Sessile papillomas have a wide base with a flat/fleshy appearance. Pedunculated papillomas have an irregular surface with a frond/cauliflower appearance.

  • Frequently found juxtalimbal, fornix, or caruncle.

  • May have one lesion or multiple.

• Treatment: Small lesions will spontaneously resolve. Larger lesions will need surgical excision.

Limbal Dermoid

• Definition: A mass of normal tissue in an abnormal position (choristoma).

• Demographics: More common in children.

• Systemic Associations: Goldenhar syndrome and Treacher Collins syndrome.

• Presentation: Smooth yellow soft subconjunctival mass, typically located inferior temporal. May have protruding hair. Will disrupt corneal architecture to differing degrees, from superficial involvement to invasion into the anterior chamber. Extensive corneal involvement can lead to astigmatism and amblyopia.

• Treatment: Surgical - simple excision for small lesions to corneal transplants for lesions with extensive corneal involvement.

Dermolipoma

• Definition: A mass of fatty tissue in an abnormal position, similar to a limbal dermoid.

• Demographics: Typically affects adults.

• Presentation: Yellow subconjunctival mass near the outer canthus. Surface of the mass will be keratinized. May contain hairs.

• Treatment: Debulking the mass. Surgery is rarely performed due to complications.

Pyogenic Granuloma

• Definition: Fibrovascular lesion that is the result of a surgery or injury.

• Location: Found on the lid or conjunctiva.

• Presentation: Dark pink fleshy conjunctival mass. Tends to be rapidly growing.

• Treatment: Topical steroid or excision.

Racial Melanosis (Conjunctival Epithelial Melanosis)

• Definition/Histology: Excessive melanin within the basal layer of the conjunctival epithelial melanocytes.

• Presentation: Presents during childhood and remains stable through adulthood. Common in dark-skinned individuals. Bilateral condition but may be asymmetric.

• Clinical Presentation: Flat, patchy brown pigmentation. Can be found throughout the conjunctiva with a higher concentration near the limbus.

• Treatment: None.

Malignant Tumors of the Conjunctiva

Primary Acquired Melanosis (PAM)

• Demographics: Common in fair-skinned middle-aged to elderly individuals.

• Two Variants:

  • PAM without atypia: Pigmentation of the conjunctival epithelium with or without melanocyte hyperplasia.

  • PAM with atypia: Pigmentation of the conjunctival epithelium with atypical melanocyte hyperplasia (considered a precancerous melanosis).

• Risk: The larger the lesion, the greater the risk for transforming to melanoma.

• Symptoms: Asymptomatic.

• Presentation: Flat, irregular brown lesion of the conjunctival epithelium. Unilateral condition. Located on palpebral, bulbar, and fornix. May be uni- or multifocal.

• Treatment: Observation or excision.

Conjunctival Melanoma

• Rarity: Uncommon condition, makes up 2\% of all ocular tumors.

• Demographics: Typically presents in the sixth decade.

• Origin: Will arise from PAM with atypia (9-32\%) or conjunctival nevus (1\%). May also occur without a previous lesion.

• Presentation: Pigmented, elevated lesion with surrounding pigmentation. Most commonly located on bulbar conjunctiva and limbus. Less commonly seen on palpebral conjunctiva and fornix. Associated feeder vessels.

• Treatment: Excision with chemotherapy, cryotherapy, or radiotherapy.

Ocular Surface Squamous Neoplasia (OSSN)

• Demographics: Typically affects older adults. Affects males more in US and Europe, and women in Africa.

• Risk Factors: UV exposure, fair skin, smoking, xeroderma pigmentosum, HIV, human papillomavirus.

• Nature: Slowly progressive lesion that may be benign, premalignant, or malignant.

• Symptoms: Visible mass with occasional conjunctivitis.

• Presentation: Fleshy, gelatinous mass. May have a papillomatous appearance. Feeder vessels will be visible. Typically located within the interpalpebral fissure, particularly at the limbus.

• Treatment: Excision.

Lymphoproliferative Lesions

• Demographics: Develops late adulthood.

• Symptoms: Irritation with painless swelling that may be bilateral.

• Presentation: Flesh-colored infiltrate on the bulbar surface or the fornix. Rarely diffuse (will mimic chronic conjunctivitis in this case). Will be mobile.

• Treatment: Radiotherapy, chemotherapy, excision, cryotherapy.

Kaposi Sarcoma

• Rarity: Rare condition that primarily affects patients with AIDS.

• Histology: Spindle-shaped cells with vascular channels and inflammatory cells.

• Presentation: Flat bright red lesion.

• Treatment: Focal radiotherapy. Excision with or without adjacent cryotherapy.

Trauma of the Conjunctiva

General Trauma Information

• Demographics: Trauma typically occurs in late adolescence or adulthood (>70). Men are typically affected more than females.

• Causes: Typically caused by sports or motor vehicle events.

Conjunctival Laceration

• Cause: Fingernail.

• Symptoms: Pain, redness, foreign body sensation.

• Presentation: Rolled conjunctival tissue, conjunctival chemosis, conjunctival hemorrhage.

• Treatment: Dependent on the size of the laceration.

  • Lacerations under 10mm: topical antibiotic ointment.

  • Lacerations over 10mm: suture repair.

  • Topical antibiotic.