Conjunctiva 3.pdf

Pterygium Wing-shaped fold of fibrovascular tissue arising from interpalpebral conjunctiva and extending into cornea Newest theory on focal limbal inflammatory process- abnormal production of cytokines as response to inflammatory insult to recover from cellular damage...

Pterygium Wing-shaped fold of fibrovascular tissue arising from interpalpebral conjunctiva and extending into cornea Newest theory on focal limbal inflammatory process- abnormal production of cytokines as response to inflammatory insult to recover from cellular damage ○ Sun, wind that change the cells (theory), grow agressively as if metaplasia is occurring Excessive production of inflammatory mediators will convert normal limbal cells to abnormally-altered pterygial cells Factors involved in inflammatory stimulus- hereditary, UV radiation, and environmental factors Treatment ○ Non-inflamed Lubricants q 3hr.-QID Sunglasses F/U 6 months ○ Mod-sev. Inflammation Mild steroids (FML/Lotemax) QID for 1 wk. Topical NSAIDS (2nd option) QID for 1 wk. Ketorolac F/U 1 wk. ○ If corneal dellen- lubricant ung and F/U daily If lesion is too elevated and every time patient blinks, any structure adjacent to the lesion is going to be dry because it cannot get covered by tear film due to the elevation and that will cause a corneal depression in a zoscher shape that is known as dellen Heavy lubrications and maybe ung ○ Surgical indications Visual axis risk because it can come back stronger and it is harder to stop it  Interfere w/ cl wear If pterygium is bothering them Very symptomatic Scar tissue will appear at pterygium means it has stopped growing ○ R/O conjunctival intraepithelial neoplasia (CIN) Sometimes this is why when removed, they look alike to the neoplasia and it is required to be sent out to pathology to R/O Pinguecula Yellow-white elevated lesion in interpalpebral conjunctiva, adjacent to limbus, but not involving cornea**** ○ More lipid like lesions Degeneration of collagen w/in substantia propia Epithelium can become thickened/calcific Betox spots? Treatment ○ Non-inflamed Lubricants q 3 hr.-QID F/U PRN ○ Inflamed Lubricants q 3 hr.-QID FML QID for 5-7 days F/U q 3-7 days Pingueculitis Degeneration of the conj. Phlyctenular Conjunctivitis (Phlyctenulosis) Delayed hypersensitivity reaction to staph proteins, TB, other agents (type 4 response from toxins) Has been associated w/ rosacea, Behcets (autoimmune disease that involves the skin and mucosa), and HIV 2 types ○ Conjunctival phlyctenule Small white nodule in the bulbar conj. in the middle of hyperemic area May also be limbal ○ Cornea phlyctenule Small white nodule at limbus, surrounded by vessels and migrate to cornea 1st and 2nd decade women living in impoverished environment (60%) Signs ○ Conjunctival 1-3 mm hard, triangular, slightly elevated, yellowish-white nodule surrounded by a hyperemic response Lesions tend to be bilateral ○ Corneal More symptomatic Begins adjacent to the limbus White mound lesion w/ a radial pattern of vascular used conjunctival vessels May migrate towards inner cornea progressing as a gray-white mass surrounded by infiltrate ○ Staph blepharitis and rosacea MCC Symptoms ○ FB sensation ○ Burning ○ Asymptomatic if mid bulbar ○ More symptoms in limbal/corneal phlyctenule Test ○ PPD, Chest x-ray (TB) ○ HLA-B51 (Behcet’s) ○ HIV Treatment  ○ Topical steroid q 2- QID, and then taper ○ If staph. Component Steroid/antibiotic component combo. Q 2-4 hr x 2 days and the QID for 7 days Líd scrubs and Erythromycin/Bacitracin ung hs Artificial tears q 2 hr.-QID ○ Severe staph Doxycycline 100 mg BID x 2-4 weeks Tetracycline 250 mg QID x 2-4 weeks EES 400 QID x 2-4 weeks ○ F/U q 5-7 days Inflammatory cells promote collagen enzymes **** we want to reduces collagenases - oral antibiotic (Tetracyclines are best, Doxy too) Superior límbic keratoconjunctivitis AKA SLK of Theodore Chronic, progressive, inflammatory disorder involving superior bulbar conjunctiva, abnormal turnover of cells Middle-aged women more affected (20-55) Associated w/ Thyroid (50% of patients w/ SLK) Also may be associated w/ RA and Sjorgrens Over 50% of SLK patients have keratoconjunctivitis sicca (KCS) SLK-CL induced variant w/ same signs: younger patients; associated w/ thimerosal products SLK resolves w/ time Unknown etiology and is suggested from mechanical trauma, TID upper lid causes friction to bulbar conj. and local tear deficiency decreases the amount of tear related nutrients thus causing added friction* Signs ○ Superior limbus sectorial thickening and inflammation from 10 o’clock-12 ○ Palpebral papillae ○ Superior SPK *stains w/ rose bengal Or Lissamine green Do not use fluorescein as it will not stain ○ Gelatinous thickening ○ Mucous secretions ○ Filamentary keratitis ○ Micropannus, not severe or too common Symptoms ○ Red eye ○ Burning ○ Photophobia  ○ FB sensation ○ Lacrimation Treatment ○ Mild Non-persevered lubricants (Refresh Plus, etc.) q 2 hr.-QID and ung hs F/U 2-3 weeks ○ Mod.-severe or NI Suilver Nitrate (0.25-1.0%), cauterizes and promotes growth of new cells Application w/ cotton tip applicator for 15-20 sec after topical anesthesia Irrigate w/ saline Erythromycin ung has for 1 wk. F/U q 1 wk ○ If mucous Acetylcysteine 10-20% QID ○ Other tx options Punctal occlusion Restasis (Off-label use) Bandage cl Cryotherapy, electrocauterization Conjunctival resection Subconjunctival hemorrhage Blood underneath conjunctiva, in one sector or more widespread Etiology: ○ Valsalva (too much straining, hard/forceful coughing, forceful constipation) ○ Trauma ○ HBP ○ Bleeding disorder ○ Medication (anti-coagulants), vitamins ○ Idiopathic CHECK BP!!! If trauma, dilate!!!! If recurrent, order CBC, PT, PTT*** for bleeding disorders Tx: none, patient reassurance ○ Lubricants  ○ Discourage use of NSAIDs and aspirin ○ Referral to internist if HBP or blood disorder suspected ○ PT/PTT, von Willebrand ○ F/U weekly Mucous Membrane Disorders Bulbous diseases affecting skin and mucous membranes that are immune mediated Autoimmune mediated reaction to antigens in the mucosal basement membrane Conditions involving the eye: cicatricial pemphigus (ocular cicatricial pemphygoid), erythema multiforme (Steven-Johnson Syndrome or EM major) Ocular Cicatrical Pemphygoid (OCP) AKA Ocular Pemphigus Vulgaris or mucous membrane pemphigoid Chronic condition Incidence— 1 in 15,000-40,000 Slightly more prevalent in female Normally occurs after the age of 55 Pathogenesis: auto-immune ○ IgA, IgG and complement cells found in conjunctiva ○ Auto antibodies directed to antigen in EBM initiate inflammatory reaction causing blister formation and later scarring ○ Drug induced OCP IDU (Idoxuridine) Echothiopate Pilocarpine Epinephrine Timodol Signs ○ Ocular: redness, photophobia, dry eye symptoms like FB sensation ○ Systemic: mucous membrane vesicles, skin vesicles  ○ Also, sub-epithelial blisters form in skin (extremities, inguinal, face and scalp); and in oral mucous membrane ○ Blisters lesions in conjunctiva heal w/ scarring, & this is the cause of complications and in the eye of vision loss Stages— is a bilateral disease that starts unilaterally ○ Stage I: Chronic conjunctivitis and sub-epithelial fibrosis, dry eye (goblet cells), burning ○ Stage II: Early fornix shortening due to conjunctiva shrinkage *trichiasis, entropion, ectropion  ○ Stage III: Symblepharon ○ Stage IV: Cicatrization leading to corneal keratinization, ankyloblepharon (lids fusion) Systemic Treatment ○ Internist, rheumatologist, dermatologist ○ Oral steroids: ○ Dapsone (Sulfone, Anti-lepra antibacterial) 100 mg QD and the 50 mg as maintenance on alt. Days * hemolytic anemia, hepatotoxic, bone marrow toxicity ○ Immunosuppressants (Cyclophosphamide 1-2 mg/kg/weight) w/ oral steroids proven to be effective ○ IV IgG Ocular tx ○ Lubricants PF q 2hr-QID and ung hs ○ If lid margin disease, treat accordingly ○ Punctal occlusion ○ For trichiasis, entropion/ectropion- bandage cl ○ F/U accordingly q few days to weeks ○ Amniotic membrane Steven’s-Johnson Syndrome Inflammatory disorder of skin and mucous membranes w/ erosive mucocutaneous lesions IV hypersensitivity Any race, any age but specially in first 3-4 decades of healthy, young individuals Precipitating factors: ○ Infectious agents like Mycoplasma pneumoniae*, Herpes Simplex, Adenoviruses ○ Drugs (most frequent) like sulfonamides*, penicillin, tetracyclines, NSAIDs, anti epileptics, thiazide diuretics, chemotherapeutic agents ○ AI diseases, allergy, cancer therapy Diagnosis:  ○ Prodrome: malaise, fever, URT, HA ○ Primary lesion is “target lesion”, red center surrounded by pale halo, and then another red halo occurring in extremeties (hands palms/feet soles) ○ Lesions may become vesicles/bullae later ○ Mouth and eyes affected. Oral lesions go from erythematous ones to bullae that can be hemorrhagic Ocular ○ Eyelid lesions from “target” lesions to crusted ○ Pseudomembrane/membranous conjunctivitis ○ Conjunctiva scarring, symblepharon, entropion/ectropion, trichiasis Symblepharon Keratinization ○ Dry eye, lagophthalmos, keratinization (cornea and conj.) ○ Iritis, episcleritis  ○ Systemic tx ○ Usually hospitalized ○ Eliminate precipitating factor ○ Oral lesions: mouthwash, top. Steroids ○ Systemic steroids: Prednisone 60-80 mg PO QD, until improvement then taper in 3-4 weeks ○ Immunosuppressive therapy Ocular Tx ○ Dry eye Non-preserved lubricants (Refresh Plus, TheraTears, Hypotears PF) q 1-2 hr, ung hs Punctal occlusion Moist. Chambers Tarsorrhaphy ○ Lid hygiene, epilation, moisten Q-tip fornix sweeping ○ Topical steroids q 2hr.-QID and cycloplegia if iritis and taper ○ Broad spectrum ab QID secondary infection Abrasion and lacerations History of trauma!!!  Abrasion: localized NaFl staining Laceration ○ Loose conj. flap or rolled up margins ○ NaFl staining ○ Sub-conj. hem. ○ Visible sclera Tx- abrasions ○ Polytrim/Aminoglycoside QID ○ May use ab oint hs (Polysporin, Erythromycin, Bacitracin) BID-QID ○ No need to patch ○ F/U q 3-7 days Tx- lacerations ○ Management for lacerations ○ Dilate, good exam ○ Antibiotic ung TID for 7 days; cycloplegia if need ○ Lacerations heal by themselves, could patch if needed ○ F/U q 3-5 days ○ If lacerations >1-1.5 cm, could refer for suturing