Congenital

Epitarsus

fold of conjunctiva on palpebral lid

Osler Weber Rendu

hereditary hemorrhagic telangiectasia

AD, dilated blood vessels on palpebral conjunctiva in star/sunflower shape 1-3 mm, violacious, blanches, increased with age

telangiectasia that bleed easily, rarely in retina and look like HTN or DM retinopathy

problems with epistaxis and GI bleeding

Congenital lymphedema

X-linked Recessive, AD

characterized by dilated lymphatic channels in the conjunctiva with edema

usually massive edema of legs

dysplasia of lymphatics

Conjunctivitis

EKC adenovirus-

peak intensity days 5-7

stage ranges from superficial epithelial keratitis to subepithelial infiltrates (SEI)

subepithelia infiltrates are immune response to viral antigens on anterior stroma

can cause symblepharon

Rx: supportive, cold compresses, topical vasoconstrictors, antihistamines, topical steroids if membranes and SEI's

EBV virus

belongs to herpesvirus family

with mono can cause conjunctivitis, dry eye syndrome, epithelial keratitis (with dendrites), stromal keratitis, OGS

Rx: resolve without treatment, antivirals not very active, can treat stromal keratitis with topical steroids

Newcastle disease

virus with poultry exposure

measles

may have papillary conjunctivitis with white avascular spots on caruncle/conjunctiva like Koplik spots in mouth

causes epithelial keratitis more often than stromal keratitis

sneeze, mild fever, malaise, photophobia, irritation, FBS

papules within 3-5 days, becomes vesicular and crusting

2 wk latency, nodule in superior or inferior conjunctiva

intense chemosis, injection, lymph nodes may appear up to 2 wks later

ocular involvement usually unilateral

Hanger Rose test 90% sensitivity skin test

Warthin Starry stain for bacilli

Doxycycline 100mg bid x 1 month

tularemia

rabbit hunters, hx of tick bites with punched out lesion

lymph nodes, fever, chills, vomiting, pneumonia but ocular involved <5%

necrotizing, ulcerating conjunctivitis, corneal ulcer, optic neuritis, dacryocystitis, panophthalmitis

with agglutination titers 1:160 or higher in 2 weeks and peak in 4-8 wks

streptomycin, tetracycline

spherical elastic movable nodule, pink then purple then black and necrotic

multiple subcutaneous nodules along lymphatics, multiple yellow nodules in conjunctiva

sporotrichosis conjunctivitis seen in HIV pts

no systemic illness

culture on Sabouraud's

KI 1 ml/day

culture conjunctiva and scrape, blood cx if febrile, VDRL, FTA, PPD, viral titers, biopsy

Reiters

signs/symptoms

triad of bilateral conjunctivitis/ iridocyclitis, urethritis, polyarthritis

conjunctivitis may last days to weeks

fever, lymph nodes, pericarditis, pneumonitis, myocarditis

less commonly see keratoderma blenorrhagicum (scaling skin eruption)

think if chronic nonfollicular mucopurlent conjunctivitis

SPK, corneal infiltrate, corneal neovascularization

dx

clinical, at least 65%-75% are HLA-B27 positive

Rx

palliative, self-limited attacks last 2 to several months

may use steroids

?treat chlamydia/dysentary which may be triggered by Reiters

Floppy Lid

associated with obesity and sleep apnea

flimsy lax upper tarsus which everts easily

see papilla, punctate epitheliopathy related to exposure, keratoconus

Rx: shield eye, tape shut, or lid tightening surgery

SLK

signs/symptoms

burning, no itch or discharge, symptoms worse than signs

corridor hyperemia, velvety papilla upper tarsus

+Rose Bengal, micropannus, fine SPK, filaments in 1/2

50% with mild thyroid dysfunction

soft contact lens can also cause similar picture

rx

lubrication, punctal plugs

scrape conjunctiva, chemical cauterization with 0.5-1.0% silver nitrate, pressure patch, soft contact lens, resect conjunctiva

Thygeson's keratitis

can often mimic SEI

recurrent hx of tearing, FBS, photophobia, decreased vision with quiet white eye

bilateral raised heaped up epithelium with microcysts seen in retroillumination can mimic HSV

coarse grey white lesions slightly elevated without flourescein stain, in central cornea

Rx

dramatically responds to topical steroids often after 2 doses, taper in one wk

some need chronic therapy due to rebound if steroids stopped

topical cyclosporin/viroptic

molluscum

SPK, pannus, follicles, pseudotrachoma

can currette, freeze or excise to produce bleeding

cryotherapy

HIV patients can have multiple recurrent lesions

in children, can avoid the needle

use topical anesthesia (2.5% lidocaine/2.5% prilocaine cream applied q10min x 2 and wait 15 min)

cryotherapy with small vitreous or large cataract probe

when ice ball forms, lift probe away from skin to avoid freezing deeper tissues

apply for 20 seconds and then repeat

post op antibiotic drops

Graft vs Host

Stage 1- conjunctiva hyperemia

Stage 2- chemosis, exudate

Stage 3- pseudomembranous

Stage 4 - corneal epithelial slough

higher stage correlates with increased severity of disease and mortality

keratoconjunctivitis sicca most commonly, cicatricial lag, ectropion, persistant epithelial defects, iritis

Ligneous

infants and children are usually affected with females > males

may have family history

chronic condition with little pain or chance for visual loss except for secondary corneal involvement

primary cause unknown, but patients seem to display aggressive inflammatory response

surgery can trigger the conjunctivitis

membranes or pseudomembranes form on the upper tarsus (thick white "woody" membrane which is compact granulation tissue)

may have systemic symptoms including fever, hydrocephalus, other mucosal membrane formation

Rx

surgical debridement followed by intensive topical heparin, steroids, and possibly alpha chymotrypsin, ?mucolytics

topical cyclosporin

Chlamydia

trachoma, serotypes A-C; inclusion conjunctivitis, serotype E-K; LGV (lymphogranuloma venerum, seropyes L1,L2, L3

Trachoma

superior pannus, SPK, corneal infiltrates,

lid destruction and exposure are key elements

serologic test unreliable because of prior exposure

tetracycline, erythromycin, or sulfonamides x 3 months

or azithromycin (single dose)

Adult chlamydial conjunctivitis

keratoconjunctivitis in sexually active adults

5% with urethritis, 1-2 wk latency, meibomianitis, lid edema and redness

follicular conjunctivitis most prominent in lower conj

EKC-like SEI

NO membranes

superior pannus (not seen in EKC)

Rx

doxycyline 100mg bid 21 days or erythromycin 250mg qid 3 wks, treat partner

single dose azithromycin 1g may be effective

topical erythromycin drops

Neonatal chlamydial conjunctivitis

no follicles, more discharge, + pseudomembrane

4-12 days post partam, r/o GC

Giemsa inclusions bodies 40%, 90% with + clamydiazime

otitis, pneumonitis in 15%, recurrance 20%

Erythromycin syrup 50mg/kg qid x 2 wks, treat mom

LGV

Parinaud's OGS, follicular conjunctivitis, conjunctival granuloma

can have keratitis, corneal neovascularization, anterior uveitis

Seasonal Allergic Conjunctivitis

signs/symptoms

rapid, lid swelling, chemosis (pale palpebral conjunctiva), itching, mucus, dellen

pressure, rhinitis/asthma, episodic

symptoms are much greater than signs

can sometimes be perennial with multiple overlying allergies

dx

clinical, Type 1 hypersensitivity only, elevated tear IgE, eosinophils in scraping in chronic cases

rx

steroids rarely indicated

antihistamines systemic and topical are useful

topical NSAIDS

mast cell stabilizers if chronic condition

Vernal (VKC)

bilateral seasonal young (3-25 year old) in warmer climates, M>F

FHx of atopic allergies

usually self limited, average 4-10 years

two types: vernal and palpebral

signs/symptoms

ITCH (worsens in evening, dust, lights, wind, rubbing), clear tears

ropy discharge but lids don't get crusted or stick together unless bacterial superinfection

giant papilla may cause ptosis

limbal involvement more in blacks and can be up to 360 degrees

Horner Trantas dots (clumps of degenerated eosinophils), clear elevated cysts

SPK, flour dusting of epithelium, intraepithelial cysts, shield ulcers usually upper cornea

pseudoarcus, myopic astigmatism, associated with keratoconus, rare corneal neovascularization

>2 eosinophils/hpf pathognomonic, increased tear histamine

eosinophilic products are major cause of corneal epithelial destruction

rx

enviromental control

lodoxamide 0.1% QID is first line drug

topical steroids- pulse rx with exacerbations

topical cyclosporine 2% qid can be used as alternative to steroids

Atopic (AKC)

keratoconjunctivits in patients with atopic dermatitis

M>F, teens to 40's, burns out by 40-50 year old, small papilla, milky edema, corneal neovascularization

hx of atopic eczema (3% of population), similar to vernal findings but no seasonal changes

signs/symptoms

atopy shiners (bags under eyes from rubbing)

symblepharon, foreshortening of inferior fornix, usually lower palpebral conjunctiva affected can mimic OCP

in severe cases bilateral cataracts (anterior subcapsular, or posterior polar), 10% of all cases

atopic dermatitis associated with keratoconus, iritis, cataract

RD from pars plana tears or ora dialysis (can have photoreceptor outer segments in anterior chamber which look like cells)

diagnosis

increased serum IgE, few eosinophils in conjunctival scraping and rarely free granules

conjunctival biopsy

increased T helper, macrophages, increased class II HLA similar to OCP and rosacea.

more complex than simple mast cell allergic rx.

No BM deposition as in OCP

rx

environmental control is essential

systemic antihistamines, nasal cromolyn, topical mast cell stabilizers

pulse steroids and cream

doxycycline for blepharitis

oral and topical cyclosporin (severe cases may need immunosuppression)

general guidelines for treatment of allergic conjunctivitis

can use stepped approach depending on severity of condition

allergy testing and environmental control is essential

cool compresses and vasoconstrictors for symptoms

levocabastine- 0.05% QID for up to 2 weeks, potent H1 receptor antagonist

lodoxamide- 0.1%, gives some symptomatic relief within two to three days, has some effect on stabilizing eosinophils

cromolyn 4%

not for acute phase because therapeutic effect requires several weeks of use

acular- 1 drop QID

oral antihistamines (such as claritin 10mg QD)

immunosuppressives

for sight threatening conditions

GPC of CL

usually develops within the first year of lens wear, especially with extended wear lenses

also seen in artificial eyes, suture ends

r/o VKC (no tear histamine, no free eosinophil granules, only 1/4 have eosinophils in scrapings in GPC)

antihistamines, mast cell stabilizers, topical steroids

switch brands/ types of lenses, increase use of enzyme to twice weekly, stop lenses

Contact dermatitis

erythema, itching, scaling of lids, papilla

chronic meds (Neomycin most commonly), metals, cosmetics, false lashes cement, fingernail polish

Rx

all get hot compresses and lid scrubs bid

can try antibiotic drops qhs to qid, if severe may use antibiotic/steroid combination drop

treat MGD assoc. with rosacea with doxycycline 100mg bid for 1 month, or tetrycycline 250mg qid/ 500mg bid for 1 month with or without topical steroids

chronic doxycycline antibx associated with vaginitis, allergy, photosensitivity, take on empty stomach, no breastfeeding

children and pregnant or nursing women must not receive systemic tetracycline. alternatively, may use erythromycin

Subconjunctival hemorrhage

resolves in 1-2 weeks

Superglue in eye

toxic to endothelium

cold water compresses to loosen adherance

wait 3-4 hours, can cut lashes

Kaposi's sarcoma

conjunctival stromal tumor which appears as reddish-blue vascular macules or nodules

Grade I,II patchy and flat and <4 mon duration, Gr III > 3mm thick

on bulbar conjunctiva or eyelid

histology: spindle-shaped cells with oval nuclei and capillary channels

Rx

standard rx with radiation

consider double freeze thaw cryo for Gr I, II on eyelids

simple excision of conjunctiva for bulbar conjunctiva leaving bare sclera

excision s/p vessel delineation by flourescein angiogram for Gr III on conjunctiva