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Subepithelial Tumors of the Conjunctiva

Key Concepts Subepithelial tumors are diverse and are reflective of the variety of cell types that reside in the subepithelial space. Systemic processes, such as inflammation or metastatic disease, may produce subepithelial masses. Lymphoproliferative disease can be associated with systemic lymphoma at the time of diagnosis or may be the harbinger of future systemic lymphoma. Expert ophthalmic pathology evaluation—including histopathology and immunohistochemistry—is invaluable in the diagnosis…

Melanocytic Neoplasms of the Conjunctiva

Key Concepts Melanocytes are a normal component of conjunctival epithelium. Melanosis is hyperproduction of melanin in the conjunctival epithelium. Bilateral, age-related melanosis of the conjunctiva in pigmented races is benign and generally not a risk factor for developing conjunctival melanoma. Nevi are composed of congenitally abnormal melanocytes. The nevus elevates the conjunctival surface contour and may be associated with clinically visible squamous inclusion cysts. Melanocytes and…

Medical and Surgical Management of Ocular Surface Squamous Neoplasia

Key Concepts Early identification and management of ocular surface squamous neoplasia (OSSN) is critical to reduce ocular morbidity. High-resolution optical coherence tomography (HR-OCT) serves as a powerful tool for noninvasive diagnosis of OSSN, especially in subtle cases or in the setting of coexisting ocular surface disease. OSSN can be treated successfully with either medical or surgical management or a combination of the two treatments. Many factors…

Epithelial Tumors of the Conjunctiva

Key Concepts Early diagnosis and treatment of ocular surface squamous neoplasia translates to preservation of the eye and vision. Clinical monitoring for recurrence is imperative following treatment. Suspicion should be raised with any unusual appearing pterygia or ocular surface tumefactions. Excision with adjunct cryotherapy or postoperative topical chemotherapy/immunomodulatory therapy provides pathology for diagnosis and is the gold standard treatment of ocular surface squamous neoplasia. Topical immunomodulatory…

Conjunctivochalasis

Key Concepts Conjunctivochalasis is a common bilateral condition characterized by redundant, loose, nonedematous conjunctiva. Its incidence increases with age, and its pathophysiology remains unclear. It is often asymptomatic; however, it can cause a range of symptoms from ocular irritation, lacrimation, pain, blurry vision, dryness, or redness. A more severe presentation—with subconjunctival hemorrhage and conjunctival protrusion with corneal exposure—is rare. Conjunctivochalasis is an important differential diagnosis that…

Ligneous Conjunctivitis

Key Concepts Ligneous conjunctivitis is a rare disorder associated with systemic plasminogen deficiency. Only type I hypoplasminogenemia (reduction in plasminogen level and activity) has been shown to cause any form of pseudomembranous disease. The most common manifestation of systemic plasminogen deficiency is chronic conjunctivitis, which can produce true membranous lesions that are highly vascularized, raised, and friable. Plasminogen-deficient patients can have systemic symptoms involving the respiratory…

Superior Limbic Keratoconjunctivitis

Key Concepts Superior limbic keratoconjunctivitis is an ocular surface disease. Discrepancy between signs and symptoms is not uncommon, and the discomfort can be disabling. Etiology is unclear, but mounting evidence suggests a mechanistic theory. Distinct histopathologic findings include epithelial keratinization, acanthosis, dyskeratosis, balloon degeneration of the epithelial nuclei, reduction in goblet cell density, and inflammatory reaction in both the bulbar and upper tarsal conjunctiva. There is…

Toxic Conjunctivitis

Key Concepts Toxic conjunctivitis is a potentially sight-threatening condition that must be recognized and managed appropriately. Toxic conjunctivitis as a result of ophthalmic medications can be clinically difficult to distinguish from allergic conjunctivitis. Careful clinical examination can provide diagnostic cues to the presence of toxic reactions to ophthalmic medications. The appearance of toxic reactions to ophthalmic medications can range from mild surface irritation to pseudopemphigoid appearance…

Erythema Multiforme, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis

Key Concepts Although historically considered as part of a continuum of vesiculobullous disease, erythema multiforme is currently thought to be a disease entity separate from Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). SJS and TEN are potentially blinding conditions. Intensive ophthalmologic management during the first 1–2 weeks of the illness is crucial for preventing long-term ocular sequelae. Eye involvement in the acute phase of SJS/TEN…

Mucous Membrane Pemphigoid

Key Concepts Mucous membrane pemphigoid (MMP) is a blinding, systemic autoimmune disease characterized by autoantibodies deposited along the basement membrane zone of mucous membranes and skin. Ocular involvement occurs in approximately 80% of patients with MMP. Clinical course is characterized by slow progression from chronic conjunctivitis to subepithelial fibrosis, fornix foreshortening, symblepharon, and ankyloblepharon formation with ocular surface keratinization. The gold standard for diagnosis of MMP…

Giant Papillary Conjunctivitis

Key Concepts Giant papillary conjunctivitis (GPC) is a noninfectious inflammatory disorder that primarily involves the superior tarsal conjunctiva. GPC is most commonly associated with contact lens use. Mild hyperemia, irritation, and mucous discharge progresses with continued exposure to the contact lens or offending item, eventually resulting in decreased contact lens comfort and wearing time in those with more significant involvement. Dual pathologic mechanisms—mechanical trauma and antigenic…

Vernal and Atopic Keratoconjunctivitis

Key Concepts Vernal and atopic keratoconjunctivitis are chronic, vision-threatening, allergic diseases of the eye. Vernal keratoconjunctivitis occurs most commonly in young males, often with a seasonal pattern, but also with occasional perennial disease. Atopic keratoconjunctivitis occurs in the second through fifth decade in patients with atopic dermatitis. Mast cell activation is implicated in both diseases; however, inflammatory cell-mediated immunopathologic changes likely drive the development of vision…

Seasonal and Perennial Allergic Conjunctivitis

Key Concepts Allergic conjunctivitis is a common cause of ocular morbidity. The symptoms are generally mild, and the diagnosis can be made clinically. It is important to distinguish allergic conjunctivitis from more severe forms of ocular disease. Human parasite defense mechanisms are involved in pathophysiology of allergies. Effective topical and systemic therapies exist to treat allergic conjunctivitis. Introduction Allergies are some of the most common medical…

Parinaud Oculoglandular Syndrome

Key Concepts Parinaud oculoglandular syndrome is characterized by granulomatous conjunctivitis with lymphadenopathy. There are multiple etiologies, many of which are animal related. The most common cause is Bartonella henselae. Tularemia, TB, syphilis, and sporotrichosis cause the greatest morbidity. The diagnosis often requires polymerase chain reaction and serologic testing. Initial treatment is based on tentative diagnosis, immune status, and severity. The management is guided by the established…

Ophthalmia Neonatorum

Key Concepts Ophthalmia neonatorum is conjunctivitis in the first month of life. Chemical etiologies present in the first 24–48 hours after birth. Gonococcal etiologies present in the first 2–5 days after birth. Chlamydial infections are the most common, presenting 5–14 days after birth. Early diagnosis by clinical suspicion and culture is imperative. Early treatment is imperative to prevent local and systemic disease, which can be blinding…

Chlamydial Infections

Key Concepts In trachoma, repeated infections with serovars A–C of Chlamydia trachomatis cause a chronic follicular conjunctivitis and subsequent cicatricial conjunctivitis, followed by entropion, trichiasis, and corneal opacity. Neonatal inclusion conjunctivitis is caused by serovars D–K of C. trachomatis infection acquired from the birth canal, and is characterized by a papillary conjunctivitis. Adult inclusion conjunctivitis is a sexually transmitted disease caused by serovars D–K of C.…

Viral Conjunctivitis

Key Concepts DNA viruses are frequently associated with vision-threatening complications, while RNA viruses usually cause more benign forms of conjunctivitis. Adenovirus is the most common etiology of viral conjunctivitis. Laboratory testing is rarely necessary for diagnosis; however, identification of the pathogen can be obtained by cell culture, polymerase chain reaction (PCR), and rapid diagnostic tests via antigen detection. Few viral entities respond to topical antiviral therapy.…

Bacterial Conjunctivitis

Key Concepts The majority of acute conjunctivitis cases are difficult to distinguish from adenoviral conjunctivitis. Bacterial conjunctivitis is typically benign with a mild and self-limited course; therefore, no antibiotic use is recommended. Urgent treatment of gonorrheal conjunctivitis is necessary to prevent severe corneal ulceration and perforation. Systemic management is the main treatment. Coinfection of Chlamydia with gonorrhea is common and treatment is targeted to both organisms.…

Conjunctivitis: An Overview and Classification

Key Concepts The morphology, type of exudate, and principally affected areas help define the etiology of conjunctivitis. Chronicity plays a key role in classifying conjunctivitis. Acute conjunctivitis is typically infectious in etiology. Masquerade syndromes must be considered in cases of chronic conjunctivitis. The conjunctiva is a thin, translucent mucous membrane whose palpebral portion lines the posterior surface of the eyelids and whose bulbar portion lines the…

Epiphora

Key Concepts Epiphora, or chronic overflow of tears, is caused by overproduction, outflow obstruction, or failure of the tear pump. Chronic ocular surface irritation is a common source of tear overproduction. The lacrimal pump is mediated by contraction of the orbicularis oculi and medial canthal tendon. The epiphora examination should include an assessment of the position of the lid and lashes, the frequency and effectiveness of…