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Noninfectious conjunctival conditions

Last updated: August 13, 2021

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The conjunctiva are highly vascularized mucous membranes that line the inside of the eyelids and sclera. They are susceptible to a wide range of conditions, of which only degenerative, traumatic, and neoplastic ones are treated here (see “Eye and orbit” for more information on the anatomy of the eye and “Conjunctivitis” for inflammatory conditions). Pinguecula is a small, yellowish, raised plaque on the conjunctiva composed of protein, fat, or calcium. Pterygium is a benign, triangular, fibrovascular wedge of conjunctival tissue, which typically grows laterally starting from the nasal conjunctiva. Subconjunctival hemorrhage is a collection of blood between the conjunctiva and the sclera that is most commonly caused by trauma. Foreign bodies are a common source of ocular trauma, e.g., dust and debris that is propelled into the eye during activities such as grinding, drilling, sawing, or welding. Pigmented lesions include ocular melanosis, a benign, unilateral, congenital pigmentation of the episclera, and primary acquired melanosis, a benign, congenital pigmentation of the conjunctiva. Benign tumors of the conjunctiva include limbal dermoid, a congenital tumor in the region of the corneal limbus, and conjunctival nevus, a pigmented tumor of the conjunctiva. Malignant tumors include squamous cell carcinoma, a mainly keratinizing squamous cell carcinoma of the conjunctiva, conjunctival melanoma, a rare malignant tumor of the conjunctiva with a high rate of recurrence and metastasis, and conjunctival lymphoma, a salmon-pink colored, malignant tumor of the conjunctiva.

References:[1]

  • Definition: a benign, triangular, fibrovascular wedge of conjunctival tissue, which typically grows laterally starting from the nasal conjunctiva
  • Epidemiology: more commonly occurs in areas with high UV radiation
  • Etiology
    • Chronic irradiation with UV light
    • Environmental irritation (e.g., hot, dry weather)
    • Genetic predisposition
  • Clinical features
    • Triangular, fibrovascular wedge of conjunctival tissue
      • Typically grows laterally starting from the nasal conjunctiva
      • Can extend to the cornea, leading to visual impairment
    • Symptoms of local irritation: scleral/corneal redness, lacrimation, foreign body sensation
    • Mild visual impairment
  • Differential diagnosis
  • Management: surgical excision (if vision is impaired)
  • Complications
    • Visual impairment
    • Reduced ocular motility
  • Prognosis: > 90% risk of recurrence

References:[2]

References:[3][4]

  • Epidemiology: the second most common form of ocular trauma after corneal abrasion
  • Etiology
    • Most commonly: Engaging in activities that propel dust and debris without protective eyewear (e.g., grinding, drilling, sawing, welding, mowing)
    • Exposure to high wind conditions (e.g., driving with the window or the top down)
  • Clinical features
    • Persistent discomfort after a sudden onset event
    • Signs of ocular inflammation: copious tearing, redness, foreign body sensation, difficulty keeping the eye open, photophobia, and blurred vision
    • Metallic foreign bodies can lead to discoloration of the surrounding tissue.
    • Severe injury and major complications (e.g., visual acuity loss) is rare.
  • Diagnostics
  • Differential diagnosis
  • Management
    • Initially, pain control (e.g., topical tetracaine), removal of contact lenses, and protection of the eye to prevent further trauma (e.g., a patch can be placed over the unaffected eye to minimize pupillary movement)
    • Removal of foreign body
    • Consider administration of prophylactic antibiotics.
  • Complications: secondary iritis in the case of metallic foreign bodies or inadequate removal
  • Prognosis
    • Most corneal foreign bodies have a very good prognosis.
    • Centrally located rust rings have a greater risk of scarring with visual disturbances.

References:[5]

Ocular melanosis (conjunctival melanosis) [6]

  • Definition: a benign, unilateral, congenital pigmentation (blue nevus) of the episclera
  • Epidemiology: more common in dark-skinned individuals
  • Etiology: accumulation of melanocytes in the eye
  • Clinical features
    • Iris heterochromia
    • Patchy slate-gray or bluish discoloration of the sclera
      • Usually unilateral
      • Subepithelial location without involvement of the conjunctiva (lesion is not displaceable with motion of the conjunctiva )
    • Increased pigmentation of the ipsilateral fundus
  • Management
    • Reassurance
    • Regular ophthalmic examination to monitor progression
  • Complications: increased risk of glaucoma and melanoma in the affected eye
  • Prognosis: The risk of progression to malignancy is ∼ 8%. [7]

Primary acquired melanosis (PAM)

  • Definition: a benign, congenital pigmentation of the conjunctiva
  • Epidemiology
    • Usually affects light-skinned individuals
    • Peak incidence at 50–60 years of age [8]
  • Clinical features
    • Flat, brown, irregularly arranged pigmentation
      • Displaceable with motion of the conjunctiva
      • Usually unilateral
      • Without cyst formation
  • Management
    • Small lesions: reassurance and regular ophthalmic examination to monitor progression
    • Mid-sized to large lesions: surgical excision and histopathologic examination
  • Complications: PAM with atypia may develop into conjunctival melanoma
  • Prognosis: increased risk of malignancy in PAM with atypia (up to 21%) [9]

Benign tumors of the conjunctiva

Limbal dermoid (epibulbar dermoid) [10]

  • Definition
  • Clinical features
  • Management
    • In mild cases: reassurance and regular ophthalmic examination to monitor progression
    • In severe cases: surgical excision

Conjunctival nevus

  • Definition: a benign tumor of the conjunctiva that can vary in color from clear to dark brown depending on degree of pigmentation and often contains clear cysts
  • Epidemiology: most common benign tumor of the conjunctiva
  • Clinical features
    • Well-defined macula with small, clear inclusion cysts
      • Usually unilateral and most commonly in the lateral eyelid region
      • Pigmentation can be partial or complete
      • Pigmentation may increase or decrease with hormonal changes (e.g., pregnancy). [11]
  • Management
    • Reassurance
    • Regular ophthalmic examination to monitor progression
    • Surgical excision if the nevus is suspicious for malignancy or for cosmetic reasons
  • Prognosis: risk of malignancy is low (< 0.01%) [12]

Malignant tumors of the conjunctiva

Conjunctival squamous carcinoma [13]

Conjunctival melanoma [15]

Conjunctival lymphoma

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  4. Doshi R, Noohani T. Subconjunctival hemorrhage. StatPearls. 2020 .
  5. Zhong J, Deng Y, Zhang P, et al. New Grading System for Limbal Dermoid: A Retrospective Analysis of 261 Cases Over a 10-Year Period.. Cornea. 2018; 37 (1): p.66-71. doi: 10.1097/ICO.0000000000001429 . | Open in Read by QxMD
  6. Pache M, Glatz-Krieger K, Sauter G, Meyer P. Expression of sex hormone receptors and cell cycle proteins in melanocytic lesions of the ocular conjunctiva. Graefe's Archive for Clinical and Experimental Ophthalmology. 2005; 244 (1): p.113-117. doi: 10.1007/s00417-005-0035-2 . | Open in Read by QxMD
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  9. Edgar A, Crutchfield G, Anderson N. Superficial radiotherapy as a treatment alternative for recurrent conjunctival squamous cell carcinoma: a case study. Journal of Medical Radiation Sciences. 2018; 65 (3): p.240-244. doi: 10.1002/jmrs.274 . | Open in Read by QxMD
  10. Patel DR, Patel BC. Ocular Melanoma. StatPearls. 2021 .
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  12. Tanenbaum RE, Galor A, Dubovy SR, Karp CL. Classification, diagnosis, and management of conjunctival lymphoma. Eye and Vision. 2019; 6 (1). doi: 10.1186/s40662-019-0146-1 . | Open in Read by QxMD
  13. Camodeca AJ, Anderson EP. Corneal Foreign Body. StatPearls. 2021 .
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  16. Shields JA, Shields CL, Mashayekhi A, et al. Primary acquired melanosis of the conjunctiva: experience with 311 eyes.. Trans Am Ophthalmol Soc. 2007; 105 : p.61-71; discussion 71-2.
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  18. Lang GK, et al.. Augenheilkunde. Thieme Verlag (2008) ; 2008