Diseases of the Conjunctiva

Diseases of the Conjunctiva Indian Medical PG Question 1: Cobblestone appearance of the conjunctiva is typically seen in which of the following conditions?

• A. Allergic conjunctivitis
• B. Chlamydial conjunctivitis
• C. Giant papillary conjunctivitis
• D. Vernal keratoconjunctivitis (Correct Answer)

Diseases of the Conjunctiva Explanation: ***Vernal keratoconjunctivitis*** - This condition is characterized by **large, flattened papillae** on the upper tarsal conjunctiva, which give it a classic **cobblestone appearance**. - It is a severe, chronic form of **allergic conjunctivitis**, often seen in children and young adults, associated with severe itching and seasonal recurrence. *Allergic conjunctivitis* - While it involves allergic reactions and sometimes papillae, the term **"cobblestone appearance"** specifically refers to the **large, flat papillae seen in Vernal Keratoconjunctivitis**, not general allergic conjunctivitis. - General allergic conjunctivitis often presents with **diffuse papillary hypertrophy** but not typically the characteristic cobblestoning unless it progresses to the chronic, severe form. *Chlamydial conjunctivitis* - This is primarily associated with **follicles** on the conjunctiva, particularly in the lower fornix, rather than a cobblestone appearance. - It is an **infectious condition**, often linked to sexually transmitted infections, and its conjunctival findings are distinct from allergic forms. *Giant papillary conjunctivitis* - While it features **giant papillae** (similar to those causing the cobblestone appearance), it is typically caused by mechanical irritation from **contact lenses** or ocular prostheses, not a primary allergic etiology like VKC. - It often affects the **upper tarsal conjunctiva** but is usually unilateral or asymmetrical and directly related to a foreign body.

Diseases of the Conjunctiva Indian Medical PG Question 2: A 25-year-old male presents with recurrent bilateral conjunctival hyperemia and a gritty sensation. Likely diagnosis?

• A. Vernal keratoconjunctivitis (Correct Answer)
• B. Herpes keratitis
• C. Episcleritis
• D. Bacterial conjunctivitis

Diseases of the Conjunctiva Explanation: ***Vernal keratoconjunctivitis*** * This is the correct diagnosis as it perfectly matches the clinical presentation: **young male patient** (VKC has male predominance, especially in adolescents/young adults), **recurrent course** (VKC is a chronic allergic condition with seasonal exacerbations), and **bilateral involvement** with gritty sensation. * VKC is a **severe form of allergic conjunctivitis** characterized by **bilateral conjunctival hyperemia**, intense itching, gritty sensation, photophobia, and mucoid discharge. The recurrent bilateral nature in a young male is pathognomonic. *Herpes keratitis* * Usually presents as **unilateral eye pain**, redness, and a characteristic **dendritic ulcer** on the cornea (seen with fluorescein staining), which is not described here. * Caused by herpes simplex virus and typically has an acute presentation rather than recurrent bilateral conjunctival symptoms. Can lead to significant vision loss if untreated. *Episcleritis* * Characterized by **localized sectorial redness** in one eye, often in a radial pattern, and is usually **mild and self-limiting**. * Typically causes minimal discomfort and does not commonly present with gritty sensation or recurrent bilateral involvement as the primary feature. *Bacterial conjunctivitis* * Typically presents with **purulent discharge** (thick yellow-green pus) and matting of eyelids, which is not mentioned in this patient's symptoms. * While it causes redness and grittiness, it's usually **acute and unilateral or sequential bilateral** (one eye then the other), and resolves with topical antibiotics within days, unlike the recurrent chronic nature described here.

Diseases of the Conjunctiva Indian Medical PG Question 3: Regarding Chlamydia infection of the eyes, true statements include the following except:

• A. Penicillin is the treatment (Correct Answer)
• B. Inclusion conjunctivitis is an acute ocular infection caused by sexually transmitted C. trachomatis strains (usually serovars D through K)
• C. Can be cultured
• D. Acute inclusion conjunctivitis typically presents with mucopurulent discharge

Diseases of the Conjunctiva Explanation: ***Penicillin is the treatment*** - **Penicillin** is ineffective against *Chlamydia trachomatis* because *Chlamydia* lacks a **peptidoglycan cell wall**, which is the target of penicillin. - The standard treatment for chlamydial infections, including ocular infections, involves **azithromycin** or **doxycycline**. *Inclusion conjunctivitis is an acute ocular infection caused by sexually transmitted C. trachomatis strains (usually serovars D through K)* - **Inclusion conjunctivitis** is indeed caused by sexually transmitted serovars of *Chlamydia trachomatis* (typically **D through K**). - It usually occurs in sexually active adults and can affect neonates through maternal transmission. *Can be cultured* - *Chlamydia* are **obligate intracellular bacteria**, meaning they can only replicate inside host cells. - While they can be grown in cell cultures, this is a specialized technique and not a typical method for routine diagnosis due to its complexity and time-consuming nature. *Acute inclusion conjunctivitis typically presents with mucopurulent discharge* - **Acute inclusion conjunctivitis** is characterized by a **mucopurulent discharge**, along with **follicular conjunctivitis** and sometimes **preauricular lymphadenopathy**. - This discharge results from the inflammatory response to the chlamydial infection in the conjunctiva.

Diseases of the Conjunctiva Indian Medical PG Question 4: What is the most common cause of superficial corneal vascularization?

• A. Graft rejection
• B. Chemical burn
• C. Interstitial keratitis
• D. Contact lens (Correct Answer)

Diseases of the Conjunctiva Explanation: ***Contact lens*** - **Inappropriate contact lens wear**, particularly extended wear or poor hygiene, is the most frequent cause of **corneal neovascularization**. - This occurs due to **chronic hypoxia** or **inflammation** from the lens leading to vessel growth into the normally avascular cornea. *Graft rejection* - While graft rejection in corneal transplantation can lead to vascularization, it is a less common cause compared to contact lens wear. - **Neovascularization** in this context often signifies a severe immune response impacting graft survival. *Chemical burn* - Chemical burns to the eye can cause significant **corneal damage** and subsequent vascularization as a **healing response** to severe injury. - However, the overall incidence of chemical burns leading to neovascularization is lower than that associated with long-term contact lens use. *Interstitial keratitis* - **Interstitial keratitis** involves inflammation of the corneal stroma, which can lead to ghost vessels or active vascularization but is a less prevalent cause of superficial corneal vascularization than contact lens-related issues. - It is often associated with systemic infections like **syphilis** or **Lyme disease**.

Diseases of the Conjunctiva Indian Medical PG Question 5: Patient developed acute redness of eye with mucopurulent discharge and halos. It did not stain with fluorescein. The halos subsided after washing with clean water and the patient responded to five day course of topical antibiotics. What should be your probable diagnosis?

• A. Immature senile cataract
• B. Uveitis
• C. Angle closure glaucoma
• D. Acute bacterial conjunctivitis (Correct Answer)

Diseases of the Conjunctiva Explanation: ***Acute bacterial conjunctivitis*** - The presence of **mucopurulent discharge**, **acute redness**, and "halos" (which can be caused by corneal edema secondary to inflammation) that resolved after washing suggest an infection. - The rapid response to **topical antibiotics** further supports a bacterial etiology, and the lack of fluorescein staining rules out corneal abrasion or ulceration. *Angle closure glaucoma* - While it can cause **halos around lights** and acute redness, it is typically associated with **severe pain**, blurred vision, and a fixed, mid-dilated pupil. - It would not normally present with **mucopurulent discharge** and would not resolve with simple washing or topical antibiotics. *Uveitis* - Uveitis can cause **redness and pain**, but typically presents with **photophobia**, ciliary flush, and often no discharge or a watery discharge, not mucopurulent. - **Halos** are not a typical symptom, and it would not resolve with washing or a short course of topical antibiotics. *Immature senile cataract* - Cataracts cause **gradual, painless vision loss** and **halos around lights** due to light scatter through the cloudy lens. - They do not cause acute redness, mucopurulent discharge, or suddenly resolve with washing.

Diseases of the Conjunctiva Indian Medical PG Question 6: All are true about Vernal conjunctivitis EXCEPT:

• A. Type of allergic conjunctivitis
• B. Cobblestone appearance
• C. Itchy eyes with other allergic problems
• D. Most signs are in lower lid (Correct Answer)

Diseases of the Conjunctiva Explanation: ***Most signs are in lower lid*** ✗ - This is **INCORRECT** and is the answer to this EXCEPT question. - **Vernal conjunctivitis (VKC)** primarily affects the **upper tarsal conjunctiva**, not the lower lid. - The characteristic **cobblestone papillae** develop on the **upper eyelid** due to friction from blinking, causing **papillary hypertrophy**. - While bulbar conjunctiva and limbus can be affected, the most severe signs are in the **upper lid**. *Type of allergic conjunctivitis* ✓ - **VKC** is correctly classified as a chronic, bilateral, severe form of **allergic conjunctivitis**. - It is typically a **Type I hypersensitivity reaction**, often associated with atopy. *Cobblestone appearance* ✓ - This refers to the characteristic **large, flattened giant papillae** that develop on the **upper tarsal conjunctiva** in VKC. - The appearance results from marked hypertrophy of these papillae, resembling cobblestones. *Itchy eyes with other allergic problems* ✓ - **Intense itching** is the cardinal symptom of VKC, often accompanied by **photophobia**, **tearing**, and stringy mucous discharge. - Patients frequently have a personal or family history of other **atopic conditions** like asthma, eczema, or allergic rhinitis.

Diseases of the Conjunctiva Indian Medical PG Question 7: Which of the following is not a primary symptom of Sjögren's syndrome?

• A. Parotid gland enlargement
• B. Dry eyes
• C. Dry mouth
• D. Systemic manifestations (Correct Answer)

Diseases of the Conjunctiva Explanation: ***Systemic manifestations*** - While Sjögren's syndrome can have **systemic manifestations**, they are secondary complications or features, not among the **primary, defining symptoms** that establish the diagnosis. - The primary symptoms directly relate to **exocrine gland dysfunction**, specifically lacrimal and salivary glands. *Dry eyes* - This is a cardinal symptom, resulting from damage to the **lacrimal glands** leading to decreased tear production. - Patients typically report a **gritty or burning sensation** in their eyes. *Dry mouth* - Another core symptom, resulting from dysfunction of the **salivary glands** and reduced saliva flow. - This can lead to difficulties in **speaking, swallowing**, increased dental carries, and oral discomfort. *Parotid gland enlargement* - This is a common and often **visible clinical sign** of Sjögren's syndrome, indicating inflammation of the **major salivary glands**. - It results from lymphocytic infiltration and is typically recurrent or persistent.

Diseases of the Conjunctiva Indian Medical PG Question 8: Epithelial xerosis of conjunctiva is caused by?

• A. Xerophthalmia (Correct Answer)
• B. Infectious conjunctivitis caused by Chlamydia trachomatis
• C. Autoimmune blistering conjunctivitis
• D. Bacterial conjunctivitis due to Corynebacterium diphtheriae

Diseases of the Conjunctiva Explanation: ***Xerophthalmia*** - **Xerophthalmia** is a medical condition characterized by **dryness of the eye**, often due to **vitamin A deficiency**. - **Epithelial xerosis of the conjunctiva** is one of the early and hallmark signs of xerophthalmia, representing the drying and thickening of the conjunctival epithelium due to goblet cell loss and squamous metaplasia. *Infectious conjunctivitis caused by Chlamydia trachomatis* - This typically causes **trachoma**, characterized by chronic inflammation, scarring, and eventual blindness. - While it can lead to dryness and scarring in later stages due to **symblepharon** or **entropion**, it does not primarily manifest as epithelial xerosis. *Autoimmune blistering conjunctivitis* - This condition involves **immune-mediated inflammation** leading to subepithelial blistering, scarring, and shrinkage of the conjunctiva. - It results in significant **ocular surface damage** and vision loss but is distinct from the primary epithelial changes seen in xerosis due to vitamin A deficiency. *Bacterial conjunctivitis due to Corynebacterium diphtheriae* - **Diphtheritic conjunctivitis** is a severe form of bacterial conjunctivitis that causes a distinctive **"pseudomembrane"** on the conjunctiva. - It leads to acute inflammation and potentially systemic illness, not primarily epithelial xerosis.

Diseases of the Conjunctiva Indian Medical PG Question 9: In a patient with acute anterior uveitis presenting with raised intraocular pressure, the PRIMARY treatment should be:

• A. Topical steroids (Correct Answer)
• B. Topical beta-blockers
• C. Cycloplegics
• D. Miotics

Diseases of the Conjunctiva Explanation: ***Topical steroids*** - **Topical corticosteroids** are the primary treatment for **anterior uveitis** to reduce inflammation, which is the underlying cause of both the uveitis and often the raised IOP. - While IOP is elevated, managing the inflammation with steroids is crucial, as the inflammation itself can lead to secondary **IOP elevation** due to trabecular meshwork dysfunction or synechiae formation. *Topical beta-blockers* - **Topical beta-blockers** are used to lower intraocular pressure, but they do not address the underlying **inflammation** in acute anterior uveitis. - Using them alone without treating the inflammation can lead to progression of the uveitis and further ocular damage. *Cycloplegics* - **Cycloplegics** (e.g., atropine, cyclopentolate) are important adjuncts in acute anterior uveitis to relieve pain from ciliary spasm and prevent posterior synechiae formation by dilating the pupil. - They do not, however, treat the **inflammation** directly or primarily address the elevated intraocular pressure. *Miotics* - **Miotics** (e.g., pilocarpine) **constrict the pupil**, which can worsen symptoms in acute anterior uveitis by increasing ciliary body spasm and potentially increasing the risk of posterior synechiae formation. - They are contraindicated in acute anterior uveitis as they exacerbate pain and inflammation, and do not treat the underlying cause.

Diseases of the Conjunctiva Indian Medical PG Question 10: Which of the following is a contraindication to topical steroids?

• A. Dendritic ulcer (Correct Answer)
• B. Herpetic stromal keratitis without epithelial defect
• C. Elevated intraocular pressure
• D. Non-infectious anterior uveitis

Diseases of the Conjunctiva Explanation: ***Dendritic ulcer*** - A **dendritic ulcer** is characteristic of **herpes simplex keratitis**, which is an active viral infection of the cornea. - **Topical steroids** are contraindicated because they can suppress the immune response, leading to viral replication, corneal melt, and potentially severe vision loss or perforation. *Herpetic stromal keratitis without epithelial defect* - In cases of **stromal keratitis**, where the infection is deeper and an intact epithelium is present, topical steroids may be used cautiously in conjunction with antiviral agents to reduce inflammation and scarring. - The primary concern with steroids in herpes simplex keratitis is activating viral replication in the presence of an **epithelial defect**, which is not present here. *Elevated intraocular pressure* - **Elevated intraocular pressure** is a known side effect of topical steroid use, especially with prolonged administration, but it is not an absolute contraindication in itself. - It necessitates careful monitoring and may require concurrent glaucoma treatment, but the primary condition needing steroids may still warrant their use. *Non-infectious anterior uveitis* - **Topical corticosteroids** are the **mainstay of treatment** for non-infectious anterior uveitis to reduce inflammation and prevent complications such as synechiae and vision loss. - The benefits of controlling inflammation in uveitis generally outweigh the risks associated with judicious steroid use.

Diseases of the Conjunctiva Flashcard 1 of 10

Question: Inclusion conjunctivitis is caused by _____.

Answer: Chlamydia trachomatis serotypes D K

Diseases of the Conjunctiva Flashcard 2 of 10

Question: Papillary hyperplasia is a _____ sign of trachoma

Answer: conjunctival

Diseases of the Conjunctiva Flashcard 3 of 10

Question: Mucus fishing syndrome is closely related to _____ conjunctivitis.

Answer: giant papillary

Diseases of the Conjunctiva Flashcard 4 of 10

Question: _____ conjunctivitis is also called as spring catarrh or warm weather conjunctivitis

Answer: Vernal

Diseases of the Conjunctiva Flashcard 5 of 10

Question: Arlt's line is a _____ sign of trachoma

Answer: conjunctival

Diseases of the Conjunctiva Flashcard 6 of 10

Question: Redness and photophobia with the following characteristic lesion is suggestive of _____ conjunctivitis

Answer: Phlyctenular

Diseases of the Conjunctiva Flashcard 7 of 10

Question: The given image is of _____ of the eye

Answer: symblepharon

Diseases of the Conjunctiva Flashcard 8 of 10

Question: Only _____ reaction is seen in VKC; no follicular reaction

Answer: papillary

Diseases of the Conjunctiva Flashcard 9 of 10

Question: Pinguecula is located _____laterally, and is more common on the nasal side

Answer: bi

Diseases of the Conjunctiva Flashcard 10 of 10

Question: What are the two most common causes of bacterial conjunctivitis?_____

Answer: Strep pnemo