Dermoid tumors (Fig. 6.46) are benign congenital growths often having protruding hairs. They are most common at the corneal limbus or in the orbit and may grow during puberty. They are removed if vision is threatened or for cosmetic reasons.

Conjunctiva

The conjunctiva is a mucous membrane. The bulbar conjunctiva covers the sclera and ends at the corneal limbus. The palpebral conjunctiva lines the lids (Fig. 6.47). Fluid within the conjunctiva is called chemosis (Fig. 6.48) and is commonly seen in allergy and in rare cases of orbital venous congestion.

Fig. 6.47 Bulbar and palpebral conjunctiva.

Fig. 6.49a Pterygium.

Fig. 6.46 Corneal dermoid.

Fig. 6.48 Chemosis.

Fig. 6.49b A pterygium is removed with a superficial lamellar dissection and excision of adjacent paralimbal conjunctiva. An autograft of conjunctiva from another area of the same eye is sutured to adjacent paralimbal area to reduce recurrences of the pterygium. Frua E, et al. Acta Ophthalmol. Scand. 2004.

To examine the inner surface of the upper lid, first warn the patient, then “flip the lid” as follows:

1 have the patient look down with eyes open;

2 grasp eyelashes of upper lid at their bases;

3 pull out and up on lashes while pushing in and down on upper tarsal margin (patient should continue to look down during examination);

4 to return lid to normal position, have the patient look up.

A pterygium (Fig. 6.49a, b) is a triangular growth of vascularized conjunctiva encroaching on the nasal cornea. Two causes are wind and ultraviolet light. It may be excised for cosmetic, comfort, or visual reasons. Recurrences of up to 30–40% are reported.

A pinguecula (Fig. 6.50) is a common, benign, yellowish elevation of the 180° conjunctiva, usually nasal but also temporal. It is composed of collagen and elastic tissue. It occasionally becomes red, especially with allergies (Fig. 6.51), and, rarely, may be removed if it is chronically inflamed, if it interferes with contact lens wear, or if it is a cosmetic problem.

Subconjunctival hemorrhages (Fig. 6.52) may be spontaneous, or result from rubbing of the eye, vomiting, coughing, elevated blood pressure, or, rarely, bleeding disorders. Recommend no rubbing, and no bearing down.

Fig. 6.53a Symblepharon: Adhesions of bulbar to palpebral conjunctiva should be lysed with a glass rod or wet cotton applicator to prevent permanent scar. From Kheirkhah

et al., 2008, Amer. J. Ophth., 146,

p. 271. With permission from Elsevier.

Fig. 6.50 Pinguecula.

Fig. 6.51 Inflamed pinguecula.

Fig. 6.52 Subconjunctival hemorrhage.

Fig. 6.53b Bullous pemphigoid causes conjunctivitis and itchy, red blisters on the skin.

A symblepharon (Figs 1.9 and 6.53a) is an adhesion of the bulbar and palpebral conjunctiva. Contracture can lead to an entropion with trichiasis. It is most commonly due to chemical burns, trachoma, epidemic keratoconjunctivitis and two immune blistering mucocutaneous diseases that involve the eye.

1.Stevens-Johnson syndrome, which is an immune reaction to a foreign antigen, usually a drug (Fig. 1.9), and could be fatal.

2.Bullous pemphigoid (Fig. 6.53b) is an autoimmune condition involving the skin and conjunctiva. It could last for years, and unlike Stevens-Johnson, it is not fatal. It is also confirmed by biopsy. Pemphix is Latin for blister.

Conjunctivitis causes redness with a gritty sensation. Common causes are tired eyes, pollutants, wind, dust, dryness, allergy, or infection (Fig. 6.54). If there is pain, it usually indicates corneal or intraocular involvement. Vascularized elevations of the palpebral conjunctiva, called papillae (Fig. 6.55), are a reaction to an inflamed eye. It is most unique to giant papillary conjunctivitis and vernal conjunctivitis.

Giant papillary conjunctivitis (GPC) is a common cause for rejecting soft contact lenses. Large papillae develop are under the lids. They could which are an immune reaction usually to mucous debris on the lenses. Rx: change to a soft contact lens that is disposed of more frequently, i.e., every two weeks or even on a daily schedule; decrease wearing time; and keep lenses especially clean.

Vernal conjunctivitis is an allergic condition in which large papillae are under the upper lid. They could abrade the cornea. It occurs in the first decade and may last for years. Both GPC and vernal conjunctivitis may be treated with a topical mast-cell inhibitor such as Cromolyn 4% solution and less often with steroid drugs.

White lymphoid elevations of the conjunctiva (Fig. 6.56) called follicles occur as a reaction to conjunctival irritation, especially from viruses, Chlamydia, and drugs.

1 Trachoma is a severe keratoconjunctivitis due to an infection by Chlamydia trachomatis. It affects 146 million people worldwide and is

Fig. 6.54 Conjunctivitis.

Fig. 6.55 Papillae of the palpebral conjunctiva.

Fig. 6.56 Follicles of the palpebral conjunctiva.

responsible for blindness in 6 million people outside the USA. It begins with papillae and follicles on the superior palpebral conjunctiva. Conjunctival shortening may result in an entropion, which causes trichiasis. Inflammation of the cornea leads to superior vascularization (pannus), occasional corneal scarring, and loss of vision (Fig. 6.57). Rx: a single dose of azithromycin, 20 mg/kg.

2 Inclusion conjunctivitis in adults is a follicular conjunctivitis with occasional keratitis. It is also due to Chlamydia trachomatis of a different serotype than that causing trachoma. This organism is the most common sexually transmitted pathogen—and, therefore, must be ruled out in sexually active people. It is the most common cause of conjunctivitis in newborns, who acquire it passing through the birth canal. Confirm with smear or culture. Rx: oral doxycycline, tetracycline, or azithromycin, and erythromycin ophthalmic ointment; treat sexual partners.

Bacterial conjunctivitis has a white–yellow discharge and is often due to Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. It is usually treated without cultures (Figs 6.58 and 6.59).

Inexpensive generic eye drops are used to treat simple infections of the conjunctiva and lids. Examples are gentamycin*, tobramycin*, sulfacetamide*, and fluoroquinolones such as ofloxacin and ciprofloxacin* (*also comes in ointments). Popular combination drops are bacitracin/neomycin/polymyxin, and polymyxin/trimethoprim (Polytrim). Ointments blur vision and are most useful for bedtime use, especially on the lid margins. Two antibiotics available only as ointments are bacitracin and erythromycin. The latter is placed in the eyes of most newborns to prevent chlamydial and other causes of conjunctivitis which might be picked up passing through birth canal (Fig. 6.45a).

Chronic bacterial conjunctivitis, sties, chalazions, and blepharitis commonly occur in acne rosacea (Fig. 4.53). This erythematous pustular dermatitis affects the forehead, cheeks, chin, and nose. Telangiectatic

Fig. 6.57 Corneal inflammation from trachoma.

Fig. 6.58 Infectious conjunctivitis.