CHAPTER 3
Clinical Approach to Ocular Surface Disorders
The next 4 chapters cover ocular surface disorders and infectious and immune-related disorders of the external eye. The following sections and tables introduce and define common clinical findings that aid in the diagnosis of these conditions (Table 3-1).
Table 3-1
Common Clinical Findings
Conjunctival Signs
Table 3-2 lists conjunctival findings, with examples of ocular and systemic conditions.
Table 3-2
Papillae
Papillae are vascular changes seen most easily in the palpebral conjunctiva where fibrous septa anchor the conjunctiva to the tarsus. With progression, these dilated vessels sprout spokelike capillaries that become surrounded by edema and a mixed inflammatory cell infiltrate, producing raised elevations under the conjunctival epithelium (Fig 3-1).
Figure 3-1 Cross-sectional diagram of conjunctival papilla with a central vascular tuft surrounded by acute and chronic leukocytes.
A mild papillary reaction produces a smooth, velvety appearance (Fig 3-2A). Chronic or progressive changes result in enlarged vascular tufts that obscure the underlying blood vessels (Fig 3-2B). Connective tissue septa restrict inflammatory changes to the fibrovascular core, producing the appearance of elevated, polygonal, hyperemic mounds. Each papilla has a central red dot that represents a dilated capillary viewed end-on. The palpebral, bulbar, and forniceal conjunctivae beyond the tarsus are less helpful in revealing the nature of an inflammatory reaction because the anchoring septa become sparser toward the fornix and permit undulation of less adherent tissue. With prolonged, recurrent, or severe conjunctival inflammation, the anchoring fibers of the tarsal conjunctiva stretch and weaken, leading to confluent papillary hypertrophy. Giant papillae are defined as those with a diameter over 0.3 mm (Fig 3-2C). The furrows between these enlarged fibrovascular structures collect mucus and pus.
Figure 3-2 Papillary conjunctivitis. A, Mild papillae. B, Moderate papillae. C, Marked (giant) papillae.
Follicles
Conjunctival lymphoid tissue is normally present within the substantia propria except in neonates, who do not have visible follicles. Conjunctival follicles are round or oval clusters of lymphocytes (Fig 3-3). Small follicles are often visible in the normal lower fornix. Clusters of enlarged, noninflamed follicles are occasionally seen in the inferotemporal palpebral and forniceal conjunctiva of children and adolescents, a condition known as benign lymphoid folliculosis (Fig 3-4).
Figure 3-3 Cross-sectional diagram of conjunctival follicle with mononuclear cells obscuring conjunctival blood vessels.
Figure 3-4 Benign folliculosis. (Courtesy of Kirk R. Wilhelmus, MD.)