COMMON CASES

Dr. Riyad Banayot

Lids, Conjunctiva and Sclera

Ocular cicatricial pemphigoid

Loss of caruncle, shallowing of the lower, tear film is poor, cornea may be opacified with neovascularization

Shallowing of the lower fornix and symblepharon, entropion, ectropion and trichiasis

Look for ulcers on the tongue or buccal mucosa, skin lesions

What conditions may simulate ocular cicatricial pemphigoid ?

Chemical burnt Steven-Johnson's syndrome Conjunctival malignancies

How would you treat this condition?

Ocular lubricant with artificial tears and ointments

Topical steroid for acute inflammation Severe cases may need systemic steroid

and immunosuppressants such as dapsone or cyclophosphamide

Oculoplastic surgery for trichiasis and entropion to reduce further damage to the cornea.

What do you see?

• There is exposure of the underlying dark uveal tissue (usually covered by the upper lid) with thinning of the surrounding sclera & conjunctiva. There are large abnormal blood vessels crossing areas of scleral loss.

• Seen mainly in women with rheumatoid arthritis.

• Look for: signs of rheumatoid arthritis (symmetrical deformities of the hand joints)

• Occasionally this condition is seen in Wegener's granulomatosis and relapsing polychondritis.

What are the types of scleritis ? Anterior scleritis:

Diffuse scleritis (most benign). 30% has underlying connective tissue disease

Nodular scleritis deep red to purple color, immobile nodule

Necrotizing scleritis (most destructive). 60% of affected patients develop ocular and systemic complications. 40% suffer from loss of vision and 29% die within 5 years of onset due to complications from vasculitis. There are two types: With inflammation & Without

inflammation Posterior scleritis:

least common, present with pain, proptosis, visual loss and restricted motility.

Can find: choroidal folds, exudative RD, papilloedema and ACG from choroidal effusion

Limbal dermoid

There is a round, raised, whitish lesion in the limbus. 

Pre-auricular skin tag

Further examination: • Significant astigmatism is present due to distortion of the cornea• The condition is associated with Goldenhar's syndrome. • look for: Preauricular skin tag, Duane's syndrome and facial asymmetry (with

mandibular under-development which may be ipsilateral or contralateral, small mouth

Name other mandibulofacial dystoses ?

Treacher-Collins' syndrome: This is an autosomal dominant condition Malar hypoplasia Absent zygomatic arch Anti-mongoloid slant of the palpebral fissure Coloboma of the outer third of the lower lids. In the lower face, there is hypoplasia of the

lower jaw with macrostomia and abnormal dentition.

The ears are usually malformed.

Basal cell carcinoma

There is a lesion in the lower lid, nodular with an ulcerated center. The surface is pearly and has telangiectasia.

Forms of lesion?

Basal cell carcinoma

- Check if the lesion is attached to the underlying structure by gently moving the lesion - Check if the punctum is involved (if present, there is a potential risk of orbital extension) - Look for loss of eyelashes (this indicates of malignancy if the nature of lesion is uncertain) - Assess the amount of skin laxity which would be important in reconstructive surgery

Further examination

What is the D.D. of BCC?

Squamous cell carcinoma Sebaceous cell carcinoma Amelanotic melanoma

What are the treatment options for BCC?

Cryotherapy Radiotherapy Excision. This is the treatment of choice.

Techniques: Frozen section techniques: After the tumor has been

excised. 1-2 mm wide strips of tissue is excised form the adjacent tissue for frozen section examination. Reconstruction is undertaken only when all margins are found to be tumor free.

Moh's micrographic surgery: Tissue is removed in lamellar layers which provide a three-dimensional mapping of the tumor excision. (it allows for retention of the maximum amount of tissue)

What do you see?

• Always examine the undersurface of the UL if you find UL entropion and/or diffuse corneal opacities. The inferior fornix is deep and there are no symblepharon (the presence of symblepharon should make one consider ocular cicatricial pemphigoid, Steven-Johnson's syndrome or chemical injury).

Other features that may suggest trachoma: • Micropannus in the superior cornea • Pits at the limbus (Herbert's pits which results from necrosis of the follicles)

On everting the eyelids, there is subtarsal fibrosis

Diffuse corneal opacities (+/- vascularization)

Differences between trachoma & adult inclusion conjunctivitis ?

Trachoma

Caused by Chlamydia trachomatis

Transmitted by flies Caused by serotypes

A, B, Ba or C. Commonly seen in

tropical countries where sanitation is poor

Causes blindness through corneal scarring from keratitis and entropion

Adult inclusion conjunctivitis Caused by Chlamydia

trachomatis Transmitted sexually Caused by serotypes

D, E, F, G, H, I, J or K Common in developed

countries