CONJUNCTIVAL CONCRETIONS (OCULAR LITHIASIS)

Signs and Symptoms

Concretions embedded in palpebral conjunctiva.

Conjunctival concretions, or lithiasis, are seen as small, white to yellow nodules superficially buried within and beneath the palpebral conjunctiva. They may occur in either the upper or lower lid; when inferior, they often appear adjacent to or underlying fluid-filled conjunctival cysts. These small, round, calculi appear to be a side effect of an aging palpebral conjunctiva, or a sequela of recurrent episodes of chronic conjunctivitis. They have been associated with chronic atopic keratoconjunctivitis and Herbert's pits following post-trachomatous degeneration.^1,2 However, they frequently occur idiopathically.

The patient with lithiasis may report a foreign-body sensation that is especially prominent upon blinking, although most patients are asymptomatic. The concretions typically remain buried, benign and unnoticed by patients until or unless they enlarge, at which time they may protrude through the palpebral tissues. Contact with the cornea leads to foreign-body sensation, as well as epithelial disruption and a potential reduction in acuity if the visual axis is involved.

Pathophysiology

Conjunctival concretions have been described as inclusion cysts filled with keratin (a protein constituent of epidermis and hair) and epithelial debris within the inferior and superior palpebral conjunctiva. However, research has confirmed that there is a granular, membranous nature to the masses, which are composed mainly of mucinous secretions of transformed conjunctival glands admixed with degenerated epithelial cells.³ Histochemically, concretions have been found to stain strongly for phospholipid and elastin, weakly for polysaccharides and negatively for amyloid, iron and glycogen.²

Ironically, there is very little calcium integrated within the accumulated material, as previously thought.²

Management

Concretions do not generally require interventional management as long as patients remain asymptomatic and the cornea is undamaged. All patients should be appropriately educated as to the etiology and prognosis of this disorder. Those who are mildly symptomatic may be palliated by the use of artificial tear solutions and/or ointments.

In more severe cases--where palpebral tissues are at risk for damage, corneal erosion has occurred or symptoms have developed, persisted or worsened--excision is the modality of choice. This may be accomplished in-office by applying an anesthetic-soaked cotton tipped applicator over the area and using a small gauge (e.g., 25gto 27g) needle to excavate and extract the small calculi. Jewelers' forceps may be very useful in gripping the concretions once the conjunctiva has been breached. In exceedingly superficial cases, simple manipulation with a cotton-tipped swab may be sufficient to loosen the nodule. After removal, the subsequent use of an antibiotic-steroid ointment (e.g., Tobradex, Alcon) helps to minimize iatrogenic inflammation and prevent infection.

Clinical Pearls

• Conjunctival concretions are avascular, granular, yellow-white masses that resemble crystals, and are visible upon lid eversion. Differ-ential diagnoses include amyloid deposits, internal hordeola, adeno-chrome deposits, debris and foreign matter or tumor.
• Concretions typically respond favorably to excision and normally do not recur after removal, but recurrence is a possibility of which patients should be educated.
• As a conservative estimate, perhaps only one patient in 50 with concretions ever requires surgical removal.⁴

Other reports in this section

• Limbal Dermoid
• Conjunctival Concretions (Ocular Lithiasis)
• Conjunctival Lymphoma
• Acute Allergic Conjunctivitis
• Phlyctenulosis (Phlyctenular Keratoconjunctivitis)