Concretions (conjunctival lithiasis)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Conjunctival epithelial inclusion cysts containing epithelial and keratin debris, sometimes with secondary calcification

Predisposing factors

Common, especially over the age of 50 years (prevalence in ophthalmology outpatient population has been reported as approximately 40%)
Chronic conjunctivitis (any cause, including contact lens wear)
Accumulation of lipid under conjunctiva, e.g. concretions grouped around an old chalazion

Symptoms

Usually none
May erode through the epithelium

  • foreign body sensation

Signs

Small white/yellow-white bodies with distinct edges in tarsal (upper or lower) conjunctiva
Single or multiple
Usually <1mm diam, sometimes up to 3mm 

  • appear larger if confluent

Usually low profile but may be raised if large

Differential diagnosis

Conjunctival retention cysts

  • thin walled cysts containing clear or translucent fluid

Follicles

  • focal lymphoid hyperplasia

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Treatment rarely required
Artificial tears and lubricating ointments (drops for use during the day, unmedicated ointment for use at bedtime)
(GRADE*: Level of evidence = low, Strength of recommendation = strong)

NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations

Eroded concretions leading to irritation can be removed at the slit lamp

  • topical anaesthetic
  • tease out with sterile hypodermic needle
  • any bleeding should respond quickly to finger pressure on the lid 
    • (N.B. check first that patient has no bleeding disorder and is not taking aspirin or anti-coagulants)
  • consider topical antibiotic as prophylactic if infection seems likely (e.g. gutt. or oc. chloramphenicol)

(GRADE*: Level of evidence = low, Strength of recommendation = weak)
 

Pharmacological

No specific drug treatment available
Topical anaesthetic and antibiotic for minor surgery as above
(GRADE*: Level of evidence = low, Strength of recommendation = weak)
 

Management category

B3: management to resolution

Possible management by ophthalmologist

Not normally required

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation  (www.gradingworkinggroup.org)
 

Sources of evidence

Haicl P, Janková H. Prevalence of conjunctival concretions. Cesk Slov Oftalmol. 2005;61(4):260-4 [Article in Czech]

Kulshrestha MK, Thaller VT. Prevalence of conjunctival concretions. Eye (Lond). 1995;9(6):797-8

Lay summary

Concretions are small white or yellowish dots, usually less than 1mm in diameter, commonly seen on the undersides of the eyelids. They contain cell debris and calcium. They may be the result of past inflammation. Occasionally they cause irritation or the feeling that there is something in the eye.

If concretions are causing symptoms, the optometrist may offer to remove them. After numbing the eye surface with an anaesthetic drop, the concretions can usually be teased out with the tip of a hypodermic needle. Rarely, antibiotic drops may be prescribed.

Such cases do not usually need to be referred to the ophthalmologist.

 

Concretions Version 5
Date of search 17.09.17
Date of revision 22.02.18
Date of publication 09.05.2018
Date for review 16.09.19
© College of Optometrists

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