4 - Lids/Lashes/Lacrimal Flashcards
Dermatochalasis
Elderly
Weak orbital septum -> redundant upper lid skin -> ptosis, pseudoptosis, loss of distinct lid creases, superior VFD
Blepharitis
- ant vs post
- symptoms
- staph vs seb
Gray line (most ant Riolan) divides, posterior = meibomitis
Often asymptomatic; vision that clears after blinking, burn/itch/fbs, tearing, CRUSTING IN THE MORNING, mild discharge
Seborrh: oily/greasy/flaky, less inflammation, more madarosis and/or misdirected growth
-assoc with seb dermatitis
Chalazion
- history
- pathophys
- signs/symp
Often have hx of similar recurrent lesions - ask about ACNE ROSACEA and seborrheic dermatitis
-evaluate for sebaceous gland carcinoma
Chronic, localized, STERILE INFLAMMATION of meibomian gland
- due to retention of normal secretions
- 25% resolve spontaneously
HARD, PAINLESS, IMMOBILE nodule without redness
Usually upper lid, asymptomatic
Hordeolum
- history
- pathophys
- signs/symp
Often have hx of similar recurrent lesions - ask about ACNE ROSACEA and seborrheic dermatitis
-can lead to preseptal
Acute STAPH INFECTION of glands
- internal = meibomian
- external = moll/zeis (aka stye)
TENDER, RED, WARM are of focal swelling
Glands affected: chalazion vs hordeolum
chalazi”ON” = “meibomiON”
Hordeola:
- internal = meibomian
- external = moll/zeis (stye)
Lid cysts
- inclusion
- milia
- dermoid
- sebaceous
I: KERATIN, congenital or acquired, white
M: SWEAT PORE occlusion, acquired, white
D: SUP-TEMP, congenital, firm + immobile
S: YELLOW/OPAQUE, solitary, smooth, retention of fluid in glands of zeis or retention of debris in meibomian
Ectropion
- pathophys
- signs/symp
Eversion of lid away from globe
#1: involutional (loss of musc tone of orb.oculi)
-also cicatricial, paralytic (bell’s), congenital
Exposure keratopathy, epiphora, brow ptosis
Entropion
- pathophys
- signs/symp
Inversion of lid against globe
#1: involutional
-also cicatricial (trachoma, OCP, SJS, etc.), congenital
Can result in pseudotrichiasis
Range of symp: mild punctate keratitis -> corneal ulceration* and pannus
*blindness from trachoma due to corneal ulceration secondary to entropion and trichiasis
Trichiasis vs distichiasis
T: lashes grow posteriorly
D: second row of lashes from MG openings
Floppy eyelid syndrome
- who
- pathophys
Obese men with obstructive sleep apnea, esp face-down sleepers
-also DM, HTN, hyperthyroidism
Significant reduction in elastin in TP -> spontaneous lid eversion
- due to mechanical trauma to TP
- leads to PAPILLARY CONJ-ITIS due to FRICTION (non-specific pabillae)
Floppy eyelid syndrome
-signs/symp
Signs: chronic PAPILLARY CONJ-ITIS, loose upper lids, punctate epithelial keratopathy (50%), keratoconus
Symp: chronic, bilateral red eyes in morning upon wakening
-often with mild mucus discharge
Ocular problems assoc with sleep apnea (3)
Floppy eyelid
NTG
NAION
(Low oxygen)
Ocular condns that most often cause red eyes in the morning (3)
Floppy eyelid
RCE
Exposure k
Benign essential blepharospasm
- who
- pathophys
Women (2:1), 50-70yo
Usually IDIOPATHIC
- corneal or conj irritation
- initially have random episodes -> progresses to involuntary spasms
Benign essential blepharospasm
- signs/symp
- systemic condn
Signs: spasms of 1) orb.oculi 2) procerus 3) corrugator
-50% have an ocular surface disorder (esp dry eye)
Symp: involuntary, sustained, repetitive, BILATERAL twitching/forceful closure, less common during sleep
Meige = BEB + lower facial abnormalities (difficulty chewing, jaw spasms, jaw pain, etc.)
-50% of pts with BEB have Meige
*tx with botox
Myokymia
Unilateral twitching of orb.oculi
Causes: sleep deprivation, too much caffeine, stress
-much more common than BEB
Basal cell carcinoma
-who
Most common skin + eyelid cancer (90% of lid malignancies)
Males (2:1)
Fair skin, UV exposure (esp B (290-320))
Pts often report chronic lesion that occasionally bleeds and won’t heal
Basal cell carcinoma
- pathophys
- signs
Malignancy of basal cell layer of epidermis
Minimally invasive (metastasis <0.1%)
Most commonly on LL (50-66%) and at medial canthus
Early: SHINY, FIRM, PEARLY nodule with superficial TELANGIECTASIA
Late: RODENT ULCER
Squamous cell carcinoma
-who
2nd most common eyelid cancer (40-50x less than BCC)
Males (2:1)
Fair skin, UV exposure (esp B (290-320))
Squamous cell carcinoma
-pathophys
Malignancy of stratus spinosum layer of epidermis
More aggressive than BCC: 13-24% undergo metastasis to nearby lymph nodes
Actinic keratosis: most common precancerous skin lesion, precursor to SCC (25% develop into SCC)
-elevated, pink/red, scaly lesion on sun-exposed skin
Squamous cell carcinoma
-signs
Variable presentation
Similar to BCC but without telangiectasia
Typically lower lid or lid margin
Keratoacanthoma
Sun-exposed areas
Early app: similar to BCC/SCC
Grow very quickly to large size (1-2cm) before slowly shrinking/spontaneously resolving
Sebaceous gland carcinoma
-who
Rare
Elderly females
Hx of chronic unilateral blepharitis or recurrent chalazia
Sebaceous gland carcinoma
-pathophys
Neoplasm of 1)meibomian 2)zeis (holocrine)
Poor prognosis: if >2cm mortailty rate is 60%
-symptoms present >6mo mortality rate is 38%
-overall mortality rate 10%
Sebaceous gland carcinoma
-signs
Varies
Often HARD AND YELLOW, assoc with MADAROSIS, thickened/red lid margins
Malignant melanoma
- who
- pathophys
Rare (<1% lid malignancies), most lethal
-age, skin color, fam hx, repeated irritation, sun exposure
Malignancy of melanoCYTES
Malignant melanoma
-signs
A: asymmetry B: border irreg C: color differences/uneven pigment D: diameter E: enlargment
Most important prognostic is depth of invasion
Dacryadenitis
- who
- pathophys: acute vs chronic
- causes (kind of reiterating from pathophys…)
Children, possible hx of recent fever/systemic infection
Inflammation of lacrimal land
Acute: bacterial (esp STAPH AUREUS), viral (esp MONO)
Chronic: MORE COMMON, from inflammatory disorders - SARCOID, tuberculosis, graves, idiopathic orbital inflammation
Causes: #1 NLDO (adult = involutional, kid = hasner) #2 maxillary sinus
Dacryadenitis
-signs/symp: acute vs chronic
Acute: S-SHAPED PTOSIS, temporal upper lid pain, redness, swelling, PREAURICULAR LYMPHADENOPATHY, fever, elev WBCs
Chronic: temporal upper lid swelling, less of everything else than acute
-may lead to inferonasal globe displacement, proptosis
Canaliculitis
-pathophys
Rare
Inflammation of canaliculi
Bacterial, viral, or fungal
-usually ACTINOMYCES ISRAELII (streptothrix): YELLOW SULFUR GRANULES after expression of canaliculi
-others: staph aureus, candida albicans, aspergillus, herpes s/z, nocardia asteroides
Canaliculitis
-signs/symp
Signs: tenderness over nasal lids, swollen “POUTING” puncta, dacryoliths, mucopurulent discharge
Symp: smoldering, unilateral red eye, often unresponsive to antibiotic tx, often misdx as recurrent conj-itis
*tx pcn
Dacryocystitis
- history
- pathophys
- causes (kind of reiterating from pathophys…)
Ask about concomitant ENT infection
Lac sac infection due to NLDO -> backflow of bacteria from NLD into sac
-common causes: STAPH AUREUS/epidermidis, pseudomonas, H FLU in children
Chronic cases should raise suspicion for epithelial carcinomas, malignant lymphomas
Causes: #1 NLDO (adult = involutional, kid = hasner) #2 maxillary sinus
Dacryocystitis
-signs/symps
Signs: prominent edema + tenderness over sac
- swelling below medial canthus tendons
- swelling above should raise suspicion for lac sac tumor
Symp: PAIN, often with crusting/tearing, occassional fever
*cystitis has more swelling, tenderness, pain than canaliculitis
Punctal stenosis
Narrowing/occlusion of puncta - no concensus on clinical definition
Usually involutional
Epiphora
Nasolacrimal duct obstruction
- who
- pathophys
- signs/symp
Congenital or acquired - acquired more common in females
Older pts: involutional stenosis
Younger: valve of Hasner blocked by membrane
-spontaneous opening around 1-2mo
Signs: epiphora, mucus, erythema, little tenderness/redness
Symp: unil tearing, discharge, crusting, recurring conj-itis
Jones testing
1: fluoroscein, five minutes
- positive = patent -> confirmed by presence of fluoro in back of throat or having them blow their nose
- if negative, go to Jones 2
2: irrigation with saline
- want: taste saline, gag, fluid recovery from nose
- if failed, DCR is next step
