5 & 6. CL Complications: Blepharitis, MGD and Papillary Conjunctivitis Flashcards
1
Q
Which condition Blepharitis or MGD is associated to contact lens wear and which one is caused due to contact lens wear?
A
Blepharitis: Not caused by CL wear, but cause problems with CL wear.
MGD: Caused by CL wear and cause problems with comfort.
2
Q
What are the 2 types of blepharitis?
A
- Anterior blepharitis
- Posterior blepharitis
3
Q
What happens in anterior blepharitis?
A
Inflammation of follicles & glands of Zeis or Moll
4
Q
What are the 2 forms of anterior blepharitis?
A
Bacterial or seborrhoeic
5
Q
Define what happens in posterior blepharitis?
A
Inflammation of meibomian glands
6
Q
What is the difference between anterior and posterior blepharitis
A
Posterior is an inflammatory response. Anterior is a non-inflammatory response.
7
Q
Why is blepharitis said to be chronic and difficult to manage?
A
It requires on-going treatment and constant medical care.
8
Q
Staphylococcal and seborrheic are characterized by?
A
Staphylococcal: hard and brittle scales around the base of the lashes.
Seborrheic: Soft and greasy scales. Lashes are greasy and stuck together.
9
Q
3 causes of Staphylococcal
A
- Direct inflammation
- Inflammatory rection to bacterial exotoxins
- Allergic reaction to bacteria themselves
10
Q
Seborrheic is related to what skin condition?
A
seborrhoeic dermatitis and acne rosacea : Ask in H&S
11
Q
What is meant by telangiectasia
A
Dilation and redness of blood vessels on the lid margin
12
Q
Describe the difference seen when scales around lashes is removed from staphylococcal blepharitis vs lash mite infestation
A
staphylococcal blepharitis: bleeding observed
lash mite infestation: no bleeding observed
13
Q
Describe what is seen in patients with seborrheic blepharitis
A
Shiny anterior lid margin, hyperemia of lid margin. Greasy scales and lashes stuck together.
14
Q
Early signs of blepharitis
A
- Anterior crusting (Collarettes)
- Lid redness (lid erythema)
- Dilated lid margin vessels (telangiectasia)
- Lid margin swelling
15
Q
Long standing signs of blepharitis
A
- Thickened lid margin (tylosis) & notching
- Trichiasis, madarosis, poliosis
- Blocked meibomian glands
- Corneal staining
- Foamy tears (saponification of tears by excess fatty acids)
16
Q
Symptoms of blepharitis
A
- Soreness, redness & irritation
- FB sensation, dryness, itching
- Burning, grittiness, mild photophobia
- May be worse than signs
- May be worse in the morning
17
Q
How is blepharitis managed?
A
Lid hygiene and warming: to loosen the collarettes, remove crusts and reduce staph levels.
Commercial products or home remedies can be used
18
Q
Medications used for blepharitis management
A
Short course of tropical antibiotics: chloramphenicol ointment
Systemic antibiotics used in cases associated with acne rosacea
Corticosteroids: Weak tropic if severe
Artificial tears: promote comfort
19
Q
What are the 3 consequences if patients with blepharitis wear contact lenses?
A
- Staph presence/infection
= increased risk of infection - Corneal staining
= discomfort & increased risk of infection (Staining is because epithelium breaks, risking infection) - Adversely affects tear film
= dry eye, reduced comfort and wearing time (WT) (due to instability of the tear film).
20
Q
How can blepharitis be managed if patients must wear contact lenses: 4 methods
A
- Lens wear management: Do not wear until advised.
- Increase lens replacement frequently: instead of monthly shift to dailies or weekly.
- Careful lens cleaning
- Refit with silicone hydrogel : they offer better comfort
21
Q
Meibomian glands are modified ..?
A
Sebaceous glands within tarsal plates
22
Q
Meibum function
A
23
Q
Meibum function
A
Oily secretion
24
Q
Functions of the oily secretion by the meibum gland
A
- Lubrication of the lid margin.
- Produce the outermost lipid layer of the normal tear film: to prevent tear film evaporation
25
Describe MGD, why is it caused?
Hyperkeratinisation of the ductal epithelium, keratinised cell debris and increased meibum viscosity
26
Is it true that MGD is the most common cause of dry eye diseases?
Yes
27
Risk factors of MGD
1.Age, gender, hormonal disturbance, systemic agents, contact lens wear
2. Secondary to skin conditions
28
What type of dry eye is caused by MGD
Evaporative dry eye
29
What is the definition of MGD
MGD is a chronic, diffuse abnormality of the Meibomian glands, commonly characterised by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion.
30
What happens to normal oily secretions to patients with MGD?
the normal oily secretion becomes semi- solid, toothpaste- like plaques
31
Causes of MGD?
Increased tear film osmolarity- this is caused hyperosmolarity and CL wear causes this. Additionally, use of a lot of electric devices: reduces blinks. Eyes become more hyperosmolar
32
Signs of MGD
Gland plugging/capping, absent or cloudy/paste-like yellowy secretion on expression, tear foaming, telangiectasia, notching, tear film instability, often leading to corneal staining
33
Describe what happens to meibomian glands in MGD?
The glands are dying, as they are dying they contract, pulling down on the lid margin.
34
MGD is diagnosed using?
Meibography : evert lower eye-lids and use infra-red light and use grading scales to grade.
35
In progressive meibomian gland disfunction what happens to the glands?
The glands become irregular cause they are dying
36
Describe hoe MGD is managed in relation to Diet, work environment, eyelid hygiene, lubrication
Diet: food rich in omega-3 or supplements can be taken. Work environment: computer use, position and duration. Eyelid hygiene: using a warming cloth to manage and clean the lids.
37
Can IPL be used to treat MGD?
YES, the device generates heat that liquefies the meibum.
38
Relationship between CL wear and MGD
CL greatly affects MG morphology. CL wear can lead to partial or complete gland loss in most CL wearers
39
How is MGD managed in patients that wear CL?
If necessary, completely cease lens wear until effectively managed.
OR:
1. Increases lens replacement frequency
2. Careful lens cleaning
3. Refit with silicone hydrogel
40
Why are silicone hydrogels preferred? And what is 1 disadvantage?
Preferred because: lower water content, less lens dehydration so better comfort.
Disadvantage: More lipid deposits so careful cleaning needed.
41
Contact lens papillary conjunctivitis is also called?
Contact lens induced/ associated papillary conjunctivitis. (CLIPC, CLPC)
42
Describe the difference in onset in patients that wear soft lens or RGP?
Soft lenses: onset within a few weeks of initial wear.
RCP: Onset up to 14 months from initial wear.
43
Is CLPC related to the immune system
CLPC, Is a non-specific immune response.
44
What are the 3 reasons that cause reactions in CLPC
1. Hypersensitivity: immune response to solution and deposited lenses
2. Mechanical trauma
3. Individual susceptibly
45
Where is papillae formed for soft contact lens wearers and for RGP wearers?
Soft contact lens wear: Central tarsal plate. RGP: Small section 0.5- 2mm localized or randomly distributed. RGPs aggravate small areas.
46
Papillae consists of what kind of tissues and what happens when this tissues become infiltrated?
Papillae consists of connective tissues. When this tissues become infiltrated: an inflammatory reaction is seen.
47
What is seen when the blood vessels in the papillae are dilated ?
When blood vessels are more dilated, this allows more inflammatory cells into the area. After a long time the conjunctiva becomes thickened and changes to microvilli is seen.
48
CLPC Symptoms (7)
1. Acute ocular discomfort
2. Lens intolerance
3. Itching
4. Mucous discharge
5. Excessive lens movement
6. Increased lens deposits
7. Reduced VA & CS
49
How is CLPC Seen under slit lamp (What mag is used, and what observations are done)?
Mag: 10-15 X
Observe CENTRAL tarsal plates, redness/ roughness. Look for conjunctival oedema and mucus formation.
50
When looking for CLPC signs the upper and lower lids are compared, why?
The difference between the 2 is observed. Because the lower lids do not move a lot in comparison to the upper lids. Hence, when blinking the lower lids do not interact much with the contact lenses.
51
What is 1 classic sign that a patient has papillae?
Central vascular trough. Hence, the vessel running through the centre of the papillae is dilated and hence, high mag is used to diagnose (40X)
52
What 3 signs are seen if the superior cornea is affected?
1. Staining
2. Infiltrates
3. Limbal redness
53
Lids are divided into 5 zones, why?
Because patients might have localized papillae that looks very different in different areas.
54
What zones are affected by soft lenses and RGP?
Soft lenses: Zone 1 and 3
RGP: Zone 3
55
What is the difference in the papillae apex of patients that wear Soft lenses in comparison to RGP lenses?
Soft lenses: Papillae apex is rounded, flattened form.
RGP: Papillae is crater- like form
56
What is seen first when lids are everted? Redness or roughness? And how are this 2 observed differently
Redness changes are seen before roughness changes. And redness changes are seen using white light initially. To look at roughness changes, fluoresce is used.
57
How is CLPC graded? Using CCLRU and Efron, describe the difference?
CCLRU: Redness and Roughness is graded. Efron: pap conj is graded.
58
CLPC prevalence has declined now because?
Good quality cleaning, deposits are no more a problem, lens do not interact with palpebral conjunctiva much.
59
Effect of overnight wear and use of daily disposables in relevance to CLPC prevalence
Overnight wear: Increases likely hood by 2 times
Daily disposable lenses decreases likely hood to 2%.
60
Recently the prevalence of CLPC isn't high, why has there been a decline over the years?
Because now lenses have good cleaning product, deposits are not much of a problem now, lens do no interact with palpebral conjunctiva much. Improvement in management and disposable lenses are now available. Better CL education is now available.
61
How long does it take to recover lower grade CLPC vs high grade CLPC?
Low grade: 1-2 weeks
High grade: Can take months to recover
62
3 ways of managing CLPC?
1. Cease lens wear initially if necessary: This allows time for the conjunctiva to recover.
2. Change lens : to hydrogel or RGP, change of material, modulus and modality
3. Change care system: check compliance, solution needs to be changed regularly.
63
How can itchyness be reduced in patients with CLPC?
Cold compress
64
Describe how lenses should be cared for for patients with CLPC?
1. Hand wash (improvement to ocular hygine)
2. Reduce wear- time
65
What is the prognosis of CLPC?
Symptoms improve quickly after removal of lenses and once patient stops wearing lenses, but papillae takes long to resolve (2 week- 6months), lens shouldn't be worn in this duration as papillae apex may scar giving whitish appearance
66
What is differential diagnosis?
Through history and symptoms, the cause of a condition is determined since various problems can be causing a condition.
67
Is giant papillary conjunctivitis associated with CL wear?
Not often, unless advanced stage
68
GPC is associated with what 5 conditions ?
1. Ocular prostheses
2. Nylon sutures
3. Scleral buckles
4. Elevated corneal abnormalities
5. Blebs
69
Follicular conjunctivitis is what kind of an infection?
Viral and chlamydial infections
70
What are the 3 signs observed for follicular conjunctivitis?
1. Watery discharge, no mucous
2. Slight irritation
3. Best observed in lower fornix
71
Is a vascular tuft present in follicular conjunctivitis?
No vascular tuff at the apex- vessels are on the outside and whiter then papillae.
72
What kind of reaction is vernal conjunctivitis?
Allergic reaction (IgE mediated response)
73
What is seen in vernal conjunctivitis ?
1. Papillae on both lids, no vessels in centre.
2. Papillae may be LARGE
3. Thick yellow discharge
