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Visit 2 CANCELLED > 6.1.4. Identifies external pathology and offers appropriate advice to patients not requiring referral. > Flashcards

6.1.4. Identifies external pathology and offers appropriate advice to patients not requiring referral. Flashcards

1
Q

Difference between Anterior & Posterior Blepharitis

A
  • Anterior = inflammation of glands of zeiss or moll; bacterial or serborrhoeic
  • Posterior = inflammation of meibomian glands
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2
Q

Differences between Staphylococcal & Seborrhoeic Blepharitis

A
  • Staphylococcal = bacterial exotoxins released by bacteria causing inflammatory response or allergic reaction to bacteria themselves
  • Seborrheic = disorder of glands of zeis or moll, related to acne rosacea & serborrhoeic dermatitis
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3
Q

What types of patient get serbahooiec?

A

Seborrhoeic dermatitis (for example, of the scalp)
Ocular rosacea (a cause of posterior blepharitis)

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4
Q

Seborrheic blepharitis is differentiated by

A

less lid redness, swelling, and telangiectasia of the lid margins as compared to staphylococcal blepharitis, but an increased amount of oily scale and greasy crusting on the lashes. So more oily vs more red.

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5
Q

Symptoms of Anterior Blepharitis

A
  • Chronic
  • Worse in mornings
  • Redness, irritation, grittiness, watery discharge
  • FB sensation, soreness, photophobia
  • Itching
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6
Q

Signs of Anterior Blepharitis (early)

A
  • Scales - hard & brittle in staphylococcal (collarettes), soft & greasy in serborrhoeic
  • Lid hyperaemia, shiny lid
  • Lid margin swelling
  • Telengectasia (lid margin veins visible)
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7
Q

Signs of Anterior Blepharitis (longstanding)

A
  • Foamy tears
  • Scarring
  • Thickened lid margin
  • Corneal staining
  • Trichiasis, Madarosis, Poliosis
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8
Q

Symptoms of Posterior Blepharitis

A
  • Dryness
  • Itchiness
  • Redness
  • CL intolerance
  • Blurred vision due to frothing of tear film (not enough lipids change properties of tear film)
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9
Q

Signs of Posterior Blepharitis

A
  • Secretions at meibomian gland orifices
  • Foam at tear meniscus
  • Plugging of orifices (glands look dilatated)
  • Conjunctival hyperaemia
  • Evaporative tears
  • Secondary signs include: punctate epithelial erosion over lower third of cornea; marginal keratitis; scarring; neovascularisation and pannus; mild papillary conjunctivitis
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10
Q

Risk factors of bleph

A
  • Age
  • Hormones
  • Gender
  • Secondary to some skin conditions
  • Diabetes
  • Makeup
  • Down’s syndrome
  • Dirty people/hygiene
  • CL wearers
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11
Q

Difference between Staphylococcal & Demodex (tough one!)

A
  • Generally same symptoms, might be milder in demodex
  • Staph has yellower greasy scales at bottom of lashes. Demodex look more cylindrical & white (dandruff cuff)
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12
Q

How to treat demodex?

A
  • Tea tree oil with eye only solutions as it’s toxic to the eye e.g. Optase solution. Done daily until sxs resolve
  • Review dry eyes & blepharitis on College of Optometrists
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13
Q

Dry eye

  • Common causes of aqueous deficient dry eye:
A
  • Common causes of aqueous deficient dry eye:
    • Sjogren syndrome (autoimmune)
    • Rheumatoid arthritis (inflammatory)
    • Lupus (inflammation)
    • Sarcoidosis (autoimmune)
    • Aging
    • Refractive surgery
    • Medications - antidepressants, antipsychotics, antihistamines, antihypertensive, anticholinergics, anti-arrhythmic
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14
Q

Dry eye

Predisposing factors:

A
  • VDU - less blinking!
  • Environment - air con, low humidity
  • Smoking
  • Contact lens wear
  • Health issues as listed above
  • Medication especially the pill!!
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15
Q

Dry eye

Symptoms (bilateral)

A
  • Irritation, FBS, Redness, Gritiness, Burning
  • Possibly blurred vision if epithelial disruption or mucous strands
  • Sxs worsen with heat, wind or smoke
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16
Q

Assessor may ask what your routine is for a dry eye assessment

Non-invasive to Invasive:

A
  • H&S
  • White light slit lamp exam - Tear quality with optic section/specular reflection at 16X, Tear meniscus height (<0.18mm is dry), Looking out for signs of blepharitis on eyelashes, eyelid margins. Looking at any redness of conjunctiva, limbus & lids. Looking out for any signs of keratitis on cornea
  • Blue light slit lamp exam - Instill NaFl. Preferably using wratten filter. Looking for signs of staining suggests dryness present/more longstanding e.g. smile stain. TBUT - watching for when the tear film breaks up, may use 10X mag to observe this more easily.
  • Lid eversion - Looking for signs of papillae, follicles etc. Especially if patient presents with itchiness &/or mucous discharge. Grading roughness, redness & noting any papillae etc.
17
Q

Lid wiper epitheliopathy:

A
  • Thought to indicate friction
  • The wiper is a small area that comes into contact with the ocular surface during a blink. If tear film isn’t working as it should or isn’t sufficient enough to lubricate it then friction occurs! This causes the below staining pattern to occur.
18
Q

LIPCOF

A

Thought to indicate friction

19
Q

QUESTIONS FOR DRYNESS:

A
  • CL wearer?
  • L: one or both eyes?
  • O: when did the dryness start?
  • F: during any particular time of the day? During windy weather?
  • T: any discharge/photophobia/grittiness/itchiness/burning/pain or sore eyes/redness/sticky eyelids/blurred vision
  • S: anything to self-treat the dryness?
  • HAS IT WORSENED SINCE?
20
Q

TESTS for dryness

A
  • Slit Lamp —> Tear meniscus (0.2-0.3mm normal, <0.18mm is dry), Palpebral conj 1.0 red no papillae (lid eversion), NaFl (write expiry date & batch number?)TBUT, record staining, Tear quality (fast/slow movement of debris, evaporative/normal as seen, mucous strands?), Grade bulbar conj redness
    • Write Efron grading scale used
21
Q

Advise for MGD:

A

“24/12 recall sooner if any problems/no symptoms improvement, explained what post bleph is, hot compress BEs 2x daily at 40 degrees for 5 mins (recommend The Eye Doctor dry eye compress), vertical upper + lid massage after warming, lid wipes like Blephaclean after to remove excretions. Advised to avoid cosmetics, especially eye liner & mascara, omega 3 supplements, improve ambient humidity, 20-20-20 rule during VDU. Told complete eradication of MGD may not be possible but long term compliance should reduce symptoms”

22
Q

Advise for Dry Eye (aqueous deficient):

A

“24/12 recall sooner if any problems/no symptoms improvement. Advised hycosan extra drops up to 3x/day taken as needed to relieve dry eye symptoms. Advised optimising environment (improve ambient humidity), diet - omega 3 supplements, 20-20-20 rule during VDU. Told complete eradication of dry eye may not be possible but long term compliance should reduce symptoms.”

23
Q

Blepharitis: if no other tx works

A
  • If first line management doesn’t work, then chloramphenicol can be used for anterior blepharitis twice daily placed into eyes or rub into lid margin with fingertip
    • Can be used for a week, then optometrist needs to review px in that time period to note improvement
24
Q

Thealoz Duo

A
  • Trehalose (3%), hyaluronic acid (*as sodium hyaluronate salt 0.15%), sodium chloride, trometamol, hydrochloric acid and water for injections.
    • Preservative & Phosphate free
    • Importance of trehalose - better stabilises against oxidative strain & maintains better tear film stability in stressful conditions like cold or hot as it’s stabilising the lipid bilayer & proteins
25
Q

Carbomer

A

component in a gel that helps it stay more viscous & increase tear retention time

26
Q

Sodium hyaluronate

A

is a sodium salt of hyaluronic acid helping to lubricate the eyes & prevent irritation

27
Q

Glycerine

A

moisturising agent

28
Q

tonicity adjustment

A

Sodium, Potassium, Magnesium & Calcium chloride

29
Q

When would you use one drop over another?

A
  • Depends on severity of symptoms e.g. if smile stain, then mild probably wont work well whereas someone with a little dryness after a long day will be better off with mild.
  • Dry eye gel - for more severe dry eye. More for before bed to work overnight.
  • Liposomal drops for evaporative e.g. Optrex Achtimist is really good!
  • Hyaluronate holds water so better for aqueous deficient

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