Eye Disorders (TOSCE) Flashcards
Eyelid Anatomy:
-Glands of Moll
modified sweat glands
Eyelid Anatomy:
-Glands of Zeiss
modified sebaceous glands
Eyelid Anatomy:
Meibomian glands
-modified sebaceous glands that produce the lipid layer of the tear film
Eyelid Functions
- primarily protects the anterior surface of the eye
- aids in regulation of light reaching the eye
- aids in tear flow through pumping a action on the conjunctival and lacrimal sacs
- helps with the distribution & elimination of tears
Explain conjunctiva
- thin, transparent, mucous membrane
- covers the inner surface of eyelids (palpebral portion) and anterior surface of the eye (bulbar portion)
- the anterior surface only covers the white of the eye
- main function is to prevent the eye from drying by secreting a moisturizing mucous
Eyelid Disorders:
List some eyelid conditions
- Hordeolum (stye)
- external
- internal
- Chalazion
- Blepharitis
Eyelid Disorders:
Conjunctivitis
- Acute Bacterial
- Hyperacute Bacterial
- Chronic
- Viral
- Seasonal Allergic
The other type of eye disorders?
dry eye
General red flags for eye disorders
- blaunt trauma
- foreign particles trapped/embedded in the eye
- ocular abrasion
- eye exposure to chemical or chemical fumes
- thermal injury - welder’s eye or snow blindness
- blurred vision (not due to ocular ointments)
- pain
- photophobia (sensitivity to light)
- redness around the cornea
- abnormal pupil
- condition lasting for more than 48hrs (**there are exceptions to this)
- contact lens wearers with conjunctivitis
Treatment goals for infections in the eye
- cure
- prevent transmission
- prevent reoccurence
Treatment goals for dry eye
- manage symptoms
- prevent complications
- identify any exacerbating factors
Pathophysiology of a Stye (Hordelum)
- can be external or internal
- acute localized infection involving either the glands of Zeiss of Moll
- most common infecting organism is S. aureus
- results in the formation of a small cyst or abscess
- unilateral, localized lid swelling, tenderness & erythema
- often associated with blepharitis
When do you refer a external hordeolum (stye) ?
if it doesn’t drain in 48 hours bc it may then require Rx antibiotics
Hordeolum (Stye) - Internal:
-involves what glands?
-involves the meibomian glands (usually deeper inside/underneath eyelid)
Hordeolum (Stye) - Internal:
often resolve within?
1-2 weeks
Hordeolum (Stye) - Internal:
warm compresses for how long?
for 5-10 minutes several times daily. Refer if not resolved in 1 week.
Hordeolum (Stye) - Internal:
if infection severe - oral antibacterials may be needed
erythromycin
cloxacillin
tetracycline
Hordeolum (Stye) - External:
describe it
- smaller & more superficial cyst or abscess
- lesion always points toward the skin
Hordeolum (Stye) - External:
How do you treat it?
- can treat with warm compresses applied 10 to 15 minutes 3 or 4 times a day
- can follow warm compresses with eyelid massages
- should drain on its own within 48 hours
- OTC antibiotic ophthalmic ointment may be applied to the affected area 3-4 times daily but is not required & not generally recommended
Prevention of a Hordeolum (Stye)
- wash hands before and after any contact with infected eye
- avoid touching eyes
- change towels and compresses after each use and do not share towels, face clothes, or pillows, etc
- proper use of eyedrops (avoid touching the eye/eyelashes) - clean the tip after use
- avoid use of eye cosmetics during infection (may have to throw away eye makeup as it may be contaminated)
- adress treating symptoms of blepharitis to help decrease recurring hordeola
Blepharitis
inflammation of the eyelids
Define Chalazion
inflammation of the meibomian glands (deep chalazion)
OR
inflammation of the Zeiss sebaceous glands (superficial chalazion)
Is chalazion an infection?
no - not an infection but an inflammation of the area
Chalazion are generally _____ in nature
chronic
Chalazion:
____ develops over a period of weeks - not acute
nodule
Chalazion:
lesion usually points towards?
the conjunctival surface
Chalazion:
Characterized by?
painless, localized redness & swelling
Chalazion:
More common in people with?
blepharitis, acne rosacea, or seborrheic dermatitis
Treatment for Chalazion?
- initial symptoms may resemble hordeolum - without the acute inflammation
- initial treatment similar to that for external hordeolum
- warm compresses 10-15 mins 3-4 times daily
- eyelid massage
- often resolve spontaneously within a few days
- refer if no improvement within 48 hours of initiating treatment
*for Pts with blepharitis, encourage regular lid hygiene to prevent recurrence
When do you refer a chalazion?
immediate referral if chalazion is painful or visual distortion/impairment
Explain the pathophysiology of blepharitis
- chronic inflammation of the eyelids
- usually bilateral
- often associated with chronic dermatological conditions such as acne rosacea or seborrheic dermatitis
- not contagious
Blepharitis:
Long-term complications may include?
- physical damage to the eyelids and cornea
- scarring, vision impairment, corneal perforation
Symptoms of blepharitis
- red, swollen, itchy lid margins, eyes red and watery
- landmark sign = eyelid is scaly
- foreign body sensation or burning
- sandy or gritty sensation in the eye - worse upon awakening (similar six’s to dry eye, but this is an EYELID disorder)
- loss of eyelashes or lashes grow abnormally
- symptoms may be unilateral or bilateral
- appearance can often be confused with conjunctivitis and/or other eyelid conditions
Landmark sign of blepharitis
scaly (like a crocodile)
Blepharitis - initial diagnosis or exacerbations require _____
referral
- usually a chronic problem
- treatment of concomitant dermatologic disorders important for long-term control
Rx treatments for blepharitis?
- antibacterial ointments (bacitracin or erythromycin) preferred to drops because of increased contact time
- short term Tx with weak corticosteroids or corticosteroid/antibacterial combinations during exacerbations
- Oral AB Tx may be required (tetracycline, minocycline, doxycycline, or erythromycin)
Treatment for blepharitis
- Regular and long-term eyelid margin hygiene essential
- warm compresses applied for 5-10 minutes
- gentle scrubbing of the lid margin: commercial eyelid scrubs (lid-care or blephagel) or a cotton swab dipped into a solution of a few drops of baby shampoo in a small amount of warm water
- recommended once or twice daily immediately after initial diagnosis or during exacerbations
- may be reduced to twice a week once under control
When do you refer Blepharitis?
refer if new onset suspected & exacerbations
Treatment Summary:
External hordeolum
- nonpharmacologic - key to prevent spread
- warm compresses, spontaneous draining
- referral after 48 hours
Treatment Summary:
Internal hordeolum
- warm compresses
- referral after 1 week
- Rx topical/oral AB
- nonpharmacologic treatment
Treatment Summary:
Chalazion
- warm compresses
- referral after 48 hours
Treatment Summary:
Blepharitis
- Referral to get diagnosis before you can treat it
- Rx ocular AB-ointment
- long-term chronic nature, discuss eyelid hygeine
Define conjunctivitis
-it is a general term referring to any inflammatory condition of the conjunctiva
What is the conjunctiva?
mucous membrane lining the back of the eyelid and the front of the eye, except the cornea
Pathophysiology of conjunctivitis
- inflammation can be hyper acute, acute, or chronic
- can be caused by viral or bacterial infections, allergies, or other irritants and dryness
- variants include hyper acute, acute & chronic bacterial conjunctivitis, viral conjunctivitis & seasonal allergic rxn
Acute bacterial conjunctivitis:
Is it self-limiting?
yes
Acute bacterial conjunctivitis:
resolves within?
2 weeks
*but treatment can often shorten the course of this disorder
Acute bacterial conjunctivitis:
is it contagious?
oh yeah man
Acute bacterial conjunctivitis:
-how do you prevent/control this?
- proper personal hygiene is important to avoid transmission
- hand-washing, separate towels and pillowcases, etc.
Acute bacterial conjunctivitis:
who should be automatically referred?
the children
and
contact lens wearers
Acute bacterial conjunctivitis:
symptoms
- acute onset generally
- usually unilateral (at least it is initially unilateral)
- mild to moderate foreign body sensation
- minimal or no itching
- generalized redness
- purulent (creamy white or pale yellow) discharge
- eyelids stick together when you first wake up
- could also have crusting on the eyelids (guh-ross)
Acute bacterial conjunctivitis:
adult treatment of drops and ointments
For mild symptoms:
- Polymyxin B/gramicidin (Polysporin or generic) drops instilled 4-6 times daily for 7-10 days
- Polymyxin B/gramicidin (Polysporin or generic) ointment should be applied to lower lid QID for 7-10 days
- should continue treatment of both drops and ointment for 2 days after symptoms have resolved
Acute bacterial conjunctivitis:
when do you refer adults to a HCP for Rx treatment?
if no improvement within 48 hours or symptoms worsen
Acute bacterial conjunctivitis:
non-pharms for adults
- warm & wet compresses applied in the morning
- irrigation of conjunctival sac to remove secretions
Acute bacterial conjunctivitis:
common Rx treatments?
- sufacetamide sodium
- trimethoprim/polymyxin (Polytrim) - Tx of choice
- erythromycin ointment
Hyperacute Bacterial Conjunctivitis:
most commonly seen in?
- neonates (babies)
- sexually active adolescents and young adults (15-24 yrs)
Hyperacute Bacterial Conjunctivitis:
Caused by what bacteria?
N. gonorrhoea
N. meningitidis
Hyperacute Bacterial Conjunctivitis:
does it cause a referral?
YEAH - immediate referral dude or ER
Hyperacute Bacterial Conjunctivitis:
symptoms
- copious yellow/green, purulent discharge
- redness
- irritation
- tenderness
Hyperacute Bacterial Conjunctivitis:
How do neonates (infants) get it?
- transmission occurs during vaginal delivery
* bilateral discharge 3-5 days after birth
Hyperacute Bacterial Conjunctivitis:
How do adults get it?
transmitted via hands and genitalia
Chronic Bacterial Conjunctivitis:
Lasts for how long?
> 4 weeks
Chronic Bacterial Conjunctivitis:
often associated with?
blepharitis, rosacea, facial seborrhoea, nasolacrimal duct obstruction
Chronic Bacterial Conjunctivitis:
does it need a referral?
YES
-because it needs topical or oral ABs
Chronic Bacterial Conjunctivitis:
non-pharmacologic Tx similar to blepharitis
- warm compresses
- lid scrubs
- avoid contaminated products
Viral conjunctivitis:
is it contagious?
highly
Viral conjunctivitis:
unilateral or bilateral?
often starts out unilateral but can end up being bilateral
Viral conjunctivitis:
most common cause
adenovirus
*HSV (herpes) or VZV (Zoster varicella) can also be the cause
Viral conjunctivitis:
often occurs in?
community epidemics (schools, daycares, etc.)
Viral conjunctivitis:
some patients have an associated ?
respiratory tract infection
Viral conjunctivitis:
how long does infection last for?
2-4 weeks
Viral conjunctivitis:
how long is it contagious for?
contagious for 2 weeks after the second eye becomes involved
Viral conjunctivitis:
symptoms
- acute red eye
- conjunctival swelling
- soreness or mild pain
- minimal or no itching
- profuse watery clear discharge
- foreign body sensation
- mild photophobia
*upper respiratory tract infection may be present
Viral conjunctivitis:
treatment
- all Pts need to be referred
- especially if there has been a recent shingles outbreak
- cold compresses
- ocular lubricants
- avoid direct contact with others for >14 days after onset of symptoms
Viral conjunctivitis:
should this make children miss school?
yes - for one week
Allergic Conjunctivitis:
also called ?
seasonal allergic rhinoconjunctivitis (hay fever)
Allergic Conjunctivitis:
caused by?
allergens such as ragweed, grass pollen, animal dander, etc.
Allergic Conjunctivitis:
unilateral or bilateral?
normally bilateral
Allergic Conjunctivitis:
symptoms?
- severe ocular itching
- some/minimal redness
- tearing
- no sign of infection
- no foreign body sensation
Allergic Conjunctivitis:
often accompanied with?
runny nose
sneezing
Allergic Conjunctivitis:
treatment and management (non-pharms)
- allergen avoidance
- cold compresses for 10-15 min TID-QID to help redness & itching
Allergic Conjunctivitis:
treatment and management
(pharmacological)
First line:
- ocular lubricants (free of preservatives) for symptomatic relief
- oral antihistamines (2nd gen preferred) - loratadine, ceritizine
Second line:
-ocular decongestants or decongestant/antihistamine combinations
Allergic Conjunctivitis:
How do oral antihistamines help?
stops itching but no decrease in redness
Allergic Conjunctivitis:
What is the caution that needs to be considered with ocular decongestants?
rebound ocular congestion
Allergic Conjunctivitis:
how do you prevent rebound ocular congestion?
do not use ocular decongestants for longer than 3-5 days
Allergic Conjunctivitis:
when do you refer?
if no response to OTC therapy within 72 hours
Allergic Conjunctivitis:
Is it preventable? How do you prevent?
yes, it can be
-try to start allergic rhinitis patients on preventative Tx at least 1 week before allergy season
Allergic Conjunctivitis:
how does an ocular decongestant work?
causes vasoconstriction - stops redness from occuring
Allergic Conjunctivitis:
How do ocular lubricants help?
- dilutes allergen and decreases allergen contact time with conjunctiva
- may create a barrier against pollens
Allergic Conjunctivitis:
how often should you use ocular lubricants?
1 drop 2-6 times daily
What are 2 pharmacological groups on the OCT market of ophthalmic/ocular decongestants?
- phenylephrine
- imidazolines (ex. naphazoline, tetrahydrozoline, oxymethazoline)
imidazolines have a _____ duration or action than phenylephrine
longer
tetrahydroazoline & oxymetazoline has ____ duration of action than naphazoline
longer
Out of the imidazolines, which generally appears to exhibit the least side effects.
oxymetazoline
What is a worry when taking ophthalmic decongestants?
systemic absorption
- OTC concentration may be insufficient to cause systemic absorption
- but the systemic circulation could occur through the nasolacrimal system
How do you minimize the effect of ocular decongestants in the systemic circulation?
you can minimize this effect by applying gentle pressure with the index finger over the tear duct for 1-2 minutes
When is ocular decongestants in the systemic circulation contraindicated?
in angle-closure glaucoma
Another precaution with ocular decongestants is possible mydriasis. Who can this occur in?
possible mydriasis with normal dosing in patients with contact lenses, lightly coloured irises, and corneal abrasion
Ophthalmic Mast Cell Stabilizers:
list an example
sodium cromoglycate
Ophthalmic Mast Cell Stabilizers:
how do they work?
blocks histamine from mast cells
Ophthalmic Mast Cell Stabilizers:
when are they used?
regularly doing allergy season to prevent redness, itching and eyelid edema
Ophthalmic Mast Cell Stabilizers:
takes up to __ days for max effect
10
Ophthalmic Mast Cell Stabilizers:
best used as a ???
preventative measure man
Dry Eye:
What are the 2 major classifications?
- aqueous tear-deficient dry eye
- evaporative dry eye
Dry Eye:
can lead to?
eyes drying out and becoming inflamed
Dry Eye:
can cause damage to?
ocular surface, scarring and reduced vision
Dry Eye:
severe forms referred to as?
KCS
-Keratoconjunctivitis Sicca
Dry Eye:
list some risk factors
- Environment - low humidity, high temp, air pollution
- Occupation - air travel, computer use
- Age
- Hormonal changes
- Wearing contact lenses
- Medical conditions (RA, Sjorgen’s syndrome)
- Ocular diseases - blepharitis, allergic conjunctivitis, infection
- Medications - anticholinergics (first gen antihistamines, TCA’s), beta blockers, diuretics
Dry Eye:
signs and symptoms
- foreign body sensation
- redness
- itchiness
- burning/stinging
- grittiness
- tired eyes
- dryness (obvs - thanks drena)
- excessive tearing
- general discomfort
- photophobia
- blurred vision
- difficulty in moving lids
Dry Eye:
treatment goals
- manage symptoms
- prevent complications
- determine the severity of the situation
- rule out any other ocular complications
Dry Eye:
non-pharmacologic treatment
- environmental changes
- use a humidifier
- avoid prolonged viewing of computer screens/video games
- encourage blinking
- avoid windy outdoor environments without eye protection (sunglasses, goggles)
- cool, moist compresses placed over closed eyelids for short-term relief
- tear duct (punctual) occlusion
Dry Eye:
nonprescription treatment
ocular lubricants:
- artificial tears
- lubricating ointments and gels (at night only man - cause it can cause blurriness)
Dry Eye:
when do you refer?
if symptoms do not resolve within 3-5 days or if they worsen
Dry Eye:
signs of preservative toxicity?
stinging and conjunctival inflammation
Dry Eye:
what do you do if a Pt is showing signs of preservative toxicity?
Either:
- switch to product with different preservative
- switch to product with no preservative
- refer to physician
Dry Eye:
characteristics of an ideal artificial tear?
- lubricates ocular surface well
- high retention time
- no preservative (for max Pt comfort)
- contains essential minerals and electrolytes to maintain good corneal health
Dry Eye:
artificial tear products that have a higher viscosity have a ____ retention time in the eye
higher
*higher viscosity products would be ointments or suspensions
Dry Eye:
combined polymers have a ____ retention time
higher
Dry Eye:
What artificial tear products are compatible with contact lenses?
GenTeal
Visine
Dry Eye:
What are two types of preservatives in artificial tear products?
- benzalkonium chloride
- oxidative preservatives (safer)
Dry Eye:
Describe benzalkonium chloride preservatives used in artificial tear products
- most frequently used but known to be toxic to corneal epithelium
- should be avoided in moderate to severe dry eye disorders
Dry Eye:
Describe oxidative preservatives used in artificial tear products
- safer alternative
- Polyquad
- Sodium chlorite (Purite) or sodium perborate - these are also referred to as “vanishing” preservative
Dry Eye:
Pts using artificial tear products with preservatives:
If they are using >___ applications per day - they should switch to a preservative-free product
4
Dry Eye:
when recommending a lubricating ocular ointment, what should you always ask about?
ask if they’d had a rxn to wool because some lubricating ocular ointments contain lanolin
Dry Eye:
What do lubricating ocular ointments contain?
petrolatum
mineral oil
sometimes lanolin (why you need to ask about wool rxn)
Dry Eye:
Do lubricating ocular ointments have preservatives?
generally do not require them
Mr. Papagiorgio voice
Dry Eye:
How do lubricating ocular ointments help?
- enhance retention time in eye which appears to increase the integrity of the tear film
- require less frequency of instillation - longer contact time
**generally administered at bedtime (blurred vision)
Dry Eye:
List some preservative-free products that Pts may be using continuously
Bion Tears
Cellufresh
Refresh Tears
Tears Naturale Free
Dry Eye:
List some products that are compatible with contact lenses
GenTeal
Refresh Contacts
Visine for Contacts
Dry Eye:
Function of artificial tears
- facilitate wetting of the cornea
- prevent drying of the affected tissue through increasing volume of fluid in the eye
Dry Eye:
Function of ocular antibiotics
-used for local infections of the superficial structures of the eye
**most common infecting organism is staphylococcus (gram +ve)
Dry Eye:
List the functions of sympathomimetics (decongestant, eye whitener)
- causes constriction of conjunctival blood vessels and conc that generally do not cause pupillary dilation
- used for relief of redness
- provides only palliative therapy, since there is no effect on conjunctival response to antigen
Dry Eye: function of lid scrubs
- eye lid cleansers
- intended for the removal of oils, debris, or desquamated skin associated with inflamed eyelid
*useful for contact lens wearer or removal of eye make-up
When recommending products for eye conditions what are some key questions to ask/information to gather?
Who is this for? Symptoms? Any vision problems or pain? Any other red flags? When did it start? Have you had this before? Consulted a doctor of optometrist? Have you tried anything to treat it yet? Any medical conditions? Any medications? Any allergies? Do you wear contacts?
Monitoring parameters:
Expected improvement for most eyelid disorders
48 hours
Monitoring parameters:
Expected improvement for
acute bacterial conjunctivitis
48 hours
Monitoring parameters:
Expected improvement for allergic conjunctivitis
72 hours
Monitoring parameters:
Expected improvement for dry eye
3-5 days
How long should you wait between drops of the same medication?
3-5 mins
How long should you wait between drops of a different medication?
5-10 mins apart
Suspensions should be instilled ____
last
Drops should be applied _____ mins before applying ointments
5-10
When should you dispose an unused multi dose product?
after 28 days
When should you dispose a single dose product?
after 48 hours
