Eyelid Part 1 and 2 (Yumori)

Question 1

Herpes Zoster Ophthalmicus

Answer 1

Acute, unilateral vesicular dermatomal skin rash. caused by varicella-zoster. common in elderly and immunocompromised. Pain distributed at the first division of the trigeminal nerve

Question 2

treating Herpes zoster

Answer 2

treat with oral anti-viral. skin lesions use Bacitracin ung BID. rule out posterior segment involvement. consult with PCP: rule out HIV

Question 3

Hutchingsons sign (Herpes Zoster)

Answer 3

nasociliary skin lesions at the tip, side and root of nose. represent the dermatomes of the external nasal and infratrochlear branches of the nasociliary nerve. power predictor of ocular inflammation and corneal denervation in zoster

Question 4

External hordeolum

Answer 4

Acute staphylcoccal infection of lash follicle and its associate gland of Zeiss or Moll. Well-defined subcutaneous eyelid nodule. Tender swelling in the eyelid margin pointing anteriorly

Question 5

External hordeolum treatment

Answer 5

treatment- warm compresses with lid massage 10 min QID. topical antibiotics BID: Bacitracin and Erythromycin.
If untreated, can progress to bacterial conjunctivitis, chalazion or preseptal cellulitis (infection involving eyelid and periorbital area)

Question 6

Internal hordeola

Answer 6

infection of the meibomian glands

Question 7

Contact dermatitis: Symptoms

Answer 7

Inflammatory response to irritant. Type IV hypersensitivity reaction. Itching, tearing, related to exposure to allergen such as eye drops or cosmetics

Question 8

Contact dermatitis: signs

Answer 8

lid: Periorbital edema: erythema
Conjunctiva: chemosis, redness, papillary reaction, watery discharge

Question 9

contact dermatitis: treatment

Answer 9

stopping exposure, re-exposure to allergen. Preservative-free artificial tears 4-8x/day. Cool compresses 4-6x/ day. Oral antihistamines (diphenydramine 25-50mg po TID-QID)

Question 10

Trichiasis

Answer 10

Posterior misdirection of lashes rubbing against the globe. can lead to punctate corneal epithelial erosions (PEE) and ocular irritation that worsens with blinking

Question 11

Trichiasis: treatment

Answer 11

epilation with forcepts q4-6 weeks. If PEE treat with antibiotic ointment TID using bacitracin or erythromycin

Question 12

Ptosis: Congenital

Answer 12

Superior tarsal fold usually absent or poorly developed: dystrophic levator muscle. Ptosis decreases in down-gaze. Chin-up position. May have weak or no eyelid crease

Question 13

Ptosis: Acquired

Answer 13

crease appears higher than usual. Ptosis in affected eye is level with or lower than normal lid in downgaze. May have increases with stress, fatigue (diurnal variation)

Question 14

Ptosis: workup history

Answer 14

determine if congenital or acquired. Onset and duration–> request previous photos. associated symptoms–> diplopia, variation, fatigue

Question 15

Ptosis: workup functional assessment

Answer 15

palpebral fissure (distance from top lashes to bottom lashes), marginal reflex distance (reflex to upper or lower lashes), marginal crease distance (upper lid crease to upper lashes). Levator function, bell’s phenomenon or lagophthalmos

Question 16

Unilateral ptosis workup for mild, moderate and severe

Answer 16

mild: 2mm
moderate: 3mm
severe: greater or equal to 4mm

Question 17

Pseudoptosis workup

Answer 17

Contralateral lid retraction. look at the level of the upper lids (MRD-1). Common cause: thyroid eye disease. Consider exophthalmometry, check for lagophthalmos, probe for systemic symptoms. Visual field testing, CN3 palsy secondary to cavernous sinus meningioma. other studies include ice pack test: myasthenia gravis, cocaine test: horner syndrome, imaging: orbital mass, labs

Question 18

Pseudoptosis: dermatochalasis

Answer 18

loose and redundant tissue fold. Draping of superior lid tissue over septum or lid margin. Middle to older age groups. Usually bilateral. Familial tendency

Question 19

pseudoptosis types

Answer 19

lack of support, contralateral lid retraction, ipsilateral hypotropia, brow ptosis, dermatochalasis

Question 20

Ptosis treatment if cause is established and symptoms are mild

Answer 20

treatment of condition: chalazion use warm compresses with massage, eyelid neoplasm use excision. Can tape upper lids open or attach eyelid crutches to glasses

Question 21

Ptosis treatment if cause is not established and/or symptoms not addressed with conservative management, include all findings and refer to

Answer 21

• neuro-ophthalmology: neurogenic, myogenic

- oculoplastics: congenital (especially important to prevent occlusion amblyopia), aponeurotic, mechanical

Question 22

Ectropion

Answer 22

Out-wardly turned eyelid margin. Epiphora, irritation, redness. can be involutional, paralytic, cicatrical, mechanical, allergic, congenital

Question 23

Ectropion: workup history

Answer 23

previous: surgery, trauma, chemical burn. Or CN7 palsy. with slit lamp can see conjunctival injection or exposure keratopathy

Question 24

ectropion treatment

Answer 24

artificial tears, lubricating ointment and eyelid taping at night. If inflamed eyelid margin use warm compresses, bacitracin or erythromycin TID. Referral to oculoplastics if long-standing, stable, or significant corneal exposure

Question 25

entropion

Answer 25

Inwardly turned eyelid margin that pushes otherwise normal lashes into globe. irritation, foreign body sensation, tearing, redness

Question 26

Entropion: determine etiology

Answer 26

involutional or cicatrical

Question 27

entropion: workup history

Answer 27

previous surgery, trauma, chemical burn, infection from trachoma, herpes simplex or varicella zoster

Question 28

entropion workup: slit lamp

Answer 28

eyelid scarring, conjunctival injection, corneal involvement including PEE/SPK from lashes, corneal thinning and ulceration

Question 29

entropion treatment

Answer 29

artificial tears, bandage soft CL, eyelid taping, treatment for PEE (erythromycin or bacitracin TID), referral to oculoplastics for permanent correction, significant corneal damage

Question 30

Floppy Eyelid Syndrome

Answer 30

Chronically red, irritated eyes, mild mucous discharge. Symptoms worse on awaking due to eyelid eversion at night. Usually bilateral, asymmetric. Typically seen in obese males

Question 31

Floppy eyelid syndrome: workup slit lamp

Answer 31

Redundant upper lid skin; loose and rubbery tarsal plates that are easy to evert. Chronic superior tarsal conjunctivitis. PEE/SPK, keratoconus?

Question 32

floppy eyelid syndrome: suspected etiology

Answer 32

abnormality of collagen and elastin fibers. spontaneous eversion of the upper eyelid during sleep. superior palpebral conjunctiva rubs against the pillow or sheets

Question 33

floppy eyelid syndrome: associations

Answer 33

keratoconus, skin hyperelasticity and joint hypermobility, obstructive sleep apnea (normal tension glaucoma), diabetes, mental retardation

Question 34

Sleep apnea (floppy eyelid syndrome)

Answer 34

characterized by abnormal pauses in breathing or instances of abnormally low breathing. excessive daytime sleepiness and fatigue. May create transient hypoxemia and increase vascular resistance.

Question 35

Normal tension glaucoma (floppy eyelid syndrome)

Answer 35

Glaucoma (optic neuropathy) WITH… open, apparently normal anterior chamber angles, glaucomatous optic nerve damage, visual loss characteristic of that seen in pt with chronic glaucoma related to an elevated IOP
Glaucoma WITHOUT… a clear abnormal IOP (IOP within normal limits, around greater or equal to 21mmHg)

Question 36

floppy eyelid syndrome: treatment

Answer 36

avoid sleeping face down, eyelid shields or eyelid taping, lubricating ointment QHS, treatment for PEE (erythromycin or bacitracin TID). Refer to: internist to rule out OSA or oculoplastics

Question 37

trichiasis is secondary to …. and should not be mistaken for….

Answer 37

chronic blepharitis and herpes zoster

entropion and pseudotrichiasis

Question 38

trichomegaly

Answer 38

excessive eyelash growth