Eyelid Part 1 and 2 (Yumori) Flashcards
Herpes Zoster Ophthalmicus
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
treating Herpes zoster
treat with oral anti-viral. skin lesions use Bacitracin ung BID. rule out posterior segment involvement. consult with PCP: rule out HIV
Hutchingsons sign (Herpes Zoster)
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
External hordeolum
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
External hordeolum treatment
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)
Internal hordeola
infection of the meibomian glands
Contact dermatitis: Symptoms
Inflammatory response to irritant. Type IV hypersensitivity reaction. Itching, tearing, related to exposure to allergen such as eye drops or cosmetics
Contact dermatitis: signs
lid: Periorbital edema: erythema
Conjunctiva: chemosis, redness, papillary reaction, watery discharge
contact dermatitis: treatment
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)
Trichiasis
Posterior misdirection of lashes rubbing against the globe. can lead to punctate corneal epithelial erosions (PEE) and ocular irritation that worsens with blinking
Trichiasis: treatment
epilation with forcepts q4-6 weeks. If PEE treat with antibiotic ointment TID using bacitracin or erythromycin
Ptosis: Congenital
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
Ptosis: Acquired
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)
Ptosis: workup history
determine if congenital or acquired. Onset and duration–> request previous photos. associated symptoms–> diplopia, variation, fatigue
Ptosis: workup functional assessment
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
Unilateral ptosis workup for mild, moderate and severe
mild: 2mm
moderate: 3mm
severe: greater or equal to 4mm
Pseudoptosis workup
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
Pseudoptosis: dermatochalasis
loose and redundant tissue fold. Draping of superior lid tissue over septum or lid margin. Middle to older age groups. Usually bilateral. Familial tendency
pseudoptosis types
lack of support, contralateral lid retraction, ipsilateral hypotropia, brow ptosis, dermatochalasis
Ptosis treatment if cause is established and symptoms are mild
treatment of condition: chalazion use warm compresses with massage, eyelid neoplasm use excision. Can tape upper lids open or attach eyelid crutches to glasses
Ptosis treatment if cause is not established and/or symptoms not addressed with conservative management, include all findings and refer to
- neuro-ophthalmology: neurogenic, myogenic
- oculoplastics: congenital (especially important to prevent occlusion amblyopia), aponeurotic, mechanical
Ectropion
Out-wardly turned eyelid margin. Epiphora, irritation, redness. can be involutional, paralytic, cicatrical, mechanical, allergic, congenital
Ectropion: workup history
previous: surgery, trauma, chemical burn. Or CN7 palsy. with slit lamp can see conjunctival injection or exposure keratopathy
ectropion treatment
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
entropion
Inwardly turned eyelid margin that pushes otherwise normal lashes into globe. irritation, foreign body sensation, tearing, redness
Entropion: determine etiology
involutional or cicatrical
entropion: workup history
previous surgery, trauma, chemical burn, infection from trachoma, herpes simplex or varicella zoster
entropion workup: slit lamp
eyelid scarring, conjunctival injection, corneal involvement including PEE/SPK from lashes, corneal thinning and ulceration
entropion treatment
artificial tears, bandage soft CL, eyelid taping, treatment for PEE (erythromycin or bacitracin TID), referral to oculoplastics for permanent correction, significant corneal damage
Floppy Eyelid Syndrome
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
Floppy eyelid syndrome: workup slit lamp
Redundant upper lid skin; loose and rubbery tarsal plates that are easy to evert. Chronic superior tarsal conjunctivitis. PEE/SPK, keratoconus?
floppy eyelid syndrome: suspected etiology
abnormality of collagen and elastin fibers. spontaneous eversion of the upper eyelid during sleep. superior palpebral conjunctiva rubs against the pillow or sheets
floppy eyelid syndrome: associations
keratoconus, skin hyperelasticity and joint hypermobility, obstructive sleep apnea (normal tension glaucoma), diabetes, mental retardation
Sleep apnea (floppy eyelid syndrome)
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.
Normal tension glaucoma (floppy eyelid syndrome)
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)
floppy eyelid syndrome: treatment
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
trichiasis is secondary to …. and should not be mistaken for….
chronic blepharitis and herpes zoster
entropion and pseudotrichiasis
trichomegaly
excessive eyelash growth
