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Anterior Seg > Eyelids & Eyelashes > Flashcards

Eyelids & Eyelashes Flashcards

1
Q

label the diagram

A
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2
Q

What are the dimensions for eyelids? (Vertical, Horizontal, Canthus angle, upperlid (children, lower lid)

A
  • Vertical:
    • 10-11mm young adult
    • 8-10mm mature adult
  • Horizontal
    • ​30-31mm
  • Canthus angle
    • ​~30^ nasally & temporally
  • Upper lid at superior corneal limbus in children
    • ​1.5-2.0mm below limbus in adults
  • Lower lid at inferior limbus
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3
Q

What are the function for eyelids?

A
  • Protective barrier from foreign material (lashes move airborne particles away from the eye)
  • Prevents desiccation
    • Secretes elements of the tear film
    • Blinking functions
      • Tears move from lateral canthus -> medial canthus
      • Zipper-like closure
  • Decrease amt of light entering the eye
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4
Q

Describe the anatomy of the lids. (label orbital septum & tarsal plate in the diagram)

A
  • Skin
    • ​Epidermis
    • Dermis
    • Skin appendages
  • Orbital septum
    • ​Fibrous membrane that separates the eyelids from anterior rim of the orbit
  • Tarsal plate
    • ​Rigidity & structure
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5
Q

Describe the anatomy of the cilia & lashes

A
  • Caruncle
    • ​Hair
    • Sebaceous gland (Zeis)
    • Sweat/sudor glands (Moll)
  • Plica semiluminaris - vestigial remnant​
    • Loose, allows for lateral eye mvmt
    • Does not stretch conjunctiva
    • Tear drainage
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6
Q

Musculature for lids (label orbicularis oculi muscle, superior tarsal muscle, aponeurosis of levator muscle, and riolans muscle in the diagram)

A
  • Orbicularis oculi
    • ​Voluntary & involuntary control
    • Gentle lid closure (sleep)
    • Pulls tears through lacrimal sac
  • Riolan’s Muscle
    • ​Ciliary portion of orbicularis
    • Holds lids against globe
  • Levator superioris aponeurosis
    • ​Elevate & retract upper lid
  • Muller’s muscle
    • ​Elevate & retract upper lid
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7
Q

Innervation

A
  • CN VII - Facial nerve
    • Temporal branch
    • Zygomatic branch
    • MOTOR control of orbicularis
  • CN V - Trigeminal nerve
    • Ophthalmic division
    • Maxillary division
    • SENSORY
  • CN III - Oculomotor nerve
    • ​superior division
    • MOTOR control of levator
  • Sympathetic nerves
    • ​Innervates Muller’s muscle
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8
Q

Vascular supply

A
  • Arteries
    • ​Facial artery
    • Superficial temporal artery
    • Infraorbital artery
    • Angular artery
    • Lacrimal artery
    • Supratrochlear artery
    • Zygomaticofacial artery
  • Veins
    • ​Facial vein
    • Angular vein
    • Superior opthalmic vein
    • Supraorbital vein
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9
Q

Eyelids: Lymphatic drainage

A
  • Anterior to orbital septum
  • All drain inferiorly
  • Deep & superficial parotid nodes/ submandibular nodes
    • Lateral 2/3 or upper lid
    • Lateral 1/3 of lower lid
  • Anterior cervical nodes - Deep & superficial
    • Medial 1/3 of upper lid
    • Medial 2/3 of lower lid
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10
Q

Name the congenital malformations

A
  • Ablepharon
  • Microblepharon
  • Ankyloblepharon
  • Eyelid coloboma
  • Epicanthus
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11
Q

Ablepharon

A

Ablepharon (A = absence; Belpharon=Eyelid)

  • Failure of lid formation
  • Globe is always exposed
  • Association with abelpharon-macrostomia syndrome (rare inherited disorders)
    • ​Macrostomia - wide, fish-like mouth
    • Absence of eyelashes/brows
    • Incompletely developed, low-set ears
    • Abnormally sparse, thin hair
    • Thin, wrinkled skin
    • Webbed fingers
    • Malformations of external genitalia
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12
Q

Microblepharon

A

Microblepharon

  • Lid formation too small for normal lid function (shortening of lid)
  • often associated with anophthalmos (absence of eye)
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13
Q

Ankyloblepharon

A

Ankyloblepharon

  • Fusion of lids to eachother via small/thin skin tag
  • May be single or multiple
  • Associations
    • Isolated congenital defect (Congenital glaucoma)
    • Ankyloblepharon Filiforme Adnatum (AFA) (Cleft palate)
  • Treatment
    • Band retraction
    • Monitor for other conditions
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14
Q

Eyelid coloboma

A

Eyelid Coloboma

  • Cleft in lid caused by incomplete closure of embyronic tissue
    • 90% occur on upper lid
    • typically forms at junction of middle & medial 1/3 of lid
  • Associations
    • ​Dermoids: normal tissue that forms in an abnormal position
    • Strabismus: have exo that develops
    • Corneal opacities
  • Implications
    • ​Exposure
    • Amblyopia: May be due to exposure & strabismus
  • Treatment
    • ​Lubrication
    • Bandage
    • Surgery
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15
Q

Epicanthus

A

Epicanthus

  • Extra fold of skin
  • May cover inner canthus
  • Do Hirschberg test to confirm
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16
Q

List the Eyelid Malposition

A

Ptosis

Dermatochalasis

Ectropion

Entropion

Lagophthalmos

Floppy eyelid syndrome

Symblepharon

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17
Q

List symptoms, etiology, & examination

A

Ptosis

  • Drooping of eyelid
  • If lower lid comes up = lower lid ptosis
  • Symptoms
    • ​Asymmetry
    • Lid sagging
    • Brow ache (Pt holding lids up)
    • Loss of superior VF
    • Loss/decrease of depth perception
    • Vision loss/amblyopia development
    • Cosmesis
  • Etiology
    • ​Aponeurotic = Defect in levator aponeurosis MOST COMMON
    • Mechanical = gravitational effect of a mass/scarring
    • Myogenic (Muscular)
      • ​Myopathy of levator
      • Myasthenia gravis
      • Muscular dystrophy
      • Chronic progressive external ophthalmoplegia = Kearns-Sayre Syndrome
    • Neurogenic
      • Innervational defect
      • CN III Palsy
      • Horner’s Syndrome
      • Marcus Gunn jaw winking
    • Pseudoptosis
    • Congenital
    • Pharmacologic
  • Examination
    • ​Margin to corneal reflex measurment
      • ​MRDI: Corneal reflex to upper lid
      • MRD2: Cornea reflex to lower lid
    • Palpebral fissure measurement: Distance between upper lid & lower lid primary gaze
    • Levator fxn measurement
      • ​Normal => 15mm, Good 12-14mm, Fair 5-11 mm; Poor <4mm
    • Upper lid crease position: Vertical distance b/w lid margin & lid crease in downgaze
      • Female ~10mm; Male~8mm
    • Pretarsal show: Distance b/w lid margin& skin fold in primary gaze
    • Fatigability: Activites to tire muscles
    • Ocular motility defects: Look for CN palsies
    • Bell phenomenon: Up & out rotation w/ eyes closed
    • Hering’s Law: Equal innervation of lids
      • Fellow lid may be elevated in compensation
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18
Q

Ptosis Examination

A
  • Margin to corneal reflex measurement: measurement of corneal light reflex to lid margin in PRIMARY gaze
  • Palpebral fissure measurement distance between upper & lower lid in primary gaze
  • Levator fxn measurement
    • ​Normal = 15mm
    • Good = 12-14mm
    • Fair = 5-11mm
    • Poor = <4mm
  • Upper lid crease position: vertical distance between lid margin & lid crease in DOWNGAZE ​
    • Female ~10mm; Male ~8mm
  • Pretarsal show ​Distance between lid margin & skin fold in PRIMARY gaze
  • Fatigability Activities to tire muscles
  • Ocular motility defect look for CN palsies
  • Bell phenomenon Up & out rotation of globe with closing of the eyes
  • Hering’s Law Equal innervation of lids​
    • Fellow lid may be elevated in compensation
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19
Q

Name the characteristics & causes of aponeurotic ptosis

A

Ptosis - Aponeurotic (MOST COMMON of ptosis for ALL PT)

  • Characteristics
    • ​High eyelid crease
    • Moderate ptosis
    • Good levator fxn
    • Worsens in downgaze
  • Causes
    • ​Aging (most common cause), usually bilateral
    • Repetitive eye rubbing
    • RGP wear
    • Previous intraocular surgery
    • Muller fatigue
    • Pregnancy
    • Lid swelling
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20
Q

Mechanical ptosis

A

Ptosis - Mechanical

  • Appearance depends on etiology
    • ​inability of eye to elevate fully b/c of something else (tumor, mass, scarring)
  • Gravitation effect of a mass or scarring
    • ​CL in upper fornix
    • Upper lid inflammation
      • Chalazion, GPS, post-traumatic/surgical
    • Neoplasm (abnormal mass of tissue may/may not be cancerous)
    • Scar tissue
  • Treatment
    • ​get rid of whatever is causing it
    • Ex. if its CL - take it out or if it’s swelling it can lead to aponeurotic ptosis
    • Anterior Orbital lesions
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21
Q

Myogenic Ptosis

A

Ptosis - Myogenic (muscle related) characteristics

  • Poor or absent lid crease
    • ​Dysgenesis of levator, fibrosis & replacement w/ adipose tissue
  • Poor Bell phenomenon
  • ​Lagophthalmos on downgaze (when looking down, unable to fully close their lids
    • Poor levator relaxation
  • Up-gaze limitation
    • ​Associated w/SR weakness
    • Compensatory chin elevation
  • Can either be congenital or acquired
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22
Q

Myogenic Congenital ptosis

A

Ptosis - Myogenic Congenital

  • Common in children
  • Unilateral or Bilateral
  • Myopathy of levator leading to poor function
  • Impairment of transmision of impulses at NMJ (neuromyopathic)
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23
Q

Myogenic Acquired Ptosis

A

Ptosis - Myogenic Acquired

  • Uncommon
    • ​Pt usually older - developed later in life
  • Localized or diffuse muscular disease
    • ​Muscular dystrophy
    • CPEO - Chronic progressive external opthalmoplegia
    • Myasthenia gravis
    • Oculopharyngeal dystrophy
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24
Q

Myasthenia Gravis

(Define, Complications, Diagnosis, Tx)

A
  • Autoimmune disease characterized by loss of ach receptor causing muscle fatigability & weakness
  • Has both myogenic & neurogenic components in ptosis
  • Female 2:1
  • Age of onset: 20-50
  • Ocular complications presenting signs in 2/3rd pt ​
    • ptosis
    • Diplopia
    • Nystagmus
    • Worsen w/fatigue
  • Complications
    • ​Difficulty chewing/swallowing
    • Altered speech
    • Difficutly breathing
  • Diagnosis
    • ​Tensilon Test
      • Edrophonium - fast acting, short duration of Ach
      • Improvement in ptosis - following injection
    • Ice-pack test
      • Ice pack applied to upper lid x 10 mins
      • Positive test - impovement in ptosis by >2mm
    • Fatiguing activities
      • ​Walking up stairs
      • Stand on toes
      • Prolonged up-gaze
      • increase in ptosis w/ fatigue is positive
    • Repetitive nerve stimulation testing
      • ​Lab testing: Serum anti-Ach receptor antibody titer or serum anti-musclespecific kinase titer
  • Tx
    • ​Medical therapy:
      • ​Acetylcholinesterase inhibitors
      • Pyridostigimine (Mestinon)
      • Oral steroids
      • Immunomodulators
    • Surgery
      • ​Thymectomy
        • ​60% have thymic hyperplasia (thymoma)
        • 10% thymic tumor
        • B-cells interact w/ T-helper cells -> anti-Ach receptor antibodies
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25
Q

Myotonic Dystrophy

(Characteristics, Types/Forms, Ocular signs)

A
  • General Characteristics
    • Autosomal Dominant
    • Occurs at any age
    • Chronic, slowly progressive multisystemic disease
    • Characteristics
      • Muscle wasting
      • Myotonia
      • Cataracts
      • Heart conduction defects
      • Endocrine changes
  • Myotonic dystrophy forms
    • ​Type 1 - Steinert disease
      • ​More common
      • More severe
      • Congenital or adult-onset (earlier development = worse sx)
      • Features: Difficulty swallowing, constipation, gallstones, uterine muscle abnormalities
    • Type 2 - Proximal myotonic myopathy
      • ​Less common - german decent
      • Less severe - slowly progressive
      • Adult - onset
      • Proximal muscles affected first - hips
  • Ocular signs
    • Ptosis
    • Cataract
    • Retinopathy
    • Near-Light reflex dissociation
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26
Q

Chronic Progressive External Opthalmoplegia

A
  • Slowly progressive paralysis of EOMs
  • Most frequent manifestation mitochondrial myopathies
  • Features
    • Symmetrical, progressive, bilateral ptosis
    • Opthalmoparesis months to years later
      • Iris & ciliary muscles remain intact
    • Orbicularis weakness
    • Associations
      • Kearns-Sayre syndrome (KSS)
      • Oculopharyngeal dystrophy
      • Myasthenia gravis
      • Graves disease
    • Tx
      • Cardiac work-up
      • Electromyography & muscle biopsy
      • Ptosis repair
      • Pharmaceuticals
        • Coenzyme Q10
        • Tetracyclines
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27
Q

Chronic Progressive External Ophthalmoplegia (KSS)

A
  • CPEO before age 20 & pigmentary retinopathy
  • Potentially fatal due to heart conduction defects
  • No sex predilection
  • Diagnosis
    • Pigmentary retinopathy + at least 1 of:
      • Cardiac conduction defect
      • CSF protein >100 mg/dL
      • Cerebellar syndrome
    • May also have
      • Mental retardation
      • Babinski sign
      • Hearing loss
      • Short stature
      • Delayed puberty
      • Various endocrine disorders
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28
Q

Neurologic Ptosis

(Characteristics, Causes)

A
  • Innervational defect
  • Causes
    • CN III palsy - horner’s syndrome
    • Marcus Gunn jaw winking
    • Myasthenia gravis
    • Ophthalmic migraine
    • MS
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29
Q

Neurologic ptosis (CN III palsy)

(Describe the etiology, diagnosis, and tx)

A
  • CN III palsy - ptosis, mydriasis, down & out misdirection
  • Etiology
    • Vasculopathic
    • Trauma
    • Compression (aneurysm)
    • Infiltrative
    • Toxic
  • Diagnosis - neuroimaging, lab testing (vitals, CBC, ESR, metabolic panel)
  • Tx: depends on etiology
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30
Q

Neurologic Ptosis (Horner’s syndrome)

A
  • Horner’s syndrome
    • Miosis, ptosis, anhydrosis, (heterochromia)
    • Loss of sympathetic innervation in pathway
      • Central
      • Pre-ganglionic - association with chest trauma & tumors
        • Pancoast’s tumor - metastasis from lung or breast
      • Post-ganglionic - most often benign
        • No anhydrosis
  • To confirm horner’s syndrome
    • Cocaine 10% - Dilates NORMAL eye, not horners
    • Apraclonidine - Dilates HORNERS pupil, does not dilate NORMAL pupil
  • To localize lesion
    • Hydroxyamphetamine
      • Dilates PRE-GANGLIONIC lesion
      • Not enough norepinephrine release to dilate post-ganglionic
    • Phenylephrine 1%
      • ​Elevates AFFECTED side due to hypersensitivity of mullers muscle
      • Dilates POST-GANGLIONIC lesion, minimally dilates PRE-GANGLIONIC, does not dilate central lesions
      • Important to rule out malignancy in central and pre-ganglionic lesions
    • Neuroimaging
      • ​Important in absence of clear h/o trauma as cause
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31
Q

Neurologic Ptosis (Marcus-Gunn jaw winking)

A
  • 5% of all congenital ptosis
  • majority are unilateral
  • Signs = retraction of ptotic lid with stimulation of ipsilateral pterygoid muscles (sucking, chewing, opening mouth) or contralateral jaw mvmt
  • Postulated etiology
    • Part of CN-V2 (madibular branch) misdirected to levator muscle
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32
Q

Ptosis (Pseudoptosis)

A
  • Causes
    • Lack of support of lid by globe due to volume deficit
      • Artificial eye
      • Microphthalmos
      • Pthisis bulbi
      • Enophthalmos
    • Contralateral lid retraction
    • Ipsilateral hypotropia
    • Brow ptosis
    • Dermatochalsis
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33
Q

Congenital Ptosis

A

Abnormal muscle development

Unilateral or bilateral

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34
Q

Ptosis surgery

A
  • Improve lid position
    • Cosmesis
    • Improve VF
  • Types
    • Conjunctiva - Muller resection
      • Mild ptosis
      • Congenital ptosis
      • Horner’s syndrome
    • Levator
      • Moderate ptosis
    • Brow suspension
      • Severe ptosis with poor levator function
      • Marcus Gunn jaw winking
      • Aberrant regeneration of CN III
      • Previous sx with poor results
  • Complications
    • Under/overcorrection
    • Lagophthalmos
    • lid lag
    • Exposure keratopathy
    • Corneal ulceration
    • Vision loss
    • Hemorrhage
    • Infection
    • Astigmatism changes
    • Ectropion/entropion
    • Cicatricial changes
    • Diplopia
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35
Q

Dermatochalsis

A
  • Common **
  • Sagging of skin of eyelids (UL>LL)
  • Bilateral, often asymmetric condition of elderly pt . >50yo
  • Progressive involution changes of aging
    • Loss of elasticity
    • Degeneration of connective tissue
  • Characterization
    • Redundancy of upper eyelid skin
      • poor adhesion to underlying musculature/CT
      • orbital fat protrusion through septum
      • Indistinct lid crease
      • Hooding of lashes
  • Complications
    • Blockage of superior/temporal VF
    • Browache &/or HA
      • Frontalis muscle used to elevate lids
    • Cosmesis
  • Treatment
    • Blepharoplasy if affects superior field of vision
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36
Q

Blepharochalasis

A
  • RARE
  • Recurrent bouts of eyelid edema leading to redundant folds of skin over lid margins
  • Adolescents or young adults
  • Recurrent episodes of eyelid edema
    • Stretching & atrophy of skin
    • Damage to levator aponeurosis -> ptosis
  • Characteristics
    • Unilateral or bilateral
    • Typically only UL
    • Herniation of orbital fat through septum
  • Stages
    • edema stage = transient painless lid edema with mild redness
    • Atonic - ptosis stage = skin appears reddish brown, becomes telangectatic & loose, overhanging onto lashes
    • Ptosis adipose = dehiscence of orbital septum with herniation of orbital fat into lid
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37
Q

Blepharoplasty

A
  • Removal of excess skin from upper or lower lids
  • Insurance covers when VF is affected from UL blocking superior portion of vision
  • Outpatient procedure
  • Topical antibiotics give for ~1wk following procedure
  • Bruising & itching are main side-effects
  • Risk
    • Poor healing
    • Persistent fat
    • Loose skin
    • DES (Dry eye syndrome)
    • Scarring due to corneal exposure if too much skin removed leaving pt unable to close eyes fully
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38
Q

Ectropion

A
  • Outward rolling of lid
  • Complications: exposure of cornea & conjunctiva
  • Risks
    • Age
    • Eye rubbing
    • Repated pulling on lids
      • CL wear
      • Eye meds
    • Floppy eyelid syndrome
    • Skin condition affecting lids
  • Sx
    • Dryness
    • FBS (Foreign body sensation)
    • Conjunctival hyperemia
    • Epiphora
    • Lid redness
  • Causes
    • Involutional
      • Age & lid laxity
      • Musculature & skin tension decreases with age
      • Most common
    • Cicatricial
      • scarring
    • Mechanical
      • Tumors near lid margin
      • Basal cell carcinoma using disruption
    • Paralytic
      • Bell’s palsy - paralysis of orbicularis
        • Exposure 2^ lagophthalmos -> epiphora
        • Causes: CN-VII, Botox
    • Congenital
      • Usually associates with other lid/systemic problems
      • Unilateral or bilateral
      • RARE
      • Ichthyosis
      • Down syndrome
  • Tx
    • Treat underlying condition
    • Lubrication
    • Bandage CL
    • Surgical repair
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39
Q

Entropion

A
  • Inward rotation of lid & appendages
  • Complicatiosn
    • Trichiasis
    • Corneal pannus
    • Scarring
    • Ulceration or perforation late
  • Sx
    • FBS
    • Tearing
    • Blurred vision
  • Causes
    • Involutional
      • Most common
      • Age related loss of lid tone & weakness of lid retractors, atrophy of orbital tissues
    • Cicatricial
      • 2^ conjunctival scarring
      • Chronic inflammation -> Fibrosis, scarring & shortening of posterior lamella
    • Spastic
      • Irritations of lid in severe corneal disease -> spasm
      • Occasionaly with generalized belpharospasm
    • Congenital
      • RARE & Often confused with epiblepharon
      • occurs from improper aponeurosis insertion of the retractor muscles
  • Tx
    • Lubrication
    • Epilation
    • Glue
    • Surgical repair
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40
Q

Epiblepharon

A
  • In-turning of lashes in the presence of normal eyelid position
    • Generally worsens in downgaze
  • More common in asians
  • Asymptomatic, resolves w/ age
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41
Q

Lagophthalmos

A
  • Incomplete lid closure
  • Sx
    • Eye irritation/FBS
    • Exposure keratopathy
    • Redness
    • Blurred VA
  • Worse overnight or in am after waking
  • Nocturnal
    • ​Sleep w/ eyes partially open
    • Dx on history, visualization of fissure with lid closure
    • Adults >children due to decrease in tear film with age
  • Orbital
    • ​Proptosis
    • Graves, orbital pseudotumor, mucocele
  • Mechanical/Cicatricial
    • ​Scarring
  • Paralytic
    • ​Bell’s unilateral CN-VII paralysis, frequent viral etiology
    • Self-limiting
      • Resolves w/in 3 months, 85% resolve in 3 weeks
    • Vascular associations - MUST rule out stroke
  • Diagnosis
    • ​Hx - ask if pt sleeps with eyes open or family member spouse reports
    • Observe blink rate & completeness
    • NaFL observeration with lids closed gently in slitlamp
    • Observe light presence/absence in slightly reclined position
  • Treatment
    • ​Mostly supportive ( lubrication & taping)
      • Tears during day
      • Ung qhs
      • Sleep masks/taping
    • Tarsorrhaphy if severe
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42
Q

Floppy eyelid syndrome

A
  • Loose eyelid skin which is easily everted
  • Generally occurs in obese, middle-aged men
  • Unilateral or bilateral
  • Frequently misdiagnosed
  • Complications
    • Exposure keratopathy
    • Drying of cornea & palpebral conjunctiva
    • Redness
    • Papillary response
  • Associations
    • Keratoconus
    • Eye rubbing
    • Skin hyperelasticity
    • Joint hypermobility
    • Obstructive sleep apnea
    • Diabetes
    • Mental retardation
  • Examination
    • Eversion of lid without excess manipulation
    • Spontaneous eversion
  • Tx
    • Supportive - lubrication, taping/masks
    • Medical - antihistamines
    • Surgical . Horizontal shortening of affected lid
    • Tx underlying condition - weight loss
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43
Q

Symblepharon

A
  • Fusion of lids to conjunctiva
    • Palpebral conjunctiva fusion bulbar conjunctiva
    • Cicatricial changes
  • Complications
    • Ocular motility disorders
    • Diplopia
    • Entropion or lagopthalmos
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44
Q

List some benign cysts & nodules

A
  • Chalazion
  • Concretion
  • Epidermal inclusion cyst
  • Epidermoid cyst
  • Dermoid cyst
  • Sebaceous cyst (pilar cyst)
  • Cyst of Zeis
  • Hydrocystoma/Cyst of Moll
  • Milia
  • Comedones
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45
Q

Chalazion

A
  • Meibomian gland lipogranuloma
  • Granulomatous inflammation from retained sebaceous secretion
  • Enlarging, painless nodules
    • Larger upper lid nodule may cause irregular astigmatism & blur vision
    • Recurrence needs to have sebaceous carcinoma ruled out
  • Tx
    • 1/3 resolves spontaneously
    • Heat
    • Excision, steroid injection, systemic antibiotics
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46
Q

Concretions

A
  • Calcified sebaceous material
  • May cause FBS
  • White to yellow color
  • may be single or multiple
  • Tx
    • None, Excision
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47
Q

Epidermal inclusion cyst

A
  • AKA epidermoid cyst, Sebaceous cyst (pilar cyst)
  • Proliferation of squamous epithelium in a confined space of the dermis or sub-dermis
  • Firm, non-tender nodule
  • Benign
  • Treatment
    • None
    • Incision & drainage for infectinon
    • Excision
48
Q

Dermoid Cyst

A
  • Developmental choristoma
    • Mass of histologically normal tissue in abnormal location
  • Generally present in 1st decade of life
  • Well circumscribed, firm, rubbery, subcutaneous mass
  • Tumors may be hair follicles, sweat or sebaceous glands
  • May be superficial or deep
  • Superficial
    • ​Firm, round, smooth, mobile mass
    • No proptosis or globe displacement
    • Superior temporal or nasal orbit
  • Deep
    • ​Older age of onset
    • Non-axial or globe displacement seen
    • Enlarge & may cause inflammation or scarring
  • Indications
    • Cosmesis
    • Vision loss
      • Irregular astigmatism
      • Deprivation of amblyopia
      • Optic nerve involvement
      • Rupture leading to granulomatous inflammatory reaction
  • Tx
    • Surgical removal - may recur if incompletely removed
49
Q

Cyst of Zeis

A
  • Obstruction of sebaceous gland associated with hair follicles
  • Small
  • Non-translucent
  • Anterior lid margin
50
Q

Hidrocystoma/Cyst of Moll

A
  • Adenoma of sweat gland - arise from apocrine or eccrine glands
  • Often on eyelid, near margin
  • Asymptomatic
  • Smooth, translucent, transilluminate
51
Q

Milia

A
  • Dead skin cells become in small pockets at surface of skin - baby acne
  • 1-2mm, white to yellow dome-shaped bmps
  • Infants or adults
  • Appear on nose, chin, cheeks, eyelids
  • Tx
    • none, excision for cosmesis
52
Q

Comedones

A
  • Blocked hair follicle - keratin & sebum plug
  • Small, skin-colored, white or black bumps
  • Open - black surface pigment
  • Closed - white, completely blocked
53
Q

List some benign tumors that may occur on the lid

A
  • Squamous cell papilloma
  • Basal cell papilloma
  • Actinic keratosis
  • Sryingoma
  • Pilomatricoma
  • Capillary hemangioma
  • Port-wine stain
  • Pyogenic granuloma
  • Xanthelasma
  • Neurofibroma
54
Q

sqamous cell papilloma

A
  • Soft, pedunculated mass with numerous finger-like projections
  • Conjunctival lesions caused from HPV - occurs mostly in children & young adults <20yrs
  • Painless without vision loss
  • often no tx required & spontaenously resolve
55
Q

Basal cell papilloma/Seborrheic Keratosis

A
  • Slightly raised, skin to light brown colored spots that thicken & darken with time
    • Stick to skin like barnacles
  • Degenerative in nature, related to aging
  • Removal often recommended b/c similar in appearance to melanomas
56
Q

Actinicic Keratosis

A
  • Multiple flat or thickened, scaly or warty, skin colored to red lesions occuring on sun-damaged skin
  • May develop into cutaneous horn
  • Considered pre-cancerous
  • Common in fair-skinned persons or those working outdoors for years without UV protection
57
Q

Syringoma

A
  • Harmless tumors of the sweat glands
  • Often occuring on eyelids
  • Skin colored to yellowish firm, round bumps 1-3mm in diameter
58
Q

Pilomatricoma

A
  • Tumor of hair follicle
  • Rare, benign
  • Solitary, firm, skin colored papule or nodule
    • Multiple lesions associated with various genetic disorders - myotonic dystrophy
  • Generally on head, neck, upper extremities
  • Most often in young children & adolescents, but can affect adults
59
Q

Capillary Hemangioma

A
  • Most common benign tumor in children *****
    • 10% all births
    • 80% head/neck
    • Predilection for UL
  • Slow progression
  • Dilations for capillaries
  • Females > males
  • More common in caucasian populations
  • No bruit or pulse
    • Spongy consistency with palpation
    • Blanch with pressure
  • Lesion worsens with crying
  • Proliferative lesions which develop shortly after birth
    • 30% present at birth
    • 50% present at 1-2 months
    • 90% present by 6 months
    • Most 80% reach max size by 3 months, although may grow up to 18 months
  • Complications
    • Mechanical ptosis
    • Amblyopia
    • Astigmatic anisometropia **
    • Strabismus
    • Exposure keratopathy
    • ON compression
  • Imaging Tests
    • US, CT, MRI
  • Tx
    • Indicated for cosmesis or risk of development of amblyopia, ON compression, corneal exposure
    • Monitor
      • Generally regress or involute - may take 3-10 years
      • 40% regress by age 4
      • 80% regress by age 8
    • Propranolol - oral or topical
    • Steroids - oral or injection
    • Laser tx
    • Surgical removal
60
Q

Port-wine stain

A
  • aka nevus flammeus
  • Large, flat patch of purple or dark red skin with well-defined borders
  • Increase in size, color & elevation over lifetime
  • May become bumpy with time
  • Complications
    • Tender/painful
    • congested with blood as to alter facial features
    • Infection
  • Sturge-Weber syndrome (encephalotrigeminal angiomatosis)
    • ​Somatic mutation of gene GNAQ - Non familial
    • Affects blood vessels of CNS, eyes & skin
    • Blood vessels grow more rapidly leading to increased number & size of vessels causing skin color changes
      • Red, purple, or blue appearance to skin
    • Unilateral > Bilateral
  • Brain involvement from increasing size of angiomas
    • May result in shrunken brain
    • Calcification in the skull
    • Seizures
    • Meningeal angioma
  • Ocular features
    • Ipsilateral glaucoma (70%)
    • Buphthalmos
    • Iris heterochromia
    • Diffuse choroidal hemangioma
    • Optic atrophy
    • Epibulbar telangiectasia
  • Tx
    • None
    • Neurology consult
    • Dermatology consult
    • tx of ocular conditions
61
Q

Pyogenic granuloma

A
  • Painful, fast-growing, vascularized polyp shaped lesion
  • Fibrovascular proliferative response to conjunctival injury
  • Causes
    • Trauma = mechanical or surgical
    • Infection
    • Hormonal influences
    • idiopathic
  • Tx
    • Steroids
    • Excision
62
Q

Xanthelasma

A
  • Deposits of cholesterol in skin
  • Yellowish subcutaneous plaque, often occuring at medial aspects of lid
  • Common, often bilateral, increasing with age
  • Association
    • Increased serum cholesterol
    • Primary biliary cirrhosis
    • Familial hypercholesterolemia
  • Tx
    • Excision
63
Q

Neurofibroma

A
  • Benign tumor of nerves
    • proliferation of schwann cells, fibroblasts & nerve axons
  • Tumor of lid causing characteristic S-shaped deformity
  • Plexiform neurofibroma
    • Larger, grow from nerves anywhere in body
    • Possibility of malignant conversion
    • Children with NF1
  • Solitary/localized neurofibroma
    • Adults, 25% with NF1
    • Grow from small nerves in /near skin
    • Small bumps appearing during puberty
    • Remain benign
64
Q

Neurofibromatosis

A
  • Group of disorders that cause tumor growth in the NS
    • NF1 = tumors in PNS
    • NF2 = tumors of schwann cells (schwannomas)
    • Schwannomatosis - Schwannomas
      • Recently classified as separate entity from NF2
  • Most tumors benign, but may become malignant
  • No gender or racial predilection
  • NF Type 1
    • ​1:2, 500-300 people world wide
    • Cause unknown ~50% of cases due to spontaneous mutation
    • Presentation - at or shortly after birth generally by age 10
    • Progressive disorder
    • Generally of normal life expectancy
    • NIH criteria for diagnosis
      • At least 2 of the following
      • 6+ cafe-au-lait spots > . 5mm in kids or >15mm in adults
      • 2+ neurofibromas or 1+ plexiform neurofibroma
      • Auxillary freckling or freckling in the inguinal regions
      • 2+ lisch nodules
      • Distinctive osseous lesion
        • Sphenoid wing dysplasia
        • Long-bone dysplasia
      • Optic pathway glioma
      • 1st degree relative with NF1
    • Associations
      • Large head circumference
      • Short stature
      • Hydrocephalus
      • epilepsy
      • Congenital heart defects
      • HTN
      • Vasculopathy
      • Learning disabilities
      • Poor language &/or visual spatial skills
65
Q

List Some Pigmented Skin Lesion

A
  • Ephelis
  • Acquired melanocytic nevus
  • Congenital melanocytic nevus
  • Cafe au lait spots
  • Nevus of Ota
66
Q

Ephelis - Freckle

A
  • Increased melanin in basal keratinocytes
  • Common in fair skinned children
  • May fade or disappear during winter months &/or with age
67
Q

Acquired melanocytic nevus

A
  • Moles
  • Most people have 20-50
  • Appear after 6mos
  • Increase in number childhood/adolescence
  • Peak 3rd decade
  • Regress with age
  • Risk of malignant transformation determined by histologic location
    • Junctional - low potential - macular or minimally raised, brown to black
    • Compound - low potential - pigmented papules, may be dome-shaped
    • Intradermal - no potential - skin colored to tan dome-shaped papules
    • Histological variants - multiple dysplastic nevi (atypical moles) - at risk for conjunctival & uveal nevi & cutaneous, conjunctival & uveal melanoma
  • Management - observation
  • Congenital Melanocytic Nevus
    • Present between birth 2 yrs
    • Range in size from small (<1cm) to giant (>40-60cm)
    • Occur in any cutaneous location
    • Tan to black in color
    • May have course terminal hairs
68
Q

Cafe-au-lait spots

A
  • Flat, coffee-colored patches
  • Solitary lesions common
  • >6 strongly suggestive of NF type I
  • May also be present in Albright’s syndrome
69
Q

Nevus of Ota/Oculodermal melanocystosis

A
  • Slate-brown to blue/grey nevus
  • Occurs on forehead or around eye
  • May have hyperpigmentation of sclera, cornea, iris or retina
  • Nevus of Hori - occurs on both side of face
70
Q

List some Malignant Tumors

A
  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Keratocanthoma
  • Sebaceous gland carcinoma
  • Kaposi sarcoma
71
Q

Basal cell carcinoma

A
  • MOST COMMON human malignancy
  • Elderly, fair skin, chronic UV exposure
  • 90% head/neck
    • 90% eyelid malignancies
    • LL > medial canthus > UL > lateral canthus
  • Presentation
    • Ulceration
    • Induration (palpable, raised, hard area)
    • Irregular borders
    • Destruction of lid margin
    • Lack of tenderness
72
Q

Sqamous cell carcinoma

A
  • Less common, more aggressive
    • Metastasis to lymph nodes in 20%
  • 5-10% eyelid malignancies
    • LL, lid margin
  • Elderly, fair complexion, chronic UV exposure
  • Presentation
    • Similar to BCC
    • Vascularization to absent
    • Rapid growth
    • Hyperkeratosis
73
Q

Keratoacanthoma

A
  • Type of squamous cell carcinoma
  • Rare
  • Fair-skinned, chronic UV exposure
  • LL
  • Presentation
    • Pink, rapidly growing hyperkeratotic lesion develops in weeks
    • Growth ceases x 2-3 mo & spontaneous involution occurs over 4-6 mo
    • Keratin-filled crater develops
    • Complete involution in about 1 yr leaving scarring
    • Rare progression to invasive or metastatic carcinoma
74
Q

Sebaceous gland carcinoma

A
  • Very rare
  • Elderly females - any age possible
  • Arising from MG, gland of zeis or sebaceous glands in caruncle
  • UL > LL
  • Presentation
    • Often resembles chalazion in early stages
    • Yellow crusting common
  • Prognosis 5-10% mortality
    • Delayed diagnosis (>6mo)
    • Size > 10 mm
    • Metastatic disease 25%
75
Q

Kaposi Sarcoma

A
  • Vascular tumor
  • Frequent association w/ HIV/AIDS
    • Occasionally only clinical manifestation of infection
  • Presentation
    • Pink, red-violet, to brown lesion
      • Color varies based on skin pigmentation & location
    • May be mistaken for hematoma or nevus
76
Q

Blepharitis

A
  • Inflammation of eyelids
  • Sx
    • Itching
    • Burning
    • Dryness
    • FBS
    • Mattered lids
    • Redness
    • Puffiness
    • Scratchiness
    • Lash loss
    • Bumps on lids
  • Signs
    • Bulbar conjunctival staining
      • Appears before corneal involvement
      • Lissamine green/Rose bengal - stains later & indicates associated DES
      • NaFL with wratten filter
    • Corneal Staining
      • NaFL
      • Mostly occurs inferiorly where lid apposes eye
      • Frequently sx worse in AM due to stagnation of tears
        • Looking for limbal staining
        • Curvilinear lesions at 10, 2, 4, & 8 o’ clock
    • Lid staining
      • ​Palpebral conjuctiva
        • ​Injection
        • Concretions
        • MG changes
        • Telangiectasia
        • Papillae or follicles
    • Lash/Lid structure
      • Mattering
        • Greasy - seborrheic
        • Hard/crust - staph
        • Cylindrical sleeves - demodex
      • Poliosis
      • Madarosis
      • Pachyblepharon
    • Tears
      • Debris, frothiness
      • Decreased TBUT due to stasis
        • Decreases oils -> increased evaporation
        • Improves w/ tx
  • Tx
    • Digital expression of glands
      • normal pts - clear oily liquid
      • MGD/MKC - rubid, inspissated glands
    • Forceful expression of glands
      • May be used as tx
      • Thick toothpaste or sing-like excretion from the glands
      • No discharge due to stenosis
77
Q

Chronic Anterior Blepharitis

A
  • Involving the lashes and anterior lid
  • Very common cause of ocular discomfort & irritation
  • Usually bilateral & symmetric
  • poor correlation of signs & sx
  • Symptoms
    • ​Burning
    • Grittiness
    • Mild photophobia
    • Crusting/mattering
    • Redness
  • characterized by remissions & exacerbations
  • Causes
    • ​Staophylococcal - hard scales & crusting at the base of lashes
      • less common & occurs in younger pts
      • Treatable and possibly curable
    • Seborrheic - hyperemic & greasy anterior lid margins with lashes sticking together
      • 95% assocation with generalized seborrhea or dermatitis
      • M > W
    • Mixed etiology
  • Treatment
    • ​Lid hygiene
    • Steroid/antibiotic combination
    • Warm compression
78
Q

Chronic Posterior Blepharitis

A
  • Meibomian gland dysfunction (MGD) & alterations in the MG secretion
  • Sx: similar to anterior
  • Meibomian seborrhea & MGD
    • Overproduction of sebum & associated rapid turnover of epithelial cells
    • Present in approx 43% of population
    • Up to 30% CL intolerance
    • Associated with rosacea & seborrhea
    • Management: lid hygiene
  • Meibomian Gland Grading Scale
    • ​0: all glands patent
    • 1: 1 or 2 partially obstructed (clear with mild pressure)
    • 2: 3+ partially obstructed
    • 3: 1-2 blocked + many partially obstructed, foam along margins
    • 4: 3+ blocked with remainder partially obstructed
79
Q

Chronic Posterior Blepharitis: Meibomian keratoconjunctivitis (MKC)

A
  • MG disease with associated corneal changes
  • More common in cool climates
  • Associations: seborrhea & rosacea
  • Presentation
    • ​Inflammation around glands, mostly posterior
    • Difficult to impossible express glands
      • Very thick
    • Tear film instability
    • Associated papillary hypertrophy
    • Associated keratitis
      • ​10, 2, 4, & 8 o’clock lesions
      • Sterile, curvilinear ulcerations or infiltrates
      • Clear zone between lesion & limbus
      • delayed type hypersensitivity reaction wtih increased cell mediated immune etiology
      • Scarring and vascularization possible
    • Anterior changes possible: madarosis, pachyblepharon, scalloped lid margins
  • Treatment
    • ​Variable, often involves steroids
80
Q

Demodicosis (Demodex)

A
  • Microscopic ectoparasite
    • demodex folliculorum
    • demodex brevis
  • Clusters at root of eyelashes
    • Burrows deep into sebaceous & meibomian gland
  • Life cycle: 14-18 day egg to larvae, 5 days adult
  • Incidence
    • 60 yo = 84%
    • 70+ yo = 100%
  • Symptoms
    • ​Itching
    • Burning
    • FBS
    • Dryness
    • Redness
    • Photophobia
    • Pain
    • Blurred Vision
  • Clinical presentation
    • ​Cylindrical dandruff
    • Lid margin inflammation
    • MGD
    • Blepharoconjunctivitis
    • Blepharokeratitis
  • Treatment
    • ​Lid hygiene
      • Cliradex
      • Sterilid
      • Blephadex
    • Tea tree oil
    • BlephEx (in office procedure to remove debris from lashes, similar to alger brush with micro-sponge top, 6-8 mins, repeated q4-6 months)
    • Demodex convenience kit - ocusoft
81
Q

Ocular Rosacea

A
  • Inflammatory condition of the skin
  • 30-50 yo, may occur in children
  • M=W
  • May occur in conjunction with or absence of cutaneous signs
  • Symptoms
    • ​FBS
    • Pain
    • Itching
    • Burning
    • Blurred vision - transient
    • Recurrent chalazion
    • Lid swelling or redness
    • Conjunctival hyperemia
  • Eyelid
    • ​Blepharitis - most common (Posterior blepharitis)
    • Telangiectasia
    • Chalazion
  • Conjunctiva
    • ​Conjunctival hyperemia
    • Papillary or follicular conjunctivitis
    • Conjunctival scarring
  • Cornea
    • Keratitis
      • Bilateral, relapsing of varying severity
      • Pannus
    • Stroma infiltrate
    • Corneal thinning
    • Dry eye
  • Other
    • ​Uveitis
    • Scleritis/Episcleritis
  • ​Treatment
    • ​Supportive therapy - topical lubricants, lid hygiene w/ massage, punctal occlusion
    • Topical therapy - Antibiotics, steroids, Restasis, Ivermectin - skin, Brominidine - skin
    • Systemic therapy
      • ​Oral antibiotics
        • ​Doxycycline - apprilon
        • Tetracyclines
        • Macrolides - young pts & those with interolerance/allergy to tetracyclines
      • Omega- 3 fatty acids
    • Surgical excision of chalazion
82
Q

Management of chronic blepharitis

A
  • often requires combination approach
  • Nutrition
    • ​Seborrhea
      • ​many pts with increased lipid deposition
      • Stop eating fatty foods
    • Anti-oxidants - may counteract free fatty acid damage
    • LNA - alpha-linolenic acid (flaxeed oil)
      • ​Beneficial role in cellular turn over
  • Hygiene
    • ​Warm compresses - Min 4 mins to dissolve waxes, up to 6x/day
    • Digital massage - assist in opening glands further
    • Lid scrubs
      • Clean debris from lid margin
      • Gentle - tissue thin & sensitive
  • Supportive Therapy
    • ​Lubrication
      • artificial tears: palliative results with q2 hr dosing, most pt compliance about 1-2x/day
    • Gels - last longer than tears, palliative results at QID dosing
    • Ointments - supply lipid component
  • Punctal occlusion - collagen, silicone, cautery
  • Forceful experession
    • ​Topical anesthetic on cotton swab with 2nd swab or finger to outer lid to apply pressure
    • Helpful in reduction of bacterial load
    • In office tx q6wks
    • Severe cases greatly improve sx after 3 sessions
  • Topical therapeutic agents
    • ​Antibiotics
      • ​Applied to lashes in scrub-like motion
      • Erythromycin or bacitracin
      • Initial presentation of corneal ulcer may require prophylactic antibiotic solution
    • Steroid ointments or solutions
      • ​Utilized for inflammatory or hypersensitivity component
      • Corneal disease: solutions
      • Lid disease: ointments
      • Combo drops/ointments often helpful
    • Bland ointment
      • ​useful in cases of demodex
      • ointment smothers the mite
    • Oral antibiotics
      • ​inhibit bacterial proliferation
      • inhibit lipase & thus free fatty acids
  • Medications
    • ​Doxycycline
      • ​Drug of choice in meibomitis
      • May cause GI distress
        • Decreased response when taken with food or acid reducer
      • Dosage
        • initial - 150-200mg
        • 25, 50, or 100 mg for maintenance dose
      • Caution: tetracyclines retard bone and dentitia development
      • Should not be used in pregnant or nursing women or in children under 12 yo
      • Warn of sensitivity to sun
    • Azithromycin
      • ​Z-pac
      • 500 mg first day, then 25mg for 5 days
    • Erythromycin
      • ​May cause GI distress
      • Safe to use in pregnancy, nursing & children
      • Adult dosing: 500mg loading dose, then 250mg QID x 4 days
      • Pediatric dosing: 30-50 mg/kg/day
83
Q

Angular Blepharitis

A
  • inflammation involving the outer angle of the lid
  • Etiology: Moraxella lacunata or staph
    • Rarely other bacteria & herpes simplex have also been implicated
  • Signs
    • ​Unilateral red, scaly, macerated & fissured skin at canthal regions (lateral>medial)
    • May have associated papillary or follicular conjunctivitis
  • Tx
    • ​Topical antibiotics
      • Bacitracin
      • Erythromycin
      • Chloramphicol
84
Q

Pthiriasis Palpebrum (Pediculosis)

A
  • Infestation of eyelashes by phthiriasis (pubic lice)
  • Occurs at any age - children & adults living in poor hygienic conditions, sexual contact
  • Sx
    • ​Chronic irritation
    • Itching of lids
  • Signs
    • ​Lice anchored to lashes by claws
    • Ova & shells appear as oval, brownish, opalescent pearls at lash base
    • Conjunctivitis is uncommon
  • Tx
    • ​Mechanical removal of louse & associated lash with forceps
    • Bland ointment applied to lashes min. BID x 10 days
    • Delousing of pt, family members, & bedding is important to prevent reinfection
85
Q

Childhood Belpharokeratoconjunctivitis

A
  • Poorly defined, but tends to be more common in asian & middle eastern population
  • Presentation: mostly about 6yo
    • Recurrent episodes of chronic redness, eye rubbing & photophobia
    • Misdiagnosed as allergic disease
  • Signs
    • Chronic anterior or posterior blepharitis
      • ​often with recurrent hordeolum or meibomian cysts
    • Conjunctival changes
      • ​Diffuse hyperemia
      • Bulbar phlyctenules
      • Bulbar or papillary hyperplasia
    • Corneal changes
      • ​SPK
      • Marginal keratitis
      • Peripheral vascularization
      • Axial subepithelial haze
  • Tx
    • ​Lid hygiene & topical antibiotic ointment at bedtime
    • Topical allow dose steroids
    • Oral erythromycin
86
Q

List some bacterial infections of the eye

A
  • External hordeolum
  • Impetigo
  • Erysipelas
  • Necrotizing fasciitis
87
Q

Hordeolum

A
  • Acute bacterial infection & subsequent abscess formation in sebaceous glands of the lids
    • may present as internal or external variants
  • Symptoms
    • ​Tender or painful lid nodules
    • Associated redness & warmth of the skin of the lid
    • No visual changes
    • Rarely have discharge - if present, generally see purulent material within the gland
    • May notice thinning of the overlying epidermis
    • May see pointing/pouting of gland
  • Demographics
    • ​Any age, race, gender
  • External Hordeolum
    • ​Involves more superficial gland of zeis at the base of the lashes
    • Often develop a pouting appearance
      • come to head & can pop like acne
    • Can be managed with topical therapy
  • Internal Hordeolum
    • ​Involve deeper meibomian glands within the tarsal plate
    • May not realize actual size without everting the lids
    • Generally require oral therapy for resolution
88
Q

Impetigo

A
  • Superficial skin infection
    • Staph aureus
    • Strep pyogenes
  • Children
  • Presentation: Erythematous macule which develop into blisters
  • Golden-yellow crusting
  • Tx: antibiotics
89
Q

Erysipelas

A
  • St. Anthony’s Fire
  • Uncommon, subcutaneous cellulitis
  • Strep pyogenes infection through open wound
  • Presentation:
    • Expanding, indurated, erythematous subcutaneous plaque
    • Fever
    • Malaise
  • Tx: oral antibiotics ​
90
Q

Necrotizing fasciitis

A
  • Very rare rapidly progressive necrosis
    • Strep pyogenes
    • Staph aureus
  • Fatal if not treated
  • Periocular infection rare
    • Periorbital redness
    • Large bullae
    • Black discoloration of skin
  • Complications
    • ​ophthalmic artery occlusion
    • Lagophthalmos
    • Disfigurement
    • Death
  • Tx: IV antibiotics ​
91
Q

What are some viral infections that could affect the eye?

A
  • Molluscum contagiosum
  • Herpes zoster ophthalmicus
  • Herpes simplex
92
Q

Molluscum contagiosum

A
  • infection by poxvirus
    • ​Direct person to person contact
    • physical contact with fomites
  • Peak incidence 2-4 yo
  • More frequent in developing countries
  • Risks
    • ​Atopic dermatitis
    • Immunocompromised pt
  • Presentation
    • ​Benign skin lesions
      • small, raised lesions with dimple center
      • white to pink color
      • 2-5mm diameter
      • May be itch, sore, red swollen
    • May occur anywhere on the body
    • Follicular conjunctivitis possible
  • Treatment
    • ​Resolution 6-12 mos to 4 yrs
    • Prevention of spread
      • Dont scratch/touch
      • Frequent hand washing/change towels, bedding
      • Cover lesions
      • Avoid certain spots during active infection
    • Topical therapy: pdophyllotoxin cream ​
    • Oral therapy: Cimetidine
    • Excision by shaving, cauterization, cryotherapy, laser
93
Q

Herpes Simplex

A
  • Viral infection
  • 2 serotypes HSV I & II
  • 90% positive for HSV I worldwide
  • Leading cause of corneal blindness worldwide
  • M=F
  • Transmission
    • Direct contact
      • ​Person to person
      • Fomites
    • More likely while pt is symptomatic
  • Primary infection
    • ​Incubation = 1-26 days, Infection = 10-14 days
    • Most pts asymptomatic
    • Systemic symptoms
    • Asymptomatic to severe presentations - 20% with h/o primary infection sx
    • Sudden onset
    • Characteristic vesicular lesions superimposed on inflammatory, erythematous base
      • Groupings of multiple vesicles in single anatomic site
      • Painful
      • 10-14 day course
    • Systemic sx
      • Fever
      • Malaise
  • Recurrent infection
    • ​Virus lays latent in nerve cell bodies & reactivates in response to trigger
    • Prodromal sx common
      • 6-53 hrs prior to first appearance of first vesicles
    • Little to no systemic sx
    • Occur in 20-40% of population worldwide
    • Prodromal sx: pain, burning, tingling, pruritis
    • Shorter duration = 5 days
    • Recurrence 1x/month - 2x/year
    • Systemic sx rare = local lymphadenopathy
    • Triggers = UV exposure, fever, menstruation, emotional stress, trauma ( trigeminal nerve manipulation, dental extractions)
94
Q

HSV I

A
  • >90% seropositive by 4th decade
  • affects eye, mouth, skin above waist
  • less commonly affects genitals
  • transmission by direct contact
  • recurrence more frequent in oral mucosa
95
Q

HSV II

A
  • Affects genitals
  • Less commonly affects eye - more severe
  • Sexual & neonatal transmission
  • Recurrence more common in genitals
96
Q

Atopic Dermatitis/Eczema

A
  • Idiopathic inflammatory condition causing itchy, red, irritated skin
  • Often appears on scalp, forehead, & face - rarely lids
  • Sx
    • Itching
    • Burning
    • Tenderness
  • Presentation
    • ​Thickening, crusting, & fissuring of lids
    • Associations with Staph blepharitis & madarosis
  • Tx
    • ​Topic emollients
    • Mild topical steroids
97
Q

HSV

(Sx, ocular involvement, Tx)

A
  • Sx
    • Tingling, itching, burning
    • Sores/blisters
    • Flu-like sx
    • Trouble urinating
    • Ocular involvement
  • Ocular involvement
    • ​Recurrent disease most common
    • Lies dormant in sensory ganglia - usually trigeminal ganglion
    • Triggers
      • ​Psychological stress
      • Physical trauma
      • Fever
      • UV light exposure
      • Viral infection
      • Topical ocular meds = Prostaglandins, B-blockers
    • Immunosuppresion
    • Signs
      • Unilateral
      • Herpetic blepharitis
      • Conjunctivitis
      • Keratitis
      • Retinitis
      • Scleritis
    • Herpetic blepharitis
      • ​clear vesicles on red erythematous base on lid margin
      • occur in groups
      • lesions ulcerate & crust while healing
        • can lead to infection
      • Corneal migration high
  • Treatment
    • ​Antiviral therapy
      • topical: Viroptic (trifluridine), zirgan (ganciclovir)
      • Oral: acyclovir, valacyclovir, famciclovir, ganciclovir
    • Steroids
    • Supportive
    • Surgical
98
Q

Herpes Zoster

A
  • Varicella zoster virus reactivation
    • Shingles
    • Primary infection is chickenpox
  • 32% of population will experience at sometime in their life
  • Incidence increases with age
    • 50% pt age 85 will have episode of zoster
  • Risks
    • ​Age
    • Physical trauma
    • Disorders of cell-mediated immunity
    • Chronic lung or kidney disease
    • Organ transplant pts
    • Autoimmune disease
    • F>M
  • complications
    • ​Post-herpetic neuralgia = pain persisting >4 months beyond onset of rash
    • Bacterial skin infection
    • Motor neuropathy
    • Meningitis
    • Herpes Zoster oticus
    • Ocular complications
    • Pts w/ 1+ . complications frequently have other comorbidities
      • DM, cancer, HIB, transplant pts
  • Clinical manifestations
    • ​Occurs in restricted dermatome
      • rarely occurs in 2+ dermatomes at the same time
      • thoracic and lumbar most common
    • Preceded by prodroma pain
    • Rash = patches of clear vesicles over erythematous base
    • Acute neuritis
    • Systemic sx (<20%)
      • HA
      • Fever
      • Malaise
      • Fatigue
    • Herpes zoster ophthalmicus
      • ​CN V1
      • 50-70% experience direct ocular involvement
      • Prodrome
        • HA, Malaise, Fever, Unilateral pain or hypesthesia along CN V1 distribution
      • Presentation
        • ​Vesicular lesions along scalp UL & tip of nose
          • Hutchinson’s sign
        • Blepharitis
        • Conjunctival involvement
        • Corneal involvement - 65%
        • Iritis 40%
        • Retinal complications
        • Optic neuritis
        • Oculomotor palsies
  • CN V Distribution
    • ​3 branches
      • Opthalmic branch: innervates scalp, forehead, upperlid,eye, tip of nose
      • Maxillary branch: innervates cheek, lower lid
      • Mandibular branch: innervates jaw, tongue
  • Treatment
    • ​Antivirals - Oral, topical, IV
    • Topical steroids or NSAIDS
    • Antibiotics
    • Lubrication
    • Cool compresses
99
Q

Allergic disorders of the eye

A
  • Contact dermatitis
  • Atopic dermatitis
100
Q

Contact Dermatitis

A
  • Skin rash occurring as a response to an irritant
    • Sensitized to irritant on first exposure & develop reaction on subsequent exposures
    • May be immediate or delayed
    • Dealyed type IV hypersensitivity reaction
  • Any age, race, gender
  • Causes
    • Medications
    • Makeups
    • Metals
  • Sx - Itching, tearing ​
  • Presentation
    • ​Lid edema
    • Scaling
    • Angular fissuring
    • Chemosis
    • Redness
    • Papillary conjunctivitis
    • PEK
  • TX
    • ​Stop exposure
    • PFATs
    • Cool compresses
    • Topical steroid
    • Steroid/antibiotic combo
    • Oral antihistamines
101
Q

List Spasms & Palsies that can occur in the eye

A
  • Myokymia
  • Blepharospasm
  • Hemifacial spasm
  • Bell’s Palsy
102
Q

Myokymia

A
  • Involuntary, fine, continuous, undulating contractions that spread across the affected striated muslce
  • Any age - young, healthy
  • Generally unilateral
  • Transient & self-limiting - hours to days
  • Triggers
    • ​Stress
    • Fatigue
    • Physical exertion
    • Increased caffeine/alcohol intake
  • Sx
    • ​Jumping
    • Quivering
  • Treatment
    • ​Spontaneous resolution
    • Stress reduction
    • Rest
    • Antihistamines
    • Quinine/Tonic water
    • Decrease caffeine, alcohol &/or tobacco consumption
    • BOTOX
103
Q

Blepharospasm

A
  • Dystonia of orbicularis oculi & other periocular muscles
    • Procerus muscle
    • Corrugator muscle
  • Benign essental blepharospasm
    • BILATERAL, involuntary orbicularis spasms
    • Synchronous
    • Symmetric
  • Female 3:1
  • 6th decade
  • Remission & exacerbations
  • Mild annoyance to disabling
  • Cause: abnormal function of the basal ganglion from an unknown cause
  • Symptoms
    • ​Increased blink rate
    • Spasm of involuntary lid closure
    • Fatigue
    • Emotional tension
    • Photophobia
  • Triggers
    • ​bright lights
    • increased stress
  • Treatment
    • ​None
    • BOTOX
    • Surgical
104
Q

Hemifacial Spasm

A
  • Uncontrollable twitching of muscles of half of the face
    • Muscle innervated by facial nerve
  • Sx
    • ​Periodic twitching & spasms of the eyelids leading to closure
    • Spreads to involve other ipsilateral facial & neck muscle
  • Cause
    • ​compression of facial nerve of the brainstem
      • Vascular anomalies, tumors, trauma
  • Treatment ​
    • Medication
      • ​Muscle relaxant
      • Mild cases
      • Tx sx
    • Botox
      • ​4-9 mo of relief per injection
      • tx sx
    • Surgical
      • ​Decompression of CN VII
      • Treats cause not sx
105
Q

Bell’s Palsy

A
  • Acute, temporary facial paralysis from damage or trauma to CN VII
  • M=W
  • Any age - majority 15-60yo
  • Sx
    • Unilateral facial paralysis of acute onset
    • HA
    • Numbness
    • DES/FBS
    • Tearing
    • Drooling
    • Dysarthria - trouble articulating speech
    • Dysphagia - trouble or discomfort swallowing
  • Signs
    • ​inability to move muscles of face
    • Smoothening of tone muscles
    • Drooping of eye, side of mouth
  • Recovery
    • ​extent of nerve damage dictates healing
    • Sx improve w/in ~ 2wks
    • Complete recovery 3-6 months
  • Treatment
    • ​None
    • Steroids
    • Antivirals
    • Supportive therapy
      • Covery eye - lubrication during daytime, taping/patching at night
106
Q

What are some examples and risk for cosmetic procedures?

A
  • Tattoo
    • ​Eyeliner
    • Eyebrows
    • Permanent makeup application
    • UL/LL
  • Risks
    • ​Same as other tattooed areas of the body
    • Infection
    • Allergy
    • Granulomas
    • Keloid formation
    • Removal
    • MRI complications
107
Q

Describe the eyelash anatomy

A
  • Cilia
  • Shed like hair
    • Regrow every 4-6wks
  • Approx. 100 per lid
    • Upper>lower
    • Lash root near base of tarsal plate -> passes through muscle -> exits anterior lid margin
    • Curves away from the globe
    • Scarring of tarsal plate, conjunctiva or inflammation can lead to lash misdirection
108
Q

List some eyelash disorders

A
  • Trichiasis
  • Distichiasis
  • Eyelash ptosis
  • Trichomegaly
  • Madarosis
  • Hypotrichosis
  • Trichotillomania
  • Poliosis
109
Q

Trichiasis

A
  • Incredibly Common
  • Posterior misdirection of lashes arising from normal origin
  • Causes
    • occuring in isolation
    • Result from scarring - chronic blepharitis & HZO (Herpes zoster ophtalmicus)
  • Symptoms
    • ​Asymptomatic
    • FBS - irritation worsens with blink
    • May cause corneal abrasions
  • Treatment
    • ​Epilation
    • Electrolysis
    • Cryotherapy
    • Argon laser ablation
    • Surgery
110
Q

Distichiasis

A
  • Congenital
    • ​Rare
    • Germ cell differentiates to pilosebaceous unit instead of meibomian gland
    • Partial or complete 2nd row of lashes emerges behind meibomian gland orifices
      • Aberrant lashes thinner & shorter, often with posterior misdirection
    • Asymptomatic until about age 5
  • Acquired
    • ​Metaplasia & dedifferentiation or MG to become hair follicules
    • Variable number of lashes iwth originate from MG orifices
      • Cilia generally non-pigmented & stunted
      • Generally asymptomatic
    • Cause
      • Late stage cicatricial conjunctivitis
      • Stevens-Johnson syndrome
      • Ocular cicatricial pemphigoid
  • Treatment
    • ​Congenital
      • ​LL: cryotherapy
      • UL: lamellar eyelid division & cryotherapy
    • Acquired
      • ​Mild: same as trichiasis
      • Severe: lamellar eyelid division & cryotherapy
111
Q

Eyelash ptosis

A
  • Downward sagging of UL lashes
  • Causes
    • Idiopathic
    • Associated with floppy eyelid syndrome
    • Dermatochalasis
    • Long-standing facial palsy
112
Q

Trichomegaly

A
  • Excessive eyelash growth
  • Causes
    • ​Acquired - drug induced (topical PGAs), malnutrition, AIDS, porphyria, hypothyroidism
    • Congenital - various syndromes, may have retinal problems or mental retardation
  • Treatment
    • ​Lubrication - protect the ocular surface ​
    • Epilation
    • Treat underlying condition
    • Adjust medications
113
Q

Madarosis

A
  • Loss of lashes
  • Causes
    • Chronic anterior lid margin disease
    • Alopecia
    • SLE
    • Trichotillomania
114
Q

Eyelash Hypotrichosis

A
  • Less than normal amount of lashes
  • Causes
    • Hereditary
    • Aging
    • Chemotherapy or other medical tx
    • Idiopathic
  • Complications
    • ​Cosmesis
    • Dry eye
    • Frequent ocular foreign bodies
  • Treatment
    • ​Latisse (Birmatoprost 0.03%)
      • Prostaglandin analog
      • Approved
      • Initially used as IOP lower drug (lumigan)
      • Side effects
        • ​IOP lowering
        • Eyelash growth - length, number & thickness
        • Increased pigmentation - skin, lashes iris
        • Conjunctival hyperemia
        • Stinging/burning
        • Anterior Uveitis
115
Q

Trichotillomania

A
  • Disorder of irresistible urge to pull out hair despite trying to stop
    • Generally scalp, eyebrows or lashes
  • Leaves bald patches
  • Develops in early teens
  • Associations
    • Depression
    • Anxiety
    • OCD
  • Treatment
    • Psychotherapy
    • Medications - non FDA approved
      • Antidepressants or antipsychotics
116
Q

Poliosis

A
  • Localized, premature whitening of lashes/eyebrows
  • Causes
    • Chronic anterior blepharitis
    • Vogt-Kayangi - Harada syndrome
    • Waardenburg syndrome
    • Vitiligo
    • Marfan syndrome

Anterior Seg (4 decks)

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