Keys Flashcards
Is basal cell carcinoma inherited?
(1) Gorlin-Goltz’s syndrome – AD - BCC, jaw cysts, minor skeletal changes (fifth phakomatosis)
(2) Bazex’s syndrome – XL - BCC, congenital hypotrichosis, follicular atrophoderma
(3) Xeroderma pigmentosa – AR - abnormal UV repair
List the causes of lid retraction in TED.
(1) Humorally-induced overaction of Müller muscle (2) Fibrotic contracture of LPS
(3) Secondary overaction of LPS-SR complex to counter fibrotic IR
(4) Proptosis
What are the systemic associations of limbal dermoids?
(1) Goldenhar Syndrome
(2) Linear Sebaceous Naevus Syndrome (3) Treacher-Collins Syndrome
List conditions where proptosis is exacerbated by valsalva.
Orbital varices; cap haemangioma;
List conditions associated with bilateral exophthalmos.
TED; CCF; Cavernous sinus thrombosis; Wegener’s; Lymphoma; Sarcoid; Craniosynostosis; IOIS;
List conditions causing enophthalmos.
Sclerosing tumours (metastatic breast ca), orbital varix, orbital wall fractures
How do you differentiate clinically and radiologically between the two main lacrimal gland tumours?
Pleomorphic Adenoma – Benign; painless, single/solid bosselated surface; (incomplete excision bad); bone remodelling
Adenoid Cystic Ca. – no intact capsule; “swiss cheese”; faster onset; painful; Ca++; bone erosion; amorphous post extension
How are nasolacrimal duct obstructions diagnosed in children?
NB. Must exclude congenital glaucoma
Epiphora; increased tear lake; mucopurulent discharge in absence of URTI; dye disappearance test
List clinical or radiological features of silent sinus syndrome.
CLINICAL: Spontaneous enophthalmos & hypoglobus. Eyelid retraction/lid lag/lagophthalmos, Deepening superior orbital sulcus, Normal vision is unaffected.
RADIOLOGICAL: partial or complete maxillary opacification, reduction of maxillary sinus volume & orbital volume enlargement. Inferior bowing of maxillary roof
How do you classify ptosis?
NB. Must examine pupils + EOM
- Neurogenic (3rd; Horners; MGJWS, blepharophimosis ptosis epicanthus inversus synd FOXL2)
- Myogenic (MDdystro; Simple Congenital, CPEO; Neuromuscular: MG, botox)
- Aponeurotic (involutional; post surg)
- Mechanical (tumours; dermatochalasis; oedema; orbital lesions; scarring)
Compare congenital myogenic to acquired aponeurotic ptosis.
(1) ULC: Weak/absent crease in normal position (congenital) vs. Higher than normal (acquired)
(2) Levator Function: Reduced (congenital) vs. Normal (acquired)
(3) Down gaze: Eyelid lag (congenital) vs. Eyelid drop (acquired)
What are the causes for pseudo-ptosis?
Hypoglobus/tropia, dermatochalasis, Enophthalmosis (phthisis/wall #); Contralat. proptosis; Contralat. UL retraction (TED)
How do you classify acquired ectropion?
- Paralytic - 2° CN VII palsy causing orbicularis weakness
- Mechanical - 2° visible/palpable mass i.e. tumour/cyst/oedema
- Cicatricial – scarring vertically shortens the anterior lamella
- Involutional - age-related lid laxity
What systemic diseases can capillary haemangiomas cause?
Kasahach-Merrit Syndrome (platelet consuption); High output CCF; Laryngeal obstruction
List three organisms that can cause preseptal cellulitis.
- Staphylococcus aureus
- Streptococcus spp (Strep. pyogenes, Strep pneumoniae)
- Haemophilus influenzae type b
What are the treatment options for lid capillary haemangiomas?
- Systemic steroids; 2. propanolol 2mg/kg; 3. interferon-alpha; 4. vincristine; 5. injected steroids;
How do you manage preseptal cellulitis?
MILD:
• Amoxycillin/Clavulante 875/125mg o BD
SEVERE:
• Flucloxacillin 50mg/kg to 2g iv QID (Gm+ve) & cefotaxime 50mg/kg to 2g iv QID (Gm-ve)
How do you manage dacrocystitis?
(1) Establish diagnosis
(2) Mild: Amoxycillin/Clavulante 875/125mg o BD
(3) Severe : Flucloxacillin 2g iv QID & ceftriaxone 2g iv D +/- incision if pouting (risk of fistula)
What are some ddx of dacryocystitis?
Dacryocoele, encephalocoele if above medial canthus, dermoid, TCC, nasopharyngeal SCC for adults
Outline your management of Thyroid Eye Disease.
ALL
1. Smoking cessation
2. Education regarding symptoms of exposure & ON compromise
3. Endocrine review
4. Rx Glc
5. Rx Exposure keratopathy
6. Cold compress for eyelid oedema,
ACUTE
1. Prednisolone o 40-100mg tapered over 6/52
2. Orbital irradiation does not improve proptosis – OK for active vertical diplopia
3. Orbital decompression if ON compression; severe exposure; globe luxation; uncontrolled IOP; cosmesis
CHRONIC
1. Stepwise Surgical Rx – Orbital Decompression → strabismus surgery → eyelid surgery (if stable TED/TFTs)
2. Decompression – not within 3cm of ant lacrimal crest + 1cm of optic canal; release periorbita (med;lat;floor)
3. Strabismus – prisms; recess fibrotic muscle; NEVER resect; adjustable (Kraus TransASOpht 1993)
4. Lids
• UL retraction: If severe - LPS recession; if mild-Mullerectomy
• LL retractor: recess ± spacer (ear/hardpalate cartilage)
How do you surgically manage paralytic ectropion?
Acute:
• Medial canthus – Lee Medial Canthotoplasty
• LTS or lateral tarsorrhaphy
• (remember gold weight & botox for UL)
Chronic:
• FTSG due to frequent cicatricial component
How do you surgically manage cicatricial entropion?
Lower lid - Mild – Retractor surgery
- Severe – Tarsal facture; Mucosal graft (to lengthen post lamellar); Excise lashes
Upper lid - Mild – Anterior lamellar repositioning
- Severe – Terminal tarsal rotation
Outline the risk factors for and management of involutional entropion?
1. Horizontal laxity • LTS / Wedge excision (AND below) 2. Lower lid retractor dehiscence (tarsal plate destabilisation) • Jones inferior retractor repair or • Everting/Quickert suture 3. AP lamellar override (orbicularis preseptal overrides pretarsal) 4. Relative enophthalmos • Weiss full thickness lid split • Temporary tape
What do you tell patients considering LPS resection for ptosis surgery?
Good Outcome: a) symmetry in 1o gaze b) will have ptosis when looking up c) will have lag when looking down
Complications: a) under>over correction b) contour irregular c) entropion d) lash ptosis e) lagophthalmos f) conjunctival prolapse
