Lacrimal Disorders Flashcards
What is dacryoadenitis?
Inflammatory enlargement of lacrimal gland, acute, chronic and cna be infectious/systemic
What do you look for in a dacryadenitis history?
Fever, discharge, systemic infection. Chronic cases may be bilateral, painless enlargement for more than a month
Does chronic or acute dacryoadenitis present more severely?
Acute.
How does chronic dacryoadenitispresent differently than acute daryoadenitis?
Usually painless, enlarged gland that is mobile, minimal ocular signs, mild to severe dry eye
How does acute dacryoadenitis present?
Firm and tender mass, unilateral and severely painful that had rapid onset
What signs are in acute dacryoadenitis?
Chemosis, conjunctival injection, mucopurulent discharge, red eyelids, swelling of lateral third of upper lid, proptosis, ocular motility restriction
May be feverish, have malaise, parotid gland enlargement and upper respiratory infection
What are the causes of dacryoadenitis?
Infectious (Viral, bacterial, Fungal) and Inflammatory
Describe Viral causes of dacryoadenitis
Most common (mumps in childhood) Epstein-barr virus Herpes zoster mononucleuosis Cytomegalovirus Echoviruses Coxacklevirus A
Describe bacterial causes of dacryoadenitis
Staphylococus aureus and streptococcus Neisseria gonorrhoeae Treponema pallidum Chlamydia trachomatis Mycobacterium leprae Mycobacterium tuberculosis
Describe some infectious causes of dacryadenitis
These are rare
Histoplasmosis
Blastomycosis
Parasite
Of the infectious causes of dacryadenitis, which is most common, which is most rare?
Viral is common
Fungal is rare
Describe inflammatory causes of dacryadenitis
Sarcoidosis (inflamed lymph nodes) Graves disease Sjogren syndrome Orbital inflammatory syndrome Bening lymphoepithelial lesion
How would you do an acute dacryoadenitis workup?
Smear and culture if discharge is present
blood culture to rule out gonorrhoe
Immunoglobin titers to specific viruses
How would you do a work up for a chronic dacryoadenitis?
See if there are chronic systemic conditions, rule out infectious causes
How does imaging on acute dacryoadenitis differ from imaging chronic dacryoadenitis?
Acute/chronic - no compressive changes in bone or globe
Chronic - Contrast scans don’t make lesions easier to notice
compression may be lacrimal tumors
How to treat Dacryoadenitis
Varies with onset and etiology.
Viral - Self limiting, use cool compresses
Bacterial/infection - Keflex until culture results come back
Hospitalize if moderate or severe
Inflammatory - Treat systemic
What are some tear layer functions?
Maintaing cornea/conj
Provides lubrication and oxygen for aforementioned
Smooth refractive surface
Describe aqueous deficient dry eye
Reduced lacrimal tear secretion, causing tear hyperosmolarity, causing epithelial inflammation
Describe two congenital causes of aqueous deficiency
Anhidrotic ectodermal dysplasia - Less sweating, madrosis, defective dentition, no sebacous glands
Or hypoplasia of lacrimal gland
Describe some nongenetic causes for aqueous deficiency
Trauma
Tumors
Inflammation (collagen vascular, viral dacryoadenitis, TB, sarcoidois,s syphillis, lymphoa)
Neurological defects (lesions of brainstem, et cetera)
Describe Sjogren’s syndrome
Autoimmune, unknown cause. Most commonly post-menopausal women, characterized by lymphocyte infiltration and atrophy of lacrimal glands, and salivary gland.
What is the triad of findings in Sjogren’s Syndrome?
KCS (Keratoconnus sicca), connective tissue diseas and xerostomia (dry mouth)
What is primary and secondary sjogren’s syndrome?
Primary - KCS and xerostomia (antibodies focus on salivary glands)
Secondary - the above with the connective tissue involvement
What is the most common form of Non-sjogren syndrome dry eye?
Age-related, other kinds are KCS and lacrimal dysfunction
Describe Primary Lacrimal Gland Deficiences
Age related Congenital alacrima (rare cause of dry eye in kids) Familial dysautonomia (Riley-Day Syndrome) - autonomic dysfunction, instable blood pressure, sweating and vasomotor control and insesnitivity to pain
Describe secondary lacrimal gland deficieinces
Lacrimal gland infiltration, sarcoidiosis, lymphoma, AIDS, graft/host disease, lacrimal gland ablation or denervation
How could cictrising conjunctivitis cause dry eye?
Obstructing gland openings is bad. Can show up in cicatricial pehmpighoid, erythema multifome or burns
Describe the incidence/populations affected with Ocular Pemphigoid
Women twice as likely as men, average 58 years for onset
Signs/symptoms of ocular pemphigoid
Inflammatory disease due to autoimmune. Chronic blistering affecting mucous membranes (eyes, oral mucosa, skin, vagina, rectum), bilateral progressive shrinking of conj, ectropion, trichasis, xerosis, VA loss due to corneal opacification
What is Reflex Sensory Block?
Reduction in sensory signal from ocular surface (sent via trigeminal sensory input) causing dry eye by decreasing reflux induced lacrimation and reducing blinke rate
Describe some causes of ocular sensory loss
Infection (Herpes simplex/Herpes zoster)
Corneal surgery (Includes refractive)
Neurotrophic keratitis (CNV ganglion/section/injection/compression)
Topical agents (Anethesthia reduces tear and blink rate)
Systemic medication (Beta blockers/atropine like drugs)
Other (CL wear, diabetes, neurotrophic keratitis)
What is Reflex Motor Block?
CNVII damage, neuromatosis or some systemi drugs causing decreased larimal secretion
Describe evaporative causees of dry eye
Intrinsic - Lid structures/dynamics affected
Extrinsic - Ocular surface disease occurs due to extrinsic exposure
Describe some Intrinsic Evaporative Causes
MGD (Popsterior blepharitis) - Gland obstruction is the most common
Associated with rosacea, seborrhea, atropic dermatitis
Dx and grade based on state of plugged glands
Disorders of lid aperture or lid/globe congruity and dynamics
(Lagopthalmous, CNVII paresis, entro/ectropion, symblepharon)
Low blink rate
Describe some Extrinsic Evaporative Causes
Ocular surface disorders (Vitamin A deficency, some topical drugs and preservatives)
CL wear
Ocular surface disesae (Dry eye)
Allergic conjunctivitis
Give some reasons as to why it’s hard to diagnose dry eye
+/- symptoms/signs
No symptoms but has clinical signs
Wet eye
Very subjective
What is Millieu Interieur?
Intrinsic factorsi n dry eye per se Low blink rate Wide aperture Aging Low androgen Systemic drugs (antihistamines, beta-blockers, antispasmodics, diuretics, some psychotropic drugs)
What is Milleu Exterieur?
External causes of dry eye per se
Low humidity
Draft/wind
Occupational environment (smoke, A/C, airline flights)
Dry Eye symptoms?
Intermittent burning/tearing Grittiness/FPS Itching, redness Intermittent VA loss Photphobia Mattering of lids/lashes
What are some problem oriented questions for dry eye Dx?
Do you experience X? (When/how often) Context (location/time) Any eye drops? Who diagnosed and when? CL wear? Arthritis? Thyroid abnomrality? Dryness in other parts of the body? Eyes sensitive to atmospheric irritants? (Smoke) Red eyes/irritated when swimming? Taking antihistamines, eye drops, diuretics, sleeping tablets, oral contraceptives, et cetera Sleeping with eyes open? Eyes irritated when you wake up? Eye make up? Any allergies? Computer use? Do you think you have dry eye?
What are some clinical signs of dry eye?
Reduction in tear meniscus Cellular debris Abnormal mucus accumulation generally in inferior cul-de-sac Conj is injected Dull appearance to eye
How to test for dry eye?
Observe blink rate/completness
Slit lamp (note tear meniscus height, avg is .2mm)
Check for debris via slit lamp and mucus strands (an early change in dry eye)
Assess lipid layer, if it’s smooth/thick or thin or irregular
Check lashes for blepharitis or scurf, changes to lashes (madrosis, poliosis, tirchiasis, broken lasyes), tylosis (irregularity of lid margin)
What is meibomianitis?
Inflammation around meibomiam gland orfirces, clogging of the openigns and solidificaiton of secretions
Causes significant tear film disruption and low TBUT
What does Schirmer Test measure?
Aqueous secretion (normal is 15mm in 5 minutes) Moderate or mild KCS is 5-10 mm in 5 minutes, and severe is less than 5mm in 5 minutes
What are the kinds of Schirmer Tests?
Schirmer I - No anestheisa to measure reflex/basal secretion
Schirmer II - Without anaesthetic to measure max reflex tearing
What is the Phenol Red Thread Test?
A string of phenol red dye placed in conj for 15 seconds. Length of wetting indicated by color change via a pH change by tears. Less than 10 mm is a symptom of dry eye
What is the tear osmolarity test?
Checking for osmolarity, it’s higher in KCS. Takes instrumentation and a bit harder to do
What is a lactoferrin immunoassay test?
Measurement of tear protein (lactoferrin) as a correlate to tear volume. Takes 3 days to process
Describe the Tear Breakup Time
Gets an idea of detection of lipid and mucin deficiences
Describe Rose Bengal Staining
Water soluble dye, stains devitalized cells, mucus, corneal filaments; stains dead cells.
Describe Lissamine Gren staining
Stains dead and devitalized cells, but not as irritating as rose bengal. Cells tend to be easier to see, BUT discolors skin
Describe Fluorescein staining
Penetrates broken epithelial surfaces and diffuses through cells to stain them. Stains ulcers and scrapes.
Describe Jones I
Fluorescein placed in conjunctival sac and have patient blow nose on tissue or put a Q-tip on nose. Positive dye indicates open drainage
Describe Jones II
Conjunctival sac washed with saline, if dye goes through see some kind of functional blockage not physical then
Describe therapeutic approaches to treating dry eye with medication
Stabilize tear film
Increase lubricicty of tears (decrease friction)
Increase aqueous production
Decrease inflammation
Create a more normal tear film environment for epithelial healing
What are the four categories of lubricant eye drops
Cellulose derivatives
Glycerin Containing
Liupid based emulsion
Polyethylene glycol/propylene glycol
What are some cellulose derivative eye drops?
Carboxymethylcellulose (CMC) - Refresh Tears/Refresh Liquigel
Hypromellose (HPMC) - Tears Naturale, Genteal
What are some Glycerin Containing eye drops?
Glycerin - Advanced Eye Relief (Dry Eye)
GLycerin with HPMC - Tears Naturale Forte, Visine Tears
Glycerin with CMC - Optive
What are some lipid based emlusion eye drops?
Refresh Endura and Soothe
What are some Polyethylene glycol eye drops?
PEG and PG with HP Guar, Systane Ultra
Describe treating Dry Eye with Artificial Tears
Most common treatment modality. But relief for short duration only.
Educate patient on use and monitor
Describe Tears Again Liposome Spray
Applied to eyelids to get better tear lubrication and contact time. Has vitamin A and E as well
Describe Restasis eye drops
Increases in Schirmer wetting, dramatic improvement in conjunctival staining and SPK. Subjective improvement and mostly used for dry eye caused by inflammation
Describe Lacrisert
A sustained-release artificial tears inserts. Placed in inferior cul-de-sac and dissolve slowly to provide relief for 12 hours
Describe Ointment based treatments for dry eye
Used with tears. Place a 1/4’’ ribbon in the inferior cul-de-sac, used before bed to avoid waking with blurry vision
Refresh PM
Lacrilube
Moisture Eyes PM
Describe Punctal Plug treatment for dry eye
Temporary placement of collagen implants in the puncta to prevent drawinage of tears to increase aqueous component of tears.
Describe Blink Therapy
Teaching a patient to blink more often and more completely to improve keratopathy, decrease friction, tear thinning and evaporation. Help maintain smooth, lubricated and clean CL surface
Describe the use of goggles and shields for treating dry eye
Retards tear evaporation in the most severe cases
Describe tear stimulation treatment for dry eye
Use of oral/topical drugs limited. Can use cholinergic agents like oral pilocarpine but not very successful and have side effects
Describe the use of Flaxseed Oil and Nutritional supplements to treat dry eye
May provide some relief for dry eye, reduces T cell lymphocyte proliferation, but can cause facial acne
Describe the use of bandage CLs in treating dry eye
Reserved for severe cases, can increase risk of infection, stagnation of tears with increased metabolic waste can then cause hypoxia of epithelium
What is FIlamentary Keratitis?
Strands of mucous attached to epithelium. In extreme dry eye cases. Remove and use AT and ointments. Often unilateral
What’s a dacryocystography?
Saline with radioactive substance injectd into sac, x-ray taken to see if there is a blockage
What is Dacryocystistis?
Congenintal/acquired infection/inflammation of lacrimal SAC (not gland)
Tends to be secondary to obstruction (streptococcus, staphylcoccus, bacteria, et cetera)
Describe congenital dacryocystitis
Frequently seen with congenital dacrystenosis. Chronic painless presentation for weeks to months, mild/moderate tenderness on palpation
Describe acquired dacryocystitis
Frequently unilateral, tends to be acute with pain around eye and orbit.
What are signs of acute dacryocystitis?
Moderate swelling of sac, some edema and redness throught inferior nasal region, occassional hardened distention of sac with focal enlargement, a purulent discharge, secondary conjunctivitis, can be secondary to preseptal cellulitis and almost always see epiphoria
What are signs of chronic dacryocystitis?
Less severe, more commonly congenital, purulent discharge exaggerated when massaging. Can persist and spontaneously remiss.
What is the workup for dacryocystitis?
Previous episodes?
Concurrent ear/nose/throat infection?
How do you evaluate a dacryocystitis?
Gentle compression of sac to try and express discharge
EOM motility effected
Check for proptosis
Gram stain and blood agar culture of discharge
Consider a CT scan of the orbit to judge severity
DO NOT DILATE AND IRRIGATE DURING ACUTE INFECTIOUS STAGE
How to treat dacryocystitis in kids?
Systemic antibiotics. Amoxicillin for kids without a fever and have a mild case. Severe cases must be hospitalized and treated
How to treat dacryocystitis in adults?
Without fever/mild cases use dicloxacillin or cephalexin. For severe cases must hospitalize and treat
How to treat dacryocystitis in general?
Topical antibiotics, warm compresses and gentle massaging, pain medication, maybe surgical correction and daily follow ups
What is the most common congenital abnormality of the lacrimal drainage system?
Congenital lacrimal obstructions, valve of Hasner hasn’t opened.
What is dacyrostenosis?
Narrowing of canaliculi
How do you evaluate a lacrimal obstruction?
Epiphoria? Observe punctal integrity/position Jones test Dilate and irrigate if possible Dacryocystorhinogram in severe cases
How to treat a lacrimal obstruction?
Treat cause of obstruction, frequent heat/firm massaging
What is a lacrimal fistula?
Chronic and untreated dacryocystitis, inflamming the sac until it perforates
What is a dacryocystorhinostomy? (DCR)
A hole is drilled between sac and bone to allow tear drainage
What’s dacryocanaliculitis?
Infection/inflammation of canaliculi. Generally caused by fungal infections
What’s a Dacryolith?
A yellow putty-like deposit blocking drainage system, secondary to fungal infections
