Lacrimal Disorders - Mark Flashcards
General Dacryodenitis Characteristics
Inflammatory enlargement of the lacrimal gland
Can be acute or chronic
Can be infectious or systemic
History: Fever? Discharge? Systemic Infection?
Describe Chronic Dacryodenitis
Less severe than acute Usually no pain Enlarged gland, but mobile Minimal ocular signs Mild ptosis may be noted secondary to enlargement of the gland. Mild to severe dry eyes
Acute Dacryodenitis
Palpebral lobe may be firm and tender upon palpitation through the lid. Palpate!
Signs and Symptoms: Unilateral, severe pain, redness, and swelling over the outer one-third of the upper eyelid
Rapid onset - hours to days
Chemosis, conjunctival injection, mucoprulent discharge (take a culture), erythema of eyelids, lymphadenopathy, swelling of the lateral third of the upper lid (s-shaped), proptosis, ocular motility restriction, globe displacement inferiorly and medially
Systemic physical signs: parotid gland enlargement, fever (need a CBC), upper respiratory infection, malaise
List the Causes of Dacryoadenitis
Infectious (from bacteria - see pg. 2 list), fungal (rare), and inflammatory.
Describe the Work Up Procedures for Acute Dacryoadenitis
Smear and culture if have purulent discharge.
Blood cultures to rule out N gonorrhoeae
Immunoglobulin titers to specific virus - not usually indicated
Describe the Work Up Procedures for Chronic Dacryoadenitis
Usually seen with chronic systemic conditions: sarcoidosis, Sjogren syndrome, graves disease, patient’s internist advice, lacrimal gland biopsy
Rule out infectious causes (rare): syphilis, leprosy, tuberculosis, and trachoma.
Dacryoadenitis Treatment
Varies with onset and etiology
Viral (most common) - self limiting: cool compresses to the area of swelling. Analgesic prn and follow up daily.
Bacterial or Infectious: Mild or moderate. Kelfex until culture results are obtained. Adults: 250-500mg PO QID and Children: 25-50mg/kg/day PO QID
Hospitalize if moderate to severe.
Inflammatory: Investigate for systemic etiology, and treat accordingly.
Chronic Dacryoadenitis - treat the underlying systemic condition (usually) and consider a lacrimal gland biopsy.
Consultations: If sarcoidosis, tuberculosis, Sjogren syndrome, or Graves Disease as etiology, consult with the internist
Give a definition of Dry Eye Syndrome
A multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.
A disturbance of the Lacrimal Functional Unit comprised of lacrimal glands, ocular surface (cornea, conjunctiva, and meibomian glands), lids, and sensory and motor nerves that connect them.
List the Functions of the Tear Film
Maintains the cornea and conjunctiva in a normal state.
Provides lubrication and oxygen for the cornea and conj
Ensures a smooth refractive surface
Pathway for movement of cytokines and proteins secreted by the lacrimal gland
List the Causes of Dry Eye Syndrome
Congenital
Ahidrotic ectodermal dysplasia: diminished perspiration, loss of eyelashes, defective dentition, and no sebaceous glands
Hypoplasia of the lacrimal gland
trauma
tumors
Inflammation: collagen vascular disease, viral dacryoadenitis, TB, sarcoidosis, syphillis, lymphoma
Neurological defects: lesions of the brainstem, cerebellopontine angle, middle fossa floor, and spehnopalatine ganglion.
Sjogren’s Syndrome - autoimmune disorder of unknown etiology. May occur at any age in men and women, most commonly in women post-menopause. Characterized by: lymphocytic infiltration and atrophy of the: main lacrimal gland, accessory lacrimal gland, and salivary gland. Higher frequency of meibomian gland dysfunction. But with Sjogrens Syndrome, there are a triad of findings: KCS, xerostomia, and connective tissue disease (but at least two of these things must be present to diagnose Sjogren’s.
Two categories of Sjogren’s: Primary and Secondary
Primary: KCS and xerostomia (+autoantibodies, +focus score minor salivary gland biopsy).
Secondary: Connective tissue disease with KCS and xerostomia
Describe Non-Sjogren Syndrome Dry Eye
Lacrimal dysfunction (no systemic autoimmune characteristics).
Most common form: age-related dry eye
KCS (Keratoconjunctivitis sicca)
Primary Lacrimal Gland Deficiencies: age-related dry eye, congenital alacrima (rare cause of dry eye in youth), Familial dysautonomia (Riley-Day Syndrome cased by autonomic dysfunction - instability of blood pressure, sweating, vasomotor control), and generalized insensitivty to pain accompanied by marked lack of emotional and reflex tearing.
Secondary Lacrimal Gland Deficiency: Lacrimal gland infiltration: sarcoidosis, lymphoma, AIDS, graft vs host disease, lacrimal gland ablation and denervation.
Obstruction of the lacrimal gland ducts: caused by cicatrising conjunctivitis; may cause cicatricial obstructive MGD: trachoma, cicatricial pemphigold and mucous membrane pemphigoid, erthema multiforme, chemical and thermal burns
Describe Ocular Pemphigoid
Inflammatory Disease of an autoimmune process. Women more commonly infected than men. Usually around 58 y.o. Chronic blistering disease that affects the eyes, oral mucosa, skin, vagina, and rectum. Characterized by bilateral, progressive shrinking of the conjunctiva, entropian, trichiasis, xerosis, and visual loss by corneal opacification. Progressive is variable with periods of remission and exacerbation.
Erythema Multiforme
Acute, self-limiting mucocutaneous disorder.
Immune complex mediated hypersensitivity disorder
affects children and young adults
precipitated by drugs, viral infections, and malgnancies (1/2 no etiology)
3-15% with severe cases die
Refer to dermatologist and internist
Begins with a nonspecific upper respiratory tract infection
Usually 1 to 14 day prodrome: fever, sore throat, chills, headache, cough, red eyes, and malaise may be present.
Vomiting and diarrhea occasionally
Mucocutaneous lesions develop abruptly (clusters of outbreaks last from 2-4 wks and lesions are nonpruritic)
Involvement of oral and/or mucous membranes may be severe enough that patients may not be able to eat or drink.
Characterized by skin vesciles, bullae, and maculopapular lesions concentrated on the hands and feet.
Erythematous patches on hands, arms, face, and neck.
bulls eye lesions
hemorrhagic crusting of the lips
bilateral conjunctivitis
Describe the Relfex Sensory Block
Lacrimal tear secretion in waking state is due to trigeminal sensory input from nasolacrimal passages and the eye.
When eyes open, there’s increased reflex sensory drive from exposed ocular surface.
Reduction in sensory drive from ocular surface favors occurrence of dry eye by: decreased reflex-induced lacrimal secretion and reducing blink rate and increasing evaporative loss.
Please give Causes of Ocular Sensory Loss
Infective : herpes simplex keratitis or herpes zpster ophthalmicus.
Corneal Surgery: limbal incision (extra-capsular cataract extraction), keratoplasty, refractive surgery (PRK, LASIK, RK)
Neurotrophic Keratitis: 5th nerve/Ganglion, Section/Injection/Compression
Topical Agents: Topical anesthesia reduces both tear secretion by about 60-75% and blink rate about 30%
Systemic Medications: beta blockers and atropine-like drugs
Other causes: chronic contact lens wear: reduction in corneal sensitivity of GP and EW CLs, Diabetes, Neurotrophic keratitis
Describe Reflex Motor Block
7th Cranial Nerve Damage: causes lacrimal hyposecretion, multiple neuromatosis, exposure to systemic drugs causing decreased lacrimal secretion (antihistamines, beta blockers, antispasmodics, diuretics, tricyclic antidepressants, SSRI’s, and psychotropic drugs
List Causes of Intrinsic Evaporative Causes
Meibomian Gland Dysfunction (posterior blepharitis): MG obstruction most common cause of dry eye. Associated with acne rosacea, seborrhoeic dermatitis, atopic dermatitis.
Diagnosis based on: presence of orifice plugging, thinkening or absence of expressed excreta.
Associated with deficient tear film lipid layer and increased tear evaporation.
Disorders of Lid Aperture and Lid/Globe Congruity or Dynamic: nocturnal lagophthalmos, seventh nerve paresis, symblepharon, entropion, ectropian, dellen.
Low blink rate.
List the Extrinsic Evaporative Causes
Ocular Surface Disorders: Vitamin A deficiency, topical drugs and preservatives (i.e. benzalkonium)
Contact Lens Wear: 35 million wearers, #1 reason for CL intolerance is discomfort and dryness.
Ocular Surface Disease (Dry Eye)
Allergic Conjunctivitis
List the Effects of the Environment of Dry Eye
Milieu Interieur: low blink rate, wide lid aperture (gaze position), Aging, Low Androgen pool, and systemic drugs (e.g. antihistamines, beta blockers, antispasmodics, diuretics, and some psychotropic drugs.
Milieu Exterieur
Low relative humidity, drafts, wind, or occupational environment: smoke, A/C, atmospheric irritants, airline flights, low tear production at night.
List the Patient Symptoms of Dry Eye
intermittent burning and tearing grittiness, foreign body sensation itching redness intermittent blurred vision, a "film" over the eyes photophobia mattering of the lids and lashes
List the clinical signs of Dry Eye
Reduction in the height of the inferior tear meniscus
cellular debris in the tear film
abnormal accumulation of mucus that tends to settle in the inferior cul-de-sac
conjunctival injection
dull appearance of the eye
Please discuss how to test tears through the biomicroscope
Tear meniscus: average height is .2mm. Helpful in diagnosing aqueous deficiency
Tear film debris and mucus strands: increased debris is seen in moderate to severe dry eye
Assess the lipid layer: smooth and thick, smooth and thin, or irregular (thick appears to exhibit bright colors while thin ones appear gray
Blepharitis: caused by bacterial (staph) infection or unknown factors associated with dry eye. Characteristics include scaly exudate around eyelash bases; matted, hard crusts around cilium, ulcers of the hair follicles; corneal staining, dilated blood vessels on the lid margin. Can also have the following: madarosis (thinning or loss of lashes), poliosis (white lashes), trichiasis (misdirected lashes), broken lashes, or tylosis (irregularity of the lid margin)
Meibomianitis: inflammation around the meibomian gland orifices, pouting of gland orifices, and solidification of meibomian secretions. Causes significant disruption of tear film stability and low TBUT seen.
Test of Tears: Please Describe Kinetics of lacrimation
Involved and not routinely used
Plastic - encased filter paper strips: eliminate variable tear evaporation
cycles of lacrimal secretion can be determined
Test of Tears: Describe the Phenol Red Thread Test
crimped end of a 70mm thread with phenol red dye is placed in the inferior conjunctival sac without anesthesia for 15 seconds. Patient looks straight ahead and blinks normally. Length of wetting indicated by color change from yellow to red due to pH of tears. Normal wetting 10-20mm (entire length of the red portion is measured from the tip). Less than 10mm correlates with symptoms of dryness
