Lid Anatomy Flashcards
What nerve controls orbicularis muscle?
CN 7
What nerve controls levator palpebrae superioris?
CN III
Mueller is controlled by sympathetic
What glands are on tarsal plates?
Zeiss and approx 30
How many lashes on upper and lower lid?
150 lashes on upper and 100 on lower
What are the 2 sebaceous glands
zeiss and meibomian
What are the sweat glands?
moll
What is blepharospasm?
involuntary bilateral spasm orbicularis
(where eyes shut and can’t open them)
females develop in 60’s
has 3:1 ratio
What is Tx for blepharospasm?
botox every few weeks to decrease muscle response. This is because lids can close while driving
What is blepharoclonus?
where patients blink a lot.
secondary to inflammation
What is Tx for blepharoclonus?
treat inflammation
What is myokymia? (think of David when muslce twitches)
eye lid twitches (fasiculation of orbicularis)
refractory period is messed up
jumping eyelid
What is etiology of myokymia?
lack of sleep, stress, medication, excessive alcohol consumption
What is Tx for mykymia?
want to prolong refractory period, cool compress, topical anti-histamine, take quinine.
Quinine found in tonic water
What is Pseudograefe?
aberrant regeneration of CN III
follows CN III palsy
elevates eye and it goes in because of MR and LFP fibers
eye will elevate when it is adducted.
What is Entropion?
Lower lids turns inward
congenital
can be confused with epiblepharon
What is most common age related involutional disorder?
entropion
treatment for entropion?
surgery, epilation, glue
What is ectropion?
outward rolling of lid where cornea and conjunctiva exposed
What are the causes for ectropion?
cicatricial or mechanical
mechanical = burns, dermatoses, tumor, trauma
What is Tx for cicatricial/mechanical ectropion?
steroids , surgery
what causes paralytic ectropion?
bells palsy. Can be induced by botox
What is etiology of congenital ectropion?
associated with other lid problems
Tx: taping, lubrication, surgery
What is nocturnal lagophthalamos?
incomplete lid closure
can be diagnosed from NaFl from tonometry
patients have inferior morning SPK
Who has lagophthalmos more kids or adults?
adults because of decreased tear production
What are the 4 types of lagophthalmos?
nocturnal, orbital, mechanical, paralytic?
What is orbital lagophthalmos?
caused by graves ophthalmopathy
what is mechanical lagophthalmos?
occurs because of facial or ocular scarring?
What is paralytic lagopthalmos?
caused because of paralysis of CN 7 because of Bell’s Palsy
cannot close lids properly
vascular association
you must rule out stroke for Bell’s Palsy
the flat side is the diseased side
What is Tx for paralytic lagophthalmos?
lubrication, taping, tarsorrhaphy ( where you stitch the lid shut)
what is congenital ptosis?
autosomal dominant
in down gaze the lid is higher than normal
what is blepharophimosis?
autosomal dominant characterized by severe bilateral ptosis lateral ectropion telecanthus (wide bridge) normally the epicanthal folds in asian children cause a slight entropian but with this condition, the epicanthus is inverted and fold the opposite way.
what is horners?
ptosis, miosis, anhydrosis
congenital or aquired
What is congenital horners?
associated with heterochromia
what is acquired horners?
no heterochromia
what is pre-ganglionic horners?
associated with chest trauma and tumors
what is post-ganglionic horners?
will be benign and NOT have a loss of sweating
What are 3 tests for horners?
cocaine 10% solution, hydroxyamphetamine, PE (phenylephrine)
How do you use cocaine?
will dilate normal eye but not horners
how do you use hydroxyamphetamine?
will not dilate post ganlionic because not enough norepinephrine
how do you use phenylephrine?
elevates side affected by muellers
IMPORTANT TO RULE OUT MALIGNANCY
what is myotonic dystrophy?
characterized by muscle wasting
patient has mournful expression
will have difficulty relaxing muscle once contracted
Ptosis, Cataract, Retinal changes: retinopathy, near light reflex dissociation, low IOPs, similar to bells, but it is bilateral.
what is myastenia gravis?
loss of receptors giving rise to muscle fatigability and weakness
90% will present with ocular signs
what is the DX for myastenia gravis?
tensilon test
use edrophonium will improve ptosis
what is the Tx for myastenia gravis?
steroids, immunosuppresives, anticholinesterases, thymectomy
What is floppy eyelid syndrome?
obese middle age men get this where lids are easily everted and cornea drys
associated with sleep anea and keratoconus
What is Tx for floppy eyelid syndrome?
lid taping or surgery
What is Dermatochalasis?
bilateral conditions in elderly patients
redundancy of the skin
What is the Tx for dermatochalasis?
can send for blepharoplasty
affects visual fields
What is a lid coloboma?
deals with children and the embryonic tissue that didn’t close
can get a cleft lid
What is the Tx for lid coloboma?
surgical repair for 3 - 6 months of age
What is cryptophtalmia?
skin is over the eyelids (fusion)
no Tx
what is the Tx for ablephara and Micorblephron?
Ablepharon = absence of the eyelid
Microblepharon = shortening of the eyelid
Tx: surgery
What is a contusion?
ecchymosis = black eye
can cause a hemorrhage that can cause IOP rise that can damage sight
What are the 3 common types of thermal burns?
flame, flash and scalding
What happens if you get a chemical burn from acid?
it is self limited and you will get a very red eye
What if you get alkali in your eye?
can cause greater destruction due to capillary closure.
IF EYE TURNS WHITE = BAD!!!
What is the Tx for burns?
irrigation for 1 - 2 mins with neutral irrigation
5 - 10 minutes of non-neutral
then you place anti-biotic and cycloplege the pt
What is an adhesive lid trauma?
This is crazy glue in your eye.
What is the Tx for adhesive lid trauma?
mineral oil soaks and a pressure patch with forceps later
What is Molluscum contagiosum?
viral skin infection
Sx: yellow nodules with follicular conjuctivitis and SPK
What is the Tx of Molluscum contagiosum ?
excision by cautery
What is a xanthelasma?
plaque like lesions occurring in the middle-age pts
occurs in younger pts with hyperlipidemia
this is higher in females than males
What is the Tx for xanthelasma?
excision by cosmesis
What is seborrheic keratoses?
a papilloma that looks like a mole growth
What is actinic keratoses?
a pre-cancerous skin lesion
found in elderly fair skinned people with h/o skin exposure
will see it on tips of ears
What is treatment of actinic keratoses?
biopsy with cryo
What is a sudoriferous cyst?
form from gland of moll
typically asymptomatic but can lead to trichasis (inward turning of eye lashes)
What is the Tx for sudoriferous cyst?
excision because lancing will increase recurrences
What is a sebaceous cyst?
occurs from hair follicles or sebaceous glands
pts are asymptomatic
What is a Tx for a sebaceous cyst?
superficial - lance
subcuteneous - let it drain
What is verrucae vulgaris or plana?
HPV viral wart
most common benign tumor of lids
Vulgaris - crusted on a stalk
plana - flat pitted appearance
what is the Tx for verrucae vulgaris or plana?
chemical cautery
do not want to lance or drain because can lead to conjunctivitis
what is a basal cell carcinoma?
most common malignant tumor
slow growing and eats away
it requires excision with biopsy followed by radiation
what is the Tx for a basal cell carcinoma?
requires excision with biopsy followed by radiation
What is a squamous cell carcinoma?
5 to 10% malignancies
more aggresive
occurs in elderly people with fair skin
what is a sebaceous gland carcinoma?
VERY RARE
usually a meibomian gland
may be present as a chalazion
What is a melonoma?
RARE
What is Karposi’s sarcoma?
vacular tumor associated with AIDS
rapid growing
What is the Tx for Karposi’s sarcoma?
radiation
What is the episclera?
dense vascular connective tissue
provides nutrition cornea
What is the vasculature for the episclera?
superficial episcleral plexus with Tenon’s capsule
What is episcleritis?
benign and sudden onset
involves 3 layers!!
what 3 layers does episcleritis involve?
conjunctival vessels
deep episcleral plexus
superficial scleral plexus (tenon’s vessels)
there are no scleral or muculature involvement
What are the symptoms for episcleritis?
MILD pain in 1 or both eyes but NOT painful
acute onset of redness
What are the clinical signs of episcleritis?
vision normal
mild tenderness
nodule that can be moved slightly
70 to 75% NO associated systemic disease
Does episcleritis affect males or females more?
occurs in females 20 to 40 years old
How to differentiate episcleritis from scleritis?
scleritis pain is deep, severe, and occurs on ipsilateral side of head/face
how to differentiate episleritis from iritis?
cells and flare in anterior chamber
how to differentiate episleritis from conjunctivitis?
discharge
need to differentiate from contact lens over wear
what is the cause of episcleritis?
it is idiopathic
if not it is a connective tissue disease
What is the history for someone with episcleritis?
someone with a rash, venereal disease, arthritis, recent viral illness
What is the work up for episcleritis?
you would look for bluish hue externally
You would drop phenylephrine 2.5% in each eye and examine the vascular pattern
Most people have simple or nodular episcleritis?
simple! and can have sectorial or diffuse
What is simple episcleritis?
has greyish infiltrates
generalized and moderate swelling
resolves quickly
What is nodular episcleritis?
nodule of localized edema
takes longer to resolve than simple
has a moveable nodule
what is the Tx for episcleritis?
none
Mild: iced artificial tears, topical decongestants
Moderate to Severe: steroid drops
or oral NSAIDS
what is the follow up for scleritis?
if on steroids check IOP weekly
check in 2 to 3 weeks if on artificial tears
what is chronic (stubborn) episcleritis?
RARE
NO necrosis
bluish color
never develops to scleritis
tell me about the anatomy of the sclera?
rich nerve supply
avascular
low metabolism
What is scleritis?
inflammatory disease that affects the sclera
What is anterior scleritis?
patient has redness in the eye
severe eye pain
what is posterior scleritis?
patient will NOT present redness and MAY NOT present eye pain
Tell me about scleritis?
uncommon, chronic
can lead to blindness and eye loss
tissue destruction
50% is due to systemic cause
Who does scleritis mostly affect?
females more than males from 40 to 60 years old
What happens in scleritis?
inflammation of deep episcleral plexus
its dark red with a bluish tint
affects choroidal vasculature
what are the symptoms for scleritis?
severe ocular pain, may wake up from sleep, recurrent episodes common, decreased VA leading to blindness
what are the signs of scleritis?
inflammation of scleral, episcleral, and conjunctival vessels,
sclera will have bluish hue
how to tell difference from episcleritis?
episleritis does NOT have the sclera involved. Episleritis is more acute, patients are younger with episcleritis and with milder symptoms
what are conditions that cause scleritis?
collagen disease metabolic disease granulmatous disease infectious disease ocular condition
What systemic disease is scleritis associated with?
connective tissue diseases and others
what is anterior scleritis?
most people have this one
non-necrotizing and vision is maintained
is diffuse and nodular
what is the Tx for anterior scleritis?
take oral NSAIDS
oral prednisone
immunosuppressive therapy
what is anterior scleritis necrotizing?
most severe form, vision threating complications, pain is extreme, collagen vasculature problems occur
THIS IS AN OPHTHALMIC EMERGENCY!!
Can secondary complications occur with anterior necrotizing with inflamation scleritis?
yes like staphyloma and ectasia
What is a staphyloma?
thinning of the sclera, bulging of the uvea,
what is ectasia? (POSSIBLE TEST QUESTION)
bulging of the sclera without uveal lining
what is anterior necrotizing without inflammation (scleromalacia perforans)?
occurs in patients with long standing rheumatoid arthritis, NO PAIN, older females
What is the Tx for Necrotizing scleritis?
oral prednisone, immunosuppressive agents, eye surgery may need to be performed
What is posterior scleritis?
can occur with anterior scleritis, restricted EOMS, proptosis, pain, tenderness, decreased vision (permanent), usually unrelated to systemic disease
What is worse anterior or posterior scleritis? (Isaac made up this question)
probably posterior
what are the ocular signs for posterior scleritis?
disc swelling, macular edema, choroidal folds or detachment
what is the Tx for posterior scleritis?
asprin, NSAIDS, steroids, immunosuppressive therapy
What is Tx for scleritis?
if infections then use anti-biotic
if foreign body the remove it
glasses or eye shield should be worn at all times
TOPICAL STEROIDS NOT EFFECTIVE
sub-conjunctival steroids are contraindicated
what is the work up for scleritis?
examine sclera everywhere
do slit lamp with the green light
do a physical exam
what do you use to diagnose scleritis?
10% phenylephrine test
will blanch conjunctival vessels and superficial episcleral vessels
WILL NOT blanch deep scleral plexus
what are pigment cuffs?
very common
short anterior ciliary arteries
associated with axonfeld’s loop
What is a blue sclera?
tissue color due to scleral thinning and exposed uvea
NORMAL for infants
what is osteogenesis imperfecta?
inherited condition
permanent blue sclera
affects skeleton, joints, teeth, skin, and eyes
what are the 3 signs for osteogenesis imperfecta?
blue sclera, deafness, and bone fractures
What is melanosis oculi?
congenital bilateral hyperpigmentation of conjunctiva, episclera, sclera, uvea, and choroid
seen in darker colored patients (LIKE GANESH but that’s messed up but hey you are going to remember it now lol)
what is the nevus of ota?
pigmentation of the periorbita skin
will distribute along ophthalmic and maxillary division of CN V
What is senile hyaline plaque?
older patients over 50 will get this
it is localized non-inflammatory thinning
reassure patient it is not cancerous
What is icterus/jaundice?
yellow pigmentation of the sclera or skin because of high concentrations of bilirubin in the blood
NEEDS A MEDICAL EXAM
What is scleral perforations?
can be due to high velocity projectiles like BB gun, fireworks, metal hammerings varying pain sight may not be detectable will have decreased IOP NO MRI for patient
What is the Tx for scleral perforations?
immediate hospitalization Fox shield (eye shield) given to patient
What is a blue sclera?
tissue color due to scleral thinning and exposed uvea
NORMAL for infants
what is osteogenesis imperfecta?
inherited condition
permanent blue sclera
affects skeleton, joints, teeth, skin, and eyes
what are the 3 signs for osteogenesis imperfecta?
blue sclera, deafness, and bone fractures
What is melanosis oculi?
congenital bilateral hyperpigmentation of conjunctiva, episclera, sclera, uvea, and choroid
seen in darker colored patients (LIKE GANESH but that’s messed up but hey you are going to remember it now lol)
what is the nevus of ota?
pigmentation of the periorbita skin
will distribute along ophthalmic and maxillary division of CN V
What is senile hyaline plaque?
older patients over 50 will get this
it is localized non-inflammatory thinning
reassure patient it is not cancerous
What is icterus/jaundice?
yellow pigmentation of the sclera or skin because of high concentrations of bilirubin in the blood
NEEDS A MEDICAL EXAM
What is scleral perforations?
can be due to high velocity projectiles like BB gun, fireworks, metal hammerings varying pain sight may not be detectable will have decreased IOP NO MRI for patient
What is the Tx for scleral perforations?
immediate hospitalization Fox shield (eye shield) given to patient