Lid Anatomy Pg 1 - 10 Ravi Flashcards
What is the outermost layer of the lids?
Dermal Layer
What is the innermost layer of the lids?
conjunctiva
the orbicularis muscle is under CN___ control
VII
the Levator is under CN___ control
III
Mueller’s is innervated by (Parasymp/sympathetics)?
sympathetics
we have apx 150-200 lashes on our __ lid, and 75-100 on our ___lid.
upper/ lower
Which glands are lipid/sebaceous in characteristics?
Zeiss/ meibomian
Which glands are sweat/sudor in characteristics?
Moll
What is cicatrization?
scarring
The lid has a ___ like closure for lubrication / protection
zipper
how many zeiss glands are there on each tarsal plate?
30
which layer of the lid has thin skin with loose sub-cutaneous (Q) tissue and prominent vascularization
Dermal layer
what is the involuntary bilateral spasm of orbicularis?
blepharospasm
which sex is blepharospasm more common in? what ratio, over what age?
females 3:1 in their 60’s (cumshot fear)
what tx can you get to reduce the muscle response seen in blepharospasm?
botox
Blepharoclonus is a condition where the patient ____ excessively leading to muscle spasm, it is believedd to be secondary to _____.
blinks/ ocular inflammation
____ is an eyelid twitch that is (unilateral/bilateral), and self limited
myokymia, unilateral
myokymia’s twitch can occur due to what 4 things? SEFM
Stress, Excess Alcohol, Fatigue, Medication
To treat myokymia you want to prolong the refractory period so muscles won’t quiver, using ____ compresses and topical ____, or even ___ which is found in tonic water
cold, antihistamine, quinine
What is the abberant regeneration of CNIII?
Pseudograefe
In a pseudograefe, following traumatic CNIII palsy, the MR fibers regrow and travel with the ___ fibers so when they elevate their eye, their eye also looks ___.
MR, IN
Marcus Gunn is congeintal in __% of patients.
5%
marcus gunn improves with ____ and is treated with ___
mouth opening/ surgery
angioedema with urticaria is secondary to ____ release (allergic response)
histamine
urticaria means the patient has ____
hives
what are some treatments for angioedema with urticaria?
oral antihistamines, cool compresses, possibly oral steroids
what are the 3 forms of anthrax?
cutaneous, respiratory, GI
anthrax is also known as ___ disease
wool sorters
who is at risk for anthrax?
people who handle wool/ veterinarians/ farmers / 3rd world countries
Which type of anthrax is seen on the eye?
cutaneous
when does cutaneous anthrax onset?
1-2 days, up to 8 weeks, most commonly within 1st 2 weeks of exposure
cutaneous anthrax may present as ____ with some differences
mild preseptal cellulitis
is the demarcation line seen with anthrax or preseptal cellulitis?
preseptal
is pain and tenderness and pus(suppuration) seen with anthrax or preseptal?
preseptal cellulitis
is itching seen seen in anthrax or preseptal cellulitis?
anthrax
anthrax can infect the body via infected wool through a ___ in the skin or in africa it can include an ____ vector
break, insect
anthrax starts with a painless _____ that looks like a spider bite
red macular rash
as anthrax progresses, it can develop vesicles and bullae which eventually ____ and ____
rupture/ ulcerate
eventually, the ruptured vesicles/ bullae from anthrax form a black necrotic ulceration called an _____
ESCHAR
an Eschar is a brown to black ulcer that is __-__cm in size, surrounded by severe edema looking pearly white and this typically sloughs in __-__ weeks.
1-5/ 2-4
Damage from the necrotic tissues in anthrax leads to _____
scarring, possibly gangrene
The classic black eschar and a history of exposure to ___ or ____ is characteristic of diagnosing anthrax.
animals/ soil
a ___ was given to all active duty military to prevent infection from anthrax.
vaccine
how many sub-Q injections are given in prevention of anthrax?
3, 2 weeks apart
boosters in prevention of anthrax are given at which month marks?
6,12,18 then annually
what works as a good protective barrier against anthrax?
gloves, long sleeves etc.
what is the drug of choice in treating anthrax?
ciprofloxacin (flouroquinolone)
what other drugs can be given to an anthrax patient to treat them?
doxycyclin, amoxicillin, penicillin G( if life threatening)
what % of lesions will sponatenously heal with treatment?
80-90%
10-20% of antrhax cases when left untreated can be ____
fatal
Anthrax can be fatal because if bacteria gets into your systemic circulation, it leads to septicemia, ____, _____, and death
shock, Renal failure
syphilis is on the rise because of its resistance to ____
penicillin
what is the primary lid lesion in syphilis called?
Chancre
some of the signs of syphilis include ____ chancre, ____ or loss of lashes, scleritis, and interstitial ____
conjunctival/ madarosis/ keratitis
what is the treatment for syphalis?
penicillin
what is a rare parasitic infection characterized as a severe allergic response leading to severe edema due to surge of lymphatic fluid in sub-Q tissue and facial tissue.
Elephantiasis
Vaccinia is also known as ___pox, it is secondary to ____ vaccine.
cow, small pox
vaccinia is contracted via ___ contact, and it is usually self limited meaning it will heal up and leave a scar.
direct
cowpox mutant can lead to widespread ____, causing skin to slough off
dermatitis
Leukoderma/ poliosis are signs characteristic of ____
vitiligo
which syndrome is associated with vitiligo?
vogt koyanagi
vitiligo is whitening with ____ esposure
sun
poliosis refers to white ___
lashes
Vitiligo can result in recurrent ____ or post inflammatory ____
uveitis, RD
which disease is known as being allergic to the sun?
xeroderma pigmentosa
Xeroderma P. is characterized by big patches known as ____ as well as scarring
macules
there is an increased risk of ____ due to sunlight reaction with xeroderma P, and patients are usually monitored from a ___ age.
cancers, young
what is an infectious condition with swelling, and well-defined expanding red line?
erysipelas
erysipelas looks like ____ but hte patient is actually systemically ___, with fever, pus around eye, very fast progression. (You can see it get worse during their visit with you
angioedema, ill
Erysipelas B-Hemolytic strep pyogenes is secondary to _____
skin trauma
B-hemolytic strep pyogenes is sometimes referred to as ___ because it eats through the tissue and expands rapidly
flesh eating
What is the tx for erysipelas?
systemic antibiotics/ hospitalization
With erysipelas doctors mark the edges of the red lesions on a patients face and see how much the disease is slowed or reversed, and decide how much ___ to give.
antibiotics
Erythema multiforme/stevens - johnson syndrome
DTH Type IV (allergic rxn) due to med, iatrogenic, 1st time is fine, but then pt allergic. red patches on hands, spreads rapidly. can cause skin to slough and kill pt. Flu symptoms 1st. bulls eye rash. starts at hands or feet and spreads. STOP the med. Targets mucous membranes. pseudomembrane formation, will bleed if pulled off. crusted lids.
Complications = fibrosis, severe scarring. dry eye(sicca) corneal perforation, iritis, symblepharon - lids fuse to conj. distichiasis - dry lid sticks to conj tx scleral lens. Epiphora.
Tx: electrolytes, topical steroids, bandage CL/ Scleral lenses, Tarsorraphy - suture lid shut, surgery
Ocular Cictrical pemphigoid
Late onset. autoimmune mucous membrane disorder. like STVNJohnsons but in older women. 1-30,000 mostly F in 60’s. Bullae(rupture) fibrosis. conj shrinks, symblepharon, scarring. Lesions start in mouth. .25-.33 suffer vision loss.
complications - bacterial keratitis. ankyloblepharon no canthus lids fused. metaplastic lashes - growing in odd spots. scarring. obliteration of fornices/ severe symblepharon.
TX: bandage, CL, tears, epilation - remove lashes with lazers. punctal occlude, tarsorraphy (Lid suture). steroids, IV cyclophosphamide, restasis.
impetigo
don’t scratch insect bites. bed bugs. or trauma. macular rash on lids and face, crusted over blister like lesions.spreads to face, lots of swelling, needs oral antibiotics. If it is localized on the face, then you only need topical antibiotics. staph or strep species. Rash like, yellow crusting. caused by picking scabs.
HZV - Shingles Varicella zoster
causes chicken pox/ shingles. herpes zoster opthalmicus occurs in the elderly. if it happens under age 50, pt is prolly immunocompromised (MS) or pt has HIV(young). Harbored in nerve roots, spreads along dermatome that root innervates.spreads along frontal nerve to forehead, upper lid, superior conj. If opthalmic of CNV then it is HZ opthalmicus. if Nasociliary nerve involved the rash will move down to tip of nerve = hutchinson’s sign. . Respects midline. very painful. One side of head and nose is involved. both sides are swollen. can cause keratitis and pannus = imune mediated blood vessels encroaching on cornea. Living neurologic virus, lives in nerves, causes deep nerve pain. extremely painful. patient can get trigmeinal neuralgia - results in high suicide rate. ptosis, madarosis, retraction.
TX: acyclovir Valtrex for 7-10 days. analgesics, prednisone, antidepressants, TCA/ gabopinton, drying lotions like calamine, steroid creame, and antihistamines.
Herpes simplex virus (HSV)
feber blister, encephalopathy. 20% of ocular HSV lid cases. vesicular looking rash will clear up eventually. there is a hereditary component. disease of children kissed by adult with virus. Vesicles, rupture, crust over, and then heal. 10-14 day duration of virus. Concerned with swellingand conjunctiva. tiny little cold sores. vesicles right on lid. Lid edema, follicular response = clear blister like lesion on the conj.
TX: aggressive tx to stop spreading. prophylaxis, ACV creme. GCV gel, antibiotics prevent 2 degree bacterial infection. calamine lotion.
tools like lipiflow and mastrota paddle can be used to ____ the lids.
express
Lid margin disease occurs in apx __% of the population
40
What are the types of Blepharitis?
staphyloccal, seborrheic, mixed staph/seb, meibomian keratoconjunctivitis (MKC), and MGD.
with bleph, a corneal stain can lead to _____
SPK
with bleph, curvilinear corneal lesions occur at __,___,___, and __ oclock
10, 2, 4, 8
with bleph you can have lid margin stains where the entire lid margin will stain _____
lissamine green.
you will definately see ___glands with bleph. there can also be ____, where the tears produce FFA’s and sterols similar to soap, bubbly tears.
capped, frothing
with bleph you will see poliosis, madarosis, and ____ which is a thick eyelid, the eyelid margins get thick and scalloped for chronic inflammation.
Pachyblepharon
Blepharitis symptoms
itching, burning, dryness, foreign body sensation, mattered lids, redness, watery eyes, puffiness, scratchiness, lash loss, bumps on lid hordeolum.
Assessment of bleph. you will see a lot of ___ and find that the ___ is low due to stasis
debris, TBUT.
stasis reduces ___ in the tear film and increases evaporation
oils
Bulbar conjunctival stain
appears long before corneal stain in patients with ocular surface disease. Best seen with yellow(wratten)filter. NaFl is more cost effective. filter removes blue and you see green. Lissamine green stains dead devitalized cells. Lissamine green staining will emerge over the regions of NaFl
Rose Bengal staining
burns like hell, very few use it. indicates dry eye. stains dead cells. not used at IEI.
Cornea Stain
we don’t examine entire cornea. we lookat where the bad lid is in apposition with the cornea, mostly the inferior cornea because this is where eyes closeand cornea and lid are in closest apposition.
We use flouresce for SPK. associated with bleph via staph exotoxin. worse in morning, staph stays concentrated in one place.
Rose Bengal - emerges over regions of NaFl. can find conjunctival rose staining from associated K. Sicca.(dry eye)
digital expression in normal patients will show
clear oily liquid, vs an MGD or MKC pt, they have thicker opaque gelatinous pus like matter come out. if you can’t express the contents when you mash lids, you have stenosis at the orifice. turbid, inspissated
Forceful expressions will show toothpaste-like string like expressions with No____
discharge, due to stenosis
palepbral conjunctival signs -
we want the classic healthy corkscrew look. injection, concretions = calcified material. yellow, corkscrew appearance of glands. deep plugging looks like they blend all together. papillae, follicles, telangiectasia = tortuous vessels (Deep Plugging)
MGD or meibomian seborrhea
over production of sebaceous materials. rapid turnover of epi cells. overproduction of sebum = lid margin stains well. clogged glands have frothing. precursor for MKC? 43% of population gets it. Responsible for up to 30% of unexplained CL intolerance. associated with roscea and generalized seborrhea.
TX: lid hygene = warm compresses. restasis, Azasite.
Grading MGD
0- all glands present
1 - 1-2 partially obstructed glands, still clear fluid
2 - 3 or more partially obstructed glands. expresses opaque fluid
4 - 3 or more blocked, remainder partially obstructed. expels toothpaste with pressure
