Lid and Lacrimal Apparatus Disorders Flashcards
Conjunctivitis
MOST COMMON diagnosis in a patient with a red eye AND discharge
Conjunctivitis Epidemiology Points
Most infectious conjunctivitis is viral in both adults and children
Bacterial conjunctivitis more common in children than adults
Bacterial Conjunctivitis
Staph aureus (common in adults)
Strep pneumo
Haemophilus influenzae
Moraxella catarrhalis
Bacterial Conjunctivitis
Redness and discharge in one eye (although it can be bilateral)
Affected eye often “matted shut” in the morning (this can also occur with viral and allergic etiologies)
Bacterial Conjunctivitis Typical Presentation
Conjunctival inflammation
Purulent discharge at the lid margins and in the corners of the eye
***More purulent discharge appears within minutes of wiping the lids
Bacterial Conjunctivitis Treatment
not usually needed unless a virulent organism is suspected or in the case of:
Neonates
Bacterial, chlamydial, and viral infections are major causes of septic neonatal conjunctivitis, with Chlamydia being the most common infectious agent.
Viral Conjunctivitis
Typically caused by adenovirus
Viral Conjunctivitis
Usually unilateral
MAY BE part of a systemic viral illness
Patient often has a burning, sandy, or gritty feeling (but NOT really pain!)
Typically more of a watery discharge during the day with perhaps some scant mucus
Viral Conjunctivitis Typical Presentation:
Only mucoid discharge if one pulls down the lower lid or looks very closely in the corner of the eye
Usually profuse tearing rather than true discharge
Palpebral conjunctiva may have a follicular or “bumpy” appearance
There may be an enlarged and tender preauricular lymph node
Viral Conjunctivitis Course
Generally self limited, parallels that of the common cold
Allergic Conjunctivitis
Cause: airborne allergens
Typically presents the same way as viral conjunctivitis but is **bilateral from the start
Noninfectious Non Allergic Conjunctivitis
Usually from transient mechanical or chemical insult:
Dry eye
Chemical splash
Following expelled foreign body (may have redness or discharge for 12-24 hours)
RED FLAGS
Reduction of visual acuity
Severe deep eye pain (NOT just an irritation)
Ciliary flush: A pattern of injection in which the redness is MOST pronounced in a ring at the limbus (the limbus is the transition zone between the cornea and the sclera)
Photophobia
Severe foreign body sensation that prevents the patient from keeping the eye open
Corneal opacity
Fixed pupil
Severe headache with nausea
Therapeutics Bacterial Conjunctivitis
Antibiotic ointment or drops
Examples: Erythromycin ointment, Sulfacetamide ointment
or Gentamyacin or Polytrim drops
Second line agents
Cipro drops: (Contraindicated in children)
Azithromycin drops
N. Gonorrhoeae Conjunctivitis
by Neisseria gonorrhoeae
Transmission usually from genitalia hands eyes
Concurrent urethritis typically present
Characterized by profuse purulent discharge
Requires immediate ophthalmologic referral and patients require hospitalization for systemic and topical antibiotic therapy to prevent vision loss
Therapeutics Viral Conjunctivitis:
Aimed at symptomatic relief
Can use OTC topical antihistamine/decongestant
Warm or cool compresses may provide additional symptomatic relief
Antiviral agents play NO role
Education: Tell patients that irritation and discharge may get worse for three to five days before getting better, that symptoms can persist for 2-3 weeks.
Therapeutics Allergic Conjunctivitis
OTC antihistamine/decongestant drops (Visine A)
OTC oral antihistamines (Benadryl, Tavist)
Mast cell stabilizers such as Olopatadine (Patanol) and Azelastine (Optivar)
NSAID ophthalmic drop such as Ketoralac (Acular)
Therapeutics Noninfectious Nonallergic Conjunctivitis
Generally a spontaneous resolution of symptoms
Topical lubricants may help provide symptomatic relief
Drops can be used every hour (Hypotears, Refresh)
Ointments provide longer lasting relief but blur vision (many patients use at bedtime) (Lacrilube, Refresh PM)
Keratoconjunctivitis sicca
Age
Female gender
Hormonal changes (decreased androgens)
Systemic diseases (DM, Parkinson)
Contact lens wearers
Systemic medications
Ocular medications—especially those w/ preservatives
Nutritional deficiencies (vitamin A deficiency)
Decreased corneal sensation
Ophthalmic surgery (corneal refractive surgery)
Low humidity environments
KS–Pathophsiology
Decreased tear production
Lacrimal gland destruction or dysfunction
Reduced volume results in hyperosmolar tear film,
this causes inflammation of the ocular surface cells
Increased evaporative loss
Excessive water loss leads to tear film instability and tear hyperosmolality
Commonly caused by meibomian gland dysfunction
Structural abnormalities of eyelid position or decreased blink function
KS—Exam/Diagnosis
Conjunctival injection bilaterally
Excessive tearing
Blepharitis
Malposition of the eyelids
Reduced blink rate
Visual impairment when eyes tested separately w/ improvement w/ increased blink rate or lubricant drops
Often need ophthalmologist referral for slit lamp exam
KS–Treatment
Depends on etiology
Blepharitis—eyelid hygiene
Ocular allergies—avoidance of allergen or meds
True KS
Artificial tears—recommend preservative free forms
Environmental strategies
Topical cyclosporine (Restasis)
Dacrocystitis
is an infection of the lacrimal sac and is often associated with a blocked duct
Dacrocystitis - Causes
Injury to the nose
Eye infection
Tumor
Nasal inflammation
Age-related changes affecting the eyes and eyelids in older adults
Blocked tear duct
Obstruction of the nasolacrimal duct by a tight inferior meatus has been noted in many infants
The most common organisms isolated from the lacrimal sacs of children with dacryocystitis include S. aureus, Haemophilus influenzae, beta-hemolytic streptococci, and pneumococci
Dacrocystitis Treatment
Warm compresses
Oral antibiotics (Bactrim, Clindamyacin)
Careful follow up… if persistent send to ophthalmologist
If extremely fluctuant, especially if the patient is sick and febrile, this suggests an abscess and the patient should be sent to an ophthalmologist
Dacrostenosis
Nasolacrimal duct obstruction Can occur anywhere in the lacrimal drainage system Most commonly at the membrane of Hasner Seen primarily in newborns and infants Persistent tearing Ocular discharge Rarely injection of the conjuctiva
Dacrostenosis Treatment
Massage
Probing
Hordeolum (Stye)
A localized infection OR inflammation of the eyelid margin involving either:
Hair follicles of the eyelashes (External Hordeolum) OR… Meibomian glands (Internal Hordeolum)
Hordeolum (Stye) How does it present?
Usually a painful, erythematous, localized mass which may produce edema of the entire lid
With an external hordeolum, you may see purulent material exuding from the eyelash line
With an internal hordeolum, there may be an opening where you see material exude on the conjunctival surface of the eyelid
Hordeolum (Stye)
Infectious Staph Aureus implicated the great majority of the time (90-95%)
Most of the time will spontaneously resolve
May progress to chronic granulation with formation of a painless mass known as a chalazion
Hordeolum (Stye) Keys with diagnosis:
Constitutional signs and symptoms (having fever, feeling sick) are NOT consistent with a hordeolum diagnosis!
***If the process involves the lid and periorbital tissues, it MUST be treated as a periorbital cellulitis, NOT as a hordeolum
Preauricular lymph nodes will NOT be enlarged in patients with a simple hordeolum (this would suggest potential spread of infection, commonly to conjunctiva
Chalazion
Also known as a meibomian gland lipogranuloma
Subacute and painless nodule
Will often disappear without treatment within a few months and virtually all will reabsorb within two years
They can be injected with a corticosteroid or surgically removed in extreme cases
Blepharitis
Inflammation involving the structures of the lid margin and involves:
Erythema
Scaling
Crusting
Disease often associated with systemic conditions such as rosacea and seborrheic dermatitis
Blepharitis History:
Burning, watering, crusting of lashes and medial canthus, scaling, erythematous eyelids
Most of the time condition has a chronic course with intermittent exacerbations
Blepharitis Physical Exam:
Eyelids show erythema and crusting of the lashes and lid margins
There may be some injection in the conjunctiva
Blepharitis Treatment:
Systematic and long-term commitment to a program of eyelid margin hygiene!!
Application of heat (warm compresses)
This promotes evacuation and cleansing of secretory passages
Mechanical washing of eyelid margin
Baby shampoo with warm water and gentle washing of the eyelid margins (NOT the skin of the lids)
Antibiotic ointment applied to eyelid margin (such as erythromycin) during exacerbations and in some stubborn cases can be used nightly for prophylaxis
Ectropion
Ectropion is eversion of the eyelid margin away from the globe
Entropion
Entropion is inversion of the eyelid toward the globe
Multiple causes:
Pterygium
This is a corneal proliferative disease associated with UV exposure that arises from the limbus and proliferates
This condition CAN move onto the cornea
Vast majority are asymptomatic and therefore is of zero consequence unless it involves the visual axis
Pinguecula
Often confused with Pterygium
Appears as a yellowish growth of the scleral conjunctiva and is usually adjacent to the limbus
As it is confined to the conjunctiva, this will NOT encroach onto the cornea
Caused by sun exposure and irritation
Capillary Hemangioma
1/3 diagnosed at birth
90% visible by 6 months
Most common presentation is as superficial tumor that develops “strawberry” appearance
Capillary Hemangioma - Treatment
Medical therapy – steroids (systemic, intralesional)
or interferon
Radiation therapy
Surgical resection for unresponsive or well-encapsulated lesions
Malignant Eyelid Tumors
Basal cell carcinoma Squamous cell carcinoma Meibomian gland carcinoma Melanoma Karposi sarcoma Merkel cell carcinoma
Basal Cell Carcinoma – Important Facts
Most common human malignancy Usually affects the elderly Slow-growing, locally invasive Does not metastasize 90% occur on the head and neck Of these, 10% occur on the eyelid Accounts for 90% of eyelid malignancies Treatment consists of excision
Squamous Cell Carcinoma
Less common but more aggressive than BCC
The majority of squamous cell carcinomas arise in solar-damaged skin and premalignant lesions (actinic keratoses)
Meibomian gland carcinoma
Also referred to as Sebaceous cell carcinoma
Lethal eyelid malignancy which can masquerade as a benign condition
Error or delay in diagnosis is common, and this tumor carries a significant mortality rate with metastasis
Melanoma
Very aggressive type of cancer that can spread rapidly
Melanoma of the eye can affect several parts of the eye, including the:
Choroid
Ciliary body
Conjunctiva
Eyelid
Karposi sarcoma
Malignant, vascular tumor that occurs mainly in AIDS patients
Usually associated with advanced disease
Merkel Cell Carcinoma
Rare but aggressive malignancy that metastasizes early to regional lymph nodes
Fast-growing, well demarcated nodule
Intact over-lying skin
