Lid and Lacrimal Appartus Disorders Flashcards
What are the two functions of the lacrimal system?
Secretory: Lacrimal gland, Conjunctival goblet cells, accessory subconjunctival glands and meibomian glands. Excretory: Removes tears via contraction of the eyelids
What is the most common diagnosis in a patient with a red eye and discharge?
conjunctivitis
Define injection
term used to describe the fine blood vessels that cause the conjunctiva to look pink or red
What are the acute conjunctivitis categories?
Infectious (Bacterial and Viral) and Noninfectious (Allergic and Non Allergic)
What are the epidemiological points of conjunctivitis?
Most infectious conjunctivitis is viral in both adults and children. Bacterial conjunctivitis more common in children than adults
What are the four most common causes of bacterial conjunctivitis?
Staph aureus (common in adults). Strep pneumo. Haemophilus influenzae. Moraxella catarrhalis
What is one of the most critical components of bacterial conjunctivitis treatment?
educate about hand washing (and not sharing linens, etc.)
What is the typical history of bacterial conjunctivitis?
Redness and discharge in one eye (can be bilateral). Affected eye often “matted shut” in the morning (this can also occur with viral and allergic etiologies)***Purulent discharge is thick and globular, and can be several colors…yellow, white, or green
What is the typical presentation of bacterial conjunctivitis?
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 (which contrasts with patients with viral or allergic conjunctivitis)
What is treatment for bacterial conjunctivitis?
usually not 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.
What commonly causes viral conjunctivitis?
adenovirus
What is the typical history of viral conjunctivitis?
Usually unilateral, MAY BE part of a systemic viral illness, burning, sandy, or gritty feeling (but NOT really pain!), watery discharge, Second eye usually becomes involved within 24-48 hours
What is typical presentation of viral conjunctivitis?
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
What is the cause of allergic conjunctivitis?
airborne allergens-> contact the eye->local mast cell degranulation-> release of chemical mediators (including histamine)
What are the presentation differences between allergic conjunctivitis and viral conjunctivitis?
allergic is bilateral from the start and there will be itching. Patient often has a history of seasonal allergies, specific allergies, asthma, and/or eczema
No preauricular lymphadenopathy
What usually causes noninfectious non allergic conjunctivitis?
Dry eye. Chemical splash. Following expelled foreign body
What are red flags of eye diseases?
Reduction of visual acuity. Severe deep eye pain. Ciliary flush. Photophobia. Severe foreign body sensation. Corneal opacity. Fixed pupil. Severe headache with nausea
What are therapeutic treatments for bacterial conjunctivitis?
Antibiotic ointment or drops (Erythromycin ointment, Sulfacetamide ointment, or Gentamyacin or Polytrim drops). Second line agents Cipro drops: (Contraindicated in children) and Azithromycin drops
Describe hyperacute bacterial conjunctivitis
Caused by Neisseria gonorrhoeae. Concurrent urethritis typically present. Characterized by profuse purulent discharge.
What is treatment for hyperacute bacterial conjunctivitis?
immediate ophthalmologic referral and patients require hospitalization for systemic and topical antibiotic therapy to prevent vision loss
What are treatment options for viral conjunctivitis?
OTC topical antihistamine/decongestant. Warm or cool compresses. Antiviral agents play NO role.
Education about hand washing
What are treatment options for 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)
What are treatment options for noninfectious nonallergic conjunctivitis?
Generally a spontaneous resolution of symptoms
Topical lubricants may help provide symptomatic relief: Drops (Hypotears, Refresh) or Ointments (Lacrilube, Refresh PM)
What is pathophysiology of decreased tear production in KS (dry eye)?
Lacrimal gland destruction or dysfunction. Reduced volume results in hyperosmolar tear film, this causes inflammation of the ocular surface cells
What is the pathophysiology of increased evaporative loss in KS (dry eye)?
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
What is the history seen with KS (dry eye)?
Dryness. Red eyes. General irritation. Gritty sensation. Burning sensation. FB sensation. Excessive tearing. Light sensitivity. Blurred vision
What do you see during exam/diagnosis of KS (dry eye)?
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
What is the treatment for KS (dry eye)?
Blepharitis—eyelid hygiene. Ocular allergies—avoidance of allergen or meds. True KS-Artificial tears, environmental strategies, Topical cyclosporine (Restasis)
What is dacrocystitis?
infection of the lacrimal sac and is often associated with a blocked duct
What are causes of dacrocystitis?
Injury to the nose . Eye infection. Tumor. Nasal inflammation. Age-related changes.Blocked tear duct. Obstruction of the nasolacrimal duct by a tight inferior meatus has been noted in many infants
What are the most common organisms isolated from the lacrimal sacs of children with dacrocystitis?
S. aureus, Haemophilus influenzae, beta-hemolytic streptococci, and pneumococci
What is treatment of dacrocystitis?
Warm compresses. Oral antibiotics (Bactrim, Clindamyacin). Careful follow up… if persistent send to ophthalmologist
What is dacrostenosis?
Nasolacrimal duct obstruction-most commonly at the membrane of Hasner. Seen primarily in newborns and infants (Persistent tearing and ocular discharge)
What is treatment of dacrostenosis?
massage and probing
What is a 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)
What is the presentation of a hordeolum (stye)?
painful, erythematous, localized mass which may produce edema of the entire lid. With an external hordeolum, there’s purulent material exuding from the eyelash line. With an internal hordeolum, there may be an opening where material exudes on the conjunctival surface of the eyelid
What is the pathophysiology of a hordeolum (stye)?
Infectious Staph Aureus implicated most of the time (90-95%). Arises from blockage. Both internal and external can arise as a secondary complication of blepharitis
When must a stye be treated as a periorbital cellulitis?
If the process involves the lid and periorbital tissues
What is the treatment of hordeolum (stye)?
Warm compresses. Antibiotics indicated only when inflammation has spread beyond the immediate area of the hordeolum-Topical ABX (Bacitracin ointment). Systemic ABX considered if disease spread. Consider removing eyelash to promote draining with external hordeola
What does education involve with hordeolum (stye)?
Do NOT to squeeze a stye. If patient not responding to conservative measures within 2-3 days, consult ophthalmologist for I & D. Patients should seek f/u care with ophthalmologist if not fully improved in 1-2 weeks
What is a chalazion?
Also known as a meibomian gland lipogranuloma. It’s a subacute and painless nodule. disappear without treatment within a few months and virtually all will reabsorb within two years. Can be injected with a corticosteroid or surgically removed in extreme cases
What is 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
What is pathophysiology of blepharitis?
Bacterial colonization of eyelids and direct microbial invasion of tissues. Generally seen in the older population, mean age is 50
What is the history presentation of blepharitis?
Burning, watering, crusting of lashes and medial canthus, scaling, erythematous eyelids
What is the physical exam presentation of blepharitis?
Eyelids show erythema and crusting of the lashes and lid margins. There may be some injection in the conjunctiva
What is treatment of blepharitis?
commitment to a program of eyelid margin hygiene!!
warm compresses, mechanical washing of eyelid margin. baby shampoo with warm water and gentle washing of the eyelid margins. Antibiotic ointment applied to eyelid margin during exacerbations. Educate that this is a chronic condition characterized by intermittent exacerbations
What is an ectropion?
Ectropion is eversion of the eyelid margin away from the globe. Causes include aging or loss of tone, scarring, infection, palsy of the facial nerves
What is treatment of ectropion?
Eyedrops and ointments manage symptoms and protect the cornea until ectropion surgery can be done
What is an entropion?
inversion of the eyelid toward the globe
Multiple causes:Muscle weakness, scars or previous surgeries, skin diseases and infections
What is treatment of entropion?
lubricating agents, surgery
What is a pterygium?
corneal proliferative disease associated with UV exposure that arises from the limbus and proliferates. asymptomatic
What is treatment of pterygium?
be irradiated or surgically removed
What is a pinguecula?
yellowish growth of the scleral conjunctiva and is usually adjacent to the limbus. Caused by sun exposure and irritation. can be surgically removed.
What is a capillary hemangioma?
superficial tumor that develops “strawberry” appearance. Visual complications – amblyopia or astigmatism. Major complications – superinfection, ulceration
What is capillary hemangioma treatment?
Medical therapy – steroids or interferons.
Radiation therapy. Surgical resection for unresponsive or well-encapsulated lesions
What is treatment for conjunctival hemangioma?
May not need treatment. Eyelid may cause problems with vision (Amblyopia or Strabismus). May go away on their own. Half go away by age 5. Almost all disappear by age 9. Laser used to remove in some cases
Describe lacrimal gland tumors?
Enlargement of lacrimal fossa with displacement of globe and no inflammatory signs. 50% epithelial, 50% lymphoproliferative. CT scan – lymphoid show smooth enlargement of gland, epithelial are irregular
What is a pleomorphic adenoma?
Benign mixed lacrimal tumor. Occurs 20 to 50 years. Painless proptosis with inferior/medial globe displacement. Slow progression. Treatment is excisional biopsy
What is an adenoid cystic carcinoma?
Most common malignant lacrimal tumor. Pain and numbness. CT with bony destruction and infiltration. 50% mortality, requires aggressive surgical Tx
Describe basal cell carcinoma
Most common human malignancy.Usually affects the elderly. Slow-growing, locally invasive. Does not metastasize. Treatment consists of excision
Describe squamous cell carcinoma
Less common but more aggressive than BCC.
arise in solar-damaged skin and premalignant lesions (actinic keratoses). Most commonly occur on the bottom eyelid.
Describe meibomian gland carcinoma (aka sebaceous cell carcinoma).
Lethal eyelid malignancy which can masquerade as a benign condition. Very rare, aggressive tumor. Commonly occur on the upper eyelid
Describe melanoma
Very aggressive, can spread rapidly. Melanoma of the eye can affect: Choroid, Ciliary body, Conjunctiva, Eyelid
What are risk factors of melanoma?
Excessive exposure to sunlight is an major risk factor. Fair-skinned and blue-eyed people are most often affected
Describe Karposi sarcoma
Malignant, vascular tumor that occurs mainly in AIDS patients
When should a diagnosis of conjunctivitis be made?
in a patient with a red eye and discharge if the vision is normal and there is no evidence of something more serious such as keratitis, iritis, or glaucoma.
