Lid and Lacrimal Disorders Flashcards
most common diagnosis in a patient with red eye AND discharge?
conjunctivitis
what term is used to describe the fine blood vessels that cause the conjunctiva to look pink/red?
-injection
Types of Conjunctivitis
- infectious
- -bacterial
- -viral
- noninfectious
- -allergic
- -non-allergic
What type of conjuntivitis is most infectious?
- viral most common in adults and children; adenovirus is most common
- bacterial is more common in children than adults
Conjunctivitis in neonates
-bacterial (chlamydial) and viral infections are major causes of septic neonatal conjunctivitis.
What are the most common types of bacteria causing bacterial conjunctivitis?
- staph aureus (adults)
- strep pneumo (child)
- h flu (child)
- moraxella catarrhalis (child)
Bacterial conjunctivitis
- contagious?
- spread via?
- risk factors
- critically educate about what?
- highly contagious
- spread by direct contact with the pt and his/her secretions or with contaminated objects/surfaces
Risk factors:
- poor hygiene practice
- poor contact hygiene
- contaminated cosmetics
- crowded living/social conditions (daycare, elementary, military)
-HAND WASHING is most critical education.
Bacterial Conjunctivitis
- History
- Presentation
- diagnostic testing
- treatment
Hx- redness and discharge in one or both eyes, matted shut eye in the AM, a lot of discharge throughout the day that is yellow, white, or green
Presents: conjunctival inflamm in one or both eyes, a lot of discharge at lid margins and in the corners of the eye, lid edema.
Diagnostic test:
-gram stain and culture, only done if things are not healing or getting better after a couple of weeks.
Tx: -usually clears by itself 10days w/o tx. -proper hand hygiene -1-3 days away from work/school -cool compress -dont wear contacts -artificial tears -meds: Gentamicin (1-2drops 4x/day 1wk) and Erythromcin (4x/day for 1 wk) CI in kids: Ciprofloxacin
Viral Conjunctivitis
- how is this spread?
- contagious?
- sx
- presentation
- tx
- -spread by direct contact with the pt and his/her secretions or with contaminated objects/surfaces
- yes, highly
Symptoms:
- burning, sandy, gritty feeling(BUT NOT PAIN, just irritation) , more of a watery discharge
- usually begins as unilateral, though 2nd eye usually becomes involved within 24-48hrs
Presentation:
- conjunctival hypermia
- watery discharge
- palpebral conjunctiva may have bumpy or follicular appearance
- may have enlarged and tender perauricular lymph node**
Tx:
- usually resolves on own in 7-10days
- cool compress
- artificial tears
- supportive measures
- keep kids out of school until resolution.
Allergic Conjunctivitis
- Cause
- presentation
- hx
- sx
- tx
cause:
- airborn allergen»>contact eye»>mast cell degranulation»> release of histamine
presentation:
- conjunctival hypermia
- watery discharge
- palpebral conjunctiva may have bumpy or follicular appearance
- may have morning crusting
- **- ALWAYS BILATERAL
- **-ITCHING
- **- no lymphadenopathy
Hx: seasonal allergies, specific allergies, asthma, eczema
Sx:
- intesnse itching or burning
- puffy eyelids
- stringy eye discharge
Tx:
- avoid irritant
- lubricate drops
- cool compress
- OTC antihistamines (may also cause drying of the eyes)
Differentiating Features in Acute Conjunctivitis
Discharge/cell type
-bacterial: purulent, polymorphonuclear leukocytes
- viral: clear, mononuclear cells
- allergic: clear, mucoid, ropy, eosinophil
Eyelid Edema:
- bacterial: moderate
- viral: minimal
- allergic: moderate-severe
RED FLAGS of Conjuncitivits
- reduction of visual acuity
- severe deep eye pain, not just irrriation
- cilliary flush (pattern of injection at the ring of the limbus)
- photophobia
- severe foreign body sensation preventing pt from keeping eye open
- corneal opacity
- fixed pupil
- severe HA w/ nausea
Hyperacute Bacterial Conjunctivitis
- caused by?
- transmitted via?
- characterized by?
- tx
- Neisseria gonorrhoeae
- transmitted genitalia»hands»eyes
- characterized by profuse purulent discharge, fever, redness, irritation, tenderness to palpation, periauricular adenopathy
- tx: requires immediate ophthalmologic referral and hospitalization for systemic and topical abx therapy to prevent vision loss.
To prescribe or not to prescribe abx?
How do we handle this dilema?
if its not bacterial do not put them on abx.
you may feel pressured to prescribe abx even when there is nothing to suggest a bacterial process b/c:
-daycare centers and schools require students with conjunctivitis to receive 24hrs of abx.
- viral= approach like you would with cold
- allergic=approach like you would with allergic rhinitis
- bacterial- Abx.
Keratoconjunctivitis Sicca (Dry Eye Syndrome)
- Factors
- types of KS
- Pathophysiology
- Common eye complaints (history)
- Diagnosis
- Treatment
Factors
- age
- female gender
- hormonal changes
- systemic diseases (DM, Parkinson)
- Contact lens wearers
- systemic medications
- ocular medication
Types:
- aqueous tear deficient
- evaporative
pathophys: decreased tear production via:
- lacrimal gland dysfunction/distruction
- increase evaporative loss
- Eye c/o:
- dryness
- red eyes
- general irritation
- gritty sensation
- burning sensation
- excessive tearing
- light sensitivity
- blurred vision
Dx:
-Schirmer Test: tests if tear production is normal by applying strip of filter paper on lower eyelid, if less than 5.5mm of wetting occurs after 5mins on two successive occassions you have positive test. Evaporative types
-Tear Breakup Test (TBUT)
flouroscien applied, pt stares until the first dry spot develops, if less than 10sec the test is positive. Tear deficiency.
Tx:
- depends on etiology
(evaporative) - meibomian gland dysfunction: warm compress and doxycycline
- seborrheic blepharitis: eyelid margin scrub and bacitracin ointment
- stay hydrated, use humidifier, avoid smoke
- True KS (aqueous tear deficient): artificial tears(preservative free) occlusion of nasolacrimal punctum, topical cyclosporine (restasis)
What is dacrocystitis?
- cause
- presentation
infection of the lacrimal sac, often associated with a blocked duct.
cause:
- pressure applied over sac causes reflux of mucoid material through puncta
- obstruction of the nasolacrimal duct by a tight inferior meatus
- S. aureus, H flu, beta hemolytic streptococci, pneumococci
presentation: pain, redness, edema around lacrimal sac
Tx of Dacrocystitis
warm compress
oral abx
if pt sick and febrile may suggest an abcess and send to ophtho.
careful follow up… if persists sent to ophtho
Dacrostenosis
- what is this?
- most common in?
- tx
-nasolacrimal duct obstruction, most commonly at the valve of hasner (inferior portion of the duct near inferior turbinate)
- seen most common in infants and newborns:
- persistent tearing
- ocular discharge
- rarely injection of the conjunctiva
Tx:
- manual compression (4-5x/day)
- probing by ophtho. between 6-9mo, may be done in office or OR requiring a stent
Hordeolum
- aka
- what is it?
- what bacteria causes?
- presentation
- diagnosis
- tx
- stye
- localized infection of eyelid margin involving either hair follicles of eyelashes or meibomian glands
- usually caused by staph aureus
presentation:
- painful, erythematous, localized mass, edema
- external hordeolum»may see material exuding from eyelash line.
- internal hordeolum»may be opening where you see material exude on the conjunctival surface of the eye
Diagnosis:
- fever and sick feeling are not consistent with this dx
- if process involves the lid and periorbital tissues you MUST treat it as periorbital cellulitis not as hordeolum
- preauricular lymph nodes will NOT be enlarged.
Tx:
- self limiting meaning it should resolve self on own.
- warm compress
- abx indicated only when inflammation has spread beyond the immediate area
- may be incised with fine tipped blade.
- if not responding to tx within 2-3 days consult ophtho
What kinds of education do you provide the pt with a stye/hordeolum?
- DONT squeeze the stye, this may spread the infection
- follow up with ophtho if not fully improved within 1-2weeks
Chalazion
- aka
- symptoms
- tx
-meibomian gland or lipogranuloma
sx:
-painless nodule
tx: often disappears without treatment within a few months and virtually all will reabsorb within 2yrs.
- hot compress
- inject corticosteroids or surgically remove in extreme cases
Blepharitis
- what is this?
- associated with what systemic conditions?
- pathophys
- risk factors
- Clinical presentation (hx and PE)
- Tx
- inflamm involving the structure of lid margin and involves:
- erythema
- scaling
- crusting
associated:
- rosecea
- seborrheic dermatitis
pathophys:
- bacterial colonization of eyelid, direct microbial invation of tissue.
RI:
-people who have tendene toward oily skin, dandruff, and dry eyes.
Presentation:
Hx:
-burning, watering, crusting, scaling, erythematous eyelids
-chronic course with intermittent exacerbations
PE:
-eyelids show erythema and crusting of the lashed and lid margins, may be some injection in conjunctiva
Tx:
- eyelid margin hygiene
- warm compress
- mechanical washing
- abx ointment during exacerbation (erythromycin)
Ectropion
- what is this?
- cause
- sx
- tx
- eversion of the eyelid margin away from the globe
- aging, facial palsy, scar tissue from burns
- dry, painful eyes, excessive tearing (epiphoria), long term conjunctivits
Tx:
-artificial tears, artificial tears lubricant at night, surgery
Entropian
- what is this?
- cause
- Risk factors
- Sx
- Tx
- inversion of eyelid toward the globe
- muscle weakness, scars, previous surgeries, skin diseases, infections
Risk factors:
- aging
- chemical burns
Sx:
- decreased vision (if conrea is damaged) (eyelashes poking the eye)
- excessive tearing
- eye pain irritation and redness
Tx:
- taping lower lid
- botox
- surgery
Pterygium
- what is this?
- sx
- Risk factors
- Tx
-noncancerous growth that starts on the conjunctiva, can move onto the conrea***
Sx:
asymptomatic
Risk:
-exposure to sun, dust, sandy wind blow areas
Tx:
- artificial tears
- surgery
Pinguecula
- how does this appear on the eye?
- causes
- sx
- tx
-yellowish growth of the scleral conjunctive and is usually adjacent to the limbus, WILL NOT encroach onto the cornea.** can be on both sides but usually on medial side.
causes
-sun exposure, irritation
Sx;
-asymptomatic
Tx:
-can be surgically removed fro cosmetic reasons
Capillary Hemangioma
- when is this diagnosed
- most common presentation
- diagnostic testing
- visual complications
- tx
diagnosed: 1/3 at birth, 90% by 6mo
Presentation: superficial tumor that develops a strawberry appearance, enlargement of hemangioma w/ valsalva
testing: CT/MRI show diffusely infiltrating non-encapsulated mass
visual complications:
-amblyopia or astigmatism
*major complications: superinfection, ulceration
Tx-
- steroids (systemic and intralesional, IFN, beta-blocker= now first line therapy)
- radiation therapy
- surgical resection
Lacrimal Gland Tumors
- what is this?
- types
-enlargemnt of lacrimal fossa with displacement of globe and no inflamm signs
- Pleomorphic adenoma
- Adenoid Cystic Carcinoma
Pleomorphic adenoma
- malignant or benign?
- age at onset
- sx
- tx
- benign mixed tumor, slow progression
- 20-50yrs
- painless proptosis (exopthalmos)/ medial globe displacement
- excision biopsy (total)
Adenoid Cystic Carcinoma
- malignant or benign?
- diagnostic testing
- sx
- tx
- most common malignant lacrimal tumor
- CT; boney destruction in inflitrate
Sx:
-pain and numbness
Tx: -requires aggressive surgical tx, 50% mortality
Malignant Eyelid Tumors
-types
basal cell carcinoma
squamous cell carcinoma
Meibomian gland carcinoma
Melanoma
Karposi Sarcoma
Merkel Cell Carcinoma
Basal Cell Carcinoma
- frequent locations
- benign or malignant?
- affects what age group?
- tx
- lower lid, medial canthus, upper lid, lateral canthus
- most common human malignancy, does not metastasize
- affects the elderly
- excision
Squamous Cell Carcinoma
- compare to Basal cell carcinoma
- cause
- common location
- tx
- less common but more aggressive than BCC
- arise in solar-damaged skinn and premalignant lesions
- commonly found on the bottom eyelid
- excision and possibly radiation
Meibomian glad carcinoma
- aka
- what is it?
- where does it commonly occur?
- treatment
- sebaceous cell carcinoma
- lethal eyelid malignancy which can masquerade as a benign condition
- upper eyelid
- excision and possible radiation
Melanoma
- Parts of the eye it affects
- major risk factor
- treatment
- choroid, ciliary body, conjunctiva, eyelid
- excessive exposure to sunlight
- excision and possibly radiation and chemo
Karposi Sarcoma
- Who does this mainly occur in?
- treatment depends on?
- treatment types
- AIDS patients
- age, status of general health, current medications, immune status
- small kaposi’s sarcomas can be removed at biopsy. Chemo, radiation are indicated if overall health and immune status allow
Merkel Cell Caracinoma
- agressive or not?
- Most common locationi
- treatments
- rare but agressive malignancy that metastasize early to regional lymph nodes- fast growing
- upper eyelid
- excision and radiation and chemo if metastasis
All conjunctivitis cases are self limited processes, true of false?
True
Conjunctivitis is a diagnosis of exclusion, true or false?
TRUE!
The diagnosis should only be made w/ red eye and discharge IF vision is normal and there is no evidence of kerititis (inflamm cornea), iritis, or glaucoma.
Is the eye being “matted shut” in the AM helpful in differentiating the cause of conjunctivitis?
- NO!
