Lid Disease - Mark Flashcards
Pediculosis/Phthiriasis Palpebrum (Lice): Signs, symptoms, and treatment
Pediculosis - body louse florid infestation
Phthririasis - crab louse usually seen in adults and associated with sexual contact (occasionally in children from close contact with parent e.g. a nursing mother)
Symptoms: discharge, red lid margins
Signs: SLEx - translucent lice (1-1.5mm),f ecal material dark red/brown granules, palpable pre-auricular node
Must treat underlying infestation (Egs, Rid, Kwell, Nix). Note: these preparations are all corneal toxic and should not be used near the eyes
Tx (to smother the lice): Vasoline, bland ungt to smother, physostigmine to kill, yellow mercuric oxide QD, remove with forceps and swabs, repeat in 2 weeks to kill hatchings because NITs are hard to kill
What is distichiasis?
Extra row of lashes typically grow from MG orifices.
Complications: trichiasis, corneal fb sensation, and tracking.
What is Concretion?
Calcified sebaceous material
Describe a Chalazion
Granulomatous, can occur secondary to hordeolum
compresses
Excision - for comsesis or if interferes with vision
Steroid injections - less common due to depigmentation that occurs on overlying skin. Can inject inner palpebral area but best to excise.
May induce astigmatism if large
Describe a hordeolum
Internal - warm compresses (because Meibomian glands involved), may require excision, peaks externally.
External- follicle at base of lash, pull lash out to drain (or lance of peak), may require excision.
Infectious in nature
Tx: Oral antibiotics
Leave scar tissue (granulomatous tissue) when resolve - chalazion. May cause astigmatism if press on the cornea.
May drain through skin or conjunctiva
Describe Angular Blepharitis including signs, symptoms, and treatment
Etiology: Moraxella or Staph. atopy
S/S: red, flaky, ulcerative canthal regions (lateral > medial) irritation, tenderness
Tx: Zn sulfate (Moxarella) or bacitracin (Staph) based on underlying etiology
Oral Antiobiotics in the Use of Managing Blepharitides - basic information
Refer to handout for information not included on this slide (e.g. dosage)
Two goals: inhibit bacterial proliferation and inhibit lipase and thus decrease free fatty acids
Patient improvement results due to a decrease in: direct toxicity of free fatty acids, substrate for bacteria to feed on, exotoxin production and thus decrease hypersensitivity
Tetracyline: old. Taken on empty stomach. Bound by calcium
Doxycycline: drug of choice for meibomitis. Taken with food and greater chance of GI distress. Reduced when taken with a meal or acid reducer
Caution! Tetracyclines retard bone and dentitia development. So never should be used in pregnant or nursing women or children under 12. Not recommended in patients with peptic ulcer disease.
Erythromycin - safe in children and pregnant or nursing women. Can cause GI distress
Topical Therapeutic Agents in the use of managing Blepharitides
Antibiotic Ointments: applied to the lashes with a cotton swab in a scrub-like action. Helpful in the managment of staph and mixed blepharitis also ulcerative forms.
Bacitracin and erythromycin - both used in labor and delivery to prevent neonatal infections.
Thick drop preparations like Besivance and Azasite. Azasite: azithromycin (same medication in a Z-pack) also has some antinflammatory action. Once a day dosage over one month reduces MGD. Metrogel for rosacea (off label use).
Note: initial presentation of corneal ulcer may require a prophylactic antiobiotic solution. Egs. Ocuflox, quixin, and polytrim are very cornea friendly.
Steroid Ointments/Solutions: utilized for inflammatory or hypersensitivity component. Solutions for corneal disease (combo treatment may be helpful), ointments on a swab for lid disease. Egs. Tobradex, blephamide, FML, Lotemax
Anti-inflammatory Treatments: Azasite daily x 1month, Restasis BID
Bland Ointment: useful in cases which demodex is identified as playing a rolue
Ointment smothers the mite. Can use tea tree oil to kill demodex as well - but burns the eyes.
Forceful Expression in the Use of Managing Blepharitides
Should be performed using topical anesthetic on a cotton swab
A second swab or your fingers is used on the outer lid to apply pressure
The patient should be educated regarding tenderness
Useful to reduce the bacterial load
Will exude - sebaceous material, cells, puss, and high bacterial load
Decreasing the nutrition for the bacteria and the number of bacteria
May be performed in office in approximately 6 week intervals
Sever cases: 3 procedures over time can produce significant improvement. Some reccomend treatment every 6 months.
New alternatives: Lipoflow - instrument has plates that warm the lids and compress the glands in pulsation to express. May provide relief for up to 6 months. Not covered by insurance but does have a code.
Another new alternative: Mastrada paddle - Titanium paddle used to press on conj and cause expression. Alternative to swabs (more comfortable), proparacaine not always necessary.
Hygiene in the use of managing blepharitides
Warm compresses up to 6 times a day, at least 5 minutes (you are trying to dissolve the waxes), and avoid old wives tales methods
Massage - to assist in opening the glands further
Lid scrubs - GENTLE. Pre-made pads or solutions or diluted baby shampoo, up to 3x day.
When you have blepharitis with meibomian involvement, utilize all 3 steps in sequence
Nutritional Management for Blephartides
Seborrhea - certain patients with seborrhea have increased lipid deposition. Work with dermatologist to reduce fatty food consumption
Antioxidants - may help counteract free fatty acid damage
Omega 3 supplements (fish oil) or flax seed oil
List the complications of Lid Margin Disease
Ulceration, perforation, corneal pannus and thinning, cicatrization, conjunctivalization/keratinization of the cornea, concretions (calcified sebaceous material), and CL intolerance
Hordeolum and corneal phlyctenules (areas of heaped inflamed tissue on cornea and conjunctiva. Resembles a pterygium)
Blepharitis Associations - Demodex
Mite that frequently inhabits the lashes
previously believed to directly lead to inflammation by over proliferation
More recent opinions and studies suggest it serves as a vector - through fecal matter it deposits stpah. aureus onto the lashes leading to collarette formation.
Blepharitis Associations - Keratoconjunctivitis sicca
K. Sicca or dry eye occurs concurrently with lid disease in a number of patients: Staph Blep 50% Seborrheic 15-33% MKC 33% MGD 25%
Blepharitis Associations - Acne Rosacea
A dermatologic condition associated with telangiectasia or the blood vessels of the face, rapid turnover of epithelial cells, pustules across the cheeks
As it progresses rhinophyma becomes apparent. It’s a condition in which the pores of the nose become swollen and the vessels become very dilated giving the nose an enlarged appearance with a very irregular surface that is very characteristic of rosacea. Frequently underdiagnosed and undertreated, particularly in AAs. Can mimic ocular pemphigoid. These patients are prone to staph infections. Strong association with lid margin disease (78% have some level of MGD), 65% have blepharitis, 51% of these will develop a secondary MKC.
Need a dermatological referal for oral antibiotic therapy/co-management
Ocular roascea may exist without other facial signs and may include blepharitis, inflammation, tearing, chalazia, hordeola, corneal vascularization, corneal and/or conjunctival scarring, corneal thinning, and perforation.
Metrogel applied to the lids may be helpful. Also doxycycline
