Lid Disorders Flashcards
What is blepharospasm
Bilateral involuntary orbicularis oculi spasms
How to treat blepharospasm?
Botox every few weeks if debilitating
What is blepharoclonus?
Excessive blinking/spasming secondary to an ocular inflammation
What is myokymia?
Fasiculations of the orbiuclaris oculi (eye twitch) that is usually self limiting.
What can cause myokymia?
Stress, fatigue, medication or alcohol.
How to treat myokymia?
Coll compresses and topical antihistamines; want to increase refractory period of muscles so there is no quiver
What is pseudograefe?
Abnormaly regeneration of CNIII affecting the MR that attaches it to the levator palpebrae superioris; causes eye to elevate when abducting
What is angioedema with urticaria?
Allergies –> Swelling and hives. Caused by histamine release and causing severe swelling and red lesions.
How to treat angioedema with urticaria?
Antihistamines, cool compresses and possibly steroids
What are the three forms of Anthrax and which is ocular?
Cutaneous (ocular) , respiratory and intestional
Anthrax incidence is a large concern for which populations?
3rd world nations, people working with wool/cattle/farms
About how long does it take for symptoms to present in Anthrax?
Most often in about 2 weeks, but can be 1-2 days or up to 8 weeks.
When anthrax presents, it may look like what condition at first? (Signs and symptoms)
Preseptal cellulitis; no tenderness, no demarcation, no pain (usually), some itching, slight injection and redness
What is the disease process of anthrax?
Painless red rashes forming into papules becoming vesciular and maybe bullous. Eventually these ulcerate or hemorrhage, forming a black necrotic ulcer (eschar)
What’s the prognosis for anthrax? Treated and untreated?
80-90% spontaneously heal, remainder may have fatal results. Death is rare with proper systemic treatment
How to treat anthrax?
Vaccine; penicilin via IV, ciprofloxacin, maybe surgical repair if eschars severe
How does syphilis present?
Primary and secondary lid lesions with conjunctival involvement, madrosis, scleritis, interestitial keratitis
How to treat syphillis?
Penicilin
What’s elephantiasis?
Rarare parasitic infection causing lymphatic fluid to build up in subcutaneous tissue with severe allergic reaction and edema
What’s vaccinia (cow pox)?
Secondary to small pox vaccine, tends to self limit and leave a scar however. Caused by contamination from vaccination site
What’s madrosis?
Losing eyelashes
What’s poliosis?
White lashes
What’s xeroderma pigmentosum?
An autosomal recessive disorder where sunlight causes progressive pigmentation changes leading to scarring and possibly increased cancer rates (allergic to sun)
What’s erysipleas?
“Flesh eating disease” Strep. pyogenes secondary to a skin trauma.
How to treat erysipleas?
Oral antibiotics
What’s Erythema multiforme/Steven-Johnson syndrome?
Type IV hypersensitivity (DTH) usually to new medication. See a severe rash with perivascular inflammation (Bulls Eye Appearance)
What are the ocular signs to Steven Johnson syndrome?
Mucous discharge, pseudomembrane formation, papillary response, bullae formation, swollen crusty lids. Can even go into scarring, dry eye, iritis, corneal perforation, symblepharon, distchiasis, epiphoria, cictrical ectropion, and be FATAL
How to treat Steven Johnson Syndrome?
Electrolytes, systemic and topical steroids in high doses, may need a bandage CL
What’s cicatricial mean?
Scarring
How is Erythema multiforme similar to ocular cicatricial pemphigoid?
Both present with similar clinical appearances. Flu symptoms, severe rash with inflammation and a bulls eye appearance
How is Ocular Cicatricial pemphigoid different thant Erythema multiforme?
Age of onset is older in ocular cicatrical pemphigoid. Also in Steven Johnson syndrome more males are affected than females
What is Ocular Cicatricial Pemphigoid?
Late onset auto immune disorder affecting mucous membranes
How do you treat ocular cicatrical pemphigoid?
A supportive style, use AT, bandage lens, epilation, tarsorraphy, punctal plugs to best use whatever tears are left; use steroids and cyclophosphamide for immunosuppression
What’s impetigo?
A common staph infection seen in kids. A bug bite that you scratched causing a rash with crusted bullae
What’s Shingles?
Chicken pox virus, commonly affecting frontal nerve (upper lid and forehead and superior conj)
What’s Hutchinson Sign and what disorder is it associated with?
Tip of nose is red; associated with shingles and indicates nasociliary branch involvement (CNV)
Signs/Symptoms of Shingles?
Headache, fever, malaise, chills, PAIN, edema, scarring that can cause persistent pain, ptosis, ectropion, madrosis, entropion or lid retraction
How do you treat Shingles?
Usually self-limiting. But can give analgeics, prednisone, antidepressants for pain and oral antivirals (Acyclovir)
What’s Herpes Simplx?
A primary lesion acquired generally when an infected adults makes contact with a child. Leads to vesicles, that rupture, crust and heal.
How do you treat herpes simplex?
Preventative treatment to prevent corneal involvement, ACV cream, GCV gel, antibiotics to prevent secondary inflammations, drying agents to prevent oozing from ruptured crusts
What are the 5 kinds of blepharitis?
Staphylococcal Seborrheic Mixed Meibomiam gland dysfunction Meibomiam keratoconjunctivitis
What are the signs of all kinds of blepharitis?
Corneal/conjunctival staining, corneal lesions at 2, 4, 8 and 10 o clock, capped glands, reduced TBUT, greasy/crusty eyelashes, poliosis and madrosis and maybe pachyblepharon
What are the symptoms of all kinds of blepharitis?
Itching, burning (in mornings), dry eye (FBS), mattered lids, redness, puffiness, scratchiness, lash loss and maybe a hordeloum
How to assess blepharitis?
TBUT (reduced generally), bulbar conj staining (best seen with LIssamine green or maybe fluorscein), corneal stains (SPK), digital expression that may be turbid and associated with pus, palpebral conj is injected, has calcifued concretions, glands are yellow and plugged, some papillae, tortuous vessels (telangiectasia)
What’s Staph Blepharitis?
Caused by staph organism, see inflammation, collarettes, madrosis, seen in younger patients
What’s Seborrheic blepharitis?
95% associated with generalized seborrhea (excessive sebum being discharged); get chronic mild inflammation, greasy crusts, papillary response
What’s Meibomiam Gland Dysfunction?
Meibomiam glands overproduce sebaceous material and have a very rapid turnover of epithelial cells
What are some complications with MGD?
Causes a third of CL intolerance, associated with rosacea and generalized seborrhea, a precursor to MKC
What’s Meibomiam Keratoconjunctivitis?
Meibomiam gland dysnfunction that involves the cornea. A delayed type hypersensitivity and tend to also see scarring and vascularization. See thick discharge.
How is MKC different from MGD?
See keratitis, and corneal lesions in the 2, 4, 8 and 10 o clock positions where lid is closest to the eye.
How to treat MKC?
Variable, but tends to involve steroids due to the DTH reaction.
How are the grands of MGD classified? (0 to 4)
0 - All glands open
1 - 1-2 glands partially obstructed with clear fluid on expression
2 - 3+ partially obstructed with an obaque fluid on expression
3 - 1-2 BLOCKED glands with many partially blocked
4 - 3+ blocked glands with everything partially blocked
Blepharitis assocations: What’s demodex?
A mite that inhabits the lashes, believed through fecal matter is depositing staph aureus into the lashes
What’s the common name for keractoconjunctivitis sicca.
Dry eye
What is the most common concurrent lid disease you see with keratoconjunctivitis sicca?
Staph blepharitis (50%), then MKC, MGD and seborrheic bleph
What’s Acne Rosacea?
Seen in older patients, flushed skin and nose tissue deformation (rhinophyma) that is generally swelling of the nose. A dermatologic condition with dilation of capillaries of face and rapid turnover of epithelial cells.
What condition can rosacae mimic?
Ocular pemphigoid
In which population is rosacea underdiagnosed in?
African-American
Signs and symptoms for rosacea?
Facial signs may be blepharitis, inflammation, tearing, chalazia, hordeola, corneal vascularzation, corneal/conjuctival scarring, corneal thinning and perforation
How do you treat roseaca?
Refer to dermatoligst for oral antibiotics
What’s a new relation seen in rosacea?
Small intestinal bacterial overgrowth (SIBO)
What’s Seborrhea?
Generalized dysfunction of sebaceous glands, overproducing and higher turnover that can be localized or diffuse.
What are signs of seborrhea?
Dermatitis, DANDRUFF, prone to eczema and may develop MKC in a third of cases.
How to treat seborrhea?
Refer to dermatologist and co-manage
What are some complications to lid margine diseases?
Ulceration/Perforation
Corneal pannus and thinning
Cicatrization
Conjunctivalizatoin/keratinization of the cornea
Concreations (calcified sebacious material)
CL intolerance
What are five management styles for Blepharitides?
Nutritional Hygeine Forceful Expression Topical Therapeutic agents Oral therapeutic agents
Describe Nutritional Management in treating blepharitis
Reducing fatty food consumption in seborrhea cases, more anti-oxidants and Omega 3 supplements. Attempting to manage cellular turnover.
Describe hygeine management in treating blepharitis
Warm compresses to dissolve waxes, massaging to open glands, gentle lid scrubbing (don’t overdo)
Describe forceful expression in treating blepharitis
Useful to reduce bacterial load in staph cases to decrease nutrition ofr bacteria and number.
Describe topical therapeutic agents used to treat blepharitis
Useful in managing staph or mixed blepharitis cases and ulcerative forms. Steroids meant to reduce inflammation/hypersensitivity, possibly prophylactic antibiotics with corneal ulcers. Thick drops generally
Describe oral antibiotic agents in treating blepharitis
Two goals, inhibit bacterial growth and inhibit lipase to decrease fatty acids. PS, Tetracycline is the prototypical compound here.
What is the drug of choice for treating MGD; and what is the major contraidincation?
Doxycycline, BUT can cause bone and dentita retardation and should NEVER be used in pregnant or nursing or kids under 12
What is a safer drug to use in children and pregnant women for the treatment of blepharitis?
Erythromycin. But can cause GI distress
What’s Angular Blepharitis?
Blephatiritis that is caused by Moraxella or Staph atopy. See flaky canthal regions, worse laterally than medially; treat with Sn sulfate or bacitracin
What’s a Hordeloum?
A red PAINFUL nodule that can be internal or external eyelids; Infectious by nature and leaves a a scar
What’s a Chalazion?
Granulomatous (large bulging) tissue that can be secondary to hordeolum, can induce astigmatism and is painless. (Can cause compression) must be excised
What’s Distichiasis?
An extra row of eyelashes growing out of the meibomiam gland openings
What’s Pediculosis/Phthiriasis Palpebrum common name?
Lice
What’s Pediculosis?
Body louse florid infestation
What’s Phthiriasis?
Crab louse seen with adults and generaly the STD form, sometimes with kids via a nursing mom
Signs and symptoms of lice?
Discharge, red itchy margins
Signs - SLE x, see translucent lice and fecal matter in lashes
How to treat lice?
Treat the underlying infestation, but these preparations are TOXIC to the cornea. So for treating it near the eye, use vasoline to bland and smother the infestation, or remove with forceps.
What’s Entropion?
When the lower lid turns in
What are the four kinds of entropion?
Congenital
Involutional
Cicatrical
Spastic
Describe congenital entropia
Rare, confused with epiblepharon which is an extran fold of skin. This happens with improper aponeurosis insertion into the retractor
Describe involutional entropion
Most common and is an age related loss of horizontal lid tone and weakness of lid retractors
Describe cicatrical entropion
It’s secondary to conjunctival scarring
Describe spastic entropion
Severe corneal disease irritating lids, may be assocaited with blepharospasm. Progression is trichiasis leading to corneal scarring and pannus
How to treat entropion?
Surgery, epilation (removing hair) or glue.
What’s ectropion?
Eyelid rolling outward to expose cornea and conjunctiva
What are four kinds of ectropion?
Involutional
Cicatrical/mechanical
Paralytic
Congenital
What’s Involutional ectropion?
Age related, lids getting lax
What’s cicatrical ectropion?
Scarring, burns, deramtoses, tumors or trauma causing lid damage. Need steroids or surgery to fix
What’s paralytic ectropion?
Possibly bell’s palsy, a paralysis of the orbicularis, secondary to lagophthalmos and can manifest epiphoria. Treat with botox
What’s congenital ectropion?
Usually associated with other lid problems, need lid taping, lubrication or surgery
What’s lagophthalmos?
Incomplete eyelid closure
What kinds of lagophthalmos are there?
Nocturnal
Orbital
Mechanical
Paralytic
What’s nocturnal lagophthalmos
Eyelids don’t close during sleep, see dry eye, SPK in the inferior lid and more common in adults than children. Idiopathic.
What’s orbital lagophthalmos?
See proptosis. Can be assocaited with Graves
What’s mechanical lagophthalmos?
Lagophthalmos due to scarring
What’s paralytic lagophthalmos?
Can be assocaited with bell’s palsy (unilateral CNVII paralysis), tends to be viral and self-limiting inflammation. Cannot close orbicularis oculi. Must rule out a stroke, treatment is supportive as tends to resolve within 3 months
What are five kinds of ptosis?
Congenital - AD, improperly developed LPS
Blepharophimosis - AD, bilateral ptosis, telecanthus, epichantus inversus, lateral ectropion, hypolastic superior orbital rim and bridge
Horner’s - Associated with sympathetic damage
Congenital - Can see heterochromia as well in the eye
Acquired Horners - has no heterochromia, lost some sympathetic innervation
Describe the three parts of the sympathetic innervation that can be damaged in Horner’s syndrome
Central
Preganglionic - Related to chest trauma/tumors or metastasizing tumors from lung/breast
Post-ganglionic - Most often benign and have no loss of sweating
Describe the Diagnoses/Tests used to check for Horner’s
Cocaine Test - Dilates normal eye, not Horner’s eye. Tests for oculosympathetic paresis
Hydroxyamphetamine - Doesn’t dilate post-ganglionic, not enough NE released.
Phenylephrine - Elevates affected side due to hypersensitivity in muller’s
What is Myotonic Dystrophy?
AD disorder, characterized by muscle wasting. Present with a mournful expression, ptosis, cataract, retinopathy, near-life reflex dissociation and a low IOP.
What is myasthenia gravis?
Autoimmune disease by a loss of AcH receptors leading to muscle weakness and fatigue
Signs of Myasthenia Gravis?
Ptosis, diplopia, nystagmus and fatigue as day progresses; In females 2:1 than men, tend to be 20-50 for onset.
What do you do to test for Myasthenia Gravis?
Tensilon Test - Inject edrophonium which is an anticholinesterase, if there is improvement then it is gravis.
How to treat Myasthenia Gravis?
Steroids, immunosupprives, anticholinesterases and thymectomy if associated thymoma present
What’s Floppy eyelid syndrome?
Seen in middle aged obese men, loose skin who have easy to evert lids, dries out cornea and palpebral conj, associated with sleep apnea and keratoconus
How to treat floppy eyelid syndrome?
Lid taping or surgery if severe
What’s dermatochalasis?
Common bilateral condition in elderly with redundancy of skin, orbital fat through septum and indistinct creases of the lid
What’s symblepharon?
Complete or partial fusion of palpebral conj to the bulbar conj
What’s Ankyloblepharon?
Adhesion between upper and lower eyelids, generally at corner of eyes
What’s the epichanthus?
Extra vertical fold over the nasal canthus
What’s lid coloboma?
A little notch in the lid, caused by incomplete closure of embryonic tissue. May be associated with dermoids, strabismus or corneal opacities, and depending on size of notch it can cause corneal exposure
How to treat lid coloboma?
Surgical repair at 3-6 months old, and supporive treatment to reduce exposure problems
What’s cryptophthalmia?
Fusion of one eye as it doesn’t develop, basically no eye
What’s a common name for ecchymosis?
Black eye.
With ecchymosis, what do you want to check and why?
IOP - hemorrhage from injury may cause a sight threatening IOP spike that needs surgery
What are the most common kinds of lid burns?
Thermal (flame, flash, scalding)
What can result from a lid burn?
Edema can increase IOP and be sight threatening
Describe how to treat a chemical burn
Immediate and profuse irrigation. If acidic chemical then these self limit, an alkali tend to lead to greater destruction of the eye.
Irrigate for 1-2 minutes for neutral chemicals, 5-10 for non-neutrals and continue until pH is normal. Then follow with antibiotic and cycloplegia
How to treat the adhesion of eyelids with glue?
Mineral oil soak and a pressure patch
What’s molluscum contagiosum?
Benign cyst/tumor; viral skin infection that is yellowish nodules that can cause conjunctivitis and SPK. Need excision
What’s Xanthelasma?
Benign cyst/tumor - lipid like plaque lesions, remove for aesthetics
What’s Keratoses?
Benign cyst/tumor - Sebhorrheic, well demarcated lesions.
What’s a Sudoriferous Cyst?
Benign cyst/tumor - form from glands of moll, clear round nodules and tend to be asymptomatic, may lead to trichiasis and cause irritation complaints
What’s the most common eyelid carcinoma?
Basal Cell
Describe Basal Cell carcinoma
Slow-growing, eats away local tissue, usually on the lower lid, pearly borders and causes central corneal ulceration. Must be excised and radiated
Describe Squamous Cell carcinoma in the eye
More aggressive than basal cell, higher chance of metastasizing, typically have a history of sun exposure but appears benign (scaly plaque-like appearance that is nodular)
Describe a sebaceous gland carcinoma
Very rare, usually involves the meibomiam gland, may present as a recurring chalazion
Describe a melanoma
Rare, can be pigmented or nonpigmented,
Describe a Kaposi sarcoma
Vascular tumor associated with AIDS that is rapidly growing and bleeds. Treat with radiation
What is the difference between a hordeolum and a chalazion?
Hordeolum is infectious, chalazion is non-infectious (granulomatous)
