lids and lashes

Question 1

give pathological conditions that affect pigmention of eye lashes

Answer 1

poliosis

Question 2

give pathological conditions that affect direction and position of eye lashes

Answer 2

-trichiasis
-distichiasis

Question 3

give pathological conditions that affect growth of eye lashes

Answer 3

-hypotrichosis
-hypertrichosis
-milphosis
-madarosis

Question 4

what is pthiriasis and what is it caused by?

Answer 4

its an infestation of the lid margins by the crab louse phthirus pubis.

Question 5

give 2 predisposing factors for phthiriasis

Answer 5

 Sexual contact with a louse-infested individual
 Can be contracted within families through poor hygiene and close
contact

Question 6

give 3 symptoms of phthiriasis

Answer 6

 Intense itching of lid margins
 Red watery eye
 Unilateral or bilateral

Question 7

give 8 signs of phthiriasis

Answer 7

 madarosis (loss of lashes)
 blepharoconjunctival hyperaemia and oedema
 superficial punctate keratopathy (SPK)
 bites leave red inflamed areas on lid margins (petechial macules)
 possible pre-auricular lymphadenopathy (swelling of lymph nodes behind the ears as a result of eye infection)
 adult lice (1.0–1.5mm long) attached to lash; almost completely
transparent (high magnification [x40] required at slit lamp)
 eggs (termed nits) in greyish white cigar-shaped shells (0.5mm long)
attached near base of lashes. Empty shells remain after hatching
 reddish-brown deposits at the base of the lashes are a mixture of louse
faeces and host blood following louse bites

Question 8

what are some differential diagnoses of phthiriasis?

Answer 8

-blepharitis
-allergic or infective conjunctivitis
-eczema affecting lid skin

Question 9

how can optoms manage phthiriasis non-pharmacologically?

Answer 9

 Sensitive counselling (i.e. by GP) required as this is a sexually
transmitted disease
 advice on personal hygiene: wash hands after touching pubic region
NB possibility of sexual abuse of children
 Remove lice, nits and shells (casts) at slit lamp
 use forceps (lice have a tenacious grip on the lashes)
 Advise on any symptoms of pubic infestation
 effective treatments (e.g. malathion, permathrin) available without
prescription from pharmacies
 Sexual partners or family members at risk should have their eyes
examined and treated if necessary
 Bed linen, towels and clothes should be washed at 60°C for at least 5
min

Question 10

how can optoms manage phthiriasis pharmacologically?

Answer 10

-apply unmedicated paraffin-based ointment like Simple Eye Ointment to lid margins to suffocate the lice
-apply permethrin 1% lotion to lashes for 10 mins with eye closed and then rinse to remove (insecticides are toxic to cornea)
-Referral via GP for management of non-ocular aspects, including tracing and screening close contacts; also screening for other sexually transmitted diseases

Question 11

what patients does does demodex mite infestation occur more commonly in?

Answer 11

-those with rosacea
-older patients

Question 12

what skin diseases could be caused by demodex mite infestation?

Answer 12

 pityriasis folliculorum
 perioral dermatitis
 scabies-like eruptions
 facial pigmentation
 eruptions of the bald scalp
 demodicosis gravis
 basal cell carcinoma

Question 13

which 2 demodex species have been found to cause blepharitis? what can they cause?

Answer 13

-in the eyelids, D. folliculorum can be found in the lash follicle: anterior
blepharitis associated with disorders of eyelashes
-D. brevis burrows deep into sebaceous glands and meibomian gland looking for sebum which is thought to be their main food source: posterior blepharitis with meibomian gland dysfunction and keratoconjunctivitis

Question 14

what are some treatments to control demodex mites?

Answer 14

-use of treatments like mercury oxide 1% ointment, pilocarpine gel, sulfer ointment and camphorated oil
-tea tree oil treatments with eitehr 50% lid scrubs or 5% lid massages to eradicate mites and reduce ocular surface inflammation

Question 15

what is trichiasis?

Answer 15

Inward misdirection of eyelashes towards the ocular surface,

Question 16

what are the three types of trichiasis?

Answer 16

 Congenital - due to failure of epithelial germ cells to differentiate
completely to Meibomian glands; autosomal dominant inheritance
 Acquired - entropion of any cause

Question 17

what can trachomatous trichiasis cause?

Answer 17

recurrent inflammation of the tarsal conjunctiva which leads to:
-entropion
-trichiasis
-potentially blinding corneal opacification

Question 18

give an example of an acquired trichiasis

Answer 18

Trachomatous trichiasis: multiple infections with Chlamydia trachomatis

Question 19

what can trichiasis be secondary to

Answer 19

-severe chemical burn
-eyelid laceration
-stevens Johnson syndrome
-ocular cicatricial pemphigoid
-chronic blepharoconjunctivitis
predisposing factors include:
-trachoma
-staphylococcal blepharitis

Question 20

what are the symptoms of trichiasis?

Answer 20

May affect one or both eyes
 Ocular discomfort, irritation, foreign body sensation
(NB: in the elderly and in people with diabetes, corneal sensitivity may
be reduced)
 Watery eye
 Red eye
 Photophobia

Question 21

what are the signs of trichiasis?

Answer 21

 Lash or lashes in contact with ocular surface
 Conjunctival injection
 Epiphora
 Corneal and/or conjunctival epithelial abrasion (stains with fluorescein)

Question 22

what are the possible complications of trichiasis?

Answer 22

 pannus (corneal neovasc)
 corneal ulceration and scarring

Question 23

what are the differential diagnoses of trachiasis?

Answer 23

 Other causes of ocular irritation / red eye
 Trichiasis should be differentiated from distichiasis, in which an extra
row of lashes grows from the Meibomian gland orifices

Question 24

how can you manage trichiasis non-pharmacologically?

Answer 24

 Epilation: remove lash(es) with forceps. Advise patient that lash(es) will
re-grow within 4-6 weeks, therefore epilation may need to be repeated
 If due to entropion, tape the eyelid for temporary relief of symptoms
 Consider therapeutic contact lens (silicone hydrogel soft, rigid mini-
scleral or scleral) for temporary relief of symptoms
 Lid hygiene for associated blepharitis

Question 25

how can you manage trichiasis pharmacologically?

Answer 25

-ocular lubricants for symptomatic relief
-surgical intervention for more severe cases with complications so do initial management and then urgent referral to secondary care

Question 26

for squamous papillomas, what are they, how would you treat them?

Answer 26

-flesh-coloured growths
consisting of squamous hyperplasia within the epithelium.
-Removal by simple excision may be performed for cosmesis or effects on
vision

Question 27

what are the two types of squamous papillomas?

Answer 27

-sessile (broad based attachment)
-pedunculated (on a stalk)

Question 28

for seborrheic keratosis, what kind of individuals does it affect?

Answer 28

older people

Question 29

for seborrheic keratosis, what causes them?

Answer 29

They develop from intradermal proliferation of basal cells within the epidermis

Question 30

for seborrheic keratosis what is it and how can it be treated?

Answer 30

-benign elevated, pigmented, crusty, greasy, stuck-on plaques (sudden increase in number or size could indicate malignancy)
-complete excision

Question 31

what are epidermal inclusion cysts and what is the treatment?

Answer 31

-are slowly enlarging keratin filled cysts. –
-They can be removed by excision and curettage

Question 32

what is verruca vulgaris? (viral wart)

Answer 32

epidermal growth caused by the human
papilloma virus that starts as small papules slightly lighter than the surrounding skin which darken and become hyperkeratotic with time

Question 33

what are the two types of verruca vulgaris?

Answer 33

-filiform/ digitate = project in a finger-like nature from their base
-plana = flat in appearance

Question 33

what can verruca vulgaris on the eyelid margin cause?

Answer 33

-punctate keratitis
-corneal pannus

Question 33

how does verruca vulgaris tend to be self limiting, how can you otherwise treat it?

Answer 33

as these lesions tend to eventually outgrow their blood supply and spontaneously involute.
-excision
-cryotherapy
-chemical cautery

Question 33

what is molluscum contagiosum, who does it more commonly affect, what can it cause?

Answer 33

-small, typically 1mm to 2mm, flesh-coloured papules often with an umbilicated centre.
-very young and immunocompromised patients
-can cause follicular conjunctivitis and are spread by skin-to-skin contact.

Question 34

what is a pyogenic granuloma, what are they made of, what are they caused by?

Answer 34

-a pinkish or red, rapidly growing vascularized mass that protrudes from the conjunctiva that bleeds with minor insults
-made of blood vessels and fibroblasts
-response to local trauma

Question 35

what are ephelides?

Answer 35

freckles, in terms of the eye can be present on the lid margins

Question 36

what are sebaceous/ pillar cysts caused by? What 3 places might they arise from?

Answer 36

blocked pilosebaceous follicles containing
sebum.
-glands of zeis within the eyelashes
-meibomian glands
-from sebaceous glands associated with hair follicles

Question 37

name 2 premalignant lesions that that can occur on the lids

Answer 37

-Actinic keratosis
-keratoacanthomas

Question 38

what is actinic keratosis?

Answer 38

pink/red/brown scaly lesion common
on sun-exposed areas of the skin such as the face, scalp, and hands.

Question 39

what is keratocanthomas? who does it most commonly affect? how do you manage it?

Answer 39

• Rapidly growing papules with a central keratin-filled core
• most commonly affects elderly or immunocompromised individuals
  -can resolve by itself after several months but complete excision is normally recommended due to risk of it becoming squamous cell carcinoma

Question 40

what is eyelid twitching called? what actually causes it to happen? when does it tend to arise?

Answer 40

-eyelid myokymia
- repetitive muscle contractions affect the
muscle of Müller and the ciliary part of the orbicularis oculi, causing
twitching or flickering.
-tends to arise when he px has periods of stress, fatigue, excessive caffeine consumption or asthenopia

Question 41

how can you confirm eyelid myokymia diagnosis?

Answer 41

-episodic nature
-localized to lids
-painless
-no functional impairment

Question 42

how can you treat eyelid myokymia?

Answer 42

-rest
-cold compress
-tonic water
-stress reduction
-botulinum toxin in cases of excessive twitching