lids and lashes Flashcards
give pathological conditions that affect pigmention of eye lashes
poliosis
give pathological conditions that affect direction and position of eye lashes
-trichiasis
-distichiasis
give pathological conditions that affect growth of eye lashes
-hypotrichosis
-hypertrichosis
-milphosis
-madarosis
what is pthiriasis and what is it caused by?
its an infestation of the lid margins by the crab louse phthirus pubis.
give 2 predisposing factors for phthiriasis
Sexual contact with a louse-infested individual
Can be contracted within families through poor hygiene and close
contact
give 3 symptoms of phthiriasis
Intense itching of lid margins
Red watery eye
Unilateral or bilateral
give 8 signs of phthiriasis
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
what are some differential diagnoses of phthiriasis?
-blepharitis
-allergic or infective conjunctivitis
-eczema affecting lid skin
how can optoms manage phthiriasis non-pharmacologically?
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
how can optoms manage phthiriasis pharmacologically?
-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
what patients does does demodex mite infestation occur more commonly in?
-those with rosacea
-older patients
what skin diseases could be caused by demodex mite infestation?
pityriasis folliculorum
perioral dermatitis
scabies-like eruptions
facial pigmentation
eruptions of the bald scalp
demodicosis gravis
basal cell carcinoma
which 2 demodex species have been found to cause blepharitis? what can they cause?
-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
what are some treatments to control demodex mites?
-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
what is trichiasis?
Inward misdirection of eyelashes towards the ocular surface,
what are the three types of trichiasis?
Congenital - due to failure of epithelial germ cells to differentiate
completely to Meibomian glands; autosomal dominant inheritance
Acquired - entropion of any cause
what can trachomatous trichiasis cause?
recurrent inflammation of the tarsal conjunctiva which leads to:
-entropion
-trichiasis
-potentially blinding corneal opacification
give an example of an acquired trichiasis
Trachomatous trichiasis: multiple infections with Chlamydia trachomatis
what can trichiasis be secondary to
-severe chemical burn
-eyelid laceration
-stevens Johnson syndrome
-ocular cicatricial pemphigoid
-chronic blepharoconjunctivitis
predisposing factors include:
-trachoma
-staphylococcal blepharitis
what are the symptoms of trichiasis?
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
what are the signs of trichiasis?
Lash or lashes in contact with ocular surface
Conjunctival injection
Epiphora
Corneal and/or conjunctival epithelial abrasion (stains with fluorescein)
what are the possible complications of trichiasis?
pannus (corneal neovasc)
corneal ulceration and scarring
what are the differential diagnoses of trachiasis?
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
how can you manage trichiasis non-pharmacologically?
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
how can you manage trichiasis pharmacologically?
-ocular lubricants for symptomatic relief
-surgical intervention for more severe cases with complications so do initial management and then urgent referral to secondary care
for squamous papillomas, what are they, how would you treat them?
-flesh-coloured growths
consisting of squamous hyperplasia within the epithelium.
-Removal by simple excision may be performed for cosmesis or effects on
vision
what are the two types of squamous papillomas?
-sessile (broad based attachment)
-pedunculated (on a stalk)
for seborrheic keratosis, what kind of individuals does it affect?
older people
for seborrheic keratosis, what causes them?
They develop from intradermal proliferation of basal cells within the epidermis
for seborrheic keratosis what is it and how can it be treated?
-benign elevated, pigmented, crusty, greasy, stuck-on plaques (sudden increase in number or size could indicate malignancy)
-complete excision
what are epidermal inclusion cysts and what is the treatment?
-are slowly enlarging keratin filled cysts. –
-They can be removed by excision and curettage
what is verruca vulgaris? (viral wart)
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
what are the two types of verruca vulgaris?
-filiform/ digitate = project in a finger-like nature from their base
-plana = flat in appearance
what can verruca vulgaris on the eyelid margin cause?
-punctate keratitis
-corneal pannus
how does verruca vulgaris tend to be self limiting, how can you otherwise treat it?
as these lesions tend to eventually outgrow their blood supply and spontaneously involute.
-excision
-cryotherapy
-chemical cautery
what is molluscum contagiosum, who does it more commonly affect, what can it cause?
-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.
what is a pyogenic granuloma, what are they made of, what are they caused by?
-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
what are ephelides?
freckles, in terms of the eye can be present on the lid margins
what are sebaceous/ pillar cysts caused by? What 3 places might they arise from?
blocked pilosebaceous follicles containing
sebum.
-glands of zeis within the eyelashes
-meibomian glands
-from sebaceous glands associated with hair follicles
name 2 premalignant lesions that that can occur on the lids
-Actinic keratosis
-keratoacanthomas
what is actinic keratosis?
pink/red/brown scaly lesion common
on sun-exposed areas of the skin such as the face, scalp, and hands.
what is keratocanthomas? who does it most commonly affect? how do you manage it?
- 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
what is eyelid twitching called? what actually causes it to happen? when does it tend to arise?
-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
how can you confirm eyelid myokymia diagnosis?
-episodic nature
-localized to lids
-painless
-no functional impairment
how can you treat eyelid myokymia?
-rest
-cold compress
-tonic water
-stress reduction
-botulinum toxin in cases of excessive twitching
what is the order of layers that make up the eyelid from outer to inner?
-skin =
-orbicularis oculi
-tarsal plate
-conjunctiva
what part of the eyelid are meibomian glands?
in the tarsal plate
what does the sebaceous tissue in the skin of the eyelids contain?
-Eyelashes
-Ciliary glands of moll: sweat glands
-Glands of zeis: sebaceous glands
give 4 eyelid malpositions
- Ectropian
- Entropian
- 7th Nerve Palsy
- Ptosis
what is ectropion? How can you diagnose it?
where the eyelid turns outwards
diagnosis with:
-the snap back test where you pull the eyelid and if it doesn’t snap back then its ectropion
-fluorescein instillation and then observe under slit lamp
what are the symptoms of ectropion?
sore, red and watery eyes
what can cause ectropian?
scarring or contracture of skin/ underlying tissue which causes the eyelid to pull away from the globe and this can be:
-involutional
-cicatrical
-paralytic - nerve palsy
-mechanical
-congenital
how do you manage someone with ectropian?
treat the symptoms and then do a routine referral
what are the symptoms of entropian?
-foreign body sensation
-blurred vision
-redness
-irritation
how do you diagnose entropion?
-ask the px to look down while you hold their upper lid and the entropion is induced
-SL and fluorescein
what are the signs of entropion?
-corneal scarring
-corneal ulcer (rare)
-conjunctival staining with fluorescein
how can you treat entropion
-artificial tears
-lid taping
-routine referral
what is and what can cause entropion?
when scarring of the palpebral conjunctiva can rotate the upper or lower lid margin towards the globe:
Causes:
cicatrizing conjunctivitis
trachoma
trauma
chemical injuries
what are the symptoms of 7th nerve palsy?
-watery eyes
-unilateral
-facial muscle weakness
what are the signs of 7th nerve palsy?
-dry eye
-sagging of eyelid/ corner of mouth
-drooping of eyebrow
how can you manage 7th nerve palsy?
-GP referral (gp may give steroids/ antivirals due to possible cause of viral infections like herpes simplex
-artificial tears
what can cause a ptosis?
-congenital
-3rd nerve palsy
-eye tumour
-diabetes / stroke
-age
when would you have to refer a lid ptosis?
if they patient wanted to correct it with surgery
name 4 benign lid lesions
-chalazion
-hordeolum
-cysts of zeis/ moll
-papilloma
name 4 malignant eyelid lesions
-BCC
-SCC
-Sebaceous carcinoma
-Malignant melanoma
what are the signs of a ptosis?
drooping of upper eyelid
does chalazion have symptoms?
no - painless
what are the signs of a chalazion?
-well defined lump- usually on upper eyelid
-granuloma (white head like dot) when you invert the eyelid
what causes a chalazion?
blocked MG
how can you manage a chalazion?
warm compress and massage 1-2 times a day for a few weeks - should go away on its own
what are the symptoms of a hordeolum?
a tender lump on the inner/outer eyelid
what causes a hordeolum?
bacterial infection
how can you manage a hordeolum?
warm compresses daily, chloramphenicol 1% ointment
what are the 2 types of hordeolum?
-internal hordeolum which is infection of the tarsal plate
-outer hordeolum is a bacterial infection of the lid margin
what are the predispositions of hordeolum?
-blepharitis
-rosacea
-dermatitis
-diabetic patients
what are the symptoms of basal cell carcinoma?
slowly developing painless lump
what are the signs of bcc?
nodules on the lower lid
what causes bcc?
sun exposure (UV)
How can you manage bcc?
urgent referral so it can be removed in surgery
what are the symptoms of scc?
rapid, painful growth
what are the signs of scc?
scaly raw lesion on the lower lid
what can cause scc?
actinic keratosis and UV
how can you manage scc?
urgent referral so it can be removed in surgery
what are the symptoms of sebaceous carcinoma?
rare -
gradual onset, vision blurs beforehand
what are the signs of sebaceous carcinoma?
-upper lid nodule
-lashes may grow in random directions
what can cause sebaceous carcinoma?
-age
where does sebaceous carcinoma start?
meibomian glands , occasionally may arise from glands of zeis
what are the symptoms of malignant melanoma?
painless migmentation
what are the signs of malignant melanoma?
changing naevus
what causes malignant melanoma?
UV exposure
how do you manage malignant melanoma?
urgent referral as it can metastasise elsewhere
give the steps of how tears drain
- tear secretion by lacrimal gland via lacrimal ducts
- blinking spreads tear film evenly across eye and pushes debris into inferior tear meniscus
- during blink, lower lid moves nasally along with inferior tear meniscus
- superior and inferior lacrimal punctum meet on lid closure and suction together
- canaliculi is squeezed and as the punctum are sealed together, this causes a pressure change and acts like a pump
- tear fluid from the canaliculi moves down into lacrimal sac
- as eyelids begin to open, punctum are sealed together creating negative pressure forcing punctum to open
- tears pumped from the lacrimal sac travel down the lacrimal duct and drain out through the inferior meatus of the nose
give 7 problems that impaired tear drainage can cause
-eyelid laxity/ malposition
-punctal or canalicular stenosis
-incomplete blink
-congenital defects
-dacryocytitis
-lacrimal pump failure
-canaliculitis
how can you test for a lacrimal punctum blockage?
using the fluorescein dye disappearance test:
Instill Fluorescein into tear film
Wait 5 minutes
Minimal or no fluorescein in tear film
indicates normal drainages
Retained fluorescein indicates a blockage
Grade 0 or 1= normal Grade 2 or 3=
abnormal
what are the symptoms of eyelid laxity or malposition?
Epiphora, irritation, redness, crusty in the morning. Symptoms are
generally mild
what are the signs of eyelid laxity or malposition?
Lower lid drooping (not full ectropion). Generally worse nasally, causing
malposition of inferior nasal punctum. Inferior corneal/conjunctival Fl staining.
Overflow of tears on Fl insertion- dye everywhere
what are the risks of eyelid laxity or malposition?
-age
-trauma/ surgery
how do you manage eyelid laxity or malposition?
manage with lubrication and lid hygiene, normally not severe enough for surgery
what is punctal/ canalicular stenosis?
narrowing or blockage of the punctum/ canaliculi
for punctal/ canalicular stenosis, what are the symptoms?
-epiphoria
-irritation
-recurring conjunctivitis
for punctal/ canalicular stenosis, what are the signs?
-grade 2 or 3 fddt
-palpation of lacrimal sac shows tear regurgitation
for punctal/ canalicular stenosis, what are the causes/ risks?
-age
-scarring
-chronic infection/ inflammation
-prostaglandin analogues
-chemo
for, punctal/ canalicular stenosis, what are is the management?
-lubrication to manage symptoms
-warm compress can soften tissue
-lacrimal syringing
-refer for surgery (punctal dilation/punctoplasty)
if severe (routine)
what are the symptoms of blink lagophthalmos?
-epiphoria
-irritation
-dry eye symptoms
what are the signs of lagopthalmos?
-MGD
-iferior Fl exposure staining
-poor tbut
what are the causes of blink lagophthalmos?
-idiopathic
-prolonged screen use/ reading
-botox
-7th nerve palsy
-bell’s palsy
how can you manage blink lagopthalmos?
-advise patient of conscious blinking
-20:20:20 rule
-blink exercises
-artificial tears
-referral is there is a secondary cause (7th nerve palsy needs emergency referral)
what are the symptoms of congenital nldo?
-watering
-frequent eye infections
-sticky discharge
what are the signs of congenital nldo?
-increased tear meniscus height
-sticky/ crusty discharge
-persistent conjunctivitis
-grade 2-3 on FDDT
what are the causes/ risks of congenital nldo?
cause:
Incomplete canalisation due to persistent membranous obstruction at opening of nasolacrimal duct
can increase risk of conjunctivitis
how do you manage congenital nldo?
-warm compress with massage
-advise parents to keep eyes clean
-chloramphenicol use if conjunctivitis is severe
-routine referral is cases are not resolved by 1 year for imaging and probing (most resolve within the year)
for dacryocystitis, what is it and what are the symptoms?
Acute bacterial infection of lacrimal sac, normally 2ndary to blockage
epiphora, nasal swelling, pain, discharge, fever
for dacryocystitis, what are the signs?
-red, tender, enlarged area at location of lacrimal sac.
-Mucopurulent discharge expressible if pressed (painful).
-Conjunctivitis and possibly pre-septal cellulitis if worsens
for dacryocystitis, who is more at risk of getting it?
-childeren with nldo and over 40s
-females 2x more likley
-trauma
-nasal surgery
for dacryocystitis,
for mild cases:
-chloramphenicol ( If not
reponding to chloramphenicol refer to GP for oral antibiotics (e.g co-amaxiclov). Still no response-urgent referral to HES (1 week))
-warm compress and massage
in severe or child cases - emergency referral
what is lacrimal pump failure? What disease is the most common cause? what are the rare causes of lacrimal pump failure?
CN 7 palsy as 7th nerve innervates orbicularis oculi muscle and lacrimal gland
-bells palsy
-stroke, tumour, virus (HS) and inflammation
what are the facial and ocular symptoms of lacrimal pump failure?
Facial: pain behind ear/increased sound sensitivity few days before.
Partial or complete facial paralysis “drooping”. Impaired taste. Pins and
needles/numbness.
Ocular: Unable to fully open/close the eye. Watery/irritable/red eye
what are the ocular signs of lacrimal pump failure?
Incomplete blink, corneal and conjunctival Fl staining, conjunctival redness, exposure keraratitis (ulcers/infiltrates). Motility should be normal!
how do you manage new cases of lacrimal pump failure?
same day refer to GP/ophthalmology for corticosteroids +/-
antivirals and confirmation of diagnosis
how do you manage old cases of lacrimal pump failure?
manage symptoms. Artificial tears and gels at night. Eyelid tape at night.
if there’s ncreased risk of exposure keratopathy can refer routinely for lid surgery
what is canaliculitis?
a bacterial infection of lacrimal canaliculus. Can be acute or
chronic
what are the symptoms of canaliculitis?
Epiphora, mucous discharge, stone-like lumps in canaliculi, swollen punctum, pain/tenderness
What are the signs of canaliculitis?
-red/white lump at puncta/ medial eyelid margin
-punctum turning outwards - ‘pouting punctum’
-mucopurulent discharge expressed by pressure on punctum/ canaliculi
-chronic conjunctivitis
what are the causes/ risks of canaliculitis?
age, immuno-compromised, punctul plugs
how do you manage canaliculitis?
-chloramphenicol
-oral antibiotics
-warm compresses and massage
-close monitoring in practice to ensure infection does not become pre-septal or dacryocystitis
what are 7 Ps to ask when assessing patient history when cc is to do with the orbit?
Pain
Proptosis
Progression – minutes / days / weeks / months
Past medical history – Thyroid dysfunction, hypertension, cancer
Perception – vision changes?
Palpable mass
Periorbital abnormalities – weakness, redness, watering
what are the 7 ps when examining the patient who may have a problem in their orbit?
Panorama – Swelling, asymmetry, goitre, scars, old photos
Perception – VA, colour, visual field (24-2)
Pupils
Proptosis – exophthalmometry (in HES), look from above
Palpate - to check if its on one side of both sides as both is more likely to be normal part of physiology
Pulsation
Periorbita – skin, lids, lymph nodes, cranial nvs,
then do full examination of globe and motility
What is pre-septal cellulitis?
a bacterial infection of the soft tissues of the eye socket in the front of the orbital septum with risk of progression into the orbit in young children
what are the symptoms of pre-septal cellulitis?
-swelling
-redness
-tender lids
-fever
-malaise
what are the signs of pre-septal cellulitis?
-inflammation of lids
-ptosis
-no proptosis
-normal EOM
-white eye
-normal ONH functions
what are the causes of pre septal cellulitis?
-more common compared to orbital cellulitis
-more common in children
-causative agents i.e. Staph, Aureus and strep
what are the risks of pre septal cellulitis?
-infection of adjacent structures like dacryoadenitis/ cystitis, hordeolum
-upper respiratory tract infection
-trauma
how do you manage pre-septal cellulitis?
for children:
emergency referral to hes for confirmed diagnosis and oral antibiotics
for adults:
referral to GP for oral antibiotics, close monitoring, emergency referral if not resolved within 48 hrs
what is orbital cellulitis?
a bacterial infection of the soft tissues of the eye socket behind the orbital septum
whats the difference between pre septal and orbital cellulitis
infection in pre septal is in front of the orbital septum whereas orbital is behind the orbital septum
what are the symptoms of orbital cellulitis?
-fever
-malaise
-periocular pain
-red
-hot
-swollen
what are the signs of orbital cellulitis?
-swollen/ tender lids
-chemosis
-proptosis
-pain/ diplopia on EOM
-optic nerve dysfunction
-reduced VA and CV
-RAPD
-proptosis
What are the causes/ risks of orbital cellulitis
-more common in younger children
-sinus disease
-respiratory infection ‘
-dental abscess
-trauma perforating the septum
-retained FBs
-any surgical intervention thats orbital/ lacrimal e.c.t.
what is the management for orbital cellulitis?
-emergency referral to HES for blood tests, imaging, drainage, antibiotics and steroids
medical emergency as can lead to loss of vision or even death
when comparing orbital and preseptal cellulitis, what is the affects of:
1. proptosis
2. ocular motility
3. VAs
4. colour vision
5. RAPD
orbital:
1. present
2. painful and restricted
3. low -severe
4. low - severe
5. RAPD is present - severe
pre septal
1. absent
2. normal
3. normal
4. normal
5. absent
what is dacryoadenitis?
inflammation of the lacrimal gland - can be uni/bilateral
what are the symptoms of dacryoadenitis?
-epiphoria
-painful/ tender swelling of the lacrimal gland/ superior lid
-warm to touch
-feeling unwell
what are the signs of dacryoadenitis?
-superior lid swelling
-ptosis
-conjunctivitis
-chemosis
-swollen glands
what are the causes/ risks of dacryoadenitis?
Inflammatory (sarcoidosis, Wegener’s granulomatosis, Sjögren’s
syndrome, thyroid eye disease)
Infection (bacterial/viral/fungal)
how do you manage dacryoadentitis?
-warm compress and massage
-chloramphenicol 1% ointment
-refer to GP for systemic disease management
what is thyroid eye disease?
Autoimmune disease - activation
of orbital fibroblasts by
autoantibodies directed against
thyroid receptors- leads to
swelling of orbital tissues and can relate to hyper, hypo or euthyroid thyroid state
what type of thyroid problems are most cases of TED linked to?
hyperthyroidism
what are the risk factors of TED?
-being female
-smoking
-poor thyroid control
-FH (Familial Hypercholesterolemia)
-stress
-grave’s disease
-radioiodine therapy
what are symptoms of hyperthyroidism?
-weightloss
-heat intolerance
-restlessness
-diarrhoea
-poor libido
-amenorrhoea
-poor concentration
-irritability
what are symptoms of hypothyroidism?
-wight gain
-always feeling cold
-fatigue
-constipation
-poor libido
-menorrhagia
-poor memory
-depression
what are signs of hyperthyroidism?
-warm peripheries
-hair loss
-tachycardia
-atrial fibrillation
-proximal myopathy
-tremor
-osteoporosis
what are the signs of hypothyroidism?
-dry coarse skin
-dry hair
-bradycardia
-pericardial effusions
-muscle cramps
-slow releasing reflexes
-deafness
what are the symptoms of thyroid eye disease?
-ocular surface irritation
-ache
-red eyes
-photophobia
-pain on EOM
-cosmetic change
-diplopia
-vision loss
what are the ocular signs of thyroid eye disease
-proptosis
-lid retraction
-lid sag
-injection
-orbital fat prolapse
-reduced motility
-keratopathies
-increased IOP which is worse in the upgaze
what is kocher’s sign?
staring appearance
what is von graefe’s sign?
lid lag on downgaze
what is dalrymple’s sign?
lid retraction
what is stellwag’s sign?
incomplete and infrequent blinking
what is enroth’s sign?
edema of lower lid
what is griffith’s sign?
lower lid lag on upgaze
What does rundle’s curve demonstrate in TED?
where patients start with TED that’s active where inflammation and symptoms may progress and worsen and then after a few years the disease becomes inactive where signs and symptoms become reduced and stop progressing as the curve flattens out
how do you manage TED in primary care?
-educate px, like quit smoking and reduce stress
-correct vision with prism
-provide lubricating drops and maybe eyelid taping at night
how do you manage TED in secondary care?
-refer to GP if TED is undiagnosed
-refer to orthoptics routinely for prism management
-CAS score of 4+ refer urgently to hes for monitoring
-Optic neuropathy= emergency same day referral to HES
why is orbital trauma serious?
can lead to fracture of globe and if pieces of bone travel into the orbit, it can cause entrapment of ocular muscles
what are the symptoms of orbital trauma?
-bruising
-swelling
-pain
-blur
-diplopia
what are the signs of orbital trauma?
reduced VA
-sub conj haems
-rapd
-orbital or lid swelling/ bruising
-limited EOM
-tears/ detachments
how do you manage orbital trauma?
If suspected blow out causing diplopia refer urgently
for assessment/surgery
Manage secondary complications as appropriate
name 3 rare lacrimal drainage system pathologies
Congenital lacrimal fistula
Lacrimal sac macocele
Lacrimal sac tumour
what is a congenital lacrimal fistula?
abnormal ducts connecting lacrimal drainage system to the skin
what are the symptoms of a Congenital lacrimal fistula?
if not asymptomatic then
-epiphoria
-soreness
-tenderness
-mucous discharge
-swelling of punctum/ fistula
what are the signs of Congenital lacrimal fistula?
-extra punctum generally inferior/ nasal to the inferior punctum and normally unilateral
-mucous discharge from punctum/ fistula
what are the causes/ risks of Congenital lacrimal fistula
idiopathic cause or abnormal development during gestation
how do you manage congenital lacrimal fistula?
if asymptomatic, no management required
if symptomatic, referral to HES for surgical intervention via cauterization/ excision
what is a lacrimal sac mucocele?
`enlargement of the lacrimal sac which can cause enlargement of the lacrimal sac causing combined obstructions of the common canalicular opening and the nasolacrimal duct
what are the symptoms of a lacrimal sac mucocele?
-epiphora
-irritation
-lump nasally
what are the signs of a lacrimal sac mucocele?
-enlarged area at location of lacrimal sac and is not tender
what are the causes of lacrimal sac mucocele?
-inflammation
-trauma
-tumour
-nasal surgery
-dacryocystitis sequelae
how can yiu manage lacrimal sac mucocele?
-lubrication
-warm compress/ massage
-refer routinely for imaging/ diagnosis
-surgery/syringing to remove obstruction
what symptoms of a lacrimal sac mass make it different to lacrimal sac mucocele?
it comes with persistent infections and bleeding from the nose/ punctum
what are the signs of a lacrimal sac mass?
-painless hard mass at the location of the lacrimal sac
-if it extends above the medial canthus then it is most suspicious of a tumour
who is most likely to have a malignant lacrimal sac mass?
people over 50 - epithelial tumours make up most of the cases
what is a carotid cavernous fistula?
abnormal anastomosis between the arterial and venous circulation, abnormal flow between the internal carotid artery and external carotid artery and cavernous sinus
why is a carotid cavernous fistula problematic?
as it produces increased vascular pressure and resistance which impedes venous drainage and leads to vascular congestion in areas that are
drained by the cavernous sinus
what are the causes of carotid cavernous fistula?
-congenital
-head trauuma
-intracranial surgery
-spontaneous due to aneurysm
what are the symptoms of carotid cavernous fistula?
-vision loss
-diplopia
-redness
-orbital/ retro orbital pain
-swelling
-swishing or buzzing sounds
-headache
-pulsatile tinnitus
what are the signs of carotid cavernous fistula?
RAPD, Pulsatile proptosis, Orbital
odema, distinct tortuous corkscrew blood
vessels that converge at the limbus,
chemosis, raised IOP, ophthalmoplegia,
retinal vein engorgement, anterior segment
ischemia, disc swelling, CN palsies
how do you manage carotid cavernous fistula?
-mild cases need urgent referral
-severe cases need emergency referral
in secondary care : imaging, superior ophthalmic vein dilation, embolization, treatment of secondary pathologies
what are the symptoms of lacrimal gland tumous?
-hard mass/ swelling on superior lid
-soreness
-frequent infections
what are the signs of lacrimal gland tumours?
-eyelid mass
-s shaped mass
and as it progresses
-facial asymmetry
-diplopia
-ptosis
-reduced eom
why are lacrimal gland tumours s shaped
due to lacrimal gland being located
temporally on superior lid
What are the causes of lacrimal gland tumours?
usually secondary to dacryoadenitis
how do you manage lacrimal gland tumours?
-urgent referral for imaging/ biopsy
-treatment depends on tumour type and wether it’s benign or malignant
what are the two types of lacrimal gland tumours and what type are lymphomas?
-epithelilal
-non epithelial
non epithelial
whats the main difference between Optic nerve gliomas and Optic Nerve
Sheath Meningiomas?
gliomas are in the first decade of life and can be both benign and malgnant whereas meningiomas occur rarely in under 20s and are benign
what are the symptoms of Optic nerve gliomas and Optic Nerve
Sheath Meningiomas?
gradual painless reduction in vision with bulging eyes
what are the signs of Optic nerve gliomas and Optic Nerve
Sheath Meningiomas?
-reduced va and cv
-compressive field loss
-rapd present
-optociliary shunt vessels
-ptosis if severe
what can trigger optic nerve gliomas?
-neurofibromatosis
what can trigger meningiomas
-being female (women 3x increased risk)
-ionising radiation
what are the symptoms of lymphomas and metastases?
-bulging eye
-blur
-diplopia
-pain
what are the signs if Lymphomas and Metastases
proptosis, reduced VA, field loss, RAPD, field loss, suspicious
retinal lesions (metastases)
what are the causes of Lymphomas and Metastases
Metastases- generally breast/lung/prostate/melonoma
Lymphoma- idiopathic. Majority = non-Hodgkins lymphoma
(blood cancer which develops in lymphatic system)
how do you manage Lymphomas and Metastases?
urgent referral to HES. Extensive imaging/biopsy.
Can be monitored or treated with excision, radiation,
chemotherapy
what is a rhabdomysarcoma?
a rare childhood cancer (average age 5-7 years) caused by a tumour located in orbital fat tissue
what are the symptoms of rhabdomysarcoma?
-proptosis is main
-eyelid swelling
-orbital mass
-ptosis
-orbital pain
what are the signs of rhabdomysarcoma
Proptosis, eyelid oedema,
chemosis,
nasolacrimal duct obstruction, choroidal folds,
disc swelling,
retinal detachment. Depends on location in the orbit, if more nasal= NLDO, posterior pole =
retinal involement
