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(2) Introductory ocular disease > Lids, Lashes & Tears > Flashcards

Lids, Lashes & Tears Flashcards

1
Q

Ectropion:

A

Outward rotation of the eyelid margin (usually
• 70% bilateral

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2
Q

Ectropion: Causes and risk factors

A

Causes:
• Involutional
• Cicatricial
• Paralvtic
• Mechanical
• Congenital

Pre-disposing factors:
• Age - as lid laxity increases

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3
Q

Ectropion: Symptoms

A

• Sore - pain / discomfort / grittiness
• Red
• Watery
• Variable depending on severity

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4
Q

Ectropion: Signs

A

• Lower lid not opposed to globe
• Punctum in abnormal position
- visible without touching lid
• Exposure keratopathy
• Conjunctival hyperaemia
• Epiphora

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5
Q

Ectropion: Tests

A

• Distraction test
lower lid pulled from globe o lax >6mm

• Snap-back test
Indicates poor orbicularis tone if poor recovery

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6
Q

Ectropion: Management

A

Mild Cases
• Reassurance & advice
• Lid rubbing may increase laxity
• Ocular lubricants

Manage exposure keratitis
• Tape lids closed to reduce exposure
• Therapeutic contact lenses
• Ocular lubricants

Moderate to severe cases
• Where significant corneal involvement and risk of infective keratitis
• Recurrent infections
• Affecting quality of life
• Refer for consideration for surgery

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7
Q

Floppy eyelid syndrome:

A

• Often the presenting symptoms which are worse in the morning, - dry, gritty eyes, affecting the eye on the side they normally sleep
• Typically affects middle aged obese men
• Spontaneous lid eversion
• Can cause dry eye and chronic papillary conjunctivitis
• Increased lid laxity:
- Abnormal distraction and snap back test

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8
Q

Entropion:

A

Inward rotation of the tarsus and lid margin
Lashes to come into contact with the ocular surface

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9
Q

Entropion: Causes and risk factors

A

Causes:
• Involutional
• Cicatricial
• Spastic
• Congenital

Predisposing factors:
• Age
• Severe cicatrising disease affecting the tarsal conjunctiva
Ocular irritation or previous surgery

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10
Q

Ectropion: Symptoms

A

• Irritation
• Foreign body sensation
• Red
• Watery
• Blurred vision

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11
Q

Ectropion: Signs

A

• Corneal/conjunctival disturbance
• Conjunctival hyperaemia
• Lid laxity (involutional entropion)
• Conjunctival scarring (cicatricial entropion)
• Absence of lower lid crease (congenital entropion)
• Distraction Test
• Snap Back Test

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12
Q

Ectropion: Management

A

• Depends on severity of symptoms

• Taping the lid to the skin of the cheek
- pull it away from the globe
- temporary relief
• Epilation of lashes
• Ocular lubricants
- drops for use during the day
- unmedicated ointment for use at bedtime
• Therapeutic contact lens to protect cornea from lashes

• Referral for surgical intervention
- Persisting symptoms despite above tx
- Recurrent infection
- risk of microbial keratitis

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13
Q

Trichiasis: Describe

A

Inward misdirection of eyelashes towards the cornea
Secondary to a number of conditions

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14
Q

Trichiasis : Causes and risk factors

A

Causes
• Congenital - failure of epithelial germ cells to differentiate completely to Meibomian glands
• Acquired - the result of another condition (entropion, abnormal growth following injury, Stevens-Johnson syndrome, or chronic blepharoconjunctivitis)

Predisposing factors
• Staphylococcal blepharitis
• Cicatricial conditions
• HZO (discussed in infections lecture)

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15
Q

Trichiasis: Symptoms

A

• discomfort, irritation
• foreign body sensation
• watery eye
• red eye

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16
Q

Trichiasis: Signs

A

• Lash(es) in contact with ocular surface
• Conjunctival hyperaemia
• Corneal epithelial abrasion
• Fluorescein staining of cornea/conjunctiva

• Chronic, severe signs:
- Pannus
- corneal ulcer
- infective keratitis

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17
Q

Trichiasis: management

A

• Epilation
- may require frequent visits

• Manage underlying cause
- Entropion
- Blepharitis

• Therapeutic contact lenses
• Ocular lubricants

• Refer if severe (significant corneal involvement)
- Electrolysis, laser photocoagulation

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18
Q

Chalazion: Describe

A

• Inflammatory and sterile lump
• Blockage of secretory gland in lid
- Meibomian gland
- Glands of Zeus & Moll

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19
Q

Chalazion: causes and risk factors

A

• Causes
- Spontaneous
- Following acute infection - internal hordeolum

• Risk Factors
- Chronic blepharitis
- Rosacea
- Seborrheic dermatitis
- Pregnancy
- Diabetes mellitus

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20
Q

Chalazion: Symptoms

A

• Painless lump (s)
• Can be recurrent
• Sometimes after infection
• Gradual increase in size (weeks/months)
• Blurred vision (if larger can induce astigmatism)

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21
Q

Chalazion: Signs

A

• Well-defined solid nodule in tarsal plate
• Lid eversion - external conjunctival granuloma
• Induced astigmatism/hyperopia
• May be associated blepharitis

22
Q

Hordeolum: Describe, predisposing factors

A

• Acute staphylococcal infection of the glands
• Usually tender and red

Predisposing Factors
• Chronic blepharitis

23
Q

Hordeolum: Types

A

Internal
• Infection of meibomian gland (internal)

External
• Infection of glands of Zeiss & Moll (external) and lash follicle (also known as a Stye)

24
Q

Hordeolum: Symptoms

A

• tender lump in eyelid
• sometimes painful
• epiphora / sticky discharge
• local redness of eye and lid

25
Hordeolum: Signs
• Tender inflamed swollen area on lid / in tarsal plate • May involve entire lid in more severe cases • May point anteriorly through the skin or posteriorly through conjunctiva
26
Chalazion: Management
• Hot compresses, hot spoon, steaming • Lid massage • Manage any associated blepharitis • Advice - Weeks/ months to resolve - If large / disrupting VA refer for Incision and curettage / steroid injection • No need for antibiotic as not associated with infection
27
Hordeolum Management:
• None - most resolve spontaneously • Hot compresses, hot spoon, steaming • Manage any associated blepharitis • Remove associated lashes (external hordeolum) • Advice - internal hordeolum may evolve into chalazion - May take weeks or months to resolve • IF non resolving /significant discharge/multiple > Antibiotic ointment (Chloramphenicol 1% gds 5-7 days) > Oral antibiotic (flucloxacillin 500mg qds 7-14 days, IP Optom / GP)
28
Describe Blepharitis and its types
• Lid Margin Disease • 3 types: - Anterior (affects lashes) - Posterior (affects meibomian glands) - Mixed
29
Blepharitis: ALL Symptoms
• Similar symptoms for all types • Can't be used as differential diagnosis between types • Hx of bilateral problems, chronic and likely relapsing • Ocular discomfort, gritty, burning, itching • Mild photophobia • Symptoms of Dry Eye ( as a consequence of blepharitis )
30
Blepharitis: Predisposing factors
• Demodex • Seborrhoeic Dermatitis • Rosacea • Long term contact lens wear
31
Blepharitis: Subtypes
• Anterior Bleph - Staphylococcal - Seborrhoeic - Demodex • Posterior Blepharitis (Meibomian Gland Dysfunction) - MG Obstruction (blockage = reduced lipid secretion) - MOST COMMON - MG Hypersecretion (excess lipid secretion)
32
Anterior Bleph : Signs Staphylococcal
• Hard, brittle scale • madarosis • Lash misdirection • Recurrent styes • Corneal involvement - Inferior staining - Pannus - Marginal keratitis • Lid margin hyperaemia, swelling, crusting • Conjunctival hyperaemia • Chronic papillary conjunctivitis
33
Anterior Bleph : Signs Seborrhoeic
• Lid Margin hyperaemia • Conjunctival hyperaemia • Greasy lid margin deposits • Associated seborrheic dermatitis
34
Anterior Bleph : Signs Demodex
• Lid margin hyperaemia • cylindrical crusting (collarette) • Chronic infestation; madarosis, trichiasis
35
Posterior Bleph : Signs Meibomian Gland Obstruction (most common)
• Thickened , white material on expression • Conjunctival and Lid hyperaemia • Abnormal lipid plugging lipid openings • Chalazia • Evaporative Dry Eye Signs - Reduced tear break up - Unstable tear film • Corneal involvement - Typically inferior third - Marginal keratitis - Pannus, scarring, neovascularisation (severe chronic cases)
36
Posterior Bleph : Signs Meibomian gland hyper secretion
• As with MD obstruction • Foamy tears - excess lipid
37
Blepharitis - Investigations
• Slit lamp exam of lid margins - Expressing glands using gentle pressure to examine meibum - Dry Eye assessment
38
Blepharitis - First line management
• Advise: - Long term management required, avoid eye cosmetics, return if symptoms persist despite compliant with tx • Lid hygiene - FOR ALL TYPES > Cleansing/cleaning > Compresses (hot) > Treat underlying associations
39
Blepharitis : Treat underlying associations (entry)
• Staphylococcal and seborrheic: - Chloranphenicol ointment, 4 weeks • Demodex infestation: - Tea tree oil • Treat dry eye
40
Blepharitis : Treat underlying associations (IP optometrist/GP)
• Mild topical steroid • Oral tetracycline antibiotic • Refer - If persisting symptoms/significant non/resolving/progressing corneal disease
41
Dry eye: Describe
• Loss of homeostasis of tear film • Accompanied by ocular symptoms
42
Dry eye: Types
1. Aqueous deficient 2. Evaporative dry eye
43
Dry eye: Aqueous deficient subtypes
• Inflammatory/systemic diseases • Lacrimal gland secretions reduced/blocked
44
Dry eye: Evaporative dry eye subtypes
• Meiboian gland disorders • Lid aperture disorders • Ocular surface disease
45
Dry eye: predisposing factors
• Females > Males = 3:2 • Increased Age (prevalence increases with increasing age) • Posterior blepharitis • Environmental factors exacerbate problems: - Smoke - Heating, air conditioning - Computer use - Contact lens wear - Long term use of eye drops (preservatives)
46
Dry eye: symptoms
Hx very useful, often makes diagnosis • Itching • Burning • Stinging • Foreign body sensation, grittiness • Dryness • Blurring of vision • Watering • Stringy Mucous Symptoms made worse by environment, normally bilateral, Hx of dry mouth/systemic diseases
47
Dry eye: Main signs
• Reduced tear film break up time - NIBUT <10-15secs - FTBUT <10secs • Ocular staining - Cornea, conjunctiva, lid margin • Reduced tear volume - Tear meniscus height, using NaFl <0.2mm in height
48
Dry eye: Other signs
• Lid wiper Epitheliopathy • Mucus strands • Filaments • Dellen (thinning) • Reduced corneal sensitivity • Increased tear osmolarity
49
Dry eye: Management Non-pharmacological
• Px education & advice • diet rich in omega-3 essential fatty acids • Treat cause • Tear preservation (punctual plugs)
50
Dry eye: Management Pharmacological
Pharmacological • Artificial tears / lubricants • Dependent upon severity consider options: - Viscosity - Preservative Vs Preservative Free? - Contains lipid substitute? • Mild / moderate - Carbomer 980 0.2% • No improvement/more severe - PF sodium hyaluronate • Short term use topical steroids (IP Optoms)
51
Dry eye: Management Referral
• Significent corneal inflammation and no improvement with Tx • Risk of microbial keratitis • Suspicion of Siogrens

(2) Introductory ocular disease (16 decks)

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