Lids, Lashes & Tears Flashcards
Ectropion:
Outward rotation of the eyelid margin (usually
• 70% bilateral
Ectropion: Causes and risk factors
Causes:
• Involutional
• Cicatricial
• Paralvtic
• Mechanical
• Congenital
Pre-disposing factors:
• Age - as lid laxity increases
Ectropion: Symptoms
• Sore - pain / discomfort / grittiness
• Red
• Watery
• Variable depending on severity
Ectropion: Signs
• Lower lid not opposed to globe
• Punctum in abnormal position
- visible without touching lid
• Exposure keratopathy
• Conjunctival hyperaemia
• Epiphora
Ectropion: Tests
• Distraction test
lower lid pulled from globe o lax >6mm
• Snap-back test
Indicates poor orbicularis tone if poor recovery
Ectropion: Management
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
Floppy eyelid syndrome:
• 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
Entropion:
Inward rotation of the tarsus and lid margin
Lashes to come into contact with the ocular surface
Entropion: Causes and risk factors
Causes:
• Involutional
• Cicatricial
• Spastic
• Congenital
Predisposing factors:
• Age
• Severe cicatrising disease affecting the tarsal conjunctiva
Ocular irritation or previous surgery
Ectropion: Symptoms
• Irritation
• Foreign body sensation
• Red
• Watery
• Blurred vision
Ectropion: Signs
• 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
Ectropion: Management
• 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
Trichiasis: Describe
Inward misdirection of eyelashes towards the cornea
Secondary to a number of conditions
Trichiasis : Causes and risk factors
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)
Trichiasis: Symptoms
• discomfort, irritation
• foreign body sensation
• watery eye
• red eye
Trichiasis: Signs
• 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
Trichiasis: management
• Epilation
- may require frequent visits
• Manage underlying cause
- Entropion
- Blepharitis
• Therapeutic contact lenses
• Ocular lubricants
• Refer if severe (significant corneal involvement)
- Electrolysis, laser photocoagulation
Chalazion: Describe
• Inflammatory and sterile lump
• Blockage of secretory gland in lid
- Meibomian gland
- Glands of Zeus & Moll
Chalazion: causes and risk factors
• Causes
- Spontaneous
- Following acute infection - internal hordeolum
• Risk Factors
- Chronic blepharitis
- Rosacea
- Seborrheic dermatitis
- Pregnancy
- Diabetes mellitus
Chalazion: Symptoms
• Painless lump (s)
• Can be recurrent
• Sometimes after infection
• Gradual increase in size (weeks/months)
• Blurred vision (if larger can induce astigmatism)
Chalazion: Signs
• Well-defined solid nodule in tarsal plate
• Lid eversion - external conjunctival granuloma
• Induced astigmatism/hyperopia
• May be associated blepharitis
Hordeolum: Describe, predisposing factors
• Acute staphylococcal infection of the glands
• Usually tender and red
Predisposing Factors
• Chronic blepharitis
Hordeolum: Types
Internal
• Infection of meibomian gland (internal)
External
• Infection of glands of Zeiss & Moll (external) and lash follicle (also known as a Stye)
Hordeolum: Symptoms
• tender lump in eyelid
• sometimes painful
• epiphora / sticky discharge
• local redness of eye and lid
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
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
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)
Describe Blepharitis and its types
• Lid Margin Disease
• 3 types:
- Anterior (affects lashes)
- Posterior (affects meibomian glands)
- Mixed
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 )
Blepharitis: Predisposing factors
• Demodex
• Seborrhoeic Dermatitis
• Rosacea
• Long term contact lens wear
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)
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
Anterior Bleph : Signs
Seborrhoeic
• Lid Margin hyperaemia
• Conjunctival hyperaemia
• Greasy lid margin deposits
• Associated seborrheic dermatitis
Anterior Bleph : Signs
Demodex
• Lid margin hyperaemia
• cylindrical crusting (collarette)
• Chronic infestation; madarosis, trichiasis
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)
Posterior Bleph : Signs
Meibomian gland hyper secretion
• As with MD obstruction
• Foamy tears - excess lipid
Blepharitis - Investigations
• Slit lamp exam of lid margins
- Expressing glands using gentle pressure to examine meibum
- Dry Eye assessment
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
Blepharitis : Treat underlying associations (entry)
• Staphylococcal and seborrheic:
- Chloranphenicol ointment, 4 weeks
• Demodex infestation:
- Tea tree oil
• Treat dry eye
Blepharitis : Treat underlying associations (IP optometrist/GP)
• Mild topical steroid
• Oral tetracycline antibiotic
• Refer
- If persisting symptoms/significant non/resolving/progressing corneal disease
Dry eye: Describe
• Loss of homeostasis of tear film
• Accompanied by ocular symptoms
Dry eye: Types
- Aqueous deficient
- Evaporative dry eye
Dry eye: Aqueous deficient subtypes
• Inflammatory/systemic diseases
• Lacrimal gland secretions reduced/blocked
Dry eye: Evaporative dry eye subtypes
• Meiboian gland disorders
• Lid aperture disorders
• Ocular surface disease
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)
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
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
Dry eye: Other signs
• Lid wiper Epitheliopathy
• Mucus strands
• Filaments
• Dellen (thinning)
• Reduced corneal sensitivity
• Increased tear osmolarity
Dry eye: Management
Non-pharmacological
• Px education & advice
• diet rich in omega-3 essential fatty acids
• Treat cause
• Tear preservation (punctual plugs)
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)
Dry eye: Management
Referral
• Significent corneal inflammation and no improvement with Tx
• Risk of microbial keratitis
• Suspicion of Siogrens
