Midterm 1 Flashcards
qhs
every bed time
epicanthus plan
No treatment is required
Parents must be reassured that their child will most likely outgrow the condition
Infants should be observed and reevaluated every 6 months
-It is possible that true esotropia, particularly accommodative esotropia, may develop
If epicanthus is limiting the pt’s visual field (VF), then surgery can be performed
Coloboma facts
- rare anomoly
- Primarily congenital, but may be 2’ to trauma
- Upper lid coloboma is often associated with cryptophthalmos – failure of eyelid formation
- The eyelid skin grows continuously from the forehead to the cheek, covering the underlying globe
Blepharospasm secondary to
FB
Trichiasis
Keratitis
Ectropion subjective
- Tearing
- Eye or eyelid irritation
- Constantly wiping eyes (exacerbates problem)
- History of burns, surgery or trauma around lids
- Concurrent Bell’s Palsy
- Asymptomatic
myokymia treatment- meds
Botulinum toxin type A (Botox)
- Injected into affected area
- 2.5-5U IM q3mo
Antihistamines
Quinine 200-300mg PO qd-bid
Tonic Water!!!!!
Comorbid diagnoses include:
w/ blepharospasm
Dry eyes (49%)
Other neurologic disease (8%)
Conditions relieving blepharospasm included:
Sleep (75%)
Relaxation (55%)
Inferior gaze (27%)
Artificial tears (24%)
Traction on eyelids (22%)
Talking (22%)
Singing (20%)
Humming (19%)
Trichiasis Surgical Care: repositioning
Lash and follicle repositioning
Directed toward the anatomical cause of the problem
ectropin
Abnormal eversion of the lower lid margin away from the globe
-usually lower lid
Dermatochalasis plan
- Can assess impact with a Visual Field
- Patients with blepharitis may benefit from lid hygiene and topical antibiotics
- Patients with dermatitis may benefit from topical steroid ointment
- In general, the treatment is surgical
Horner’s syndrome
- Ipsilateral findings of mild ptosis, miosis, and anhidrosis
- The inferior eyelid may be elevated
- Because of the lack of sympathetic innervation to the iris melanocyte development, a difference in the iris color between the eyes may result (heterochromia)
coloboma + eyelids
Trichiasis
Dermoid tumors
blinking
- Average about 15-20 blinks / minute
- One blink takes about 0.25 seconds
- Disease may alter rates (ex. Pakinson’s, Hyperthyroid)
- Partial blinks
- Aggravated by keratoconjunctivitis sicca (dry eye)
- -Remember contact lens wearers
ptosis treatement- things to check for during exam
Head posture should be carefully examined
-If the patient acquires a chin-up posture due to the worsening of ptosis, surgery may be indicated
-The patient should be checked for astigmatism due to the compression of the droopy eyelid
Staphylococcus aureus on lid margin
S. aureus is normally present on the lid margins of a small number of individuals
primary goal of coloboma treatment
Corneal protection is the primary goal in the medical treatment of eyelid colobomas
Angular Blepharitis
-Localized eczematoid inflammation of the lid at the outer canthus and sometimes medial canthal region
Staphylococcal form
Dry and scaly
Moraxella form
Wet
- macerated lid with whitish, frothy discharge
- Angular blepharitis may also involve the conjunctiva
- All forms of angular blepharitis call for treatment with an antibiotic ointment
- May need to try different antibiotics based on bacteria type
Hypersensitivity to staphylococcal toxins Ag-Ab-Complement triggered
Ag (staph product) +
Ab (produced in conjunctiva) +
complement components (from limbal blood vessels) –>
C3a and C5a (chemotactic factors for white cells from the limbal blood vessels)
White spot in cornea of an accumulation of white cells
entropion subjective
- Ocular irritation
- Foreign-Body sensation (FB sensation)
- Pain or no pain
- Tearing
- Red-eye
- Light sensitivity (photophobia)
- Possible decreased vision
treatment for mild ectropion
Lubrication and moisture shields are helpful if significant corneal exposure exists
Mild dryness - RTC 1-2 wks to evaluate the efficacy of therapy
If conjunctiva is markedly keratinized, a lubricating ointment should be used several days or weeks prior to ectropion repair
- taping lids
- wipe eyelids ip and in (towards the nose)
myogenic ptosis
Myasthenia Gravis
-Abnormality at the neuromuscular junction
- Fatigability of voluntary muscle
- Ptosis: bilateral but asymmetrical
- Pt may have a history of fluctuating ptosis and strabismus
entropion treatment- botox
botulinum toxin (BOTOX®)
- small amounts are quite effective for the treatment of spastic entropion
- Weakens the pretarsal orbicularis oculi muscle
Dermatochalasis objective
The eyelid skin should be evaluated carefully
-Amount of skin redundancy, thickness of the skin, skin inflammation, and skin lesions
Presence of an upper eyelid crease should be noted and measured
-Normal upper eyelid crease falls 8-12 mm above the lid margin; generally higher in women
-Levator muscle function is usually intact
Eyelid margin position also should be noted
Normal upper eyelid margin position should fall ~1 mm below the superior limbus
s. epidermidis etiology
overgrowth– usual present on the lid margins (normal flora)
- inflammatory response of the body
coloboma + Sclera
Epibulbar Dermoid Tumor
Trichiasis plan
Lubricants may decrease the irritant effect of lash rubbing
If a more serious disease is the cause - medical therapy should be geared toward that disease
ectropion causes: cicatricial
congenital
Cicatricial (scarring)
-Due to chemical burn, surgery, trauma, chronic dermatitis, surgery, fractures, and other causes of scars
congenital is rarely an isolated anomaly
Electrocautery for ectropion
at the junction of conjunctiva and lower margin of the tarsus
vertical lines are placed inside the eyelid- poke holes– scarring pulls up lid
treatment for cicatricial ectropion
Cicatricial ectropion following trauma or lid surgery,
-digital massage may help stretch the scar
Skin grafts are another option
- May be obtained from the upper lid if dermatochalasis (discussed later) is present
- Preauricular or postauricular skin is another alternative
Associated Marginal Infiltrate
- wbc infiltrate cornea between the epithelium and stroma (subepithelial)
- white spot on cornea periphery with a clear area between it and limbus
- does not stain with fluorscein
- wbc die + release enzymes that damage the epithelium above infiltrate
coloboma + Lens
Cataract (anterior)
Subluxation
Meibomian Seborrheic Blepharitis
etiology
Excessive oil production
Quality of oil is abnormal
surgical treatment ectropion
Tarsorrhaphy
lids partially sewn together
-if cornea is exposed
Meibomian Seborrheic Blepharitis
objective
- Frothing of tears
- “Oil slick” in tear film
- TBUT may be reduced
- Conjunctival injection
- Lid tissue appears normal
Trichiasis causes trauma
Postsurgical
- Floor fracture repair or blepharoplasty
- After enucleation
- After ectropion repair
Chemical
- Alkali burns to the eye
- Medical drops (eg, glaucoma drops)
Thermal burns to face/lids
what is seb bleph associated with
stpah super infection
- plan = same for staph bleph
Distichiasis
lashes that are growing out of the meibomian glands (2nd row of lashes)
ectropion diagnosis
The lid distraction test
-how far the lid margin can be pulled away from the globe
> 8mm = lid margin laxity
The snap test
-How quickly the lid margin snaps back against the globe after it has been pulled away from it
> 1-2 seconds indicates lid margin laxity
Blepharospasm therapy
Reassurance!
Oral meds are not too effective
Botulinum toxin type A (Botox)
Injected along upper and lower eyelid
20-25U per eye IM q3mo
Most require re-injection in 3-4 months
Surgical
- Last choice in therapy
- Involves removal of the orbicularis
- Reserved for those who are unresponsive to botulinum toxin
Antibiotics ointment applied to lid margin
- bacitracin
- erythromycin
- gentamicin
- tobramycin
- reginmen
Bacitracin
-Cell wall inhibitor
Erythromycin
-Macrolide
Gentamicin
-Aminoglycoside
Tobramycin
-Aminoglycoside
Regimen
Moderate: qhs or bid
Severe: tid or qid
Dermatochalasis plan: surgical plan
Upper eyelid blepharoplasty should always be performed following a careful history and examination prior to the surgery
Associated Phlyctenule
-Hypersensitivity reaction to staph toxins
- Raised white lesion on conjunctiva, limbus, or cornea
- Can move over cornea, pulling blood vessels and scarring as it goes
Blepharospasm symptoms
Increased blink rate (77%)
Eyelid spasms (66%)
Eye irritation (55%)
Midfacial or lower facial spasm (59%)
Brow spasm (24%)
Eyelid tic (22%)
do marginal infiltrates stain?
no
3rd nerve palsy
defective adduction, depression and elevation
normal abduction
entropion medical therapy
May be warranted for pts who decline surgery
Ocular lubrication and tear preparations
- Helpful for protecting the ocular surface
- May break the cycle in pts with spastic entropion 2’ to dry eye syndrome
Cicatricial entropion surgery
- Depends on the degree and etiology of scarring
- Mild cases - removal of scar
- More extensive scarring may require grafts
Cautery is another option (temporary) – Poor aesthetics
-vertical lines on exterior lid
coloboma why?
May result from the defective fusion of temporal and nasal waves of mesodermal tissue
Ischemia
Could cause problems in part of the lid that is farthest from the principal blood supply
Colobomas can effect many different structures (ex. iris, retina, ONH, etc)
Ectropion objective
- Outward turning of the eyelid margin
- Exposure keratopathy: Inflammation of the cornea caused by irritation
- Conjunctival injection: Dilated blood vessels, which give a red appearance to the conjunctiva/sclera
- Keratinization (2’ to conj drying)
what do tetracyclines inhibit
lipase synthesis by the bacteria
Epiblepharon
The pretarsal orbicularis muscle and the skin covering the eyelid push the eyelashes vertically or inwards
- The eyelid margin is in a normal position
- Usually resolves spontaneously as the face matures
staph bleph treatment- lid hygiene
- remove crusts
- remove bacteria
- increase blood circ to lid margin
- two step- warm compress + lid scrubs
Goblet cells
-In conjunctival epithelium
Secrete mucin
-Abundant at plica semilunaris (caruncle)
-None on limbus or mucocutaneous junction
pseudoptosis
- dermatochalasis- excessive skin
- prosthetic eye
- contralateral lid retraction
ectropion causes
Acquired
- Involutional (lid laxity age)
- Paralytic (nerve issues)
- Cicatricial (due to scarring)
- Mechanical (Something is pushing or causing it)
- Allergy (swelling)
Congenital (born that way)
Neurogenic ptosis
Horner’s syndrome
Deficient innervation of CNII to the levator
- Diabetes Mellitus ( DM)
- Aneurysms of the internal carotid artery
-Thyroid eye disease
frequently can be associated with dermatochalasis
-Associated with infiltration of the orbital fat and extraocular muscles with immunoglobulin complexes
Myokymia
Fasciculation of the orbicularis
“An annoying twitch”
Etiology:
Stress, tension, lack of sleep, caffeine, etc.
OPTOMETRY SCHOOL!
entropion causes
Involutional
Acute Spastic
Cicatricial
Congenital
ectropion objective- may also note
Punctate Epithelial Erosions (PEE)
- Corneal epithelium loss
- Caused by a variety of conditions
- ex. tear abnormalities, exposure, etc
Phlyctenule
Treatment
Treat the staphylococcal blepharitis and add:
Topical steroid q2h to qid Prednisolone acetate Dexamethasone Loteprednol Or… Topical antibiotic/steroid combination such as tobramycin with dexamethasone, or tobramycin with loteprednol q2h to qid
orbicularis muscle (palpebral portion)
- Striated
- Eyelid closing muscle - used in blinking and voluntary winking
- Keeps lid tight to globe
baby shampoo for lid scrub
- The baby shampoo is first diluted one-to-one with water in a ‘cup’ in the palm of the hand.
- This is then mixed by rubbing with the clean fingertips and then applied in a gentle oval scrubbing motion to the margin and eyelash base of the closed eyelid for 1 minute, followed by a fresh water facial rinse.
- The baby shampoo can alternatively be diluted in a container (e.g. plastic cup) and scrubbing performed using a washcloth wrapped around a finger (after dipping it in the diluted shampoo). A cotton tip applicator may be used alternatively.
- NOT recommended anymore due to drying effects
Blepharoclonus
Increased frequency of blinking
Increased closure phase
Caused by
- Irritation
- Inflammation
Most frequently seen in children
Trichiasis objective
- Physical examination helps to elucidate the cause of lash misdirection
- Treatment based on cause of misdirection
- Examine both the upper and the lower lids
Levator aponeurosis
-Striated
-Lid opening muscle
-Innervated by CN III
-Fibers pass through the
orbicularis to attach to the skin
Trichiasis subjective
FB sensation Red eyes Pain Photophobia Tearing
Trichiasis causes autoimmune
Ocular cicatricial pemphigoid
ectropion assessment
Take careful history
Slit-lamp exam – check for P.E.E., exposure keratopathy, etc.
Treatment is based on cause and severity
treatment for mild ptosis
Observation is required if no signs of amblyopia, strabismus, and abnormal head posture
Follow-up every 3-4 months for signs of amblyopia due to congenital ptosis
External photographs can be helpful in monitoring patients.
Blepharospasm subjective
essential blepharospasm - increased blink rate and intermittent eyelid spasms
Blepharospasm commonly is associated with dystonic movements of other facial muscles
Changes associated with long-standing blepharospasm include:
- eyelid and brow ptosis
- Dermatochalasis
- Entropion
- canthal tendon abnormalities
Marcus Gunn “jaw-winking” syndrome
- Anomalous innervation pattern
- Lid elevation occurs with mastication or with movement of the jaw to the opposite side
Dermatochalasis subjective
A functional (obstructs superior field) and / or a cosmetic problem
In addition, patients may note:
- ocular irritation
- Entropion of the upper eyelid
- Ectropion of the lower eyelid
- Blepharitis
- Dermatitis
Wolfring
- near tarsus; basal aqueous secretion
- Both assist lacrimal gland in aqueous secretion
- Only lacrimal gland has reflex secretion (tearing)
Epicanthus
a crescent fold of skin that extends from the side of the nose to the lower lid and partially covers the inner canthus
Invariably bilateral
Although it may be asymmetrical
Normally, asymptomatic
permanent fixes for ectropion
Involutional ectropion
Most surgeons elect to shorten and tighten the lower lid – called a Tarsal Strip
Usually only a few stitches that are often removed 7 to 14 days later
Almost immediate resolution of the condition
blepharoplasty
Seborrheic Blepharitis etiology
allergic bleph
Unknown
-Often associated with seborrheic dermatitis
-Chronic disorder of the skin/head areas where sebaceous glands are abundant
-Dandruff (AKA scurf) - excessive shedding of dead skin cells of the scalp - is often a symptom of seborrheic dermatitis
Congenital entropion
- Very rare
- Usually in the lower eyelid
- It may arise due to a number of underlying developmental abnormalities
staph bleph follow up
1-3 weeks depending on severity and medications prescribed
-if cornea involved then follow up within days
Patient education
- Chronic condition - Usually exacerbations and remissions
- Goal: to control not cure
- Importance of daily lid hygiene
- Medication for acute flare-ups
what does pus indicate?
bacterial infection
Trichiasis plan surgical
Lash and follicle destruction surgery
Preferred for segmental or focal trichiasis.
Epilation – usually temporary
- When lash grows back - often short and irritating
- Often leaves the lash follicle
Electrolysis
- Can be effective
- Often painful for the pt and tedious for the surgeon
Wedge resection of the lid
-Requires a full-thickness resection of the lid margin
Radiofrequency ablation
-Extremely effective
Cryosurgery - effective, but many potential complications
treatment: surgery ptosis
Done by:
Shortening of the levator
Must have some levator function
Frontalis suspension procedure
- Levator function must be poor
- The lids are linked to the frontalis movement
lid position in downgaze ptosis
congenital: the ptotic lid appears higher in downgaze
acquired: ptotic lid is equal to the non-ptotic lid
A large lid coloboma plan
immediate surgical closure is usually needed to prevent corneal compromise
A 2-stage reconstruction may be required
Consists of a tarsal –
-reconstruction w/ skin graft
coloboma + Cornea
Exposure keratopathy
Corneal scarring
Eyelid Coloboma
- full-thickness defect of the eyelid
Triangular defect
-Base of the notch primarily at the margin
It primarily affects upper lid
-Usually between the inner and middle third of the lid
If in the lower lid
-Usually between the middle and outer third of the lid
amount of ptosis
different between fissures
mild 1-2mm
moderate 2-3mm
severe > 4 mm
BlephEx
- Rysurg
- Medical grade disposable micro-sponge spins along edge of eyelids and lashes
- Removes scurf/debris and exfoliates eyelids
- Proparacaine usually instilled prior to treatment
- Eyes rinsed afterwards
- 6 -8 minute procedure
orbicularis muscle (orbital portion)
- Striated
- Eyelid closing muscle - used in forced closure
what innervates the facial nerve?
CN VII - facial
Hypochlorous acid 0.02%
- Ocusoft HypoChlor™
- Spray or gel
- Used as needed or daily
- Can be used with lid wipes
- Spray form often used AM
- Gel form often used PM
- Generic versions as well
Cicatricial entropion
Result of scaring of the palpebral conjunctiva
-A consequent inward rotation of the lid margin
Digital eversion of the eyelid margin is difficult in cases of cicatricial entropion
Mechanical ptosis
Excessive weight
- Edema
- Tumors
Traumatic
-Lacerations effecting nerves or muscles
ptosis objective
One lid appears lower
Can look at old family picture to assess for any changes in ptosis
entropion objective
- The eyelid is turned in!
- P.E.E. (from exposure)
- Foreign body tracking
- Conj injection
- Corneal ulcer
- Decreased corneal sensation
- Corneal scarring if long-term
Dermatochalasis Differential Diagnoses
- Entropion
- Floppy Eyelid Syndrome
- Steatoblepharon
- ptosis
staph bleph
Secondary mechanism of inflammation
Production by the bacteria of lipase
- -> breaks down the lipids in the tears
- -> free fatty acids (FFAs)
- -> trigger inflammatory and irritative response
staph bleph subjective
- depends on severity
- chronic irritation and burning
- FB
- tender lids (hordeola/chalazia)
- crusts on lashes
- lids stick together in morn
- complaint of red irritated lids
what do docycycline inhibit
staph exotoxin- induced cytokines and chemokines
- helpful even if the bacteria are resistant to the antibiotic effect
Dermatochalasis causes
The most common cause is a normal aging phenomenon
Trauma
Pts with severe periorbital edema may develop redundancy of the eyelid skin
- This can be severe enough to cause a functional visual field defect
- Chronic renal insufficiency can be associated with periorbital edema
- Chronic dermatitis
Meibomian Seborrheic Blepharitis
treatment
- lid margin cleaning
- lubricants
Blepharospasm affected
Patients over 50
F>M
There are at least 50,000 cases of blepharospasm in the United States
Up to 2000 new cases diagnosed annually
The prevalence is approximately 5 in 100,000
Muller’s muscle
- Originates from the underside of the levator
- Smooth
- Lid opening muscle
- Innervated by the sympathetic system
- Inserts into superior tarsus
Orbital septum
- Attaches peripherally at the periosteum at the orbital margin
- Centrally, it fuses with levator aponeurosis (upper lid) and the tarsal plate (lower lid)
- Acts as diaphragm to separate orbital structures from lid structures
seb bleph subjective
- wet bleph
- Frequently asymptomatic
- Possible morning “mattering”
- Dry eye complaints (poor tear film)
- Symptoms may depend on other concurrent processes
Trichiasis causes
Stevens-Johnson syndrome
Vernal keratoconjunctivitis
congenital ptosis
- 90% of ptosis cases
- Present at birth
- 70% of cases are unilateral
what type of hypersensitivity reaction is phlyctenule
Type IV reaction
entropion Surgical Therapy
- Multiple surgical procedures have been described
- The most common procedures utilized in the management are as follows:
- Repair of involutional entropion
- Repair of the horizontal laxity
types of acquired ptosis
Neurogenic
Myogenic
Aponeurotic
-Where the levator aponeurosis has undergone structural changes which reduces its ability to lift the eyelid
Mechanical
angular bleph etiology
-Chronic lid irritation
-Skin drying, scaling, cracking in outer canthi
Cause
-Moraxella lacunata
-Staphylococcus epidermidis
-Staphylococcus aureus
floppy eyelid syndrome
Disorder of the eyelids that is associated with severely redundant and lax eyelids
Skin and muscles are affected
Tarsal plate develops a rubbery consistency
When chronic, this leads to markedly redundant and lax eyelid skin and orbicularis muscle
Associated Marginal Infiltrate
treatment
treat bleph + add
Topical steroid q2h to qid Prednisolone acetate Dexamethasone Loteprednol Or…
Topical antibiotic/steroid combination such as tobramycin with dexamethasone (Tobradex), or tobramycin with loteprednol (Zylet) q2h to qid
(every 2 hours)
medial ectropoim
lateral
tarsal
Medial
-Can see an everted medial aspect of the lid
Lateral
-Can see an everted lateral aspect of the lid
Tarsal (complete)
-Can see the entire lower lid everted
trichiasis Objective
Look for
Conjunctival scarring
FB tracking on cornea (linear defects)
Entropion
Distichiasis
Symblepharon formation
Staphylococcal Blepharitis etiology
Infection of the lash follicles and lid margins with s. aureus or s. epidermidis
seb bleph interpalpebral pee
spreads toxicity around cornea
lid scrubs
- diluted baby shampoo + water or commercially available cleansers
- scrub lid margin
- bid to qid after warm compress
seb bleph treatment
- plain jane
- lid hygiene
- lubricants
- follow 2-4 weeks
- pt education on chronicity
seborrheic bleph objective
-Greasy, waxy scales at the base of the lashes that flake off easily (dandruff-like)(AKA scurf)
-Skin of the lid a little greasy
- not infecive =>
inflam + allergic
ziess gland
- around hair follicle
- Unilobular gland
- Produce oils for the lash follicles
clinical evaluation for congenital ptosis
If congenital ptosis obscures any part of the pediatric pt’s visual field, surgery must be performed to correct the problem early in life
- Otherwise, a permanent loss of vision may occur as a result of amblyopia
- Occlusion amblyopia
- Astigmatism from the compression of the droopy eyelid
coloboma + Conjunctiva
Injection
Symblepharon
Malformation of the caruncle
what does CN VII cause?
- eyelids to close
- mouth and cheeks to ‘smile’
- forehead to ‘furrow’
most common form of ectropion
involutional
- Horizontal lid laxity
- Usually due to age-related weakness
- Most patients are elderly
- Laxity-related ectropion typically begins medially
- With time, the central lid margin and the lateral lid may evert
Steatoblepharon
Herniation of the orbital fat in the upper or lower eyelids.
staph bleph objective
- crusts along lash line at the base of lashes
- dried pus
- encircles crust= collarette
- crust at lash base can appear oily
- infected follicles and madarosis
- ulcers at base of lashes
- trichiasis
- tylosis- red thickened hardened lid margin
- secondary conjuctivities
ectopion
In pts with suspected facial nerve palsy:
Orbicularis dysfunction can be tested by
- Asking pt to show their teeth rather than smile
- Compare elevation of the angles of the lips
- Inferior scleral show should be distinguished from ectropion
angular bleph treatment
moraxella- zinc sulfate 0.25% solution
staph- bacitracin or erythromycin
Cicatricial entropion scar tissue
Scar tissue of the conjunctiva is usually a result of:
- Trauma
- Infections
- Chemical burns
punctal ectropion
If you can see the puncta without manipulation, this is punctal ectropion
Blepharospasm
Any abnormal tic or twitch of the eyelid
Bilateral involuntary orbicularis contraction: results in eye closure
Spasmodic
Idiopathic
Tarsal plate
- Dense fibrous connective tissue
- Responsible for structural integrity of the lids
- Upper plate about 1 cm high x 2.5 cm wide
- Lower tarsal plate smaller dimensions
acquired ptosis causes
Affliction of the nerve supply to the lid musculature
Diseases of the muscles
Mechanical interferences in elevation
Dermatochalasis
Redundant and lax eyelid skin overhanging the margin
Mainly seen in elderly
Age of onset most frequently is noted in the 40s and progresses with age
Some patients have a familial tendency and develop dermatochalasis in their 20s
Acute spastic entropion
Usually occurs as a result of ocular irritation
May be due to an infectious, inflammatory, or traumatic (eg, surgical) processes
Orbicularis oculi muscle overwhelms the oppositional action of the lower eyelid retractors
Most of these patients often have an involutional component.
Meibomian Seborrheic Blepharitis
subjective
dry eye complaints
lubricants
if keratitis cornea
-dry eye secondary to lid condition
- Artificial tears qid or prn
(when necessary)
Punctate epithelial erosions (PEE)
- subjective for staph bleph
- rxn to bacterial exotoxins
- PEE in inferior third of the cornea
- PEE stains with fluorescein
- divits in the cornea epithelium that cause fluorescein to fluress
what happens if inflam is caused by bacteria?
PMNs (polymorphonucleosides) move from the blood into the tissue to fight the infection through phagocytosis
dead PMNs + protein clot = pus
ectropion causes: medical; allergic
Mechanical
Due to herniated orbital fat, eyelid tumor and others
Allergic
Contact dermatitis
Dermatochalasis causes
- Gravity
- Loss of elastic tissue in the skin, and
- Weakening of the connective tissues
-More common in the upper eyelids but can be seen in the lower eyelids
oral antibiotics
Valuable when unusually severe
entropion causes
involutional
- May be due to numerous problems
- The patient may exhibit horizontal laxity of the medial and/or lateral canthal tendons.
Aponeurotic ptosis
Loss of levator tone and / or degeneration of levator attachments
Usually bilateral
Most common acquired ptosis
coloboma: Treatment of small defect
Treatment of small defects (or large defects awaiting surgery) include the following:
Artificial tears and ointment
Moist chamber optical bandages
Bedtime patching
moll gland
sweat
oil production
what happens during the inflammation response staph bleph
- dilation of blood vessels (redness)
- increased vasc permeability (edema + blood proteins)
- ## Movement of PMNs from blood into tissue
entropion treatment hygiene + CL
Eyelid hygiene, antibiotics, and steroids
-Useful for treating blepharitis, which may cause spastic entropion
-Bandage Contact Lens to protect cornea
Trichiasis causes infectious
Blepharitis
Herpes zoster
Trachoma (chlamydia)
what was the primary cause of phylctenules
TB
- pts who were immigrants from areas with tb or peeps who acquired it
now staph is primary cause again
epicanthus objective
Pseudo-esotropia
-A condition in which the alignment of the eyes is straight; however, they appear to be crossed
More common in infants and toddlers, esp those of Asian decent
- Normally present in fetal life from the 3rd to 6th month
- If this normal fetal structure fails to regress, clinical epicanthus is seen
Common in those with autosomal dominant inheritance patterns (ex. trisomy 21)
Krause
near fornix; basal aqueous secretion
Meibomian gland
- Sebaceous gland (oil)
- Provides the oily layer of the tear film
- Meibomian gland opening just behind the lashes
warm compress
soak lids with warm wet compress (lids closed)
10-15 min bid-qid
(2xday, 4xday)
-Blepharochalasis
separate and distinct from dermatochalasis
A rare disorder that typically affects the upper eyelids
Characterized by intermittent eyelid edema
Results in relaxation of the eyelid tissue and resultant atrophy
Unilateral in ~50%
congenital ptosis causes
Irregularity of the levator muscle (myogenic)
- Fibrous and adipose tissues are present in muscle belly, rather than normal muscle fibers
- Diminishes ability of the levator to contract and relax1
- Abnormality of CN III superior division (neurogenic)
- nerve signals are not strong enough
Hypothyroid
Body lacks sufficient amounts of thyroid hormone
what are the two major causes of hypothryoid
- Inflammation
Most common cause of inflammation is autoimmune thyroiditis (Hashimoto’s Disease) - The broad category of “medical treatments”
The treatment of many thyroid conditions warrants surgical removal of a portion or all of the thyroid gland
Hyperthyroid
Condition caused by the effects of too much thyroid hormone
what is the most common underlying cause of hyperthyroidism?
graves’ disease
- An autoimmune disease
- -Autoantibodies (Thyroid-stimulating immunoglobulins) attach to specific activating sites
- -This causes the thyroid gland to grow and make more hormone
TED mechanism
- TED pts produce autoantibodies that bind to fibroblasts cells with in the eye socket
- fibroblasts produce chemical signals
what is the hallmark of active TED
accumulation of orbital glycoaminoglycans (hylauronic acid) –> leads to swelling + congenstion in and around the eye socket
what is the main AB is produced by TED pts
TSI- thyroid stimulating immunoglobin
- amount of TSI correlates w/ TED severity – can be tested in blood
what are the orbital changes with TED
Increase in orbital volume causes forward protrusion
-Results in proptosis, restricted eye muscle movement and, in some patients, optic neuropathy
why/how does the proptosis occur
- enlarged ocular muscles + soft tissue
- glycoproteins accumulate
- pushes eyes forward
- presses on ON
- reduced eye movements
- strabismus
what is the major risk factor of TED
- smoking
- radioiodine
TED overview
a multisystem autoimmune disorder
euthryoid condition
eye signs of graves disease occur in pt who is not hyperthyroid
10%
active phase TED
congestive inflam phase
- red + painful eyes
- thyroid therapy shortens active phase
TED symptoms
Dry Eyes Puffy Eyelids Angry-looking eyes Bulging eyes Diplopia Visual loss Field loss Dyschrmoatopsia Photopsia on upgaze Ocular pressure or Pain
what is the easiest way to classify TED by structure
LIDS
- lid retraction
- puffy lids
lid lag
Von Graefe’s sign
Delay of upper lid in following globe movement in downward gaze (Von Graefe’s sign) *
lid lag
Dalrymple sign
Lid retraction in primary gaze
how to manage lid signs
lubrication
surgery after 6m-1y
conjunctival chemosis
extrusion of orbital fat
Conjunctiva and Corneal Signs
by structure
Injected, chemotic conjunctiva
Superior limbic keratoconjunctivitis
Signs of corneal exposure and ulceration
conj cornea management
Management
Lubrication
-Elevate head during sleep
Tinted cosmetic lenses
Steroids (systemic and periocular)
Orbital decompression
removal of one or more of the walls in the orbit- gives more space for ON
EOM signs w/ TED
Apparent under-activity of extraocular muscles
-Most common is fibrosis of IR Causing diplopia on up-gaze -2nd most common is MR -Then the SR and Levator -Finally the LR
elevated IOP on upgaze
EOM signs management
Lubrication
Eye patching or prisms
Meds
Steroids
botulinum toxin
Surgery - wait 6 months to 1 year
Fundus Signs w/ TED
-optic neuropathy- compression of ON
optic nerve signs management
Orbital decompression
IV then oral Steroids
Nospecs
class 0 No physical sign or symptoms
nOspecs
class 1 only signs, no symptoms (upper eyelid retraction, stare + eyelid lag
noSpecs
class 2 Soft tissue involvement (symptoms +signs
nosPecs
class 3 proptosis
nospEcs
class 4 extraocular muslce involvemen
nospeCts
class 5 corneal involvement
nospecS
class 6 sight loss (optic nerve involvement
VISA
order of what should be treated first
Vision loss
Inflammation / congestion and Activity in TED
Strabismus / motility
Appearance / exposure
