Ocular Disease 3.1-3.4 Flashcards
What is sclerotic scatter and what is it used for?
a. Too look for corneal clarity
b. Illumination and ocular about 60 degrees apart. Focus light on temporal limbus (should create halo around iris) – creating total internal reflection. Look outside of oculars
What is a optic section used for?
a. Depth
b. Van herick angles
What is a conical beam used for?
a. Look for cells and flare (should be dark adapted)
What is specular reflection and what is it used for?
a. Idea of equal angles – incident and reflective angle. Focus light on purkinje image – endothelium and epithelium light up
b. Can also be used to look at posterior and anterior lens surface
What is indirect illumination used for?
a. Non- opaque corneal lesions – like those seen in EBMD
What are the lesions in EBMD called?
a. Map dot
b. Fingerprint
- What are you looking at when using the cobalt blue filter + NaFl?
a. Tear film and corneal integrity
b. NaFl stains defects
- What can you see with the cobalt blue filter, but no NaFl
a. Fleisher ring - will appear black
Decemets membrane
- What is the Fleisher ring?
a. Circular Iron deposit at base of cornea seen in keratoconus. In descemets
- Alkali vs acidic burn
a. Alkali – blanches = ichemia, more penetrate deeper and faster because of disruption of the fatty acids in the cell membrane due to increase in pH.
- What is the most common alkali agent causing burns?
a. CAOH
- Why does an abrasion cause a mitotic pupil?
a. An irritated cornea sends a signal to the iris via CN 5 = reflex
- How do you treat an abrasion and why?
a. Doxy – to inhibit MMP’s = enemies
- What causes a recurrent Corneal Erosion?
a. Abrasion
b. All corneal dystrophies
- You see a foreign body with a sterile infiltrate, what is the cause?
a. Vegetative or plant matter
b. NOTE: a sterile infiltrate is not always seen in plant or vegetative foreign bodies
- What does it mean if you see linear vertical corneal scratches?
a. Superior lid foreign body
- What causes a hyphema? What testing should you do?
a. Sickle cell – especially if have recurrent hyphema
b. Trauma
c. Clotting disorder – recurrent hyphemas
d. NSAIDs/ blood thinners
e. Idiopathic
i. Do sickle cell testing, CBC, PT/PTT
- What must you avoid if you have a hyphema or orbital fracture?
a. Gonio and scleral depression for 1 month minimum because it can cause rebleeds
- What is a positive seidel sign?
a. Leaky NaFL – indicates Aqueous leaking out of eye
b. Indicated an open globe wound – good to do it when see any corneal/ conj trauma
- When do you need a B scan?
a. To view post pole if unable to do BIO/78/90 – for RD
b. To differentiate between a melanoma ( optically empty) and a choroidal nevus
c. Optic nerve head drusen – lights up
- What are the different types of hyphema?
a. 8 ball hyphema – entire anterior chamber is filled with blood
b. Microhyphema – only see RBCs suspended with a slit lamp in the anterior chamber
- What is iridodialysis ?
a. The iris root is torn from the CB.
- What do you need to monitor for with a patient who has iridodialysis?
a. Angle recession glaucoma
- What is the thinnest and thickest part of the iris?
a. The iris root is the thinnest part of the iris
b. Collarette = thickest
- What is lens subluxation and what does it mean?
a. Means trauma has occurred
- You see a vossius ring and subluxation, what does this mean?
a. Trauma
- What is a vossius ring ?
a. Posterior pigments epithelium of iris hit the anterior lens surface
- What does the iris pigmented epithelium turn into?
a. Iris pigmented epithelium -> NPCE -> sensory retina
- What is corneal blood staining and what does it mean?
a. Cornea is stained with blood due to compromised in corneal endothelial cells.
b. Means that the patient had a hyphema
- What are you worried about when you see corneal blood staining and why does this occur? How do you resolve this?
a. High IOP because RBCs accumulate in the trabecular meshwork.
b. Have the patient elevate their head by 30 degrees.
- What indicates that a patient has a metallic foreign body?
a. Rust ring surrounding the foreign body
- What must you not do if you believe patient has a metallic foreign body?
a. MRI
- What is the weakest bone in the orbit and what is the thinnest bone?
a. Weakest = maxillary
b. Thinnest = ethmoid
- What bones make up the floor?
a. My Pal ZZZ on the floor – maxillary, palatine, zygomatic
- What bones make up the roof of the orbit?
a. FrontLess – frontal and lesser wing of sphenoid
- What bones make up the lateral wall of the orbit?
a. Great Z – greater wing of the sphenoid and the zygomatic
- What bones make up the medial wall of the orbit?
a. SMEL – sphenoid, maxillary, ethmoid, lacimal
- What are the most common orbital fractures?
a. Blow out fracture = fracture to the floor
- Why does a blowout fracture occur?
a. Trauma leading to an increase in intra- orbital pressure
- What should you tell a patient to avoid doing if they have an orbital fracture and why?
a. Do not blow nose for 48 hours!
b. It can cause an orbital infection
- What are 3 unique symptoms a patient might complain of with a blow out fracture?
a. Diplopia
i. Why and what test do you do?
1. due to IR being caught (can’t look up) – (+) forced duction
b. Crepitus (crackling) during palpation of medial orbit or after nose blowing
c. Hypoesthesia of the cheeks
i. due to trapped infraorbital nerve – V2 branch
- What are some signs of a blowout fracture?
a. Step off fracture at rim– ie. bone poking
b. Enopthalmos
c. Sub conj heme
- Where is V1 located?
a. Above the orbit
- What are the branches of V2 and where is it located?
a. Located below the eye
b. Zygomatic and the infraorbital
- What is commito retinae? Symptoms? What are complications? How is it treated?
a. Vitreous hitting back of the eye – specifically hits the outer PR segments and RPE are affected
b. Aymptomatic
c. Permanent visual field loss
d. Usually self-limiting within 3-6 weeks, white will disappear 48-72 hours
- What is Berlin’s edema?
a. Commit retinae at the macula
- What UV range does the vitreous block?
a. 300-350
- What does the vitreous store?
a. Glucose
- Where is glucose stored in the eye?
a. Vitreous
b. Corneal epithelial cells
- What is purtscher’s retinopathy? What does it look like?
a. Think “purchest ret” – associated with acute chest compression trauma
b. Looks like CRVO – but less hemes and very large and lot of CWS
- What causes purtscher’s like retinopathy?
a. Acute pancreatitis
b. Renal failure
c. Long bone fractures
- Where are CWS located?
a. NFL
- What does a negative forced duction test indicate?
a. Cranial nerve palsy
- What is a choroidal rupture? What is it caused by? Complications?
a. Crescent shaped tears concentric to the ONH – usually temporal
b. Trauma
c. Complication – CNVM
- Why does a CNVM occur?
a. Break in Bruch’s
- What conditions cause a break in Bruch’s and why?
a. CHBALAS
i. Choroidal rupture – due to trauma
ii. Histoplasmosis – due to choroiditis
iii. Best’s disease – RPE degeneration
iv. Angioid streaks – decrease in elastin
v. Lacquer cracks – stretching
vi. AMD – drusen
vii. Scar
- How many layers are there in Bruch’s and what are they?
a. 5 layers
b. Basement membrane if RPE
c. Inner collagenous layer
d. Elastic layer
e. Outer collagenous layer
f. Choriocapillaris endothelium basement membrane
- What is eyelid ecchymosis
a. Black eye caused by blood leaking into the subcutaneous tissue
- How can a patient loose their vision with trauma? When do you see changes post trauma?
a. Can get a optic neuropathy – may not appear for weeks post trauma
- What is an optic neuropathies?
a. Pallor of the ONH
- Why do you get prolapsed orbital fat? What does it look like?
a. When the orbital septum becomes weak
b. Swollen corners of eyes
- What is the orbital septum and its function?
a. Membrane sheath that is located anterior to the orbit (goes from the orbit rim to the eyelids
b. Divides the eyelids in half – separates the orbicularis from rest of the eyelid
- What is preseptal cellulitis?
a. An infection anterior to the orbital septum
- What causes preseptal cellulitis?
a. Ocular infections – hordeolum (focal), dacryocystitis
b. Skin trauma – insect bite, puncture wound
c. Systemic infections – middle ear infection/ upper respiratory infection
- What is a chalazion?
a. Scar tissue post hordeolum
b. No pain
- What are the symptoms of preseptal?
a. Eyelid ptosis, red, hot
- Which is more common preseptal cellulitis or orbital cellulitis?
a. preseptal cellulitis
- What is orbital cellulitis
a. An infection posterior to the septum
- What causes orbital cellulitis?
a. Sinus infection
i. Ethmoid sinusitis: because the ethmoid bone is the thinnest and the infection can spread easily through the thin lamina papyracea
b. Orbital infection
i. Dacyoadenitis, dacryocystitis, preseptal cellulitis spreading
c. Orbital fracture
d. Dental infection
- How do you differentiate preseptal cellulitis from orbital cellulitis?
a. Fever, EOM restriction/ pain, proptosis, decreased VA , don’t feel good, APD = orbital
- What is the leading cause of exophthalmos in kids?
a. Orbital cellulitis
- What are complications of orbital cellulitis if not treated early?
a. Meningitis
b. Mucormycosis in diabetics
- What is Mucormycosis?
a. A fungal infection that can occur in diabetics as a result of orbital cellulitis
b. This is life-threatening
- What is an indication that a patient has mucormycosis?
a. Black eschar
- What is black eschar?
a. Black necrotic tissue in the mouth and nose
- How can you diagnose orbital cellulitis?
a. CT
- Who gets TED?
a. 40 year old female
- What is the reason a patient may go to the doctor for TED?
a. Complain of heart palpitations, heat intolerance, hair loss and weight loss ie. too much sympathetic
- What is the grading system for TED?
a. NO SPECS
i. N – no signs or symptoms initially
ii. O – only signs no symptoms
1. Upper lid Retraction – caused my Mueller’s ( sympathetic control)
2. Dalrymple’s sign
3. Von Graefe’s sign
4. Kocher’s sign
iii. S – soft tissue involvement
1. Lid edema
2. Chemosis
iv. P – proptosis
1. Caused by muscles swollen behind the eye
v. E – EOM involvement
1. (+) FD test
vi. C – Corneal Involvement
1. SLK = superior limbic Keratoconjunctivitis
2. Punctate keratitis
3. Ulcers
vii. S – sight loss due to ONH Compression
1. Because swollen EOMs choke nerve –> leads to disc edema -> pallor
2. May see APD, low color vision, VF loss, Decreased VA
- What is Von Graefe’s sign?
a. Upper eyelid lag during down gaze
- What is Kocher’s sign?
a. The globe lag compared to lid movement when looking up
- Why does SLK occur in ted?
a. Due to friction caused by the new position of the lid
- What is SLK associated with?
a. TED
b. Cls
c. Dry eye n
- What EOM’s are first involved in TED?
a. I’M So Lazy
i. I = inferior rectus first
ii. M = medial rectus
iii. S = superior rectus
iv. L = lateral rectus
- is Dalrymple’s sign?
a. Looks like patient is staring due to upper lid retraction
- What is the pathyophys of TED?
a. The thyroid releases T3 and T4 normally to the brain
b. If there is not enough T3 and T4 then the brain releases TSH to the thyroid
c. This causes that thyroid to release more T3 and T4
d. TED = TSH mimic ( auto ab to TSH receptor) - this increases T4 and T3- the brain detects high T4 and T3 and inhibits the release of TSH via negative feedback
e. The thyroid stimulating antibodies go after the EOMs and orbital tissue – causing fibroblast proliferation + inflammation
i. EOMs inflamed and thickened
- How is ted diagnosed?
a. High T3,T4
b. Low TSH
c. CT/MRI to look for enlargement of EOMs ONLY
d. Exophthalmometry
e. VF for ONH defects
- What are Exophthalmometry norms? What are abnormal findings?
a. White people: 12-33 mm
b. Asian: 12 – 18 mm
c. Black: 12-24 mm
d. NOTE IF VALES AND HIGHER AND IF GREATER THAN 3 MM DIFFERENCE = ABNORMAL
- What is the strongest risk factor for the development of TED?
a. Cigarette smoking
- 40 - 50 year old patient presents with unilateral/bilateral proptosis, what are your differentials?
a. Orbital pseudotumor
b. TED
c. Cavernous hemangioma – if unilateral
- What differentiates TED from Orbital pseudotumor?
a. In orbital pseudotumor both the EOMs and the tendons are enlarged
b. In TED only the EOMs enlarged
- What is a capillary hemangioma?
a. Benign orbital tumor in kids
b. “ think – capillaries = small, so seen in kid”
- What are complications of capillary hemangiomas?
a. Deprivation amblyopia if the visual axis is blocked
- What is the treatment of capillary hemangiomas?
a. No treatment, usually shrink by age 7
- What is a cavernous hemangioma?
a. Benign orbital tumor in adults
- Who gets a Carotid Cavernous Fistula?
a. 20 yo M usually by a motor accident-causing trauma to the cavernous sinus
- What is a Carotid Cavernous Fistula?
a. An abnormal communication between the arterial and venous systems
b. When the blood entering the cavernous sinus cannot drain due to high pressure in the ICA, this leads to a back flow of venous blood to the eye leading to the triad
- What is the triad of the cavernous sinus fistula?
a. Chemosis
i. NOTE: not associated with itching
b. Pulsatile proptosis
c. Ocular bruit = abnormal sound of blood flowing through an artery that is partly/ completely obstructed
- What other signs may you notice in cavernous sinus fistula besides the triad?
a. Because the cavernous sinus contains CN 3,4,6, V1, V2, sympathetic fibers + ICA
i. CN palsy, loss of sensation in CN V ( above and below eye)
b. High IOP
c. Red eye – due to blood flowing back into eye
- What is chemosis + itching mean?
a. Allergy
- Explain the venous drainage system of the eye
a. The eye drains by 2 veins
i. Inferior ophthalmic veins
ii. Superior ophthalmic veins
b. Both veins empty into the cavernous sinus
c. The cavernous sinus drains into the sigmoid sinus
d. Goes into the internal jugular vein
e. Goes to the heart
f. Aorta -> common carotid -> ICA -> ophthalmic artery -> CL MS LSE
- What are the branches of the aorta?
a. ABCS. (R-> L )
i. Aorta
ii. Brachiocephalic
iii. Common carotid
iv. Subclavian
- What are the branches of the Subclavian?
a. Vertebral artery
- What do the vertebral arteries join to form?
a. Basilar artery which becomes the Posterior cerebral artery
- What are the branches of the common carotid?
a. ICA
b. ECA
- What are the branches of the ICA?
OPAM
a. Ophthalmic artery
b. Posterior communicating artery
c. Anterior cerebral artery
d. Middle cerebral artery
- What are the branches of the ophthalmic artery?
a. CL MS LSE
i. CRA
ii. Lacrimal artery
iii. Muscular artery
iv. SPCA
v. LPCA
vi. Supraorbital artery
vii. Ethmoid artery
- Where is a dermoid cyst found?
a. Superior temporal quadrant
Who gets dermoid cysts?
diagnosed in early childhood- first decade of life
what is a dermoid cyst?
well-defined mass seen on CT.
what are symptoms of a dermoid cyst?
proptosis
Who gets neurofibromas?
young to middle age adults
what is a neurofibroma?
benign yellow-white tumor of astrocytes located in the superior orbit.
may see multiple.
What is another name for neurilemmoma?
Schwannoma
what is a neurilemmoma? Where does it start forming?
benign tumor of Schwann cells .
IT starts developing in V1
Who gets neurilemmoma?
young to middle age adults
what is a symptom of neurilemmoma?
gradual proptosis
what is another name for a Optic nerve glioma?
Juvenile pilocystic astrocytoma
what is an optic nerve glioma?
most common intrinsic tumor of the optic nerve
who get optic nerve gliomas?
young kids
What is a meningioma?
begin brain tumor with occur in 40 yo women
what is the most common intracranial tumor to invade the orbit?
sphenoid meningiomas
What is RhaBDomyoscarcoma? What does it do?
most common primary pediatric orbital malignancy.
primary means starts in orbit and travel elsewhere
Rapid bone destruction tumor
What are symptoms of RhaBDomyoscarcoma?
progressive unilateral proptosis
who gets RhaBDomyoscarcoma?
7 years old is the average age of diagnosis
what is neuroblastoma?
the most common secondary pediatric orbital malignancy.
starts in the abdomen
secondary means state elsewhere and then goes to eye.
Who gets lymphomas?
60 year old
What are symptoms of lymphoma?
gradual proptosis
APD
Vision loss
What do orbital tumors frequently cause?
progressive vision loss
gradual proptosis
diplopia
APD
What is another name for orbital pseudo tumor?
idiopathic orbital inflammatory syndrome
who gets orbital pseudo tumor?
middle age
what causes orbital pseudotumor?
idiopathic inflammation of everything including the lacrimal gland
what are symptoms of orbital pseudotumor?
acute onset of unilateral pain (not in TED), red eye [ NOT IN TED], diplopia, or decreased vision.
periorbital swelling (inflammation behind the eye)-> hyperopic shift
What is the treatment of orbital pseudotumor?
steroids
signs of allergies
chemosis + itching + papillae
Differentials if see chemosis not associated with itching/ papillae in young to middle age adults?
- cavernous sinus fistula
- idiopathic orbital inflammation
What is Tolosa- Hunt syndrome?
type of idiopathic orbital inflammation that affects the cavernous sinus and SOF.
what are symptoms of Tolosa- Hunt syndrome?
acute painful exopthalmos, diplopia, ipsilateral palsies (CN 3,4,6), loss of sensation above and below the eye (V1, V2)
What should you suspect if you see bilateral orbital pseudotumor in adults?
systemic vasculitis or lymphoma
what is phthisis bulbi?
shrinkage and atrophy of the globe.
what is anopthalmos?
no eyeball
what is micropthalmos?
small globe
what is enopthalmos?
eyeball retracts/ goes into the orbit
what is enucleation?
removal of the eyeball leaving muscles, EOMS
what is evisceration?
removal of the inside of the eyeball. sclera, and stuff outside stay
what is exenteration?
everything is removed - eyeball, EOMs and orbital fat.
Who gets ocular rosacea?
45 yo F
what is ocular rosacea?
a lid disease that leads to a peripheral ocular surface disease .
Specifically affects where the lids touch the Cornea causing a rxn (phylectenuales, SEI)
What is the pathophys of ocular rosacea?
IDIOPATHIC
it affects the sebaceous glands.
Specifically, this is an over rxn to the staph that normally hangs out on our skin.
What are signs of ocular rosacea?
- telangiectasia ( vessels that send inflammation to tissues)
- rhinophyma ( large nose due to hypertrophy of sebaceous glands)
- facial flushing ( butterfly rash/ malar rash)
Where do you see butterfly rash?
lupus
ocular rosacea
What are triggers of facial flushing with rosacea?
alcohol
spicy foods
exertion
caffeine
lots of sun exposure
what are sebaceous glands and what is their method of section
zeis, meibomian
Holocrine
What causes telangiectasia?
- rosacea
- basal cell
- coats disease
who gets coats disease?
unilateral condition in 8 yo males
what happens in coats disease?
exudates are released from light bulb type vessels
leading to exudative detachment
leading to leukocoria
What are complications of ocular rosacea?
if the corneal rxn gets too bad this leads to infiltrate spillover into the epithelium.
this leads to an epithelial defect
which can lead to an ulcer.
what is an ulcer?
epithelial defect + sub epithelial infiltrate
how does Staph affect the eyes?
lids : chalaxion/ hordeoloum/ clogged glands/ bleph
peripheral cornea : sub epithelial infiltrate, SPK, dry eye, Neo
Limbus: Phylectenuale/ staph marginal keratitis
what is a Phylectenuale?
a lymphocyte at the limbus
what causes phylectenuales?
STAPH = #1
TB
When do you see SEI
cls wearer
staph rxn
What are the 4 types of hypersensitivity?
ACID
Type 1 = A - anaphylactic ( IgE = allergy - occurs fast 30 mins)
type 2 = C - cytotoxic (grandma, bad. cells enter the body and no heal — IgE and IgM)
Type 3 = I - immune complex (autoimmune response, antigen-Ab complex)
Type 4 - D- delayed (T-cell - occurs 2-3 days later)
examples of type 3 hypersensitivity
lupus (affects DNA), RA ( affects cartilage)
examples of type 4 hypersensitivity
poison IVY
contact dermatitis
What drug inbits T cells?
restasis
how do you treat contact dermatitis?
steroids
what can cause contact dermatitis? Drugs?
cosmetics, nail polish, drugs ( aminoglycosides, BAK)
symptoms of contact dermatitis
perioprbital swelling
chemosis
papillae
What is the spectrum of fluroquinolones? what are they used for? what is their MOA? why do we use them over amnioglycosides?
borad spectrum
ulcers
1) inhibit DNA gyrase
2) inhibit topoisomerase 4
less resistance
what are aminoglycosides? What is their spectrum? What is their MOA? what are the drugs? Why do we not use them as much?
- fluroquinolones of 30 years ago
broad spectrum
Tobragent 30 - tobramycin/ gentamycin and affect the 30 s subunit of ribosome
Cause problems with corneal epithelium ( SPK, delayed corneal regeneration)
Who does ocular cicatricial pemphigoid affect?
65 year old female
What causes ocular cicatricial pemphigoid
Chronic autoimmune idiopathic mucous membrane disorder. Ie. affects anything with a mucous membrane (conj, esophagus, mouth, etc)
- type II hypersensitivity against conj basement membrane
- drug induced from timolol, epinephrine, and pilocarpine
What are signs of ocular cicatricial pemphigoid?
symblepharon
conj scarring/fibrosis
ankyloblepharon
what is a symblepharon?
when the palpebral and orbital conj stick together
what is an ankyloblepharon?
when eyelids are fused
Compliations of ocular cicatricial pemphigoid
- goblet cells/ meibomian glands/ glands of Krause/ glands of wolfing/ ducts of main lacrimal gland destroyed. —> leads to sever ocular surface disease
- entropion/trichiasis / corneal ulcer, keratitis, neo
What is Stevens- Johnson syndrome?
type 3 or 4 hypersensitivity reaction that affects mucous membranes
mostly type 4
what causes Stevens-johnson syndrome?
drug induced - sulfonamides , amoxicillin
infection
what are symptoms of acute Stevens-johnson syndrome?
not feeling good, fever, HA, nausea, vomiting
skin lesions - red, bull’s eye , papule
ocular lesions - conjunctivitis + pseudomembrane ; if caused by bacteria - then can lead to endopthalmitis
what are symptoms of chronic Stevens-johnson syndrome?
- symblepharon
- entropion/trichiasis / corneal ulcer, keratitis, neo -
what is dermatochalasis? what can it cause? what are the signs?
lots of upper lid skin caused by a weak orbital septum.
can cause ptosis/ pesudoptosis
what are the 2 main types of blepharitis? what kind of bleph do they both cause?
- staphylococcal
- seborrheic
- both can cause anterior and posterior bleph
What is the difference between anterior and posterior bleph?
They are separated by the grey line
what is the grey line?
part of the muscle of riolan
what is the muscle of riolan?
palpebral part of the orbicularis oculi
What is the difference between seborrheic and styphylococcal bleph?
Seborrheic bleph has less inflammation and causes oily greasy scales with flaking. Also has more madarosis
what is madarosis?
eyelash loss
think eyelashes get mad and loss
what is trichiasis?
misdirected eyelashes
what glands cause a chalazion?
meibomian
what is a chalazaion?
sterile inflammation of a meibomain gland. NO INFECTION
How do you treat a chalazion?
steroid
triamcinolone ( causes depigmentation)
what are you worried about if a patient has recurrent chalazion?
sebaceous gland carcinoma
What is a hordeoloum? of what glands?
staph infections of meibominan, zeis, or moll glands
what is an internal hordeolum?
affects the meibomian glands
what is an external hordeolum?
affects the glands of Zeis/ Moll
this is also called a stye
what is the treatment of a hordeolum?
keflex
augmentin
doxy - if allergic to cephalosporins
bactrim
what glands makeup the lipid layer of the tears?
meibomian, zeis, moll
what is the secretion method of the glands of moll?
apocrine
what is the function of the glands of zeis?
lubricate the lashes
What is an inclusion cyst
benign lesion caused by trauma/ surgery
can be white due to keratin accumulation
What lesions are associated with keratin?
inclusion cyst
bitot spots
what are bitot spots?
keratin on the conj caused by vitamin A deficiency.
What can a lack of vitamin B1 do?
in alcoholics can cause problems
ex. wernicke-korsakoff syndrome
what is milia?
caused by the occlusion of sweat pores or pilosebaceous follicles
what are the sebaceous glands of the eye?
meibomian and zeis
what are glands of moll?
modified swear glands
What causes ectropion?
PC ACTS BS
P: paralytic - ex bells palsy (CN 7 lower motor neuron issue)
C: cicatricial
A:age- related/ involutional = NUMBER 1 Cause
C:congenital
T:trauma
s: scar tissue
B:burns
S:surgery
what are symptoms of ectropion?
exposure keratopathy
epiphora
What are causes of entropion?
age
cicatricial
trachoma
what is distichiasis?
a second row of eyelashes from the meibomian glands
what is the leading cause of blindness in 3rd word countries.
trachoma
what is the pathophys of trachoma?
chlamydia serotype( trA-Coma)
infection starts in the upper eyelid (ie. there are follicles in the upper lid). The follicles scar over and create Arlt’s line. This leads the eyelid to introit, causes lashes to scrape against the cornea.
This is what causes the blindness because it leads to corneal infection- then ulcer.
This is an infection, pt also has a swollen lumph node
What conditions are associated with sleep apnea?
ie. low O2 -> heart issues etc.
1. floppy eyelid syndrome
2. NTG (drance hemes in the NFL, not enough perfusion to ONH w
3. NAION (HTN,DM)
4. keratoconus
5. CSCR
What arteries provide O2 to the ONH?
SPCA -> circle of Zinn
who gets floppy eyelid syndrome?
overweight males with sleep apnea
what is the pathophys of floppy eyelid syndrome?
- thinking “ fat Elastin syndrome”
- these patients have a decrease in elastin. ( ie. in lids/ throat-> snore because throat collapses)
- when patients are sleeping face down, there is a spontaneous lid eversion that occurs exposing the superior tarsal plate.
- the plate gets papilla conjunctivitis due to friction and leads to trauma.
what are signs of floppy eyelid syndrome?
red eyes in the morning
chronic papillary conjunctivitis
Punctate epithelial keratopathy
What is benign essential blepharospasm? what muscles?
repetitive bilateral twitching/ forceful closing of the eyes. Caused by spasms of the orbicualris oculi, procures, corrugators.
what causes benign essential blepharospasm?
idiopathic, but can due to conj/cornea irritation as well.
what is the treatment for benign essential blepharospasm?
botox
what is Meige’s syndrome?
benign essential blepharospasm + lower face abnormalities (jaw pain/spasm/can’t open mouth, trouble chewing)
What is myokomia? And what muscle?
one eye twitches caused by palpebral part of the orbicularis oculi
what causes myokomia?
tired, stress, caffeine
which is more common myokomia or benign essential blepharospasm?
myokomia
List the malignant tumors of the eye from worst to best.
1) malignant melanoma
2) sebaceous gland
3) squamous cell carcinoma
4) basal cell carcinoma
what does basal cell carcinoma affect?
it affects the stratum basal layer of the skin ( contains melanocytes ie. melanoma can occur here)
What is the most common eyelid cancer?
basal cell carcinoma (BCC)
What UV light is more likely to cause BCC?
UVB because it is more prevalent.
NOTE: UVC is the most dangerous, but is blocked by the atmosphere.
what are the stages of basal cell carcinoma?
- early stage - “early pearly” : pearly, shiny firm with telangiectasia
- rodent ulcer ( ie. central ulcer)
what is affected in squamous cell carcinoma?
stratum spinosum layer of the epidermis.
What is actinic keratosis?
the is the a precancerous skin lesion that is a precursor to squamous cell carcinoma.
Looks like a pink, red, scaly lesion on sun-exposed skin
What is the difference between BCC and SCC?
location and SCC has NO telangiectasia
What is keratoacanthoma?
also on sun exposed area.
these grow fast and shrink slowly and spontaneously resolve
What is sebaceous gland carcinoma?
neoplasm of the sebaceous glands. NOTE can be mistaken for a recurrent chalazion. If there is madarosis = true eyelid cancer!!
When is a sebaceous gland carcinoma considered to be deadly?
greater than 2 cm
What does malignant melanoma go after?
melanocytes!
what characteristics increase the suspicion for a malignant melanoma?
A: asymmetry
b: border irregularity
c: color difference
d: large diameter
e: enlargement of the lesion
What are the 2 most important prognostic factors once a malignant melanoma has been diagnosed?
depth of invasion
size of the lesion
What is the fxn of CN 7 in tears?
produce tears
drain tears via horners muscle and make the lacrimal sac huge
what is Horners muscle and what does it do?
surrounds the canalliculi.
What happens to Horners muscle when you blink?
it shortens the canaliculi and opens the sac to pump tears into it
How long is the vertical canaliculi?
2 mm
How long is the horizontal canaliculi?
8 mm
What is the number one symptom of a NLDO?
epiphora
what is the number one cause of a NLDO in an adult and number 2 ?
involutional stenosis ie. age related.
This causes narrowing of the NLD such leads to back flow.
number 2 = maxillary sinusitis
what is the number one cause of a NLDO in a child?
valve of hasher issue
Dacryocystitis and NLDO
Anything that causes NLDO can cause a Dacryocystitis
What is the number one cause of a canaliculli infection?
actinomycete isrraeli
Think Israel has lots of canals
what is dacryoadenitis?
inflammation of the lacrimal gland
What causes acute dacryoadenitis?
infection!
bacterial: STAPH, gonnorrhea, streptococci
Virus: herpes, influenza, mono, mumps
What are the symptoms of acute Dacryoadenitis?
s shaped ptosis
pain
redness
temporal eyelid swelling
pre-auricular lymphadenopathy - ie. high WBC
fever
who gets Dacryoadenitis?
kids and young adults
What causes chronic Dacryoadenitis?
inflammatory disorders:
- sarcoid
- mono
- tb
- graves
- Idiopathic orbital pseudotumor
what is more common acute or chronic Dacryoadenitis?
chronic
what are the symptoms of chronic Dacryoadenitis?
temporal eyelid swelling
less red, pain, and swelling compared with acute
globe can be moved inferior Nasal + proptosis
How can you tell someone has actinomycete isrealii?
see yellow sulfur granules after expressing canaliculli
what are symptoms of canaliculitis?
unilateral red eye that is not responsive to antibiotics.
swollen nasal parts of upper and lower eyelid
swollen punctum = pounding punctum
darcyolith = concretion from canaliclli
pus with palpation of lacrimal sac
can be misdiagnosed as recurrent conjunctivitis
what is the number one cause of dacryocystitis?
NLDO
what causes dacryocystitis?
lacrimal sac infection that is caused when the drainage system is clogged, leading to black flow of bacteria from the nasolacrimal duct into the lacrimal sac.
what bacteria cause the lacrimal sac infection in dacryocystitis?
staph aureus
stash epidermidis
pseudomonas
haemophilus influenza in kids
what are complications of dacryocystitis?
orbital cellulitis
if chronic be concerned about malignant lymphoma/ carcinomas. (note with carcinoma may see blood in tear film ie. hemolacruia)
how do you treat dacryocystitis? what should you not do?
keflex, doxy, bactrim, etc.
DO NOT do surgery or irrigate the lacrimal sac
what are signs and symptoms of dacryocystitis?
swelling below the medial cantal tendon
edema, tenderness, pain where lacrimal sac is located
fever
what are you suspicious of if you see swelling about the medial cantal tendon?
lacrimal sac tumor
what should you be worried about if a patient has a chronic dacryocystitis? What is one sign of this?
carcinomas, and malignant lymphomas.
note with carcinomas may see hemolacria with palpitation of the lacrimal sac.
what is hemolacria ?
blood in the tear film
What has more swelling, tenderness and tearing
dacryocystitis or canaliculitis?
dacryocystitis
what is punctual stenosis ?
narrowing/occlusion of the punch due to age
- tiny puncta diameter
what is a sign of punctual stenosis ?
epiphora
When does the valve of hasner open in newborns?
spontaneously opens 1-2 months after birth.
what to do if the valve of hasner has not opened in newborns?
digital massage
how to do a Jones 1 test? what do the results mean?
put in NaFl into inferior fornix. wait 5 mins. check for NaFl in back of throat or have patient blow their nose.
- (+) jones test : saw NaFl on tissue after blow nose/ on back of throat
- (-) jones test: did not see NaFl - do a jones 2 test
how to do a Jones 2 test? what do the results mean?
irrigation of punctum
- fluid comes out of same punctum = problem in upper or lower canaliculus ( proximal to the common canaliculus)
- fluid comes out of the opposite punctum = Nasal lacrimal obstruction distal to the common canaliculus
- gag reflex or fluid in nose - obstruction is cleared
what do you do if the patient fails jones II?
DCR = dacryocystorhinostomy
How is trachoma treated?
azithromycin
What are the 2 eye problems caused by sleep apnea?
chronic Normal tension glaucoma
- because low o2
NAION
- lack of o2 to the ONH
NOTE: floppy eyelid syndrome is seen in sleep apnea
What condition is TED associated with?
Myasthenia Gravis and grave’s disease
