P-external Flashcards
48 p/w burning and itching of eyelid
description
ddx
eval
mgmt
lids w telangiectasia, scurf, crusting without lash loss
blepharitis: scurf, lid telangiectasia, MGD
ocular roseacea: facial telangiectasia, rhinophyma
sebaceous cell carcinoma: lid distortion, lash loss
hx: onset, duration, progression, severity
exam: features of each ddx
mgmt:
-warm compresses, lid hygiene, lubrication
-if fails conservative: doxy
-if rosacea: doxy, avoid exacerbating foods (alcohol, spicy food), derm referral, avoid steroids as they can develop K thinning and perforation
-counsel:
–mgmt is chronic
–risk of chalazia that may require surgical intervention
–if doxy: minimize sun exposure, avoid in children and pregnant/nursing women
description
ddx
eval
mgmt
erythematous nodular eyelid mass
chalazion / hordeolum
sebaceous cell carcinoma
pyogenic granuloma
hx: onset, progression, recurrence, RFs (rosacea, blepharitis, trauma)
exam: MGD / scurf, lid distortion / telangiectasia, lid eversion for possible pyogenic granuloma
mgmt:
-warm compresses, lid hygiene, lubrication
-if fails conservative: topical or PO abx -> intralesional steroid injection but counsel regarding hypopigmentation / atrophy / very low risk of CRAO -> incision and curettage with path especially if recurrent
-if rosacea: PO doxy, derm referral, avoid steroids as they can thin out K in rosacea patients leading to perforation
-good prognosis
36M p/w eye redness and ocular irritation
description
ddx
eval
mgmt
waxy pallor umbilicated nodule
-molluscum contagiosum: follicular conjunctivitis, K subepithelial stromal infiltrates, pannus (2/2 irritation from shed viral particles = henderson-patterson corpuscle)
-basal cell carcinoma: telangiectasias, crater defect, pearly
-nevus / skin tag
hx: onset, progression, RFs (immunocompromised state - cancer, chronic steroids, immunosuppressants, HIV)
exam: red eye, other lesions on body (if multiple, suspect STD / immunocompromised state)
mgmt:
-contagious thus rec good hygiene
-cryo or surgical excision w curettage -> path
-counsel: even without treatment, can self resolve but may lead to K pannus/NV.
-f/u 2 wks to review pathology and eval for expected resolution of symptoms
description
ddx
eval
mgmt
conj leukoplakia / gelatinous lesion + sectoral injection and sentinel vessels. Extends onto K with pannus and K opacity
-ocular surface squamous neoplasia (specifically conjunctival intraepithelial neoplasm)
-ptygeria
-amelanotic melanoma
-hereditary benign intraepithelial dyskeratosis (picture): haliwa indian ancestry
-hx: onset, progression, RFs (ancestry, personal or family h/o cancer, smoking, HPV, HIV, immunocompromise)
-exam: ocular VS, lid lesion (evert), Hertel, VF, gonio, DFE for CB / retina lesions, skin lesion, lymadenopathy
-testing:
–ASOCT for K (OSSN is hyper-reflective and abrupt transition)
–impression cytology
–US for CB
–map biopsy (not needed for corneal OSSN)
–If intraorbital extension a concern, image brain/orbits/head/neck
mgmt (inclusive of K portion)
-excisional biopsy w wide margins, no-touch technique, double freeze thaw cryotherapy to conj edge + alcohol epitheliectomy for K involvement
-if diffuse (positive map biopsy): MMC / 5FU drops, IFNa
-if refractory: radiation
-if intraocular extension: enuc
-if orbital extension: exenteration
-if mets: oncology referral
-good prognosis if excised fully w clear margins but must follow closely for recurrence and local invasion > met, 3-4mo w LFTs/CT brain and chest
description
ddx
eval
mgmt
wing shaped vascularized lesion extending onto K, no dellen or epi defect
pterygia: typically in 3 and 9’ positions, can develop dellen proximal to leading edge
CIN: leukoplakia / gelatinous appearance, + feeder vessels
trauma/chemical burn: can look like pterygia but only anterior edge is adherent
pannus (contact lens, herpes, blepharitis / rosacea, atopy)
hx: onset, duration, progression, RFs (trauma, chemical burns, work environment, eye protection/sunglasses, contact lens wear)
exam: ocular VS, fluorescien staining
mgmt:
-if asymptomatic and outside visual axis: refract, sunglasses, lubrication can halt progression (inciting factors such as wind, sun and dust can cause progression)
-if inflamed, can give steroid gtts but need to monitor IOP
-if symptomatic / on visual axis: surgical excision + MMC +amniotic membrane graft
-good prognosis
description
ddx
eval
mgmt
conjunctival pigmented lesions
primary acquired melanosis: nodularity = atypical
complexion related melanosis: bilateral and feathers out peripherally in darkly pigmented patients
conj melanoma
nevus: has cysts / is mobile
hx: onset, progression, RFs (cutaneous melanoma, complexion, sun, FHx)
exam: look for other lesions, intraocular extension (evert lids, gonio, dilate), lymphadenopathy
testing:
- AS-OCT and UBM to assess extent of lesion
- if intraorbital suspect, then image CT brain/orbits/head/neck/chest
mgmt
-if small: observe and f/u 6mo
-if large / atypical: excisional biopsy w wide margins, no touch technique, double freeze thaw cryo to conj edge + alcohol epitheliectomy for K involvement + map biopsy of bulbar and palpebral conj
-if atypia or positive map biopsy): topical MMC (punctal plugs to minimize absorption)
-if intraocular: enuc
-if orbital involvement: exenteration
-if mets: chemo/radiation
-counsel
+pagetoid spread: >75% progress to invasive melanoma
+atypia: 50% progresses to melanoma
-atypia: rarely progresses to melanoma
–if melanoma: onc referral (sentinel node biopsy, LFTs + CT for mets workup, chemo/radiation)
–local disease @ 5yrs: 85% survival, 40% recurrence
–diffuse disease: poor survival
–f/u 3-4mo for monitoring
description
ddx
eval
mgmt
subconjunctival salmon-colored mass in fornix
-lymphoma (non-hodgkin’s; more rarely T cell lymphoma and hodgkin’s)
-lymphoid hyperplasia
-amyloidosis: small red/purple skin rash (picture)
-benign surface tumor (papilloma, pyogenic granuloma)
-malignant surface tumor (SSC, amelanotic melanoma)
hx: onset, progression, risk factors (h/o lymphoma, immune status, issues with other organ systems)
exam: ocular VS, hertel, lid lesions (evert), uveal lesions, choroidal lesions, optic nerve, adenopathy
testing: CT orbit to determine extent of lesion
-biopsy -> fresh path for PCR and flow cytometry (excisional if small, incisional ok if big)
-if lymphoma (most common MALT): local external beam radiation usually curative for lesions confined to the orbit; onc referral for systemic workup (CBC, pet/CT, MRI, bone marrow biopsy) +/- chemo
-good prognosis if local
-if systemic, ok prognosis if responsive to chemo
description
ddx
eval
erythematous medial canthal mass, inferior to the canthal tendon
dacryocystitis
preseptal cellulitis
lacrimal sac tumors
hx: onset, progression (fever, pain, discharge), RFs (trauma, surgery, sinusitis, prior episodes, immunocompromise)
exam: ocular VS, hertel, fluctuance, discharge w pressure, ?abscess, SLE, DFE, nasal endoscopy for polyps / masses / septal deviation / inverted papilloma
testing:
-culture any expressed exudates
-if atypical location or orbital signs (proptosis, RAPD, EOM limitation): CT for ?orbital process / sinus disease / tumors
mgmt of dacryocystitis
-sac pressure -> culture exudate
-if systemically well: PO abx (cephalexin) x 14days
-if systemically unwell or orbital cellulitis: IV abx (vanc + ctx) x 48hrs -> PO abx
-if unresponsive, then likely due to abscess: incision and drainage, pack open - risk of fistula
-DCR in 7-10 days, after inflammation has calmed down
-counsel: recurrence expected without DCR but otherwise good prognosis
description
ddx
eval
mgmt
left lower lid lesions w madarosis (lash loss)
-basal cell carcinoma: most common eyelid cancer, nodular most common type (pearly w telangiectasia), location I>M (most aggressive) >S>L, pathology w palisades and cracking artifac
-squamous cell carcinoma: painful mets (2/2 spreads along nerves), keratin pearls on path
-sebaceous cell carcinoma: most common in upper eyelid, foamy cytoplasm on path though can look similar to BCC - distinguish from BCC based on more mitotic figures
hx: onset, progression, associated symptoms (recurrent chalazion), RFs (h/o cancer, sun exposure, smoking, immunosuppression, FHx)
exam: full eye exam, lid eversion, caruncle, skin exam, lymphadenopathy
testing:
-biopsy; fresh for oil red O; map biopsy for sebaceous due to propensity for pagetoid spread (skip lesions)
-if any orbital involvement -> CT/MRI
mgmt
-for all: wedge resection (to clear margins, either Mohs or wide excision) + lid reconstruction;
-if caruncle involvement, need to eval lacrimal drainage system
-if orbital involvement: exenteration
-for BCC/SCC: IFNg
-referral to derm and onc for mets workup +/- sentinal LN biopsy (if large or lymphadenopathy)
-if mets: chemo/radiation (rads if low confidence in full excision)
-f/u: POW1, POM1, q3-4mo to monitor for recurrence or mets
-counsel sun protection, risk of mets and importance of surveillance
-cure rate is high for BCC
75F w chronic unilateral lid irritation
description
ddx
eval
erythematous right eye lids w madarosis
–sebaceous cell carcinoma: most common in upper eyelid, foamy cytoplasm on path though can look similar to BCC - distinguish from BCC based on more mitotic figures
-basal cell carcinoma: most common eyelid cancer, nodular most common type (pearly w telangiectasia), location I>M (most aggressive) >S>L, pathology w palisades and cracking artifacts
-squamous cell carcinoma: painful mets (2/2 spreads along nerves), keratin pearls on path
-unilateral blepharitis
hx: onset, duration, progression, associated symptoms (recurrent chalazion), RFs (h/o cancer, sun exposure, FHx)
exam: full eye exam, lid exam, K decompensation, skin exam, lymphadenopathy
testing: biopsy, if any orbital involvement -> CT/MRI
mgmt
-for all:
–wedge resection (to clear margins, either Mohs or wide excision) + lid reconstruction
–if extensive locally but not mets, then consider exenteration
-for BCC/SCC: IFNg
-for sebaceous: map biopsy due to propensity for pagetoid spread (skip lesions)
-referral to derm and onc for mets workup +/- sentinal LN biopsy
-if mets: chemo / radiation
-f/u: POW1, POM1, q3-4mo to monitor for recurrence or mets
-counsel sun protection, risk of mets and importance of surveillance
description
ddx
eval
mgmt
significantly loose and everted eyelids
floppy eyelids
vernal conjunctivitis / giant papillary conjunctivitis
atopic keratoconjunctivitis
toxic keratoconjunctivitis
hx: onset, duration, progression, associated symptoms (FBs, photophobia, discharge, seasonal, heavy snoring, daytime fatigue), RFs (OSA, obesity, HTN, meds)
exam: ocular VS, assess lid laxity / spontaneous eversions, assess K via fluorescein, look for features of vernal / atopic / infectious conjunctivitis, BMI, BP, heart exam
testing: sleep study if not already diagnosed
-lubrication (drops during the day, ointment/tape/moisture chamber at night)
-abx ointment if K epi defect
-if fails conservative mgmt, can consider eyelid tightening surgery
-counsel minimizing contact lens wear, proper mgmt of OSA lest HTN and cardiac disease
Nerve innervations
1. K sensation
2. lid closure
3. lid opening
- CN5
- CN7
- CN3
description
ddx
eval
mgmt
right lower lid ectropion
4 types of ectropion:
-involutional: age related laxity
-mechanical: mass effect (tumor)
-paralytic
-cicatricial
hx: onset, duration, progression, RFs (cancer, stroke, trauma, surgery, allergies, OCP, eyelid rubbing), assess severity (epiphora, symptoms bothersome?)
exam: evert lids (symblepharon, keratinization), look for lid architecture distortion or madarosis, ?lagophthalmos, ?exposure keratopathy / ulcers, skin lesions, neuro exam
-lubricate: tears, ointment
-if involutional: horizontal lid tightening (lateral tarsal strip; medial spindle for punctum)
-if mechanical: biopsy mass and excise with repair
-if paralytic: tarsorrhaphy vs. horizontal lid tightening vs. gold weight
-if cicatricial: excise scar and repair w graft
-counsel regarding r/b/a of different mgmt options
ddx
eval
mgmt
3 types of entropion:
-involutional: age related laxity + overriding orbic + disinsertion of the eyelid retractors
-spastic
-cicatricial (OCP, SJS, GVHD, chlamydia)
hx: onset, duration, progression, RFs (eyelid rubbing, prolapsed orbital fat, trauma, surgery, allergies, OCP), assess severity (epiphora, symptoms bothersome?)
exam: assess lid laxity, overriding orbic, prolapsed orbital fat, facial spasm, ?keratopathy / ulcers
-lubricate: tears, ointment
-BCL to protect K
-if involutional: horizontal lid tightening + eversion suture for orbic override + reinsert lid retractors
-if spastic: botox -> definitively orbic debulking
-if cicatricial: excise scar and repair w graft
-counsel regarding r/b/a of different mgmt options
unilateral pain over upper eyelid
description
ddx
eval
mgmt
inflamed lacrimal gland
dacryoadenitis
orbital cellulitis
idiopathic orbital inflammatory disease
lacrimal gland tumor / mets
hx: onset, duration, progression, associated symptoms (eyelid swelling, fever, discharge), RFs (viral/bacterial infection, sinus disease, cancer)
exam: ocular VS, hertel, resistance to retropulsion, lid eversion, palpate for masses, lymphadenopathy
testing: CBC if fever, CT orbit, culture any discharge
-empirically treat w abx for 24 hrs
-if orbital signs, admit for IV abx
-if no response to abx, trial steroids
-cool compresses and analgesics as needed
-follow daily to monitor for orbital involvement
-good prognosis if treated early and no complications from orbital involvement
dog bite
description
ddx
eval
mgmt
full thickness lid laceration at the medial margin
-full thickness margin-involving lid laceration
-full thickness margin and canilicular involving lid laceration
hx:
-mechanism of injury
-dog’s immune status
-patient’s immune status
-last PO
-med allergies
exam:
-full eye exam to assess damage (esp FB, open globe, muscle entrapment, K defect, RD)
-probe to assess canalicular involvement
testing: CT to assess orbital fractures
mgmt:
-IV broad spectrum abx (e.g. ampicillin) -> PO augmentin x2 wks
-consider rabies ppx
-surgical repair w intubation of canalicular system to prevent epiphora
-erythromycin ointment to wound x 5days
-counsel regarding face tape and intubation x 6-9mo - return to clinic if it falls out
-return precautions: worsening pain / erythema, discharge, fever
60M w growth on right eyelid
description
ddx
eval
mgmt
well circumscribed, telangiectatic, appears cystic lesion, no madarosis
hidrocystoma
inclusion cyst: 2/2 trauma or inflammatory conditions
squamous papilloma: HPV
basal cell carcinoma
eccrine gland carcinoma
hx: onset, progression (old photos), symptoms (painful, bothersome), RFs (cancer, previous eye lesions, other skin lesions, inflammation, allergy)
exam: palpate, transilluminate, ?madarosis, ?lid architecture distortion / umbilication, skin examination, lymphadenopathy
testing:
-likely benign thus not necessary unless patient eager for definitive diagnosis, then can biopsy w path
mgmt
-photo for documentation and monitoring
-observe vs. excisional biopsy w path
-educate patient about different eyelid lesions and how they may return upon removal
-if monitoring, f/u 2mo
-return precautions for any changes to the lesion
dx
inclusion cyst
dx
squamous papilloma
rare dx
eccrine gland carcinoma
ddx
eval
mgmt for chlamydia
viral conjunctivitis (adenovirus)
–recent onset, unilateral to bilateral spread, watery discharge x 10-14 days
–subepithelial infiltrates can irritate and decrease vision (later stages)
–pre-auricular adenopathy
herpes
–skin lesions, dendrites etc.
–pre-auricular adenopathy
chlamydia
–STD/international travel
–pre-auricular adenopathy
-Herbert’s pit
lyme
-bull’s eye rash
-hearing loss
parinaud’s oculoglandular syndrome
- follicular conj w lymph node involvement from e.g. bartonella cat scratch disease
molluscum
–umbilicated lid lesions
–no pre-auricular adenopathy
medicamentosa
–no pre-auricular adenopathy
acute: viral
chronic: trachoma, lyme, molluscum, medicamentosa
hx: onset, progression, associated sxs (pain, vision change, discharge, fever, URI, STD), RFs (sexual history, immune status, cat), eval for papillary conjunctivitis (allergy, atopic, OSA, contact lens)
exam: ocular VS, evert lids, arlt’s line, K infiltrate, keratitis, herbert’s pit, lymphadenopathy
testing: chlamydia ELISA / giemsa stain / PCR
mgmt:
- PO azithro x1 dose or doxy x 7 days
- treat partners
- counsel: spontaneous resolution in 6-18mo without treatment
Routes of seeding for orbital cellulitis
direct inoculation from skin break
contiguous spread from sinusitis or dacryocystitis
hematogenous spread from systemic infections
