Pupil and Eyelid Disorders Flashcards by Meg Beese

What causes pupil constriction?

The parasympathetic fibres which travel with the Oculomotor nerve and innervate the circular muscles/sphincter pupillae

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What causes pupil dilation?

Muscles in the eye that are innervated by adrenaline.

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What causes abnormal pupil shape?

Trauma to the iris
Cataract surgery, other eye operations
Anterior uveitis
Acute angle closure glaucoma (due to ischaemic damage to the muscles)
Rubeosis iridis - neovascularisation of the iris.
Coloboma - genetic malformation of the eye
Tadpole pupil - spasm in the dilator muscles causing misshapen pupil associated with migraines.

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Causes of mydriasis?

mydriasis - dilated pupil

3rd nerve palsy 
Raised intracranial pressure
Trauma 
Congenital 
Stimulants 
Anticholinergic medications

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Causes of miosis?

Pupil constriction

Horners
Cluster headache 
Neurosyphillis 
Opiates 
Nicotine
Pilocarpine eye drops

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How does a third nerve palsy present?

Ptosis - drooping eyelid
Mydriasis
Divergent strabismus - down and out position

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Why do you get ptosis in a third nerve palsy?

Due to defective innervation of the elevator palpebrae superioris

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What is the course of the 3rd nerve through the skull to the eye?

Travels in a straight line through the cavernous sinus

Travels close to the posterior communicating artery

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What are the causes of a third nerve palsy?

Can be idiopathic

sparing of the pupil? Microvascular cause as the parasympathetic fibres are spared.

Without sparing of pupil? Compression with a tumour, trauma, cavernous sinus thrombosis, posterior communicating artery aneurysm, raised ICP

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What is Horners syndrome?

Triad of ptosis, miosis and anhydrosis.

Enophthalmos is common.

Light and accommodation reflexes are not affected.

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What causes Horners syndrome?

Damage to the sympathetic nerves to the eye.

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What is the course of the sympathetic trunk?

Starts in the spinal cord at a thoracic level and ascends up the spinal cord (preganglionic nerves) and enter the sympathetic ganglion at the base of the neck.

Exit sympathetic ganglion as postganglionic nerves. Travel to the head alongside the internal carotid artery.

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How do you locate the lesion of Horners syndrome?

This can be deducted depending on the location of the anhydrosis.

Central lesions - arm, trunk and face

Preganglionic lesions - face only

Postganglionic lesions - no anhydrosis

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What are the causes of Horners syndrome?

The 4 S’s, the 4 T’s and the 4 C’s

Central (S)
Stroke
multiple Sclerosis 
Swelling (tumours) 
Sringomyelia

Torso
Tumour (pan coast)
Trauma
Thyroidectomy
Top rib (cervical rib)

Cervical
Carotid aneurysm
Carotid artery dissection
Cavernous sinus thrombosis 
Cluster headaches

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What condition is associated with Horner’s syndrome?

Heterochromia - these patients can be born with Horners syndrome

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How do you test for Horner’s syndrome?

Cocaine eyedrops

In patients with no pathology, this will cause dilation of the pupil.

In Horner’s syndrome there will be no pupillary changes

Adrenaline drops will dilate a pupil with Horner’s syndrome but not with a healthy pupil.

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What is a Holmes Adie pupil?

Unilateral dilated pupil that is sluggish to react to light, caused by damage to the postganglionic parasympathetic fibres.

Causes unknown, may be viral.

What is Holmes Adie syndrome?

Holmes Adie pupil with absent ankle and knee reflexes.

What is an Argyll Robertson pupil?

Specific finding in neurosyphillis (Prostitute pupil)

Constricted pupil that focuses on near objects (constricts) but does not react to light.

ie. Accommodation reflex present but pupillary reaction to light absent.

What is blepharitis and what is it associated with?

Inflammation of the eyelid margins causing a gritty/dry sensation in the eye. Associated with dysfunction of the meibomian glands

What can blepharitis cause?

Styles and chalazions.

Management of blepharitis?

Hot compresses and gentle cleaning of eyelid margins.

Lubricating eyedrops to relieve symptoms - e.g. Hypomellose drops (last 10 mins), polyvinyl alcohol (middle viscous), carbomer drops (30-60 minutes).

What is a stye?

Also known as Hordeolum externum. Infection of the gland of Zeis (sebaceous glands at the end of eyelashes) or gland of Mol (sweat glands at the base of eyelash).

Tender gland at the base of the eyelid.

Managed with hot compress and analgesia to help with symptoms.

What is a chalazion?

AKA Hordeolum internum - infection of meiobian glands. May point inwards towards the eye underneath the lid.

Treated with hot compress and analgesia. Chloramphenicol can be considered if associated with conjunctivitis. Surgical drainage required as a rarity.

What is entropian?

Eyelid turns inwards with lashes against the eyeball. Can cause damage/ulceration of cornea.

Management of entropion?

Taping eyelid to prevent turned downwards and use regular lubricating eyedrops to prevent eye drying out. Surgical procedures.

What is ectropion?

Eyelid turns outwards with inner aspect of eyelid exposed. This affects bottom lid and leads to exposure keratopathy.

Management of ectropion?

Mild cases do not require treatment. Lubricating eyedrops prescribed to keep eye lubricated. Surgical procedures can be considered.

What is trichiasis?

Inward growth of the eyelashes. This results in pain and corneal ulceration.

Management of trichiasis?

Same day referral to ophthalmology as sight risking condition. Epilation is first line management. recurrent cases may require cryotherapy, laser therapy, etc.

What is peri-orbital cellulitis and how do you differentiate from cellulitis?

Skin and superficial tissue inflamed around the orbit. Painful and inflamed. Differentiated from orbital cellulitis is orbital movement is maintained and can be ruled out with CT scan.

Management of peri-orbital cellulitis?

PO or IV antibiotics as per local guidelines (usually Co-Amoxiclav PO 7 days)

What is orbital cellulitis?

Infection around eyeball involving tissues behind orbital septum. Pain on eye movement, reduced eye movements and changes in vision. Abnormal pupil reactions and proptosis.

Management of orbital cellulitis?

Medical emergency - immediate admission required and IV antibiotics (IV Ceftriaxone as per Leicester guidelines, add Metronidazole IV if nasal septum assumed to be involved). At least 10 days of antibiotics required. Sometimes surgical drainage required.

What is conjunctivitis?

Inflammation of the conjunctiva - the thin layer of tissue that covers the inside of the eyelid and the sclera of the eyeball its self. Bacterial, viral or allergic in aetiology

Clinical presentation of conjunctivitis?

Unilateral or bilateral red eyes Itchy/gritty sensation Discharge from eye common. Does NOT cause pain, photophobia or reduced visual acuity.

How does bacterial conjunctivitis present?

Purulent green discharge with pus. Inflamed conjunctiva Eyelids stuck together on waking up Highly contagious

How does viral conjunctivitis present?

Associated with clear discharge Associated with coroyzal symptoms Tender pre-auricular lymph nodes. Also very contagious

Differential diagnosis of an acute red eye?

Red eye with no pain and visual acuity in tact: Conjunctivitis Episcleritis Subconjunctival haemorrhage ``` Painful red eye Glaucoma Anterior uveitis Scleritis Corneal abrasions/ulcerations Keratitis Foreign body Trauma to the eye ```

Management of conjunctivitis?

Usually self resolving in 1-2 weeks Hygiene advice - do not share towels, don't rub eyes and don't wash hands. Avoid use of contact lenses. Clear discharge using cooled boiled water and cotton wool swab. Antibiotic eye drops (chloramphenicol or fusidic acid). If <1 month old - urgent ophthalmological review as associated with gonococcal infection and is sight threatening.

What is allergic conjunctivitis?

Contact with allergens causing swelling of conjunctiva and eyelids. Managed with antihistamines (PO and topical) or mast cell stabilisers (e.g. sodium cromoglycate)