wk7: AED - Complex Conjunctivitis and Lids and Blepharitis Flashcards
Is ophthalmia neonatorum usually unilateral or bilateral?
bilateral
List the causes of ophthalmia neonatorum (5)
Chlamydia
Gonococci
Herpes Simplex
Simple bacterial conjunctivitis
Chemical
Which cause of ophthalmia neonatorum is the most common in the U.S?
Chlamydia
Of the causes of ophthalmia neonatorum, which ones are via exposure during delivery? (3)
Chlamydia
Gonococci
Herpes Simplex
Which pathogens/substances cause ophthalmia neonatorum due to exposure after delivery? (2)
Simple bacterial conjunctivitis (usually post-delivery)
Chemical
At what times do the different types (based on causes) of ophthalmia neonatorum manifest? (5)
Gonococcal: manifests 24-48 hours after delivery
Herpes Simplex: manifests around 1 week after delivery
Chlamydial: manifests around 2nd week after delivery
Simple bacterial - not stated, probably varies. Chemical -probably depends, but you’d expect quick onset. Silver nitrate drops for instance have onset 2 hours
How long does ophthalmia neonatorum from silver nitrate drops last?
About 24 hours
Why would you administer silver nitrate drops to babies? (1)
prophylaxis for gonococcal infection
What dfferential diagnosis exist for ophthalmia neonatorum? (1) How does this differ?
Nasolacrimal duct obstruction - has a bit of gooey eye you can wash out with no sign of redness
How do you treat chemically caused ophthalmia neonatorum?
irrigate with sterile saline and frequent non-preserved artificial tears
How do you treat non-chemically caused ophthalmia neonatorum? (1.5)
Immediate referral for isolation of pathogen and tx with appropriate antibiotic/antiviral
What are the 2 types of adult chlamydial conjunctivitis?
Adult inclusion conjunctivitis
Trachoma
What 3 species are responsible for chlamydial conjunctivititis in adults?
C. trachomatis
C. psittaci
C. pneumoniae
Is C. trachomatis in humans more or other animals?
almost exclusively human
What serotypes of C. trachomatis are involved in trachoma? (4)
A, B, Ba, C
What serotypes of C. trachomatis are involved in inclusion conjunctivitis or paratrachoma? (1)
Serotypes D-K
What do C. trachomatis serotypes L1, L2 and L3 do? (1.5)
are agents that infect tissues deeper to the epithelium and cause lymphogranuloma venereum
When does ophthalmia neonatorum present?
Within first 4 weeks of life
How is adult inclusion conjunctivitis most commonly transmitted? (1)
sexually
What are the symptoms of adult inclusion conjunctivitis? (6)
mucopurulent discharge (or watery)
gritty FB sensation
sometimes blurred vision (uni or bilateral)
often chronic, may seem acute
often assoc. with urethritis, vaginitis, cervicitis
high percentage of chlamydial STDs asymptomatic
List the signs of adult inclusion conjunctivitis (5)
Usually unilateral
Follicles (particularly upper tarsal conjunctiva, limbal follicles also possible)
Conjunctival chemosis
Preauricular or submandibular lymphadenopathy common
Marginal subepithelial corneal infiltrate + superior pannus in chronic prolonged cases
Define pannus
an abnormal layer of fibrovascular tissue or granulation tissue. e.g. a corneal pannus means the growth of fine blood vessels onto the clear corneal surface
How hard is adult inclusion conjunctivitis to treat?
Very easy to treat, just one tablet. GP will prescribe - 1 azithromycin will take care of it. However, the chlamydial version will have to be tracked by the health department as it’s a transmissable disease so a swab will need to be taken.
What ddx exist for adult inclusion conjunctivitis? (3)
adenoviral keratoconjunctivitis
herpes simplex keratitis
trachoma
List treatment strategies for adult inclusion conjunctivitis (4)
Refer px + sexual partners to GP or sexual health clinic for lab test
Co-existing infections also need to be identified and treated
Mx of ocular signs+symptoms with topical tetracycline (note: does not treat full extent of systemic)
Oral medication critical: azithromycin 1gm PO or erythromycin 250mg QiD 2 to 6 weeks
What is the main problem associated with trachoma?
While it is a mild infection, the problem comes with repeated reinfections in poor hygeine areas. People can get up to 200 reinfections. Can lead to blindness due to this
List the symptoms of trachoma (3)
onset in early childhood with early FB sensation
often unilateral (initially), mucopurulent discharge with prolonged, remittent course (appears recurrent)
scarring trachoma leads to trichiasis, dry eye and reduced vision due to corneal opacities
What might early trichiasis lead to for the patient on presentation? (1)
significant corneal pain
What are the signs of trachoma? (5)
main sign: superior bulbar + palpebral conjunctival follicular response
chronic inflammation (over many years), causes:
- conjunctival scarring (e.g. Arlt’s line)
- corneal infilitrates
- superior corneal pannus
- scarring of limbal follicles (Herbert’s pits)
What is the main cause of blindness in people with trachoma? (1)
Trichiasis
In trachoma grading, what do the following acronyms stand for:
TF
TI
TS
TT
CO
TF: trachomatous inflammation, follicular
TI: trachomatous inflammation, intense
TS: trachomatous scarring
TT: trachomatous trichiasis
CO: corneal opacity
What ddx exist for trachoma? (4)
adult inclusion conjunctivitis
other causes of conjunctival cicatrisation
other causes of recurrent conjunctivitis
other causes of superior corneal pannus
How do you tx trachoma? (5)
ID source of exposure
Refer for surgical tx
Corneal grafts rarely successful
Inactive scarring requires topical lubrication + other dry eye mx approaches
Prevention: improved hygeine, access to clean water, fly reduction programs
Do you treat a community that has endemic trachoma with azithromycin?
No you have to deal with the hygeine first. Otherwise, the people you treat will just get it again from poor hygeine and/or others in the community. So you’d have to keep treating them which would build up potential azithromycin resistance
Can anterior and posterior blepharitis coexist?
yes. Often these 2 conditions can coexist
What proportion of blepharitis patients have posterior blepharitis? Is posterior blepharitis more common or less common than anterior?
About 70-90% of blepharitis patients have posterior blepharitis (so posterior is more common)
How can we differentiate anterior blepharitis (i.e. blepharitis ocurring on anterior lamella) from posterior? (2.5)
Can use:
- Marx’s line (grey line posteriorly)
- skin on anterior surface
So a simple way to tell if it’s anterior is to see if the blepharitis is anterior to the grey line. If it’s anterior to the grey line that means it’s anterior blepharitis (note: delimited = marked boundary)
Define blepharitis
Inflammation of eyelid
What is the mechanism cause behind posterior blepharitis?
meibomian gland dysfunction
How can you categorise anterior (lamella) blepharitis? (2) Can both of these occur at same time?
staphylococcal anterior blepharitis (bacteria)
seborrheic anterior blepharitis (scalp dandruff) (more common)
Describe seborrheic anterior blepharitis
eyelashes become greasy and stuck together. A very waxy product
Where does anterior blepharitis occur? (1.5)
infection involves the lid margin anterior to the meibomian glands and including the lashes
In regards to anterior blepharitis:
- is it usually unilateral or bilateral?
- symmetrical or asymmetrical?
- acute or chronic?
Usually:
- bilateral
- symmetrical
- chronic
What happens to the skin and lid margins in anterior blepharitis? (1)
they become scaly and oily
Name a reason why staph and seborrheic blepharitis co-occur
seborrheic lid condition promotes excess growth of skin staph. colonies
What is the consequence of staph predominating over seborrhea in anterior blepharitis? (2)
staph exotoxins cause ocular surface and lid margin irritation, inflammation
List the symptoms of anterior blepharitis (3)
Ocular surface burning and FB sensation
Sticky crusting along lid margins
Mild photophobia (corneal PRR/SPK)
What is the hallmark sign of anterior blepharitis? (1)
Crusting
What are the signs of anterior blepharitis?, excluding long standing cases (4)
Redness/telangiectasia/thickening of anterior lid margin
Lid crusting at base of lashes (note: if staph, = oily ‘scurf’; If sebor, = crust)
Excessive lipid on lid margin
Poor tear film and/or marginal keratitis
What are the signs of long-standing anterior blepharitis? (6)
Mild, chronic papillary conjunctivitis
Trichiasis, madarosis (lash loss) and poliosis (lash pigment loss)
Recurrent bacterial conjunctivitis
External/internal hordeolum
Lid/lash base ulceration (recurrent staph infection)
Bacterial keratitis
If you suspect blepharitis, and they don’t have crusting, what question is useful to ask?
Did they have crusting in the morning that they wiped off
What ddx exist for anterior blepharitis? (3)
posterior blepharitis
basal, squamous or sebacious cell carcinoma
dry eye syndrome
How do you assess anterior blepharitis? (4)
Careful symptomology
Slit lamp (lid margins and ocular surface) with fluorescein
Tear work up
Skin assessment (associations)
How do you treat anterior blepharitis? (4)
Lid therapy (mainstay tx)
Tear supplements (for ocular surface problems)
Antibiotic ointment (for if staph infection)
Mild topical steroids
How would we carry out lid therapy on patients with anterior blepharitis? (2) When should we follow up lid therapy to check success? (1)
Scrub lid margins with low irritant surfactant (e.g baby shampoo or commercial products)
Sterile sodium bicarbonate sol. (also useful) up to 4 x day (works for staph, seborr)
Follow up the lid therapy 2-4 weeks to gauge success
When might hot compresses and lid massage be provided to patients with anterior blepharitis? (1)
Only when co-existing POSTERIOR blepharitis is present
How do you apply antibiotic ointment to anterior blepharitis patients? (1)
rub the ointment into the lid margins
What is the purpose of topical steroids for anterior eye patients? (1)
reduces inflammation along lid margin
What surgical technique could benefit a patient with meibomian gland dysfunction? (1)
Meibomian gland expression
Briefly explain meibomian gland expression (1). What might you find in an MGD patient when doing so? (4)
manually express the miebomian glands to secrete their contents.
Findings include:
- some glands won’t secrete
- some glands may secrete fetta cheese like substance
- some glands may secrete gooey toothpaste like substance
- some glands may secrete oily substance (what you want)
(note: don’t necessarily expect to find all of this in one patient)
If manually expressed meibomian glands are producing an unusual substance, what does this say about the tear film? (1)
unstable
How painful is meibomian gland expression? (1) What can you do to reduce pain from this procedure? (1)
Very. You can pre-warm the meibomian glands (e.g. warm compress) so they flow better, to reduce pain
Explain Lipiflow (3)
Lipiflow thermal pulsation system:
A device used for meibomian gland expression that uses heat and peristaltic motion to evacuate obstructed meibum. One section of the device goes behind eyelids to provide warmth, while an outer section gently massages the lids against the inner section
What condition can meibomian gland expression be helpful for treating? (2)
MGD associated with anterior blepharitis
or just MGD on it’s own
How long did an observational study find Lipiflow to be effective for? (1)
effects lasting up to 3 years after a single treatment
What is the major limitation of Lipiflow? (1)
Expensive: around 1800 dollars per treatment
What does IPL stand for (1) and how can it be used to treat meibomian gland dysfunction? (2)
Intense Pulse Light: acts like a heat lamp to melt secretions and open blocked meibomian glands
How frequently is IPL treatment undertaken in patients with MGD?
3-4 treatments over several months
Is this technique a conclusive way to treat MGD?
No, however the technique is showing promise
What is noteworthy about demodex? (2)
Causes blepharitis and it doesn’t have an anus
How does incidence of demodex change with age? (1)
incidence increases exactly with age: 20% of 20 year olds have it, 80% of year olds have it
Are demodex infestations a sign of poor hygeine?
Not necessarily
Name 2 treatments to kill demodex
TTO (tea tree oil)
Ivermectin 3mg one tablet PO
What is the disadvantage of tea tree oil? (1)
toxic to cornea and conjunctiva
How often and at what dose do you apply tea tree oil in patients with demodex?
weekly application of 50% TTO combined with daily use of TTO shampoo or lid wipes
What causes ocular rosacea? (1)
Unknown
What is Ocular Rosacea?
An inflammation of the eye causing redness, burning and itching that typically is an ocular manifestation of rosacea, a chronic skin condition that involves acne like appearance and red patches on the skin
What is a classic hallmark of a patient with ocular rosacea?
butterfly rash across nose and cheeks
If you suspect a female patient has ocular rosacea but don’t see a butterfly rash, what might you ask the patient?
Ask patient to come into clinic early without their makeup to see if it was covered by the makeup
How does rosacea present on the face typically? (2)
butterfly rash
mild erythema with telangiectasia to nodular eruptions of cheeks and nose
What is erythema?
superficial reddening of the skin, usually in patches
Define telangiectasia
a condition characterised by dilation of capillaries causing them to appear as small red or purple clusters on the skin
What gender is more often affected by rosacea?
male incidence higher than female
What age group is most commonly affected by rosacea?
30-40 years of age
What lifestyle choices may exacerbate rosacea in a patient? (2)
alcohol
spicy food
can rosacea result in postules and scarring?
yes
What is a postule?
a small blister or pimple on the skin containing pus
What percentage of rosacea cases have ocular involvement?
5-10%
List the symptoms of ocular rosacea (5)
facial flush
red eye
recurrent styes and chalazia
burning/gritty sensation
photophobia
List the signs of ocular rosacea (6)
Blepharitis (usually MGD) with possible purulent discharge from MGs
Telangectasia of lid margin
Conjunctivitis
Chalazion/Internal hordeolum
Keratitis (SPK to corneal thinning)
Rarely results in: corneal scarring, corneal neovascularisation, corneal thinning and perforation
What ddx exist for ocular rosacea (2)
Blepharitis without rosacea
Other forms of non-infective conjunctivitis and keratitis
How can you treat ocular rosacea? (5)
Topical antibiotic (if microbial association)
Oral tetracyclines or macrolides - mainstay tx
Lid therapy (for ant + post bleph)
Tear supplements
Mild topical steroids
What can you use to tx skin rash in a patient with ocular rosacea? (2)
metronidazole gel
oral tetracyclines or macrolides
What benefit to topical steroids provide in tx of ocular rosacea? (2)
treatment of conjunctival inflammation and keratitis
