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(2) introductory ocular disease > Lids, Lashes & Tears > Flashcards

Lids, Lashes & Tears Flashcards

1
Q

Ectropion:

A

Outward rotation of the eyelid margin (usually
• 70% bilateral

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2
Q

Ectropion: Causes and risk factors

A

Causes:
• Involutional
• Cicatricial
• Paralvtic
• Mechanical
• Congenital

Pre-disposing factors:
• Age - as lid laxity increases

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3
Q

Ectropion: Symptoms

A

• Sore - pain / discomfort / grittiness
• Red
• Watery
• Variable depending on severity

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4
Q

Ectropion: Signs

A

• Lower lid not opposed to globe
• Punctum in abnormal position
- visible without touching lid
• Exposure keratopathy
• Conjunctival hyperaemia
• Epiphora

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5
Q

Ectropion: Tests

A

• Distraction test
lower lid pulled from globe o lax >6mm

• Snap-back test
Indicates poor orbicularis tone if poor recovery

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6
Q

Ectropion: Management

A

Mild Cases
• Reassurance & advice
• Lid rubbing may increase laxity
• Ocular lubricants

Manage exposure keratitis
• Tape lids closed to reduce exposure
• Therapeutic contact lenses
• Ocular lubricants

Moderate to severe cases
• Where significant corneal involvement and risk of infective keratitis
• Recurrent infections
• Affecting quality of life
• Refer for consideration for surgery

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7
Q

Floppy eyelid syndrome:

A

• Often the presenting symptoms which are worse in the morning, - dry, gritty eyes, affecting the eye on the side they normally sleep
• Typically affects middle aged obese men
• Spontaneous lid eversion
• Can cause dry eye and chronic papillary conjunctivitis
• Increased lid laxity:
- Abnormal distraction and snap back test

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8
Q

Entropion:

A

Inward rotation of the tarsus and lid margin
Lashes to come into contact with the ocular surface

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9
Q

Entropion: Causes and risk factors

A

Causes:
• Involutional
• Cicatricial
• Spastic
• Congenital

Predisposing factors:
• Age
• Severe cicatrising disease affecting the tarsal conjunctiva
Ocular irritation or previous surgery

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10
Q

Ectropion: Symptoms

A

• Irritation
• Foreign body sensation
• Red
• Watery
• Blurred vision

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11
Q

Ectropion: Signs

A

• Corneal/conjunctival disturbance
• Conjunctival hyperaemia
• Lid laxity (involutional entropion)
• Conjunctival scarring (cicatricial entropion)
• Absence of lower lid crease (congenital entropion)
• Distraction Test
• Snap Back Test

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12
Q

Ectropion: Management

A

• Depends on severity of symptoms

• Taping the lid to the skin of the cheek
- pull it away from the globe
- temporary relief
• Epilation of lashes
• Ocular lubricants
- drops for use during the day
- unmedicated ointment for use at bedtime
• Therapeutic contact lens to protect cornea from lashes

• Referral for surgical intervention
- Persisting symptoms despite above tx
- Recurrent infection
- risk of microbial keratitis

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13
Q

Trichiasis: Describe

A

Inward misdirection of eyelashes towards the cornea
Secondary to a number of conditions

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14
Q

Trichiasis : Causes and risk factors

A

Causes
• Congenital - failure of epithelial germ cells to differentiate completely to Meibomian glands
• Acquired - the result of another condition (entropion, abnormal growth following injury, Stevens-Johnson syndrome, or chronic blepharoconjunctivitis)

Predisposing factors
• Staphylococcal blepharitis
• Cicatricial conditions
• HZO (discussed in infections lecture)

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15
Q

Trichiasis: Symptoms

A

• discomfort, irritation
• foreign body sensation
• watery eye
• red eye

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16
Q

Trichiasis: Signs

A

• Lash(es) in contact with ocular surface
• Conjunctival hyperaemia
• Corneal epithelial abrasion
• Fluorescein staining of cornea/conjunctiva

• Chronic, severe signs:
- Pannus
- corneal ulcer
- infective keratitis

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17
Q

Trichiasis: management

A

• Epilation
- may require frequent visits

• Manage underlying cause
- Entropion
- Blepharitis

• Therapeutic contact lenses
• Ocular lubricants

• Refer if severe (significant corneal involvement)
- Electrolysis, laser photocoagulation

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18
Q

Chalazion: Describe

A

• Inflammatory and sterile lump
• Blockage of secretory gland in lid
- Meibomian gland
- Glands of Zeus & Moll

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19
Q

Chalazion: causes and risk factors

A

• Causes
- Spontaneous
- Following acute infection - internal hordeolum

• Risk Factors
- Chronic blepharitis
- Rosacea
- Seborrheic dermatitis
- Pregnancy
- Diabetes mellitus

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20
Q

Chalazion: Symptoms

A

• Painless lump (s)
• Can be recurrent
• Sometimes after infection
• Gradual increase in size (weeks/months)
• Blurred vision (if larger can induce astigmatism)

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21
Q

Chalazion: Signs

A

• Well-defined solid nodule in tarsal plate
• Lid eversion - external conjunctival granuloma
• Induced astigmatism/hyperopia
• May be associated blepharitis

22
Q

Hordeolum: Describe, predisposing factors

A

• Acute staphylococcal infection of the glands
• Usually tender and red

Predisposing Factors
• Chronic blepharitis

23
Q

Hordeolum: Types

A

Internal
• Infection of meibomian gland (internal)

External
• Infection of glands of Zeiss & Moll (external) and lash follicle (also known as a Stye)

24
Q

Hordeolum: Symptoms

A

• tender lump in eyelid
• sometimes painful
• epiphora / sticky discharge
• local redness of eye and lid

25
Q

Hordeolum: Signs

A

• Tender inflamed swollen area on lid / in tarsal plate
• May involve entire lid in more severe cases
• May point anteriorly through the skin or posteriorly through conjunctiva

26
Q

Chalazion: Management

A

• Hot compresses, hot spoon, steaming
• Lid massage
• Manage any associated blepharitis
• Advice
- Weeks/ months to resolve
- If large / disrupting VA refer for Incision and curettage / steroid injection
• No need for antibiotic as not associated with infection

27
Q

Hordeolum Management:

A

• None - most resolve spontaneously

• Hot compresses, hot spoon, steaming

• Manage any associated blepharitis

• Remove associated lashes (external hordeolum)

• Advice
- internal hordeolum may evolve into chalazion
- May take weeks or months to resolve

• IF non resolving /significant discharge/multiple
> Antibiotic ointment (Chloramphenicol 1% gds 5-7 days)
> Oral antibiotic (flucloxacillin 500mg qds 7-14 days, IP Optom / GP)

28
Q

Describe Blepharitis and its types

A

• Lid Margin Disease

• 3 types:
- Anterior (affects lashes)
- Posterior (affects meibomian glands)
- Mixed

29
Q

Blepharitis: ALL Symptoms

A

• Similar symptoms for all types
• Can’t be used as differential diagnosis between types

• Hx of bilateral problems, chronic and likely relapsing
• Ocular discomfort, gritty, burning, itching
• Mild photophobia
• Symptoms of Dry Eye ( as a consequence of blepharitis )

30
Q

Blepharitis: Predisposing factors

A

• Demodex
• Seborrhoeic Dermatitis
• Rosacea
• Long term contact lens wear

31
Q

Blepharitis: Subtypes

A

• Anterior Bleph
- Staphylococcal
- Seborrhoeic
- Demodex

• Posterior Blepharitis (Meibomian Gland Dysfunction)
- MG Obstruction (blockage = reduced lipid secretion) - MOST COMMON
- MG Hypersecretion (excess lipid secretion)

32
Q

Anterior Bleph : Signs
Staphylococcal

A

• Hard, brittle scale
• madarosis
• Lash misdirection
• Recurrent styes

• Corneal involvement
- Inferior staining
- Pannus
- Marginal keratitis
• Lid margin hyperaemia, swelling, crusting • Conjunctival hyperaemia
• Chronic papillary conjunctivitis

33
Q

Anterior Bleph : Signs
Seborrhoeic

A

• Lid Margin hyperaemia
• Conjunctival hyperaemia
• Greasy lid margin deposits
• Associated seborrheic dermatitis

34
Q

Anterior Bleph : Signs
Demodex

A

• Lid margin hyperaemia
• cylindrical crusting (collarette)
• Chronic infestation; madarosis, trichiasis

35
Q

Posterior Bleph : Signs
Meibomian Gland Obstruction (most common)

A

• Thickened , white material on expression
• Conjunctival and Lid hyperaemia
• Abnormal lipid plugging lipid openings
• Chalazia

• Evaporative Dry Eye Signs
- Reduced tear break up
- Unstable tear film

• Corneal involvement
- Typically inferior third
- Marginal keratitis
- Pannus, scarring, neovascularisation (severe chronic cases)

36
Q

Posterior Bleph : Signs
Meibomian gland hyper secretion

A

• As with MD obstruction
• Foamy tears - excess lipid

37
Q

Blepharitis - Investigations

A

• Slit lamp exam of lid margins
- Expressing glands using gentle pressure to examine meibum
- Dry Eye assessment

38
Q

Blepharitis - First line management

A

• Advise:
- Long term management required, avoid eye cosmetics, return if symptoms persist despite compliant with tx

• Lid hygiene - FOR ALL TYPES
> Cleansing/cleaning
> Compresses (hot)
> Treat underlying associations

39
Q

Blepharitis : Treat underlying associations (entry)

A

• Staphylococcal and seborrheic:
- Chloranphenicol ointment, 4 weeks
• Demodex infestation:
- Tea tree oil
• Treat dry eye

40
Q

Blepharitis : Treat underlying associations (IP optometrist/GP)

A

• Mild topical steroid
• Oral tetracycline antibiotic

• Refer
- If persisting symptoms/significant non/resolving/progressing corneal disease

41
Q

Dry eye: Describe

A

• Loss of homeostasis of tear film
• Accompanied by ocular symptoms

42
Q

Dry eye: Types

A
  1. Aqueous deficient
  2. Evaporative dry eye
43
Q

Dry eye: Aqueous deficient subtypes

A

• Inflammatory/systemic diseases
• Lacrimal gland secretions reduced/blocked

44
Q

Dry eye: Evaporative dry eye subtypes

A

• Meiboian gland disorders
• Lid aperture disorders
• Ocular surface disease

45
Q

Dry eye: predisposing factors

A

• Females > Males = 3:2
• Increased Age (prevalence increases with increasing age)
• Posterior blepharitis

• Environmental factors exacerbate problems:
- Smoke
- Heating, air conditioning
- Computer use
- Contact lens wear
- Long term use of eye drops (preservatives)

46
Q

Dry eye: symptoms

A

Hx very useful, often makes diagnosis
• Itching
• Burning
• Stinging
• Foreign body sensation, grittiness
• Dryness
• Blurring of vision
• Watering
• Stringy Mucous

Symptoms made worse by environment, normally bilateral, Hx of dry mouth/systemic diseases

47
Q

Dry eye: Main signs

A

• Reduced tear film break up time
- NIBUT <10-15secs
- FTBUT <10secs

• Ocular staining
- Cornea, conjunctiva, lid margin

• Reduced tear volume
- Tear meniscus height, using NaFl <0.2mm in height

48
Q

Dry eye: Other signs

A

• Lid wiper Epitheliopathy
• Mucus strands
• Filaments
• Dellen (thinning)
• Reduced corneal sensitivity
• Increased tear osmolarity

49
Q

Dry eye: Management
Non-pharmacological

A

• Px education & advice
• diet rich in omega-3 essential fatty acids

• Treat cause
• Tear preservation (punctual plugs)

50
Q

Dry eye: Management
Pharmacological

A

Pharmacological
• Artificial tears / lubricants
• Dependent upon severity consider options:
- Viscosity
- Preservative Vs Preservative Free?
- Contains lipid substitute?

• Mild / moderate - Carbomer 980 0.2%
• No improvement/more severe - PF sodium hyaluronate
• Short term use topical steroids (IP Optoms)

51
Q

Dry eye: Management
Referral

A

• Significent corneal inflammation and no improvement with Tx
• Risk of microbial keratitis
• Suspicion of Siogrens

(2) introductory ocular disease (16 decks)

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