4 - Lids/Lashes/Lacrimal

Question 1

Dermatochalasis

Answer 1

Elderly

Weak orbital septum -> redundant upper lid skin -> ptosis, pseudoptosis, loss of distinct lid creases, superior VFD

Question 2

Blepharitis

• ant vs post
• symptoms
• staph vs seb

Answer 2

Gray line (most ant Riolan) divides, posterior = meibomitis

Often asymptomatic; vision that clears after blinking, burn/itch/fbs, tearing, CRUSTING IN THE MORNING, mild discharge

Seborrh: oily/greasy/flaky, less inflammation, more madarosis and/or misdirected growth
-assoc with seb dermatitis

Question 3

Chalazion

• history
• pathophys
• signs/symp

Answer 3

Often have hx of similar recurrent lesions - ask about ACNE ROSACEA and seborrheic dermatitis
-evaluate for sebaceous gland carcinoma

Chronic, localized, STERILE INFLAMMATION of meibomian gland

• due to retention of normal secretions
• 25% resolve spontaneously

HARD, PAINLESS, IMMOBILE nodule without redness
Usually upper lid, asymptomatic

Question 4

Hordeolum

• history
• pathophys
• signs/symp

Answer 4

Often have hx of similar recurrent lesions - ask about ACNE ROSACEA and seborrheic dermatitis
-can lead to preseptal

Acute STAPH INFECTION of glands

• internal = meibomian
• external = moll/zeis (aka stye)

TENDER, RED, WARM are of focal swelling

Question 5

Glands affected: chalazion vs hordeolum

Answer 5

chalazi”ON” = “meibomiON”

Hordeola:

• internal = meibomian
• external = moll/zeis (stye)

Question 6

Lid cysts

• inclusion
• milia
• dermoid
• sebaceous

Answer 6

I: KERATIN, congenital or acquired, white

M: SWEAT PORE occlusion, acquired, white

D: SUP-TEMP, congenital, firm + immobile

S: YELLOW/OPAQUE, solitary, smooth, retention of fluid in glands of zeis or retention of debris in meibomian

Question 7

Ectropion

• pathophys
• signs/symp

Answer 7

Eversion of lid away from globe
#1: involutional (loss of musc tone of orb.oculi)
-also cicatricial, paralytic (bell’s), congenital

Exposure keratopathy, epiphora, brow ptosis

Question 8

Entropion

• pathophys
• signs/symp

Answer 8

Inversion of lid against globe
#1: involutional
-also cicatricial (trachoma, OCP, SJS, etc.), congenital
Can result in pseudotrichiasis

Range of symp: mild punctate keratitis -> corneal ulceration* and pannus
*blindness from trachoma due to corneal ulceration secondary to entropion and trichiasis

Question 9

Trichiasis vs distichiasis

Answer 9

T: lashes grow posteriorly

D: second row of lashes from MG openings

Question 10

Floppy eyelid syndrome

• who
• pathophys

Answer 10

Obese men with obstructive sleep apnea, esp face-down sleepers
-also DM, HTN, hyperthyroidism

Significant reduction in elastin in TP -> spontaneous lid eversion

• due to mechanical trauma to TP
• leads to PAPILLARY CONJ-ITIS due to FRICTION (non-specific pabillae)

Question 11

Floppy eyelid syndrome

-signs/symp

Answer 11

Signs: chronic PAPILLARY CONJ-ITIS, loose upper lids, punctate epithelial keratopathy (50%), keratoconus

Symp: chronic, bilateral red eyes in morning upon wakening
-often with mild mucus discharge

Question 12

Ocular problems assoc with sleep apnea (3)

Answer 12

Floppy eyelid
NTG
NAION

(Low oxygen)

Question 13

Ocular condns that most often cause red eyes in the morning (3)

Answer 13

Floppy eyelid
RCE
Exposure k

Question 14

Benign essential blepharospasm

• who
• pathophys

Answer 14

Women (2:1), 50-70yo

Usually IDIOPATHIC

• corneal or conj irritation
• initially have random episodes -> progresses to involuntary spasms

Question 15

Benign essential blepharospasm

• signs/symp
• systemic condn

Answer 15

Signs: spasms of 1) orb.oculi 2) procerus 3) corrugator
-50% have an ocular surface disorder (esp dry eye)

Symp: involuntary, sustained, repetitive, BILATERAL twitching/forceful closure, less common during sleep

Meige = BEB + lower facial abnormalities (difficulty chewing, jaw spasms, jaw pain, etc.)
-50% of pts with BEB have Meige

*tx with botox

Question 16

Myokymia

Answer 16

Unilateral twitching of orb.oculi

Causes: sleep deprivation, too much caffeine, stress
-much more common than BEB

Question 17

Basal cell carcinoma

-who

Answer 17

Most common skin + eyelid cancer (90% of lid malignancies)
Males (2:1)
Fair skin, UV exposure (esp B (290-320))

Pts often report chronic lesion that occasionally bleeds and won’t heal

Question 18

Basal cell carcinoma

• pathophys
• signs

Answer 18

Malignancy of basal cell layer of epidermis
Minimally invasive (metastasis <0.1%)
Most commonly on LL (50-66%) and at medial canthus

Early: SHINY, FIRM, PEARLY nodule with superficial TELANGIECTASIA
Late: RODENT ULCER

Question 19

Squamous cell carcinoma

-who

Answer 19

2nd most common eyelid cancer (40-50x less than BCC)
Males (2:1)
Fair skin, UV exposure (esp B (290-320))

Question 20

Squamous cell carcinoma

-pathophys

Answer 20

Malignancy of stratus spinosum layer of epidermis
More aggressive than BCC: 13-24% undergo metastasis to nearby lymph nodes

Actinic keratosis: most common precancerous skin lesion, precursor to SCC (25% develop into SCC)
-elevated, pink/red, scaly lesion on sun-exposed skin

Question 21

Squamous cell carcinoma

-signs

Answer 21

Variable presentation
Similar to BCC but without telangiectasia
Typically lower lid or lid margin

Question 22

Keratoacanthoma

Answer 22

Sun-exposed areas
Early app: similar to BCC/SCC
Grow very quickly to large size (1-2cm) before slowly shrinking/spontaneously resolving

Question 23

Sebaceous gland carcinoma

-who

Answer 23

Rare
Elderly females
Hx of chronic unilateral blepharitis or recurrent chalazia

Question 24

Sebaceous gland carcinoma

-pathophys

Answer 24

Neoplasm of 1)meibomian 2)zeis (holocrine)
Poor prognosis: if >2cm mortailty rate is 60%
-symptoms present >6mo mortality rate is 38%
-overall mortality rate 10%

Question 25

Sebaceous gland carcinoma | -signs

Answer 25

Varies | Often HARD AND YELLOW, assoc with MADAROSIS, thickened/red lid margins

Question 26

Malignant melanoma - who - pathophys

Answer 26

Rare (<1% lid malignancies), most lethal -age, skin color, fam hx, repeated irritation, sun exposure Malignancy of melanoCYTES

Question 27

Malignant melanoma | -signs

Answer 27

``` A: asymmetry B: border irreg C: color differences/uneven pigment D: diameter E: enlargment ``` Most important prognostic is depth of invasion

Question 28

Dacryadenitis - who - pathophys: acute vs chronic - causes (kind of reiterating from pathophys...)

Answer 28

Children, possible hx of recent fever/systemic infection Inflammation of lacrimal land Acute: bacterial (esp STAPH AUREUS), viral (esp MONO) Chronic: MORE COMMON, from inflammatory disorders - SARCOID, tuberculosis, graves, idiopathic orbital inflammation ``` Causes: #1 NLDO (adult = involutional, kid = hasner) #2 maxillary sinus ```

Question 29

Dacryadenitis | -signs/symp: acute vs chronic

Answer 29

Acute: S-SHAPED PTOSIS, temporal upper lid pain, redness, swelling, PREAURICULAR LYMPHADENOPATHY, fever, elev WBCs Chronic: temporal upper lid swelling, less of everything else than acute -may lead to inferonasal globe displacement, proptosis

Question 30

Canaliculitis | -pathophys

Answer 30

Rare Inflammation of canaliculi Bacterial, viral, or fungal -usually ACTINOMYCES ISRAELII (streptothrix): YELLOW SULFUR GRANULES after expression of canaliculi -others: staph aureus, candida albicans, aspergillus, herpes s/z, nocardia asteroides

Question 31

Canaliculitis | -signs/symp

Answer 31

Signs: tenderness over nasal lids, swollen “POUTING” puncta, dacryoliths, mucopurulent discharge Symp: smoldering, unilateral red eye, often unresponsive to antibiotic tx, often misdx as recurrent conj-itis *tx pcn

Question 32

Dacryocystitis - history - pathophys - causes (kind of reiterating from pathophys...)

Answer 32

Ask about concomitant ENT infection Lac sac infection due to NLDO -> backflow of bacteria from NLD into sac -common causes: STAPH AUREUS/epidermidis, pseudomonas, H FLU in children Chronic cases should raise suspicion for epithelial carcinomas, malignant lymphomas ``` Causes: #1 NLDO (adult = involutional, kid = hasner) #2 maxillary sinus ```

Question 33

Dacryocystitis | -signs/symps

Answer 33

Signs: prominent edema + tenderness over sac - swelling below medial canthus tendons - swelling above should raise suspicion for lac sac tumor Symp: PAIN, often with crusting/tearing, occassional fever *cystitis has more swelling, tenderness, pain than canaliculitis

Question 34

Punctal stenosis

Answer 34

Narrowing/occlusion of puncta - no concensus on clinical definition Usually involutional Epiphora

Question 35

Nasolacrimal duct obstruction - who - pathophys - signs/symp

Answer 35

Congenital or acquired - acquired more common in females Older pts: involutional stenosis Younger: valve of Hasner blocked by membrane -spontaneous opening around 1-2mo Signs: epiphora, mucus, erythema, little tenderness/redness Symp: unil tearing, discharge, crusting, recurring conj-itis

Question 36

Jones testing

Answer 36

1: fluoroscein, five minutes - positive = patent -> confirmed by presence of fluoro in back of throat or having them blow their nose - if negative, go to Jones 2 2: irrigation with saline - want: taste saline, gag, fluid recovery from nose - if failed, DCR is next step