Diagnosis and management of Lid margin disease Flashcards Preview

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Flashcards in Diagnosis and management of Lid margin disease Deck (53)
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what is the eye lid
give 2 reasons why the lid margin is important

- a moveable fold of skin

lid margin important because:
- thats where the oil is secreted and spread across the surface
- also spreads tear film across ocular surface


what 4 things does the eyelid margin contain (from out to in)

- Eyelash zone: 2-3 rows of eye lashes

- Grey line: represents the location of Riolans muscle and divides the lid into anterior and posterior lamellae

- Meibomian gland duct openings

- Mucocutaneous junction


what does the grey line on the eyelid margin represent

the location of Riolans muscle and divides the lid into anterior and posterior lamellae


what do the eye lashes represent

it initiates the blink reflex


what is Riolans muscle and what is its clinical feature

- it is the marginal bit of the orbicularis muscle

- clinical feature = is a incision line for the lid margin in surgery because it is a blood free area so can avoid the major blood vessels here


what is a new technique to view the meibomian glands on a slit lamp

Infra-red imaging


what is the description of the meibomian gland by the German physician Heinrich Meibom in 1666

what differs about the meibomian gland on the upper eyelid margin

- Large sebaceous glands located in the tarsal plates of the eyelids
~30-40 glands
- Longer and more numerous in the upper lid


what does each meibomian gland consist of and what does this do

- multiple secretory acini
- which open onto a central duct that discharges its contents onto the lid margin


what causes the meibomian gland to express its oil and what does it form once expressed

- the action of the orbiculares muscle as it contracts expresses the oil onto the flat surface of the lid margin
- it is picked up by the eyelid and spread across the surface of the teat film, forming the lipid layer


what do the meibomian glands synthesis and secrete
what is this critical for
what condition does it need to be in and why

- synthesise and secrete a complex mixture of lipids that spread onto the tear film

- to reduce tear evaporation and contribute to tear stability
i.e. for the integrity of the tear film so that it doesn't break up between blinks

- the lipid needs to be liquid and free flowing at the surface temperature of the eye which is a melting range of 19.5°C to 40°C (standard room temperature)
- for the lipid layer to spread and ensures lipid mixture fluidity


what has research found a relationship between

blinking and expression of glands e.g. impaired blinking even with normal production of meibomian gland oil = won't be distributed effectively


what term is used to describe the secretion of lipids from the meibomian glands



what is the meibomian gland described as
what is it affected by and what does this determine

- described as a tap
- affected by the hormone androgens
- androgens determines the level of secretion


what is very elastic and what causes this to expand

- the ducts
- the meibomian glands makes the ducts expand

(and the orbicularis oculi squeezes and exerts force on the duct, causing it to express the oil)


what is a term preferred over blepharitis

lid margin disease


mention 7 points about lid margin disease

- Amongst the most frequently encountered ocular diseases (however it is often undetected)

- The condition is usually chronic, with relapses (symptomatic) and remissions

- Typically bilateral

- It is a complex disorder with multiple causes

- Closely linked with dry eye disease/MGD (at least 50% of cases)

- Has been linked to the development of post-operative infection (endophthalmitis) following ophthalmic surgery (sight threatening and morbidity)

- Diagnosis and management of lid margin disease can present a challenge for eye care professionals


what is ‘Blepharitis’ a general term for
what is lid margin disease applied specifically to
what is lid margin disease classified according to

- a general term for inflammation of the eyelids

- also known as marginal blepharitis, is applied specifically to inflammation of the lid margin

- classified according to the locus of the disease


what 3 locations is lid margin disease classified into

- Anterior lid margin disease: affecting the anterior lid margin and eyelashes

- Posterior lid margin disease: affecting structures posterior to the grey line, including Meibomian gland dysfunction (MGD)

- Mixed anterior and posterior disease

Signs of each condition is very distinct so is very easy to distinguish between the first 2


other than locus of the disease, what else can lid margin disease be classified according to

its aetiology: inflammatory or infectious


what is infectious classification on lid margin disease caused by

microorganisms: mostly bacterial and always linked to staphylococcus aureus which live at the base of the lashes


when can staphylococcus aureus and staphylococcus epidermis lead to inflammation and lid margin disease and what happens and what consequence does this lead to

- when they become into excessive amounts

- these bugs produce lots of toxins and they secrete into the tear film

- consequence = cornea can get affected
- it can rarely be viral, fungal or parasitic


which parasite is more commonly contributing to lid margin disease



name 2 cutaneous associations to lid margin disease

- Acne Rosacea
- Seborrheic dermatitis


with the acne rosacea (cutaneous association to lid margin disease):
who is it more common in
when does it tend to occur
what signs is it associated with
- where on the body is it affected
- how many cases does it have ocular involvement

- In fair-skinned people, particularly women (twice as common than men)

- Occurs in the second half of life (40+)

- Associated with facial flushing and telangiectasia, papules and pustules

- Affecting the forehead, cheeks and nose

- Ocular involvement in 50% of cases (i.e. 1 in 2 chance)


with seborrheic dermatitis (cutaneous association to lid margin disease):
what is it
where does it occur
what signs is it characterised by

- Chronic, relapsing inflammatory skin condition

- Occurring in skin areas rich in sebaceous glands such as the scalp, face, chest

- Characterized by scaling and poorly defined erythematous (red) patches

the meibomian gland is sebaceous, hence is people have sebaceous gland disease = will have problems with the meibomian glands


list 10 symptoms of lid margin disease
and 2 symptoms it may cause
what do the symptoms vary in

- ocular surface discomfort
- itching
- burning
- irritation
- dryness
- watering/tearing
May also complain of:
- vision fluctuation
- puffiness or redness of the margins of the eyelids
- crusting on the lashes
- eyelids being stuck shut in the morning

- May cause contact lens intolerance
- May be linked with particular activities e.g. computer use or driving

- Symptoms vary in frequency and severity


where does anterior lid margin disease predominantly affect
what do you have to rely on to determine that it is anterior lid margin disease

- Predominantly affects the lid margin in the region of the eyelashes

- Have to rely on clinical signs rather than symptoms


what has anterior lid margin disease been linked to
what else has been linked to the pathogenesis of anterior lid margin disease and ocular rosacea

- linked to an overgrowth of Gram positive bacteria (particularly Staphylococcus species) on the lid margins

- Mite infestation (Demodex) of the lashes has also been implicated in the pathogenesis of anterior blepharitis and ocular rosacea


how can you diagnose an anterior lid margin disease to be caused the the Demodex mite/parasite and what can an extreme case of this do to the eyelashes

- pull out the eyelash, as the mites bury themselves at the base of the eyelash, so need to examine an epilate eyelash under the microscope

- extreme case can cause misdirection of the eyelashes, pointing backwards into the ocular surface = trachiasis


what is anterior lid margin disease characterised by
what is it associated with
what are the signs
what else may it show

- Characterised by scaling or ‘collarettes’ at the base of the eyelash

- Associated with loss or misdirection of lashes

- Redness of the lid margins and conjunctival hyperaemia

- May show corneal involvement e.g. superficial punctate keratitis


list the 8 sequelae of anterior lid margin disease from bad to the worst

- chalazia/hordeola
- loss of cilia
- dry eyes
- punctate keratitis
- pannus
- phlyctenules
- corneal ulceration
- endopthalmitis


explain how a extreme example of anterior lid margin can involve marginal keratitis

it is where the bugs associated with anterior blepharitis, particularly staphylococcus aureus have secreted toxins which caused an inflammatory reaction to the peripheral cornea


what is posterior lid margin disease commonly associated with
what is this characterised by
what is this strongly associated with

- Meibomian gland dysfunction (MGD)

- Characterised by terminal duct obstruction (plugging of glands) and qualitative/quantitative changes in Meibomian gland secretion

- Strongly associated with evaporative dry eye and contact lens intolerance and reduced wearing time


what 4 things does all the classification of MGD lead to

- alteration of tear film
- eye irritation
- clinically apparent inflammation
- ocular surface disease including dry eye


what did the workshop define MGD as

a chronic diffuse abnormality of the meibomian glands, commonly characterised by the terminal duct obstruction and/or qualitative/quantitative changes to the glandular secretion. this may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation and ocular surface disease


what is the appearance of normal openings of the meibomian gland

- little droplets of oil on the surface of the lid margin
- oil is clear with no debris = normal meibomian gland secretion is melted


what may the early stages of MGD not be associated with

what may the early signs of MGD display

what is the treatment of early stages of MGD like

- MGD may not be associated with clinical signs and symptoms of posterior blepharitis

- Display altered quantity or quality of secretion - oil is not clear, it is opaque, granular and contains debris

- Treatment for early-stage disease is relatively simple, and there may be good reason to offer treatment at this preclinical stage


list 7 signs of MGD

- Measurable Meibomian gland drop out (if severe MGD allowed to progress)
- Altered Meibomian gland secretion
- Plugging of Meibomian gland openings
- Lid margin hyperaemia
- Foaming of tears
- Notching of posterior lid margin (anatomical change of glands which prevents smooth contour of lid margin)
- Retroplacement of Meibomian gland orifices


what are the signs of end stage MGD and wha does this result in

- opaque meibomian gland secretion which is granular and thick
- this clogs the openings and can be completely blocked

- results is: unable to form lipid layer of tear film

- by applying digital pressure to get the gland to express and squeeze out the opaque secretion


list 3 tests you will perform in a general clinic in patients presenting with symptoms of ocular surface disease as a suitable sequence

- Dry eye investigation (e.g. tear meniscus height, tear break up time, Schirmer test, corneal and conjunctival staining with fluorescein and (lissamine green))

- Observation of morphologic features of the lid margins

- Expression: quantification of meibum expressibility/quality


what is done in a basic dry eye assessment and what is done in a advanced dry eye assessment

- tear meniscus height

- schirmer test


which 2 ways can the grading of meibomian gland excretion be carried out

Meibum quality is assessed in 8 glands of the central third of the lid (0= clear, 1=cloudy, 2=cloudy with debris (granular), 3= thick (like toothpaste). Grade 0-3 for each of 8 glands (range 0-24)

Expressivity of meibum from 5 glands (1= 3-4 glands expressive, 2= 1-2 glands expressive, 3= no glands


explain how meibum quality is assessed and the grading criteria it consists of

- assessed in 8 glands of the central third of the lid

- 0 = clear
- 1 = cloudy
- 2 = cloudy with debris (granular)
- 3 = thick (like toothpaste)

Grade 0-3 for each of 8 glands (range 0-24)
e.g. if all 8 glands had a thick secretion, then the grade = 24


how is the grading (quantitative) criteria of the expressivity of meibum

- from 5 glands

- 1 = 3-4 glands expressive
- 2 = 1-2 glands expressive
- 3 = no glands


what are the 4 main options for lid margin disease management

- Lid hygiene

- Warm compresses

- Pharmacotherapy
Topical antibiotics
Systemic antibiotics

- Dietary changes


what is the clinical description, clinical signs and management of stage 1 lid margin disease

clinical description:
- no symptoms of ocular discomfort, itching or photophobia

clinical signs: of MGD based on gland expression
- minimal altered secretions: grade >2 -


what is the clinical description, clinical signs and management of stage 2 lid margin disease

clinical description:
- minimal to mild symptoms of ocular discomfort, itching or photophobia

clinical signs:
- scattered lid margin features
- mildly altered secretions: grade >4 -


how can someone with lid margin disease improve lid hygiene as their management

- Using a mild solution of baby shampoo in warm water, clean the eyelids with cotton wool or cotton buds. Clean well into the base of the lashes removing crusting

- Alternatively use commercially available products

- 1-2 times per day initially reducing to once a day as the condition improves

- Avoid cosmetics (especially eyeliner and mascara)


how can someone with lid margin disease increase the lid temperature to influence the delivery or meibomian lipid as their management

- Warm compresses: apply to closed eyes for 5-10 mins 1-2 times per day

- Warm flannel or commercially available products (e.g. eye bag)

- May be associated with eyelid massage


describe how you will do lid massages following warm compresses as a management for lid margin disease

- To massage the eyelids use the index finger and sweep the pad of the finger from the inner to outer canthus (stabilise the lid by placing the index finger of the other hand on the outer cants)

- Repeat this with the lower lid, placing the pad of the finger just below the lashes at the inner canthus and sweeping outwards towards the temple

- Repeat 5 to 10 times over about 30 seconds immediately following the warming


what 3 pharmacotherapy management options are there for lid margin disease

- Ocular lubricants or liposomal spray to manage associated dry eye

- Topical antibiotics to reduce bacterial load on the lid margins
e.g. fusidic acid or chloramphenicol

- Systemic tetracyclines (oral antibiotic) used in the treatment of rosacea and some evidence for their effectiveness in MGD e.g. doxycycline, minocycline 50-100mg 1-2 times per day, thought to work by supressing bacterial lipases that alter Meibomian secretions


why are systemic tetracyclines (oral antibiotic) used for treating lis margin disease
name 2 types of these
their dose and how many times a day they should be taken
what is it's mechanism

- Systemic tetracyclines (oral antibiotic) used in the treatment of rosacea and some evidence for their effectiveness in MGD
- doxycycline, minocycline
- 50-100mg 1-2 times per day
- thought to work by supressing bacterial lipases that alter Meibomian secretions


which dietary modification is thought to be beneficial for the management of lid margin disease

Some evidence (but weak) for the benefit of omega-3 fatty acid supplements