Flashcards in Eye and Eyelid Disorders Deck (81)
Describe the anatomy of the eyelid?
Multilayer tissue covered externally by the skin and internally by a thin mucocutaneous epithelial layer
There is a middle layer, glands of Moll, the gland of Zeiss and Meibomian glands
What is the middle layer of the eyelid?
Glandular tissue and muscles for eyelid movement
What are the glands of Moll do?
They are modified sweat glands on the edge of the eyelid (waterline)
What is the gland of Zeiss?
Modified sebaceous glands at the bottom of the eyelashes
What are the Meibomian glands?
Modified sebaceous glands that produce the lipid layer of the tear film that goes along the eyelid
What are the functions of the eyelid?
Primarily protect the anterior surface of the eye
Aids in the regulation of light reaching the eye
Aids in tear flow through pumping action on the conjunctival and lacrimal sacs
Helps with the distribution and elimination of tears
What is the conjunctiva?
Thin, transparent, mucous membrane
It covers the inner surface of eyelids (palpebral portion) and anterior surface of the eye (bulbar portion)
The anterior surface only covers the white of the eye
Main function is to prevent the eye from drying by secreting a moisturizing mucous
What are some eye conditions?
What are the different types of eyelid conditions?
Hordeolum (stye; either external or internal)
What are the different types of conjunctivitis?
What are general red flags for eye disorders?
Foreign particles trapped/embedded in the eye
Eye exposure to chemical or chemical fumes
Thermal injury - Welder's eye or snow blindness
Blurred vision (not due to ocular ointments)
Photophobia (light causes dramatic pain in the eye)
Redness around the cornea
Condition lasting for more than 48 hours (note: are exceptions to this)
Contact lens wearers with conjunctivitis
What are the treatment goals for an infection in the eye?
What are the treatment goals for dry eye?
Identify any exacerbating factor(s)
What is a hordeolum?
Aka a stye
It is an acute localized infection involving either the glands of the Zeis or Moll (external hordeola) or the meibomian glands (internal hordeola) of the eyelid
Results in the formation of a small cyst or abscess
Unilateral, localized lid swelling, tenderness and erythema
Often associated with blepharitis
What causes a hordeolum?
The most common infecting organism is S. aureus
Describe an external hordeolum
Smaller and more superficial cyst or abscess
Lesion always points towards the skin
How do we treat external hordeolum?
Can treat with warm compresses applied 10-15 minutes 3-4 times a day. Can follow warm compresses with eyelid massage and it should drain on its down within 48 hours
OTC antibiotic ophthalmic ointment may be applied to the affected area 3-4 times daily but it is not required and not generally recommended
Refer to a physician if it doesn't drain (48 hours) - may then require prescription antibiotics (i.e., topical eythromycin or possibly oral treatment)
Describe an internal hordeolum?
Involves the meibomian glands (usually deep inside/underneath eyelid)
Usually larger and more discomfort than external styes
Lesion can point either to the skin or to the conjunctiva
Often resolves within 1-2 weeks
How do we treat internal hordeolum?
Warm compresses for 5-10 minutes several times daily. Refer if not resolved in 1 week.
If not resolved then it may not drain on its own and may require an incision and prescription ophthalmic ointment (bacitracin or erythromycin)
If infection is severe, oral antibacterials may be needed (erythromycin, cloxacillin or tetracycline)
How is transmission of styes prevented?
Wash hands before and after any contact with infected eye
Avoid touching eyes
Change towels and compresses after each use (do not share towels, facecloths, pillows, etc.)
Proper use of eye drops (avoid touching the eye/eyelashes) - clean the tip after use
Avoid use of eye cosmetics during infection
Address treating symptoms of blepharitis (if present) to help decrease recurring hordeola
What is a chalazion?
Inflammation of the meibomian glands (deep chalazion) or Zeis sebaceous glands (superficial of the area)
Generally chronic in nature
Nodule develops over a period of weeks (not acute)
Lesion usually points towards to the conjunctival and swelling
What are symptoms of a chalazion?
Characterized by painless, localized redness and swelling
How is more likely to develop a chalazion?
More common in people with blepharitis, acne rosacea or seborrheic dermatitis
How are chalazions treated?
Initial symptoms may resemble hordeolum without the acute inflammation
Initial treatment is similar to that for external hordeolum (warm compresses 10-15 minutes 3-4 times daily, eyelid massage, often resolves spontaneously within a few says, refer is no improvement within 48 hours of initiating treatment)
Immediate referral if chiazzino is painful or visual distortion/impairment
For patients with blepharitis, encourage lid hygiene to prevent recurrence
What is blepharitis?
Chronic inflammation of the eyelids
Often associated with chronic dermatological conditions (acne rosacea, seborrheic dermatitis)
It's not contagious
Long term complications may include physical damage the eyelids and cornea, scarring, vision impairment, corneal perforation
What are the symptoms of blepharitis?
Red, swollen, itchy lid margins, eye red and watery
Landmark sign: eyelid is scaly
Foreign body sensation or burning
Sandy or gritty sensation in the eye - worse upon awakening (similar symptoms to dry eye but this is an eyelid disorder)
Loss of eyelashes lashes grow abnormally
Symptoms may be unilateral or bilateral
Appearance can often be confused with conjunctivitis and/or other eyelid conditions
How is blepharitis diagnosed?
Initial diagnosis or exacerbations require referral
Usually a chronic problem
Treatment of concomitant dermatologic disorders important for long-term control
What are the prescription treatment options for blepharitis?
Antibacterial ointments (bacitracin or erythromycin) preferred to drops because of increased contact time
Short-term treatment with weak corticosteroids or corticosteroid/antibacterial combinations during exacerbations
Oral antibiotic treatment may be required (tetracycline, minocyline, doxacyline or erythromycin)
What are non-pharmacological treatment options for blepharitis?
Regular and long-term eyelid margin hygiene is essential
Warm compresses applied for 5-10 minutes
Gental scrubbing of the lid margin (commercial eyelid scrubs, at cotton swab dipped into a solution of a few drops of baby shampoo in a small amount of warm water)
Recommend once or twice daily immediately after initial diagnosis or during exacerbations
May be reduced to twice a week once under control
Refer if new onset suspected and exacerbations
What is conjunctivitis?
General term referring to any inflammatory condition of the conjunctiva (mucous membrane lining the back of the eyelid and the front of the eye, except the cornea)
Inflammation can be hyper acute, acute or chronic
What can cause conjunctivitis?
Caused by viral/bacterial infections, allergies, other irritants and dryness
Describe acute bacterial conjunctivitis
Usually self-limiting and resolves after 2 weeks (treatment often shortens the course)
Highly contagious (proper personal hygiene is important to avoid transmission, i.e., hand washing, separate towels, etc.)
Children should be automatically referred to health care provider
Contact lens wearers should be referred due to high risk (patients should wear glasses during the course of treatment)
What are the symptoms of acute bacterial conjunctivitis?
Generally has acute onset
Usually unilateral (or initially unilateral)
Mild to moderate foreign body sensation
Minimal or no itching
Purulent (creamy white or pale yellow) discharge
-eyelids stick together on awakening
-crusting on the eyelids
What are the OTC treatments for acute bacterial conjunctivitis for adults?
For mild symptoms: Polymyxin B/gramicidin drops instilled 4-6 times a day or polymyxin B/gramicidin eye ointment applied to lower lid QID for 7-10 days
Treatments should continue for 2 days after symptoms have resolved
If no improvement within 48 hours or symptoms worsen refer to health care provider for prescription treatment
What is non-pharmacological treatment for acute bacterial conjunctivitis for adults?
Warm and wet compresses applied in the morning
Irrigation of conjunctival sac to remove secretions
What are the prescription treatment options for acute bacterial conjunctivitis for adults?
Trimethoprim/polymyxin is the treatment of choice
What is hyperacute bacterial conjunctivitis?
Most commonly seen in neonates and/or sexually active adolescents and young adults (15-24 years)
Severe, sight threatening
Caused by N. gonorrhoea or N. meningitides
Immediate referral or emergency room
What are the symptoms of hyperacute bacterial conjunctivitis?
Copious yellow/green, purulent discharge, redness, irritation, tenderness
How is hyperacute bacterial conjunctivitis transmitted?
In infants, transmission occurs during vaginal delivery (bilateral discharge 3-5 days after birth)
In adults it is transmitted via hands and genitalia
What is chronic bacterial conjunctivitis?
Condition lasting over 4 weeks
Often associated with blepharitis, rosacea, facial seborrhoea, nasolacrimal duct obstruction
Referral is necessary (topical or oral antibiotics)
What are non-pharmacological treatment options for chronic bacterial conjunctivitis?
Avoid contaminated products
Describe viral conjunctivitis?
Can be bilateral (often starts out unilateral)
Often occurs in community epidemics (schools, daycares, etc.)
Some patients have an associated respiratory tract infection
Infection can last from 2-4 weeks (contagious 2 weeks after the second eye becomes involved)
What is the most common cause of viral conjunctivitis?
Adenovirus is the most common cause (Herpes simplex/zoster can also be the cause)
What are the symptoms of viral conjunctivitis?
Acute red eye, conjunctival swelling, soreness or mild pain, minimal or no itching, profuse watery clear discharge, foreign body sensation, mild photophobia
Upper respiratory tract infection may be present
How is viral conjunctivitis treated?
All patients should be referred to a health care professional especially if recent shingles outbreak
Cold compresses, ocular lubricants
Avoid direct contact with others for 14 days or more after onset of symptoms
Children should not go to school for a minimum of 1 week
What is allergic conjunctivitis?
Seasonal allergic rhinoconjunctivitis (hay fever) is the most common type of conjunctivitis
Caused by allergens such as ragweed, grass pollen, animal dander, etc.
History of allergies or seasonal allergic rhinitis
Often accompanied with runny nose, sneezing
What are the symptoms of allergic conjunctivitis?
Severe ocular itching, some/minimal redness, tearing, no signs of infection, no foreign body sensation
What are non-pharmacological treatment options for allergic conjunctivitis?
Cold compresses for 10-15 minutes TID-QID to help redness and itching
What are pharmacological treatment options for allergic conjunctivitis?
First line: ocular lubricants (free of preservatives) for symptomatic relief
Oral antihistamines (second generation is preferred) - loratadine, cetirizine (stops itching, no decrease in redness)
Ocular decongestants or decongestant/antihistamine combinations (second line for mild to moderate SAC) - they could cause rebound ocular congestion and avoid in narrow angle glaucoma/caution with uncontrolled hypertension, etc.
If no response to OTC therapy within 72 hours refer to physician (likely requires prescription eye drop)
What do ocular lubricants do?
Dilutes allergen and decreases allergen contact time with conjunctiva
May create a barrier against pollen
1 drop 2-6 times daily
What are some examples of ocular lubricants?
Artificial tears (polyvinyl alcohol)
Refresh (polyvinyl alcohol)
Tears Naturale (hypromellose dextran 70)
What are the two pharmacological groups of ophthalmic decongestants on the OTC market?
What are examples of imidazolines?
What is different about imidazolines (compared to phenylephrine)?
Imidazolines have a longer duration of action than phenylephrine
Tetrahydrozoline and oxymetazoline has longer duration of action than naphazoline
Oxymetazoline generally appears to exhibit the least side effects
Do ophthalmic decongestants treat conjunctivitis?
None of them actually treat the underlying effects of the histamine in the eyes; they are only treating the symptoms of redness by causing constriction
They shouldn't be used in bacterial and viral conjunctivitis
What are some precautions for decongestants?
OTC concentration may be insufficient to cause systemic absorption but systemic circulation could occur through the nasolacrimal system (minimize this effect by applying gently pressure with the index figure over the tear duct for 1-2 minutes)
Contraindicated in angle-closure glaucoma
Possible mydriasis with normal dosing in patients with contact lenses, lightly coloured irises, and corneal abrasion (temporary but not serious)
What are ophthalmic mast cell stabilizers?
Blocks histamine from mast cells
Used regularly during allergy season to prevent redness, itching and eyelid oedema
Takes up to 10 days for maximum effect. Must be started before the allergy season to prevent symptoms
What are the two major classifications of of dry eye?
Aqueous tear-deficient dry eye
Evaporative dry eye
What can result from dry eyes?
Can lead to drying out, and becoming inflamed
Can cause damage to the ocular surface, scarring and reduced vision
What are the severe forms of dry eye referred to as?
Keratoconjunctivitis Sicca (KCS)
What are the risk factors for dry eyes?
Environment (low humidity, high temperature, air pollution)
Occupation (air travel, computer use)
Contact lense wearer
Medical conditions (RA, Sjogrens syndrome)
Ocular disease (blepharitis, allergic conjunctivitis, infection)
Medications (anticholingerics (first generation antihistamine, TCAs), beta blockers, diuretics)
What are the signs and symptoms of dry eye?
Foreign body sensation
Itchiness or scratchiness
Burning or stinging
Difficulty in moving lids
What are the treatment goals of dry eye?
There is no cure
Determine the severity of the situation
Rule out other ocular complications
What are non-pharmacological treatment options for dry eye?
Environmental changes (avoid smoke, don't smoke)
Avoid prolonged viewing of computer screens or video games (encourage blinking)
Avoid windy outdoor environments without eye protection (sunglasses, goggles)
Cool, moist compresses placed over closed eyelids for short-term relief
Tear duct (punctal) occlusion
What are non-prescription treatment options for dry eye?
Ocular lubricants (artificial tears, lubricating ointments and gels (at night))
They contain preservatives that can be toxic to the eye
Whens should someone with dry eyes be referred?
If symptoms do not resolve within 3-5 days or if they worsen, refer to doctor
What are signs of preservative toxicity? What should be done?
Signs of preservative toxicity include stinging and conjunctiva inflammation
Switch to product with different preservative, preservative-free product or to a physician
What are the characteristics of an ideal artificial tear?
Lubricates ocular surface well
High retention time
No preservative, for maximum patient comfort
Contains essential minerals and electrolytes to maintain good corneal health
What are the key differences between artificial tear products?
Difference in viscosity of the polymers
Compatibility with contact lenses
What are the different polymers used for artificial tears?
How does viscosity affect artificial tears?
Higher viscosity - higher retention time in the eye (ointments and suspensions)
Combined polymers have higher retention time (these agents are useful in moderate to severe dry eyes)
What are some products that are compatible with contact lenses?
Visine for Contacts
What are the different types of preservatives?
Oxidative preservatives (safer alternatives)
Patients requiring over 4 applications per day should use preservative-free
Describe the use of benzalkonium chloride
Most frequently used preservative but known to be toxic to corneal epithelium
Should be avoided in moderate to severe DED
Describe the use of oxidative preservatives
Sodium chlorite (Purite) or sodium perborate - these are also referred to as "vanishing" preservatives
Describe lubricating ocular ointments
Contain petrolatum, mineral oil, with or without lanolin
Generally do not require preservaties
Generally used for moderate to severe dry eyes
What do lubricating ocular ointments do?
Enhance retention time in the eye which appears to increase the integrity of the tear film
Require less frequency of in instillation - longer contact time
Generally administered at bedtime (blurred vision)
How are products for dry eyes determined?
Determine the severity of the dry eye condition
Consider frequency of use
Is the patient using other ocular medications?
Is the patient wearing contact lenses? Consider drops that are compatible (GenTeal, Refresh Contacts, Visine for Contacts)
Why is it important to know if the patient is using other ocular medications?
These meds may contain preservatives and you may want to minimize the exposure to ocular preservatives
Patients requiring continuous use should use a preservative-free product (Bion Tears, Cellufresh, Refresh Tears, Tears Naturale Free)
When should patients see improvement?
Most eyelid disorders: 48 hours
Acute bacterial conjunctivitis: 48 hours
Allergic conjunctivitis: 72 hours
Dry eyes: 3-5 days
Refer is no improvement within these time frames