eye lid, lacrimal and orbit disease

Question 1

where is the lacrimal gland located

Answer 1

just below the orbital rim

Question 2

3 functions of the eyelid

Answer 2

1. maintain lubrication
2. protection from infection
3. prevent drying

Question 3

4 types of tear film disorder + causes

Answer 3

1. low tear quantity (age, damage to gland, etc.)
2. poor quality tears (belpharitis)
3. disturbance of blink reflex (e.g. post surgery)
4. increased evaporation through exposure (CN VII palsy, surgery, thyroid eye disease, poor orbicularis tone etc.)

Question 4

what can exposure of the ocular surface lead to (2)

Answer 4

1. drying
2. microbial ketatitis -> loss of vision

Question 5

4 symptoms of dry eyes

Answer 5

1. irritation
2. stinging
3. burning
4. red sticky eye in the morning

Question 6

what is lagophthalmos

Answer 6

incomplete eyelid closure (leads to exposure of ocular surface)

Question 7

what is blepharitis

Answer 7

inflammation of the eyelids - occurs when tiny oil glands near the base of the eyelashes become clogged, causing irritation and redness

Question 8

blepharitis in young pts vs old

Answer 8

young - usually anterior lid margin
old - posterior lid margin

Question 9

what is chalazia and what condition is it associated with

Answer 9

a small swelling or lump on your eyelid because of a blocked gland; often associated with blepharitis

Question 10

treatment for chalazia (4)

Answer 10

1. sponteneous resolve (usually)
2. hot lid massage
3. incision and cutturage
4. lid hygeine (underlying blepharitis)

Question 11

what is entropion

Answer 11

when the eyelid is rolled inward against the eyeball

Question 12

5 causes of entropion

Answer 12

1. lid laxity
2. aging
3. congenital
4. spastic (muscle spazams)
5. cicatricial (chronic inflammation leading to fibrosis, scarring and shortening of the posterior lamella)

Question 13

how can entropion be unmasked

Answer 13

asking pts to close their eyes forcibly

Question 14

6 symptoms of entropion

Answer 14

1. irritation (e.g. due to eyelashes rolling in and touching occular surface)
2. watering
3. grittiness
4. stickiness
5. recurrent infections
6. intermittent presentation

Question 15

what is the definative treatment for entropion + 3 other treatments

Answer 15

definitive - surgery (everting sutures, lid tightening)

others - lubricants, taping, botox (short term, useful if surgery waiting list is long)

Question 16

which type of surgery is most definitive for entropion

Answer 16

lateral canthal sling

Question 17

what is ectropion

Answer 17

when the eyelid is turned outwards away from the eyeball

Question 18

3 causes of ectropion

Answer 18

1. lid laxity/aging
2. paralytic (CN VII palsy)
3. cicatrical (shortening of ant. lamella)

Question 19

6 symptoms of ectropion

Answer 19

1. asymptomatic
2. watering
3. red appearance
4. discharge
5. blurred vision
6. stinging/pain (if exposed)

Question 20

ectropion treatment (2)

Answer 20

lubrication, surgery

Question 21

what needs to be excluded in a ptosis presentation

Answer 21

acute neurology

Question 22

what is ptosis

Answer 22

drooping of upper eyelid

Question 23

what needs to be checked on examination with ptosis (6)

Answer 23

1. lid heights and variability as the eye moves
2. lid movements
3. ocular surface dryness
4. pupil reactions
5. obicularis tone and function
6. visual function

Question 24

what might acute onset ptosis indicate (3)

Answer 24

serious underlying pathology
1. horner’s syndrome (look for pupil asymmetry)
2. CN III palsy
3. myasthenia gravis
etc.

Question 25

6 causes of ptosis

Answer 25

1. congenital (dystropic muscle that hasnt developed properly) 2. aponeurotic/senile 3. traumatic 4. neurogenic 5. myogenic 6. mechanical

Question 26

what might ptosis increase the risk of developing in children and why

Answer 26

amblyopia - occurs when the eyelid is encroaching on the pupilary axis and therefore leads to impaired vision in that eye -> brain begins to supress input from that eye etc.

Question 27

4 characteristics of benign lid lesions

Answer 27

1. long history 2. gradual change 3. asymptomatic often 4. possibly tender e.g. acute stye

Question 28

4 characteristics of malignant lid lesions

Answer 28

1. recent onset 2. rapid growth 3. bleeding 4. pigmented (rare, red flag if seen)

Question 29

4 characteristics of benign lid lesions on examination

Answer 29

1. distinct edges 2. cystic 3. no loss of lashes 4. no destruction of lid architecture

Question 30

7 characteristics of malignant lid lesions on examination

Answer 30

1. ill defined borders 2. loss of lashes 3. destruction of the lid architecture 4. bleeding 5. ulceration 6. diplopia 7. extension into orbit

Question 31

5 examples of benign lid lesions

Answer 31

1. chalazion (cystic appearance) 2. cyst of moll (fluid filled lesion arising from the gland of moll 3. papilloma 4. cyst of zeiss (blockage of acessory glands) 5. xanthelasma

Question 32

3 examples of pre-malignant lid lesions

Answer 32

1. ketatocanthoma 2. lentigo maligna 3. solar keratosis

Question 33

4 examples of malignant lid lesions

Answer 33

1. BCC (nodular) 2. BCC (inflitrative) 3. SCC 4. Merkel cell cancer

Question 34

how can merkel cell cancer be treated and what is the side effect of this

Answer 34

Radiotherapy (very sensitive to RT) can damage lacrimal system leading to increased risk of dryness

Question 35

3 treatment options for periocular BCCsa

Answer 35

1. excision (conventionsl) 2. excision (Mohs - refer to derm, usually if lesion is close to important structures or borders are ill defined) 3. reconstruction (post surgery)

Question 36

what is the risk from neglecting a BCC

Answer 36

extension into the orbit

Question 37

3 examples of lacrimal system disorders

Answer 37

1. dacryocystisis 2. dacryodenitis 3. nasolacrimal duct obstruction (leads to watery eyes)

Question 38

what is dacryocystitis

Answer 38

the inflammation and infection of your tear sac

Question 39

what is dacryoadenitis

Answer 39

inflammation in one or both of your lacrimal glands

Question 40

characteristic eye lid shape seen in dacryoadenitis

Answer 40

S shaped lip contour

Question 41

dacryoadenitis treatment

Answer 41

typically conservative- may require antibiotics but typically resolves without complications

Question 42

what is IgG4 disease

Answer 42

a chronic, immune-mediated disorder that often manifests with multiorgan involvement and tumor-like masses most often affecting the pancreas, bile ducts, lacrimal glands etc.

Question 43

what can be done if lacrimal gland swelling doesnt resolve spontaneously

Answer 43

lacrimal gland debulking surgery; CT head to look for nefarious causes

Question 44

management for dacryocystitis

Answer 44

1. oral Abx 2. drain 3. dacryocystorhinostomy (a connection between the lacrimal sac and nasal mucosa is made to allow tears to drain here

Question 45

why does dacryocystitis arise

Answer 45

usually due to fibrosis of the lacrimal tracts, often hx of recurrent rhinitis as a cause of this

Question 46

6 general symptoms of orbital disease

Answer 46

1. diplopia 2. swelling around the eye 3. bluging prominent eye 4. awareness of a lump 5. ache behind the eye 6. pain on eye movements

Question 47

7 general signs of orbital disease

Answer 47

1. restriced eye movements 2. swelling around the eye 3. proptosis (abnormal protrusion or displacement of an eye) 4. lid retraction 5. reduced vision 6. reduced colour vision (early sign!!) 7. pupil abnormalities

Question 48

what is orbital cellulitis and how is it managed

Answer 48

an infection that involves the eye and the eye structures within the bony cavity of the face medical emergency - admission and IV abx, abcess drained endoscopically

Question 49

what is proptosis

Answer 49

abnormal protrusion or displacement of an eye - eye may appear bigger as it is being pushed forwards

Question 50

why is the eye pushed forwards in proptosis

Answer 50

the eye is surrounded by the bony orbital cavity on all other sides -> the only direction it can expand in

Question 51

what underlying condition is the most common cause for ptoptosis

Answer 51

thyroid eye disease (TED)

Question 52

other causes for proptosis (not TED - 2)

Answer 52

1. primary orbital tumours (lymphoma, glioma) 2. metastasis (breast, prostate, lung)

Question 53

what is thyroid eye disease

Answer 53

an autoimmune disease in which the eye muscles and fatty tissue behind the eye become inflamed

Question 54

red flags for urgent ophthal referal (7)

Answer 54

1. exposure of the eye 2. double vision and ptosis 3. reduced vision 4. rapidly growing suspicious eye lid lesion 5. proptosis 6. swelling in lacrimal gland or sac area 7. entropion (eyelid is rolled inward against the eyeball)

Question 55

4 red flags for routine referral to ophthal

Answer 55

1. long standing lid lesion with no suspiciuos features 2. gradual onset adult ptosis 3. non painful ectropion 4. watery eye alone

Question 56

how is ocular perfusion pressure calculated

Answer 56

2/3 mean arterial pressure - IOP