Eyelids & Eyelashes Flashcards

Question

Myotonic Dystrophy (Characteristics, Types/Forms, Ocular signs)

Answer 1

* **General Characteristics** * Autosomal Dominant * Occurs at any age * Chronic, slowly progressive multisystemic disease * Characteristics * Muscle wasting * Myotonia * Cataracts * Heart conduction defects * Endocrine changes * **Myotonic dystrophy forms** * **Type 1** - **Steinert disease** * ****More common * More severe * Congenital or adult-onset (earlier development = worse sx) * Features: Difficulty swallowing, constipation, gallstones, uterine muscle abnormalities * **Type 2 - Proximal myotonic myopathy** * ****Less common - german decent * Less severe - slowly progressive * Adult - onset * Proximal muscles affected first - hips * **Ocular signs** * Ptosis * Cataract * Retinopathy * Near-Light reflex dissociation

Answer 2

* Slowly progressive paralysis of EOMs * **Most frequent manifestation mitochondrial myopathies** * Features * Symmetrical, progressive, bilateral ptosis * Opthalmoparesis months to years later * Iris & ciliary muscles remain intact * Orbicularis weakness * Associations * Kearns-Sayre syndrome (KSS) * Oculopharyngeal dystrophy * Myasthenia gravis * Graves disease * Tx * Cardiac work-up * Electromyography & muscle biopsy * Ptosis repair * Pharmaceuticals * Coenzyme Q10 * Tetracyclines

Answer 3

* CPEO before age 20 & pigmentary retinopathy * Potentially fatal due to heart conduction defects * No sex predilection * Diagnosis * Pigmentary retinopathy + at least 1 of: * Cardiac conduction defect * CSF protein \>100 mg/dL * Cerebellar syndrome * May also have * Mental retardation * Babinski sign * Hearing loss * Short stature * Delayed puberty * Various endocrine disorders

Answer 4

* Innervational defect * Causes * CN III palsy - horner's syndrome * Marcus Gunn jaw winking * Myasthenia gravis * Ophthalmic migraine * MS

Answer 5

* CN III palsy - ptosis, mydriasis, down & out misdirection * Etiology * Vasculopathic * Trauma * Compression (aneurysm) * Infiltrative * Toxic * Diagnosis - neuroimaging, lab testing (vitals, CBC, ESR, metabolic panel) * Tx: depends on etiology

Answer 6

* Horner's syndrome * Miosis, ptosis, anhydrosis, (heterochromia) * Loss of sympathetic innervation in pathway * Central * Pre-ganglionic - association with chest trauma & tumors * Pancoast's tumor - metastasis from lung or breast * Post-ganglionic - most often benign * No anhydrosis * To confirm horner's syndrome * **Cocaine 10%** - Dilates **NORMAL** eye, not horners * **Apraclonidine** - Dilates **HORNERS** pupil, does not dilate **NORMAL** pupil * To localize lesion * **Hydroxyamphetamine** * Dilates **PRE-GANGLIONIC** lesion * Not enough norepinephrine release to dilate post-ganglionic * **Phenylephrine 1%** * ****Elevates **AFFECTED** side due to hypersensitivity of mullers muscle * Dilates **POST-GANGLIONIC** lesion, minimally dilates PRE-GANGLIONIC, does not dilate central lesions * Important to rule out malignancy in central and pre-ganglionic lesions * **Neuroimaging** * ****Important in absence of clear h/o trauma as cause

Answer 7

* 5% of all congenital ptosis * majority are unilateral * Signs = retraction of ptotic lid with stimulation of **ipsilateral** pterygoid muscles (sucking, chewing, opening mouth) or **contralateral** jaw mvmt * Postulated etiology * Part of CN-V₂ (madibular branch) misdirected to levator muscle

Answer 8

* Causes * Lack of support of lid by globe due to volume deficit * Artificial eye * Microphthalmos * Pthisis bulbi * Enophthalmos * Contralateral lid retraction * Ipsilateral hypotropia * Brow ptosis * Dermatochalsis

Answer 9

Abnormal muscle development Unilateral or bilateral

Answer 10

* Improve lid position * Cosmesis * Improve VF * Types * Conjunctiva - Muller resection * Mild ptosis * Congenital ptosis * Horner's syndrome * Levator * Moderate ptosis * Brow suspension * Severe ptosis with poor levator function * Marcus Gunn jaw winking * Aberrant regeneration of CN III * Previous sx with poor results * Complications * Under/overcorrection * Lagophthalmos * lid lag * Exposure keratopathy * Corneal ulceration * Vision loss * Hemorrhage * Infection * Astigmatism changes * Ectropion/entropion * Cicatricial changes * Diplopia

Answer 11

* Common \*\* * Sagging of skin of eyelids (UL\>LL) * Bilateral, often asymmetric condition of elderly pt . \>50yo * Progressive involution changes of aging * Loss of elasticity * Degeneration of connective tissue * Characterization * Redundancy of upper eyelid skin * poor adhesion to underlying musculature/CT * orbital fat protrusion through septum * Indistinct lid crease * Hooding of lashes * Complications * Blockage of superior/temporal VF * Browache &/or HA * Frontalis muscle used to elevate lids * Cosmesis * Treatment * Blepharoplasy if affects superior field of vision

Answer 12

* RARE * Recurrent bouts of eyelid edema leading to redundant folds of skin over lid margins * Adolescents or young adults * Recurrent episodes of eyelid edema * Stretching & atrophy of skin * Damage to levator aponeurosis -\> ptosis * Characteristics * Unilateral or bilateral * Typically only UL * Herniation of orbital fat through septum * Stages * **edema stage =** transient painless lid edema with mild redness * **Atonic - ptosis stage** = skin appears reddish brown, becomes telangectatic & loose, overhanging onto lashes * **Ptosis adipose** = dehiscence of orbital septum with herniation of orbital fat into lid

Answer 13

* Removal of excess skin from upper or lower lids * Insurance covers when VF is affected from UL blocking superior portion of vision * Outpatient procedure * Topical **antibiotics** give for ~1wk following procedure * Bruising & itching are main side-effects * Risk * Poor healing * Persistent fat * Loose skin * DES (Dry eye syndrome) * Scarring due to corneal exposure if too much skin removed leaving pt unable to close eyes fully

Answer 14

* Outward rolling of lid * Complications: exposure of cornea & conjunctiva * **_Risks_** * Age * Eye rubbing * Repated pulling on lids * CL wear * Eye meds * Floppy eyelid syndrome * Skin condition affecting lids * **_Sx_** * Dryness * FBS (Foreign body sensation) * Conjunctival hyperemia * Epiphora * Lid redness * **_Causes_** * **Involutional** * Age & lid laxity * Musculature & skin tension decreases with age * Most common * **Cicatricial** * scarring * **Mechanical** * Tumors near lid margin * Basal cell carcinoma using disruption * **Paralytic** * Bell's palsy - paralysis of orbicularis * Exposure 2^ lagophthalmos -\> epiphora * Causes: CN-VII, Botox * **Congenital** * Usually associates with other lid/systemic problems * Unilateral or bilateral * RARE * Ichthyosis * Down syndrome * **_Tx_** * Treat underlying condition * Lubrication * Bandage CL * Surgical repair

Answer 15

* Inward rotation of lid & appendages * **Complicatiosn** * Trichiasis * Corneal pannus * Scarring * Ulceration or perforation late * **Sx** * FBS * Tearing * Blurred vision * **Causes** * **Involutional** * Most common * Age related loss of lid tone & weakness of lid retractors, atrophy of orbital tissues * **Cicatricial** * 2^ conjunctival scarring * Chronic inflammation -\> Fibrosis, scarring & shortening of posterior lamella * **Spastic** * Irritations of lid in severe corneal disease -\> spasm * Occasionaly with generalized belpharospasm * **Congenital** * RARE & Often confused with epiblepharon * occurs from improper aponeurosis insertion of the retractor muscles * **Tx** * Lubrication * Epilation * Glue * Surgical repair

Answer 16

* In-turning of lashes in the presence of normal eyelid position * Generally worsens in downgaze * More common in asians * Asymptomatic, resolves w/ age

Answer 17

* Incomplete lid closure * Sx * Eye irritation/FBS * Exposure keratopathy * Redness * Blurred VA * Worse overnight or in am after waking * **Nocturnal** * ****Sleep w/ eyes partially open * Dx on history, visualization of fissure with lid closure * Adults \>children due to decrease in tear film with age * **Orbital** * ****Proptosis * Graves, orbital pseudotumor, mucocele * **Mechanical/Cicatricial** * ****Scarring * **Paralytic** * ****Bell's unilateral CN-VII paralysis, frequent viral etiology * Self-limiting * Resolves w/in 3 months, 85% resolve in 3 weeks * Vascular associations - MUST rule out stroke * **Diagnosis** * ****Hx - ask if pt sleeps with eyes open or family member spouse reports * Observe blink rate & completeness * NaFL observeration with lids closed gently in slitlamp * Observe light presence/absence in slightly reclined position * **Treatment** * ****Mostly supportive ( lubrication & taping) * Tears during day * Ung qhs * Sleep masks/taping * Tarsorrhaphy if severe

Answer 18

* Loose eyelid skin which is easily everted * Generally occurs in obese, middle-aged men * Unilateral or bilateral * Frequently misdiagnosed * Complications * Exposure keratopathy * Drying of cornea & palpebral conjunctiva * Redness * Papillary response * Associations * Keratoconus * Eye rubbing * Skin hyperelasticity * Joint hypermobility * Obstructive sleep apnea * Diabetes * Mental retardation * Examination * Eversion of lid without excess manipulation * Spontaneous eversion * Tx * Supportive - lubrication, taping/masks * Medical - antihistamines * Surgical . Horizontal shortening of affected lid * Tx underlying condition - weight loss

Answer 19

* Fusion of lids to conjunctiva * Palpebral conjunctiva fusion bulbar conjunctiva * Cicatricial changes * Complications * Ocular motility disorders * Diplopia * Entropion or lagopthalmos

Answer 20

* Chalazion * Concretion * Epidermal inclusion cyst * Epidermoid cyst * Dermoid cyst * Sebaceous cyst (pilar cyst) * Cyst of Zeis * Hydrocystoma/Cyst of Moll * Milia * Comedones

Answer 21

* Meibomian gland lipogranuloma * Granulomatous inflammation from retained sebaceous secretion * Enlarging, painless nodules * Larger upper lid nodule may cause irregular astigmatism & blur vision * Recurrence needs to have sebaceous carcinoma ruled out * Tx * 1/3 resolves spontaneously * Heat * Excision, steroid injection, systemic antibiotics

Answer 22

* Calcified sebaceous material * May cause FBS * White to yellow color * may be single or multiple * Tx * None, Excision

Answer 23

* AKA epidermoid cyst, Sebaceous cyst (pilar cyst) * Proliferation of squamous epithelium in a confined space of the dermis or sub-dermis * Firm, non-tender nodule * Benign * Treatment * None * Incision & drainage for infectinon * Excision

Answer 24

* Developmental choristoma * Mass of histologically normal tissue in abnormal location * Generally present in 1st decade of life * Well circumscribed, firm, rubbery, subcutaneous mass * Tumors may be hair follicles, sweat or sebaceous glands * May be superficial or deep * **Superficial** * ****Firm, round, smooth, mobile mass * No proptosis or globe displacement * Superior temporal or nasal orbit * **Deep** * ****Older age of onset * Non-axial or globe displacement seen * Enlarge & may cause inflammation or scarring * **Indications** * Cosmesis * Vision loss * Irregular astigmatism * Deprivation of amblyopia * Optic nerve involvement * Rupture leading to granulomatous inflammatory reaction * **Tx** * Surgical removal - may recur if incompletely removed

Answer 25

* Obstruction of sebaceous gland associated with hair follicles * Small * Non-translucent * Anterior lid margin

Answer 26

* Adenoma of sweat gland - arise from apocrine or eccrine glands * Often on eyelid, near margin * Asymptomatic * Smooth, translucent, transilluminate

Answer 27

* Dead skin cells become in small pockets at surface of skin - baby acne * 1-2mm, white to yellow dome-shaped bmps * Infants or adults * Appear on nose, chin, cheeks, eyelids * Tx * none, excision for cosmesis

Answer 28

* Blocked hair follicle - keratin & sebum plug * Small, skin-colored, white or black bumps * **Open - black surface pigment** * **Closed - white, completely blocked**

Answer 29

* Squamous cell papilloma * Basal cell papilloma * Actinic keratosis * Sryingoma * Pilomatricoma * Capillary hemangioma * Port-wine stain * Pyogenic granuloma * Xanthelasma * Neurofibroma

Answer 30

* Soft, pedunculated mass with numerous finger-like projections * Conjunctival lesions caused from HPV - occurs mostly in children & young adults \<20yrs * Painless without vision loss * often no tx required & spontaenously resolve

Answer 31

* Slightly raised, skin to light brown colored spots that thicken & darken with time * Stick to skin like barnacles * Degenerative in nature, related to aging * Removal often recommended b/c similar in appearance to melanomas

Answer 32

* Multiple flat or thickened, scaly or warty, skin colored to red lesions occuring on sun-damaged skin * May develop into cutaneous horn * Considered pre-cancerous * Common in fair-skinned persons or those working outdoors for years without UV protection

Answer 33

* Harmless tumors of the sweat glands * Often occuring on eyelids * Skin colored to yellowish firm, round bumps 1-3mm in diameter

Answer 34

* Tumor of hair follicle * Rare, benign * Solitary, firm, skin colored papule or nodule * Multiple lesions associated with various genetic disorders - myotonic dystrophy * Generally on head, neck, upper extremities * Most often in young children & adolescents, but can affect adults

Answer 35

* Most common **benign** tumor in children \*\*\*\*\* * 10% all births * 80% head/neck * Predilection for UL * Slow progression * Dilations for capillaries * Females \> males * More common in caucasian populations * No bruit or pulse * Spongy consistency with palpation * Blanch with pressure * Lesion worsens with crying * Proliferative lesions which develop shortly after birth * 30% present at birth * 50% present at 1-2 months * 90% present by 6 months * Most 80% reach max size by 3 months, although may grow up to 18 months * Complications * Mechanical ptosis * Amblyopia * Astigmatic anisometropia \*\* * Strabismus * Exposure keratopathy * ON compression * Imaging Tests * US, CT, MRI * Tx * Indicated for cosmesis or risk of development of amblyopia, ON compression, corneal exposure * Monitor * Generally regress or involute - may take 3-10 years * 40% regress by age 4 * 80% regress by age 8 * Propranolol - oral or topical * Steroids - oral or injection * Laser tx * Surgical removal

Answer 36

* aka **nevus flammeus** * Large, flat patch of purple or dark red skin with well-defined borders * Increase in size, color & elevation over lifetime * May become bumpy with time * **Complications** * Tender/painful * congested with blood as to alter facial features * Infection * **Sturge-Weber syndrome (encephalotrigeminal angiomatosis)** * ****Somatic mutation of gene GNAQ - Non familial * Affects blood vessels of CNS, eyes & skin * Blood vessels grow more rapidly leading to increased number & size of vessels causing skin color changes * Red, purple, or blue appearance to skin * Unilateral \> Bilateral * **Brain involvement from increasing size of angiomas** * May result in shrunken brain * Calcification in the skull * Seizures * Meningeal angioma * **Ocular features** * Ipsilateral glaucoma (70%) * Buphthalmos * Iris heterochromia * Diffuse choroidal hemangioma * Optic atrophy * Epibulbar telangiectasia * Tx * None * Neurology consult * Dermatology consult * tx of ocular conditions

Answer 37

* Painful, fast-growing, vascularized polyp shaped lesion * Fibrovascular proliferative response to conjunctival injury * Causes * Trauma = mechanical or surgical * Infection * Hormonal influences * idiopathic * Tx * Steroids * Excision

Answer 38

* Deposits of cholesterol in skin * Yellowish subcutaneous plaque, often occuring at medial aspects of lid * Common, often bilateral, increasing with age * Association * Increased serum cholesterol * Primary biliary cirrhosis * Familial hypercholesterolemia * Tx * Excision

Answer 39

* Benign tumor of nerves * proliferation of schwann cells, fibroblasts & nerve axons * Tumor of lid causing characteristic S-shaped deformity * **Plexiform neurofibroma** * Larger, grow from nerves anywhere in body * Possibility of malignant conversion * Children with **NF1** * **Solitary/localized neurofibroma** * Adults, 25% with NF1 * Grow from small nerves in /near skin * Small bumps appearing during puberty * Remain benign

Answer 40

* Group of disorders that cause tumor growth in the NS * **NF1** = tumors in PNS * **NF2** = tumors of schwann cells (schwannomas) * Schwannomatosis - Schwannomas * Recently classified as separate entity from NF2 * Most tumors benign, but may become malignant * No gender or racial predilection * **NF Type 1** * ****1:2, 500-300 people world wide * Cause unknown ~50% of cases due to spontaneous mutation * Presentation - at or shortly after birth generally by age 10 * Progressive disorder * Generally of normal life expectancy * **NIH criteria for diagnosis** * At least 2 of the following * 6+ cafe-au-lait spots \> . 5mm in kids or \>15mm in adults * 2+ neurofibromas or 1+ plexiform neurofibroma * Auxillary freckling or freckling in the inguinal regions * 2+ lisch nodules * Distinctive osseous lesion * Sphenoid wing dysplasia * Long-bone dysplasia * Optic pathway glioma * 1st degree relative with NF1 * **Associations** * Large head circumference * Short stature * Hydrocephalus * epilepsy * Congenital heart defects * HTN * Vasculopathy * Learning disabilities * Poor language &/or visual spatial skills

Answer 41

* Ephelis * Acquired melanocytic nevus * Congenital melanocytic nevus * Cafe au lait spots * Nevus of Ota

Answer 42

* Increased melanin in basal keratinocytes * Common in fair skinned children * May fade or disappear during winter months &/or with age

Answer 43

* Moles * Most people have 20-50 * Appear after 6mos * Increase in number childhood/adolescence * Peak 3rd decade * Regress with age * **Risk of malignant transformation determined by histologic location** * Junctional - low potential - macular or minimally raised, brown to black * Compound - low potential - pigmented papules, may be dome-shaped * Intradermal - no potential - skin colored to tan dome-shaped papules * Histological variants - multiple dysplastic nevi (atypical moles) - at risk for conjunctival & uveal nevi & cutaneous, conjunctival & uveal melanoma * **Management** - observation * **Congenital Melanocytic Nevus** * Present between birth 2 yrs * Range in size from small (\<1cm) to giant (\>40-60cm) * Occur in any cutaneous location * Tan to black in color * May have course terminal hairs

Answer 44

* Flat, coffee-colored patches * Solitary lesions common * \>6 strongly suggestive of NF type I * May also be present in Albright's syndrome

Answer 45

* Slate-brown to blue/grey nevus * Occurs on forehead or around eye * May have hyperpigmentation of sclera, cornea, iris or retina * **Nevus of Hori** - occurs on both side of face

Answer 46

* Basal cell carcinoma * Squamous cell carcinoma * Keratocanthoma * Sebaceous gland carcinoma * Kaposi sarcoma

Answer 47

* MOST COMMON human malignancy * Elderly, fair skin, chronic UV exposure * 90% head/neck * 90% eyelid malignancies * LL \> medial canthus \> UL \> lateral canthus * Presentation * Ulceration * Induration (palpable, raised, hard area) * Irregular borders * Destruction of lid margin * Lack of tenderness

Answer 48

* Less common, more aggressive * Metastasis to lymph nodes in 20% * 5-10% eyelid malignancies * LL, lid margin * Elderly, fair complexion, chronic UV exposure * Presentation * Similar to BCC * Vascularization to absent * Rapid growth * Hyperkeratosis

Answer 49

* Type of squamous cell carcinoma * Rare * Fair-skinned, chronic UV exposure * LL * **Presentation** * Pink, rapidly growing hyperkeratotic lesion develops in weeks * Growth ceases x 2-3 mo & spontaneous involution occurs over 4-6 mo * Keratin-filled crater develops * Complete involution in about 1 yr leaving scarring * Rare progression to invasive or metastatic carcinoma

Answer 50

* Very rare * Elderly females - any age possible * Arising from MG, gland of zeis or sebaceous glands in caruncle * UL \> LL * Presentation * Often resembles chalazion in early stages * Yellow crusting common * Prognosis 5-10% mortality * Delayed diagnosis (\>6mo) * Size \> 10 mm * Metastatic disease 25%

Answer 51

* Vascular tumor * Frequent association w/ **HIV/AIDS** * Occasionally only clinical manifestation of infection * **Presentation** * Pink, red-violet, to brown lesion * Color varies based on skin pigmentation & location * May be mistaken for hematoma or nevus

Answer 52

* Inflammation of eyelids * Sx * Itching * Burning * Dryness * FBS * Mattered lids * Redness * Puffiness * Scratchiness * Lash loss * Bumps on lids * **Signs** * **Bulbar conjunctival staining** * Appears before corneal involvement * Lissamine green/Rose bengal - stains later & indicates associated DES * NaFL with wratten filter * **Corneal Staining** * NaFL * Mostly occurs inferiorly where lid apposes eye * Frequently sx worse in AM due to stagnation of tears * Looking for limbal staining * Curvilinear lesions at 10, 2, 4, & 8 o' clock * **Lid staining** * **Palpebral conjuctiva** * ****Injection * Concretions * MG changes * Telangiectasia * Papillae or follicles * **Lash/Lid structure** * Mattering * Greasy - seborrheic * Hard/crust - staph * Cylindrical sleeves - demodex * Poliosis * Madarosis * Pachyblepharon * **Tears** * Debris, frothiness * Decreased TBUT due to stasis * Decreases oils -\> increased evaporation * Improves w/ tx * Tx * **Digital expression of glands** * normal pts - clear oily liquid * MGD/MKC - rubid, inspissated glands * **Forceful expression of glands** * May be used as tx * Thick toothpaste or sing-like excretion from the glands * No discharge due to stenosis

Answer 53

* Involving the lashes and anterior lid * Very common cause of ocular discomfort & irritation * Usually **bilateral & symmetric** * poor correlation of signs & sx * **Symptoms** * ****Burning * Grittiness * Mild photophobia * Crusting/mattering * Redness * **characterized by remissions & exacerbations** * **Causes** * **Staophylococcal** - hard scales & crusting at the base of lashes * less common & occurs in younger pts * Treatable and possibly curable * **Seborrheic** - hyperemic & greasy anterior lid margins with lashes sticking together * 95% assocation with generalized **seborrhea or dermatitis** * M \> W * Mixed etiology * **Treatment** * ****Lid hygiene * Steroid/antibiotic combination * Warm compression

Answer 54

* **Meibomian gland dysfunction (MGD)** & alterations in the MG secretion * Sx: similar to anterior * **Meibomian seborrhea & MGD** * Overproduction of sebum & associated rapid turnover of epithelial cells * Present in approx 43% of population * Up to 30% CL intolerance * Associated with rosacea & seborrhea * Management: lid hygiene * **Meibomian Gland Grading Scale** * **0:** all glands patent * **1: 1 or 2** partially obstructed (clear with mild pressure) * **2: 3+** partially obstructed * **3: 1-2** blocked + many partially obstructed, foam along margins * **4: 3+** blocked with remainder partially obstructed

Answer 55

* **MG** disease with associated corneal changes * More common in cool climates * **Associations**: seborrhea & rosacea * **Presentation** * ****Inflammation around glands, mostly posterior * Difficult to impossible express glands * Very thick * Tear film instability * Associated papillary hypertrophy * **Associated keratitis** * ****10, 2, 4, & 8 o'clock lesions * Sterile, curvilinear ulcerations or infiltrates * Clear zone between lesion & limbus * delayed type hypersensitivity reaction wtih increased cell mediated immune etiology * Scarring and vascularization possible * Anterior changes possible: **madarosis, pachyblepharon, scalloped lid margins** * **Treatment** * ****Variable, often involves steroids

Answer 56

* **Microscopic ectoparasite** * demodex folliculorum * demodex brevis * **Clusters at root of eyelashes** * Burrows deep into sebaceous & meibomian gland * Life cycle: 14-18 day egg to larvae, 5 days adult * **Incidence** * 60 yo = 84% * 70+ yo = 100% * **Symptoms** * ****Itching * Burning * FBS * Dryness * Redness * Photophobia * Pain * Blurred Vision * **Clinical presentation** * ****Cylindrical dandruff * Lid margin inflammation * MGD * Blepharoconjunctivitis * Blepharokeratitis * **Treatment** * ****Lid hygiene * Cliradex * Sterilid * Blephadex * Tea tree oil * **BlephEx** (in office procedure to remove debris from lashes, similar to alger brush with micro-sponge top, 6-8 mins, repeated q4-6 months) * Demodex convenience kit - ocusoft

Answer 57

* Inflammatory condition of the skin * 30-50 yo, may occur in children * M=W * May occur in conjunction with or absence of cutaneous signs * **Symptoms** * ****FBS * Pain * Itching * Burning * Blurred vision - transient * Recurrent chalazion * Lid swelling or redness * Conjunctival hyperemia * **Eyelid** * ****Blepharitis - most common (Posterior blepharitis) * Telangiectasia * Chalazion * **Conjunctiva** * ****Conjunctival hyperemia * Papillary or follicular conjunctivitis * Conjunctival scarring * **Cornea** * Keratitis * Bilateral, relapsing of varying severity * Pannus * Stroma infiltrate * Corneal thinning * Dry eye * **Other** * ****Uveitis * Scleritis/Episcleritis * **Treatment** * **Supportive therapy** - topical lubricants, lid hygiene w/ massage, punctal occlusion * **Topical therapy** - Antibiotics, steroids, Restasis, Ivermectin - skin, Brominidine - skin * **Systemic therapy** * **Oral antibiotics** * ****Doxycycline - apprilon * Tetracyclines * Macrolides - young pts & those with interolerance/allergy to tetracyclines * **Omega- 3 fatty acids** * **Surgical excision of chalazion**

Answer 58

* often requires combination approach * **Nutrition** * **Seborrhea** * ****many pts with increased lipid deposition * Stop eating fatty foods * **Anti-oxidants** **-** may counteract free fatty acid damage * **LNA - alpha-linolenic acid (flaxeed oil)** * ****Beneficial role in cellular turn over * **Hygiene** * ****Warm compresses - Min 4 mins to dissolve waxes, up to 6x/day * Digital massage - assist in opening glands further * Lid scrubs * Clean debris from lid margin * Gentle - tissue thin & sensitive * **Supportive Therapy** * **Lubrication** * artificial tears: palliative results with q2 hr dosing, most pt compliance about 1-2x/day * **Gels** - last longer than tears, palliative results at QID dosing * **Ointments** - supply lipid component * **Punctal occlusion** - collagen, silicone, cautery * **Forceful experession** * ****Topical anesthetic on cotton swab with 2nd swab or finger to outer lid to apply pressure * Helpful in reduction of bacterial load * In office tx q6wks * Severe cases greatly improve sx after 3 sessions * **Topical therapeutic agents** * **Antibiotics** * ****Applied to lashes in scrub-like motion * Erythromycin or bacitracin * Initial presentation of corneal ulcer may require prophylactic antibiotic solution * **Steroid ointments or solutions** * ****Utilized for inflammatory or hypersensitivity component * Corneal disease: solutions * Lid disease: ointments * Combo drops/ointments often helpful * **Bland ointment** * ****useful in cases of demodex * ointment smothers the mite * **Oral antibiotics** * ****inhibit bacterial proliferation * inhibit lipase & thus free fatty acids * **Medications** * **Doxycycline** * ****Drug of choice in meibomitis * May cause GI distress * Decreased response when taken with food or acid reducer * Dosage * **initial** - 150-200mg * 25, 50, or 100 mg for maintenance dose * Caution: tetracyclines retard bone and dentitia development * Should not be used in pregnant or nursing women or in children under 12 yo * Warn of sensitivity to sun * **Azithromycin** * ****Z-pac * 500 mg first day, then 25mg for 5 days * **Erythromycin** * ****May cause GI distress * Safe to use in pregnancy, nursing & children * Adult dosing: 500mg loading dose, then 250mg QID x 4 days * Pediatric dosing: 30-50 mg/kg/day

Answer 59

* inflammation involving the outer angle of the lid * **Etiology**: *Moraxella lacunata or staph* * Rarely other bacteria & herpes simplex have also been implicated * **Signs** * ****Unilateral red, scaly, macerated & fissured skin at canthal regions (lateral\>medial) * May have associated papillary or follicular conjunctivitis * **Tx** * ****Topical antibiotics * Bacitracin * Erythromycin * Chloramphicol

Answer 60

* Infestation of eyelashes by **phthiriasis** (pubic lice) * Occurs at any age - children & adults living in poor hygienic conditions, sexual contact * **Sx** * ****Chronic irritation * Itching of lids * **Signs** * ****Lice anchored to lashes by claws * Ova & shells appear as oval, brownish, opalescent pearls at lash base * Conjunctivitis is uncommon * **Tx** * ****Mechanical removal of louse & associated lash with forceps * Bland ointment applied to lashes min. BID x 10 days * Delousing of pt, family members, & bedding is important to prevent reinfection

Answer 61

* Poorly defined, but tends to be more common in **asian & middle eastern** population * Presentation: mostly about 6yo * Recurrent episodes of chronic redness, eye rubbing & photophobia * Misdiagnosed as allergic disease * **Signs** * **Chronic anterior or posterior blepharitis** * ****often with recurrent hordeolum or meibomian cysts * **Conjunctival changes** * ****Diffuse hyperemia * Bulbar phlyctenules * Bulbar or papillary hyperplasia * **Corneal changes** * ****SPK * Marginal keratitis * Peripheral vascularization * Axial subepithelial haze * **Tx** * ****Lid hygiene & topical antibiotic ointment at bedtime * Topical allow dose steroids * Oral erythromycin

Answer 62

* External hordeolum * Impetigo * Erysipelas * Necrotizing fasciitis

Answer 63

* Acute bacterial infection & subsequent abscess formation in sebaceous glands of the lids * may present as **internal** or **external** variants * **Symptoms** * ****Tender or painful lid nodules * Associated redness & warmth of the skin of the lid * No visual changes * Rarely have discharge - if present, generally see purulent material within the gland * May notice thinning of the overlying epidermis * May see pointing/pouting of gland * **Demographics** * ****Any age, race, gender * **External Hordeolum** * ****Involves more superficial gland of zeis at the base of the lashes * Often develop a pouting appearance * come to head & can pop like acne * Can be managed with topical therapy * **Internal Hordeolum** * ****Involve deeper meibomian glands within the tarsal plate * May not realize actual size without everting the lids * Generally require oral therapy for resolution

Answer 64

* Superficial skin infection * Staph aureus * Strep pyogenes * Children * **Presentation:** Erythematous macule which develop into blisters * Golden-yellow crusting * **Tx:** antibiotics

Answer 65

* St. Anthony's Fire * Uncommon, subcutaneous cellulitis * *Strep pyogenes* infection through open wound * **Presentation:** * Expanding, indurated, erythematous subcutaneous plaque * Fever * Malaise * **Tx:** oral antibiotics ****

Answer 66

* Very rare rapidly progressive necrosis * ***Strep pyogenes*** * ***Staph aureus*** * Fatal if not treated * Periocular infection rare * Periorbital redness * Large bullae * Black discoloration of skin * **Complications** * ****ophthalmic artery occlusion * Lagophthalmos * Disfigurement * Death * **Tx:** IV antibiotics ****

Answer 67

* Molluscum contagiosum * Herpes zoster ophthalmicus * Herpes simplex

Answer 68

* infection by **poxvirus** * ****Direct person to person contact * physical contact with fomites * Peak incidence 2-4 yo * More frequent in developing countries * **Risks** * ****Atopic dermatitis * Immunocompromised pt * **Presentation** * ****Benign skin lesions * small, raised lesions with dimple center * white to pink color * 2-5mm diameter * May be itch, sore, red swollen * May occur anywhere on the body * Follicular conjunctivitis possible * **Treatment** * ****Resolution 6-12 mos to 4 yrs * Prevention of spread * Dont scratch/touch * Frequent hand washing/change towels, bedding * Cover lesions * Avoid certain spots during active infection * **Topical therapy:** pdophyllotoxin cream **** * **Oral therapy:** Cimetidine * Excision by shaving, cauterization, cryotherapy, laser

Answer 69

* Viral infection * 2 serotypes HSV I & II * 90% positive for HSV I worldwide * Leading cause of **corneal blindness** worldwide * M=F * Transmission * **Direct contact** * ****Person to person * Fomites * More likely while pt is symptomatic * **Primary infection** * ****Incubation = 1-26 days, Infection = 10-14 days * Most pts asymptomatic * Systemic symptoms * Asymptomatic to severe presentations - 20% with h/o primary infection sx * Sudden onset * Characteristic vesicular lesions superimposed on inflammatory, erythematous base * Groupings of multiple vesicles in single anatomic site * Painful * 10-14 day course * Systemic sx * Fever * Malaise * **Recurrent infection** * ****Virus lays latent in nerve cell bodies & reactivates in response to trigger * Prodromal sx common * 6-53 hrs prior to first appearance of first vesicles * Little to no systemic sx * Occur in 20-40% of population worldwide * **Prodromal sx**: pain, burning, tingling, pruritis * Shorter duration = 5 days * Recurrence 1x/month - 2x/year * Systemic sx rare = local lymphadenopathy * **Triggers** = UV exposure, fever, menstruation, emotional stress, trauma ( trigeminal nerve manipulation, dental extractions)

Answer 70

* \>90% seropositive by 4th decade * affects eye, mouth, skin above waist * less commonly affects genitals * transmission by direct contact * recurrence more frequent in oral mucosa

Answer 71

* Affects genitals * Less commonly affects eye - more severe * Sexual & neonatal transmission * Recurrence more common in genitals

Answer 72

* Idiopathic inflammatory condition causing itchy, red, irritated skin * Often appears on scalp, forehead, & face - rarely lids * **Sx** * Itching * Burning * Tenderness * **Presentation** * ****Thickening, crusting, & fissuring of lids * Associations with *Staph* blepharitis & madarosis * **Tx** * ****Topic emollients * Mild topical steroids

Answer 73

* **Sx** * Tingling, itching, burning * Sores/blisters * Flu-like sx * Trouble urinating * Ocular involvement * **Ocular involvement** * ****Recurrent disease most common * Lies dormant in sensory ganglia - usually trigeminal ganglion * **Triggers** * ****Psychological stress * Physical trauma * Fever * UV light exposure * Viral infection * Topical ocular meds = Prostaglandins, B-blockers * **Immunosuppresion** * **Signs** * Unilateral * Herpetic blepharitis * Conjunctivitis * Keratitis * Retinitis * Scleritis * **Herpetic blepharitis** * ****clear vesicles on red erythematous base on lid margin * occur in groups * lesions ulcerate & crust while healing * can lead to infection * Corneal migration high * **Treatment** * ****Antiviral therapy * topical: Viroptic (trifluridine), zirgan (ganciclovir) * Oral: acyclovir, valacyclovir, famciclovir, ganciclovir * Steroids * Supportive * Surgical

Answer 74

* Varicella zoster virus reactivation * Shingles * Primary infection is chickenpox * 32% of population will experience at sometime in their life * Incidence increases with age * 50% pt age 85 will have episode of zoster * **Risks** * ****Age * Physical trauma * Disorders of cell-mediated immunity * Chronic lung or kidney disease * Organ transplant pts * Autoimmune disease * F\>M * **complications** * ****Post-herpetic neuralgia = pain persisting \>4 months beyond onset of rash * Bacterial skin infection * Motor neuropathy * Meningitis * Herpes Zoster oticus * Ocular complications * Pts w/ 1+ . complications frequently have other comorbidities * DM, cancer, HIB, transplant pts * **Clinical manifestations** * ****Occurs in restricted dermatome * rarely occurs in 2+ dermatomes at the same time * thoracic and lumbar most common * Preceded by prodroma pain * Rash = patches of clear vesicles over erythematous base * Acute neuritis * Systemic sx (\<20%) * HA * Fever * Malaise * Fatigue * **Herpes zoster ophthalmicus** * **CN V1** * 50-70% experience direct ocular involvement * Prodrome * HA, Malaise, Fever, Unilateral pain or hypesthesia along CN V1 distribution * **Presentation** * ****Vesicular lesions along scalp UL & tip of nose * **Hutchinson's sign** * Blepharitis * Conjunctival involvement * Corneal involvement - 65% * Iritis 40% * Retinal complications * Optic neuritis * Oculomotor palsies * **CN V Distribution** * ****3 branches * **Opthalmic branch:** innervates scalp, forehead, upperlid,eye, tip of nose * **Maxillary branch:** innervates cheek, lower lid * **Mandibular branch:** innervates jaw, tongue * **Treatment** * ****Antivirals - Oral, topical, IV * Topical steroids or NSAIDS * Antibiotics * Lubrication * Cool compresses

Answer 75

* Contact dermatitis * Atopic dermatitis

Answer 76

* **Skin rash occurring as a response to an irritant** * Sensitized to irritant on first exposure & develop reaction on subsequent exposures * May be immediate or delayed * **Dealyed type IV hypersensitivity** reaction * Any age, race, gender * **Causes** * Medications * Makeups * Metals * **Sx** - Itching, tearing **** * **Presentation** * ****Lid edema * Scaling * Angular fissuring * Chemosis * Redness * Papillary conjunctivitis * PEK * **TX** * ****Stop exposure * PFATs * Cool compresses * Topical steroid * Steroid/antibiotic combo * Oral antihistamines

Answer 77

* Myokymia * Blepharospasm * Hemifacial spasm * Bell's Palsy

Answer 78

* Involuntary, fine, continuous, undulating contractions that spread across the affected striated muslce * Any age - young, healthy * Generally unilateral * Transient & self-limiting - hours to days * **Triggers** * ****Stress * Fatigue * Physical exertion * Increased caffeine/alcohol intake * **Sx** * ****Jumping * Quivering * **Treatment** * ****Spontaneous resolution * Stress reduction * Rest * Antihistamines * Quinine/Tonic water * Decrease caffeine, alcohol &/or tobacco consumption * BOTOX

Answer 79

* Dystonia of orbicularis oculi & other periocular muscles * Procerus muscle * Corrugator muscle * Benign essental blepharospasm * BILATERAL, involuntary orbicularis spasms * Synchronous * Symmetric * Female 3:1 * 6th decade * Remission & exacerbations * Mild annoyance to disabling * **Cause**: abnormal function of the basal ganglion from an unknown cause * **Symptoms** * ****Increased blink rate * Spasm of involuntary lid closure * Fatigue * Emotional tension * Photophobia * **Triggers** * ****bright lights * increased stress * **Treatment** * ****None * BOTOX * Surgical

Answer 80

* Uncontrollable twitching of muscles of half of the face * Muscle innervated by facial nerve * **Sx** * ****Periodic twitching & spasms of the eyelids leading to closure * Spreads to involve other ipsilateral facial & neck muscle * **Cause** * ****compression of facial nerve of the brainstem * Vascular anomalies, tumors, trauma * **Treatment** * **Medication** * ****Muscle relaxant * Mild cases * Tx sx * **Botox** * ****4-9 mo of relief per injection * tx sx * **Surgical** * ****Decompression of CN VII * Treats cause not sx

Answer 81

* Acute, temporary facial paralysis from damage or trauma to CN VII * M=W * Any age - majority 15-60yo * Sx * Unilateral facial paralysis of acute onset * HA * Numbness * DES/FBS * Tearing * Drooling * Dysarthria - trouble articulating speech * Dysphagia - trouble or discomfort swallowing * **Signs** * ****inability to move muscles of face * Smoothening of tone muscles * Drooping of eye, side of mouth * **Recovery** * ****extent of nerve damage dictates healing * Sx improve w/in ~ 2wks * Complete recovery 3-6 months * **Treatment** * ****None * Steroids * Antivirals * Supportive therapy * Covery eye - lubrication during daytime, taping/patching at night

Answer 82

* **Tattoo** * ****Eyeliner * Eyebrows * Permanent makeup application * UL/LL * **Risks** * ****Same as other tattooed areas of the body * Infection * Allergy * Granulomas * Keloid formation * Removal * MRI complications

Answer 83

* Cilia * Shed like hair * Regrow every 4-6wks * Approx. 100 per lid * Upper\>lower * Lash root near base of tarsal plate -\> passes through muscle -\> exits anterior lid margin * Curves away from the globe * Scarring of tarsal plate, conjunctiva or inflammation can lead to lash misdirection

Answer 84

* Trichiasis * Distichiasis * Eyelash ptosis * Trichomegaly * Madarosis * Hypotrichosis * Trichotillomania * Poliosis

Answer 85

* Incredibly Common * Posterior misdirection of lashes arising from normal origin * **Causes** * occuring in isolation * Result from scarring - chronic blepharitis & HZO (Herpes zoster ophtalmicus) * **Symptoms** * ****Asymptomatic * FBS - irritation worsens with blink * May cause corneal abrasions * **Treatment** * ****Epilation * Electrolysis * Cryotherapy * Argon laser ablation * Surgery

Answer 86

* **Congenital** * Rare * Germ cell differentiates to pilosebaceous unit instead of meibomian gland * Partial or complete 2nd row of lashes emerges behind meibomian gland orifices * Aberrant lashes thinner & shorter, often with posterior misdirection * Asymptomatic until about age 5 * **Acquired** * ****Metaplasia & dedifferentiation or MG to become hair follicules * Variable number of lashes iwth originate from MG orifices * Cilia generally non-pigmented & stunted * Generally asymptomatic * **Cause** * Late stage cicatricial conjunctivitis * Stevens-Johnson syndrome * Ocular cicatricial pemphigoid * **Treatment** * **Congenital** * ****LL: cryotherapy * UL: lamellar eyelid division & cryotherapy * **Acquired** * ****Mild: same as trichiasis * Severe: lamellar eyelid division & cryotherapy

Answer 87

* Downward sagging of UL lashes * Causes * Idiopathic * Associated with floppy eyelid syndrome * Dermatochalasis * Long-standing facial palsy

Answer 88

* Excessive eyelash growth * **Causes** * **Acquired** - drug induced (topical PGAs), malnutrition, AIDS, porphyria, hypothyroidism * **Congenital** - various syndromes, may have retinal problems or mental retardation * **Treatment** * **Lubrication** - protect the ocular surface **** * Epilation * Treat underlying condition * Adjust medications

Answer 89

* Loss of lashes * Causes * Chronic anterior lid margin disease * Alopecia * SLE * Trichotillomania

Answer 90

* Less than normal amount of lashes * **Causes** * Hereditary * Aging * Chemotherapy or other medical tx * Idiopathic * **Complications** * ****Cosmesis * Dry eye * Frequent ocular foreign bodies * **Treatment** * **Latisse (Birmatoprost 0.03%)** * Prostaglandin analog * Approved * Initially used as IOP lower drug (**lumigan**) * **Side effects** * ****IOP lowering * Eyelash growth - length, number & thickness * Increased pigmentation - skin, lashes iris * Conjunctival hyperemia * Stinging/burning * Anterior Uveitis

Answer 91

* Disorder of irresistible urge to pull out hair despite trying to stop * Generally scalp, eyebrows or lashes * Leaves bald patches * Develops in early teens * Associations * Depression * Anxiety * OCD * **Treatment** * Psychotherapy * Medications - non FDA approved * Antidepressants or antipsychotics

Answer 92

* Localized, premature whitening of lashes/eyebrows * Causes * Chronic anterior blepharitis * Vogt-Kayangi - Harada syndrome * Waardenburg syndrome * Vitiligo * Marfan syndrome

Eyelids & Eyelashes Flashcards

(116 cards)