Lacrimal and TED Lecture 9/1 Flashcards
Define Dacryoadenitis
Inflammation of the lacrimal gland.
Dacryoadenitis - Clinical Presentation
acute - unilateral, swollen lid and lacrimal system, severe pain and pressure in the supratemporal area of the orbit. no vision changes
presents in hours to days
chronic - more common form. Can Present bilaterally with painless enlargement of the lacrimal gland. no vision changes
for than one month or longer
Note: infectious causes are rare, but when they occur, bacterial gram +ve
Dacryoadenitis - Dx
Diagnosis is made from clinical presentation
Dacryoadenitis - Treatment and Management
Viral (MC) - self-limiting, supportive measures (warm compress, NSAIDS)
Bacterial - initiate with 1st gen cephalosporins (Keflex) until culture
fungal or protozoan - treat accordingly
inflammatory - steroids and investigate for systemtic etiology
Dacryoadenitis - DDX
- dacrocystitis
- viral conjunctivitis
- bacterial conjunctivitis
Dacrocystitis - Definition
lacrimal sac is inflammation of the lacrimal sac. Usually accompanied by blockage of the lacrimal duct
Dacrocystitis - Dx
Diagnosis is based on clinical presentation
Dacrocystitis - Treatment
- Distended and erythematous with discharge and tenderness: I&D
- Non-tender without discharge:
- massage in infants
- irrigation in adults
- midly tender with discharge: warm compresses and antibiotics (depends on culture), but first line is Augmentin
Dacrocystitis - Clinical Presentation
- lacrimal sac is frequently blocked, with tears draining out of eye
- palpable and visible mass over lacrimal sac, which is located just inferior to the medial canthus
- in acute, sometimes with erythema, tenderness and discharge (indicative of infection as complication)
- can be chronic, then manage surgically by opening blocked duct
- can also be congenital
Dacrocystitis - DDX
- Neoplasm
- mass above medial canthus suspicious
- non-mobile masses more likely to be neoplasm
- blood on irrigation or spontaneous discharge of blood
- MRI/CT is definitive when in doubt
- orbital cellulitis
- conjunctivitis
- sarcoidosis complications
- blepharitis (adult)
Thyroid Eye Disease (TED)
Definition
- Autoimmune disorder
- often, but not always in hyperthyroid patients
- e.g., Hashimotos thyroiditis
- leads to characteristic changes in the eye
TED - etiology
TED has two phases:
- Inflammatory (first 6-18 months)
- post-inflammatory (beyond inflammatory phase)
Entire process is cyclic:
- anti-TSH receptor or anti-IFG-1 receptor attacks orbital fibroblasts
- causes activation and release of chemokines (IL-16/RANTES)
- attracts T cells to area
- more inflammatory factors released, fibroblast proliferation and fat accumulation
- GAG casues swelling
- IL-6 causes B cells to accumulate, more ab and the cycle starts all over again
TED - Clinical Manifestations
- Upper eyelid retraction (the stare)
- sympathetic overstimulation of Muller muscle
- later enlargement of superior levator
- Restrictive ophthalmopathy - trouble looking fully
- IR>MR>SR>LR usual sequence
- those with trouble looking upward (SR) or outward (LR) are at risk for optic nerve compression
- Proptosis - bulging eyes
- due to GAG causing inflammation
- due to fibroblasts –>adipocytes
- CON - compression of the optic nerve (and maybe blood supply)
- between 2-5% get this
- severely limits eye movement
- if proptosis is not possible, may make CON more likely, because globes can’t move
TED - Epidemiology
- Women more likely than men
- But, men more likely to develop SEVERE TED
- Smoking linked to TED and progression (dose-response dependent based on cigarette #)
- RAI (treatment for thyroid) may worsen TED
TED - Management and Prevention
(Get Euthyroid first)
- Mild -
- Most cases and mild and will improve spontaneously
- 74% in study needed no Rx or supportive therapy only
- artificial tears
- establish euthyroid status
- selenium - slowed progression
- Moderate/Severe -
- IV methylprednisolone pulse, PO steriods later with taper (effective, but hard to do outside Europe)
- orbital radiation
- Rituximab (Mab) - Note that this treatment is still experimental. can have bad side effects like serum sickness and infusion reaction. Also $$
- Surgical -
- Emergent - immediate decompression when CON unresponsive to IV steriods or severe proptosis with exposure
- Elective - delay until pt. is euthyroid and stable for 6-9 months
- Sequenced approach:
- decompression
- extraocular muscle surgery
- lid retraction surgery
- dermatochalasis (fat protrusion)
- Sequenced approach:
