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Flashcards in Lacrimal Disorders Deck (91):
1

What is dacryoadenitis?

Inflammatory enlargement of lacrimal gland, acute, chronic and cna be infectious/systemic

2

What do you look for in a dacryadenitis history?

Fever, discharge, systemic infection. Chronic cases may be bilateral, painless enlargement for more than a month

3

Does chronic or acute dacryoadenitis present more severely?

Acute.

4

How does chronic dacryoadenitispresent differently than acute daryoadenitis?

Usually painless, enlarged gland that is mobile, minimal ocular signs, mild to severe dry eye

5

How does acute dacryoadenitis present?

Firm and tender mass, unilateral and severely painful that had rapid onset

6

What signs are in acute dacryoadenitis?

Chemosis, conjunctival injection, mucopurulent discharge, red eyelids, swelling of lateral third of upper lid, proptosis, ocular motility restriction
May be feverish, have malaise, parotid gland enlargement and upper respiratory infection

7

What are the causes of dacryoadenitis?

Infectious (Viral, bacterial, Fungal) and Inflammatory

8

Describe Viral causes of dacryoadenitis

Most common (mumps in childhood)
Epstein-barr virus
Herpes zoster
mononucleuosis
Cytomegalovirus
Echoviruses
Coxacklevirus A

9

Describe bacterial causes of dacryoadenitis

Staphylococus aureus and streptococcus
Neisseria gonorrhoeae
Treponema pallidum
Chlamydia trachomatis
Mycobacterium leprae
Mycobacterium tuberculosis

10

Describe some infectious causes of dacryadenitis

These are rare
Histoplasmosis
Blastomycosis
Parasite

11

Of the infectious causes of dacryadenitis, which is most common, which is most rare?

Viral is common
Fungal is rare

12

Describe inflammatory causes of dacryadenitis

Sarcoidosis (inflamed lymph nodes)
Graves disease
Sjogren syndrome
Orbital inflammatory syndrome
Bening lymphoepithelial lesion

13

How would you do an acute dacryoadenitis workup?

Smear and culture if discharge is present
blood culture to rule out gonorrhoe
Immunoglobin titers to specific viruses

14

How would you do a work up for a chronic dacryoadenitis?

See if there are chronic systemic conditions, rule out infectious causes

15

How does imaging on acute dacryoadenitis differ from imaging chronic dacryoadenitis?

Acute/chronic - no compressive changes in bone or globe
Chronic - Contrast scans don't make lesions easier to notice
compression may be lacrimal tumors

16

How to treat Dacryoadenitis

Varies with onset and etiology.
Viral - Self limiting, use cool compresses
Bacterial/infection - Keflex until culture results come back
Hospitalize if moderate or severe
Inflammatory - Treat systemic

17

What are some tear layer functions?

Maintaing cornea/conj
Provides lubrication and oxygen for aforementioned
Smooth refractive surface

18

Describe aqueous deficient dry eye

Reduced lacrimal tear secretion, causing tear hyperosmolarity, causing epithelial inflammation

19

Describe two congenital causes of aqueous deficiency

Anhidrotic ectodermal dysplasia - Less sweating, madrosis, defective dentition, no sebacous glands
Or hypoplasia of lacrimal gland

20

Describe some nongenetic causes for aqueous deficiency

Trauma
Tumors
Inflammation (collagen vascular, viral dacryoadenitis, TB, sarcoidois,s syphillis, lymphoa)
Neurological defects (lesions of brainstem, et cetera)

21

Describe Sjogren's syndrome

Autoimmune, unknown cause. Most commonly post-menopausal women, characterized by lymphocyte infiltration and atrophy of lacrimal glands, and salivary gland.

22

What is the triad of findings in Sjogren's Syndrome?

KCS (Keratoconnus sicca), connective tissue diseas and xerostomia (dry mouth)

23

What is primary and secondary sjogren's syndrome?

Primary - KCS and xerostomia (antibodies focus on salivary glands)
Secondary - the above with the connective tissue involvement

24

What is the most common form of Non-sjogren syndrome dry eye?

Age-related, other kinds are KCS and lacrimal dysfunction

25

Describe Primary Lacrimal Gland Deficiences

Age related
Congenital alacrima (rare cause of dry eye in kids)
Familial dysautonomia (Riley-Day Syndrome) - autonomic dysfunction, instable blood pressure, sweating and vasomotor control and insesnitivity to pain

26

Describe secondary lacrimal gland deficieinces

Lacrimal gland infiltration, sarcoidiosis, lymphoma, AIDS, graft/host disease, lacrimal gland ablation or denervation

27

How could cictrising conjunctivitis cause dry eye?

Obstructing gland openings is bad. Can show up in cicatricial pehmpighoid, erythema multifome or burns

28

Describe the incidence/populations affected with Ocular Pemphigoid

Women twice as likely as men, average 58 years for onset

29

Signs/symptoms of ocular pemphigoid

Inflammatory disease due to autoimmune. Chronic blistering affecting mucous membranes (eyes, oral mucosa, skin, vagina, rectum), bilateral progressive shrinking of conj, ectropion, trichasis, xerosis, VA loss due to corneal opacification

30

What is Reflex Sensory Block?

Reduction in sensory signal from ocular surface (sent via trigeminal sensory input) causing dry eye by decreasing reflux induced lacrimation and reducing blinke rate

31

Describe some causes of ocular sensory loss

Infection (Herpes simplex/Herpes zoster)
Corneal surgery (Includes refractive)
Neurotrophic keratitis (CNV ganglion/section/injection/compression)
Topical agents (Anethesthia reduces tear and blink rate)
Systemic medication (Beta blockers/atropine like drugs)
Other (CL wear, diabetes, neurotrophic keratitis)

32

What is Reflex Motor Block?

CNVII damage, neuromatosis or some systemi drugs causing decreased larimal secretion

33

Describe evaporative causees of dry eye

Intrinsic - Lid structures/dynamics affected
Extrinsic - Ocular surface disease occurs due to extrinsic exposure

34

Describe some Intrinsic Evaporative Causes

MGD (Popsterior blepharitis) - Gland obstruction is the most common
Associated with rosacea, seborrhea, atropic dermatitis
Dx and grade based on state of plugged glands

Disorders of lid aperture or lid/globe congruity and dynamics
(Lagopthalmous, CNVII paresis, entro/ectropion, symblepharon)

Low blink rate

35

Describe some Extrinsic Evaporative Causes

Ocular surface disorders (Vitamin A deficency, some topical drugs and preservatives)
CL wear
Ocular surface disesae (Dry eye)
Allergic conjunctivitis

36

Give some reasons as to why it's hard to diagnose dry eye

+/- symptoms/signs
No symptoms but has clinical signs
Wet eye
Very subjective

37

What is Millieu Interieur?

Intrinsic factorsi n dry eye per se
Low blink rate
Wide aperture
Aging
Low androgen
Systemic drugs (antihistamines, beta-blockers, antispasmodics, diuretics, some psychotropic drugs)

38

What is Milleu Exterieur?

External causes of dry eye per se
Low humidity
Draft/wind
Occupational environment (smoke, A/C, airline flights)

39

Dry Eye symptoms?

Intermittent burning/tearing
Grittiness/FPS
Itching, redness
Intermittent VA loss
Photphobia
Mattering of lids/lashes

40

What are some problem oriented questions for dry eye Dx?

Do you experience X? (When/how often)
Context (location/time)
Any eye drops?
Who diagnosed and when?
CL wear?
Arthritis?
Thyroid abnomrality?
Dryness in other parts of the body?
Eyes sensitive to atmospheric irritants? (Smoke)
Red eyes/irritated when swimming?
Taking antihistamines, eye drops, diuretics, sleeping tablets, oral contraceptives, et cetera
Sleeping with eyes open?
Eyes irritated when you wake up?
Eye make up?
Any allergies?
Computer use?
Do you think you have dry eye?

41

What are some clinical signs of dry eye?

Reduction in tear meniscus
Cellular debris
Abnormal mucus accumulation generally in inferior cul-de-sac
Conj is injected
Dull appearance to eye

42

How to test for dry eye?

Observe blink rate/completness
Slit lamp (note tear meniscus height, avg is .2mm)
Check for debris via slit lamp and mucus strands (an early change in dry eye)
Assess lipid layer, if it's smooth/thick or thin or irregular
Check lashes for blepharitis or scurf, changes to lashes (madrosis, poliosis, tirchiasis, broken lasyes), tylosis (irregularity of lid margin)

43

What is meibomianitis?

Inflammation around meibomiam gland orfirces, clogging of the openigns and solidificaiton of secretions
Causes significant tear film disruption and low TBUT

44

What does Schirmer Test measure?

Aqueous secretion (normal is 15mm in 5 minutes)
Moderate or mild KCS is 5-10 mm in 5 minutes, and severe is less than 5mm in 5 minutes

45

What are the kinds of Schirmer Tests?

Schirmer I - No anestheisa to measure reflex/basal secretion
Schirmer II - Without anaesthetic to measure max reflex tearing

46

What is the Phenol Red Thread Test?

A string of phenol red dye placed in conj for 15 seconds. Length of wetting indicated by color change via a pH change by tears. Less than 10 mm is a symptom of dry eye

47

What is the tear osmolarity test?

Checking for osmolarity, it's higher in KCS. Takes instrumentation and a bit harder to do

48

What is a lactoferrin immunoassay test?

Measurement of tear protein (lactoferrin) as a correlate to tear volume. Takes 3 days to process

49

Describe the Tear Breakup Time

Gets an idea of detection of lipid and mucin deficiences

50

Describe Rose Bengal Staining

Water soluble dye, stains devitalized cells, mucus, corneal filaments; stains dead cells.

51

Describe Lissamine Gren staining

Stains dead and devitalized cells, but not as irritating as rose bengal. Cells tend to be easier to see, BUT discolors skin

52

Describe Fluorescein staining

Penetrates broken epithelial surfaces and diffuses through cells to stain them. Stains ulcers and scrapes.

53

Describe Jones I

Fluorescein placed in conjunctival sac and have patient blow nose on tissue or put a Q-tip on nose. Positive dye indicates open drainage

54

Describe Jones II

Conjunctival sac washed with saline, if dye goes through see some kind of functional blockage not physical then

55

Describe therapeutic approaches to treating dry eye with medication

Stabilize tear film
Increase lubricicty of tears (decrease friction)
Increase aqueous production
Decrease inflammation
Create a more normal tear film environment for epithelial healing

56

What are the four categories of lubricant eye drops

Cellulose derivatives
Glycerin Containing
Liupid based emulsion
Polyethylene glycol/propylene glycol

57

What are some cellulose derivative eye drops?

Carboxymethylcellulose (CMC) - Refresh Tears/Refresh Liquigel
Hypromellose (HPMC) - Tears Naturale, Genteal

58

What are some Glycerin Containing eye drops?

Glycerin - Advanced Eye Relief (Dry Eye)
GLycerin with HPMC - Tears Naturale Forte, Visine Tears
Glycerin with CMC - Optive

59

What are some lipid based emlusion eye drops?

Refresh Endura and Soothe

60

What are some Polyethylene glycol eye drops?

PEG and PG with HP Guar, Systane Ultra

61

Describe treating Dry Eye with Artificial Tears

Most common treatment modality. But relief for short duration only.
Educate patient on use and monitor

62

Describe Tears Again Liposome Spray

Applied to eyelids to get better tear lubrication and contact time. Has vitamin A and E as well

63

Describe Restasis eye drops

Increases in Schirmer wetting, dramatic improvement in conjunctival staining and SPK. Subjective improvement and mostly used for dry eye caused by inflammation

64

Describe Lacrisert

A sustained-release artificial tears inserts. Placed in inferior cul-de-sac and dissolve slowly to provide relief for 12 hours

65

Describe Ointment based treatments for dry eye

Used with tears. Place a 1/4'' ribbon in the inferior cul-de-sac, used before bed to avoid waking with blurry vision
Refresh PM
Lacrilube
Moisture Eyes PM

66

Describe Punctal Plug treatment for dry eye

Temporary placement of collagen implants in the puncta to prevent drawinage of tears to increase aqueous component of tears.

67

Describe Blink Therapy

Teaching a patient to blink more often and more completely to improve keratopathy, decrease friction, tear thinning and evaporation. Help maintain smooth, lubricated and clean CL surface

68

Describe the use of goggles and shields for treating dry eye

Retards tear evaporation in the most severe cases

69

Describe tear stimulation treatment for dry eye

Use of oral/topical drugs limited. Can use cholinergic agents like oral pilocarpine but not very successful and have side effects

70

Describe the use of Flaxseed Oil and Nutritional supplements to treat dry eye

May provide some relief for dry eye, reduces T cell lymphocyte proliferation, but can cause facial acne

71

Describe the use of bandage CLs in treating dry eye

Reserved for severe cases, can increase risk of infection, stagnation of tears with increased metabolic waste can then cause hypoxia of epithelium

72

What is FIlamentary Keratitis?

Strands of mucous attached to epithelium. In extreme dry eye cases. Remove and use AT and ointments. Often unilateral

73

What's a dacryocystography?

Saline with radioactive substance injectd into sac, x-ray taken to see if there is a blockage

74

What is Dacryocystistis?

Congenintal/acquired infection/inflammation of lacrimal SAC (not gland)
Tends to be secondary to obstruction (streptococcus, staphylcoccus, bacteria, et cetera)

75

Describe congenital dacryocystitis

Frequently seen with congenital dacrystenosis. Chronic painless presentation for weeks to months, mild/moderate tenderness on palpation

76

Describe acquired dacryocystitis

Frequently unilateral, tends to be acute with pain around eye and orbit.

77

What are signs of acute dacryocystitis?

Moderate swelling of sac, some edema and redness throught inferior nasal region, occassional hardened distention of sac with focal enlargement, a purulent discharge, secondary conjunctivitis, can be secondary to preseptal cellulitis and almost always see epiphoria

78

What are signs of chronic dacryocystitis?

Less severe, more commonly congenital, purulent discharge exaggerated when massaging. Can persist and spontaneously remiss.

79

What is the workup for dacryocystitis?

Previous episodes?
Concurrent ear/nose/throat infection?

80

How do you evaluate a dacryocystitis?

Gentle compression of sac to try and express discharge
EOM motility effected
Check for proptosis
Gram stain and blood agar culture of discharge
Consider a CT scan of the orbit to judge severity
DO NOT DILATE AND IRRIGATE DURING ACUTE INFECTIOUS STAGE

81

How to treat dacryocystitis in kids?

Systemic antibiotics. Amoxicillin for kids without a fever and have a mild case. Severe cases must be hospitalized and treated

82

How to treat dacryocystitis in adults?

Without fever/mild cases use dicloxacillin or cephalexin. For severe cases must hospitalize and treat

83

How to treat dacryocystitis in general?

Topical antibiotics, warm compresses and gentle massaging, pain medication, maybe surgical correction and daily follow ups

84

What is the most common congenital abnormality of the lacrimal drainage system?

Congenital lacrimal obstructions, valve of Hasner hasn't opened.

85

What is dacyrostenosis?

Narrowing of canaliculi

86

How do you evaluate a lacrimal obstruction?

Epiphoria?
Observe punctal integrity/position
Jones test
Dilate and irrigate if possible
Dacryocystorhinogram in severe cases

87

How to treat a lacrimal obstruction?

Treat cause of obstruction, frequent heat/firm massaging

88

What is a lacrimal fistula?

Chronic and untreated dacryocystitis, inflamming the sac until it perforates

89

What is a dacryocystorhinostomy? (DCR)

A hole is drilled between sac and bone to allow tear drainage

90

What's dacryocanaliculitis?

Infection/inflammation of canaliculi. Generally caused by fungal infections

91

What's a Dacryolith?

A yellow putty-like deposit blocking drainage system, secondary to fungal infections