Lid and Lacrimal Apparatus Disorders

Question 1

Conjunctivitis

Answer 1

MOST COMMON diagnosis in a patient with a red eye AND discharge

Question 2

Conjunctivitis Epidemiology Points

Answer 2

Most infectious conjunctivitis is viral in both adults and children
Bacterial conjunctivitis more common in children than adults

Question 3

Bacterial Conjunctivitis

Answer 3

Staph aureus (common in adults)
Strep pneumo
Haemophilus influenzae
Moraxella catarrhalis

Question 4

Bacterial Conjunctivitis

Answer 4

Redness and discharge in one eye (although it can be bilateral)
Affected eye often “matted shut” in the morning (this can also occur with viral and allergic etiologies)

Question 5

Bacterial Conjunctivitis Typical Presentation

Answer 5

Conjunctival inflammation
Purulent discharge at the lid margins and in the corners of the eye
***More purulent discharge appears within minutes of wiping the lids

Question 6

Bacterial Conjunctivitis Treatment

Answer 6

not usually needed unless a virulent organism is suspected or in the case of:
Neonates
Bacterial, chlamydial, and viral infections are major causes of septic neonatal conjunctivitis, with Chlamydia being the most common infectious agent.

Question 7

Viral Conjunctivitis

Answer 7

Typically caused by adenovirus

Question 8

Viral Conjunctivitis

Answer 8

Usually unilateral
MAY BE part of a systemic viral illness
Patient often has a burning, sandy, or gritty feeling (but NOT really pain!)
Typically more of a watery discharge during the day with perhaps some scant mucus

Question 9

Viral Conjunctivitis Typical Presentation:

Answer 9

Only mucoid discharge if one pulls down the lower lid or looks very closely in the corner of the eye
Usually profuse tearing rather than true discharge
Palpebral conjunctiva may have a follicular or “bumpy” appearance
There may be an enlarged and tender preauricular lymph node

Question 10

Viral Conjunctivitis Course

Answer 10

Generally self limited, parallels that of the common cold

Question 11

Allergic Conjunctivitis

Answer 11

Cause: airborne allergens

Typically presents the same way as viral conjunctivitis but is **bilateral from the start

Question 12

Noninfectious Non Allergic Conjunctivitis

Answer 12

Usually from transient mechanical or chemical insult:
Dry eye
Chemical splash
Following expelled foreign body (may have redness or discharge for 12-24 hours)

Question 13

RED FLAGS

Answer 13

Reduction of visual acuity
Severe deep eye pain (NOT just an irritation)
Ciliary flush: A pattern of injection in which the redness is MOST pronounced in a ring at the limbus (the limbus is the transition zone between the cornea and the sclera)
Photophobia
Severe foreign body sensation that prevents the patient from keeping the eye open
Corneal opacity
Fixed pupil
Severe headache with nausea

Question 14

Therapeutics Bacterial Conjunctivitis

Answer 14

Antibiotic ointment or drops
Examples: Erythromycin ointment, Sulfacetamide ointment
or Gentamyacin or Polytrim drops
Second line agents
Cipro drops: (Contraindicated in children)
Azithromycin drops

Question 15

N. Gonorrhoeae Conjunctivitis

Answer 15

by Neisseria gonorrhoeae
Transmission usually from genitalia  hands  eyes
Concurrent urethritis typically present
Characterized by profuse purulent discharge
Requires immediate ophthalmologic referral and patients require hospitalization for systemic and topical antibiotic therapy to prevent vision loss

Question 16

Therapeutics Viral Conjunctivitis:

Answer 16

Aimed at symptomatic relief
Can use OTC topical antihistamine/decongestant
Warm or cool compresses may provide additional symptomatic relief
Antiviral agents play NO role
Education: Tell patients that irritation and discharge may get worse for three to five days before getting better, that symptoms can persist for 2-3 weeks.

Question 17

Therapeutics Allergic Conjunctivitis

Answer 17

OTC antihistamine/decongestant drops (Visine A)
OTC oral antihistamines (Benadryl, Tavist)
Mast cell stabilizers such as Olopatadine (Patanol) and Azelastine (Optivar)
NSAID ophthalmic drop such as Ketoralac (Acular)

Question 18

Therapeutics Noninfectious Nonallergic Conjunctivitis

Answer 18

Generally a spontaneous resolution of symptoms
Topical lubricants may help provide symptomatic relief
Drops can be used every hour (Hypotears, Refresh)
Ointments provide longer lasting relief but blur vision (many patients use at bedtime) (Lacrilube, Refresh PM)

Question 19

Keratoconjunctivitis sicca

Answer 19

Age
Female gender
Hormonal changes (decreased androgens)
Systemic diseases (DM, Parkinson)
Contact lens wearers
Systemic medications
Ocular medications—especially those w/ preservatives
Nutritional deficiencies (vitamin A deficiency)
Decreased corneal sensation
Ophthalmic surgery (corneal refractive surgery)
Low humidity environments

Question 20

KS–Pathophsiology

Answer 20

Decreased tear production
Lacrimal gland destruction or dysfunction
Reduced volume results in hyperosmolar tear film,
this causes inflammation of the ocular surface cells
Increased evaporative loss
Excessive water loss leads to tear film instability and tear hyperosmolality
Commonly caused by meibomian gland dysfunction
Structural abnormalities of eyelid position or decreased blink function

Question 21

KS—Exam/Diagnosis

Answer 21

Conjunctival injection bilaterally
Excessive tearing
Blepharitis
Malposition of the eyelids
Reduced blink rate
Visual impairment when eyes tested separately w/ improvement w/ increased blink rate or lubricant drops
Often need ophthalmologist referral for slit lamp exam

Question 22

KS–Treatment

Answer 22

Depends on etiology
Blepharitis—eyelid hygiene
Ocular allergies—avoidance of allergen or meds
True KS
Artificial tears—recommend preservative free forms
Environmental strategies
Topical cyclosporine (Restasis)

Question 23

Dacrocystitis

Answer 23

is an infection of the lacrimal sac and is often associated with a blocked duct

Question 24

Dacrocystitis - Causes

Answer 24

Injury to the nose
Eye infection
Tumor
Nasal inflammation
Age-related changes affecting the eyes and eyelids in older adults
Blocked tear duct
Obstruction of the nasolacrimal duct by a tight inferior meatus has been noted in many infants
The most common organisms isolated from the lacrimal sacs of children with dacryocystitis include S. aureus, Haemophilus influenzae, beta-hemolytic streptococci, and pneumococci

Question 25

Dacrocystitis Treatment

Answer 25

Warm compresses Oral antibiotics (Bactrim, Clindamyacin) Careful follow up… if persistent send to ophthalmologist If extremely fluctuant, especially if the patient is sick and febrile, this suggests an abscess and the patient should be sent to an ophthalmologist

Question 26

Dacrostenosis

Answer 26

``` Nasolacrimal duct obstruction Can occur anywhere in the lacrimal drainage system Most commonly at the membrane of Hasner Seen primarily in newborns and infants Persistent tearing Ocular discharge Rarely injection of the conjuctiva ```

Question 27

Dacrostenosis Treatment

Answer 27

Massage | Probing

Question 28

Hordeolum (Stye)

Answer 28

A localized infection OR inflammation of the eyelid margin involving either: ``` Hair follicles of the eyelashes (External Hordeolum) OR… Meibomian glands (Internal Hordeolum) ```

Question 29

Hordeolum (Stye) How does it present?

Answer 29

Usually a painful, erythematous, localized mass which may produce edema of the entire lid With an external hordeolum, you may see purulent material exuding from the eyelash line With an internal hordeolum, there may be an opening where you see material exude on the conjunctival surface of the eyelid

Question 30

Hordeolum (Stye)

Answer 30

Infectious Staph Aureus implicated the great majority of the time (90-95%) Most of the time will spontaneously resolve May progress to chronic granulation with formation of a painless mass known as a chalazion

Question 31

Hordeolum (Stye) Keys with diagnosis:

Answer 31

Constitutional signs and symptoms (having fever, feeling sick) are NOT consistent with a hordeolum diagnosis! ***If the process involves the lid and periorbital tissues, it MUST be treated as a periorbital cellulitis, NOT as a hordeolum Preauricular lymph nodes will NOT be enlarged in patients with a simple hordeolum (this would suggest potential spread of infection, commonly to conjunctiva

Question 32

Chalazion

Answer 32

Also known as a meibomian gland lipogranuloma Subacute and painless nodule Will often disappear without treatment within a few months and virtually all will reabsorb within two years They can be injected with a corticosteroid or surgically removed in extreme cases

Question 33

Blepharitis

Answer 33

Inflammation involving the structures of the lid margin and involves: Erythema Scaling Crusting Disease often associated with systemic conditions such as rosacea and seborrheic dermatitis

Question 34

Blepharitis History:

Answer 34

Burning, watering, crusting of lashes and medial canthus, scaling, erythematous eyelids Most of the time condition has a chronic course with intermittent exacerbations

Question 35

Blepharitis Physical Exam:

Answer 35

Eyelids show erythema and crusting of the lashes and lid margins There may be some injection in the conjunctiva

Question 36

Blepharitis Treatment:

Answer 36

Systematic and long-term commitment to a program of eyelid margin hygiene!! Application of heat (warm compresses) This promotes evacuation and cleansing of secretory passages Mechanical washing of eyelid margin Baby shampoo with warm water and gentle washing of the eyelid margins (NOT the skin of the lids) Antibiotic ointment applied to eyelid margin (such as erythromycin) during exacerbations and in some stubborn cases can be used nightly for prophylaxis

Question 37

Ectropion

Answer 37

Ectropion is eversion of the eyelid margin away from the globe

Question 38

Entropion

Answer 38

Entropion is inversion of the eyelid toward the globe | Multiple causes:

Question 39

Pterygium

Answer 39

This is a corneal proliferative disease associated with UV exposure that arises from the limbus and proliferates This condition CAN move onto the cornea Vast majority are asymptomatic and therefore is of zero consequence unless it involves the visual axis

Question 40

Pinguecula

Answer 40

Often confused with Pterygium Appears as a yellowish growth of the scleral conjunctiva and is usually adjacent to the limbus As it is confined to the conjunctiva, this will NOT encroach onto the cornea Caused by sun exposure and irritation

Question 41

Capillary Hemangioma

Answer 41

1/3 diagnosed at birth 90% visible by 6 months Most common presentation is as superficial tumor that develops “strawberry” appearance

Question 42

Capillary Hemangioma - Treatment

Answer 42

Medical therapy – steroids (systemic, intralesional) or interferon Radiation therapy Surgical resection for unresponsive or well-encapsulated lesions

Question 43

Malignant Eyelid Tumors

Answer 43

``` Basal cell carcinoma Squamous cell carcinoma Meibomian gland carcinoma Melanoma Karposi sarcoma Merkel cell carcinoma ```

Question 44

Basal Cell Carcinoma – Important Facts

Answer 44

``` Most common human malignancy Usually affects the elderly Slow-growing, locally invasive Does not metastasize 90% occur on the head and neck Of these, 10% occur on the eyelid Accounts for 90% of eyelid malignancies Treatment consists of excision ```

Question 45

Squamous Cell Carcinoma

Answer 45

Less common but more aggressive than BCC | The majority of squamous cell carcinomas arise in solar-damaged skin and premalignant lesions (actinic keratoses)

Question 46

Meibomian gland carcinoma

Answer 46

Also referred to as Sebaceous cell carcinoma Lethal eyelid malignancy which can masquerade as a benign condition Error or delay in diagnosis is common, and this tumor carries a significant mortality rate with metastasis

Question 47

Melanoma

Answer 47

Very aggressive type of cancer that can spread rapidly Melanoma of the eye can affect several parts of the eye, including the: Choroid Ciliary body Conjunctiva Eyelid

Question 48

Karposi sarcoma

Answer 48

Malignant, vascular tumor that occurs mainly in AIDS patients Usually associated with advanced disease

Question 49

Merkel Cell Carcinoma

Answer 49

Rare but aggressive malignancy that metastasizes early to regional lymph nodes Fast-growing, well demarcated nodule Intact over-lying skin