Ocul Dis-Lids

  1. Trichiasis
    • -Lash misdirection
    • -v. common, esp elderly
    • -idiopathic, chronic blepharitis, trachoma (Chlamydia leading to infection), basal cell carinoma
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    • Trichiasis
    • -ocular irritation, worse with blinking
    • –hyperemia and epiphora–unilateral or bilateral
    • –inward turning lashes
    • –corneal staining
  3. Mx of trichiasis
    –artificial tears–epilation of lashes•regrow in 1-2 months–lid hygiene•If blepharitis–broad spectrum prophylactic antibiotics (preventative)–bandage contact lens–surgical removal•electrolysis; laser ablation; cryotherapy
  4. Madarosis
    • Decrease in number or complete loss of lashes
    • –Lid margin disease (e.g. chronic blepharitis)
    • –Skin disorders (e.g. psoriasis)
    • –Systemic disease (e.g. leprosy)
  5. Blepharitis
    • –Chronic, bilateral inflammation of the lid margins (may affect tear film, cornea, conj)
    • -V. common, esp. with increasing age
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    What is this? Signs?
    • Anterior Blepharitis (Seborrhoeic)
    • (•Burning•Grittiness•Mild photophobia)
    • •Greasy anterior lid margins•Lashes may stick together•Scales on lashes and skin of lid
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    What is this? Signs?
    • Staph. blepharitis
    • •Scales and crusts at base of lashes•Hyperaemia and telangietasis of anterior lid margin (due to TOXINS of Staph)
  8. Mx of Anterior Blepharitis
    • Lid Hygiene (warm compresses, lid scrubs, lubricants)
    • Antibiotic ointment (erythromycin or bacitracin, polysporin)
    • Topical steroids for conj and/or corneal involvement (fluoromethalone)
  9. Posterior Blepharitis
    • Meibomian Gland Dysfunction or meibonianitis
    • -Roscea (common skin disorder), idiopathic skin disease (facial)
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    What is this? Signs?
    • Posterior Blepharitis
    • –Posterior lid margin hyperaemic–Telangiectasis of lid margin–Obstructed meibomian orifices (inspissated)
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    What is this?
    • Posterior blepharitis
    • -see inspissated glands -> oil in tear film (Px will have blurry vision)
  12. Complications of posterior blepharitis
    • -Tear film instability (discomfort, blurred vision)
    • -Corneal and Conjunctival involvement
    • -Chalazion formation (more about this later)
    • -Systemic causes of the blepharitis
  13. Mx of posterior blepharitis
    • -Lid Hygiene (Warm compresses•Meibomian gland expression•Lid Scrubs•Artificial Tears)
    • -Antibiotics for Ocular Rosacea (Systemic tetracycline or doxycycline or erythromycin)
  14. Chalazion
    • -sterile, block meibomian gland
    • -common, esp. for Px with posterior bleph, rosacea, seborrhoeic dermatitis
    • -asymptomatic, may press on cornea -> blur vision, blepharitis, unslightly
  15. Image Upload 6
    What is this? Signs?
    • Chalazion
    • -non-tender, palable lump in lid
  16. Mx of Chalazion
    • -Topical therapy ineffective!
    • -wait, may clear w/o treatment (hot compresses, digital massage qid)
    • -Steroid Injection (triamcinolone)
    • -Systemic antibiotic (tetracycline) for recurrent chalazia or with rosacea
    • -Surgery
    • -CONSIDER sebaceous gland carcinoma if reoccurs!
  17. Hordeolum
    • -Infection of lid glands (internal or external, commonly acute staph infection)
    • -Common in those with chronic blepharitis
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    What is this? Signs?
    • Internal Hordeolum
    • •Tender, painful swelling within tarsal plate
    • •May discharge through skin of lid or through palpebral conjunctiva
  19. Mx of internal hordeolum
    • •Warm compresses*
    • •Antibiotics (systemic) rarely needed
    • •May leave a residual nodule after healing – this may require surgical removal
  20. External hordeolum
    • •Acute staph infection of gland of Zeiss or Moll
    • -common stye
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    What is this? Signs? Mx?
    • External hordeolum (stye)
    • •Tender swelling in lid margin
    • •Points anteriorly through skin
    • •Mx: Warm compresses•Removing lash (epilation) may speed resolution (almost never necessary)•Antibiotics not indicated
  22. Xanthalasma
    • -Yellowish, subcutaneous plaques of cholesterol and lipid
    • -common in elderly, may indicate hyperlipidemia in younger Px
    • -get cholesterol checked! Surgery for cosmetic reasons
  23. Cyst of Moll vs. cyst of zeiss
    -differential diagnosis
    • -Fluid filled cyst on lid margin, blockage
    • -common (moll more common than zeiss)
    • -moll: clear fluid (apocrine), zeiss translucent (oily)
    • -differntial: sebaceous cysts (yellow, waxy, spongy)
  24. Sebaceous cysts
    • -blockage of sebaceous glands (yellow, waxy, spongy)
    • -uncommon
    • -monitor growth for carcinoma!
  25. Milia
    • Tiny white superficial cysts
    • -Derived from hair follicle or sebaceous glands
    • -Very Common, not a big deal
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    What is this? def'n, prevalence, Mx, Signs?
    • Viral Wart
    • Pedunculated or broad based, pigmented or unpig., raspberry like surface
    • -benign eyelid tumor, squamous papilloma
    • -Very Common (>1/10), more frequent with age
    • -Can be surgically removed
  27. Image Upload 10
    What is this?
    • Seborrhoeic Keratosis
    • -Benign eyelid tumor
    • -Overactivity of the sebaceous glands characterized by excessive secretion of sebum or an alteration in its quality, resulting in an oily coating, crusts, or scales on the skin.
    • -Common in the elderly
    • -Uncommon on lids (1/1000)
  28. Actinic Keratosis
    • Benign Eyelid Tumours
    • -Most common pre-malignant skin lesion, rare on lids
    • -refer to dermatologist
  29. Sturge-Weber Syndrome
    • -a rare disorder that is present at birth. A child with this condition will have a port-wine stain birthmark (usually on the face) and nervous system problems.
    • -Naevus (subcutaneous cavernous hemangioma, red patch) involves trigeminal nerve distribution
    • -uncommon (1/50,000)
    • -may be angiomas in brain (tumor of lymph and bvs), high risk of ipsilateral glaucoma
  30. Basal Cell Carcinoma
    • -Malignant Eyelid Tumours
    • -most common skin cancer, common in elderly (rare for lids to be affected -likelihood: lower lid, medial canthus (risk for orbital involvment)
    • -Related to sunlight exposure
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    What is this? Signs?
    • Basal Cell Carcinoma
    • •Shiny, firm, pearly nodule•Fine vessels on surface•Initial growth is slow•Develops central ulceration, raised edges, with dilated vessels at edges
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    What is this? Prevalence? Risk factor?
    • Squamous cell carcinoma
    • -less common than basal cell carcinoma, more aggressive though
    • -metastasize (basal cell carcin does not metastasize)
    • -may arise from actinic keratosis
    • -more rapid growhth, no surface vascularization
  33. Entropion
    • -uncommon
    • -age (incrased horizontal lid laxity and atrophy of the orbital tissues -> globe moves posteriorly)
    • -congential due to hypertrophy of musculature
    • -scarring of tarsal conj (trauma, chemical burns, inflammatory conditions, trachoma)
    • -spasm (surgical trauma, blepharospasm due to dry eye or Tourette's syndrome)
  34. Mx of entropion
    • –artificial tears
    • –prophylactic antibiotic
    • –epilation of lashes in minor cases
    • –electrolysis (remove lashes)
    • –lid taping
    • –bandage contact lens
    • –mucous membrane (cictricial/scarring cases)
    • -surgery (tighten or shorten the skin)
  35. Ectropion
    • -an outward turning of the eyelid margin–almost exclusively the lower lid
    • -Common
    • –FB sensation–hyperemia–epiphora, corneal staining
    • -age, scarring, mechanical, paralytic (CN7 causing lack of tone in orbicularis ie. Bell's Palsy)
  36. Mx of extropion
    • –artificial tears & ointment at night
    • –lid taping at night
    • –lid surgery if severe (tarsorrhaphy (lids stitched partially together) or inferior lid shortening)
  37. Marcus Gunn Jaw Winking Syndrome
    • –Ptosis reduces on mouth opening–Abnormal levator innervation from N5 (trigeminal)
    • –5% of congenital ptosis
  38. Congenital Ptosis
    Striated muscle dystrophy of the levator muscle–Often cause unknown–May be hereditary–Can also involve SR
  39. Aponeurotic Ptosis
    • -most commonly a breakdown of tarsal plate (the tendon of levator)
    • -often seen in senile (adipose tissue replaces levator) or postoperative (esp. CatS), blunt trauma, CL wear
  40. What is this? def'n? Signs?Image Upload 13
    • Horner's Sympathetic Palsy
    • Acquired or congenital innervational defect–III N palsy, oculosympathetic palsy
    • Signs: Neurogenic ptosis (weak Muller), miosis (unopposed sphincter), cycloplegia, exotropia (LR and SO function, no drepression in abduction), loss of sweating in acquired cases, lesion below superior cervical ganglion (external carotid artery plexus affected)
  41. CN3 palsy with blown pupil
    • -cerebral anuerysm compressing CN3
    • -emergency, life-threatenging (MRI)
  42. –CN3 palsy with pupil spared
    • –diabetes; hypertension
    • -microangiopathy
  43. Etiology of Horner's Syndrome
    • -stroke
    • -tumor (lung carcinoma), thyroid (check neck), Pancoast tumor (arm pain), neuroblastoma (children), cluster migraine, Herpes Zoster, cavernous sinus (intracranial) tumor))
  44. Myasthenia Gravis
    -most affected
    • Disorder of neuromuscular transmission characterized by weakness and fatigability of skeletal muscles (autoimmune reaction to decrease ACh receptors)
    • -eye lid droop, transient double vision with fatigue, flutating muscle weakness
    • -benign tumor of thymus (remove thymus, myasthenia gravis will go away)
    • -elderly Px
  45. Myotonic Dystrophy
    • -genetic disease (Autosomal dominant)
    • -Signs: –bilateral ptosis; orbicularis weakness; lid closure; extraocular muscle dysfunction; poor blinking; dry eyes, cataracts
  46. Ptosis Mx
    • -severe cases may require surgery (esp congenital cases) shorten Muller, levator resection (most common), attach superior lid to frontalis muscle
    • -watch for corneal exposure after surgery
  47. Sign of thyroid dysfunction in lids
    contralateral lid retraction (pseudoptosis)
  48. Dermatochalasis def'n
    excessive skin on upper lids
  49. Etiology of ipsilateral decreased vertical fissure height resulting in pseudoptosis
    • -shrunken globe (micophthalmos)
    • -eye displaced backward (enophthalmos)
    • -congenitally abesent (anophthalmos)
  50. Image Upload 14What is this? def'n? prevalence? etiology?
    • Preseptal cellulitis
    • -Spread of local infection to subcutaneous tissues anterior to orbital septum
    • -uncommon to rare
    • -complication of hordeolum, skin trauma
  51. Differential diagnosis: preseptal cellulitis and orbital cellulitis
    • Preseptal: normal vision, normal pupil, normal motility
    • Orbital: Fever, Malaise & Pain, Reduced Vision(optic nerve involvement), Proptosis (protruding), Ophthalmoplegia (restricted mov't) POTENTIALLY LIFE-THREATENING
  52. Treatment of preseptal and orbital cellulitis
    • preseptal: oral antibiotics (cephalexin, amoxicillan/clavulanic acid)
    • orbital: hospitalization, antibiotics (IV, IM, Oral), blood tests, CT scan
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Ocul Dis-Lids