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168 Cards in this Set

  • Front
  • Back
what is blepharitis?
infection or inflammation of the lids, lid margins, and/or lashes
staph bleph =
staphylococcal blepharitis
most common type of blepharitis?
staph bleph
what is staph bleph?
bacterial colonization of the lids and lashes
which bacteria cause staph bleph?
1) staphylococcus epiderMIDIS
2) staphylococcus aureus
3) corynebacterium
4) propionibacterium acnes
what is the most prevalent flora organism?
staphylococcus epidermidis
most common pathogen in ocular disease in US adults?
staphylococcus aureus
pathology of staph bleph?
exact pathology unknown
1) direct microbial invasion of tissues
2) immune-system mediated damage
3) damage from bacterial exotoxins, waste products, and/or enzymes
4) demodex
what is demodex?
intradermal parasite that is associated w/ staph bleph
where does demodex live?
in sebaceous glands and hair follicles of humans and animals
demodex may cause, contribute to, play a role in, or be a consequence of __
bacterial blepharitis
T/F: controversy exists as to whether demodex is incidental, or whether its presence contributes to, or is even the primary cause of blepharitis and other skin infxns
true
T/F: demodex may be a side effect of a different primary infection w/ other microbes
true
how does demodex contribute to bacterial-related blepharitis?
- by mechanical blockage
- host immune response (in pts w/ lowered immune system)
Tx for demodex?
- Tx of non-ocular tissues is w/ topical antibiotics:
*** metronidazole gel and ointment (MetroGel)
2) tea tree oil
3) sodium sulfacetamide
oral version of MetroGel?
flagyl
T/F: metronidazole gel is FDA approved for ocular use
false. however, it has been used to treat other eyelid conditions (acne, ocular rosacea)
benefits and cons of sodium sulfacetamide?
benefit - cost-effective

con - high allergy rate
causes of blepharitis?
bacterial, seborrheic, viral , allergic, etc
signs of staph bleph?
1) scurfs or collarettes
2) hyperemia of lid margin
3) if chronic --> madarosis, trichiasis, poliosis, and tylosis ciliaris
4) if severe --> ulcerative blepharitis
5) can cause associated conjunctivitis --> papillary rxn on conj
6) may see corneal defects (inferior PEK)
complaints associated w/ staph bleph
1) FBS
2) crusting of lids (esp in a.m)
3) itching, tearing, burning
4) symptoms associated w/ associated conjunctivitis (if present)
what are hard, brittle scales surrounding the lashes and on the lid margin
scurfs or collarettes
what is madarosis?
loss of lashes
what is poliosis?
whitening of lashes
what is tylosis ciliaris?
thickening of lid margin
what is it called when the lid margin thickens?
tylosis ciliaris
what is ulcerative bleph?
ulceration of the lid margin when crusts are removed
what are collarettes?
lid debris from staph bleph;

surround the base of lashes
what are sleeves?
long collaretes; more severe presentation
what are scurves or scurfs?
general debris around/on lashes, not specific for any diagnosis
__ are general debris around the lashes while __ are debris from staph bleph
scurfs;

collarettes
if you have ulcerative blepharitis, what drug should you use?
antibiotic OINTMENT, not drop
what are the corneal changes seen in staph bleph?
1) inferior PEK
2) marginal infiltrates, ulcers, pannus, and phylctenues
what is the most common corneal defect seen in staph bleph?
inferior PEK
in what part of the cornea are changes associated w/ staph bleph most commonly seen?
@ points where lids most frequently intersect the cornea
(2, 4, 8, 10 o clock)
Tx for staph bleph?
1) lid hygiene (HOT compress, lid massage, lid scrubs) for almost all forms of bleph
2) may need Antibiotic to eradicate bacterial colonization of lid
T/F: azasite antibiotic drops BID is an off label use of the drug that is nevertheless commonly used
true
what drugs would you prescribe to a patient w/ staph bleph
1) azasite antibiotic drops BID
2) antibiotic ung applied w/ a clean fingertip or sterile Qtip to the lid margin BID-QID (1/4 to 1/2 INCH RIBBON APPLIED TO LID MARGIN qhs)
3) sodium sulfacetamide (alone or in combo w/ steroid)
4) steroid-antibiotic combo ung when inflamm is as predominant as the infectious signs
5) severe --> oral antibiotics or request dermatology consult to control the infxn
staph bleph may become ___, leading to complications. careful compliance w/ lid hygiene instructions is necessary
chronic
___ compress is first
warm
vertical massage if any __component
meibomian or seborrheic
lid scrub instructions
scrub gently w/ eyes CLOSED; DILUTED baby shampoo (1:1 w/ H2O)
__ are available for lid scrubs
commercial preps
when would you consider scrubbing the eye w/ only H2O?
W/ older pts or pts w/ sensitive skin types
MGD =
meibomian gland dysfunction
MGD is a family of conditions that includes...
1) SEBORRHEIC bleph
2) meibomianitis
3) meibomian seborrhea
another name of meibomianitis?
meibomitis
staph bleph is more of a ___ bleph while meibomianitis is more of a __ bleph
anterior;
posterior
describe seborrheic bleph
oily flakes and debris on eyelids and lashes
what other conditions is seborrheic bleph usually associated w/?
1) generalized seborrheic disorder (like acne rosacea or seborrheic dermatitis)
2) oily skin, eyebrows, etc
S/S of seborrheic bleph?
1) scales and flakes (greasier than staph belph)
2) often associated w/ other MGD such as obstruction of the meibomian glands
3) BURNING
what is the primary symptom in all forms of MGD?
burning
what is seborrhea?
an increase in the amt of normal meibomian secretions (oil) being liberated into the tear film and onto the lid margins
___ is almost always seen in association w/ seborrheic bleph?
meibomian seborrhea
S/S of seborrheic bleph?
1) burning (CC)
2) itching, tearing
3) FBS
4) *** foam in tear meniscus & oil slick appearance to tear film
5) may cause dec'd VA due to altered viscosity of tear film
T/F: for staph bleph, complaints often seem out of proportion to the clinical picture
true
___ is known as posterior bleph
meibomianitis
what is meibomianitis?
stagnation or solidification of meibomian secretions
does meibomianitis involve all the glands?
- primary involves all glands
- secondary has scattered gland involvement
S/S of meibomianitis?
1) domed caps on meibomian glands
2) thickened red lid margins w/ oily texture
3) reduced TBUT
4) seborrheic bleph
what happens when capped meibomian glands are expressed?
a thick creamy material is liberated
why do pts w/ posterior bleph have a reduced TBUT?
b/c the outermost lipid layer of the tears is disrupted
___ will most likely also be present in pts w/ meibomianitis?
seborrheic bleph
T/F: All stages of MGD are treated in the same way
true

(Tx for seb bleph = Tx for meibomian seborrhea = Tx w/ meibomianitis)
Tx for MGD?
1) careful lid hygiene - emphasize the compress/massage
2) use AT liberally
3) sometimes use oral meds
4) topical steroids
5) restasis if chronic
6) if systemic disease - co-manage w/ PCP, need topical and/or oral steroids and other systemic drugs
7) suggest shampoo for seborrhea
how would your lid instructions be diff for a pt w/ seb bleph compared to a pt w/ staph belph? why?
for seb bleph, emphasize the compress/massage to loosen and liberate the secretions of the meibomian glands
why would you use AT liberally after the hygiene procedure for pts w/ MGD?
to wash out the oils that have been liberated
why are oral meds sometimes necessary for MGD? what drugs can we use?
- decrease oil secretions
- oral doxycycline and tetracycline are anti-seborrheic agents
would you ever use topical steroids for Tx of MGD?
yes, it can be used SHORT-term to reduce significant ocular inflamm if it is present
what is restasis? why would you use it to treat MGD?
- restasis = cyclosporine A
- treats CHRONIC MGD as an option to steroids in ROSACEA
cyclosporine A is also known as __
restasis
use of __ for MGD is an off label Tx
restasis
what's an example of a systemic disease that is sometimes present in MGD pts?
acne rosacea
what might you suggest a pt with MGD to do?
use Selsun on the scalp and eyebrows if necessary
in what category do most cases of bleph fall into?
mixed seborrheic-staphylococcal bleph
Is the Tx for mixed seb-staph bleph the same as Tx for seb bleph or Tx for staph bleph?
NO, neither


(no ung for mixed when seb is predominant!)
Tx for mixed seb-staph bleph
1) lid hygiene
2) w/ or w/o antibiotics (dont use ung when seb is predominant)
when should you not use ointments? why?
for mixed seb-staph bleph b/c ointments are greasy and may exacerbate an already oily lid, WHEN SEBORRHEA IS PREDOMINANT as opposed to bacterial
when is lid scrub contraindicated?
ulcerative bleph
usual causes of angular blepharitis?
moraxella or staphylococcus species
S/S of angular bleph?
1) chronic hyperemia
2) desquamation
3) ulceration of lateral and medial canthal regions
4) redness and tenderness of affected area
Tx for angular bleph?
1) best - zinc sulfate 0.25% ointment (zincfrin)
2) alternative - erythromycin
how can zinc sulfate 0.25% be purchased?
OTC w/o Rx
brand name of zinc sulfate 0.25%?
zincfrin
what is phthiriasis palpebrarum?
public lice infestation of lids and lashes
______ is public lice infestation of lids and lashes
phthiriasis palpebRARum
S/S of phthiriasis palpebrarum?
1) chronic bleph
2) FBS
3) itching
4) irritation
5) hyperemia
6) etc associated w/ other types of bleph
what does phthiriasis palpebrarum causes?
chronic bleph
Tx for phthiriasis palpebrarum?
1) Stye ung (yellow mercuric oxide) or bland ointment for a min of 10 days
2) use forceps to manually tweeze to remove cilia to which nits are attached
3) clean lids/head/genitalia with RID (OTC) or kwell (Rx, avoid eye) shampoo
4) instruct on proper hygiene (launder linens, towels, etc)
how do you smother lice and their eggs on the lids and lashes?
by slathering a thick layer of Stye ung or bland ointment for min of 10 days
what is stye ung?
yellow mercuric oxide
what is bland ointment?
unmedicated eye ointment normally used for lubrication
what parts of the body should ppl with phthiriasis palpebrarum shampoo?
1) lids
2) head
3) lice
difference b/c RID and Kwell
- they are shampoos for lice
- RID is OTC but kwell needs Rx
- for kwell, must avoid eye area
what is an internal hordeolom?
bacterial infection of the meibomian glands, deep w/in the lid
what is bacterial infection of the meibomian glands, deep w/in the lid?
internal hordeolum
which has a prolonged onset and course, internal or external hordeolum?
internal hordeoloum
internal hordeolum may be associated w/ ___ and __
preseptal cellulitis and staph bleph
s/s of internal hordeolum?
1) associated preseptal cellulitis or staph bleph
2) moderate to severe PAIN and WARM sensation of entire lid w/ very painful nodule w/in the inflamed lid
3) if severe - swollen PAN on SAME side
PAN + pain and warmth in lid

Dx?
internal hordeolum
s/s of internal hordeolum are more common in the __ lid
upper
Tx for internal hordeolum?
1) mild - hot compress, BID-QID w/ monitoring
2) moderate-severe - hot compresses as soon as ORAL antibiotics are on board
3) in resistance cases - surgical incision after lesion is quiet
MOA of hot compress?
increases blood flow to area --> brings immune system component in more frequent proximity to the infxn
why must you monitor pts w/ internal hordeolum closely?
b/c hot compress can inadvertently spread the infxn to adjacent tissues if the infxn is too much for the immune system to neutralize on its own
why don't topical antibiotics work for internal hordeolum?
b/c they don't reach the infected lesion, which is within the meibomian glands
internal hordeolum is bacteial infxn of __
meibomian glands
when is surgical incision done for pts w/ internal hordeolum? why?
- only after the lesion is as quiet as possible w/ medical therapy
- to avoid spreading of infxn to entire lid (preseptal cellulitis)
describe the use of PAN to Dx internal hordeolum
- PAN indicates moderates or severe (so use oral antibiotics)
- no PAN indicates mild
what is a stye?
external hordeolum
you must follow up w/ a pt w/ internal hordeolum for signs of __
preseptal cellulitis
difference b/w internal hordeolum and preseptal cellulitis?
internal hordeolum is isolated to only a few glands but preseptal cellulitis involves the whole lid
differentiate b/w internal hordeolum, external hordeolum, and chalazion
- internal and chalazion both affect the meibomian glands while external affects the glands of zeis of moll
- internal and external are both bacterial infections while chalazion is lipogranulomatous inflamm
what is external hordeolum?
acute bacterial infxn of a gland or glands of zeis or moll
what type of bacteria usually cause external hordeolums?
staphylococcal
external hordeolum is almost always associated w/ ___
staph bleph
S/S of external hordeolum?
1) localized area of redness, tenderness, and inflamm at LID MARGIN, rt adjacent to or surrounding a lash
2) yellow point
3) PAIN of acute and recent onset
4) associated w/ staph bleph
3)
what type of hordeolum involves pain of acute and recent onset?
external
T/F: internal hordeolum is painful while external is not
FALSE
- both painful
- prolonged onset for internal, recent onset for external
Tx for external hordeolum?
1) usually drains w/o assistance w/in 3-4 days of pointing
2) HOT compress may hasten pointing
3) epilate 1-2 involved lashes to create drainage channel from infected glands OR puncture w/ a sterile needle THEN COVER W/ ANTIBIOTIC UNG
what is "pointing"?
white capping (seen in external hordeolum)
external hordeolum is a stye at __
the lid margin (adjacent to or surrounding a lash)
what are 2 important differences b/w chalazion and hordeolums?
1) chalazions are STERILE (NOT INFECTED)
2) chalazions are not painful
what is a chalazion?
chronic, sterile, lipogranulomatous inflamm of meibomian gland due to abnormal retention of normal oily secretions
cause of chalazion?
abnormal retention of normal oily secretions
chalazions may occur __ or may follow __
spontaneously;
an internal hordeoloum infxn
what is chalazion commonly associated with?
1) other meibomian lid disease
2) acne rosacea
3) concurrent or past belpharitis
how does a chalazion look like?
like a hard, immobile, NONTENDER lump. it can point...
1) towards external lid surface --> looks like lump on lid
2) inwards toward palpebral conj --> more visible w/ lid eversion
25% of cases of __ will resolve spontaneously over 6 months
chalazion
how long does it take chalazions to resolve without treatment?
25% will resolve over 6 months
Tx for chalazion?
1) new and small - hot compress w/ vigorous digital massage QID x 4-6 wks
2) hard or large - directly INJECT steroids (injected from palpebral conjunctival side, not from skin side)
3) resistant - lanced (cut) and drained
why are steroids used for chalazions w/ long-standing presence?
b/c the cells involved are inflammatory (so they're susceptible to steroids)c
what does lanced mean?
cut
why do antibiotics not work on chalazions?
b/c it's sterile and not infected
what is a key differential Dx fo chalazion?
sebaceous cell carcinoma
when should you suspect sebaceous cell carcinoma instead of chalazion?
1) it the chalazion is recurrent in the same location
2) if associated w/ LOSS OF LASHES

(refer out - lesion needs to be lanced and biopsied)
T/F: there is a high mortality rate w/ sebaceous cell carcinoma
true
is sebaceous cell carcinoma, a rare or common tumor?
rare tumor
what does sebaceous cell carcinoma involve?
the meibomian glands,
or less commonly the zeiss glands
what can sebaceous cell carcinoma mimic?
chalazia, bleph, etc
what is pyogenic granuloma?
highly vascular lesion that occurs after trauma or surgery, or more rarely an infxn
super-responsive scar tissue is known as __
pyogenic granuloma
how can pyogenic granuloma look like?
an internal hordeolum or chalazion
T/F: pyogenic granuloma can appear in spots that previously had an internal hordeolum or chalazion
true
pyogenic granuloma is mostly ___, NOT ___
small capillaries;
NOT REALLY PYOGENIC OR A GRANULOMA
Tx for pyogenic granuloma
surgical excision
what is preseptal cellulitis?
infxn of the eyelid anterior to the orbital septum and beneath the skin
what is the orbital septum?
the superficial surface lid tissue
general cause of preseptal cellulitis?
arises from pre-existing infxn in the anterior portion of the ocular structures
give examples of infxns (diseases) that can cause preseptal cellulitis?
dacryocystitis, conjunctivitis, internal/external hordeolum
what is dacryocystitis?
infxn in the lacrimal sac
how can infected material enter lid tissues (which causes preseptal cellulitis)?
a penetrating lid injury
S/S of preseptal cellulitis?
1) red
2) swollen
3) PAINFUL
4) WARM to touch
5) can have PAN on same side
what organisms cause preseptal cellulitis?
1) KIDS - strep or H. flu
2) ADULTS - staph
patients w/ preseptal cellulitis have an associated acute fever if they are infected w/ __
H. flu
Tx for preseptal cellulitis?
1) oral antibiotics
2) warm compress (once on oral Ab)
3) blood cultures
4) if suspect meningitis, hospital for lumbar puncture --- require IV antibiotics
__ can help to identify the organism causing preseptal cellulitis if response to antibiotics is __
blood cultures;

slow or absent
when would you suspect meningitis in a preseptal cellulitis pt?
if they have high FEVER or STIFF NECK
if you suspect meningitis in a pt w/ __, the pt may be __
preseptal cellulitis;
hospitalized for a lumbar puncture
some __ infections are associated w/ meningitis.

what drugs would be required in these cases?
H. flu;


IV antibiotics
what condition must you rule out when suspecting preseptal cellulitis?
orbital cellulitis
orbital cellulitis most often arises from __
sinusitis
which of the following is life-threatening, preseptal or orbital cellulitis? both? neither?
orbital cellulitis
in orbital cellulitis, you see the findings for preseptal cellulitis in addition to...
1) proptosis
2) limitation of EOMs
3) extreme pain
4) obliteration of the lid crease
5) dec'd VA
6) APD
if there is any question about the diagnosis for preseptal/orbital cellulitis, what should you do?
hospitalize the pt immediately and/or seek a 2nd opinion STAT

(immediate referral to ER/hospital for IV antibiotic Tx)
which of the following conditions are a medical emergency?
1) 3rd nerve palsy w/ pupil involvement
2) orbital cellulitis
T/F: orbital cellulitis enlarges the lid crease?
FALSE; obliterates it
T/F: preseptal cellulitis is not painful, but orbital cellulitis is.
FALSE

both painful (but orbital is worse)
external hordeola involve the __, at the glands of __
lid margin;
zeis and moll