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66 Cards in this Set
- Front
- Back
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What are some causes to dry eyes? |
-Elderly: decrease lacrimal gland secretions -Vitamin A Deficiency: decrease in mucin production -Sjogren's Syndrome: Immune mediated inflammation of the lacrimal glands -Chemical burns: loss of goblet cells -Trauma to facial nerve |
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What are some risk factors to dry eyes? |
-History of severe conjunctivitis -Eyelid defects (Exopthalmos, bell's palsy) -Drug induced (Diuretics, accutane, tricyclic antidepressants, antihistamines) -Sjogren's, rheumatoid -Environmental factors -Contact lens -Age (older than 50, especially after menopause) -Prolonged use of computers |
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What are some subjective signs/symptoms of dry eyes? |
-Ocular fatigue -Sandy/gritty sensation in the eye -Itching, burning, irritation, or dryness -Profuse tearing |
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What is a diagnostic test you can run for dry eyes? |
-Schirmer's test (done by ophthalmologist) -A folded end of filter paper is hooked over the lower lid and the patient is instructed to keep his/her eye lightly closed -Wetting is measured after 5 minutes. -Less than 5mm is usually abnormal |
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There are 4 levels of treatment of dry eyes. Describe the first level of treatment for dry eyes. |
-Focused on environmental -Eliminate offending systemic medication -Use artificial tears, lubricants, gels, ointments -Artificial tear: 1gtt QID for 3-4 weeks -Room humidifier for 2 weeks -Minimal exposure to air conditioning or heating |
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Describe the second level of treatment for dry eyes. |
-Do this if the prior level is not effective -Ocular lubricants -Cyclosporine ophthalmic emulsion (Restasis) 1gtt every 12 hours (very expensive) -May take 6 weeks to work -Or refer to ophthalmologist prior to prescribing topical steroids (dexamethasone) |
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Describe Level 3 and 4 of treatment for dry eyes. |
3: refer to ophthalmologist if level 1 and 2 fail 4: Systemic anti-inflammatory agents or surgical interventions |
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What supplements can you recommend for dry eyes? |
-Omega 3, omega 6 fatty acids -Vitamin A Drops -Accupuncture |
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What is the correlation between Vitamin A deficiency and dry eyes? |
-Associated with severe ocular surface dryness with keratinizaiton of conjunctiva (Bitot spots) and night blindness |
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If you have dry eyes, when should you refer to an ophthalmologist? |
-When symptoms are not relieved with tear supplementation and environmental strategies -If the etiology is not clear **Immediate referral if red painful eye, visual disturbance |
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What is blepharitis? |
Inflammation of the eyelids and margins -May be acute (ulcerative/non-unlcerative) or chronic (intermittent exacerbations) -Most frequent complaint: ongoing eye irritation and eye redness |
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What is acute blepharitis caused by? |
-Usually caused by a bacterial infection (usually Staph) -Affects the eye lash follicles and meibomian glands -May also be caused by a virus (herpes simplex, varicella zoster) |
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Describe acute nonulcerative blepharitis. |
-Accelerated skin shedding and blockage of the meibomian gland -Allergies (d/t intense itching, rubbing, rash) -Lice infestations -Poor hygiene -Immune suppression (diabetes) -Yeast infections |
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Describe acute ulcerative blepharitis. |
-May become chronic -May extend to the cornea and conjunctiva -Staphylococcus -Recurrent styes or chalazions -Virus (herpes simplex or varicella zoster) |
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Describe chronic blepharitis. |
-Noninfectious inflammation of unknown origin -Meibomian gland dysfunction -Can be seen in acne rosacea, seborrhea, eczema, acne rosacea, and occasional seen in Down's |
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Describe meibomian gland dysfunction. |
Lipid composition is abnormal and gland ducts and orifices become thickened with hard, waxy plugs |
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What is the patient at risk for developing if they have meibomian gland dysfunction? What are the symptoms? And how do you treat it? |
Secondary keratoconjunctivitis sicca -A chronic bilateral desiccation of the conjunctiva and cornea due to an inadequate tear film -Signs: frequent blinking because of irritation, scattered, fine punctate loss of corneal epithelium -Treat with topical tear supplements |
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What is the clinical presentation of chronic blepharitis? |
Red eyes, gritty sensation, burning sensation, excessive tearing, itchy eyelids, red-swollen eyelids, crusting or matting of eyelashes in th emorning, flaking or scaling of the eyelid, light sensitivity, and blurred vision |
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Describe the objective signs of nonulcerative chronic blepharitis. |
Scales, erythema, edema along the lid margins that are easily removed, and lashed crusted with dried serous fluid |
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Describe the objective signs of ulcerative chronic blepharitis. |
Scales, erythema, lid margin edema, small ulcerated lesions at the lid margins, possibly may have pustules at the base of the hair follicles that may crust and bleed, eye lid may become fused with sleep, loss of lashes |
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Describe the chronic clinical presentation of meibomian gland dysfunction. |
Dilated thickened gland orifices that when pressed exude a waxy, thick, yellowish secretion. |
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Describe the chronic clinical presentation of seborrheic blepharitis |
Greasy, easily removable scales develop on eyelid margins |
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Most patients w/ sebblepharitis and meibomian gland dysfunction have symptoms of: |
Foreign body sensation, grittiness, eye strain and fatigue, and blurring with prolongedvisual effort |
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What are some diagnostic tests for chronic blepharitis? |
-Obtain a culture and sensitivity for discharge -Slit lamp exam -Usually diagnosed by presentation and response to therapy |
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How will Chronic blepharitis that does not respond to treatment be treated next? |
Chronic blepharitis that does not respond to treatment may require biopsy to exclude eyelid tumors that can simulate the condition |
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Describe the prognosis for acute and chronic blepharitis. |
Acute: Most often responds to treatment but may recur and develop into chronic blepharitis Chronic: Is recurrent and resistant to treatment |
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What is the management of blepharitis? |
Blepharitis is usually chronic without definitive cure Good lid hygiene -Wash the eye with antibacterial soap and water -Warm compresses to eye for comfort daily for 10 to 20 minutes 2-4x a day -Lid massage -Stop use of contacts -Avoid rubbing eyes -Follow up in 2 weeks |
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What is the management for acute ulcerative blepharitis? |
-Azithromycin ophthalmic solution 1% up to 4 weeks -Erythromycin ointments -Gentamycin 0.3% QID for 7-10 days |
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What is the management for acute viral blepharitis (herpes, varicella zoster)? |
Herpes: Acyclovir 400mg PO TID for 7 days Varicella Zoster: Famcyclovir 500mg TID or valcyclovir 1g PO TID for 7 days |
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What is the management of chronic blepharitis? |
-Warm compresses to melt the waxy plugs -Gentle cleansing of the eyelid margins 2 times a day with a cotton swab dipped in a dilute solution of baby shampoo -Topical antibiotic ointment: Bacitracin/ polymyxcin B or sulfacetaminide 10% BID for up to 3 months -Severe cases: –Tetracycline250mg 4 times a day for 4 weeks or Doxycycline 100 mg bid, Zpack(azithromycin 5 day Tx) |
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When should you refer to an ophthalmologist when treating blepharitis? |
•Allpatients with ulcerative blepharitis refer to Ophthalmologist. •Ifyou suspect herpes simplex or Varicella Zoster this patient will need a sameday appointment. (even if the eye looks clear and you see shingles along the nose, cheek, etc.) •Anypatient nonresponsive to treatment |
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What is exophthalmos and how do you treat it? |
-Bulging (proptosis) of the anterior eye out of orbit -Characteristic of Grave's disease (hyperthyroid) -Can cause eyelids to fail to close during sleep, results in dry eyes and irritation -Maintain adequate moisture to prevent dryness and use artificial tears |
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If a patient has infectious proptosis, what are some differentials and diagnostic tests you can run? |
–Orbitalcellulits(Refer to ER, CT SCAN) –Mucormycosis(Fungal infection, Refer to ER) –Sinusdisease (CT Scan, ER) |
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If a patient has inflammatory proptosis, what are some differentials and diagnostic tests you can run> |
–Pseudotumor(Refer for CT Scan, MRI) –Thyroidopathy(TSH, Free T4,) |
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If a patient has a neoplastic proptosis, what diagnostic tests should you run? |
Refer for CT scan, MRI, CBC Refer to oncology and opthalmology |
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What is entropion? |
-Eyelid folds inward -Eyelashes rub against the cornea and irritates it -Can lead to scarring of the eyelid or nerve damage |
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What are symptoms of entropion and how do you treat it? |
-Tearing, redness and pain around the eye, sensitivity to light, sagging skin around eye -Treatment is surgery |
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What is ectropion? |
-Turning out of the eyelid "rolled out" or sagging away from the eye -Exposes the conjunctiva and usually affects the lower eyelid |
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What are some causes to ectropion? |
-Aging process, weakening of the connective tissue of the eyelid -Congenital defect -Facial palsy -Traumatic injury (burns, scarring) -Skin cancer |
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Describe subjective signs of ectropion. |
-Dry eyes -excess tearing -eyelid turns outward -chronic conjunctivitis -keratitis -gritty feeling -pain -mucous discharge -crusting of the eye lid |
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What is the management of ectropion? |
-Artificial tears -Lubricant -Surgery to tighten muscles (blepharoplasty) |
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What are some complications to ectropion? |
Corneal abrasions, corneal ulcers, and eye infections |
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What is epiphoria? |
Overproduction of tears -Reflex overproduction of tears due to a deficiency of the tear film Can be caused by canalicular infections (Candida, actinomyces israelii) |
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What are some risk factors to epiphoria? |
•Belpharitis •Allergicconjunctivitis •Exposureto cold, air conditioning, or dry environment •Lidproblems (Scleroderma,stiffen lids, Lidlaxity) •Age:Over production of tears by the lacrimal gland •Congenitalobstruction |
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What are signs and symptoms of epiphoria? |
-Unilateral tearing (obstructive) -Bilateral (environmental irritant) |
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What are some differentials to epiphoria? |
•Excessivetears •Dendriticulcer–Herpesvirus •Congenitalglaucoma •Dacryocystitis •Reflextearing caused by dry eyes •Belpharitis |
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Describe the signs and symptoms of congenital glaucoma |
Red eye, photophobia, cloudiness cornea -Usually noticed within the first few months |
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What is dacryocystitis? |
–Inflammationof the lacrimal sac •Candevelop periorbital cellulitis•Approximately6% of newborn have congenital obstruction within the first weeks of life. –Moistheat and massage usually help to resolve |
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How can you diagnose epiphoria? |
Culture any drainage expressed from the lacrimal sacs |
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What is the treatment plan for epiphoria? |
•Eliminateidentified irritant •Givea trial of artificial tears •Followup 48 hours to evaluate improvement |
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What is the treatment plan for dacryocystitis? |
–Hot compresses 4 times a day –Antibiotics •Dicloxacillin 250 mg 4 times a day for 7 days •Erythromycin 250 mg 4 times a day for 7 days Follow up in 48 hours to evaluate improvement |
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What is a hordeolum? |
-Stye -Infection of the glands of the eyelids or follicle of an eye lash -Usually caused by Staphylococcus aureus |
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Where is internal hordeolum? Where is external hordeolum? |
Internal: swelling under conjunctival side of eyelid (Meibomian gland) External: Swelling under the skin of the eye lid |
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What are signs/symptoms of hordeolum? |
-Eyelid tenderness -Sudden onset of a purulent discharge |
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What are some differentials for hordeolum? |
Chalazion, blepharitis, and xanthoma |
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What is the treatment of hordeolum? |
–Warmcompresses to reduce inflammation and promote spontaneous drainage •Massagelesion: 10 min 4 times per day –Gentlywash lids with diluted baby shampoo two to four times a day –Erythromycinophthalmic ointment or sulfacetamide sodium ophthalmic ointment four timesdaily to lid margins. –Referto an ophthalmologist for I & D if unresponsive. |
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What is a chalazion? |
•Agranulomatous inflammation of the Zeis or meibomian glands. •Formswhen underlying meibomitisresults in stasis of gland secretions and the contents of the glands (sebum)are released into the tarsus and adjacent tissues and causes a noninfectiousinflammatory reaction. -Can occur following an internal hordeolum |
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What are subjective signs of chalazion? |
•Swelling •Nontenderpalpable nodule •Sizeof pea •PointInside the lid •Discomfortor irritation due to swelling •Feelingof a foreign body in the eye •Ifinfection is present the entire lid becomes painfully swollen |
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What is the management of chalazion? |
–Warmmoist compresses for 15 minutes 4 times a day –Usuallyit is self limiting and resolves spontaneously –Ifinfection: Sulfacetamideophthalmic ointment 10% 4 times a dayfor 7 days, TobradexOphthalmic drops: 1-2 drops every 2 hours for first 24-48 hours then every 4-6hours. Treat for 5 days –Interchalazioncorticosteroid injection by ophthalmologist. –If noimprovement, Incisionand curettage by an ophthalmologist |
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What are some causes to conjunctivitis? |
-Bacterial (Staph, H. Influenzae, strep pneumoniae) -Viral (Adenovirus-most common, herpes simple, varicella zoster) -Fungal |
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What are some common causes to conjunctivitis? |
Noninfectious: toxicity, allergy Can be transmitted sexually |
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What is the clinical presentation and physical exam for bacterial infections? |
–Thick,yellow, sticky exudate on the lids. Worse in the morning, eyelids stucktogether. –Purulentdischarge is thick and lobular near the corners of eyes -After wiping eyes, purulent discharge appears within minutes –Beginunilaterally, can easily spread to other eye –Verycontagious through contact |
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Describe hyper-acute bacterial conjunctivitis (N. Gonorrhea) |
–Severe and sight threatening. Immediate referral to ophthalmology •Profuse purulent discharge present within 12 hours of inoculation. •Rapidly progressive redness, irritation and tenderness to palpation. |
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What is the clinical presentation for viral conjunctivitis? |
–Begin bilateral or starts in one eye yet quickly spreads to other eye (within 24-48 hours) –Foreign body sensation (Sandy or gritty feeling) –Preaurical lymphadenopathy –May have systemic symptoms: fever, myalgia, URI symptoms –Watery discharge or mucoserous discharge –The third through 5th day are typically the worse then symptoms resolve –Highlycontagious |
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What will you see on the physical exam for viral conjunctivitis? |
–Mucoid discharge if one pulls down the lower lid in the corner of the eye. –Usually profuse tearing rather than discharge –The tarsal conjunctiva may have a follicular or “bumpy” appearance. –There may be enlarge and tender preauricular node. |
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What is the clinical presentation for allergic conjunctivitis? |
–Caused by airborne allergens contacting the eye –Presents with bilateral symptoms –Bilateral redness –Severe pruritus (cardinal symptom of allergy) –Moderate tearing –No exudate History of hay fever or allergy LEFT OFF ON SLIDE 81 |
