Ophthalmology Conditions Quiz

Marcus Gunn Jaw-Winking Phenomenon

• Affects 5% of congenital ptosis cases.
• Primarily unilateral.
• Etiology is unknown, but involves a misdirected branch of the mandibular nerve to the levator muscle.
• Signs include ptotic lid retraction triggered by jaw movements (chewing, sucking), mouth opening, or contralateral jaw movement, with less common stimuli like jaw protrusion, smiling, swallowing, and teeth clenching.
• Doesn't improve with age.
• Treatment is surgical, involving levator muscle disinsertion and advancement, potentially with brow suspension.

Floppy Eyelid Syndrome (FBS)

• Commonly seen in obese patients with obstructive sleep apnea (OSA).
• Can be unilateral or bilateral.
• Characterized by a soft, rubbery, and easily everted eyelid.
• Often found in middle-aged obese patients.
• Associated with OSA, keratoconus, skin elasticity issues.
• Cause is loss of tarsal integrity, decreased elastin in the tarsus, and tarsal plate elongation.
• Symptoms include upper eyelid drooping in the morning due to pillow pressure.
• Signs include extremely lax upper eyelid skin, loose tarsal plate (rubbery), and easy eversion of the eyelid, with folds that can be easily pulled away.
• Possible associated conditions include papillary conjunctivitis, keratopathy (punctate, filamentary).
• Treatment varies and depends on the severity:
  • Associated with OSA: weight loss, evaluation by a pulmonologist.
  • Mild cases: Lubricants q2-4h and PM ointments, antibiotics if necessary, eye shield at night or taping, avoid face-down sleeping.
  • Moderate to severe cases: Horizontal shortening surgery, or pentagonal excision.

Punctal Stenosis

• Generational or involutional disease.
• Primary Stenosis: Absence of punctual eversion, often due to chronic blepharitis or idiopathic reasons, cicatricial conjunctivitis, Stevens-Johnson syndrome (SJS), use of 5-Fluorouracil (which doesn't scar). Anti-metabolites are toxic to the conjunctiva and prevent scarring.
• Treatment involves dilation or punctoplasty (mucosa heals faster).
• Secondary/Involutional Stenosis (common in >65): Initial treatment is puncta dilation. If ineffective, punctoplasty.
• Punctual Eversion: Older age.
• Treatment corrects ectropion, retropunctial cautery (shrinks skin), medial conjunctivoplasty.
• Symptoms: constant epiphora (excessive tearing), increased lacrimal meniscus, and tearing on the sides, skin dryness, and irritation/burning sensation.
• Diagnosis: Puncta diameter <0.3 mm, inability to intubate with a 26G cannula.

Trichotillomania

• Characterized by intense impulses to pull out hair.
• Management involves psychological support.
• Manifestation: hair loss, patchy appearance.
• May be associated with stress or schizophrenia.

Meibomian Gland Dysfunction (Posterior Blepharitis)

• Characterized by excessive meibomian gland secretion, recurrent capping of orifices with oil globules, hyperemia (redness), and telangiectasia (dilated blood vessels) of the posterior lid margin, usually lasting more than three weeks.
• Signs include: capping of gland orifices, expressed toothpaste-like material, foamy eyelid margin, oily/foamy tear film.
• Treatment:
  • Warm compresses with fingertip massage (5-10 min, QID).
  • Lid scrubs (BID/TID then QD).
  • Fish oil/omega-3 fatty acids (EPA, DHA 2000 mg or flaxseed).
  • Short-course topical steroids (Lotemax) or antibiotic-steroid drops (Tobradex), up to QID or ointment BID.
  • Azithromycin ophthalmic drops (BID x 2 days then QD x 12 days/14 days).
  • Oral treatment for moderate to severe or resistant cases:
    • Doxycycline (100mg BID x 4 weeks, then 50-100mg QD x 3-6 months - avoid in pregnancy).
    • Erythromycin (250mg BID then QD in pregnancy & breastfeeding).
    • Azithromycin (500mg x 3 days or Z-pack, can be given to pregnant women).
  • Consider topical cyclosporine (Restasis 0.05%).
  • In-office treatments (LipiFlow, IPL, intraductal meibomian gland probing).
  • Treat associated conditions (rosacea, dry eye).

Herpes Zoster Ophthalmicus

• Reactivation of latent varicella-zoster virus (VZV) in cranial nerve V.
• History of chickenpox in childhood.
• Signs include: Prodrome, painful, unilateral, dermatomal (following trigeminal zones) maculopapular skin eruption, followed by vesicles, ulceration, and crusting, severe pain. Pain resolves in 2-6 weeks but may leave permanent scarring.
• Ocular involvement includes conjunctivitis (65%) and keratitis (12%).
• Complications (50%) include lid scarring, entropion, ectropion, trichiasis, madarosis, punctual stenosis, lid necrosis, and lagophthalmos.
• Postherpetic neuralgia (PHN): common, can last 3+ months.
• Treatment:
  • Cool compresses, topical antibiotics, systemic acyclovir, famciclovir, or valacyclovir (start <72 hours of rash).
  • Immunocompromised patients: IV acyclovir.
  • PHN management: tricyclic antidepressants (amitriptyline, doxepin), gabapentin, pregabalin.
  • Prednisolone (reduce PHN).
  • Vaccination: Zostavax (reduces herpes zoster in >50yo.) & Shingrix.

Demodex

• Parasitic infestation of hair follicles by Demodex folliculorum or Demodex brevis.
• Mostly asymptomatic.
• Signs include thin, semi-transparent crusting at lash base, redness, itching, collarets (red/dark brown skin discoloration).
• Treatment: tea tree oil lid scrubs, Blephadex (BID), Omega 3/6 fatty acids, oral ivermectin (200mcg/kg PO single dose, repeat in 7 days for resistant cases).

Tick Infestation of the Eyelid

• Removal is crucial.
• Potential for Lyme disease, Rocky Mountain fever, African tick bite fever, or tularemia.
• Doxycycline prophylaxis.
• Monitor symptoms for 4-10 days.

Canaliculitis

• Inflammation of the canaliculi (Meibomian glands are absent).
• Often misdiagnosed as recurrent conjunctivitis.
• Etiology varies (bacterial - Actinomyces israelii, Streptothrix; Staph. aureus, Nocardia asteroides; viral - Herpes simplex, Herpes Zoster; fungal - Candida albicans, Aspergillus).
• Symptoms: Unilateral red eye, unresponsive to antibiotics, pain over the nasal portion of the eyelid, swollen puncta.
• Diagnosis: Mucopurulent discharge, dacryoliths.
• Treatment: Warm compresses, topical fluoroquinolones (10 days), Canaliculotomy (incision/curettage) for non-responders.

Dacryocystitis

• Acute Dacryocystitis: Frequently associated with ear, nose, or throat infections. Lacrimal drainage system obstruction leads to bacterial backflow.
• Etiology: Staphylococcus aureus, Staph. epidermidis, Pseudomonas, H. influenzae.
• Symptoms: pain, crusting, tearing, occasional fever.
• Signs: prominent swelling and tenderness, hyperemia over the lacrimal sac region, swelling below medial canthal ligament.
• Treatment: warm compresses, oral antibiotics (amoxicillin/clavulanate, levofloxacin). Avoid irrigation!
• Chronic Dacryocystitis: Chronic epiphora, mucocele (painless swelling), suspect malignant disease (epithelial carcinomas, lymphomas, blood in the tear film).
• Signs: Swelling above medial canthal ligament.
• Treatment: Address underlying condition, if appropriate consider DCR (Dacryocystorhinostomy).

Dacryoadenitis

• Inflammation of the lacrimal gland, more common in children and young adults.
• Symptoms: increased tearing, swelling of the outer 1/3 of the temporal upper eyelid, pain, redness.
• Signs: acute - S-shaped ptosis; chronic - less redness, swelling, pain.
• Causes: acute (infections - Staphylococcus aureus, Neisseria gonorrhoeae, Streptococci, viruses - mumps, mononucleosis, influenza, herpes zoster, Epstein Barr).
• Chronic (inflammatory disorders - Sarcoidosis, TB, Graves' disease, idiopathic orbital inflammation, Sjögren's syndrome)
• Treatment: depends on the cause (antibiotics, antiviral, anti-inflammatory, testing).

Test your knowledge on unique ophthalmic conditions such as Marcus Gunn jaw-winking phenomenon and Floppy Eyelid Syndrome. Explore their characteristics, etiology, symptoms, and treatment options. Ideal for students and professionals in the field of ophthalmology.