Final Exam Key Points-Gil.pdf

Final Exam Key Point List-Gil Material Viral Conjunctivitis • Non-specific Acute Follicular Conjunctivitis o Most Common, sore throat, common cold • Pharyngoconjunctival Fever (PCF) o Adenovirus 3, 4, and 7 o Children (Swimming pool conjunctivitis) o 30% keratitis o Severe sore throat, common cold •...

Final Exam Key Point List-Gil Material Viral Conjunctivitis • Non-specific Acute Follicular Conjunctivitis o Most Common, sore throat, common cold • Pharyngoconjunctival Fever (PCF) o Adenovirus 3, 4, and 7 o Children (Swimming pool conjunctivitis) o 30% keratitis o Severe sore throat, common cold • Epidemic Keratoconjunctivitis o Adenovirus 8, 19, and 37 o Most Severe, 80% keratitis o Subepithelial infiltrates o Severe photophobia or pain o +PAN • Treatment o Spontaneous resolution 2-3 weeks, treatment is unnecessary o Reduce transmission risk (Hygiene) o Topical Steroids for patient comfort, Prednisone 0.5 QID (caution in patients with Keratitis, corticosteroids can enhance viral replication) o Discontinue CTL use o AT’s o Topical Antihistamines for itching, Alloway/Pataday o Removal of pseudomembrane o Topical AB if secondary infection Allergic Conjunctivitis • Acute Allergic Conjunctivitis o Young children playing outside in the summer o Acute itching, watering, chemosis o Cold compress • Seasonal Allergic Conjunctivitis o Hay fever eyes (spring and summer mostly) o MOST COMMON o Type 1 hypersensitivity reaction from common allergens o Given mast cell stabilizers or antihistamine • Perennial Allergic Conjunctivitis o All year (worse in Autumn) o Type 1 hypersensitivity reaction to household allergens o Mast cell response • Treatment o AT’s o Cool Compress o Antihistamines/Decongestant for nasal congestion and chemosis, Naphcon A, Vascon A, Opcon A o Mast Cell Stabilizers, Nedocromil, Cromolyn Sodium, Iodoxamide o Dual Action antihistamines and mast stabilizers, Azelastine, Ketotifen, Olopatadine o Steroids, Alrex, Lotemax o Oral Antihistamines for moderate to severe cases, Cetirizine HCL, Loratadine, Diphenhydramine HCl Giant Papillary Conjunctivitis • CL wear 95% (extended wear, poor replacement), Glaucoma filtering blebs, scleral buckle • Non-infections, due to mechanical trauma, and immune response or environmental • Symptoms o Itchy, red o FBS o Early, Scant mucous discharge. Late, Ropy mucous o Photophobia o More severe after CL removal • Signs o Superior tarsal hyperemia, variable mucous discharge o CL protein deposits o Eyelid ptosis o Keratopathy is rare • Treatment o Removal of CTL (several weeks) o Removal of other causes (sutures, prosthesis) o Topical § Mast cell stabilizers § Antihistamines § NSAIDs § Antihistamines/Mast Cell Stabilizer combo § Topical Steroids Allergic Keratoconjunctivitis (Atopic) • Young to middle-aged adults (Atopic Dermatitis association) • Worse in the winter • Symptoms o Bilateral Itching of eyes o Watery discharge o Redness o Photophobia, Pain • Signs for Eyelids o Dennie’s lines or Dennie-Morgan folds (extra folds under lower lid due to periorbital edema and rubbing) o “Atopy Shiner”- bags under eyes from constant rubbing o Hertoghe Sign: absence of lateral portion of eyebrows • Signs for Conjunctiva o Watery discharge o Hyperemia o Small papillae o Diffuse scaring o Moderate symblepharon, froniceal shortening, keratinization of caruncle • Treatment o Allergen Avoidance o o o o o o o o o o o o o Cool compress Lid hygiene Bandage CTL in persistent epithelial defects Mast cell stabilizers Topical Antihistamines Combined Antihistamines/Mast cell stabilizers (rapid onset of action) NSAIDs Steroids for severe exasperations and keratopathy, Flurometholone, Prednisolone, Loteprednol Steroid Ointment, Hydrocortisone Immunomodulators (if steroids are ineffective, last thing to give), Tacrolimus Oral Steroids in severe cases, Prednisolone Systemic Antihistamines Systemic Antibiotics to promote healing, Doxycycline, Azithromycin Acute Bacterial Conjunctivitis • Self-limiting (Staph Aureus in adults, Haemophiles in Children) • Symptoms o Acute Onset (starts unilateral then bilateral after 1-2 days) o Redness, burning o FBS o Eyelids stuck together upon wakening • Signs o Moderate-severe discharge (Mucopurulent or purulent) o Normal VA o Conjunctival Injection o SPK, peripheral corneal ulcer • Treatment o Antibiotics § Aminoglycosides, Trimethoprim/Polymyxin (Polytrim), Tobramycin (Tobradex) § Quinolones, Ciprofloxacin, Ofloxacin, Gatifloxacin, Moxifloxacin § Macrolides, Azithromycin, Erythromycin o Systemic Antibiotic Treatment § H. Influenzae: Augmentin (amoxicillin/clavulanate) § Gonococcal: Ceftriaxone, Quinolones, Macrolides, Azithromycin § Meningococcal, refer immediately o Follow up every 3-5 days o Never patch o Topical steroids to reduce scarring in membranous and pseudomembranous o No CTL use o Monitor the cornea Gonococcal Conjunctivitis • Signs o Severe purulent discharge o Conjunctival chemosis o Pseudomembranes o Papillary reaction o Marked PAN • • • o Tender and swollen eyelids o Peripheral ulcer in severe cases Symptoms o Hyperacute onset (rapidly progress from unilateral to bilateral) o FBS o Redness o Eyelids stuck together Ocular Treatment o 1st Choice- Ciprofloxacin sol o Bacitracin or Erythromycin ung o Chloramphenicol-aplastic anemia o With corneal involvement, Fluroquinolone- Gatifloxacin, Moxifloxacin, Ciprofloxacin, Besifloxacin Systemic Treatment o Ceftriaxone IM o Hospitalize if corneal involvement or unable to visualize cornea- Ceftriaxone IV o Urologist referral o F/U every 2-3 days o Possible Chlamydia co-infection: Azithromycin, Doxycycline, or Erythromycin Fungal Keratitis • Most common cause after traumatic corneal injury • Candida or Aspergillus • Symptoms o Pain, Photophobia o Tearing o Decreased VA o Watery/Mucopurulent discharge • Aspergillus Signs o Feathery/fluffy margins o Possible satellite infiltrates o Rapid progression to necrosis and thinning o Endophthalmitis w/o perforation • Candida Signs o White-yellow densely suppurative (wet) • Treatment o Topical Antifungals § Candida: Amphotericin B, Econazole, Natamycin, Fluconazole, Clotrimazole § Filamentous: Natamycin, Econazole, Amphotericin B, Miconazole o Systemic Antifungals (severe cases, lesions near the limbus or suspected endophthalmitis) § Voriconazole, Itraconazole, Fluconazole o Anterior chamber washout in unresponsive patients o Perforation: penetrating keratoplasty Acanthamoeba Keratitis • Symptoms o Blurred VA o Pain • • • o Minimal discharge Early Signs o Punctate or pseudodendrites o Severe pain (out of proportion) Late Signs o Radial Keratoneuritis o Patchy anterior stromal infiltrates that progress to rung ulcer Treatment o Refer to Corneal Specialist o Topical Antiseptics: PHMB, Chlorhexidine o Topical Antibiotic: Neomycin, Polymyxin B, Gramicidin o Topical Antifungals: Voriconazole Chlamydia Conjunctivitis • Symptoms o Subacute onset (unilateral or bilateral) o Watering o Discharge o Acute Follicular Conjunctivitis • Signs o Watery or mucopurulent discharge o Tender PAN o Large follicles (chronic cases develop papillae) o SPK initially, then perilimbal subepithelial corneal infiltrates after 2-3 weeks • Treatment o Azithromycin, Doxycycline, Erythromycin, Amoxicillin, or Ciprofloxacin o Re-testing 6-12 weeks after treatment o Follow up every 2-3 weeks Bacterial Keratitis • Symptoms o Severe pain, Photophobia o Red Eye o Decreased VA o Mucopurulent or Purulent Discharge • Pseudomonas Aeruginosa (most common and damaging) o Thick mucopurulent discharge (green) o Hypopyon o Central epithelial defect w dense stromal infiltrate o Rapid progression (can perforate cornea in 48 hours) • Staph Aureus o Well-defined white-grey or creamy stromal infiltrate (may enlarge to form a dense stromal abscess) o May have satellite lesions o May cause anterior uveitis and hypopyon • Strep Pneumoniae o Very suppurative or crystalline appearance o Severe uveitis and hypopyon is characteristic • Treatment o Hospitalize in aggressive disease (Hypopyon/Risk of Perforation) o Antibiotic Monotherapy, Fluroquinolone: Moxifloxacin, Ciprofloxacin, Ofloxacin, Gatifloxacin, Besifloxacin o Antibiotic Duo-therapy, Cephalosporin + Aminoglycoside: Cefazolin or Vancomycin + Gentamicin or Tobramycin o Subconjunctival Antibiotics: Cephalosporins, Gentamicin o Mydriatics to prevent posterior synechia: Cyclopentolate, Homatropine, Atropine o Steroids (wait 24-48 hours after AB): Prednisolone, Dexamethasone o Systemic Antibiotics § N. Meningitis: Benzylpenicillin, Ceftriaxone § H/ Influenza: Amoxicillin w Clavulanic Acid § N. Gonorrhea: Ceftriaxone o Severe Corneal Thinning: Ciprofloxacin, Doxycycline o Perforation: Bandage CTL, Tissue Glue, Penetrating Keratoplasty, Graft, or Corneal Transplant HSV Keratitis • Symptoms o Pain, Photophobia o Redness o Serous discharge o Tearing o Decrease VA • Signs o Decreased corneal sensitivity • Recurrent HSV Infections o Epithelial Disease § Dendritic Ulcers (edges stain well w Rose Bengal) § Corneal Vesicles § Geographic Ulcers § Marginal Ulcers o Neurotrophic Keratopathy § Reduced corneal innervation and decreased tear secretion § Poor corneal wound healing § Oval ulcer w smooth borders, usually inferior • Stromal Disease o Interstitial Keratitis § Stromal inflammation without primary involvement of the epithelium and endothelium § Antigen-antibody-complement cascade § Infiltrate w diffuse neovascularization § Weasley Ring & Stromal Thinning § Result of congenital Syphilis 90% o Necrotizing Stromal Keratitis § Result from direct live virus invasion into stroma § Severe stromal inflammation w necrosis that can lead to corneal thinning and perforation • Endotheliitis (disciform keratitis) o Secondary to stromal edema, due to an immune reaction o Focal disc-shaped stromal edema, overlying Keratic Precipitates • o Commonly w mild to moderate iritis Treatment o Topical steroids are contraindicated in active epithelial disease o Topical: Ganciclovir gel, Trifluridine o Oral Antiviral (main treatment): Acyclovir 400 mg, Famciclovir, Valaciclovir o Cycloplegia: Homatropine, Scopolamine o Skin lesions: Acyclovir Cream HZV Keratitis • Signs o Varying depending on corneal involvement o More severe in immunocompromised patients o Unilateral, affecting dermatomes o Prodrome o Hutchinson’s • Ocular Signs o SPK o Pseudodendrites o Anterior Stromal Keratitis o Neurotrophic Keratopathy • Treatment o Topical Treatment is ineffective o Oral: Famciclovir, Valacyclovir, Acyclovir 800 mg o IV (Encephalitis): Acyclovir o Systemic Corticosteroids: Prednisolone Herpes Simplex Virus • Symptoms o Pain, Itching, and Redness o Eyelid and periocular lid vesicles with erythematous base • Associated o Papillary conjunctivitis (Mild secretion/FB sensation) o Discharge o Lid Swelling o Punctate or dendritic corneal ulcers can develop • Treatment o Cold compress o Oral Systemic: Acyclovir 400 mg, Famciclovir, Valacyclovir o Topical (pt w blepharoconjunctivitis or corneal involvement): Ganciclovir, Trifluridine, Vidarabine Varicella Zoster Virus • Cool saline or Domeboro compress • Topical Antibiotic: Erythromycin or Bacitracin • Systemic: Acyclovir 800 mg, Famciclovir, Valacyclovir Neurotrophic Keratopathy • History of past SX, CL wearing, systemic disase • Trigeminal nerve neuropathy (V1-nasocillary) • Symptoms o Redness, Tearing o Decreased VA o FBS o Swollen eyelids o Corneal findings worse than symptoms • Signs o Decreased corneal sensitivity o Early: SPK and perilimbal injection o Late: Sterile inferior oval ulcer • Treatment o Suspend medications o Topical Lubricants o Topical Insulin like growth factor- Cenergermin o Anticollagenase agents: Acetylcysteine or tetracycline o Protection: taping, Botox, tarsorrhaphy, therapeutic silicone CTL o Perforation: keratoplasty Exposure Keratoplasty • Abnormal Lid Closure (Bell’s Palsy, Eyelid SX, Thyroid Disease) • Symptoms o Redness, burning o FBS o Worse in the morning • Signs o Hyperemia o SPK mild to corneal ulceration o Decrease corneal sensitivity • Treatment o AT’s and Ointment at night o Taping lid closed at night o Bandage silicone hydrogel or scleral CTL o Amniotic Membrane Fabry’s Disease • Metabolic Keratopathy (x-linked lysosomal storage disorder) • Caused by deficiency of alpha-galactosidase enzyme • Systemic o Periodic burning pain in extremities and GI tract o Cardiomyopathy and renal disease • Ocular o Golden-brown corneal vortex pattern o Fabry Cataract: wedge or spoke shaped posterior cataract o Conjunctival Corkscrew Vessels o Retinal vascular tortuosity Cystinosis • Metabolic Keratopathy (AR Lysosomal disorder CNTS) • Widespread tissue deposition of cystine crystals • Pediatric renal failure • Keratopathies develop in the first year and progress • Photophobia, epithelial erosions, VA impairment • Treatment: Systemic Cysteamine Keratoconus • AD inheritance, begins around puberty • Non-inflammatory progressive degeneration, initially damages Bowman’s Membrane • Starts unilaterally • Associated ocular conditions o VKC & AKC (rubbing) o Blue Sclera o Floppy Eyelid o Retinitis Pigmentosa • Associated Systemic Conditions o Downs o Osteogenesis Imperfecta o Marfan’s o Atopic Dermatitis • Symptoms o Photophobia o Glare, ghost images o Monocular diplopia o Hydrops (corneal swelling and opacity) • Late Signs o Vogt’s Striae: vertical lines in the deep stroma o Munson’s Sign: lower lid protrusion on downgaze o Rizzuti’s Sign: Conical reflection on the nasal cornea when light shown from temporal side • Treatment o Avoid eye rubbing o Soft CTL in early cases o Rigid CTL or Scleral or higher degrees of astigmatism o Corneal collagen cross-linking: Riboflavin (vitB12) o Intracorneal ring segment implantation o Keratoplasty or SALK in severe cases o Hydrops Treatment: Cycloplegia, Hypertonic 5% saline ointment, soft bandage CTL Keratoglobus • Extremely rare • DDX is from congenital glaucoma and megalocorena • Cornea develops globular rather then conical • Associated w generalized corneal thinning Keratoconjunctivitis Sicca • Dry eye disease (post-menopausal women, medications, systemic disease, environmental) • Symptoms o Burning, dryness, tearing, itching o Increase blinking o Photophobia o CL intolerance o FBS • Signs o Thin tear meniscus o Decrease Schirmer Test o Decrease TBUT o Conjunctival Hyperemia o Debris in tear film o Corneal Filaments o Acne Rosacea, Blepharitis • Aqueous Tear Deficient Dry Eye o Sjogren’s Syndrome Dry Eye § Primary • 95% females, second most common autoimmune rheumatic disease • Aqueous deficient (dry mouth, reduced salivary secretion) § Secondary • Primary with features of an autoimmune tissue disease (RA, SLE) • 50% of dry eye cases o Non-Sjogren’s Syndrome § Aqueous deficient secondary to lacrimal gland dysfunction • Primary (stenosis, age related) • Secondary (inflammation, obstruction, reflex hyposecretion) • Evaporative Dry Eye o Intrinsic: MGD, lid position disorder, low blink rate o Extrinsic: ocular surface disease, CL wear • Treatment o Tear Augmentation: AT’s during the day, Ointment at night o Tear Preservation: Punctal occlusion, Lateral Tarsorrhaphy, Tape lids o Ocular Surface Treatment § Mucomyst (Acetylcysteine) § Vitamin A § Immunomodulators: Cyclosporine, Lifitegrast Epithelial Basement Membrane Dystrophy • Epithelial Dystrophy (most common anterior corneal dystrophy) • AD, more common in females • Second decade of life onset • Thickening of basement membrane into the epithelium, creating cysts and lines • Deficient hemidesmosomes • Symptoms o Asymptomatic o Minor episodes of discomfort • • Signs o Dot-like and microcystic epithelial lesions o Subepithelial map-like patterns surrounded by a faint haze o Whorled fingerprint-like lines Treatment o Lubricating ointment o Hypertonic Saline solution o Bandage CL o Anterior Stromal Puncture o YAG Laser micro-puncture o Epithelial Debridement o Phototherapeutic keratectomy Messmann’s Dystrophy • Epithelial Dystrophy • AD, first year of life • Irregular thickening of the epithelial BM and intraepithelial cysts • Symptoms o Often asymptomatic o Symptoms may occur w ruptured cyst or recurrent corneal erosions • Signs o Bilateral, non-progressive o Extensive intraepithelial cysts, diffusely spread across the entire cornea (uniform in size) • Treatment: Lubrication Reis-Bücklers Dystrophy • Bowmans Layer/Anterior Stromal Dystrophy • AD (TGFB1) • Diagnose early in life due to pain • Abnormal replacement of bowman’s layer w connective tissue bands • Painful episodes due to recurrent erosions in early childhood, could have visual impairment • Signs o Bilateral, symmetric o Subepithelial grey-white geographic opacities o Most concentrated in the central cornea and spare to the peripheral cornea (incrase density with age) o Reduced corneal sensation • Treatment o Treat recurrent erosions o Excimer Keratectomy Thiel-Behnke Corneal Dystrophy • Bowman Layer/Anterior Stromal Dystrophy (honeycomb-shaped corneal dystrophy) • Bowman’s layer curly fibers on electron microcopy • Symptoms: Recurrent Erosions in childhood • Signs o Subepithelial opacities o Develop in a network of tiny rings or honeycomb like morphology Lattice Corneal Dystrophy • Stromal corneal Dystrophy • AD (TGFB1) • Amyloid-stains w Congo red • Symptoms o Recurrent erosions o Blurring occurs later • Signs o Refractile anterior stroma dots, form a fine lattice o Spares periphery o Generalized stromal haze progresses and impairs vision o Reduced corneal sensation • Treatment: Penetrating or deep lamellar keratoplasty Granular Corneal Dystrophy Type I • Stromal Corneal Dystrophy • AD (TGFB1) • Hyaline- stains w Masson trichome • Symptoms o Glare, Photophobia o Blurring as progression occurs o Recurrent erosions are uncommon • Signs o Discrete white central anterior stromal deposits that resemble sugar granules (or cum) o Gradual increase in number in size, deeper and outwards spread o Limbal clear zone o Corneal sensation impaired • Penetrating or deep keratoplasty Granular Corneal Dystrophy Type II • Stromal Corneal Dystrophy • AD (TGFB1) • BOTH Hyaline and Amyloid • Symptoms o Mild recurrent erosions o Visual impairment later • Signs o Usually present at the end of the first decade o Fine superficial opacities progress to form stellate or annular lesions • Corneal Trauma accelerates progression, Refractive surgery is contraindicated Macular Corneal Dystrophy • Stromal Corneal Dystrophy • AR (CHST6), Iceland • Aggregation of Glycosaminoglycans intra and extracellularly • Symptoms o Early visual deterioration • • o Signs o Very common recurrent erosions Dense but poorly delineated greyish-white spots centrally in the anterior stroma and peripherally in the posterior stroma o No clear zone o Early thinning o Late thickening from edema o Sensation is reduced Treatment: Penetrating keratoplasty Schnyder Corneal Dystrophy • Stromal Corneal Dystrophy • AD (UBIAD1) • Disorder of corneal lipid metabolism (phospholipid and cholesterol deposits) • Symptoms: visual impairment • Signs o Early central haze o Progresses to more widespread full thickness involvement o Subepithelial crystalline opacites present in 50% • Treatment: Excimer keratectomy or corneal transplantation Fuchs Endothelial Corneal Dystrophy • Posterior Corneal Dystrophy • AD (COL8A2) • Bilateral acceleration endothelial cell loss, more common in women • Increased prevalence of open-angle glaucoma • Symptoms o Gradually worsening blurring, particularly in the morning due to edema o Onset is usually middle age or alter • Signs o Corneal gutatta o Presence of irregular warts or “excrescences” on Descemet membrane o Beaten Metal appearance • Treatment o Topical sodium chloride o Hair dryer for corneal dehydration o Rupture bullae: bandage CTL, cycloplegia, antibiotic ointment and lubricants o Keratoplasty (DSAEK or DMEK) o Rho-kinase inhibitor CHED • • • • • Diffuse thickening of Descemet Membrane CHED 1: AD CHED 2: AR (SLC4A11), More severe and common, associated w deafness Symptoms o Photophobia o Watering (CHED 1) Signs • o Corneal clouding and thickening (neonatal CHED 2, first year CHED 1) o Nystagmus (CHED 2) Treatment: Lamellar or penetrating keratoplasty Mooren Ulcer • Corneal Degeneration • Bilateral in young patients, men 40-70 y/o • Progressive circumferential peripheral stromal ulceration • Benign/Typical 75%: older patients, unilateral • Malignant/Atypical: more aggressive, bilateral, younger patients, severe pain, Indian males • Chronic vasculitis of limbal vessels, leading to ischemic necrosis and peripheral ulcerative keratitis • Symptoms o Pain may be severe o Photophobia o Blurred VA • Signs o Peripheral ulceration o Crescent-shaped gray infiltrate, involving the superficial one-third of the stroma o Variable epithelial loss o NO clear zone o Vascularization o Iritis is not uncommon • Complications o Severe astigmatism o Secondary bacterial infection, cataract, glaucoma • Treatment o Topical Steroids every hour o Prophylactic topical AB o Topical Cyclosporine o Tacrolimus ointment: effective in controlling refectory cases o Other: ATs, acetylcysteine Amniotic Membrane • Biological Treatment for regenetaion of the cornea • Decrease inflammation, scaring, and angiogenesis • Thick BM • Contains collagen and proteins and growth factors LASIK and Complications • Epithelial Flap made w microkeratome • Excimer laser applied to the anterior stromal bed • Flap is reattached • Range: -10D to +4, up to 5D cylinder • Requirements o 250 um must remain under the flap to maintain integrity o Flap 150 um o Ablation depth, 15 um/diopter • • Complications o Pain in first 24 hours (corneal wound, flap dislocation) o Serious infection (1-3 days post op, can lead to corneal melting, irregular astigmatism and scarring) o Microbial Keratitis § Early onset in the first 2 weeks, late 2-3 weeks § Symptoms: blurred VA, photophobia, redness pain § Treatment: Fluroquinolone + Vancomycin, flap lift and irrigation, oral Doxycycline o Flap complication o Corneal Ectasia (anterior protrusion due to corneal thinning) o Glare o Residual Refractive error o Dry eye (most common side effect) o Central Toxic Keratopathy § Meibomian gland secretion, marking ink, talc form glove are reported inciting factors § Symptoms: Pain, Redness, Photophobia, Glare, and halos between 2-6 days § DDX Microbial Keratitis o Diffuse Lamellar Keratitis (DLK or Sands of the Sahara) § Inflammatory, non-infectious § 2-3 days after sx § Topical steroids if no response irrigate beneath the flap o Epithelial Ingrowth (most common complication after LASIK enhancement) § Treat w AB and Topical Steroid o Corneal Haze Enhancement o Earliest time is 3 months, 6 months preferred Ptosis Surgical Treatment • Abnormal low position of the upper lid in primary gaze • Symptoms: Dropping of the upper lid, visual loss especially when reading • Signs: Diplopia, ocular motility changes, HA, neck pain • Neurogenic: innervation defect such as CN 3 palsy and Horner’s syndrome • Myogenic: myopathy of the levator muscle or impairment of transmission at neuromuscular junction • Aponeurotic: defect of the Levator Aponeurosis o Involutional o Age-related condition caused by dehiscence, disinsertion or stretching of the levator aponeurosis o Due to fatigue of the muller muscle, worsens towards end of the day • Mechanical: caused by the gravitational effect of a mass or by scaring o Dermatochalasis, Large tumors, Heavy scar tissues, severe edema, anterior orbital lesions • Simple Congenital Ptosis o Failure of neuronal migration or failure in muscular development o AD o Unilateral or bilateral ptosis, absent lid crease, poor levator function • Congenital Ptosis o In downgaze the ptotoic lid is higher than the normal because of poor relaxation of the levator muscles o In contrast to acquired ptosis, which the affected lid is either level or lower than the normal lid on downgaze o o o o • Associated w superior rectus weakness, compensatory chin elevation, refractive errors Treatment: sx in preschool years Marcus Gunn Jaw Winking § 5% of all causes of congenital ptosis § Most are unilateral § Mandibular division of CN V is misdirected to the levator muscle § Signs • Retraction of the ptotoic lid in conjugation w stimulation of the ipsilateral pterygoid muscles • Does not improve w age § Treatment: SX Moebius: Congenital Ectropion, 7th CN palsy (lagophthalmos) Treatment o Conjunctiva-Muller Resection o Levator Advancement o Brow (Frontalis) Suspension Concretions • Chronic conjunctival inflammation (Trachoma) • Multiple tiny yellow-white deposits of epithelial debris w keratin • Could be calcified • Asymptomatic • Treatment: Removal w needle in SL with topical anesthetics Madarosis • Loss of all eyelashes • Local: chronic anterior lid margin disease, tumors, burns, radio or cryotherapy • Skin disorders: Generalized alopecia • Systemic disease: SLS, Myxedema, syphilis, lepromatous leprosy • Following removal: procedures for Trichiasis, trichotillomania Subconjunctival Hemorrhage • Blood underneath the conjunctiva • Causes o Valsalva o Medications o HTN o Blood clotting disorder o Vitamin C deficiency • Diagnosis o CBC o PT/PTT o Sickledex • Treatment o Unnecessary o Lubricants Necrotizing Fasciitis • Severe infection of subcutaneous tissues and skin • S. Pyogenes or S. Aureus • Signs o Periorbital redness and edema followed by formation of large bullae and black discoloration o Necrosis due to thrombosis • Complications o Ophthalmic artery occlusion o Lagophthalmos o Disfigurement • Treatment: IV Antibiotics: PCN G Lagophthalmos • Incomplete lid closure • Types o Orbital: associated to proptosis o Paralytic: CN 7 palsy o Mechanical: lid scarring o Tumors: Acoustic neuroma or Parotid gland tumor • Treatment o Mild: Topical ointments, ATs, taping o Moderate: AB ointment, consider moisture chamber o Severe: SX Floppy Eyelid Syndrome • Typically, in obese middle-aged who sleep face down • Associated: OSA, Keratoconus, Skin Elasticity • Causes o Loss of tarsal integrity, decrease in elastin tarsus o Elongation of tarsal plate o Overweight • Treatment o OSA: lose weight, pneumologist evaluation o Mild: Lubricants, AB if necessary (Erythromycin or Bactrim/Polytrim), eye shield or taping if necessary o Moderate: surgical horizontal shortening, pentagonal excision Chalazion • Sterile Lipogranulomatosis inflammation of Meibomian Gland • May follow internal hordeolum • Signs o Well-defined, immobile, firm, non-tender nodule o Chalazion that does not resolve w conservative treatment o Painless • Treatment o Warm compress, gentle massage o Topical AB ung (if lesion is draining): Erythromycin or Bacitracin o Topical AB/Steroid ung (inflammation): Tobradex o o o o Incision and Curettage after 1 month w no improvement Triamcinolone infection (steroid, not for dark skin) Recurrent: biopsy to rule out malignancy (sabulous carcinoma) Multiple and Recurrent: Doxycycline, Minocycline, Tetracycline, Erythromycin Demodicosis (Dermodex) • Parasitic hair follicle (can turn into chronic Bleph) • Signs o Thin, semitransparent crusting at the lashes base in the hair follicles o Irritation, redness, itching o Collarets • Parasite consumes epithelium cells, causes hyperplasia and keratinization, leads to cuffing • Accumulation of waste material in follicles and sebaceous glands • Treatment o Tea Tree oil lid scrubs (Blephadex) o Omega 3 and 6 fatty acids o Ivermectin for resistant oral treatment Seborrheic Blepharitis • Hyperemic and greasy anterior lid margins with soft scales and adherence of lashes Meibomian Gland Dysfunction (Posterior Blepharitis) • Excessive meibomian gland secretion • Capping of meibomian gland orifices with oil globules • Hyperemia • Telangiectasis of the posterior lid margin • Pressure on lid margin may excrete turbid or toothpaste-like expression • Treatment o Hot compress w massage o Lid Scrubs o Fish oil and Omega 3 fatty acid o Lotemax or Tobradex o Azithromycin o Oral: Doxycycline, Erythromycin, Azithromycin, Cyclosporine o In-office heat or expression o Intense pulsed light o Meibomian gland probing Meibomianitis • Inflammation of the Meibomian Glands • Relate to poor blinking, poor diet, demodex, rosacea, CL, or aging • Most dry eye patients have MGD • Symptoms o FB sensation o Tearing, Burning • Signs: Hyperemic lid margin capping, Creamy secretion upon expression, dry eye, SPK • Treatment is the same as MGD Canaliculitis • Inflammation of the Canaliculi • Bacterial is most common- Actinomyces Iraelii • Symptoms o Unilateral red eye o Unresponsive to AB treatment o Often misdiagnosed recent conjunctivitis • Signs o Pouting puncta o Dacryoliths o Mucopurulent discharge w palpation over the lacrimal sac • Treatment o Warm compress to canalicular region o Topical Fluroquinolone: Ciprofloxacin, Ofloxacin, Moxifloxacin o No response: Canaliculotomy Acute Dacryocystitis • Commonly associated to concomitant ENT infections • Lacrimal sac infection (occurs when lacrimal drainage system is obstructed) • NLDOà Back flow of bacteria from lacrimal lase to lacrimal sac (staph aureus, H. Influenzae in children) • Symptoms o Pain o Crusting and tearing o Occasional fever • Signs o Prominent swelling and tenderness over the lacrimal sac area o Hyperemia o Swelling below medial canthal ligament • Treatment o Warm compress o Oral AB: Amoxiclav (Amoxicillin/Clavulanate) o Irrigation and probing NOT performed o Incision and drainage if pus points and an abscess is about to drain o DCR after acute infection is controlled Chronic Dacryocystitis • Chronic epiphora • Associated to recurrent unilateral conjunctivitis • Mucocele, painless swelling at the inner cantus • Pressure on sac results in mucopurulent canalicular reflex • Chronic cases suspect Epithelial Carcinomas or Malignant Lymphomas o Blood into tear film w palpation of lacrimal sac o Swelling above the medial canthal ligament Dacryoadenitis • More common in children and young adults • Inflammation of the Lacrimal Gland • HX of recent fever • Inflammation of Lacrimal gland that can be acute or chronic o Acute: secondary to an infection o Chronic: secondary to inflammatory disease • Symptoms o Swelling in the outer 1/3 of the temporal upper eyelid o Pain o Redness • Signs o Acute § S-Shaped ptosis § Temporal eyelid pain, redness, and swelling § PAN § Occasional fever § Elevated WBC § Culture of the discharge § Orbital CT scan for proptosis or restriction o Chronic § Temporal eyelid swelling § Less redness, swelling, and pain compared to acute § May lead to inferonasal globe displacement and proptosis § Lacrimal gland biopsy when uncertain of malignancy • Treatment o Acute § HSV or HZV: Acyclovir, Famciclovir, Valaciclovir § Staph or Strep: Augmentin (if severe, Ampicillin-Sulbactam) § Mycobacterium TB: Isoniazid, Rifampin, and Pyrazinamide § Treponema Pallidum (Syphilis): Penicillin G o Chronic: treat underlying inflammatory disorder, Prednisolone PO Congenital NLDO • Membranous blockage at the Valve of Hasner (most common cause) • 5-30% of newborns • 20% epiphora of neonates • Spontaneous opening of Valve of Hasner occurs frequently 1-2 months after birth o Digital massage is indicated if not opening • DO NOT probe until 12 months of age • Signs o Epiphora o Superimposed bacterial conjunctivitis- TX w Topical AB o Gentle pressure over the lacrimal sac may cause mucopurulent discharge • Treatment o Massage o Probing § 13 months w/o resolution or sooner if infection or discharge