Periorbital Disease PDF

Periorbital Disease V644 OCULAR DISEASE I  FACE AND COMPLEXION REALLY….. Look at your patients Observe Facial symmetry Complexion Rashes Lesions Examples: Skin cancers Neurological Skin conditions Rosacea Eczema ...

Periorbital Disease V644 OCULAR DISEASE I  FACE AND COMPLEXION REALLY….. Look at your patients Observe Facial symmetry Complexion Rashes Lesions Examples: Skin cancers Neurological Skin conditions Rosacea Eczema  left eye lid droop! FACIAL SYMMETRY Facial features Look at the overall appearance, shape and mobility. Forehead wrinkles and nasolabial folds should be symmetrical Go back to understand 4th nerve palsy! Eyebrows symmetric? can't fully blink OD; will complain of dry eye Eyelids symmetric? 4th nerve palsy, OD Ptosis Proptosis Blink: complete, partial, asymmetric Mouth level or drooping Smile symmetric  Periorbital edema Definition: swelling of soft tissue around the eye “Puffy” Systemic cause vs localized cause Example of causes: Allergies Seasonal Contact Infection: viral or bacterial Hypothyroidism Systemic causes: Think Kidney & Hypothyroidism  PITTING EDEMA You apply pressure and there's a "pit" -After pressure has been applied to the area of swelling, the depression/imprint remains long after. -Normally the tissue rebounds within seconds.  Systemic causes of periorbital edema: Nephrotic Syndrome Linked to kidney disease Edematous and pale face Swelling first appears around the eyes upon waking. Can become severe. Later in day, swelling will be reported around the ankles. Pitting edema will be noted (ankles)  Systemic Causes of Periorbital Edema: Florid Myxedema: swelling and thickening of the skin Linked to severe hypothyroidism Dull skin Puffy face Swelling around the eyes Does not pit with pressure. The hair & eyebrows are dry, coarse and thinned. The skin is dry and thickened  Observed Facial Features: Parkinson’s Mask-like face Decreased blink rate (2-3/min vs 15- 20/min normal): Dry eye, vision fluctuation, poor vision Classic stare with chin down and fixation peering upwards Skin slightly oily; blepharitis is common Neck and upper body flexed forward Observed Facial Features: FACIAL ASYMMETRY Neurological: Go learn this Lower vs. Upper motor neuron Notice forehead wrinkles: one side is smooth, one side has wrinkles  FACIAL ASYMMETRY Bell’s palsy A unilateral facial paralysis of sudden onset involving inflammation of the facial nerve (CN VII), usually of viral etiology commonly herpes virus; usually a diagnosis of exclusion as there's no way to test for it Distal to the CNS ganglion therefore it is a lower motor neuron defect Lower motor neuron defect which affects both the upper & lower face. Lower motor neuron affects upper & lower face Patient is negative for other (systemic) neurological findings: Diagnosis of exclusion  FACIAL ASYMMETRY Bell’s palsy Patient complains of watery eye “cannot blink”. Smile is asymmetric. Forehead wrinkles appear only on one side. Prognosis is good with 90% recovery over several weeks. 20% will show some residual weakness.  FACIAL ASYMMETRY Upper motor neuron defect A central lesion (CNS), MS, CVA (TIA / Stroke) or tumor. Affects the lower face only. Pt able to lift both brows and wrinkle forehead & weakly close both eyes. Positive for other neurological signs. upper motor neuron affects lower face only Prognosis is guarded: depending on etiology  FACE AND COMPLEXION Inspect the patient’s skin and complexion. Look for rashes, blemishes, lesions ASK about derm conditions Most facial dermatological findings fall into one of 4 general categories Infectious: bacterial, viral, fungal Metabolic dermatitis (nutritional, endocrine) Contact dermatitisbased on what the pt has been in contact w/ Neoplasms abnormal growth BACTERIAL INFECTIONS eem-pair-tie-go Impetigo: Etiology: Staphylococcus aureus Streptococcus pyogenes Preschool & young adults vesicles, red base with “honey- colored” crust Symptoms: none to mild Onset days to weeks Slow spread Scars rarely Treatment: penicillinase resistant oral antibiotics Not treated topically!  BACTERIAL INFECTIONS seen in elderly, poorly controlled diabetics Erysipelas: a skin infection (cellulitis) involving the dermis may extend to superficial cutaneous lymphatics Greater risk in older adults, diabetics, obesity Facial in 20% of cases (2nd most common site) Lower extremities most common Signs & symptoms: tender to painful, red, sharply demarcated, warm, swollen Malaise, fever 1:1000 More frequent in males Treatment: oral antibiotics, prompt referral  VIRAL INFECTIONS Simplex = Simply sores Herpes Simplex Virus (HSV) aka “Cold sores”, “Fever blisters” less fearful term to be used w/ pts Common All ages & sex Increased incidence with age, UV exposure, fever, stress Lip most common site but can be seen on eyelids/nares/skin. Symptoms: prodrome of tingling, pain, burning Vesicular rash to crusting lasting 2-6 wks Treatment: oral antiviral speed healing, decrease viral shedding Risk of ocular involvement Spread by contact  Can also be seen around the pt's back VIRAL INFECTIONS Herpes Zoster Virus (HZV) Anyone w/ a weak immune system is susceptible “Shingles” to HZV Reactivation of the varicella zoster (chickenpox) virus 10 to 20% of population All ages & sex, increased incidence with age, fatigue, stress, immunosuppressants Symptoms: prodrome of pain, burning Rash: vesiclular, open to crusting lasting ~10 days Full resolution 4-5 weeks Risk of ocular involvement with CN 5 outbreak complication: post herpetic neuralgia Type text here  VIRAL INFECTIONS Molluscum contagiosum Common superficial pox virus infection, direct contact Lesions = Elevated clusters Children 40yo), males> females, genetic - Sun exposed areas, lighter skin types - Invasion frequent, metastases rare - Head & face, sun exposed skin - Slow growing, months to years - Hard nodule, pearly rolled edge - central ulceration, may bleed -Treatment: cryosurgery around eyes; excision with radiation elsewhere - 95% cure rate  Neoplasms DDx: Sebaceous Hyperplasia - Fairly common, confused with basal cells carcinomas - Onset middle age (>40yo), males> females, genetic - Soft yellow papules, 1-3mm raised, donut shaped - Forehead & cheeks, - Sun exposed skin frequently. - Will have central pore - Treatment: electrocautery Sebaceous Hyperplasia  Neoplasms Prognosis: Likely course/outcome of a disease Squamous Cell Carcinoma seen on lips; associated w/ smokers -Second most common cancerous skin lesion - Onset: older age (>55yo), males> females, genetic - Lighter skin types, sun exposed, X-ray, arsenic - Slow growing, Invasion frequent, metastases possible - Sun exposed skin: Face, dorsa of arms & hands, legs - Hard nodule, adherent scale - Asymptomatic - Will ulcerate & bleed - Treatment: excision with radiation - 90% 5-year rate90% early have a 5year survival rate; prognosis is good if caught Example: Lip secondary to pipe smoking  Neoplasms Nevus (plural-Nevi) - Benign skin tumors of nevus cells - Anywhere on skin - Correlated with sun exposure - Common, avg #15-40, AA #2-11 - Brown to flesh color - large variance in shape & types: Macule(flat) to papule(raised) - Risk of converting to dyplastic nevi based on skin type, # of nevi and sun exposure.  Neoplasms Freckles Freckle vs. Nevus Freckle: flat tan hyperpigmented area 1-6mm that appear before age 3.** An overproduction of melanin Nevus - 1% newborns, peak at puberty Nevus: Benign neoplasms that appear before age 30. Melanocytes grow in clusters or clumps  Neoplasms Malignant Melanoma - Prevalence: 15/100,000, 1-2% of all CA deaths - 5% males 6% females - Onset 30-50 years old, median 37 years - Life time risk is 1:50 (2010) - 2002 1:75, 1992 1:105, 1935 1:1500 - Highest risk: light skin type I&II, only 2% non-whites - Risk increased: (MMRISK) - M moles dysplasic >5mm - M moles common >50 - R red hair and freckling - I inability to tan - S Severe sunburn < age 14 - K kindered positive family Hx  Neoplasms excision can affect lid function Malignant Melanoma - Most common site upper extremities & back in males, females back & legs - Irregular color, shape, size, elevation - Rapid change 2-6 mos - Most common type is Superficial Spreading, 70% - Treatment: total excisional biopsy - Metastases 15-26% of stage I/II MM - Death rate: 3 times that of other skin cancers - 33 to 93% survival rate  Neoplasms ABCDE’s of Malignant Melanoma A = Asymmetry of diameter & height B = Border irregularity (blurred & scalloped) C = Color variegation within single lesion D = Diameter > 6mm (pencil rule) E = Enlargement & evolution (changing)  BIOPSY How to study = case history and diagnosis, especially differential diagnosis, baseline management/tx of pts, will have pictures