Conjunctival, lacrimal, and lid disorders

If you think I'm corny now, just wait till I get cornea

Conjunctivitis

What is the most common eye disease that is characterized by the inflammation of the conjunctiva causing Red eye

adenovirus

What is the most common cause of viral conjunctivitis

Viral conjunctivitis

Patient presents to the clinic with a foreign body in her eyes. She states “it feels like there’s a piece of sand in there.” She also reports that this started 2 days ago in her left eye and now her right eye is starting to feel the same way. She reports that in the mornings, her eyes are crusted over. On a physical exam you note conjunctival injection, and that her eye is extremely watery with scant discharge. What are we thinking team?

highly contagious, benign, self-limited

Characteristics of viral conjunctivitis

Staph A.

What is the most common cause of bacterial conjunctivitis in adults?

Strep pneumoniae, H. Influenzae, Moraxella catarhhalis

What is the most common cause of bacterial conjunctivitis in kids?

Bacterial conjunctivitis

Patient presents to the clinic for an eye issue. She reports that her eyes are stuck shut upon waking and that she has noticed a thick green discharge throughout the day. On a physical exam you note unilateral redness and a thick, globular greenish purulent discharge. What are we thinking team?

hyperacute bacterial conjunctivitis

An inflammation of the conjunctiva that occurs due to N. gonorrhoeae (direct inoculation from genitals to eyes)

Ophthalmology immediately, Hyperacute bacterial conjunctivitis

Patient presents to the ER with rapidly progressive eye redness and irritation. While collecting a complete history, your patient reports promiscuous sexual behavior and a recent diagnosis of urethritis. On a physical exam you note profuse purulent discharge that the patient reports an onset about 12 hours ago. Eyes are extremely tender on palpation. Lid, preauricular nodes and conjunctiva swelling is noted. Who you gonna call? What are we thinking?

dry eye, chemical splash, spontaneously expelled ocular foreign body

Types of noninfectious, nonallergic conjunctivitis

chemosis

swelling of the conjunctiva

dry eye

A noninfectious, nonallergic conjunctivitis characterized by chronic or intermittent redness or discharge

allergic conjunctivitis

An irritation of the conjunctiva caused by an IgE mediated mechanism that results in bilateral redness, profuse watery or mucus discharge, and itchiness. Patient history is usually positive for seasonal allergies or another allergy.

24 hrs

noninfectious nonallergic conjunctivitis typically improve spontaneously in _____.

culture of discharge (hyperacute only), rapid test (adenoviral)

Laboratory testing for conjunctivitis

confirm normal vision, exclude keratitis (or pseudo), iritis, angle closure glaucoma, foreign body, pterygium, hordeolum, blepharitis

To diagnose with conjunctivitis we must

Self-limited, therapy reduces symptoms but doesn’t alter course

Course of viral, allergic, nonspecific conjunctivitis

Self limited (8-14 days) topical antibiotics may shorten the course if given before day 6

Course of bacterial conjunctivitis

topical antihistamines/decongestants (naphazoline, naphazoline-pheniramine), lubricating agents, warm/cool compresses

Treating viral conjunctivitis

Its gonna get worse before it gets better (3-5 before improvement starts and may persist for 2 weeks)

In patients diagnosed with viral conjunctivitis what do we need to tell them

Erythromycin eye ointment, Trimethoprim-Polumyxin B (refer if no improvement in 1-2 days)

How are we managing a basic bacterial conjunctivitis?

topical fluoroquinolone (floxacin, gatifloxacin), no contacts until 24 hrs symptom free

How are we managing contact wearers with bacterial conjunctivitis?

OTC topical lubricants (hourly with no side effects)

What can we give patients with nonallergic conjunctivitis to help manage symptoms?

wash your hands, don’t touch your eyes, don’t share things like handkerchiefs, daycares may require treatment to allow the kid back (decreases bacterial conjunctivitis)

Patient education measures for conjunctivitis

pterygium

A triangle shaped wedge of fibrovascular conjunctival tissue that is associated with chronic sun-exposure and is more common in tropical regions or older males that work outdoors

medially, laterally

Pterygium starts ____________ on the nasal conjunctiva and extends __________ onto the cornea

pterygium, OTC lubricants maybe surgical excision if it worsens

A 65 y/o male presents to the clinic with unilateral blurry vision. While collecting a history he reports that he use to work outside until he recently retired. He also reports that his eye has been irritated and his wife has noticed that his eye looks different. On a physical exam you note redness of a triangular wedge that extends from the cornea to the conjunctiva and that the the wedge is more than halfway to the center of the pupil. What are thinking and what’s the game plan?

If >45% corneal radius that impairs vision/eye movement varies based on growth/degree of astigmatism (not cosmetic reasons high recurrence rate)

When do we consider surgical excisions of a pterygium?

OTC topical lubricants (drops, ointment, gels, artificial tears), topical decongestants, NSAIDS, glucocorticoids

Managing most pterygium and pinguecula symptoms includes

pinguecula

A degenerative condition that is characterized by yellowish, slightly raised conjunctival lesions that arise at the limbal conjunctiva (edge of iris) BUT remains confined to the conjunctiva with NO corneal involvement

space between triangle lesion and edge of cornea

What is a major defining factor between pinguecula and pterygium

nasal/temporal/both conjunctiva

Common sites of pinguecula

Dacryocystitis

An infection of the lacrimal sac that is due to a congenital or acquired obstruction of the nasolacrimal system typically seen in infants and adults over 40

Staph A, Streptococci

Acute Dacryocystitis is caused by an infection of what?

Staph epidermidis, streptococci, gram-negative bacilli

Chronic Dacryocystitis is caused by an infection of what?

Blood and drainage cultures, emergent ophthalmology consult, Dacryocystitis

Patient presents to the ER with a red, swollen mass under the eye. On a physical exam you note the lacrimal sac is warm to the touch and tender on palpation. You note purulent discharge. What do we need to order? What are we thinking?

chronic

What type of Dacryocystitis results from bacterial overgrowth in the stagnant tear pool of the lacrimal sac and is characterized by mucopurulent drainage from the puncta (tear holes) without overt signs of infection?

preseptal/orbital cellulitis, sepsis, meningitis

Complications of Dacryocystitis

Urgent referral to ophthalmology, oral clindamycin (mild), IV vancomycin + 3rd gen cephalosporin (severe)

What’s the plan in treating Dacryocystitis?

Infectious keratitis

An infection of the cornea that can be caused by bacteria, virus, fungi, or parasites

Staph A., Pseudomonas A., Strep pneumoniae, Diphtheroids, coagulate-negative staph

What bacteria can cause infectious keratitis?

bacterial keratitis

Patient presents to the ER for a foreign body sensation in her eye. While collecting a history you discover that she is a night shift nurse who often falls asleep in her contacts. While speaking to the patient, you note she is having a hard time keeping her affected eye open and asks you to turn the lights off. On a physical exam you find some corneal opacity and a white, round spot on the eye. Mucopurulent discharge is present and the eye is red. What are we thinking team?

Same-day referral to opthalmology, cultures, 4th gen topical antibiotics (gatifloxacin, moxifloxacin)

When it comes to bacterial keratitis, how are we managing this?

HSV

What is the most common cause for viral keratitis that is typically self-limited?

Viral keratitis

Patient presents to the ER with a foreign body sensation in her eye. While collecting a history, your patient request the to turn the lights off. On a physical exam you note the eye is red and a watery discharge is present. On a flourescein stain you find branching lesions on the eye. What are we thinking team?

oral/topical antivirals (ganciclovir (topical) acyclovir (oral)), urgent referral to opthalamology

Regarding Viral keratitis, what’s our game plan?

Hordeolum

A localized red, swollen, tender infections of the glands of the eye lids that have increased incidence in patients with skin conditions like rosacea and seborrheic dermatitis that is caused by staph aureous or can be steril.

Meibomian

A hordeolum that occurs on the conjunctival surface of the lid is due to the infection of what gland?

Stye

A hordeolum that is usually smaller and on the lid margin due to an infection of the gland of moll/zeis?

warm compress, massage, stop wearing eye makeup, referral to ophthalmologist to I and D if not resolved in 1-2 weeks or recurrent?

How are we treating hordeolum?

Chalazion

A sterile, nontender inflammatory rubbery nodule that results from a blocked Zeis or meibomian gland that can occur on the upper or lower lids and may distort vision if large

Warm compress, referral opthalomologist for removal or glucocorticoid injection if persistent

Treating a chalazion

hordeolum

What can progress to cause a chalazion?

BCC, sebaceous cell carcinoma, meibomian gland carcinoma

If a chalazion is recurrent or persistent, what do we need to check for?

blepharitis

What is an inflammatory condition of the eyelid margin that can be posterior or anterior

Anterior blepharitis

inflammation at the base of the eyelid typically due to the colonization of staph a. and staphlycocci or in association with seborrhea on the face

Posterior blepharitis

Inflammation of the inner eyelid near the meibomian glands due to the hyperkeratinization of the gland’s epithelium leading to altered secretions creating a environment for bacterial growth. Strongly associated with roseacea and seborrheic dermatitis.

posterior

What type of blephatitis is more common?

Slit lamp eye exam to look at the meibomian glands, distinguish anterior vs. posterior

A patient presents to the clinic for “pink eyes.” They also report a gritty/burning sensation, light sensitivity, and excessive tearing. They state that their vision is sometimes blurry but improves if they blink more. A physical exam shows that their eyes are red and swollen, the eyelashes are crusted and matted, the skin around the eyelids are flaking and scaley. What is the next step in the treatment of this patient?

conjunctivitis, hordeolum, chalazion, eyelid malignancy

If we’re thinking blepharitis what needs to be in the differential

alleviated symptoms, minimize future exacerbations (eyelid hygiene)

Main management of blepharitis

warm compress followed by an eyelid massage, gentle cleansers, artificial tears

Treating mild-moderate blepharitis

topical antibiotics (bacitracin, erythromycin, cipro), oral antibiotics (tetra, doxy, mino, erythromycin), topical glucocorticoids

If the blepharitis is not responding to standard treatment

symptoms that don’t respond to treatment, severe eye redness/pain/light sensitivity, impaired vision, corneal abnormalities, concern for malignancy

In what cases of blepharitis would we need to refer to ophthalmology?

entropion

A condition common in older people where one of the eyelids (usually the lower one) turns inward toward the eye

degeneration of eyelid fascia

Why is entropion common in older people

If eyelashes rub on the cornea

In entropion when is surgery indicated?

botox

What can we use to temporarily correct entropion?

ectropion

A condition common in people of advanced age that is characterized by the outward turning of the eyelid

excessive tearing, exposure keratitis, cosmetic problem

In ectropion, when is surgery indicated?