EENT: Eyes and Ears

Punctum:

where tears drain

Meibomian gland:

oil secretion

The ____ chamber is aqueous.

anterior

Anterior chamber:

cornea, limbus, iris, ciliary body

Limbus:

ring around cornea

The ____ chamber is vitreous.

posterior

Posterior chamber:

sclera, choroid, retina

Entropion pathogenesis:

lid laxity with lid margin directed inward toward globe

Entropion population:

elderly

(tarsal atrophy)

Entropion symptoms:

foreign body sensation, erythema, tearing

Entropion diagnosis:

clinical

Entropion treatment:

ophthalmology referral, surgery, rewetting drops

Ectropion pathogenesis:

lid laxity with lid margin directed away from globe

Ectropion population:

elderly

(tarsal atrophy)

Ectropion symptoms:

dry eye, erythema, tearing

Ectropion diagnosis:

clinical

Ectropion treatment:

ophthalmology referral, surgery, rewetting drops

Blepharitis definition:

erythema and edema of eye lid

Causes of blepharitis:

scurf, meibomian gland dysfunction, mite infestation

Blepharitis symptoms:

foreign body sensation, edema, erythema

Blepharitis symptoms if caused by scurf:

dandruff in lashes and erythema and lash margins

Blepharitis diagnosis:

clinical

Blepharitis treatment:

warm compress and lid scrub, artificial tears q3-4h, erythromycin oph oint 0.5% 1/4" inside lid BID-QID x 5 days

Blepharitis treatment if of staphylococcal origin:

doxycycline 100mg PO BID x 1 month

Chalazion definition:

nodule on eyelid

Chalazion cause:

obstruction of meibomian gland

Chalazion symptoms:

nodule on lid that is mildly TTP and pain with eye movement

Chalazion diagnosis:

clinical; silt lamp with inverted lids to r/o carcinoma

> 50% of chalazion cases resolve with:

warm compress/lid massage and lid margin cleanse

Treatment for chalazion if unresolved:

prednisolone oph susp 1%,1gtt BID and erythromycin oph oint 0.5% 1/2" BID

Hordeolum pathogenesis:

bacterial infection in hair follicle > lesion at base of lashes

Hordeolum symptoms/presentation:

pustular nodules that are erythematous and TTP

Hordeolum diagnosis:

clinical

> 50% of hordeolum cases resolve with:

warm compress/lid massage and lid margin cleanse

Treatment for hordeolum if unresolved:

prednisolone oph susp 1%, 1gtt BID and erythromycin oph oint 0.5% 1/2" BID

Orbital cellulitis definition:

infection of soft tissue of eye socket

(skin, fat, EOM)

Orbital cellulitis usual cause:

local spread from ethmoid sinusitis

Dacryocystitis, dental infection, trauma, foreign body, surgery, or hematogenous spread of other infections are also causes of...

orbital cellulitis

Orbital cellulitis symptoms:

ptosis, chemosis, pain with EOM

Complications of orbital cellulitis:

vision loss or penetrating infection

What bacterial agents are causes of orbital cellulitis?

s. aureus, s. pyogenes, s. pneumoniae

Orbital cellulitis diagnosis:

clinical; CT for paraseptal v. orbital; blood, nose, throat cultures

Orbital cellulitis treatment:

hospitalization and ophthalmology consult; vancomycin 1g IV q12 AND ceftriaxone 1g IV BID; I&D if abscess present

Periorbital cellulitis definition:

infection of anterior portion of eyelid

What bacterial agents are causes of periorbital cellulitis?

s. aureus and s. pyogenes

Periorbital cellulitis symptoms:

unilateral ocular pain, erythema, swelling, chemosis

Periorbital cellulitis diagnosis:

clinical; CT if questionable

Periorbital cellulitis treatment:

amoxicillin/clavulanic acid 875/125mg PO BID x 7-10 days

When is hospitalization recommended in cases of periorbital cellulitis?

children less than 1 or who can't cooperate, severely ill, orbital involvement, failure to respond to outpatient therapy in 24-48h

What symptom is critical in differentiating between periorbital and orbital cellulitis?

orbital cellulitis: pain with EOM

periorbital cellulitis: no pain with EOM

Dacryocystitis definition:

inflammation of the lacrimal sac

Dacryocystitis cause:

obstruction of nasolacrimal duct with resultant stagnation of tears

Dacryocystitis acute symptoms:

erythema, edema, pain

Dacryocystitis chronic symptoms:

edema localized to lacrimal sac

Dacryocystitis diagnosis:

clinical; cultures; CT facial bones/sinuses to r/o abscess

Acute dacryocystitis treatment:

amoxicillin/clavulanic acid 875/125mg PO BID x 7-10 days and surgery

Acute dacryocystitis can often result in what secondary infection?

orbital cellulitis

If acute dacryocystitis results in orbital cellulitis, what is the treatment?

ampicillin/sulbactam 1.5g IV q6

Chronic dacryocystitis treatment:

surgery

Dacryoadenitis definition:

inflammation of the lacrimal gland

Acute dacryoadenitis is usually due to...

infection: viral, bacterial, fungal

What bacteria cause acute dacryoadenitis?

s. aureus and s. pneumo

Chronic dacryoadenitis is usually due to...

inflammation

(autoimmune/rheumatic)

What inflammatory conditions are associated with chronic dacryoadenitis?

sjogren syndrome, sarcoidosis, crohn's

Dacryoadenitis symptoms:

erythema and TTP of superotemporal orbit with lacrimal gland enlargement, S-shaped lid margin, suppurative lacrimal duct discharge

Dacryoadenitis diagnosis:

clinical; lab: ANA, ANCA, anti-SSA/SSB; CT

Treatment for acute dacryoadenitis:

viral: self-limited; bacterial: amoxicillin/clavulanic acid

Treatment for chronic dacryocystitis:

manage underlying condition; rheumatology/ophthalmology referral

Dacryostenosis definition:

obstruction of nasolacrimal duct

Most cases of dacryostenosis are...

congenital

How can dacryostenosis be acquired?

chemo and radioiodine therapy

Dacryostenosis symptoms:

persistent tearing and debris on lashes

Dacryostenosis CONCERNING symptoms:

purulent discharge, bluish swelling of skin overlying lacrimal sac, photophobia, clouding

Dacryostenosis diagnosis:

dye disappearance test

Dacryostenosis treatment:

lacrimal massage and ophthalmology referral if > 6 months old

Keratoconjunctivitis sicca definition:

hypofunction of lacrimal glands > loss of aqueous component of tears

Causes of keratoconjunctivitis sicca:

aging, systemic disease, environment, vitamin A deficiency, drugs

What systemic diseases are associated with keratoconjunctivitis sicca?

sjogren syndrome, DM, Parkinson's

Keratoconjunctivitis sicca symptoms:

erythema/injection, gritty FB sensation, light sensitivity, blurred vision

Keratoconjunctivitis sicca diagnosis:

clinical and ocular surface disease index

Physical exam findings of keratoconjunctivitis sicca:

conjunctival injection/dryness, excessive tearing

What two tests are used to diagnose keratoconjunctivitis sicca?

fluorescein staining and Schirmer test

Keratoconjunctivitis sicca treatment:

manage underlying condition, ocular lubricants, topicals

Conjunctivitis definition:

inflammation of the conjunctiva

Allergic conjunctivitis is associated with a hx of...

asthma and eczema

Allergic conjunctivitis is associated with acute...

sinus congestion, rhinorrhea

Allergic conjunctivitis symptoms:

acute eye itching, watery discharge, limbus irritation, cobblestone papillae

Allergic conjunctivitis diagnosis:

clinical

Allergic conjunctivitis treatment:

cold water rinse/cold compress, artificial tears, ketorolac oph soln 0.5% 1gtt q6h PRN, olopatadine oph soln 0.1% 1gtt BID PRN

Treatment for severe allergic conjunctivitis:

prednisolone op soln 1%, 1-2gtt BID-QID, prednisolone 10 mg PO taper (60mg-10mg, 6-day)

Viral conjunctivitis causes:

adenovirus, HSV, VZV

Viral conjunctivitis symptoms:

tearing, itching, foreign body sensation, mild pain, photophobia, injection of conjunctiva

Viral conjunctivitis is usually concomitant with...

URI sx

Viral conjunctivitis diagnosis:

clinical

In viral conjunctivitis, what test should also be considered and why?

fluorescein stain to r/o corneal ulceration

Viral conjunctivitis treatment:

cold water rinse/cold compress and artificial tears

What bacterial agents can cause bacterial conjunctivitis?

s. aureus, s. pneumoniae, h. flu, p. aeruginosa, m. lacunata, n. gonorrhea, c. trachomatis

Bacterial conjunctivitis causes:

poor contact hygiene or contaminated cosmetics

Bacterial conjunctivitis symptoms:

severe erythema, purulent discharge, photophobia

Bacterial conjunctivitis diagnosis:

clinical; culture