Lids, Lashes, Lacrimal

what causes dermatochalasis

weakened orbital septum with age

2 main types of blepharitis

staph and seborrheic

both can cause anterior and posterior blepharitis

what is seborrheic blepharitis associated with

seborrheic dermatitis

how does seborrheic bleph differ from staph bleph

seborrheic bleph is less inflamed and more oily/greasy, has more eyelash loss (madarosis) and misdirected lashes

2 things to ask about when patient has hordeolum or chalazion

history of acne rosacea or seborrheic dermatitis

chalazion

localized sterile inflammation of an MG due to retention of secretions

chalazion prognosis

25% resolve on their own

chalazion presentation

hard, immobile, painless nodule without redness on the upper lid

concern with recurrent chalazion

malignancy, especially sebaceous gland carcinoma

what is a hordeolum

staph infection of eyelid glands

what is a stye

external hordeolum that effects glands of zeis or moll

internal vs. external hordeolum

external: stye, affects glands of zeis or moll

internal: affects MGs

hordeolum presentation

tender, red, warm area of focal swelling on lid

inclusion cyst

lesion from trauma or surgery that appears white due to keratinous debris accumulation

milia

white lesion from the occlusion of sweat pores or pilosebaceous follicles

dermoid cyst

firm, immobile lesion of normal tissue in abnormal location

sebaceous cyst

retention of fluid in glands of zeis or debris in MGs

yellow or opaque smooth lesions

most common cause of ectropion

age-related (involutional) loss of muscle tone of orbicularis oculi

main sign of ectropion

exposure keratopathy

main cause of ectropion

age-related (involutional)

main cause of cicatricial entropion

trachoma

cicatricial means from scarring

what can entropion do to lashes

trichiasis: posterior lash growth

distichiasis: second row of lashes

what causes blindness in trachoma

corneal ulceration from entropion and trichiasis

typical floppy eyelid syndrome patient

obese man with obstructive sleep apnea

what causes floppy eyelid syndrome

reduced elastin in tarsal plate, often seen in face down sleepers

what can friction in floppy eyelid syndrome cause

papillary conjunctivitis

3 ocular conditions that cause red eyes in the morning

floppy eyelid syndrome

RCEs

exposure keratopathy

benign essential blepharospasm

idiopathic involuntary, bilateral, repetitive blinking from spasms of orbicularis, corrugator, and procerus

meige’s syndrome

benign essential blepharospasm with lower facial abnormalities (jaw pain, jaw spasms)

50% of patients with BEB

BEB vs. myokymia

BEB: idiopathic, bilateral, 3 muscles

myokymia: classic causes, unilateral, 1 muscle (orbicularis)

what is the most common skin cancer in the US

basal cell carcinoma

what is the most common eyelid cancer

basal cell carcinoma (90% of malignancies)

pathophys of BCC

malignancy of basal layer of epidermis

can be due to increased sun exposure (especially UV-B)

BCC prognosis

less than 0.1% metastasis

BCC presentation and progression

shiny, firm, pearly nodule with superficial telangiectasia

often bleeds and does not heal

common on LL

progresses into central ulceration

2nd most common eyelid cancer

squamous cell carcinoma

more common in males

pathophys of SCC

malignancy of stratus spinosum layer of epidermis

what is the precursor to SCC

actinic keratosis

most common pre-cancerous skin lesion

SCC prognosis

more aggressive than BCC, 13-24% metastasize

presentation

like BCC without telangectasia

rough erythematous plaque that can look flat or elevated

keratoacanthoma

fast growing benign tumor with central plaque or ulceration

keratoacanthoma prognosis

often grows large and then spontaneously resolves

pathophys of sebaceous gland carcinoma

neoplasm of sebaceous glands (MGs or zeis)

prognosis of sebaceous gland carcinoma

lesion greater than 2 cm has 60% mortality

overall 10% mortality rate

sebaceous gland carcinoma presentation

hard tumor with thickened, red lid margins and madarosis

often looks like chalazion

most lethal primary skin cancer

malignant melanoma

pathophys of malignant melanoma

malignancy of melanocytes (cells that produce pigment)

ABCDE of malignant melanoma suspicion

Asymmetry

Border irregularity

Color differences

Diameter (large)

Enlargement of lesion

2 most important malignant melanoma prognostic factors

depth of invasion

size of lesion

who is dacryoadenitis most commonly impacting

kids and young adults

pathophys of dacryoadenitis

inflammation of lacrimal gland (chronic or acute)

most common cause of acute vs. chronic dacryoadenitis

acute: bacteria or virus

chronic: inflammatory disease (sarcoid, TB, graves, idiopathic orbital inflammation)

what disease has 25% lacrimal gland involvement

idiopathic orbital inflammation

presentation of acute dacryoadenitis

S-shaped ptosis, upper lid pain, redness, swelling, preauricular lymphadenopathy, fever, elevated WBC count

presentation of chronic dacryoadenitis

temporal upper lid swelling with less redness, swelling, and pain than acute

can cause proptosis and globe displacement

most common cause of canaliculitis

actinomyces israelii

canaliculitis caused by a. israelii has what presentation

yellow sulfur granules expressed at canaliculi

presentation of canaliculitis

pouting punctum, tenderness of nasal UL and LL, mucopurulent discharge when palpating lacrimal sac

what to ask about with dacrycystitis

concomitant ear, nose, or throat infection

pathophys of dacryocystitis

lacrimal sac infection with NLDO, causing backflow of bacteria from NLD into the lacrimal sac

dacryocystitis swelling is below:

medial canthus tendon

if swelling is located above medial canthus tendon, suspect:

lacrimal sac tumor

chronic cases of dacryocystitis should raise suspicion for what 2 diseases

epithelial carcinoma

malignant lymphoma

is dacryocystitis or canaliculitis more painful and swollen

dacryocystitis

what should you not do during acute dacryocystitis

do not attempt to irrigate or refer for surgery until treatment has been initiated

what is acquired punctal stenosis most often caused by

older age has progressive narrowing and occlusion of puncta

most common symptom of punctal stenosis

epiphora

most common cause of NLDO in older patients

involutional stenosis

most common cause of NLDO in younger patients and prognosis

membranous blockage at valve of hasner

spontaneous opening usually occurs 1-2 months after birth

NLDO often causes secondary _______

dacryocystitis

what does a positive jones 1 test indicate

patent lacrimal system

when is jones 2 testing performed

negative jones 1 result

reflex fluid out of the same punctum being injected during jones 2 indicates

canaliculus obstruction

retrograde flow through the opposite canaliculus during jones 2 testing indicates:

nasolacrimal blockage

what is the most common cause of congenital ptosis

failure of levator muscle to properly develop

plaque

palpable flat lesion on skin more than 0.5 cm

macule

localized area of color change without elevation

ex: freckle

papule

small, palpable lesion with solid elevation usually less than 0.5 cm in size

vesicle

small fluid-filled lesion

nodule

solid area of elevated skin enlarged in 3 dimensions

aponeurotic ptosis

most common, defect in levator aponeurosis

moderate ptosis with high eyelid crease and good levator function

most commonly from aging

mechanical ptosis

ptosis due to mass or scarring

myogenic ptosis

myopathy of levator muscle

poor or absent lid crease

can be congenital or from disease (MG, myotonic dystrophy, CPEO, kearns sayre)

neurologic ptosis

innervational defect that leads to lid drooping

often from CN defects