Anterior Segment Lecture 3

Fat is only in the located in the ___ portion of th eyelid skin

orbital

Horner's muscle

Deep palpebral fibers that wrap around the lacrimal canaliculi

move tears

Riolan's muscle

at lid margin around both sides of each meibomian gland openings

maintains lif globe congruity

espress meibum

Gray line

Gray line

divides lid into aterior and posterior

Superior Levator Muscle

retract upper eyelids

1. Ligaments

form sleeve around SPL and changes its direction to superoinferior

superior transverse ligament (Whitenall's)

Intermusclar transver ligament

2. Levator Aponeurosis

fan like tendinous expansion of the SPL

pierces the orbital septum and attaches to superior tarsal plate

attachment to skin and orbicularis = upper lid crease

3. Tarsal Muscle of Muller

posterior inferior expasion of the SPL

smooth muscle with sympathetic autonomic innervation

Inferior Rectus Muscle

1. Capsulopalpebral Fascia (lower lid aponerousis)

extension of the inferior rectus muscle sheath and inferior suspensory ligaments

retract the lower lid

(like aponerosis)

2. Inferior tarsal muscle

Extension of inferior rectus muscle sheath inserting into lower palpebral conjunctiva and lower tarsal plate

smooth muscle with sympathetic autonomic innervation

(like muller muscle)

orbital septum

barrier

separates the anterior and posterior extend of the orbit

continuous with periorbital and periosteum of the orbital rim bones

Zeis glands

sebaceous glands

coats lash follicles with sebum

Moll glands

sweat (apocrine) glands

Meibomian glands

sebaceous glands

embedded in tarsal palte

secrete meibum which forms lipid ayer of tear film

Accessory lacrimal glands

Sectrtions contribute to aqueous layer of the tear film

Wolfring Glands

Kruse glands (fornix)

Look at blood supply

Hordeolum Symptoms

Tender

painful

warm

red

swollen

acute onset

Hordeolum signs

Visible palpable, well defined subcutaneous nodule

may be one or multiple

Hordeolum Etiology

inflammation of the sebaceous glands due to bacterial infection

95% due to staph. aureus

Staphylcoccus epidermidis

both gram (+)

Hordeolum Epidemiology

common

affects every age and demographic

30-50

females>males

Hordeoulm risk factors

blepharitis

ocular rosacea

meibomian gland dysfunction

immunocompromised states

poor eyelid hygiene (excessive makeup)

External hordeolum

infection of glands of zeis and moll

Internal hordeolum

infection of meibomian gland

Differential of Hordeoulum

Chalazion (painless)

Orbital cellulitis (proptosis, double vision)

preseptal cellulitis (entire periorbital region)

sebaceous cell carcinoma (recurrent chalazion, eyelid thicking, loss of lashes, non acute)

Hordeolum treatment

warm compress with digital massage 10 min session x4/day

internal hordeolum treatment

Oral abibiotic

follow up 7-10 days

External hordeolum treatment

topical antibiotic

or topical antiobiotic steroid combo

follow up 7-10 days

Hordeolum Antibiotic treatment

Cephalexin (Keflex) 500 mg

take 1 capsule BID by mouth for 7-10 days

Augmentin 500 mg take 1 capsule BID by mouth for 7-10 days

Doxycycline 100 mg take 1 capsule BID by mouth for 7-10 days

Cephalexin (Keflex)

Bactericidal

Gram (+)

Contra: Warfarin

ADR:

Steven Johnson Syndrome

X-sensitivity with penicillin

Augementin

Bactericidal

Gram (+) and some (-)

ADR:

Steven Johnsons

Z-sensitivity with Cephalosporin

Doxycycline

Bacteriostatic

Gram (+)(-)

Contra: children less than 8 and pregnancy

bone rgowth and tooth discolotation

ADR: Photosensitivity

Psuedotumor cerebri

Topical Antibiotic

Erythromycin 0.5% ophthalmic ointment apply over lesion BID for 2 weeks

Tobradex 0.3-0.1% apply over lesion BID x2 weeks

Erythromycin

Bacteriostatic

gram (+)

Very safe

Tobradex (tobramycin/dexamethasone)

bactericidal

Gram + and -

contra: Glaucoma

ADR: Delayed corneal healing

IOP spike

post. subcapsular cataract

Chalazion Symptoms

painless

bump

few moths

Chalazion signs

palpable solid bump

mildly red

non tender !!!

not warm

Chalazion etiology

obstruction of the sebaceous gland with resultant lipogranuloma formation

seconday to hordeolum

Chalazion epidemiolgy

common

affects every age

30-50

Females=males

Chalazion risk factors

blepharitis

ocular rosacea

meibomian gland dysfunction

use of Velcade for multiple myeloma

Chalazion differentials

Hordeolum ( acute, focal pain)

Orbital cellulitis (proptosis, diplopia, pain)

Preseptal (redness of entire lid)

sebaceous cell carinoma (recurrent chalazion, eyelid thickning, loss of lashes)

Chalazion: Treatment (Conservative)

Warm compress with digital massage 10 min session x4day

Chalazion: Treatment pharmaceuticals

Doxycycline 20 mg BID Po x 4 weeks FU Few weeks

Tobradex 0.3-0.1% apply over lesion BID x2 weeks FU few weeks

Chalazion treatment (invasive)

no improvement with conservative mangement or large and chronic

1. intralesional steroid injetion

2. incision and curettage

Preseptal Cellulitis symptoms

Painful

red

swollen

"i had____"

insect bite

stye

sinus infection

cut to skin

Preseptal Cellulitis signs

eyelid red

warm ad tender to touch

Possibly swollen shut

Preseptal Cellulitus etiology

inflammation of the periorbtial tissue anterior to the orbital septum

bacterial infection (S. aureus)

from another adjacent infection such as hordeoulm, sinitis, or injury

Preseptal Celllulitis epidemiology

more common in youn adults and children

more common than orbital cellulitis

no specific race or gender

Preseptal Celllulitis Risk factors

hordeolum

dacrocystitis

upper respiratory tract infection/sinitis

trauma

Preseptal Celllulitis Differentials

Hordeoulm (acute, painful, nodule)

Orbital cellulitis (proptosis, double vision, and pain)

contact dermitis (nontender, itchy, alelrgic reaction)

sebaceous cell carcinoma ( recurrent chalazion, thickineing, loss of lashes)

Pre-septal Cellulitis: treatment

oral antibiotic

Augementin 875mg take 1 capsule BID by mouth for 7-10days (higher dosing than hordeolum)

Sulfamethoxazole/Trimethoprim (Bactrim) 800 mg/160mg take 1 capsule BID by mouth for 7-10 days

(if alelrgic to penicillin or exposure to MRSA)

Sulfamethoxazole/Trimethoprim (Bactrim) contraindicaitons

sulfa allergy

pregnancy

Preseptal Cellulitis follow up

daily

Preseptal Cellulitis : no improvement or worsening of s+s

admit to hospital for orbtial CT scan and switch to IV antibiotics

Ocular Rosacea: signs and symptoms

eyelid/facial telangectasia

ttearing

FB senstion

irritation

burning

Flares on and off with

alcohol

spciy foods

caffeine

hot weather

sunlight

Ocular Rosacea etiology

auto immune mediated chronic inflammatory disorder

blood vessel dilaiton

leakage of inflammatory substances into the skin

Ocular Rosacea Epidemiology

Northern European ancestoery

2-3x more common in females

20% have ocular rosaces without cutaneous rosacea

Ocular Rosacea risk factors

associated triggers: alcohol, spicy food , heat, sunlight, caffeine

Possible correlation with Demodex Folliculorum or H pylori

Ocular Rosacea Slit lamp examination

- Telangiectatic vessels at lid margin

- associated Meibomian gland dysfunction and demodex blepharitis

- Corneal disease (Keratitis, pannus)

Ocular Rosacea Gross examination

May have rhinophyma

- associated with cutaneous rosacea

- more seen in men

Ocular Rosacea differetials

Preseptal cellulitis (pain, entire eyelid)

Lupus Erythmatosis ( malar rash, multiorgan dysfunction)

Contact dermititis (nontender, itchy, allergic)

Atopic Dermatitis (scaly, pathcy, and discolration of skin)

Ocular rosacea treatment

Educate on avoiding triggers

Eyelid Hygiene (treat secondary demadox belph)

Oral Antibiotic

Intense Pulse Therapy (IPL)

Oral Antibiotic for ocular Rosacea Low Maintenance Dose

Low Maintenance Dose

Doxycycline 20 mg take 1 capsule BID by mouth for 3-4 months

anti inflammatory action

decrease MMP

Anti-angiogenic

Oral Antibiotic for ocular Rosacea Acute Dose

Doxycycline 100 mg take 1 capsule BID by mouth 3-4 weeks

Intense Pulsed Light Therapy (IPL)

- non-laser high intensity light

Light absorbed by tissue is converteed to heat destroying telangiectiasia but not surrounding tissues

Intense Pulsed Light Therapy (IPL) contraindications

darker skin tones at higher risk of complications (Fitzpatrick skin type scale)

Photosensitivizing medications (Doxy) *******

Allergic Contact Dermatitis signs and symptoms

Eyelids are

puffy

red

ithcy

tearig

FB sensation

Came in contact with ____ a few days ago

Erythema, flaking, crusting rash, edema

ocular surface involvement: conjunctival chemosis

Allergic contact dermatitis etiology

acute inflammation caused by an immunologic hypersensitivity to an allergic stimulus

Common ingredients

Ophthalmic drops

Airborne and aerosolized ingredients

Plan and animal protein

Allergic contact dermatitis Epidemiology

higher in females (jewlry, makeup, fragrances)

affects all demographics but may be higher in fairer skin

Allergic contact dermatitis risk factors

age (infants, elderly)

occupation (exposer to allergens)

history of atropic dematitis (more breaks in skin)

Allergic contact dermatitis pathophysiology

delayed/cell mediated type 4 hypersensitivity reaction

48-72 hours after exposure

T cells must be sensitized first

Allergic Contact Dermatitis Differentials

- Herpes zoster ( painful, unilateral)

Preseptal Cellulitis (pain,s welling entire lid)

Ocular Rosacea (telectasia of eyelid margin)

Atopic dermatis (chronic, scaly patches)

Allergic contact dermatitis Treatment

Identify ad remove inciting agent

cold compresses, several times daily

Allergic contact dermatitis Treatment IF crusted/weeping lesions

Prophylaxis antiobiotic

Erythromycin 0.5% ung QHS OU along eyelids for 1 week

Contact dermatitis treatment

FML 0.1 BID 7-10dats Taper to QD for 1-2 weeks

Corticosteroid

OR

Tacrolimus 0.03% -0.1% BID to affected area 7-10 days

FML contraindicaitons

IOP pressure spike

post. subcapsular cataract

Tacrolimus contraindications

Macrolide allergy

Children <2

Pregnancy

Immunocompromised

BBW: Cancer

Atopic Dermatitis signs and symptoms

Acute: red crusting blisters

Chronic: Diffuse dry, sclay, itchy pacthes of skin

Discoloration

Leathery and lichenified

Dennie Morgan Folds and allergic shiners

remission and relapse

"on and off"

" flares up"

Atopic Dermatitis Etiology

Genetic and environmental factors

Atopic triad: atopic dermatitis, allergic rhinitiis, asthma

Atopic Dermatitis epidemiology

starts in ifacncy

80% affected before age 6

REmission periods with relpase in adult hood

40% have concurrent atopic keratoconjunctivitis

Atopic Dermatitis Risk factors

Family history

genetic mutation that predisopes for imapired skin barrier

enviormental exposures

Atopic Dermatitis Pathophysiology

defect skin battier

over expression of Type 2 Hel[er cells and IgE

Atopic Dermatitis Differntials

Seborrheic Anterior Belph ( scaling of eyelid margin only)

Psoriasis (well defined patches)

Ocular Rosacea (teliectasia)

Allergic Contact dermititis (acute, purely allergic reaction)

Atopic dermatitis treatment

Treat ocular complications as needed

consult dermatology for non-ocular AD

consider treating periorbital AD

Atopic Dermatitis if crusting and weaping lesions

Erythromycin 0.5% ung QHS OU along eyelids for 1 week

FML 0.1 BID 7-10dats Taper to QD for 1-2 weeks

OR

Tacrolimus 0.03% -0.1% BID long term but not to exceed 6 weeks

Blepharochalasis signs and symptoms

acute phase: painless edema of the upper eyelid margins

Chronic phase: wrinkled redundant, thinned eyelid skin

relapsing and remitting edema

3-4x year

Blepharochalasis etiology

idiopathic recurrent episodes of painless edema of upper eyelids with and without redness/ithcing

may be part of larger syndrome or disease

related to hormonal changes during puberty

Blepharochalasis Epidemiology

Rare

Females>males

Onset before 30

Blepharochalasis Risk factors

hormonal changes

genetic predisoption

Blepharochalasis pathophysiology

unclear inflammaotry mediated etiology

IgA deposits noted within periorbital tissue with increased elastolysis actovity

Blepharochalasis Differentials

Dermatochalasis (age related, increased laxity)

Preseptal cellulitys (painful, swelling, redness of entire lid)

Hordeolum (acute, focal, painful

Allergic Contact dermitis ( allergic rxn, ithcy)

Blepharochalasis treatment: acute phase

FML 0.1% BID OU for 7-10 days

Taper to QD OU for 1-2 weeks

Follow up 2-4 weeks

Repeat when reactivates

Blepharochalasis treatment: chronic phase

surgical blepharoplasty once quiescent for at least 2 years

Vitiligo

absence of melanin in skin

Poliosis

absence of melanin in hair follicles of eyelashes and eyebrows

Associated conditions

- Vogt-Koyanagi- Hardara Syndrome (VKH)

- Tuberous sclerosis complex

- Waardenburg's syndrome