conjunctiva, lacrimal, and lip disorders

what is the conjunctiva

the mucous membrane that lines the inside surface of the eye lids and covers the surface of the globe up to the limbus

what is the limbus

the junction of the sclera and the cornea

the portion of the conjunctiva covering the globe

bulbar conjunctiva

the portion of the conjunctiva lining the eye lids

tarsal conjunctiva

what is the most common eye disease

inflammation of the conjunctiva (conjunctivitis aka pink eye

possible causes for acute conjunctivitis and whats more common

viral or bacterial (viral is more common)

most common viral cause of conjunctivitis

adenovirus

symptoms of viral conjunctivitis

redness (conjunctival injection), morning crusting, watery discharge w scant or serous discharge, feels like something is stuck in their eye, bilateral withing 24-48hrs, symptoms worsen for first 3-5days then slowly improve over 1-2wks

benign and self limiting conjunctiva infection thats easily treated but neeed to make sure to rule out more serious stuff when diagnosing

viral conjunctivitis

what causes bacterial conjunctivitis in adults

staph aureus

what causes bacterial conjunctivitis in kids

strep pneumonia, haemophilus influenzae, moraxella catarrhalis

how is bacterial conjunctivitis spread

highly contagious, spread by direct contact w secretions or contaminated objects/surfaces

bacterial conjunctivitis symptoms

yellow/green thick purulent discharge, unilateral redness and discharge (sometimes bilateral), eye “stuck shut” when waking

hyperacute bacterial conjunctivitis cause

neisseria species (N. gonorrhoeae)

how is hyperacute bacterial conjunctivitis transmitted

direct contact from genitalia to hands to eyes

hyperacute bacterial conjunctivitis symptoms

profuse purulent discharge within 12hrs of inocculation, redness, irritation, tender to palpation, chemosis, lid swelling, tender preauricular adenopathy

what is chemosis

swelling or edema of the conjunctiva due to the oozing of exudate from extra permeable capillaries

nonspecific sign of eye irritation, conjunctiva becomes swollen and gelatinous looking

how do you diagnose hyperacute bacterial conjunctivitis

gram stain of discharge will see gram negative diplococci

what do you do if you see a pt w hyperacute bacterial conjunctivitis

immediate opthalmologic referral

cause of allergic conjunctivitis

airborn allergen contacting eye, IgE from mast cells

triangular wedge of fibrovascular conjunctival tissue

pterygium

where does pterygium start

starts medially on nasal conjunctiva and extends laterally onto cornea

a non cancerous conjunctiva issue that just has cosmetic concerns but may lead to slight vision blurring if it crosses the cornea, associated w chronic sun exposure (seen more in old men who work outside)

pterygium

pterygium symptoms

mild redness adn irritation, may not notice until it appeas white against the iris, vision impairment is less common and happens when it crosses the cornea, not an urgent concern and pts normally wait to get treatment until it affects ADL

a degenerative eye condition thats often confused w pterygium

pinguecula

an infection of the lacrimal sac due to congenital or acquired obstruction of the nasolacrimal system

dacryocystitis

who gets dacryocystitis

infants (nasolacrimal duct gets obstructed) or adults over 40

acute causes of dacryocystitis

staph aureus or strep

chronic causes of dacryocystitis

staph epidermidis, strep, gram neg bacteria

most common cause of congenital nasolacrimal duct obstruction

incomplete canalization at the distal end (ie, closest to the nose), leaving an imperforate membrane at the valve of Hasner

eyelid disorders

blepharitis, hordeolum, chalazion, ectropion, entropion

modified sebaceous glands located within the tarsal plates of the eyelids and responsible for the secretion of the oily layer of the tear film

meibomian glands

function of the oily layer of the tear film

prevents tear evaporation, reduced surface tension of the tear layer and facilitates the spread of tears, and is critical for normal eye lubrication

commonly inc in pts w underlying skin conditions

hordeolum

hordeolum cause

staph aureus or can be sterile (ACUTE)

why is hordeolum seen more in pts w underlying derm issues like rosacea or seb dermatitis

bc overproduction/ blockage of gland can be caused by derm issues (either bc of inflammation or secretions block the glands)

granulomatous inflammation of Zeis or meibomian glands (CHRONIC)

chalazion

allergic conjunctivitis symptoms

itching (cardinal symptom), bilateral redness, profuse watery or mucoserous discharge

pt comes to clinic complaining of both eyes being itchy, watery eyes everytime they go outside in the spring. what is this and what antibody is it mediated by

allergic conjunctivitis, IgE mediated

noninfectious, nonallergic conjunctivitis cause

mechanical or chemical

examples of noninfectious, nonallergic conjunctivitis

dry eye (can cause chronic or intermittent redness or discharge, seen in v windy/hot places)

chemical splash (redness and discharge due to mechanical irritation of washing out chemical)

spontaneously expelled ocular foreign body (redness and discharge for 12-24hrs)

how long does noninfectious, nonallergic conjunctivitis normally last

normally improve on their own within 24hrs

conjunctivitis differentials

keratitis, iritis, angle closure glaucoma (immediate optho referral), hordeolum, blepharitis, foreign body, pterygium, pseudomonal keratitis (contact lens wearers)

how is conjunctivitis diagnosed

diagnosis of exclusion, take a culture of the discharge (for hyperacute conjunctivitis), rapid test for adenoviral conjunctivitis

since conjunctivitis is a diagnosis of exclusion what do we need to exclude to make the diagnosis

need normal vision, no evidence of keratitis, iritis, or angle closure glaucoma, and no focal pathology in the lids like hordeolum or blepharitis

what is the disease course for viral, allergic, and nonspecific conunctivitis

self limited, dont need treatment, specific therapy can reduce symptoms but doesnt alter length of time

what is the disease course for bacterial conjunctivitis

self limited (8-14days) BUT topical antibiotic eye drops can shorten clinical course if given before day 6

viral conjunctivitis treatments

no specific antiviral agent, topical antihistamine/decongestants (naphazoline or naphazoline-pheniramine) or non-antibiotic lubricating agents for symptomatic relief, warm/cool compress, tell ot irritation and discharge will get worse for 3-5 days before it gets better (may last up to 2wks)

the med is used to temporarily relieve eye redness, puffiness, itching and watering often seen in allergies

naphcon A and Ocuhist

a decongestant (sympathomimetic amine) that works by temporarily narrowing the blood vessels in the eye

Naphazoline

an antihistamine that works by blocking histamines

pheniramine

bacterial conjunctivitis treatment

erythromycin opthalmic ointment (llotycin), trimethoprim-polymyxin B (polytrim) or fluoroquinolone for contact lens wearers

if you have a pt w bacterial conjunctivitis who would we prescribe ointment to over eye drops

kids, ppl w poor compliance or ppl who have a hard time administering eye meds BUT ointments can blur vision for 20 min so be aware

nonallergic conjunctivitis treatment

normally resolves on its own, OTC topical lubricants for symptom relief

why would you prescribe antibiotics for conjunctivitis

reduces spread (only if its bacterial) but mostly bc most schools require kids get 24hrs of topical therapy before they can come back to school

what can happen if pterygium crosses the cornea

induce astigmatism causing blurry vision

over 3.5mm o(over halfway over pupil center) = significant blurring

over45% of the corneal radius may affect the visual axis and the resultant opacity can impair visual acutiy

pterygium treatment

only symptomatic relief (OTC topical lube, topical decongestants, NSAIDS and glucocorticoids), cant stop progression or cause regression

can use surgery if lesion is big and hurts visual acuity, but dont doi it for cosmetic resions cause itll prob reoccur

pinguecula symptoms

yellowing slightly raised conjunctival lesion that doesnt involve the cornea, gap between pinguecula and edge of cornea

why is there no concern for visual impairment in pinguecula

bc it doesnt cross the cornea

pinguecula treatments

symptomatic management (OTC topical lube, topical decongestants, NSAIDS and glucocorticoids)

dacryocystitis symptoms

redness, swelling, war,, tenderness of lacrimal sac, maybe purulent discharge. commonly occurs w dacryocystoceles

chronic dacryocystitis cause

bacterial overgrowth in the stagnant tear pool of the lacrimal sac (will see mucopurulent drainage from puncta but no other signs of infection)

what do we do w dacryocystitis

refer to ophthalmology start w emperic systemic antibiotic therapy (mild=oral clindamycin, severe= (IV vancomycin and 3rd gen cephalosporin), get blood and drainage cultures

causes of bacterial keratitis

staph aureus, pseufomonas aeruginosa, coagulase-neg staph, diphtheroids, strep pneumoniae most often bc of overnight contact lens use

bacterial keratitis symptoms

feels like theres something in your eye, hard to keep eye open, round white spot on eye, red eye, photophobia, infiltrate or ulcer can be seen w penlight, stains w fluorescein, mucopurulent discharge

what does the presence of a corneal infiltrate indicate

lots of wbc’s in corneal stroma

nor all corneal infiltrates are corneal ulcers

if its a true corneal ulcer or infectious keratitis what will you see

loss of corneal tissue bc pathogen produces an enzyme that breaks down/destruction of corneal tissue (OCCULAR EMERGENCY) (ulcer=loss of tissue)

how do we diagnose bacterial keratitis

put fluorescein dye in eye and itll light up under UV light

bacterial keratitis treatment

refer to ophthalmology, topical antibiotics (4th gen fluroquinolone like gatifloxacin or moxifloxacin)

viral keratitis cause

herpes (HSV)

viral keratitis symptoms

red eye, photophobia, foreign body sensation, watery discharge, faint branching grey opacity on penlight exam thats best seen w fluorescein

HSV keratitis treatment

refer to optho, often self limiting, topical or oral antivirals (ganciclovir drops or oral acyclovir)

chalazion symptoms

nontender, nonpainful rubbery nodule on the ipper or lower lid, less erythema, might distort vision if its big

chalazion treatment

most resolve w/o treatment in a few days-wks, warm compress

if its persistent or recurring refer to to ophth and do assessment to see if its cancer

difference between hordeolum and chalazion

hordeolum- painful internal or external infection

chalazion- non painful inflammation

a common and chronic recurrent inflammatory condition of the eyelid margin near the meibomian glands, more common posteriorly than anteriorly

blepharitis

hyperkeritinization of the gland epithelium → altered secretions promotes staph growth, strong association w rosacea and seborrheic dermatitis

posterior blepharitis

inflammation at the base of the eyelashes, either from staph or in association w seborrhea on the face

anterior blepharitis

blepharitis symptoms

red, swollen itchy eyes, gritty or burning sensation, excessive tearing, crusting or matting of eyelashes esp in morning, flaking or scaling of the eyelid skin, light sensitivity, blurred vision that improves w blinking

blepharitis treatment

good lid hygine, warm compress, wash lids w dilute baby shampoo, artificial tears

if that does work try topical bacitracin, erythromycin or ciprofloxacin on eyelids or oral tetracycline, doxycycline, minocycline, erythromycin and topical glucocorticoids

when should you refer blepharitis to optho

refractoy symptoms, severe redness pain or light sensitivity, impaired vision, corneal abnormalities or if youre worried about cancer

degenration of the lid fascia often on the lower lid and normally in old ppl (refer to ophth)

entropion

outward turning of the lower lid, seen in old ppl

ectropion

entropion treatments

surgery if lashes rub on cornea, or botox for temp correction

ectropion treatments

surgery when theres excessive tearing, exposure keratitis or its a cosmetic concern