Ophtho Disorders

Name Condition: Localized abscess of eyelid margin

Hordeolum (stye)

Most common cause of Hordeolum?

Staph aureus

External hordeolum aka what?

Stye (infection of eyelash follicle or external sebaceous glands)

Internal hordeolum: Inflammation or infection of what?

Meibomian gland

CP: Localized red, swollen, warm, tender nodule/pustule on eyelid on conjunctival surface

Hordeolum

Tx for Hordeolum

Warm moist compresses

• may add topical abx ointment if actively draining

Name Condition: Painless indurated granulomatous inflammation of internal Meibomian sebaceous gland

Chalazion

CP: Painless, localized, hard, rubbery and non-tender nodule on conjunctival surface of eyelid above eyelashes

Chalazion

Tx of Chalazion

• Conservative: eyelid hygiene and warm compresses

• Refractory: ophthalmologist referral

If tumor involves lid margin, what should be done by oculoplastic specialist only to avoid deformity of the lid?

Excision

Common types of tumors on eyelids (4)

BCC, SCC, Meibomian gland CA, Malignant melanoma

Name Condition: Inflammation of eyelid margins

Blepharitis

What is the most common type of Blepharitis?

Posterior

What is Posterior blepharitis caused by?

Meibomian gland dysfunction

What are the 2 types of Anterior Blepharitis?

1. Infectious

2. Seborrheic

Inflammation of eyelid skin and base of eyelashes

MC bug of Blepharitis?

Staph aureus

CP: Burning, erythema, crusting, scaling and red rimming of eyelid; gritty sensation and flaking on lashes or lid margins

Blepharitis

Tx of Blepharitis

1st line = Eyelid hygiene

• Severe or Refractory: ophtho mgmt

• For flares: Bacitracin, Erythromycin, Azithromycin

• Long term: Doxy

Name Condition: Inward (inverted) turning of eyelid and lashes

Entropion

Entropion is most commonly seen in who?

Elderly w degeneration of lid fascia

Tx for Entropion

Lubricating eye drops and moisture

Sx correction if needed

Name Condition: Outward (everted) turning of eyelid and lashes d/t relaxation of orbicularis oculi muscle

Ectropion

Ectropion is most commonly seen in who?

Elderly (tend to be bilateral)

• can be congenital, infectious or part of CN 7 palsy

Tx for Ectropion

Lubricating eye drops and moisture

Sx correction if needed

Name Condition: Aka “blocked tear duct”

• common in infants

• tearing

• often resolves spontaneously w growth

Congenital nasolacrimal duct obstruction

Tx for Congenital nasolacrimal duct obstruction

• Probing of nasolacrimal system if necessary

• No Abx unless develops redness and tenderness → Dacryocystitis

Name Condition: Infection of lacrimal sac often d/t obstruction of nasolacrimal duct

Dacryocystitis

Acute CP: Unilateral tearing (epiphora) and signs of infection → pain, tenderness, edema, erythema and warmth to inferior medial canthal (nasal) side/lower lid area; may have purulent discharge

• Chronic CP: Mucupurulent drainage from puncta

Dacryocystitis

MC bugs of Acute Dacryocystitis

Staph aureus, Strep pneumo

Tx of Dacryocystitis

• Acute: warm compresses + systemic abx

  • Mild: Clina, Cefuroxime, Cefazolin

  • Severe: IV Vanc + Ceftriaxone

• Chronic: Dacryocystorhinostomy

What condition is commonly misdiagnosed as hordeolum?

Dacryocystitis

Name Condition: Inflammation of lacrimal gland

Dacryoadenitis

Name Subtype of Dacryoadenitis: Inflammation >1 mo caused by noninfectious inflammatory disorders (Sjogren, sarcoidosis, thyroid eye dz)

Chronic Dacryoadenitis

Name Subtype of Dacryoadenitis: Usually infectious

Acute Dacryoadenitis

MC bug of acute Dacryoadenitis

Staph aureus

CP: Soft tissue swelling or fullness, erythema, and tenderness, esp localized in region of lateral (outer 1/3) upper lid

Dacryoadenitis

CP of subtype of Dacryoadenitis: Intense severe eye discomfort, tenderness and erythema

Bacterial Dacryoadenitis

Tx of Chronic Dacryoadenitis

Mgmt of underlying systemic disorder

Tx of Bacterial Dacryoadenitis

• mild: Cephalexin, TMP/SMX, Amox-Clav

• severe: IV Nafcillin, IV Amp-sulbac, IV Vanco (if MRSA)

• viral: supportive, resolves spont.

Name Condition: Mumps of lacrimal gland

Endemic parotitis

Name Condition: Congenital or acquired nasolacrimal duct narrowing or obstruction

Dacryostenosis

CP:

• Excessive eye watering (epiphora), eyelashing matting, thick & yellow tears

• Lack of accompanying signs or sxs of infx (fever, conjunctivitis)

• Palpation of lacrimal sac may cause reflux of tears

Dacryostenosis

Diagnosis of Dacryostenosis

Lack of normal Fluorescein clearance (accumulates after 5 min)

• clinical dx

Tx of Dacryostenosis

• Conservative mgmt: Crigler (lacrimal sac) massage (gentle massage in downward motion to nasolacrimal duct 3-4 times/day to promote drainage)

• Lacrimal probing if >6-10mo

• Ophtho referral if >12mo

Name Condition: Slow growing thickening of bulbar conjunctiva that remains confined to conjunctiva

• consists of fat, protein and calcium

Pinguecula

CP: Grey, white yellow slightly elevated nodule (mass) MC on bulbar conjunctiva

• does NOT grow onto cornea

• visual actuity unaffected

Pinguecula

Tx for Pinguecula

No tx needed

• resection if chronically inflamed or cosmetic concern

Name Condition: Slow-growing thickening of bulbar conjunctiva tissue that may extend onto corneal surface

Pterygium

CP: Elevated, superficial fleshy, triangular-shaped growing fibrovascular mass that usually starts medially (nasal side of eye) and extends laterally

• often bilateral

Pterygium

Risk factors of Pterygium

• Outdoor exposure assoc w UV exposure in tropics, sand, wind, dust

• Use hats and sunglasses to reduce incidence

Tx of Pterygium

• Supportive: Artificial tears (top. lubricants)

• Sx removal if growth affects vision

MC bug of Bacterial Conjunctivitis

Staph aureus

CP:

• Purulent or mucopurulent ocular discharge, usually thick, globular and painless

• No itching

• Conjunctival erythema, ocular irritation and tearing

• Lid crusting have “stuck shut” appearance

• Vision normal

• Polymorphonuclear leukocytes

Bacterial Conjunctivitis

Diagnosis of Bacterial Conjunctivitis

Clinical → fluorescein staining to look for keratitis or corneal abrasions

Tx for Bacterial Conjunctivitis

• Self-limiting, Abx if given before day 6

• Non-contact wearers: Erythromycin ophthalmic ointment or Trimethoprim-polymyxin B drops

• Contact wearer: Ciprofloxacin, Ofloxacin, Moxifloxacin (cover Pseudomonas)

Name Condition: Hyperacute bacterial conjunctivitis

Gonococcal Conjunctivitis

Gonococcal conjunctivitis is caused by what bug?

N. gonorrhoeae

CP: Profuse (copious) purulent discharge of striking amt

• marked chemosis (conjunctival edema), eyelid swelling and tender preauricular adenopathy

Gonococcal Conjunctivitis

Diagnosis of Gonococcal conjunctivitis

Giemsa and Gram stains

Is N. gonorrhoeae gram pos or neg?

Gram neg

Tx for Gonococcal conjunctivitis

• Emergent ophtho eval, top and systemic abxs

• Systemic abx: Single 1g IM Ceftriaxone + tx for Chlamydia

  • severe: IV Ceftriaxone

• Top abx: FQ, saline irrigation

MC source of transmission of Viral conjunctivits

Swimming pools

MC bug of Viral conjunctivitis

Adenovirus

CP: Watery or mucoserous discharge

• starts unilateral → bilateral w/in 24-48h

• lid crusting w “stuck shut” appearance

• cobblestone mucosa

• no/mild itching; node involvement

• mononuclear cells

PE: Ipsilateral enlarged and tender preauricular LAD

Viral conjunctivitis

Tx for Viral conjunctivitis

Mainstay: self-limited, supportive

• warm/cool compresses, artificial tears, antihistamines (Olopatadine), top antihistamines w/ decongest. (Pheniramine-Naphazoline)

Name Condition: Inflammation of conjunctive in response to contact w an allergen → type I (IgE) rxn → local mast cell degranulation, release of histamine

Allergic conjunctivitis

CP:

• Bilateral conjunctival erythema, clear, watery, mucoserous or scant stringy discharge w no sig visual changes

• Marked ocular pruritus

• Hx allergic s/s or atopy, mild/intense itching

• Eosinophils

PE: cobblestone mucosa, watery or mucoid stringy discharge, chemosis (conjunctival erythema), eyelid edema

Allergic conjunctivitis

What CP distinguishes allergic conjunctivitis from viral?

Marked ocular pruritus

Tx for Allergic conjunctivitis

• Mainstay: supportive (self-limited)

• Top. antihistamines (H1 blockers): Olopatadine (antihistamine/mast cell stabilizer), Pheniramine-Naphazoline (antihistamine & decongest)

Name Condition: Neonatal conjunctival infx contracted by newborns during delivery

Ophthalmia neonatorium (neonatal conjunctivitis)

Day 1: Chemical conjunctivitis is d/t what?

Silver nitrate (AgNO3)

2-5 days after birth: MC bug

Gonococcal

CP: Profuse exudate and eyelid swelling

2-5d after birth (Ophthalmia neonatorum)

Tx for Gonococcal neonatal conjunctivitis (2-5d)

Single dose IM or IV Ceftriaxone

• Prophylaxis: top. Erythromycin

Tx for Day 1 (Ophthalmia neonatorum)

Artificial tears

5-7d after birth, MC bug

• can develop PNA

Chlamydia trachomatis

Tx for 5-7d after birth (Ophthalmia neonatorum)

Azithromycin, Erythromycin

Prophylaxis of Ophthalmia neonatorum

• Erythromycin ointment 0.5% for gonococcal conjunctivitis

• Best method: Maternal screening and tx of Chlamydial infx

Name Condition: Mild infx of eyelid and periocular tissue anterior to orbital septum

Periorbital (Preseptal) cellulitis

MCC of Periorbital preseptal cellulitis

Sinusitis or eyelid infx (S. aureus)

CP: Unilateral ocular pain, erythema, edema of eyelid

Periorbital (Preseptal) cellulitis

Diagnosis of Periorbital Preseptal cellulitis

Clinical → absence of proptosis, chemosis, ophthalmoplegia (extraocular muscle weakness), ocular pain w extraocular movement distinguishes Preseptal from Postseptal

• CT or MRI if dx is uncertain

Tx for Periorbital (Preseptal) cellulitis

Outpt (>1yo, mild):

• absence of trauma: Amox-clav or Cephalexin

Inpt (<1yo, severe): CT, IV broad spectrum abx

Name Condition: Serioud infx of orbit (fat & ocular muscles) posterior to orbital septum

Orbital (Postseptal) cellulitis

Etiology of this condition: MC secondary to sinus infxs (Ethmoid sinusitis)

Orbital (Postseptal) cellulitis

CP: Ocular pain w/ eye movements, ophthalmoplegia, diplopia, proptosis (bulging), visual changes

• eyelid edema &/or erythema

Orbital (Postseptal) cellulitis

Diagnosis of Orbital (Postseptal) cellulitis

High Resolution CT → infx of fat & ocular muscles behind septum

Tx for Orbital (Postseptal) cellulitis

Admit + IV Vanco + Ceftriaxone or Cefotaxime

• Metronidazole or Clinda can be added for anaerobic coverage

Orbital (Postseptal) cellulitis is MC in what age group?

Children 7-12yo

Which is more common: Preseptal cellulitis or Orbital cellulitis?

Preseptal cellulitis

Name Condition: Foreign body in eye and Abrasion of cornea

Ocular foreign body & Corneal abrasion

CP: Excruciating eye pain, foreign body sensation, photophobia, blurred vision, tearing, erythema, blepharospasms

Ocular foreign body & Corneal abrasion

Diagnosis for Ocular foreign body & Corneal abrasion

• Check visual acuity first (usually normal or blurring of vision)

• Fluorescein staining: corneal abrasion (“ice rink”/linear) & epithelial defect w increased fluorescein uptake but no infiltrate or conreal opacity seen

• Pain often relived w/ instillation of ophthalmic anesthetic drops (Proparacaine, Tetracaine) → use one time

Tx for Ocular foreign body & Corneal abrasion

24h ophtho f/u + abx drops

• non-contact: Erythromycin ointment

• contact: Ciprofloxacin, Ofloxacin

CI for Ocular foreign body & Corneal abrasion

Do NOT patch if P. aeruginosa infx is suspected

• abx w/ corticosteroids are NOT permitted bc they can prolong healing, increase susceptibility to superinfection

Name Condition: Blood btw conjunctiva and sclera

• generally asymptomatic

• causes: spontaneously, minor trauma, Valsalva assoc w coughing, sneezing, straining or vomiting

• vision normal

Subconjunctival Hemorrhage

Tx for Subconjunctival Hemorrhage

Self-limiting, harmless

Name Condition: Grossly visible layering of blood in anterior chamber of eye (gross fluid level)

• decreased visual acuity

Hyphema

MCC of Hyphema

Trauma (blunt or penetrating injury to eye)

Diagnosis of Hyphema

• r/o visual/life threatening injuries (globe rupture, orbital compartment syndrome)

• CT w/o contrast if globe rupture suspected, check IOP