Self-Care II Exam 1: Eye Care (Sharma)

Anterior Blepharitis:

• _______ by _______

• May alter _______ secretion due to:

  • _______

  • _______-mediated immune reaction to staphylococcal _______

  • Provoke _______ to staphylococcal _______

  • Combination of these mechanisms

• _______, _______ folliculoris and _______, are typically present on eyelids of patients with blepharitis and its role is implicated in the pathophysiology. 

• Patients with mites show _______.

Lid-colonization, Staphlococcus aureus, meibomian gland, direct infection, cell, exotoxin, allergic response, antigens, Mites, Demodex, D Brevis, collarettes

Posterior Blepharitis: 

• Exact pathophysiology is unknown

• Possibly _______ of _______

• _______ may cause the formation of free FAs by digesting _______. This increases the _______ of meibum preventing its expression from the glands → possibly facilitate _______ of Staphylococcus

unknown, staph infection, meibomian gland, bacterial lipase, meibum, MP, growth

_______ Blepharitis:

• Symptoms usually worse in the _______

• _______ Blepharitis

  • Hard scales + crusting around eyelash bases, called collarettes scarring and notching of the lid margin, trichiasis (misdirected eyelashes), loss of lashes or pigmentation of lashes in severe long-standing cases

  • Frequent with:

    • Eyelash loss

    • Eyelash misdirection

    • Matted, hard scales/collarettes (eyelid deposits)

    • Eyelid ulceration with severe exacerbations

    • Mild-to-moderate injection, phlyctenules may occur (Conjunctiva)

    • Aqueous Tear Deficiency

    • Inferior punctate epithelial erosions, peripheral/marginal infiltrates (10, 2, 4, and 8 o’clock), scarring, neovascularization and pannus, thinning, phlyctenules (cornea)

    • Derm Disease: atopy rarely

Anterior, morning, Staphylococcal,

_______ Blepharitis:

• _______ Blepharitis

  • Greasy lid margin with lashes sticking together

  • Scales on lid margin + lashes

  • Dry eye symptoms present in many patients

  • Associated Conditions: dermatitis on face and scalp Acne, Rosacea, Eczema, Use of retinoids

  • Frequent with:

    • Oily or greasy eyelid deposits

    • Mild injection (Conjunctiva)

    • Aqueous Tear deficiency

    • Inferior punctate epithelial erosions (cornea)

    • Derm Disease: _______ dermatitis

Anterior, Seborrheic, Seborrheic

Posterior Blepharitis:

• Swollen eyelids

• Capping of meibomian gland orifices with oil globules

• Dry eye symptoms in almost all patients

• Associated conditions: Cutaneous Rosacea, Seborrhoeic dermatitis, Acne vulgaris treated with isotretinoin, Long-term contact lens wear

• Melbomian Gland Dysfunction

  • Eyelash misdirection may occur with long-standing disease

  • Excess lipid, foamy discharge (eyelid deposits)

  • Eyelid scarring may occur with long-standing disease

  • Occasional to frequent, some times multiple chalazia

  • Mild-to-moderate injection, papillary reaction of tarsal conjunctiva 

  • Aqueous Tear deficiency

  • Inferior and superior punctate epithelial erosions, fine infiltrates superiorly and inferiorly, scarring, neovascularization and pannus, ulceration (Cornea)

  • Derm Disease: Rosacea

Posterior,

Non-pharmacological:

1. Maintain _______

   1. Lid cleaning to mechanically _______

   2. Scrubbing of the lid margins _______ with a cotton tips dipped in a diluted solution of _______

   3. 2-3 drops of baby shampoo in 1 cup of cooled boiled water OR Commercially available _______ soaked in soap/alcohol are available

2. Facilitate _______

   1. _______ applied for about _______ to facilitate melting + extrusion of meibomian gland secretions

   2. Recommend warm _______ or commercially available _______

   3. Recommend _______ after warm compress

   4. Emphasize on regularity and continuation as the symptoms improve

3. Manage _______

good lid hygiene, remove crusts, 1-2x/day, baby shampoo, lid scrubs, meibomian gland secretions, warm compress, 10 mins 2x/day, wet towel, eye masks, eye massage, dry eye

Pharmacological:

1. Eliminate _______

   1. _______ → claim to eliminate Demodex

   2. _______ component: 4-terpineol

2. _______

3. Manage _______

Demodex, tea tree oil scrubs, Active, Topical/oral antibiotics, dry eye

_______ (_______)

• Self limiting Staphylococcus aureus infection of:

  • Glands of Zeis and Moll

  • Meibomian glands

  • Almost always painful!

Hordeolum, Sty

Hordeolum (Sty): 2 types

• 1. External

  • Infection of _______

  • _______ inflammation with _______ formation

  • Sxs

    • Localized tender red swelling _______ eyelid

    • Develops _______-filled area

    • Drains within _______

• 2. Internal

  • Infection of _______

  • Sxs

    • Localized tender red swelling _______ eyelid

    • Onset + drainage is _______

Zeis and Moll gland, focal, abscess, adjacent to, yellow pointed pus, few days, 1 or 2 meibomian glands, on the, more prolonged

_______

• Chronic sterile lipogranulomatous inflammation of meibomian gland

• Painless and away from eyelid margin

• Associated with Demodex brevis infection but its role in etiology is not clear

• Sxs

  • Hard painless growth w/o redness that develops over _______

  • Much more common in _______

Chalazion, several weeks, upper eye lid

_______: Management

• External

  • Warm compression several times a day

  • Epilation of the involved eye lash

  • Stab incision with a sterile needle

  • Topical application of solution or ointment of polymyxin B/bacitracin or tobramycin

• Internal

  • Small lesion: Warm compression several times a day

  • Large lesion: Oral antibiotics

    • _______ mg _______ for _______

    • Alternative:

      • Erythromycin

      • Azithromycin

      • Cephalosporin

Hordeolum, Dicloxacillin 125-250, QID, 1-2 weeks

_______: Management

• _______ followed by vigorous _______ several times a day for _______

• _______ injection of 0.1-0.2 ml _______

  • Use tuberculin syringe fitted with 27/30-gauge needle

  • Through skin of the lid for anterior chalazion

  • Topical anesthesia and through conjunctiva for posterior chalazion

  • _______ resolves in _______ after injection

  • Maximum _ injections

  • SEs: Local discomfort at the site of injection, skin depigmentation, retinal/ choroidal blood vessel occlusion (can be prevented by withdrawing the syringe to rule out injection in the blood vessel).

• _______

Chalazion, warm compression, digital massage, 2-4 weeks, Intralesion, Triamcinolone Acetonide, Chalazion, 1-2 weeks, 2, surgical excision

Composition of Tear Film:

• Layer of fluid covering the _______

• Its volume is _______ μl

• Secreted at a rate _______ μl/min

• _______ layer secreted by:

  • Meibomian glands (located _______),

  • Gland of Zeiss + Moll (located at the _______)

• _______ layer

  • Lacrimal glands (One each located _______)

  • Glands of Krause + Wolfring (Located _______)

• _______ layer

  • Goblet cells present in the _______

  • Corneal & conjunctival epithelial cells

  • These cells form the _______ layer of cells present on _______ & conjunctiva

eye surface, 6-7, 2, Lipid, inside the eyeball, base of each eyelash, Aqueous, above each eyeball, under the eyelids, Mucous, conjunctiva, outermost, cornea

KNOW IMAGE

KNOW IMAGE

Sxs of Dry Eye:

• _______

• Difficulty wearing _______

• _______ around eyes

• _______ in the initial stages

• Foreign _______ (sandy/gritty)

• _______, _______, _______ sensation

If left untreated → corneal _______, _______, and _______

Redness, contact lenses, stringy mucous, excessive tearing, body sensation, itching, burning, scratchy, ulceration, scarring, vision loss

Dry Eye Non-Pharmacological: Patient Education

• Enough water intake: ___ liters (___ cups) for men, ___ liters (___ cups) for women

• _______ deliberate blinking while working on computer

• Position computer screen _______ eye level so that upper eye lid minimizes _______

• Consider _______

• Keep hairdryer & car air conditioner directed _______ from eye

• Do not sleep _______ the fan

• Use of _______ during winter indoors

• Consider stopping _______

• Keep away from _______ environment

3.7, 15.5, 2.7, 11.5, frequent, below, evaporation, wrap-around glasses, away, directly under, humidifier, smoking, dusty/smoky

Artificial Tear Ingredients:

• Active Ingredient:

  • _______: a primarily water‐soluble polymer, which is applied topically to the eye to protect + lubricate mucous membrane surfaces and relieve dryness + irritation.

  • Following 4 demulcents are used in artificial tears:

    • a) _______ derivatives:

      • Carboxymethylcellulose (CMC),

      • Hydroxypropyl Methylcellulose (HPMC, Hypromellose)

    • b) _______:

      • Propylene glycol, Polyethylene glycol, Glycerin, Polysorbate 80

    • c) _______:

      • Polyvinyl alcohol, Povidone

    • d) _______

Demulcent, Celluloses, Polyols, Alcohols, Dextran 70

Artificial Tear Ingredients:

• Universal (Inactive) ingredients

  • _______, _______, _______, _______, _______ based buffer

  • Biologically active chemicals listed under inactive ingredients

    • _______: Protect the cells against _______osmolarity-mediated injury

      • Trehalose, Carnitine, Erythritol

    • _______: _______

      • Sodium hyaluronate

    • _______: 

      • Hydroxypropyl Guar gum

    • Prevention of _______: 

      • Oils (Castor oil, Flax seed oil, Mineral oil)

NaCl, KCl, MgCl2, CaCl2, Phosphate/Bicarbonate, Osmoprotectants, hyper, Humectants, absorb and retain water, Mucin Mimetic Action, Water Evaporation

Artificial Tear Ingredients:

• Preservatives

  • _______ preservatives

    • _______: Oxychloro complex containing 99.5% chlorite, 0.5% chlorate

      • Upon instillation, light breaks it into sodium chloride, O2, H2O

    • _______ (Dequest): Upon instillation, light breaks it down to low levels of H2O2

  • _______ compounds

    • _______ is a high MW quaternary ammonium compound with microbicidal activity but has very low toxicity to corneal/conjunctival epithelial cells

    • _______ (BAK) is high MW quaternary ammonium compound

      • Multiple studies show it is toxic to corneal/conjunctival epithelial cells

  • Best to _______ BAK-containing eye drops in patients of dry eye

• pH typically _______ → Most tears are _______ (few _______ = Thera tears)

Vanishing, Purite, Sodium Perborate, Quaternary Ammonium, Polyquaternium-1, Benzalkonium Chloride, avoid, neutral, isotonic, hypotonic

• Preservative-containing artificial tears → _______

• For ≥6 use/day → _______ eye drops

4-6x/day, unit-dose single-use

Algorithm for choosing artificial tears/gels/ointments:

1. For MILD cases start w/_______ tears typically _______ or _______-based

   1.  AND Recommend _______

2. Increased _______

   1. Max 4_______

   2. >_ preservative-free

3. Recommend tears with _______, especially with _______ component

   1. _______ + (Trehalose, Hyaluronic acids, Oils, Glycerin, Polysorbate)

   2. OR Switch to _______ containing tears (Guar gum, Mineral oil)

4. Consider addition of _______ tears

   1. Optometrist or ophthalmologist referral → Sxs do NOT improve/worsen

5. Supplement with _______

   1. Optometrist or ophthalmologist referral → Sxs do NOT improve/worsen

single active ingredient, CMC, HPMC, lifestyle modifications, Frequency, 4-6x/day with preservatives, 6, multiple active ingredients, lipid, CMC, Polyols, gel-based, nighttime ointments

1. Tear Supplementation: _______

2. Tear Conservation: _______

3. Tear-Film Stabilizer: Perfluorohexyl octane (_______)

4. Inhibit Ocular Surface Inflammation: _______ and Lifitegrast (_______)

5. Tear/Mucous Secretion Stimulation: Varenciline (_______) and Acoltremon (_______)

Artificial Tears, Ointments and Punctal Plugs, Meibo, Cyclosporine, Xiidra, Tyrvaya, Tryptyr

Tear conservation

• Ointments

  • Recommended for _______ use only since they Interfere with _______

  • Recommend to take the contact lenses off

  • Apply _______inch inside the lower eye lid

  • Close the eyes for _______

nighttime, vision, 1/4-1/2, lower, 2 minutes

Tear conservation

• Punctal plugs

  • Prevent the _______ → retaining the _______

  • Inserted under _______ using jeweler's forceps either into punctum or canaliculus

  • 2 types of materials

    • _______

    • _______

    • Available in a variety of sizes

  • Limitations

    • Spontaneous extrusion

    • Replacement has higher rate of expulsion

tear outflow, tear film, topical anesthesia, Silicone, Collagen

Tear-film stabilizer

• _______ (Meibo)

  • _______ vial

  • One drop _______

  • Remove the contact lens → reinsert after _______

  • MOA: Forms a _______ on the top of _______ + prevents _______. Just like the _______

Perfluorohexyl Octane, Non-Aqueous Non-Preservative multidose 4x/day, 30 mins, non-aqueous barrier, tears, evaporation, natural lipid layer

Inhibit ocular surface inflammation

• Cyclosporine: 

  • _______: emulsion/single or multi-dose

  • _______: nanosphere solution/single-dose

  • _______: semi-fluorinated alkane solvent /multi-dose/ non-aqueous + preservative-free

  • Storage at room temperature 15°-25 °C (59°-77 °F) for all 3 formulations

  • MOA: _______, _______ the _______ of cytokines esp _______, and thus _______ proliferation + differentiation

  • Ophthalmic cyclosporine:

    • Decreases ocular surface _______ + increases _______

    • Instill one drop _______ in the affected eye

    • Indicated for _______ dry eye

  • SEs:

    • _______ sensation upon instillation is the most common SE (17% pts)

    • Conjunctival hyperemia, discharge, eye pain, foreign body sensation, pruritus, stinging, blurring (in 1-5% pts).

  • Counsel patient on:

    • _______ a few times before application

    • Allowing a minimum of _______ interval between instillation of cyclosporine and artificial tears or other eye drops

    • Not to use while wearing contact lenses; Lenses should be removed prior to application and can be re-inserted _______ after instillation of the drops

Restasis, Cequa, Vevye, calcineurin inhibitor, inhibits, synthesis, IL-2, inhibits T lymphocyte, inflammation, tear production, 2x/day, moderate to severe, burning, inverting the bottle, 15 mins, 15 mins

Inhibit ocular surface inflammation

• Lifitegrast (Xiidra): Solution/Single-Dose

  • Storage at room temperature 20°-25 °C (68°-77 °F)

  • _______ function-associated _______ (_______) _______

  • Decreases ocular surface _______

  • Instill one drop _______ in the affected eye

  • SEs: _______, conjunctival _______, _______, _______, increased _______, eye _______, eye _______

  • Counsel patient on:

    • Allowing a minimum of _______ interval between instillation of lifitegrast and artificial tears or other eye drops

    • Not to use while wearing contact lenses; Lenses should be removed prior to application and can be re-inserted _______ after instillation of the drops

Lymphocyte, antigen-1, LFA-1, antagonist, inflammation, 2x/day, blurred vision, hyperemia, eye irritation, HA, lacrimation, discomfort, pruritus, 15 mins, 15 mins

Tear/mucous secretion stimulation (Comparable Efficacy of Tryptyr and Tyrvaya)

• _______ (Tyrvaya)

  • _______ 0.03mg

  • _______ receptors on _______ nerves to stimulate _______

  • SEs: _______, _______, _______ irritation

  • Instruct the patient to prime the pump by _______ in the air

  • Reprime by _______ if the bottle has not been used for >_______

  • Wipe the nasal applicator with a clean tissue

  • Do not _______

  • Store: _______

Varenicline, Nasal Spray, stimulates nicotinic cholinergic, parasympathetic, tear production, sneezing, cough, nose and throat, 7 sprays, 1 spray, 5 days, shake or freeze, room temperature

Tear/mucous secretion stimulation (Comparable Efficacy of Tryptyr and Tyrvaya)

• _______ (Tryptyr)

  • _______ solution 0.003%, _______ unit _______

  • One drop _______, Remove contact lenses before use

  • Store: _______

  • MOA: _______ receptors

Acoltremon, acoltremon ophthalmic, single, preservative-free, 2x/day, refridgerator, stimulates TRMP8