OCULAR DISEASE (TREATMENT REVIEW) - 1

BLEPHARITIS & MEIBOMIAN GLAND DISEASE

Lid hygiene

Hold a very sterile gauze pad over your eyes for 10 mins. While doing this, gently massage eyelids vertically. Then, use a clean gauze pad moistened w/ diluted baby shampoo (mixed w/ equal parts water) to gently clean your lids & lashes. Keep eyes gently closed, & make sure you clean right along the base of your lashes where most debris will collect. Do not re-use the same cleaning pad on subsequent treatments.
Can also use a commercially prepared lid scrub (available w/o prescription in the CL care area of your regular drugstores).
Follow cleaning w/ 1-2 drops of AT to flush out any xs oils from your tear film.

Staphylococcal blepharitis

 burning, itching, tearing, fbs  scales, hyperemia, papillae, inf pek  sev = ulcerative bleph  chronic = madaroisis, trichiasis, poliosis, tylosis ciliaris  staph / Lid hygiene
Top AB ung [Bacitracin OR Erythromycin BID-QID]
Severe = Top Steroid/AB ung, Oral AB, Derm consult

Seborrheic blepharitis

 same as above but greasier  seb disord / Lid hygiene
Oral AB [Doxycycline 100mg BID 1st d  50mg QD OR Tetracycline 250mg QID]
Seborrheic shampoo for scalp & brows

Meibomian seborrhea

 foam, “oil slick”  assoc seb bleph / Lid hygiene
Sev = Oral AB [Doxycycline 100mg BID 1st d  50mg QD OR Tetracycline 250mg QID]

Meibomianitis

 domed caps  assoc staph bleph / Express
Lid hygiene
Resist = Oral AB [Doxycycline 100mg BID 1st d  50mg QD OR Tetracycline 250mg QID]
Mod-sev = Oral AB [low maintenance dosage of Doxycycline]

Mixed seb-staph blepharitis

/ Same as for staph bleph alone w/o AB ung

Angular blepharitis

 moraxella, staph  ulcerated canthus / Top AB ung [Zinc sulfate 0.25% ung OR Erythromycin ung]

Phthiriasis palpebrarum

 chronic bleph  assoc pubic lice / Bland ung
Remove cilia
Clean w/ RID or Kwell
Instruct proper hygiene

Internal hordeolum

 staph infect of meib gl  sev pain, warmth  ipsilat PAN  assoc staph bleph, presep cel / Mild = Hot compresses BID-QID
Mod-sev = Oral AB [Amoxicillin, Dicloxacillin, OR Erythromycin 250mg QID]
Resistant = Surgery

External hordeolum

 staph infect of zeis & moll  assoc staph bleph / None (self-draining w/i 3-4 days of pointing)
Hot compresses
Epilate lashes
Puncture w/ sterile needle
Top AB ung [Gentamicin]

Chalazion

 sterile  non-tender  assoc meib lid dz, rosacea / None (25% resolve spontaneously over 6 mos)
Hot compresses QID for 4-6 wks
Steroid injection [Kenalog-10 10%]
Resistant = lanced & drained

Preseptal cellulitis

 ant to orb sept  pain, warmth, fever  ddx orb cel (eom limit, +apd,  va) / Hot compresses
Oral AB [Amoxicillin, Dicloxacillin for staph, Cephalosporin for H flu]
Blood cultures to identify org
Suspected meningitis = hospitalize + lumbar puncture + IV AB

EYELID DISORDERS

Lubricate
AT drops & ung

Coloboma

 congen  missing  unilat, upper lid common  prob = exp keratopathy / Lubricate
Infect or risk of = Top AB ung [Bacitracin]
>75% absent = Surgery (w/i 48 h of birth, in 3-6 mos if less sev)

Distichiasis

 congen  access row of lashes / None unless corn involve
Mild = lubricate
Advanced = epilate, electrolysis
Sev = cryotherapy

Epicanthal fold

 congen  redundant fold  bilat / None (children may outgrow condition)

Acquired ptosis

 upper lid lower in downgaze  aponeurotic most common age related ptosis / 3rd nerve palsy (neurogenic)
None (usually resolve w/i 90 d)  F/U 1 wk to ensure no pupil involve
Pupil involve = neurologist STAT
Horner’s syndrome (neurogenic)
Sympathomimetic [Phenylephrine 2.5%]
Dermatochalasis/”pseudoptosis” (mechanical)
Aponeurotic (myogenic)
Surgery unless >30% VF cut
M. gravis (myogenic)
Treat syst dz

Congenital ptosis

 upper lid higher in downgaze / Surgery (delay until ~ 4 yo unless severe)

Floppy eyelid syndrome

 lost of elastin  rubbery tarsal plate  sup palp papillary response, spk / Tape lids / Eye shields
Infect or risk of = AB ung [Bacitracin OR Gentamicin] F/U every 3-7 days until stable
Surgery has variable results

Blepharospasm

 bilat  invol orb oculi contraction / Treat underlying oc dz
Sev = botox inj, surg removal of orb oculi

Lid myokymia

 dz, stress, fatiguq / Reassurance
Antihistamine
Quinine

Ectropion

 etiology = involution or age (most common), cn vii palsy, cicatricial, mech, allerg, congen / Lubricate
Tape lids
Infect or risk of = AB ung  F/U 1-2 wks
Surgery (delay in infants)

Entropion

 etiology = involution or age (most common), cicatricial, spastic, congen / Tape / Superglue / CL
Infect or risk of = AB ung  F/U as needed
Mild = epilate lashes
Surgery

Trichiasis

 etiology = chron bleph, entrop, idoipath / Lubricate
PEK present = AB ung, CL
Remove (epilate, electrolysis, cryotherapy)

Lagophthalmos

 etiology = nocturnal, orbital/ proptotic, mechan, paralytic / Lubricate
SCL / Tape lids
Tarsorrhaphy

EYELIDS LUMPS & BUMPS

Malignancies
  1. asymmetry
  2. border irregularity
  3. color irregularity
  4. diameter > 6 mm
  5. elevation

Cyst of Moll (sudoriferous cyst)
 clear / Excise

Cyst of Zeis

 opaque / Excise

Sebaceous cyst

 yellowish-white, multiple, central punctum (blackhead) / Excise

Xanthelasma

 cholesterol / Young patients = investigate for hyperlidemia
Older patients = counsel, reassure
Excise (but can recur)

Molluscum contagiosum

 wart  unbilicated lesion w/ umbilicated ctr  cheesy core / Puncture & express
Excise
R/O basal cell carcinoma

Papilloma

 viral  cauliflower  pedunculated = verruca vulgaris, flat = verruca plana

Keratoacanthoma

 rapid growth  central keratin core / Excise if no resoln (small # progress to squamous cell carcinoma)

Hemangioma

 local mass w/ vasc changes  worse when crying (children) / Excise for cosmesis or if vision compromised

Actinic keratosis

 pre-malignant  yellow, rough, crusty  bleeds easily / Excise promptly

Squamous cell carcinoma

 metastatic (very dangerous)  deeply ulcerated, elevated edges / Radical excision

Basal cell carcinoma

 not metastatic  pearly borders, ulcerated ctr, variable pigm / Photodocumentation
Excise

Nevus

 dermal = rarely progr  junc = may progr to malig melan / Refer any suspicion

Malignant melanoma

 most common cause of 1 intraoc tumor  ABCDE rule

Kaposi’s sarcoma

 1/3 of AIDs pts  dark purple nodule or plaque / Surgery / Radiation / Chemotherapy

DISEASES & DISORDERS OF THE LACRIMAL SYSTEM

Lipid (meibomian, zeis, moll), Aqueous (lacrimal, krause, wolfring), mucin (globlet)
Lacrimal = reflex + basal, krause & wolfring = basal

DISORDERS OF TEAR PRODUCTION

Tear = impr refract, remove dead epi, supplies oxygen, lubricates, provides immunity
Schirmer: no anes = reflex + basal, anes = basal (< 5 mm after 5 min = hyposecretion)

Aqueous deficiency

Immune-based (sjogren’s synd)
Keratoconjunctivitis sicca: most common cause of aq deficiency, women, assoc syst dz, worse during day, mucus threads (clumping of mucin)
Non-immune-based (non-sjogren’s)
Lacrimal dz
  • Riley-day synd (familial dysautonomia): congen, short life span, rare
  • Congenital alacrima: lack of aq prod @ birth, poor gl form or cranial n paresis, rare
Lacrimal obstruction
  • Dacryoadenitis: lacrimal gland, “s”-shaped lid, unilat, +PAN
  • Lacrimal gland tumors: rare, benign or malig, granulomas
Facial paralysis: cn vii damage

Evaporative dysfunction

Oil deficiency
Blepharitis: staph secrete lipase  foam
Acne rosacea: excess oil  burning
Meibomian gland dysfunction
Lid related
Ectropion, entropion, bell’s palsy, incomplete blink, lagophthalmos
Proptosis
Exophthalmos
Lid margin defects
CL induced
Oc surface disorders
Pterygium
Pinguecula

Mucin deficiency

Avitaminosis A
Traumatic destruction
Ocular cicatricial pemphigoid: chronic; progressive; inflam dz; autoimmune; subepithelial bullae formation  auto-antibody  bullae rupture  scar  symblepharon, entropion, ectropion, trichiasis, lagophth; scarring destroys goblets
Tx = difficult, top & oral steroids, oral immunosuppressive, bandage Cl, oral vit A
Steven-johnson syndrome
Similar to OCP but acute & recurrent, males, toxic or allerg rxn

TREATMENT OF DRY EYE

Treat underlying cond
Tear augmentation
AT drops
AT ung
AT inserts
Tear preservation
Reversible punctal occlusion (collagen or silicone plugs)
Irreversible punctal occlusion (cautery, laser, cryotherapy)
Lateral tarsorrhaphy
Low water bandage SCL
Tape lids shut at bedtime
Oc surface tx
Mucomyst (breaks up mucus strands)
Vit A tx

DISORDERS OF THE DRAINAGE SYSTEM

C/O epiphora (ddx pseudoepiphora – xs tearing from dry eye or irritation)
Puncta  canaliculus  lacrimal sac  nasolacrimal duct  valve of hasner

Testing the Lacrimal Drainage System

Dilation & irrigation
Hard stop = canaliculus intact
Soft stop = problem (collection of infectious material)
Pt tastes saline = normal
Reflux of saline or infected material = obstruction of nasolacrimal sac
Dye disappearance test
Unilateral c/o epiphora
Jones test
No fluid = complete obstruction
Fluorescein-stained fluid appears = partial distal (farther from eye) obstruction of nasolacrimal duct
Clear fluid = tears can not enter system naturally
Reflux of saline or infected material = infection or neoplasm of common canaliculus, lacrimal sac, or upper (proximal) nasolacrimal duct

Tumors of the Lacrimal Drainage System

Uncommon, benign or malig, painless, bloody tears

ABNORMALITIES OF THE EXCRETORY SYSTEM

Congenital abnormalities

Punctal agenesis or atresia: 0 or poor formation
Lid disorders: ectropion, entropion  poor apposition
Nasolacrimal duct obstruction: valve of hasner does not dissolve, most frequent cause of congen epiphora, tear stagnation  infect
Tx = vigorous downward massage, top AB, forced irrigation, surgery

Acquired abnormalities

Punctal stenosis: age-related (most common cause of acquired epiphora), chronic inflam
Tx = punctal dilation
Lid disorders
Canalicular stenosis: trauma, scarring
Tx = surgery
Canaliculitis: infect causing dacryloists (stones); actinomyces, candida, herpes; hx of chronic red eye, resistence to AB therapy, soft stop
Tx = D & I alone or combo w/ top or oral anti-infect agent
Dacryocystitis: inflam of lacrimal sac; s aureus, h flu, strep, pneumococcus, pus regurgitate when lac pressed externally, tender to touch (non-tender  suspect mucocele (potential emerg)  refer to specialist)
Tx = top or oral AB, IV if severe, dacryocystorhinostomy
Acquired nasolacrimal duct obstruction: nasal dz

CONGENITAL ABNORMALITIES, DEGENERATIONS, & CONJ LUMPS & BUMPS

RED/PINK LESIONS

Subconjunctival hemorrhage

 htn, bleeding disord, valsalva maneuvers, trauma, asprin overuse, idiopath  bulbar only / None (self-resolving w/i 2 wks)
Alternate hot & cold packs
Recurrent = full med eval

Hemangioma

Kaposi’s sarcoma

Lymphoid tumors

 light pink to salmon-colored, bulbar  benign = lymphoid hyperplasia, malig = lymphoma / Must excise & biopsy to determine benign or malign

LIGHT/CLEAR LESIONS

Concretions

 white-yellow ca++ deposits, palp  asympt / Cut & remove if irritation

Retention cysts

 clear palp or bulb / Drain (but will refill)
Recurrent = Excision of conj below

Pinguecula

 sun expose  inflamed = Pingueculitis / AT
Decongestants
Excise for cosmesis

Pterygium

 basophilic degen of bulb stroma conj  stocker’s line / AT
Decongestants
Excise (67% will recur, 95% of recur w/i 12 mos w/ faster subseq recur)
Best = conj sliding flap

Dermoid cysts

 cong tumor (meso- & ecto-derm)  white to pale yellow, inf temp limbus  hair / Excise for cosmesis

DARK LESIONS

Axenfeld’s loop

 blue-black ciliary n loops / None

Adenochrome deposits

 cause = epinephrine, propine  black, well-circumscr / None

Nevus of ota

 cong  bluish (dermis) / Photodocumentation (follow dark iride pts closely)

Conjunctical nevus

 cong  brown, well-circum  may see cysts in lesion (confirms benign) / Photodocumentation
Lesion enlarges, ulcerates, hemorrhages, changes pigm, devel feeder vessels = Refer for biopsy

Acquired melanoma

 spontan devel  brown, diffuse, “sprinkled”  30-40 yo  15%  malig melan  choroidal melan / Photodocumentation
F/U q 3-6 mos  If suspicious = Refer for biopsy
Conjunctival malignant melanoma / Photodocumentation
F/U q 3-6 mos  1st sign of threat = Refer for biopsy or excision

Primary ocular melanoma

 assoc dysplastic nevus syndrome / Removed by limited externeration

VARIABLE COLOR LESIONS

Papilloma
 40+ yo  sessile (flat), pedunculated (on stalk)  viral, non-viral (pre-cancerous) / None
Excise if symptomatic

Sebaceous cell carcinoma

 intraepithelial dysplasia  assoc tumor of meib or zeis / Highly recalcitrant case of bleph = Tissue biopsy
Ocular surface squamous neoplasia
 3rd most common oc tumor (after melanoma & lymphoma)  abnormal stem cell devel  mid-50, white, male, <30 lat from equator, uv-b exposure / Diagnosis (PAP type test, impression cytology, biopsy)
Best Tx = wide excision w/ 2-3 mm clear margin

OTHER CORNEAL & CONJUNCTIVAL INFECTIONS & INFLAMMATIONS

Chlamydia infection

 trachoma = eye to eye by fly, upper palp follicles, arlt’s line, herbert’s pits, underdevel countries
 adult inclusion conj = std, lower palp more effected, PAN, SEIs, ddx = ekc (monocytes & neutroph in discharge) / Doxycycline 100mg BID 1st day  100mg QD x 21 d OR Azithromycin 1g QD x 1 dose (for underdevel countries)
Allergic pts = Tetracycline 250mg QID x 21 d OR Erythromycin 500mg QID x 21 d
Adult inclusion only = co-manage w/ gynecologist/urologist

Toxic & irritative follicular conj

 mixed papp & foll  ddx trachoma (no herbert’s pits) / Remove irritants
Supportive
Superior Limbic Keratoconjunctivitis
 chronic, recurrent  10-2  +RB  assoc thyroid dz & dry eye / AT, punctal occlusion, pulse of steroids, Acetylcysteine drops, Cromolyn sodium drops, 0.5% Silver nitrate, bandage SCL, thermal cautery of conj, surgical conj resection (highly successful)

Phlyctenulosis

 staph endotoxin  assoc staph bleph, tb / Instruct good hygiene (most imp)
Suspected TB = CXR
Mod-sev = Vasoconstrictors, Top Steroid/AB drops

Ophthalmia Neonatorium

 chlamydia  papillary resp / Mandatory prophylaxis = 1% Silver nitrate OR Erythromycin 0.5%
Chlamydia = Oral Erythromycin x 10-14 d
Gonococcal = IV “cillin” drugs x 7 d w/ Top AB
Non-gonoccocal = Top Bacitracin ung w/ Gentamicin q 3-4 h  taper as cond responds
HSV = Viroptic 1% dosing

Neurotrophic keratopathy

 loss of corn innerv  epith defect  s/p hzv, cn v surg, tumor (acoustic neuroma) / Lubricate
Bandage SCL w/ Cycloplegic + AB
Tarsorrhaphy

Thermal / UV keratopathy

 confluent SPK in interpalp zone / Treat as corn abrasion
Bandage SCL w/ Cycloplegic + AB

Thygeson’s SPK

 epi keratitis, w & q eye, +RB, bilat fain gray coarse pek  no stromal involve / Pred Mild x 3 d  taper
Alrex
Bandage SCL / PP
Interstitial keratitis
 stroma  ghost vessels  syphilis / Identify & treat syst infect
Active = Steroids + Cycloplegic
Vision impair = keratoplasty

Ocular cicatricial pemphigoid

 chronic, autoimmune, scarring, 65+ yo  female  dry eye synd  ultimate vision loss / Dry eye synd = aggressive AT drops & ung
Top retinoid ung (vit A) if therapeutic benefit after monocular trial
Chronic bleph & meibomianitis = lid hygiene, oral doxycycline, top AB
Active & rapid progression = chemotherapy
Less active & not rapidly progressive = Prednisolone 1mg/kg/day  taper as responds OR Dapsone 1mg/kg/day (not exceeding 200mg/day)
Other chemotherapeutic agent if above ineffect = Methotrexate, Azathioprine

Steven-Johnson syndrome

 similar to OCP but acute & recurrent / Treat aggressively w/ Top Anti-inflam

Ocular Rosacea

 lipid prod / Oral Tetracycline 250mg QID OR Retinoic acid

Psoriasis

/ Supportive
Treat syst dz

Connective tissue disease

/ Supportive
Treat syst dz

DISEASES & DISORDERS OF THE CORNEA

CONGENITAL DISORDERS

Megalocornea

 bilat  sharp, delineated limbal region  x-linked r  high myopia & astig  marfan’s / None

Microcornea

 steep  suscep to ACG

Oval cornea

 vert oval = reiger’s anom, turner’s, microcornea  horiz = sclerocornea

Keratoconus

 progress  non-inflam  bilat  irreg astig (egg-shaped mires, scissoring)  fleischer’s ring, vogt’s striae, break in bowman’s, predom corn nerves, hydrops (break in descemets), munson’s sign (v-shape in downgaze), rizzuti’s sign  assoc atopic cond, down’s, ret dz, mv prolapse / RGP
Acute hydrops = PP / SCL, cycloplegic, analgesic
Sev = Penetrating keratoplasty (PKP), corn transplant

Pellucid Marginal Degeneration

 thinning 4-8  hydrops / Surgical correction

Keratoglobus

 rare  present at birth  thinnest near limbus  perforation common  assoc leber’s, blue sclera / NO RGP
Epikeratophakia surg

Posterior keratoconus

 unilat  assoc post synech, ret & choroid sclerosis, lens prob  cong, trauma / None unless corneal scarring sev  PKP

Sclerocornea

 marble-like  bowman’s absent

Posterior embryotoxin

 hypertrophied schwalbe’s (ant displaced)

Axenfeld-Reiger syndrome

 asymm  post embryotoxin, glauc, iris hypoplasia, devel defects of teeth & bones

Peter’s anomaly

 leukoma  endo & descemet’s absent  assoc w/ ant pyramidal cat, microcorn, sclerocor, infantile glauc

CORNEAL DYSTROPHIES

Epithelium

/ Meesman’s dystrophy: epith cysts in 1st year  cysts rupture in early adulthood
Only during symptomatic phase (rupture)
Bandage SCL
Sev = superficial keratectomy
Epithelial basement membrane dystrophy: most common; maplike (neg staining), dots,
 fingerprints; maps & fingerprints = aberrant , multilaminar project of thickened BM, does not cause symptoms unless RCE
None unless erosion occurs
Dystrophic corneal erosion (RCE): loss of hemidesmosomes; acute pain when waking
Mild = AB drops w/ SCL
Sev = AB ung, cycloplege, PP
Any “open” cornea = F/U q 24 h until healed
NaCl 5% drops/ung prophylactically to hasten adherence
Bland ung
Debridement
Last resort = PTK, superficial keratectomy

Bowman’s layer

/ Reis-Buckler’s dystrophy: central, early = fince reticular opacities, later = irregular corneal surface; gray-white opacities w/ varying epi thickness, ridges or spokes; RCE 3-4X a yr; Hudson-Stahli lines, distorted keratometry
RCE = Standard mgmt
VA severely affected = PTK, superficial keratectomy, lamellar keratoplasty, penetrating keratoplasty
Anterior mosaic dystrophy: gray-white polygonal opacities separated by clear spaces, “crocodile skin”

Stroma

/ Granular dystrophy: uncommon; discrete, sharp borders, clear limbal zone
Macular dystrophy: AR; common; indisctinct margins, cornea thinned, extend to limbus
Lattice dystrophy: refractile lines & dots, limbus clear
Central crystalline dystrophy (of Schnyder): yellow-white opacities (cholesterol crystals), polychromatic appearance
Work-up for hyperlidemia, hypercholesterolemia
PKP (rare, crystals reform in grafts)
Central cloudy dystrophy: crocodile shagreen

Endothelial

/ Posterior polymorphous dystrophy: bandlike figures
None
Corn edema = treat as for Fuch’s dystrophy
Fuch’s dystrophy: guttata (excrescenses from descemet’s, gold in direct, black vacuoles in retro), stromal/epi edema, subepi scarring
5% NaCl drops or ung qhs and in am (later in dz process may need to give throughout the day)
Hair dryer held at arm’s length to dry corneal surface
Top Beta blockers to  IOP

CORNEAL DEGENERATIONS

Iron deposition

 Hudson-stahli line  green, brown, yellow, white  deep epi line of palp closure / None

Coat’s white ring

 small oval, white, ring of dots  assoc w/ prev corn metallic FB / None

White limbal girdle of vogt

 fine white lines (radial)  subepi hyperelastosis, mild hyaline degen / None

Calcific band keratopathy

 begins limbal 3 & 9  grayish haze @ bowman’s  “swiss cheese” /  vision or mechanical irritation = chelation w/ EDTA, manual scraping, PTK, lamellar keratoplasty
Salzmann’s nodular degeneration
 blue/gray, fibrous lumps in superficial stoma  assoc phlyctenular keratoconj  iron pigm rings / Lumps can be removed individually if not heavily vascularized
Lamellar KP or PTK

Corneal arcus