Differentiate between pustule and papule

(I know its disgusting, but do it anyway!)

A papule is simply a red and inflamed lesion on the surface of the skin.

It is called a pustule when it becomes filled with pus and get s a white head. ew

Define Telangiectasia

(and 100 points if you can spell it without looking)

Symptoms:

Facial erythema

Papules and pustules

Telangiectasia

Rhinophyma

What condition could cause all of these?

Doxycycline, 100mg twice a day for 4-6 weeks

or

Topical Metrodiazole gel twice a day for 5-8 weeks

as well as

dietary and environmental restrictions on the things that cause flare-ups

LOTS!

Meibomian gland dysfunction and infection

Blepharitis & Conjunctivitis

Poor tear film

PEE

Corneal vascularization and thinning (keratitis)

Pustule-like caps on meibomian glands

Inflammation of lids surrounding the glands

Serrated lid margins

Conjunctival injection

Dry eye

Warm Compresses

Meibomian Gland expression

Antibiotics like Doxycycline if necessary

Herpes simplex virus looks much like Impetigo.

Differential Diagnosis is important since medications are so different for the two conditions. 

Oral antibiotics (Cephalosporins, Macrolides etc.) 

Washing

Topical antibiotics (Bacitracin)

Fever and chills

Generally poor feeling (Malaise)

Painful patches on skin 

Sharply demarcated areas of swelling/redness

External=infection of Zeis gland

Internal=infection of Meibomian gland

T/F?

Lid pain, edema and erythema accompanied by constitutional signs and symptoms are indicative of a hordeolum

False

Constitutional signs are not consistent with a Hordeolum, all the others may be. 

Symptoms of a hordeolum should be localized to the eyelid. 

Self-drainage

Warm soaks

Topical antibiotics for persistent infections

Epilation

Chalazion=meibomian cyst

Chalazions are basically remnants of hordeolums, they are no longer hot/active infections. They are 'cold,' firm to the touch and non-tender

Warm compresses

Steroid injection 

Incision and Curettage

Arise from different gland types

Zeis are less translucent and are filled with a more oily substance

Forms when any sebacous gland gets blocked-can form anywhere on the body

Non-painful

Generally prevented by good hygiene but not always

Will reform unless entire cyst is excised

Warm Compress, massage and topical antibiotic if pus present.

Most resolve on their own, probing can be considered if it persists 6 months, or even surgery

This is a procedure used to relieve an acquired nasolacrimal duct obstruction. 

An opening is created between the lacrimal sac and the  nasal cavity, bypassing the rest of the lacrimal drainage system.

Long and narrow ducts

A diverticulum off the lacrimal sac allows fluid to stagnate and bacteria accumulate

Trauma

dacryoliths

Sinus/nasal inflammation

Warm Compress 

Systemic and Topical Antibiotics

Aspirate lacrimal sac for cultures/susceptibility

Viral:

Mumps

Epstein-Barr

Herpes Zoster

Bacterial: 

Staphylococci

N. gonnorrhoeae

Symptoms:

Temporal upper lid swelling

tearing/erythema/warmth

Fever

Discharge

What do you suspect is the problem?

Warm compress is all that is available to treat that type of viral infection.

It is more of a palliative treatment than a resolution.

Infection of the duct between the punctum and the lacrimal sac.

Is often caused by uncommon agents (yeasts, fungi, bacteria, virus' etc.)

Erythema and swelling of the punctum and surrounding tissues

Conjunctivitis around  the medial canthus

Fluorescein is applied to the eye, after a few minutes have passed the nasal pathway is checked for drainage of the fluoroscein. 

It is a test used to ensure the tear flow system is patent and normal.

Tearing/constantly wiping

Irritation

Dry eye

PEE 

Exposure keratopathy

Conjunctival Injection

Keratinization

Involutional (with age)

Paralytic

Cicatrical (due to scarring)

Mechanical

Allergies

1. Punctal (if the puncta is exposed)

2. Medial

3. Lateral

4. Tarsal-involves the entire lower lid

Tarsal Strip (Blepharoplasty)

-where the lower lid is shortened and therefore tightened

Lubrication

Moisture shields

Lubricating ointment if conj is keratinized

Digital Massage

Skin Graft

Foreign body sensation/Irritation

Pain

Tearing

Red eye

Photophobia

PEE

Foreign body tracking

Conjunctival injection

Corneal ulcer

decreased corneal sensation

corneal scar

Involutional 

Acute Spastic

Cicatricial

Congenital

Infectious or traumatic process that create irritation

or

when the action of the eyelid retractors is not enough to counteract the orbicularis oculi muscle.

Trauma

Infections

Chemical Burns

Steven's Johnson syndrome

Ocular cicatricial pemphigoid (OCP)

1.Epiblepharon

2. Eyelid retraction

3. Trichiasis

4. Distichiasis

Infectious

Autoimmune (OCP)

Inflammatory

Trauma

(First would always be to treat the underlying problem that is causing the trichiasis)

Epilation

Electrolysis

Radiofrequency ablation

Cryosurgery

Wedge resection of the lid

Full thickess defect of the eyelid

Often associated with cryptophthalmos

Lubricants and ointments

Moist chamber optical bandages

Bedtime patching

Entropion of the upper eyelid

Ectropion of the lower eyelid

Blepharitis

Dermatitis

Trauma

Severe periorbital edema (chronic renal insufficiency)

Thyroid eye disease

Floppy eyelid syndrome

Book surgery 

Lid hygiene education

Topical antibiotics

Possibly a topical steroid if infection has been cleared

Myogenic-irregular levator

Neurogenic-Abnormality of CN III superior division

Have the patient tip their chin up and look at you,  (downgaze)

If it is congenital the ptotic lid will appear higher up,

if it is acquired they will be equal

Neurogenic

Myogenic

Mechanical

Aponeurotic

Diabetes Mellitus

Internal Carotid Artery aneurysm

-These both result in insufficient innervation to CN III and thus the levator

Myasthenia Gravis

Ptosis  will be bilateral and may fluctuate in this case along with strabismus

-Due to a loss of muscle tone in the levator muscle and/or degeneration of the levator attachments.

It is usually bilateral and is the most common acquired ptosis

Measure the width of each palpebral fissure

If they are more than 4mm different between the 2 eyes, it is termed 'severe.'

Levator function

Pupils (PERRLA)

This visual field occlusion can lead to amblyopia and eventually permanent vision loss

It can also cause astigmatism from the compression of the droppy lid

Shortening the levator (if there is still some levator function)

Frontalis Suspension-Linking the eyelids to the Frontalis (done if levator function is poor)

An increased frequency of blinking and increased closure phase

Caused by irritation and inflammation

Involuntary contraction and relaxation of the orbicularis

-basically a twitch

Caused by stress/tension/dehydration etc.

1. Remove the cause of the tension/stress

2. Botox injection

3.Antihistamines

4.Quinine

Eyelid/brow ptosis

Dermatochalasis

Entropion

Canthal Tendon Abnormalities

Sleep/Relaxation

Artificial tears

singing/humming/talking

Botox type A

T3=Triiodothryonine

T4=Thyroxine

Inflammation

and 

Medical Treatments that reduce the size of the thyroid

The thyroid enlarges to try to compensate for the loss of function (goiter)

The Pituitary releases more TSH

There is less T4

1. Overactivity of thyroid gland (hyperthyroidism and possibly thyroid hyperplasia)

2. Infiltrative Ophthalmopathy-Inflammation of tissues around the eyes-->swelling

3. Infiltrative Dermopathy-Thickening of skin on lower legs

T/F

The majority of Graves' disease patients will suffer severe eye problems because of the disease

False

only 1/20 do

Describe Ophthalmic Graves' Disease

aka Euthyroid Graves' Disease

1. Proptosis

2. Restricted EOMs

3. Optic neuropathy

1. Smoking

2. Being female

3. Radioiodine

1. By Structure

2. NOSPECS

3. Clinical Activity Score

4. VISA

In Griffiths it is the  lower lid that is slower than the globe in upgaze

In Kocher's it is the globe that is slower, it lags behind the upper lid in upgaze

Lid Lag

Lid tremor (closed)

Reduced blinking

Increased pigment of eyelid skin

Topical alpha adrenergic blockers (Reserpine, Dapiprazole etc.)

Topical beta adrenergic blockers (Propanolol)

Botox

Conjunctival Chemosis

Superior Limbic Keratoconjunctivitis

Corneal exposure w or w/o pannus formation and ulceration

Antibiotics

Steroids

Lubricants

Elevated head during sleep

tinted Cosmetic lenses

Orbital decompression

Exophthalmos

Ocular Bruit (hear abnormal sounds with a stethoscope)

1st-fibrosis of IR

2nd Fibrosis of MR

1. Lubricants

2. Lid taping

3. Steroids

4. Sew the lids together (Tarsorrhaphy)

Congested retinal veins

Swollen disc

Chorioretinal striae

Pale, atrophic disc

       N-No physical ss

                      O-Only signs, no symptoms

                    S-Soft tissue involvement

P-Proptosis

           E-EOM involvement

               C-Corneal involvement

 S-Sight loss

1. Lacrimation

2.Photophobia

3.Foreign body sensation

4. Retrobulbar discomfort

Vision

          Inflammation

      Strabismus

                    Appearance/exposure

1. Thyroid Function-determining levels of T4, T3 and TSH

2. Anatomic-Imaging

3. Optometric testing

1. Exophthalmometry

2. EOMs 

3. Measure palpebral fissure

4. Observation of lids in down and upgaze

5. Slit Lamp exam with staining

6. Dilated fundus exam

1. Meds to correct thyroid dysfunction

2. Thyroidectomy

3. Ocular lubricants

4. Systemic steroids for corneal damage

5. Narrow palpebral fissure

6. Surgical Decompression of Orbit

7.Local radiation

8. EOM surgery when stable

Amoxicillin/Clavulanate (Augmentin)

500mg p.o tid for 10days

Staphylococcus aureus

Streptococcus species

Haemophilus influenzae type B

Proptosis

EOM Restriction

Mucor

Aspergillus