Lid Lesions and more

DINA M KAKISH, OD ,FAAO UNIVERSITY OF MICHIGAN /Meibomianitis

Hordeolum/Chalazions

Dacryocystitis/

Preseptal / Overview /Eczema Lesions

Herpes Simplex/Zoster

Orbital Fractures

Triaging the Case #1

25 year old male graduate C/C: itching of the with student mild redness- No discharge No watering No No vision blur No Corrective lenses Lid margin appears slightly red 1. What is your 2. Blepharitis Diagnosis and 3. Hordeolum () Plan? 4. None of the above

Blepharitis/Meibomianitis

 Signs/Symptoms  itching  Flaking of eye lids  Redness of lids  Foreign body sensation  If chronic may cause ocular surface issues (dry eye)  There is an increase risk of hordeolum/  Common in patients with / Seborrheic dermatitis  Can be due or worsened by poor lid hygiene  Sleeping with make up on  extensions Treatment

Warm compresses 2 to 4 times daily

Lid washes twice daily • Helpful in removing eye makeup and for seasonal Artificial 4 times daily if patient has dry eye symptoms

If moderate/severe may need steroid/ ointment • Maxitrol (neomycin and B sulfates and ) • Tobradex ( tobramycin and dexamethasone) Warm Compresses

Wash your hands thoroughly

Moisten a clean washcloth or paper towel with warm water

Close eyes and place washcloth on eyelids for about 10 minutes (warm up again if necessary)

May also use commercially available eye masks Lid Washes/Scrubs

Wash and dry Wash and dry hands

Mix Mix a small amount of baby shampoo with water or use commercially available solution/pads

Close close one eye and gently rub solution across lids and lash line with clean cloth

Rinse Rinse with cool water

Repeat on Repeat on other eye- using new cloth Eyelid

Eyesite.org Demodex Collerettes

m.baomoi.com Treatment

Tea-Tree Oil Eyelid Scrubs

Eyelid Cleansers with hypochlorous acid

Oral Metronidazole + orally was more effective then Ivermectin alone •International Journal of infectious disease •Small study Clinical trials of Ivermectin 0.1% Metronidazole 1% cream •In phase 3 clinical trials Case#2 21 years old female C/C: swollen red upper left eyelid for 2 days No redness of the eye, No Photophobia, No discharge, No tearing, No decrease in Vision Hurts when she blinks She wears contact lenses- she does Not sleep in her contacts On examination- painful to touch, & of the upper eyelid. No redness of the eye

Vision is 20/20 R 20/20 L http://optometry-today.com/hordeolum-stye/ No on What is your 1. Conjunctivitis Diagnosis and 2. Hordeolum Plan? 3. Preseptal Cellulitis 4. Chalazion Signs/Symptoms  Pain/tender to touch  May see pustule on the lid margin Hordeolum  Edema and erythema of the eyelid  Vision is generally not affected  is normally clear Treatment

Treatment is dependent on severity

Warm compresses 2 to 4 times daily

Oral antibiotic • Dicloxacillin or Keflex • Must think about MRSA • Athletes, hospital employees

 Signs/symptoms  Lump/bump on lid  No pain/tenderness  No of www.chalazion.me surrounding tissue

Chalazion Treatment

Warm compresses

If there is no response to treatment, then removal by will be need 18 year old C/C: irritation and redness of the eyes and sometime the eyes hurt No discharge, No photophobia, No itching , No decrease in vision Worse after doing near work Patient does not wear contacts or glasses Case #3 Patient is on Accutane On examination Eyes appear red at 3 and 9 O’clock Vision is 20/20 R 20/20 L No pain on eye movement  -Normal What is your 1. Blepharitis Diagnosis and 2. Plan? 3. Hordeolum (stye) 4. None of the above Dry Eye

 Symptoms:  Foreign body sensation  Gritty sandy feeling in the eye  Redness  Tearing  Pain and photophobia  Causes:  Eyelid issues – issue  Medications: antihistamines, Accutane, antidepressants  Age  Increase near work – 40 to 50% reduction in blink rate with any near work Treatment

Artificial Tears 4 to 6 times daily

Warm compresses

Take Breaks when doing near work ( 20/20 rule)

Restasis( cyclosporine 0.05% )/ Xiidra (lifitegrast 5%)

Punctal plugs  50 year old female Case #4  C/C: excessive tearing, some irritation in the corner of the right eye  No photophobia No mattering in am, no mucous discharge, no decrease vision, no itching, no redness of the eye  On examination  Vision 20/20 R 20/20 L  Some tenderness in the nasal aspect of the lower right eyelid  +  No conjunctival injection  EOM: full and no pain on movement

EyeHealthWeb.com What is your 1. Hordeolum Diagnosis and 2. Dacryoadenitis Plan? 3. 4. None of the above

Dacryocystitis

 Inflammation/ of the  Discharge can be excreted from the punctum when pressure is applied  Can be due to stenosis or blockage of the duct  Signs/symptoms  Erythema and Tenderness over the lower nasal aspect of the eyelid  Epiphora Treatment

Oral

•Augmentin 500/125 tid or 875/125 bid

Warm compresses with gentle massage 4 times daily

Needs to be referred for further evaluation, may need incision/drainage or surgical correction Case #5

21 yr old female  She was seen by her Ophthalmologist in Chicago over break  Dx with Hordeolum and treated with Keflex qid  She has been on Keflex for 3 days with no improvement

Atlas of Ophthalmology  History:  Is the area painful or warm to touch? No  Is her vision blurred? No  Fever? No  Eye redness? No  Previous occurrence? Yes treated and What Next? cleared with Keflex about 1 yr ago  Recent hospitalizations or MRSA ? Yes MRSA infection on forearm about 4 weeks ago  Any other health issues? No  No other Medications, NKDA, Non-Smoker Examination

Visual acuity 20/20 R 20/20 L without correction

Edema in the superior temporal area of the upper left eyelid- No pain on palpation Not warm to touch

All other structures were normal What is the Diagnosis?

1.Dacryoadenitis 2.Dacryocystitis 3.Hordeolum 4.None of the above

 Inflammation/infection of the  Swelling of the lateral upper 1/3 of the eye lid  If suspect infection- treat with oral Dacryoadenitis antibiotics  if suspect inflammation-  may need CT to rule out mass  Think about autoimmune disease (Sjogren) Treatment

 Patient was referred to Kellogg Eye Center urgently  She was seen that day-  The Ophthalmologist ordered a CT  CT was negative  Patient was scheduled for lacrimal gland to rule out Sjogren Case #5 follow up

 Less than 48 hours later  Patient presented to ED with pain level of 10/10  Another CT was run- + for cyst behind the  Patient was admitted to hospital and treated with IV  While in the hospital – biopsy of lacrimal gland was done Preseptal Cellulitis Vs Orbital Cellulitis Preseptal Cellulitis

Signs/Symptoms  Tenderness, Erythema, Edema and Warmth of the eyelid and periorbital area.  Often history of , local skin abrasions, hordeolum, or insect bites.  May complain of fever Treatment

Oral antibiotic- must cover for MRSA

• 300mg every 8 hours ( monotherapy) • Bactrim DS (Sulfamethoxazole/Trimethoprim) plus one of the following- , Augmentin, or 3rd generation (cefpodoximne) • This is to cover both MRSA and Group A strep • ( , ) Preseptal Cellulitis

Patient must be followed closely – return within 24 to 48 hours

 If patient is non compliant, or S/S do not improve or Worsen- must send to Emergency department Cellulitis

Signs/Symptoms  Erythema  Tenderness  Edema  Proptosis  Pain on eye movement  EOM restriction  Decrease in visual acuity  Conjunctival injection  Fever Treatment

 Refer to Emergency Department  Patient will need orbital CT  Patient will be admitted and given IV antibiotics Eye Lid Skin Issues /Eczema Treatment Oral Antihistamine

Steroid Cream ( Hydrocortisone 1% OTC )- • can thin the skin/discoloration • max 1 week • Usually works within 3 days Cold compresses

CerAve /Cetaphil Cream or Lotion • If eczema will continue long term If treatment does not work may try cream • Usually refer to Dermatology at that point  21 year old female  C/C: multiple pink eyes in the last 2 months, she was treated with antibiotic drops, gets better Case #6 than returns. In the past 4 weeks she has noticed these bumps on her lid as well  She does not wear corrective lenses  No pain No photophobia No decrease Vision No mattering or mucous discharge in am  Some watering  On Examination  Vision 20/20 R 20/20 L  Conjunctival injection grade 1+  Small lesions on the lower lid below the lash line

Eye Physicians & Surgeons, PCEyelid Lesions What is your 1. Viral Conjunctivitis Diagnosis and 2. Mulluscum Contagiosum Plan? 3. Hordeolum (stye) 4. None of the above Treatment

 Removal of lesions  Treat the conjunctivitis  Cold compresses, artificial teas  May need steroid drop

 Scholesterol-filled yellow plaques  lhigh cholesterol ( 50% association)w, soft lesUs%0%ateral

https://medical-dictionary.thefreedictionary.com/xanthelasma of eye lid Treatment Send to eye care for evaluation • If suspect ocular involvement Oral antivirals for 7 to 10 days • Acyclovir 400mg 5 times a day • Famciclovir 250mg 3 times a day • Valacyclovir 1000mg 2 times a day Corneal dendritic lesions

 Signs/Symptoms:  Photophobia  Pain-if recurrence may not be  Redness  Tearing  Treatment:  Zirgan (ganciclovir)

American Academy of Ophthalmology  Viroptic (trifluridine)  May use Oral antivirals What about Recurrence and does it really matter?

Herpetic Study (HEDS) Recurrence rates: 1 year 10% 2 years 23%, 5 years 36% Studies have shown that Acyclovir 400mg twice daily significantly decreased rate of recurrence (45% decrease) Herpes Zoster

 Hutchinson sign  Zoster on the tip of the nose  predicts higher risk of ocular involvement  Treatment is oral antiviral  If patient has any ocular symptoms send to eye care for evaluation Malignant Lesions

 Basil Cell Carcinoma –most common Signs/symptoms  Nodular Lesion Ulceration Loss of Lashes Irregular boarders Lack of tenderness Destruction of lid margin architecture Basil Cell

BOPSS

https://emedicine.medscape.com/article/1213781-overview Squamous cell

Specialist Eye Centre Bathurst Triaging Eye Emergencies Level of Urgency

Level Time period within to be seen Immediate Within hours to same day depending on situation Urgent Within 24 hours Semi- Urgent Within 1 week Routine Within 1 to 2 months Immediate Urgency

 May need to be seen within hours or that day of Ocular insult ( not limited to this list )  Blunt trauma  Foreign Body  /Corneal Abrasion  Chemical exposure  General Triage Questions

When did the Right eye , left Pain? 1 out of 10 incident occur? eye or both? scale

Any mucous Redness of the discharge or Vision blur? eye? tearing?

Do you where Do you sleep in Any increase in contacts or the contact light sensitivity? glasses? lenses? Case #7

20 year old female calls and states that her friend has gotten a chemical What do we say in her eye in the next?? chemistry lab. She would like advise as to what they should do? When did this occur? Triage questions What did you get in the eye? for Do you wear contact lenses?- if so remove Chemical immediately exposure Did you flush the eye? – if not flush immediately for 15-20 minutes with copious amounts of water then go to Emergency Department  Immediately flush the eye for 15 to 20 minutes  must test ph of the eye and then flush for 15 minutes and retest ph. This process Treatment must be repeated until the ph is 7(neutral).  If patient calls on the phone we should instruct them to flush the eye for 15 to 20 minutes then go to ED Chemical Exposure

 Patient who have a true chemical exposure to the eye need to go to ED  20 year old male  C/C: patient was playing basketball and was elbowed in the right eye  No photophobia No watering No discharge No  + pain +bruising + pain on eye movement Case #8  On examination  Vision is 20/20 R 20/20 L  Pupils are normal  EOM- might be slight restriction on superior gaze  + pain on movement  Eyelid edema and bruising What might be the issue?

BRUISED/BLACK EYE ORBITAL FRACTURE Structure of the Orbit

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Life in the Fast Lane Fante Eye and Face Centre

The weakest portions of the Orbit are thin orbital floor (maxilla) and the lamina papyracea (ethmoid bone) medially and inferiorly Orbital Fracture

 Signs/Symptoms  Bruising/swelling of eyelid  Bony tenderness and swelling  Vision blur  Pain on Eye Movement  Diplopia  Restriction of Eye Movement  Numbness of cheek, teeth or face  Orbital dystopia- asymmetry or displacement of the Orbits

If you suspect Orbital fracture needs CT Explore Plastic American Academy of Ophthalmology Triage questions for Blunt Trauma

How did the injury occur?

Are you seeing double?

Does it hurt to move your eye? Examples of Blunt Trauma

 punch/poke in the eye  Auto/ bicycle accident  Bungie cord

If orbital break is suspected will need CT. Therefore, referral to ED is warranted Foreign Body

 Examples  Leaf  Facial scrub  Sand  Glass  Metal Triage questions for FB

What were you doing at Drilling/hammering? Walking on campus? the time of the incident? After washing face?

Where you wearing eye protection at the time of the incident? Foreign body ( FB )

 Most FB should be seen by eye care or referred to ED especially:  Patient was in an auto accident and glasses chattered into eye.  Patient was using a drill at the time of the incident 19 year old C/C: patient slept in contact lenses last night and awoke with left eye red and painful.  + redness +photophobia + watering + pain 5/10 Case#9  No mucous discharge No itching No decrease in vision On examination:  20/20 R 20/20 L  Grade 2+ injection  small white infiltrate on the What might this be?

CORNEAL ULCER CORNEAL ABRASION Triage questions for the Corneal Ulcer/Abrasion

When/How did the incident occur?

Do you wear contact lenses?

Do you sleep in the contact lenses?

Do you have pain? On a scale from 1 to 10

Are you sensitive to light?

Are you getting any discharge from the eye?

Vision Blur? . Tend to occur more often in Contact wearers . 5 times more likely to occur in Corneal Ulcer a patient that sleeps in the contact lens . Can be sight threatening Corneal Ulcer/Abrasion

 Signs/Symptoms  Pain  Photophobia  Tearing  Redness  Vision is not always be affected Treatment fo corneal ulcer

Discontinue all contact lens wear

th Besivance (besifloxacin) 4 generation Ophthalmic Zymaxid (gatifloxacin) suspension VIGAMOX® (moxifloxacin) Case #10

19 year old male patient C/C: He noticed a small dark spot in his vision 2 days ago What do we think this is ??

Floater

Retinal detachment When did you first notice the issue?

Has it gotten worse? Triage questions for Any flashing lights? Retinal Is there a decrease in vision? Detachments Any Loss of Vision

Any shadows in the periphery (side vision) Retinal Detachments

 Signs/Symptoms include  , black/grey spots in vision, peripheral vision loss, spider web , flashes of light.  Vision may not be affected. If vision is normal patient must still be evaluated.  Retinal Detachments are sight threatening and should be seen same day  Patients can be evaluate for Retinal Detachments by /Ophthalmology or go to ED

References

 Bagheri,N & Wajda, B ( 2017). The Wills Eye Manual ( 7th edition), Wolters Kluwer  Up to Date  Am J Ophthalmol. 2011 Jun;151(6):1030 -1034.e1. doi: 10.1016/j.ajo.2010.11.024. Epub 2011 Feb 19. Clinical treatment of ocular Demodex folliculorum by systemic ivermectin.  International Journal of Infectious Diseases Volume 17, Issue 5, May 2013, Pages e343-e347 Evaluation of the efficacy of oral ivermectin in comparison with ivermectin–metronidazole combined therapy in the treatment of ocular and skin lesions of Demodex folliculorum  Arch Ophthalmol. 2010 Sep; 128(9): 1178–1183.doi: 10.1001/archophthalmol.2010.187:The Incidence, Recurrence and Outcomes of Eye Disease in Olmsted County, Minnesota, 1976 through 2007: The Impact of Oral Antiviral Prophylaxis Ryan C. Young, David O. Hodge, Thomas J. Liesegang, and Keith H. Baratz  https://www.cdc.gov/mrsa/  Change of Blink Rate in Viewing Virtual Reality with HMDKim, Jungho; Yadav, Sunil Kumar; Yoo, Jisang; Kwon, Soonchul.Symmetry; Basel Vol. 10, Iss. 9, (Sep 2018).  Asthenopia and Blink Rate Under Visual and Cognitive LoadsBy: Gowrisankaran, SPublication Date: 2012-01-01 OPTOMETRY AND VISION SCIENCEVolume: 89I ssue: 1Page: 97 – 104  Blepharitis Organism-Specific Therapy :Updated: Jun 30, 2016 :Karen K Yeung, OD, FAAO; Chief Editor: Michael Stuart Bronze, MD more..https://emedicine.medscape.com/article/2014952-overview