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Eyes


Dx Image Management
BENIGN NODULAR LESIONS
Pterygium

 



This picture shows the typical wedge-shaped appearance of a pterygium extending onto the cornea.
Dx: Slit-lamp examination, Fluorescein staining

Asymptomatic: UV Light

Ocular irritation, burning, or itching: without visual sx, rapid growth, or cosmesis concerns:
-Artificial Tears:
-- Hypromellose ophthalmic : 2 drops into the affected eye(s) every hour when required
- Topical Steroid:
-- Fluorometholone ophthalmic : (0.1%) 1-2 drops into the affected eye(s) two to four times daily

Visual impairment or rapid enlargement or poor cosmesis:
- Surgery

Recurrent Pterygium:
- Surgery

Pinguecula

 


They may enlarge slowly but is a benign condition requiring no treatment.
Artificial tears are occasionally used if there is discomfort or to reduce minor injection of blood vessels.
If cosmesis is a concern surgical excision is sometimes done. Occasionally a pinguecula may become inflamed, a condition referred to as pingueculitis. The cause of pingueculitis is unknown but there are no known infectious agents associated with its manifestation. If an inflamed pinguecula is causing discomfort or cosmetic concerns it may be treated with anti-inflammatory prescription.

Topical Steroid:
-- Fluorometholone ophthalmic : (0.1%) 1-2 drops into the affected eye(s) two to four times daily

Xanthelasma  Xanthelasma are always benign lesions. Therapy is usually undertaken only for cosmetic reasons.
Lipid lowering may induce regression of xanthelasma in some patients, although the effect is not consistent.
Removal can be attempted with surgery, carbon dioxide laser, or
Topical 100 % trichloroacetic acid
(Tri-Chlor) apply to lesion x1 then cover w/ dressing x5-6 days, but recurrence is common.
Mollusca contagiosa  Molluscum may resolve spontaneously within one year.
Treatment options include simple excision, class="font12" bgColor="#F0F0F0" vAlign="top" align="left" width="95%" colspan="3"> MALIGNANT NODULAR LESIONS
Basal cell carcinoma

 

Mohs' chemosurgery and excision with frozen-section control.
Cryosurgical techniques are also being developed that are effective at a lower cost, and better preserve the surrounding structures
Squamous cell carcinoma eyelid

 

The clinical diagnosis should be confirmed by incisional biopsy.
Wide local surgical excision with frozen section is usually sufficient for cure. Orbital l exenteration may be necessary in cases of deep invasion.
Mohs' chemosurgery and excision with frozen section control.
The reported recurrence rate with the former method is approximately 2%.
Sebaceous carcinoma

 

Wide surgical excision is the main treatment modality for sebaceous carcinoma.
Disappointing results have been reported with radiation and d Mohs' surgery although no prospective studies have been performed.
Excision with frozen section control appears to be the most tissue sparing procedure with the highest cure rate. Orbital exenteration may be necessary for large tumors
Kerato-acanthoma

 

They resemble squamous cell carcinomas histologically, most will spontaneously regress with scar formation.
SOLITARY LESION:
- First Line:
  - Conventional surgical excision
  - Mohs surgery
- Alternative:
  - Imiquimod 5% cream 
WART-LIKE LESIONSNS
Squamous papilloma

 

The most common benign tumor of the eyelid is squamous papilloma, a lesion caused by the human papillomavirus.
It presents as a frond-like (skin tag) or lobular projection of skin that contains a central vascular core.
Simple excision or cryotherapy is curative
Seborrheic keratosis

 

Seborrheic keratoses appear as greasy, brownish, crust-like lesions "stuck on" to the eyelid. They commonly are seen in the elderly. Enlargement occurs outwardly; shave biopsy is usually sufficient for this benign condition
Actinic c keratosis

 

Unlike seborrheic keratosis, actinic keratosis is a premalignant condition. It predisposes to squamous cell carcinoma in 20 % of cases.
Lesions are usually dry, scaly, and flat with an erythematous base.
Biopsy, followed by surgical excision or cryotherapy, is recommended.
Cutaneous horn

 

A cutaneous horn usually presents as a dark protrusion of packed keratin from the surface of the skin.
It typically overlies an area of malignancy (basal cell or squamous cell carcinoma).
Biopsy of the horn and underlying skin is performed for diagnosis of the underlying conditiontd>
CYSTIC LESIONSNS
Epidermal inclusion cysts

 

An epidermal inclusion cyst is a solitary, slow growing, mobile, firm, round, subcutaneous nodule most commonly found on the upper eyelid. It typically forms after trauma or surgery, or may be congenital. Cysts can become infected or rupture, causing an inflammatory reaction.
Surgical excision
with the complete wall of the cyst is recommended to prevent recurrence
Milia Milia are pinpoint, multiple, firm, white lesions that usually occur on both the upper and lower eyelids. They are caused by the plugging of hair follicles (pilosebaceous units) by keratin.
Therapy consists of puncture of the lesions with a pin and expression of the contents
Dermoid cyst

 

Dermoid cysts are usually recognized in infancy, and often grow during puberty. They are firm, mobile, subcutaneous cysts found most commonly in the lateral brow or upper eyelid regions. Attachment to the frontozygomatic skull suture often is present and sometimes can extend far back into the orbit 

Orbital imaging is indicated if the full extent of the cyst cannot be palpated or orbital extension is suspected. Complete excision without disrupting the cyst wall is curative. Cyst rupture will produce an inflammatory response

 

Kissing nevusus

 

 
PIGMENTED LESIONS
Benign nevus Most eyelid nevi are acquired, presenting in adolescence or early adulthood. The risk of malignant transformation is about 5 percent. Nevi may be seen at different stages:
-
  Junctional: flat with nevus cells at the interface of the epidermis and dermis.
-  Compound: the epidermal nevus cells migrate into the dermis and produce skin elevation.
Intradermal: the cells lie entirely within the dermis.

Interesting forms are the divided or kissing nevus, which involves both the upper and lower lids, Congenital Blue nevus, which is flat and smooth and may be removed for cosmetic reasons, and the Nevus of Ota, a large, diffuse nevus of the he periocular area seen in blacks and Asians that may predispose to malignant melanoma
Melanoma Malignant melanoma accounts for about 1 % of all eyelid malignancies but about two-thirds of tumor-related deaths from eyelid malignancies  p; Cutaneous melanomas can be classified into subgroups: lentigo maligna melanoma (5 %), superficial spreading melanoma (70 %), and nodular melanoma.
On the eyelid, however, the nodular variety is the most common
VASCULAR LESIONS
Port wine stain affecting an adult with Sturge-Weber syndrome

 


 The port wine stain (also called nevus flammeus) is a cavernous hemangioma consisting of dilated blood vessels. It is associated with the Sturge-Weber syndrome. This lesion is congenital and usually covers the eye and nearby facial skin, typically in the distribution of a branch of the trigeminal nerve. It does not blanch with pressure. It may be associated with ocular and leptomeningeal vascular hamartomas as well as glaucoma and retinal detachment.
Argon laser therapy has been somewhat successful at removing these lesions
Kaposi's sarcoma eyelid

 

Kaposi sarcoma is an aggressive, reddish, highly vascular, elevated mass that is seen most often in patients with AIDS. It can also be seen rarely in elderly men from Mediterranean regions. The tumor may be lymphatic or viral in origin. Some spontaneously resolve.
Cryotherapy, intralesional chemotherapy, surgical excision, and irradiations have been used with varied success with this condition.
Superficial hemangiomas of infancy Superficial hemangiomas of infancy (replacing the older term "capillary hemangioma") occur in 1 - 2 % of children, with girls more often affected than boys. This benign tumor usually is present at birth or manifests by six months of age. It consists of a bright red papule, nodule, or plaque raised above clinically normal skin. Superficial hemangiomas are believed to be hamartomatous proliferations of vascular endothelial cells. Approximately seventy percent will spontaneously regress by the age of seven years. 
Because of the propensity of the tumor to shrink on its own, treatment is usually limited to large tumors and those that may cause the lid to occlude the pupil. Continued occlusion could lead to amblyopia and subsequent strabismus.
Treatments include intralesional steroid injection, radiotherapy, laser therapy, surgery, and rarely systemic steroids

 

Conjunctival neoplasia with corneal extension  

 

Assessment of the Red EyeEye

  Acuity Foreign body sensation Photophobia Discharge Cardinal feature Treat/refer
Lids/lashes
Stye/hordeoleum Nl - - None Tender Treat
Chalazion Nl - - None Nontender Treat
Blepharitis Nl - - Dry crusting Chronic Treat
Conjunctiva
Conjunctivitis
Bacterial Nl - - Mucopurulent Discharge all day Treat
        Viral       Mucoserous None/URI Treat
Allergic       Mucoserous Itching Treat
Non-specific (toxic or dry eye syndrome) Nl - - Watery    
Episcleritis Nl - - None Sectoral injection, dull ache Treat
Subconjunctival hemorrhage Nl - - None Extravasated  blood Treat
Cornea
Abrasion Nl or down + + Watery History/trauma defect revealed by fluorescein Treat
Contact lens overwear Nl or down + + Watery History Treat
Foreign body Nl or down +">+ + Mucoserous History/traumauma Treat initially by attempt to remove by irrigation or swab; refer if still present after 24 hr
Infectious keratitis
Bacterial Nl or down + + Muco-purulent White spot on cornea spots stains w/fluorescein Refer, same day/ emergent
Viral Nl or down + + Watery Gray, branching opacity dendrite; dendrite revealed w/fluorescein Refer, 1 to 2 days/ urgent
Anterior chamber/iris
Iritis Nl or down - + None/watery Miotic pupil Refer, 1 to 2 days/urgent
Hyphema Nl or down - +/- None/watery RBC "level" Refer, same day/emergent
Hypopyon Nl or down - +/- None/purulent WBC "level" Refer, same day/emergent
Iris/lens
Angle closure Nl or down - +/- None/watery Fixed, mid-dilated pupil Refer, same day/emergent
 
Red Eye
Lids/lashes
Hordeolum / Stye

 


Both internal and external hordeola can be treated with warm compresses, placed off and on for about 15 minutes at a time approximately four times per day.

If, despite continued treatment with warm compresses, the hordeolum hardens into a chalazion and does not reduce in size within one to two weeks, the patient should be referred to an ophthalmologist for consideration of incision and curettage.

If there is concurrent preseptal cellulitis, oral antibiotics with Staphylococcal coverage are appropriate. However, cellulitis is uncommon, and it may be difficult to distinguish secondary cellulitis from sterile inflammation.
Chalazion  Antibiotics are not indicated since chalazion is a granulomatous condition.
Small chalazia: often resolve without intervention.
Larger lesions: frequent hot compresses may allow them to drain although typically most clear spontaneously in weeks to months.
Symptomatic patients with recalcitrant lesions can be referred to an ophthalmologist for incision and curettage or direct glucocorticoid injection .
Persistent or recurring chalazia should be checked histopathologically for possible sebaceous cell, basal cell, or meibomian gland carcinoma.
 
Blepharitis 
Blepharitis is associated with crusting of the eyelashes, thickening of the eyelids, telangiectatic vessels along the lid margins, and plugging of the meibomian glands
Meibomian gland dysfunction

 

Lower eyelid with inflammation of the tarsal conjunctiva and cloudy oil and plugging at the meibomian gland orifices
INFECTIOUS KERATITIS
Eye manifestations of HSV-1 infection 

(Viral Keratitis)


Fluorescein staining patterns in a case of herpes keratitis
URGENT OPTHO REFERRAL
The fine branching elements distinguish this from the linear or geographic pattern of a traumatic corneal abrasion, although the clinical presentations may be quite similar


NO STEROIDS
Bacterial keratitis  EMERGENT OPTHO REFERRAL
The white corneal opacity suggests purulence necrosis
Rosacea keratitis

 



Active keratitis. The cornea is invaded by two prominent vascular leashes showing active infiltration at their central tips. In addition, there is marked bulbar conjunctival hyperemia and a circumferential pannus. There is also gross obstructive meibomian gland dysfunction
ANTERIOR CHAMBER/IRIS
Hyphema associated with endophthalmitis  EMERGENT OPTHO REFERRAL
Hyphema associated with trauma  EMERGENT OPTHO REFERRAL
A layer of blood at the bottom of the anterior chamber.
 
Hypopyon  A postoperative eye showing a hypopyon, the layering of white blood cells in the anterior chamber
CONJUNCTIVITIS
Bacterial conjunctivitis

 

Primary Options:
  • azithromycin ophthalmic : (1%) 1 drop into the affected eye(s) twice for one day, then once daily for 4 days
  • erythromycin ophthalmic : (0.5%) apply to the affected eye(s) four times daily
  • polymyxin B/trimethoprim ophthalmic : (10,000 units/mg) 1 drop into the affected eye(s) four times daily

Secondary Options

  • bacitracin ophthalmic : (500 units/g) apply to the affected eye(s) every 3-4 hours
  • sulfacetamide ophthalmic : (10% solution) 1-2 drops into the affected eye(s) every 1-3 hours during the day and less frequently at night; (10% ointment) apply to the affected eye(s) four times daily and at bedtime
  • bacitracin/polymyxin B topical : apply to the affected eye(s) four times daily


Hyperacute (gonorrheal) - topical plus systemic antibiotics

  • Primary Options
    ceftriaxone : 1 g intramuscularly as a single dose
    -- AND --
    doxycycline : 100 mg orally twice daily for 7 days
    or

    azithromycin : 1 g orally as a single dose
    -- AND --
    bacitracin ophthalmic : (500 units/g) apply to the affected eye(s) every 3-4 hours
    or

    ciprofloxacin ophthalmic : (0.3%) 1 drop into the affected eye(s) four times daily
     
Viral Conjunctivitis Viral conjunctivitis typically presents as injection, watery or mucoserous discharge, and a burning, sandy, or gritty feeling in one eye.

Treatment:
(topical antihistamines ± artificial tears)

  • Primary Options
    epinastine ophthalmic : (0.05%) 1 drop into the affected eye(s) twice daily or
    azelastine ophthalmic : (0.05%) 1 drop into the affected eye(s) twice daily or
    olopatadine ophthalmic : (0.2%) 1 drop into the affected eye(s) once daily or
    nedocromil ophthalmic : (2%) 1-2 drops into the affected eye(s) twice daily or
    ketotifen ophthalmic : (0.025%) 1 drop into the affected eye(s) twice daily or
    pheniramine/naphazoline ophthalmic : (0.025%/0.03%) 1-2 drops into the affected eye(s) up to four times daily or
    alcaftadine ophthalmic : (0.25%) 1 drop into the affected eye(s) once daily
    -- AND/OR --
    hypromellose ophthalmic : 2 drops into the affected eye(s) every hour when required or
    carboxymethylcellulose ophthalmic : 2 drops into the affected eye(s) every hour when required or
    hydroxypropyl cellulose ophthalmic : 2 drops into the affected eye(s) every hour when required
     
  • Topical corticosteroids
    loteprednol ophthalmic : (0.2%) 1 drop into the affected eye(s) four times daily or
    prednisolone acetate ophthalmic : (1%) 1-2 drops into the affected eye(s) two to four times daily
     
  • Topical ganciclovir
    Ganciclovir ophthalmic : (0.15%) 1 drop into the affected eye(s) five times daily
Acute seasonal conjunctivitis

 

Acute seasonal conjunctivitis classically presents with eyelid and conjunctival erythema and swelling. It is almost always bilateral

Treatment:

  • Cromolyn ophthalmic : (4%) 1-2 drops into the affected eye(s) every 4-6 hours or
    lodoxamide ophthalmic : (0.1%) 1-2 drops into the affected eye(s) every 6 hours
    -- AND/OR --
  • Epinastine ophthalmic : (0.05%) 1 drop into the affected eye(s) twice daily or
    azelastine ophthalmic : (0.05%) 1 drop into the affected eye(s) twice daily or
    pheniramine/naphazoline ophthalmic : (0.025%/0.03%) 1-2 drops into the affected eye(s) up to four times daily or
    alcaftadine ophthalmic : (0.25%) 1 drop into the affected eye(s) once daily
    -- AND/OR --
  • Cetirizine : 5-10 mg orally once daily or
    loratadine : 10 mg orally once daily or
    fexofenadine : 180 mg orally once daily or given in 2 divided doses
    olopatadine ophthalmic : (0.2%) 1 drop into the affected eye(s) once daily or
    nedocromil ophthalmic : (2%) 1-2 drops into the affected eye(s) twice daily or
    ketotifen ophthalmic : (0.025%) 1 drop into the affected eye(s) twice daily
    -- AND/OR --
  • Cetirizine : 5-10 mg orally once daily or
    loratadine : 10 mg orally once daily or
    fexofenadine : 180 mg orally once daily or given in 2 divided doses
    -- AND/OR --

    Topical Steroids:
  • Loteprednol ophthalmic : (0.2%) 1 drop into the affected eye(s) four times daily
  • Prednisolone acetate ophthalmic : (1%) 1-2 drops into the affected eye(s) two to four times daily
Allergic Conjunctivitis Allergic conjunctivitis typically presents as bilateral redness, watery discharge, and itching.

Treatment:

  • Cromolyn ophthalmic : (4%) 1-2 drops into the affected eye(s) every 4-6 hours or
    lodoxamide ophthalmic : (0.1%) 1-2 drops into the affected eye(s) every 6 hours
    -- AND/OR --
  • Epinastine ophthalmic : (0.05%) 1 drop into the affected eye(s) twice daily or
    azelastine ophthalmic : (0.05%) 1 drop into the affected eye(s) twice daily or
    pheniramine/naphazoline ophthalmic : (0.025%/0.03%) 1-2 drops into the affected eye(s) up to four times daily or
    alcaftadine ophthalmic : (0.25%) 1 drop into the affected eye(s) once daily
    -- AND/OR --
  • Cetirizine : 5-10 mg orally once daily or
    loratadine : 10 mg orally once daily or
    fexofenadine : 180 mg orally once daily or given in 2 divided doses
    olopatadine ophthalmic : (0.2%) 1 drop into the affected eye(s) once daily or
    nedocromil ophthalmic : (2%) 1-2 drops into the affected eye(s) twice daily or
    ketotifen ophthalmic : (0.025%) 1 drop into the affected eye(s) twice daily
    -- AND/OR --
  • Cetirizine : 5-10 mg orally once daily or
    loratadine : 10 mg orally once daily or
    fexofenadine : 180 mg orally once daily or given in 2 divided doses
    -- AND/OR --

    Topical Steroids:
  • Loteprednol ophthalmic : (0.2%) 1 drop into the affected eye(s) four times daily
  • Prednisolone acetate ophthalmic : (1%) 1-2 drops into the affected eye(s) two to four times daily
Nodular episcleritis 

Episcleritis is a localized ocular redness from inflammation of the episcleral vessels. In natural light, vessels appear salmon pink and are movable over the scleral surface. Usually benign and self-limited, episcleritis may be nodular, as shown here, or may show only redness and dilated vessels
CORNEA
Corneal abrasion

 


Slit Lamp Examination:
1. Tetracaine opth, Put in 1-2 drops in affected eye.
2. Place Fluorescein stain strip on the side of the eye, Have pt close eyes
3. Turn off room lights, turn on Slit lamp. 

Removal:

Any retained foreign body needs to be removed to prevent further damage. Any remaining rust rings from metal debris should be removed at a follow-up appointment within 24 to 48 hours.
Contact lenses should not be worn while the eye recovers. Contact lens use may be restarted once approved by an ophthalmologist or, for small defects, once the patient has been symptom-free for 24 hours.
 

Rx:
Analgesic:
Diclofenac ophthalmic : (0.1%) 1 drop into affected eye(s) up to four times daily, #5mL
-OR-
Cyclopentolate ophthalmic : (1%) 1 drop into affected eye(s) every 6-8 hours, # 2 mL

ABx:
Tobramycin ophthalmic (Tobrex) :
(0.3%) 1-2 drops into affected eye(s) every 2-4 hours, or apply ointment to affected eye(s) every 3-4 hours. #5 mL
 

Tetanus.



Corneal infiltrates or ulcers

 


Two small corneal white spots that are either infiltrates or ulcers (indicated by the arrows) are shown with normal light illumination
Corneal foreign body  Corneal foreign body that has been present for several days, resulting in inflammatory reaction to iron in the foreign body and causing local haze and surface breakdown that picks up stain
Corneal pannus

 

 
IRIS/LENS
Acute angle closure glaucoma  EMERGENT OPTHO REFERRAL
The conjunctival vessels are dilated, especially near the cornea (ciliary flush) and the cornea is slightly hazy (edematous
Anterior Uveitis  The irregular pupil shape is caused by inflammatory adhesion of the iris margin to the anterior lens surface superiorly
- Prednisolone ophthalmic 1%, 1-2 gtts into affected eye(s) 2-3 x daily
- Optho Consult if infected

Source: uptodate.com