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61. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy

). Assess for lymphadenopathy, facial or distal extremity swelling (may be signs of drug-induced hypersensitivity syndrome [DIHS]/drug reaction with eosinophilia and systemic symptoms [DRESS]). Assess for pustules or blisters or erosions in addition to areas of “dusky erythema,” which may feel painful to palpation. To assess for a positive Nikolsky sign, place a gloved finger tangentially over erythematous skin and apply friction parallel to the skin surface. Nikolsky sign is positive if this results (...) in the nares, sores or discomfort in the oropharynx, odynophagia, hoarseness, dysuria, sores or discomfort in the vaginal area for women or involving the meatus of the penis for men, sores in the perianal area, or pain with bowel movements. ○ Physical examination: include vital signs and a full skin examination specifically evaluating all skin surfaces and mucous membranes (eyes, nares, oropharynx, genitals, and perianal area). Assess for lymphadenopathy, facial or distal extremity swelling (may be signs

2018 American Society of Clinical Oncology Guidelines

62. Guidelines of care for the management of basal cell carcinoma

carcinoma. Area L consists of trunk and extremities (excluding hands, feet, nail units, pretibia, and ankles); area M consists of cheeks, forehead, scalp, neck, and pretibia; and area H consists of central face, eyelids, eyebrows, periorbital skin, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, ear, genitalia, hands, and feet. Greatest tumor diameter. Location independent of size may constitute high risk. Area H constitutes a high-risk area on the basis of location

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2018 American Academy of Dermatology

63. Ectropion

Ectropion Ectropion submit The College submit You're here: Ectropion Ectropion The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care. Share options Aetiology Outward rotation of the eyelid margin (usually lower). Occurs in approx. 4% of the population over 50 (bilateral in 70%). Various causes: involutional (age-related degeneration) most common horizontal lid (...) laxity weakness of pretarsal part of orbicularis oculi muscle weakness of medial and lateral canthal tendons Cicatricial: scarring +/- contracture of skin and underlying tissues trauma burns skin tumours actinic skin changes due to prolonged sun exposure Paralytic (refer to Clinical Management Guideline on Facial Palsy) Mechanical tumour at or near the lid margin lid swelling due to inflammation from infection or allergy Congenital rare bilateral condition Predisposing factors Lid laxity increases

2018 College of Optometrists

64. CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)

of Europ Soc Ophthalmol, Helsinki 1985: 383-4 Lay summary Contact lens-associated papillary conjunctivitis (CLAPC) is an inflammatory condition affecting the transparent membrane which lines the back of the upper eyelid (tarsal conjunctiva). It can occur in people wearing soft or rigid contact lenses or an ocular prosthesis (artificial eye). People suffering from this condition experience eye irritation, which may lead them to abandon contact lens wear. The vision may be blurred intermittently (...) . The eyes are often red and the underside of the upper lid shows minute cobblestone-like swellings called papillae. Treatment for CLAPC initially consists of improving contact lens hygiene and replacing lenses more frequently. Eye drops such as anti-histamines or mast cell stabilisers are often required to relieve symptoms and improve clinical signs. In more severe cases it may be necessary to use steroid eye drops for short periods. CL-associated Papillary Conjunctivitis (CLAPC) Giant Papillary

2018 College of Optometrists

65. Cellulitis, preseptal and orbital

in Denniston AKO and Murray PI: Oxford Handbook of Ophthalmology, 3rd edition, OUP 2014) Contrast-enhanced CT scanning should be performed in all patients with symptoms and signs suggestive of orbital cellulitis Differential diagnosis Preseptal cellulitis: orbital cellulitis hordeolum (external or internal) acute blepharitis viral conjunctivitis with eyelid swelling allergic conjunctivitis with eyelid swelling angioneurotic oedema (if bilateral): could indicate severe systemic allergic reaction, e.g (...) and Haemophilus species Predisposing factors Preseptal cellulitis: upper respiratory tract infection dacryocystitis hordeolum impetigo (skin infection) trauma, sharp or blunt, around eye recent surgery around eye Orbital cellulitis: acute sinusitis (especially ethmoid sinusitis) trauma including orbital fracture dacryocystitis preseptal cellulitis dental abscess Symptoms Preseptal cellulitis: acute onset of swelling, redness and tenderness of lids fever malaise irritability in children Orbital cellulitis

2018 College of Optometrists

66. Conjunctivitis medicamentosa

Conjunctivitis medicamentosa is a condition in which a drug applied to the eye as drops or ointment, a cosmetic or some other substance reaching the eye surface, causes an irritative or allergic reaction. Some drugs are more likely than others to create this problem, including some antiglaucoma agents and some antibiotics. It can also be caused by preservatives in the medication. The patient notices redness, stinging or burning and possibly eyelid swelling and/or blurred vision. Once recognised (...) , but individual susceptibility to conjunctivitis medicamentosa varies widely Symptoms Initial improvement in the original condition requiring treatment Then apparent deterioration despite proper compliance with regimen Irritation, ocular pain, stinging, burning, photophobia Ocular redness Lid swelling Blurred vision Signs Diffuse punctate staining of cornea and/or conjunctiva Chronic epithelial defects (due to toxic inhibition of epithelial healing) Sometimes: corneal oedema pseudodendrites disciform stromal

2018 College of Optometrists

67. Conjunctivitis (Acute Allergic)

provoking an immediate (Type I) IgE-mediated response Common in children Allergens include: grass pollen, animal dander Predisposing factors History of allergic disease; can also occur without such history Symptoms Sudden eyelid swelling Ocular itching May be unilateral (if a direct contact response) Signs Lid oedema and erythema Conjunctival chemosis (oedema): may bulge over lid margin or limbus Watery or mucoid discharge (mild) Usually no papillae No corneal involvement Differential diagnosis Seasonal (...) A, Sastre J, Montoro J, Jáuregui I, Dávila I, Ferrer M, Bartra J, Mullol J, Valero A. Allergic Conjunctivitis and H1 Antihistamines. J Investig Allergol Clin Immunol. 2009;19,Suppl.1:11-18 Lay summary Acute allergic conjunctivitis is an allergic reaction of the eyes, which causes a sudden swelling and redness of the eyelids and conjunctiva (the membrane covering the white of the eye), often associated with itching. It usually occurs in predisposed individuals, typically following exposure to grass

2018 College of Optometrists

68. Hordeolum

These infections are usually staphylococcal Predisposing factors Chronic blepharitis Symptoms Tender lump in eyelid Epiphora Local redness of eye and lid Signs External hordeolum Tender inflamed swelling of the lid margin. May point anteriorly through the skin Occasionally, multiple abscesses involve entire eyelid Internal hordeolum Tender inflamed swelling within the tarsal plate. More painful than a stye. May point anteriorly through the skin or posteriorly through the conjunctiva Differential diagnosis (...) of the eyelid. An internal hordeolum affects the Meibomian (oil) glands within the eyelids whereas an external hordeolum (commonly referred to as a stye) affects the glands associated with the eyelashes. Both conditions cause red and tender swellings of the eyelid. Traditional remedies such as hot spoon bathing and/or warm compresses may relieve symptoms. In some cases, treatment with antibiotic drops or ointment is needed to speed up recovery. In the case of a severe infection, antibiotic tablets may

2018 College of Optometrists

69. Trauma blunt

be vocational (e.g. boxing) Symptoms Pain varies from mild to severe Epiphora Visual loss (variable) Photophobia Possible diplopia Signs Mild cases (usually with good corrected vision) eyelid swelling (oedema), ecchymosis (bruising) conjunctival chemosis, subconjunctival haemorrhage unexplained subconjunctival haemorrhages in babies and young children may indicate non-accidental injury corneal abrasion Severe cases (usually with some loss of visual function) infraorbital nerve anaesthesia (lower lid, cheek (...) , side of nose, upper lip, teeth) may indicate orbital floor fracture disturbance of ocular motility: restriction or diplopia due to tissue swelling or muscle tethering by orbital (‘blow-out’) fracture enophthalmos (sunken eye) may also indicate orbital fracture among paediatric patients, orbital floor blow-out fractures may occur with minimal soft-tissue signs (‘white-eyed blow-out fracture’) nasal bleeding (direct trauma, or could indicate skull fracture) corneal oedema or laceration AC: hyphaema

2018 College of Optometrists

70. Nasolacrimal Duct Obstruction

Guideline on ) iatrogenic (e.g. repeated probing, eyelid surgery) secondary to ectropion or punctal eversion Mechanical (trauma, tumours, obstruction by lashes or foreign matter, e.g. dacryoliths [calcium stones], punctal/canalicular plugs) Infection of canaliculi (canaliculitis) rarely, due to Actinomyces (Streptothrix sp.) – a Gram-positive bacillus such cases usually unilateral pouting’ punctum typical Local infection (chronic sinusitis, dacryocystitis) Predisposing factors Age: congenital in babies (...) for size (normally 0.2 to 0.3 mm diameter) apposition to the globe and marginal tear strip contact with opposite lid on eye closure Differential diagnosis Congenital Congenital glaucoma (acute) Punctal atresia (congenital absence or abnormal narrowing of puncta) Acquired Rule out inflammation or infection (pain, discharge, swelling, redness, mucus reflux on syringing in adults, history of sinusitis): canaliculitis (chronic mucopurulent conjunctivitis, punctum expresses chalky concretions, redness

2018 College of Optometrists

72. CRACKCast E119 – Allergy, Hypersensitivity, Angioedema, and Anaphylaxis

, used for BB overdoses) [10] Compare and contrast the management of angioedema with urticaria and without urticaria Urticaria appears as papules or wheals that consist of central swelling with surrounding reflex erythema, and it is associated with itching or a burning-type sensation. These lesions are a result of mediators (predominantly histamine) released from mast cells. They tend to occur on the extremities and trunk and are usually transient, with skin often returning toits normal appearance (...) inhibitor–induced angioedema, the inhibition of ACE, one of the main inactivators of bradykinin, results in increased bradykinin levels. ACE inhibitor–induced angioedema has a predilection for the face, often involving the, lips, eyelids, tongue, larynx, or pharynx. The highest incidence occurs in the first month of therapy but has been reported to occur as many as 10 years after therapy was initiated. Wisecracks [1] List the types of immune reactions and give an example of each Refer to box 109.1

2017 CandiEM

74. CRACKCast E022 – Red and Painful Eye

Etiology Symptoms Important differences to periorbial cellulitis Maxillary/ethmoid sinusitis Orbital trauma Dental Infection Need CT to rule out abscess Eyelid swelling / redness Warmth of skin overlying orbit Tenderness over bone Palpebral injection/chemosis of the conjunctiva Fever Ill / Toxic appearance Blurred vision Proptosis Painful or limited extraocular movements § Binocular diplopia Edema of optic disk Venous engorgement of the retina Management: Further Work Up: Treatments Measure IOP, if >20 (...) to perceive light V: Visual field testing Confrontational field testing (not accurate for small field cuts) But this rarely changes the ED management E: External examination Of both external eyes and surrounding structures (facial bone fracture, etc.) Globe position: exop/enophthalmos (proptosis) Conjugate gaze Periorbital soft tissues, bones, sensation i. Examination of upper a lower eyelids, including eversion*** Ensure no foreign body ii. Assess adjacent structures E: Extraocular muscle movement Assess

2017 CandiEM

75. CRACKCast E128 – Thyroid and Adrenal Disorders

of thyrotoxicosis: Autoimmune, infectious, drug induced, endocrine, silent/subclinical, factitious [2] List 5 ophthalmologic findings in hyperthyroidism / Graves’ Ophthalmopathy is a classic finding in Graves’ disease; it is thought to result in a proliferation of orbital fibroblasts differentiating into adipocytes and orbital infiltration of inflammatory cells. Patients subsequently present with diplopia, photophobia, tearing, grittiness, and pain because of corneal exposure, as well as eyelid edema, hyperemia (...) of destruction and eventual fibrous replacement of the gland’s follicular tissue. Infiltrative disorders, Congenital thyroid dysfunction, Pregnancy, Radiotherapy, Medications, Lithium Amiodarone Infection, Surgery, Inadequate dietary iodine intake, (#1 cause worldwide) Thyroid medication noncompliance, Previous treatment of thyrotoxicosis. Symptoms of hypothyroidism: Sinus bradycardia Diastolic heart failure Dyspnea on exertion Decreased exercise capacity Constipation Menorrhagia Periorbital swelling Goiter

2017 CandiEM

76. CRACKCast E133 – Parasitic Infections

Trypanosomiasis and African Trypanoso miasis American Trypanosomiasis (Chagas Disease): Causative Agent: Trypanosomiasis Cruzi Endemic Region: South America Vector: Reduviidae bug (Assassin/Kissing Bug) Clinical Presentation: Romana sign – swelling of the ipsilateral eye and eyelid to the bite from inadvertent spreading of infected bug feces into the eye Complications: Myocarditis Dilated Cardiomyopathy Meningo-Encephalitis (can be chronic) Treatment: Nifurtimox / Benznidazole African Trypanosomiasis (African

2017 CandiEM

77. CRACKCast E071 – Ophthalmology Part B

management Scleral globe rupture Occurs in setting of blunt or penetrating trauma May be obvious (contents oozing) or subtle Symptoms: VA / pain Signs: Bloody chemosis / severe subconjunctival hemorrhage / Tear drop pupil RAPD / poor VA / no red light reflex Do NOT do tonometry CT: Only 75% sens. Treatment: Eye shield Head of bed > 45 degrees NPO Antiemetics Analgesics Antitussives Broad spectrum abx: Ceftriaxone & gentamicin & vancomycin 7) List 5 indications for ophtho consultation for eyelid (...) lacerations Laceration of the eyelids Need to search for a penetrating injury and foreign body Simple superficial lacerations not involving the eyelid margin can be treated in emerg. Simple 6-0 / 7-0 interrupted sutures removed in 3-5 days Complex lacerations needing referral: Lac of the lid margin Of the canalicular system (medial eyelid) Involving the levator or canthal tendons Through orbital septum Presence of orbital fat*** = no subcutaneous fat in the eyelids so the fat is likely from a globe injury

2017 CandiEM

78. CRACKCast E071 – Ophthalmology Part A

, lubrication Optho follow up PO acyclovir as effective as IV acyclovir for vitreous penetration 8) Define and manage a) Hordeolum, aka “Styes” / Chalazion Localised, nodular, inflammatory processes Hordeolum Chalazion Etiology Begins as a diffuse swelling and erythema of eyeLID margin Inflammation of glands of Zeis or HAIR follicles — Staph. species Obstructed Meibomian gland — > Swelling within the lid surface. ***lid margin is NORMAL*** Symptoms Pain, swelling redness “” Treatment Warm compresses for 15 (...) out abscess Eyelid swelling / redness Warmth of skin overlying orbit Tenderness over bone Palpebral injection/chemosis of the conjunctiva Fever Ill / Toxic appearance Blurred vision Proptosis Painful or limited extraocular movements Binocular diplopia Edema of optic disk Venous engorgement of the retina Further Work Up: Treatments: Measure IOP, if >20 may need surgery Blood cultures CT orbits to rule out: Foreign body Emphysema Hematoma Abscess Osteomyelitis Cavernous sinus thrombosis Consider

2017 CandiEM

79. Guidelines for care of patients with actinic keratosis

/amenability; ??? very ?exible/amenable. First hospital clinic attendance NHS tariff 2014–15: £104. 178 Hospital follow-up attendance: £68. GP visit: £44. 179 © 2017 British Association of Dermatologists British Journal of Dermatology (2017) 176, pp20–43 28 Guidelines for actinic keratosis 2017, D. de Berker et al.8.2 Active treatments All topical therapies for AK may result in side-effects of irrita- tion. Some AKs proceed to ooze, crusting and soreness with local swelling. Details are cited (...) the eye. 162 Studies undertaken in ophthalmology suggest that treatment is possible with close supervision. Treatment can be combined with care of the eye. In a case series of 14 patients treating periocular skin with 5-FU 5% twice daily for 2 weeks, antibi- otic ointment was coprescribed and used until the area had healed. 163 Six of the 14 AKs were on the upper eyelid and nine abutted a lid margin. Five patients required a second course of treatment, but overall clearance was complete in all cases

2017 British Association of Dermatologists

80. Orbits, Vision and Visual Loss

described inflammatory condition that may account for a significant percentage of patients that have been previously described as idiopathic [39-41]. Manifestations include eyelid or periocular swelling, lacrimal gland enlargement, extraocular muscle involvement, intraorbital mass, proptosis, and cranial nerve V involvement. CT CT of the orbits with contrast is often the initial imaging modality in the emergent setting for suspected infection [2,7,42,43]. CT is superior to MRI for foreign body (...) the scope of this article. Discussion of Procedures by Variant Variant 1: Traumatic visual defect. Suspect orbital injury. Initial imaging. Patients with traumatic orbital injury may have injuries that are isolated to the orbit or have intracranial manifestations, depending on the mechanism and severity of injury. In the United States, orbital trauma accounts for approximately 3% of visits to the emergency department [8]. Orbital injury should be suspected if periorbital soft-tissue swelling, hyphema

2017 American College of Radiology

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