PANCE Blueprint EENT (7%)

Lacrimal disorders (PEARLS)

NCCPA™ PANCE Eyes, Ears, Nose, and Throat Content Blueprint eye disorders ⇒ lacrimal disorders

Dacryoadenitis and Dacryocystitis Dacryoadenitis

Patient with dacryoadenitis will present as → a 32-year-old woman presents to the emergency department with a 2-day history of pain, redness, and swelling in the outer corner of her right eye. She denies any vision changes, discharge, or trauma. She has no significant past medical history and is not on any medications. On physical examination, you note localized erythema and swelling over the lateral aspect of her right upper eyelid. Her visual acuity is normal, and there is no proptosis.

Dacryoadenitis is inflammation of lacrimal (tear-producing) glands usually caused by bacteria or a virus that initiates the inflammation (supratemporal)

DX: The diagnosis is based on clinical observation ⇒ CT orbits if chronic

TX:

  • If the cause of dacryoadenitis is a viral condition such as mumps, simple rest and warm compresses may be all that is needed
  • For other causes, the treatment is specific to the causative disease

Dacryocystitis

Patient with dacryocystitis will present as →  a 58-year-old woman presents to the emergency department with a 3-day history of increasing pain, redness, and swelling in the inner corner of her left eye. She also reports some purulent discharge from the same eye. She denies any vision changes or trauma. On physical examination, you note localized erythema, warmth, and swelling over the medial canthal area of her left eye. Her visual acuity is normal.

Dacryocystitis is an infectious obstruction of the nasolacrimal duct (inferomedial region)

DX:

  • In acute cases of dacryocystitis, a tear duct massage can be performed to express material for culture and gram stain
  • In patients who appear to be acutely toxic or those who present with visual changes, imaging (CT), and bloodwork should be considered

TX:

  • Acute dacryocystitis (< 3 months) is treated with systemic antibiotics
  • Chronic dacryocystitis (> 3 months) typically presents with fewer inflammatory signs and requires surgical therapy for the underlying cause

Left side Dacryocystitis woman 80 years

Left-sided dacryocystitis

Keratoconjunctivitis sicca
The patient will present as → a 48-year-old woman who complains of chronic eye irritation, dryness, and a gritty sensation in both eyes. She notes that her symptoms worsen at night and after prolonged periods of reading or screen time. She reports mild discomfort with bright lights and occasional blurred vision. Her medical history includes rheumatoid arthritis. On examination, her eyes appear slightly reddened with decreased tear meniscus, and she blinks frequently. Given her symptoms and history of autoimmune disease, keratoconjunctivitis sicca (dry eye syndrome) is suspected. A Schirmer’s test reveals tear production of less than 5 mm in 5 minutes, confirming significantly reduced tear production. The patient is advised to use artificial tears frequently throughout the day and is prescribed an ophthalmic lubricating ointment for nighttime use. A follow-up visit is scheduled to monitor her response to therapy.

Keratoconjunctivitis sicca, or dry eye syndrome, is characterized by chronic cornea and conjunctiva dryness due to insufficient tear production or increased tear evaporation

  • Common causes include autoimmune diseases, aging, certain medications, and environmental factors like prolonged screen exposure
  • Symptoms typically involve dryness, burning, and blurred vision, often worsening at night or after extended screen use

DX:  Relies on clinical symptoms and tests like Schirmer's Test, Tear breakup test (TBUT), and fluorescein staining

TX:  Include artificial tears, anti-inflammatory eye drops, environmental modifications, and punctal plugs to relieve symptoms and prevent complications like corneal ulcers or vision impairment

Schirmer's test

Schirmer's test, placing the strip in the lower eyelid pouch

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