2 Flashcards
features of Disciform keratitis (HSV)
- Disc-shaped stromal edema
- intact epithelium
- Mild iritis with localized granulomatous KP (mutton fat)
- ↑IOP
- No necrosis or corneal neovascularization
features of Necrotizing interstitial keratitis (HSV)
- multiple or diffuse, whitish corneal stromal infiltrates
- +- epithelial defect
- Stromal inflammation, thinning, neovascularization. → cornea may perforate
- Iritis, hypopyon, glaucoma
- Bacterial and fungal superinfection
how to treat HSV Corneal Epithelial Disease?
- Antiviral (e.g. Ganciclovir 0.15% ophthalmic gel, trifluridine 1% drops, vidarabine 3% ointment)
- cycloplegic
- taper topical CS
- debridement
- aft 1-2 wks unresolved→ consider superinfection
- discontinue topical antiviral
- nonpreserved artificial tear ointment
- Abx ointment
how to treat HSV corneal stromal disease?
Depending on severity, vision and types.
- Cycloplegic
- Topical Antiviral prophylaxis (prevents HSV keratouveitis)
- Topical CS (e.g. prednisolone acetate 1% / loteprednol 0.5%)
- Topical Abx (epithelial defect)
- Aqueous suppressants (↑IOP) avoid PG
- Tissue adhesive/corneal transplantation (corneal perforation)
what should be noted when treating HSV corneal stromal disease w/ Topical CS ?
Diagnose and treat any associated overlying epithelial defect and bacterial superinfection w/ Abx drops/ointment.
[Topical steroids are contraindicated in those with infectious epithelial disease.]
local SE of topical antivirals and Rx
toxic / allergic reaction: papillary / follicular conjunctivitis (typically aft 3 wks)
Rx: switch to oral antivirals
what additional work-up should be conducted in VZV eye disease compared to HSV?
- dilated fundus: acute retinal necrosis
2. Systemic: Immunodeficiency
systemic steroids use in Immunocompromised patients
Immunocompromised patients should not receive systemic steroids
topical antivirals or systemic oral antivirals for patients w/ VZV ocular findings
systemic oral antivirals 7-10 ds(e.g. acyclovir, famciclovir, valacyclovir)
duration of acute conjunctivitis
< 4 wks
“vital signs” of ophthalmology
Vision, pupil, and pressure [bf dilating]
which tissue has the highest protein concentration in the body?
The lens (65% water, 35% protein)
The thinnest bone in the orbit
lamina papyracea
bone that breaks most often during blunt trauma to the orbit
maxillary bone
Where does the retina get its nutrition supply?
- inner 2/3rds: retinal vessels.
- outer 1/3: choroid plexus.
Which full-thickness eyelid laceration is more dangerous – medial or lateral lacerations?
medial (canalicular tear-drainage system)
Which extraocular muscle doesn’t originate at the orbital apex?
inferior oblique (orbital floor)
ddx of itchy eyes
- Conjunctivitis (esp. allergic, vernal, and viral), giant papillary conjunctivitis
- blepharitis,
- dry eye syndrome,
- contact lens-related problems
- topical drug allergy or contact dermatitis
difference btw hordeolum(stye) and chalazion
- chalazion: blocked inflamed swollen Meibomian glands, nontender
- stye: ifxn of a sebaceous gland or eyelash follicle, superficial to the tarsal plate, painful
DDx of tearing
- lids, lashes,
- lacrimal
- cornea
- conjuctiva
follicles vs. papillae
- Follicles: viral, chlamydial, toxic
- dome-shaped, avascular/white nodules, filled w/ lymphocytes
- Papillae: allergic, bacterial
- flat-topped, red dots(central vessel) of varying sizes
signs of viral conjunctivitis
- Inf palpebral conjunctival follicles
- tender palpable preauricular LN
membranous vs. pseudomembranous conjunctivitis
- membranous: removal difficult w/ bleeding
- psedomembranous: removal easy w/o bleeding
corneal findings in viral conjunctivitis/epidemic keratoconjunctivitis
- punctate keratopathy
- Fine intraepithelial microcysts
- Subepithelial infiltrates (SEIs) (a few wks aft onset)
most common cause of viral conjunctivitis
Adenovirus
variants of viral conjunctivitis
- Epidemic keratoconjunctivitis
- Pharyngoconjunctival fever
- Acute hemorrhagic conjunctivitis (last 1-2wks)
course of viral conjunctivitis
- self-limited
- first 4 to 7 ds: gets worse
- 2 to 3 weeks:resolve (potentially longer with corneal involvement).
Rx of viral conjunctivitis/epidemic keratoconjunctivitis
- avoid contact, handwashing
- tears
- cool compress
- antihistamin(e.g. epinastine0.05%)
- peel
topical drops for allergic conjunctivitis
severity
-tears
-antihistamine/mast cell stablizer
[Mild topical steroid (e.g., loteprednol / fluorometholone) for severe]
[+ Oral antihistamine (e.g., diphenhydramine / loratadine) in moderate-to-severe]
signs of vernal/atopic conjunctivitis
- sup. and limbal papillae
- Horner-Trantas dots (limbal raised white dots of degenerated eos)
- sup. corneal shield ulcer
- SPK
why should patients on topical steroids should be monitored regularly?
IOP
how to treat shield ulcer?
- topical steroids (e.g.loteprednol, prednisolone acetate, dexamethasone)
- topical Abx
- cycloplegic
what feature is prominent in bacterial conjunctivitis?
Purulent white-yellow discharge
two types chlamydial conjunctivitis
- chlamydial inclusion conjunctivitis (STD)
2. trachoma (poor hygiene, endemic area)
Tetracycline derivatives are contraindicated in
- children <8 yr,
- pregnant,
- nursing mothers.
Arlt line
linear or stellate scarring of superior tarsal conjunctiva
seen in trachoma
Herbert’s pits
depressions in superior limbus due to involution and necrosis of follicles
(seen in trachoma)
Corneal findings in trachoma
- epithelial keratitis,
- focal multifocal peripheral and central stromal infiltrates,
- superficial fibrovascular pannus (most sup.1/3)
WHO classifications of trachoma
- TF (follicular): >5 follicles on the upper tarsus.
- TI (intense): Inflammation with thickening obscuring >50% of the tarsal vessels.
- TS (scarring): Cicatrization of tarsal conjunctiva with fibrous white bands.
- TT (trichiasis): Trichiasis of >=1 eyelash.
- CO (corneal opacity): Corneal opacity involving at least part of the pupillary margin.
Late complications of trachoma
- Severe dry eyes,
- trichiasis,
- entropion,
- keratitis, corneal scarring, superficial fibrovascular pannus, Herbert pits (scarred limbal follicles), corneal bacterial superinfection, and ulceration.
DDx of Chronic follicular conjunctivitis
- Chlamydia
- Viral (adenovirus)
- Bacterial (Moraxella, Staphylococcus aureus)
- Molluscum contagiosum
- Microsporidial keratoconjunctivitis
- Toxic conjunctivitis/medicamentosa
DDx of chronic conjunctivitis
- Chronic follicular conjunctivitis
- Parinaud oculoglandular conjunctivitis (Figure 3)
- Silent dacryocystitis
- Contact lens–related problems
- Conjunctival tumors
- Autoimmune disease
what may cause sub-conjunctival hemorrhage?
- Valsalva
- Traumatic (isolated/ w/retrobulbar hemorrhage or ruptured globe)
- HTN, DM
- Bleeding disorder.
- Antiplatelet or anticoagulant meds
- Topical steroid therapy
- Hemorrhage due to orbital mass (rare)
- Idiopathic.
sub-conjunctival hemorrhage usually clears w/n
2-3 wks
most prominent sx of scleritis
- severe and boring eye pain
- radiate to forehead, brows, jaw, sinuses
- awaken at night
- worse w/ eye movement and touch
characteristics of episcleral vessels
- large, radial
- movable
- blanch w/ topical phenylephrine 2.5%
Episcleritis vs. Conjunctivitis
Conjunctivitis: Diffuse redness and discharge with follicles or papillae.
most common cause of episcleritis?
unknown 60%
Characteristic violaceous scleral hue seen in natural light is seen in _______
scleritis
scleritis vs. episcleritis
Episcleritis: Sclera not involved.
- blanch with topical phenylephrine.
- more acute
- younger
- mild symptoms, if any.
causes for scleritis
up to 50%: systemic disease, typically CTD or vasculitic
the ISNT rule of neuroretinal rim (NRR)
thickness: I>S>N>T
I & S focal notching seen in glaucoma
The pressure measurements on the Goldman were calibrated using an average corneal thickness of
about 540nm
what is Tenon’s capsule?
Tenon’s capsule is the deep fascia of the eyes. It is a fibrous layer surrounding the globe of the eye from the ciliary margin of the cornea backwards to the entrance of the optic nerve.
Ant 1/3 back of conjunctiva
Mid 1/3 muscle sheaths
Post 1/3 orbital fat, optic nerve sheath
what sign is diagnositic of canaliculitis?
Expression of mucopurulent discharge or concretions from the punctum.
ddx of canaliculitis
- Dacryocystitis
- Chalazion
- Nasolacrimal duct obstruction
how to treat canaliculitis?
- remove(canaliculotomy)
- irrigate(abx)
- Abx drops and Abx p.o. /nystatin/trifluridine
- warm compresses
is topical Abx enough for Dacryocystitis?
No. systemic is also needed.
After 10 years, how many diabetics will show signs of retinopathy, and how about after 15 years ?
> 50%;nearly 90%
what can be seen on the retina of patients w/ Nonproliferative diabetic retinopathy (NPDR)?
- microaneurysms,
- dot-and-blot hemorrhages,
- Cotton-wool spots
- venous beading
- other vascular anomalies.
how to tell if it bleeds w/n the superficial RNFL or deep in the retina?
dot-and-blot : deep
flame: superficial
what outcomes can occur in PDR?
1.Neovascularization→ into the vitreous fluid→
vitreous movement or contraction→ retinal detachment
→sudden hemorrhaging with subsequent vision loss→vessels regress and scar down→massive traction on the retina
2. NVI → sudden neovascular glaucoma
the most common cause of blindness in diabetic patients
macular edema
retinal detachment definition
an abnormal separation between the sensory retina and the underlying RPE and choroid plexus
which population is prone to have retinal detachment?
- Myopic. (thinner retina)
- eye surgery(cataract extraction)
- traumatic sports
types of retina detachment
- rhegmatogenous (most common)
- traction (vitreous or DR neovascular)
- exudative（breakdown of the blood-retina barrier）
floaters in elderly people over 65
suspect PVD (posterior vitreous detachment)
most worried outcome of PVD
Retina detachment
sx of retina detachment
- Flashing lights/photopsias
- Floaters
- dark curtain
flashing lights+floaters
retinal detachment until proven otherwise.
Shafer’s sign
Suspended pigment particles may be seen floating in the anterior vitreous(“tobacco dust” )
It is pathognomonic for a retinal tear.
which needs surgery sooner, macula-on or macula-off retina detachment?
macula on (to make sure it STAYS on)
surgery for retina detachment
- laser or cryoprobe (tear/hole)
- Scleral buckling: a silicone band ‘indents’ for anterior breaks at the equator
- pneumatic retinopexy (injects bubble of gas or silicon oil)
- vitrectomy(severe and complicated)
drusen
yellow extracellular breakdown deposits that form deep in Bruch’s membrane.
Rx for dry ARMD
monitor and antioxidant vitamin
metamorphopsia
distorted lines that might indicate macular edema (amsler grid)
techniques to treat wet ARMD
- PDT (photodynamic therapy): coagulate the blood vessels without destroying the retina around it
- Lucentis(Ranibizumab, anti-VEGF)/Avastin(Bevacizumab)
Risk Factors of ARMD?
- FHx
- smoking
- obesity
- HTN
- hypercholesterolemia
How do we treat PDR?
PRP (pan retinal photocoagulation):ablating the peripheral ischemic retina with a laser→ VEGF↓
mechanisms in diabetic retinopathy that might lead to ↓vision
- Macular edema
- Vitreous hemorrhage
- Retinal detachment
What is a PVD?
posterior vitreous detachment – with aging the vitreous jelly liquefies and contracts. A sudden contraction can cause new floaters.
Weis ring
a piece of optic disk debris that has pulled off with the posterior vitreous detachment(PVD).
Wet ARMD
choroidal neovascularization that has grown up through Bruch’s membrane.
features of visual distortion in Migraine
- Multicolored photopsias in a zig-zag pattern that obstructs vision,
- lasts approximately 20 minutes.
- A headache may or may not follow.
- Normal fundus examination.
does Chronic retinal breaks (Usually asx) need treatment?
A retinal break surrounded by pigment suggests chronicity and usually does not require treatment.
most common cause of cotton wool spot
DM
Hollenhorst plaque
Cholesterol emboli that are typically refractile, orange, and seen at retinal vessel bifurcations.
The normal ratio of diameter of a retinal vein to a retinal artery at a given distance from the center of the optic disc
3:2
Approximately 70% of arteriovenous crossings are normally of the type
artery in front of vein
retinal signs of chronic hypertensive retinopathy
- AV nicking
- copper/silver wiring
- CWSs
- flame-shaped hemorrhages
- arterial macroaneurysms
- central or branch occlusion of an artery or vein
- rarely NV
retinal signs of acute/malignant hypertensive retinopathy
- ‘macular star’ hard exudate
- retinal edema
- CWSs
- flame-shaped hemorrhages
- optic nerve head edema
- rarely serous RD/VH
- Elschnig spots
Elschnig spots
small, black spots surrounded by light yellow
haloes which represent focal choroidal infarcts
Intraretinal microvascular abnormalities (or IrMAs)
shunt vessels and appear as abnormal branching or dilation of existing blood vessels (capillaries) within the retina that act to supply areas of non-perfusion in diabetic retinopathy
severe non-proliferative diabetic retinopathy criteria
“4-2-1”
- diffuse (traditionally >20) intraretinal hemorrhages in all 4 quadrants,
- 2 quadrants of venous beading,
- 1 quadrant of prominent intraretinal microvascular abnormalities (IRMA)
IRMAs vs NV in DR
IRMAs:
- larger
- more broad arrangement
- intraretinal
- do not leak on FA
signs of ant. uveitis
- cells and flares in AC
- ciliary flush
- keratic precipitates(KP)
CWSs found in a healthy patient without underlying diabetes or hypertension
consider HIV testing
Rx of ant. uveitis
- cycloplegics
- topical steroids
- systemic steroids(r/o infxn)
- glaucoma(avoid pilocarpine)
- causes
Bilateral recurrent alternating anterior uveitis
very characteristic of HLA-B27 uveitis
hard drusen vs. soft drusen
- hard: small, discrete, round, punctate nodules
2. soft: larger, pale yellow or gray, without discrete margins that may be confluent
