AE Flashcards
1
Q
Type 1 ocular allergy response phases and mechanism?
A
1) Sensitization phase, Early phase, Late phase
2) pollen antigen binds to igE b cell and Th2 cell
Initial response) igE antibody binds to mast cell, primary and secondary mediator release, vasodilation, vascular leakage.
Late phase) Eosinophil activated by TH2 and Mast cell, releases granules, leukocytes, mucous secretion, mucousal oedema
2
Q
Mast cell responses and what they cause
A
mediator is histamine
Vasodilation (redness) -prostaglandins, leukotrines, platelet activating factor
Increased permeability (swelling) -prostaglandins, leukotrines, platelet activating factor
Nerve stimulation (itching)
epithelial cells - recruitment of additional inflam cells
3
Q
Classification of allergy (conjunc)
A
Allergic conjunctivitis (seasonal, perennial) Vernal keratoconjunctivitis Atopic keratoconjunctivitis giant papillary Conjunctivitis contact and drug induced allergy
4
Q
Pharmaceutical treatment of allergic conjunctivitis
A
Mast cell stabilizers - competitive antagonist against IgE to mast cell surface. Prevents degranulation
Anti histamines - competitive antagonist of histamine receptor on vessels, nerves and epith cells. Prevents mast cell degranulation
10 min action
Dual action meds combine them both
vasoconstrictors reduce redness and swelling but combined with antihistamine
5
Q
Seasonal vs Perennial Allergic conjunc
and treatment
A
S) season, grass. pollen. etc
treatment) monitor levels and choose when, close fitting sunglasses, wash hands
P) All yr, dustmites
treatment) wash bedding reularly 60 deg, clean all areas, dehumidifier
6
Q
Allergic conjunctivitis (signs, sx, treatment)
A
Signs) lid swelling, mucous discharge
sx) itchy eyes, burning, watery eyes, photophobia
treatment) steroids or sodium cromoglycate
7
Q
Giant Papillary conjunc. Cause, signs, sx, treatment
A
mech and chem irritation, usually CL wearers with deposit build up
Signs) conjunctival hyperaemia, mucous, thickening and opacification of palpebral conjunctiva w larger papillae
sx) itching on lens removal, blurring of vision, CL intolerance
Treatment) rigid lens/soft enhanced with more wetability, dailies, if unresponsive then Mast cell stabilizers
8
Q
Vernal Keratoconjunctivitis who, signs and sx,
A
bilateral, usually males (3-25yrs) , warm climates
signs) large papillae in palpebral conjuncitva, sight threatening
sx) itching, photophobia, pain
9
Q
Atopic Keratoconjunctivitis, who and signs
A
sight threatening, teenagers to early 20’s, FOH atopy, atopic dermatitis
signs) thickened eyelids, flattened velvety papillae, bleph
10
Q
Treatment for Vernal and Atopic Keratoconjunctivitis
A
Steroids - block release of enzymes which release prostaglandin and leukocytes
SE - cataract, iop elevation
NSAIDs (non steroidal anti inflam drugs) - inhibit cyclooxygenase, no prostaglandin production
CI) asthma
can delay corneal healing
Immunosuppressants against T lymphocytes
cyclosporin 2%
in untreated, blinding
11
Q
Contact ocular allergy (cause, explanation, differential diagnosis)
A
contact dermatitis + drug induced allergic conjunctivitis
Hypersensitivity because of chemicals. eg cl sol, pilocarpine
sunlight expose - photocontact dermitits
DD) Viral/bacterial conjunc
12
Q
Types of keratitis (Red eye)
A
Bacterial, Fungal, Viral,
13
Q
Bacterial Keratitis, factors causing and appearance
A
Factors - DE, Entropion, CL, corneal abrasion, steroid use, decreased vision
appearance - staphylococcus cause white oval infiltrate/ulcer around iris
14
Q
Fungal Keratitis, how?
A
Trauma w vegetable matter, yeast keratitis affects cornea with pre existing disease
15
Q
Viral Keratitis, how?
A
Adenovirus,
Herpes simplex direct transmission through secretion,
Herpes zoster may involve trigeminal nerve
16
Q
Peripheral corneal ulcer types
A
Marginal, Moorens, system disorder
17
Q
Bacterial Conjunctivits sx
A
sx - gritty, sticky, mucous discharge.
18
Q
Viral Conjunctivitis sx, and what it can lead to.
A
Bilateral, watery, follicular
1) Leads to punctate keratitis
2) Sub-epith opacities
3) anterior stromal infiltrates
19
Q
Inclusion Conjunctivitis sx, what it leads to, treatment
A
chlamydia, large follicles near limbus,
1) Can lead to superior epithelial keratitis
2) sub epith infiltrates
treat with tetracycline
20
Q
Trachoma, cause, process, treatment
A
carried by common fly, follicular reaction in upper lid
blindness by conjunctival, corneal, eyelid scarring
tetracycline treatment and lid/corneal surgery
21
Q
Episcleritis, what is it, types, sx, treatment
A
- inflammation of episclera
- nodular or diffuse
- unilateral redness and discomfort
- topical steroids if severe
discomfort rather than scleritis pain
22
Q
Scleritis, types, associations
A
Anterior, Posterior, Scleromalacia
-assoc - herpes zoster, gout, Crohn’s, erythmatosus
23
Q
Ocular protective system (from foreign bodies)
A
Surrounding anatomy orbital fat eyelashes/lid tears to wash away corneal structure
24
Q
Classifying a foreign body
A
Metallic/non Embedded/Superficial Penetrating/non solid/L/G slow/fast projectile small/large objects
25
Symptoms of a foreign body and metal FB
```
photophobia
lacrimation
blepharospasm - lids shutting tightly
acute pain - sudden pain
hyperaemia - redness
reduced vision
```
Metal can cause rust ring and can enter globe
26
Slit lamp procedure for FB
DIffuse, sclerotic scatter, direct, indirect, retro, optic section
27
Blow out fracture, Features
1) Posterior displacement of globe by object
2) orbit fractured at weakest pain
3) soft tissues herniate into maxicillary sinus
Features - enophthalmos, eye elevation reduced, loss of sensation
28
Photokeratitis, sx, Welders flash
UV exposure
FB sensation, photophobia,
lacrim, blepharospasm, reduced VA, hyperaemia
WF - bloodshot, acute onset arc eye from uv exposure, symptoms gone by 48hrs
29
alkali injuries, how and compared to acid
1) loss of corneal epithelium
2) clouding/oedema
3) ischaemia of blood vessels
4) neovasc
5) glaucoma
acid is better as self limiting coagulation of surface
30
Treating Foreign body
advice - protective eyewear
irrigation - wash
therapeutics - if epithelial, broad spectrum antibiotics
31
Foreign Body removal and Surgery
Removal - Cottonbud, anaesthesia, rust ring removed with needle
Photo- therapeutic keratectomy
32
Pterygium - what is is, who?
grey opacity at nasal limbus, can be temporal
conjunc overgrows cornea in triangle shape
hot climate
33
Scleral lenses, what are they?, when did they come about?, why use them?, downside
1) lens extending out of sclera, hard lenses 14mm+
2) First type of CL, glass shells 1888, poor oxygen and repeatability
3) Keratoconus, pellucid marginal degen, post corneal trauma, post keratoplasty, post lasik, protective
4) uncomfortable, some eyes too hard to fit and can get dust under lens
34
Modern history of scleral lenses (PMMA)
1) PMMAs introduced in 1900's
2) tailored to eye shape, still not reproducible
3) RGP material from the 1970's
35
Types of scleral lens and how it is fit
- Full 18-24mm
- Mini 15-18mm - vault cornea entirely (doesnt touch cornea or limbus, lands on sclera.
Fit odd shapes, protect, minimalize scarring)
Fitting sets used and calculated from topography
- Semi 13-15mm
36
Scleral lens insertion and removal
1) px looks down and holds lower lid
2) practitioner holds upper lid and inserts with other hand
3) record rotational axis stability
1) massage inferior bubble
2) scissor technique
3) DMV 45 plunger
37
Specification required to for toric mini scleral lens
- sag
- power
- over refraction
- mod to limbal fit and scleral landing
- axis of rotation markers
38
Care products
Soft lens solutions
no preservative saline
alcohol cleaner if necessary
39
Obstacles to successful wear of scleral lenses and how to overcome
1)Conjunctival prolapse - conjunc sucked up under lens. Harmless, when limbus over vaulted, choose lens diameter appropriately.
2)Deposits - front (leads to poor wetting) or back, can be hard to clean well when steep. Use progent
.
3)Excessive settling back - large lens, larger landing zone to spread weight more evenly
4)Fogging - fluid reservoir cloudy after a few hours, px remove and refil, worse in first month.
Due to lipids, use non preserved saline, closer fit, change ratio of artificial tear to saline
40
Early and Modern Orthokeratology and why?
E - conventional hard lens, flatter over time and daytime worn. 1,2D myopia, unstable fit
M - Accelerated, overnight and reverse geometry lens for stability. Full correction attempted w first pair.
W - decrease progression by 45%
-->reversible - corneal thickness recovers fully after one night of no lens wear, curvature after a week, rx UVA after 2 weeks
- ->convenient, unaffected by dry eye, myopia. No lenses lost in day, can go swimming etc, cleaned in morning when more awake
- ->management,
41
ORTHO-K LENS DESIGN
OVERALL D - 10.50 to 11mm, 360 degrees fit in periphery to allow even fit across distribution zone
Central zone - 6mm D, K(flat) - Rx
Fitting zone - Reverse curve (very steep, bring CL to cornea), approx 0.6mm, adjust to improve centration
Alignment zone - 1mm, responsible for centration, and channel for tear film forces
Peripheral zone - 0.4mm radius 11mm
42
Corneal toxicity and Ortho - k
Back surface peripheral torics
limbal to limbal astig
usually when cyl is over -1.50DC
43
How does ortho K work?
- Flattens central cornea without touching it.
- Redistributes corneal tissue instead of blending
- may not be plano
44
Who does ortho k work for?
Rx - Best for myopia -1 to -5, with the rule corrected up to -2.50DC. Against the rule up to -1.00DC
Corneal health - Keratoconus, scarring, LASIK, DE, anterior segment disease, abnormal topog
Systemic diseases - Diab reduces corneal sensitivity and healing
Lifestyle - convenience of not wearing in day
, patient expectations. Not for OCD BRUDDAS
45
How to fit Ortho K? types and fluoro
Fitting set/inventory
- initial trial fit
- from inv stock
- no topographer
- NaFl assessment
Empirical
- No trial fit
- custom made
- less chair time
- trouble shooting included
Fluoro
- open eye, not closed
- lens
46
Ortho K After Care visit and what is a good result.
1st visit - visit after 1 night - (impression, slit lamp, va - expect 2D reduction, slower with astigmats, residual refraction, topography.
possible glare
2nd visit - after 5-7 night - impression, unaided va, slit lamp, topog, subjective
3rd visits - after 10-14 nights - impression, unaided va, slit lamp, topog, subjective
Good result - comfortable over night, happy with vision, minimal staining, topography shows well centred
47
Topography - Ortho K
Bullseye - good outcome
DECENTRATION -
- Smiley face - high riding (WTR astig), Increase sagittal depth.
- Frowny face or- low riding, decrease sagittal depth.
- Central - central island pattern. sagittal depth too high so decrease it
- Lateral Decentration - too small, choose larger diameter
48
Specialist CL types, px who may require, poor VA
Bandage CL - after LASIK, thin and plano hydrogels worn for 3-4 days constantly. Allow epithelium to convalesce.
Therapeutic CL - Drug delivery in glauc/dry eye. And some individuals find more comfortable w allergies
Scleral lenses, coloured, post lasik, irreg shapes
Poor VA:
Albino, coloured lens remove light sensitivity as photophobic px
CL telescope system
highpower negative CL, appropriate positive specs lens
49
Advantages of specialist CL
spectacle VA inadequate, fitting of conventional poor, better image quality
50
Prosthetic lenses
painted lens and shells
- produce iris/mask scar/hide tropia
- can be used to mask aniridia
51
Therapeutic CL uses
1) form of bandage CL for drug delivery
2) protect against trauma
3) high water content espec after LASIK
52
Irregular corneas and how to check shape
- Primary corneal ectasia - keratoconus, keratoglobus, pellucid MD
- Recurrent erosion
- post surgery
Topography as keratometers only do the centre
53
Keratoconus, what, who, treatment, personality, sx, signs, what happens with CL, keratometry, what lenses for treatment
- Collagen disorder, reshaping of cornea into a cone
- usually bilateral and from FOH
- HARD LENSES, thickness graft
- obsessive
- irreg astig, worsening va, vogt stress lines, munsons sign (v shaped lower lid)
- reduced tolerance and eye rubbing
- oval shaped mires >47 dioptres, >1.50D difference between eyes
- Hybrid CL (soft perm) Soft periph, rigid centre
- Piggy CL -GP fitted over a soft
- Scleral CL
- No7 lens, C3/C4 design, three point touch
54
Corneal warpage
changing of corneal shape due to long term hard lens use.
NOT thinning
distorted keratometry mires
55
Spherical aberration, why
high positive power of eye,
compensated by periph corneal flattening,
higher R.I. of cornea and lens
56
Nidek OPD, what is it used for and how does it work?
corneal topography, wavefront tech
1) retina scanned with IR slit beam
2) reflections captured by photoreceptors
3) aberrations distort reflections
57
Opthonix Z view aberrometer, ft
High res wavefront tech
| PD, pupillary diameter, internal reading target and internal fixation
58
WestHeimer 1965
CL
steep curves, moves with eye, spherical aberration
Specs
shallow curvatures, movement of visual axis relative to eye, astig aberration
59
Embryology
- 3 weeks ->lens placode from surface ectoderm
- 6 weeks ->lens vesicle
- 12 weeks ->tunica vasculosa lentis
- 28-38 weeks ->degen of tunica vasculosa lentis
60
Macroscopic anatomy of lens
- Lens
Diameter - 10mm
Thickness - 4mm
Anterior face radius - 10mm
Posterior face radius - 6mm
61
Microscopic anatomy of lens
- Anterior lens epithelium - single cuboidal layer
- Lens capsule - basement membrane of lens epithelium
- Lens Zonules of Zinn - ligament of lens, w collagen fibrils
- Lens fibres - produced throughout life, parallel to curved surface
-Lens Zones - concentric area of refractive index
subcapsular zone (clear)
cortical zone (newly formed fibres) 1.38
Nuclear zone old fibres 1.40RI
62
Lens composition
- lower h2o content compared to the rest, 64%
- lens w high protein content, 35%
- 1%lipid, ph 6.9
63
Lens transparency, losing transparency and UV absorption
- Ordered arrangement of lens fibres, small refractive index difference between materials.
- Transparency loss - due to: protein aggregation, changes in tissue hydration, break down of membranes, changes in cytoskeletal structure.
- Lens UV absorption - development of fluorophores and pigment. So discolouration. This protects retina from UV damage. The result is the lens fluorescence.
- also by corticosteroids, smoking, diabetes
64
Lens aging
- width and density increases with age, 100mg to 250mg
- radii increases with age
- yellowing and browning with age
65
Types of cataract, risk factors
- Nuclear - light scattering due to brunescence
- Cortical - wedge shaped periph
- Posterior - abnormal epithelial cells
RF - cardiovasc diseas, diab, smoking, low anti oxidants, low socio economic status
66
Referral of lens and calculation
- opacification, no complete cut off
- when q of life reduced
P= 18 + (1.25 X RX) P IS IRIS SUPPORTED IOL
P = 1336 (4R - L) / (L - C) (4R -C)
R is corneal radius, C is anterior chamber depth
No n of aq/vit, or Rx
67
Types of scan and features
A-scan (2D) - interprets echoes from an axial beam, which reflects on intervening structures.
- shows 4 peaks: anterior cornea, anterior lens, posterior lens, retina.
B-scan (2D) - move in arc pattern 40-50 deg, can produce simultaneous A scans.
- surfaces shown as amplitudes shown as blips
- no echoes from fluid, blood cells might show tiny echoes.
M-scan - Time motion ultrasonography, look at tissue in realtime to see vascular changes. Similar to pregnancy tech
- follow up for tumours,
68
Couching
1) Perforating eyeball with sharp instrument
2) through cataract and into vitreous
However, lens proteins spread in eye, severe inflammation
69
Aphakic IOL (originals)
Heavy IOL, corneal endothelium loss, anterior uveitis, posterior capsule sclerosis
70
Anaesthesia, phacoemulsification, limbal relaxing incisions
1)
- 2-3ml lignocaine + intravenous sedative 6%(peribulbar)
Topical: - amethocaine + lignocaine (anterior chamber)
Comes down to px pref and surgery type
2)
- Ultrasonic probe inside eye allows lens emusification.
- Cuts tip into particles and takes in
- posterior capsule preserved and acts as support for IOL
- self seals
- allows efficient removal of lens material
- utilizes small incisions
3)
- corneal astig only 15% >2D
- surgical incision will flatten 0.75 dc on steep axis (more positive)
- 15 deg per dioptre of experience
71
Post Operation refraction
- check sph-equivalent
| - pre-op biometry
72
Nd YAG laser capsulotomy, posterior subcapsular rupture rate
Post cataract surgery, posterior subcapsular becomes cloudy.
Rise in IOP, increased risk of RD
Half of all complications,
indicator of surgeon quality, vit loss and RD
73
IOL materials
1) Silicone - 1.41-1.46
- flexible, strong, hydrophobic (increases cellular reactions). silicone oil sticks
2) Acrylic (hydrogels) - 1.55
- soft, tendency to stick, reduced rejection
3) PMMA - 1.49 STIFF
74
IOL implants, types, new implants
1) round edge
2) square edge
- posterior, anterior, pos with rounded edge
New implants)
- UV blocking/violet blocking ->AF-1 Hoya
- Quality ->Thinoptic
- Astigmatism ->Staar Toric
- Phakic ->Verisyse
- Adjustment ->Calhoun vision - 4D vision
75
Micro incision cataract surgery
1) Smallest incision size - 1.45
2) less chance for post op complications
3) quicker visual recovery
4) less force on zonules
Lens - akreos MI60, hydrophilic acrylic, 1.8mm incision required
76
Multifocal IOL's, Diffractive vs Refractive, accommodative
```
D
- grating on posterior surface,
- Light divided between distance and near foci
- reduction in contrast sensitivity
R
- range of powers on anterior surface
- all light reaches retina
- haloes and slight reduction in contrast sensitivity
```
Accommodative
1) Hinged optic - forward movement in response to accom
2) Cillary body contracts, vitreous cavity pressure rises, IOL moves forward
3) This movement increases positive power
77
Refractive surgery.
Initial consultation, pre surgery considerations, assess, corneal refraction, contact lens magnification formula, effect on IOP
1) leave out cl: (2 weeks soft lenses, 4 weeks hard)
must be stable.
2) VA, cycloRx, VF, AE, fundus, IOP, consent
3) diameter, pachymetry, biometry, topography, tear film quality, muscle balance, amp of accom.
4)
hyperopia - greater accom demand in specs than CL
myopia - less accom demand in specs than CL
5) CLM = 1 – d(m) Fsp d is BVD
6) Reduces IOP, corneal graft raises.
IOP DOESNT CHANGE, THE MEASUREMENT DOES
78
Keratoplasty and types
Penetrating corneal thickness grafts, taken from a donor then sutured on
1) Lamellar refractive keratoplasty
- keratophakia - human/synthetic insert
- keratomileusis - removed and reshaped
- Epikeratoplasty - cornea layer scraped away, lenticular placed on top
2)Keratectomy - tissue removed, crescent shape cut out to correct astig
3) Keratotomy - radial patterns cut into cornea for spherical correction, not on axis, weakens cornea, may cause globe rupture,
- radial - radial incisions
- astigmatic - transverse patterns alongside cataract extraction
4)Thermokeratoplasty - heating probe in mid periph, shrinks collagen, central steepening, for hyperopia
- Nichrome wires - 600 deg for 0.3 sec. Problematic
as unstable
-Ho - YAG laser - 55-60 deg, 1-3DS
- Conductive - radiowaves 65 deg, 0.6 secs.
79
Myopic and hyperopic PhotoRefractiveK, excimer laser keratotomy, how does it work?
1) myope - remove tissue to create flattening
hyperope - remove med periph tissue, causing steepening
2)
- Photorefractive keratectomy (PRK)
- insert speculum, anaesthetise, px looks at target, epithelium removed, dry surface bed, zap
>POST OP - VA may be poor due to rx, PAIN,
antibiotics, stabilise, 6-12 weeks
>Early complications - mild ptosis, infections, glare,
haloes
>Late complications - regression, persistent haze,
irreg topography, recurrent erosion
- Laser assisted in-situ keratomileusis (LASIK)
speculum insert, anaesthise, fixate, raise iop to 50, blackout, create flap, dry, zap, replace flap
>POST OP - flap is repositioned, epithelium grows
over cut, quick recovery and stability. Less initial
pain
- Laser assisted in-situ epithelial keratmileusis or Laser assisted sub-epith keratectomy (LASeK)
>POST OP - epithelium will gradually be replaced,
less pain,
VA quickly stable, stabilise within a month
3)
excimer - break molecular corneal bonds, remove and not burn
80
LASIK procedure
1) insert speculum
2) anaesthese cornea
3) fixation target seen
4) raise IOP w suction ring to 50 - 60mmhg
5) CRA blocked so blackout
6) corneal flap (microkeratome) , dry surface, laser, then replace flap
81
Solid state laser
- Higher wavelength, short duration laser
picosecond (10)-9or femtosecond (10)-12
-laser to cut the flap via infrastromal ablations
- femtosecond
restoring flexibility to lens, so fibres can slide and change shape
Recent developments
- custom wavefront
- iris recog software
- faster eye tracker
- quicker repetition rate
future
-single unit, changing wavelengths and flapless
82
Munnerlyn Formula
t = -(S2 x D) / 8(n-1)
S is the diameter,
D is the power,
T is the thickness
83
Other refractive procedures
- Intrastromal Ring - silicone ring placement PMMA up to -4.50DS
- Implantable Contact Lenses -
posterior phakic, implantable CL, periph iriditomy.
-3 to -20D, +4 to +14
anterior phakic, iris claw lens
- Clear Lens extraction
Cataract surgery, phacoemulsification, higher R.I.,
foldable and multifocal IOL.
- Intracorneal inlays - lamellar corneal flap
1) inlay changing corneal curvature - Rayndrop
2) inlay increasing depth of focus - Kamra Inlay
3) refractive inlays, alter refraction index - flexivue
and icolens
- Presbyopic surgery -
- multifocal ablation,
good - excimer laser, easily enhanced w
retreatment, can be reversed.
bad - temp as CL changes w age, corneal
remodelling, compromised distance vision
- monovision, - Lasers, IOLs and
- Thermokeratoplasty
- Scleral enlongation bands,
Scleroectomy
- Scleral surgery
- Schachars theory - zonules slack and lens bows in
relaxed position, lens cannot bow further when
cillary contracts
- Scleral surgery - inc lens/cillary body distance
Radial incisions, silicone placed in these, allows
Cillary Body to shift out
- multifocal
- IOL,
- Accommodating IOL
- PresVIEW - scleral implant to restore accom,
outside of visual axis, low SR, no FB sensation
84
DIsorders of the eyelashes
```
Trichiasis - misdirected eyelashes
Distichiasis - metaplastic eyelashes
entropion - inward rolling of eyelid
ectropion - outward rolling of eyelid
epiblepharon - pretarsal muscle and skin ride above margin
```
85
Blepharoptosis and ptosis, infections, ocular prutis
Blepharoptosis
- congenital - Levator Dystrophy, Congenital Horners syndrome
- Hereditary - Myasthenia Gravis, ocular myopathy, systemic myopathy, CPEO
Ptosis
- History - onset, duration, course, assoc sx, lid surgery, FOH
- Examination - full ophthalmic exam, lid exam,
- pay attention to - bells syndrome, lagophthalmos
- treatment - educating, support groups, botulinum, surgery
```
-> Infections
BACTERIAL
- Necrotizing fasciitis
- stye
- chalzion
- Infected Chalazion
VIRAL
- Herpes Zoster
- Herpes Simplex
- Molluscum contagiosum
- Viral Warts
```
Ocular Pruritis
-Contact Dermatitis (Dermatoblepharitis)
Remove cause, cool compress, MSC, antihistamines, NSAIDS, steroids
-Atopic dermatitis (eczema)
Remove cause, corticosteroids, lubrication of eyelids, Antihistamines and MSC
-Allergic conjunctivitis
Remove cause, specs shields, vasoconstrictors, MSC, anti histamines, NSAIDS, corticsteroids
-Vernal /atopic keratoconjunctivitis
Anti histamines, MSC, steds, supertarsal cortico steroid injection
-Contact lens– induced giant papillary conjunctivitis
discontinue CL, refit CL with MSC, and refractive surgery considered
-Viral conjunctivitis
-Dry eye syndrome
-Blepharitis/ Meibomian gland dysfunction
->DIAGNOSIS
skin patch test
86
Lumps and Bumps BENIGN
> Squamous papilloma - sessile or pedunculated lesion, SHAVE IT OFF
> Keratoacanthoemeba - horn lower lid, biopsy
> Sebaceous - Subcutaneous mass containing desquamated cells and keratin. Surgical excision
> Cyst of Moli - benign tumours of sweat glands. fluid filled cyst on eyelid, manage by surgical excision
> Capillary haemangioma - benign tumours of capillary endothelium, rapid growth. Beta blockers, corticosteroids,
> Port wine stain - malformation, always persists through life, flat pink skin patch, cryotherapy, laser, radiation
> Pyogenic granuloma - vascular proliferation, due to irritation or trauma, red mushroom shape, surgical excision
> Nevi - pigmented lesion, low malignancy potential, excision biopsy
> Xanthelasma - yellow ish plaques, often bilateral, surgical excision, co2 laser, topical trichloroacetic acid
> Eyelid Neurofibroma - benign nerve sheath tumour, excision is difficult
> Conjunctival Granuloma - granuloma on pos lid surface: chalazia or trauma. SHAVE EXCISION BIOPSY
>
87
Lumps and Bumps MALIGNANT
Suspicious signs of malignancy
- change in size, bleeding, destruction of skin, redirecting/destorying eyelashes, regrown after removed
> Basal cell carcinoma - eyelid tumour
RF - sun exposure
> Squamous cell carcinoma - less common,
> Sebaceous gland carcinoma - arising from meibomian gland, recurrent chalazoin, bleph,
> Melanoma - rare aggressive tumour from melanocytes. change in shape and colour, irregular surface
88
Disorders of the periocular skin
> Rosacea - redness of face, inflam of periocular region
warm compresses, eyelid hygiene, drops/ointment, antibiotics, immunosuppressive agents
> Seborrhoeic Keratosis
skin plaques, skin aging, greasy scaling skin patch, medical surgical
> Actinic Keratosis - may progress to squamous cell carcinoma, UV induced, thick, scaly, crusty skin patches, excision or cryotherapy
> Bowens diseases - squamous cell carcinoma
persistent brown/red spots, excision or cryotherapy
> Lentigo Maligna - malignant cells in superficial skin, progress to Melanoma. Treatment - monitor, complete excision
>
89
Corneal Diseases, Layers, Congenital clouding,
Layers
1) Tear film
2) Epithelium
3) Bowmans
4) Stroma
5) Duas Layer
6) Descemets
7) Endothelium
```
Congenital clouding
S - SCLEROCORNEA
T - TEARS IN DESCEMETS
U - ULCERS
M - METABOLIC
P - PETERS ANOMALY
E - EDEMA
D - DERMOID
```
90
Corneal conjunctival conditions
- Microcornea - <10mm, rest of eye normal
- Posterior embryotoxon - irregular ridge, schwalbes
ring
- Sclerocornea - limbus not well defined, severe
- Dystrophy - primary inherited,
Epithelial - microcysts, meesmans
Stromal - granular, lattice, macular
Endothelial - CHED, Fuchs
- Map dot fingerprint/ Cogans - epith basement
membrane, microcysts, subepithelial ridges,
geographic opacities
- Keratoconus - cornea thin and protrudes - progressive for 10-20 yrs until 30, Fleishcers ring, vogts striae, Hydrops, munsons sign
Treatment - crosslinking, rgp, corneal transplant
- Keratoglobus - entire cornea protrudes, thinning, rupture likely
- Pellucid marginal degeneration - BI, crescent shaped area of bilateral thinning
- iridocorneal endothelium disease - iris atrophy and neavus
-
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Corneal dystrophy types
- Meesmann's dystrophy - inherited, sx - FB, small grey white opacities
Granular dystrophy - axial, grey opaque granules, good vision until middle age
Lattice dystrophy - branching opacities, early reduction of vision
Macular dystrophy - grey opaque spots with indistinct borders, erosive sx
Schnyder's dystrophy - opacities from lipids and cholesterol, corneal transplant required
Corneal guttata - First stage of Fuchs dystrophy
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Fuch's dystrophy - slowly progression of oedema in elderly. MNGMENT
Hypertonic 5% NaCl
IOP control
BCL
PKP
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- Vortex dystrophy - deposits in Whorl's pattern.
Amiodarone intake, Indomathacin intake, Fabry’s
disease
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Corneal degenerations
• Lipid keratopathy
- Arcus sensils - white circle around iris periph due to decomp of fatty corneal materials
• Band keratopathy
- calcium band caused by: Chronic uveitis, End-stage glaucoma, Phtisis bulbi, Hypercalcemia.
Treat - surgical debridement
* Pingueculae/pterygia
* Salzmann nodular degeneration
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Acute Corneal disorders
* Dellen - tear film instability, thinning, following strabismus and glauc surgery
* Corneal abrasions - trauma, pain, red eye, epith loss w fluroescein, give antibiotics, NSAIDS
* Recurrent corneal erosions - lacrimation, photophobia, brown oedema in anterior stroma, use bandage CL, phototherapeutic keratectectomy
* Persistent epithelial defects - treat infection, bandage lens, nerve growth factor
* Epithelial basement membrane dystrophies
Non infective keratitis -
- Marginal - staphyloccoci ecotoxin cause hypersensitivity reaction, subepithelial infiltrate, mngmnt - antibiotics, lid hygiene
- periph corneal melt - caused by rheumatoid arthritis, the cornea periph reabsorbs. Give steroids, treat underlining condition and keratoplasty
- Moorens ulcer - caused by ischaemic necrosis, progressive and painful, steroids, immunosuppressants or chemotherapy
- Terriens Marginal Degen - bilateral thinning of periph cornea, with neovasc. Lamellar KP treatment
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Corneal Infections
- Bacterial Keratitis -
Rf - CL, age, trauma, surgery, meds
sx - rapid VA drop, pai, photophobia, discharge,
exam - epithelial ulceration, epithelial oedema, hypopyon
diagnosis - corneal scrapings, laboratory diagnosis
management - monotherap = fluoroquinolone
dual = oflaxicin, penicillin, gentimicin
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Viral keratitis
Adenovirus - follicular conjunc, pain, consider steroids
Herpes - dendritic ulcer - branches ending in beads, stromal infiltrate
Herpes - geographic ulcer - after steroid treatment, consider debridement anti virals
Herpes - stromal keratitis - hypersensitivity, iritis, scarring. Use topical steroids
Herpes - zoster keratitis, VS virus reactivated in ophthalmic division of V-CN
involvement of nose, Hutchinsons signs, bleph and conjunc
stromal keratitis is a sign, uveitis, episcleritis and scleritis
treatment: antibiotics, lubricants, steroids, analgesics for pain
Herpes fungal keratitis - spread deep into AC, fungi able to proliferate in cornea and resist host defence.
RF - improper CL wear, home made saline, swimming, tap water to wash
Acanthamoeba keratitis - ring infiltrates, sclero keratitis, dendritiform lesions
Treatment - multidrug therapy - PHMB, BROLENE, CHLORHEXADINE, TOPICAL STEDS
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CL ECON
20% drop out in first few months
Proactive eye care practitioners - many ECP's wait for practitioners to ask, but they may be unaware that they are potential candidates
When proactive approach, 6x more new wearers
How to introduce CL:
- profession, sports/theater/sales (eyecontact
better), hot and cold environ fog specs
- high rx specs are bulky
- note previous exp from lenses
- trial pair and benefits
- understand prev experience, address fear and
understand why failed, address expectations
When to introduce
- H/S, worn before or family
- offer trial at end, time of spec deliv
- probe on profession, hobbies, limitations of specs
- match benefits of CL w Px req
After Care visit Q
- ask how doing, relate to job hobbies etc, feeling after 5 mins, air conn room, cl wetting
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- Opportunity to upgrade
more drops req
eye turns red by end of day
hold mobile further away
husbands reading specs
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- CL correction for Astig
sph soft, toric soft, RGP
- CL material - modulus, friction, internal lubrication, oxygen
permeability, hydration and geometry (thickness
and edge design)
Disinfecting system
- incompatibilities between SH and preservatives
-
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Lids and lumps, conditions (Cancers, the rest memorise from PP)
- Basal cell carcinoma - skin cancer, head/neck/eyelid, doesnt heal, telangiectasia
may be younger px, excision & skin graft req
- Squamous cell carcinoma - Less common, lower lid, can become deep
rf - UV - sun, tanning beds, outdoor occupation, smoking, light skin/hair, surgical excision req
BCC VS SCC
B - slow, less blood, little scab, less freq if excision
S - fast growth, bleeds easily, scabs more, freq
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- Malignant Melanoma - 50's,
rf - sun, complexion, foh, sun sensitivity, poor tanning, freckling
MOLE BECOMING THIS Signs
- Asymm shape
- Border irregularity
- Colour variation
- Diam >5mm
Do Biopsy
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- Sebaceous cell carcinoma
rare, upper lid, firm and small enlarges, rock hard, telangiectasia, swelling, conjunctival hyperaemia, biopsy
suspect: yellow tumour, eyelash loss, destrcution of meibomian glands, atypical bleph, recurrent chalazion
- H/S taking
characteristics, duration, discharge, bleeding/telangiectasia, change in col/size, history of skin cancer
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Conjunc, episcleral and scleral abnormalities
- Conjunctival hyperaemia - in all conjuc,
DD perilimbral injection from uveitis
- Conjunctival Changes - haem, inflam, degen, pigmentation, lumps
- Subconjunc haem - trauma, venous pressure (coughing), hypertension
management - careful exam, systemic, referral if ned
- Conjunctival follicles - lymph follicles, viral or chlamydial.
- Conjunctival papillae - upper or lower fornix, telengiectasia
- Conjunctival and pseudo membranes -
True form - inflam exudate secreted by microorganisms. Tearing and bleeding.
- Adenoviral, vernal, gonoccoccal conjuc, removed by peeling
-Viral conjunctivitis -
Adenovirus, watery, photophobia, foreign body sensation, Chemosis, pseudomembrane
Chlamydia - prominent follicular response,
non tender preauricular lymphadenopathy
Trachoma - acute - follicles & keratitis
chronic - scarring, pannus
ft - DE, trichiasis, entropian
Allergic Conjunctivitis - hyperaemia, chemosis, mucoid, papillary reaction
- Atopic - itching, watery, mucoid discharge, vascularisation
- Vernal - seasonal, itching, watery, mucoid discharge, corneal epithelial defects. Horner Trantas dots, thick limbus
- Giant papillary conjunctivitis - inflam of conjunc, hypertrophy of superior tarsus, caused by CL
Steven Johnson Syndrome
Acute inflam of skin and mucous membrane
virus and drugs
Conjunctival degenerative conditions
- Pingecula - conjunctival callouses growing adjacent to cornea 3 or 9 o clock.
- Pterygium - growth of conjunctiva extending over cornea, by UV light. use sun specs, lubricants, steroids, refer for surgery
- Conjunctival concretions - FB or calcium lesions
- Episcleritis - inflam of episcleritis, signs - sectoral injection. Treatment - anti inflam agents, cold compress, monitor IOP,
- Scleritis - scleral inflam, autoimmune, women, keratitis, uveitis, cataract, glauc, thinning
sx - very severe pain
signs - red, assoc with uveitis
Complications - cataracts, glaucoma, RD
Treatment - anti inflam therapy
Anterior - sectorial, nodular, diffuse, necrotising
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- Conjunctival Naevus
modified melanocytes
junctional, compound and subepithelial
inclusion cysts
rarely malignant
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- Racial melanosis
Benign, non progressive
- Primary acquired melanosis
Pigmentation, acquired, beware change
- Conjunctival intraepithelial Neoplasia
Localised to epithelium, spectrum of disease, index of suspicious
- Chemical injuries
ACID, ALKALI, BLINDING
