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OralBoards > Anterior Segment > Flashcards

Anterior Segment Flashcards

1
Q

What is the differential diagnosis for papillary reaction on injected palpebral conjunctiva (patient presents with ocular irritation, redness, itching) ?

A

Vernal Keratoconjunctivitis (VKC)
Atopic keratoconjunctivitis (AKC)
Giant papillary conjunctivitis (retained foreign body - suture, contact lens)
Superior Limbic Keratitis (SLK)

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2
Q

What is the differential diagnosis for epithelial whorl like pattern (Vortex keratopathy) aka corneal verticillata?

A 
FACTS IN (identifying whorls in cornea)
F: Fabry's
A: amiodarone
C: chloroquine/chlorpromazine
T: Tamoxifen/Thioridazine
S: Subconj gentamicin
I: Indomethacin/ibuprofen
N: naproxen

Medications (Amiodarone, Indomethacin, Chloroquine/Hydroxychloroquine)
Systemic disease: Fabry’s (alpha-galactosidase deficiency)
Healed epithelial defect
Dendrite

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3
Q

What is the differential diagnosis for patient with severe eye pain upon awakening in the morning and slit lamp photo showing small map lines and dots?

A

Recurrent corneal erosion secondary to map dot fingerprint dystrophy (ABMD) or previous trauma
Other basement membrane dystrophies

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4
Q

What is the differential diagnosis for SL photo of eye with pointing of the inferior lid margin in downgaze (Munson’s sign) suggestive of keratoconus?

A

Keratoconus
Pellucid marginal degeneration
Keratoglobus
Keratoectasia after LASIK

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5
Q

What systemic disease/disorders are assoc with Keratoconus?

A 
Down syndrome
Atopy (asthma, eczema) - Atopic Keratoconjunctivitis (AKC)
VKC
Retinitis Pigmentosa (RP)
Leber Congenital Amaurosis (LCA)
Marfan's 
Floppy eyelid syndrome
CHED, PPMD
Mitral valve prolapse
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6
Q

What is the differential diagnosis for peripheral corneal thinning and vascularization?

A

Peripheral ulcerative keratitis (PUK) (cornea & sclera affected)
Mooren Ulcer (no “more” than cornea - only cornea affected)
Terrien marginal degeneration (painless, starts at the Top then advances circumferentially, leading edge of lipid and stains negatively with fluorescein)
Staph marginal
Exposure
Furrow degeneration (painless, seen in the clear zone between senile arcus and limbus)

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7
Q

What are important review of systems or systemic associations with PUK (peripheral ulcerative keratitis)?

A

History of joint pain to suggest rhematoid arthritis (RA), Lupus, Wegener’s (Granulomatosis with Polyangiitis), and Polyarteritis nodosa.

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8
Q

What is the differential diagnosis for a hypopyon?

A

Anterior uveitis
Behcet’s
Endophthalmitis

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9
Q

Differential diagnosis for transillumination defects?

A

Pigment dispersion syndrome / glaucoma (PDS/PDG)
PXF (pseduoexfoliation syndrome/glaucoma)
Trauma, recent ocular surgery
Albinism
HSV/HZV (Herpetic)

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10
Q

Differential diagnosis for white round paracentral corneal lesions in an asymptomatic middle age woman?

A

Salzmann’s nodular degeneration

Spheroidal degeneration from solar elastosis

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11
Q

What is commonly associated with Salzmann nodules?
What should be excluded?
What would you focus for on exam?

A

chronic inflammatory ocular/periocular conditions
Exclude interstitial keratitis, vernal keratoconjunctivitis, phlyectenule, TB, trachoma
Evaluate lids for blepharitis, palpebral conj for follicles or papillary reaction, and for Arlt’s line.
Examine cornea for abrasion, infiltrates, AC reaction

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12
Q

What is the differential diagnosis for mucous, debris and filaments on the cornea which stain with fluorescein?

What would you check on exam?

A

dry eye syndrome
filamentary keratitis
conjunctivitis
exposure keratopathy

Exam: Schirmers test (less than 5 mm is abnormal), measure TBUT, examine lid margins for blepharitis, evaluate lid closure to rule out exposure looking for lagopthalmos, look for conjunctival papillary or follicular reaction.

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13
Q

Differential diagnosis for unilateral eye redness and fluorescein stained cornea with dendritic formation with terminal bulbs?

A

HSV
HZV
Recurrent erosion syndrome

  • periocular skin for vesicles, conj for follicles, corneas for dendrite that stain well with fluroescein and rose bengal, look for terminal bulbs. disciform keratitis or interstitial keratitis.
  • zoster is dermatomal whereas HSV can cross dermatomes
  • dendrites in zoster HZV have NO terminal bulbs, stain best with rose benegal and look stuck on.
  • check corneal sensation as it is usually decreased in herpes
  • obtain corneal culture for gram stain, aerobic and anaerobic bacteria and viral pcr
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14
Q

What is treatment for HSV keratitis?

A

oral acyclovir 400 mg 5 times daily OR valacylovir 500 mg 3 times daily

For skin lesions - prescribe antibiotic ointment to prevent secondary bacterial infection

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15
Q

What is the differential diagnosis for corneal edema and a mid-dilated pupil?

A

Acute angle closure glaucoma, Pupillary block, Plateau iris
PAS, neoevascular glaucoma
Phacomorphic glaucoma, zonular weakening (trauma, PXF, Marfan’s)
Posterior segment mass
Choroidal effusion: topomax, buckle, excess laser
Aqueous misdirection (malignant glaucoma)

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16
Q

What is the differential diagnosis for follicular reaction with watery discharge?

A 
Viral conjunctivitis, adenovirus
Molluscum contagiosum
Medicamentosa
Chlamydia
Herpes
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17
Q

What is differential for yellow material within a superior bleb?

A

Blebitis
Nodular scleritis
Nodular episcleritis

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18
Q

What is the differential for lens subluxation?

A 
Trauma
Marfan's 
Homocystinuria
Pseudoexfoliation syndrome
Weill-Marchesani
Syphilis

Examine body habitus for tall stature, long fingers. Marfan’s patients can have aortic aneurysm (connective tissue is weak and can have outpouching)

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19
Q

What is differential diagnosis of pseudoexfoliation syndrome (lens with fibrillary flakey material in concentric pattern?

A

Pseudoexfoliation (PXF) syndrome or PXF glaucoma
True exfoliation
Amyloid
Uveitis

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20
Q

Differential diagnosis for hyphema?

A

Traumatic hyphema
Diabetes
Rule out open globe injury and IOFB

21
Q

Differential diagnosis for 35 year old contact lens wearer complaining of pain, redness, worsening vision for 24 hours - slit lamp photo showing large central mucopurulent corneal ulcer

A 
Bacterial keratitis -Pseudomonas
Acanthomoeba
Topical anesthetic abuse
Herpes virus
Trauma
Gonorrhea (ask for STI factors)
22
Q

Differential diagnosis eye redness and boring eye pain (scleritis)

A

Scleritis

Episcleritis

23
Q

Differential diagnosis for splash / chemical injury with injection, chemosis, ?limbal blanching, corneal edema

A

Chemical burn (alkali, acid)
acute angle glaucoma
traumatic iritis
globe trauma

24
Q

What is treatment for chemical injury?

What is the patient education/prognosis?

A

start treatment as soon as possible using copious irrigation with BSS until pH at 7.0. Inspect fornices for debris, sweep and irrigate fornices.
Start cycloplegics, antibiotics every 1 hour
Lower eye pressure
use steroids for first 7 days
consider doxycycline for matrix metalloproteinase inhibition
consider vitamin c -ascorbate to augment healing
consider amniotic membrane graft
Prognosis: guarded, follow daily. complications are glaucoma, symblepharon, retinal necrosis (alkali), may need limbal stem cell transplant

25
Q

Differential diagnosis for episcleral pigmentation that appears “slate gray”

A 
Ocular melanocytosis
Conjunctival nevus
Primary acquired melanosis
Episcleral melanoma
Uveal melanoma
26
Q

Differential diagnosis of macular hole

A

macular hole
macular pucker
CME intraretinal cyst

27
Q

Definition of stages of macular hole?

Stage I, II, III, IV

A

Stage I = impending hole
Stage II-IV = full thickness hole

Stage II = less than 400 microns and no PVD
Stage III = greater than 400 microns and no PVD or operculum
Stage IV = hole with cuff and complete PVD

Observe stage I as 50% will resolve spontaneously
PPV with ILM peel for stage II-IV
If operated within first 6 months can regain half of visual loss.

28
Q

Ddx of bulls eye maculopathy

A

Chloroquine/hydroxychloroquine toxicity

Cone dystrophy (ERG with non recordable photopic response)

Macular degeneration (AMD)

Stargardt or Fundus Flavimaculatus (pisciform fish like flecks and FA with dark choroid)

Battens (patients typically have history of seizures, ataxia, and progressive dementia with retinal findings of pigmentary retinopathy. Battens is AR lysozyme storage disease)

29
Q

Ddx of fundus photo with sea fan shaped neovascular fronds with exudates and hemorrhage.

A

Sickle cell retinopathy
Sarcoid sea fan neovascularization
Diabetic retinopathy
Eales peripheral retinopathy of unknown etiology

30
Q

What is treatment for sickle cell retinopathy?

A

Scatter laser (PRP) to surround seafans is the current treatment for seafans.

31
Q

Ddx for diffuse 4 quadrant flame shaped hemorrhages following the nerve fiber layer, and optic disc edema?

A 
CRVO
Diabetes
Hypertensive retinopathy
Radiation retinopathy
Papilledema
Retinal venous inflammatory diseases such as lupus or sarcoidosis
32
Q

What is the history/physical exam and work up CRVO?

A

ask about history of: DM, radiation, htn, headaches, transient visual obscurations, glaucoma, thyroid disease, hypercoaguable disease, vasculitis (lupus, syphilis, sarcoid), medications (OCP, diuretics, tetracycline, tretinoin), orbital tumors.

exam: vision, pupils, hertel, ocular motility, gonioscopy, eye pressure, dfe looking for NVD and macular edema.
FA and OCT to evaluate for macular edema and whether it is ischemic vs non-ischemic.

Check BP, evaluate for DM (A1c), order screening labs: CBC, PT/PTT, ESR/CRP, lipid panel, homocysteine, sarcoid suspects - ACE, lysozyme, CT chest, atypical cases - syphilis, lyme, ANA). Cardiovascular and hypercoaguable work up as needed

Patient counseling/education: 10% chance of contralateral eye developing a CRVO or BRVO

33
Q

Ddx of non high-risk PDR?

A

Diabetic retinopathy (NPDR or PDR with or without clinically significant macular edema)

Hypertensive retinopathy

Retinal venous obstruction

Retinal venous inflammatory disease (Lupus or Sarcoidosis)

34
Q

DDx of BRVO with macular edema?

What would you ask the patient about on history/physical?

A

Diabetes
Hypertensive retinopathy
Retinal venous inflammatory disease (Lupus or Sarcoidosis)

Ask about a history of any known history of DM, HTN, hyperlipidemia, glaucoma, or other diseases

35
Q

What is the cause of BRVO?

A

BRVO is usually due to arterio-sclerotic cardiovascular disease at an AV crossing.

Recommend PCP provide optimal control of, bp, lipids, diet, exercise.

36
Q

What is ddx for retinal whitening with cherry red spot?

A

CRAO from emboli or GCA
Sickle cell
Tay Sachs
Niemann-Pick (present in younger children)

If patient is younger:

  • Sickle cell
  • Hypercoaguable states (anti-phospholipid)
  • Syphilis
  • Collagen Vascular disease (ANA, ANCA)
37
Q

What is history/physical exam/eval for CRAO picture?

A

Ask about history of: HTN, carotid disease, cardiovascular disease, sickle cell, hypercoaguable states, syphilis, migraines, collagen vascular disease.

Exam: vision, pupils for RAPD, dfe for emboli. CRAO can also occur with GCA so look for emboli. Ask about GCA ROS: temple pain, jaw claudication, headache, etc. Get ESR and CRP. Check blood pressure!
Order labs: A1c, blood sugar, PT/PTT, ANA, RF, FTabs, SPEP, anti-phospholipid antibodies.
Refer for cardiovascular work up: echo, carotid ultrasound, EKG, holter monitor

38
Q

What is the definition for early stage dry AMD?

A

Several small drusen (less than 63 microns - hard) OR few intermediate drusen (greater than 63 microns but less than 125 microns)
*NOTE: central retinal vein width = 125 microns

39
Q

What is the definition for intermediate dry AMD

A

Extensive small or medium sized drusen
OR 1 or more large drusen
OR non-central geographic atrophy

40
Q

What is the definition of advanced AMD?

A

Defined by presence of central geographic atrophy or choroidal neovascularization

41
Q

What signs do you look for on exam if concerned about Keratoconus?

A

Irregular astigmatism: decreased VA, scissors reflex on retinoscopy, steep keratometry with irregular mires, abnormal corneal topography)
Apical corneal thinning and scarring
Fleischer ring (epi iron line deposition at base of cone)
Vogt’s striae: deep stromal vertical stress lines at apex of cone
Munson’s sign: protrusion of lower lid with downgaze
Rizzuti’s sign: triangle of light on iris from penlight beam focused by cone

42
Q

How is keratoconus diagnosed by corneal topography?

A

3 specific parameters can be used to aid in diagnosis of Keratoconus:

  1. central corneal power > 47.2
  2. difference in corneal power > 0.92 in fellow eye
  3. I-S value (difference between average inferior and superior corneal powers 3mm from center > 1.4D
43
Q

What are tx options in KCN?

How do you treat hydrops?

A 
Depending on severity:
Glasses or RGPs
Corneal cross linking
Intracorneal ring segments (Intacs)
Penetrating keratoplasty
LASIK IS CONTRAINDICATED!

Hydrops: acute corneal edema due to a break in Descemet’s membrane causing opaque edematous cornea, ciliary injection, AC cell/flare.
Tx of hydrops is supportive: steroids, cycloplegic, BCL

44
Q

What are the characteristic signs/symptoms of acanthamoeba keratitis?

A

PAIN out of proportion
Early signs: mild and non-specific. epithelial irregularities, epithelial or anterior stromal infiltrates, and pseudodendrites.
Later signs: deep stromal infiltrates (ring-shaped, disciform, or nummular), corneal perforation, satellite lesions, persistent epithelial defects, radial perineuritis, scleritis, and anterior uveitis with hypopyon
Advanced signs include stromal thinning and corneal perforation.

45
Q

What stains and culture media or other testing can be done to confirm diagnosis of acanthamoeba?

What is treatment for acanthamoeba?

A

Stains: giemsa, calcafuor white
Corneal scraping - Culture media: non-nutrient agar with E.coli overlay
Confocal microscopy to evaluate for cysts

Tx: combination of antibacterial, antifungal, antiparasitic agents – chlorhexidine and PHMB biguanides.

There is a 30% recurrence rate after PK.

46
Q

What are the types (and assoc signs) of blepharitis?

A

Anterior blepharitis (seborrheic or staphylococcal): debris at base of the eyelashes (scurf/collarettes), lid margin erythema, loss of eyelashes, conj injection – sequelae: pannus, phlyctenules, corneal infiltrates, ulcers

Posterior blepharitis (MGD): assoc with rosacea, meibomian glands appear capped, dilated, or visibly obstructed. Secretions can be turbid and thicker than normal. Telangiectasias and lid scarring may also be present in this area. Chalazia frequent

Angular (assoc with Moraxella)

47
Q

What are the etiologies of ectropion?

A

There are four main types of ectropion: involutional, cicatricial, paralytic, mechanical.

Involutional ectropion: increased horizontal laxity of the lower eyelid and disinsertion of the lower eyelid retractors.

Cicatricial ectropion: shortening of the anterior lamella, which is comprised of the skin and orbicularis muscle.

Paralytic ectropion is caused by decreased orbicularis muscle tone supporting the lower eyelid (Bell’s palsy)

Mechanical ectropion can occur when a mass, such as a tumor, displaces the lower eyelid margin.

48
Q

How to treat the different types of ectropion?

A

Involutional ectropion: horizontal shortening (lateral tarsal strip), repair of lower eyelid retractors

Cicatricial ectropion: cicatrix revision/relaxation, horizontal tightening, vertical lengthening with full thickness graft

Paralytic ectropion: usually resolves within 6 months with Bell’s palsy, otherwise lateral tars, upper eyelid gold weight

Mechanical ectropion: treat underlying condition

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