Clinical Approach to Ocular Surface Disorders

Question 1

Differential diagnosis for acute follicular conjunctivitis?

Answer 1

“Adeno hardly happens to careful nuns”

Adenovirus, HSV, hemorrhagic (coxsackievirus), Chlamydia, Newcastle’s (from chickens)

Question 2

Differential diagnosis for chronic follicular conjunctivitis?

Answer 2

“Passing tough tests mostly means late cramming”

Parinaud’s (Bartonella and others), Trachoma, toxic (most common, esp from glaucoma gtts), Moraxella, Molluscum, Lyme, Chlamydia

Question 3

What are papillae made of?

Answer 3

Dilated vessels surrounded by edema and a mixed inflammatory infiltrate and anchored down by fibrous septa

Question 4

enlarged, non-inflammed follicles in inferotemporal and forniceal conj in asymptomatic children and adolescents?

Answer 4

benign lymphoid folliculosis

Question 5

what are follicles comprised of?

Answer 5

lymphocytes

Question 6

what cells comprise mutton-fat KP?

Answer 6

macrophages

Question 7

name 4 common classes of systemic drugs which can cause with dry eyes?

Answer 7

beta-blockers, anticholinergics, antihistamines, diuretics

Question 8

What is a normal tear meniscus height? What is considered pathologic?

Answer 8

1.0 mm; <0.3 mm

Question 9

how long does it take for cyclosporine to work for aqueous tear deficiency? what percentage of patients with moderate to severe ATD benefit from this drug?

Answer 9

2-3 months. 50%

Question 10

how should patients be instructed to take oral doxycycline?

Answer 10

without dairy products

Question 11

what are common side effects of systemic tetracyclines?

Answer 11

GI upset and photosensitivity

Question 12

what is the effect of punctal occlusion on MGD?

Answer 12

worsens MGD

Question 13

what are the findings in ocular rosacea?

Answer 13

excessive sebum secretion, chronic blepharitis, recurrent chalazia, eyelid margin telangiectasias, chronic conjunctivitis, marginal corneal infiltrates, ulcerative keratitis, corneal neovascularization

Question 14

mainstay of treatment of ocular rosacea?

Answer 14

systemic tetracyclines

Question 15

anterior eyelid inflammation with crusting/scaling of anterior eyelid skin with greasy consistency? primary treatment?

Answer 15

seborrheic blepharitis; eyelid hygiene (lid scrubs, warm compresses if a/w MGD)

Question 16

hard, brittle, fibrinous eyelid scales, matted eyelid crusting, varying degrees of madarosis, poliosis, trichiasis: diagnosis and treatment?

Answer 16

staphylococcal blepharitis; eyelid hygiene +/- topical bacitracin, erythromycin, azithromycin, +/- topical steroids

Question 17

crusting and ulceration of lateral canthal eyelid skin?

Answer 17

Moraxella angular blepharoconjunctivitis

Question 18

unilateral limbal nodular inflammation accompanied with engorged conjunctival vessels: diagnosis? immunology? causes in developed v. underdeveloped areas? treatment?

Answer 18

phlyctenule; type IV hypersensitivity reaction; S aureus; M tuberculosis; topical steroids

Question 19

multiple marginal corneal infiltratres with clear intervening space between limbus?

Answer 19

staphylococcal marginal hypersensitivity reaction

Question 20

difference between internal v external hordeola?

Answer 20

External: occur on anterior eyelid in gland of Zeis; Internal: posterior eyelid in meibomian gland.

Question 21

difference between hordeolum and chalazion? treatment?

Answer 21

• Hordeolulm: infectious abcess of gland of Zeis or meibomian gland.
• Chalazion: chronic lipogranulomatous inflammation of meibomian gland or gland of Zeis
• conservative treatment with warm compresses for both. intralesional steroid or incision and drainage for chronic, persistent chalazion

Question 22

systemic problems associated with floppy eyelid syndrome? ocular findings in addition to floppy eyelid?

Answer 22

obesity and sleep apnea. papillary conjunctivitis, keratoconus

Question 23

what labs would you order in somebody diagnosed with superior limbic keratoconjunctivitis?

Answer 23

TSH and free T4

Question 24

treatment of SLK?

Answer 24

topical anti-inflammatories, BCL, amniotic membrane graft, serum tears, thermocauterization or surgical resection of superior bulbar conj

Question 25

what enzyme is upregulated in recurrent corneal erosion syndrome?

Answer 25

gelatinase (MMP-2 and MMP-9)

Question 26

treatment for recurrent corneal erosion?

Answer 26

antibiotic ointments for acute phase; then topical steroids, doxycycline, BCL, anterior stromal micropuncture, epithelial debridement, PRK

Question 27

topical drops associated with neurotrophic keratopathy?

Answer 27

anesthetics, NSAIDs, trifluridine, beta blockers, CAIs

Question 28

trichiasis v distichiasis?

Answer 28

trichiasis is lash from normal location on eyelid margin oriented posteriorly with risk of corneal contact. distichiasis is a lash originating from an abnormal location such as a Meibomian gland orifice

Question 29

well circumscribed pattern of lissamine green or rose bengal staining on inferior and inferior bulbar conj?

Answer 29

mucous fishing syndrome

Question 30

what percentage of limbal stem cells are needed for normal ocular resurfacing?

Answer 30

25-33%

Question 31

wavelike irregularity of the corneal surface emanating from the limbus seen with fluorescein staining?

Answer 31

limbal stem cell deficiency

Question 32

primary and secondary causes of limbal stem cell deficiency?

Answer 32

primary: aniridia, sclerocornea, MEN syndrome, KID (keratitis-icthyosis-deafness syndrome), xeroderma pigmentosa, ectodermal dysplasia
secondary: chemical or thermal burn, Stevens-Johnson, MMP, ocular surgery or radiation, contact lens use, mitomycin C, conjunctival neoplasia, pterygium, herpes, trachoma

Question 33

mechanism of aqueous tear deficiency in Sjogren syndrome?

Answer 33

T-cell mediated autoimmune destruction of lacrimal glands

Question 34

lab tests used to diagnose Sjogrens?

Answer 34

anti-Ro (SS-A) or anti-La (SS-B) antibodies

Question 35

prominent systemic finding in ichthyosis? treatment of corneal degeneration in ichthyosis?

Answer 35

diffuse skin scaling. lubrication. topical steroids are not helpful

Question 36

heredity and genetics of xeroderma pigmentosum? ocular findings?

Answer 36

AR. defect in DNA repair, especially from UV-induced damage. basal, squamous (most common), or melanotic cancers of conj or eyelids, dry and inflamed conjunctiva, corneal decompensation

Question 37

gastric bypass patient with severely dry eyes and foamy gray triangle on bulbar conj: diagnosis, pathophysiology, histology of lesion

Answer 37

xerosis; vitamin A deficiency leading to loss of mucous production by conjunctival goblet cells; keratinized epithelium, inflammatory cels, debris, and Corynebacterium xerosis