External disease Flashcards
DDx for this photo
Blepharitis
Ocular rosacea with blepharitis
Herpes simplex keratitis
Sebaceous cell carcinoma
DDx for this clinical finding in a 46 year old male
Chalazia/hordeolum
Presepetal cellulitis
Pyogenic granuloma
Sebaceous cell carcinoma
36 year old male complains of eye redness and ocular irritation.
Waxy pallor umbilicated nodule lesions on eyelid
Molluscum cantagiosum
Basal cell carcinoma
Nevus
Hx of chronic ocular irritation, red eye, look at lesion to confirm if umbilicated. expect for basal cell to be nodular border and with crater defect. check for follicular conjunctivitis, do full eye exam. Ask about other lesions on body and if multiple lesions would be suspicious for systemic STDs, immunocompromised state such as HIV or chemotherapy, steroid use, or steroid sparing agents. Would order testing accordingly based on answers.
Tx: lesion near eyelid can cause chronic conjunctivitis due to shedding of viral particle onto ocular surface (henderson patterson corpuscle). can develop corneal pannus. Recommend simple surgical excision with curretage and send tissue for pathologic eval.
Removal of lesions lead to resolution of ocular irritation.
60 year old male with this clinical finding.
Conjunctival and limbal leukoplakic lesion with sectoral injection and sentinel vessels. Gelatinous characteristic of lesion extending onto cornea with leading edge of pannus and corneal opacity.
Ddx:
Ocular surface squamous neoplasia (OSSN)
Inflamed pinguecula
Amelanotic melanoma
Hx/PE/Eval: History of recent trauma or history of ocular surgery, UV light exposure in lighter pigmented individual, xeroderma pigmentosum, Hx of HPV infection (subtype 16 and 18), HIV status, other immunosuppresion, smoking history
Ask about onset of lesion, progression slow or rapid, cutaneous skin cancer or melanoma history. Examine lesion for leukoplakia/keratinization, look for other skin lesions, inspect eye for pterygia/pinguecula. Check for adenopathy, full eye exam vision pupils pressure, check gonioscopy for cilary body and dfe for retina lesions. transcleral illumination to identify intraocular lesions. Hertels to eval for proptosis, EOM, visual field. If concern for intraorbital extension, image MRI brain/orbits head and neck, CBC and LFTs.
Tx: excisional biopsy with wide margins using no touch technique, cryo to conj edge and partial keratectomy then mmc drop therapy. follow closely for recurrence and metastasis. If metastasis noted, refer to oncology.
Prognosis good if fully excised with clean margins but close follow up.
45 year old male from Panama with the following clinical finding.
Wing shaped fibrovascular lesion extending onto cornea. No dellen or epithelial defect noted in clinical photograph.
Ddx:
Pterygium, OSSN, Trauma or chemical burn, Pannus from contact lens wear, blepharitis, rosacea, herpes or atopy
Hx/PE/Eval: Onset and progression of lesion slow or rapid, symptoms, any inciting trauma or hx of chemical burn injury to eye, work environment - wear glasses, sun or wind exposure, CL wear intolerance. conj healing after trauma can look similar but in these cases only the anterior edge of conj is adherent in contrast to fibrovascular pannus seen in pterygia.
Perform full eye exam, vision pupils pressure, slit lamp exam looking for leukoplakia/gelatinous characteristics or feeder vessels which would raise my concern for OSSN or if lesion is not in typical 3 or 9 oclock location.
If asymptomatic, counsel patient on UV sun protection/eye protection to halt progression. If dellen or DES, treat with lubrication.
If symptomatic, encroaching visual axis, CLW intolerance, recommend excision followed by MMC and conjunctival autograft/rotational flap or AMG placement in repair.
60 year old caucasian man with the following clinical finding.
Conjunctival pigmented lesion.
Ddx:
Conjunctival melanoma
Primary Acquired Melanosis (PAM)
Complexion-associated melanosis
Nevus
Hx/PE/Eval:
History of cutaneous cancers/melanoma, perform full eye exam looking for intraocular extension from conjunctiva or from an ocular melanoma. Check for lesions on other eye. Look at lids, fornices, caruncle for other hyperpigmented lesions. Look for intralesional cystic component which suggests benign nevus. If bilateral and in darkly pigmented individual consider complexion assoc. melanosis.
CHECK FOR LYMPHADENOPATHY. Perform gonioscopy to assess ciliary body and get UBM to assess for ciliary body lesions.
Tx: Excsional biopsy via no touch technique with wide margins, cryo to conj edges, alcohol epitheliectomy for cornea involvement, map biopsies of bulbar and palpebral conj. Start mitomycin topical therapy. If positive for melanoma would send to oncology for metastatic work up and consider sentinel lymph node biopsy. If orbit involved, extenteration, radiation/chemotherapy.
Prognosis: good if early and non-metastatic case. Case with metastic disease - prognosis is guarded. Survival at 5 years for local disease is 85%. 5 year recurrence is 40%.
What are the differential diagnoses and possible etiologies to entropion?
What do you look for on exam to explain cause?
Involutional
Cicatricial
Spastic
History/exam: prior ocular surgery, trauma, disorder?
Exam:
*Lid tone (snap back test)
*Lower lid margin position (sagging)
*Ability to rotate the lower lid by pressing on the inferior tarsal border
What is the treatment/management for these types of entropion?
- involutional
- cicatricial
- spastic
Ocular surface must be protected from inturned lashes by frequent lubrication/ointment.
Involutional: lid taping, thermal cautery, Quickert suture (Quickert Evert), horizontal or vertical lid shortening and or lid retractor repair
Cicatricial: excision of scar with possible anterior lamellar resection/resection, tarsal fracture, tarsal graft, or conj/mucuous membrane graft.
Spastic: lid taping, thermal cauter, botox, quikert suture lateral tightening with transconj advancement of lid retractors
What other conditions are associated with floppy eyelid syndrome and what are the treatment options for FES?
Obesity
Obstructive sleep apnea
Keratoconus
Eyelid rubbing
Tx: lid taping, patch, shield lids, consider surgery with horizontal lid tigthening procedure
What is diagnosis, pathology of this leasion?
Which ocular disease is most commonly associated?
What is treatment?
Band keratopathy
Calcium deposits at level of epithelium, bowmans membrane and anterior stroma.
Chronic ocular irritation - JRA anterior uveitis, intraocular silicone oil, interstitial keratitis, phthisis, trauma, hyperparathyroidism, renal disease, gout
Treatment: Chelation with sodium EDTA and scraping of epi/calcium deposits with blunt spatula - calcium deposits can re-occur but can repeat chelation
What are characteristic findings of fungal keratitis?
How to treat?
Feathery edges
Satellite lesions
Endothelial plaque
May penetrate Descement’s membrane
Tx: topical antifungal - Natamycin and cycloplegia. NO TOPICAL STEROIDS!!! For severe infection, systemic antifungal - amphotericin B
42 year old male with history of poor vision.
What is the diagnosis, what are the etiologies?
What is treatment of active disease?
Interstitial keratitis
*Syphilis
*HSV/VZV
*TB
*Mumps
*Rubella
Other causes: sarcoidosis and Cogan syndrome
Tx active disease with topical steroid, cycloplegia, treat underlying cauase
Chronic inactive IK with scarring can be treated with lamellar or PK.
Lesion suspicious for conjunctival lymphoma.
How would you work up the patient, what is tx?
What is risk of systemic lymphoma in patients with an ocular lymphoid lesion?
Biopsy lesion send for fresh tissue - flow cytology and immunohistochemical studies to determine type of lymphoid tumor
(DDx: conj lymphoma, benign reactive lymphoid hyperplasia). 50% are MALT.
Patient needs oncology consult and systemic work up to determine if orbital or systemic involvement: CBC with differential, SPEP, ESR, CT orbits, CT chest/abdomen, bone scan.
Tx: is based diagnosis and extent of lesion – external beam radiation, chemo, surgery.
Risk of systemic lymphoma depends on LOCATION of lesion:
1) HIGHEST (67%) for eyelid lesion
2) 35% for orbit lesion
3) LOWEST (20%) for conjunctival lesion
Concerning lid lesion on a 78 year old woman who scratched her eyelid 3 weeks ago and it bled but it hasn’t healed yet.
DDx?
Basal cell carcinoma
Squamous cell carcinoma
Keratoacanthoma
Malignant melanoma
What are the characteristic findings of basal cell carcinoma?
Common nodular BCC: raised, pearly, nodular borders and telangiectasia. There may be central ulceration and distortion of normal lid architecture including eyelash loss and scarring.
Less common morpheaform BCC: more agressive - appears as firm flat plaque with ulceration and indistinct borders penetrates into dermis -can have pagetoid spread.
