Final Flashcards
Why would you want to consider doing a forehead lift before you do an eyelid lift?
A forehead lift needs to be completed before an eyelid lift so that the patient will be able to close their eyelids. If an eyelid lift is completed before a forehead lift, the eyelids will be stuck with a “stare” appearance due to the skin being extremely tight
What is one way to determine if eyelid ptosis is obstructing vision in patients with dermatochalasis
To assess the visual loss caused specifically by the dermatochalasis you should do a tape and untaped visual field
What is the main precaution you need to take into consideration when evaluating a cutaneous horn?
The main concern is that the base of the horn could be a SCC
What is the most useful component of a VF in determining insurance coverage for ptosis surgery
Although we do not usually use the grey scale, insurance companies use the grey scale to determine if a ptosis surgery should be covered or not
A patient presents ortho upon arrival, however after measuring unilateral VAs, you notice a small XT OD that recovers in 6 seconds. What is their score on the Holmes Control Scale?
Their score is a 2 on the Holmes scale. There is no XT until dissociation and recovered in more than 5 seconds.
What would you suspect if a patient presents with a Duane’s-like deviation post strabismus surgery and what should you do?
A slipped muscle. Refer back to surgeon ASAP
What are 3 examples of scenarios when an unsatisfactory alignment following strabismus surgery should be sent back to the surgeon?
- If patient is outside if monifixation range.
- If patient has diplopia
- If patient still has a constant strabismus
What are some things to try before referring an exotropic patient for strabismic surgery
Monitor
Patch
Over minus glasses
Amblyopia therapy
In order to qualify for strabismus surgery, why must the patient have at least 10 prism diopters of deviation at distance or near ?
Because it still falls within panum’s circle so they have some binocularity.
Why can a patient with a congenital cataract not have an IOL implant immediately following cataract surgery and what is a great alternative treatment option?
A patient with a congenital cataract cannot have an IOL implant immediately after surgery due to complications later with the IOL, due to the eye still growing the IOL could dislocate , and not being certain of the refractive power needed. As Dr. Sanders recommended, an alternative option would be a contact lenses, specifically RGPs being more successful due to customizability, and easier insertion and removal.
What is the over-refraction goal for an aphakic baby? And why?
-3.00 Diopters because a baby’s world is up close. This way she can see her mommy’s face clearly :)
What is the most common type of esotropia?
The most common type is an accommodative esotropia.
A patient comes in with a slipped muscle, what will be observed in EOM’s and saccades? What should be done immediately after?
The EOMs and saccades will be limited in the field of that muscle’s action. This could potentially act like Duane’s syndrome. This should be immediately sent back to the surgeon.
In a case of pediatric nystagmus, what kind of lenses show more potential for correction (spectacle or contact lenses)? According to Dr. Sanders, why might this be the case?
Contact lenses because the patient will have edge awareness and will create a feedback loop to dampen the nystagmus
This is the type of surgery where a muscle is tightened by removing the anterior part of the muscle and reattaching the shortened muscle to the original insertion site?
Muscle resection
According to Dr. Sanders, which test is the best way to find out if a patient would benefit from a bifocal?
MEM
What is Soemmering’s Ring and what condition is it associated with? What are management options for this condition?
It’s the ring that is formed by the fusion of the anterior and posterior capsule of the lens. It is associated with aphakia and can be managed by the insertion of an IOL, or the use of a contact lens.
You’re performing a follow up examination after a strabismus surgery on a 10 year old patient. You notice corneal edema, uveitis, and folds in descemet’s membrane. What do you do next?
You would treat with steroids, then refer back to the surgeon because these are signs of ischemia due to anterior ciliary artery compression
A child presents to your clinic with an accommodative esotropia. You do a wet retinoscopy and find +0.75 DS OD and +0.50-0.25x160 OS. Would you prescribe this prescription?
Yes, you would prescribe the full plus prescription since the patient has an esotropia in order to promote good fusion and relax the patient’s accommodation.
According to Dr. Cowen, what is an important ocular surface condition to consider before a patient has ptosis surgery?
Dry eye, because widening the palpebral fissure can induce or worsen dry eye symptoms.
what is important to remember when referring patients to plastics for ptosis in regards to insurance paying for treatment?
It has to affect their daily life
What is the best type of visual field to perform on a patient when evaluating whether or not they are eligible for surgery for ptosis?
64-point superior screening
What is the Kestenbaum procedure?
It is a surgical procedure for nystagmus. It is used to rotate the eyes in the direction of the head turn. This is to produce a gaze palsy towards the side to which the eyes are normally directed.
How do you grade a patient on the Homles Control Scale? What is worse, a 0 or 5?
You want to look at the patient for 30 seconds because once they are dissociated with a cover test there is no control over the eyes. You are looking at if the eye is turned in and if so, how long/does it ever regain fixation. A 5 is worse because that is a constant exotropia, where as 0 is an exophoria.
When would a hypertropic patient be ready for surgery?
If the patient is diplopic/symptomatic, has decreased stereo, and/or a significant head tilt.
Which two binocular vision conditions has VT been PROVEN to work for?
Convergence insufficiency and TBI have been proven to be helped by vision therapy.
Why is a pterygium most likely seen on the nasal conjunctiva?
Because light is reflected off the side of the nose
What is the best way to prevent recurrence of a pterygium?
Wear UV blocking sunglasses
What is the most appropriate course of treatment for Salzmann’s Nodular Degeneration?
Superficial keratectomy, good sir
According to Dr. Sander‘s lecture, during strabismus surgery what can cause a mild chorioretinal scar and what should be done during post-op to look for this finding?
Scleral Perforation. Although rare needles can perforate into the superchoroidal space or the choroid causing a chorioretinal scar. A retinal exam should be performed after surgery to check for this finding.
Under what circumstances would keratoprosthesis be indicated for a patient?
Anytime there a corneal transplant has failed or there’s a risk of an unsuccessful transplant, Student Doctor Jacob Webster!
Dr. Cowen described the surgeries he preforms as relatively safe however, what is one major complication that he discussed that would lead to a decrease in vision, severe pain and proptosis?
Retrobulbar Hemorrhage
Why would you not want to use fluorescein on a rust ring?
The fluorescein will settle into where the foreign body is and cover the rust ring’s borders. It makes it more difficult to remove the entire ring.
According to Dr. Cowen, what is the ideal post-op follow up time to see the oculoplastic surgeon?
1 week!
You want to do cold compresses for 3-5 days to prevent bruising and after 5 days you want to give them warm compresses for their tear film and bruising. So at 7 days it would allow for them to have the bruising and some of the swelling to be reduced for a proper evaluation.
What are possible complications from the iStent?
Cataract, hyphema/IOP spike, inflammation/angle synechiae
Hi. Muscle resection, as described by Dr Sanders, has two main goals. One is to move the muscle insertion closer to the muscle origin, while the other is..?
Student doctor Jeremy Penn, it also weakens the muscle
What are four complications of Kahook Dual Blade Goniotomy (KDB)?
The complications are cataract, hyphema/IOP spike, inflammation/angle synechiae and cyclodialysis cleft.
What was the disadvantage of a standard Baerveldt tube when considering the ripcord?
The IOP would not be lowered until the ripcord was removed in order to open the pathway.
What are some of the differences between micro pulse vs. G probe
The micropulse does not sit in one spot (move 180 degrees every 10 seconds that) and is used to delay more risky surgeries. Micropulse has much less popping because it has less energy (not cooking), micropulse has less IOP reduction and less inflammation. Phthisis is not common. Micro-pulse cannot be used to NVG. Post op for micropulse you use steroids q12 hours and taper accordingly.
G probe has more popping due to higher energy. Phthisis is more common with this procedure. Post op steroids are used q1-2 h and taper more slowly. This can be used in NVG.
What is the proper needle insertion position when performing an emergency pericentesis?
Well Trav, with an open ended 30 gage needle, insert horizontally through the limbus inferior to the pupil. Slightly tilt up to avoid damage in case the patient has a Bell’s Phenomenon.
What do you give to “steroid responders” postop from their fistulizing blebs?
Give the steroids anyway. It’s important to monitor for any IOP spikes while administering the steroids and respond with the appropriate treatment when it occurs. The benefit outweigh the risk, especially if you carefully monitor the patient during the treatment process.
What technique can be used to identify angle structures when the angle is minimally pigmented?
Corneal light wedge
If a TM is normal, how much angle must be closed in chronic ACG before the IOP rises above normal?
270 degrees
What quadrant closes last in CACG from narrow angles?
Inferior
What iris type sheds the most pigment with a PI (pigment storm)?
Dark brown iris
If there is PAS in the angle is a PI indicated?
A PI will not help and is not indicated
Your patient is considering SLT surgery. While performing gonioscopy, at first glance you believe you see your corneal light wedge terminate at the trabecular meshwork. What other, sometimes pigmented and speckled structure, might you be really seeing?
Sampaolesi’s line
Which has lower IOP results: Trabeculectomy or Tube? Which is more prone to infection?
Trabs for both. Blebs are more exposed and can leak
A 45 year old white male presents to clinic with a new vertical deviation. What tests should be ordered as part of an adult strabismus work-up?
MRI Brain/Orbits with and without contrast, CT of the orbits, CVA imaging, ESR, CRP, TSH, Free T4, Anti-Acetylcholine Esterase
antibodies (blocking, binding, modulating), and ESR, CRP, Platelets
What does it mean to have a patient with a “perfect storm” in terms of IOP, gonio findings, and pigmentation? Why would a slight elevation (IOP of, say, 19 to 24 OU) worry you in this otherwise seemingly healthy patient?
The perfect storm is considered normal to low 20s in IOP, gonio showing 270 degree closure, and darkly pigmented eyes. A quick elevation in pressure is indicative to act quickly in order to reduce the risk of damage.
What is the most important thing to consider when treating Salzmann nodules?
They should be resected before they reach the optic zone
What are some conditions that can be related to neurological disease and manifest as ocular motility disorders
Strab and nystagmus
What are the criteria for diagnosing infantile nystagmus syndrome? (INS)
Infantile onset and ocular motor recordings show diagnostic (accelerating) slow phases
Usually side effects from strab surgery happen in less than what percent of the population?
5%
What are the 4 common post op complications seen with strab surgery? (There are more than 4)
Under/Over-corrections, slipped muscles, infection, new deviation (including paradoxical UHARC)
What is the treatment of choice in a case of congenital glaucoma
Usually some type of angle surgery to help outflow of aqueous rather than pharmacotherapy
What is the most common vitreoretinal condition they see at Akrons Children’s
ROP
What aspects of basic surgical technique are included in the Halstead Principle
Identify tissue
Gentle handling
Hemostasis
Asepsis
Why are proline sutures preferred material/stitch for oculoplastics repair?
They are preferred because in post op day 7, all you have to do is remove the tape and pull the string then the suture will come right out. There is also minimal inflammation with this
If you are performing gonio on a patient and the most posterior structure you see is Schwalbes line (no visible TM), would you educate the patient on an LPI or SLT? Why?
Educate the patient on an LPI, as an SLT shouldn’t be performed if the TM isn’t visible because that’s your target for SLT.
What’s the typical time of onset for infantile esotropia? How many months?
0 to 6 months
When closing a tissue, what are some things you as a dr must do before letting the patient leave ?
remove draping, apply additional betadine over wound to sterilize it, apply antibiotic onto incision site, drape and cover with sterile gauze to protect.
also provide proper patient education on what they should expect in terms of pain, how to clean properly, as well as what to look for when it comes to signs of infection.
What should be done when removing a pterygium to the firing conjuncgiva below it
Cut a square out and rotate it and suture it back on.
Treat the area with MMC and then rinse away before rotating the flaps
Put a CL on at the end
Post op for pterygium
BSCL Antibiotics QID Slide BSCL to check epi beneath it If healed, ABX BID until BSCL removed Steroid QID tapered one dose per week
Treatment for pterygium
If not painful, not noticeable not affecting vision LEAVE IT ALONE
Pterygium and cataract surgery
If planning custom cataract surgery,remove the pterygium, even if its not bothersome
What is the most important thing to consider in treating Salzmanns nodules and pterygia
Both should be resected beforethey reach the corneal optical zone
Indications for emergency paracentesis
Emergent IOP
Formed AC
Have equipment and meds
Call surgeon first
Technique for emergency paracentesis
Reassuring tone Topical anesthesia Betadine and abx Lid speculum Extra drop if betadine Open ended, sterile, 30 gauge needle Horizontal through limbal cornea inferior to pupil, parallel to iris Wait for IOP to drop Withdraw need Compress needle tract Betadine chaser Hourly ABX drops
Reason for the slightly upward tilt of the needle for emergency paracentesis
If they have a bells phenomenon, the needle will just come out
Why does the needle need to be parallel to the iris for emergency paracentesis
Longer tract, self sealing
Takes 20s
Ideal MIGS
Fast and easy procedure
Quick recovery, no blurry vision
Minimal risk
Efficacious
Examples of MIGS
Cataract surgery ECP TS-CPC Istent KDB
Cataract surgery as MIGS
Efficacy of about 1/3 glaucoma drop
35% of people being able to stop one drop
ECP for MIGS
Efficacy of just under one drop
8% IOP reduction
Without 40% stopping at least one drop
ECP general info for MIGS
- fiber optic endoscope, 175 Watt xenon light, 810nm diodelaser
- 360 degrees treatment of anterior ciliary processes
- processes shrink and whiten some
- lessens aqueous production
- approved for phakic and pseudo-phakic
Complications of ECP for MIGS
- inflammation (iritis, CME, angle synechiae)
- hyphema
- IOP spike (pigmentary debris and inflammation)
Contraindications for ECP for MIGS
Uveitis
CME
Angle neo
Post op for ECP for MIGS
More inflammatory prone so we need durezol
- q2h x 2 weeks
- TID x 1 week
- BID x 1 week
- qd x 1 week
TS-ECP for MIGS
Avoids cooking too long like the G probe when using the micropulse
TS-ECP MIGS efficacy
G Probe: more IOP reduction (40-70% r3duction)
MicroPulse Probe (15-30% IOP reduction)
Complications for TS-ECP
Inflamamtion
Phthisis bulbi 1-4%
Can use G probe with NVG/ischemia (not micropulse)
Post op for TS-ECP
G probe
- q1h or q2h steroid drops
- slow taper
MicroPulse Probe
-QID steroid tapered weekly
IStent MIGS
Smallest FDA approved
Titanium (safe for MRI)
L shaped stent bypasses TM
Approved for pseudophakia
Istent complications
Cataracts
Hyphema/IOP spike
Inflammation/angle synechiae
Contraindications of istent
Phakic
Neo
Closed angle (can try GSL first)
Post op for istent
Just cataract drops (and prior glaucoma meds
Efficacy just under 1 drop or so
4.5% IOP reduction
With 50% of that data pool stopping at least one drop
KDB MIGS efficacy
1.5 drops or so
20% reduction of IOP with 28% of people stopping one drop
Wide range (10-60% drop)
Causes more heme
Post op for KDB MIGS
Durezol 0.05% QID x 1 week TID BID QD
Post opt meds for fistulizing surgery can hope prevent
Scarring of blebs
ESP if thick, non elevated, non translucent, vascularized
Steroids
(Steroid responders need steroids to prevent scarring of their blebs)
Signs of infection after incision
Excessive discomfort, drainage, redness more than 5mm beyond wound margins, swelling, induracton, tenderness, lymphatic streaks, lymph node enlargement, and fever
Post op meds for biopsy
Erythromycin ung QID x 7 days
RTC 1-4 weeks for evaluation of resolution
Patient instructions post op biopsy
Pain should subside after 24-48 hours, come back if it doesnt
Remove patch before bedtime and reapply ointment
Clean gently after 12-24 hours, do not submerge
Chalazion steroid post op
Erythromycin BID x 3-5 days
Resume hot compresses in 2-3 days
RTC2-4 weeks for eval
Pain should subside 24-48 hours
Clean gently after 12-24 hours
Chalazion I/C post op
Erythromycin ung QID x 7 days
Resume hot compresses in 2-3 days
Rtc 1-4 weeks for evaluation of resolution
Lesion ABCDE
Asymmetry Borer Color Diameter Evolving
Preseptal cellulitis tx (topical)
Warm compresses TID
Polymyxin B/bacitracin ung QID(if bacterial conjunctivitis is present)
Tetanus toxoid PRN
Abx tx for mild preseptal
Augmentin
Cefpodoxime
Cefdinir
If allergic to PCN
- TMP/sulfa
- moxi
What oral meds can be used for someone who has orbital cellulitis and is improving with IV
Augmentin
Cefpodoxime
