Friedman external dz/adnexa Flashcards
Lid lesion DDx
squamous cell carcinoma (or SCC variant - keratoacanthoma) BCC Sebaceous cell carcinoma inflamed actinic keratosis tricholemmoma Merkel cell tumor
Merkel cell tumor
Merkel cell carcinoma Highly malignant with frequent metastases at presentation Fast-growing, violaceous,
Keratoacnthoma Rx
complete excision of lesion
Sebaceous cell carcinoma Rx
wide excsiion with frozen section and conjunctival map Bx
Exenteration - performed for orbital extension or pagetoid spread
XRT for palliation
Scleritis DDx
Systemic assoc (50%) 30% have collagen vascular dz - RA, ankylosing spondylitis, SLE, polyarteritis nodosa, Wegener's, relapsing polychondritis
Other etiologies - herpes zoster, syphilis, TB, leprosy, gout, porphyria, idiopathic
Work-up: CBC with diff, RF/anti-CCP, ANA, ANCA, VDRL/RPR, FTA-ABS, PPD, CXR
what dz causes anterior necrotizing scleritis w/o inflammation (scleromalacia perforans)?
RA
signs of posterior scleritis
chorioretinal folds serous RD vitritis ON edema "T" sign - thickened sclera on B-scan U/S
Conjunctival lesion DDx and next step
CIN (atypical cells confined to the epithelium w/o penetration of BM often @ limbus, usually no KNV) lymphoid lesion pterygium/pinguecula papilloma squamous cell carcinoma
Excisional Bx
Rx for squamous cell carcinoma
Treatment?
Excision with 4mm margins & thin scleral flap
Treat base with alcohol
Treat margins with cryo
Topical interferon, MMC, 5-FU gtts if large
Gelatinous lesion
Location?
Interpalpebral zone near limbus
Most common conjunctival tumor?
Squamous cell carcinoma
Most common eyelid tumor?
Basal cell carcinoma
Name medications that cause conjunctivitis?
Propine, Iopidine, Alphagan, Neomycin
Conjunctival Squamous Papilloma - location and demographics, pathology
Location
Children?
fornix, multiple, pedunculated
Adults?
limbus, single, sessile
Viral association?
Children: HPV 6 & 11
Adults: HPV 16 & 18
Pathology?
Papillary fibrovascular fronds
Must excise in adults to differentiate from CIN
May recur in multiple sites
Oncocytoma
Metaplasia of ductal & acinar cells of accessory lacrimal glands Usu. pink lesion on caruncle Pathology: Large eosinophilic cells Glandular spaces Numerous mitochondria
Pyogenic Granuloma
Fibrovascular tissue growth usu. over chalazion or conj surface surgery
Usu. fleshy lesion on palpebral conjunctiva
Pathology:
Small-caliber vasculature
Collagen stroma
Entropion evaluation and types
lid tone (snapback test) lower lid margin position (sagging)
cicatricial: scar excision with possible anterior lamellar resection/recession, tarsal fracture/graft or conjunctival/mucous membrane grafts
involutional: thermal cautery, quickert suture, horizontal or vertical lid shortening, lid
spastic -thermal cautery, botox injection, quickert suture, horizontal or vertical lid shortening, lid
Follicular conjunctivitis DDx
virus (adenovirus, HSV)
chlamydia
molluscum
drug rxn
True membrane conjunctivitis
strep
gonoccocus
croneybacterium
chemical burns
conjunctivitis questions
H/o URI, anyone with eye infection?
CL?
had a sTD in past?
conjunctivitis exam
preauricular lymphadenopathy eyelid lesions pseudomembrane on inferior tarsal conjunctiva subconj hemorrhage SEI in cornea
chlamydia conjunctivitis path and Rx
path: basophilic cytoplasmic inclusion in epithelial cells
systemic and topical Abx with tetracycline or erythromycin
Rx all sexual partners
Interstitial keratitis DDx
Diffuse infiltrate with thickened stroma Regression leaves ghost vessels Causes? Syphilis (most common cause if bilateral) Herpes simplex, herpes zoster Tuberculosis, leprosy
Other casues: mumps, rubella, lepropsy, onchocerciasis, sarcoidosis, Cogan’s
Interstitial keratitis Treatment?
Treatment? topical steroids
Cogan’s syndrome?
Interstitial keratitis with hearing loss
Meniere’s like vestibular dysfunction
Associated with URI
Treatment? systemic steroids
congenital syphilis findings
optic nerve atrophy salt and pepper fundus deafness notched teeth saddle nose sabre shins
Acute dacryoadenitis
infection 2/2 staph, mumps, EBV, VZV, N. Gonorrhea
Cx/gram stain of D/c - CBC with diff +/- blood Cx
lacrimal gland tumors
50% lyphoproliferative or 50% epithelial
>50% epithelial tumors are pleomorphic adenomas (benign mixed tumor) and 50% malignant (adenoid cystica carcinoma and malignant mixed tumros)
lacrimal gland Rx (benign)
Complete en bloc excision w/o Bx 2/2 rupture of pseudocapsule can result in recurrence and malignant transformation.
Basal Cell Carcinoma location and pathology
Most common eyelid malignancy
More common on?
Lower lid > medial canthus (worst Px 2/2 invasion of lacrimal drainage system)> upper lid > lateral canthus
Pathology?
Basal cell nests
Peripheral palisades
Basal Cell Carcinoma - two forms and Rx
Two forms?
Nodular
Most common
Firm, raised, pearly
Morpheaform
Much more aggressive
Firm, flat with indistinct borders
Slender tendrils. pagetoid spread
Treatment?
Excision w/ Mohs’ surgery
Rarely metastasize
Sebaceous Carcinoma
Mimics chronic blepharitis or recurrent chalazion
More common in upper lid where there are more meibomian glands
Pathology?
Foamy cytoplasm
Pagetoid spread (intraepidermal spread of clusters of tumor cells)
“skip lesions”
Special stain?
Oil red O stains lipid in cytoplasm (must be fresh/frozen, as paraffin embedding destroys lipids)
Highly malignant
Muir-Torre Syndrome?
Multiple sebaceous neoplasms
Keratoacanthosis
Visceral tumors (colon CA most common)
Inheritance: AD
Symblepharon DDx
chemical burn S-J syndrome OCP trachoma herpes zoster atopic keratoconjunctivis scleroderma GVH disease
chemical injury grading
based on severity of cornea damage and ischemia
Stevens Johnson Syndrome
Erythema multiforme major
Type III immune hypersensitvity
Usu. in young patients
Caused by drugs (esp. antibiotics - sulfa, pencillin) or infection (mycoplasma, HSV, adenovirus, strep)
Signs:
Pseudomembranous conjunctivitis, symblepharon, trichiasis, severe dry eyes, corneal scarring/vascularization
Treatment:
Amniotic membrane, IV steroids
Topical abx, lubrication, symblepharon lysis
Mooren ulcer - Demographic/Signs
Idiopathic (?autoimmune) Inflammatory peripheral thinning Starts peripherally with leading undermined edge progressing circumferentially then centrally Painful; epithelium missing Perforation with minor trauma
Mooren ulcer - types and treatment
2 types:
1: unilateral, older pts, slow progression
2: bilateral, West African males, rapid progression, most w/ coexisting parasitemia
Treatment:
excision of adjacent conjunctiva (lots of immune cells), steroids, CL, immunosuppressants
Terrien Marginal Degeneration
Idiopathic Noninflammatory peripheral thinning Begins superiorly, slowly spreads circumferentially; with pannus Painless; epithelium intact Perforation rare High ATR astigmatism 2nd/3rd decade, progressive
Similar form in childhood:
Fuchs superficial marginal keratitis
How to differentiate Mooren from PUK?
Usu. autoimmune dx (e.g. RA) in PUK
PUK involves sclera
Treatment: underlying disease
Reis-Buckler dystrophy
Honeycomb opacification of central cornea
Painful erosions
Inheritance? AD (Ch 5; BIGH3/TGFB1)
Gene product? keratoepithelin
Pathology?
Bowman’s layer absent and replaced by thickened, “sawtooth” fibrocellular tissue
EM shows?
Rod-shaped bodies
Thiel-Behnke dystrophy
Reis-Buckler type II
Honeycomb opacification of central cornea
EM shows?
Curly fibers
Meesmann Dystrophy
Inheritance? AD Onset in 1st decade Bilateral Often asymptomatic; erosions rare Pathology? Epithelial cells contain peculiar substance (PAS+ material) and epitheliail basement membrane is thickened
Marginal keratolysis work-up
CBC with diff RF/anti-CCP ANA ANCA UA
Primary acquired melanosis
Proliferation of melanocytes (pre=cancerous)
No cysts (unlike nevus)
may grown and involve cornea
Usually middle-age to elderly white people
If PAM + atypia, 46% risk for conjunctival melanoma
Malignant melanoma
55% from PAM, 25% from nevus, 20% de novo
Pagetoid spread
May be amelanotic
Treatment: “no touch” excision, freeze-thaw cryo to margins, alcohol to base
Worse prognosis if?
Caruncle, fornix, palpebral conj
But better prognosis than cutaneous melanoma
Keratoconus Dx
1) Central cornea power > 47.2
2) difference in cornea power between fellow eyes > 0.92 D
3) I-S value (difference between average inferior and superior cornea powers 3 mm from the center of the cornea): >1.4 D
