General Pathology Of The Eye Flashcards
2) Orbital inflammation and infection(5)
Orbital cellulitis- ac infl. Post. To orbital septum, limited motility + malaise. 60% sinuses(ethm/frontal)- infants (tooth). Exophthalmos, chemo sis, lim. Motility, leukocytosis, incr ESR.
Preseptal cellulitis- more frequent.w/out chemosis/limited motility. Tx with IV atb (oxa/penicillin).leads to optic neuritis->atrophy->blind.
Cavernous sinus thrombosis- rare. Thrombus in presence of purulent infection spread from middle ear/petrousbone/orbital cavity/skin. Headache,stupor,fever,vom.,bilateral exophthalmos, epics legal/conj. venous stasis + total opthalmoplegia. If optic n.->orbital apex syndrome.
Orbital pseudo tumour(myositis)- lymphocytic orbital Tumor of UO. Sev. Inflammation,eyelid swelling,chemosis,uni/bilateral exophthalmos. Ocular m. Involvement->lim.mobility->diploplia. CT/MRI then biopsy to confirm. Tx: systemic CST + radiotherapy.
Orbital periostitis- infl of periosteum, usually bac(actinomycetes,TB,syphillis). Osteomyelitis, tooth infl(infants). Less sev. Cellulitis w/out motility disturbances.
3) Orbital tumours (10)
All displace globe-> exophthalmos + lim. Motility.
1)Hemangioma- most comm. benign in children&adult. Sup.nasal region. Capillary(children!tx:CST/radiotherapy), cavernous (adult!tx only when axis is occluded + amblyopia(strabismus) or if incr. risk of optic neuropathy.
2) Dermoid/epidermoid cyst- most comm. orbital tumour in child.choriostomas->displace dermal/epidermal structures(deeper). ant.orbital septum. Tx: complete removal.
3) Neurinoma(neurofibroma)- assoc w/ Reckling Hausen neurofibromatosis. If in optic canal-> removed.
4) Meningioma- from optic n. Or cranium (sphenoid Meningioma). Sx: exophthalmos,lim.motil,compressive optic neuropathy. Meningiomas of optic n. Sheath=histologically benign.
5) Leukemic infiltration- ALL+AML. Sx: exophthalmos+ infl.
6) Lymphoma- isolation/systemic disease.only slightly malig.(exc.burkitts). Tx: radio/chemo tx.
7) Rhabdomyosarcoma- commonest 1* malig.in child. Rapid growth+inflammation(excl. cellulitis).tx:radio/chemo tx.
8)METS- children:orbital cavity>choroid. Neuroblastomas.
Adults:opposite. Adenoblastomas(breast,lung,prostate,colon,testis) or extraocular extension of intraoc.tumors.
9) Optic n.glioma- 25%assoc w/ neurofibromatosis. Good prog.
10) Lacrimal gland
4) orbital fractures (4)
Roof- frontobasal,orbitofrontal.
Lateral- orbitozygomatic.
Medial- orbitoethmoidal.
Floor- retromarginal(blow out fracture).
1) Roof: falling on sharp object,blow to forehead. Hematoma,craniofacial bone destr. Ext.to ant.cranial fossa. Visual function dmg.(ischemic neuropathy of optic n.). Tx:decompress optic channel,megadoses CST. If small->none.
2) Lateral: blunt trauma, part of zygomaticomaxillary complex. Pain,hematoma,chemosis,vis.disturbances,eyeball displacement(diploplia,enopthalmos). CT/MRI. Tx: surgery(persistent diploplia,lim.mouth opening). Flattening facial region, cover 1 eye.
3) Medial- blunt trauma.hematoma,subcut.ephysema(ethm.air cells). CT. Tx: release entrapped tissue.
4) Floor- blow out(sudden increase in orbital pressure from striking force). Usually maxill.sinus(thinnest). Sx:swelling,hematoma,pseudoptosis,diploplia,rupture of rectus->inability to move eye up/down, n.infraorbitis->paresthesia/hypothesia. Hamlock:wide break orbital floor.enopthalmos.no rectus involvement.
Hanging drop:fissure fracture w/ soft tissue entrap.
X-RAY/CT. surgery for entrapment.
1) Disorders of the eyelids
Developmental(4)
Deformities (11)
Developmental(4) Coloboma Epicanthal folds-> sev. Esotropia Blepharophimosis Ankyloblepharon
Deformities (11)
Ptosis- unilateral(n), bilateral(m), congen, acq.
Entropion- congen, spastic, cicatricial (folds inwards)
Ectropion- congen, senile, paralytic, cicatricial (turned outwards)
Trichiasis-(inward fold inward)
Blepharospasm-(orb.oculi)- extra pyramid. Disease. Trigeminal neuralgia/psychogenic
Contact eczema
Edelman
Seborrheic blepharitis- scaly, bilateral
HSV- unilateral vesicles at mucus skin junction
Herpes zoster- Intracell. 40-60 reactiv. Chicken pox.sev pain in opth n,Clear vesicles
Abscesses- pus collection
5) Disorders of the lacrimal gl.&drainage system(7)
1)Dacrocystitis- infl. Lacrimal sac (due to obstruction of nasolac.duct). Acute: Unilateral,50-60y,fluid retention->infection by staph/Pneumococci/pseudomonas. Malaise,fever,LN involvement.
Abcess->fistula(incr.risk sepsis).DD:hordeolum/orbital cellulitis.
Chronic: obstr.2*to chronic inflammation of nasal mucosa. Incr.lacrimation,no sy of inflam.compression->pus! Can lead to serpingous corneal ulcer. Tx: surgical(dacrocystorhinostomy)-connection btw duct+nasal mucosa.
Neonatal:6%newborn->stenosis(persistent valve of hesner). Swollen,red,tender,pus. Tx: spontaneous,atb,irrigation/probing/massage.
2) Cannaluiculitis- inf.of only 1 canaliculus.rare.stricture->inflam. Swollen,red,tender,pus+CONCREMENT. Tx: atb,surgical incision(to remove concretements).
3) Tumors of sac- malig.papillomas,carcinomas,sarcomas. Unilateral,painless swelling.
4) Keratoconjunctivitis sicca- dry eyes syndrome(decr.production/incr.evaporation).
5) Epiphora- incr.lacrimation.hypersecretion/obstr. emotion,irritation,smoke,dust,FB,inj./infl.)
6)Dacroadenitis- rare infl.of lacrimal gl.
Acute: intense infl+tenderness. Pneumo/staphylococci. Relation w/measles,mumps,diphtheria,influenza&scarlet fever.
DD:hordeolum/eyelid Abcess/orb.cellulitis.
Chronic:incomplete healed acute/sarcoidosis/leukemia. If bilateral->mikulicz syndrome. No pain,s-curve. Tx: CST.good prog.
7)tumors of gland-6%orbital neoplasms. Rare in children. Pleomorphic adenoma(most freq. benign). Pleomorphic adenocar.,adenocystic ca(malig). Slow, displaced inf+med(diploplia).
6) conjunctivitis-bac,viral,neonatal,allergic.(4)
- infl.eye surface(vascular dilation,cellular infiltrate,exudation).acutecrusts. Dx:clinically. Tx:ointments, drops (genta/tobramycin/chlortetracycline/chloramphenicol)
2) viral-epidemic,Keratoconjunctivitis(most common). Type18/19 adenovirus (direct contact,8-10d incubation). Resp+ocular secretions. Unilateral,illacrimation,itching,watery mucoid,swelling,red police semilunaris&caruncle. Nummular keratitis (coin like infiltrate on pcr. Untxable,resolves2w. artificial tears/cold compress. Prophylaxis: no itching/contact/avoid CST.
3) Neonatal- 10%newborns-chlamydia(also gonorr.)infection at birth from undetected STI. Sy/sx manifest 2-4d(mild->life threatening). Gonococcal=medical emergency. Sx: pus accumulate,tight+swollen eyelids. DD:neonatal Dacrocystitis(only symptomatic 2-4w). Tx:gonocc(topical&systemic PNC), chlamydia(erythromycin).
4) Allergic:
Seasonal:hay fever (spring/summer), pollen
Perennial:whole year(exacerbat. Autumn), dust mites+fungal Ag.
Giant papillary conjunctivitis-FB(contact lens).
Phylctenular Keratoconjunctivitis- delayed allergic rx to microbial proteins.
Sx:red,watery,itchy,sneezing,nasal discharge,chemosis.
Tx:desensitisation
7) Conjuctival tumors (5).
Benign-freq, malig-rare.
1) Epibulbar Dermoid-round grey/yellow/white.congen.tumor located at limbus-corneal stromatolites. Isolated or symptom of Goldenhar syndr.(oculoauriculovertebral dysplasia -w/outer ear deformities+periauricular appendages). Removed cosmetically/r of globe perforations.
2) Hemagioma- small cavernous prolif.of BV. Congen.anomaly. Resolved spontaneous 7y, if not->surgery.
3)Epith.conj.tumors-
Conj.cyst- benign,harmless. Small,clear,fluid filled inclusions of conj. Appear post-op (strabismus correction)/post trauma/spontaneous. Removed surgically (marsupialization).
Conj.papilloma- viral from bulbar/palpebral conj. benign. Can be branching pediculate/blood based lesions. Entirely removed.
Conj.carcinoma- whitish,raised,thickened,surface forms plateau. Kerat.sq.cell.carcinoma (Epith.dysplasia->Ca in situ. Tx: excision+post op radio tx.
4)Melanocytic conj.tumors:
Nevus- birthmark,near limbus in temp.portion of palpebral fissure/caruncle. Benign,raised,congen.tumor. 50%hollow unpigm.cystic space. Pigm/unpigm. Size incr.w/age.incr.pigm.w/hormones/sunlight. Can degenerate into melanomas (compl. Excision).
Melanosis-pigm.thickening of conj.epith. Rare. Unclear etio.>40y. Irregular diffused pigm.+thickening of Epith. Mobile w/acq.nonmobile w/congen. Brown colour. Tx: combined excision/cryoagglutination of deeply pigm.layers.
50%melanomas dvlp from Melanosis, other 50% from Nevus. Not as aggressive as melanoma.multiple recurrence produce scarring->symblepharosis(fusion of eyelids&conj.)
Congen.melanosis-benign,subepith.in episclera. Conj.epith not involved. Bluish grey.
5)Conj.lymphoma- salmon coloured conj.thickening in inf.fornix. Diagnosis:biopsy&histology. Can be benign lymphoid hyperplasia->malig.lymphoma. Tx:chemo/radio tx.
8) Chemical conjuctivitis &keratosis(2)
1)alkalic burns- coagulation necrosis.
2)acidic burns- liquefactive necrosis.
Tx: remove necrotic tissue +CST 1w.
Complications:
symblephera(partial/compl.adhesion of palp./bulbar conj.).prevented by glass stick 2d.
Leucoma(dense white corneal opacity, 2*glaucoma)
9) Corneal infections (2)
Protective MOA: refl.eye closing,tear flushing,hydrophobic Epith.(diffusion barrier),fast regen.
Predisposing factors:blepharitis,dacrostenosis,Epith.changes,contact lenses,lagopthalmos(inability to close eyes),neuroparalytic disorders,trauma,ISuppression.
Events: corneal lesion->stroma->atb infiltration(opacification)->hypopyon->infect entire cornea->stromal meltdown to descemet membr.->protrude ant.->perforation of descemet->aq.humor leak=corneal ulcer. Progressive vision loss->iris prolapse.
1) Bac-90%
s.aureus,epidermis (slow,little pain).
S.peumoniae(serpingous corneal ulcer,v.painful.
P.aeruginosa(grey/black exudate.ringshaped Abcess,rapid.painful)
Only gonocc.&diphtheria penetrate intact corneal Epith. Moderate-sev.pain,photophobia,imp.vision,tearing,purulent discharge,Edelman,deep injection.
Tx: corneal ulcer(emergency),hypopyon(atb,causes irritation of ciliary body +immobilisation by mydriasis). Surgical if broad superficial necrosis/inefficient healing(require flap from placenta) or desmocele(emergency keratoplasty).
2) Viral- HSV(common cause.90%popn carriers. 1infection(blepharitis/conjuctivitis). Recurrence triggered by UV,stress,menstruation. V.painful,photophobia,lacrimation,eyelid swell,imp.vision,recurrence freq in stroma+Epith.
Dendritic keratitis-branch Epith.lesions(necrosis). Visible under fluorescent dye. Reduced corneal sensitivity. May progress to stromal.
Stromal keratitis-purely stromal(intact Epith.), slit lamp shows disciform infiltrate,sup/deep vascular &endoth.plaques.
Endothelitis- present in aq.humor(opacification of stroma). Can cause2glaucoma. Endothel.plaques,iris inv.+pigm.loss.
3) mycotic-from improper atb use. Aspergillus,c.albicans. Red eye,corneal ulcer,White stromal infiltrate,satellite lesions,hyphae in stroma,hypopyon. Tx: intraconazole.
4) Acanthameoba- rare.contact lens/trauma/sauna.painful photophobia,lacrimation.
10) Corneal dystrophies (3) and degeneration (4)
Corneal degeneration:
1)Calcific band keratathy: y of chr.uveitis&ketatitis(infl.of ant.chamber),w/shrinkage of eyeball in juvenile polyarthritis. Calcific deposits on bowmans layer. Transverse zone of opacification in palpebral fissure,limbus remains clear. Significant imp.vision(removed by cheating with NA-EDTA)
2)Peripheral furrow keratitis: grp of disorders leading to thinning/melting of periph.cornea. Progress to perforation.
I)AI: collagenosis,marginal keratitis,sclerokeratitis.
II)trophic:lack of tear film
III)unknown degen.process: terriens marginal degen./Moorens ulcer.mostfreq in RA. Tx:underlying disorder.
3)Keratomalacia: vitA defic->xerosis of conj.&night blindness.
Corneal dystrophies: hered.corneal metabolic dysfunction leading to bilateral opacification of layers.rare.progressive.non-Inflam. Genetic disorders manifest 1st-2nd decade(exc. Fuchs-40-50y). Classified according to layer of cornea.
1) Epith.corneal dystrophy: ant. Logan(BM),messman(Epith.),reisova-bucklersova(bowmans).
2) stromal corneal dystrophy: granular(hyaline),lattice(amyloid),Macular(acidic mucopolysacc.- most sev.).
3) endothel:Fuchs. Irreg.warts of descemet membr.secreted by Ann.endoth.cells. Endothel.decompensation(stromal edema,blurred vision,Epith.edema). Tx: freq.application hyperosmolar sol.(remove H2O),transplant&cataract extraction.
Sx:incr.loss visual acuity,may req corneal transplant. Macular dystrophy(sev.loss of acuity by 2nd decade). Epith.&stromal(painful,recurrent corneal erosion). Fuchs(grad.loss of endoth.cells->bullous keratopathy,hydration of cornea,stromal edema+epith.bullae.vision worse in the morning (incr.swelling at night).
- Myopia,hyperopia,astigmatism, presbyopia(4).
1) Myopia: short sightedness. Discrepancy btw refractive power&axial length of eye. Light rays converge ant.to retina. 25%pts btw20-30 axis shift->esotropia(strabismus,1/both eyes turned inward).ant.chamber is deep,ciliary m.atrophy. Vol.of vitreous body too small->collapse->opacification. Incr.r.retinal detachment).
DD:glaucoma(decr.pressure,decr.rigidity).
Tx: excess RP must be reduced(diverging lens, concave). RP=negativeD (D=1/f). F= focal point in m. Positive miniscal shape reduces lens aberrations. Contact lenses (decr.size less than glasses, decr.aberrations). Closer minus lens (weaker RP, must be stronger than necessary).
2)hyperopia: far sightedness.convergence post.to retina. 20%pts 20-30 have RP exceeding +1D. Newborn hyperopia. In advanced age,refraction shifts to myopic(due to sclerosis of ncl). Can be axial or refractive(less common).
Axial:congen.shallow ant.chamber,thick sclera,well dvlp ciliary m.(exposed to acute angle closure glaucoma, can be provoked by mydriasis). Forms:1)aphakia(absence of lens,dislocation),2)post-op.
In young pts: accommodation can compensate sight, leads to asthenopie(eye strain).
Esotropia&presbyopia occur w/age(loss of accom.)
Diagnosis:opthalmoscope(blurred optic disc, elevated retina too big for globe,tortuous vascularise,ciliary m.constantly under tension=latent hyperopia).
Tx: converging lens,convex. Spherical lenses,strongest pt can tolerate.
3)Astigmatism: lack of focal point. Curvature anomaly of refractive media. Parallel incident, light rays don’t converge. 42%>0.5D,20%>1D(req.correction). Refraction produces 2focal points. Midway(image equally distorted). Lack focal point(all refractive media comprise total astigm.(ant.+post.surface of cornea&lens.rare.)
External:ant.surface of cornea. Internal:sum of other media. Degree of astigm.changes during life.
Classified according to meridian:
I)W/rule:(most common)-vertical(70-110)
II)against rule:-horizontal(160-200)
III)oblique:(20-70,110-160)
Irreg.astigm.: RP is irregular,multiple focal points caused by ulceration,scarring,pen.trauma,adv.keratoconus,cataract,lenticonus.
Dx:keratoscope(gross estimation of astig.): regular(normal rings), irreg(distorted). Corneal topography(video keratoscopy). Javal opthalmometer(measures corneal curvature=RP of cornea).
Tx:untx.in children->uncorrected amblyopia. Regular->cylinder lenses. Irreg->can’t use glasses. Solid lenses/keratoplasty(lens removal).
4) Presbyopia: physiolog. Decr.accomodation w/age.when range of accom
12) Principles of reactive surgery(11)
Surgical tx of refractive errors.
1) astigmatic keratotomy(AK): parallel incision of cornea in steep median to flatten cornea&decr.dioptric power. The longer the incision&closer to cornea=greater flattening. Max 5D corrected. Indication: high degree,regular astigm.
Adv: incision outside optical axis.
Disadv:effect only W/deep incision(95%depth).
2) Radial keratotomy(RK): 1stdeveloped.limited use.correction of myopia by flattening central dome of cornea (4-6 radial incisions,decr.RP). Doesn’t influence optic centre of cornea.
Indication: moderate myopia (
13) disorders of sclera&episclera (7)
1) colour change: normal(dull white), conj./ciliary injection&infl(red), thinning sclera(blue), jaundice(yellow),ochronosis(homogenate deposits, brown).
2) staphyloma: bulging sclera, thinning degen. underlying uveal tissue. Most common- post. Staphyloma in sev myopia. Also scleritis.
3) Ectasia: thinning&bulging w/out uveal involvement.2*to infl.
4) trauma: freq.w/penetrating trauma. Tx: If 8mm past limbus retinal cryopexy or retinal tamponade.
5)Inflammation: most often ant(episcleritis, ant.scleritis). Classified:
I)location: ant/post.to equator.
II) depth: sup.(episcleritis)/deep(scleritis)
III) nature: diffused(scleritis)/circumscribed(epi),nodular(both)/non necrotising(scleritis).
6)Episcleritis: circumscribed/segmental.nodular infl.btw sclera&conj. rarely due to systemic disease, occas.infl.
Sx: uni/bilateral segmental reddening, slight tenderness, hyperaemic facial sheath vessels, sclera isn’t swollen, small mobile nodules.
Tx:resolve spontaneously1-2w. If severe CST&nsaids.
7) Scleritis: diffused/localised. Classified into ant./post.
Ant: non necrotizing (nodular/diffused) or necrotising(w/ or w/out infl., pts are older.). 50% due to systemic AI/rheumatic disease.
Post:not assoc. w/ specific disease, only infl.
Sx: pain,reddening(exc. scleromalacia perforans).
I)non necrotising(nodular): edematoys, swollen,non mobile (Tx:CST)
II)non necrotising(diffused): more severe infl., one segment/entire surface. (Tx:CST).
III)necrotising(w/infl.): circumscribed reddening. Sclera thins as lamella of collagen fibers melt. Choroid shows.(Tx:CST&immunosuppressives).
IV)necrotising(w/out infl.): scleromalacia perforans. Females w/ history of RA. Yellow necrotising patch on sclera, which becomes thin and see through.(no Tx->graft).
V)post.scleritis: result in exopthalmos(proptosis), imp.motility(myositis),exudative retinal detachment+macular/optic disc edema.
14) uveitis(4)
Infl.of iris,ciliary body and/or choroid. Dmgs endothel.of intraocular vessels w/collapse of retinoblood barrier. Dilation of BV,leakage,migration of leukocytes.
Classified: ant.(iritis,iridocyclitis), intermed.(cyclist is,vitritis),post.(choroiditis). All together=panuveitis(acvitreous opacification.
Complic:when chr.->cataract. Possible link to MS,Lyme disease.
Tx: CST,IS,pars plans vitrectomy
4)post.(chorioretinitis,choroiditis): acute,no pain, vitreous opacities(decr.vision),pale bulb,yellow infl affecting retina&choroid,macular edema.
Tx:inf.(atb/antiviral), AI(immunosuppressants, CST)
15) tumors of uvea(6)
1) malig. Melanoma: most common intraoc.tumor. Isochoroidal(80%), unilateral tumors in iris(8%), detected earlier than ciliary body(12%) &choroid. 50-70y, unilateral.
2) iris melanoma: a symptomatic,but METS cells in. Angle of ant.chamber->2glaucoma.removed by segmental iridectomy.mostly on lower half,pigmented,pupil distortion.
3) ciliary melanoma: changes in accomodation&refraction. Resected. Episcleral vessel extension &2retinal detachment&glaucoma.
4)choroidal melanoma: symptomatic w/ macular involvement. Decr.visual acuity/shadow on field of vision+retinal detachment.
Dx: translumination,U.S.,angiography(fluorescin)
Tx: brachytherapy(radioisotope). >8mm-> enucleation. photocoag.thermotherapy.
5)METS: ca breast/lung. Flat,little pigmentation.
Tx: iris: enucleation, ciliary:cyclectomy,iridocyclectomy,radiotx,enucleation.
Most common METS location: liver(60%), subcut(24%),lung(7%)
Benign:
6)choroidal nevi:11%popn, can lead to 2*neovasc+retinal edema. When macula involved,decr vision.usually asymptomatic.
