Inflammation, Thyroid, Cornea Flashcards
What does intermediate uveitis entail?
peripheral retina, pars plana, vitreous
What are mutton fat KPs?
dense, oily appearance of epitheliod cells and macrophages in granulomatous uveitis
What are fine KPs?
fine debris, keratic precipitates of lymphocytes, non-granulomatous
What are koeppe iris nodules?
granulomatous or non-granulomatous at pupillary border
What are bussaca iris nodules?
found on iris surface (midperiphery) in granulomatous uveitis
Iris atrophy
diffuse in simplex and sectoral in zoster
Fuch’s uveitis and iris changes
heterochromia due to chronic inflammation
IOP in uveitis
initially decreased due to inflammation and poor function of ciliary body, later increased due to trabeculitis and synechiae
What grading scale does anterior chamber cells/flare use?
SUN (using 1 mm slit lamp beam)
What is an approximate grading for cells?
0 <1// 1+ 6-15// 2+ 16-25// 3+ 26-50// 4+ >50
Should you see cells if you see flare?
ideally yes because of molecular weight but that does not always apply clinically
What is an approximate grading for flare?
0 none// 1+ faint// 2+ moderate aka iris details clear// 3+ marked// 4+ intense fibrin and plastic aqueous
What diseases are associated with nongranulomatous uveitis?
HLAb27, juvenile idiopathic arthritis, trauma, glaucomacyclitic crisis
What diseases are associated with granulomatous uveitis?
sarcoid, syphilis, TB, lens induced, sympathetic ophthalmia, VKH
When should you order a work up after uveitis?
bilateral, granulomatous, recurrent, children, panuveitis, posterior uveitis/retinal vasculitis, necrotizing retinitis
Treatment of uveitis?
aggressive corticosteroid treatment
What are topical corticosteroids?
prednisolone acetate, dexamethasone, difluprednate, loteprednol, fluorometholone
What are injectable corticosteroids?
triamcinolone acetonide, methylprednisone, betamethasone
What are oral corticosteroids?
prednisone, methylprednsione packs
What healthcare individuals might you consult in uveitis?
rheumatology, infectious disease, retina/ophthalmology
What is the most common orbital disorder in adults?
graves orbitopathy
What is the most common cause for proptosis
graves orbitopathy
What is the female male ratio of graves orbitopathy?
9 to 1
What are risk factors for ocular complications of thyroid disease
increased age at onset, smoking, use of radioactive iodine therapy
TED pathophysiology
development of autoantibodies stimulate thyroid gland which can lead to goiter, t-cell mediated response in orbit; t-cell response affects orbital fibroblasts
How do tcells and orbital fibroblasts interact?
adipogenesis, accumulation of GAGs and resultant tissue edema, infiltration of lymphocytes and mast cells, fibrosis of extraocular muscles
What are the two phases of TED?
active and inactive/latent
What is the active phase of TED?
active inflammatory process: periorbital edema and erythema, conjunctival injection and edema, eyelid retraction, ptosis, diplopia, lasts longer in smokers
What is the inactive/latent fibrotic stage of TED?
plateau of active inflammation: reduced chemosis/injection/edema and persistent proptosis/lid retraction/diplopia
What are clinical features of TED?
lid retraction, lid lag on down gaze (von graefe), lid edema, exophthalmos, EOM changes, ON changes
What EOM changes occur in TED?
upgaze and abduction especially, inferior>medial>superior>lateral recti>obliques
Explain lid retraction
lid retraction occurs in 82% of patients may be due to increased sympathetic tone, overaction of the levator and superior rectus muscles to compensate for inferior rectus restriction or inflammation and scarring of the levator complex
What are secondary effects of TED?
exposure keratoconjunctivitis/lagophthalmos, diplopia due to EOM involvement/strabismus, APD due to ONH compression, increased IOP from compression effects
Where may IOP be higher in TED?
in upgaze because of compression
What is NOSPECS
no signs or symptoms, only signs and no symptoms, soft tissue involvement with signs and symptoms, proptosis, EOM involvement, corneal involvement, sight loss
What is VISA?
vision/optic neuropathy, inflammation/orbital congestion, strabismus, appearance/exposure
What is EUGOGO?
breaks down graves orbitopathy into activity (severity of inflammation) and severity (impact on QOL/risk of vision loss)– clinical activity score: pain, redness, warmth, swelling, impaired function; severity assessment: eyelid measures, proptosis, EOMs, corneal integrity, neuropathy
Systemic symptoms of thyroid dysfunction
hair loss, heat or cold intolerance, weight loss/change, skin changes, memory difficulties, mood changes
What labs do you run for TED?
serum TSH (sensitive thyrotropin), free thyroxine T3 T4, thyroid related antibodies and thyroid peroxidase antibodies + anti-microsomal and anti-TSH
Orbital imaging
MRI for muscle bellies, CT for bone with decompression surgery
Management of TED
smoking cessation, lubricants, lid taping, short term fresnel, orbital decompression, orbital steroids, steroid sparing agents, orbital irradiation, glaucoma meds
What is tepezza?
inhibits insulin like growth factor-1 which plays a role in upregulating fibroblastic activity
How does tepezza work?
infusion every few weeks for 8 total treatments, reduces proptosis and associated exposure symptoms, reduced diplopia
What are the anterior corneal dystrophies?
epithelial basement membrane dystrophy, meesman dystrophy, reis-bucklers/thiel-behnke
Which corneal dystrophies are in Bowmans?
reis-bucklers and thiel-behnke
What are the stromal corneal dystrophies?
lattice, granular, macular
What are endothelial corneal dystrophies?
fuchs
What is the most common anterior corneal dystrophy?
epithelial basement membrane dystrophy
What improper developments of the basement membrane occur in EBMD?
thickened and misdirected development into the epithelium, intraepithelial microcysts degenerating epithelial cells, fibrillary material between descemets and bowmans
What are symptoms of EBMD?
dry eye, fluctuating vision, pain association with RCE, blur from irregular astigmatism
What are signs of EBMD?
intraepithelial lesions-gray, map patches, dots, fingerprint, whorls, best seen on retro illumination
What is the treatment of EBMD?
debridement, pressure patch, bandage CL for RCE, anterior stromal puncture for RCE, phototherpeutic keratectomy, superficial keratectomy, chronic hypertonic solution and ointment
What are hypertonic solutions
Muro 128 and freshkote
How does freshkote work?
polyvinyl pyrrolidone and polyvinyl alcohol create oncotic gradient for freshkote to reduce microcystic edema
What are signs of meesmann dystrophy?
diffuse intraepithelial cysts especially intrapalpebral, visualized well on retro illlumination
When does Meesmann present?
as young as age 1 but symptomatic in adult years
What are symptoms of meesmann?
mild irritation, DES, pain with ruptured cysts
What happens with cysts in Meesmann?
cysts may rupture like small bullae, ruptured cysts may scar
What are treatments of Meesmann?
bandage CL, superficial keratectomy
What are signs of reis bucklers?
sub-epithelial, reticular opacities in central cornea; may eventually have central opacification with irregular astigmatism
What are symptoms of reis bucklers?
reduced VA, pain from recurrent erosions
What are the treatments of reis bucklers?
bandage CLs for RCE, various keratoplasties (lamellar, penetration)
What dystrophy often occurs in a graft
reis bucklers, lattice, macular
What are signs of lattice dystrophy?
refractile lines in anterior stroma become more dense, opaque
What are symptoms of lattice dystrophy?
decreased VA, pain from RCE
What are treatments for lattice dystrophy?
bandage CL for RCE, PKP
What are signs of granular dystrophy?
dense, white clumps of opacities in anterior stroma, central with clear spaces between opactities that progress into hazy areas
What are symptoms of granular dystrophy?
erosions are rare, opacities progress and intervening space becomes haze reducing VA
What are treatments of granular dystorphy?
PKP when VA is reduced, possibly PTK
What makes macular dystrophy rare?
autosomal recessive inheritance
What are signs of macular dystophy?
hazy, gray stomal lesion extending to limbus
What are symptoms of macular dystophy?
PKP when VA is reduced
What are signs of Fuch’s?
guttata formation indicating abnormal endothelial cell function resulting in corneal edema
What are symptoms of fuch’s?
blur, glare, colored haloes worse in am, pain from ruptured bullae
What are treatments for fuchs?
hypertonic solutions, PKO, descemet’s stripping automated endothelial keratoplasty
What is keratoconus?
a corneal ectasia
What are symptoms of keratoconus?
decrease vision, distortion, pain form hydrops, vision changes starting in teens
What are signs of keratoconus?
irregular astigmatism, apical thinning, steepening cornea, vogt stria, fleischer ring, munson sign, central corneal scarring
What are treatments of keratoconus?
rigid CLs, intacs, DALK, PKP, collagen crosslinking
RPR/VDRL
syphilis
ACE
sarcoidosis, TB
FTA-ABS/MHA-TP
syphilis
ANCA
autoimmune vasculitis (Wegeners)
Chest xray
TB, sarcoid, SLE
Hertel norms
white 12-20 mm and AA 12-24 mm
What is normal critical flicker fusion frequency?
33 dB, lower is decreased sensitivity
Lenses for keratoconus
Jupiter-sclera, rose K-RGP, synergeyes-RGP/hydrogel hybrid, accukone-RGP, SO2-scleral multifocal, Centracone-RGP
At what endothelial cell count do pumps struggle to function?
<500 cells/mm^2
What technique helps evaluate endothelial cells?
specular microscopy
Polymegetheism
change in cell size
Pleomorphism
change in cell shape
Guttata
focal clumping of excess abnormal basement membrane on descemets that has a beaten metal appearance especially on retro illumination
What is descemet’s stripping automated endothelial keratoplasty DSAEK
partial thickness corneal transplant corneal layer, exchange patient’s damaged endothelium and descemets membrane with donor tissue with healthy posterior stroma/descemet/endo
Advantages of keratopasty (PKP)
faster healing, quicker visual improvement, less surgery induced astigmatism, predictable and minimal change in anterior surface topography, sutures not necessary, decrease risk of wound dehiscence, decrease risk intra-operative expulsive suprachoroidal hemorrhage
Episcleritis treatment
palliative therapy with AT and FML, clinically Pred Forte with possible oral NSAID
Etiologies of episcleritis
idiopathic, collagen vascular disease, gout, infectious
What percent of RCE patients have EBMD?
50%
What demonstrates negative staining
EBMD
What is a RCE treatment?
anterior stromal puncture (creates scar and thus adhesion to anterior stromal bed, avoid visual axis) or phototherapeutic keratectomy which is a excimer laser to bowmans that increases collaged and hemidesmosome activity
Dalrymple’s sign
lid retraction/ scleral show superiorly
