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Cornea and Anterior Segment > Keys > Flashcards

Keys Flashcards

1
Q

What are the criteria for the classification of Sjögren’s Syndrome?

A

(1) Ocular Symptoms – daily dry eyes 3/12; CFBS; ocular lubricants >3/day
(2) Oral symptoms – daily dry mouth 3/12; swollen salivary glands as adult; fluids to aid swallowing food
(3) Ocular signs – Schimer I test (4 Bijsterveld score
(4) Histopathological – focus of conglomeration of >50 mononucleear cells in 4mm2 of glandular tissue
(5) Salivary Gland – delayed salivary uptake/secretion; parotid sialectasis; ↓ unstimulated salivary flow
(6) Autoantibodies – ab to Ro/SS-A or La/SS-B

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2
Q

Describe the clinical features of Mooren’s ulcer.

A

Chronic, painful PUK which has overhanging edge; associated with HepC

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3
Q

Describe the clinical and molecular features of OCP.

A

(1) Loss of caruncle; medial canthal keratinisation; forniceal shortening; keratinisation of cornea/conj; subconj scarring; punctual/canalicular closure; symblepharon; ankblepharon
(2) IHC: fresh sample: IgG localised in BM; Bullae: Ab to conj epithelium β4 intergrin (disrupts hemidesisomes)

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4
Q

What are the clinical features of keratoconus?

A

High irreg astig; reduced spectacle VA; Vogt striae; Rizzuti’s phenom; Munson’s sign; prominent corneal nerves; Fleischer ring; “Charleux” oil droplet; retinoscopic scissoring

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5
Q

What are the ocular and systemic associations with keratoconus?

A

(1) OCULAR - LCA, RP, VKC, Ectopia lentis

(2) SYSTEMIC - Down’s; Atophy; Turner’s Syndrome; Marfan’s Syndrome; Mitral valve prolapse

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6
Q

What are the Rabinowitz & MacDonnell criteria for diagnosis of keratoconus?

A

(1) Central power > 47.2 D
(2) I/S difference > 1.6D (diff. between 3mm below and above centre)
(3) KISA% >100% (quantifies reg & irreg astig into 1 value; suspect 60-100%)

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7
Q

What are the causes of band keratopathy?

A

(1) Idiopathic, Chronic ocular disease (inflammation eg. JCA), phthisis bulbi, IK, silicone oil.
(2) Hypercalcaemia - hyperparathyroidism, vitD toxicity, sarcoidosis, Chronic renal failure, gout

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8
Q

What is Axenfeld’s and Reiger’s anomaly?

A

(1) Axenfeld: post. embryotoxon + ant.synechiae
(2) Reiger: post. embryotoxon + ant.synechiae + iris atrophy + pupil distortion (FOXC1;PITX2)
(3) Reiger syndrome: post. embryotoxon + ant.synechiae + ‘polycoria’ + ‘corectopia’ + hypodontia/umbilical/anal stenosis

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9
Q

What systemic conditions may be associated with peripheral corneal ulceration?

A

RA, Wegener’s granulomatosis, SLE, PAN, Acne rosacea, leukaemia, TB, VZV

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10
Q

What is Macular Corneal Dystrophy? What is its genetics?

A

(1) No clear areas between opacities; to periphery; deep earlier; less recurrences compared to granular
(2) AR; carbohydrate sulfurtransfurase6 - CHST6 (16q22); 3 types based on antigen to keratin sulfate

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11
Q

What systemic conditions may be associated with Macular Corneal Dystrophy?

A

(1) Hurler’s - severe mucopolysaccaridosis - course facies; MCD, mental retardation, hernias, hepatosplenomegaly
(2) Scheie - mild mucopolysaccaridosis - stiff joints, peripheral MCD, Aortic regurg
(3) Morquio- mucopolysaccaridosis - short stature, skeletal & dental changes; MCD

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12
Q

What are the causes of a congenitally opaque cornea?

A

S – sclerocornea (clear centrally)
T – trauma to Descmets
U – ulcers - HSV
M – metabolic – mucopolysaccharidoses, mucolipidoses
P – Peter’s anomaly (opaque centrally) Peter’s Plus: dwarfism; genitourinary + Mental retardation + deafness – 50% get glc
E – endothelial dystrophy - CHED
D – dermoid

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13
Q

How can rheumatoid arthritis effect the eye?

A

(1) Secondary Sjögren’s Syndrome; episcleritis; slceritis;
(2) Corneal:
A - Stromal lysis in presence of Inflammatory Infiltrate – paracentral/PUK
B - Stromal lysis in absence of Inflammatory Infiltrate – paracentral

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14
Q

What are the clinical features of Vitamin A deficiency?

A

(1) Nyctalopia – retinal function does not always correspond to AS finding
(2) Xerophthalmic fundus – yellow-white spots in peripheral retina
(3) Conjunctival xerosis - without (X1A) or with Bitôt spots (X1B) - Bitôt spot path: keratinised epith; epithelium cells, debris, Corynebacterium xerosis (gives foamy appearance)
(4) Corneal xerosis (X2)
(5) Corneal ulceration – keratomalacia 1/3 (X3B) of corneal surface

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15
Q

List causes of filamentous keratopathy.

A

KCS; Infections (adeno, HSV, staph); trauma (abrasions, SCL, lacrimal gland radiation); KCN; SLK; Dry Eye; RCES

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16
Q

List causes of prominent corneal nerves.

A

MENIIb; KCN; NF; FED; Refsum synd; ichthyosis; leprosy; cong glc;

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17
Q

What are the causes for vortex keratopathy?

A

Chloroquine, Amiodarone, NSAIDs (eg. Indomethacin), Tamoxifen, Fabry Disease [Conjunctival aneurysms, cataracts, papilloedema, Angiokeratomas, cardiomyopathy, CRF]

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18
Q

What are the causes for decreased corneal sensation?

A

V lesion (acoustic neuroma; surgery, CVA); HSV; VZV; DM; Contact lens wear; topical drops, LASIK, cocaine

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19
Q

List causes for chronic conjunctivitis.

A

Chlamydia inclusion conj; trachoma; molluscum contagiosum (unilat); microsporidial; toxic/drops
DDx: Parinaud oculoglandular conj.; silent dacrocystitis; cannaliculitis, contact lens-related; MALT; Sebac Cell Ca

20
Q

What are the causes for cicatrising disease?

A

PROGRESSIVE: GVHD; Atopy; Lichen planus; Linear IgA; OCP (Bx +ve vs –ve); paraneoplastic pemphigoid (GALLOP)
NON-PROGRESSIVE: Drug induced (pilo/practolol); Infection (trachoma, Neisseria; β H Strep); Trauma (chemical, radiation); SJS

21
Q

What features must be assessed on specular microscopy?

A

(1) CD – cell density - Birth 3000 cells/mm2; Adult >2500 cells/mm2; min required 400-700 cells/mm2; loose ~0.5% pa
(2) CV – coefficient of variation = SD of cell area/ mean cell area; N=25; Decompensate if > 40 ↑CV=polymegathism
(3) pleomorphism – fewer cells with hexagonal shape

22
Q

List causes for dry eye.

A

Idiopathic; CT disease (Sjogren S); Wegner’s; Cicatricial disease; Drugs (BB; OCP); sarcoid; Vit A; post LASIK

23
Q

What are the causes of iris heterochromia?

A

FHIC; Cong. Horner’s Syndrome; Trauma (sideroris); Melanoma; Meds (PGA); Waardenburg’s synd; Sturge-Weber Synd

24
Q

List the common commensal organisms in the conjunctival sac.

A
  • Staphylococcus epidermidis
  • Staphylococcus aureus
  • Corynebacterium spp (diphtheroids)
  • Propionibacterium acnes
25
Q

What is the differential diagnosis of a conjunctival membrane and pseudomebrane?

A

MEMBRANE: Bacterial conj (strept, pneumococci, corynebacterium diphtheria); chemical burns, ligneous, adenovirus, HSV
PSEUDOMEMBRANE: All of above + OCP, SJS, SLK, gonnococal and chlamydial infection in newborns

26
Q

List the common causes of viral conjunctivitis.

A
  • Adenovirus (most common)
  • Herpes simplex virus (mainly type 1)
  • Molluscum Contagiosum (a poxvirus)
  • Varicella-zoster virus
  • Picornavirus (enterovirus 70, coxsackie A24)
27
Q

How do you medically treat ocular cicatricial pemphigoid?

A 
(1) LUBRICANTS
•	Treat ocular surface dryness/blepharitis 
•	Punctal plugs (if not closed by scarring
(2) STEROIDS
•	Topical steroids (cautious for corneal melt)		- (3) DAPSONE
•	Dapsone 50-100mg oral daily
•	SE: anaemia – FBC & G6PD prior to Rx
(4) OTHER IMMUNOSUPPRESSANTS
•	 MTX
•	MMP
•	Cyclophosphamide
•	Rituxumab (CD20 supression)
(5) PLASMAPHORESIS
PRINCIPLES:
•	Withdraw after disease quiescent for 3-6/12
•	Surgery – entropion/keratoprosthesis
28
Q

How do you treat Chlamydial conjunctivits?

A

General: Azithromycin 1g oral
If pregnant: erythromycin 500mg o BD for 14/7
If neonatal: erythromycin elixir 50mg/kg/day for 14/7 + Rx parents

29
Q

How do you treat Gonococcal conjunctivitis?

A

(1) Antibiotics
• If no corneal involvement: Ceftriaxone 1g im and ciprofloxacin q2h
• If corneal involvement: ceftriaxone 1g iv BD (can perf rapidly) and moxifloxacin (1.0%) q1h
(2) Saline irrigation
(3) Screen/treat for concurrent Chlamydial infection
(4) Treat all partners

30
Q

How do you treat neonatal conjunctivits for which no particular organism is suspected?

A

(1) Urgent gram stain
(2) Exclude dacrocystitis, NLD obstruction, congenital glaucoma
(3) Use erythromcin ointment QID + erythromycin elixir 50mg/kg/day for 14/7

31
Q

How do you treat fungal keratitis?

A 
(1) TOPICAL ANTIFUNGALS
•	g.  Amphotericin B 0.15% (Candida) q1h
or 
•	g. Natamycin 5% (filamentous) q1h
•	Can give g. voriconazole 1% q1h
•	Can debride epithelium for penetration
(2) CYCLOPEGICS
•	Atropine 1% if hypopyon
(3) CONSIDER SYSTEMICS
•	Consider voriconazole 200mg oral BD
32
Q

How do you treat band keratopathy?

A

After managing underlying cause – debride epithelium then wipe with EDTA 3%

33
Q

How do you treat Acanthomoeba keratitis?

A

(1) Polyhexamethyl biguanide 0.02% (PHMB) or chlorhexidine 0.02% q1h
(2) Propamide 0.1% (brolene) q1h (needs to be treated for 2-6 months due to cysts)
(3) Voriconazole 200mg BD
(4) NSAIDs if scleritis
(5) Topical steroids use once infection controlled controversial

34
Q

How do you treat blepharitis?

A

(1) Lid hygiene / warm compress / Artificial tears
(2) Use oc chlorsig to lids
(3) Consider cyclosporine 0.05% BD (esp for meibomitis)
(4) Doxycycline 50mg o D for 6/12 (CI in children; pregnant; breast-feeding – use erythromycin 200mg D)

35
Q

What are the treatment options for recurrent erosion syndrome?

A

(1) Lubricants always – BCL + chlorsig if acute – extended wear CL if not healing
(2) Alcohol delamination (20% for 40s) Doxycycline 100mg BD; flarex QID
(3) Anterior stromal puncture ( ~27G needle to ~ 100μm outside visual axis) ~ 45% symptom free at 5yrs
(4) Epithelial debridement & diamond burr polishing of BM (will leave ~ 50% symptom free at 5yrs)
(5) Transepithelial phototheurapeutic keratectomy – excimer laser ablation (1D of hyperopia; 80% symptom free at 20mths)

36
Q

How do you manage alkaline corneal burns?

A 
PRINCIPLE:
1. Always aim to identify the chemical
2. Exclude systemic burns (AIRWAY?)
ACUTE TREATMENT:
1.	Irrigate with Morgan Lens till pH 7.0-7.2	
2.	g maxidex q1h (if grade 2 or above BUT must taper by 10/7 if epithelium not healed)
3.	g chlorsig QID
4.	g citrate 10% q2h
5.	g atropine 1% BD
6.	g ascorbate 10% q2h
7.	Ascorbate (Vit C) 2g o D
8.	Ural sachet TDS / doxycycline
CHRONIC TREATMENT:
1. Lubricants -  preservative free
2. Debride necrotic epithelium
3. Tenon’s advance; AMT; LSCF;
4. Lids; PK (delay >6/12); keratoprosthesis
37
Q

Outline your principals for the management of keratoconus.

A 
(1)  Education
•	Avoid eye rubbing
•	Atopy management
(2) Correct refractive errors
•	Glasses/SCL/RGP
(3) Collagen Cross linking if:
•	Progressing K’s (documented before VA↓)
•	CCT>400μm
•	Young with progressive myopia
(4) Intrastromal rings (intacts)
•	Need clear cornea + CCT>400 + K380: ALTK; DALK; FSALK
•	CCT <380: DALK; FSALK
•	Peripheral thinning: TILK (tuck in)
•	Hydrops/scarring: PK (urgent if vascularised)
38
Q

Compare PK to DSAEK.

A 
PK:
•	Large wound "open sky"
•	Weaker structural strength
•	Longer recovery (1-1.5yrs)
•	Potential VA 6/6
•	Rejection rate same
•	Complications higher (suture abscess; irregular astig, wound dehiscence)
•	Less difficult
•	Lens status phakic
DSAEK:
•	Small wound
•	Stronger/ Intact globe
•	Quicker (3-6/12)
•	1 line less than PK (hyperopic shift)
•	Rejection rate same
•	Less complications
•	Learning curve (5-10% dislocation rate)
•	Best if PCIOL
39
Q

What axis do you cut a corneal suture on and when can a corneal suture be removed after laceration repair?

A

(1) Cut at the steep axis – ie the axis of the + cyl (or 90 away from – cyl
(2) Can be removed after 6-12/52

40
Q

Outline your management for Dry Eye Syndrome.

A
  1. Manage underlying condition – referral to rheumatologist etc for RA; Sarcoidosis; OCP.
  2. Preservative free lubricants (cellufresh / refresh plus) q1h + ointment (GenTeal gel)
  3. Cyclosporine 0.05% QID
  4. Punctal plugs (collagen inserts – temporary; acrylic – reversible; cautery permanent)
  5. Remove filaments – consider 10% acetylcysteine (Mucomyst) QID
  6. Serum drops (20% QID)
  7. Moisture chamber nocte
  8. Surgical - Lateral tarsorrhaphy/Botox
41
Q

How do you manage FED or pseudophakic bullous keratopathy?

A
  • hypertonic saline 5% (Muro 128) – hairdryer at arms length
  • Reduce IOP if elevated
  • If ruptured bullae – give antibiotic / hydrophilic BCL
  • Graft – PK vs DSEK (if no ACIOL) vs Gunderson if no visual potential - remember the hyperopic shift with DSEK
42
Q

How do you manage corneal graft rejection?

A 
FEATURES OF REJECTION:
Definite: flare; cells KPs on donor endothelium; line
Probable: no rejection line
Possible: gradual graft edema nil else
TREATMENT:
(1) Epithelial
•	Double current dose of PF or PF QID (which ever is more)
(2) Endothelial
•	PF q1h
•	Cyclosporine A 0.5%
•	Oral prednisolone
•	Homatropine BD
•	Control IOP
43
Q

Outline your management of allergic/atopic conjunctivits?

A
  1. Eliminate agent 2. Cool compress 3. Lubricant 4. Olopatadine 0.1% BD 5. NSAID 6. g Steroid 7. o Antihist 8. CSA
44
Q

How do you treat Superior Limbic Keratoconjunctivitis?

A

(1) Rx underlying cause (50% associated with TED), blepharitis
(2) As per dry eye - lubricants ++, punctal plugs, cyclosporine 0.05% BD
(3) Silver nitrate 0.5% applied
(4) Acetylcystein 10% if filaments
(5) surgical resection /cautery

45
Q

What are the types of lattice dystrophy?

A

(1) Type I – classic, type AA amyloid, no systemic amyloid deposition; <10yrs old – TGFβ1 (5q31)
(2) Type II – systemic amyloidosis, less lines & more peripheral, May have cranial & peripheral neuropathy (Meretoja’s syndrome); 30-40yrs old – Gelsolin (9q34)

Cornea and Anterior Segment (2 decks)

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