Keys Flashcards
What are the criteria for the classification of Sjögren’s Syndrome?
(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
Describe the clinical features of Mooren’s ulcer.
Chronic, painful PUK which has overhanging edge; associated with HepC
Describe the clinical and molecular features of OCP.
(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)
What are the clinical features of keratoconus?
High irreg astig; reduced spectacle VA; Vogt striae; Rizzuti’s phenom; Munson’s sign; prominent corneal nerves; Fleischer ring; “Charleux” oil droplet; retinoscopic scissoring
What are the ocular and systemic associations with keratoconus?
(1) OCULAR - LCA, RP, VKC, Ectopia lentis
(2) SYSTEMIC - Down’s; Atophy; Turner’s Syndrome; Marfan’s Syndrome; Mitral valve prolapse
What are the Rabinowitz & MacDonnell criteria for diagnosis of keratoconus?
(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%)
What are the causes of band keratopathy?
(1) Idiopathic, Chronic ocular disease (inflammation eg. JCA), phthisis bulbi, IK, silicone oil.
(2) Hypercalcaemia - hyperparathyroidism, vitD toxicity, sarcoidosis, Chronic renal failure, gout
What is Axenfeld’s and Reiger’s anomaly?
(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
What systemic conditions may be associated with peripheral corneal ulceration?
RA, Wegener’s granulomatosis, SLE, PAN, Acne rosacea, leukaemia, TB, VZV
What is Macular Corneal Dystrophy? What is its genetics?
(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
What systemic conditions may be associated with Macular Corneal Dystrophy?
(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
What are the causes of a congenitally opaque cornea?
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
How can rheumatoid arthritis effect the eye?
(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
What are the clinical features of Vitamin A deficiency?
(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
List causes of filamentous keratopathy.
KCS; Infections (adeno, HSV, staph); trauma (abrasions, SCL, lacrimal gland radiation); KCN; SLK; Dry Eye; RCES
List causes of prominent corneal nerves.
MENIIb; KCN; NF; FED; Refsum synd; ichthyosis; leprosy; cong glc;
What are the causes for vortex keratopathy?
Chloroquine, Amiodarone, NSAIDs (eg. Indomethacin), Tamoxifen, Fabry Disease [Conjunctival aneurysms, cataracts, papilloedema, Angiokeratomas, cardiomyopathy, CRF]
What are the causes for decreased corneal sensation?
V lesion (acoustic neuroma; surgery, CVA); HSV; VZV; DM; Contact lens wear; topical drops, LASIK, cocaine
List causes for chronic conjunctivitis.
Chlamydia inclusion conj; trachoma; molluscum contagiosum (unilat); microsporidial; toxic/drops
DDx: Parinaud oculoglandular conj.; silent dacrocystitis; cannaliculitis, contact lens-related; MALT; Sebac Cell Ca
What are the causes for cicatrising disease?
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
What features must be assessed on specular microscopy?
(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
List causes for dry eye.
Idiopathic; CT disease (Sjogren S); Wegner’s; Cicatricial disease; Drugs (BB; OCP); sarcoid; Vit A; post LASIK
What are the causes of iris heterochromia?
FHIC; Cong. Horner’s Syndrome; Trauma (sideroris); Melanoma; Meds (PGA); Waardenburg’s synd; Sturge-Weber Synd
List the common commensal organisms in the conjunctival sac.
- Staphylococcus epidermidis
- Staphylococcus aureus
- Corynebacterium spp (diphtheroids)
- Propionibacterium acnes
What is the differential diagnosis of a conjunctival membrane and pseudomebrane?
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
List the common causes of viral conjunctivitis.
- Adenovirus (most common)
- Herpes simplex virus (mainly type 1)
- Molluscum Contagiosum (a poxvirus)
- Varicella-zoster virus
- Picornavirus (enterovirus 70, coxsackie A24)
How do you medically treat ocular cicatricial pemphigoid?
(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
How do you treat Chlamydial conjunctivits?
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
How do you treat Gonococcal conjunctivitis?
(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
How do you treat neonatal conjunctivits for which no particular organism is suspected?
(1) Urgent gram stain
(2) Exclude dacrocystitis, NLD obstruction, congenital glaucoma
(3) Use erythromcin ointment QID + erythromycin elixir 50mg/kg/day for 14/7
How do you treat fungal keratitis?
(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
How do you treat band keratopathy?
After managing underlying cause – debride epithelium then wipe with EDTA 3%
How do you treat Acanthomoeba keratitis?
(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
How do you treat blepharitis?
(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)
What are the treatment options for recurrent erosion syndrome?
(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)
How do you manage alkaline corneal burns?
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
Outline your principals for the management of keratoconus.
(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)
Compare PK to DSAEK.
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
What axis do you cut a corneal suture on and when can a corneal suture be removed after laceration repair?
(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
Outline your management for Dry Eye Syndrome.
- Manage underlying condition – referral to rheumatologist etc for RA; Sarcoidosis; OCP.
- Preservative free lubricants (cellufresh / refresh plus) q1h + ointment (GenTeal gel)
- Cyclosporine 0.05% QID
- Punctal plugs (collagen inserts – temporary; acrylic – reversible; cautery permanent)
- Remove filaments – consider 10% acetylcysteine (Mucomyst) QID
- Serum drops (20% QID)
- Moisture chamber nocte
- Surgical - Lateral tarsorrhaphy/Botox
How do you manage FED or pseudophakic bullous keratopathy?
- 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
How do you manage corneal graft rejection?
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
Outline your management of allergic/atopic conjunctivits?
- Eliminate agent 2. Cool compress 3. Lubricant 4. Olopatadine 0.1% BD 5. NSAID 6. g Steroid 7. o Antihist 8. CSA
How do you treat Superior Limbic Keratoconjunctivitis?
(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
What are the types of lattice dystrophy?
(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)
