KMK Cards Book 1 Flashcards
Abnormal findings w/in NFL include:
- CWS (aka soft exudates), commonly d/t diabetes
- Splinter hemorrhages (aka Drance hemes), at or near the optic disc.
- Flame hemorrhages, associated w/ retinal vascular pathologies (diabetes, hypertensive retinopathy, retina vein occlusions)
**issues in the NFL are more superficial
Pathology found in INL
Dot or blot hemorrhages (deep retinal vascular pathology).
Astrocytes, define
Define: astrocytes are fibrous cells that provide structure to nerve fibers and retinal capillaries. Performing similar function as Muller cells.
Astrocytes replace the foot plates of Muller cells at the optic disc. This means that the internal limiting membrane (INL) is not present over the optic disc.
Define Muller Cells
Most common glial cell present exclusively in retina. Extends from ELM to the ILM. Most muller cell bodies are located within the INL. Gives structural and nutritional support.
- Maintains alignment of retina.
- provides nutrients to retina and aids in glycogen metabolism (excess glucose is converted in glycogen and stored here for the photoreceptors to use).
- Absorbs and recycles metabolic waste products such as GABA and glutamate.
Microglial cells, define
- phagocytosis cells
- responds to inflammation and/or injury
- found anywhere in retina
Central retinal artery, CRA
There are 2 capillary networks from the CRA: superficial capillary network in the NFL and a deep capillary network in the INL (near OPL).
- central retinal vein will drain inner retinal layers while the outer retinal layers will be drained by the vortex veins
Foveala, define
Last area of the retina to develop. It is completely avascular and contains only cones (no ganglion cells, bipolar or other cells).
- Retina is thickest just outside the fovea in the parafoveal region.
- Retinal layers present: RPE, photoreceptors layer, ELM, ONL, Henle’s fiber layer, and ILM.
Peripheral retina; what happens at the periphery?
- terminates approximately 5 mm anterior to the equator of the eye at the Ora Serrata. Ora Serrata is a 2 mm band at the anterior-most portion of the retina and composed of dentate processes and oral bays.
- RPE becomes pigmented ciliary epithelium
- neural retina significantly thins and transitions into the NPCE.
- Vitreous base (strongest point of attachment) extends over and posterior to the Ora Serrata.
- thinning out of the retinal vasculature
Dentate processes, define
Extensions of peripheral retina onto par plana of the ciliary body
Oral bays, define
Extensions of pars plana into the peripheral retina
which nerves carry out the gag reflex?
CN9 and CN10
Glossopharyngeal and Vagus
CN-10 (Vagus) palsy
Uvula deviates away from the lesion; palate does not elevate; patient will report hoarse voice
CN-12, hypoglossal palsy
Tongue deviates towards side of lesion
Optic nerve, define
Composed of ganglion cell bodies w/in the GCL of retina
- axons converge at the optic disc, exit the sclera at lamina cribrosa, and leave orbit via optic foramen to travel through the optic canal.
CN-2, optic nerve, destinations
- LGN: relays to primary visual cortex (V1)
- Protectal nucleus: pupil innervation
- Superior colliculus: control of saccades; contra lateral and FEF
Edinger-Westphal nucleus; define
Provides parasympathetic innervation to the ciliary and iris sphincter muscles through the ciliary ganglion.
- Edinger-Westphal is within the nucleus of CN-3 that is within the superior colliculus, which is ultimately within the midbrain.
What nuclei are CN-3 connected to?
Connected to CN 4, 6, and 8 by the medial longitudinal fasciculus (MLF).
CN-3 nuclei also receives information from the superior colliculus and the visual cortex.
How does CN-3 enter the orbit?
Through the superior orbital fissure.
Travels close to posterior communicating artery before piercing roof of the cavernous sinus. Within cavernous sinus, CN-3 receives sympathetic innervation from the internal carotid artery plexus. Then it finally goes through the superior orbital fissure after separating into superior and inferior divisions.
CN-3 superior division
- Muller’s muscle (upper eyelid)
- superior levator
- SR (which is a contra-lateral muscle)
CN-3 inferior division
- MR, IR, IO
- iris sphincter (parasympathetic, pupillary constriction)
- ciliary muscle (accommodation)
CN-3 lesion/palsy
“Down and out” eye (exotropia and hypotropia)
CN-3 palsy w/ pupil-involvement
- fixed and dilated pupil
- suspicion for aneurysm of the posterior communicating artery (most likely located at the junction between the posterior communicating artery and the internal carotid artery)
CN-3 palsy w/ pupil sparing
- most likely d/t ischemia of the small blood vessels that nourish the inner fibers of CN-3
- most likely d/t systemic condition (diabetes or hypertension)
- low chance of compressive lesion
CN-4, Trochlear nerve; connection
Connected to nuceli of CN 3, 6, and 8 via the MLF (medial longitudinal fasciculus). Also connected to superior colliculus via tectobulbar tract, which then connects to the visual cortex.
Pt w/ superior oblique palsy, d/t right trochlear nerve lesion will cause…
- left superior oblique palsy
- pt tilt head towards right
Superior oblique origin:
anatomical origin: lesser wing of sphenoid bone
Physiological origin: trochlea
V2 - Maxillary division track
- V2 travels along inferior lateral portion of the cavernous sinus before entering the foramen rotundum of the greater wing of the sphenoid.
What is the nerve supply to the lower eyelid?
Zygomaticofacial –> infraorbital –> infratrochlear nerve
The infratrochlear nerve (branching from the nasociliary nerve) provides nerve supply to the medial portion of the lower eyelid (majority) and the upper eyelid.
V2 (maxillary division): zygomatic nerve
Carries parasympathetic fibers from the pterygopalatine ganglion of CN-7 to the lacrimal nerve of V1 to stimulate lacrimation.
Where is the abducens nucleus located?
Pons
Fibers leave the nucleus between the pons and the medulla and then makes a tight bend over the petreous ridge of the temporal bone before entering the cavernous sinus.
Where does the CN-6, abducens nerve, enter and exit?
CN6 enters the orbit through superior orbital fissure and passes through the common tendinous ring before innervating the lateral rectus.
A CN-6 palsy will cause what type of deviation?
ESO deviation w/ horizontal diplopia that is most apparent at distance and may also present w/ a head turn toward the affected side.
Course of CN-7, facial
Input in the CN7 begins int he pre-central motor cortex in the frontal lobe. The fibers then descend within the corticobulbar tract to the pons, where the facial motor nucleus and superior salivatory/lacrimal nuclei are located.
- Fibers exit the nuclei of CN-7 as a main motor root and the nervous intermedium root (carries parasympathetic fibers of CN-7).
What forms the vidian nerve? (part of CN-7)
Greater petrosal nerve w/ the deep petrosal nerve.
- Greater petrosal nerve carries parasympathetic innervation to the lacrimal gland.
- Deep petrosal nerve contains post-ganglionic sympathetic fibers.
Which terminal branch of CN-7 carries taste fibers from the anterior 2/3 of the tongue and provides parasympathetic supply to the submandibular and sublingual glands?
chorda tympani nerve
The main root of CN-7 passes through the stylomastoid foramen and enters the parotid gland where it divides into 5 branches (temporal, zygomatic, buccal, mandibular, and cervical branches) to supply the muscles of facial expression.
What do the temporal and zygomatic branches innervate?
Temporal: procures, corrugated, occipital frontalis, and the orbicularis oculi.
Zygomatic: orbicularis oculi
Which nerve provides innervation to the parotid gland?
CN-9, glossopharyngeal nerve
Your patient’s right lower face is paralyzed with slight drooping of the mouth. He is still able to close his eyes and wrinkle his forehead. Where is the lesion?
Supranuclear lesion of the left side (contralateral muscles of the lower face affected).
Parasympathetic innervation to the eye originates from the midbrain (CN-3) and the pons (CN-7). What are the three major functions parasympathetic innervation plays in the eye?
- miosis (via iris sphincter, CN3)
- accommodation (ciliary muscle, CN3)
- lacrimation (lacrimal gland, CN7)
Which nerve/ganglion ultimately takes in the sensory information from LPCNs and SPCNs?
trigeminal ganglion
SPCNs: original from ciliary ganglion and carry post-ganglionic sympathetic and parasympathetic fibers to various anterior structures of the eye. They also carry sensory information from the eye back to the ciliary ganglion via the nasociliary nerve.
LPCNs: branch from nasociliary nerve of V1. Caries post-ganglionic sympathetic fibers to the eye, as well as carry sensory information from eye back to the trigeminal ganglion.
By 6 months, infants have been shown to demonstrate 20/20 visual acuity with what form of measurement?
Pattern VEP testing
Examples of forced choice preferential looking.
Teller, cardiff, & broken wheel
When is the spatial visual acuity with FCPL 20/20?
20/20 at 3-4 years
1 month: 20/600-20/1200
1 year: 20/50-20/60
Which is vergence in infant equivalent to adult levels?
By six months of age.
Temporal vision is measured by the critical flicker frequency. When does this reach adult levels in infants?
Three months of age
Which acuity takes the longest to develop?
Vernier acuity, for finely distinguishing lines. Develops at 6-8 yrs.
Define occlusional amblyopia. Examples include congential cataracts, ptosis, or corneal opacities
Aka form deprivation amblyopia. Occurs when deprivation of vision during critical period (7-9 years).
3 forms of refractive amblyopia
Anisometropic amblyopia: eye with blurred retinal image develops less.
Isometropic amblyopia: large symmetrical blurring, neither eye gets a clear image.
Meridional amblyopia: uncorrected astigmatism during critical period.
Define strabismic amblyopia
Constant, unilateral deviation of one eye compared to the other.
Alternating strabismus will not result in amblyopia. Patients will have poor stereopsis.
Common cause of a bitemporal hemianopsia?
Classically caused by a pituitary gland tumor that compresses the nasal fibers from each eye that cross at the optic chiasm.
Which VF defects do lesions anterior to the chiasm and most commonly due to glaucoma cause?
- VF defects that respect horizontal midline
Which VF defects do lesions post-chiasmal and commonly due to strokes cause?
- VF defects that respect the vertical midline
Optic nerve lesions, define.
- cause asymmetric visual field loss between the eyes
- defects typically respect the horizontal midline
- defects may be bilateral but they are NOT congruous
- an APD can occur if asymmetrical damage between the optic nerves is greater enough
- visual field defects will correspond to the location of the lesion within the retinal nerve fiber layer
Retinal lesions, define.
- causes asymmetric visual field loss between the eyes (common w/ optic nerve lesions)
- defects do not respect the horizontal or vertical midlines
- defects may be bilateral but they are not congruous
When does foveal maturation occur?
at approximately 4 years of age
The anterior lens epithelium attributes to the development of the remaining nuclei: (in the following order)
fetal nucleus, juvenile nucleus, adult nucleus, and lens cortex
When does the adult nucleus form?
Contains lens fibers that are formed from birth to sexual maturation.
When is the lens cortex formed?
Contains lens fibers formed after sexual maturation.
define induction
Induction refers to how the development of one tissue influences the development of another tissue; an example during ocular development is how optic cup formation stimulates lens development.
Which embryonic layer forms the corneal epithelium?
surface ectoderm (epithelium, lids, and glands)
- also responsible for conjunctival/eyelid epithelium, lens, meibomian, Zeis, Moll, Krause, and Wolfing glands
- also the lacrimal gland, lacrimal sac, canaliculi, nasolacrimal duct, and caruncle
Which embryonic layer contributes to the formation of the corneal stroma and endothelium?
neural crest cells
- also responsible for TM, iris and CB stroma
- also sclera, choroid, and vitreous
Haab’s striae; define
folds in Descemet’s membrane
- possibly d/t increase in IOP (congenital glaucoma)
Buphthalmos; define
A character of congenital glaucoma (same/associated w/ staphyloma). It is an enlargement of the eye prior to the age of 3 secondary to elevated IOP.
Which filter do you use when trying to visualize the retinal NFL better?
Green (red free) for retina. Enhances contrast.
Which wavelength of light has an increased association with the development of macular degeneration?
485-510 nm. Blue violet light
Define Salus sign
Indication of grade 2 hypertensive retinopathy. Deflection of retinal veins at arteriovenous crossings
Which two signs are associated with grade 3 hypertensive retinopathy?
Bonnet sign
Gunn sign
At which peaks do erythrolabe, chlorolabe, and cyanolabe absorb light?
Erythrolabe: 565nm
Chlorolabe: 535nm
Cyanolabe: 430nm
Normal arden ratio?
(Light peak)/(dark trough)
1.85 is normal, less is abnormal
Where is the rhodopsin molecule found in a rod photoreceptor?
Membrane of the outer segment
What type of action potential do bipolar, photoreceptor, and horizontal cells do?
Graded potentials, not action potentials
BPH
What is the smooth endoplasmic reticulum responsible for?
- steroid production in the adrenal cortex
- storage and breakdown of glycogen and detoxification of lipid soluble drugs
- storage and release of calcium for muscle contractions in muscle cells.
Describe direct cell to cell signaling via Gap Junctions
Gap junctions connect cytoplasm of adjacent cells and serve as a passageway for small hydrophilic molecules, ions, and metabolites to pass directly from one cell to another.
Examples include the heart and intraocular lens
Define rhodopsin
An example of a transmembrane protein that is stimulated by photons to produce a signal transduction cascade within photoreceptors.
Secondary protein made of alpha helices.
What’s the strongest chemical bond?
Covalent bonds, involving the sharing of electrons between two molecules.
List of essential amino acids.
Histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine.
Conditionally essential or semi-essential amino acids include: arginine, cysteine, glutamine, and tyrosine.
Describe AA tryptophan
Precursor for serotonin, a NT
Describe tyrosine
Amino acid derived from phenylalanine.
Precursor for dopamine, epinephrine, and norepinephrine (catecholamine neurotransmitters).
With tyrosinase (absent in albinism) becomes melanin.
Which amino acids are precursor for nucleotide synthesis?
Glycine, glutamine, and aspartate.
Define IgM
First antibody made in response to an antigen. Found primarily in blood and on the surface of immature b-cells.
Describe IgG
Most plentiful Ab in the body. Able to cross placenta.
Describe IgA
- primary antibody in excretions (tears, saliva, mucous, and breast milk)
Describe IgD
Antigen receptor on surface of mature B-cells
Describe IgE
- binds to allergens and triggers histamine release from mast cells, leading to allergy symptoms and type 1 hypersensitivity reactions
- protection against parasites.
Describe collagen
- begins with hydroxylation (cofactor Vit C) of lysine and proline residues within the polypeptide strands of procollagen.
- golgi apparatus then modifies procollagen into tropocollagen
- tropocollagen connected together through covalent bonds to form collagen fibrils
Type 1 collagen
Found in cornea, sclera, and Bowmans membrane.
Osteogenesis imperfecta is an AD defect in the production of type 1 collagen. Resulting in multiple fractures, poor wound healing, hearing loss, and blue sclera.
Type 2 collagen
Found in vitreous.
Type 4 collagen
Found in descemets membrane
Type 5 collagen
Found in cornea, maintains uniformity
Diseases effecting collagen
- systemic lupus erythematoses and rheumatoid arthritis: autoimmune disorders where body attacks healthy collagen fibers.
- ehlers-danlos syndrome: abnormal type 1 & 3 collage. Resulting in loose and hyperextended joints, hyperelastic skin, aortic dissection, blue sclera and corneal thinning
- osteoporosis: decreased levels with aging
Vitamin B1 and deficiency
Thiamine
Disorder d/t deficiency: beriberi, causing peripheral nerve damage (delirium, memory loss, oculomotor paralysis, and heart failure).
Vitamin B2
Riboflavin
Define angular cheilitis
Cracking of skin and corners of mouth, can be caused by riboflavin deficiency
Vitamin B3
Niacin, can be derived from tryptophan
Define pellagra
Can be caused by chronic niacin deficiency. Symptoms: diarrhea, dermatitis, and dementia
Vitamin B6
Pyridoxine
Vitamin B12
Cobalamin
Most common deficiency worldwide, seen often with alcoholism.
Pernicious anemia
An autoimmune disorder that destroys the parietal cells of the stomach, causing a loss of production of intrinsic factor necessary for vitamin B12 absorption.
Deficiency of folic acid (folate)
Spina bifida Anencephaly Megaloblastic anemia Diarrhea Glositis
Calciferol
Vitamin D
Most toxic fat soluble vitamin
Tocopherol
Vitamin E
Least toxic fat soluble vitamin
Wilsons disease (aka hepatolenticular degeneration)
Results from large accumulation of copper. Patients may have a Kayser-Fleischer ring on the cornea and sunflower cataracts.
Fat soluble vitamin
ADEK
Antioxidants
ACE
What is the initiation codon for every mRNA strand?
AUG, standing for amino acid methionine
Define introns
Part of DNA that does not code for proteins
Define extrons
Part of DNA that does code for proteins and are intermixed with introns.
What are the modifications made to mRNA prior to exportation from the cell nucleus?
Addition of a modified GTP 5’ cap
Addition of a 3’ poly A tail (multiple As)
Introns are spliced from the mRNA sequence.
Define missense mutation
New codon specifies a different amino acid, leading to alterations in protein function (sickle cell disease)
Define nonsense mutation
New codon is a stop codon.
Define Frameshift mutations
Occurs when the addition or deletion of neucleotides causes a shift in the reading frame of codons during translation of RNA, resulting in the production of an incorrect amino acid sequence. These mutations are often nonsense mutations.
Define trinucleotide mutations
Caused by errors in DNA replication that result in an abnormal number of repeated trinucleotides within a gene. Examples of diseases include Huntington’s disease, fragile X syndrome, and myotonic dystrophy.
There is an increase in severity of each successive generation due to increase of the trinucleotide repeat.
Define southern, northern, and western blot techniques.
SunDay, No Rain, Why not Picnic
These different techniques are used to detect either DNA, RNA, or proteins within tissues.
Define vitravene
Vitravene is the first FDA approved anti-sense drug for the treatment of CMV retinitis in immunocompromised patients.
Which drugs interfere with cell walls?
Bacitracin, penicillins, cephalosporins, and vancomycin.
Define bacterial transformation
Transformation is when a segment of DNA is taken up by the cell and incorporated into the bacterial chromosome.
Define bacterial transduction.
A segment of DNA within a phage particle is taken up by the cell and incorporated into the bacterial chromosome.
Define bacterial conjugation
A segment of DNA is directly transferred from a donor male cell to a recipient female cell via a sex pilus.
The male cells contain a F plasmid for the sex pilus.
Define staphylococcus aureus
Gram positive
Catalase positive
Coagulase positive
Causes approximately half of all ocular infections. Including conjunctivitis, blepharitis, bacterial keratitis, hordeola, abscesses, boils, and acute bacterial endocarditis. Staph hypersensitivity resulting from chronic staphylococcus blepharitis can include the formation of infiltrates near the corneal limbus.
Toxic shock syndrome. Includes high fever, vomiting, and watery diarrhea.
Define staphylococcus epidermidis
Gram positive cocci
Catalase positive
Coagulase negative
Define streptococcus pneumonia
Gram positive cocci, facultative anaerobes
Classically grow in pairs
Catalase negative
Can cause pediatric bacterial conjunctivitis and corneal ulcers.
Most common cause of bacterial pneumonia, meningitis, and otitis media.
Which medications would you use to treat blepharitis or a hordeola?
These are classically caused by gram positive bacteria and so can be treated with:
- topical ointments (bacitracin, erythromycin, and polysporin)
- oral agents (dicloxacillin and doxycycline)
You discover a cocci bacteria that is gram positive, catalase negative, and grows in chains. Which streptococcus is this most likely?
Streptococcus pyogenes
Common cause of bacterial pharyngitis (strep throat). Can also cause scarlet fever, rheumatic fever, impetigo, and toxic shock.
List some gram positive rods.
- bacillus anthracis (anthrax)
- clostridium (c. botulinum causes botulism)
- corynebacterium diphtheria (can penetrate intact corneal epithelium)
Define pseudomonas aeruginosa
Motile, oxidase positive, gram negative
- grape juice odor and blue/green pigment.
- common with corneal ulcers in contact lens wearers (must differentiate from amoeba), burn victims, and immunocompromised patients.
Patient presents with painful red eye with thick mucopurulent discharge, often accompanied by hypopyon. What do you want to treat this with?
Should be concerned with pseudomonas. Need gram negative fighting rx (fluoroquinolones).
Which bacteria should you culture with chocolate agar (Thayer Martin Agar)?
Haemophilus influenza (gram negative rod) Neisseria gonorrhea (gram negative cocci, can penetrate intact cornea)
List gram negative cocci bacteria
- neisseria gonorrhea
- neisseria meningitidis (meningitis, culture on blood agar)
- moraxella catarrhalis (shared eye makeup)
- bordatella pertussis (whooping cough)
List gram negative enteric bacteria
- escherichia coli (e. coli, conjunctivitis, corneal ulcers, endophthalmitis)
- klebsiella pneumonia (pneumonia, sinusitis, pharyngitis)
- proteus mirabilus
- serritia marcescens (red pigment)
Two types of mycobacteria (slight gram stain positive, acid-fast)
Mycobacterium tuberculosis (fever, night sweats, weight loss) Mycobacterium leprae (leprosy)
Define treponema pallidum
Sexually transmitted disease either congenital or acquired.
Causes syphilis. Conjunctivitis is seen in either secondary or tertiary phase, not primary.
Argyll-Robertson pupil and interstitial keratitis are two ocular findings.
Treatment with penicillin.
Define different types of chlamydia trachomatis
- chlamydial inclusion conjunctivitis is chronic STD caused by serotypes D to K.
- trachoma conjunctivitis is caused by serotypes A to C. Leading cause of preventable blindness in the world (corneal ulceration).
Patient presents with a chronic red eye and large inferior palpebral conjunctiva follicles.
Chlamydia most likely cause. STD test referral to PCP.
Leading cause of ophthalmia neonatorum
Leading cause in US is chlamydia.
Treatment is erythromycin ointment.
Define rickettsia (gram stain, triad, associated disease, treatment)
Gram negative stain, obligate intracellular parasites transmitted by insect vectors.
- triad of headache, fever, and rash
- causes Rocky Mountain Spotted Fever through tick bites.
- treatment of doxycycline
The bacteria Mycoplasma does not contain a cell wall. Therefore, its resistant to pencillin. What can you treat mycoplasma with instead?
Clindamycin, erythromycin, and azithromycin.
Which cells are responsible for tissue transplant rejections?
T killer cells through type 4 hypersensitivity reactions
Test to be ordered for patient with suspected giant cell arthritis
CBC, ESR, CRP
ESR & CRP indicate 97% specificity.
HLA-B27 tests for
Reactive arthritis
Ankylosis spondylitis
HLA-B54 tests for
Glaucomatocyclic crisis
List all granulomatous inflammation (marked with collections of large, activated macrophages with a squamous cell-like appearance)
- bacterial (tuberculosis, leprosy)
- fungal (histoplasmosis, blastomycosis)
- foreign body (suture, vascular graft)
- unknown (sarcoid, syphilus)
What does histamine cause?
Vasodilation Decreased BP Bronchoconstriction (inhibited by epinephrine) Tachycardia Increase in leukotrienes
Which immunoglobulins are involved with type two hypersensitivity?
IgM and IgG
What causes phlyctenulosis?
Result of type 4 delayed hypersensitivity reaction, usually from staphylococcal infection secondary to blepharitis
Your pediatric patient has a negative RF and a positive
ANA lab results. She has asymptomatic, chronic, bilateral, non granulomatous, anterior uveitis. What should be part of your ddx?
Juvenile idiopathic arthritis (juvenile rheumatoid arthritis)
Sjogrens syndrome triad
Dry mouth, dry eyes, and arthritis.
Affecting females 40-60.
Describe sarcoidosis (rheumatologic disease)
- non caseating granulomatous
- 25% with ocular involvement, 75% of this with anterior granulomatous uveitis
- increased levels of angiotensin converting enzyme, ACE
- lung involvement (indicating chest xray)
- sometimes asymptomatic with complaints of breathing difficulties, dry cough, and unusual rashes.
Associated with Bells Palsy (cn 7, exposure keratitis) - vasculitis (candle wax drippings) and diffuse vitritis (cotton ball opacities in inferior vitreous)
Define ankylosing spondylosis (rheumatologic disease)
Chronic inflammation of spine and large joints. Order a sacroiliac x-ray.
Classic bamboo spine, sarcoilitis, uveitis, and aortic regurgitation.
Young males, 10-30 years.
90% positive with HLA-B27 gene.
Describe reactive arthritis (Reiters syndrome, rheumatologic disease)
Triad: uveitis, conjunctivitis and/or anterior uveitis and arthritis.
(+) HLA-B27
Common opportunistic infections in someone with AIDS
Pneumocystic pneumonia, PCP pneumonia caused by Pneumocystis joroveci
- toxoplasmosis
- mycobacterium tuberculosis
- CMV, HSV, Kaposi’s sarcoma (herpes virus HHV-8)
Define impetigo (describe the skin lesion)
Gram positive infection with classic honey colored crusted lesions. Very common in children.
Which HSV is most commonly associated with ocular manifestations?
HSV 1
Patient with herpes presents with Hutchinsons sign, blepharoconjunctivitis with vesicles at the lid margin, and episcleritis. Which type of herpes is this most likely?
HZV, herpes zoster virus
Which drugs can cause aplastic anemia (pancytopenia)?
- antibiotics: trimethoprim, pyrimethamine
- acetazolamide (a CAI)
- chemotherapy drugs: methotrexate
Define pernicious anemia and which vitamin malabsorption it is most associated with.
Pernicious anemia is characterized by autoantibodies against the parietal cells of the stomach, resulting in decreased production of intrinsic factor.
Affecting B12 absorption.
Describe what a Roth spot looks like and which conditions it is characteristic of.
A retinal hemorrhage with a white spot in the middle (Roth spot). It is characteristic of leukemia and endocarditis.
Define thromocytosis
Elevated platelet count.
Caused by inflammation, kidney disease or spleen removal.
Define thrombocytopenia
Decrease in platelets
Causes include infection, liver failure, and bone marrow disorders.
Describe pathophysiology of diabetic macular edema.
Caused by microaneurysms and dilations of capillary walls. Pericytes, endothelial foot plates that surround the vessels, are damaged, allowing leakage of blood and fluid with resulting edema.
There are many different hemorrhages found within the body. Define the following hemorrhages: petechiae, purpura, ecchymoses, and hemothorax/hemopericardium/hemoperitoneum
Petechiae: 1-2mm hemes in the skin.
Purpura: greater than 3mm hemes associated with trauma, local vascular inflammation, and low platelet counts.
Ecchymoses: greater than 1-2cm and include subcutaneous hematomas or bruises.
Hemothorax/hemopericardium/hemoperitoneum: large accumulations of blood in body cavities.
What are the lab results for someone with atherosclerosis?
And what are the normal values?
Increased total cholesterol, LDL, and CRP.
Decreased HDL.
Good values:
Total 40
LDL:
Describe findings for hypertensive choroidopathy, which is often seen in young patients with acute hypertension.
Elschnig spots and Siegrist streaks.
What are common signs and symptoms of rheumatic fever?
In 75-80% of cases the mitral valve is attacked, often requiring valve replacement later in life. Common signs and symptoms include fever, elevated ESR, red hot joints, and endocarditis
Describe the Circle of Willis. Which arteries are involved?
The Circle of Willis is a meeting loop for the BASILAR artery, the INTERNAL CAROTIDS, and the ANTERIOR and POSTERIOR COMMUNICATING arteries (small arteries bridging the basilar and internal carotids). The Circle of Willis forms an arterial circle beneath the brain and allows for a system of redundancy for the flow of the blood to the intracranial tissue.
Basilar artery goes to POSTERIOR CEREBRAL, which supplies temporal and occipital lobes.
Internal carotid artery supplies ANTERIOR CEREBRAL and MIDDLE CEREBRAL. Anterior cerebral supplies frontal lobe while middle cerebral (last and largest branch of ICA) supplies frontal lobe, lateral surfaces of the temporal and parietal lobes, and the occipital lobe.
List some antiepileptics
- phenytoin
- phenobarbital
- carbamazepine
- valproic acid
________ is substituted for ___________ in sickle cell anemia.
Valine is substituted for glutamic acid due to single base pair mutation in the Beta globin gene.
Patient has the following list of symptoms. Which headache is this most likely?
- Male, 40 years old
- unilateral headache 2 times a day, lasting less than 1 hour. Occurs either middle of the night or in the morning.
Cluster Headache
- Often present with red eyes and/or nasal stuffiness and can cause a transient or permanent ipsilateral Horner’s syndrome.
- Occurring in smokers and alcohol drinkers.
- Female, has been occurring all her life (55 yo now).
- Headache is from mild to intense and is worse when she is stressed out. Sometimes occurs before a migraine.
- Feels like headache is wrapped around her head.
Pt has Tension Headache
- Band-like distribution w/ varying intensities. (Frontalis muscle)
Pt used to experience headaches since she was 25 yo, stopped since her 50th birthday.
- photosensitivity & slight nausea
- Lasts for hours (minimum of 4hrs and a max of 72hrs) and it’s worse when she has exercised.
Which headache did your patient used to experience?
Migraine headache
Triggers include dehydration.
Pt experiences a headache that wakes him up in the middle of the night.
- He has experienced nausea, vomiting, and visual changes that have all increased with time.
- Headaches are throughout the day, but worse in the morning.
What does your patient have?
Interrupting sleep? You should consider a brain tumor. But remember that less than 1% of patients with brain tumors have headaches as their only symptom.
Pt comes in for CEE. But mentioned having had an upper respiratory tract infection.
Upon further questioning he gives you the list of symptoms.
- fever
- headache
- neck stiffness
- Occasional nausea, vomiting, sweats, weakness, myalgias, and photophobia.
After your DFE, you noticed papilledema.
What does your patient have? And is your procedure?
- Meningitis (likely viral, but can also be caused by bacteria, tuberculosis, fungi, or chemical agents).
Order CT-scan followed by lumbar puncture to check for increased CSF.
What is the most common primary malignant brain tumor?
glioblastoma multiforme
- can cross corpus callosum
- prognosis of less than one year life expectancy
Most common benign brain tumor?
Meningioma (but could be malignant as well)
- usually found in middle aged women
- arise from arachnoid cells and extend to brain
Noticed that your patient of 10 years has had a progression of proptosis over the years. He reports no symptoms.
Dx?
Schwannoma (tumor of Schwann cells).
Often localized in CN-8 (vestibulocochlear). Can be referred to as acoustic schwannoma. Rare, most common in young to middle-aged adults.
Your pt’s chart documents two separate central nervous system lesions on at least two occasions. The lesions both involved white matter. She now is diagnosed with multiple sclerosis. What is the most common presenting symptom of MS?
- optic neuritis (25% of patients). Pt will show decreased VA/color, (+) APD. Classically presents as sudden, non-progressive onset of monocular vision loss.
- other ocular findings include pain on eye movement (90%), internuclear ophthalmoplegia (INO), and diplopia.
- Can experience Uhthoff’s phenomenon: increased in body temperature, which could be followed by a decrease in acuity.
Causes of papilledema
- Guillain-Barre Syndrome
- Meningitis
- pheochromocytoma
- stage 4 hypertensive retinopathy (malignant retinopathy)
Guillain-Barre Syndrome is characterized by inflammation and demyelination of peripheral nerves and motor fibers of the ventral roots. It will classically present w/ symmetric ascending muscle weakness that begins in the distal lower extremities.
What are some ocular findings?
- Adie’s tonic pupil (d/t ciliary ganglion lesion, dx w/ 0.125% pilocarpine)
- diplopia (multiple CN palsies)
- facial diplegia
- papilledema (d/t elevated protein levels in CSF)
Myasthenia gravis is an autoimmune disease d/t blockade of neuromuscular signals d/t autoantibodies binding to ACH (acetylcholine) receptors. Affecting all ages, but mostly younger women and older men.
Associated w/ thymic tumor (thymoma), rheumatoid arthritis, and lupus. Systemic symptoms include respiratory weakness and weakness of the jaw muscles.
What are some ocular findings?
- ptosis and diplopia (secondary to external ocular muscle weakness, worse w/ beta-blockers)
- Symptoms worse at end of the day.
The following neurodegenerative diseases are associated w/ deposits or lack of specific substances in the brain. Fill in the blanks.
- Alzheimer’s disease: __________
- Vascular dementia: ___________
- Parkinson’s disease: __________
- Alzheimer’s disease: develop deposits (plaques) of a protein called BETA AMYLOID and disorganized masses of protein fibers known as neurofibrillary tangles.
- Vascular dementia: blood clots or fatty deposits (cerebral microinfarcts) w/in vessels
- Parkinson’s disease: deficiency in dopamine in striatum d/t degeneration of neurons in substantia nigra
Parkinson’s symptoms go by TRAP (tremor at rest, akinesia, postural instability).
What are some medications?
- Levodopa, Bromocriptine, Carbidopa, and Sinemet®
Horner’s syndrome causes sympathectomy of the face, d/t a lesion above T-1. Signs and symptoms include what triad?
- Triad: ptosis, miosis, anhydrosis
- associated w/ cluster headache and Pancoast tumor (which affects preganglionic sympathetic fibers)
Patient has extreme thirst and polyuria resulting from a lack of ADH (anti-diuretic hormone) or a deficiency in renal response to ADH.
Which diabetes does this patient have and what are treatment optiosn?
Diabetes Insipidus
Tx: increased fluid intake, intranasal desmopression (ADH analog), indomethacin, or HCTZ for nephrogenic causes.
Pt has increased TSH and decrease free T4 and T3.
Dx?
Hypothyroidism (cold intolerance, hypoactivity, weight gain, fatigue, lethargy, decreased appetite, constipation, weakness, myxedema, dry cool skin, and coarse hair.
Most common cause of hypothyroidism in iodine-sufficient areas in the worse is Hashimoto’s Thyroiditis (autoimmune attack of thyroid gland). Females, 45-65 year old.
Pt has elevated T4 and decreased TSH. Which condition is this, and what is the most likely underlying cause?
Hyperthyroidism, caused by Grave’s disease (autoimmune condition caused by TSH autoantibodies). Causes excessive production of T3 and T4. Females, 40-50 yo.
1% of patients developing myasthenia gravis.
Symptoms include heart palpitations, weight loss, heat intolerance and/or hair loss.
Graves’ Ophthalmopathy: proptosis and upper lid retraction are common signs. Superior limbic keratoconjunctivitis is an uncommon, bilateral, inflammatory reaction associated w/ thyroid disease.
Pt has hypercalcemia w/ bone pain, pathologic fractures, renal stone, constipation, mental changes, and fatigue.
Dx and possible Tx.
Dx: primary hyperparathyroidism
Tx: parathryoidectomy
Your hyperparathyroidism patient undergoes a (para)thyroidectomy, what’s the most common side effect?
Hypoparathyroidism
Symptoms include tetancy, muscle cramps, irritability, carpopedal spasms, convulsions, and mental retardation.
- Decreased serum calcium.
- Ocular: cataracts, uveitis, blurry vision
Pt has chronic adrenocortical deficiency that is result of autoimmune atrophy of adrenal glands. Symptoms include weakness, fatigue, anorexia, weight loss, nausea, and vomiting, diarrhea, abdominal pain, muscle and joint pains, and amenorrhea.
What is the name of this disease?
Addison’s disease
Pt has excessive corticosteroids on the body. Usually this is d/t chronic, prescribed corticosteroid medications. Pt presents w/ central obesity, a moon face, and a buffalo hump. May also have osteoporosis, hypertension, poor wound healing, hyperglycemia, and elevated serum cortisol levels.
What is the name of this disease?
Cushing’s Syndrome (hypercortisolism)
Pt has a rare condition caused by a tumor secreting excessive amounts of norepinephrine and epinephrine.
What is this condition called?
Pheochromocytoma
- can affect any age (commonly 40-60 yo).
- symptoms include elevated BP, papilledema, severe h/a, perspiration, heart palpitations, and anxiety w/ a sense of impending doom.
(Quick Dx: Pain via h/a, Palpitations, Pallor, and Perspiration)
Glomerular disease that is associated w/ hypertension, edema, and active urine sediment w/ hematuria, blood casts, and protein-uria.
What is this condition?
Nephritic syndrome
Which glomerular disease is associated w/ greater than 3.5 g of protein in urine that is accompanied by hypoalbuminemia, hyperlipidemia, and edema?
Nephrotic syndrome
What is the classic triad of renal cell carcinoma?
Triad: flank pain, hematuria, and abdominal renal mass
- Patients usually asymptomatic.
- first diagnostic test is abdominal ultrasound
Glomerular disease that is associated w/ hypertension, edema, and active urine sediment w/ hematuria, blood casts, and protein-uria.
What is this condition?
Nephritic syndrome
Which glomerular disease is associated w/ greater than 3.5 g of protein in urine that is accompanied by hypoalbuminemia, hyperlipidemia, and edema?
Nephrotic syndrome
What is the classic triad of renal cell carcinoma?
Triad: flank pain, hematuria, and abdominal renal mass
- Patients usually asymptomatic.
- first diagnostic test is abdominal ultrasound
Patient has chlamydia, the most common bacterial sexually transmitted disease in the US. Caused by Chlamydia trachomatis.
He has inclusion conjunctivitis (chronic infection w/ large inferior, palpebral conjunctival follicles).
What is the Tx plan?
Tx of chlamydia include Azithromycin or Doxycycline
“C” for Chronic conjunctivitis
Female pt infected with Neisseria Gonorrhea. Pt experiences common symptoms of gonorrhea which include severe, hyperacute, purulent discharge.
How should you treat this patient?
Treatment of gonorrhea consists of a single dose of Ceftriaxone 125 mg IM plus Doxycycline 100 mg p.o. bid x 7 days.
- Doxycycline will be given w/ ceftriaxone to cover for chlamydia (most common STD in US) because chalmydia trachomatis often cohabitates with N. Gonorrhea.
Which stain do you confirm the dx of HSV with?
Wright-Giemsa stain
Which spirochete bacteria causes Syphilis?
Treponema pallidum
Primary/early phase = cancre (painless ulcer in genital region)
Secondary lesions = eye, kidney, mucous membranes, skin, CNS or liver
Tertiary phase = nerve system and ophthalmic lesions including an Argyll Robertson pupil
Describe an Argyll Robertson pupil (found in tertiary phase of syphilis)
(-) APD
(-) direct light response
(+) nerve accommodative response
List ocular manifestations of syphilis (Treponema pallidum).
- interstitial keratitis, retinitis, and retinal vasculitis
- salt and pepper fundus and flame-shaped retinal hemorrhages
- Uveitis (less than 1% of uveitis patients, can be granulomatous or non-granulomatous)
- cranial nerve and optic neuropathies (diplopia)
- acute multifocal chorioretinitis and vitritis (panuveitis) (similar to toxo)
What are the screening tests (active infection) for syphilis?
- RPR: rapid plasma reagin test
- VDRL: veneral disease research laboratory test
- EIA: enzyme immunoassay test
What are the diagnostic tests (lifetime infection) for syphilis (treponema pallidum)?
- FTA-ABS (fluorescent treponemal antibody absorption test
- TPPA: treponema pallidum particle agglutination assay dark field microscopy
- MHA-TP: microhemagglutination assay
What is a common tx for BPH (benign prostate hypertrophy)?
Terazosin (Flomax®), which relaxes prostate muscles. Alpha-1-blocker.
Side effect of floppy eye syndrome
Describe pre-eclampsia which can occur from 20 wks of gestation to 6 wks post-partum. Occurring d/t pregnancy.
Pre-eclampsia is characterized by triad of blood pressure greater than 140mmHg, protein in urine, and swelling in the lower extremities.
- Best tx is delivery.
Eclampsia occurs w/ above symptoms AND mother experiencing SEIZURES.
Breast feeding occurs because oxytocin (from __________ ________) allows milk ejection and prolactin (from the __________ _________) allows for milk production.
Oxytocin is from the posterior pituitary = milk ejection
Prolactin is from the anterior pituitary = milk production
(PROlactin = PROduction)
What are the most common INCIDENCES of cancers in women and men in the US?
Women: breast > lung > colon cancer
Men: prostate > lung > colon cancer
What are the most common causes of CANCER DEATH in women and men in the US?
Women: lung > breast > colon cancer
Men: lung > prostate > colon cancer
Describe the most severe (100% fatal) neural-tube defect disorder in neonates - anencephaly.
Anencephaly is when the orbital bones are nearly normal in size, but there is an absence of normal brain and cranial bone tissue.
What is the number one cause of congenital malformation?
Fetal alcohol syndrome
What is the generic term that includes non-progressive varied infections, toxins, and congenital malformations in infants?
Cerebral palsy
List side effect of Rubella (German Measles?)
- microphthalmia
- glaucoma
- infant cataracts
- heart defects
When you see infant cataracts, what should be included in your ddx?
- galactosemia (diabetes?)
- rubella
Which bacteria and medication (not necessarily in combination) can result in peptic ulcer disease (generally duodenal or gastric ulcer)?
- Helicobacter Pylori
- chronic NSAID use
What is the treatment for peptic ulcer disease?
- H2 bocker
- Proton pump inhibitor (PPI)
- Combination therapy (either the H2 blocker or PPI with 2 antibiotics for H. Pylori)
How can you tell if the peptic ulcer is duodenal or gastric?
Gastric ulcer’s main symptom would be pain soon after eating.
What is the name of the condition where normal esophageal lining is replaced by metaplastic columnar cells; occurs as a result of squamous changing to columnar cells?
Barrett’s Esophagus, which can lead to esophageal adenocarcinoma, which requires surgical resection of the esophagus.
Treatment would include long-term PPI (proton pump inhibitors).
Which conditions are HLA-B27 positive again? U-CRAP
U-CRAP
- ulcerative colitis
- Crohn’s disease
- reactive arthritis
- ankylosing spondylitis
- psoriatic arthritis
Copper needs to enter the circulation in the form of ceruloplasmin. When this fails to occur, you get copper accumulation that is most concentrated in the liver, brain, and cornea (Kayser-Fleischer Ring).
What is the name of this condition?
Wilson’s disease.
Some manifestations include a sunflower cataract, cirrhosis of the liver, basal ganglia degeneration, and dementia.
Tx includes pencillamine (Cuprimine®) that is a chelating agent (binds copper). Ocular side effects of pencillamine include ocular myasthenia (diplopia, ptosis), ocular pemphigoid, and optic neuritis.
Which 2 enzymes that are contained within liver cells will always be released into the blood in increased concentrations d/t hepatitis (regardless of the etiology)?
AST and ALT liver enzymes
There are 5 types of Hepatitis (viral inflammatory condition of the liver parenchyma that leads to necrosis) which types have a vaccine or medication readily available?
- Hep A: vaccine available (0, 6-12 months), spread via fecal oral route, limited infection.
- Hep B: vaccine available (0, 6-12 months), spread via blood, IV drugs, and sex. Active infection w/ brief course.
- Hep C: No vaccine available. Spreads like Hep B. Chronic hepatitis will develop in approximately 80% of pts. Tx available (ribovirin with interferon)
- Hep D: carried only w/ Hep B as a superinfection. Increased morbidity and mortality.
- Hep E: no vaccine available, spread fecal oral route.
Which type of hepatitis has vaccines readily available?
Hep A (fecal oral rout) and Hep B (blood, IV drugs, and sex)
What is the name for yellowing of the skin and conjunctiva caused by a build-up of urobilinogen (converted from conjugated bilirubin by bacteria and directly from heme metabolism) and bilirubin? This commonly occurs in cirrhosis, hemolytic disorders, and obstructive gallbladder disorders.
Jaundice
Common bacteria responsible for otitis media (pain in ear) and treatment (hint, gram + bacteria are responsible)?
- Strep. Pneumoniae and H. Influenza responsible.
- Tx: amoxicillin or other gram positive agents
Otitis media common in infants and children.
What is the name of the condition that includes episodic and often severe vertigo, hearing loss, and tinnitus (ringing of ears)?
Meniere’s disease (disorder of the inner ear)
What is the disease that is marked by an enlargement of air spaces and a decrease in recoiling because of destruction of the alveolar walls.
Symptoms will include shortness of breath (dyspnea), decreased breath sounds, and tachycardia.
Emphysema (pink puffers)
- narrowing of small airways and break down of lung tissues
What is the disease marked by productive cough for 3 consecutive months in 2 or more years d/t hypertrophy of mucous-secreting glands in the bronchioles.
Common symptoms will include cyanosis of the fingers and toes and wheezing/crackling of lungs.
Chronic bronchitis (blue bloaters)
Pt is treated with an inhaled steroid for his asthma, what is the most likely pathophysiology of his asthma?
Chronic inflammation of the airways.
Pt most likely does not have an acute reversible bronchoconstriction – otherwise he would have just been on beta-2 agonist inhaler for bronchodilation (albuterol, isoproterenol, and metaproterenol)
Which ocular medication would be contraindicated in patient’s with asthma?
Beta-blockers for glaucoma (timolol, betaxolol)
What is the treatment for TB, tuberculosis (mycobacterium tuberculosis)?
- RIPES
Rifampin, isoiazid, pyrazinamide (not on NBEO outline), ethambutol
What are the 2 most common etiologies for someone with chronic, bilateral, anterior, granulomatous uveitis?
TB and sarcoid
Influenza is an acute respiratory illness caused by what?
Influenza A or B viruses. Symptoms include fever, cough, rhinitis, headache, and myalgias
What are neoplasms with an epithelial embryologic origin?
Adenocarcinoma, squamous cell carcinoma
What are neoplasms with a lymphoproliferative embryologic origin?
Leukemia, lymphoma
What is a neoplasm with a mesenchymal embryologic origin?
Sarcoma
What is the most common primary ORBITAL MALIGNANCY (neoplasm)?
Rhabdomyosarcoma is a connective tissue cancer that causes bone destruction. Arises from mesenchymal (connective) tissue.
What is the SECOND MOST COMMON form of skin cancer and results from metaplasia?
Squamous cell carcinoma (no telangectasia present)
Which genes (when activated) turn cancer “on” by allowing mutated cells, which normally die secondary to apoptosis, to survive and proliferate into a cancer?
Oncogenes
Example: “Ras” oncogene which has been found to play a role in specific cancers
Which genes have a repressive effect on the regulation of the cell cycle and/or promote apoptosis when turned “on,” thus preventing DNA damage and regulates cellular activities?
Tumor Suppressor genes.
The loss of tumor suppressor genes, such as the BRCA gene in breast cancer, can lead to cancer.
What is the name of the condition that involves protein malnutrition resulting in skin lesions, anemia, edema, and liver malfunctions? The clinical presentation will include a very swollen belly on a malnourished appearing patient.
Kwashiorkor
What is the name of a protein calorie malnutrition resulting in tissue wasting? Clinical appearance will be an overall wasting and weight loss in affected individuals.
Marasmus
Wernicke-Korsakoff syndrome is a deficiency of which vitamin? It is associated with alcoholism and can lead to a toxic optic neuropathy that leads to bilateral temporal optic nerve pallor.
Deficiency in vitamin B1 (thiamine)
Benzodiazepines are given to which patient? (The one with depression or the one with anxiety).
Benzos are given to the patients with anxiety, not depression.
Schizophrenia is due to increased levels of ___________ in the mesolimbic region. Patients are treated with antipsyhotic medications.
Increased levels of dopamine in the mesolimbic region.
When the cobalt blue filter is used without fluorescein, you observe black rings on the cornea. What is this deposit most likely and which disease is it associated with?
You are seeing iron rings (appearance of black w/ cobalt blue filter) that are present in Fleischer rings (keratoconus).
When you have commotio retinae in the macula, where trauma causes disruption of RPE from the photoreceptor outer segments, it is given the name of _____________. Also includes gray white discoloration in area.
Berlins edema
Vossius ring is pigment imprint made on the anterior lens surface from contact with……
Posterior pigmented iris epithelium during trauma
This can develop into a traumatic cataract.
Which bacteria most likely affect adults and children, including in orbital cellulitis?
Adult: staphylococcus aurea (strep as well)
Children: haemophilus influenza
Sign caused by upper eyelid lag on down gaze.
Von Graefe’s sign
Sign when there is globe lab compared to lid movement when looking up.
Kocher’s sign
Sign when lid retraction occurs resulting in a stare appearance.
Dalrymple’s sign
There is a clinical triad of chemosis, pulsatile proptosis, and ocular bruit. What condition would this patient have?
Carotid cavernous fistula
Results from an abnormal communication between the arterial and venous systems.
What goes through the carotid cavernous?
CN 3, 4, 6, V1, V2; 5 and 7 dont go through.
True or False.
In thyroid eye disease, there is widespread inflammation throughout the orbit including the tendons of the EOMs.
FALSE
Tendons of EOMs are not inflamed in TED.
Here we are talking about a possible orbital pseudotumor (rare) and you would order a CT/MRI to aid in diagnosis because this will show enlargement of EOMs and TENDONS.
Orbital pseudotumor is an idiopathic inflammatory process that can impact any soft tissue component of the orbit. What is the name of another rare idiopathic orbital inflammation, but this time affecting the cavernous sinus and superior orbital fissure?
Tolosa-Hunt syndrome
What procedure involves removal of the globe?
Enucleation
Which procedure involves removal of the inner contents of the eyes? The sclera and other orbital contents remain.
Evisceration
Which procedure involves removal of ALL contents of the orbit, including EOMs and orbital fat?
Exenteratiom
Where do internal and external hordeolums affect?
Internal affects meibomian glands.
External affects the glands of Zeis or Moll. Also know as a stye.
What is an eversion of the lid away from the globe of the eye called? The most common cause is age related (involutional) loss of muscle tone of the orbicularis oculi.
Ectropion
What is an inversion of the eyelid against the globe called? Causes include age related, cicatricial (trachoma, OCP, Stevens Johnson syndrome, chemical burns, previous lid surgeries, trichiasis, distichiasis), and congenital (rare).
Entropion
Trichiasis: eyelashes grow posteriorly from their site of origin
Distichiasis: a second row of eyelashes arises from the meibomian gland openings
Benign essential bleharospasm (BEB) involves which ocular muscles?
- orbicularis oculi
- procerus
- corrugator
Which syndrome is characterized by BEB and lower facial abnormalities (i.e. Difficulty chewing and opening the mouth, jaw spasms, jaw pain, etc.)?
Meige’s syndrome; approximately 50% of patients with BEB have Meige’s.
Which muscle is involved in myokymia?
- orbicularis ocular ONLY
Which eyelid cancer is the most common (90% of all eyelid malignancies), associated w/ UV exposure (especially UV-B), and usually consists of a chronic shiny, firm, pearly nodule with superficial telangiectasia that can eventually develop central ulceration (into a “rodent ulcer”)
Basal Cell Carcinoma
Which layer does squamous cell carcinoma affect?
Stratus spinosum layer of the epidermis. Will appear similar to BCC, but without surface telangiectasia.
Your patient in Phoenix, AZ has a central plaque located on their eyelid. The tumor grows very quickly to a large size (1-2cm) and then suddenly started shrinking. At their next annual eye exam, the plaque is gone! Which maligancy is this?
Keratoacanthoma
- has a similar appearance to BCCs and SCCs.
Pt has a recurrent chalazia. You later realize it is a neoplasm of the sebacious glands of the eyelids (meibomian and Zeis glands) that may be associated with prior radiation therapy. Which malignancy is this?
Sebaceous gland carcinoma
What are the ABCDE characteristics of suspicious skin lesions for malignant melanoma? Remember that the depth of invasion and lesion size are the two most important pronostic factors for malignant melanoma.
A: asymmetry B: border irregularity C: Color difference (uneven pigmentation) D: Diameter (large) E: Enlargement of the lesion
Define punctal stenosis.
Defined as a narrowing or occlusion of the puncta of the upper and/or lower lids. Commonly defined as a punctal diameter less than 0.3mm or as the inability to intubate the puncta with a 26 gauge cannula.
Which valve is blocked in the 5-30% of newborns with nasolacrimal duct obstruction?
Valve of Hasner
Spontaneous opening of the valve of Hasner will frequently occur 1-2 months after birth.
Jones 1 and 2 testing is used to evaluate the ability of the tears to pass through the lacrimal drainage system. When you have reflex of fluid through the same punctum, this indicates an obstruction where?
Obstruction w/in upper or lower canaliculus = reflex of fluid through same punctum.
Nasolacrimal blockage: retrograde flow through the opposite canaliculus and punctum
If the Jones 2 test failes, a dacryocystorhinostomy (DCR) should be performed.
What’s another name of conjunctival concretions?
Ocular lithiasis
You notice a pigmented patch with indistinct margins located somewhere on the conjunctiva of the right eye. What do you write in the chart?
Primary Acquired Melanosis, PAM
Though can be benign, it has premalignant potential. 30% of cases progress to malignant melanoma. You should be more suspicious of nodular lesions with increased vascularity and/or increased growth.
What do you call a pigmented or non-pigmented lesion (previously from PAM) on the conjunctiva?
Conjunctival melanomas: commonly arise from PAM (50-75% of cases), less commonly from a pre-existing nevus (33% of cases) and rarely de novo.
Most important prognostic indicator for progression to malignancy is the thickness of lesion. Most common site of metastasis is the liver.
Conjunctival intraepithelial neoplasia, CIN, is the MOST COMMON conjunctival malignancy in the US. It is also known as Bowen’s disease or conjunctival squamous dysplasia. Which malignancy is CIN able to progress to?
Squamous cell carcinoma
You see a pedunculated, benign, red, vascular lesion of the palpebral conjunctiva on your patient; what is this called?
Pyogenic granuloma (results from trauma, surgery, chalazion, or other sources of chronic irritation).
Pt experiences acute (within an hour) onset of redness that began in one eye and then to the other. He has foreign body sensation, mucopurulent discharge, and his eyelids are stuck together when he wakes up. What is this? And what is the treatment?
Simple bacterial conjunctivitis.
H. Influenza in children.
S. Epidermidis or S. Aureus in adults.
Symptoms subside 10-14 days without treatment.
Pt experiences a hyperacute (know the minute) onset of severe purulent discharge. Additional symptoms include redness, foreign body sensation, and eyelids stuck together upon waking up. It started in one eye, now both eyes are affected. Which bacterial conjunctivitis is responsible for this?
Gonococcal conjunctivitis (Neisseria gonorrhea) Important Signs: severe purulent discharge (often w/ pseudomembranes), marked preauricular lymphadenopathy.
N. Gonorrhea can invade an intact cornea!! (CNHL)
Preauricular lymphadenopathy and pseudomembranes are typically associated with viral conjunctivitis. What is the only bacterial conjunctivitis that can commonly cause both these signs?
Neisseria gonorrhea
Xerophthalmia can cause excessive evaporation leading to ocular surface disease. What is another name for xerophthalmia and what finding is it associated with on the conjunctiva?
Vitamin A deficiency (decreasing amount of goblet cells). Associated with Bitot’s spots on the conjunctiva.
http://webeye.ophth.uiowa.edu/eyeforum/atlas/photos/Bitots-spot.jpg
What are the associated conditions of keratoconus? T-DOME
Turner syndrome, Down’s syndrome. Osteogenesis imperfecta, Marfan’s syndrome, Ehlers-Dalos syndrome.
Also associated with atopic dermatitis and mitral valve prolapse.
Which ring made of iron deposits at the base of the cone (best seen w/ cobalt blue filter, appearing dark) is seen Keratoconus? And when does this sign occur?
Fleischer’s Ring, which is an EARLY sign.
Vogt’s striae (vertical lines in deep stroma), Munson’s sign (lower lid protrusion on downsize), Rizzuti’s sign (conical reflection on the nasal cornea when a light is shown from the temporal side) and hydrous (tears in Descemet’s membrane that result in edema and rupture of the epithelium) are all signs of Keratoconus.
During which stage of the disease progression do these signs occur?
Late stage.
Patients coming in with corneas measuring 48-54D should be diagnosed with which form of Keratoconus?
a. mild
b. moderate
c. severe
Answer: B, moderate
mild 54D
Autosomal recessive ocular diseases:
- keratoglobus
- Macular Dystrophy
- Usher’s syndrome (w/ congenital hearing loss)
- Stargardt’s disease (most common hereditary macular dystrophy).
- gyrate atrophy
Which corneal dystrophy results in abnormal development and replacement of Bowman’s layer with collagen?
a. Meesman’s Dystrophy
b. Reis-Buckler Dystrophy
c. EMBD: epithelial basement membrane dystrophy
d. Cogan’s microcytic dystrophy
Answer: B, Reis-Buckler Dystrophy
- The amount of recurrent corneal erosions are common in early life and decrease with age.
Logan’s microcytic dystrophy is the same as EMBD. (aka Map-Dot Fingerprint, ABMD)
Which stromal corneal dystrophy is (relatively) common after LASIK and is a rare variant of granular dystrophy? It is characterized by granular AND lattice-like deposits within the central stroma. It is also known as granular-lattice dystrophy.
Avellino dystrophy
Which mutation is responsible for granular, lattice, and avellino dystrophies? (Macular stromal dystrophy is NOT associated with this gene mutation).
TGFB1, transforming growth factor beta 1
Which stromal corneal dystrophy is associated with current or past high cholesterol?
Schnyder’s Dystrophy (“Schnyder eats too many buttery pretzels”)
What are the types of deposits for the stromal dystrophies? Marilyn Monroe Got High in LA
Macular = Mucopolysaccharide deposits Granular = Hyaline deposits Lattice = Amyloid deposits
In Fuchs’ Endothelial Dystrophy when the endothelial cell counts are less than 500 cells/mm2 edema can occur in which layer of the cornea?
stromal edema
Describe the DSEK treatment for Fuchs’ Endothelial Dystrophy.
Takes out the endothelial, Descemet’s membrane and the posterior stroma.
You find bilateral subtle patches of vesicles (hallmark sign), band lesions (linear “train track lesions”) and diffuse opacities at the level of Descemet’s membrane and the endothelium. What posterior corneal dystrophy do you think you’re seeing?
Posterior polymorphous dystrophy
Bilateral, autosomal dominant occurring 2nd or 3rd decade (can be a “cloudy corneal” at birth)
Pt has congenital glaucoma. You see horizontal cracks (clear parallel lines) in Descemet’s membrane from increased IOP. What are these cracks called?
Haab’s striae
What is an anteriorly displaced Schwalbe’s line called? And what disease is this a hallmark for?
Posterior embryotoxin, a hallmark for Axenfeld-Rieger Syndrome.
What has posterior embryotoxin + angle abnormalities + increased glaucoma risk?
Axenfeld anomaly
What has posterior embryotoxin + increased glaucoma risk + iris stromal abnormalities?
Rieger ANOMALY
What has posterior embryotoxin + increased glaucoma risk + iris stromal abnormalities + systemic abnormalities?
Rieger SYNDROME
Gram (-) pathogens:
- Pseudomonas aeruginosa: most common gram (-) found in severe bacterial keratitis.
Which bacteria can invade an intact corneal epithelium? CNHL
Corynebacterium diphtheria, Neisseria gonorrhea and meningitides, Haemophilus, and Listeria
Define corneal ulcer.
(+) infiltrate
(+) corneal epithelial defect
Do infiltrates stain?
NO (to very mild
What type of agar should suspected Aspergillus or Fusarium species be cultured on?
Sabouraud’s agar
What is the name of a condition found in HSV keratitis that is characterized by an infiltrate with diffuse neovascularization, an immune ring (Wessley ring), stromal thinning and subsequent scarring?
Interstitial keratitis; the epithelium and endothelium are NOT INVOLVED.
- Most patients are born with IK as a result of congenital syphilis (90%). In the US, IK is typically a result of herpetic disease.
Endotheliitis is a secondary stromal edema due to an immune reaction against a viral antigen or live virus within the corneal endothelium. What is another name of endotheliitis?
disciform keratitis
- Unlike interstitial keratitis, stromal infiltrates and neovascularization are NOT PRESENT in disciform endothelilitis (keratitis)
Post herpetic neuralgia and depression is present in which herpetic infection?
Varicella zoster virus, HZV
An older patient presents with a unilateral peripheral crescent-shaped gray infiltrate on their cornea. The ulcer continues to enlarge concentric to the limbus with an overhanging edge. After 3 weeks it appears the ulcer has self-limited. Pt reports severe pain, redness, tearing and photophobia.
What kind of peripheral ulcerative keratitis is this called?
Mooren’s ulcer
Staphylococcal marginal keratitis results from what type of hypersensitivity response (typically to chronic staphylococcal blepharitis)?
Type 3 hypersensitivity response
Rheumatoid arthritis, systemic lupus erythrematosus (SLE), polyarteritis nodosa, and Wegener’s granulomatosis can cause peripheral corneal thinning and/or ulcer because they are all what type of system vascular disorder?
systemic collagen vascular disorders (there are other disorders not mentioned here)
Systemic conditions that cause increased serum calcium or phosphorus levels, including gout (check uric acid levels), hypercalcemia, sarcoidosis, and renal failure (check blood urea nitrogen and creatine levels) can result in this condition? (calcium deposits found in Bowman’s membrane or in the sub-epithelial space that appear as white spots w/ a swiss-cheese pattern)
Band keratopathy; calcium deposits located 3 and 9 o’clock in the periphery so patients are usually asymptomatic.
Where does lipid deposition occur in Arcus senilis?
Peripheral cornea beginning on Descemet’s membrane and is subsequently deposited on Bowman’s layer before extending into the stroma.
If you have unilateral arcus, you should consider carotid disease on the side WITHOUT the arcus.
Arcus in patients younger than 50 is associated with an increased risk of coronary artery disease; lipid profile should be completed.
Corneal farinata is known as bilateral “flour dust.” Where are corneal farinata located?
most commonly in the central deep stroma
Corneal graft rejection is a type 4 hypersensitivity response. When it is a stromal rejection it is associated with subepithelial infiltrates and is known as what?
Krachmer’s spots (stromal rejection w/ SEI)
- Endothelial rejection line is characterized by WBCs on the endothelium that form a Khodadoust line.
Are the following absolute or relative contraindications for refractive surgery?
- younger than 18 years old, w/ unstable refractive findings within the last year
- unrealistic expectations
- keratoconus, active herpes simplex keratitis, contact lens warpage
- connective tissue disease (i.e. keloid formers), collagen vascular disease, immunocompromised disease (i.e. chronic steroid use)
absolute contraindications for refractive surgery
Are the following absolute or relative contraindications for refractive surgery?
- blepharitis, dry eye syndrome, chronic eye rubbing, ocular surface disease, large pupils
- diabetes mellitus
- primary open angle-glaucoma
- pregnancy
- retinal thinning/lattice degeneration
relative contraindications for refractive surgery
Which part of the cornea is removed in LASIK (laser-assisted in situ keratomileusis)?
anterior stromal bed
Your patient presents with a fine, granular, sand-like infiltrate approx 2-3 days after their LASIK surgery. They sometimes experience photophobia, blurry vision, foreign body sensation and pain… and sometimes they don’t notice it. What is this condition known as? Sands of the Sahara (but what’s another name for it?)
Diffuse lamellar keratitis (DLK).
Rare, inflammatory, non-infectious reaction that occurs at the lamellar interface between the corneal flap and the stroma. Most likely caused by toxins (i.e. blade debris, microkeratome oil). DLK is less common w/ disposable microkeratomes.
You notice either a faint gray line or white, milky deposits within 2 mm of the flap edge interface 1 month after your patient’s LASIK procedure. What is this complication known as?
Epithelial ingrowth
Pt usually asymptomatic and condition is not treated unless progression documented, the visual axis obstructed, greater than 2 mm ingrowth occurs from flap edge, or results in corneal astigmatism. Epithelial ingrowth is the most common complication associated w/ a LASIK enhancement!!! (DED is the most common w/ the first LASIK procedure).
What are the small, star-shaped, pigmented deposits on the anterior capsule of the lens called? They are the residual remnant of the tunica vasculosa lentis.
Epicapsular stars
Lens to examine the optic disc, macula, posterior pole and central vitreous. Non-contact. Provides a stereoscopic, erect, and magnified image.
Hruby lens
The three-mirror lens provides a stereoscopic, reversed (anterior-posterior direction), and magnified image of the retina 180 degrees away from the position of the mirror. What does each mirror view?
- Trapezoidal mirror (angled at 73º from corneal plane)
- Square mirror (67º from the corneal plane)
- Bullet mirror (59º from the corneal plane)
- Trapezoidal mirror: equator region & vortex views; this is your most peripheral
- Square mirror: used to evaluate the area between anterior equator and ora serrata
- Bullet mirror: used to evaluate the anterior chamber angle and the ora serrata. (least peripheral)
What is the sign associated when retinal pigment epithelium is released into the anterior vitreous after a retinal tear? What is another name this sign goes by?
Share’s sign, aka “tobacco dust”
Which type of hemorrhage is located between the retina and an intact posterior vitreous face; appearing very red and often has a keel shape?
pre-retinal vitreal hemorrhage
Which type of hemorrhage is located within the vitreous (anterior to the posterior vitreous face)? Chronic cases will appear yellow.
Vitreous Hemorrhage; diabetic retinopathy is the most common cause of a spontaneous vitreous hemorrhage (31-54% of cases)
What is the ocular disease most commonly associated with CRVOs?
Glaucoma; up to 40-60% of patients w/ CRVO have POAG.
Neovascular glaucoma is a major concern in patients with CRVOs and is most likely to develop within the first 3 months of diagnosis; what is a nickname for this glaucoma?
90 day glaucoma
- 33% of ischemic cases develop NG
- 6% of non-ischemic develop rubeosis or angle neovascularization
Ischemic CRVO is worse than non-ischemic. Which test is necessary to identify ischemic CRVO?
10 DD or more of non perfusion on fluorescein angiography.
90% of cases present with 20/200 vision or worse, and the prognosis is poor (final VA CF or worse)
Which tests should be ordered for a suspected GCA, giant cell arthritis?
ESR: erythrocyte sed rate
CRP:
In order to meet the diagnosis for severe NPDR the pt has the meet one of the three criteria of the 4-2-1 rule. What are the three rules?
- severe retinal hemorrhage in 4 quadrants
- venous beading in 2 quadrants
- IRMA in 1 quadrant
Proliferative diabetic retinopathy occurs in 5% of patients with DR and is dx’d based on the presence of neovascularization. The risk of vision loss is characterized by High Risk Characteristics, what are these HRCs?
- NVD greater than 1/4 DD w/in 1 DD of the ONH.
2. Any NVD or NVE w/ an associated vitreous or pre-retinal hemorrhage.
To be dx’d with macular edema you need to have one of three criteria. List criteria for CSME.
Clinically significant macular edema:
- retinal thickening w/in 500µm (1/3 DD) of the foveal center
- hard exudates w/in 500µm of the foveal center w/ adjacent retinal thickening
- retinal thickening of at least 1DD w/in 1DD of the foveal center
Which HTN retinopathy scale is this? (name)
Stage 1: mild to moderate diffuse narrowing of the retinal arteries (w/o focal constriction)
Stage 2: stage 1 plus focal constriction of the retinal vasculature (arteriovenous nicking) and exaggeration of the arterial light reflex.
Stage 3: stage 2 plus retinal hemorrhages, CWS, hard exudates (likely in star configuration w/in the OPL radiating away from fovea) and retinal edema
Stage 4: stage 3 plus papilledema (malignant HTN). Patients w/ malignant hypertension must be hospitalized immediately due to a high risk of stroke! BP at this stage is usually >220/120.
Keith-Wagener-Barker classification
What are choroidal infarcts that occur in severe HTN retinopathy known as?
Elschnig spots
Pt presents with unilateral dot/blot hemorrhages of the mid peripheral funds, dilated non-tortuous retinal veins, narrowed retinal arteries, and possible NVD and/or anterior segment (NVI/NVA).
What are your ddx? List reasoning.
Ddx: giant cell arteritis, ocular ischemic syndrome (OIS), venous stasis retinopathy
Venous stasis and OIS can be secondary to atherosclerosis or GCA.
Venous stasis: no anterior segment involvement
OIS: anterior segment signs and symptoms. Commonly associated with systemic HTN, DM, and cardiac disease. Cardiac disease is the most common cause of a 40% 5-year mortality rate in these patients.
What is the condition found in Waldenstrom’s macroglobinemia, multiple myeloma, serum positive rheumatoid arthritis, systemic lupus erythematous, and HIV infection that is the most common cause of hyperviscosity retinopathy?
hyperglobulinemia
In hyperviscosity retinopathy there is an increase in resistance of blood flow secondary to elevated levels of plasma proteins, red blood cells, and/or WBCs, resulting in impaired circulation of blood and oxygen through the microvasculature.
What is the epidemiology of retinopathy of prematurity (retrolental fibroplasia)?
- premature infants (
Give differential list of ocular conditions commonly associated with leukocoria (white pupillary reflex resulting from fibrovascular scarring secondary to a tractional RD in cases of ROP)?
- Coat’s (20% leukocoria)
- ROP
- Retinoblastoma (50% leukocoria)
- toxocariasis
What is the most common intraocular malignancy in children?
retinoblastoma
What is the most common primary intraocular malignancy?
choroidal melanoma
What study established the four main risk factors that increase the risk of progression from dry to wet ARMD?
What are the risk factors?
Macular Photocoagulation Study Group
- Multiple soft drusen (especially if confluent)
- focal hyper pigmentation
- HTN
- smoking
Define classic versus occult CNVMs?
Classic CNVMs: well-defined membrane that fills with dye during the early phase of FA
Occult CNVMs: poorly-defined membrane w/ late appearing and less intense leakage during FA.
At what stage of a macular hole is a positive Watzk-Allen sign reported
Stage 3; large, full-thickness hole w/ an operculum
Define nictalopia.
Night blindness
Symptoms of retinitis pigmentosa and the classical triad of signs
Symptoms: - night blindness (most common symptom)
- peripheral vision loss
- associated w/ Usher’s syndrome = (+) hearing loss
Signs: retinal bone-spicule pigmentation (pigment clumping in the mid-periphery), arteriolar attenuation, and waxy optic disc pallor
- ERG used for diagnosis: in the early stages of RP the scotopic ERG is reduced while the photopic ERG is relatively normal.
Which dystrophy is the most common hereditary macular dystrophy and has a normal ERG in early stages of the disease?
Stargardt’s disease
- ERG will be normal in early stages of the disease, becoming abnormal as the condition progresses.
Which retinal/choroid disease is x-linked recessive (all males affects and daughters are carriers) and due to a deficiency in rap gerangyl-geranyl transferase, an enzyme utilized in membrane metabolism?
choroideremia
What are the differential diagnosis for night blindness?
- RP (retinitis pigmentosa)
- choroidermia
- gyrate atrophy
What are the differential diagnosis for bull’s eye maculopathy?
- Stargardt’s disease
- progressive cone dystrophy
- chloroquine and hydroxychloroquine toxicity
- thioridazine toxicity
Pt presents with a normal ERG but an abnormal EOG, which condition is this indicative of?
Best’s disease
Pt presents to clinic with bilateral chorioretinal degeneration due to a deficiency in the mitochondrial enzyme ornithine aminotransferase.
Gyrate atrophy.
Ornithine blood plasma levels will be high and can help in the diagnosis if the clinical picture is unclear.
Where is the retinal break expected if your patient reports a field defect in the inferior nasal quadrant and flashes of light in their temporal quadrant?
Flashes of light is of no value!!!
Inferior nasal quadrant defect = superior temporal retinal break
What causes an angioid streak?
Large breaks in Bruch’s membrane that result from damage to the elastic core of Bruch’s membrane. 50% of cases are idiopathic; remaining cases are due to systemic disease.
What are the common causes of angioid streaks? PEPSI
Pseudoxanthoma elasticum (most common cause) Ehlers-Dalos syndrome Paget's disease Sickle-cell disease idiopathic
What is the name given to increased pigmentation anterior to Schwalbe’s line?
Sampaolesi’s line, which is associated w/ pseudoexfoliation syndrome and pigment dispersion syndrome.
During your examination you notice vertically oriented pigment lines on the corneal endothelium, pigment on the anterior capsule of the lens and iris surface and trabecular meshwork hyper pigmentation. What major dx are you thinking of and what’s another part of the eye you should check?
pigment dispersion syndrome (glaucoma)
Transillumination defects
The risk for glaucoma at 5 years is 10%; the risk at 15 years is 15%.
Normal tension glaucoma puts females at higher risk. Additional risk factors include vascular disorders such as Raynaud’s phenomenon or migraines, low blood pressure, sleep apnea, hyper coagulation, and taking BP medications before bedtime (may decrease ocular perfusion pressure).
Which ethnicity is most at risk for NTG?
highest prevalence among Japanese patients
What are anterior sub capsular opacities that result from lens epithelial cell ischemia and necrosis secondary to high IOP?
glaucomflecken
What is Topamax a treatment for and a glaucoma related side effect?
Tx: migraines, weight loss, and epilepsy
Side effect: acute secondary angle closure
What is the difference between peripheral anterior synechiae (PAS) and posterior synechiase (PS)?
PAS: iris (pigments) sticky on trabecular meshwork
PS: iris pigments stick to the lens; ultimate cause of iris bombe and pupillary block when there is 360 degrees of attachment between iris and lens, moving the iris anteriorly into contact w/ the TM.
Pt comes in with the corneal endothelium having a “beaten metal” appearance with corneal edema and corectopia. What syndrome is this?
Chandler’s Syndrome (part of iridocorneal endothelial, ICE, syndromes)
Nodules are seen on the anterior iris surface, which ICE syndrome is this?
Cogan-Reese syndrome (iris-nevus syndrome)
Pt presents with acute trabeculitis that results an acute elevation of IOP (40-60mmHg). There are a few cells in the anterior chamber and gonioscopy reveals an open angle.
This is known as Posner-Schlossman syndrome, a type of inflammatory glaucoma. What is another name for this?
Glaucomatocyclitic crisis
Which imaging instrument uses a scanning laser polarimetry to detect thinning of the RNFL?
GDR (Laser Diagnostics Technology)
Which imaging instrument uses optic coherence tomography?
OCT
Which imaging instrument uses a confocal scanning laser ophthalmoscopy for a topographical evaluation of the ONH and peripapillary retina?
HRT (Heidelberg Engineering)
