KMK Ocular Disease Flashcards
Sclerotic scatter
Evaluate corneal clarity.
illuminate a parallelepiped beam 60 on temporal limbus.
Observe with naked eye.
When someone is naked, people scatter!
Specular reflection
Evaluate corneal endothelium and lens surfaces.
1mm wide beam, Oculars should be set directly in front of patient and beam should be at 45-60 degree away. Set the beams at equal incidences.
Indirect illumination
Used to evaluate non-opaque corneal lesions such as micro cysts.
Good way to detect fleisher rings in KCN
Use cobalt blue filter without dye
Will appear black
Alkali burns are __x more common than acidic
-Common agents
2x
Alkali: Ammonia, fertilizer, cleaning agents, lye, drain cleaners, magnesium hydroxide, fireworks, lime, cement, airbag residue,
Acidic: Glass polisher, rust remover, battery acid, PAVA spray.
Most common cause of alkali burns
Calcium Hydroxide
K defect with no SEI
Corneal abrasion
Vossius ring
pigment ring on the anterior lens capsule due to trauma. iris smacks lens. Likely will see this with hyphema.
Examples of positive forced ductions
Graves
Browns
Duanes
Orbital floor fracture
Commotio retinae
Disruption of RPE and outer segments of PR cells
Resolves within 3-6 weeks
Berlins edema in macula
Iridodialysis difference from angle recession
Iridodialysis- Disinsertion of the iris root from the CB
Appears as peripheral iris hole on retro
Monitor for angle recession glaucoma due to possible TM damage secondary to trauma
What can occur if orbital cellulitis is not treated?
Cavernous sinus thrombosis, brain abscess or meningitis.
Diabetics and immunocompromised can develop mucormycosis, an aggressive fungal infection. Black necrotic tissue in mouth and nose.
TED is related to what other systemic conditions
MG
What do these mean in TED
- Von Grafes sign
- Dalrymple’s sign
- Kocher’s sign
- Von Grafes sign: Upper eyelid lag during downgaze.
- Dalrymple’s sign: Staring appearance
- Kocher’s sign: Globe lag compared to lid movement when looking up.
Hertel Exophthalmometry norms
Asians: 12-18
Caucasians: 12-22
AA: 12-24
No more than 3mm asymmetry.
Most common benign orbital tumor in children
Capillary hemangioma
Rapid growth and spontaneous involution
Most common benign orbital tumor in adults
Cavernous hemangioma
4th-6th decade, females
Progressive, painless, unilateral proptosis.
Tumor usually arises in the muscle cone.
Yellow/white tumor of astrocytes
Neurofibroma
Optic nerve glioma/juvenile pilocytic astrocytoma
Most common intrinsic tumor of the ONH
Common ages 2-6
NF type 1
Most common benign brain tumor
Meningioma
Middle age women
Most common primary and secondary pediatric orbital malignancy
Rhabdomyosarcoma
Neuroblastoma- most commonly arises from tumor in the abdomen, mediastinum, or neck (associated horners)
Orbital pseudotumor/idiopathic orbital inflammatory syndrome
Rare, may be acute, recurrent or chronic.
Young to middle age patients.
Impacts any soft tissue in the orbit. Appearance can vary significantly depending on the orbital tissue involved.
Acute onset of unilateral pain, red eye, diplopia, and decreased vision.
Chemosis without itching Increased IOP Swelling of tendons and muscles Hyperopic shift Lacrimal gland and sac inflammation
Bilateral? Lymphoma or systemic vasculitis (wegener’s, PAN)
Chemosis without itching? think
Think orbital cause.
Cavernous sinus fistula or IOIS
Tolosa Hunt
Idiopathic orbital inflammation that can affect the cavernous sinus and SOF
Acute and painful exophthalmoplegia due to ipsilateral palsies of CN 3, 4, and 6.
Loss of sensory innveration may also occur since V1 and V2 travel thru the SOF.
Anophthalmos
Absence of ocular tissue within the globe
Enucleation, evisceration, and exentration
Removal of globe
removal of inner contents of the eye- leave sclera
Removal of all contents of the orbit, including EOMs and orbital fat.
Signs of rosacea
Papules on the cheek and forehead with telangiectasia and rhinopehyma (sebaceous gland hypertrophy of the nose) and facial flushing.
Facial flushing may occur with triggers such as alcohol, exertion, spicy foods, caffeine and increased sun exposure.
can cause ocular rosacea- inspissated meibomian glands, phlyctenules, staph marginal keratitis, SPK corneal neo and dry eye
Medications that can cause contact dermatitis
Aminoglycosides- Tobragent30 Trifluridine Cycloplegics Glaucoma meds Preservatives
PERIORBITAL swelling
When do you see periorbital swelling
Contact dermatitis
Ocular cicatricial pemphigoid
65 year old female subacute onset
Idiopathic mucous membrane disorder that commonly affects the oral and ocular mucous membranes
Type II hypersensitivity due to autoantibodies targeting conj basement membrane.
Can be induced by timolol, epinephrine or pilocarpine.
Sym/ankyloblepharon
Entropion and trichiasis with ulceration, neo, and keratinization.
SJS
Type 3 or 4 hypersensitivity that affects mucous membranes.
Due to sulfa drugs, penicillin, aspirin, barbiturates, tetracyclines, NSAIDs or infections (herpes, adenovirus)
Acute phase 2-4 weeks, can be chronic.
Prodrome, diffuse erythema or bullseye lesions, papule on the palms of hands and feet.
Severe, bilateral conjunctivitis with pseudomembranes.
Which 2 syndromes cause symblepharon
Steven Johnsons (type 3 or 4) Ocular Cicatricial pemphigoid (type 2)
2 types of blepharitis
Staph and seborrheic
Seborrheic is associated with less lid inflammation, more oily, greasy scales with flaking and more eyelash loss.
Patients often asymptomatic, but may report vision that clears after blinking, burning, itching or foreign body sensation.
Milia
Due to occlusion of sweat pores or pilosebaceous units
Ectropion most common causes and signs
Age related (involutional- Loss of muscle tone of the orbicularis oculi) Bells palsy
Signs- exposure keratopathy, epiphora, brow ptosis
Entropion signs and causes
- Involutional
- Cicatricial:
Trachoma- leading cause of blindness world wide
SJS
OCP
Chemical burns
Mild punctate keratitis to corneal ulceration and panes
Floppy eyelid syndrome
Loss of elasticity in the tarsal plate, poor CT. Face down sleeping at night.
Mechanical trauma to arsal plate.
Friction –> papillary conjunctivitis
think LOW O2. this can lead to NTG, NAION
Meige’s syndrome
Benign essential blepharospasm + lower face abnormalities
Most common precancerous skin lesion
Actinic keratosis, precursor to squamous cell
Elevated, pink or red. Scaly lesion on sun-exposed skin that does not heal.
25% develop in SCC
Main difference in appearance between basal and squamous cell
Basal cell has telangiectasia, squamous cell does not.
Keratocanthoma lifespan
Sun exposed areas with early appearance similar to BCC and SCC (central plaque)
Grow very quickly and then slowly shrink- spontaneously resolve.
Sebaceous gland carcinoma. If greater than 2mm, mortality rate is
60%
Overall is 10%
Once a malignant melanoma has been diagnosed, the two most important prognostic factors are
Depth of invasion and size of lesion
Dacryoadenitis
What causes the acute and chronic presentations? Which is more common
Acute- infection
Chronic- inflammatory disorders such as sarcoid, TB, graves. This is more common
S shape ptosis
Dacryoadenitis
How to know if actinomycetes israellii caused canaliculitis
Yellow sulfur granules after expression
What causes conj concretions
-other name
Ocular lithiasis
Friction of mucous and epithelium + calcium
Primary Acquired Melanosis PAM
Precursor to malignment melanoma, 30% progress.
Unilateral acquired pigmentation with indistinct margins
on the conj
Common in elderly white people
1 precursor to conjunctival melanoma
PAM
Primary acquired melanosis
Conjunctival intraepithelial neoplasia (CIN)
AKA Bowens
AKA Conjunctival squamous dysplasia
Most common conj neoplasia
premalignant to squamous cell carcinoma (risk is low if BM remains intact)
Elevated, gelatinous mass with neo and keratinization.
95% at the limbus within the interpalpebral fissure.
Most common conj neoplasia
CIN
What is premalignant to squamous cell carcinoma
CIN
Conjunctival intraepithelial neoplasia
Pyogenic granuloma
Pedunculated, benign, red, vascular lesion of the palpebral conj due to surgery, trauma, or infection.
Pyro think red= pyromaniac
What bacteria causes simple bacterial conjunctivitis in adults and kids
Kids- H influenza (gram negative)
Adults- Staph aureus (gram, catalase, coagulase positive)
Most adenovirus infections result from what
Upper respiratory tract or nasal mucous infection.
There are over 45 serotypes 1/3 are associated with eye infections
Transmission occurs from direct contact, ocular secretions, equipment.
All 3 adenoviral syndromes are associated with
Follicles, pseudomembranes, and diffuse conjunctival hyperemia.
Most follow from a systemic viral infection.
Toxic causes of follicles
Molluscum, parinauds catscratch, phthiriasis palpebraum (public lice)
Acute non specific follicular conjunctivitis
-serotypes
1-11 and 19
Most common
-Diffuse red eye, inf follicles, tearing, mild discomfort
PCF viral conjunctivitis
-Common serotypes
Pharyngoconjunctival fever 3-5 and 7 More commonly affects children HIGHLY contagious Triad: Fever, follicles, pharyngitis (sore throat) Rare corneal involvement
EKC
-serotypes
Most serious form of adenovirus conjunctivitis.
8,19,37
Pain and corneal involvement !!!!!! Other 2 types of viral conjunctivitis do not have corneal involvement (80%)
pre-auricular lymphadenopathy
Serotype 8, 80% corneal involvement, symptomatic 8 days after exposure, 8 days after that –> SEI’s, non contagious.
Presence of a palpable node in a patient with suspected adenoviral infection is always pathognomonic for ___
EKC
2 types of allergic conjunctivitis
Seasonal and perennial (less common type 1 rxn. Year round response to household allergens like dust)
VKC
8 year old boy with asthma or eczema.
Seasonal outbreaks during warm months
Superior HUGE cobblestone papillae that can cause a shield ulcer on the cornea. May also see truants dots- papillae on the limbus.
AKC is what type of hypersensitivity reaction
1 and 4
do follicles or papillae contain a central vessel
Papillae
serves as the source of infiltration of eosinophils, mast cells, neutrophils and lymphocytes.
Associated with allergies, bacteria, and friction. q
GPC is most likely to occur with which CL material
GPC can occur due to what other sources?
SiHy due to high amount of protein deposits.
But can also occur due to sutures, blebs, scleral buckle, prosthetic.
CL solution reactions. What are the two most toxic types
Thimerosal and chlorhexadine
3 causes of SLK
CL
Dry eye
Thyroid
** all related to friction ***
Classic complication of CLs that ride too high
Classic complication of CLs that ride too low
High- Corneal warpage
Low- 3 and 9 o clock staining
SEAL: Superior epithelial arcuate lesion
Superior corneal staining
secondary to tight extended wear hydrogel CLs
Keratoconjunctivitis
Implies simultaneous inflammation of the cornea and conj.
Adult inclusion chlamydia is due to serotypes ___
How do you treat?
D-K
1000mg 1 dose
Doxycycline
3 conditions with swollen pre-auricular nodes
Gonnorhhea
Chlamydia
EKC
Signs of adult inclusion conjunctivitis
Inferior follicles + some papillae. Chronic, lasting 3-12 months. May spread bilaterally. Sub epi infilatrates. Pain with urination Node inflammation
Trachoma serotypes and symptoms
A-C trAChoma Bilateral Superior follicles + some papillae Arlt's line and herberts pits Pannus Node involvement 3rd world country, poor country
Leading cause of preventable blindness worldwide
Trachoma
Phlyctenules
due to what
-location
-what is it made of
Type 4 hypersensitivity reaction to staph
-bleph is the most common culprit
Ask if they have a history of Tb
Can be on the conj or cornea.
Made of lymphocytes
Common cause of parinauds ocularglandular syndrome
-Symptoms
Cat scratch fever is the most common cause- caused by bartonella henselae.
“paranoid about cats”
Unilateral granulomatous, swollen nodes, conjunctivitis.
Signs of Phthiriasis palpebrarum
Pubic lice- transparent lice and white nits attached to the eyelashes. Blood tinge debris on lids and lashes
Pre-auricular lymphadenopathy
pinguecula/pterygium
- Etiology
- What does it do to the conj/K
UV light exposure or chronic dryness
Degeneration of collagen fibers.
Damages Bowman’s membrane on the cornea, leading to WTR astigmatism.
stockers line (iron deposits) may be present at the leading edge
Stockers line is seen when
Pterygium
Causes of episcleritis and presentation
70% idiopathic
Other causes: Collagen vascular/inflammatory diseases (RA, SLE, UCRAP)
Unilateral, sectoral injection, 80% simple 20% nodular,
Groupings of scleritis
- Necrotizing (15%)
- Necrotizing with inflammation (5%)
- Necrotizing without inflammation (10%)(scleromalacia perforans) - Non-Necrotizing (85%)
- Diffuse (60%)
- Nodular (25%)
Most common form of scleritis
Diffuse scleritis
Worst form of scleritis
33% die within a few years due to autoimmune disease
Signs
Necrotizing with inflammation
May cause peripheral K melt, keratitis, scleral thinning, anterior uveitis, cataracts, secondary glaucoma.
Necrotiazing without inflammation is due to
Chronic RA
Asymptomatic, gray-blue patches of scleral thinning due to exposure of underlying uvea
Episcleritis and scleritis
- Unilat or bilat
- causes
- Onset
Episcleritis is unilateral
- 70% idiopathic, other causes due to collagen vascular diseases like RA, SLE, or UCRAP.
- acute
Scleritis is bilateral.
- 50% due to systemic autoimmune conditions like vascular disease (RA) or Wegener’s Granulomatosis.
- Gradual onset
What a seg infection has severe, boring pain that radiates to forehead and awakens pt at night
Scleritis
Axenfeld loop
LPCN from nasocil (LINES)
Congenital anomaly. Focal, pigmented, elevated area.
What occurs secondary to the breakdown in blood aqueous barrier
Uveitis
50% of patients with uveitis are __ positive
HLA-B27
70% if the condition recurs.
Usually related to ankylosing spondylitis.
HLA-B27
U ulcerative colitis- IBD C Chrons R Reiters A Ankylosing P psoriatic arthritis
Acute anterior uveitis is less than __ duration
3 month
Why does anterior uveitis cause pain?
Congestion and irritation of the anterior ciliary nerves.
Anterior uveitis is based on the presence of
White blood cells in the anterior chamber
Anterior uveitis main threats to vision
PS, PAS, CME, cataracts (PSC)
Granulomatous uveitis presenttion
Mutton fat KPs- macrophages
Koeppe nodules- granulomatous AND non granulomatous
Busacca nodules
Stellate KP’s are found in what diseases
Fuch’s heterochromic iritis
Herpetic uveitis
Bechet’s is common in who
Young adults of asian and middle eastern descent.
Hypopyon, mouth ulcers, genital ulcers.
Glaucomatocyclitic crisis/Posner-Schlossman
Unilateral
Mild iritis with recurrent, self limiting episodes of elevated IOP
Secondary to traubeculitis
3 major conditions that will present with unilateral cells in the anterior chamber with acute elevated IOP (30-50)
Posner Schlossman
Herpes zoster / simplex
Fuch’s
Chronic granulomatous uveitis is usually associated with
Sarcoid- AA females, abnormal chest scan, elevated ACE levels.
TB- Positive PPD test, abnormal chest x ray, night sweats.
Herpes simplex/zoster- Stellate KPs
Syphilis: may have interstitial keratitis (stromal inflammation without primary involvement), maculopapular rash
Most common cause of interstitial keratitis
Congenital syphilis, TB, and herpes simplex.
Stromal inflammation WITHOUT primary involvement of epithelium or endothelium.
Acute stromal edema and neo
Congenital syphilis triad
Hutchinson’s teeth (small, widely spaced), deafness and IK
Why does posterior uveitis sometimes result in WBCs in the vitreous and sometimes not?
Inflammation of retina–> breakdown in blood retinal barrier –> WBC in vitreous. Pts may have floaters and decreased VA.
Inflammation of the choroid without significant involvement of the retina (like histoplasmosis) does not affect blood retinal barrier and pt will not have a vitritis.
Most common cause of posterior uveitis in the US
How do they contract it
Toxoplasmosis
90% contracted through transplacental transmission if the mother contracts it during pregnancy. May result in convulsions, cerebral calcifications, and retinochoroiditis. Most cases are mild and just have chorioretinal scar.
10% acquired from cat feces and/or undercooked meat.
Most common scenario of toxoplasmosis recurrence
Recurrence of an old, stable, congenital lesion is the most common cause of infectious retinitis.
at 25 years old, pt will have unilateral redness, photophobia, floaters, uveitis, vitritis, and decreased VA.
Focal fluffy retinal lesion adjacent to old inactive scar with overlying vitiritis (HEADLIGHT IN THE FOG)
headlight in the fog
Toxoplasmosis
Sarcoid panuveitis findings
Cotton ball opacities (retinitis)
Candle wax drippings (vasculitis)
Others: Dacryoadenitis Dry eye Chronic, bilateral, granulomatous uveitis CN VII palsy ON disease !!!!!!!!!!!!!
Iris coloboma usually located in which quadrant
Inferior nasal
May see coloboma elsewhere- CB, zones, choroid, retina, ON
Iris malignancy
-What layer of the iris, what location and what are concerning signs
Stroma, inferior, feathery margins, greater than 3mm
Can be pigmented or amelanotic
Dellen
Area of cornea that wets poorly, leading to stromal dehydration and corneal thinning.
Dye will POOL
Adjacent to areas of elevation
Exposure keratopathy is due to which 2 things
CN 7- bells, CVA, aneurysm, MS, herpes
Orbicularis oculi- eyelid surgery, TED, nocturnal lagophthalmos, floppy eyelid
Most common cause of filamentary keratopathy
Dry eye
Composed of degenerated epithelial cells and mucous
How does UV keratitis cause damage to the K?
Excessive absorption below 300nm can cause hyperactiviation of K+ Channels (very sensitive to pH)
Loss of intracellular K+ results in cell death
Which 2 tests are diagnostic for evaporative dry eye
Meibomography, expression of meibomian glands.
All types of dry eye are characterized by which of the following?
Tear hyperosmolarity, tear film instability.
AKA increased tear osmolarity, decreased TBUT
Hydrops vs bullae. What layer are they in?
Hydrops is due to KCN. Tears in descent’s membrane that results in edema and rupture of the epithelium.
Bullae is edema in the epithelium due to due Fuchs.
Three types of tearing.
How does Schirmer testing isolate them?
Reflex, basal, emotional
Schirmer 1 is WITHOUT anesthetic and measures all three types of aqueous secretions. Normal is >10mm in 5 mins.
Schirmer 2 is WITH anesthetic and only measures the basal aqueous secretions. Normal is >5mm in 5 minutes.
How does an increased in tear hyperosmolarity contribute to dry eye?
Results in an inflammatory cascade that damages the ocular surface and releases inflammatory mediators into the tears.
Both types of dry eye cause hyperosmolarity.
Abnormal: Greater than 308 or 8 difference between each eye.
Prolopased orbital fat vs prolapsed SOOF
Steatoblepharob
Malar bags
Pt who wear soft CL and RGPs should discontinue CL wear how many days before surgery
soft Cl- 2 week
RGPs- 3 weeks
An axial length change of 1mm corresponds to how many diopters?
3.00D
What drops can be used pre and post op to decrease the risk of CME
NSAIDS
Hemolacria
blood in tears
Bulbar conj salmon patch
Conj Lymphoma
What % of the population has physiologic aniso
15%
Primary and secondary sjogrens
Primary- Dry eye, dry mouth, dry eyes.
Secondary- triad + another autoimmune disease.
Non sjogrens aqueous deficient dry eye
Primary lacrimal gland deficiencies-
Age related, the most common type of non-sjogrens dry eye.
Secondary lacrimal gland deficiencies- Think ABC!
A- Attacked glands due to inflammation infiltration: Sarcoid, lymphoma, AIDs
B- Blocked: Trachoma, pemphigoid, thermal burns.
C- Cut nerves: Damage to CNV1 or VII due to CL wear, diabetes, bells palsy.
Two forms of evaporative dry eye
- Intrinsic:
- MGD
- Lid structure: Proptosis, nocturnal lagophthalmos
- Low blink rate: Intense concentration, Parkinson’s - Extrinsic:
- Ocular surface disease: Vitamin A deficiency, topical anesthetics, topical preservatives.
- CL wear.
How many patients with KCN have it by AD inheritance?
When do symptoms appear
10%
Condition begins around puberty
KCN etiology
Non-inflammatory, progressive and degenerative disease of unknown etiology
Stromal collagen fibril displacement due to loss of adhesion between fibrils, which results in corneal thinning and protrusion due to DEGRADATION OF THE FIBRILS BY MMPS!
Ocular conditions associated with KCN
Allergic- VKC, AKC, floppy eyelid
Connective tissue- Fuchs, PPMD, granular dystrophy, lattice
Hereditary- conditions that cause eye rubbing to stimulate vision. Aniridia, RP, Lebers, ROP, cone dystrophy.
Systemic conditions associated with TDOME
T- Turners D-Down syndrome O- Osteogenesis imperfecta M- Marfans E- Ehler's Dalos
Early and late signs of KCN
Early- Fleisher’s ring, scissor reflex on retinoscopy, irregular mires on keratometry, and inferior steepening on topography.
Late signs- Vogt’s Striae (vertical lines in the stroma that disappear with pressure), munson’s sign, Rizzuti’s sign (conical reflection on the nasal cornea when a light i shown from the temporal side), and hydros (tears in descemets)
pellucid marginal degeneration
Most commonly presents in early adulthood (20-40 years)
Collagen abnormalities that begins in a crescent-shape inferiorly, usually at 4 and 8 o clock. IOP causes the cornea to protrude right above the area of thinning (not within the area of thinning like in KCN)
Pt usually asymptomatic, ATR astig.
Similarities and differences of KCN and PMD
PMD- Does not have Fleisher’s ring or Vogt’s stream.
Both can develop hydrops, which are tears in descent’s membrane.
Keratoglobus
Onset at birth.
Associated with Ehler’s dances syndrome, blue sclera, an leber’s
Diffuse corneal thinning from limbus to limbus.
EBMD / Cogans
Excessive basement membrane dystrophy
Abnormal epithelial adhesion and excessive BM production
Typically asymptomatic. But can be pain, photophobia, and vision loss.
Charactertized by negatives staining. Too much BM underlying epithelium. Fluorescene slides off.
3 main groupings of dystrophies:
Anterior
Stromal
Endothelial/posterior
Anterior:
- EBMD
- Meesman’s (snail track) A multitude of ruptured cysts or RCE
- Reis Buckler (replaces bowman with collagen)
Stromal: Marilyn Monroe got hers in LA
- Macular
- Granular
- Lattice
- Schnyders
Endothelial/posterior:
- Fuchs
- PPMD
Meeseman’s
Multitude of intraepithelial cysts, bilaterally, that spread across the entire cornea.
AD
Reis Bucklers Dystrophy
Replaces Bowmans with collagen
Bilateral, symmetric, sub epithelial grey opacities.
Least common but most severe stromal dystrophy that will affect vision much earlier.
Macular dystrophy
Signs of macular dystrophy
Diffuse, superficial, central strombe haze between 3-9 years of age.
Progresses to a cloudy cornea with mucopolysaccharide deposits with irregular boarders that are present in all layers of the cornea. Extend limbus to limbus.
Most common dystrophies due to the TGFB1 gene
Granular- hyaline deposits (snowflake like) in the stroma.
Avelllino Dystrophy is a rare variant of granular that has granular and lattice like deposits.
Lattice- Amyloid deposits (Branching, lattice like)
Fuch’s
What % have a positive family history
30%
AD, female predilection, more common in 60+
Do Fuch’s patients have a thick or thin pachymetry findings?
Thick because K edema
Concerning endothelial cell count number
500
400-700 required to prevent edema.
Kids have around 3-4k
By 80 years old, down to 1-2k
PPMD
Posterior polymorphous dystrophy
Patch of vesicles that create a band (train track lesions) on descent’s and the end.
Metaplasia of the endothelial cells. They have an endothelium that acts like an epithelium. These cells may spread into the angle and cause glaucoma
Megalo cornea
X linked
Males
13mm horizontal diameter
Steep Ks
May have Marfans, Ehler’s Danlos, or osteogenesis imperfecta.
At risk of developing glaucoma
Microcornea
AD inheritance
Less than 10mm horizontal K diameter
Hyperopic
Shallow angle –> Glaucoma
Cornea Plana
Corneal curvature equal to the scleral curvature
Bilateral flat Ks, less than 38D
Associated with sclerocorneo (due to bilateral scleralization- opacification and vascularization) and micro cornea.
Complications due to aniridia
Autosomal dominant
Corneal lesions Lenticular changes- cataracts Glaucoma !!!!!! 75% foveal hypoplasia disc hypoplasia
Axenfeld-Rieger Syndrome
Continuum of disorders where patient suffer from anterior seg developmental abnormalities that affect the anterior chamber.
50% develop glcuaom
PE
Axenfeld anomaly
Reiger anomaly
Reiger Syndrome
PE- 15% of normal people have. Does not put you at risk for glaucoma.
Axenfeld anomaly- PE + angle abnormalities + glaucoma risk
Reiger anomaly- PE + angle abnormalities + glaucoma risk + iris stromal abnormalities (corectopia, iris hypoplasia)
Reiger Syndrome- PE + angle abnormalities + glaucoma risk + iris stromal abnormalities + systemic abnormalities (mental retardation, skeletal abnormalities)
Peter’s Anomaly
Patients are born with central white corneal opacities with iris adhesions.
Bilateral.
70% develop secondary glaucoma..
An infiltrate without an overlying defect means what
An infiltrate is a sign of your bodies immune system attacking an antigen via antibodies. But no defect means there is no sign of infection.
Sterile infiltrate
Define
Sterile infiltrate
Sterile ulcer
Infectious ulcer
Sterile infiltrate- Infiltrate without epi defect (sign of immune system attacking an antigen with antibodies. Immune mediated, no infection)
Sterile ulcer- infiltrate with epi staining less than infiltrate size.
Infectious ulcer- infiltrate with epi staining the same size as the infiltrate. (bugs attacking K)
What 2 scenarios would cause fungal keratitis
What is the most common fungus
- Trauma with veg matter
- Immunocompromised
Both caused by candida
Culture fungi on what agar
Sabouraud’s agar.
It’s fun to drive a subaru !
appearance of a fungal keratitis with aspergillum/fusarium vs candida
aspergillum/fusarium– Epi defect with underlying grey-white corneal infiltrate with feathery edges
candida- Similar appearance as bacterial ulcer.
How to culture acanthamoeba
Non-nutrient agar with heat killed E-coli
Early and late signs of acanthamoeba
early- barely any SPK. Severe pain.
late- Radial keratoneuritis (inflammation of the corneal nerves) and patchy stromal infiltrates that progress to form a ring ulcer.
Only type of scleritis associated with glaucoma
Necrotizing with inflammation
Other name for phthiriasis palpebrarum
pediculosis ciliaris
After a thermal/UV burn, symptoms get worse how many hours after the event?
6-12 hours
Lab test to run for Sjogrens
Anti SSA, SSB
Tumor that pt might have with
Sjogrens
MG
Sjogrens: Non Hodgkin’s Lymphoma
MG: Thymoma
Corneal ectasias
KCN
PMD
Keratoglobus
1 disease associated with a CRVO
POAG
CRVO occurs because the vein is able to cork on itself. Usually veins are held in place by a thick, strong RNFL. In POAG, the RNFL weakens and the vein is able to cork on itself.
Emboli and thrombus. Which is associated with vein and artery occlusions?
Thrombus= Clot that stays where it was formed. Vein occlusion.
HTN/DM –> artery compresses vein –> thrombus
Embolus= Clot moves from where it was formed. Artery occlusion, GCA.
HTN sets pt up for CRVO, BRVO, CRAO, BRVO
DR VOS
-All can lead to what 3 things?
Proliferative retinopathy
DM ROP Vein occlusion OIS Sickle Cell
Worried about tractional RD, vitreous hemes, and VEGF getting into the angle
Types of epithelial diseases in HSK
Corneal vesicles/punctate keratopathy: Small lesions that represent earliest epithelial signs related to HSK
Dendritic- most common presentation. Boarder stains pink, center stains green.
Geographic- Wider
Marginal ulcer- Located near limbus. SEI + epi defect + limbal injection
How can HSK affect the eye
- Bleph
- Conjunctivitis
- Neurotrophic
- Epithelium- vesicles, dendrite, geographic, marginal.
- Stroma- IK, necrotizing
- Endothelium- Disciform
Types of stromal diseases due to HSK
- IK- Inflammation that began in the stroma without primary involvement of the epi or endothelial.
Infiltrate + diffuse neo + stromal thinning + stromal scar + wessley ring (Immune ring) - Necrotizing. could occur due to IK or infiltration of the stroma by epi or endo HSK. May lead to thinning and perforation.
Types of endothelial diseases due to HSK
Dendritic
Focal, disc shaped stromal edema overlying KPs stuck on the endothelium.
Focal, no neo, no infiltrate, disc shape
Difference between IK and Disciform
IK:
Stroma
Diffuse infiltrate
Diffuse neo
Disciform:
- KP on the endothelium
- No infiltrate
- No neo
- Overlying focal stromal edema
- Disc shape
What conditions have prodromes
Zoster
Migraine
How do dendrite and pseudodendrites stain
Dendrite:
Rose stains boarders
Fluorescein stains inside
pseudodendrite:
Rose stains entire thing
Fluorescein does not stain well
Pseudodendrite has stuck on appearance, no end bulbs
Zoster eyelid signs
Trichiasis Entropion Ectropion Madarosis Poliosis
Ocular signs of HZV
Could develop episcleritis, scleritis, 40% have uveitis, trabeculitis, cataracts, ARN, optic neuritis, cranial nerve palsies (leads to poor EOM innervation)
Post herpetic neuralgia
Pain persisting beyond 1 month after rash onset or rash resolution.
Most common complication post zoster.
Affects 7%
What is a macular star
Exudate in Henle’s layer
What is exudate
Lipoprotein and macrophages leaking out of the deep capillary network
retinal edema or exudate first?
Pre existing condition –> Hypoxia –> edema –> exudate
Some type of retinal/vascular compromise breaks down the retinal capillary system and leads to liberation of blood contents.
see exudate? know edema has been there a while.
Exudate is found in the OPL or can spread throughout the inner 1/3 from ILM to ELM
Where is acute and diffuse edema located
Acute- INL and OPL
Diffuse- ILM to RPE
What occurs before/after CWS
Significant ischemic event –> CWS –> neo
3 conditions that exclusively cause PUK
Mooren’s Ulcer
Staph marginal keratitis
Collagen vascular disorders
Mooren’s Ulcer
Need more info !! Idiopathic. No systemic disease! 70 year old male Unilateral peripheral infiltrate Mild to moderate symptoms Could be associated with hep C
Vasculitis of the limbal blood vessels –> ulcer on the peripheral cornea that spreads circumferentially. Grey, crescent shape. Ulcer has a huge over hanging edge
Ulcer at the limbus that has a huge, over hanging edge
Moorens
Staphylococcal marginal keratitis
Causes PUK
Sterile ulcer (due to bugs hanging out, staining is less than infiltrate)
Immune system over reacts to staph wherever lid touches eye (2,4,8,10)
Type III hypersensitivity response
Collagen vascular disorder
PUK due to RA, SLE, PAN, or Wegeners.
Mild symptoms
Terrien’s Marginal Degeneration
Stuck up 30 year old male (bilateral thinning SN, ATR astigmatism)
No ulcer, idiopathic, non inflammatory.
May lead to perforation. Associated with panus. The rest of the eye is quiet- no AC reaction or conj injection or epi defect.
**mooren’s ulcer (causes PUK) is similar but it has an overlying epithelial defect. Terriens does not have an epi defect, just infiltrate.
Salzmann’s Nodular Degeneration
Mrs. Salzmann, a 60 year old women walking around with a blue bowtie, bowing to people. And she’s very happy. Very beat up women, maybe homeless.
-blue grey nodules in bowmans layer composed of hyaline.
Signifiant corneal inflammatory disease- MGD, trachoma, phlycentulosis, VKC, dry eye, IK. but can be asymptomatic.
Band keratopahty
- What layer
- what causes it
High serum calcium or phosphorus levels (grout0 and hypercalemia (hyperparathyroidism), renal failure.
After trauma
Uveitis(common in JIA pts) dry eye, exposure keratopathy
Arcus begins on what layer of K and moves where
Begins on Descemets–> bowmans –> stroma
When is Arcus concerning
Unilateral- carotid disease on the side without Arcus.
Younger than 50
What 2 layers can crocodile shagreen be on?
Descemets (posterior) or bowmans (anterior)
Corneal Farinata
Bilateral flour dust deposits in the aroma.
AD
Signs of stromal rejection after a K graft
Krachmer’s spots
SEIs after graft surgery
Signs of endothelial rejection after K graft
Khodadoust lines
WBCs on the endothelium in a line
Absolute CI of refractive surgery
Under 18
Unrealistic expectations
KCN, active herpes, CL warpage on K
CT disease (keloids), collagen vascular disease, immunocomp (on systemic steroids)
Keratotomy
Keratectomy
Keratotomy - knife making incisions
Keratectomy- removal of tissue with laser
Main SE from radial keratotomy
Progressive hyperopic shifts
PRK
Photorefractive keratectomy
Corneal epi, bowmans, and superficial stromal tissue is REMOVED.
Excimer laser applied.
400 residual K required after.
1-2 week healing because K epi must regrow.
Benefits to PRK
Painful and poor vision for 1-2 weeks after BUT
better for people who might damage flap (athletes, boxers) Less risk of ectasia Less aberrations less dryness Cheaper
Main differences after PRK and LASIK
After PRK- missing bowmans, 400 residual required, pain and slow healing
After LASIK- thinner stroma, flap, 250 residual required, less pain and fast healing
LASIK stands for
Laser- assisted in situ keratomileusis
Conductive keratoplasty
Used to tx presbyopia and low hyperopia
using radio frequencies
Refractive surgery allowed with KCN
Intrastromal corneal rings (intacs)
PMMA rings inserted into stroma to flatten the K
Clear lens extraction
Cataract surgery but no cataract.
Remove clear lens and put in an IOL to reduce the refractive error.
No residual accommodation remains.
Astigmatic keratotmy
K incisions made with diamond blades to relax the cornea in steep mer.
Similar to RK but just in astig meridians.
Most common SE of LASIK
Dry eye since corneal nerves are severed
LASIK side effects
Pain in 24 hours Serious infection (usually gram positive) Flap complications Corneal ecstasies Residual refractive error Glare Dry eye Diffuse lamellar keratitis or sands of sahara (fast and furious, 2-3 days PO) Epithelial ingrowth (slow, 1 month PO) Corneal haze
Diffuse lamellar keratitis (sands of the sahara)
Fast and furious Shows up 2-3 days PO Inflammatory, non infectious reaction that occurs between the K flap and stroma. Fine, sand like infiltrate May be response to toxins (blade debris)
Epithelial ingrowth after LASIK
Slow growth, 1 month PO
Faint grey line within 2mm of flap edge.
Asymptomatic.
Not tx unless progression or visual axis obstructed.
Most common LASIK complication after an enhancement
Epithelial ingrowth
What 2 measurements are used to calculate the appropriate IOL power
Axial length by A scan and keratometry
Average axial length is ____
If the calculation is off by 1mm, that corresponds to how many D
average is 24
1mm difference is 3D error in the calculated IOL power
3 classes of medication of concern before cat surgery
Anticoagulants, alpha blockers, prostaglandins
Etiologies of CRVO
Oral contraceptive pills POAG (40-60%) Protein S, C, antithrombin III deficiency Antiphospholipid antibody syndrome Collagen vascular disease AIDS
Signs of vein occlusion
Retinal hemes Collaterals dilated tortuous veins CWS Optic disc edema
What are collaterals
Veins that become visible over several weeks-months after vein occlusion.
Often on the disc.
Permit blood flow between the retinal and choroidal circulations, help drain blood and retinal edema into the choroid circulation.
What is the leading cause of vision in ischemic and non-ischemic CRVOs
Macular edema
2 types of CRVO
Ischemic (33%) - Vision is worse than 20/200, poor prognosis. 10DD or more of non-perfusion.
Non ischemic (67%)
60% of BRVO occur in what quadrant
ST at AV crossing since they both share adventitia
**If it does not occur at an AV crossing, consider a vascular disorder.
CRAO has what acuity
20/400
UNLESS cilioretinal artery is present to spare the macula (present in 15-30% of patients)
Which condition has a cherry red spot
CRAO
How will the retina appear after the patient has a CRAO/BRAO
The edema and whitening will resolve in weeks, but the retinal tissue remains non-functional and the patient will have permanent visual field defect.
High risk characteristics of developing PDR
NNV > 1/4 DD
NVD associated vitreous or pre retinal heme
NVE associated vitreous or pre retinal heme
How does macular ischemia appear
Enlarged foveal avascular zone (hypo fluorescent)
Macular edema can occur at any stage of diabetic ret.
What are the criteria for CSME
**based on the presence of retinal thickening within the fovea
- Retinal thickening within 500 micrometers (1/3DD) of the fovea
- Hard educates within 500 micrometers of the fovea with adjacent retinal thickening
- Retinal thickening at least 1DD within 1DD of the fovea
**pt only needs to meet one of these criteria to have CSME
A CRAO causes tremendous damage to the retina. How will the Erg of a person who suffered from a CRAO be affected?
A wave will remain since this is the PR supplied with blood by the choroid
The B wave will disappear since this is the bipolar & muller cells that are supplied with blood from the CRA
Normal diurnal fluctuation in patients with and without glaucoma
With- variation of 10mmHg
without- 2-5mmHg variation
Difference between PAS and AS
PAS- Iris and TM
AS- Iris and K
Layers of the lens
Nucelus- Embyronic, fetal, juvenile, adult
Cortex
Capsule
Fuch’s spots
RPE hyperplasia and may be associated with CNV in pathological myopia.
Elschnig’s spots in the retina
Areas of chorioretinal necrosis due to local occlusion of choriocap
seen in pts with HTN
An enlarged blind spot is associated with
Papilledema or peripapillary atrophy
Two types of primary angle closure glaucoma are :
What causes secondary angle closure?
Pupillary block
Plaeeau iris
Secondary angle closure glaucoma is due to mechanisms that push or pull the angle closed such as neo or phagomorphism
ORBSCAN studies in patients with KCN show
Steepening of the posterior K
KCN is characterized by anterior central or paracentral corneal stromal thinning.
Glaukomflecken
ASC opacities that develop secondary to necrosis and ischemia of the lens after an acutely elevated IOP
Vitreous condition that is pathognomonic for blunt trauma?
Vitreous base avulsion
Central retinal problems in pathological myopia
Fuch's spots Laquert cracks ERM macular hole Pavingstone degeneration
Most common cause of mortality rate in OIS?
Cardiac disease
HTN associated secondary conditions
Vascular occlusions (artery pressing on vein --> turbulent blood flow --> thrombus --> CRVO) Macroaneurysm NAION Ocular motor nerve palsies Worsening of diabetes
What layers of the retina are affected in macro aneurysms
Multi level- sub retina, intraretina, preretinal and or vitreous heme
surrounding exudate in a ring
Usually located at AV crossing
Symptoms of venous stasis ret/OIS
Gradual vision loss
Dull periorbital painm
Amaurosis Fugax
Signs: UNILATERAL dot blot hemes in mid-periph, dilated non-tortuous veins, narrow arteries, NVD/NVE
Amaurosis Fugax
Type of TIA characterized by transient MONOCULAR vision loss that typically lasts seconds to minutes.
Vision returns to normal
Common cause: carotid artery embolus
TIA
Temporary neurologic defect due to transient loss of blood flow to the brain
Perfusion restored in less than 24 hours (but usually 15 minutes)
Most common cause of hyper viscosity retinopathy
Hyperglobulinemia (excess immunuglobulins in blood) making blood more viscous.
This condition is found in Wadenstrom’s macroglobulinemia
Interferon retinopathy occurs within ___ months after interferon has started.
Patient without retinopathy should be followed how often?
retinopathy will occur within 3-5 months of starting
Follow patient every 6 months
Retinopathy will resolve after treatment is discontinued
3 forms of macular telangiectasia
Mac Tel Type 1: Congenital and unilateral. May be a variant of coat’s- looks very similar with exudate and hemes.
Mac Tel Type 2: Acquired and bilateral. Middle age and elderly. No exudation. Dilated vessels begin temporal to the macula and may progress to atrophy or macular holes.
Mac Tel Type 3: Occlusive vascular disease
Another name for ROP
Retrolental fibroplasia
ROP occurs in who
What part of the retina is most susceptible
premature (32 weeks) or low birth weight (less than 1,500g) who receive oxygen therapy.
Temporal retina- usually finishes development during the 9th month gestation
Retinoblastoma
- What causes it
- Hereditary?
- Signs
Mutation in Rb tumor suppressor gene
All bilateral cases are hereditary, 20% of unilateral cases are hereditary
Bilateral cases have 50% chance of passing mutation to children
Leuko, strab
Leukocoria DDX
Coats, toxocariasis, retinoblastoma, ROP
Another name for abnormal CHRPE that are associated with FAP
RPE hamartomas
Multifocal, bilateral, tear drop shape
70% of people with FAP have RPE hamartomas
Orange pigment on a suspicious nevus. What is it and what do you think
It is accumulation of lipofuscin. Sign that nevus has progressed to melanoma
Size and depth of nevus that is sus
Greater than 2mm elevation and 6mm in diameter or close to ONH
Not sus- overlying drusen
Risk factors of AMD
75+ Female White Fam Hx Light iris cig use (2.5x) Hyperopes (2.5x more risk of exudative AMD)
AMD pathogenesis
Nutritional factors and light toxicity
% of dry vs wet/exudative AMD
90% dry, 10% wet
Dry AMD
- Accounts for what % of AMD
- Appearance
- What % of people go blind
90% of AMD
Characterized by the presence of drusen and RPE abnormalities (mottling, granularity, focal hyperpigmentation)
Most patients do not have severe vision loss but 12% will lose vision due to geographic atrophy
4 main risk factors that increases the risk of progression from dry to wet AMD
Multiple soft drusen (esp. if confluent)
Focal hyperpigmentation
HTN
Smoking
Exudative/wet AMD
- Accounts for % of AMD cases
- Common symptoms
- Characterized by what
- Incidence of involvement of the fellow eye with wet AMD is estimated to be
10% of AMD
Metamorphopia, central scotoma, rapid vision loss
Characterized by CNV that leak blood or plasma sub retinal or sub RPE. PEDs can occur in dry and wet.
After 5 years, risk of condition becoming bilateral is 40-85%
How can a PED present in both dry and wet AMD
Dry- presents as drusenoid PED
Wet- Serous fluid under RPE
Classic vs occult CNV during IVFA patterns
Classic is well defined. Fills space during early phases of FA
Occult is not well defined.
Histo and toxoplasmosis differences
Histo- bilateral, multifocal, due to bird or bat droppings (fungus), choroiditis. No vitritis.
Toxo- Unilateral, single lesion due to undercooked meats or cat poop (parasite). Retinitis and vitritis present.
Define pathological myopia based on rx and axial length
Rx: Greater than -6.00D
Axial length: greater than 26.5
4 stages of macular hole
1- impending hole with loss of foveal depression. Yellow spot at fovea.
2- Round, small, full thickness hole with pseudo-operculum.
3- Large full thickness hole with operculum. + Watzke-Allen sign
4- Stage 3 + PVD
Signs and symptoms of albinism
Hypopigmentation Foveal hypoplasia ONH hypoplasia MicroK Nystagmus Strab Misrouting of the temporal ON fibers through the chiasm
Symptoms: Photophobia, reduced BCVA
Most common retinal dystrophy
RP
RP
Most common inheritance pattern
most common associated systemic condition
AD
Ushers
Most common hereditary macular dystrophy
StargARdt’s
Onset early in life
Autosomal recessive
Signs of Stargardts
Bilateral yellow flecks
Bulls eye maculopathy (beaten bronze)
Salt and pepper
Acanthameoba of the retina
What causes Stargardts
AR condition due to a mutation the ABCA4 gene that is a protein responsible for moving all trans retinal from the photoreceptor disc lumen to the cytoplasm.
This leads to degeneration of the PR and RPE.
Variant of same disorder- Fungus Flavimaculatas.
Choroidermia
X linked recessive
Deficiency in RGG transferase, enzyme used in membrane metabolism.
Progressive, diffuse atrophy of the RPE and choriocap, exposing the underlying sclera.
Night blindness and peripheral vision loss
5 stages of Bests
- Pre vitelliform. No symptoms but abnormal Arden ratio (below 1.8) on EOG.
- Vitelliform. 2 egg yolk macular lesions
- Pseydohypopyon.
- Vitelliruptive. Scrambled egg
- End stage. CNV
*Normal ERG, abnormal EOG.
Difference between Best’s and adult vitelliform
Bests: Onset in childhood
Adults: Onset at 30-50 years. Signs may be similar, but prognosis is better. Minimal metamorphosis, mild acuity loss.
Gyrate Atrophy
Symptoms by age 10
Bilateral chorioretinal degeneration due to a deficiency in the mitochondrial enzyme ornithine aminotransferase. The ornithine levels in the body become high, damaging choroid/retina.
Most common cause of rhegmatogenous retinal detachment
Myopia
40% of RRD’s occur in myopic eyes
Risk factors for rheg RD
Previous ocular surgery PVD trauma Family hx lattice **Myopia 40%
Rheg is defined as
Retinal BREAK due to atrophic holes or tractional tears
What causes atrophic holes
Round, small, full thickness defect not associated with traction.
Chronic atrophy of the retina usually located ST
Poor nutrition, common in high myopes with long eyeballs.
Retinoschisis
-2 types and appearances
Occurs in 4-7% of the population, bilateral
Bullus elevation is most common Unlike RD, the retina is immobile Absolute VF defect Most pts are hyperopes Shethed retinal vessels occur in the elevated retinal layer of retinoschisis
Typically asymptomatic
Inner and outer wall breaks can occur. Outer breaks are more dangerous and can cause RD.
Angioid streak cause
Angiod streaks from the disc
Due to damage of the elastic core of bruch’s
50% idiopathic, other causes are systemic
Pseudoxanthoma elastic Ehlers dances Pagets Sickle cell Idiopathic 50%
APMPPE
Acute posterior multifocal placoid pigment epitheliopathy
Viral posterior uveitis
Good prognosis, resolves.
Central areolar choroidal dystrophy
AD condition with bilateral large areas of geographic atrophy in the macula. Will cause vision in the 4-5th decades. Poor prognosis
Senile Choroidal atrophy
Choroidal thinning and may cause an exaggerated tigroid fungus appearance as you can see more of the choroidal vasculature.
Most common source of optic neuropathy
glaucoma
Leading cause of irreversible blindness world wide
Glaucoma
Risk factors for conversion of ocular HTN to POAG
High IOP Race- AA 4x more likely Family Hx Age 90% over 55 Thin K
Glaucoma risk based on CCT
High risk if under 555
Low risk is over 585
PXE syndrome demographics
Caucasians, Scandinavian descent
PDS is common in what demographics
Bilateral, caucasians, males, myopes, 30s
How can angle recession cause glaucoma
Recessed iris and widened CB. Usually due to blunt trauma.
Although angle is wide open, the TM is damaged and can cause glaucoma.
NTG
- What is it
- Demographics
- Risk factors
- SIgns
Type of POAG in which NFL is damaged at lower pressures
IOP less than 21 with open angles and glaucomatous nerve damage.
Females, japanese at higher risk
Other risk factors: Vascular disorders: Raynauds, migraines, Low BP, sleep apnea, taking Bp meds before bed (may decrease ocular perfusion pressure)
Pressure on the high end of normal, drance hemes are more common, dense VF defects closer to fixation.
Examples of primary and secondary angle closure glaucoma
Primary- Pupillary block or plateau iris
Secondary- neovascular, uveitic, congenital, ICE, inflammatory (Fuch’s, posner schlossman, phacolytic hypermature cataract)
Plateau iris
Anteriorly positioned ciliary processes that push peripheral iris forward into contact with the TM
Convex peripheral iris.
PI will not help
Greatest threat to vision during acute angle closure
CRAO
IOP is higher than the perfusion pressure of the CRA
Topamax/Topiramate is used for what
What can it cause
Migraines, weight loss, epilepsy.
Causes choroidal effusion and can cause bilateral angle closure
Buphthalmos
Enlarged eye, K diameter greater than 12mm.
Occurs in patients with congenital glaucoma
Congenital glaucoma and increased IOP —> enlarges eye
ICE syndromes
Abnormal corneal endothelium that grows into the angle, causing secondary open angle glaucoma.
Essential iris atrophy-
Chandler’s Syndrome
Iris-Nevus Syndrome (Cogan Reese)
Also abnormal pupil
Extent of normal VF
100 degrees temporal, 60 superior and nasal, 70 inferior