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Cornea/Refractive/Lens > Lesions/Conjunctivitis > Flashcards

Lesions/Conjunctivitis Flashcards

0
Q

immunocompromised pts on valtrex SE

A

TTP/HUS
thrombotic thrombocytopenic pupura
hemolytic uremia syndrome

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1
Q

pseudomonas

A

“soup” appearance, explosive onset, can perforate cornea within the day.
Gram negative.
MCC bacterial keratitis in soft contact lens wearers.

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2
Q

CIN (conjunctival intraepithelial neoplasia)

A

CIN typically begins at the limbus and consists of dysplastic cells involving a varying amount of the epithelial layer. These dysplastic cells DO NOT penetrate the basement membrane. The standard treatment for CIN is complete surgical excision of the lesion with 3-4 mm margins and cryotherapy to the bordering conjunctiva.

Newer alternatives include topical interferon-alpha2b (most popular), mitomycin-C (MMC), and 5-fluorouracil eyedrops (5-FU).

Remember that if you see CIN in a young person, order an HIV panel.

CIN = squamous cell in situ

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3
Q

What type of inclusion body caps the nucleus and is formed by Chlamydia?

A

Halberstaedter-Prowazek bodies seen in chalmydia trachoma

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4
Q

What type of inclusions seen in HSV and HZV?

A

Cowdry type I bodies (Lipschutz inclusions)

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5
Q

Enlarged K nerves

A

Men type IIB, phytanic acid storage disorder (Refsum dz), leprosy (Hansen dz), acanthamoeba, neurofibromatosis, familial dysautonomia (riley-day syndrome).

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6
Q

Conditions that cause K nerves to be more visible

A

keratoconus, ichthyosis, fuchs, congenital glaucoma, corneal edema

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8
Q

What is most likely to cause decreased vision

A

surface irregularities (like mild epi edema) decrease VA to greater degree than stromal changes (like stromal scarring/edema)

Mnemonic: When you are in the front of the class (epi), you have more impact

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9
Q

Majority of fungal infections in southern USA are due to…

A

Fusarium infection. Rx with Natamycin 5% (commercially available)

Mnemonic: (Nat)alie is eFUSsive. Natamycin = Fusarium

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9
Q

Culture Aerobic bacteria

A

Blood & chocolate (agar), thioglycollate broth

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10
Q

Rx for candida and aspergillus

A

amphotericin B or voriconazole (both topical and oral can be given)

Mnemonic = CAABV: Canny Aspiring Amateurs B’ Voracious
Candida, aspergillus, amp B, voriconazole

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12
Q

Culture Anaerobic bacteria

A

Thioglycollate broth

CATs are anaerobic

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13
Q

Culture Neisseria

A

Thayer Martin agar

Mnemonic: NTM. Neisse slays (THAYs) Martin

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13
Q

Culture Acanthamoeba

A

non-nutrient agar with E. Coli overlay

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14
Q

Culture mycobacteria

A

Lowenstein-Jensen agar

Mnemonic: Mycobacterial Lowers JARs (Jensen AgaR)

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15
Q

Culture fungus

A

Saboruraud’s agar

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17
Q

Culture non-TB mycobacteria

A

Middlebrook agar

Mnemonic:Think of a LASIK patient with their atypical mycobacteria floating in the middle of a brook

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17
Q

Rx of lesion found on the palpebral conj

A

Benign nevi are RARELY found on the palpebral conj. Always Bx these lesions, along with lesions found on the tarsal conjunctiva, caruncle, plica semilunaris, fornix, palpebral conj

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18
Q

Papillae

A

Red dot (central vascular tuft) surrounded by edema and an inflammatory reaction. Occur in areas where fibrous bands anchor conj to tarsus.

Most obvious in upper eyelid.

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19
Q

Cornea keloids

A

very bright white and can look like dermoids

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20
Q

Ophthalmia Neonatorum

A

Conjunctivitis <1day: chemical (2/2 silver nitrate gtts). Resolves by day 2

Days 2-4: N. gonnorhea
-can occur up to 3 weeks after birth
-most purulent vs all others. can cause corneal ulceration and eventually perforate the eye very quickly
Rx: systemic ceftriaxone (systemic infection: meningitis & sepsis). Gtts: moxifloxacin

Days 6-7: Staph, Strep, H. flu, enterococci (tx = erythromycin or bacitracin)

Days 5-14: HSV (RARE. multinucleated giant cells; tx = acyclovir)
Chlamydia (cytoplasmic inclusion on Giemsa; tx = erythromycin/azithromycin; tx mother = doxycycline)
-chlamydia can present earlier if rupture of membranes (PAPILLARY b/c baby)

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21
Q

Chronic follicular conjunctivitis

A

bird fancier’s dz (chlamydia psittaci = abrupt fever, dry cough, HA, HSP) with CHRONIC FOLLICULAR CONJUNCTIVITIS EQUALLY involving superior/inferior palpebral conjunctiva +/- macropannus (> 1 mm), diffuse PEE, possible bulbar follicles. Rx: doxycycline 100 mg PO BID x 2 mo. 2nd line = oral erythromycin or azithromycin

classic presentation: young/ middle-aged adult who presents with an abrupt fever, dry cough, and headache +/- (e.g.hepatomegaly and splenomegaly).
vs.
trachoma = preferentially involves the SUPERIOR palpebral conjunctiva and adult inclusion conjunctivitis (LOWER palpebral conjunctiva)

Mnemonic: Polish suitemate, now with older with a bird, is coughing with fever. She has a headache because she has follicles on superior and inferior palpebral conj. She has gotten bigger as she has gotten older (macropannus).

It is chlamydia so CAD (Chalmydia Rx = azithromycin or doxycycline)

"Passing Tough Tests Means Last Minute Studying"
Parinauds oculoglandular syndrome
Trachoma
Toxic (viroptic, miotics, atropine, brimonidine, aproclonidine)
Morexella
Lyme
Molluscum (pox virus)
Chlamydia inclusion conjunctivitis
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22
Q

Salzmann nodular degeneration

A

hyaline material deposited IN BOWMAN’s layer.

Thought to be 2/2 chronic irritation of cornea

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24
Q

Dacryoadenitis (inflammation of the lacrimmal gland)

A

MC 2/2 sterile inflammatory dz (orbital pseudotumor variant)

EBV = MCC viral dacryoadenitis, esp will see multifocal K infiltrates

Mnemonic: think of Brooks (EBV) with dacyroadenitis.

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25
Q

“Mooren like” PUK

A

Hepatitis C highly assoc/w/Mooren-like PUK

MCC PUK = autoimmune dz. Peripheral K infiltrate with epi loss. PAINFUL.

Other etiologies: RA (MC), HZV/HSV, TB, gonorrhea, syphilis, AIDS

Rx: conj recession. TREAT UNDERLYING systemic dz

Mnemonic: Fuck hep C (PUK Hep C)

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26
Q

K topography I-S value in keratoconus

A

I-S values compare the steepness of the inferior cornea to the superior cornea

Keratoconus has steepening of the inferior to superior cornea
Values > 1.2

Mnemonic: comparing one half (1/2 or 1.2) to the other in keratoconus K topo

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27
Q

Viral conjunctivitis

A

SEVERE FOLLICULAR CONJUNCTIVITIS.
adenovirus, epidemic keratoconjunctivitis

SEI (WBC and immune-complex deposits)

EKC: pseudomembranes OR true membranes
preauricular LA

27
Q

Epibulbar dermoid vs. dermoid cyst

A

epibulbar dermoid (INFEROTEMPORAL; like where the K is thinnest)

dermoid cyst (MC superotemporally)

28
Q

Epibulbar dermoid

A

assoc/w/Goldenhar syndrome (dental/skeletal abnml, KYPHOSIS, rib abnml, butterfly vertebra,e hemivertebrae), preauricular skin tags

DO NOT EXCISE as they extend deep into the cornea. Shave Bx or superficial lamellar dissection may improve astigmatism. MC occurs inferotemporally.

Induces PLUS cylinder 90 degrees away

Dermoid, like terrien’s = induces cyl 90 degrees away.

29
Q

Bacteria and K lesions

A

Bitot cells - vit A deficiency, Corynebacterium xerosis (keratinized epithelium, debris, inflammatory cells) –> release gas as a byproduct

Actinomyces israelii = MC assoc/w/canaliculitis

Strep virdians = MC assoc/w/infectious crystalline keratopathy. esp occurs in post-penetrating keratoplasty

30
Q

atopic keratoconjunctivitis

A

shield-like anterior subcapsular cataracts and plaque-like posterior subcapsular cataracts. multi-factorial etiology: patients rub their eyes more often, patients use steroids more often, and these patients have an immunologic response to skin epithelial cells which may cross-react to lens epithelial cells.

These patients are more susceptible to HSV corneal involvement secondary to an altered immunologic state. They may also have peripheral marginal infiltrates and punctate epithelial erosions but they aren’t characteristic of the disease.

Mnemonic: Susan Curtis is going to need a shield (anterior/PSC cataracts) against the HSV

31
Q

Cornea crystals

A

Mnemonic: MGL BSS CCMM D
Magnificent Granules Lack Bouncy Schnyder’s Strep.
Coherent Characters Make Musty Dummies (dumbcane)

M/G/L
Bietti's & Schnyder's dystrophy
Strep viridans
Ciloxan deposits
Cystinosis
Multiple Myelnoma
Monoclonal Gammopathy
Diffenbachia "dumbcane" w/calcium oxalate crystals
32
Q

Parinaud’s ocularglandular syndrome

A

Granulomatous conjunctivitis with regional lymphadenopathy (rare syndrome)
u/L granulomatous conjunctivitis (flat, gelatinous, hyperemic, granulomatous lesions develops on the tarsal conjunctiva, fornix, or bulbar conjunctiva) that develops ~1 week after exposure to a causative microorganism.
~2 weeks later u/L firmtender preauricular/submandibular lymph nodes
constitutional symptoms (e.g. fever, malaise, headache)

Bartonella henselae.
Other causes: tularemia (transmitted by rabbits), sporotrichosis, TB, and syphillis

No”gold-standard” Rx: azithromycin, doxycycline

33
Q

Acute hemorrhagic conjunctivitis (AHC)

A

follicular conjunctivitis and subconjunctival hemorrhages. It is commonly caused by enterovirus type 70, and coxsckievirus A24 variant. It is rarely caused by adenovirus type 11.

A24E70 (Ariel = A24E70) -follicles and blood

34
Q

neonatal inclusion conjunctivitis

A

neonatal inclusion conjunctivitis (i.e. one of the ophthalmia neonatorum diseases) strangely results in a papillary (i.e. not follicular) reaction.

35
Q

Gonorrhea conjunctivitis Rx

A

Gonorrhea conjunctivitis can be treated with IM injection of 1 gram of ceftriaxone, eye lavage every hour, and treatment for the high rate of concurrent chlamydia. Never put steroids on an infectious process!

G/C = Gonorrhea/ceftriaxone

36
Q

presentations of adenoviral syndrome

A

classic

1) simple follicular conjunctivitis (multiple serotypes)
2) pharyngoconjunctival fever (most commonly serotype 7),
3) epidemic keratoconjunctivitis (EKC; usually serotype 8, 19, or 37, subgroup D).

generally has small conjunctival hemorrhages, preauricular lymphadenopathy, and pseudo or true membrane formation. Subepithelial infiltrates generally occur 7-14 days after the start of eye symptoms.

Mnemonic: Epidemic = 8 19. 8+1 = 9. 37D. 37Ds are epidemic with 819. Pharyngoconjunctival: 8-1= 7.

37
Q

Simple follicular conjunctivitis.

A

Simple follicular conjunctivitis. This syndrome is self-limited and without systemic symptoms. Most patients will not even seek care for this type of adenoviral ocular infection. An epithelial keratitis can occur, but it is usually short-lived and mild.

38
Q

Pharyngoconjunctival

A

Pharyngoconjunctival fever. This is the type of adenoviral infection with prominent systemic symptoms including fever, headache, and a sore throat. Again, any corneal involvement is very mild.

39
Q

Epidemic keratoconjunctivitis

A

Epidemic keratoconjunctivitis (EKC). This is the only subtype of adenoviral infection with significant corneal involvement. This syndrome is characterized by rapid bilateral involvement, preauricular adenopathy, “pseudomembranes” or true conjunctival membranes, and moderate-to-severe tearing and light sensitivity. Corneal signs can include large cornea erosions and/or multifocal subepithelial infiltrates (SEIs). These SEIs can be so prominent as to obscure vision.

40
Q

follicular conjunctivitis lasting longer than 4 weeks

A

DDx: adult inclusion disease, trachoma, toxic conjunctivitis, Parinaud’s oculoglandular syndrome, Axenfeld’s conjunctivitis, Thygeson’s superficial punctate keratitis, acne rosacea, and benign lymphoid hyperplasia.

Herpes simplex may indeed be the cause of follicular conjunctivitis*. However, it is usually self-limited or recurrent rather than chronic.

Mnemonic: PAT (Parinaud/Axenfeld/Thygeson). has long-standing toxic acne including trachoma.

41
Q

Ligneous conjunctivitis

A

Ligneous conjunctivitis is secondary to type 1 plasminogen deficiency. This is a very rare condition. It has “woody” membranes on the conjunctiva (generally palpebral).

The deficiency in type 1 plasminogen leads to hypofibrinolysis. The membranes can be excised, but it is recommended to use adjuvant mitomycin-C (MMC) or an amniotic membrane graft at the time of excision. These membranes can recur and may also resolve spontaneously.

RxL topical plasminogen application.

42
Q

Axenfeld’s conjunctivitis

A

insidious onset and is accompanied by a scanty discharge in which mononuclear cells (lymphocytes) predominate. The follicles involve the entire conjunctiva, including the upper tarsal plate, but are firm and do not break up when pressure is applied. The cornea is not involved, and probably for this reason, the disease is asymptomatic.

Because Axenfeld’s chronic follicular conjunctivitis is not associated with florid corneal involvement and does not produce conjunctival scarring, it has been classified as a disease entity separate from trachoma. Most of the observations on Axenfeld’s follicular conjunctivitis were made before the slit lamp was widely used, and it is likely that small degrees of keratitis and pannus may have been overlooked. Moreover, in mild trachoma, a chlamydial agent is rarely demonstrated and the disease produces little, if any, scarring. Therefore, it is possible that Axenfeld’s conjunctivitis is a mild form of trachoma that runs a self-limiting course under the relatively hygienic conditions of a children’s institution. In such cases, a regular course of trachoma therapy with oral tetracycline or erythromycin should be administered.

43
Q

Urrets-Zavalia syndrome

A

Mnemonic: Brian Zavalia has tURRets with fixed pupil (PS denervation of iris sphincter) with sector iris atrophy

Presentation of a fixed dilated pupil with sector iris atrophy after PKP (original report)

Also see in DALK, trab, argon laser PI
cause of this syndrome is not completely understood, but is thought to be a result of parasympathetic denervation of the iris sphincter.

44
Q

Some exclusion criteria preventing use of donor cornea.

A

There are many conditions that prevent the use of a donor cornea (too many to list here). These exclusionary criteria include: death of unknown cause; active septicemia; HIV/hepatitis B/C infection; and active ocular inflammation (e.g. scleritis).

45
Q

ocular melanocytosis

A

2/2 focal proliferation of subepithelial melanocytes
ocular melanocytosis involves pigmentation of the episclera and not the conjunctiva, it is not mobile
About 1/2 of patients with ocular melanocytosis have ipsilateral dermal melanocytosis (Nevus of Ota) and a proliferation of dermal melanocytes in the periocular skin of V1 and V2.

~ 10% of ocular melanocytosis patients develop GLAUCOMA. The risk of uveal (not conjunctival) melanoma in patients with ocular melanocytosis is 1:400 which is much greater than the sporadic risk in the general population.

Only 5% of cases of ocular melanocytosis are bilateral

Nevus of Ota - 10% glaucoma, 1:400 uveal melanoma..

46
Q

Type of bacteria in infectious crystalline keratopathy

A

Alpha-Hemolytic Streptococcus species

In infectious crystalline keratopathy, the epithelium is often intact, and there is minimal surrounding inflammation. The most common organism causing ICK is Streptococcus viridans. This bacteria is Gram-positive, so it would show up as blue on the Gram stain.

3Cs - Corticosteroid use, contact lens wear, and corneal grafts can all predispose to this condition.

47
Q

Phlyctenulosis

A

assoc/w/S. aureus in developed countries & Mycobacterium tuberculosis in developing countries
Si/Sx: limbal nodules with vessel engorgement. typically necrose centrally and involute over the course of 2-3 weeks. A scar is left behind in limbal hlyctenulosis. generally not associated with scarring or decreases in vision.
delayed (type IV) hypersensitivity reaction to bacterial cell wall antigens (BSC says that staphylococcal marginal keratitis is also type 4)

48
Q

stye vs. chalazion

A

External hordeola = styes, 2/2 secondary to underlying Staph Aureus infections

chalazion = lipogranulomatous inflammation involving holocrine glands (either meibomian or Zeis)
Histologically, a zonal granulomatous inflammatory response centered around lipid is seen.

meibomian and Zeis glands= located within the tarsus (meibomian) and near the lid margin (Zeis)

Mnemonic: CHMZ. CHristine Me/Ze: Chalazion, Holocrine, Meibomian, Zeiss

49
Q

severe rosacea leading to keratitis

A

Rosacea generally occurs in patients aged 30-60 years old. It can be associated withrhinophyma (enlarged nose) although the strength of the association has recently been questioned. It is more frequently seen in females. Rosacea leads to meibomian gland dysfunction which leads to a decreased lipid layer in the tears and decreased tear break up times

50
Q

dry eye -osmolarity, lsozyme, lactoferrin.

A

Virtually all forms of dry eye are associated with increased osmolarity. This feature can be tested with “osmometers” which are becoming more widely available in routine clinical practices.

DECREASED lysozyme and lactoferrin levels

basic secretion test is one of the standard tests of tear secretion. It is performed by anesthetizing the patient’s eye, blotting out the excess tears, and then placing a filter paper strip at the junction of the middle and lateral thirds of the lower eyelids. Any value greater than or equal to 10 mm is considered “normal.”

51
Q

Sessile conjunctival papillomas

A

Sessile lesions are flat as opposed to pedunculated which are raised and wart-like.

Sessile conjunctival papillomas are associated with HPV 16 + 18.

Mnemonic: stay away (b/c of HPV) from looking (conj papilloma) at sexy (sessile) teenagers (16-18)

52
Q

Pedunculated conjunctival papillomas

A

Pedunculated conjunctival papillomas are associated with HPV 6 (kids) + 16 (adults).

Pedunculated 616

53
Q

Kaposi’s sarcoma

A

herpes type 8. Secondary to malignant transformation of vascular endothelium.

54
Q

oncocytoma

A

An oncocytoma= slow-growing cystadenoma. Its origin is from ductal and acinar cells of main and accessory lacrimal glands.

Mnemonic: Oncocytoma cries (lacrimal) slowly (slow-growing)

55
Q

congenital glaucoma vs trauma

A

Hab’s straie in glaucoma = horizonta

Vagina –> Vertical tears centrally

56
Q

What is the differential diagnosis of acute follicular conjunctivitis?

A

adeno hardly ever happens to careful nuns

Adenovirus
Herpes
Hemorrhagic conjunctivitis (picornavirus)
Chlamydia inclusion conjunctivitis (picornavirus)
Newcastles disease

57
Q

Conjunctival melanomas

A

occur most commonly in white ppl
mortality rate = 25% ( better than that from uveal or cutaneous melanoma)
MC (70%) arise from pre-exisiting primary acquired melanosis (PAM) lesions.

Characteristics of conjunctival melanomas that portend an especially bad prognosis include those
arising de novo, melanomas not involving the limbus, and residual tumor at the surgical margins after excision.

58
Q

Interstitial DDx

A

Interstitial DDx
In Kenya Cogan Saw Two Laughing Hyenas Making Love

IK =
Cogan
Syphilis
TB
Lyme
Herpes
Measles
LGV/Leishmaniasis
59
Q

Primary acquired melanosis

A 
Primary acquired melanosis
flat with irregular margin
pigmentation may wax and wane
intraepithelial, no cysts
atypia: mild, moderate, severe

1 clock hour involvement approximately 1.7x risk progression to melanoma

60
Q

chronic blepharoconjunctivitis

A

The most common cause of chronic blepharoconjunctivitis is Staphylococcus aureus. But Moraxella lacunata is specifically associated with a chronic angular blepharoconjunctivitis. This condition is characterized by crusting and ulceration of the skin in the lateral canthal angle. It can also produce a papillary or follicular reaction of the tarsal conjunctiva.

61
Q

suspect Demodex when…

A

You should start to suspect Demodex-associated blepharitis in the following situations:

When a patient’s blepharitis is recalcitrant to conventional treatments
Cylindrical dandruff is present at the base of the lashes
When there is madarosis or recurrent trichiasis.

The classic treatment for Demodex-associated blepharitis is with tea tree oil (TTO) (e.g. daily scrub with 50% TTO and/or lid massage with 5% TTO ointment). One of the commercial formulations of TTO is marketed as Cliradex®.

62
Q

onjunctival lymphoma vs. reactive lymphoid hyperplasia.

A

diffuse sheet of lymphocytes (CD45 immunostain is a marker for lymphocytes, though it does not differentiate between B and T cells), which may indicate conjunctival lymphoma vs. reactive lymphoid hyperplasia.

Lesions that consist mostly of small, monotonous lymphocytes, that exhibit germinal centers, and that also contain a small number of plasma cells are most likely to be benign, while lesions that exhibit very large, atypically-shaped lymphocytes, with coarse chromatin, prominent nucleoli, and numerous mitoses are usually malignant. Fortunately, most conjunctival lymphomas (2/3) are localized and not associated with systemic lymphoma.

In order to distinguish between reactive lymphoid hyperplasia and lymphoma, immunostains and flow cytometry can be performed to evaluate if the lesion consists mostly of B cells, T cells, or a mixture of both.

Benign: a mixture indicates a polyclonal origin,
Malignant: predominance of B or T cells indicates monoclonality,

A combination of immunostains, flow cytometry, and morphology of the individual cells must be used to make a diagnosis.

Lymphoid hyperplasia (low grade B cell lymphoma) and lymphoma are grossly indistinguishable. Pathology requires a fresh tissue specimen. Patients should always be referred for a medical evaluation to rule out systemic lymphoma.According to the BCSC, approximately 20% of patients with a conjunctival lymphoid tumor have detectable extraocular lymphoma.

Clinically, these tumors appear as diffuse, elevated pink masses (buzzword: salmon patch) usually in the fornix. Since it is difficult to distinguish between a benign (i.e. lymphoid hyperplasia) versus a malignant mass (i.e. lymphoma) on clinical exam alone, a biopsy is mandatory. In addition, asystemic workup should be undertaken to rule out systemic lymphoma.

The majority of these tumors are non-Hodgkin’s type B cell lymphomas and occur in patients over the age of 50 years or are immunosuppressed.

63
Q

serovars that are associated with the different Chlamydial diseases

A

Trachoma: serovars A-C.
Adult and neonatal inclusion conjunctivitis: serovars D-K
lymphogranuloma venereum: L1-L3,

Some memorable mnemonics:

“trAChoma” –> serovars A-C
“DicK” - which references that adult/neonatal inclusion conjunctivitis are due to sexually-transmitted disease

64
Q

Trachoma

A

Trachoma = leading cause of preventable blindness world-wide.
Rx: poor hygiene transmitted eye-to-eye or by flies and other household fomites.

Dx made by observing 2 of the following 4 findings: conjunctival follicles on the upper tarsal conjunctiva, limbal follicles and their sequela (Herbert’s pits), typical tarsal conjunctival scarring, and vascular pannus most marked on the superior limbus.

Rx: active trachoma consists of topical and oral tetracycline, erythromycin, or azithromycin.

65
Q

porphyria cutanea tarda and mimicker

A

These patients may get conjunctival scarring leading to symblepharon with a similar clinical appearance to bullous pemphigoid. These patients have “tea-colored” urine that becomes more apparent on standing.

Mimicker: Alkaptonuria (‘black urine disease’) has the characteristic darkening of the urine on standing due to elevated urinary homogentisic acid levels

66
Q

band keratopathy

A

deposition of calcium hydroxyAPATITE

Cornea/Refractive/Lens (7 decks)

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