lids

Question 1

Which of the following systemic diseases is MOST commonly associated with the presence of a positive Cogan’s lid twitch sign?

Multiple sclerosis
Grave’s disease
Myasthenia gravis
Systemic lupus erythematosus

Answer 1

Myasthenia gravis

Cogan’s lid twitch sign is characterized by an overshoot of the upper eyelid on a vertical saccade from down-gaze to the primary position (when the patient first looks downward for a short period of time). The upper eyelid will also often twitch in a nystagmoid fashion or slowly droop back to a ptotic primary position. It is thought that this sign is a result of a transient improvement in lid strength after a short rest of the levator when in downgaze, followed by a drop in the lid in primary position as the levator begins to fatigue again. Cogan’s lid twitch is most commonly associated with myasthenia gravis.

Question 2

Which of the following correctly describes the drainage pathway of tears?

Puncta-> caniculi-> lacrimal sac-> nasolacrimal duct-> inferior meatus
Puncta-> lacrimal sac-> caniculi-> nasolacrimal duct-> inferior meatus
Puncta-> caniculi-> nasolacrimal duct-> lacrimal sac-> inferior meatus
Puncta-> lacrimal sac-> nasolacrimal duct-> caniculi-> inferior meatus

Answer 2

Puncta-> caniculi-> lacrimal sac-> nasolacrimal duct-> inferior meatus

Question 3

Dry eyes can cause blurred vision, stinging and foreign body sensation. How do the tears seen in people with dry eyes compare to those with normal eyes?

Lower osmolarity
Increased lysozyme concentration
Lower pH than normal
Higher pH than normal

Answer 3

Higher pH than normal

The tear film in people with dry eyes displays a higher pH than that of normal eyes. The change in pH is attributable to the fact that the osmolarity of the tears increases, thus increasing the pH. Many drug companies have taken advantage of this knowledge and applied it in their manufacture of artificial tears. Alcon, the company that invented Systane, ultilizes a component called Hydroxypropyl-guar (HP-Guar) which is a gel-forming matrix. Upon instillation of Systane into the eye, the liquid transforms into a gel. The difference in pH between the tear film and the artificial tears leads to an alteration in the cross-linking between HP-Guar and borate (another ingredient in the artificial tears), causing the creation of a gel-like layer that allows for increased ocular contact time. Studies show that the tear lysozyme content is decreased in people who suffer from dry eyes.

Question 4

Which 2 of the following glands are considered accessory lacrimal glands, producing a small portion of the aqueous component of the tears? (Select 2)

Meibomian glands
Glands of Zeis
Glands of Krause
Glands of Wolfring
Glands of Moll

Answer 4

About 95% of the aqueous component of tears is produced by the main lacrimal gland; the accessory lacrimal glands of Wolfring and Krause produce the remainder.

The meibomian glands and glands of Zeis are sebaceous glands, while the glands of Moll are apocrine glands.

Question 5

The lymphatic system serves many important roles in the human body. The lateral portion of the eyelid lymphatics drain into which of the following structures?

The pre-auricular lymph node
The conjunctiva
The submandibular lymph node
The puncta

Answer 5

The pre-auricular lymph node

Question 6

Which of the following eyelid glands are sebaceous glands that secrete sebum into the hair follicle that coats the shaft of the eyelash?

Glands of Krause
Glands of Zeis
Meibomian glands
Glands of Wolfring

Answer 6

Glands of Zeis

Question 7

An abnormally high positioned upper eyelid crease is indicative of which of the following types of eyelid ptosis?

Neurogenic
Congenital
Myogenic
Aponeurotic
Mechanical

Answer 7

Aponeurotic

Clinical findings associated with an aponeurotic ptosis include a mild to moderate upper eyelid ptosis, an abnormally highly positioned upper eyelid crease, and good levator function. This type of ptosis most commonly occurs in elderly patients in whom there is a stretching of the levator aponeurosis that results in elongation of the length of the muscle and a resultant ptotic upper eyelid.

The upper eyelid crease measurement is the vertical distance between the upper lid margin and lid crease when the patient is looking in down-gaze. It is typically 10mm in females and 8mm in males.

Question 8

Which of the following is an example of a congenital ptosis?

Muscle disease such as myasthenia gravis
Cranial nerve III lesion
Developmental failure of the levator palpebrae superioris
Cicatricial or scar tissue
Fat deposits in the upper lid resulting in increased weight of the eyelid
Involutional

Answer 8

Developmental failure of the levator palpebrae superioris

Question 9

You decide to perform the Schirmer 1 test (without anesthetic) on a 23 year-old patient with symptoms of dry eye. After a period of 5 minutes, which of the following values indicates the threshold whereby any measurement below this is considered abnormal?

12mm
18mm
25mm
15mm
10mm

Answer 9

10mm

Question 10

Which 3 of the following bones make up the floor of the orbit? (Select 3)

Palatine
Zygomatic
Maxillary
Sphenoid
Ethmoid
Frontal

Answer 10

Zygomatic,Maxillary,Palatine

Orbital roof bones: lesser wing of sphenoid, orbital plate of the frontal
Lateral wall bones: greater wing of sphenoid, zygomatic
Medial wall bones: maxillary, lacrimal, ethmoid, sphenoid

Question 11

Dacryocystitis refers to inflammation or infection of which of the following structures of the eye?

Puncta
Nasolacrimal duct
Lacrimal sac
Lacrimal gland

Answer 11

Lacrimal sac

Question 12

You are measuring the palpebral fissure height in a patient reporting drooping of his upper eyelid. Which of the following BEST describes the normal positioning of the upper and lower eyelids in comparison to the limbus?

The upper lid normally rests about 1mm lower than the upper limbus, and the lower lid rests about 2mm above the lower limbus
The upper lid normally rests about 2mm lower than the upper limbus, and the lower lid rests about 1mm lower than the lower limbus
The upper lid normally rests about 2mm lower than the upper limbus, and the lower lid rests about 1mm above the lower limbus
The upper lid normally rests about 1mm lower than the upper limbus, and the lower lid rests about 2mm lower than the lower limbus

Answer 12

The upper lid normally rests about 2mm lower than the upper limbus, and the lower lid rests about 1mm above the lower limbus

The palpebral fissure height is a measurement of the distance between the upper and lower eyelid margins when the patient is looking in primary gaze. This particular measurement is typically less in males (7-10mm) as compared to females (8-12mm). The normal positioning of the upper and lower eyelids are as follows: the upper eyelid usually rests about 2mm below the superior limbus, while the lower eyelid position is typically 1mm above the lower limbus.

marginal-reflex distance (MRD). The MRD can be defined as the distance between the upper eyelid margin and the resultant corneal reflection caused by directing a patient’s gaze at a penlight held by the examiner. This measurement is normally 4-4.5mm.

Question 13

Weakness of which of the following extraocular muscles is MOST commonly associated with a simple congenital eyelid ptosis?

Superior oblique
Medial rectus
Inferior rectus
Inferior oblique
Superior rectus
Lateral rectus

Answer 13

Superior rectus

Weakness of the superior rectus muscle is the most common ocular motility abnormality associated with a simple congenital ptosis. This is due to the close embryological association of the levator and the superior rectus; these two muscles develop from the same myotome. Keep in mind that extraocular muscle surgery must be performed prior to ptosis correction due to the associated lid position changes that will occur once the eye position is adjusted.

Question 14

Which of the following BEST describes the actions of the lacrimal system that occur when the eyes close during a blink?

Horizontal canaliculi are shortened, puncta moves medially, and lacrimal sac expands
Horizontal canaliculi are shortened, puncta moves medially, and lacrimal sac collapses
Horizontal canaliculi are lengthened, puncta moves temporally, lacrimal sac expands
Horizontal canaliculi are lengthened, puncta moves temporally, and lacrimal sac collapses

Answer 14

Horizontal canaliculi are shortened, puncta moves medially, and lacrimal sac expands

Question 15

Reflexive blinking is caused primarily by which of the following actions?

Stimulation of the orbicularis and inhibition of the levator palpebrae superioris
Inhibition of Mueller’s muscle and stimulation of the levator palpebrae superioris
Inhibition of the orbicularis and stimulation of the levator palpebrae superioris
Stimulation of Mueller’s muscle and inhibition of the levator palpebrae superioris

Answer 15

Stimulation of the orbicularis and inhibition of the levator palpebrae superioris

Question 16

Your 21 year-old female patient reports that her upper eyelid has been intermittently twitching for the past 2 weeks. She states that these symptoms typically occur before important tests and eventually resolve on their own. What is the MOST likely diagnosis of this ocular condition?

Blepharoclonus
Eyelid myokymia
Hemifacial spasm
Blepharospasm

Answer 16

Eyelid myokymia

Question 17

What is the average period of time an eyelash of an adult continues to grow?

1 month
2 months
6 months
4 months

Answer 17

2 months

Question 18

A 34 year-old patient presents to your office with a chief complaint of redness and irritation of his eyelids and his eyelashes occasionally sticking together. Upon biomicroscopy, you notice hyperemic and greasy eyelid margins, and soft scales scattered along the eyelid margins and eyelashes. What is the MOST likely diagnosis of this patient’s symptoms?

Seborrheic blepharitis
Meibomian gland dysfunction
Bacterial conjunctivitis
Angular blepharitis
Staphylococcal blepharitis

Answer 18

answer is Seborrheic blepharitis( scaly , stick together , greasy , hyperemic )

Seborrheic blepharitis

• Soft scales are present and located along the eyelid margin and eyelashes
• Anterior lid margins appear greasy and hyperemic
• Eyelashes commonly stick together

Staphylococcal blepharitis
- Scales and crusts are typically harder
madarosis, trichiasis, and poliosis

Meibomian gland dysfunction
- Capping of meibomian gland
Tear film is usually oily

Question 19

You are evaluating the function of the levator muscle in a patient with a suspected myogenic ptosis. A measurement less than what value would be considered abnormal?

5mm
12mm
9mm
16mm

Answer 19

below 12mm is abnormal

Question 20

Which of the following terms describes eyelash loss?

Epicanthus
Madarosis
Telecanthus
Ciliary dyskinesia
Poliosis

Answer 20

answer is Madarosis

Epicanthus = orbital fold or Mongolian fold of the eyelid.
Telecanthus is a term that describes increased distance between the eyelids at the medial canthus.

Question 21

Herpes zoster is a virus that generally affects only one side of the face. A zoster lesion seen on the tip of the nose is seen as a sign and may signal the presence of ocular involvement roughly 75% of the time. What is the name of this sign?

Hutchinson’s sign
Meyer’s sign
Munson’s sign
Horner’s sign

Answer 21

Hutchinson’s sign

Question 22

Many skin anomalies may mimic malignant lesions. Which of the following skin conditions has the HIGHEST risk of becoming malignant?

Seborrhoeic keratosis
Cutaneous horn
Actinic keratosis
Papilloma

Answer 22

Actinic keratosis

Actinic keratosis is a precursor to squamous cell carcinoma and appears as scaly, dry skin that does not heal. People with skin that is of lighter pigmentation along with excessive exposure to ultraviolet light tend to be most at risk for development of this condition.

Papillomas may take on various forms and may be viral or non-viral in origin. They can commonly be found on the eyelids or surrounding orbital skin. Viral warts tend to grow at an accelerated rate while non-viral papillomas are fairly slow to grow. Papillomas can mimic neoplastic growths so be sure to rule this out while watching carefully for color change, ulceration, lash loss, bleeding, and vascularization.

Cutaneous horns or tags are also benign and are likely a form of papilloma but appear to involve more keratin. Treatment is similar to that of a papilloma.

Seborrhoeic keratosis is more commonly seen in middle-aged and elderly persons. This benign, epidermal growth is quite superficial and does not extend into the dermis. It appears like a brown plaque that has been stuck onto someone’s skin. The borders are very distinct and there may be some elevation. The lesions may be removed if the patient is concerned about cosmesis.

Question 23

A 43-year old woman is seen at your office concerned about the fact that she constantly seems to have styes on her eyelids and her eyes are continually red and irritated. Biomicroscopy reveals meibomitis and blepharitis along with lid telangiectasia and a TBUT of 4 seconds for each eye. She also reports that her cheeks, nose, forehead and chin are easily flushed, especially when exposed to heat or cool temperatures. Given the above findings, what is your tentative diagnosis?

Hordeolum
Dry eye syndrome
Systemic lupus erythematosus
Rosacea

Answer 23

Rosacea

Rosacea is a condition that causes excessive blushing of the face, with or without ocular involvement. Rhinophyma (a large, bulbous, red nose) is common in rosacea. Patients will often complain of facial flushing that is exacerbated with extreme temperature exposure, exertion, or the ingestion of hot beverages. This condition is seen two times more frequently in women. Ocular implications commonly include blepharitis, meibomitis, telangiectasia, dry eye syndrome, and occasional corneal involvement such as superficial punctate keratitis, pannus, and neovascularization. Treatment of facial rosacea includes oral tetracycline, topical metronidazole and retinoid compounds. Ocular rosacea is best treated by managing concomitant lid diseases along with artificial tears. While a hordeola and dry eye syndrome do occur in rosacea, these should not be your primary diagnoses. Remember to look at the overall broad picture and not just the pair of eyeballs.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that has the capability of affecting many areas of the body. A common finding of SLE is called the malar (or butterfly) rash that is seen in roughly half of the individuals affected by this disorder. This rash generally occurs on the cheeks and over the nose bridge and worsens with ultraviolet light exposure. Concurrent eye conditions with SLE are primarily secondary to complications from the medications used to manage the condition such as oral corticosteroids and anti-malarials.

Question 24

Contraction of the orbicularis oculi to close the eye aids in movement of tears through the lacrimal canaliculi and nasolacrimal drainage system via the action of which section of the muscle?

Muscle of Horner
Orbital portion of the orbicularis oculi
Muscle of Mueller
Muscle of Riolan

Answer 24

Muscle of Horner

The muscle of Horner (also known as the pars lacrimalis) is part of the palpebral portion of the orbicularis oculi. The fibers for the muscle of Horner come from the lacrimal crest and encircle the lacrimal canaliculi. This assists the flow of tears into the nasolacrimal drainage system when the orbicularis oculi contracts to close the eye. The muscle of Riolan (also known as the pars ciliaris) is another section of the palpebral portion of the orbicularis oculi; it lies near the lid margin to maintain the margins next to the globe. The orbital portion of the orbicularis oculi is mainly responsible for forced closure of the eyelids. The muscle of Mueller (also known as the superior tarsal muscle) is a sympathetic smooth muscle that acts to widen the palpebral fissure.

Question 25

Which 3 of the following muscles of the face are responsible for retraction of the eyelids? (Select 3)

Corrugator
Muller's
Procerus
Orbicularis oculi
Frontalis
Levator palpebrae superioris

Answer 25

Muller’s
Frontalis
Levator palpebrae superioris

The eyelid retractors are muscles of the face that serve to open the eyelids. The primary retractor of the upper lid is the levator palpebrae superioris. The levator originates on the orbital roof near the orbital apex. The levator muscle is about 40mm in length with an additional 14-20mm that represents the levator aponeurosis. The aponeurosis splits in the anterior and posterior portions, which insert at the pretarsal orbicularis and the anterior surface of the tarsus, respectively.

Muller’s muscle is also important in opening the upper lid. It originates underneath the levator aponeurosis and extends to insert at the superior tarsal border. This muscle is responsible for about 2mm of elevation of the upper lid.

The frontalis muscle also acts as a weak retractor of the eyelid but is mostly responsible for lifting the eyebrows. By elevating the eyebrows, the frontalis may provide an additional 2mm of retraction of the upper eyelids.

Question 26

Your patient reports constant epiphora of the right eye. You wish to determine if there is a blockage of her tear drainage system. You perform lacrimal irrigation. During the procedure, the plunger of the cannula is depressed with great difficulty, and the fluid is regurgitated through the puncta that you are irrigating. What is the CORRECT interpretation of these findings?

There is a blockage that is distal to the common caniculus
There is a blockage that is proximal to the common caniculus
There is an obstruction of the lacrimal duct of the opposite eye
The passageway is clear; there is no obstruction at this time

Answer 26

There is a blockage that is proximal to the common caniculus

If the saline is released by the opposite puncta, then there is a blockage located distally to the common caniculus. If the plunger cannot be depressed, or the fluid is expressed by the same puncta that is being irrigated, then the obstruction is proximal to the common caniculus.

Question 27

When evaluating a nevus of the eyelid, which of the following characteristics is indicative of stability (i.e., benign)?

Ulceration
Uniformity of color within the lesion
The presence of inactive hair follicles within the lesion
Greater than 6 mm in diameter
Irregular, indistinct borders

Answer 27

Uniformity of color within the lesion

When evaluating a suspicious nevus of the skin surrounding the eye, it is important to remember your “ABCDEs”. A=asymmetry, B=borders, C=color, D=diameter, E=evolution. A benign nevus tends to be symmetrical such that one can almost fold it in half and the sides would be evenly matched. The borders of a benign nevus are typically regular and distinct. The uniformity of the color should be assessed, rather than the actual level of pigmentation; evenness of pigmentation indicates stability. In general, the diameter of a benign nevus does not exceed 6 mm; although this is obviously not true all of the time, some small nevi may be malignant, and some large nevi (i.e., greater than 6 mm) can be benign. Lastly, most benign nevi tend to be rather flat (as opposed to elevated) with no change or evolution over time. Generally, hair growing out of the lesion is a positive sign, as this indicates that the hair follicle is intact. A cancerous lesion tends to kill the follicle; in this case, hair will no longer sprout. Remember, nevi should be stable and not change in shape, color, or size. ANY change in the nevus warrants a biopsy. Photo documentation is key when following a nevus or with any suspicious lesion.

Question 28

Numerous reports have suggested that increased tear film osmolarity is a key consequence in dry eye. Although osmolarity is not easily measured in the clinical setting, tear osmolarity increases in most dry eye sub-types due to which of the following processes?

Decreased capillary exchange leads to ionic bonding
In aqueous tear deficiency, the lacrimal gland produces more ionic species
The lipid layer is altered in most dry eye states, leading to ion pairing
Patients with dry eye tend to blink less than normals, leading to increased evaporation
Reactive oxygen species are increased in the tears of most dry eye sub-types; this increases osmolarity
Loss of tear stability induces an increased evaporation rate, leading to increased osmolarity

Answer 28

Loss of tear stability induces an increased evaporation rate, leading to increased osmolarity

normal tear osmolarity is less than or equal to 300 Osm/L, with values exceeding 308 Osm/L indicating increased osmolarity.

Question 29

Tear volume in a normal, healthy, young adult measures approximately between which of the following values?

9. 0-12.0
10. 0-16.0 microliters
11. 0-20.0 microliters
12. 0-5.0 microliters
13. 0-8.0 microliters

Answer 29

6.0-8.0 microliters

Question 30

Chronic blepharitis, if left untreated, can cause which of the following structural changes to the anterior ocular segment?

Hypertelorism
Distichiasis
Tristichiasis
Madarosis

Answer 30

Madarosis

Distichiasis is a rare congenital phenomenon marked by an absence of meibomian glands. In the place of the meibomian glands is an extra row of eyelashes.

tristichiasis is a very rare occurrence in which a person possesses three rows of eyelashes.

Question 31

Which of the following systemic disorders is MOST commonly associated with the presence of yellow, soft, raised, plaque-like lesions that generally occur in the medial canthal region of the eyelid?

Leukemia
Lymphoma
Hypertension
Hyperlipidemia
Diabetes mellitus

Answer 31

Hyperlipidemia

Question 32

The superior palpebral levator muscle is primarily responsible for retraction of the upper lid. Which of the following structures acts as a fulcrum to change the anteroposterior direction of the levator to superoinferior?

Superior transverse ligament (Whitnall’s ligament)
Superior tarsal muscle (muscle of Muller)
Superior oblique muscle
Inferior oblique muscle
Capsulopalpebral fascia

Answer 32

Superior transverse ligament (Whitnall’s ligament)

The superior palpebral levator muscle is primarily responsible for retraction of the upper lid. The sheath of this muscle blends with the sheath of the superior rectus muscle as it approaches the eyelid at the orbital apex; the superior transverse ligament (Whitnall’s ligament) acts as a fulcrum to change the direction of the muscle from anteroposterior to superoinferior in direction. The levator apopneurosis is a fan-shaped fibrous connection that penetrates the orbital septum and extends into the upper lid, anchoring the skin and creating the palpebral sulcus.

Question 33

An infection of the subcutaneous tissue anterior to the orbital septum is known as which of the following ocular conditions?

External hordeolum
Preseptal cellulitis
Internal hordeolum
Orbital cellulitis
Pyogenic granuloma

Answer 33

answer is Preseptal cellulitis

which is defined as an infection of the soft subcutaneous tissue anterior to the orbital septum. If an infection occurs anywhere in the orbit posterior to this septum, it is known as orbital cellulitis.

An internal hordeolum is a localized infection of the meibomian glands, while an external hordeolum is described as an acute infection with abscess formation of the glands of Zeiss and Moll. A pyogenic granuloma is a proliferative fibrovascular response to prior inflammation, surgery, or trauma.

Question 34

Which of the following most accurately describes the meibomian glands?

Apocrine glands
Mucous glands
Lacrimal glands
Sebaceous glands

Answer 34

sebaceous glands, hollicrain = meibomian, ziess

The meibomian glands are sebaceous glands embedded in the tarsal plate of the eyelids that provide the outer lipid portion of the tear film. The pores of these glands open along the lid margin posterior to the cilia. There are approximately 30-40 glands on the upper lid and 20-30 on the lower lid.

Question 35

The ocular condition in which redundant upper lid skin is present, in association with skin laxity and loss of muscle tone, is known as which of the following?

Entropion
Ptosis
Floppy eyelid syndrome
Dermatochalasis
Blepharochalasis

Answer 35

Dermatochalasis

Question 36

Which of the following skin conditions is considered to be benign and has the LOWEST risk of malignancy?

Actinic keratosis
Squamous cell carcinoma
Basal cell carcinoma
Keratoacanthoma

Answer 36

Keratoacanthoma

Keratoacanthoma appears very much like squamous cell carcinoma (SCC) in that it tends to progress rapidly and appears to ulcerate. This condition typically occurs in middle-aged and elderly patients of Caucasian descent on areas of the skin that are exposed. The lesion appears elevated, and eventually the center will produce a scab-like plug of keratin. The margins surrounding the plug will be rolled. At some point the keratin plug will fall out, resulting in the formation of a pit, and the lesion will regress. Most patients and clinicians do not like to wait this condition out due to its similarities to SCC.

Actinic keratosis is a pre-cursor to squamous cell carcinoma and appears as scaly, dry skin that does not heal. People with skin that is of lighter pigmentation along with excessive exposure to ultraviolet light tend to be most at risk for development of this condition.

Squamous cell carcinoma (SSC) is thankfully one of the rarest malignancies but due to its ability to metastasize can be quite dangerous. This malignancy has the ability to progress rapidly and has a high affinity for people who spend a lot of time in the sun, especially those who are light-skinned. The only way to definitively diagnose SCC is to refer for a biopsy and ensuring the use of Mohs technique. This strategy takes more time but ensures that the lesion is removed. Essentially, Mohs procedure calls for removal of tissue and biopsy of the surrounding borders. If the borders prove to be malignant then more tissue is removed and biopsied. This continues until the borders prove to be free of any carcinoma.

Basal cell carcinoma (BCC) is the most common malignant lid lesion and mercifully tends to be very slow-growing. BCC generally appears as a waxy, translucent nodule. Eventually the nodule will ulcerate. Patients may bring these to your attention and tell you that they have “had it for years and it just does not seem to heal”. Whenever you hear this it is best to send out for biopsy via Mohs technique. BCC very rarely metastasizes.

Question 37

A common cause of epiphora in infants is caused by a small membrane that covers over which of the following structures?

The valve of Hasner
The puncta
The lacrimal gland
The canaliculus

Answer 37

The valve of Hasner

It is common for mothers of young infants to note that one eye (or both eyes) of her infant constantly tears in conjunction with the presence of mucopurulent discharge. This epiphora results from a blockage of the nasolacrimal passageway caused by a membrane covering the valve of Hasner. The majority of blockages will self-resolve without intervention (80-90% of infants) within the first 12 months of life. Treatment may include massage of the nasolacrimal sac several times a day in an effort to rupture the membrane.

Question 38

Ptosis can be caused by dysfunction or damage to which of the following muscles?

Pars ciliaris (Riolan’s muscle)
Muscle of Horner
Inferior rectus
Superior tarsal muscle (muscle of Muller)

Answer 38

Superior tarsal muscle (muscle of Muller)

Question 39

While several tests such as tear stability and ocular surface staining are global tests diagnostic for the presence of dry eye, what is a specific test that can differentiate aqueous tear deficiency from meibomian gland dysfunction (MGD)?

A detailed dry eye questionnaire to allow for score-based symptomology
The Schirmer I test, which is considered abnormal if the strip wetting is less than 10 mm in 5 minutes without anesthesia
Meibomian gland atrophy/dropout as measured by meiboscopy
Conjunctival staining by lissamine green, which is worse in MGD
Tear clearance, which is normal in MGD

Answer 39

The Schirmer I test, which is considered abnormal if the strip wetting is less than 10 mm in 5 minutes without anesthesia

Question 40

You notice a palpable flat elevation of the skin on the left upper lid of your 73 year-old male patient that is about 2.5cm in diameter. What is the proper dermatological term for this type of lesion?

Papule
Plaque
Nodule
Vesicle
Macule

Answer 40

Plaque

Plaque: a palpable but flat lesion of the skin that is greater than 0.5cm in diameter.

• Macule: a localized area of color change without any associated infiltration or elevation (the surface is smooth). The lesion may be pigmented (as in a freckle), hypopigmentation (vitiligo), or erythematous (in a capillary hemangioma). The area of change is typically less than 1.5cm in diameter.
• Papule: small palpable lesions in which there is a solid elevation of the skin. These lesions are usually less than 0.5cm in diameter, may be flat-topped or dome-shaped, and may be a single lesion or present as multiple lesions.
• Vesicle: a small fluid-filled lesion that is typically less than 0.5cm in diameter. There may be a single lesion or multiple lesions.
• Nodule: a solid area of elevated skin; a papule that is enlarged in three dimensions (height, width, and length).

Question 41

Trichiasis is an inward turning of one or multiple eyelashes towards the eyeball. Which of the following is the MOST common cause of trichiasis?

Entropion
Lid myokymia
Trauma
Chronic blepharitis

Answer 41

Chronic blepharitis

Question 42

A 53-year old male complains of pain, irritation, watering, and foreign body sensation of the left eye. Upon slit lamp examination, you notice several eyelashes emanating from the meibomian glands that are turned inward toward the globe. What is this condition known as?

Meibomian gland dysfunction
Trichiasis
Trichotillomania
Distichiasis
Madarosis

Answer 42

answer is Distichiasis= extra lashes row from meibomian gland area( abnormal place)
trichiasis = inward lashes from original place
tristichaisis = 3 row of lashes

Question 43

An 81-year old female reports that her eye has been watering more frequently over the past month; you decide to administer the primary Jones dye test (Jones I). After 5 minutes, the application of a cotton-tipped applicator to the inferior turbinate reveals the presence of dye in the area. Taking this into consideration, what is the MOST likely cause of the patient’s epiphora complaint?

Hypersecretion of tears
Dysfunction of the valve of Hasner
Punctal stenosis
Complete nasolacrimal duct obstruction
Partial nasolacrimal duct obstruction

Answer 43

Hypersecretion of tears

The primary Jones dye test can be utilized to determine the patency of the nasolacrimal system. 1-2 drops of fluorescein are instilled into the inferior fornix of the eyes while the patient is in an upright position and blinking her eyes normally. After a period of 5 to 10 minutes, a cotton-tipped applicator is used to swab the undersurface of the inferior turbinate on each side of the nasal passage.

When the primary Jones dye test is positive (dye is recovered from the inferior turbinate of the nose), practitioners may conclude that the system is patent and that no significant blockage of the nasolacrimal drainage structure is likely. However, minor stenosis or physiologic dysfunctions cannot be completely ruled out. Patients who have a positive result on the Jones I test are more likely to experience symptoms of epiphora that are secondary to primary oversecretion of tears, rather than a dysfunction in lacrimal drainage (as in the above question).

When the primary Jones dye test is negative, the probability of an obstruction or dysfunction in lacrimal drainage is much greater; however, this test alone is not sufficient to document this conclusion. The secondary Jones dye test is then necessary to determine the severity and location of the obstruction.

Question 44

Which cranial nerves are responsible for opening and closing the eye?

The oculomotor nerve (CN III) opens the eye and the facial nerve (CN VII) closes the eye
The facial nerve (CN VII) opens the eye and the trigeminal nerve (CN V) closes the eye
The oculomotor nerve (CN III) opens the eye and the trigeminal nerve (CN V) closes the eye
The trigeminal nerve (CN V) opens the eye and the facial nerve (CN VII) closes the eye

Answer 44

The oculomotor nerve (CN III) opens the eye and the facial nerve (CN VII) closes the eye

Question 45

Oral acyclovir is most effective for patients presenting with eyelid findings associated with herpes zoster if administered within which of the following periods following the onset of the disease?

72 hours
7-10 days
10-12 hours
4-5 days
24 hours

Answer 45

Oral acyclovir is the mainstay of therapy for patients diagnosed with herpes zoster ophthalmicus. This systemic treatment is maximally beneficial if it is initiated within 72 hours from the onset of the disease (usually the appearance of eyelid lesions). The use of oral acyclovir typically results in quick resolution of skin vesicles, decreases the amount of pain the patient experiences, and reduces the duration of viral shedding and appearance of new lesions. Acyclovir has also been shown to significantly reduce the incidence of ocular findings such as episcleritis, keratitis, and iritis. The recommended dosage is 800mg orally 5 times per day for 7-10 days.

Question 46

Which 2 of the following BEST describe the definition as well as the normal value for the margin-reflex distance 1 (MRD1), which is commonly utilized in the evaluation of a ptosis? (Select 2)

MRD1 is the distance between the lower eyelid margin and the corneal reflection of a penlight that the patient is directly viewing
The average MRD1 measurement is about 4-4.5mm
MRD1 is the distance between the upper eyelid margin and the corneal reflection of a penlight that the patient is viewing directly
The average MRD1 measurement is about 6-6.5mm
The average MRD1 measurement is about 2-2.5mm

Answer 46

answer is The average MRD1 measurement is about 4-4.5mm, MRD1 is the distance between the upper eyelid margin and the corneal reflection of a penlight that the patient is viewing directly

MRD2 is the distance from the corneal reflex to the lower eyelid margin
average MRD2 measurement is about 6-6.5mm