Lids Lashes Adnexia Flashcards

Question 1

Q

Function of eyelids

Answer

A

Prevent ocular desiccation (Drying of eye)
Protects the globe
Grandular secretion - maintain pre-ocular tear film
Spontaneous blinking (10-15/min at near 5/min)
Reflex blinking - responce to irritants
Closure during sleep

Question 2

Q

Lid Coloboma (Incomplete closure of tissue)

Answer

A

Not Hereditary
Gaps notches in lids
Superior - junction of inner to middle 1/3 of lid
Inferior - junction of middle to lateral 1/3 of lid

Question 3

Q

Lid coloboma

Ocular complications
Management

Answer

A

Complications:

Tear film unstable
Corneal epithelium disruption
Ocular dissication
Sec infections

MX and treatment

Gel during the day (increase viscosity) ung PM / Gtt 6/pd

Oculoplastic SX

Question 4

Q

Epicanthal folds

Answer

A

Common - Autosomal dominant - Inherited

Redundant folds of skin from upper lid to inner canthus and covers cruncle

Can self resolve / Px with down syndrome

Pseudo-strab (esotropia)

MX - Optional SX

Question 5

Q

Epicanthal folds

CT + variation

Answer

A

Reversed epicanthal fold - only bottom lid has fold

Cover test: Norm Hirsberg 0.5mm nasal of midline

Every 1/2mm = 11 pd

Question 6

Q

Distichiasis

Answer

A

Hereditary - Autosomal dominant

Meibomian glands replaced by lashes / Hair growing out of meibomian glands

Lashes irritate cornea / cause tracking staining

Px - FB sensation, tearing, prone to corneal infection + scarring

MX - Epilation , Bandage CL, Electrolysis, cryo treatment, Art gel lubricant, Laser treatment

Question 7

Q

Blepharophimosis

Answer

A

Hereditary - Autosomal dominant

Narrowing of lid fissure Horizontally and vertically

Ddx - Epicanthal folds and Ptosis

RISK - Amblyopia

MX - Sx

Question 8

Q

Alcohol Fetal symdrome

caused 1st + 2nd trimester

Answer

A

Blepharophimosis (Epicanthal folds + Ptosis)

Other facial features:

Wader Nares (flaring nostrils)

Philtrum - flatter(no ridge) larger in dist betwwen nose and lip

Flat thin upper lip

Micrognatia (Smaller lower mandible)

Rail road ears (sup notch not fully rounded) ears lower down

Question 9

Q

Ectropion

Answer

A

Outward eversion of lower lid, away from globe, Poor lid apposition

Symptoms: Red eye, hypereamia of bulbar conjuctiva

FB sensation

Signs: Increased lacrimation

Hypereamia , Conjuctival drying, Exposure keratitus

MX - Horizontal shorming of lids SX

Artificial tear lubricant. AM gtt 6/pd PM ung

Question 10

Q

Ectropion

Classifications (causes)

Answer

A

Congenital - Rare

Involutional - Horizontal taxity 2nd to Aging

Paralytic - 7N palsy (Temp or perm)

Spastic: dt trauma / Orbicularis muscle contraction everts lid

Cicitricial - Skin contraction due to scarring

Allergic - Thickend skin, pul lid from globe

Mechanical - Growth in lid margin

Question 11

Q

Bell’s Palsy

Answer

A

Unilateral Facial Palsy

Sudden onset, Mild to severe paralysis

Symptoms: Sensitive to sound (Hyperacusis)

Pain in ear and jaw, Facial droop

Inability to raise eyebrow

Etiology - Viral (Herpes zoster)
Acoustic Adenoma
Ideopathic
Ischemia
Lyme’s disease (tick bite fever)

MX - ave 3wk. - 6 mnth recovery

Lubricate - gtt unpreserved 6/pd gel
Ung PM
Tape lids

Question 12

Q

Entropion

Answer

A

In turning of ids of eithe superior or inferior lid

Symptoms: Tearing - inc corneal sensitivity

FB sensation
Hypereamia

Ethiology

Congenital
Involutional - Aging
Cicatricial - Chemical injury
Trachoma (chronic infection Bacterial)

MX:

Epilation
Electrolysis
Cauterization
Bndg CL
Art lubricants 6/pd gel better

Question 13

Q

Trichiasis

Answer

A

Random misdirected lashes turn in

Causes: Entropion, Chronic lid/ conjuctival disorders,

Symptoms: Tearing / Irritation / Redness / FB sensation

Signs: Eye lashes abrading conj + cornea (NaFl staining)

MX:

Epilation
Electrolysis
Cauterization
Bndg CL
Art tears 6/pd Ung pm

Question 14

Q

Blepharochalasis

Answer

A

Repeated Idiopathic episodes of acute eyelids swelling

Rare + idiopathic

Skin stretches large amounts - has a redundent lose skin with premature wrinkling

Mx - Blepharoplasty, Only considered after disease is quit

Question 15

Q

Dermatochalasis

Common in older px /

Answer

A

Loosend or redundent skin on upper eyelid more sup-temp

Middle to older Px’s

Common - cause Aging

Eyelid looses elastisity

Symptoms:

Reduced visual acuity + Fields (in front of nodal point) SUP TEMP
Brow ache (using frontalis muscle to lift lid)
Induced trichiasis - upper lid weight
Pseudo Ptosis

Question 16

Q

Ptosis

Features + Signs

Answer

A

Features

Damage or developmental failure to the levator muscle
dystrophy of superior rectus muscle,
damage to CN 3 which can cause the upper eyelid to droop

Signs/Findings

NORM : the upper eyelid usually sits in between the limbus and the top of the pupillary margin (2mm from the limbus and 2mm from the top of the pupillary margin)

→ in ptosis, the upper eyelid droops

Question 17

Q

Congenital Ptosis

Cause and Signs

Answer

A

Secondary to development of or isolated dystrophy of the levator muscle

● Primary gaze ptosis
● Absence of tarsal folds
● Impaired movement of lids in upgaze and downgaze

CAUSES

● Marcus Gunn Jaw Winking Syndrome (5% of cases)
● Blepharophimosis (5% of cases)
● Superior rectus weakness (25% of cases)

Question 18

Q

Acquired Ptosis

Findings and causes

Answer

A

Findings

Brow/frontal headaches
Presence of tarsal fold
Acute seeing double or droopy eyelid

Causes of acquired ptosis

● Trauma → damage to CN 3 and muscle innervation

● Surgical damage

● Oculomotor/CN 3 palsy → the pupil undergoes noticeable changes like having a fixed, dilated pupil and the eye would turn downwards and outwards due to the lack of muscle innervation

● Horner’s syndrome → would result in a little ptosis

● Diabetes → ischemic changes along the CN 3 pathway

Question 19

Q

Treatment and Grading of PTOSIS

Answer

A

Surgery - oculo-plastic surgeon

Lid Crutch - spring on the edge of RX

● Gradient of Ptosis

Mild Ptosis - lid top of pupil - visual axis unobstructed

Moderate Ptosis - lid covers sup pupil - visual axis obstructed or unobstructed

Severe Ptosis - lid mid to inf pupil - visual axis significantly obstructed (could possibly cause amblyopia)

Question 20

Q

LID EXCURSION TEST (explain)

levator muscle

Answer

A

Steps ■ Immobilize the frontalis muscle by placing the thumb firmly against the patient’s brow with the eyes in downgaze

■ The patient then looks down as far as possible and the amount of excursion is measured with a ruler

■ Ask patient to slowly look up

■ Patient then is looking up as far as possible and the amount of excursion is measured with a ruler

Question 21

Q

Turning in of lashes

Answer

A

Trichiasis

Question 22

Q

small, focalized area of eyelash loss

Answer

A

Madarosis (missing)

Can be caused by chronic blepharitis (most common cause) or injury (the lid structure is changed which could leave scar tissue)

Question 23

Q

complete loss of hair/eyelashes

Answer

A

Alopecia (alles uit)

chemotherapy + other causes

Question 24

Q

whitening of the eyelashes

Answer

A

can be 1 or 2 eyelashes or a whole row of eyelashes

○ Can be caused by albinism, chronic lid problems (like blepharitis), some systemic diseases

Question 25

Q

abnormal rows of lashes coming out of Meibomian orifices

Answer

A

Districhiasis

lashes coming out of Meibomian orifices

usually misdirected eyelashes

Question 26

Q

thickening of lid margins

Answer

A

Tylosis thick

○ More common/observable on the lower lids

○ Thicker and darker lid

○ Usually permanent

○ Apposition can be normal with Tylosis or apposition can be abnormal if an ectropion forms due to the extra weight of the eyelid ○ Can be caused by chronic inflammation to the lid

Question 27

Q

Lid Nevus / Nevi

Answer

A

flat and uniform Benign

Slightly darker/more concentrated pigmentation
Usually congenital
born but noticeable until puberty

~8 to 10 mm in size

Question 28

Q

Papilloma

space between lesions / Rasberry surface

Answer

A

Benign epithelial growth → epithelial cells grow upwards from skin ○ Non-infectious → happens secondary to toxins in the environment or UV light exposure

○ Can be pigmented or non-pigmented

○ Can be singular or multiple

○ Avascular ○ Raised surface

○ Well defined/textured lesions

Question 29

Q

Type of Papiloma ?

Answer

A

Sessile

■ Broader base

■ Dome-shaped

■ Slightly bumpy

Question 30

Q

Type of papiloma?

and Mx

Answer

A

Pedunculated

■ Smaller base
■ Very narrow in shape
■ Raspberry-like bumps

MX:

Question 31

Q

Treatment Papilloma

Answer

A

Document the papilloma and monitor its growth + Size

○ Excision

○ Laser treatment

○ Chemical cauterization (uncommon)

○ Bichloroacetic acid → is an older treatment option that is not really used much anymore as it uses a strong acid to ‘burn off’ the papilloma (con: this procedure is done very close to the eye, and it would be very bad for acid to get into the eye)

Question 32

Q

Xanthelasma

Answer

A

Multiple soft yellow deposits (plaques) under the skin on the inner aspect of the lower and upper lids

deposits are slightly elevated / asymmetric

-Causes/Etiology -

elevated serum cholesterol levels

Younger patients (40-50 year old) with Xanthelasma chances of having high cholesterol > older patients
Medical evaluation is indicated -
Case HX medication is called Lipitor or last check up

Question 33

Q

Treatment and Management

Answer

A

Laser treatment

- Excision - stability in their management of cholesterol → 1 year or more

Side note: will not go away on their own and can return if cholesterol inc
Bichloroacetic acid → is an older treatment option that is not really used much anymore as it uses a strong acid to ‘burn off’ the xanthelasma (con: this procedure is done very close to the eye, and it would be very bad for acid to get into the eye)

Question 34

Q

Sudoriferous Cyst

Answer

A

○ Involves clogged or blocked sweat glands (Glands of Moll)

○ focalized (Alone) benign lid lesions along the lid margin

○ Surfaces are smooth

○ fluid-filled

■ This build-up of fluid causes the cyst to have a very taut surface

■ Clear, oily fluid

Question 35

Q

Identify

Treatment and Management

Answer

A

Sudoriferous Cyst

○ Excision with drainage

■ Should “lance” (cut the cyst) across quite drastically and then allow the contents to drain

■ If popped and not LANCED the skin would regrow and the cyst would form again

Question 36

Q

Sebaceous Cyst

Answer

A

blocked sebaceous glands (Meibomian Glands)

focalized benign lid lesions that occur along the lid margin sup + inf
The surface smooth
filled with oil/sebum
This buildup of sebum causes the cyst to have a very taut surface
Yellow, opaque and lipid in content

Question 37

Q

Identify

Treatment and Management

Answer

A

Sebaceous Cyst

- Excision with drainage

Should “lance”/cut the cyst directly across and allow for drainage

Question 38

Q

Malignant lid lesions

ABC

Answer

A

● “A, B, C” → Asymmetry, Bleeding, Color

○ Asymmetry → mirror images if line drawn through? asymmetrical in size

○ Bleeding → bleeds? Tumors typically have really rich blood supply

○ Color → is the lesion uniform in color? Does it have patches where it is lighter or darker?

○ History of growth/changes in size

○ Vascularization or ulceration ○ Skin surface changes → is the area drier than normal? Is the area peeling more than normal?

○ Loss of hair growth in the area of the lesion and surrounding the lesion

Question 39

Q

Basal Cell Carcinoma

Answer

A

Most common eyelid malignancy 90%
Predominantly derived from epithelial tissue
Non-metastatic → doesn’t move from one organ to another
Extensive local destruction

Slow growing (unusual for tumors)

Grows laterally then posteriorly
Basal cell carcinomas can recur if not properly removed

Question 40

Q

Basal Cell Carcinomas

Risk Factors?

Answer

A

Age (>60 years of age)
Vocation (outdoors during sunlight)
Exposure to UV radiation
Race (Caucasian or more fair-skinned)

Question 41

Q

Types of Basal Cell Carcinomas

Answer

A

Nodular Type - Most common, early stages of Basal Cell Carcinoma - Slightly raised - Dome/rounded shape → in the center, there is a small depression

~5 to 10 mm in size - Pearly and translucent edges → the surface around the eroded/indented center shines a bit

Fine telangiectatic blood vessels

2) Ulcerative Form

The surface loses its fine skin lines - Umbilication and subsequent erosion (surface becomes more indented)
Ulcerative center - Flaky skin around the periphery
Increase vascularization of the telangiectatic blood vessels

Question 42

Q

Identify, Treatment and Management

Answer

A

All must be referred for removal!

Excision via Mohs’ technique
Frozen section surgery → freezing the area of the basal cell carcinoma to kill the cancer cells and then excising it
Radiotherapy → high energy beams of light (photons) to damage the DNA of the cancer cells
Cryo-surgery → using liquid nitrogen to cause irreversible tissue damage

Question 43

Q

Moth’s Technique

Answer

A

Step 1 → surgically remove the visible part of the tumor
Step 2 → biopsy the specimen
Step 3 → pathologist prepares frozen sections of the biopsy on glass slides
Step 4 → cells are microscopically examined to confirm the presence of basal cell carcinoma cells
Step 5 → if residual tumor is found, a further layer of tissue is removed to be analyzed under a microscope by a pathologist
Step 6 → once all cells have been microscopically examined and there is no more tumor found (normal cells will be surrounding the cancerous cells), the wound is reconstructed by the surgeon

Question 44

Q

Acute and Chronic Staphylococcal Blepharitis

Bacteria Involved?

Answer

A

Most common lid disorder - Affects the eyelids 75% of the time and the conjunctiva 75% of the time

Gram positive
2 types: Staphylococcus Aureus and Staphylococcus Epidermis

Question 45

Q

Acute Staphylococcal Blepharitis

Hx , signs and Symptoms

Answer

A

○ Sudden onset , Acute inflammation → 1 week
○ Can be unilateral or bilateral
○ worsens in the first 24 to 48 hours and then decrease severity

● Symptoms

Red eye
Lids are sticky with a crusty material on the lids/lashes
Difficulty opening eyelids AM
Burning/“foreign body sensation”(If cornea involved)

● Signs/Objective Findings

Lid margin hyperemia
Collarettes / crusty/sticky material located at the base of the lashes, close to the lid margin
Bulbar and palpebral conjunctiva are redder and the blood vessels are more dilated (hyperemia)
Cornea - Exotoxins from bacteria can cause SPK

Question 46

Q

Identify, Treatment and Management

Px Entance test expected results

Answer

A

ACUTE STAPHYLOCOCCUS BLEPH

Management and Treatment

1)Warm compresses - Commercial / Non-comercial. ★ non-commercial warm compress 4x a day (QID) for 10 minutes → in the morning when they wake up, at lunch time, in the early evening and at bedtime

2)Lid Scrubs - Non-commercial lid scrubs , acute/short term use / J&J no-tear Baby Shampoo 9:1 GENTLY rub along the upper and lower lid ★ Official treatment protocol: non-commercial lid scrub should be done 4x a day AFTER the warm compress

■ Topical broad-spectrum antibiotics Polytrim / 1gtt TID 1week after hydiene Polysporin 1 ung qhs / 1 week

■ Artificial Tears : 1 gtt TID or QID / 1 week if SPK

■ Discontinue and discard any eye make-up products

Question 47

Q

Chronic Staphylococcal Blepharitis

Features

Answer

A

HX - Chronic disease → weeks to months & recur
- Typically Bilateral
- Usually associated with other ocular surface findings
- The bacteria can be resistant to antibiotics
- The elderly population- immune systems weaker

Symptoms

- Red eye
- Lids are sticky with a crusty material on the lids/lashes
- Difficulty opening eyelids in the morning - Burning/“foreign body sensation”
- “Lumps and bumps” → patients will describe the condition like this

Question 48

Q

Chronic Staphylococcal Blepharitis

SIGNS

Answer

A

Upper or lower lid hyperemia
complications along lid margin - Madarosis / Poliosis / Tylosis
- Irregular lid margins
- Collarettes at the base of lashes
- Rosettes along lid margin
- Internal and External Hordeolum - Acute infections of glands
- Chalazion
Corneal findings SPK - Exotoxins on the inferior or superior part of the cornea
- Consequential dry eye issues - The ocular surface of the eye is changing which results in poor tear stability (the lipid → aqueous → mucin layers of the tear film are changing)

Question 49

Q

Identify and full treatment / Management plan

CHRONIC

Answer

A

Chronic Staphylococcal Blepharitis

Warm compresses / Commercial 10min QID OU
Lid Scrubs Commercial after warm compresses QID, For 2weeks then taper to TID 2weeks - up to 8wks while improvement noted then 1wk / month to prevent return
Topical Steroid- antibiotic combination. Pred-G TID / 7-10 days
Artificial Tears unpreserved Shorthand: 1 gtt TID or QID / 6 weeks - 6 months
Oral Antibiotics Doxycycline 50 mg daily PO for ~3-6 months
BlephEx / Mechanical lid scrubber

- Hypochlorous acid BID / 10 days

Discontinue and discard any eye make-up products

Question 50

Q

Seborrheic Blepharitis

Symptoms and Signs

Answer

A

Common ‘dandruff’ on the lid margin area
Can affect the scalp, face and brow area
Caused variety of factors including hormones, infection, stress and nutrition
Underlying Staphylococcal Blepharitis infection

Symptoms

Isolated Seborrheic Blepharitis Asymptomatic but if Seborrheic Blepharitis is in combination with an Staphylococcal Blepharitis infection, the patient will probably have symptoms ○ Burning/“foreign body sensation” in eyes ○ Bilateral involvement of both eyes

Question 51

Q

Seborrheic Blepharitis

Signs

Answer

A

Very mild lid hyperemia if any

Collarettes might be found on the lashes → can either be found at the base of the lashes or suspended on the lashes

○ No lid margin ulcerations

Question 52

Q

Identify

Treatment and Management

Answer

A

Seborrheic Blepharitis

Warm compresses (3-4x a day for 10 minutes for 1 week)

Lid scrubs J&J shampoo 3-4x a day for 1 week

Hair/scalp treatment with selenium sulfide shampoo (Run-off onto lids

○ Discontinue any make-up products

○ Follow up appointment 2 to 4 weeks after first appointment

Question 53

Q

Angular Blepharitis

Features and Symptoms

Answer

A

Frequent in dry/warmer climates

Commonly found in the elderly - Staphylococcus aureus

- Alcoholics - Moraxella

Symptoms

“Red eye on one part of the eye”

Skin changes - Irritation/itchy sensation
Could be described as “all of a sudden” onset

Question 54

Q

Angular Blepharitis

Signs

Answer

A

In the lateral canthus area, there could be redness/hyperemia
Dermatological findings
Excoriation → “cracked” skin
Maceration → “softened” skin

Question 55

Q

Identify

Treatment and Management (2 variations)

Answer

A

Staphylococcus aureus infection - topical antibiotics for bacteria along lid margin

Gentamicin : 1 gtt TID / 1 week

Moraxella infection, prescribe zinc sulphate solution to reduce the number of bacteria along lid margin

1 gtt QID / 1 week
- Discontinue any make-up products
- Could also recommend patient to follow lid hygiene protocol (warm compresses + lid scrubs) for 1 week

Question 56

Q

Meibomian Gland Dysfunction (Meibomianitis)

Features

Answer

A

Characterized as a hypersecretion of lipid production
Inflammation along the lid margins and ocular irritation
Excessive secretion of lipids
Affecting tear production/tear film in eye
Meibomian orifices are blocked

Lipids from the Meibomian glands in the eyelids

Lipids allow for a smooth surface in the eye and consistent refraction of light

Lipids prevent evaporation of the underlying aqueous layer

Lipids provide the forces for redistributing the tears evenly across the tear film after blinking

Question 57

Q

Meibomian Gland Dysfunction (Meibomianitis)

Symptoms and Diagnosis

Answer

A

Symptoms Variable if their tear film is unstable complain

Dryness ○ Blurriness ○ Blinking irritation ○ Tired eyes ○ Burning sensation

● Diagnosis - look at lid margins

○ Examine the Meibomian gland orifices blocked or clogged

○ Press gently on the lid margin - clear/oily fluid comes out → if not, more yellow and sebum-like?”

○ If blocked/clogged and yellow/sebum is coming out → indicates the Meibomian glands are not functioning at an optimal level

Question 58

Q

Identity

Treatment and Management

Answer

A

Meibomian Gland Dysfunction (Meibomianitis)

○ Lid hygiene/warm compresses

○ Expression of oil glands ■ Allow patient to sit with a warm compress in the office for 10 to 15 minutes ■ “Express” their Meibomian glands

● 1 drop of proparacaine 20/20 ● Place one wetted Q-tip patient’s inner lid margin and also outside role and express to top

○ Oral antibiotics - Doxycycline calm down inflammation and control the secretions of the Meibomian glands

■ Not a common method to manage this gland dysfunction, but can prescribe a low dosage over several months ● Doxycycline 50 mg daily PO for ~3-6 months

Question 59

Q

Meibomian gland dysfunction classification

2 types

Answer

A

Classifications

Meibomian gland hypersecretion

■ The Meibomian gland isproducing lipids but the ducts/orifices are blocked

■ The lipids are not getting on to the tear film

○ Meibomian gland anatomy is changing

■ This can happen with age

■ The Meibomian glands can shrink and become stunted (atrophy) ■ Can check for this using infrared imaging to anatomically see the extension of the Meibomian glands

Question 60

Q

External Hordeolum

Features and Symptoms

Answer

A

Acute Staphylococcal infection of the Gland of Zeiss - - Characterized by a focal swelling on the lid margin
- Tends to worsen on the 2nd or 3rd day
- Bump pointing outwards - Red - Tender to the touch (pain) - Warm in temperature to the touch
- May develop a “pus point”

Symptoms

Sudden and recent onset
- Progressively getting worse
- Reg bump along the upper or lower lid margin
- Bump enlarging over a couple of days
- Tender to the touch (“pain”)

Question 61

Q

External Hordeolum

Signs

Answer

A

Signs/Objective Findings

- Focal area along lid margin elevated
- Red
- Dome-shaped
- Tender to the touch
- Warm to the touch
- Pus point pointing outwards towards the observer
- Swelling/edema

Question 62

Q

Identify

Treatment and Management

Answer

A

May resolve on its own (usually within a week)

Warm compresses - QID for 10 mins for 1 week - If improve, can lessen warm compresses to BID for 10 mins until week is finished - Warm compresses can accelerate the process of healing
Lid Scrubs - underlying Blepharitis - initiate the lid hygiene protocol (warm compresses + lid scrubs 4x a day for 10 mins for 1 week) - Broad spectrum topical antibiotics
Debatable treatment method - Can prescribe: Polytrim 1 drop TID (3x/day) for 1 week
Discontinue and discard any makeup products

Question 63

Q

Internal Hordeolum

Features and Symptoms

Answer

A

Acute onset and infection

○ Staphylococcal infection to Meibomian glands

○ Infection will involve **more surface area of the tarsal area **

○ Infection leads to acute inflammation ■ Redness ■ Tenderness/pain in the area ■ Swelling/edema ■ Warmth

● Symptoms

○ came on very suddenly (recent onset)

○ The bump is progressively getting worse

○ Focal area of elevation along the upper or lower lid margin

○ The bump has been enlarging over a couple of days

○ Very tender to the touch (pain)

Question 64

Q

Internal Hordeolum

Signs and considerations

Answer

A

○ Focal area along lid margin that is elevated

○ Redness in the area

○ peak of elevation does not point outwards / no pus point

○ Tender to the touch ○ Warm to the touch

An internal Hordeolum can lead to Preseptal cellulitis

■ The internal hordeolum usually stays in one spot, but it can spread on to the lid adnexa area → will not be a focalized region anymore → this can lead to the preseptal cellulitis → if this occurs, we should act more aggressively in treatment

○ Orbital cellulitis ■ Rarer condition than preseptal cellulitis ■ This condition is considered an ocular emergency → an Ophthalmologist or ER doctor should be contacted ■ Orbital cellulitis usually occurs due to ocular injury/trauma

Answer 65

A

INTERNAL HORDEOLUM

■ Warm compresses ● 10 minutes QID 1 week

● The heat from the warm compresses will “get the infection going” as the heat will increase the infection so it will heal faster

■ Lid hygiene ● If underlying blepharitis is suspected, suggest the lid hygiene regimen

● Remember lid hygiene = warm compresses + lid scrubs

■ Discontinue and discard any eye makeup products

Answer 66

A

Preseptal cellulitis

● Broad spectrum topical antibiotics ● Polytrim 1 gtt TID / 1 week

● Polysporin: 1 ung qhs / 1 week

● Combine the Polytrim and Polysporin antibiotics for one week!

● Make sure the patient is informed on their responsibility to complete their prescribed antibiotic → if the patient stops mid-week, they could be causing bacterial resistance ● Polytrim is implemented AFTER lid hygiene

Answer 67

A

○ Orbital cellulitis

■ If a patient presents to your office with orbital cellulitis, write a prescription for a strong topical antibiotic (ex: Vigamox drops) that they can pick up from a pharmacy on their way to the hospital

See attached table

Answer 68

A

Chronic lipo-granulomatosis inflammation of Meibomian glands → caused by retention of granular and granulomatous tissue

NO ACUTE SIGNS OF INFLAMMATION

result from non-resolved internal hordeolums

Waste product secretions Meibomian glands don’t dissipate

Symptoms

- Raised, red bump
- Focal area of elevation along the upper or lower lid adnexa - Bump enlarges over a long period of time (gradual!)
- Hard round nodule
- Not tender to the touch! No pain!
- Slow onset, sterile swelling

Answer 69

A

Signs/Objective Findings

Elevated focal lesion
Dome-shaped
Not tender/painful to touch!
Not warm to touch!

Answer 70

A

Chalazion

Warm compresses AGGRESSIVELY! - The chalazion might resolve Only if small
Commercial warm compress and urge the patient to do the warm compresses 6 times a day for 10-15 minutes for 2 to 3 weeks
Excision and Biopsy - aggressive warm compress treatment and the chalazion is still unresolved or large to start with recommend excision
excision should biopsy the specimen afterwards to confirm or reject the presence of sebaceous cell carcinoma

Steroid Injections

Answer 71

A

Very common type of mite (8-legged)

○ Human manifestation is called demodicosis

○ bilateral

○ Risk factors ■ Elderly population ■ Warmer climates

Symptoms

○ Sore lids/redness in the morning

○ Itching AM (Defining symptom)

○ Burning sensation ○ Crusting on lid margins and lashes ○ Bilateral ○ Chronic

Answer 72

A

○ Bilateral lid involvement

○ Inflamed lid margin

○ Collarettes are “wrapped like a sleeve” on cilia → start from the base and move up cylindrically along the cilia

■ Remember, the collarettes in Acute and Chronic Staphylococcal Blepharitis are mainly found on the base of the lashes and the collarettes in Seborrheic Blepharitis are usually suspended on the lashes

Microscope in Lab

Pull 4 lashes from each lid using a tweezer ■ If there is >6 demodex, considered excessive

Answer 73

A

DEMODEX

○ Topical Steroids - the itching and inflammation

○ Lid Hygiene ■ Warm compress 4x a day (QID) for 10 minutes followed by lid scrubs

○ Newer Treatment = Tea Tree Oil 50% consentration

■ Should recommend the commercial brands of Tea Tree Oil (Oust Demodex Cleanser, Cliradex wipes, etc.)

■ Official treatment protocol: Cliradex BID / 10 days ● After 10 days, use 1x a day for another 10 days

Answer 74

A

Pediculosis: a parasitic infection - Lice (plural); louse (singular)

2 types: Phthiris pubis: crab louse on lids due to spacing and density
Transmitted sexually/promiscuity

Symptoms

- Sore lids/redness
- Itching (all day long/constant!)
- Burning sensation (tear film is affected)
- Crusting on lid margin/lashes - Bilateral lid involvement

Answer 75

A

Phthiriasis Palpebrarum

Ointment - Antibiotic + steroid ointment : Pred-G TID ung / 1 week
Antibiotic to fight the blepharitis infection and steroids to control itching/soreness
Remove nits manually - sterilized forceps and pull off every nit from the lashes and destroy
return to clinic in 2-3 days
Patient might have lice still alive that could still be reproducing - Continue having the patient come in every 2-3 days until the lashes look completely clean - Lid Hygiene - Can also recommend warm compresses + lid scrubs

Answer 76

A

Bilateral lid involvement
- Inflamed lid margin (hyperemia)
- Secondary signs of blepharitis (collarettes at the base of lashes)
- Red/black deposits on the eyelashes - Fecal material of the louse → usually causing the itching/allergic reaction - Nits (eggs) wrapped around the cilia
- Eggs are laid by the female louse on the lashes - The female lays 2-3 eggs in 24 hours - Adult louse is mature for 15-25 days - The eggs look like translucent balloons on the cilia

Answer 77

A

Hygiene - Wash affected clothes and sheets on high heat for 20-30 minutes or place in a sealed bag to suffocate/kill lice

Family Considerations - Partner: need to let significant others know they might have same condition - Family: other family members might have same condition especially if due to cramped living quarters

General Physician - Need to involve general physician as there may be lice on other parts of the body

Answer 78

A

○ Often seen in children

○ Found in the HIV/AIDS population Used to be larger (due to immuno-compromised systems)

○ DNA pox virus: epidermal (skin) infection

○ Insidious onset (the disease “creeps up” and forms)

○ Characterized by painless wart-like lesions

Answer 79

A

Multiple lesions transmitted by contact → auto-inoculation

→ found on the lid adnexa area

○ Usually 2-10 mm round, central depression

■ If HIV is involved, the lesions are a lot larger (>1 cm)

○ Center of the lesion has cheesy-colored contents

○ Hair follicles and skin surrounding the lesion look normal!

○ May cause secondary follicular conjunctivitis

Answer 80

A

MOLLUSCUM CONTAGIOSUM

○ Sometimes the lesions go away on their own

■ Tell the patient not to touch their face/orbital area

○ Excision wait ~1 year to make sure the virus isn’t active anymore (no new lesions appearing)

○ Cauterization

Answer 81

A

Viral involvement (Human Papilloma Virus - HPV)

Can affect the lower or upper lid adnexa
Signs - Characterized by “frondular” growth
Little lesions together (look like cauliflower or broccoli florets) - Branched together, no space between them and pointing outwards

Answer 82

A

VERUCCA

May regress with time

Cauterization when no longer active
After many months, if no growth is occurring, can cauterize or laser

Answer 83

A

○ Allergic reactions

○ Exogenous source (plant or cosmetic product)

○ Can affect other parts of the face

○ Unilateral or bilateral ocular presentation

Symptoms

○ Itching ○ Redness to lid adnexa ○ Increased lacrimation (if close to lid margin) ○ Adnexa swelling

Answer 84

A

○ Redness to skin surface

○ Edema (swelling of lid adnexa)

○ Maybe bilateral or unilateral

○ Excessive tearing

○ Flaking of the skin surface

Answer 85

A

Contact Dermatitis

○ Cold compresses 4 to 6 times a day for 1 week

○ Antihistamine

○ Topical steroids ■ Cream or ointment applied to area for 1-2 weeks

■ Steroids not used langer than 2 wks ● If steroids get in the eye, IOP can increase ● If steroids are used for a long time, the skin in that area can thin out

○ Remove exogenous agents ■ If a specific cream or beauty product was the culprit, get rid of it!

Answer 86

A

Focal hyperplasia (enlargement of an organ or tissue due to increased reproduction of cells)

○ Little pockets of lymphocytes found in the conjunctival stroma (newly formed lymphoid tissue)

● Size 0.5mm to 2mm

● Location - palpebral conjunctiva (can check lower palpebral and evert the lid to check upper palpebral)

Pathophysiology - Localized cell-mediated immune response (could happen when you have a toxic reaction to an eye drop)

Answer 87

A

Appearance

○ Elevated ○ Clear/milky/translucent centers ○ Blood vessels located at the BASE of the follicle

○ If the eye is red and the patient is presenting with follicles, the problem is the follicles and need to determine the cause!

Causes ○ Toxins: irritants to patient’s eye cause patient to develop hypersensitivities ○ Examples: Molluscum contagiosum, chemicals, viruses

Answer 88

A

○ A condition that children and young adolescents might have (NOT a disease and NOT caused by a virus or toxin)

○ Eye is very “quiet” → not red or hyperemic

○ Due to hyperactive lymphatic system

○ Disappears with age

Answer 89

A

Histopathology - Non-specific response to irritants (allergy or bacteria related) to conjunctiva

Fibrovascular in origin

Small to very large
Location - Elevations usually found on the upper and lower palpebral conjunctiva (upper more common)

Answer 90

A

Appearance

- Elevated
- Deeper red (very vascular looking) → “meaty red”
- Blood vessels at the core of the papilla
- Increased neutrophils to area to fight bacterial infection or increased eosinophils to fight allergic reaction

Causes - Bacterial infections - Contact lens overwearing - Allergies

Other Facts - Giant papillae occur in vernal conjunctivitis (seasonal allergies) - Giant papillae also occur due to contact lens wear

Answer 91

A

● Appearance Elevated, smooth/taut surface

Clear-like fluid (vacuoles) → blister appearance

● Location - found in the interpalpebral zone / Found on the bulbar and palpebral conjunctiva

● Causes

Cellular degeneration (epithelial cells not sloughing off correctly)

● Treatment - Removal by lancing (lance → drain → flatten) if of cosmetic concern

Answer 92

A

Drainage Pathway: puncta (small opening) → lacrimal canaliculi → lacrimal sac (tears drain into here) → nasolacrimal duct → finally drains into the inferior meatus

Puncta - upper and lower

Canaliculus - upper and lower canaliculus → join form the common canaliculus

Lacrimal pump - _Valve at the entry point of the common canaliculus /_prevents backflow
Lacrimal sac - Attached to the periosteum - Fibers from the orbicularis oculi muscle help with blinking and spread the tears along the eye - The negative pressure in the lacrimal sac helps to push tears along passageway

Answer 93

A

Test patency or blockage between the puncta and the inferior meatus

● Jones Test 1 Procedure

○ Place NAFl in the eye ○ several minutes, blow their nose into tissue paper OR use a Q-tip and swab nose

○ Examine the tissue paper or Q-tip for fluorescein residue → if the yellow stain is present, then there is good drainage/patency ●

Jones Test 2 - force NaFl solution into caniculus

Answer 94

A

Regurgitation Test Procedure

Put NAFl in eye
slit lamp /cobalt blue filter
Pull the lower lid slightly away and locate the lower puncta
Press on the nasolacrimal sac - Tears should go back out the way they came from (emerge from the puncta) - If the yellowish tears reemerge, the system is patent

Answer 95

A

★ Stenosis/blocked puncta / AGE / Inflamation of the area

MX & TX - Probing or Sx if not sucessful

★ Entropion of the lid → inversion of the puncta

★ Ectropion of the lid → eversion of the puncta

Answer 96

A

Infants

● Stenosis of puncta and canaliculi opening in the nasolacrimal d

● 1 month old, nasolacrimal duct should open NORM

● Uni / Bilateral ● asymmetric

MX & TX ○ Reassure lacrimal system should open up in time by their own (canalize)

○ Accelerate ■ Gently massage nasolacrimal sac ■ Use warm compresses (4-5x a day for a few minutes)

○ Surgery ■ If not open ~1 year after birth, might refer for surgery ■ Dacryocystorhinostomy (DCR) ■ Infection because of stenosis

■ In this case, the lacrimal sac area would be red, tender/painful to the touch, elevated and warm ■ refer pediatrician oral antibiotics

Answer 97

A

Acute infection and inflammation of the lacrimal sac due to closing of the puncta

50-60 yrs old - women dt anatomical difference Smaller opening

Symptoms

- Sudden and recent onset
- Progressively getting worse
- Red
- Tender/painful
- Elevated
- Excessive tearing

Answer 98

A

Signs

- Red focal elevated lesion
- Tearing
- Inner canthal area to lacrimal sac involved
- Firm nodule
- If infection spreads further, complications like preseptal cellulitis

Answer 99

A

Dacryocystitis

Warm compresses
Topical antibiotics - Broad spec. Polytrim / Gentamycin

Tobramycin QID 1 week

Oral antibiotics 1 week

Answer 100

A

Dry eye is a multifactorial disease of the ocular surface

Loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles

Answer 101

A

Dry Eye in clinic

○ Determine the risk factors for the patient AGE / SEX
○ Determine the symptoms the patient is experiencing
○ Determine the ocular surface damage - Na Fl Staining / Inflamation all lacrimal structures
○ Determine tear film stability Tear Qaulity
○ Determine tear production TBUT

Answer 102

A

Lacrimal gland → type of exocrine gland; consists of lobular ducts and acini aqueous layer / innervated by the ophthalmic branch of the trigeminal nerve (CN 5) and has some sympathetic innervation
Accessory glands of Krautz and Wolfring → contribute to aqueous secretions; found in the subconjunctival tissue
Meibomian glands → found in the tarsal plate; produce lipid/oil

Conjunctival Goblet cells → found in epithelium of conjunctiva; aqueous/mucin production

Answer 103

A

○ Meibomian Glands and the Glands of Zeiss
○ Stabilizes the tear film
○ Reduces evaporation of aqueous content
○ Composed of cholesterol, fatty acids and phospholipids
○ Lowers surface tension
○ Allows for smooth refraction of light
○ Provides forces for redistribution of tear film after the blink

● Deficiencies Causes

○ Lid problems (entropion, ectropion, blepharitis)
○ Contact lenses
○ Meibomian Gland dysfunctions
○ Bell’s Palsy Lag opthalmos

Answer 104

A

Lacrimal Gland and Accessory Glands of Krause & Wolfring

○ Basic aqueous tear secretions

○ Composed of salts, proteins, glucose, lactate, water soluble molecules, lactoferrin and lysozymes

● Deficiencies due to…

○ Decrease in lacrimal gland tear production
○ Atrophy AGE
○ Decreased sympathetic innervation or problem with CN 3

Answer 105

A

Mainly by Goblet cells in the conjunctiva + crypts of Henle and glands of Manz
On corneal epithelium microvilli → converts corneal epithelium from hydrophobic to a hydrophilic

● Deficiencies dt

○ Lack of Vitamin A
○ Trachoma → thicker upper lid surface and disrupts Goblet cell mucin production
○ Lasik surgery → during surgery, a suction ring is placed around the cornea and can disrupt Goblet cell mucin production

Answer 106

A

Mucin Layer and Glycocalyx

○ Mucins 1, 4 and 16 (MUC) are associated with corneal and conjunctival epithelial layers and helps to develop the glycocalyx

○ The glycocalyx is produced by the corneal epithelium, which attracts mucin and allows for good adherence between mucin layer and corneal epithelial microvilli

Answer 107

A

Traditional**

■ 3 distinct layers (lipid → aqueous → mucin)

Contemporary

■ Still 3 layers but instead of all the layers being separate from each other, there is different concentrations of mucin spread out through the aqueous layer

■ Higher concentrated towards the corneal epithelium and less mucin concentrated towards the top of the aqueous layer

Answer 108

A

Elevated tear osmolarity is characteristic of dry eye

A decrease in goblet cell density would have a decrease in mucin
Lactoferrin and Lysozymes in the aqueous layer - immunological components
If aqueous production decreases, the concentration of lactoferrin and lysozymes would also decrease which would affect tear osmolarity
Surface changes to the epitheliums in the eye (cornea, lens, conjunctiva) can cause inflammatory mediators to be released in too high of concentrations in the tear film which will also increase tear osmolarity

Answer 109

A

Patient History & Risk Factors for Dry Eye

● Age / Meibomian glands atrophy - decrease in oil production and decrease in androgen hormone production → regulate leads to a decrease in tear production ○ Androgen hormones regulate Meibomian and Lacrimal gland production

● Gender

○ Androgens immuno-suppressive (inflamation mediators)

○ Females levels change menopause, pregnancy, breast feeding, and oral contraceptives

○ Less ANDROGEN than ESTROGEN

instead of inflammatory mediators being kept at a lower level on the ocular surface, there will actually be more inflammatory mediators on the ocular surface

Answer 110

A

● Environmental factors

○ Air quality ○ Pollution ○ Smoking ○ Air dryness ○ Altitude ○ Lack of humidity

● Vocation/Lifestyle

○ Prolonged computer usage ○ Frequent air travel ○ Working in arid conditions ○ Prolonged reading

Answer 111

A

Systemic Medical History

○ Rheumatoid Arthritis ■ An increase in inflammatory mediators ○ Sjörgen’s Syndrome ■ Autoimmune disease that is one of the main causes of dry eye

■ The autoimmune disease disrupts lacrimal glands

■ 9:1 ratio females to males ■ Sjörgen’s Syndrome Triad: dry eye + dry mouth + arthritis

○ Grave’s Disease ○ Acne Rosacea ○ Diabetic patients

● Systemic Medications

○ Antihistamines/decongestants (Benadryl) ○ Hypertension medications (diuretics, beta blockers) ○ Antidepressants (Prozac, phenothiazines) ○ Oral contraceptives (birth control pills) ○ Alcohol derived medications (NyQuil) ○ Parkinson Disease medications

Answer 112

A

Ocular Medications

Preservatives cytotoxic (Benzylcodium Chloride BAK)
BAK only short term - cytotoxic (increase inflammatory mediators, decrease Goblet cell mucin production) and can change tear osmolarity

● Contact Lens Wearer

Pre-lens tear film is thinner / DECr tear exchange and INCr evaporation

● Refractive Surgery (Lasik)

3 to 6 months post-op
Damaged Goblet cells Dt ring suction around the limbus
Goblet cell mucin production DECr
Px uses Gtt and the goblet cell regenerate
Lasik surgery neurotrophic theory → nerve endings damaged and no sensory information to lacrimal gland DECr production Aqueos

Answer 113

A

1) Aqueous Deficiency

not producing enough tears
T cell mediated inflammatory reaction to the lacrimal gland causes a decrease in tear production
ocular surface irritated and inflammation is increased
Constant cycle of low-grade inflammatory states

2) Evaporation

Due to Meibomian gland dysfunction altered lipid metabolism OR age/atrophy of the Meibomian glands
Meibomian gland oil changes from trans unsaturated fats to saturated fats causing OBSTRUCTION
Obstruction leads to hyperosmolarity and INCr evaporation → inflammation will occur
Age/atrophy of the Meibomian glands /

Answer 114

A

A) Sjörgen Syndrome

Autoimmune disease associated with Triad of dry eye + dry mouth + arthritis

B) Non-Sjörgen Syndrome

lacrimal gland blocked or lacrimal gland atrophy

C) Intrinsic

- Meibomian glands not producing enough oil
- Lid structure has been altered
- Not blinking enough
- Drug induced

D). Extrinsic

- Contact lens wearer
- Preservatives like BAK
- Vitamin A deficiency
- Ocular surface diseases

Answer 115

A

● Burning/stinging sensation dt tear film changing

● FB sensation dt corneal epithelium damage to the

epithelium → a feeling of scratchiness/grit/irritation

● Tearing/increase in reflex tearing → compensation leads for dry eye leads to the brain realizes the eye is dry and thus sends a signal to counter / excessive tearing

● Dryness

● Fluctuating Blurry vision during 7A Tear film not evenly distributed

Answer 116

A

PX: ALLERGIES , BLEPHARITIS and MEIBOMIANITIS >> Risk Dt lipid layer being disrupted

LID appositional disorders

(ECTROPION, CHRONIC LID INFLAM, LID CLOSURE , BLINK PATERNS)

Anterior lid problems - Staphylococcus blepharitis

- Seborrheic blepharitis

Posterior lid problems. - Meibomian dysfunction
Eye drops - Preservatives are cytotoxic BAK / Thimerisol
Viral conjunctivitis - loss of Goblet cells = release of cytokines and leukotrins

which are inflammatory mediator

Answer 117

A

★ Lid Evaluation

Lagophthalmos
lid apposition abnormalities - ectropion cause punctal eversion
lid margin - Chronic Blepharitis / / Meibomeinitis Decreased lipids

★ Evaluate blink rate and tear flow

● Flow lacrimal gland medially + down to drainage /medial canthus
● Tear flow facilitated by the blinking action of the eye
DECr Blink rate. tear flow might be compromised
Blink rates NORM 15/MIN. NEAR work 5/MIN
○ Incomplete blinking / DECr quality of the blink
○ Can advise patients on the correct way of blinking

■ Side note, “20-20-20” rule and advise on correct blinking

Answer 118

A

Look for lid blinking patterns

Inferior corneal staining pattern NaFL / SPK on lower cornea dt a lack of Lubrication
Blink evaluation (LipiView II Ocular Surface) How well lipids distribute
Uses infra Red to examine structure of meibomian glands for Atrophy

● Look at the Lacrimal Drainage pathway

stenosis/blockage of puncta OR blockage of the nasolacrimal duct might

Answer 119

A

Tear MENUSCUS Height
Schirmers 1 and 2
Strip Meniscometry
Phenol Red Thread

Answer 120

A

● Tear Meniscus / Prism - Add NaFl and measure tesr lake with Cobalt blue filter

The normal amount of meniscus height is 0.2 to 0.5 mm

● Schirmers I Testing (Reflex and Normal)

Norms
■ >15 mm in 5 minutes = normal
■ 5 mm to 10 mm in 5 minutes = significant dry eye
■ <5 mm in 5 minutes = severe dry eye

● Schirmers II Testing (Basic tear only)

■ proparacaine anesthetic NB Dry eye

Norms
■ <5 mm in the eye in 5 minutes = dry eye

Answer 121

A

Phenol Red Thread Test

15 seconds ○ Norms

■ >20 mm in 15 seconds = normal

■ 10 mm to 19 mm in 15 seconds = borderline dry eye

■ <10 mm in 15 seconds = severe dry eye

Strip Meniscometry Tube (SM Tube)

○ Norms

■ >5 mm in 5 seconds = normal

■ <5 mm in 5 seconds = abnormal (dry eye)

Answer 122

A

● Invasive Tear Film Break Up Time (TFBUT) (As I DID)

■ Repeat this procedure 3 times and then average the results
○ Norms
■ 20 to 30 seconds = average
■ >10 seconds = normal
■ <10 seconds = abnormal (dry eye)

● New Tear Film Break Up Time (TFBUT)

microquantities of fluorescein dye (5 μl)
○ Newer Reference Values
■ >5 seconds = normal
■ <5 seconds = dry eye

● Non-Invasive Tear Film Break Up Time

■ Machine concentric rings how long it takes in seconds for
the concentric rings to lose their structure
○ Norms
■ >10-18 seconds = normal
■ <10 seconds = abnormal, dry eye

Answer 123

A

NaFl● Using a slit lamp + cobalt blue filter + fluorescein dye examine the corneal staining and loss of epithelial cells
● Isolated loss = superficial punctate keratitis (SPK)
● Coalesced areas = punctate erosions

Lissamine Green

○ devitalized (dead) cells
○ cyan/blue-green color on conjunctival surface /WHITE light
○ Dye washes out of the eye very quickly

Rose Bengal Pink

○ evaluate devitalized (dead) cells

○ Looks like a pink/red color on the conjunctival surface / White

○ Dye lingers for longer (10 to 15 minutes) and is also slightly cytotoxic

Answer 124

A

● Filamentary Keratitis and Rose Bengal Staining

Filamentary Keratitis dead epithelial cells become Mucin coated and form filaments.
These filaments drag up and down with lid movements and scrape against the cornea causing a FB sensation and burning pain

severe dry eye

Answer 125

A

○ The Line of Marx delineates the wet and dry parts of the epithelium Sup and Inf

Posterior to the Meibomian gland openings

Stained with Lissamine Green to see any ocular surface changes

NORM very thin / Become thicker and move anteriorly in certain diseases

CLEAN KERITANISATION with SPUD

Answer 126

A

Lid Wiper Epitheliopathy (acquired condition)

■ Dt abrasions of the lid and cornea due to a small tear film on the eye → if there is a small tear film, there is potential lid and cornea interaction and this can cause friction and alter the lid margin area

○ Stains Lissamine Green and extends more posteriorly down the palpebral conjunctiva from the Line of Marx

○ The thickness, width, convexity and surface area of the staining how much irritation is occurring

Answer 127

A

Use for Sjorgens Syndrome Px

Rapid Pathogen Screening

Elevated protein in tears, Only tests for Matrix Metalloproteinse

MMP-9

Answer 128

A

Meibography

To view the anatomy of the meibomian glands / Usually done with Infra Red

KORB-Blackie method to check for lid seal

Answer 129

A

Autosomal Dominant

DEF: exaggerated Schwalbe’s line (Termination of Descemet’s membrane)
posterior cornea at 3 & 9 o’clock , also be a ring.

Schwalbe’s line is visible only with gonio, but in 15% normals it is displaced anteriorly.
It is seen as an irregular line or ridge up to 2 mm central to limbus and posteriorly.
The corneal surface between the line and the limbus is usually clear.

Answer 130

A

Any growth beyond the normal arcade

New vessels deep or superficial can be accompanied by sub-epithelial fibrous tissue or stromal scarring.
Scarring/fibrous tissue - clarity of the stroma is reduced
*Micropannus** - 1 to 2 mm beyond the normal arcade
*Causes**: inclusion conjunctivitis, staphylococcal blepharitis, contact lens wear, vernal conjunctivitis

Gross pannus - Extension greater than 2 mm

Causes: trachoma, phlyctenulosis, acne rosacea, atopic keratoconjunctivitis, contact lens wear, staphylococcal blepharitis

Conclusion: - if it is new or large, try to find etiology

Answer 131

A

Localized thinning of stroma next to raised area, secondary to poor wetting and resultant stromal dehydration.

-Adjacent to raised mass : pinguecula or thick contact lens edge.
- Stroma not hydrated - scarring and vascularization.
-Dellen have intact epithelium
-pinguecula and pterygiums don’t cause Dellen. So, a specific human antigen factor involved.
-Llittle or no risk of perforation.

Conclusion: treated to prevent scarring and vascularization. Remove cause / treat with lubricants, bandage CL etc.

Answer 132

A

Herpes Simplex

Rose Bengal stains dead devitalized cells very well

Answer 133

A

NEGATIVE staining

Consider: Possible recurrent corneal abrasion / Erosions

Answer 134

A

SPK

Superficial punctate Keratistis (DRY EYE)

FB scar, 2nd NaFl diffused into epithelium at site of injury after some time

Answer 135

A

Stay Transparent
Refractive – 75% of refractive power
Protective – protects internal eye from the outside environt

NORMS:
• Dimensions – 11.6 mm horizontally and 10.6 mm vertically

cornea at birth – +- 10mm H x10 mm V
• Central thickness is 0.53 mm and 0.70 peripherally.

Corneal Layers:

Epithelium
Basement Membrane
Bowman’s Membrane
Stroma
Dua’s Layer
Descemet’s Membrane
Endothelium

Answer 136

A

5-7 Layers 50 microns in depth

Basal columnar cells, which are attached by hemidesmosomes to basement membrane

Wing cells are in two or three rows

Surface cells are long and thin with flat nuclei arranged in 2 layers and joined by bridges.

The surface area of the outermost cells is increased by micro-plicae and microvilli to facilitate the absorption of mucin. This is important in corneal wetting.

7-14 days from division to desquamation

Answer 137

A

Basement Membrane

• Secreted by basal cells
• 6-8 weeks to regenerate
• Anchors to Bowman’s/stroma
• Disruption may lead to recurrent corneal erosions

Bowman’s
• Strong barrier to injury, pressure, and infection 11-17 micron in depth
• Homogeneous condensation of the anterior stroma lamellae - continuous with the corneal stroma
• It is an acellular structure and does not regenerate when damaged
• it stops approximately 1 mm short of the corneoscleral junction
• It scars when it is disturbed

Answer 138

A

90% of the thickness of the cornea

• ]Collagen producing fibroblasts (keratocytes), collagen fibrils, and ground substance.
• The fibrils are of uniform size and extend across the entire length of the cornea as bundles (lamellae). his regular lattice structure is why we have the extreme transparency of the cornea.
• The ground substance,- composed of proteoglycans. The proteoglycans help keep the fibrils in shape.

DUA

well-defined, acellular, strong layer in the pre-Descemet’s cornea.
may have impact on posterior corneal surgery and the understanding of corneal biomechanics and posterior corneal pathology such as: acute hydrops, pre-
Descemet’s dystrophies.

Answer 139

A

Descemet’s Membrane
• Basement membrane of endothelium - Terminates in Schwalbe’s line, anterior limit of angle
• Elastic but can easily be broken away from stroma
• Composed of a fine lattice work of collagen fibrils consisting of an anterior banded zone,
• Normal thickness of Descemet’s is 3-4 microns at birth but increases to 10-12 microns
Endothelium

• Single layer of flat, amiototic cells arranged in a hexagonal
• Barrier function
• Pump function key in maintaining corneal transparency
• Babies range from 3,500 to 4,000 cells per mm2.
In normal adult corneas, cell density is approximately 3,000 to 3,500 cells per mm2.
If cell density falls below 500 to 700 cells per mm2, it is increasingly difficult to maintain optical

Answer 140

A

Innervation
• Sensory innervation - ophthalmic division of the trigeminal nerve(V) via the long ciliary nerves that branch in the outer choroid, near the ora serrata
• middle third of the cornea / lose their myelin sheath after traversing 0.5-2.0 mm into the cornea

Bowman’s take an approximate 90 degree turn and terminate in the epithelium.

*nine months** for regeneration of damaged nerves
*Cornea Blood Supply**
conjunctival episcleral and scleral vessels that are around the corneo-scleral limbus
• The oxygen and nutritional requirements - atmosphere/ tear film anteriorly and the aqueous posteriorly.
• Eyes are shut, oxygen is derived from conjunctival capillaries.

Answer 141

A

Contain blood vessels and lymphatics
Source of neovascularization
Dentate conjunctival projection into cornea
Important in epithelial regeneration

• The palisades & corneal stem cell population same area.

Answer 142

A

It is not a disease
• The normal cornea is 78% water.
• 5% above the normal level, begins to scatter light
• response to/clinical sign of insult
• Clarity - pump function of the corneal endothelium
balances the fluid accumulating effect of intraocular hydrostatic pressure and corneal swelling pressure.
• Disturbances of the balance occur with problems in the epithelium and endothelium.
• When corneas imbibe water and swell, the distance between the fibrils increases but the fibril radii are not changed
• Normal epithelium and endothelium have tight junctions that restrict the flow of electrolytes and fluid through.

Answer 143

A

Epithelial edema - hydropic basal epithelial cell degenerativechanges and the development of extra-epithelial cellular fluid-filled spaces cysts/bullae.

Epithelium edema, the surface turns gray and loses its luster. The patient will suffer from decrease vision and glare.

Epithelial edema can present as epithelial microcysts, microcystic edema or epithelial bullae.

Epithelial microcysts are small, round, refractile lesions that originate in the basal layers migrate toward the surface, and stain.

Bullae - excess fluid accumulates / epithelial layers to separate from the basement membrane. They appear as flat, pebble- like lesions

Bullae break it exposes the nerve endings and your patient can be in significant pain.

Answer 144

A

Age of onset
Duration of symptoms
Unilateral or bilateral
Family Hx of corneal disease
Ocular medications
Previous ocular disease or surgery
Diurnal variation
Environmental effects on symptoms

Answer 145

A

Contact lenses
Epithelial defects (i.e. abrasion, ulcer)
Swimming
Medicamentosa (Inflamation of nasal mucosa / nasal spry overuse)
Angle closure glaucoma or high pressure open angle glaucoma

Answer 146

A

SIGNS

An irregular, distorted corneal reflex
central circular clouding CCC (sclerotic scatter)
Epithelial Defect - halo of edema
Swimming and Medicines - roughened epithelium and loss of transparency

• Clinical Symptoms

Usually significant, Discomfort / FB sensation
Decreased visual acuity
Halos around lights, foggy vision
Spectacle blur after wearing RGP

Answer 147

A

o Removing the cause (i.e. refit contacts)
o Non-preserved carboxymethylcellulose
o Hypertonic NaCl Muro 5 & 2 %
o Increase evaporation (fan, hair dryer)
o If secondary to stromal edema, remove the cause of the stromal edema
o Lower IOP
o Topical glycerin is used in acute angle glaucoma to clear the cornea so you can look at the angle
o Bandage Contact Lens therapeutic for bullous changes

For treating recurrent corneal erosions:

o Eyes with poor vision – you can use anterior stromal cautery scars to form firm adhesions between epithelium and underlying stroma

o Amniotic membrane
o Anterior Stromal Puncture
o Excimer laser
o Collagen Cross linking – riboflavin and UVA

Answer 148

A

Endothelium pump or barrier function decreased
Advanced stromal edema leads to epithelial edema (Buckling of Epithelium
mildly disordered fibrillar distributions and regions called “lakes”
Lakes - fluctuations in the refractive index, which increase light scattering
Corneal hypoxia leads INCr of lactate in the stroma. This increases the osmotic pressure Causes edema ensues. Acidosis impairs endothelial cell function, exacerbates stromal edema.
clinically appears as a painless, cloudy, thickening of the corneal stroma.
There is usually only mild reduction is va and mild glare

Answer 149

A

Hypoxia - Soft contact lenses
Fuch’s endothelial dystrophy
Focal keratitis
Surgical trauma or trauma
Endothelial dysfunction
Infections (corneal ulcers or endophthalmitis)
Uveitis , with keratic precipitates
Rupture of Descemet’s membrane (birth trauma or keratoconus)
Acute angle closure glaucoma
Long-standing increased IOP from open angle glaucoma
Toxic substances in the anterior chamber

Answer 150

A

Signs

Increase in width of the slit beam, folds in the Descemet’s
Pachymetry increases as edema does
>5% you begin to see vertical striae in posterior stroma
10-12% of cases, folds in Descemet’s membrane
The stroma can be clear and still be edematous.

• Clinical Symptoms
o Minimal, until very advanced

o May complain of glare

Answer 151

A

If possible, treat underlying causes (CL, treat iritis)
Lower IOP (above 21mmHg)
Steroids if edema caused from inflammation (temporarily increase
endothelial cell tight junctions)
Topical glycerin in acute angle glaucoma to clear the cornea
IOP exceeds stromal swelling pressure epithelium edema occurs
o However if endothelium function is compromised epithelium edema can happen with

Answer 152

A

DSAEK
Descemet and endothelial layers and a very small amount of stroma are stripped

from the donor and placed on the inner surface of the cornea of the recipient o Adheres to new cornea / air bubbles
o Patient lies on his back for 24 hours to allow the air bubbles to tamponade the graft to the posterior stroma

DMEK

Descemet and endothelial layer are stripped same a DSAEK only tissue is thinner, better results but more difficult to do.

Answer 153

A

IOP

In normal eyes, IOP has little effect on stromal thickness

However, when IOP exceeds stromal swelling pressure epithelium edema occurs

However, if endothelium function is compromised epithelium edema can happen with

pressures as low at 30

Answer 154

A

Decreased vision and glare if on the visual axis
• Bowman’s layer and the stroma scar

Grading Scars
o Nebular - faint
o Macular - translucent
o Leukoma - opaque
Scars are the result of an insult to the stromal matrix, activating keratocytes cells to gather at the site of insult and synthesize new collagen.
o This new collagen is a different type from the old collagen and is not as transparent.

Answer 155

A

o After wounding, transparent keratocytes differentiate into migratory fibroblasts
o Fibroblasts migrate into the wound margin
o At the wound margin, fibroblasts differentiate into non-motile, contractile myofibroblasts

o After wound closure, myofibroblasts disappear
o The persistence of myofibroblasts in a wound correlates with fibrotic healing
o There is also disorganized fibrillar and lamellar structures; vacuoles within and around keratocytes; convolutions and discontinuities in the basement membrane

Answer 156

A

Corneal Neovascularization

Beyond 1-2 mm of limbus is neovascularization.
• Neovascularization Causes

tight soft contact lenses
trachoma
superior limbal keratitis
Anoxia appears to trigger some neovascularization.

• Neovascularization- decreased VA if cross visual axis.
• Neovascularization in the stroma is more characteristic of interstitial keratitis, 90% secondary
to congenital syphilis but can be secondary to other systemic diseases (i.e. TB, mumps)
• Vessels not perfused with blood are called ghost vessels
• Infectious neo is usually deep in the stroma

Answer 157

A

• Infections
Bacterial / Viral. / Fungal
• Foreign bodies
• Contact lens wear and over wear
• Burns
o Heat o Radiation o Chemical

Majority involve epithelium. Bowman’s layer is very tough. Epithelial injury to the eye is very painful.
• An abrasion of the cornea involves removing corneal epithelial cells. Certainly, deeper abrasions will also involve deeper corneal structures.

Answer 158

A

• Pain or Discomfort
first division of the trigeminal nerve, it has a subepithelial plexus and a stromal plexus. In eyes with corneal abrasion or bullous keratopathy, the direct stimulation of bare nerve endings causes severe pain. Patients with only mild punctate erosions may complain only of slight irritation which is made worse by blinking. Pain from inflammation or spasm of the ciliary body

• Halos
• Impairment of Visual Acuity
May be secondary to the loss of transparency from the wound itself or from the tears leaking into the wound

• Photophobia
Caused by abnormal, strong light induced miosis to an inflamed iris and ciliary spasm

• Lacrimation (excessive tearing)
Secondary to reflex stimulation of corneal nerves. Its degree frequently parallels the severity of the photophobia.

Answer 159

A

Sliding of adjacent epithelial cells to cover denuded area starts within an hour

An enzyme is released from the damaged cells to loosen the tight attachments so they can slide

Fibronectin is also secreted by the cells and this acts like glue to hold cells together.

Mitosis begins within 24 hours from the distant cells. Within 3 days from the damaged area

The healing goes quicker if the temperature is increased

Only the basal cells, amplifying cells, and stem cell undergo mitosis

Corneal transient amplifying cells (TACs) are migratory cells which move from the limbus towards the cuboidal basal layer of the central cornea and become corneal basal

Jagged shaped edges are harder to heal.

If the basement membrane is involved, the process is markedly slowed

The basement membrane takes between 6-8 weeks to regenerate.

The epithelium cannot adhere to Bowman’s without the basement membrane

When the whole cornea is denuded, such as in a chemical burn, re-epithelialization occurs

from migration of conjunctival cells from the Palisades of Vogt’s

Answer 160

A

First make sure no foreign body still in eye / Evert sup lid
Before dye check for cells in the anterior chamber
QID / q4h
• gtts: Polytrim (polymyxin B and sulfate trimethoprim), Vigamox (moxifloxacin), Tobrex (tobramycin), or Ciloxan (ciprofloxacin).
OR
• ung: Polysporin(polymyxin B and Bacitracin) or tobramycin BID or QID
• If abrasion is from a finger nail or piece of paper these abrasions are more prone to recurrent corneal erosions and you should use an ung at night for at least a month
• Cycloplegia prevent a reflexive iritis
• Depending on the size and location, monitor daily or within 24 hours and then every other day until it is healed
• Pressure patch if area is greater than 10 mm2

(do not patch an abrasion soft contact lenses or
material is organic matter) DO NOT leave on for longer than 24hrs

• T patching / treatment with bandage contact lens / collagen shield. / amniotic membranes

Answer 161

A

Prevent a traumatic iritis Topical cycloplegic agent

cyclopentalate 1% bid (cyclogel), Homatropine 2% or 5% bid to tid ALT Acular / Levro nepafac TID

Mild pain: Acetaminophen 500 mg every 4 to 6 hours,

ibuprofen 400 to 600 mg every 4 to 6 hours, naproxen 250 to 500 mg twice a day
Moderate pain: Acetaminophen with codeine (30 mg codeine) every 6 hours

Answer 162

A

NEGATIVE STAINING

Antibiotic if positive staining still present

UNG for as long as negative staing persists
Systane Nighttime Lubricant Eye Ointment (3.5 g )
Refresh PM, Refresh Lacrilube
Ocusoft Retain PM Ointment
Genteal Ointment
cyclo when to d/c- if no iritis and not a red angry eye and epithelium is all healed

Answer 163

A

A penetrating wound passes into the structure
A perforating wound passing through a structure

You can diagnose if something has Perforated the cornea by using the Seidel sign test to see if any aqueous fluid is leaking out.

You perform this by wiping a wet strip of fluorescein over the wound and viewing how the dye appears. With a positive Seidel, you can see the clear aqueous running through the yellow stain

Answer 164

A

UNG - PM Preventative
Pressure patch, then UNG Pm and Gtt AM
Punctal Plugs
Debridement of Epithelium
Bandage contact lenses (Prolonged)

Newer therapies:

blood-derived eye drops
amniotic membrane graft application
judicious application of topical corticosteroids.

Surgical procedures

Epithelial debridement with diamond burr polishing (DBP),
Anterior stromal puncture (ASP)
Excimer laser phototherapeutic keratectomy

Answer 165

A

Muro 128 ointment 5.0%, h.s.

FreshKote t.i.d.

Loteprednol 0.5% q.i.d. for two weeks, then b.i.d. for six weeks. (Check the patient’s IOP around week three or four.)

Doxycycline 20mg b.i.d.

Why Doxycycline?

Patients with recalcitrant recurrent corneal erosions often show increased levels of matrix metalloproteinase (MMP) enzymes. These enzymes dissolve the basement membrane and fibrils of the hemidesmosomes, which can lead to the separation of the epithelial layer. ) together with a topical corticosteroid (such as prednisolone)
Some doctors give 50 mg of Doxy bid

Answer 166

A

Ulcer - Definition according to Dictionary of Ophthalmology
• Corneal Ulcer is a superficial loss of corneal tissue as a result of infection andinflammation which had led to necrosis.
It involves disruption of the epithelial layer with involvement of the corneal stroma T

• A necrotizing lesion with or without an abscess; inflammation-mediated breakdown affects the epithelium and stroma

Answer 167

A

Treatment

o Irrigate
o Cotton swab
o Spud or Magnetic Spud or 25-gauge needle
o Alger brush
o Remember to always flip lids to ensure a foreign body is not embedded under the upper lid.
o After foreign body is removed, treat the corneal abrasion

Answer 168

A

Arcus

white or yellowish ring with a clear zone at the limbus
Composed of cholesterol esters, cholesterol, and low-density lipoproteins in stroma
-first in the inferior cornea in the stroma near Descemet’s membrane,
Men >. Women

PX <50 A serum lipid profile should be obtained.
-The presence of unilateral arcus may suggest vascular occlusion on the side without arcus.

Ask for Meds Lipitor

Answer 169

A

Limbal Girdle of Vogt

Degeneration of sub epithelial collagen - cause may or may not be related to UV exposure

-White crystal-like appearance with or without a clear zone, almost always at 3 and 9 o’clock.

2 types:

Type 1 is separated from the limbus by a clear translucid zone. The reason for the clear zone can be explained by the fact that calcium deposition ends at the termination of Bowman’s, which is not at the same location as the sclero-limbal junction.

Vogt’s limbal girdle is a normal finding in any age:
• 55% of eyes 40 -60
• 93 % of eyes 70 -90
Conclusion: normal finding, no management needed

Answer 170

A

Hudson-Stahli line

Iron deposition at level of Bowman’s
Yellowish, brown irregular line just inferior to mid-pupil, near where the margins meet -It may be more common in dry eye patients or patients with tear flow problems.

-Frequency parallels age: 20 = 20%, 60 = 60%

Conclusion: very common, usually a normal finding. When you are first learning to use a slit lamp, this is difficult to see.

Answer 171

A

Descemet’s Striae

Small, linear striation in Descemet’s membrane, often are seen in otherwise normal corneas
They are usually vertically oriented but can be tilted slightly

Conclusion: no clinical significance; however, if large, may be associated with stromal/corneal edema

Answer 172

A

Mosaic Shagreen also called Crocodile Shagreen

Grayish white, polygonal opacities separated by clear spaces.
They look like crocodile leather.
Can be seen either anteriorly or posteriorly; probably results from relaxation of the normal tension on Bowman’s layer.
They are most commonly seen centrally.

Conclusion: Normal, no clinical significance except in some rare cases, anterior shagreen can be associated with trauma.

Answer 173

A

Hassal-Henle Bodies/Guttata

-If peripheral, they are called Hassal-Henle Bodies. If central, they are called Guttata.

Guttata are nodular thickening of Descemet’s membrane.
Composed of collagen - byproducts of the endothelial cells.
In specular reflection, they have an orange peel appearance.
With direct illumination, they appear as refractile circular excavation in the endothelium.
They can also be associated with corneal trauma and inflammation

Conclusions:
First sign of Fuch’s Endothelial Dystrophy.
Consider doing pachymetry.

Answer 174

A

Corneal Farinata

Is an age-related corneal change comprising of many tiny, dust-like gray dots and flecks in the deep stroma.
The term is derived from farinaceous or flour-like.
The deposits are more prominent centrally and best seen with retro-illumination.
The condition is usually bilateral and does not interfere with vision.
The exact cause is unknown but they are probably lipofuscin, which is a degenerative pigment found in aged cells.

Conclusion: normal finding, no management needed

Answer 175

A

*Corneal Farinata (bilateral)**
age-related many tiny, dust-like gray dots and flecks in the deep stroma.
*farinaceous or flour-like.**
The deposits are more prominent centrally and best seen with retro-illumination.

Conclusion: normal finding, no management needed

Answer 176

A

*Band Keratopathy**
Calcium salts deposit in the interpalpebral zone in basement membrane
Deposits start as gray and flat, but as they progress, they become white and elevate the overlying epithelium, later they can spread to Bowman’s layer and anterior stroma
calcium and phosphate in concentrations that approach their solubility product
Evaporation of tears tends to concentrate solutes and to increase the tonicity of tears; this is especially true in the intrapalpebral area, where the greatest exposure of the corneal surface to ambient air occurs.
Elevated serum calcium or serum phosphate can tip the balance in favor of precipitation
It begins in periphery and extends to visual axis

Band keratopathy is associated with long standing inflammation of the eye, prolonged uveitis, prolonged glaucoma, systemic hypercalcemia (hyper-parathyroid disease), juvenile rheumatoid arthritis, chronic exposure of the cornea to mercury, taking thiazides, Vitamin D toxicity, silicon oil in the eye, and in rare cases it can be inherited.

Answer 177

A

*labs:** serum calcium. / albumin. / magnesium. / and phosphate levels; blood urea nitrogen, and creatinine.
*ACE (Angiotensin-converting enzyme) levels** if you suspect SARCOIDOSIS
*uric acid** levels if gout is suspected.

Conclusion: Treat by removing the epithelium and scraping with a knife and applying a chelating agent. Repeated application of calcium binding agent, EDTA (ethylenediaminetetraacetic acid) and scraping of the corneal surface after removing the epithelium is usually effective to treat relatively mild cases. Excimer laser keratectomy may be used for cases with deep involvement

Answer 178

A

Most common corneal dystrophy
They are interchangeably called Cogan’s, Fingerprint, and Map-Dot
women > men. 40-70
autosomal dominance but then presents as Early onset 4-8 yrs
Identified mutations: TGFB1/BIGH3 gene

Answer 179

A

• Phenothiazine (antipsychotics) – mechanism of action is related to blockage of dopamine receptors in the central nervous system.
o Most common drug is Chlorpromazine (thorazine)
o Fine yellow-brown white deposits in deep corneal stroma in the intrapalpebral region

􏰀 Deposits are first seen on anterior crystalline lens

o Dose-dependent

o UV triggers

Drug Deposition in/on the Cornea

o Corneal changes reversible and nothing to worry about

o However, retinopathy can be a major problem

Answer 180

A

Epithelial Basement Membrane (BM) Dystrophy

*Dots**
Gray-white intra-epithelial opacities that very in size and shape
The intra-epithelial microcysts (pseudocysts) contain nuclear debris, cytoplasmic debris, and lipids.

They are probably inverted basal cells which continue to
proliferate
- Cysts may discharge spontaneously onto the corneal surface and disappear, producing an erosion in the process

Answer 181

A

Epithelial Basement Membrane dystrophy

*Fingerprints**
Clusters of concentric, contoured lines that occur in any area of the cornea
Fingers are actually basement membrane projecting up and trapping the anteriorly migrating cells
They are best seen by retro-illumination, in which they appear refractile
Some lines branch out and other terminate with clubs

Answer 182

A

Epithelial Basement Membrane Dystrophy

Maps

Irregular, geographic-shaped, circumscribed areas that are commonly seen, usually alone or combined with dots
Maps can be surrounded by gray-white borders or may blend gradually into the normal cornea
Map-like changes are related to multilaminar thickening of basement membrane with extension of the aberrant membrane into overlying epithelium
Extensions contain fine fibrillar granular material and are 2 to 6 mm in thickness

Answer 183

A

*Epithelial BM Dystrophy Symptoms**
Most ASYMPTOMATIC (Observed)
Major complaint → dry eye
Tear film is disturbed epithelium UNeven
Other complaints → recurrent erosions Usually on Awakening
Patients experience a foreign body sensation, pain, photophobia, or tearing
Usually happens in the morning, upon awakening.

Answer 184

A

Epithelial BM Dystrophy Findings
● Slit Lamp
○ All of the defects may appear under negative NaFl staining
■ Disruptions in the tear film secondary to the uneven epithelium; appears as a black spot in a normally smooth, green appearance of the tear film stained with NaFl

○ Maps and microcysts are seen as positive staining when they break through
○ Fingerprints can be seen as a combination of negative and positive staining

Answer 185

A

dry eye - Mention
- Lubricating drops Unpreserved
-

*Recurrent erosions**
Ointment at night or hyperosmotic agents
Drops and ointment may be necessary
Follow abrasion protocol for acute erosions
Discontinue CL wear
Other options: bandage contact lens, collagen shields, amniotic membranes
Phototherapeutic keratectomy with excimer laser to anterior 2-4 μm of Bowman’s

Answer 186

A

● Slowly progressive / Bilateral disease
→ results in decreased vision and pain in some cases
● Fuchs’ develops dt Guttata. nodular thickening of Descemet’s membrane abnormal byproducts of the endothelial cells
○ Stromal and epithelial edema can result
● Female > Males 50/60
● Inherited as an autosomal dominant trait and known Genetic link

Answer 187

A

Endothelial Cell Count
- Normal Pattern:
present at birth, usually about 5,000 cells/mm2
- There is a normal, progressive and slow loss aging
- By the 40’s - 3,000 cells/mm2
- By the 70’s or 80’s - 2,500-2,000 cells/mm2
- With Fuchs’ Corneal Dystrophy, the rate of cell loss is accelerated!!!

Fuchs’ Dystrophy Pattern:
By the 50’s or 60’s, too many cells may have deteriorated
Below 500 cells/mm2 → cornea begins to swell, and the vision becomes blurred

- Tools to measure endothelial cell count
- Specular microscopy counts below 1,000 mm2 indicate
problems with cataract surgery

Answer 188

A

● Pathway (simplified):
○ Significant Guttata → endothelial cell function (pumps) compromised → stromal edema occurs (separates lamellae and causes lakes to form) → edema alters the epithelial integrity (can be mild or cause major bullae to form) → bullous keratopathy if bullae become large enough → corneal scarring

Answer 189

A

Epithelial edema / clear cysts that are causing nodular elevation of the surface (bedewing)Sclerotic scatter
Fine, clear cysts will cause negative staining (using NaFl)
Fingerprint patterns
Subepithelial pockets of fluid can be seen with slit lamp →
begins in the basal cell layer and later spreads
Epithelial bullae develop → due to the coalescence of microcysts
Can decrease Visual Acuity
Very painful if bullae burst
Vascularization and scarring can occur in advanced cases

Answer 190

A

● In the beginning, epithelial edema worse AM - partial Hypoxia and DECr evaporation

● Fuchs’ patients have a higher incidence of glaucoma because problem with the endothelium, also tends to cause same problem with the trabecular meshwork

Answer 191

A

● higher incidence of glaucoma Link between endo problem and TM trabecular meshwork
● Patient Edu
● Prescribe topical sodium chloride 5% drops 4 times a day, ointment every night at bedtime.
● Apply warm air morning to dehydrate the cornea.
● Reduce intraocular pressure with topical medications if pressure >20–22 mmHg. /Done to reduce corneal edema
○ DO NOT use Carbonic Anhydrase

DIAMOX / TRUSOPT /AZOPTIC
● Treat ruptured corneal bullae as recurrent corneal erosion
○ Consider cycloplegic, antibiotic ointment, and patching
○ If persistent or large epithelial defect, consider bandage contact lens

Answer 192

A

- Conical ectasia (bulging) of the central cornea

Central or paracentral stromal thinning
Apical protrusion (Munson sign)
Irregular astigmatism
Non-inflammatory
80% of the cases are bilateral
No ethnic or gender bias
*- An unexpected increase in astigmatism (case history is important!)**

Answer 193

A

● Sporadic and dependent on external factors and stimuli that lead to inception and progression of keratoconus
● Eye rubbing dt Allergies
● Familial occurrence
○ Autosomal dominant with incomplete penetrance
○ Familial keratoconus → many of affected members have other connective tissue disorders such as syndactyly, Raynaud’s or brachydactyly
● Slightly higher incidence in South Asia and Middle East
● Also associated with Down’s, Marfan’s, RP, Neurofibromatosis, Ehlers Danlos Syndrome
● Associated with vernal keratoconjunctivitis, atopic dermatitis, and other atopic diseases

○ About 50% of patients reported significant eye rubbing

Answer 194

A

Early Stages
● scissor type reflex
● Distorted K-reading → central mires are oval
● Usually steeper than 48D
● Photokeratoscopy shows irregular reflected rings
● Topography → cone is usually central and slightly inferior, and asymetry

*Later Stages of Keratoconus**
Munson’s sign (visible lid protruding outwards)
Apex thins then you see stria in the posterior stroma (Vogt’s striae) which disappear with gentle pressure on the cornea
Unable to refract to 20/20 with glasses because

irregular astigmatism develops
- Reticular scarring of Bowman’s membrane
- Fleischer ring appears
- Iron deposition in the epithelium around a portion of or the entire base of the cone
- Best seen with slit lamp + cobalt blue filter + fluorescein dye
- Stromal nerves become more visible
- Fine anterior stromal scars seen near cone apex, caused by ruptures of Bowman’s layer
- As stroma thins the number of corneal lamellae decrease
- Diameter of collagen fibrils increases as does the inter-fibrillary distance
- However, hexagonal arrangement of fibrils does not change and distance does not
increase to the point that clarity is lost

Answer 195

A

1.) Nipple

● Small (<5 mm)
● Steep curvature
● The apex is often central or paracentral and is slightly displaced inferiorly

2.) Oval

● Medium (5-6 mm)
● Ellipsoid and usually inferotemporal

3.) Globus

● Largest (>6 mm)
● May involve over 70% of the cornea

Answer 196

A

● Hydrops is a break in Descemet’s membrane and underlying endothelium. This allows aqueous humor to leak into the stroma and cause stromal edema
● Occasional Break in Descemet’s Membrane
increased stromal edema (corneal hydrops)
○ Reduced VA and Pain
○ Edema increase the size of the cornea by 2-3 times
○ Aqueous leaking into cornea
○ Usually resolves in a couple of months (2-4 months)

● Treatment of Corneal Hydrops
○ Topical antibiotic (ciprofloxacin) QID
○ Hypertonic saline ointment (Muro 128) QID
○ Ocular antihypertensive (DIAMOX) lower IOP and decrease the posterior forces on the cornea
○ Occasionally, steroid gtts QID (to reduce risk of neovascularization)

Answer 197

A

Glasses
Rigid contact lenses
*- Piggyback lenses**
Intacs (surgery)
Scleral lenses
Corneal cross linking
Keratoplasty (about 10-20% of patients will need a corneal transplant)

Answer 198

A

Removing the corneal epithelium
and applying riboflavin drops to the eye
● After the cornea is saturated with the riboflavin (Vitamin B2) the eye is exposed to the ultraviolet (UVA) light. The UVA light interacts with the riboflavin stiffer bonds between collagen
● Minimal corneal thickness of 400 μm to avoid problems with endothelium
● increases corneal rigidity by inducing additional cross-links
within or between collagen fibers
● Corneal Collagen Cross-Linking appears to stop the progression of Keratoconus in rapidly
progressing patients! Importantly, it is NOT a cure!
● Corneal Collagen Cross-Linking Complications

○ Pain
○ Epithelium infections
○ Anterior stromal haze
○ Corneal melt

Answer 199

A

*Kayser-Fleischer Ring** - Very rare!
Yellowish brown but may appear gold, red, blue, green or any other mixture of these colors
1-3 mm wide circumlimbal ring at level of Descemet’s membrane
Caused byWilson ’s disease (abnormal copper deposition)

- Wilson’s Disease:
- A genetic disorder in which excess copper builds up in the body
- Copper deposited in the liver, then the kidney, and eventually the brain and cornea!
- Inherited as an autosomal recessive metabolic defect linked to chromosome 13
common presentation is progressive neurologic diseaseand ataxia from copper deposited in the CNS
- Treatment → low copper diet and chelating

CONCLUSION: if you see this very rare condition, refer the patient to internist. Pshychiatric Hospital if in Brain

Answer 200

A

Krukenberg Spindle
● Vertical, spindle-shaped pigment deposition on endothelium (usually lower half of cornea)
● Associated with pigment dispersion syndrome, pigmentary glaucoma and pseudo
exfoliation syndrome glaucoma
● Iris moves backwards and it hits the zonules → over time zonule pigment ‘rubs off’ and moves into aqueous humor and deposits in the endothelium but also deposits in the trabecular meshwork which causes a problem
● Iris transillumination → the released pigment can cause the Krukenberg Spindle

Answer 201

A

Stokers line - At head of pterygium

Fleischers Ring - Base of cone Keratoconus

Coat’s - FB removal site

Ferry line - around filtering Bleb glaucoma

Answer 202

A

Type: Phenothiazine

CHLORPRAMAZINE

Causes fine yellow / brown / white deposits on ant christaline lens

Dose dependent

Triggered by UV / reversable but check for retinopathy

Answer 203

A

oblate spheroid that is avascular and lacks both nerves and connective tissue
Suspended by zonular fibers (made by ciliary epithelium) and insert 1-2um into outer capsule
Lens grows only anterior, posterior surface no epithelium.
Metabolic needs - aqueous and the vitreous
Capsule permeable to water, ions and small molecules

Answer 204

A

Transparent
Avascular
Thus the aqueous meets its metabolic requirements
Biconvex structure
Refracts light
Provides accommodation
Lens grows continually - new fibers are laid down continually
ls a wonderful UV-filter to protect the retina

Answer 205

A

o The lens yellows / Brunessence
o Light transmission is decreased
o It becomes harder
o Loss of accommodative ability
o Protein aggregation
o Problems with reactive oxygen species

Answer 206

A

Definition: An opacity of the lens

May be a small, local opacity or a diffuse, general loss of transparency

Clinically Significant Cataract: causes a significant reduction in visual acuity or a functional impairment

Lens clouding

Lens mostly water (2/3) and protein (1/3)
The protein has a christaline structure / maintains clarity /highest protein content in the body.
Protein clumping results in opacification of lens

Answer 207

A

Cataracts can occur secondary to

Aging
Hereditary factors
Trauma
Inflammation
Nutritional disorders
Radiation
Meds
Idiopathic

Answer 208

A

Diabetes

Drugs
o Corticosteroids - posterior subcapsular cataracts
o Phenothiazines: stellate cataracts
o Psoralens, a class of drugs used along with light therapy to treat skin disorders, such as psoriasis, can cause central cortical changes
o exogenous estrogen use
Smoking: increased nuclear sclerotic
Increase vitreous syneresis nuclear sclerotic
Alcohol (high consumption)
Myopés
Uveitis, acute angle closure glaucoma
Vitrectomy
Vitreal injection

Obesety Increased body mass index

Answer 209

A

Nuclear sclerotic (NS)
most common / CaucasiansCortical 27.7%

Slightly more common as first cataract in Asian

Posterior Sub-Capsular (PSC) 19.7%

Commonly associated with systemic diseases and medicat

Answer 210

A

Clinical Findings

Spoke-like projections in the periphery towards the center

AKA spoke or cuneiform

Pathophysiology
o The cortex is less compact than the nucleus and is therefore more prone to becoming over hydrated as a result of electrolyte imbalance
o intumescence (swelling) / lamellar clefts / opacities
Early changes may include vacuoles, water clefts, and lamellar
separation
o Water clefts

Answer 211

A

Cortical Cataract

Answer 212

A

Diffuse yellow/brown color changes in lens nucleus

Pathophysiology
o Sclerosis: age-related changes in density (index of refraction)
o physiochemical changes in the alpha, beta and
gamma crystallins
• These proteins undergo oxidation, non-enzymatic glycosylation,
proteolysis, phosphorylation, and other processes which lead to
aggregation of high molecular weight proteins
o Reduced amount of glutathione
o Chemical modification of lens proteins leads to yellowing, then
browning

Answer 213

A

After a vitrectomy 60-98% get a nuclear cataract within 2 years

Secondary to increased oxygen near the lens after the
vitrectomy

Hyperbaric chambers – increased oxygen exposure can
cause the patient to have huge increases in myopia and a
progression to nuclear cataracts

CARBON MONOXIDE POISENING / SCUBA

Answer 214

A

Dense, granular appearance of the posterior layers of lens cortex

Early iridescent sheen, to more granular and plaque-like

Central opacities and vacuoles

Often located along visual axis

Pathophysiology
o Epithelial cell proliferation at pole with fluid filled areas within
o Associated with UV exposure and steroids
o Younger age than NS or cortical

Most visually distressing type / Pupil Decr in size when you age or read

Answer 215

A

PSC Cataract

Answer 216

A

STEROIDS

> 15mg/day of prednisone for more than one year have PSC.

Anti-VEGF

*intravitreal injection of 4 mg
(0. 1 ml) of triamcinolone acetonide**

cataract and intraocular pressure
(IOP) rise of at least 5 mmHg (IOP responder).
40
Kena log

Answer 217

A

Lens epithelial cell seem to express a steroid binding
protein, altering gene expression which appears to lead to:
o Cell proliferation / Cell differentiation / Cell apoptosis / Modulation of glucose metabolism / Modulation of membrane channels

etiology

transactivation and transrepression of
genes as well as modulation of the activity of proteins

Answer 218

A

POSTERIOR SUB-CAPSULAR

CATARACT

Answer 219

A

Nuclear sclerosis
o Graded by evaluating the average color or opalescence

Cortical cataract
o Grading should be visualized as a total amount of spoking present
o If one of the spokes goes
through the visual axis, Decr in VA

Posterior Sub-Capsular
o Graded on the basis of the percentage of the area of the posterior
capsule obscured

Answer 220

A

Cloudy or blurry vision
Colors seem faded
Glare around headlights
Reduced contrast sensitivity
A halo may appear around lights
Poor night vision
Double vision or multiple images in one eye
Frequent prescription changes in RX
Decrease in blue perception

Answer 221

A

O’Scope - Matches what You can see. 20/20 PX should be clos to the same Acuity

Potential Acuity Meter (PAM)

Better to assess NS, Connected to Slitlamp

Laser Inferometry

Best results In mild to Moderate

BAT Brightness Acuity Tester

For Px with Good VA but glare is a problem.

Potential acuity Pinhole technique

Answer 222

A

Posterior subcapsular
o Usually progresses the fastest
o Usually near vision is more affected than distance
o Not unusual to go from minimal to needing surgery in 6-12 months
o Explain things to the patient

Nuclear sclerotic
o Change in index of refraction results in an increase in minus,

Always consider Add - Keep the amount of Add constant or higher

Cortical
o Progresses the slowest
o In some cases patient becomes more hyperopic

Answer 223

A

Atopic dermatitis – PSC and Anterior SC

A positive correlation was found between atopic cataract development and a decreased inducibility of superoxide dismutase. This suggests that atopic cataract development is correlated with oxidative damage of the lens and related to chronic inflammation.

o Arch Dermatol.

Diabetic: 5-fold increase in the prevalence of
cataracts
o Hyperglycemia is the primary cause
Y Children can demonstrate snowflake, which are reversible
o Snowflake cataracts are white, sub-capsular opacities related to
high blood sugar in children andin patients with type1 diabetes
o Adults demonstrate the usual age-related cataracts, but at an
earlier age
Diabetic patientsmay also demonstrateChristmas Tree
cataracts

Answer 224

A

Glittering, multicolored, needle-like opacities

Pathophysiology

o Associated with metabolic dysfunction (i.e. diabetes) o Consists of cholesterol crystals

o “It is concluded that cystine is the most likely candidate for the Christmas tree needles and that the needles probably are formed as the result of an age-related aberrant breakdown of crystallins induced by elevated Ca2+ levels.”

o Associated with Myotonic Dystrophy Y This type of Cataract can be: o Unilateral or bilateral

o Usually does not affect vision Cataracts: cataract _

Answer 225

A

Round, translucent irregularity

Pathophysiology
o Associated with galactosemia (inability to metabolize galactose)
o Cataracts usually form within a few weeks of birth
o Cataract formation due to a high concentration of dulcitol/galactitol
(a product of galactose reduction) within the lens
o Dulcitol causes water to be drawn into the lens fibers (similar to the
sorbitol cataract in DM patients)
o With the Oil Droplet, early modification of diet can cause resolution

Answer 226

A

Star- or rosette-shaped

Pathophysiology
o Secondary to blunt trauma
o Usually found at interface of anterior cortex and anterior nucleus
o May also occur under anterior or posterior capsule, or both
o Rupture of superficial cortex at the suture lines may account for
rosette appearance
o May be a delayed appearance as initial swelling

Trauma may also lead to findings such as Vossius’ Ring or Focal Cortical Cataract

Answer 227

A

Traumatic Cataract

Answer 228

A

Vossius’ Ring

Deposit of melanocytes from pupillary border of the iris due to blunt trauma

Answer 229

A

Opacity present at birth

Infantile opacities / occur after birth
Unilateral cataracts are usually isolated sporadic incidents.

o Can be associated with:
• Ocular abnormalities (eg, posterior lenticonus, persistent hyperplastic primary vitreous, anterior, segment dysgenesis, posterior pole tumors)
• Trauma
• Intrauterine infection (rubella)

Bilateral cataracts are often inherited and associated with other diseases.

o Common causes are:
• Hypoglycemia
• Trisomy (eg, Down, Edward, and Patau syndromes)
• Myotonic dystrophy
• Prematurity

Answer 230

A

Epicapsular Stars
Congenital cataract

Answer 231

A

Small, round or oval, dense dot approximately 125-350 mm in
diameter white in color black in retro
o Surface of the posterior lens capsule
o Slightly nasal to the center of the lens

o Remnant of the fetal hyaloid vascular system

Answer 232

A

Affecting ONLY one layer of the crystal lens, which is
surrounded by clear areas

Involves a particular lamella of the lens, both anteriorly and
posteriorly

Most common type of congenital cataract
Usually bilateral and symmetric
VA Good

Answer 233

A

Congenital Nuclear Cataract

Answer 234

A

Sutural Cataract

Does not progress / Forms at Y suture

Answer 235

A

Round, discoid, opaque mass
Central- posterior part of the lens, involving the subcapsular cortex and capsule
o VA reduced

Pathophysiology
o Autosomal dominant inheritance pattern

Answer 236

A

Opacity of the anterior subcapsular cortex and capsule
o Usually bilateral
o Frequently autosomal dominant

o Central opacity involving the anterior capsular

o Associated with: microphthalmos, persistent pupillary membrane,
and anterior lenticonus

Answer 237

A

Small, bluish punctate opacities of
the peripheral cortex

Answer 238

A

Club-like opacities that lie in deep cortex and surround the lens
nucleus like a crown

autosomal dominant
o Can be associated with Down’s Syndrome

Answer 239

A

Developmental anomaly of the lens in which the posterior portion
of the lens bulges outward in a cone-shape.

Associations include microcornea, anterior lentiplanus, glycinuria, and Duane’s syndrome.

Answer 240

A

Can be associated with retinal detachments and hypoplastic
optic nerves

CAT sx risk of retinal detachment

Answer 241

A

Phenothiazine
Steroid

Amiodarone –anterior subcapsular Stellate
Tetracylines
Sulfa drugs

Answer 242

A

Mature Complete Cataract

Answer 243

A

Hyper-mature Cataract

Nucleus sinks in lens

Answer 244

A

Marfan’s syndrome autosomal dominant genetic disease in which a
fibrillin gene mutation causes weak zonules

o Displacement is usually superior temporal
Homocystinuria autosomal recessive – rare methionine and homocysteine
levels are elevated
o Lens is displaced down and in
Ehlers Danlos Syndrome
Osteogenesis Imperfecta
Contusion injury
Pseudoexfoliation
Syphilis

Answer 245

A

Radial incisions using diamond blade Insisions 90% of corneal thickness deep

Refractive effect controlled by

number of incisions,
depth of incisions
size of the central clear zone

Answer 246

A

Long-term fluctuation of vision
Halos and glare (When insisions are in the line of sight)

Progression to farsightedness (hyperopia)

Kerato-ectasia (Corneal ectasia)

Neovascularization

Answer 247

A

PRK

LASIK

Answer 248

A

Patient Consultation & Education
Pre-operative exam

Surgery (ODs can perform in some states)
Kentucky / louisianna / Oklahoma

Post-operative exam

Answer 249

A

Age 18+
Refractive Error: Amount meets FDA guideline -0.50 to -12.00 / +6.00 / -6.00 Astig
Stability <0.50D change 1Yr
VA (sc) < 20/40
Ocular and Systemic

Medical History: Not contain any “absolute” contraindications

Answer 250

A

Diabetic retinopathy - accelerates
Glaucoma - Sx has IOP to 65mmHg / Need Steroids gtt post sx
Visually significant CAT - rather do CAT sx
Corneal ectasia Ie. Keratoconus
Active ocular herpes - Zoster Ophthalmicus / Herpes Simplex
Severe dry eye
Exposure Keratopathy Ie. Sjogren’s syndrome

Monocular (actual or functional)

Amblyopia or Strabismus

Answer 251

A

Mild - Moderate Dry Eye
Blepharitis (all signs resolved)
EBMD(epi/base/mem/def) PRK only
Corneal scarring PRK vs. LASIK
 Amblyopia(see specific guidlines)
Thinner Pachymetry than average corneal pachymetry

Answer 252

A

Mild- ( 20/40+ may be okay
Worse than 20/40, px considered monocular (contraindication)

Pre-laser BCVA= Post-laser BCVA
(may gain 1-2 lines)could improve BCVA
Help in patients with Anisometropia

Answer 253

A

Auto-immune disease
Lupus Erythematous (SLE), Rheum Arthritis, Thyroid Disease
Increased risk of inflammation

Immune Suppression
Increased risk of infection
(HIV+ is relative contraindication, if immune system is intact & stable, likely one eye at a time)
Pregnancy
Must wait 4-6 months* after giving birth/nursing

Any Illness affecting wound healing
Medications – MANY!
Systemic steroids, Plaquenil, Amiodarone, Imitrex, Accutane
Pacemaker

Answer 254

A

Diabetes (Type I & II)

Diabetic retinopathy is a systemic disease and contra indicated
Active Atopy (Eczema, Psoriasis, Dermatitis)
First control

Epilepsy (no episode in the past 12 mo)

Answer 255

A

NASA Astronauts- intralase LASIK only

Navy & Special forces- PRK only

Army/Air Force- Either LASIK or PRK

Answer 256

A

VA:

 Uncorrected Visual Acuity

Best Corrected Visual Acuity

Entrance Testing:
Confrontation fields, EOMs, BV/Cover Test, ocular dominance

Pupils: Photopic Scotopic (Prevent glare)

Refraction
Dry vs Cycloplegic
Push plus & maximize magnitude of astigmatism
1% Cyclopentolate or 1% Tropicamide

Binocular Vision Assessment
Slit lamp exam
IOP
Dilated retinal exam

Answer 257

A

Lids/lashes

Blepharitis
Lagophthalmos
Incomplete blink
Meibomian gland dysfunction

Cornea(Dry eye)

Quality of tear film
Superior punctate erosions or keratitis
EBMD

Manage Dry Eye FIRST
Aggressive artificial tears supplementation
Occlusive punctal plugs
Topical cyclosporine (Restasis)
Topical Steroid (pulse dose)

Oral supplements:
Omega 3 fatty acids (1000mg BID)
Doxycycline (50-100mg BID)

Answer 258

A

Rule out any lenticular, vitreous or retinal disease
Thorough examination of dilated media, posterior pole and
peripheral retinal exam

Baseline IOP (Post lasik art lowered)

Answer 259

A

*Corneal Topography**
* Pentacam**
Topography vs. Tomography
“Belin-Ambrosio” scans
Global pachymetry

Aberrometry-Wavefront analyzers

Objective refractive error
Higher order aberrations
Measures pupil size
Pachymetry

Answer 260

A

Rule out abnormal corneal contour
 Normal Cornea:
Prolate shape + Uniform in appearance
Approx 42-46D at the center

Abnormal Cornea:

Inferior steepening, lobster-claw/kissing dove pattern
(Pallucid marginal degeneration)
Rule out Contact lens related abnormalities
 Serial topography may be needed
Verify post-operative results

Answer 261

A

Ultrasonic pachymetry is standard of care
Will determine whether patient is a suitable candidate

More important for higher refractive errors
Average corneal thickness ~ 535-545um
Must have enough corneal tissue for healthy residual stromal bed

Thinner corneas= relative contraindication* - need room for
enhancement
Consider PRK/LASEK if not enough corneal tissue for LASIK

Answer 262

A

LASIK Residual Stromal Bed (RSB)

= Corneal Pachymetry Treatment depth –LASIK flap thickness
According to the FDA,
LASIK RSB must be >250µm
 Most surgeons prefer 300µm

PRK Residual Stromal Bed (RSB)= Corneal PachymetryTreatment depth
PRK RSB must be >350µm stromal tissue + ~50um
(epithelium)= 400um

Answer 263

A

LASIK RSB=Corneal Pachymetry -Treatment depth[(sph +cyl)x15µm]—lasik flap thickness

Answer 264

A

Corneal Ectasia: progressive instability and weakening of
corneal integrity, resulting in a significant increase in the
posterior and anterior corneal curvature.

CAUSES

<250um RSB
Corneal thinning dystrophies (pre operative
subtle/subclinical KC)
Thick corneal flaps

Answer 265

A

Review Informed consent:
Surgical site to provide
Discuss risks and temporary side effects (risk of blindness, dry eye, glare & haloes etc.)

Discuss Goals and Limitations of the procedure

Mild Spec RX for night-time driving
Reading glasses for Presbyopia
Enhancement for high refractive errors

Pre-operatively

D/C CL wear
No restrictions on eating
D/C eye make up x minimum 3 days prior to surgery day
Review intraoperative procedure details
XXXX Review Pre/Post-OP Medication schedule
XXXX Topical antibiotic QID 1 day prior to surgery date

Answer 266

A

May still require eye glasses for Distance or Near activitiesÆ No vguarantees
Under-correction or over-correction

A lessening or increasing effect of the surgery over time

Infections
Dry eyes - generally treatable (greatest until 3mo then back to baseline) May be permanent

Anisometropia

Loss of BCVA
Injury or perforation of the cornea - loss of vision
Thinner than 250 micron RSB increases risk of complications

Answer 267

A

Soft spherical daily/extended wear: 1 week
Soft toric wear: 2 weeks

Rigid gas permeable Corneal RGPs, Scleral lenses, ortho-keratology:
Minimum of 1 month
1 month per decade of wear
(ex 20 years of wear needs to be out for 2 months)

Answer 268

A

Length of procedure:
Quick: 10-15 min in Laser suite
Actual procedure time: <5 min
Actual time spent in office: up to 2-4 hours

Lids/lashes prepped
Sedative/Anxiolytic, PO
Driver needed

Answer 269

A

Visual Recovery:
LASIK (faster)
Day 1 usually see 20/25-20/20!
Upto 3 mo for full visual recovery

PRK (Slower)
Fluctuations in vision upto 5-7 days
Day 5- expect 20/25-20/20 vision
Upto 6 mo for full visual recovery

Painfull

LASIK
pressure with suction cup
slight “scratchiness/FB sensation” day 1-5 post op

PRK
discomfort while epithelial layer regenerates
“scratchiness/FB sensation” upto 2-5 days post-op
Bandage contact lens in place x 5 days

Answer 270

A

Mostly temporary

Pain or discomfort (upto 48 -72hours)
FB sensation

Increased sensitivity to light
Glare and haloes around lights

Upto 3 mo- LASIK
Upto 6 mo- PRK

Haze or fluctuating vision

Answer 271

A

*MOST COMMON** 85% Mainly due to 2 reasons:
FAST recovery
MINIMAL discomfort/pain post-operatively

Flap Creation:
Blade: Microkeratome
Laser: Intralase=Femtosecond laser
“Bladeless”
Laser Ablation (refractive correction)
Standard/Conventional
Custom

Answer 272

A

2 components - Cuts circular corneal flap
Cutting head
Oscillating blade

Suction ring
Attaches to globe for stability of cutting head
Raises IOP to at least 65mmhg
cornea upwards & firms cornea no movement with cutting blade
suction ring determine flap size

Answer 273

A

Wavelight FS200: Intralase - programmed specific depth
IOP elevated, then laser causes “photodisruption”
Air bubbles seaparate corneal layers flap created

ADVANTAGES

Uniform Flap thickness
Planar/thinner flaps - less (neurotrophic) dry eye
Programmable depth
 Wider range and higher Refractive errors
Thinner corneas
less flap complications and irregularities
Less risk of irregular astigmatism

DISADV
More post-op cornea edema (intralase) due to more energy

Answer 274

A

Myopia: flattens central cornea
Hyperopia, indirectly steepens central cornea by
removing tissue from periphery

2 Modalities

Conventional: Spherocylindrical only
Less predictable
Ablates central vs peripheral corneal differently - Higher order abberations
Glare/haloes/contrast sensitivity post-operatively

Custom:
_Wavefront-error measurement t_echnology
Ablation profile customized with Wavefront scan

refractive map of the entire visual system across the pupillary zone
A prescription at each and every point of the cornea
Incorporates both high and low order aberrations
Low-order aberrations: Sphere (myopia/hyperopia), Cylinder
High-order aberrations: Coma, Trefoil, Spherical aberration, etc

Answer 275

A

Measure and compensate for ocular cyclotorsion

Significant Astigmatism
eliminates human error marking

Confirm the patient’s identity and eye being treated
* Iris is Unique to an Idividual
measure and compensate for pupil center shift

compensate
for differences in pupil size between wavefront capture
and laser delivery

Answer 276

A

mild oral sedative (ex. Xanax) approx 30 min prior

Once in the surgery suite:

Topical anesthetic drops instilled
Skin is prepped with povidone iodine (antiseptic)
Eyelids/eye lashes may taped. Lid speculum for microkeratome but not intralase
Femtosecond Laser flap creation:~6 seconds
Pt transfer from Femtosecond laser to excimer laser: ~7 s
Excimer laser treatment of ex -5: ~Approximately 7 seconds

Specific sounds/smells during procedure

Answer 277

A

No showering x 24 hours
No swimming (lake or pool)/hot tubs x 2weeks
No eye make-up x 7day
No exercise/heavy lifting x 7 days
No gardening x 7 days
No scuba diving x 1 month
Avoid dry/dusty environments
Wait 3 months = kickboxing, karate, skydiving
Consider PRK
Limit travel/vacation for 1 week / To be cleared for Drving

Eye shields x 7 nights
Usually provided by the laser center
Sunglasses x 24 hours –every waking hour and then x 7days
when outdoors
No rubbing or squeezing eyes x 7 days

Answer 278

A

Schedule:
1-day
5-day or 1-week
1-month
3-month

Anual check up (free augmentation)

Answer 279

A

Visual acuity : Expect mild hyperopia (over comp)
Flap Check - alignment and clarity
Cornea - SPK signs of infection and inflammatio
Subconjuntival hemorrhages Reassure patient
SPK - Increase dose lubrication
Foreign body sensation, check for
epithelial defect and flap striae
Usually no pain

Answer 280

A

Visual acuity + Refraction (Hyperopia)
Possible asthenopia - Give Readers
Flap check - infection/inflammation Rule out: Diffuse Lamellar Keratitis (DLK)

After 7 nights:
eye make-up + discontinue wearing shields at night

Answer 281

A

Month 1
Confirm vision is progressing normally
Flap intact
Rule out: epithelial in-growth
IOP check (Check if STEROID Responder)

Month 3
Confirm uncorrected visual acuity is stable
Flap intact

Answer 282

A

Interface opacities (debris/lint fibers)

No risk for infections

Do not need to be removed

Can be seen as early as Day 1 post-op

RBC - From neo at edge of flap, get trapped under flap

Answer 283

A

Epithelial defects

edge of the flap 1st few days post op

Monitor for signs for signs of epithelial ingrowth
Poor corneal epithelial adherence EBMD
Heal within 24 -48 hours

Answer 284

A

FLAP BUTTONHOLES “island” of uncut cornea

Causes:
Steep cornea (>46D)
Loss of suction
Reduction of IOP

FREE CAP: = hinge detaches

Causes:
Flat corneas (K<39D)
Poor suction
Improper settingsfor the microkeratome blade

INCOMPLETE FLAP: Incomplete termination

Interference of the forward movement of the microkeratome
Lid speculum, lids/lashes, conjunctiva or drapes
Loss of suction

Answer 285

A

MACROSTRIAE

Gross linear folds caused by misalignment of flap to
stromal interface
VA reduction dt optical aberrations & irregular astigmatism

Treatment
caught early (1-4 weeks)- easier to lift, stretch and
smooth flap Surgical Sponge
May need to suture

Answer 286

A

NEUTROTROPHIC DRY EYE

Decreased corneal sensation
Decreased tear secretion
Decreased blink reflex
Delayed epithelial healing
SPK staining
Increased risk of infection/inflammation
Fluctuating vision

POST OP dry eye:

Damage to goblet cell function dt suction ring - mucin deficiency

*less pressure w Femtosecond laser vs Microkeratome blade

Corneal curvature alterations
Interrupts wetting / Tear film uneven causing tears to
stagnate

Epithelial toxicity
Artificial tears (preserved)
Medications

Answer 287

A

Preservative-free Artificial tears (x 1 mo)
Gel ointments (as needed)
Cyclosporine 0.05% (Restasis) BID
Topical Steroids
Punctal plugs
Oral Doxcycline

Environmental modification

Personal humidifier
Good hydration
Fish Oils

Answer 288

A

Non-specific sterile inflammatory response to a corneal
insult
Incidence: 1/200-1/500
Should be checked for DLK D1. - D7
white sand underneath the flap

Causes
Bacterial toxins from sterilizer
“outbreaks/sequential patients”
Meibomian secretions
Machine cleaner/oils from microkeratome
Excessive femtosecond laser energy (intralase)

Answer 289

A

Symptoms
Initially mild photophobia/sandy-gritty sensation
Feels like dry eye / VA decreases

Signs
 Diffuse haze at the flap interface
Begins peripherally or para-centrally migrates centrally
Appears “wave-like”
Progresses, coalesce, into clumps of inflammatory material
NO AC reaction
Although rare- if left untreated, flap melting can occur

Answer 290

A

detected early —good prognosis

treat with aggressive steroid therapy even at day 1
Pred Forte is instilled hourly for the first 24 hours.
If improvement in 24 hours, PF taper at QID until the
* *inflammation has** resolved.

Taper steroid 2-3 wks IOP (STEROID RESPONDERS)
IOP’s must be closely monitored
Change to a “or add ocular hypotensive

Answer 291

A

Epithelial cells growing under the flap edge
“pearls or nests” of epithelium that are translucent white/gray in color
Progresses centrally from edge of the flap

Higher with enhancement or trauma
*less common with Intralase
Graded in stages – 1, 2, 3
Typically seen @ 1month

Answer 292

A

Grade 1+
limited to within 2mm of flap edge
no associated flap edge changes

Self –limiting

Grade 2+
ingrowth extending >2mm past flap edge
slight flap edge erosion/thickening/melting
Should be lifted and cells removed

Grade 3+
Flap erosion and melting
Flap lifting and cell removal.
They are at risk for corneal melt if left untreated

May need to suture flap to prevent recurrence/further growth

Answer 293

A

Very rare, Months to heal

Cells damage during procedure

Answer 294

A

Risk Factors:
Steep K-values (High Myopia)
Thin/asymmetric pachymetry
Asymmetric, progressive, irregular, high astigmatism
Decentered corneal apex
Abnormal topography
Patients with or FHX of Keratoconus, Pellucid marginal degeneration,forme fruste KCN
+atopy/eye rubbing

Answer 295

A

Signs:
Inferior Corneal Steepening
Corneal thinning
Progressive myopia
Irregular or oblique astigmatism
Loss of BCVA
Treatment:
Rigid gas permeable

Corneal Intacs
Corneal crosslinking
Corneal Transplants

Answer 296

A

4+months for Myopic patients
6+months for Hyperopic patients
Enough corneal stromal tissue RE-Cut flap
Enhancements if regression is significant and cornea adequately healed
Criteria – UCVA 20/40 or worse and -1.00D or worse refraction
Benefits must outweigh risks!

Answer 297

A

Thin corneas
Irregular corneas (abnormal topography/tomography)
EBMD, RCE
Corneal scarring
Anatomical issues- fissure size/orbital depth
Enhancements
Armed services
Contact sports/occupations
Football player/athletes
Flap fear!

Answer 298

A

Advantages:
Improved outcomes for thinner or irregular corneas
Avoids complications of a corneal flap (LASIK)
Less overall tissue manipulated

No suction ring (LASIK)

Disadvantages

Higher risk of infection/inflammation

Post operative discomfort / Re-epithelialization 1wk

Slow visual rehabilitation - several weeks before BCVA is achieved
Risk of stromal scarring

Answer 299

A

Epithelium is removed

Chemical debridement (5-25% Alcohol or 4% Cocaine)
Mechanical debridement- rotating abrasive brushes or manual w a brush/spatula
Laser debridement (with or without manual debridement)

Excimer laser (same as used for LASIK) ablates underlying stroma

Bandage CL placed on cornea

*Epithelium** to grow back (~5-7 days)
*Remove BCL** once epithelium is 100% healed

Answer 300

A

Mytomycin- C (anti-tumor, antibiotic activity)
MMC 0.02%-0.05% is used for ~20 seconds after ablation
Reduces post-op corneal haze and scarring
Especially useful for higher RX corrections

Risks of MMC - Delay re- epithelialization / Longer discomfort

BCL - Silicone Hydrogels

Acuvue - Oasys

Air optix N&D

Answer 301

A

Re-Epithelialization

4-6 days (BCL stays until 100% epithelialized)

Peak discomfort @ 2-3 days postop
Visual decrease @ 3-4 days postop
Followed DAILY until BCL removed

Answer 302

A

Ways to minimize scarring:
Intra-operatively use Mytomycin-C
Intra-operatively use Chilled BSS (balanced saline solution)
Oral Vitamin C (1000mg)- start pre-operatively

Reduce sunlight exposure –post operatively
Steroid use x 1 mo post operatively

Recovery Time

Vision is good in about a week, great in about a month
Day 1:UCVA is normally20/40 to 20/80
Day 3-5: UCVAmay be aslow as 20/200-20/400
Day 7: UCVAnormally20/20 to 20/40
Recovery dependent on:
Level of activity Individual physiology, healing pattern
Age
Level of refractive error

Answer 303

A

Orals Meds
Tylenol (acetaminophen) or Advil (ibuprofen)
Take as needed with food, do not take in addition to Vicoden
OR
Vicodin (acetaminophen + hydrocodone)

Vitamin C- 500mg BID 4mnths pre + 4Months Post

Answer 304

A

NO makeup, swimming, use of hot tubs, gardening, dry/dusty
environment for 1 week

NO exercise or strenuous activity x 1 week

OK to shower @ Day 1 but keep eyes closed

Driving when vision improves to 20/40 +

Answer 305

A

Days 1-5 (until epithelium is 100% healed)
Assess UCVA / Worse 3-5days epi healing
VA clearing week 1 and considerably by weeks 3-4
First 5 days:

Patient should be wearing a bandage contact lens
DO NOT stain/remove CL
Assess Fit- ensure lens is in place/not moving excessively
Rule out infections/corneal infiltrates/tight lens

Document % healed Daily

Answer 306

A

Copious amounts of topical lubricant - float lens
Drag inferiorly or temporally(Px Nasaly) FORCEPS
BE CAREFULL TO NOT PULL THE NEW EPITHELIUM OFF

D/C Antibiotic next day, Continue steroids
irritated/discomfort for an additional 1-2
day after CL removed
CONTINUE lubrication

Answer 307

A

2 week

UCVA
Manifest Refraction ~+/- 1.00D for regression
IOP* (Steroid Response)
IOP less - Thinner Cornea

Month 1, 2, 3, 4, 5, 6

UCVA
Refraction and BCVA = pre-op BCVA
IOP
Corneal Evauation clarity

Answer 308

A

Diffuse corneal reticular haze is a normal part of healing
Onset @ 2 weeks
Peaks @ 3 months
Clears @ 6 months

Risk of permanent haze
1%- mild to moderate Myopia
2-5% - severe Myopia

Answer 309

A

Sub-epithelial
Qualitative and Quantitative reduction in BCVA
Significant haze without reduction in VA

Predisposing Factors:
High Myopia
Previous refractive surgery

Treat only if significant

Steroids:
Ex 1% Prednisolone Acetate (PRED FORTE) Q1-2H x 2-3 week
If improvement - - taper

Answer 310

A

Open wound higher risk of:
Inflammation 1/1000
Infection/Infiltrates: 1/1000
Scarring/Haze: 1/100
Pain: 1/10
Risk of regression is higher

Corneal edema from tight lens
May see folds in Descemet’s membrane
Requires contact lens removal and antibiotic ointment “patch”

Answer 311

A

POST-OP PRK complications

Infectious CORNEAL INFILTRATE

Larger
Central cornea
Larger defect IN ablation zone - Confluent Ulcer
Ant. Chamber reaction
Progress with time/increase in size
More discomfort

Answer 312

A

Bacteria 90% are gram+

flora on the ocular surface Mycobacteria, Acanthomoeba
instruments, solutions, tap water, swimming pools,

TREATMENT

4th generation fluoroquinolone
Vigamox/Gatifloxacin Q15min x 6 hours, then decrease to Q1H
(waking hours)
Fortified antibiotics
May need to culture*
DON’T WAIT TO REFER TO SURGEON

Answer 313

A

MRSA keratitis
LASIK and PRK
Eye-lid cultures - patient is a carrier? re-infection
Pre-OP treatment of blepharitis
Prophylaxis: Use of 4th gen Fluroquinolone or bacitracin
Monocular treatment in known carriers

Treatment
Fortified oral Vancomycin & topical fluoroquinonole

Answer 314

A

SMILE: Small Incision Lenticule Extraction
No flap
Femtosecond laser only
FDA approval 2016
-1.00 to -8.00 sph, upto -0.50 astigmatism
Correction of myopia only
Patient must be 22yr +

Answer 315

A

Inflammation is defined as localized:

Heat (Warm to Touch)
Swelling CHEMOSIS (more pronouced at limbus)
Redness
Pain Tender to touch

• Inflammation is a result of:

Irritation
Injury
Infection

Answer 316

A

blinking reaction and flushing of tears
lysozymes, lactoferrin provide protection from micro-organisms
epithelial glycocalyx prevents bacterial adherence to corneal surface
mucous aids in trapping bacteria preventing corneal penetration

Answer 317

A

*Hyperacute** conjunctivitis
Neonatal conjunctivitis
post-operative infection

Intra introit injections

routine treatment has failed
corneal ulcer: central

Answer 318

A

Cultures - Incubated / Sensitivety tested /

Conjunctival smear for analysis of white blood cells
(cytological testing)

neutrophils -Bacterial
eosinophils - Allegic
basophils - Allergic

leukocytes - Viral

Conjunctival scraping - Aneastetic - Kimura spatula

Better than smear

Answer 319

A

VA, pupils. EOM

Pre-auricular adenopathy – feel nodes in front ear
lids for blepharitis, Meibomian gland orifices
Lower fornix for discharge + conj inflamation
Follicles and papilla: lower and upper palpebral conjunctiva
Chemosis (Ridge at limbus)
Cells and Flare (Before Dye)
Qaulity of Tear film -Dry EYE
Observe cornea for staining patterns, infiltrates, ulcers: stain with Fl. and Rose
Bengal or Lissamine green (Conj)
Posterior synechiae near pupil margin (stuck to lens)
• IOP after anterior chamber evaluation
• Observation of optic nerve and macula evaluation necessary at minimum for a problem specific examination.

Answer 320

A

Hyperemia (redness/injection)/Hemorrhage

Diffuse / circumlimbal and nasal fornix

Chemosis (swelling) Allergies

Discharge

Bacteria Muccus / Viral Serrous

Papillae / Very red bv at surface

Follicles / BV at base, fluid filled

Membrane/Pseudo-membrane - Caused by fibrin in discharge

Answer 321

A

muco-purulent type discharge
exogenous pathogens
- Staphlococcus aureus
- Staphlococcus epidermidis
- Streptococcus pneumonae
- Haemophilus Influenzae
Fundamental tissue changes
- hyperemia
- edema
- discharge
Mono - Binoc - Incr in intesity first few days

Answer 322

A

Bulbar Conjunctiva

Hyperemia (meaty red)

circumlimbal area is usually clear
hyperemia greater towards the fornices

Palpebral conjunctiva
Papilla (Superior lid)

Cornea involvement Dt exotoxins

- PAN

+ PMN

Answer 323

A

Lid hygiene – warm compressors and lid scrub
- QID 10min commercial
Lavage - BD reduce mucus in eye
Antibiotic
- Polysporin qhs / Polytrim QID 1week
- Cyloxin QID
Disgard cosmetics
non-resolvingpatients - after 48 hours
consider cultures and sensitivity
consider a second opinion or secondary site of infection.
confirm compliance
consider non-bacterial microbial infections

Answer 324

A

Hyperacute Bacterial Conjunctivitis
OCULAR EMERGENCY
• The intensity of the inflammatory changes with an
overflowing purulent discharge - HYPERACUTE

Can penetrate the cornea 24hrs

Cause:

Neisseria Gonorrhoeae
Neisseria Meningitis

Answer 325

A

Subjective:

EXAGERATED Progression ofacute bacterial conjunctivitis
Tenderness and marked edema around adnexa - copious discharge
intermittent blurred vision

Objective:

Hyperemia lids margin
Marked - hyperemia of conjunctiva
Chemosis around adnexa
POS pre-auricular node
mucopurulent discharge

Answer 326

A

suspect N. Gonorrhea unless proven otherwise

Ocular emergency / LAB workup indicated

Treatment:

Topical & Systemic Antibiotics
- BABY -Eurithromycin. / Silver nitrate
- ADULT: 4th Gen Flouroquinelones Moxyfloxicine 1gtt 15min
Lavage
Refer
treatment needed for related systemic signs

Answer 327

A

accompanies a chronic blepharitis
Variable symptoms

burning
Irritation,
Foreign body sensation
- lids stuck together especially in the morning

Objective

Lid involvement

- madarosis
- tyalosis; poliosis
Evert he lids → Papillae. PMN.
recurrent chalazion, hordeoli
collarettes at the base of the lashes

Auto - immune rxn
- cornea involvement: sub-epithelial infiltrates SEI (Grey white lesions per cornea)

superficial punctate keratitis SPK

Answer 328

A

Short and long term management and treatment
Warm Compressors – tapered scheduled over time Lid scrubs –tapered scheduled over time
Topical Antibiotics –drops (day), ointment (night) - x 1 week or drops only
Artificial tears drops- several times a day
Avoid any make-up products/discard any recent use of make up products
Use of steroids
Use of oral antibiotics

Answer 329

A

Causes

*TOXINS**: developed HYPERSENSITIVITIES.
eg: Molluscum Contagiosum VIRAL,

chemicals ALLERGIES.

Answer 330

A

*NOT a disease**
*Children to young adolescents** - eye is very quiet
due to hyperactive lymphatic system
disappears with age

Answer 331

A

Elevated, deeper red vascular, with a blood vessel at the core of the papilla
increased and polymorphonuclear neutrophils (PMNs); eosinophils.

Causes

-bacterial infections

contact lens wear
allergies

Answer 332

A

Appearance: clear like vacuoles; spherical in shape

DT: Cellular degeneration on the surface of conj

Location: bulbar and palpebral conjunctiva 00

Signs And Symptoms : asymptomatic

TX & MX

Lubricating Gtt: QID 4-6wks Then taper

Lancing

Answer 333

A

PINGUECULA(E)
Very common
Location
interpalpebral zone of the bulbar conjunctiva
Pathiophysiology: Fibrovascular degeneration
Causes →Environmental / Mechanical CL / UV

PX education

Answer 334

A

Pingeuculitis

Inflamed Pinqeucula

Answer 335

A

Pterygium

When it passes limbus destroys Bowman’s membrane replacing it with a fibro-vascular layer SCARRING

*Appearance: fleshy,** triangular growth that extends onto the cornea; apex points towards the pupil
*Growth pattern Varies**

Symptoms:

blurry vision monocular
diplopia dry eye
foreign body sensation red eye

Answer 336

A

Stokers Line

At the edge of pterygium / No progression

Pterygium

Causes irregular astigmatsim / Dry Eye

MX

FML - BID Finish coarse

Art tears QID -6/pd As lomg as needed

Removal sx / Conjunctival Grafts

Answer 337

A

CONCRETIONS / Lithiasis

Small yellow white deposits on upper or lower palpebral conjunctiva
• ~1-3mm in size
• representative of a degeneration (aging palbebral conjunctiva) or chronic allergies
• Instead degenerating epithelial cells and mucin secretion

Answer 338

A

Axenfeld loop
Bulbar conjuctiva

Cilliary nerve loops varaible amount of pigment

Answer 339

A

MELANOSIS:

CONGENITAL More Pigmented individuals
- diffuse pigmentation visible on sclera/conjunctiva

Answer 340

A

*NEVUS:**
if the pigmentation is grouped it maybe called nevus - may increase in pigmentation -document
usually flat

Answer 341

A

ADENOCHROME DEPOSITS

exogenous source. ie: medications

Dark pigment granuales Inferior Fornix

*-**usually occurred when patients are placed on
*epinephrine** medication for glaucoma treatment

**Pro-drug - Propine

Effects Reversed

Answer 342

A

*MELANOMA:**
concerned about changing in size and if elevated
newly acquired pigmentation
from a nevus or spontaneously from sun exposed areas

Answer 343

A

TRAUMATIC - MUST Do fundus examination and Prelims

Good Hx to determine the frequency + Cause

NON-TRAUMATIC

spontaneous increase in venous pressure
→ * coughing fit * sneezing

- diabetic
* vomiting
* straining: mechanical lifting
picking up weights giving birth

* post- surgical
* medications: blood thinner eg. Aspirin
* some bacterial and viral conjunctivitis
* blood pressure
eg: Epidemic keratoconjunctivitis
BPA
severe or un-controlled

Answer 344

A

* patient re-assurance always needed
* the hemorrhage will disappear depends on size approx. 7-21 days
dilate the pupil to check the anterior portion of the eye and the retina in traumatic cases

Answer 345

A

Ocular allergic conditions:

Type I: anaphylactic or immediate hypersensitivity
Type IV: cell mediated reactions
Type III: immune -complex reactions

SIGNS

Vasodilatation of blood vessels
Itching
Chemosis to lid area and conjunctiva
Mucous discharge (Eosinoplils IGE)
Conjunctival lab tests: eosinophils & basophils

Answer 346

A

Hot And dry
Age group: ~3 to 20-25 years of age
Early onset before puberty Male > Female 3:1
“Recurrent for ~4-10 years and then stops
IgE mediated hypersensitivity

Symptoms

*-intense itching**
photophobia
ropy, stringy mucous discharge -red eye
*-bilateral**

Answer 347

A

Vernal Conjuntivitis

PALPABRAL FORM: Giant Papillae / Cobblestone

Forms Superior lids/ Pseudo ptosis

Answer 348

A

Limbal form VERNAL Conjunctivistis

Gelatinous precipitates
Trantas Dots: Eosinopils + Mast Cells + Epithelial cells

Diffuse Hypereamia

Marked Chemosis

Answer 349

A

Neovascularization of cornea
Pannus (Fibrovascular tissue)
SPK superiorly and centrally
Can lead to ulcer (Shield formation over ulcer)

Answer 350

A

MX & TX

cold compressors QID stops itching (Mask in fridge)
Antihistamine and mast cell stabilizer ophthalmic

PATANOL BID OU 4-6WKS
PATADAY QD
ZADITOR BID

LAVAGE 2 x per day
Non preserved art tears 1gtt GID - 6pd

preparations
•Lavage 2✗perday
• Non preserved artificial tears drops

Answer 351

A

ADDITIVE MX

• Steroids - side effects – cataracts, increase in IOP

QID -2 WKS STOP

PRED FORTE

LOTEMAX (Not affect IOP Expensive)

FML

Answer 352

A

Symptoms

itching (Primary Complaint
eye lid swelling
mucoid to watery like discharge
red eye
bilateral

MX & TX

Cold compressors QID
Artificial tears drops
Antihistamine and mast cell stabilizers
- PATANOL BID OU
- ZADITOR BID OU
Lavage BID
Protective eye wear

Answer 353

A

GPC

Giant Papillary Conjunctivitis

Contact lenses: (HIGH WATER + IONIC)

lens deposits abrade the conjunctiva epithelium, exposing the immune system to the antigen on lens
- Decr wearing time
- Exess Movement
- Rubbing
- Mucoud discharge
CHANGE TO AOSEPT / PEROXIDE SYSTEM

Answer 354

A

discontinue CL wear
alternative CL
1. RGP
2. Dailies / RX
cleaning regiment change - PEROXIDE
GTT mast cell stabilizers with antihistamine
1. Patanol / Pataday / Zaditor BID 4-6wks
2. ADDITIVE FML LOTAPREDNOL
Cold Compress

Answer 355

A

Preservative not medication or drug itself

BAK / Sulphar Gtt / Thimersol

immediate reaction
redness

SIGNS:

Diffuse SPK
Stinging burning Sensation
Hypereamia

MX & TX

Supportive

Flush with saline / Unpreserved Tears 6xpd 1week

Avoid allergen

Answer 356

A

FOLLICLES in

VIRAL CONJUNCTIVITIS (Pink Eye)

Symptoms:

tearing
diffuse conjunctival hyperemia
FB
one or both eye involvement

Signs

follicles
corneal involvement: Sub-epithelial infiltrates (SEI), Superficial punctate keratitis (SPK)
- PAN
Discharge: usually watery/serous
Laboratory : cytological response -lymphocytes

Answer 357

A

Adenovirus DNA virus / 6 sub-groups

B&D Occular infections - Attaches to Surf Proteins

* Pharyngoconjunctival Fever (PCF)
- Type #3
- Swimming pool
- Eye + respitory secretions
* Epidemic keratoconjunctivitis (EKC)
- Type B
- Most severe - Survive on surfaces for a long time
- Auto enoculation

Answer 358

A

Fever
pharyngitis
follicular conjunctivitis
superficial keratitis SPK
unilateral
+PAN
CHEMOSIS

MX & TX

very contagious

Self - limiting

avoid contact with others
stay away from work environment or schools
disinfection at office and home

TX - Palative

Unpre Art Tears with SPK 7-10 days QID+

Answer 359

A

Symptoms

extremely contagious

may have feeling of malaise (tiredness)
starts unilaterally and then becomes bilateral

FB sensation

Signs:

MARKED Follicles
+PAN
FB sensation - SPK (membrane caused)
copious discharge / White Water
Severe conjunctival chemosis
pseudo-membrane Sup >> Inferior
sub-conjunctival hemorrhages

Answer 360

A

Week 1

TX

Lavage BID try and reduce membrane formation
Cold Compresses
SPK -Art Tears Unpreserved QID++
Remove Membrane Manually

OFF - LABEL (In office only) Need Px Consent

Betadine Opthalmic Solution

Aneastetic
- Rinse Eye well (toxic)
Expect Significant SPK
Art tear Gell post
Can be repeated

Answer 361

A

Active Viral Shedding 10-14 days

Subepithelial elevated Areas

Answer 362

A

SEI - central

Sub-epithelial infiltrates

Antigen antibody reaction to Viral particles

AUTO-Immune

Answer 363

A

White grey feathery boundries

If not in pupil - Steroid use contraversial

Central - PRED Forte Gtt

8 - 1wk

6 - 2wk

4 - 3wk

taper to 1gtt for 1month

Answer 364

A

RPS Adenoviral detector
2 Antigen specific antibodies capture the viral antigens/particles
RPS detector notes proteins within the adenovirus
The kit consists of 2 parts: collection of sample

Dab about 4-6 times and keep for additional 3 seconds

immunoassay testing
Takes about 10 minutes to obtain the results

Answer 365

A

Herpes zoster or shingles

Immunocompromised Individuals more at risk

HIV / Transplant px / Chemotherapy
Stress
average age of onset >45 years

Answer 366

A

Symptoms:

Fever / Malaise / HA
Pins and Needles sensation
1-4 days before skin surface affected / 1-3 Dermatomes in same region 1 sided
intensely painful vesicular eruption of a single sensory nerve. thoracic nerve
- Macular rash small flat spots
- papular rash Erythematous
- Vesicles 24hrs Blister like fluid filled
Post herpatic Neuralgia - > 1 month extreme pain
2-3wks crusts and acute phase subsides

Answer 367

A

Nasociliary involvement - Lesion on the side ofthe nose

*Hutchingson’s sign - ocular involvement**
If you see a vesicle, look to see if it respects the dermatome

Answer 368

A

PSEUDO dendrites better stained with ROSE Bengal

Gancyclovir GTT HS

Oral Mx - Start 72hrs

Valacyclovir (Valtrex): 1000mg TID for 10 days

Longer treatment - BID x 2 then / qh 2wks

*Acylovir** (Zovirax):(safer)800mg 5x/day for 10 days
*Famciclovir - 500mg TID for 10 days**

Answer 369

A

Zostavax vaccine - 2006

Live attenuated vaccine

CONTRA-INDICATION - Immuno compromised

Shingrix vaccine - 2017

Glycoprotein E and adjuvant system
2 doses
2 to 6 months apart
>90% reduction in HZ

Answer 370

A

Subjective:

watery discharge - Photophobia

*Corneal sensitivity dec at repeated=infection**
foreign body sensation -
red eye - unilateral

Objective

•SPK

• Dendrites with terminal end bulbs
• RISK of epithelial involvement becoming stromal

Answer 371

A

HERPES SIMPLEX

Debridement (Decr viral particles)
• Topical antiviral: Viroptic solution (triflururidine)
1. VIROPTIC 1 gtt 9x pd till healed - QID 1wk
2. Acyclovir Gtt 5xpd till dendrites heal Then TID 1Wk
3. ZIRGAN Gel 0.15% Gtt 5pd then TID 1wk
Acyclovir 400mg -5x a day 7-10 days
* Valacyclovir 500mg -3x a day 7-10 days*Famciclovir 250mg -3x a day 7-10 days