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KMK > Ocular Disease > Flashcards

Ocular Disease Flashcards

1
Q

What is sclerotic scatter used for?

A

evaluate corneal clarity (see with the naked eye)

move illumination to 60 degrees, illuminating the temporal limbus w/ a parallel piped about 1mm in width

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2
Q

What is an optic section used for?

A

angle depth and localize depth of the lesion

beam is ~0.5mm wide and illumination system is moved to optimize oblique view of the tissue

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3
Q

What is a conical beam used for?

A

assess anterior chamber for cells and flare

the pt should be dark adapted

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4
Q

What is specular reflection used for?

A

evaluate corneal endothelium and anterior and posterior surfaces of the lens

beam is 1 mm wide. oculars are directly in front of the pt and beam moved 45-60 degrees from the oculars

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5
Q

What is indirect illumination used for?

A

non-opaque corneal lesions (microcysts, fingerprint lesions) EBMD, ABMD

oculars are focused on the area adjacent to the beam. The beam is approx 1.0 mm wide and moved 60 deg from the ocular

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6
Q

What is cobalt blue filter used for?

A

check corneal and tear film integrity

When filter is used w.o fluorescein - useful in detecting subtle fleischer ring

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7
Q

What is the pH of the eye?

A

7.4

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8
Q

What are the signs and symptoms for alkali and acidic burns?

A

Symptoms: normal or decreased vision, pain, FBS, photophobia, tearing, and blepharospasm

Signs: SPK, sloughing of entire epithelium, conjunctival injection, chemosis, ciliary injection, anterior chamber reaction, conjunctival hemorrhage, scleral and limbal blanching, increase IOP in severe burns

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9
Q

Which of the following has the worse prognosis?

alkali burns
acidic burns

A

alkali burns b/c they raise tissue pH causing a break down of fatty acids causing faster penetration

they are twice as common

“basic burns are bad”

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10
Q

What are some examples of alkali agents?

A

fertilizers, common cleaning agents, drain cleaners, magnesium hydroxide (flares, fireworks), lime (plaster,mortar, cement, white-wash, mouthwash), air bag residue

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11
Q

What are some examples of acidic agents?

A

hydrofluoric acid (glass polisher, rust remover, industrial cleaners), sulfuric acid (fertilizers, explosvies, dyes, battery acid), nitric acid (fertilizers, explosives, rocket propellant), chromic acid (wood preservation), and PAVA spray (pepper spray that contains pelargonic acid)

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12
Q

What is the most common cause of alkali burns?

A

hydroxide

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13
Q

Which signs is an indicator of ischemia 2’ to alkali burns

A

limbal blanching = leads to scarring

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14
Q

What are the signs and symptoms for a corneal abrasion

A

signs: injection, sharp pain (esp after blinking), tearing, blurred vision, photophobia, mild anterior chamber rxn, miosis

symptoms: corneal defect that stains w/ fluorescein with NO SEI

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15
Q

What are the signs and symptoms for conjunctival abrasion?

A

symptoms: pain, FBS, tearing

signs: conj injection or associated subconj heme

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16
Q

What are the signs and symptoms for a foreign body?

A

Symptoms: tearing, photophobia, blurred vision, injection

Signs: FB w/ or w/o sterile infiltrate, corneal edema, mild anterior chamber reaction, rust ring

also check UL for FB - can cause vertical/linear corneal scratch

always check VA before removing FB

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17
Q

What are the signs and symptoms for a ruptured globe?

A

M>F (3:1), young to middle aged

Symptoms: pain, blurred vision, redness, photophobia, tearing

Signs (non-exhaustive list): full-thickness laceration, severe conj heme, EOM restriction, leakage of intraocular contents, low IOP, (+) seidel sign, hyphema, commotio retinae, choroidal rupture, tractional retinal detachment

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18
Q

Which test would provide information if a wound leak exist?

A

(+) seidel’s sign, fluorescein dye will appear as a dark stream (diluted by the aqueous) withinthe green dye of the tears

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19
Q

Which drug is used for RCE and EBMD?

A

doxycycline can knock out MMPs

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20
Q

What can cause a hyphema?

A

sick cell retinopathy, clotting disease, (systemic disease), idiopathic, hx of blunt or penetrating trauma

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21
Q

What should you do if you see a hyphema?

A

DO NOT perform gonio or scleral depression until 1 moth post-injury to prevent rebleeding

B-scan if it occludes the fundus and concerned about retinal detachment

elevate head (30 degrees) allowing RBCs to settle inferiorly

Run CBC/PT/PTT, ask about sickle cell, systemic diseases, use of NSAIDS, warfarin, clopidogrel, aspirin, dipyridamole

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22
Q

What are the signs and symptoms of a hyphema?

A

symptoms: blurred vision, pain,

Signs: blood in the anterior chamber, can be red or black hyphema, vossius ring, sphincter tear, iridodialysis, catarcts, lens subluxation, commotio retinae, angle recession (60% of cases), incr IOP

corneal blood staining (may occur in late stages) - assoc. with large hyphemas, rebleeds, elevated IOP, comprised corneal endothelial cells

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23
Q

What are the 2 types of hyphemas?

A

8 ball - 100% of anterior chamber

microhyphema - rRBC suspended in the AC can only be viewed with a slit lamp

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24
Q

What questions should you ask about if you see an idiopathic hyphema?

A

Use of NSAIDS aspirin, warfarin, clopidogrel, dipyradamole

CBC

PT/PTT

sickle cell screening

sickle cell/clotting disease in AA and mediterranean pts

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25
Q

Define iridodialysis

A

trauma where iris root separates from ciliary body

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26
Q

What test should you order if you suspect an intraocular foreign body?

A

do NOT order an MRI if it is a metal FB

order CT scan/B scan

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27
Q

What are the signs and symptoms of intraocular foreign body?

A

symptoms: pain, decreased vision

signs: transillumination defect (TID), distorted pupil, hyphema, decr IOP, (+) seidel sign, microcystic edema of the peripheral cornea, inflamamtion

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28
Q

What are the signs and symptoms of an orbital fracture?

A

Symptoms: pain, binocular diplopia, cerpitus on palpation of the medial orbital area

signs: subconj heme, enopthalmos, diplopia, step-off fracture of the orbital rim, globe ptosis, infraorbital hypoesthesia, asymmetric monocular PDs (>3mm difference), hyphema, angle recession (nonexhastive list),

trapped inf rectus or inf oblique (limits upgaze & downgaze), damage to infraorbal nerve causing hypoesthesia, periorbital creptius (aka orbital emphysema)

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29
Q

How long should you avoid doing gonio or scleral depression on a pt with orbtial fracture? What else should the pt avoid to do?

A

4 weeks after trauma

pt should avoid blowing nose within 48 hours of trauma in order to limit risk of orbital infection (cellulitis)

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30
Q

What is the weakest bone within the orbital wall?

A

maxillary

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30
Q

What’s the weakest bone within the orbital wall?

A

ethmoid

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30
Q

What are some examples of (+) forced duction?

A

Graves ophthalmopathy
Orbital floor fracture
Brown syndrome
Duane retraction syndrome

eye CANNOT be moved

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30
Q

What are some examples of negative forced duction?

A

CN nerve palsy

eye CAN be physically moved

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30
Q

What are the signs an symptoms of commotio retinae

A

causes disruption of the RPE and photoreceptors outersegment.

Signs: gray-white discoloration, retinal heme, choroidal rupture

Symptoms: asymptomatic, acute vision loss if trauma occurs with the macula

aka Berlin’s edema if located in the macula

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30
Q

When does commotio retinae usually resolve?

A

3-6 weeks, permanent vision/visual field loss may occur

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31
Q

What is iridodialysis? What should you watch for in these pts?

A

disinsertion of the iris root from the ciliary body, appears like a retinal hole that’s best seen with retroillumination

monitor for angle recession glaucoma due to possible TM damage 2’ to trauma

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32
Q

Vossius ring

A

pigment ring on the surface of lens from the posterior pigment iris 2’ to trauma

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33
Q

Purtscher’s retinopathy What is it characterized by?

A

Retinopathy associates with acute chest compression trauma

Characterized by diffuse reitnal heme, exudates, CWS

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34
Q

What are other causes of purtscher’s retinopathy?

A

acute pancreatitis, renal failure, long bone fractures (among others)

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35
Q

Choroidal rupture

A

occur in 5-10% of blunt ocuclar trauma

single area or multiple areas of subret heme, usually within the temporal posterior pole, with crescent shaped tears concentric to the ONH

associated with CNVM at the margins of the tear (occurs in 5-10%) of pt

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36
Q

Eyelid ecchymosis

A

bruise or black eye 2’ to trauma from leaky blood vessels in the subcutaneous tissue

look for underlying ocular damage

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37
Q

Signs of conjunctival and corneal laceration

A

seidel’s test to determine if an open globe wound is present

good prognosis unless laceration involves the visual axis

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38
Q

What can cause choroidal rupture?

A

CHBALA

Choroid rupture
Histoplasmosis
Best disease
AMD
Lacquer cracks
Angioid streaks

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39
Q

What can cause a prolapsed orbital fat? What are some signs and symptoms?

A

Aging can weaken the orbital septum causing extraconal fat to prolapse into the UL and LL and surrounding skin

Signs: outpouching of skin of the UL and LL and adnexa with soft palpitation, lid malformation

Symptoms: asymptomatic, irritation, tearing, blurred vision, redness

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40
Q

What is preseptal cellulitis? What are some signs?

A

infection of the anterior orbital septum. more common in young adults and children during the winter months

Signs: eyelid edema, erythema, ptosis, warmth, no pain to w/ mild tenderness, hard bump on eyelid (NO ORBITAL CONGESTION)

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41
Q

What are some common causes of preseptal cellultis?

A
  1. ocular infection: acute hordeolum, dacryocystitis
  2. systemic infection: nearby upper respiratory tract or middle ear infection
  3. skin trauma: puncture wound, insect bites
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42
Q

What is the leading cause of exopthalmos in children?

A

orbital cellulitis

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43
Q

What should you ask about if a pt has orbital cellulitis?

A

fever, sinus/dental infection, recent trauma

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44
Q

What is orbital cellulitis? What are some common causes? What should you be worried about?

A

infection of the posterior orbital septum

  1. sinus infection: especially ethmoid sinusitis
  2. orbital infection: dacryoadentitis, dacryocystitis, progression of preseptal cellulitis
  3. orbital fracture
  4. dental infection

diabetics worse (mycormycosis)

worry about meningitis, proptosis can lead to optic atrophy

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45
Q

What are some signs and symptoms of orbital cellulitis

A

fever, EOM restriction, pain, proptosis, decreased VA

signs: eyelid edema and redness

symptoms: red eye, pain, decreased vision, HA, fever, general malaise, reduced color vision, APD and diplopia with pain on eye mvmt due to EOM restrictions

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46
Q

What is the prognosis of orbital cellulitis?

A

can cause serious infection that can result in a cavernous sinus thrombosis, brain abscess, and/or meningitis if not caught early and managed appropriately

Diabetics and immunocompromised pt with orbital cellulitis can develop mucormycosis, an aggressive fungal infection that can be-life-treahtening; these pts have a characteristic “black eschar” (black necrotic tissue) in their mouth and nose

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47
Q

How can you tell the difference between presceptal cellulitis vs orbital cellulitis?

A

Preseptal will NOT have decreased vision, proptosis, fever, pain on eye mvmt, or EOM restrictions, all of which are common in orbital cellulitis

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48
Q

What is the strongest risk factor for thyroid eye disease (graves Opthalmopathy)?

A

smoking cigarette 2-9X greater risk

female predilection 8:1, 4th-5th decade of life, 1% will develop myasthenia gravis

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49
Q

What is thyroid eye disease (graves ophthalmopathy) characterized by?

A

Autoimmune disease characterized by TSH receptor antibodies directed against the EOMs and orbital tissue, causing fibroblast proliferation and significant inflammation and thickening of EOMs that results in ON compression in the late stage of the disease

can cause hyperthyroidism

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50
Q

What are some signs and symptoms of thyroid eye disease (graves opthalmopathy)?

A

symptoms: prominent eyes, chemosis, FBS, tearing, photophobia, pain, diplopia, decreased vision, and color vision loss

signs: unilateral or bilateral (often asymmetric), proptosis, UL retraction, eyelid erythema, edema, conjunctival/caruncle injection and edema, decreased color vision, EOM restrictions and APD. IOP may be elevated in primary and up gaze

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51
Q

What is the most common cause of unilateral or bilateral proptosis in middle-aged pts?

A

Thyroid eye disease

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52
Q

NO SPECS

A

grading system of thyroid related ophthalmopathy

N - no signs or sx
O - only signs, no sx (lid retraction, dalrymple’s sign)
S - soft tissue involvement such as lid edema and conj chemosis
P - proptosis
E - EOM involvement, diplopia, IR affected first (IM SLO)
C - corneal involvement (punctate keratitis, SLK, ulceration)
S - sight loss due to optic nerve compression)

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53
Q

Which EOM is affected first in thyroid eye disease?

A

inferior rectus (IM SLO)

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54
Q

What’s the greatest threat to vision in thyroid eye disease?

A

optic nerve compression due to enlarged EOMS

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55
Q

What tests would you perform to diagnose thyroid eye disesase?

A

(+) Forced duction

CT/MRI to view

enlargement of EOMs

Exophthalmometry to measure proptosis

VF to detect ON compression

Blood work (T3/T4/TSH) to measure thyroid function

look for:
VG sign: UL lag during downgaze
Kocher’s sign: globe lag compared to lid mvmt when looking up
Dalrymple’s sign: lid retraction resulting in a stare apperance

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56
Q

What are the Hertel norms for adults?

A

12-22mm caucasians
12-18mm asians
12-24mm AA

abnormal if higher OR presence of >3mm asymmetry. make sure to record the base (19)!

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57
Q

What is the Carotid-Cavernous Fistula caused by? (CCF)

A

abnormal communication between the arterial and venous system

Head trauma, spontaneously (from ruptured internal carotid aneurysm), high pressure blood from the carotid artery builds up in the cav sinus and impedes return of venous blood back to the cav sinus = build up of pressure behind the globe causing a clincal triad of chemosis, pulsatile proptosis, ocular bruit

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58
Q

What is the clinical triad for CCF? What are other signs of CCF?

A

pulsatile, chemosis, ocular bruit, proptosis

episcleral venous congestion, periorbital tissue swelling, elevated IOP, diplopia 2’ to 3,4,6 palsies and loss of lid/face sensation on the affected side due to CN 5 palsy

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59
Q

What is the most benign tumor in children?

A

capillary hemangioma

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60
Q

When is capillary hemangioma usually diganosed?

A

6 months after birth

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61
Q
A

Capillary hemangioma

  • dx by 6 months
  • blanches with pressure
  • mainly in children
  • gradually involute by age 7
  • can cause proptosis and deprivation amblyopia if the visual axis is blocked
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62
Q
A
  • benign orbital tumor in adults
  • occurs 4th - 6th decade
  • F>M
  • progressive, painless, unilateral proptosis as the tumor most commonly arises posterior to the globe within the muscle cone
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63
Q

What image does this show?

When is it dx? Signs & symptoms?

A

Dermoid cyst

  • usually located S/T quadrant
  • dx 1st decade
  • noticeable proptosis
  • CT scan will show a mass
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64
Q

Review: capillary hemangiomas occur in ___ while cavernous hemangiomas will occur in ____

A

children, adults

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65
Q

What would you dx this pt with?

A

Neurofibroma

  • yellow/white tumor of astrocytes
  • common in young to middle aged adults
  • assoc w/ neurofibromatosis
  • CT scans shows a mass that’s located in the superior orbit
  • unilateral or bilateral or isolated
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66
Q

Neurilemmoma (Schwannoma)

A
  • tumor of the schwann cell
  • common in young adult to middle age
  • located in the superior orbit
  • develops within the first division of CN 5
  • gradual onset of painless, progressive proptosis
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67
Q
A

Optic nerve glioma (juvenile pilocytic astrocytoma)

  • symptoms within 1st decade of life (ages 2-6)
  • Infant cases w/ optic nerve glioma are associated with neurofibromatosis type 1 in up to 30-50% of cases (NF type 1)
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68
Q

What’s the most common benign brain tumor

A

meningioma

  • typically occurs in middle aged women
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69
Q

What is the most common intracranial tumor to invade the orbit?

A

sphenoid meningioma from the sphenoid bone

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70
Q

What is the most common primary pediatric orbital malignancy?

A

Rhabdomyosarcoma

  • rapid bone destructing tumor that causes progressive unilateral proptosis
  • avg age of dx is 7 yo

“starts in the orbit and travels elsewhere”

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71
Q

What is the most common secondary pediatric orbital malignancy?

A

Neuroblastoma

most commonly arise from a tumor in the abdomen, mediastinum, or neck (may have associated horner’s syndrome)

” starts elsewhere and travels to the brain”
“blast to the brain”

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72
Q

What is the most common malignant tumor in pts that is 50-70 yo?

A

Lymphoma

  • APD and insidious progressive proptosis
  • 60% 5-year survival rate
    -proptosis in one eye

salmon patch

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73
Q

What are the signs and symptoms of an orbital tumor?

A

** GRADUAL ** progressive vision loss, proptosis, diplopia, APD

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74
Q

What would you suspect in a patient with proptosis in a 70 yo vs 40 yo

A

70 yo = lymphoma (unilateral)

40 yo = TED (unilateral or bilateral)

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75
Q

What is the 3rd most common orbital disorder in adults?

A

orbital pseudotumor ( Idiopathic orbital inflammatory syndrome)

  • rare condition
  • young to middle age pts
  • may be acute, recurrent, or chronic
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76
Q

What are some signs and symptoms of orbital pseudotumor?

A

Symptoms: acute onset of unilateral pain, red eye, diplopia, and/or decr vision, may be bilateral in children, 50% of affected children will have fever nauea, and vomiting

signs:
- lid ptosis
- periorbital swelling
- lacrimal gland enlargement
- conjunctival chemosis
- reduced sensation due to CN V1 involvement
- incr IOP on the affected side
- Optic nerve swelling
- EOM restrictions (causing external ophthalmoplegia) and proptosis due to inflammation of orbital contents

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77
Q

What should you think about when you see unilateral chemosis?

A

chemosis can be due to allergic conjunctivits but if it’s unilateral thin of idiopathic orbital inflammation as a DDx (IOI) esp in young to middle aged pts

esp if it’s without itching

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78
Q

What causes Tolosa hunt syndrome?

A

cavernous sinus issue or inflammation
and the SOF

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79
Q

What are the signs and symptoms of tolosa hunt syndrome?

A

acute and painful exopthalmoplegia and diplopia due to ipsilateral palsies of CN 3,4,6

V1 and V2 damage can cause loss of sensory innervation to their areas of distribution may also occur

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80
Q

What goes through the cavernous sinus?

A

CN 3,4,6, V1, V2

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81
Q

What is your DDx if you see bilateral proptosis or orbital pseudotumor?

A

systemic vasculitis (Wegner’s granulomatosis, polyarteritis nodosa, or lymphoma

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82
Q
A

Phtisis Bulbi

shrinkage and atrophy of globe as a result of trauma, infection, surgery, or advanced dz

assoc with inflammation, hypotony, and a blind eye

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83
Q

Anopthalmos

A

absence of ocular tissue within the globe, primary cases are very rare

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84
Q
A

microphthalmos

small globe, congenital in nature

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85
Q
A

Enophthalmos

retraction of the bloge within the orbit due to trauma

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86
Q

What are ocular prosthesis made out of?

A

methyl methacrylate, usually fit in pts with anopthalmos 2’ to surgical procedure

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87
Q

Removal of the globe

A

enucleation

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88
Q

removal of inner contents of the eye , sclera, and other orbital contents remain

A

evisceration

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89
Q

removal of ALL contents of the orbit, including EOMS and fat

A

externation

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90
Q
A

ocular rosacea

  • affects the sebaceous gland (MG)
  • F>M, but men have it worse
  • middle-aged adults
  • Northern European ancestry
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91
Q

What are the signs and symptoms for ocular rosacea?

A

Symptoms: redness, burning, FBS, ocular irritation

Signs: telangiectasia, rhinophyma, facial flushing (malar butterfly rash)

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92
Q

What are some triggers for acne rosacea?

A
  • alcohol
  • exertion
  • spicy foods
  • increased sun exposure
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93
Q

What other eye conditions present with telangectasia?

A

Basal cell
Acne rosacea
coats disease (unilateral)

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94
Q

where does SEI start?

A

stroma

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95
Q

What can cause phlyctenules?

A

staph
TB

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96
Q

ocular rosacea can cause lid dz, which results in what type of ocular surface dz?

A

phlyctenules, spha marginal keratitis, SPK, corneal neo (inf), and dry eye syndrome

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97
Q

What type of reaction is contact dermatitis?

A

type 4 hypersensitivity rxn

  • delayed T cells
  • develop 24-72 hours after exposure
  • makeup, shampoo, soaps, hairspray, fingernail polish, perfumes, jewelry, poison ivy, cls solution
  • medications: aminoglycosides, trifluridine, cycloplegics/mydriatics, glaucoma meds, preservatives
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98
Q

Review: What are examples of aminoglycosides?

A

tobramycin, gentamicin

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99
Q

What glaucoma medications can cause type 4 contact dermatitis?

A

Alphagan, timolol, trusopt

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100
Q

What preservatives can cause contact dermatitis?

A

thimerosol
BAK

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101
Q

What are the signs and symptoms of contact dermatitis?

A

Symptoms: acute periorbital swelling, redness, itching, tearing

Signs: unilateral or bilateral erythema and crusting of the lid and peri orbital tissues and significant conjunctival chemosis

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102
Q
A

Ocular cicatricial pemphigoid (OCP)

idiopathic mucous membrane disorder, chronic autoimmune affecting the ocular and oral membrane

  • rare conditions that affects F>M
  • avg age 65 yo
  • sig # of these pts develop bilateral blindness ~10-30 years after dx
  • type 2 hypersensitivity reaction
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103
Q

What eye drops can cause OCP?

A
  • timolol
  • epinephrine
  • pilocarpine
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104
Q

What are the signs and symptoms of OCP?

A

Symptoms: redness, dryness, FBS, decreased vision

Signs: conjunctival fibrosis and scarring (seen as fine white striae), bilateral symblepharon, ankyloblepharon, stretched inferior fornices due to shortening of the conj tissue

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105
Q

What is the prognosis of OCP?

A

disease results in destruction of the goblet cells, MG, and glands of krause and wolfring, main lacrimal gland, and severe ocular surface dz

late stage findings include entropion, trichiasis, w/ resulting ulceration, neo, keratinization

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106
Q

What type of sensitivity is SJS?

A

type 3 or type 4 hypersensitivity that affects mucous membranes

most commonly drug-induced, infectious agents

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107
Q

What drugs can cause SJS?

A

sulfonamides (most common)

phenytoin, penicillin, aspirin, barbituates, isoniazid, tetracyclines, NSAIDs, immunizing vaccinations

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108
Q

What infectious agents can cause SJS?

A

HSV, mycoplasma pneumonia, adenovirus, streptococcus species

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109
Q

What are the acute signs (vs chronic signs) and symptoms of SJS?

A

Acute signs: fever, malaise, HAs, nausea, vomiting, skin lesions (diffuse erythema - target or classic bulls-eye lesions and papules on the palms of hands and soles of feet)

ocular lesions - severe bilateral, diffuse conjunctivitis assoc. w/ pseudomembranes
- bacterial conjunctivitis can progress to endopthalmitis in severe cases

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110
Q

What are some chronic signs/symptoms (vs acute) of SJS?

A

Chronic signs/symptoms:

Eyelid pathology: entropion, ectropion, trichiasis, MG damage

Conjunctival pathology: symblepharon, foreshortening of fornices, conjunctival keratinization, limbal stem cell damage, which leads to subsequent corneal pathology

Corneal pathology: ulcers, neo, scars, perforation

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111
Q

What’s the cause of dermatochalasis?

A

redundant upper eyelid skin, weakened orbital septum often causing ptosis, pseudoptosis, and loss of typical distinct eyelid creases

can cause superior VF loss in severe cases

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112
Q

What are 2 main types of blepharitis?

A

staphylococcal blepharitis

seborrheic blepharitis

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113
Q

What are signs and symptoms of blepharitis?

A

often asymptomatic, may report vision clears after blinking, itching, FBS, tearing, crusting (esp in the AM), and mild discharge

seborrehic blepharitis is frequently assoc. with seborrheic dermatitis

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114
Q
A

chalazion

  • chronic, localized, sterile inflammation of MG due to retention of normal secretions
  • resolves spontaneously w/o tx
  • ask about acne rosacea and seborrheic dermatitis
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115
Q

What are the signs and sx of chalazion?

A

hard, painless, immobile nodule without redness that is most commonly located on UL

pts are most likely asymptomatic

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116
Q

Recurrent chalazia warrant what?

A

possible malignancies, sebaceous gland carcinoma

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117
Q

What’s the difference between internal hordeolum vs chalazion

A

hordeolum is an infection vs chalazion is non-infectious inflammation

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118
Q

What bacteria is typically associated with hordeolum?

A

staphylococcus infection

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119
Q

What’s the difference between internal vs external hordeolum?

A

internal = MG
external = zeis and moll

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120
Q

What’s another name for style?

A

external hordeolum

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121
Q

What are the signs and symptoms of a hordeolum?

A

tender, red, warm area of focal swelling of the lid

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122
Q

What layer of the skin does an eyelid cyst occur at?

A

epithelium of the epidermis and dermal tissues (often assoc. with meibomian, sebaceous and sweat glands of the eyelids)

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123
Q

What are the signs and sx of an eyelid cyst?

A

most common complaint is cosmesis

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124
Q

What are different examples of an eyelid cyst?

A
  • inclusion cyst: congenital or acquired lesion. Appears white due to the accumulation of keratinous debris.
  • milia: an acquired lesion, appear white due to occlusion of sweat pores or pilosebaceous follicles
  • dermoid cyst: congenital lesion that is firm and immoble, located on S/T or sup nasal eyelid
  • sebaceous cyst: retention of fluid within the glands of zeis or debris in MG . They are solitary, smooth lesions that are yellow or opaque
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125
Q
A

Ectropion

eversion of the eyelid away from the globe due to loss of muscle tone of the OO

mostly age related

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126
Q

What are other causes for ectropion? What are the signs/sx

A

mechanical (tumor), cicatricial (scar tissue, trauma, chemical burns, skin dz, previous lid sx), paralytic (facial nerve palsy), congenital

signs/sx: exposure keratopathy, epiphora, brow ptosis

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127
Q
A

Entropion

inversion of the eyelid against the globe

  • age-related (involution), most common
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128
Q

What are other causes of entropion

A

Age related

cicatrical (SJS, cicatricial, OCP, chemical burns, previous lid sx, trichiasis, distichiasis)

congenital

can cause pseduotrichiasis

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129
Q

What are the signs/sx of entropion

A

mild punctate keratitis, corneal ulcer, pannus

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130
Q

What is the large reason for blindness in trachoma?

A

corneal ulceration 2’ to entropion and trichiasis

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131
Q
A

Floppy eyelid syndrome

most common in obese men with obstructive sleep apnea

  • reduce elastin within the tarsal plate, predominantly in face-down sleepers (mechanical trauma) from eyelid and pillow contact
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132
Q

What are the signs and symptoms of floppy eyelid syndrome?

A

spontaneous lid eversion, papillary conjunctivitis (from friction)

assoc w/ obstructive sleep apnea, diabetes, hyperthyroidism, HTN

symptoms: chronic, bilateral, red eyes in the AM upon wakening w/ mild mucus discharge

signs: chronic papillary conjunctivitis w/ loose UL that evert easily, punctate epithelial keratopathy and keratoconus are noteworth corneal assoc.

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133
Q

What are the most common conditions that causes red eyes in the AM

A

FES, RCE, exposure keratopathy

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134
Q

Benign Essential Blepharospasm (BEB)

A
  • mainly in pts 50-70 yo
  • 2X more common in F
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135
Q

What are the signs and sx of BEB?

A

Sx: Involuntary, sustained, repetitive bilateral twitching or forceful closing of the eye

Signs: spasm of the procerus, corrugator, orbicularis oculi muscles

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136
Q

Why does BEB occur?

A

50% of pts with BEB have an ocular surface disorder that may be exacerbating the spasms

50% of pts w/ BEB have meige’s syndrome - characterized by BEB and lower facial abnormalities (difficulty chewing, oepning mout, jaw spasm, jaw pain, etc)

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137
Q

Myokymia

A

unilateral twitching of the orbicularis oculi, doesn’t affect the corrugator or procerus muscles

commonly caused by sleep deprivation, too much caffeine, and/or stress

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138
Q

What’s the key difference between BEB and myokyma

A

BEB = bilateral, uses 3 muscles (OO, procerus, and corrugator)

myokyma = unilateral, uses 1 muscle (OO)

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139
Q

What are the 3 types of malignant tumors on the eyelid from least to most aggressive

A
  1. Basal cell carcinoma (BCC)
  2. Squamous cell carcinoma (SCC)
  3. Sebaceous gland carcinoma
  4. Malignant melanoma
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140
Q

What of the 3 malignant eyelid tumors is the most common in the US?

A

BCC

  • M>F (2:1)
  • sun/UVB exposure (290-320)
  • chronic bleeds and will not heal
  • minimally invasive
  • affects the stratum basal
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141
Q

What are the signs and symptoms of BCC?

A
  • shiny, firm, pearly nodule, superficial telangiectasia, rodent ulcer

commonly on the LL and medial canthus

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142
Q
A

squamous cell carcinoma

  • affects stratum spinosum
  • M>F (2:1)
  • 2nd most common eyelid cancer but 40-50x less common than BCC
  • UVB exposure (290-320)
  • precursor is actinic keratosis
  • prior radiation, fair skin, burn scars, chemical exposure (smoking), other forms of chronic irritaton
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143
Q

What is the precursor of SCC

A

actinic keratosis

  • pink red scaly lesion on sun exposed skin that does not heal
  • 25% develop into SCC
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144
Q

What are the signs and sx for SCC?

A

often present similar to BCC but without surface telangiectasia. classically described as erythematous plaque that appears rough, scaly, and or ulcerated, and may be flat or elevated.

most commonly located on the LL or lid margin

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145
Q

how can you tell the difference between SCC and BCC

A

SCC has not telangiectasia

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146
Q

Keratocanthoma

A

can appear very similarly to BCC and SCC

usually found in sun-exposed areas and has an early appearance that is similar to BCC and SCC

these tumors can grow very quickly to a large size 1-2cm before they slowly shrink and often spontaneously resolve

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147
Q
A

Sebaceous gland carcinoma

  • more common in elderly F
  • hx of chronic unilateral blepharitis or recurrent chalazia
  • neoplasm of the sebaceous gland
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148
Q

What is the prognosis for a sebaceous gland carcinoma?

A

poor, if the lid lesion is >2cm the mortality rate is 60%

if present longer than 6 months, the mortality rate is 68%

overall mortality rate is 10%

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149
Q

What are the signs and symptoms for sebaceous gland carcinoma?

A

tumor is often hard and yellow

assoc w/ madarosis, thickened and red lid margins, common on the UL and lymphadenopathy

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150
Q
A

malignant melanoma

  • most lethal skin cancer
  • malignancy of the melanocytes
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151
Q

What are the risk factors for malignant melanoma?

A

age, skin, color, fam hx, repeated irritation, sun exposure

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152
Q

What are the signs you should look for in malignant melanoma?

A

A - Asymmetry
B - Border irregularity
C - Color differences
D - Large diameter
E - Enlargement of the lesion

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153
Q

What are the 2 most important prognostic factors of malignant melanoma?

A

depth and size of the lesion

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154
Q
A

Dacryoadenitis - inflammation of the lacrimal gland

  • more common in young adults and children
  • ask if there’s any hx of fever or systemic infection
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155
Q

What are some causes for dacryoadenitis?

A

Acute infections:
staph aureus, neisseria gonorrhoeae, streptococci

Viruses: mumps, mononucleus, influenza, herpes zoster

Chronic infections: sarcoidosis, tuberculosis, graves dz, idiopathic orbital inflammation,

25% of pts with orbital inflammation will have lacrimal gland involvement

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156
Q

What are the signs and symptoms of dacryoadenitis?

A

Swelling of the outer 1/3rd of the temporal UL

acute: S-shaped ptosis, temporal upper eyelid pain, redness, swelling, preauricular lymphadenopathy, occ fever, elevated WBC count

chronic: temporal UL swelling w/ less redness, swelling, and pain compared to acute dacryoadenitis. chronic cases may lead to inferonasal globe displacement and proptosis

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157
Q

What is canaliculitis caused by?

A

most common culprit is actinomyces israelii which is characterized by yellow sulfur granules after expression of the canaliculi

other culprits include staph aureus, candida albicans, aspergillus, nocardia asteroides, herpes simplex, herpes zoster

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158
Q

What are the signs and symptoms of canaliculitis?

A

sx: smoldering, unilateral red eye unresponsive to antibiotic tx, often misdx as recurrent conjunctivitis

signs: tenderness over the nasal portion of the UL and LL, pouting puncta, dacryoliths, mucopurulent discharge that occurs w/. palpation over the lacrimal sac region

“a lot of canals in Israel w/ yellow rocks”

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159
Q
A

Dacryocystitis: lacrimal sac infection

  • ask about concomitant ear, nose, throat infection
  • characterized by swelling below the medial canthal tendon
  • TREAT FIRST, do not attempt sx or irrigation w/ acute cases
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160
Q

What causes a dacryocystitis?

A

obstruction of the drainage system causing a backflow of bacterio from the nasolacrimal duct into the lacrimal sac

staph aureus, staph epidermis, pseudomonas, H. influenzae in children

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161
Q

What should you suspect if you see swelling ABOVE the medial canthal tendon?

A

lacrimal sac tumor

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162
Q

What if you see a chronic case of dacryocystitis? What should you suspect?

A

epithelial carcinomas and malignant lymphomas

carcinomas can express blood into the tar film with palpitation of the lacrimal sac

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163
Q

What are the signs and symptoms of lacrimal sac?

A

sx: pain, crusting and tearing, occ fever

signs: prominent edema and tenderness over the lacrimal sac

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164
Q

Which one has worse swelling, tenderness and pain?

dacryocystitis or canaliculitis?

A

dacryocystitis

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165
Q

what’s the most common cause of dacryocystitis?

A

NLD is the #1 cause

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166
Q

What is the most common cause of punctal stenosis?

A

age

causing narrowing (or occlusion) of the puncta of the UL and LL

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167
Q

What’s the clinical definition of punctal stenosis?

A

less than 0.3 mm or inability to intubate the puncta with a 26 gauge cannula

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168
Q

What’s the signs and symptoms of pts with punctal stenosis?

A

epiphora, ocular irritation

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169
Q

Nasolacrimal duct obstruction (NLDO)

A
  • congenital or acquired (acquired is more common in F).
  • older pts = commonly caused by involutional stenosis. chronic sinus dz, dacryocystitis, nasoorbital trauma
  • Young pts = blockage of the valve of hasner
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170
Q

When does the valve of hasner spontaneously open? What can you do if it doesn’t?

A

1-2 months after birth

digital massage

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171
Q

What are the signs and symptoms of NLDO?

A

sx:unilateral tearing, discharge, crusting, and recurrent conjunctivitis

signs: epiphora, mucus reflex from puncta after compression on the lacrimal sac, medial lower eyelid erythema, mild to no redness or tenderness around the puncta

secondary dacryocystitis can occur in cases of congenital NDLO due to stagnant tears in the lacrimal sac

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172
Q

What are Jones 1 and 2 testing used for?

A

evaluate the ability of tears passing through the lacrimal drainage system

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173
Q

Describe a positive jones 1 and jones 2 test

A

(+) jones 1: presence of fluorescein in the back of the throat or after blowing their nose

only performs jones 2 if jones 1 is negative

(+) jones 2: if pt tastes saline, performs gag reflex, or if fluid is recovered from the nose, the obstruction is cleared

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174
Q

If jones 2 did not work, what’s the next step?

A

Dacryocystorhinostomy DCR

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175
Q

What does jones 2 tell you if there’s backflow within the same punctum? what about backflow of fluid in the opposite canaliculitis and punctum?

A

same punctum = obstruction within the upper or lower canaliculus

retrograde flow through the opposite canaliculus and punctum = obstruction distal to the common canaliculus

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176
Q

conjunctival cyst

A

aka retention cyst/inclusion cyst

common, benign, fluid filled sac on the conj that may cause irritation

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177
Q

Conjunctival concretions

A

superficial, white-yellow deposits of mucous secretions and epithelial cells in the palpebral conj

calcium

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178
Q

Conjunctival Nevus

A
  • benign proliferation of the melanocytes
  • begin around puberty or early adulthood (within 1st decade of life)
  • unilateral, solitary, flat, feely mobile, inclusion cyst within the lesion
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179
Q

What’s the most common location for conjunctival nevus?

A

juxtalimbal followed by plica and caruncle

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180
Q

Primary acquired melanosis (PAM)

A

unilateral acquired pigmentation with indistinct margins that is more common in elderly white pts

  • can be benign or have premalignant potential (30% cases progress to malignant melanoma)
  • nodular region, increased vascularity, and increased growth are suspects for malignancy
  • needs biopsy
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181
Q

Conjunctival melanomas

A
  • 2’ to uncontrolled proliferation of melanocytes
  • found almost exclusively in Caucasians and usually develop around age 50
  • can be pigmented or non-pigmented
  • most commonly arise from PAM, less commonly from a pre-existing nevus
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182
Q

What is the most common site of metastasis for conjunctival melanoma?

A

liver

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183
Q

What’s the most important prognosis indicator for progression to malignancy?

A

thickness

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184
Q
A

Conjunctival intraepithelial neoplasia (CIN)

aka bowens disease or conjunctival squamous dysplasia

  • most common conjunctival neoplasia in the US
  • unilateral, premalignant condition that can progress to squamous cell carcinoma
  • appearance = elevated mass w/ neo, most of them are found at the limbus but can progress to the cornea
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185
Q

What are the risk factors for CIN?

A

UVB exposure, smoking, exposure to petroleum derivatives, fair skin, xeroderma pigmentosa, HIV, HPV

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186
Q

PAM can progress to ____
CIN can progress to ___

A

conjunctival melanoma
conjunctival squamous cell carcinoma

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187
Q
A

Conjunctival squamous cell carcinoma

  • rare, slow-growing, malignant tumors that typically present in elderly caucasian males
  • most commonly derived from CIN
  • usually found limbus and may involve adjacent cornea
  • commonly contains feeder vessel
  • associated with UV radiation and HPV
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188
Q
A
  • pedunculated, benign, red, vascular lesion of the palpebral conj
  • caused by trauma, sx, chalazion, or other sources of chronic irritation
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189
Q

conjunctival granuloma

A
  • inflamed area (white, yellow, transulucent, or brown)
  • located within the conj stroma from retained FB, sx, trauma, infections (Parinaud’s oculoglandular syndrome) or associated systemic conditions
  • asymptomatic or c/o ocular irritation and FBS
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190
Q

What is the most common cause of bacterial conjunctivitis?

Children?
Adults?

A

More common in children than adults

children - H. influenzae
adults - S. aureus, S. epidermidis

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191
Q

What are the signs and symptoms of bacterial conjunctivitis?

A

sx: acute onset of redness that begins in one eye and becomes bilateral, FBS, eyelids stuck together upon wakening

sx subsides 10-14 days w/o tx

Signs: discharge, mucopurulent, corneal signs and preauricular lymphadenopathy are rare

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192
Q

What does chocolate agar (Thaeyer martin) test for?

A

H. influenzae (gram -)
N. Gonorrhea (gram -)

“Hersheys & Nestles chocolate”

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193
Q

What bacteria penetrates the cornea?

A
  1. corynea bacteria
  2. H. influenazae
  3. N. gonnorrhea
  4. Listeria

“CHaNeL”

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194
Q

What would you use to tx gonorrhea

A

cephalosporin higher generation

ceftriaxone (3rd) - attacks gram -

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195
Q

Gonococcal Conjunctivitis

A
  • sexually transmitted dz most common in young adults w/ hx of multiple sex partners
  • transmitted in infants as they pass through the vagina during birth
  • dx w/ chocolate agar (Thayer-martin agar)
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196
Q

What are the signs and symptoms of Gonococcal Conjunctivits?

A

sx: hyperacute onset of severe purulent discharge, redness, FBS, eyelids stuck upon wakening, becomes bilateral over time

signs: severe purulent dischare, conj chemosis (often with psudeomembranes), severe papillar rxn, marked preauricular lymphadenopathy, tender, swollen eyes, corneal ulcers (can invade)

Systemic sx
Men = purulent urethral discharge 3-5 days after incubation
Women = discharge less common, asymptomatic

ALL PTS SHOULD BE EVALUATED FOR CO-EXISTING CHLAMYDIA

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197
Q

Which bacteria commonly causes preauricular lymphadenopathy and pseudomembranes?

A

N. gonorrhea

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198
Q

Adenoviral conjunctivitis

A
  • adults > children
  • due to upper respiratory tract or nasal mucosal infection
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199
Q

How long is adenoviral conjunctivitis highly contagious for?

A

2 weeks (12-14 days)

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200
Q

What are the signs and symptoms of adenoviral conjunctivitis?

A

acute nonspecific follicular conjunctivitis, pharyngoconjunctival fever (PCF), and epidemic keratoconjunctivitis (EKC)

follicles, pseudomembranes, conjunctival hyperemia,

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201
Q

What are the 3 types of adenoviral conjunctivitis? What’s the difference between the 3?

A
  1. acute nonspecific conjunctivitis
  • serotypes 1-11 and 19
  • most common type of adenoviral infection
  • presents with diffuse red eye, conj follicles in the inferior fornices, tearing, mild discomfort, corneal involvement
  1. PCF
  • serotypes 3-5, 7
  • aka swimming pool conjunctivitis
  • children > adults
  • low-grade fever, pharyngitis, corneal involvement is not common
  1. EKC
  • most serious type of adenoviral conjunctivitis
  • serotypes 8,19,37
  • pain and corneal involvement
  • clinical sx occur 8 days after initial exposure to the virus
  • superficial keratitis common during acute phase
  • SEIs occur 3rd week - pt is no long contagious at this point
  • always presents with preauricular lymphadenopathy
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202
Q

What’s the most common adenoviral infection?

A

acute nonspecific follicular conjunctivitis, serotype 1-11, 19

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203
Q

What’s the most serious type of adenoviral conjunctivitis infection?

A

EKC, serotype 8,19,37

remember rules of 8:
- caused serotype 8
- sx 8 days after exposure
- SEIS 8 days after onset of sx

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204
Q

What are the signs and symptoms of EKC?

A

sx: rapid onset of redness, tearing, mild discomfort, preauricular lymphadenopathy, starts in one eye and spreads to the fellow eye

signs: acute follicular conjunctivitis in the inf fornices,pseudomembrane formation, preauricular lymphadenopathy, diffuse keratitis

ALWAYS CHECK NODES

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205
Q
A

Molluscum contagiosum

Rare. common in communities with poor hygiene.
- mot common in children and young adults
- infection of the skin caused by DNA pox virus via direct contact
- if multiple nodules are present consider HIV or other immunodeficiency conditions

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206
Q

What are the signs and symptoms for molluscum contagiosum?

A

single or multiple dome-shaped, umbilicated, waxy nodules located on the lid margin
- usually asymptomatic or complains of mild mucus discharge
- rupture may lead to follicular conjunctivitis and superficial pannus

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207
Q

What’s another example of unilateral follicular conjunctivitis?

A

molluscum contagiosum, herpes simplex

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208
Q

What test would you perform to dx HIV?

A

western blot or ELISA

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209
Q

What are the 2 types of allergic conjunctivitis?

A
  1. seasonal allergic conjunctivitis (pollen)
  2. perennial allergic conjunctivitis ( mites, dust, animal dander)
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210
Q

What are the signs and symptoms of allergic conjunctivitis?

A

chemosis, papillae, redness, itching, tearing, watery discharge

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211
Q

VKC (vernal keratoconjunctivitis)

A
  • affects young males under the age of 10 that live in hot, dry climates
  • 2-10 years before resolving around puberty
  • occurs in pts w/ predisposed atopic systemic conditions (rhinitis, asthma)
  • 40-75% of patients w/ VKC have eczema or asthma, 40-60% of fmhx of atopy
  • common in warm months but may have sx year round
212
Q

What are the signs and symptoms of VKC?

A

sx: intense itching, photophobia, thick mucous discharge, proptosis
- initial outbreak is the most severe and decreases in intensity over time

Sign: prominent papillae on limbus (trantas dots) or UL palpebral conjunctiva (cobblestone papillae)
- corneal involvement punctate epithelial keratitis > large erosions, leading to plaque formation and localized ulcer

213
Q

What’s the difference between VKC and AKC?

A

VKC is predominantly on the conjunctiva and cornea

214
Q

AKC

A
  • most common in young to middle-aged adults w/ hx of atopic conditions, esp atopic dermatitis
  • NOT seasonal, type 1 and type 4 hypersensitivity mechanism
215
Q

What are the signs and symptoms of AKC?

A

sx: bilateral itching of eyelids
watery discharge, redness, photophobia, and pain

signs:
- scaly thickened swollen eyelid
- Dennies lines
- atopy shiners (eye bags from constant rubbing)
- papillae (more prominent inf)
- corneal neo, cataracts are more common in AKC
- symblepharon formation in inf fornices may occur in severe cases and mimic ocular cicatricial pemphigoid

216
Q

Atopic dermatitis

A

the type of chronic eczema that starts in early infancy, 60% dx within first year of life
- hallmark signs = pruritis and rash
- 10% develop shield cataracts between ages 15 and 30

217
Q

REVIEW: What’s the difference between papillae and follicles?

A

Papillae:
- contain central vessels as source for infiltration of eosinophils, mast cells, neutrophils, lymphocytes
- small in size <1mm
- associates w/ bacterial or allergic conjunctivitis
- nonspecific sign of inflammation

Follicles
- Avascular, white-gray nodules typically located in the tarsal and fornix conjunctiva
- immature lymphocytes and macrophages concentrate in the center of the nodule
- CHAT with your follicles
chlamydia, herpes, adenovirus, toxic

218
Q

GPC

A

non-infectious inflammatory disorder associates with friction and immune response to cls surface deposits or environmental factors

  • caused by silicone hydrogel cls, exposed sutures, blebs, buckles, prosthetics
  • allergies
  • most commonly assoc w/ extended wear of soft cls
  • ask about the replacement schedule, cleaning system, and recent switch to silicone hydrogel lens
  • avg length of time of cls wear before development of GPC is 8 months, may develop as early as 3 weeks
219
Q

Solution hypersensitivity/toxicity

A
  • subtle signs and symptoms after switching to a new cls cleaning system
  • most often due to chlorhexidine or thimerosal
220
Q

What’s the signs and symptoms for solution hypersensitivity?

A

sx: redness, burning, reduced cls wear time due to dryness or discomfort - esp after cls insertion after cleaning

signs: follicular conjunctivitis, diffuse conjunctival injection, and diffuse SPK

221
Q

Pannus larger than __ mm is of concern w/ cls wear according to the FDA

A

1.5mm

this is due to chronic hypoxia, watch for sup neo pannus

222
Q

Corneal warpage

A

alteration in corneal shape due cls material that is classically seen in long-term PMMA wearers or GP wearers with poorly fitting cls

in rare cases, it can be seen with poorly fitting cls (typically low Dk, extended wear, and/or cls

223
Q

What are the signs and sx of corneal warpage?

A

pts often report vision is clear in cls but blurry in gls, ghost image, diplopia

irregular astig, can mimic keratoconus, on topo, a high riding cls can cause inf steepening over time

224
Q

How can you tell the difference between corneal warpage vs keratoconus?

A

corneal warpage can be distinguished in that corneal warpage will not have other corneal findings consistent with keratoconus and will improve with discontinuing/refitting cls

225
Q

What causes SLk?

A

Due to cls hyperesnitivity rxn or poor cls fit

cls/ wear
thyroid eye disease
dry eye

226
Q

What are the signs and symptoms for SLK?

A

signs: superior bulbar, upper tarsal conjunctival injection. Papillary rxn, corneal filaments are uncommon, unlike SLK in thyroid disease

227
Q

Contact lens deposit

A

common cls abusers who are not replacing lenses on schedule or who are not cleaning their lenses properly

if deposits are ONLY on the back surface - pt may be cleaning cls incorrectly, reinstruct pt to use finger and palm of hand for digital cleaning

a stronger cleaner or weekly enzyme cleaner should be considered

228
Q

Deposits on GP lens vs soft cls

A

GP lens - plaque

soft cls - jelly bumps

229
Q

Tight lens syndrome

A

occurs when a cls fitting is too tight, resulting in poor mvmt with blink (appears stuck on the cornea)

most common in high myopes (>-8.00) cls that are too steep, or abnormally small (<13mm) or large (>15mm) OAD

less common in hyperopes and pahkes

230
Q

What are the signs and sx of tight lens syndrome?

A

Sx: redness that worsens after cls are removed, hazy vision, halos, dryness

Signs: injection or indentation around limbus and distorted k mires that clear with blinking
- severe cases may result in mild to severe corneal edema or corneal blebs and an anterior chamber rxn
- corneal abrasion may occur after removal of cls

231
Q

What’s the most common complication assoc with GP cls?

A

3 and 9 o’clock staining

  • classically due to low-riding GP cls that do not adequately cover the cornea
  • poor spreading of the tears across the exposed corneal surface
  • chronic 3 and 9 o clock staning may lead to dellen formation, pseudopterygia, corneal neo

pt may be asymptomatic or complain of horizontal redness

232
Q

What’s the classic complication of a cls is riding too high?

A

corneal warpage

233
Q

What’s the classic complication of a cls is riding too low?

A

3 & 9 o’clock staining

234
Q

Superior epithelial arcuate lesion (SEAL)

A
  • arcuate shape of sup corneal staining within 1 mm of the limbus
  • mostly occurs due to 2’ tight extended wear hydrogel cls. Loose cls that chafe or cls with poor wettability may also cause SEAL
  • ~30% cases are asymptomatic
235
Q

What are the signs and sx of seal?

A

sx: FBS, irritation, and corneal subepithelial infiltrates

sign: superior corneal staining 1mm froml imbus

236
Q

Dimple veiling

A
  • characterized by small depression within the cornea that pool fluorescein
  • caused by small gap bubbles that become trapped underneath a cls (most often GP lenses)
237
Q

Keratoconjunctivits

A

simultaneous inflammation of the cornea and conjunctiva

can be caused by bacterial infection, viral infections, herpes simplex, zoster, fungal infection, atopy, allergic, vernal, toxic rxns, factitious dz

238
Q

What should you ask about if you suspect your pt having chlamydia?

A
  • multiple sex partners
  • pain during urination

occurs predominantly in you adults who are sexually active

239
Q

What are the 2 types of chlamydia eye infection?

A
  1. adult inclusion conjunctivitis
  • serotypes D-K
  • spread via direct inoculation (swimming pool, sharing cosmetics)
  • ocular manifestations begin 5-14 after inoculation
  1. trachoma
  • most prevalent between ages 1-5 yo
  • leading cause of preventable blindness
  • 3rd most common causes of blindness world wide after cataracts and glaucoma
  • primary risk factor is living in a community with poor hygiene
  • most infections spread eye to eye (fomites, flies, shared cosmetics are other routes of infection)
240
Q

What are the 3 leading cause of blindnessworld wide?

A

cataracts
glaucoma
trachoma

241
Q

What is the serotype for Chlamydial AIC?

A

D-K

242
Q

What are the signs and symptoms of chlamydial AIC?

A

sx: acute follicular & papillary conjunctivitis that become chronic, most infections begin unilaterally, but bilateral involvement develops
- infection can persist for 3-12 months if not tx

signs: follicles (limbal or palpebral) AND papillae that are mostly concentrated in the inf palpebral conjunctiva and fornices, preauricular lymphadenopathy, scant mucopurulent discharge, matting of the lids, corneal involvement 30-85% of pts include punctate keratitis, superior pannus, and subepithelial infiltrates (more peripheral in location compared to EKC)

243
Q

What’s the leading cause of opthalmia neonatorum in the US?

A

chlamydia (other causes HSV, gonorrhea)

acute conjunctivitis in newborns

244
Q

What do you treat chlamydial AIC with?

A

doxycycline and azithromycin

245
Q

What are the serotypes for trachoma?

A

A-C

246
Q

What’s the difference between AIC and trachoma?

A

AIC
- serotypes D-K
- unilateral
- papillary and follicular rxn predominantly on INF
- preauricular nodes

trachoma
- serotypes A-C
- bilateral
- papillary and follicular rxn predominantly SUP - ultimately spreads thru entire conjunctiva

both cause follicular conjunctivitis

247
Q

What are the signs and symptoms for trachoma?

A

Early: Follicular conjunctivitis predominantly on sup conjunctiva, mucopurulent discharge, lymphadenopathy, and mild superior pannus

Late: Arlt lines (white scarring of the sup tarsal conjunctiva) and herbert’s pits (depression of limbal con after resolution of limbal follicles); progressive tarsal conjunctival scarring can lead to distortion of the eyelids and subsequent corneal ulceration from trichiasis

248
Q

What is preauricular lymphadenopathy associated with?

A
  • chlamydia (trachoma and inclusion conjunctivitis)
  • parinauds oculoglandular syndrome
  • EKC
  • gonococcal conjunctivitis
  • phthiriasis palpebrarum
249
Q

SLk

A
  • mostly affects females around 50yo
  • chronic inflammatory rxn mot commonly associated with k sicca, thyroid dz, cls wear, flare-ups, and remissions that eventually cease over time
  • cause: anything that involves friction, cls, TED, cls wear
250
Q

What are the signs and symptoms for SLK?

A

sx: redness, FBS, frequent blinking, no discharge.

signs: thickened, red, superior bulbar conj that is most prominent at the limbus, bilateral, with adjacent SPK and filamentary keratitis, the upper tarsal conj can have a velvety appearance as a result of diffuse papillary hypertrophy

251
Q

Phlyctenular Keratoconjunctivits

A
  • most common in teenage years with higher occurrence in females
  • ask if pt has had a hx of TB
  • most commonly a result of type 4 hypersensitivity to staph (blepharitis is the most common culprit), TB protein, and acne rosacea
252
Q

What are the signs and symptoms of type 4 hypersensivity?

A

Sx: tearing, FBS, itching associated with conjunctival and corneal phlyctenules, significant photophobia common with corneal phlyctenules

signs: phlyctenules can be located on the cornea or conjunctiva

  1. conjunctival phlyctenules: occurs mostly at the limbus w/ pink fleshy nodules with conjunctival injection
  2. corneal phlyctenules; commonly occur near limbus as small, white (lymphocytic) nodule with adjacent conj injection
253
Q

when should PPD test for TB be read?

A

48-72 hours

type 4 hypersensitivity (T cells, delayed)

254
Q

Ligneous conjunctivitis

A

“PLASMINOGEN deficiency”

  • rare, starts during childhood
  • systemic disorder
  • may affect mucous membranes throughout the body (mouth, ear, vagina)
255
Q

What are the signs and symptoms of ligneous conjunctivitis?

A

signs: thick, white, “woody” membranous plaques of the superior tarsal conjunctiva

LIG rhymes with TWIG = woody plaques

sx: chronic tearing, FBS, photophobia, constant discomfort and cosmetic concerns in advance stages

256
Q

What is plasmin important for?

A

plasmin derives from plasminogen

  • plasmin catalyzes break down of fibrin stopping unwanted clot formation within the healthy vessels throughout the body

“PREVENTS CLOT”

257
Q

Parinaud’s oculoglandular syndrome

A

” CAT SCRATCH”

  • rare, exposure to cats, dogs, rabbits squirrel and ticks
  • common causes: cat scratch fever (bartonella henselae), tularemia (via ticks rabbits, squirrels), TB and syphylis
258
Q

What are the signs and symptoms for Parinaud’s oculoglandular syndrome?

A

sx: red eye, FBS, mucopurulent discharge

signs: unilateral, granulomatous, follicular, palpebral conjunctivitis, preauricular/submandibular lymphadenopathy, fever, rash

259
Q

Phthiriasis palepbrarum (pediculosis ciliaris)

A

aka crab louse

  • found in hair follicles of genital region
  • infection of eyelash, eyebrows, facial hair
  • unilateral or bilateral
260
Q

What are the signs and symptoms of phthiriasis palpebrarum (pediculosis ciliaris)

A

sx: mild itching of eyelids, marked inflammation with burning, itching, tearing, blurred vision

signs: transparent lice and white nits (egg sacs) attached to the eyelashes, blood-tinged debris on lids and lashes, mild to severe chronic follicular conjunctivitis, preauricular lymphadenopathy

Associated w/ follicles due to toxicity (CHAT)

261
Q

What causes sleeving at the base of the lashes?

A

demodicosis

262
Q

Subconjunctival hemorrhage

A
  • caused by valsalva, medications (aspirin, coumadin), HTN, blood clotting disorder (Sickle cell)
  • order CBC, PT/PTT, and Sickledex for idiopathic and recurrent cases, especially in pts of african or Mediterranean descent
263
Q

Pterygium/Pinguecula

A
  • associates with UV exposure and environmental exposure; common in individuals who work outdoors, - UV exposure and chronic dryness are believed to have cause degeneration in the collagen fibrils within the conjunctival stroma
264
Q

What are the signs and symptoms of pterygium/pinguecula?

A

sx: range from asymptomatic to irritation, redness, decreased vision (depending on location of the pterygium)

signs: both located at 3 and 9 o’clock
- pingueculum: yellow-white deposit next to the limbus
- pterygium: triangular fibrovascular growth of bulbar conjunctiva that extends onto the cornea, destroying bowman’s membrane and often leading to WTR astig due to flattening of horizontal meridian, stocker’s line maybe present at the anterior edge of the pterygium

265
Q

Pterygium affects which part of the cornea?

A

bowmans

266
Q

Episcleritis

A
  • most common in young adults (around 2nd-4th decade), Hx of frequent occurrences is common
  • benign, self-limiting, often idiopathic, can be associated with systemic dz
267
Q

What are the systemic dz associates with episcleritis?

A
  • collagen vascular/inflammatory dz: RA, lupus, UCRAP
  • spirochetes: lyme, syphilis
  • Virus: zoster, HSV, mumps
  • metabolic dz: gout
  • vasculitic dz: temporal arteritis, wegener’s granulomatosis, behcet’s dz, polyarteritis nodosa
  • Dermatological dz - acnea rosacea
268
Q

What are the signs and sx of episcleritis?

A

sx: acute unilateral, red eye, mild pain

signs: mostly sectoral injection (or simple, nodular), nodule can be slightly moved with cotton tip applicator

269
Q

Scleritis

A
  • F>M
  • 4th to 6th decade
  • less common than episcleritis
  • anterior scleritis can be divided into non-necrotizing and necrotizing scleritis
270
Q

Non-necrotizing scleritis

A

Diffuse: most common and most benign,

Nodular: deep, focal, painful injected immobile nodule

271
Q

Necrotizing scleritis

A

Necrotizing with inflammation: WORST form, 33% of pts may die as a result of severe autoimmune dz, ocular or systemic complications including anterior uveitis, sclerosing keratitis, peripheral corneal melt, scleral thinning, cataracts, secondary glaucoma

Necrotizing without inflammation (scleromalacia perforans): typically result of RA, complete lack of sx and minimal injection, asymptomatic, large, gray-blue patches of scleral thinning (due to exposure of uvea)

272
Q

What can cause a blue sclera?

A

scleritis
topical steroids
minocycline

273
Q

What’s the most common cause for necrotizing scleritis?

A

RA followed by wegener granulomatosis (collagen vascualr dz)

274
Q

What are the signs and symptoms for necrotizing scleritis?

A

sx: severe, boring ocular pain (hallmark), that radiates to the ipsilateral forehead, brow, jaw, and awakens pt during the night. gradual onset of redness and decrease in vision (except for scleromalacia perforans)

signs: sectoral or diffuse inflammation of the large, deep vessels that cannot be moved with a cotton swab. Edematous or thin sclera with a classic bluish hue under natural light. typically bilateral (episcleritis is unilateral)

275
Q

what type of scleritis is associated with RA?

A

scleromalacia perforans

276
Q

Hyaline plaque

A

benign, oval-shaped areas of scleral thinning that occur with age and allow underlying visibility of the uvea

277
Q

How can you differentiate between scleritis vs episcleritis?

A

Scleritis
- gradual onset
- more significant ocular pain
- bluish hue due to scleral thinning
- bilateral
- more commonly associated with systemic disorder

episcleritis
- acute onset
- asymptomatic
- red eye
- unilateral and sectoral
- more common

2.5% phenylephrine will result in conjunctival blanching in a pt with episcleritis

278
Q

What can cause severe ocular pain?

A

scleritis
anterior uveitis
corneal abrasion, erosion, ulcers
acute angle closure glaucoma

“CASA” corneal pathology, abrasion, scleritis, angle closure

279
Q

Axenfeld’s nerve loop

A

congenital anomaly characterized by focal, pigmented, elevated are where the posterior ciliary nerve loops are visible in the sclera

can be painful

LPCA - branch of nasociliary of V1

280
Q

Anterior Uveitis

A

break down of the BAB

  • occurs more in younger adults
  • peak incidence 2nd-4th decade, rarely above 70 yo
  • 50% with acute anterior uveitis is due to HLA-B27
    -50% of new acute anterior uveitis have associated spondyloarthropathy; 80% of these pts have akylosing spondylitis
281
Q

Which systemic diseases are associated with HLA-B27?

A

UCRAP

ulcerative colitis
crohns dz
reactive arthritis
ankylosing spondylitis
psoriatic arthritis

282
Q

What are the signs and symptoms of anterior uveitis?

A

sx: pain, redness, photophobia, lacrimation, decreased vision (esp with CME), chronic anterior uveitis may be asymptomatic or report blurred vision/dull ache

pain is due to congestion and irritation of the anterior ciliary nerve

signs: dx based on presence or absence of WBC in the anterior chamber, PS, PAS, cataract formation, CME, flare, hypopyon, circumlimbal injection of conj vessels, decreaed IOP in the involved eye, KPs

283
Q

Why is IOP initially decreased for anterior uveitis?

A

ciliary body inflammation

increase in IOP can occur in later stages because of PS, PAS, steroid tx, chronic TM damage

284
Q

What can occur in chronic uveitis?

A

cyclitic membranes - fibrovascular membranes that extend from the CB into the posterior chamber and may involve the lens

285
Q

non-granulomatous vs granulomatous findings for anterior uveitis

A

KPs - characteristic of non-granulomatous etiology
- Koeppe nodules

granulomatous (TB, syphylis)
- mutton fat KPs: greasy appearance, loc middle and lower cornea
- Koeppe nodules: WBC located on pupillary margins
- Busacca nodules: WBC located on the iris stroma EXCEPT the pupillary margin

stellate KPs around found in fuch’s heterochromic iritis and herpetic uveitis

286
Q

Acute non-granulomatous is associated with which conditions?

A

UCRAP

  • inflammatory bowel dz: usually bilateral w/ posterior uveitis. characterized with diarrhea with alternating episodes of constipation. rare in ulcerative colitis but more common with crohns dz
  • Reactive arthritis: young males with urethritis, polarythritis, and conjunctivitis
    “cant see cant pee cant climb a tree”
  • ankylosing spondylitis: M>F, in 3rd decade, lower back pain that improve with exercise
  • psoriatic arthritis: asymmetric, peripheral small, joint pain, and psoriatic lesions on the knees elbows and scalp
  • Behcet’s dz: most common in young adults of Asian and middle eastern descent, acute recurrent hypopyon iritis and mouth and genital ulcers. may also be associated with retinal vasculitis, cataracts and glaucoma
  • lyme dz: hx of tick bites, skin rash, and/or arthritis, may cause non-gran or granulomatous uveitis
  • Glaucomatocyclitic crisis: unilateral, mild iritis with recurrent, self-liming episodes of elevated IOP (30-40s), 2’ to trabeculitis, fine KPs, and open angle on gonio
287
Q

What conditions will present with unilateral cells in the anterior chamber with acutely elevated IOP? (30-50mmHg)

A

Posner schlossman syndrome: rare to mild AC, everything else looks normal

HSV or HZ: reduced corneal sensitivity, concurrent corneal edema, dendrite or pseudo dendrite, vesicular rash along the affected dermatome that respects the vertical midline

Fuchs heterochromic iridocyclitis: rare to mild cells in AC, NVA is often present on gonioscopy, significant iris atrophy and cataracts

288
Q

What conditions are associated with chronic granulomatous, anterior uveitis?

A
  • sarcoidosis: AA, F>M, bilateral, may be posterior or panuveitis, abnormal chest radiograph and increased and increased ACE levels
  • TB: +PPD test, abnormal chest x-ray, night seats, may have posterior or panuveitis
  • HSV/HZ: incr IOP in involved eye, stellate KPs, corneal edema, and/or epithelial defects, zoster will present with vesicles along affected dermatome
  • Syphilis: assoc interstitial keratitis, maculopapular rash, +VDRL,RPR and FTA-ABS or MHA-TP, Interstitial keratitis (stromal inflammation without involvement of epithelium or endo)
  • JIA: most common cause of uveitis in children, bilateral uveitis in young girls, (-)RF (+)ANA
  • Fuchs’ heterochromic iritis: most common in pts with blue eyes, unilateral mild uveitis w/ fine, stellate KPs, angle neo, iris heterochromia, associated with glaucoma/cataracts, often asymptomatic
289
Q

What’s the most common cause of interstitial keratitis?

A

congenital syphilis (90%), TB, HSV

  • IK is characterized by acute stromal inflammatory edema and neo –> progress to diffuse stromal neo sparing the line of sight
  • Late stages stromal vessels clear leading to ghost vessels, corneal scarring, irregular astig
290
Q

Congenital syphilis triad

A

Hutchinson’s teeth, deafness, interstitial keratitis

additional signs include: saddle-nose deformity and frontal bossing (prominent forehead)

291
Q

What is associated with stellate KPs?

A

fuch’s heterochromic iritis and herpes

292
Q

T or F: Pars planitis is typically associated with systemic conditions.

A

FALSE

chronic intermediate uveitis characterized by inflammation over the pars plana (aka snow banking) and peripheral retina; it is NOT associated with systemic conditions

293
Q

What systemic conditions are associated with posterior uveitis?

A
  • Toxoplasmosis
  • sarcoidosis
  • syphilis
  • CMV

posterior uveitis is the inflammation of the retina, choroid, or both

294
Q

What are the signs and sx of posterior uveitis?

A

may or may no have WBC in the vitreous (break down of BAB), floaters/decreased vision

often asymptomatic unless the macula is involved

ask about rashes, tick bites, risk factor for AIDs and breathing difficulties

295
Q

What’s the most common posterior uveitis in the US?

A

Toxoplasmosis

296
Q

What is the culprit for toxoplasmosis?

A

Parasitic infection caused by toxoplasma gondii

may be congenital or acquired (eating undercooked meat or inhaling cat feces)

297
Q

Toxoplasmosis may be acquired or congenital, which one is more common?

A

congenital via transplantal transmission accounting for 90% of cases

severe systemic involvement results in the triad of convulsions, cerebral calcifications, and retinochoroiditis. Most cases are mild and leave insignificant chorioretinal scars

298
Q

What are the signs and symptoms for toxoplasmosis?

A

acquired and reactivated congenital lesion is the most common cause of infectious retinitis

  • young pt, unilateral redness, photophobia, floaters, uveitis, vitritis, decreased vision
  • avg onset 25 yo
  • focal, fluffy, yellow-white retinal lesion adjacent to the old inactive scar with an overlying vitritis “head-lights in a fog”
299
Q

Does histoplasmosis cause a vitritis?

A

NO, it causes choroiditis without vitritis

multifocal punched out yellow-white lesion in the periphery with associated peripapillary atrophy and maculopathy; common in the Ohio-Mississippi River valley

300
Q

Toxo vs histo

A

toxo
- retinovitritis
- parasite
- unilateral
- unifocal
-25 yo

histo (CHBALA = break in bruchs)
- choroiditis
- fungal
- multifocal
- peripapillary
- CNVM
- atrophy maculopathy, histo spots in the periphery

301
Q

What are some ocular findings in sarcoidosis

A
  • Retinal vitritis: cotton ball opacities inf vitreous
  • Retinal vasculitis: candle-wax droppings - sheathing around retinal veins and yellow-white exudates caused by periphlebitis
  • chronic dacryoadenitis
  • dry eye
  • CNV 7 palsy
  • chronic, bilateral, anterior granulomatous uveitis
  • Retinal vasculitis
  • Vitritis
  • Optic nerve dz (unilateral optic disc edem, papilledema
302
Q

Syphyllis

A

2’ syphilis may result in acute multifocal chorioretinits with vitritis or panuveitis

303
Q

what’s the most common ocular infection and leading cause of blindness in AIDS?

A

CMV

304
Q

Cytomegalovirus (CMV)

A
  • white patches of necrotic retina with hemorrhagic retinitis and vascular sheathing
  • occur in pts with CD4 counts <50
  • toxoplasmosis and progressive outer retinal necrosis (PORN)
  • more intravitreal heme and less vitritis compared to toxo
    -PORN has minimal amts of vitritis (similar to CMV) and hemorrhage (less than CMV)
305
Q

Iris coloboma

A
  • localized defect or notch in the iris tissue resulting from incomplete closure of embryonic fissure of the optic vesicle during gestation
  • typically located in the inf nasal quad
306
Q

What are the signs an sx of an iris coloboma

A
  • typically located in the inf nasal quad
  • Complete iris coloboma: key-hole pupil (extend from pupil margin to peripheral cornea)
  • Incomplete iris coloboma: iris transillumination defect on retroillumination
  • often assoc. with other ocular colobomas (CB, zonular, choroidal, retinal, ON)
307
Q

Iris Malignancy

A
  • Malignant tumor that arises from abnormal proliferation of melanocytes within the iris stroma
  • most are thought to arise from iris nevi
308
Q

What are the signs and symptoms of iris malignancy?

A
  • pigmented or amelanotic
  • loc within the stromal tissue in the inf quadrant
  • irregular feathery margins and diameter greater than 3mm

any iris lesion in yonger pts (<40 yo) with high risk characteristics including associated hyphema, ectropion, uveae, angle involvement, inf iris loc, diffuse feathery margins, should be evaluated for potential iris melanoma

309
Q

Dellen

A
  • an area of the cornea that wets poorly, leading to stromal dehyration, corneal thinning, with resulting pooling of fluorescein within the affected area
  • adjacent to pterygia, filtering blebs, tumors, poor fitting RGP lens
  • asymptomatic or FBS or other dry eye sx
310
Q

Exposure keratopathy

A

abnormal or incomplete lid closure due to an issue with CN 7 or the orbicularis oculi

CN 7 issues = bells palsy, CVA, aneurysm, MS, HSV, HZ

OO issues: eyelid sx causing ectropion, TED, nocturnal lagopthalmos, floppy eyelid syndrome

311
Q

What are the signs and sx of exposure keratopathy?

A

Sx: redness, FBS, burning, sx worse in the AM

signs: mild SPK on inf 1/3rd of cornea, corneal ulceration, decr corneal sensitivity

312
Q

Filamentary keratopathy

A

chronic sx of irritation and dryness are common, hx of multiple episodes

caused by chronic inflammation of the cornea and/or any disorder that disrupts the ocular surface

  • K sicca (common causes: FES, SLK, corneal erosions, penetrating keratoplasty, cls overwear, neurotrophic keratopathy
313
Q

What are the signs and sx of filamentary keratopathy?

A

sx: Mild to severe FBS with photophobia, epiphora, blurred vision, blepharospasm

signs: filaments composed of degenerated epithelial cells and mucous that remain attached to the epithelial surface. RAnge in size 0.5 to 10mm and may appear short, long or stringy. Filaments will stain with fluorescein

Filaments = FRICTION
late = stringy
early = comma s -shaped

314
Q

What causes SPK?

A
  • Cls wear
  • corneal infections
  • DES
  • blepharitis
  • corneal exposure 2’ to lid malposition ( CN 7, palsy ectropion, TED)
  • chemical burns
  • allergic response to topical meds (BAK aminoglycosides)
  • Trichiasis, distichiasis
  • FES
  • superficial FB
  • exposure to intense UV light
  • LASIK (due to decr corneal sensation)
315
Q

What are the signs and symptoms of SPK?

A
  • pinpoint defects on the corneal epithelium that stain with fluorescein
  • asymptomatic in mild cases or blurred vision, irritation, FBS, photphobia, redness, tearing
316
Q

Thygeson’s superficial punctate keratophathy

A
  • most common 2nd to 3rd decade
  • recurrent
317
Q

What are the signs and sx of thygesons SPK?

A

Sx: FBS, photophobia, tearing, occasional blurred vision, eye is relatively quiet, chronic and bilateral

Signs: bilateral, small, multiple, asymmetric, gray-white of superficial, intraepithelial, raised central corneal lesions
- acute attacks: last 1-2 months before resolving, stain lightly with fluorescein, exacerbation often recur 6-8 weeks
- remission - period of inactive dz in btw acute attacks, do not stain with fluorescein during remission

318
Q

Neurotrophic keratopathy (NK)

A

V1 damage, reducing corneal sensitivity

BIG ULCER = NO PAIN

  • ask about past surgical procedures, medications, cls wear, systemic dz
319
Q

What are common causes of neurotrophic keratopathy?

A

Directly affect V1 - HSV, HZ, diabetes, lasik, cls wear, conditions that causes corneal epithelial injury (RCE, corneal dystrophies), surgeries (ablative procedures for trigeminal neuralgia, maxillary facial repair), meds (timolol, betaxolol, diclofenac)

damage to CN 7 (due to impaired reflex tearing), tumors, CVA, bells palsy, surgeries (removal of acoustic neuroma), or other conditions that damages CN 7

320
Q

Review: What are the 3 branches of V1?

A

NFL

nasociliary - cornea & tip of nose
frontal - supratrochlear and supraorbital
lacrimal - lateral

321
Q

What are the signs and symptoms of NK?

A

sx: redness, tearing, decr vision, FBS, swollen eyelids, corneal findings are worse than what sx indicate

signs: decreased corneal sensivity**, SPK, perilimbal injection, sterile inferior olva ulcer (often assoc. w/ iritis), without sig inflammation

non-healing epithelial defects which can ulcerate if not treated, corneal perforation

322
Q

RCE

A
  • poor hemidesmosomes attachment to the underlying BM in pts with hx of corneal abrasion or EBMD
323
Q

signs and sx for RCE

A

sx: recurrent episode of acute pain that mostly occurs upon awakening

signs: corneal abrasion that stains with fl

324
Q

Thermal/Ultraviolet Keratopathy

A

less than 300nm UV light

  • hx of prolonged sun exposure, welding, skiing, or sunlamp use w/o protection
  • epithelium and bowmans layer absorb wavelengths below 300nm, excessive absorption of wavelength can cause hyperactivation of K+ channels, with resulting loss of intracellular K+ and cell death
325
Q

What are the signs and sx of thermal/ultraviolet keratopathy?

A
  • pain, photophobia, blurred vision, sx worse 6-12 hrs after incident
  • signs: confluent SPK w/ fl stain
326
Q

what are some medications that can cause dry eyes?

A

Anticholinergic effects
- ASHCT
- Antihistamines “phen” & promethazine
- Antipsychotic: chlorpromazine, thiordiazine
- Antidepressants: TCAs (amitriptyline, imipramine), MAOI (phenelzine), SSRIs (fluoxetine, escitalopram)
- anti-anxiety: diazepam
- muscle relaxant: cyclobenzaprine
- Ipratropium

Additional drugs
- isoretinoin
- b-blockers
- oral contraceptives
- hormone replacement therapy
- ADHD
- diuretic

327
Q

What are some systemic conditions that may cause dry eye?

A

TED, collagen vascular disease (ex. RA, sjogren’s, SLE)

328
Q

What are the sign and symptoms for dry eye?

A

burning, dryness, tearing, itching, increased blinking, photophobia, cls intolerance, FBS, sx worse at the end of the day

signs:
- decr TBUT and increased tear osmolarity
- Aqueous deficient: thin tear meniscus (<0.2mm), decr schirmers, and decr phenol red thread

329
Q

What does schirmers specifically test for? What are normal and abnormal findings for schirmers?

A

schirmers 2 allows for isolation of basal tearing

Schirmer 1: without anesthetic
Normal >10mm wetting within 5 mins
Abnormal <5mm wetting within 5 mins

Schirmer 2: with anesthetic
Normal >5mm within 5 mins

330
Q

What are the 3 types of tearing ?

A

reflex, meotional, basal

331
Q

What’s a normal finding on phenol red thread?

A

normal result is >10mm of wetting after 15 sec

332
Q

What are some evaporative dry eye signs?

A
  • TBUT less than 10 sec
  • Poor expression of the MG (toothpaste consistency)
  • MG atrophy on meibography

other signs:
- conjunctival hyperemia
- debris in the tear film
- corneal filaments
- signs of underlying conditions (acne rosacea, blepharitis)
- variable corneal and/or conjunctival staining with fl and lissamine green staining

333
Q

while performing a TearLab test, what would a dry eye result show?

A

> 308 mOSm/L or >8 mOSm/L difference between the eyes

tear “hyper”osmolarity

334
Q

Primary sjogrens

A

dry eye and dry mouth

2nd most common autoimmune rheumatologic dz (RA is the first)

335
Q

Secondary sjogrens

A

dry eye, dry mouth, and autoimmune connective tissue dz (RA, SLE, polyarteritis nodosa, wegener’s granulomatosis)

336
Q

Dry eye, name an example for each

attacked glands
blocked gland ducts
cut nerves

A

attacked glands - sarcoid, lymphoma, AIDS, graft vs host dz

Block gland ducts - trachoma, pemphigoid, erythema multiforme, chemical and thermal burns

Cut nerves - corneal sx (LASIK, PRK, RK), diabetes, cls, bells palsy, systemic drugs, neurotrophic keratits, infection (HSV, HZ),

337
Q

Evaporative dry eye:

intrinsic
extrinsic

name an ex for each

A

Intrinsic:
- MGD and excess tear evaporation(most common),
-proptosis (TED, craniostenosis),
- nocturnal lagophthalmos
- low blink rate (increase concentration w/ phone use)
- parkinsons dz ( decr dopanergic neuron)

Extrinsic
- vit A deficiency (xerophthalmia)
- topical anesthetics (red blink rate, red reflex lacrimal gland secretion)
- topical preservatives (BAK)
- cls wear

338
Q

What happens if a pt has vitamin A deficiency?

A
  • aqueous deficient dry eye
  • bitot spot

Vit A is important goblet cell and glycocalyx development

339
Q

Keratoconus

A
  • AD
  • commonly begins around puberty
  • ask about frequent changes in eye prescription or hx of eye rubbing (atopy)
  • initial damage to bowmans
  • stromal collagen fibril displacement due to loss of adhesions of fibrils causing corneal thinning and potrusion (degradation of fibrils by MMP)
340
Q

What is keratoconus associated with?

A

atopy, cls wear, ocular and systemic conditions, TDOME

  • Allergic (VKC, AKC, FES)
  • Connective tissue (Fuch’s endothelial dystrophy, posterior polymorphous dystrophy, granular dystrophy, lattice dystrophy
  • Hereditary (aniridia, RP, lebers congenital amaurosis, ROP, cone dystrophy)

TDOME
- turners syndrome
-down syndrome
- osteogenesis imperfecta
- Marfans syndrome
- Ehlers danlos

341
Q

What are the signs and symptoms for keratoconus?

A

Sx: Progressive decreased vision, photophobia, glare monocular diplopia, and ghost images, acute vision loss if hydrops develop

signs: inferior, central or paracentral stromal thinning that is typically bilateral, asymmetric, and progressive, irregular astig that is poorly corrected with gls or cls

342
Q

early and late signs of keratoconus

A

Early: fleischer’s ring, scissor reflex, irregular mires on k’s, inf steepening on topo

late: Vogt’s striae, munson sign, Rizzuti’s sign, hydrops

343
Q

how do you classify mild, moderate, and severe keratoconus?

A

mild - < 48D
moderate - 48-54D
severe - >54D

344
Q

Pellucid Marginal Degeneration (PMD)

A

most common in early adulthood (20-40 yo)
- possibly due to collagen abnormality, protrude ABOVE the area of thinning

345
Q

What are the signs and symptoms of PMD?

A
  • bilateral, painless, corneal thinning 4-8 o’clock, high ATR astig , kissing doves or crab claws on topo
346
Q

PMD vs Keratoconus

A

Keratoconus
- fleischer’s ring
- cone
- vogt striae
- corneal scarring more common
- protrusion within the thinned area

PMD
- sudden vision loss from hydrops (less common than keratoconus)
- kissing doves
- protrusion above thinning

347
Q

Keratoglobus

what is it associated with?

A
  • onset typically at birth
  • may be acquired from advanced keratopathy, trauma or exophthalmos
  • Associated with ehler’s danlos syndrome, blue sclera, lebers congenital amaurosis
348
Q

What are the signs of keratoglobus?

A
  • Diffuse thinning, most concentrated in the periphery
  • globular shape cornea
  • can result in acute corneal edema due to rupture of descemet’s membrane
  • corneal perforation can occur with minor trauma
349
Q

EBMD, maptdot, fingerprint, ABMD, Cogans microcystic dystrophy

A
  • most common anterior dystrophy
  • AD
  • Females
  • abnormal epithelial adhesion and excessive BM production (trapping mature cells underneath BM)
350
Q

What are the signs and sx of EBMD?

A

sx: asymptomatic, not progressive, vision loss, pain, photophobia can result from corneal changes or RCE

signs: negative staining of maplines, dots, and/or fingerprints (best seen with retroillumination)

351
Q

Meesman’s dystrophy

A
  • AD
  • notable within 1st year of life
352
Q

What are the signs and sx of meesman dystrophy?

A

sx: asymptomatic, sx may occur due to ruptured cyst or RCE (both likely to occur before middle age)

signs: extensive, bilateral, clear intraepithelial cysts that are diffusely spread across the cornea (most dominant in the interpalpebral region)

353
Q

List all the Anterior corneal dystrophy

A
  • EBMD
  • meesman dystrophy
  • Reis-Buckler dystrophy
354
Q

Reis-buckler dystrophy

A
  • AD, dx early due to ocular pain
  • abnormal development and replacement of Bowman’s layer with collagen
355
Q

What are the signs and symptoms of reis buckler dystrophy?

A

Sx: painful episodes due to RCE common in early life, few recurrent episodes as we age

signs: Bilateral symmetric, subepithelial gray reticular opacities that are most concentrated in the central cornea and spare the peripheral cornea, these opacities typically get worse with age

356
Q

List the corneal dystrophies

A
  • Macular dystrophy
  • Granular
  • Schnyder
  • Lattice

“Mary Got So Laced”

357
Q

Macular Dystrophy

A
  • AR
  • least common of the stromal dystrophies and affect VA much earlier
358
Q

What are the signs and symptoms for macular dystrophy?

A

sx: progressive vision loss and episodes of irritation and photophobia (2’ to RCE), severe vision loss occurs by age of 20-30

signs: diffuse superficial stromal haze between 3 and 9 yo, diffuse stromal oppacification, stromal thinning, multiple gray-white opacities (mucopolysaccharides deposits) with irregular borders that are present in all layers of the cornea and extends to the limbus

359
Q

Granular dystrophy

A
  • AD
  • onset 1st decade but will not experience vision loss until middle age
360
Q

signs and sx for granular dystrophy

A

small snowflake granules (hyaline deposits), in the central stroma, deposits eventually spread towards the epithelium and deep stroma, becoming confluent and resulting in decr VA

RCE rare

361
Q

Avellino dystrophy

A

rare, aka granular-lattice dystrophy in the central stroma

362
Q

Lattice dystrophy

signs and symptoms?

A

AD
- Anterior stromal haze w/ branching, refractile, lattice-like lines (amyloid deposits)
- decreased VA, 3rd decade
- result from sig corneal scarring and haze
- RCEs common

363
Q

lattice, avellino and granular dystrophy have what type of mutation?

A

Transforming growth factor beta 1 (TGFB1)

Macular dystrophy is NOT a TFGB1 factor**

364
Q

Schnyder’s dystrophy

signs and sx?

A
  • AD, ask abt hx of or current high cholesterol
  • strong association with hyperlipidemia, xanthelasma, corneal arcus, non-progressive
  • characterized by fine yellow-white ring of stromal crystals with ahze in the corneal stroma
  • pts are usually asymptomatic
365
Q

mnemonic for corneal stromal dystrophy

A

“Marilyn Monroe Got Hers in LA”

Macular- Mucopolysaccharide
Granular- Hyaline
Lattice - amyloid

366
Q

What are the most common symptoms for pts with anterior/stromal corneal dystrophy?

A

decreased vision
painful recurrent corneal erosions

367
Q

Fuch’s Endothelial dystrophy

A
  • AD
  • F>M
  • 60 yo or older
  • 30% have a fam hx
  • posterior lamina of descemet’s is produced in excess and is seen as clumps (guttata)
  • decreased endothelial cell density (hallmark of fuch’s)
368
Q

What are the signs and symptoms of fuch’s dystrophy?

A

sx:
- asymptomatic until later in life 50-60s yo
- progression results in hazy vision that is worse in the AM w/ pain and glare

signs:
- apparent in early 30-40s
- decreased endothelial cell density associated with pleomorphism and polymegathism
- endothelial guttata (beaten metal appearance)
- thick pachys
- stromal edema (most concerning), it can spill over into the epithelium, leading to painful bullae and scarring

369
Q

at what cell count does stroma commonly occur at?

A

500 cells/mm2

370
Q

What pumps does the endothelial layer have?

A

Na+/K+

371
Q

What can accelerate Fuch’s dystrophy?

A

cataract sx, esp at endothelial cell counts less than 1000 cell/mm2

372
Q

What are the endothelial cell count in children

A

3000-4000 cells/mm2

373
Q

What’s the avg endothelial cell count at 80 yo?

A

1000 cells/mm2

374
Q
A
375
Q

What’s the minimum endothelial cell count require to prevent corneal edema?

A

400-700 cells/mm2

376
Q

Posterior polymorphous dystrophy

A
  • AD
  • occurs within 2nd-3rd decade of life , may manifest a cloudy cornea at birth
377
Q

What are the signs and symptoms of PPD?

A

sx:
- slowly progressive or non-progressive
- most pts are not dx until 30-50 yo
- decreased vision 2’ corneal edema

signs:
- bilateral, often asymmetric, findings that occur at descemet’s membrane and endothelium
- patches of vessicles (hallmark), band lesions (linear train track lesions, diffuse opacities,
- in severe cases (rare), corneal edema and bullae lead to painful vision loss

378
Q

Why should you perform gonio on a pt with PPD?

A

PPD results in metaplasia of the endothelial cells, these cells have the potential to spread over the iris and angle resulting in angle-closure glc from PAS formation

379
Q

What’s the only corneal dystrophy that is autosomal recessive?

A

macular

380
Q

Which corneal dystrophy should you perform gonio on?

A

PPD

endothelial cells grow into the angle

381
Q

Megalocornea

A
  • rare, X-linked condition that always affects males
  • bilateral corneal horizontal diameter of 13mm or greater, highly myopic with steep corneas, but often have good acuity with correction
  • stretching of ocular tissues can lead to lens subluxation and angle abnormalities, resulting in glaucoma
  • Systemic associations include marfan’s syndrome, Ehlers-danlos syndrome, osteogenesis imperfecta
382
Q

Microcornea

A
  • rare AD or recessive inherited condition that may be unilateral or bilateral
  • characterized by horizontal diamter of <10mm
  • usually hyperopic and at risk for 2’ angle closure glc due to shallow AC
383
Q

Cornea Plana

A
  • Rare AD or autosomal recessive inherited condition
  • corneal curvature is equal to the scleral curvature (hallmark)
  • associated with sclerocornea and microcornea
  • bilateral flat corneas (less than 38D and often as low as 20-30D)
  • hyperopia, shallow AC, increased risk of 2’ AC
384
Q

Aniridia

A
  • Rare bilateral condition, AD
  • degree can vary from partial to complete loss of iris tissue
  • corneal lesions (opacity, microcornea, pannus), lenticular changes (cataract, lens subluxation), and posterior segment abnormalities (glc ~75% of case, foveal hypoplasia, disc hypoplasia, choroidal colobomas)
385
Q

Haab’s striae

A
  • results from congenital glc
  • characterized by horizontal cracks (parallel lines), lenticular changes in descemet’s membrane from increased IOP vs vertical cracks from forceps delivery during birth)
386
Q

Axenfeld-Riegers Syndrome

A
  • characterized by a continuum of disorders = posterior embryotoxin, axenfeld anomly, reiger anomaly, riegers syndrome
  • these pts suffer from ant seg developmental abnormalities that affect the ant chamber angle
  • 50% of pts with this condition develop glc
387
Q

Posterior embryotoxin (PE)

A

anterior displaced schwalbes line

hallmark of axenfeld-reiger syndrome
- these pts are not at risk for glc

388
Q

Axenfeld anomaly

A

PE + angle abnormalities + increased glc risk

  • angle abnormalities include prominent iris processes that travel to the level of PE, often obscuring scleral spur
389
Q

Reiger anomaly

A

PE + angle abnormalities + increased glc risk + iris stromal abnormalities

  • iris stromal abnormalities include displaced pupil (corectopia) and iris hypoplasia iris hypoplasia with resulting hole within the iris tissue (polycoria)
390
Q

Rieger syndrome

A

PE + angle abnormalities + increased risk of glc + iris stromal abnormalities + systemic abnormalities

  • systemic abnormalities include mental retardation, dental, craniofacial, genitourinary, and skeletal abnormalities
391
Q

Peter’s Anomaly

A
  • rare condition in which pts are born with a central white corneal opacity (leukoma) with iris adhesion
  • 80% bilateral
  • 70% develop 2’ glc, pts may also develop edema and cataracts
392
Q

Limbal dermoid

A
  • normal dense connective tissue with hair follicles and sebaceous glands that is displaced in an abnormal location
  • usually inferotemporal limbus
393
Q

What are the risk factors for infectious keratitis?

A

contact lens wear, dry eye, exposure keratopathy, neurotrophic keratopathy, atopathy, trauma, lid abnormalities, bullous keratopathy

394
Q

Bacterial keratitis

A
  • most common cause is cls wear esp extended-wear
  • most common microbes involved are psuedomonas aeruginosa, staph epidermidis, staph aureeus, haemophilus influenzae, moraxella catarrhalis
395
Q

what’s the most dangerous bacterial infection?

A

Pseudomonas gram (-)

characterized by significant thick mucopurulent discharge, hypopyon, dense stromal infiltrate, rapid progression (can perforate the cornea within 48 hours)

396
Q

which bacteria can invade intact epithelium?

A

CHaNeL

Corynebacterium
Haemophilus
Neisseria gonorrhea and menigitidis
Listeria

397
Q

What are the sign and symptoms of bacterial keratitis?

A

Sx: severe pain, red eye, photophobia, decreased vision

sign: a corneal stromal infiltrate with an overlying epithelial defect, infectious corneal ulcer

398
Q

What does it mean when you see an infiltrate?

A

pts immune system is attacking an antigen via antibody

aka sign of infection

399
Q

corneal ulcer

A

infiltrate with an overlying epithelial defect

400
Q

Which of the following describes a fluorescein staining area to lesion ratio of 1:1

sterile infiltrate
infectious corneal ulcer
sterile corneal ulcer

A

infectious corneal ulcer

401
Q

Which of the following describes a fluorescein staining area to lesion ratio less than 1:1

sterile infiltrate
infectious corneal ulcer
sterile corneal ulcer

A

sterile corneal ulcer

402
Q

Which of the following describes an infiltrate that does not stain with fluorescein

sterile infiltrate
infectious corneal ulcer
sterile corneal ulcer

A

sterile infiltrate

403
Q

Fungal keratitis

A
  • most common type of corneal ulcer after traumatic corneal injury from vegetable matter
  • candida infections = often in chronic corneal dz, immunocompromised or severely debilitated pts (in normal human flora but deadly if infection in immunocompromised pts)
  • aspergillus and fusarium = more common after vegetable matter trauma
404
Q

What should you culture a fungi on ?

A

sabouraud’s agar

405
Q

What are the sign and symptoms of a corneal fungal infection?

A

sx: pain, photophobia, tearing, decreased vision

sign:
Aspergillus/fusarium = epithelial defect w/ underlying gray-white corneal infiltrate, feathery edges, possible surrounding satellite infiltrates

candida = similar appearance to a bacterial ulcer

406
Q

Acanthamoeba Keratitis

A
  • parasitic infection w/ bad cls hygiene ( tap water, homemade saline solution, swimming, hot tub while wearing cls)
  • most common protozoa found in soil and water and within oral cavity of humans
407
Q

If you suspect acanthamoeba keratitis, what agar should you use?

A

heat-killed E.coli

408
Q

What are the signs and symptoms of acanthamoeba keratitis?

A

Signs:

Early: punctate or pseudodendritic epithelial defects, associated with severe pain w/ out of proportion signs

Late: radial keratoneuritis (inflammation of the corneal nerves) and patchy anterior stromal infiltrates that gradually progress to form a ring ulcer

Sx: blurred vision, pain, minimal discharge

409
Q

What culture/smears would you use for infectious keratitis

Bacteria
Fungi/Yeasts
Fungi
Haemophilus and Nisseria
Aerobic and Anaerobic bacteria
Acanthamoeba

A

Gram stain (smear) - bacteria

KOH or Giemsa stain (smear) - fungi/yeast

Sabaroud’s agar culture plate - fungi

Chocolate agar culture plate - haemophilus and Nisseria

Thioglycolate culture broth - aerobic and anaerobic bacteria

Non-nutrient agar culture plate with E.coli overlay - acanthamoeba

410
Q

HSV

A
  • DNA virus most common in young patients. Ask about hx or previous cold sores
  • Primary exposure: occurs in children 6 months - 5yo, may experience mild virus-type syndrome
  • Recurrent HSV: latent infection in the trigeminal ganglion, can be triggered by physical or emotional stress from sun exposure, fever, and immunosuppression (non-exhaustive list)
  • Tissue damage from HSV is due to direct invasion, neurotrophic mechanisms or by the immune system response to HSV
411
Q

What are the signs and sx for HSV?

A

sx: pain, redness, serous discharge, tearing, photophobia and decreased vision

signs: decreased corneal sensitivity is common

peform cotton swab test

acute unilateral anterior granulomatous uveitis, trabeculitis, acute retinal necrosis

412
Q

Primary exposure of HSV usually results in

A

conjunctivitis or blepharitis

413
Q

Recurrent HSV infections can be classified into the following

A

Epithelial
Neurotrophic Keratopathy
Stromal dz
Endotheliitis

414
Q

recurrent HSV on the epithelium can cause what?

corneal vesicles
Dendritic ulcers
Geographic ulcers
Marginal ulcers

A

Corneal vesicles: aka punctate keratopathy, earliest signs of reactive HSV

Dendritic ulcers: stains well w/ fl and rose bengal

Geographic ulcers: wider than dendritic ulcers, associated with use of topical steroids

Marginal ulcers: loc close to limbus as a stromal infiltrate with overlying epithelial defect and associated w/ limbal injection

415
Q

Recurrent HSV - neurotrophic keratopathy

A

reduced corneal innervation, decr tear secretion, leading to poor corneal wound healing

  • occurs in pts who have had infectious epithelial keratitis
  • neurotrophic ulcer appears as an oval defect with smooth borders, often preceded by punctate epithelial erosions that progress to an ulcer
416
Q

What’s the difference between neurotrophic ulcers vs geographic ulcers?

A

Neurotrophic ulcers are located inf and oval appearance with smooth borders vs. Geographic ulcers result in irregular epithelial defects w/ scalloped borders

417
Q

Recurrent HSV stromal disease includes?

IK
Necrotizing stromal keratitis

A

Interstitial keratitis (IK):
- infiltrate with diffuse neovascularization, an immune ring (Wesley ring), stromal thinning an subsequent scarring
-IK is stromal inflammation WITOUT primary involvement of epithelium or endothelium
- result from antigen-antibody complement cascade against a live virus or viral antigen retained within the corneal stroma

Necrotizing stromal keratitis
- result from direct invasion of the stroma
- severe stromal inflammation with necrosis that can lead to corneal thinning and perforation

418
Q

Recurrent HSV - endothelium

Endotheliitis (Disciform keratitis)
Disciform endotheliitis

A
  • Disciform keratitis: immune rxn against viral antigen or live virus within the corneal endothelium
  • Disciform endotheliitis: most common form of endotheliitis. characterized by focal, disc-shaped, stromal edema overlying keratic precipitates. often accompanied by mild to moderate iritis
419
Q

HZV

A
  • VZV is the initial invading organism
  • primary infection (chicken pox)
  • VZV is transported to the trigeminal ganglia and other neural cell bodies where it becomes dormant
  • affecting 95% of children by the age of 5
  • old age, trauma, neurodegeneration, immunosuppression may contribute to reactivation of the virus resulting in HZV
420
Q

HZV usually affects older people, if you see HZV in a pt that is younger than 50 what should you consider doing?

A

check for immunosuppression

HZV is contagious in those who have not had chicken pox

421
Q

What are the signs and sx of HZV?

A
  • signs are more severe in immunocompromised pts
  • unilateral
  • pre zoster = tingling, malaise, fever (prodrome)
  • active zoster = vesicular rash that does not cross the midline, blepharoconjunctivitis if vesicle is present on the lid margin
    -post-zoster = post herpetic neuralgia and depression
422
Q

Activation of HZV along the ophthalmic branch of the trigeminal ganglion can lead to the following eyelid and corneal signs

A

Eyelid = trichiasis, ectropion, entropion, madarosis, poliosis

Corneal = punctate epithelial keratitis, psuedodendritic keratitis, anterior stromal keratitis, interstitial keratitis, endotheliitis, keratouveitis, neurotrophic keratopathy, exposure keratophathy

episcleritis, scleritis, uveitis, can be gran or non-gran, associated w/ sig KPs, corneal edema, and posterior synechiae

trabeculitis
cataracts
acute retinal necrosis
optic neuritis
CN palsies

423
Q

What would you see if a pt had HZV in the eye

A

stain w/ fl or rose bengal, pseudodendrites w/ NO terminal bulb

424
Q

What does Hutchinson’s sign indicate?

A

rash on the nose indicates high risk of ocular involvement of HZV

425
Q

Post-herpetic neuralgia (PHN)

A

pain persisting beyond 1 month after rash onset or rash resolution
- most common complication of HZV
- severe onset can lead to suicide in pts over 70 yo w/ chronic pain

426
Q

Mooren’s ulcer

A
  • more common in men 40-70 yo (but may occur in all ages)
  • benign and malignant mooren’s ulcer
  • painful, progressive, chronic vasculitis of the limbal blood vessels that lead to ischemic necrosis and peripheral ulcerative keratitis
  • idiopathic
  • autoimmune
  • associated w/ hep C viral infection or hookworm infestation
427
Q

Benign vs. Malignant mooren’s ulcer

A

Benign (typical or limited)
- unilateral
- affects the elderly
- mild to mod sx
- responds well to tx

Malignant (atypical)
- bilateral
- affects younger pts (esp black males)
- severe sx
- responds poorly to tx & progresses relentlessly

428
Q

What are the signs and sx of mooren’s ulcer?

A
  • often severe pain, redness, tearing, photophobia
  • decreased vision due to irregular astig
  • associated iritis or ulcer is in central location

Sign:
- unilateral peripheral crescent-shaped gray infiltrate in an older pt that progresses to an ulcer
- ulcer may be self-limited or spread circumferentially and/or centrally in the late stages of the condition

429
Q

Staphylococcal Marginal Keratitis

A
  • ask about a hx of similar recurrent episode
  • Type 3 hypersensitivity to staph aureus, usually occur in pts with chronic bleph
430
Q

What are the signs and sx of staph marginal keratitis?

A
  • asymptomatic, acute photophobia, pain, tearing, redness, decreased vision

signs:
- stromal infiltrate ( multiple and bilateral) loc in the periphery
- classically occur at 2,4,8,10 o’ clock where lid margins touch the limbus
- look for phlyctenules, blepharitis, acne rosacea
- residual, thinning, superficial neo, peripheral scarring

431
Q

What is an infiltrate?

A

immune-mediated response NOT infectious

432
Q

What systemic conditions can cause peripheral corneal thinning/or ulcers?
(collagen vascular disorders)

A

RA, SLE, polyarteritis nodosa, Wegener’s granulomatosis
- asymptomatic, pain, redness, decreased vision
- peripheral corneal thinning/ulcers with or without inflammation
- unilateral or bilateral
- may be associated with scleritis, episcleritis, keratoconjunctivitis sicca

433
Q

What causes Whorl keratopathy?

A
  • fabry’s dz w/ use of chloroquine, hydroxychloroquine, amiodarone, indomethacin, tamoxifen

CHAI-T

434
Q

Fleischer’s ring

A

iron ring at the base in keratoconus

435
Q

Rust ring

A

metallic FB

436
Q

Hudson stahli line

A

common in elderly, iron deposits found in the middle and lower third of the cornea

437
Q

Stocker’s line

A

iron deposit found at the edge of a pterygium

438
Q

Ferry’s line

A

iron deposit on the leading edge of a filtering bleb

439
Q

Kayser-Fleischer Ring

A

accumulation of copper that occurs in pt with liver disorders and Wilson’s dz

440
Q

Band Keratopathy

A

Calcium deposits in Bowmans layer (white swiss cheese pattern)

441
Q

Terrien’s Marginal Degeneration

A
  • most common in men 20-40 yo
  • Idiopathic non-inflammatory degenerative condition that results in slowly progressive
    peripheral stromal thinning, perforation in 15% of pts
442
Q

What are the signs and sx of terrien’s Marginal degeneration?

A
  • asymptomatic, progression can lead to irregular astig (ATR) and decreased acuity

Signs:
- superonasal, bilateral (typically asymmetric)
- slowly, progressive, thinning with an associated vascularized pannus
- no AC rxn, no conj injection, no overlying epithelial defect

443
Q

What’s the difference between mooren’s ulcer vs terrien’s marginal degeneration

A

Mooren’s ulcer has an overlying epithelial defect

444
Q

Salzmann’s Nodular Degeneration

A
  • female predilection, 6th decade
  • degenerative dz that follow episodes of keratitis
  • associated with sig corneal inflammatory dz including MGD, trachoma, phlyctenulosis, VKC, keratoconjunctivitis sicca, interstitial keratitis, can be idiopathic
445
Q

What are the sign’s and sx of salzmann’s nodular degeneration

A

Sx:
- asymptomatic, pain if RCE develops in epithelial cells overlying the nodule, reduced vision if nodule is located within the visual axis

Signs:
- Hyaline plaque deposits between epithelium and bowmans
- midperipheral, elevated blue-gray or yellow-white nodular lesions
- unilateral or bilateral
- nodules often located within or adjacent to old corneal scar or pannus

“60 yo F w/ bad dry eye, wears a blue bow tie, and likes to get high (hyaline)”

446
Q

White limbal Girdle of Vogt

signs and sx?

A
  • age related condition that is very common
  • 40-60 yo, nearly 100% over 80 yo
  • signs/sx: bilateral, chalk-like linear opacties of nasal limbus (3 and 9 o’clock). Pts asymptomatic
447
Q

Band Keratopathy

A
  • chronic inflammation and ocular surface dz (uveitis, dry eye, exposure keratopathy)
  • trauma
  • systemic conditions: incr calcium or phosphorous levels, gout, hypercalcemia, hyperparathyroidism, renal failure, sarcoidosis
448
Q

What are the signs and symptoms of band keratopathy?

A

often asymptomatic, FBS, decreased vision (if calcium plaques move centrally)

Signs:
- Calcium deposits on ant bowman’s or subepithelial space
- appears like a swiss cheese pattern within interpalpebral portion of the cornea

449
Q

Arcus senilis

A
  • most common peripheral corneal opacity
  • 100% over 80 yo
  • assoc with aging and high cholesterol
  • signs: bilateral and symmetric circumferential 1mm band within the peripheral cornea, with a clear zone of separation to the limbus
450
Q

When is arcus of concern?

A
  • Unilateral arcus and associated with carotid disease on the side WITHOUT arcus
  • younger pts <50 yo associated with an increase risk of coronary artery disease, lipid profile is warranted in these cases
451
Q

Crocodile shagreen

A
  • bilateral, gray-white polygonal stromal opacities
    “cracked ice appearance” either near bowmans layer or occasionally near descement’s
  • caused by irregularly arranged folds of collagen

asymptomatic and benign

452
Q

Corneal Farinata

A
  • bilateral flour dust deposits that are most commonly located in the central deep stroma
  • Aging or AD
    asymptomatic
453
Q

What type of reaction is a corneal graft rejection?

A

type 4 hypersensitivity response to the donor cornea

454
Q

What would each graft rejection look like if you saw it through a slit lamp?

epithelial rejection
stromal rejection
endothelial rejection

A

epithelial - elevated, irregular epithelium
stromal - subepithelial infiltrate (Krachmer’s spot)
endothelium - WBC on endothelium that form a khodadoust line

455
Q

Khodadoust line

A

associated with endothelium rejection

456
Q

What are the absolute contraindications for refractive sx?

A
  • younger than 18 yo
  • unrealelistic expectations
  • Keratoconus, active HSV, cls warpage
  • CT dz (keloid formers), collagen vascular dz, immunocompromised dz (chronic steroid user)
457
Q

What are the relative contraindications for refractive sx?

A
  • blepharitis, DES, chronic eye rubbing, ocular surface dz, large pupils
  • DM (3 months of stabilization)
  • POAG - if not well controlled
  • pregnancy
  • retinal thinning/lattice degeneration
458
Q

How long should a pt go without cls before refractive sx? What about RGP wearers?

A

3-14 days

14-21 days for RGPs

459
Q

Radial Keratotomy (RK)

A

Radial incisions made with a diamond knife to flatten the the peripheral corneal stroma

  • Causes progressive hyperopic shift
460
Q

Photorefractive Keratectomy (PRK)

A

corneal epithelium, bowmans, and stromal tissue are removed (No flap), excimer laser used on the central corneal or mid peripheral cornea

Tx range: -8D to +4D, up to 4D of cyl

400um residual cornea is required after tx

  • use of mitomycin C during the procedure reduces stromal haze
461
Q

What’s the healing time for PRK compared to LASIK?

A

PRK has a longer healing time 1-2 weeks vs 1-2 days for lasik

lasik = less pain and less post-op haze compared to PRK

462
Q

What laser does PRK use?

A

excimer

463
Q

Careers at risk for trauma (military, boxing, martial arts) recommend which refractive procedure?

A

PRK because there is no flap complication

PRK has less risk for corneal ectasia, less induction of higher order aberrations, less post-op dryness, requires less corneal thickness, cheaper compared to lasik

464
Q

LASIK

A

epithelial flap made with amicrokeratome, an excimer laser is applied to the anterior stromal bed and then flap is reattached

Tx range: -10D to +4D, up to 5D cyl (clear lens extraction can be performed on pts who exceed LASIK RE requirements)

465
Q

What is the thickness requirement for LASIK?

A

250um must remain under the flap to maintain corneal integrity

flap is 150um thick
ablation depth is 12um/diopter

Total pachy - flap thickness (160-200) - ablation depth (12um/diopter) = 250 or greater

466
Q

Femtosecond Laser Flap

A

same procedure as lasik but flap is made with a femtosecond laser creating a thinner flap (100um)

it removes the risk of mechanical malfunction of the microkeratome and is associated with less post-op dry eyeLaser

467
Q

epithelial keratomileusis (LASEK or E-Lasik)

A

flap made with diluted alcohol instead of microkeratome

468
Q

Epi-LASIK

A

blunt plastic blade is used to create an epithelial flap

469
Q

Conductive keratoplasty (CK)

A

tx presbyopia, low hyperopia and residual astig after previous sx

  • uses radiofrequency energy to shrink collagen fibers in the peripheral corneal stroma, allowing central cornea to steepen
  • regresses in about 2-3 years, sx can be repeated

Tx range: +0.75D to +3.00D with less than 0.75D of astig

470
Q

Intrastromal Corneal rings (Intacs)

A

PMMA rings are inserted into the peripheral stroma to flatten corena (shortens the corneal arc length); rings can be removed or exchanged

approved for keratoconus

Tx: -0.75 to -3D, does not tx hyperopia

471
Q

Clear lens Extraction

A

Cat sx without cataracts IOL selected reduces the RE

  • no accommodation remains unless use of multifocal or accommodating lens
  • Large tx range
472
Q

Phakic IOL (Implantable Contact Lens)

A
  • IOL implants in phakic eye, used to alter power of total eye
  • IOL is angle supported iris supported, or sulcus supported
    -REQUIRES LPI
  • can be used to tx larger range of RE compared to corneal sx and IOL is removable. Also preserves natural accommodation (unlike CLE)
473
Q

Astigmatic keratotomy (AK)

A

Corneal incisions are made with diamond blades to relax the cornea in the steepest meridian

474
Q

Wave-front guided, custom corneal sx

A
  • Reduces higher corneal aberration (ex. coma, spherical) in addition to correcting RE (ex. lower aberrations which acct for 90% of all abberations)
  • Can be done with LASIK or PRK = better quality in vision and improved contrast and acuity and less glare
475
Q

What VA is considered successful in refractive sx?

A

20/40

476
Q

What are the complications of lasik?

A

Pain, serious infection, flap complications, corneal ectasia, residual refractive error, glare, dry eye, DLK, epithelial ingrowth, corneal haze

477
Q

Review of flap complications from lasik

Button holes
Free caps
Flap folds
Flap dislodgement

A

Button holes = cap perforation, hole in flap, common in steep cornea or deep set eyes

Free caps = no hinge, common in flat corneas

Flap folds
- macrostriae = full thickness w/ undulating, parallel stromal folds from slippage or mal positioning during sx. typically require tx by lifting and repositioning
- microstriae = fine, irregular, multi-directional folds in bowmans layer that typically resolve on their own, only tx if it’s visually significant

Flap dislodgement = more common with keratome flaps than femtosecond laser due ot accidentally touching the eye, or form fruste keratoconus are more at risk.

478
Q

Corneal ectasia

A

anterior protrusion of the cornea due to thinning

Pts with high myopia, undetected keratoconus, forme fruste keratoconus are more at risk

corneal ectasia may occur at anytime after sx

479
Q

Residual refractive error post lasik

A
  • pts may be over or under-corrected or may have regression after sx (more common in RE >-8D)
  • Pts can be fit with GPs or reverse geometry lenses after 8-12 weeks (may fit sooner w/ soft cls)

refractive sx enhancement may be considered

480
Q

Glare post-lasik

A

Worse glare is expected with small ablation zone, large pupils, monovision correction, and higher refractive errors

481
Q

What’s the most common side effect of LASIK sx?

A
  • most common side effect of LASIK, aqueous deficient nonsjogren’s
  • corneal nerves severed = decreasing sensitivity and neural feedback to the lacrimal gland
  • often improves 1-2 months
482
Q

Diffuse Lamellar keratitis (DLK or sands of sahara)

A
  • inflammatory, non-infectious reaction that occurs at the lamellar surface (between the flap and the stroma)
  • characterized by fine, gramnular, sand-like infiltrate that typically present 2-3 days after sx
  • possibly due to response to toxins but unsure of etiology
  • DLK is less common with disposable microkeratomes
483
Q

What are the sign and symptoms of DLK?

A

asymptomatic, photophobia, blurred vision, FBS, and pain

can lead to vision loss (from scarring and corneal melt) if not properly managed

484
Q

What’s the most common complication associated with LASIK enhancement?

A

Epithelial ingrowth

485
Q

Epithelial ingrowth

A

Lasik complication commonly observed at 1 month post-op as a faint gray line or white, milky deposits within 2mm of the flap edge interface

asymptomatic and condition is not tx unless the visual axis is obstructed, 2mmingrowth occurs from the flap edge, or results in corneal astig

486
Q

corneal haze-post lasik

A

risk increases w/ higher RE

normally present for several weeks after PRK

487
Q

What is the retreatment criteria for enhancement post-lasik?

A

The earliest time for retreatment is 3 months but 6 months is preferred

  • Astig >0.75 causing sx
  • Astig greater or equal to 0.75D from target in an unhappy pt
  • Uncorrected VA of 20/30 or worse in an unhappy pt
488
Q

Will IOP readings be falsely higher or lower after lasik sx?

A

most likely lower due to thin corneas

489
Q

Most common aging cataracts

A
  • NS
  • myopic shift, improved reading “second sight”
490
Q

Cortical cataract

A

radial spoke like opacities
- induce hyperopic shift

491
Q

Anterior subcapsular cataract

A

located underneath the anterior lens capsule

492
Q

Posterior subcapsular cataract

A

located directly in front of the posterior lens capsule
- affects near vision > distance
- usually caused by steroids (systemic or topical)
- WORST glare compared to other cataracts

493
Q

What are infant cataracts associated with?

A

galactosemia or rubella

494
Q

What’s the most common type of congenital or infantile cataract?

A

lamellar (zonular) cataract (surrounds the embryonic nucleus)

495
Q

Cataract that appears like a tiny dot-like or flake-like white or bluish green opacities?

A

cerulean cataract

496
Q

What are examples of presenile cataracts?

A

associated with diabetes mellitus, myotonic dystrophy (PSC christmas tree cataract), Wilson’s dz, hypocalcemia, and atopic dermatitis

497
Q

What are examples of traumatic cataracts?

A

rosette

also look for vossius ring

498
Q

Toxic cataracts - anterior subcapsular

A
  • chlorpromazine (stellate cataracts)
  • amiodarone (deposits)
  • miotics (vacuoles)
  • gold salts (gold deposits) - used to tx RA
499
Q

Toxic cataracts - posterior subcapsular

A

corticosteroids

500
Q

Secondary cataracts

A
  • anterior uveitis
  • myopia
  • RP
  • gyrate atrophy
501
Q

What appears as a small star-shaped pigment located on the anterior capsule of the lens?

A

epicapsular stars - remnants of the tunica vasculosa lentis

502
Q

Symptoms of cataracts

A
  • blurred vision
    -glare
  • reduced contrast
  • RE shift
  • difficulty with ADL (reading, recognizing faces, watching TV, driving)
503
Q

What are some tests you can perform for cataracts?

A

Potential acuity meter (PAM): can help determine how much lenticular changes are impacting acuity to better predict post-op VA

Brightness acuity tester (BAT): assess glare disability

Axial length: determined by A-scan or IOL master (usues partial coherence interferometry); axial length and K measurements are used to calculate appropriate IOL power

B-scan ultrasound: evaluate post seg if cataracts are too dense

504
Q

What are the important values when needing to calculate the appropriate IOL lens for cataract sx?

A

Axial length and K’s

505
Q

What is the avg axial length

A

24mm

1mm error in axial length measurement corresponds to 3D error in the calculated IOL power

506
Q

What medications should you look out for prior to cataract sx?

A

anticoagulants (coumadin)
alpha-blockers (Flomax) - cause floppy iris syndrome
prostaglandins

507
Q

Ocular conditions you should look for before referring out for cataract sx

A
  • acute/chronic uveitis
  • severe blepharitis
  • Fuch’s endothelial dystrophy (bullous keratopathy)
  • pseudoexfoliation
508
Q

Intracapsular cataract extraction (ICCE)

A

entire lens and capsule removed
- requires a large incision
- higher risk of RD
- resulted in aphakia and need for “cataract glasses” (~+12D)
- also required surgical PI to prevent vitreous prolapse and pupillary block

this sx is not done any more, “ICE age”

509
Q

Extracapsular cataract extraction (ECCE)

A

lens is removed but capsule remains
- incision is large b/c lens is removed as a whole
- IOL is inserted into the capsule

sx done today!

510
Q

Drugs that cause floppy iris syndrome

A
  • osin drugs
    terazosin, prozosin, tamsulosin
511
Q

Phacoemulsification

A

form is ECCE where lens is fragmented with an ultrasound before removal
- smaller incision that rarely requires sutures
- aqueous will push against the flap to close it
- utilizes clear corneal incision for lens removal

512
Q

Femtosecond laser

A
  • used to make corneal incisions (including relaxing incisions for astig), anterior capsulorhexis, lens fragmentation (makes phacoemulsification easier)
513
Q

Cataract Post-op complications

A
  • Striate keratopathy
  • Acute post-op bacterial endophthalmitis
  • Delayed post-op bacterial endopthalmitis
  • Toxic anterior segment syndrome (TASS)
  • lens subluxation
  • PCO
  • CME
  • RD
  • Wound leak
  • suprachoroidal heme
  • elevated IOP
  • corneal edema

-diplopia (pre-existing strab, EOM restriction/paresis, monocular diplopia, central fusion disruption, idiopathic)

  • ptosis (lid speculum)
  • uveitis, glaucoma, hyphema syndrome (UGH) - ill-fitting ACIOL rubbing on iris, can cause elevated IOP
  • induced corneal astig (pre-existing or 2’ to wound leak)
  • Iritis - 2’ to sx trauma, retained lains material, endophthalmitis, eye predisposed to uveitis and aggravated by sx
514
Q

Striate keratopathy

A

post-op corneal edema and folds in descemet’s membrane, resolves without tx within days

515
Q

Acute post-op bacterial endophthalmitis

A

sx occurs 2-4 days of the procedure and includes progressive decr vision, redness, and increasing eye pain

  • mostly gram (+) bacteria: staph epidermidis, staph aureus
  • sig AC reaction which can be accompanied by hypopyon, vitritis, chemosis, eyelid edema, fibrous exudate, mucous discharge, corneal edema, and reduced red reflex
516
Q

Delayed post-op bacterial endopthalmitis

A
  • sx occur within a week to 1 month after the procedure
  • vision loss is insidious and pain gradually worsens
  • Fungal post-op endopthalmitis is also a commonly delayed complication
517
Q

Toxic anterior segment syndrome (TASS)

A

sterile inflammatory reaction that leads to toxic damage to the ant seg structures - due to chemical exposure during sx (denatured viscoelastic, preservatives, bacterial endotoxins, cleaner, etc)
- present 12-48 hrs post op with decreased vision, no to mild pain, diffuse limbus to limbus corneal edema, hypopyon, fibrous membrane, no vitritis (or mild spillover), and increased IOP

MUST RULE OUT INFECTIOUS ENDOPHTALMITIS

518
Q

Causes of lens subluxation?

A

Marfans and PXF
Trauma (#1 cause)
Ehlers danlos, Weill Marchesani syndrome, homocystinuria

519
Q

Review: Which systemic conditions causes keratoconus?

A

T-DOME (all affect type 1 collagen)

Turner syndrome
Down syndrome
Ostogenesis imperfecta
Marfans
Ehlers danlos (cause RD)

520
Q

What other ocular effects can ehlers-danlos syndrome and osteogenesis imperfecta can cause?

A

keratoconus, blue sclera, megalocornea,

ehlers can cause lens subluxation

marfans can cause retinal detachment - and cause more serious ocular complication

521
Q

Posterior capsular opacification (PCO)

A
  • most common post-op complication following cat sx
  • equatorial epithelial cells migrate to cover the posterior capsule 2-6 months after sx
  • Elschnig pearls type of PCO most common in children who undergo cat sx
522
Q

Cystoid Macular Edema (CME)

A
  • most common reason for decreased VA after cat sx
  • DME, CRVO/BRVO, RP, ARMD, ERM, retinal vasculitis (sarcoidosis, behcet’s syndrome) and coats
  • inflammation due to trauma from sx
  • Irvine gass syndrome: CME after cataract sx
  • 6-10 weeks after sx
  • hyperfluorescent on FA (petaloid pattern) around macula and ON
  • most resolve within 6 months
523
Q

Causes of RD

A
  • high myopia
  • lattice degen
  • hx of RD in the fellow eye
  • fam hx of RD
524
Q

Wound leak post-op cat sx

A
  • occurs in the early post-op period, initiated by Valsalva maneuver, trauma, or suture failure
  • (+) seidel sign, hypotony, iris prolapse, (will point towards the wound), choroidal detachment (fluid accumulates in the suprachoroidal space), shallow AC
  • pts with an open wound are at risk for endopthalmitis - tx promptly!
525
Q

Elevated IOP cataract post-op

A

retained viscoelastic, steroid response, inflammatory debris or RBC clogging the TM, pupillary block, retained lens material

526
Q

corneal edema cat post-op

A
  • characterized by folds in descemet’s, bullae, and/or microcysts that slowly resolve
  • High IOP can cause microcystic edema
  • Low IOP can cause descemet’s folds
  • surgical trauma can casue edema due to shock wave from phaco or intraoperative use of viscoelastic material
    -pre-existing corneal dz
  • bullous keratopathy - more common w/ aphakia and AC IOLs
  • Haptic rubbing on endo can cause damage and edema
527
Q

Hruby lens

A

noncontact examination of the optic disc, macula, posterior pole and central vitreous

provides stereoscopic, erect, and magnified image

528
Q

Three-mirror lens

What degrees and what is it used to evaluate for?

Trapezoid mirror
bullet mirror
square mirror

A

performed in pts with peripheral retinal concerns like peripheral vascular disease, hx of blunt trauma, at risk w/ RD

stereoscopic, reversed and magnified image of retina 180 deg away from the position of the mirror

Trapezoidal mirror = 73 degrees, evaluate equator region

square mirror = 67, ant equator and ora serrata

Bullet mirror = 59 degrees, eval AC angle and ora serrata

529
Q

What kind of image does a 78/90D lens provide?

A

real, inverted, reversed image

530
Q

What image does a BIO provide?

A

magnified, reverse, and inverted

531
Q

a red-free filter can be used for what?

A

eval NFL, choroidal lesions, small hemes

532
Q

What happens when you place a red-free filter over a choroidal nevus?

A

disappears

533
Q

Scleral depression

A

allows oblique viewing of the retina (similar to 3 mirror)

534
Q

When should you avoid performing a scleral depression?

A

any perforation of the eye , surgery, hyphema, ruptured globe

KMK (18 decks)

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