Oculoplastics Flashcards
1
Q
DDx
A
“arterialized” episcleral vessels.
Carotid cavernous fistula
cavernous sinus thrombosis
venous malformations
scleritis with vortex vein blockade
2
Q
Posterior orbital mass with sclerotic changes
A
metastatic prostate cancer
a/w osteobalstic lesions
3
Q
MC orbital metastasis in men
A
Lung cancer
4
Q
MC orbital metastasis in women
A
breast cancer
5
Q
MC leukemia to metastasize to the orbit
A
ALL
6
Q
Muscle and nerve of the lacrimal pump system
A
pretarsal orbicularis oculi muscle
CN VII
7
Q
Features of this syndrome
A
telecanthus (widended intercanthal distance)
epicanthus inversus (fold of skin extending from the lower to upper eyelid but most prominent in the lower eyelid)
severe ptosis
8
Q
90% of eyelid malignancies are this type
A
BCC
9
Q
Location of occurance of BCC
A
lower eyelid (50%-60%)
medial canthus (25%-30%)
upper eyelid
lateral canthus
10
Q
Inheritance pattern of blepharophimosis syndrome
A
AD
11
Q
Inheritance of myogenic congenital ptosis
A
AR
12
Q
Typical presentation
A
Keratoacanthomas (KAs)
growth over 4-8 weeks, spontaneous regression over several months
13
Q
Hypoplasia of the orbit, eyelids, and adnexal structures
A
anophthalmia
14
Q
Retrobulbar injection results in
A
incyclotorsion and depression of eye
Trochlear nerve (IV) intact incyclotorsion and infraduction
15
Q
A
16
Q
45 yo M pain right orbit x 9 months. Next step
A
incisional biopsy of lacrimal gland
lacrimal gland with calcification and adjacent bony thinning/erosion
adenoid cystic carcinoma
17
Q
prevents reflux of tears from the lacrimal sac into the canaliculi
A
valve of Rosenmuller
18
Q
Tx for microphthalmia
A
Socket expansion techniques SOON AFTER BIRTH
19
Q
Next step
A
full-thickness biopsy and possible conjuncitival map biopsies
sebaceous adenocarcinoma
20
Q
Asian with mechanical entropion of the lower eyelid margin
A
epiblepharon
lower eyelid pretarsal muscle and skin ride above the lower eyelid margin to form horizontal fold of tissue that causes cilia to assume vertical position
21
Q
Arteries that supply blood to the bulbar conjunctiva
A
anterior ciliary arteries
arise from muscular branches of the ophthalmic artery
22
Q
differenitates hemifacial spasm from benign essential blepharospasm
A
hemifacial spasms persist in sleep
23
Q
lacrimal gland biopsy should avoid these structures
A
lacrimal ducts of palpebral lobe.
Only biopsy orbital lobe
24
Q
characteristic of cicatricial entropion of the lower eyeld
A
posterior lamellar shortening
25
large flat eyelid lesion with irregular borders and varied pigmentation. Dx and next step?
**superficial spreading melanoma**
total surgical excision with margin evaluation
26
unsafe to dissect from upper face to lower face arcoss anterior zygomatic arch because risk for damaging this structure
temporal branch of facial nerve
27
Treatment to eliminate epiphora in patients with total obstruction at common canaliculus
conjunctivodacryocystorhinostomy (CDCR)
28
Next step
thickening of left MR muscle and tendon = **myositis**
## Footnote
**Cytoplastmic staining pattern (c-ANCA)**
**Antinuclear antibody (ANA)**
**ACE**
**Lysozyme**
**IgG4**
29
anterior lamellar deficiency
cicatricial ectropion of lower eyelid
30
unilateral involvement of eyelid protractor muscles that persist at night
hemifacial spasm
31
bilateral involvement of eyelid protractors with s/s abate at night
benign essential blepharospasm (BEB)
32
Contraindication for laser resurfacing techniques for eyelid periocular skin surface irregularities or rhytids (skin rinkles)
**significant uncorrected lower eyelid laxity**
collagen vascular disease (SLE)
unrealistic expectations
33
Direction globe displaced when child with congenital orbital cleft cries
**inferolaterally**
herniation of intracranial contents into orbit (meningoceles , encephaloceles, meningoencephaloceles)
MC location medial canthus near bridge of nose
34
protrusion of meninges through congenital cleft
meningocele
35
protrusion of brain tissue through congenital cleft
encephalocele
36
protrusion of meninges + brain tissue through congenital cleft
meningoencephalocele
37
Removal of BCC from lacrimal sac or NLD, when should lacrimal outflow system be reconstructed
5 years to minimize tumor spread
38
Causative source of orbital cellulitis in child
**single organism**
Haemophilus
39
Causative source of orbital cellulitis in adult
**polymicrobial**
staphylococcus or streptococcus species
40
5-7 year old sudden onset and rapid evolution of proptosis. Diagnosis and types?
**embryonal (MC)**"everyone" 80% of cases, 95% 5-year survival
**alveolar (worst)**"awful" 9% of cases, 65% 5-year survival
**pleomorphic (LC, best prognosis)**"please" 97% 5-year survival
**Botryoid**
41
Hughes tarsoconjunctival flap contraindicated in young children because..
risk of amblyopia
requires 2-4 wees of occlusion
42
Location with lowest risk of systemic lymphoma
**conjunctiva**
greater for orbital
highest for eyelid
43
frequent cause of acute spastic entropion
intraocular surgery
44
Treatment for tearing with absent lacrimal system
conjunctivodacryocystorhinostomy (CDCR)
45
repair large lower defect involving 50% of eyelid
modified Hughes procedure
46
tissue layer that the temporal (frontal) branch of CN VII is found
temporoparietal fascia
47
results from failure of the choroidal fissure to close in the embryo
microphthalmia with orbital cyst
48
NLD opens into the
inferior meatus
49
posterior ethmoidal cells open into
superior meatus under the superior turbinate
50
structures that drain into the middle meatus
frontal sinus
maxillary sinus
anterior and middle ethmoid air cells
51
Mutation in blepharophimosis syndrome
FOXL2 gene on chromosome 3
52
Sum of MRD1 and MRD2
vertical interpalpebral fissure height
53
Test levator function
measuring upper eyelid excursion from downgaze to upgaze with frontalis muscle function negated
54
lytic bony changes on CT and superotemporal orbital mass
Diagnosis and associated condition?
eosinophilic granuloma
## Footnote
**diabetes insipidus**
55
Small tuft of eyelashes a few milimeters lateral to and above the eyelash line in 2 year old with epiphora?
**aberrant lacrimal ductules**
Tx: simple excision
56
MC ocular finding in infant with unilateral small orbit and no visible eye
**microphthalmia**
no visible eye but actually have microphthalmic globe. Anopthalmia is very rare
57
DDx for scleritis + nasal inflammation
cANCA associated vasculitis (granulomatosis with polyangiits) (GPA)
relapsing polychondritis
syphilis
58
% of patients with GPA that have scleritis
25%
59
Surgical approach for tumor of lacrimal gland
eyelid crease incision
60
anterior and posterior origins of the medial canthal tendon fuse just temporal to what structure
lacrimal sac
61
located where the levator muscle transitions into the levator aponeurosis
Whitnall ligament
| (superior transverse ligament)
62
MC s/s of TED
**Eyelid retraction 90%**
Exophthalmos (60%)
restrictive extraocular myopathy (40%)
ON dysfunction (5%)
63
sheets of poorly differntiated malignant cells showing few cross striations
Embryonal rhabdomyosarcoma
64
fibrovascular strands with rounded rhabdomyoblasts along strands or freely floating in alveolar spaces
Alveolar rhabdo (most malignant)
65
easily visualized cross-striations
Pleomorphic rhabdo
least common, best prognosis
66
originate from undifferentiated orbital mesenchymal cells
rhabdomyosarcoma
67
Location of injury in traumatic optic neuropathy
**lesser wing of the sphenoid bone**
fx through or adjacent to optic canal
68
elevated eyelid crease with normal levator function (\> 15 mm) with ipsilateral compensatory eyebrow elevation
involutional or aponeurotic ptosis
69
absent or poorly formed eyelid crease
congenintal ptosis
70
Child with craniofacial abnormalities and fingers that are fused together
Apert syndrome
71
premature closure of one or more sutures of the skull bones
craniosynostosis
72
MC craniosynostosis
Crouzon syndrome
73
Craniofacial clefting
Treacher Collins and Godenhar syndrome
74
Underdeveloped lower jaw
Treacher Collins-Franceschetti syndrome or mandibulofacial dysostosis
75
incomplete development of the first and second branchial arches resulting in unilateral ear, nose soft palate lip and mandible deformities
Goldenhar syndrome or oculoauriculovertebral syndrome
76
A/w Goldenhar syndrome
limbal dermoid and strabismus
77
Where does the orbital septum of the upper eyelid fuse with the levator aponeurosis?
2-5 mm above the supreior tarsal border
78
Acts as a pulley for the force of the levator muscle and provides suspensory support for the upper eyelid and the superior orbital tissues
Whitnall ligament
79
Structure involved in all Le Fort fractures
**pterygoid plates**
By definition, Le Fort fractures must extend posteriorly through the pterygoid plates
80
pulsating exophthalmos after MVA
**orbital roof fx**
Zygomaticomaxillary complex (ZMC) are quadripod fractures because zygoma is fractured at 4 of its articulations with adjacent bones
81
82
adhesion of conjunctival surfaces
symblepharon
83
vertical shortening and horizontal lengthening of the affected eyelid
euryblepharon
84
30% upper eyelid defect but primary closure results in too much tension. Best option?
**lateral canthal lysis**
Cut superior limb of lateral canthal tendon to allow 3mm to 5 mm of mobilization
85
Assesses the stability of tear film
tear breakup time
TBUT
86
Toddler with ptosis and chin-up position. Important determinant of surgical technique and next step
**Levator function**
moderate to good - levator resection
Poor - frontalis sling
87
Subconjunctival granulomas with bx revealing noncaseating granulomas with epithelioid cells (histiocytes)
Sarcoidosis
88
MC orbital site affected in sarcoid
lacrimal gland
89
Laser used to ablate lash follicle
argon laser
90
Laser used for skin resurfacing
erbium:YAG
CO2
91
Tx for nasolabial folds
hyaluronic acid filler
92
mass effect that weigs or pulls down the upper eyelid
mechanical ptosis
93
Vessels that pass through the superior ophthalmic fissure
recurrent branch of middle meningeal artery
superior ophthalmic vein
94
epicanthus in which fold is most prominent in the upper eyelid (Normal Asian)
epicanthus tarsalis
95
epicanthus in which fold is most prominent in the lower eyelid
epicanthus inversus
96
epicanthus in which fold involves upper and lower eyelids equally
epicanthus palpebralis
97
epicanthus in which fold arises from eyebrow region and runs to lacrimal sac
epicanthus supraciliaris
98
Type 1 blepharophimosis-ptosis-epicanthus inversus syndrome BPES differes from type 2 in this way
type 1 includes early loss of ovarian function in women
99
Sites for orbital decompmression
100
Congenital choristomas lined by keratinized epithelium and dermal appendages
orbital dermoid cysts
101
Best imaging for orbital varices
contrast enhanced radiologic imaging (sprial CT) or contrast MRI during a valsalva (or other means of decreasing venous return) - shows enlargement of engorged veins
102
low flow venous malformation that result from vascular dysgenesis
orbital varices
103
high flow developmental anomalies that result from vascular dysgenesis
arteriovenous malformations (AVMs)
104
105
Obese, ocular irritation, mild mucous discharge worse on awakening and chronic papillary conjunctivitis. Next step?
Sleep studies to r/o sleep apnea
106
Tx for cicatricial entropion
**address underlying cause**
**tarsal fracture operation** (mild to moderate cicatricial changes)
**tarsal plate graft** (severe cicatricial changes)
107
baseball to head with optic neuropathy and retinal arterial pulsations
decreased perfusion of globe and optic nerve (OCS) from retrobulbar hemorrhage
remember OCS is a clinical diagnosis!!!
108
enophthalmos at rest with proptosis on valsalva
venous malformation - orbital varix
109
MC benign neoplasm of the orbit
cavernous hemangiomas
110
Lethal tumor from the meibomian glands of tarsal plate; from glands of Zeis a/w eyelashes
sebaceous adenocarcinoma
111
Etiology of orbital inflammation?
Infectious
Vasculitic
Autoimmune
Nonspecific
Granulomatous
'I VANG'
112
American thyroid association recommends initial screening with
TSH and free T4
Sensitivity of 99.5% and specificity of 98%
113
Muscle included in myectomy for facial dystonia
**orbicularis oculi (protractor)**
myectomy removes much of the protractors of the eyelids
114
retractor of the lid
levator palpebrae
115
Tx for punctal ectropion
**medial spindle procedure**
shortens posterior lamella of medial eyelid
116
Tx for Tarsal ectropion
horizontal tightening (lateral tarsal strip) and **advancement and reattachment of lower lid retractors to correct vertical laxity**
117
Eyelid is completely everted
tarsal ectropion
118
Orbital fracture that may cause trismus? (lockjaw)
Zygomatic fracture
119
Le Fort I
pyramidal break that involves lower portion of maxillary bone, "floating palate"
no ophthalmic problems
120
Cylindroma
adenoid cystic carcinoma
121
drawback to dermis-fat graft for acquired anophthalmos
unpredictable resorption of volume
122
may result in continued orbital expansion in a child born with microphthalmic eye
dermis-fat graft
123
lentigo simplex prognosis
flat pigmented spots larger in diameter than ephelides (freckles) **benign** and do not require treatment
124
MC melanoma on eyelid
**lentigo maligna melanoma** - invasive vertical growth phase in 10%-20%
## Footnote
**nodular melanoma**
125
variant of angioneurotic edema, rare condition characterized by intermittent swelling of the eyelid resulting in thin and wrinkled skin that can give appearance similar to dermatochalasis
blepharochalasis -
126
variant of this disease
angioneurotic edema
## Footnote
**blepharochalasis**
127
embryologic origin of solitary fibrous tumor
**mesenchymal**
spindle-shaped cells strongly CD34 positive
128
embryologic origin of fibrous histiocytoma
mesenchymal
129
embryologic origin of osteomas
mesenchymal
130
embryologic origin of fibrous dysplasia
mesenchymal
131
Blunt trauma to right orbit with droopy eyelid and MRD1 of 1.5 mm and levator function of 5mm. Dx and Tx
**traumatic ptosis**
observation for 6 months before surgical intervention
132
Tx for optic nerve sheath meningioma
observation
133
Surgical space accessed to drain abscess a/w ethmoid sinusitis
**subperiosteal space -** between bone and periorbita
most peripheral space in orbit closest to sinuses
134
135
Abscesses usually occur in this space
subperiosteal space
136
How to minimize notching of the eyelid margin
precise suture placement and critical suture tension
137
Best approach for superior lesions
vertical lid-splitting orbitotomy
138
At risk for
oculodermal melanocytosis (Nevus of Ota)
Glaucoma - 10% with pigmentation of TM and GL
139
140
Multiple eyelid lentigines, flat, pigmented spots larger than ephelides may be a/w
**Peutz-Jeghers syndrome**
*melanotic macules - fade in early adulthood, persist in buccal mucosa. Not in malar surface like freckles. On lips and eyelids*
intestinal polyposis with increased risk for colon cancer
141
branch of facial nerve that innervates corrugator supercilii muscle
**temporal (frontal)**
innervates the superior part of the facial mimetic muscles
142
treatment of lacrimal sac carcinomas
**aggressive surgical resection including exenteration if necessary**
50% recurrence rate of malignant invasive squamous and transitional cell carcinoma of the lacrimal gland
143
MC site for traumatic orbital fractures
**1. lamina papyracea**
2. maxillary bone (posteriomedial)
144
misdirection of the lashes with normal origin from anterior aspect of lid
trichiasis
145
abnormal growth of lashes from meibomian gland orifices
distichiasis
146
congenital condition in which eyelashes are abnormally long greater than 12 mm central and 8 mm in peripheral
Trichomegaly
147
