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OPOT 4002 > OPHHAA > Flashcards

OPHHAA Flashcards

1
Q

Causes of cicatrising eye disease:

A

Trauma: Sx (pterygium/OSSN), thermal, Radiation, Alkali/Acid
Autoimmune: Ocular pemphigoid, SJS
Infectious: trachoma
Allergic: VKC, AKC

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2
Q

Radiotherapy can manage:

A

Pterygium (B-rad)
OSSN
Choroidal melanoma/metastasis
Retinoblastoma
Graves Ophthalmopathy
* Risks Cicatrising ocular surface

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2
Q

Steven-Johnson syndrome / Toxic epidermal necrosis
Patho/description:

A

Rare complication from medication. Dermatological emergency, TEN is severe form of SJS
- SJS: <10% of body skin peeling
- TEN: > 30%
Patho:
Type 4 HS reaction to trigger > cytotoxic T / NK cells targeting keratinocytes > epidermal necrosis
Triggers:
- Infection (HSV, HIV, Hep)
- Antibiotics (pencillin, Cephalosporin, Ciprofloxacin)
- NSAIDS
- Vaccination
- Graft-vs-host
All ages, U/women, 100 times more for HIV

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2
Q

OCP patho:

A

Subset of mucous membrane pemphigoid (MMP)
- AAD, bilateral progressive cicatricial conjunctivitis
Defect in immunoregulation > autoantibodies against conjunctival basement membrane > complex formed w/autoantigen > complement activation > cytokine release / fibroblast activation > collagen formation / chronic inflammation
U/60yo, women (2:1), 0.05% incidence
- ^risk: HLA- DR2, DR4, DQw7

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3
Q

Ocular cicatricial pemphigoid (OCP) signs/symptoms/management:

A

Symptoms:
- DED (hyperemia, FBS/grit, watering, itching)
- Diplopia, photophobia, blepharospasm
- Oral ulcers > skin ulcers
Eyelid signs:
- Trichiasis
- MGD, blepharitis
Conj. signs:
- Papillae, Follicles
- Symblepharon, fornix shortening, fibrosis
- Ankyloblepharon
Cornea signs:
- Superficial punctate keratitis
- Epith./Stromal defect
- Neovasc.
FOSTER CLINICAL STAGING:
Stage 1: Chronic conjunctivitis (redness/irritation)
- cortico. and lubricating drops
- Systemic anti-inflammatory Dapsone 50mg/day
Stage 2: Symblepharon formation (fibrous tissue between conj.)
- Cortico. and Sx for scarring
Stage 3: fornix shortening (recesses between lid-globe)
- Systemic immunosuppressive Methotrexate
Stage 4: Ankyloblepharon (eyelid fusion)
- Mucous membrane grafting

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4
Q

OCP clinical response:

A

DDX:
- Bac./Viral conjunctivitis (Acute, discharge)
- VKC/AKC (Seasonal)
- SJS/TEN (Skin rash, Acute)
Diagnosis:
- Elderly Px, bilateral slowly progressive conj. cicatrization
- Conj. biopsy > Immunofluorescence (basement membrane assess)
- Immuno-peroxide assay
Management:
- Ocular Prednisolone acetate 1% Hourly until acute symptom relief > QID
- Systemic anti-inflammatory Dapsone 50mg/d
- Systemic immunosuppressive methotrexate 1g/d
- Lubricating drops > punctal occlusion > autologous serum > bandage CL
- Epilation > fornix/lid Sx. > mucous membrane graft
Explaination:
Inflammation U/controlled well
Relapes 1/3
Life-long follow-up
- Progressive, to blindness if untreated

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5
Q

Trachoma background:

A

Leading cause of infectious blindness
- Poor sanitation, crowding, unclean water
Obligate intracellular bacterium (Chlamydia trachomatis)
Gram-negative, serotype A-C
- Initial Active> Mild mucopurulent conjunctivitis | U/5yo or women
- Repeated > Cicatricial | U/middle age

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5
Q

SJS/TEN signs/symptoms/management:

A

Prodromal:
- Malaise, cough
Ocular symptoms:
- Hyperemia, tearing
- DED, pain/FBS/Grit
- Blepharospasm, photophobia, diplopia
Ocular signs:
- Trichiasis, MGD, blepharitis
- Papillae/Follicles, Symblepharon, fornix shortening, ankyloblepharon
- SPK, stromal ulcer/opacity, neovasc.
Systemic:
- Rash: face > mucosa (oral, anus)
- Macule > papule > vessicle > bullae > peeling
Management:
- ICU hospitalization > Burn treatment
- Discontinued offending agent
Ocular management:
- Aggressive lubrication
- Topical Pred-acetate 1% hourly
- Symblepharon lysis
- Corneal/Conj. graft
- Limbal stem cell transplantation

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6
Q

Viral conjunctivitis:

A

U/adenovirus (75%), otherwise Herpes, Epsterin, HIV
- Adenovirus has no effective treatment, refer if no resolution by 7d
Follicular conjunctivitis:
Mildest, adenovirus serotype 1-11, 19
- acute onset
- Unilateral > spread bilateral
- Watery, conj. hyperemia, follicles/papillae, preauricular LA
- Self resolving
Pharyngoconjunctival fever:
Adenovirus serotype 3, 4, 7
Pharyngitis, fever, follicular conjunctivitis
- corneal punctate epitheliopathy
- Conj. hyperemia/injection, watery, Preauricular LA
- Resolve 2w, Cold compress, lubricant, Murine drops (naphazoline 0.1%|A-adrenergic agonist)
- Short-term FML (0.25%) QID
Epidemic keratoconjunctivitis:
Severe, Adenovirus serotype 8, 19, 37, Contagious
- Follicular and Papillary conjunctivitis
- Conj. injection, Epiphora
- Led edema, membranes, conj. scarring > Symblepharon
- Corneal SPK, subepithelial opacities
- Pred-acetate 1% QID, Resolves 3w
- Cold compress, decongestant, anti-histamines
- Educate on contagion
HSV conjuntivitis:
Primary or recurrent, unilateral
- Irritation, watery, hyperemia
- Mixed follicular papillary
- Lid vesicles
- Topical acyclovir ointment 3% 5/d for 7d
- Oral acyclovir 400mg 5/d for 7d
HZ conjuntivitis:
1/2nd branch of CNV, unilateral
- Skin rash, respecting midline
- U/keratitis and uveitis
- Requires ophthal
Acute hemorrhagic conjuntivitis:
Picornavirus, enterovirus, coxsackievirus
- Rapid, severe, painful follicular conjuntivitis
- Subconj. haemorrhages
- Supportive treatment, resoves 7d

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6
Q

Trachoma patho:

A

Initial/Active infection:
Direct contact/fly transmission > Conj. epith. invasion (assisted by micro abrasion) > 5-10d Incubation period (replication) > HS 4 reaction to anigens > immune cell response (macrophage/neutrophil) > mild mucopurulent follicular conjuntivitis
Cicatricial phase: Repeat infection > Chronic inflammation >
- Continued pro-inflammatory cytokine production (IL-1, TNF-a/g) > tissue damage
- Fibroblast activation > ECM production > Conj. cicatrization
Scarring/goblet cell loss > Entropion > Trichiasis > Corneal keratitis > pannus > ulcer
WHO GRADING SCALE:
1. TF (Trachomatous Follicular)
Chronic follicular conjunctivitis
1. TI (Trachomatous Intense)
Papillary hypertrophy
1. TS (Trachomatous Scarring)
Conj. fibrous tissue formation
1. TT (Trachomatous Trichiasis)
Lash touching globe
1. CO (Corneal Opacity)
Corneal ulceration

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6
Q

Trachoma signs:

A

Alt’s line: White scar on tarsal conj.
Herbert’s pits: Dark limbal depressions (necrosis of follicles)
WHO GRADING SCALE:
1. TF (Trachomatous Follicular)
Chronic follicular conjunctivitis (several white bumps), Preauricular lymphaneo.
- Irritation, epiphora, redness
2. TI (Trachomatous Intense)
Papillary hypertrophy, tarsal thickening (BV obsuration)
- Pain, epiphora, mucopurulent discharge, Photophobia
3. TS (Trachomatous Scarring)
Conj. fibrous tissue formation
- Asymptomatic > light FBS
4. TT (Trachomatous Trichiasis)
Lash touching globe > evident lash removal, entropion
- Pain, epiphora, mucopurulent discharge
5. CO (Corneal Opacity)
Corneal ulceration
- Blur, Chronic pain, photophobia

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7
Q

Ligneous conjuntivitis:

A

Rare, chronic, recurrent conjunctivitis
Congenital def. of type-1 plasminogen > poor fibrin breakdown > fibrin pseudo membrane formation
- Thick yellow pseudo-membranes on tarsal conj
- Chronic redness, irritation, FBS
- Membrane growth > mechanical ptosis, corneal scar/perforation
Management:
Topical tissue-Plasmogen activator
Sx pseudomembrane excision (under GA)
Regular follow-up: care corneal ulcer

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7
Q

Trachoma clinical response:

A

DDX:
- Viral/bacterial/Allergic/Toxic conjunctivitis
- SJS/TEN
- Adult inclusion conjunctivitis
Diagnosis:
- Conjunctival scrape > Staining (inclusion bodies), PCR, Cell culture
Management:
Oral azithromycin 20mg/kg (max 1g) one dose (Yearly for high risk)
- Binds 50S ribosomal subunit of bacteria > no mRNA translation
Topical tetracycline ointment 1% BID for 6w
WHO SAFE:
- Surgery for advanced disease
- Antibiotics to clear infection
- Facial cleanliness
- Environmental improvement

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8
Q

Tetracycline:

A

BS-antibiotic, Bacteriostatic
Binds reversibly 30S subunit of bac. ribosomes > inhibition tRNA binding > protein synthesis loss
Oral 500mg qid (3w)
Ointment 1% BID

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8
Q

Adult inclusion conjuntivitis:

A

C.tracomatis D-K, Direct contact W/genital secretions > Incubation (5-14d)
- Conj. injection, watering/mucopurulent
- Follicular conjuntivitis, papillae, SPEE
- Preauricular lymphadenopathy, Pannus
DDX/clinic:
- Sexual Hx
- Conj. swab PCR
- Conj. scrape culture
Treatment: Otherwise chronic conjunctivitis
- Oral Azithromycin 1gm; or 3w of
- Tetracycline 500mg qid
- Doxycycline 100mg bid
- Erythromycin 500mg qid
- Topical tetracycline ointment 1% BID 3w
- Treatment of sexual partners

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9
Q

Conjunctivitis clinical response:

A

Pain/Photophobia/VA loss > Ophthal
DDX:
1. Infectious / non.
2. Acute, hyper-acute, chronic
3. Primary / secondary
Viral: most common
- Watery, non-itchy, Follicular, Preauricular lymph adenopathy
Bacterial: U/children
- Muco-/purulent discharge, Lid matting, non-itchy
Allergic: Spring/Summer
- watery, Itchy

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10
Q

Bacterial Forms of conjunctivitis:

A

Bacterial conjunctivitis:
U/ Staph au, Strep p, H-influenza (children)
- Acute bilateral, Assoc. blepharitis
- Conj. hyperemia, purulent discharge > Lid matting
- Grit/FBS, R/membranes
- Self-limiting 2w, anti-biotics speed process slightly “wait and see”
- If purulent/CLs > Chlorsig 0.5% QID 7d (till resolution)
- Warm compress, lid cleaning, lubricants
Hyperacute conjuntivitis:
Neisseria gonorrhoeae, Very fast onset
- Copious purulent discharge, Conj. injection, VA loss
- Lid swelling, eye pain/burn, preauricular LA
- Referral for systemic antibiotics
Chronic bacterial conjuntivitis:
Bac. Conj. > 4w, U/Staph a
- bilateral matting, follicular conjunctivitis
- no itching, chronic irritation/grit
- Blepharitis > Lid hygiene, hot compress, scrub, antibacterial
- Long term antibiotics
- FML (0.25%) QID

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11
Q

Allergic conjunctivitis:

A

Seasonal/Perennial:
T1 HS to pollen/dander
- Redness, itching, tearing
- Assoc. allergic symptoms
- Avoid allergens, topical antihistamine
Acute atopic:
T1 HS to pollen
- Bilateral, hyperemia, watering, itching
- Chemosis, papillae, mucoid (severe)
- FH atopy
- Topical antihistamine: Zyrtec Cetirizine
- Allergen avoidance, cold compress, oral Cetirizine
Chronic atopic:
Persistent/recurrent atopic, assoc. eczema/asthma
- Bilateral, burning, mucoid, hyperemia
- papillary hypertrophy, SPK, ulcers, lid edema/chemosis
- Horner-Trantas dots (white dots)
- Corticosteroids w/symptom relief
GPC:
T1/4 HS to CL/prosthesis (Allergen and mechanical)
- Upper palpebral conj. giant papillae
- Tarantas dots/gelatinous nodules at limbus
- Itching, CL mucous, pain on removal
- Requires removal of CL
- Topical antihistamines, mast cell stabilizers and cortico.

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12
Q

Allergic conjuntivitis patho:

A

T1 HS: Antigen-presenting cells (dendritic) bind/present allergen (pollen) to T-cells in lymph nodes > CD4+Tcell activation (Th2) > cytokine (IL-4) release > B cell activation > IgE antibody (for pollen) production > IgE sensitize mast cells
Re-exposure > mast cell degranulation > immune mediator release > histamine/prostaglandins > vasodilation, irritation, swelling
- Response in minutes
T4 HS: APCs present to T-cells > CD4+ T cell differentiation to Th1 > Activation of macrophages, CD8+ T cells > Mac. damage tissue, CD8+ kill cells with antigens
- Response in days, U/chronic

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13
Q

Topical treatments for allergic conjuntivitis:

A

Antihistamines: H1 receptor antagonist > Blocks histamine binding to cells
- Ketotifen Fumarate 0.025% BID
- Levocabastine 0.05% BID
Mast cell stabilizers: Membrane stabilization prevents degranulation
- Lodoxamide 0.1% BID
- Also inhibits Ca influx to mast cells (needed for degranulation)
- Sodium cromoglycate 2% QID
Cortico: Phospholipase A2 inhibition, required for Prostaglandin synthesis
- Flurometholone 0.1% QID
- loteprednole 0.2% QID
* Glucocorticoid receptor agonist > suppresses cell migration
Immunomodulators: Calcineurin inhibition (enzyme for Tcell activation, IL-2 transcription)
- Cyclosporin 0.05% BID
- Tacrolimus 0.03% BID

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14
Q

General DDX conjuntivitis:

A
  • Virus common, w/follicles
  • Allergic has itch and papillae
  • Bacterial U/self limiting
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15
Q

Blepharitis:

A

Bacterial lid infection
- Atopy, DED, Demodex
Anterior blepharitis (Staph. a, or seborrhea)
- Grit/Burn/itch, DED, lid crusting, tearing
- Stye, chalazion, marginal keratitis
- Chronic staph > Trichiasis
- Seborrhoeic > Hyperemic greasy lid margins and dandruff
1. Reassurance “Life-long, no cure, recurrant”
2. Lid hygiene (warm comp. lid scrub/massage)
3. Antibiotic (Topical erythromycin 0.5% QID)
4. Cortico. (FML 0.1 QID)
Posterior blepharitis:
- Meibomian capping
- Hyperemia of lid margin, oily tear film
- Secondary > papilliary conjuntivitis, SPK, DED
1. Reassurance “recurrance common”
2. Lid hygiene (warm comp. lid massage/scrub)
3. Oral antibiotics (Doxycycline 100mg BID 1w > daily 6w)
4. Antibiotic ointment
5. Cortico. (FML 0.1% QID)

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16
Q

Causes of pseudoptosis:

A

No pathology of lid muscle:
- Dermatochalasis
- Enopthalmos
- Micropthalmos

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17
Q

Classification of ptosis:

A

Congenital
1. abnormal LPS development > absent lid crease
Acquired
- Neurogenic
- CN3 palsy
1. Down/Out dilated pupil
- Horner’s
1. Constricted pupil, anhidrosis
- MG jaw winking
- Myogenic
- MG
1. AAD against Ach receptors at NMJ
2. Fatigue, cogan’s lid twitch
- CPEO
1. Mitochondrial myopathy
- Mechanical
- pseudoptosis
- Aponeurotic
- Involutional
1. Age related dehiscence of LPS
2. High lid crease, full motion

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18
Q

Hx ptosis:

A

Age of onset/duration (congenital)
Pupil asymmetry
Diplopia
Headache
Trauma (neck injury)
Systemic symptoms (DM, HT, MG, CPEO)
Ptosis variability (MG)

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19
Q

Clinical testing for ptosis:

A

VA w/pinhole
Motility
- CN3, MG, CPEO
Pupils
- Anisocoria CN3/Horners
Slit lamp
- Tumor / scar
- Ptosis assess: Margin reflex distance, Palpebral fissure height, LPS function
- MRD: Corneal reflex U/5mm from lid margin
- PF: Lid margins U/9mm apart
- LPS: >15mm travel from down gaze to up
- Assoc. clinical signs
- 30s upgaze (MG)
- MG jaw-winking

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20
Q

Ectropion:

A

Eversion of lower lid from globe
Involutional (age > lid laxity), paralytic (CN7), Cicatricial (CPO), trauma (Chemical/burn)
- Epiphora (puncta displaced)
- Thick/keratinized tarsal conj.
1. Involutional: Lower lid tightening
2. Cicatricial: Scar excision w/grafts
3. Paralytic: Botulinum toxin

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21
Q

Entropion:

A

Inversion of lid from involution (age), cicatritial (OCP)
- Pseudotrichiasis
- Corneal lesion/ulcer
- Pain, redness
1. Lubricants, taping, BCL
2. Lateral tarsal straip Sx

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22
Q

Visual pathway and chiasm crossing:

A
  1. Retina
  2. ON
  3. Chiasm
    1. Inf. Nasal retina fibers (sup.-temp. VF) loop to contralateral ON before crossing (anterior Willebrand)
    2. Sup. nasal fibers (Inf.-Temp. VF) Loop to ipsilateral ON before crossing (posterior Willebrand)
    3. Macula fibers cross at posterior chiasm
  4. Tract
    1. Horizontal VF and contralateral macula fibers
  5. LGN
  6. Optic radiation
    1. Ant./Inf. radiations > Inf. retina fibers (sup. contra. VF quadrant), Incongruous
    2. Pos./Sup. radiations > Sup. retina fibers (Inf. contra. VF quadrant), Congruous
  7. Primary visual cortex
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23
Q

Causes of ON lesions:

A
  • Optic neuritis
    • MS
    • Syphilis
  • Toxic and nutritional neuropathy
    • Alcohol poison
    • Vit B def
  • Ischemic optic neuropathy (N/AION)
    • GCA
    • HT
  • Lebers hereditary optic atrophy
  • Papilledema, IIH (ON comp.)
  • Glaucoma
  • Tumors (chiasmal)
    • Pituitary adenoma
    • meningioma
  • Vascular
    • Aneurysm
    • DM
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24
Q

ON lesion signs:

A
  • VA loss
  • Color deficiency
    • RG blindness
  • Poor brightness/contrast sensitivity
    • RAPD
  • Afferent pupil defect
  • VF defect
    • Central scotoma
    • Altitudinal
    • Nerve fiber bundle
    • Centro-caecal scotoma (Macula to OD)
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25
Q

Optic path scotomas:

A
  • Bilateral junctional scotoma of Traquair
    • Lesion at wilbrand’s knee (loop of inf.-nasal fibers)
    • Central scotoma on lesion (meningioma) side
    • Sup. quadrantanopia on contralateral
  • Bitemporal hemianopia
    • Pituitary adenoma, R/Craniopharyngioma
    • Assoc. bow tie atrophy
  • Binasal hemianopia
    • Bilateral carotid artery aneurysm
  • Homonymous hemianopia
    • Lesion of optic tract
    • Optic atrophy: Bow-Tie (contralateral), Temporal half of retina (Side of lesion)
  • Quadrantanopia
    • Upper: Ant./Inf. Radiation lesion (Pie in the sky)
      • Assoc. Contralateral hemiparesis (weakness)
      • Incong. > alternate pattern between eyes
    • Lower: Pos./Sup. Radiation lesion (pie on the floor)
      • Assoc. Agraphia (poor writing)
      • U/cong.
  • Congruous homonymous hemianopia W/macula sparring
    • Ant. visual cortex lesion (Middle cerebral artery occlusion)
    • Cong. > similar bilateral presenting
  • Congruous homonymous macula defect
    • Pos. visual cortex lesion (Posterior cerebral artery occlusion)
    • Cong. > similar bilateral presenting
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26
Q

Pituitary adenomas:

A

Basophilic: Ant. pituitary, alters ACTH release (Regulates cortisol) > cushing disease
- Obesity, moon face, brusing
- Assoc. DM/HT
1. Blood cortisol check
2. Sx tumor excision
Acidophilic: Inf. pituitary, alters GH > Gigantism (children)/Acromegaly (adults)
- Sweating, head/extremity enlargement
- Assoc DM/HT, Cardiomyopathy
1. Glucose tolerance test > GH measured
2. Bromocriptine (dopamine agonist) > Radiotherapy > Trans-sphenoidal hypophysectomy
Chromophobe adenoma: Post. pituitary, alters Prolactin > Galactorrhoea syndrome
- Infertility (women) / Hypogonadism (men)
1. CT/MRI
2. Bromocriptine (dopamine agonist) > Radiotherapy > Trans-sphenoidal hypophysectomy
Optic symptoms of pituitary adenoma:
- Bitemporal hemianopia, Colour desat. (RG loss), Bow-tie optic atrophy
- Headache of brow, VA/Depth loss, diplopia (pressure on cavernous sinus)

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27
Q

Microbial keratitis organisms and presentation:

A
  • Bacteria: Rapidly progressive, boggy ulcer
  • Trauma, CLs
    • gram positive: Fluoroquinolone (moxifloxacin)
    • Well-defined ulcer, moderate corneal haze
      • Staph aureus
      • Strep pneum
      • Nocardia > Wreath-like ulcer (rare)
    • Gram negative: Aminoglycoside (gentamycin)
    • Ill-defined ulcer, severe haze, more discharge
      • Pseudomonas
      • Moxarella > Corneal oedema
  • Fungi: Immunocomp. (yeast), Vegetive (Filamentous)
  • Slow progression, dry elevated ulcer, Pseudodendrites
    • Yeast: Natamycin
    • Feathery W/satelites
      • Candida
    • Filamentous: Amphotericin
    • Button infiltrate
      • Fusarium
  • Viral: No trauma
  • Dendritic, dry ulcer
    • Herpetic: Acyclovir
  • Protozoa: CLs, Dirty water
  • Very painful, epiphora, photophobia, dry
    • Acanthamoeba
      • Water contact, forms dormant resistant cyst
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28
Q

Risk factors for microbial keratitis:

A
  • CLs (most)
  • Trauma
  • Lid infection
  • DED
  • Exposure keratopathy
  • neurotrophic keratitis
  • Immunosuppressives (cortico.)
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29
Q

Clinical response to microbial keratitis:

A

DDX: Bac./Fung./Viral/Acan.
- Lids: Blepharitis/vesicles
- Conj./AC: hypopyon cells/flare, discharge
- Cornea: Sensation, Ulcer
- NaFl stain > measure and distinguish ulcer
Management:
1. Scrape > gram stain / DDX fungal/acan.
1. Treat immediately (ocular emergency) while waiting for results
Bacterial: BS Monotherapy Quinolone
* Systemic for perforation/nesseria
- Gram positive: Moxifloxacin 0.5% hourly until review > QID
- Staph a (CL assoc.): chlorsig 0.5% per hour until review
- Gram negative: Ciprofloxacin 0.3% 4/h 6h > 2/h for 36h (until review)
Fungal: Polyenes REFER
Educate that it will take up to 12w till resolution
* Systemic antifungal for deep infection
- Fusarium: Natamycin 5% hourly > taper
- Candida: Amphotericin 0.15% hourly >taper
Acanthamoeba: Combination cocktail REFER
Educate treatment may take months
- Biguanide Polyhexamethylene: 0.02% hourly
- Diamidine Hexamidine 0.1% hourly
Viral: Acyclovir 3% QID

  • SCUT showed no significant benefit for bacterial ulcer

CORTICO. IS CONTRA. FOR DENDRITIC./FUNGAL ULCER

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29
Q

Describe herpetic eye disease:

A

Leading cause of unilateral infectious blindness
- Alpha: HSV 1/2, VZV
- Beta: Cytomegalovirus
- Gamma: Epstein-Barr

30
Q

HSV patho:

A

DNA virus, HSV-1 via secretion contact (oral)
- Most have exposure by 5y, 10% clinical disease
Mucous membrane exposure > Virus enters corneal epith. > Nerve ending retrograde to CN5 / Corneal latency > Active replication / ganglion latency > anterograde to epith. > primary infection:
- Blepharoconjunctivitis
- Unilateral skin vesicles/ulcers, redness
- Acute follicular conjunctivitis, R/keratitis
- Periauricular LA
Triggering factor (Stress/fever/prostaglandin analogues/immunosuppression)> Latent ganglion replication > recurrent infection
- Epithelial: Actively replicating > punctate keratitis >
- Dendritic ulcer: Linear dichotomous (splits into 2) lesion w/terminal bulb
- Rose bengal/NaFl stains Bulb/central defect
- Epith. haze, ^IOP, desensitization
- Geographic: Immunocomp./Untreated
- Marginal keratitis: Leukocyte infiltrates stroma at limbus
- Dendritic ulcer overlays stromal infiltrate
- DDX staph (desensitisation)
- Resistant to treatment > Trophic ulcer
- Metaherpetic (trophic): Poor healing/Cortico, no active rep.
- Smooth boarders, poor tear surfacing
- reverse staining
- Stromal:
- Immune stromal keratitis: Immune HS response to non-replicating virus
- Stromal haze, no/small epith. involvement
- Ghost vessels, immune ring
- Stromal necrotizing: Live virus in stroma > immune and viral response
- Stromal infiltrates W/epith ulcer/necrosis
- melting/perforation
- Assoc. uveitis, trabeculitis, glaucoma
- Endothelial disciform keratitis: Endoth. inflammation > stromal edema
- Stromal/epith. haze, round lesions
- Keratic precipitates
- AC: keratouveitis
- Granulomatous or non-granulomatous
- Mutton fat KPs
- Iritis
- Synechiae, cataract, glaucoma

31
Q

HZO:

A

Vesicle exposure > Initial chicken-pox skin rash > viral latency in sensory ganglia (U/CN5) > trigger reactivation (age, stress) > anterograde via ophthalmic branches (frontal/lacrimal/nasociliary)
- Prodromal: malaise/fever
- Skin: Midline respect
- Macule > Papule > vesicle > pustule
- Hutchinson’s sign
1. Palliative W/cool compress
- Lids: Common
- Blepharitis
- Vesicles
- Conjunctiva: Vulnerable to secc. bac. infection
- Follicles, papillae
- membranes
1. Topical antibiotics, lubricants, cool compress
- Cornea: NaFl/RB staining
- SPK, Pseudodendrites
1. Debride
- Stromal keratitis
1. Pred 1% QID
- Stromal neurotrophic keratitis
1. BCL, lubrication, antibiotics
- Epi/scleritis > Uveitis > Retinal necrosis
1. NSAIDS > Steroids W/acyclovir

31
Q

HSV clinical response:

A

DDX keratitis
- Classical ulcer
- PCR and smear test otherwise
Management: HEDS 1/2 found no benefit of oral acyclovir for stromal/epith.
Epithelial: Self resolve 3w
- If >4mm, marginal, stromal: topical acyclovir 3% 5/d (up to 10d), and debride
- Metaherpetic ulcer: cease toxic medication (cortico./acyclovir) > BCL, autologous serum, graft
Stromal non-necrotizing: REFER
- Pred acetate 1% QID
- Acyclovir 3% 5/d (up to 10d) to prevent replication
Stromal necrotizing: REFER
- Debride epith. (reduce antigens for stromal)
- Acyclovir 3% 5/d (up to 10d), AND
- Acyclovir 400mg 5/d AND
- Pred acetate 1% QID, or Cyclosporine 0.05% BID
Keratouveitis: REFER
- Same as above

32
Q

POAG:

A

Diagnosis requires:
Applanation IOP>21, glaucomatous ON damage, open AC, Characteristic VF loss, absence of secc. signs (nothing blocking outflow)
- Andersons criteria: GHT on 2 consecutive tests, 3 non-edge points on PD-plot (2<5%, 1<1%), PSD probability <5%
Risk factors:
- >80yo, Afro-American, FH/Genetic (MYOC/OPTN), Rural, smoking
- IOP>21, myopia
- OATS found CCT<555um sig. risk
Patho: Cause of outflow resistance unknown; likely debris in TM
- Mechanical: ^IOP > GC axon compression at lamina cribrosa > lost retrograde trophic transport > GC death
- Vascular: ^IOP compromises ON bloodflow > ischemia/hypoxia of GCs
- Apoptotic: Mechanical/ischemic stress > programmed GC death
Symptoms:
- Blur: Painless, progressive
- Poor DA
Examination:
- VA, colour perception
- Pupils (RAPD to rule out glaucoma)
- applanation tono (IOP)
- >21 (two occasions), asymmetry >5
- Diurnal variation 8 (greater variation in glaucoma Px)
- Gonio, Pachymetry (CCT)
- ONH assessment
- SIO
- Stereo fundus photo
- red-free photo (RNFL)
- OCT (RNFL/GCL)
- VF (24-2): affect in Bjerrums area

33
Q

Interpretation of VF results:

A

Reliability indicies:
- Fixation loss (>20%)
- FP: response to infrathreshold stimuli 40db
- FN: non-response to suprathreshold stimuli (after response)
Grey scale and numeric data: Little clinical value
- Retinal sensitivity in db
Total deviation plot: db difference to normative for age group
- Global VF deviation > cataract/media opacity
Pattern deviation: Most useful
- Highlights localized VF loss
Global indicies:
- MD: mean deviation from norm
- -6/12/<-12 : Mild, moderate, severe
- PSD: Pattern deviation from norm
- 0 in normal and blindness
- VFI: VF score as percent
- 0% for blindness
Glaucoma Hemifield Test: Primary glaucoma diagnosis
- 5 zones in superior VF mirrored on inferior VF, differences indicate poor GHT
1. outside normal limits: <1% Px show this much difference
2. Borderline: 1-3%
3. General reduction/high sensitivity: <0.5% have difference
4. within normal

33
Q

Perimetry types

A

SITA test area and when to use them:
Kinetic: Map areas of equal retina sensitivity via Px report of stimulus loss
Static: Threshold of retinal points
- 30-2: central 30’, 76 points
- 24-2: central 30’ (Nasal side), 54 points
- 10-2: Central 10’, 68 points
NHMRC glaucoma guide: 24-2 is best compromise
- Esterman: Suprathreshold (95% should be seen if normal) of 120 points

34
Q

Glaucomatous VF changes:

A

ON axon damage > peripheral VF loss
- GCL has arcuate path
- Temporal axons curve around macula
1. Paracentral scotoma: localized VF loss (U/nasal)
1. Partial notch
2. Nasal step: Loss at nasal VF
1. Sup/inf notch
3. Arcuate: loss of sup./inf VF (double arcuate if both)
1. Assoc. inf./sup. notch
2. More temporal than nasal step notch
4. Ring scotoma: Everything but macula

34
Q

Congenital cataracts:

A

AD inheritance (50% to pass on)
- Assoc. systemic: Anridia, Farby disease
Crystallin genes (CRYA/CRYB)
- Cerulean (blue dot)
- Sutural (Y-shaped)
- Lamellar (layered opacity)
- Ant/pos Polar (opacity at edge)

35
Q

Optic nerve head evaluation for glaucomatous changes:

A
  • Size/shape: Disc is 2-2.5 DD from fovea
    • Bayonetting (BV wraping edge of rim)
    • Nasalization (BV curve nasally)
    • Barring (BV lose initial position on NRR)
    • Laminar dot sign (can show as physiological)
      • NRR thinning > cribrosa tissue revealed
  • NRR
    • CDR >0.65, Asymmetry >0.2
    • ISNT
    • Thinning / notching / nasal cupping
  • Haemorrhage:
    • ON haem: Linear perpendicular to ONH
      • can follow PVD/OD drusen
    • Drance haem: assoc. glauc.
      • Predictor of NFL loss once it clears
  • NFL: wedge defect
    • Arcuate axon damage > darkening from ON
  • PPA
    • Alpha: hypo/hyper pigmentation of RPE
      • present in non/-glaucoma
    • Beta: Chorioretinal atrophy w/visible sclera
      • Common in glaucoma, also normal w/age
  • GCL: OCT for early glaucoma changes
    • Progression analysis
35
Q

POAG management:

A

Target IOP:
- Ocular HT: 20% decrease
- Glauc. damage: 30% decrease
- Advanced glauc: <14mmHg
Aqueous production decrease:
- B-blocker
- A-adrenergic agonist
- CAI
Increase trabecular outflow:
- parasympathomimetic
- Rho Kinase inhibitor
Uveo-scleral outflow:
- Prostaglandin analogues: FIRST CHOICE (greatest efficacy)
- A-agonists
Laser trabeculoplasty: outflow enhance (First-line, we have to provide as an option)
- TM irritation > macrophage recruitment > debris removal
Cyclophotocoagulation: Inflow decrease (CB burned)
Trabeculectomy: penetrating filtration Sx
- New pathway outflow under visible bleb
Tube-Shunt Sx

36
Q

Aqueous drainage:

A

Ciliary processes > Pos. chamber > AC >
1. 75% > TM > SC > collector channels > episcleral veins
2. 25% > CB > suprachoroidal space > Venous circulation

37
Q

PACG patho:

A

PACS:
- 180’ of TM cant be seen on gonio
PAC:
- PACS w/^IOP
- Pupil block/Plataeu iris
PACG:
- Glaucomatous optic neuropathy
- Corresponding VF loss

38
Q

PACG risk factors:

A

60yo, Female (3:1), Chinese, FH
Shallow AC, ^CCT, Short axial length, plateau iris
Precipitating factors:
- Dim lighting > dilation
- Stress
- Sympathetic NS activation > dilation
- Anti-cholinergic (dilation)
- Atropine, Cyclopentolate, tropicamide
- Antihistamine/psychotics
- Adrenergic (sympathetic > dilation)
- Phenylephrine, Epinephrine

38
Q

PACG Hx:

A

Onset (PAAC/PACG)
- Dim light/Stress on onset
Uni/Bilateral (U/unilateral)
Pain/redness/water/photophobia/blur/halos
Headache/nausea/vomiting
- Hx > intermittent
Trauma, Sx, Systemic
Medications
- Sympathomimetic, parasympatholytic
FH

39
Q

AAC management:

A

REFER
1. medical: IOP reduction: (give them B-blockers on their way)
1. IV acetazolamide 500mg (Oral if IOP<50)
2. Topical timolol 0.5%
3. Topical Prednisolone 1%
4. Topical pilocarpine 2% (After IOP<30)
1. Doesn’t do much for initial attack
5. Analgesics
2. Laser: MUST HAPPEN
1. Bilateral peripheral iridotomy (small hole hidden by upper lid)
3. Sx: If IOP^ despite medical/laser
1. Iridectomy (outer section)
2. Iridoplasty (burn marks around periphery)
3. Cat. if assoc.

39
Q

Clinical response to PACG:

A

VA
- C.edema
Pupils (RAPD-neg.)
IOP
SLE
- Cornea haze, Pupil mid-dilated
- VH: Grade 4>3>2>1>0
- CBB>S.spur>TM>Schwalbe’s.L>Closed angle
- AC depth
- Shallow AC will have shadow from 90’ lamp >1/3 iris
- AAC > Cells/flare
- Secc. causes
- Lens induced
- Iris/CB tumor
- Angle neovasc.
Gonio
- Acute PAC do other eye
VF
OCT

40
Q

AAC patho:

A

Mid-dilation of pupil > relative pupillary block > iris bombe > appositional angle closure > Synechial angle closure
- Sudden ^IOP > Endoth. pump failure > Corneal oedema
Signs:
- Circum-corneal hyperemia
- Corneal edema
- Vertically oval pupil
- Sphincter Ischemia at sup./Inf. pupil > vertical mid-dilation
- Iris atrophy
- Recurrent attack
- Shallow AC W/irido-corneal contact
- IOP > 40
- AC cells/flare
- ^IOP > B.AqueousB loss

41
Q

DDX AAC:

A

Acute ant. uveitis (hypopyon)
Uveitis W/^IOP
Phacomorphic glaucoma (mat. cat.)
NV glaucoma
- Rubeosis following retinal ischemia > VEGF release > migration to AC
Malignant glaucoma
Plateau iris: Common
- Iris physiologically displaced, pushing on angle
- wont respond to peripheral iridotomy
Iridocyclitis (AC inflammation/cells block TM) > S.OAG
- Slow onset, IOP not as high
- Iris membrane formation
Lens dislocation
- Lens moves to AC > Visible lens > S. Acute closure
- Post. C. > Darkness where the lens isnt
Chemical injury: S.OA
- Ensure limbus not ischemic
- Requires setroids
Fuch’s heterochromic iridocyclitis
- Unilateral ^IOP, cyclitic, cataract, KPs
- Non-responding to cortico. is classic
Steroid induced glaucoma > TM cellularity alteration > S.OAG
- Horners trarantas dots, GPC

41
Q

Chronic angle closure:

A

AAC > persistant synechial closure > slow IOP^ > Pathological cupping and glaucoma
- Present like POAG but closed angle
- Needs filtration Sx

42
Q

Muscle actions

e.g Looking up-right:

A

MR: adduction
LR: Abduction
SR: Elevation > Intorsion > Adduction
IR: Depression > Extorsion > Adduction
SO: Intorsion > Depression > Abduction
IO: Extorsion > Elevation > Abduction
- Dextroelevation: R SR; L IO

42
Q

Secondary glaucoma:

A

OAG: reduces TM outflow
- Pseudo-exfoliation (common)
- 60yo, scandinavian
- Lysyl oxidase mutation (LOXL1) > Defect elastin metab. > fibrous material in TM
- Assoc. zonule weakness, Three-rings on lens, deposition on pupil margin
- Req. medical > laser trabeculoplasty (SLT>Argon)
- Pigment dispersion
- 30yo, males, 15% develop glaucoma
- Concave iris > Zonule-Iris abrasion > Pigment liberation > deposition in TM
- Pigment on cornea (Krukenberg spindle), Iris transillumination
- Assoc. zonule weakness, lens subluxation
- Req. Medical > SLT
- Hyphema
- Trauma, Sx, iris NV/tumor, bleeding disorder
- Graded 0-4
- Req. cyclo, cortico, Sx
- Phacolytic
- Hypermature cat. > cortical matter discharge > inflammatory reac. > TM blocked by cells/lens material
- CCC, corneal edema, deep AC, cells/flare, lens grey
- Req. Systemic medication > cat. Sx
- Angle recession
- Blunt trauma > tear in CB > ciliary artery rupture and TM scarring
- Assoc. hyphaema, Peripheral iris detachment
- Req. B-blockers, CAI, A-agonist > Trabeculectomy
- Post-laser (iridotomy/plasty/ trabeculoplasty)
- Inflammation/iris pigment release > TM block
- Apraclonidine 1% 1h before laser
- Req. B-blocker, CAI, A-agonist
ACG: pupil block, or angle closure

*come back to secc. ACG

42
Q

DR:

A

Insulin resistance/AAD > Hyperglycemia > endoth. damage, pericyte loss, Basement thickening
- ^Vascular permeability > BRB loss > leakage > Hard exudates
- Pericye loss > capillary occlusion > microaneurysms, dot/blot haem, CWS (retinal infarct)
Ishcaiemia/hypoxia > VEGF production > PDR
- NV, Vit. haem, CMO, TRD
U/asymptomatic, or blur/flucuation
1. VA w/pinhole
2. Fundoscopy/ photography
3. Fluroescein angiography
1. Capillary leakage, ischaemia, NV
4. OCT/-A: oedema/leakage
5. Assoc. DM
1. Cataract (snowflake)
2. Glaucoma
3. DED, Corneal
- Anti-VEGF
- Ranibizumab (lucentis)
- DRCR.net Protocol 1 showed visual improvement over PRP
- Aflibercept (Eyela)
- DRCR. showed improvement moreso for severe DMO

43
Q

Keratoplasty:

A

Penetrating keratoplasty: Full thickness
Deep anterior lamellar keratoplasty: Faster healing, reduced rejection
- Keratoconus, scars
Descemet’s stripping endothelial keratoplasty:
- Fuch’s endoth. dystrophy, ICE
Descemets membrane endothelial keratoplasty:
- Bullous keratopathy
1. Post-op Req. BS moxifloxacin 0.5% 1w, Pred-acetate 1% 3m, cyclopentolate 1% 1w, B-blocker (If ^IOP)
2. Suture removed 1y
Complications:
- Graft failure, rejection, synechiae, ^IOP

44
Q

Corneal graft rejection:

A

Donor antigens recognized by host immune cells > APC present to T-cells > CD4/8 helper/cytotoxic T-cells > cytokine (IL-2, INF-y, TNF-a) recruitment
- C.T-cells destroy donor cells
- Macro. NK cells release cytotoxic mediatorys
- Cytokines induce inflammation
Signs:
1. Epithelial rejection:
1. Corneal rejection line
2. Endothelial rejection
- Khodadoust line, endoth. damage > stromal oedema
- Oedema, KPs, ^IOP
Req. Pred-Acetate 1% hourly 48h > 6/d 2w > QID
- Systemic cyclosporine for high risk

44
Q

Vascular venous occlusions:

A

Risk factors: Both
- ^Age, HT/DM/H.lipid/H.chol.
- smoking, ^BMI
- CRVO from POAG
- BRVO from artery atherosclerosis > venous compression
CRVO S/S:
Ischmic if RAPD, severe VA loss
- Sudden unilateral painless loss of vision, VF defect
1. BV tortuisity
2. Widespread flame, D/B haem.
3. CWS
4. OD swelling
5. Mac. edema
BRVO S/S:
- Sudden unilateral painless loss of vision, quadrant specific
1. Sectoral haem.
2. CWS
3. BV tortuisity
Fundoscopy > Fluorescein angiography > OCT-/A
- Req. Blood tests for systemic
1. Anti-VEGF: Ranibizumab (Lucentis)
1. BRAVO trial showed BRVO Mac. edema improvement
2. CRUISE showed same for CRVO
2. Cortico.
1. GENEVA showed dexamethasone implant improves VA for ME
3. Laser photocoag.
1. BVOS/CVOS showed grid-LP only worthwhile for BRVO

45
Q

Vascular artery occlusions:

A

Risk factors:
- ^Age, GCA, Arrythmia, HT/DM/H.lipid/H.chol.
- Smoking, carotid artery disease
CRAO S/S:
- Sudden painless vision loss “black curtain”
- Vision loss severe
1. Pale retina
2. Cherry-red spot
3. Box-carring (Vessel bumps)
4. RAPD
BRAO S/S:
- Sudden painless vision loss (segment)
1. Segmental whitening
2. Emboli at occlusion
Fundoscopy > Fluorescein angiography > OCT-/A
- Req. bloods for systemic, Carotid ultrasound, cardiac check
1. Ocular massage, paper-bag
2. Throbolytic therapy
3. Hyperbaric oxygen

45
Q

Cataract clinical response:

A

Hx:
Symptoms
- Progressive painless vision loss
- Light/glare sens.
- Rx changes “second sight”
- Monocular diplopia/halos
- Desaturation
- Poor working
Ocular history, trauma, Sx
DM, medication, allergies
Clinic:
1. VA w/ph
2. Contrast/glare sens.
3. RAPD
4. Dilated slit-lamp
1. LOCS3
5. IOP
6. Fundus (pos. pathology)
Management:
Tinted specs, Rx change
1. Sx if VA<6/12, symptomatic, falls risk
- Contra. systemic, PDR
- Complications: Corneal edema, ^IOP, IOL dislocation
- Endophthalmitis (2w post-op)
- Irvine-Gass Syndrome (Pseudophakic CME)
- IOL rupture/dislocate > ^inflammatory mediators in Vit./Aque. > BAB/BRB loss > CME
- Petaloid pattern on FFA
- Req. topical NSAIDS/Cortico.

*come back for cat patho and types

46
Q

Abarrent regeneration:

CN3

A

Misdirected regenerating nerve fibers > synkinesis of EOM, lid, pupil
- Elevation of UL on downgaze
- Retraction of UL on downgaze / adduction
- Pupil constriction on adduction
- Retraction of globe

46
Q

Oculomotor nerve path (CN3):

A
  1. Nucleus: Root fibers of SR/MR/IR/IO, Levator P./Pupil
    1. Lesion on right brain: Right pupil, IO/IR/MR defect, Left SR loss, bilateral LP loss
      - Infarct, Haem, neoplasm, abscess
  2. Fasciculus: Passes important nuclei
    1. Lesion is the same as with nucleus
    2. Assoc. neurological symptoms tremors (red-nuclei nearby)
  3. Basilar: pass PC/SC-artery, far from other nerves
    1. Isolated CN3 palsy > Likely in basilar portion
    2. PCA aneurysm common
      - Trauma (hematoma), Aneurysm, meningitis, sarcoidosis
  4. Intra-cavernous sinus: near other CNs
    1. Present w/other CN palsy > cavernous sinus fistula
      - Pituitary adenoma, craniopharyngioma, CS thrombosis
  5. Intraorbital: Seperates into sup./inf. division
    1. Sup: LPS, SR
    2. Inf: MR, IR, IO, pre-ganglionic fibers from edinger-westphal
      - Orbit compression, TED
      Pupilomotor fibers: supplied by pia BVs on nerve surface
      • Compressive lesions (aneurysm) will be pupil involving
        - Medical emergency
      • DM/HT will be pupil sparring
47
Q

Clinical response to CN3 palsy:

A

Risk factors
Pupil
- Ensure uninvolved > recheck in a week
Assoc. nerve palsy
1. Blood glucose, HbA1c, c-reactive protein, BP, CT angiography, MRI, LP (csf check for infection)
Management:
- Medical: DM/HT, pupil sparring
1. Self resolve in 6w
2. NSAID, patching, fresnel prism
- Surgical: for aneurysm

47
Q

Trochlear and abducens nerve:

A

CN 4 Supplies SO
- Long path, no adjacent CNs > isolated palsy
- Lesion > hypertropia worse on gaze to opposite side (unopposed IO)
- Head tilt to opposite side
- Parks 3-step test:
- Primary gaze (determine which eye hyper tropic) > “if” R SO palsy > tilt head left/right > Hypertropia worse on right tilt
Abducens nerve: CN6
Supplies LR
Stretched by raised ICP > localized lesion

48
Q

Facial nerve:

A
  1. motor fibers: facial expression
  2. Sensory
  3. Parasympathetic: Lacrimal
  4. Special sensory: Ant. tongue
    Has intra/extra-cranial path > Nucleus (splits into branches)
    - Upper motor neuron from cortex
    • UMN Lesion > paralysis of contralateral lower quarter of face
      - Lower from nucleus
    • LMN lesion >Paralysis of ipsilateral whole half face
      LMN palsy causes:
  5. idiopathic (bells palsy)
  6. Trauma
  7. Infection HZ
  8. Neoplasm
  9. Vascular
  10. DM/HT
  11. Iatrogenic
    Clinical for facial nerve palsy:
    - Forehead wrinkling (frontalis muscle)
    - Eye closure (orbic.)
    - Wide smile
    - Whisteling
    - Blowing
    Bells palsy: idiopathic
    - Facial dysesthesia
    - epiphora, pain, altered taste, lacrimal dysf.
    Aberrant rege
    - gustatory fiber (salivary) misdirection > tears on chew
48
Q

Non organic vision loss:

A

Disparity of visual symptoms/signs > psychological
- U/women, young
- uni/bilateral, VA/VF, sudden/progressive
1. Smooth mobility, flinch on light, not looking at hands during tasks
2. Hx inconsistent/prior evaluations, “grey-out” vision loss
3. Tunnel vision (VF wont increase with distance change on tangent screen)
Multifactorial: Anxiety, PTSD
- Monocular NOVL > Prism/steriopsis to find VA
- Binocular > Near-Far VA discrepancy, menace reflex (flinch on jumpscare), nystagmus on drum rotation
1. Educate on reversibe condition
2. refer to mental health/behaviorual therapy

49
Q

Retinoblastoma:

A

Most common ocular malignancy in children
- Hereditary: Bilateral (asymmetrical), onset >1y
- Non-h: unilateral, onset >2y
Knudsons two hit hypothesis:
1. Hereditary: Germ cell mutation > retina cell mutation > RB
2. Unilateral: Sporadic 2 retinal mutation
- Tumor Suppressory gene (“RB gene”) of long arm in chromosome 13
1. Endophytic (Growth>vit) > Exophytic (Growth>sub-ret.) > Infiltrating (Diffuse ret-wide) > invasion of vascular supply > Fungating mass (Sudden growth w/necrosis)
Symptoms:
- Leukocoria (white reflex)
- Strabismus/proptosis, VA loss, pseudo-hypopyon (tumor cells in AC)
DDX (white reflex):
1. hereditary: retinoschisis
2. Developmental: Cataract, corneal opacity
1. Assoc. microphthalmos (retinal dysplasia)
3. Inflammatory: Toxocariasis/mosis, Orbital cellulitis
4. Tumor: retinal hemangioma
5. Ret-prematurity, Coats’ disease
Diagnosis:
- Exam under GA
- Fundoscopy > white lesion(s)
- IOP (asymmetry) > AC check
- CT: Rapid-growth > Vascular invasion > necrosis > Calcification (visible)
- Ensure no ON invasion
- MRI (T2), Aqueous tap, Ultrasound (calcification)
Histology: W/complete blood workup (systemic)
1. Flexer-Wintersteiner Rosettes: Flower appearance (lumen, columnar petals)
2. Homer wright rosettess: Radial cells in fiber tangles
3. Fleurettes: Tumor cells w/ photoreceptor differentiation
RB classification:
Group A>B>C>D>E
<3mm, >3mm, Defined tumor, Widespread tumor, Extensive
Management:
- enucleate w/ orbit radiotherapy
- Advanced
- Cryotherapy
- Small peripheral, risk RRD
- Laser photocoagulation
- Small posterior, risk retina hole/occlusion
- Iodine 125 brachytherapy plaque
- Radiotherapy cant be used for hereditary
- Causes bone growth cessation but less damage surrounding structure

49
Q

AMD grading/management:

A

AREDS classification:
- No AMD: few small drusen
- Early AMD: intermediate drusen or RPE abnormal
- Intermediate: Extensive intermediate or 1 Large drusen, geographic atrophy not over fovea
- Advanced: GA involving fovea, or exudative
Dry AMD treatment:
AREDS 1: Vitamins decrease VA loss
AREDS 2 Lutein, zeaxanthin combination w/beta carotene, omega-3
Wet AMD: AREDS says treat from intermediate stage

49
Q

AMD:

A

Multifactorial
- ^Age 50yo, smoking, Caucasian (UV), women, HT, hyperopia, cataract
- Genes CFH, Apolipoprotein E2 (APOE), ABCA4
- Complement factor H mutation > altered complement activation > increased inflammation > AMD
Age/Oxidation > Poor RPE metabolism > Drusen > separation from BM, inflammation > thickening, calcification, degeneration of BM > hydrophobic barrier to choroid > RPE separation from choriocapillaris
Hypoxia > VEGF > CNV > NV membrane > hemorrhage, fibrovascular proliferation, bruchs thickening
- Drusen: lipofuscin/immune protein
- small < intermediate < large | <63,<123,>124um
- Hard drusen: small, bright
- Soft: Intermediate, pale, ill-defined
Dry AMD 90%:
- asymptomatic, blur, poor LA/DA/contrast/colour, meta. facial recognition
- Hard drusen, RPE hypertrophy/atrophy (OCT)
- Soft drusen > risk of progression
Exudative AMD:
- Bilateral/asymmetrical, painless progressive central blur/scotoma
1. Acute: NV membrane
2. Insidious: PED
- Choroidal/sub-retinal NVM, SR fluid, SR haem. SR lipid.
- RPE detachment (PED)
- Drusenoid, serous, hemorrhagic, fibrovascular (NV)
1. OCT-A: assess macula NV
1. Type1/2/3: Sub-RPE/RPE-NSR/NSR-choroid
2. FFA: CNV assess
1. Classic:
1. Early: defined hyperf.
2. Late: progressive leakage
2. Occult type-1 (Fibrovascular)
1. Early: no leak
2. Late: diffuse leak
3. Occult 2 (undetermined)
1. Early: no leak
2. Late: focal/defined leak
Retinal angiomatous proliferation (RAP):
Form of wet AMD (NV from NSR down to choroid)
U/male, 80yo, bilateral
- Proliferation of retina capillaries > telangiectasis > juxta-foveal lesions
Stage 1/2/3: intraretinal NV/SRNV/CNV

50
Q

Macular hole:

A

Full thickness loss of macular
U/idiopathic 60yo > Trauma (young), women (2:1)
- ^Cardiovascular, HT, myopia, CME
Stage 1a (Impending): Tangential traction by vit
Stage 1b: muller cell cone pulled from PRs > structure loss, centripetal PR displacement
- Fovea elevation, yellow dot, Cavity
1. 50% self resolve with PVD
Stage 2 (small): Dehiscence in cavity roof
- <400um thickness, metamorphosia, VA 6/15-120
Stage 3 (full): Roof avulsion
- >400um thick, VA <6/120
- Red base w/yellow dots, SRF grey “crater”
- Operculum
Stage 4: Complete PVD
Clinical:
- Asymptomatic, Central blur/scotoma, meta.
1. VA loss, defined round lesion at macula w/yellow deposits
1. Watze-Allen test: Beam macula, reflex displaced at macula
2. OCT (staging), amsler, Ultrasound B-scan
3. FFA (window defect)
Managed: Stage 2 and above
- Vitrectomy w/ILM peel and gas tamponade
- Typan blue, perfluoropropane, face down posture 2w
- Risk RD, cat, retinal tear

51
Q

ERM:

A

Proliferation of avasc.-fibrous membrane
U/unilateral, 50yo
Idiopathic: PVD > ILM dishience > migration/proliferation of glial cells and remaining hyalocytes
Secondary (10%): Liberation/proliferation of RPE/glial cells > inflammation > BRB loss > proliferative vitreoretinopathy
- RRD, trauma, PRP, IO inflammation/Sx
Clinic:
- VA loss, meta. central photopsia
1. Glistening reflex, retina displacement (OCT), psuedohole
Asymptomatic > observation
Sx: Vitrectomy w/ERM peel and gas tamponade
- prognosis ^w/ short duration, no TRD, VA>6/24

51
Q

CSR:

A

U/male, 30yo, cortio.
- Steroids > overexpression of corticoid receptors of endoth. > up-regulation of Ca/K channels > vasodilation
^Type-A, HT, OS-apnea, AAD, pregnancy
- ^Cortisol/Epinephrine > autoreculation of choroidal circulation
Idiopathic: Abnormal choroidal circulation > hyperpermeability/vascular dys. > ^choroid thickness, BV dilation > RPE dysfunction > pump failure
- Blur, meta. micropsia (visual minification), dyschromatopsia, contrast loss
1. VA (6/6-6/60), round pos. elevation
- Amsler, OCT, FFA
- Smokestack: Hyperfluroescence rises to sup. lesion
Req. cortico. disc. stress relief
- U/spontaneous resolution > healed retina can seem bumpy w/drusen
- laser photocagulate

52
Q

Scleritis:

A

Severe inflammation of sclera, chronic, sight-threatneing
U/women, AAD (RA/SLE), 50yo
Anterior scleritis 98%: moderate pain, photophobia, tearing, violaceous, pain on movement (EOMs)
- Diffuse: Scleral edema
- Nodular: several immobile nodules
- Necrotizing:
- W/inflammation: intense BV congestion/pain, scleral thinning, spread to corneal/CB/TM
- Wo/inflammation: Severe thinning (visible black choroid), Cornea pulling>astig. induced, otherwise asymptomatic
1. AAD blood work-up
2. Prednisolone 1% QID
3. Oral prednisolone 1mg/kg
4. Immunosuppressives
Posterior scleritis: behind rectus muscle insertion
- VA loss W/Wo pain, can present with ant. scleritis
- RD, ON edema, CWS
- B-scan shows pos. scleral thickening
1. AAD blood work-up
2. Oral NSAID ibuprofen
3. Oral Prednisolone 1mg/kg (up to 80)
4. Immunosuppressives

52
Q

Episcleritis:

A

Inflammation of episcleral connective tissue
Benign, recurrent, self-limiting
- More common than scleritis
- U/female, young, AAD, idiopathic
Pink injection, no discharge/cornea/AC/glaucoma/photophobia
Diffuse episcleritis: 70%
- Irritation, Global redness, stress/allergy/trauma
Focal:
- Painful, sectoral, elevations of episclera, AAD assoc.
DDX:
- CLARE (CLs)
- Infiltrates, Cirbum limbal
- Conjunctivitis
- Scleritis
- 2.5% phenylephrine will blanch vessels
- Corneal/AC involved, photophobia, blue BVs
- Iritis
- Photophobia, miotic pupil
- KPs, AC cells flare
Management: Self-resolve in 2w
- FML 0.1% QID for 1w>taper
- NSAID kertorolac 0.5% if not responding

52
Q

Tests for systemic diseases:

A

Complete blood count (CBC): leukemia
Erythrocyte sedimentation rate (ESR): SLE, RA
C-reactive protein (CRP): RA, SLE
HLA-B27: Arthritis, ankylosing spondylitis
Antineutrophil cytoplasmic antibodies (ANCA): Vasculitis (Wegeners)
Enzyme linked immunosorbent assay (ELISA): Lyme disease
Venereal disease research laboratory (VDRL): Syphilis

53
Q

Cellulitis:

A

Preseptal cellulitis: Soft tissue inflammation ant. septum
- Trauma, bites, stye/chalazion, Staph a
1. Heavy swelling, pus discharge
2. Assoc. ethmoid sinusitis (nasal infection)
Req. oral antibiotics, abscess drain
Orbital cellulitis: Infection of soft tissue post. septum
U/male, children, winter
- Infectious spread from nasal sinus, lacrimal, stye
- Nasal (ethmoid) spread from thin wall, numrous formanina for nerves, bony dishisence
1. Fever, malaise, headache, sinusitis Hx, eye pain, blur
3. Proptosis, lid swelling/redness, conj chemosis, coneal haze, RAPD, poor motility,
4. ^IOP, exposure, optic neuritis, orbit abscess, CS thrombosis
DDX: Dacryocysitis, trauma, neoplastic
- Req. IV BS antibiotics
- Cephalosporins and vancomycin
- Sx for severity

53
Q

TED:

A

U/Smoker, women, 30yo, graves
- CTLA4, TCR genes
AAD > ABs against TSHR target orbit fibroblasts > FB activation > adipogenesis/myogenesis (fat/muscle hypertrophy) and GAG/HA synthesis (fluid influx) > ^orbit pressure
- Grit, photophobia, DED, thyroid symptoms
1. Proptosis/lid retraction, VA loss, RAPD, colour defect, motility loss
2. Exposure keratopathy, fibrosis, diplopia, ^IOP, ON compression
Req. thyroid function test, ultrasonography, MRI
- Serum T4 high, TSH low
1. Cease smoking: w/counsilling
2. Thyroidectomy/radiodine
1. IV cortico.
3. Orbid radiation: fibroblast are sensitive > lowers activity
1. Strabismus/lid Sx
4. Lid taping, fresnel prism, meisure chamber, lubricants, botox

54
Q

Intraocular tumors:

A

Choroidal melanoma: melanocyte malignancy
- U/asymptomatic > meta. VF loss, floaters
- Dome shaped dark/orange mass, drusen
- Fundus auto-fluorescence shows simultaneous retinal and choroidal circulation
1. DDX: naevi, RD, retinoblastoma
2. observe <2mm, otherwise plaque radiotherapy > chemotherapy
Choroidal nevus: variably pigmented area
- Flat, stable size, well-defined, drusen
1. DDX melanoma:
1. >2mm, SRF, Orange pigment, <3mm of OD, no drusen, hollow OCT
Choroidal hemangioma: slow growing, benign vascular tumor
- U/cauc. no metastasis
- Orange/red mass, SRF, degeneration
1. Observation > laser photocoagulation > plaque RT

55
Q

Ischemic optic neuropathy:

A
  1. Ant. (A/NAION): Acute infarction of ONH
    Second common cause ON loss after glauc.
    - AION (5%) from GCA; U/50yo women, Scandinavian
    • systemic vasculitis of large BVs (extra-/cranial)
    • Low PD-ligand1 expression w/trigger (VZV) > T cell overactivation > infiltrates w/ giant cells and GFs > narrow lumen w/hyperplasia > ischemia
      1. Fever, fatigue, myalgia (muscle pain on chew), weight loss, headache (temporal)
      2. Irreversible VA loss, amaurosis fugax, diplopia, CN3 palsy
      1. can cause C/BRAO, cilio-RA occlusion
        1. Chalky disc oedema, CWS, normal contralateral
    • Req. CRP (high), FFA (delayed choroidal filling)
    • IV cortico
      - NAION (95%):
    • DM/HT/H-chol. sleep apnoea
    • Acute, painless, unilateral vision/colour/VF loss
      1. RAPD, disc edema/haemorrhages
      2. contralateral OD at risk (small, crowded, OD drusen)
    • Req. GCA exclusion
      • 50% self resolve
55
Q

Papilledema:

A

bilateral non-inflammatory disc swelling from ICP>15mmHg (otherwise is called disc edema)
- IIH U/ fat, female, fertile
- IC mass, cerebral edema (trauma), Sleep apnoea, poor CSF absorption, ventricular obstruction
^ICP > pressure differential to IOP > altered axoplasmic flow > axoplasmic stasis > ischemic vision loss > oedema
1. Throbbing headache (waking/coughing), pulsatile tinnitis, diplopia (CN6), color loss, RAPD
- Early: normal VA/VF, disc blurred/hyperemic small haem. normal macula
- Late: poor VA, severe hyperemia/elevation/absent cup, venous congestion, ON haem./exudates/CWS
- Chronic: pale disc, loss of cup, VF constriction
- Atrophic: VA severe, disc grey/white, slight elevation, thin BVs, indistinct margins
1. DDX pseudo-oedema:
1. Red-free > light reflex of nerve
2. no exudates/CWS/haem.
2. OCT: Double hump, increased thickness
3. LP: 250mm of water
4. CSF analysis
Requires management of ICP

55
Q

Benign lesions:

A

SC papilloma: most common, raspberry
- excision
BV papilloma: wart, brown
- excision
Actinic keratosis: UV, hyperkeratotic plaque
- Biopsy > excision
Melanocytic nevus: Pigmented lesion
- cosmetic excision
Neurofibroma: several soft lesions
Capillary hemangioma: strawberry nevus, blanches
- observation > systemic cortic.
Port-wine: pink no blanch
- laser
Pyogenic granuloma: rapid vascular
- excision
Xanthelasma: yellow plaque, lipidemia
- Excision

56
Q

Inflammatory lesions:

A

Chalazion: MG obstruction/inflammation
- slow, painless, assoc. MGD
- Warm compress > cortico injection
Stye: staph infection of zeiss (external hordeolum)
- pain, red, tender
- warm compress, epilation
Epidermal inclusion: Sx assoc. firm mobile nodule
- excision
Dermoid: embryonic epidermal inclusion
- excision
- BCC: common cancerous mass
- pearly/pink, ulcer/bleed
- Excision w/cryo
SCC: rapid from actinic, metastatic
- hyperkeratotic/ulcerative/cutenous horn
- Radial excision
SGC: slow, meibomian cancer
- radial excisi

57
Q

Optic neuritis:

A

T-cell infiltration > cytokine/mediator release > myelin loss and axonal damage
* Typical ON: Retrobulbar, Perineuritis, Neuroretintis (macular star)
U/young, healthy, female, AAD
- Acute VA loss, unilateral, retrobulbar pain on move
- Progresses for 2w > Resolves in 6w > recurrence
1. VA/VF/Color loss, RAPD, neurological defect, disc swelling
1. VF: diffuse, BS enlarged, hemi/quad, nasal step/arcuate/central/centro-caecal
2. OCT: RNFL thinning at ON/mac.
3. MRI: Brain lesions (T2), Active inflammation (T1 gadolinium)
Req. counselling MS (ON indicates 1/4% MS by 15y, increased if MRI found lesions)
- IV methylprednisolone: acute/VA loss
- Observation
- Never oral cortico. (^recurrent)
1. MS: interferon beta (Avonex)
Atypical ON: not assoc. MS
- neuromyelitis optica from anti-aquaporin4 antibodies
- Sarcoidosis: bilateral
- Cat scratch
- Drug induced (ethambutol)
1. VA loss/OD swelling more severe, retinal drusen, haem. vasculitis
Req. MRI, chest X-ray, bloods
- NMO: IV methyl prednisolone, plasmapharesis
- Cat scratch: antibiotics and cortico.
- AAD: steroids
- Induced: drug cessation

58
Q

Corneal degenerations:

A

Dystrophies: U/bilateral, symmetrical, young, FH, central
- Band keratopathy: Ca in epith/BM/stroma
- Dust like horizontal band over visual axis
- Idiopathic > uveitis, hereditary
- Systemic work-up, EDTA 1% for 5 minutes
- Keratokonus
Degenerations: U/asymmetrical, elderly, neg-FH, peripheral, inflammation, uni/bilateral
- Arcus senilis: most common peripheral opacity
- Grey ring of stromal lipid, Age>limbal BV loss > leak 12/6’
- Benign, younger > indicates hyperlipidemia
- Vogt’s limbal girdle: U40yo, female
- Band at 3/9’ limbus, BM accumulation
- T1/T2: Clear interval of vogt/no clear zone
- Corneal farinata: Flower like
- Grey central stromal opacites wo/inflammation
- Crocodile shagreen: U/elderly
- Polygonal grid opacity of stroma
- Spheroidal: protein deposits on epith./BM/stroma
- U/male, UV, burns
- Req. UV protection > superficial keratectomy
- Salzmann nodular degeneration: grey discrete hyaline nodules
- U/50yo, cauc. female, chronic inflammation
- FBS, blur
- Req. lubricant, topical FML 1% > superficial keratoplasty
- Lipid keratopathies: yellow chol. deposit in superficial cornea
- Primary: spontaneous, no vasc.
- Secondary: infection (HSV) > vasc.
- Req. argon laser photocoagulation of BVs
- Mooren’s ulcer: painful peripheral invasion from limbus
- U/60yo, AAD, diagnosis of exclusion
- FML 1%
- Young presntatino > malignant > wont respont to treatment
- Terriens marginal: painless slow peripheral thinning
- Stromal thinning, overlying pannus w/lipid at leading edge
- U/men, 20yo, assoc epi/scleritis
- Req. graft
- Pellucid marginal degeneration: bilateral crescent inf. thinning
- No inflammation
- req. pachymetry
- DDX keratokonus: no vogt striae or change to CCT

58
Q

Anterior Uveitis:

A

BV dilation/congestion, leucocyte accumulation > Exudative leak from BV > aqueous flare/cells > KPs, vitreous opacities
Acute ant. uveitis (70%): Idiopathic, lasting <3mo
- Lids/conj: ciliary injection
- Cornea: KPs, oedema (blur), band keratopathy
- AC: cells/flare, hypopyon, hyphaema, vitritis
- AC cell grade: 1-4 as 6-50+ cells
- Flare: 1-4 as faint-plastic aqueous
- Iris: pattern loss, koeppe/busacca nodules, atrophy, pos. synechiae, NV
- pupil: constricted, sluggish reaction
- Lens: Pigment on capsule, cataract
- IOP: Low if CB inflammed, or high (secc. glauc)
- Secc. Retinitis, optic neuritis
Causes:
- Immune mediated: Non-granulomatous
- Ankylosing spondylitis: HLA-B27 > spine inflammation
- Reiter syndrome: Arthritis > conjunctivitis
- Psoriatic arthritis: HLA-B27/17 > arthritis
- Behcet’s: HLA-B51 > ulcers and arthritis
- Vogt-Koyanagi: HLA-DR1/4 > granulomatous panuveitis
- Infectious: granulomatous
- Masquerade: wont respond to treatment
Management:
- Skin test: Behcet, TB
- Serology: syphilis, toxocara/plasma, sarcoidosis
- Imaging: choroiditis
1. Cyclo: iris/ciliary spasm, synechiae break/prevent
2. Cortico:
1. Acute ant: topical
2. Intermediate uveitis/pan uveitis: intraocular
3. systemic if no response
3. Systemic antibiotics: infectious uveitis
Chronic ant. uveitis: Asymptomatic, non-/granulomatous
- uveitis signs in white eye

59
Q

Posterior uveitis:

A

Infectious: Toxocara/plasma, TB, syphilis, viral
- Toxoplasmosis: common, unilateral, cats
- Focal necrotizing retinitis “headlight in fog”
- Req. cocktail therapy
- Toxocariasis: dog/cat roundworm
- retinal granuloma
- Req. systemic steroids
- Viral retinitis: herpes > ARN or PORN
- Acute retinal necrosis: Vitritis/arteritis/periphlebitis, confluent peipheral necrosis
- progressive outer retinal necrosis: cracked mud appearance
- CMV: AIDs/Transplant infection > attacks veins > frosted/bushfire branch
- TB: Choroiditis > Tubercles
- bright yellow spots similar to ON under retina
- expansion of choroid, can have assoc. PEDs
- Can present as Neuroretintis
- Syphilis: mimics any uvitis
- Req. penicillin
Non-infectious: white dot syndromes, U/need steroids and immunosuppressives
- Acute posterior multifocal placoid pigmented epitheliopathy
- HLA-B7/DR2, sudden bilateral VA loss, central scotoma
- Several yellow large lesions, RD, disc edema
- Req. steroids
- Multiple evanescent white dot syndrome
- Unilateral VA loss, Best visual resolution
- several yellow small dots, vitritis, disc edema, RAPD
- Punctate inner choroidopathy
- Acute bilateral VA loss
- several bright white spots, NEVER HAS VITRITIS
- U/self resolve
- Birdshot choroidopathy: Caucasian HLA-A29 positive > AA to retinal S antigen
- Chronic, bilateral, progressive blur
- Several cream coloured irregular lesions clustered near OD
- Common recurrence
- Serpiginous choroidopathy: HLA-B7 > AA to retinal S antigen
- Chronic, progressive, recurrent bilateral
- Irregular white sub-epith. infiltrates
- appears like confluent APMPPE

60
Q

OSSN:

A

UV-B (immunosuppressive), HPV, smoking, genetics
- genes damages: Oncogene (RAS), TS (RB1), Apoptosis regulator (p53)
FBS, redness, u/limbal (stem cells)
- no correlation to how sinister it is
Conjunctival intraepithelial neoplasia:
- Variable presentation: Papillary/gelatinous/leukoplastic/nodular
- Feeder BVs, granular staining
Squamous cell carcinoma:
- Similar to CIN, more rased, immobile, large feeder BVs
- Req. biopsy:
- increased cell thickness, pigmentation
1. Surgical excision (without touching lesion): small lesions, high recurrence
2. Cryotherapy: U/with surgery, removes microcirculation
3. Radiotherapy: diffuse/extensive lesion
4. Topical chemo: 180’ limbal involvement
1. Mitomycin C, interferon a2b, 5-fluorouracil

OPOT 4002 (6 decks)

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