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1
Q

intraocular lymphoma
1. workup
2. most common type
3. mgmt
4. prognosis

A
  1. MRI brain (2/2 techincally CNS lymphoma)
  2. diffuse large b cell (vs. NHL intraorbital)
  3. radiation and chemo (vs. local radiation for intraorbital)
  4. same as intraocular + CNS lymphoma: >50% survival after 2 yrs
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2
Q

scleral malacia look alike without uveitis history

dx
eval
mgmt

A

senile scleral plaque

none needed

degenerative change -> monitor for progressive thinning. Good prognosis

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3
Q

ddx

Testing
mgmt for FEVR

A

PHPV: unilateral
toxocariasis: unilateral, uveitis, sick
ROP: unusual to have exudates
FEVR: bilateral but asymmetric, FHx

FA: peripheral nonperfusion and NV (leakage) for FEVR
Bscan: calcifications for RB

PRP for NV
PPV for RD
Screen family members
variable prognosis

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4
Q

Coat’s disease
Presentation
tests
mgmt
counsel

A

young Boy, unilateral exudates -> RD, no NV / vitritis / FHx (sporadic)

OCT: exudates in outer retina
FA: leaking telangiectasias in Coats (lightbulb aneurysms), double circulation in RB
Bscan: no calcification in Coat’s, yes calcification in RB

Mgmt:
- mild (no macular threat): observe
- moderate: laser telangiectasias and non-perfusion
- severe (extensive RD): PPV
**- steroids can decrease exudate but counsel risks **

Counsel stabilizes by adolescence

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5
Q

ddx for involuntary facial movements (dystonic movements)

A

Hx: since when, how long, how often, stressors / alleviators, gone during sleep?, effect on vision and quality of life?
Exam: unilateral vs. bilateral, stylomastoid foramen mass? neuro exam

essential benign blepharospasm (sustained and forceful, needs botox)
myokymia (intermittent, mgmt by rest / decreasing stress / caffeine)

Hemifacial spasm: unilateral periocular and perioral,
- MRI/MRA: ?vessel ectasia or masses or stroke/MS affecting CN7
- botox -> benzodiazepine -> surgical sponge to separate ectatic vessel from CN7
- ectatic vessels are benign causes -> good prognosis w botox

Meige syndrome: bilateral, entire face, extinguishes during sleep
- no workup needed
- botox (onset 3 days, lasts 3 months) -> myectomy

physiologic facial synkinesis (involuntary movements a/w voluntary ones)

Tourette’s

Tardive Dyskinesia (anti-psychotics, GI promethaine and metoclopramide)

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6
Q

ddx
eval
mgmt

A

racemose angioma
- a/w Wybur Mason syndrome (ipsilateral vascular malformation of the brain (seizures, cognitive problems) and mandible (h/o dental bleeding), congenital, sporadic)
- FA: abnormal AV connections, no leakage
- MRI/MRA brain
- no tx -> maximize vision through refraction, amblyopia, low vision services (nml - 20/200 depending on location)
- monitor for VH and NVG

capillary hemangioblastoma (answer pic)
-a/w VHL -> pheochromocytoma, cerebellar hemangioblastoma, renal cell carcinoma
-OCT to characterize lesion thickness, +SRF
-FA leaks
-MRI/MRA
-laser smaller lesions, cryo larger lesions
-monitor for VH and CME
-genetic testing and counselling; co-manage w medicine; decreased life expectancy

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7
Q

CHARGE syndrome

exam
workup
mgmt
prognosis

A

-exam: colobomas (lid, iris, lens, retina), microphthalmia
-workup with peds (multisystem), examine parents, genetic testing (CHD7)
-manage strab, amblyopia, CNV, RD
-prognosis: variable depending on location, stable through life unless CNV or RD occurs

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8
Q

postop patient.
DDx?

A

cellulitis
abscess
seroma
hematoma

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9
Q

what is this?

A

jackson cross cylinder for refining cyl and axis during MRx (spherical equivalent of 0)

axis first: turn towards preferred direction until flipping makes no difference
power 2nd: add +/- power as preferred until flipping makes no difference; decrease sphere to keep Seq the same

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10
Q

eval

mgmt for CHED

A

-hx: Rubella, HSV, forceps, mucopolysaccharidosis, FHx
-Exam: syndromic features, congenital glaucoma -> ?rubella (pigmetnary retinopathy), K defects, anterior segment dysgenesis, pachymetry
-Tests: rubella serology, CHED genetic testing
-Mgmt:
clear visual axis -> DSEK / PK (good prognosis but can reject)
amblyopia management
assess for hearing loss (Harboyan syndrome)

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11
Q

description
ddx
eval
mgmt

A

scleral show, RPE changes
Sxs: teenage boy w nyctalopia -> progressive VF loss -> central vision loss (same as RP)
RFs: FHx

Choroideremia (x-linked, progressive loss of RPE and choriocapillaris)
Gyrate Atrophy
RP
Usher Syndrome
Albinism

Tests:
- HVF: ring scotoma -> central loss later in life
- OCT: CME, outer retinal tubulations
- FAF: loss of RPE = hypo
- FA: scalloped area of lost choriocapillaris
- ERG: loss of scotopic -> loss of photopic later in life
- genetic (CHM for choroideremia, plasma ornithine or gyrate)

Mgmt:
- lutein supplement -> gene therapy trials, vision services
- if CME: CAI

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12
Q

dx?
how to separate from cellulitis
organism
tests
mgmt
prognosis

A

necrotizing fasciitis

skin trauma in immunocomopromised patient -> group A strep -> pallor and subcutaneous emphysema

tests: BMP, CBC, CT (fat stranding, thickened tissue, emphasema), swab and culture

mgmt: surgical debridement + IV abx -> PO abx unpon improvement

prognosis: rapidly progressive and can be life threatening

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13
Q

microphthalmia:

ddx
workup
mgmt

A

ddx: isolated vs. syndromic

workup: genetics, TORCHES, VEP for visual potential, Ascan and Bscan for measurements

Mgmt: maximize vision and cosmesis: AL less than 16 needs expanders as ocular formation drives orbital formation (clear conformers vs. opaque grafts depending on visual potential); negative VEP can opt for enucleation -> prosthesis

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14
Q

Incontinentia PIgmenti
Presentation
Exam
Testing
Mgmt
Counsel

A
  • females only (lethal in males), FHx
  • NVE (no macular drag - FEVR, PHPV, toxocara, ROP, no vitritis - toxocara), splashed paint, abnormal teeth, cognitive disability
  • genetic testing for NEMO
  • mgmt: PRP, co-management w peds
  • Counsel good visual prognosis if no complications like RD
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15
Q

Optic pit

testing
mgmt
counsel

A

OCT nerve to characterize pit
OCT mac: ?hole ?CNV
FA: ?CSCR

if no macular involvement: observe
if yes macular involvement: laser temporal to disc (poor results) and PPV (theory is that traction helped great the serous RD)
prognosis varies; 20/20 with isolated pit, 20/200 w maculopathy

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16
Q

Canaliculitis

Presentation
ddx
Exam
Test
Mgmt
Counsel

A
  • infectious (red, warm, painful, mucousy and granular yellow discharge)
  • migrated punctal plug / dacryolith / actinomyces/ viral, neoplasm, cellulitis, trauma
  • push to express granules / pus / blood; probing if not too inflamed
  • topical abx, warm compresses and massage -> most will need canaliculotomy w topical abx and silicone stent to prevent scarring
  • good prognosis
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17
Q

type of scotoma?
ddx?

A

-Ring scotoma
-ring scotoma -> central vision loss, progressive nyctamlopia: RP, choroideremia, Bietti

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18
Q

ddx for salt and pepper fundus

A

Cone-rod dystrophy: RP / Usher / Goldman Favre / choroideremia / Leber’s congenital amaurosis
Infections: syphilis, rubella
Inflammatory: DUSN (diffuse unilateral subacute neuroretinitis)
Phenothiazine tox

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19
Q

Renitis pigmentosa

  • presentation
  • exam
  • testing
  • mgmt
  • counsel
A

-Presentation triad: nyctalopia -> ring scotoma -> vision loss in middle age
-Exam triad: bony spicules, waxy pallor, vascular attenuation
-Testing: genetics, ERG (reduced rod, impaired cone)

mgmt
-if CME: CAI
-if Usher: audiology
-vision services (including UV and blue light blocking)
-genetic counseling / gene therapy
-prognosis depends on mode of inheritance (20/30 to 20/200)

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20
Q

iris nodules that are diffuse and the same color -> dx?

A

iris mamillations, a/w melanocytosis and NF1, usually sporadic but can be inherited

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21
Q

ddx for intermediate uveitis (peripheral snowballs + vasculitis)

tests
mgmt
prognosis

A

MS
inflammatory: sarcoid, IBD
infectious: TB/ siphylis / lyme / toxocara
idiopathic = pars planitis
lymphoma

tests: uveitis labs, OCT mac for CME, FA for vasculitis, diagnostic vitrectomy

mgmt:
-treat underlying cause (PCN for siphylis, plasmapheresis for MS)
- if mild non-infectious, can observe. Otherwise steroids -> immunosuppression
- f/u q1wk -> q 3-6months
- prognosis varied

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22
Q

infant with nystagmus and pokes eyes. +AR FHx

dx
exam
tests
mgmt
counsel

A

Leber’s congenital amaurosis
early onset poor vision -> poking, nystagmus, strab; normal fundus -> salt and pepper fundus
Tests: ERG extinguished, OCT atrophy
Mgmt: no tx -> maximize vision, vision services, genetics
Prognosis: stable but poor vision

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23
Q

ddx for xmas tree cataract

testing
mgmt

A

myotonic dystrophy (ptosis, EOM deficits, slow pupils, low IOP)
hypoparathyroidism
hypoCa
idiopathic

Testing:
- genetics
- CMP for Ca, Mg, PO4, parathyroid hormone

co-manage with medicine; CEIOL if safe to do so. Good prognosis.

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24
Q

prognosis for diabetic papilopathy

A

DM (even if well controlled) -> ischemic damage to nerve -> disc swelling -> self resolves over months with good prognosis though some ON atrophy is common

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25
ddx for episodic swelling and redness of bilateral eyelids tests mgmt and counsel
blepharochalasis hereditary angioedema (needs FHx) test: serum c1 inhibitor (low in angioedema, normal in blepharochalasis) observe: usually peaks in teenage years (2/2 hormones), then decreases after. Good prognosis. May need eyelid surgery for any skin redundancy or lid laxity.
26
special considerations for CEIOL in post RK eye
hyperopic surprise - K edema - incision gaping: avoid via scleral tunnel - avoid by using ASCRS calculator / Haigis formula and aim -1D myopic
27
epiphora due to neoplastic obstruction of NLD -> DCR?
no!
28
What is it? Principle? How to use
manual keratometer assumes K is a reflective surface (convex mirror) -> uses Snell's law to calculate refractive power in D focus plus sign via eyepiece -> **alignment marker to lateral canthus** -> adjust axis and power until 3 cirles are aligned (answer pic, e.g. 42D @170, 43D @ 80 -> 1D WTR astigmatism)
29
diffuse conj injection 2/2 sturge weber -> cosmetic management?
opaque white colored scleral lens. drops not effective If local, can surgically excise, or thermocoagulate. Not very effective for diffuse episcleral hemangiomas and higher risk.
29
sarcoidosis (autoimmune inflammatory) features testing mgmt
AA, female, b/l panuveitis (conj injection, granulomatous KP, iris nodules, posterior synechiae, beads on a string vitritis, CME), dyspnea, lacrimal gland enlargement conj or skin nodule biopsy (non-caseating granuloma), uveitis labs (elevated ACE and lysozyme), OCT mac (CME), **chest CT (b/l hilar adenopathy)** topical steroid + cycloplegia while awaiting TB/syphilis testing -> PO + periocular steroid -> immunosuppressives co-manage with medicine other organ systems (e.g. neuro-sarcoid) monitor for sequelae of uvietis and steroids
30
young male, no HTN, DM, radiation, cardiovascular disease -> dx? features testing mgmt counsel
HIV retinopathy microangiopathy -> heme, CWS, AV nicking (**similar to HTN**) FA: capillary drop out, **microaneurysms** monitor with **fundus photos**, co-manage with medicine minimal effect on vision
31
most common outcome of congenital esotropia
monofixation syndrome (small angle strab, mild amblyopia in non-fixating eye -> mild stereopsis)
32
dx in a child mgmt
epiblepharon protect K; will outgrow but if signfiicant K compromise, can removal skin and part of orbic
33
What are these? DDx? if h/o open globe -> features? tests? mgmt counsel
dalen fuchs nodules (epithelioid cells between RPE and bruch's membrane) VKH SO mutton fat KP, AC cell, **exudative RD and disc edema** FA: hyper **Bscan: uveal tract thickening** topical steroid + cyclo while awaiting r/o labs -> PO steroid -> immunosuppression, **maintain for months after resolution** monitor for sequelae of uveitis prognosis better if treated early
34
ddx for neuroretinitis mgmt prognosis
infectious: bartonella, TB, syphillis (**not viral**) idiopathic: viral-induced autoimmune (**prone to relapse**) azithro while awaiting labs as bartonella most likely -> tailor therapy to underlying cause if bartonella serology neg, retest in 6wks both infectious and idiopathic usually self limited with good final VA but can give steroids for idiopathic
35
ddx eval mgmt counsel
Isolated eyelid coloboma upper eyelid: goldenhaar (**limbal dermoid**, preauricular skin tags, ears, dental and skeletal abnormalities) lower eyelid: Treacher Collins (facial clefting) hx: gestational, birth, new born, visual behavior Exam: keratopathy, dermoid, other colobomas / staphylomas, syndromic features comanage syndromes with peds lubricate K aggressively Eyelid recontrusction -<1/3 direct closure -<2/3 tensel flap ->2/3 skin graft
36
ddx for endos behaving like epis
epithelial downgrowth (argon laser to iris membrane burns white rather than brown) ICE PPMD
37
Young patient features exam testing mgmt counsel
b/l gradually declining vision with **normal exam at first** in a young patient with FHx chorioretinal atrophy resembling AMD but in young patient testing: -OCT loss of outer retinal layers -FAF/FA hypo (RPE loss) - **peripherin genetics testing** - **ERG (normal b wave vs. reduced b wave in cone dystrophy)** - **EOG (normal vs. arden <1.65 in Best disease)** no treatment -> vision services
38
mgmt of limbal dermoid
- if visually insignificant: CRx - if visually significant: surgical debulking (UBM to to assess depth for surgical planning), will likely have remnant - genetic screening - comanage with peds any syndromes - good prognosis
39
ddx features mgmt counsel
STUMPED, most likely metabolic = mucopolysaccharidosis (Hurler, Schie) given facial features -facial features (depressed nose bridge, hypertelomerism), K opacity, FHx tests: -UBM and Bscan given no view -urine testing for mycopolysaccharides -genetic testing mgmt: -genetic counselling and co-manage with peds -clear visual axis: PK, CRx -counsel: **enzyme replacement therapy can slow disease progression, recurrence can occur in graft**
40
mgmt of V patterned XT
-if good control: orthoptic exercises -otherwise surgical repair: MALE (MR to apex, LR to end)
41
dermoid cyst management
if superificial and freely mobile: ok to not image and oberve if tethered and causing proptosis: CT and excise intact (to avoid inflammation) counsel: most common orbital mass in children, normal tissue trapped during development, if ruptures can cause inflammation but if excised, excellent prognosis
42
asymptomatic teenager ddx features mgmt counsel
choroidal osteoma Choroidal hemangioma Choroidal granuloma Choroidal met Calcification (dystrophic) Features: pale subretinal well defined w scalloped borders, mildly elevated, **no SRF** RFs: hypercalcemic conditions - hyperparathyroidism, **malignancy, sarcoid, TB** Tests: Bscan pseudooptic nerve, **FA diffuse stains** +/- CNV, labs (Ca, PO4, ALP - normal in osteoma but abnormal in mets) if asymptomatic: observe w Amsler grid **if CNV: anti-VEGF** significant CNV risk leading to vision loss
43
myelinated RNFL (must have occured by 3yo) a/w? tests mgmt
a/w: gorlin goltz, nf1, high myopia *hair flip: get my number no tests - clinical dx, sporadic no tx needed - CRx and monitor for strab / amblyopia
44
Dx RFs Tests Mgmt Counsel
CHRPE (flat, no other features of melanoma) RFs: if multiple (vs. isolated or clustered), then a/w FAP, Turcot (colon + brain cancer) Tests: fundus photos for monitoring, **gentic testing AD APC**, colonoscopy Mgmt: no ophtho intervention needed Counsel: only visually significant if reaches fovea, rare.
45
posterior staphyloma vs. coloboma mgmt
staphylomas are usually located around the optic nerve clinical diagnosis, no tx unless CNV/RD -> maximize vision and workup for CHARGE / gorlin goltz / trisomy 13/18
46
ddx tests mgmt
familial dominant drusen **stargardt** Pattern dystrophy **Sorsby** OCT mac for drusens FAF for drusens (hyper) FA for ?CNV no tx -> maximize vision, amsler. If CNV, then anti-VEGF genetic testing and counseling **prognosis: good vision until mid-age**
47
lacrimal canaliculus neoplasia -> infected asbcess -> mgmt?
I&D the abscess, culture, +topical and PO abx Once no longer inflammed, malignancy workup (MRI, biopsy)
48
74M awakens to find new scotoma ddx mgmt counsel
subhyloid heme: AMD PVD with tear HTN retinopathy DR **spontaneous** observe to resolution unless: - CNV: anti-VEGF and treat underlying cause - traction or non-clearing: PPV good prognosis, **ok to continue aspirin**
49
ddx? testing
xanthelesma sebaceous hyperplasia **sarcoidosis** testing: lipid panel. if uncertain, can biopsy mgmt: observation vs. laser vs. acid peel vs. surgical excision counsel: comestic, not functional. LIkely recurrence after removal. Controlling systemic lipids can slow down growth.
50
toxocara mgmt
3 forms: endophthalmitis (babies), central vs. peripheral granulomas. testing: ELIZA for toxocara antigen but **neg does not r/o; OCT for TRD** mgmt: steroids +/- albendazole (effectiveness controversial) Counsel: central granuloma has best outcomes 2/2 no macular drag (20/50), endophthalmitis 20/200
51
mgmt for angioid streaks
amsler grid, FA for CNV -> anti-VEGF co-manage any underlying conditions with medicine counsel asympatomatic but **elevated risk of bleeds post minor trauma**, CNV
52
interpret this
top: RD overlying choroidal thickening bottom: dual circulation with leakage
53
painless rapid growth over 3 wks -> dx? mgmt?
keratoacanthoma incisional biopsy (keratin filled crater) -if no atypia: observe for spontaneous resolution over months vs. cryotherapy -if yes atypia: Mohs with reconstruction -**if multiple: workup for visceral malignancies** good prognosis
54
worth 4 dot: red OD, green OS, tested at near and distance 1. normal 2. suppresses OD vs. OS 3. strab without ARC 4. central suppression 2/2 monofixation syndrome
1. 2 green, 1 red, 1 alternating depending on ocular dominance 2. 3 green vs. 2 red 3. 5 dots, 3 green and 2 red, offset from each other 4. normal at near (2/2 larger VF), 1 eye suppressed at distance (2/2 central projection only)
55
infant with FHx of similar findings dx? mgmt
CHSD genetic testing for DCN if mild: observe, CRx if visually significant: PK good prognosis with transplant but rejectino can occur
56
heavy patient with new onset mass dx? mgmt counsel
prolapsed fat (not lipodermoid because those are firm and present since birth) RFs: age, straining, high BMI, connective tissue weakness if uncertain: biopsy if mild: observe if symptomatic (blocks VF, present proper lid closure): surgical excision (open conj and tenon, excise at base, meticulous hemostasis, close) advise weight loss. Good prognosis but can recur.
57
surgeries for ptosis
mullerectomy, levator advancement if brow ptosis -> frontalis sling
58
Marcus Gunn Jaw winking (abberrant connection between 3 and 5 - congenital vs. regenerative after trauma or infection. Abberrant regeneration may improve while congenital does not) testing mgmt counsel
**EKG (marcus gunn predisposed to cardiach arrythmias). No MRI** CRx, amblyopia and strab management surgery: - levator myectomy to dampen wink - frontalis sling to address ptosis - counsel risks of surgery and exposure
59
orbital inflammation, unsure if infectious or inflammatory -> mgmt?
trial iv abx for 24 hrs. If no improvement, then switch to steroids. labs: temp, CBC, uveitis labs
60
teenager presents for blurry central vision. +FHX in males dx mgmt counsel
OCT shows retinoschisis shine light beam to confirm absolute scotoma (vs. relative in RD) FAF (B) red-free photograph (C) optional genetic testing for RS1 x-linked juvenile retinoschisis -**if CME: CAI** -if RD: PPV -genetic counselling -**prognosis variable**

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