OphthoQuestions Flashcards
intraocular lymphoma
1. workup
2. most common type
3. mgmt
4. prognosis
- MRI brain (2/2 techincally CNS lymphoma)
- diffuse large b cell (vs. NHL intraorbital)
- radiation and chemo (vs. local radiation for intraorbital)
- same as intraocular + CNS lymphoma: >50% survival after 2 yrs
scleral malacia look alike without uveitis history
dx
eval
mgmt
senile scleral plaque
none needed
degenerative change -> monitor for progressive thinning. Good prognosis
ddx
Testing
mgmt for FEVR
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
Coat’s disease
Presentation
tests
mgmt
counsel
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
ddx for involuntary facial movements (dystonic movements)
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)
ddx
eval
mgmt
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
CHARGE syndrome
exam
workup
mgmt
prognosis
-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
postop patient.
DDx?
cellulitis
abscess
seroma
hematoma
what is this?
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
eval
mgmt for CHED
-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)
description
ddx
eval
mgmt
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
dx?
how to separate from cellulitis
organism
tests
mgmt
prognosis
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
microphthalmia:
ddx
workup
mgmt
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
Incontinentia PIgmenti
Presentation
Exam
Testing
Mgmt
Counsel
- 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
Optic pit
testing
mgmt
counsel
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
Canaliculitis
Presentation
ddx
Exam
Test
Mgmt
Counsel
- 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
type of scotoma?
ddx?
-Ring scotoma
-ring scotoma -> central vision loss, progressive nyctamlopia: RP, choroideremia, Bietti
ddx for salt and pepper fundus
Cone-rod dystrophy: RP / Usher / Goldman Favre / choroideremia / Leber’s congenital amaurosis
Infections: syphilis, rubella
Inflammatory: DUSN (diffuse unilateral subacute neuroretinitis)
Phenothiazine tox
Renitis pigmentosa
- presentation
- exam
- testing
- mgmt
- counsel
-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)
iris nodules that are diffuse and the same color -> dx?
iris mamillations, a/w melanocytosis and NF1, usually sporadic but can be inherited
ddx for intermediate uveitis (peripheral snowballs + vasculitis)
tests
mgmt
prognosis
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
infant with nystagmus and pokes eyes. +AR FHx
dx
exam
tests
mgmt
counsel
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
ddx for xmas tree cataract
testing
mgmt
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.
prognosis for diabetic papilopathy
DM (even if well controlled) -> ischemic damage to nerve -> disc swelling -> self resolves over months with good prognosis though some ON atrophy is common
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.
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
epiphora due to neoplastic obstruction of NLD -> DCR?
no!
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)
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.
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
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
most common outcome of congenital esotropia
monofixation syndrome (small angle strab, mild amblyopia in non-fixating eye -> mild stereopsis)
dx in a child
mgmt
epiblepharon
protect K; will outgrow but if signfiicant K compromise, can removal skin and part of orbic
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
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
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
ddx for endos behaving like epis
epithelial downgrowth (argon laser to iris membrane burns white rather than brown)
ICE
PPMD
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
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
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
mgmt of V patterned XT
-if good control: orthoptic exercises
-otherwise surgical repair: MALE (MR to apex, LR to end)
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
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
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
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.
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
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
lacrimal canaliculus neoplasia -> infected asbcess -> mgmt?
I&D the abscess, culture, +topical and PO abx
Once no longer inflammed, malignancy workup (MRI, biopsy)
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
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.
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
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
interpret this
top: RD overlying choroidal thickening
bottom: dual circulation with leakage
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
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
- 2 green, 1 red, 1 alternating depending on ocular dominance
- 3 green vs. 2 red
- 5 dots, 3 green and 2 red, offset from each other
- normal at near (2/2 larger VF), 1 eye suppressed at distance (2/2 central projection only)
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
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.
surgeries for ptosis
mullerectomy, levator advancement
if brow ptosis -> frontalis sling
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
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
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
