Opto prep lid/ orbit

Question 1

Which 2 of the following glands are considered accessory lacrimal glands, producing a small portion of the aqueous component of the tears? (Select 2)

Glands of Krause

Glands of Wolfring

Glands of Zeis

Glands of Moll

Meibomian glands

Answer 1

About 95% of the aqueous component of tears is produced by the main lacrimal gland; the accessory lacrimal glands of Wolfring and Krause produce the remainder.

The meibomian glands and glands of Zeis are sebaceous glands, while the glands of Moll are apocrine glands

Question 2

What is the average period of time an eyelash of an adult continues to grow?

1 month

6 months

2 months

4 months

Answer 2

2 months

Eyelashes grow at a fairly slow rate. A single eyelash grows on average for two months and then falls out after a period of roughly three to five months.

Eyelashes tend to grow faster and have a quicker turnover rate in children.

Question 3

When evaluating a nevus of the eyelid, which of the following characteristics is indicative of stability (i.e., benign)?

Uniformity of color within the lesion

Greater than 6 mm in diameter

Ulceration

The presence of inactive hair follicles within the lesion

Irregular, indistinct borders

Answer 3

Uniformity of color within the lesion

hen evaluating a suspicious nevus of the skin surrounding the eye, it is important to remember your “ABCDEs”. A=asymmetry, B=borders, C=color, D=diameter, E=evolution. A benign nevus tends to be symmetrical such that one can almost fold it in half and the sides would be evenly matched. The borders of a benign nevus are typically regular and distinct. The uniformity of the color should be assessed, rather than the actual level of pigmentation; evenness of pigmentation indicates stability. In general, the diameter of a benign nevus does not exceed 6 mm; although this is obviously not true all of the time, some small nevi may be malignant, and some large nevi (i.e., greater than 6 mm) can be benign. Lastly, most benign nevi tend to be rather flat (as opposed to elevated) with no change or evolution over time. Generally, hair growing out of the lesion is a positive sign, as this indicates that the hair follicle is intact. A cancerous lesion tends to kill the follicle; in this case, hair will no longer sprout. Remember, nevi should be stable and not change in shape, color, or size. ANY change in the nevus warrants a biopsy. Photo documentation is key when following a nevus or with any suspicious lesion.

Question 4

Many skin anomalies may mimic malignant lesions. Which of the following skin conditions has the HIGHEST risk of becoming malignant?

Papilloma

Cutaneous horn

Seborrhoeic keratosis

Actinic keratosis

Answer 4

Actinic keratosis

Actinic keratosis is a precursor to squamous cell carcinoma and appears as scaly, dry skin that does not heal. People with skin that is of lighter pigmentation along with excessive exposure to ultraviolet light tend to be most at risk for development of this condition.

Papillomas may take on various forms and may be viral or non-viral in origin. They can commonly be found on the eyelids or surrounding orbital skin. Viral warts tend to grow at an accelerated rate while non-viral papillomas are fairly slow to grow. Papillomas can mimic neoplastic growths so be sure to rule this out while watching carefully for color change, ulceration, lash loss, bleeding, and vascularization.

Cutaneous horns or tags are also benign and are likely a form of papilloma but appear to involve more keratin. Treatment is similar to that of a papilloma.

Seborrhoeic keratosis is more commonly seen in middle-aged and elderly persons. This benign, epidermal growth is quite superficial and does not extend into the dermis. It appears like a brown plaque that has been stuck onto someone’s skin. The borders are very distinct and there may be some elevation. The lesions may be removed if the patient is concerned about cosmesis.

Question 5

Contraction of the orbicularis oculi to close the eye aids in movement of tears through the lacrimal canaliculi and nasolacrimal drainage system via the action of which section of the muscle?

Muscle of Horner

Orbital portion of the orbicularis oculi

Muscle of Mueller

Muscle of Riolan

Answer 5

Muscle of Horner

The muscle of Horner (also known as the pars lacrimalis) is part of the palpebral portion of the orbicularis oculi. The fibers for the muscle of Horner come from the lacrimal crest and encircle the lacrimal canaliculi. This assists the flow of tears into the nasolacrimal drainage system when the orbicularis oculi contracts to close the eye. The muscle of Riolan (also known as the pars ciliaris) is another section of the palpebral portion of the orbicularis oculi; it lies near the lid margin to maintain the margins next to the globe. The orbital portion of the orbicularis oculi is mainly responsible for forced closure of the eyelids. The muscle of Mueller (also known as the superior tarsal muscle) is a sympathetic smooth muscle that acts to widen the palpebral fissure.

Question 6

You are measuring the palpebral fissure height in a patient reporting drooping of his upper eyelid. Which of the following BEST describes the normal positioning of the upper and lower eyelids in comparison to the limbus?

The upper lid normally rests about 2mm lower than the upper limbus, and the lower lid rests about 1mm above the lower limbus

The upper lid normally rests about 2mm lower than the upper limbus, and the lower lid rests about 1mm lower than the lower limbus

The upper lid normally rests about 1mm lower than the upper limbus, and the lower lid rests about 2mm above the lower limbus

The upper lid normally rests about 1mm lower than the upper limbus, and the lower lid rests about 2mm lower than the lower limbus

Answer 6

The upper lid normally rests about 2mm lower than the upper limbus, and the lower lid rests about 1mm above the lower limbus

The palpebral fissure height is a measurement of the distance between the upper and lower eyelid margins when the patient is looking in primary gaze. This particular measurement is typically less in males (7-10mm) as compared to females (8-12mm). The normal positioning of the upper and lower eyelids are as follows: the upper eyelid usually rests about 2mm below the superior limbus, while the lower eyelid position is typically 1mm above the lower limbus. A unilateral ptosis can be quantified by comparing these measurements to the contralateral eye. A ptosis up to 2mm may be graded as mild; a 3mm ptosis is considered moderate; a ptosis of 4mm or more is deemed severe.

Another important measurement in evaluating a ptosis is the marginal-reflex distance (MRD). The MRD can be defined as the distance between the upper eyelid margin and the resultant corneal reflection caused by directing a patient’s gaze at a penlight held by the examiner. This measurement is normally 4-4.5mm

Question 7

An 81-year old female reports that her eye has been watering more frequently over the past month; you decide to administer the primary Jones dye test (Jones I). After 5 minutes, the application of a cotton-tipped applicator to the inferior turbinate reveals the presence of dye in the area. Taking this into consideration, what is the MOST likely cause of the patient’s epiphora complaint?

Dysfunction of the valve of Hasner

Hypersecretion of tears

Partial nasolacrimal duct obstruction

Punctal stenosis

Complete nasolacrimal duct obstruction

Answer 7

Hypersecretion of tears
The primary Jones dye test can be utilized to determine the patency of the nasolacrimal system. 1-2 drops of fluorescein are instilled into the inferior fornix of the eyes while the patient is in an upright position and blinking her eyes normally. After a period of 5 to 10 minutes, a cotton-tipped applicator is used to swab the undersurface of the inferior turbinate on each side of the nasal passage.

When the primary Jones dye test is positive (dye is recovered from the inferior turbinate of the nose), practitioners may conclude that the system is patent and that no significant blockage of the nasolacrimal drainage structure is likely. However, minor stenosis or physiologic dysfunctions cannot be completely ruled out. Patients who have a positive result on the Jones I test are more likely to experience symptoms of epiphora that are secondary to primary oversecretion of tears, rather than a dysfunction in lacrimal drainage (as in the above question).

When the primary Jones dye test is negative, the probability of an obstruction or dysfunction in lacrimal drainage is much greater; however, this test alone is not sufficient to document this conclusion. The secondary Jones dye test is then necessary to determine the severity and location of the obstruction.

Question 8

Numerous reports have suggested that increased tear film osmolarity is a key consequence in dry eye. Although osmolarity is not easily measured in the clinical setting, tear osmolarity increases in most dry eye sub-types due to which of the following processes?

Reactive oxygen species are increased in the tears of most dry eye sub-types; this increases osmolarity

The lipid layer is altered in most dry eye states, leading to ion pairing

Loss of tear stability induces an increased evaporation rate, leading to increased osmolarity

In aqueous tear deficiency, the lacrimal gland produces more ionic species

Decreased capillary exchange leads to ionic bonding

Patients with dry eye tend to blink less than normals, leading to increased evaporation

Answer 8

Loss of tear stability induces an increased evaporation rate, leading to increased osmolarity

Tear instability leads to greater evaporation and higher osmolarity through a mechanism of concentration of the remaining tears, since only the aqueous tear portion evaporates rather than the ionic species. Several studies have indicated that normal tear osmolarity is less than or equal to 300 Osm/L, with values exceeding 308 Osm/L indicating increased osmolarity. As a single measure, tear osmolarity has recently been found to correlate the best (r squared 0.55) to dry eye severity of several clinical tests in a large,

Question 9

A 34 year-old patient presents to your office with a chief complaint of redness and irritation of his eyelids and his eyelashes occasionally sticking together. Upon biomicroscopy, you notice hyperemic and greasy eyelid margins, and soft scales scattered along the eyelid margins and eyelashes. What is the MOST likely diagnosis of this patient’s symptoms?

Meibomian gland dysfunction

Bacterial conjunctivitis

Staphylococcal blepharitis

Seborrheic blepharitis

Angular blepharitis

Answer 9

Seborrheic blepharitis

Explanation - Seborrheic blepharitis

• Soft scales are present and located along the eyelid margin and eyelashes
• Anterior lid margins appear greasy and hyperemic
• Eyelashes commonly stick together

Staphylococcal blepharitis

• Scales and crusts are typically harder and are mainly located around the base of the eyelashes (collarettes)
• Eyelid changes usually occur in conjunction with chronic staph blepharitis, such as scarring and notching, madarosis, trichiasis, and poliosis
• Conjunctival hyperemia, papillary conjunctivitis, stye formation, marginal keratitis, phlyctenulosis, tear film instability, and dry eye are also commonly associated with staphylococcus blepharitis

Angular blepharitis

• Involves the lateral portion of the eyelid
• Signs include scaly, red, and macerated skin, with occasional associated papillary and follicular conjunctivitis

Meibomian gland dysfunction

• Capping of meibomian gland orifices with hyperemia and telangiectasia of the eyelid margin
• Tear film is usually oily and froth is commonly observed on the eyelid margin
• Pressure on the lid margin will usually result in turbid secretions, and in some cases inspissation is so severe that expression of glands is impossible

Bacterial conjunctivitis commonly presents with symptoms of debris on the lashes and eyelashes sticking together; however, signs of mucous and conjunctival hyperemia are usually present.

Question 10

Which 2 of the following BEST describe the definition as well as the normal value for the margin-reflex distance 1 (MRD1), which is commonly utilized in the evaluation of a ptosis? (Select 2)

The average MRD1 measurement is about 6-6.5mm

The average MRD1 measurement is about 2-2.5mm

MRD1 is the distance between the lower eyelid margin and the corneal reflection of a penlight that the patient is directly viewing

MRD1 is the distance between the upper eyelid margin and the corneal reflection of a penlight that the patient is viewing directly

The average MRD1 measurement is about 4-4.5mm

Answer 10

MRD1 is the distance between the upper eyelid margin and the corneal reflection of a penlight that the patient is viewing directly

The average MRD1 measurement is about 4-4.5mm

The margin reflex distance 1 (MRD1) is the vertical distance between the corneal reflex produced by a penlight that the patient is viewing directly and the upper eyelid margin. MRD2 is the distance from the corneal reflex to the lower eyelid margin. The average MRD1 measurement is about 4-4.5mm, and the average MRD2 measurement is about 6-6.5mm. These measurements are helpful in evaluating potential eyelid ptosis or retraction.

Question 11

Which of the following skin conditions is considered to be benign and has the LOWEST risk of malignancy?

Squamous cell carcinoma

Keratoacanthoma

Actinic keratosis

Basal cell carcinoma

Answer 11

Keratoacanthoma

Keratoacanthoma appears very much like squamous cell carcinoma (SCC) in that it tends to progress rapidly and appears to ulcerate. This condition typically occurs in middle-aged and elderly patients of Caucasian descent on areas of the skin that are exposed. The lesion appears elevated, and eventually the center will produce a scab-like plug of keratin. The margins surrounding the plug will be rolled. At some point the keratin plug will fall out, resulting in the formation of a pit, and the lesion will regress. Most patients and clinicians do not like to wait this condition out due to its similarities to SCC.

Actinic keratosis is a pre-cursor to squamous cell carcinoma and appears as scaly, dry skin that does not heal. People with skin that is of lighter pigmentation along with excessive exposure to ultraviolet light tend to be most at risk for development of this condition.

Squamous cell carcinoma (SSC) is thankfully one of the rarest malignancies but due to its ability to metastasize can be quite dangerous. This malignancy has the ability to progress rapidly and has a high affinity for people who spend a lot of time in the sun, especially those who are light-skinned. The only way to definitively diagnose SCC is to refer for a biopsy and ensuring the use of Mohs technique. This strategy takes more time but ensures that the lesion is removed. Essentially, Mohs procedure calls for removal of tissue and biopsy of the surrounding borders. If the borders prove to be malignant then more tissue is removed and biopsied. This continues until the borders prove to be free of any carcinoma.

Basal cell carcinoma (BCC) is the most common malignant lid lesion and mercifully tends to be very slow-growing. BCC generally appears as a waxy, translucent nodule. Eventually the nodule will ulcerate. Patients may bring these to your attention and tell you that they have “had it for years and it just does not seem to heal”. Whenever you hear this it is best to send out for biopsy via Mohs technique. BCC very rarely metastasizes.

Question 12

Tear volume in a normal, healthy, young adult measures approximately between which of the following values?

2. 0-5.0 microliters
3. 0-20.0 microliters
4. 0-8.0 microliters
5. 0-16.0 microliters
6. 0-12.0

Answer 12

6.0-8.0 microliters

Tear volume has been measured by several methods to be approximately 6-7 microliters in normal individuals, with lesser values occurring in conditions of aqueous tear deficiency. This has implications for drug delivery, since the normal ophthalmic drop volume varies between 25 and 50 microliters, effectively overwhelming the native tear value upon instillation.

Question 13

Which of the following is an example of a congenital ptosis?

Fat deposits in the upper lid resulting in increased weight of the eyelid

Cicatricial or scar tissue

Cranial nerve III lesion

Involutional

Muscle disease such as myasthenia gravis

Developmental failure of the levator palpebrae superioris

Answer 13

Developmental failure of the levator palpebrae superioris

A congenital ptosis generally is the result of a failure of the levator palpebrae superioris (LPS) to develop properly, resulting in an upper droopy eyelid.

Acquired etiologies of a ptosis include:
Mechanical, such as increased weight of the eyelid making it too heavy for the LPS to lift caused by fat deposition or edema.

Cicatricial, caused by injury resulting in scar tissue.

Involutional, the LPS begins to degrade as age increases resulting in a loss of function.

Myogenic, caused by muscle dystrophies or diseases like myasthenia gravis.

Question 14

he ocular condition in which redundant upper lid skin is present, in association with skin laxity and loss of muscle tone, is known as which of the following?

Blepharochalasis

Ptosis

Dermatochalasis

Floppy eyelid syndrome

Entropion

Answer 14

Dermatochalasis

Dermatochalasis refers to excess upper lid skin, which leads to the appearance of baggy eyelids and a pseudoptosis. Typically, there is associated laxity of the eyelid skin and loss of muscle tone. It is most commonly observed in elderly patients as a result of aging skin and muscle changes. In patients with dermatochalasis, if the redundant upper eyelid tissue is retracted, the position of the upper lid is typically normal; this is an important differentiating factor between a pseudoptosis seen in conjunction with dermatochalasis and a true eyelid ptosis.

Entropion is an abnormal inward rotation of the eyelid margin and tarsus toward the globe.

Blepharochalasis is a condition of the upper eyelids that results from recurrent episodes of non-painful, non-pitting edema. It leads to the appearance of redundant, wrinkled, and atrophic upper eyelid skin.

Floppy eyelid syndrome most commonly affects middle-aged, obese men who sleep face-down; this results in friction of the lids against the pillow, causing the lids to become everted. The loose and rubbery tarsal plates and excessive upper eyelid skin makes the lids easily evert with the application of gentle pressure on the skin below the brow.

Question 15

Ptosis can be caused by dysfunction or damage to which of the following muscles?

Inferior rectus

Muscle of Horner

Superior tarsal muscle (muscle of Muller)

Pars ciliaris (Riolan’s muscle)

Answer 15

Superior tarsal muscle (muscle of Muller)

Ptosis is a condition in which the upper eyelid sags. It can be caused by dysfunction of either the superior palpebral levator or the superior tarsal muscle (muscle of Muller). Because the levator is the major muscle responsible for raising the upper eyelid, ptosis from levator damage is often more severe then ptosis from dysfunction of the muscle of Muller.

The muscle of Horner (also known as the pars lacrimalis) is part of the palpebral portion of the orbicularis oculi. The fibers for the muscle of Horner come from the lacrimal crest and encircle the lacrimal canaliculi. This assists the flow of tears into the nasolacrimal drainage system when the orbicularis oculi contracts to close the eye. The muscle of Riolan (also known as the pars ciliaris) is another section of the palpebral portion of the orbicularis oculi; it lies near the lid margin to maintain the margins next to the globe. The orbicularis oculi is the major muscle responsible for closing the eyelids.

Question 16

The superior palpebral levator muscle is primarily responsible for retraction of the upper lid. Which of the following structures acts as a fulcrum to change the anteroposterior direction of the levator to superoinferior?

Superior oblique muscle

Inferior oblique muscle

Capsulopalpebral fascia

Superior tarsal muscle (muscle of Muller)

Superior transverse ligament (Whitnall’s ligament)

Answer 16

Superior transverse ligament (Whitnall’s ligament)

he superior palpebral levator muscle is primarily responsible for retraction of the upper lid. The sheath of this muscle blends with the sheath of the superior rectus muscle as it approaches the eyelid at the orbital apex; the superior transverse ligament (Whitnall’s ligament) acts as a fulcrum to change the direction of the muscle from anteroposterior to superoinferior in direction. The levator apopneurosis is a fan-shaped fibrous connection that penetrates the orbital septum and extends into the upper lid, anchoring the skin and creating the palpebral sulcus.

The capsulopalpebral fascia is the retractor of the lower eyelid and is an extension of the sheath of the inferior rectus muscle and the suspensory ligament.

The muscle of Muller (also known as the superior tarsal muscle) is a sympathetic smooth muscle that acts to widen the palpebral fissure.

Question 17

Your 21 year-old female patient reports that her upper eyelid has been intermittently twitching for the past 2 weeks. She states that these symptoms typically occur before important tests and eventually resolve on their own. What is the MOST likely diagnosis of this ocular condition?

Hemifacial spasm

Eyelid myokymia

Blepharospasm

Blepharoclonus

Answer 17

Eyelid myokymia

A diagnosis of eyelid myokymia is characterized by the presence of intermittent, unilateral lid twitching or fluttering that may involve either the upper or lower eyelids. This ocular condition can occur as a result of several different triggering factors, most notably fatigue, stress, and increased levels of caffeine. This condition is generally benign and self-limiting, and it typically resolves within a period of several days to several weeks.

Blepharoclonus is an ocular condition that is most commonly observed in young children, in which the etiology is frequently unknown. The condition may present as either an increase in blink rate, or increased duration of lid closure upon blinking.
Patients diagnosed with blepharospasm will typically present with symptoms of uncontrollable eyelid closures, contractions, or twitches of the eyelid muscles. In some cases, the twitching will radiate to the nose, face, and even the neck area. Twitching in patients with blepharospasm are much more severe than that of eyelid myokymia (which is barely visible).

hemifacial spasm usually occurs in patients in their 5th to 6th decades of life. It is characterized by briefs spasms of the orbicularis oculi muscle, which eventually spreads to involve the facial area in the distribution of the facial nerve

Question 18

common cause of epiphora in infants is caused by a small membrane that covers over which of the following structures?

The canaliculus

The valve of Hasner

The lacrimal gland

The puncta

Answer 18

The valve of Hasner
It is common for mothers of young infants to note that one eye (or both eyes) of her infant constantly tears in conjunction with the presence of mucopurulent discharge. This epiphora results from a blockage of the nasolacrimal passageway caused by a membrane covering the valve of Hasner. The majority of blockages will self-resolve without intervention (80-90% of infants) within the first 12 months of life. Treatment may include massage of the nasolacrimal sac several times a day in an effort to rupture the membrane.

Question 19

Chronic blepharitis, if left untreated, can cause which of the following structural changes to the anterior ocular segment?

Madarosis

Hypertelorism

Distichiasis

Tristichiasis

Answer 19

Madarosis

Blepharitis is a condition caused by pathogens, usually of Staphylococcus origin, that colonize along the eyelid margins. The bacteria produce exotoxins which take the form of flakes and are generally seen along the base of the eyelashes. Unfortunately, this condition is chronic but will wax and wane in its presentation. Long-term complications include madarosis (missing lashes), trichiasis, neovascularization of the eyelid margin, keratitis, erythema, phlyctenule formation and infiltrates. Patients may complain of dry, irritated eyes, stinging, pain, itching, frequent eye infections, foreign body sensation, and decreased acuity (if there is corneal involvement). Treatment includes eye lid scrubs, antibiotic ointments and sometimes transient topical steroid use to decrease lid inflammation (usually used in conjunction with a topical antibiotic). Occasionally oral antibiotics are prescribed, especially in the event of poor compliance.

Distichiasis is a rare congenital phenomenon marked by an absence of meibomian glands. In the place of the meibomian glands is an extra row of eyelashes.

Hypertelorism is a term used to describe the incidence in which the orbits are located quite far apart. This generally occurs along with other congenital cranium anomalies.

Tristichiasis is a very rare occurrence in which a person possesses three rows of eyelashes.

Question 20

Which cranial nerves are responsible for opening and closing the eye?

The oculomotor nerve (CN III) opens the eye and the facial nerve (CN VII) closes the eye

The facial nerve (CN VII) opens the eye and the trigeminal nerve (CN V) closes the eye

The trigeminal nerve (CN V) opens the eye and the facial nerve (CN VII) closes the eye

The oculomotor nerve (CN III) opens the eye and the trigeminal nerve (CN V) closes the eye

Answer 20

The oculomotor nerve (CN III) opens the eye and the facial nerve (CN VII) closes the eye

All of the cranial nerves listed have names and numbers correctly matched. The oculomotor nerve innervates the levator palpebrae superioris (which opens the eye), along with Mueller’s muscle (which is controlled by the sympathetic nervous system). The facial nerve innervates the muscles of facial expression including the orbicularis oculi, which closes the eye. The trigeminal nerve provides sensory innervation to the eyelids and cornea.

Question 21

Which of the following correctly describes the drainage pathway of tears?

Puncta-> lacrimal sac-> caniculi-> nasolacrimal duct-> inferior meatus

Puncta-> caniculi-> nasolacrimal duct-> lacrimal sac-> inferior meatus

Puncta-> lacrimal sac-> nasolacrimal duct-> caniculi-> inferior meatus

Puncta-> caniculi-> lacrimal sac-> nasolacrimal duct-> inferior meatus

Answer 21

Puncta-> caniculi-> lacrimal sac-> nasolacrimal duct-> inferior meatus

The tears drain into the puncta and travel through the caniculi to the lacrimal sac; they then drain into the nasolacrimal duct and finally into the inferior meatus.

Question 22

Weakness of which of the following extraocular muscles is MOST commonly associated with a simple congenital eyelid ptosis?

Superior rectus

Medial rectus

Lateral rectus

Inferior oblique

Superior oblique

Inferior rectus

Answer 22

Superior rectus
Weakness of the superior rectus muscle is the most common ocular motility abnormality associated with a simple congenital ptosis. This is due to the close embryological association of the levator and the superior rectus; these two muscles develop from the same myotome. Keep in mind that extraocular muscle surgery must be performed prior to ptosis correction due to the associated lid position changes that will occur once the eye position is adjusted.

Question 23

Correct answerDacryocystitis refers to inflammation or infection of which of the following structures of the eye?

Lacrimal sac

Puncta

Lacrimal gland

Nasolacrimal duct

Puncta

Lacrimal gland

Nasolacrimal duct

Answer 23

Lacrimal sac
Dacryocystitis refers to inflammation of the lacrimal sac, commonly caused by nasolacrimal duct obstruction or infection. Symptoms of dacryocystitis typically involve pain, redness, and swelling over the medial canthal aspect of the lower eyelid where the lacrimal sac resides. Additionally, patients will also commonly complain of watery eyes or of mucous that may extrude from the punctum upon digital pressure. The mainstay of treatment for cases of dacryocystitis includes oral antibiotics; however, in some patients surgical treatment may be necessary.

Remember that inflammation of the lacrimal gland, located at the medial aspect of the upper lid, is known as dacryoadenitis.

Question 24

The lymphatic system serves many important roles in the human body. The lateral portion of the eyelid lymphatics drain into which of the following structures?

The pre-auricular lymph node

The conjunctiva

The submandibular lymph node

The puncta

Answer 24

The pre-auricular lymph node

The lateral 2/3 of the upper lid and the lateral 1/3 of the lower lid lymphatics drain into the pre-auricular lymph node located directly in front of the ear. The medial 1/3 of the upper eye lid and the medial 2/3 of the lower lid lymphatics drain into the submandibular node located just under the jaw-line. Therefore, it is very important to evaluate these two nodes separately, especially when a condition of viral etiology is suspected.

Question 25

A 43-year old woman is seen at your office concerned about the fact that she constantly seems to have styes on her eyelids and her eyes are continually red and irritated. Biomicroscopy reveals meibomitis and blepharitis along with lid telangiectasia and a TBUT of 4 seconds for each eye. She also reports that her cheeks, nose, forehead and chin are easily flushed, especially when exposed to heat or cool temperatures. Given the above findings, what is your tentative diagnosis?

Hordeolum

Dry eye syndrome

Systemic lupus erythematosus

Rosacea

Answer 25

Rosacea

Rosacea is a condition that causes excessive blushing of the face, with or without ocular involvement. Rhinophyma (a large, bulbous, red nose) is common in rosacea. Patients will often complain of facial flushing that is exacerbated with extreme temperature exposure, exertion, or the ingestion of hot beverages. This condition is seen two times more frequently in women. Ocular implications commonly include blepharitis, meibomitis, telangiectasia, dry eye syndrome, and occasional corneal involvement such as superficial punctate keratitis, pannus, and neovascularization. Treatment of facial rosacea includes oral tetracycline, topical metronidazole and retinoid compounds. Ocular rosacea is best treated by managing concomitant lid diseases along with artificial tears. While a hordeola and dry eye syndrome do occur in rosacea, these should not be your primary diagnoses. Remember to look at the overall broad picture and not just the pair of eyeballs.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that has the capability of affecting many areas of the body. A common finding of SLE is called the malar (or butterfly) rash that is seen in roughly half of the individuals affected by this disorder. This rash generally occurs on the cheeks and over the nose bridge and worsens with ultraviolet light exposure. Concurrent eye conditions with SLE are primarily secondary to complications from the medications used to manage the condition such as oral corticosteroids and anti-malarials.

Question 26

Herpes zoster is a virus that generally affects only one side of the face. A zoster lesion seen on the tip of the nose is seen as a sign and may signal the presence of ocular involvement roughly 75% of the time. What is the name of this sign?

Horner’s sign

Munson’s sign

Hutchinson’s sign

Meyer’s sign

Answer 26

Hutchinson’s sign

Hutchinson’s sign occurs when a zoster lesion is seen on the tip or the side of the nose. This sign may signal the presence of ocular involvement. If Hutchinson’s is observed, the eye is involved roughly 75% of the time. Conversely, 25% of patients who have a negative Hutchinson’s sign will have ocular implications.

Munson’s sign is seen in keratoconus, although it offers little diagnostic value anymore. Basically, when patients with advanced keratoconus look down, the lower lid will appear ‘V’ shaped due to central displacement by the protruding cornea.

Prior to the characteristic skin eruption seen in measles, the conjunctiva may take on a glassy appearance, followed by swelling of the semilunar fold a few days later. This is known as Meyer’s sign.

Question 27

Which 3 of the following bones make up the floor of the orbit? (Select 3)

Palatine

Maxillary

Frontal

Zygomatic

Sphenoid

Ethmoid

Answer 27

Palatine, Maxillary, Zygomatic

MZP = FLOOR 
F+ lesser = ROOF
Z+Greater= Lateral 
LES M = Medial 
The orbital floor consists of three bones: the palatine, maxillary, and zygomatic bones. It is the floor of the orbit that is most susceptible to orbital blow out fractures due to the relative weakness of the posteromedial portion of the maxillary bone. 

Orbital roof bones: lesser wing of sphenoid, orbital plate of the frontal
Lateral wall bones: greater wing of sphenoid, zygomatic
Medial wall bones: maxillary, lacrimal, ethmoid, sphenoid

Question 28

Which of the following systemic disorders is MOST commonly associated with the presence of yellow, soft, raised, plaque-like lesions that generally occur in the medial canthal region of the eyelid?

Lymphoma

Diabetes mellitus

Leukemia

Hyperlipidemia

Hypertension

Answer 28

Hyperlipidemia

The condition described in the above question is known as xanthelasma. Xanthelasma are yellowish, soft, velvety, raised lesions that typically present in the area of the upper eyelid near the medial canthus. These lesions generally occur in middle-aged or older adults and are more commonly observed in women. They typically present bilaterally and symmetrically and can enlarge in size over time.

Xanthelasma has been associated with certain medical conditions including hyperlipidemia, hypercholesterolemia, obesity, and cardiovascular changes. Of these disorders, the most commonly related condition is high cholesterol, in which close to 50% of patients presenting with xanthelasma will exhibit elevated lipid levels when tested.

Management of xanthelasma should include blood testing and evaluation for the presence of various hyperlipidemias, if unknown. The eyelid lesions are usually observed but can be surgically excised in cases where an improvement in cosmesis is desired or if the lesion becomes uncomfortably enlarged. Occasionally, medical treatment alone for elevated serum lipids can bring about significant resolution of xanthelasma.

Question 29

Which 3 of the following muscles of the face are responsible for retraction of the eyelids? (Select 3)

Corrugator

Levator palpebrae superioris

Orbicularis oculi

Procerus

Muller’s

Frontalis

Answer 29

Levator palpebrae superioris
Muller’s
Frontalis

Retraction not OPEN

he eyelid retractors are muscles of the face that serve to open the eyelids. The primary retractor of the upper lid is the levator palpebrae superioris. The levator originates on the orbital roof near the orbital apex. The levator muscle is about 40mm in length with an additional 14-20mm that represents the levator aponeurosis. The aponeurosis splits in the anterior and posterior portions, which insert at the pretarsal orbicularis and the anterior surface of the tarsus, respectively.

Muller’s muscle is also important in opening the upper lid. It originates underneath the levator aponeurosis and extends to insert at the superior tarsal border. This muscle is responsible for about 2mm of elevation of the upper lid.

The frontalis muscle also acts as a weak retractor of the eyelid but is mostly responsible for lifting the eyebrows. By elevating the eyebrows, the frontalis may provide an additional 2mm of retraction of the upper eyelids.

Question 30

Which of the following systemic diseases is MOST commonly associated with the presence of a positive Cogan’s lid twitch sign?

Systemic lupus erythematosus

Myasthenia gravis

Grave’s disease

Multiple sclerosis

Answer 30

Myasthenia gravis
Cogan’s lid twitch sign is characterized by an overshoot of the upper eyelid on a vertical saccade from down-gaze to the primary position (when the patient first looks downward for a short period of time). The upper eyelid will also often twitch in a nystagmoid fashion or slowly droop back to a ptotic primary position. It is thought that this sign is a result of a transient improvement in lid strength after a short rest of the levator when in downgaze, followed by a drop in the lid in primary position as the levator begins to fatigue again. Cogan’s lid twitch is most commonly associated with myasthenia gravis.

Question 31

An abnormally high positioned upper eyelid crease is indicative of which of the following types of eyelid ptosis?

Myogenic

Mechanical

Congenital

Neurogenic

Aponeurotic

Answer 31

Aponeurotic

Clinical findings associated with an aponeurotic ptosis include a mild to moderate upper eyelid ptosis, an abnormally highly positioned upper eyelid crease, and good levator function. This type of ptosis most commonly occurs in elderly patients in whom there is a stretching of the levator aponeurosis that results in elongation of the length of the muscle and a resultant ptotic upper eyelid.

The upper eyelid crease measurement is the vertical distance between the upper lid margin and lid crease when the patient is looking in down-gaze. It is typically 10mm in females and 8mm in males.

Question 32

Trichiasis is an inward turning of one or multiple eyelashes towards the eyeball. Which of the following is the MOST common cause of trichiasis?

Entropion

Trauma

Chronic blepharitis

Lid myokymia

Answer 32

Chronic blepharitis

While all of the above options other than lid myokymia can cause trichiasis, the most common cause stems from chronic blepharitis. Trichiasis can cause irritation, discomfort, lacrimation, corneal epithelial defects, and, if left untreated for long periods of time, scarring. Treatment includes epilation, bandage contact lenses, cauterization, electrolysis, cryosurgery, or Argon laser photocoagulation of the offending follicle or follicles. In the event of blepharitis, it is important to prescribe proper lid hygiene.

Question 33

While several tests such as tear stability and ocular surface staining are global tests diagnostic for the presence of dry eye, what is a specific test that can differentiate aqueous tear deficiency from meibomian gland dysfunction (MGD)?

Meibomian gland atrophy/dropout as measured by meiboscopy

Conjunctival staining by lissamine green, which is worse in MGD

The Schirmer I test, which is considered abnormal if the strip wetting is less than 10 mm in 5 minutes without anesthesia

Tear clearance, which is normal in MGD

A detailed dry eye questionnaire to allow for score-based symptomology

Answer 33

The Schirmer I test, which is considered abnormal if the strip wetting is less than 10 mm in 5 minutes without anesthesia

Whether aqueous tear production is normal or not can be determined using the cotton thread tear test or the Schirmer I test without anesthesia. The Schirmer I without anesthesia essentially becomes a stress test since it is so irritating; if the patient cannot produce aqueous tears under irritating conditions, the main lacrimal gland is probably compromised. Conversely, meibomian gland dropout can be observed in both aqueous tear deficiency and MGD, possibly due to inflammatory processes on the ocular surface.

Question 34

Reflexive blinking is caused primarily by which of the following actions?

Stimulation of Mueller’s muscle and inhibition of the levator palpebrae superioris

Stimulation of the orbicularis and inhibition of the levator palpebrae superioris

Inhibition of the orbicularis and stimulation of the levator palpebrae superioris

Inhibition of Mueller’s muscle and stimulation of the levator palpebrae superioris

Answer 34

Stimulation of the orbicularis and inhibition of the levator palpebrae superioris

Reflexive blinking has many etiologies all of which result in stimulation of different pathways, but all of the pathways have one common outcome:closure of the eyelids via stimulation of the orbicularis and inhibition of the levator palpebrae superioris.

Question 35

Which of the following eyelid glands are sebaceous glands that secrete sebum into the hair follicle that coats the shaft of the eyelash?

Meibomian glands

Glands of Krause

Glands of Wolfring

Glands of Zeis

Answer 35

Glands of Zeis

The sebaceous glands of Zeis coat the shaft of the eyelashes and prevent cilia from becoming brittle. The glands of Moll, also known as ciliary glands, are modified apocrine sweat glands found next to the base of the eyelashes and anterior to the meibomian glands. The glands of Moll are prone to blockage and infection which can manifest as a sty. The meibomian glands are sebaceous glands but their function is to secrete the lipid portion of the tear film. The accessory lacrimal glands of Krause and of Wolfring produce an aqueous secretion similar to the main lacrimal gland that contributes to the tear film.

Question 36

A 53-year old male complains of pain, irritation, watering, and foreign body sensation of the left eye. Upon slit lamp examination, you notice several eyelashes emanating from the meibomian glands that are turned inward toward the globe. What is this condition known as?

Meibomian gland dysfunction

Trichotillomania

Distichiasis

Trichiasis

Madarosis

Answer 36

Distichiasis

Distichiasis is a condition of the eyelids in which eyelashes originating from a position posterior to the normal row of lashes grow inward toward the eye. Typically, these lashes emanate from the meibomian gland orifices and may consist of an entire extra row of cilia, or may be focal with only a few abnormal lashes. Distichiasis may be congenital or can be acquired secondary to chronic eyelid inflammatory conditions, surgery, or when an eyelid tumor is present. There is no evidence of entropion in these cases.

Trichiasis occurs when eyelashes originating from a normal position grow inward toward the globe. Again, there is no entropion of the eyelid margin. This condition can occur after eyelid trauma, surgery, chronic blepharoconjunctivitis, cicatricial pemphigoid, trachoma, or may also be idiopathic.

Madarosis is a loss of lashes, usually due to either a congenital condition or as a result of an infectious condition. Trichotillomania occurs secondary to a compulsive urge to pull out one’s own hair and/or eyelashes.

Question 37

An infection of the subcutaneous tissue anterior to the orbital septum is known as which of the following ocular conditions?

Orbital cellulitis

Pyogenic granuloma

Preseptal cellulitis

Internal hordeolum

External hordeolum

Answer 37

Preseptal cellulitis

Preseptal cellulitis is defined as an infection of the soft subcutaneous tissue anterior to the orbital septum. If an infection occurs anywhere in the orbit posterior to this septum, it is known as orbital cellulitis.

An internal hordeolum is a localized infection of the meibomian glands, while an external hordeolum is described as an acute infection with abscess formation of the glands of Zeiss and Moll. A pyogenic granuloma is a proliferative fibrovascular response to prior inflammation, surgery, or trauma.

Question 38

You are evaluating the function of the levator muscle in a patient with a suspected myogenic ptosis. A measurement less than what value would be considered abnormal?

9mm

5mm

16mm

12mm

Answer 38

12mm

measuring levator function (upper eyelid excursion) is a very helpful test in aiding in the diagnosis of a ptosis and identifying the underlying etiology. The measurement is achieved by having the patient look down while placing a thumb firmly against the brow to negate the action of the frontalis muscle. The patient is then instructed to look up as far as possible, and the amount of excursion is measured with a ruler.

• Average levator function is about 15mm
• A value of 12mm or above is considered “good”
• “Fair” levator function is 5-11mm
• 4mm or less is considered “poor”
• Typically anything below 12mm is considered abnormal

Question 39

Which of the following terms describes eyelash loss?

Madarosis

Ciliary dyskinesia

Poliosis

Telecanthus

Epicanthus

Answer 39

Explanation - Madarosis is a term that describes loss of the eyelashes (ciliary madarosis) or the eyebrows (superciliary madarosis). Poliosis is a term that describes a decrease or absence of melanin or color in the eyelashes. Ciliary dyskinesia is a rare genetic condition that causes a defect in the cilia lining of the respiratory tract. Epicanthus is a synonym for the orbital fold or Mongolian fold of the eyelid. Telecanthus is a term that describes increased distance between the eyelids at the medial canthus.

Question 40

you decide to perform the Schirmer 1 test (without anesthetic) on a 23 year-old patient with symptoms of dry eye. After a period of 5 minutes, which of the following values indicates the threshold whereby any measurement below this is considered abnormal?

10mm

18mm

25mm

15mm

12mm

Answer 40

10mm

When the Schirmer test is performed properly, patients with normal tear production will have a total amount of tear secretion that wets at least 10mm of the filter paper after a period of 5 minutes in the eye.

Before placing the Schirmer strip in the eye, the eye should be gently dried of any excess tears using a cotton-tipped applicator at the inferior conjunctival fornices on both sides. The filter paper should be folded 5mm from one end and placed in the lower conjunctival sac near the junction of the middle and outer third of the lower eyelid. Care should be taken not to touch the strip to the cornea or eyelashes upon insertion. After 5 minutes, the filter paper should be removed and the amount of paper that is moist is measured from the fold.

Question 41

Which of the following BEST describes the actions of the lacrimal system that occur when the eyes close during a blink?

Correct answer Horizontal canaliculi are shortened, puncta moves medially, and lacrimal sac expands

Horizontal canaliculi are lengthened, puncta moves temporally, lacrimal sac expands

Horizontal canaliculi are lengthened, puncta moves temporally, and lacrimal sac collapses

Horizontal canaliculi are shortened, puncta moves medially, and lacrimal sac collapses

Answer 41

Horizontal canaliculi are shortened, puncta moves medially, and lacrimal sac expands

As a person closes his eyes during a blink, the pre-tarsal orbicularis oculi compresses the vertical component of the canaliculi and shortens the horizontal canaliculi, which in turn causes the puncta to move medially. Simultaneously, the lacrimal portion of the orbicularis oculi also contracts, which results in expansion of the lacrimal sac. This action creates negative pressure, which draws the tears from the ocular surface through the canaliculi and into the sac.

Question 42

Dry eyes can cause blurred vision, stinging and foreign body sensation. How do the tears seen in people with dry eyes compare to those with normal eyes?

Increased lysozyme concentration

Lower pH than normal

Higher pH than normal

Lower osmolarity

Answer 42

Higher pH than normal

The tear film in people with dry eyes displays a higher pH than that of normal eyes. The change in pH is attributable to the fact that the osmolarity of the tears increases, thus increasing the pH. Many drug companies have taken advantage of this knowledge and applied it in their manufacture of artificial tears. Alcon, the company that invented Systane, ultilizes a component called Hydroxypropyl-guar (HP-Guar) which is a gel-forming matrix. Upon instillation of Systane into the eye, the liquid transforms into a gel. The difference in pH between the tear film and the artificial tears leads to an alteration in the cross-linking between HP-Guar and borate (another ingredient in the artificial tears), causing the creation of a gel-like layer that allows for increased ocular contact time. Studies show that the tear lysozyme content is decreased in people who suffer from dry eyes.

Question 43

Oral acyclovir is most effective for patients presenting with eyelid findings associated with herpes zoster if administered within which of the following periods following the onset of the disease?

24 hours

10-12 hours

4-5 days

72 hours

7-10 days

Answer 43

72 hours

Oral acyclovir is the mainstay of therapy for patients diagnosed with herpes zoster ophthalmicus. This systemic treatment is maximally beneficial of it is initiated within 72 hours from the onset of the disease (usually the appearance of eyelid lesions). The use of oral acyclovir typically results in quick resolution of skin vesicles, decreases the amount of pain the patient experiences, and reduces the duration of viral shedding and appearance of new lesions. Acyclovir has also been shown to significantly reduce the incidence of ocular findings such as episcleritis, keratitis, and iritis. The recommended dosage is 800mg orally 5 times per day for 7-10 days.

Question 44

Your patient reports constant epiphora of the right eye. You wish to determine if there is a blockage of her tear drainage system. You perform lacrimal irrigation. During the procedure, the plunger of the cannula is depressed with great difficulty, and the fluid is regurgitated through the puncta that you are irrigating. What is the CORRECT interpretation of these findings?

There is a blockage that is proximal to the common caniculus

The passageway is clear; there is no obstruction at this time

There is a blockage that is distal to the common caniculus

There is an obstruction of the lacrimal duct of the opposite eye

Answer 44

There is a blockage that is proximal to the common caniculus

Lacrimal irrigation is performed when an obstruction of the tear drainage system is suspected. Dilation of the puncta generally precedes irrigation. Once the puncta is anesthetized and dilated, a cannula is inserted and saline is injected. If the patient reports that they taste saline, or if they cough because of the fluid in their throat, the drainage system is considered open. If the saline is released by the opposite puncta, then there is a blockage located distally to the common caniculus. If the plunger cannot be depressed, or the fluid is expressed by the same puncta that is being irrigated, then the obstruction is proximal to the common caniculus.