P-AnteriorSegment Flashcards

Question

PXF - how to describe desposits - ddx for fibrillary deposits - eval

Answer 1

- white fibrillary flakey material in a concentric pattern - PXF --scandinavian descent --painless --sampolesi line, phacodonesis, pupillary TID, glaucomatous change - true exfoliation --glass blower / welder --painful w photophobia --capsular delamination - amyloid --deposition of hyaline ECM into various body parts = mass lesion in any other location **--tissue biopsy for definitive dx** - uveitis --AC cell

Answer 2

- DM - sickle cell - **mechanism of injury** (sharp? duration? rebleed? vision loss? eye protection?) - confounding factors (DM? Sickle cell?) - eval extent of damage: open globe? IOP elevation? lens subluxation? vitreous/retinal heme? RD? Bscan if no open globe - **after wks: gonio for angle recession** - to decrease bleed: bed rest, shield, HoB elevation - **for pain: tylenol (avoid NSAIDs)** - gtts: PF, cycloplegia, IOP gtts if elevated IOP (but avoid CAI if sickle cell) - AC washout if K staining or >50% after 8 days or uncontrolled IOP --**IOP 60 after 2 days, 25 after 1wk, 25 after 1 day in sickle cell** - **daily f/u initially given risk of rebleed -> high IOP, most likely 3-7 days after initial hyphema** - counsel re eye protection

Answer 3

- pseudomonas -- CL use: cleaning, overnight - gonorrhea --sexual history - herpes --other signs of herpes: skin rashes, pain and injection, dendrites, pannus, disciform keratitis, interstitial keratitis, trabeculitis, ARN/PORN - acanthomeba -- lake / hot tub -- **slow presentation** - fungal -- trauma w organic matter -- slow presentation - topical anesthetic abuse (epi defect -> ring ulcer, answer pic) - trauma - test wound and CL + CL case: gram stain and culture -- chocolate = thayer martin: gonorrhea -- blood: majority of bacteria -- thioglycolate: anaerobic -- sauborauds: fungi - abx: fortified broad spectrum (vanc + ceftaz q1h) -> **if approaching sclera, PO fluoroquinolone** - **dc CL wear** - daily followup - guarded prognosis; will most likely scar and need K transplant

Answer 4

Diffuse conj injection w bluish hue - scleritis - episcleritis - conjunctivitis -hx: onset, progression, recurrence, sxs (boring pain w radiation to **forehead** and jaw, **tender to palpation**, decreased VA) RFs (RA, lupus, ANCA vasculitis, polyarteritis nodosa, polychondritis, ankylosing spondylitis, IBD, gout, herpes / syphilis / TB / lyme) -exam: VA, tender to palpation, conj injection that does not blanch w phenyl, **?nodules**, ? inflammation (KP, cell, vitritis, retinal granulomas, exudative RD) - testing: 50% a/w systemic disease so CBC, ESR/CRP, ANA, ANCA, RF, C3/4, ACE, TB, syphilis, uric acid, Xray of sacroiliac joint Mgmt: - if non-necrotizing: PO NSAIDs (for pain and inflammation) - **if necrotizing: PO steroid w GI PPX -> steroid sparing immunosuppressant like MTX** - if AC cell: gtt steroid + cycloplegia - tx underlying disease: medicine and rheum referral - monitor for scleral thinning; recommend eye protection to prevent perforation; may need patch graft - responds to tx and recurrence decreases w tx of underlying disease - prognosis good if non-necrotizing; bad if necrotizing or **posterior scleritis**

Answer 5

hx: - mechanism of injury: type of chemical, duration of exposure, irrigation? eye protection? exam: - VA and IOP - skin: facial burns - fornix: evert lids for ?FB, check pH - ocular surface: chemosis, limbal ischemia (blanching) / necrosis, K defect / edema - intraocular: siedel, AC cell, retinal necrosis (in severe alkali burns). AVOID PHENYLEPHRINE AS TO NOT WORSEN LIMBAL ISCHEMIA -grade severity: I = no limbal ischemia II = <1/3 limbal ischemia III = 1/3-1/2 limbal ischemia IV = >1/2 limbal ischemia Mgmt: - Irrigate until pH at 7 - sweep fornices - Based on severity: I: abx, **PF x 7 days, tears, cycloplege for comfort, timolol if IOP elevated** II: +ascorbate to augment healing, + doxy for MMP inhibition III: +amniotic membrane or prokera IV: +limbal stem cell transplant pending perf: glue, patch graft, PK - follow daily Counsel: - symblepharon - K scar **- glaucoma** - retinal necrosis

Answer 6

-episcleral pigmentation that appears "slate gray" -ocular melanocytosis -conj nevus -episcleral melanoma -uveal melanoma -eval hx: family? how long it has been present, old photos -eval other pigmentation: on skin, **on palate**, on DFE, unilateral vs. bilateral (Ota = v1-v2, Ito = unilateral beyond v1-v2, Hori = bilateral) -eval lesion: raised? nodular? mobile? conj vs. sclera? **feeder vessels?** -eval associated symptoms: IOP -obtain photos to monitor lesion -monitor for glaucoma -monitor for uveal lesions -counsel risk of glaucoma (10%), uveal melanoma (1/400), melanoma of skin/conj/orbit, and rare risk of malignant transformation -**comanage w derm (can laser skin for cosmesis)**

Answer 7

-keratinized conjunctiva = bitot spot -**xerophthalmia** = spectrum of ocular disease caused by severe Vitamin A deficiency --ask about reduced intake (diet, eating disorder, chronic alcoholism), absorption (biliary cirrhosis, bowel disease) or storage (CF, liver disease) --keratomalacia (drying and clouding; picture) /ulcers/persistent epi defects --retinal manifestations: nyctalopia, small, white, deep retinal lesions scattered throughout the posterior pole --vit A lab -DES **-allergic conjunctivitis**: ask about med allergies -SJS/TEN: recent sulfa meds - refer to internist for workup and management of vit A def - lubricate - monitor for resolution - counsel re importance of sufficient vit A

Answer 8

endstage OCP (autoimmune conjunctivitis that leads to cicatrization (i.e. scarring) of the conjunctiva) -symbelpharon + forniceal shortening -eyelid trichiasis / entropion -K keratinization / pannus / scarring -oral ulcers / scarring SJS / GVHD / **linear IgA def / rosacea** prior trauma (chemical, mechanical, radiation) **h/o membranous conjunctivitis (EKC, trachoma)** medicamentosa: difficult to distinguish from OCP but will resolve after stopping the offending agent hx: onset, progression, associated symptoms (eye irritation: redness, FB sensation, dry, tearing), RFs (h/o conjunctivitis, trauma, surgery, chemical injury, radiation) exam: ?active inflammation, lid malposition, K compromise, examine oral mucous membranes for ulcers testing: no biopsy if quiescent for fear of reactivation. If active inflammation, then can biopsy: insitu fluorescent stain for **C3, IgA, IgM, IgG**. If lid malposition / k compromise, then biopsy at time of surgery. If oral ulcer, biopsy. aggresive lubrication, warm compresses, lid hygiene, **epilation** if severe: topical (pred, cyclo) and PO (pred -> MTX) avoid eyelid surgery until quiescent (**no role for PK 2/2 poor outcome**), then **(lateral tarsal strip, everting suture, symblepheron ring)** refer to GI/derm/ENT for other mucosal involvement (can be lethal from GI/pulm complications) remits and relapses, most respond to therapy follow active disease weekly, then q6mo

Answer 9

STUMPED sclerocornea (prompt pic): cycloplegic refraction trauma ulcer metabolic (mucopolysaccharidosis - Hurler's, Scheie) peter's anomaly endothelial dystrophy (CHED, answer picture) dermoid

Answer 10

Dysgenesis of anterior segment during development -> K opacity -> amblyopia -gestation/birth/newborn screen, FHx -other anterior segment eval (EUA if necessary) : cycloplegic refraction, gonioscopy, IOP -DFE / Bscan -syndromic features exam -**rubella serology** -Amblyopia: refractive correction, patching -Glaucoma: gtts -surgical treatment: --K transplant (poor graft prognosis) --lysis of iris strands from K may improve opacity --CE if lens-K touch -if bilateral: a/w microphthalmia with linear skin defects @ risk for cardiac arrhythmias and other systemic anomalies **-a/w Axenfeld-Rieger syndrome and congenital rubella** -genetic counselling -mixed prognosis

Answer 11

-ABCD: asymmetry, border, color, diameter -iris nevus -iris melanoma -stromal cyst -iris met of Juvenile Xanthogranuloma (picture, rare **benign histiocytic proliferation** that develops in infants and young children; Touton giant cells) -h/o: timing, evolution, other cancers -look for hyphema, **intraocular inflammation**, gonioscopy -UBM, serial photographs

Answer 12

- eval elsewhere for primary/mets: CT chest, abd, pelvis, LFTs - if dx in doubt, then FNA though this is rarely necessary - **tx w brachytherapy or proton beam irradiation over enucleation (excellent globe conservation rates without worsened mortality)** - discuss cataracts, radiation retinopathy and lifetime risk of mets

Answer 13

Uveal: liver > lung and bone Conj: head and neck lymph nodes

Answer 14

- fine diffuse infiltrate located at the level of the flap with some grouped collections in the central visual axis - diffuse laminar keratitis - **herpetic stromal keratitis** - epithelial ingrowth (picture) - foreign bodies at flap interface - h/o: type of surgery? complications? postop regimen? compliance? trauma? - evolution: time of onset? progression? - exam: ocular vital signs, seidel, fluorescein for dendrites, depth of material, flap necrosis, AC reaction, endophthalmitis

Answer 15

**I: onset 1-2 days**, peripheral infiltrates only **II: onset 3-4 days**, peripheral -> central w decreased VA III: central. **likely to scar** IV: stromal melt. -lubricate w PFAT -anti-inflammatory: PF q1h +/- PO steroid -when III/IV: lift flap and irrigate -low threshold for culture. In addition to standards, add on atypical mycobacteria (Lowestein-Jensen). -Prognosis good with I/II, guarded w III/IV -Follow daily

Answer 16

adults: diabetes, sickle, OIS, RVO pediatric: IP, ROP, FEVR, Norrie IOS: - sx: light induced amaurosis, pain that improves w lying down - exam: anterior inflammation + posterior retinopathy = conj injection, K edema, **NVI**, CB shutdown, midperiphery retinal heme, CME; carotid bruit, BP - **FA: delayed filling beyond 30sec, diffuse leakage** - labs: A1c, lipid panel - carotid US, echo - consider stroke workup: CBC, non-con head CT, EKG

Answer 17

- PRP / anti-VEGF - **steroid and cycloplegics if inflammation** - co-manage w medicine: pain control, stop smoking, daily asa, if subtotal stenosis, then carotid endarterectomy, manage underlying cardiovascular disease - monitor for NVG q3mo - guarded prognosis

Answer 18

-herpes -stroke / CN V palsy / **acoustic neuroma** -trauma / contact lens / chemical burn / radiation -**topical anesthetic abuse** hx: onset, progression, sxs (pain, decreased vision, h/o ulcers), RFs (stroke, DM, acoustic neuroma, CN V palsy, herpes, contact lens, topical meds, **crack/cocaine**, trauma, radiation) exam: ocular VS, lag, K sensation / staining / infiltrate / pannus, iris atrophy, neuro exam -if no epi defect: ATs -if yes epi defect but no ulcer: abx, bcl/prokera, tarsorrhaphy -if yes ulcer: add on doxy and vit C

Answer 19

-iridodialysis (separation of iris from CB) -cyclodialysis (separation of CB from SS, picture) -ICE -Axenfeld-Rieger hx: onset, progression, sxs (pain, VA, glare), RFs (trauma, surgery, herpes) exam: VA, IOP, TID, gonio for angle recession or PAS, **hyphema**, AC cell, **phacodonesis**, CDR, RT/RD, choroidals testing: **UBM**, RNFL, HVF Mgmt: - IOP control w gtts, PO diamox, tube/trab - if intolerable glare, opaque contact lenses -> iris reconstruction (9-0 prolene siepser knot)

Answer 20

-Fuch's heterochromic iridocyclitis: unilateral, **painless**, constellation of findings: --low grade anterior inflammation --iris heterochromia --prominent angle vessel -> Amsler sign -Congenital Horner's -Waardenberg: genetic condition w **hearing loss** and changes in coloring of hair (white lock), skin, and eyes -ICE -iris melanoma -Sturge Weber (hyperpigmentation on affected side; exact mech unknown) hx: onset, progression, sxs (VA, iritation, redness), RFs (birth trauma, herpes infections, FHx, h/o cancer) exam: VA, IOP, pupil size, long vessels that insert high in the angle (easily nicked during CEIOL -> hyphema = amsler sign), KP/AC cell, iris pigmentations / nodules / TID, posterior synechiae, PSC, cupping **testing: RNFL, HVF** Mgmt: -low level inflammation does not respond well to steroids thus no PF -if elevated IOP: gtts, glc surgery -counsel re hyphemas during CEIOL

Answer 21

Bleb leak: low bleb, low IOP overfiltration: high bleb, low IOP ciliary body insufficiency: low bleb, low IOP choroidal effusion high IOP: aqueous misdirection, choroidal heme, pupillary block hx: surgical report, **postop straining, postanesthesia vomiting** exam: VA, IOP, bleb (height, siedel), chamber (AC depth, IK touch, LK touch), choroidal folds / effusion, hypotony maculopathy testing: bscan, OCT Management - if leak: BB, atropine, BCL -> revision. **If LK touch, reform AC surgically sooner**. - if CB insufficiency: PF - if choroidals: atropine - counsel: prognosis can be good but risk of belb failure and endophthalmitis. Avoid straining and return precautions.

Answer 22

uveal melanoma met melanocytoma hx: onset, progression (prior exams), sxs (pain, VA), RFs (cancer), **associated sxs (SOB, abd pain, bone pain b/c most common site of met by uveal melanoma is liver, lung and bone)** exam: VA, IOP, gonio, SLE and DFE to assess extension of lesions (iris, choroid, sclera, sentinel conj vessel), RD testing: UBM, Bscan, consider biopsy, CT chest/abd Management - onc referral for met workup and co-management - if localized: brachy or proton beam for medium, large needs enuc - **if met: chemo / radiation** Education - Poor prognosis - **Met rate 25%** - **Survival rate 70% at 5 years if no met, if met 8% at 2 years** - **Needs to monitor for recurrence**

Answer 23

-Staph Marginal Keratitis –reaction to staph antigens: peripheral stromal infiltrates +/- epi break / ulcers –abx for underlying staph infection –mild steroids to reduce inflammation

Answer 24

conj: mobile and blanches episcleral: immobile but blanches scleral: immobile and does not blanch

Answer 25

impending perf or <3mm hole: glue + amniotic membrane >3mm: patch graft (small piece, full thickness or partial thickness) or lamellar Keratoplasty or PK non-healing ulcers w low visual potential: gundersen flap lubricate + **topical abx + BB** +**doxy and vit C** good prognosis

Answer 26

trauma (sectoral) DM (snowflake, prompt pic) steroids **uveitis** myotonic dystrophy (xmas tree) Cu (sunflower, answer pic) **atopic dermatitis (anterior subcapsular)**

Answer 27

Hudson-stahli: tear stain in elderly tear star: post RK patient irregular anterior K leading to tear pooling: e.g. salzmann nodule, healed ulcer Ferry: inferior to filtering bleb fleischer: bottom of KCN cone stocker: edge of ptyrigium rust ring: FB (can leave if asymptomatic or remove w diamond bur)

Answer 28

**steroid gtts can slow down progression** grossly remove invading epi, may need en bloc excision of involved tissue -> corneoscleral graft **if drainage angle and CB involved -> cryotherapy -> likely need K graft later 2/2 endo damage** manage secondary glaucoma (gtts, tube, CPC) prognosis poor 2/2 secondary glaucoma

Answer 29

- pathergy test (no biopsy) - **pred gtts and cycloplegia while awaiting infectious workup** - if infectious workup negative and disease not improved on topicals, start PO pred -> immunosupression and co-manage systemic immune suppression with medicine - **counsel waxing waning course, poor prognosis** - **follow daily initially, then space out to q6mo**

Answer 30

epi cells growing across the posterior capsule (thus why very frequent in peds -> posterior capsolotomy at time of CEIOL) good size capsulorhexis **full removal of lens epi** full removal of viscoelastic from behind the optic to encourage bag-IOL adhesion square edged lens patient cannot participate / no view active uveitis / CME

Answer 31

- manage underlying disease - -inflammatory: PO steroid w **GI ppx** -> immunosuppression **- -infectious: abx** - manage symptoms: PO NSAIDs **- if AC cell: topical steroid, cycloplegia** **- if high risk of perforation: scleral patch graft** - counsel regarding sequelae of uveitis, fx of treatment, f/u monthly -> 4x/yr

Answer 32

most are idiopathic and recurrences are common thus workup only if suspicious history mild: tears and cool compresses **moderate: steroid gtts severe: steroid gtts + PO NSAID (ibuprofen 600 QID)**

Answer 33

steroid gtts and cycloplegia while awaiting infectious workup if inflammatory: PO steroid w GI ppx -> immunosuppression if infectious: treat infection and if syphillis (PCN G), **workup for commonly associated STDs** monitor for uveitis sequelae and fx of treatment

Answer 34

**atropine** LPI -> if still block, lensectomy **glaucoma management**

Answer 35

hard contact lens to maximize vision cross linking no eye rubbing **if pending perf -> crescent lamellar keratectomy**

Answer 36

For iris nodule: **AS OCT (epi-iris lesions without stromal extension)** high dose steroids gtts tapered over 3 months -> **PO steroid or excise if recurrent hyphema** co-manage w peds for other organ manifestations **stabilizes or regresses in the first 5 years**, good prognosis if no complications (hyphema -> glaucoma)