P-AnteriorSegment Flashcards
11M w ocular irritation and itching
description
ddx
eval
mgmt
everted lid w giant papillae and injection
-vernal: young boy, upper palpebral conj, horner trantas dots, shield ulcer
-atopic: older, upper and lower palpebral conj, subepi fibrosis, K pannus, subcapsular cataract
-allergic: no K involvement and follicles (not papillae)
-giant papillary conjunctivitis: retained FB such as suture and contact lens
-OSA
-hx: onset (seasonal?), progression, sxs (pain, itching, discharge, vision change), RFs (alleviating factors, trauma, OSA)
-exam: ocular VS, lid (laxity, scaling, eversion for FBs), K staining, horner trantas dots, shield ulcers, fibrosis, subcapsular cataract
Mgmt
-Symptomatic: ATs, cool compress, topical mast cell stabilizers and antihistamines, pulse steroids - add GI ppx, warn about IOP
-If atopy: oral antihistamine
-If shield ulcer: no steroid, + antibiotics drops
-Followup: weekly unless ulcer, then daily
Counsel
-seasonal in nature (treat before spring time), improves w age
-avoid CL during spring time
-risk of keratoconus from eye rubbing
description
ddx
eval
mgmt
K deposits in whorl like pattern
-K verticillata from FIPAT:
–fabry: conj and retinal telangiectasia, kidney problems, neuropathic pain
–indomethacin
–plaquneil / chloroquine, phenothiazine
–amiodarone
–tamoxifen
-scar
-dendrites
-iron line (fleischer ring, tear star)
hx: onset, progression, recurrence, sxs (pain, VA change, discharge), RFs (Mhx, meds, trauma)
exam: VA, K, conj and retinal telangiectasia
mgmt:
-if meds: benign and doesn’t usually affect vision thus no need to stop meds BUT
–monitor for plaquenil tox or tamoxifen/amiodarone optic neuropathy
–if med stopped, lesion does resolve
-if Fabry: refer to medicine for workup and management of kidney problems and neuropathic pain
-followup annually
-Ddx
-Eval
-Mgmt
-counselling
- map dot dystrophy = epithelial basement membrane dystrophy = anterior basement membrane dystrophy
- other corneal dystrophies (macular, granular, RB/TB)
- trauma
- exposure keratopathy
hx: onset, progression, sxs (pain, vision change), RFs (prior episodes, trauma, surgery, contact lens, lid closure abnormalities, FHx)
exam: VA, K level of involvement / defects
testing: fluorescein
Mgmt:
- Acutely: ATs, abx, ointment
- Chronic: ATs, ointment, BCL x 2-3mo
- if unresponsive: debride, phototherapeutic keratectomy but hyperopic shift can occur
- prognosis good for resolving over months but recurrence is common
-description
-ddx and what to look for
-mgmt
-followup and education
- pointing of the inferior lid margin in downgaze: Munson’s sign
-keratoconus:
–sxs: sudden pain (hydrops), vision changes, refractive changes
–RFs: atopy, eye rubbing, contact lens, floppy eyelid, Marfan’s (Mitral valve prolapse), Ehler Danlos, Down syndrome, RP, FHx
–other signs: scissoring, rizzuti (picture), vogt striae, fleischer ring (Fe deposit), thinning (pachymetry), scarring
–K topo and pachy w inferior thinning
-keratoglobus:
–onset at birth
–K topo w global protrusion and thinning (though more thin) in the periphery
–TM visualizable without gonio
-post LASIK ectasia: worsening vision wks to yrs post laser correction
–tx similar to keratoconus (refactive correction -> CXL -> PK)
-pellucid marginal degeneration: crab-claw defect on K topo, beer belly ectasia (protrusion above thinning), onset in 20s-40s
Mgmt
-optical correction: glasses -> rigid gas permeable contact lenses
-tx atopy and dry eye to decrease eye rubbing
-if progressive, then UV crosslinking
-if hydrops: muro, cycloplegia, protective lenses; if reactive inflammation causing elevated IOP, then glaucoma gtts
-if central scarring: PK/DALK
-followup q6mo
-slow progression is expected but most do well w contact lenses and if K tx is needed, one of the disease entities with highest rate of success
45F p/w redness, pain and photophobia:
-description
-ddx
–what to look for
slit lamp photo showing peripheral K thinning and vascularization
- peripheral ulcerative keratitis
–K+scleral involvement; painful 2/2 epi loss
–a/w inflammatory diseases (RA, lupus, wegener’s, polyarteritis nodosa, TB/syphillis/lyme/hep C)
–exam: K defect / infiltrate / thinning, scleritis, AC cell, posterior synechiae, vitritis
–testing: CBC, ESR, CRP, RF, ANA, ANCA, TB, syphilis, CXR, hep C - Mooren Ulcer (picture)
–K involvement only; painful 2/2 epi loss
–a/w helminth and hep C but is a dx of exclusion - Terrien Marginal degeneration
– 20-30yos (T=thirties)
– painless; fluorescein neg
– starts superiorly (T=top) and advances circumferentially with leading edge of lipid
– ATR astigmatism
– similar to Fuchs superficial marginal keratitis in children
–unknown cause - Furrow degeneration
– senile
– painless
– in the clear zone between senile arcus and limbus - Dellen
management of
- PUK
- Mooren
- Terrien
- Furrow
For both PUK and Mooren:
- lubricate
- recess conj
- if infectious ulcer: culture -> fortified abx
- if perforated: tectonic keratoplasty
For PUK: treat underlying disease w PO steroid -> immunosuppressives
For Mooren: BCL (because more chronic), anti-inflammatory (NSAIDs, steroids, immunosuppressives)
*rule out TB/syphlis before initiating systemic steroids
For Terrien/Furrow
- tx astimagtism
For Terrien: perf is rare but can tx w crescent lamellar Keratoplasty
- counsel eye protection and risk of perf
hypopyon
- ddx
- what to look for
- anterior uveitis
–RA, ankylosing spondylitis (back pain worse upon awakening in a young man)
–psoriasis, lupus, UC, ANCA vasculitis, polyarteritis nodosa, polychondritis, sarcoidosis, Fuch’s heterochromic iridocyclitis
–herpes / syphilis / TB / lyme (fever, SOB)
– look for KPs, stellate KP (Fuch’s heterochromic iridocyclitis, prompt pic), mutton fat KP (granulomatous causes such as TB, syphilis, sarcoidosis, Behcet’s, JIA, VKH, picture), PAS - Behcet’s:
–oral/genital ulcers, erythema nodosum
–silk road ethnicity
–vitritis, retinitis, retinal vasculitis - lens issue: phacolytic, phacoantigenic, lens particle, UGH
- Endophthalmitis: h/o recent trauma, eye procedures, hypopyon, vitritis
Uveitis labs
Infectious:
-CBC
-syphilis: RPR/FTA-Abs, VDRL
-TB: Quant gold, PPD -> CXR
-Lyme: lyme titers
Inflammatory:
-ESR/CRP
-autoimmune: RF (RA), ANA (collagen vascular - dsDNA+ for lupus), ANCA (vasculitis like wegener’s)
-Ankylosing spondylitis: HLA-B27, sacroiliac films
-Sarcoid: ACE, lysozyme, chest CT
Ankylosing spondylitis w anterior uveitis: mgmt
-followup
-complications
uveitis:
- PF q1h w slow taper -> PO steroid once TB/syphillis ruled out
- cycloplegia to prevent PAS
AS:
- rheum referral w NSAIDs + immunosuppresion
-f/u weekly initially w return precautions
-counsel: recurrent, complications (glaucoma, cataract, macular edema)
iris trans illumination defects: DDx and what to look for
- pigmentary dispersion (mid-periphery)
–young myopic man w blurry vision / halos after exercise
–pig deposits on the K endo (Krukenberg’s spindle, also seen in uveitis and trauma), lens zonules (Scheie = zentmeyer line), TM - PXF (pupillary):
–scandanavian descent
–PXF deposits on the lens, sampelosi line, phacodonesis - traumatic / iatrogenic
- herpetic
- albinism (photophobia, foveal hypoplasia -> poor vision -> nystagmus, strab)
Management of PDS
- Manage as glaucoma suspect: IOP check, nerve exam, OCT, HVF q 6mo
- Treat any glaucoma: gtts, SLT. Avoid incisional sx due to higher risk for hypotony
- counsel regarding pigment storm
- description
- ddx
- eval
-mgmt
- white round paracentral K lesions
-Salzmann Nodule: asympatomatic, h/o chronic inflammation
-Spheroidal Degeneration: brownish golden, located in interpalpebral fissure b/l -> tears
-Phlyctenule: type IV hypersensitivity reaction -> pain, photophobia, h/o TB/staph/trachoma; can progress to ulcers -> manage underlying inflammation (PF) / infection and any K perf
-Scarring
hx: onset, progression, sx (pain, photophobia, VA, discharge), RFs (trachoma, herpes, TB/syphlis/lyme, RA, lupus)
exam: VA, blepharitis, conj papillae / follicles / arlt’s line, interstitial keratitis, AC cell, posterior synechiae, vitritis, retinitis, optic neuritis
path: hyaline deposit between epi and bowman
Mgmt:
–ATs
–if astigmatism: RGP
–if bothered: keratectomy (diamon burr) -> PTK
–if extension into stroma (rare): lamellar keratoplasty
–prognosis good but can recur after excision
ddx
eval
mgmt
- Interstitial keratitis: endpoint of many inflammatory/infectious etiologies that primarily affect the K stroma. Significant pain and photophobia
-K scar
-K ulcer
hx:
-onset
-progression: active?
-sxs: pain, photophobia, discharge
-RFs: herpes, syphillis / TB / lyme (fever, hearing loss, SOB), autoimmune (cogan syndrome against K and cochlea)
exam:
- VA to assess severity
- IOP to assess trabeculitis and risk for steroids
- K: epi defect / ulcer, pachymetry for edema, scarring
- AC: KP, cell, posterior synechiae
- DFE: vitritis, retinitis, optic neuritis, scarring
- systemic: Hutchinson teeth, saddle nose, skin rash
testing:
- RPR/FTA, quantiferon, lyme
- if hearing loss: MRI to look for cochlear inflammation a/w Cogan syndrome
mgmt:
- steroid gtts - counsel about IOP elevation
- refer to medicine for underlying infectious/inflammatory disease
- if sig scarring once inactive, can offer PKP - counsel about possible rejection and need for steroids / additional surgeries
- good prognosis unless scarring
ddx
eval
mgmt
Filamentous keratitis: 2/2 severe dry eye:
- exposure: thyroid, superior limbic keratitis (a/w thyroid and filaments, pictured in answers)
- autoimmune: sjogren
hx: onset, progression
-sx: (pain, vision change, discharge)
-RFs: autoimmune (e.g. Sjogren’s)
exam: VA, MGD, papillae, lag, K PEE/abrasion
testing: Schirmer, fluorescein
labs: if suggestive on history, SSA, SSB, RA, ANA
Mgmt:
- lubricate: tears and ointment, punctal plugs, restasis
- tx symptoms: BCL + abx ppx but monitor closely
- remove filaments using jewelers
- prognosis good but chronic; risk of K infections
- description
- ddx and what to look for
- mgmt
- dendrites with terminal bulbs
- HSV/HZV
–RFs: immune compromise, stress, atopy, sun exposure, sexual contact / prior cold sores
–other symptoms of herpes: sores, skin vesicles (HZV follows dermatomes, HSV crosses) particularly on the eyelids and nose tip (Hutchinson’s sign), eye pain / discharge, follicles, decreased K sensation, dendrites (HZV = no bulbs, stuck on), K NV, disciform keratitis, interstitial keratitis, trabeculitis, ARN/PORN - recurrent erosions
- acanthomeba
- tx HSV: PO acyclovir 400 3x/day, abx ointment to skin lesions to prevent bacterial superinfection
- tx symptoms: cycloplegic, cool compresses
- if stromal or disciform keratitis: pred gtts 6x/day w taper after epi defects heal
- if no improvement after 2wks: noncompliance vs. acanthomeba -> culture (viral culture medium + non nutrient agar with ecoli overlay) and stain (calcafluor white) -> PHMB if acanthomoeba
- tx typically successful but recurrences are common. PPx w antiviral may be beneficial
Stain for yeasts, fungi (mucor), parasitic (acanthomeba)
calcafluor white
DDx for acute angle closure
- eval
- mgmt
- AACG: angle closure, PAS, hyerpopia, FHx, dim light, h/o inflammation
- NVG: NVA, NVI, DM, OIS
- phacomorphic glaucoma w zonular weakening: trauma, PXF, marfan’s
- choroidal effusion: topamax, buckle, excess laser
- aqueous misdirection: surgery
- eval extent of damage: IOP, K edema, glaucomaflecken (picture), nerve pulsation and cupping, ischemia (CRVO, CRAO)
- if choroidal effusion: IOP gtts, steroids, mydriatics
- if aqueous misdirection: IOP gtts, mydriatics -> open posterior capsule if pseudophakic, laser vitreous phase through PI if phakic -> vitrectomy
Mgmt of adenoviral conjunctivitis (including EKC)
-frequent hand washing: contagious until hyperemia and tearing resolves
-cool tears
-if itching: antihistamine
-if subepithelial infiltrates: mild steroids and follow for resolution
-if persistent past 14days, culture for chlamydia
Blebitis
- ddx
- eval
- mgmt
- nodular scleritis / episcleritis: h/o inflammatory (RA, lupus, GPA), h/o infectious (syphilis / TB / lyme)
- bleb related endophthalmitis: vitritis
- grade the blebitis: Siedel for leaks
–1: localized purulence in bleb
–2: AC reaction
–3: +vitritis = endophthalmitis - grade 1: most likely staph so ocuflox q1h
- grade 2: ocuflox or vanc/tobra q30min + PF after 24hrs of improvement
- grade 3: tap/culture/inject vanco + ceftaz
- Followed daily until resolution; guarded prognosis depending on severity
- counsel re endophthalmitis and bleb failure
- description
- ddx
- eval
- mgmt
- beaten bronze; answer shows K guttata - different terminologies (beaten bronze usually refers to ICE while guttata indicates Fuchs) but similar appearance
- Fuch’s Endothelial Dystrophy: worse in the morning and improves by evening, painless
- Pseudophakic bullous keratopathy: CEIOL + bullae, painful
- Congenital hereditary Endothelial Dystrophy: AR, onset at birth, +nystagmus and epithelial edema, no pain/photophobia, not progressive
- Posterior Polymorphous dystrophy (PPMD): AD, onset after 1yo, wide presentation can include pain, cloudy stroma decreasing vision, glaucoma. Progressive
- Chandler Syndrome / ICE if unilateral
- all K dystrophies: microcystic edema, pachymetry, specular microscopy
hx: onset, progression, sxs (pain, worse in AM, unilateral vs. bilateral), RFs (FHx, prior CEIOL)
exam:
-VA and IOP
-SLE: K bullae / d folds / edema / guttata / fibrosis
testing: pachymetry and specular microscopy
Mgmt:
- muro to manage edema
- lower IOP if elevated to reduce K edema but avoid dorz given endo dysfunction
- if ruptured bullae: abx + bcl
- if severe: PK, DSEK or DMEK
Counsel:
- some forms are genetic thus recommend exams for family members
- painless unless bullae develops with subsequent epithelial rupture
- slowly progressive; counsel re CEIOL
ICE
- pathophysiology
- 3 entities
- ddx
- eval
- mgmt
- what glc meds to avoid?
- ?herpes -> abnormal endo cloning -> reversal of light dark pattern.
All sporadic and unilateral:
-iris nevus = cogan reese: pigmented iris nodules produced by contracting endo membrane
-chandler: silvery endo cells w k edema (prompt picture)
-essential iris atrophy: abnormal endo spread onto surface of the iris -> atrophy
ddx:
- PPMD (answer pic): inherited and bilateral, vesicles or bands on specular microscopy
- Axenfeld Rieger: glaucoma, hypodontia, mandibular hypoplasia, redundant periumbilical skin
- Aniridia: glaucoma
Eval:
-hx: onset, progression, sxs (pain, VA, ?bilateral), RFs (FHx, herpes)
-exam: VA, IOP, gonio, CDR, K edema, K endo, iris nevus / atrophy, hypodontia, mandibular hypoplsai, redundant periumbilical skin
-testing: pachy for edema, specular microscopy (bright borders), RNFL, HVF
Mgmt:
-IOP gtts, but avoid xlt 2/2 uveitis, CAI 2/2 endo dysfunction, tube
-muro for edema
-if severe, PK
lens subluxation vs. dislocation
subluxation = partial
dislocation = free floating in the vitreous
Lens subluxation:
ddx
eval
mgmt
- trauma
- Marfan’s: superotemporal lens
– FHx
– tall, kyphoscoliosis, long fingers, Aortic aneurysms/dissection and other heart defects -> warrants ppx abx prior to surgery to prevent endocarditis
– increased risk of retinal detachment - homocystinuria: inferonasal lens
– tall, scoliosis, chest deformities, mental retardation, seizures, thrombotic events under general anesthesia
– nitro-prusside test - Weill-Marchesani: microspherophakia (picture)
– short, short fingers, heart defects
– ADAMTS10
–amblyogenic high myopia due to lens - PXF
– look for deposits
- Syphilis
– RPR and VDRL
Eval:
-hx: onset, progression, sxs (VA, monocular diplopia), RFs(Marfan’s, homocystinuria, FHx, syphilis)
-exam: features of ddx, MRx
Mgmt
- if asx: observe
- if sx: glasses / contacts -> CEIOL / aphakic lenses
- if IOP: gtts, LPI for any pupillary block
- Referral for medical management of Marfan/Homocystinuria/Syphilis including genetic counseling
Signs and symptoms of syphilis: systemic and congenital and ocular
tests
systemic:
- primary: painless chancres
- secondary: rash on palm and soles
- tertiary: cardiovascular and neuro syphilis
- congenital: saddle nose deformity / frontal bossing / hutchinson teeth
ocular:
- primary: interstitial keratitis
- secondary/tertiary/latent: panuveitis
tests:
- RPR / VDRL
- FTA-abs
- Warthin starry stain on path for spirochetes
PXF
- how to describe desposits
- ddx for fibrillary deposits
- eval
- 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
Traumatic hyphema
-ddx
-eval
-mgmt
- 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
Purulent K ulcer
- ddx and what to look for
- mgmt
- 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
pain
-description
- ddx
- eval
- mgmt
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
chemical burns
- eval
- mgmt
- complications
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
-description
-ddx
-eval
-mgmt
-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)
description
ddx and eval
mgmt
-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
ddx
eval
testing
mgmt
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
congenital K opacification: ddx
STUMPED
sclerocornea (prompt pic): cycloplegic refraction
trauma
ulcer
metabolic (mucopolysaccharidosis - Hurler’s, Scheie)
peter’s anomaly
endothelial dystrophy (CHED, answer picture)
dermoid
Peter’s anomaly
- eval
- mgmt
- counseling
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
Iris mass
-description
-ddx
-eval
-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
Iris melanoma
- mgmt
- counselling
- 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
primary met sites for
- uveal melanoma
- conj melanoma
Uveal: liver > lung and bone
Conj: head and neck lymph nodes
34F 1 wk out from refractive surgery, pain + decreased VA
-description
-ddx
-eval
- 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
DLK
- grading
- mgmt
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
NVI
-ddx
features of OIS
workup
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
Mgmt of OIS
- 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
Neurotrophic keratopathy
ddx
eval
mgmt
-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
ddx
eval
mgmt
-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)
ddx
eval
mgmt
-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
low IOP after glaucoma surgery
ddx (vs. high IOP)
eval
mgmt
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.
Ciliary body melanoma
ddx
eval
mgmt
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
young child
-Staph Marginal Keratitis
–reaction to staph antigens: peripheral stromal infiltrates +/- epi break / ulcers
–abx for underlying staph infection
–mild steroids to reduce inflammation
how to tell if conj vs. episcleral vs. scleral vessel?
conj: mobile and blanches
episcleral: immobile but blanches
scleral: immobile and does not blanch
Management of descemetocele
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
young patient with cataract
ddx
trauma (sectoral)
DM (snowflake, prompt pic)
steroids
uveitis
myotonic dystrophy (xmas tree)
Cu (sunflower, answer pic)
atopic dermatitis (anterior subcapsular)
DDX for iron line on K
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)
Management of epithelial downgrowth
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
mgmt for behcet’s
- 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
What is PCO
how to minimize
contraindications to YAG
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
mgmt of scleromalacia perforans = necrotizing scleritis
- 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
% of anterior uveitis that is idiopathic
50%
mgmt of episcleritis
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)
mgmt of anterior uveitis
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
mgmt of weill marchesani
atropine
LPI -> if still block, lensectomy
glaucoma management
mgmt of pellucid
hard contact lens to maximize vision
cross linking
no eye rubbing
if pending perf -> crescent lamellar keratectomy
test and mgmt and counsel for juvenile xanthogranuloma
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)
