Signs and Symptoms

Question 1

Prolapsed orbital fat

Answer 1

Asymptomatic, unless causing lid malposition/exposure keratopathy

Question 2

Preseptal cellulitis

Answer 2

Entire eyelid edema, erythema, ptosis, warmth, no pain to mild tenderness, hard bump on eyelid. NO orbital congestion, no reduced vision, no fever

Question 3

Orbital cellulitis

Answer 3

Red eye, pain, decreased vision, headache, fever, general malaise, decreased colour vision, APD, proptosis, diplopia, pain on EOMs due to restriction

Question 4

Thyroid eye disease

Answer 4

Prominent eyes (u/l or b/l proptosis), chemosis, FBS, tearing, photophobia, pain, diplopia, decreased vision, colour vision loss, upper lid retraction (Dalrymple sign), lagophthalmos (dry eye), SPK, eyelid erythema and edema, conj injection and edema, EOM restriction, APD, IOP may be elevated.

Question 5

Thyroid eye disease grading system:

Answer 5

N - no signs or symptoms
O - only signs but no symptoms
S - soft tissue involvement (lid edema, chemosis, etc.)
P - proptosis
E - EOM involvement (IR usually affected first, IMSL)
C - corneal involvement (SPK, ulceration)
S - sight loss due to optic nerve compression

Question 6

Von Graefe sign

Answer 6

Upper eyelid lag during downgaze

Question 7

Kocher sign

Answer 7

Globe lag compared to lid movement when looking up

Question 8

Carotid Cavernous Fistula

Answer 8

Triad: chemosis, pulsatile proptosis, ocular bruit
Other signs - episcleral venous congestion, periorbital tissue swelling, elevated IOP, diplopia (from CN 3,4,6 palsy), loss of lid/face sensation on the affected side (CN5 palsy)

Question 9

Capillary hemangioma

Answer 9

Superficial vascular lesion (strawberry nevus) with rapid growth. Can cause proptosis and deprivation amblyopia if visual axis blocked.

Question 10

Cavernous hemangioma

Answer 10

Painless progressive blurry vision, u/l proptosis, possible diplopia, can lead to compressive optic neuropathy, choroidal folds, and hyperopic shift. Vascularized benign growth which CT will show as a well-defined intracranial mass that does not invade surrounding structures but may displace them.

Question 11

Dermoid cyst

Answer 11

Commonly located superior-temporally at the zygomaticofacial suture, painless, smooth palpable choriostoma comprised of a fibrous wall which encases sebaceous glands, sweat glands, and hair follicles. (Normal tissue in an abnormal location)
Diplopia, ptosis, proptosis can occur

Question 12

Neurofibroma

Answer 12

Benign, yellow-white tumour of astrocytes, usually in superior orbit, can be isolated, multiple, u/l or b/l

Question 13

Rhabdomyosarcoma

Answer 13

Rapid, bone-destructing tumour often superonasally, that causes progressive unilateral proptosis. Eyelid discolouration and edema. Headaches, sinusitis and nose bleeding if involving sinus.

Question 14

Neuroblastoma

Answer 14

Acute onset of u/l or b/l superior orbital mass, proptosis, and eyelid ecchymosis “raccoon eyes”. CT shows evidence of bony erosion

Question 15

Orbital pseudotumour / idiopathic orbital inflammatory syndrome

Answer 15

Acute “explosive” onset of unilateral pain, red eye, diplopia, swollen eyelids, blur/decreased vision. Bilateral involvement may occur in children (30% of cases) and half of affected children will have fever, nausea, vomiting.
Lid ptosis, periorbital swelling (hyperopic shift), lacrimal gland enlargement, u/l conjunctival chemosis, reduced corneal sensation, increased IOP on involved side, optic nerve swelling, EOM restrictions and proptosis.

Question 16

Tolosa-Hunt syndrome

Answer 16

Acute and painful exophthalmoplegia and diplopia due to ipsilateral palsies of CN3,4,6 and loss of sensory innervation due to damage to V1 and V2

Question 17

Phthisis bulbi

Answer 17

Shrinkage and atrophy of the globe as a result of trauma, infection, surgery, or advanced disease
Assoc w/hypotony, inflammation, blind eye

Question 18

Ocular rosacea

Answer 18

Redness, burning, FBS, ocular irritation, characterized by papules on the cheek and forehead with telangiectasia, rhinophyma, and facial flushing. Lid disease, MGD, blepharitis, hordeola, chalazia, OSD, SPK, corneal neo inferiorly, dry eye syndrome

Question 19

Contact dermatitis

Answer 19

Acute periorbital swelling, redness, itching, tearing, u/l or b/l erythema and crusting of the lid, significant conjunctival chemosis

Question 20

Ocular cicatricial pemphigoid

Answer 20

Sub-acute onset of nonspecific symptoms including redness, dryness, FBS, and/or decreased vision. Conj fibrosis, scarring (seen as fine white striae), bilateral symblepharon, ankyloblepharon, and stretched inferior fornices due to shortening of the conj tissue

Question 21

Stevens-Johnson syndrome

Answer 21

Acute - systemic prodrome of fever, malaise, headache, nausea, vomiting, followed by skin lesions (diffuse erythema or classic target/bulls eye, and papules on palms and soles), ocular lesions are severe bilateral diffuse conjunctivitis assoc. w/pseudomembranes, can progress to endophthalmitis in severe cases
Chronic - entropion, ectropion, trichiasis, meibomian gland damage, symblepharon, foreshortening or the fornices, conj keratinization, limbal stem cell damage, corneal pathology (scars, ulcers, perforation)

Question 22

Blepharitis

Answer 22

Often asymptomatic, may have blur that clears after blinking, burning, itching, FBS, tearing, crusting and mild discharge. Seborrheic blepharitis has oily, greasy scales with flaking, and more eyelash loss or misdirected growth compared to staph blepharitis which has more inflammation

Question 23

Chalazia

Answer 23

Hard painless immobile nodule without redness that is most commonly located on the upper lid, typically asymptomatic

Question 24

Hordeolum

Answer 24

Tender, red, warm area of focal swelling on lid

Question 25

Inclusion cyst

Answer 25

Congenital or acquired lesion (secondary to trauma or surgery) found on the lid and surrounding adnexal tissue that often appears white due to the accumulation of keratinous debris

Question 26

Milia

Answer 26

Acquired lesion found on the lid and surrounding skin that may appear white and is due to occlusion of sweat pores or pilosebaceous follicles

Question 27

Sebaceous cyst

Answer 27

Retention of fluid in glands of Zeis or retention of debris in the meibomian glands. Usually solitary smooth lesions that are yellow or opaque

Question 28

Ectropion

Answer 28

Exposure keratopathy, epiphora, brow ptosis

Question 29

Floppy Eyelid syndrome

Answer 29

Chronic bilateral red eyes in the morning often with mild mucus discharge. Chronic papillary conjunctivitis with loose upper lids that evert easily, PEK (50%), keratoconus

Question 30

Benign essential blepharospasm

Answer 30

Involuntary, sustained, repetitive bilateral twitching and/or forceful closure of the eyelids that is less common during sleep. Spasms of orbicularis oculi, procerus,and corrugator

Question 31

Basal cell carcinoma

Answer 31

Varies in appearance, most commonly presents as a shiny, firm pearly nodule with superficial telangiectasia. If not caught, can progress to central ulceration “rodent ulcer”. Most commonly on lower eyelid and medial canthus

Question 32

Squamous cell carcinoma

Answer 32

Variable presentations, often appear similar to BCC but WITHOUT surface telangiectasia, classically described as an erythematous plaque that appears rough, scaly, and/or ulcerated and may be flat or elevated. Most commonly located on the lower eyelid or lid margin

Question 33

Sebaceous gland carcinoma

Answer 33

Varies, the tumour is often hard and yellow. Assoc w/madarosis,thickened and red lid margins (most common on upper lid), and lymphadenopathy

Question 34

Malignant melanoma

Answer 34

Characteristics that increase suspicion: Asymmetry, Border irregularity, Colour differences (uneven pigmentation), Large diameter, Enlargement of the lesion
Most important prognostic factors are depth of invasion and size of the lesion

Question 35

Dacryoadenitis

Answer 35

Swelling of the outer 1/3 of the temporal upper eyelid (region near the lacrimal gland), acute - classically presents with an S-shaped ptosis, temporal upper eyelid pain, redness, swelling, preauricular lymphadenopathy, an occasional fever, and elevated WBC count. Chronic - presents as temporal upper lid swelling with less redness, swelling, and pain compared to acute. Chronic may lead to inferno nasal globe displacement and proptosis.

Question 36

Canaliculitis

Answer 36

Smouldering, unilateral red eye often unresponsive to antibiotics, often misdiagnosed as recurrent conjunctivitis. Tenderness over the nasal portion of the upper or lower eyelid, a swollen puncta “pouting puncta”, dacryoliths, and mucopurulent discharge that occurs with palpation over the lacrimal sac region

Question 37

Dacryocystitis

Answer 37

Swelling below the medial canthal tendon, (swelling above the medial canthal tendon is suspicious for lacrimal sac tumour), pain, often with crusting and tearing, occasional fever, prominent edema and tenderness over the lacrimal sac area. Typically more swelling and tenderness than canaliculitis.

Question 38

Nasolacrimal duct obstruction

Answer 38

Unilateral tearing, discharge, crusting, and recurrent conjunctivitis. Epiphora, mucus reflex from the puncta after compression of the lacrimal sac, medial lower eyelid erythema, and mild to no redness or tenderness around the puncta.

Question 39

Conjunctival cyst

Answer 39

common, benign, fluid-filled (typically clear) sac on the conjunctiva that may cause irritation, also referred to as an inclusion or retention cyst

Question 40

Conjunctival concretions

Answer 40

superficial, whitish-yellow deposits of mucous secretions and epithelial cells in the palpebral conjunctiva. Also called ocular lithiasis

Question 41

Conjunctival nevus

Answer 41

rare, benign proliferation of melanocytes that presents 10-20yo, typically unilateral, solitary, flat (or slightly elevated), freely mobile, occasionally non-pigmented (30%). Inclusion cysts within the lesion are diagnostic for a conj nevus. Most common location is the juxtalimbal area followed by plica and caruncle

Question 42

Primary Acquired Melanosis (PAM)

Answer 42

unilateral acquired pigmentation with indistinct margins, usually flat, benign but has premalignant potential, 30% progress to malignant melanoma. Nodular lesions with increased vascularity or growth are most suspicious. Biopsy!

Question 43

Conjunctival melanoma

Answer 43

uncontrolled proliferation of melanocytes, pigmented or non-pigmented, most arise from PAM, most suspicious factor is thickness/elevation

Question 44

Conjunctival intraepithelial neoplasia (CIN)

Answer 44

can vary, most commonly is a unilateral, elevated, gelatinous mass with neo, 95% found at limbus within interpalpebral fissure, “hair pin” vessels

Question 45

Conjunctival squamous cell carcinoma (SCC) / OSSN

Answer 45

rare, slow-growing, malignant tumor found at limbus, may involve adjacent cornea, commonly contains a feeder vessel

Question 46

Pyogenic granuloma

Answer 46

pedunculated, benign, red, vascular lesion of the palpebral conj that results from trauma, sx, chalazion, or other chronic irritation

Question 47

conjunctival granuloma

Answer 47

inflamed area (white, yellow, or brown) located within the conj stroma that results from retained foreign bodies, sx, trauma, infections, or assoc systemic conditions (sarcoid)
asymptomatic or FBS and irritation

Question 48

Simple bacterial conjunctivitis

Answer 48

acute onset of redness, usually begins in one eye then spreads to the other, FBS, mucopurulent discharge, PAL rare

Question 49

gonococcal conjunctivitis

Answer 49

hyperacute onset of severe purulent discharge, redness, FBS, chemosis often w/pseudomembranes, severe papillary reaction, (+) preauricular lymphadenopathy, tender and swollen eyelids. peripheral corneal ulceration in severe cases.

Question 50

adenoviral conjunctivitis

Answer 50

recent cold/URI, FBS, itching, burning, gritty feeling, serous discharge, diffuse hyperemia/redness, +PAL, lid edema, follicles and pseudomembranes.
PCF will also have fever and sore throat
And EKC will have bilateral central SEIs 2-3wks after infection onset and severe pain

Question 51

Molluscum contagiosum

Answer 51

single or multiple dome-shaped, umbilicated, waxy nodules located on the lid or lid margin. Rupture of nodule can lead to chronic follicular conjunctivitis and superficial pannus

Question 52

Allergic conjunctivitis

Answer 52

conj chemosis, papillae, itching, tearing, watery discharge (can be ropey)

Question 53

Vernal keratoconjunctivitis

Answer 53

intense itching, photophobia, ptosis, thick mucus discharge, initial outbreak most severe. bilateral prominent papillae, cobblestone papillae (upper palp conj) or Trantas dots on the limbus. Can have corneal involvement with PEK -> large erosions, and eventually shield ulcer

Question 54

Atopic keratoconjunctivitis

Answer 54

bilateral itching of eyelids, watery discharge, redness, photophobia, pain. Prominent outer eyelid (thickened, swollen), Dennie’s lines, “atopy shiners”, papillae are more prominent inferiorly, can lead to corneal neo, cataracts (10%), and KCN (from itching), symblepharon may also form in inferior fornices in severe cases and mimic OCP

Question 55

Follicular reaction

Answer 55

CHAT - chlamydia, herpes, adenovirus, toxicity

Question 56

papillae vs. follicles

Answer 56

papillae - inflamed areas of elevated conj that contain a central vessel, infiltration of eosinophils, mast cells, neutrophils and lymphocytes. non-specific sign of inflammation
follicles - avascular, white/gray nodules in tarsal and fornix conj, immature lymphocytes and macrophages in center of nodule, assoc. w/ CHAT

Question 57

GPC

Answer 57

itching, scant mucus discharge (early) or ropy mucus discharge (later), decreased CL wear time, photophobia. Mild to severe papillae of the upper palp. conj, ptosis, mucus in eye and on CL. papillae > 0.3mm in diameter, giant is >1.0mm when they coalesce

Question 58

Solution hypersensitivity/toxicity

Answer 58

recent switch to new solution, severe reactions most commonly to chlorhexidine or thimerosal, redness/burning after CL insertion, reduced CL wear time, follicular conjunctivitis, diffuse conj injection, diffuse SPK

Question 59

Corneal warpage

Answer 59

initially patients often report that vision is clear in CLs but blurry in glasses, also complain of ghost images or diplopia. irregular astigmatism, can mimic KCN (high riding lens causes inferior steepening of cornea over time)