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Flashcards in Cornea Deck (111):
1

What's a fleischer ring

Base of cone in KC

2

Bacteria that penetrate the corneal epithelium

Cornyeabacterium
Aegyptius (hemophilia)
Nisseria
Acanthamoeba
Listeria
Shigella

3

What's a stocker line

Head of ptyregium (sTock = pTyregium)

4

What's a Ferry's line

Adjacent to filtering bleb (Ferry = Filtering)

5

What's a Hudson - Stahli line

Horizontal line at lower 1/3 of cornea. Normal aging (stAhli = Age)

6

DDx of prominent corneal nerves

GRAFIK PENDANT

- congenital Glaucoma
- Refsum
- Acanthamoeba, amyloid
- Fuch's
- Ichthyosis
- KC

- failed PK
- mEn 2b
- neurofibromatosis
- Dry eyes, Drugs
- Aging
- Leprosy (not sure why this is N)
- Trauma

7

Membranes

(SnM = sjs, neisseria give membranes)

SJS
Neisseria

Strep pyogenes
Diphtheria

8

Pseudomembranes

EKC, HSV
OCP, GVHD
Chalmydia
Ligneous
Kawasaki

9

Conj vessel anneurysms

Fabry's dz
Sentinel vessels to underlying melanoma
Ataxia telangiectasia
SWS
Sickle cell
DM
Gangliosidosis

10

Angular blepharitis

Moraxella, staph

11

Phlyctenules

TB
Staph

Candida, rosacea, HSV

Type IV hypersensitivity

12

Types of chalmydia

A-C Trachoma
D--K STD

13

Signs of trachoma

"Hey FATSO" (ironic because most people with trachoma are malnournished :(

Herbert pits
Follicles sup>inf
Arlt's line (cicatrizing conjunctiva)
Trichiasis
Superior pannus, superior papillae
Opacification of cornea

14

DDx of SPK

Eyelids
- eyelid malposition
- poor eyelid closure
- trichiasis

Poor secretion of tears
- Primary (Sjogren)
- Secondary due to inflammation (Sarcoid infiltration of lacrimal gland)
- Secondary due to drops (anti-cholinergics, anti-histamines)

Inflammation
- infections
- blepharitis
- CL use
- BAK, drop toxicity

15

DDx of dendrites

HSV
VZV
Acanthamoeba
Healing abrasion
CL trauma

16

Pre-auricular lymph nodes

Parinaud's oculo-glandular
EKC
HSV
Gonorrhea, chlamydia
Trachoma
Lid cellulitis/dacryoadenitis
Newcastle

17

Definition of Parinaud's oculo-glandular syndrome

GRANULOMATOUS follicular conjunctivitis with regional lymphadenopathy

18

Disciform keratitis ddx

HSV
VZV
early PBK

19

Acanthamoeba rx

Brolene
PHMB
Chlorhexidine
Neomycin
Ketoconazole
Doxy (?)

20

Gonorrhea rx

IV ceftriaxone + bacitracin ointment/vigamox gtts
Co-treat for chlamydia

21

Chalmydia rx

Erythro oral + ongt
Doxy/azithro oral
Find and treat sexual partners

22

Parinauds bugs

SS, TT, ABC

Syphillis
Sporotrichosis

TB
Tularemia

Actinomyces
Bartonella Henslae
Coccidiomycosis

Ricksettia
LGV

23

Acute follicular conjunctivitis

Infectious
- Newcastle (lasts 1 week)
- viral (EKC, HSV, VZV)
- bacterial (chlamydia, staph, strep)

Immune
- hayfever
- allergy to drops

24

Chronic follicular conjunctivitis

Infectious
- Viral (EKC, HSV, VZV)
- bacterial (chalmydia, staph, strep)
- Parinaud's
- trachoma

Immune
- hayfever
- allergy to drops

25

Papillary conjunctivitis

- Trachoma
- VKC (giant)
- SLK (fine)
- Floppy eyelid
- mucous fishing syndrome
- blepharitis

26

GPC ddx

- CL (mostly RGP)
- suture
- prosthesis
- other FB
- VKC
- atopic

27

Keratinization of conj

Vitamin A
Squamous tumors
Chronic irritation
trachoma
OCP, SJS

28

Nummular keratitis

HSV, VZV
Lyme
Others...

29

Keratitis with vestibular symptoms

Cogan's
PAN
Syphillis
Wegener's
Sarcoid
VKH/SO
CPA tumor

30

Chronic unilateral conjunctivitis

Lid malposition
Gtts
Bacterial or viral conjunctivitis
Parinaud's
Inflammatory (episcleritis, scleritis, or AC inflammation)
OCP/SJS

31

Inflammatory conj nodules

Phlyctenule
Ptyregium
Squamous papilloma, CIN, or SCC
Trauma
Pyogenic granuloma
Epidermal inclusion cyst
Dermoid, lipodermoid
Nodular scleritis, episcleritis

32

Filamentary keratitis

Basically the same ddx as dry eye

Eyelids
- eyelid malposition
- poor eyelid closure

Poor secretion of tears
- Primary (Sjogren)
- Secondary due to inflammation (Sarcoid infiltration of lacrimal gland)
- Secondary due to drops (anti-cholinergics, anti-histamines)

Inflammation
- infections
- blepharitis
- CL use
- VKC

Infections:
- HSV, EKC, VZV

33

Cicatricial conjunctivitis

DAIT

Drugs
- many drops
- SJS

Autoimmune
- OCP
- VKC
- Allergy
- sarcoid

Infectious
- trachoma
- EKC, HSV, VZV
- any other infections

Trauma
- chemical
- mechanical
- post-surgery

34

Congenital cloudy cornea

G-STUMPED (don't forget the G!!)

Congenital glaucoma
Sclero-cornea
Trauma
Ulcer
MPS (Hurler, Scheie)
Peter's anomaly or anterior segment dysgenesis
Endothelial dz (CHED, PPMD)
Dermoid cyst

35

Corneal pannus

CL use
Trauma (chemical, mechanical)
HSV, other infectious keratitis
Blepharitis
Ptyregium

36

Corneal crystals

Cystinosis
Schnyder's crystalline dystrophy (assoc with systemic high cholesterol)
Lattice degen (amyloid)
Infectious crystalline keratopathy (strep viridans)
Multiple myeloma
Gout (uric acid crystals)

37

Keratoconus - associations

Eye rubbing
Down's
Floppy eyelids
Dry eye, blepharitis
Atopy, vernal
LCA

38

Blue sclera

Nevus of Ota
Deep nevus/melanoma
Thinned sclera (scleromalacia, necrotizing scleritis)
Connective tissue dz (Ehler's Danlos, RA, osteogenesis imperfecta)

39

Leukoplakia

Vit A deficiency (Bitot spots)
Squamous papilloma, CIN, SCC
Ptyregium, pinguecula

40

Spontaneous breaks in DM

Trauma (usually vertical for forceps)
Congenital glaucoma (Haab striae, usually horizontal)
Vogt striae (concentric to cone in KC)

Hydrops from KC

41

Spontaneous hyphema - adults and kids

Both:
- bleeding diathesis
- trauma
- after intra-ocular surgery

Kids:
- Juvenile xanthogranuloma
- RB
- Leukemia

Adults:
- Fuch's hetereochromic iridocyclitis
- NVI/A
- Iris nevus/melanoma
- anticoagulants

42

Diffuse KP

NGAU
GAU

Fuch's heterochromic iridocyclitis
Infectious keratitis
Endophthalmitis
PK rejection

43

Verticellata

"C-FAIC"

Chlorpromazine
Fabry's disease
Amiodarone
Indomethacin
Chloroquine

44

HSV vs VZV epithelial keratitis

HSV:
- dendritis
- terminal bulbs
- bed stains with fluorescein
- edges stain with rose bengal or lissamine green

VZV:
- may be pseudo-dendrites
- no terminal bulbs
- minimal staining

45

Copper deposits in cornea

Kayser Fleischer ring
Chalcosis

46

Kayser Fleischer ring

Wilson's dz
Copper IOFB
Primary biliary cirrhosis
Multiple myeloma
Lymphoma, leukemia

47

Guttata ddx

Old age (Hassle Henle bodies)
Fuch's
old KP
pigment from PDS
Interstitial keratitis
Macular corneal dystrophy

48

How deep is an LRI

600 um (75% thickness?)

49

Salmon patch ddx

Lymphoma, lymphoid hyperplasia
Amyloid
Sarcoid
Vascular tumor (cap hemangioma)
Amelanotic nevus

50

Scleritis - risk of untreated dz

DEATH. 25% die in 5 years from systemic disease in necrotizing scleritis

Local:
- scleral thinning and perforation

51

Scleritis - causes

Idiopathic
SLE
RA
Wegener's
GCA
B27+
PAN
Crohn's
Infectious (TB, syphillis, HSV, leprosy, HZV)

52

How do you treat scleritis

Systemic rx needed:

- NSAID if mild
- steroid if more severe
- may need immunosuppression

Sub-tenon steroid is contraindicated (may increase risk of perforation)

53

Corneal hypoesthesia ddx

HSV, HZV, acanthamoeba
Corneal trauma, surgery, PK, Lasik
CN V palsy (trauma, tumor, surgery)
Congenital (Riley Day)
Toxic (chemical burns, crack cocaine use)

54

Conj melanoma can come from what (and relative %)

From Pam - 67%
from nevus - 25%
de novo - 10%

20-30% of conj pam can become malignant (?)

55

Neonatal conjunctivitis causes

Viral: HSV
Bacterial: gonorrhea, chlamydia, staph, strep, e coli, etc
Chemical: silver nitrate

56

DDx of interstitial keratitis

In kenya, cogan saw two laughing hyenas making love

Cogan
Syphillis
TB
Lyme
HSV
Measles/Mumps
LGV, leischmeniasis

57

Signs of penetrating ocular trauma

Seidel +ve
Shallow AC
Peaked pupil
Iris-K touch in a focal area
Extruded eye contents
360 degree sub-conj hemorrhage
Low IOP
Lens capsule defect
Acute lens opacity

58

What is Giemsa stain for

Fungi
Acanthamoeba
Chlamydia
HSV

59

What is Gomori stain for

Fungi
Acanthamoeba

60

What is PAS stain for

Anything with a basement membrane

61

For a corneal ulcer, what plates/media do you want

Gram stain slides
Blood agar (most bacteria)
Chocolate agar (Hemophilus, Neisseria)
Saborrhaud's (fungi)
Thioglycolate broth (anaerobes)
Non-nutrient agar with e coli overlay (acanthamoeba)
Lowenstein-Jensen (mycobacteria)

62

How do you classify fungi with examples. What drug is each group most sensitive to

Molds vs yeast
Yeast are septated or non septated

Molds (CC) = cryptococcus, candida. Rx with ampho-B
Septated yeast (FA) = fusarium, aspergillus. Rx with natamycin
Non-septated yeast (MR) = mucor, rhizopus. Rx with ampho-B

All can be treated with the conazoles.

63

What do you treat dapsone with? What do you have to check first?

OCP or leprosy
Check G6PD first

64

Who gets infectious crystalline keratopathy?

After PK with chronic steroid use.
Rx with vanco

65

Levels of evidence

Systematic review with meta analysis
RCT
Cohort studies
Case series
Case report
Expert opinion

66

Band keratopathy - local and systemic causes

Local:
- phthisis
- IK
- silicone oil
- uveitis

Systemic
- hypercalcemia
- vitamin D toxicity
- hyperparathyroid
- hypophosphatemia
- milk alkali syndrome
- renal failure
- sarcoidosis

67

Types of collagen

I - corneal stroma
II - vitreous
III - corneal stromal scars
IV - any basement membrane

68

What can you get from specular microscopy (3)

Endothelial cell count
Pleimorphism (variation in shapes)
Pleomegathism (variation in size)

69

Fluorescein vs rose bengal vs lissamine green

Fluorescein - epithelial defects
Rose / green - devitalized epithelium

70

Wilson's dz gives you what findings (ocular & systemic), and how to treat

Kayser Flesicher ring & sunflower cataract (same as chalcosis)
Systemic: tremor, dysarthria, ataxia

Rx with penicillamine

71

What sphingolipidoses give you a cherry red spot

Tay Sachs
Sandhoff

(Neimann pick gives you red spot, but it's a lipidosis)

72

What are the mucopolysacharidoses and what findings do they give you

All the H's and S's

Type I: Hurler, Schie - corneal changes
Type II: Hunter
Type III: San fillipo

All give RPE changes, but only type I give corneal changes too

73

What are the lipidoses and what do they give you

Fabry's - corneal verticellata
Gaucher, Neimann Pick - cherry red spot

74

Grades of chemical damage to cornea/limbus

I - limbus ok, mild epi defect
II - >1/3 limbal blanching. Mild stromal haze
III - >1/2 limbal defect, stromal haze obscuring iris
IV - complete limbal blanching, no view of AC

75

Dx criteria for Sjogren (4)

1. Dry eye (KCS)
2. Xerostomia (dry mouth, decreased parotid flow)
3. Labial biopsy
4. Evidence of systemic dz on blood work (RF, ANA, ANCA, etc)

76

How do you treat chemical exposure to the eye (immediate vs later vs late)

3 principals to any corneal damage: remove inciting factors, support surface healing, and prevent infection

1. flush, flush, flush. Use a q-tip to remove any particles from fornices.
2. Lubricate aggressively
3. Antibiotics, consider PF
4. Collagenase inhibitors (oral doxy, vitamin C)

If not helping:
- consider gunderson flap, amniotic membrane
- lyse symblepharon
- tarsorrhaphy

Long term:
- limbal stem cell transplant
- PK

77

Squamous tumors of the conj and how to treat them

Benign --> malignant:

1. Squamous papilloma: excise with cryo
2. CIN: excise with wide margins, cryo to edges, consider MMC/5FU
3. SCC: 4 mm margins. Cryo and MMC/5FU
4. Mucoepidermoid carcinoma: as SCC but may also need enuc or exenteration if extensive spread.

78

Compare PAM vs racial melanosis

Racial is congenital in darker skinned people. No chance of malignancy.

PAM is acquired. In lighter skin. 20-30% chance of malignancy - bx if becomes thickened. Otherwise watch it with photos.

79

How do you manage someone with suspected conj melanoma

Take photos
No touch excision with wide margins
Partial sclerectomy
Watch for recurrences (often amelanotic)

80

Vascular lesions of the conj

Cavernous hemangioma
Kaposi sarcoma
Lymphangioma

81

Describe BCC pathology

Nests of basaloid cells
peripheral pallisading
Nests pull away from surrounding tissue ("clefting")
Low cytoplasm
Few mitotic figures

82

Describe SCC pathology

Eosinophilic cells in nests and strands
Invade through BM into dermis
Intracellular bridges
+ mitotic figures

83

What is the inheritance pattern of corneal dystrophies (with exceptions)

All are AD except macular AR

84

What corneal dystrophies go to the limbus

M's: Macular and Meesman's

85

What corneal dystrophies have systemic associations

Lattice type 2 (Meratoja - systemic amyloid)
Schnyder's Crystalline dystrophy (high cholesterol in 1/3)

86

What stains for MPS

Alcian blue & colloidal iron
(remember because iron is also blue)

87

What stains for amyloid

Congo red & Crystal violent
(both are C, and red/violet are similar colours)

88

What stains for hyaline

Masson trichrome

89

Name 5 anterior corneal dystrophies

ABMD
Meesman's
Thiel Benke
Reis Buchler
Gelatinous drop like dystrophy

90

Name 8 stromal dystrophies

Macular
Granular
Lattice

CHSD
Schnyder's crystalline dystropher
Fleck dystrophy
Central cloudy dystrophy of francois
Avellino

91

Name 3 endothelial dystrophies

CHED
PPMD
Fuch's

92

What is each type of IgG responsible for

IgG - crosses placenta
IgM - primary immune response
IgA - in tears/secretions
IgD - in newborns
IgE - mast cells (atopy)

93

What are the useful HLA associations in ophthalmology

B27 - 4 things (AS, Reiters, psoriatic, IBD)
A29 - Birdshot
B51 - Behcet
DR4 - SO, VKH

94

PRK contraindications and risks

CI:
- thin cornea
- ectasia (KC, pellucid)
- unstable refraction
- dry eye
- current infection
- collagen vascular disease
- pregnancy
- keloids

Risks:
- ectasia
- corneal haze
- infectious keratitis
- recurrent corneal erosion
- glare
- haloes
- under/overcorrection/astigmatism

95

LASIK contraindications and risks

CI:
- thin cornea
- ectasia (KC, pellucid)
- unstable refraction
- dry eye
- current infection
- pregnancy
- connective tissue diseases

Risks:
- ectasia
- corneal haze
- infectious keratitis
- glare
- haloes
- under/overcorrection/astigmatism

Flap complications:
- buttonhole
- free flap
- flap dislocation (during or after surgery)
- interface haze
- epithelial ingrowth, fibrous downgrowth
- DLK

96

PK storage media

Moisture chamber @ 4 degrees
M-K medium
Dexol
Optisol (*best one)
Cryopreservation - forever

Discontinued: K-sol, corneal storage medium (CSM)

97

Describe epithelial ingrowth and when/how to treat

If advancing to visual axis, causing flap melt, or disloding the flap, raising the flap causing astigmatism, etc.

Raise the flap, irrigate/scrape out the cells, and replace the flap. Some people suture/glue the flap down. Some people scrape off the epithelium overlying the flap area where the ingrowth happened.

98

Features of VKC

"GLHT-SRK" (bad acryonym, sorry)

GPC
Limbal follicles
Horner-Trantas dots

Shield ulcers
Ropy mucous
Filamentary keratitis

99

Features of trachoma

"Hey FATSO"

Herbert pits
Follicles sup>inf
Arlt's line, cicatricing conjunctivitis
Trichiasis, lid malposition
Superior pannus, superior papillae
Opacification of the cornea

100

How to treat trachoma

Prevention: clean water, better facial hygiene
Treatment: acutely, can give antibiotics (azithro, doxy, erithro + ongt)
After the scarring has set in: lubrication, fix lid positions, fix trichiasis. Maybe cornea surgery for extensive scarring?

101

Contrast DLK vs infectious keratitis

DLK:
1-6 d after LASIK
Eye is quiet, not inflamed
Haze is grainy, like sand. Not dense or confluent
Va may be mildly affected or asymptomatic

Infection:
3-10 d after LASIK
angry, red eye with conj injection
pain, often decreased va
ac rxn, kp
visible infiltrate

102

What is Michaels & Zeuss stain for

OCP

103

When do you use glutaraldehyde for tissue fixation

EM for rhabdomyosarcoma - see cross striations

104

What are the 4 types of hypersensitivity and give examples of each

ACID

I - acute: hayfever, allergy to gtts, vernal, atopic, GPC
II - complement mediated: OCP, Moorens
III - immune complex deposition: SJS, marginal infiltrates, disciform, SEI
IV - delayed: VKH, SO, phlectenules, graft rxn, IK, granulomas

105

Features of SLK

Super conj: thick, redundant, injected, has PEE that stain with fluorescein or rose
Papillae of superior tarsus
Filamentary keratitis

Associated with thyroid in 50%
70% female

106

How to treat SLK

Attack the conj:
1 surgical resection
2 chemical cautery (silver nitrate solution, never use the stick... whatever the stick is?!?)
3 thermal cautery

lubricate
large bandage CL

107

PK rejection risks

Young age
Infectious etiology for PK
Non-compliance with therapy
Vascularization at the graft-host junction
Ongoing AC inflammation
Previous rejection

108

Signs of PK rejection

Stromal edema
Endothelial rejection line (Khodadoust line)
KP
AC rxn
High IOP

109

GVHD features

Dry eye (decreased production)
Cicatrication of the conj, symblepharon
Lid malpositions
Some drugs give optic neuritis (cyclosporine - resolves with discontinuation)

110

How to treat dry eye

Fix lid malposition
Lubricate (gtts, ongt)
Punctal plugs
BCL
serum drops
moisture chamber goggles
use humidifer at home
treat blepharitis (WC, scrubs, doxy)
restasis

111

How do stromal dystrophies present?

Macular - decreased va
Granular - asymptomatic, decreased va, or RCE
Lattice - decreased va