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Flashcards in Cornea & external disease Deck (230):
1

atopic keratitis is associated with?

Anterior subcapsular

RA, SLE, Wegener

PAN, GCA, sarcoidosis

2

superior limbic keratoconjunctivitis associated to

CL wear and thyroid dysfunction

70% female

ages 30-50

recurrent for 1-10 years then resolves spontaneously

3

superior limbic keratitis treatment

large CL

4

epidemic keratoconjunctivitis

adenovirus 8 and 19

mostly bilateral

subepithelial infiltrates

membranes and pseudomembranes

5

what is this?

Q image thumb

conjunctival squamous papilloma

6

tell me about conj squamous papilloma

viral association

can happen in children or adults

in children HPV 6 and 11

in adults hPV 16 and 18

ust do biopsy to dif from CIN

may recurr in multiple sites

7

tell me about conj CIN (conj intraepithelial neoplasia)

usually at limbus,

plaque

fleshy

8

conjunctival pigmented lesions?

  • ocular melanocytosis
    • gray discoloraiton of sclera
    • mostly unilateral
    • predilection in Asians
    • can lead to uveal melanoma and malignant melanoma
    •  

 

  • PAM
    • pam w/o atypia
    • pam with atypia = 46% risk of conj melanoma

 

  • conjunctival malignant melanoma
    • 55% from pam
    • 25 % from nevus
    • 20% de novo
      • can be amelanotic
      • better prognosis than cutaneouworse prognosis if palpebral, fornix or caruncules

9

tell me about conj malig melanoma

conjunctival malignant melanoma

55% from pam

25 % from nevus

20% de novo

can be amelanotic

better prognosis than cutaneouworse prognosis if palpebral, fornix or caruncules

10

PK most commoon indications?

PBK 25%

KCN 15%

Fuchs 14%

 

cildren's ---Peter's anomaly

11

PK matching needed?

only ABO matching but no HLA matching

 

in children use small sized graft

12

corneal tissue storage?

  • Glycerin
  • 4 deg chamber (72 hrs)
  • Optisol; CSM (weeks)
  • Cryopreservation (months

13

what happens if the pk graft is oversized?

increased chance of rejection

decreased astigatism

increased AC depth

14

corneal transplant rejection can be of 2 types...

epithelial

endothelial

15

what s the chance of endothelial rejection in PK?

what is the % of clear corneas at 1 year?

pk due to what condition have worse orse prognosis?

  • 20%
  • 90%
  • 65% near at 1 year

------------------------------------

  • low risk corneas PK  success at 5 years is 95%
  • high risk recipient (peripheral NV) PK success is 65%
  • Rejection
    • Dx only if cornea has been clear for at least 2 weeks
    • corneal edema
    • K precipitates on graft
    • stromal infiltrates
    • epithelial rejection line
    • subepithelial infiltrates
    • Khodadoust line (photo)

 

 

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16

most important factor o LRI calcs?

patient's AGE!!!!!!!!

17

blue sclera DDX

Osteogenesis imperfecta

ehler danlos

distinguish from ocular melanosis and scleral thinning

18

causes of neurotrophic ulcer?

HSV or VZV

CN V palsy

topical anesthesic abuse

leprosy

19

enlarged corneal nerves?

 MEN II B

like men to be jaja

20

tell me about different iron k deposits

ALL LOCATED ON THE EPITHELIUM

  • stocker line on pterygium
  • fleisher ring = keratoconus
  • ferry line = filtering bleb
  • hudson stanli line = inferior cornea 

21

DDX of newborn corneal opacity?

STUMPED

S clerocornea

T rauma (forceps at birth)

Ulcer

M ucopolysacaridosis

P eters

Endothelial dyst (CHED)

Dermoid

Conenital glaucoma

22

dif between PBK and Fuchs

PBK-pseudophakic bullous keratopathy

BOTH are endothelial pathology

absent endothelium

DESCEMET is THICK in fuchs and normal on PBK

there is guttata in fuchs but no guttata in PBK

23

What are keratocytes?

  • They are modified fibroblasts
  • Fibroblasts are cells that produce collagen
  • So keratocytes are important in the corneal stroma
  • They are more abundant in the anterior stroma than in the posterior
  • Keratocytes decline with age

24

what are the different schirmer tests?

  • Basic secretion test!  

    Put topical anesthetic

    Blot the excess of fluid

    Read in 5 minutes

    <3mm is abnormal

    3-5mm equivocal

  • Schirmer I

    NO ANESTHESIA

    Blot excess fluid

    Read in 5 mins

    <5mm is abnormal

    5-10 equivocal

  • Schirmer II

    NO ANESTHESIA

    Blot excess fluid

    Insert paper strip

    Stimulate nasal mucosa!!!!

    Read in 2 mins!!!!

    <15mm abnormal

  • Phenol red-impregnated thread test

25

is schirmer test done with topical anesthesia?

  • NOOOOOO
  • shirmer is without anesthesia
  • the normal test that we do and think its schirmer its actually a BASCI SECRETION TEST
  • this is abnormal if <3mm in 5 mins

26

what is the difference between schirmer I and schirmer II?

  • both are without topical anesthesia
  • shirmer I is regular test normaly done
  • schirmer II is stimulating nasal mucosa
  • for this reason Schirmer I you read in 5 mins but Schirmer II in 2 mins as this is more uncomfortable
  •  

27

What is conductive keratoplasty?

  • Non-invasive procedure

    Uses radiofrequency

    To correct prebyopia and hyperopia

    With or wo astigmatism

    Can also be used to do lasik enhancements

    Gives heat  by radiofrequency in the peripheral cornea and cause CENTRAL CORNEA STEEPENING

    Used only for small amount of hyperopia correction

    DOES NOT CORRECT ASTIGMATISM

    Good to create monovision

    Not ok if astigmatism is over 0.75D

28

What is labrador keratopathy

  • Its also know as speroidal degeneration
  • Bilateral
  • Interpalpebral
  • Due to UV exposure
  • Does not affect vision
  • Treat with lubrication

29

What is Fraser syndrome

  • Autosomal recesive
  • Inherited syndrome
  • Mutaiton in FRAS1
  • Criptophthalmos
  • Micropenis
  • Criptorchidism
  • Malformations: ears, nose, larynx, kidneys

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30

what could this be?

Q image thumb

  • Frazier syndrome
  •  
  • Autosomal recesive
  • Inherited syndrome
  • Mutaiton in FRAS1
  • Criptophthalmos
  • Micropenis
  • Criptorchidism
  • Malformations: ears, nose, larynx, kidneys

31

name the types of conjunctivitis

1) allergic

2) infectious

3) due to medications

Allergic & infectious

 

  • Allergic
    • Atopic
      • Anterior sub-capsular cataract
      • Association with
      • RA, SLE
      • Wegener, PAN
      • GCA
      • Sarcoidosis,TB
      • HSV, VZV
    • Vernal
      • Cobblestone papillae
      • Horner-trantas dots
      • Shield ulcer
    • Ligneous Conjunctivitis
      • In children
      • Firm membrane + woody induration
      • Fibrin deposition
    • SLK superior-limbic keratoconjunctivitis
      • Associated with SCL wear & thyroid
      • 70% female
      • Age 30-50
      • Recurrent for 1-10 years
      • Treatment large CL, silver nitrate
  • Infectious
    • EKC Epidemic KC
      • Adenovirus 8 & 19
      • Mostly bilateral
      • Pre-auricular lymphadenopaty
      • Membranes and pseudomembranes
      • Sub-epithelial infiltrates
      • Hypopyon (rare)
    • Chlamydial conjunctivitis
      • Follicular
      • Treatment: tetracycline
    • Newcastle's disease
      • Unilateral
      • Follicular
      • Pre-auricular lymphadenopathy
      • By Paramyxovirus
      • Poultry handlers
      • Self-limited - lasts 1 week
  • Related to medications
    • Alphagan
    • Iopidine
    • Neomycin

32

name the 4 allergic conjunctivitis

Atopic

Vernal

Ligneous

SLK

33

which conjunctivitis is associated with anterior subcapsular cataracts?

Atopic

34

  • which conjunctivitis is associated with...
  • RA, SLE
  • Wegener, PAN
  • GCA
  • Sarcoidosis,TB
  • HSV, VZV

Atopic conjunctivitis

35

what is vernal conjunctivitis?

  • Vernal=spring
  • Seasonal recurring
  • In boys
  • Hx atopia
  • Type I and IV
  • Itching, mucoid d/cphotophobia
  • Blepharospasm
  • TWO FORMS
  • Palpebral
  • Limbal

36

what is the meaning of VERNAL?

fromthe spring

de la primavera

37

what is vernal conjunctivitis?

  • seasonal
  • from the spring
  • Itching, mucoid d/c photophobia
  • Blepharospasm

 

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38

what is this?

Q image thumb

vernal conjunctivitis

39

what is this?

Q image thumb

horner tantras dots

seen in vernal conjunctivitis

they are lumps of degenerated epithelial cells

40

what is Ligneous Conjunctivitis?

In children

Firm membrane + woody induration

Fibrin deposition

41

what is superio limbic keratitis SLK?

  • Associated with SCL wear & thyroid
  • 70% female
  • Age 30-50
  • Recurrent for 1-10 years
  • Treatment large CL, silver nitrate

42

what is EKC Epidemic KC?

  • Adenovirus 8 & 19
  • Mostly bilateral
  • Pre-auricular lymphadenopaty
  • Membranes and pseudomembranes
  • Sub-epithelial infiltrates
  • Hypopyon (rare)

43

what is Newcastle's disease?

  • infection of domestic poultry and other bird species
  • with virulent Newcastle disease virus (NDV).
  • worldwide problem
  • presents primarily as an acute respiratory disease, but depression, nervous manifestations, or diarrhea may be the predominant clinical form.

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44

how to differenciate viral from bacterial conjunctivitis?

Its not a clear cut

  • Viral
    • respiratory infection Hx
    • lymphadenopathy
    • Watery discharge
    • follicles mucoid discharge (nos so common)
  • Bacterial
    • can have watery discharge
      • can have follicles
      • watery discharpurulent, not pathodnomonic of disease
    •  

45

in general, What is a hypersensitivity reaction?

State in which the body reacts with an EXAGERATED immune response to a FOREIGN agent

46

What are the 4 types of hypersensitivity reactions?

I: ANAPHYLACTIC

  • Allergen (pollen, venom food, contaminated materials)
  • IgE
  • Mast cell degranulation & basophils
  • Release histamine, PGs, leukotrienes, serotonine
  • examples
  • Anaphylaxia, hay fever
  • ASTHMA
  • HIVES
  • Eczema

II: CYTOTOXIC

  • Antigen
  • Cytotoxic cells
  • IgG/IgM
  • Complement activation
  • Cell destruction
  • Examples:
  • Blood transfusion reactions
  • Autoimmune hemolytic anemia

III: immune-complex

  • Immune complex (antigen-antibody)
  • Different cells
  • Complement activation
  • Massive recruitment of neutrophils
  • Examples:
  • Glomerulonephritis
  • RA, SLE

IV: cell mediated

  • Antigen
  • Activated T cell H
  • Release cytokines
  • Activate Macrophages
  • Produce cellular damage
  • Examples:
  • Contact dermatitis
  • Tubercular lesions
  • GRAFT REJECTION
  • What are atopic people?
  • People that tent toproduce IgE responses (asthma, hay fever)

47

  • Anaphylaxia, hay fever
  • ASTHMA
  • HIVES
  • Eczema

ALL are examples of what hypersensitivity reaction

type I

48

  • Blood transfusion reactions
  • Autoimmune hemolytic anemia

ARE examples of what hypersensitivity reaction?

tye II

49

  • Glomerulonephritis
  • RA
  • SLE

ARE examples of what hypersensitivity reaction?

type III

50

  • Contact dermatitis
  • Tubercular lesions
  • GRAFT REJECTION

ALL ARE examples of what type of hypersensitivity reaciton?

type IV

51

What are atopic people?

People that tent to produce IgE responses (asthma, hay fever)

52

describe type I hypersensitivity?

  • Allergen (pollen, venom food, contaminated materials)
  • IgE
  • Mast cell degranulation & basophils
  • Release histamine, PGs, leukotrienes, serotonine
  • examples
    • Anaphylaxia, hay fever
    • ASTHMA
    • HIVES
    • Eczema

53

describe type II hypersensitivity reaction

  • Antigen
  • Cytotoxic cells
  • IgG/IgM
  • Complement activation
  • Cell destruction
  • Examples:
    • Blood transfusion reactions
    • Autoimmune hemolytic anemi

54

describe type III hypersensitivity reaction

  • Immune complex (antigen-antibody)
  • Different cells
  • Complement activation
  • Massive recruitment of neutrophils
  • Examples:
    • Glomerulonephritis
    • RA
    • SLE
    • Marginal keratitis

55

describe type IV hypersensitivity reaction

  • Antigen
  • Activated T cell H
  • Release cytokines
  • Activate Macrophages
  • Produce cellular damage
  • Examples:
    • Contact dermatitis
    • Tubercular lesions
    • GRAFT REJECTION

56

What is contact dermato blepharitis?

  • Reaction to cosmetics, medications or other substances
  • Type I - IgE immediate
  • Delayed 24-72 hours - type IV
  • Itching, erythema, swelling, conj redness, chemosis

57

What is atopic dermatitis

  • Chronic condition
  • In suceptible people
  • Begins in childhood
  • IgE
  • Presentation:
    • Pruritus
    • Skin lesions
    • Periorbital darkening
    • Ectropion
    • Choronic conjunctivitis
    • Erythematous rash or scally patches, dry skin
  • Family hx or PMH of asthma, hay fever, etc
  • Corneal ectasia
  • Keratoconus
  • Marginal pellucid degeneration

58

What is Hay fever?

  • Hay fever is Seasonal Seasonal  (its allergic rhinitis)
  • IgE
  • Type I
  • Allergen is typically Airborne
  • In contact with conjunctival mast cells
  • These patients usually have asthma or rhnitis
    • Itching is the hallmark
    • Mucoid discharge
    • Conj hyperemia
    • Eyelid swelling
  • Challenge test
  • Management
    • Cold compress
    • AT
    • Topical steroids
    • Topical nsaids
    • Mast-stabilizers
    • Systemic antihistamines

59

what is this?

Q image thumb

horner-tantras dots of VKC

60

VKC treatment?

  • Mast stabilizers
  • May need chronic use
  • Use mast stabilizers 2 weeks before the season
  • May need to move to cooler environment
  • Other tools for severe cases?
  • Steroids
  • Cyclosporine

61

What mutation causes Thiel-Behnke corneal dystrophy?

TGFB1

62

What is Thiel-Behnke corneal dystrophy? Inheritance? Mutation? Very similar disease? Characteristics?

  • Autosomal dominant
  • Mutation TGFB1 - produces keratoepithelin
  • Very similar to Ries-Bucklers (can only tell difference by electron microscopy - on TB you see CURLY fibers
  • Affects bowman layer
  • Causing honeycomb opacities at bowman level CENTRAL'
  • Causes recurrent erosions (more in reis-buckler)

63

What diseases are caused by TGFB1 and by UBIAD1?

TGFB1 - causes Thiel-Behnke and Ries-Bunklers

UBIAD1 - Schnyder corneal dystrophy

64

what are the stromal dystrophies?

  • there are 5 or 6 but only 3 important
    1. macular 
    2. granular
    3. lattice

65

WHAT IS THIS CORNEAL PATHOLOGY? STAINS WITH CONGO RED AND HAS AMYLOID

ITS LATTICE CORNEAL DYSTROPHY

66

what is this corneal pathology? 

stains with mason trichrome

rock candy like

its granular corneal dystrophy

hyaline deposits that stain

67

what is this corneal pathology?

Mason trichrome stain

anterior stromal hyaline deposits

Granular type 2 (Avellino)

68

what is this corneal pathology?

stains with alician blue

Macular corneal dyst

69

what is this corneal pathology?

oil red stain

cholesterol deposits

Schnyder

70

marylin monroe pnemonic is for what type of corneal dystrophies?

for the STROMAL

71

which are the main corneal stromal dystrophies?

macular

granular

lattice

72

which corneal dystrophies are AD and which AR?

  • only ONE AR (MaculAR)
  • all rest AD

73

what are the symptoms of corneal dystriphies?

bilateral

  • corneal erosions = tearing, redness, FBS
  • corneal deposits
  • corneal opacities

74

in corneal dystrophy what to associate if:

honeycomb

Thiel-biehkel

Ries buckler

 

75

alician blue in the cornea?

mucopolysaccharides

Macular dyst

La macula de Alicia

76

mason trichrome in the cornea?

hyaline materials

granular

77

congo red in the cornea

Amyloid 

Lattice dystrophy

78

cornea with..

  1. amyloid deposits
  2. hyaline deposits
  3. mucopolysacharides

  1. lattice
  2. granular
  3. macular

79

what are the associations of atopic conjunctivitis?

RA, SLE, Wegener, PAN, GCA

sarcoid, gout, TB, HSV, VZV

80

what kind of cataracts to you see in atopic keratoconjkunctoivits?

 

anterios sub capsular ASC

81

what to think if you see cobblestone papillae

or horner trantas dots

or the shield ulcer?

Q image thumb

vernal conjunctivitis

V for variable - seasonal

hot weather cities

 

82

what is this?

Q image thumb

LIGneous conjunctivitis

  • RARE, INHERITED
  • AUTOSOMAL RECESSIVE
  • PLG gene
  • CHRONIC
  • Recurrent
  • conjunctivitis
  • WOOD-FIRE fibrinous pseudomembranes on PALPEBRAL conjunctiva
  • may have association with systemic disease

83

wood-fire pseudomembranes in the palpebral conjunctiva?

its LIGneous conjunctivitis

  • inherited
  • autosomal recessive
  • in children
  •  

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84

what conjuncti vitis is associated with CL wear ot thyroid dysfunction?

SLK

superior limbic keratoconjunctivitis

70% female

ages 30-50

RECURRENT

tmt: large CL

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85

what is this?

Q image thumb

SLK

superior limbic keratoconjunctivitis

70% female

ages 30-50

RECURRENT

tmt: large CL

86

whic allergic conjunctivitis is ALL year and which Varies during seasons?

AKC ALL year Atopic

VKS Vernal Variable seasonal

87

which conjunctivitis is associated with Adenovirus 8 and 19?

EKC epidemic keratoconjunctivitis

Bilateral 90%

Pre-auricular lymphadenopathy

membranes & pseudomembranes

subepithelial infiltrates!!!!

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88

what to think if you see subepithelial infiltrates?

EKC

adenovirus 8 and 19

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89

what medications can cause conjunctivitis?

iopidine and Alphagan

also neomycin

90

what is newcastle disease?

  • unilateral
  • follicular conjunctivitis
  • preauricular lymphadenopathy
    • in poultry handlers (aves de corral gallinas)
    • paramixovirus
    • self limited in 1 week

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91

how to treat chlamydia conjunctivitis?

tetracycline

92

what is this?

Q image thumb

conjunctival squamous papilloma

  • in children :
    • fornix
    • multiple
    • pedunculated
  • adults
    • limbus
    • single
    • sessile
  • associated with virus
    • children HPV 6&11
    • Adults HPV 16&18
  • Path: papillary fibrovascular fronds

Tmt: excise  to make sure is not CIN

may recur

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93

whic are good and bad prognostic factors of conjunctival melanoma?

GOOD prognosis

  • epibilbar location

BAD prognosis

  • palpebral
  • orbital or scleral invasion
  • pagetoid spread
  • involvement of eyelid margin
  • foto is from a conjunctival melanoma epibulbar

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94

what is this?

Q image thumb

staphyloccocal marginal keratitis

  • its a PERIPHERAL sterile infiltrate
  • white small dot
  • produce by staphiloccoci toxine
  • usually in the setting of
    • chronic blepharitis
    • extended CL wear
    • in adults
  • Tmt:
    • antibiotic gtts: vigamox, ciloxan, tobramycin
    • erythromycin ointment bedtime

95

what is this corneal exam in a patient with severe ocular pain?

  • mooren's corneal ulcer
  • this is the idiopathic corneal ulcer
  • its very painful
  • its chronic
  • progressive

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96

what is this?

Q image thumb

salzman nodules

97

what is this?

Q image thumb

Terrien's marginal degeneration

 

98

what is this?

Q image thumb

crocodile shagreen

99

what is this?

Q image thumb

pellucid marginal degeneration

100

what are the main DDx to thing when you see peripheral corneal thinning?

think:

  • QUIET EYE
    • Terrien's marginal degeneration
    • Pellucid marginal degeneration
    • Furrow degeneration
    • Dellen
  • HOT EYE - be a detective
    • hypopion? ----> infectious ulcer
      • staphyl marginal keratitis
    • non-infectious----> autoimmune
      • look for RA, SLE, Wegener, vasculitis
      • Mooren's ulcer (unknown reason) -chronic, progressive and very painful, centripetal
      • Don't miss wegener because that can kill patient
      •  

101

how to differenciate PUK vs Mooren's by symptoms?

Q image thumb

you CAN'T

both have pain

both have peripheral thinning

PUK is unilateral and Mooren bilateral

photo is from Mooren's

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102

what is this?

if its unilateral and the patient has RA

Q image thumb

PUK

103

what is Terrien's marginal degeneration?

  • Painless
  • Non-inflammatory
  • Peripheral corneal thinning
  • NO ULCER
  • Starts superior and grows circumferentially around BUT NOT CENTRAL
  • Clear zone with vascularization between thinning and limbus

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104

what is pellucid corneal degeneration?

  • INFERIOR CORNEAL THINNING
  • Irregular against-the –rule astigmatism
  • Blurry visionn due to astigm but asymptomatic
  • Often confused with keratoconus
  • Bilateral
  • No inflammation
  • Normal epithelium
  • ABSENT or BROKEN BOWMAN
  • Crescent shaped
  • Gets super thin 20% of normal CCT
  • Slowly progressive over years
  • Never do lasik
  • 2nd-5th decade of life
  • Can coexist with keratoconus
  • Not hereditary
  • Management is with glasses or contact lenses only minority of 12% require PK (needs large 9mm button so too risky for neovascularization)

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105

what is this?

Q image thumb

salzman nodular degeneration

  • Rare
  • Non-inflammatory
  • Degeneration
  • More common in females
  • Bilateral 63%
  • Around age 60
  • Also due to absent or broken bowman
  • On exam
  • Superficial
  • Bluish-white 1-3mm
  • Raised lesions
  • In the peripheral cornea
  • Symptoms
  • Irritation and dryness
  • FBS
  • Decreased vision in advanced cases – astigmatism irreguar
  • Treatment: lubrication, cyclosporine and for some cases PTK

107

what is Mooren ulcer?

  • its an IDIOPATHIC peripheral corneal ulceration
  • PAINFUL!!!!!!!!!!!!!!! photophobia, tearing
  • Bilateral disease, RARE disease
  • Crescent-shaped peripheral corneal ulcer undermined central edge with EPI defect
  • Stromal melting
  • limbal inflammationcentripetal growth in 4-12 months
  • bed of furrow vascularized (furro=surco)
  • affects stroma never descemet
  • leaves opacification
  • NV on the ulcer but not beyond
  • HLA-DR-17
  • risk factors surgical or accidental trauma
  • RARE disease
  • histology: lymphocitic infiltration with neutrophils, Eo, plasma cells, mast cells

109

what is the DDx of a peripheral ulcer or thinning?

  • QUIET EYE
  • Terrien's marginal degeneration
  • Pellucid marginal degeneration
  • Furrow degeneration
  • Dellen
  • HOT EYE - be a detective, hypopion? ----> infectious ulcer
  • staphyl marginal keratitis
  • non-infectious (this is PUK)----> autoimmune – mostly UNILATERAL
  • look for RA, SLE, Wegener, vasculitis
  • Mooren's ulcer (unknown reason) -chronic, progressive and very painful, centripetal
  • Don't miss wegener because that can kill patient
  • PUK unilateral, autoimmune, sclera involved
  • Mooren bilateral, pain, idiopathic
  • Both have pain, epithelium loss, stromal melt

110

what is this in the setting of keratoconus?

Q image thumb

corneal hydrops

111

what is this clinical sign?

Q image thumb

rizutti sign

112

what is the brown line next to pterygium?

Q image thumb

stocker's line

114

peripheral corneal thinning in a quiet eye? DDx

 

  • Terrien's marginal degeneration
  • Pellucid marginal degeneration
  • Furrow degeneration
  • Dellen

117

if pellucid and terriens are both

quiet eye

focal corneal thinning

what is the difference?

pellucid is INFERIOR slowly progress

Terrien's starts SUPERIOR and goes circunferentially

 

118

what is the histologic findings that explains these:

keratoconus

ellucid

terrien?

abscence of Bowman's layer

120

is salzman more common in males or females?

in females

121

with what diseases is keratoconus associated?

  • Atopy
  • Down syndrome
  • LCA
  • Ehler’s Danlos
  • Eye rubbing
  • Sleep apnea
  • Flopy lid syndrome

122

what is the prevalence of keratoconus?

1 in 2K

123

what is keratoconus? where is the thinning?

  • Common corneal disorder
  • Central or paracentral (inferior thining)
  • Progressive
  • Thinning or steepening (inferior)
  • Causes irregular astigmatism
  • Bilateral but asymmetric

127

what is the difference between kaiser-fleischer ring and

Fleischer ring?

  • the kaiser-fleischer ring
    • in wilson's disease
    • cupper
  • the fleischer ring
    • in keratoconus
    • iron
  • BOTH are a brown ring but the one in keratoconus is around the cone (more central)

128

129

What is the difference between stromal and endothelial Herpes simplex keratitis?

  • Both give cloudy cornea
  • Stromal is autoimmune process in the cornea (AKA disciform keratitis)
    • Often neovascularization
    • Classified in
    • Necrotizing (epithelium also involved) - risk of corneal melt and perf
    • Non-necrotizing (immune or intersticial)
  • Endothelial is due to inflamation or infection from the virus.

    Treat with oral acyclovir!!!!!!!!!!!!!!

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130

What visual acuity tests are available for kids?

  • Teller AC
  • Allen cards
  • Tumbling E
  • HOTV cards
  • Crowding bars
  • Lea symbols
  • Allen cards

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132

what is this?

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staphyloccocal marginal keratitis

133

what is this?

mooren's corneal ulcer

this is the idiopathic corneal ulcer

its very painful

its chronic

progressive

AWFUL!

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134

what is this?

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salzman nodules

135

what is this?

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Terrien's marginal degeneration

 

136

what is this?

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crocodile shagreen

137

what is this?

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pellucid marginal degeneration

139

how to differenciate PUK vs Mooren's by symptoms?

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you CAN'T

both have pain

both have peripheral thinning

PUK is unilateral and Mooren bilateral

photo is from Mooren's

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140

Minimum residual bed after lasik?

250 microns

141

what is this?

if its unilateral and the patient has RA

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PUK

143

what is Terrien's marginal degeneration?

  • Painless
  • Non-inflammatory
  • Peripheral corneal thinning
  • NO ULCER
  • Starts superior and grows circumferentially around BUT NOT CENTRAL
  • Clear zone with vascularization between thinning and limbus

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144

what is pellucid corneal degeneration?

  • INFERIOR CORNEAL THINNING
  • Irregular against-the –rule astigmatism
  • Blurry visionn due to astigm but asymptomatic
  • Often confused with keratoconus
  • Bilateral
  • No inflammation
  • Normal epithelium
  • ABSENT or BROKEN BOWMAN
  • Crescent shaped
  • Gets super thin 20% of normal CCT
  • Slowly progressive over years
  • Never do lasik
  • 2nd-5th decade of life
  • Can coexist with keratoconus
  • Not hereditary
  • Management is with glasses or contact lenses only minority of 12% require PK (needs large 9mm button so too risky for neovascularization)

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147

what is this?

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salzman nodular degeneration

  • Rare
  • Non-inflammatory
  • Degeneration
  • More common in females
  • Bilateral 63%
  • Around age 60
  • Also due to absent or broken bowman
  • On exam
  • Superficial
  • Bluish-white 1-3mm
  • Raised lesions
  • In the peripheral cornea
  • Symptoms
  • Irritation and dryness
  • FBS
  • Decreased vision in advanced cases – astigmatism irreguar
  • Treatment: lubrication, cyclosporine and for some cases PTK

151

what is Mooren ulcer?

  • its an IDIOPATHIC peripheral corneal ulceration
  • PAINFUL!!!!!!!!!!!!!!! photophobia, tearing
  • Bilateral disease, RARE disease
  • Crescent-shaped peripheral corneal ulcer undermined central edge with EPI defect
  • Stromal melting
  • limbal inflammationcentripetal growth in 4-12 months
  • bed of furrow vascularized (furro=surco)
  • affects stroma never descemet
  • leaves opacification
  • NV on the ulcer but not beyond
  • HLA-DR-17
  • risk factors surgical or accidental trauma
  • RARE disease
  • histology: lymphocitic infiltration with neutrophils, Eo, plasma cells, mast cells

152

what is this in the setting of keratoconus?

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corneal hydrops

153

what is this clinical sign?

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rizutti sign

154

what is the brown line next to pterygium?

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stocker's line

156

what is the DDx of a peripheral ulcer or thinning?

  • QUIET EYE
  • Terrien's marginal degeneration
  • Pellucid marginal degeneration
  • Furrow degeneration
  • Dellen
  • HOT EYE - be a detective, hypopion? ----> infectious ulcer
  • staphyl marginal keratitis
  • non-infectious (this is PUK)----> autoimmune – mostly UNILATERAL
  • look for RA, SLE, Wegener, vasculitis
  • Mooren's ulcer (unknown reason) -chronic, progressive and very painful, centripetal
  • Don't miss wegener because that can kill patient
  • PUK unilateral, autoimmune, sclera involved
  • Mooren bilateral, pain, idiopathic
  • Both have pain, epithelium loss, stromal melt

158

peripheral corneal thinning in a quiet eye? DDx

 

  • Terrien's marginal degeneration
  • Pellucid marginal degeneration
  • Furrow degeneration
  • Dellen

161

if pellucid and terriens are both

quiet eye

focal corneal thinning

what is the difference?

pellucid is INFERIOR slowly progress

Terrien's starts SUPERIOR and goes circunferentially

 

162

what is the histologic findings that explains these:

keratoconus

ellucid

terrien?

abscence of Bowman's layer

164

is salzman more common in males or females?

in females

165

with what diseases is keratoconus associated?

  • Atopy
  • Down syndrome
  • LCA
  • Ehler’s Danlos
  • Eye rubbing
  • Sleep apnea
  • Flopy lid syndrome

166

what is the prevalence of keratoconus?

1 in 2K

167

what is keratoconus? where is the thinning?

  • Common corneal disorder
  • Central or paracentral (inferior thining)
  • Progressive
  • Thinning or steepening (inferior)
  • Causes irregular astigmatism
  • Bilateral but asymmetric

171

what is the difference between kaiser-fleischer ring and

Fleischer ring?

  • the kaiser-fleischer ring
    • in wilson's disease
    • cupper
  • the fleischer ring
    • in keratoconus
    • iron
  • BOTH are a brown ring but the one in keratoconus is around the cone (more central)

172

patinets with fuchs dystrophy have worse vision in the AM or PM?

  • in the AM worse vision due to increased corneal edema that occurs overnight
  • when the eyelids are closed there is increased hypoxia to the endothelium
  • during the day, tears evaporate and cornea dehydrates

 

173

what is PISK?

  • pressure induced stromal keratitis
    • its a LASIK complication
    • due to prolonged steroid use 10-20 days
    • causing fluid accumulation at the flap interface
    • IOP is falsely low
    • tmt: stop steroids
  • DLK - diffuse lamellar keratitis
    • early lasik complicaiton eraly EARLY
    • treat with steroids

174

what is the most common orbita lmethastasis in a woman?

from breast

(in men is prostate)

175

what isn conductive keratoplasty?

 

176

what is this leukoplakic lesion?

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this is conjunctival CIN intraepithelial neoplasia

  • premalignant lesion
  • no corneal neovasc
  • common location: limbus

Dont get confused with Squamous cell Carcinoma (see this card photo)

  • gelatinous
  • interpalpebral near limbus
  • this is the MOST COMMON conjunctival tumor

Don't get confused with Conjunctival Squamous Papilloma

  • this is BENIGN
  • virus associated

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177

which is the most common tumor of the

1) conjunctiva

2) eyelid?

1) conjunctiva most common: Squamous cell Carcinoma

2) eyelid most common: Basal cell carcinoma

Dr. W likes basal cell

178

what could this be?

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pyogenic granuloma

  • its fibrovascular tissue
  • over chalazion or sutures from sx

179

what is this?

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Oncocytoma

  • its a metaplasia of accessory lacrimal glands
  • at the caruncule
  • histo
    • large eosinophils
    • glandular spaces
    • mitochondria
    •  

180

if you see histology with Pagetoid spread... what do you think?

Pagetoid is BAD news

  • Pagetoid in histoology means
    • upward growth of deeper layers to the surface

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181

what ocular diseases occur in Oculodermal malanocytosis (nevus of the ota)

  • uveal melanoma
  • malignant melanoma
  • glaucoma - 10%
  • unilateral 95%
  • more in Asians

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182

malignant melanoma of the conjunctiva comes from?

  • 55% from PAM
  • 25% from nevus
  • 20% de novo

183

what are bad prognostic factors of  conjunctival melanoma?

  • location:
    • caruncule
    • fornix
    • palebral conj

BUT BETTER prognosis than cutaneous melanoma

184

how to treat conj melanoma?

no touch approach

excision, free-thaw cryo to margins

alcohol to base

185

epithelium has tight junctions? how often are cells replaced?

Does bowman regenerate?

  • yes tight junctions and replaced q 7-14 days
  • NO BOWMAN DOES NOT regenerate
  • Endothelium does not regenerate

 

186

what is the normal endothelial cell count in:

  1. birth
  2. children
  3. adults

  1. birth: 3800
  2. children: 3500
  3. adults: 2400

187

what s corneal thickness in the center and in the periphery?

central 520

periphery+40

188

what is the corneal water content?

what is the corneal innervation?

78% water!!!!

LONG POSTERIOR ciliary nerves

that is why epi abrasion hurts so much because they are LONG

189

corneal layer thicknesses?

in microns

  • Epi:    50
  • Bow:  10
  • Strom:   500-700
  • Desce:   5-15
  • Endo:      5

190

what is the size of a

microcornea

megalocornea

Microcornea

  • <10mm adults, <9mm newborns
  • uni or bilat
  • AD or sporadic
  • Associated to:
    • Ehlers-Danlos
    • Hyperopia
    • Angle closure

Megalocronea

  • >13mm adults >12 newborns
  • bilateral
  • X-linked
  • increased risk of glaucoma
  • associated with:
    • Down syndrome
    • marfan
    • alport
    • osteogenesis impoerfecta

 

191

what size fo cornea do you see in

down syndrome, marfan and alport?

megalocornea >13mm

192

what is the difference between

NANOphthalmos and MICROphthalmos

  • Microphthalmos
    • small DISORGANIZED eye
    • Assoc: PFV
  • Nanophthalmos:
    • small NORMAL eye
    • Associ:
      • hyperopia
      • angle closure
      • choroidal effusion

193

what is the risk of doing cataract sx in a Nanophthalmic eye?

risk of choroidal effusion (better do ECCE)

194

what is this?

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Bitot's spots

  • build-ups of keratin in the conjunctiva
  • oval, triangular or irregular shape

due to vit A defficiency

195

in short... what is ocular cicatricial Pemphigoid?

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  • OCP
    • cicatricial = scar
    • pemphigoid = blister or swelling
  • SYSTEMIC AUTOIMMUNE INFLAMMATORY
  • is an AUTOIMMUNE conjunctivitis
  • that lead to cicatrization of the conj
  • can lead to blindness
  • can affect other membranes, oral mucosa, esophagus vagina, etc
  • CHRONIC, SLOWLY PROGRESSIVE

196

what type of ocular hypersensitivity is OCP?

what are the symptoms?

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  • hypersensitivity type 2
  • symptoms
    • red aye, tearing
    • dry eye
    • itching, heavy eyelid, FS
    • photophobia
    • discharge

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197

how to treat OCP?

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systemic steroids

immunosupresants

198

DDX of of conjunctival scarring?

  • OCP
  • steven-johnson
  • GVHD
  • rosacea
  • trachoma

199

how do you diagnose OCP?

what hypersensitivity it is?

  • hypersensitivity type 2
  • diagnosis clinical confirmed by biopsy
    • conj or bucal mucosa
    • IgA deposits on basement membrane
    • clinic
      • dry eyes
      • symblepharon
      • trichiasis
      • corneal scarring
  • ITS A PATIENT WITH VERY VERY VERY BAD DRY EYES!!!!!!!!!!!!!!!!!!!!!!!!!!!!! SCARRING!!!!!!!!!!!!!!!!!
  • CORNEA HECHO PEDAZOS!!!!!!!!

200

OCP IS ASSOCIATED TO WHAT HLA?

ASSOCITAED TO ANY MEDICATIONS?

  • HLA-B12
  • dapsone
  • cyclophosphamide

201

what type of hypersensitivity is:

Steven-Johnson?

OCP?

  • Steven-Johnson is: type 3
  • OCP: type 2

Steven-Johnson AKA erythema multiforme

  • caused by drugs - antibiotics or infection

What can the ophthalmologist do?

  • amniotic membrane
  • IV steroids
  • lubrication, symblepharon lysis

202

What HAL associated with

1) OCP

2) Sjogrens

  1. OCP ------HLA-B12
  2. Sjogren------HLA-B8
    • shogren also Anti-La and Anti-Ro (la rola de Sjogren)

203

what antibodies are present in Sjogren?

la rola de Sjogren

Anti-Ro

Anti-La

204

  • patient with
    • lacrimal and parotid swelling
    • hx of TB or sarcoid or lymphoma/leukemia

Mikulicz syndrome

205

patient with

  • decreased tear production
  • slugish pupil
  • light near dissociation
  • hypersensitivity to pain

Riley Day Disease

206

in DES what happens to:

  1. osmolarity
  2. lysozyme
  3. lactoferrin

 

  1. osmolarity:   increased
  2. lysozyme:   decreased
  3. lactoferrin:   decreased

207

what nerves are involved in teariing reflex?

  • afferent:    V1 nasociliary branch
  • efferent:   parasympathetic

208

TEARS:

  • what is in the tears?
  • what antibodies?
  • what is the rate of production?

  • tears have lactoferrin and lysozymes
  • IgA, E, G, M (no D)
  • 2 microlit/min (same as aq humor)

209

what is the treatment of blepharitis?

•Artificial tears

•Lid hygiene

•Warm compress

•Doxycycline 100mg PO QD-BID (4-6wks only)

•Restasis (topical CsA) 1gtt BID

•Kineret (IL-I antagonist)

210

what is angular blepharitis?

blepharitis near canthi

caused by moraxella

211

what is the difference between an internal and external hordeolum?

both are cause by Staph Aureus

  • internal : meibomian glands
  • external: Zeiss glands (AKA stye)

Chalazion (both MG and Zeiss)

  • granulomatous - TOUTON GIANT cells

 

 

 

212

what cells form the granulomatous reaction of a chalazion?

TOUTON GIANT cells

213

what is this?

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its Thygeson's SPK

  • unknown etiology
  • its a SPK superficial punctate keratitis
    • bilateral
    • elevated oval corneal intraepithelial,
    • whitish-gray opacities
  • Chronic
  • Recurrent
  • symptoms
    • photophobia
    • tearing
    • FBS
    • pain, blurry vision

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214

when do you see ghost vessels in the cornea?

after intersticial keratitis

215

what are causes of intersticial keratitis?

  • syphilis
  • HSV
  • HZV
  • TB

216

what is cogan syndrome?

  • recurrent intersticial keratitis
  • hearing loss
  • fatigue
  • weight loss

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217

what are these growth media adequate for?

  • Blood agar
  • Thioglycolate
  • Sabouraud
  • Thayer-Martin
  • Chocolate

  • Blood agar:      aerobic
  • Thioglycolate:    anaerobics
  • Sabouraud:    fungus
  • Thayer-Martin:     Neisseria
  • Chocolate:    H.Influenza

218

what are some differences between HSV and VZV infection?

  1. dendritic lesions?
  2. iris atrophy?
  3. rash?
  4. laterality?
  5. Tmt?

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219

what to suspect in a patient with poor contact lens hygene that loves swimming pools?

what is the clinical picture and tmt?

  • suspect Acanthamoeba
  • VERY PAINFULL out of proportion!!!
    • lesion can look dendritic
    • central corneal infiltrate
    • enlarged corneal nerves
    • ring infiltrate in late stages
  • Due to cysts and trophozoites
  • Stains with CALCOFLUOR white
  • Tmt: chlorhexidine may need PKP

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220

what is the most common corneal yeast infection?

what is the most common filamentous K infection?

how do you treat them?

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  • yeast: candida >>>>>>>> Ampho B
  • filament: fusarium >>>>>>>>>>>>. Natamycin

221

what is Crystalline keratopathy?

  • due to excessive steroid use
  • subtle
  • minimal infiltrate
    • caused by Strep and candida

222

what is this?

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223

c-shape or crab-claw on topography?

pellucid marginal degeneration

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224

what is this?

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spheroidal degeneration

  • brown deposits in stroma
  • bilateral
  • INTERPALPEBRAL
  • males
  • due to UV exposure

225

name tthe epithelial dystrophies?

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226

what corneal pathology gives pain the morning?

Map dot fingerprint

227

name the corneal dystrophies

epithelial

stromal

endothelial

  • epithelial
    • meesman
    • ABMD
  • Bowmans
    • Reis-Buckler
    • Thiel-Behnke
  • stromal
    • anterior
      • Macular
      • granular
      • lattice
    • medial
      • Gelatinous
        • AR, rare
        • Amyoid
      • Schnyder crystalin
        • OIL RED
        • CENTRAL
        • recurrs after PK
      • Fleck dystrophy - unilateral non progressive
  • Endothelial
    • fuchs
      • central guttata
      • polymegatism, pleomorphism
      • sporadic
    • PPMD
      • endothelial cells behave like EPITHELIAL cells
      • similar to ICE
      • 14% have high IOP

228

what is the difference between Fuchs and PBK?

both have absent endothelium

but...

Fuchs: thick descemet and guttata

PBK: no thick descemet, no guttata

 

229

what is this corneal cloudiness in an infant?

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its CHED

  • Bilateral
  • congenital corneal edema
  • endothelium atrophic or absent
  • blueish ground glass cornea
  • 2-3 x nomral CCT
    • type 1
      • less common
      • at age 1-2
      • no nystagmus
      • photophobia, tearing, pain
      • slowly progressive
    • type 2
      • more common
      • present at birth
      • stationary
      • nystagmus
      • no photophobia or tearing

230

what is the main difference between CHED (endothelial) and CHSD (stromal)?

  • CHED has super thick corneas
  • CHSD has normal CCT

231

what are th emain causes for a claudy cornea in newborns?

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232

is mucopolysaccharidosis a cause of neonatal cloudy cornea?

yes

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233

what chromosome contains the gene PAX6 and what diseases are associated with this?

Aniridia

Peters anomaly

AD keratitis

234

which are the only 3 corneal dystrophies that are autosomal recessive?

MaculAR

Gelatinous droplike

Lattice (this can be AD also)

235

what is the name of the disease with alpha-galactosidase defficiency?

what is the inheritance?

features?

  • Fabry disease
  • X-linked (remember fabulous hunter)
  • ophthalmic:
    • cornea verticilatta
    • optic atrophy
    • posterior cataract
    • retiinal vessel tortuosity
  • systemic:
    • renal failure
    • psychomotor retardation
  • disgnosis: in urrine

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236

DDx of cornea verticillata?

  • Fabry disease
  • medications:
    • Amiodarone
    • iindomethacine
    • Phenotiazine
    • Chloroquine
    • hydroxicloroquine
    • chlorpromazine

237

what is the treatment for band keratopathy?

  • EDTA or
  • PTK

238

which disease has high cooper but low ceruloplasmin?

wilson's disease

Kaiser-fleischer ring

(located in Descemet)

239

what is the ferry line? in the eye :)

and the stocker line?

and the Fleischer ring?

  1. iron line next to filtering bleb
  2. iron line next to pterygium
  3. ring around cone in keratoconus

 

240

what is a neurotrophic ulcer?

what is the etiology?

 

  • Neurotrophic keratopathy is
    • degenerative disease
    • of corneal epithelium
      • from impaired corneal innervation
      • reduced corneal sensitivity
    • keratopathy, ulcers, perforation
  • Etiology
    • HSV, VZV
    • CN V palsy
    • topical anesthesic abuse
    • leprosy

241

name 2 diseases with blue sclera?

dont get confused to the scleraal thinnin in scleritis of RA or with ocular melanosis

Q image thumb

  • osteogenesis imperfecta
    • decrased collagen 1
    • fractures from minor trauma
  • Ehlers-Danlos disease (photo)
    • deffect in collagen synthesis
    • AR
    • also fx form minor trauma
    • hyperextensibility
    • cardiac abnormalities, AO diseation

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242

what is the most common readon of needing a PK in children and adults?

  • children:   Peter's anomaly
  • Adults
    • PBK   20%
    • KCN   15%
    • Fuchs    14%

243

what are corneal transplant Donor Contraindictaitons?

  • unknown cause of death
  • Lymphoma, HIV, Hepatitis, sepsis, CNS infecitons
  • corneal scars, pterygium, Fuchs
  • iris neoplasia

244

what kind of donor size to choose in children?

  • small button because the sclera is flaccid
  • this revents PAS or early suture removal

245

after PK who do you manage

epithellial rejection vs endothelial rejection?

  • epithelial: topical steroids
  • endothelial: topical + IV steroids????

246

after PK how many grafts are clear at 1 year?

how may of PK due to HSV?

  • 90% clear at 1 year
  • if due to HSV only 65%

247

what happens if you place a donor button that is oversized?

  • you increase the chances of rejection
  • although you have less astigmatismand deeper A/C

248

when doing lasik, is it better to have a superior or a nasal hinge flap?

nasal is better

the superior gives more dryness

249

name LASIK complications

  • DLK: irrigation and steroids, refloat flap
  • buttonhole: dont ablate, put flap back and then PRK

250

what is the effect on the cornea of

  1. INTACS
  2. thermokeratoplasty
  3. LRI

  1. intacs flatten cornea (good for myopia)
  2. thermokeratoplasty (steepen cornea - good for presbyopia gives monovision)
  3. flattens cornea
    • corrects 0.5- 3D
    • use only in regular astigmatism
    • incisions placed at the STEEP AXIS
    • effects depends on age and length
    • longer the more you correct 6mm is normal
    • two LRIs corrects more
    • depth is 450 to 600 microns

251

limbal relaxing incisions

  • how much astig can you correct with them?
  • where do you put the incisions?
  • how deep are the incisions?
  • how long are the incisions?
  • how many incisions?
  • factors that influence result?

  • flattens cornea
  • corrects 0.5- 3D
  • use only in regular astigmatism
  • incisions placed at the STEEP AXIS
  • effects depends on age and length
  • longer the more you correct 6mm is normal
  • two LRIs corrects more
  • depth is 450 to 600 microns

252

what is with the rule astigmatism?

  • remember axis and power are 90 degrees appart. For ex: if axis is at 180, the power is at 90
  • The power of a cylinder is 90 degrees away (on the meridian)
  • WITH the rule (remember 30 degree range so for 90 means 60-120) is in CHILDREN
    • the steeper curvature is vertical
    • eye is STEEPER in the VERTICAL meridian
    • this means there is
      • (+) power at 90 and
      • (-) power at 180
    • to correct this,
      • ADD more PLUS to HORIZONTAL meridian or
      • ADD more MINUS to VERTICAL

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253

what are signs of endothelial corneal rejection?

  • low risk corneas PK  success at 5 years is 95%
  • high risk recipient (peripheral NV) PK success is 65%
  • Rejection
  • Dx only if cornea has been clear for at least 2 weeks
  • corneal edema
  • K precipitates on graft
  • stromal infiltrates
  • epithelial rejection line
  • subepithelial infiltrates
  • Khodadoust line (photo)

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254

what os this in the exam of a patient s/p PL?

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its the Khodadoust line 

---------------------------------

  • low risk corneas PK  success at 5 years is 95%
  • high risk recipient (peripheral NV) PK success is 65%
  • Rejection
  • Dx only if cornea has been clear for at least 2 weeks
  • corneal edema
  • K precipitates on graft
  • stromal infiltrates
  • epithelial rejection line
  • subepithelial infiltrates
  • Khodadoust line (photo)

255

what are the 4 types of corneal tx rejection?

  • There are several forms of immune rejection including
  • ·        epithelial, 2%
    • o   line near engorged limbal vessels
    • o   with migration
    • o   line has lymphociytes
    • o   precedes endothelial rejection by weeks
  • ·        subepithelial, 1%
    • o   subepithelial infiltrates
    • o   precede endothelial rejection by weeks
  • ·        endothelial, 50%
    • o   the most common
    • o   corneal edema
    • o   KP on the graft
    • o   Kodacyous line
  • ·        mixed. 30%
  •