Friedman external dz/adnexa

Question 1

Lid lesion DDx

Answer 1

squamous cell carcinoma  (or SCC variant - keratoacanthoma)
BCC
Sebaceous cell carcinoma
inflamed actinic keratosis
tricholemmoma
Merkel cell tumor

Question 2

Merkel cell tumor

Answer 2

Merkel cell carcinoma Highly malignant with frequent metastases at presentation Fast-growing, violaceous,

Question 3

Keratoacnthoma Rx

Answer 3

complete excision of lesion

Question 4

Sebaceous cell carcinoma Rx

Answer 4

wide excsiion with frozen section and conjunctival map Bx

Exenteration - performed for orbital extension or pagetoid spread
XRT for palliation

Question 5

Scleritis DDx

Answer 5

Systemic assoc (50%)
30% have collagen vascular dz - RA, ankylosing spondylitis, SLE, polyarteritis nodosa, Wegener's, relapsing polychondritis

Other etiologies - herpes zoster, syphilis, TB, leprosy, gout, porphyria, idiopathic

Work-up: CBC with diff, RF/anti-CCP, ANA, ANCA, VDRL/RPR, FTA-ABS, PPD, CXR

Question 6

what dz causes anterior necrotizing scleritis w/o inflammation (scleromalacia perforans)?

Answer 6

RA

Question 7

signs of posterior scleritis

Answer 7

chorioretinal folds
serous RD
vitritis
ON edema
"T" sign - thickened sclera on B-scan U/S

Question 8

Conjunctival lesion DDx and next step

Answer 8

CIN (atypical cells confined to the epithelium w/o penetration of BM often @ limbus, usually no KNV)
lymphoid lesion
pterygium/pinguecula
papilloma
squamous cell carcinoma

Excisional Bx

Question 9

Rx for squamous cell carcinoma

Answer 9

Treatment?
Excision with 4mm margins & thin scleral flap
Treat base with alcohol
Treat margins with cryo
Topical interferon, MMC, 5-FU gtts if large

Gelatinous lesion
Location?
Interpalpebral zone near limbus

Question 10

Most common conjunctival tumor?

Answer 10

Squamous cell carcinoma

Question 11

Most common eyelid tumor?

Answer 11

Basal cell carcinoma

Question 12

Name medications that cause conjunctivitis?

Answer 12

Propine, Iopidine, Alphagan, Neomycin

Question 13

Conjunctival Squamous Papilloma - location and demographics, pathology

Answer 13

Location
Children?
fornix, multiple, pedunculated

Adults?
limbus, single, sessile

Viral association?
Children: HPV 6 & 11
Adults: HPV 16 & 18

Pathology?
Papillary fibrovascular fronds
Must excise in adults to differentiate from CIN
May recur in multiple sites

Question 14

Oncocytoma

Answer 14

Metaplasia of ductal & acinar cells of accessory lacrimal glands
Usu. pink lesion on caruncle
Pathology:
Large eosinophilic cells
Glandular spaces
Numerous mitochondria

Question 15

Pyogenic Granuloma

Answer 15

Fibrovascular tissue growth usu. over chalazion or conj surface surgery
Usu. fleshy lesion on palpebral conjunctiva
Pathology:
Small-caliber vasculature
Collagen stroma

Question 16

Entropion evaluation and types

Answer 16

lid tone (snapback test)
lower lid margin position (sagging)

cicatricial: scar excision with possible anterior lamellar resection/recession, tarsal fracture/graft or conjunctival/mucous membrane grafts
involutional: thermal cautery, quickert suture, horizontal or vertical lid shortening, lid

spastic -thermal cautery, botox injection, quickert suture, horizontal or vertical lid shortening, lid

Question 17

Follicular conjunctivitis DDx

Answer 17

virus (adenovirus, HSV)
chlamydia
molluscum
drug rxn

Question 18

True membrane conjunctivitis

Answer 18

strep
gonoccocus
croneybacterium
chemical burns

Question 19

conjunctivitis questions

Answer 19

H/o URI, anyone with eye infection?
CL?
had a sTD in past?

Question 20

conjunctivitis exam

Answer 20

preauricular lymphadenopathy
eyelid lesions
pseudomembrane on inferior tarsal conjunctiva
subconj hemorrhage
SEI in cornea

Question 21

chlamydia conjunctivitis path and Rx

Answer 21

path: basophilic cytoplasmic inclusion in epithelial cells

systemic and topical Abx with tetracycline or erythromycin
Rx all sexual partners

Question 22

Interstitial keratitis DDx

Answer 22

Diffuse infiltrate with thickened stroma
Regression leaves ghost vessels
Causes?
Syphilis (most common cause if bilateral)
Herpes simplex, herpes zoster
Tuberculosis, leprosy

Other casues: mumps, rubella, lepropsy, onchocerciasis, sarcoidosis, Cogan’s

Question 23

Interstitial keratitis Treatment?

Answer 23

Treatment? topical steroids

Question 24

Cogan’s syndrome?

Answer 24

Interstitial keratitis with hearing loss
Meniere’s like vestibular dysfunction
Associated with URI
Treatment? systemic steroids

Question 25

congenital syphilis findings

Answer 25

``` optic nerve atrophy salt and pepper fundus deafness notched teeth saddle nose sabre shins ```

Question 26

Acute dacryoadenitis

Answer 26

infection 2/2 staph, mumps, EBV, VZV, N. Gonorrhea Cx/gram stain of D/c - CBC with diff +/- blood Cx

Question 27

lacrimal gland tumors

Answer 27

50% lyphoproliferative or 50% epithelial >50% epithelial tumors are pleomorphic adenomas (benign mixed tumor) and 50% malignant (adenoid cystica carcinoma and malignant mixed tumros)

Question 28

lacrimal gland Rx (benign)

Answer 28

Complete en bloc excision w/o Bx 2/2 rupture of pseudocapsule can result in recurrence and malignant transformation.

Question 29

Basal Cell Carcinoma location and pathology

Answer 29

Most common eyelid malignancy More common on? Lower lid > medial canthus (worst Px 2/2 invasion of lacrimal drainage system)> upper lid > lateral canthus Pathology? Basal cell nests Peripheral palisades

Question 30

Basal Cell Carcinoma - two forms and Rx

Answer 30

Two forms? Nodular Most common Firm, raised, pearly Morpheaform Much more aggressive Firm, flat with indistinct borders Slender tendrils. pagetoid spread Treatment? Excision w/ Mohs’ surgery Rarely metastasize

Question 31

Sebaceous Carcinoma

Answer 31

Mimics chronic blepharitis or recurrent chalazion More common in upper lid where there are more meibomian glands Pathology? Foamy cytoplasm Pagetoid spread (intraepidermal spread of clusters of tumor cells) “skip lesions” Special stain? Oil red O stains lipid in cytoplasm (must be fresh/frozen, as paraffin embedding destroys lipids) Highly malignant

Question 32

Muir-Torre Syndrome?

Answer 32

Multiple sebaceous neoplasms Keratoacanthosis Visceral tumors (colon CA most common) Inheritance: AD

Question 33

Symblepharon DDx

Answer 33

``` chemical burn S-J syndrome OCP trachoma herpes zoster atopic keratoconjunctivis scleroderma GVH disease ```

Question 34

chemical injury grading

Answer 34

based on severity of cornea damage and ischemia

Question 35

Stevens Johnson Syndrome

Answer 35

Erythema multiforme major Type III immune hypersensitvity Usu. in young patients Caused by drugs (esp. antibiotics - sulfa, pencillin) or infection (mycoplasma, HSV, adenovirus, strep) Signs: Pseudomembranous conjunctivitis, symblepharon, trichiasis, severe dry eyes, corneal scarring/vascularization Treatment: Amniotic membrane, IV steroids Topical abx, lubrication, symblepharon lysis

Question 36

Mooren ulcer - Demographic/Signs

Answer 36

``` Idiopathic (?autoimmune) Inflammatory peripheral thinning Starts peripherally with leading undermined edge progressing circumferentially then centrally Painful; epithelium missing Perforation with minor trauma ```

Question 37

Mooren ulcer - types and treatment

Answer 37

2 types: 1: unilateral, older pts, slow progression 2: bilateral, West African males, rapid progression, most w/ coexisting parasitemia Treatment: excision of adjacent conjunctiva (lots of immune cells), steroids, CL, immunosuppressants

Question 38

Terrien Marginal Degeneration

Answer 38

``` Idiopathic Noninflammatory peripheral thinning Begins superiorly, slowly spreads circumferentially; with pannus Painless; epithelium intact Perforation rare High ATR astigmatism 2nd/3rd decade, progressive ``` Similar form in childhood: Fuchs superficial marginal keratitis

Question 39

How to differentiate Mooren from PUK?

Answer 39

Usu. autoimmune dx (e.g. RA) in PUK PUK involves sclera Treatment: underlying disease

Question 40

Reis-Buckler dystrophy

Answer 40

Honeycomb opacification of central cornea Painful erosions Inheritance? AD (Ch 5; BIGH3/TGFB1) Gene product? keratoepithelin Pathology? Bowman’s layer absent and replaced by thickened, “sawtooth” fibrocellular tissue EM shows? Rod-shaped bodies

Question 41

Thiel-Behnke dystrophy

Answer 41

Reis-Buckler type II Honeycomb opacification of central cornea EM shows? Curly fibers

Question 42

Meesmann Dystrophy

Answer 42

``` Inheritance? AD Onset in 1st decade Bilateral Often asymptomatic; erosions rare Pathology? Epithelial cells contain peculiar substance (PAS+ material) and epitheliail basement membrane is thickened ```

Question 43

Marginal keratolysis work-up

Answer 43

``` CBC with diff RF/anti-CCP ANA ANCA UA ```

Question 44

Primary acquired melanosis

Answer 44

Proliferation of melanocytes (pre=cancerous) No cysts (unlike nevus) may grown and involve cornea Usually middle-age to elderly white people If PAM + atypia, 46% risk for conjunctival melanoma

Question 45

Malignant melanoma

Answer 45

55% from PAM, 25% from nevus, 20% de novo Pagetoid spread May be amelanotic Treatment: “no touch” excision, freeze-thaw cryo to margins, alcohol to base Worse prognosis if? Caruncle, fornix, palpebral conj But better prognosis than cutaneous melanoma

Question 46

Keratoconus Dx

Answer 46

1) Central cornea power > 47.2 2) difference in cornea power between fellow eyes > 0.92 D 3) I-S value (difference between average inferior and superior cornea powers 3 mm from the center of the cornea): >1.4 D