MT2 Flashcards
(150 cards)
1
Q
Posner Schlossman Syndrome is a type of ________ glaucoma, thought to be from _________
A
inflammatory glaucoma
Herpes simplex etiology
2
Q
Posner Schlossman Syndrome affects who most likely?
A
males
young to middle aged
3
Q
6 ocular signs of Posner Schlossman Syndrome
A
- Unilateral
- Highly elevated IOP (40-60mmHg) which may cause corneal edema if >60mmHg
- Sentinel KPs
- Trace cells in the AC and stellate cells on the endo
- Severe pain, little photophobia
- Possible mid-dilated fixed pupil
4
Q
What will gonio views look like with Posner Schlossman Syndrome?
A
Angles will be wide open
5
Q
Lab tests for Posner Schlossman Syndrome
A
no lab testing - clinically dx with gonio (open angles)
6
Q
5 treatment options for Posner Schlossman Syndrome
A
1. Lower pressure: Topical BB (BID)
Add CAI if IOP extremely elevated
- Methazolamide 25-50 mg PO 2-3x/day
- Acetazolamide 500 mg PO (BID) )
Topical A2 agonist (TID)
Alphagan
Combo BB + A2A
- Treat trabeculitis with topical steroid (QID x 1 week)
- Oral antiviral tx for suspected HS etiology
Acyclovir 400 mg/5x/day (2g total) - Topical cycloplegics if symptomatic
Homatropine - Hyperosmotic agents if IOP dangerously high and can harm ONH → use for treating corneal edema
7
Q
Cause of phacolytic uveitis
A
lens proteins from mature/hypermature cataract cause a uveitis
8
Q
7 possible ocular signs of phacolytic uveitis
A
- elevated IOP → corneal edema if high enough
- Prominent/large cells in the AC and patches of cells stuck to lens surface
- Intense flare
- Hypopyon rare
- Decreased VA from cataract
- Pain, photophobia, severe injection
- Retinitis perivasculitis is possible
9
Q
Gonio presentation on lens induced uveitis
A
open angles
10
Q
4 treatment options for lens induced uveitis
A
- Reduce IOP: topical glaucoma meds. Oral meds if IOP is very high
- Topical steroids to ↓ inflammation
- Cycloplegics to shore up blood ocular barrier
- Immediate referral for cataract removal
11
Q
Cause of lens particle uveitis
A
#1 from cataract surgery → lens proteins cortex then blunt trauma or YAG laser
12
Q
4 possible ocular signs of lens particle uveitis
A
- Small fragments of lens cortex, particles in AC> PC
- High IOP (50+) → corneal edema if high enough
- High cells and flare → hypopyon possible e
- Persistent inflammation → pupillary block glaucoma and inflammatory membranes
13
Q
How does gonio appear with lens particle uveitis
A
open angles
possible synechiae
14
Q
How is lens particle uveitis clinically diagnosed?
A
post surgical/cataract removal
15
Q
3 treatment options for lens particle uveitis
A
- Reduce IOP: Topical/oral glaucoma meds (aqueous suppressants bc TM clogged)
- Topical steroids/cycloplegics
- Immediate referral for removal of lens particle from AC and prevent pupillary block glaucoma
16
Q
Cause of UGH syndrome
A
IOL induced uveitis
→ “uveitis, glaucoma, hyphema”
17
Q
7 possible ocular signs with UGH syndrome
A
- elevated IOPs (50+)
- KPs (gran and non-gran)
- AC chamber cells and cells on IOL
- Viritis possible
- CME possible
- Mal positioned haptics of IOL
- iris transillumination defects
18
Q
Treatment for UGH syndrome
A
refer back to surgeon
19
Q
Laser induced uveitis cause
A
1: YAG capsulotomy → shockwaves breakdown the blood ocular barrier
ALT or SLT
20
Q
2 ocular signs of laser induced uveitis
A
- cells with little flare
2. pseudophakia
21
Q
2 treatment options for laser induced uveitis
A
- Topical steroid (q4h)
- Topical cycloplegic (BID)
Usually resolves in 1 week
22
Q
What is the cause of intermediate uveitis/pars planitis?
A
idiopathic
*but consider SIMPLE
23
Q
Pars planets affect ______ year olds and ______ race
A
young adults (15-30yo)
no race predilection
Chronic
24
Q
7 possible ocular signs of pars planitis
A
- bilateral
- blurred vision and floaters without pain or photophobia
- Snowballs: 2-3+ cell in hyaloid space/anterior vitreous → spillover to AC and posterior vitreous → Coalesce into snowbanking in inferior era
- CME may develop due to chronic nature
- accommodation difficulties
- Synechiae
- Possible: PVD, vit heme, RD, retinal tears, peripapillary edema
25
What ddx's should be considered with intermediate uveitis?
```
S: sarcoidosis
I: IBD
M: MS
P: Pars Planitis
L: Lyme disease
E: Etc: Toxocariasis, TB, hep C
```
26
How is intermediate uveitis treated?
1. No treatment for 20/40 or better
2. If 20/40 or worse from CME:
- Topical steroids Q1-2h
- Periocular steroid
- Oral steroid 4-6 weeks
3. If steroids fail can try cryotherapy
4. Vitrectomy (pars plana)
5. Immunosuppressive agents
- cyclophosphamide
27
List the 8 types of posterior uveitis
1. toxoplasmosis
2. candidiasis uveitis
3. toxocariasis
4. TB choroiditis
5. presumed ocular histoplasmosis
6. coccidiomycosis
7. Sympathetic ophthalmia
8. VKH syndrome
28
Most common posterior uveitis
toxoplasmosis
29
Toxoplasmosis is caused by ________, commonly found in ______-
Intracellular protozoan (ingest oocyst)
found in cat hosts, raw/undercooked meat (lamb, pork), raw milk
30
Active form of toxoplasmosis is _____
inactive form of toxoplasmosis is ________
active: tachyzoite
inactive: bradyzoite
31
4 possible ocular signs of toxoplasmosis
1. blurred vision (vitritis)
2. Floaters without pain
3. white-yellow retinal lesion with hazy vitreous (headlights in the fog)
4. CME/CNVM for late signs
32
Acquired toxoplasmosis most commonly manifests in
AIDS patients
33
Acquired toxoplasmosis first attack usually occurs age _____
10-20 yo
34
Acquired toxoplasmosis systemic signs
1. cold like symptoms that persist over time (mono/rubella)
| 2. fever, malaise, HA, sore throat, myalgia, blurred vision
35
Congenital toxoplasmosis usually occurs when?
initial infection during pregnancy (2nd trimester)
36
Signs of congenital toxoplasmosis
3 C's: convulsions, calcifications, chorioretinitis
possible leukocoria with other eye usually unaffected
Hydrocephalus if early enough onset
*kid fails a school screening
37
ELISA results if toxoplasmosis is congenital vs. acquired
congenital: increase IgA, IgM
acquired: increased IgE/IgG
38
If CBC and platelets counts go below 100,000 what toxoplasmosis drugs should be reversed?
pyrimethamine
| folinic acid
39
If suspected toxoplasmosis in immunosuppressed patient what tests should be performed. Why?
HIV test + CT scan because immunocompromised patients can have brain affected too
40
Treatment options for toxoplasmosis
If far enough in the periphery and the pt is healthy and not immunocompromised, you can leave it alone. But if the pt is immunocompromised or the lesion is near the ONH, Blood vessel, or macula, you have to treat them ! 4-6 week drug therapies:
1.
- Topical cycloplegics BID or QD
- Topical steroid (q1h to q6h) for anterior seg
2. Active lesions 2-3D of ONH or macula
-Pyrimethamine 75 mg PO then 25 mg PO BID
Denies folic acid to toxo
Don’t take vitamins with folic acid!
Don’t give to pregnant/breastfeeding women (substitute clindamycin)
-Folinic acid 10 mg PO BID x 2 weeks
Helps build neutrophils, stops secondary pyrimethamine effects (neutropenia)
-Sulfadiazine 2 gm PO then 1 g PO QID
Pulls away folic acid from toxo via PABA
3. Few days after #2, can start Prednisone (20-80 mg PO) to reduce vitritis if toxo near macula or retina
Don’t use systemic steroids on immunocompromised
4. Clindamycin (150-300 mg PO QID) (solo tx or with #2)
Warn of pseudomembranous colitis (bloody stools)
Can sub tetracycline (250 mg PO QID)
5. Alternative tx: Bactrim w/ or w/o clindamycin and prednisone
Reduce recurrence pre-cataract surgery
6. Topical steroids (Q1h-Q6h) for AC reaction
7. Topical cycloplegics agents (BID or QD) for AC reaction
8. Adjunct cryotherapy, laser, or vitrectomy though not very effective
41
Potential causes of candidiasis uveitis
1. fungemia (candidiasis) association
2. cancer patients
3. IV drug abuse
4. HIV /severely immunocompromised patients
5. Long term steroids
6. Long term hemodialysis/catheter use
42
Possible signs of candidiasis uveitis
1. Plaque like ulcerations (lesions) on oral mucosa
2. decreased VA
3. Floaters (#1 complaint)
4. Pain and photophobia
5. multifocal yellow-white retinal lesions (1 to several DD in size)
6. "cotton balls" in the vitreous
7. vitreal haze
8. Abscesses
9. Possible retinal hemes w/ or w/ pale centers and RD
10. Possible hypopyon
43
5 treatments for candidiasis uveitis
1. Hospitalization recommended, notify infectious dz specialist
2. Fluconazole 200-400 mg PO QD
- Also: mitraconozole, voriconazole, caspofungin 70, itraconazole, or micafungal work
3. Intravitreal amphotericin B for resistant cases
4. Topical cycloplegic agent (BID or QD) if spillover of cells
5. Topical and/or oral anti glaucoma meds
44
Possible causes of tuberculosis choroiditis
reactivation of dormant TB bacilli = HIV individuals, recent immigrants, hx of exposure to TB
45
Sex predilection in tuberculosis choroiditis
men > women
46
High risk groups for tuberculosis choroiditis
1. Native hawaiians
2. Pacific Islanders
3. Asians
4 American indians
5. Alaska natives
47
#1 ocular complaint with candidiasis uveitis
floaters
48
Signs of tuberculosis choroiditis
1. Long term cough, bronchitis, dyspnea, bloody sputum, fever, weight loss, hemoptysis, drenching night sweats
2. (+) PPD sign → chest x-ray
3. Phlyctenular keratoconjunctivitis
4. Granulomatous uveitis
5. Serpiginous like Choroiditis: multifocal discrete lesions
6. Dalen Fuchs nodules: yellow-white small choroidal lesions (elevations in back of eye)
7. Retinal vasculitis and exudative RD, CME
8. Concomitant anterior uveitis/involvement
49
What are dale Fuchs nodules?
granulomatous lesions that occur in lacrimal gland, conj, mainly in the lungs as well as in the choroid and seen in TB. In the choroid they appear as elevated yellowish nodules surrounded by RPE.
50
3 Treatment options for TB choroiditis
1. Anti-TB treatment (ATT) for choroiditis
Isoniazid/pyrazinamide/ethambutol/rifampicin
2. Systemic corticosteroids in conjunction with ATT to prevent damage to ocular tissues from inflammatory response
3. Topical cycloplegics and topical corticosteroids if anterior uveitis + ATT
51
What are the possible side effects of ethambutol use?
Optic neuritis, R/G dyschromatopsia, central scotoma, disc edema and optic atrophy
Side effects occur in 1-3%
52
Toxocariasis tends to affect _______ at age ______
males > females
| age 7.5
53
Causes of toxocariasis choroiditis
embryonate eggs of toxocara roundworm parasite:
1. Eating food/soil contaminated with dog feces
2. history of eating pica (geophagia) in SE US
54
Signs of initial toxocariasis infection
Initial infection: fever, cough, skin lesions, convulsions
55
9 possible ocular signs of toxocariasis choroiditis
1. Near always unilateral when ocular
2. Leukocoria (granuloma)
3. Elevated white retinal lesion seen at PP
4. Fibrous (tractional) band from lesion to ONH
5. Vision based on possible macular scarring
6. Endophthalmitis
7. Severe vitritis (#1 cause of vision loss) → diffuse endopthalmitisis, macular retinal granuloma, peripheral retinal choroidal granulomas
8. Cataracts from inflammation, steroid use
9. Tractional RD
10. glaucoma
11. Mac scarring
56
Most reliable test and readily available for evaluation of antibodies directed against toxocariasis
ELISA
57
3 treatment options fo toxocariasis
1. Anthelmintic drugs → but death of worm may cause worse inflammation (controversial to use!**)
- Thiabendazole
- Diethylcarbamazine
- Albendazole
2. Prednisone for secondary anti inflammatory response
- Periocular steroids if active
- Oral steroids if active (but problematic giving kids pills)
3. Pars plana vitrectomy to get rid of traction bands
58
Presumed ocular histoplasmosis most frequently occurs in what areas
river valley areas of "histo belt"
- mississippi
- ohio, Missouri, etc
59
POH patient profile
Whites
20-50yo
HLA-B7
60
POH causes
from fungal spores transmitted by chickens, bat droppings
61
Systemic signs of POH
summer flu: acute pneumonitis, chronic form, progressive acute form
may get calcifications in lung, liver, spleen
62
Ocular signs of POH
1. triad: multiple (4-8) choroidal histo spots, peripapillary atrophy (from underlying choroiditis), maculopathy (sight threatening, choroid looks like ground glass)
2. CLEAR vitreous***
3. Mac swelling and blood → Macular disciform scar
4. RPE detachments probable
5. Hemorrhage lesions in 63% of people
6. CSR in 10%
63
PPA + histo in the posterior pole increases likelihood of macular disease to _____%
40%
64
If you suspect macular disease with POH, what 2 tests should you perform?
1. OCT
| 2. Amsler grid
65
this test may activate macular histoplasmosis
Histoplasmin skin test
66
Treatments for POH
1. Anti-VegF treatment
Avastin (1st line), Lucentin, Eyelea
2. Treatments not done anymore
- Photodynamic therapy
- Submacular surgery
- Macular translocation
3. Corticosteroids: old treatment → anti-angiogenesis
67
Coccidiomycosis is endemic where?
southwest US
| "valley/desert fever"
68
Systemic signs of Coccidiomycosis
Pulmonary infection (75%): fever, pleuritic, productive cough, erythema nodosum
Associated URI
69
Ocular signs of Coccidiomycosis
1. choroiditis
2. Phylctenulosis
3. Episcleral, conjunctival, and lid lesions
4. multiple yellow-white chorioretinal lesions with pigmented borders "punched out lesions"
70
Treatments for coccidiomycosis
1. Antifungals for choroiditis
- Fluconazole/ ketoconazole/ Itraconazole for mild cases
- Ketoconazole is FDA approved
- 400 mg/day minimum recommended
2. Topical steroids for phlyctenular conjunctivitis
Pred Forte 1% Q3h
```
3. For systemic disease or first trimester of pregnancy
Amphotericin B (IV)
```
71
Cause of sympathetic ophthalmia
#1: penetrating trauma (usually w/in 4-8weeks)
surgeries
72
patient profile for sympathetic ophthalmia
1. white men
| 2. 6-80 yo
73
How does sympathetic ophthalmia occur in both eyes
Harm to 1 eye causes other to react:
| Trauma → ocular protein antigen in melanocyte→ peripheral antigen cell to spleen → attacks both eyes → granulomatous
74
Ocular presentation for sympathetic ophthalmia
1. large mutton fat KPs with severe AC reaction
2. small, depigmented nodules (dalen fuchs) at live of RPE
3. PAS, Neo of iris, cataracts, exudative RD, papillitis
75
Patient profile for Vogt-Koyanagi-Harada Syndrome
1. highly pigmented groups (Japanese, American Indian, Hispanic, Latin)
2. Women, 20-50yo
76
Signs with Vogt Koyanagi Syndrome
Bilateral anterior uveitis, vitiligo, poliosis, alopecia, dysacusis
77
Harada Disease signs
Posterior uveitis, CSF pleocytosis, exudative RD
78
Stage 1 of VKH
Prodrome syndrome:
| - HA, orbital pain, stiff neck, vertigo, fever, tinnitus (75% have auditory sympt.), CSF lymphocytosis (>80%)
79
Stage 2 of VKH
Acute Uveitic:
-acute bilateral blurring of vision, ocular pain from ciliary spasm, multifocal choroiditis (diffuse, bilateral, granulomatous), multifocal detachment of sensory retina, Dalen Fuchs nodules, exudative RDs
80
Stage 3 of VKH
Convalescent:
| vitiligo (10-63%) (suglura’s sign), alopecia(60%), poliosis. Uveal depigmentation (sunset glow sign)
81
Stage 4 of VKH
Chronic recurrent:
| mainly anterior uveitis, but 43% recur w/i 3mo, 52% w/i 6mo
82
Ocular presentation of VKH syndrome
1. blurry vision
2. floaters
3. photophobia
4. pain
5. redness bilateral
6. massive Dellen Fuchs nodules
7. large areas of exudation with accompanying HA
8. stiff neck
9. vomiting
10. fever, nausea, malaise
83
VKH treatment options
1. Topical steroids for uveitis
Pred Forte 1% Q1h
2. Oral steroids for back of eye
Prednisone 60-80 mg PO QD with antacid or histamine H2 blocker (Ranitidine)
3. Topical cycloplegic (QD or BID) for pain
4. Treat specific neurologic deficits as they occur
5. If above unsuccessful, immunosuppressive agents
6. Patient should be hospitalized, monitor weekly
7. New tx philosophy (2017)
- Systemic corticosteroids + Cellcept for initial treatment with acute VKH uveitis as it may prevent sunset glow fundus
84
etiology of iris nevus
Benign
| Pigmented lesion in iris stroma
85
Iris nevus signs
should be flat and not involve the pupil
mild ectropion uvea may be present
Composed to minimal disruption of the stroma
86
treatment for an iris nevus
none - monitor and photodocument
87
Most common type of uveal tract tumor
malignant iris tumor
88
Signs of a malignant iris tumor
1. Pigmented or nonpigmented
2. Rarely has heterochromia with secondary glaucoma
3. Vascularity variable
4. Pupillary distortion, irdocyclitis, glaucoma are complications
89
Treatment for a malignant iris tumor
1. Medical care
- Periodic slit lamp exam
- Photographic documentation
- Ultrasonographic biomicroscopy (UBM)
2. Surgical care
- Sector iridectomy for small tumors
- Iridocyclectomy for tumors invading the angle
- Radioactive plaque (brachytherapy) or external beam irradiation
- Enucleation
90
Metastatic tumors of the uveal tract are primary from what 3 sites?
1. Breast
2. Lung
3. Prostate
91
Metastatic tumors of the uveal tract signs
1. pink or yellow mass
92
patient profile of ciliary body melanoma
1. peak age of 55 years old
| 2. whites, particularly of N European descent
93
Signs of a ciliary boy melanoma
1. Blurred vision from increased unilateral astigmatism, VF loss, and pain from glaucoma or iridocyclitis
2. Floaters
3. Severe ocular pain
4. Dilated episcleral blood vessels (sentinel vessels) feeding the metabolically active tumor and visible through conj overlying it
5. Unexplained low IOP as compared to fellow eye (diff of 5 mmHg or more is dx)
6. May grow into AC, pushing on iris root
94
Treatment options for ciliary body melanoma
1. Enucleation is the classic approach to posterior ciliary body melanomas
2. External beam irradiation with either protons or helium ions
3. Plaque brachytherapy alternative to enucleation for medium-size posterior uveal melanomas <10 mm height and 15 mm diameter
95
____% of choroidal nevi turn into melanomas
1%
96
Patient profile for choroidal nevi
1. history of skin cancers or other cancers
2. Caucasians
3. Moley type person
97
Ocular signs of choroidal nevus
1. brown gray mass with thickness <2 mm
2. Overyling drusen
3. RPE atrophy
4. Subretinal fluid/orange pigment overlying tumor
98
TFSOM-UHHD
3+ risk factors met means _______
<3 risk factors met means _______
3+: refer for eval
<3: photo document, return in 6 months
```
TFSOMUHHD - “to find small ocular melanoma using helpful hints daily”. If theres 3 or more of these, REFER
Thickness - is it elevated
Fluid
Sx
Orange pigment
Margin within 3 mm of disk
Ultrasonographic hollowness
Absence of halo
Absence of drusen
```
99
Treatment for choroidal nevus
1. Management determined by risk of transforming into a choroidal melanoma
2. Using TFSOM-UHHD risk factors:
- 0 risks: 3% chance of metastatic growth at 5 years
- 1-2 risk factors: monitor every 4-6 months
- During 1st year, monitor at least 2x
100
Choroidal melanoma:
- if caught early/small _____% will be alive at 5 years
- if caught medium size ____% will be alive at 5 years
- if caught large size ____% will be at 5 years
early: 90%
medium: 65-75%
large: 45%
101
Patient profile for choroidal melanoma
Caucasian
Light colored eyes
Fair skin
Propensity to burn when exposed to UV light
Rare in blacks or dark pigmented individuals
Increased risk with number of nevi and freckles
102
Signs of a choroidal melanoma
1. blurred vision
2. paracentral scotoma
3. painless and progressive field loss
4. floaters
5. severe ocular pain
6. Will be diffuse, mushroom/dome shaped, amelanotic or melanontic, small/med/large and most commonly at the PP 7. weight loss, marked fatigue cough, change in bowl or bladder habits (suggest malignancy with choroidal metastasis)
103
Treatment for choroidal melanoma
1. TTT (transpupillary thermotherapy) for small pigmented melanomas
2. Plaque brachytherapy for treating near nerve melanomas
3. External beam irradiations with protons or helium ions
4. Pars plana vitrectomy endoresection
5. Block excision (sclerouvectomy)
6. Enucleation indicated for 10-15% of patients - usually large tumors or circumpapillary tumors
104
goldenhar syndrome signs
1. Dermoid at inferotemporal limbus
2. Preauricular skin tags
3. Eyelid colobomas
4. Vertebrae skeletal defects (typically scoliosis)
105
Treatment for goldenhar syndrome
1. Refer for surgery (plastics/neurosurgeon)
106
Crouzon syndrome signs
```
Exophthalmos
Hypertelorism
Strabismus
Nystagmus
Optic atrophy(secondary to chronic papilledema)
Shallow orbits, exotropia
Exposure keratitis, globe luxation
```
107
Treatment for crouton syndrome
1. Refer for surgery (plastics/neurosurgeon)
108
Causes of orbital cellulitis
1. adjacent sinusitis (80% of orbital cellulitis cases, most commonly ethmoid sinus)
2. skin infection
3. Dacryocystitis
4. extension of endopthalmitis
5. endogenous bacteremia (staph or strep)
6. if immunocompromised or uncontrolled diabetes, consider mucomycosis cause (fungal)
109
Orbital cellulitis signs
```
Acute increasing edema, erythema and pain around eye over several hours to days
Generally more painful UL > LL
Pupil involvement (sluggish, possible APD)
Proptosis
Decreased vision
Pain and limitations on ocular movement
Fever
Anorexia
Marked chemosis
Elevated IOP
Moderate to marked leukocytosis
```
History of underlying sinus disease possible
Acute URI, skin infection or trauma possible
110
If orbital cellulitis is left untreated what can occur?
Must treat or can lead to cavernous sinus thrombosis and/or death
111
Possible associations with idiopathic orbital inflammatory syndrome
Possibly associated with Crohn’s disease, SLE, RA, DM, AS, or hx of AI disease
*idiopathic, diagnosis of exclusion
112
Patient profile for IOIS
peak age 40-60yo
113
Ocular signs of IOIS
```
Generally asymptomatic
Inflammation within hours
Myositis
Dacryoadenitis
Posterior scleritis
Inflammation of orbital fat
Inflammation of orbital apex → KEY: tendons will be affected (unlike w/thyroid eye disease!)
Periorbital pain
Diplopia
Visual changes if ONH affected
Boggy eyelid edema, erythema
Conjunctival chemosis and/or injection
Proptosis
External ophthalmoplegia
Choroidal detachment and optic swelling if posterior scleritis
```
KEY: no sinusitis association, no trauma hx
114
Testing that must be completed if suspected IOIS
If suspected, orbital imaging a must:
- CT
- MRI w/gadolinium = best at dx IOIS
- Echography: useful for suspected posterior scleritis
Orbital biopsy:
- Pts who don’t respond to corticosteroid tx, atypical presentation, recurrent inflammatory episodes, known history of local or distant malignancy, or LG inflammation
115
Treatment for IOIS
1. First line = high dose oral corticosteroids
1.0-1.5 mg/kg/day
Symptoms may rebound during steroid taper
Inflammation not sensitive to steroids/inability to taper = atypical → consider alternative diagnoses
2. Second line
Parenteral steroids: IOIS related optic neuropathy
NSAIDs: for corticosteroid taper in pts who re-flare at lower corticosteroid doses
Local intralesional corticosteroid injections
Off label triamcinolone acetonide
For local inflam. masses or dacryoadenitis
Controversial use due to potential side effects, injection risks
Immunomodulators
Antimetabolites, TNF, biologics (infliximab)
For pts who cannot tolerate steroids
116
Teratoma or dermoids?
- present at birth
- present early childhood
teratomas
dermoids
117
At junction of bony sutures of orbit (frontozygomatic suture most commonly)
From embryonic ectoderm → typically superotemporal, not fixed to overlying skin: partially mobile, smooth, and not tender to touch. Don’t affect vision or increase IOP. Generally asymptomatic unless ↑ in size/rupture, rare proptosis/globe displace
dermoid or epidermoid cysts
118
Arise from aberrant germ cells (gonads, retroperitoneum, or mediastinum) → rapidly growing, proptosis noted at birth/early infancy, typically unilateral
orbital teratomas
119
testing for congenital orbital tumors
Orbital CT (w/axial and coronal views) or MRI with surgical planning
120
Treatment for a dermoid
If asymptomatic: follow up routinely
If large or symptomatic (globe displacement, pain, inflamed)
Consider referring promptly
Excision surgery
121
Treatment for a teratoma
prompt referral
122
Teratoma: if proptosis in a child, also consider _______ as possible etiology
rhabdomyosarcoma
123
Denies folic acid to toxoplasmosis. can't use in pregnant or breastfeeding women or if CBC/platelet count drops below 100,000
pyrimthamine
124
for a pregnant/breastfeeding woman needing toxoplasmosis treatment, what is a good alternative to pyrimethamine?
clindamycin
125
helps build neutrophils and stop secondary accents of pyrimethamine (neutropenia, bleeding out)
treatment for toxoplasmosis
folinic acid
126
pulls folic acid away from toxoplasmosis with PABA
sulfadiazine
127
Possible side effect of clindamycin
pseudomembranous colitis (bloody stools)
128
substitute for clindamycin for toxoplasmosis treatment
tetracycline
129
alternative treatment for toxoplasmosis, helps reduce recurrence of toxoplasmosis pre-cataract surgery
Bactrim with or without clindamycin and prednisone
130
2 diseases that present with phylectules
TB choroiditis
| coccidomycosis
131
Bones of the orbit (6)
```
frontal
lacrimal
ethmoid
zygomatic
palentine
sphenoid
```
132
thinnest bone in the orbit
ethmoid
133
bone in orbit to most likely break from trauma
maxillary
134
most common orbital disease in US
grave's (thyroid) disease
* *scleral show is first sign (LPS impacted)
* *IR most commonly affected
135
If patient presents with decreased BCVA and you suspect it may be ONH related. How do you verify?
CV testing
| pupils (APD?)
136
6 P's of orbital disease
```
Pain
Progression
Proptosis
Palpation
Pulsation
Periorbital changes
```
137
Proptosis: location of the mass is always in what direction compared to the proptosis?
opposite
ex: lacrimal gland tumor: (down and in proptosis)
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(+) retropulsion means what?
when the eye is pushed back it resists being moved back
| e.g. cavernous sinus hemangioma
139
White men and white women normal Hertel exopthalmometry values
men: 16.5mm
women: 15.4mm
140
Black men and black women normal Hertel exopthalmometry values
men: 18.5
women: 17.8mm
141
Exopthalmometry norms:
- children:
- Asians:
- Caucasians:
- African Americans:
- children: 14.5-16mm
- Asians: 12-18mm
- Caucasians: 12-20mm
- African Americans: 12-24mm
142
True or false: if thyroid the cause tendons will be affected
false
143
best test for isolating muscle
red lens
144
What is Brailley's sign?
IOP normal on primary gaze but pressure increases on up gaze because of the tethering effect of IR: pull on the eye and IOP increases
145
If you suspect trauma with sinus involvement, how can you test?
test by having patient plug nose and blow air: air will go into sinus and push eye out (orbital emyphesema) or air will go underneath skin and blow it up (subnormal emphysema)
146
sound made when air leaves tissues. When pushing globe back sounds like paper being cracked/crackling noise as the air leaves the orbit. Indicates communication between the sinus and orbit and therefore a risk for orbital cellulitis
crepitus
147
CAT scan: great for _____ and _____
bones
| detecting metals
148
MRIs: great for ______, _______, ______-
vascular disease
rhadomyosarcoma
piece of plastic
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congenital anopthalmos
orbit didn't form
150
new initial treatment with acute VKH uveitis as it may prevent sunset glow fundus
Systemic corticosteroids + Cellcept
