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Ocular Disease: Lecture 5: Eyelids (2) Flashcards

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1
Q

Lid Placement Diseases

  1. What are 3 types of Ocular Myopathies?
A
  1. Myasthenia Gravis
  2. Myotonic Dystrophy
  3. Chronic Progressive External Ophthalmoplegia
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2
Q
A
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3
Q

Lid Displacement Diseases: Ocular Myopathy

Myasthenia Gravis

  1. Type of disease?
  2. What is damaged?
    a. Leads to what symptom?
    b. However, it doesn’t effect what muscles?
  3. Tends to be seen more in whom?
A
  1. AI disease
  2. Damage to Ach receptors in Striated Muscle
    a. Weakness + fatigability of skeletal muscles
    b. Doesn’t effect Cardia or Involuntary Muscles
  3. Females Predilection
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4
Q

Lid Displacement Diseases: Ocular Myopathy

Myasthenia Gravis

  1. Is it just ocular or systemic?
    a. When can it occur?
    b. When is it more common in women?
  2. % that have ocular muscle involvement?
  3. % that will have ocular symptoms as their initial concern?
A
  1. Can be either or both.
    a. Any age, but most common time is third decade
    b. Less than 40 (women more likely); Equal after that.
  2. over 90%
  3. 60% (2/3 have ptosis and diplopia)
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5
Q

Lid Displacement Diseases: Ocular Myopathy

Myasthenia Gravis: Signs/Symptoms

  1. 6 of them
A
  1. Difficulty breathing (rare, but serious)
  2. Dysarthria (speaking)
  3. Dysphagia (swallowing)
  4. Inability to chew
  5. Myopathic Facies
  6. Peripheral Weakness
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6
Q

Lid Displacement Diseases: Ocular Myopathy

MG

  1. Major Ocular Sign?
    a. How does it present?
    b. When is it worse?
  2. Other Sign?
A
  1. Ptosis
    a. Bilateral and Asymmetric
    b. At the end of the day, or with prolonged upgaze
  2. Cogan Twitch: Brief Upshoot of lids when moving from downgaze to primary gaze
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7
Q

Lid Displacement Diseases: Ocular Myopathy

MG: More ocular signs

  1. Diplopia: Type and how does it present?
  2. What type of movements and when can they be seen?
  3. What else is possible?
A
  1. Vertical; May present as Pseudo internuclear Ophthalmoplegia
  2. Nystagoid Movements; May be seen in Extreme Gaze
  3. Bizarre Ocular Motility is Possible
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8
Q

Lid Displacement Diseases: Ocular Myopathy

MG: Investigation

  1. What test is done?
A
  1. Edrophonium (Tensilon) Test
    a. Anticholinesterase
    b. Increases Ach that’s available at the NMJ.
    c. Increase Muscle function for a brief period (10 minutes)
    d. IV injection of Tensilon
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9
Q

Lid Displacement Diseases: Ocular Myopathy

MG: Investigation (2)

  1. What other test can be done? (probably safest)
A
  1. Ice Test; Ice placed on Ptotic Lid for 2 minutes; Improvement in Ptosis
    * a 2mm Improvement is a POSITIVE RESULT!
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10
Q

Lid Displacement Diseases: Ocular Myopathy

MG: Treatment

  1. What 5 things can be done?
A
  1. Anticholinesterase Drugs
  2. Immunosuppression
  3. Plasma Exchange
  4. Steroids
  5. Thymectomy
    * They HAVE to be REFERRED for Co-Management
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11
Q

Lid Displacement Diseases: Ocular Myopathy

Myotonic Dystrophy

  1. how common is it? Type of disorder?
  2. What is it?
  3. Number of types and which is less severe?
A
  1. RARE; Autosomal Dominant
  2. Delayed muscular relaxation after voluntary Effort
  3. 2 Types;

DM 2 has less severe systemic Effects and a Better Prognosis

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12
Q

Lid Displacement Diseases: Ocular Myopathy

Myotonic Dystrophy: Ocular Manifestations

  1. Type of Cataract and what does it look like?
  2. One other common thing?
  3. 4 Uncommon manifestations
A
  1. Early onset cataract. CHRISTMAS TREE
  2. Ptosis
  3. a. External Ophthalmoplegia
    b. Hypotony
    c. Optic Atrophy
    d. Pigmentary Retinopathy
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13
Q

Lid Displacement Diseases: Ocular Myopathy

Myotonic Dystrophy: Ocular Manifestations

  1. Type of Cataract and what does it look like?
  2. One other common thing?
  3. 4 Uncommon manifestations
A
  1. Early onset cataract. CHRISTMAS TREE
  2. Ptosis
  3. a. External Ophthalmoplegia
    b. Hypotony
    c. Optic Atrophy
    d. Pigmentary Retinopathy
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14
Q

Lid Displacement Diseases: Ocular Myopathy

Myotonic Dystrophy:

  1. What 2 treatments are there?
A
  1. Exercise

2. Prevent Muscle Wasting

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15
Q

Lid Displacement Diseases: Ocular Myopathy

Chronic Progressive External Ophthalmoplegia

  1. It refers to a group of disorders w/various etiologies, but it involves what 2 things?
  2. Can be an independent condition or associated with what 2 other conditions?
A
  1. Ptosis, and Progressive Bilateral Ocular Immobility

2. Kearns-Sayre Syndrome; Oculopharyngeal Dystrophy

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16
Q

Lid Displacement Diseases: Ocular Myopathy

Chronic Progressive External Ophthalmoplegia

  1. What’s usually the first sign?
    a. Uni or bilateral?
    b. Symmetric or asymmetric?
A
  1. Ptosis
    a. Bilateral
    b. Asymmetric
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17
Q

Lid Displacement Diseases: Ocular Myopathy

Chronic Progressive External Ophthalmoplegia

Kearns-Sayre Syndrome

  1. Cause
  2. What does it do to EOMs?
  3. What does the fundus look like?
A
  1. Mitochondrial DNA Deletions
  2. “Ragged” EOMs: Accumulate Abnormal Mitochondria
  3. “Salt and pepper” Fiundus
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18
Q

Lid Displacement Diseases: Ocular Myopathy

Chronic Progressive External Ophthalmoplegia

Kearns-Sayre Syndrome

  1. Cause
  2. What does it do to EOMs?
  3. What does the fundus look like?
A
  1. Mitochondrial DNA Deletions
  2. “Ragged” EOMs: Accumulate Abnormal Mitochondria
  3. “Salt and pepper” Fiundus
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19
Q

Disorders of Lashes: Trichiasis

  1. How common is it?
  2. What does it cause?
  3. Chronic Rubbing leads to what 3 things?
  4. May be 2ndary to what?
A
  1. Very
  2. Posterior Misdirection of Lashes
  3. Corneal Pannus; Corneal Ulceration; P.E.E. of Cornea
  4. May be 2ndary to Scarring or can Occur Independently
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20
Q

Disorders of Lashes: Trichiasis

Cause

  1. One cause is Independent of what?
  2. Scarring of Lid Margin (3)?
A
  1. Independent abberant Growth

2. Chronic Blepharitis; Herpes Zoster; Trauma

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21
Q

Disorders of Lashes: Trichiasis

Treatment

  1. 5 types of treatment?
A
  1. Argon Laser Ablation
  2. Cryotherapy
  3. Electrolysis
  4. Epilation
  5. Surgery
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22
Q

Disorders of Lashes: Distichiasis

  1. What is it?
  2. Where does it emerge from?
  3. 2 ways you can get it?
A
  1. Partial or Complete Second Row of Lashes
  2. Emerge at or behind Meibomian Gland Orifice
  3. Congenital or can be Acquired
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23
Q

Disorders of Lashes: Distichiasis

Congenital

  1. Type of Genetic condition?
  2. What goes wrong?
  3. Aberrant Lashes are what 2 things, and may be directed which way?
A
  1. Autosomal Dominant; Inherited Condition
  2. Cells destined to be Meibomian Glands will differentiate into a Pilosevaceous Unit
  3. Thinner and Shorter; May be directed Posteriorly
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24
Q

Disorders of Lashes: Distichiasis

Congenital: Treatment

  1. Lower Lid (1)?
  2. Upper Lid? (2)
A
  1. Cryotherapy

2. Cryotherapy and Lamella Division

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25
Disorders of Lashes: Distichiasis Acquired 1. Due to what? 2. Called what? a. 3 things
1. Due to de-differentiation of Meibomian Glands 2. Cicatrizing Conjunctivitis a. Chemical Injury b. Ocular Pemphigoid c. Stevens Johnson
26
Disorders of Lashes: Distichiasis Acquired: Treatment 1. Mild form? 2. Severe?
1. Same as trichiasis | 2. Lamellar Eyelid Division and Cryotherapy
27
Disorders of Lashes: Eyelash Ptosis 1. What is it? 2. It can be IDIOPATHIC or associated with what 3 things? 3. No turning of what?
1. Downward Sag of upper eyelid lashes 2. a. Dermatochalasis b. Facial Palsy c. Floppy Eyelid Syndrome 3. No turning in of the Lid Margin
28
Disorders of Lashes: Eyelash Ptosis Treatment 1. Main thing to treat? 2. Other things to think about?
1. Treat underlying Etiology 2. a. Supportive b. Surgery to change position is possible but only if VERY Symptomatic (Anterior Lamellar Repositioning)
29
Disorders of Lashes: Trichomegaly 1. What is it? 2. Acquired Causes? (4) 3. Congenital Causes? (4)
1. Excessive eyelash Growth 2. a. AIDS b. Drug Induced c. Hypothyroidism d. Malnutrition 3. a. Cornelia de Lange Syndrome b. Goldstein Hutt Syndrome c. Hermansky Pudlak Syndrome d. Oliver McFarlane Syndrome
30
Disorders of Lashes: Trichomegaly 1. treatment? (3)
1. a. Epilation b. Lash Trimming c. Lubrication
31
Disorders of Lashes: Madarosis 1. What is it? 2. Causes? (9)
1. Decrease in the number of Lashes 2. a. Alopecia b. Burns c. Chronic Lid Margin Disease d. Leprosy e. Lid Tumor f. Psoriasis g. SLE h. Syphilis i. Trichotillomania***
32
Eyelid Neoplasms: General Considerations 1. What is more common? 2. Which is more varied? 3. Characteristics of benign? (5)
1. Benign more common than Malignant 2. Benign more varied 3. a. Lack of induration or ulceration b. Limited/No Growth c. Preservation of normal lid margin structure d. Regular border e. Uniform Color
33
Eyelid Neoplasms: General Considerations 1. What is more common? 2. Which is more varied? 3. Characteristics of benign? (5)
1. Benign more common than Malignant 2. Benign more varied 3. a. Lack of induration or ulceration b. Limited/No Growth c. Preservation of normal lid margin structure d. Regular border e. Uniform Color
34
Eyelid Neoplasms 1. Benign Nodules and Cysts? (7)
1. Chalazion 2. Epidermal Inclusion Cyst 3. Sebaceous Cyst 4. Cyst of Zeis 5. Cyst of Moll 6. Milia 7. Comedones
35
Benign Nodules and Cysts: Chalazion 1. What is it? 2. Acute or Chronic? 3. Infectious or Sterile? 4. 2 other things about it?
1. Meibomian Cyst 2. Chronic 3. Sterile 4. Granulomatous and Inflammatory
36
Benign Nodules and Cysts: Chalazion (2) 1. Cause? 2. Is it infectious? 3. Who is at a higher risk of this?
1. Due to retained secretion 2. Non-infectious (Infection = Hordeolum) 3. Meibomian Gland disease and Rosacea are at higher risk
37
Benign Nodules and Cysts: Chalazion Presentation 1. Gradually what? 2. May have what in it? 3. What is the IMPORTANT thing to KNOW?
1. Gradually enlarging painless nodule (will have pain when inflamed) 2. Polyploidal Granuloma 3. r/o sebaceous gland Carcinoma presents like a reoccurring chalazion * Older Patient; Lid thickening; Unilateral Chronic Blepharitis; Madarosis; Poliosis
38
Benign Nodules and Cysts: Chalazion Treatment 1. Major thing to do? 2. What surgery can be done? 3. What else?
1. Monitor!! (1/3 resolve spontaneously) 2. Surgically Curetted 3. Steroid Injection a. Preferred if NEAR PUNCTUM b. Triamcinolone and Lidocaine injected into lesion thru Conjunctiva c. 80% success! *Doxycycline Prophylaxis..
39
Benign Nodules and Cysts: Epidermal Inclusion Cyst 1. Characterisitcs? (3) 2. 2 types of lesions? 3. Implantation of what? 4. Treatment? (1)
1. Slow Growing, Round, Firm 2. Superficial or Subcutaneous Lesions 3. of Epidermal Cells into Dermis following trauma or surgery 4. Excision
40
Benign Nodules and Cysts: Sebacious Cyst (Pilar) 1. What is it? 2. Rarely seen where? 3. Treatment?
1. Blocked Pilosebaceous Follicle (Puss filled cyst) 2. on the eyelid (Medial Canthus) 3. Excision
41
Benign Nodules and Cysts: Cyst of Zeis 1. What is it? 2. What does it obstruct? 3. Treatment?
1. Small Non-translucent non tender cyst on anterior lid margin 2. Obstructed gland of Zeis 3. Excision
42
Benign Nodules and Cysts: Cyst of Moll 1. What is it? 2. Treatment?
1. Small, translucent non tender cyst on anterior lid margin (obstructed gland of Moll) 2. Excision
43
Benign Nodules and Cysts: Milia 1. What is it? 2. How does it occur? 3. Treatment? (3)
1. Tiny epidermal Inclusion Cysts; Blocked Pilosebaceous Units (Retained Keratin) 2. Tiny, white, round, superficial Papules; Occur in Crops 3. Excision; Electrolysis; Curettage
44
Benign Nodules and Cysts: Comedones 1. What is it? a. Open = ? b. Closes = ? 2. Treatment? (2)
1. Keratin and Sebum plugs in the opening of hair follicles a. Blackheads b. Whiteheads 2. Cleansing; Excision if necessary (Comedone Extractor)
45
1. Benign Epidermal Tumors: 3 of them?
1. Squamous Cell Papilloma 2. Basal Cell Papilloma 3. Actinic Keratosis
46
Benign Epidermal Tumors: Squamous Cell Papilloma 1. How common is it? 2. What is it referred to as? 3. Appearance?
1. Very Common 2. "Skin Tag" 3. Variable Appearance
47
Benign Epidermal Tumors: Squamous Cell Papilloma 1. General Presentation? (3) 2. Treatment? 3. Differential Diagnosis? (3)
1. a. Flesh colored, narrow based, pedunculated lesion b. Raspberry like broad based (sessile) Lesion c. Hyperkeratotic Filiform Lesion 2. Excision 3. a. Viral Warts b. Intradermal Nevus c. Seborrheic Keratosis
48
Benign Epidermal Tumors: Squamous Cell Papilloma (2) Signs 1. What is it? 2. Treatment? 3. Differential Diagnosis (3)?
1. Greasy brown plaque with a friable verrucous surface; Appears "stuck on" 2. Excision 3. a. Basal Cell Carcinoma b. Melanoma c. Nevus
49
Benign Epidermal Tumors: Squamous Cell Papilloma (2) Signs 1. What is it? 2. Treatment? 3. Differential Diagnosis (3)?
1. Greasy brown plaque with a friable verrucous surface; Appears "stuck on" 2. Excision 3. a. Basal Cell Carcinoma b. Melanoma c. Nevus
50
Benign Epidermal Tumors: Actinic Keratosis 1. Also called what 2 things? 2. How common is it? 3. Seen in whom? 4. In who most of the time? 5. Due to what?
1. Solar Keratosis; Senila Keratosis 2. Common; Slow growing lesion 3. Eldery 4. Fair skinned 5. Excessive Sunlight; Most common on forehead and backs of hands. (*Low risk of converting to Squamous cell carcinoma)
51
Benign Epidermal Tumors: Actinic Keratosis 1. How does it present? (4) 2. Treatment?
1. a. Can be nodular or wart like (Gives rise to cutaneous horn) b. Distinct border c. Hyperkeratotic Plaque d. Scaly Surface 2. Biopsy: Excision or Cryotherapy
52
1. 4 Benign Pigmented Lesions?
1. Freckle 2. Congenital Melanocytic Nevus 3. Acquired Melanocyted Nevus 4. Nevus of Ota
53
Benign Pigmented Lesions: Freckle (Ephelis) 1. What is it? 2. Where found? 3. Malignant potential?
1. Brown Macule: Increased Melanin in the basal layer of the epidermis 2. Sunlight exposed areas 3. None. No treatment needed.
54
Benign Pigmented Lesions: Congenital Melanocytic Nevus 1. How common is it? 2. What does it resemble? 3. Large lesions may undergo what?
1. Uncommon 2. Resemble Acquired Nevi 3. Large lesions may undergo Malignant Transformation (15%)
55
Benign Pigmented Lesions: Congenital Melanocytic Nevus Presentation 1. Size normally? 2. Color? 3. AKA? 4. Rarely what?
1. Small (usually) 2. Uniform Color 3. Kissing (Split) Nevus: Involved upper and lower lid; May contain hair 4. rarely extremely large: "Giant hairy nevus"
56
Benign Pigmented Lesions: Congenital Melanocytic Nevus 1. Giant Hairy Nevus Treatment?
1. Complete excision (if necessary)
57
Benign Pigmented Lesions: Acquired Melanocytic Nevus 1. Size? 2. 3 Classifications?
1. Small, usually darkly pigmented lesions 2. a. Junctional b. Compound c. Intradermal
58
Benign Pigmented Lesions: Acquired Melanocytic Nevus Junctional Nevus 1. Seen in whom? 2. Color? 3. Cells located where? 4. Risk for Malignant Transformation?
1. Young peeps 2. Brown macule or plaque 3. Cells located AT the Junction of Epidermis and Dermis 4. Low risk
59
Benign Pigmented Lesions: Acquired Melanocytic Nevus Compound Nevus 1. Seen in whom? 2. Papule look? 3. Color? 4. Cells extend from what to what? 5. Risk for malignant transformation?
1. Middle aged peeps 2. Raised papule 3. Light tan to Dark Brown 4. Extend from Epidermis into the Dermis 5. Low risk
60
Benign Pigmented Lesions: Acquired Melanocytic Nevus Treatment 1. If what 2 things? 2. What can be done?
1. a. Malignancy Concerns b. Cosmetic concerns 2. Excision: MUST be complete a. Unable to differentiate recurrence from Melanoma
61
Benign Pigmented Lesions: Acquired Melanocytic Nevus Treatment 1. If what 2 things? 2. What can be done?
1. a. Malignancy Concerns b. Cosmetic concerns 2. Excision: MUST be complete a. Unable to differentiate recurrence from Melanoma
62
Benign Pigmented Lesions: Nevus of Ota (Oculodermal Melanocytosis) 1. uni or bilateral? 2. Macule color? 3. Found in what 2 things? 4. Ipsilateral what? 5. Present at what?
1. Unilateral; (10% can be bilateral) 2. Blue-gray macule 3. V1 and V2 4. Ipsilateral Melanocytosis of Sclera 5. Present at birth or w/in 1st year
63
Benign Pigmented Lesions: Nevus of Ota (Oculodermal Melanocytosis) 1. Increased risk for what? 2. Very low risk for what? 3. Treatment? (3)
1. for Glaucoma 2. for Malignant transformation 3. a. None required b. Monitor for Glaucoma c. Recently very successful laser treatment (cosmetic improvement)
64
1. 2 Benign Adnexal Tumors?
1. Syringoma | 2. Pilomatricoma
65
Benign Adnexal Tumors: Syringoma 1. Type of Proliferations? 2. Arise from what? 3. Papule types? 4. Treatment? (2)
1. Benign 2. from Eccrine glands 3. Small, Multiple papules 4. Unecessary; Can remove for cosmetic (Blade/laser excision, laser ablation, etc)
66
Benign Adnexal Tumors: Pilomatricoma 1. What is it? 2. Seen in whom? 3. More common in whom? 4. Most common proliferation of what?
1. Benign skin tumor derived from hair follicle 2. Children and young adults 3. More common in women 4. of Hair cells seen in Ophthalmologic setting
67
Benign Adnexal Tumors: Pilomatricoma 1. how does it present? 2. Treatment?
1. Deep, purplish, mobile nodule: May be hard due to calcification 2. Excision
68
Miscellaneous Benign Tumors? (6)
1. Port Wine Stain 2. Pyogenic Granuloma 3. Xanthelasma 4. Neurofibroma 5. Molluscum Contagiosum 6. Verrucae Vulgaris
69
Miscellaneous Benign Tumors: Port Wine Stain 1. Also called what 2 things? 2. Rare congenital subcutaneous lesion a. Follows what? b. Most often found where? 3. What is it? 4. usually uni or bilateral? 5. May be associated with what Syndrome?
1. a. Nevus Flammeus b. Cavernous Haemangioma 2. a. Follows dermatome b. Most often on face but may be located elsewhere 3. Capillary malformation in the skin 4. Usually unilateral 5. Sturge-Weber Syndrome
70
Miscellaneous Benign Tumors: Port Wine Stain 1. Presentation?
1. a. Well demarcated soft pink patch (no blanching w/pressure) b. Darkening of lesions with age c. Hypertrophy of overlying skin (becomes course nodular and friable)
71
Miscellaneous Benign Tumors: Port Wine Stain Ocular Presentation 1. Glaucoma seen in what % of patients with facial lesions? a. % of glaucoma in patients when facial lesions involve V1 and V2? b. Less frequent if what? c. Increased with what 2 things?
1. 10% a. 27-45% b. If only V1 or V2 and not both c. with eyelid involvement and episcleral venous pressure (elevated IOP)
72
Miscellaneous Benign Tumors: Port Wine Stain Treatment 1. What laser treatment? a. When can it be performed? 2. What does it do? 3. What need to be done after this?
1. Pulse Dye Laser Treatment (Selectively destroys superficial capillaries) a. Very early in life (as early as 1 wk old) 2. Decreases amt of skin discoloration in a flat lesion (may require several treatments over several years) 3. Manage glaucoma
73
Miscellaneous Benign Tumors: Port Wine Stain Sturge Weber Syndrome 1. What is it? 2. Trisystem diesease? 3. Bisystem Disease?
1. Congenital Phacomatosis 2. a. Face b. Eyes c. Leptomeninges (2 innermost layers covering the brain: Pia and Arachnoid) 3. a. Face and Eyes b. Face and Leptomeninges
74
Miscellaneous Benign Tumors: Pyogenic Granuloma 1. Presentation (5)? 2. Composed of what tissue? 3. Etiology? (2) 4. Treatment?
1. a. Fast growing b. occasionally painful c. Polypoidal red lesion d. Possible bleeding e. Vascularized 2. Granulation tissue 3. 2ndary to surgery, trauma, or infection; May be idiopathic 4. Excision
75
Miscellaneous Benign Tumors: Pyogenic Granuloma 1. Presentation (5)? 2. Composed of what tissue? 3. Etiology? (2) 4. Treatment?
1. a. Fast growing b. occasionally painful c. Polypoidal red lesion d. Possible bleeding e. Vascularized 2. Granulation tissue 3. 2ndary to surgery, trauma, or infection; May be idiopathic 4. Excision
76
Miscellaneous Benign Tumors: Xanthelasma 1. how common? 2. Uni or bilateral? 3. Age group? 4. Can be associated with what?
1. Relatively common 2. Bilateral (usually) 3. Middle-aged/Elderly 4. Hyperlipidemia (young males)
77
Miscellaneous Benign Tumors: Xanthelasma 1. Presentation (2) 2. Treatment? (2)
1. a. Multiple yellowish subcutaneous plaques b. Medial Aspect of eyelids 2. a. Excision b. Carbon Dioxide Laser
78
Miscellaneous Benign Tumors: Neurofibroma 1. What is it? 2. Where can it occur? 3. What typically affect children with Neurofibromatosis 1? 4. What typically affect adults? 5. Comprised of what 3 things?
1. Benign nerve sheath tumor 2. anywhere in the body 3. Plexiform Neurofibromas 4. Solitary Neurofibromas 5. Schwann cells, Fibroblasts, Nerve Axons
79
Miscellaneous Benign Tumors: Neurofibroma 1, Presentation? 2. Treatment a. Solitary Lesion? b. Plexiform Lesion?
1. Typically affects upper lid ("S-shaped deformity") 2. a. Excision b. Very difficult; Often diffuse
80
Miscellaneous Benign Tumors: Verruca Vulgaris 1. What is it? a. Papilloma of what origin? 2. 2ndary to what infection? 3. One of the most common skin growths: risk of malignancy?
1. Benign Epithelial Hyperplasia a. Papilloma of Viral Origin 2. to HPV infection (common wart) 3. Low risk
81
Miscellaneous Benign Tumors: Verruca Vulgaris 1. Presentation? 2. Treatment?
1. Variable colored b. can be round and flat (verruca plana) c. Or can be finger like projection from a broad base (Verruca digitata)!!! 2. Excision for cosmetic concerns.

Ocular Disease (11 decks)

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