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Oral Exam Qs

Oral Exam Qs. For Mcs & MD. Burning. Burning. More common Blepharitis, dry-eye syndrome, conjunctivitis (discharge or eyelid sticking additionally).

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Oral Exam Qs

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  1. Oral Exam Qs For Mcs & MD

  2. Burning

  3. Burning More common Blepharitis, dry-eye syndrome, conjunctivitis (discharge or eyelid sticking additionally). Less common Corneal problem (fluorescein staining of the cornea usually), inflamed pterygium/pinguecula, episcleritis, superior limbic keratoconjunctivitis.

  4. Decreased Vision

  5. Decreased Vision Transient visual loss (vision returns to normal within 24 hours, usually within 1 hour). More common: - Few seconds (usually bilateral): Papilledema. Few minutes: Amaurosis fugax [transient ischemic attack (TIA); unilateral], vertebrobasilar artery insufficiency (bilateral). - 10 to 60 minutes: Migraine (with or without a subsequent headache). Less common Impending central retinal vein occlusion, ischemic optic neuropathy, ocular ischemic syndrome (carotid occlusive disease), glaucoma, sudden change in blood pressure, central nervous system (CNS) lesion, optic disc drusen, giant cell arteritis.

  6. 2. Visual loss lasting longer than 24 hours. 1. Sudden, painless loss. More common Retinal artery or vein occlusion, ischemic optic neuropathy, vitreous hemorrhage, retinal detachment, optic neuritis (usually pain with eye movements). Less common Other retinal or CNS disease. 2. Gradual, painless loss (over weeks, months, or years). More common Cataract, refractive error, open-angle glaucoma, chronic retinal disease [e.g., age-related macular degeneration (ARMD), diabetic retinopathy]. Less common Chronic corneal disease (e.g., corneal dystrophy), optic neuropathy/atrophy (e.g., CNS tumor).

  7. 3. Painful loss: Acute angle-closure glaucoma, optic neuritis (pain with eye movements), uveitis, corneal hydrops (keratoconus).

  8. Double Vision

  9. Double Vision 1. Monocular (The double vision remains when the uninvolved eye is occluded.) Refractive error, corneal opacity or irregularity, cataract, dislocated natural lens or lens implant, extra pupillary openings, macular disease.

  10. 2. Binocular (The double vision is eliminated when either eye is occluded.) 1. Typically intermittent: Myasthenia gravis, intermittent decompensation of an existing phoria. 2. Constant: - Isolated sixth-, third-, or fourth-nerve palsy; - orbital disease (e.g., thyroid eye disease, orbital inflammatory pseudotumor, tumor); cavernous sinus/superior orbital fissure syndrome; status post ocular surgery (e.g., residual anesthesia, displaced muscle); status post trauma (e.g., orbital wall fracture with extraocular muscle entrapment); Internuclear ophthalmoplegia, vertebrobasilar artery insufficiency, other CNS lesions.

  11. Flashes of Light More common Retinal break or detachment, posterior vitreous detachment, migraine, rapid eye movements (particularly in darkness). Less common - CNS (particularly occipital lobe) disorders, - retinitis, - entopic phenomena.

  12. Spots in Front of the Eyes (Floaters)

  13. Spots in Front of the Eyes(Floaters) 1. Transient: Migraine. 2. Permanent or long-standing. More common: Posterior vitreous detachment, posterior uveitis, vitreous hemorrhage, vitreous condensations/debris. Less common: corneal opacity.

  14. Blood in Schlemm’s Canal on Gonioscopy

  15. Blood in Schlemm’s Canal on Gonioscopy Compression of episcleral vessels by a gonioprism (iatrogenic), Sturge–Weber syndrome, arteriovenous fistula (e.g., carotid–cavernous sinus fistula), superior vena cava obstruction, hypotony.

  16. Eyelid Swelling

  17. Eyelid Swelling 1. Associated with inflammation (usually erythematous). More common Hordeolum, blepharitis, conjunctivitis, preseptal or orbital cellulitis, trauma, contact dermatitis. Less common Ectropion, corneal abnormality, urticaria/angioedema, insect bite, dacryoadenitis, erysipelas, eyelid or lacrimal gland mass. 2. Noninflammatory: Chalazion; prolapse of orbital fat (retropulsion of the globe increases the prolapse); laxity of the eyelid skin; cardiac, renal, or thyroid disease; eyelid or lacrimal gland mass.

  18. Pigmentation of the Conjunctiva

  19. Pigmentation of the Conjunctiva Racial pigmentation (perilimbal), nevus, primary acquired melanosis, melanoma, ocular and oculodermal melanocytosis (congenital, blue, epi-scleral, not conjunctival), Addison’s disease, mascara, pregnancy, radiation, drug (e.g., chlorpromazine) or metal (e.g., argyrosis from silver).

  20. Blood in AC

  21. Hyphema After ocular trauma Post-intraocular surgery, bleeding from iris or corneal wound Iris neovascularization, herpes simplex or zoster iritis, blood dyscrasia or clotting disorder (e.g., hemophilia), intraocular tumor (e.g., juvenile xanthogranuloma, retinoblastoma, leukemia).

  22. Etiology (of Spontaneous Hyphema or Microhyphema)

  23. Etiology (of Spontaneous Hyphema or Microhyphema) Must exclude the possibility of occult trauma. Neovascularization of the iris or AC angle (e.g. from diabetes, old central retinal vein occlusion, ocular ischemic syndrome, chronic uveitis). Blood dyscrasia. Iris–intraocular lens chafing. Other (e.g., leukemia, retinoblastoma, juvenile xanthogranuloma, child abuse).

  24. Hypopyon

  25. Hypopyon Infectious corneal ulcer (e.g. hypopyon ulcer), endophthalmitis, severe iritis, reaction to an intraocular lens or retained lens matter after cataract surgery, intraocular tumor necrosis [e.g., retinoblastoma (pseudohypopyon),

  26. Corneal Edema

  27. Corneal Edema 1. Congenital: Congenital glaucoma, congenital hereditary endothelial dystrophy, posterior polymorphous dystrophy (PPMD), birth trauma (forceps injury).

  28. 2. Acquired: Early postoperative, aphakic or pseudophakic bullous keratopathy, Fuchs’ endothelial dystrophy, contact lens overwear, trauma, acute angle-closure glaucoma and other causes of acute increase in intraocular pressure, - corneal hydrops (acute keratoconus), - herpes simplex or zoster keratitis, iritis, - failed corneal graft, - iridocorneal endothelial (ICE) syndrome.

  29. SUPERFICIAL PUNCTATE KERATOPATHY (SPK)

  30. SUPERFICIAL PUNCTATE KERATOPATHY (SPK) Etiology Symptoms Signs Workup Treatment

  31. Etiology SPK is nonspecific but is most commonly seen with the following disorders: Dry-eye syndrome (Poor tear lake or a decreased tear break-up time. Blepharitis (Erythema, telangiectasias, and/or crusting of the eyelid margins, Meibomian gland dysfunction. Trauma (Can occur from relatively mild trauma, such as chronic eye rubbing) Exposure keratopathy (Poor eyelid closure with failure to cover the entire globe. Topical drug toxicity (e.g., neomycin, gentamicin, or any drops with preservatives, including artificial tears) Ultraviolet burn/photokeratopathy Mild chemical injury (Chemical Burn)

  32. 8. Contact lens–related disorder (e.g., chemical toxicity, tight-lens syndrome, contact lens overwear syndrome, giant papillary conjunctivitis. 9. Foreign body under the upper eyelid (Typically linear SPK, fine scratches arranged vertically) 10. Conjunctivitis (Discharge, conjunctival injection, eyelids stuck together on awakening. 11. Trichiasis/distichiasis (One or more eyelashes rubbing on the cornea. 12. Entropion or ectropion (Eyelid margin turned in or out. Area of SPK is superior or inferior. 13. Floppy eyelid syndrome (Extremely loose eyelids that pull away from the eye very easily.

  33. Symptoms Pain, photophobia, red eye, foreign-body sensation.

  34. Signs Critical Signs - Pinpoint corneal epithelial defects (stain with fluorescein) - may be confluent if severe. Other Signs - Conjunctival injection, - watery or mucoid discharge.

  35. Workup 1. History: Trauma? Contact lens wear? Eyedrops? Discharge or eyelid matting? Chemical or UV exposure? 2. Evaluate the cornea and tear film (Slitlamp). 3. Evert the upper and lower eyelids, and look for a foreign body. 4. Check eyelid closure and eyelid laxity, and look for inward-growing lashes. 5. Inspect contact lenses for fit (if still in the eye) and for the presence of deposits, sharp edges, and cracks.

  36. Treatment According to the cause: treat the underlying disorder. SPK is often treated nonspecifically as follows: (A) Non–contact lens wearers: 1. Non–contact lens wearer with a small amount of SPK Artificial tears q.i.d., preferably nonpreserved b. Can add a lubricating ointment 2. Non–contact lens wearer with a large amount of SPK a. Topical Antibiotic drops & oint. for 3 to 5 days. b. Cycloplegic drops (e.g., cyclopentolate, for relief of pain and photophobia. c. Optionally, pressure patch for the first 24 hours, after applying cycloplegic drops and antibiotic ointment.

  37. (B) Contact lens wearers: a. Discontinue contact lens wear. b. Artificial tears 4 to 6 times per day, preferably nonpreserved (e.g., Refresh Plus or Theratears). c. Broad-spectrum eye drops & ointment e.g. Fluoroquinolone [e.g., ofloxacin, ciprofloxacin (e.g., Ciloxan)] or tobramycin drops 4 to 6 times per day, and tobramycin or ciprofloxacin ointment. d. Cycloplegic drops (e.g., cyclopentolate, for relief of pain and photophobia. ??? Eye Patch

  38. DO NOT patch contact lens–related epithelial defects.

  39. Superficial Punctate Keratopathy May be: 1. Superior 2. Inferior 3. Interpalpebral Q. Mention causes of each type.

  40. Answer Superior: Subtarsal FB Vernal keratoconjunctivitis Superior limbic keratoconjunctivitis 2. Interpalpebral Keratoconjunctivits sicca Neurotrophic ulcer UV exposure 3. Inferior 1. Staphylococcal blepharitis 2. Trichiasis, entropion 3.Lagophthalmos 4. Drug toxocoty

  41. Enlarged Corneal Nerves

  42. Enlarged Corneal Nerves Most important:Multiple endocrine neoplasia type IIb (medullary carcinoma of the thyroid gland, pheochromocytoma, mucosal neuromas). Others: Keratoconus, keratitis, neurofibromatosis, Fuchs’ endothelial dystrophy, Refsum’s syndrome, trauma, congenital glaucoma, failed corneal graft, leprosy.

  43. Corneal Filaments

  44. Corneal Filaments(FILAMENTARY KERATOPATHY) Etiology Symptoms Signs Workup Treatment

  45. Etiology Dry-eye syndrome (Most common cause. Can be associated with an autoimmune collagen–vascular disease such as Sjögren’s syndrome. Superior limbic keratoconjunctivitis (Superior conjunctival injection and fluorescein staining, superior corneal pannus. Recurrent corneal erosions (Recurrent spontaneous corneal abrasions often occurring upon awakening. Patching (e.g., postoperative, after corneal abrasions) Neurotrophic keratopathy Chronic bullous keratopathy

  46. Symptoms: Moderate-to-severe pain, red eye, foreign-body sensation, photophobia.

  47. Signs Critical Signs - Short strands of epithelial cells and mucus attached to the anterior surface of the cornea at one end of the strand. - The strands stain with fluorescein. Other Signs - Conjunctival injection, - poor tear film, - punctate epithelial defects.

  48. Workup 1. History, especially for the previously mentioned conditions. 2. Slit-lamp examination with fluorescein staining.

  49. Treatment 1. Treat the underlying condition. 2. Consider debridement of the filaments: After applying topical anesthesia (e.g., proparacaine), gently remove filaments at their base with fine forceps or a cotton-tipped applicator. 3. Lubrication with one of the following regimens: 1. Artificial tears (e.g., Refresh Plus) 4 to 8 times per day and artificial-tear ointment (e.g., Refresh PM) qhs. 2. Sodium chloride, 5%: drops q.i.d. and ointment qhs. 3. Acetylcysteine, 10% (e.g., Mucomyst), q.i.d. If the symptoms are severe or this treatment fails, then consider a bandage soft contact lens, unless the patient has severe dry eyes. Extended-wear bandage soft contact lenses may need to be worn for months.

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