ANTERIOR SEGMENT Flashcards

Question

What are the findings of HSK in 1. epithelial 2. stromal 3. endothelial

Answer 1

Epithelial: SPKs --> stellate erosions --> dendritic ulcer with terminal bulbs --> geographic ulcer. Reduced corneal sensation Stromal: Interstitial haze, mimics bacterial ulcer, diffuse opacities with corneal vascularisation and lipid exudation / scarring. Increased IOP, AC activity. Endothelial: Disciform, wessley ring (stromal halo with cornela oedema), endothelitis, central KPs

Answer 2

Epithelial: topical aciclovir 3%/ganciclovir 0.15% 5 x day +/- debridement Stromal: Oral aciclovir 400mg 5xday / topical ganciclovir 5x day then 3x day, topical steroids if no epithelial defect 4 hours after Endothelial: Aciclovir 400mg 5 x day/ topical ganciclovir 5 x day then 3x day topical steroids 48 hours after

Answer 3

1. Pseudodendrites (no terminal bulbs, supercifical) 2. Nummular (anterior stromal infiltrates) / disciform keratitis later

Answer 4

All : 800mg 5 times a day for 5 days Epithelial: Topical lubricants Stromal: Down-titrating topical steroids Endothelial: Down-titrating topical steroids

Answer 5

Ocular 1. Glaucoma 2. Episcleritis/Scleritis 3. ARN/PORN 3. Optic neuritis 4. Cranial nerve palsy Systemic 1. Cerebral vasculitis (stroke) 2. Neuralgia

Answer 6

Infectious 1. Bacterial: Syphilis, TB, Lyme 2. Viral: HSV, VZV, EBV 3. Parasitic: Acanthomoeba, Onchoceriasis Non-infectious Sarcoid Lymphoma Autoimmune (RA, GPA) Cogan's syndrome (interstitial keratitis + hearing loss) Trauma

Answer 7

Conservative: BCL, patching Medical: Topical lubricants, topical Abx, cycloplegia Systemic: Tetracyclines Surgery: Mechanical debridement, alcohol delamination, PTK, anterior stromal micropuncture (if outside vision axis)

Answer 8

Stage 1 : Irregular epithelium Stage 2 : Persistent epithelial defect Stage 3 : Stromal involvement --> ulcer/melting/descmetocele/perforation

Answer 9

1. Cranial VII palsy 2. Lid abnormality : nocturnal lagophthalmos (most common), ectropion, floppy eyelid syndrome, surgical (overcorrection of ptosis) 3. Orbital disease: Proptosis, TED

Answer 10

Conservative: Lubricants, corneal Medical: Oral tetracycline, serum eye drops Surgical: Amniotic membrane graft, tarsorrhaphy

Answer 11

CHAI - T C: chloroquine H: Hydroxychloroquine A: Amiodarone I : Indomethacin T : Tamoxifen

Answer 12

Macular pathology: hydroxychloroquine Optic neuropathy: amiodarone

Answer 13

1. Hordeolum/chalazion 2. Phylectenular marginal keratitis 3. conjunctival injection 4. pannus/scarring 5. recurrent erosions 6. corneal thinning/perf (rosacea)

Answer 14

Staphylococcal: 1. antibiotic ointment to lid margin (erythromycin) 1-2 / day for several weeks 2. consider mild topical steroid of significant inflammation or marginal phylctenular keratitis Seborrhoeic: 1. Treat scalp/seborrhoea (selenium sulfide shampoo) alongside lid hygeine Posterior MGD 1. Doxycycline 100mg BD for 1-2 weeks (tapered) or pulses of erythromycin 2. Topical ciclosporin/lifitegrast Demodex 1. Collarette debridement + tea-tree oil derivatives 2. Topical / oral ivermectin 3. Lotilaner 0.25% emerging

Answer 15

Rizutti: Presence of conical wedge shaped reflection on nasal cornea when penlight is shone from temporal side (advanced keratoconus) Munson: characteristic V-shaped indentation in the lower eyelid that appears when a person with advanced keratoconus looks downward (keratoconus)

Answer 16

4 Cs 1. Calcium levels (sarcoid, multiple myeloma, hyperparathyroidism) and Urate levels 2. Chronic eye disease (chronic retinal detachment, late HSV infection, chronic graft rejection, exposure keratopathy 3. Chemical exposure (intraocular silicone oil, thiazides, mercury, phosphate-containing drops) 4. Congenital (Norrie's disease)

Answer 17

Bilateral Central yellow/white crystals in anterior stroma with haze + arcus (subepithelial) Loss of photopic vision Associated with hypercholesterolaemia and paraproteinaemias GENETIC DEFECT: UBIAD gene on chromosome 1 Investigations: 1. Slit lamp examination 2. Anterior Segment OCT 3. Staining: Stains Oil Red O Red (cholesterol) 3. Bloods: Fasting cholesterol and triglyceride levels, cystinosis screen

Answer 18

Lattice: AD (TGFB1) Macular: AR (CHST6 on 16) Granular: AD (TGFB1) Combined granular-lattice (Avellino): AD (TGFB1) Schnyder: AD: UBIAD1

Answer 19

Lattice: 3 types Refractile anterior stromal dots coalecsing into fine filamentous criss cross lines that spares the periphery. Reduced corneal sensation Type 1 is more common than Type 2 Type 2: Meretoja syndrome - type 2 lattice dystrophy + cranial (CN7) and peripheral neuropathy, skin laxity and cardiorenal disease (amyloidosis) Type 3: Rare, Japanese Granular Asymmetric bilateral central to paracentral crumb like opacities, spares peripheries. Spares limbus. Corneal sensation reduced

Answer 20

Fine superificial opacities progress to form stellate/annular lesions with deeper criss/cross linear opacities Can extend to limbus

Answer 21

1. Macular dystrophy 2. Schyner's crystalline dystrophy

Answer 22

Suitable: >2200cells/mm2 Unsuitable: <1000cells/mm2 Corneal decompensation: <700cells/mm2

Answer 23

CHED 1: AD - Bilateral mild corneal oedema from infancy. Progressive. CHED 2: AR - bilateral severe corneal oedema from birth, reduced VA, ambylopia with nystagmus. Deafness

Answer 24

Cluster of lines/vesicles, irregular broad bands or diffuse haze across posterior cornea (snail tracks) + iridocorneal adhesion (PAS) --> epithelial like changes in the endothelium Associated with corectopia, glaucoma (open/closed angle) PPCD + retinal flecks = Alport syndrome PPCD GENE P - Posterior corneal involvement P - Polymorphous endothelial cell transformation (epithelial-like) C - Congenital / detected in early adulthood D - Dominant inheritance G - genetic mutations ZEB1 (most common, PPCD3) COL8AE2 (PPCD2) OVOL2 (PPCD1) E - Endothelial proliferation N - Non-inflammatory E - elevated IOP risk due to angle involvement

Answer 25

Discrete clear Epithelial vesicles centrally which spread peripherally

Answer 26

Both have grey/white subepithelial opacities --> most dense centrally and increase to form a reticular pattern Thiel is less individually defined, have "curly fibres" on electron microscopy

Answer 27

Filamentous: hyphae and enzymes that penetrate stroma Yeast: pseudohyphae with proteases/phospholipases aiding invasion

Answer 28

1. Ocular mucous membrane pemphigoid (OCP) 2. Steven Johnsons/Toxic Epidermal Necrolysis 3. Chemical burns 4. Trachoma 5. Chronic medicamentosa 6. Ocular rosacea 7. Trauma/radiation

Answer 29

1. Fornix foreshortening 2. Subepithelial fibrosis 3. Symblepharon --> Ankyloblepharon (look for inferior symblepharon on downgaze with lower lid traction)

Answer 30

Foster: clinical milestones 1. Subconjunctival scarring 2. Fornix foreshortening 3. Symblepharon 4. Ankyloblepharon / Frozen Globe Mondino: Inferior fornix depth loss: 0%, 25%, 50%, 75%, Tauber modifiers: Adds on symblepharon, guides monitoring/therapy escalation

Answer 31

1. Trachoma inflammation - follicular: >5 follicles on upper tarsal conjunctiva 2. Trachoma inflammation - intense: Pronounced thickening/ inflammation > 50% of tarsal area 3. Trachomatous scarring - conjunctival scarring visible 4. Trachoma trichiasis - 1 eyelash rubbing on globe 5. Corneal opacity - opacity involving the pupillary margin

Answer 32

Congenital: Aniridia, Xeroderma pigmentosum Acquired: 1. Injury - chemical, thermal, UV 2. Inflammatory - OMP, SJS, PUK, VKC, Graft vs host disease 3. Ocular - contact lens wear, neurotrophic cornea, preservative drop toxicity, multiple pterygium surgeries

Answer 33

1. Conjunctivalisation onto corneal surface 2. Persistent epithelial defects/inflammation/calcification 3. Loss of palisades of vogt 4. Whorled appearnce of corneal epithelium 5. Limbal ischaemia

Answer 34

History: Chemical injuries, UV, contact lens wear, previous pterygium surgery Investigations 1. Impression cytology: Mucin-containing goblet cells on corneal epithelium, absence of CK 3 and CK12. 2. Immunoflourescence: Check for IgG, IgA, C3 deposits in OMP 3. Confocal microscopy: Limbal pallisades viewing.

Answer 35

MESS M - Microcysts E - Epithelium involved S - Symptoms mild S - Slit lamp shows vesicles

Answer 36

Lash and Lid Malposition 1. Epilation/electrolysis 2. Tarsal fracture (Wies) for marginal ciactricial entropion 3. Posterior lamellar replacement Symblepharon 1. Lysis + AMT/conjunctival or buccal mucous membrane graft 2. Rings/Scleral shells to maintain fornices Ocular surface reconstriction (LSCD) Cultivated oral mucosal epithelial transplant (SJS)

Answer 37

EKC: serotypes 8, 19, 37 - keratitis 80% and more severe PCF: serotypes 3,7, mild keratitis <30%

Answer 38

1. Inferior tarsal follicles 2. Tender preauricular node 3. Subconjunctival haemorrhages 4. Subepithelial infiltrates 5.Membrane/pseudomembranes EKC specific: pseudomembranes, large erosions, sub-epithelial infiltrates

Answer 39

1. Membranes/pseudomembranes 2. Visually significant subepithelial infiltrates --> can delay viral clearance

Answer 40

Shedding takes 2 weeks - no sharing towels, meticulous hand hygiene

Answer 41

Benign congenital choristoma containing ectodermal and mesodermal tissues --> can cause astigmatism and ambylopia

Answer 42

Goldenhar syndrome

Answer 43

1. Ferry - Trabeculectomy margin 2. Stocker - Pterygium margin 3. Hudson-Stahli - horizontal inferior 1/3rd of cornea (idiopathic) 4. Fleischer - base of cone in epithelium - keratoconus

Answer 44

1. DMEK: only Descemet's and endothelium - (10-20um thickness) - Faster visual recovery - Lowest induced hyperopia/astigmatism - Technically difficult, higher early graft detachment/rebubbling rates 2. DSAEK/DSEK: Posterior stroma + Descemet's + Endothelium (80-150um) - Easier - Slower visual recovery 3. PK: Stromal scarring, ectasia, previous graft failure - Higher risk of astigmatism - Higher risk of rejection

Answer 45

PAM: acquired unilateral flat pigmented lesion of conjunctiva affecting middle-aged white patients arising de novo PAM without atypia: Benign proliferation of melanocytes PAM with atypia: Premalignant abnormal melanocytes with nuclear atypia --> can breach the basement membrane

Answer 46

1. Histological atypia 2. Growth/irregular borders 3. Involvement of palpebral conjunctiva or caruncle

Answer 47

1. Excisional biopsy with no-touch technique with cryotherapy to adjacent conjunctiva to reduce recurrence 2. Topical mitomycin C --> widespread PAM with atypia 3. Amniotic membrane graft if large areas excised

Answer 48

1. UV exposure (interpalpebral limbus) 2. HPV (16/18) 3. HIV 4. Immunosuppresion 5. Smoking 6. Xeroderma pigmentosum 7. CIN

Answer 49

Conjunctival/limbal: Gelatinous/papilliform/ plaque like leukoplakic mass with sharp borders, feeder vessels interpalpebral zone Corneal: Translucent grey epithelial sheet from limbus with fimbriated/pseudopodial margins (islands possible)

Answer 50

Conservative 1. Address risk factors: Stop smoking, UV protection 2. Punctal occlusion during chemo to reduce systemic absorption risk Medical 1. Topical chemotherapy with mitomycin C or interferon alpha2beta Surgical 1. Excisional biopsy with wide margins, intraoperative and postoperative MMC 2. Lamellar sclerectomy if deep scleral involvement 3. Exeenteration for orbital invasion Follow up: 3-6 monthly in year 1-2, then yearly Full ocular survey (double eversion) + regional node palpation

Answer 51

History: Ask about risk factors, HPV, HIV, Smoking, Immunosuppresion, UV exposure, check preauricular and submandibular lymph nodes Ophthalmic - Anterior segment: Photos and OCT - Biopsy: Dysplastic changes breaching basement membrane - Impression cytology if biopsy not available

Answer 52

MARGIN M: medial/peripheral location A: Antigen-antibody reaction R: Rosacea or blepharitis association G: Grey-white infiltrates I: Immune mediated N: No epithelial defect

Answer 53

FEED ME F: Fuch's E : Endothelial failure post-cataract surgery (pseudophakic bullous keratopathy) E: Endothelial rejection post-PK / DSAEK D: Descemet's membrane detachment M: Microcystic oedema due to endothelial dysfunction E: Endothelial feailure in irido-corneal endothelial syndrome (selective cases)

Answer 54

Ipsilateral iris hyperchromia Iris mammillations Ipsilateral hyperpigmentation of face Subconjunctival flat/grey lesion More common in males/orientals

Answer 55

LARGE L: Lattice A: Avellino R: Reis-Buckler G: Granular E: EMBD

Answer 56

THYGESON T - Teens/young adults H - Hazy central coarse opacities Y - Years of relapses G - Grey granular crumb like epithelial spots E - Epithelium only S - Steroid responsive O - Often bilateral, asymmetric N - Non-minimally staining / negative staining

Answer 57

1. Systemic immunosuppresion - Dapsone (mild after G6PD testing), methotrexate, mycophenolate, azathioprine 2. Severe - cyclophosphamide (oral/IV) + systemic steroids 3. Biologics - rituximab

Answer 58

Age of onset: PMD in adults (30-50s), keratoconus begins in adolescence/early adulthood Location of protrusion/thinning: PMD - protrusion lies above area of maximal thinning Keratoconus: Protrusion and thinning coincide, typically inferocentrally Associated findings: Hydrops, scarring, Vogt's striae in Keratoconus, rare in PMD

Answer 59

1. Unilateral redness and photophobia 2. Small white/pink nodules on limbus or bulbar conjucntiva surrounded by engorged vessels 3. Corneal phyctelnules may ulcerate and cause pannus

Answer 60

1. Topical anaesthesia 2. Central 9mm of corneal epithelium removed 3. 0.1% Riboflavin every 1-5 minutes for 30 minutes 4. Exposure to UVA light (365nm wavelength) for 30 mins (5.4 J 5. Topical antibiotic 6. BCL insertion Contraindications 1. CCT <400 2. Age >35yo

Answer 61

1. Adult inclusion - inferior palpebral conjunctiva findings 2. Trachoma - superior palpebral conjunctiva findings 3. Chlamydia psittaci: equal involvement of superior and inferior palpebral conjunctiva

Answer 62

Both have intraepithelial microcysts --> Meesman has diffuse evenly spaces cysts, X-linked Lisch has densly packed cysts.

Answer 63

Conjunctival biopsy with direct immunofluorescence --> Linear deposition of IgG, IgA, C3 along the epithelial basement membrane zone

Answer 64

HPV 6, 11 (papilloma) HPV 16, 18 (malignancy)

Answer 65

1. Subepithelial elevated nodules (gray/white/blue) in a circular configuration involving central or paracentral cornea 2. Subepithelial fibrosis at 3 and 9 o clock in patients who wear hard contact lenses 3. Irregular astigmatism, photophobia and foreign body sensation

Answer 66

1. Limited - affects middle-aged to elderly Caucasian patients, unilateral and responsive to treatment 2. Aggresive - young African patients, bilateral, resistent to treatment and higher risk of perforation --> associated with helminthic toxins (parasites)

Answer 67

1. Grey infiltrate at leading udge with no limbal clear zone (unlike marginal keratitis and terrien's) 2. No scleritis 3. Stromal melt, progresive peripheral ulceration Associations 1. Hepatitis C 2. Autoimmune

Answer 68

1. Endophthalmitis - immunocompromised patients 2. Descemetocele - progressive stromal melting --> descemetocele 3. Wound dehisence - localised infection at suture site weaken the graft-host junction in the early post-operative period

Answer 69

STUMPED S: Sclerocornea T: Trauma/tears in descemet's U: Ulcer M: Metabolic conditions P: Peters E: Endothelial defect D: Dermoid

Answer 70

1.FPC location (fornix, palpebral, caruncle 2.Thickness > 1mm 3.Recurrence 4.Multifocal lesion 5.De novo origin 6.Tumours not involving limbus 7.Pagetoid/lymphatic spread

Answer 71

1. Persistent unilateral keratoconjunctivitis 2. Infiltrates cornea, sclera and globe 3. Rarely metastasise

Answer 72

Earliest: Lid margin staining Diagnostic indicator: Bulbar conjunctival staining

Answer 73

Other stromal corneal dystrophies 1. Macula 2. Lattice 3. Avellino 4. Schnyder's corneal dystrophy Deposition 1. Vortex Keratopathy 2. Crystalline keratopathy

Answer 74

1. Granular --> Clear stroma, Macular --> Cloudy stroma 2. Granular --> central involvement, Macular --> peripheral and central 3. Granular --> No corneal thinning, Macular --> corneal thinning 4. Granular --> hyaline stains with masson trichrome, Macular --> muco-polysaccharides stain with Alician blue 5. Granular --> AD inheritance Macular --> AR inheritance

Answer 75

Acute erosion: Lubricants, hypertonic saline for corneal oedema and to improve epithelial adhesion, antibiotic ointment, cycloplegia, BCL. Conservative: Photophobia - tinted glasses Refractory: 1. Anterior stromal puncture (usually for post-traumatic cases, not used centrally to to possibility of scarring) 2. superficial keratectomy (allows for more uniform regrowth with alcohol delamination) 3. Diamond Burr polishing - smoothen Bowmen's membrane and promote better adhesion 4. PTK: excismer laser treatment to remove superficial pathology and provide smooth surface for epithelial basement membrane attachment 5. Reduced vision: DALK or PK (can recur)

Answer 76

1. Small discrete sharply demarcated grayish/white opacities in anterior central stroma, with intervening clear stroma and sparing of periphery 2. Opacities vary in shape and can be either drop-shaped, crumb-shaped or ring shaped (Crumb-like opacities)

Answer 77

My lovely Granny Macula Lattice Granular

Answer 78

***I would classify causes of corneal opacity by affected corneal layer and tailor further assessment based on depth, laterality, vascularisation and associated inflammation Epithelium: - Epithelial scarring - recurrent erosions, trauma - Limbal stem cell deficiency (chemical burns, steven Johnsons) - Band keratopathy - Lipid keratopathy - Neurotrophic keratopathy Bowman's layer: - Trauma (Bowman's doesn't regenerate, permanent scar) - Reis-Buckler's dystrophy - Thiel-Behnke dystrophy Stroma -Infective : Herpes simplex, bacterial, fungal, acanthomoeba - Inflammatory/Immune: Interstitial keratitis (syphilis, TB), PUK, Mooren's ulcer - Ectatic - Keratoconus - Degenerative - Salzmann, Terrien's - Dystrophies: Macular, granular, lattice - Trauma: Corneal scars, mucopolysaccharidosis, cystinosis Stromal opacities tend to be visually significant due to light scatter Descemet's membrane - Haab striae (congenital glaucoma) - Descemet's membrane rupture - Hyodrops scars Endothelium - Fuch's - Endothelitis (HSV, CMV) - ICE syndrome Congenital 1. Peter's anomaly 2. Sclerocornea 3. Congenital hereditary endothelial dystrophy 4. Birth trauma

Answer 79

Superficial causes - chronic blepharitis/ocular surface disease - limbal stem cell deficiency - ocular cicatricial pemphigoid - exposure keratopathy - vitamin A deficiency Deep stromal causes - interstitial keratitis (syphilis, tb lyme) - Herpes (simplex + zoster) keratitis - PUK - Moorens - Severe microbial keratitis Mixed - Chemical injuries - Ocular cicatricial pemphigoid - Graft failure/rejection

Answer 80

Optical - restoration of corneal clarity : 1. keratconus 2. corneal scarring secondary to herpes simplex, infections, trauma, 3. Deep stromal corneal dystrophies Tectonic - restoration of corneal integrity: 1. Corneal thinning - inflammatory/immune (PUK), Infective, Ectatic, Traumatic (burns), neurotrophic 2. Threatened / actual perforation - infective, inflammatory, neurotrophic, trauma, ectatic (post-hydrops rupture) Therapeutic: Infective keratitis

Answer 81

No absolute, just relative 1. Epithelial dysfunction secondary to limbal stem cell deficiency 2. Severe neurotrophic cornea 3. . Stromal vascularisation involving more than 2 quadrants 4. . Multiple (2+) graft failures

Answer 82

1. Higher risk of graft rejection 2. Risk of suture related complications 3. Risk of traumatic wound dehiscence and globe rupture

Answer 83

Intraoperative 1. Retained Descemet's membrane - presence of double AC on post-op day 1 2. Scleral perforation from bridal suture placement 3. Haemorrhage: AC haemorrhage from iris damage or suprachoroidal explusive haemorrhage Early post-operative 1. Wound leaks (shallow AC/Seidels +ve) - can be controlled by BCL, resuturing not necessary 2. Epithelial defect: Lubricants/BCL/ tarsorrhaphy, decreased steroids 3. Suture related complications: - immune infiltrates (multiple on recipient side of cornea and treat with topical steroids and removal of suture) - Kaye dots (small epithelial dots a short distance from sutures on donor side, not pathological and disappears after suture removal) 4.- **Endophthalmitis** Late post-operative

Answer 84

Graft rejection: Immune attack against donor endothelium (usually first 3 years) Causes: - Epithelial rejection: elevated epithelial rejection line those stains with fluorescein—responds to topical steroids * Subepithelial infiltrates: immune reaction seen only in the donor tissue without associated conjunctivitis—responds to topical steroids Endothelial rejection line (khodadoust line): does not extend beyond graft-host junction with KP’s at the leading edge with an overlying hazy and oedematous stroma +/− DM folds—if left untreated this line will proceed across the donor endothelium from the point of origin at the graft wound leaving damaged endothelium behind it—treat with intensive topical steroids * Diffuse endothelial rejection: isolated or diffuse KP’s are scattered across the endothelium and are limited to the donor endothelium and often associated with an AC reaction—treat with intensive topical steroids Graft failure: permanent loss of graft clarity or function either primary or secondary causes Primary: Straight away, corneal opacity and haze never clears Secondary causes: - irreversible rejection - chronic endothelial cell loss -poor donor quality - intraoperative trauma to donor endothelium - prolonged flat AC in the immediate postoperative period - HSV reactivation

Answer 85

- red eye - AC activity - Raised IOP - Keratic precipitates - Corneal oedema - Khodadoust line

Answer 86

- Corneal stromal vascularisation - Reduced corneal sensation - Ocular surface disease (Dry eye, OCP, SJS) - Previous graft failure - Large graft size (8–8.5 mm) and eccentric grafts

Answer 87

Early: Amber or golden spherical deposits peripherally in interpalpebral zone - subepithelial / anterior stromal Moderate: Central involvement Advanced Visual axis involvement Bilateral small translucent amber-colored oil droplet spherules in the superficial corneal stroma located in interpalpebral zone Droplets can coalesce to form larger, nodular elevated opacities causing hazy appearance

Answer 88

1. Salzmann nodular degeneration + : both have superficial nodules -: Salzmann are blueish white and follow ocula rsurface inflammation, whereas spheroidal degeneration are amber coloured and UV related 2. Band keratopathy + : Both are lesions which occur in interpalepbral space -: Band - calcium deposits, usually white/grey and leave clear zone at limbus, spheroidal degenertation starts at limbus 3. Corneal dystrophy

Answer 89

Grade 1: Fine droplets in peripheral nasal/temporal limbus Grade 2: Droplets spreading to central cornea Grade 3: Large prominent nodules significantly impairing vision and cause surface irregularity

Answer 90

1. Occupational/environmental exposure: History of working outdoors in high UV environments (fishermen, farmers) 2. Exposure to wind/sand/extreme cold 3. Previous ocular surface disease/trauma

Answer 91

1. Slit lamp biomicroscopy - assess depth and extent of spherules 2. Anterior segment OCT: Localise depth of deposits (usually superficial stroma) 3. Topography - quantify degree of irregular astigmatism caused by nodules

Answer 92

1. Conservative: UV protection with wrap-around sunglasses and hats, environmental protection 2. Medical: PF lubricants to improve tear film and reduce foreign body sensation 3. Surgical: - **superficial keratectomy:** manual debridement of nodules of they affect vision or cause persistent irritation - **phototherapeutic keratectomy (PTK)** - using an excimer laser to smooth corneal surface after manual removal - **Lamellar or penetrating keratoplasty** - only in rare cases where opacification is deep and VA cannot be restored by superficial means

Answer 93

1. **Iris melanoma with hyphaema**: melanomas typically >3mm in diameter, thicker than 1mm more likely to progressively grow 2. **Ciliary body melanoma with anterior extension** 3. **Iris neovascularisation** : rubeosis iridis due to neovascular glaucoma can cause sponatenous hyphaema 4. **Traumatic hyphaema**

Answer 94

ABCDEFG A: Age (younger age at diagnosis) B: Blood (spontaneous hyphaema) C: Clock hour (inferior location) D: Diffuse growth pattern E: Ectropion uveae F: Feathery / satellite margins G: Glaucoma (secondary)

Answer 95

1. Inferior iris lesion 2. Ectropion uvae 3. Corectopia Angle findings 1. Tumour seeding, infiltration

Answer 96

**Conservative: 1. Serial anterior segment photographs every 3-6 months for low risk lesions 2. ultrasound B scan **Medical **1. Hyphaema management - cycloplegics, steroids, IOP agents **Surgical **1. Iridectomy/Iridocyclectomy with cosmetic contact lens 2. Radiotherapy - plaque Ruthenium-106/Iodine 125 for medium size tumours 3. Proton beam therapy - alternative for larger/diffuse melanomas 4. Enucleation : Extensive lesions, extrascleral extension, uncontrolled secondary glaucoma******

Answer 97

Marked displacement of the pupil (eccentric, not central) - correctopia Irregular pupil shape Distorted iris architecture with areas of traction and iris strands Poor central pupillary alignment with the visual axis Want to check VA, IOP, angle findings, trauma history, uveitic history

Answer 98

Ts Thinning: Peripheral stromal thinning which spreads circumferentially Top thinning: Superior thinning more common Thin vascularisation: Superficial Lipid deposition at edge of thinning Epithelium intact Irregular astigmatism/against-the-rule: Gutter thinning

Answer 99

HISTORY 1. Demographics : 20-40 male 2. Visual symptoms: Blurring due to irregular astigmatism 3. Pain: Confirm absence of pain to rule out inflammatory causes 4. Systemic health: Rule out systemic vasculitis INVESTIGATIONS Slit lamp: assess depth of gutter and presence of lipid/pannus Anterior segment OCT: measure residual stromal thickness Corneal topography: quantify degree of irregular astigmatism

Answer 100

Conservative 1. Glasses / RGPs to correct high against the rule irregular astigmatism 2. Safety glasses : polycarbonate lenses to protect thinned cornea Medical - nil Surgical - Indications: Impending perforation, uncorrectable astigmatism Crescenteric lamellar keratoplasty: tectonic or optical Annular ring keratoplasty: advanced circumferential disease Full thickness banana graft: if perforation

Answer 101

1. Moorens' Ulcer: painful active epithelial defect with an overhanging edge 2. PUK : painful, active stromal loss, 3. Marginal keratitis: Clear limbal zone 4. Corneal Arcus: clear inteval and does not involve corneal thinning

Answer 102

1. Spheroidal degeneration: Golden-brown oil droplets in interpalpebral zone 2. Band keratopathy: Calcium deposits in interpalpebral zone 3. Terrien's marginal degeneration: superior peripheral thinning with intact epithelium 4. Phylencticular conjunctivitis: acute, painful, intense injection with vessels

Answer 103

1. Chronic MGD 2. Contact lens-wear (long-term) 3. Corneal scarring (interstitial keratitis, trachoma, trauma)

Answer 104

Foreign body sensation, gradual blurring of vision (nodules encroaching visual axis) 1. Slit lamp examination with flourescein staining - check for epithelial defect and negative staining above raised nodules (tear film thinning over nodules) 2. Corneal topography: Degree of irregular astigmatism 3. Anterior segment OCT: Can show subepithelial nodular changes

Answer 105

Conservative Lid Hygeine: underlying MGD Scleral lenses (RGPs): irregular astigmatism and comfort Surgical: SK: Superficial keratectomy: remove nodules in subepithelial plane PTK: Smooth basement membrane after manual removal and reduce risk of recurrence

Answer 106

1. Keratoconus: reduce corneal irregularity and astigmatism in patients intolerant of contact lenses 2. Post-LASIK ectasia: 3. Pellucid Marginal Degeneration: regularise the topography 4. Low Myopia: historically.

Answer 107

Inserted in mid-peripheral corneal stroma Flatten the central cornea Often combined with corneal cross-linking

Answer 108

1. Raised IOP secondary to steroid response or PUPILLARY BLOCK 2. Wound leak: Shallow AC, Positive seidel's test 3.Infection: Fungal/Bacterial keratitis or endophthalmitis 4. Epithelial defects 5. Primary Graft Failure: persistent corneal oedema from day 1.

Answer 109

“GRAFT FAILS” G – Glaucoma R – Rejection A – Astigmatism F – Failure T – Trauma (wound dehiscence) F – Infection A – Abscess (suture) I – Irregular epithelium L – Leak S – Suture problems

Answer 110

Graft rejection: Epithelial rejection: raised epithelial lines Stromal rejection: Stromal oedema Endothelial rejection: Khadodoust line Astigmatism Irregular astigmatism due to suture tension or graft/host mismatch Suture related complications 1. Loose sutures 2. Suture abscess 3. Vascularisation

Answer 111

1. Graft failure: Corneal decompoensation 2. Corneal vascularisation: Increased rejection risk 3. Recurrence of original disease: 4. Post-keratoplasty glaucoma: Chronic IOP elevation 5. Infectious crystalline keratopathy: Needle-like branching crystalline stromal infiltrates in corneal graft and immunocompromised corneal patients

Answer 112

1. Yellow white crystalline stromal opacity 2. Starts peripherally and extends centrally 3. Associated superficial/deep vessels 4. Opacity follows the direction of corneal vessels

Answer 113

1. Interstitial keratitis: Salmon patch injection, stromal oedema, deep vascularisation 2. Schnyder Corneal Dystrophy: Bilateral central crystalline opacities with corneal arcus (UBIAD gene) 3. Band keratopathy: Calcium deposits in Bowman's layer, horizontal interpalpebral distribution / swiss cheese holes 4. Spheroidal degeneration

Answer 114

1. Primary (rare): no corneal vascularisation, bilateral, associated with systemic lipid disorders 2. Secondary: associated with corneal neovascularisation, often unilateral - Infectious: HSK, HZO, microbial - Inflammatory: Interstitial keratitis, phlyctenular keratoconjunctivitis, rosacea - Degenerative: chronic blepharitis, exposure keratopathy - Trauma/surgery: penetrating injury, graft rejection

Answer 115

Ophthalmic 1. Slit lamp photography: document extent of lipid and location of feeder vessels 2. Anterior segment OCT: assess dephth of lipid deposition within stroma 3. Corneal topography: Assess for irregular astigmatism Systemic 1. Fasting lipid profile: rule out hyperlipidaemia 2. Syphilis/TB serology: Rule out IK causes 3. Autoimmune screening: ANA/ANCA if autoimmune disease suspected

Answer 116

Conservative: Treat underlying cause (blepharitis/herpetic disease) RGP lenses Medical 1. Control inflammation: topical steroids or cyclosporine (to control feeder vessels) Surgical 1. Argon laser photocoagulation: Target feeder vessels at limbus to induce regression 2. Fine Needle Diathermy: Cauterisation of vessels under slit lamp 3. Anti-VEGF injections: Subconj or intrastromal (Bevacizumab) to induce regression 4. Superficial keratectomy, lamellar keratoplasty (deep stromal lipid deposition) 5. Penetrating keratoplasty: Visual axis involvement with significant scarring --> higher graft rejection risk due to pre-existing neovascularisation

Answer 117

1. Superior AC oil bubble floats upwards 2. Contact with corneal endothelium 3. Shallow AC with elevated IOP Longstanding cases 1. Band-shaped keratopathy 2. Corneal decompensation 3. Endothelial failure in aphakia: create inferior peripheral iridectomy (Ando iridectomy) : Allows aqueous flow beneath oil bubble to prevent pupillary block

Answer 118

1. Corneal endothelium damage/corneal decompensation (bullous keratopathy) 2. Secondary glaucoma: Pupillary block, angle obstruction, trabecular infiltration

Answer 119

Normally prevented by: intact posterior capsule lens barrier iris–lens diaphragm Migration occurs when these barriers are disrupted. Common mechanisms 1️⃣ Aphakia (most important) ⭐ No lens → direct passage into AC 2️⃣ Posterior capsule rupture 3️⃣ Zonular weakness 4️⃣ Large iridectomy / surgical defects 5️⃣ Overfill with silicone oil 6️⃣ Supine positioning early post-op Risk factors: Aphakia Complicated cataract surgery Trauma Large peripheral iridectomy Long-term silicone oil tamponade Hypotony Repeated intraocular surgery

Answer 120

Slit lamp examination: Size of oil bubble, endothelial touch, AC dephth, lens status, peripheral iridectomy patency IOP, Gonioscopy (silicon oil drops, PAS) Anterior segment OCT + Specular microscopy + corneal pachymetry: Assess for endothelial cell loss. B scan: PVR/retinal detachment recurrrence

Answer 121

Conservative: observe if no cornela touch, normal IOP, early post-operative Medical 1. Positioning (face-down) 2. IOP control drops Surgical. Indications: Corneal touch, uncontrolled IOP, endothelial compromise 1. Anterior chamber washout 2. Silicon oil removal 3. Inferior peripheral iridectomy if pupillary block present

Answer 122

1. Fine branching refractile lines resembling spider webs --> Begin centrally and spread peripherally 2. Intervening stroma is clear, but can progress to diffuse subepithelial haze with limbal sparing (peripheral 1-2mm) 3. Usually bilateral 4. Evidence of recurrent erosions: Epithelial irregularity, microcysts, focal staining

Answer 123

1. Granular dystrophy 2. Macular dystrophy 3. Reis-Bucklers dystrophy

Answer 124

History: typical history present in first decade of life with RCES, and significant visual impairment occurs in 4th/5th decade Investigations - Anterior segment OCT: hyperreflective deposits in subepithelial/anterior stromal layers - Corneal topography: check for irregular astigmatism Histology: Amyloid deposits, Congo Red Positive, apple-green bifringence under polarised light Systemic: - Neuro examination to rule out cranial nerve palsies - Check for systemic amyloidosis - Check for cardiorenal disease Genetic testing: TGFB1 mutation

Answer 125

1. Type 1: Classic - isolated corneal disease 2. Type 2: Meretoja syndrome - systemic amyloidosis, cranial neuropathies, facial nerve palsy, lax skin. Corneal signs START PERIPHERALLY and move centrally

Answer 126

Conservative - Lubricants, BCL Medical - Lubricants, hypertonic saline, topical antibiotics (if epithelial defect) Surgical - Mild: PTK (clearing subepithelial haze) , anterior stromal puncture (peripheral) epithelial debridement - Severe: DALK, PK --> recurrence can occur after graft.

Answer 127

Diffuse: Generalised inflammation, painful deep violacious hue (moderate) Nodular: Localised, tender, immobile nodule Necrotising without inflammation (scleromalacia perforans) : Classically in long-standing chronic seropositive RA; quiet eye, painless scleral thinning and blue hue. Angiography --> vascular occlusion Necrotising with inflammation: Severe pain, avascular white patches, scleral thinning, risk of perforation

Answer 128

Ophthalmology: Scleritis + peripheral corneal infiltrates (PUK) Other: Glomerulonephritis/pneumonitis and saddle nose deformity

Answer 129

Inflammation of cartilage affecting the ear, nose (saddle-nose), trachea/larynx and large cardiac vessels. Can also cause episcleritis.

Answer 130

Non-infectious and infectious. Infectious scleritis normally caused by pseudomonas most commonly after.. 1. pterygium surgery 2. strabismus surgery 3. trabeculectomy 4. VR surgery

Answer 131

Non-necrotising: 1. Oral NSAIDS: Flurbiprofen or indomethacin 50mg TDS 2. systemic immunosuppresion with steroids: oral 1mg/kg/day then gradual taper. Topical steroids help with symptoms. Necrotising: needs systemic immunosuppresion - MTX, cyclophosphamide, mycophenolate, inflixamab - with rescue therapy with IVMP, PO steroids Subconjunctival steroid is controversial: risk of perforation / high IOP. INFECTIOUS CAUSES MUST BE RULED OUT PERIOR TO IMMUNOSUPPRESION Referral to rheumatology to co-ordinate care.

Answer 132

RCS thickening (retina, choroid, sclera) in VKH and sympathetic ophthalmia Posterior scleritis

Answer 133

FUCHS F - Fine stellate KPs U - Unilateral uveitis with spillover with no posterior synechiae C - Cataract - PSC common H - Heterochromia due to diffuse iris stromal atrophy with iris nodules S - Secondary glaucoma

Answer 134

SOCK 1. Scleromalacia perforans 2. Osteogenesis imperfecta - brittle bones, hyperextended joints, sensorineural hearing loss and hyperopia 3. Connective tissue disorders (EDS, Marfans, pseudoxanthoma elasticum) 4. Keratoconus/Keratoglobus

Answer 135

1. ANA positive 2. RF negative 3. Oligoarthritis 4. Lower extremity arthritis 5. Lack of wrist arthritis 6. Female

Answer 136

Gross corneal opacities Iris abnormalities: Polycoria, Anridia, post-traumatic causes

Answer 137

1. Herpes keratitis 2. Prominent/enlarged corneal nerves

Answer 138

Step 1: Rule out congenital glaucoma first 🚨 photophobia ⭐, blepharospasm, tearing + irritability corneal clouding, enlarged eye Examine: corneal diameter (>12 mm suspicious) corneal haze Haab striae IOP (if possible) optic nerve tear meniscus height ↑ crusting at medial canthus reflux from punctum with pressure eyelid malposition (rare) Lacrimal sac compression test ⭐ Press over lacrimal sac: mucopurulent reflux from punctum → diagnostic of CNLDO Fluorescein dye disappearance test (FDDT) Instil fluorescein: Normal: clears within 5 minutes Delayed clearance: nasolacrimal obstruction likely History: Onset since birth → likely CNLDO later onset → consider infection, trauma, glaucoma Laterality unilateral more common in CNLDO bilateral possible but raises suspicion of glaucoma Discharge type watery → obstruction mucopurulent → secondary infection Redness Suggests: conjunctivitis, dacryocystitis

Answer 139

Conservative: 1. Crigler massage: Downward pressure over sac 4-5 times a day Surgical 1. If persistent > 12 months -->syringing and probing 2. repeat probing, balloon dacryoplasty, silicone tube intubation, DCR (rare in infants)

Answer 140

History: Ask about recurrent corneal erosion symptoms 1. Slit lamp examination: 2. Staining: Stains Mucopolysaccarides Alician Blue 3. Anterior segment OCT: Corneal thinning 4. Systemic: Urinary GAGs 5. Genetic testing: CHST6 (autosomal recessive)

Answer 141

Acute erosion: Lubricants, hypertonic saline for corneal oedema and to improve epithelial adhesion, antibiotic ointment, cycloplegia, BCL. Conservative: Photophobia - tinted glasses Refractory: 1. Anterior stromal puncture (usually for post-traumatic cases, not used centrally to to possibility of scarring) 2. superficial keratectomy (allows for more uniform regrowth with alcohol delamination) 3. Diamond Burr polishing - smoothen Bowmen's membrane and promote better adhesion 4. PTK: excismer laser treatment to remove superficial pathology and provide smooth surface for epithelial basement membrane attachment 5. Reduced vision: DALK or PK (less commonly recurs)

Answer 142

1. Bacterial keratitis: Wet infiltrate, pseudomonas/staphylococcus 2. Fungal keratitis: Feathery margins, satellite lesions, immobile 'sticky' hypopyon 3. Acanthamoeba keratitis: Ring infiltrate, history of contact lens water exposure 4. Herpetic geographical ulcer: Recurrence, reduced corneal sensitivity 5. Post infective keratitis/endophthalmitis/TASS 6. Non-infectious keratitis: Marginal keratitis, Mooren's ulcer, PUK.

Answer 143

History 1. Contact lens wear: Swimming/Shower/Sleeping 2. Recent vegetative trauma/use of steroids 3. Immunosuppresion Ophthalmic 1. Corneal scraping: Scraping for culture and gram stain: Gram stain, Giemsa stain, KOH mount. Plate samples on Blood agar, Chocolate agar and Sabouraud agar 2. Corneal PCR 3. Corneal impression Membrane 4. Corneal biopsy 5. Anterior segment OCT: Depth of stromal involvement and monitor for thinning 6. Confocal microscopy: Consider if fungal

Answer 144

Admission Medical: 1. Fortified intensive antibiotics: Ceftazidime (50mg/ml), Vancomycin (50mg/ml) 2. Cycloplegia: Atropine 1% TDS to manage ciliary spasm and prevent formation of posterior synechiae 3. No steroids until epithelial defect has healed 4. Oral ciprofloxacin 500mg BD/moxifloxacin 400mg OD If not responding.. 1. Add second agent (eg cefuroxime) 2. Consider witholding treatment for 12-24 hours and then re-scraping 3. Consider alternative causing organism 4. CORNEAL BIOPSY 5. Amniotic membrane for persistent epithelail defect 6. Corneal glue for small perforation <3mm 7. Tectonic corneal graft >3mm for larger perforation

Answer 145

History - Alport syndrome: XR condition - sensorineural deafness, glomerulonephritis Examination - Vesicular lesions: transparent round cysts in line/clusters - Band lesions: Horizontal with scalloped edges - Gonioscopy: PAS seen - Lens: Anterior lenticonus - Fundus: Pigmentary retinopathy Bloods 1. Renal function tests and Urinanalysis: Alports 2. Hearing Tests: Alports

Answer 146

Conservative: Observe: usually asymptommatic Medical: Screen for glacuoma: Treat medically/surgically Surgical 1. PK - if significant reduced vision 2. GDD if uncontrolled glaucoma

Answer 147

1. Endothelial dystrophies: Fuchs', CHED 2. ICE syndrome: PAS, corectopia, glaucoma 3. Axenfeld-Reiger syndrome 4. Congenital Glaucoma

Answer 148

1. Endothelial corneal guttata: Beaten metal apperance 2. Corneal stromal oedema with MD folds 3. Microcystic epithelial oedema --> bullae --> erosions 4. Subepithelial fibrosis scarring between epithelium and Bowman's membrane 5. POAG 6. TCF4 genetic association

Answer 149

1. Pseudophakic bullous keratopathy 2. ICE syndrome (Chandler's) 3. PPCD 4. CHED 5. Pseudoguttae: Post-trauma, post-intra-ocular inflammation --> transient and disspear with resolution of underlying condition 6. Hassall-Henle Bodies: Normal aging change - guttata located in peripheral cornea rather than centrally 7. PDS: Krukenburg's sspindle can mimic guttata

Answer 150

Stage 1: Central guttata, asymptommatic Stage 2: Confluent guttata, stromal oedema Stage 3: Epithelial oedema and bullae formation Stage 4: Subepithelial fibrosis and scarring

Answer 151

History 1. Transient blurring in morning (overnight tear film evaporation reducing corneal hydration) 2. Pain: Suggests ruptured bullae 3. Family history: AD with female preponderance Investigations 1. Pachymetry: CCT - 600-640um in presence of guttata suggests significant oedema 2. Specular Microscopy: Endothelail cell density (ECG), pleomorphism (shape variation), polymegathism (size variation). ECD <1000 cells/mm2 increases risk of decompensation 3. AS-OCT: Visual Decemet's membrane and map stromal oedema 4. Genetic testing: TCF4 gene association

Answer 152

Medical 1. Hypertonic saline 5% drops: Drops during day and ointment at night to dehydrate cornea via osmosis 2. Warm Air: Use a hair dryer at arms length to speed up tear evaporation Surgical 1. DMEK: Gold standard: Transplants only Descemet's and endothelium - faster recovering and lower rejection 2. DSEK/DSAEK: Transplanting endothelium, Descemet's and posterior layer of stroma: Significant corneal scarring 3. DSO: Descemet stripping only. Removing central guttata without transplant --> allows patient own peripheral cells to migrate centrally (only for specific cases with healthy peripheral counts)

Answer 153

AMBER A: Amber/Gold droplets peripheral interpalpebral cornea M: Many Glistening /coalescent nodules nodules B: Band-shaped distribution E: Epithelial irregularity R: Rough surface Clear superior cornea under upper lid

Answer 154

BANDS B: Band keratopathy: Both in interpalpebral space - caclium deposits limbal sparing, spheroidal generally starts peripherally (at limbus) A: Amyloid dystrophy N: Nodular Salzmann Degeneration: superifical nodules - typically bluish white and follow chronic ocular surface inflammation (phlyctenular keratitis) D: Droplet keratopathy (Lipid keratopathy), crystalline keratopathy, drug-induced keratopathy

Answer 155

Vortex: ACATS A: Amiodarone C: Chloroquine A: Antimalarials (hydroxychloroquine) T: Tamoxifen S: Some others : Indomethacin, phenothiazines Crystalline keratopathy: CIG C: Ciprofloxacin I: Indomethacin G: Gold

Answer 156

History: High UV exposure, chronic eye disease, ask about irritants (wind/sand) Investigations 1. Anterior segment OCT 2. Topography (irregular astigmatism)

Answer 157

Conservative: 1. UV protection: Wrap-around sunglasses and wide-brimmed hats Medical 1. Preservative-free lubricants to improve tear film and reduce foreign body sensation Surgical 1. Superficial keratectomy: Manual debridement 2. PTK: Excimer laser to smoothen corneal surface 3. Lamellar/penetrating keratoplasty: Rare when opacification is deep and significant VA

Answer 158

WHITE W: White/Yellow hazy stromal deposits near vessels H: Hazy cornea I: Irregular margins T: typically peripherally and enlarge towards vessel E: Enlarging lipids adjacent to feeder vessels

Answer 159

Corneal inflammation --> neovascularisation --> vessels leak serum lipids and deposit into stroma Primary: Rarer, no corneal vascularisation, no prior inflammation, often central (idiopathic lipid deposition) Secondary - Infective: HSK, Trachoma, IK causes (syphilis) - Inflammatory/atropic: VKC, Moorens, Marginal, Rosacea - Contact lens related: hypoxia - Surgery: PK, LASIK complications

Answer 160

History - HSK history, syphilis history Investigations - Anterior segment OCT (depth of lipid deposition) Bloods - Lipid profile (systemic hyperlipidaemia) - Syphilis serology

Answer 161

Conservative - Treat underlying cause (blepharitis, HSK) Medical - Topical steroids/cyclosporin can reduce leakiness of vessels Surgical - Fine needle diathermy: Needle used to cauterise vessels - Argon Laser photocoagulation: Feeder vessels at limbus to induce regression - Anti-VEGF injections: Intrastromal/subconj to induce regression of neovascularisation - PK: Significant scarring - high risk of graft rejection

Answer 162

Central corneal opacity + iridocorneal adhesions CORNEA: - Central well-demarcated corneal leukoma - Peripheral cornea clear - Absent endothelium and Descemets membrant at leukoma site - Iridocorneal adhesions - Keratolenticular adhesions TYPE 1: Opacity + iridocorneal adhesions + normal lens (best prognosis) TYPE 2: Opacity + keratolenticular adhesions + lens abnormalities (cataract, lenticulocorneal touch) (worse prognosis) PETERS PLUS: Ocular findings + systemic associations (short stature, cleft palate, ear abnormalities

Answer 163

STUMPED S: Sclerocornea T: Trauma (forceps injury at birth) U: Ulcer (neonatal keratitis) M: Metabolic: Mucopolysaccharidosis P: Peters anomaly E: Endothelial Dystrophy (CHED) D: Dermoid (limbal)

Answer 164

History: Birth history (trauma), FH of eye disease, systemic developmental delays or abnormalities (cleft palate, heart defects) Investigations EUA: IOP, corneal diameter (megalocornea), A scan UBM: visualize the iridocornela and lenticulocorneal adhesions behind opacity Genetic testing: PAX6, PITX2, FOXC1, CYP1B1 associations Renal/Cardiac/Paediatric screen: Peter plus

Answer 165

Ophthalmic 1. Amblyopia prevention: Aggressive patching of better eye and pupillary dilation (to allow vision through clear periphery) started early 2. Glaucoma control : medical management with aqueous suppressants Surgical 1. Optical iridectomy: Create new pupil via iridectomy 2. PK: guarded prognosis 3. GDD/Cyclodiode: Manage glaucoma

Answer 166

I-FOCAL-G I: Iris hypoplasia - large pupil appearance, thin iris stump, transillumination defects F: Foveal hypoplasia: Reduced VA, Nystagmus. O: Optic nerve hypoplasia C: Cataract (50-85%) A: Aniridia-associated keratopathy due to LSCD: Vascular pannus, epithelial instability L: Lens subluxation G: Glaucoma: 50-75%: Angle dysgenesis 80%: Primary due to ADD of PAX6 (11p13) 20%: Sporadic: WAGR syndrome (Wilms tumor, aniridia, genitourinary anomalies, developmental delays

Answer 167

1. Axenfield-Rieger anomaly: Iris strands and crossing angle 2. ICE syndrome: Iris atrophy/holes 3. Iris Coloboma: inferonasal --> part of CHARGE syndrome 4. Traumatic iridialysis: Unilateral, history of trauma

Answer 168

History: Poor vision, photophobia, family history of eye problems, childhood kidney tumours EUA: Slit lamp examination: megalocornea, gonioscopy, posterior segment examination OCT macula: foveal hypoplasia, optic nerve hypoplasia High-Frequency UBM: Visualise iris stump and ciliary body Systemic: 1. Renal US: screen every 3 months until 8yo 2. Genetic testing: PAX6 mutations (11p3 deletion)

Answer 169

Conservative 1. Foveal/optic nerve hypoplasia/nystagmus: Tinted contact lenses, sunglasses 2. Foveal/optic/nystagmus: Ambylopia management Medical 1. Glaucoma: IOP lowering drops 2. LSCD/AAK: Lubricants Surgical 1. Cataract: High risk of zonular instability and aniridia fibrosis syndrome (membrane across posterior IOL surface) 2. Glaucoma surgery: GDDs/Cyclodiode 3. LSCD/AAK: Keratolimbal allograft, boston keratoprosthesis

Answer 170

CHARGE syndrome: Coloboma, Heart Defects, Atresia, Retardation, Genital abnormalities, Ear abnormalities

Answer 171

1. Eyelid, iris, lens, chorioretinal, optic nerve coloboma 2. Microphthalmia 3. Nystagmus 4. Cataract 5. Glaucoma 6. Retinal Detachment

Answer 172

1. Corneal scraping - Gram Stain & Giemsa staining - Grocott's Methenamine Silver (Fungal hyphae) - Calcofluor White: If flourescent microscopy available - Cultures: Sabouraud Dextrose agar at room temp 2. AS/OCT, Confocal Microscopy: Visualise fungal hyphae deep in stroma if surface too scared 3. Anterior chamber tap for PCR and culture 4. Corneal biopsy

Answer 173

1. Mooren's Ulcer: Painful, active epithelial defect with overhanking edge 2. PUK: Inflammatory, painful, associated with scleritis, shows active stromal loss/ulceration 3. Arcus Senilis: Lucid interval at the limbus and does not involve corneal thinning 4. Dellen: Localised dehydration thinning

Answer 174

1. Hyperopic Shift - cornea flattens decades after surgery --> hyperopia 2. Diurnal instability: Fluctuations in IOP and corneal hydration --> refractive error change between morning and evening 3. Incision Gaping: Scars never reach full tensile strength of normal cornea --> prone to traumatic rupture 4. Infectious Keratitis

Answer 175

RUB EYES 1. Rubbing eyes: Strongest risk factor 2. UV exposure 3. Behavioural atopy: Eczema/asthoma 4. Ehlers-Danlos syndrome/Marfans/Down's syndrome/Osteogenesis Imperfecta 5. Young age 6. Excess contact lens wear 7. Sleep apnoea 8. Others: Previous craniosynstosis, previous LASIK

Answer 176

Vogt striae: Vertical stress lines in deep stroma --> disappear with gentle pressure on globe Fleischer ring: Iron deposition at base of cone, seen with blue cobalt light Munson sign: V-shaped lower indentation in downgaze Rituzzi sign: conical light reflex on nasal limbus Retinoscopy signs: Scissoring reflex, oil droplet reflex

Answer 177

1. Corneal ectasias: Pellucid : Bilatearl inferior corneal thinning with max protrusion just superior to thinning, Crab-claw appearance on power map on pentacam 2. Keratoglobus: Bilateral globular protrusion of cornea --> generalised thinning more marked in periphery 3. Post-traumatic ectasia (Post-LASIK) 4. Protrusion of cornea subsequent to corneal thinning

Answer 178

Anterior: VKC, Floppy eyelid syndrome Posterior: LCA, RP,

Answer 179

History - Atopic disease - Hx of connective tissue disorders Examination - Lids: Floppy eyelid syndrome, upslanting palpebral apeture (Downs) - Conjunctiva: Papillae, Horner-Trantas Dots (VKC) - Sclera: Blue sclera (osteogenesis imperfecta) - Lens: Ectopia lentis (Marfan's, EDS) - Retina: Bone spiculed pigmentation, - Eye movements: nystagmus (LCA) - Refraction: Scissoring, oil droplet reflex Investigations Corneal topography (Rabinowitz-McDowell indices) - Central corneal power > 48.7D - Sim-K Astigmatism > 1.5D - Inferior-superior dioptric asymmety >1.2 - Skewed radial axes (SRAX) >21 degrees Inferior steeping, asymmetric bow-tie, skewed radial axes Pachymetry: Reduced central thickness: Thinnest point (inferior/paracentral) Amsler-Krumeich classification based on K readings, refraction, scarring and corneal thickness Stage 1: Mild astigmatism Stage 2: Myopia and thinning Stage 3: Marked ectasia Stage 4: Central scarring

Answer 180

Conservative 1. Spectacles: Regular astigmatism 2. RGP lenses: Irregular astigmatism Surgical 1. CXL : Progressive keratoconus to strength stromal collagen and prevent progression: Dresden protocol 2. ICRS: Intrastromal corneal ring segments to remodel and flatten central cornea. Indications: Clear central cornea, contact lens intolerance, >400microns centrally 3. Keratoplasty (PK/DALK - if normal DM). Indications: Intolerance to CL, severe irregular astigmatism, significant stromal scarring affecting visual axis

Answer 181

1. Inferior peripheral thinning with ectasia above thinning 2. Irregular thinning 3. Inferior crescentic thinning with no vessels/lipid 4. High against-the-rule astigmatism

Answer 182

Corneal topography: Crab-claw pattern Pachymetry: Inferior peripheral thinning Anterior segment OCT: Location and extent of thinning

Answer 183

6 months --> 10 years later: Progressive inferior corneal steepening and irregular astigmatism progression (myopic shift after LASIK) 1. Residual stromal bed <250-300 microns - highest risk factor 2. Posterior elevation on tomography MANAGEMENT: EARLY CXL to halt progression

Answer 184

Examination: - 10% blanching with phenylephrine - Posterior scleritis (T-sign on US), choroidal folds, choroidal effusions, exudative RD, CMO, optic disc oedema Systemic examination - Hands: MCP/PIP joints, any deformities - Rashes: SLE (discoid, malar rash), PAN (livedo reticularis) Bloods Autoimmune screen: c-ANCA (GPA, PAN), p-ANCA (Churg-Strauss syndrome/EGPA), ANA (SLE), Rheumatoid Factor, anti-CCP (RA), HLA-B27 (IBD) CXR: pulmonary haemorrhage Urinalysis: Proteinuria and haematuria: GPA

Answer 185

OCP: Foster's classification Stage I: Subepithelial conjunctival fibrosis Stage II: Fornix shortening Stage III: Sympblepharon formation Stage IV: Ankyloblepharon / keratinisation of surface Other: Entropion, Trichiasis Corneal: Punctate keratopathy, keratinisation, vascularisation SJS/TEN - pseudomembranous conjunctivitis - corneal ulceration - lid margin keratinisation, scarring - symblepharon, trichiasis, instable tear film - stromal neovascularisation, LESC failure - persistent dryness - keratoconjunctivitis sicca Trachoma (C Trachoma serovirus A-C) - Herbets Pits - Alrt's line - Cicatraicial lid changes

Answer 186

Histopathology: OCCP: 1. Conjunctival biopsy: Michel's transport medium from bulbar conjunctiva: Look for subepithelial fibrosis and chronic inflammation 2. Direct Immunoflourescence: IgG, IgA and C3 deposition in linear pattern across epithelial basement membrane SJS/TEN Conjunctival biopsy: Absence of goblet cells TEN: Skin biopsy (Referral to plastics/dermatology) Bloods OCCP: Anti-BP180, ELISA. SJS/TEN: Raised inflammatory markers Trachoma Seroversion A-C (chlamydia trachomatis)

Answer 187

OCP Conservative: Treat sicca syndrome: Artificial tears, ointments, punctal occlusion (if Schirmer < 5 mins), treat blepharitis Medical: Blepharitis management: oral doxycycline 50-100mg for 6 weeks on, 6 weeks off Immunomodulation: Active and progressive cases: Mild - Dapsone + Oral prednisolone Moderate - MTX, AZT or MMF + oral prednisolone Severe: IV/PO Cyclophosphamide + oral pred Surgical Keratoprosthesis for stage 4 disease SJS/TEN MAIN: Refer to intensive burns unit for management Acute management Conservative: Frequent conjunctival irritation, PF lubricants Medical: topical steroids, placement of symblepharon ring Surgical: - Amniotic membrane graft/tarrsorrphaghy for persistent epithelial defect - Stem cell transplantation for LECS - Gunderson flap for impending perforation - Lamellar keratoplasty/PK if perf impending - Boston keratoprothesis for end stage Trachoma - Azithromycin 1g PO

Answer 188

Conservative: Treat underlying cause: MGD - warm compression lubricants Medical: trea underlying chronic inflammation, conjunctival scarring, symblepharon formation, trichiasis Surgical Partial: AMG + Sector conjunctival epitheliectomy Total: Conjunctival limbal autograft from contralateral eye, if bilateral involvement, then keratolimbal allograft

Answer 189

1. Spheroidal Degeneration: Golden-yellow deposits in interpalpebral area 2. Salzmann nodular degeneration 3. Vortex keratopathy 4. Corneal dystrophy

Answer 190

History: Chronic JIA, uveitis, previous RD requiring silicone oil. Hx of gout, CKD, hypercalcaemia symptoms (stones, groans, moans), calcium supplements Ophthalmic: Anterior segment OCT: Astigmatism Bloods - U&Es, Calcium, Phosphorous, Uric Acid - ACE, PTH levels, endocrine referral - CXR: sarcoidosis

Answer 191

Conservative: Monitor Medical: Lubricants, topical steroids or NSAIDs if inflammed Surgical Indications: recurrent episodes, cosmesis, decreased vision due to astigmatism/pterygium encroaching axis Simple - Excision with conjunctival autograft Recurrent: Conj autograft +/- AMG +/- mitomycin C Large: Lamellar keratoplasty

Answer 192

1. Pseudopterygium: secondary to ulcer or Terrien's marginal degeneration 2. Non-pigmented conjunctival lesion - CIN/OSSN 3. Phlyectenular keratitis 4. Pingueculitis

Answer 193

Conservative: - Treat underlying cause - Lubricants Surgical 1. EDTA chelation 2. PTK - residual opacity 3. Superficial keratectomy: If associated with fibrous pannus

Answer 194

Patient factors: Pre-existing dry eye or ocular rosacea Surgical factors: Flap creation, intraoperative epithelial defeects Environmental factors: Contaminants (powder from gloves)

Answer 195

sterile inflammatory reaction in the LASIK flap interface, typically occurring within the first few days after surgery, characterised by fine granular white infiltrates - Interface granular infiltrates - No epithelial defect - Peripheral then central - No AC activity DLK staging Stage 1: Peripheral interface only Stage 2: Central interface involvement Stage 3: Dense central interface with VA reduction Stage 4: Stromal melting

Answer 196

1. Microbial keratitis post Lasik/interface keratitis 2. Epithelial ingrowth post-LASIK 3. Interface-fluid syndrome

Answer 197

Medical: High dose topical steroids (pred acetate HOURLY), consider oral steroids Surgical 1. Flap lifting and irrigation 2. Keratoplasty in advanced cases

Answer 198

Pre-operative: Poor patient selection Intraoperative - Flap related issues: Incomplete/irregular flap, button-hole, corneal perforation - Photoablation issues: Treatment decentration, interface debris Post-operative Early: 1. Dislodged flaps: Emergency repositioning +/- sutures + BCL to prevent epithelial ingrwoth 2. Diffuse lamellar keartitis: White sand like granular deposits without epithelial defect/AC activity --> treat aggresively with steroids 3. Epithelial ingrowth: Hazy around flap --> Flap lift and scrape if encroaching visual axis Late 1. Dry eye 2. Post-LASIK ectasia

Answer 199

Benign: Conjunctival papillopa Pre-malignant: Limbal dermoid Malignant: OSSN, SCC, Lymphoma Other: Limbal stem cell deficiency

Answer 200

History: Risk factors - HPV, HIV, immunosuppresion, smoking, pale, UV Ophthalmic - Anterior segment: photos and OCT - Biopsy: Dysplastic changes (increased nuclear-to-cytoplasmic ratio, atypia) confined to epithelium - Impression cytology if biopsy not available

Answer 201

Conservative: Observe Medical: Topical chemotherapy with MMC, 5-FU considered if MMC intolerance Surgical: Excisional biopsy with wide margins and cryotherapy --> especially if leukoplakic variant

Answer 202

Eyelids: Telangiectasia, MGD, blepharitis, chalazion/stye Conjunctiva: Chronic hyperaemia Cornea: Punctate epithelial erosions, peripheral neovascularisation, peripheral infiltrates/thinning

Answer 203

Conservative: Warm compresses and lid hygeine Medical: - Management of dry eye - Oral tetracyclines: 50-100mg doxycycline daily - Short course of topical steroids (FML/loteprednol) for severe inflammation - Topical antibiotics (azithromycin) Surgical - Superficial keratectomy for vascularised/scarred corneas - Fine needle diathermy/Argon laser photocoagulation/anti-VEGF for corneal vascularisation

Answer 204

- Conjunctival injection - Subconj haemorrhage - Corneal opacification, conjunctivalisation - Limbal ischaemia - Cicatricial changes --> sympblepharon, ankyloblepharon

Answer 205

Roper Hall Classification: Cornea clarity, limbal ischaemia, prognosis Grade I: Clear, No LI, Excellent Grade II: Hazy iris visible, <1/3 LI, Good Grade III: Opaque iris obscured, <1/2 LI, Guarded Grade IV: Opaque: > 1/2 LI, Poor Dua Classification: Clock hours limbal involvement and conjunctival involvement

Answer 206

1. Limbal Stem Cell Deficiency 2. Other injuries: Thermal, UV radiation 3. Inflammatory: OMMP, SJS, PUK, Mooren's Ulcer

Answer 207

1. Neutralisation of pH with irrigation (can use Morgan contact lens) 2. Evert lids and fornices --> remove retained matter Mild chemical injury: Topical antibiotics PF, Cycloplegia PF, BCL, lubricants PF, oral analgesia Severe chemical injury: Add topical steroid PF, Topical ascorbic acid, oral ascorbic acid and doxycycline. Manage IOP. Surgical 1. AMT: persistent epithelial defect, moderate/severe 2. Limbal stem cell transplant 3. Keratoplasty: Late stage only

Answer 208

1. Microbial keratitis 2. Chemical injury / burns 3. Cicatricial: OCP/SJS/TEN/Trachoma, LSCD 4. Atopic: VKC, Ocular rosacea 5. Herpes simplex

Answer 209

1. Salmon patch stromal haze with fluffy margins 2. Deep stromal vascularisation 3. Late: Lipid keratopathy and ghost vessels 4. Corneal scarring

Answer 210

History: HSV cold sores, immunosuppression, contact lens wear (acanthomoeba), TB symptoms, hearing loss (syphilis and Cogan's syndrome), sexual history Ophthalmology - Acanthomoeba: scrape with non-nutrient agar (e coli) - HSV PCR - Anterior segment OCT Bloods - Syphilis: VDRL, FTA-ABS - HIV - TB: IGRA test, T spot/Quantiferon, AFB sputum culture - Lyme serology - Autoimmune screen - Cogans syndrome: FBC (eosinophilia), ESR (raised), hearing test Hutchinsons triad: Interstital keratitis, notched incisors, sensorineural deafness: Congenital syphilis

Answer 211

If syphilis: IM benzathine penicillin G (2.4 million units IM weekly x 3 doses) If neurosyphilis: IV penicillin G 18-24 million units/day for 10-14 days Conservative - Glasses/contact lenses to improve astigmatism Medical - Inflammation: Steroids - Ciliary spasm: Cyclopegia - Underlying treatment: eg antivirals Surgical 1. Fine needle diathermy/mitomycin C for active corneal vessels 2. PK/DALK for improvement from scarring when inactive.

Answer 212

1. Discrete grey-white crescenteric opacity across LASIK flap margin

Answer 213

1. Diffuse lamellar keratitis: Presents day 1-day 6 - more granular/diffuse 2. Microbial keratitis along flap edge 3. Interface Fluid syndrome (Pressure-Induced Stromal Keratopathy PISK): Interface fluid due to high IOP (steroid response) 4. Interface debris: Lint or surgical drape fibers

Answer 214

1. Epithelial defect at the time of LASIK 2. Flap-related issues - Flap dislocation/trauma - Re-lifting the flap for enhancement procedures 3. Patient factors - Older age - History of EBMD - Prior corneal surgery Presents usually 1 month post surgery

Answer 215

Observation 1. If < 2mm from flap edge and stable, no visual axis involvement 2. Contacts/glasses for irregular astigmatism Surgical 1. Flap lift and epithelial removal (mechanical debridement 2. If recurrence: 20% ethanol to stromal bed, PTK, sutures to secure flap, consideration of mitomycin C 0.02%.

Answer 216

1. Branching needle like opacities with crystalline/snowflake appearance in anterior or mid-stroma in a grafted eye 2. No associated corneal inflammation 3. Associated with chronic epithelial defect/suture tract Streptococcus viridans / staphylococcus / pseudomonas / fungi (Candida)

Answer 217

History: Ask about chronic topical steroid use, ask about topical cyclopsorine/immunosuppresion, previous graft surgery Investigations 1. Corneal scrape: Insufficient --> needs corneal stash biopsy or suture-track culture 2. Gram stain and culture 3. In vivo confocal microscopy: Highly reflective branching needle-like structures

Answer 218

Medical management: Longstanding 1. Intensive antibiotics: Fortified vancomycin (50mg/ml) or Fluoroquinolones 2. Intrastromal antibiotics: Vancomycin into crystalline area 3. Reduce/stop steroids Surgical management 1. Laser (PTK/YAG) YAG laser can disrupt bacterial biofilm 2. Repeat PK once infection is refractory

ANTERIOR SEGMENT Flashcards

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