Ophtalmology

1. EyeAnteriorStructuresPathlogiesandDisorders Fielmann Optometrist IrinaJagilovich e-mail: irina.jagilovica@gmail.com

2. DISORDERS OF LASHES 1. Trichiasis 2. Metaplastic lashes 3. Distichiasis 4. Phthiriasispalpebrarum 5. Madarosis 6. Poliosis

4. Burns, radiotherapy or cryotherapy

5. Poliosis Premature localized whitening of hair Ocular associations Chronic anterior blepharitis Sympathetic ophthalmitis Systemic associations Vogt-Koyanagi-Harada syndrome Waardenburg syndrome

8. Phthiriasispalpebrarum Infestation of lashes by pubic crab louse and its ova (nits) Typically affects children in poor hygenic conditions

9. Staphylococcal blepharitis Chronic irritation worse in mornings Hyperaemia and telangiectasia of anterior lid margin Scarring and hypertrophy if longstanding Scales around base of lashes (collarettes)

10. Complications of staphylococcal blepharitis poliosis madarosis trichiasis Recurrent styes Marginal keratitis Tear film instability

11. Seborrhoeicblepharitis Shiny anterior lid margin Greasy scales Hyperaemia of lid margin Lashes stuck together

12. Meibomianitis Inflamed and blocked meibomiangland orifices Meibomian cyst formation

13. Meibomianseborrhoea Oil globules over meibomian gland orifices Oily and foamy tear film

15. Rupture and crust

17. KeratitisTreatment - topical antivirals

20. Cyst of Zeiss

21. Sebaceous cyst

23. Keratoacanthoma

24. Naevi

25. Capillary haemangioma

26. Port-wine stain

27. Pyogenicgranuloma

29. Molluscumcontagiosum Painless, waxy, umbilicated nodule May be multiple in AIDS patients Chronic follicular conjunctivitis Occasionally superficial keratitis

30. Xanthelasma Common in elderly or those withhypercholesterolaemia Yellowish, subcutaneous plaques containing cholesterol and lipid Usually bilateral and located medially

31. Eyelid cysts Cyst of Moll Translucent On anterior lid margin Cyst of Zeis Opaque On anterior lid margin

32. Viral wart (squamous cell papilloma) Most common benign lid tumour Raspberry-like surface

33. Keratoses Seborrhoeic Actinic Common in elderly Affects elderly, fair-skinned individuals Discrete, greasy, brown lesion Most common pre-malignant skin lesion Flat ‘stuck-on’ appearance Rare on eyelids Flat, scaly, hyperkeratotic lesion

34. Keratoacanthoma Uncommon, fast growing nodule Acquires rolled edges and keratin-filled crater Involutes spontaneously within 1 year

35. Naevi Elevated Flat, well-circumscribed Has both intradermal and junctional components May be non-pigmented Pigmented No malignant potential Low malignant potential

36. MALIGNANT EYELID TUMOURS 1. Basal cell carcinoma 2. Squamous cell carcinoma 3. Meibomian gland carcinoma 4. Melanoma 5. Kaposi sarcoma

37. Basal Cell Carcinoma - Important Facts 1. Most common human malignancy 2. Usually affects the elderly 3. Slow-growing, locally invasive 4. Does not metastasize 5. 90% occur on head and neck 6. Of these 10% involve eyelids 7. Accounts for 90% of eyelid malignancies

38. Nodular basal cell carcinoma Shiny, indurated nodule Slow progression Surface vascularization May destroy large portion of eyelid

39. Ulcerative basal cell carcinoma(rodent ulcer) Chronic ulceration

40. Sclerosing basal cell carcinoma Indurated plaque with loss of lashes Spreads radially beneath normal epidermis May mimic chronic blepharitis

41. Squamous cell carcinoma Nodular Ulcerative Less common but more aggressive than BCC No surface vascularization

42. Meibomian gland carcinoma Hard nodule; may mimic chalazion Very large tumour Diffuse thickening of lid margin and loss of lashes Conjunctival invasion; may mimic chronic conjunctivitis

43. Melanoma Plaque with irregular outline Blue-black nodule with normal surrounding skin May be non-pigmented Variable pigmentation

44. Kaposi sarcoma Vascular tumour occurring in patients with AIDS Usually associated with advanced disease Very sensitive to radiotherapy

45. Entropion & ectropion

46. Horner syndrome Caused by oculosympatheticpalsy Usually unilateral mildptosis and miosis, anisocoria Normal pupillary reactions

48. Signs of conjunctivitis Usually bilateral, acute watery discharge and follicles Subconjunctivalhaemorrhages and pseudomembranes if severe

49. Signs of keratitis Focal, subepithelialkeratitis Focal, epithelial keratitis May persist for months Transient

50. Progression of vernal conjunctivitis Diffuse papillary hypertrophy, most marked on superior tarsus Formation of cobblestone papillae

51. Limbal vernal Trantas dots Mucoid nodule

53. Papilloma

54. Epibulbardermoid

57. Squamous cell carcinoma

58. Kaposi sarcoma

60. Melanoma

62. Presents in childhood or early adulthood

63. Not caused by infection

64. Infection with papilloma virus

65. Single and unilateral

69. Soft, movable, subconjunctival mass

71. Juxtalimbal fleshy avascular mass

73. Conjunctival melanoma From naevus Primary From PAM with atypia Very rare Most common type Solitary nodule Sudden appearance of nodules in PAM Frequently juxtalimbal but may be anywhere Sudden increase in size or pigmentation

75. May spread extensively

76. Presents in late adulthood

77. Rarely metastasizes

79. Vascular, slow-growing tumour of low malignancy

80. Very sensitive to radiotherapy

82. Benign or malignant

84. Marginal keratitis Progression Subepithelial infiltrate separated by clear zone Vascularization followed by resolution Circumferential spread

86. Bilateral and chronicProgression Peripheral inferior vascularization Subepithelial infiltration Thinning and perforationif severe

89. Resolves spontaneously or extends onto cornea

91. Associated with non-necrotizing scleritisProgression Superficial or mid-stromal infiltration Opacification and vascularization

92. CORNEAL INFECTIONS 1. Bacterial keratitis 2. Fungal keratitis 3. Acanthamoebakeratitis 4. Infectious crystalline keratitis Herpes simplex keratitis -Epithelial -Disciform 6. Herpes zoster keratitis

94. Chronic ocular surface disease

95. Corneal hypoaesthesiaExpanding oval, yellow-white, dense stromal infiltrate Stromal suppuration and hypopyon

96. Fungal keratitis Frequently preceded by ocular trauma with organic matter Greyish-white ulcer which may be surrounded by feathery infiltrates Slow progression and occasionally hypopyon

98. Symptoms worse than signsPerineuralinfiltrates (radial keratoneuritis) Small, patchy Anteriorstromal infiltrates Ulceration, ring abscess& small, satellite lesions Stromal opacification Treatment

100. Usually associated with long-term topical steroid use

101. Particularly following penetrating keratoplasty White, branching, anterior stromal crystalline deposits

103. Herpes zoster keratitis Nummular keratitis Acute epithelial keratitis Develops in about 50% within 2 days of rash Develops in about 30% within 10 days of rash Small, dendritic or stellate epithelial lesions Multiple, fine, granular deposits just beneath Bowman membrane Tapered ends without bulbs Halo of stromal haze May become chronic Resolves within a few days

105. Vogt white limbal girdle

106. Crocodile shagreen

108. Secondary3. Band keratopathy 4. Spheroidal degeneration 5. Salzmann nodular degeneration

110. Occasionally associated with hyperlipoproteinaemia

112. Vogt white limbal girdle Innocuous and very common in elderly Bilateral White, crescentic line along nasal and temporal limbus Type 1 - separated from limbus by clear zone Type 2 - not separated by clear zone

114. Usually bilateralPolygonal stromal opacities separated by clear space Most frequently involve anterior stroma (anterior crocodile shagreen) Occasionally involve posterior stroma (posterior crocodile shagreen)

116. Rarely progression to Fuchs dystrophyTiny dark spots on central endothelium

117. Lipid keratopathy Primary Secondary Common, secondary to previous disciformkeratitis Rare, occurs spontaneously in avascular cornea Unilateral stromal deposits with vascularization Usually unilateral stromal deposits without vascularization

119. Subepithelial calcificationProgression Central spread of calcification Interpalpebrallimbalopacification Small holes within calcified area Separated by clear zone

121. Meesmann

123. Granular I, II, III (Avellino)

126. Neither familial nor progressive

127. Recurrent corneal erosions in about 10% of casesDots Cysts Fingerprints Maps

128. Signs of Cogan dystrophy Microcysts Dots Maps Fingerprints

129. Reis-Bucklers dystrophy .. Onset - early childhood with recurrent corneal erosions Honeycomb appearance Superficial polygonal opacities keratoplastyif severe

131. Clear in retroillumination

132. Grey in direct illuminationTreatment- not required

133. Schnyder dystrophy Onset - second decade with visual impairment Subepithelial ‘crystalline’ opacities Treatment- excimer laser keratectomy

134. Lattice dystrophy type I Onset - late first decade with recurrent corneal erosions Progression Fine, spidery, branching lines within stroma Later general haze may submerge lesions Treatment - penetrating keratoplasty if severe

135. Granular dystrophy type I Onset - first decade with recurrent corneal erosions Progression Eventual confluence Initial superficial and central crumb-like opacities Later deeper and peripheral spread but limbus spared Treatment - penetrating keratoplasty if severe

136. Fuchs endothelial dystrophy Onset - old age Progression Eventually bullous keratopathy Later central stromal oedema Gradual increase in cornea guttata with peripheral spread Treatment- penetrating keratoplasty if advanced

137. CORNEAL ECTASIAS 1. Keratoconus 2. Keratoglobus 3. Pellucid marginal degeneration

138. Morphological classification of keratoconus Nipple cone Oval cone Globus cone Small and steep curvature Larger and ellipsoidal Largest

139. Signs of keratoconus Bilateral in 85% but asymmetrical Prominent corneal nerves Oil droplet reflex Vogt striae Bulging of lower lids on downgaze Munson sign Fleischer ring & scarring Acute hydrops

140. Keratoglobus Onset usually at birth Bilateral protrusion and thinning of entire cornea Associations - Leber congenital amaurosis and blue sclera

144. Non-necrotizing nodular

145. Necrotizing with inflammation

146. Necrotizing without inflammation ( scleromalaciaperforans ) 3. Posterior scleritis

150. May take longer to resolve

151. Treatment - similar to simple episcleritisLocalized nodule which can be moved over sclera Deep scleral part of slit-beam not displaced

155. Diffuse 7. Choroidal metastatic carcinoma 8. Choroidal osseous choristoma 9. Melanocytoma

156. Iris Melanoma 1. Very rare - 8% of uveal melanomas 2. Presentation - fifth to sixth decades 3. Very slow growth 4. Low malignancy 5. Excellent prognosis

157. Iris melanoma Usually pigmented nodule at least 3 mm in diameter Invariably in inferior half of iris Occasionally non-pigmented Surface vascularization Angle involvement may causeglaucoma Pupillarydistortion, ectropion uveaeand cataract

158. Differential diagnosis of iris melanoma Adenoma of pigment epithelium Large iris naevus distorting pupil Leiomyoma Ciliary body melanoma eroding iris root Metastasis to iris Primary iris cyst

163. Presentation - 6th decade

164. May be discovered by chance

166. Anterioruveitis Posterior synechiae Hypopyon

168. 45% are positive for HLA-B27

169. Initially no systemic disease

170. Minority subsequently develop ankylosing spondylitisFibrinousexudate Residual pigment on lens

172. Ocular features

173. Systemic features

177. Myotonic dystrophy

178. Atopic dermatitis

179. Trauma

180. Drugs

183. Posterior2. Nuclear 3. Cortical 4. Christmas tree

184. Subcapsular cataract Anterior Posterior

186. Causes increasing myopia

188. Christmas tree cataract Polychromatic, needle-like opacities May co-exist with other opacities

189. Classification according to maturity Immature Mature Hypermature Morgagnian

191. Wrinkles in anterior capsule

193. Electric shock

196. Follows acute angle-closure glaucoma

197. High myopia

199. Anterior axial bulge

200. Unilateral - usually sporadic

201. Associated with Alport syndrome

202. Bilateral - familial or in Lowe syndrome

204. Weill-Marchesani syndrome

205. Homocystinuria 4. Treatment options

207. MegalocorneaAnterior uvealtumours Degenerate eye

208. Ocular features of Marfan syndrome Upward subluxation Lattice degeneration Axial myopia Zonuleusually intact Angle anomaly and glaucoma Blue sclera Cornea plana

209. Weill-Marchesani syndrome Ocular features Systemic features Short stature Microspherophakia Short stubby fingers (brachydactyly) Usually anterior lens subluxation Mental handicap Angle anomaly and glaucoma

213. Lens-induced glaucoma

214. Endothelial touch