Ocular Disease - Midterm 1 Lids Part 1

1. Keratoacanthoma spontaneously regresses by involution but very often mistaken for squamous cell. Because of this appearance, usually excised during phase of involutional regression. If there is a recurrence after excision is was almost definitely BCC or SCC, not keratoacanthoma.

True

False

pg. 29-30

Explanation

pg. 29-30

2. Port wine stains are often associated with what syndrome?

Horner's syndrome

Sturge-Weber syndrome

Moh's syndrome

Noon's syndrome

pg. 34

Explanation

pg. 34

3. Changes in the lid margin are primarily due to either staphylococcal and/or meibomian gland disorders, not to simple seborrheic processes

True

False

pg. 62

Explanation

pg. 62

4. Basal cell carcinomas (BCC) metastasize quickly and is a fast growing lesion. Patients will often report the growth came out of nowhere and they just noticed it

True

False

Metastasis is unlikely if it does it will go to the regional lymph node. Therefore you need to palpate preauricular and sudmandiublar nodes for swelling and tenderness.
Patients will most likely report that it has been there for a long time, it doesnt' go away and does not heal

It spreads by direct metastasis

Explanation

Metastasis is unlikely if it does it will go to the regional lymph node. Therefore you need to palpate preauricular and sudmandiublar nodes for swelling and tenderness.
Patients will most likely report that it has been there for a long time, it doesnt' go away and does not heal

It spreads by direct metastasis

5. Absence of superior lid sulcus in Caucasian people will lead you to believe the person could have a congenital ptosis, especially if the person is young.

True

False

The absence of a superior lid sulcus in Caucasian people can indicate a congenital ptosis, particularly in younger individuals. This suggests that the person may have been born with a drooping upper eyelid, which could be a result of a developmental issue. Therefore, it is true that the absence of a superior lid sulcus in Caucasian people could lead one to suspect a congenital ptosis.

Explanation

The absence of a superior lid sulcus in Caucasian people can indicate a congenital ptosis, particularly in younger individuals. This suggests that the person may have been born with a drooping upper eyelid, which could be a result of a developmental issue. Therefore, it is true that the absence of a superior lid sulcus in Caucasian people could lead one to suspect a congenital ptosis.

6. A concerned mother bring in her 6 yo daughter. She reports the child is having trouble at school. While walking to the exam room you notice the child's OD eye shows heterochromia irides and a slight ptosis. Although you still need to do a full exam, take a case history and ask to look at old family photos, what condition is at the top of your differential diagnosis list?

Marcus Gunn jaw winking syndrome

Neonatal myasthenia gravis

Congential Horner's syndrome

Duane's retraction syndrome

If significant obstruction of pupil and/or apparent reduced acuity or dislike for fixation with the eye then consult with pediatric ophthalmologist is strongly advised. Ptosis must be eliminated to prevent occlusion amblyopia

Pediatric neurology (or ophthalmology) consult if congenital Horner’s or suggestion of neonatal myasthenia gravis

Duane's retraction syndrome - pg. 7
Marcus Gunn jaw winking syndrome - pg 11
Congential Horner's syndrome - pg. 11

Explanation

If significant obstruction of pupil and/or apparent reduced acuity or dislike for fixation with the eye then consult with pediatric ophthalmologist is strongly advised. Ptosis must be eliminated to prevent occlusion amblyopia

Pediatric neurology (or ophthalmology) consult if congenital Horner’s or suggestion of neonatal myasthenia gravis

Duane's retraction syndrome - pg. 7
Marcus Gunn jaw winking syndrome - pg 11
Congential Horner's syndrome - pg. 11

7. What danger could accompany entropion?

Distichiasis

Epiphora

Poliosis

Trichiasis

Blepharospasm

Distichiasis - congential anomaly characterized by absence if meibomian glands which have an extra row of lashes at their location - pg. 10

Poliosis - normally seen in vitiligo - pg. 12

Blepharospasm - pg. 18

Explanation

Distichiasis - congential anomaly characterized by absence if meibomian glands which have an extra row of lashes at their location - pg. 10

Poliosis - normally seen in vitiligo - pg. 12

Blepharospasm - pg. 18

8. Squamous cell carcinoma (SCC) can often arise from what pre-existing conditions?

Capillary hemangioma

Existing actinic keratosis or a cutaneous horn

Nevus of Ota

Hutchison's freckle

Port wine stain

Hutchison's freckle - precursor to malignant melanoma
Nevus of ota - can develop into a malignant melanoma

Developmental vascular lesions - Capillary hemangioma and port-wine stain

Explanation

Hutchison's freckle - precursor to malignant melanoma
Nevus of ota - can develop into a malignant melanoma

Developmental vascular lesions - Capillary hemangioma and port-wine stain

9. You have a 57yo Caucasian male who comes into to your office after an OMD gave them a referral for VT. during slit lamp evaluation who notice there appears to be an adhesion b/t the upper and lower eyelids on the temporal aspect of their eye. You have the patient look to the right and to the left and tug on the eye a little bit, You can envision where the eyelid probably once was. Since this is only present on one eye it gives the patient the appearance of a strabismus. You decide to place the patient on immunosuppressive medication, b/c this acquired anomaly is normally due to autoimmune condition, in this case you chose cyclosporine. The patient is very adamant about getting this repaired so you make a referral to a oculoplastic surgeon. On the referral what diagnosis would you provide?

Euryblepharon

Ankyloblepharon

Vitiligo

Cicatricial entropion

Atonic entropion

pg. 12 -13

Explanation

pg. 12 -13

10. A 67 yo Caucasian male has come into your office with a chief complaint of irritation and pain in their eye. During the patient's case history you find out they have recently immigrated from South Africa. On slit lamp evaluation you notice a scar on the tarsal conjunctiva. You suspect the patient has an inflammation of the tarsal conjunctiva such as a trachoma. What diagnosis would you type into EMR.

Cicatricial entropion

Dermatochalaisis

Spastic entropion

Blepharochalaisis

pg. 13

Explanation

pg. 13

11. Augmentin (aka amoxicillin/clavulanic acid) at a dosage of 250-500 TID can be used to treat staphylococci, streptococci and H.flu

True

False

pg 52-53

Explanation

pg 52-53

12. What danger does a basal cell carcinoma (BCC) that is located in the medial canthal region present to the patient?

It has a high chance of metastasis

Surgery by Moh's technique is less likely to be successful, thus treatment will be limited to cryo and conventional surgery

It is more likely to directly extend intracranially without apparent nature when grossly observing the lesion

It is less dangerous in this region because it is further from the regional lymph node

pg. 38

Explanation

pg. 38

13. Select the false statement regarding the management of trichiasis

Cauterization of follicles is a highly valued and useful treatment

Electrolysis destroys lash follicles, however the procedure is quiet painful

If > 1/3 of lashes are turned in, surgery is warranted rather than electrolysis: cryosurgery and argon laser photocoagulation

pg. 22

Explanation

pg. 22

14. What oral antibiotic did Dr. Tong say was to be prescribed for individuals with a hordeolum and a sensitive stomach?

Oracea 40mg BID

Achromycin 250-500 QID

Erythromycin EES 400mg QID

Doryx 50,100,200mg BID

pg. 45

Explanation

pg. 45

15. Select the false statement

Spastic entropion occurs in elderly due to age-related lid changes

Vitiligo is usually accompanied by poliosis and alopecia

Option 2 - Most common cause is blepharospasm due to ocular irritation, injury, inflammation(conjunctivitis, keratitis,etc.). Caused by excessive contraction of palpebral portion of orbicularis (or very rarely atrophy of the lid retractors)

Explanation

Option 2 - Most common cause is blepharospasm due to ocular irritation, injury, inflammation(conjunctivitis, keratitis,etc.). Caused by excessive contraction of palpebral portion of orbicularis (or very rarely atrophy of the lid retractors)

16. Blepharitis is the most common cause of trichiasis

True

False

pg. 21

Explanation

pg. 21

17. A 6yo male is brought in by his mother for an eye exam during summer vacation. During the exam you notice the child has lesions, they are larger bistered areas with superficial crust. Since you are doing your residency at the Indian Health services clinic you decide to take care of the lesions and help improve the child's appearance. You soak the lesions with Burow's solutions for 20 minutes to soften the crust and for its astringent action then you gently debride the crust with a washcloth. You would prefer to use the newest drug therapy Mupirocin (Bactroban) 2% ointment because its effective against both Staph and group A Strep. However since you are at Indian health services all you can do is use chlorhexidene solution to further cleanse the area after which you dry the lesions and apply Polysporin without a covering bandage.

Actinic keratosis

Bullous Impetigo

Benign melanotic lesions

Keratoacanthoma

pg. 53

Explanation

pg. 53

18. Which statement is false?

The most common cause of madarosis is staph blepharitis

Management of an ingrown cilia requires prophylaxis with a topical antibiotic ointment

Dermatochalasis may have a herniation of orbital fat through the orbital septum causing puffy, "swollen" appearance.

A verruca is generally a non-viral version of a papilloma

Blepharochalaisis is the recurrences of edema that result in streching of periorbital skin, loss of elasticity.

A verruca is generally a non-viral version of a papilloma. This statement is false because a verruca is actually a viral infection caused by the human papillomavirus (HPV). A papilloma, on the other hand, can refer to any benign tumor that grows on the surface of the skin or mucous membranes, and it can be caused by various factors, including viral infections. Therefore, a verruca is a type of papilloma that is specifically caused by HPV.

Explanation

A verruca is generally a non-viral version of a papilloma. This statement is false because a verruca is actually a viral infection caused by the human papillomavirus (HPV). A papilloma, on the other hand, can refer to any benign tumor that grows on the surface of the skin or mucous membranes, and it can be caused by various factors, including viral infections. Therefore, a verruca is a type of papilloma that is specifically caused by HPV.

19. Which of the following is not considered a lid characteristic in staphylococcal blepharitis.

Erythema

Elevated WBC count

Puffy from fluid accumulation

Tender to palpation

Acute changes due to hypersensitivity

pg. 56

Mnemonic: PETA = Puffy, erythema, tender, acute changes

Explanation

pg. 56

Mnemonic: PETA = Puffy, erythema, tender, acute changes

20. Which of the following is not an oral antibiotic that can be used for the treatment of preseptal cellulitis?

Erythromycin

Bactrim

Maxitrol

Augmentin

pg.52
Maxitrol -Topical Antibiotic Steroid Combo

Explanation

pg.52
Maxitrol -Topical Antibiotic Steroid Combo

21. Primary meibomitis is the least serious/least threatening stage of meibomitis

True

False

pg. 67
Most severe variety of meibomian gland dysfunction. Strong association w/dermatological conditions such as rosacea. Frequent chalazia

Explanation

pg. 67
Most severe variety of meibomian gland dysfunction. Strong association w/dermatological conditions such as rosacea. Frequent chalazia

22. Select the false statement

Cicatricial entropion is usually caused by inflamation of tarsal conjunctiva from infection such as trachoma

Management for congential entropion is surgical reformation of tarsal plate

Trichiasis can cause corneal epithelial defects such as corneal infections, ulcers, damage and scarring in anterior stroma

pg 13-14

Option 1 - refers to ectropion

Explanation

pg 13-14

Option 1 - refers to ectropion

23. Select the false statement regarding oral antibiotics for staphylococcal blepharitis

They are the first line of treatment for blepharitis

Doses of oral antibiotics depend on patient's age, weight, and severity of condition

Tetracycline is contraindicated for pregnant and lactating females as well as children under 12

pg.60

Explanation

pg.60

24. Which of the the following topical antibiotic drops is/are allowed to be used for pediatrics in ages >8yo?

Ciloxan/ciprofloxacin 0.3%

Azasite/azithromycin 1%

Zymar/gatifloxacin 0.3%

Vigamox/moxifloxacin 0.5%

pg. 15
JUST REMEMBER ONLY THE TETRACYCLINE DROP CAN BE USED ON PEDS, all the other drops are of the fluoroquinolone and aminoglycoside drug class

Explanation

pg. 15
JUST REMEMBER ONLY THE TETRACYCLINE DROP CAN BE USED ON PEDS, all the other drops are of the fluoroquinolone and aminoglycoside drug class

25. Which of the following is not a differential diagnosis for blepharospasm.

Functional (hysterical)

Myokymia

Tardive dyskinesia caused by antipsychotic medications (Prolixin, Haldol)

Blepharoclonus

Ocular disease (local irritation, inflammatory process, or foreign body)

pg. 19

Explanation

pg. 19

26. Seborrheic Blepharitis

Can also be referred to as posterior blepharitis, when this occurs there can be a significant build-up of fatty esters

There is frequent occurrence with dermatologic conditions such as Rosacea

Signs include frothing of tear film at outer canthi, papillary conjunctivitis, bulbar conjunctival hyperemia, retention cysts and concretions

First line therapy is lid hygiene and Azasite or TobradexST

Inflammation exists concurrently with stagnation spotty, scattered involvement of abnormal glands

The other options are in refers to meibomitis

Explanation

The other options are in refers to meibomitis

27. Which statement is false regarding Myokymia?

Causes include anemia, anterior segment irritation, excessive use of alcohol or tobacco

Suggest oral quinine 200-300mg qd to tid for stubborn cases, but contraindicated in pregnant women since increases risk of abortion.

Dirty water orally bid to tid is another suggestion for the treatment of myokymia

Option 2 - Tx option for blepharospasm

Explanation

Option 2 - Tx option for blepharospasm

28. Select the true statement regarding antibiotic ointments for staphylococcal blepharitis

Erythromycin causes extreme hypersensitivity reactions and high toxicity to tissue

Tobramycin is very good against staphylococci and must primarily reserve it for keratitis, due to its effectiveness against Pseudomonas aeruginosa

There is no risk of delayed hypersensitivity reaction and very little resistance of staphylococci to Neomycin

Gentamicin is a very poor choice against staphylococci at present so it should never be used long term

Bacitracin is has high toxicity, it is available only in oral form, there is extreme resistance and hypersensitivity.

pg 59-60

Explanation

pg 59-60

29. Developmental vascular lesions

Can change in color with venous return; activities such as straining, crying, lifting can cause redder appearance

Usually spontaneously regress completely by age 5

Will often present with signs of acute inflammation such as redness, heat, pain, swelling etc.

Produce flat reddish or pink lobulated lesion on skin

pg. 34

Explanation

pg. 34

Submit

30. Early diagnostic sign of preseptal cellulitis is conjunctival hyperemia and chemosis (moderate to severe); these frequently precede proptosis and diplopia

True

False

For orbital cellulitis
pg.51

Explanation

For orbital cellulitis
pg.51

31. The classic appearance of squamous cell carcinoma (SCC) is a center which slowly ulcerates with an increase in size. It tends to have darkened, ulcerated center.

True

False

The description is for a BCC - pg. 37
4 types of BCC: nodular (common); superficial (back and trunk); sclerosing waxy yellow "scar tissue"; indistinct borders, multicentric type

SCC does NOT have a classical appearance: it can be raised nodule; flat crusty area; flat scaly area; ulcerated bleding lesion, thickened margins - pg. 39

Explanation

The description is for a BCC - pg. 37
4 types of BCC: nodular (common); superficial (back and trunk); sclerosing waxy yellow "scar tissue"; indistinct borders, multicentric type

SCC does NOT have a classical appearance: it can be raised nodule; flat crusty area; flat scaly area; ulcerated bleding lesion, thickened margins - pg. 39

32. Erythromycin can often clear an unresolved hordeolum which remained inflamed while progressing into a chalazion or a chalazion which has become reinfected. Dosage would be 1-2gm/day. 3-4 weeks.

True

False

Ans: Tetracycline does the above.
pg. 49

Explanation

Ans: Tetracycline does the above.
pg. 49

33. Select the appropriate treatments for the management of ectropion since the goal will be to prevent discomfort, tearing, secondarykeratinization and or infection.

Extended wear contact lens to protect cornea

Steroids to decrease infection

Surgical treatment

Broad spectrum antibiotic if recurrent infections auch as blepharitis, conjunctivitis or keratitis

pg.16

Explanation

pg.16

Submit

34. Which statements are true in the management of papillomas?

Generally no treatment is indicated and the patient just need to be reassured

Lance it with a 18-27 gauge needle then cover with broad spectrum antibiotic

Option 2 - excision technique for sudoriferous cysts

Explanation

Option 2 - excision technique for sudoriferous cysts

Submit

35. Sebaceous gland cysts

Are elevated rounded lesions caused by blockage of the gland of Moll

Can be divided into three types: Dermal, compound, and junctional

Have their cystic nature apparent in indirect/proximal illumination

Can manifest as subcutaneous or superficial in depth

Option 1 - refers to sudoriferous cysts
Option 2 - refers to nevi
Option 3 - refers to sudoriferous cysts

Explanation

Option 1 - refers to sudoriferous cysts
Option 2 - refers to nevi
Option 3 - refers to sudoriferous cysts

36. Preseptal Cellulitis

Orbital cellulitis can worsen into preseptal cellulitis

Causes include dental surgery, ethmoidal wall fracture or other trauma

Common organisms involved include H.influenzae in children and Strep and Staph in adults

Signs include diplopia, pain on eye movement, external ophthalmoplegia, optic nerve edema and ischemia with variable/mild VA loss

The drug of choice for treatment is a topical antibiotic steroid combo

pg.50-52

Option 2 and 4 are in reference to orbital cellulitis

Antibiotic/steroid ointment - TMZ is not PG Blep: TobradexST, Maxitrol, Zylet, Pred-G, Blephamide - Tx for staphlococcal blepharitis

Explanation

pg.50-52

Option 2 and 4 are in reference to orbital cellulitis

Antibiotic/steroid ointment - TMZ is not PG Blep: TobradexST, Maxitrol, Zylet, Pred-G, Blephamide - Tx for staphlococcal blepharitis

37. Which of the following topical antibiotic ointments is not suggested for pediatric use?

Ciloxan/ciprofloxacin 0.3%

Ilotycin/erythromycin 0.5%

Tobrex/tobramycin 0.3%

Neosporin/polymyxin B/neomycin/gramicidin

pg. 14

Explanation

pg. 14

38. Which statements are true regarding seborrheic blepharitis

Lid margin hyperemia can be due to neovascularization from chronic staphylococci, markedly inflamed meibomian glands, ocular rosacea

It is best treated by using alternating ointments (bactracin and erythromycin) the first five nights qHS of each month

Scurf are also referred to as dandruff-like scales, they can be confused with fibrinous scales in appearance

It is very responsive to steroids

Option 2 and Option 4 - pg. 58 & 60

Explanation

Option 2 and Option 4 - pg. 58 & 60

Submit

39. What is the third line treatment for meibomian gland dysfunction? What medication do you need to use?

Azasite or TobradexST 1 gtt BID for 2days, then 1 gtt qHS for 1 month

Cyclosporine/Restasis 1 gtt BID

Doxycycline 50mg BID x 2 weeks, then taper to 20mg qDaily

Tetracycline 250mg QID x 2 weeks. Slow taper to maintenance dose of 250mg per day or every other day

pg. 68

Additional new treatment modalities: Intraductal meibomian gland probing; LipiFlow thermal pulsation system
Life long condition

Explanation

pg. 68

Additional new treatment modalities: Intraductal meibomian gland probing; LipiFlow thermal pulsation system
Life long condition

40. Staphylococcal exotoxins may cause hypersensitivity reactions. Select the two conditions that apply and are allergic responses of conjunctiva and cornea to chronic exotoxin release.

Phlyctenules

Keratitis

Marginal corneal infiltrates

Tylosis

Hyperemic conjunctiva adjacent to corneal involvement

Hypersentivity reactions associated with staphylococcal blepharitis, occurs over days and weeks, rather than hours.

Keratitis is due to pooling of exotoxins in tear lake, also due to lipases breaking lipis into surface active free fatty acids and from poor blinking

Tylosis - thickening of eyelashes, permanent strucutural changes, changes due to exotoxins damaging tissue.
pg. 56

Explanation

Hypersentivity reactions associated with staphylococcal blepharitis, occurs over days and weeks, rather than hours.

Keratitis is due to pooling of exotoxins in tear lake, also due to lipases breaking lipis into surface active free fatty acids and from poor blinking

Tylosis - thickening of eyelashes, permanent strucutural changes, changes due to exotoxins damaging tissue.
pg. 56

Submit

Ocular Disease - Midterm 1 Lids Part 1

1. Keratoacanthoma spontaneously regresses by involution but very often mistaken for squamous cell. Because of this appearance, usually excised during phase of involutional regression. If there is a recurrence after excision is was almost definitely BCC or SCC, not keratoacanthoma.

2.

What first name or nickname would you like us to use?

2. Port wine stains are often associated with what syndrome?

3. Changes in the lid margin are primarily due to either staphylococcal and/or meibomian gland disorders, not to simple seborrheic processes

4. Basal cell carcinomas (BCC) metastasize quickly and is a fast growing lesion. Patients will often report the growth came out of nowhere and they just noticed it

5. Absence of superior lid sulcus in Caucasian people will lead you to believe the person could have a congenital ptosis, especially if the person is young.

7. What danger could accompany entropion?

8. Squamous cell carcinoma (SCC) can often arise from what pre-existing conditions?

11. Augmentin (aka amoxicillin/clavulanic acid) at a dosage of 250-500 TID can be used to treat staphylococci, streptococci and H.flu

12. What danger does a basal cell carcinoma (BCC) that is located in the medial canthal region present to the patient?

13. Select the false statement regarding the management of trichiasis

14. What oral antibiotic did Dr. Tong say was to be prescribed for individuals with a hordeolum and a sensitive stomach?

15. Select the false statement

16. Blepharitis is the most common cause of trichiasis

18. Which statement is false?

19. Which of the following is not considered a lid characteristic in staphylococcal blepharitis.

20. Which of the following is not an oral antibiotic that can be used for the treatment of preseptal cellulitis?

21. Primary meibomitis is the least serious/least threatening stage of meibomitis

22. Select the false statement

23. Select the false statement regarding oral antibiotics for staphylococcal blepharitis

24. Which of the the following topical antibiotic drops is/are allowed to be used for pediatrics in ages >8yo?

25. Which of the following is not a differential diagnosis for blepharospasm.

26. Seborrheic Blepharitis

27. Which statement is false regarding Myokymia?

28. Select the true statement regarding antibiotic ointments for staphylococcal blepharitis

29. Developmental vascular lesions

30. Early diagnostic sign of preseptal cellulitis is conjunctival hyperemia and chemosis (moderate to severe); these frequently precede proptosis and diplopia

31. The classic appearance of squamous cell carcinoma (SCC) is a center which slowly ulcerates with an increase in size. It tends to have darkened, ulcerated center.

32. Erythromycin can often clear an unresolved hordeolum which remained inflamed while progressing into a chalazion or a chalazion which has become reinfected. Dosage would be 1-2gm/day. 3-4 weeks.

33. Select the appropriate treatments for the management of ectropion since the goal will be to prevent discomfort, tearing, secondarykeratinization and or infection.

34. Which statements are true in the management of papillomas?

35. Sebaceous gland cysts

36. Preseptal Cellulitis

37. Which of the following topical antibiotic ointments is not suggested for pediatric use?

38. Which statements are true regarding seborrheic blepharitis

39. What is the third line treatment for meibomian gland dysfunction? What medication do you need to use?

40. Staphylococcal exotoxins may cause hypersensitivity reactions. Select the two conditions that apply and are allergic responses of conjunctiva and cornea to chronic exotoxin release.