What layer in the upper face sags with age and is tightened with face lift?
SMAS (superficial musculoaponeurotic system). In upper face, facial nerve is superficial to SMAS. In lower face, facial nerve is deep to SMAS. Do surgery accordingly (Stay deep to SMAS in upper face, and inverse in lower face).
Name three things on differential for hemorrhages in multiple ocular layers
2. Valsalva retinopathy
3. Terson syndrome
What areas are to be avoided in CPC and why?
3:00 and 9:00, location of ciliary nerves (painful to treat there)
Name the most common ocular side effects of these three TB drugs:
1. Pink tears and conjunctivitis
2. Toxic optic neuropathy
3. Toxic optic neuropathy
What enzyme is inhibited by corticosteroids in the production of prostaglandins? What about by NSAIDs?
Corticosteroids block phospholipase A2
NSAIDs block cyclooxygenase
What is the Goldman-Witmer coefficient?
Method used in Europe for diagnosis of ocular toxoplasmosis. Ratio of anti-toxo IgG in aqueous to anti-toxo IgG in serum.
Name three systemic disease associated with recurrent subconjunctival hemorrhage
3. Poor clotting
Anterior lenticonus is associated with what systemic abnormality?
Alport's syndrome (refer to nephrologist)
What is 1 year risk of severe (1 of 4:2:1) NPDR progressing to PDR? What about very severe NPDR (2 of 4:2:1)?
Very severe: 45%
Do upside-down single piece lenses affect the final refraction? What about 3-piece lenses?
Single piece lenses don't. Three-piece lenses do. The haptics are in front of the plane of the optic in a three-piece, to keep the optic away from the iris if it is placed in the sulcus. Thus, if placed upside down, optic will be in front of the desired plane, resulting in the need for an increased myopic correction.
What is the typical progenitor of Reiter's syndrome?
Dysentery (Shigella, Salmonella, Chlamydia, etc). >90% are HLA-B27 positive.
What finding should make you think skew deviation and not CN IV palsy?
Incyclotorsion of hypertropic eye (would be excyclotorsion in CN IV palsy, since SO is an intorter).
Cough, coryza, conjunctivitis -- think what?
Measles, which can cause retinopathy (heme, macular star, disc edema), and eventually look like RP after infection has waned.
Name some features of oculopalatal nystagmus
Vertical, pendular, bilateral
Caused by stroke, usually delayed onset
Associated with rhythmic movements of face, tongue, pharynx, larynx, or extremities
Hypertrophy of inferior olivary nucleus on MRI is very specific
What three structure define Mollaret's triangle?
Inferior olivary nucleus
What is the name of the syndrome in which the peripheral cornea becomes progressively more edematous after cataract surgery, while the central cornea remains clear?
What two associations are important to remember about morning glory disc?
1. Serous RD
2. Occult transsphenoidal basal encephalocele
How do you distinguish iris atrophy in HSV from VZV?
Patchy in HSV (like patch of vesicles)
Sectoral in VZV (like a dermatome)
What are the three branches of the ophthalmic division of CN V?
Lacrimal, frontal, nasociliary
Lacrimal doesn't branch
Frontal branches into supratrochlear, supraorbital
Nasociliary branches into short and long ciliary
What four muscles are innervated by the third nerve nucleus (include laterality)?
Ipsilateral MR, IR, IO
CHED has two forms, AR and AD. Which is present at birth, has nystagmus, is not painful, and doesn't progress?
What demographic is at highest risk for hypotony maculopathy after glaucoma surgery?
Young myope (think pigmentary)
Compact stroma but with epithelial edema in acute post-op period after phaco, think what?
High IOP from retained cohesive viscoelastic
What is the average age of diagnosis in RB for patients with A) known family hx? B) bilateral disease? C) unilateral disease?
Known family hx: 4 mths
Bilateral disease: 14 mths
Unilateral disease: 24 mths
What muscles are supplied by the inferior division of CN III?
AND medial rectus
What is the cycle time for periodic alternating nystagmus?
2-4 minutes (null, fast one side, fast other side, null)
Name the only two non-infectious entities that commonly present with hypopyon.
1) HLA-B27 related uveitis
What are the three glaucomas that benefit most from laser trabeculoplasty?
Whenever there is vitreous to the wound, what do you have to make sure of?
That there is no external vitreous. This could be a conduit for bacteria --> vitreous wick syndrome.
Common phaco complication in Fuchs heterochromic iridocyclitis and why?
Anterior chamber hemorrhages from nicking the long vessels across the angle during wound creation
Recurrent facial paralysis + perioral edema + lingua plicata = ?
Lip biopsy will show granulomatous inflammation
Where is the most common location for an aneurysm causing a pupil-involving third?
Junction of PCOM and ICA
What is Alexander's law?
Nystamus is always more pronounced on gaze toward the fast-beating component
What is the volume of one drop of medication from a standard bottle?
50 microliters (that's why you never need to write for more than 1 drop, since tear volume is only 7 microliters)
Name some clinical features suggestive of malignancy in an iris lesion.
Growth, increased vascularity, sectoral cataract, glaucoma
How is risk difference defined?
Same as absolute risk reduction. Just subtract the treated risk from the untreated. E.g. 10% untreated, 5% if treated, risk difference is 5.
What does AAION show on FA?
Patchy choroidal perfusion due to vasculitis of SPCA supplying choroid and nerve head
Which more commonly leads to rupture of Bruch's and CNVM: small or large laser spot size?
Small (think of it as more concentrated)
What anatomic area should you think of with see-saw nystagmus?
Parasellar area, midbrain -- e.g. craniopharyngioma
What anatomic area should you think of with periodic alternating nystagmus?
Cervicomedullary junction, cerebellar nodulus
True or false: LPI is indicated for topiramate-induced angle closure.
False (does not involve pupillary block. It's due to pseudo-plateau. Stop topiramate. Do aqueous suppressants. Do cycloplegics to deepen chamber.
What are some risk factors for suprachoroidal hemorrhage?
Old person, myope, glaucoma surgery, trauma, blood thinners
True or false: Viroptic, topical beta blockers, and topical NSAIDs are all associated with poor corneal epithelial wound healing.
What is the direction of ectopia lentis in Marfan's?
Superotemporal (Marfanoids are so tall they think they are superior). Homocysteinuria inferonasal.
What is the pathophysiology/embryology of Peter's anomaly?
Failure of lens vesicle to separate from surface ectoderm. Causes absence of corneal endothelium and Descemet's.
Equally prominent upper and lower medial eyelid skin fold
Epicanthus palpebralis (TPI from superior to inferior prominence)
Lower medial eyelid skin fold more prominent than upper
Epicanthus inversus (TPI from superior to inferior prominence)
Upper medial eyelid skin fold more prominent
Epicanthus tarsalis (TPI from superior to inferior prominence)
Mid peripheral DBH and light-induced amaurosis in old hypertensive diabetic. Think what?
Ocular ischemic syndrome
What is the treatment for river blindness (onchocerciasis)?
Ivermectin (annually for more than 10 years, since it doesn't kill the adult worms)
True or false: Adie's tonic pupil is associate with loss of accomodation
True. Parasympathetic postganglionic disruption of fibers leaving ciliary ganglion = mydriasis and loss of accomodation
Partial failure of eyelids to separate with residual strands connective upper/lower lid
Long horizontal palpebral fissure, short vertical fissure, associated with blepharophimos
What foods have a cross-reactivity with latex, making patients with allergy to these foods predisposed to latex allergy?
What percent of phakic patients with Retisert will get a cataract by 2 years? What percent will need a glaucoma filter?
100% will get cataract by 2 years
30% will get glaucoma tube
What are the three most common causes of spontaneous vitreous hemorrhage?
2. Retinal break without detachment
(4. RRD, 5. Neo after CRVO/BRVO)
What are the two epithelial layers of the ciliary body?
Think of pigment as something you can see, on the outside
Where do you apply laser in sickle cell retinopathy with NV?
Peripheral to the NV -- kill the retina it's feeding, kill the NV.
DON'T laser proximal to the NV -- you can cause breaks and CNVM
What two systemic diseases are associated with Christmas tree cataracts?
1. Myotonic dystrophy
Untreated patients are more likely to have worsening visual fields than treated patients. What trial?
True or false: aqueous suppressants and topical carbonic anhydrase inhibitors are a good idea in leaky cataract wound and hypotonous eye.
True -- decrease aqueous flow, allowing wound to seal
How do you give steroids around surgery time for a patient chronically on steroids?
100 mg hydrocortisone IV before, during, and after surgery
Slit like iris displaced one way, lens dislocated in opposite direction. Diagnosis? Inheritance?
Ectopia lentis et pupillae
How is peripheral ulcerative keratitis distinguished from Moorens'?
Moorens' ulcer only involves the cornea
PUK involves cornea and sclera
What is the most appropriate initial treatment for choroidal rupture?
May eventually get CNVM and need Avastin
What is the typical history and exam in RBCD?
age 10-20, positive family history, confluent and coarse opacities in central cornea, recurrent erosions
Bilateral oscillations with jaw movements in a patient with diarrhea. Think what? Do what?
Oculomasticatory myorhythmia. Associated with Whipple disease. Treat with antibiotics.
Where is the common canaliculus in relation to the medial canthal tendon?
The common canaliculus lies in between the anterior and posterior portions of the medial canthal tendon, which attaches to the anterior and posterior lacrimal crests
What patient with JIA is most likely to have chronic smoldering uveitis?
Female, pauciarticular (<5 joints)
What happens when the angle of incidence is greater than the critical angle?
Total internal reflection -- light reflects instead of refracting
In calculating IOL power with silicon oil, how must your calculation be adjusted?
Silicon causes a hyperopic shift, so add 3.00 D to the power of the lens you would normally choose
Where is the superior orbital fissure (bone-wise)?
Between the greater and lesser wings of the sphenoid
What is the only periorbital gland that functions by apocrine secretion?
Glands of Moll (sweat) -- Molly is a sweaty ape
Does corneal transplant help in opacification associated with aniridia?
NO. The opacification is due to limbal stem cell deficiency. Transplant those stem cells instead.
Inferior corneal thinning with protrusion of cornea above the thinning
Pellucid marginal degeneration
BRAO, bilateral sensorineural hearing loss, and encephalopathy: diagnosis?
Susac syndrome. Women age 20-40. Unknown cause. Treat with IV steroids.
What is the most common hereditary optic atrophy?
Dominant optic atrophy, OPA-1 gene on chromosome 3 involved in 50-75%
What sinus is just medial to the optic canal?
Sphenoid -- be careful of optic nerve damage during transsphenoidal surgery
What is the pathology of Salzmann's nodular degeneration?
Hyaline in Bowman's from chronic irritation
What is a good mnemonic for Hermansky-Pudlak?
The four P's:
Pulmonary fibrosis (cause of death)
Retinoblastoma in one eye, retinocytoma in the other eye. Chance of offspring having it?
Retinocytoma = retinoblastoma for genetic purposes
What is the only class B glaucoma drug?
Brimonidine, interestingly enough
But don't give to nursing mothers -- gets in breast milk
Perception that an object moving perpendicular is actually moving toward or away from you is known as what? What does it usually signify?
Pulfrich effect. Recovery from optic neuritis.
True or flase: loose zonules (eg Marfan's, PXE) are associate with anterior capsular phimosis.
True. The loose zonules don't hold things put.
What do you do during phaco if you suspect suprachoroidal hemorrhage?
1. Close wound
2. Inject cohesive
3. Consider posterior sclerotomies, starting in IT quadrant
Who meets AREDS criteria? (list four)
1. 1 large druse (>125 microns, size of large vessel at disc)
2. Multiple intermediate drusen
3. Severe unilateral AMD
4. Non-subfoveal GA
Total paralysis of CN VI. You've waited 6 months. What is the preferred management?
Muscle transposition surgery
Would do R-R if some function had been regained, but for total paralysis, muscle transposition is indicated
Central areolar choroidal dystrophy is autosomal dominant and looks like very early GA. What gene causes it?
Does atrophia and phthisis put you at increased risk of intraocular malignancy?
Yes, atrophia and phthisis put you at increased risk of intraocular malignancy, so you should get annual B-scan.
Middle-aged female with enophthalmos and unilateral limited motility
Breast cancer metastatic to orbit
Name three corneal measurements that are cutoffs for increased risk of pseudophakic bullous keratopathy after cataract surgery.
1. Endothelial cell count <1000
2. Coefficient of variation >0.3 (polymegathism, different cell sizes)
3. Pachymetry >650
Most common cause of dorsal midbrain syndrome in a) children, b) young women, c) adults?
Dorsal midbrain syndrome:
kids: pinealoma, congenital aqueductal stenosis
young women: MS
adults: midbrain stroke
For a very dense cataract, you might want more suction force on your phaco tip. Do you choose a bigger angle tip or smaller angle for that?
More oval, less circular --> more force
How can occlusion of the ophthalmic artery and the central retinal artery be distinguished?
Ophthalmic artery also supplies choroid, so if it's occluded, will have silent choroid
What are the only two proven treatments for ocular-involving SJS?
Amniotic membrane transplant
Pulse steroids IV
Name five things can cause retinochoroidal collaterals (optociliary shunts)
1. Chronic papilledema
2. Old CRVO
3. Chronic glaucoma
4. Optic nerve sheath meningioma
5. Optic nerve glioma
What procedure is done for significant torsional deviation (e.g. bilateral CN IV palsy)?
Split SO fibers
What is the direction of the NLD as it moves inferiorly?
All the bad connotation directions: down, back, and out
What glaucoma drop should be avoided if the patient has a history of herpetic keratitis?
Can cause reactivation
Multiple tricholemmomas -- small crust lesion on face -- marker for breast/thyroid cancer. Eponym?
Name two diseases on the differential for acute idiopathic enlarged blind spot. What diagnostic test is indicated (besides fields)?
Get a mERG
Name three weaker steroids that are good to use to avoid steroid response
What is a good rule of thumb for how much skin to leave behind in chalasis surgery?
10 mm from incision to brow
10 mm from incision to margin
20 mm total
What anti-emetic is contraindicated in infants? Why?
severe respiratory depression, death
Do kids with nystagmus prefer to gaze in the direction of the fast phase or slow phase?
Slow phase. Left-beating nystagmus kids will want to look to the right, so they'll have a left head turn.
Alexander's law: nystagmus is worse looking toward fast phase. Basically, they will point their head toward the fast phase.
Name another inherited disease besides Axenfeld-Rieger with posterior embyrotoxon
Also presents with jaundice, cardiac defects
JAG1 on chromosome 20
If you have to use a CAI in a patient with history of kidney stones, which do you pick?
What causes Bitot spots? foamy deposits at limbus
Vitamin A deficiency
related to Corynebacterium, which forms gas that makes lesion foamy
How can orbital apex syndrome be distinguished from cavernous sinus pathology?
By optic nerve involvement -- if vision is fine, it isn't orbital apex
What strabismus surgery puts acuity at greatest risk if there is a complication?
Inferior oblique advancement
It involves reattachment more posteriorly, and if you perf the eye that's where the macula is.
Treatment of nystagmus:
Prisms with apices away from head turn
Surgery with rotation of eyes toward head turn
What effect does oral prednisone alone (no IV) have in initial optic neuritis on recurrence?
Oral prednisone as monotherapy DOUBLES the risk of recurrence. So it is never used as monotherapy.
True or false: PRP in areas of traction is a good idea.
PRP can cause further contraction -- worsening the traction, causing vit heme or RD.
Flat, thin cornea, hyperopia, sheet-like posterior corneal opacity in first decade of life, AD inheritance. Diagnosis?
Posterior amorphous corneal dystrophy
Unilateral arcus senilis should make you do what?
Get a carotid Doppler to look for CONTRALATERAL carotid disease. -- the clear eye might have the pathologic blood supply.
What are the three causes of involutional entropion?
1. Horizontal lid laxity
2. Disinsertion of the lower lid retractors
3. Overriding preseptal orbicularis
Do reinsertion of retractors and lateral tarsal strip to address all of them.
What clinical feature best distinguishes atopic from vernal keratoconjunctivitis?
VKC typically involves only the superior conj
AKC affects superior and inferior
Also VKC is seasonal
Third nerve fascicular lesion and contralateral ataxia/coordination problems
C for coordination, C for Claude