Professional Documents
Culture Documents
Dr Abdullah Fouad
Index
4) Neuro Ophthalmology…………….…………….…………….……. 12
9) Glaucoma…………….…………….…………….…………….…………. 58
From Exams
Ophthalmologic signs of TTP may be: (Eyewiki)
A) Retinal: hemorrhage, arterial or venous occlusion, or serous retinal detachment.
B) Cranial nerves: anisocoria or ocular misalignment.
C) Papilledema (optic disc edema due to increased intracranial pressure)
D) Others hypertensive choroidopathy, retinopathy, and optic neuropathy have also been reported.
Ocular Disorders associated with Thrombocytopenia : (Kanski)
1- Capillary Hemangioma (Kasabach–Merritt syndrome)
2- Albinism (Hermansky–Pudlak syndrome)
3- Drug induced (Pyrimethamine > as a treatment of Toxoplasmosis)
Regarding ocular involvement in Graft Versus Host disease (GVHD), a mean Schirmer’s test in both eyes
of less than 5mm is characteristic
Rifampicin >> Pink-tinged tears
Quinilones >> inhibition of nucleic acid synthesis
Anaphylactic Shock >>IgE
Burkitt’s lymphoma >> Epstein-Barr virus
Metabolic Syndrome >> 3 or more of (Large waist – High Triglyceride – Reduced HDL – increased BP –
increased Bood Sugar)
In the inflammation cascade, cell membrane lipids are converted to arachidonic acid by phospholipase
A2, and prostaglandins are then formed by cyclooxygenases (COX).
Corticosteroids reduce inflammation by → increase the synthesis of lipocor ns → block phospholipase
A2 → prevents the conversion of phospholipids to arachidonic acid
Tumor Necrosis Factor (TNF) → Infliximab, Adalimumab, Etanercept.
Rituximab→ (It’s not TNF) is a monoclonal antibody directed against CD20 positive cells mainly B
lymphocytes useful in treatment of Behcet disease and Wegener granulomatosis.
From Exams
In Von Hippel-Lindau lesions (retinal angiomatosis), Multiple angiomas may be found in the same eye
(80% of cases are familial)
Regarding Malignant Melanoma of Choroid>>Histological cell type is the most significant prognostic
indicator
Regarding Malignant melanoma of the Uvea >>Tomours involving the CB carry a worse prognosis
Ataxia telangectesia (Louis-Bar syndrome)>> increased incidence of cancer
Regarding Optic Atrophy >> loss of ganglion cell axons
Scattered, well demarcated tumours of the retina composed of glial cells >> Tuberous Sclerosis
BCC of the eye lid >> Mohs’ Surgery carries a better than 95% better cure rate for BCCs
Regarding Malignant Melanoma of the uvea :
- Spindle cell melanoma → best prognosis
- Epithelioid melanoma → worst
- Mixed-cell type (mixture of spindle and epithelioid cells) → intermediate prognosis
Regarding Uveal Melanoma → Monosomy of chromosome 3 carries poor prognosis, especially with
gains in chromosome 8. Chromosome 3 loss associated with a reduction of the 5-year survival
probability from approximately 100% to 50%.
Choroidal Melanoma → Presenta on peaks at around the age of 60 years (Range 45-80 years).
Mortality is up to 50% at 10 years. Every millimeter of increasing thickness promotes and increasing 5%
risk for metastasis by 10 years follow up.
The American Cancer Society reports: (Regarding Choroidal Melanoma)
Flexner-Wintersteiner Rosette “characteristic for RB” → consists of tumor cells surrounding a central
lumen that contains cytoplasmic extensions from the tumor cells.
cells
Pseudorosettes “CNS ependymomas “→ Collections of tumor cells around blood vessels (It’s called a
pseudorosette because the central structure isn’t part of the tumor)
The figures below are → Bilateral diffuse uveal melanocytic proliferation (BDUMP), a very rare
paraneoplastic syndrome occurring usually in patients with systemic, often occult, malignancy. It is
characterized by the proliferation of benign melanocytes in the outer choroid often manifesting with
multiple naevus-like choroidal lesions. (Kanski)
4) Neuro Ophthalmology
From Exams
The following findings may suggest the need for additional evaluation of those patients presumed to
have migraine:
1-Headache
ache or aura always occurring on the same side.
NAION AAION
Prognosis 50% achieve 6/9 or better, though 25% will only 40% are associated with permanent
reach 6/60 or worse visual loss
Pain painless periocular pain is common
Fellow 10% after 2 years, 25% in 6 days
eye 15% after 5 years. 95% of untreated patients.
Regarding GCA → Multinucleated Giant cells are not necessary on the pathologic specimen to confirm
the diagnosis; however, when they are present, they are most often situated near the fragmented
internal elastic membrane. (eyewiki)
- ESR normal in 20%
- The CRP has a higher sensitivity than ESR; when used together the sensitivity increases to 97-99%.
- Histopathological findings persist for at least 2-6 weeks after commencing steroids.
Fundoscopic clues to a diagnosis of AAION over NAION include the following:
1- Chalky-white ONH edema (in NAION, the ONH is often hyperaemic).
2- Cotton-wool spots away from the ONH, which indicate concurrent retinal ischemia (cotton-wool spots
on or adjacent to the ONH can be present in NAION).
3- delayed optic nerve and choroidal filling while in NAION delayed optic nerve filling but normal
choroidal filling (normally, the choroid fills completely within 3–5 seconds, before the retinal arteries
do).
4- Normal or large cup in the fellow eye (in NAION, a small cup–disc ratio is common).
Occurrence of NAION in the second eye produces the clinical appearance of pseudo Foster Kennedy
syndrome, in which the previously affected ONH is atrophic and the currently involved ONH is
edematous.
Aberrant regeneration is common after trauma or compression by an aneurysm or tumor but does not
occur with microvascular ischemia.
Regarding Aberrant regeneration → Any combina on of synkine c movement of the muscles innervated
by the third nerve may be present (e.g., elevation of the upper eyelid on downward gaze or adduction;
adduction of the eye on attempted vertical gaze; limited elevation and depression of the eye with
retraction of the globe on attempted vertical gaze; or pupillary constriction with extraocular muscle
movement). (Eyewiki). However Classic findings include eyelid retraction with adduction or pupillary
miosis with elevation, adduction, or depression. (AAO)
- “Pseudo Von-Graefe Sign:” elevation of upper eyelid on downward gaze or adduction
Congenital Horner syndrome is usually caused by birth trauma to the brachial plexus. Nontraumatic
Horner syndrome in infants and children raises the possibility of neuroblastoma arising in the
sympathetic chain of the chest. In these circumstances, MRI of the head, neck, and chest is indicated.
Imaging in Horner cases is not indicated except in acute acquired cases or cases of increasing
hetetrochromia, in contrast to congenital or longstandig cases with over a year with no other localizing
lesions.
In progressive supranuclear palsy:
- downward gaze is generally affected, becoming smaller and slower. This is in distinction to the dorsal
midbrain syndrome, in which upward saccades are generally affected.
- Saccades are affected more than pursuits.
- Affects the Voluntary movements, but Spare the involuntary movements (e.g. intact Bell's
phenomenon)
The most common cause of an acquired 6th nerve dysfunction in children is a neoplasm. This is
followed by trauma, elevated intracranial pressure, inflammatory causes and post-viral etiologies.
(eyewiki).
Sixth nerve palsy in a child is a common post-viral syndrome and typically resolves entirely of its own
accord. Nonetheless, neuroimaging should be arranged to exclude intracranial pathology. The second
most common aetiology of childhood abducens palsy is increased intracranial pressure (either a CNS
tumour or idiopathic intracranial hypertension) (Eyedocs)
Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder of children and young
adults that affects the central nervous system (CNS). It is a slow, but persistent, viral infection caused by
defective measles virus.
Miller-Fisher syndrome (MFS), which is observed in about 5% of all cases of GBS, classically presents as a
triad of ataxia, areflexia, and ophthalmoplegia. TTT: IV immunoglobulin (IVIg) or plasmapheresis.
- Acute onset of external ophthalmoplegia is a cardinal feature.
- Anti-GQ1b antibodies are prominent in MFS, and have a relatively high specificity and sensitivity for
the disease.
- MFS causes descending paralysis, while GBS ascending paralysis.
Uhthoff symptom occurs with optic neuritis and is a decrease in vision with an increase in body
temperature.
Lhermitte sign is the electric shock sensation with neck flexion and is found in patients with multiple
sclerosis.
prosopagnosia, the inability to distinguish faces, caused by bilateral medial inferior occipitotemporal
lesion
Riddoch phenomenon occurs in patients with ‘cortical blindness’ who are able to perceive objects in
motion, but cannot see stationary objects.
Papilledema, although commonly present in 90% of patients with pseudotumor cerebri (idiopathic
intracranial hypertension), is not necessary for the diagnosis.
DD of BL motility deficit + pupil involvement includes Guillain–Barré syndrome and botulism. In Guillain–
Barré syndrome Lumbar puncture may reveal elevated protein, and anti-GQ1b antibodies are often
present.
From Exams
Regarding Neuroblastoma:
- Children presenting with opsoclonus have a good prognosis
- The adrenal gland is the most common site of origin
Rate Toxoplasmosis fetal transmission (in contrast to severity)
- less than 6% in the 1st trimester.
- 60-81% in the 3rd trimester.
Signs of Orbital cellulitis + Black discoloration of the nasopharynx >> Rhino-Orbital Mucormycosis
Periventricular leukomalacia >> commonly associated with Optic disc cupping **
Plus disease in ROP >>Significant Venous engorgement and Arterial tortuosity
The 4Δ base-out prism test is the least reliable method of documenting a central suppression
scotoma:
- Patients with bifixation may recognize diplopia when the prism is placed before an eye but make no
Faden (posterior fixation suture) → weakening the muscle without affecting it in the 1ry position.
Inferior rectus muscle paresis with diplopia in downgaze following blowout fracture of the orbit or
operative trauma → can be treated by Contralateral inferior rectus recession with a posterior fixation
suture.
Pulling the inferior rectus muscle forward, as in a resection → advances the lower eyelid upward (Lower
eyelid elevation); recessing this muscle pulls the lower eyelid down, exposing bare sclera below the
lower limbus. Surgery on the superior rectus muscle is somewhat less likely to affect upper eyelid
position. Release of the lower eyelid retractors or advancement of the capsulopalpebral head is helpful
to prevent lower eyelid retraction after inferior rectus muscle recession.
The most appropriate type of needle for suturing the sclera in strabismus surgery → Micro-spatulated
(risk of perforation is lower)
(The two basic types of needles are vertical cutting (See Figure 11A) and side cutting or spatulated (See Figure 11B). The
preferred side cutting or spatulated needle has a flat top and bottom, thereby reducing the chance of inadvertent perforation
deep into the globe or the roof of the scleral tunnel above. The vertical cutting needle, with the sharp pointed up or down, can
either penetrate too deep or cut the roof of the scleral pass above)
From Exams
Distichiasis mainly affects the lower lid.
- The majority of patients also manifest primary lymphoedema of the legs (lymphoedema– Distichiasis
syndrome).
- Cryotherapy → effective but carries a high rate of local adverse effects, and is less commonly
performed than previously
- Electrolysis → frequently multiple treatments are required to obtain a satisfactory result.
Regarding Non-Hodgkin Lymphoma of the orbit and ocular adnexa >>They are usually B-Cell lymphoma
Upper lid retraction caused by thyroid eye disease can be treated with recession of levator aponeurosis
Ankyloblepharon
Nevi are the third most common benign lesions encountered in the periocular region (after papillomas
and epidermal inclusion cysts). They arise from nevus cells, which are incompletely differentiated
melanocytes in the epidermis and dermis and in the junction zone between these 2 layers.
Ephelides, or freckle is a small, brown spot on the skin, the malar areas, eyelids, or the conjunctiva.
Ephelides arise from hyperpigmentation of the basal layer of the epidermis. The number of epidermal
melanocytes is not increased, but they extrude more than the usual amount of pigment into the
epidermal basal cell layer.
Junctional nevi are flat or slighly elevated and are comprised of nests of nevus cells in the basal
epithelial layer. They have the greatest potential for malignant transformation to melanoma by
comparison to intradermal nevi and compound nevi.
Other types of pigmented lesions:
- Nevus of Ota: diffuse congenital deep dermal nevus of the periocular skin
- Blue nevus: deeply located dermal nevus present at birth with very little elevation.
- Spindle cell nevus: compound nevus of childhood with bizarre cellular components but no malignant
potential.
Congenital nevi have a 5-10% lifetime risk of transformation to melanoma.
Xeroderma pigmentosum is characterized by skin damage on exposure to sunlight, leading to
progressive cutaneous abnormalities. It is inherited in an autosomal recessive (AR) fashion. Affected
patients have a bird-like facies and a great propensity to the development of basal cell carcinoma
(BCC), squamous cell carcinoma (SCC). It is due to a decreased ability to repair DNA damage such as
that caused by ultraviolet (UV) light.
- Large Defect (>50% eyelid) → Either Eyelid sharing “Cutler-Beard (Bridge) procedure” for upper lid
and “Hughes” procedure for lower lid or Mustarde cheek rotational flap for very large defect.
Immunocompromised patients are at increased risk of SSC.
Sebaceous gland carcinoma (SGC) is a highly malignant and potentially lethal tumor, the tumor within
the tarsal plate tends to progress to an intraepidermal growth phase, which may extend over the
palpebral and bulbar conjunctiva.
- A fine papillary elevation of the tarsal conjunctiva (not extra epidermal) may indicate pagetoid spread
of tumor cells.
- Wide surgical excision is mandatory for adequate treatment of sebaceous adenocarcinoma.
- Orbital exenteration may be considered for recurrent or large tumors invading through the orbital
septum.
- Sentinel lymph node (SLN) biopsy is considered for patients with eyelid sebaceous cell carcinoma
with high-risk features (recurrent lesions or extensive involvement of the eyelid or orbit)
- Sebaceous carcinomas are relatively radioresistant.
Kaposi sarcoma is highly radiosensitive tumours.
Management of trachomatous trichiasis in endemic regions → Bilamellar tarsal rotation with either
absorbable or a nonabsorbable suture.
Treatments for trichiasis and recurrence: (NCBI)
- Cryotherapy → 90% success and the least recurrence, but significant risk of complications
- Argon laser → 67.9% successful with no evidence of recurrence
- Electrolysis → me consuming, suitable only for isolated eye lashes with a high recurrence rate.
- Epilation → the simplest method, not suitable for a large number of lashes and the lashes tend to
regrow within few weeks.
Collarettes of staphylococcal blepharitis → fibrinous crust.
A frequent complaint of patients with aponeurotic ptosis is worsening of the ptosis when they look
down because the eyelid has no opposition on downgaze.
Ptosis → restriction of both the upper and lower visual fields.
Dermatochalasis → upper field but not lower field defect.
Muller muscle-conjunctival resection is indicated for small degrees of involutional ptosis.
Some wooden orbital foreign bodies may be missed on CT and are seen better on MRI.
Regarding orbital fracture repair → transcaruncular approach to the medial wall will avoid the
complication of postoperative lower lid retraction.
Calvarial (the top part of the skull) graft represents a notable exception to the usual rule of late
remodelling resorption seen in other corticocancellous bone grafts. This is due to diploic vascular
system of this bone.
The incidence of traumatic optic neuropathy (TON) in the setting of a closed traumatic head injury in
various studies ranges from 0.5-5%. (mesdscape)
Spontaneous visual improvement occurs in up to about half of indirect injury patients.
Waardenburge syndrome (WS) → AD, patchy areas of depigmentation of the hair and skin in piebald-
like distribution, heterochromia, broad nasal root, congenital deafness (20%). An estimated 2 to 35%
of all congenital deafness results from WS.
From Exams
Superior limbic keratoconjunctivitis (SLK) is associated with abnormal thyroid function (usually
hyperthyroidism)
Natamycin "Polyene" → Filamentous fungi (Fusarium and Aspergillus).
Amphotericin → Aspergillus and Candida.
Miconazole → Paecilomyces lilacinus.
Flucytosine → an adjunc ve agent for treatment of Candida spp.
Fusarium Keratitis → Responds well to Imidazole antibiotics e.g. Fluconazol (answer sheet 2019&2017)
Histoplasmosis may be a cause of fungal keratitis (Case reports in india).
https://www.sciencedirect.com/science/article/pii/S2452403416300115
Miconazole is effective against yeast and filamentous.
http://www.scielo.br/scielo.php?pid=S0034-72802013000200014&script=sci_arttext&tlng=en
Terrien Marginal Degeneration >> more in Men (75%). (Kanski)
Typically affects 20-40 years patients (AAO). Onset after the 4th decade. (Answer sheet!!!).
Typically begins superiorly. (AAO)
Skin Scarring is a characteristic clinical feature to distinguish HZ Keratitis from HS Keratitis
Rheumatoid Arthritis causes dry eye syndrome by altering the functions of the lacrimal glands.
Trachoma is more common in females
In Salzmann nodular degeneration >> hyaline material deposits in Bowman layer
SJS >>Type IV immune-complex reaction
Classically, the most common cause of neonatal conjunctivitis is due to post-delivery use of ophthalmic
silver nitrate used in the prophylaxis of ocular gonococcal infections
Chlamydial conjunctivitis (C. trachomatis serotypes D-K) is the most common infective cause of
neonatal conjunctivitis.
Neonate tears also lack immunoglobulin IgA
Neonatal Conjunctivitis:
- Chemical conjunctivitis (Typically presents within first 24 hours following birth)
- Neisseria gonorrhea (3-5 days after birth)
- C. trachomatis (5-14 days)
- HSV (1-2 weeks)
Collarettes of staphylococcal blepharitis > fibrinous scales.
Moraxella lacunata > Angular Blepharitis
Pseudo-epihheliomatous hyperplasia > is found in Keratoconus and Keratocanthoma
Goldenhar syndrome (First branchial arch abnormalities) > triad of epibulbar choristomas (Dermoid),
preauricular skin appendages, and pretragal blind ending fistulas in association with mandibular facial
dysplasia.
As regard Cystinosis, Topical cysteamine → may be beneficial to reverse corneal crystal forma on.
Oral cysteamine → may be beneficial for re nopathy and op c neuropathy.
In PKP → Con nuous (Running) suture pa erns are not recommended for pediatric cases.
- The single interrupted suture technique is the ideal technique in pediatric cases, because it provides
for better wound apposition and a more stable wound as sutures began to loosen over time.
5 year survival rate for penetrating keratoplasty for keratoconus is approximately 90%. And less than
50% when the indication is corneal edema due to endothelial failure from intraocular surgery, and even
lower when the eye is aphakic.
Overall risk of failure for re-grafts is about 50% at five years.
10% to 16% of all corneal transplants around the world are regrafts.
90% of corneal grafts are clear greater than 1 year postoperatively.
65% of corneal grafts performed for HSV Keratitis remains clear greater than 1 year postoperatively.
Overall the incidence of an endothelial graft rejection episode is 20% to 25% post-PK according to most
studies. (Khodadoust line) (Eyedocs)
There are many connective tissue disorders that are associated with scleral disease. Rheumatoid
arthritis is the most common.
Scleritis may occur in isolation (43%) or in association with several types of systemic disorders (57%).
Chronic ocular inflammation is the most common cause of band keratopathy, particularly juvenile
idiopathic arthritis (JIA).
The causes of band keratopathy include:
age
ocular disease
o chronic uveitis (especially JIA)
o phthisis bulbi
o silicone oil
o alkali injury
systemic causes
o hypercalcaemia
o hyperphosphataemia
o hyperuricaemia
hereditary
The intial therapy of Corneal Hydrops in Keratoconus >> hypertonic saline drops, Cycloplegic and topical
steroids. May resolve enough that no surgery is needed.
Fuch's endothelial dystrophy is the most common posterior corneal dystrophy (and the most overall).
Hassall-Henle bodies → histologically similar to gu ata except they occur in the periphery.
The most common stromal dystrophy is lattice, followed by granular.
Macular corneal dystrophy, the least common of the classic stromal dystrophies.
Map-dot-fingerprint (Cogan) dystrophy is the most common anterior dystrophy. The most common
dystrophy associated with RCE is Cogan's (map-dot-fingerprint) dystrophy.
Of the 3 common stromal dystrophies (lattice, macular and granular), lattice is the most commonly
linked to RCE. (In Kanski RCE is very rare in Lattice AND Very common in Macular)
Reis–Buckler dystrophy, Avellino (granular 2 + lattice) dystrophy → chromosome 5q31.
Bacteria that are able to penetrate a healthy corneal epithelium;
eria Family → Neisseria, Diphtheria, Listeria and H. Influenza
Iris atrophy is more common with HZV than HSV.
(in HZV: Sectorial atrophy, in HSV: moth-eaten peri-pupillary defects)
HSV →Dentric ulcer with characteristic terminal buds (its bed Stained well with Fl. And The virus-laden
cells at the margin of the ulcer stain with rose Bengal)
HZV → Dentric epithelial lesions (not ulcer) that are smaller and finer than herpes simplex dendrites,
and have tapered ends without terminal bulbs (Stained better with rose Bengal than with Fl.).
(The active viral replication causes sloughing of epithelial cells in HSV, whereas in HZV, the epithelial
cells are swollen and heaped up )ﯾﺘﻜﻮم.
Hyperventilation, rather than hypoventilation, can be used during cases under general anesthesia to
decrease vitreous pressure.
Peters anomaly is the most frequent indication for penetrating keratoplasty in children.
In Radial Keratotomy →the dioptric effect per incision decrease significantly a er 8 of incisions.
Micropapillae are more common in contact lens wearers than the classic giant papillae
From Exams
Lyme disease → Borrelia burgdorferi & False +ve result for syphilis (Both are spirochetes)
Neurological involvement is common in Lyme disease (40%)
Cat-Scratch disease → Bartonella henselae
Juvenile xanthogranuloma (JXG) → (Early Childhood –Multiple skin lesions -Heterchromia- Hyphema-
Touton Giant Cell) **
Syphilis may cause Ischemic Optic Neuropathy
Sub-tenon injection of Corticosteroid is contraindicated in Toxoplasmosis associated with active
Chorioretinitis **
Immune recovery Uveitis → induced by cidofovir in patients taking HAART therapy
Reactive arthritis (ReA, also known as Reiter syndrome) is characterized by a triad of non-specific
urethritis, conjunctivitis and arthritis. (75% HLA-B27) (20% AU)
The likelihood to develop reactive arthritis:
- Following a sexually-acquired infection → Men > females 9 times
- Following a gastrointestinal infection → Men = Females.
In humans the MHC (HLA) is found on chromosome 6.
HLA haplotypes that most commonly associated with acute anterior uveitis → HLA-B27
The MOST common cause of uveitis in patients under 20 years of age → Idiopathic anterior uvei s.
The most likely to be normal in Ankylosing spondylitis → Thoracic spine.
Psoriasis → AAU 7% - HLA-B27
Risk factors for Chronic Non-Granulomatous Anterior Uveitis in JIA:
1- ANA +ve
2- Oligoarticular
3- Female
Posterior uveitis is the most common presentation of intraocular TB (involvement of retina alone is
uncommon).
TB drug therapy can cause ocular and systemic side effects: (particularly hepatic and neurologic ones)
- Isoniazide and Ethambutol → Optic neuritis in few treated patients.
- Rifampicin → blepharo-conjunctivitis and pink tinged tears.
Drug resistant tuberculosis (DR-TB) is strongly associated with HIV infection.
The tuberculin skin test; PPD (Protein purified derivative) or Mantoux tuberculin skin test (TST) →
measures Cell mediated delayed hypersensitivity (type 4) to tuberculoprotein.
Ocular tuberculosis is usually not associated with clinical evidence of pulmonary tuberculosis, as up to
60% of extrapulmonary tuberculosis patients may not have pulmonary disease.
IV penicillin G is the recommended treatment for all forms of neurosyphilis and for syphilitic eye disease.
All forms of natural and semisynthetic penicillins can cause allergy, but it is more commonly seen after
parenteral than oral administration. Penicillin G is the most common drug implicated in drug allergy.
Incidence is probably highest with procaine penicillin, as procaine itself is allergenic.
In neurosyphilis, the serum VDRL test may be negative and cerebrospinal fluid VDRL may be positive.
Eye complications are more commonly found in patients with long standing multibacillary
“Lepromatous” than paucibacillary “Tuberculoid” leprosy.
Nearly 25% of patients worldwide with chronic ocular Behcet disease have visual acuity less than
20/200. AAO UVEITIS
Uncommon complications of Toxoplasma retinitis → Periarteritis resulting in BRAO. Kanski
Acute zonal occult outer retinopathy (AZOOR) is more common in females (in one or both eyes of young
or middle-aged).
Leukotriene B4 (LTB4) is a leukotriene involved in inflammation. It is produced from leukocytes in
response to inflammatory mediators and is able to induce the adhesion and activation of leukocytes on
the endothelium, allowing them to bind to and cross it into the tissue.[1] In neutrophils, it is also a
potent chemo-attractant, and is able to induce the formation of reactive oxygen species and the
release of lysosomal enzymes by these cells.[1] It is synthesized by leukotriene-A4 hydrolase from
leukotriene A4.
Cysticercosis is an infection caused by the eggs of Taenia solium, or pork tapeworm. It is the most
common parasitic infestation affecting the central nervous system (CNS), and approximately 90% of
patients with cysticercosis have CNS involvement. When the CNS is involved in cysticercosis, it is called
CT: multiple calcified lesions. CT: numerous lesions. MRI: multiple, large, cysticercus
cysts in the basal cisternal spaces.
9) Glaucoma
From Exams
Regarding Hyphema >> the risk of Rebeelding is greatest 3-5 days after the injury
POAG >> the prevalence is 3-8 times higher at 80 than at 40 years old
FH risk factor of POAG > risk to siblings “brother or sister” is 4 times and to offspring 2 times the normal
population risk.
In POAG > the vertical cup-to-disc diameter ratio increases faster than the horizontal one, leading to an
increase of the quotient of horizontal-to-vertical cup to-disc ratios to values lower than 1.0.
NTG >> more common in women
The rise of IOP takes 2-4 weeks or up to 6 weeks after starting ocular steroid.
Systemic hypertension is associated with a lower risk of the presence of glaucoma because higher
blood pressure is associated with improved optic nerve perfusion, So over treatment of systemic
hypertension may be a factor to glaucoma progression in some cases and should be avoided.
Ocular perfusion pressure is the difference between the arterial BP and the intraocular pressure (IOP),
and has been shown in population studies to be linked to increased risk for the development and
progression of glaucoma.
Disc hemorrhage most commonly inferotemporally , their presence is a risk factor for the development
and progression of glaucoma.
Increase in corneal thickness of 10 microns results in increase IOP by 1mm Hg.
Paracentral, small, relatively steep depressions constitute approximately 70% of all early glaucomatous
field defects.
The earliest defect due to glaucoma is generalized decreased sensitivity.
Typically the central island of vision and the infertemporal visual field are retained until late in the
course of glaucomatous optic nerve damage.
As nasal fibers and the maculopapular bundle are typically spared until late in the disease process, it is
common to have a central or temporal island of vision remaining in eyes with advanced glaucoma.
Mitomycin C inhibits Fibroblast proliferation.
Kinetic perimetry is more efficient at holding the tested person's attention than static.
Manual perimetry is more efficient at holding the tested person's attention than Automated.
Adverse effects of PG analogues include conjunctival hyperemia (as a result of vasodilation ) more with
bimatoprost and travoprost.
Thymoxamine is alpha receptor blockers that revese pharmachological dilation.
The basic protocol for Argon laser trabeculoplasty:
1- Spot size of 50 micron.
2- Power of 300-1000mwatt.
3- Spot duration of 0.1 second.
4- Laser spot placed at the junction of the anterior non-pigmented and the posterior pigmented edge
of trabecular meshwork.
A cyclodialysis cleft is a separation of the ciliary body from the scleral spur, creating a direct connection
between the anterior chamber and the suprachoroidal space. Many will spontaneously close, but those
Topical or systemic corticosteroids are not a risk factor for POAG; rather, it is a risk factor for steroid
induced Secondary OAG.
Applanation tonometry→ Use of excessive fluorescein causes thick mires and an overestimation of IOP.
Applanation tonometry→ if corneal as gma sm is greater than 3D, IOP is underestimated for with the-
rule astigmatism and overestimated for against-the-rule astigmatism.
A pupillary diameter of less than 3 mm can cause general depression of the Visual field.
On the Goldmann perimeter, The III4e test object will have twice the diameter (size) and four times the
area of the II4e test object.
A fixation loss occurs when the patient responds as if seeing a light when a target is displayed in his blind
spot.
Intermittently, the perimeter will pause and the motorized light will change position, but no stimulus
will be presented. If the patient presses the button, a false-positive response is recorded.
Topical timolol has been shown to decrease HDL.
Allergic Conjunctivitis with Glaucoma drugs → Bromonidine 20%, Dorzolamide 1-2%. PG analogs more
commonly produce conjunctival hyperemia than true allergic conjunctivitis.
CAI may cause idiosyncratic and transient acute myopia.
Using CAI → aqueous produc on in the eye is not significantly reduced until more than 90% of the
carbonic anhydrase activity is inhibited.
The most common cause of bleb failure → Episcleral fibrosis.
Apraclonidine side effects → dry mouth, eyelid retrac on, mydriasis, and conjunc val blanching.
Colchicine affects Collagen Cross-linking and thereby decreases sCar formation.
BAPN (β-aminoproprionitrile), an inhibitor of lysyl oxidase, blocks collagen crosslinking.
5-FU inhibits fibroblast proliferation by acting selectively on the S phase of the cell cycle.
5-FU stimulates thymidylate synthetase.
Mitomycin C is an alkylating agent that decreases DNA synthesis by causing DNA crosslinking.
Mitomycin C is a potent antifibrotic that inhibits fibroblast proliferation. It is injected Subconjunctival.
Because of its toxicity and mutagenic intracameral injection must be avoided.
Haemolytic glaucoma → haemoglobin-laden macrophages block the trabecular meshwork (may occur
within days of hemorrhage)
Isolated depressed quadrantic defects in perimetry result if the patient misses the early portion of the
test in which the machine attempts to determine the threshold for each quadrant.
Echothiophate → is advisable to discon nue the drug several weeks before surgery:
1- Causes a disruption of the blood-aqueous barrier, which may cause increased inflammation after
intraocular surgery.
2- Indirect sympathomimetic agents also block other cholinesterases, including plasma
pseudocholinesterase, which deactivates succinylcholine. Patients may be paralyzed for extended
periods of time after anaesthesia with succinylcholine and need to be warned about this.
Brimonidine is the safest anti-Glaucoma drug in early pregnancy (However, their use in late pregnancy
and during breast-feeding should be avoided because they can cross the blood-brain barrier causing CNS
depression and apnoea in the neonate)
Sub-conjunctival injections of 5- FU in the post- trabeculectomy are administered 180 degrees from the
bleb to minimize intraocular diffusion and the risks of bleb leakage.
15% of patients with Fuchs heterochromic iridocyclitis will have secondary open-angle glaucoma.
(in Kanski up to 60%!)
Specular Microscopy is the best means to predict how the cornea will respond after cataract surgery.
3. Stickler's syndrome → maxillary and mandibular hypoplasia, epicanthus, a long philtrum, and the
Pierre-Robin's anomaly.
Hereditary fundus dystrophies such as RP, Leber's congenital amaurosis, gyrate atrophy and Sickler's
syndrome may be associated with PSC.
Lamellar cataract may be inherited or caused by:
rubella
diabetes
galactosaemia
hypocalcaemia
Anterior chamber IOL's can cause corneal decompensation from loss of endothelial cells, especially if the
ACIOL is mobile and ill-fitted.
From Exams
The intravitreal antibiotic regimen that was used in endophthalmitis vitrectomy study >> Vancomycin
and Amikacin
Autofluorescence can be detected on standard fundus photography >> with the excitation and barrier
filters both in place (both filters on)
Obesity and a poor diet predispose to AMD
Regarding wet AMD → AVEGF may slow visual loss in up to 90% of affected people
Dry AMD → comprising around 90% of diagnosed disease.
According to Age-Related Eye Disease Study 2 (ARED2) Beta-carotene (anti-oxidant) almost certainly
increases the incidence of lung cancer in current and former smokers.
Regarding ARMD → a gene c component can be iden fied in up to 50-75% of cases. ‘’Tyr402His at
10q26 (Complement factor H locus), and Ala69Ser (LOC387715)’’
Incontinentia pigmenti >> loss of pericytes and BM thickening.
Age at onset significantly modifies the long-term risk of proliferative retinopathy in Type 1 Diabetes:
- The highest risk → 5–14 years
- The lowest risk → 15–40 years.
- Onset at age <5 years may have a protective effect on the development of retinopathy
The majority of CRVOs are associated with hypertension. However, in the younger population, a
secondary systemic etiology may be the cause such as protein C/S deficiency, or elevated serum
homocysteine, or a hyperviscosity syndrome such as multiple myeloma or Waldenstrom’s (abnormal
serum electrophoresis).
The following Figure shows the appearance of multiple peripapillary cotton-wool spots in an
asymptomatic patient that are characteristic of interferon retinopathy. DD → DM,HTN,HIV
CVM Retinitis → Spot diagnosis (Rhegmatogenous RD may be associated 25 %)
High myopia is likely to cause a negative angle kappa, which leads to pseudo-esotropia. A large angle
kappa causes a pseudo-exotropia.
Spontaneous retinal dialyses, often in patients with a family history of retinal dialysis and/or RD.
Spontaneous retinal dialyses > Inferotemporal
Traumatic retinal dialyses > Superonasal
Dialysis May Cause RD > Slowly progressive
Usher’s syndrome is the most common cause of combined deafness and blindness.
EOG reflects the activity of the RPE and the photoreceptors. This means that an eye blinded by disease
proximal to the photoreceptors will have a normal EOG.
The EOG is particularly useful in Best disease (Best vitelliform dystrophy) where the light rise is
consistently abnormal while the ERG is usually unaffected.
The Arden ratio of EOG, the ratio of the Light peak (Lp) to dark trough (Dt) is used to determine the
normalcy of the results. An Arden ratio of 1.80 or greater is normal, 1.65 to 1.80 is subnormal, and <
1.65 is significantly subnormal.
Regarding ERG → Rods cannot respond to stimuli flickering above 20 Hz, meaning the 30 Hz flicker
isolates the cone response. Cone responses can be elicited in normal eyes up to 50 Hz, after which point
individual responses are no longer recordable (‘critical flicker fusion’). (20+30=50)
Causes of a negative ERG (Selective Absence of b-wave or enverted ERG):
Congenital stationary night blindness
X-linked retinoshisis
CRAO
Enophthalmos as a result of resorption of orbital fat → Leber's congenital amaurosis (Oculodigital
syndrome may occur, in which constant rubbing of the eyes by the child causes enophthalmos as a
result of resorption of orbital fat).
The duration of intra-ocular gases are as follows:
air: 5 days
SF6: 2 weeks
C3F8: 2 months
SF6 has the highest expansile rate for any intraocular gas, which can cause dramatic spikes in IOP in the
post-operative period.
Retinoschisis RD
Refraction myope hypermetrope
Location supero-temporal infero-temporal
Scotoma relative absolute
Pigments present absent
Surface corrugated smooth
Shifting Fluid may be present absent
Reaction to PRP no reaction reaction
Chromosome Condition
13q14 retinoblastoma
1p Stargardt's
19 myotonic dystrophy
granular, Avellino, Reis-Buckler and
5q
Lattice I dystrophies