CONTENTS

Contributors vii Photorefractive Surgery Complications (Late) 31

Foreword xxi Pigmented Conjunctival Lesion(s) 32
Preface xxiii Proptosis 33
Acknowledgments xxiv ptosis 34
Recurrent Corneal Erosion Syndrome 35
I. Algorithms
Retinal Detachment 36
Acute Conjunctivitis
Retinal Hemorrhage 37
Acute Primary Angle Closure Glaucoma 2
Retinal Neovascularization 38
Blepharitis 3 Secondary Angle-Closure Glaucoma 39
Bull's Eye Maculopathy 4
Stromal Corneal Dystrophies 40
Cataract: Age-Related 5
Subluxated or Dislocated Lens 41
Choroidal Folds 6
Tearing 42
Choroidal Tumors 7
Toxic Retinopathies 43
Conjunctival Lesions 8
Transient Visual Loss 44
Conjunctival Tumors 9
Vasculitis 45
Corneal Edema 10
11. Topics
Cotton Wool Spots 11
Crystalline Retinopathy 12 Abducens/Cranial Nerve VI Palsy Sixth (VI)
Nerve Palsy 46
Dry Eye 13
Achromatopsia 48
Enophthalmos 14
Acne Rosacea 50
Esotropia 15
Acute Anterior Uveitis 52
Eyelash Loss 16
Acute Primary Angle-Closure Glaucoma 54
Eyelid Swelling 17
Acute Retinal Necrosis/Necrotizing
High lOP in Children 18
Herpetic Retinitis 56
Idiopathic Orbital Inflammatory Syndrome, Atypical 18A Adie Tonic Pupil 58
Idiopathic Orbital Inflammatory Syndrome, Typical 188 Age-Related Macular Degeneration and Polypoidal
lridocorneal Endothelial Syndrome 19 Choroidal Vasculopathy 60
Iris Tumors 20 Age-Related (Senile) Retinoschisis 62
Keratoconus 21 Aicardi Syndrome 64
LASIK Postoperative Complications-Complaints of Albinism 66
Blurred Vision 22 Allergic Conjunctivitis 68
Lens Related Glaucoma 23 Alpert Syndrome 70
Leukocoria 24 Amaurosis Fugax 72
Low Vision Management 25 Amblyopia 74
Malignant Glaucoma 26 AMD-Dry 76
Neonatal Conjunctivitis 27 AMPPE (Acute Multifocal Placoid Pigment
Night Blindness 28 Epitheliopathy) 78
Ocular Hypertension 29 Angioid Streaks 80
Photorefractive Keratotomy Complications (Early) 30 Anisocoria in Children 82
XXV
 Acute ConiuncUviUs

ACUTE CONJUNCTIVITIS

Follicles present

Mucoid/purulent Preauricular lymph

node and/or sick
contacts?

Colleen Halfpenny

1
Acute Primary Angle Closure Glaucoma

ACUTE PRIMARY ANGLE CLOSURE GLAUCOMA

Signs and symptoms may include ocular pain, decreased vision,

nausea, edematous cornea, shallow anterior chamber, and mid-dilated
pupil. Gonioscopy shows angle closure. Intraocular pressure is elevated.
I
I Pupillary block II
Medical management with topical
and oraVIV agents as necessary
to lower intraocular pressure
I
Perform laser peripheral
iridotomy if possible. Consider
topical glycerin if the cornea
is edematous.

If laser peripherallridotomy If peripherallridotomy Is If laser peripheral lrldotomy

is successful and the prassure
is controlled
I I
Consider peripheral
iridotomy in the other eye
I
Follow patient to: assess
continued patency of
lrldotomy, gonioscope to
ensure angle remains open,
evaluate intraocular pressure
and optic nerve for signs
of glaucoma
successful but pressure
is Lr!controlled
If the angle remains
closed or very narrow,
consider other mechanisms
(e.g., aqueous misdirection)
If angle appears open
but pressure remains
uncontrolled, consider
filtering procedure
is unsuccessful or if it is not
possible to be performed
I
Consider argon laser
peripheral iridoplasty
if possible
If neither laser peripheral
iridotomy or lridoplasty are
able to be performed, or if
neither procedure is successful
I
Peripheral iridectomy.
Consider filtering procedure if
optic nerve appears
significantly damaged.

Tak Yee Tania Tai

2
 BlephariUs

BLEPHARITIS

I Blepharitis: Management
I
I I I
I Mild ~ I Moderate I I Severe ~
I I I
Corneal stromal,
Inspissated oil
Crusting, thickened infiltrates,
glands, telar9e<:tatic
eyelid margins vascularization, skin
lid margins
rosacea, rhinophyma

I I I
Eyelid hygiene, warm Warm compresses, Oral antibiotics
compresses, margin topical antibiotics {doxycycline, minocycline,
scrubs, artificial tears, {azlthromycln, bacitracin, azlthromycin), topical
topical antibiotics erythromycin), steroids {short term),
(ointment or drugs) artificial tears topical antibiotics

Colleen Halfpenny

3
Dull's Eye Maculopathy

BULL'S EYE MACULOPATHY

Description: Central foveal hyperpigmentation surrounded by a ring ares of hypopigmentation

•
Key History:
•
Key Ophthalmic Exam & Ancillary Tests:

•Age • VIsual acuity

• Symptoms (central visual acuity (VA) loss, color vision, • Color vision
photophobia) • Fluorescein angiogram
• PMH (rheumatologic diseases, neurologic disease) • Electroretinogram
• Systemic and herbal meds (plaquenil) • VIsual field
• Family history of vision loss

l l
Ocular Diseases: Systemic Diseases: Medication Toxicity:

1. Cone dystrophy 1. Juvenile neuronal ceroid 1. Hydroxychloroqulne (Piaquenil)

2. Stargardt'a (flndua flavimaculatus) llpofuaclnoela (aka; Splalmeyer- 2. Chloroquine (Aralen)
3. Age-related macular Vogt-Sj6gren dl....a, 3. Clofazi'nine (Lamprene)
degeneration (ARMD) Batten dlaeaae, JNCL) 4. Uva ursi (tea extract)
4. Central areolar choroidal 2. Bardet-Biedl syndrome
dystrophy 3. Hal ervorden-Spa1z syndrome
5. Benign concentric amular 4. Fucosldosis
macular dystrophy 5. Leigh disease
6. Fenestrated sheen
macular dystophy
7. Leber's congenital
amaurosis

I
~

• Age< 30
'
Cone Dystrophy

• Central VA loss
•Age<SO
'
Stargardt's

• Central VA loss
• Age> 50
ARMD

• Dry or Wet
• Ages4-8
JNCL

• Neurodegeneraliva
Hydroxychloroquine
or Chloroquine

• Dose-dependent effect
• Abnormal color VA • Aut Rae > Aut Dom. • DFE: Drusen, retinal lysosomal storage • Plaquenl : >6.5rng/kg/day
• Photophobia • Accum. of liposfucin pigment epithelium disease • Chloroquine: >3mg/kg/day
• Dilated fundus • DFE: yellow flecks or (RPE) changes, • Rapidly progressive • Basad on ideal body weight
examination (DFE): "Bull's Eye" later in geographic atrophy, VA loss • Central VA loss
normal early in disease subretinal fluid, • Seizuras, ataxia • DFE: Early RPE changes,
disease; later • Fluorescein subrelinal • DFE: "Bull's Eye" later "Bull's Eye" changes
"Bull's Eye" changes angiogram (FA): hemorrhage • ERG: Electronegative • Humphrey visual field (HVF):
• Electroretinogram "Silent choroid" • FA: choiroldal early in the disease 1 0-2 red stimulus; paracentral
(ERG): Subnormal • ERG: normal in early neovascuiar scotoma
cone function stages of disease membrane (CNVM) • Retinopathy may progress
despite cassation of medication

Alok S. Bansal, Joseph I. Maguire

4
 Cataract: Age-Related

CATARACT

I Cataract: Age related ~

I
I I I
Cortical Nuclear Posterior subcapsular
I I I
• Yellowing of the lens Plaque-like formation in
Develops as spoke-like nucleus the posterior portion of
opacities in the anterior • Increase in refractive the lens, usually in the
peripheral cortex index visual axis

I I I
• Initial vision good • Decreased distance • Affects reading early,
• Symptomatic glare vision glare
• Often difficult to predict • Refractive shift toward • Also found with chronic
vision and symptoms myopia steroid use, radiation,
based on lens inflammation
appearance

Edward A. Jaeger

5
Choroidal Folds

CHOROIDAL FOLDS

Key History: Key Ophthalmic Exam: Ancllary Tests to consider.

• Visual symptoms (metamorphopsia, • VIsual acuity and refraction • Fluorescein angiogram

pain, photophobia} • Intraocular pressure • ~can ultrasonography
• Prior ocular surgery, trauma? • Fundus exam w/ special attention to: • Orbital CT/MRI
• History of rheumatologlc disease? • Disc edema?
• Associated serous retinal detachment?
• Mass lesion?
•Inflammation?
• Orbital exam (proptosis, rnoalty}

• Male > Female 1. Postoperative 1. Posterior scleritis 1. Retrobulbar mass 1. Pseudopapilledema

• Typically normal VA
• Usually hyperopic
• Bilateral, asymmebic
• Associated with
idiopathic weal
effusion
a. Cataract extraction 2. Vogt-Koyanagi- 2. Choroidal mass a. Optic disc drusen
b. Glaucoma filtration surgery Harada disease a. Melanoma b. Alagillea syndrome
c. Vitrectomy 3. ldiopalhic orbital b. Metastasis 2. Papilledema
2. Trauma inflammation 3. Thyroid eye diseasa
3. Cyclodialysis cleft 4. Scleral buckle
5. Retrobulbar anesthesia

Alok S. Bansal, Joseph I. Maguire

6
 Choroidal Tumors

CHOROIDAL TUMORS

Common symptoms: blurred vision,

floaters, flashes, rarely pain

Congenital
hypertrophy
of retinal
pigmented
epithelium
(RPE)

Fine needle
aspiration
biopsy

Carol Shields

7
Conjunctival Lesions

CONJUNCTIVAL LESIONS

Common causes: pterygium, pingueculum,

nevus, melanoma, prmary acquired
melanosis, racial melanosis,
squamous cell carcinoma (SCC),
sebaceous CA, lymphoma/benign
reactive ly!Tllhoid hyperplasia (BRLH)
I
r Pigment ~
Yes No
I
Vascular (intrinsic

Yes
I Corneal
component

I No Yes
or feeders)

No
I I I

I Feeder vessel
nodule
I Bilateral
~ Corneal
component
Salmon color ~
Yes No ~s I No
I
Yes I No Yes
r
No

I Melanoma ~ ~I ~ ~
Pr1mary Cysts SCC/Cervical Papilloma Lymphoma/ White/
acquired
melanosis
I RacWJ
melanosis intraepithelial
neoplasia
ameloblastoma
news CINISCC
BRLH
amyloid
I gelatinous

I
(PAM) (CIN)
sebaceous
CA
pterygium
SebCA

~ Pinguaculum
SebCA
1
~s No

Nevus ~I PAM
~

Sara Lally

8
 Conjunctival Tumors

CONJUNCTIVAL TUMORS

Conjunctival Tumors
(associated systemic
conditions)

Bilateral: HBID, CollYllon causes: Presence of

ring dermoid synd, congenital, fair cysts: nevus,
herniated fat complexion, aging, UV lymphangioma
exposure, tobacco use,
immunosuppr9SSion

Pigmented

Lymphangioma Complex
{Turner's synd; choristoma
Nonne Milroy (organoid
Miege) nevussynd)

Metastasis (skin Cavernous

melanoma) hemangioma
{Srurge Weber)

CIN ~
conjunctival intraepithelial neoplasia
HBID hereditary benign intraepithelial dyskeratosis in Haliwa Indians
~
MM ~multiple myeloma
PAM ~ primary acquired melanosis
sec ~ squamos cell carcinoma
Synd ~ syndrome

Hyunjin J. Kim
9
Corneal Edema

CORNEAL EDEMA

No

No
Early Pseudophakic or
postoperative aphakic bullous Inflammatory
edema keratopathy glaucoma (Iritis,
HSV, VZV, toxo,
CMV)

Neovascular
glaucoma

Angle-closure
glaucoma

Michael J. Pro

10
 Cotton Wool Spots

COTTON WOOL SPOTS

• Sm.~ II, whitish, fluffy, sll1htly ele1111bld lesions that appear to float within the Inner retina (•soft Exudates•)
• Ulcely due to Interruption of axoplasmlc from focal Ischemia associated with occlusion of pre -capillary arterioles
• A systemic e1111luatlon Is always warrantl!!d with thl!! finding of an Isolated cotton wool spot

I
I I I

I lachemlc ~ I Embolic ~ I Immunologic I lnt.ctlous I Neoplastic I I Traumatic I Taxlc I

I I I

• Dlabl!!tes Mellitus
• Hypertension
• Carotid Emboli
• Cardiac Emboli
• Systemic Lupus
Erythematosus
• HIV Infection
• Rocky Mountain
•Leukemia
•MI!!tastatlc
•SI!!VI!!re
Chest/Head
I•
Interferon I
• Ocular lschl!!mic (following cardiac • Dermatomyositis Spotted FI!!VI!!r Carcinoma Trauma
Syndrome surgery) • Polyarteritis • en Scratch FI!!W!r •Multiple (Purstcher's)
• Retina I Vascular • Deep Venous Nodosa (Bartol\l!!la Myeloma • Ch ildbirth
Occlusion Emboli •Scleroderma Henslae} •Blood • Post-Membra !\I!
•Anemia • Fore11n Bodies •Behcet's • Leptospirosis Dyscras1as Peel
• Radiation (IVDA) • Giant Cell Arteritis • Onchocerciases • NerVI! Fi bl!!r Lrf!!r
•Air Emboli •Cryollobulinemia • Bacteremia uu:erlltlon
• Flit Emboli (lone •Hemolytic • Fungemia
bone fractures) Uremla/Thombotlc
• Pllncreatttis Thrombocytopenic
(White Blood Cell Purpurll Work-up:
Emboli) • Chronic Ren..l •Blood Pressure (Hypertension, RetJnal vascular Occlusion)
Failure •CBC (Neoplasia, Blood Dyscrnlll, Anemlll, Thrombocytopenlll)
•Metllbollc P11nel (Ren11l F11ilure, Coll;acen Vucul11r Dlseue)
• Amylilse/Lipue (Pll ncrelltltls)
l<8y History: • UA (Lupus, Renal Fa llure, Hemolytic Uremia}
• Sexulll History •HebAlC (Diabetes Mellitus)
• Alalhoi/Druc Use •SPEP (Multiple Myeloma, Waldenstrom's)
• TraVI!!I HI story •Blood Cultures (Bacterial Endocardit is, Fungemia}
• Precnancy • ANA (Lupus, Coll<~gen Vascular Diseue)
• Past Med leal HI story •ANCA (Polyarteritis Nodosa, Wegener's)
• Recent Trauma/Surgery •ESR/CRP (Collagen Vasculllr Disease, Endocarditis, Giant Cell
• Med !cations Arteritis)
• Review of Systems (Rashes, FeVI!!rs, Helldllches, Arth ralgias, • Urine HCG (Precnancy)
• Fatigue, Shortness of Breath, Chest Pain, Frequent Urination) •HIV

Andre Witkin

11
Crystalline Retinopathy

CRYSTALLINE RETINOPATHY
Description: Crystalline deposits within the posterior segment including the retinal vasculature

I
•Age
• Vision loss (can be asymptomatic}
/
Key History:

\ '
Key Ophthalmic Exam & Ancillary Tests:

• Location and color of crystals

• Presence of macular edema
• PMH (cardiovascular disease, HTN, br&ast cancer} • Consider FA if intravascular crystal or retinal infarct
• Systemic medication, health foods, oral tanning agents • Carotid doppler if vascular risk factors
•Intravenous drug use • Diabetes testing if JFT

/ I \
Primary Ocular D i -

1. Juxtafovealtelangieclasis (JFT)
2. Bielll's crystalline dystrophy
Embolic Dl&eaaes

1. Calcium emboli
2. Cholesterol emboli
Systemic Diseases

1. Cystinosis Cnlantile fonn}

2. Oxalosis
1. Tamoxlfen
"
Medication Toxicity:

2. Can1h8XIIrlthlne
3. Calcified macular drusen 3. Platelet -ll:lr1n emboli 3. Hyperomilhinaemia 3. Talc (IV drug use)
4. Longstanding retinal detachment 4. S)Ogren-l.ars&on syndrome 4. Nitrofurantoin
5. Methoxyflurane anesthesia

--'
JFT

• Telangiectatic
'
Bielti's crystalline dystrophy

• Symptoms during 30s

'
Embolic Allllociallons

• Calcium =while, distal

'
Cystinosis

• Rare AR lysosomal
'
Tamoxifen

• For treabnent of
capilar1es leading to • Lmbal crystals not retinal infarct storage dison:ler hormone receptor
crystal deposition required for diagnosis • Cholesterol =orange, • Severe renal disea&e positive breast cancer
• Tiny yelow crystals • Yellow crystals at all often at vessel bifurcations • Crystal deposits in • Doae-dependen1 effect
anterior to ILM levels of retina =
• Pllllelet- fibrin dull cornea, conjLI"ICIIva, but exact limit unknown
• Can diMIIop maaJiar • RPE lllrophy and white, often from and retina fl.7 grams or more}
edema and CNV pigment clumping carotid atheromas • Crystals at level of RPE • Crystals Ill inner retina
• Allllociallon with • AR and AD inheritance and choroid scattered around macula
diabetes throughout postarior pole • May cause macular edema
• Vision can improve after
stopping drug but crystals
typically remain

Char DeCroos

12
 Dry Eye

DRY EYE

Aqueous deficient

Contact lens
vitamin A
Secondary defteiency
(RA, SLE, medication
Wegener's, (environmental)
scleroderma,
etc.)

Blepharitis (see
algorithm)

Idiopathic SurgicaV
(age-related?) radiation
Induced

Colleen Halfpenny

13
Enophthalmos

ENOPHTHALMOS

Enophthalmos

Orbital floor
fracture
No

Scirrhous breast History of orbital

carcinoma radiation or
metastatic to ortlit surgery

Katharine G. Gold

14
 Esotropia

ESOTROPIA

New onset esotropia

I
I Previous
I
Comltant

I
~ lncomitant

I
~ surgery ~
for exotropia

I
Full examination Consider cranial If no other cause,
including vision and nerve palsy, orbital consider strabismus
cycloplegic refraction intracranial pathology surgery
or trauma, ocular
myasthenia,
thyroid eye disease

I I I
I Poor vision ~
one eye
Congenital
esotropia
~ IEqual vision ~
both eyes
I
Sensory esotropia
with possible
amblyopia
H~h ~
I hyperopia High
myopia
~ I refractive
No significant
error
I Nystagmus. Consider
MRI if no other cause
and if normal possible
I surgery for nystagmus
Treat cause of Prescribe ~ses Prescribe glasses blockage syndrome
vision loss and
reevaluate
appropriate for age
and reevaluate
and reevaluate
....,
esotropia
Consider
neuroimaging for
I Possible cyclic ~
esotropia
Nonaccommodative
convergence excess
intracranial esotropia
pathology for acute
onset com itant I
esotropia Consider
strabismus

I Orthophoric
in glasses
I Residual esotropia
at near. Prescribe
bifocal for high AC/A
Residual
esotropia at near
and distance
surgery

ratio and reevaluate

I
Orthophoric in I Residual esotropia
I bifocal Consider
glasses in bifocal glasses strabismus surgery

Consider strabismus
surgery for remai'ling
esotropia

Barry Wasserman, David Lally

15
Eyelash Loss

EYELASH LOSS

Eyelash loss ~
I (madarosis)

I
I

I Noeyelid
associated Associated ~
lesion
I eyelid lesion

1 Blepharitis 1
I
Trauma or
chemical injury
I
Trichotillomania ~ I Alopecia
areata
I Discoid lupus
(may or may not
have associated
Lesion with
benign
features
Lesion
suspicious for
malignancy
Treat chronic
10 the eyelids
I Behavioral ~ lesion) -1
inflammatory
Medication therapy IRheumatology ~
concition
induced (i.e.,
chemotherapy)
cansultation
I Biopsy (inclsional v.
excislonal) and
treatment

I observation
Close If any suspicion for
malignancy then biopsy
should be performed

Amanda Matthews

16
 Eyelid Swelling

EYELID SWELLING

Eyelid swellng

Soft Insect Foreign Conjunctiuitis MediCBmentosa fistula Benign Malignant

tissue bite body lid lid
edema under Corrtact lesions lesions
lid dermalltls

Idiopathic Canaliculitis Mucocele Blepharitis Atopy Sarcoidosis Thyroid

orbital eye diseiiSB
inflammatory Mycobecterium
syndrome

Preseptal Hordedum
CEIIIUiitis

Michael Rabinowitz

17
High lOP in Children

HIGH lOP IN CHILDREN

I High lOP in children

< 3-4 years of age
I
I
~
Differentiate congenital/infantile glaucoma from
secondary and acquired forms of glaucoma in childhood

Other ocular/
systemic
I 1-Vo lensectomy7 I 1-Vo ocular
trauma?
~ I Hlo !uveitis? I
abnormalities
present?

Yes
I
I No Yes
I
No Yes
I
No Yes
I
No

Secondary Aphakic or Traumatic Uveltic

glaucoma: i.e.,
persistent ocular
pseudophakic
glaucoma
glaucoma
I glaucoma

fetal vasculature,
Axenfeld-Reiger
spectrum, aniridia,
retinopathy of
prematurity, Lowe
syndrome,
microspherophakia,
and other disorders

I Congenital/infantile glaucoma
~

Andrea Knellinger Sawchyn

18
 Idiopathic Orbital Inflammatory Syndrome, Atypical

IDIOPATHIC ORBITAL INFLAMMATORY SYNDROME, ATYPICAL

Rheumatology consultation
for lmmunosuppressantsfmodulators

Katherine A. Lane, Jurij R. Bilyk

18A
Idiopathic Orbital Inflammatory Syndrome, Typical

IDIOPATHIC ORBITAL INFLAMMATORY SYNDROME, TYPICAL

Poor response o r
recurrence deslte adequate
dosage and taper

Specific inflammation
Consider intraorbital (granulomatous,
sterlods, NSAIDs, vasculitic)
XRT (? biopsy)

Rheumatology consultation
for immunosuppressants

Katherine A. Lane, Jurij R. Bilyk

188
 lridocorneal Endothelial Syndrome

IRIDOCORNEAL ENDOTHELIAL SYNDROME

I Corneal edema

I Infant ~ Adult
I
• Congenital glaucoma
• Congenital comeal
dystrophies
• Birth tralM11a
• Peter's anomaly
• Sclerocomea
• Mucopolysaccharldosls
• Fuch's endothelial
dystrophy
• Toxic reaction from
topical agents or systemic
medications
• Posterior polymorphous
dystrophy (PPMD)
I
I ~
I Bilateral ~ I With abnormal
iris findings
r Unilateral l
• Glaucoma (uncontrolled
I Bl ateral I Unilateral I after intraocular surgery)
•Trauma
• Uveitis
•Trauma
• Neovascular
glaucoma ~ Chandler's syndrome
(subet of ICE syndrome)
1--
• Slowly progressive
• Axenfeld-Rieger
• "Hammered Silver"
syndrome
endothelial appearance
• Pigmentary glaucoma
with lriCOntroled
intraocular pressure

Iris news Progressive

syndrome iris atrophy
(subset of ICE (subset ot ICE
syndrome) syndrome)

• Distorted pupl
(corectopia)
• Iris atrophy
• Glaucoma in
approximately 50% of
affected Individuals

Michael J. Pro

19
Iris Tumors

IRIS TUMORS

Common iris
tumors: nevus,
freckles, iris pigment
epithelium cysts

Children with Increased History of cancer

associated &kin intraocular with systemic
lesions and anterior pressure, anterior metastasis
chamber inflammation chamber seeding

~~~----~====I:==~ ~
Juvenle
xanthogranuloma

Iris
melanocytoma

Periodic observation every

6 months with slit lamp Increase intraocular
photographs and pressure and diffuse
ultrasound biomicroscopy anterior chamber
seeding

Plaque
brachylhefapy

Carlos Gustavo

20
 Keratoconus

KERATOCONUS

I Diagnosis of keratoconus I
I
Based on history of progressive
astigmatism, clinical signs, and
corneal imaging studies

I
All patients should be counseled
on avoidance of eye Nbblng and
nocturnal eye pressure. Screen
patients for sleep apnea.
I

-·
I

I andPre-clinical ~ Intermediate Advanced

I Acute hydrope
...lymga
I
I mge
I

No or limited clinical findings
but evidence of ectasia on
imaging studies and variable
astigmatism on exam
May be difficult to
refract to 20120
I Cyclopegia, hypertonic
Spectacle and contact
less correction typically
achieve satisfactory vision
I Unsatisfactory
Evidence of
progression?
I vision?
Corneal crosslinki"lg may be
considered (not yet FDA
approved) to slow progression
and flatten cornea
Pronounced corneal ectasia Prominent cone Sudden vision loss
with steepened apex and
pos&lble early scarring I and/or scarring
I
wilh pain, redness,
watering, photophobia
and haze
Poor contact lens Due to break in
Poor spectacle corrected and spec-corrected Desc. membrane
visual acuity visual acuity
I
Spectacle correction often Try rigid and saline and patching or
unsatisfactory so offer speciaHy lens fittings a bandage contact lens
astigmatism correcting I for comfort until resolution
contact len686 (soft, rigid,
or hybrid)
vision?
I
Unsatisfactory
Cornea
transplantation
(DALK, PK, IEK)
Intrastromal ring segments
may Improve vision and
contact lens tolerance

Brad Feldman

21
LASIK Postoperative Complications-Complaints of Blurred Vision

LASIK
Pollloperative compliclltiona: ~
I complllinta ol blurred viaion

118 the L.ASIK ftap ~

in position?
\tJB No

I Corneal opacity
on slit lamp exam?
II I Fllfl d..-..ton: requires llfl relloal
OOGwO~~gm~~
I
lolls I No

118 tllere a _red

eye or PM17
II 1~eye
tikHea red
or pain?
II
\tJB I No \tJB I No

I M~nulent I
dlecharge and a
I'• a local I I Epilhalial dalact I I Ia the ocular

- ·-_ ....--·--.
fooal opacity? thereopacity?
corneal surface amooth
oltlle cornea?
and wr~kl&-lree?

·---.,
'Ills I No lolls I No \tJs I No
\tJB No
I
COrnaal cultu..,
and..,..,..Lit
DII!Ho-
-to: .....
lllariY
,._.,,
llpllbol..l

Uouollycanbe ......... ..........

DlfrL1M .....I. . -LAIIIII:
...,_
Punclolll
Is tile blurred
Dry.,. Filii at.: Slit
viai01'1

·-··-
lloptorcuiVoo lnlammolon -I'IIIMI,bo.C lnllornma1lonln tubrloalon.
alimi'lated with ayndrome: Sl• lamp exam

--·
end lrrlgollon I In the lop _.... ..,rg~coo~ 1hellopl-
~· bast apactacle
lamp...., &hews
irllorlaooLFottlled
lll'llibiolico.~
lnllorlaoe. Mild
...,....... end
--Flop
lnta~onllt
i• en:;ra.ching
on the vi.,..
--"'*'"'
-do.
ben~

~IOpicol
lncr8MO
lubriclOiion.
con.-
corractlon? ahowa pooctate
epithelial
!lollf111108in
pooling
•nln...,..taptc.l
I
III'Cblgolt • end 1n1go11on. uto,couotoga IIDradlo ....-lplugo III'OIIIona. Treat highlighting
..................
-..y ••
...-. llapmolt,ar
lmpUingvlolon
by lrdlclng
prw.-ll<lllueo
lamelar-.r:llia.
-lldfWiono.
'Ills No
with aggraAive
lubrication and
toplcel ateroid8.
rklgaaln the
llap.ll the
irnog~B'
aatigmlllilm.
I 0vw w
und..-aor1'811tlan
fll""~ 8r'I'DI'
,II Normal
posll'8fnlc:tiw
topography?
I striae are
severe enough
to llltact vision,
aurglcel
tl'llfltnllnt is
\tJs I No ruqulred:
rwmcM~Iol
Hlgherwder filM! LASIK epilhallum,
-.rr.tiana: -ia:Comeal lifting and
Can be thinning and amoothlng ol
diagnosed wtth lnle!lor ftep.
wavefront staepenlng on
Imaging. Visual topography.
symptonns may Ttaatment
Include glare, oplona Include
haloe, and rlgldgu
doul*lg ol permeable
images. lenaea,
intrastromal
corneal ring
aagmenta, and
corneal
transplantation.

Elizabeth Hofmeister

22
 Lens Related Glaucoma

LENS RELATED GLAUCOMA

No

History of trauma,
surgery, disruption of
lens capsule?
Yes No

Granulomatous uveitis, Iridescent particles,

keratic precipiates, white material in AC,
hypopyon hypermature cataract,
severe pain

White fluffy cortical

lens particles
intheAC

Rachel M. Niknam

23
Leukocoria

LEUKOCORIA

Persistent Retinal
Family history hyperplastic dysplasia,
of eye disease primary vitreous coloboma
~==:t:::::==..:N~o (PHPV)

Retinoblastoma
(or other Intraocular
malignancy)

Familial exudative
vitreo-retinopathy
Endophthalmitis (FEVR)

Incontlnentia
pigmenti
(females only)

Retinal
astrocytoma

Jonathan Salvin

24
 Low Vision Management

LOW VISION MANAGEMENT

I Low vision refraction ~

(trail frame @ 1O')
I

No
~ High plus (> + 600D) wortt-up
with better eye @ near
r VA>20/40? I ~s
I
~ Able to read 1.0 M
continuous text and
add<+ 4.00

I
I
Able to read 1.0 M
continuous text
I Yes No

~s No I +Give refraction with ~ Edmonds Rehab System -

3-4.00 diopter add start at level above
r best continuous text
High plus reading glasses for Edmonds Rehab System -
better eye. Occlude fellow eye. start at level above I
best continuous text
Follow-up in 6 weeks
Ret 3 months to consider
handheld magnifiers, telescopes, I Able to read 1.0 m
or electronic aids Follow-up in 6 weeks continuous text? (If no,
return to previous step)
Able to read 1.0 m
continuous text? (If no,
return to previous step)
I
High plus reading glasses for
I better eye. Occlude fellow eye.
High plus reading glasses for Ret 3 months to consider
better eye. Occlude fellow eye. handheld magnifiefs, telescopes,
or electronic aids
Ret 3 months to consider
handheld magnifiers, telescopes,
or electronic aids

Scott Edmonds
25
Malignant Glaucoma

MALIGNANT GLAUCOMA

1·• Shallow anterior chamber (peripheral and central)

lOP: normal (if early) or high (more likely)
I

~
No pupillary block No simulating conditions
• Patent iridotomy • Choroidal hemorrhage/effusion
• Other posterior space
occupying mechanism
I I
Mecical treatment
• Cycloplegia+ mydriasis (i.e., atropine/phenylephrine)
• lOP management (aqueous suppressants, osmotics if needed)
I
Laser treatment
• Nd:YAG disruption of
anterior hyaloid face in
pseudophakic/aphakic
cendidates
I
Surgical management
• Pars plana vltrectorny with
goal to create a unicameral
eye (ensure free communication
between iridotorny, zonules,
anterior hyaloid)

Anand Mantravadi

26
 Neonatal ConiuncUviUs

NEONATAL CONJUNCTIVITIS
I
Chemical
conjunctivitis
(silver nitrate or
I co=tis ~
Congenital
nasolacrimal duct
obstruction
Chlamycla
trachomati9
I Herpes
simplex virus
~
gentamicin)
I ~leu~~ ~ ~
I
Observation,
and gram stain Nasolacrimru
sac massage
I -j Culture I H Virru culture I
lubrication, I
discontr.ue offending
agent or home ~medy I Gram negative I Gram positive ~ Toplcru antibiotic
coverage if
Erythromycin 50 Systemic acyclovir 60
- secondary
mglkg/day for
2-3weeka
mglkgfday divided in
3 doses lor 14-21 days
Appropriate topical infection evident
coverage of choice
balled on cultUres
Topical erythromycin Topical tlifluridine
I - ointment 4xlday for optional if systemic

----i Neisseria
gonorrhea
I I CXher gram
negative&
I 2-3 weeks optional therapy in&titutad

~ Treat mother and ~

Appropriate topical sexuru partners
Frequent saline
H irrigation coverage ol choice
based on cultures

Single dosa
cefltlaxone 25-50
m~ IV or IM (not
to exceed 125mg)

Treat mother and

H sexual partners

Test for other STOs

and start concomitant
treatment for chlamydia

Consider inpatient
admission for possible
systamic infection or
comaal involvement

Jonathan Salvin and Sharon Lehman

27
Night Blindness

NIGHT BLINDNESS (NYCTALOPIA)

Congenital? I
Yes _l No

~
I Progressive?
I
I
No
I History of surgery
ortr111.1ma?
I
_l
Yes I No
Retinitis I Normal fundus? Jl
pigmentosa (RP) Refractive Vitamin A
~ No
surgery deficiency
Progressive cone-rod (i.e., RK, (xerophthalmia)
dystrophy Congenital Oguchi's PRK, l.ask)
stationary night disease Drugs (i.e., alcohol,
Choroideremia bllndn988 (i.e., chloroquine, etc.)
X-linked) Fundus
Sorsby's fundus albipunctatus High myopia
dystrophy
Cataracts
Refsum's disease

Marlon Maus

28
 Ocular Hypertension

OCULAR HYPERTENSION

10P>21 mm ~
Normal eye exam

I
Risk factors
• Increased age
• Family history ot primary
open-angle glaucoma
(POAG)
• Pressure level
• Central corneal thickness
• Disc conftguration
• Male gender
• High myopia

No I lW

Close observation Discuss with patient the

Monitor similar to POAG risk of POAG development
for several years Decide to treat or observe

I
I
Observe
~ I Treat
~
I I
Close observation Topical medications,
Monitor similar to POAG selective laser
for several years trabeculoplasty (SLT)
Close monitoring similar to
POAG for several years

I
I Nodamage ~
I
Consider stopping treatment
and monitoring closely

Tara A. Uhler

29
Photorefractive Keratotomy Complications (Early)

Photorefractive Keratotomy Complications (Early)

Photorefractive
keratotomy: earty
postoperative
complications (week 1)

Colfl)laints of
blurred vision

Pain/red f1Y8?
Yes I No

I Corneal opacity on Normal post-op course.

sit lamp exam? Visual recovery occurs
gradually after PRK

Yes I No
I

Mucopurulent Bandage contact ~

discharge, surroooding lens in place?
corneal edema,
Yes I No
persistent epithelial

Yes
defect
I No
I
I

Contact lens
moves well?
I I Epithelial defect
of cornea?
~
Yes I No Yes I No
Infectious keratitis: Central toxic
• Remove and culture
bandage contact lens
• Corneal cultures
keratopathy:
• Bland central opacity
without significant
Using post op
eye drops
I

TiltJt bandage
contactlens.Ren10ve
~ Replace bandage ~
contact lens
l Dry ocular surface:
increase lubrication
~
and smears inllamrnation and oral lens and replace
• Fortified anti:Jiotlcs • Usualy appears after pain mads? with a lens with
• Consider antilungals epithelial defect a flatter base curve.
if feathery edge or has healed
satellite lesions
Yes No

Normal postoperative Patient education

course: reassurance regarding proper
and close follow-up post-op rneds

Elizabeth Hofmeister

30
 Photorefractive Surgery Complications (Late)

Photorefractive Surgery Complications (Late)

Photorefractive
keratotomy: late
complications (second
postoperative week
and beyond)

I Complaints of
blurred vision
I
I Pain/red eye? I
Yes I No

Was the surgical Is there a I

epithelial defect
doc~.mented as healed?
I comeal opacity? II
Yes I No Yes No

I
I
Is there a new
epithelial defect?
1 Delayed epithelialization:
increases risk for scarring
Yes 1 No and haze. Treat
aggressively with
management of ocular
surface disease and dry
eye. Watch for secondary
infectious keratitis.

Recurrent corneal erosion: Dry ocular surface: ~

AHhough PRK and
phototherapeutic keratectomy
(PTK) can be curative for patients
with recurrent corneal erosins,
they can oocaslonally occur de
novo following PRK. Unlike typical
recurrent erosions caused by
shearing trauma, post PRK
recurrent erosions respond well
to aggressive topical lubricants
and bandage contact lens and
seldom require surgical intervention.
increase lubrication. I
I
Reticular or lacy central
opacitiea: Post PRK Haze
• No associated inflammation
• Manifest refraction
shows myopia and/or
astigmatism
• Risk factors include
deeper ablation depths,
noncompliance with
topical steroid regimen,
and UV exposure
• Often Improves with
topical steroids. Patients
on long steroid regimens
must be monitored closely
for steroid-induced
increase lOP.
DenM, dlecltorm central Normal post-op cou ....:
opacity: Central Toxic Visual recovery after PRK
Keratopathy requires 3-6 months.
Encourage the use of
• Bland central opacity
topical lubricants and
without significant
treat lid margin disease.
inftammation
• Associated with comeal
flattening or thinning with
associated hyperopia
• Does not improve with
topical steroids, but can
gradually improve over time

Elizabeth Hofmeister

31
Pigmented Conjunctival Lesion(s)

PIGMENTED CONJUNCTIVAL LESION(S)

No

Observation
versus excisional
biopsy

Britt Parvus

32

• Pain ismore commonly
associated with
lnllammatory conditions
• Neoplastic process often
present WI'th painless proptosis
• Presence of numbness may
indicate neuropathic spread of
tumor (e.g ., squamous CA)
I Inflammatory l!--
I Infectious
I Neoplastic It-
I Vascular
1-
Proptosis
PROPTOSIS
• Check exophthalmomelry
• Check lid position
,...-
• Rule out 8110phthalmos,
lid retraction • Normal expophthalmometry
- measurements vary by
~
gender and race
Contralateral • Up to 2 mm difference
enoplhalmos or between the two sides may
~ Pain? ed
lid ratraction may
give appearance of
r--- be within nonnallimits
• Caution if eyes ara not
apparent proptosis aligned: if the aye being
measured is not centrally
aligned an inaccurate
-
measurament may result
'-
l l
Adul:
~ I Child
~
II.g., Thyroid IIY8 disll888
• 11 cause of bilateral proptosis
• 11 cause of unlateral p!OpiO&is
rTiming 'of onset I
I
lcJiopBthlc OI1JitB/ lnllammatlon
I Congenital ~ r Gradual ~ I '
Acute ~
1 e.g., Orl:Jital CBIIulitis
1
Primary vs. rnefastic e.g., Dllrmoid cyst Neoplastic lnffsmmatorylinfectious
bntast, lung, prostate
reprasent common mets
Capillary hemangioma
TIMitoma
e.g., Schawannatr~~~,
mllflingiomB
e.g., cellulill& = i# 1 cause
of proptosis In children
Scirrhous breast CA may Vascular Neoplastic
ll.g., varix e.g., Rhabdomyosancoma
9.(1., Gai/9/TIOUS
Vascular
e.g., lymphangioma
h91'Tll111(11oma
Varix
Lymphsngioma
I
I
~
otrtan Imaging ' ~
Obtain imaging:
CTvs. MRI
CT: balhtr at imaging bony anatomy, faster,
cheaper, easier to access; caution when
ordering in children due to radiation exposure
MRI: better soft tissue resoltlon, better BValuatlon
of brain parenchyma, better evaluation of
VBIICI.IIar lesions
Ort»tal ultrasound: consider In vascular lesions
Vladimir Yakopson
33
Ptosis

PTOSIS
I
I I

l Congenital ~ Acquired
~
I I

I Levator ,
dysgenesis
~ [ T ra~.matic Pseudo-ptosis
(other ophthalmic
No other
ophthalmic
abnormalities) abnormalities
Neurogenic:
congenital Homers,
3rd nerve
Other:
blepharophlmosis,
double elevator
~ Enopththalmus or
microphthalmia
Pupils ~ syndrome
H~ners I
palsy, synkinetic palsy
-----1 + Anisocoria It-
~ Peri-orbital
-
Cranial nerve Ill
palsy (pupil-
edema, cellulitis
involving)

~
Contralateral
eyelid retraction

~
Conjunctival
inflammation
- Anisocoria

~ ~
Intraocular Extraocular Cranial nerve Ill
inflammation motility palsy (pupil-sparing)
I
Eyelid ma&B
Limited
1-
- (chalazion,
tumor etc.)
~
Chronic progreBBive
external
ophthalmoplegia

-1 Brow ptosis, Full

dermatochalasis

II I H Myasthenia
gravis

Full levator
function
Limited levat~
function
~ y Orbital mass
or inflammation

I
I ~
Aponeurotic/
involutional Muscular
dystrophy etc

I
l Tra~.matic
~

Katherine A. Lane

34
 Recurrent Corneal Erosion Syndrome

RECURRENT CORNEAL EROSION SYNDROME

No

Matrix metalloproteinase
inibltors {doxycycline,
topical steroids)

Debridement with
diamond burr polshing

Phototherapeutic
keratectomy {PTK)

Colleen Halfpenny

35
w RETINAL DETACHMENT :a
en Ill
c!:
::I
HPI: !!.
•0.-7 11:1
• Ocular trauma? Penellllling vs. Blunl?
• F - ("lightning bolt In plllpll"'Y')
·F-
•Curtalna
i
:::r
3

-
• Previous eye surgery?
•Chrunicily Ill
::I

At.g...__..
•CIWIIIdtlyful-dillconlinuity
ollie ..Unal Uuua pruvl.-....,... Ill
Elalcldft
• c.IINid b y - or
choroidal con~ 111111
~­
•Causadtlyac:.
HIIUaonraUnaiU'f-
[ ~~
llllfnaach&la I
luld to llbftlnel space a Cl'8llt8 RD d i - RPE or l*lod relirllll •NOIHIIOblle
•Rheglllllllog'*""'" nllinal...........,_
• From fie Greek Rttegma tor 'rent'
boln1er •-ng luld Ill buld-
up in the aub-notinai-
•Concave
•Calleadlo Senile
• Hyperapla 70%
...........
•X-Iinbd(89%)
Ch-lc-~-"shhlttng rhagmatoganouo

I 31ypeeof
rllllnal-
ftuid" peltllm varying .., position
• Smooth.....,.. aurr.. (no-)
.-tachrnant with
contnaction a t -
and cnoa1lon o l -
• lnleto18mporlll70%
• 8uparalaT1poaral 25%
•Biamral~%
B-ral
Splltt~dNFL
• lnteroleq)orai 110%

lui--
•lnfllron-58%

.-u--
Arr1oafrom
•T,..:

vi.._._,
rent i n -
Ueeua from v - - . traction
• Hor.M . _ (lha lfl!l i8 point of
max
• Hole: ruund or oval
...... . , _ _ i t y
......ad by atraphy no
vitreoua nction
d&ln881Gon at the one-
• Dialylie: full thiokn...

- - - b l u n t trauma
•VI....,.dlattacllad
DOx:
1. T..nora (melanoma, milia)
2. HaiiWlglomo.
3. Centnal aaruus
pa~pheral cysloid

No dam8lalllon line
Doma llhapad
with IVFA n_,...
Stallabl macula: CME

"-!pheral .:hale: no
-naion Ill ora, t•ra
llllf""""""'lclopathy
• Typiedy tight -ions • No fnaa flapping ~radge ~teocholoma alongVIIIII{VH)
• 30-45% ol RD - - 4. HallldiiM<H
.,. pa~vucular often- with holes in lattloll •ln-amporalf""""runual 5.CoaladiBBBB8 Oobrwall bl8llk can
vit...,us hornorrhage degoMn.Uon 6. U...l afblon lead Ill rhi!JIII -
::tJ • Slow prog..-on
7.Hypel'lllnoliW8IIIIIf!lllllCY
~.
..... 8. Systarnlc lupus """"30 yaara die• not
thnaalan macula Hno
"'~ Exam:
•VIt...,ua COllis (SdlaBiora &lgn)
Retinal - with PVD
• 5% will floaiBra
Olhtorbreaka
1.0parQllum
II Rapalr ~ arylhamaloul
9 . - d pregnancy outerrwtlna-
• Vllillla prw-nllinlll or vit...,us • 13% .,_.and • Rlllina torn all 10.0ptic.-pilll
Ill In ollloB: pnaumaUo r d n - DOx:
:::r h....,"'- (with PVD 70%
oltnelc)
pholop&laa 2.Giantratlnlll-
• Oaf: >80 .-grass or • Localize break? 1. Pru-U.. d i -
• 12% pholopalaa alana
• Mobile 3 dock hot.n dU ·-lnlllpMor llllfnopathy
• Macula on or d.....-tlon llnll'? thicllne88notlnai- 8dockhoo.n 2.PVR
• Sctn d~ of bot! eyes ·R-Iaa • Multiple- within 3.1...........
(ldontlly lattloll, 1111-lllc.) t8clll*ally surgical 1.5 dock hour lanllgn body
• No pathOlOgy 180
notlnal - wlllch
Is prune Ill poo-..atNe .-u-DIIItf
• Noprot ifenltiva Repair:
~nglaalona: llinollllinapathy
1. l..alttoa .-;-ration vtno-palhy • VIsion -nl~ (macula
4C).5C)% of CU88
• 8% of all eyes • Can they poaition? involving at f bl8llk -ope)
• Close flltlaoHJp? • Vlt-.y with or without
• 30% olal RD Ollcloly !rum
buckle, ...... and poeeible
comllhdlon uaoclallon ·~ ellac:fw8 . .coma oil tamponada
with myapla)

•-r
• Graale.t praportlon .. myapaa
• 8 Ill -8 claptllr1l In OR:
• Modalllla ri1)'0IMIS ha,.. mana 1. Sclaral lluclde-Sagmantal
po&l-cafaract- RD vs.Endrd~
2. Cystic llllfrllll'-'rltd phalcic or young?
• 5% ol all eulopliad eyes •92% lllfllctMI
•With PVD oen oa... 10% 2.Prlmary~
ol p~rnary RD •P-phaldc?
• 88-eo% al'lectiv8
3. llucki&IVhctDmy
•110% lllfllctMI
 Retinal Hemorrhage

RETINAL HEMORRHAGE

I Retinal Hemorrhages can be sub-classified by their appearance and location

I
Pnt-Ratinal
•aoat-Shaped•
~ Nerw Fibltr Layer
•Flame-Shaped•
Dot and Blot
Small, Round,
I White-Centered
•Rotn Spots•
5u i).RIItinal
Darker red,
5u!).RPE
Very Dark, Wei~
Very Common Amorpnous, Deep Defined, Deep
Neovascular Optic Neuropathy Thromboembolic to Retinal Vessels
*See dlfllrenllll •l'ilp ledem~ Blood Dyscrasia •Bacterial Traum;tlc
lllpalllgf •ISchemic optic •Anemia endocarditis Traumatic • Choroidal rupture
prollfwlltlw neuropathy • Thrombocytopenia •Bacteremia • Choroidal rupture • Penetr.rtin11eye
~ •GiaucOillil •Anoxia •HIV • Penetratill8 eye trauma
• CNVM (Rare I •Optic Nerve Edema •Leulernia •Collapn vasculilr traum~
• Multiple mveloma disease Neovascular
• Coasulopathy Vascular •CNVM
Traumatic
• Shaken Baby Blood Dyscrasia • Retinal • Polypoidal choroidal
Syndrome Microvascular •Anemia macroaneurism vasculopatlrf
• Blunt Trauma • Hypertension • Thrombocytopenia • Retinal capilary
• Valsalva Retinopathy • Retinal venous •AIIIlli;! hemangiobi;!stoma
• Te rson's Syndrome obstruction •Leukemia
• Di;!betic retinopathy • Multiple rnye lorna Neovascu Ia r
0 (OilfiUiopalhy
• Radiiltion •CNVM
Vitreoretinal • Ocui;!r ischemi;! • Polypoidal choroidal
Traction Miaovascular vasculopathy
•PVD Traumatic • Hypertension
• Retinal Tear • Shalen baby • Retinal venous
• Rheamatosenous • Blunt trauma obstruction
• Rl!tinal Detachment •PVD • Diabetic retinopatlrf
• Chldbirth radi;!tion
Vascular • Intracranial •Ocular ischemi;!
• Hernorrhase • Fa lowing heart
•Retinal
sursery
Macroaneurism
•Capillary Thromboembolic
Hemangioblastoma • Bacterial Traumatic
endocarditis • lntracrani;!l
hernorrhafll!
• Bactere rnia
•HIIf
• Collapn vascular
disease

*All causes of Dot-Blot hemorrhage can also cause nerve fiber layer hemorrhages

Andre Witkin

37
Retinal Neovascularization

RETINAL NEOVASCULARIZATION

Hlstnry of"''" or facial RT

Dilated and tnrruous Hl!ltDI'yofDM RBre causes M•c1B
retlnalvan(s) MAs I IRH
Vltreouo homorrh011e Venousbeacfrw c:ws
Hypenlf~a>~lty oyndrome
IRH IRMA MAo
CCRst111o
c:ws Rettnal "'udaoes ME
ME Idlopotlic oa:tuol"" ortlrlolltio
IRH l!lrdshotCR Exudates

cb
ME ~tl'nal vua.llrtf1 I

lo.L ~
T~oplnna.l1 Rild latlon retinop;rthy ~
Olorafdal melanoma
OYorlcRD
InconUnontlo pfsm<nU
llettnltto ple:mentDoa
Loubmio

Slclde cell trait or disease
Sea fan of NV
Sclerosed vessels
Dull gray pertph.,.al fundus
Vanous mrt1loslty
Bhu:k sunburm:
Salmon patr:h
p.,.fpherol """ocular retina Premarure Infant No hlstDry of premorurlty M>F lnMior retinal Abnormal CXR/chest CT
Mldperlpheral: AV!Isrular periph.,..l PositiVe famdy hlstx>ry 501x>80yo snowbanklrw/onowballs Elevated ACE(~]
• Mlaoaneuryams, retina Bilab!ral p..-lpharal capillary Carotl'd dtsea~e Vitreous cells EIOV!Ited lysozyme
• DdataUon of capillary dhannels Demoraotion line nonperruslon Deaeased vflfon
Biopsy wllh nonca'""til"'l
•Tort1Josfty of nelghboriri!YeSsels Plus di...,se Flmbrated border IX> vessels Pertorbltlll or orular pain cranulomas
• Olorfaatl'nal !ICinl VH~ T~~mporal maa.llar dragtrw; Ddated retinal vans (not Posltl'vesallum SCZiin
~ PerlpheroiiOCUdote
tDrbJous]Art8t'al att:enuatl'on

~
:rr-ctllelntraretinol depooltl : ~ MldperlpheraiiRH
Iris NV
llettnal deb!chm...,t Abnormal ophthalmodyn•-

~
mometry

Eale'sdlsease ROP FEVR

~

Nikolas London

38
 Secondary Angle-Closure Glaucoma

SECONDARY ANGLE-CLOSURE GLAUCOMA

I
1-ts!ory of rec.nt
ocular surgery
l No hlslory of
ocular surgery
~

I Owar
aonogrsphy
~ Unlateral ~ Blataral ~

I Sift-lamp exam I Topiramata ~

Choroidal No choroidal use
affusion or effusion or
hemonhage hemorrhage
Cydoplagics,
lllllrolds,
Antiglaucoma drU!ageol

~~00 ~
rneds, Retinal effusion
c:ycloplegics, dtllachrnent
8l8roid8 surgery
I
I I
Cyclopleglcs and Cyciopleglcs and

I~~Mid I u~~~ed antlglaucoma

meda axcept
anllglaucoma
rneds, 11188r
xalatan lridoplasty

8 I ~effusion II
or hemorrhage
I Hypermatura Normal or mase I Iris NV I Iris atrophic

I Controlled
lOP
II Uncontrolled
lOP
cat, lens
subiiiXadoo
or abnormal
pigmentation
in anlerior I NVG I
hole, iris nevus,
corneal edama,
bridgi ng broad
I I segment baaed PAS
~
I Cootinua
cyclopleglcs
Nd: Yag laser
anterior
Phacomorphic
glaucoma
Ocular 80110
lntravltn~al
anti-
VEGF, PRP and
antigllu:oma
ICE
andFAJ hyaloldotomy I and ant syndrome
mads
I I PI, antiglaucoma ~ segmentUBM

I vitrec:tomy
Anterior
mads
I Iris and ciliary
Trab + MMC,
shunt, or
ITn~at Ilks a
case with
body tumor POAG

~
cyciodestructive
or cyst, poet
axl::on prooeduras
segment
IUmors,serous
retinal detachment

Manage
appropriately

M. Reza Razeghinejad

39
Stromal Corneal Dystrophies

STROMAL CORNEAL DYSTROPHIES

Stromal corneal dystrophies

Gray/white
opacities with cloudly
intervening spaces

Colleen Halfpenny

40
 Subluxated or Dislocated Lens

SUBLUXATED or DISLOCATED Lens

Subluxated or
dislocated lens/
Intraocular lens

I Crystalline lens
(ectopia lentis)
~
I Intraocular lens
(pseudophakia)
~

Ocular diaordera Systemic clsordera Trauma Early L...

1) Retinitis pigmentosa
2) Retinopathy of prematurity
3) Aniricia
4) Congenital glaucoma
5) Iris coloboma
6) PHPV
7) Rieger's syndrome
8) Megalocornea
9) Simple ectopia Iantis
(usually AD)
10) Ectopia Iantis e1 pupillae
1) Marfan's syndrome
2) Homocy&tin~ia
3) Weii-Marchesani
syndrome
4) Ehlel'a-Danlos syndrome
5) Syphilis
6) Hypertyainemia
7) SuHHe OXidase deficiency
8) Sturge-Weber syndrome
9) Refsum's syndrome
10) Crouzon's clsease
11) Scleroderma
1) Ocular trauma, 1) latrogerk
usually blunt (inadequate cap&Uiar
2) Previous ocular support or z.ooolar
sugery, usually dehiscence)
vltnlo-retinal 2) Zonulopathy
(z.ooolar insufficiency
secondary to pseudo-
exfoliatiOn syndrome,
RP, ROP, uwltis,
previou81rauma)
1) Cepsule contractiOn
(phimo&i& with
z.ooolysis secondary to
XFS, previous vltreo-
~alsurgery,trau~
uveitis, RP, ROP)
2) Scleral sut~n
hydrolysis (usually
greater than saven
years following scleral-
sutured IOL)

Robert Behar

41
Tearing

TEARING

I Dye disappearance
I Normal, check
Schirmer's
Abnormal I

I
I

I
I
I Minimal change on I [Increased tear film I
~
Abnormal DDT, check Schirmer's or overflow
(diY eye)

I DIY eye
treatment
II Probe and irrigate ~
canaliculus
I Abnormal ISchirmer normal ~ I Probe and Irrigate
canaliculus
I
(diY eye) or Increased

Lacrimal drain
open, no treatment
Obstrucrted,
recommend lacrimal
I Treat
dl)' eye
Probe and Irrigate
canaliculus
I I
Obstructed
outflow ~
needed surgery I
Also perform P & I Canalicular, consider Nasolacrimal duct
Examine for to rule out lacrimal canalcular surge!)' obstructed,
P~X~ctoplasty,
hypersecretion, stenosis as secondal)' orCDCR consider OCR
canallculoplasty,
lkl malposHlon, cause of tearing
&tenting, OCR, or
keratitis, etc. CDCR depending on
location and extent of Duct open, Obstructed, needs
obstruction functional lacrimal surQSIY to
obstruction address area of
stenosisfobstructlon
(e.g., punctoplasty,
Examine for OCR, etc.)
lkllaxity, tear
pumpfal ure

Consider horizontal tightening

of ld or temporal)' &tenting of
drain for functional obstructions

Scott Goldstein
42
 Toxic Retinopathies

TOXIC RETINOPATHIES

Crystalline Uveitis CME Retina and Vasculilr

I
retinopathy RPE disruption damage

I o
o
Rif.Jbutin
Cidofovir
o
o
Prostasland in analoss
Nicotinic acid
o Epinephrine Aminoglycosides Oral contraceptives
oIntraocular injection o May result in
may result in thromboembolic
I I macular infarct ion vascular occlusion
Tamoxifen Talc others
o Typically >30 ms/day o Small, intravascular o canthaxanthine
o Decreased VA and crystals seen in o Antiretrovirals Interferon
color vision chronic IV d riJ8 o Methoxyflurane
o Vascular closure
o Perifovea~ crystalline abuser associated with
intra retina I de posits o Can lead to retinal immune complex
t-/-CME exchemla, vascular deposition
o ERG: Decreased a- occlusion, NV, o Findings may

and bwaves and/orVH resemble NPDR

I I I

Th loridazine Chlorpromazine Chloroquine or Hydroxychloroquine other causes:

o Typically > 1200 rr181day o Typically 1200 to 2400 o Chloroquine: Typically >3.5 mslk«fd"f or 300 g • Antiretrovirals
o Decreased VA, nyctalopia, and rr181day for 12 or more cumulative o Carmustine (Cisplatin
dyschromatopsia months o Hyd roxychloroq uine: Typically >6.5 rns/kt/day or and BCNU)
o Pigment de posltio n In the o Pigment deposition in the 700gtotal o Cisplatin
pe rip hera I retina, cornea, lens, retina, cornea, lens, o RPE mottlin& may progress to bulls-eye o Clofazimine
eyelids eyelids and optic. nerve o ERG: enhanced a-wave, decreased b-wave o Corticosteroids
o ERG: decreased a- and b-waves pallor o VF: central scoto rna to red test object o Deferoxamine
o Potasium Iodate
o Quinine sulfate

Nikolas London

43
Transient Visual Loss

TRANSIENT VISUAL LOSS (TVL)

Ocular disease

Comeal Large vessel

abnormalities a1herosderotlc
disease

Angle closure
Glaucoma Cardloembolic
Large vessel
Cardloerrbolic Vertebrobasilar
a1herosderotic
dissection
Hyphema disease
Vasculitis

Hypercoaguable
states

Retinal
vasospasm

Central retinal
vein occlusion

Papilledema optic
nerve drusen

Mary Ellen P. Collum

44
 VasculiUs

VASCULITIS

Ramal vascuilis 1

Necrotizing Aneurysmal cws lntraretinal +HIVELISA

re11nls dllltatlon of infiltrates and western blot
Inferior retinal
ONHand Major criteria: Abnormal CXR/chest CT snowbankingl
retinal arterioles • Oral apthous ulcers Elev111ed ACE (60-90%) snowballs
• Genital ulcera Elevated lysozyme Vrtreous cells
• Skin lesions CBCD Oeukopenia, Peripheral ava&eular
• Ocular dieeese eosinophilia In 24%) retina
Minor crtterla 24-hour urine Midperipheral:
• Arthritis (hypercalcurla In 4%) • Microaneurysm&
•GIIeaions Biopsy with non- • Dilatation of capillary
• Occlusive vascular lesions ea&eeting granuldmas channels
• Migratory thrombophlebitis Positive gallum scan • Tortuosity of neighboring
• CNS Involvement
vessels
• Pulmonary artery aneurysm

ll..l
• Chorloretlnal scars
• lnterstitallung changes

I Beh~rs I I ELs ~

Frosted branch angiitis
4/11 ACR criteria:
• Malar rash
• Di&coid ra&h
• Photosensitivity
• Oral ulcers
• Arthritis
• Serositis
• Renal disorder
• Leukopenia/lymphopenia
• Hemolytic anemia
or thrombocylopen
• Neurologic disorder
• Positive anti·DNA,
Clinical findings (unexplained
fever, abdominal pain, renal
failure, hypertension, arthralgia,
muscle tenderness or weakne&1>,
subcutaneous nodules, skin ulcers,
pain in the abdomen or extremities,
or rapidly developing hypertension)
Biopsy (necrotizing arteritis)
Arteriography (aneurysms in
medium-sized arteries)
Chronic, unexplained M ACA criteria PosHive serum
respiratory symptoms and •Asthma cryoglobulins
signs (Including • Eosinophilia Abnormal urinalysis
otitis media in adult&) • Paranasal sinusili& Elevated BUNter
Elevated ESA and CAP, • Pulmonary lnftltrates Elevated tranamlnases
decreased serum albumin • Histologic evidence of va&eulitis PosHive AF
and total protein, anemiua, with extravascular eosinophils (lypee I and II)
thrombocytosis, mild eosinophilia, • Mononeuritis multiplex or Abnormal CXR
elevated serum creatinine polyneuropathy
Urinalysis with dysmorphlc
RBCs and ABC cast&, proteinuria Elevated CAP levels and ESA
may be dalected Abnormal urinalysis
Positive o-ANCA Positive p-ANCA
Positive biopsy

"l
antl-8mllh antibody, or
antiphosholipid antibodies
• Elevated ANA

ICh"ll Cryoglobulnemia

Nikolas London

45